ChanBeDu/relevant_section_length · Datasets at Hugging Face

2,254

157,629

27748

Discharge summary

report

Admission Date: [**2156-6-30**] Discharge Date: [**2156-7-7**] Date of Birth: [**2081-1-7**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2724**] Chief Complaint: Right and left Subdural Hematomas, Left IPH and Major Surgical or Invasive Procedure: None History of Present Illness: 75 y/o urdu speaking male transferred from outside hospital for subdural hematoma. Pt. was found on side of road next to bicycle. Unknown LOC - pt. does not remember event. History unclear because of language barrier. However, pt. reportedly c/o of left sided CP and mild headache, denied neck pain SOB N/V abd back pain weakness numbness to OSH. Sustained lac to left eye. CT head with new on old SDH bilaterally R>L 1.6cm, no shift. INR 7, FFP 2 units and vit K 5units at OSH. Past Medical History: Diabetes, Htn, CAD and prior stroke for which he is on Coumadin Social History: Urdu speaking large involved family Family History: Noncontributory Physical Exam: O: T: BP: 151/65 HR: 79 R: 21 O2Sats: 100% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: Right ERRL&A, EOMs intact, large hematoma over left eye and eyelid swollen shut Neck: C-collar in place. Lungs: CTA bilaterally, no w/c/r Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+, ND Extrem: Warm and well-perfused. No C/C/E. 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. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 1.5 to 1.0 mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to finger rub bilaterally. 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. Moving all extremities. No pronator drift Sensation: Intact to light touch bilaterally. Reflexes: B T Br Pa Ac Right 1+------------> Left 1+------------> **difficult to assess b/c pt having difficulty relaxing** Toes downgoing bilaterally Coordination: normal on finger-nose-finger Pertinent Results: [**2156-6-30**] 02:10PM URINE RBC-[**11-29**]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 [**2156-6-30**] 02:10PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2156-6-30**] 02:10PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014 [**2156-6-30**] 02:10PM WBC-13.2* RBC-4.39* HGB-12.5* HCT-35.1* MCV-80* MCH-28.4 MCHC-35.5* RDW-15.1 [**2156-6-30**] 02:10PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2156-6-30**] 02:10PM URINE GR HOLD-HOLD [**2156-6-30**] 02:10PM URINE HOURS-RANDOM [**2156-6-30**] 02:10PM URINE HOURS-RANDOM [**2156-6-30**] 02:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2156-6-30**] 02:10PM CK-MB-4 cTropnT-<0.01 [**2156-6-30**] 02:10PM ALT(SGPT)-28 AST(SGOT)-25 CK(CPK)-118 ALK PHOS-68 AMYLASE-87 TOT BILI-0.4 [**2156-6-30**] 02:10PM ALT(SGPT)-28 AST(SGOT)-25 CK(CPK)-118 ALK PHOS-68 AMYLASE-87 TOT BILI-0.4 [**2156-6-30**] 02:21PM HGB-10.4* calcHCT-31 [**2156-6-30**] 02:21PM GLUCOSE-169* LACTATE-1.9 NA+-142 K+-3.1* CL--111 TCO2-20* Brief Hospital Course: Mr [**Known lastname **] was admitted to the Trauma SICU and followed for Q1 VS and Neurochecks. He was awake, alert and followed basic commands in English, repeat head CT showed stable blood in ventricles and bilateral subdural. He had an opthamology consult for Left Periorbital ecchymoisis have no compartment syndrome, no retrobulbar heme on CT they recommend follow up on discharge On HD#3 he was transferred to the surgical floor on his first few hours on the floor he became confused and agitated. A repeat CT showed no new blood and metabolic work up showed no sign of pneumonia but did have a UTI for which he was started on Levofloxin. A Geriatric consult was obtained and he was started on Zyprexa which did improve his agitation. His neurologic status waxed and waned and he would have periods of being wide awake at night and sleepy during the day. He had some difficulty with swallowing and had a video swallow. The recommendations were soft diet with thin liquids; single sips and crush meds. He developed fevers on [**7-5**] blood cultures are pending, his antibiotics were changed for aspiration pneumonia and entercoccus in his urine. Chest XRay were performed which did not show a pneumonia on [**7-7**] a repeat CXR showed no evidence of pneumonia. Pt to get 3 more days of ampicillin and 5 more days of flagyl for UTI/?aspiraation. Repeat head CTs showed resolution of blood. His C-Spine showed ? C5 loss of height an MRI was of poor quality but did not show any obvious new injuries his collar was cleared clinically. Pt was discharged to rehab on HD#7. Medications on Admission: Coumadin Plavix Diabeta Folic acid Ativan Diovan Advacor Toprol XL 200mg Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 2. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: [**1-12**] Injection TID (3 times a day). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Ampicillin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 6 days. 9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 10 days. Tablet(s) Discharge Disposition: Extended Care Facility: [**Location (un) 1036**] - [**Location (un) 620**] Discharge Diagnosis: Right sided Subdural Hematoma, Left IPH, and Left sided subdural hematoma UTI Aggitation/confusion Thrombocytopenia Discharge Condition: Neurologically stable Discharge Instructions: Return to ER if you develop headache, dizziness, neck pain, or sudden neurological problems Continue medication for UTI Supervision with ambulation Followup Instructions: Follow up with Dr [**Last Name (STitle) 548**] in 4 weeks with a head CT, call [**Telephone/Fax (1) 2992**] Completed by:[**2156-7-7**]

[ "287.5", "V58.61", "250.00", "401.9", "852.22", "790.92", "E826.1", "298.9", "599.0", "873.42" ]

icd9cm

[ [ [] ] ]

[ "38.91" ]

icd9pcs

[ [ [] ] ]

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1,714

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26898

Discharge summary

report

Admission Date: [**2125-2-22**] Discharge Date: [**2125-3-1**] Date of Birth: [**2102-9-25**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2145**] Chief Complaint: Code Sepsis Major Surgical or Invasive Procedure: Left IJ line A line History of Present Illness: 22yo F with no significant PMHx is transferred from [**Hospital 1474**] Hospital with sepsis. The pt was in her USOH until Tues when she started to develop some abdominal pain and n/v with ?diarrhea. She had several episodes of emesis that night with improvement in her abdominal pain and discomfort. The following day however she was found by her room mate to be lying in her bed covered in emesis. She was lethargic and was difficult to awaken and appeared confused. 911 was called and she was BIBA to [**Hospital 1474**] Hospital at 20:00. At [**Hospital1 1474**], the pt was found to be febrile to 103, tachycardic to 164 and hypotensive to 90/60 with RR of 24 and SaO2 of 96% on RA. She was A+O x1 and appeared lethargic/sedated. Her pulse was noted to be weak and thready and her skin was cool and dry. Her stool was described as green, malodorous and heme positive (sent for cultures). Her serum and urine tox screen was neg, she had a WBC count of 16.1 with 53% bands, her Hct was 45, Plt was 154 and lactic acid was 4.4. She was noted to be coagulopathic with INR of 1.8, Fibriongen was 442 (nml 150-400) and D-dimer was 8400 (nml 0-499). Her BUN and Cr was 34 and 2.7 with Ca of 7.8, gap was 19 with Gluc of 93. UA was significant for [**5-2**] WBC, moderate bacteria, moderate Lueks and neg Nitrite with rare coarse granular casts and HCG was neg. She was given Toradol 30mg IV x1 for pain and n/v. A Head CT was found to be wnl. An LP was planned but due to coagulopathy was deferred. Instead the pt was given Vanc/Ceftriaxone at 21:00. [**Last Name (un) **] also received 6L of NS for BP support. The pt was intubated at the OSH for airway protection due to lethargy prior to transfer to [**Hospital1 18**] -> ABG: 7.2/30/620. Just prior to leaving, the pt also received Zosyn 3.375g IV x1, Acyclovir 1g IV x1 as well as D5+150mEq of Bicarb at 100cc/hour and was transferred with levophed (pt did not require any but was sent with pressors in case she became hypotensive). . Of note, a pelvic exam was performed at the OSH and a tampon was removed as per verbal report. The tampon was not described as particularly gross, bloody or mal-odorous. Pelvic exam was otherwise wnl without significant discharge. As per the mother, the pt recently had her period over the weekend. At [**Hospital1 18**] ED from verbal report, there was no evidence of discharge or vaginal bleeding on pelvic exam. Of note, her room mate also had GI sx one day prior to development of her sx but is other well. Her mother denied any recent travel hx, any change in diet, or any other sick contact aside from room mate. . In the [**Hospital1 18**] ED, the pt was afebrile to 98.1, tachycardic to 129, and was normotensive at 143/76 and SaO2 was 100% on vent. A code sepsis was called. A Left IJ was placed in ED under sterile conditions. A CXR demonstrated acceptable positioning of ETT and IJ line placement. Some evidence of pulmonary edema was evident but n obvious pleural effusions or infiltrates. A non-contrast (no PO or IV contrast) CT Abd was performed as was a bedside RUQ US. Neither study demonstrated any significant findings. The pt was given 1L of D5W with 3amps of Bicarb, 1L of NS as well as two units of FFP and Mg. The pt produced approximately 400cc of urine during her ED stay. Pt was seen by surgery who agreed with cont. resuscitation and recommended repeat Abd/Pelvic CT once ARF is resolved. . The pt was transferred to the [**Hospital1 18**] MICU directly from the ED. Past Medical History: None Social History: The pt is a senior at [**Location (un) 1475**] College. She also student teaches at [**Location (un) 1475**] HS. She lives with her room mate in [**Location 8391**]. Tob: denies EtOH: social Illicit drugs: mother denies Family History: Mother: Similar episode of sepsis/?toxic shock 6 years ago at [**Hospital 1263**] Hospital; thought to be due to toxic shock syndrome but no clear dx was given. At the time, she also had GI sx and facial flushing as well. Father: CVA at age 40s with residual motor weakness Sister: A+W Brother: A+W Physical Exam: VS: Tc: 98.7, HR: 124, BP: 128/56, RR: 18, SaO2: 100% on Vent FiO2: 100% GEN: intubated, not sedated but not following commands initially, later following commands, NAD HEENT: PERRL, anicteric CV: RRR, S1, S2, no m/r/g Chest: CTA bilaterally, anteriorly and laterally Abd: soft, NT, ND, BS+ bilaterally Ext: cool, slightly erythematous - especially flushed face and LE, but no obvious rashes, no petechiae, no splinter hemorrhages. Neuro: unable to assess Pertinent Results: STUDIES: Significant labs at OSH: WBC: 16.1 with 53% Bands Hct: 45 Plt: 154 Lactic Acid: 4.4 . INR: 1.8 Fibriongen: 442 (nml 150-400) D-dimer 8400 (0-499) . BUN: 34 Cr: 2.7 Ca: 7.5 Gap: 19 . UA: [**5-2**] WBC, mod Bacteria, mod Leuk, Neg Nitrite, rare coarse granular casts. HCG: Neg . TB: 3.8 Direct bili: 2 Alk Phos: 53 AST: 121 ALT: 86 LDH: 396 . Serum tox: Salicylate <2, Acetaminophen <10, Ethyl Alc <10 Urine tox: Opiate, Cocaine, Amphetamine, Cannabinoid, Barbituates: neg . . STUDIES AT [**Hospital1 18**]: ECG [**2125-2-22**]: ST at 120s, nml axis, nml intervals, low voltage in limb leads, no acute ST or T wave abnormalities. CXR [**2125-2-22**]: There has been placement of a left IJ central venous catheter with the distal tip at the caval atrial junction. The endotracheal tube is at the level of the aortic knob. The sideport and tip of the nasogastric tube is below the gastroesophageal junction. Cardiac silhouette and mediastinum is normal. There is prominence of the pulmonary vascular markings, suggestive of mild pulmonary edema. There are no signs of focal consolidation or pleural effusions. Abd and Pelvic CT [**2125-2-22**]: 1. Peripancreatic fluid suggesting pancreatitis. Small amount of ascites. . CT abd and pelvis [**2125-2-24**]: 1. Small amount of intrahepatic free fluid; amount of peripancreatic free fluid has decreased since the last examination. 2. Bilateral moderate pleural effusions and associated compressive atelectasis. 3. Anasarca. 4. No discrete fluid collections to suggest intra-abdominal or intrapelvic abscess. 5. Fatty liver. 2. Duodenal edema possibly representing duodenitis or other primary process (i.e. ulcer), however, this exam is limited by lack of oral and IV contrast. The presence of free fluid in the abdomen could also explain this finding. RUQ US [**2125-2-22**] (wet read): diffuse GB wall edmea (most likely due to fluid), no sludge, no stones, no dilated CBD, no pericholecystic fluid Brief Hospital Course: 22yo F with no significant PMHx who presents with code sepsis secondary to toxic shock syndrome . . # Sepsis/SIRS: The pt has severe SIRS with elevated WBC with bandemia, tachycardia and what appears to be multi-organ failure suggesting severe SIRS. The source of the inflammatory reaction was felt most likely to be toxic shock from tampon use given MSSA on vaginal culture and patient being unsure of how long her tampon was in place. Patient was initially briefly on pressors and aggressively resuscitated with 9-10 liters of isotonic saline. OB/GYN and ID consults were obtained and the patient was started in broad spectrum antibiotics. ID consult recommended oxacillin and clindamycin for toxin. All cultures done at [**Hospital1 1474**] were negative and with the exception of the above mentioned and all cultures while at [**Hospital1 18**] were also negative with the exception of the vaginal culture which grew MSSA. Patient was transferred to the floor where she was tolerating good PO and was cleared by PT to return home and autodiuresed from her agressive fluid resuscitation. At discharge she was advised to not use tampons in the future and was discharged with a 14 day course of dicloxacillin and follow up in infectious disease clinic. At discharge toxin assay sent to the CDC is pending as is MRSA rectal swab screen. # Coagulopathy: Most likely due to low grade DIC from sepsis. Toxic shock syndrome can also cause thrombocytopenia. Lack of schistocytes on smear argues against TTP/HUS. Fibrinogen normalized and patient had no signs of bleeding. . # Pancreatitis: Initial CT scan showed peripancreatic fluid, but initial amylase and lipase were WNL. Follow up CT showed improvement of fluid and it was felt likely was secondary to aggressive fluid resuscitation. A GI consult was obtained. Amylase and lipase continued to trend down and her diet was advanced. . # Elevated LFT's: This was felt likely to be secondary to toxic shock syndrome which can cause hepatic dysfunction versus sepsis/hypotension leading to shock liver. LFTs trended down as her clinical status improved. Medications on Admission: MEDICATIONS: 1. Previfin (monophasic OCP) . ALLERGIES: NKDA Discharge Disposition: Home Discharge Diagnosis: 1. Toxic shock syndrome 2. Sepsis 3. Pancreatitis 4. Transaminitis 5. Renal failure Discharge Condition: Hemodynamically stable, afebrile, tolerating PO Discharge Instructions: You were admitted to the hospital with toxic shock syndrome likely secondary to an infection from a tampon. You should NOT use tampons in the future. If you have any fevers, chills, nausea, vomitting, abdominal pain, diarrhea or any other concerning symptoms, call your doctor or come to the emergency room. Please finish your entire course of antibiotics. Please keep all of your follow appointments. Followup Instructions: You should follow up with your primary doctor in [**12-25**] weeks. You have a follow up appointment with the Infectious disease clinic with DR. [**First Name (STitle) **] TAN Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2125-3-23**] 9:00. If you cannot keep this appointment, please call to reschedule. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]

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icd9cm

[ [ [] ] ]

[ "96.71", "96.04", "38.93" ]

icd9pcs

[ [ [] ] ]

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12,177

155,250

8710

Discharge summary

report

Admission Date: [**2185-2-1**] Discharge Date: [**2185-2-21**] Date of Birth: [**2134-1-28**] Sex: M Service: MEDICINE Allergies: Zosyn Attending:[**First Name3 (LF) 2145**] Chief Complaint: Resp distress Major Surgical or Invasive Procedure: Intubation Central line Arterial line History of Present Illness: 51 yo M with h/o EtOH and s/p R lobectomy transferred from OSH intubated for respiratory distress and L PNA. In [**Name (NI) **] pt's BP dropped, he was tachycardic (SVT) and cardioversion was attempted x 1 w/o success. An amiodarone gtt was started. . Per report from pt's sister, pt lived in a crack house and has poor contact w/ the rest of the family. On the day of admission, pt's house burned down and he went to live w/ a friend. The friend became concerned about pt's persistent productive cough. He denied of any other c/o at that time. The friend brought him to [**Name (NI) 16843**] Hosp for evaluation. Of note, he has been drinking alcohol daily ? [**2-5**] drink /day. . He was tranferred to the MICU where he was mainatined on a ventilator and on pressors, started on vanco/zosyn/azithro for PNA, had NSTEMI in the setting of sepsis with peak trop 0.14 and had ECHO which revealed EF 20% thought to be [**1-6**] sepsis, started on ACE-I and ASA holding BB as HR could not tolerate,treated for alcohol withdrawl on CIWA, was thrombocytopenic with negative HIt Ab thought to be [**1-6**] sepsis v ETOH. On [**2-7**] he was extubated, O2 sats 93-96% on 4 L NC, BPs in 120's-140's/50'-80s and was felt stable to tranfer to the floor. On arrival to the floor, patient reported feeling tired, but otherwise denied CP, SOB, HA, dysuria, palpitations. Past Medical History: 1. EtOH abuse- reports drinking about [**12-9**] vodka per day up to time of admission. reports previous hospitalization for ETOH withdrawal. Unsure if he has ever had a seizure. 2.s/p R lobectomy 3. s/p colostomy and urostomy which were revised Social History: active drinker, lived in crack house (per sister report), socially isolated from family. Family very interested in helping him stop drinking. SW involved during this admission. Family History: Non-contributory Physical Exam: Gen: Intubated, sedated HEENT: NC/AT, Pinpoint pupils, OP clear, nares clear Neck: Supple, no LAD CV: s1s2 tachy Resp: coarse crackles over LLL, otherwise good air mvmt Abd: soft, NT/ND Ext: cool, no edema, no burns on transfer to the floor PE: Vitals:`T 98.2 BP 120/62 HR 70 R 20 93 % on 2 L NC. Gen: Middle aged male. lying in bed, comfortable, resting, breathing with NC with no accessory muscle use HEENT: NC/AT, PERRL, OP clear, nares clear Neck: Supple, no LAD CV: RRR, nl S1, S2 Resp: coarse crackles over LLL, decreased BS on right Abd: soft, NT/ND Ext: no edema, no calf tenderness Pertinent Results: [**2185-2-1**] 11:36PM TYPE-ART PO2-115* PCO2-34* PH-7.42 TOTAL CO2-23 BASE XS--1 [**2185-2-1**] 11:36PM LACTATE-2.4* [**2185-2-1**] 08:10PM TYPE-ART PO2-140* PCO2-43 PH-7.35 TOTAL CO2-25 BASE XS--1 [**2185-2-1**] 08:10PM GLUCOSE-131* LACTATE-2.8* K+-4.3 [**2185-2-1**] 08:10PM HGB-12.4* calcHCT-37 O2 SAT-99 [**2185-2-1**] 08:10PM freeCa-1.18 [**2185-2-1**] 07:52PM PT-15.3* PTT-30.2 INR(PT)-1.4* [**2185-2-1**] 04:48PM TYPE-ART PO2-82* PCO2-45 PH-7.32* TOTAL CO2-24 BASE XS--3 [**2185-2-1**] 03:52PM TYPE-ART PO2-90 PCO2-52* PH-7.28* TOTAL CO2-25 BASE XS--2 [**2185-2-1**] 03:52PM GLUCOSE-184* LACTATE-2.9* K+-4.8 [**2185-2-1**] 03:52PM freeCa-1.14 [**2185-2-1**] 02:44PM TYPE-ART PO2-77* PCO2-44 PH-7.25* TOTAL CO2-20* BASE XS--7 [**2185-2-1**] 01:41PM CK(CPK)-52 [**2185-2-1**] 01:41PM CK-MB-NotDone cTropnT-0.09* [**2185-2-1**] 01:41PM CALCIUM-6.9* PHOSPHATE-2.9 MAGNESIUM-2.3 [**2185-2-1**] 01:41PM WBC-8.6 RBC-3.76* HGB-13.0* HCT-37.6* MCV-100* MCH-34.5* MCHC-34.5 RDW-14.2 [**2185-2-1**] 01:41PM PLT COUNT-62* [**2185-2-1**] 01:21PM TYPE-ART PO2-86 PCO2-38 PH-7.23* TOTAL CO2-17* BASE XS--10 [**2185-2-1**] 01:21PM LACTATE-3.4* [**2185-2-1**] 12:02PM TYPE-ART PO2-79* PCO2-47* PH-7.17* TOTAL CO2-18* BASE XS--11 [**2185-2-1**] 12:02PM GLUCOSE-211* LACTATE-3.0* K+-5.2 [**2185-2-1**] 12:02PM freeCa-1.12 [**2185-2-1**] 09:49AM TYPE-ART PO2-80* PCO2-68* PH-6.98* TOTAL CO2-17* BASE XS--17 [**2185-2-1**] 09:49AM LACTATE-3.6* [**2185-2-1**] 09:49AM freeCa-1.11* [**2185-2-1**] 09:41AM GLUCOSE-165* UREA N-17 CREAT-0.6 SODIUM-137 POTASSIUM-5.1 CHLORIDE-114* TOTAL CO2-16* ANION GAP-12 [**2185-2-1**] 09:41AM CALCIUM-6.4* PHOSPHATE-4.2 MAGNESIUM-2.5 [**2185-2-1**] 09:41AM WBC-10.2 RBC-3.64* HGB-12.4* HCT-38.0* MCV-104* MCH-33.9* MCHC-32.6 RDW-14.0 [**2185-2-1**] 09:41AM PLT COUNT-70* [**2185-2-1**] 08:16AM TYPE-ART PO2-120* PCO2-58* PH-7.05* TOTAL CO2-17* BASE XS--15 [**2185-2-1**] 04:59AM ALT(SGPT)-26 AST(SGOT)-86* CK(CPK)-91 ALK PHOS-69 AMYLASE-29 TOT BILI-1.2 [**2185-2-1**] 04:59AM LIPASE-24 [**2185-2-1**] 04:59AM cTropnT-0.14* [**2185-2-1**] 04:59AM ALBUMIN-2.5* CALCIUM-6.5* PHOSPHATE-4.2 MAGNESIUM-1.4* [**2185-2-1**] 04:59AM CORTISOL-16.7 [**2185-2-1**] 04:59AM HBsAg-POSITIVE HBs Ab-NEGATIVE HBc Ab-POSITIVE [**2185-2-1**] 04:59AM HCV Ab-POSITIVE [**2185-2-1**] 04:59AM WBC-13.34*# RBC-4.26* HGB-14.3 HCT-43.8 MCV-103* MCH-33.7* MCHC-32.7 RDW-14.1 [**2185-2-1**] 04:59AM NEUTS-44* BANDS-24* LYMPHS-6* MONOS-4 EOS-0 BASOS-0 ATYPS-8* METAS-12* MYELOS-2* [**2185-2-1**] 04:59AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-1+ STIPPLED-1+ TEARDROP-1+ PAPPENHEI-1+ [**2185-2-1**] 04:57AM URINE COLOR-[**Location (un) **] APPEAR-Clear SP [**Last Name (un) 155**]->=1.035 [**2185-2-1**] 04:57AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2185-2-1**] 04:57AM URINE RBC-[**10-24**]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 [**2185-2-1**] 03:35AM TYPE-ART PO2-90 PCO2-51* PH-7.11* TOTAL CO2-17* BASE XS--13 [**2185-2-1**] 02:22AM TYPE-ART TEMP-37.3 RATES-/14 TIDAL VOL-500 PEEP-10 O2-100 PO2-88 PCO2-64* PH-7.09* TOTAL CO2-21 BASE XS--11 AADO2-575 REQ O2-93 -ASSIST/CON INTUBATED-INTUBATED [**2185-2-1**] 01:38AM TYPE-ART TEMP-37.3 RATES-14/ TIDAL VOL-800 PEEP-10 PO2-72* PCO2-31* PH-7.04* TOTAL CO2-9* BASE XS--21 -ASSIST/CON INTUBATED-INTUBATED [**2185-2-1**] 01:38AM O2 SAT-89 CARBOXYHB-1 MET HGB-1 [**2185-2-1**] 01:24AM GLUCOSE-129* LACTATE-3.1* NA+-137 K+-4.4 CL--104 TCO2-21 [**2185-2-1**] 01:15AM UREA N-17 CREAT-0.7 [**2185-2-1**] 01:15AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2185-2-1**] 01:15AM URINE HOURS-RANDOM [**2185-2-1**] 01:15AM URINE HOURS-RANDOM [**2185-2-1**] 01:15AM URINE GR HOLD-HOLD [**2185-2-1**] 01:15AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2185-2-1**] 01:15AM PT-15.3* PTT-30.8 INR(PT)-1.4* [**2185-2-1**] 01:15AM FIBRINOGE-345 [**2185-2-1**] 01:15AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019 [**2185-2-1**] 01:15AM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2185-2-1**] 01:15AM URINE RBC-[**2-6**]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 . Microbiology: Blood cultures: No growth Urine cultures: No growth Urine legionella: negative Pleural fluid: negative gram stain and no growth on culture, AFB smear negative Bronchial washings: no growth on culture, AFB smear negative, gram stain negative Pleural tissue: gram stain negative, culture negative . Imaging: [**2185-2-1**]: Abdominal U/S: 1. Edematous thickened gallbladder wall, which can be seen in hepatitis and edematous states, such as heart failure and hypoproteinemia.2. Hyperechoic hepatic echotexture, consistent with fatty infiltration.3. Right pleural effusion. Also, trace ascites and left perinephric fluid . [**2-1**]: CT chest: 1. Extensive consolidation of left lower lobe and partial consolidation of left upper lobe, with minimal left pleural effusion. 2. Right lung tree-in-[**Male First Name (un) 239**] opacities and small right pleural effusion. This represents pneumonia versus aspiration pneumonia. 3. Filling defects vs motion artifact in right pulmonary circulation. This was not an angiographic CT, so if pulmonary embolism is a concern, chest CTA is recommended. 4. Fatty liver. 5. Small amount of free fluid around pancreas. Clinical correlation is recommended. If indicated, abdominal CT can further characterize this finding. 6. Healed rib fractures. . [**2-1**] Echocardiogram: MEASUREMENTS: Left Atrium - Long Axis Dimension: *4.8 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 4.5 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 3.6 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 0.9 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: *5.8 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 20% (nl >=55%) Aorta - Valve Level: 3.5 cm (nl <= 3.6 cm) Aortic Valve - Peak Velocity: 1.0 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.5 m/sec Mitral Valve - A Wave: 0.5 m/sec Mitral Valve - E/A Ratio: 1.00 Mitral Valve - E Wave Deceleration Time: 138 msec TR Gradient (+ RA = PASP): 22 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Mildly dilated LV cavity. Severe global LV hypokinesis. Severely depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size. AORTA: Normal aortic root diameter. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Mild [1+] TR. PERICARDIUM: No pericardial effusion. Conclusions: 1. The left atrium is mildly dilated. 2. The left ventricular cavity is mildly dilated. There is severe global left ventricular hypokinesis with some preservation of basal posterior and basal lateral wall motion. Overall left ventricular systolic function is severely depressed. . [**2185-2-8**] Echocardiogram: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2185-2-1**], biventricular systolic function is now normal. . [**2-10**]: CT abdomen and pelvis: IMPRESSION: 1. No focal abnormality is noted in the left abdomen or pelvis to explain the patient's pain. 2. Fluid in the colon consistent with diarrhea but no colon wall thickening is present. 3. Large bilateral pleural effusions, decrease in the consolidation in left lower lobe. Pathology: Pleural fluid cytology showed no malignanct cells Pleural tissue: 1. Granulation tissue, acute and chronic inflammation, organizing hemorrhage and fibrino-purulent exudate. 2. No evidence of malignancy. [**2-17**]: Abdominal u/s: 1. Increased echogenicity of the liver is again noted most consistent with fatty infiltration. Other processes such as fibrosis or cirrhosis cannot be excluded on ultrasound. 2. Incomplete evaluation of the gallbladder secondary to the patient's ingestion of a meal prior to scanning. The gallbladder is contracted and no stones are seen. The mild dilatation of the common bile duct may be secondary to post- prandial increased flow of bile. Brief Hospital Course: 51 yo M with h/o ETOH abuse with PNA and sepsis originally intubated for respiratory failure, s/p extubation on [**2-7**], with stable O2 sats and BPs, with large complicated parapneumonic effusion s/p thoracentesis x2 with residual moderate sized effusion followed by VATS on [**2-14**] with improved pain, JP drain placed, fever resolved on PO levofloxacin and Flagyl with new acute renal failure CRE 1.9 thought to be AIN, but no casts in urine improving after d/c'ing Zosyn # Resp Distress/Sepsis/MICU course: Pt was intubated for hypoxic respiratory distress at the outside hospital. This was thought to be [**1-6**] PNA/ARDS and cardiogenic shock. His CT chest showed LLL PNA and no effusion. He had an ECHO that showed global hypokinesis EF 20% likely in the setting of septic shock. Initially, he needed to be on vecuronium for paralytic as pt was desynchronous w/ the vent, but this was stopped on [**2-2**] as pt did not require it. His oxygenation and ventilation improved from [**Date range (1) 30498**] and maintain on AC w/ low tidal volume ARDS ventilation strategy. He was initially hypotensive, but was fluid resuscitated,and briefly started on Levophed gtt. He was weaned off Levophed on [**2-2**]. He also failed [**Last Name (un) 104**] stim and was started on hydro/fludro replacement on [**2-2**]. He was continued on his broad spectrum ABX, was extubated on [**2-7**] and was transferred to the floor. . # PNA: On admission, sputum showed rare OP flora and his urine legionella was negative. He was started on vanco/Zosyn and azithromycin. All blood cultures remained negative. On transfer to the floor he was maintained on these antibiotics and then was subsequently changed to levofloxacin and Flagyl. He then developed abdominal pain. A CT abdomen was unremarkable, but CXR revealed a large pleural effusion. A thoracentesis was performed and revealed a complicated parapneumonic effusion. He was restarted on Zosyn and continued on Flagyl. He had another thoracentesis as there was still residual effusion and eventually a thoracic surgery consult was obtained and performed a VATS and 2 JP drains were placed. Throughout this time he had only low grade temperatures and was hemodynamically stable. All cultures were negative. His abdominal pain improved after his thoracentesis and was felt to be a referred pain as it was the whole left side of his abdomen and C. Diff was negative x 2. His JP drains were removed and he remained afebrile on levofloxacin and Flagyl. He was discharged on 7 further days of antibiotics to complete a total of a 4 week course. # Cardiogenic shock: He had poor extremity perfusion and poor EF on TTE w/ global hypokinesis on [**2-2**] (admission). There was no indication for dobutamine and IABP as pt improved greatly from [**Date range (1) 30498**] w/ serial fluid boluses. He had elevated CK MB and trop on [**2-2**] w/ persistent ischemic changes on EKG. It was decided to medically manage now w/ maintaining BP and started ASA. No need to do urgent cardiology consult as this likely to represent NSTEMI in setting of septic shock. His echocardiogram was repeated on [**2-8**] which revealed a normal ejection fraction and therefore it was felt that all of his hypokinesis and ischemic changes were in the setting of septic shock. . # h/o EtOH:He started to show signs of withdrawal on [**2-4**]. He required large amounts of Valium additionally for sedation/agitation, so he was switched to propofol gtt( [**2-4**]), and versed gtt was stopped per hypotension. He was maintained on propofol gtt until his extubation on [**2-6**]. He was then changed to Ativan prn CIWA>10, q2 hrs. He some signs of alcohol withdrawal but he was able to maintain calm on [**2-9**]. He was also given thiamine and folate. He had no further signs of alcohol withdrawal on transfer to the floor. A social work and addictions consult was obtained. Initially he wanted to pursue an inpatient detox program, but later in the hospitalization, he decided that he would rather do an outpatient program. He was provided with all of the information for outpatient follow up. . # Renal failure: Patient developed a sudden increase in his creatinine. He had no other electrolyte abnormalities and continued to make urine. His renal failure was felt to be secondary to AIN most likely from Zosyn given that he was restarted on this a few days prior to development of his renal failure. His antibiotics were changed to levofloxacin and Flagyl. He had a few eosinophils in urine but no casts. Also stopped ASA as could be another possible [**Doctor Last Name 360**], but much less likely. Creatinine trended down from a peak of 1.9 to 1.5 at discharge. He will have his labs checked as an outpatient to ensure his creatinine continues to improve. . # Rash: Patient has a rash on his scalp and face. He reported using the cal-stat soap on his face which exacerbated his symptoms. This was felt to be seborrheic dermatitis and Triamcinolone cream to affected area [**Hospital1 **] and selenium shampoo was administered with good improvement. . # Hepatitis: Patient had a transient elevation of LFTs while in the ICU likely secondary to shock liver in the setting of sepsis. His LFTs trended down to normal range as he improved clinically. RUQ ultrasound revealed increased echogenicity of the liver consistent with fatty liver. Though he did not have symptoms of hepatitis hepatitis B serologies were sent in the ICU. These show negative Hep B surface antibody, positive surface antigen, positive core antibody. The issue of possible chronic hepatitis B infection has not yet been addressed with him, and should be discussed as an outpatient. His PCP has been informed of this by written letter. . # Code: Full Medications on Admission: None Discharge Medications: 1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 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. Triamcinolone Acetonide 0.025 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for dermatitis. Disp:*qs * Refills:*0* 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed: Do not exceed 4 g per day. 6. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days. Disp:*21 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Sepsis 2. Pneumonia 3. Complicated parapneumonic effusion s/p VATS 4. Acute renal failure Secondary: 1. Alcohol abuse Discharge Condition: Hemodynamically stable, afebrile, stable renal function, satting well on RA. Discharge Instructions: You were admitted to the hospital with a severe pneumonia and pleural effusion. If you have shortness of breath, fevers, chills, chest pain, swelling in your legs or any other concerning symptoms call your doctor or come to the emergency room. . Please take all of your medications as directed. . Please keep all of our follow up appointments. Followup Instructions: Please make a follow up appointment with Dr. [**Last Name (STitle) 1159**] [**Telephone/Fax (1) 20587**] in the next week. You will need to have blood drawn to follow you kidney function. You have a follow-up thoracic surgery appointment with Dr. [**First Name (STitle) 1532**] [**Name (STitle) 1533**], MD Phone:[**0-0-**] Date/Time: Tuesday, [**2185-3-1**] 3:30 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]

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Discharge summary

report

Admission Date: [**2102-8-9**] Discharge Date: [**2102-8-18**] Date of Birth: [**2038-2-24**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1990**] Chief Complaint: rash, hypotension Major Surgical or Invasive Procedure: -central line placement -arterial line placement History of Present Illness: This is a 64 year old female with a history of pustular psoriasis and hypertension who presents with hypotension. She was in her usual state of health until 2-3 weeks ago when she began to note a rash consistent with her psoriasis throughout her body sparing her face. She was seen by her PCP who gave her what appears to be a 2 week course of prednisone, completed 1 week ago. Her rash was accompanied by nausea and vomitting. She also felt chills and subjective fevers and began to have worsening lightheadedness and SOB on exertion. She notes that this is consistent with her prior flare of pustular psoriasis that led to a hospitalization in [**2101-12-12**]. She was seen first at an OSH where she was noted to have SBP 60s and was given 4 L NS and started on levophed and RIJ placed. She was also given hydrocortisone 50 mg IV x 1, vancomycin and zosyn. At [**Hospital1 18**] ED her vitals were 98.8 (Tmax 100.3), 113/53, HR 96, RR 18, 96% 2L. She was seen by dermatology who performed a skin biopsy and she was transferred to the [**Hospital Unit Name 153**]. On the floor, she reports [**4-21**] pain along her rash, improved from before and mild nausea. Review of sytems: (+) Per HPI (-) Denied chest pain or tightness, palpitations. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Hypertension Pustular psoriasis- was on soriatane until 3 months ago. Social History: Lives with husband in [**Name (NI) **]. Works as a business office manager at a surgery clinic. Denies ETOH or tobacco. Family History: Father with psoriasis Physical Exam: ADMISSION: Vitals: T: 97.7 BP:111/60 P: 96 R: 19 O2: 97% 3L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD, RIJ site c/d/i Lungs: Bibasilar crackles, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Diffuse erythemaous scaly plaques sparing palms, soles and face Pertinent Results: **FINAL REPORT [**2102-8-13**]* URINE CULTURE (Final [**2102-8-13**]): KLEBSIELLA PNEUMONIAE AMPICILLIN/SULBACTAM-- 8 S 4 S CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CEFUROXIME------------ <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- <=16 S <=16 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S BLOOD CULTURES: NGTD DISCHARGE LABS: - CBC: WBC-6.4 RBC-3.18* Hgb-9.4* Hct-29.0* MCV-91 MCH-29.6 MCHC-32.5 RDW-16.5* Plt Ct-391 - CHEM 7: Glucose-128* UreaN-30* Creat-1.7* Na-142 K-4.0 Cl-107 HCO3-25 Calcium-8.7 Phos-4.5 Mg-2.0 UricAcd-8.5* - IRON STUDIES: calTIBC-230* Ferritn-509* TRF-177* IMAGING: RENAL U/S: The right kidney measures 9.2 cm and the left kidney measures 9.9 cm. There is no hydronephrosis, mass or calculus seen in either kidney. There is a 1.8 x 1.8 x 1.5 cm simple cyst arising from the interpolar region of the right kidney. The urinary bladder is well distended and is unremarkable. IMPRESSION: No evidence of hydronephrosis ECHOCARDIOGRAM: The left atrium is mildly dilated. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. There is an anterior space which most likely represents a fat pad. IMPRESSION: Normal biventricular regional and global systolic function. Mild aortic regurgitation. Mild mitral regurgitation. Moderate pulmonary artery systolic hypertension. No vegetation identified. PATHOLOGY: Skin, right upper arm (A): Subcorneal pustule formation with adjacent spongiotic epidermal hyperplasia and numerous intraepidermal and superficial dermal neutrophils (see note). Note: Scattered Gram positive cocci are noted within the superficial stratum corneum; otherwise, no micro-organisms are identified in GMS, PAS, and Gram-stained sections. In conjunction with the clinical history, the histologic findings are most consistent with pustular psoriasis with impetiginization; however, a pustular drug eruption / acute generalized exanthematous pustulosis cannot be entirely excluded. Case reviewed by Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **], who concurs with this interpretation Brief Hospital Course: 64 yo female with a history of pustular psoriasis transferred from OSH with cutaneous eruptions, MSSA bacteremia, septic shock. # Septic shock: Pressures initially maintained on Levophed, with agressive IVF support (TBB +21L in ICU). Also received Vancomycin/Zosyn. She was weaned off pressors within 48h. OSH Bld Cx noted to grow MSSA (see below) and patient was started on Nafcillin. Urine culture with two different Klebsiella species (see below) and patient was started in Ciprofloxacin. OSH central line was discontinued, and all blood and tip cultures during hospitalization at [**Hospital1 18**] were negative. After pressors were weaned in the ICU, patient remained normotensive with no episodes of hypotension during the hospitalization. # Acute eruption of Pustular psoriasis: Evaluated by dermatology with biopsy. Clinical exam, history, and biopsy c/w flare of pustular psoriasis flare with MSSA superinfection. Psoriasis was on her extremities and torso, but spared her palms/soles/face. Notably, she had slurred speech, flushing and pruritic reaction post-Soriatane, which the patient says is normal for her. Patient was started on Soriatane 50 per derm with good effect and improvement of her psoriatic patches. SHe will be continued on this as an out patient and need q1-2 week LFT monitoring until LFT's are stable. Additionally, she should have her lipids checked in [**4-17**] weeks. She has also received benadryl prn for itching while on treatment. Patient also started on Prednisone 10mg ([**8-10**]) per Dermatology, which was tapered to 5mg and then discontinued ([**8-14**]). Wound care, per Dermatology, included Clobetasol, Muporicin, and initial Saran wrapping which were discontinued prior to discharge. Psoriatic lesions improved during hospitalization and remained stable for several days prior to discharge. #MSSA Bacteremia: OSH Bld Cx with MSSA. Patient started on Nafcillin 2g IV Q6H ([**8-12**]) with plan to complete 14d course ([**Date range (1) 96317**]). A TTE was performed and was negative for vegetation, with preserved systolic function. Following antibiotic initiation patient remained afebrile during hospitalization. #UTI: Urine culture with two distinct Klebsiella species (pan-sensitive). Patient completed 6d course of Ciprfloxacin 500mg po Q12H for complicated cystitis ([**Date range (1) 48068**]). Plan was initially for 7d course, but regimen was discontinued after 6d secondary to concern of potential Ciprofloxacin related AIN (see below, discontinuation per Renal). Of note, at time of discontinuation patient was afebrile x5d with no urinary symptoms. Concern for persistent infection was low. # Acute renal failure: Patient's Cr on admission 2.2 (unknown baseline) thought to be most likely [**2-13**] hypotension. Creatinine nadir of 1 during ICU stay and subsequently increased to peak of 2 in the setting of multiple medication exposures. Urine electrolytes were c/w ATN though the possibility of AIN could not be ruled out. Patient seen by Renal who felt AIN was a possibility, with potential agents including PPI, Ciprofloxacin, Nafcillin, Soriatane. Additionally, given modestly elevated serum uric acid level, and modestly elevated Urine Uric Acid/Cre ratio, the possibility of a psoriasis-related urate nephropathy was also considered. Of note, patient was initially noted to be oliguric during ICU course, though secondary phase of ARF was associated with adequate UOP. On discharge her Cre had decreased from 2 to 1.9 to 1.7. Given the reassuring Cre trend, the decision was made that she was safe for discharge with repeat serum chemistries to be drawn on [**2102-8-22**] and called to her physician's office. #Hypoxemia: On hospital day [**6-18**] patient complained of worsening dyspnea, with a stable O2 requirement of 1.5-2L. A CXR at the time showed potential interval development of a RML/RLL opacity. Consideration was given to HAP vs. fluid overload vs. psoriasis related ARDS/[**Doctor Last Name **]. Hypoxemia resolved with a single dose of Lasix. Patient remained afebrile, with no other si/sx of PNA and empiric coverage was not initiated. # Hypertension: Patient's home regimen (Diovan 30mg qd, HCTZ 12.5mg qd, Lasix 20mg qd) was held given initial hypotension. SBP during hospitalization ranged 120-140 and regimen was held given noted renal failure above. On discharge patients SBP continue to range between 120-140. Given the evolving nature of her ARF the decision was made to not restart her home regimen and defer consideration to PCP (PCP f/u made as below). #Anemia: Patient recieved 1U pRBC during ICU course for Hct 24 in the setting of mild chest pain (Hct 32 on admission; Hct nadir with likely dilutional component given agressive IVF in ICU of 22L and concomitant decrease of other cell lines at the time). An EKG at the time showed no e/o ischemia. Following transfusion, Hct was stably 28-30 without intervention. Iron studies were consistent with AOCD and a stool guiac was negative. #CODE: FULL Medications on Admission: 1. Diovan 30mg po qd 2. HCTZ 12.5 po qd 3. Lasix 20mg PRN (LE edema) Discharge Medications: 1. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for pruritis. 2. Nafcillin 2 gram Recon Soln Sig: Two (2) grams Intravenous every six (6) hours for 8 days: Last dose [**2102-8-26**]. Disp:*64 grams* Refills:*0* 3. 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. 4. Acitretin-Emollient No.26 25 mg Kit Sig: Fifty (50) mg Miscellaneous daily (): if dispensed in kit, please dispense adequate amount for 50mg qd for 30 days. Disp:*30 tabs* Refills:*2* 5. Outpatient Lab Work Please draw chem 7, and LFT's (ALT, AST, Alk phos and total bilirubin) on [**2102-8-22**]. Call results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 96318**] [**Telephone/Fax (1) 96319**] 6. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 3 days: Do not drive or drink alcohol while taking this medication. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Rockinghan VNA & Hospice Discharge Diagnosis: Pustular Psoriasism MSSA Bacteremia Klebsiella UTI Acute Renal Failure Hypoxemia Discharge Condition: Stable. Discharge Instructions: You were admitted to the hospital with a flare of pustular psoriasis as well as low blood pressure that required you to be in the ICU and were initially on medication to support your blood pressure. You also were found to have an infection of your bloodstream as well as your urine. You were started on appropriate and antibiotics for each infection. You have completed the treatment for the urine infection and will continue on treatment for the bloodstream infection at home. You were evaluated by Dermatology who recommended Soriatane for the treatment of your pustular psoriasis. During your hospitalization you were found to be in renal failure. You were evaluated by the Renal Service who felt the renal failure may have been due to one of the medications you were taking which was stopped. The renal failure may also have been secondary to your pustular psoriasis flare. Your renal function improved and it will be recheck on Monday and the results given to your PCP. The following medication changes were made: ADDED: Soriatane, for your psoriasis ADDED: Nafcillin - last dose [**2102-8-26**] for your bloodstream infection STOPPED: Diovan 30mg po qd - your PCP may restart STOPPED: HCTZ 12.5 po qd - your PCP may restart STOPPED: Lasix 20mg PRN (LE edema) - your PCP may restart These blood pressure medications were stopped because they can worsen renal failure and your blood pressure was well controlled while you were here. Your PCP may restart them when you see her next week. If you have heart burn, you can take Ranitidine (Zantac), please do not take Omeprazole as it could worsen your renal failure. Please return to the ED if you notice new or worsening skin lesions/eruptions, fevers/chills, worsening headache, shortness of breath, abdominal pain, diarrhea, difficult or painful urination, or anything that is concerning to you. It was a pleasure meeting you and participating in your care. Followup Instructions: Please follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 96318**] (appointment has been made for [**8-22**] at 3pm). You also have a appointment with Dr. [**First Name8 (NamePattern2) 8771**] [**Last Name (NamePattern1) 1557**] at the [**Hospital3 2358**] in Dermatology. If you would like to see a kidney doctor, you can reach the [**Hospital1 18**] division at ([**Telephone/Fax (1) 10135**].

[ "799.02", "785.52", "595.0", "038.11", "995.92", "584.5", "285.29", "401.9", "696.1" ]

icd9cm

[ [ [] ] ]

[ "38.93", "86.11" ]

icd9pcs

[ [ [] ] ]

12001, 12056

5813, 10822

332, 382

12181, 12191

2637, 3300

14162, 14610

1994, 2017

10942, 11978

12077, 12160

10848, 10919

12215, 14139

3316, 5790

2032, 2618

275, 294

1594, 1747

410, 1576

1769, 1841

1857, 1978

20,135

108,081

12802

Discharge summary

report

Admission Date: [**2173-8-26**] Discharge Date: [**2173-9-7**] Date of Birth: [**2101-7-17**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: chest pain. Major Surgical or Invasive Procedure: [**2173-8-30**] - CABG x 3(LIMA->LAD, SVG->OM, RCA) History of Present Illness: 72yoM with h/o CAD s/p recent stenting x 2 to LAD ([**2173-8-11**]), and recent admission to [**Hospital1 18**] (discharged [**2173-8-25**]) for intermittent chest/abdominal pain anorexia and fatigue, at which time he ruled out for MI (please refer to discharge summary for details of this admission). Hospital course was complicated by ARF (likely due to dehydration and medications), guaiac positive stool with hct drop (?gastritis - LFTs nl, abd u/s nl, endoscopy planned as outpatient). His antihypertensive regimen was optimized and he was switched to EC aspirin to prevent medication-related gastritis prior to discharge. A few hours after returning home, he ate some frozen pizza, then began to feel diaphoretic. Soon after that he began to have severe [**9-20**] chest pressure radiating to his jaw and the back of his neck. This was similar to anginal pain that he has had before, and if anything it was even more severe than the pain he had prior to his recent stents. He then presented the following day to an OSH with CP and SOB. He was found to be in rapid afib with rate in 140s. He was started on cardizem drip and given metoprolol 50mg [**Hospital1 **], heparin drip, aspirin, and plavix. He also received IV nitroglycerin for CP. He was not completely CP free until aruond 11pm when he had been on nitro gtt for some time. Troponin was 4.9 at the OSH. According to the discharge summary, the patient was in SR at the time of transfer. He was also started on levoquin for a UTI. Past Medical History: CAD, s/p stents and angioplasty GERD PUD Hyperlipidemia Hypertension Social History: lives with wife. Family History: +CAD in family. Physical Exam: VS: 98.5, 170/74, 58, 18, 96% on RA gen: NAD, resting comfortably CV: RRR, nl s1/s2, III/VI systolic murmur at LUSB. chest: CTA b/l, no crackles or wheezes abd: soft, NT/ND, +bs, no organomegaly, groin: cath site well healed. b/l 1+ femoral artery bruits. extr: warm, dry, no c/c/e, 2+ radial and DP pulses b/l neuro: a&ox3, grossly non-focal Pertinent Results: [**2173-8-30**] 05:40AM BLOOD WBC-11.2* RBC-3.43* Hgb-10.2* Hct-30.6* MCV-89 MCH-29.8 MCHC-33.4 RDW-14.2 Plt Ct-457* [**2173-8-27**] 05:40AM BLOOD Neuts-63.5 Lymphs-23.5 Monos-5.5 Eos-7.2* Baso-0.3 [**2173-8-30**] 05:40AM BLOOD Plt Ct-457* [**2173-8-30**] 05:40AM BLOOD PT-13.6* INR(PT)-1.2 [**2173-8-30**] 05:40AM BLOOD Glucose-94 UreaN-41* Creat-2.4* Na-140 K-4.1 Cl-105 HCO3-26 AnGap-13 [**2173-8-30**] 05:40AM BLOOD ALT-33 AST-20 LD(LDH)-157 AlkPhos-115 TotBili-0.5 [**2173-8-28**] 07:07AM BLOOD CK-MB-NotDone cTropnT-0.18* [**2173-8-27**] 10:45AM BLOOD CK-MB-NotDone cTropnT-0.14* [**2173-8-26**] 09:30PM BLOOD CK-MB-NotDone cTropnT-0.17* [**2173-8-30**] 05:40AM BLOOD Albumin-3.2* [**2173-8-29**] 06:32AM BLOOD Calcium-9.3 Phos-4.0 Mg-1.8 . CXR: The heart, mediastinal and hilar contours are within normal limits. Minimal blunting of the left costophrenic angle is noted posteriorly. The lungs are clear without focal areas of consolidation. The osseous structures are within normal limits with the previously noted prominence of the left anterior 7th rib no longer evident. IMPRESSION: No evidence of CHF or pneumonia. . Coronary Angiogram (OSH, [**2173-8-11**]): severe 3VD; drug eluting stent to 90% ramus lesion, 100% proximal RCA lesion, 60% proximal LAD lesion; collateral filling of R PDA and PLB. [**2173-9-7**] 06:05AM BLOOD WBC-16.1* RBC-3.86* Hgb-11.6* Hct-34.6* MCV-90 MCH-30.0 MCHC-33.4 RDW-15.5 Plt Ct-629* [**2173-9-7**] 06:05AM BLOOD Plt Ct-629* [**2173-9-6**] 05:00PM BLOOD Glucose-158* UreaN-50* Creat-2.7* Na-139 K-4.6 Cl-102 HCO3-27 AnGap-15 [**2173-9-2**] 02:00AM BLOOD ALT-42* AST-36 LD(LDH)-310* AlkPhos-92 [**2173-9-2**] Renal Ultrasound The right kidney measures 10 cm, with normal echogenicity, without evidence of mass, stones, or hydronephrosis. The left kidney measures 8.5 cm, and appears to be atrophic. Foley catheter is noted. [**2173-9-1**] Right upper quadrant Ultrasound Normal son[**Name (NI) 493**] appearance of the gallbladder [**2173-8-30**] EKG Sinus rhythm with borderline short PR interval but with out evidence of ventricular pre-excitation Otherwise normal ECG Since previous tracing of [**2173-8-29**], probably no significant change Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2173-8-26**] for further management of his chest pain and rapid atrial fibrillation. Diltiazem and beta blockade was used with good rate control. Heparin was started for anticoagulation in addition to his current plavix and aspirin use. Given his known severe coronary artery disease, the cardiac surgical service was consulted for surgical revascularization. Mr. [**Known lastname **] was worked-up in the usual preoperative manner. Levofloxacin was started for a urinary tract infection. Given his history of guaiac positive stool and anemia, his hematocrit was watched closely and remained stable. Although he had known, asymptomatic carotid artery stenosis, it was decided to delay intervention until after his surgical revascularization. On [**2173-8-30**], Mr. [**Known lastname **] was taken to the operating room where he underwent coronary artery bypass grafting to three vessels. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, Mr. [**Known lastname **] [**Last Name (Titles) 5058**] neurologically intact and was extubated. Beta blockade, aspirin and plavix were resumed. He converted back into atrial fibrillation which was rate controlled with beta blockade and the addition of amiodarone. He was pancultured for leukocytosis which was negative. The renal service was consulted for an elevated creatinine. Urinary eosinophils were negative and a renal ultrasound showed an atrophic left kidney. It was presumed that he had acute tubular necrosis from bypass and that his creatinine would likely recover. Mr. [**Known lastname **] was transfused for postoperative anemia. As he remained in atrial fibrillation, coumadin was started for anticoagulation. His pacing wires and chest tubes were removed when protocol was met. His renal function slowly improved. A right upper quadrant ultrasound was performed for elevated liver enzymes and nausea which was negative. On postoperative day five, Mr. [**Known lastname **] was transferred to the cardiac surgical step down unit for further recovery. He continued to be gently diuresed towards his preoperative weight. The physical therapy service worked with him daily to help with his postoperative strength and mobility. Mr. [**Known lastname **] continued to make steady progress and was discharged home on postoperative day eight. He will follow-up with Dr. [**Last Name (STitle) **], his cardiologist and his primary care physician as an outpatient. Medications on Admission: Meds on discharge from [**Hospital1 18**]: 1. Nitroglycerin SL prn 2. Clopidogrel 75 mg daily 3. Nifedipine SR 30 mg daily 4. Hydralazine 50 mg Q6H 5. Nitroglycerin 0.2 mg/hr Patch q24HR 6. Pantoprazole 40 mg q12h 7. Metoprolol Tartrate 50 mg [**Hospital1 **] 8. Aspirin EC 81 mg daily 9. Sucralfate 1 g QID 10. Clonidine 0.2 mg/24 hr Patch Weekly . Meds on Transfer: plavix 75 nifedipine SR 60 hydralazine 50 q8h protonix 40 daily metoprolol 50 [**Hospital1 **] aspirin EC 81mg sucralfate 1g QID clonidine patch morphine sulfate 2mg IV prn levaquin 500mg daily heparin gtt cardizem gtt Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. 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* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*150 Tablet(s)* Refills:*2* 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 7 days: Then decrease dose to 200 mg PO daily . Disp:*35 Tablet(s)* Refills:*0* 10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO at bedtime: Take as directed by Dr. [**Last Name (STitle) **] INR goal of [**1-13**].5. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: Coronary artery disease. Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. Do not lift more than 10 lbs. for 2 months. You should not drive for 4 weeks. Do not use lotions, creams, or powders on wounds. You should shower daily, let water flow over wounds, pat dry with a towel. Call our office for sternal drainage, temp>101.5. Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks. See Dr. [**Last Name (STitle) 39450**] on Wed. [**9-15**] @ 11AM. Office# is: [**2173**] Make an appointment with Dr. [**Telephone/Fax (1) 39451**] Completed by:[**2173-9-8**]

[ "496", "V45.82", "285.9", "584.5", "428.0", "427.31", "599.0", "433.10", "403.91", "410.91", "414.01" ]

icd9cm

[ [ [] ] ]

[ "99.04", "36.15", "39.61", "89.60", "36.12" ]

icd9pcs

[ [ [] ] ]

9202, 9258

4668, 7218

332, 386

9327, 9335

2452, 4645

9682, 9928

2056, 2073

7855, 9179

9279, 9306

7244, 7594

9359, 9659

2088, 2433

281, 294

414, 1912

1934, 2005

2021, 2040

7612, 7832

46,620

134,031

16894

Discharge summary

report

Admission Date: [**2135-8-13**] Discharge Date: [**2135-8-16**] Date of Birth: [**2057-7-21**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2387**] Chief Complaint: Transferred from NEBH with RCA STEMI Major Surgical or Invasive Procedure: cardiac catheterization with 2 drug eluting stents to right coronary Artery. History of Present Illness: Mr. [**Known lastname **] is a 78 year old male with history of HLD, Hypertension, and MI (medically managed 15 years ago), who presented to an outside hospital with chest discomfort. Pt states he awoke not feeling well with discomfort the morning of [**8-12**]. At that time he thought it was secondary to indigestion and describes a substernal pain rated at [**2136-3-22**]. Pt denies any radiation of that pain, palpitations, diaphoresis, or shortness of breath. Pt went to work and while driving developed some dizziness which reguired him to pull over. When he returned home his wife encouraged him to go to the doctor and had a friend who is a nurse check his blood pressure which was found to be 160/90. At that time patient went to the ED. Throughout this entire time pt states pain increased in severity. . At [**Hospital 7145**] hospital he was given SL NTG, maalox, prtonix on arrival. EKG showed sinus with rate of 73, ST elevation in II, III, aVF with TWI in V5,V6. Stable LAFB. Cardiac enzymes initially trop 0.3, CK 116, then on 2nd set troponin 5.43, CK 440. He was given plavix 300mg on the morning of [**8-13**], one inch nitropaste, lopressor 25mg q6. At that time he was transfered to [**Hospital1 18**] for cardiac catheterization. . In the CCU, pt is hemodynamically stable. With resolution of his chest pain with no nausea/vomiting, shortness of breath, abdominal pain or diaphoresis. . 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, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -h/o MI 3. OTHER PAST MEDICAL HISTORY: Arthritis COPD GOUT Asthmatic bronchitis Chronic Kidney disease RBBB Back pain 3.5cm AAA Colon polyps diverticulosis GERD Iron deficiency Vitamin D deficiency peripheral neuropathy benign prostatic hypertropy right shoulder fracture/pain (7 months ago) s/p CCY s/p sinus surgery Social History: Patient lives in [**Hospital1 392**] with wife. Where he breeds and races horses. Married. Two children, 4 grandchildren. -Tobacco history: Smokes [**2-22**] PPD x 50 years, Quit approx 10 years ago. -ETOH: Occasionally will have 1-2 drinks with dinner, no nightly -Illicit drugs: None Family History: Brother died at 56 of MI. Father/Mother cause of death unknown Physical Exam: VS: T= 97.9 BP=112/62 HR=63 RR= 20 O2 sat= 98%RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: Sclera anicteric. PERRL, EOMI. NECK: Supple, without JVD CARDIAC: Distant heart sounds, RR, normal S1, S2. No m/r/g. LUNGS: Diffuse expiratory wheezes, No crackles appreciated, No rhonchi ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. Right Groin sp Cath. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Radial 2+ DP 2+ PT 2+ Left: Radial 2+ DP 2+ PT 2+ Pertinent Results: Pertinent Labs: [**2135-8-13**] 07:59PM CK(CPK)-995* [**2135-8-13**] 07:59PM CK-MB-78* MB INDX-7.8* [**2135-8-13**] 09:40AM WBC-10.8 RBC-2.93* HGB-10.0* HCT-30.2* MCV-103* MCH-34.3* MCHC-33.2 RDW-13.8 [**2135-8-13**] 09:40AM PLT COUNT-251 [**2135-8-13**] 09:40AM PT-14.4* PTT-34.1 INR(PT)-1.2* [**2135-8-13**] 09:40AM GLUCOSE-153* UREA N-15 CREAT-0.9 SODIUM-136 POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-26 ANION GAP-10 [**2135-8-14**] 04:21AM BLOOD ALT-28 AST-108* CK(CPK)-813* [**2135-8-14**] 04:21AM BLOOD calTIBC-225* VitB12-612 Folate-15.1 Ferritn-170 TRF-173* [**2135-8-14**] 04:21AM BLOOD Triglyc-94 HDL-35 CHOL/HD-3.2 LDLcalc-58 [**2135-8-13**] Cardiac Cath: 1. One vessel coronary artery disease. 2. Sucessful thrombectomy, PTCA and stenting of a thrombotic occlusion at the mid RCA with two overlapping DESs. 3. Unsuccessful POBA to the mid-distal RPDA for an embolic occlusion. [**2135-8-15**] Echocardiogram: The left atrium is elongated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal half of the inferior and inferolateral walls. The remaining segments contract normally (LVEF = 50 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild to moderate ([**1-21**]+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad. IMPRESSION: Mild symmetric left ventricular hypertrophy with regional systolic dysfunction c/w CAD (PDA distribution). Mild-moderate mitral regurgitation most likely due to papillary muscle dysfunction. Brief Hospital Course: Mr. [**Known lastname **] is a 78 year old male with history of HLD, Hypertension, and MI (medically managed 15 years ago), who presented to OSH after 6 hours of chest discomfort. He had evidence of an inferior STEMI and was transferred to [**Hospital1 18**] to the cardiac catheterization lab where he was found to have complete occlusion of the mid RCA treated with 2 overlapping DES. His RPDA was unable to be opened up despite several attempts. 1) RCA STEMI - treated with two drug eluting stents. He was transferred directly to the cardiac catheterization lab where he was found to have 100% MID occlusion of the RCA sp successful overlapping DES x2 to mid RCA with possible embolization of thrombus in distal RPDA. At the end of the catheterization he had persistent occlusion of the RPDA despite multiple meds/ptca. He did well post catheterization with no complications. His CK peaked at 995 post catheterization. His post PCA echocardiogram showed mild regional left ventricular systolic dysfunction with hypokinesis of the basal half of the inferior and inferolateral walls. The remaining segments contract normally and his LVEF = 50 %. He also has [**1-21**]+ MR felt to be likely due to papillary muscle dysfunction post MI. He is being discharged on plavix 75mg daily, ASA 325mg daily. His home verapamil was discontinued and he was started on metoprolol and a low dose of lisinopril. He was also treated with atorvastatin 80mg which can be changed back to his home dose of 40mg on discharge as his lipid panel shows very good control. He will follow up with his outpatient cardiologist Dr. [**Last Name (STitle) 2912**]. 2. Hypertension - his outpatient hypertension regimen was changed during his admission. His verapamil was discontinued and he was changed to metoprolol and lisinopril which were titrated for blood pressure control prior to discharge. 3. Asthma: He was continued on his home regimen of advair, spiriva, albuterol and ipratropium. 4. Benign Prostatic Hypertrophy: Stable. He was continued on Flomax. 5. History of 3.5cm Abdominal Aortic Aneurysm: unclear current status, no acute issues during this admission. He will need to follow up with his PCP post discharge to determine appropriate monitoring. 6. Lower extremity swelling - recently started on furosemide as an outpatient. This was held during this admission and on discharge in order to maximize room for metoprolol and lisinopril titration as his blood pressure was marginal. This can be restarted as an outpatient at the discretion of his PCP and cardiologist. .CODE: FULL Code. COMM: Wife, [**Name (NI) **] ([**Telephone/Fax (1) 47596**]) Medications on Admission: lipitor 40mg daily verapamil ER 90mg daily centrum daily ecotrin 325mg daily os cal 500 + D atrovent prn advair 500/50 1 inh [**Hospital1 **] spiriva 1 ing daily Flomax 0.4mg [**Hospital1 **] combivent prn furosemide 20mg daily Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*11* 3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO BID (2 times a day). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Advair Diskus 100-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for dyspnea, wheezing. 11. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 12. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 13. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: ST elevation Myocardial Infarction EF 50% Hyperlipidemia Hypertension Asthma Ventricular Tachycardia Discharge Condition: stable Discharge Instructions: You had a heart attack and was transferred to [**Hospital1 **] for a cardiac catheterization and a successful thrombectomy and stenting of an occlusion at the mid right coronary artery with two overlapping Drug Eluting stents. Your echocardiogram showed that you have some mild weakness in the motion of your heart. You will have another echocardiogram in about 1 month to assess for changes. Medication changes: 1. STOP taking furosemide and Verapamil 2. Continue your Lipitor at 40 mg daily 3. Start Metoprolol Succinate at 100 mg daily 4. Start Plavix (clopodigrel) daily for at least one year and possibly longer. Do not stop taking Plavix unless Dr. [**Last Name (STitle) 2912**] tells you to. 5. continue to take a full aspirin, 325mg, with the Plavix daily 6. Start taking Lisinopril 2.5 mg daily to help you heart recover from the heart attack. . Call Dr. [**Last Name (STitle) 2912**] if you have any chest pain, trouble breathing, nausea, fevers, bleeding, vomiting or dizziness. Call the cathterization lab if you have increasing swelling, bruising, tenderness or bleeding from you right groin site. . No driving for one week. You will need to talk to Dr. [**First Name (STitle) 1356**] about when you can start driving again. Followup Instructions: Cardiology: Dr. [**Last Name (STitle) 2912**] Phone: ([**Telephone/Fax (1) 47597**] Date/time: [**9-12**] at 1:15pm . Primary Care: Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) 1356**] Phone: [**Telephone/Fax (1) 1983**] Date/time: [**2135-8-23**] at 3:00pm. [**Doctor First Name **], [**Location (un) 86**]

[ "441.4", "410.41", "280.9", "272.4", "427.1", "403.90", "585.9", "274.9", "426.4", "493.20", "600.00", "530.81" ]

icd9cm

[ [ [] ] ]

[ "36.07", "00.40", "37.23", "88.56", "00.66", "00.46" ]

icd9pcs

[ [ [] ] ]

10041, 10047

5728, 8388

352, 431

10192, 10201

3736, 3736

11488, 11823

3111, 3175

8667, 10018

10068, 10171

8414, 8644

10225, 10618

3190, 3717

2470, 2478

10638, 11465

276, 314

459, 2376

3752, 5705

2509, 2790

2398, 2450

2806, 3095

53,309

168,484

19669+57074

Discharge summary

report+addendum

Admission Date: [**2184-11-2**] Discharge Date: [**2184-11-9**] Date of Birth: [**2108-8-2**] Sex: F Service: UROLOGY Allergies: Penicillins / Folic Acid / Diphenhydramine / Sulbactam / metformin Attending:[**First Name3 (LF) 824**] Chief Complaint: nephrolithiasis Major Surgical or Invasive Procedure: Cystoscopy, right ureteroscopy, laser lithotripsy, stent placement. History of Present Illness: 76 year old woman with a history of COPD, OSA, HTN/HL, who presented today for a scheduled outpatient staged ureteroscopy with laser lithotripsy of right UPJ stone, who was transferred to the ICU for acute onset of tachypnea following the procedure today. Patient reports she has had progressively worsening shortness of breath over the past year. She is only able to walk 10 steps before she is out of breath. She reports associated lightheadedness but denies chest pain/pressure. She denies a known diagnosis of COPD, however, has been placed on several inhalers in the last year to suggest that she carries this diagnosis (spiriva/symbicort/singulair/ prn albuterol). She does not wear oxygen at home, but does have a home CPAP machine for OSA. She reports that her machine broke 2 months ago so she has not used it recently. At home she sleeps in a lounge chair, and becomes short of breath when laying flat. On [**2184-11-2**] she presented for part 2 of a staged ureteroscopy with lithotripsy to remove the remaining [**11-24**] of her right UPJ stone. Part 1 of this procedure took place on [**2184-10-19**] without complications and patient was discharged home on the same day. Patient tolerated the procedure today without issue. She was noted to be hypertensive to 180s intraoperatively with ST depressions but was otherwise hemodynamically stable. Following the procedure, ECG showed ST depressions in V3-V5. She had a set of cardiac enzymes which were negative. While in the PACU, she became acutely tachypneic requiring increasing oxygen requirement. On exam, she had bilateral inspiratory and expiratory wheezes and was given lasix 20mg IV and albuterol nebulizer x 2 with transient improvement in symptoms. She was also given 0.5mg ativan for anxiety and 5mg IV labetolol for hypertension. As she had ongoing tachypnea with rates in the 30s, sat'ing 95% on NRB but desat'ing to <90% on 6L face mask, and febrile to 102.7, patient was transferred to the ICU for further management. On arrival to the ICU, patient's vital signs were T101.8 P86 BP 127/42 RR 23 O2Saat 99% on NRB. She was changed to 6L NC and continued to sat in the high 90s. She had audible wheezing and mild accessory muscle use which improved with time. Shortly after arrival, patient became hypotensive to 80-90s. Her UOP decreased and she continued to be febrile up to 102. However, she was asymptomatic. Past Medical History: -?COPD- progressively worsening SOB over past year, medicated as such -Obstructive sleep apnea- on home CPAP -Hypertension -Hyperlipidemia -h/o CVA [**2181**] with residual right facial droop, right upper/lower extremity weakness -h/o "failed" stress test in [**2174**], cardiac cath reportedly "clean", no intervention performed -Celiac disease -Diabetes mellitus, diet controlled -Hypothyroidism -Major depressive disorder -s/p R total knee replacement [**2181**] -s/p cholecystectomy [**2172**] Social History: Patient lives at home alone. She has one cat. She has never been married and has no children. She is a retired schoolteacher. She used to teach kindergarten and second grade. She had 7 siblings, but many have died and she is no longer in touch with those still living. She grew up in [**Location 1268**], where she still resides. - Tobacco: denies past or present use, extensive exposure to second hand smoke from family - Alcohol: denies past or present use - Illicits: denies Family History: Father- died of MI, age 69 Mother: died at 82 ?????? heart and renal failure. 7 brothers/sisters- extensive cardiac history and COPD (all smokers) No children. (5 of the siblings suffered from heart disease and 4 of them died because of an MI at the age of 45-55). One brother with DM. Physical Exam: Admission Physical Exam: Vitals: T: 101.8 BP: 127/42 P: 86 R: 23 O2: 99% on 6L NC General: Obese female speaking in short sentences, in NAD HEENT: Sclera anicteric, MMM, oropharynx clear without lesions/exudate, adentulous Neck: JVP not elevated, no lymphadenopathy palpated Lungs: No accessory muscle use, no pursed lip breathing, but speaking in short sentences. Prolonged expiratory phase with diffuse expiratory wheezing, no crackles appreciated CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Obese, +BS, soft, NTND GU: No CVA tenderness, foley in place draining blood tinged/concentrated urine Ext: Cool toes, good capillary refill, 1+ LE edema in ankles, 1+DP/PT pulses bilaterally Neuro: A+Ox3, CN II-XII intact, strength 5/5 b/l Discharge Physical Exam: WdWn woman, NAD, AVSS normal appearing respiratory effort w/out tachypnea abdomen obese, soft, nt/nd extremities w/out pitting edema Pertinent Results: Admission Labs: 17:00 CK 50 CKMB 2 Trop-T <0.01 23:15 CK 159 CKMB 3 Trop-T 0.36 WBC 23.3 Hgb 11.0 Hct 33.4 Plts 349 N:93.2 L:1.9 M:3.9 E:0.8 Bas:0.1 Na 141 K 4.2 Cl 103 CO2 29 BUN 31 Cr 1.5 Gluc 152 [**2184-11-3**] @ 04:50 Trop 0.25 [**2184-11-3**] @ 13:10 Trop 0.15 EKG: - PACU @ 17:06 [**11-3**]- Sinus @ 82, normal intervals, 1mm ST depressions in V3-V5, no T wave changes, no Q waves - ICU @ 23:06 [**11-3**]- Sinus at 91, normal intervals, 1mm ST depressions in V2-V3, no T wave changes, no Q waves - ICU @ 03:03 [**11-4**]- Sinus at 69, normal intervals, no ST depressions, no T wave changes, no Q waves Imaging: CXR [**2184-11-2**]- AP chest compared to most recent prior chest radiograph [**2182-6-23**]: Moderate cardiomegaly has increased. Pulmonary vascular engorgement and mediastinal fullness in the right lower paratracheal station could represent early cardiac decompensation, there may be very mild interstitial pulmonary edema. There is no indication of appreciable pleural effusion and no pneumothorax. Transthoracic echocardiogram [**2184-11-3**]- The left atrium is mildly dilated. 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 normal (LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). There is a mild resting left ventricular outflow tract obstruction. The right ventricular cavity is mildly dilated with normal free wall contractility. The diameters of aorta at the sinus, ascending and arch levels are normal. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened (?#). There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild-to-moderate mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Mild right ventricular dilation. Mild to moderate mitral regurgitation. Mild pulmonary hypertension. Compared with the prior study (images reviewed) of [**2182-6-21**], there is more mitral regurgitation. The right ventricle appears mildly dilated. [**2184-11-5**] 07:35AM BLOOD WBC-8.7# RBC-3.14* Hgb-9.8* Hct-30.7* MCV-98 MCH-31.1 MCHC-31.8 RDW-12.9 Plt Ct-323 [**2184-11-5**] 07:35AM BLOOD Neuts-61.5 Lymphs-30.7 Monos-5.5 Eos-2.0 Baso-0.3 [**2184-11-5**] 07:35AM BLOOD Glucose-97 UreaN-37* Creat-1.4* Na-139 K-4.5 Cl-106 HCO3-27 AnGap-11 [**2184-11-5**] 07:35AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.3 [**2184-11-3**] URINE ---NEGATIVE URINE CULTURE-FINAL INPATIENT [**2184-11-2**] BLOOD CULTURE---NEGATIVE Blood Culture, Routine-FINAL INPATIENT [**2184-11-2**] BLOOD CULTURE---NEGATIVE Blood Culture, Routine-FINAL INPATIENT Brief Hospital Course: 76 yo F with h/o reported COPD, OSA, HTN/HL, s/p right ureteroscopy with lithotripsy and stenting presenting with acute onset of tachypnea, fever and hypotension. # Respiratory distress/tachypnea- Acute onset of tachypnea following procedure seemed most consistent with flash pulmonary edema. In addition, given underlying lung disease, it is possible that patient had transient bronchospasm. Patient was given 20mg IV lasix and albuterol nebulizers prior to transfer to the ICU, and improved greatly upon arrival. She was started on steroids as there was concern that in the setting of tachypnea with fever and hypotension, patient may be having anaphylactic reaction to a medication given during the procedure, however, as patient tolerated same exact procedure several weeks ago without issue, this was less likely. Steroids were also given to reduce bronchospasm, but as patient was so clinically improved on HD1, steroids were discontinued. She was weaned off nasal cannula.... # Hypotension- In setting of fever and leukocytosis following instrumentation, concern was high for sepsis. Patient met SIRS criteria with fever, white count, and tachypnea. Blood and urine cultures were sent, patient was broadly covered with vancomycin and cefepime. Despite low urine output, there was no evidence of end-organ hypoperfusion as patient mentated well and creatinine remained stable without an elevation in lactate. Patient was bolused fluids and did not require pressors. An A-line was placed for closer hemodynamic monitoring. By HD1, patient's pressures were stabilized, she was afebrile and white count was trending down with improvement in urine output. # NSTEMI- Patient became acutely hypertension to 180s intraoperatively with reported ST depressions on telemetry. Following the procedure, EKG showed ST depressions in V3-V5 and on arrival to the ICU ST depressions were still present in V2-V3. Troponin peaked at 0.36, then was downtrending, with normal CKMB. Patient was given aspirin 325mg, and heparin drip was deferred as likely cause of troponin leak was demand ischemia in the setting of hypertension. An echocardiogram on HD 1 showed no regional wall motion abnormalities. # s/p lithotripsy with stent placement- Patient was co-managed in ICU with urology team. # COPD- No records to indicate known COPD, however, patient's medications suggest she carries the diagnosis. No signs of COPD exacerbation at this time, more likely transient bronchospasm following procedure, therefore steroids were deferred. # Obstructive sleep apnea- Patient's home CPAP machine has been broken for 2 months. # Hypertension- holding olmesartan in setting of hypotension # Hyperlipidemia- Continued home simvastatin, especially given concern for ACS. # Hypothyroidism- Continued home levothyroxine # Depression- Continued abilify and citalopram # GERD- Continued home omeprazole [**Hospital1 **] # Celiac disease- patient given gluten free diet # Osteoarthritis- holding diclofenac for now # Transitional issues- - Diagnosis of COPD? - CXR with evidence of ?mediastinal lymphadenopathy- will need outpatient CT chest - Given demand ischemia, troponin leak, patient will need outpatient stress test - Culture data pending Ms. [**Known lastname 11925**] was admitted to Dr.[**Name (NI) 825**] Urology service after after the Cystoscopy, right ureteroscopy, laser lithotripsy, stent placement. She was transferred to the ICU for acute onset of tachypnea following the procedure. Please see dictated operative note for full details. The patient received peri-operative antibiotic prophylaxis. She was transferred from the PACU from the ICU in stable condition to the general surgical floor. She remained over the weekend waiting for bed assignment and for occupational therapy evaluaton and further physical therapy. At discharge Ms. [**Last Name (Titles) 53250**] pain was well controlled with oral pain medications, she was tolerating a regular diet and ambulating with cane/walker assistance and voiding without difficulty. She was given explicit instructions to follow-up with Dr. [**Last Name (STitle) 770**], her PCP and [**Name Initial (PRE) **] cardiologist. She also understands that she must follow-up for definitive stone management and ureteral stent removal/exchange. Medications on Admission: Furosemide 40mg po qAM Olmesartan 20mg po daily Aspirin 81mg po daily Simvastatin 40mg po daily Budesonide/formoterol 2 puffs INH [**Hospital1 **] Tiotropium 1 capsule INH qHS Montelukast 10mg INH qHS Levalbuterol/albuterol HFA prn SOB Levothyroxine 0.025mg po qAM Citalopram 40mg po daily Aripiprazole 10mg po daily Diclofenac 100mg po qHS Trazodone 25mg po qHS prn insomnia omeprazole 20mg [**Hospital1 **] Discharge Medications: 1. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. budesonide-formoterol 80-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation twice a day. 5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation HS (at bedtime). 6. montelukast 10 mg Tablet Sig: One (1) Tablet PO qHS. 7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**11-23**] Inhalation every 4-6 hours as needed for shortness of breath or wheezing: use either albuterol or levalbuterol (not both). 8. levalbuterol tartrate 45 mcg/Actuation HFA Aerosol Inhaler Sig: [**11-23**] Inhalation every 4-6 hours: use either albuterol or levalbuterol (not both). 9. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 11. aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. diclofenac sodium 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO at bedtime. 13. trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as needed for insomnia. 14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 15. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days: last day [**11-8**]. 16. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 17. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 18. acetaminophen 500 mg Capsule Sig: Two (2) Capsule PO every six (6) hours as needed for pain: max acetaminophen is 4grams in 24hrs. Discharge Disposition: Extended Care Facility: [**Hospital1 **] Nursing & Therapy Center - [**Location 1268**] ([**Location (un) 86**] Center for Rehabilitation and Sub-Acute Care) Discharge Diagnosis: PRIMARY: Sepsis, UTI Secondary: Nephrolithiasis PREOPERATIVE DIAGNOSIS: Right ureteral stone, impacted. POSTOPERATIVE DIAGNOSIS: Right ureteral stone, impacted. 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 11925**], It was a pleasure taking care of you during your hospitalization. You were admitted because you had difficulty breathing and low blood pressure after your procedure to remove your kidney stones likely due to infection from the stones. We treated you with antibiotics and intravenous fluids. You also had transiently low blood flow to your heart because of low blood pressures. We would like you to follow up with a cardiologist. We made the following changes to your medications: STARTED Ciprofloxacin (last day [**11-8**]) INCREASED aspirin from 81mg to 325mg daily. Your olmesartan has been held alos. Please discuss these medication changes with your cardiologist. Discharge instructions with URETERAL STENT PLACEMENT : You have an indwelling ureteral stent that MUST be removed and/or exchanged in the next few weeks time. Please follow-up as advised. You may experience some pain associated with spasm of your ureter especially while there is an INDWELLING URETERAL STENT. This is normal -Resume all of your pre-admission/home medications except as noted above. -No vigorous physical activity for 2 weeks. -Expect to see occasional blood in your urine and to experience urgency and frequency over the next month. -You may experience some pain associated with spasm of your ureter. This is normal. Take IBUPROFEN as directed and take the narcotic pain medication as prescribed if additional pain relief is needed. -Tylenol should be your first line pain medication, a narcotic pain medication has been prescribed for breakthrough pain >4. Replace Tylenol with narcotic pain medication. -Max daily Tylenol (acetaminophen) dose is 4 grams from ALL sources, note that narcotic pain medication also contains Tylenol -Make sure you drink plenty of fluids to help keep yourself hydrated and facilitate passage of stone fragments. -You may shower and bathe normally. -Do not drive or drink alcohol while taking narcotics or operate dangerous machinery -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool softener, NOT a laxative -If you have fevers > 101.5 F, vomiting, severe abdominal pain, or inability to urinate, call your doctor or go to the nearest emergency room. Call your urologist??????s office for follow-up AND if you have any questions. Followup Instructions: -You should schedule an appointment with cardiology when you get to Rehab and follow up with your primary care doctor as soon as possible. PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 11144**]. Dr. [**Last Name (STitle) 11139**] can facilitate referral to cardiology as well. -Call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office ([**Telephone/Fax (1) 7707**] ‎for follow-up AND if you have any questions. Completed by:[**2184-11-8**] Name: [**Known lastname 9904**],[**Known firstname **] T Unit No: [**Numeric Identifier 9905**] Admission Date: [**2184-11-2**] Discharge Date: [**2184-11-9**] Date of Birth: [**2108-8-2**] Sex: F Service: UROLOGY Allergies: Penicillins / Folic Acid / Diphenhydramine / Sulbactam / metformin Attending:[**First Name3 (LF) 9906**] Addendum: rehab stay anticipated to be less than 30 days. Major Surgical or Invasive Procedure: Cystoscopy, right ureteroscopy, laser lithotripsy, stent placement. Brief Hospital Course: rehab stay anticipated to be less than 30 days. Discharge Disposition: Extended Care Facility: [**Hospital1 **] Nursing & Therapy Center - [**Location 205**] ([**Location (un) 42**] Center for Rehabilitation and Sub-Acute Care) [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9907**] MD [**MD Number(1) 9908**] Completed by:[**2184-11-9**]

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icd9cm

[ [ [] ] ]

[ "59.8", "55.22", "56.0" ]

icd9pcs

[ [ [] ] ]

18971, 19287

18899, 18948

18806, 18876

15148, 15148

5142, 5142

17791, 18768

3889, 4177

12989, 14756

14960, 15127

12556, 12966

15331, 15820

4217, 4964

15849, 17768

285, 302

438, 2849

5158, 8204

15163, 15307

2871, 3370

3386, 3873

4989, 5123

74,144

101,504

51596

Discharge summary

report

Admission Date: [**2193-10-14**] Discharge Date: [**2193-10-17**] Date of Birth: [**2109-8-16**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7651**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 84 year old male with PMH significant for systolic heart failure EF 30%, HTN, hyperlipidemia, DM, CAD s/p CABG who presented with dyspnea on exertion of 3 days in duration. Patient presented to his pcp [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] and was referred to ED following a CXR which demonstrated bilateral pleural effusion. Patient reports he has not been taking his Lasix (60 mg [**Hospital1 **]) for the past "few" days. He reports associated cough, exertional dyspnea, fatigue and increasing lower extremity edema. Denies dyspnea at rest, PND or worsened orthopnea (sleeps with head of bed elevated at baseline). Denies chest pain or palpatations. Patient denies fevers, chills. Per his PCP, [**Name10 (NameIs) **] is ongoing concern about medication compliance at home with cardiac meds. . Presenting vitals to ED HR 53, BP 131/49, RR 26, O2 sat 81% 6L. Patient was placed on NRB, then Bipap, then transferred to ICU on 100% ventimask. In ED patient was given Lasix 40 mg IV, Nitropaste 1 inch, Levaquin and ASA. Due to respiratory compromise he was transferred to the ICU for futher care. . On review of systems, he denies any prior history of deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. He denies syncope or presyncope. The rest of the review of systems was negative in detail. Past Medical History: CAD s/p CABG x4v '[**74**] CHF EF 30-40% PVD DM c/b neuropathy HbgA1c 6.0% 4/09 CVA Gastritis Carotid stenosis HTN Hyperlipidemia BPH Depression Chronic constipation T12 compression fracture Cataract s/p surgery Glaucoma Social History: He grew up in [**State 5887**], has been living in [**Location (un) 86**] since [**2130**]. He is a veteran of World War II. He worked as a coal miner and then as a manual laborer. He has been retired for years. He is widowed and now living with his son and girlfriend (both are HCP). Distant history of smoking 40 years x 2 pack/yr, quit over 20 years ago. No alcohol use. No drug use. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: on admission: VS: T=98.7 BP=135/52 HR=56 RR=20 O2 sat=100% venti-mask GENERAL: Breathing on ventimask. 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: Unable to appreciate JVP. CARDIAC: Distant heart sounds. Irregular rate, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Decreased breath sounds left base, crackles right base. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Chest x-ray [**2193-10-14**] 1. Increased size of small-to-moderate right and tiny left pleural effusion with associated central vascular congestion compatible with CHF. 2. Increased left retrocardiac opacity which likely represents atelectasis, although pneumonia would be difficult to exclude. Pertinent Results: [**2193-10-14**] 04:20PM BLOOD WBC-7.2 RBC-4.11* Hgb-11.7* Hct-35.9* MCV-87 MCH-28.5 MCHC-32.6 RDW-17.0* Plt Ct-219 [**2193-10-17**] 06:50AM BLOOD WBC-6.5 RBC-3.74* Hgb-11.0* Hct-32.4* MCV-87 MCH-29.3 MCHC-33.8 RDW-16.7* Plt Ct-216 [**2193-10-14**] 04:20PM BLOOD PT-39.8* PTT-38.0* INR(PT)-4.2* [**2193-10-17**] 01:13PM BLOOD PT-22.2* PTT-33.4 INR(PT)-2.1* [**2193-10-14**] 04:20PM BLOOD Glucose-170* UreaN-27* Creat-1.3* Na-140 K-3.6 Cl-103 HCO3-26 AnGap-15 [**2193-10-17**] 06:50AM BLOOD Glucose-103 UreaN-28* Creat-1.3* Na-140 K-3.8 Cl-102 HCO3-31 AnGap-11 [**2193-10-14**] 04:20PM BLOOD CK-MB-5 proBNP-2458* [**2193-10-14**] 04:20PM BLOOD cTropnT-0.02* [**2193-10-15**] 12:03AM BLOOD CK-MB-NotDone cTropnT-0.02* [**2193-10-15**] 06:02AM BLOOD CK-MB-NotDone cTropnT-0.03* [**2193-10-15**] 06:02AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.2 [**2193-10-17**] 06:50AM BLOOD Calcium-8.6 Phos-4.3 Mg-2.1 Brief Hospital Course: In summary, Mr. [**Known lastname **] is a 82M with CAD s/p CABG, systolic CHF who presented with dyspnea on exertion for 3 days duration in the setting of medication non-compliance. He was admitted to the cardiac intensive care unit and showed significant improvement with diuresis. . # Respiratory Distress: Patient's symptoms of dyspnea on exertion, increased lower extremity edema and non compliance with lasix suppported acute systolic CHF episode. CXR also supported this with b/l pleural effusions and associated central vascular congestion. Patient transferred from ED on venti mask. There was less concern for pneumonia as no symptoms, fever or elevated white count. Trigger of acute CHF was most likely med non-compliance; there were no EKG changes to suggest ACS, cardiac enzymes were never significantly elevated, and the patient denied increase of salt in diet. Patient was on 60 mg po BID lasix at home however was not taking it because of his frustration with needing to urinate frequently while on the medication. Pt did well with diuresis and fluid restriction and was transfered to the floor after a couple days in the ICU. He was discharged with an indwelling foley cath to help with his urine output and medication non-compliance with a follow-up appointment scheduled with urology. . # RHYTHM: Rate controlled atrial fibrillation. He was supratherapeutic on his INR on admission therefore warfarin was initially held. His outpatient Metoprolol was continued at 25mg qd. He was discharged with instructions to follow up in [**Hospital 2786**] clinic for titration of his warfarin dosing, and to resume coumadin dose at 7mg on [**10-18**] and [**10-19**] and [**10-20**] prior to [**Hospital 2786**] clinic visit. . # Coronaries: 3vd s/p CABG. His aspirin, statin and beta blocker were continued as an inpatient. His lisinopril was held given his acute renal failure. . # Acute renal failure: Hyaline casts on admission Ua were concerning for poor perfusion. Creatinine elevated mildly from baseline of 1.1, peaked at 1.5, then was downtrending prior to admission with a discharge creatinine of 1.3. Meds were renally dosed, electrolytes repleted and Lisinopril held. Would recommend outpatient follow-up to ensure complete resolution of his renal failure. . # HTN: his amlodipine was continued for hx of hypertension, lisinopril held as noted previously. . # DM: treated with NPH and insulin sliding scale while inpatient . # Depression: his celexa and risperidone were continued in the inpatient setting. . # Glaucoma: Brimonidine/Dorzolamide/Timolol were continued in the inpatient setting. The patient was full code, this was confirmed with [**Name (NI) **] [**Name (NI) **], [**First Name3 (LF) **]/HCP [**Telephone/Fax (1) 106933**]. Medications on Admission: MEDICATIONS: confirmed with son AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth daily BRIMONIDINE - 0.15 % Drops - 1 gtt(s) OD [**Hospital1 **] CITALOPRAM 40 mg Tablet - 1and [**1-18**] Tablet(s) by mouth once a day DORZOLAMIDE-TIMOLOL 0.5 %-2 % Drops - 1 gtt OD twice a day FINASTERIDE - 5 mg Tablet - 1 Tablet(s) by mouth once a day FUROSEMIDE - 40 mg Tablet - 1.5 Tablet(s) by mouth twice a day LISINOPRIL 40 mg Tablet - 1 Tablet(s) by mouth daily METOPROLOL SUCCINATE - 25 mg Tablet once a day PILOCARPINE HCL [PILOPINE HS] 4 % Gel - apply OD at bedtime RISPERIDONE 1 mg Tablet - 1.5 Tablet(s) by mouth at bedtime SIMVASTATIN - 20 mg Tablet 1 Tablet(s) by mouth once a day for WARFARIN - 10 mg MWF, every other day 7 mg tablet ASPIRIN - (OTC) - 81 mg Tablet once a day INSULIN NPH HUMAN RECOMB [HUMULIN N] - (Dose adjustment - no new Rx) - 100 unit/mL Suspension - 14 units twice a day Discharge Medications: 1. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 3. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 4. Pilocarpine HCl 4 % Drops Sig: One (1) Drop Ophthalmic QHS (once a day (at bedtime)). 5. Citalopram 40 mg Tablet Sig: 1.5 Tablets PO once a day. 6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 8. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 9. Risperidone 1 mg Tablet Sig: 1.5 Tablets PO at bedtime. 10. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fourteen (14) units Subcutaneous twice a day. 13. Outpatient Lab Work Please check INR and Chem-7 on Monday [**10-21**] and call results to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 1144**]. Discharge Disposition: Home With Service Facility: [**Hospital1 3894**] Health VNA Discharge Diagnosis: Acute on Chronic systolic congestive Heart Failure Acute Renal Failure Diabetes Mellitus Type 2 Coronary Artery Disease Hypertension Hyperlipidemia Discharge Condition: stable BP= 124/53 HR= 56 weight= 190 pounds Discharge Instructions: You had an episode of congestive heart failure from stopping Lasix at home. We have restarted your Lasix and kept a Foley catheter in. You will see Dr. [**Last Name (STitle) 770**] next week for evaluation. In the meantime, empty the foley bag whenever it gets full. The visiting nurse will help you with this at home as well. Weigh yourself every morning, call Dr.[**Doctor Last Name 3733**] if weight > 3 lbs in 1 day or 6 pounds in 3 days. Adhere to 2 gm sodium diet Fluid Restriction: 1500cc or about 8 cups. . Medication changes: 1. do not take Coumadin today. Resume coumadin on [**10-18**] and [**10-19**] and [**10-20**] and take 7 mg. Please check INR on [**10-21**] and the [**Hospital3 271**] will tell you how much to take. 2. Take your lasix twice daily at 60 mg Followup Instructions: Urology: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2193-10-24**] 11:45. Please call the office for directions. Primary Care: [**Last Name (LF) **],[**First Name3 (LF) **] A. Phone: [**Telephone/Fax (1) 1144**] Date/Time: [**10-24**] at 11:00am. Cardiology: Dr. [**First Name4 (NamePattern1) 4648**] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 62**] Date/time: Tuesday [**10-29**] at 2:20pm.

[ "438.9", "357.2", "584.9", "V15.81", "311", "250.60", "401.9", "427.31", "600.00", "414.01", "790.92", "428.0", "272.4", "V45.61", "428.23", "440.20", "V15.82", "V58.67", "433.10", "365.9", "V58.61", "786.09", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "93.90", "99.17" ]

icd9pcs

[ [ [] ] ]

9501, 9563

4645, 7416

337, 343

9755, 9801

3723, 4622

10625, 11128

2541, 2623

8360, 9478

9584, 9734

7442, 8337

9825, 10340

2638, 2638

10360, 10602

278, 299

371, 1871

2653, 3704

1893, 2116

2132, 2525

109

140,167

14802

Discharge summary

report

Admission Date: [**2141-12-18**] Discharge Date: [**2141-12-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1973**] Chief Complaint: Malignant hypertension Major Surgical or Invasive Procedure: None History of Present Illness: 24 year old female with ESRD on HD, SLE, malignant HTN presents with headache and abdominal pain beginning this morning. Patient had her hemodialysis day before yesterday. She has had multiple admissions to [**Hospital1 18**] with hypertensive urgency with symptoms of headache and abdominal pain. Has had extensive work-up for abdominal pain including ex-lap on [**2141-10-27**] which was negative. Patient states that her headache and abdominal pain are similar in characteristics to her previous admission. Patient denies any fever, chills, nightsweats, chest pain, shortness of breath, abdominal pain, nausea, vomitting, diarrhea, constipation, blood in stool, dysuria, hematuria, change in vision, hearing, weakness or numbness. In the ED, initial vitals were T97, BP253/170, HR100, RR24 100%RA. Was initially given 10mg IV Labetalol once and then started on drip at 2mg/hour. She also received hydralazine IV 10 mg once and 2 inch nitropaste. She morphine 4mg once for pain and 4mg Zofran for nausea. Her BP elevated as high as 270/174 and his labetolol was switched to nicardipine 1mg/kg/min. On arrival to the MICU her vitals were T 96.4 HR 99 BP 175/120 RR 15 100%RA. Patient was comfortable. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with LE paresis in [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: Vitals: 97.5 122/80 88 18 100%RA. Gen: sleeping, easily arousable, appears comfortable. HEENT: AT/NC, L eye prosthetic non-reactive, R pupil reactive, MMM. Heart: S1S2 RRR, III/VI SEM heard best at apex, + S3 Pulm: CTA b/l, no w/r/r. Abd: normal bowel sounds, midline scar well-healed, soft, nontender, prior PD site with dry dressing, patient with tenderness to palpation over prior PD cath site, no guarding/rebound Ext: no edema, no clubbing, WWP. R femoral HD catheter in place. Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact. Pertinent Results: Admission: [**2141-12-18**] 02:00AM BLOOD WBC-5.8 RBC-3.30* Hgb-10.1* Hct-30.3* MCV-92 MCH-30.7 MCHC-33.5 RDW-20.7* Plt Ct-199 [**2141-12-18**] 02:00AM BLOOD PT-14.2* PTT-32.1 INR(PT)-1.2* [**2141-12-18**] 02:00AM BLOOD UreaN-35* Creat-5.0* Na-138 K-5.5* Cl-103 HCO3-21* AnGap-20 [**2141-12-18**] 02:00AM BLOOD ALT-16 AST-69* CK(CPK)-89 AlkPhos-109 TotBili-0.4 [**2141-12-18**] 02:00AM BLOOD Lipase-73* [**2141-12-18**] 02:00AM BLOOD CK-MB-NotDone cTropnT-0.07* [**2141-12-19**] 06:45AM BLOOD Calcium-8.1* Phos-5.1* Mg-1.8 [**2141-12-18**] 03:52PM BLOOD dsDNA-NEGATIVE [**2141-12-18**] 03:52PM BLOOD CRP-11.5* [**2141-12-18**] 03:52PM BLOOD C3-68* C4-19 [**2141-12-20**] 12:09PM BLOOD Type-ART pO2-158* pCO2-42 pH-7.36 calTCO2-25 Base XS--1 [**2141-12-18**] 02:08AM BLOOD pO2-52* pCO2-38 pH-7.39 calTCO2-24 Base XS--1 Comment-GREEN TOP [**2141-12-20**] 12:09PM BLOOD Lactate-0.9 [**2141-12-18**] 02:08AM BLOOD Glucose-68* Lactate-1.3 Na-140 K-4.8 Cl-103 [**2141-12-23**] 03:00PM BLOOD WBC-4.7 RBC-2.35* Hgb-7.1* Hct-22.3* MCV-95 MCH-30.3 MCHC-31.9 RDW-20.6* Plt Ct-131* [**2141-12-23**] 12:55AM BLOOD PT-14.7* PTT-66.2* INR(PT)-1.3* [**2141-12-18**] 03:52PM BLOOD ESR-21* [**2141-12-23**] 03:00PM BLOOD Glucose-97 UreaN-42* Creat-6.6* Na-138 K-4.3 Cl-106 HCO3-23 AnGap-13 [**2141-12-18**] 02:00AM BLOOD ALT-16 AST-69* CK(CPK)-89 AlkPhos-109 TotBili-0.4 [**2141-12-23**] 03:00PM BLOOD Calcium-8.6 Phos-4.5 Mg-1.8 [**2141-12-18**] 04:23PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.008 [**2141-12-18**] 04:23PM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG [**2141-12-18**] 04:23PM URINE RBC-<1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-12 TransE-<1 Micro: Blood Cx- [**12-18**]: No growth Urine Cx- [**12-18**]: No growth [**12-18**] TTE The left atrium and right atrium are normal in cavity size. A possible secundum type atrial septal defect is seen by color Doppler (clip [**Clip Number (Radiology) **]) There is severe symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function. There is no significant resting LVOT gradient, but a mild gradient (30mmHg peak) is seen with Valsalva manuever. 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. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is a small circumferential pericardial effusion without echocardiographic signs of tamponade. IMPRESSION: Marked symmetric left ventricular hypertrophy with normal regional/global systolic function and mild inducible LVOT gradient. Mild aortic regurgitation. Mild pulmonary artery systolic hypertension. Possible secundum type atrial septal defect. Compared with the prior study (images reviewed) of [**2141-10-19**], a possible secundum type atrial septal defect is now suggested. If clinically indicated, a follow-up study with saline contrast and/or a TEE would be better able to characterize the possible atrial septal defect. CLINICAL IMPLICATIONS: Based on [**2140**] 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. [**12-18**] CXR IMPRESSION: 1. Cardiomegaly with findings suggestive of mild pulmonary edema. 2. Bibasilar linear opacities suggesting atelectasis, although developing pneumonia cannot be excluded. 3. No evidence of free intraperitoneal air. [**12-20**] MRV IMPRESSION: No appreciable change since the MRV chest exam dated [**2141-5-30**]. SVC is patent. Again seen is occlusion of the right internal jugular and left brachiocephalic veins. Right external jugular vein is provides the major venous drainage from the neck. Brief Hospital Course: 24 year old Female with SLE, ESRD on HD and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ED. 1. Malignant Hypertension: The patient had her hemodialysis two days prior to admission. Initially in the ED her BP was 253/170. She was given 10mg IV Labetalol and started on a labatelol drip. She also received hydralazine IV 10 mg once and 2 inches of nitropaste. She had morphine 4mg and 4mg Zofran for nausea. Her BP remained elevated so she was switched to nicardipine 1mg/kg/min. The patient was transferred to the MICU. In the ICU she was continued on the Nicardapine drip and her pressures decreased to 175/120. Nephrology was consulted and dialysis initiated in the AM. The Nicardapine drip dc'd on [**12-19**] and pt transferred to floor. While on the floor the patient had question of angioedema and markedly elevated BP. She was readmitted to the MICU on [**2141-12-20**]. Patient's Aliskerin was also held for conern for angioedema. The renal team removed her tunneled dialysis catheter that had a cuff out, and replaced it with a temporary femoral line. The patient's PD catheter was removed. The patient was briefly on a nitro drip for hypertension. The patient's nifedepine was increased to 120mg. The patient was transferred to the floor with stable blood pressures, BP 124/72 on [**12-21**]. The morning of [**12-22**], the patient was noted to have a BP up to 247/120 at 0800. Hypertension persisted throughout the morning with BPs 210s-240s systolic. HR during this time was in the 90s. She received a total of 60 mg IV hydralazine over the course of the morning as well as 0.1 mg PO clonidine. She was also given her normal AM BP meds and restarted on aliskarin. Due to persistent hypertension, she was transferred to the ICU for further care. On arrival to the ICU, the patient reported severe abdominal pain over the site of recently removed PD catheter. She denied any headache, nausea, vomiting, diarrhea, constipation, or lower extremity swelling. She reports bilateral calf cramping but no leg swelling. She denies any difficulty breathing or chest pain. She took her AM BP meds without difficulty. Her blood pressure decreased to 130s-140s/60s without further intervention. She was transferred back to the floor on [**12-23**] and signed out AMA. 2. Angioedema: On [**12-20**] the patietn developed facial swelling and evidence of angioedema by ENT. The patient reported that her face is more swollen which was confirmed by her mother on the floor. The patient was give lasix IV as she has been unable to have any negative filtration with HD. The patient was started on decadron 10mg q8hr, famotidine, diphenhydramine for the edema. Her tekturna was discontinued for concern that it might be causing angioedema. She denied difficulty with her breathing at that time, but was very somnulent. On arrival to the MICU her vitals were stable and oxygenating well at 100% on face mask. The patient's airway was supported with a nasal trumpet. The patient underwent MRV that showed no progression of her clot. Patient was diuresed with lasix and dialysis with significant improvement in her symptoms. She was treated with prednisone and decadron, famotidine and benadryl for angioedema. The patient was maintained on her heparin drip for her SVC syndrome. 3. Abdominal Pain: The patient has had extensive prior workup that has been unrevealing. The Transplant surgery team removed the PD cath on [**12-21**]. She continued to have abdominal pain post-op. She was continued on PO dilaudid 2mg po prn. She continuned to complain of abdominal pain throughout her admission and continued to requested IV dilaudid. 4. ESRD: The patient is on a T/Th/Sat schedule. She was closely followed by the renal team. She had dialysis on [**12-19**]. The patient's tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. The patient also had her PD catheter removed on [**12-21**] secondary to chronic abdominal pain. The patient was scheduled to have dialysis on [**12-23**]. 5. Hx of SVC/brachiocephalic DVT: Her coumadin was held during last admission for supratherapeutic INR. She was admitted with a subtherpeutic INR of 1.2 She was started on a heparin drip. She was also started on Coumadin 2mg PO qday, but was held on [**12-19**] in prep her PD catheter removal. She was continuned on the heparin drip and her coumadin continued to be held in preparation for placement of a tunneled dialysis catheter by IR. However, the patient signed out AMA and thus it was not placed. 6. Anxiety: Pt recently saw psychiatrist who started her on Celexa. She was continued on Celexa 20mg PO daily. 7. Anemi of CKDa: The patient's Hct was 30.3 on admission. It trended down to 22.3 on discharge when she left AMA. There was no evidence of active, acute bleeding. THis is likely seoncdary to her ESRD. The patient was closely monitored. 8. Systemic Lupus Erythematosis: Rheumatology was consulted and does not suspect acute flare and dsDNA, C3, C4 nl, ESR and CRP slightly elevated. Her Echo did not suggest worsening pericarditis. She was continued on her home prednisone dose of 4mg daily. 9. Obstructive Sleep Apnea: CPAP for sleep with 7 pressure. Medications on Admission: Aliskiren 150 mg [**Hospital1 **] Clonidine 0.3mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 800mg PO TID Hydromorphone 4mg PO q4H PRN Nifedipine ER 90mg PO qday Prednisone 4mg PO qday Lorazepam 0.5mg PO qHS Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Warfarin held on discharge [**2141-12-14**] due to supratherap INR Discharge Medications: As patient signed out AMA, no medications were issued. She was told to resume her admission medications, however no instructions were taken by the patient. Discharge Disposition: Home Discharge Diagnosis: 1) Hypertensive urgency 2) Abdominal pain 3) End stage renal disease on hemodialysis 4) Venous thromboembolism Discharge Condition: Signed out AMA Discharge Instructions: Pt signed out AMA Return to the hospital with any concerning symptoms. Be sure to call your doctor's office on [**Month/Day/Year 766**] to arrange hemodialysis and review your medications and discuss follow-up plan. Followup Instructions: Follow-up with your Dr. [**Last Name (STitle) **] next week, and call [**Last Name (STitle) 766**] to arrange your hemodialysis. Completed by:[**2141-12-26**]

[ "300.4", "E878.1", "285.21", "996.56", "423.9", "403.01", "995.1", "V12.51", "E942.6", "V58.61", "710.0", "425.1", "585.6", "327.23", "287.4", "V58.65", "789.09" ]

icd9cm

[ [ [] ] ]

[ "38.95", "54.95", "97.82", "93.90", "39.95" ]

icd9pcs

[ [ [] ] ]

14347, 14353

8284, 13643

307, 313

14508, 14525

4287, 7477

14790, 14951

3544, 3669

14167, 14324

14374, 14487

13669, 14144

14549, 14767

3684, 4268

7500, 8261

245, 269

341, 1547

1569, 3316

3332, 3528

27,259

101,650

32547

Discharge summary

report

Admission Date: [**2176-11-16**] Discharge Date: [**2176-12-4**] Date of Birth: [**2111-1-21**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: IVC filter, tracheostomy and percutaneous gastrostomy tube placement History of Present Illness: Ms. [**Known lastname 75891**] is a 65 F who was transferred [**Hospital 75892**] Hospital with gallstone pancreatitis. The patient reports that the pain began at 11am with nausea and small bouts of comitting. The patient denies alcohol use. She reports that at the time of admission, her abdominal pain has improved Past Medical History: HTN, DM, DVT [**2173**], hyperlipidemia, anxiety, PSHx: D&C Social History: The patient denies alcohol use. She is married by separated from her husband who is an alcoholic and banned from her housing complex. She also denies tobacco, drug use. She lives independently. Family History: noncontributory Physical Exam: On admission: 97.1 80-120 ST 140/60 16 97% AAOx3 tachycardic, regular rhythm CTA b/l + BC, spigastric tenderness, - [**Doctor Last Name 515**] sign mild abdominal dilation DRE: Guiac neg, NL tome no c/c/e Pertinent Results: [**2176-11-16**] 09:37PM BLOOD WBC-26.7* RBC-5.11 Hgb-14.0 Hct-43.8 MCV-86 MCH-27.4 MCHC-32.0 RDW-13.7 Plt Ct-297 [**2176-12-4**] 03:12AM BLOOD WBC-11.2* RBC-3.43* Hgb-9.3* Hct-30.1* MCV-88 MCH-27.1 MCHC-30.9* RDW-16.7* Plt Ct-981* [**2176-11-16**] 09:37PM BLOOD PT-13.0 PTT-26.2 INR(PT)-1.1 [**2176-12-4**] 03:12AM BLOOD PT-13.3 PTT-29.5 INR(PT)-1.1 [**2176-12-4**] 03:12AM BLOOD Plt Ct-981* [**2176-11-16**] 09:37PM BLOOD Plt Smr-NORMAL Plt Ct-297 [**2176-12-4**] 03:12AM BLOOD Glucose-219* UreaN-16 Creat-0.6 Na-145 K-4.5 Cl-108 HCO3-33* AnGap-9 [**2176-11-16**] 09:37PM BLOOD Glucose-323* UreaN-19 Creat-1.0 Na-144 K-2.9* Cl-105 HCO3-26 AnGap-16 [**2176-12-2**] 01:45AM BLOOD ALT-23 AST-34 AlkPhos-295* Amylase-52 TotBili-0.4 [**2176-12-3**] 02:44AM BLOOD AlkPhos-229* [**2176-11-16**] 09:37PM BLOOD ALT-124* AST-102* LD(LDH)-236 AlkPhos-197* Amylase-1494* TotBili-2.0* DirBili-1.6* IndBili-0.4 [**2176-12-2**] 01:45AM BLOOD Lipase-32 [**2176-11-16**] 09:37PM BLOOD Lipase-2211* [**2176-12-4**] 03:12AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.5 [**2176-11-16**] 09:37PM BLOOD Albumin-3.7 Calcium-9.0 Phos-2.9 Mg-1.5* [**2176-11-20**] 12:33AM BLOOD calTIBC-202* Ferritn-155* TRF-155* [**2176-11-23**] 11:26AM BLOOD Lactate-0.8 K-4.7 [**2176-11-29**] 03:31AM BLOOD freeCa-1.13 [**11-16**]: RIGHT UPPER QUADRANT ULTRASOUND: Exam is somewhat limited due to patient body habitus. The liver is unremarkable with no focal lesions. The gallbladder has multiple gallstones, with a large gallstone measuring up to 1.4 cm. There is no wall thickening or pericholecystic fluid to suggest cholecystitis. No son[**Name (NI) 493**] [**Name (NI) **] sign was present. The common bile duct is markedly dilated measuring 1.5 cm, and there is central intrahepatic biliary ductal dilatation, raising the possibility of a distal CBD obstruction. The distal CBD and pancreas are not able to be visualized due to overlying bowel gas. The portal vein is patent with anterograde flow. There is no ascites [**11-17**]: ERCP: Ten fluoroscopic spot images obtained during ERCP procedure without radiologist present. Cholangiogram demonstrates dilated intra- and extra- hepatic bile ducts. There is suggestion of irregularity of the intrahepatic ducts which may be projectional. No filling defect is identified within the opacified biliary tree. The cystic duct is normally opacified. IMPRESSION: Intra- and extra-hepatic biliary dilatation. No filling defect is identified within the biliary tree. [**11-18**]: Ampullary mucosal biopsy: Ampullary mucosa with focal acute inflammation and fibrinopurulent exudates consistent with ulceration. [**11-26**]: U/S FINDINGS: The study is limited due to patient's body habitus. The liver texture is within normal limits allowing for technique. The gallbladder demonstrates multiple gallstones. There is no gallbladder wall edema or pericholecystic fluid. There is no intra- or extra- hepatic biliary ductal dilatation, and the common duct measures 7 mm. Main portal vein is patent with antegrade flow. [**12-2**]:CT- 1. Extensive severe pancreatitis with diffuse enlargement of the pancreas and fat stranding and ongoing formation of peripancreatic fluid collection/pseudocyst with attenuated SMV. Diffuse peritoneal fat stranding suggestive of panperitonitis with bowel dilatation. 2. Cholelithiasis. 3. Small ascites, slightly decreased in the lower pelvis. 4. Diffuse anasarca. 5. Diverticulosis. 6. Post G-tube placement. 7. New pneumomediastinum within the pericardial fat along the pericardium, of unknown etiology. Clinical correlation with recent procedure and interventions is recommended. Brief Hospital Course: On transfer to [**Hospital1 18**], Ms. [**Known lastname 75891**] was admitted to the trauma service and transferred to the SICU for further evaluation. She was made NPO, with IVF and a FOley was placed; the patient refused an NGT at the time. The patient's pain was to be controlled, and the patient was consented for an ERCP. THe patient received subcutaneous heparin for DVT prophylaxis, her hematocrit was watched on a dialy basis, ad the patient was put on an insulin sliding scale. The patient was [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] 3 at admission. A RUQ ultrasound was performed revealing cholelithiasis without cholecystitis, and CBD dilation as well. On [**11-17**], the patient underwent an ERCP with sphincterotomy; the report read "Intra- and extra-hepatic biliary dilatation. No filling defect is identified within the biliary." Her post procedure course was complicated by increased secretions, and hypoxia to 78%; the patient was made aware of the risk of aspiration pneumonia and respiratory distress, but she refused both an NGT and intubation at the time. The patient was made comfortable with anti-anxiety and pain medications, and her vital signs were closely monitored. The patient required fluid bolusing for volume depletion. A geriatric consult was called for further treatment and evaluation while the patient was in the ICU as the patient became delirious and had been quite agitated despite lorazepam and Haldol. Geriatrics recommended low dose dilaudid for pain control PRN, altering the dose of Haldol, removing all unneccessary tubes, lines and drains, and getting the patinet on a better sleep cycle. On [**11-18**], the patient became tachypneic to a respiratory rate in the 30s, oxygen saturation of 82% on RA, and was put on a face tent as she was not tolerating other oxygen supplementation. The patient's vital signs were unstable, and the patient was combative and aggressive. Her mental status began deteriorating, and the patient required intubation for airway protection, and adequate sedation for safety during hospital treatment. The patient was started on Unasyn for pneumonia (aspiration). On [**11-19**], the patient was intermittently tachycardic with decreased urine output; she was bolused for presumed volume depletion; her urine output improved and her renal function remained within normal limits. The patient also had an OGT and subsequently a DObhoff tube placed for tube feeds. The patient's respiratory status was frequently monitored and changed according to evaluations. Her sedation and ventilation were attempted to be weaned. Her hospital course was complicated by post-procedure fevers; blood cultures were sent when the patient spiked, and chest x-rays, urine analysis/cultures were also taken. The patiemt was noted to have a R base consolidation, and went for bronchoalveolar lavage on [**11-23**]. The patient was put on vancomycin and later levo as well as zosyn for empiric VAP treatment; these antibiotics were stopped when appropriate, i.e, when cultures returned with sensitivities, and/or fevers and leukocytosis decreased. The patient was diuresed when appropriate as she was fluid overloaded with pleural effusions during her hospital stay. A right sided pleural effusion was worsening, and the patient underwent a pleural tap and pigtail placement to expand the lung and rule out empyema as the patient continued to be febrile with some vital sign lability. The patient had stable post procedure anemia until [**11-26**], at which time, the patient had to be transfused 2units of prbcs. As the pt continued to be vent dependednt, the patient underwent a trach, IVC filter, and PEG on [**11-27**]; for details please see operative note. Om [**11-30**], the patient's trach was inadvertently dislodged, and an emergent trach had to be placed; placement was confirmed by bronch. The patient was discharged to rehab on [**12-4**] in stable condition; she was hemodynmically stable, afebrile, tolerating tube feeds, off antibiotics, with normalizing wbc and LFTs. Medications on Admission: GLipizide, Lipitor, Metformin, Lisinopril, Prilosec Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 2. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 4. Bisacodyl 10 mg Suppository Sig: Ten (10) mg Rectal DAILY (Daily): Suppository(s). 5. Acetaminophen 160 mg/5 mL Solution Sig: 325-650 mg PO Q6H (every 6 hours) as needed for fever. 6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze. 7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 8. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Insulin Regular Human Injection 16. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg Injection Q6H (every 6 hours) as needed for n/v. 17. Magnesium Sulfate 4 % Solution Sig: Sliding SCale Injection PRN (as needed). 18. Calcium Gluconate 100 mg/mL (10%) Solution Sig: Sliding Scale Intravenous ASDIR (AS DIRECTED). 19. Potassium Chloride Intravenous 20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 21. Potassium Phosphate Dibasic 3 mMole/mL Parenteral Solution Sig: Sliding Scale Intravenous ASDIR (AS DIRECTED). 22. Lorazepam 2 mg/mL Syringe Sig: 0.5-1.0 mg Injection Q4H (every 4 hours) as needed for agitation. 23. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 24. Roxicet 5-325 mg/5 mL Solution Sig: [**5-30**] ml PO every [**4-26**] hours. 25. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: Gallstone pancreatitis Discharge Condition: stable Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * 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. * Continue to ambulate several times per day. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in [**1-23**] weeks; make an appointment at [**Telephone/Fax (1) 6429**]

[ "574.21", "263.8", "V12.51", "280.0", "276.6", "276.51", "577.2", "300.00", "507.0", "519.02", "401.9", "293.0", "272.4", "250.80", "518.82", "794.8", "577.0", "482.0", "511.9" ]

icd9cm

[ [ [] ] ]

[ "99.21", "97.23", "31.1", "99.04", "38.93", "34.91", "51.14", "38.7", "57.94", "33.24", "96.72", "51.88", "43.11", "96.04", "51.85", "96.6" ]

icd9pcs

[ [ [] ] ]

11373, 11453

4977, 9067

330, 401

11520, 11529

1330, 4954

12619, 12747

1063, 1080

9169, 11350

11474, 11499

9093, 9146

11553, 12596

1095, 1095

276, 292

429, 750

1109, 1311

772, 834

850, 1047

78,597

162,193

42360

Discharge summary

report

Admission Date: [**2188-11-14**] Discharge Date: [**2188-11-19**] Date of Birth: [**2125-7-24**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: Exertional dyspnea Major Surgical or Invasive Procedure: [**2188-11-15**] Urgent Two Vessel Coronary Artery Bypass Grafting utilizing saphenous vein grafts to left anterior descending and obtuse marginal arteries. History of Present Illness: This is a 63 year old white male with exertional mid scapular discomfort and mild shortness of breath with mountain climbing, mowing in hot weather since summer. Denies diaphoresis, rest symptoms or chest/jaw pain. He underwent a stress echo today, with 6mm downward sloping ST depression across anterolateral precordial leads. Had anterior chest pain during this. Subsequent cardiac catheterization at [**Hospital6 5016**] revealed a critical 90% left main lestion. Since catheterization, he has denied chest pain or symptoms. He was urgently transferred to the [**Hospital1 18**] for surgical revascularization. Past Medical History: Hypertension Environmental Asthma Social History: 15 pack year history of tobacco, quit 15 years ago. No history of excessive ETOH and/or abuse. Married, lives with his wife. [**Name (NI) **] is a ski instructor, and writer. Family History: Adopted, family history unknown Physical Exam: Pulse: 74 Resp:14 O2 sat:98% RA BP Right:130/70 Left:130/74 Height: 66" Weight: 79.5kg General: WDWN male in no acute distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema: none Varicosities: None Neuro: Grossly intact [x] Pulses: Femoral Right:2 Left:2 DP Right:1 Left:1 PT [**Name (NI) 167**]:1 Left:1 Radial Right:2 Left:2 Carotid Bruit Right:none Left: none Pertinent Results: [**2188-11-15**] Intraop TEE Report: The patient developed cardiogenic shock from myocardial ischemia several minutes after the inductuion of general anesthesia. Due to this, no pre-bypass echocardiographic imaging could be performed. This study is composed of post bypass imaging obtained with the patient receiving epinephrine and norepinephrine by infusion and in sinus rhythm. POST BYPASS 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. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with moderate mid to distal septal and anteroseptal as well as apical hypokinesis. Overall left ventricular systolic function is mildly depressed (LVEF= 40-45 %). The right ventricular cavity appears somewhat dilated with normal free wall contractility. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 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. Physiologic mitral regurgitation is seen (within normal limits). There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results in the operating room at the time of the study. . [**2188-11-19**] WBC-7.0 RBC-4.40* Hgb-9.6* Hct-29.5* RDW-18.7* Plt Ct-163 [**2188-11-18**] WBC-10.5 RBC-4.88 Hgb-11.0* Hct-33.0* RDW-19.2* Plt Ct-161 [**2188-11-17**] WBC-10.3 RBC-4.67 Hgb-10.2* Hct-30.9* RDW-18.8* Plt Ct-119* [**2188-11-16**] WBC-10.5 RBC-4.57* Hgb-10.2* Hct-30.9* RDW-19.3* Plt Ct-126* [**2188-11-15**] WBC-14.1* RBC-4.23* Hgb-9.1* Hct-28.1* RDW-18.1* Plt Ct-138* [**2188-11-14**] WBC-8.0 RBC-6.26* Hgb-12.8* Hct-40.0 RDW-16.2* Plt Ct-212 [**2188-11-19**] Glucose-83 UreaN-27* Creat-1.1 Na-140 K-3.9 Cl-98 HCO3-33* [**2188-11-18**] Glucose-124* UreaN-26* Creat-1.1 Na-136 K-4.0 Cl-97 HCO3-32 [**2188-11-17**] Glucose-109* UreaN-17 Creat-1.0 Na-136 K-3.9 Cl-101 HCO3-28 [**2188-11-15**] Glucose-124* UreaN-21* Creat-1.4* Na-143 K-4.0 Cl-109* HCO3-23 [**2188-11-14**] Glucose-105* UreaN-13 Creat-1.0 Na-138 K-4.1 Cl-103 HCO3-24 [**2188-11-19**] Calcium-8.5 Phos-3.3 Mg-2.1 [**2188-11-14**] Albumin-4.7 Calcium-9.7 Phos-3.8 Mg-1.9 Brief Hospital Course: Mr. [**Known lastname 91748**] was admitted to the cardiac surgical service. Given his critical left main lesion, he remained in the CVICU and was started on intravenous Heparin. He remained pain free and stable intravenous therapy. Preoperative evaluation was unremarkable and he was cleared for surgery. The following day, Dr. [**Last Name (STitle) **] performed two vessel coronary artery bypass grafting surgery. Operative course was notable for cardiogenic shock from myocardial ischemia several minutes after the inductuion of general anesthesia. This required resuscitative efforts and emergent surgical intervention. For further operative details, please see operative note. Following surgery, he was admitted back to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. He maintained stable hemodynamics and weaned from inotropic support without difficulty. On postoperative day two, he transferred to the SDU for further care and recovery. Beta blockade was resumed and advanced as tolerated. He remained in a normal sinus rhythm. Over several days, he continued to make clinical improvement with diuresis and was eventually cleared for discharge to home on postoperative day four. Prior to discharge, all appropriate followup appointements were arranged. Medications on Admission: Lisinopril 5mg daily, Aspirin 81mg daily, Toprol 25mg daily Discharge Medications: 1. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*90 Tablet, Chewable(s)* Refills:*2* 6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: Please take with KCL. Disp:*14 Tablet(s)* Refills:*0* 8. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 7 days: Please take with Lasix. Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 1514**] Regional VNA Discharge Diagnosis: Coronary artery disease, s/p CABG Hypertension Cardiac Arrest(perioperative) 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 Right/Left - healing well, no erythema or drainage. Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge . **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2188-12-24**] at 1:00pm, [**Telephone/Fax (1) 170**] Cardiologist: Dr. [**Last Name (STitle) 29070**], appt pending at discharge - please call office to confirm appt date Wound check: [**2188-11-27**] at 10:15am at [**Hospital Unit Name **], [**Location (un) 551**] . Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **] in [**4-22**] weeks, [**Telephone/Fax (1) 85866**] . **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:[**2188-11-19**]

[ "413.9", "414.01", "785.51", "427.5", "E878.2", "493.00", "401.9", "997.1" ]

icd9cm

[ [ [] ] ]

[ "37.91", "36.12", "99.60", "39.61" ]

icd9pcs

[ [ [] ] ]

7052, 7120

4569, 5902

331, 490

7241, 7455

2131, 4546

8381, 9102

1398, 1431

6012, 7029

7141, 7220

5928, 5989

7479, 8358

1446, 2112

273, 293

518, 1133

1155, 1190

1206, 1382

3,292

174,266

8560

Discharge summary

report

Admission Date: [**2125-1-19**] Discharge Date: [**2125-1-21**] Service: MEDICINE Allergies: Codeine / Adhesive Attending:[**First Name3 (LF) 2485**] Chief Complaint: Anemia Major Surgical or Invasive Procedure: Blood transfusion. History of Present Illness: 81 yo woman with hx of CAD, Afib, CKD here after few weeks of progressive fatigue and anemia over which time she noted dark black stools which she attributed to her iron supplementation, she has been off iron for a few weeks and was started on IV iron and eopgen shots per her nephrologist as anemia thought to be secondary to her renal insufficiency. They were unable to transfuse her with a Hct of 23 b/c of difficult anitbody match and very trying other methods to support her anemia. She has had chronic anemia initially was on B12 shots, but increasing difficulty recently. She was transfused many yrs ago and also after her right BKA. . She was seen at [**Hospital3 7569**] and noted to have an INR 10.1 and Hct 14.9, was given 2uFFP, Vitamin K and sent over because of difficult to transfuse anemia and Gi evaluation. . NGL here was clear with 400cc per ED and stool was dark brown with guiaic positive. . Currently getting 1uPRBC and 2u FFP and overall still feels tired but has her chronic arthritis pain. She denies any CP, SOB or palpitations. She admits to DOE at 10-15 feet, some nausea, but no vomiting, no abd pain or other complaints. Past Medical History: Paroxysmal Atrial fibrillation on coumadin CAD CHF normal EF, diastolic dysfunction Anemia-- chronic of unknonw etiology Rheumatic fever at age 7, no known valvular disease Diabetic diet controlled, very sensitive to insulin Right elbow surgery. Right hip total joint arthroplasty with sciatic injury and neuropathy s/p stasis ulcers and gangrene resulted in right right BKA Bilateral mastectomy for breast cancer; the first 23years ago, the second 15 years ago. Status post cataract surgery in both eyes. Bladder cancer, status post surgery with recurrent bladder polyps, has placed local chemo [**Doctor Last Name 360**] placed by her chemo Status post foot surgery in [**2117**] Hypertension times 35 years Diabetes mellitus, diet controlled times three to four years Gout Chronic renal insufficiency with a baseline of mid 2's Hx of DVT Social History: She is a retired office worker. Lives with her husband, son and daughter in law [**Name (NI) 2048**] [**Name (NI) 30075**] her HCP [**Telephone/Fax (1) 30076**]. She does not smoke, nor does she drink. Family History: Her mother died at 68 of a heart attack. Her father died at 57 of stomach cancer. Physical Exam: VS: T 98.0 BP 133/45 P 64 R18 Sat 99%Ra and 100%2L GEN aao, nad HEENT PERRL, MMM, +pallor conjunctiva, neck supple with minimal JVD CHEST CTAB no wheezes, crackles. CV RRR no murmurs, distant heart sounds. ABD soft, Nt/ND, +BS, guaiac +, brown stool. EXT right BKA, left LE with trace LE edema, 1+Dp pulses NEURO a&ox3, cn ii-xii intact; motor, sensory, coordination, and language grossly intact. Pertinent Results: [**2125-1-20**] 11:33PM BLOOD WBC-18.8*# RBC-3.28*# Hgb-10.4*# Hct-28.0*# MCV-85 MCH-31.7 MCHC-37.2* RDW-20.7* Plt Ct-328 [**2125-1-19**] 07:00AM BLOOD WBC-10.8 RBC-1.37*# Hgb-3.9*# Hct-13.1*# MCV-95# MCH-28.2 MCHC-29.6* RDW-23.6* Plt Ct-418 [**2125-1-19**] 07:00AM BLOOD Neuts-81.4* Lymphs-12.5* Monos-3.3 Eos-2.3 Baso-0.5 [**2125-1-19**] 07:00AM BLOOD PT-18.8* PTT-39.9* INR(PT)-2.5 [**2125-1-19**] 07:00AM BLOOD Plt Ct-418 [**2125-1-19**] 07:00AM BLOOD Ret Aut-7.5* [**2125-1-19**] 07:00AM BLOOD Glucose-124* UreaN-70* Creat-2.7* Na-143 K-4.3 Cl-108 HCO3-22 AnGap-17 [**2125-1-20**] 11:33PM BLOOD Glucose-122* UreaN-66* Creat-2.6* Na-140 K-4.0 Cl-105 HCO3-23 AnGap-16 [**2125-1-19**] 07:00AM BLOOD ALT-11 AST-12 LD(LDH)-164 CK(CPK)-46 AlkPhos-62 Amylase-78 TotBili-0.1 [**2125-1-19**] 07:00AM BLOOD CK-MB-2 cTropnT-<0.01 [**2125-1-20**] 11:33PM BLOOD Calcium-8.1* Phos-3.2 Mg-1.8 [**2125-1-19**] 07:00AM BLOOD calTIBC-265 VitB12-385 Folate-7.6 Hapto-230* Ferritn-220* TRF-204 [**2125-1-19**] 07:00AM BLOOD TSH-4.1 [**2125-1-19**] 09:48PM BLOOD Free T4-1.1 . ECG: Sinus rhythm. First degree atrio-ventricular conduction delay. Left bundle-branch block with secondary repolarization abnormalities. Brief Hospital Course: A/P: 81 yo woman with CAD, Afib, CHF, CKD admitted with worsening anemia in setting of supratherapeutic INR. Was seen at OSH but had difficult antibodies for RBC transfusion, transferred to [**Hospital1 18**] for further management. . Anemia: Likely acute blood loss superimprosed on chronic underproduction from chronic kidney dx or even possibly from her history of local chemotherapy for bladder cancer treatment. Hct increased from 13 on admission to 28 with 4 units pRBCs. Patient had melanotic stools x1, otherwise was asymptomatic. Was diuresed with IV lasix with transfusions, and her BB/CCB were held on admission, so as not to mask reflex tachycardia in the setting of acute blood loss. At the time of discharge, she was hemodynamically stable and her home doses of BB and CCB were restarted. . GI bleed: Pt. was transfused to support anemia, and anticoagulation was reversed with Vit. K and FFP. Pt. will have a colonoscopy/EGD as outpatient to be arranged this week. Aspirin and coumadin will be held until after GI studies are completed. Pt. has h/o labile INR and was supratherapeutic (INR 2.5) on admission, so will have to be cautious when anticoagulation is restarted. Encouraged Pt. to have frequent INR checks. Medications on Admission: atenolol 50 mg p.o. [**Hospital1 **] glucosamine chondroitin allopurinol 100mg qd coumadin 2.5 M-F/1.25 S/S lasix 40mg qd norvasc 10mg qd prevacid 30mg qd tapazole 5mg qd oscal Discharge Medications: 1. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*15 Tablet(s)* Refills:*0* 2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO twice a day. 3. Glucosamine / Chondroitin 4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. 5. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 6. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 8. Methimazole 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Anemia, GI Bleed Discharge Condition: Fair, stable. Discharge Instructions: Continue to monitor your symptoms. Return to the emergency room immediately for bloody or black stools, chest pains, shortness of breath, increased lightheadedness, or any other symptom which concerns you. . For today ([**1-21**]) only, if you are feeling short of breath, please take an extra lasix (furosemide) pill. . Please arrange for colonoscopy as soon as possible. . Please arrange to see a PCP after your colonoscopy so that your coumadin can be restarted. Do not take coumadin or aspirin until this appointment. . Please continue to take all your other meds as you have been doing. Followup Instructions: Follow up with gastroenterology on Tuesday for a colonoscopy as scheduled. . PCP: [**Name10 (NameIs) 30077**],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 16827**] Completed by:[**2125-1-21**]

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icd9cm

[ [ [] ] ]

[ "99.04", "99.07" ]

icd9pcs

[ [ [] ] ]

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4284, 5520

233, 254

6405, 6421

3060, 4261

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5748, 6315

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5546, 5725

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2639, 3041

187, 195

282, 1439

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11,758

185,416

30452

Discharge summary

report

Admission Date: [**2166-5-7**] Discharge Date: [**2166-5-20**] Date of Birth: [**2102-10-12**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 1148**] Chief Complaint: abdominal pain and shortness of breath after elective colonoscopy Major Surgical or Invasive Procedure: colonoscopy blood transfusions History of Present Illness: 63 yo F hx COPD (2L O2 at home), CAD who was admitted on [**5-7**] for elective polypectomy. Experienced COPD exacerbation post-colonoscopy. Her ASA, plavix were stopped 6 d ago. Pt developed a small amount of BRBPR after her colonoscopy, then at about 4 PM, she had a large amount of BRBPR about 1L. She then was noted to become tachycardiac to 110 and BP dropped to 50's. Pt placed in T-[**Last Name (un) **] position, BP improved to 90s. Additional IV access obtained, NS wide open and 2U PRBCs of emergency release blood were initiated. Pt transferred to ICU, where 2 additional 18 bore IV's placed and pt received additional NS. BP on MICU arrival 110's, improved to 150's with resuscitation at which point NS stopped. HCT noted to have dropped 10 points since this AM. PRBCs continued. Pt notes increased abdominal pain especially when coughing and increased distention. Pt mentating well throughout, and extremities warm well perfused throughout. Pt denies chest pain. Mild increase in SOB after agressive IVF. No recent fevers, chills, stable O2 at home. Past Medical History: 1. CAD--no stents or CABG as per patient 2. PVD with stents 3. DM 4. Hypertension 5. Hyperlipidemia 6. GERD 7. OSA Social History: Long smoking history, occasional alcohol, no drug use. Intermittent home oxygen Family History: NC Physical Exam: VS: Temp: 98 BP:122/60 HR:102 RR:22 95%3 litersO2sat . general: pleasant, uncomfortable secondary to pain, mildly tachypneic, obese HEENT: EOMI, anicteric, no sinus tenderness, MMM, op without lesions, lungs: diffuse wheezes, poor air movement heart: RR, S1 and S2 wnl, no murmurs, rubs or gallops appreciated abdomen: distended, decreased bowel sounds, diffuse tenderness, no rebound or guarding, extremities: 1+ edema skin/nails: no rashes neuro: AAOx3. Cn II-XII intact. 5/5 strength throughout. Pertinent Results: [**2166-5-7**] COLONOSCOPY: Findings: Protruding Lesions Three polyps were found in the cecum, ascending colon and splenic flexure. The cecal polyp was 1 cm and sessile. The ascending colon polyp was 2 cm and pedunculated. The splenic flexure polyp was 4 cm and semi-pedunculated. Other procedures: A single-piece polypectomy was performed using a hot snare over a saline pillow in the cecum. A single-piece polypectomy was performed using a hot snare in the ascending colon. A piece-meal polypectomy was performed using a hot snare in the splenic flexure. The polyps were completely removed. SPOT injection was applied for tattooing with success in the splenic flexure. Impression: Three polyps were found in the cecum, ascending colon and splenic flexure. The cecal polyp was 1 cm and sessile. The ascending colon polyp was 2 cm and pedunculated. The splenic flexure polyp was 4 cm and semi-pedunculated. A single-piece polypectomy was performed using a hot snare over a saline pillow in the cecum. A single-piece polypectomy was performed using a hot snare in the ascending colon. A piece-meal polypectomy was performed using a hot snare in the splenic flexure. The polyps were completely removed. SPOT injection was applied for tattooing with success in the splenic flexure. . [**2166-5-7**] CXR: Small right pleural effusion. . [**2166-5-7**] PORTABLE ABDOMEN: No evidence of obstruction or free air. . [**2166-5-7**] ECG: Sinus rhythm and frequent atrial ectopy. The QRS morphology in leads V1-V2 again appear to be position related as compared to the previous tracing of [**2166-4-28**]. There is now frequent atrial ectopy. Otherwise, no diagnostic interim change. . [**2166-5-8**] PORTABLE ABDOMEN: Significantly dilated loops of large bowel for which CT can be performed for further evaluation if clinically warranted. . [**2166-5-8**] CXR: Right pleural effusion, stable since day prior. No consolidation. . [**2166-5-8**] ECG: Sinus tachycardia @ 125. Poor R wave progression. Compared to the previous tracing of [**2166-5-7**] the ventricular rate is faster. Atrial premature beats are absent. . [**2166-5-9**] ECHO: 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. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. There is no valvular aortic stenosis. The increased transaortic gradient is likely related to high cardiac output. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. There is an anterior space which most likely represents a fat pad. . [**2166-5-11**] CT ABD/PELVIS: Uncomplicated cecal bascule, observed with 180 rotation, but without obstruction. This appearance raises the possibility that recent symptoms could related to transient torsion of the bascule. No evidence of free air. . [**2166-5-11**] KUB: Markedly dilated loops of bowel are again demonstrated, with large diagonally oriented loop of bowel extending from the pelvis to the right side of the abdomen measuring about 13 cm in diameter. This is similar in dimension to the previous examination. Although possibly due to a colonic ileus, the a volvulus or other cause of obstruction should be considered, and further evaluation with CT may be considered as previously recommended on [**2166-5-8**]. . [**2166-5-12**] TRANSVAGINAL PELVIS U/S: 1. Fibroid uterus which contains small fibroids in anterior and posterior fundus. 2. The endometrium measures 5 mm in thickness with no focal lesion. 3. The ovaries were not visualized. . [**2166-5-14**] 1:49 am STOOL CONSISTENCY: SOFT Source: Stool. CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2166-5-14**]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. . Brief Hospital Course: 1) Abdominal pain post polypectomy: Patient initially admitted for pain control post polypectomy. This was believed secondary to post polypectomy syndrome. Given cipro/flagyl for total 14 days. Pain improved. Also had dilation of colon moderately that improved prior to discharge. CT scan abdomen/pelvis showed cecal dilatation, with evidence of underlying cecal malrotation and hypermobility (ie. abnormal fixation), which may result in cecal "bascule" or volvulus. This may place patient at higher risk of volvulus or malrotation in the future. No obstruction seen. Continue bowel regimen. Recommend follow up colonoscopy arraged in 6 months to eval polypectomy site. Biopsies showed adenoma. . 2) GIB: Patient had lower GIB day after admission requring transfusion 3U PRBCs and transfer to MICU. Stabilized without recurrence. Patient to restart plavix/aspirin now at discharge. . 3) COPD exacerbation: Worsened after procedure. Initially required higher oxygen levels that were then weaned back to home 2L NC. Continued on nebs. Discharge again with theophyline. Steroids were increased initially and then tapered back down to outpatinet regimen of prednisone 4mg [**Hospital1 **]. . 4) Menorrhagia: Patient had episode menorrhagia after not receiving premarin for a few days. Transvaginal ultrasound revealed largest width of endometrium at 5mm. Rec follow up as outpatient and possible referral to gynecology for biopsy. . 5) CAD/HTN: Continue ASA (held while here), statin. BP meds held around time of GIB. Have discontinued nitro patch and dyazide as BP well controlled without them. Can consider restarting as outpatient if needed. No cardiac events while here. . 6) DM Type 2: Patient had lower insulin dosing when made NPO and now back on outpatient regimen. Blood sugars slightly high while here; continue to monitor and consider increasing long acting insulin as needed. . 7) Leukocytosis: WBC around 18-20 in days prior to discharge. C diff negative times two. Found new infiltrate on CXR so started on ceftriaxone and will receive 7 days total antiobiotics (ceftin as outpatient). Spoke with PCP who says patient has had leukocytosis for a while. Consider referral to hematology if persists for further evaluation. Manual diff normal while here. . 8) Medications on Admission: Medications:(obtained from patient's sister at [**Telephone/Fax (1) 72382**]-[**Name2 (NI) **]) 1. aspirin 81 2. plavix 75--has peripheral stents, was off for 5 days prior to [**Last Name (un) **]-as per GI, ok to restart 3. lisinopril 20 4. diltiazem xr 240 daily 5. theophylline 400 xr 6. protonix 40 7. lipitor 80 8. prednisone 4mg [**Hospital1 **] 9. kcl 20 meq [**Hospital1 **] 10. prempro 0.625 11. triamterene/hctz-37.5/25 12. nitropatch 0.4mg qAM 13. 48 units 70/30 q AM and 24 units NPH q PM with regular sliding scale 14. Advair 15. Combivent q6h 16. albuterol prn 17. tums Discharge Medications: 1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 2. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. 3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 5. Theophylline 400 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once 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. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day). 9. Conjugated Estrogens 0.625 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty Four (24) Units Subcutaneous qpm. 11. Insulin Asp Prt-Insulin Aspart 100 unit/mL (70-30) Solution Sig: Forty Eight (48) Units Subcutaneous qam. 12. Insulin Regular Human 100 unit/mL Cartridge Sig: as directed Injection four times a day as needed for per sliding scale. 13. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 14. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 15. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation QID (4 times a day). 16. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 days. 17. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 days. 18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. Ceftin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Discharge Disposition: Extended Care Facility: [**Hospital **] Rehab Discharge Diagnosis: GIB post polypectomy post polypectomy syndrome COPD exacerbation menorrhagia Type 2 diabetes uncontrolled with complications Hospital acquired pneumonia cecal malrotation and hypermobility (ie. abnormal fixation) Leukocytosis Discharge Condition: Stable Discharge Instructions: You were admitted after a polypectomy/colonoscopy. This was complicated by a gastrointestinal bleed and worsening of your COPD. These have both been stablized and you will go to rehab for further strengthening. Please call your PCP or return if you develop worse abdominal pain, bleeding. . You also had an episode of vaginal bleeding while here when your premarin was held. We recommend you consider follow up with a gynecologist to make sure there are no further abnormalities. . Your wbc count was elevated while here as well. We found no clear no source of infection and recommend getting this repeated as an outpatient. You should also consider a referral to a hematologist if this continues to persist. Followup Instructions: You have a follow-up appointment scheduled with Dr. [**Last Name (STitle) 26225**] (PCP) on [**2166-5-26**] at 1:00. [**Telephone/Fax (1) 72383**] . You should contact your gastroenterologist, Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 72384**]) regarding a follow up appointment and arrangements for repeat colonoscopy in 6 months.

[ "250.02", "401.9", "530.81", "272.4", "E878.8", "486", "626.2", "998.11", "211.3", "491.21", "414.01" ]

icd9cm

[ [ [] ] ]

[ "45.42" ]

icd9pcs

[ [ [] ] ]

11247, 11295

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347, 379

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1728, 1732

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11316, 11544

8778, 9364

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1747, 2248

242, 309

407, 1475

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51,874

151,466

3095

Discharge summary

report

Admission Date: [**2159-11-2**] Discharge Date: [**2159-11-8**] Service: SURGERY Allergies: Statins-Hmg-Coa Reductase Inhibitors Attending:[**Doctor First Name 5188**] Chief Complaint: Abdominal pain, vomiting Major Surgical or Invasive Procedure: Exploratory Laparoscopy Adhesions with closed loop and small bowel strangulation. History of Present Illness: 85 year-old lady with Severe COPD (home oxygen 4L), CAD, obstructive cardiomyopathy presents with abdominal pain and vomiting since noon the day prior to admission. Patient lives at assisted care facility. She had a BM in the AM, but in the late afternoon/early evening she had severe diffuse abdominal pain and had episodes of bilious vomiting. She had not passed flatus recently when she came to the ED. She denies any fevers/chills. No melena or BRBPR. . In ED her initial vitals were, T 97, BP 153/91, HR 84, RR 15 98% on 4LNC. She recived cipro IV 400 mg and flagyl 500 mg IV. CT abdomen and pelvis was concerning for closed loop SBO. Patient was taken to OR. She underwent exploratory laproscopy, lysis of adhesions and small bowel resection. EBL was 75 ml. Patient had an Aline placed. She was started on propofol gtt and required phenylephrine gtt for hypotension. . On arrival to [**Hospital Unit Name 153**], patient was unable to give any history due to sedation. Past Medical History: COPD on [**3-14**] L O2 at home CAD s/p NSTEMI in [**3-16**] (cath showed 30% L main, 50% LAD disease) CHF - obstructive cardiomyopathy Pulmonary HTN Hyperlipidemia Hypothyroidism S/p TAH Hiatal hernia s/p herniorrhaphy Presbyacusis DVT [**7-/2157**] on coumadin . SURGICAL HISTORY: TAH, hiatal hernia repair, cataract surgery L eye Social History: Approximately 20 pk-yr smoking Hx, quit 30yr ago, no ETOH, no IVDA, lives at an [**Hospital3 **] facility. Able to walk in the NH with portable oxygen. Fairly functional but last week has been taking too much morphine. Family History: Father with heart disease, mother with melanoma. Physical Exam: GENERAL: Sedated lady HEENT: ET tube in place, normocephalic, atraumatic. MMM. Neck Supple CARDIAC: Regular rhythm, normal rate. Normal S1, S2. Difficult to assess murmurs due to coarse breath sounds LUNGS: Coarse breathsounds diffusely ABDOMEN: Soft, nondistended. EXTREMITIES: No edema. . At Discharge: Vitals:98.3, 76, 100/49, 22, 94% on 3L GEN: NAD, A/Ox3 CV: RRR, no m/r/g RESP: CTAB, no w/r/r ABD: soft, ND, appropriately TTP, +BS, +flatus Incision: midline abdomen OTA with staples, CDI Extrem: no c/c/e Pertinent Results: [**2159-11-2**] 12:22AM BLOOD WBC-10.0 RBC-5.19 Hgb-14.5 Hct-44.0 MCV-85 MCH-27.8 MCHC-32.8 RDW-15.0 Plt Ct-297 [**2159-11-2**] 06:36PM BLOOD WBC-12.1* RBC-4.60 Hgb-12.9 Hct-38.6 MCV-84 MCH-28.1 MCHC-33.4 RDW-14.6 Plt Ct-331 [**2159-11-5**] 06:30AM BLOOD WBC-7.9 RBC-4.26 Hgb-12.1 Hct-36.3 MCV-85 MCH-28.4 MCHC-33.3 RDW-15.2 Plt Ct-286 [**2159-11-2**] 02:21AM BLOOD PT-12.4 PTT-24.2 INR(PT)-1.0 [**2159-11-3**] 03:12AM BLOOD PT-13.7* PTT-26.2 INR(PT)-1.2* [**2159-11-2**] 12:22AM BLOOD Glucose-176* UreaN-18 Creat-1.0 Na-138 K-6.0* Cl-99 HCO3-29 AnGap-16 [**2159-11-3**] 03:12AM BLOOD Glucose-152* UreaN-17 Creat-0.8 Na-138 K-4.2 Cl-105 HCO3-23 AnGap-14 [**2159-11-7**] 08:05AM BLOOD Glucose-99 UreaN-8 Creat-0.6 Na-142 K-3.7 Cl-103 HCO3-32 AnGap-11 [**2159-11-2**] 12:22AM BLOOD ALT-17 AST-51* LD(LDH)-766* CK(CPK)-97 AlkPhos-80 TotBili-0.6 [**2159-11-2**] 09:20AM BLOOD ALT-11 AST-24 AlkPhos-76 TotBili-0.5 [**2159-11-2**] 12:22AM BLOOD cTropnT-<0.01 [**2159-11-6**] 12:54AM BLOOD CK-MB-5 cTropnT-0.01 [**2159-11-2**] 09:20AM BLOOD Albumin-3.7 Calcium-8.9 Phos-3.4 Mg-2.5 [**2159-11-7**] 08:05AM BLOOD Calcium-8.3* Phos-3.2 Mg-2.1 . Micro/Imaging: [**2159-11-6**] TTE severe pulm atrial htn, LVH, EF>55%, resting LV outflow [**Last Name (un) **] [**2159-11-3**] CXR clear [**2159-11-2**] CTa/p dilated SB loops, 2 transition pts [**2159-11-2**] Sputum cx contaminated [**2159-11-2**] Bcx No growth Brief Hospital Course: The patient is an 85 year-old woman with severe COPD (on home oxygen 4L), CAD, obstructive cardiomyopathy who presented with closed loop small bowel obstruction s/p exploratory laparoscopy, lysis of adhesions and small bowel resection. She was transferred to the ICU for post-operative monitoring after becoming hypotensive, briefly requiring pressors, when started on propofol. . Brief ICU Course: . # S/p exploratory laparoscopy, lysis of adhesions and small bowel resection: Patient tolerated surgery well. She was given a morphine PCA for pain control and treated with cefazolin perioperatively. She was extubated successfully the next morning and weaned quickly down to 2-4L oxygen by nasal canula after diuresis. She was started on a perioperative beta-blocker, which was given intravenously while the patient was kept NPO. . # Hypotension: Patient was bolused 2L IVFs overnight for low blood pressures, but she did not require pressors to be restarted. Her blood pressures remained stable in the low 100s systolic. - DNR/DNI had been reversed for surgery --> readdress code status? (discuss w daughter) General Surgery: Operative course uncomplicated, noted to have strangulated segment of bowel which was resected. Routinely observed in PACU, and transferred to Stone 5 for post-op care. Remained NPO with NGT to suction. POD3-minimal NGT output. Tolerated clamp trial. NGT removed. Remained NPO until bowel function returned. Pain controlled with PCA. Abdominal incision intact with staples, CDI. Diet advanced gradually from sips to regular food as bowel function and abdominal distention improved. Reported flatus. IV fluid discontinued. Foley removed. Voided without issue. Medications switched to oral. Pain well controlled with oral Tylenol. Physical Therapy consulted. Patient ambulates with walker at baseline. Activity not at baseline. Required assistance and further REHAB. Screened for REHAB, discharhed once surgically/medically ready. Ambulated in halls with walker. . Patient was on telemetry to monitor her cardiac status. She had three observed episodes of SVT which was self-limited to <1 minute. EKG after each event revealed no changes from baseline. Cardiology consultation requested an echo to re-assess cardiac status. It revealed stable severe pulm artery hypertension, left ventricular hypertrophy, EF>55%, and resting LV outflow obstruction. Cardiology also recommended increasing her statin, starting & continuing beta-blockade, holding her home verapamil, and initiating low-dose ACE inhibitor. These recommendations were completed prior to discharge. The patient remained stable on this regimen with no visible signs of tachycardia via Telemetry. . At discharge, abdominal incision intact with staples. REHAB facility to remove stables on Monday [**11-12**] (post-op day 10) if sugical wound intact and healed. Steri strips will be applied. . Patient will follow-up with Dr. [**Last Name (un) 14682**] in a few weeks after discharge. . Anticoagulation: Patient has history of DVT in 6/[**2157**]. She was treated with Coumadin for about 2 years, and has been off therapy for about a year. THis information was confirmed with both patient and patient's daughter. Medications on Admission: Very unreliable with medications. Confirmed with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1356**] (Hospice NP) Morphine (Roxinall) 4 mg [**Hospital1 **], q4h prn Synthroid 50 mcg daily Protonix 40 mg daily Colace Dulcolax 2 tabs prn Discharge Medications: 1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO Q 12H (Every 12 Hours): Hold SBP<110, HR<65. . 7. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheezes. 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever: Do not exceed 4000mg in 24hrs. 11. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Nasal once a day. Discharge Disposition: Extended Care Facility: [**Hospital **] LivingCenter Discharge Diagnosis: Small-bowel obstruction intra-operative ectopy-related to CHF post-op SVT-cardiology consulted Discharge Condition: Stable Tolerating a regular diet Adequate pain control with oral medication Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Recommend a low sodium diet. Fluid Restriction: not applicable. . 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 vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or 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. *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *Avoid driving or operating heavy machinery while taking pain medications. * 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. * Continue to ambulate several times per day. . Incision Care: -Your staples will be removed at on Monday [**11-12**] at the REHAB facility. Steri strips will be applied. -Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. . You were evaluated by the hospital's cardiology service who made some changes to your heart/blood pressure medication. . Medication: 1. Lopressor: This medication was started for the first time during this admission. Continue as prescribed. 2. Verapamil: Please discontinue this medication-Lopressor has been started in its place. 3. Aspirin: Dose was increased from 81mg daily to 325mg daily. 4. Lisinopril: This is a new medication for blood pressure and heart rate. Take as prescribed. Followup Instructions: 1. Please follow-up with Dr. [**Last Name (un) 14682**] [**Telephone/Fax (1) 5189**] in [**1-12**] weeks. 2. Follow-up with PCP & Cardiologist within 1 week after discharge from REHAB facility. [**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**] Completed by:[**2159-11-8**]

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Discharge summary

report

Admission Date: [**2204-3-25**] Discharge Date: [**2204-4-17**] Date of Birth: [**2132-1-10**] Sex: F Service: MEDICINE Allergies: Aspirin / Penicillins Attending:[**Doctor First Name 3298**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: BiPAP positive pressure ventilation Intubation History of Present Illness: 72F with history of severe COPD on home o2 2L NC, restrictive lung disease with probable obesity hypoventilation, CAD s/p MI, CHF (EF~25% in [**2201**]) presenting from facility after desaturation to the 70[**Hospital **] transferred to MICU for continued management of hypoxia. Per report, patient with acute onset SOB since 530am. VS 96.8 100 22 126/63 02 78%. Placed on facemask with O2 improving to 94-96%. Transferred to [**Hospital1 **]. Spoke with [**Last Name (un) **] house; per nurse patient had been in USOH over preceding weeks with stable weights, no increasing O2 requirement. No productive cough, fever, wheeze. Baseline VS: 120s-150s, HRs: 80s-90s in sinus. Patient did have a CXR on [**2-29**] which was consistent with mild vascular congestion and lasix was increased from 60mg QD to 80mg QD x5days; since then has returned to standing 60mg dose. In the ED, initial VS: 83 108/55 72%RA. ABG: 7.39/51/67/32, on FiO2%:30; Rate:/32; TV:350; PEEP:5. CXR consistent with pulm edema but can't rule out underlying pna. Patient received levo/ctx, lasix 40mg IV. UOP >500cc after 40mg IV lasix. After intervention 95-97% and symptomatically improved on BiPAP. On arrival to the MICU, patient reports that she is feeling better but is able to relay limited history. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - HTN - Diabetes - CAD s/p status post MI in [**2199**] - CHF - COPD - Obesity Hypoventilation - CVA [**2199**] - now in wheelchair and cannot move LE - Degenerative disk disease - Bipolar disorder - Hypothyroidism PAST SURGICAL HISTORY: - s/p L TKA [**2192**] - s/p cataract surgery R eye [**2200**] Social History: - Lives in [**Location 1188**] house for last 12-18 months. - Has seven children but is not currently in contact with them. - Prior tobacco use from age 15-67, 1ppd. - Had h/o of EtOH problems for '6 years' but cannot say when. - No illicit drug use. Family History: - Father died of MI at 45. Mother, age [**Age over 90 **], alive. No h/o CVA Physical Exam: On admission: General: NAD Neck: supple CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: crackles at bases Abdomen: soft, non-tender, non-distendedGU: no foley Ext: warm, well perfused, Discharge Physical Exam: GENERAL - Chronically ill appearing 72 yo F breathing comfortably on 3L NC in no respiratory distress, no accessory mm use. Oriented to person and occasionally to place (oriented to person at baseline). Waxing and [**Doctor Last Name 688**] mental status, somnolent at times, clear and cooperative at others. During acute exacerbations she can be agressive HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear NECK - Supple, no [**Doctor First Name **], no thyromegaly, no JVD, no carotid bruits LUNGS - Reduced air movement, wet cough, lungs clear to auscultation overall though with occassional expiratory wheezes. HEART - S1 S2 clear and of good quality, no MRG ABDOMEN - Obese, NABS, soft/NT/ND EXTREMITIES - WWP, no [**Location (un) **], 2+ pulses (radials, DPs) SKIN - no rashes or lesions NEURO - Waxing and [**Doctor Last Name 688**] mental status as above. Interactive and answering questions appropriately when mentally clear though somnolent and answering "yes, no" questions at others. No focal neurologic deficits Pertinent Results: Admission Labs: [**2204-3-25**] 06:45AM BLOOD WBC-12.2*# RBC-3.21* Hgb-10.5* Hct-32.4* MCV-101* MCH-32.6* MCHC-32.3 RDW-13.8 Plt Ct-247 [**2204-3-25**] 06:45AM BLOOD Neuts-74* Bands-3 Lymphs-16* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2204-3-25**] 06:45AM BLOOD PT-12.1 PTT-28.9 INR(PT)-1.1 [**2204-3-25**] 06:45AM BLOOD Glucose-120* UreaN-52* Creat-1.4* Na-144 K-5.4* Cl-101 HCO3-33* AnGap-15 [**2204-3-25**] 06:45AM BLOOD CK-MB-3 proBNP-4383* [**2204-3-25**] 06:45AM BLOOD cTropnT-0.01 [**2204-3-25**] 03:00PM BLOOD CK-MB-2 cTropnT-0.01 [**2204-3-25**] 03:00PM BLOOD Calcium-8.5 Phos-4.5 Mg-2.4 [**2204-3-25**] 06:45AM BLOOD TSH-0.69 [**2204-3-25**] 08:13AM BLOOD Type-ART Rates-/32 Tidal V-350 PEEP-5 FiO2-30 pO2-67* pCO2-51* pH-7.39 calTCO2-32* Base XS-4 Intubat-NOT INTUBA Vent-SPONTANEOU [**2204-3-25**] 07:05AM BLOOD Lactate-1.5 Discharge Labs: [**2204-4-17**] 05:40AM BLOOD WBC-6.6 RBC-2.94* Hgb-9.2* Hct-29.7* MCV-101* MCH-31.3 MCHC-31.0 RDW-14.8 Plt Ct-324 [**2204-4-17**] 05:40AM BLOOD Glucose-78 UreaN-17 Creat-1.0 Na-141 K-4.0 Cl-104 HCO3-31 AnGap-10 [**2204-4-17**] 05:40AM BLOOD Calcium-9.0 Imaging: CXR [**2204-3-25**]: There is marked cardiomegaly, with upper zone redistribution and interstial and some pulmonary edema. There is more confluent opacity at R>L basess, consistent with collapse and/or consolidation. No gross effusion, though small effusions could be present. The mediastinal contours and hila appear prominent on this exam. There is marked cardiomegaly, with upper zone redistribution and interstial and some pulmonary edema. There is more confluent opacity at R>L basess, consistent with collapse and/or consolidation. No gross effusion, though small effusions could be present. The mediastinal contours and hila appear prominent on this exam. CXR [**4-1**]: ET tube tip now is in appropriate position, is approximately 5 cm from the carina. Allowing the difference in positioning of the patient, there has been interval increase in left lower lobe opacity consistent with increasing pleural effusion and atelectasis. Moderate right pleural effusion with large right lower lobe atelectasis is grossly unchanged. Cardiomegaly cannot be evaluated. The main pulmonary arteries are enlarged consistent with pulmonary hypertension. Mild pulmonary edema is unchanged. There are no new lung abnormalities. ET tube tip is in the stomach. CT Chest [**2204-4-3**]: CT OF THE CHEST: Mediastinal, axillary and hilar lymph nodes do not meet size criteria for pathology. A nasogastric tube is noted in standard position. Minimal atherosclerotic calcification is noted within the aortic arch and descending aorta. Bilateral pleural effusions are noted, right greater than left. On the right, the pleural effusion tracks into the fissure and is likely loculated. Minimal adjacent compressive atelectasis is noted. There is minimal pulmonary edema. Areas of air trapping are likely due to poor inspiratory effort. Pulmonary artery measures 3.5cm consistent with pulmonary hypertension. Again noted is moderate cardiomegaly. There is a small pericardial effusion. Airways are patent to the subsegmental level. CT OF THE ABDOMEN: The liver, spleen and visualized portions of the left kidney are unremarkable. An adrenal nodule measures 3.2 x 3.1 cm and is of indeterminate consistency. A 7.2 x 6.5 cm hypodensity arising from the upper pole of the right kidney is slightly increased in size compared to the most recent prior examination and appears consistent with a simple renal cyst. A small right adrenal nodule is unchanged. Visualized osseous structures show no focal lytic or sclerotic lesions suspicious for malignancy. IMPRESSION: 1. Bilateral pleural effusion, Right >Left. On the right, the pleural effusion tracks into the fissure and is likely loculated. 2. Minimal pulmonary edema. Areas of air trapping due to poor inspiratory effort. 3. Pulmonary artery 3.5cm consistent with pulmonary hypertension. 4. Small pericardial effusion. Moderate Cardiomegaly. 6. Left adrenal nodule is indeterminate and incompletely seen on the prior examination. This should be further evaluated with MRI. Right adrenal nodule stable since the prior. 7. Right upper pole renal cyst increased in size compared to the prior exam. EEG: This is an abnormal EEG because of a slow theta background and bursts of generalized delta slowing which are consistent with a mild to moderate diffuse encephalopathy which is etiologically non- specific. Excessive low voltage beta activity could be consistent with a medication effect. CT Head [**2204-4-8**]: No acute intracranial abnormality CXR [**2204-4-9**]: Interval withdrawal of right PICC line with tip in the upper superior vena cava. Increased right middle lung collapse. Stable bilateral pleural effusions and retrocardiac opacification. CXR [**2204-4-11**]: As compared to the previous radiograph, there is unchanged moderate cardiomegaly with moderate pulmonary edema. In addition, there is increasing volume loss of the right upper lobe with subsequent opacification of this anatomic region, potentially representing recent or developing pneumonia. CXR [**2204-4-12**]: 1. Increased bibasilar opacification on the right greater than the left, consistent with small bilateral pleural effusions with associated atelectasis, worse in the right middle lobe. Superimposed pneumonia cannot be excluded in the appropriate clinical setting. 2. Improved aeration at the right upper lobe consistent with resolved atelectasis. 3. Persistent mild pulmonary edema Micro: Blood culture [**2204-3-25**]: No growth Urine culture [**2204-3-25**]: no growth Sputum culture [**2204-3-25**]: [**2204-3-25**] 3:45 pm SPUTUM Source: Expectorated. **FINAL REPORT [**2204-3-28**]** GRAM STAIN (Final [**2204-3-26**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). [**2204-3-29**] 6:15 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2204-3-31**]** GRAM STAIN (Final [**2204-3-29**]): <10 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [**2204-3-31**]): SPARSE GROWTH Commensal Respiratory Flora. GRAM STAIN (Final [**2204-4-4**]): <10 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. BCx [**2204-4-4**] Negative URINE URINE CULTURE [**2204-4-10**] Negative Brief Hospital Course: Patient is a 72F with history of severe COPD, restrictive lung disease with obesity hypoventilation, CAD s/p MI, CHF initially admitted to MICU for somnolence, respiratory distress and hypoxia, transferred to medicine floor and course complicated by encephalopathy, aspiration and HCAP # Hypoxic Respiratory Failure: On initial presentation DDx included COPD vs CHF vs PE vs PNA. On initial presentation she was treated with CAP coverage with CTX and levofloxacin. TTE showed preserved global systolic function with EF of 40-45%. PE was considered, but held off on CT given [**Last Name (un) **] and other more likely diagnoses. LENI's were negative. She improved with diuresis and was weaned from BiPAP to nasal canula on HD#1 supporting CHF exacerbation as etiology. On transfer to medicine floor patient maintaining O2 sats in low 90s on 5L NC. Antibiotic regimen changed to Levofloxacin only to complete course for CAP. IV lasix diuresis was continued with effective diuresis of 500cc-1L per day. On HD4 acute renal failure developed and so diuresis was discontinued. She became increasingly somnolent between HD 3 and 4 with minimal air movement and increased expiratory wheezes. Arterial gas completed on HD4 for somnolence. ABG showed increasing hypercarbia so patient was transferred to MICU for BiPAP. Given her increased somnolence and hypercarbia she was subsequently intubated. Pt completed a seven day course of levofloxacin for CAP and was successfully extubated on [**4-1**]. Following extubation she continued to have pulm edema on CXR and was diuresed with lasix 80 mg [**Hospital1 **] until her creatinine began on rise. On [**4-4**] she developed a leukocytosis with increased sputum production. She was subsequently treated with Vanc/Cefepime for health care associated pneumonia. Chest CT did not show any focal consolidation, but did show bilateral pleural effusions with a possible loculation. IR US and CT, as well as IP were consulted, but none of the services felt there was enough fluid to be drained. Once stable she was transferred to the medicine floor. Patient triggered many times for hypoxia to mid-70s during the early mornings. These were thought to be related to somnolence from overnight and inability to clear mucous plugging/aspiration. Pulm was consulted for BiPAP since possibly hypercarbia overnight contributing to AMS. Mental status too poor for BiPAP and acute episodes of hypoxia transient in nature favored to be aspiration in origin vs plugging. Aspiration/nutrition was treated below and as mental status improved episodes resolved. She was stable on 3 L O2 by nasal cannula >48hrs prior to discharge. #Encephalopathy: Patient with waxing and [**Doctor Last Name 688**] MS on initial hospitalization and continued to wax and wane throughout admission. She was treated for infection as above, U/A was negative. TSH was normal. Pt's mental status initially improved after BiPAP but somnolence developed while on medicine floor. ABG showed developing hypercarbic respiratory distress so patient transferred to MICU for BiPAP and ultimately intubation. After extubation pt was still somnolent, oriented only to self. ABG's were all at baseline with pC02's in the 60's. Seroquel was held and gabapentin discontinued. [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] she is alert and oriented at baseline. CT head without acute process or stroke, EEG showing generalized encephalopathy without seizures or epileptiform discharges. On transfer to the medical floor she continued having fluctuating mental status consistent with delirium. After holding sedating meds and treating infection encephalopathy continued improving and at time of discharge she slept if not stimulated but awoke easily and was pleasant and interactive but not completely oriented. # Nutrition: Frequent hypoxic transient episodes likely aspiration events [**3-1**] encephalopathy. Aspiration related to mental status and poor cooperation. Initial speech and swallow evaluation failed patient and she was placed NPO. In MICU, NGT placed and tube feeds started. Unfortunately, her mental status declined and she would not cooperate with repeated S/S reevaluations. On medicine floor decision was made to pull NGT, keep NPO and evaluate again. Additional Speech and swallow successful [**2204-4-11**], cleared for nectar thick liquids and pureed diet. Decision was made to PO challenged over weekend with calorie counting. Calorie counting revealed that she was not maintaining adequate nutrition, only eating 500 calories of goal 1500 cal per day. Readdress with family after PO challenge revealed family firmly against NGT and PEG tube. Family aware that her nutritional status may continue to deteriorate and she may become malnourished without supplemental tube feeds but they are hopeful she will continue to improve. # CHF: Chronic, systolic heart failure with LVEF of 25%. Acute on chronic systolic CHF exacerbation contributing to pulmonary edema and poor respiratory status. Persantine stress [**2200-4-25**] without evidence of ischemia. Many risk factors for CAD but no evidence of ischemic cardiomyopathy. On Carvedilol, Plavix, Lasix, Lisinopril and Simvastatin outpatient. After improvement in hemodynamics and titrated diuresis patient was restarted on Carvedilol 6.25 mg PO BID and Lasix 60mg PO Daily per outpatient regimen. Lisinopril held for hyperkalemia but eventually restarted as acute renal failure resolved and Cr stable > 24 hours at time of discharge. Also continued Simvastatin 40mg qhs, Plavix 75mg QD # CAD, native vessel: Pt never had signs or symptoms of ACS. She was continued on clopidogrel throughout hospitalization. Beta blocker was held for hypotension but restarted prior to discharge. # Acute on chronic renal failure: Admission creatinine 1.4; baseline 0.8-1.0 from [**2200**]; per rehab 1.1-1.3. Pre-renal in etiology on admission. Cr was trended down with initial diuresis supporting poor forward flow in setting of CHF exacerbation. With aggressive diuresis patient developed ARF likely [**3-1**] overdiuresis. Lasix was discontinued and creatinine trended back to baseline to nadir of 0.8. Lasix was restarted on [**4-3**] for volume overload and again discontinued on [**4-5**] [**3-1**] hypotension. Eventually Lasix titrated back to home dosing of 60mg PO daily. # Anemia: Anemia of chronic disease, stable. # Hyperkalemia: K 5.4 in ED. Received lasix in the ED. Most likely [**3-1**] renal failure, hyperkalemia resolved, patient never had EKG changes. While on tube feeds she had hyperkalemia as well requiring change to Nepro. After change in tube feeds and with diuresis her K stabilized. While on Lisinopril and not eating well potassium remained stable as well. # Diabetes: Diabetes Mellitus, Type II, well controlled without complications. Chronic, stable on Lantus and Metformin as an outpatient. Continued Lantus and HISS while inpatient. Reduced Lantus to 50 units QHS because of a few hypoglycemic episodes while not taking in adequate PO. # Hypothyroidism: Continued levothyroxine replacement. TSH was normal. # Hx of Bipolar disorder: Continued depakote, held seroquel secondary to somnolence. # h/o epilepsy: Not a true history, must have been entered because of Depakote use as above. Per family, she has never had a seizure episode and is on Depakote for Bipolar D/O. Additionally, EEG while inpatient without epileptiform activity. Transitional issues: - Needs continued speech and swallow eval (NG tube vs. G tube) if not maintaining caloric intake to meet demands - Needs continued monitoring for aspiration risk with swallowing - Needs monitoring of her mental status - Readdress outpatient CPAP if mental status improves - Will likely need physical therapy as part of rehabilitation - Continue holding Seroquel, Trazadone and Gabapentin - Repeat chest chest x-ray in [**5-4**] weeks to monitor resolution of PNA and/or effusion - CODE: Full code, discussed with family and HCP - CONTACT: Health [**Name2 (NI) **] Proxy is daughter [**Name (NI) 13409**] C:(primary) [**Telephone/Fax (1) 108814**], H: [**Telephone/Fax (1) 108815**] another contact is [**Name (NI) **] (another daughter but not HCP) [**Telephone/Fax (1) 108816**] Medications on Admission: Lantus 54qhs, Nololog SS Bisacodyl 10mg QD Milk of Mag 400mg/5ml Seroquel 100mg [**Hospital1 **] prn agitation Seroquel 200mg QD Seroquel 800mg qhs Depakote 500mg QD Depakote 1250mg SR qhs Simvastatin 40mg qhs Trazadone 50mg qhs Lasix 60mg QD Advair 500/50 [**Hospital1 **] Carvedilol 6.25 [**Hospital1 **] Gabapentin 300mg [**Hospital1 **] Tylenol 975mg TD Artificial Tears Lisinopril 5mg QD Metamucil Metformin 1000 tab MVU Naproxen Plavix 75mg QD Levothyroxine 137.5mcg Colchicine 0.6mg Discharge Medications: 1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. insulin glargine 100 unit/mL Solution Sig: Fifty (50) units Subcutaneous at bedtime. 7. insulin lispro 100 unit/mL Solution Sig: Two (2) units Subcutaneous ASDIR: ASDIR by sliding scale. 8. metformin 1,000 mg Tablet Sig: One (1) Tablet PO once a day. 9. levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Depakote 500 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 11. Depakote 250 mg Tablet, Delayed Release (E.C.) Sig: Three (3) Tablet, Delayed Release (E.C.) PO at bedtime. 12. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 13. Milk of Magnesia 400 mg/5 mL Suspension Sig: One (1) dose PO once a day as needed for constipation. 14. Advair Diskus 500-50 mcg/dose Disk with Device Sig: One (1) IH Inhalation twice a day. 15. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain or fever. 16. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. polyvinyl alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed) as needed for dry eyes. 18. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours). 19. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 20. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. Discharge Disposition: Extended Care Facility: [**Hospital 671**] [**Hospital 4094**] Hospital - [**Location (un) 86**] Discharge Diagnosis: Malnutrition Encephalopathy Hypoxic Respiratory Failure CHF exacerbation COPD exacerbation Health Care Associated Pneumonia Chronic restrictive lung disease Obesity Hypoventilation syndrome Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Ms. [**Known lastname **], It was a pleasure treating you during this hospitalization. You were admitted to [**Hospital1 69**] because of respiratory distress. You were initially admitted to the MICU because of hypoxic respiratory failure. You received positive pressure ventilation and IV diuresis with improvement in your symptoms. Your course was complicated by readmission to MICU for COPD exacerbation and CO2 retention causing altered mental status. You also received positive pressure ventilation and intubation during that MICU stay as well. COPD exacerbation was thought related to either underlying pneumonia for which you were treated, aspiration or progression of your underlying pulmonary disease. With improvement in your mental status your breathing improved and you had less frequent episodes of hypoxia. These hypoxic episodes were thought related to aspiration events. You should continue to maintain strict aspiration precautions when you eat to reduce the risk of aspiration pneumonia. You were also evaluated by the Pulmonary consult team who felt you may benefit from BiPAP at night but your mental status is a contraindication to use. You should talk to your pulmonologist about starting BiPAP when your mental status improves. The following changes to your home medications were made: - STOP Trazadone, this may be worsening your mental status - STOP Seroquel, this may be worsening your mental status - STOP Gabapentin, this may be worsening your mental status - START Albuterol and Atrovent every 6 hours - REDUCE Lantus to 50 units QHS - No other changes were made to your medications, please continue taking as previously prescribed. Other instructions: - Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Name: [**Doctor Last Name **],[**Female First Name (un) **] L. Location: [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **] Address: 545A CENTRE ST, [**Location (un) **],[**Numeric Identifier 6809**] Phone: [**Telephone/Fax (1) 608**] *Your primary care physician as been informed that you have been discharged. Someone will come to your home to follow up for your hospitalization within 72 hours. Department: PULMONARY FUNCTION LAB When: MONDAY [**2204-4-30**] at 10:40 AM 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: MONDAY [**2204-4-30**] at 11:00 AM 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 Department: CARDIAC SERVICES When: WEDNESDAY [**2204-5-2**] at 9:40 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "E928.9", "349.82", "403.90", "780.09", "276.2", "244.9", "428.43", "412", "276.0", "458.29", "518.81", "428.0", "491.21", "V45.82", "357.2", "414.8", "E944.4", "276.7", "584.5", "599.70", "518.89", "263.9", "933.1", "585.3", "278.03", "250.60", "414.01", "482.9", "V12.54", "E915", "V58.67", "V43.65", "285.29", "278.00", "296.80" ]

icd9cm

[ [ [] ] ]

[ "38.97", "93.90", "96.6", "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

21595, 21694

10939, 18426

303, 352

21928, 21928

4129, 4129

23906, 25186

2738, 2817

19770, 21572

21715, 21907

19254, 19747

22105, 23883

4991, 10916

2389, 2453

2832, 2832

18447, 19228

1680, 2128

244, 265

380, 1661

4145, 4975

2846, 3048

21943, 22081

2150, 2366

2469, 2722

3073, 4110

9,253

173,715

405

Discharge summary

report

Admission Date: [**2142-5-21**] Discharge Date: [**2142-5-29**] Service: MEDICINE Allergies: Valium Attending:[**First Name3 (LF) 3556**] Chief Complaint: mixed respiratory failure Major Surgical or Invasive Procedure: intubation History of Present Illness: [**Age over 90 **]yo man with h/o Parkinson's disease, multiple prior admissions for aspiration pneumonia most recently [**2142-4-23**], who presents again from [**Hospital 100**] Rehab after the staff there had "trouble waking him up" this AM, and found him to be in mixed respiratory failure. On the prior admit, the pt was diagnosed with a LLL pna and treated with vancomycin/zosyn. Per his wife, the patient was doing relatively well last week, still in the MACU at [**Hospital 100**] Rehab since his recent discharge from [**Hospital1 18**] but with a plan to transition to the regular floor soon. His ABG on [**2142-5-16**] was 7.34/69/55 on room air, which is close to his baseline pCO2. On Saturday 2d PTA, the pt's wife noted that he was congested more than baseline, initially unable to cough, but then improved after neb treatments with the production of brown-pink secretions. He had hyperglycemia to FS 223, which per wife he has never had before (no h/o DM). By Saturday night though he was doing well, less congested and speaking clearly. Then, Sunday AM, he was congested again and though he received nebs he was not able to cough out the secretions. Per the Pulmonologist note from Sunday PM, he was then found to be poorly arousable, with RR 30, shallow breathing, lungs clear, O2 sat 90% on pulse oximeter. ABG performed, 7.20/107/44, O2 sat 68% on ABG, presumably on room air though unclear. BIPAP was written for (IPAP 16, EPAP 3), though it is not clear if this was started. He was shortly thereafter intubated after the Pulmonologist confirmed his Full Code status with the pt's wife. After intubation, it was noted that he had copious thick yellow secretions in his trachea, which were felt to be the culprit causing obstruction and hypercarbia/hypoxemia. With suctioning his breathing improved, and he was transferred to [**Hospital1 18**] for further work up. The patient remained awake the whole time. He was noted to have a temp of 100.4F this AM. . Upon arrival to the [**Hospital1 18**] ED, he appeared to be in no respiratory distress. His initial ABG was 7.34/67/315. He was found to be febrile to 100.4F, with HR 60s-70s, SBPs ranged 60s-80s. His CXR was concerning to the ED staff for RUL/RLL processes (though appears to have only persistent LLL , and he was given CTX, Vanc, and Flagyl out of concern for nosocomial vs. aspiration pna. His urine was leuk esterase (+) on UA, culture pending. Blood cultures were also sent. He received 1L NS for hypotension, and subsequently his pressures were still low so he was started on a dopamine drip via a newly-placed RIJ (per report, sterile placement via ultrasound in the ER). He also had a 18G PIV placed, and has a PICC line from [**Hospital **] Rehab that is of unclear age or indication (felt to be from prior need for IV abx). His ECG was notable for Q-wave in V1, ST elevations laterally, concerning for ischemia. TnT 0.10, CK 22, MB not done. Lact 0.6. He was given ASA 325mg PR. His wife confirmed that he is full code. Past Medical History: 1. h/o aspiration PNA - Tx with levo, unasyn, vanco/zosyn in the past 2. h/o aspiration s/p swallow eval with swallowing difficulty, s/p [**Hospital 282**] placement on [**10-9**] 3. Parkinson's 4. Osteoporosis 5. T11/12 compression fx 6. LLE osteomyelelitis as a child/Chronic osteomyelitis, quiescent. 7. granulomatous liver disease 8. LUE rotator cuff tear 9. Prostate cancer s/p orchiectomy in [**2126**] 10. s/p laminectomy L4-5 11. Cataracts s/p surgery [**46**]. Glaucoma 13. Hypertension Social History: The patient has a sixty-pack-year history of tobacco. He quit in [**12/2098**]. He lives in a NH for the past 2 years. He is a retired history professor. He reports no alcohol intake. Family History: Non-contributory Physical Exam: PE: VS: T 97 HR 77 BP 124/96 RR 14 O2 100% on vent VENT: AC 550 x14 FIO2 of 50/PEEP 5 GEN: sedated, intubated HEENT: NC/AT, MMM, ET tube in place NECK: supple, no LAD; RIJ presep cath in place without bleeding/hematoma LUNGS: coarse throughout, decreased BS at L base HEART: RR, with 3/6 systolic murmur at the LL-sternal border. ABDOMEN: +b/s, soft, [**Last Name (LF) **], [**First Name3 (LF) **] in place without erythema or discharge EXTREMITIES: 1+ pitting edema bilat. Ext warm. PICC in R upper arm, PIV in R forearm Pertinent Results: Upon admission: [**2142-5-21**] 5.3 >-------<205 30.5 133 | 99 | 29 | ---------------<134 4.8 | 32 | 0.6| Lactate: 0.6 Cardiac enzymes negative. Cultures: [**2142-5-22**] 1:36 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2142-5-24**]** GRAM STAIN (Final [**2142-5-22**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. RESPIRATORY CULTURE (Final [**2142-5-24**]): RARE GROWTH OROPHARYNGEAL FLORA. YEAST. SPARSE GROWTH. [**2142-5-21**] 10:45 am URINE Site: CLEAN CATCH **FINAL REPORT [**2142-5-22**]** URINE CULTURE (Final [**2142-5-22**]): YEAST. 10,000-100,000 ORGANISMS/ML.. [**2142-5-21**] Blood: Negative Studies: [**2142-5-21**] 10:22 EKG: NSR at 65 with freq PACs, LAD, normal intervals, Q in II/III/aVF, poor R-wave progression, 0.5mm ST elev in I,aVL,V1-V3, TWI in III. C/t prior ECG [**2142-5-2**], Q waves old, poor R-wave prog old, ST elev new. . [**2142-5-21**] CXR: INDICATIONS: [**Age over 90 **]-year-old man with Parkinson's disease, pneumonia, and left effusion, intubated. CHEST, AP SUPINE: Comparison is made to [**2142-5-2**]. The patient is now intubated. The endotracheal tube terminates approximately 4 cm above the carina near the thoracic inlet. The lung volumes are low. The cardiac and mediastinal contours are similar. Markedly calcified subcarinal lymphadenopathy is again noted. There is persistent left lower lobe opacity with an effusion, as well as a new mild congestive heart failure or pulmonary venous hypertension. IMPRESSION: 1. Status post endotracheal intubation. 2. Persistent left lower lobe opacity. 3. Mild congestive heart failure or fluid overload. . [**2142-5-21**] AXR: Single supine AP: Part of the left hemipelvis is not included in the study. The study is also centered around the pelvis rather than including the whole abdomen. The visualized portion of the abdominal cavity demonstrate normal bowel gas pattern with stool noted within the ascending colon and sigmoid colon. The bone and soft tissues structures are unremarkable. IMPRESSION: No acute abdominal pathology is identified. No evidence of obstruction or free intra-abdominal air is noted. . [**2142-5-26**] CXR: Worsening right lower lobe opacity, suspicious for pneumonia. Brief Hospital Course: [**Age over 90 **] yo M with h/o aspiration PNA, swallowing difficulty, parkinsons, who p/w acute hypercarbic respiratory failure. [**Age over 90 3553**] followed by stress EKG negative for ischemia. Patient extubated [**2142-5-27**] and is planned to transition to [**Hospital 100**] Rehab [**2142-5-29**]. . 1. Respiratory Failure: mixed hypercarbia and hypoxemia likely from mucus plugging in setting of poor reserve from underlying restrictive lung disease and LLL pna. He has a history of hypercarbia possibly due to neuromuscular weakness of respiratory muscles due to Parkinsons. CTA neg for PE. . During his stay the patient has an 8 day antibiotic treatment for nosocomial PNA with ceftaz and vancomycin as he was found to have gram positive cocci in pairs in his sputum. He continued on his albuterol and ipratroprium nebulizers on nasal cannula. A neurology consult on [**2142-5-28**] suggested that the patient should see neuromuscular in follow up and a decision can be made at that time whether any further EMG studies are needed but no further eval at this time with regards to investigating a neuromuscular source of his hypercarbia. In addition the patient had transient pulmonary edema that improved with lasix admiinstration. . While in house, the patient was given an overnight trial of BIPAP as the patient is chronically hypercarbic with weak respiratory muscles secondary to Parkinson's disease. While he did not tolerate the procedure well we believe that he may benefit from a repeated trial when he is healthier 2-3 months discharge. . 2. Parkinsons: The patient was continued on his home regimen of Parkisons medication including cabidopa/levidopa and mirapex while in house . 3. Glaucoma: The patient was continued on his home regimen of drops. . 4. Hypertension: Controlled with lisinopril 20 and lasix as needed. . 5. Osteoporosis: Osteoporosis drugs were held during this admission. The patient should be reevaulated for possibly re-starting an anti-osteoporosis regimen as an outpatient. . 6. Chest pain: The patient described chest pain but had a negative EKG. It improved during his hospital stay and a spontaneous breathing trial followed by stress EKG to evaluate for ischemia was negative. Medications on Admission: -Insulin SS q6h prn -Ipratropium nebs q6h -Lisinopril 10mg qday -MVI qday -Hydrocodone-Acetaminophen 1 TAB PO Q6H:PRN -Senna 2 TAB PO QHS -Fexofenadine 60 mg PO BID -Fluticasone Propionate NASAL 1 SPRY NU [**Hospital1 **] -Entacapone 200 mg Q 5Am, 8AM, 11Am, 2PM, 5PM, 8PM, 11PM -Pramipexole 0.125 mg Q 5AM, 8AM, 11AM, 2PM, 5PM, 8PM -Pramipexole 0.1875 mg @ 11PM qday -Carbidopa-Levodopa (25-100) 2 TAB PO Q5AM, 8AM, 11AM, 2PM, 5PM, 8PM, 11PM -Docusate Sodium (Liquid) 100 mg PO BID -Omeperazole 20mg PO Q24H -Artificial Tears 1 DROP BOTH EYES TID -Chlorhexidine Gluconate 15 ml PO BID -Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS -Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES [**Hospital1 **] -Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN -Calcium/Vit D 500mg [**Hospital1 **] -Hep 5000 SQ TID Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) injection Injection TID (3 times a day). 2. Hexavitamin Tablet [**Hospital1 **]: One (1) Cap PO DAILY (Daily). 3. Carbidopa-Levodopa 25-100 mg Tablet [**Hospital1 **]: Two (2) Tablet PO 7X/D (). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1) Tablet, Delayed Release (E.C.) PO once a day. Tablet, Delayed Release (E.C.)(s) 5. Latanoprost 0.005 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic HS (at bedtime). 6. Polyvinyl Alcohol 1.4 % Drops [**Hospital1 **]: 1-2 Drops Ophthalmic TID (3 times a day). 7. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: [**12-5**] PO BID (2 times a day). 8. Lisinopril 20 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 9. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Month/Day (2) **]: Two (2) nebs Inhalation Q4H (every 4 hours) as needed. 10. Calcium Carbonate 500 mg Tablet, Chewable [**Month/Day (2) **]: One (1) Tablet, Chewable PO BID (2 times a day). 11. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 12. Entacapone 200 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO 7x/day (). 13. Ipratropium Bromide 0.02 % Solution [**Month/Day (2) **]: Two (2) nebs Inhalation Q6H (every 6 hours). 14. Lactulose 10 g/15 mL Syrup [**Month/Day (2) **]: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 15. Aspirin 325 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 16. Fluticasone 50 mcg/Actuation Aerosol, Spray [**Month/Day (2) **]: One (1) Spray Nasal [**Hospital1 **] (2 times a day). 17. Pramipexole 0.125 mg Tablet [**Hospital1 **]: One (1) Tablet PO six times per day (). 18. Dorzolamide-Timolol 2-0.5 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 19. Senna 8.6 mg Tablet [**Hospital1 **]: 1-2 Tablets PO BID (2 times a day). 20. Fexofenadine 60 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 21. Pramipexole 0.125 mg Tablet [**Hospital1 **]: 1.5 Tablets PO qday (). 22. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital3 **] Center Discharge Diagnosis: respiratory failure aspiration pneumonia parkinson's disease anemia chronic respiratory failure Discharge Condition: stable Discharge Instructions: Please take your medications as prescribed. If you develop shortness of breath, fever, or any other concerning symptoms please contact a health care provider [**Name Initial (PRE) 2227**]. Followup Instructions: Provider: [**Name10 (NameIs) 3557**] [**Name8 (MD) 3558**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2142-6-4**] 2:30 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2142-7-9**] 9:30 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**] Completed by:[**2142-5-29**]

[ "276.2", "427.89", "518.84", "507.0", "V10.46", "V44.1", "365.9", "785.59", "733.00", "401.9", "934.9", "285.9", "332.0" ]

icd9cm

[ [ [] ] ]

[ "96.71", "38.93", "96.04", "96.6", "00.17", "96.72" ]

icd9pcs

[ [ [] ] ]

12422, 12472

7063, 9298

241, 254

12612, 12621

4608, 4610

12859, 13288

4031, 4050

10157, 12399

12493, 12591

9324, 10134

12645, 12836

4065, 4589

175, 203

282, 3293

4625, 7040

3315, 3813

3829, 4015

48,546

170,878

1381

Discharge summary

report

Admission Date: [**2164-3-13**] Discharge Date: [**2164-3-25**] Date of Birth: [**2083-1-6**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1990**] Chief Complaint: Expressive Aphasia Major Surgical or Invasive Procedure: None History of Present Illness: 81 yo M who was previously very funcitonal, who was transferred for neurosurgical evaluation after presenting with SAH found on CT scan from OSH. Per discussion with his wife, the patient was last seen at 7am that morning and was acting normally. She did not hear from her throughout the day which was a bit abnormal. She called him at 4pm when he did not show up to pick her up from work as expected. He was able to answer the phone but was not able to speak. She then had her neighbor go check on him. When she arrived 10 minutes later, he was still aphasic and they call 911. He was then brought by ambulance to an OSH where CT imaging revealed a SAH. He was transferred to [**Hospital1 18**] for neurosurgical evaluation. Neurosurgery thought an intervention would not be helpful, and his CT imaging has showed appropriate evolution of the bleed. Past Medical History: s/p Meningioma resection, [**2140**] h/o TIA: [**2156**] p/w confusion, + antithrombotic therapy, no residual deficits h/o Seizures: none for > 10 years, attributed to prior brain surgery Hypertension Hypercholesteremia Hypothyroidism s/p L knee replacement [**2162**] Right spermatocele Congenital toe webbing Eye surgery, bilateral Carpal tunnel disease Social History: Very functional at baseline. Lives with wife (married for 30+ years) who is still working, but he is retired. Smoked previously but quit 45 years ago. Drinks approximately 1 drink weekly. No services at home prior to current hospitalization. Family History: Non-contributory Physical Exam: Admission: T:97.7 BP:99/70 HR:112 RR:16 O2Sats95% RA Gen: WD/WN, comfortable, NAD. [**Year (4 digits) 4459**]: Pupils:PERRL EOMs-appears intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: unable to test due to aphasia Language: + dysarthria, aphasia Discharge: Gen: WD/WN, lying on side in bed, rousable to loud voice or noxious stimuli, minimal eye contact [**Name (NI) 4459**]: upper/lower dentures, cannot visualize oropharynx; remainder of exam limited by patient cooperation Neck: supple, no masses or asymmetry PULM: spontaneous fair symmetric resp effort, CTAB posteriorly without w/r/r though not participating in deep breaths for exam CV: RRR without appreciable m/r/g ABD: active BS, flat, no appreciable masses, patient does not grimace with deep palpation but spontaneously resists somewhate MsK: no gross joint effusions, erythema, warmth Skin: no visible rashes or e/o skin breakdown Neurological: not interactive. Moving bilateral upper extremities equally; moves left foot when bottom touched (wife states he's ticklish); minimal movement right foot and mostly in response to touching left; toes mute on L and downgoing on R Pertinent Results: [**2164-3-14**] WBC-16.5* RBC-3.75* Hgb-11.9* Hct-33.3* MCV-89 MCH-31.9 MCHC-35.9* RDW-13.6 Plt Ct-275 [**2164-3-14**] Glucose-128* UreaN-24* Creat-0.8 Na-138 K-4.6 Cl-103 HCO3-29 AnGap-11 [**2164-3-14**] CK(CPK)-100 [**2164-3-14**] CK-MB-3 cTropnT-0.01 [**2164-3-14**] Calcium-7.9* Phos-3.2 Mg-1.8 [**2164-3-14**] Phenyto-26.4* DISCHARGE [**2164-3-25**] 06:30AM WBC 14.9*, Hb 11.4, HCT 31.5, Plt 462* [**2164-3-25**] 06:30AM Glu 115, BUN 24, Cr 0.8, Na 133, K 3.7, Cl 97, HCO3 28 ENZYMES & BILIRUBIN [**2164-3-25**] 06:30AM ALT 215, AST 146, LD(LDH) 433, AlkPhos 86, TotBili 0.6 IMAGING: CTA HEAD W&W/O C & RECO NON-CONTRAST CT OF THE HEAD: The patient is a status post left frontoparietal craniotomy, related to the resection of meningioma, as reported on the prior study. Extensive areas of intraparenchymal, subarachnoid, and subdural hemorrhages, have not significantly changed compared to the most recent study done approximately three hours earlier. There is no significant change in the surrounding edema, around the left parietal intraparenchymal hematoma. No obvious new areas of hemorrhage are noted. There is mild mass effect, on the left lateral ventricle, which is not significantly changed. Again unchanged small hypodense areas, noted in the left frontal white matter, likely chronic in nature, related to chronic infarcts, are unchanged. There is mild shift of the midline structures to the right side, unchanged. Small retention cysts are noted in the left maxillary sinus. There is unchanged appearance of the hyperostosis of the left frontal and the squamous temporal bones and small amount of pneumocephalus. CT ANGIOGRAM OF THE HEAD: Significant atherosclerotic vascular calcifications are noted in the intracranial arteries, in the vertebral, in the cavernous carotid segments as well as extending into the supraclinoid segments and the distal vertebral arteries, right more than left. Small foci of air, noted in the left middle cranial fossa, extending into the infratemporal fossa as described on the prior study are unchanged. The major intracranial arteries are otherwise patent, without focal flow-limiting stenosis, occlusion, or aneurysm. There is fetal PCA pattern noted. The right distal vertebral artery, is markedly narrowed in caliber, which may be related to hypoplasia and superimposed atherosclerotic disease and stenosis. The right vertebral artery is not completely included on the present study, from its origin. IMPRESSION: 1. No significant change in the multiple areas of intracranial hemorrhage, with some surrounding edema and minimal shift of the midline structures. 2. No evidence of aneurysm. 3. Extensive/significant atherosclerotic disease, in the intracranial arteries, predominantly in the right distal vertebral, cavernous segments, with decreased flow in the right vertebral artery, which may be due to hypoplasia and superimposedatherosclerotic stenosis. Further evaluation of the neck vessels can be considered. CT HEAD W/O CONTRAST [**3-17**]: IMPRESSION: No appreciable increase in extent of multi-compartmental hemorrhage with bilateral subdural hematomas, diffuse subarachnoid hemorrhages, and multifocal hemorrhagic contusions. Increasing hypodensity surrounding areas of parenchymal hemorrhage is consistent with continued evolution of areas of contusions. There is tiny new right lateral intraventricular hemorrhage. Mild leftward subfalcine herniation and mass effect on the left lateral ventricle is similar to that previously seen. NOTE ADDED IN ATTENDING REVIEW: The progressive, relatively symmetric low- attenuation regions involving both frontal lobes may relate to evolving hemorrhagic contusions, as suggested above. However, they appear disproportionate to the amount of parenchymal blood, as much of the hemorrhage in this region, particularly on the right, appears extra-axial, and wedge-shaped rather than rounded. In addition, they may involve overlying [**Doctor Last Name 352**] matter and represent cytotoxic rather than vasogenic edema; acute infarction, particularly of "watershed" type, given the sparing of parasagittal vascular territory, is an additional consideration. CHEST (PA & LAT) [**3-19**]: In comparison with the study of [**3-17**], there is no change on the frontal view. The heart is within normal limits in size and there is no vascular congestion or pleural effusion. On the lateral projection, there is suggestion of some increased opacification posteriorly in the lower lung zone. This could well represent merely crowding of normal vessels. In view of the clinical history, the possibility of a pneumonia cannot be definitely excluded, though this is not supported on the frontal view. BILAT LOWER EXT VEINS [**3-19**]: IMPRESSION: No evidence of deep vein thrombosis. CT HEAD W/O CONTRAST [**3-19**]: NON-CONTRAST HEAD CT: Redemonstrated is extensive multifocal intracranial hemorrhage, including intraparenchymal, subarachnoid, and subdural bleeds. Most conspicuous are bilateral frontal and temporal lobe IPH, with significant associated underlying edema, presumably secondary to contusion. Subarachnoid blood is also seen along the lateral convexities, with small, unchanged subdural collections also present. Again seen is mass effect from the large right frontal hemorrhage, with approximately 8 mm shift of normally midline structures to the left, constituting subfalcine herniation. There are no areas of new hemorrhage. There is no ventriculomegaly to suggest development of hydrocephalus. The basilar cisterns remain preserved. There is no transtentorial or uncal herniation appreciated. There is no definite intraventricular hemorrhage appreciated on today's study. The patient is status post prior left temporal craniotomy. There are no suspicious lytic or sclerotic osseous lesions. The visualized paranasal sinuses and mastoid air cells remain normally pneumatized and clear. ECHO [**3-21**]: The left atrium is elongated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is an anterior space which most likely represents a fat pad. IMPRESSION: Suboptimal image quality. Normal global left ventricular function. No vegetation identified. If clinically suggested, the absence of a vegetation by 2D echocardiography does not exclude endocarditis. LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2164-3-22**]: The liver demonstrates normal echotexture and architecture, without focal liver lesion seen. The main portal vein is patent with normal hepatopetal direction of flow. No intra- or extra-hepatic biliary duct dilatation is noted; the common duct measures 6 mm. The gallbladder appears normal, without evidence of stones. The pancreatic body and tail is obscured by overlying bowel gas; the visualized portions of the body and head appear unremarkable. The visualized abdominal aorta maintains normal caliber. The spleen is not enlarged, measuring 10.6 cm. No ascites is seen. The kidneys measure 11.6 cm on the right and 11.3 cm on the left. Note is made of a 9 mm right lower pole cyst, otherwise no evidence of stone, hydronephrosis or solid mass is seen in the kidneys. IMPRESSIONS: No abdominal pathology seen to account for the patient's symptoms. CT HEAD W/O CONTRAST [**2164-3-22**] Continued evolution of multifocal intracranial hemorrhage, with decreased density and conspicuity of blood products on today's study. Extensive edema is unchanged, with most prominent edema seen in the right frontal lobe, resulting in mass effect upon the adjacent sulci, frontal [**Doctor Last Name 534**] of the ipsilateral ventricle, and subfalcine herniation. These findings are unchanged compared to prior examination. CT CHEST / ABD / PELVIS W/CONTRAST Study Date of [**2164-3-23**] 4:33 PM 1. No findings to explain leukocytosis and daily fevers. 2. Numerous diverticula of the descending and sigmoid colon without acute diverticulitis. 3. Small focus of air in the urinary bladder, correlate with recent instrumentation. 4. Extensive atherosclerotic calcification. 5. Multiple nodules in the right lobe of the thyroid. If not previously evaluated, this can be further investigated via thyroid ultrasound on a non-emergent basis. Brief Hospital Course: On [**3-13**], Mr. [**Known lastname 8360**] was admitted to ICU for frequent neurologic monitoring and assessment after abnormal behavior reports by family, and aphasia. Pt remained neurologically stable with persisting dysphasia. On [**3-14**], he was determined to be appropriate for transfer to the neurosurgical floor. On [**3-14**], his urine culture also grew positive for coag negative staph, and he was started on a course of cipro for days. On [**3-18**], after completing his cipro for UTI, he was found to be febrile to 102 degrees. On [**3-19**] Neurology service was consulted to evaluate the need for his multi antiseizure meds. They recommended continuing on his home regimen, as the etiology of antiseizure needs is relatively unclear. At this point, he was able to talk somewhat with his wife ([**2-21**] word sentences), and tolerated some oral intake. On [**3-20**] he was noted to be minimally arousable, which is similar to his initial presentation. His wife also noted he was gripping his head, had face flushed and and grimacing, but that he was using upper extremities. Throughout the admission, he has had a fever from 101-102, treated [**Date range (1) 8361**] with Ciprofloxacin for urinary tract infection. Chest x-rays have been unremarkable, and a leukocytosis (11-20K) has been persistent. Given persistent fever, Infectious disease was consulted [**3-20**]. Patient was transferred to the Medical service on [**2164-3-21**] given no planned neurosurgical interventions and persistent fever and leukocytosis. The rest of his hospital course (on the medical service) is as follows: # FEVER / LEUKOCYTOSIS: Upon transfer, etiology had not been identified despite extensive work-up. Specifically, he has had negative blood cultures, urine cultues without an identifiable pathogen and negative imaging including repeat CXR and LENIs. Given that he is hospitalized, there is always concern for C.diff but abdominal exam fairly benign and no reported loose stools. Also would consider aspiration PNA given poor swallowing but no changes on CXR. Given prolonged bed rest, at risk for skin breakdown but no evidence of this given nursing diligence with turning. No appreciable murmur on exam, but previously instructed to take antibiotics with dental procedure so may have valvular abnormaliteis. [**Month (only) 116**] also be due to an intra-abdominal process such as acute hepatitis given LFTs elevated, but not to the point of an acute viral process. Did not performed LP given acute bleed and at low risk for a concurrent meningitis. Other considerations included drug fever (though no clear causative agents), central fever s/p SAH or occult seizure activity. TTE [**3-21**] without clear vegetations but Echo poor quality due to patient unable to cooperate fully with exam. [**Doctor First Name **], ANCA, RF all negative for autoimmune process. [**3-22**] RUQ ultrasound ordered for transaminitis revealed no intrabdominal pathology. Upon discharge, all blood cultures were no growth to date. Stool culture were no growth. CT chest/abd/pelvis was obtained to assess for occult infection and revealed no evidence of an infectious process. Additionally, given transaminitis, a hepatitis panel was obtained and was negative. Besides 3 days of Cipro for UTI, patient was not given further antibiotics. After an extensive work-up, infectious disease signed-off on [**2164-3-24**] as fevers were thought to likely be of central origin. # Subarachnoid Hemorrhage: Noted on OSH CT with expected evolution per NeuroSurgery. On AEDs already given h/o seizure s/p meningioma resection. NC-CT head [**3-22**] with expected interval change, no worsening edema or midline shift. Patient was continued on Oxcarbazepine 600 mg PO BID & Phenytoin. Given repeatedly low levels of Phenytoin, his daily dose was increased. Additionally, his Aggrenox was held throughout his stay and his BP goal was SBP > 100 and < 160. Upon discharge had scheduled follow-up with Dr. [**First Name (STitle) **]. Also planned to have PT/OT at rehab. # HYPERTENSION: Elevated inpatient and likely [**2-20**] central process. Previously on HCTZ 25 daily and Enalapril 10 mg daily. While on Nuerosurgery service, he was treated with Atenolol, Hydralazine, HCTZ and Enalapril with only fair control and getting Hydralazine PRN. Upon transfer to medicine, patient's Enalapril was increased to [**Hospital1 **] and Hydralazine PRN was discontinued. HCTZ was also discontinued given hyponatremia and he was started on Amlodipine. As above, BP goal per neurosurgery is SBP > 100 and < 160. # TRANSAMINITIS: Unclear etiology, not noted previously. Shouldn't be [**2-20**] SAH, but could be medication effect. Also could be infectious etiology. Hepatitis panel sent as above. Lipitor was held given these values but should be restarted as an outpatient. Upon discharge, was scheduled to have these rechecked [**2164-3-28**]. # DIABETES: Initially on regular sliding scale, will transitioned to humalog SS. Given his need to have > 20U of Humalog on his ISS, he was also started on low dose Glargine. # HYPOTHYROID: TSH checked inpatient and found to be 0.51. Given age and concern for pro-arrythmic state in elderly, ideally TSH would be >1. Decreased Levoxyl to 112mcg daily given relatively suppressed TSH. Will need TSH checked in 6 weeks post-discharge. # HYPERLIPIDEMIA: Longstanding and s/p TIA in past. Denies history of coronary disease per wife. [**Name (NI) **] Simvastatin given transaminitis but should be restarted as ; restart ASAP # ASPIRATION RISK: Patient on aspiration precautions and s/p speech and swallow evaluation with modifications per their recommendations. While inpatient was kept on aspiration precautions and with diet modifications per swallow evaluation. # BPH: Urinating s/p foley removal. Continued on Finasteride. # HYPONATREMIA: Developed [**3-21**] AM after poor po intake the day prior. Volume status difficult to assess as patient unable to fully cooperate with exam but no peripheral edema, MM appear moist. Urine Osm / Na consistent with SIADH. Placed on fluid restriction to 1200mL daily and Hydrochlorothiazide was discontinued. Resolved to 133 by the day of discharge. # THYROID NODULES: Noted on [**2164-3-23**] CT Chest. Should be followed as outpatient by primary care physician. # DIET: Consistency: Soft (dysphagia); Thin liquids CODE STATUS: FULL Medications on Admission: Aggrenox 1 [**Hospital1 **] Lipitor 20mg daily HCTZ 25 daily Enalapril 10 mg daily Finasteride 5 mg daily Synthroid 125 micrograms daily Trileptal 300 mg: 2 tablets [**Hospital1 **] Dilantin 50 mg infantab: chew 3 morning, 2 evening, 3 night Discharge Medications: 1. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 2. Finasteride 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 3. Oxcarbazepine 600 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 4. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day): Hold for loose stools. 5. Multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 6. Atenolol 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily): Hold for HR<60 or BP<100 . 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 8. Levothyroxine 112 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily): This has been decreased while inpatient. 9. Calcium Carbonate 1,000 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO BID (2 times a day): Do not give simultaneously with Levothyroxine . 10. Enalapril Maleate 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 11. Amlodipine 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 12. Insulin Glargine 100 unit/mL Solution [**Last Name (STitle) **]: Four (4) units Subcutaneous at bedtime. 13. Insulin Sliding Scale Please use Humalog insulin sliding scale, start at fingerstick 150 give 2u, increase by 2u for each additional 50 increase to maximum 400. 14. Outpatient Lab Work Please check LFTs on Wednesday, [**2164-3-28**]. If markedly different than discharge or concerned for acute process, please further evaluate as necessary. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: Bilateral Subarachnoid Hemorrhage, left Subdural hematoma, fever Secondary: Seizure disorder, hypertension Discharge Condition: Neurologically and hemodynamically stable. Discharge Instructions: You were admitted with bleeding in your brain. You were followed by Neurosurgery and no intervention was done. You then developed fevers. Complete work-up of your fevers revealed no positve cultures or imaging. Once stable, you were discharged to rehab for further physical and occupational therapy. General Instructions: - Exercise should be limited to walking; no lifting, straining, or - Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. - You were on Aggrenox prior to your injury, this medication has been stopped and you should discuss this with your primary doctor - You have been prescribed Phenytoin for antiseizure prophylaxsis, you will require blood work to monitor levels. 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 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: Please call your regular physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8362**] at [**Telephone/Fax (1) 8363**] to schedule an appointment in [**10-31**] days after discharge. NEUROSURGERY FOLLOW-UP Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8364**], MD Phone:[**Telephone/Fax (1) 1669**] Date/Time:[**2164-4-26**] 1:30 Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2164-4-26**] 1:00

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

20612, 20678

12171, 18618

333, 339

20839, 20884

3250, 8091

22108, 22585

1883, 1901

18910, 20589

20699, 20818

18644, 18887

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1916, 2192

275, 295

367, 1225

8100, 12148

2207, 3231

1247, 1604

1620, 1867

412

109,897

27082

Discharge summary

report

Admission Date: [**2138-3-18**] Discharge Date: [**2138-3-25**] Date of Birth: [**2062-5-2**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Decreased exercise tolerance with dypsnea on exertion Major Surgical or Invasive Procedure: AVR (23mm CE pericardial))/MVR (29mmCE, pericardial)/TV Repair (32mm ring)/CABG X 1 (SVG > OM) on [**2138-3-18**] History of Present Illness: 75 y/o african american male with known rheumatic heart disease with recent shortness of breath and hospital admission for congestive heart failure. Also c/o decreased exercise tolerance, DOE, and fatigue. Past Medical History: Aortic Stenosis Mitral Regurgitation and Stenosis Tricuspid Regurgitation Coronary Artery Disease Rheumatic Heart Disease congestive Heart Failure Hypercholesterolemia Diverticulitis ?GERD h/o Prostate Cancer s/p prostatectomy s/p testicular surgery Social History: Retired parking officer. Lives with wife. Quit smoking [**9-28**] after 1/2ppd x 35 yrs. Rare ETOH Family History: Non-contributory Physical Exam: VS: 84 20 160/84 160/80 5'[**41**]" 112# General: 75 y/o male in NAD Skin: Unremarkable, W/D HEENT: EOMI, PERRL, NC/AT Neck: Supple, FROM, -JVD Chest: CTAB -w/r/r Heart: RRR 3/6 syst. murmur Abd: Soft, NT/ND, +BS Ext: Warm, well-perfused, -edema, few varicosities bilat R>L Neuro: A&Ox3, MAE, non-focal Pertinent Results: Echo [**3-18**]: Prebypass: The right atrium is markedly dilated. There is moderate global left ventricular hypokinesis. Overall left ventricular systolic function is moderately depressed. Resting regional wall motion abnormalities include moderately depressed inferior wall basal and mid portions. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis. Moderate to severe (3+) aortic regurgitation is seen. Aortic annulus measures 23 mm. The mitral valve leaflets are severely thickened/deformed. The mitral valve shows characteristic rheumatic deformity. There is moderate mitral stenosis. Moderate (2+) mitral regurgitation is seen. Severe [4+] tricuspid regurgitation is seen. Moderate sized left pleural effusion. Post bypass: Biventricular systolic function is unchanged. Bioprosthetic valve seen in the mitral position. Valve appears well seated and the leaflets move well. Trace mitral regurgitation. Bioprosthetic valve seen in the aortic position. Leaflets move well and the valve appears well seated. Trace aortic regurgitation present. Annuloplasty ring seen in the tricuspid position. Trace to mild tricuspid regurgitation present. CXR [**3-24**]: Resolution of failure. Cardiomegaly persists. [**2138-3-18**] 02:05PM BLOOD WBC-17.6*# RBC-2.95*# Hgb-8.9*# Hct-25.9*# MCV-88 MCH-30.3 MCHC-34.5 RDW-13.3 Plt Ct-106* [**2138-3-20**] 03:36AM BLOOD WBC-19.2* RBC-2.85* Hgb-8.6* Hct-24.4* MCV-86 MCH-30.3 MCHC-35.4* RDW-15.2 Plt Ct-126* [**2138-3-24**] 09:00PM BLOOD WBC-10.8 RBC-3.66* Hgb-11.2* Hct-31.3* MCV-86 MCH-30.5 MCHC-35.6* RDW-14.0 Plt Ct-171 [**2138-3-18**] 02:05PM BLOOD PT-18.8* PTT-58.3* INR(PT)-1.8* [**2138-3-22**] 03:17AM BLOOD PT-13.0 PTT-30.8 INR(PT)-1.1 [**2138-3-18**] 03:20PM BLOOD UreaN-13 Creat-0.7 Cl-114* HCO3-23 [**2138-3-24**] 06:09AM BLOOD Glucose-120* UreaN-16 Creat-0.7 Na-138 K-3.2* Cl-101 HCO3-26 AnGap-14 [**2138-3-24**] 06:09AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.8 [**Last Name (NamePattern4) 4125**]ospital Course: Mr. [**Known lastname 131**] was seen initially as an outpatient and had his entire pre-operative work-up done prior to hospital admission for surgery. He was a same day admit on [**2138-3-18**] and was brought to the operating room where he underwent a aortic valve repair, mitral valve repair, tricuspid valve replacement and coronary artery bypass graft x 1 by Dr. [**Last Name (Prefixes) **]. Please see op note for surgical details. Following surgery patient was transferred to the CSRU in stable condition receiving Epinephrine, Milrinone, and Propofol. Early on post-op day one he was weaned from sedation, awoke neurologically intact and extubated. He was weaned off of all pressors/inotropes by post-op day two. Beta blockers and diuretics were started and he was gently diuresed towards his pre-operative weight. He was slightly anemic with a Hgb of 24.4 and was transfused 1u PRBC's. At time of discharge his Hgb was 31. Chest tubes and epicardial pacing wires were removed per protocol. Had sleep study on post-op day 3 secondary to difficulty swallowing. He became febrile between post-op day 3 and 4 and was empirically started on Vancomycin and Levaquin. Multiple cultures came back negative but was found to have LLL consolidation (presumed PNA). He was transferred to the cardiac surgery step down unit on post-op day four. His temperature decreased on pod#5, but had elevated WBC. PT worked with patient during entire post-op course for strength and mobility. Patient became confused and psychiatric consult was done. Infectious disease was also consulted secondary to fever/WBC/PNA. Over next couple of days patient was stable with normal exam, vital signs, and stable labs. He was discharged home with VNA services on post-op day seven and the appropriate follow-up appointments. Medications on Admission: Aspirin 81mg qd, Lisinopril 20mg qd, Simvastatin 40mg qd, Antacids prn Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**11-25**] Puffs Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. Disp:*1 MDI* Refills:*2* 7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 MDI* Refills:*2* 8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day for 7 days: then 200 mg daily until d/c'd by Dr. [**Last Name (STitle) 3659**]. Disp:*60 Tablet(s)* Refills:*0* 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO twice a day for 7 days. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 12. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. Disp:*5 Tablet(s)* Refills:*0* 13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. Disp:*7 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital **] Hospice and VNA Discharge Diagnosis: Aortic Stenosis/Mitral Regurgitation and Stenosis/Tricuspid Regurgitation/Coronary Artery Disease s/p Aortic Valve Replacement, Mitral Valve Replacement, Tricupid Valve Repair, Coronary ARtery Bypass Graft x 1 Rheumatic Heart Disease Hypercholesterolemia Discharge Condition: good Discharge Instructions: may shower, no bathing or swimming for 1 month no creams, lotions or powders to any incisions no lifting > 10# for 10 weeks [**Last Name (NamePattern4) 2138**]p Instructions: with Dr. [**Last Name (STitle) **] in [**12-27**] weeks with Dr. [**Last Name (STitle) **] in [**12-27**] weeks with Dr. [**Last Name (Prefixes) **] in 4 weeks Completed by:[**2138-3-25**]

[ "398.91", "507.0", "396.8", "272.0", "285.9", "397.0", "414.01", "997.3" ]

icd9cm

[ [ [] ] ]

[ "35.33", "35.21", "39.61", "36.11", "35.23" ]

icd9pcs

[ [ [] ] ]

7291, 7353

374, 489

7651, 7657

1485, 3576

1129, 1147

5549, 7268

7374, 7630

5454, 5526

7681, 7806

7857, 8047

1162, 1466

3627, 5428

281, 336

517, 724

746, 997

1013, 1113

6,567

118,159

25376

Discharge summary

report

Admission Date: [**2193-6-30**] Discharge Date: [**2193-7-16**] Date of Birth: [**2114-2-25**] Sex: F Service: MEDICINE Allergies: Ativan / Seroquel Attending:[**First Name3 (LF) 2704**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Right internal jugular vein line placement Coronary catheterization No aneurysm surgical repair performed per patient and family wishes. History of Present Illness: This is a 79 female with coronary artery disease (s/p CABG [**2178**]), atrial fibrillation, chronic renal insufficiency, and known thoracic aortic aneurysm (7.5cm, previously refused intervention) who presented w/ two days of chest pain radiating to the back. Upon presentation the pain was stabbing, sternal in location and radiating to the back. The patient had experienced this type of pain before but not to this degree of severity (subj. [**8-31**]). She initially presented to [**Hospital1 **] [**Location (un) 47**] where BP150s, EKG T wave inversions in V4-6. She was given sublingual nitroglycerin w/ some relief, then metoprolol 5mg IV, morphine, ativan. Hct 23, K 2.7, INR 7.5. Given 2FFP, 5mg PO VitK, 1U PRBCs, CT (I-) revealed slt expansion of thoracic aneurysm, wet read by radiology here revealed descending dissection (but limited by lack of contrast). During [**Location (un) **], started on nipride drip, second unit PRBCs given. Chest pain free on arrival. Hct 22.4, INR 2.1. Patient has (per report) previously refused surgery for aneurysm, however, per patient was told that the surgery would not help, and is now amenable. Past Medical History: Paroxysmal atrial fibrillation CAD s/p CABG ('[**78**] vessels unk) Thoracic Aortic Aneurysm CRI (baseline 1.1-1.3, ?necrotic kidney) Renovascular hypertension Hypothyroidism Social History: Lives with husband at home who has had a stroke. Neighbors have been assisting. Family History: Non-contributory Physical Exam: VS: HR-80, BP 97/54, RR14 Gen: NAD HEENT: Eye: Right eye broken blood vessel Neck supple, +JVD Heart: nl rate, S1,S2 diastolic decrescendo murmur Lung: CTA-bilaterally, no R/R/W Abdomen: flat, soft, non-tender, non-distended +BS; R femoral bruit Extremities: no c/c/e Pertinent Results: Labs on admission [**2193-6-30**] 09:54PM GLUCOSE-442* UREA N-59* CREAT-1.4* SODIUM-131* POTASSIUM-3.1* CHLORIDE-97 TOTAL CO2-23 ANION GAP-14 [**2193-6-30**] 09:54PM CK-MB-NotDone cTropnT-<0.01 [**2193-6-30**] 09:54PM CALCIUM-8.1* PHOSPHATE-3.2 MAGNESIUM-2.1 IRON-185* [**2193-6-30**] 09:54PM WBC-5.6 RBC-2.58* HGB-7.8* HCT-22.4* MCV-87 MCH-30.2 MCHC-34.8 RDW-14.8 . Labs on discharge [**2193-7-16**] 05:50AM BLOOD Glucose-107* UreaN-26* Creat-1.1 Na-138 K-4.1 Cl-110* HCO3-21* AnGap-11 [**2193-7-16**] 05:50AM BLOOD Calcium-8.9 Phos-2.7 Mg-2.0 [**2193-7-16**] 05:50AM BLOOD WBC-7.5 RBC-3.38* Hgb-10.5* Hct-29.0* MCV-86 MCH-31.1 MCHC-36.3* RDW-13.3 Plt Ct-200 . RADIOLOGY Preliminary Report . MRA KIDNEY W&W/O CONTRAST [**2193-7-15**] 3:19 PM MRA KIDNEY W&W/O CONTRAST; MR CONTRAST GADOLIN Reason: evaluate for renal artery stenosis Contrast: MAGNEVIST [**Hospital 93**] MEDICAL CONDITION: 79 year old woman with aortic anuerysm and uncontrolable hypertension on multiple anti-hypertensive medications.Pt only has one kidney REASON FOR THIS EXAMINATION: evaluate for renal artery stenosis INDICATION: History of aortic aneurysm and uncontrollable hypertension on multiple antihypertensive medications. TECHNIQUE: Multiplanar T1 and T2-weighted images were performed. Renal MRA technique was used. Pre and post-contrast axial and coronal 3-D T1-weighted images through the central abdominal vasculature were obtained. Multiplanar and 3-D reformatted images were obtained along with subtraction sequences. COMPARISON: None. RENAL MRA: Normal flow is noted in the left renal artery. There is a single left renal artery. Motion artifact slightly limits evaluation of the right renal artery. However, allowing for this, there is likely focal short segment high-grade stenosis at the origin of the right renal artery. A single right renal artery is noted. Diffuse irregularity is noted throughout the abdominal aorta consistent with atherosclerotic disease. There is moderate widening of the aorta at the thoracoabdominal junction. The thoracic aorta is incompletely evaluated on this study. ABDOMEN MRI: The left kidney measures 11.8 cm and the right kidney measures 8.8 cm. There is differential increased enhancement in the left kidney versus the right. Both kidneys have overall delayed uptake. There is limited soft tissue detail for other intraabdominal organs due to motion artifact. Multiplanar reformatted images and 3-D reformatted images were obtained on the workstation and were integral in evaluating renal artery anatomy. IMPRESSION: 1. Normal left renal artery flow. 2. Short segment high-grade stenosis at the origin of the right renal artery. 3. Right kidney atrophy with delayed enhancement. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4347**] . RADIOLOGY Final Report CAROTID SERIES COMPLETE PORT [**2193-7-3**] 12:48 PM CAROTID SERIES COMPLETE PORT; [**Last Name (un) **] DUP EXTEXT BIL (MAP/DVT) P Reason: PREOP THORACIC ANEURYSM REPAIR [**Hospital 93**] MEDICAL CONDITION: 79 year old woman with CAD who presented with CP secondary to thoracic aortic aneurysm REASON FOR THIS EXAMINATION: evaluation of carotids STUDY: 1. Carotid series complete preop for aneurysm repair. 2. Venous duplex. Patient in need of venous conduit. FINDINGS: Duplex evaluation was performed of both carotid arteries. Moderate to significant plaque was identified on the left. On the right, peak systolic velocities are 87, 108, 172 in the ICA, CCA, ECA respectively. The ICA to CCA ratio is 0.8. This is consistent with less than 40% stenosis. On the left, peak systolic velocities are 262, 50, 41 in the ICA, CCA, ECA respectively. The ICA to CCA ratio is 5.2. This is consistent with a 70-79% stenosis. There is antegrade flow in both vertebral arteries. IMPRESSION: Moderate to significant left-sided plaque with a 70-79% stenosis. On the right, there is a less than 40% carotid stenosis. Venous Duplex: Both greater saphenous veins have been harvested. Right lesser saphenous vein is patent with diameters ranging from 0.28-0.42 cm. On the left, the lesser saphenous vein is patent with diameters ranging from 0.30-0.31. Of note, more proximally the vein forms multiple branches. IMPRESSION: Patent bilateral LSV with diameters as noted DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: SAT [**2193-7-6**] 11:45 AM . Echo [**2193-7-1**] Conclusions: The left atrium is mildly elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size.There is mild global left ventricular hypokinesis with focal inferior akinesis. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic arch is markedly dilated/aneurysmal. The descending thoracic aorta is moderately dilated. No discrete dissection is seen (best excluded [**Month/Day/Year **]/CT/MRI). The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Mild to moderate ([**12-23**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Markedly dilated aortic arch and moderately dilated descending thoracic aorta. Mild-moderate aortic regurgitation. Mild symmetric left ventricular hypertrophy with regional systolic dysfunction c/w CAD. If clinically indicated, a [**Last Name (LF) **], [**First Name3 (LF) **] MRI, or thoracic CT would be better able to characterize the aortic aneurysm/presence of a dissection. Based on [**2184**] AHA endocarditis prophylaxis recommendations, the echo findings indicate a moderate risk (prophylaxis recommended). Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD on [**2193-7-1**] 13:58. [**Location (un) **] PHYSICIAN: . Cath [**2193-7-1**] COMMENTS: 1. Coronary angiography revealed native 3 vessel disease and savenous vein graft disease in one of the three grafts. The LMCA had a 99% ostial stenosis. The LAD was occluded proximally. The LCX was a nondominant vessel with a moderate size ramus intermedius patent. The LCX was occluded in the proximal segment. The RCA was a dominant vessel with diffuse disease throughout its course up to 50%. The PDA was occluded at its origin. 2. Graft angiography revealed a subtotally occluded SVG-->RCA/PDA with origin and mid segment lesions of 99%. The SVG--> OM1/D1 is patent without lesions. The LIMA--> LAD is patent and does not cross the midline. 2. Thoracic angiography revealed an ascending aneurysm of 4 cm with transverse aneurysm of 8.0 cm in a type II arch. The descending aorta has ectasia with bicoronate aneurysm of teh diaphragm. 3. Limited hemodynamics revealed elavated systemic pressures. 4. Left ventriculography was deferred due to high contrast administration. FINAL DIAGNOSIS: 1. Three vessel native coronary artery disease. 2. Occluded SVG->RCA. 3. Severe systemic HTN. 4. Ascending thoracic aneurysm. ATTENDING PHYSICIAN: [**Last Name (Prefixes) 413**],[**First Name3 (LF) 412**] Brief Hospital Course: 79 y/o female with CAD s/p CABG, who presented with chest pain radiating to the back in the setting of a known 7.5 cm thoracic aortic aneurysm and no elevation in cardiac enzymes. . 1. Thoracic Aneurysm / Hypertension . Surgical Management: Although initially agreeable to the possibility of surgical intervention, after thorough discussion of the risks and benefits of the procedure, the patient declined what is described as a high-risk intervention. Her family was in agreement with her decision, which remained durable during the length of stay. Her goals were to minimize all medications, and "no procedures!" . Medical Management Keeping with this philosophy, it was felt that strict blood pressure control, using multiple anti-hypertensive agents, would give her the best chance of prolonging life, and keeping high quality of living. Initially managed with a nitroprusside drip, multiple agents were added in sequence. . Agents used included IV nitroprusside (d/c'd), IV nitroglycerin, diltiazem (max), HCTZ 25, Lisinopril 40, Labetolol (switched to metoprolol), amlodipine (max), clonidine, lasix 20, Toprol 200 qd, and minoxidil 5 [**Hospital1 **]. Maximal doses of the antihypertensive agents were attained before starting additional agents. The patient requried use of all of these to maintain goal SBP 120-140 mm Hg. . By [**2193-7-12**], the patient was weaned off all IV drips (nitroprusside -> nitroglycerin -> off), and transferred to the floor for further management. Her SBP on the discharge regimen (see attached) was 130-140 mm Hg, at her goal range. . [**Hospital **] hospital course was complicated on [**7-14**] - [**7-15**] with a period of hypotension, low urine output, increasing creatinine and numbness in the right arm. Pt also had guaic positive stools. Hematocrit at this time was 27.2. At this point the decision was made to stop all anti-hypertensive medications, give fluid boluses and to transfuse the patient one unit. The patient's blood pressures and urine output improved. Hematocrit improved to 29.2. The numbness in her right arm resolved. . Thereafter the patient was slowly restarted on anti-hypertensives. On the day of discharge the patient was sent home with the following anti- hypertensives: Toprol 100, Imdur 120, Clonidine patch, Norvasc 10. SBP on discharge was stable at 130. . 2. Guaic positive stools Patient had guaic positive stools intermittently throughout her hospital course. Cultures were sent and were negative. Pt has been afebrile and there has been no increase in WBC. Pt's hematocrit was monitored and she was transfused as needed. Pt reports that she has had a colonoscopy within the past 5 years. She recalls it being normal. While a colonoscopy would be needed to rule out a malignancy, patient's GI bleed may be a reflection of ischemia secondary to her worsening thoracic aneurysm. . 3. DNR/DNI: Comfort Measures Only As previously stated, the patient has decided that would not want any type of surgical intervention to repair the thoracic aneurysm. She has decided that she would like to go home and spend her remaining days with her family. The patient is aware that it is not possible to pinpoint when her aneurysm will rupture. She understands that it can occur at any time and that she will be sent home on anti-HTN, morphine and nitrates to keep her as comfortable as possible. . Patient is not a candidate for hospice, but she will be receiving home VNA services. She also has homemaker services in place. The patient has identified her neighbors as a strong support network. Medications on Admission: Atenolol Labetalol Lipitor Levothyroxine Coumadin Discharge Medications: 1. Levothyroxine Sodium 25 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Clonidine 0.3 mg/24 hr Patch Weekly Sig: Two (2) Patch Weekly Transdermal QFRI (every Friday). Disp:*8 Patch Weekly(s)* Refills:*2* 5. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 7. Imdur 120 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Thoracic Aortic Aneurysm Discharge Condition: Good Discharge Instructions: You are being discharged with new anti-hypertensive medications to medically manage your thoracic aneurysm. Please adhere to these medications. A visiting nurse will be coming by to check in on you. Followup Instructions: You should make an appointment to see your PCP [**Name Initial (PRE) 176**] 1 week of being discharged from the hospital. If you are unable to control your pain at home go to the emergency room. Bring discharge summary with you if you do need to come back to the hospital. Completed by:[**2193-8-7**]

[ "996.72", "405.91", "244.9", "272.0", "427.31", "441.2", "411.1", "V45.81", "414.01", "584.9", "440.1" ]

icd9cm

[ [ [] ] ]

[ "38.93", "37.22", "99.07", "88.52", "88.55", "99.04" ]

icd9pcs

[ [ [] ] ]

14355, 14404

9775, 13356

289, 428

14472, 14478

2247, 3115

14727, 15029

1926, 1944

13457, 14332

5426, 5513

14425, 14451

13382, 13434

9540, 9752

14502, 14704

1959, 2228

239, 251

5542, 8482

456, 1613

8514, 9523

1635, 1811

1827, 1910

74,764

193,017

6987

Discharge summary

report

Admission Date: [**2178-11-6**] Discharge Date: [**2178-11-16**] Date of Birth: [**2114-3-24**] Sex: M Service: CARDIOTHORACIC Allergies: Inderal La / Lipitor Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest and bilateral arm pain. Major Surgical or Invasive Procedure: Aortic valve replacement (21mm St. [**Male First Name (un) 923**] tissue), coronary artery bypass grafts x 3 (LIMA-LAD, SVG-OM, SVG-PDA) [**11-6**] History of Present Illness: 64 year old male with past medical history noted below who presented to the emergency department in early [**Month (only) 359**] with chest pressure and heaviness. He was admitted and ruled out for a myocardial infarction. A stress test was positive and he was cathed. Cath showed severe 3-vessel disease. He was felt to be stable and discharged by cardiology with plan to return for CABG. He returned on [**2178-11-6**] and underwent coronary artery bypass graft surgery times three. Past Medical History: Peripheral vascular disease Hypertension Hyperlipidemia Aortic stenosis Chronic renal insufficiency degenerative joint disease cerebrovascular disease S/P appendectomy S/P aortobifemoral bypass, [**2168**] S/P right hypogastric artery endarterectomy, [**2177**] s/p multiple pacemaker implants central venous thrombosis Social History: The patient retired in [**2147**] from the [**First Name8 (NamePattern2) 8314**] [**Last Name (NamePattern1) **] Corporation and has since been a pool hussler and investor. Social history is significant for a 60+ pack year smoking history. Social ETOH use now per patient. daily narcotic use for shoulder pain Family History: Family history is notable for a father who died of a heart attack at age 53, a mother who is still living at 89 who has diabetes and recently had a heart attack. He has 4 brothers and 1 sister. One brother recently died of liver cancer. One brother has diabetes and kidney failure. Another brother has diabetes and is s/p multiple bypasses and stents. Physical Exam: discharge: Anxious, reasonable when talked to Chest: lungs clear to auscultation, sternum stable COR: regular rate, normal S1S2. II/VI systolic murmur loudest at apex Abdomen: numerous well healed incisions. Normoactive bowel sounds. Soft and nontender Extremities: warm with trace edema Pertinent Results: [**2178-11-16**] 05:40AM BLOOD WBC-8.1 RBC-2.58* Hgb-7.9* Hct-23.9* MCV-92 MCH-30.5 MCHC-33.1 RDW-15.5 Plt Ct-404 [**2178-11-11**] 03:26AM BLOOD PT-12.1 PTT-26.7 INR(PT)-1.0 [**2178-11-14**] 07:35AM BLOOD Glucose-138* UreaN-50* Creat-2.0* Na-142 K-4.3 Cl-108 HCO3-22 AnGap-16 [**Known lastname **],[**Known firstname 2922**] [**Medical Record Number 26188**] M 64 [**2114-3-24**] Radiology Report CHEST (PORTABLE AP) Study Date of [**2178-11-11**] 9:05 AM [**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2178-11-11**] SCHED CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 26189**] Reason: repeat CXR, eval for possible left upper ptx [**Hospital 93**] MEDICAL CONDITION: 64 year old man intubated, post cabg REASON FOR THIS EXAMINATION: repeat CXR, eval for possible left upper ptx Final Report AP CHEST 9:31 A.M., [**11-11**] HISTORY: Possible prior pneumothorax. New lines and tubes. IMPRESSION: AP chest compared to [**11-10**] at 10:01 p.m. Moderate left pleural effusion is slightly larger. Small right pleural effusion, if any. Normal post-operative cardiomediastinal silhouette. No pneumothorax. Nasogastric tube would need to be advanced several centimeters to move all the side-ports into the stomach. Other lines and tubes in standard placements. Feeding tube has been removed. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] Approved: WED [**2178-11-11**] 11:52 AM Imaging Lab Brief Hospital Course: This 64 year old white male has known aortic stenosis and coronary artery disease and has been extensively worked up for surgery. He was admitted at this time for elective cardiac surgery. He went to the operating room on [**2178-11-6**] where surgery was performed as noted. See operative report for details. He weaned from bypass easily on no pressors. He was coagulopathic and received extra protamine, FFP, and platelets which corrected these and slowed postoperative bleeding. He remained hemodynamically stable. He had episodic severe agitation on awakening. He was extubated on POD1 and within one hour, complained of pain, breathing problems and became apneic. He then had jerking motions suggestive of seizure. He was reintubated for acute respiratory failure. A CT of the head was negative and EEG showed no lateralized or epileptiform features. He was seen by neurology. Dilantin loading was done, but no further dosing ordered. On POD2, he was stable and on lightening sedation he became very agiated, thrashing and hypertensive. He nodded to questions but was not reliable. Given his substance abuse history and behaviors, Ativan and Methadone were recommended by the Pain service. (Information from his brother, indicates that the patient takes [**3-31**] Percocets a day for chronic shoulder pain and drinks several times a week. He also indicated that there is central venous thrombosis from the patients 7 pacer implants for brady arrhythmias and syncopal episode over the years.) To ensure hemodynamic stability, he remained intubated and sedated for several days. Tube feedings were initiated and followed closely by the Nutrition service. Once his anti-hypertensive regimen along with analgesic control was optimized, he was re-exubated on POD6. He was transferred to the step down floor on POD 7. He had several episodes of attempting to leave the hospital late at night. He was not combative and reqired Haldol IV on the 1st night only. He was then placed on Haldol PO twice daily. He had trouble with walking feeling dizzy and unsteady but insisted he go home. He slowly improved and on POD 10 he was cleared by physical therapy and was alert and oriented. He was discharged to home in stable condition. Medications on Admission: Plavix 75mg/D Imdur 30mg/D Metoprolol 25mg/D Allopurinol 100mg/D Ezetimide 10mg/D Furosemide 40mg/G HCTZ 25mg/D Lisinopril 40mg/D ASA 325mg/D percocet prn NTG 0.4mg sl prn Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 7 days. Disp:*14 Capsule(s)* Refills:*0* 3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**3-29**] hours as needed. Disp:*50 Tablet(s)* Refills:*0* 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Ferrous Gluconate 325 mg (36 mg Iron) Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 8. Vitamin C 500 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. Disp:*60 Tablet Sustained Release(s)* Refills:*2* 9. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 10. 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* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: coronary artery disease s/p coronary artery bypass grafts x 3 (LIMA-LAD, SVG-OM, SVG-PDA), aortic valve replacement (21mm St. [**Male First Name (un) **] tissue) [**11-6**] aortic stenosis hypertension hyperlipidemia peripheral vascular disease chronic renal insufficiency cerebrovascular disease s/p permanent dual chamber pacemeker insertion s/p appendectomy s/p aortobifemoral bypass graft degenerative joint disease Discharge Condition: good Discharge Instructions: no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks shower daily, no baths or swimming no lotions, creams or powders to incisions report any redness of, or drainage from incisions report any fever greater than 100.5 report any weight gain greater than 2 pounds a day or 5 pounds in a week take all medications as directed Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) [**Hospital 409**] clinic in 2 weeks Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20561**] in 2 weeks ([**Telephone/Fax (1) 26190**]) Please call for appointments Completed by:[**2178-11-16**]

[ "272.4", "276.7", "403.90", "286.9", "715.91", "996.01", "780.39", "518.81", "V12.54", "E878.2", "413.9", "338.29", "305.1", "585.9", "998.11", "348.30", "424.1", "414.01", "291.81", "304.01" ]

icd9cm

[ [ [] ] ]

[ "35.21", "96.72", "39.61", "99.05", "36.12", "36.15", "99.07", "96.6", "96.04" ]

icd9pcs

[ [ [] ] ]

7524, 7579

3865, 6103

318, 468

8043, 8050

2350, 3013

8457, 8744

1668, 2026

6325, 7501

3053, 3090

7600, 8022

6129, 6302

8074, 8434

2041, 2331

249, 280

3122, 3842

496, 982

1004, 1325

1341, 1652

5,978

115,143

25789

Discharge summary

report

Admission Date: [**2146-4-3**] Discharge Date: [**2146-4-7**] Date of Birth: [**2120-3-29**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1042**] Chief Complaint: Abdominal Pain, Nausea, Vomitting Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 64236**] is a 26 y/o man with IDDM for 8 years who presents with several days of nausea/vomiting and abdominal pain. Two weeks ago, he was diagnosed with sinusitis/sinus infection and given antibiotics. He first noticed epigastric abdominal pain about one week ago, constant, without relation to food. It was a strong, sharp pain that did not radiate. Notably, he had been taking ibuprofen 800 mg q3h for headache associated with sinusitis at that time. In past 2-3 days noticed increased nausea with vomiting. Denies hematemesis. Notes that he last kept something liquid down yesterday morning, but vomitted up everything (both liqiuds and solids) through the day and night. Thus, he came to [**Hospital1 18**] ED that night. Took insulin during that time intermittently but this is typical for him. . His insulin control and FSG checking has chronically been very poor. He admits to taking insulin about 5 times per week. Further, when he does take it, he taked a standing dose of 10U Reg and 30U of 70/30. He takes his FSG about 1 per month due to discomfort with the prick. He has chronic polyuria and polydypsia. He reports getting regular vision checks with [**Last Name (un) **] center and no knowledge of neuropathy, kidney disease, or eye problems. . On ROS, he denies HA, changes in vision, hearing, or swallowing. No fever, sweats, chills, weight loss. He eats very well. No CP, palps, PND, orthopnea. No SOB, pain with breathing, cough, wheeze. No recent bowel of bladder dysfunction. No troubles with limb weakness, sensory changes, poor coordination. He does feel episodes of hypoglycemia if he does not eat following insulin: sweating, palpitations, and anxiety. Past Medical History: IDDM: Poorly controlled DKA X 3 Periperal neuropathy Social History: Patient denies any tobacco use. Uses ETOH socially. No drug use. Patient is a mental health worker in [**Last Name (un) 64237**] center, he currently lives with fiance. Pt is engaged and expecting daughter in next week. Lives in [**Location 18600**]. Family History: Family history positive for DM,CVA, cardiac disease [**Name (NI) **] mother died at age 45 from heart disease related to diabetes No family history of sickle cell disease Physical Exam: T: 98.8 BP: 139/78 HR: 112 RR: 17 O2 100% RA Gen: Pleasant, well appearing young male in no acute distress, lying comfortably in bed HEENT: No conjunctival pallor. No scleral icterus. MM slightly dry. OP clear. Eye funduscopic exam WNL (no exudates, edema, wiring) NECK: Supple, No LAD, JVD not elevated while sitting upright. No goiter CV: Tachycardic, regular, no appreciable murmur. Physiologically splitting S2. LUNGS: clear to auscultation bilaterally, no wheezing or rhonchi ABD: soft, nontender to palpation, no hepatosplenomegaly EXT: warm, well perfused throughout, no peripheral edema SKIN: No rashes or ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. 5/5 strength throughout. [**1-19**]+ reflexes, equal BL. Normal coordination. Distal foot sensation to light touch decreased. Pertinent Results: MICU Results: [**2146-4-3**] 08:17PM BLOOD WBC-14.6*# RBC-5.97 Hgb-15.6 Hct-48.8 MCV-82 MCH-26.2* MCHC-32.0 RDW-12.6 Plt Ct-327 [**2146-4-3**] 08:17PM BLOOD Glucose-404* UreaN-16 Creat-1.3* Na-143 K-4.5 Cl-99 HCO3-12* AnGap-37* [**2146-4-4**] 02:46AM BLOOD Calcium-9.8 Phos-2.9 Mg-1.9 [**2146-4-3**] 09:52PM BLOOD ALT-13 AST-11 AlkPhos-75 TotBili-0.3 [**2146-4-4**] 12:22PM BLOOD %HbA1c-14.8* Floor Transfer: [**2146-4-5**] 04:30AM BLOOD WBC-10.1 RBC-4.97 Hgb-13.2* Hct-39.9* MCV-80* MCH-26.6* MCHC-33.1 RDW-13.0 Plt Ct-267 [**2146-4-5**] 04:30AM BLOOD Glucose-187* UreaN-10 Creat-0.7 Na-142 K-3.0* Cl-110* HCO3-19* AnGap-16 [**2146-4-6**] 06:30AM BLOOD Glucose-232* UreaN-8 Creat-0.7 Na-145 K-3.9 Cl-111* HCO3-24 AnGap-14 [**2146-4-5**] 04:30AM BLOOD Calcium-9.1 Phos-2.2* Mg-1.8 CXR: FINDINGS: The lungs are well expanded and clear. The mediastinum is unremarkable. The cardiac silhouette is within normal limits for size. No effusion or pneumothorax is evident. The visualized osseous structures are unremarkable. IMPRESSION: No acute pulmonary process. Brief Hospital Course: On arrival to MICU, patient complaining of ongoing nausea and epigastric pain. Vomitting X 2 was witnessed by house staff, the second episode occurring with a small amount of hematemesis. No subsequent hematemesis or significant Hct change. In the MICU, he was placed on insulin drip, IVF, and electrolytes (most notably K) were repleted as needed. His Anion Gap narrowed from 30 to 13 by transfer to floor. His FSGs were initially high 400s and fluctuated between 200-500 in the MICU. Following stabilization, the patient was transferred to the medical floor. His FSG was 420 upon transfer. He was receiving standing NPH [**Hospital1 **] and Regular ISS with meals. On floor day 1, his FSGs were in the 200s. His anion gap closed. Potassium and Phos were repleted. The [**Last Name (un) **] center was also consulted. . Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Insulin Lispro 100 unit/mL Insulin Pen Sig: As per sliding scale Units Subcutaneous four times a day: Use number of units indicated on sliding scale for your measured blood glucose level before breakfast, lunch, dinner, and at bedtime. Disp:*2 Pens* Refills:*5* 3. Insulin Glargine 300 unit/3 mL Insulin Pen Sig: Forty (40) Units Subcutaneous at bedtime. Disp:*2 Pens* Refills:*2* 4. Lancets Misc Sig: One (1) lancet Miscellaneous qachs. Disp:*120 lancets* Refills:*2* 5. Test strips One test strip qachs dispense 120 Discharge Disposition: Home Discharge Diagnosis: Primary: Diabetic ketoacidosis, IDDM with features of insulin resistance. Discharge Condition: Good Discharge Instructions: You were admitted to the hospital for diabetic keto-acidosis. Diabetic ketoacidosis (DKA) is a severe and life threatening condition that results from uncontrolled blood sugar. This episode of DKA happened becuase you were not regularly taking insulin and becuase your blood sugar was very high. Your recent sinus infection could have also worsened your condition. As a result of this condition, you required admission to the intensive care unit. During your hospitalization, your blood sugar, electrolytes, and metabolism, in general, were restored to a more normal condition. It is extremely important that you keep your blood sugars at more normal levels or this life-threatening condition will happen again. Also, you will develop eye problems, kidney disease, worse leg numbness, and heart disease if your sugars are not controlled better. In order to control your sugars, you need to follow the Insulin regimen that was prescribed by the [**Last Name (un) **] center. You will have to take 2 types of insulin. You will take a dose of long acting insulin (Lantus) every night and this dose will be constant. You will take a dose of Humalog insulin before every meal based on the sliding scale chart - thus you have to check your sugar at this time. If you find that you are unable to follow the above insulin plan, you have to call your doctor at the [**Hospital **] clinic. Due to your high use of Motrin before admission, you irritated the lining of your stomach. Thus, we treated this problem with a medicine to decrease the acid in your stomach called pantoprazole. You should continue taking this medicine until you see your PCP and [**Name9 (PRE) 10748**] your stomach problem. If you begin to again experience increasing nausea, vomitting, abdominal pain, or any other concerning symptom, you should contact your PCP or go to the ER. Followup Instructions: You need to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3636**] for diabetes care. Your first appointment is [**4-29**] at 4PM. This appointment is very important!!! You can call ([**Telephone/Fax (1) 17484**] and ask for Dr.[**Name (NI) 64238**] office if this time does not work. You need to schedule an appointment with you primary care doctor within the next few weeks to followup your stomach pain after taking Motrin.

[ "357.2", "E935.9", "276.8", "250.13", "535.51", "250.63" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6116, 6122

4541, 5364

347, 353

6240, 6247

3456, 4518

8146, 8612

2443, 2616

5387, 6093

6143, 6219

6271, 8123

2631, 3437

274, 309

381, 2082

2104, 2158

2174, 2427

7,275

134,683

43675

Discharge summary

report

Admission Date: [**2137-3-4**] Discharge Date: [**2137-3-5**] Date of Birth: [**2078-11-11**] Sex: M Service: MEDICINE Allergies: Penicillins / Iodine; Iodine Containing / Carbamazepine Attending:[**First Name3 (LF) 338**] Chief Complaint: change in mental status Major Surgical or Invasive Procedure: Hemodyalysis History of Present Illness: 58 yo M with ESRD on HD, seizure disorder, HCV, presents with confusion and SBP in 250/140's. Patient was found eating soap and trying to break into neighbour's house. Per his son, he missed HD on [**Name (NI) 2974**] but went on Saturday. He says his father gets confused with episodes of seizure although his current behavior is not typical for these. He does not know of any recent illness. He reports his father has been tappering off Ativan from 1 mg tid to 0.5 mg [**Hospital1 **] which has been making [**Last Name (un) **] less drowsy. He also told his son he may not have taken all of his BP meds the last few days. . In the ED, VS 97.6 90 235/149 22 92% RA. Started on On labetalol gtt, Toprol XL 200 mg po, Ativan 1 mg IV,ASA. Evaluated by nephrology with plans to dialyse this AM. EKG showing LVH with strain, unchanged, TnT 0.22. Patient transfered to ICU for close monitoring and treatment of hypertensive emergency. . Upon arrival to the floor, patient confused and non cooperative. Denies CP, sob, no f/c/s, no n/v/d, no HA, dizziness, denies any complaints. Past Medical History: - Seizure disorder: since childhood, began as generalized tonic-clonic. He was treated with phenobarbitol and Mysoline. Later, was changed to Depakote and Dilantin. Depakote was discontinued roughly 4 years ago due to elevated ammonia levels. Since, then his seizures have increased in frequency and severity. As a result, muliple medications inculding Lamictal, Trileptal, Tegretol and Keppra have been tried and he has most recently been on combination of Keppra and Lamictal. His seizures have been occuring about once every 1-2 months. Usual episodes are characterized by confusion and disorientation with rare, generalized tonic clonic episodes. h/o of non-convulsive status -ESRD on HD (M,W,F) due to idiopathic glomerulonephritis, s/p 2 failed renal transplants -labile hypertension -hypothyroidism -peripheral [**Last Name (un) 1106**] disease -hypoparathyroidism -hepatitis C -CHF-systolic w/ EF 45% and diastolic dysfunction (echo [**12/2135**]) -SVT/AVNRT s/p ablation -multiple fistulas -H/O MRSA line infection -Recent admission [**2136-2-29**] for infected L upper arm AV fistula. -h/o mechanical falls admitted [**1-16**] -h/o VRE, MRSA Social History: Lives at home, on disability, has two sons. smokes 1ppd x 40 yrs, no etoh, drugs. Family History: Mother with breast CA; father alive with CAD & CHF; sons healthy. Physical Exam: VS: 98.0 185/108 72 14 100% 2L NC GEN: cachectic, ashen color, NAD, talkative but confused HEENT: OP dry, PERRL, sclera dull NECK: supple, prominent carotid pulsations, right tunneled IJ LUNGS: bibasilar crackles, good air entry CVS: nl S1 S2, RRR ABD: soft, NT, slightly distended, BS+, liver crosses midline, edge palpable 2 cm below left costal margin, spleen not enlarged EXT: wasted, warm, dry, 2+ dp pulses b/l Neuro: A&O x 3 but confused, says "why do they only play Silent Night at [**Holiday **]", CN II-XII intact, PERRL, full strength thoughout, sensation intact; no asterixis Pertinent Results: [**2137-3-4**] 02:00AM BLOOD WBC-10.8# RBC-4.20* Hgb-12.0* Hct-35.5* MCV-85 MCH-28.7 MCHC-33.9 RDW-18.4* Plt Ct-221 [**2137-3-5**] 04:06AM BLOOD WBC-5.0# RBC-3.97* Hgb-11.4* Hct-33.6* MCV-85 MCH-28.6 MCHC-33.8 RDW-18.6* Plt Ct-216 [**2137-3-4**] 02:00AM BLOOD Neuts-81.5* Lymphs-12.1* Monos-5.6 Eos-0.3 Baso-0.5 [**2137-3-4**] 02:00AM BLOOD Anisocy-2+ Poiklo-1+ Microcy-1+ [**2137-3-4**] 02:00AM BLOOD Plt Ct-221 [**2137-3-4**] 12:09PM BLOOD PT-12.8 PTT-32.4 INR(PT)-1.1 [**2137-3-5**] 04:06AM BLOOD Plt Ct-216 [**2137-3-4**] 02:00AM BLOOD Glucose-88 UreaN-56* Creat-7.3*# Na-142 K-5.5* Cl-94* HCO3-24 AnGap-30* [**2137-3-4**] 12:09PM BLOOD K-3.7 [**2137-3-4**] 04:58PM BLOOD Glucose-102 UreaN-36* Creat-4.8*# Na-140 K-4.2 Cl-99 HCO3-28 AnGap-17 [**2137-3-5**] 04:06AM BLOOD Glucose-97 UreaN-46* Creat-5.5* Na-141 K-4.5 Cl-101 HCO3-25 AnGap-20 [**2137-3-4**] 02:00AM BLOOD ALT-20 AST-40 CK(CPK)-137 AlkPhos-114 Amylase-56 TotBili-0.8 [**2137-3-4**] 12:09PM BLOOD CK(CPK)-95 [**2137-3-4**] 04:58PM BLOOD CK(CPK)-77 [**2137-3-4**] 02:00AM BLOOD cTropnT-0.22* [**2137-3-4**] 12:09PM BLOOD CK-MB-NotDone cTropnT-0.21* [**2137-3-4**] 04:58PM BLOOD CK-MB-NotDone cTropnT-0.20* [**2137-3-4**] 02:00AM BLOOD Albumin-4.6 Calcium-9.7 Phos-8.2*# Mg-2.3 [**2137-3-4**] 04:58PM BLOOD Calcium-9.1 Phos-6.1*# Mg-2.1 [**2137-3-5**] 04:06AM BLOOD Calcium-8.5 Phos-8.5*# Mg-2.3 [**2137-3-4**] 02:00AM BLOOD Ferritn-279 [**2137-3-4**] 02:00AM BLOOD Osmolal-317* [**2137-3-4**] 12:09PM BLOOD Ammonia-41 [**2137-3-4**] 12:09PM BLOOD TSH-1.9 [**2137-3-4**] 01:25PM BLOOD Type-[**Last Name (un) **] Temp-36.1 pH-7.35 [**2137-3-4**] 02:16AM BLOOD Lactate-2.7* K-5.8* [**2137-3-4**] 01:25PM BLOOD freeCa-1.13 . CHEST (PORTABLE AP) [**2137-3-4**] 2:15 AM . AP UPRIGHT PORTABLE CHEST X-RAY: A right internal jugular central venous catheter is again seen. The distal tips are not clearly identified, but are likely positioned in the SVC. The cardiac silhouette is enlarged but stable. The aorta is extremely tortuous. The left atrium is extremely enlarged. The hila appears slightly more prominent than on prior exam, and there is minimal pulmonary [**Month/Day/Year 1106**] redistribution. No pneumothorax is seen. Plate-like atelectasis is again seen at the right lung base, less prominent than on prior exam. There has been interval resolution of a right lung base opacity. No definite consolidation or effusion is noted. The surrounding soft tissue and osseous structures are stable. IMPRESSION: 1. No definite consolidation. Interval resolution of previously seen right lung base opacity. 2. Mild/moderate CHF. 3. Plate-like atelectasis at left lung base. . CT HEAD W/O CONTRAST [**2137-3-4**] 1:59 AM . FINDINGS: There is no significant interval change since the prior exam. There is no intra- or extra-axial hemorrhage, mass effect, or shift of normally midline structures. Low attenuation in the right parietal, and left frontal white matter are again noted. A left basal ganglia lacunar infarction is less clearly identified on today's study, possibly related to slice selection. The density values of the remaining brain parenchyma are within normal limits. The [**Doctor Last Name 352**]-white matter differentiation is preserved. Prominence of the extra- axial spaces mainly in the posterior fossa are unchanged since [**2135-10-31**]. The visualized paranasal sinuses are clear. Tiny amount of fluid is seen in scattered left mastoid air cells. Prominent subcutaneous calcifications are likely venous in origin. IMPRESSION: No intracranial hemorrhage or mass effect. No significant interval change since [**2137-1-27**]. . EEG IMPRESSION: This is an abnormal EEG due to the independent left and right parietal sharp waves, as well as the disorganized and slow background rhythm and bursts of generalized delta slowing. The first abnormality suggests independent left and right parietal cortical irritability, while the the last two abnormalities suggest a mild to moderate encephalopathy, which may be seen with infections, toxic metabolic abnormalities, ischemia or medications. . ECG Sinus rhythm. Possible left atrial abnormality. Left anterior fascicular block. Non-specific intraventricular conduction delay of the left bundle-branch block type. Left ventricular hypertrophy. Non-specific ST-T wave abnormalities which may be due in part, to left ventricular hypertrophy. Compared to the previous tracing of [**2137-1-26**] no significant change. Brief Hospital Course: Mr. [**Known lastname 93850**] is a 58 yo M with ESRD on HD, labile hypertension, seizure disorder who presents in a confusional state with SBP 230/140s. His hospital course is summarized below by problem. . # Hypertensive Emergency. Patient presented with likely hypertensive encephalopathy. Patient reportedly did not take all of his BP meds prior to admission. The differential included seizure or post ictal state given a history of non convulsive seizures that present with odd behavior/confusion. He was treated with a Labetalol gtt which was rapidly tapered off. He was urgently dialysed. His blood pressure remained elevated at 180s/110s. 3L of fluid were removed with HD. He was restarted on all of his outpatient BP medications including ACEI, CCB, BB and clonidine. On the day of discharge his BP was improved to 140-180/60-80's. His regimen was not changed. He will follow up with Dr. [**Last Name (STitle) 5762**] as scheduled. In addition, an ammonia level was checked which was normal and his LFTs were within normal range. He did not have asterixis on exam. He was treated with empiric lactulose however hepatic encephalopathy is less likely. . # ESRD on HD. Patient carried a diagnosis of idiopathic glomerulonephritis s/p failed renal transplantation x 2. His Cr was 7.3, K of 5.5, Phos 8.2, Lactate 2.7 AG of 28 on admission likely secondary to uremia. He was urgently dialysed with removal of 3L of fluid. He refused any recommended changes in his renal medication regimen including increasing phosphate binders. . # Seizure dsrd. Long standing, has failed multiple regimens in the past, recurrent seizures per OMR. The only recent changes were that the patient was tapered his Ativan dose due to sedation during the day. Per his son he was more alert on this new regimen however his behavior was not entirely consistent with his prior seizure activity. Neurology changed his regimen slightly by given him 1 mg of Ativan qHS. An EEG showed evidence of encephalopathy likely secondary to his underlying hypertension as well a pattern possibly consistent with a post ictal state. He as not in status during the EEG. His mental status improved on the day of discharge to his reported baseline per his PCP. [**Name10 (NameIs) **] is to continue Lamictal, Keppra and Ativan for seizure management. . # CHF. Mildly fluid overloaded on exam likely secondary to diastolic CHF in setting of malignant hypertension. H/o both systolic/diastolic CHF, EF 45% (echo [**12-16**]). His blood pressure was treated as above. He remained able to lie flat, sating well on room air. Fluid was removed with HD. . # HCV. Not on treatment. LFTs wnl, ammonia level wnl. Transiently treated with lactulose. Outpatient follow up required. . # Hypothyroid. TSH was 1.9. Not on treatment. . Patient was discharged home directly from the ICU with improved BP control, mentation improved. Patient is scheduled for outpatient follow up. He was provided a list of his medication and any changes. Medications on Admission: - Nephrocaps 1 daily - Lamictal 250 mg b.i.d. - Keppra 375 mg b.i.d. and 250 mg after each HD session (3x per wk) - Lorazepam 0.5 mg b.i.d. - Toprol-XL 200 mg once daily - Nifedipine 120 mg once daily - Lisinopril 20 mg once HS - Plavix 75 mg once daily - ASA 81 mg once daily - Clonidine 0.1 mg b.i.d. - Prevacid 30 mg once daily - Nortriptyline 10 mg q.h.s. - tums Discharge Medications: 1. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Month/Year (2) **]: One (1) Cap PO DAILY (Daily). 2. Levetiracetam 250 mg Tablet [**Month/Year (2) **]: 1.3 Tablets PO BID (2 times a day). 3. Levetiracetam 250 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO AFTER HD ON HD DAYS (). 4. Lamotrigine 100 mg Tablet [**Month/Year (2) **]: 2.5 Tablets PO BID (2 times a day). 5. Lorazepam 1 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 6. Lorazepam 0.5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a day). 7. Nortriptyline 10 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO HS (at bedtime). 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 9. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR [**Last Name (STitle) **]: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily). 10. Lisinopril 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime). 11. Clopidogrel 75 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 12. Clonidine 0.1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 13. Nifedipine 60 mg Tablet Sustained Release [**Last Name (STitle) **]: Two (2) Tablet Sustained Release PO DAILY (Daily). 14. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO DAILY (Daily). 15. Calcitriol 0.25 mcg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*0* 16. Sevelamer 800 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Hypertensive Encephalopathy Secondary: ESRD on HD Labile Hypertension Seizure disorder Hepatitis C Discharge Condition: Good - improved BP control and improved mental status Discharge Instructions: Please take all of your medications as directed. Please follow up with your Doctors as listed below. Please return to the hospital immediately with any confusion, headaches, dizziness, shortness of breath, chest pain or any other problems. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Followup Instructions: Neurology: Provider: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 1217**], MD Phone:[**Telephone/Fax (1) 2928**] Date/Time:[**2137-6-21**] 8:30 Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5762**] in the next week to make a follow up appointment. Tel: [**Telephone/Fax (1) 608**] Please continue your hemodyalysis as you were prior to being admitted to the hospital. Completed by:[**2137-3-5**]

[ "403.01", "428.40", "V15.88", "443.9", "437.2", "585.6", "244.9", "070.70", "345.90", "305.1" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

13053, 13059

7909, 10894

338, 352

13212, 13268

3444, 7886

13660, 14115

2751, 2819

11312, 13030

13080, 13191

10920, 11289

13292, 13637

2834, 3425

275, 300

380, 1457

1479, 2636

2652, 2735

68,713

174,373

3661

Discharge summary

report

Admission Date: [**2181-10-13**] Discharge Date: [**2181-10-24**] Date of Birth: [**2100-8-20**] Sex: F Service: MEDICINE Allergies: Keflex / Bactrim Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Transfer for management of painless jaundice Major Surgical or Invasive Procedure: Endotracheal Intubation Central line access Arterial line access History of Present Illness: Ms. [**Known lastname 16590**] is an 81 yo female with a history of atrial fibrillation diastolic heart failure, s/p cholecystectomy, and hospitalization for ESBL Klebsiella UTI ([**2181-9-26**]) who was transferred from [**Hospital3 **] for work-up of LFT abnormalities. Per OSH records patient was noted to be jaundiced while in rehab on [**2181-10-2**]. Her AP at that time was 568, AST 198, ALT 300 and TBili 5.58. She underwent abdominal u/s on [**10-7**] normal liver and bilateral pleural effusions. On [**10-11**] she had CT Abd at [**Hospital3 417**] Hosp as an outpt that showed normal liver, spleen, pancreas and bilateral pleural effusions. Following this study, she was transferred from rehab to [**Hospital3 **] on [**2181-10-11**] for further work-up. On admission to [**Hospital1 **] her AP was 1206 and bili 15.9. Patient transferred to [**Hospital1 18**] for further work-up of her LFT abnormalities . Patient was transferred directly to the medical floor. On arrival to the floor her SBPs were in the 70's. After about 500cc NS SBPs increased to the 80's. Her temperature was 95.2 and she was sating 95% on 2L. ABG was pH7.27 pCO233 pO277 HCO316. She was transferred to the MICU given her hemodynamic instability. Past Medical History: (per OSH records): Atrial Fibrillation Diastolic Heart Failure s/p pacemaker [**8-2**] HTN OA h/o pleural effusions, s/p thoracentesis x 3 all transudative h/o multi-lobular PNA [**5-3**] Depression UTI, ESBL Klebs, proteus and E.Coli h/o DVT on left [**9-2**] Social History: Has been in and out of rehab and [**Hospital **] Hosp since [**5-3**]. Denies any ETOH, smoking or illicit drug use. Family History: noncontributory Physical Exam: At Admission: Vitals: T: BP: P: R: 18 O2: General: alert, oriented, lethargic HEENT: + scleral icterus, MMM, oropharynx clear Skin: + jaundice Neck: supple, JVP not elevated, no LAD Lungs: Reduced breath sounds at base, L>R. No wheezes or crackles CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, 3+ LE edema from ankles to knees Pertinent Results: LABS ON ADMISSION: [**2181-10-13**] 04:44PM BLOOD WBC-12.4* RBC-3.37* Hgb-10.3* Hct-32.7* MCV-97 MCH-30.6 MCHC-31.5 RDW-18.6* Plt Ct-409 [**2181-10-13**] 04:44PM BLOOD Neuts-75* Bands-5 Lymphs-15* Monos-1* Eos-1 Baso-0 Atyps-3* Metas-0 Myelos-0 NRBC-2* [**2181-10-13**] 04:44PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-1+ Polychr-1+ Target-1+ Burr-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 16591**]1+ [**2181-10-13**] 04:44PM BLOOD PT-27.2* PTT-57.3* INR(PT)-2.7* [**2181-10-13**] 04:44PM BLOOD Fibrino-563* [**2181-10-13**] 04:44PM BLOOD Glucose-42* UreaN-39* Creat-1.2* Na-141 K-3.4 Cl-116* HCO3-13* AnGap-15 [**2181-10-13**] 04:44PM BLOOD Albumin-2.0* Calcium-6.7* Phos-4.1 Mg-1.6 [**2181-10-13**] 04:44PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV Ab-POSITIVE [**2181-10-15**] 08:27AM BLOOD AMA-NEGATIVE [**2181-10-13**] 10:36PM BLOOD Smooth-NEGATIVE [**2181-10-13**] 10:36PM BLOOD [**Doctor First Name **]-NEGATIVE [**2181-10-13**] 04:44PM BLOOD IgG-909 [**2181-10-13**] 04:44PM BLOOD HCV Ab-NEGATIVE LFT TREND: [**2181-10-13**] 04:44PM BLOOD ALT-199* AST-233* LD(LDH)-256* CK(CPK)-16* AlkPhos-1136* Amylase-36 TotBili-13.5* [**2181-10-14**] 03:30AM BLOOD ALT-609* AST-1215* LD(LDH)-1277* CK(CPK)-51 AlkPhos-1090* TotBili-16.3* [**2181-10-14**] 10:20PM BLOOD ALT-2497* AST-6244* LD(LDH)-4500* AlkPhos-1053* TotBili-18.5* [**2181-10-15**] 03:59AM BLOOD Amylase-243* [**2181-10-15**] 08:43AM BLOOD CK(CPK)-150* [**2181-10-15**] 03:16PM BLOOD ALT-2204* AST-3672* LD(LDH)-1314* CK(CPK)-113 AlkPhos-1040* TotBili-17.7* [**2181-10-16**] 02:45AM BLOOD ALT-1862* AST-2292* LD(LDH)-849* CK(CPK)-100 AlkPhos-1043* TotBili-18.0* [**2181-10-17**] 03:56AM BLOOD ALT-912* AST-880* LD(LDH)-486* AlkPhos-693* TotBili-20.2* TROPONIN TREND: [**2181-10-13**] 04:44PM BLOOD CK-MB-NotDone cTropnT-0.02* [**2181-10-14**] 03:30AM BLOOD CK-MB-NotDone cTropnT-0.03* [**2181-10-15**] 08:43AM BLOOD CK-MB-6 cTropnT-0.11* [**2181-10-15**] 03:16PM BLOOD CK-MB-6 cTropnT-0.11* [**2181-10-16**] 02:45AM BLOOD CK-MB-5 cTropnT-0.11* Brief Hospital Course: Patient is an 81 yo female with progressive painless jaundice over the past two weeks now presenting with hypotension and hypothermia likely representing sepsis. Patient initially presented with hypotension, tachycardia and leukocytosis of 12,000 with bandemia. Pressures initially improved with NS boluses though MAPs remained in the mid-50's. Initial infectious sources that were considered included urosepsis especially given urine cx positive for ESBL E.Coli and Cholangitis given cholestatic picture. Chest x-ray also demonstrated patchy opacities in the left mid-lung which concerning for possible pnuemonia. Patient was initially started on Meropenem, Flagyl and Vancomycin. Central venous and arterial access was also obtained and patient was intubated. She was also started on pressors to maintain MAPS > 65. CT abdomen and US were performed to evaluate for CBD dilitation which were negative. Sputum cultures were obtained which were possitive for MRSA and urine cultures were obtained which were possitive for E.Coli and Enterococcus. Initial labs showed a large transaminitis with elevated AP and TB. ERCP was consulted who recommended ERCP vs. MRCP to evaluate for obstruction. Liver was also consulted who felt the most likely etiology given normal imaging was drug induced intrahepatic cholestasis with components of shock liver vs. obstruction. They also recommended MRCP vs. transjugular biopsy; however, patient had a pacer and was not well enough to tolerate the biopsy. Hepatitis serologies were checked and were negative. Transaminases trended down throughout her stay while AP and TB remained elevated. Patient began to experience atrial fibrillation with RVR to the 150's which was somewhat controlled after loading with digoxin. Patient also began to experience anuric renal failure with diffuse anasarca. Renal was consulted regarding possibility of CVVH vs. HD; however, after discussion with family, this was not consistent with her long term goals of care and thus deferred. A TTE was performed which showed an LVEF of 30-35%. Wound care was consulted and recommended continuing adequate skin moisturizer to prevent tissue breakdown. Attempts were made to wean pressors but the patient remained pressor dependent throughout her stay. Family meetings were routinely held discussing goals of care. On [**10-23**] the family agreed to no escalation of care and on [**10-24**] the family asked for patient to be made CMO. She was extubated and all medications were stopped. Patient subsequently expired in the evening on 9/31. Medications on Admission: Protonix 40mg daily Metoprolol XL 100 PO BID ASA 81 mg daily Remeron 30mg qHS Lactobacillus 1 tab PO BID Iron 325mg PO daily Flonase 110 mcg IH daily Combivent 1 puff [**Hospital1 **] Coumadin 1.5 mg daily Colace 100mg Po BID Lasix 40mg PO daily Tylenol PRN Discharge Medications: Patient Expired Discharge Disposition: Expired Discharge Diagnosis: Patient Expired Discharge Condition: Patient Expired Discharge Instructions: Patient Expired Followup Instructions: Patient Expired [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "511.9", "E947.9", "038.11", "428.0", "428.32", "715.89", "790.92", "785.52", "E934.2", "276.4", "599.0", "790.4", "576.8", "V66.7", "V45.01", "584.9", "041.4", "482.42", "311", "397.0", "401.9", "424.0", "427.31", "V12.51", "276.6", "789.59", "518.81", "570", "995.92" ]

icd9cm

[ [ [] ] ]

[ "33.24", "96.6", "96.72", "38.93", "38.91", "96.04" ]

icd9pcs

[ [ [] ] ]

7624, 7633

4715, 7275

331, 397

7692, 7709

2649, 2654

7773, 7927

2094, 2111

7584, 7601

7654, 7671

7301, 7561

7733, 7750

2126, 2630

247, 293

425, 1659

2668, 4692

1681, 1943

1959, 2078

81,413

125,632

33756

Discharge summary

report

Admission Date: [**2149-3-16**] Discharge Date: [**2149-3-21**] Date of Birth: [**2073-4-1**] Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 13565**] Chief Complaint: unresponsive Major Surgical or Invasive Procedure: none History of Present Illness: 75y F with complex medical history (see below), but relatively well functioning, [**Name (NI) 62341**], independent at baseline, with no known seizure history, although she was seen here in [**2146**] to r/o stroke and never diagnosed with an etiology of her episodes of ?speech arrest/confusion, and ended up with an endarterectomy. We are consulted on her today in the ED after she was transferred from an OSH ([**Hospital3 **]) with c/f seizure. She was in her USOH on Saturday, and Sunday night up to at least 3:30am (her daughter, who was staying the night at the pt's house to help care for her and her husband, said she got up to get some food from the kitchen at that time and seemed normal). However, she did not awaken at her usual time, 8:30am, and by 9:40 the daughter ([**Name (NI) 78082**] [**Name (NI) 78083**] [**Telephone/Fax (1) 78084**] cell) went up to see why not. She found her mother lying in bed on her left side, staring straight ahead with a "vacant look," and not responding to questions. The daughter was stopping the demented husband from shaking her to get her attention when she saw her mother convulsing for several seconds and "foaming at the mouth," noting that it looked like an episode she witnessed in a different relative who became hypoglycemic and seized once before. The daughter did not see whether the eyes were open or closed, but they were closed afterwards. The patient stopped shaking and remained non-responsive as before. She left the room (so as not to worry the husband further) and called EMS, who took the patient to the OSH. There, she had a HCT that was unremarkable (uploaded to our PACS), relatively normal VS, an LP with 0 WBC (by report), and a CXR (also in our PACS) with left lower lobe atalectasis vs. aspiration vs. PNA (no clinical c/f pneumonia). They gave her a dose of IV levofloxacin purely, as far as I can tell, because of the CXR finding. Additionally, she had a troponin-*I* of 0.4 and was given ASA. She also had some sort of episode on the CT table for which she was given Ativan 1mg IV. There was no EEG, and as far as I can tell no AED was given (besides the 1mg Ativan). She was transferred to [**Hospital1 18**] and we (Neurology) were called on arrival. When she arrived, her VS were afeb HR 80-90 BP 140s-160s/80s RR mid-teens, SaO2 97% RA. Mildly hyponatremic/hypochloremic on labs ((not overtly volume-deprived per VS / on exam), with troponin-*T* of 0.10 --> 0.05; ECG was at pt's baseline with RBBB and LAFB, SR/ST. The ED consulted Cardiology, who were not surprised by the very mild trop elevation in the setting of likely seizure / tachycardia in a patient with known CAD; they recommended trending the troponin and ECG (though not very useful with extensive conduction system disease) and controling SBP<140 and HR<80 with IV MTP; possible stress test. On arrival, she would open her eyes briefly to voice, but seemed lethargic and did not speak or orient visually. She moved all extremities, but did not initially seem to comprehend or follow any commands. Both arms had hypertonic flexion, but not flexor posturing. CK (with respect to cardiac versus or plus possible seizure and RUE hypertonicity) was 313 4pm --> 513 12am. Exam was otherwise basically unremarkable (see below). She improved over the next hour or so (squeezed Right hand on command, said "hi" to son-in-law, looked to either side when asked). We loaded her with IV Keppra 1000mg and admitted her to the ICU (see A&P below). Past Medical History: Hypertension Hyperlipidemia Diabetes Type 2 on oral hypoglycemics CAD s/p 3 vessel CABG [**2140**] Bladder CA s/p resection now with neobladder and urinary stoma Peptic Ulcer Disease Cholecystectomy Social History: Lives at home with her husband who also has multiple health problems. [**Name (NI) 4084**] [**Name2 (NI) 1818**], no ETOH. No illicit or IVDU. Family History: No family history of seizures Physical Exam: General: Awake, lethargic initially, but improved; NAD. Does not speak or follow most commands (see below). HEENT: Normocephalic and atraumatic. No scleral icterus. Mucous membranes are moist. ?lipstick?. Hard to open eyes or oropharynx (patient resists). Neck: Supple, with full passive range of motion. No lymphadenopathy was appreciated. No JVD. Pulmonary: Lungs moving air bilaterally anteriorly. Non-labored breathing. No retractions. Cardiac: Reular rate and rhythm, ?split S2 (vs. S3), 1-2/6 SEM. Abdomen: Soft, non-tender, and non-distended, + normoactive bowel sounds. No masses or organomegaly were appreciated. Extremities: Some muscle wasting evident in both legs. Arms are flexed 90deg and hypertonic (see below). Warm and well-perfused, no clubbing, cyanosis, or edema. 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. ***************** Neurologic examination: Mental Status exam: Awake and alert. Initially closes eyes unless repeatedly calling her name, but opens eyes to voice. Over the next hour or so, began orienting eyes towards speaker on calling her name(left or right, daughter or examiner). Unable to perform further MS testing because pt. does not follow commands except to squeeze my fingers on the Right. No e/o neglect looks left and looks right. Moves right and left UE/LE non-purposefully. -Cranial Nerves: I: Olfaction not tested. II: PERRL, 3 to 2mm, hard to examing because patient strongly closes eyes and resists exam. Blinks to threat from all angles. III, IV, VI: EOMs seem full horizontally, but see above re. difficult to assess. No nystagmus is evident. V: cannot test, except for intact eye-blink/corneals. VII: No ptosis when opens eyes (symmetric lids); face seems symmetric with no flattening of either nasolabial fold, although does not smile or open mouth. VIII: Hearing intact to name-calling "[**Known firstname **]" or "mom" (orients eyes towards speaker on either side). IX, X: Could not assess (pt will not open mouth. [**Doctor First Name 81**]: could not assess. XII: could not assess. -Motor: * Both UEs (but Left more than right) partly flexed (and wrists slightly as well), and both arms were very difficult to passively extend (esp. on the Left). Not flexor posturing per se, just very hypertonic. Pt moves the arms/hands (non-purposefully), and squeezed fingers on the Right, not the Left). No tremor or fasciculations were observed. -Sensory: Withdraws both LEs equally to mild noxious stimulation (toe-pinch). No response to mild noxious stimulation in the arms. -Reflex examination (left; right): brisk everywhere, but symmetric and no spread or clonus Biceps (++;++) Triceps (++;++) Brachioradialis (++;++) Quadriceps / patellar (++;++) Gastroc-soleus / achilles (+;+) Plantar response was mute-to-Flexor bilaterally. -Coordination/Gait: Could not assess Pertinent Results: Labs on admission: [**2149-3-16**] 04:15PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-<1 BLOOD-TR NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009 [**2149-3-16**] 04:15PM PLT COUNT-382# [**2149-3-16**] 04:15PM [**2149-3-16**] 04:15PM WBC-10.1 RBC-3.99*# HGB-12.9# HCT-37.5# MCV-94 MCH-32.3* MCHC-34.3 RDW-13.8 NEUTS-86.0* LYMPHS-10.9* MONOS-2.5 EOS-0.1 BASOS-0.4 [**2149-3-16**] 04:34PM GLUCOSE-153* LACTATE-1.3 NA+-133* K+-3.7 CL--93* TCO2-23 [**2149-3-16**] 04:40PM CK-MB-7 [**2149-3-16**] 04:40PM cTropnT-0.10* [**2149-3-16**] 04:40PM CK(CPK)-313* [**2149-3-16**] 04:40PM GLUCOSE-147* UREA N-15 CREAT-0.9 SODIUM-131* POTASSIUM-3.8 CHLORIDE-94* TOTAL CO2-22 ANION GAP-19 [**2149-3-16**] 11:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.007 BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-NEG RBC-<1 WBC-3 BACTERIA-FEW YEAST-NONE EPI-0 MUCOUS-RARE [**2149-3-16**] 11:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2149-3-17**] 12:00AM WBC-8.8 RBC-4.02* HGB-12.9 HCT-38.1 MCV-95 MCH-32.1* MCHC-33.9 RDW-13.9 PLT COUNT-399 NEUTS-84.0* LYMPHS-13.0* MONOS-2.3 EOS-0.1 BASOS-0.5 [**2149-3-17**] 12:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2149-3-17**] 12:00AM TSH-1.9 [**2149-3-17**] 12:00AM %HbA1c-5.8 eAG-120 [**2149-3-17**] 12:00AM calTIBC-256* FERRITIN-233* TRF-197* [**2149-3-17**] 12:00AM ALBUMIN-3.6 CALCIUM-9.7 PHOSPHATE-3.0 MAGNESIUM-1.7 IRON-42 [**2149-3-17**] 12:00AM cTropnT-0.05* [**2149-3-17**] 12:00AM ALT(SGPT)-27 AST(SGOT)-30 LD(LDH)-319* CK(CPK)-513* ALK PHOS-89 AMYLASE-32 TOT BILI-0.4 Labs on discharge: [**2149-3-20**]: 137 | 102 | 11 / 102 AGap=13 4.3 | 26 | 0.8 \ CK: 1368 MB: 3 137 | 104 | 10 / 114 AGap=13 4.4 | 24 | 0.7 \ Ca: 8.5 Mg: 1.4 P: 3.0 CK: 1494 MB: 3 Trop-T: <0.01 LFTs: ALT: 31 AP: 74 Tbili: 0.2 Alb: 3.0 AST: 40 LDH: 230 CBC: 8.5 > 11.2 / 33.2 < 340 Coags: PT: 11.9 PTT: 24.4 INR: 1.0 [**2149-3-19**]: Chem: 136 | 104 | 12 / 137 AGap=13 4.4 | 23 | 0.8 \ CK: 1486 MB: 3 LDH: 198 Chem: 135 | 101 | 14 / 124 AGap=15 4.9 | 24 | 0.8 \ CK: 2231 MB: 3 Trop-T: <0.01 Ca: 9.2 Mg: 1.6 P: 2.1 LDH: 349 Urine Myoglob: Presumptively Negative Coag: PT: 11.5 PTT: 23.2 INR: 1.0 Chem: 137 | 105 | /143 AGap=13 4.4 | 23 | 0.8 \ CK: 1644 MB: 3 Trop-T: <0.01 Ca: 8.6 Mg: 1.6 P: 1.6 ALT: 26 AP: 66 Tbili: 0.2 Alb: 3.2 AST: 33 LDH: 246 Cholesterol:94 CRP: 38.3 CBC: 7.4 > 10.0 / 30.4 < 183 SED-Rate: 14 Studies: [**2149-3-20**] Radiology CHEST (PA & LAT): Cardiomegaly without evidence of congestive heart failure. [**2149-3-20**] Cardiology ECHO: Mild regional left ventricular systolic dysfunction, c/w CAD. Moderate mitral regurgitation. Mild pulmonary hypertension. [**2149-3-19**] Radiology CHEST (PORTABLE AP): In comparison with the study of [**3-16**], there is some persistence of opacification at the left base consistent with effusion and underlying atelectasis. The possibility of superimposed pneumonia in this region could not be excluded in the appropriate clinical setting. There is enlargement of the cardiac silhouette with some pulmonary vascular congestion in this patient who has intact midline sternal wires following CABG procedure. Displacement of the lower cervical trachea to the left is again consistent with a thyroid mass. [**2149-3-18**] Cardiology ECG: Normal sinus rhythm with occasional premature atrial complexes. Right bundle-branch block with left anterior fascicular block. Non-specific inferolateral T wave abnormalities. Compared to the previous tracing of [**2149-3-17**] the findings are similar. [**2149-3-17**] Radiology MR HEAD W/O CONTRAST: Limited sequences of the brain with motion artifact demonstrate no large intracranial mass. Age-related involutional changes are demonstrated. [**2149-3-17**] Cardiology ECG: Sinus rhythm. Right bundle-branch block with left anterior fascicular block. Non-specific inferior and lateral T wave abnormalities. Compared to the previous tracing T wave inversions in the lateral leads have improved. [**2149-3-17**] Neurophysiology EEG: Abnormal EEG with background slowing and disorganization suggestive of a mild diffuse encephalopathy with superimposed bursts of generalized bifrontally predominant delta slowing suggestive of a subcortical or deeper midline irritative process. This may represent a vascular insufficiency and may be related to the cardiac arrhythmia noted. [**2149-3-16**] Radiology CHEST (PORTABLE AP): Contour of the left diaphragmatic pleural surface elevated laterally looks like pleural effusion. A lateral view would help to see if there is left lower lobe consolidation as well. The right lung and right pleural space are unremarkable. Cardiomegaly is moderate to severe. There is no pulmonary edema but there is mild pulmonary vascular congestion. Displacement of the trachea suggests a large goiter, particularly at the right lobe. No pneumothorax. [**2149-3-16**] Cardiology ECG: Sinus tachycardia. Right bundle-branch block with left anterior fascicular block. Probable left ventricular hypertrophy. Compared to the previous tracing of [**2146-10-6**] QRS complex is slightly wider. The T wave inversions in the lateral leads may be related to the conduction abnormality. Ischemia cannot be entirely excluded. Clinical correlation and a repeat tracing are suggested. Micro: [**2149-3-19**] URINE URINE CULTURE, final: MIXED BACTERIAL FLORA (>= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [**2149-3-17**] MRSA SCREEN MRSA SCREEN, final: No MRSA isolated. [**2149-3-16**] BLOOD CULTURE Blood Culture, Routine: pending, no growth to date [**2149-3-16**] BLOOD CULTURE Blood Culture, Routine: pending, no growth to date Brief Hospital Course: Mrs. [**Known lastname **] is a 75 year old woman with complex PMH including prior L-CEA (for suspicion of TIAs causing slowed/arrrested speech in [**2146**]; negative MRI/stroke w/u), CAD s/p 3 vessel CABG, HTN, DM2, and HL presented with two episodes of shaking including at OSH consistent with generalized tonic clonic seizure. Neurologic: With a story suspicious for seizure Keppra 750mg PO BID was started. MRI was negative for stroke or large mass but was not great quality given the motion artifact. She will likely need additional outpatient imaging. Her aspirin was increased from 81 to 325 as stroke prophylaxis. An EEG showed background slowing and disorganization suggestive of a mild diffuse encephalopathy with superimposed bursts of generalized bifrontally predominant delta slowing suggestive of a subcortical or deeper midline irritative process. This may represent a vascular insufficiency and may be related to the cardiac arrhythmia noted. No seizure activity experienced while in the hospital. She should continue Keppra 750 mg [**Hospital1 **] for seizure prophylaxis on discharge. Cardiovascular: She was kept on her home antihypertensive/cardioprotective meds: HCTZ, nitropatch, metoprolol, lisinopril, ASA, and simvastatin. Cardiology consulted with initial trop of 0.1, which later trended downward to less than 0.01. ECHO revealed mild regional left ventricular systolic dysfunction with focal basal inferior hypokinesis. Cardiology believes that she likely had an ischemic event at some point between [**2146**] and now. Aspirin, metoprolol, and lisinopril were continued for for primary prevention. Her simvastatin was held due to elevated CK, but she should follow up with her outpatient cardiologist and will need to be restarted on an antilipid [**Doctor Last Name 360**], likely Atorvastatin or pravastatin as she had elevated CK while on simvastatin. Pulmonary: On Chest X ray, heart is enlarged but stable in size. Aorta is tortuous. The previously reported pulmonary vascular congestion has resolved. Chronic blunting of left costophrenic sulcus is likely predominantly due to an enlarged pericardial fat pad as demonstrated on CT abdomen study of [**2146-8-9**]. Musculoskeletal: Bones are diffusely demineralized, and severe compression deformities are present in the mid thoracic spine. She was given Tyelonol 3 for pain relief. Per her daughter who is a nurse confirmed that these are old and she will require outpatient follow up. Nutrition: She was evaluated for a swallow evaluation and a diet of thin liquids and ground solids was suggested. While in the hospital 1:1 supervision for aspiration precautions was administered including: a) feeding when most awake and alert b) alternating bites/sips and c) checking for pocketing on the left. Oral care was performed three times daily. Meds were given whole with thin liquids. These recommendations were shared with the patient, nurse and medical team. Renal: Patient has a urostomy in place following bladder resection . She was hyponatremic on admission, which resolved throughout her hospital course. Her creatinine remained stable between 0.7 and 1.0 throughout admission and did not rise despite increased CK levels. Hematology: She had an elevated CK thought to be secondary to tonic clonic seizure activity. Her CK levels continued to elevate, so her statin was discontinued at that time. CK levels began to trend downward with IV fluids. She will follow up with her PCP to restart [**Name Initial (PRE) **] statin on resolution of CK levels. She did have an elevated lactate, but no hyperphosphatemia or hyperkalemia. Endocrine: Patient has non insulin dependent DM controlled on oral antihyperglycemics. She was placed on an insulin sliding scale while in the hospital with finger stick blood sugars in the 100 to 150 range throughout admission. Infectious disease: Urinalysis revealed elevated WBC and bacteria, so patient was started on Bactrim. Culture returned with mixed flora consistent with genital contamination. A repeat urinalysis revealed decreased WBC and fewer bacteria, so she should should complete a 7 day total course of Bactrim on discharge (through [**2149-2-25**]). Dispo: She will be discharged to a rehabilitation facility in [**Location (un) 38**], MA. Following her rehabilitation, she should follow up wither her cardiologist/PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 78085**]. Medications on Admission: - HCTZ 12.5 mg PO daily - Simvastatin 80 mg PO QHS - Nitroglycerin 0.4 mg/hr dis, 1 patch daily - Metoprolol tartrate 50 mg PO BID - Tramadol 0.5 tab PO Q8H - Glyburide-Metformin 1 tab PO BID - Omeprazole 20 mg PO daily - Levothyroxine 88 mcg PO daily - Aspirin 81 mg PO daily - Metocopramide 10 mg PO TID - Magnesium oxide (Mg-Ox) 400 mg PO BID - Docusate sodium 100 mg Cap PO BID - Lisinopril 20 mg PO daily Discharge Medications: 1. levetiracetam 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day) as needed for seizure ppx. 2. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily) as needed for htn (home med). 3. nitroglycerin 0.4 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal Q24H (every 24 hours) as needed for CAD/angina pain (home med). 4. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for CHF/htn (home med). 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day) as needed for GERD (home med / home dose). 6. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for hypoT4 (home med/home dose). 7. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for anxiety (home med / home dose). 8. lisinopril 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily) as needed for HTN/CHF (home med / home dose). 9. acetaminophen-codeine 300-30 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for Pain. 10. aspirin, buffered 325 mg Tablet Sig: One (1) Tablet PO once a day. 11. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 4 days: Please take twice daily for 4 more days following discharge (through [**2149-2-25**]). 12. Reglan 10 mg Tablet Sig: One (1) Tablet PO three times a day. 13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation ppx. 14. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Primary diagnosis: - Seizures - Urinary tract infection - Rhabdomyolysis Secondary diagnosis: - Hypertension - Hyperlipidemia - Non insulin dependent diabetes mellitus - Coronary artery disease s/p 3 vessel CABG - Bladder CA s/p resection now with neobladder and urinary stoma - Peptic ulcer disease Discharge Condition: Mental Status: Continues to fluctuate with intermittent decreased attention, though there has been marked improvement from admission. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance. Discharge Instructions: Dear Mrs. [**Known lastname **], It was a pleasure taking care of you. You were admitted to the hospital after being found by your daughter unresponsive after experiencing seizure activity. You were initially seen at [**Hospital **] and transferred to the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Medical Center on [**2149-3-17**]. When you arrived, you were having problems with your memory and attention and had difficulty speaking, which improved over your hospital course, but did not return to your baseline level of function. Due to your seizure, you had muscle breakdown, so we stopped your Zocor. You should follow up with your primary care doctor to restart this or a similar drug when your CK levels return to normal. You were also experiencing back pain while in the hospital as a result of the longstanding compression fractures in your spine. Prior to your hospitalization, you were taking Ultram for you back pain, but since this drug may increase the likelihood of seizures, we recommend that you discontinue Ultram and start taking tylenol with codeine which provided you relief in the hospital. Medication changes: Please start taking: - Tylenol with codeine [**1-19**] TAB by mouth every 4 hours as needed for pain (DO NOT EXCEED 3000 gram of acetaminophen per day) - Resume your diabetes medications when you leave the rehab facility: glyburide-metformin (Glucovance 1 tab by mouth twice daily) Please stop taking: - Tramadol (Ultram), this drug may increase your risk of seizures - Simvastatin (Zocor), contact your primary care physician to restart [**Name Initial (PRE) **] statin medication when your CK levels return to baseline Followup Instructions: Please follow up with your primary care physician/cardiologist when you leave the rehabilitation facility: Cardiology: Name: [**Last Name (LF) **],[**First Name3 (LF) **] Address: 237A [**Street Address(1) **] ROUTE 6, [**Location **],[**Numeric Identifier 21478**] Phone: [**Telephone/Fax (1) 9674**] Fax: [**Telephone/Fax (1) 78086**] Neurology Follow Up DRS. [**Name5 (PTitle) **]/VANHAERENTS Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2149-4-22**] 2:30 Completed by:[**2149-3-21**]

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Discharge summary

report

Admission Date: [**2179-5-13**] Discharge Date: [**2179-5-23**] Date of Birth: [**2115-9-8**] Sex: M Service: MEDICINE Allergies: Unasyn Attending:[**First Name3 (LF) 3531**] Chief Complaint: arm pain Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 3517**] is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement, severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated LFTs, who presented to the ED with chest pain and L arm pain. By report of wife and patient he has had bad gout over the past several weeks to months. Principally this has been involving his right foot limiting his ability to walk. In the past few days had increasing right arm pain that patient thought was also his gout. Then starting about yesterday, patient had severe left arm pain at the shoulder and the elbow. This is ultimately what prompted him to come to the ED. ROS notable for +sharp midsternal chest pain with coughing, non-productive cough, sinus congestion for several weeks, chills. Patient denied back pain, neck pain, pain with chewing, changes to his urine output or other complaints beyond those noted. . Of note, recent medication changes include uptitration of allopurinol to 250mg PO qday for gout after recent gout flare [**4-7**]. . In the ED, initial vs were: T101.4 HR71 BP90/42 RR20 100%RA . Blood pressures dropped to the 70s systolic and he was given 1L IVF, a CVL was placed and CVP was 13-16. A R IJ was placed and after dopamine was turned up to 20mcg/min, he was started on Levofed and dopamine was weaned down. He was given Vanc and Levofloxacin and nothing further due to allergy to Unasyn. He underwent non-contrast CT of the abdomen which was grossly normal. CXR was clear. A FAST scan in the ED did not show pericardial effusion, kidneys without hydronephrosis. Received 3L NS, ASA 325, Vanco 1gram Morphine 4mg IV x1. Levo/aztreonam ordered but not given. . On arrival to the floor, patient c/o total body pain, and feeling cold. Past Medical History: Nonischemic cardiomyopathy, LVEF 15-20% ICD placement for primary prevention of sudden cardiac death Diabetes mellitus type 2 insulin dependent Gout Peripheral neuropathy Chronic atrial fibrillation Chronic kidney disease Elevated transaminases, unknown etiology Umbilical hernia repair, [**8-/2175**] Gallstone pancreatitis s/p ERCP ([**2176-6-28**]) Internal hemorrhoids Hemoglobin C carrier Social History: The patient is originally from [**Country 3515**] currently living with his wife. Returned to [**Location 3515**] this past fall, but came back to US after severe gout flare of his foot. No smoking. He quit alcohol use, no IV drug use. He says his diet is generally difficult because he feels like any food he eats causes gout flare . Family History: No first-degree relatives with coronary artery disease. His mother had breast cancer. . Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: THREE VIEWS, LEFT SHOULDER: Examination is limited by nonstandard views as well as the overlying pacemaker. There is moderate degenerative change at the acromioclavicular joint with narrowing and subchondral sclerosis. The glenohumeral joint appears intact. There is no visualized fracture. . THREE VIEWS, LEFT ELBOW: There is no fracture or abnormal alignment. There is no joint effusion. Mineralization is normal. . NON-CONTRAST CHEST CT: Imaged thyroid gland is grossly unremarkable. There is a left-sided cardiac pacer with the lead terminating in the right ventricle. There is also a right internal jugular intravenous catheter with the tip at the mid-distal SVC. A few subcentimeter mediastinal lymph nodes with no evidence of lymphadenopathy are noted. There is no hilar or axillary lymphadenopathy on this non-contrast study. The aorta demonstrates atherosclerotic calcifications. Atherosclerotic calcifications of the coronary arteries are also seen. Heart is enlarged. There is no pericardial effusion. Bibasilar atelectatic changes and/or pneumonia, left more than right are noted. Mild emphysema is likely present. Calcified granulomas in the right lower lobe (2:46 and 2:30) are noted. There is no pneumothorax or pleural effusion. NON-CONTRAST ABDOMINAL CT: The unenhanced liver, spleen, pancreas, adrenals are unremarkable. Small pericholecystic fluid was also seen on prior study. Both kidneys are in normal anatomic location. A focal, somewhat band-like calcification in the interpolar region of the left kidney is stable since [**Month (only) 205**] [**2177**]. There is a probable 2-mm nonobstructive stone in the inferior pole of the left kidney (2:74). There is no hydronephrosis. Abdominal aorta and iliac vessels demonstrate severe atherosclerotic calcifications with no aneurysmal dilatation. There is no retroperitoneal hematoma. Evaluation of the GI tract demonstrates no evidence of bowel obstruction or bowel wall thickening. Tubular blind ending structure in the right lower quadrant likely represents a normal appendix. NON-CONTRAST PELVIC CT: The urinary bladder is collapsed and contains a Foley atheter. Air within the urinary bladder is likely secondary to instrumentation. Bilateral small fat-containing inguinal hernias are seen. The rectum contains stool, otherwise unremarkable. Seminal vesicles are symmetric. The prostate gland measures about 5 cm in transverse diameter. The urinary bladder wall thickening may be secondary to underdistension. A few mildly prominent inguinal lymph nodes are noted. A hypoattenuating structure measuring 2.3 cm in the right lower abdomen to the right of the urinary bladder is stable. . OSSEOUS STRUCTURES: There is no bony lesion to suggest malignancy or infection. . IMPRESSION: 1. Left lower lobe atelectasis or pneumonia. Mild emphysema. 2. Small amount of pericholecystic fluid was also seen on prior study. Please clinically correlate. 2. Probable 2 mm nonobstructive left renal calculus. . [**2179-5-13**] 08:14AM BLOOD RheuFac-<3 [**2179-5-13**] 08:14AM BLOOD ANCA-NEGATIVE B [**2179-5-13**] 08:14AM BLOOD Cortsol-7.1 [**2179-5-13**] 02:21PM BLOOD Cortsol-6.8 [**2179-5-13**] 03:10PM BLOOD Cortsol-10.1 [**2179-5-13**] 04:14PM BLOOD Cortsol-10.7 [**2179-5-12**] 10:50PM BLOOD Glucose-134* UreaN-61* Creat-4.2*# Na-132* K-4.5 Cl-98 HCO3-21* AnGap-18 [**2179-5-17**] 04:10AM BLOOD Glucose-215* UreaN-89* Creat-1.7* Na-138 K-3.9 Cl-110* HCO3-17* AnGap-15 [**2179-5-12**] 10:50PM BLOOD PT-37.9* PTT-48.4* INR(PT)-3.9* [**2179-5-17**] 04:10AM BLOOD PT-20.3* PTT-32.1 INR(PT)-1.9* [**2179-5-12**] 10:50PM BLOOD WBC-6.3 RBC-3.82* Hgb-10.1* Hct-28.7* MCV-75* MCH-26.3* MCHC-35.1* RDW-19.8* Plt Ct-135* [**2179-5-17**] 04:10AM BLOOD WBC-9.0 RBC-3.71* Hgb-9.8* Hct-27.8* MCV-75* MCH-26.5* MCHC-35.3* RDW-20.2* Plt Ct-157 Brief Hospital Course: This is a 63 year old male with PMH of severe systolic HF with an EF=25%, afib on coumadin, who presented with hypotension and found to have questionable adrenal insufficiency in the setting of a likely gout flare. . #. Hypotension: Possibly due to adrenal insufficiency, given symptoms of fever, hypotension, diarrhea, high eosinophils, hyponatremia, and hyperkalemia with low cortisol failed ACTH stimulation ([**Last Name (un) 104**] stim 6->10->10). Confounding factors are that colchicine causes diarrhea and allopurinol induces hypereosinophilia. An abdominal CT without contrast showed no evidence of adrenal pathology. Initially, the patient had fever and tachypnea concerning for septic shock possibly from a pulmonary source as a possible pneumonia was seen on CT scan. He did have a normal lactate and no leukocytosis. Septic arthritis was considered given prominent joint complaints and history of gout, although his joint was tapped by [**Last Name (un) **] and was negative for infection. He was on vasopressors on admission, but weaned off over 48 hours. He was subsequently normotensive with a normal lactate. He was started on IV hydrocortisone in the ICU which was transitioned to oral prednisone on [**5-16**]. [**Last Name (un) **] endocrine team recommended a quick prednisone taper to 20mg on [**5-19**], 10mg on [**5-20**], then off on [**5-21**]. The patient's pressures remained stable off of prednisone for greater than 24 hours. Cortisol and free cortisol levels were sent on [**5-22**] when the patient was off of steroids for 24 hours and he was sent home on prednisone 5mg daily until he can be followed up in the [**Last Name (un) **] endocrine clinic. CMV, HIV, RPR, and TSH were all sent to rule out other causes of adrenal insufficiency. HIV, CMV, and RPR negative. TSH was low with high free T4 and low T3 attributed to SICU thyroid. It is therefore unlikely that the patient is panhypopit. The patient said that a PPD placed 3 months prior was negative for Tb. An adrenal MRI was considered to rule out hemorrhage while on coumadin or infection but could not be performed with his ICD in place. . #. Gout: The patient redeveloped right ankle swelling and pain on [**5-20**] in the setting of decreasing his prednisone from 20mg to 10mg. Allopurinol was continued and he was restarted on daily colchicine. His uric acid level was 5.8 on [**5-20**]. Colchicine was restarted with a 1.2mg dose followed by 0.6 mg dose on [**5-20**]. He was started on low dose prednisone 5mg daily both to prevent gout and hypotension (from possible adrenal insufficiency) until he follows up as an outpatient with endocrinology. . #. Infection/sepsis: The patient was febrile and admission blood cultures were growing coag negative staph which was likely a contaminant. CT chest on admission showed an opacity that was read as being consistent with atelectasis vs. PNA. He received empiric broad spectrum antibiotics (Zosyn, vancomycin, flagyl) in the ICU until [**5-17**], but they were discontinued prior to transfer to the floor. The patient remained afebrile, but developed a leukocytosis with peak WBC count of 12.3 on [**5-20**] which was likely secondary to a gout flare as the leukocytosis resolved after proper gout treatment and no abx. TTE showed no evidence of vegetations on valves or hardware. [**Month/Year (2) 2225**] tapped his swollen joint in the ICU and it was negative for infection. His central line was removed on [**5-20**] and the catheter tip culture was negative. All blood and urine cultures were negative. . #. Hyperglycemia: The patient initially had poor glucose control in the setting of high dose steroids. He required an insulin gtt in the ICU and was started on Lantus/HISS upon transfer from the ICU. His sugars improved dramatically as he was weaned off of steroids and he was discharged on his home Novolog sliding scale. . #. [**Last Name (un) **]: The etiology was likely pre-renal given that his UA was bland. His creatinine peaked at 4.2 and improved with IVFs. A renal U/S was normal and his creatinine was his creatinine was back down to his baseline of 1.1 upon discharge. His home Diovan was restarted on [**5-22**]. Torsemide was held given his hypotension and potential to provoke gout flare. Given his severe CHF, the torsemide may need to be restarted as an outpatient. His ankles did have 1+ edema, but his lungs were clear on discharge. . #. Elevated INR: The patient's INR trended up to 11.5 on [**5-14**] requiring vitamin K administration. The etiology of this rise was unclear, but may have been secondary to poor PO intake prior to admission. His Coumadin dose was decreased to 2 mg daily before discharge with therapeutic INRs resulting. . #. CHF: The patient has non-ischemic cardiomyopathy with an EF=25% and severe TR. Initially, all of his cardiac meds except for digoxin were held given his hypotension requiring pressors. He was restarted on his home Diovan 40mg on [**5-22**] and his carvedilol 3.125mg [**Hospital1 **] was restarted upon discharge. His home torsemide was not re-initiated given his hypotension and the potential of triggering another gout flare. His digoxin level was low at 0.4 but was not adjusted in the setting of his fluctuating renal function. He should follow-up with Dr. [**First Name (STitle) 437**] ans an outpatient for further titration of his cardiac meds. . #. Atrial Fibrillation: His home carvedilol was held initially given his hypotension, but was restarted on discharge. His digoxin level was low at 0.4 but was not adjusted in the setting of his fluctuating renal function. He was continued on Coumadin at discharge after it was initially held for an INR=11. . #. Sinusitis: The patient has had several months of sinus congestion and was started on fluticasone nasal spray. . #. Eosinophilia: His absolute eosinophil count on admission was about 900 and has been noted in past labs. This finding was concerning for malignancy, occult parasitic infection, or Churg-[**Doctor Last Name 3532**]. However, his eosinophilia improved with steroids and ANCA was negative. . #. Communication: Patient and [**Name (NI) 3516**] (wife) who works in Radiology for [**Hospital1 18**] and can be reached at home [**Telephone/Fax (1) 3518**], cell [**Telephone/Fax (1) 3519**], work [**Numeric Identifier 3533**] . #. Code: Confirmed full code. Medications on Admission: Allopurinol 250mg PO qday Carvedilol 3.125 PO BID Colchicine 0.6mg PO qday Digoxin 125mcg PO qday Insulin sliding sclae Lantus [**First Name8 (NamePattern2) **] [**Last Name (un) **] order -> does not need or take Spironolactone 12.5mg PO qAM -> d/c'd as per patient Torsemide 40mg PO BID Valsartan 40mg PO qday Warfarin 4mg M/W/Fri, 3.5mg the other 4 days Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 2. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-30**] Sprays Nasal QID (4 times a day) as needed for rhinorrhea. 6. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). Disp:*1 bottle* Refills:*2* 7. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:*30 Tablet(s)* Refills:*2* 8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Outpatient Lab Work please check INR twice per week and fax results to [**Hospital 191**] [**Hospital 2786**] clinic at [**Hospital1 18**], fax [**Telephone/Fax (1) 3534**] 10. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 11. Novolog 100 unit/mL Solution Sig: per sliding scale units Subcutaneous as directed. Disp:*1 bottle* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary diagnosis: Hypotension, acute gout flare . Secondary diagnoses: -Idiopathic cardiomyopathy EF=25% -type 2 diabetes -elevated LFTs -atrial fibrillation on coumadin -peripheral neuropathy -chronic kidney injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [**Hospital1 69**] for evaluation of arm and chest pain. You were found to have dangerously low blood pressure and were admitted to the Intensive Care Unit where IV medications were given to keep your blood pressure up. Initially, it was thought that your blood pressure could be low because of an infection. However, we were not able to find any source of infection. Since infection was not the likely cause of your low blood pressure, we were concerned that you did not have enough of a hormone called cortisol in your blood. Cortisol helps keep the blood pressure at normal levels, and is secreted by a gland above your kidney called the adrenal gland. Your cortisol levels were found to be low, which made us suspect a problem with your adrenal glands. In the meantime, your gout began to flare up and you were treated with colchicine and allopurinol. . It is very important that you follow up with [**Hospital **] clinic next week. Until then, please take 5 mg of prednisone per day, as prescribed. This dose will make sure that you have cortisol activity in your system and will thus make sure your blood pressure stays up. . The following changes were made to your home medication regimen: - You should take allopurinol 200mg daily - You should take Flonase for your runny nose - You should change your Coumadin dose to 2mg daily - You should continue on prednisone 5mg Please do not take torsemide or spironolactone until instructed to do so by Dr. [**First Name (STitle) 3535**]. Followup Instructions: Please follow-up with all of your outpatient medical appointments listed below: . 1. Please call Dr.[**Name (NI) 3536**] office tomorrow to set up an appointment with him this week. Please keep track of your daily weights. You will need to see Dr. [**First Name (STitle) 437**] to discuss when to restart your fluid management medications, torsemide and spironolactone. . 2. Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 3535**], at [**Telephone/Fax (1) 250**], tomorrow to set up an appointment. . 3. The [**Last Name (un) **] endocrine clinic should call you with an appointment to follow-up the possibility of your adrenal insufficiency as an outpatient. If you do not hear from them in 1 week, please call ([**Telephone/Fax (1) 3537**] to schedule an appointment. . 4. Department: [**Telephone/Fax (1) **] When: THURSDAY [**2179-5-27**] at 11:30 AM With: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 3538**] [**Telephone/Fax (1) 2226**] Building: LM [**Hospital Unit Name **] [**Location (un) 861**] Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE . 5. Department: [**Doctor First Name **] When: THURSDAY [**2179-6-10**] at 11:00 AM With: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 3538**] [**Telephone/Fax (1) 2226**] Building: LM [**Hospital Unit Name **] [**Location (un) 861**] Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE . 6. Department: [**Doctor First Name **] When: WEDNESDAY [**2179-7-21**] at 1 PM With: [**First Name11 (Name Pattern1) 2890**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2226**] Building: LM [**Hospital Unit Name **] [**Location (un) 861**] Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE

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icd9cm

[ [ [] ] ]

[ "38.91", "81.91", "38.93" ]

icd9pcs

[ [ [] ] ]

15232, 15289

7262, 13666

275, 281

15550, 15550

3432, 7239

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227, 237

309, 2048

15329, 15361

15565, 15677

2070, 2466

2482, 2823

71,974

158,924

54158

Discharge summary

report

Admission Date: [**2185-1-11**] Discharge Date: [**2185-1-16**] Date of Birth: [**2119-3-28**] Sex: M Service: MEDICINE Allergies: Lipitor Attending:[**First Name3 (LF) 898**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: EGD x3 Flex sig under anesthesia Cortis CVL placement History of Present Illness: 65 y/o male with hx of colon cancer s/p subtotal colectomy with ileosigmoid anastomosis in [**2167**], prostate cancer managed conservatively, CAD s/p DES about a year and half ago, presents with sudden onset of hematochezia. . This is the third episode of hematochezia in the last two weeks. He had a prostate biopsy on [**12-30**] and 1 hour later he had severe lower GI bleed from the site of the biopsy which responded to packing in the ED. One week ago (last Tuesday), he again developed second episode of hematochezia of the same intensity and was taken to OSH where he was again packed. The next day, the packs were removed and this time he was bleeding. He had a quick flexsig when they noted a bleeding vessel at the site of the prostate biopsy that was clipped and the bleeding stopped. [**1-10**] at ~9:00 PM, he strained for bowel movement and noticed brisk rectal bleeding. He was taken to an OSH. At patient's request the ED physician did not put a packing but instead tried to stop bleeding by a foley baloon dilation but that failed to stop the bleed and he was transferred to [**Hospital1 **] for further management. . His initial VS in the ED was, 98, 71, 136/77, 14, 100% However in the ED his BP fell suddenly to SBP in 60s. He received a total of 5 units of PRBCs in the ED, 2 units FFP and 1 unit platelets. A cordis was placed in right IJ. The patient has been off asa and plavix for more than 5 days now after consultation with his cardiologist. He denies any abdominal pain. He was transferred urgently to thhe IR suite for possible embolization. On transfer to IR his vital signs were HR 91, BP 103/72, RR 17, sPO2 100% on 2L NC. . Radiology reported from IR that patient immediately started bleeding when packing was removed. Bleeding appeared to be due to AV fistula involving superior hemorrhoidal artery. Six coils were placed with good result and no residual bleeding identified after rectal balloon deflated. Serial HCT in IR suite were 31.4, 26.9, 31.8. (In total he received 7 units PRBC, 2 units FFP, 1 unit PLT for blood products since arrival to [**Hospital1 18**].) He was then transferred to the ICU. Past Medical History: Colon cancer s/p subtotal colectomy with ileo sigmoid anastomosis in [**2167**] - Coronary artery disease s/p DES [**4-28**] - High cholesterol - Hypertension - Low testosterone - Obesity - Prostate cancer on active surveillance Social History: TOBACCO: denies ETOH: beer 3-4 times per week ILLICITS: denies, no IVDA Self employed and is rebuilding his business franchise Family History: His father passed away from lung CA at age 62 and his mother died at 87 having had a prior CABG in her 80s. Physical Exam: VS: T 96.3, HR 92, BP 102/75, RR 13, O2Sat 100% 2L NC GEN: Sedated, laying flat HEENT: PERRL, EOMI, no pallor, scleral edema NECK: Supple PULM: CTAB anteriorly CARD: RRR, S1S2 normal, no m/r/g ABD: S, NT, ND, NABS, verticle scar along left abdomen RECTAL: Active bright red bleeding with clots pooling between legs EXT: No edema, pulses 2+ Pertinent Results: IMAGING: [**1-12**] CXR: FINDINGS: In comparison with the earlier study of this date, there has been placement of an orogastric tube that extends to the lower body of the stomach. The patient has taken a somewhat better inspiration. There is still atelectatic change at the left base, though this is less prominent than on the previous study. The right lung is clear. . [**1-12**] CT Abd: IMPRESSION: 1. Mild dilatation of the small bowel loops where oral contrast is located with a relatively collapsed loop at the distal jejunum/proximal ileum, but with more normal distal ileum. This could reflect normal small bowel distension due to oral contrast vs. a partial low-grade small-bowel obstruction. No free air. 2. Small amount of free fluid surrounding the liver along with mostly pelvic retroperitoneal fluid. These findings are suggestive of fluid overload. 3. Multiple subcentimeter hypodense lesions throughout the liver and are too small to characterize. The previously seen atypical FNH is also visualized. 4. Small bilateral pleural effusions with associated compressive atelectasis. Brief Hospital Course: 65 y/o male with hx of colon cancer s/p subtotal colectomy with anastomosis, prostate cancer, CAD s/p DES 1.5 years ago, who initially presented on [**1-10**] with sudden onset of hematochezia, now s/p 13 units PRBCs, 6 FFP, 3 units platelets and 2 units cryo, s/p hemrrhoidal artery coiling, transferred out of the MICU to the floor with stable Hcts and hemodynamics. . #. GIB: Upon arrival to the ICU on [**1-11**], patient passed large bright red blood and clots x 2; he received 1 u PRBCs, 1 U cryo on floor. Surgery was consulted and took the patient to the OR. Under GA, they put a stitch in site of what looked like prior bleeding at the AV fistula; and packed the rectum. Patient remained intubated for EGD, which showed some bright blood in oropharynx, probably NGT/intubation trauma and stomach full of food and coffee grounds, but no active bleeding. Repeat EGD on [**1-12**] showed patient still had coffee grounds, and a suspected AVM underlying the debris. PPI drip was subsequently started and patient was safely extubated. On [**1-13**], 3rd EGD was done and showed showed laryngeal ulcer; ENT was consulted and concluded ulcer was likely seondary to ET tube trauma. He continued to have melena, and he recived an additional 2 units PRBCs, Hct increased from 26 to 31. In total, he has received 13 units PRBCs, 6 FFP, 3 units platelets and 2 units cryo during this admission. Thus, 2 sources currently suspected: Upper GI bleed from AVM, causing coffee grounds seen on CT scan and hemorrhoidal AVM causing BRBPR s/p prostate biopsy on [**12-30**]. His Hcts remained stable for the remainder of admission. . #. Fevers: Patient spiked a fever to 101.2 around the time of intubation; he was placed emperically on vanco/zosyn. CT abdomen/pelvis showed no source for fevers. Antibiotics were subsquently stopped the next day as patient afebrile with no sourceLikely occured in the setting of induction for intubation absed on timing. No obvious source of infection, blood cultures NGTD, C diff negative. He remained afebrile remainder of admission. . #. CAD/hyperlipidemia: ASA, plavix initially held. Aspirin 162 mg was restarted on [**1-15**]. His plavix will be stopped on discharge. Continued statin/ezetemibe . #. Hypertension: Metoprolol initially held, then restarted once hemodynamically stable. Medications on Admission: 1) Acetaminophen 650 mg PO Q6H:PRN pain 2) Metoprolol tartrate 25 mg PO DAILY 3) Ezetimibe 10 mg PO DAILY 4) Rosuvastatin 40 mg PO DAILY 5) Aspirin 81 mg PO DAILY 6) Plavix 75 mg PO DAILY (On hold for >5 days) Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 2. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. triamcinolone acetonide 0.05 % Ointment Sig: thin layer Topical twice a day for 7 days: apply thin layer to affected area twice daily as needed for rash. Disp:*qs * Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Upper and Lower Gastrointestinal Bleeding Contact Dermatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were seen in the hospital because of an upper and lower GI bleed. You were transfused many units of red blood cells. You had an artery that was bleeding near your rectum, and this was coiled by interventional radiology. We also started you on a proton pump inhibitor called pantoprazole to help heal the bleed that was found in your upper gastrontenstinal tract. On discharge, you blood counts were all stable and there were no new signs of bleeding. You had developed a minor rash which was likely just an irritation from the sheets at the hospital. We are giving you some steroid ointment which you can use on this rash until it resolves. If your rash does not resolve within the next week please call your physician's office to have it further evaluated. Because of this episode of bleeding, you should STOP taking the Plavix but CONTINUE to take aspirin. We made the following changes to your medications: STOPPED PLAVIX STARTED Pantprazole twice a day STARTED Triamcinalone cream for your rash which you should use for the next 7 days It was a pleaure taking care of you during your hospital stay. Followup Instructions: Please make an appointment to see your primary care doctor, Dr. [**Last Name (STitle) **] [**Last Name (STitle) **], within the next week at [**Telephone/Fax (1) 3070**]. You should also follow-up with the GI doctors. Please call their office at ([**Telephone/Fax (1) 2233**] to make an appointment within the next several weeks.

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icd9cm

[ [ [] ] ]

[ "45.13", "48.23", "31.42", "39.98", "39.79" ]

icd9pcs

[ [ [] ] ]

7768, 7774

4518, 6848

273, 328

7879, 7879

3399, 4495

9168, 9503

2913, 3023

7108, 7745

7795, 7858

6874, 7085

8030, 8921

3038, 3380

8950, 9145

228, 235

356, 2498

7894, 8006

2521, 2752

2768, 2897

418

140,563

7706

Discharge summary

report

Admission Date: [**2163-3-1**] Discharge Date: [**2163-3-9**] Service: CARDIAC [**Doctor First Name **] HISTORY OF PRESENT ILLNESS: This is an 82 year old female who has a known history of aortic stenosis and coronary artery disease, who reports increasing dyspnea on exertion over the last several years. The patient was referred to [**Hospital1 69**] for cardiac catheterization. The cardiac catheterization showed an ejection fraction of 55%, left ventricular end diastolic pressure of 20, aortic valve area of 0.5 cm squared, peak aortic valve gradient of 72 and 100% proximal right coronary artery lesion. An echocardiogram of [**2163-1-24**] showed moderate concentric left ventricular hypertrophy, ejection fraction of 65%. aortic stenosis with trace aortic insufficiency, peak aortic gradient of 117 mm of mercury and mean aortic gradient of 88 mm of mercury, mild tricuspid regurgitation and mild mitral regurgitation. The patient was referred to Dr. [**Last Name (STitle) **] for surgery. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Aortic stenosis. 3. Glaucoma. 4. Status post partial colectomy in [**2151**] for colon carcinoma. 5. History of paroxysmal atrial fibrillation. 6. Osteoarthritis. 7. Status post hernia repair times two. 8. Status post tonsillectomy. 9. Status post percutaneous transluminal coronary angioplasty to left anterior descending in [**2152**]. PREOPERATIVE MEDICATIONS: 1. Imdur 60 mg p.o. q. day. 2. Betapace 80 mg p.o. twice a day. 3. Corgard 10 mg p.o. twice a day. 4. Lipitor 5 mg p.o. q. day. 5. Xanax 0.25 mg p.o. three times a day. 6. Enteric coated aspirin 325 mg p.o. q. day. 7. Cardizem 60 mg p.o. q. a.m. and 30 mg p.o. q. p.m. and 30 mg p.o. q. h.s. 8. Xalatan eye drops, two drops o.u. q. a.m. 9. Alphagan eye drops, two drops o.u. three times a day. ALLERGIES: No known drug allergies. HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] on [**2163-3-1**]. She was taken to the Operating Room for an aortic valve replacement with a 19 mm [**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial valve and a coronary artery bypass graft times one, saphenous vein graft to the right coronary artery with Dr. [**Last Name (STitle) **]. Total coronary pulmonary bypass time was 115 minutes; cross clamp time 88 minutes. Please see operative note for further details. The patient was transferred to the Intensive Care Unit in stable condition. On the first postoperative evening, the patient awoke and followed commands; however, the patient was slow to extubate from mechanical ventilation as she was slow to fully awake. Postoperatively she was weaned and extubated on postoperative day number one without difficulty. The patient required Neo-Synephrine on postoperative day one to maintain adequate blood pressure. The patient was started on Lasix with good response. On postoperative day number two, the patient had an episode of atrial fibrillation. The patient was started on Amiodarone. As the patient was on Sotalol preoperatively, an Electrophysiology Service consultation was obtained and they initially recommended restarting the Sotalol. The patient converted to sinus rhythm and maintained sinus rhythm for less than 24 hours and again had an episode of atrial fibrillation. The patient was started on Lopressor as well. On postoperative day number three, the patient was transferred from the Intensive Care Unit to the regular part of the hospital. The patient continued to have episodes of atrial fibrillation and the patient's Sotalol had been discontinued. Electrophysiology Service was again consulted and they recommended anti-coagulation and cardioversion if patient remained in atrial fibrillation; however, the patient's platelet count postoperatively had decreased. On postoperative day three, the patient's platelet count had dropped to 62. Heparin antibody was sent and it was subsequently negative and the patient's platelet count began to rise. The patient was started on heparin for anti-coagulation. On postoperative day number six, the patient was taken to the Electrophysiology Service Laboratory where she underwent a transesophageal echocardiogram to rule out thrombus in her atria. The echocardiogram showed no clot, normal left ventricular function, mild to moderate mitral regurgitation, mild tricuspid regurgitation and no pericardial effusion. Cardioversion was attempted by the Electrophysiology Service and the patient had a very brief episode of sinus rhythm again converted into atrial fibrillation. It was recommended by the Electrophysiology Service to load the patient on Amiodarone and if the patient continued in atrial fibrillation after a month on Amiodarone and anti-coagulation, to again attempt cardioversion. The patient began working with Physical Therapy. It was recommended by Physical Therapy that the patient could benefit from a stay at a short term rehabilitation. By postoperative day number seven, the patient was cleared for a discharge to rehabilitation and she will be discharged on postoperative day number eight. CONDITION AT DISCHARGE: Temperature maximum 98.8 F.; pulse 85 in atrial fibrillation; blood pressure 108/58; respiratory rate 18; room air oxygen saturation 94%. The patient's weight is 82.3 kilograms. Preoperatively the patient weighed 79 kilograms. Neurologically the patient is alert and oriented times three, nonfocal. Heart is irregularly irregular. II/VI systolic ejection murmur, no rub. Breath sounds are decreased at bilateral bases. Otherwise, clear. Abdomen with positive bowel sounds, soft, nontender, nondistended, tolerating a regular diet. Sternal incision: Staples are intact. There is no erythema and there is no drainage. The sternum is stable. The right lower extremity vein harvest site is clean and dry. There is no erythema or drainage. In the patient's lower extremities, she has one plus pitting edema. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Aortic stenosis. 3. Status post coronary artery bypass graft and aortic valve replacement. 4. Postoperative atrial fibrillation. DISCHARGE MEDICATIONS: 1. Lasix 20 mg p.o. twice a day times seven days. 2. Potassium chloride 20 mEq p.o. twice a day times seven days. 3. Colace 100 mg p.o. twice a day. 4. Zantac 150 mg p.o. twice a day. 5. Enteric coated aspirin 81 mg p.o. q. day. 6. Percocet 5/325, one to two p.o. q. four to six hours p.r.n. 7. Lipitor 5 mg p.o. q. day. 8. Amiodarone 400 mg p.o. three times a day times five days and then 200 mg p.o. three times a day times seven days and then 200 mg p.o. twice a day times 14 days, then 200 mg p.o. q. day. 9. Lopressor 50 mg p.o. twice a day. 10. Coumadin; the patient should receive a daily dose after checking a PT and INR and adjust Coumadin for a goal INR of 2.0 to 2.5. 11. Lovenox 60 mg subcutaneously twice a day until INR is greater than 1.5. DISCHARGE INSTRUCTIONS: 1. The patient will also have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts Monitor placed with tracings to be transmitted to Dr. [**Last Name (STitle) 73**] as directed during the loading phase of her Amiodarone. 2. The patient should follow-up with Dr. [**Last Name (STitle) 27998**] in one to two weeks. 3. She is to follow-up with Dr. [**Last Name (STitle) 27999**] in one to two weeks. 4. The patient should follow-up with Dr. [**Last Name (STitle) **] in three to four weeks. DISPOSITION: The patient is to be discharged to rehabilitation in stable condition. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern1) 1541**] MEDQUIST36 D: [**2163-3-8**] 15:53 T: [**2163-3-8**] 16:07 JOB#: [**Job Number 28000**]

[ "997.1", "428.0", "V10.05", "414.01", "424.1", "427.31" ]

icd9cm

[ [ [] ] ]

[ "88.72", "39.61", "35.21", "36.11" ]

icd9pcs

[ [ [] ] ]

5984, 6149

6172, 6937

1905, 5130

6961, 7839

1444, 1887

5146, 5963

145, 1017

1039, 1418

7,900

116,176

7877

Discharge summary

report

Admission Date: [**2201-7-26**] Discharge Date: [**2201-7-29**] Date of Birth: [**2140-12-29**] Sex: M Service: MEDICINE Allergies: Verapamil / Iodine; Iodine Containing Attending:[**First Name3 (LF) 905**] Chief Complaint: dizzyness Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 60 yo man with hx of IDDM with diabetic neuropathy, chronic renal failure, bilateral foot ulcers, heart failure with implanted defibrillator, atrial flutter on coumadin, and peripheral vascular disease s/p right leg bypass, who presented to ED today with a one week history of dizziness and mild headache. Pt states he noted the onset of room spinning when he stood up but it would resolve when he sat back down; it was associated with tinnitus but no nausea/vomiting or hearing loss. He notes that this am he may have fallen towards the left. He also noted a mild persistent frontal headache, no neck stiffness, fever, chills. On the morning of admission, pt woke up and stood to walk to the bathroom and could barely make it due to severe vertigo, again, no nausea. He came to the ED and it was found that his INR was 16 and he had a small SAH on head CT. Of note, pt states that he tripped over the vacuum cord 3 weeks ago and hit his left hip and elbow, cannot remember if he hit his head, no LOC. Neurology and neurosurgery evaluated the pt in the ED and given his multiple medical problems, he was admitted to the MICU for close monitoring. He received 4units of FFP, and 10mg po vitamin K. . ROS: no fever/chills, no n/v/d, no abd pain, no BRBPR, no dysuria, no chest pain, no sob Past Medical History: Past Medical History: 1. Diabetes type 2 2. diabetic neuropathy with bilateral foot ulcers on heels 3. CRF, baseline cr 3.4 4. CHF, EF ?30% with implanted defibrillator 5. atrial flutter 5. pulmonary fibrosis 6. peripheral vascular disease s/p right leg bypass graft 7. depression 8. gout Social History: Patient lives alone, does own ADL's, no drugs, has VNA. Family History: NC Physical Exam: Per Note of Dr. [**Last Name (STitle) 28360**] T: 98.8, BP: 179/79, R: 61, RR: 12, O2 100% on 2L GEN: NAD SKin: multiple ecchymoses with palpable small hematomas HEENT: PERRL, EOMI, MMM CV: RRR, [**3-1**] diastolic murmur heard best at RUSB Chest: clear ABD: +BS, soft, NTND Ext: no edema, foot drop on right, decreased sensation in bilateral feet; left foot with slow oozing ulcer on heel. Neuro: CN 2-12 intact; old ptosis on left; strength 5/5 upper ext bilaterally; no dorsiflexion on right [**2-25**] nerve injury; [**5-28**] strenght in hip flexion; nl reflexes b/l. Pertinent Results: [**2201-7-26**] 12:10PM PT-49.3* PTT-76.5* INR(PT)-16.1 [**2201-7-26**] 12:10PM WBC-14.5*# HCT-31.4* [**2201-7-26**] 12:10PM PLT COUNT-269 [**2201-7-26**] 08:48PM PT-17.3* PTT-40.0* INR(PT)-2.0 [**2201-7-26**] 12:10PM GLUCOSE-134* UREA N-79* CREAT-3.2* SODIUM-137 POTASSIUM-5.0 CHLORIDE-104 TOTAL CO2-17* ANION GAP-21* FOOT AP,LAT & OBL LEFT [**2201-7-26**] 4:33 PM IMPRESSION: Loss of the visualization of the cortical bone of the base of the 5th metatarsal and of the lateral aspect of the cuboid. This is concerning for osteomyelitis. Correlate with site of ulcer. Bone scan could be performed. The study and the report were reviewed by the staff radiologist. CT HEAD W/O CONTRAST [**2201-7-26**] 3:31 PM IMPRESSION: Small amount of subarachnoid hemorrhage seen superiorly in a right frontal sulcus. The study and the report were reviewed by the staff radiologist. CT HEAD W/O CONTRAST [**2201-7-27**] 10:40 AM COMPARISON: [**2201-7-26**]. IMPRESSION: Stable appearance of small subarachnoid hemorrhage in a right frontal lobe sulcus CHEST (PA & LAT) [**2201-7-26**] 3:22 PM Reason: eval for infiltrate IMPRESSION: No definite evidence of acute pneumonia. Postoperative changes in the right hemithorax with stable fibrothorax. An addendum will be dictated when more recent films become available. ADDENDUM: There is no significant change since the prior CXR of [**2200-9-4**]. The study and the report were reviewed by the staff radiologist. ECG: AV paced at 60; no st-t changes Brief Hospital Course: 60y/o M with h/o a flutter on coumadin, CHF s/p ICD, DM type 2, who presents with one week of dizziness, headache and found to have a small post frontal bleed in setting of supratherapeutic inr 16. 1. Post frontal bleed: Spontaneous bleed in setting of supratherapeutic INR of 16, patient denied any recent trauma prior to arrivel though did attest to having fallen ~3 weeks ago. Per neuro findings were c/w new/recent bleed, they said that if bleed would have happened 3 weeks ago the composition of the blood would have changed and not lit up as it did on CT scans. Inr was reveresed with 4U FFP and 10mg vitamin K. Inr dropped to 2's within 8 hours of admission. Per neuro no focal neurological defects on exam. His repeat CT was unchanged and did not show progression of bleed. His headaches and dizziness resolved. CTA was not performed due to his CRI with creatinines at mid 3's and MRI/MRA not done due to his ICD. Neurosurgery s/o and recommended f/u as outpatient in their clinic in 2 weeks with CT s contrast prior to visit. Neuro also signed off without furhter recommendations. 2. Coagulopathy: unclear as to why patient presented with elevated INR of 16, no change in diet, no change in medications, could have been antibiotics but patient had been off them some time. Possibly poor nutrition as both PT and PTT corrected with vit K doses x 2. After reversal patients coags remained stable and within normal. He was not restarted on his coumadin and we recommended that he be started as an outpatient by pcp. 3. Leukocytosis: unclear etiology, no focal signs of infection, chest x ray was clear, ua was normal, no si/sx's of infection, his left heel ulcer appeared normal with no evidence of puss, erythema, tenderness. Pt was afebrile thoughout stay and abx were not started. Prior to discharge patients white count began to decrease. No further w/u was done. 4. Acute on CRF: [**2-25**] prerenal/hypovolemia. Improved with hydration. Stable. 5. Foot ulcers: X ray was taken of left foot ulcer and showed cortical erosion of the 5th metatarsal but did not correlate with location of ulcer. Podiatry was consulted and said that changes that were seen on the X ray are [**2-25**] his severe deformities and not due to osteomyelitis. They recommended wet to dry dressings and daily dressing changes. 6. DM2: glucoses remained stable, continued on his outpatient medication regimen. 7. HTN: stable, continued on his outpatient med regimen 8. Cardiac: CHF: euvolemic, salt and fluid restricted, continued on heart failure meds. CAD: continued on bb and asa Rhythm: a fib, stopped coumadin and reversed inr. Did not restart coumadin due to CNS bleed, will have pcp restart as outpatient. Restarted amiodarone. 9. Gout: stable, c/w allopurinol. 10. Depression: c/w fluoxetine 11. Hypercholesterolemia: c/w lovastatin and welchol. 12. Full Code Medications on Admission: allopurinol 100mg' amiodarone 200mg' aspirin 325mg' centrum darvocet prn fluoxetine 20mg' HCTZ 25mg' Lisinopril 2.5mg' lotrisone 0.05% [**Hospital1 **] lovastatin 10mg' procrit 20,000 2x per week toprol xl 150mg' vitamin c 500mg' warfarin 5mg' except 7.5mg on Tuesdays Welchol 625mg [**Hospital1 **] Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Medication Humulin 22u qam, 12-14u qpm 7. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily). 8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. Lovastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. WelChol 625 mg Tablet Sig: One (1) Tablet PO twice a day. 13. Centrum Silver Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital1 3894**] Health VNA Discharge Diagnosis: Posterior frontal cerebral bleed Left heel ulcer Acute renal failure Coagulopathy: supratherapeutic INR of 16 Secondary diagnosis: Atrial flutter Heart failure Diabetes Mellitus type 2 Hypertension Gout Depression OSA Discharge Condition: stable Discharge Instructions: Please take all your medications as prescribed and follow up with all your recommended appointments. Please call your doctor if you develop: fevers, chills, chest pain, shortness of breath, confusion, dizziness, vertigo or other concerning symptoms. Your primary care physician will determine when you restart the coumadin. You also need to set up an appointment with the neurosurgeon that was following you in the hospital. Your primary care phsysician should set up a CT of your head prior to seeing the neurosurgeon. Followup Instructions: Please call to schedule an appointment with your primary care phsyciain Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 1144**]. Please schedule your appointment within one week. Please call to make an appointment with Dr. [**Last Name (STitle) **] (Neurosurgery) at [**Telephone/Fax (1) 2992**], please make the appointment within 2-4 weeks from your day of discharge. You will need to have a CT scan of your head done prior to seeing him. Your primary care physician will help facilitate that. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Where: BA [**Hospital Unit Name **] ([**Hospital Ward Name **] COMPLEX) PODIATRY Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2201-7-31**] 10:50 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Where: BA [**Hospital Unit Name **] ([**Hospital Ward Name **] COMPLEX) PODIATRY Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2201-8-4**] 1:30 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 9119**] [**Name12 (NameIs) 28361**] PRACTICES Where: [**Name12 (NameIs) 9119**]-PRIVATE PRACTICES Phone:[**Pager number 28362**] Date/Time:[**2201-7-31**] 12:30 [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

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icd9cm

[ [ [] ] ]

[ "99.07", "99.05" ]

icd9pcs

[ [ [] ] ]

8329, 8391

4180, 7046

308, 314

8654, 8662

2650, 4157

9232, 10506

2037, 2041

7396, 8306

8412, 8523

7072, 7373

8686, 9209

2056, 2631

259, 270

342, 1636

8544, 8633

1680, 1948

1964, 2021

63,531

141,903

42772

Discharge summary

report

Admission Date: [**2131-1-12**] Discharge Date: [**2131-2-5**] Date of Birth: [**2062-11-23**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1390**] Chief Complaint: Necrotizing fascitis and sepsis Major Surgical or Invasive Procedure: [**2131-1-13**], L shoulder debridement, Emergency cricothyroidotomy, [**Hospital1 **] joint expl / L claviculectomy/Sthyroid muscle [**2131-1-14**], ligated left IJV, excised SCM, L submandibular gland [**2131-1-16**], Debridement / R arm closure [**2131-1-23**], Closure neck wound, tracheostomy [**2131-1-25**], Debridement and vac placement RUE [**2131-1-31**], Video-assisted thoracoscopic left decortication History of Present Illness: 68 yo with PMH of HTN who was in good health until 2 weeks prior to admission when he started having "flu like symptoms" consistent with sore throat, left shoulder pain and fevers up to 103, patient took ibuprofen with no control of the symptoms. Of note patient has very poor peridental care and 17 days ago "Pull out his tooth". Symptoms worsted about 5 days ago with spread swelling and erythema of his L neck and shoulder, increasing pain, fever, chills, and rigors. He also develop painless jaundice 2 days ago. He went to [**Hospital 487**] hospital when he was hypotensive and initially resuscitated with IVF. Labs revealed a leukopenia of 4.2, bandemia to 18, thrombocytopenia of 15, hyponatremia, bilirubin of 13.2, and [**Last Name (un) **] with Cr 3.5. CT showed multiple locules of gas area within and around the L acromioclavicular joint. Diffuse subcutaneous edema and soft tissue swelling of L neck. No mediastinal lymphadenopathy, no mediastinal hematoma Emphysematous changes are noted in the upper lobes. Multifocal pneumonia possible septic emboli. Liver attenuation no radio opaque gallstones. No biliary ductal dilation. He was transferred to [**Hospital1 18**] for further management. Past Medical History: Hypertension Social History: Lives with his wife [**Name (NI) **] in southern [**Name (NI) **]. Quit smoking 16 years ago, prior to that 48 pack year history. No ETOH or drugs. Exercises frequently. Family History: Noncontributory Physical Exam: On transfer to [**Hospital1 18**]: T 97.4 P93 BP97/64 RR25 Sat96RA GEN: A&O, NAD HEENT: Scleral icterus,Jaundice, dentition very poor. Very dry mucosas, swelling edema and erythema of the left neck spreading down to the 4th intercostal space and lateral to the left shoulder CV: RRR, No M/G/R PULM: Bilateral crackles, no wheezing ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses, no tender on palpation on RUQ, [**Doctor Last Name **] sign negative Ext: No LE edema, LE warm and well perfused Pertinent Results: [**2131-1-12**] 08:00PM BLOOD WBC-4.2 RBC-4.28* Hgb-13.6* Hct-39.4* MCV-92 MCH-31.7 MCHC-34.4 RDW-14.8 Plt Ct-14* [**2131-1-12**] 08:00PM BLOOD Glucose-117* UreaN-120* Creat-2.6* Na-134 K-3.3 Cl-105 HCO3-14* AnGap-18 [**2131-1-12**] 08:00PM BLOOD ALT-39 AST-53* CK(CPK)-61 AlkPhos-144* Amylase-39 TotBili-13.8* DirBili-13.2* IndBili-0.6 CT Neck/Chest [**2131-1-13**]: 1. In this patient with known necrotizing fasciitis status post debridement, locules of air seen tracking along the left strap muscles (from hyoid-thyroid level), left acromioclavicular joint are concerning for additional sites of necrotizing infection. Please refer to the CT neck for further information. 2. Multifocal bilateral pulmonary consolidations, with the largest areas of consolidation in the left lower lobe and lingula. Some of the foci in the left lung demonstrate cavitiation. Differential considerations for these findings are multi-focal pneumonia, multifocal necrotizing pneumonia, or possibly septic emboli. 3. Moderate-sized left pleural effusion. RUQ US [**2131-1-13**]: A small hypoechoic nodule adjacent to the gall bladder fossa. Although this could represent an area of focal fat, the liver does not appear to be echogenic on the current exam. Therefore further characterization of this area is recommended with an MRI when clinically appropriate. Normal gallbladder. CT Head [**2131-1-19**]: 1. No evidence of intracranial process. 2. Fluid within the sphenoid sinuses, mastoid air cells, and middle ear cavities is consistent with history of recent intubation. CT Chest [**2131-1-21**]: 1. Interval progression of the large left pleural effusion which now appears loculated and is concerning for an empyema, although assessment is difficult in the absence of intravenous contrast. 2. Extensive debridement of the left shoulder region with resection of the lateral clavicle in the interval since the prior procedure. Swelling of the left latissimus dorsi and abnormal low-attenuation material extending between the surgical bed and this region. 3. Multifocal pulmonary nodules may reflect focal pneumonia; however, followup CT when the patient's clinical condition improves is recommended to ensure resolution. 4. A cluster of small cavitary lesions in the left lung are difficult to assess given the collapsed state of the lung. No convincing evidence of an abscess, although assessment is limited due to the lack of intravenous contrast. 5. New small volume ascites. CT Chest [**2131-1-26**]: 1. Significant decrease in multiloculated left pleural effusion with chest tube in place. Moderate pleural effusion has mildly increased in size in comparison to prior study. 2. Multiple bilateral multifocal pulmonary opacities representative of multifocal pneumonia have decreased in size. 3. Marked improvement in aeration of the left upper lobe. 4. Extensive debridement at the left shoulder region with resection of the left lateral clavicle is again noted along with swelling of the left latissimus dorsi. However, the extent of swelling has decreased in comparison to prior study. Pleural fluid from thoracentesis [**2131-1-27**]: NEGATIVE FOR MALIGNANT CELLS. Reactive mesothelial cells, histiocytes, neutrophils, and lymphocytes VIDEO OROPHARYNGEAL SWALLOW [**2131-1-29**]: Gross aspiration with nectar-thickened liquids and ice chips Brief Hospital Course: Mr. [**Known lastname 7049**] was initially accepted by the [**Hospital 18**] Medical ICU in the early hours of [**2131-1-13**] upon transfer from the OSH. Recognizing that the CT read indicated subcutaneous gas along with its infectious etiology, surgery was consulted immediately and he was taken to the operating room for operative debridement. In the OR, he was a difficult intubation and there was difficulty in securing the airway, prompting an emergency cricothyroidotomy. He underwent extensive debridement of the soft tissues of his left shoulder and was taken back to the Trauma Surgical ICU post-operatively, no pressors and broad spectrum antibiotics. In the morning, the anesthesia/ICU/ACS team opted to convert his perc cricothyrotomy to an endotracheal intubation with the use of a pediatric bronchoscope and glide scope. Orthopaedics and ENT were consulted and he returned to the OR with orthopaedics, ENT and ACS later that morning for further debridement of his left shoulder extending distally to his forearm and proximally up his left neck. Please see the operative notes for additional details. Over the coming days, he returned to the OR on [**1-14**] and then [**1-16**] with ENT, Ortho and ACS for further debridements. His wound appeared to be improving with less necrotic tissue and overall improved vascularity and from [**1-16**] until [**1-23**], his wound care was managed at bedside with once to twice daily dressing changes along with debridement as necessary. With the wound healing well, on [**1-23**] he was taken to the OR with ENT for conversion of his ETT to a tracheostomy and closure of his neck wound. On [**2131-1-25**] he returned to the OR for final debridement and placement of a wound VAC over the shoulder. Following this debridement he was noted to have an empyema on the L side, he was taken to the OR by thoracic surgery on [**2131-1-31**] for a washout and decortication. His final chest tube was removed on [**2131-2-3**]. He had a G-J tube placed for feeding access on [**2131-2-1**]. He will follow up with plastic surgery as an outpatient to schedule his skin graft In addition to Acute Care Surgery, ENT, Orthopaedics, Thoracic, and Plastic Surgery were involved in his operative care. Details of his course, by systems: Neuro: Was intubated and sedated for much of his ICU stay. He was slow to awake with sedation off and in light of his thrombocytopenia early in his hospitalization, a CT head was obtained on [**2131-1-19**] which did not show evidence of a bleed. He gradually awoke and by [**2131-1-23**] (after receiving Trach) was awake, following commands and engaging in conversation. Pain control was with Tylenol and oxycodone prn. CV: Initially maintained on vasopressors which were gradually weaned as his sepsis resolved. He did flip into atrial fibrillation with RVR for which he was on a Diltiazem drip and ultimately transitioned to his home dose of diltiazem. He was transferred to the surgical floor on [**2131-1-26**] and remained in normal sinus rhythm. There have been no further issues from a cardiovascular perspective. Resp: Intubated initially with emergent cricothyroidotomy which was then transitioned to an ET tube. This was eventually converted to a tracheostomy on [**2131-1-23**] by ENT. He was weaned from the ventilator thereafter and he was tolerating Trach mask upon transfer from the ICU to the floor on [**2131-1-26**]. His oxygen saturations were monitored continuously and remained stable on Trach mask. Concerned for extension of his infectious process into his mediastinum, the team obtained a CT Chest on [**2131-1-21**]. This demonstrated a known pleural effusion (seen on CXR prior) but there was concern of loculation and suggestive of empyema. A chest tube was placed yielding ~ 800 cc seropurulent fluid (ultimately culture negative). Thoracic surgery was consulted for potential VATs debridement but this was deferred initially, it was eventually performed on [**2131-1-31**]/. Interventional Pulmonology was consulted to evaluate for resolution of the collection with potential pigtail drainage but did not find any additional drainable collections. His chest tube was placed to water seal. He had a repeat CT scan on [**2131-1-26**] to evaluate for progression which showed significant decrease in multi loculated left pleural effusion, but an increase in size of the pleural effusion. Because the effusion had not been completely drained with the chest tube, on [**2131-1-31**] he went to the operating room with thoracic surgery and underwent Video-assisted thoracoscopic left decortication. Anterior, posterior and basilar chest tubes were placed, and kept to suction postoperatively. They were removed sequentially, with the final chest tube being removed on [**2131-2-3**]. GI: He had an NGT initially through which he received tube feeds, which he tolerated without difficulty. This was changed to a Dobbhoff tube on [**2131-1-26**]. He had an attempted esophageal intubation for the purposes of a TEE on [**2131-1-18**] (to evaluate for cardiac vegetations) through which it was difficult to effectively intubate the esophagus due to presumably surrounding edema. Nonetheless, this did not clinically lead to any issues -- he continued to tolerate tube feeds. He failed a speech/swallow evaluation on [**2131-1-25**] and was re-evaluated with a video-swallow study on [**2131-1-26**], which showed evidence of gross aspiration. Therefore, a G-J tube was placed by interventional radiologists on [**2131-2-1**] and tube feeds were continued through the J tube, with the G tube placed to gravity. He will need reevaluation with speech/swallow as an outpatient to determine when he will be capable of eating. GU: Septic initially, his Cr was 2.6 on admission. He continued to have normal urine output throughout his course though and this trended downwards to normal, at 1.2 on discharge from ICU to floor on [**2131-1-26**]. On the floor, his creatinine remained less than 1.2 and his urine output remained adequate. His creatinine was 0.6 on discharge. ID: He was initially treated with broad spectrum antibiotic coverage including vanc, Zosyn, and clindamycin. Micafungin was added on [**1-16**] and switched to fluconazole on [**1-18**]. The vanc and Clinda were dc'd on [**1-18**]. He was continued on Zosyn/[**Last Name (LF) **], [**First Name3 (LF) **] ID recommendations, he will need to continue these antibiotics until his skin graft is placed by plastic surgery. He grew multiple mixed bacteria from his wounds. Results from the outside hospital micro resulted fusobacterium necrophorum and streptococcus intermedius. [**Hospital1 18**] wound cultures grew coag negative staph, neisseria, Peptostreptococcus, fusobacterium, and [**Female First Name (un) **]. Because of his sepsis, ID recommended a workup including TEE to rule out endocarditis. It was negative. MSK: He was followed closely by Physical and Occupational therapy during his stay and is being recommended for acute rehab after his hospital stay. Medications on Admission: Diltiazem ER 300 mg daily Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) inj Injection TID (3 times a day). 2. docusate sodium 50 mg/5 mL Liquid Sig: Five (5) mL PO BID (2 times a day): per JT. 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation: CRUSHED per JT. 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation: per JT. 5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation: CRUSHED per JT. 6. insulin regular human 100 unit/mL Solution Sig: One (1) dose Injection four times a day as needed for per sliding scale. 7. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours): CRUSHED per JT. 8. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours). 9. ranitidine HCl 15 mg/mL Syrup Sig: 150mg PO BID (2 times a day): CRUSHED per JT. 10. diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours): CRUSHED per JT. 11. Tylenol Extra Strength 500 mg/15 mL Liquid Sig: 15-30 ML's PO every six (6) hours as needed for pain. 12. oxycodone 5 mg/5 mL Solution Sig: Five (5) ML's PO every [**3-30**] hours as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 8957**] Discharge Diagnosis: 1. Necrotizing fascitis left upper extremity 2. Sepsis 3. Pneumonia 4. Complex parapneumonic effusion 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 with necrotizing fascitis which is a serious skin infection that involved a portion of your left arm and shoulder. You have had multiple operations to control spread of the infection and to treat the areas of your body that were affected. A special dressing called a VAC dressing has been placed in the affected area to help with the healing process in order for a skin graft to be done in the future. You also developed a fluid collection in your lung which required an operation to drain. You are recovering well from the infection and all the procedures you have undergone. You are now being discharged from the hospital and going to an extended care facility to continue rehabilitation. You currently have a VAC over your wound, this will need to be changed every 3days with black foam VAC dressing. Since it is such a large wound it has required 2 lollipops connected to Y piece and VAC suction device. It was last changed on the day of discharge. In addition you will require trach care, you have a small area of wound opening in your trach incision, this should be packed daily with iodoform packing. You have been cleared for a passy-muir valve by our SLP therapists, but you will need to be reevaluated by the therapists at rehab for you ability to eat. You will continue to need tube feeds via the J tube port of your G-J tube as below; the G tube port should stay to suction. You will need to continue to recieve your antibiotics via PICC line until plastics performs your skin graft. Followup Instructions: Department: THORACIC SURGERY When: THURSDAY [**2131-2-22**] at 2:30 PM With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: TUESDAY [**2131-3-6**] at 1 PM With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 853**] in the ACUTE CARE CLINIC Phone: [**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: SURGICAL SPECIALTIES When: MONDAY [**2131-2-19**] at 2:15 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], MD [**Telephone/Fax (1) 31444**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2131-2-5**]

[ "510.9", "276.1", "995.92", "287.5", "451.89", "V15.82", "285.9", "785.52", "584.9", "038.9", "728.86", "518.81", "276.2", "518.89", "478.6", "401.9", "527.8", "415.12" ]

icd9cm

[ [ [] ] ]

[ "31.42", "83.39", "83.44", "46.32", "33.24", "31.1", "96.6", "38.62", "83.45", "96.04", "40.41", "96.72", "34.91", "80.81", "86.74", "34.52", "34.04", "86.28", "26.32", "86.22", "77.81", "80.11", "38.97" ]

icd9pcs

[ [ [] ] ]

14656, 14730

6199, 13286

336, 752

14876, 14876

2835, 6176

16621, 17655

2231, 2248

13362, 14633

14751, 14855

13312, 13339

15059, 16598

2263, 2816

265, 298

780, 1992

14891, 15035

2014, 2028

2044, 2215

27,390

110,930

25353

Discharge summary

report

Admission Date: [**2136-6-28**] Discharge Date: [**2136-7-9**] Date of Birth: [**2066-3-12**] Sex: M Service: SURGERY Allergies: Vancomycin Attending:[**First Name3 (LF) 473**] Chief Complaint: pancreatic cancer Major Surgical or Invasive Procedure: [**2136-6-28**] - Retroperitoneal lymph node biopsies, exploratory laparotomy, open cholecystectomy History of Present Illness: This 71-year-old man with severe chronic obstructive pulmonary disease presents with pancreatic cancer that is borderline resectable. He was prepared by a Pulmonology consult deemed to be an acceptable but high risk for pancreatic resection and he opted to proceed. He was electively brought to the operating room for a planned Whipple procedure, but intra-operatively it was noted that serosal implants existed beyond the nodal disease which rendered this stage IV pancreatic cancer and the operation was aborted. Retroperitoneal lymph node biopsies, exploratory laparotomy and open cholecystectomy was performed. Past Medical History: PMH: COPD, on home oxygen 2L continuously; Anxiety; Depression; OSA; Hx of ARF; DMII, HTN, CAD s/p PTCA [**35**] yrs BU, ?seizures vs. syncope PSH: open appendectomy, tonsillectomy, bilateral carotid stents Social History: Patient retired (used to work for oxygen device company) and lives with his mother in [**Name (NI) 7740**]. Has 5 children. Previously smoked 3-4 packs/day x 45 years gradually decreasing for past 8 years, now 0.75 pack per day. Patient states he quit alcohol 30 years ago. Prior crack/cocaine x 2 yrs. Quit a few yrs ago. Family History: Mother CABG [**14**], alive 95. Father died at of pancreatic cancer at age 72. Physical Exam: VITALS: Afebrile, vitals signs stable. HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear. Mucous membranes moist. Neck supple without lymphadenopathy. CVS: Regular rate and rhythm, without murmurs, rubs or gallops. S1 and S2. RESP: Clear to auscultation bilaterally without adventitious sounds. No wheezing, rhonchi or crackles. ABD: soft, non-tender, non-distended, with normoactive bowel sounds. No masses or peritoneal signs. EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses INCISION: incision is clean, dry and intact, without evidence of erythema or drainage, staples have been removed. Pertinent Results: [**2136-6-28**] 05:21PM BLOOD WBC-11.1* RBC-3.43* Hgb-10.8* Hct-32.7* MCV-95 MCH-31.5 MCHC-33.1 RDW-15.3 Plt Ct-169 [**2136-6-28**] 05:21PM BLOOD Glucose-115* UreaN-17 Creat-0.6 Na-140 K-3.6 Cl-111* HCO3-25 AnGap-8 [**2136-7-2**] 12:39PM BLOOD CK-MB-3 cTropnT-<0.01 [**2136-6-28**] 05:21PM BLOOD Calcium-8.7 Phos-2.6*# Mg-1.4* [**2136-7-2**] CHEST (PA & LAT): Right basal opacity most consistent with atelectasis. No evidence of pneumothorax is present. Increased bilateral lung lucency most likely reflects emphysema [**2136-7-2**] CT ABD & PELVIS WITH CONTRAST: status-post CCY, with a moderate amount of free intermediate density fluid in the perihepatic region and gallbladder fossa, extending to the inferior margin of the liver. No rim enhancement. Small amount of pneumoperitoneum, relates to the recent surgery. Biliary stent in place, with minimal pneumobilia, without biliary dilation. Stable pancreatic ductal dilation, secondary to known pancreatic mass. Mild narrowing of the SMV, just proximal to the confluence. Bilateral trace pleural effusions with basal atelectasis. Small amount of simple pelvic free fluid. No retroperitoneal air to suggest duodenal perforation. Brief Hospital Course: NEURO/PAIN: The patient was maintained on IV pain medication in the immediate post-operative period and transitioned to PO narcotic medication with adequate pain control on POD#3. The patient had some mental status changes in the post-operative period, which was attributed to his medications versus acute post-op delirium changes. He had serial neurologic exams. His medication list was optimized to avoid anticholingeric or delirium-inducing medications. It appeared that his home Xanax was discontinued on admission and when resumed his mental status improved. The patient remained alert and oriented to person and place, but not always date/time. CARDIOVASCULAR: The patient remained hemodynamically stable intra-op and in the immediate post-operative period. He did experience some episodic hypotension post-op requiring re-intubation and fluid resuscitation. Their vitals signs were closely monitored with telemetry. The patient's home anti-hypertensive medications were resumed on POD#[**4-13**] once his pressures responded to fluids. His home dose of Plavix was restarted on POD#5, and his aspirin was continued immediately post-op. A right-sided central venous catheter was placed pre-op and removed on POD#5 when he was deemed hemodynamically stable. RESPIRATORY: The patient was extubated in the immediate post-op period successfully. His ABG revealed evidence of hypercarbia and carbon dioxide retention post-op and he required re-intubation on POD#0. The patient had no episodes of desaturation or pulmonary concerns following being extubated after this pulmonary episode. The patient denied cough or respiratory symptoms following this, and was maintained on nebulizers and pulmonary treatments. Pulmonology was consulted pre-op for clearance, and they continued following post-op, and they recommended continuing his MDIs. Pulse oximetry was monitored closely and the patient maintained adequate oxygenation. He had a CXR on POD#5 which showed some right lower lobe atelectasis, but otherwise was reassuring. GASTROINTESTINAL: The patient was NPO following their procedure and maintained on IV fluids for hydration while NPO. Serial abdominal exams were performed, and once flatus resumed, the patient was transitioned to a clear liquid diet and their IV fluids were hep-locked on POD#[**4-13**]. The patient experienced no nausea or vomiting. A regular diet was initiated on POD#[**6-15**] and the patient tolerated this well. There was some concern on POD#4 that the patient was clinical worsening. His WBC was elevated to 21, he spiked low grade temperatures and had new-onset tachycardiac (with stable EKG findings) which raised the concern for anastomotic leak or intra-abdominal bleeding. On POD#4, an upright abdominal X-ray revealed no free air and a CT of the abdomen and pelvis showed only a simple peri-hepatic fluid collection with post-operative changes and no extravasation of contrast or perforation. He was empirically placed on IV Vancomycin and Zosyn with improvement. He was closely monitored with serial abdominal exams, which were reassuring. GENITOURINARY: The patient's urine output was closely monitored in the immediate post-operative period. A Foley catheter was placed intra-operatively and removed on POD#2, at which time the patient was able to successfully void without issue. On POD#4 a Foley catheter was replaced for some low urine output and the need for monitoring given the previous concerns for anastomotic leak or bleeding. The patient's intake and output was closely monitored for urine output > 30 mL per hour output. The Foley was successfully removed again on POD#8. The patient's creatinine was stable. HEME: The patient's post-op hematocrit was stable and trended closely. The patient remained hemodynamically stable and did not require transfusion. The patient's coagulation profile remained normal. The patient had no evidence of bleeding from their incision. ID: Their white count was 21 post-operatively (POD#4) and their incision was closely monitored for any evidence of infection or erythema. The patient initially only received standard peri-operative antibiotics, but was started on empiric IV Vancomycin and Zosyn on the evening of POD#4 given concerns for anastomotic leak or infection. Blood and urine cultures were obtained for low grade temperatures. He clinically improved with IV antibiotics and his fevers resolved. Blood cultures revealed [**3-16**] bottle positive for gram negative rods which speciated E.coli that was pan-sensitive. He was continued on IV Zosyn and transitioned to PO-Cipro for a 2-week course, which he will complete on discharge. ENDOCRINE: The patient's blood glucose was closely monitored in the post-op period with Q6 hour glucose checks. Blood glucose levels greater than 120 mg/dL were addressed with an insulin sliding scale. His home anti-hyperglycemic medications were resumed when diet was restored. PROPHYLAXIS: The patient was maintained on heparin 5000 units SQ [**Hospital1 **] for DVT/PE prophylaxis and encouraged to ambulate immediately post-op once cleared by physical therapy. The patient also had sequential compression boot devices in place during immobilization to promote circulation. GI prophylaxis was sustained with Protonix/Famotidine when necessary. The patient was encouraged to utilize incentive spirometry, ambulate early and was discharged in stable condition. He was discharged home with his family, as rehabilitation was recommended, but the family declined. Medications on Admission: albuterol 5 mg/mL, alprazolam 1 mg'''', plavix 75 mg', effexor 75 mg' QOD, finasteride 5 mg', fluticasone-salmeterol 250/50 mcg', glipizide 2.5 mg'', ipatroprium-albuterol 18/103 mcg'', lisinopril 10 mg', metoprolol 100 mg', percocet 5/325 mg QID, promethazine 6.25 mg/5 mL', aspirin 325 mg', docusate 100 mg', flaxseed oil, magnesium oxide 400 mg'', omega-3 FAs 1000 mg'' Discharge Medications: 1. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: [**2-12**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day). 2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for SOB/wheeze. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold if diarrhea. Disp:*60 Capsule(s)* Refills:*2* 4. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation QID (4 times a day). 5. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. venlafaxine 75 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 11. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 14. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 15. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 17. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 18. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed for anxiety. 19. alprazolam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for agitation. 20. ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 21. glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 22. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: 1. Unresectable metastatic pancreatic cancer 2. Gram negative bacteremia 3. Delirium 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 Dr.[**Name (NI) 9886**] surgical service for evaluation and management of your pancreatic malignancy. You are now being discharged home. Please follow these instructions to aid in your recovery: Please call your doctor or go to the emergency department if: * You experience new chest pain, pressure, squeezing or tightness. * You develop new or worsening cough, shortness of breath, or wheezing. * You are vomiting and cannot keep down fluids, or your medications. * If you are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include: dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit, or have a bowel movement. * You experience burning when you urinate, have blood in your urine, or experience an unusual discharge. * Your pain is not improving within 12 hours or is not under control within 24 hours. * Your pain worsens or changes location. * You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. * You develop any other concerning symptoms. General Discharge Instructions: * Please resume all regular home medications, unless specifically advised not to take a particular medication. * Please take any new medications as prescribed. * Please take the prescribed analgesic medications as needed. You may not drive or operate heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. * Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. * Avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. * Please also follow-up with your primary care physician. Incision Care: * Please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. * Avoid swimming and baths until cleared by your surgeon. * You may shower and wash incisions with a mild soap and warm water. Gently pat the area dry. * If you have staples, they will be removed at your follow-up appointment. * If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2835**] Date/Time:[**2136-7-23**] 8:45 [**Hospital Ward Name 23**] 3, [**Hospital Ward Name **] . Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2136-8-17**] 11:40 Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2136-8-17**] 12:00 Provider: [**Name10 (NameIs) **] [**Name8 (MD) 611**], M.D. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2136-8-17**] 12:00 . Please follow up with your PCP [**Last Name (NamePattern4) **] [**3-15**] weeks after discharge

[ "250.00", "V46.2", "300.4", "518.0", "998.59", "276.2", "305.1", "V45.82", "327.23", "785.0", "496", "E878.6", "790.7", "197.6", "518.81", "574.10", "780.09", "157.0", "414.01", "V12.54", "041.4", "196.2", "401.9" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04", "51.22", "54.23", "40.11", "03.90" ]

icd9pcs

[ [ [] ] ]

11701, 11756

3563, 9065

287, 389

11885, 11885

2350, 3540

14526, 15214

1622, 1702

9489, 11678

11777, 11864

9091, 9466

12068, 13197

14008, 14503

1717, 2331

13230, 13992

229, 249

417, 1034

11900, 12044

1056, 1266

1282, 1606

4,875

155,268

24768

Discharge summary

report

Admission Date: [**2154-9-21**] Discharge Date: [**2154-10-11**] Service: MEDICINE Allergies: Aspirin / Penicillins / Zocor Attending:[**First Name3 (LF) 1145**] Chief Complaint: Transferred with STEMI Major Surgical or Invasive Procedure: Cardiac catheterization Intraaortic balloon pump placement Arterial line placement Swan-Ganz catheter placement History of Present Illness: 84 year old male with PMH of CAD, hx MI ([**2134**]), DM, presented to OSH ED with N/V and SOB x a few days. EKG showed ST elevations in V2 with Qs in II and aVF and hyperacute T waves in V3 with ST depression in V5-6. Troponin was 15.65 and CK was 603 and MB was 123. He also had a transaminitis, a Cr of 1.8 and a U/A positive for Leuk Esterase and WBCs. The pt was given levoquin 500IV x 1, heparin gtt, integrillin, reglan. He was hypotensive with a SBP of 80-100 s/p 1500cc fluid bolus. He was then transferred to [**Hospital1 18**]. Here he underwent a cardiac catheterization where he was found to have a total occlusion of the mid LAD, subtotal occlusions of the LCx, and a diffusely calcified RCA. A balloon was passed and inflated in the mid LAD but unable to pass 80% stenosis distally. No stent placed secondary to ASA allergy. Hemodynamics demonstrated increased filling pressures with decreased CO/CI. The pt was started on dobutamine and IABP for cardiogenic shock. Past Medical History: Prostate CA (brachytherapy) NIDDM CAD s/p MI ([**2134**]) Social History: Married, HCP nephew and [**Name2 (NI) 802**] Family History: Noncontributory Physical Exam: 96, HR 99, BP 97/45, RR 31 100% O2 Gen: Pale, minimally responsive man in bed HEENT: Perrla, EOMI, MMM CV: RRR S1,S2 Holosystolic murmur, No R/G Lung: Rales Abd: Soft, NT, ND, BSNA Ext: No C/C/E Skin: No lesions Neuro: CN II-XII intact, A and O x 3 Pertinent Results: Echo [**2154-9-22**]: LV EF 20% severely dilated LV RV severely depressed fxn. valves: 2+ MR . EKG OSH 1)NSR @ 100, Left axis, LBBB, DOwnsloping ST depressions in 1, L, V4-6 2)NSR @ 75, LAD, ST elev. V2, ST depr V5-6, Peaked T V3, Q 2 and F . OSH Labs: ABG 7.42/22/78; ALT 254; AST 213; Alk Phos 49; T Bili 1.4; Alb 3.6; D. Bili 0.37; HCT 30.1; Plt 207; Na 135, K 5.4, Cl 103, Bicarb 20, BUN 56, Cr. 1.8, Gluc 270 . Cardiac Cath at [**Hospital1 18**] [**9-21**] 1. Selective coronary angiography of this right dominant patient revealed severe two vessel CAD. The LMCA had calcifications and minor distal lesion. The proximal LAD was normal, however after a large septal that gave off collaterals to the right, the LAD was totally occluded. The distal LAD was also totally occluded but filled from left to left collaterals (septal to PDA to distal LAD). The LCX had diffuse non flow limiting disease but the OM1 had subtotal occlusion and filled from collaterals from the distal LCX. The RCA was not able to be engaged but appeared to be totally occluded and heavily calcified. The distal PDA filled from L to R collaterals. 2. Hemodynamics revealed severe elevation of right and left filling pressures with PCWP of 29mmHG and mean RA of 15mmHG. The cardiac output was severely depressed with index of 1.46 by Fick. 3. Ventriculogram was deferred due to heavy dye burden 4. Successful recanalization of the mid LAD followed with POBA with 2.0 balloon with significant improvement (see PTCA comments). 5. Insertion of IABP for hemodynamic support. Brief Hospital Course: Assessment: 84 year old male with PMH of CAD (S/P MI), DM admitted with STEMI [**2-13**] occluded mid LAD complicated by cardiogenic shock on IABP for BP support and PO amio for rapid atrial fibrillation, unable to be weaned off pressors and eventually made comfort measures only. . Hospital course is reviewed below by problem: . 1) Cardiogenic shock - As per the HPI, the patient was initially put on IABP for pressure support post-catheterization but became hypotensive and was found to have severe aortic stenosis ([**Location (un) 109**] 0.5cm). He was placed on dobutamine, levophed, and vasopressin. He was unable to be weaned off these medications, and after a long course, decided to stop the IV pressors and become comfort measures only. . 2) S/P STEMI - He had a difficult PTCA to mid LAD only, with cath complicated by difficulty passing wire. He was determined not to be a candidate for valvuloplasty. He was treated with plavix, statin, and ASA until made CMO. . 3) New onset atrial fibrillation - This was treated with amiodarone. . 4) Infection - He was treated with levofloxacin 250 daily for a UTI, then vancomycin, ceftaz, and flagyl for empiric coverage. Cultures never grew any organisms, and the antibiotics were stopped when he was made CMO. . 5) GI Bleed - He had guaiac positive stool on exam at his first cath on [**9-22**], but his Hct remained stable. . 6) Acidosis - Near the end of his hospitalization, he was found to have both an anion and nonanion gap acidosis. These were thought to be secondary to renal failure, with contribution from starvation ketoacidosis and possibly lactic acidosis. He was well compensated and only infrequently was acidemic. He was treated with bicarbonate, but this was stopped when his cardiac output continued to drop despite the treatment. . 7) DM - He was maintained on insulin SS for tight BS control until made CMO. Medications on Admission: Plavix, HCTZ, spironolactone 25, flomax, lasix, digoxin, pravachol Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A

[ "250.40", "410.71", "427.31", "785.51", "276.2", "414.8", "414.01", "599.0", "V10.46", "584.9", "412", "285.9", "396.2", "276.5", "585", "V66.7", "398.91", "578.9" ]

icd9cm

[ [ [] ] ]

[ "99.20", "37.61", "38.93", "99.04", "37.23", "99.61", "88.56", "36.01", "97.44" ]

icd9pcs

[ [ [] ] ]

5457, 5466

3427, 5311

261, 374

5518, 5528

1856, 3404

5580, 5586

1555, 1572

5428, 5434

5487, 5497

5337, 5405

5552, 5557

1587, 1837

199, 223

402, 1395

1417, 1477

1493, 1539

56,703

108,712

46617

Discharge summary

report

Admission Date: [**2105-1-6**] Discharge Date: [**2105-1-15**] Service: SURGERY Allergies: Nasonex / Ibuprofen / Aspirin / Aspartame / Bufexamac / Celecoxib / Floctafenine Attending:[**First Name3 (LF) 5547**] Chief Complaint: abdominal pain / incarcerated Spigelian hernia Major Surgical or Invasive Procedure: exlap, 30 cm small bowel resection History of Present Illness: Pt is 85 y/o F with h/o Crohn's disease, right hemicolectomy in [**2095**] for colon cancer, CAD, afib who presents with abd pain concerning for ischemic bowel. Pt initially presented to OSH one week ago with complaints of chest pain and was ruled out for MI. Pt developed some RUQ abd pain a few days into her admission, but her abd pain acutely worsened 2 days ago and was associated with nausea and vomiting. Her abdomen was also noted to be tympanitic. She had a NG tube placed for her symptoms, which was subsequently pulled. KUB initially was nonspecific. She had a repeat KUB yesterday which showed some dilated small bowel loops and WBC count increased to 25 with 26% bands. On admission it was noted that her Cr had increased to 3.4 and urine output decreased. Her abd pain continued to worsen and pt was noted to have severe tenderness on right side on exam with rebound tenderness and guarding. NGT was placed again today with 1 liter output. Pt was ordered for CT scan but apparently pt refused study because of claustrophobia. For concern for need for operation, pt was transferred to [**Hospital1 18**] for further management. Past Medical History: CAD s/p angioplasty Afib htn COPD asthma gallstones diverticulosis Crohn's Colon ca s/p right hemicolectomy hysterectomy nephrectomy hernia repair Social History: No ETOH or smoking. Pt lives by herself. Family History: Breast cancer and CVA. Physical Exam: AVSS General: A&O x3, NAD CV: RRR Chest: CTAB Abd: S/NT/ND; incision with small amt peri-incisional erythema, improved from previous Ext: WWP Pertinent Results: [**2105-1-12**] 06:24AM BLOOD WBC-7.9 RBC-3.80* Hgb-10.5* Hct-32.5* MCV-86 MCH-27.5 MCHC-32.2 RDW-13.7 Plt Ct-202 [**2105-1-11**] 05:05AM BLOOD WBC-10.5 RBC-4.05* Hgb-11.2* Hct-34.4* MCV-85 MCH-27.7 MCHC-32.7 RDW-13.7 Plt Ct-228 [**2105-1-10**] 09:03PM BLOOD WBC-10.5 RBC-4.15* Hgb-11.5* Hct-35.4* MCV-85 MCH-27.7 MCHC-32.5 RDW-13.9 Plt Ct-233 [**2105-1-6**] 04:54PM BLOOD WBC-24.7*# RBC-4.96 Hgb-14.1 Hct-40.0 MCV-81* MCH-28.4 MCHC-35.2* RDW-13.6 Plt Ct-323 [**2105-1-10**] 05:30PM BLOOD PT-13.6* PTT-33.6 INR(PT)-1.2* [**2105-1-14**] 07:20AM BLOOD Glucose-98 UreaN-26* Creat-0.8 Na-139 K-3.9 Cl-103 HCO3-26 AnGap-14 [**2105-1-13**] 06:40AM BLOOD Glucose-96 UreaN-30* Na-144 K-3.6 Cl-107 HCO3-33* AnGap-8 [**2105-1-6**] 04:54PM BLOOD Glucose-138* UreaN-87* Creat-4.0*# Na-139 K-4.7 Cl-93* HCO3-32 AnGap-19 [**2105-1-7**] 02:09AM BLOOD ALT-17 AST-23 CK(CPK)-37 AlkPhos-72 TotBili-0.7 [**2105-1-6**] 10:54PM BLOOD ALT-17 AST-22 CK(CPK)-31 AlkPhos-65 Amylase-61 TotBili-0.7 [**2105-1-11**] 11:51AM BLOOD CK(CPK)-29 [**2105-1-11**] 05:05AM BLOOD CK(CPK)-31 [**2105-1-10**] 09:03PM BLOOD CK(CPK)-29 [**2105-1-11**] 11:51AM BLOOD CK-MB-2 cTropnT-<0.01 [**2105-1-11**] 05:05AM BLOOD CK-MB-2 cTropnT-LESS THAN [**2105-1-10**] 09:03PM BLOOD CK-MB-2 cTropnT-<0.01 [**2105-1-14**] 07:20AM BLOOD Calcium-7.9* Phos-3.2 [**2105-1-13**] 06:40AM BLOOD Albumin-2.6* Calcium-8.3* Phos-3.4 Mg-2.1 Iron-27* [**2105-1-12**] 06:24AM BLOOD Calcium-8.1* Phos-3.7 Mg-2.2 [**2105-1-13**] 06:40AM BLOOD calTIBC-235* Ferritn-238* TRF-181* [**2105-1-13**] 06:40AM BLOOD Triglyc-162* [**2105-1-7**] 02:09AM BLOOD Digoxin-2.0 . Echo [**6-12**]: normal EF, moderate TR, mod pulm htxn. . DIAGNOSIS: Small intestine; resections (A-O): Full thickness mucosal necrosis with acute inflammation and associated transmural edema and hemorrhage (see comment). Serosal acute inflammation. Serosal adhesions. ADDENDUM: No fungal organisms are identified on a GMS stain. Four reactive lymph nodes are identified in the submitted mesenteric fa Clinical: 85 year old woman with peritonitis. Exploratory laparotomy, lysis of adhesions and small bowel resection . Brief Hospital Course: Ms. [**Known lastname 47639**] was admitted on [**1-6**] to the ICU for managment of abdominal pain which was concerning for ischemic bowel. Due to claustrophobia, patient was unable to undergo CT scan, however her exam and history were highly concerning for ischemic bowel and after discussion with the patient and family, it was decided to go ahead with surgery. She underwent an exploratory laparotomy and lysis of adhesions on the day of admission, and at that time she was found to have an incarcerated Spigelian hernia with necrotic small bowel. The necrotic bowel was resected and patient was managed postoperatively in the ICU. Initially she required ventilatory support and low-dose levophed. She was treated empirically with vancomycin and zosyn peri-operatively. Creatinine was elevated to 4 perioperatively but decreased with IV fluids. On [**2105-1-8**], patient was extubated and out of bed to a chair. Her WBC count was 12 and she was afebrile. She was in atrial fibrillation but rate controlled. On [**2105-1-9**], she was transferred from the ICU to the floor and TPN was started. On [**2105-1-10**], she conitinued to auto-diurese. Her pulse oximetry decreased to 88% on room air and she was re-started on 2L O2 by NC. She complained of left-sided chest pain, similar to the type she has at home for which she normally takes SL nitroglycerin. She was given SL nitro x2 and refused IV morphine, stating her pain was better. EKG showed Afib, CXR showed no acute change, and cardiac enzymes were negative x3 over the next 24 hours. On [**2105-1-11**], she was re-started on her home pain medications and the O2 was weaned succesfully to room air. On [**2105-1-12**], a picc line was placed for continued TPN, patient reported passing flatus, and diet was started on clears and advanced to regular diet. On [**2105-1-13**], patient was tolerating a regular diet. Her abdominal incision was noted to be mildly erythematous, and she was started on cipro and flagyl empirically. On [**2105-1-14**], patient was doing well, out of bed to chair. TPN was discontinued in the morning and she was screened for rehab. The incisional erythema was stable/decreased from the previous day, and the inferior aspect of the wound was opened [**3-9**] centimeters and a small amount of serosanguinous fluid was expressed and sent for culture. On [**2105-1-15**], patient's blood sugars stable overnight off of TPN for 24hrs. Surgical status continues to be stable. Abdominal incision continues with Moist saline packing with decreased erythema. Contact Dr.[**Name2 (NI) 12822**] office with concerns regarding incision. She will continue with PO Cipro/Flagyl for another 8 days. PO intake has been adequate. Continue to monitor PO intake at Rehab. Medications on Admission: amilodipine-benazepril 5/20mg 1 tab PO daily aspirin 81mg PO daily digoxin 250mcg PO daily lasix 40 mg daily imodium 2mg PO BID toprol 25 mg [**Hospital1 **] ursodiol 300 mg daily prilosec 20 mg daily immodium prn MVI 1 tab PO daily vit B6 50mg PO daily Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. 9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 10 days. 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 12. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: Oaks Long Term Care Facility - [**Location (un) 5503**] Discharge Diagnosis: incarcerated Spigellian hernia, necrotic small bowel, status post exploratory laparotomy, 30 cm small bowel resection Discharge Condition: stable Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * 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. *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *Avoid driving or operating heavy machinery while taking pain medications. * 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. * Continue to ambulate several times per day. . Incision Care: -Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. TPN Orders: -Check you blood sugars 4 times per day, at the same time each day. -Treat with insulin injections as indicated. -Check serum sodium levels at rehab and adjust TPN as needed; sodium levels were borderline high during this admission. Followup Instructions: 1. Please follow-up with Dr. [**Last Name (STitle) 1924**] to get your staples removed in [**2-6**] Please call his office for an appointment: [**Telephone/Fax (1) 7508**]. 2. Follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 9674**] in 1 week OR as needed. . Wound cultures are pending at time of discharge. Completed by:[**2105-1-15**]

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icd9cm

[ [ [] ] ]

[ "38.93", "45.62", "54.59", "46.75", "99.15", "53.59" ]

icd9pcs

[ [ [] ] ]

8347, 8429

4139, 6906

333, 369

8590, 8598

1997, 4116

10374, 10808

1795, 1819

7210, 8324

8450, 8569

6932, 7187

8622, 9768

9783, 10351

1834, 1978

247, 295

397, 1548

1570, 1719

1735, 1779

27,863

183,198

26554

Discharge summary

report

Admission Date: [**2135-3-23**] Discharge Date: [**2135-4-1**] Date of Birth: [**2066-6-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 562**] Chief Complaint: Nausea/Vomiting --> Diabetic Ketoacidosis Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a 68 yo M w/ Type 1 IDDM, hyperlipidemia and CRI (Cr baseline 1.3) who presents with worsening nausea/vomiting x several days. . Patient actually reports nausea and vomiting x several months which has more recently worsened. On [**3-17**] he was seen in the [**Hospital1 18**] ED w/ n/v thought likely [**3-5**] to constipation from using oxycodone. He was d/c-ed with a bowel regimen. His nausea has not improved since that time - for the last 3 days patient has severely decreased POs, taking only saltines and water. Because of this, he was concerned about taking regular insulin doses, so cut back from humalog [**Hospital1 **] 17units -> 10units. On the morning of admission he did not use any insulin. He denies flu/URI symptoms, sick contacts, different food, new travel. No dysuria/polyuria. No CP, SOB. Slight diarrhea, decreased sleep and 8lb weight loss/month. Last BM was several days ago. He does report distance hospitalization for DKA, was hospitalized w/ hypoglycemia several years ago. . On arrival to ED, VS were 96.6, HR 100, PB 137/43, O2 99%. Bs was 704. Patient was started on insulin gtt (10u bolus w/ 10U/hr), received 1.5L fluid. He received Zofran, Reglan and Ceftriaxone 1gm IV. He was also given Ativan 1mg re: ? n/v [**3-5**] opioid withdrawal. CT Abd/Pelvis was benign, lactate 3.8. Past Medical History: 1.Type I DM - dx [**2106**], HbA1c on [**3-24**] was 8.9 2. Hyperlipidemia 3. One kidney, congenital 4. Legally blind in L eye [**3-5**] MVA 5. CRI - baseline 1.3-1.4 6. Hypertension 7. Lumbar radiculopathy (L5?) Social History: Patient lives in [**Location (un) 4398**] w/ partner [**Name (NI) **]. Recently retired school administrator, retired now as a consultant. Prior 15-pk year history, quit 30+ years ago. [**2-2**] EtOH drinks/day, no illicits. Family History: Mother 77 d colon CA, father 86 d CAD s/p MI; 9 siblings: 1 d lung CA, 1 d colon CA (none under 50). Diabetes runs in the family. Physical Exam: on arrival to ICU: VS: Temp: 98.2 HR: 117 BP: 119/62 RR: 26 O2sat: 100% on RA GEN: pleasant and talkative, comfortable, NAD HEENT: PERRL, EOMI, anicteric, dry mucous membranes NECK: 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, scant b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e, warm, 2+ DP/PT pulses SKIN: no rashes/no jaundice NEURO: AAOx3. No focal deficits Pertinent Results: CXR ([**3-23**]): Small opacity at the left lung base is highly suggestive of atelectasis. A tiny focus of aspiration cannot be entirely excluded but is felt less likely. . KUB ([**3-23**]): No radiographic evidence for obstruction or free air. Significant evacuation of previously noted stool from colon. Findings are suggestive of right renal and ureteral calculi that have undergone prior lithotripsy. Correlate history and urinalysis. [**2135-3-23**] 10:27PM TYPE-[**Last Name (un) **] PO2-37* PCO2-25* PH-7.22* TOTAL CO2-11* BASE XS--16 INTUBATED-NOT INTUBA [**2135-3-23**] 10:27PM LACTATE-3.8* [**2135-3-23**] 10:15PM GLUCOSE-509* UREA N-31* CREAT-2.1* SODIUM-142 POTASSIUM-4.1 CHLORIDE-95* TOTAL CO2-11* ANION GAP-40* [**2135-3-23**] 10:15PM PHOSPHATE-5.5* [**2135-3-23**] 05:00PM GLUCOSE-704* UREA N-25* CREAT-1.9* SODIUM-136 POTASSIUM-4.9 CHLORIDE-87* TOTAL CO2-11* ANION GAP-43* [**2135-3-23**] 05:00PM CK(CPK)-72 [**2135-3-23**] 05:00PM CK-MB-NotDone cTropnT-<0.01 [**2135-3-23**] 05:00PM WBC-15.2*# RBC-4.64 HGB-14.8 HCT-44.3 MCV-96 MCH-31.9 MCHC-33.4 RDW-11.8 [**3-24**] HbA1c - 8.9 . MRI ABDOMEN W/O & W/CONTRAST [**2135-3-30**] 1:45 PM MRI ABDOMEN W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESS Reason: ? malignancy Contrast: MAGNEVIST [**Hospital 93**] MEDICAL CONDITION: 68 year old man with hx Type I DM p/w DKA and intractable nausea/vomiting. DKA now resolved but concern for occult malignancy contributing to N/V. REASON FOR THIS EXAMINATION: ? malignancy CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: Diabetes with diabetic ketoacidosis, intractable nausea and vomiting. Evaluate for occult malignancy. COMPARISON: Non-contrast CT of the abdomen and pelvis [**3-23**], [**2135**]. TECHNIQUE: Multiplanar T1- and T2-weighted images of the abdomen were acquired on a 1.5 Tesla magnet including dynamic 3D imaging obtained prior to, during, and after the uneventful intravenous administration 0.1 mmol/kg gadolinium-DTPA. Multiplanar 2D and 3D reformations along with subtraction images were generated on an independent workstation. MRI OF THE ABDOMEN WITH AND WITHOUT INTRAVENOUS CONTRAST: The liver is normal in signal intensity and enhancement without focal hepatic lesions. Hepatic arteries, hepatic veins, and portal veins are widely patent. There is mild segmental intrahepatic biliary duct dilatation involving the medial left lobe of the liver, but no intraluminal filling defects, peribiliary enhancement, or extrinsic mass effect is identified. The right-sided intrahepatic bile ducts and extrahepatic bile ducts are normal in caliber and smooth in contour. The pancreas demonstrates diffuse fatty atrophy, but otherwise demonstrates no focal lesions and enhances normally. The main pancreatic duct is normal in caliber and contour. No peripancreatic edema or fluid collections are present. Adrenal glands and spleen are within normal limits. A congenitally dysplastic right kidney is again noted. The left kidney appears within normal limits. No hydronephrosis is identified. The abdominal aorta is normal in caliber. No pathologically enlarged mesenteric or retroperitoneal lymph nodes are seen. There is no free fluid. Small hiatal hernia is present. Within the lateral wall of the duodenal bulb, there is a prominent rounded mass of soft tissue identified, which likely corresponds to the patient's ulcer seen on EGD performed the same day. The remainder of the bowel is unremarkable without evidence of obstruction. No suspicious focal bone marrow signal abnormalities are identified. L1 vertebral hemangioma is present. Multiplanar 2D and 3D reformations were essential in providing multiple perspectives for the dynamic series. IMPRESSION: 1. No intra-abdominal malignancy identified. 2. Segmental intrahepatic biliary duct dilatation involving the left lobe, of uncertain etiology. This finding may be the sequela of prior cholangitis. 3. Duodenal thickening probably corresponding to bulb ulcer seen on endoscopy. 4. Dysplastic right kidney. Brief Hospital Course: # Diabetic Ketoacidosis: The patient presented with nausea/vomiting and was found to have a glucose of 704 with an anion gap of 48. There was no source of infection found; the likely source of his DKA was likely his decreased use of insulin. The patient was treated with insulin drip in the intensive care unit and was converted back to subcutaneous insulin upon discharge to the floor. He was followed by [**Last Name (un) **] during his inpatient stay. # Acute renal failure: The patient has baseline chronic renal insufficiency with a creatinine of 1.2 - 1.3. On admission Cr was 1.9, which was likely pre-renal due to hypovolemia from persistent vomiting and poor PO intake. His creatinine returned to baseline with hydration. # Nausea/Vomiting: The patient had persistent nausea and vomiting despite a normal gastric emptying study. A GI consult was obtained and an endoscopy was performed that showed gastritis, esophagitis, and a bleeding duodenal ulcer. He was started on sucralfate and twice-daily PPI with improvement in his symptoms and an ability to eat. # Hypertension: The patient was maintained on his home regimen of Valsartan. # Hyperlipidemia: Patient was continued on [**Last Name (un) 7396**] 20 QHS and ASA 81. # Radiculopathy - continued Neurontin 600mg TID. Medications on Admission: Medications: Diovan 160mg [**Name (NI) 244**] (unclear if correct dose) [**Name (NI) 7396**] 20mg QD ASA 81mg Neurontin 600mg TID Oxycodone 5mg [**2-2**], Q4-6hrs PRN Viagra 100mg PRN Humalog mix 75/25, 17U QAM/17U QPM Humalin for PRN Discharge Medications: 1. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Rosuvastatin 40 mg Tablet Sig: Two (2) Tablet PO once a day. 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 5. Compazine 10 mg Tablet Sig: One (1) Tablet PO every 6-8 hours for 15 doses. Disp:*15 Tablet(s)* Refills:*0* 6. Prevpac 500-500-30 mg Combo Pack Sig: as directed PO as directed for 14 days: Each pack contains a full day's supply of medication, consisting of two 30-milligram capsules of lansoprazole, four 500-milligram capsules of amoxicillin, and two 500-milligram tablets of clarithromycin. Take half the supply in the morning and the remainder at night. Prevpac can be taken with or without food. Swallow each pill whole; do not crush or chew. . Disp:*14 packs* Refills:*0* 7. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day) for 10 days. Disp:*40 Tablet(s)* Refills:*0* 8. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: as directed Subcutaneous twice a day: 17 u AM, 17 u PM. 9. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous as directed: scale as directed by your PCP and by your carbohydrate counting. Discharge Disposition: Home Discharge Diagnosis: Primary 1. Diabetes, Type I 2. Diabetic keto-acidosis 3. Gastritis, H. Pylori 4. Esophagitis Discharge Condition: Good Discharge Instructions: You were admitted with diabetic ketoacidosis. Your ketoacidosis resolved. Your nausea and vomiting was investigated with an endoscopy which showed inflammation in the esophagus and stomach. It also showed an infection with H. Pylori, a common cause of gastritis. You should take all your medications as directed. You should follow up with your PCP [**Last Name (NamePattern4) **] 2 weeks. You should return to the ED or call your PCP for any worsening abdominal pain, nausea, vomiting, light headedness, dizziness, or other concerning symptom Followup Instructions: You should call Dr. [**Last Name (STitle) **] for a follow up appointment. Your appointments are listed below: Provider: [**Name10 (NameIs) 1089**] [**Name11 (NameIs) 1090**], MD Phone:[**Telephone/Fax (1) 1091**] Date/Time:[**2135-4-11**] 3:40 Completed by:[**2135-4-7**]

[ "272.4", "250.13", "753.0", "584.9", "532.90", "535.50", "530.19", "724.4", "041.86", "276.52", "403.90", "585.9" ]

icd9cm

[ [ [] ] ]

[ "45.16" ]

icd9pcs

[ [ [] ] ]

9822, 9828

6972, 8271

355, 361

9965, 9972

2925, 4200

10569, 10845

2217, 2349

8557, 9799

4237, 4384

9849, 9944

8297, 8534

9996, 10546

2364, 2906

274, 317

4413, 6949

389, 1720

1742, 1957

1973, 2201

13,150

161,818

13210

Discharge summary

report

Admission Date: [**2180-4-16**] Discharge Date: [**2180-5-14**] Date of Birth: [**2137-3-6**] Sex: F Service: [**Location (un) **] Note: This discharge summary will briefly summarize the patient's extensive Intensive Care Unit course. HISTORY OF PRESENT ILLNESS: The patient is a 43 year old female with a history of intravenous drug abuse, hepatitis C and alcohol abuse who originally presented to an outside hospital on [**4-10**], with complaints of hematemesis. In the Emergency Room, the patient was noted to be febrile and jaundice with a hematocrit of 16,000 and platelet count of 8,000. The patient was intubated for airway protection and admitted to the Intensive Care Unit, where her seven day course was notable for pancytopenia, hepatic insufficiency, DIC and the discovery of tricuspid valve endocarditis. The patient received large blood product resuscitation and reportedly stopped bleeding from her nasogastric tube. By report, echocardiogram revealed an approximately 5 cm tricuspid vegetation and she had gram positive cocci in clusters on culture. The patient was treated with gentamicin, clindamycin and Vancomycin and she was transferred to [**Hospital6 256**] on [**4-16**]. Here, the patient was found to have Peptostreptococcus and Fusobacterium as the presumed sources of her endocarditis. The patient was treated with penicillin and Flagyl. She remained critically ill on a ventilator and pressors despite optimal antibiotic therapy. She continued to have persistent fevers and repeat echocardiogram revealed 2+ tricuspid regurgitation, positive bubble study and a persistence of the mass. Given the apparent failure of medical management, the patient went to the Operating Room on [**5-3**], for tricuspid valve repair. She underwent a posterior and mid septal resection and bicuspidization repair. The patient tolerated the procedure relatively well and returned to the Intensive Care Unit in moderately stable condition. She subsequently underwent bronchoscopy on [**5-9**]. Both samples of the BAL and pleural fluid revealed no growth. The patient subsequently developed a nosocomial lingula infiltrate presumed secondary to the ventilator and was started on Ceftazidime. The patient was gradually weaned off of pressors and was finally extubated on [**5-13**]. She remained stable and was transferred to the General Medicine Floor on [**5-14**], for continued management of her right-sided endocarditis with septic pulmonary emboli and nosocromial pneumonia. PAST MEDICAL HISTORY: 1. Intravenous drug abuse; 2. Alcohol abuse; 3. Hepatitis C; 4. Cellulitis [**2179-9-27**] secondary to intravenous drug abuse; 5. Multiple traumas and broken bones; 6. Migraine headaches; 7. History of scoliosis. ALLERGIES: Aspirin and Motrin reported to cause the patient to bleed. MEDICATIONS ON TRANSFER TO THE FLOOR: Penicillin G 4 million units intravenously q. 4 hours; Flagyl 500 mg intravenously q. 8; Nystatin swish and swallow; Miconazole powder; Tylenol; Dilantin 100 mg p.o. t.i.d.; Colace 100 mg p.o. b.i.d.; Ceftazidime 1 gm q. 8 hours; Magnesium oxide 400 mg p.o. q.d.; Ativan 2 to 5 mg intravenously q. 2-4 hours; Atrovent and albuterol nebulizer treatments; Percocet 1 to 2 q. 4 to 6 hours prn; Tramadol 50 mcg q.i.d.; Protonix 40 mcg p.o. q.d. SOCIAL HISTORY: The patient smokes one pack per day. She has a history of polysubstance abuse as mentioned above. PHYSICAL EXAMINATION: The patient had a temperature of 97.7, blood pressure 110/68, pulse 79, respiratory rate of 20, she was sating 98% on 4 liters. In general, she is an alert, chronically ill-appearing female who complains of right arm soreness. Her head, eyes, ears, nose and throat examination revealed left pupil is larger than her right but both are reactive. Her extraocular movements are intact. Her neck is supple without lymphadenopathy. She has regular rate and rhythm with II/VI systolic ejection murmur over the lower left sternal border. Her sternal wound is clean and without erythema, swelling or exudate. Respiratory examination, she has coarse rhonchi throughout. Her abdomen is soft, nontender, nondistended with normoactive bowel sounds. No hepatosplenomegaly. Extremities are warm with 1+ lower extremity edema to the mid shins. LABORATORY DATA: The patient had white blood cell count of 13.8, hematocrit 30.8, platelet count of 366. She had a sodium of 138, potassium 3.6, chloride 101, carbon dioxide 31, BUN 5, creatinine .2, glucose 79, calcium 8.0, phosphate 2.8, magnesium 1.3. Radiology studies - Computerized tomography scan of the chest on [**5-8**] revealed cavitary lung nodules and multifocal groundglass opacities, improved from the prior study. Marked progression in alveolar consolidation in the left lower lobe and lingula consistent with superimposed secondary infection. A moderate to large pericardial effusion. Increase in her bilateral pleural effusions, moderate on the right and small on the left. Computerized tomography scan of her abdomen on [**5-9**], the liver, spleen, adrenals and kidneys were unremarkable. She has extensive ascites and anasarca. Chest x-ray from [**5-13**], revealed continued patchy opacities at both bases. Microbiologic data - BAL from [**5-9**], revealed 2+ polys, no organisms and no growth on culture. Pleural fluid [**5-9**], no growth. Blood culture from [**5-9**] and [**5-8**] revealed no growth to date times two sets. Sputum from [**5-7**], revealed rare growth or oropharyngeal Flora. Stool from [**5-7**], Clostridium difficile negative. The catheter tip from [**5-6**], no growth. Urine culture [**5-6**], greater than 100,000 organisms/ml of yeast. HOSPITAL COURSE: The patient is a 43 year old woman with a history of intravenous drug abuse and alcohol abuse admitted with tricuspid valve endocarditis presumed secondary to Peptostreptococcus and Fusobacterium, status post surgical repair who was transferred to the General Medical Floor from the Intensive Care Unit for further management. 1. Infectious disease - Per the Infectious Disease Consult Service, the patient is to be continued on Flagyl and Penicillin to complete a four week course starting on [**3-14**]. In addition, given her likely ventilator associated pneumonia, she will be continued on Ceftazidime to complete a two week course, ending on [**5-23**]. Of note, the patient will need a repeat computerized tomography scan of her chest in several months to evaluate for any interval change in the status of her lungs. 2. Pulmonary - The patient was continued on nebulizer treatments as needed. Her oxygen saturations remained relatively stable, ranging from approximately 95 to 97% on 4 liters of oxygen by nasal cannula. The patient received chest physical therapy as well as an aggressive pulmonary toilet. As mentioned previously, the patient will require a repeat computerized tomography scan of her chest to evaluate for any interval change. 3. Heme - The patient was noted to have anemia. She had her stools guaiaced and they were negative for evidence of blood. The patient's iron studies were most consistent with anemia of chronic disease. 4. Pain - The patient complained repeatedly of nonspecific diffuse pain. Given her drug abuse history, it was very difficult to ascertain whether the pain was real or not. We thus attempted to minimize her narcotic use. We provided her with Tramadol and Percocet as needed for pain. Despite this, the patient continued to request pain medications. Of note, the patient has indicated a desire to attend a detoxification facility. We recommend that at the end of her rehabilitation stay, the patient be evaluated for potential placement in an inpatient detoxification facility. 5. Disposition - The patient was seen by the physical therapy service, who felt that she would benefit from an acute rehabilitation stay to return to her previous level of functioning. By the time the patient arrived to the General Medical Floor her condition was significantly improved. Our focus became finding an appropriate facility for her. DISCHARGE DIAGNOSIS: 1. Tricuspid valve endocarditis, status post posterior and mid septal resection and bicuspidization repair. 2. Septic pulmonary emboli. 3. Ventilatory associated pneumonia. 4. Intravenous drug abuse. 5. Hepatitis C. DISCHARGE MEDICATIONS: 1. Penicillin G 4 million units intravenous q. 4 hours for a four week course starting [**5-14**] 2. Flagyl 500 mg intravenously q. 8 for a four week course starting [**5-13**] 3. Ceftazidime 1 gm intravenously q. 8 hours for a course completed on [**5-21**] 4. Magnesium oxide 400 mg p.o. q.d. 5. Atrovent/Albuterol nebulizers as needed 6. Percocet 1 to 2 q. 4-6 hours prn 7. Tramadol 50 mcg p.o. q.i.d. prn 8. Protonix 40 mg p.o. q.d. 9. Heparin 5000 units subcutaneously q. 12 hours [**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D. [**MD Number(1) 7855**] Dictated By:[**Last Name (NamePattern1) 11732**] MEDQUIST36 D: [**2180-5-17**] 16:54 T: [**2180-5-17**] 17:17 JOB#: [**Job Number 40283**]

[ "421.0", "997.3", "038.49", "745.5", "486", "391.1", "284.8", "518.81", "070.54" ]

icd9cm

[ [ [] ] ]

[ "39.61", "33.24", "96.6", "38.93", "35.14", "96.04", "35.71", "96.72", "34.91" ]

icd9pcs

[ [ [] ] ]

8394, 9154

8149, 8371

5727, 8128

3468, 5709

287, 2531

2554, 3328

3345, 3445

59,496

158,272

54355

Discharge summary

report

Admission Date: [**2107-2-23**] Discharge Date: [**2107-3-2**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1171**] Chief Complaint: SOB Major Surgical or Invasive Procedure: None History of Present Illness: The pt is a 84y/o F with a PMH of traumatic subarachnoid hemorrhage, prior CVA with persistent speech, mixed valvular disease with preserved systolic function, DM type 2, and atrial fibrillation presenting with hypoxia. ? increased L sided weakness from baseline. The patient was at her nursing home when her daughter visited her at ~5pm on [**2107-2-23**]. She noticed her mother [**Name (NI) 15598**]'t look well while she was being fed by one of the staff. The daughter noticed that her face was angled funny and her mother complained of right sided face pain. A few minutes later the breathing became difficult. The daughter stated that she then asked that her mother be transferred to the hospital. . The patient was recently admitted to [**Hospital1 18**] on [**2107-2-3**] with hypoxia, secondary to aspiration event. She required a MICU stay with intubation due to worsening respiratory distress in the setting of mucus plugging and lobar collapse treated with bronchoscopy. Her presentation was ultimately attributed to aspiration pneumonitis. At that time she also was noted to have AF with intermittent RVR, and CHF with bilateral pleural effusions. She was treated with aggressive diuresis, with subsequent metabolic alkalosis diamox was added to furosemide. Diltiazem was titrated, as well as Digoxin for HR control and low dose lisinopril was also started. She was also treated with a 7 course of ceftazidime for Pseudomonal UTI. . In the ED, initial vitals were T:98.2 HR: 72 BP: 139/59 RR: 24 O2Sat:100%NRB. Patient received Vancomycin 1gm IV, Zosyn, lasix 40mg IV X2. CXR demonstrated pulmonary edema and b/l effusions. She was intially placed on CPAP given hypoxia and tachypnea however following lasix she was weaned to 5L NC. Vitals prior to transfer to medical floor: T 100.0, BP 132/46, HR 70, RR 29, 100% on 5L NC. . On arrival to the medical floor, the patient was sleeping peacefully and looked at her baseline according to her daughter. The patient's daughter stated that normally her mother does not walk and rarely gets out of bed. She is able to have a conversation but occasionally appears to hallucinate and talk to people not in the room. Past Medical History: Atrial fibrillation CVA [**3-/2097**] CAD DM Breast cancer s/p lumpectomy and chemotherapy Cholecystectomy [**7-/2098**] Social History: lives with daughter, husband passed away 1 month ago, no tobacco, occasional EtOH, no drugs. Family History: Non-contributory Physical Exam: VS - 97.8 125/56 82 20 100%5L Gen: WDWN elderly female in NAD. sleeping comfortably HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP mid thyroid cartilage. CV: PMI located in 5th intercostal space, midclavicular line. irreg irreg, normal S1, S2. 2/6 systolic murmur at LLSB. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. crackles at bases with upper airway sounds radiating throughout. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: sacral pressure sore. Neuro: A,Ox3. intermittently using profanity and perseverating on questions pupils round and reactive. face symmetric. palate and tongue midline. moving 4 extremities symmetrically. . 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: [**2107-2-23**] 10:22PM LACTATE-2.4* [**2107-2-23**] 10:15PM GLUCOSE-161* UREA N-34* CREAT-1.0 SODIUM-144 POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-28 ANION GAP-16 [**2107-2-23**] 10:15PM estGFR-Using this [**2107-2-23**] 10:15PM CK(CPK)-18* [**2107-2-23**] 10:15PM cTropnT-0.01 [**2107-2-23**] 10:15PM CK-MB-NotDone proBNP-4963* [**2107-2-23**] 10:15PM WBC-10.5 RBC-3.37* HGB-9.5* HCT-31.1* MCV-92 MCH-28.0 MCHC-30.4* RDW-17.1* [**2107-2-23**] 10:15PM PLT COUNT-393 [**2107-2-23**] 10:15PM PT-13.5* PTT-25.3 INR(PT)-1.2* [**2107-2-23**] 10:15PM GRAN CT-8090 Brief Hospital Course: Patient is an 84 year old woman with history of valvular heart disease, traumatic SAH, DM2 and stroke presented with sudden onset shortness of breath and hypoxia with bilateral basilar infiltrates associated with nonspecific lateral ST-T changes w/o fever or sputum production. pt was found to be in heart failure and treated accordingly. There was also question of PNA, for which she rec'd antibiotics. . #. Acute Diastolic Heart Failure/Valvular Heart Disease Patient presented with Dig effect on EKG, with Dig level of 1.8. Patient continued on reduced dose of 0.125mg daily. Lasix drip was stared with fluids goals of [**12-30**].5 negative daily. Diuresis was achieved and the patient was discharged on Lasix 40mg [**Hospital1 **]. Diltiazam was stopped and replaced with Carvedilol, with good results. The pt was discharged on this Lasix Carvedilol combination after good diuresis and resolution of SOB. Patient required 30mEq KCl on average per day in setting of lasix and was therefore discharged on K-Dur supplementation with recommended CHM7 check at rehab one week after discharge. . #. Possible Pneumonia: Concern for possible Aspiration PNA. Patient's oxygen requirement improved dramatically with diuresis. Pt remained afebrile during course. Completed full 5 day course of Azithromycin. . . #. L sided Weakness - per report the patient has a history of CVA in [**2096**] with residual left sided weakness. Likely consistent with recrudescence of old deficits. Family, per nursing reports, feels that patient at her baseline. Patient remained at baseline. . #. CAD - Chest pain free on presentation, nonspecific ischemic ECG changes, likely dig effect. CE neg x 2. Aspirin and statin were continued and Digoxin was continued 125mg alternating with 250mcg QD. - Continue aspirin and statin . # AF: Pt. Well rate controlled. Not on warfarin given recent traumatic SAH in [**Month (only) 1096**]. Pt continued on Coreg and Digoxin. . # DM: Held Metformin and Glyburide, con't SSI. Resumed outpatient regimen on discharge. . #. Depression/Dementia: Stable. Continue outpatient regimen of fluoxetine and mirtazapine. . #. FEN: During recent hospitalization was evaluated by speech and [**Last Name (LF) **], [**First Name3 (LF) **] continue nectar thick liquids and ground consistency solids. Continue aspiration precautions and supervision during meals. Patient has been refusing POs intermittently. [**Month (only) 116**] have to consider G tube in future. . #. Access: R midline, PIV . #. PPx: Continue outpatient omeprazole, heparin SC . #. Code: DNR/DNI status confirmed . #. Dispo: to rehab with f/u with Dr. [**Last Name (STitle) **] in 4 weeks and recommended CHM7 check one week after discharge. . Medications on Admission: Aspirin 81 mg daily Docusate Sodium 100 mg [**Hospital1 **] Multivitamin daily Fluoxetine 20 mg daily Rosuvastatin 10 mg Tablet daily Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H Omeprazole 20 mg daily Metformin 1000mg [**Hospital1 **] Mirtazapine 15 mg Tablet QHS Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS Insulin Lispro sliding scale Digoxin 125 mcg and 250 mcg on alternating days Diltiazem HCl 60 mg Tablet PO QID Ipratropium Bromide neb q6 Acetazolamide 250 mg PO Q12H Lisinopril 5 mg DAILY (Daily). Lasix 40 mg Tablet daily Glyburide 5 mg Tablet daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 2. Docusate Sodium Oral 3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Multivitamins Oral 6. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): 125 mcg and 250mcg on alternating days. 11. Ipratropium Bromide 0.02 % Solution Sig: [**12-31**] Inhalation Q6H (every 6 hours) as needed. 12. Acetazolamide 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold for SBP under 100. 14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for BP < 90 or HR < 50. 16. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. 17. Insulin Insulin Lispro Sliding Scale as per standard 18. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 19. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 9475**] Care Center - [**Location (un) 3146**] Discharge Diagnosis: Primary - Acute on Chronic diastolic heart failure - Hypertension Secondary - Aortic stenosis Discharge Condition: Afebrile, vitals stable. Discharge Instructions: You were hospitalized because you had shortness of breath. After a thorough work up, you were found to be in heart failure. As a result, fluid was removed from you and subsequently your shortness of breath improved. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction to 2.0 L. . Medications as recommended below. . Follow-up as recommended below. . Please return immediately for any chest pain, unremitting SOB or fever. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] within 4 weeks of discharge. You will need to call ([**Telephone/Fax (1) 5455**] to set up this appointment. Completed by:[**2107-3-2**]

[ "427.31", "250.00", "507.0", "511.9", "V10.3", "438.89", "728.89", "428.33", "424.1", "707.05", "401.9", "428.0", "707.22" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9226, 9312

4435, 7159

273, 280

9450, 9477

3837, 4412

10015, 10206

2752, 2770

7779, 9203

9333, 9429

7185, 7756

9501, 9992

2785, 3818

230, 235

308, 2480

2502, 2625

2641, 2736

54,609

173,864

42775

Discharge summary

report

Admission Date: [**2173-2-26**] Discharge Date: [**2173-3-3**] Date of Birth: [**2107-8-7**] Sex: M Service: MEDICINE Allergies: Lipitor / Augmentin / Golytely Attending:[**First Name3 (LF) 983**] Chief Complaint: Dyspnea, tachypnea Major Surgical or Invasive Procedure: Endotracheal intubation History of Present Illness: The patient is a 65-year-old man with a history of MI one year ago and placement of a biventricular IC device who presented to [**Hospital3 **] earlier today with acute dysnea and tachypnea. At [**Hospital1 **], the patient was seen to have bilateral pulmonary edema and was started on levofloxacin and a nitroglycerin drip. Cardiology at [**Hospital1 18**] was consulted, and the patient was transferred for further work-up after he required intubation at [**Hospital3 **]. . In the ED, Cardiology was again consulted on arrival of patient. Again, inferior Q waves seen and a new right bundle branch block and T waves in anterior leads. Overall, however, they felt that the patient's clinical picture was more consistent with sepsis than with acute coronary syndrome. The patient's antibiotics were expanded from levofloxacin to vancomycin, levofloxacin, and flagyl. In addition to possible pneumonia, the patient's urinalysis was suggestive of infection. The patient's blood pressures were in the 90s SBP, so his nitro gtt was discontinued. Because his blood pressure did not recover, the patient was given a right IJ and started on norepinephrine. Before transfer to the MICU, the patient was sent for a CTPA, given concern for pulmonary embolism. . On arrival to the MICU, the patient is intubated and sedated. Past Medical History: 1. Ischemic Cardiomyopathy with EF 15-20% range. Class III/IV heart failure. 2. STEMI (syncope x 2, sob) [**2172-8-4**] s/p cath with 3VD requiring IABP. S/p CABG x 3 (LIMA-LAD, SVG-OM2, SVG-rPDA) and MV repair (28 mm [**Last Name (un) 3843**]-[**Known firstname **] full annuloplasty ring) c/b mediastinal bleeding and taken back to OR for re-exploration x 2. Prolonged hospitalization/rehab and finally returned home in late [**Month (only) 1096**]. Patient states stil has grounding wire in his chest that they were unable to remove and just cut below his skin. 3. [**Hospital1 **] ER [**2172-11-29**] with left sided weakness and vertigo. CT negative. US without significant carotid stenosis. Mildly hypotensive and medications Spironolactone and Lasix were discontinued. (?) CVA. 4. Atrial Fibrillation: patient denies 5. Hx of NSVT 6. Recent admit to [**Hospital1 **] with presyncope, orthostasis, and volume depletion 7. Hyperlipidemia- intolerant of statins 8. Vertigo - improved on Meclezine which he has stopped 9. Spina Bifida 10.Hemorrhoids/rectal bleeding 11.Hiatal Hernia 12.Chronic constipation/retained stool by colonoscopy/fecal incontinence 13.Sinusitis/allergic rhinitis 14.Asthma 15.Bone spur 16.Dislocated shoulder 17.BPH 18.Eczema 19.Sleep Apnea- does not tolerate CPAP 20.Insomnia 21.Blepharitis 22.Neck surgery to remove a "gland" Social History: Lives alone. He does not have any children. He has very supportive neighbors. Retired from the post office. He does not use any assistive devices. Family History: Father died of stroke at age 84. Mother died at age 65 with asthma. Brother had MI and CABG at age 46. Physical Exam: Admission physical exam: General: Intubated, sedated HEENT: Sclera anicteric, intubated, pinpoint pupils but reactive Neck: supple, JVP not readily apprehended Chest: Midsternal scar CV: Regular rate and rhythm, normal S1 + S2, quiet heart sounds, no murmurs auscultated Lungs: Mild crackles at bases to anterior auscultation, diminished sounds on lower left Abdomen: soft, non-tender, non-distended, bowel sounds present GU: Foley in place Ext: Warm, well perfused, 2+ pulses. Neuro: Intubated, sedated, unable to follow commands. Pertinent Results: Admission labs: [**2173-2-26**] 01:41AM BLOOD WBC-10.2 RBC-4.42* Hgb-12.9* Hct-40.9 MCV-93 MCH-29.1 MCHC-31.5 RDW-13.4 Plt Ct-454* [**2173-2-26**] 05:13AM BLOOD Glucose-110* UreaN-20 Creat-1.2 Na-136 K-4.1 Cl-109* HCO3-18* AnGap-13 [**2173-2-26**] 05:13AM BLOOD Digoxin-1.3 [**2173-2-26**] 01:43AM BLOOD Glucose-121* Lactate-2.4* Na-138 K-4.2 Cl-108 calHCO3-16* . Discharge labs: [**2173-3-3**] 05:15AM BLOOD WBC-5.5 RBC-4.16* Hgb-11.8* Hct-37.1* MCV-89 MCH-28.5 MCHC-31.9 RDW-13.5 Plt Ct-422 [**2173-3-3**] 05:15AM BLOOD Glucose-109* UreaN-17 Creat-0.7 Na-139 K-3.6 Cl-106 HCO3-21* AnGap-16 . Microbiology: Rapid respiratory virus screen and culture [**2173-3-1**]: POSITIVE FOR PARAINFLUENZA TYPE 3 . Imaging: . CTA chest [**2173-2-26**]: 1. Right lower lobe pneumonia with a small parapneumonic effusion. 2. Complete collapse of the left lower lobe and moderate left pleural effusion. While the left lower lobe collapse may be due to mucoid mpaction, the presence of mediastinal and hilar lymphadenopathy raises suspicion for an endobronchial or hilar lesion. However, this is difficult to assess at this point since the patient's lymphadenopathy may be reactive and due to pneumonia. As a result, a dedicated Chest CT with contrast is recommended after resolution of pneumonia for further characterization. Furthermore, consultation with pulmonology is recommended as the presence of an endobronchial lesion needs to be excluded. 3. No evidence of pulmonary embolism or acute aortic injury. Brief Hospital Course: 65 yo M with CAD s/p MI and CABG, CHF (EF 15%), BiV ICD, initially admitted to the MICU with pneumonia, complicated by septic shock. The patient was treated with antibiotics, with resolution of his respiratory failure and septic physiology. Antibiotics were narrowed to just levofloxacin, and the patient was discharged with a plan for a total 8-day course. . # Community-acquired pneumonia, complicated by septic shock and respiratory failure: The patiented presented with shortness of breath. He developed respiratory failure and hypotension, requiring intubation and norepinephrine gtt. Chest imaging showed right lower lobe pneumonia and complete collapse of the left lower lobe. The patient was treated with vancomycin, cefepime, levofloxacin, with improvement in his hemodynamics and respiratory status. Cultures were notable only for parainfluenza. Cefepime was stopped on [**3-1**]. Vancomycin was stopped on [**3-2**]. The patient was discharged on [**3-3**], with a plan to treat with levofloxacin until [**3-7**]. . # Respiratory failure: This was felt to be multifactorial, with pneumonia, sepsis, pleural effusion, and pulmonary edema all contributed. The patient was intubated for several days before being extubated on [**2-28**]. Over the next several days, he was weaned off of supplemental oxygen and discharged on room air. . # Septic shock: The patient developed hypotension, requiring norepinephrine gtt. He blood pressure eventually stabilized, and he was transitioned out of the ICU. . # Left lower lobar collapse: CTA showd left lower lobar collapse and mediastinal/hilar lymphadenopathy, concerning for an endobronchial or hilar lesion. Repeat chest CT following resolution of the pneumonia, and pulmonary consultation were recommended. The inpatient team spoke with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], the patient's PCP, [**Name10 (NameIs) 4120**] the need to follow up on this finding. The possibility of a tumor and the need for prompt follow-up was also discussed with the patient. . # Ischemic cardiomyopathy, with chronic systolic heart failure: EF is 15-20%. Initially there was concern for pulmonary edema, and the patient was started on a nitroglycerin gtt. Subsequently, the patient became hypotensive, at which point nitroglycerin was stopped, fluids were given, and the patient was started on a norepinephrine gtt. As the patient improved, he was diuresed. Carvedilol was restarted and lisinopril was added. The patient was discharged with close cardiology and primary care follow-up. . # CAD s/p CABG: MI was ruled out with serial enzymes. Aspirin was continued. . # History of atrial fibrillation: The patient remained in sinus rhythm. His cardiology was contact[**Name (NI) **] to discuss the patient's stroke risk, and consideration of anticoagulation. Together with cardiology, the decision was made to hold off on anticoagulation for now and have this addressed at the time of outpatient follow-up. . # Urinary retention/Benign prostatic hypertrophy: The patient's Foley catheter was removed upon transfer out of the ICU. However, the patient developed urinary retention, requiring replacement of the Foley. The patient was treated with finasteride and tamsulosin. The Foley was removed on the day of discharge, and the patient was able to void, with a 130 cc residual on bladder scanning. The patient was discharged on Avodart and tamsulosin. Outpatient urology follow-up was arranged. Medications on Admission: Lasix 20mg pantoprazole 40mg tamsulosin 0.4 mg lisinopril 5mg Potassium 10meq spironolactone 25mg Discharge Medications: 1. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 days. Disp:*4 Tablet(s)* Refills:*0* 2. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. 4. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO once a day. 5. nasocort AQ Sig: Two (2) sprays Nasal once a day. 6. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 8. cyclosporine 0.05 % Dropperette Sig: One (1) drop each eye Ophthalmic twice a day. 9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO once a day. 15. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2* 16. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 17. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:*1 box* Refills:*0* Discharge Disposition: Home With Service Facility: guardian healthcare Discharge Diagnosis: Primary: 1. Septic shock. 2. Community-acquired pneumonia, complicated by septic shock. 3. Left lower lung lobe collapse. 4. Bilateral pleural effusions 5. Urinary retention . Secondary: 1. Chronic systolic heart failure 2. Atrial fibrillation 3. Coronary artery disease 4. Hyperlipidemia 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 low blood pressure and respiratory failure. You needed a breathing tube. You were found to have pneumonia and were treated with antibiotics. As you improved, you were able to breath without the breathing tube, and your blood pressure improved as well. . You are being discharged on an antibiotic called levofloxacin that you can take by mouth for the next 4 days. It is very important that you complete your course of antibiotics. . While in the hospital, you had a CT scan of your chest, which showed collapse of the left lower lobe of your lung, as well as some enlarged lymph nodes in your chest. This could be related to your pneumonia, but it could also indicate a lung tumor. For this reason, you will need repeat CT scan of your chest when your pnemonia has resolved. We have discussed this with Dr. [**First Name (STitle) **], and you should speak with her about this at the time of follow-up. . You had some difficulty urinating, requiring replacement of your Foley catheter. You were started on a medication called Flomax (tamsulosin). You are being discharged on the Flomax, as well as the Avodart, which you were taking perviously. We have arranged for you to follow up with your urologist. Your Foley cathether was removed prior to discharge, and you were able to urinate, although you had some mild retention of urine. If you are unable to urinate, you need to go to the emergency room. . We added a new medication called lisinopril for your heart failure. We spoke with your cardiologist and your primary care doctor, who will further adjust your medications as needed. Due to started lisinopril, you will need to have your kidney function and electrolytes checked in [**11-30**] weeks. Please discuss this with your primary care doctor. . There are some changes to your medications: 1. Start lisinopril 2.5 mg daily (for blood pressure and heart failure) 2. Start Flomax (tamsulosin) 0.4 mg at bedtime (for urinary problems) 3. Continue levofloxacin (antibiotic for pneumonia) for 4 more days. 4. Start ipratropium (nebulizer) every 6 hours as needed for wheezing or shortness of breath. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Name: [**Last Name (LF) 1877**],[**First Name3 (LF) 539**] E. Location: [**Hospital3 **] INTERNAL MEDICINE Address: [**Street Address(2) 4472**] [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**] Phone: [**Telephone/Fax (1) 4475**] Appointment: MONDAY [**3-8**] AT 4:30PM **You also said you had an appointment with your primary care doctor tomorrow [**2173-3-3**] at 10:45 a.m. Please call your PCP tomorrow morning to clarify when your appoinment is. **Please speak with your PCP about the need for a referral to a Pulmonologist within 2-4 weeks of your discharge from the hospital.** . Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Specialty: CARDIOLOGY Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 4474**] Phone: [**Telephone/Fax (1) 4475**] Appointment: FRIDAY [**4-9**] AT 2:15PM . Name: [**Last Name (LF) **], [**Name8 (MD) **] MD Specialty: UROLOGY Location: [**Hospital **] HOSPITAL Address: [**Location (un) **], STE#2206 [**Location (un) **], [**Numeric Identifier 60377**] Phone: [**Telephone/Fax (1) 92423**] Appointment: TUESDAY [**3-11**] AT 9AM

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icd9cm

[ [ [] ] ]

[ "33.24", "38.97", "96.71" ]

icd9pcs

[ [ [] ] ]

10643, 10693

5430, 8896

307, 332

11026, 11026

3911, 3911

13426, 14721

3238, 3343

9044, 10620

10714, 11005

8922, 9021

11177, 12977

4291, 5407

3383, 3892

13006, 13403

249, 269

360, 1676

3927, 4275

11041, 11153

1698, 3057

3073, 3222

48,827

153,312

35540

Discharge summary

report

Admission Date: [**2132-4-29**] Discharge Date: [**2132-5-4**] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 618**] Chief Complaint: Transfer from OSH for ICH Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname **] is a [**Age over 90 **] year old right handed male presenting with R hemisphere ICH. He was last seen or heard from two days ago (Sunday). Today his grandson went to his home to do some repairs and found that he did not answer the door. He was later found minimally conscious on the floor next to his chair. He was taken to [**Hospital3 3583**] where a head CT revealed a large R hemisphere hemorrhage with intraventricular spread. At [**Hospital1 46**] he was apparently able speak in simple phrases to his grandson. [**Name (NI) **] was given vec, succ, fentanyl, midaz, mannitol, fosphenytoin, intubated and started on a propofol drip and med-flighted to [**Hospital1 18**]. Repeat Head CT revealed decrompression of the R frontal component of the hemorrhage in the R frontal subarachnoid space. ROS: unable to offer. previously well, living alone and fully independent per family. Past Medical History: Atrial Fibrillation- not on coumadin Hypertension BPH Social History: lives alone, several children, grandchildren in the area. distant smoking history. no known ETOH or drug abuse. Family History: noncontributory Physical Exam: T 97, BP 140/70, HR 72, R 22, 100% CMV Gen- critically ill, intubated and sedated HEENT- NCAT, slight Subcutaneous emphysema, anicteric sclera Neck- in hard C-collar. CV- distant sounds, RRR, no mrg Pulm- diffuse rhonci Abd- soft, nd, BS+ Extrem- friable skin, however no CCE Neurologic Exam: MS- unresponsive to voice or deep noxious stim CN- slight anisocoria, R pupil 2mm and minimally reactive to light, L pupil 1.5mm and minimally reacitve to light. Intact corneal reflex. No blink to threat. Unable to test oculocephalics. + gag. Motor/sensory- internally rotates LLE to nailbed pressure. Withdraws RLE in plane of bed. Withdraws R arm. No movement to noxious on L arm to noxious. plantar response down on left, up on right. Pertinent Results: [**2132-4-29**] 11:40PM TYPE-ART PO2-430* PCO2-39 PH-7.40 TOTAL CO2-25 BASE XS-0 [**2132-4-29**] 08:47PM SODIUM-146* [**2132-4-29**] 08:47PM OSMOLAL-312* [**2132-4-29**] 02:21PM COMMENTS-GREEN TOP [**2132-4-29**] 02:21PM LACTATE-1.8 [**2132-4-29**] 02:10PM GLUCOSE-223* UREA N-38* CREAT-1.7* SODIUM-141 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-24 ANION GAP-17 [**2132-4-29**] 02:10PM estGFR-Using this [**2132-4-29**] 02:10PM CK(CPK)-3751* [**2132-4-29**] 02:10PM cTropnT-0.07* [**2132-4-29**] 02:10PM CK-MB-25* MB INDX-0.7 [**2132-4-29**] 02:10PM ALBUMIN-3.6 CALCIUM-9.0 PHOSPHATE-3.7 MAGNESIUM-2.5 [**2132-4-29**] 02:10PM WBC-21.1* RBC-5.27 HGB-16.9 HCT-47.1 MCV-89 MCH-32.0 MCHC-35.8* RDW-13.6 [**2132-4-29**] 02:10PM NEUTS-82.8* LYMPHS-9.7* MONOS-7.3 EOS-0.1 BASOS-0.1 [**2132-4-29**] 02:10PM PLT COUNT-218 [**2132-4-29**] 02:10PM PT-13.1 PTT-29.6 INR(PT)-1.1 [**2132-4-29**] 02:10PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021 [**2132-4-29**] 02:10PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-100 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2132-4-29**] 02:10PM URINE RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-NONE EPI-0 [**2132-4-29**] 02:10PM URINE HYALINE-[**6-25**]* [**2132-4-29**] 02:10PM URINE AMORPH-MOD Brief Hospital Course: [**Age over 90 **]yo RHM with large multifocal R hemisphere hemorrhage, consistent with amyloid angiopathy. CT head showed two large right frontal intraparenchymal hemorrhages. largest measures 6.2 x 2.7 cm with an adjacent smaller hemorrhage measuring 2.1 x 1.9 cm. 3 mm leftward shift of the septum pellucidum. right frontal subarrachnoid hemrrhage measuring up to 2.4 cm. Intraventricular extension of hemorrhage in the lateral ventricles bilaterally. Because of the severity of the case and patient's will, family opted to make him comfort measures only and patient expired on [**2132-5-4**]. Medications on Admission: Aspirin 81mg daily Diltiazem 240mg daily Finasteride 5mg daily Digoxin 0.125mg daily Metoprolol 50mg daily Lasix 20mg daily Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired - respiratory arrest secondary to extensive right intraparenchymal hemorrhage Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Completed by:[**2132-5-5**]

[ "486", "431", "V45.72", "E888.8", "V45.79", "V10.05", "427.31", "276.0", "277.39", "781.94", "852.05", "600.00", "401.9", "799.1" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

4358, 4367

3554, 4152

287, 293

4496, 4505

2249, 3531

4561, 4690

1460, 1478

4326, 4335

4388, 4475

4178, 4303

4529, 4538

1493, 1770

222, 249

321, 1236

1787, 2230

1258, 1314

1330, 1444

6,477

134,927

23052

Discharge summary

report

Admission Date: [**2191-2-18**] Discharge Date: [**2191-2-23**] Date of Birth: [**2117-9-21**] Sex: M Service: MEDICINE Allergies: Gentamicin Attending:[**First Name3 (LF) 1145**] Chief Complaint: status post cardiopulmonary arrest Major Surgical or Invasive Procedure: Endotracheal intubation History of Present Illness: 73m DM2, HTN, h/o endocarditis, presents with hypotension, status post cardiopulmonary arrest. Pt was noted by wife to have been appearing somewhat ill for the last several days. On day of admission, pt was being helped upstairs by wife when he suddenly slumped over and was unresponsive. Found by EMS to be pulseless and nonshockable rhythm. Intubated in the field. Wife unable to stop the resuscitation effort in the field despite the DNR/DNI paper work. Started on multiple pressors on arrival, but unresponsive with fixed pupils. Past Medical History: Type 2 Diabetes Myasthenia [**Last Name (un) **] s/p thymectomy Endocarditis in [**2189**] Hypertension Toe Amputation Chronic lower back pain s/p lumbar sacral injection Social History: Lives with wife, does not smoke. Drinks two EtOH drinks a night. Family History: Non contributory Physical Exam: Pulseless, apneic. No breath sounds, no heart sounds. Patient pronounced dead on hospital day number 6. Pertinent Results: [**2191-2-18**] 09:30PM PT-14.9* PTT-40.9* INR(PT)-1.4 [**2191-2-18**] 08:58PM PH-7.20* [**2191-2-18**] 08:58PM GLUCOSE-186* LACTATE-10.0* NA+-139 K+-4.4 CL--102 TCO2-13* [**2191-2-18**] 08:58PM HGB-12.0* calcHCT-36 O2 SAT-89 CARBOXYHB-0.4 MET HGB-0.6 [**2191-2-18**] 08:58PM freeCa-1.00* [**2191-2-18**] 08:50PM GLUCOSE-193* UREA N-41* CREAT-1.5* SODIUM-144 POTASSIUM-4.9 CHLORIDE-104 TOTAL CO2-6* ANION GAP-39* [**2191-2-18**] 08:50PM ALT(SGPT)-55* AST(SGOT)-102* LD(LDH)-422* ALK PHOS-106 AMYLASE-67 TOT BILI-0.4 [**2191-2-18**] 08:50PM LIPASE-19 [**2191-2-18**] 08:50PM CK-MB-3 cTropnT-0.08* [**2191-2-18**] 08:50PM ALBUMIN-3.1* CALCIUM-8.6 PHOSPHATE-6.9* MAGNESIUM-2.2 [**2191-2-18**] 08:50PM ASA-NEG ETHANOL-79* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2191-2-18**] 08:50PM URINE HOURS-RANDOM [**2191-2-18**] 08:50PM URINE GR HOLD-HOLD [**2191-2-18**] 08:50PM WBC-24.9* RBC-3.88* HGB-12.1* HCT-37.2* MCV-96 MCH-31.3 MCHC-32.7 RDW-13.5 [**2191-2-18**] 08:50PM PLT COUNT-408 [**2191-2-18**] 08:50PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.021 [**2191-2-18**] 08:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2191-2-18**] 08:45PM PO2-340* PCO2-30* PH-7.15* TOTAL CO2-11* BASE XS--17 INTUBATED-INTUBATED EEG This is an abnormal portable EEG due to the presence of occasional, low amplitude sharp and slow waves seen both synchronously and independently over the parieto-occipital regions, more so on the right. This finding suggests cortical dysfunction in these areas and may lead to an increased risk for seizure activity. In addition, the background rhythm was noted to be slow and disorganized reaching the 5 Hz theta frequency range with occasional generalized delta frequency slowing. This finding suggests deep, midline subcortical dysfunction and is consistent with a moderate encephalopathy. ECHO Study Date of [**2191-2-21**] The left and right atrium are moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated with thinning/akinesis of the basal half of the inferior wall and hypokinesis of the basal half of the inferolateral wall. The remaining segments contract well [Intrinsic left ventricular systolic function may be more depressed given the severity of valvular regurgitation.] The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The aortic root is mildly dilated. The aortic valve leaflets are moderately thickened but no aortic stenosis or aortic regurgitation is seen. The mitral valve leaflets are moderately thickened and supporting apparatus is fibrotic/calcified, but no mitral stenosis is suggested. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. MRI Brain: No acute areas of brain ischemia are [**Date Range 12681**]. Tiny low signal intensity region seen along the ventral surface of the medulla, possibly acute versus chronic blood products. Clinical correlation is necessary and followup imaging is likely advisable (see above report). This report was given to medicine resident in charge of the patient on [**2191-2-22**] at 2:15 p.m. Brief Hospital Course: 73 yo man with MMP here s/p cardiopulm arrest. Following multiple discussions with family regarding patient's intubation and resuscitation despite legal documentation, it was decided initially that patient should be evaluated by neurology to assist with determination of anoxic brain injury and recovery of function as well as echocardiogram to determine whether or not a massive myocardial infarction may have occurred. Echocardiogram revealed no significant akinesis or dyskinesis, however, significant MR [**First Name (Titles) **] [**Last Name (Titles) 12681**], and inferiolateral hypokinesis. MRI brain did not identify significant evidence of diffuse anoxic brain injury, however EEG revealed spike and slow wave suggesting anoxic encephalopathy and seizure activity. Patient was started on phenytoin. Despite weaning of sedating medications, patient continued to have only minimal neurological function, and family decided on hospital day 6 to extubate and withdraw care. Patient was pronounced dead on [**2191-2-23**] with family at bedside. Medications on Admission: Prednisone 10 Zestril 40 Cadizem 360 Pravachol 20 Insulin NPH and regular ASA Fosamax Calcium Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Status post cardiopulmonary arrest Probable anoxic brain injury Myocardial infarction Discharge Condition: Expired Discharge Instructions: NA Followup Instructions: NA

[ "396.0", "348.1", "358.00", "250.00", "410.91", "V58.65", "518.84", "401.9", "724.2" ]

icd9cm

[ [ [] ] ]

[ "00.17", "96.72" ]

icd9pcs

[ [ [] ] ]

6011, 6020

4782, 5839

306, 331

6149, 6158

1349, 4759

6209, 6214

1190, 1208

5983, 5988

6041, 6128

5865, 5960

6182, 6186

1223, 1330

232, 268

359, 897

919, 1091

1107, 1174

4,718

107,655

19700

Discharge summary

report

Admission Date: [**2169-6-14**] Discharge Date: [**2169-7-7**] Date of Birth: [**2096-6-30**] Sex: F Service: [**Last Name (un) **] HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old female, who was transferred from an outside hospital for an infected pancreatic pseudocyst. She has a history of gallstone pancreatitis for which she came to [**Hospital1 **] Hospital in [**2169-4-10**]. In [**Month (only) 547**], she developed a pseudocyst, which was felt to have decreased in size on followup CT. However, the patient presented to her primary care physician [**Last Name (NamePattern4) **] [**2169-6-12**] with a complaint of 10 days of malaise and decreased appetite. She was admitted to the outside hospital on [**6-13**] and started on IV antibiotics. A preliminary CT scan report showed "evidence of pancreatic abscess with pockets of air." On admission to [**Hospital1 **] Hospital, the patient reports feeling weak and tired without a desire to eat. She denies abdominal pain, shortness of breath, chest pain, nausea, vomiting, diarrhea, constipation, or fevers. PAST MEDICAL HISTORY: Hypertension. Non-insulin dependent-diabetes mellitus. Gallstone pancreatitis (03/[**2169**]). Remote history of seizure disorder. Renal cell carcinoma ([**2167**]). COPD. PAST SURGICAL HISTORY: Status post left nephrectomy in [**2167**]. Status post appendectomy at age 16. ALLERGIES: No known drug allergies. MEDICATIONS AT HOME: 1. Dilantin 200 mg b.i.d. 2. Lopressor 50 mg b.i.d. 3. Metformin 500 mg q.d. 4. Protonix. PHYSICAL EXAMINATION: Vital signs - 99.2, 79, 140/60, 14, and 94 percent on room air. General - pale, tired. Heart - regular, rate, and rhythm without murmur, gallop, or rub. Pulmonary - CTAB. Abdomen - soft, obese, nontender, nondistended, no rigidity, no rebound, no guarding, no masses palpable, abdomen full. Extremities - no clubbing, cyanosis, minimal pitting edema. LABORATORIES FROM OUTSIDE HOSPITAL: Sodium 137, potassium 4.4, chloride 104, bicarbonate 20.6, BUN 22, creatinine 1.0, glucose 90, calcium 7.7, magnesium 1.8, phosphorus 2.7. White blood cells 14.6, hematocrit 27, platelets 41. AST 50, ALT 69, total bilirubin 0.6, alkaline phosphatase 229, amylase 69, lipase 210. Dilantin 1.3. HOSPITAL COURSE: The patient was admitted for a pancreatic abscess status post gallstone pancreatitis, made NPO, placed on IV fluids, and Zosyn was started. Blood cultures were also drawn, which were subsequently negative. The patient's laboratories on admission included a hematocrit of 24.4, for which the patient received 1 unit of packed red blood cells. The patient also had Dilantin levels drawn, which were initially 2.9. She was loaded with Dilantin, and over the course of the remainder of her hospital stay she remained in the 10-20 range, the last Dilantin level being 12.8 on [**7-1**]. On hospital day three, the patient received a PICC line and began receiving TPN with the expectation that she would go to the OR once her nutritional status was improved. The patient continued to be afebrile with Zosyn and TPN until she was taken to the OR on hospital day 11 ([**2169-6-20**]). The patient's hematocrit had remained stable up to that point and was 28.8 on the day of her surgery. On [**2169-6-20**], the patient underwent an open cholecystectomy along with open drainage of the pancreatic pseudocyst. Patient tolerated the procedure well. Please see dictated OP note for further details. Intraoperatively, two swabs and a tissue culture were taken and sent. They later came back with vancomycin-sensitive Enterococcus. The patient was presumptively treated with Zosyn and fluconazole postoperatively. In the course of the operation, the patient required a total of 10 liters of fluid and due to low urine output postoperatively, the patient continued to require ongoing fluids to maintain her urine output. The patient, on the day of the operation, positive 6 liters on postoperative day one. On postoperative day two, the fluid requirement decreased and the patient was net 0 fluids. Because of the large quantity of fluids required, patient was kept intubated and sedated for several days. On postoperative day two with a hematocrit of 27, the patient received 1 unit of packed red blood cells. This brought her hematocrit only up to 29. On postoperative day three, the patient's TPN was restarted and the patient was begun on vancomycin along with Zosyn and fluconazole. The patient's white blood cell count postoperatively had been elevated up to 23.6, but by [**6-25**] was down to 12.7, and continued to trend down from there until two days prior to discharge when her white blood cell count had leveled out at 7.5. On postoperative day three, diuresis was begun and the patient was a net negative 2 liters for the day. This level of diuresis continued to through postoperative day nine as the patient remained in the ICU, that is to say she lost approximately 1.5 to 2 liters per day during that period. On [**6-26**], a routine rectal swab showed vancomycin-resistant Enterococcus in the patient's rectum, however, it was not thought that the patient required any change in her antibiotics, so she was kept on Zosyn and vancomycin, the fluconazole haven been stopped a few days prior. The patient continued to be difficult to extubate and on [**7-1**], underwent a bronch with a culture that was ultimately negative. On postoperative day 13, the patient's wound was noted to have a bit of cellulitis on the right and was therefore opened and packed with wet-to-dry dressing. The patient was finally extubated on postoperative day 13 after a very long vent wean. Wound cultures were sent from the open wound and later came back as showing rare growth of gram- positive cocci. Patient was continued on her TPN and tube feeds were begun. However, those tube feeds were relatively short-lived and the patient was started on a clear diet on postoperative day 14 and sent to a floor. Also all of her oral medications were restarted. She continued, however, on TPN. The other side of the patient's wound was later opened and packed wet-to-dry so that both sides were ultimately opened on the patient's discharge. The two sides were opened approximately 3 cm with the left side draining a greater amount of fluid than the right. On the floor, the patient did well, tolerated her clear diet, and was advanced to a regular diet without difficulty. Her TPN was ended on the day of her discharge, and a repeat surveillance CT was obtained. Please see the CT report for details. The patient was discharged to a rehab facility on [**2169-7-7**]. DISCHARGE CONDITION: Good. DISPOSITION: To rehab facility. DISCHARGE DIAGNOSES: Hypertension. Non-insulin dependent-diabetes mellitus. Gallstone pancreatitis (03/[**2169**]). Remote history of seizure disorder. Renal cell carcinoma ([**2167**]). Chronic obstructive pulmonary disease. Status post debridement and drainage of pancreatic pseudocyst. DISCHARGE MEDICATIONS: 1. Dilantin 100 mg p.o. t.i.d. 2. Metoprolol 25 mg p.o. b.i.d. 3. Glucophage XR 500 mg p.o. q.d. 4. Protonix 40 mg p.o. q.d. 5. Albuterol inhaler 1-2 puffs q.6h. 6. Atrovent inhaler two puffs q.6h. 7. Insulin-sliding scale. FOLLOW-UP PLANS: The patient is to call Dr.[**Name (NI) 2829**] office to arrange a follow-up appointment in [**2-10**] weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 11162**] Dictated By:[**Last Name (NamePattern1) 15517**] MEDQUIST36 D: [**2169-7-6**] 12:46:51 T: [**2169-7-6**] 13:23:36 Job#: [**Job Number 53292**]

[ "577.2", "E878.8", "250.00", "682.2", "574.10", "998.59", "401.9", "496", "780.39" ]

icd9cm

[ [ [] ] ]

[ "99.04", "96.6", "38.93", "51.22", "99.15", "33.24", "52.4" ]

icd9pcs

[ [ [] ] ]

6692, 6733

6755, 7030

7053, 7279

2295, 6670

1473, 1565

1332, 1452

1588, 2277

7297, 7680

182, 1107

1130, 1308

50,793

112,639

39924

Discharge summary

report

Admission Date: [**2131-6-23**] Discharge Date: [**2131-6-28**] Date of Birth: [**2045-2-7**] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 4691**] Chief Complaint: Abdominal pain. Major Surgical or Invasive Procedure: [**6-23**] Exploratory laparotomy and adhesiolysis for small-bowel obstruction. History of Present Illness: Mrs.[**Doctor Last Name 7517**] is a 86 year-old female who presents to the [**Hospital1 18**] ER after awaking that morning with lower abdominal pain. Patient was otherwise in her usual state of health until day of admission when she noted bilateral lower abdominal pain. The pain was initially dull and gradually worsened over the course of the day. This was associated with several episodes of nausea and vomiting. She had not been passing flatus, however has passed loose stool. Past Medical History: Hypertension. Social History: Lives alone in [**Hospital1 **]. Widowed 11 years ago, no children. No tobacco/ETOH. Niece lives in [**Location 2199**]. Family History: father died of throat cancer, mother of uterine cancer, no h/o stroke Physical Exam: On admission: Physical Exam: Vitals: T 97.8 P 67 BP 146/63 RR 18 O2 97%RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, mild lower abdominal distention, tender to palpation in the lower abdomen, no rebound or guarding, no palpable masses or hernias Ext: No LE edema, LE warm and well perfused On discharge: Vitals T 98.5 po, HR 59, SBP 138/54, RR 16, sat 95% RA. Gen: AAO x 3, extremely hard of hearing. Card: S1, S2. Regular with occasional premature beats. Pulses 2+ in UE, LE. Lungs: Posteriorly clear bilaterally, diminished in right lower lobe. Abd: Active BS. Soft, non-tender, non-distended. Vertical mid-line incision closed with staples. CDI. No exudate or drainage noted. GI: Voiding. Extrem: Cool, well perfused. Pertinent Results: [**2131-6-22**] 06:10PM BLOOD WBC-12.9* RBC-4.02* Hgb-11.6* Hct-33.8* MCV-84 MCH-28.8 MCHC-34.2 RDW-13.9 Plt Ct-311 [**2131-6-22**] 06:10PM BLOOD Neuts-88.0* Lymphs-8.7* Monos-2.6 Eos-0.3 Baso-0.3 [**2131-6-22**] 06:10PM BLOOD Plt Ct-311 [**2131-6-22**] 09:18PM BLOOD PT-10.3 PTT-29.6 INR(PT)-0.9 [**2131-6-22**] 06:10PM BLOOD Glucose-124* UreaN-24* Creat-1.1 Na-135 K-5.0 Cl-98 HCO3-30 AnGap-12 [**2131-6-22**] 06:10PM BLOOD ALT-13 AST-19 AlkPhos-57 TotBili-0.6 [**2131-6-25**] 06:05AM BLOOD CK(CPK)-387* [**2131-6-25**] 02:30PM BLOOD CK(CPK)-413* [**2131-6-25**] 06:05AM BLOOD CK-MB-7 cTropnT-0.04* [**2131-6-25**] 02:30PM BLOOD cTropnT-0.04* [**2131-6-22**] 06:10PM BLOOD Albumin-4.2 Calcium-9.6 Phos-3.9 Mg-2.0 [**2131-6-22**] 06:08PM BLOOD Lactate-1.2 [**2131-6-26**] 03:11AM BLOOD WBC-10.7 RBC-3.31* Hgb-9.7* Hct-27.9* MCV-84 MCH-29.2 MCHC-34.6 RDW-13.8 Plt Ct-268 [**2131-6-27**] 05:55AM BLOOD Glucose-127* UreaN-36* Creat-0.8 Na-136 K-3.7 Cl-102 HCO3-28 AnGap-10 [**2131-6-27**] 05:55AM BLOOD Calcium-8.0* Phos-2.7 Mg-2.3 [**2131-6-22**] CT A/P with contrast 1. Findings concerning for closed loop obstruction with evidence of mesenteric edema and ascites. Early bowel ischemia cannot be excluded. 2. Fat-containing abdominal wall hernia. [**2131-6-25**] ECG Atrial fibrillation with rapid ventricular response. Non-specific ST-T wave abnormalities, likely secondary to rate. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 156 0 70 286/454 0 -1 157 [**2131-6-25**] CXR (AP) No previous images. Cardiac silhouette is mildly enlarged. There is engorgement of ill-defined pulmonary vessels, consistent with the clinical impression of congestive failure. Poor definition of the hemidiaphragms is consistent with bilateral effusions and compressive atelectasis at the bases. [**2131-6-26**] CXR (AP) In comparison with the study of [**6-25**], there is increased haziness of the right hemithorax, suggesting worsening layering pleural effusion. Again there is evidence of congestive failure with bilateral effusions and basilar atelectatic changes. Mild enlargement of the cardiac silhouette persists. Brief Hospital Course: Mrs.[**Doctor Last Name 7517**] was admitted to [**Hospital1 18**] on [**6-23**] with complaints of abdominal pain. Imaging revealed a closed-loop bowel obstruction. She was kept NPO and IV fluids were initiated. An NG tube was inserted for decompression of her stomach. While NPO, the patient's hypertension was treated with IV lopressor and hydralazine as needed. She was taken to the OR on [**6-23**] where she underwent a exploratory laparotomy with lysis of adhesions. Please see the operative report for further details. Ms. [**Name13 (STitle) **] was transferred from the surgical floor to the ICU on [**6-25**] for atrial fibrillation w/ RVR. She was placed on a diltiazem infusion to control her heart rate. The patient was loaded with digoxin and given a dose of IV furosemide during the time of rapid atrial fibrillation. Serial troponin levels where checked, all of which were within normal limits, and an ECG was obtained. It was also discovered that she had a urinary tract infection (positive UA) with an elevated serum WBC, so she was started on a short course of ciproflaxacin. She returned to the floor on [**2131-6-26**] and placed on telemetry monitoring. Her rhythm was noted to be in sinus rhythm. She was hypertensive to the 180s systolic with IV Lopressor. Additional IV anti-hypertensives were initiated. When she was able to tolerate POs, she was placed on her home anti-hypertensive medications Amlodipine 10mg PO QD and Labetalol 200mg [**Hospital1 **] PO which provided adequate blood pressure control. She was placed on a regular diet which she tolerated well. On [**2131-6-27**], Mrs.[**Doctor Last Name 87796**] diet was advanced to regular. She tolerated the oral intake well, had positive flatus and began moving her bowels. IV fluids and foley catheter were discontinued as well. Physical therapy was ordered for evaluation of her function status prior to discharge. At the time of discharge, Mrs.[**Doctor Last Name 7517**] is hemodynamically stable and afebrile. Telemetry shows normal sinus rhythm with occasional PACs and PVCs. Her leukocytosis has resolved. She has minimal abdominal pain and has required little analgesia. Her entire home medication regime has been resumed. Follow-up appointments have been made with her PCP and the ACS service. Medications on Admission: Miralax, MVI, Colace 100'', Labetalol 200'', Ranitidine 150'', Amlodipine 10', Norvasc 5', Xalatan 0.005% eye drops daily, ASA 81', losartan potassium 50''. Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Labetalol 200 mg PO BID 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 6. Ranitidine 150 mg PO BID 7. Hydrocortisone Cream 0.5% 1 Appl TP TID:PRN itching Place thin layer sparingly to back as needed for itching. 8. Losartan Potassium 50 mg PO BID 9. Polyethylene Glycol 17 g PO DAILY 10. Acetaminophen 325-650 mg PO Q6H:PRN pain Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA of [**Location (un) 5087**] Discharge Diagnosis: Closed loop obstruction Intermittent rapid atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to [**Hospital1 69**] with abdominal pain. Imaging showed that you suffered from a small bowel obstruction. You were taken to the operating room on [**6-23**] where you underwent a lysis of adhesions. Since that time, our bowel function has returned and you have resumed a regular diet. Please follow with your PCP as well as in the [**Hospital 2536**] clinic at the appointment scheduled for you below. Your staples will be removed at this appointment. ACTIVITY: o Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. You may climb stairs. o You may go outside, but avoid traveling long distances until you see your [**Hospital 5059**] at your next visit. o Don't lift more than 20-25 lbs for 4-6 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. o You may start some light exercise when you feel comfortable. o You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. o Heavy exercise may be started after 6 weeks, but use common sense and go slowly at first. HOW YOU [**Month (only) **] FEEL: o You may feel weak or "washed out" for 6 weeks. You might want to nap often. Simple tasks may exhaust you. o You may have a sore throat because of a tube that was in your throat during surgery. o You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. o You could have a poor appetite for a while. Food may seem unappealing. o All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your [**Month (only) 5059**]. YOUR INCISION: o Your incision may be slightly red around the staples. This is normal. o You may gently wash away dried material around your incision. It is normal to feel a firm ridge along the incision. This will go away. o Avoid direct sun exposure to the incision area. o Do not use any ointments on the incision unless you were told otherwise. o You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your [**Month (only) 5059**]. o You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. o Over the next 6-12 months, your incision will fade and become less prominent. YOUR BOWELS: If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. If you go 48 hours without a bowel movement, or have pain moving the bowels, call your [**Month (only) 5059**]. PAIN MANAGEMENT: It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your [**Name2 (NI) 5059**]. You will receive a prescription from your [**Name2 (NI) 5059**] for pain medicine to take by mouth. It is important to take this medicine as directied. Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. Your pain medicine will work better if you take it before your pain gets too severe. Talk with your [**Name2 (NI) 5059**] about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your [**Name2 (NI) 5059**] has said its okay. If you are experiencing no pain, it is okay to skip a dose of pain medicine. Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the folloiwng, please contact your [**Name2 (NI) 5059**]: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. If you have any questions about what medicine to take or not to take, please call your [**Name2 (NI) 5059**]. DANGER SIGNS: Please call your [**Name2 (NI) 5059**] if you develop: - worsening abdominal pain - sharp or severe pain that lasts several hours - temperature of 101 degrees or higher - severe diarrhea - vomiting - redness around the incision that is spreading - increased swelling around the incision - excessive bruising around the incision - cloudy fluid coming from the wound - bright red blood or foul smelling discharge coming from the wound - an increase in drainage from the wound Followup Instructions: Department: Primary Care Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10543**] When: Wednesday [**2131-7-11**] at 1:15 PM. Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**] Phone: [**Telephone/Fax (1) 4475**] Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: THURSDAY [**2131-7-19**] at 2:15 PM With: Dr. [**Last Name (STitle) **] [**Name (STitle) **] in the ACUTE CARE CLINIC Phone: [**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2131-6-28**]

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Discharge summary

report

Admission Date: [**2120-1-10**] Discharge Date: [**2120-1-11**] Date of Birth: [**2068-7-6**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2736**] Chief Complaint: CC:[**Hospital1 76627**] Major Surgical or Invasive Procedure: 1. Successful PTCA and stenting of the mid RCA with a Taxus drug eluting stent. 2. Successful direct stenting of the 2nd OM with a Cypher drug eluting stent. History of Present Illness: 51 yoF w/ a h/o HTN, HL, DM, 36 pk year smoking history, and Fam Hx of [**Hospital **] transferred to [**Hospital1 **] for an elective cath for unstable angina. She had an IMI in [**2117**] which was treated with RCA bare mental stent (prox and distal) at [**Hospital1 **]. In [**6-29**] she again had an NSTEMI tx w/ Lcx bare metal stenting and 1 month later presented with ACS- underwent a cath and had a instent restenosis of the RCA stents placed 2 years earlier, taxus stent was placed. LCx was patent at that time. Few weeks prior to admission she had a recurrence of her anginal symptoms which are her typical symptoms of tightness in her mid-sternal region and chest pain radiating to her axilla bilaterally. No N/V/diaphoresis. Associated with dyspnea. These symptoms are non-exertional. She underwent a cardiac catheterization which revealed a 90% stenosis of the RCA in between the two previously placed stents and an OM2 stent with a 60% instent restenosis. EF 60%. She was transferred from [**Hospital1 **] following her diagnostic cath for intervention. Here at the [**Hospital1 **] her RCA was stented with a 3.0 taxus DES and LCx was stented with a 2.5 Cypher DES. . Initially upon groin insertion she had a vagal episode and required 1 of atropine. Subsequently immediately post sheath pull her SBP dropped 100 to 70 systolic and her HR dropped to the 40s. She responded to 2 of atropine, again she responded to this. She had at that time also complained of lower abdominal pain and back pain, her foley was draining well and her physical exam performed by the NP at that time revealed a benign abdominal exam. 2 hours post sheath pull her husband and her noticed bleeding externally at her femoral insertion site, she called the nurse who applied pressure, the patient's blood pressure dropped initially to systolic of 90 and subsequently to a nadir of 70 and was nauseas and vomiting,She was given 2 of atropine without response and the code team noticed she became somnolent with an altered mental status. She was started on fluids and 10mcg/kg of dopamine with a response in her BP to the systolics in the 170s and HR in the 170s. Her EKG at the time was sinus tach rate of 135 with 2mm STE in the inferior leads and ST depressions in I and aVL. Dopamine was d/c'd and her HR came down, repeat EKGs at a HR of 100 revealed a resolution of her EKG changes. . Past Medical History: PAST MEDICAL HISTORY: CAD s/p multiple stents, MI in [**2117**] RCA stent, MI in [**6-29**] s/p LCx stent, [**7-29**] ACS and taxus stent to RCA HTN Hyperlipidemia DM 2 PVD known subclavian stenosis, plan for iliac intervention in [**1-29**] Rheumatoid arthritis . Cardiac Risk Factors: + Diabetes, + Dyslipidemia, + Hypertension . Cardiac History: no h/o CABG, no PPM . [**7-29**] [**Hospital1 **] cath LMCA normal LAD normal LCx stent in mid portion w/ 20% stenosis distal aspect RCA 60% proximal stenosis (near ostia), diffuse 30% in stent stenosis in proximal stent, new 90% stenosis in Mid RCA, 70% instent stenosis in distal RCA stent. 60-70 % stenosis of native RCA distal to stents. *Taxus in distal RCA stent, and another overlaping taxus in distal stent, another taxus in mid RCA stenosis and a proximal taxus stent. . [**2120-1-9**] Cath [**Hospital1 **]: LMCA normal LAD normal Lcx OM2 stent in OM2 has 60% diffuse instent restenosis RCA ostial stent patent, prox RCA diffuse 20% instent restenosis, mid RCA stents widely patent, in gap b/w mid and distal RCA 90% stenosis, distal RCA normal. Social History: SOCIAL and FAMILY HISTORY: 36 pack years history of smoking- quit [**7-29**]. Works full time as warranty administrator at a car dealership. Denies ETOH use, lives w/ her husband and has 3 children. Family History: father had an MI at 46, mother alive. Two sisters no CAD, Brother w/ DM. Physical Exam: PHYSICAL EXAMINATION: VS: T 97.4 , BP 134/89 , HR 96 , RR 16 , O2 99 % on 5L NC Gen: NAD, AOx3, somnolent obese female HEENT: NCAT. JVP 8 but difficult to assess given body habitus. PERRL 6mm down to 2mm bilaterally. EOMI, Sclera anicteric. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. slight petechial hemorrhages of hard palate. CV: nl S1 and S2 w/ physiologic splitting of S2, [**1-28**] cresc decresc murmur best heard @ USB w/o radiation. Chest: anteriorly clear bilaterally Abd: Obese, soft, slightly distended. Ext: No c/c/e. distal pulses intact. Groin sites no bruits or hematomas, dressing w/ slight blood ooze, no active bleeding. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: [**2120-1-11**] 03:05PM BLOOD WBC-9.3 RBC-3.65* Hgb-12.1 Hct-35.8* MCV-98 MCH-33.1* MCHC-33.8 RDW-13.0 Plt Ct-377 [**2120-1-11**] 05:17AM BLOOD Glucose-120* UreaN-7 Creat-0.6 Na-139 K-4.1 Cl-104 HCO3-28 AnGap-11 . [**2120-1-10**] 05:17PM BLOOD CK(CPK)-49 [**2120-1-11**] 01:40AM BLOOD CK(CPK)-147* [**2120-1-11**] 05:17AM BLOOD CK(CPK)-163* [**2120-1-10**] 05:17PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2120-1-11**] 01:40AM BLOOD CK-MB-6 cTropnT-0.01 [**2120-1-11**] 05:17AM BLOOD CK-MB-7 cTropnT-0.01 . [**2120-1-10**] 07:21PM BLOOD %HbA1c-7.7* [**2120-1-11**] 05:17AM BLOOD Triglyc-82 HDL-38 CHOL/HD-3.1 LDLcalc-65 [**2120-1-10**] 05:14PM BLOOD Glucose-146* Lactate-2.2* Na-137 K-4.8 Cl-102 . [**2120-1-10**] 09:39PM BLOOD Type-ART pO2-137* pCO2-51* pH-7.40 calTCO2-33* Base XS-5 [**2120-1-10**] 05:14PM BLOOD Type-[**Last Name (un) **] pO2-134* pCO2-42 pH-7.38 calTCO2-26 Base XS-0 . Cardiac cath [**1-10**] BRIEF HISTORY: 51 year old female with a history of coronary artery disease s/p PCI to the RCA in [**2119-6-23**] with four Taxus drug eluting stents (3x12mm; 3x20mm; 2.5x12mm; 2.5x8mm Prox to distal) along with PCI to the LCX with a bare metal stent in [**2119-7-23**]. Pt complained of increasing pain with exertion. Diagnostic catheterization at outside hospital demonstrated a 90% lesion between the proximal and mid RCA lesion along with 70% in-stent restenosis of the first obtuse marginal bare metal stent. Pt transferred for planned intervention. . INDICATIONS FOR CATHETERIZATION: 1. Two vessel coronary artery disease 2. Planned intervention to the RCA and OM . PROCEDURE: Left Heart Catheterization: was performed by percutaneous entry of the left femoral artery, using a 6 French right [**Last Name (un) 2699**] catheter, advanced to the ascending aorta through a 6 French introducing sheath. Coronary Angiography: was performed in multiple projections using a 6 French XB and a 6 French JR4 catheter, with manual contrast injections. Percutaneous coronary revascularization was performed using placement of drug-eluting stent(s). Percutaneous coronary revascularization of an additional vessel was performed using placement of drug-eluting stent(s). Conscious Sedation: was provided with appropriate monitoring performed by a member of the nursing staff. . **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM **RIGHT CORONARY 1) PROXIMAL RCA DIFFUSELY DISEASED 40 2) MID RCA DIFFUSELY DISEASED 90 2A) ACUTE MARGINAL NORMAL 3) DISTAL RCA DIFFUSELY DISEASED 30 4) R-PDA NORMAL 4A) R-POST-LAT NORMAL 4B) R-LV NORMAL . **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM **LEFT CORONARY 5) LEFT MAIN NORMAL 12) PROXIMAL CX NORMAL 13) MID CX DIFFUSELY DISEASED 13A) DISTAL CX DIFFUSELY DISEASED 14) OBTUSE MARGINAL-1 NORMAL 15) OBTUSE MARGINAL-2 DIFFUSELY DISEASED 70 . PTCA COMMENTS: . Initial angiography demonstrated a diffusely diseased right coronary artery with a 90% de [**Last Name (un) 11083**] lesion between the proximal and mid RCA Taxus drug eluting stents. We decided to treat this lesion with PTCA and stenting. Aspirin, Clopidogrel and Bivalrudin were started prophylactically. Multiple guide catheters were used to engage the RCA including the JR 4, [**Doctor Last Name **] 0.75 and Hockey stick. The hockey stick engaged the artery. A prowater guide wire crossed the lesion with minimal difficulty. The lesion was predilated with a Maverick (2.5x9mm) balloon inflated to 8 atm. We were unable to pass a Taxus stent into the ostium of the RCA due to poor guide support. The Hockey Stick guide was exchanged for a [**Doctor Last Name **] 1 guide which provided adequate support throughout the case. The [**Doctor Last Name **] 1 guide provided enough support to to deliver a Taxus (3x20mm) drug eluting stent which was deployed at 16 atm. The stent was then postdilated with a Quantum Maverick (3x15mm) balloon inflated to 18 atm. We next dilated up the two proximal stents from her previous intervention with the the Quantum Maverick (18 atm three times). Final angiography demonstrated no angiographically apparent dissection, no residual stenosis and TIMI III flow throughout the vessel. . We next turned our attention to the 70% in-stent restenosis of the 2nd obtuse marginal. A 6F XB provided excellent support throughout the procedure. A prowater guidewire crossed the lesion with minimal difficulty. We treated the lesion with an IC bolus of Nitroglycerine (200 mcg). The lesion was then predilated with a Cypher (2.5x18mm) drug eluting stent. Final angiography demonstrated no angiographically apparent dissection, no residual stenosis and TIMI III flow throughout the vessel. The patient left the cath lab in stable condition and free of angina. . COMMENTS: 1. Selective coronary angiography of this right dominant system demonstrated two (2) vessel coronary artery disease. The right coronary artery demonstrated diffuse disease throughout the vessel including a 90% de [**Last Name (un) 11083**] lesion between the proximal and mid RCA stents. All four stents were patent with some in-stent restenosis in the proximal/ostial and mid RCA. The left main was a small vessel with mild luminal irregularities. The left anterior descending artery was not well engaged/visualized (See diagnostic catheter). The left circumflex was a small caliber vessel with mild diffuse throughout including a 70% in-stent stenosis in the OM 2 bare metal stent. 2. LV ventriculography was deferred. 3. Successful PTCA and stenting of the RCA with a Taxus (3x20mm) drug eluting stent which overlapped the two previous which was postdilated with a Quantum Maverick 3.0 mm balloon. Final angiography demonstrated no angiograpahically apparent dissection, no residual stenosis and TIMI III flow throughout the vessel (See PTCA comments). 4. Successful direct stenting of the 2nd Obtuse Marginal with a Cypher (2.5x18mm) drug eluting stent. Final angiography demonstrateed no angiographically apparent dissetion, no residual stenosis and TIII flow (See PTCA comments). . FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Successful PTCA and stenting of the mid RCA with a Taxus drug eluting stent. 3. Successful direct stenting of the 2nd OM with a Cypher drug eluting stent. . [**1-10**]: CXR . IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: Pulmonary vasculature is normal. Lungs are clear and there is no pleural effusion or pneumothorax. Cardiac silhouette is borderline enlarged and the azygos vein is distended consistent with elevated central venous pressure or volume. EKG [**2120-1-10**] pre cath NSR, rate 53, nl axis and intervals and q and inverted T in III. Post cath EKG unchanged. EKG during period of tachycardia, post dopamine for hypotension: sinus w/ rate 150 and 2-3mm STE in inverior leads as well as ST depressions in I and aVL. Brief Hospital Course: 51 yoF w/ a PMHx significant for CAD, s/p 2 MIs and multiple stent placement, who was transferred to [**Hospital1 18**] for therapeutic cardiac cath for unstable angina. Pt has stent placement in RCA and OM2. During the removal of the cath in the lab pt developed hypotension and bradycardia in response to administering groin pressure. Pt was given atropine x 3, w/ resolution of symptoms. Two hours after angiosheath removal pt developed oozing. Pt again developed hypotension with groin pressure. Pt was noted to have mental status changes at this time. An ABG was done which showed an elevated level of CO2. A code was called and pt was intubated briefly. With in minutes she self extubated and was breathing with out distress, able to protect her airway. She was started on dopamine and transferred to CCU for further management. She was weaned off of dopamine with in hours. She had no more episodes of hypotension or bradycardia during her hospital stay. She was afebrile, blood cultures and urine cultures were drawn and both negative for bacterial growth. Her hematocrit was stable during her hospital stay. No significant hematoma was noted on exam. Pt was felt to be low probability for an RP bleed based on exam and stable hct. . It was felt that her symptoms of hypotension and bradycardia were secondary to a vasovagal response caused by groin pressure. The mental status changes and hypercapnea the patient experienced were transient and associated with atropine administration. Pt remained stable for 24 hours before discharge. The only medication changed at discharge was norvasc 10mg. This medication was held at discharge. . PROBLEMS: . #.Coronary Artery Disease: 4 stents in RCA and 1 in LCx prior to cath on [**1-10**]- on this date rec'd two additional stents. She has a LMCA w/ mild luminal irregularites and of small caliber, Lcx 70% instent restenosis in the BMS placed in a large OM2 branch and RCA w/ 90% stenosis between two stents. Two DES placed in these two lesions. Pt with unstable angina w/ multiple prior stents w/ a Taxus (3x20mm) drug eluting stent which overlapped the two previous which stents in the right coronary artery. A Cypher (2.5x18mm) drug eluting stent was placed in the 2nd obtuse marginal artery. Continue plavix 75mg daily, continue ASA 325mg daily . #Hypotension / bradycardia- 3 episodes of hypotension / bradycardia all in the setting of groin manipulation. The first two responded to atropine and the third responded to dopamine. All three episodes were thought to be [**2-24**] to vasovagal response occurring w/ groin pressure. No signs of bleed or infection. .. # mental status - initially s/p code sluggish in response, but follows commands, moving extremities spontaneously, pupils equal reactive to light 5->2mm, delta MS felt [**2-24**] atropine. Pt had an elevated WBC count that normalized after 1 day. ABG revealed slightly elevated co2, but mental status continued to improve. Resolved by discharge. Urine culture, blood culture and chest xray were all negative. . # DM: on Lantus and glyburide at home. Pt was continued on lantus during her hospital stay. Pt discharged on home lantus and glyburide dose. Patients renal function had a Cr of 0.8, but received dye load of 330ml of cardiac cath on [**1-10**]. HgBA1C 7.7% . # PVD f/u w/ Dr. [**First Name (STitle) **] [**First Name (STitle) **] in early [**Month (only) 404**] for PVD and intervention. . # HTN: Patient discharged on lisinopril 10mg daily and lopressor 25mg po bid. Patients blood pressure was a systolic of 110 at discharge. Home Norvasc dose of 10mg was held at discharge. . # PVD f/u w/ Dr. [**First Name (STitle) **] [**First Name (STitle) **] in early [**Month (only) 404**] for PVD and intervention. . Follow up: Please follow up with Dr. [**Last Name (STitle) **] in the first week of [**Month (only) 404**]. Please follow up in clinic with Dr. [**Last Name (STitle) 1295**]. You are scheduled for an apointment for [**2-9**] at 1130am at [**Location (un) 76628**], Ma. Please call if you have to reschedule [**Telephone/Fax (1) 6256**]. Please follow up on Thursday [**1-18**] at 11:15pm with Dr. [**Last Name (STitle) 37063**] [**Street Address(2) 76629**] in [**Location (un) 29789**]. If you can not keep this appointment please call to reschedule at [**Telephone/Fax (1) 37064**]. Medications on Admission: Aspirin 325mg daily plavix 75 mg daily protonix 40mg daily colace 100mg daily metoprolol 25mg [**Hospital1 **] glyburide 5 mg daily lantus 40 units daily simvastatin 40mg daily norvasc 10mg daily lisinopril 10m daily. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: CAD Hypotension secondary diagnosis: HTN Hyperlipidemia DM PVD Discharge Condition: Stable, normal blood pressure and heart rate. Chest pain free. Discharge Instructions: Mrs. [**Known lastname **] you were admitted to the hospital for elective cardiac cath. You had two stents placed during your cardiac cath. A Taxus (3x20mm) drug eluting stent which overlapped the two previous which stents in your right coronary artery and a was postdilated with a Quantum Maverick 3.0 mm balloon was placed. A Cypher (2.5x18mm) drug eluting stent was placed in your 2nd obtuse marginal artery. During your cath procedure you developed some hypotension "low blood pressure" and bradycardia "low heart rate." It was felt that the drop in your blood pressure was due to a "vasovagal response", where pressure applied to major blood vessels can cause a reflex drop in blood pressure and heart rate. You received some medications that helped raise your heart rate and blood pressure. . You then were then sent to the hospital floor. Later after the removal of your angiocath from your groin, you developed groin bleeding. Pressure was placed on your groin to stop the bleeding and you again dropped your blood pressure and developed a confused mental status. We again think that the blood pressure drop was secondary to the pressure placed on your groin, another "vasovagal episode" You were confused during this time period and it was noted that the carbon dioxide levels in your blood had elevated. We believe this confusion and elevated carbon dioxide levels was caused by the atropine you received earlier to raise your heart rate. You were briefly intubated to support your airway. Then extubated. You had no more similar episodes of hypotension during your hospital stay. Your RBC counts stayed relatively stable during your hospitalization making us think that it was not a bleed that caused your low BP. Your blood and urine cultures did not show any bacterial growth, making an infection a less likely cause for your blood pressure drop. We restarted your home medications. Aspirin 325mg daily plavix 75 mg daily protonix 40mg daily colace 100mg daily metoprolol 25mg [**Hospital1 **] glyburide 5 mg daily lantus 40 units daily simvastatin 40mg daily lisinopril 10m daily. The only medication we stopped temporarily was your Norvasc. We wanted to you to have a couple of days of normal blood pressure before restarting your novasc 10mg. You discharged w/ no more episodes of low blood pressure or low heart rate. Take ASA and Plavix daily uninterrupted, for prevention of stent thrombosis. Stopping these medications may result in a heart attack . Please follow up with your primary care physician with in the next 1-2 weeks. . If you develop dizziness, chest pain, SOB, arm pain, worsened swelling in your groin or any overall worsening in your condition please go to the emergency room immediately. . Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in the first week of [**Month (only) 404**]. Please follow up in clinic with Dr. [**Last Name (STitle) 1295**]. You are scheduled for an apointment for [**2-9**] at 1130am at [**Location 76628**], Ma. Please call if you have to reschedule [**Telephone/Fax (1) 6256**]. Please follow up on Thursday [**1-18**] at 11:15pm with Dr. [**Last Name (STitle) 37063**] [**Street Address(2) 76629**] in [**Location (un) 29789**]. If you can not keep this appointment please call to reschedule at [**Telephone/Fax (1) 37064**].

[ "272.4", "401.9", "250.00", "458.29", "411.1", "443.9", "414.01", "714.0", "427.89", "V58.67" ]

icd9cm

[ [ [] ] ]

[ "36.07", "00.41", "00.66", "88.56", "00.46", "96.04", "37.22" ]

icd9pcs

[ [ [] ] ]

16616, 16622

12011, 15759

338, 498

16749, 16814

5099, 6571

19597, 20171

4270, 4344

16643, 16643

16373, 16593

11186, 11988

16838, 19574

4359, 4359

15771, 16347

4381, 5080

6604, 11169

275, 300

526, 2907

16700, 16728

16662, 16679

2951, 4037

4053, 4064

30,075

144,615

30670

Discharge summary

report

Admission Date: [**2110-8-5**] Discharge Date: [**2110-10-30**] Date of Birth: [**2041-5-21**] Sex: M Service: CARDIOTHORACIC Allergies: Ativan Attending:[**First Name3 (LF) 2969**] Chief Complaint: Carcinoma of the distal esophagus Major Surgical or Invasive Procedure: [**2110-8-5**] 1. Bronchoscopy 2. Attempted transhiatal esophagectomy with conversion to Ivor-[**Doctor Last Name **] transthoracic esophagectomy 3. Feeding jejunostomy 4. Pyloromyotomy [**2110-8-7**] Bronchoscopy [**2110-8-20**] 1. Bronchoscopy 2. Esophagogastroduodenoscopy 3. Exploratory thoracotomy with drainage of pleural and mediastinal abscesses, revision of esophagogastric anastomosis, reinforced with pericardial thymic flap and total right lung decortication [**2110-8-21**] 1. Exploratory thoracotomy with evacuation of hemothorax 2. Control of bleeding 3. Intercostal muscle flap reinforcement of esophagogastric anastomosis [**2110-8-26**] Flexible bronch with aspiration of secretions [**2110-9-8**] 1. EGD 2. ERCP with unsuccessful stent placement in pancreatic duct due to papilla edema [**2110-9-10**] 1. EGD with esophageal stent placement 2. ERCP with pancreatic duct stent placement [**2110-9-16**] EDG with successful esophageal stent removal [**2110-9-17**] EDG with new esophageal stent placement History of Present Illness: Mr. [**Known lastname **] is a 69-year-old gentleman with multiple prior abdominal procedures including Nissen fundoplication and open cholecystectomy, who presents with biopsy-proven adenocarcinoma of the distal esophagus. Preoperative staging suggested a T2 N0 lesion and given his good performance status he was recommended for primary resection with a decision regarding adjuvant therapy based on true pathologic stage. He agreed to proceed. Dr. [**Last Name (STitle) **] discussed a transhiatal approach given the distal nature of this lesion. His preoperative workup did show that he had a prior Nissen fundoplication which had slipped up into the chest. Past Medical History: 1. Invasive CA of GE junction, Barrett's esoph s/p remote fundoplication (20 yrs ago @[**Hospital1 **]) 2. Open CCK 3. Diverticulitis 4. Benign colon polyps 5. B/L cataracts Family History: non contributory Physical Exam: general: well appearing man in NAD HEENT: unremarkable Cor: RRR S1, S@ ABD: Extrem: no C/C/E neuro: no focal deficits Pertinent Results: IMAGING AS FOLLOWS: [**2110-8-7**]: echo: Conclusions: The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF>75%). The right ventricular cavity is dilated. Right ventricular systolic function is normal. The aortic root is moderately dilated at the sinus level. 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. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is an anterior space which most likely represents a fat pad. Esophageal tissue pathology: [**2110-8-20**] DIAGNOSIS: A. Distal esophagus (A-C): 1. Esophagus segment with gangrenous necrosis and focal bacterial overgrowth. 2. No evidence of malignancy. B. Proximal stomach (D-H): 1. Stomach segment with gangrenous necrosis and bacterial overgrowth. 2. No evidence of malignancy. torso CT scan [**2110-9-1**]: CT OF THE CHEST: The large fluid collection in the right pleural space that extended across the midline into the mediastinum and into the abdominal cavity has decreased in size. Three chest tubes in the right hemithorax are identified and one chest tube on the left is identified. There is fluid seen in bilateral major fissures. The area of ground-glass change in the left upper lobe anterior segment has resolved. There is air present in the extrapleural anterior mediastinal space. Re-identified are multiple lymph nodes within the mediastinum, which are likely reactive. No pulmonary nodules are seen. There is no pericardial effusion. CT OF THE ABDOMEN: Although the study is limited by lack of contrast, the liver, spleen, adrenals appear unremarkable. The peripancreatic fluid has decreased in size. The portocaval fluid is unchanged. A jejunostomy drain is in place. The small bowel and large bowel is unremarkable. Re-demonstrated is stranding and infiltration of the anterior omentum likely secondary to post-op changes. There is no free air. CT OF THE PELVIS: There is a small amount of free fluid in the dependent portion of the pelvis. The rectum, sigmoid, bladder, seminal vesicles, and prostate appear unremarkable. BONE WINDOWS: No evidence of suspicious lytic or sclerotic lesions. IMPRESSION: 1. Interval improvement of right pleural space fluid collection secondary to leak. Small bilateral pleural effusions are visualized status post esophagectomy and gastric pull-up. 2. Small amount of mediastinal/extrapleural air has developed in the left anterior hemithorax. ERCP [**2110-9-7**]: Five spot fluoroscopic images were obtained in the gastroenterology without a radiologist present. Very limited biliary cholangiogram demonstrates a slightly prominent distal CBD with no filling defects. Pancreatic duct cholangiogram demonstrates slightly dilated pancreatic duct without evidence of stricture or filling defects and evidence of active extravasation of contrast noted within the region of the pancreatic body/tail. For further details, please consult the ERCP report available on CareWeb. Torso CT scan [**2110-9-16**]: IMPRESSION: 1. Interval worsening of the esophageal leak adjacent to the right pleural cavity which is drained through right chest tube. 2. Unchanged moderate bilateral atelectatic changes at lung bases, which is more severe on the right side. Small bilateral pleural effusion is unchanged. Extension of inflammation within the right posterior chest wall is also unchanged. 3. Pancreatic stent is in place. Unchanged appearance of peripancreatic edema and small pseudocyst. 4. No intraabdominal or pelvic fluid collection is identified. 5. Small amount of free fluid tracking along the porta hepatis is unchanged. ERCP [**2110-9-17**]: ERCP: Two spot fluoroscopic images were obtained during endoscopy for guidance of procedure without a radiologist present and was subsequently sent for review. The images are limited due to overlying artifact from wires and the patient's hand superimposed over the abdomen. The images demonstrate endoscope within the region of the esophagus with a stent in the upper portion of the esophagus. Per endoscopy report, the stent was removed with a new stent placed successfully. IMPRESSION: Per endoscopy report, a previously placed stent in the upper third of the esophagus was removed and was replaced by a new esophageal stent successfully. CT Torso [**2110-10-28**] 1. Resolution of previously identified periesophageal contrast collection. Slight decrease in amount of periesophageal stranding with interval replacement of esophageal stent which contains debris distally. 2. No significant interval change to bilateral small-to-moderate simple pleural effusions with probable subjacent atelectasis. Medial and lateral components on the right side raise concern for loculation. Remaining right- sided chest tube tip is retracted when compared to prior examination. 3. Persistent peripancreatic inflammatory changes with identification of known leak/small fluid collection and tract anteriorly where the surgical drain now terminates. No evidence of pseudocyst or pancreatic necrosis. 4. Decreased air component within presumed omental infarction. 5. Wall thickening of ascending and proximal transverse colon suggestive of early colitis although evaluation is slightly limited due to lack of contrast progression into the large bowel. Recommend clinical correlation. Labs: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2110-10-30**] 05:11AM 17.4* 2.81* 8.2* 25.7* 92 29.1 31.7 17.3* 696* [**2110-10-29**] 06:32AM 25.1*# 2.95* 8.7* 27.1* 92 29.6 32.2 17.5* 721* [**2110-10-28**] 06:06AM 12.3* 2.58* 7.9* 23.6* 92 30.7 33.6 17.3* 56 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2110-10-30**] 05:11AM 101 17 0.8 136 3.8 101 29 10 Source: Line-picc [**2110-10-29**] 06:32AM 100 12 0.9 133 4.0 97 30 10 [**2110-10-28**] 06:06AM 107* 9 0.6 136 4.1 101 31 8 ENZYMES & BILIRUBIN ALT AST (LDH) AlkPhos Amylase TotBili DirBili IndBili [**2110-10-29**] 06:32AM 12 29 199 213* 84 0.3 [**2110-10-23**] 05:50AM 14 28 210* 58 0.2 Cultures: [**2110-10-29**] 9:19 pm FLUID,OTHER Source: empyema tube fluid. GRAM STAIN (Final [**2110-10-29**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. FLUID CULTURE (Pending): ANAEROBIC CULTURE (Pending [**2110-10-29**] Blood Cultures: pending [**2110-10-24**] 8:02 am STOOL CONSISTENCY: SOFT Source: Stool. CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2110-10-25**]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. [**2110-10-10**] 5:31 pm PLEURAL FLUID GRAM STAIN (Final [**2110-10-10**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. FLUID CULTURE (Final [**2110-10-14**]): KLEBSIELLA PNEUMONIAE. HEAVY GROWTH. Trimethoprim/Sulfa sensitivity testing available on request. ENTEROCOCCUS SP.. MODERATE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. QUANTITATION NOT AVAILABLE. _________________________________________________________ KLEBSIELLA PNEUMONIAE | ENTEROCOCCUS SP. | | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S DAPTOMYCIN------------ S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S MEROPENEM-------------<=0.25 S PENICILLIN------------ 4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- S VANCOMYCIN------------ <=1 S ANAEROBIC CULTURE (Final [**2110-10-14**]): NO ANAEROBES ISOLATED. FUNGAL CULTURE (Final [**2110-10-23**]): [**Female First Name (un) **] ALBICANS. Fluconazole SENSITIVE BY [**Doctor Last Name **]-[**Doctor Last Name **] Brief Hospital Course: Mr. [**Known lastname **] was admitted on [**2110-8-5**] and underwent attempted transhiatal esophagectomy with conversion to Ivor-[**Doctor Last Name **] transthoracic esophagectomy and a feeding jejunostomy. He tolerated the procedure and was transferred to the SICU intubed. His post-operative course was complicated by an anastomotic leak and a pancreatic fistula. Neurological: Pain control was initially achieved with an epidural and dilaudid PCA. He was then transitioned over to roxicet elixir via the J-tube. Cardiovascular: He went into rapid a-fib and was placed on a diltiazem drip in the ICU, which converted him to sinus rhythmn. He was later switched to IV Lopressor which provided adequate rate control. In the ICU his hypotension was managed with fluid boluses rather than vasopressors. Pulmonary: On [**2110-8-20**] he underwent a right thoracotomy, right decortication, and drainage of right chest empyema. On [**2110-8-21**] he underwent an exploratory thoracotomy for evacuation of a hemothorax and control of bleeding. Gastrointestinal: A JP drain was left to drain the abdomen just superior to the pancreas. Tube feeds were started on POD #4 and advanced to goal rate. On POD #15 ([**2110-8-20**]) he was taken to the OR for an esophagogastric leak where he underwent an anastomotic revision. On [**2110-8-21**] during an exploratory thoracotomy, an intercostal muscle flap reinforcement of the esophagogastric anastomosis was performed. On [**2110-9-8**] an EGD showed a chest tube in the esophageal lumen, which was pulled back and an ERCP was performed on the same date and a pancreatic stent was unable to be placed due to papilla edema. On [**2110-9-10**] an esophageal stent was placed via EGD and a pancreatic duct stent was placed via ERCP. A CT scan obtained on [**2110-9-11**] revealed a persistent esophageal leak. On [**2110-9-16**] the esophageal stent was removed via EGD. On [**2110-9-17**] a new esophageal stent was placed via EGD. On POD #57 he passed a bedside swallowing test and was started on clear liquids. On [**2110-10-17**] the esophageal stent was removed via EGD. On [**2110-10-22**] the esophageal stent was replaced and the pancreatic stent was replaced. Genitourinary: Good diuresis with lasix. His renal function remained within normal limits throughout his hospital course. Endocrine: His blood sugars were well controlled with sliding scale insulin. Hematologic: He was started on SQ heparin for DVT prophylaxis. He was transfused 3 units of PRBCs on [**8-5**] for his initial operation and 2 units of FFP on [**2110-8-7**]. Another unit of PRBCs was transfused on [**2110-8-9**] after his hematocrit dropped from 32 to 27. He received 3 units of PRBCs and 4 units of FFP on [**2110-8-20**]. He received 14 units of PRBCs, 6 units of FFP, 1 unit of platelets, and 1 unit of Cryo on [**2110-8-21**]. Infectious Disease: An ID consult was obtained and he was placed on an antibiotic regimen of Vancomycin, Cipro, and Fluconazole for the anastomotic leak and MRSA and non-fermenting gram-negative rods isolated on pleural fluid culture. On [**2110-9-13**] he developed a [**Last Name (LF) **], [**First Name3 (LF) **] the Cipro was discontinued and Meropenem was added. On [**2110-9-15**] vancomycin was stopped and Daptomycin was started to cover enterococcus and MRSA; the meropenem was continued to cover GNR's in pleural fluid. On [**2110-9-30**] fluconazole was discontinued and Caspofungin was started. The course of antibiotics was completed on [**2110-10-10**]. He remained afebrile until [**2110-10-11**] when he developed fevers. Infectious disease was reconsulted and recommended restarting Daptomycin until cultures return. The PICC line was changed and the tip culture revealed no growth. On [**2110-10-13**] the empyema culture grew klebsiella, enterococcus and [**Female First Name (un) **] albicans. Infectious disease recommended changing Daptomycin, Meropenum to Unasyn 3gms and starting Diflucan 200 mg once through [**2110-10-31**] for a three week course. On [**2110-10-28**] after his chest CT he developed a temp of 102.3, was pancultured. The preliminary cultures grew GNR and GPC in pairs, chains and clusters no change from previous cultures. The UA was negative, cultures pending. He remained afebrile and the white count was trending down. Infectious disease recommended to continue present course of antibiotics and follow cultures. Disposition: He continued to work with physical therapy and was transferred to [**Hospital1 700**]. Medications on Admission: omeprazole, lisinopril, amitriptyline, zocor, ASA, MVI Discharge Medications: 1. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Hospital1 **]: One (1) Inhalation every 4-6 hours as needed. 2. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2 times a day): hold for loose stools. 3. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) Injection TID (3 times a day). 4. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation every 4-6 hours. 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily): via J-tube. 6. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs PO Q4H (every 4 hours) as needed. 7. Guaifenesin 100 mg/5 mL Syrup [**Last Name (STitle) **]: 5-10 MLs PO Q6H (every 6 hours) as needed. 8. Ampicillin-Sulbactam 3 gm IV Q6H End date 9/31/07 9. Fluconazole in Saline(Iso-osm) 200 mg/100 mL Piggyback [**Last Name (STitle) **]: One (1) Intravenous Q24H (every 24 hours). 10. Amitriptyline 50 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO HS (at bedtime) as needed. 11. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: per sliding scale Injection ASDIR (AS DIRECTED). 12. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Last Name (STitle) **]: One (1) ML Intravenous DAILY (Daily) as needed. 13. Lasix 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day: Via J-Tube: crush fine. 14. Lopressor 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day: via J-tube Hold for HR < 60 SBP < 100. 15. Ativan 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime: via J-tube. 16. Ativan 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day: via J-tube crush fine. 17. Potassium Chloride 20 mEq Packet [**Last Name (STitle) **]: One (1) PO once a day. 18. Potassium Chloride 20 mEq Packet [**Last Name (STitle) **]: One (1) PO once a day. 19. Potassium Chloride 20 mEq Packet [**Last Name (STitle) **]: Two (2) Packet PO ONCE (Once) for 1 doses. Discharge Disposition: Extended Care Facility: [**Hospital1 **] Discharge Diagnosis: Barrett's Esophagus s/p Transthoracic esopagectomy Esophageal anastomic leak s/p stent placement Diverticulitis Appendectomy Benign Colon Polops s/p Open Cholecysectomy [**2109**] s/p Fundoplication 20 yrs ago Discharge Condition: Deconditioned Discharge Instructions: Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if experience -Fever > 101 or chills -Increased shortness of breath, cough or sputum production -Chest pain Chest tube (empyema tube):monitor daily output. Chest tube site change freuently to keep site clean and dry Pancreatic Drain please keep safety pin in place. Pancreatic Drain site: ConvaTec Active Life Pouch and [**Last Name (un) **] seal. change as needed. J-Tube: flush with 50cc q8hrs with water. Flush with 50cc of water before and after meds. Should J-tube fall out replace immediately. PICC line 5 French double lumen via left basilic vein (43 cm) located in the distal SVC: flush qshift as needed with heparin flush Monitor CBC, lytes, BUN/Cre & LFT's Complete antibiotics course through [**2110-11-1**] Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] on [**11-20**] @ 11:00am the [**Hospital Ward Name 5074**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) **] Report to the [**Location (un) **] Radiology Department for a Chest x-ray 45 minutes before your appointment Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] call for an appointment [**Telephone/Fax (1) 1231**] Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1437**] [**Telephone/Fax (1) 25843**] Completed by:[**2110-10-30**]

[ "458.29", "997.1", "511.8", "693.0", "510.9", "998.11", "518.5", "997.4", "150.5", "787.91", "427.31", "401.9", "997.3", "V09.0", "998.6" ]

icd9cm

[ [ [] ] ]

[ "96.05", "51.85", "46.39", "34.04", "96.06", "99.15", "42.89", "34.51", "34.03", "45.13", "51.10", "52.93", "34.1", "38.93", "96.6", "44.29", "34.09", "42.42" ]

icd9pcs

[ [ [] ] ]

17693, 17736

10947, 15512

308, 1343

17990, 18006

2417, 10924

18845, 19410

2246, 2264

15619, 17670

17757, 17969

15538, 15596

18030, 18822

2279, 2398

234, 270

1371, 2033

2055, 2230

56,470

178,440

39700

Discharge summary

report

Admission Date: [**2183-9-13**] Discharge Date: [**2183-9-18**] Date of Birth: [**2103-6-2**] Sex: F Service: MEDICINE Allergies: Shellfish Derived Attending:[**First Name3 (LF) 425**] Chief Complaint: fall Major Surgical or Invasive Procedure: [**9-13**]: trans-venous pacing [**2183-9-16**]: Dual chamber [**Company 1543**] Pacemaker Placement History of Present Illness: 80 yo female with history of CAD s/p 4 vessel CABG, DM2, and HLD who presented to an OSH s/p fall and found to have a new SAH and meningeal bleed. Patient lives with her daughter who heard a loud thump early on morning of admission and found her mother fully dressed in the bathroom lying on the floor with her face turned toward the bathtub. She was initally disoriented but was able to get her mother to the bed before she was taken to the hospital. Patient does not remember the incident only afterwards being on the bed. After the fall she had a headache, she was nauseated, and was noted to have increasing confusion throughout the day. She was not having any changes in vision, sensation, dysarthria, dysphagia, or weakness upon admission. Patient was brought to an outside hospital and found to have subarachnoid hemorrhage, transferred to [**Hospital1 18**] for further managment. Patient appeared somewhat confused on admission, endorsed to a little dizziness, with improvement in nausea and headache symptoms. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: 4 vessel CABG at [**Hospital3 2358**] -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: DM type II Appendectomy Social History: Lives with daughter. [**Name (NI) **] smoking, EtOH, ilicit drug use Family History: heart disease Physical Exam: On Admission to T-SICU: O: T:97 BP: 97/42 HR: 50 R 14 O2Sats 100 Gen: WD/WN, comfortable, NAD. HEENT: Pupils:R eye surgical pupil 3->2. Left eye 2-1.5 cm Neck: Supple. Nontender Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert X 3, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**1-5**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-7**] throughout. No pronator drift Sensation: Intact to light touch and propioception bilaterally. Decreased vibration in lower extremities Reflexes: B T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Toes upgoing BL Coordination: normal on finger-nose-finger PHYSICAL EXAM ON ADMISSION TO CCU: VS: T: 99.2, BP: 168/72, HR: 67, RR: 22, O2 sats 98% on NC GENERAL: Elderly woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. right pupil 2mm ovoid, larger than L, L reactive to light, EOMI. NECK: Supple with JVP flat. CARDIAC: Normal rate, regular rhythm. 2/6 SEM at R+LUSB, LLSB and apex. 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: Soft, NTND. No HSM or tenderness. EXTREMITIES: No edema, no clubbing, 2+ pulses SKIN: No lesions, warm dry. NEURO: Cranial nerves [**2-14**] intact grossly with the exception of her right pupil (may be due to cataract surgery). Otherwise no focal deficits. 5/5 strength, normal sensation. Gait not assessed. PULSES: Right: Carotid 2+ Radial 2+ Left: Carotid 2+ Radial 2+ . Physical Exam on Discharge: VS: 99.4 afebrile overnight, 132/50 (127-150/52-64) 62 (59-67) 18 99% RA I/O; 8 hr: 0/300ml 24 hr: 680/2500 GENERAL: Elderly woman in NAD. Having clear in depth conversation with me this morning, alert and oriented. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. NECK: Supple with JVP flat. CARDIAC: Normal rate, regular rhythm. [**3-8**] early peaking SEM at R+LUSB, radiates to carotids and apex. LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No edema, no clubbing, 2+ pulses b/l NEURO: Cranial nerves [**2-14**] intact with the exception of her right pupil (larger than left). Otherwise no focal deficits. 5/5 strength, normal sensation. Able to mobilize to commode. Pertinent Results: [**9-13**] CT Head: IMPRESSION: 1. Allowing for interscan differences, there is no significant short- interval change. 2. Known subarachnoid hemorrhage in the right Sylvian fissure and suprasellar cistern. 3. No significant mass effect, and no evidence of developing hydrocephalus. 4. Sell-circumscribed right frontovertex extra-axial hematoma. . CTA HEAD W&W/O C & RECONS Study Date of [**2183-9-13**] 7:01 PM IMPRESSION: 1. No significant change in the overall amount or distribution of the acute subarachnoid hemorrhage, in an "aneurysmal" distribution. 2. This likely relates to acute rupture of a 5.0 x 3.5-mm saccular aneurysm at the bifurcation of the right MCA, with no other aneurysm seen to involve the vessels of the circle of [**Location (un) 431**] or their major branches. 3. Well-defined extraaxial hematoma at the right frontal vertex, as well as a possible component of subdural hemorrhage along the floor of the right middle cranial fossa, likely related to the reported history of recent fall, which may in turn relate to the aneurysmal hemorrhage. 4. No finding to specifically suggest acute vasospasm or territorial infarction. . CT HEAD W/O CONTRAST Study Date of [**2183-9-13**] 11:56 PM IMPRESSION: 1. Allowing for interscan differences, there is no significant short- interval change. 2. Known subarachnoid hemorrhage in the right Sylvian fissure and suprasellar cistern. 3. No significant mass effect, and no evidence of developing hydrocephalus. 4. Sell-circumscribed right frontovertex extra-axial hematoma. . CT Torso W/CONTRAST Study Date of [**2183-9-14**] 12:00 AM IMPRESSION: 1. No acute traumatic injury. 2. Moderate degenerative changes in the thoracolumbar spine, most prominent in the lower lumbar region. 3. Moderate cardiomegaly with moderate coronary artery calcification. The patient is status post open chest surgery. 4. Tiny gallbladder sludge without acute cholecystitis. . Portable TTE (Complete) Done [**2183-9-15**] at 11:46:58 AM Conclusions The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . CT HEAD W/O CONTRAST Study Date of [**2183-9-15**] 12:57 AM FINDINGS: Redemonstrated within the right frontal vertex is a hyperattenuating well-marginated 2.4 cm extra-axial hematoma that is stable in both size and appearance since the prior examination. In addition, a moderate amount of subarachnoid hemorrhage seen layering in the right sylvian fissure extending to the suprasellar cistern and along the temporal cortices is unchanged in extent. There is no new focus of hemorrhage. Ventricles are unchanged in size and configuration, with no evidence of intraventricular hemorrhage extension or worsening or hydrocephalus. The [**Doctor Last Name 352**]-white matter differentiation is preserved. Redemonstrated are prominent bifrontal extra-axial CSF spaces. There is no acute fracture. The visualized portions of the paranasal sinuses and mastoid air cells remain well aerated. IMPRESSION: 1. Allowing for differences in technique, no interval change since examination from [**2183-9-13**] of a moderate amount of subarachnoid hemorrhage layering within the right sylvian fissure, along both temporal cortices and the suprasellar cistern. 2. Stable well-circumscribed right frontal vertex extra-axial hematoma. . EEG [**2183-9-15**] FINDINGS: ROUTINE SAMPLING: The recording began at 8 in the morning on the 13th and showed a very low voltage record bilaterally. At 8:55 that morning there emerged some rhythmic 3 Hz slowing primarily in the right parietal area, waxing and [**Doctor Last Name 688**] over the next minute or so. By video, the patient had rhythmic shaking of the left arm with some semi-voluntary appearing movement of the trunk and right side, as well. After the first 20 seconds or so, the left arm movement appeared to be more of a jerking. Electrographically and clinically, the seizure did not appear to spread beyond that area. The same seizure pattern recurred at 9:21. This episode lasted over a minute and had similar clinical manifestations. The record remained of low voltage with mostly faster frequencies for the rest of the recording, with background voltages remaining stable and symmetric. Relative frequency analysis showed more delta activity relative to [**Name2 (NI) 14595**] activity late in the morning and again for the hour just before the end of the study, but these activities remained quite symmetric. SPIKE DETECTION PROGRAMS: Showed no clear epileptiform discharges. SEIZURE DETECTION PROGRAMS: Showed primarily muscle artifact. PUSHBUTTON ACTIVATIONS: There were three. The first was at 9:21 and showed the second focal seizure, as described above. The second pushbutton event was a repetition of the same seizure 10 seconds later. The third was another six minutes later and showed some spike and slow activity broadly over the left hemisphere. By video, there was some continued jerking of the left arm. SLEEP: No normal waking or sleeping patterns were evident. CARDIAC MONITOR: Showed a generally regular rhythm. IMPRESSION: This EEG recording monitored cerebral function from 8 in the morning until near 4 p.m. on the [**1-15**]. It showed two electrographic seizures, the second with some evidence of spread to the contrlateral side. Both seizures appeared to begin in the right central parietal area and lasted for just a few minutes. Otherwise, the background rhythm was of low voltage and remained symmetric throughout the study. There were no other epileptiform features. . CTA [**2183-9-17**] *** Preliminary Report *** No evidence of new hemorrhage or infarction. Stable appearance of extra-axial hematoma and interval resorption of a significant portion of subarachnoid blood. Stable appearance of 5 x 3.5 mm right MCA bifurcation aneurysm with no evidence of intracerebral vasospasm. . . . Neurophysiology Report EEG Study Date of [**2183-9-15**] . OBJECT: ROE, EKG, VIDEO, [**9-15**] TO [**2183-9-16**]. THERE WERE THREE PUSHBUTTON ACTIVATIONS. . FINDINGS: ROUTINE SAMPLING: The recording began at 8 in the morning on the 13th and showed a very low voltage record bilaterally. At 8:55 that morning there emerged some rhythmic 3 Hz slowing primarily in the right parietal area, waxing and [**Doctor Last Name 688**] over the next minute or so. By video, the patient had rhythmic shaking of the left arm with some semi-voluntary appearing movement of the trunk and right side, as well. After the first 20 seconds or so, the left arm movement appeared to be more of a jerking. Electrographically and clinically, the seizure did not appear to spread beyond that area. The same seizure pattern recurred at 9:21. This episode lasted over a minute and had similar clinical manifestations. The record remained of low voltage with mostly faster frequencies for the rest of the recording, with background voltages remaining stable and symmetric. Relative frequency analysis showed more delta activity relative to [**Name2 (NI) 14595**] activity late in the morning and again for the hour just before the end of the study, but these activities remained quite symmetric. . SPIKE DETECTION PROGRAMS: Showed no clear epileptiform discharges. SEIZURE DETECTION PROGRAMS: Showed primarily muscle artifact. PUSHBUTTON ACTIVATIONS: There were three. The first was at 9:21 and showed the second focal seizure, as described above. The second pushbutton event was a repetition of the same seizure 10 seconds later. The third was another six minutes later and showed some spike and slow activity broadly over the left hemisphere. By video, there was some continued jerking of the left arm. SLEEP: No normal waking or sleeping patterns were evident. CARDIAC MONITOR: Showed a generally regular rhythm. . IMPRESSION: This EEG recording monitored cerebral function from 8 in the morning until near 4 p.m. on the [**1-15**]. It showed two electrographic seizures, the second with some evidence of spread to the contrlateral side. Both seizures appeared to begin in the right central parietal area and lasted for just a few minutes. Otherwise, the background rhythm was of low voltage and remained symmetric throughout the study. There were no other epileptiform features. Brief Hospital Course: [**Known firstname **] [**Known lastname **] is an 80 year old female with CAD s/p CABG, HTN, HLD, and DMII that was transferred from an outside hospital after an episode of syncope and fall, where she was found to have an acute subarachnoid hemorrhage and transferred to [**Hospital1 18**] for further management. . #Bradycardia, syncope: The patient was initially admitted to the Trauma ICU for monitoring and management of her acute subarachnoid hemorrhage. However, the night of admission she developed bradycardia that progressed to an asystolic arrest, received CPR for approximately 30-45 seconds and spontaneously recovered without atropine or epinephrine. Initially a temporary transvernous pacer wire placed through a Right IJ, but patient accidentally removed it, so transcutaneous pacer pads were placed which patient did not end up needing overnight. Permanent [**Company 1543**] dual chamber (AV leads) pacemaker was implanted [**2183-9-16**]. Her bradycardia was believed to be secondary to sick sinus syndrome. She received Vancomycin post-operatively for 2 days and did not experience any immediate complications from the pacemaker placement. . # Subarachnoid Hemorrhage: Upon admission, she was found to have a 5 x 3.5 mm right MCA bifurcation aneurysm and a new subarachnoid hemorrhage on head CT. The bleed was believed by Neurosurgery team to be most likely secondary to head trauma after her fall, not secondary to aneurysm. She was initially admitted to the Trauma SICU with Neurosurgical consult. She was initially monitored with Q1 hour neuro checks, intervals were gradually lengthened as patient showed no neurological deficits. After asystolic episode described above, patient was transferred to CCU. Shortly after arrival to the CCU she developed a fever, delerium and was having left sided partial seizures. She was seen by neurosurgery and was started on Keppra and an EEG was done for several hours. EEG over eight hours showed "two electrographic seizures, the second with some evidence of spread to the contrlateral side. Both seizures appeared to begin in the right central parietal area and lasted for just a few minutes." She had no witnessed repeat seizures the following day. Repeat CT on [**2183-9-15**] showed no interval change in the size of intracranial hemorrhage. Her fever and delerium resolved, and were most likely believed to be secondary to her intracranial bleed. CTA was performed on [**2183-9-17**] and showed no evidence of cerebral vasospasm, partial resorption of the bleed, and a stable ovoid aneursym. Re-construction of the CTA still pending. Patient was alert and oriented with normal neurological exam, as described above, upon discharge. . # Urinary Tract Infection: Patient was febrile and delirious on transfer from TICU. Out of concern for a possible UTI by urine analysis, she received one dose of levofloxacin in the TICU and then received a 3 day course of Bactrim in the CCU. Urine cultures were all negative. Pneumonia was unlikely as chest x-ray did not reveal an infiltrates. Her fever resolved and her delerium improved. . # Hypertension: Due to episodes of bradycardia prompting permanent pacemaker placement, her home antihypertensives including atenolol, imdur, and lisinopril were held. Additionally, neurosurgery recommended allowing her blood pressures to autoregulate and run slightly higher than normal secondary to her intracranial lesion. Her home antihypertensives were held upon discharge and can be restarted as an outpatient according to her neurosurgeon and primary care physician's recommendations. . # Diabetes: She was maintained on an insulin sliding scale during her admission and her glucophage was resumed upon discharge. . # CAD with history of CABG: Her home aspirin and plavix were held in context of her intracranial bleed. Her primary care physician was [**Name (NI) 653**] to investigate whether she had a prior PCI/indication for plavix. It is known that she had PTCA in [**2182-11-3**]. Her PCP will investigate further and restart plavix once her bleed is stable if clinically indicated. Her aspirin will resume upon follow up with neurosurgery. She was continued on pravastatin for hyperlipidemia. . #Follow up: Neurosurgery team should follow-up on final read of CTA and 3D reconstruction which was not available at time of discharge. Patient has followup appointment set with Primary Care Physician. . The patient was full code for this admission. . Medications on Admission: Glucophage 500 mg [**Hospital1 **] IMDUR 120 mg qday Plavix 75 mg PO daily Atenolol 25 mg PO daily Pravastatin 40 mg PO qHS B12 500 mcg qday Aspirin 81 mg daily Lisinopril 10 mg PO daily Discharge Disposition: Home Discharge Diagnosis: Subarachnoid hemorrhage Bradycardia Asystolic arrest Urinary tract infection 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 **], You were brought to the hospital because you were experienced a fainting spell which resulted in a fall that caused bleeding in your brain. You heart also stopped and you briefly required CPR. It was determined that you required a permanent pacemaker, which was placed without complications. Because of the bleeding in your brain you also expereienced seizures which were treated with medication. You also had a brief episode of fevers and there was concern for a possible urinary tract infection and you received antibiotics. Imaging showed that your bleeding stablized and you were able to be discharged from the hospital in stable condition to complete your recovery. . The following changes were made to your medications: - Please START taking Keppra 500mg [**Hospital1 **] for seizure prophylaxis - Please STOP taking aspirin for now. You can restart this medication as directed by your primary care physician. [**Name Initial (NameIs) **] Please STOP taking plavix for now. You can restart this medication if your primary care physician tells you to. - Please STOP taking lisinopril for now. You can restart this medication when your neurosurgeon and primary care doctor tell you to. - Please STOP taking your Imdur for now. You can restart this medication when your neurosurgeon and primary care doctor tell you to. - Please STOP taking your atenolol for now. You can restart this medication when your PCP tells you to. - You can take Tylenol 325mg 1-2 tabs every 6 hours as needed for headache or pain. - Please continue to take all of your other home medications as prescribed. . Please be sure to keep all follow-up appointments with your PCP and other health care providers. . It was a pleasure taking care of you and we wish you a speedy recovery. Followup Instructions: Please be sure to keep all follow-up appointments with your primary care physician and other health care providers. . Please follow-up with your primary care physician and [**Name9 (PRE) 87491**] should [**Location (un) 1131**] the final results of CTA (special imaging of your head)which were not available at time of discharge. . Department: CARDIAC SERVICES (Device clinic) When: THURSDAY [**2183-9-25**] at 10:00 AM With: [**First Name11 (Name Pattern1) 539**] [**Last Name (NamePattern4) 13861**], NP [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: CARDIAC SERVICES When: THURSDAY [**2183-9-25**] at 10:40 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Primary Care Physican: [**Last Name (LF) **],[**First Name3 (LF) **] J [**Telephone/Fax (1) 63780**] Wednesday, [**10-1**] at 1:45pm [**Location 9583**], MA . Neurosurgery: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] The office of Dr. [**First Name (STitle) **] will call you with an appointment -- if you do not hear from them by tomorrow, Friday, [**9-19**], please call their office. ([**Telephone/Fax (1) 79734**] Completed by:[**2183-9-18**]

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Discharge summary

report

Admission Date: [**2133-8-20**] Discharge Date: [**2133-8-25**] Service: MEDICINE Allergies: Flagyl / Proton Pump Inhibitors (Benzimidazole) Attending:[**First Name3 (LF) 99**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: This is an 85 year old male with history of diastolic heart failure, copmlete heart block (now s/p PPM [**6-7**]) ESRD on HDHD, h/o MRSA bacteremia and thrombocytopenia, likely secondary to drug reaction (PPI?) who presents from [**Hospital 100**] rehab with dyspnea. Patient reports SOB x 1 day. He denies any chest pain, palpitations, N/V, abdominal pain, diarrhea, fevers, chills or recent cough. Patient states he was walking with PT/OT and became SOB and dizzy. Per ED report patient felt better after HD yesterday, but continued with SOB today along with AMS. ABG done at [**Hospital 100**] Rehab which showed increased CO2 and decreased PaO2 from baseline so he was transferred to [**Hospital1 18**] for further care. In the ED: Temp 97, HR 71, BP 122/53, RR 15 88% on RA 99% on NRB and then on CPAP. CXR done which showed worsening bilateral pleural effusions. He was given CTX 1gm x 1, Levaquin 500mg IV x 1, Vanco 1gm IV x 1 and was transferred to MICU. On arrival, patient stated he was feeling well. +mild SOB. CPAP was removed and patient was with 98% O2 saturation on 2LNC. ABG: 7.21 // 77 // 149 // 32 Past Medical History: Diastolic Congestive Heart Failure: ECHO [**3-7**] EF of 50% & severe LVH Atrial fibrillation previously on Coumadin (until GI bleed [**6-7**]), failed cardioversion s/p Pacemaker placement [**6-7**] for complete heart block Peripheral vascular disease s/p right lower extremity bypass Hiatal hernia with intrathoracic stomach (confirmed by [**2133-6-16**] CT) Hypertension Gout ?Prostate followed by Urology (denies symptoms of BPH) Chronic Kidney Disease on HD Social History: Patient has an insurance business and worked daily until recent sicknesses. No current tobacco use. There is no history of alcohol abuse. Occupation: Owns Insurance business Drugs: None Tobacco: None Alcohol: None Other: Family History: There is no family history of premature coronary artery disease or sudden death. Patient's daughter had "kidney disease" and is now s/p renal transplant. 2 sons and 1 daughter. Physical Exam: Tmax: 36.8 ??????C (98.2 ??????F) Tcurrent: 36.8 ??????C (98.2 ??????F) HR: 70 (70 - 76) bpm BP: 107/53(64) {82/16(37) - 112/93(97)} mmHg RR: 27 (14 - 27) insp/min SpO2: 100% Heart rhythm: AV Paced Height: 65 Inch General Appearance: Well nourished, No acute distress, Overweight / Obese, No(t) Thin, Anxious, No(t) Diaphoretic Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva pale, No(t) Sclera edema Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t) Endotracheal tube, No(t) NG tube Lymphatic: Cervical WNL, Supraclavicular WNL, No(t) Cervical adenopathy Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t) Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split , No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical), (Percussion: No(t) Resonant : , No(t) Hyperresonant: ), (Breath Sounds: No(t) Clear : , Crackles : midway up posterior lung fields, No(t) Bronchial: , No(t) Wheezes : , Diminished: bilateral bases) Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended, No(t) Tender: , No(t) Obese Extremities: Right: 2+, Left: 2+, to ankles bilaterally Musculoskeletal: No(t) Muscle wasting Skin: Not assessed, Rash: Neurologic: Follows simple commands, Responds to: Not assessed, Oriented (to): person, place, time, Movement: Not assessed, Tone: Not assessed Pertinent Results: [**2133-8-20**] 01:21PM PT-14.5* PTT-31.3 INR(PT)-1.3* [**2133-8-20**] 01:21PM PLT SMR-VERY LOW PLT COUNT-61* [**2133-8-20**] 01:21PM NEUTS-68 BANDS-0 LYMPHS-13* MONOS-9 EOS-10* BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2133-8-20**] 01:21PM WBC-6.9 RBC-3.30*# HGB-10.8* HCT-36.9*# MCV-112* MCH-32.7* MCHC-29.2* RDW-17.3* [**2133-8-20**] 01:21PM CALCIUM-9.5 PHOSPHATE-3.8 MAGNESIUM-2.4 [**2133-8-20**] 01:21PM CK(CPK)-28* [**2133-8-20**] 01:21PM GLUCOSE-106* UREA N-20 CREAT-3.8*# SODIUM-140 POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-31 ANION GAP-14 [**2133-8-20**] 01:30PM cTropnT-0.23* [**2133-8-20**] 01:31PM LACTATE-0.9 [**2133-8-20**] 01:31PM TYPE-ART PO2-149* PCO2-77* PH-7.21* TOTAL CO2-32* BASE XS-0 INTUBATED-NOT INTUBA [**2133-8-20**] 03:59PM TYPE-ART PO2-95 PCO2-58* PH-7.30* TOTAL CO2-30 BASE XS-0 Brief Hospital Course: Pt is an 85 year old male with history of diastolic heart failure, copmlete heart block (s/p PPM [**6-7**]) ESRD on HDHD, h/o MRSA bacteremia and thrombocytopenia, likely secondary to drug reaction (PPI?) who presented from [**Hospital 100**] rehab with dyspnea. Initially admitted to MICU with dyspnea and ? CO2 retention requiring BiPAP. Pt was called out to the floor and did well for several days. He was then noted to be hypoxic at dialysis. he also underwent therapeutic thoracentesis on right side with good relief. The following morning, he was found to be somnolent with myoclonic jerking. ABG demonstrated 7.24/70/89 on 3 L/min. He was transferred back to the MICU for ? bipap. He was noted to be continually hypercarbic throughout his admission. Pt's BPs continued to drop and he became unable to tolerate HD. On the day prior to death, dialysis had to be stopped prematurely (removed 2.2L) due to hypoxia and hypotension. The morning of his death, he was noted to be acutely hypoxic and hypercarbic. CXR revealed a collapsed left lung and increase in right sided pleural effusion. Discussed situation with family and it was decided to not escalate care (had been decided upon to make him DNR/DNI the night before). Over the course of the day, he became increasinly hypoxic, hypercarbic, acidotic, and hypotensive. He was pronounced deat at 17:25 on [**2133-8-25**]. Family was present and declined autopsy. . #. Dyspnea: Patient presented from rehab with acute dyspnea and SOB with walking the day of admission likley from increasing pleural effusions. Patient had been afebrile, without leukocytosis, bandemia or cough making PNA very unlikely. Given that CTX/Levaquin/Vanco started in the ED were D/Ced. Nephrology was notified that the patient was admitted and Pt was sent to HD for ultrafiltration on the day of transfer off of the MICU. CEs were negative. #. End Stage Renal Disease: Patient on MWF HD treatments. Pt continued HD as an in patient with removal of excess fluid. #. C Diff colitis: Patient with (+) C diff tox x 3 during admission in [**Month (only) 205**]. On Vanco at [**Hospital 100**] rehab until [**2133-8-24**]. Vanco 250mg PO QID was continued as an in patient. #. Diastolic heart failure: Last ECHO [**2133-7-17**] with EF >55% and mild mitral regurgitation. HD was done as above. #. Atrial Fibrillation: Patient is currently V-paced. We continued outpatient amiodarone. Anticoagulation was held given recent history of GI bleed. #. Thrombocytopenia: Thought to be [**1-31**] to drug reaction one month ago (PPI), currently at 61, down from 113 at last admisstion. This suggests the possibility of MDS. Follow up with a hematologist may be indicate in the future as an outpatient, but since the remainder of his counts are WNL no H/O consult was called. Medications on Admission: Amiodarone 200mg daily Calcium Gluconate 650mg TID Midodrine 5mg TID Simethicone 80mg [**Hospital1 **] Vanco 250mg PO QID Vit B/Vit C/Folic Acid Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Completed by:[**2133-8-25**]

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icd9cm

[ [ [] ] ]

[ "34.91", "39.95" ]

icd9pcs

[ [ [] ] ]

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4837, 7652

261, 267

7945, 7954

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8010, 8048

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295, 1436

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1948, 2175

7,695

154,714

400

Discharge summary

report

Admission Date: [**2180-4-25**] Discharge Date: [**2180-5-13**] Date of Birth: [**2115-9-8**] Sex: M Service: MEDICINE Allergies: Unasyn / Oxycodone Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: ICD firing, CHF exacerbation Major Surgical or Invasive Procedure: none History of Present Illness: 64 year old male with PMHx of severe non-ischemic cardiomyopathy with EF 25%, s/p ICD placement [**2175**], mild-mod MR/TR, DM, ICD, Afib on coumadin, gout, hypothyroidism, CKD p/w vtach and ICD firing. Last Wednesday he returned from [**Country 3515**] which is where he spends most of the year. He went to clinic to see Dr. [**First Name (STitle) 437**] day prior to admission and appeared volume overloaded, admitted to running out of his prescriptions for at least 2 weeks. He also had not been adhering to low salt diet. Amiodarone was started in clinic for device discharges, noted to have seven episodes of VF and VT on device check yesterday. This morning, his ICD fired again and was advised to go to ED. He felt no sx when his ICD fired, butper report from wife, he appeared to have seizure activity during this morning's shock. . In the ED, VS were 98.2 73 119/67 20 100%. He was noted to be fluid overloaded on exam. Seen by EP in the ED who recommended amiodarone loading for multiple episodes of VT/VF. . On arrival to floor, he complains of being tired. No chest pain, shortness of breath, nausea, vomiting. His lower extremities are swollen but he says this is stable. Also has chronic orthopnea. . On review of systems, 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 absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. Past Medical History: Nonischemic cardiomyopathy, LVEF 15-20% ICD placement for primary prevention of sudden cardiac death Diabetes mellitus type 2 insulin dependent Gout Peripheral neuropathy Chronic atrial fibrillation Chronic kidney disease Elevated transaminases, unknown etiology Umbilical hernia repair, [**8-/2175**] Gallstone pancreatitis s/p ERCP ([**2176-6-28**]) Internal hemorrhoids Hemoglobin C carrier Social History: The patient is originally from [**Country 3515**] currently living with his wife. Returned to [**Location 3515**] this past fall, but came back to US after severe gout flare of his foot. No smoking. He quit alcohol use, no IV drug use. He says his diet is generally difficult because he feels like any food he eats causes gout flare . Family History: No first-degree relatives with coronary artery disease. His mother had breast cancer. . Physical Exam: Admission: VS: 99.9 112/69 76 20 97% RA GENERAL: obese M 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 JVD to level of mandible. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 2/6 systolic murmur, no r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. crackles at bases bilaterally, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: +bilateral 3+ pitting edema to above knees. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ . On Discharge: Temp Max: 99.9 Current: 98.9 HR: 76-84 BP: 92-102/58-64 RR: 18, O2 Sat: 99% RA 24 hour I= 920 O= 1300 8 hour I= 150 O= 400 Gen: more awake, alert, appropriate with questions, still talking softly. NAD. HEENT: sclera slightly icteric. MM dry. neck supple, JVP 10cm CV: PMI located in 5th intercostal space, heart sounds distant, regular, S1S2, faint systolic murmur RESP: clear ABD: non-distended, soft, hypoactive BS, no tenderness, unable to appreciate liver margin. EXTR: skin thickened, dry, no open areas, no edema, no joint tenderness or erythema. NEURO: A/O, quiet, MAE. Pulses: Right: DP 1+ PT 1+ Left: DP 1+ PT 1+ Skin: intact, dry skin Pertinent Results: CBC: [**2180-4-25**] 05:15PM BLOOD WBC-6.5 RBC-3.84* Hgb-12.1* Hct-32.5* MCV-85# MCH-31.6# MCHC-37.3* RDW-16.7* Plt Ct-48*# [**2180-5-2**] 07:59AM BLOOD WBC-5.0 RBC-4.80 Hgb-14.6 Hct-40.4 MCV-84 MCH-30.4 MCHC-36.2* RDW-16.2* Plt Ct-188 [**2180-5-7**] 04:06AM BLOOD WBC-6.9 RBC-3.81* Hgb-11.9* Hct-31.7* MCV-83 MCH-31.2 MCHC-37.5* RDW-16.4* Plt Ct-185 [**2180-5-11**] 07:10AM BLOOD WBC-11.3* RBC-4.47* Hgb-13.7* Hct-37.6* MCV-84 MCH-30.6 MCHC-36.5* RDW-17.3* Plt Ct-144* [**2180-5-12**] 07:15AM BLOOD WBC-10.3 RBC-4.03* Hgb-12.3* Hct-33.8* MCV-84 MCH-30.5 MCHC-36.4* RDW-17.4* Plt Ct-159 [**2180-5-13**] 09:20AM BLOOD WBC-10.8 RBC-3.94* Hgb-12.3* Hct-32.9* MCV-84 MCH-31.2 MCHC-37.4* RDW-17.4* Plt Ct-163 . Coags: [**2180-4-27**] 07:16PM BLOOD PT-38.2* PTT-47.7* INR(PT)-4.0* [**2180-4-30**] 06:05AM BLOOD PT-34.5* PTT-45.0* INR(PT)-3.5* [**2180-5-1**] 07:45AM BLOOD PT-22.8* PTT-36.7* INR(PT)-2.1* [**2180-5-3**] 04:00AM BLOOD PT-16.2* PTT-31.0 INR(PT)-1.4* [**2180-5-6**] 03:45AM BLOOD PT-21.8* PTT-150* INR(PT)-2.0* [**2180-5-6**] 09:13PM BLOOD PT-22.8* PTT-84.8* INR(PT)-2.1* [**2180-5-10**] 03:46AM BLOOD PT-34.0* PTT-54.3* INR(PT)-3.5* [**2180-5-13**] 09:20AM BLOOD PT-31.2* INR(PT)-3.1* . BMP: [**2180-4-24**] 04:00PM BLOOD UreaN-37* Creat-2.2* Na-138 K-3.7 Cl-96 HCO3-29 AnGap-17 [**2180-4-26**] 09:25PM BLOOD Glucose-159* UreaN-33* Creat-1.8* Na-134 K-3.9 Cl-97 HCO3-28 AnGap-13 [**2180-4-28**] 07:50PM BLOOD Glucose-149* UreaN-36* Creat-2.2* Na-133 K-3.9 Cl-94* HCO3-29 AnGap-14 [**2180-5-3**] 04:00AM BLOOD Glucose-103* UreaN-32* Creat-2.6* Na-133 K-3.9 Cl-90* HCO3-34* AnGap-13 [**2180-5-6**] 03:45AM BLOOD Glucose-178* UreaN-34* Creat-2.5* Na-128* K-3.0* Cl-88* HCO3-29 AnGap-14 [**2180-5-8**] 05:00PM BLOOD Glucose-167* UreaN-39* Creat-2.2* Na-128* K-3.5 Cl-88* HCO3-29 AnGap-15 [**2180-5-13**] 09:20AM BLOOD Glucose-121* UreaN-60* Creat-2.8* Na-129* K-4.5 Cl-90* HCO3-29 AnGap-15 . LIVER FUNCTION TESTS: [**2180-4-26**] 07:10AM BLOOD ALT-14 AST-33 CK(CPK)-240 AlkPhos-98 TotBili-2.6* [**2180-5-5**] 03:47AM BLOOD ALT-11 AST-67* LD(LDH)-250 CK(CPK)-400* AlkPhos-126 TotBili-4.4* DirBili-2.9* IndBili-1.5 [**2180-5-10**] 03:46AM BLOOD ALT-10 AST-64* LD(LDH)-330* AlkPhos-204* TotBili-2.5* . Minerals: [**2180-4-26**] 07:10AM BLOOD Calcium-7.5* Phos-2.8 Mg-1.5* [**2180-4-28**] 07:50PM BLOOD Calcium-7.9* Phos-3.1 Mg-1.9 [**2180-5-3**] 04:00AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.5 [**2180-5-9**] 04:12PM BLOOD Calcium-8.8 Phos-2.8 Mg-1.9 [**2180-5-11**] 07:10AM BLOOD Calcium-8.2* Phos-4.0 Mg-2.0 . ######################################################## MICRO: [**2180-5-2**]: URINE CULTURE (Final [**2180-5-3**]): NO GROWTH [**2180-5-3**]: MRSA SCREEN (Final [**2180-5-5**]): No MRSA isolated. [**2180-4-27**]: FECAL CULTURE (Final [**2180-4-29**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2180-4-29**]): NO CAMPYLOBACTER FOUND. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2180-4-28**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). [**2180-5-2**]: Staph aureus Screen (Final [**2180-5-4**]): STAPH AUREUS COAG +. RARE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- R ERYTHROMYCIN---------- R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 1 S TRIMETHOPRIM/SULFA---- <=0.5 S ################################################### IMAGING: CXR: [**2180-5-1**]: IMPRESSION: 1. No pneumothorax. 2. Stable mild vascular engorgement 3. Unchanged moderate-to-severe cardiomegaly. . [**2180-5-2**]: IMPRESSION: No acute cardiopulmonary process . [**2180-5-4**]: SINGLE FRONTAL VIEW OF THE CHEST: Left-sided pacer lead ends in the expected location of the right ventricle, unchanged. A left-sided chest tube ends near the apex. There is no pneumothorax. Right-sided catheter remains in the upper SVC. There is gaseous distention of the stomach. Otherwise, little change from the prior study. . U/S gallbladder and liver: [**2180-5-7**]: IMPRESSION: 1. Normal liver echotexture, without biliary dilatation. 2. Irregular appearance of the gallbladder wall, but without ultrasound suggestion of active cholecystitis. . KUB: [**2180-5-7**]: There is marked distention of a small bowel loop and transverse colon due to ileus. No evidence of fecal impaction. Air-fluid levels cannot be assessed. This is a single supine portable view of the abdomen. ################################################## ECHO: [**2180-5-2**]: The left atrium is moderately dilated. The right atrium is markedly dilated. Left ventricular wall thicknesses are normal. Overall left ventricular systolic function is severely depressed (LVEF= 25%) with inferior/inferolateral akinesis/severely hypokinesis and hypokinesis elsewhere. The right ventricular cavity is dilated with borderline normal free wall function. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. . [**2180-5-3**] Moderate to severe spontaneous echo contrast is seen in the body of the left atrium. Moderate to severe spontaneous echo contrast is present in the left atrial appendage. Moderate spontaneous echo contrast in the LV as well.No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is severely depressed (LVEF= 20 %). with moderate global RV free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the results on [**2180-5-3**] at 1030am. . [**2180-5-5**]: There is a small, mobile, echodense mass associated with a catheter/pacing wire in the right atrium (best seen in subcostal views). Differential diagnosis includes a fibrin strand, thrombus or vegetation. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is severe global hypokinesis (EF 25%), with worse contraction of the inferior/inferolateral walls. Right ventricular chamber size is normal. There is mild global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. Trivial mitral regurgitation is seen. There is no pericardial effusion.\ . [**2180-5-11**]: LVOT VTI in baseline pacing mode = 10.7 cm RV pacing alone: LVOT VTI = 11.5 cm LV-RV 10 msec offset: LVOT VTI = 12.8 cm LV-RV 20 msec offset: LVOT VTI = 13.3 cm LV tip to ring (LV-RV offset 0 msec): LVOT VTI = 14.0 cm LV tip to ring (LV-RV offset 30 msec): LVOT VTI = 12.3 cm LV ring to RV coil (LV-RV offset 0 msec): LVOT VTI = 13.2 cm LV ring to RV coil (LV-RV offset 30 msec): LVOT VTI = 11.2 cm LV tip to RV coil (LV-RV offset 0 msec): LVOT VTI = 13.3 msec Brief Hospital Course: 64 year old male with PMHx of severe non-ischemic cardiomyopathy with EF 25%, s/p ICD placement [**2175**], mild-mod MR/TR, DM, ICD, Afib on coumadin, gout, hypothyroidism, CKD p/w vtach and ICD firing, also with decompensated CHF. # VT/VF and ICD firing: evaluated by EP in the ED and started on 400 mg amiodarone TID for amio loading for 7 days, then changed to 400 mg daily daily x 1 month. Likely [**3-1**] volume overload and electrolyte abnormalities, resolved after diuresis. Will continue amiodarone as outpatient and decrease to 200mg Daily after 1 month. EP also saw the patient and adjust his lead placement. ECHO on [**5-11**] evaluated his heart function after change in lead placement and it showed marked improvement in squeeze of his vintricles. He will be followed up in the outpatient by EP. # Decompensated CHF/PUMP: Pt did not take torsemide while in [**Country 3515**] and also did not adhere to low Na diet. Diuresed on lasix gtt with [**Hospital1 **] metolazone and was euvolemic after several days. CRT was considered as it would potentially benefit patient with low EF, wide QRS, so EP was consulted for upgrade to [**Hospital1 **]-V pacer. EP team unable to place lead in coronary sinus in cath lab due to coronary sinue anatomy. Pt was transferred to surgery for epicardial placement of [**Hospital1 **]-V pacer for CRT. Upon transfer to the floor he was placed on Levophed/Milrinone with a lasix gtt and these were titrated to keep MAPs >60 and UOP>30. His digoxin was also continued. To increase efficiency of systolic function and increase time in BiV pacing, he was betablocked with metoprolol and his pacemaker rate was increased to 80. Over concerns with tachycardia, his levophed was switched to neosynephrine. His UOP fluctuated but remained >30 for most of his stay in the CCU. Weaning his pressors proved to be a challenge however and were kept on for several days. A repeat ECHO on milrinone showed slightly improved EF to 20-25%. He was effectively diuresed and was weaned off of milrinone. In the CCU he was diuresed and was net negative almost 6L. Initially his BP remained low and Creatinine began trending up. There was some concern that he was going to be milrinone dependent. His [**Hospital1 **]-V pacer was also adjusted and his pump function seemed to improve. His BP improved as well as his creatinine. At the time of discharge his fluid status was optimized, he was off of milrinone and doing well and he will be sent to Rehab. . # CORONARIES: no ischemic changes on EKG, trop mildly elevated to 0.02, no sx of angina. Monitored on tele, continued metoprolol. . # RHYTHM/Afib: Monitored on tele, noted to have afib. On coumadin at home, however INR supratherapeutic at 4.0 so was held on admission. Pt was given 5 mg vitamin K prior to EP attempt at BiV pacer, and again prior to epicardial lead placement. Also continued digoxin. His coumadin was then restarted. In the setting of amiodarone he became supratherapuetic quickly. His coumadin was held and on the day of discharge his INR was 3.1. He will have his INR checked at Rehab and they will restart his coumadin at 2mg when his INR is between [**3-2**]. # Hypothyroidism: had not been taking levothyroxine, TSH 17 on admission, however is AOx3, no periorbital edema or concern for myxedema coma. Repeat TSH was 24. He needs to have his TSH, total T4, T3 resin in 1 week and follow up with endocrinology. # Elevated bilirubin: Pt [**Name (NI) 3539**] was noted to be elevated. It was trended for some time and there was concern about disease of the gallbladder or liver. RUQ U/S shows no significant changes and no signs of infection or obstruction. It was noted that his [**Name (NI) 3539**] has been chronically elevated for years and has been worked up in the past with no definitive diagnosis. His LFTs were no longer trended and he remained asymptomatic. # HTN: We discontinued his valsartan and we uptitrated his metoprolol 200mg PO Daily. # gout: continued allopurinol at decreased dose in [**Last Name (un) **] (100 mg daily) and daily colchicine. # Diabetes: cont lantus and SSI with novolog #Code status: Full code (confirmed on this admission) Medications on Admission: ALLOPURINOL - 300 mg Tablet - 1 Tablet(s) by mouth daily AMIODARONE - 200 mg Tablet - one Tablet(s) by mouth daily COLCHICINE - 0.6 mg Tablet - 1 Tablet(s) by mouth once a day COMPRESSION STOCKINGS - - Wear on both legs each night at bedtime 15-20mm h2o DIGOXIN - 125 mcg Tablet - one Tablet(s) by mouth daily on tues-thurs-sat INSULIN ASPART [NOVOLOG] - (Prescribed by Other Provider) - 100 unit/mL Solution - per sliding scale INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) - 100 unit/mL Solution - 15 units as needed or depending on sugar level LEVOTHYROXINE [LEVOXYL] - 50 mcg Tablet - 1 tablet by mouth daily - No Substitution METOLAZONE - 2.5 mg Tablet - one Tablet(s) by mouth in the morning on Tu-Th-Sa take one tablet 30 minutes prior to taking torsemide METOPROLOL SUCCINATE - 25 mg Tablet Extended Release 24 hr - ONE Tablet(s) by mouth daily TORSEMIDE - 20 mg Tablet - 4 Tablet(s) by mouth in the morning VALSARTAN [DIOVAN] - 40 mg Tablet - one Tablet(s) by mouth daily WARFARIN - (not sure who gave him rx) - 5 mg Tablet - 1 (One) Tablet(s) by mouth once a day as directed to maintain INR 2.0-3.0 WARFARIN - 4 mg Tablet - 1 Tablet(s) by mouth daily or as directed WARFARIN - 1 mg Tablet - Take up to 4 Tablet(s) by mouth daily or as directed by coumadin clinic Medications - OTC ACETAMINOPHEN [TYLENOL EXTRA STRENGTH] - (OTC) - 500 mg Tablet - 2 Tablet(s) by mouth only as needed LOPERAMIDE [ANTI-DIARRHEA] - (Prescribed by Other Provider) - 2 mg Tablet - 1 Tablet(s) by mouth as needed with diarrhea from colchicine MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - (OTC) - Tablet - 1 Tablet(s) by mouth once a day SODIUM BICARB-SODIUM CHLORIDE [NASA MIST] - 1 % Aerosol, Spray - 1 spray nasal twice a day as needed for runny nose Discharge Medications: 1. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 2. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO 3X/WEEK (TU,TH,SA). 4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. 9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Until [**2180-6-1**] and then decrease to 200mg PO Daily. 11. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Please hold warfarin and Check INR on Sunday [**2180-5-14**]. If below 3 start warfarin at 2mg. . 12. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 13. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. metoprolol succinate 200 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 15. insulin glargine 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous at bedtime as needed for As needed for high sugar. 16. insulin lispro 100 unit/mL Solution Sig: As per sliding scale Subcutaneous QACHS. 17. Outpatient Lab Work TSH, total T4, T3 resin Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Acute on chronic systolic congestive heart failure: holding [**Last Name (un) **] because of [**Last Name (un) **] Ventricular tachycardia Acute on Chronic Kidney Injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were seen in the hospital for firing of your ICD and for fluid overload. The fluid overload was most likely caused by a worsening of your heart failure, since you had not been taking medications for several weeks. The heart failure worsening likely was also the cause of arrhythmias (irregular heart rhythms) that caused your defibrillator to fire. For your fluid overload, you were treated with IV lasix and the swelling in your legs improved. It will be very important to continue taking your medications at home to avoid having the fluid build up again. You should weigh yourself every morning and call your doctor if weight goes up by more than three pounds in one day or five pounds in three days, as this can be a sign of fluid overload. We made the following changes to your medications: 1. Stop taking Metolazone and valsartan 2. Increase Metoprolol to 100 mg daily 3. Decrease Allopurinol because of your kidney function 4. Decrease Torsemide to 20mg per day 6. Increase amiodarone to 400 mg daily for 10 days, then decrease to 200 mg 7. STart Colace, seanna and miralax to prevent constipation 8. STart trazadone to help you sleep. Followup Instructions: Department: CARDIAC SERVICES When: TUESDAY [**2180-5-16**] at 3:00 PM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: CARDIAC SERVICES When: TUESDAY [**2180-5-16**] at 3:30 PM With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Please call Dr. [**Last Name (STitle) 3540**] and make an appoinmtent after you fax him the results of the thyroid lab work. Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 3540**] [**Hospital1 18**] - Division of Endocrinology View Map [**Location (un) 830**], [**Hospital Ward Name 452**]/Rose 1 [**Location (un) 86**], [**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 1803**] Fax: [**Telephone/Fax (1) 3541**]

[ "790.92", "250.00", "V53.32", "428.23", "427.1", "276.8", "426.3", "244.9", "V58.67", "397.0", "585.9", "427.41", "785.51", "427.31", "425.4", "424.0", "E934.2", "V58.61", "428.0", "584.9", "274.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "86.09", "00.51" ]

icd9pcs

[ [ [] ] ]

20060, 20126

12487, 16685

315, 322

20340, 20340

4509, 12464

21668, 22685

2882, 2973

18499, 20037

20147, 20319

16711, 18476

20491, 21267

2988, 3828

3842, 4490

21296, 21645

247, 277

350, 2091

20355, 20467

2113, 2509

2525, 2866

30,132

154,077

33160

Discharge summary

report

Admission Date: [**2101-1-22**] Discharge Date: [**2101-2-5**] Date of Birth: [**2080-1-29**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2534**] Chief Complaint: s/p Stabbing assault Major Surgical or Invasive Procedure: 1. 4 compartment release, fasciotomy left lower extremity 2. irrigation and debridement of medial and lateral fasciotomies, with closure of medial fasciotomy and vacuum placement on lateral fasciotomy 3. washout and debridement of fasciotomy with lateral fasciotomy closure 4. washout of left lower extremity and bronchoscopy, with bronchoalveolar lavage History of Present Illness: 20 yo M brought in with atab wound to his right chest in the third intercostal space. +ETOH, +marijuana on patient at time of arrival. A trauma stat was called immediately. A chest tube was placed at the bedsite with immediate release of 300 cc of bloody return, a second tube was also subsequently placed. The patient was intubated and taken to the TICU. Past Medical History: none Social History: Lives at home w/parents, is currently not working, but plans to go to community college in spring. Family History: Noncontributory Physical Exam: Upon admission: 101.8 F (rectal) 141 82/41 R 30 98% NRB mask General: moderate distress Eyes: wnl Neck: trachea midline Respiratory: decreased breath sounds on right, no crepitus Cardiovascular: nl rate regular rhythm Chest: deep 2 inch stab wound Gastrointestinal: soft, non-tender, ansus/perineum normal Musculoskeletal: MAEW Skin: wwp Pertinent Results: on admission: [**2101-1-22**] 01:18AM WBC-13.5* RBC-4.99 HGB-16.1 HCT-45.1 MCV-90 MCH-32.3* MCHC-35.7* RDW-13.5 [**2101-1-22**] 01:18AM ASA-NEG ETHANOL-116* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2101-1-22**] 02:15AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-POS amphetmn-NEG mthdone-NEG [**2101-1-22**] 01:18AM PLT COUNT-258 [**2101-1-22**] 01:18AM PT-15.4* PTT-29.7 INR(PT)-1.4* [**2101-1-22**] 01:26AM GLUCOSE-197* LACTATE-12.7* NA+-144 K+-3.4* CL--104 TCO2-10* pertinent imaging: [**1-22**]: Head CT - R epidural hematoma, L acute subdural hematoma, L frontal parenchymal hemorrhage with subarachnoid hemorrhage, Complex R temporal bone fracture extending to the sphenoid sinus with hemorrhage in the right side of sphenoid sinus, external and middle ears and some mastoid air cells. [**1-22**]: C-spine - no acute fractures [**1-22**]: CT C/A/P - R rib fractures w/ ptx and subq emphysema r chest wall into the right neck. Focal hypodensity of the inferior liver, ? focal liver laceration. Small amount of perihepatic fluid or hemorrhage. Fluid within the lesser sac, nonspecific. Displaced right scapular fracture. Consolidation and/or atelectasis involving the lung bases bilaterally. Small focal areas of probable pulmonary contusion on the right. Anterior wedging of the T12 vertebral body. [**1-22**]: CXR - Chest tube and CVL in good position [**1-22**]: Head CT - no interval change [**1-22**]: CTA Head: no dissection repeat head CT [**1-23**] (prelim): no interval change Shoulder x-ray [**1-23**]: low grade AC joint sprain, mildly displaced right scapular fracture Multiple right-sided rib fractures, subcutaneous emphysema of the right lateral chest wall, and right-sided chest tube [**1-25**]: CT Head - unchanged from previous [**1-26**]:RUE U/S - Acute occlusion R axillary v.; thrombosis R basilic v. Brief Hospital Course: He was admitted to the Trauma ICU after initial stabilization in the emergency department. He was kept on telemetry, and was extubated the following morning. A cardiac ECHO was repeated which did not show signs of cardiac tamponade, but only a small pericardial effusion. On HD 1, he began to complain of left leg pain, with decreased DP sensation, 0/5 extensor hallicus longus strength. Pressures in his left leg were measured to be high, and he had q2hour exams. He was taken to the OR in the evening for fasciotomy of possible evolving compartment syndrome. No evidence of necrosis was seen. For further information, please refer to the operative report. On HD 2, his pain was better controlled, and a plan was made for delayed closure of his leg. The patient had a repeat ECHO, and CTA performed to rule out PE given the patient's persistent tachycardia. On HD 3, he went back to the OR for medial fasciotomy closure, and a wound vac was placed on his lateral fasciotomy. On HD 4, he was transferred to the floor, advanced to a regular diet, and one of his two chest tubes was removed. The patient continued to make good progress. On HD 5, he returned to the OR with orthopedics. His vac was changed in the OR as his fasciotomy was unable to be closed. On HD 6, he was taken to the OR for washout of his lower extremity wound in the setting of a temperature to 103.3. Bronchoscopy was also performed and lavage was sent. His PCA was discontinued, and he began to work with physical therapy on walking. His second chest tube was removed. The patient was taken to the OR for multiple washouts and debridements of his leg. The leg was finally closed on HD 15. Patient was sent home on POD 14 with physical therapy and plans to follow up in trauma clinic and with orthopedics in [**1-12**] weeks. Medications on Admission: None Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 3. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for constipation. 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 5. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours). 6. Outpatient Physical Therapy Please have physical therapy work with patient specifically his left leg. This script is good for 10 sessions. Discharge Disposition: Home Discharge Diagnosis: s/p Multiple stab wound assault Right pneumo/hemothorax Lower extremity compartment syndrome Discharge Condition: Good Discharge Instructions: You have been admitted to [**Hospital1 69**] after sustaining a stab wound. You have been managed by the trauma and orthopedics teams. You have gone to the operating room for your left leg pain for concern for compartment syndrome. Initially, you had your leg left open. A wound vac was subsequently placed and you incision is now closed. Please [**Name8 (MD) 138**] MD or visit ER if you experience any of the following symptoms: Temp>101.5, chest pain, shortness of breath, severe abdominal pain, nausea/vomiting, redness or drainage from around the any of the wounds. You will need to call the trauma clinic to schedule a follow up appointment in approximately 1 week. You may shower however do not bathe in a tub or go swiming. Please keep the wound clean and dry. You do not need to cover the incision. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 519**] in Trauma clinic 1 week from your discharge. Please call [**Telephone/Fax (1) 6429**] to make an appointment. Follow up with Dr. [**Last Name (STitle) 1005**], Orthopedics, in 2 weeks, call [**Telephone/Fax (1) 1228**] for an appointment.

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icd9cm

[ [ [] ] ]

[ "99.04", "93.59", "96.04", "83.14", "38.93", "86.22", "83.32", "33.24", "34.04", "96.71" ]

icd9pcs

[ [ [] ] ]

6075, 6081

3518, 5331

334, 691

6219, 6226

1631, 1631

7089, 7388

1240, 1257

5388, 6052

6102, 6198

5357, 5363

6250, 7066

1272, 1274

274, 296

719, 1079

1645, 3495

1101, 1107

1123, 1224

10,616

122,738

27988

Discharge summary

report

Admission Date: [**2161-6-3**] Discharge Date: [**2161-6-5**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1711**] Chief Complaint: Transfer from OSH for Aortic Abscess Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 16905**] is an 83 year old man with a PMH significant for DM2, COPD, PVD, AS, AI needing valve replacement who presented to OSH with fatigue and dyspnea thought to be related to his valvulopathy and CHF +/- related to MI or PNA. He was initially treated with Levofloxacin. Subsequently, Strep Viridans grew from blood cultures (1 out of 2 bottles)and he underwent a TTE which showed only AS and AI. He then suffered from respiratory failure (thought to be related to his AI/CHF) requiring intubation. A TEE then found a 1.5 x 2 cm abscess in the NCC region of the Aorta abutting the LA. Culture data from his S. Viridans then came back sensitive to Cefalosporins and he was started on Rocephin and given a dose of Aminoglycosides. He was subsequently transferred to BIMDC for probably surgery to his Aortic root and valve. Social History: Married. Pt is primary caregiver [**First Name (Titles) **] [**Last Name (Titles) 68154**] wife. Quit [**Name2 (NI) **] 40+ yrs ago; Rare ETOH Family History: Father died of CAD in 50's; Mother died in 80s (unknown) Physical Exam: [**Age over 90 **]F 115/52 105 16 100% O2 Sats AC 700x14 Fio2 0.5 PEEP 5 GEN: Pt intubated, alert. Responds to questions with head nods. Follows commands (hand squeeze on appropriate side) HEENT: Pinpoint pupils, MMM NECK: Supple, No LAD, No JVD CV: RR, NL rate. NL S1, S2. III/VI HSM RUSB; II/VI Diastolic rumble, rubs or [**Last Name (un) 549**]. 2+ pulses throughout. LUNGS: Occasional ronchi BL, No W/C ABD: Soft, [**Name (NI) **] (pt alert enough to respond to commands and stimuli) Slightly distended. NL BS. Liver enlarged to 2cm below ribs and palpable spleen. EXT: No edema. 2+ DP pulses BL SKIN: Sternal scar from prior surgery; Bilat leg scars (medial) from bypass [**Doctor First Name **]. CCY scar on Abd. NEURO: CN 2-12 grossly intact. Preserved sensation throughout. [**1-19**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred Pertinent Results: [**2161-6-3**] 05:40PM PT-15.0* PTT-34.5 INR(PT)-1.3* [**2161-6-3**] 05:40PM PLT COUNT-181 [**2161-6-3**] 05:40PM NEUTS-91.8* LYMPHS-4.2* MONOS-3.7 EOS-0.1 BASOS-0.1 [**2161-6-3**] 05:40PM WBC-24.6* RBC-4.18* HGB-13.1* HCT-38.6* MCV-92 MCH-31.4 MCHC-34.0 RDW-13.3 [**2161-6-3**] 05:40PM TSH-1.5 [**2161-6-3**] 05:40PM ALBUMIN-3.1* CALCIUM-8.2* PHOSPHATE-4.5 MAGNESIUM-2.1 [**2161-6-3**] 05:40PM CK-MB-2 cTropnT-0.18* [**2161-6-3**] 05:40PM LIPASE-53 [**2161-6-3**] 05:40PM ALT(SGPT)-83* AST(SGOT)-54* LD(LDH)-266* CK(CPK)-136 ALK PHOS-134* AMYLASE-118* TOT BILI-1.4 [**2161-6-3**] 05:40PM GLUCOSE-166* UREA N-31* CREAT-1.7* SODIUM-141 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-23 ANION GAP-18 [**2161-6-3**] 05:59PM O2 SAT-98 [**2161-6-3**] 05:59PM LACTATE-1.6 [**2161-6-3**] 05:59PM TYPE-ART PO2-140* PCO2-35 PH-7.42 TOTAL CO2-23 BASE XS-0 [**2161-6-3**] 06:00PM O2 SAT-66 [**2161-6-3**] 06:00PM TYPE-MIX [**2161-6-3**] 10:18PM URINE RBC-21-50* WBC-0-2 BACTERIA-MOD YEAST-NONE EPI-0-2 [**2161-6-3**] 10:18PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2161-6-3**] 10:18PM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.023 . TEE ([**2161-6-3**] in RI): EF 30%. Eccentric AI. 1.5-2cm abscess in NCC area --> [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 68155**] communication with aorta. Mod TR, Mild MR. . EKG: AFib with rate 100. Nl Axis and intervals. RBBB. PVCs. . TTE Conclusions: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is top normal/borderline dilated. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The aortic root is markedly dilated. The ascending aorta is moderately dilated. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. There is at least moderate aortic valve stenosis. Mild (1+) aortic regurgitation is seen. An echodense mass is seen in the posterior aortic root at the noncoronary sinus of Valsalva, protruding into the left atrium and measuring 1.8 by 1.7 cm. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is a small to moderate sized pericardial effusion. There are no echocardiographic signs of tamponade. Impression: aortic root abscess/phlegmon . TEE GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the procedure. No TEE related complications. Resting tachycardia (HR>100bpm). The rhythm appears to be atrial fibrillation. Echocardiographic results were reviewed with the houseofficer caring for the patient. Left pleural effusion. Conclusions: No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. LV systolic function appears depressed. Right ventricular systolic function is normal. The sinuses of Valsalva are dilated. There are complex (>4mm) atheroma in the ascending aorta, aortic arch, and descending aorta. The aortic valve leaflets are severely thickened/deformed. The severity of the aortic stenosis was not determined. There are two moderate-sized regions of inflammation/vegetation (0.8 cm each) on the left and non-coronary cusps of the aortic valve at the area of leaflet coaptation. An aortic annular abscess is seen (0.8 - 1.2 cm), in the region of the left and non-coronary cusps. Moderate to severe (3+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is a trivial/physiologic pericardial effusion. . Brief Hospital Course: ASSESSMENT: The patient is an 83 year old man with CAD s/p CABG, HTN, DMII, [**Hospital 2182**] transferred from OSH with aortic valve endocarditis and abscess. . # AV Endocarditis/Abscess: Evidence of this per TEE at OSH in conjunction with fevers. Pt grew Strep Viridans 1/2 bottles sensitive to Cephalosporins. Has hx of AVD to native valve. Pt now hemodynamically stable on low dose of Levophed. CP free. TTE/TEE at [**Hospital1 18**] revealed 2 abscesses at aortic root and preserved EF. We continu Ceftriaxone 2mg daily (discussed with ID) and added additional antibiotics (Vancomycin and Flagyl). CT surgery was made aware of patient and prepared to discuss options with family but felt that his prognosis was grim. He expired on HD #1. Family was en route but was updated frequently. At time of death, he required 3 pressors and could not maintain his BP. In addition, his heart rate was >160. . # AFib: Unclear of duration, but has been documented to be in and out of AFib since admission to OSH. - Rate poorly controlled and we held on nodal agents at first given risk of heart block in setting of abscess. PRN BB was given eventually despite pressors for HR >140s. - We held Coumadin or Heparin gtt anticoagulation given intracranial bleed in past but will administer Sub Cutaneous Heparin 5000 units TID . # Respiratory failure: Secondary to AI/CHF. On vent throughout admission until time of death. . # DM2: RISS and QACHS FS . # Hypothyroidism: Levothyroxine at transfer dose . # FEN: NPO (nutrition consult pending); No need for IVFs given Swan #s; . # PPx: Heparin Sub Cu, PPI . # CODE: FULL CODE . # COMM: With son, pt, wife . # DISP: Expired. Family aware. RI transfer MD aware. . Medications on Admission: Ceftriaxone 2g IV q24' Synthroid 50mcg daily Protonix ASA 81 mg daily Heparin SC 5000u TID Ativan/Morphine Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

[ "038.0", "443.9", "447.9", "496", "V15.82", "785.51", "427.31", "V17.3", "421.0", "428.0", "518.81", "250.00", "785.52", "V66.7" ]

icd9cm

[ [ [] ] ]

[ "88.72", "96.6", "96.71", "38.93" ]

icd9pcs

[ [ [] ] ]

8213, 8222

6339, 8055

297, 303

8273, 8282

2307, 6316

8338, 8348

1353, 1411

8243, 8252

8081, 8190

8306, 8315

1426, 2288

221, 259

331, 1177

1193, 1337

29,478

163,798

32816

Discharge summary

report

Admission Date: [**2103-2-23**] Discharge Date: [**2103-2-24**] Date of Birth: [**2024-9-4**] Sex: F Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 3326**] Chief Complaint: respiratory arrest Major Surgical or Invasive Procedure: none History of Present Illness: 78 year-old female with chronic trach presented to ER for hypoxia, s/p respiratory arrest in ER, admitted to [**Hospital Unit Name 153**]. At her vent facility she was found to be blue and hypoxic. Out of concern for a right-sided PTX, she was sent to the ED. In the ED BP133/66, HR 82, 98% on Portable CXR was without PTX. Repeat CXR with concern for PNA, and she was given levofloxacin, ceftriaxone and ativan 1mg x2. She was about to be discharged to her nursing home, when she had a respiratory arrest at 9:58 pm. She underwent chest compressions for 30 seconds, no meds were given. Upon taking down her trach dressings, it was apparent that the trach tube was disconnected from respirator. They reconnected the trach tube with resolution of her hypoxia. She was admitted to the [**Hospital Unit Name 153**] for overnight monitoring. Past Medical History: -Ventillator dependence since [**1-5**] s/p trach (perhaps due to GBS), successfully decanulated in [**10-7**], however readmitted [**Date range (1) 76415**] for evaluation of small tracheal mass and desaturated in the setting of bronchoscopy and trach was replaced. -chronically vented with settings of: AC 0.6/500/12/5 -HTN -CHF -DMII c/b neuropathy -anemia -CAD -syncope -hyperlipidemia -COPD -Afib Social History: former smoker, quit 20 years ago Family History: NC Physical Exam: T:96 BP:143/46 P:86 RR:15 O2 sats:96% AC 0.6/500/12/5 Gen: obese, elderly female, tracheostomy, anxious, clapping and reaching out at nurses HEENT:NCAT, PERRL, EOMI Neck: no masses CV: RRR no MRG, nl S1, S2 Resp: vented breath sounds, CTAB anteriorly Abd: obese, NABS, soft, NTND, no guarding/rigidity/rebound Ext: no pedal edema, 2+ symmetric pedal pulses, extremities warm to palpation Neuro: lower extremity strength 3/5, moving all 4 extremities Pertinent Results: [**2103-2-23**] 05:05PM WBC-10.2 RBC-2.85* HGB-8.7* HCT-26.8* MCV-94 MCH-30.4 MCHC-32.4 RDW-15.0 [**2103-2-23**] 05:05PM NEUTS-90.7* LYMPHS-5.4* MONOS-3.4 EOS-0.3 BASOS-0.2 [**2103-2-23**] 05:05PM PLT COUNT-243 [**2103-2-23**] 05:05PM PT-13.4 PTT-27.2 INR(PT)-1.1 [**2103-2-23**] 05:05PM CK-MB-NotDone [**2103-2-23**] 05:05PM cTropnT-<0.01 [**2103-2-23**] 05:05PM CK(CPK)-22* [**2103-2-23**] 05:05PM GLUCOSE-121* UREA N-26* CREAT-0.7 SODIUM-143 POTASSIUM-3.8 CHLORIDE-114* TOTAL CO2-24 ANION GAP-9 [**2103-2-23**] 11:22PM LACTATE-0.9 [**2103-2-23**] 11:22PM TYPE-ART TEMP-37.0 RATES-16/15 TIDAL VOL-550 PEEP-5 PO2-88 PCO2-52* PH-7.39 TOTAL CO2-33* BASE XS-4 -ASSIST/CON INTUBATED-INTUBATED VENT-CONTROLLED [**2103-2-24**] CXR: 1. Mild pulmonary vascular congestion. Brief Hospital Course: 78 year-old female with chronic trach presented to ER for hypoxia, had respiratory arrest in the setting of trach coming detached from the ventillator, stable throughout ICU course with no acute issues. 1)Hypoxia/respiratory arrest - most likely due to trach being detached from the ventillator. Likely accidental however concern that patient may possibly detach trach on her own in order to get the attention of staff. On admission to [**Hospital Unit Name 153**] she is stable and saturating well on usual vent settings. Initially transferred to ED out of concern for hypoxia/possible PTX. She was started on vanomycin and zoysn on [**2-24**] for planned course of 2 weeks for possibility of ventillator associated pneumonia given purulent secretions from trach and question of RLL opacity on CXR. There was no pneumothorax evident on CXR. During her admission she was continued on CMV 50%/550/16/5. 2)Brief cardiac arrest - had brief episode of pulselessness in the ED after becoming acutely hypoxic following detachment of trach. She did have chest compressions however no medications or shocks administered. Pulse returned promptly after re-attaching ventillator. No changes on EKG. 3)Chronic respiratory failure s/p trach -> possibly [**3-3**] GBS, also with element of tracheomalacia, continue with outpatient treatment regimen. Has had all prior care at [**Hospital1 2177**], would recommend follow up and continued outpatient managment at [**Hospital1 2177**] given that patient is well known to that hospital. She was maintained on her usual vent settings, nebs, spiriva and prednisone, with no changes to dosing or regimen. 4)anxiety/depression - h/o night time anxiety, per medical records she responds well to seroquel. Has a 24 hour sitter at her rehab facility. She was continued on her regimen of seroquel standing and prn, wellbutrin and celexa. 5)Tremor -continue primidone 6)HTN: continue outpatient regimen of lisinopril, lopressor 7)DMII - continue with lantus, hss. She was only given 1/2 dose of usual insulin however she was hypoglycemic this morning most likely due to prolonged NPO. She was resumed on her tube feeds overnight. 8)Chronic bilateral knee/hip pain - She was continued on her outpatient regimen of percocet. 9)PPX: SC Heparin, bowel regimen 10)Code Status: presumed full Medications on Admission: Percocet 5/325 Q4hrs prn Colace 100 [**Hospital1 **] lopressor 25 [**Hospital1 **] lisinopril 10 qday hydralazine 25mg q4hr prn heparin 5000 sc tid seroquel 50qHS and 25mg [**Hospital1 **] seroquel 12.5mg [**Hospital1 **] prn spiriva 18 daily celexa 20mg daily albuterol prn prednisone 10mg daily zantac 150mg daily wellbutrin 75mg [**Hospital1 **] MTV primidone 250mg TID lantus 34 units qHS lispro 3 units q4 SQ Discharge Medications: 1. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). Tablet(s) 2. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day) as needed for anxiety. 3. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 5. Docusate Sodium 50 mg/5 mL Liquid Sig: as directed PO BID (2 times a day). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 10. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Ranitidine HCl 15 mg/mL Syrup Sig: One [**Age over 90 1230**]y (150) mg PO BID (2 times a day). 13. Bupropion 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 15. Primidone 50 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 18. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 19. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 20. Insulin Lispro 100 unit/mL Solution Sig: Three (3) units Subcutaneous every four (4) hours. 21. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous at bedtime: titrate back to outpatient dose of 34 units QHS . 22. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1) Intravenous Q6H (every 6 hours): for total of 14 days, start date [**2-24**]. 23. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: 1000 (1000) mg Intravenous Q 24H (Every 24 Hours): start date [**2103-2-24**], continue for 14 days. Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital Discharge Diagnosis: Respiratory Arrest Pneumonia Discharge Condition: Fair Stable on home ventillator settings Discharge Instructions: You were admitted to the hospital because of acute respiratory distress/arrest due to disconnection of your tracheostomy tube from the ventillator. Your hear also stopped beating for a few seconds as well. You improved very quickly once your ventillator was reattached. You stayed in the ICU overnight and did very well. You were continued on all of your usual medications with no changes made. You are being transferred back to the rehab facility that you came from. Please continue with your previously arranged outpatient care. You should follow up with your primary care doctor within one to two weeks after discharge from the hospital. Followup Instructions: Please follow up with your primary care doctor in [**1-31**] weeks. Please follow up with your pulmonologist at [**Hospital3 9947**] as previously arranged.

[ "414.01", "496", "357.0", "V46.11", "401.9", "518.84", "V55.0", "250.60", "272.4", "486", "V10.05", "357.2", "427.31", "428.0", "V58.67" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

7917, 7972

2953, 5289

286, 292

8045, 8088

2141, 2930

8783, 8944

1651, 1655

5754, 7894

7993, 8024

5315, 5731

8112, 8760

1670, 2122

228, 248

320, 1159

1181, 1585

1601, 1635

14,008

160,109

8306

Discharge summary

report

Admission Date: [**2137-2-25**] Discharge Date: [**2137-3-12**] Date of Birth: [**2059-5-6**] Sex: F Service: MEDICINE Allergies: Strawberry / Shellfish Attending:[**First Name3 (LF) 458**] Chief Complaint: Aortic stenosis, CHF and lower GI bleed Major Surgical or Invasive Procedure: cardiac catherization History of Present Illness: 77 year old woman tranferred from the [**Hospital 1474**] hospital for consideration of aortic valve replacement. Admitted to the [**Hospital1 1474**] on [**2-14**] with UTI sepsis, pneumonia and colitis after presenting a syncopal episode. Her BP was found to be 60/palp. She was given IVFs and antibiotics and transferred to the CCU. She suffered a PEA arrest and was briefly intubated, but was extubated within a few hours per her family. She underwent a Echocardiogram that revelaed AS with a valve area of 0.7 and and abdominal imaging that revealed a 4.2 cm AA. She was evaluated by Vascular surgery, but was not felt to be a surgical candidate. Patient had multiple episodes of abdominal pain and bloody diarrhea following an episode of PEA arrest. CT showed an area of colon consistent with inflammation / infection / ischaemia and a fusiform aortic anneurysm. She was treated with multiple antibiotic regimens while at [**Hospital1 1474**]. Her course was also complicated by acute on chronic renal faily with creatinine up to 3.7 but back to 1.4-1.6 by discharge. On aspirin for many years, but denies any other NSAID use recently. Bowels have settled down over the past week. Currently no pain in the abdomen. Had 2 bowel movements today - semi solid maroon stool, guaiac positive. Last colonoscopy 3-4 years ago at [**Hospital1 1474**]. Reportedly removed polyps. Denies CP, SOB, dizziness and breathing feels improved. 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. She denies recent fevers, chills or rigors prior to admission to OSH. She denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: COPD CKD with baseline creatinine around 2.0 AS valve area 0.6 cm DM2 - but denies formal diagnosis of this Hypothyroidism [**2135**] - primary lung carcinoma T2M0N0. Excised, no recurrence. [**2135**] - left hip replacement [**2133**] - right total hip replacement x2 [**2128**] - CABG [**2128**] - LIMA to LAD, SVG OM/D1/RCA Social History: Social history is significant for the absence of current tobacco use, quit 9 years ago, denies drug use, occasional wine. There is no history of alcohol abuse. Family History: Father died of MI at age 60, sister died of ? CA, grandfather died of MI. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: T 98.1, BP 125/50 , HR 101 , RR 18 , O2 93 % on 3 L Gen: Elderly female sitting up in bed in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa, MM dry. Neck: Supple with JVD hard to asses given line in place CV: RR, normal S1, S2. No S4, no S3 appreciated, [**3-21**] sysolic mumrur at RUSB. Chest: Resp were unlabored, no accessory muscle use. crckles [**1-16**] way up lung flield s bilaterally Abd: soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; 2+ DP Neuro: CN II-XII intact, strength in upper and lower extremities [**5-20**] and equal Pertinent Results: ADMISSION LABS: [**2137-2-26**] 01:00AM BLOOD WBC-10.3 RBC-2.87* Hgb-8.8* Hct-27.3* MCV-95 MCH-30.5 MCHC-32.0 RDW-14.7 Plt Ct-345# [**2137-2-26**] 01:00AM BLOOD PT-13.2 PTT-29.8 INR(PT)-1.1 [**2137-2-26**] 01:00AM BLOOD Plt Ct-345# [**2137-2-26**] 01:00AM BLOOD Glucose-81 UreaN-35* Creat-1.4* Na-144 K-5.1 Cl-109* HCO3-23 AnGap-17 [**2137-2-26**] 01:00AM BLOOD ALT-16 AST-23 LD(LDH)-217 AlkPhos-93 Amylase-191* TotBili-0.7 [**2137-2-26**] 01:00AM BLOOD Albumin-2.9* Calcium-8.6 Phos-3.4 Mg-1.3* ADMISSION EKG: NSR rate 93, nl axis, PVC, biphasic T waves in V2-V6, nl intervals. [**2137-2-26**] TTE: The left atrium is normal in size. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the basal inferior and inferolateral walls. The remaining walls contract normally and overall EF is preserved.. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). There are simple atheroma in the aortic root The ascending aorta is 0.6 cm2). Mild to moderate ([**1-16**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**1-16**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. The pulmonic valve leaflets are thickened. No pericardial effusion seen. IMPRESSION: Severe aortic stenosis (0.6 cm). Mild to moderate aortic regurgitation. Moderate symmetric LVH with mild regional LV dysfunction but overall preserved function. Moderate pulmonary hypertension. Mild to moderate mitral regurgitation. [**2-25**] CXR: There are new bilateral interstitial opacities and peribronchial cuffing, more striking on the right than left, since [**2136-10-18**]. The appearance is most suggestive of interstitial pulmonary edema, arising in the setting of underlying emphysema. The patient also has known subpleural fibrosis, better characterized on a prior CT from [**2136-4-19**]. Small bilateral pleural effusions are also present. The patient is status post CABG, and elevation of the left hemidiaphragm appears unchanged. [**2137-3-2**] Tagged RBC Study: No evidence of gastrointestinal bleeding [**2137-3-4**] Colonoscopy: Diverticulosis of the sigmoid colon and descending colon upto 40cm (area reached). Erythema, congestion and ulceration involving 2/3rd of circumference in the distal descending colon( at 40cm)-- findings highly suggestive of ischemic colitis Brief Hospital Course: SEVERE AORTIC STENOSIS Ms. [**Known lastname 3549**] has severe AS with a valve area of 0.6, as well as mild to moderate aortic regurgitation. Given her ischemic bowel (see below), she was not considered an acute surgery candidate. A temporizing aortic valvuloplasty was considered on [**2137-3-7**] with the hopes that she would be eligible for AVR in several weeks to months once her gut has stablized. The cardiac catheterization showed a mean gradient of 23mmHg across valve hence no valvuloplasty was performed. Throughout her hospitalization, she required large volumes of IVF (and briefly levophed pressor support) to maintain blood pressures, but she maintained her oxygen saturation and did not require mechanical ventillation at any point. Aortic valvuloplasty was considered to help heal mesenteric ischemia. However, during her repeat cardiac catheterization her AV gradient was measured using an aortic catheter and an LV catheter via a transeptal approach which showed less severe gradient than on ECHO. Therefore, no valvuloplasty was pursued and valve replacement was not currently recommended given significant operative risk. . GI BLEED Ms. [**Known lastname 3549**] was admitted from the OSH with active lower GI bleeding, requiring multiple blood transfusions to maintain her hematocrit. Abdominal CT from the OSH was concerning for ischemic colitis. At [**Hospital1 18**], the GI service was consulted and performed a tagged RBC study on [**2137-3-2**], which showed no active bleeding. Despite his, she continued to have bloody stools and decreasing hematocrit. A colonoscopy was performed on [**2137-3-4**], which showed erythema, congestion and ulceration of the descending colon, consistent with ischemic colitis. By [**2137-3-5**], her bleeding stopped and her hematocrit had stabilized. The GI surgery service followed Ms. [**Known lastname 3549**] throughout her admission and deferred bowel surgery at this point because of her high operative risk. She completed a 7 day course of cipro/flagyl/ampicillin per surgical recommendations. Her GI bleeding slowly resolved over the course of her admission. . CAD Pt s/p CABG [**2128**] with LIMA --> LAD, SVG to D1 / OM / RCA. Has biphasic Twaves in lateral leads, unchanged from prior. No chest pain. She was continued on her aspirin and started on Atorvastatin 40mg, favored over her home Zetia for cholesterol control. On further questioning with family, the patient develops leg cramps from statins. Should continue to monitor. She had a cardiac catheterization which showed 3 vessel disease but no intervention was performed. Given patient's significant operative risk, she was further risk stratified with a persantine MIBI which showed normal myocardial perfusion. Medical management was elected. . Chronic Kidney Disease Likely [**2-16**] HTN, baseline Cr 2.0. Currently improved from baseline to 1.0, unclear if [**2-16**] loss of muscle mass vs. improved forward flow. Continued to maximize cardiac output / renal perfusion with afterload reduction. No further diuresis given. . HTN Currently SBP in 110s. Started lopressor 50mg [**Hospital1 **]. Decreased lisinopril to 5mg daily. Diltiazem was discontinued. Restarting HCTZ 25mg will be left up to Dr. [**Last Name (STitle) 7047**] at her outpatient follow visit in 2 weeks time. Medications on Admission: ACETAMINOPHEN 500 mg--1 to 2 tablet(s) by mouth as needed ALPHAGAN P 0.15 %--in each eye twice a day ASPIRIN 81 mg--1 (one) tablet(s) by mouth once a day CARTIA XT 180 mg--1 (one) capsule(s) by mouth once a day COMBIVENT 18 mcg-103 mcg (90 mcg)/Actuation--1 (one) three times a day Calcium 600 + D 600 mg (1,500 mg)-200 unit--1 (one) tablet(s) by mouth once a day HYDROCHLOROTHIAZIDE 25 mg--1 (one) tablet(s) by mouth once a day LISINOPRIL 10 mg--1 (one) tablet(s) by mouth once a day LORAZEPAM 1 mg--1 (one) tablet(s) by mouth once a day Levothyroxine 25 mcg--1 (one) tablet(s) by mouth once a day MOTRIN 100 mg--2 (two) tablet(s) by mouth twice a day PRILOSEC 20 mg--1 (one) capsule(s) by mouth once a day Senior Vitamin --1 (one) tablet(s) by mouth once a day TRAVATAN 0.004 %--in each eye twice a day TYLENOL ARTHRITIS 650 mg--1 (one) tablet(s) by mouth ULTRAM 50 mg--1 tablet(s) by mouth every 6-8 hours as needed for pain ZETIA 10 mg--1 (one) tablet(s) by mouth once a day INPATIENT MEDICATIONS: Acetaminophen 650 mg PO Q6H:PRN Ascorbic Acid 500 mg PO DAILY Aspirin EC 81 mg PO DAILY Ciprofloxacin HCl 500 mg PO DAILY Ezetimibe 10 mg PO DAILY Heparin 5000 UNIT SC TID Insulin SC (per Insulin Flowsheet) Levothyroxine Sodium 25 mcg Magnesium Sulfate 2 gm IV ONCE MetRONIDAZOLE (FLagyl) 500 mg PO TID Metoprolol XL (Toprol XL) 6.25 mg PO DAILY Pantoprazole 40 mg PO Q12H TraMADOL (Ultram) 25 mg PO Q8H:PRN Vancomycin 1000 mg IV Q48H Discharge Medications: 1. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-16**] Puffs Inhalation Q6H (every 6 hours) as needed. 8. Brimonidine 0.15 % Drops Sig: One (1) Ophthalmic [**Hospital1 **] (). 9. Travoprost 0.004 % Drops Sig: One (1) Ophthalmic qpm (). 10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: Lifecare West Discharge Diagnosis: aortic stenosis GIB hypothyroid AAA CKD Discharge Condition: stable Discharge Instructions: you were admitted for for aortic valve replacement. your hospital course was complicated by concern for gi bleed. you had a cardiac catheterization which showed normal gradient and you did not have a aortic valvuloplasty. you were discharged to a rehab facility in order to regain your strength. return to the er if you develop worsening chest pain and dyspnea or any worrisome symptoms. Followup Instructions: Called and spoke with Dr.[**Name (NI) 9654**] office at [**Telephone/Fax (1) 8725**], they will call patient within the next 2 days and have her come into the office within the next 7-10 days. Provider: [**First Name11 (Name Pattern1) 2389**] [**Last Name (NamePattern1) 2390**], MD Phone:[**0-0-**] Date/Time:[**2137-4-25**] 2:30

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icd9cm

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49561

Discharge summary

report

Admission Date: [**2142-11-12**] Discharge Date: [**2142-11-17**] Date of Birth: Sex: F Service: Neurology HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 1968**] is a 75-year-old right-handed female with a history of hypertension who was found to be unconscious on the ground on the morning of admission date. She was last seen two days prior to admission. Neighbors found piled up magazines and newspapers from the day prior to admission. Due to the patient's state of consciousness, review of systems, past medical history, medications, allergies, social history, and family history could not be obtained. PHYSICAL EXAMINATION ON ADMISSION: Blood pressure was 140/72. Intubated on synchronized intermittent mandatory ventilation. The patient could not breathe over the ventilator. The neck felt supple. No carotid bruits. Head was atraumatic. Pulmonary and cardiovascular examinations were unremarkable. The abdomen was soft and nondistended. No cyanosis or skin rash could be witnessed. The [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) 2611**] Coma Scale was 6 (eyes 1, verbal 1, and motor 4). The patient's eyes were closed. Did not open with noxious stimulation or command. Bilaterally present corneal reflex. Did not respond to visual threat. Funduscopic examination was difficult because of small pupils. The pupils were equal in size at 1.5 mm and reactive bilaterally. Nystagmus was not present. No gaze preference or eye deviation. No grimace after noxious stimulation of the periocular notch. Gag reflex was absent. Oxycephalic testing was negative. Motor examination showed withdrawal response present in all limbs except for the left arm. On sensory examination, .................... posturing could be seen after noxious stimulation. The patient withdrew with her legs when stimulated. No response when the left arm was stimulated. The reflexes were symmetric. No clonus was present. The toes were upgoing bilaterally. LABORATORY EXAMINATION: White count was 19.1. Urinalysis with over 50 white blood cells. INR was 2.4. Creatine kinase was 1445. HOSPITAL COURSE: On admission, a magnetic resonance imaging showed a large right-sided intraparenchymal bleed with midline shift. The patient was admitted to the Neurology Service, and her neurological status was monitored every hour in the Intensive Care Unit. The patient received Dilantin intravenously in order to prevent seizures. Her blood pressure was monitored. She received mannitol to reduce the brain edema. The Neurosurgery Service was urgently called upon for consult, and they suggested no further neurosurgical intervention at that time. Despite blood pressure controls, and mannitol treatment, and therapy for her urinary tract infection, the patient's neurological status deteriorated consistently, and she was found to be posturing on [**11-15**]. Her chest x-rays showed signs of pneumonia as well. On [**11-15**], the patient's brother was [**Name (NI) 653**], and a meeting was conducted with him. The patient's code status after this meeting was changed to do not resuscitate/do not intubate. The patient continued on mechanical ventilation, and regular blood gases were obtained to assess adequate oxygenation. On [**11-16**], the patient's neurological status had deteriorated significantly and she had no response to stimulation. The Neurosurgery Service was re-consulted, and they strongly discouraged any surgical intervention at that time. On [**11-17**], the patient expired. [**First Name11 (Name Pattern1) 4224**] [**Last Name (NamePattern4) **], M.D. Dictated By:[**Last Name (NamePattern1) 728**] MEDQUIST36 D: [**2143-2-14**] 15:16 T: [**2143-2-14**] 15:37 JOB#: [**Job Number 103667**]

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icd9cm

[ [ [] ] ]

[ "96.71", "38.91" ]

icd9pcs

[ [ [] ] ]

2165, 3821

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684, 2147

22,310

127,984

26360

Discharge summary

report

Admission Date: [**2199-1-13**] Discharge Date: [**2199-2-5**] Date of Birth: [**2177-5-16**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2090**] Chief Complaint: Inability to ambulate, diplopia. Major Surgical or Invasive Procedure: 1. Lumbar puncture 2. Duodenal biopsy 3. Sural nerve and muscle biopsy History of Present Illness: Patient is a 21 year old male with mental retardation with history of viral encephalitis/ADEM who presented to [**Hospital1 18**] with fever, altered MS and inability to walk. The patient has been having low grade temperatures at the house. At baseline, he was what sounds like cerebral palsy, mild ataxia (he is wheelchair dependent), and slurred speech. He was becoming more drowsy and started having worsened slurred speech and inability to ambulate. He was seen at [**Hospital1 18**] ED on [**2199-1-4**] with respiratory symptoms of difficulty breathing/cough in addition slurred speech and ataxia. It was thought at time that primary respiratory disease may have been contributing to exacerbation of prior deficits from infectious/inflammatory CNS disease (Hospitalization [**Hospital1 18**] [**Month (only) 205**]-[**2198-8-14**]). He was discharged from ED and his residential home did not think he ever improved. . [**Known firstname 65219**] has been hospitalized for neurological deficits in the past. In the years [**2191**] and [**2192**], he had neurological symptoms that were alternatively labeled meningitis, encephalitis, and ADEM. He recovered from this episode with only mild clumsy walking. He was again seen in [**2198-3-14**] for left facial droop but otherwise nonfocal exam. MRI at that time showed "a focus of increased T2 and FLAIR signal in right cerebral peduncle". . Patient again developed neurologic issues in [**2198-7-14**] with progressive gait instability and speech became more garbled. He was admitted to [**Hospital1 18**] from [**Date range (3) 65220**]. On [**2198-8-5**] MRI with gadolinium showed progression of the T2 signal abnormality and contrast enhancement within the pontomesencephalic portion of brainstem. This was thought to be atypical of demylinating lesions. Lumbar puncture showed 13 WBC with atypical lymphocytes in CSF. Over the first 24 hours of that admission patient had problems with secretions and then he had more ataxia, unability to speak, and facial weakness. CSF analysis for infectious etiology negative (cryptococcal antigen neg, HSV neg, EBV neg, protein electrophoresis showed no oligoclonal banding, viral cx, fungal cx, AFB neg, VZV neg, serum mycoplasma and HIV neg. Patient was treated with 5 days of steroids and improved speech, drooling and gait. During that hospitilization he developed aspiration pneumonia. He later worsened neurologically, becoming anarthric, drooling. Repeat MRI showed progression of brainstem enhancing lesion extending from pons, spreading to the inferior cerbellar peduncle and extending to the left thalamic lesion. He again was treated with 5 days of IV steroids and transitioned to 5 week course of oral steroids. CTA head negative for vasculitis. He continued to have problems swallowing and went home on a dysphagia diet. . He was discharged to a rehab hospital on a steroid taper and eventually recovered to his baseline. Past Medical History: 1. Meningoencephalitis versus Acute Disseminated Encephalomyelitis 2. Post Traumatic Stress Disorder 3. Attention Deficit Hyperactivity Disorder 4. Microcytic anemia 5. Asthma 6. Obstructive sleep apnea (on CPAP at night) Social History: He lives in group home (the [**Month (only) 116**] Center). History of substance abuse. Patient's Legal Guardianship is through the Department of Social Services. Contact = [**First Name8 (NamePattern2) 3075**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 65221**]. Supervisor = [**First Name8 (NamePattern2) **] [**Last Name (un) 65222**] [**Telephone/Fax (1) 65223**]. Family History: Family history reveals both parents with substance abuse issues. His siblings, 2 brothers and 1 sister, are described as healthy. Physical Exam: PHYSICAL EXAM ON ADMISSION: O: Tm: 100.6 Tc: 99.3 BP: 145 / 86 HR: 72 RR: 24 O2Sat96% Gen: African American , obese male; drowsy. HEENT: NC/AT. Anicteric. MMM. Thrush in OP. Neck: Supple. No masses or LAD. No JVD. No thyromegaly. Lungs: Coarse UA sounds thoughout. Cardiac: RRR. S1/S2. No M/R/G. Abd: Soft, NT, ND, +NABS. No rebound or guarding. Extrem: Warm and well-perfused. No C/C/E. . Neuro: Mental status: Drowsy but rouses to voice. Orientation: Oriented to person, place, and date. Attention: Able to say [**1-28**] forwards but unable to do 20->1 Registration intact. Recall: 0/3 objects at 5 minutes. Language: Speech severly dysarthic with good comprehension and repetition. Naming intact [**4-18**]. No apraxia, no neglect. [**Location (un) **] intact. . Cranial Nerves: I: Not tested II: Pupils left pupil 5mm->4 mm/ L 2.5-> 2.5 mm. Inattentive for confrontation but blinks to threat bilaterally. III, IV, VI: Has lateral nystagmus on endagaze to right. Is not able to fully abduct right eye. V, VII: Has diminished nasolabial on right lower. Overall poor facial strength and tone. Unable to raise eyebrows. Reports normal touch in V1, V2, V3. VIII: Hearing intact to finger rub bilaterally. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations, moves weakly side to side. . Motor: Increased tone throughout but greater in UE, left greater than right. Patient has giveway weakness. [**Doctor First Name **] Tri Bic WE WF FE FF R 5- 5 5 5 5 5- 5- L 5 5 5 5 5 5 5 Note: (IPs sustained 15 sec antigravity, at least 3+). . IP HipAd HipAb Quads Hamstrings DF PF [**Last Name (un) 938**] TE TF R 3+ 5 5 5 5 5 5 5 5 5 L 3+ 5 5 5 5 5 5 5 5 5 . Sensation: Patient responds "yup" to all modalities. Unable to obtain more clear exam. Does not have sensory level on back/thorax. . Reflexes: B T Br Pa Ac 3+ with crossed adductors and jaw jerk. Grasp reflex absent. Toes upgoing bilaterally. . Coordination: Normal on finger-nose-finger mild dysmetria and intention tremor, rapid alternating movements with slow taps bilaterally, mild incoordination with heel to shin (?weakness). . Gait: Patient sits at edge of bed but refuses to walk. Pertinent Results: Pertinent Results: [**2199-1-13**] 05:30PM BLOOD WBC-8.4 RBC-5.85 Hgb-14.9 Hct-44.3 MCV-76* MCH-25.5* MCHC-33.6 RDW-13.6 Plt Ct-281 [**2199-1-16**] 10:00AM BLOOD Neuts-90.1* Bands-0 Lymphs-5.3* Monos-3.6 Eos-0.9 Baso-0.1 [**2199-1-13**] 05:30PM BLOOD Neuts-71.5* Lymphs-20.5 Monos-5.8 Eos-1.2 Baso-1.0 [**2199-1-14**] 09:59AM BLOOD ACA IgG-17.0* ACA IgM-8.2 [**2199-1-15**] 09:35AM BLOOD ESR-20* [**2199-1-13**] 05:30PM BLOOD Glucose-83 UreaN-11 Creat-1.0 Na-141 K-4.0 Cl-103 HCO3-25 AnGap-17 [**2199-1-24**] 06:56AM BLOOD Glucose-75 UreaN-15 Creat-0.8 Na-135 K-3.7 Cl-103 HCO3-25 AnGap-11 [**2199-1-21**] 05:37AM BLOOD Albumin-3.1* Calcium-8.6 Phos-3.4 Mg-2.2 [**2199-1-14**] 07:15AM BLOOD ANCA-NEGATIVE B [**2199-1-15**] 09:35AM BLOOD CRP-37.8* [**2199-1-17**] 10:20AM BLOOD GQ1B IGG ANTIBODIES-PND [**2199-1-14**] 07:15AM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODY IGM-Test [**2199-1-14**] 07:15AM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODY, IGG-Test [**2199-1-14**] 07:15AM BLOOD ANGIOTENSIN 1 - CONVERTING [**Last Name (un) **]-Test [**2199-1-13**] 08:30PM CEREBROSPINAL FLUID (CSF) WBC-395 RBC-5* Polys-83 Lymphs-12 Monos-5 [**2199-1-13**] 08:30PM CEREBROSPINAL FLUID (CSF) TotProt-52* Glucose-49 [**2199-1-18**] 03:40PM CEREBROSPINAL FLUID (CSF) VARICELLA DNA (PCR)-PND [**2199-1-18**] 03:40PM CEREBROSPINAL FLUID (CSF) HERPES 6 PCR-PND [**2199-1-18**] 08:50PM CEREBROSPINAL FLUID (CSF) MULTIPLE SCLEROSIS (MS) PROFILE-Test Name [**2199-1-13**] 10:25PM CEREBROSPINAL FLUID (CSF) ENTEROVIRUS PCR-Test [**2199-1-13**] 10:25PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS PCR-Test Name [**2199-1-13**] 03:28PM CEREBROSPINAL FLUID (CSF) EBV-PCR-Test . MRI brain [**2199-1-14**]: Since [**2198-8-22**], new enhancement of the posterior pons and mid brain with new swelling of the left cerebral peduncle. Resolution of the enhancement of the lower pons, left inferior and middle cerebellar peduncles, and the left internal capsule/thalamus. . The above findings may represent demyelinating disease vs. lymphoma. Sarcoid is another possibility, although this would be an unusual presentation. . MRI C-Spine [**2199-1-14**]: No abnormal signal or enhancement of the cervical and upper thoracic cord. . EEG [**2199-1-15**]: This is a mildly abnormal EEG in the waking and drowsy states. Occasional bursts of theta slowing was seen in a random distribution, suggesting a mild encephalopathy, which may be seen with infections, medications, toxic metabolic abnormalities or ischemia. No focal, lateralizing or epilpetiform features were noted. . CT torso [**2199-1-17**]: 1. No evidence of mass or lymphadenopathy within the chest, abdomen, or pelvis. . Scrotal US [**2199-1-19**]: Normal bilateral testicular ultrasound. No evidence of testicular mass. . Duodenal biopsy [**2199-1-23**]: Within normal limits. . Sural nerve and muscle biopsy [**2199-1-24**]: The biopsies lack diagnostic evidence of a vasculitis. The muscle does have some difficult to categorize and non-specific myopathic features. . MR head and MRA [**2199-1-25**]: Significant improvement in the enhancement seen within the posterior pons and mid brain on examination from [**2199-1-14**]. No new areas of abnormal enhancement identified. Normal MR spectrographic analysis of the midbrain and pons. . Liver Ultrasound [**2199-1-28**]: No hepatobiliary abnormality is identified. Brief Hospital Course: Patient was admitted for concern of meningitis, brainstem encephalitis to General Neurology Service. . 1. Neurology: Upon admission, patient had copius oral secretions, minimal alertness, worsening spasticity, and ophthalmoplegia with left 3rd nerve involvement and bilateral 6th cranial involvement. Lumbar puncture on admission showed WBC 150 wbc, 160 rbc with diff of 77%polys, 12% lymphs, 11% monos with TP 52, glucose 49; gram stain with 2+PMNs. He was kept in ICU for concern of poor handling of secretions and was stable for step-down unit the next day. MRI brain on admission showed new enhancement of the posterior pons and mid brain with new swelling of the left cerebral peduncle since [**8-19**] scan. There was resolution of the prior enhancement of the lower pons, left inferior and middle cerebellar peduncles, and the left internal capsule/thalamus. MRI C-spine was normal. [**Known firstname 65219**] was making some mouthing movements that were concerning for seizure. However, a routine EEG showed occasional bursts of theta slowing in a random distribution, suggesting a mild encephalopathy. . Over the first week of his hospital course, his opthalmoplegia worsened and he developed facial diplegia. He had increased tone in all extremities and had extensor posturing to minimal stimulation. He had a hyperactive gag and jaw jerk indicative of pseudobulbar palsy. He was treated with 5 day course of Solumedrol without improvement. He was then started on 5 day course of IVIG and [**Known firstname 65219**] was noted to be more alert and improved extraocular movements by day 3 of this treatment. Patient started on Ampicillin, Ceftriaxone, Vancomycin, Acyclovir upon admission for concern of bacterial meningitis/HSV encephalitis. Acyclovir was discontinued once HSV PCR negative. Though CSF bacterial cultures were negative, he continued on course of ceftriaxone/vancomycin/ampicillin for 13 days. Patient had repeat lumbar puncture for further work-up of brainstem findings. . Work-up of his condition included 2 lumbar punctures, muscle/nerve biopsy by neurosurgery and small bowel biopsy by GI for concern of Whipple's disease. Differential diagnosis of etiology included 1. infection (though Serum Toxoplama IgM and IgG Ab Neg, Serum Cryptococcal Ag Neg, Serum Mycoplasma Ab IgM neg, IgG pos (1.7), Serum EBV Ab panel Neg, Serum Lyme Neg, RPR non-reactive and CSF EBV PCR negative, CSF Enterovirus PCR negative, CSF cx negative, CSF HHV6 negative, CSF Lyme negative, CSF VZV negative; CSF TB-PCR and GQ1B IgG Ab PENDING), 2. inflammatory, eg demyelinating disease ([**Doctor First Name **] Neg, ANCA Neg, Anticardiolipin IgG 17 (nl 0-15), Anticardiolipin IgA 8.2 (nl 0-12.5), ACE 15, ESR 20, CRP 37.8, CSF-PEP No oligoclonal banding, CSF IgG index and synthesis rate normal, CSF Whipple's PCR negative; work-up for Behcet's including ophthamological exam for uveitis and skin test with subcutaneous injection of saline negative) and 3. neoplastic (cytology sent, CT torse negative for adenopathy, scrotal US negative for mass). . A repeat lumbar puncture on [**2199-1-22**] showed 3 wbc, 0 rbc, TP 26, glucose 81; gram stain was negative. Cytology sent was sent and showed atypical lymphocytes but flow studies will have to be repeated at later date becuase poor sample. A MRS [**First Name (STitle) **] was done on [**2199-1-25**] and showed improvement in the enhancement seen within the posterior pons and mid brain on examination from [**2199-1-14**]. No new areas of abnormal enhancement were identified and there was normal MR spectrographic analysis of the midbrain and pons. Tissue samples of small bowel was within normal limits. Tissue of left gastrocnemius showed mild myopathy, chronic and active and no inflammatory findings on sural nerve pathology. Review of old medical records from [**Hospital3 1810**] of [**Location (un) 86**] ([**2192-6-6**]) indicated that midbrain was biopsied during a similar presentation of illness with T2 bright lesions in midbrain and pons. This biopsy revealed only gliotic changes in grey and white matter. No evidence of tumor or inflammatory changes. There were rare "rod cells" and lymphocytes associated with disorganized fragment of leptomeninges suggestive of encephalitis. A metabolic work-up had not been initiated at [**Hospital1 **] and patient had very long chain fatty acids (within normal limits), MMA (80 with normal range 87-318) sent on this admission. Further metabolic work-up may be considered in future. . Final results of muscle/nerve biopsy are pending. . On discharge, his bulbar function has improved, as has his strength. He is now, however, showing signs of pseudobulbar affect (mainly inappropriate laughter). He continues to have difficulty with speech and swallowing, as well as sitting up without support. . 2. CV/Resp: Patient was initially admitted to ICU for concern of poor handling of secretions. He developed an oxygen requirement several times during his hospitalization, which usually improved with suctioning. He was stable on room air at the time of discharge. . 3. FEN/GI: Mr. [**Known lastname **] was fed via NG tube until he was more alert. During a speech and swallow evaluation on [**2199-1-29**], it was determined that patient should remain NPO. A PEG tube was inserted. His AST/ALT were elevated on [**2199-1-26**]. GI was consulted and it was thought that his transaminitis was most likely drug-induced due to ceftriaxone. Labs were sent for possible infectious causes: HCV ab neg, HBsAg neg, HBsAb pos, HBcAb neg; HCV and CMV viral loads pending. A liver ultrasound was normal. On [**2-3**], his AST/ALT began to trend downwards. Patient was also noted to have constipation and was kept on an aggressive bowel regimen. . 4. Heme: Patient noted to have an anemia of chronic disease. Hct decreased from 36 to 29 on [**2199-1-27**]. DIC labs, coags, stool guaics were normal. . 5. ID: See Neuro. Patient had low grade fevers for which he was cultured on [**2199-1-23**]. BCX and UCX were negative. He had an episode of hematuria on [**2199-1-30**] with the Foley inserted. Blood cultures were negative. Foley was removed. . 6. Rehab: Patient worked with PT for concern of spasticity. . 7. Rheum: Rheum service consulted for concern of vasculitis who suggested angiogram in future. . 8. Ophthalmology: An ophthamologic exam was done to look for signs of uveitis which may be consistent with Behcet's disease. Exam was negative for uveitis but was found to have an increased cup-to-disc ratio and increased intraocular pressure. Follow-up was recommended in 6 mos to evaluate for glaucoma, especially given treatment with steroids. Medications on Admission: 1. Flonase 2 sprays q nostril/qday 2. Albuterol prn 3. Loratidine 10 mg po qd 4. Singulair 10 mg po qd Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution [**Date Range **]: One (1) Injection TID (3 times a day). 2. Albuterol Sulfate 0.083 % Solution [**Date Range **]: One (1) Inhalation Q4-6H (every 4 to 6 hours) as needed for wheeze. 3. Insulin Regular Human 100 unit/mL Solution [**Date Range **]: One (1) Injection ASDIR (AS DIRECTED): Insulin sliding scale as attached, while on steroids. 4. Nystatin 100,000 unit/mL Suspension [**Date Range **]: Five (5) ML PO BID (2 times a day) as needed for thrush. 5. Docusate Sodium 50 mg/5 mL Liquid [**Date Range **]: One (1) PO BID (2 times a day). 6. Senna 8.6 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 7. Magnesium Hydroxide 400 mg/5 mL Suspension [**Date Range **]: Thirty (30) ML PO Q6H (every 6 hours) as needed. 8. Bisacodyl 10 mg Suppository [**Date Range **]: One (1) Suppository Rectal HS (at bedtime) as needed. 9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 10. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal DAILY (Daily). 11. Prednisone 20 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO DAILY (Daily): Decrease dose by 10mg every Friday then taper off. 12. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **] (2 times a day). 13. Bacitracin Zinc 500 unit/g Ointment [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2 times a day). 14. Flonase 50 mcg/Actuation Aerosol, Spray [**Hospital1 **]: One (1) Nasal twice a day. 15. Loratadine 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 16. Singulair 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 17. Tubefeeding: Replete w/fiber Full strength; Tubefeeding: Replete w/fiber Full strength; Starting rate: 10 ml/hr; Advance rate by 10 ml q8h Goal rate: 80 ml/hr Residual Check: q8H Hold feeding for residual >= : 100 ml Flush w/ 100 ml water q8h Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: 1. Brainstem encephalitis 2. Asthma Discharge Condition: Improved with continued speaking and swallowing deficits. Moves all limbs antigravity but still with hypertonia, hyperreflexia and right>left upper motor neuron pattern of weakness. Discharge Instructions: 1. Continue to monitor LFTs until there is resolution of his elevated transaminases. . 2. Continue on 6 week prednisone taper with reduction in dose by 10 mg every Friday. . 3. He will require ongoing physical therapy for improvement in strength of axial muscles and upper and lower extremities with goal of independent sitting and walking. Followup Instructions: The following appointments have already been scheduled: 1. Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2199-2-21**] 3:00 2. Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2199-2-22**] 9:40 3. Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2199-2-22**] 10:00 . Follow-up with ophthalmology to monitor for glaucoma, given cup-to-disc ratio found in-house. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**] MD [**MD Number(1) 2107**] Completed by:[**2199-2-5**]

[ "787.2", "493.90", "573.3", "799.02", "599.7", "280.9", "327.23", "323.9", "570", "564.00", "319", "343.9", "719.7", "E930.5", "782.1" ]

icd9cm

[ [ [] ] ]

[ "43.11", "03.31", "96.6", "83.21", "38.93", "99.14", "04.12", "45.16" ]

icd9pcs

[ [ [] ] ]

18753, 18823

9929, 16582

348, 421

18903, 19087

6583, 9906

19476, 20236

4042, 4174

16736, 18730

18844, 18882

16608, 16713

19111, 19453

4189, 4203

276, 310

449, 3384

5011, 6545

4217, 4624

4639, 4995

3406, 3629

3645, 4026

70,222

159,475

40274

Discharge summary

report

Admission Date: [**2196-12-9**] Discharge Date: [**2196-12-17**] Date of Birth: [**2129-8-2**] Sex: M Service: CARDIOTHORACIC Allergies: Afrin Attending:[**First Name3 (LF) 1505**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2196-12-9**] Aortic valve replacement, 27-mm Mosaic tissue heart valve History of Present Illness: 67 year old male has a history significant for type II diabetes, non-Hodgkin's Lymphoma which was treated with chemotherapy initially in [**2183**]. In [**2192**], he had a recurrence and had chemotherapy and then had a stem cell transplant done in [**2-4**]. Since then, he has been experiencing shortness of breath with exertoinal. Of note he has been on prednisone for over three years. Over the past year, his dyspnea has gotten progressively worse and is associated with lightheadedness. This occurs with activity such as climbing one flight of stairs. He was recently referred for an echocardiogram and was found to have aortic stenosis. Cardiac Cath also revealed severe aortic stenosis and he was referred for cardiac surgery. Past Medical History: Transient global amnesia [**11-5**] Diabetes mellitus Mild renal insufficiency Aortic stenosis Non-Hodgkin's Lymphoma [**2183**] chemotherapy, recurrence [**2192**] (tx w chemo and stem cell transplant) Pericardial effusion [**2193**] Anxiety Past Surgical History s/p autologous stem cell transplant [**2-4**] Social History: Race:Cuacasian Last Dental Exam:1 month ago, Wife is calling to fax clearance Lives with:wife Occupation:retired Tobacco:denies ETOH:denies Family History: non-contributory Physical Exam: Pulse:92 Resp:16 O2 sat:97%/RA B/P Right:198/96 Left:194/100 Height:6'2" Weight:280 lbs General: NAD, overweight white male 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 2/6 systolic murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact x Pulses: Femoral Right: cath site Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right/Left: none Pertinent Results: CXR [**12-14**]: Small bilateral pleural effusions with improvement in pulmonary vascular congestion and no evidence of pneumopericardium. [**2196-12-9**] 11:25AM BLOOD WBC-17.8*# RBC-2.68*# Hgb-8.3*# Hct-25.1*# MCV-94 MCH-31.0 MCHC-33.2 RDW-16.7* Plt Ct-98* [**2196-12-12**] 03:59AM BLOOD WBC-8.4 RBC-2.94* Hgb-8.8* Hct-27.2* MCV-92 MCH-30.1 MCHC-32.5 RDW-16.9* Plt Ct-82* [**2196-12-17**] 05:35AM BLOOD WBC-5.3 RBC-2.98* Hgb-9.0* Hct-27.6* MCV-93 MCH-30.1 MCHC-32.5 RDW-16.4* Plt Ct-132* [**2196-12-9**] 11:25AM BLOOD PT-14.4* PTT-27.5 INR(PT)-1.3* [**2196-12-11**] 02:03AM BLOOD PT-12.8 PTT-23.0 INR(PT)-1.1 [**2196-12-9**] 01:22PM BLOOD UreaN-16 Creat-1.1 Na-140 K-4.6 Cl-110* HCO3-19* AnGap-16 [**2196-12-13**] 08:40PM BLOOD Glucose-97 UreaN-33* Creat-1.3* Na-137 K-3.9 Cl-101 HCO3-25 AnGap-15 [**2196-12-17**] 05:35AM BLOOD Glucose-203* UreaN-23* Creat-1.3* Na-138 K-3.9 Cl-100 HCO3-28 AnGap-14 [**2196-12-11**] 02:03AM BLOOD Calcium-8.5 Phos-4.2 Mg-2.2 [**2196-12-14**] 03:35PM BLOOD Calcium-8.1* Phos-3.5 Mg-2.2 Brief Hospital Course: Mr. [**Known lastname 6522**] was a same day admit after undergoing pre-operative work-up after his cardiac cath. On [**12-9**] he was brought directly to the operating room where he underwent an aortic valve replacement. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation awoke neurologically intact and extubated. Beta blockers and diuretics were started and he was diuresed towards his pre-op weight. Chest tubes and epicardial pacing wires were removed per protocol. He remained in the unit for several days for management of glucose and tachycardia. Transferred to the floor on post-op day four for further management and to begin increasing his activity level. There were some concerns for his safety about going home due to gait/occasional confusion issues. Cleared for discharge to [**Last Name (un) **] in [**Hospital 4444**] rehab on post-op day 8. Please note attached sliding scale and fixed dose insulin regimen. All f/u appointments were advised. Medications on Admission: ACYCLOVIR - (Prescribed by Other Provider) - 400 mg Tablet - 1 Tablet(s) by mouth twice a day FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth twice a day INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) - 100 unit/mL Solution - 80 units [**Hospital1 **] INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider) - 100 unit/mL Solution - 20 units id OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth daily PREDNISONE - (Prescribed by Other Provider) - 10 mg Tablet - 1.5 Tablet(s) by mouth dailyh SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth daily SULFAMETHOXAZOLE-TRIMETHOPRIM - (Prescribed by Other Provider) - 400 mg-80 mg Tablet - 1 Tablet(s) by mouth 3x weekly Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 2 weeks. 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 4. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (TU,TH,SA). 6. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 7. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 8. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for SOB. 9. ipratropium bromide 0.02 % Solution Sig: One (1) neb IH Inhalation Q6H (every 6 hours) as needed for sob/wheezes. 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): plan for PCP to do slow taper as an outpt. 12. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 13. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Lasix 40 mg Tablet Sig: One (1) Tablet PO three times a day for 7 days: TID for one week, then [**Hospital1 **] dosing as clinically indicated. 15. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day). 16. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 17. insulin glargine 100 unit/mL Solution Sig: One (1) Subcutaneous twice a day: 15 units [**Hospital1 **]. 18. insulin lispro 100 unit/mL Solution Sig: One (1) Subcutaneous four times a day: Humalog per attached sliding scale . Discharge Disposition: Extended Care Facility: [**Hospital 11851**] Healthcare & Rehabilitation Center - [**Location (un) 620**] Discharge Diagnosis: Aortic Stenosis s/p Aortic Valve replacement Past medical history: Transient global amnesia [**11-5**] Diabetes mellitus Mild renal insufficiency Aortic stenosis Non-Hodgkin's Lymphoma [**2183**] chemotherapy, recurrence [**2192**] (tx w chemo and stem cell transplant) Pericardial effusion [**2193**] Anxiety Past Surgical History s/p autologous stem cell transplant [**2-4**] Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage edema- 2+ b/l LEs Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] on [**12-29**] @ 2:15 Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Cardiology to call pt w/appt (sched for 2nd week of [**Month (only) 1096**]) Please call to schedule appointments with your Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**5-2**] weeks [**Telephone/Fax (1) 31019**] **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:[**2196-12-17**]

[ "427.31", "786.09", "427.89", "250.00", "285.9", "458.29", "424.1", "V42.82", "276.2", "593.9", "300.00", "202.80", "287.5", "781.2" ]

icd9cm

[ [ [] ] ]

[ "88.72", "39.61", "35.21" ]

icd9pcs

[ [ [] ] ]

7276, 7384

3408, 4508

292, 367

7805, 7987

2363, 3385

8910, 9555

1638, 1656

5370, 7253

7405, 7450

4534, 5347

8011, 8887

1671, 2344

233, 254

395, 1131

7472, 7784

1481, 1622

12,323

111,362

13055

Discharge summary

report

Admission Date: [**2121-8-18**] Discharge Date: [**2121-8-29**] Date of Birth: [**2062-1-10**] Sex: F Service: CARDIOTHORACIC Allergies: Morphine Attending:[**First Name3 (LF) 1505**] Chief Complaint: DOE Major Surgical or Invasive Procedure: [**2121-8-18**] #29 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Mechanical MVR, CABG x 1(SVG->RCA) History of Present Illness: 59 year old with history of CAD s/p MI in the past with PTCA and stents to her LAD and RCA. She did relatively well until she developed DOE and [**Male First Name (un) 1902**] at which time her MR was discovered. Past Medical History: lipids [**Male First Name (un) **] Skin Ca [**Male First Name (un) 1902**] MI [**2109**] MR tobacco abuse s/p T&A s/p tubal ligation s/p stenting x [**Numeric Identifier 4719**] following MI PTCA of RCA [**2109**] Social History: lives alone .5 ppd x 40 years occasioal Etoh Family History: Father deceased at age 68 of MI Physical Exam: WDWN in NAD warm dry, no rashes NCAT PERRL Anicteric OP benign teeth in good repair no jvd Lungs CTAB 3/6 systolic murmur RRR normal s1, split s2 Abdomen benign superficial spider varicosities Neuro grossly intact Pertinent Results: [**2121-8-28**] 07:15AM BLOOD WBC-8.3 RBC-3.61* Hgb-11.3* Hct-32.8* MCV-91 MCH-31.3 MCHC-34.4 RDW-15.2 Plt Ct-358 [**2121-8-28**] 07:15AM BLOOD Plt Ct-358 [**2121-8-28**] 07:15AM BLOOD PT-22.6* INR(PT)-3.7 [**2121-8-27**] 05:34AM BLOOD PT-22.5* PTT-37.1* INR(PT)-3.7 [**2121-8-26**] 02:25AM BLOOD PT-19.9* PTT-83.2* INR(PT)-2.8 [**2121-8-25**] 03:17AM BLOOD PT-16.8* PTT-65.9* INR(PT)-1.9 [**2121-8-24**] 02:56AM BLOOD PT-14.3* PTT-71.2* INR(PT)-1.4 [**2121-8-23**] 02:17AM BLOOD PT-13.4* PTT-26.7 INR(PT)-1.2 [**2121-8-28**] 07:15AM BLOOD Glucose-91 UreaN-18 Creat-1.0 Na-137 K-4.1 Cl-96 HCO3-31 AnGap-14 [**2121-8-28**] 07:15AM BLOOD Mg-2.1 [**2121-8-29**] 03:23PM BLOOD PT-21.6* INR(PT)-3.4 Brief Hospital Course: Post operatively she was transferred to the ICU in critical but stable condition on milrinone, epinephrine and levophed. On POD 1 she was noted to be moving her left leg less than her right. She was seen in consultation by the stroke team who recommended CT, she was unable to get a CT scan and her LLE weakness improved. She also had atrial fibbrilation for which she was started on amiodarone. She was ready for discharge on POD 10. Medications on Admission: lipitor 10'5, lasix 80'', lopressor 50', lisinopril 20', asa Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*0 Tablet(s)* Refills:*0* 2. Furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day. 3. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): for 1 weeks, then 200 mg QD. 13. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital 6981**] Nursing Home Discharge Diagnosis: CAD, MR MI s/p stents [**2111**] lipids tobacco abuse MR [**First Name (Titles) **] [**Last Name (Titles) 1902**] Skin Ca s/p T&A s/p Tubal ligation Discharge Condition: Good. Discharge Instructions: Shower daily, wash incision with soap and water and paty dry. No lotions, creams or powders. No lifting more than 10 pounds or driving. Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Followup Instructions: Dr. [**Last Name (STitle) **] 4 weeks Dr. [**Last Name (STitle) 23097**] 2 weeks Completed by:[**2121-8-29**]

[ "401.9", "416.0", "997.1", "427.31", "424.0", "414.01", "272.0", "V45.82", "997.02", "428.0", "305.1", "V10.83", "287.5" ]

icd9cm

[ [ [] ] ]

[ "35.24", "89.60", "99.04", "00.13", "36.11", "39.61" ]

icd9pcs

[ [ [] ] ]

3701, 3760

1958, 2394

279, 401

3953, 3961

1240, 1935

4262, 4374

958, 991

2505, 3678

3781, 3932

2420, 2482

3985, 4239

1006, 1221

236, 241

429, 643

665, 880

896, 942

9,919

111,871

50483

Discharge summary

report

Admission Date: [**2157-11-17**] Discharge Date: [**2157-11-25**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 905**] Chief Complaint: tachypnea Major Surgical or Invasive Procedure: none History of Present Illness: 89F with h/o HTN, bilat cerebellar strokes, frontal stoke, sciatica, dementia, who presented with a "head cold" x few days. She developed a low grade temperature, nonproductive cough most of the day today, and reported sob overnight. In the am, her caregiver noticed she was breathing rapidly and called EMS. The patient presented to the ED with a 100 % O2 saturation on NRB and no room air saturation was recorded. She had a temperature of 104 and bp of 207/97. She was initially placed on a ntg gtt with minimal response in BP. She was also started on labetalol. Her chest XR was without infiltrate but severely rotated. Given her fever and bandemia she was treated for pneumonia with ceftriaxone and clindamycin (suspected aspiration). She was briefly started on bipap and then switched to NRB but continued to be tachypneic in the ED to 40's although satting well and MICU evaluation was called. At baseline the patient walks with ta walker, is incontinent. Rec'd flu shot per home health aid. ROS: no ns/chills/cp/appetite or dietary changes / abdominal pain /nausea /diarhea/hematuria/dysuria Past Medical History: B cerebellar strokes, frontal stoke hypertension sciatica IBS dementia hyperactive bladder Social History: Lives at home with 24 hour caregiver. [**Name (NI) **] who lives in [**Hospital1 **] is healthcare proxy & very supportive. EtOH socially in the past, none since strokes, smoked most of her life but quit many years ago. Family History: noncontributory Physical Exam: (at admission) VS: 97.0 axil, 85/37, 175, 32, 99% on NRB Gen: thin elderly female in no apparent distress HEENT: nc/at, perrl, eomi, mmd, poor oral hygeine CV: rrr, no murmurs/r/g Lungs: diffuse ronchi, inspiratory wheezes, left>right, good air movement Abd: s, nt, nd, active bs Ext: no c/c/e Skin: mottled diffusely . (at discharge) VS: T97.3, BP 140/80, HR 68, O2Sat 95-6% on 4.5L NC Lungs: course breath sounds throughout but good air movement Pertinent Results: Trop T peaked at 0.04, CK peaked at 143 (MB was 3) WBC was 11.7 at admission CT angio of chest without evidence of pulm embolism CXR with basilar opacities c/w pneumonia ECG: (during 2nd [**Hospital Unit Name 153**] stay) was atrial fibrillation Brief Hospital Course: 88F with h/o HTN, bilat cerebellar strokes, frontal strokes, sciatica, IBS, dementia, bladder incont who initially p/w a low grade F, nonprod cough, tachypnea on [**11-17**]. In ED, temp 104; SBP 200s, placed on ntg gtt & labetalol. Tx for PNA w/ceftriaxone and clindamycin. Pt was watched o/n in [**Hospital Unit Name 153**] due to tachypnea then called out to medicine floor [**11-18**]. On [**11-19**], shortly after trying some nectar-thickened POs, pt developed resp distress thought to be fr aspiration & sent back to [**Hospital Unit Name 153**] where her resp status stabilized with conservative management. Blood Cx fr [**11-17**] grew gram-positive cocci in prs & clusters on [**11-19**]. Pt also developed new atrial fibrillation in [**Hospital Unit Name 153**], controlled w/dilt drip which was transitioned to metop PO. Pt returned to [**Location 213**] sinus rhythm. Pt's O2 need decreased from facemask to nasal cannula with stable sats in the mid-90s. Pt also failed speech/swallow study in [**Hospital Unit Name 153**] so IR placed NGT which was kept in place for 2 days with tube feeding. # ID/Pulm: Pt likely had community-acquired pneumonia leading to bacteremia. Pt then with aspiration pneumonia prompting the 2nd transfer to ICU. CXR w/RLL retrocardiac opacity. Chest CT [**11-20**] neg for PE. BCx [**12-19**] bottle fr [**11-17**] grew coag-neg staph on [**11-19**]. Repeat CXR with bibasilar opacities. After initial treatment, pt remained afebrile & VS stable throughout remainder of hospital stay. Pt was initially on ceftriaxone/azithro but this was transitioned to levofloxacin/flagyl for aspiration PNA. Plan total 14 day course (5 additional days at discharge). Pt was on nonrebreather oxygen mask in [**Hospital Unit Name 153**] but was weaned to simple facemask then to nasal cannula with sats in the mid-90s. # Atrial fibrillation: Pt had 1st known episode while she was in [**Hospital Unit Name 153**] in the setting of hypoxia, infection, and respiratory distress. Pt was rate-controlled w/dilt drip which was transitioned to PO metoprolol. Pt converted back to NSR and remained with a regular rhythm throughout remainder of hospital stay. Pt's TSH was WNL. Pt discharged home on atenolol (see below). Recommend titrating up atenolol if pt returns to atrial fibrillation. # Hypertension: Given h/o multiple strokes, pt's BP was was to maintain SBP in 130-150 range. Pt was continued on metoptolol with good BP control and this was changed to daily atenolol at discharge. Recommend increasing atenolol dose if pt becomes hyertensive above goal BP after discharge. # Dementia/Psych/Neuro: chronic microvasc infarctions seen in past CTs; bilat cerebellar strokes in past; R-cerebellar & R-occipital strokes in [**11-18**]. Pt was continued on Plavix, Aggrenox, and Celexa. # Hypernatremia: developed during hospital stay while having limited POs but resolved w/IVF & tubefeeds. # FEN: Pt failed swallow study [**11-21**]. Post-pyloric NGT placed by IR [**11-22**] for temporary feeding. This was pulled out on [**11-24**]. Family has made it clear that they do NOT want PEG (with understanding that pt likely will not be able to meet her nutritional needs) and medical team agrees with this. After extensive discussion about aspiration risk of allowing pt to eat vs role of food for pt's comfort and quality of remaining life, family (including healthcare proxy) decided to allow pt to eat pureed and thickened foods (with full aspiration precautions such as having pt upright when taking POs). Family understands significant risk for another aspiraton event. Pt was on RISS for hyperglycemia during hospitalization but this was discontinued at discharge due to stable FS glucose. # Prophyl: pt was on PPI, SC heparin throughout hospital stay for GI & DVT prophylaxis. These were discontinued at discharge as pt will go home with hospice. # Communic: Medical team communicated regularly with pt's [**Month (only) 802**] who is healthcare proxy. [**Telephone/Fax (1) 105160**] (W) or [**Telephone/Fax (1) 105161**] (C). After multiple, extensive discussions with family, including HCP, pt was made DNR/DNI and then comfort measures only. The patient is being discharged home with hospice services. Family discussion also included that pt would not be transferred back to hospital for acute care as the primary goal is the patient's comfort. Medications on Admission: On admission: folate lipitor 10 mg daily plavix 75 mg daily celexa 20 mg daily aggrenox 25/20 [**Hospital1 **] mvi On transfer to MICU [**11-19**]: folate, mvi lipitor 10 mg daily plavix 75 mg daily celexa 20 mg daily aggrenox 25/20 [**Hospital1 **] levofloxacin 500 mg daily flagyl 500 mg tid captopril 25 mg tid metoprolol 25 mg [**Hospital1 **] Discharge Medications: 1. Dipyridamole-Aspirin 200-25 mg Capsule, Multiphasic Release Sig: One (1) Cap PO BID (2 times a day). Disp:*60 Cap(s)* Refills:*2* 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) dose Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*60 dose* Refills:*0* 4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. Disp:*5 Tablet(s)* Refills:*0* 6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 5 days. Disp:*15 Tablet(s)* Refills:*0* 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever. Disp:*90 Tablet(s)* Refills:*0* 8. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for itching. Disp:*1 tube* Refills:*0* 9. Nebulizer with Adult Mask Device Sig: One (1) kit Miscell. as directed. Disp:*1 kit* Refills:*0* 10. Albuterol Sulfate 5 mg/mL Nebu Soln Sig: One (1) dose Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*60 doses* Refills:*2* 11. Oxygen-Air Delivery Systems Device Sig: One (1) device Miscell. as directed. Disp:*1 kit* Refills:*0* 12. oxygen 5L via NC continuous 13. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO q1-2h as needed for pain or dyspnea: sublingual. Disp:*10 mL* Refills:*0* 14. Levsin SL solution prn 15. Lorazepam SL solution prn Discharge Disposition: Home With Service Facility: Healthcare [**Hospital 94111**] Hospice Discharge Diagnosis: aspiration pneumonia hypertension dementia and h/o cerebrovascular accidents Discharge Condition: stable, tolerating thickened POs, minimal physical activity Discharge Instructions: contact primary care physician or hospice services with any questions Followup Instructions: follow-up with Dr. [**Last Name (STitle) 1728**] as needed [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**] Completed by:[**2157-11-25**]

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43092

Discharge summary

report

Admission Date: [**2181-3-14**] Discharge Date: [**2181-3-22**] Date of Birth: [**2114-9-18**] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Bactrim / SEROVENT / fentanyl / midazolam Attending:[**First Name3 (LF) 2186**] Chief Complaint: Obtundation Major Surgical or Invasive Procedure: None History of Present Illness: 66 female with PMHx significant for DM2, HTN, gastric adenocarcinoma who was recently discharged from [**Hospital1 18**] on [**2181-3-7**] s/p subtotal gastrectomy on [**2181-2-21**] who now presents after being found obtunded [**2181-3-14**] at home. . According to the patient's husband, she has been complaining of abdominal pain since leaving the hospital. She has also had intermittent nausea & vomiting, which she had also experienced during her last admission. .The patient states that she has been taking her insulin as prescribed since leaving the hospital. She was evaluated by [**Last Name (un) **] during her previous admission for elevated blood glucose in the post-operative setting. She was started on long-acting insulin prior to discharge with a plan to follow up with [**Last Name (un) **] as an outpatient. . In the ED: Initial VS: 97.4 127 34 92/47 100 % on NRB On arrival, FSBG read critically high. Initially chem 7 revealed glucose 843, K 5.3, creat 1.7 (from 1.0 on discharge), bicarb 6, WBC 18.2 with 90% polys, no bands. Venous lactate 9.1, AG 44. ABG: 7.07/20/115/6. The patient was given 10 units IV insulin bolus & started on insulin gtt at 10 units per hour. One hour later, ABG: 6.98/21/89/5. Repeat chemistries showed gap 35, glucose 768. In total, she received 5.5 L NS in the ED. CXR showed patchy opacification R > L although low lung volumes. EKG unremarkable for ischemic changes but revealed peaked T waves. As such, the patient was given calcium gluconate. The patient was started on IV levofloxacin and IV vancomycin for presumed CAP. IV Flagyl was subsequently started to cover intra-abdominal pathogens. She was given 5 mg IV morphine for pain. . In the ICU, her anion gap closed. CT Abn/Pelvis showed a small fluid collection in the subcutaneous tissues along the incision site c/w postoperative seroma, new compression deformities at the superior endplate of T11 and L1 compared to study on [**2181-1-9**]. She was seen by surgery who agreed there was no intra-abdominal abscess and thus no need for intervention. On [**2181-3-16**], C. diff was negative, so IV flagyl was discontinued. CXR was negative so vancomycin was stopped and a decision to continue cefepime for 7 day course ([**Date range (3) 92936**]) was made. . On the medical floor, she denies any pain or problems. She is unable to remember any problems she had prior to becoming obtunded. . Review of Systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies visual changes, headache, dizziness, sinus tenderness, neck stiffness, rhinorrhea, congestion, sore throat or dysphagia. Denies chest pain, palpitations, orthopnea, dyspnea on exertion. Denies shortness of breath, cough or wheezes. Denies nausea, vomiting, heartburn, diarrhea, constipation, BRBPR, melena, or abdominal pain. No dysuria, urinary frequency. Denies arthralgias or myalgias. Denies rashes. No increasing lower extremity swelling. No numbness/tingling or muscle weakness in extremities. No feelings of depression or anxiety. All other review of systems negative. Past Medical History: Gastric adenocarcinoma (dx [**9-/2180**]) Ductal carcinoma of breast: T1c, N0, M0 stage IB hypertension hyperlipidemia diabetes venous insufficiency OSA rheumatic heart disease asthma factor VIII inhibitor PSH: Subtotal gastrectomy [**2181-2-21**] R Mastectomy b/l vitrectomy b/l cataracts Social History: Lives with her husband. [**Name (NI) **] tobacco, no EtOH, no drugs. Works as social worker Family History: No family history of cancer. Physical Exam: Admission Exam: VS: 98.3 149/57 98 20 98% RA; 0/10 pain GEN: No apparent distress HEENT: no trauma, pupils round and reactive to light and accommodation, no LAD, oropharynx clear, no exudates CV: regular rate and rhythm, no murmurs/gallops/rubs PULM: Clear to auscultation bilaterally, no rales/crackles/rhonchi GI: soft, non-tender, non-distended; no guarding/rebound;surgical scar c/d/i EXT: no clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV present NEURO: Alert and oriented to person, place and situation; CN II-XII intact, [**3-31**] motor function globally DERM: no lesions appreciated Pertinent Results: [**2181-3-14**] 11:47PM TYPE-[**Last Name (un) **] PO2-41* PCO2-40 PH-7.31* TOTAL CO2-21 BASE XS--5 [**2181-3-14**] 11:47PM GLUCOSE-110* LACTATE-4.3* NA+-137 K+-3.9 CL--108 [**2181-3-14**] 08:30PM GLUCOSE-225* LACTATE-3.7* NA+-135 K+-3.8 CL--106 TCO2-22 [**2181-3-14**] 07:53PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.019 [**2181-3-14**] 07:53PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-150 KETONE-10 BILIRUBIN-SM UROBILNGN-2* PH-5.5 LEUK-TR [**2181-3-14**] 07:53PM URINE RBC-16* WBC-7* BACTERIA-NONE YEAST-NONE EPI-0 [**2181-3-14**] 07:53PM URINE GRANULAR-8* HYALINE-8* [**2181-3-14**] 07:53PM URINE AMORPH-RARE [**2181-3-14**] 07:53PM URINE MUCOUS-RARE [**2181-3-14**] 07:52PM GLUCOSE-236* UREA N-15 CREAT-1.3* [**2181-3-14**] 07:52PM CALCIUM-8.0* PHOSPHATE-1.2* MAGNESIUM-1.7 [**2181-3-14**] 06:16PM GLUCOSE-165* NA+-134 K+-3.9 CL--105 TCO2-21 [**2181-3-14**] 05:56PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016 [**2181-3-14**] 05:56PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE->1000 KETONE-10 BILIRUBIN-MOD UROBILNGN-4* PH-5.0 LEUK-TR [**2181-3-14**] 05:56PM URINE RBC-8* WBC-5 BACTERIA-NONE YEAST-NONE EPI-0 [**2181-3-14**] 05:56PM URINE HYALINE-9* [**2181-3-14**] 05:56PM URINE MUCOUS-RARE [**2181-3-14**] 04:23PM GLUCOSE-284* LACTATE-2.7* NA+-135 K+-4.1 CL--102 TCO2-22 [**2181-3-14**] 03:09PM TYPE-MIX PH-7.30* [**2181-3-14**] 03:09PM GLUCOSE-349* LACTATE-2.8* NA+-134 K+-4.7 CL--104 TCO2-20* [**2181-3-14**] 03:09PM freeCa-1.17 [**2181-3-14**] 03:04PM GLUCOSE-390* UREA N-15 CREAT-1.5* SODIUM-136 POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-20* ANION GAP-17 [**2181-3-14**] 03:04PM CALCIUM-8.1* PHOSPHATE-1.5*# MAGNESIUM-1.9 [**2181-3-14**] 02:53PM VoidSpec-CLOTTED SP [**2181-3-14**] 01:44PM TYPE-CENTRAL VE PH-7.30* [**2181-3-14**] 01:44PM GLUCOSE-416* [**2181-3-14**] 01:44PM freeCa-1.19 [**2181-3-14**] 12:53PM TYPE-MIX [**2181-3-14**] 12:53PM GLUCOSE-458* LACTATE-3.7* NA+-135 K+-3.9 CL--104 TCO2-15* [**2181-3-14**] 11:38AM GLUCOSE-497* [**2181-3-14**] 10:30AM TYPE-ART TEMP-36.4 O2 FLOW-2 PO2-116* PCO2-21* PH-7.25* TOTAL CO2-10* BASE XS--15 INTUBATED-NOT INTUBA COMMENTS-NASAL [**Last Name (un) 154**] [**2181-3-14**] 10:30AM LACTATE-5.1* NA+-136 K+-4.1 CL--105 [**2181-3-14**] 10:30AM O2 SAT-97 [**2181-3-14**] 10:22AM GLUCOSE-659* UREA N-17 CREAT-1.6* SODIUM-136 POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-9* ANION GAP-31* [**2181-3-14**] 10:22AM CALCIUM-7.8* PHOSPHATE-3.9 MAGNESIUM-1.5* [**2181-3-14**] 10:22AM WBC-21.0* RBC-2.27* HGB-6.9* HCT-24.4* MCV-108*# MCH-30.4 MCHC-28.3*# RDW-18.1* [**2181-3-14**] 10:22AM PLT COUNT-382 [**2181-3-14**] 07:56AM LACTATE-7.7* [**2181-3-14**] 07:50AM GLUCOSE-768* UREA N-18 CREAT-1.7* SODIUM-137 POTASSIUM-4.8 CHLORIDE-97 TOTAL CO2-5* ANION GAP-40* [**2181-3-14**] 07:50AM ACETONE-LARGE OSMOLAL-338* [**2181-3-14**] 07:10AM TYPE-[**Last Name (un) **] TEMP-36.8 PO2-89 PCO2-21* PH-6.98* TOTAL CO2-5* BASE XS--26 [**2181-3-14**] 06:35AM URINE HOURS-RANDOM [**2181-3-14**] 06:35AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2181-3-14**] 06:35AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012 [**2181-3-14**] 06:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-80 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2181-3-14**] 06:19AM TYPE-[**Last Name (un) **] PO2-115* PCO2-20* PH-7.07* TOTAL CO2-6* BASE XS--23 [**2181-3-14**] 06:19AM LACTATE-9.1* [**2181-3-14**] 06:10AM GLUCOSE-843* UREA N-17 CREAT-1.7* SODIUM-135 POTASSIUM-5.3* CHLORIDE-90* TOTAL CO2-6* ANION GAP-44* [**2181-3-14**] 06:10AM estGFR-Using this [**2181-3-14**] 06:10AM ALT(SGPT)-12 AST(SGOT)-16 ALK PHOS-71 TOT BILI-0.2 [**2181-3-14**] 06:10AM LIPASE-11 [**2181-3-14**] 06:10AM ALBUMIN-2.9* [**2181-3-14**] 06:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2181-3-14**] 06:10AM WBC-18.2*# RBC-2.34* HGB-6.8* HCT-27.6* MCV-118*# MCH-29.2 MCHC-24.7*# RDW-18.3* [**2181-3-14**] 06:10AM NEUTS-90* BANDS-0 LYMPHS-7* MONOS-2 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2181-3-14**] 06:10AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-3+ MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL TARGET-OCCASIONAL SCHISTOCY-OCCASIONAL BURR-3+ [**2181-3-14**] 06:10AM PLT SMR-NORMAL PLT COUNT-405 [**2181-3-14**] 06:10AM PT-12.4 PTT-30.5 INR(PT)-1.1 IMMAGING: [**2181-3-14**] Radiology CHEST (PORTABLE AP): PORTABLE AP CHEST RADIOGRAPH: In the interim since the prior examination, there has been removal of the feeding tube and right central line. A right Port-A-Cath tip projects over the cavoatrial junction. Bilateral low lung volumes are noted with areas of atelectasis at the right lung base. Moderate cardiomegaly appears increased since [**2181-2-13**], although this may be accentuated by low lung volumes. Bilateral vascular congestion is concerning for pulmonary edema. Findings were discussed with Dr.[**Last Name (STitle) 13162**] at 7:45am on [**2181-3-14**] via telephone. The study and the report were reviewed by the staff radiologist. [**2181-3-15**] Radiology CT ABD & PELVIS WITH CO: FINDINGS: There are trace bilateral pleural effusions or pleural thickening and minimal adjacent atelectasis. The previously seen small nodule in the left lower lobe along the pleura is no longer seen. The visualized heart and pericardium are unremarkable. The liver enhances homogeneously without focal lesions. The gallbladder is decompressed and unremarkable. The spleen is unremarkable. The adrenal glands are unremarkable. The kidneys and ureters are unremarkable. The bladder is decompressed with Foley catheter in place. The uterus is normal. The adnexa are not well visualized. The patient is status post partial gastrectomy. The visualized stomach and small bowel are unremarkable. The colon, appendix, sigmoid, and rectum are unremarkable. No evidence of obstruction. There is no free fluid. There is no free air. There is no mesenteric, retroperitoneal, or pelvic lymphadenopathy identified. There is soft tissue stranding throughout the subcutaneous tissues likely from mild edema. A small fluid collection measuring 2.2cm AP x 2.3cm T x 8.8cm CC along the incision site most likely represents postoperative seroma. There is no definite surrounding stranding or rim enhancement to suggest abscess. The intra-abdominal vasculature is patent. The central superior deformity of L3 without retropulsion is unchanged. There are new deformities at the superior endplates of T11 and L1 compared to [**2181-1-9**] representing new compression fractures, no evidence of retropulsion. IMPRESSION: 1. A small fluid collection measuring 2.2cm AP x 2.3cm T x 8.8cm CC in the subcutaneous tissues along the incision site most likely represents postoperative seroma. There is no definite surrounding stranding or rim enhancement to suggest abscess, however infection of this fluid collection cannot be ruled out by CT. 2. There are new compression deformities at the superior endplate of T11 and L1 compared to study on [**2181-1-9**]. The previously seen superior endplate deformity at L3 is unchanged. 3. Patient is status post partial gastrectomy with no intra-abdominal findings to explain patient's symptoms. These findings were discussed with Dr. [**Last Name (STitle) **] at 5:02pm on [**2181-3-15**] by telephone. The study and the report were reviewed by the staff radiologist. [**2181-3-16**] Radiology CHEST (PORTABLE AP): IMPRESSION: Previous interstitial pulmonary edema has cleared and mediastinal and pulmonary vascular engorgement have resolved, although the heart is still mildly enlarged. The lungs are clear aside from minimal residual edema, or atelectasis at the base of the left lower lobe. Pleural effusion is small, if at all, on the left. A right subclavian infusion port, ends in the mid SVC. No pneumothorax. CULTURES: URINE CULTURE (Final [**2181-3-15**]): <10,000 organisms/ml. MRSA SCREEN (Final [**2181-3-16**]): No MRSA isolated. C. difficile DNA amplification assay (Final [**2181-3-16**]): Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. [**2181-3-14**] BLOOD CULTURE Pending Brief Hospital Course: 66 F DM2, recent subtotal gastrectomy for gastric adenocarcinoma, p/w DKA & ARF. Initially admitted to the ICU on [**3-14**] and transferred on [**3-16**] to the floor. . #. DKA: Ms. [**Known lastname 50155**] was admitted on [**3-14**] with significant obtundation and acidosis. She was found to have glucose levels in 800, bicarb of 6, AG 39, ketones in urine. Also WBC was elevated at 18 and Cr was 1.7. She was admitted to the ICU and treated with insulin bolus and subsequently with insulin gtt. There was a substantial free water deficit and she was aggressively hydrated and repleted with electrolytes when needed. With this regimen, the anion gap closed and she was transitioned to SQ insulin and iv D5 with better control. The acidosis was multifactorial- elevated lactate, DKA, and diarrhea. The precipitating cause of the DKA is unclear. Potential sources included HCAP and post-surgical infection. She and her husband have both stated that she has been taking her insulin as instructed. Abd CT showed a small fluid collection measuring 2.2cm AP x 2.3cm T x 8.8cm CC in the subcutaneous tissues along the incision site most likely representative of postoperative seroma - surgery felt this was not infected and not responsible for precipitating DKA. CXR revealed bilateral low lung volumes with areas of atelectasis at the right lung base. She was intitially treated with vanco/levo/flagyl. Flagyl was empirically given for possible C.diff, but stool c.diff returned negative. Subsequent CXR revealed no evidence of infection and so the abx regimen was switched simply to cipro. A 7-day empiric treatment course of cipro was given - for the low-possibility that pneumonia was present on admission. Urine cx was negative. . GI: the patient is s/p gastrectomy on [**2181-2-21**] for gastric adenocarcinoma. She presented with recurrent nausea and diarrhea since previous admission. Incision did not appear infected. Low suspicion for intraabdominal abscess. CT abdomen negative for infection/inflammation. She was treated with morphine and oxycodone prn. Zofran was made standing. Reglan was continued and ativan PRN was given. Ativan appeared to be most effective in relieving her nausea. Her nausea and vomiting is unchanged since her last hospitalization at which time an upper GI series showed no obstruction and KUB was normal. Given persistent diarrhea, stool cultures were sent - C.diff was negative. The leading thought was that this was partially attributed to a dumping syndrome - and she was made well aware of the need to take small/frequent meals and avoid high-fat, high-sugar meals and minimize large bolus intake at a time. On this regimen, she was vomiting/diarrhea free for 48 hours. Her sugars were also under better control. . . #. Hyperlipidemia: Continued home rosuvastatin . #. Depression: Stable. Continued home duloxetine . #. Hypertension, benign: was stable throughout the hospital stay. Metoprolol and verapamil were held in ICU. Metoprolol was restarted on the floor. Verapamil was discontinued. She continue on her home valsartan. . #. Obstructive sleep apnea: Continue CPAP . #. Venous stasis: Lasix was initially held but was restarted on transfer to the floor. . #. Gastric adenocarcinoma: Last chemo [**2181-1-22**]: Cycle 3, day 1 of epirubicin and Xeloda. She will need to f/u with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with hem-onc after discharge. . . #. Acute renal failure: Resolved after hydration. Creatinine 1.7 on presentation from 1.0 on discharge. Likely prerenal in setting of hypotension, nausea, vomiting, diarrhea, DKA. . # Discharge plan: Ms. [**Known lastname 50155**] will be seen by Home PT, nursing, and nutrition. She was seen by PT and was noted to be deconditioned but strong enough to receive home PT. She continues to be substantially weakened from her hospitalization, recent surgeries, DKA, and chemotherapy regimen. She is not strong enough to return to work and she was instructed to follow up with her PCP to determine when she can return to work. Given her recent medical condition and the stresses associated with work, it is unlikely that she will be able to return to work in the immediate-to-intermediate future (at least 2 weeks). . FEN:heart healthy, diabetic diet . Prophylaxis: Heparin sub-Q 5000 Units TID for VTE prophylaxis. . Code Status: Full Code (confirmed with HCP, pt's husband) Medications on Admission: Home medication list (as per d/c summary [**2181-3-7**]): 1. albuterol sulfate 90 mcg/actuation HFA 2 puffs Inhalation twice a day 2. ProAir HFA 90 mcg/actuation HFA Aerosol 2 puffs Inh q4-6 hours prn sob 3. Vitamin B-12 1,000 mcg/mL Solution Injection 4. duloxetine 30 mg E.C. 2 capsules PO Daily 5. fluticasone 220 mcg/actuation Aerosol Sig: 2-5 puffs Inh twice a day 6. furosemide 40 mg Tablet Sig: One (1) Tablet PO qam 7. furosemide 20 mg Tablet Sig: One (1) Tablet PO qpm 8. metoprolol tartrate 50 mg 1 Tablet PO BID 9. Singulair 10 mg 1 Tablet PO daily 10. omeprazole 20 mg E.C. 2 Capsules E.C. PO daily 11. prazosin 2 mg 2 Capsules PO BID 12. Maxalt-MLT 10 mg Rapid Dissolve 1 Tablet PO once a day 13. rosuvastatin 5 mg 2 Tablet PO daily 14. Diovan 320 mg Tablet Sig: One (1) Tablet PO once a day 15. verapamil 180 mg E.R. 1 Tablet PO once a day 16. Calcium 600 + D(3) 1 po daily 17. Xeloda 500 mg 2 Tablets PO twice a day 18. lorazepam 0.5 mg 1 Tablet PO Q4H as needed for anxiety 19. nystatin 100,000 unit/mL Suspension 5 mL PO twice a day. 20. ondansetron 8 mg Rapid Dissolve 1 Tablet PO every 8 hours prn nausea 21. prochlorperazine maleate 1 po prn nausea 22. oxycodone 5 mg 1-2 Tablets PO Q4H prn pain 23. docusate sodium 100 mg 1 Tablet PO once a day 24. metoclopramide 5 mg 1 Tablet PO four times a day 25. Humalog 100 unit/mL Per sliding scale Sub-Q2 hours after meals and QHS 26. Lantus 100 unit/mL 10 units Subcutaneous qam 27. Lantus 100 unit/mL 12 units Subcutaneous at bedtime Discharge Medications: 1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. furosemide 40 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 3. furosemide 20 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 4. valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. metoclopramide 5 mg/5 mL Solution Sig: One (1) PO QID (4 times a day). 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Ativan 0.5 mg Tablet Sig: 0.5 Tablet PO every four (4) hours as needed for nausea: Please take only 0.25 mg (half a 0.5 mg tablet) as needed for nausea. Disp:*30 Tablet(s)* Refills:*1* 10. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. Disp:*90 Tablet(s)* Refills:*1* 11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. psyllium Packet Sig: One (1) Packet PO TID (3 times a day). Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnosis - DKA Secondary Diagnoses - Gastric Mass s/p gastrectomy - Diabetes type 2 - Hypertension - ? Pneumonia 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. Your sugars improved with IV insulin. You were treated for a possible infection with antibiotics. You continued to have nausea, vomiting, and loose stools. Your medications were adjusted to help control your symptoms. You should take your zofran regularly three times a day instead of just as needed. Ativan can be taken as needed for nausea Followup Instructions: Name: [**Hospital **] [**Name Initial (MD) **] [**Name8 (MD) 1395**], MD Specialty: Primary Care When: Monday [**3-26**] at 9:30am Location: [**Hospital1 **] HEALTHCARE - [**State 3753**]GROUP Address: [**State **], [**Apartment Address(1) 3745**], [**Location (un) **],[**Numeric Identifier 822**] Phone: [**Telephone/Fax (1) 2205**] We are working on a follow up appointment with Dr. [**Last Name (STitle) **] in the next 1-2 weeks. You will be called at home with the appointment. If you have not heard within 2 business days or have questions, please call [**Telephone/Fax (1) 6568**]. Please contact Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office at [**Last Name (un) **] Diabetes Center to have a follow up appt within the next 1-2 weeks Name: [**Last Name (un) **] [**Name Initial (MD) **] [**Name8 (MD) 1395**], MD Specialty: Primary Care When: Monday [**3-26**] at 9:30am Location: [**Hospital1 **] HEALTHCARE - [**State 3753**]GROUP Address: [**State **], [**Apartment Address(1) 3745**], [**Location (un) **],[**Numeric Identifier 822**] Phone: [**Telephone/Fax (1) 2205**] We are working on a follow up appointment with Dr. [**Last Name (STitle) **] in the next 1-2 weeks. You will be called at home with the appointment. If you have not heard within 2 business days or have questions, please call [**Telephone/Fax (1) 6568**]. Please contact Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office at [**Last Name (un) **] Diabetes Center to have a follow up appt within the next 1-2 weeks

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

20067, 20125

12846, 16495

362, 368

20292, 20292

4596, 12823

20860, 22424

3925, 3955

18839, 20044

20146, 20271

17315, 18816

20443, 20837

3970, 4577

2820, 3484

311, 324

397, 2801

20307, 20419

16511, 17289

3506, 3799

3815, 3909

12,122

132,864

52847

Discharge summary

report

Admission Date: [**2198-2-5**] Discharge Date: [**2198-2-8**] Date of Birth: [**2140-12-30**] Sex: M Service: MEDICINE Allergies: Anacin Attending:[**First Name3 (LF) 9240**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 57 yo M h/o asthma, COPD (FEV1 44%, FEV/FVC 56% pred), HTN, GERD, DM2, HL p/w dyspnea X 4 days. Pt was in USOH until 4 days ago when developed congestion/green nasal discharge. Mildly dyspneic at the time. The following day developed cough productive of green sputum. Pt with worsening dyspnea this am, unable to walk more than a few steps without becoming dyspneic (baseline able to walk greater than 5 miles). Dyspnea not responsive to inhaler. (+) subjective fever X 24 hours. Pt has also had 2-3 episodes of L-sided CP, non-radiating, occuring after cough while sitting down. Denies abd pain/n/v/d. ROS o/w negative. . In ED vitals: 96.6, hr 107, bp 148/68, 19, 100% ra. Pt appeared in resp distress with exp wheezes on exam. CXR demonstrated no acute cardiopulmonary process. ABG 7.39/45/167. Labs notable for wbc 12.6. Pt with albuterol neb continuously, later spaced out to q2h, but pt could not tolerate any further spacing--pt would begin coughing and become dyspneic. Otherwise pt given azithro 500 mgX1, prednisone 60 mg X1. Transferred to [**Hospital Unit Name 153**] for further management. Past Medical History: 1. Diabetes type 2. 2. Hypertension. 3. Asthma, COPD. 4. Hypercholesterolemia. 5. GERD. 6. Chronic knee pain. 7. Chronic renal insufficiency Social History: Lives with daughter, smoked [**2-6**] ppd X 40 years, occ beer, no illicits Family History: Mother had MI at 73 and HTN. Father had DM. Physical Exam: Temp 98.3 BP 152/79 Pulse 100 Resp 28 O2 sat 93% 2L NC Gen - Alert, no acute distress, presently breathing comfortably HEENT - MMM, EOMI Neck - no JVD, no cervical lymphadenopathy Chest - mild exp wheezes at apices, rhonchi left base CV - Normal S1/S2, RRR, no murmurs appreciated Abd - Soft, nontender, nondistended, with normoactive bowel sounds Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally Neuro - Alert and oriented x 3 Skin - No rash Pertinent Results: [**2198-2-5**] 11:59AM PT-11.8 PTT-28.5 INR(PT)-1.0 [**2198-2-5**] 11:59AM WBC-12.6* RBC-4.86 HGB-13.0* HCT-38.6* MCV-80* MCH-26.8* MCHC-33.7 RDW-15.1 [**2198-2-5**] 11:59AM NEUTS-93.7* BANDS-0 LYMPHS-4.1* MONOS-1.5* EOS-0.5 BASOS-0.3 [**2198-2-5**] 11:59AM CK-MB-6 cTropnT-<0.01 [**2198-2-5**] 11:59AM CK(CPK)-353* [**2198-2-5**] 07:19PM CK-MB-12* MB INDX-1.9 cTropnT-<0.01 [**2198-2-5**] 07:19PM CK(CPK)-631* . CXR: No acute pulmonary process identified. . TTE: 1. The left atrium is mildly dilated. The left atrium is elongated. 2.There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. The gradient increased with the Valsalva manuever. 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. 5.The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. 6.There is mild pulmonary artery systolic hypertension. 7.There is no pericardial effusion. Brief Hospital Course: A/P:57 yo M h/o asthma, COPD (FEV1 44%, FEV/FVC 56% pred), HTN, GERD, DM2, HL p/w dyspnea X 4 days. . Dyspnea: Appeared consistent with COPD exacerbation in setting of recent viral URI. Treated with prednisone initially 60 mg, sent home on a few week taper. Continued on albuterol/atrovent nebs. Will follow up with o/p pulmonologist. . chest discomfort: Reports episodic chest pain, although not exertional. TTE checked to rule out wall motion abnormality, which showed no wall motion abnormality hyperdynamic EF and a mild LV outflow tract obstruction. Pt. may benefit from outpatient refer to a cardiologist. . DM2: Held oral meds when admitted but restarted on d/c, continued on lantus. . HTN: cont home procardia, HCTZ . renal faliure: pt's cr 1.4, at his baseline, suspect DM nephropathy, follow up with Dr. [**Last Name (STitle) 1366**] as o/p. . GERD: home ppi . comm: [**Name (NI) **] [**Name (NI) **] (hcp) [**Telephone/Fax (1) 108990**] Medications on Admission: albuterol prn aspirin 81 mg daily avandia 4 mg [**Hospital1 **] combivent 2 puffs qid glucophage 850 mg tid hctz 25 mg daily glyburide 10 mg [**Hospital1 **] lantus 10 units qhs procardia 60 mg daily wellbutrin 150 mg [**Hospital1 **] protonix 40 mg daily Discharge Medications: 1. Prednisone 10 mg Tablet Sig: As directed Tablet PO once a day: Take 6 tabs daily for 3 days, then take 5 tabs daily for 3 days, then take 4 tabs daily for three days, then 3 tabs daily for three days, then 2 tabs daily for 3 days, then one tab daily for three days, then stop. Disp:*63 Tablet(s)* Refills:*0* 2. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours) for 2 days. Disp:*2 Capsule(s)* Refills:*0* 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed. Disp:*qs 1 month* Refills:*2* 4. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous at bedtime. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 inhaler* Refills:*2* 10. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*qs 1 month* Refills:*2* 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 16. Metformin 850 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 17. Avandia 4 mg Tablet Sig: One (1) Tablet PO twice a day. 18. Wellbutrin SR 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. Discharge Disposition: Home Discharge Diagnosis: COPD Flare Asthma Attack Upper Respiratory Infection Left Ventricular Outflow Tract Obstruction Type 2 Diabetes, Uncontrolled Hypertension Discharge Condition: stable Discharge Instructions: Please continue your medications as listed below. Please make sure you follow up with your PCP in the next week. Please also follow up with your pulmonologist in the next 2 weeks. Followup Instructions: 1. Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 5500**], M.D. Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2198-2-16**] 10:45 2. Provider: [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] [**Name8 (MD) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**] Date/Time:[**2198-2-26**] 9:40 3. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3150**], MD Phone:[**Telephone/Fax (1) 250**] Please call for an appointment in the next week. 4. Please follow up with your pulmonologist in the next 2 weeks.

[ "493.22", "585.9", "403.90", "583.81", "272.0", "747.3", "530.81", "250.42" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6711, 6717

3506, 4455

286, 292

6900, 6909

2248, 3483

7137, 7728

1707, 1752

4762, 6688

6738, 6879

4481, 4739

6933, 7114

1767, 2229

227, 248

320, 1426

1448, 1597

1613, 1691

22,076

154,613

266

Discharge summary

report

Admission Date: [**2160-11-15**] Discharge Date: [**2160-11-28**] Date of Birth: [**2079-11-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2186**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: 1. VATS 2. Bilateral chest tubes History of Present Illness: The patient is an 80 year old Russsian speaking man with coronary artery disease, decreased LV function without prior symptoms of congestive heart failure, hypertension, and atrial fibrillation (on coumadin) status post pacemaker and a recent diagnosis of malignant ascites (non small cell CA vs. adenocarcinoma), primary unknown who presents with hypoxia at 88% on RA. Per the patient and his daughter, the patient began having increased dyspnea over the past two to three days which was associated with a mild increase in pedal edema and a large increase in his abdominal ascites. Of note, the patient denies CP, new cough, recent URI, urinary SX, HA, dizziness, myalgias, arthralgias, F/C. He had mild abdominal pain, decreased appetite, mild nausea without emesis. He has hard BM every other day. He denies any recent travel, and has been relatively immobile. Past Medical History: HTN GERD BPH s/p thymectomoy with partial sternotomy in '[**59**] (for mediastinal mass seen incidentally on CT) CAD (last cath here in '[**47**], showed minor branch coronary artery disease in the OM2, sees Dr. [**Last Name (STitle) **] CHF (last TTE here in '[**51**], EF 30-35%, mild-severe MR, mild-mod TR) Afib (on coumadin) h/o pulmonary nodules s/p pacemaker placement [**2149**] s/p R cataract surgery Social History: Lives in "community center". His family, including his wife, son, granddaughter, and daughter in law are involved in his care. Non-smoker. Rare EtOH use. Family History: Noncontributory Physical Exam: PE: T: 97.8 BP: 116/76 HR: 96 RR: 27 O2: 100% RA Gen: Cachectic male lying in bed breathign quickly. HEENT: NCAT EOMI MMM. No scleral icterus noted, conjunctiva pink. Slightly elevated JVD Chest: Decreased breath sounds at bases bilaterally, R>L. Dullness to percussion at both bases bilaterally. Tachypnic. CV: RRR nl S1, S2, no m/r/g. Abd: Distended. Shifting dulness. Taught skin. No hepatosplenomegaly noted. No tenderness upon palpation. BS x 4. Extremities: Warm, well perfused. Mild 1+ edema at the feet bilatearally. Neuro: Patient A & O x 3. Pleasant affect, interactive with us and his daughter. [**Name (NI) 595**] speaking only. Pertinent Results: Labs [**11-15**]: WBC 11.2, HCT 35.3, Plt 289 (88.7% N, 7.8% L) PT: 14.7 PTT: 25.6, INR: 1.3 Na 133, K 4.9, Cl 98, HCO3 21, BUN 43, Cr 2.1 Glu 232 AST 14, AP 80, AST 22, [**Doctor First Name **] 51, Lip 29 Ascites [**11-15**]: TOT PROT-4.6 GLUCOSE-124 LD(LDH)-526 WBC-3000* RBC-[**Numeric Identifier 2596**]* POLYS-2* LYMPHS-43* MONOS-55* Imaging: [**11-15**] RUQ U/S: A stable appearance of the liver. The portal vein is patent and demonstrates hepatopedal flow. 2. Cholelithiasis is again noted. 3. Moderate amount of ascites. A spot was marked for paracentesis to be performed by the clinical staff. 4. The right pleural effusion. [**11-15**] CXR: Interval redevelopment of moderately large left-sided pleural effusion. Increased retrocardiac opacity consistent with atelectasis, effusion, or consolidation. Brief Hospital Course: 1. Shortness of breath/Malignant Pleural Effusion/Pulmonary Embolism: The patient was ROMI with negative enzymes x 3. A paracentesis was performed that resulted in mild improvement of symptoms. The patient was assessed by interventional pulmonology and thoracic surgery and the decision was made to defer thoracentesis and proceed with a VATS. The patient had a left sided VATS with biopsy and pleurodesis on [**11-20**]. He tolerated the procedure well but required several boluses of fluid rafter the procedure for low UOP and BP. He also spiked a fever to 101.5 and had low oxygen sats with increasing oxygen requirement. Overnight he was triggered for hypotension with a BP of 102/60 (down from 120s-160s in the PACU) and had an episode of desaturation to 85% on FiO2 50% FM + 4L NC in addition to tachypnia. The patient's O2 requirement continued to increase until he required a NRB. An IP consult was obtained that recommended transfer to the MICU for management of ? Talc pneumonitis versus pulmonary edema (as seen on CXR and with effusions visualized on U/S). In the MICU the patient had a right chest tube and R subclavian line placed. An [**11-21**] echo was positive for right atrium and ventricle dilitation, 3+ tricuspid regurgitation suggestive of possible PE. A [**11-21**] CTA was positive for “Extensive pulmonary emboli, particularly in the right lung, the largest in the proximal portion of the pulmonary artery to the right upper lobe. Small subsegmental pulmonary artery embolism in the left lingula. Right middle lobe consolidation may reflect pulmonary infarction, or consolidation. A [**11-21**] LENI was positive for left superficial deep vein thrombus. Troponins were found to be elevated to 0.17 and thought to be secondary to increased heart strain. Anticoagulation with IV heparin was started. The patient was started empirically on a course of flagyl and levofloxacin. During his stay the patient's oxygen requirement slowly diminished. The family declined the option of placing an IVC filter. On the floor the patient was kept anticoagulated with a heparin SS and transitioned to lovenox on discharge. His chest tube was pulled prior to discharge. . 2. Malignancy of unknown origin: During his stay the patient was evaluated by hematology/oncology, who determined that further characterization would be required with an outpatient PET/CT on [**12-2**]. The patient has a [**12-4**] followup appointment with thoracic oncology at which point his PET/CT will be reviewed and a plan for further treatment will be made. . 3. ARF: The patient had an episode of ARF with creatinine elevated to 2.1 from baseline of 1.2. This was thought to be secondary to third spacing and poor po intake of fluids resulting in decreased intravascular volume. With hydration and encouragement of PO intake his creatinine returned to 0.9. . 4. Anemia: Patient iron labs sent, determined to have low iron and low TIBC consistent with anemia of chronic disease. . 5. Afib: Coumadin held at first for procedure, heparin SS after VATS. Pt. dischraged on lovenox. . 6. BPH: patient on terazosin. 7. GERD: Maalox, pantoprazole. 8. Ascites: 3.5 drained upon admission, sterile. Repeated day of discharge for palliation, an additional 5L removed. . ***************** ####DISPO#### PLEASE NOTE. Family aware of diagnosis. Patient wants physicians and nursing staff to speak to family about his condition, and defers to them to divulge any information that they feel is necessary to him (re: dx and prognosis). Medications on Admission: 1.COUMADIN 1MG--4mg by mouth every day 2.ENALAPRIL MALEATE 10MG--One by mouth daily 3.HYTRIN 1MG--One at bedtime 4.OMEPRAZOLE 20MG--Once a day 5.VENLAFAXINE HCL 37.5 MG--One tablet every morning, and two tablets at bedtime 6.LASIX 20 mg--1 tablet(s) by mouth daily 7.OXYCODONE 5 mg--1 tablet(s) by mouth q4-6 hours as needed for pain Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Albuterol Sulfate 0.083 % Solution Sig: [**2-11**] Inhalation Q6H (every 6 hours) as needed. 4. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 5. Oxycodone 5 mg/5 mL Solution Sig: [**2-11**] PO PRN: Q4-6 as needed for pain. 6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 7. Morphine 2 mg/mL Syringe Sig: [**2-11**] Injection Q4H (every 4 hours) as needed for pain. 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 9. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO TID (3 times a day). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 12. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1) Intravenous Q8H (every 8 hours) as needed for nausea. 13. Lovenox 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous twice a day. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] of [**Location (un) 55**] Discharge Diagnosis: 1. Adenocarcinoma of unknown primary 2. Pleural effusion 3. Ascites 4. Pulmonary embolism 5. Acute Renal failure 6. Anemia of chronic disease 7. Atrial fibrillation 8. Benign prostatic hypertrophy 9. Poor nutrition 10. Hypertension 11. GERD Discharge Condition: Stable. Intermittently requires O2 by NC. Discharge Instructions: Please take your medicines as prescribed. If you have any shortness of breath, chest pain, or any other concerning symptoms please contact a physician [**Name Initial (PRE) 2227**]. Followup Instructions: Please follow up with your PET/CT scan on [**2160-12-2**] at 12:00. Your other appointments are: Provider: [**Name10 (NameIs) **] [**Name8 (MD) 490**], MD, PHD[**MD Number(3) 708**]:[**0-0-**] Date/Time:[**2160-12-4**] 9:00 Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**] Date/Time:[**2160-12-4**] 11:00 Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2161-5-6**] 2:30

[ "518.81", "401.9", "453.41", "415.11", "414.01", "285.29", "428.0", "799.02", "427.31", "600.00", "E849.7", "197.6", "530.81", "E878.8", "199.1", "V45.01", "428.30" ]

icd9cm

[ [ [] ] ]

[ "38.93", "34.04", "33.22", "54.91", "34.92" ]

icd9pcs

[ [ [] ] ]

8548, 8620

3423, 6962

326, 360

8905, 8950

2584, 3400

9181, 9633

1879, 1896

7346, 8525

8641, 8884

6988, 7323

8974, 9158

1911, 2565

279, 288

388, 1258

1280, 1692

1708, 1863

75,240

179,768

1990

Discharge summary

report

Admission Date: [**2165-6-27**] Discharge Date: [**2165-6-28**] Date of Birth: [**2103-7-13**] Sex: M Service: MEDICINE Allergies: All allergies / adverse drug reactions previously recorded have been deleted Attending:[**First Name3 (LF) 99**] Chief Complaint: alcohol withdrawal Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a 61 year old male with a history of polysubstance abuse, Hepatitis C infection, CAD s/p stent in [**2163**], and distant left arm amputation who presented to the ED requesting detox last night on [**2165-6-26**]. He reported that his last drink was at 3:00 PM earlier that day. He was recently admitted to [**Hospital1 18**] from [**2165-5-22**] to [**2165-5-24**] for alcohol withdrawal and suicidal ideation. . During his previous admission, he remained hemodynamically stable, but continued to require Diazepam approximately every 2 hours per CIWA scale, receiving a total of 170 mg over three days. His CIWA [**Doctor Last Name **] was driven primarily by anxiety and agitation. It was not clear whether his symptoms were entirely due to alcohol withdrawal or his underlying psychiatric condition. Psychiatry was consulted, and was placed on Section 12. He was discharged to the [**Hospital1 1680**] inpatient psychiatric unit for further evaluation and treatment. . In the ED, initial vital signs were T 99.2, BP 167/96, HR 101, RR 16, and SpO2 96% on RA. Exam showed signs of alcohol withdrawal with tremor, agitation, and headache. EKG showed NSR at 93 bpm with small R waves in III and aVF unchanged from prior and no acute ischemic changes. He received Diazepam 10 mg PO twice in the early morning. He continued to show signs of withdrawal and received an additional Diazepam 10 mg IV three times. He was given Thiamine 100 mg, Folic acid 1 mg, and a Multivitamin. Labs were checked at 07:00 with serum ethanol level 96 and otherwise negative serum tox screen. No urine tox screen was performed. His electrolyte panel showed bicarb 25 and anion gap 15, but was otherwise unremarkable. His WBC count was elevated to 12.2 with normal diff except for 1% metas. He denied any localizing symptoms of infection and no infection workup was started. His platelets were low at 100, and significantly down from 229 on [**2165-5-24**]. His Hct was 43.3, slightly up from his baseline. . He continued to have withdrawal symptoms despite receiving a total of Diazepam 50 mg in the ED with CIWA remaining elevated primarily for agitation, tremor, and headache. He remained hemodynamically stable in the ED and was alert, oriented, and conversant. There was no evidence of seizure activity, delirium, or hallucination. He was admitted to the ICU for continued monitoring and treatment of his withdrawal. Vitals prior to transfer were T afebrile, BP 140/70, HR 110, and SpO2 100% on RA. . Once in the ICU, he continued to score on CIWA and reported anxiety, tremor, and headache. He was hemodynamically stable with HR in the 90s and BP in the 130s-140s. He spiked a fever to 101.2 on arrival. He reported that he had been drinking about 0.5 gallons of vodka daily since shortly after discharge from [**Hospital1 1680**]. He also reported that he has recently been taking 6-8 mg of Klonopin and Xanax daily, as well as [**3-5**] Vicodin daily. He denied any injection drug use in several years since a prior suicide attempt. He denied any current active suicidal ideation. He says that he has been trying to take his Aspirin, but sometimes forgets. His chief complaint was headache for which he requested narcotic pain medications or Tramadol. Past Medical History: - Polysubstance abuse, including heroin>40 years and multiple BZDs - Hit by a car at the age of 4 and suffered extensive injuries including a skull fracture, bilateral broken legs and required above the elbow amputation of the left arm. - Hepatitis C diagnosed 10-15 years ago, never treated - Right hip arthritis - Cellulitis - CAD s/p stent in [**2163**] Social History: Originally from [**Location (un) **]. No family in the area. Currently homeless. Spent 17 years total in prison. # Tobacco: Has smoked [**12-2**] PPD for over 40 years. # Alcohol: Multiple admissions for detox. Currently reports drinking 0.5 gallons vodka daily. # Illicits: Polysubstance abuse with narcotics including heroine and multiple benzodiazepines. Prior 40 year history of IVDU. Family History: No family history of seizure, stroke, SCD. Physical Exam: Admission Physical Exam: Vitals: T 101.2, BP 140/79, HR 98, RR 17, SpO2 96% on RA General: Alert, attentive, oriented x3, agitated with tremor, no nystagmus HEENT: Sclera anicteric, dry MMs, oropharynx clear, dentures Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally. Initial rhonchi in upper lung fields that cleared with cough. CV: Regular rate and rhythm. Normal S1, S2. Early peaking C-D murmur at RUSB and LLSB without radiation. Abdomen: Bowel sounds present. Soft, non-tender, mildly distended and tympanic. No rebound tenderness or guarding. GU: No foley Ext: Warm, well perfused. Left arm amputated above elbow and atrophied. Distal pulses 2+. No cyanosis, clubbing, or edema. Skin: Healing abrasion on right lower leg. ICU Discharge Exam: Patient left AMA. Pertinent Results: [**2165-6-27**] 07:00AM ASA-NEG ETHANOL-96* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG . [**2165-6-27**] 07:00AM WBC-12.2*# RBC-4.68 HGB-15.1 HCT-43.3 MCV-93 MCH-32.2* MCHC-34.8 RDW-14.1 [**2165-6-27**] 07:00AM NEUTS-70 BANDS-0 LYMPHS-24 MONOS-3 EOS-2 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [**2165-6-27**] 07:00AM PLT SMR-LOW PLT COUNT-100*# . [**2165-6-27**] 07:00AM GLUCOSE-87 UREA N-11 CREAT-0.9 SODIUM-143 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-25 ANION GAP-19 [**2165-6-27**] 07:00AM ALBUMIN-4.2 CALCIUM-8.6 PHOSPHATE-3.2 MAGNESIUM-1.7 . [**2165-6-27**] 07:00AM ALT(SGPT)-43* AST(SGOT)-106* LD(LDH)-434* ALK PHOS-100 TOT BILI-0.7 . MICRO: none IMAGING: CXR [**6-27**]: IMPRESSION: Given striking finding of increased size of the mediastinal compared with chest film only one month ago, we communicated to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10936**] that a PA and lateral chest radiograph was recommended to better assess mediastinal widening and cardiac size as well as likely aspiration pneumonia. CXR [**6-28**]: IMPRESSION: Aspiration pneumonia with multifocal pneumonia in the right middle and both lower lobes. Mild cardiomegaly has developed in the last month. Brief Hospital Course: The patient is a 61 year old male with a history of polysubstance abuse, Hepatitis C infection, CAD s/p stent in [**2163**], and left arm amputation who presented to the ED requesting detox with last drink at 3:00 PM on [**2165-6-26**]. He required significant amounts of Diazepam in the ED with continued withdrawal symptoms, but remained HD stable. . # Alcohol Withdrawal: Pt has had multiple admissions for alcohol detox, several with an apparent mixed withdrawal picture due to his concurrent narcotic and benzodiazepine abuse. He scored on CIWA for agitation, anxiety, and tremor, but as with prior admission there was a question of whether his symptoms were truly due to withdrawal versus underlying psychiatric conditions or pt desire for benzodiazepines, as total body tremor present on exam was not observed when patient was sleeping or not being actively observed. He was ordered for Diazepam 10 mg PO Q1H PRN CIWA >10, receiving a total of 120mg of Diazepam. He received maintenance IVF, zofran for nausea, and multivitamin, thiamine and folate. The patient left AMA after a psychiatry consult found no psychiatric contraindication to discharge and that he was compentent. . # Suicidal Ideation: While trying to obtain ICU consent from the patient, he voluntarily admitted to having suicidal ideation. Psychiatry was consulted and found no psychiatric contraindication to discharge. Patient left AMA. . # Polysubstance Abuse: He has a history of narcotics and benzo abuse in addition to alcohol, and has previously had admissions with mixed withdrawal states. Serum tox screen in the ED was negative except for ethanol, but urine tox screen was not performed. Urine tox screen was positive for benzodiazepenes, but otherwise negative. . # Leukocytosis: His WBC count was elevated to 12.2 on admission with diff showing 70% neutrophils, no bands, and 1% metas. He denied any current localizing symptoms of infection, and has been afebrile. He has shown similar mild leukocytosis on prior admissions for detox, and is unlikely to have an acute infection, but a portable CXR and UA would be a reasonable screen given his ICU admission. CXR showed possible aspiration pneumonitis, now resolved. UA was ordered but not sent. # Thrombocytopenia: His platelet count was down to 100 on admission from a prior baseline in the mid 200s. He has never had similar low counts in the past. The differential includes medication effects (uncertain what he received at recent psych admission), alcohol toxicity, bone marrow process, or liver disease. His diff did show 1% metas, which is of uncertain significance. He has not received heparin recently. Platelet counts trended up. . # Anion Gap: He had an elevated anion gap of 15 on admission with normal bicarb 25. This likely represents a combined anion gap metabolic acidosis from his alcohol abuse and possibly a respiratory alkalosis from hyperventilation or metabolic alkalosis related to volume depletion. Anion gap resolved on subsequent labs. . # Hepatitis C Infection: He has a reported history of HCV infection due to IVDU. He reports that he has not been treated, but that he has seen a liver specialist in the past and vaccinated against HAV and HBV. LFTs were elevated on admission but trended down to within normal limits thereafter, with residual AST/ALT ratio 2:1 suggestive of alcoholic hepatitis but no other active liver pathology. . # CAD: He has a history of CAD with stent in [**2163**] and several recent ED visits for chest pain with negative workup, including negative exercise stress test on [**2165-4-23**]. He currently denies any symptoms concerning for ACS. EKG in the ED showed no acute ischemic changes. Monitored on telemetry without events. Continued home Aspirin 325 mg PO daily. . Medications on Admission: (per last discharge [**2165-5-24**] in OMR) Aspirin 325 mg PO daily -- taking intermittently Acetaminophen 650 mg PO Q6H PRN pain -- not taking Olanzapine 2.5 mg PO TID PRN agitation -- not taking Diazepam 10 mg Taper -- completed at [**Hospital1 1680**] Discharge Medications: (Patient left AMA) 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Alcohol Withdrawal Hepatitis C 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 treatment of alcohol withdrawal. You were takent to the ICU due to frequent monitoring requirement. You were treated with diazepam for your withdrawal. You were having suicidal thoughts during your hospitalization. The psychiatry doctors saw [**Name5 (PTitle) **] and deemed you competent, not suicidal and ok to discharge. You decided to leave against medical advice. Followup Instructions: Please follow up with your primary care doctor next week and ask about potential detox facilities as well as social work referral.

[ "V62.84", "V49.60", "291.81", "V45.82", "287.5", "305.1", "414.01", "571.1", "276.2", "070.70" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11003, 11009

6611, 10391

354, 360

11084, 11084

5362, 6588

11668, 11802

4478, 4522

10697, 10980

11030, 11063

10417, 10674

11235, 11645

4562, 5308

5324, 5343

296, 316

388, 3672

11099, 11211

3694, 4053

4069, 4462

44,342

128,115

43954

Discharge summary

report

Admission Date: [**2129-4-23**] Discharge Date: [**2129-5-20**] Date of Birth: [**2112-1-27**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2145**] Chief Complaint: nausea, vomiting, abdominal pain, rash Major Surgical or Invasive Procedure: Arterial line. Temporary femoral HD line IR placed HD line History of Present Illness: Mr. [**Doctor Last Name 94406**] is a 17 year old male from [**Country 7192**] who has been in the US for the last year who presented to [**Hospital3 62353**] the day prior to admission to [**Hospital1 18**] with 1 week of feeling generally unwell with abdominal pain, HA, nausea, vomiting with specks of blood, a diffuse, itchy head to toe rash, blisters on his feet. He has currently been doing temp work but has had no recent steady work. No recent travel or other exposures. Denies any ingestions. . At [**Hospital3 15402**], he was found to be in ARF with elevated K and peaked TWs on ECG. He received Ca, bicarb, insulin, glucose, and kayexalate and was transferred to [**Hospital1 18**]. . In [**Hospital1 18**] ED, 98.7, 130/90, 88, 18, 97% RA. Labs were repeated and were remarkable for WBC 11.4 with 84% PMNs and 2% bands. Lytes with Cr 17.5, BUN 215, K 6.2, bicarb 23, Phos 9.4, Ca 5.7. AG 33. VBG 7.47/37/37. Lactate 2.2. LFTs showed AST 2395, ALT 1212, LDH [**Numeric Identifier **]. Tbili, albumin, and coags normal. Lipase 331. Urine and serum tox screens were negative. Trop 0.28, CK 309,700, MB 308. U/A with >50 RBCs, WBC [**5-18**], pro 500. ECG was improving per report. He was having frequent loose stools due to his kayexalate. He received 3L of NS. In the ED, he denied any chest pain, cough, SOB. He complained of RLQ pain and was guiaic positive. He had a CT abdomen performed which showed mildly dilated loops of bowel and also showed air in the epicardial fat, and widespread lung opacities. He then went for a CT of the chest which showed penumomediastinum and again showed widespread parenchymal opacities. After findings of pulmonary opacities, he was given Zosyn. His K also remained elevated with low Ca and he received additional Ca prior to transfer. Just prior to transfer to the ICU, he complained of more difficulty breathing, began vomiting coffee ground emesis and dropped his O2 sats to 75% on RA and was intubated. Post-intubation, he had significant white frothy sputum. . Upon arrival to the MICU, further history could not be obtained as patient is intubated and sedated. Past Medical History: Since the age of 8, patient has had periods of frequent respiratory problems with SOB, cough and fevers every 2-3 months in [**Country 7192**]. Also during this time patient began to develop chronic headache, nausea, vomiting and body aches. Social History: Originally from [**Country 7192**]. Has been in the US for the last year. Denies tobacco, EtOH, illegal drug use aside from marijuana 6 months ago. Works as a cranberry picker in [**Location (un) 5503**]. Lives with his father and his siblings and various other family members in a crowded apartment infested with rodents, insects, poorly cleaned. When in [**Country 7192**], multiple toxin exposures when working at gas stations (would swallow diesel while transferring gas using a hose and his mouth) and corn fields (including pesticides such as Tamaron and 20/20). See Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **] OMR note for further details). Family History: 18 y/o cousin who passed away from unknown etiology. Cousin worked in similar fields to patient. 8 y/o brother with similar complaints of chronic nausea, vomiting and abdominal pain. Physical Exam: T: 99.6 BP: 153/109 HR: 96 Vent: AC 400 x 20, PEEP 10, FiO2 100% SaO2: 10% Gen: intubated, sedated HEENT: No conjunctival pallor. No icterus. Mild mucosal breakdown in inside of lips. No strawberry tongue. Posterior pharynx exam limited by intubation. NECK: Supple, No LAD. JVP low CV: RRR. nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**] LUNGS: Diffusely rhonchorous with symmetric breath sounds. No appreciable subcutaneous crepitus ABD: NABS. Soft, NT, ND. No HSM EXT: WWP. Trace hand and pedal edema. Bounding distal pulses, symmetric SKIN: Nonblanching macules predominantly on chest, also on back and feet. Excoriated papules on arms and legs and multiple excoriations on all extremities. Desquamation in perianal region without fluctuance or other skin changes to suggest forniere's. Large unroofed blisters on the ball of each foot with active bleeding. NEURO: PERRL. Withdraws all extremities to noxious stimuli. Pertinent Results: [**2129-4-23**] 12:03AM BLOOD WBC-11.4* RBC-4.50* Hgb-13.9* Hct-38.6* MCV-86 MCH-30.8 MCHC-35.9* RDW-12.3 Plt Ct-162 [**2129-4-23**] 12:03AM BLOOD Neuts-84* Bands-2 Lymphs-8* Monos-5 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2129-4-23**] 02:15PM BLOOD I-HOS-DONE [**2129-4-23**] 12:03AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2129-4-23**] 12:03AM BLOOD PT-12.4 PTT-25.8 INR(PT)-1.0 [**2129-4-23**] 09:13PM BLOOD Fibrino-453* D-Dimer-As of [**11-9**] [**2129-4-23**] 09:13PM BLOOD FDP-10-40* [**2129-4-25**] 11:09PM BLOOD Fibrino-364 . Bronchoscopy - Bronchial Lavage: NEGATIVE FOR MALIGNANT CELLS. Pulmonary macrophages. No bronchial epithelial cells present. . Blood Culture, Routine (Final [**2129-4-29**]): NO GROWTH. . FECAL CULTURE (Final [**2129-4-24**]): NO SALMONELLA OR SHIGELLA FOUND . CAMPYLOBACTER CULTURE (Final [**2129-4-25**]): NO CAMPYLOBACTER FOUND . OVA + PARASITES (Final [**2129-4-25**]): NO OVA AND PARASITES SEEN . CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2129-4-23**]): Feces negative for C.difficile toxin A & B by EIA. . FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2129-4-24**]): NO E.COLI 0157:H7 FOUND. . ASO Screen (Final [**2129-4-25**]): < 200 IU/ml PERFORMED BY LATEX AGGLUTINATION. Reference Range: < 200 IU/ml (Adults and children > 6 years old). . Respiratory Viral Culture (Final [**2129-4-26**]): No respiratory viruses isolated. . CRYPTOCOCCAL ANTIGEN (Final [**2129-4-24**]): CRYPTOCOCCAL ANTIGEN NOT DETECTED. . CSF;SPINAL FLUID Source: LP #4. GRAM STAIN (Final [**2129-4-24**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2129-4-26**]): NO GROWTH. FUNGAL CULTURE (Final [**2129-5-13**]): NO FUNGUS ISOLATED. VIRAL CULTURE (Preliminary): No Virus isolated so far. \ . Source: oral ulceration r/o routine cx. VIRAL CULTURE (Final [**2129-5-4**]): HERPES SIMPLEX VIRUS TYPE 1. CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY. . Blood Culture, Routine (Final [**2129-5-15**]): NO GROWTH. . URINE CULTURE (Final [**2129-5-9**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML. . URINE CULTURE (Final [**2129-5-12**]): NO GROWTH. . Staph aureus Screen (Final [**2129-5-8**]): STAPH AUREUS COAG +. RARE GROWTH. OXACILLIN RESISTANT . [**2129-5-17**] 06:50AM BLOOD WBC-6.6 RBC-3.19* Hgb-9.5* Hct-27.7* MCV-87 MCH-29.8 MCHC-34.3 RDW-15.2 Plt Ct-682* [**2129-5-11**] 07:45AM BLOOD Neuts-63.8 Lymphs-22.9 Monos-8.1 Eos-4.9* Baso-0.3 [**2129-4-27**] 11:03AM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL [**2129-5-17**] 06:50AM BLOOD Plt Ct-682* [**2129-5-20**] 06:55AM BLOOD Glucose-90 UreaN-21* Creat-1.0 Na-138 K-4.5 Cl-105 HCO3-25 AnGap-13 [**2129-5-11**] 07:45AM BLOOD ALT-57* AST-51* LD(LDH)-712* CK(CPK)-331* AlkPhos-103 TotBili-0.4 [**2129-5-8**] 07:50AM BLOOD Lipase-113* [**2129-5-20**] 06:55AM BLOOD Calcium-8.7* Phos-2.6* Mg-1.8 [**2129-5-15**] 07:40AM BLOOD calTIBC-252* Ferritn-817* TRF-194* [**2129-5-16**] 07:40AM BLOOD PTH-10* [**2129-5-12**] 07:35AM BLOOD Cortsol-20.5* [**2129-5-10**] 07:55AM BLOOD HBsAb-POSITIVE HBcAb-NEGATIVE IgM HBc-NEGATIVE Brief Hospital Course: HOSPITAL COURSE: 17 year old Guatemalan male without significant past medical history who presented with 1 week of nausea, vomiting, abdominal pain, diarrhea, diffuse rash found to have rhabdomyolysis, acute renal failure due to ATN, diffuse pulmonary infiltrates, and pneumomediastinum requiring MICU admission. Hospital course complicated by a retroperitoneal bleed s/p renal biopsy. Patient's rhabdomyolysis and ATN improved and he was discharged without need for hemodialysis. . # Rhabdomyolysis: Patient admitted with CK > 300,000, which downtrended to ~300 prior to discharge. Etiology of rhabdomyolysis is unclear after extensive work-up: -- Given constellation of fevers, rash, and myalgias, differential diagnosis includes infectious etiology, toxic exposure, or underlying metabolic muskuloskeletal disorder exacerbated by one of the above etiologies. No evidence of crush injuries, illegal drug use such as cocaine, medications such as statins to explain rhabdomyolysis. Other etiology includes extensive heat exposure from field toil leading to rhabdomyolysis. Patient is a cranberry picker in the US, and has reportedly been chronically ill in the setting of extensive toxin exposure history from [**Country 7192**] including swallowing leaded diesel, and working with organophosphates in corn fields (see note from Dr. [**Last Name (STitle) **] in OMR). Patient has extensive infectious disease work-up performed, including rapid respiratory viral culture and screen (negative), influenza titers (positive for past or recent infection), an LP without evidence of meningitis, adenovirus (negative), EBV (negative), cocksackie virus (negative), HSV/VZV antigens (negative), CMV titers (negative), hepatitis titers/viral loads (negative), stool cultures for SSYCE organisms (no growth), blood, urine cultures with no growth, BAL lavage (no growth), denge fever (negative), leptospirella (negative), mycoplasma titers (negative), trichonella (negative), and HIV testing have all been negative. Noted to be MRSA positive (nasal swab S. aureus with rare growth). Initially patient was treated with Vancomycin/Zosyn, which were discontinued once patient was extubated and there was no source of bacterial source identified. Rheumatology and neuro-MSK consulted, decided etiology is unlikely that of an acquired muscular disorder, polymyositis, or dermatomyositis, and recommended biopsy of muscle in 1 month after rhabdomyolysis resolved. Patient will need muscle biopsy on discharge. . # Respiratory failure: Patient was intubated in the ED for worsening SOB, hypoxia. He did not initially complain of respiratory symptoms but started vomiting coffee ground emesis and was intubated for airway protection. Chest CT showed pulmonary infiltrates. Bronchoscopy showed no evidence of infection, and was thought to be due to ARDS in the setting of his rhabdomyolysis and generalized inflammed state. Patient was extubated 2 days after intubation. Subsequent CXRs showed resolution of the infiltrates. . # Acute renal failure: Patient admitted with creatinine of 17.5, and hemodialysis was initiated. Renal biopsy showed ATN likely secondary to rhabdomyolysis, and acute glomerulonephritis as a result (ASO titers were negative). Biopsy complicated by retroperitonal bleed which tamponaded off without intervention. No evidence of HUS (no [**Doctor First Name **], thrombocytopenia, and stool cultures negative for E. coli 0157:H7). Patient underwent post ATN diuresis and urine output increased. He did not require hemodialysis on discharge and Creatinine improved to 1.2 on discharge. . # Urinary Tract Infection: Noted to have UTI with low grade fevers. Foley was removed and IV ceftriaxone administered. Patient treated for seven days with IV ceftriaxone. # Pneumomediastinum: Noted on CT on admission. Likely due to increased intrathoracic pressure from vomiting. Differential diagnosis includes Borhaave's syndrome. Patient had barium swallow per thoracic surgery recommendations which showed no esophageal rupture. Patient was tolerating POs on discharge. Primary care physician should arrange follow up with thorassic surgery regarding need for repeat imaging on discharge. # Abdominal pain: Inflammation from his transaminitis versus generalized illeus from rhabdomyolysis. Stool cultures without evidence of infection. Abdomen was benign. Eventually resolved. # Blisters: Noted to be bilateral and on the balls of both fee. Likely traumatic and work-related (patient reports poor footwear/wearing flip flops). Exposure to wet bogs left blisters appearing macerated. Dermatology was consulted and reccomended standard wound care (kerlix, bactroban) which led to blisters improved. # Rash: Patient noted to have maculopapular diffuse rash on admission, consistent with viral exanthem vs toxin mediated mechanism. Dermatology consulted for rule out of Henoch-Schonlein purpura, but thought the rash was likely toxin mediated. Patient noted to have some desquamation of his fingers thought to be due to resolution of inflammation/edema in addition to loss of hyperkeratotic skin acquired through years of sun exposure and work. Patient also noted to also have millaria crystallina (heat rash) treated with cooling blankets, daily baths, and decreased room temperature. # Transaminitis/Elevated Pancreatitis : Likely secondary to rhabdomyolysis. Liver followed in ICU, ruled out other causes of transaminitis including viral infections Salmonella (ruled out with stool cultures), toxic-metabolic etiologies. AMA, [**Last Name (un) 15412**] negative. Transaminitis improved to normal prior to discharge. # Retroperitoneal bleed: Associated with renal biopsy and uremic platelets. Patient received ddAVP in ICU. Hematocrit stabilized, RP bleed clinically appeared to have tamponaded off. Patient's back pain likely associated with RP bleed. #Mucositis: Mild palatal erosions on exam and perianal irritation appears improved. Palatal erosions may also be bite trauma from intubation. No frank mucosal bleeding noted on exam. Improved on discharge. #hypercalcemia: Patient had elevated Ca (peak of 13.5 on [**5-13**]). Believed to be secondary to rhabdomyolysis. No evidence of hyperparathyroidism, hyperthyroidism or hypoaldrenalism. Treated with IVF, calcitonin and IV bisphosphonate and improved to 8.7 on discharge. Medications on Admission: none Discharge Medications: none Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Rhabdomyolysis Acute renal failure due to acute tubular necrosis Pneumomediastinum Transaminitis . Secondary diagnosis: retroperitoneal bleed Discharge Condition: afebrile, hemodynamically stable Discharge Instructions: You were admitted with a diagnosis of rhabdomyolysis (intense muscle damage) that affected your liver and your kidneys. You went into renal failure and required hemodialysis. Your renal function improved and your hemodialysis was discontinued. Your course was complicated by high levels of calcium which were treated with IV fluids, calcitonin and IV bisphonates. Your calcium improved. . You are not being discharged on any new medications. . It is very important that you follow up with your new pediatrician at Greater [**Hospital 5503**] Health Center. We have made you a follow-up appointment. You also need to follow up with our endocrinologists. Return to the hospital or call your PCP if you experience any of the following symptoms: chest pain, fever > 101 F, shortness of breath, vomiting with blood, worsening rash, decreased urine output, abdominal pain, or any other symptoms not listed here concerning enough to warrant physician [**Name Initial (PRE) 2742**]. Followup Instructions: You have an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 94407**] at the Greater [**Hospital 5503**] Health Center on [**5-26**] at 11 am. Please call to reschedule if you are unable to keep this appointment. You can reach her office at([**Telephone/Fax (1) 83431**] and her fax number is ([**Telephone/Fax (1) 94408**]. We will fax a copy of your discharge summary to her office and have already spoken with her to give her an update on your hospital course. listed below are additional appointments that have been scheduled for you here at the [**Hospital1 **]. . MD: Dr [**First Name8 (NamePattern2) 1312**] [**Last Name (NamePattern1) **] Specialty: Endocrinology Date and time: [**6-3**] at 9am Location: [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 436**] Phone number: [**Telephone/Fax (1) 1803**] Special instructions if applicable: With Spanish Interpreter Appointment #2 MD: Dr [**First Name4 (NamePattern1) 429**] [**Last Name (NamePattern1) 118**] Specialty: Nephrology Date and time: Location: [**Hospital Ward Name 23**] [**Location (un) 436**] Phone number: [**Telephone/Fax (1) 60**] Special instructions if applicable: Office will be calling you with a F/U appointment [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**] Completed by:[**2129-5-20**]

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icd9cm

[ [ [] ] ]

[ "50.11", "38.93", "88.42", "33.24", "38.95", "96.04", "03.31", "96.71", "99.04", "39.95" ]

icd9pcs

[ [ [] ] ]

14297, 14303

7874, 7874

355, 415

14508, 14543

4693, 7851

15567, 16934

3541, 3726

14268, 14274

14324, 14324

14239, 14245

7891, 14213

14567, 15544

3741, 4674

276, 317

443, 2564

14463, 14487

14343, 14442

2586, 2830

2846, 3525

75,470

122,223

48853

Discharge summary

report

Admission Date: [**2160-12-7**] Discharge Date: [**2160-12-11**] Date of Birth: [**2083-2-25**] Sex: M Service: MEDICINE Allergies: Penicillins / Ativan Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: fatigue Major Surgical or Invasive Procedure: none History of Present Illness: 77M with inoperable NSCLC adenocarcinoma stage IIIA (T1N2M0) s/p carboplatin paclitaxel x6 as a sensitizing regmen with definitive XRT. Also CAD and CHF (EF 35-40%) His last dose of chemotherapy was on [**2160-10-23**] C6 Carboplatin 2 AUC paclitaxel 50 mg/m2 and completed XRT with 6660 cGy to the tumor and nodes on [**2160-11-5**]. He was admitted [**Date range (1) 47017**] for hemoptysis, nausea, odynophagia. CTA negative for PE but found evidence of radiation-induced mid-esophagitis. He was managed conservatively with magic mouthwash. His odynophagia had resolved swiftly. His Aspirin was held at time of discharge. He now p/w weakness and n/v x5 days. Not tolerating POs secondary to dysguesia and vomitting after eating. no F/C/NS. minimal cough with new (in last 10 days) "gorilla snot" sputum, DOE worsened since radiation. Minimal constant non radiating CP since radiation. Patient has been receiving regular fluid boluses and has gone longer than he had previously tolerated. In the ED, comfortable, pale, CTA, RRR, Abd soft NT ND, Rectal, external hemmorhoids, guiac neg. 1l ns Past Medical History: Past Oncologic History: NSCLC adenocarcinoma stage IIIA (T1N2M0) - [**2160-7-4**] Presented with cough and unintentional weight loss of 30 lbs - [**2160-7-24**] CT chest ordered given symptoms, ongoing tobacco abuse revealed 2 spiculated nodules and necrotic mediastinal adenopathy - [**2160-7-29**] PET CT showed that the 2 pulmonary nodules were FDG avid with lymphadenopathy of at least two nodes in the left paratracheal station - [**2160-8-4**] Brain MRI w/o evidence of metastatic disease - [**2160-8-18**] Bronchoscopic Bx of the mediastinal nodes revealed NSCLC adenocarcinoma - [**2160-9-4**] Met with Medical Oncology and Radiation Oncology. Given cardiac comorbidities, planned to proceed with XRT with concomitant carboplatin paclitaxel - [**2160-9-18**] C1 Carboplatin 2 AUC paclitaxel 50 mg/m2 with concomitant XRT - [**2160-9-25**] C2 Carboplatin 2 AUC paclitaxel 50 mg/m2 with concomitant XRT - [**2160-10-2**] C3 Carboplatin 2 AUC paclitaxel 50 mg/m2 with concomitant XRT - [**2160-10-9**] C4 Carboplatin 2 AUC paclitaxel 50 mg/m2 with concomitant XRT - [**2160-10-16**] C6 Carboplatin 2 AUC paclitaxel 50 mg/m2 with concomitant XRT - [**2160-10-23**] C6 Carboplatin 2 AUC paclitaxel 50 mg/m2 with concomitant XRT - [**2160-11-5**] Completed XRT with 6660 cGy to the tumor and nodes Other Past Medical History: - Ongoing tobacco abuse - CAD s/p MI in [**2124**], [**2129**] and [**2134**]-87 - CABG [**2135**] - Stress test [**8-/2160**] with mild ischemic disease - Distant CVA with some redisual left-sided weakness - s/p CEA - Depression - HTN - Hyperlipidemia - Hypothyroidism - Right macular degeneration on an intraoccular injection clinical trial at [**Hospital1 2025**] which has improved his disease - s/p right hip replacement Social History: - Tobacco: age 10 to 50 4 PPD, since age 50 1 PPD, >100 pack years - Alcohol: Social - Illicit: Denies - Occupation: DOD driver - Exposures: Denies - Living situation: Lives with wife Family History: - Mother: CAD - Father: CAD - Grandmother: Breast cancer Physical Exam: Admission Physical Exam: [**11-13**] VS: T97.5 bp 120/82 HR 102 SaO2 98RA RR 17 SaO2 98 RA Triage [**12-7**]: 99.3 88 107/53 22 95% Admit: 2159- hr 84-108/56-18-93%, GEN: Elderly man in NAD, awake, alert, talkative HEENT: EOMI, sclera anicteric, conjunctivae clear, OP dry and without lesion NECK: Supple, no JVD appreciated CV: RRR, normal S1, S2. Somewhat musical [**1-30**] complex systolic murmur heard best at apex. No r/g appreciated CHEST: Resp unlabored, no accessory muscle use. decreased breath sounds on the right side; 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 SKIN: No rash, warm skin PSYCH: appropriate Discharge Physical Exam: No corneal reflex No response to painful stimuli No heart beat or breath sounds with auscultation of chest for 1 minute Time of death 07:11 on [**2160-12-11**] Pertinent Results: Admission labs: WBC-3.1* RBC-2.10* HGB-7.1* HCT-19.9* MCV-95 MCH-34.0* MCHC-35.9* RDW-15.7* NEUTS-80.6* LYMPHS-9.4* MONOS-8.6 EOS-1.0 BASOS-0.3 RET AUT-2.9 HAPTOGLOB-338* FERRITIN-455* LD(LDH)-499* TOT BILI-0.5 GLUCOSE-138* UREA N-20 CREAT-1.0 SODIUM-129* POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-22 ANION GAP-14 Imaging: CXR [**2160-12-7**]- Frontal and lateral views of the chest were obtained. Please note per history, the patient has history of lung cancer. Comparison is also made to scout radiograph from CT from [**2160-11-12**]. Large area of opacity projecting over the left lung is worrisome for infectious process, alternatively progression of malignancy/lymphangitic spread. Opacity is seen to a lesser extent in the right lung. There may be superimposed pulmonary edema. No large pleural effusion or pneumothorax is seen. Again seen, the upper two sternal wires are fractured. Cardiac and mediastinal silhouettes are stable. CXR [**2160-12-8**]- As compared to the previous radiograph, there is a minimal increase in extent of the pre-existing parenchymal opacities. This increase is most noticeable in the right upper lobe. No other relevant changes. Status post sternotomy, CABG, moderate cardiomegaly, the presence of a small left pleural effusion cannot be excluded. Transthoracic echocardiogram [**2160-12-9**]- Poor image quality.The left atrium is moderately dilated. A small secundum atrial septal defect is present. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with inferior and infero-lateral akinesis and distal septal, distal anterior and apical hypokinesis. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2160-8-28**], the degree of MR [**First Name (Titles) **] [**Last Name (Titles) **] seen has increased slightly (degree of MR [**First Name (Titles) 12314**] [**Last Name (Titles) 102625**] on prior report). CT Head [**2160-12-10**]- WET READ- 1. No evidence of acute hemorrhage, edema, mass effect, or major vascular territory infarction. Evaluation of small mass, however, is limited in the absence of IV contrast. 2. Remote right middle cerebral artery infarction. Brief Hospital Course: 77 M with history of stage IIIa NSCLC, sCHF with EF 35-40%, CAD s/p CABG presenting initially for n/v/[**Hospital **] transferred to ICU for hypotension, hypoxia, and fever. # Respiratory distress: Patient transferred to ICU on HD 1 due to episode of hypotension and hypoxia while receiving blood transfusion. Patient continued to be hypotensive and hypoxic throughout the day with an increasing O2 requirement. He spiked a fever and CXR was concerning for new pneumonia, so vancomycin, cefepime and levofloxacin were started. Patient was transferred to the ICU for close monitoring. His blood pressure remained stable with normal mentation and good urine output, and he did not require any fluid boluses or pressors. He continued to require a non rebreather to maintain oxygen saturations, and de-sat'ed to 70s without the facemask. Concerns were for bacterial pneumonia vs PCP pneumonia vs radiation pneumonitis vs worsening of underlying malignancy. Patient was initially put on steroids to treat radiation pneumonitis in addition the antibiotics as above to cover hospital acquired bacterial pneumonia. Patient's oxygen requirement increased overnight on HD 3 and so treatment for PCP pneumonia was started with high dose bactrim. Steroids were altered to treat PCP rather than radiation pneumonitis. Beta glucan and galactomannan were also sent on HD 2. Once patient was made comfort measures only, antibiotics and steroids were discontinued, and focus was turned towards controlling tachypnea and dyspnea with morphine and albuterol/ipratropium nebulizers. Patient was kept on shovel mask and nasal cannula and was given morphine as needed for assistance with breathing. Family requested to have oxygen removed, and start morphine drip. Drip started, and nasal cannula/shovel mask removed and patient expired within 30 minutes. # Right MCA stroke: On HD 3, housestaff was called to bedside for acute change in patient's breathing. Patient was noted to have left sided neglect in addition to complete left sided hemiplegia. A code stroke was called and a CT of the head showed a non-hemorrhagic stroke in the right MCA, adjacent to prior stroke. TPA was not given as neurology felt that it was high risk for re-bleed of prior stroke. Patient was started on aspirin 325mg, however, once decision was made to make patient comfort measures only, aspirin was discontinued. # Insomnia: Patient struggled with insomnia throughout admission. He was prescribed olanzapine in the outpatient setting which helped him sleep at doses of 15mg qHS. With the assistance of palliative care, patient was continued on olanzapine 10mg qHS. He was also given morphine as needed for comfort as part of his difficulty sleeping was secondary to his tachypnea. # Goals of care: Several goals of care discussions occurred during hospitalization. Following patient's stroke, he and his family decided that they wanted him to be comfort measures only and to go home with hospice. However, patient developed increased work of breathing and family requested morphine boluses. Patient was made comfortable with morphine boluses, then morphine drip and expired at 07:11am on [**2160-12-11**]. Medications on Admission: 1. atenolol 100 mg qd 2. atorvastatin 20 mg qd 3. doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. fluoxetine 40 mg qd 5. levothyroxine 175 mcg qd 6. nitroglycerin 0.3 mg Tablet prn 7. olanzapine [**5-6**] qHS 8. prochlorperazine maleate 10 mg Tablet q6 PRN 9. triamcinolone acetonide 0.1 % Ointment [**Hospital1 **] 10. multivitamin qd 11. lidocaine-diphenhyd-[**Doctor Last Name **]-mag-[**Doctor Last Name **] 200-25-400-40 mg/30 mL Mouthwash Sig: One (1) teaspoon Mucous membrane every four (4) hours as needed for pain. Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Non-small cell lung cancer Right MCA stroke Discharge Condition: Patient expired Discharge Instructions: Patient expired Followup Instructions: Patient expired [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11158, 11167

7332, 10533

297, 303

11254, 11271

4435, 4435

11335, 11489

3429, 3487

11126, 11135

11188, 11233

10559, 11103

11295, 11312

3527, 4229

250, 259

331, 1432

4451, 7309

2783, 3211

3227, 3413

4254, 4416

78,840

171,226

55079

Discharge summary

report

Admission Date: [**2124-10-1**] Discharge Date: [**2124-10-10**] Date of Birth: [**2075-6-15**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 598**] Chief Complaint: Fall Major Surgical or Invasive Procedure: [**2124-10-2**]: IVC filter History of Present Illness: 49 year old female +Etoh and fall down 8 stairs, sustaining multiple injuries and + loss of consciousness. OSH CT head negative per report. Pt found to hypotensive with Hct 25 in the ED. Past Medical History: PMH: none PSH: none Social History: She is married. + ETOH on admission. Family History: Non contributory. Physical Exam: Physical Exam upon presentation: HR: 108 BP: 114/67 Resp: 15 O(2)Sat: 92 Low Constitutional: Comfortable HEENT: abrasions/ecchymosis to face, stable face, laceration to lip, perrl/eomi withou pain, no proptosis Oropharynx within normal limits Chest: Clear to auscultation, ecchymosis to chest Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nontender, Nondistended GU/Flank: No costovertebral angle tenderness Extr/Back: ecchymosis/edema to L wrist, distal NVI Skin: No rash, Warm and dry Neuro: CN intact, MAE Psych: Normal mood Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae Physical Examination upon discharge: VS: 98.9, 80, 132/80, 18, 95/RA GEN: Comfortably resting in chair, NAD. CV: Normal S1, S2. RRR No MRG. PULM: Lungs Clear to auscultate bilaterally. No W/R/R. ABDOMEN: S/NT/ND + Bowel sounds. No N/V/D. EXT: + pedal pulses. warm to touch. No edema, cyanosis, clubbing. NEURO: AAOx4 Psych: normal mentation. Pertinent Results: CT torso [**2124-10-1**] (final): 1. Small bilateral pleural effusions with adjacent atelectasis or aspiration. No pneumothorax. 2. Burst type vertebral body fractures in the thoracic spine and L1 and L2 transverse processes fractures. MRI could be performed for evaluation of cord injury. 3. Tiny amount of fluid adjacent to the IVC. This could be related to IVC injury, although it is not as large as would be expected given the timeline of patient's accident and current study. Low threshold to rescan the patient to evaluate for IVC injury if patient becomes unstable. 4. Colonic mural fat deposition suggests chronic inflammation. Diverticulosis without diverticulitis. 5. A 1.3-cm left thyroid nodule. Non-urgent ultrasound is recommended for further evaluation. 6. A 4 x 2 cm right adnexal cyst and heterogenous appearance of cervix. The latter may be secondary to blood products from phase of patient's cycle, but follow-up pelvic ultrasound recommended to evaluate both findings. 7. Fibroid uterus. CT maxillofacial [**2124-10-1**] (prelim): Numerous bilateral facial fractures and left occipital condyle fracture. Right lateral lamellar fracture includes intracranial extent, placing patient at risk for CSF leak. MR T/L spine [**2124-10-1**] (final): 1. As on the concurrent CECT torso, there are acute burst-compression fractures of the T3, T6, T7 and T8 vertebrae. These findings are most marked at the T3 and T6 levels, where there is some retropulsion, effacing the ventral thecal sac without cord remodeling or compression. 2. No acute alignment abnormality or associated ligamentous injury. 3. Normal thoracic spinal cord signal intensity through the conus medullaris. 4. No lumbar vertebral compression fracture; the L1 and L2 right transverse process fractures are better-seen on the CT. 5. Degenerative disc disease at the L4-L5 and L5-S1 and several cervical levels, as detailed above. L wrist films (final): Distal radial and ulnar styloid fractures. [**10-2**] CTA: 1. Mild clot burden of acute pulmonary thromboembolus involving the segmental and subsegmental right lower lobe and lingular pulmonary arteries. There is mild pulmonary arterial hypertension without evidence of right heart strain. 2. Small bilateral pleural effusions and basilar atelectasis. 3. Diffuse hepatic steatosis. 1.2 cm hypodense lesion is incompletely evaluated on this phase of contrast-enhanced examination. This could be further evaluated with liver ultrasound or dedicated contrast-enhanced liver cross-sectional imaging. 4. Redemonstration of burst fractures involving the T3, T6 through T8 vertebral bodies as previously mentioned. [**10-2**] LENIS: No bilateral lower extremity deep venous thrombosis. CT abd/pelvis [**10-3**]: 1. Bilateral pleural effusion with adjacent atelectasis versus aspiration/infection. . Fluid adjacent to the IVC is less prominent on today's study compared to prior examination. 3. Simple appearing free fluid is noted around the right kidney, new since the prior exam with no evidence of contrast excretion or renal laceration noted to suggest urinoma or hematoma. Recommend attention to this region on follow up imaging. If there is clinical concern, then short interval follow up may be obtained. 4. Burst fractures of T7 and T8 vertebral bodies as well as L1 and L2 [**2124-10-8**] 06:50AM BLOOD WBC-9.7 RBC-3.89* Hgb-9.4* Hct-30.3* MCV-78* MCH-24.1* MCHC-30.9* RDW-19.4* Plt Ct-329 [**2124-10-7**] 05:00AM BLOOD WBC-15.5* RBC-3.54* Hgb-8.7* Hct-27.3* MCV-77* MCH-24.6* MCHC-31.8 RDW-19.7* Plt Ct-332 [**2124-10-1**] 04:23AM BLOOD WBC-14.4* RBC-3.42* Hgb-7.4* Hct-25.4* MCV-74* MCH-21.5* MCHC-29.1* RDW-19.0* Plt Ct-360 [**2124-10-1**] 09:50AM BLOOD WBC-14.4* RBC-3.24* Hgb-7.0* Hct-24.3* MCV-75* MCH-21.6* MCHC-28.9* RDW-19.2* Plt Ct-352 [**2124-10-1**] 05:17PM BLOOD Hct-24.0* [**2124-10-9**] 11:22AM BLOOD PT-16.3* INR(PT)-1.5* [**2124-10-8**] 06:50AM BLOOD Plt Ct-329 [**2124-10-1**] 04:23AM BLOOD PT-11.1 PTT-26.1 INR(PT)-1.0 [**2124-10-1**] 04:23AM BLOOD Plt Ct-360 [**2124-10-1**] 09:50AM BLOOD Plt Ct-352 [**2124-10-1**] 04:23AM BLOOD Fibrino-280 [**2124-10-8**] 06:50AM BLOOD Glucose-99 UreaN-9 Creat-0.5 Na-140 K-3.4 Cl-104 HCO3-26 AnGap-13 [**2124-10-7**] 05:00AM BLOOD Glucose-105* UreaN-11 Creat-0.6 Na-139 K-3.4 Cl-104 HCO3-25 AnGap-13 [**2124-10-6**] 12:26AM BLOOD Glucose-132* UreaN-11 Creat-0.6 Na-136 K-3.6 Cl-101 HCO3-25 AnGap-14 [**2124-10-1**] 09:50AM BLOOD Glucose-108* UreaN-10 Creat-0.6 Na-141 K-4.0 Cl-109* HCO3-19* AnGap-17 [**2124-10-1**] 05:17PM BLOOD ALT-121* AST-115* CK(CPK)-754* [**2124-10-8**] 06:50AM BLOOD Calcium-8.0* Phos-2.5* Mg-2.1 [**2124-10-7**] 05:00AM BLOOD Calcium-7.8* Phos-3.3 Mg-2.3 [**2124-10-1**] 09:50AM BLOOD Calcium-7.4* Phos-3.4 Mg-1.8 Brief Hospital Course: She was admitted to the Acute Care surgery team and was transferred to the Trauma ICU for closer monitoring of her sustained injuries. Her hospital course is as follows per body system: Neuro: She was transitioned to acetaminophen with Dilaudid for breakthrough pain after extubation. A TLSO brace was ordered for nonoperative management of her T3, 6, 7, and 8 vertebral body fractures, and a soft cervical collar was maintained for her left occipital condylar fracture after she was evaluated by the Ortho spine service. The TLSO brace needs to be worn whenever HOB is greater than 30 degrees and when patient is out of bed. She was evaluated by physical and occupational therapy, and they recommended rehab. At time if discharge, she is alert and oriented x3, and she can move all her extremities. Patient will follow up with Ortho Spine in [**3-3**] weeks. Cardiovascular: Stable on admission, the patient had recurrent desaturations with tachycardia on [**10-2**], and given her recent trauma, high index of suspicion for PE resulted in a CTA which confirmed bilateral segmental PEs. On [**2124-10-2**], an IVC filter was placed. A heparin drip was started and later transitioned to Coumadin therapy. However, her INR was sub therapeutic so patient was started on Lovenox bridge prior to discharge. Her coumadin was continued and INRs were checked daily. On day of discharge, her INR was 1.5. Respiratory: She was successfully extubated on [**10-5**] and her oxygen requirement was weaned. Upon discharge, she was saturating above 93%-98% on room air. GI: Tube feeds were started [**10-3**], and advanced to goal. She passed a speech and swallow evaluation after extubation on [**10-5**], and tolerated a regular ground diet thereafter. She is on a bowel regimen and has moved her bowels. GU: A Foley catheter was placed on admission and urine output was monitored. This remained adequate, and gentle diuresis was performed prior to extubation. her Foley catheter was removed and she is voiding adequate amounts of urine without difficulty. Heme: She required 1u pRBC on [**10-2**] and 2u on [**10-3**] for a slow downtrend in her hematocrit to 21. No evidence of bleeding was identified on repeat CT of the abdomen and pelvis, and this stabilized without further intervention. Her last hematocrit was stable at 30.3 on [**2124-10-7**]. MSK: The Ortho trauma service was consulted in the ED, and recommended a sling and no weight bearing of the left upper extremity. She can bear weight using a platform walker for mobility. Plastic surgery recommended delayed, outpatient repair of her facial fractures. She will be seen in the [**Hospital 3595**] clinic within a week after discharge. Medications on Admission: None Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 2 Days 3. Docusate Sodium (Liquid) 100 mg PO BID 4. Enoxaparin Sodium 100 mg SC Q12H 5. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain 6. Metoprolol Tartrate 25 mg PO TID hold for sbp<110,hr<60 7. Senna 1 TAB PO BID 8. Warfarin 7.5 mg PO ONCE Duration: 1 Doses Adjust dose daily based on INR goal of [**3-3**]. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: S/p fall Injuries: T3,6,7,8 vertebral body fracture Left occipital condyle fracture Left distal radius, ulnar styloid fracture Depressed fracture Right orbital floor Right ant/med/lat maxillary wall fracture Left anterior maxillary wall fracture Right lip laceration Nasal bone fracture Acute Blood Loss 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 were admitted after a fall involving multiple injuries. While you were at the hospital, you were seen by orthopedics, plastics and trauma service for several spinal and facial fractures. You developed blood clots in your lungs, so you underwent IVC filter placement in order to prevent any more clots traveling to your lungs. You will go to a rehab where you will continue blood thinners for 6 months and receive physical therapy to help you in your recovery. Followup Instructions: * Your insurance records are incomplete- please call our registration department at ([**Telephone/Fax (1) 22161**] before your first appointment. Department: DIV OF PLASTIC SURGERY When: FRIDAY [**2124-10-13**] at 3:30 PM With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern1) 6751**], MD [**Telephone/Fax (1) 6742**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: ORTHOPEDICS When: FRIDAY [**2124-10-20**] at 11:55 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: FRIDAY [**2124-10-20**] at 12:15 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27362**], PA Specialty: Orthopedics/Spine When: Wednesday [**2124-10-25**] at 12pm Location: [**Hospital1 **] Address: [**Location (un) **], [**Hospital Ward Name **] [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3573**] This appointment is with Dr. [**Last Name (STitle) 3572**] physicians assistant, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27362**]. Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD When: WEDNESDAY [**2124-10-25**] at 2:30 PM With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2124-10-24**]

[ "241.0", "805.4", "427.89", "285.1", "458.8", "305.00", "873.43", "507.0", "721.3", "802.6", "571.8", "861.21", "415.19", "802.4", "780.09", "E880.9", "801.02", "805.2", "802.0", "511.9", "813.44" ]

icd9cm

[ [ [] ] ]

[ "27.51", "96.72", "38.93", "96.6", "38.7", "96.04", "33.24", "79.02", "88.51" ]

icd9pcs

[ [ [] ] ]

9634, 9706

6455, 9165

308, 337

10061, 10061

1703, 6432

10732, 12844

666, 685

9220, 9611

9727, 10040

9191, 9197

10244, 10709

700, 1362

264, 270

1378, 1684

365, 553

10076, 10220

575, 596

612, 650

22,861

147,405

12220

Discharge summary

report

Admission Date: [**2138-1-19**] Discharge Date: [**2138-1-21**] Service: [**Hospital Unit Name 38208**] COMPLAINT: Inferior myocardial infarction. HISTORY OF PRESENT ILLNESS: This is a 79 year-old man with a history of recent ischemic cerebrovascular accident versus transient ischemic attack in [**Month (only) 404**] with cardiac risk presented to an outside hospital on [**1-19**] initially with lightheadedness, which later progressed to right sided chest pain. Electrocardiogram showed inferior ST elevation, increased anterior progression in the anterior leads with ST depression anteriorly for presenting posterior Q waves and ST elevation. The ST elevation in lead 2 and lead 3 represented most likely circumflex involvement. The patient also had T electrocardiogram. At the outside hospital he was not thrombolised, because of this question of a recent cerebrovascular accident. He was started on aspirin, nitroglycerin and heparin and made chest pain free. They cycled cardiac enzymes at the outside hospital. The second set of CK were greater then 5000. At the outside hospital the patient also progressed into congestive heart failure, which was treated with Lasix. After the second set of enzymes the patient was transferred to [**Hospital1 18**]. He arrived at 11:00 p.m. on the evening of [**1-19**]. He was chest pain free at that time. He had no ST elevations on his electrocardiogram that had progressed to Q waves at that time. He was started on Integrilin and continued on his other medications and went to the [**Hospital Unit Name 196**] Service for monitoring. He went for cardiac catheterization and intervention on [**2138-1-20**]. During the cardiac catheterization, his PAO2 dropped to 46% and his mixed venous sat was in the mid 20%. These numbers prompted intubation for hypoxia and insertion of a balloon pump and initiation of pressor support with Dopamine for cardiogenic shock. The patient had a ruptured plaque seen in his D dominant left circumflex at the take off of the OM1. The circumflex was angioplastied and stented with two stents. He was then brought up to the Coronary Care Unit. After approximately ten minutes in the Coronary Care Unit the patient progressed from normal sinus rhythm into complete heart block. The patient was transcutaneously paced and then a transvenous pacing wire was implanted and the patient was placed on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] pacer at a rate of 70. The patient remained stable in this condition for the rest of the night. His urine output, however, decreased as the patient progressed into acute renal failure. the patient had the corresponding electrolyte abnormalities to go with his acute renal failure. On [**2138-1-21**] the patient's son and wife visited the patient at the hospital. They asserted that the patient did not want any life support. He stated this numerous times over the course of his life and directed that the patient's wishes compelled them to withdraw life support. At that time the medication drips were discontinued. The pacing was discontinued. The patient was transiently maintained on his native rhythm, but then proceeded to cardiac arrest at approximately 1:00 p.m. on [**1-21**]. The patient was pronounced dead. At that time the son and the wife were with the patient. The attending was also notified. The family consented to an autopsy. The patient died of cardiac arrest secondary to acute myocardial infarction. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15176**], M.D. [**MD Number(1) 15177**] Dictated By:[**Last Name (NamePattern1) 8228**] MEDQUIST36 D: [**2138-1-21**] 15:31 T: [**2138-1-24**] 06:27 JOB#: [**Job Number 38209**]

[ "401.9", "414.01", "785.51", "250.00", "276.7", "428.0", "593.9", "410.41", "426.0" ]

icd9cm

[ [ [] ] ]

[ "96.04", "37.23", "37.78", "37.61", "36.06", "88.56", "36.01", "88.53", "96.71" ]

icd9pcs

[ [ [] ] ]

187, 3791

11,201

175,064

22862

Discharge summary

report

Admission Date: [**2122-1-15**] Discharge Date: [**2122-2-11**] Date of Birth: [**2058-8-17**] Sex: F Service: MEDICINE Allergies: Amoxicillin / Erythromycin Base / Dipentum / Asacol / Purinethol / Colazal Attending:[**First Name3 (LF) 3984**] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: Right Internal Jugular Catheter Right Femora Vein Catheter Left Radial Artery Catheter History of Present Illness: Patient is a 63 yo female with history of severe COPD and asthma on chronic prednisone therapy and home O2 with a poor basline exercise tolerance with DOE walking across the room. She has been hospitalized several times in the past ten years but has had no prior intubations. On [**2122-1-5**] she complained of increasing shortness of breath and went to see her PCP. [**Name10 (NameIs) **] her PCP's office her sat's were in the 80's and she was in moderate respiratory distress. She improved slightly with nebs and refused hospitalization at that time. She went home and was started on 40 mg Prednisone. She did not have a significant improvement over the next week. On [**2122-1-12**] she became acutetly SOB while walking to the car to go to her follow up appointment with her PCP and instead went to the local ED in [**Location (un) 45887**] VT. At the ED her ABG was 7.24/ CO2 79/ O2 91. She was admitted and initially maintained on NC then bipap (which she did not tolerate). At 1 am on [**1-14**] her blood gas was 7.11/ 113/ 85 and she was inubated. She was placed on SIMV at 10x500 16PSV FIO2 )0.4. Her blood gas on these sttings was 7.29/64/74. She was started on solumedrol 125mg q6 and IV aminophylline 20 mg/hr. She was transferred to the [**Hospital Unit Name 153**] for managment of high peak airway pressures up to the high 40's. Past Medical History: COPD on chronic prednisone with a baseline O2 requirment and dyspnea with minimal exertion Asthma Ulcerative Colitis Fractured L hip Social History: Patient lives with her husband in [**Name (NI) 45887**] VT, she works part time as a special-ed teacher. She has a distant smoking history and occasional EtOH. Physical Exam: T: 99.5 BP: 136/74 HR:122 Gen: Patient sedated but in some distress on the vent with very strong abdominal excursions. HEENT: PERRL [**2-4**] OU, modereate chemosis, no JVD Chest: very distant breath sounds, expiratory wheezes throughout CV: tachy, RRR no MRG AB: soft during inspiration rigid during expiration, +BS Ext: no c/c/e Neuro: does not respond to sternal rub Pertinent Results: [**2122-1-15**] 08:40AM BLOOD WBC-16.6* RBC-3.79* Hgb-12.6 Hct-37.9 MCV-100* MCH-33.3* MCHC-33.3 RDW-13.5 Plt Ct-376 [**2122-1-15**] 08:40AM BLOOD Neuts-91* Bands-3 Lymphs-3* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* [**2122-1-15**] 08:40AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL [**2122-1-15**] 10:00AM BLOOD PT-12.1 PTT-23.7 INR(PT)-0.9 [**2122-1-15**] 08:40AM BLOOD Plt Smr-NORMAL Plt Ct-376 [**2122-1-15**] 08:40AM BLOOD Glucose-129* UreaN-10 Creat-0.6 Na-139 K-5.5* Cl-103 HCO3-31* AnGap-11 [**2122-1-15**] 08:40AM BLOOD Calcium-7.4* Phos-2.4* Mg-2.4 [**2122-1-16**] 08:39AM BLOOD Theophy-2.5* [**2122-1-15**] 07:45AM BLOOD Type-ART pO2-88 pCO2-81* pH-7.18* calHCO3-32* Base XS-0 [**2122-1-15**] 07:45AM BLOOD Lactate-1.0 [**2122-1-15**] 04:29PM BLOOD K-4.7 [**2122-1-15**] 10:27AM BLOOD freeCa-1.09* Echocardiogram ([**2122-2-5**])- Limited/poor study secondary to patient being tachycardic. LV systolic function appears depressed with probable mid to distal anteroseptal hypokinesis and possible apical hypokinesis but views are technically suboptimal for assessment of regional wall motion. Estimated ejection fraction ?45-50%. Brief Hospital Course: When the patient arrived on [**1-15**] she was awake and anxious, and with respiratory disynchrony on SIMV mode. She was started on Versed 4mg/hr and Fentanyl 100mcg/hr with good effect on comfortable on the ventilator. We discontinued the Theophylline and continued the Levoquin and Ceftriaxone that were initiated at the OSH. On [**1-16**] her chest exam deteriorated with very poor air movement and wheezes. She also had very high "auto"-PEEP, as high as 25. She was restarted on IV aminophylline and her sedation was increased and paralysis was considered. With increased sedation her "autt"-PEEP decreased as well as her PIPs. Auto-PEEP was an issue daily and she required periodic removal from the ventilator to exsuflate the auto-PEEP. On [**1-21**] the patient became tachycardic to the 130's and hypertensive to the 150's SBP in the setting of decreasing sedation and vent disynchrony. She started on propofol and her HR and BP normalized. An EKG taken at the time showed ST depressions in leads v4-6 and t wave changes in II and III. Cardiac enzymes were negative. Auto-PEEP continued to be an issue in times of sedation weaning so the patient was kept fully sedated on propofol while versed and fentanyl were slowly weaned. In light of the fact that the main obstacle to extubation was aggitation during weaning of sedation a tracheostomy was thought to be of benefit because it would be less uncomfortable. She was evaluated by IP but her anatomy was too difficult for a percutaneous trach. Thoracic surgery was consulted, however on the day of her procedure her PTT became elevated into the 60's in isolation of any other coagulation abnormality. She was given FFP and her PTT trended down appropriately. It was therefore decided that the SC Heparin was responsible for the elevated PTT. She received a Trach and PEG on [**1-26**]. Weaning attempts were again initiated however the patient had several episodes of hypertension to the 170's and tachycardia to the 120's. She was treated with IV lopressor PRN that transiently normalized her HR and BP. Her EKGs showed no evidence of ischemia. On [**1-28**] she was started on an esmolol drip for HR control. Hypotension then became an issue and the esmolol was discontinued. Her blood pressure continued to fluctuate and she recieved several NS boluses during hypotensive episodes and lopressor PRN for tachy/hypertension. She became more awake and interactive for the first time on [**1-30**] and was following commands appropriately. Patient continued to improve but had limited range of motion. An EMG was done which was consistent with diffuse myopathy suggestive of ICU myopathy. Neurology was consulted who recommended tapering steroids and occupational and physical therapy. Steroids were tapered down to standing dose of prednisone 5mg qd. Patient spiked a temperature on [**2-2**] while on vancomycin. Vancomycin was switched to linezolid and patient breifly started on levofloxacin and aztreonam for empiric treatment of ventilator associated pnuemonia. Patient wound swab from trach site came back positive for VRE and MRSA. Levofloxacin and aztreonam were discontinued after blood cultures showed no growth and sputum clture came back positive for only MRSA. Patient to complete 14 day course of linezolid (Day#1 was [**2-2**]). An EKG was done on [**2122-2-4**] for concern for prolonged QT interval. Patient's QT interval was normal however patient now had diffuse TWI in precordial leads which were not seen on EKG on admission. Patient had an echocardiogram done which was a limited study but showed a LVEF of 40-50% and septal and apical hypokinesis. However cardiac enzymes were flat. Patient was started on beta-blocker which was titrated up as patient blood pressure tolerated. Once patient more stable will need further evaluation of heart function outpatient. Patient with elevated blood sugars during admission, which was felt to be secondary to steroids. Patient initially on insulin drip and then swtiched to NPH and insulin sliding scale. She continued to do well on the vent and was slowly weaned down on the vent on pressure support. Medications on Admission: Theophylline 500 mg qd Singulair 10 mg QD Lorazepam 0.5 mg PRN Temazepam 15mg PRN Prednisone 3 mg QD Albuterol MDI PRN Atrovent 2 puffs QID Flovent [**Hospital1 **] Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 4. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours). 5. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q2-4H (every 2 to 4 hours) as needed. 7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID (3 times a day). 8. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 9. Acetaminophen 160 mg/5 mL Elixir Sig: One (1) PO Q4-6H (every 4 to 6 hours) as needed. 10. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl Topical PRN (as needed) as needed for rash. 11. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash. 12. Lidocaine HCl 2 % Gel Sig: One (1) Appl Urethral PRN (as needed) as needed for pain rash. 13. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). 14. Morphine Sulfate 10 mg/5 mL Solution Sig: One (1) PO Q4H (every 4 hours) as needed. 15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed). 16. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 17. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. 18. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 21. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 22. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QD () as needed for anxiety. 23. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 24. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fifteen (15) units Subcutaneous qam. 25. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Ten (10) Units Subcutaneous at bedtime. 26. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 59111**] Discharge Diagnosis: COPD exacerbation Pneumonia Cardiomyopathy Discharge Condition: Stable - Patient with ICU myopathy that should improve daily with physical and occupational therapy. Patient on ventilator however improving everyday, and continued to be weaned off. Discharge Instructions: Please follow up with your Primary Care doctor [**First Name (Titles) **] [**Last Name (Titles) 59112**] of rehabilitation. During your admission your heart function was found to be depressed. Once your condition is more improved you should either follow up with your primary care doctor for further evaluation of your heart function. Followup Instructions: Please follow up with your primary care doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 59113**] for further evaluation of your heart function, COPD management, and workup for diabetes. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

[ "401.9", "285.29", "458.29", "482.41", "288.8", "425.4", "518.84", "286.9", "493.20", "427.89", "359.81" ]

icd9cm

[ [ [] ] ]

[ "96.72", "38.93", "43.11", "99.04", "38.91", "00.14", "31.1", "96.6" ]

icd9pcs

[ [ [] ] ]

10526, 10574

3785, 7941

356, 444

10661, 10846

2569, 3762

11231, 11572

8156, 10503

10595, 10640

7967, 8133

10870, 11208

2177, 2550

296, 318

472, 1827

1849, 1984

2000, 2162

58,008

151,725

20254

Discharge summary

report

Admission Date: [**2167-5-6**] Discharge Date: [**2167-6-10**] Date of Birth: [**2100-3-19**] Sex: F Service: SURGERY Allergies: Aldomet / Morphine Attending:[**First Name3 (LF) 1384**] Chief Complaint: neutropenia volume overload Major Surgical or Invasive Procedure: [**2167-5-31**] Liver [**Month/Day/Year **] [**2167-6-1**] Takeback, oversew R hepatic vein staple line [**2167-6-5**]: Roux tube cholangiogram [**2167-6-9**]: Roux Tube Cholangiogram History of Present Illness: 67-year-old female with hepatic cirrhosis secondary to PSC presents with neutropenia of unknown etiology. She is being admitted for work-up of neutropenia not responsive to neupogen on [**5-4**] and [**5-5**]. No fever. On evaluation, she is alert and oriented to person and place but not to time completely. She also has reported 5 bowel movements a day on lactulose. She was recently admitted from [**2167-4-22**] to [**2167-5-2**] on the [**Year/Month/Day **] surgery service in the SICU for hypotension for fall, hypotension requiring pressors and fluid resuscitation, hypothermia, bradycardia. Her hypotension was felt be due to dehydration from extensive diarrhea with the whole clinical picture likely suggestive of sepsis as the main case. She was started on empiric antibiotics including vancomycin, zosyn, and flagyl in addition to PO vancomycin for presumed C. diff. GI source was explored with abdominal CT indicative of increased rectal and pan-colonic wall thickening since [**2167-1-31**] suggestive of colitis either infectious or inflammatory. Urine culture from [**4-22**] had ESBL E. coli sensitive to meropenum, which was started on [**4-22**]. Sputum culture on [**4-22**] isolated ESBL E. coli with meropenem continued (14 day total course, [**4-22**] - [**5-5**]) . She was also on IV flagyl. ID was consulted with impression of ESBL E. coli colonizing the respiratory/GU tract with evidence of toxemia and bacteremia. There was no clear etiology with no intrabdominal source on noncontrast CT of abdomen. She also had diarrhea for which she was to complete a 2 week course with PO vancomycin ([**4-27**] - [**2167-5-10**]) empirically for C. diff. She prior discharge summary for full details. . 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, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: PSC c/b Cirrhosis (last MELD 18), jaundice and ascites, encephalopathy now s/p orthotopic liver [**Year/Month/Day **] [**2167-5-31**] - UC - Psoriasis - Asthma - HTN - ESBL E. Coli cystitis - Hypoxic respiratory failure - CAD s/p NSTEMI s/p PCI to LX with BMS on [**2167-2-12**] - Anemia and thrombocytopenia secondary to chronic liver disease - Cutaneous Candidiasis and Psoriasis - Hysterectomy Social History: - Denied EtOH/tobacco - quit 25 years ago, No illicit drugs - Married and lived with husband and daughter - Worked as rad tech, now on disability Family History: - Father: deceased from unknown cancer, Sister has lung cancer Physical Exam: VS - T 96.9 BP 99/42 (ranging SBP 90-100 at facility) HR 60 RR 18 100 RA Admit weight pending (weight 190 lbs at nursing facility on [**2167-5-2**], 193.8 lbs on transfer) GENERAL - NAD, yellow HEENT - NC/AT, PERRL, EOMI, sclerae icteric, MMM, OP clear NECK - supple LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, obese/NT EXTREMITIES - WWP, bilateral pitting edema to above knees SKIN - multiple purpura on hands LYMPH - no cervical LAD NEURO - awake, A&Ox2, CNs II-XII grossly intact, muscle strength [**6-4**] throughout, sensation grossly intact Pertinent Results: On Admission: [**2167-5-6**] WBC-1.7* RBC-3.13* Hgb-9.2* Hct-27.2* MCV-87 MCH-29.5 MCHC-34.0 RDW-21.7* Plt Ct-48* Neuts-14* Bands-1 Lymphs-69* Monos-8 Eos-1 Baso-1 Atyps-6* Metas-0 Myelos-0 PT-24.6* PTT-64.9* INR(PT)-2.3* Glucose-63* UreaN-37* Creat-1.2* Na-136 K-3.5 Cl-109* HCO3-16* AnGap-15 ALT-43* AST-37 CK(CPK)-14* AlkPhos-135* TotBili-23.0* HBsAg-NEGATIVE HBsAb-BORDERLINE HBcAb-NEGATIVE At Time of [**Year/Month/Day **] [**2167-5-31**] WBC-5.0 RBC-2.41* Hgb-7.5* Hct-22.9* MCV-95 MCH-31.2 MCHC-32.8 RDW-24.2* Plt Ct-29* PT-23.5* PTT-45.9* INR(PT)-2.2* Glucose-97 UreaN-39* Creat-2.0* Na-135 K-4.3 Cl-95* HCO3-29 AnGap-15 ALT-41* AST-65* LD(LDH)-158 AlkPhos-127* TotBili-25.9* Albumin-5.0 Calcium-9.4 Phos-4.6* Mg-2.2 At Discharge [**2167-6-10**] WBC-8.1 RBC-3.38* Hgb-10.1* Hct-30.5* MCV-90 MCH-29.8 MCHC-33.1 RDW-16.8* Plt Ct-125*# PT-14.4* PTT-27.4 INR(PT)-1.2* Glucose-111* UreaN-94* Creat-1.7* Na-138 K-4.2 Cl-105 HCO3-23 AnGap-14 ALT-30 AST-16 AlkPhos-95 TotBili-2.6* Calcium-7.6* Phos-3.9 Mg-1.7 Brief Hospital Course: 67-year-old female with hepatic cirrhosis secondary to PSC presented with neutropenia likely multi-factorial that resolved. Hospital course complicated by volume overload refractory to hepatorenal therapy and diuretics and requiring hemodialysis with ultrafiltration. #. Neutropenia Patient had ANC below 100 prior to admission with admission ANC of 300. Her ANC climbed to 3770 on [**2167-5-11**]. Hematology impression was likely multifactorial with baseline pancytopenia related to liver disease and antibiotic effect. Following completion of her ESBL UTI treatment her ANC returned to >1000 and remained there throughout her hospitalization. # Renal Failure Her creatinine was 1.2 on admission elevated from baseline ~ 0.8 secondary to diarrhea and poor PO intake. Subsequently developed hepatorenal syndrome with ineffective fluid excretion requiring initiation of hemodialysis with ultrafiltration on [**2167-5-22**]. At the time of initiating therapy she had 50 liters of excess volume and required ultrafiltration of 3-5L daily. A hemodialysis holiday was tried on [**5-31**] - [**6-1**] with evidence of continued significant renal impairment requiring ongoing HD/UF therapy. She received a tunneled HD catheter and continued HD/UF until [**6-5**]. Creatinine was improved as was volume status. She is discharged on 80 mg PO Lasix [**Hospital1 **] until re-evaluation in clinic. #. PSC complicated by cirrhosis with jaundice, ascites, and encephalopathy. She is on the [**Hospital1 **] list with a MELD of 41. During hospital course, she was AAOx3 with no asterixis. She was continued on rifaximin, ursodiol, lactulose, mesalamine. Patient had marked jaundice, increased MELD score from prior hospitalization and was transplanted on [**2167-5-31**]. # Asthma She had signs of active symptoms or evidence of exacerbation. She was continued on albuterol and advair. # Prior ESBL E. Coli cystitis Patient had prior infection. Urine culture again showing ESBL organisms ranging from 10,000 - 100,000. She remained afebrile and without urinary symptoms. # CAD s/p NSTEMI with PCI to LX with BMS ([**2-10**]) CK index of 21% in setting of sepsis and PCI to LX with BMS with 3 x 22 mm Integretti stent in [**2167-1-31**]. She had 3-month plavix course. She was continued on ASA 81 at rehab and atorvastatin is on hold until clinic. # Psoriasis She was continued on clobetasol #. Cholangitis prophylaxis She was continued on ciprofloxacin. #. L-spine fractures from last hospitalization Neurosurgery consulted during last hospitalization. She was placed on vitamin D and calcium. She should follow-up with Dr. [**Last Name (STitle) **] in 8 weeks with CT L-spine ([**Telephone/Fax (1) 1669**] to schedule) ********** Patient received orthotopic liver [**Telephone/Fax (1) **] on [**2167-5-31**]. She was taken to the OR by Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] who performed a Liver [**Last Name (NamePattern1) **] with Roux-en-Y hepaticojejunostomy. The patient had no initial complications and was transferred to the ICU in stable condition. Approximately 12 hours after the initial surgery was completed, although initially stable, she developed large amounts of bloody output from her drains and was taken emergently back to the operating room. After a careful search and taking care of a number of small bleeding areas which were oozing, when the surgica team came to the right hepatic vein which had previously been stapled, it was noted to be bleeding and this was clearly the source. This was oversewed this with 5-0 Prolene and hemostasis was achieved. The abdomen was washed out copiously and she was closed, still with the 2 JPs and Roux tube to gravity. The patient was maintained on CVVH for the first two days in the ICU, and then was switched to hemodialysis, more for fluid removal than toxin removal. Creatinine highest value post [**Last Name (NamePattern1) **] was 2.6. BUN was as high as 104 and this was trendng down slowly by the time of discharge with values of 94 and 1.7 upon discharge. Fluid volume status was aided by the use of lasix which will be continued as an outpatient. Last hemodialysis was [**6-5**]. The temporary line was removed following that session and no further lines were required for HD. The patient received routine induction immunosuppression to include solumedrol 500 mg intra-op with taper, cellcept, which was eventually changed to 500 mg QID due to GI intolerance and heartburn, and prograf was started on the evening of POD 0, and trough values followed daily with dosage adjustments per level. Following the takeback, the patient was extubated later that evening and was able to be transferred to the regular surgical floor on POD 4. She remained afebrile throughout hospitalization. The Roux tube had minimal to no drainage on a daily basis. The initial Roux study showed that the drain was not sitting in the bowel and there was some concern for leak. 4 days later the cholangiogram was repeated. This again showed to Roux not in effective position, so the Roux tube was removed prior to discharge to rehab as a CT also obtained that same day showed the Roux tube did appear displaced, entering the right upper abdomen and tracking superiorly to the inferior tip of the right lobe of the liver. There were no fluid collections so second JP drain was removed prior to d/c. LFTs have trended back towards normal, AST, ALT are WNL. T Bili 2.6 on discharge. She is tolerating diet, had return of bowel function. While on steroids she does not need to be restarted on mesalamine, however this should be reconsidered when the steroid taper is complete. Patient is also requesting follow up with ortho as an outpatient for pre-existing issues. This should be arranged in the outpatient setting. Medications on Admission: 1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. clobetasol 0.05 % Cream Sig: One (1) Appl Topical Q12H (every 12 hours) as needed for proriatic: apply to psoriatic as needed . 4. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig: One (1) Puff Inhalation DAILY (Daily) as needed for resp. 5. ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): [**Hospital1 **] to anterior abdomen, QHS to pannus fold and inflammed nail beds . 6. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 7. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. ursodiol 300 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). 13. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing, cough. 15. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) as needed for Pain: no more than 2000mg/day. 16. clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day) as needed for mouth pain. 17. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 11 days. 18. loperamide 2 mg Capsule Sig: One (1) Capsule PO DAILY (Daily): monitor for constipation. 19. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 20. spironolactone 100 mg Tablet Sig: One (1) Tablet PO once a day. 21. ibandronate (?) 22. Lorazepam 0.5 mg 1 tablet PO qHS prn anxiety 23. ondansetron 4 mg 1 tablet PO q 8 hr prn nausea 24. oxycodone 5 mg [**2-1**] cap PO q 4 hr prn back pain 25. Lactulose 15 mL PO/NG [**Hospital1 **] 26. ciprofloxacin 500 mg Tablet 1 Tablet(s) by mouth once a day (cholangitis proph) Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day: bare metal stent. 2. prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily): Per [**Hospital1 **] clinic taper. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for heartburn. 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 7. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 8. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 9. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 10. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (TU,FR). 11. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 12. clobetasol 0.05 % Cream Sig: One (1) Appl Topical Q12H (every 12 hours) as needed for psoriatic lesions. 13. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation DAILY (Daily) as needed for sob/wheeze. 14. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. oxycodone 5 mg Tablet Sig: [**2-1**] - 1 Tablet PO Q6H (every 6 hours) as needed for pain. 17. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours): Check trough level Thursday [**6-11**]. Fax results to [**Telephone/Fax (1) 697**]. 18. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg Injection Q8H (every 8 hours) as needed for nausea/vomiting. 19. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day: Follow daily weights. 20. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO twice a day: While taking lasix. Discharge Disposition: Extended Care Facility: [**Hospital3 **] hosp-[**Location (un) **] Discharge Diagnosis: neutropenia, hypervolemia, acute kidney injury, hyponatremia, coagulopathy, anemia, primary sclerosing cholangitis cirrhosis now s/p liver [**Location (un) **] 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 will be transferring to [**Hospital3 **] Please call the [**Hospital3 1326**] Office [**Telephone/Fax (1) 673**] if patient has any of the following: fever, chills, nausea, vomiting, jaundice, inability to take medications, increased abdominal pain or distension, bleeding, incision redness/bleeding. Please weigh patient daily and report gain or loss of greater than 3 pounds in a day or 5 pounds in a week. Is currently on lasix and will likely require dosage adjustment in the future [**Month (only) 116**] shower, no tub baths or swimming No heavy lifting Followup Instructions: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2167-6-22**] 10:30 CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2167-6-23**] 10:15 [**Name6 (MD) **] [**Last Name (NamePattern4) 9151**], MD Phone:[**Telephone/Fax (1) 1669**] Date/Time:[**2167-6-23**] 10:30 [**Last Name (LF) 54376**],[**First Name3 (LF) **] A [**Telephone/Fax (1) 54377**]: Please call for appointment Completed by:[**2167-6-10**]

[ "276.1", "571.5", "285.29", "787.02", "284.1", "E878.0", "362.81", "998.11", "789.59", "V45.82", "275.3", "696.1", "112.1", "276.8", "572.3", "493.90", "924.11", "595.0", "008.45", "414.01", "286.9", "041.4", "276.69", "571.6", "412", "E917.9", "379.21", "289.4", "288.00", "780.52", "276.2", "041.04", "556.9", "572.4", "584.9", "276.7", "287.5" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.93", "00.93", "50.59", "87.54", "39.98", "54.12", "38.95" ]

icd9pcs

[ [ [] ] ]

15209, 15278

5003, 10795

305, 491

15482, 15482

3969, 3969

16253, 16740

3230, 3295

13144, 15186

15299, 15461

10821, 13121

15665, 16230

3310, 3950

238, 267

2260, 2629

519, 2242

3983, 4980

15497, 15641

2652, 3050

3066, 3214

65,036

152,779

54294

Discharge summary

report

Admission Date: [**2158-8-11**] Discharge Date: [**2158-8-13**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 974**] Chief Complaint: Patient s/p fall, found down in home. Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **]M with history of Afib not on coumadin, HTN, CHF found down at home by daughter, on ground surrounded by blood and feces for unknown time period. Pt is confused, is poor historian, cannot recall fall. Lac and bruise over L eye, multiple abrasions on extremities. No H/A, CP, SOB, abd pain. Incontinent of stool. In c-collar. PMH:Afib, HTN CHF PSH:AAA [**2148**], coronary stents [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] [**2153**] [**Last Name (un) 1724**]:Plavix 75', Aspirin 81", Lopressor 100", Lasix 20', Naproxen 250", Uloric',Colchicine ALL: NKDA Past Medical History: PMH:Afib, HTN CHF PSH:AAA [**2148**], coronary stents [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] [**2153**] Social History: Lived alone in his apartment, his daughters were very involved with his care Family History: non-applicable Physical Exam: Pt expired while on the trauma service. [**2158-8-13**] - 3:30pm On arrival, pt was without pulse, no spontaneous breathing observed, to auscultation there was not heart beat or breath sounds. His pupils and corneas were non-reactive/without reflex. Pertinent Results: [**2158-8-11**] 09:55AM GLUCOSE-97 UREA N-80* CREAT-2.4*# SODIUM-146* POTASSIUM-4.7 CHLORIDE-120* TOTAL CO2-16* ANION GAP-15 Brief Hospital Course: [**Age over 90 **]yr old M with hx of CAD, Afib (not on coumadin), HTN, CHF was "found down" in his kitchen at home by his daughter on the ground surrounded by blood and feces for an unknown period of time. He was brought by EMS to ED on [**2158-8-10**] and admitted to SICU. Daughters state that he has had progressively worsening SOB limiting his ambulation, but has remained independent in his ADLs and iADLs at home. He was initially evaluated in the ED and he was A&Ox3 and carrying on a conversation. He had recalled the fall, but no other further details. He was admitted to SICU with Neurosurgery and SICU consults. In the evening [**2158-8-11**] was called by ICU team that he had a new onset of left facial weakness and was not responding. Per nurse, he had been saying more words and stating that he was in his living [**Apartment Address(1) 101873**] minutes prior to emergent neurology consult. During examination, he moved his right arm and did say the word "no" in response to new face mask placement. At this time a long family discussion was undertaken - and the patient was made CMO by his 2 daughters, his health care proxy. [**Name (NI) **] was transferred to the floor with the thought of making him comfortable overnight before transferring him home with hospice care. [**2158-8-13**] - 3:30pm Called to [**Age over 90 **]yo pt's room by nursing after family noticed cessation of breathing by pt. Pt was made CMO and transferred from TICU to floor on [**2158-8-12**] with intent to go to outpatient hospice on [**2158-8-14**]. On arrival, pt was without pulse, no spontaneous breathing observed, to auscultation there was not heart beat or breath sounds. His pupils and corneas were non-reactive/without reflex. The pt was pronounced dead at 3:30pm with the family present, the cause of death was a C-Spine fracture and proximally, cardiopulmonary failure. A report of death form was completed, the medical examiner's office contact[**Name (NI) **]. The family refused an autopsy. Dr. [**Last Name (STitle) **], attending physician was made aware immediately. Medications on Admission: none Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: n/a Followup Instructions: n/a

[ "274.9", "873.42", "428.0", "427.31", "805.05", "585.9", "403.90", "805.04", "E885.9", "276.0", "900.89", "V45.82", "723.0", "414.01", "584.9", "921.1" ]

icd9cm

[ [ [] ] ]

[ "86.59" ]

icd9pcs

[ [ [] ] ]

3808, 3817

1635, 3724

298, 304

3868, 3877

1484, 1612

3929, 3935

1180, 1196

3779, 3785

3838, 3847

3750, 3756

3901, 3906

1211, 1465

221, 260

332, 923

945, 1070

1086, 1164

67,112

136,356

35562

Discharge summary

report

Admission Date: [**2154-3-3**] Discharge Date: [**2154-3-9**] Date of Birth: [**2075-11-14**] Sex: F Service: MEDICINE Allergies: Vicodin Attending:[**First Name3 (LF) 2387**] Chief Complaint: Dyspnea and back/neck pain Major Surgical or Invasive Procedure: None History of Present Illness: 78 DM, PAD known severe AS [**Location (un) 109**] 0.9cm2 mean gradient of 20mmHg, CHF EF 35-40% with regional variation, 3vd cath 1mo ago, RLE angioplasty/stent for poorly healing TMA now presents with dyspnea and pain. Last evening around 10pm, she developed back/neck pain while at rest that subsided somewhat by trying to sleep/rest, but she awoke at 4am with wheezing, concerning enough to call her daughter and present to [**Hospital3 **]. Her sats were recorded to be in the 70s. She received lasix (20mg IV by report) with improvement in respiratory status, and was transferred to [**Hospital1 18**] for further management. At the [**Hospital1 18**] ED, her presenting vitals were 99.9, 90/44 HR 113 RR 21 Sat 100% NRB. Her BP dropped to 83/47 lowest recorded, and she received a 250cc saline bolus. She was weaned down on her oxygen to 4L NC. Given her BP, she was admitted to the cardiac ICU for further monitoring. 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. All of the other review of systems were negative. Cardiac review of systems is notable for absence of frank chest pain, paroxysmal nocturnal dyspnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: AS 0.9cm2, gradient 20by echo, 40 by cath Diabetes PVD Hypertension Hypercholesterolemia Hypothyroidism SVT status post ablation Tachycardia, sinus PSH: Right TMA in [**11-3**] Left TMA in '[**51**] Left femoral/popliteal bypass in [**2151**] R femoral/popliteal bypass in [**11-3**] Thyroidectomy Right hip fracture Social History: Tobacco Use: Former smoker Alcohol Abuse: No history of alcohol abuse. Family History: Daughter with MI in 50s. Physical Exam: Gen: WDWN elderly female 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 *10-12 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. III/VI SM at RUSB. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Wet rales 1/2 up Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Neuro: Pulses: Right: Carotid 1+ Femoral 1+ Popliteal 0+ Left: Carotid 1+ Femoral 1+ Popliteal 0+ Pertinent Results: [**2154-3-3**] 08:15AM BLOOD WBC-9.0 RBC-2.97* Hgb-9.3* Hct-27.9* MCV-94 MCH-31.4 MCHC-33.4 RDW-15.5 Plt Ct-297 [**2154-3-7**] 06:55AM BLOOD WBC-8.4 RBC-2.87* Hgb-9.1* Hct-26.3* MCV-91 MCH-31.6 MCHC-34.6 RDW-15.3 Plt Ct-391 [**2154-3-3**] 08:15AM BLOOD Glucose-208* UreaN-15 Creat-0.8 Na-136 K-4.4 Cl-101 HCO3-28 AnGap-11 [**2154-3-7**] 06:55AM BLOOD Glucose-113* UreaN-35* Creat-0.7 Na-139 K-4.0 Cl-99 HCO3-31 AnGap-13 [**2154-3-3**] 08:15AM BLOOD cTropnT-0.05* [**2154-3-3**] 08:15AM BLOOD CK-MB-NotDone cTropnT-0.06* proBNP-5950* [**2154-3-3**] 04:33PM BLOOD CK-MB-NotDone cTropnT-0.10* [**2154-3-3**] 08:15AM BLOOD ALT-14 AST-16 CK(CPK)-39 AlkPhos-40 TotBili-0.5 [**2154-3-3**] 08:15AM BLOOD Lipase-27 [**2154-3-4**] 01:41AM BLOOD TSH-2.5 [**2154-3-5**] 11:39AM BLOOD %HbA1c-5.8 Urine cx ([**3-3**]): negative Blood cx ([**3-3**] x2, [**3-5**] x2): NGTD CXR ([**3-3**]): Interval development of pulmonary edema; repeat PA and lateral when clinically feasible may be beneficial. LE U/S ([**3-3**]): No DVT of either lower extremity. TTE ([**3-4**]): The left atrium is elongated. The left ventricular cavity is mildly dilated with severe global hypokinesis (LVEF = 25-30 %). The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [**2154-1-28**], global left ventricular systolic function is more depressed (and apprears global) and the severity of aortic stenosis has progressed. No discrete vegetations identified (does not exclude with deformed valves). CXR ([**3-5**]): In comparison with the study of [**3-3**], the hemidiaphragms are more sharply seen. The pulmonary vascularity is less pronounced. These findings are consistent with decreasing pulmonary [**Date Range 1106**] congestion and pleural effusions. Some streaks of atelectasis persist, especially at the left base. There is a vague suggestion of an area of increased opacification involving the right mid lung laterally. This could possibly reflect a developing area of consolidation. Brief Hospital Course: 1) Acute on chronic systolic heart failure: Was diuresed with boluses of furosemide (20-60mg IV) with care to avoid overdiuresis due to her AS and subsequent preload dependence. TTE showed global LV systolic dysfunction and severe aortic stenosis. Her breathing improved with diuresis and she was weaned off O2. Her outpatient furosemide was increased from 20mg once a day to 40mg once a day. She was started on lisinopril 2.5mg daily, which can be uptitrated as tolerated. Metoprolol was increased from 12.5mg twice daily to 37.5mg three times a day but her blood pressure could not tolerate and she was weaned back to metoprolol 12.5mg PO BId. She remained in sinus tachycardia in the 100-110s range, which per patient and daughter has been her baseline for at least 40 years. Also, her blood pressure has not tolerated past attempts to control her heart rate with medications. Regarding her AS, she was seen by CT surgery for AVR, and will follow up as an outpatient for this and CABG. 2) PVD: Status post recent TMA revision with wound vac in place over R dorsal foot. [**Date Range **] surgery was consulted and felt this wound was not infected. She was discharged with the wound vac in place. 3) CAD: Plan is for patient to undergo CABG once her right foot wound has healed. She was treated with ASA, clopidogrel, atorvastatin, and metoprolol. She had no evidence of acute ischemia during her hospitalization. 4) Fevers: CXR did not suggest pneumonia, urine culture was negative, and blood cultures were negative to date at discharge. No evidence of leg DVT on ultrasound. Her fever curve trended down and she had no leukocytosis. 5) Anemia: Chronic and stable. She was transfused 1 unit pRBCs in case anemia was contributing to her tachycardia, although her HR remained elevated. 6) DM: Her oral hypoglycemics were held while in house and she was monitored on RISS. She was transitioned back to her PO meds at discharge. Her other chronic medical problems remained stable and she was continued on her outpatient regimen. Medications on Admission: ATORVASTATIN [LIPITOR] 40MG PO DAILY CLOPIDOGREL [PLAVIX] 75 mg daily FENOFIBRATE NANOCRYSTALLIZED [TRICOR] 48 mg daily FUROSEMIDE 20 mg PO DAILY GLIMEPIRIDE [AMARYL] 4 mg [**Hospital1 **] LEVOTHYROXINE 150 mcg daily METFORMIN - 1,000 mg [**Hospital1 **] METOPROLOL TARTRATE - 12.2mg PO BID PENTOXIFYLLINE [TRENTAL] 400 mg Sustained Release TID PIOGLITAZONE [ACTOS] 45 mg Tablet daily POTASSIUM CHLORIDE [KDUR] 20mEq daily ALENDRONATE 75mg PO Weekly SITAGLIPTIN [JANUVIA] 100 mg Tablet daily Medications - OTC ASPIRIN 325 mg DAILY DOCUSATE SODIUM - 100MG PO BID FERROUS SULFATE 325 mg [**Hospital1 **] VITAMIN B COMP & C NO.3 [B COMPLEX PLUS VITAMIN C] - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Glimepiride 4 mg Tablet Sig: One (1) Tablet PO daily (). 8. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Sitagliptin 100 mg Tablet Sig: One (1) Tablet PO daily (). 10. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO TID (3 times a day). 12. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 13. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO once a day. 14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 15. Micro-K 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day. 16. Tricor 48 mg Tablet Sig: One (1) Tablet PO once a day. 17. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day. Discharge Disposition: Home With Service Facility: VNA Carenetwork Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Congestive Heart Failure Exacerbation 2. Peripheral [**Hospital1 **] Disease 3. Sinus Tachycardia 4. Hyperlipidemia 5. Type 2 Diabetes Mellitus Discharge Condition: Stable. Patient is tolerating room air and is back to her baseline condition. Discharge Instructions: You were admitted to the hospital with shortness of breath. This was thought likely related to your congestive heart failure. Your breathing improved with increased doses of your diuretic. You were also evaluated by the [**Hospital1 1106**] surgeons who did not think your foot infection looked infected. You should continue to follow-up with your outpatient cardiologist, [**Hospital1 1106**] surgeon, and cardiothoracic surgery team when you are discharged. . We have made the following changes to your medications: - furosemide (lasix) - we have increased this medication from 20mg once a day to 40mg once a day - we held your metformin and pioglitazone while you were in the hospital. You may restart these medications once you return home. - potassium supplementation as before . Please return to the hospital if you developed shortness of breath, chest pain, increased lower extremity swelling, changes in your weight, fevers, shaking chills, night sweats, nausea, vomiting, diarrhea, palpitations, or passing out. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day or 6 poounds in 3 days. Adhere to 2 gm sodium diet Fluid Restriction: 1.5 liters a day or about 6 cups per day Followup Instructions: Please follow-up with your surgeon and the [**Name8 (MD) 1106**] lab at your previously scheduled appointments: - Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2154-3-15**] 1:00 - Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2154-3-15**] 1:45 . Cardiology: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]: please make an appt to see Dr. [**Last Name (STitle) **] the week of [**3-18**]. Completed by:[**2154-3-9**]

[ "428.23", "723.1", "414.01", "427.89", "787.01", "724.5", "440.29", "311", "E878.5", "785.51", "707.14", "458.9", "733.90", "428.0", "285.29", "997.69", "424.1", "458.29", "401.9", "780.60", "414.8", "440.4", "733.00" ]

icd9cm

[ [ [] ] ]

[ "93.57" ]

icd9pcs

[ [ [] ] ]

9248, 9294

5183, 7218

294, 301

9504, 9584

2995, 5160

10846, 11413

2162, 2188

7973, 9225

9315, 9315

7244, 7950

9608, 10097

2203, 2976

10126, 10823

228, 256

329, 1717

9334, 9483

1739, 2057

2073, 2146

29,460

107,533

32387

Discharge summary

report

Admission Date: [**2183-1-28**] Discharge Date: [**2183-2-7**] Date of Birth: [**2125-9-5**] Sex: M Service: CARDIOTHORACIC Allergies: Codeine Attending:[**First Name3 (LF) 2969**] Chief Complaint: esophageal cancer Major Surgical or Invasive Procedure: esophagectomy History of Present Illness: The patient is a 57-year-old gentleman who was previously diagnosed with T3, N1 esophageal cancer of the distal esophagus. The patient had had a feeding jejunostomy placed through a left lower quadrant incision and had undergone preoperative chemoradiation therapy. The patient had tolerated this well and, after review of post- therapy images, it was decided to proceed with a tri- incisional esophagectomy. Past Medical History: Esophageal CA Diabetes Mellitus Type 2 Pulmonary emboli Social History: lives w/ wife no etoh former smoker- quit 10 yrs ago. was 3 ppd for many years Family History: non-contributory Physical Exam: general: well appearing, in NAD HEENT: left neck incision healing well w/ small area of irritation d/t staples which are now removed. Chest: decreased at the bases other wise clear. POC site clean- de-accessed. Cor: RRR S1, S2 Abd: round, soft, NT, ND. Distal portion of midline incision opened and packed w/ NS-Wet to Dry - wound bed clean beefy red w/ minimal serosang draiange. J-tube site clean and dry. extrem: No C/C - minimal pedal edema neuro: alert and oriented x3. no deficits Pertinent Results: CXR [**2-2**] COMPARISON: [**2183-2-2**] and [**2183-1-22**]. HISTORY: 52-year-old man with recent chest tube, status post esophagectomy, evaluate for pneumothorax. FINDINGS: In the interim, the right chest tube has been removed. No residual pneumothorax is noted. Otherwise, no significant interval change since the prior examination. There are persistent left basilar streaky opacities noted likely secondary to underlying atelectasis. There is peripheral opacity seen in the right hemithorax, unchanged from the previous examination. Surgical neck staples are seen along the left side of the neck. Minimal blunting of the right costophrenic angle that could be secondary to effusion and atelectasis. IMPRESSION: Status post removal of a right chest tube drainage catheter with no evidence of residual pneumothorax. CTA [**2-5**] IMPRESSION: 1. Small loculated right hydropneumothorax. Small layering left pleural effusion. 2. Bilateral atelectases. 3. No evidence for pulmonary embolism. 4. Free intraperitoneal air and fluid, all likely post-operative, though evaluation for a perforated viscus is thus suboptimal. If there is clinical concern for perforation, Gastrografin contrast can be orally administered and the patient can be rescanned to evaluate Brief Hospital Course: Pt was admitted the day prior to surgery for heparin gtt for history of PE. Taken to the OR on [**2183-1-28**] for Flexible bronchoscopy, tri-incisional esophagectomy with esophagogastric anastomosis. NGT, anastomotic JP drain to bulb sxn. J-tube to gravity. Bilat chest tubes to sxn w/ serosang drainage. An epidural was placed for pain control w/ good effect. Post op pt was admitted to the SICU intubated. POD#1 pt was extubated w/o incident. POD#2 pt transferred from ICI to floor for ongoing post-op care. Trophic tube feeds started. chest tubes to water seal w/ resultant PTX- back to sxn w/ lung re-expansion. POD#4 chest tubes to water seal w/ stable cxr. left chest tube d/c'd. NGT d/c'd. POD#5 return of bowel function - tube feed advanced slowly to goal over subsequent days. POD#6 grape juice test- negative. Started on clears liquid. right chest tube d/c'd w/ stable CXR. POD#7 Epidural d/c'd Lovenox restarted at 120 mg [**Hospital1 **]. Did not [**Last Name (un) 1815**] Roxicet. Started on po Dilaudid w/ good effect. progressing well w/ PT- cleared for home. POD#8 c/o shortness of breath and general not feeling well. cxr, labs and clinical exam stable. abd midline incision slightly red at distal aspect- opened - wound bed clean, no drainage. POD#9 subjective c/o SOB persists despite stable clinical exam. CTA done to r/o PE given recent PE history. CTA neg. symptoms resolved. Diet progressed to full liquids. POD#10 d/c'd to home w/ vna services and tube feed. will return to see Dr. [**Last Name (STitle) **] on [**2-20**] w/ barium swallow at the time of that visit. Medications on Admission: ASA 81', metformin 1000', glucotrol 10', MVI Lovenox was held prior to surgery Discharge Medications: 1. Enoxaparin 120 mg/0.8 mL Syringe [**Month/Year (2) **]: One (1) Subcutaneous [**Hospital1 **] (2 times a day). Disp:*60 doses* Refills:*2* 2. Glipizide 5 mg Tablet [**Hospital1 **]: Three (3) Tablet PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 5. Metformin 500 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID: crush this medication and take by mouth w/ apple sauce or pudding. 6. Hydromorphone 2 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q3H (every 3 hours) as needed. Disp:*80 Tablet(s)* Refills:*0* 7. tube feed replete w/ fiber at 95cc/hr continuous Flush w/ 50cc water every 6hrs and before and after hook up or discontinue feeds tube feed pump and supplies Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: esophageal ca s/p VAD/open J ([**2182-10-28**]), DM2, s/p CCY ([**2179**]), h/o PE esophagectomy Discharge Condition: good 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, abdominal pain, difficulty swallowing or if you develop foul smelling drainage from your abd incision. 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. Continue Full liquid diet until seen by Dr. [**Last Name (STitle) **]. Lovenox 120mg twice daily. Will require Coumadin for 6 months follow. Will Call his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17025**] for referral to [**Hospital **] clinic. Continue fingerstick blood sugars and keep log. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**]: [**2183-2-20**] at 11am on the [**Hospital Ward Name 516**] [**Location (un) **] [**Hospital Ward Name 23**] Clinical Center. BEFORE your appointment Report to the [**Location (un) **] Radiology Department for a Chest X-Ray and barium swallow on [**2183-2-20**] at 9:30am. Completed by:[**2183-2-7**]

[ "E849.7", "338.12", "250.00", "V12.51", "151.0", "V85.32", "196.1", "512.1", "V15.82", "E878.2" ]

icd9cm

[ [ [] ] ]

[ "42.42", "96.6", "33.22", "44.29" ]

icd9pcs

[ [ [] ] ]

5424, 5475

2764, 4359

290, 306

5616, 5623

1476, 2741

6703, 7080

936, 954

4488, 5401

5496, 5595

4385, 4465

5647, 6680

969, 1457

233, 252

334, 745

767, 824

840, 920

61,095

134,793

43970

Discharge summary

report

Admission Date: [**2158-10-24**] Discharge Date: [**2158-11-3**] Date of Birth: [**2074-2-17**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 7055**] Chief Complaint: ventricular tachycardia Major Surgical or Invasive Procedure: [**2158-10-25**] - Attempted VT ablation History of Present Illness: 84 yo woman with h/o HTN, dementia, breast cancer s/p lumpectomy/chemo 20 yrs ago and VT, evaluated at [**Hospital1 18**] in [**7-/2158**] at which time she did not undergo ablation and instead was loaded with Amiodarone who then presented to [**Hospital1 **] with incessant VT and is now transferred to [**Hospital1 18**] for further management. . In [**Month (only) 216**] a holter monitor showed >[**2146**] runs of VT. She initially presented to her PCP with intermittent [**Name9 (PRE) 94431**], which initiated her work up including holter. She was subsequently admitted to [**Hospital1 18**]. During admission had [**2-3**] short runs (<30) of Ventricular tachycardia, which were asymptomatic and with blood pressures at her baseline. She opted for medical management with amiodarone, amio loaded and monitored in house. cMRI at that time showed mildly enlarged left ventricular cavity size with mild global hypokinesis, mildly depressed LVEF at 55%. The effective forward LVEF was mildly depressed at 51%. No CMR evidence of prior myocardial scarring/infarction. Normal RV, Mild MR. [**First Name (Titles) **] [**Last Name (Titles) 1834**] stress EKG after amiodarone loading which did not induce any VT. Subsequent holter monitor showed no VT but ocassional Ventricular Bigeminy. . Since this most recent admission, the patient reports feeling well. Denies any episodes of chest pain, palpitations, shortness of breath, trouble breathing, dizziness, light-headedness, or fainting episodes. The patient reports being in her usual state of health, and she went to her PCP appointment for what she thinks was a normal follow up appointment (she cannot remember for what). As per documentation from OSH, went to PCP for swollen ankles/cough, then developed CP and EKG showed sinus tachycardia. At OSH, had EP study on [**2158-10-23**] and found to have persistent wide complex tachycardia [**1-4**] autonomic focus. ECHO on [**2158-10-20**] with EF 40% (down from 55% in [**7-13**]) and ruled out for MI. On ROS, denies any chest pain, shortness of breath, trouble breathing, palpitations, light-headedness, dizziness, syncope. Pt had difficulty remembering her [**Date Range **], but reports that nothing has been bothering her since last discharge. Past Medical History: CARDIAC RISK FACTORS: Dyslipidemia, Hypertension OTHER PAST MEDICAL HISTORY: Depression, dementia, breast cancer s/p lumpectomy/chemo 20yrs previously, anxiety, b/l total knee replacement, s/p appy, s/p tonsillectomy Social History: Lives at home with husband, forgetful at baseline -Tobacco history: Smoked 4 years back in college. -ETOH: denies -Illicit drugs: denies Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM: GENERAL: pleasant elderly woman, NAD, laying comfortably in bed, AAOx3, but had difficulties remembering what happened/why she initially presented to PCP, [**Name10 (NameIs) **] [**Name11 (NameIs) 4459**]: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP edge of mandible CARDIAC: irregular heart rate, S1, S2, no murmurs/rubs/gallops appreciated, no S3, S4 LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: warm, well perfused, [**12-4**]+ LE pitting edema b/l SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ . Discharge exam: Vitals - Tm/Tc: 98.2/97.6 HR:66-68 BP: 120-128/62-71 RR:18 02 sat: 96% 2L, 90% RA. In/Out: Last 24H: [**Telephone/Fax (1) 94432**] Last 8H: 100/450 Weight: 68 (71.3)different scale . Tele: SR, rate 50's-60's, no VEA . FS: none . GENERAL: 84 yo M in no acute distress [**Telephone/Fax (1) 4459**]: mucous membs moist, no lymphadenopathy, JVD at 12cm CHEST: Crackles bibasilar Left> right, no wheezes, no rhonchi CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or gallops, pos diastolic click ABD: soft, non-tender, non-distended, BS normoactive. no rebound/guarding. EXT: wwp, 2+ edema feet and ankles. DPs, PTs 2+. NEURO: CNs II-XII intact. 5/5 strength in U/L extremities. SKIN: no rash PSYCH: alert, oriented x2-3, pleasant and cooperative Pertinent Results: [**2158-10-25**] 03:16AM BLOOD WBC-6.0 RBC-3.53* Hgb-10.0* Hct-30.6* MCV-87 MCH-28.2 MCHC-32.6 RDW-15.5 Plt Ct-164 . [**2158-10-31**] 04:20AM BLOOD WBC-7.6 RBC-3.60* Hgb-10.1* Hct-31.7* MCV-88 MCH-27.9 MCHC-31.8 RDW-15.6* Plt Ct-196 . [**2158-10-27**] 04:24AM BLOOD PT-12.5 PTT-34.2 INR(PT)-1.1 . [**2158-10-25**] 03:16AM BLOOD Glucose-100 UreaN-22* Creat-1.0 Na-140 K-4.3 Cl-106 HCO3-26 AnGap-12 . [**2158-10-31**] 04:20AM BLOOD Glucose-102* UreaN-22* Creat-1.0 Na-140 K-4.2 Cl-100 HCO3-35* AnGap-9 . [**2158-10-31**] 04:20AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.2 . [**2158-10-25**] 03:16AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.0 . [**2158-10-26**] CHEST (PORTABLE AP) - The cardiac silhouette is mildly to moderately enlarged, and is accompanied by pulmonary vascular congestion. Hazy opacity in left perihilar region could potentially represent early asymmetrical edema, but is not fully characterized on this portable view. Small pleural effusions are present bilaterally, with adjacent basilar atelectasis. . [**2158-10-27**] MRSA screen - negative [**2158-10-31**] Urine culture - vaginal flora . Labs at discharge: [**2158-11-3**] 07:05AM BLOOD WBC-6.9 RBC-3.46* Hgb-9.5* Hct-30.4* MCV-88 MCH-27.5 MCHC-31.4 RDW-16.1* Plt Ct-210 [**2158-11-3**] 07:05AM BLOOD Glucose-96 UreaN-24* Creat-1.0 Na-141 K-3.9 Cl-101 HCO3-34* AnGap-10 [**2158-11-3**] 07:05AM BLOOD Mg-2.0 Brief Hospital Course: 84 y.o woman with h/o HTN, dementia, breast cancer s/p lumpectomy/chemo 20 yrs ago and VT evaluated at [**Hospital1 18**] in [**7-/2158**] at which time she did not undergo ablation and instead was loaded with Amiodarone who then presented to [**Hospital1 **] with incessant VT and is now transferred to [**Hospital1 18**] for further management. . ACTIVE ISSUE: . # VENTRICULAR TACHYCARDIA - Has failed medical management with amiodarone, which was started on admission in [**Month (only) 216**]. Lidocaine and Procainamide were used without effect to try to convert her VT. She then [**Month (only) 1834**] a limited endocardial ablation, however, this failed to ablate the right ventricular outflow tract focus. Later she was given Flecainide which converted her rhythm to NSR but later reconverted to VT, so the dosing was increased. We maintained her on Flecainide 150 mg PO twice daily, which she tolerated. We also tried to add a low-dose beta-blocker to this regimen, but this resulted in some intermittent bradycardia and hypotension, which resolved with discontinuation of the beta-blocker. While on this medication, her electrolytes were closely monitored and her QRS complex was monitored for widening given the anti-arrhythmic medication. The electrophysiology service was following her during this admission. QTc at time of discharge is 0.47 secs. . CHRONIC ISSUES: . # Acute on Chronic Diastolic CHF: cMRI performed [**7-/2158**] with estimated LVEF 50-55%. Cardiac catheterization was without obvious stenosis, performed at the outside hospital. She did have mild crackles appreciated on lung exam (on admission), but does not have LE pitting edema or JVP elevation. A CXR showed mild pulmonary edema, and she received only PRN IV Lasix dosing because she was asymptomatic with SBPs in 100s and does not take home diuretics. She responded to gentle IV Lasix dosing and diuresed appropriately without overt signs of failure. We monitored her in's and out's and performed daily weights. Her electrolytes were optimized. We continued her home dosing of Aspirin 81 mg PO daily. She was not currently on a statin medication. She is still on 2L NP of oxygen and desaturates to 85% on RA with ambulation, 90% on RA at rest. She will need strict I/O's, daily weights and additional PO furosemide if her weight is increasing. Unclear dry weight but weight at discharge is 68kg. . # DEMENTIA: She had stable evidence of short-term memory loss. We continued her Namenda 10 mg PO BID and we continued her Citalopram 20 mg PO daily, as her mood remained stable and her affect favorable. Her husband appears to be somewhat forgetful but her daughter and son are involved. . # S/P BILATERAL TOTAL KNEE REPLACEMENTS: Tolerated Tylenol 650 mg PO Q4-6H as needed for pain control. Patient was not complaining of any pain this admission. Her gait is shuffling with some weakness, she will need physical therapy to regain lost mobility. . # BREAST LESION - noted on cMRI last admission; patient should follow this up as an outpatient with PCP regarding further imaging (e.g. mammography or breast U/S) . TRANSITION OF CARE ISSUES: 1. Will need close monitoring of her rhythm and assessment for pre-syncopal [**Year (4 digits) **] given her ventricular tachycardia history and use of anti-[**Year (4 digits) 94433**]. Will need electrolyte monitoring as an outpatient. Please check Chem-7 on Monday [**11-6**]. 2. In speaking with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD, if the patient continues to develop bradycardia or hypotension in the setting of anti-[**Last Name (LF) 94433**], [**First Name3 (LF) **] need to later consider pacemaker placement, but this seems unlikely at this time. She is tolerating the Flecainide well. 3. She will be discharged with 2 liters of oxygen therapy via nasal cannula which can be weaned as tolerated as she diureses 4. Will need close monitoing of fluid status as above with additional furosemide as needed for goal of 500cc negative every day until she is off oxygen and her pedal swelling has improved. Medications on Admission: 1. Multivitamin 1 tab PO daily 2. Namenda 10 mg PO BID 3. Citalopram 20 mg PO daily 4. Aspirin 81 mg PO daily 5. Amiodarone 200 mg PO BID 6. Calcium and Vitamin D (uncertain dosage) 7. Acetaminophen 325 mg PO Q6H PRN pain 8. Omega-3 Fatty Acids 1 tab PO daily Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Calcium 500 With D 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO once a day. 4. omega-3 fatty acids 1,000 mg Capsule Sig: One (1) Capsule PO once a day. 5. memantine 10 mg Tablet Sig: One (1) Tablet PO bid (). 6. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. flecainide 50 mg Tablet Sig: Three (3) Tablet PO Q12H (every 12 hours). Disp:*180 Tablet(s)* Refills:*0* 9. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day as needed for weight gain or increasing edema: In addition to 40 mg of lasix standing dose. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: Primary Diagnoses: 1. Ventricular tachycardia originating from right ventricule outflow tract . Secondary Diagnoses: 1. Hypertension 2. Hyperlipidemia 3. Dementia 4. Depression 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: Patient Discharge Instructions: . You were admitted to the Coronary Care Unit (CCU) at [**Hospital1 771**] on [**Hospital Ward Name 121**] 6 regarding management of your irregular heart rhythm (ventricular tachycardia). You were initially managed with medications and we found that you responded best to Flecainide. You tolerated this medication well. There was also a electrophysiologist that attempted to ablate your rhythm, but the source was not found and medication was used for treatment instead. You were doing well and discharged in stable condition. . Please call your doctor or go to the emergency department if: * You experience new chest pain, pressure, squeezing or tightness. * You develop new or worsening cough, shortness of breath, or wheezing. * You are vomiting and cannot keep down fluids, or your medications. * If you are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include: dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit, or have a bowel movement. * You experience burning when you urinate, have blood in your urine, or experience an unusual discharge. * Your pain is not improving within 12 hours or is not under control within 24 hours. * Your pain worsens or changes location. * You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. * You faint or pass out * You develop any other concerning [**Hospital Ward Name **]. . CHANGES IN YOUR MEDICATION RECONCILIATION: . * Upon admission, we ADDED: START: Flecainide 150 mg by mouth twice daily (every 12-hours) START: Furosemide 40 mg daily . * The following medications were DISCONTINUED on admission and you should NOT resume: DISCONTINUE: Amiodarone . * You should continue all of your other home medications as prescribed, unless otherwise directed above. Followup Instructions: We spoke with Dr. [**Last Name (STitle) 5051**], your Cardiologist, and he recommended that you see Dr. [**First Name (STitle) 1075**]. His office will call you within 24-hours to schedule follow-up. His contact information is: Name: LOVE,[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: HEART CENTER OF [**Hospital1 **] Address: [**Location (un) **], SECOND FL, [**Location (un) **],[**Numeric Identifier 7398**] Phone: [**Telephone/Fax (1) 6256**] Fax: [**Telephone/Fax (1) 33001**]

[ "401.9", "300.00", "V43.65", "294.20", "V10.3", "428.31", "427.1", "611.9", "272.4", "428.0", "311" ]

icd9cm

[ [ [] ] ]

[ "37.34", "37.26", "99.69" ]

icd9pcs

[ [ [] ] ]

11557, 11631

6292, 7656

329, 371

11852, 11852

4904, 5998

13960, 14505

3075, 3191

10676, 11534

11652, 11748

10391, 10653

12067, 13937

3206, 4109

11769, 11831

4126, 4885

266, 291

6018, 6269

399, 2663

11867, 12011

7672, 10365

2762, 2904

2920, 3059

41,370

118,674

1919

Discharge summary

report

Admission Date: [**2164-8-15**] Discharge Date: [**2164-8-17**] Date of Birth: [**2115-6-12**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 106**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac cathetherization with placement of [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] in distal RCA History of Present Illness: 49 yo male with history of tobacco use and mild hyperlipidemia presenting with acute onset substernal chest pain. Pain started around 1pm on day of admission while he was at work in a surgery at [**Location (un) 745**] [**Hospital 3678**] Hospital (works with Red Cross in apheresis). Had non-radiating substernal pain/pressure, initially thought it was his GERD, but then began feeling diaphoretic, nauseated, and with shortness of breath. He went to the ED at NWH, where ECG showed inferior ST elevations and posterior ST depressions concerning for STEMI. Given 324mg aspirin (chewed), 2mg IV morphine, 0.4mg nitroglycerinx2 and started on heparin gtt with a bolus. Transferred urgently to the cath lab at [**Hospital1 18**] for intervention. . Upon arrival to the cath lab, the patient was given another aspirin and loaded with plavix 600mg. Angiography showed complete occlusion of the distal RCA with fresh thrombus. He had export thombectomy with removal of thombus revleaing <50% plaque just before bifurcation and moderate disease distally in the PDA. He had [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] placed with restoration of flow at 2:50pm. Immediately following restoration of flow he had maked bradycardia and hypotension treated with atropine and dopamine. He was hemodynamically stable at the end of procedure and sent to CCU for further care. . Patient reports that at baseline he is relatively healthy person and denies any exertional chest pain or SOB with climibing three flights of stairs. He denies any orthopnea or PND. He denies any family history of early MIs or strokes. . Currently in the CCU patient reports that his chest paain and shortness of breath has resolved now. No nausea or diaphoresis. . REVIEW OF SYSTEMS: Cardiac review of systems is notable for absence prior episodes 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: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: - Cervical arthritis s/p anterior fusion from C5 to C7. - GERD - Prior history of GI bleeding with normal EGD. - Erythema Migrans treated prophylactly for Lyme disease in [**8-/2163**] s/p appendectomy in [**2141**]. s/p pilonidal cyst excision in [**2134**]. s/p hernia repair in [**2126**]. s/p tonsillectomy in [**2121**]. Social History: Patient lives alone in [**Hospital1 **]. He works for red cross in the therpuetic apheresis lab. -Tobacco history: 40 pack year history of smoking. Cut down on smoking 10 years ago. Cureently smoking 2 cigarets/day. -ETOH: 2 drinks/week. -Illicit drugs: None. No IVDU or cocaine. Family History: Father and both granparents died from MIs in their 60s. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. No family history o strokes, PE or DVTs. Physical Exam: Vitals: Afebrile, 120s/70s, HR 70s, O2 99%2L GENERAL: Appears well in NAD. Sitting in bed. Oriented x3. Mood, affect appropriate. HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Dry mucous membranes. NECK: Supple with JVP of 8. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: Tattoes in the upper arm. No rashes or lesions. 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: [**2164-8-15**] 05:16PM BLOOD WBC-8.5 RBC-5.04 Hgb-14.9 Hct-43.8 MCV-87 MCH-29.6 MCHC-34.0 RDW-13.3 Plt Ct-166 [**2164-8-15**] 05:16PM BLOOD PT-12.0 PTT-40.3* INR(PT)-1.1 [**2164-8-15**] 05:16PM BLOOD Glucose-91 UreaN-22* Creat-0.8 Na-140 K-4.0 Cl-107 HCO3-22 AnGap-15 [**2164-8-15**] 05:16PM BLOOD CK-MB-55* MB Indx-11.2* cTropnT-0.68* [**2164-8-15**] 05:16PM BLOOD %HbA1c-5.6 eAG-114 [**2164-8-15**] 05:16PM BLOOD Calcium-9.3 Phos-2.9 Mg-1.9 . Discharged labs: [**2164-8-17**] 05:15AM BLOOD WBC-7.8 RBC-4.70 Hgb-13.9* Hct-41.3 MCV-88 MCH-29.5 MCHC-33.5 RDW-13.2 Plt Ct-175 [**2164-8-17**] 05:15AM BLOOD Glucose-95 UreaN-20 Creat-0.9 Na-142 K-4.3 Cl-106 HCO3-28 AnGap-12 [**2164-8-16**] 05:48AM BLOOD CK-MB-89* MB Indx-10.4* cTropnT-2.10* [**2164-8-17**] 05:15AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.2 [**2164-8-15**] 05:16PM BLOOD %HbA1c-5.6 eAG-114 . Cardiac Cath: 1) Selective coronary angiography of this right-dominant system demonstrated one-vessel coronary artery disease. The RCA was totally occluded in the distal segment of the vessel, with thrombus notable in the distal segment of the vessel prior to the PLV/PDA bifurcation. The LMCA, LAD, and LCx had no angiographically-apparent flow-limiting stenoses. 2) Limited resting hemodynamics revealed mild systemic arterial hypertension, with a central aortic pressure of 138/83 mmHg. 3) Successful aspiration thrombectomy and direct stenting of the distal RCA with a 2.75 x 16 mm Promus Element [**Month/Day/Year **] (see PTCA comments). FINAL DIAGNOSIS: 1. Total occlusion of the distal RCA with thrombus status post successful export thrombectomy and drug-eluting stenting. 2. No angiographically-apparent stenoses in the LMCA, LAD, and LCx. 3. Successful aspiration thrombectomy and PCI of the distal RCA with a 2.75 x 16 mm Promus Element [**Month/Day/Year **] . TTE [**2164-8-16**]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with basal inferior/inferoseptal hypokinesis. The remaining segments contract normally (LVEF = 45-50%). 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 stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w PDA disease. Brief Hospital Course: 49 yo male with history of tobacco use and mild hyperlipidemia admitted for RCA STEMI s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] on [**2164-8-15**]. . # RCA STEMI: Around 1pm [**2164-8-15**] while he was at work in the OR at [**Location (un) 745**] [**Hospital 3678**] Hospital (works with Red Cross in apheresis lab) he had acute onset severe substernal chest pain, SOB, n/v diarphoresis. He went to the ED at NWH, where ECG showed inferior ST elevations and posterior ST depressions concerning for STEMI. Given 324mg aspirin (chewed), 2mg IV morphine, 0.4mg nitroglycerin x2 and started on heparin gtt with a bolus. Transferred urgently to the cath lab at [**Hospital1 18**] for intervention. Upon arrival to the cath lab, the patient was given another aspirin and loaded with clopidogrel 600mg. Angiography showed complete occlusion of the distal RCA with fresh thrombus. He had export thombectomy with removal of thombus revleaing <50% plaque just before bifurcation and moderate disease distally in the PDA. He had [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] placed with restoration of flow at 2:50pm. Immediately following restoration of flow he had maked bradycardia and hypotension treated with atropine and dopamine. In the CCU he reported resolution of his chest pain, shortness of breath, nausea and diaphoresis. His CK-MB peaked at 107 and trended down to 87. He was started and continued on clopidogrel, aspirin, atorvastatin, lisinopril, and low dose metoprolol with a HR in the 50s-60s. TTE post cath revealed mild symmetric left ventricular hypertrophy with normal cavity size and EF 45-50%. Mild focal hypokinesis with basal inferior/inferoseptal hypokinesis c/w CAD. On day of discahrge patient was seen by physical theraphy and cleared to go home. He was encouraged to stop smoking and to follow up with Dr. [**Last Name (STitle) **] on [**9-28**], [**2164**] for cardiology follor up. . # GERD: Patient has history of severe GERD managed on omeprazole 40mg [**Hospital1 **]. He did not have any symptoms of GERD during this hospital course. He was continued on same dose on discharge. . # Cervical Arthiritis: Pain well controlled on acetominophen. . # Code: Full Code . Transtion of Care: - No pending labs - Patient will follow up with PCP and cardiologist for further management and care. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Omeprazole 40 mg PO BID Discharge Medications: 1. Omeprazole 40 mg PO BID 2. Aspirin EC 325 mg PO DAILY RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 3. Atorvastatin 80 mg PO DAILY RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 4. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 5. Lisinopril 5 mg PO DAILY hold for sbp <100 RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 6. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 Discharge Disposition: Home Discharge Diagnosis: Myocardial Infarction of the right coronoary artery Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr [**Known lastname 10675**], It was a pleasure taking care of you while you were in the hospital. You had a myocardial infarction (heart attack) and were taken to the cardiac cath lab. There you had the blood vessel (in your case the right coronary artery) that was blocked. The cardiologist was able to open that artery up and placed a stent to keep it open. You did well following the procedure. You were placed on a number of new medications while you were in the hospital. They are listed below. You are to take the aspirin for the rest of your life and you are to take the plavix for at least 1 year or until Dr. [**Last Name (STitle) 2052**] tells you can stop it. Please do not stop it unless you discuss it with your cardiologist for any reason. Please keep your follow up appointments. New Medications: Aspirin 325mg Daily Clopidogrel (Plavix) 75mg Daily Lisinopril 5mg Daily Metoporol Succinate 25mg Daily Atorvastain 80mg po daily Followup Instructions: Department: INTERNAL MEDICINE When: THURSDAY [**2164-8-23**] at 11:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8244**], MD [**Telephone/Fax (1) 2789**] Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site *Please arrive 5-10 minutes prior to your appointment. Department: ADULT SPECIALTIES When: FRIDAY [**2164-9-28**] at 12:40 PM With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD [**Telephone/Fax (1) 7773**] Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site Please call our registration department to make sure we have all your demographic information up to date. The number is [**Telephone/Fax (1) 10676**]. Completed by:[**2164-8-17**]

[ "530.81", "410.91", "V45.4", "427.89", "414.01", "721.0", "E879.0", "458.29", "305.1" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

10272, 10278

7090, 9476

314, 430

10374, 10374

4320, 4320

11494, 12391

3274, 3489

9651, 10249

10299, 10353

9502, 9628

5847, 7067

10525, 11471

3504, 4301

2529, 2598

2232, 2424

264, 276

458, 2213

4336, 5830

10389, 10501

2629, 2956

2446, 2509

2972, 3258

31,163

141,099

25731

Discharge summary

report

Admission Date: [**2111-1-18**] Discharge Date: [**2111-1-27**] Date of Birth: [**2038-11-10**] Sex: F Service: MEDICINE Allergies: Penicillins / Cephalosporins / Bactrim Attending:[**First Name3 (LF) 2840**] Chief Complaint: hematochezia Major Surgical or Invasive Procedure: Colonoscopy. Selective angiograpy of left colic artery via femoral artery catheterization. History of Present Illness: Pt is a 72 yo female with pmhx CKD (cr 2.1-2.8) thought to be [**1-31**] lithium use in past, hypernatremia [**1-31**] DI from lithium use in past, bipolar disorder and GIB who presents from nursing home with melena. NG lavage in ED was negative. Per report patient had a low blood pressure in the nursing home but normotensive in the ED and not tachycardic. Hct at admit 26. She recieved protonix 40 mg IV x 1 and has 2 PIV. Patient admitted to micu for close monitoring. At admit pt feels well, no dizziness, cp, sob, abd pain, nausea, vomiting although patient is poor historian given dementia. Past Medical History: bipolar disorder CKD hypernatremia thought to be due to DI from past lithium anemia thought to be [**1-31**] CKD and iron deficiency hyperlipidemia dementia h/o GIB HTN DM2 GERD h/o stroke Social History: She has lived at [**Hospital 100**] Rehab for the past two years. She is a retired dental hygienist. She does not smoke, drink or use any herbal or illicit drugs nor has she ever used them in the past. Family History: Her family history is notable for a grandfather with renal disease of unknown etiology. Her sister had some sort of cancer, and she does not know if diabetes or hypertension runs in the family. Her son has had a heart attack, but otherwise her kids are healthy. Physical Exam: VS: Temp: 97.2 BP: 143/74 HR: 87 RR: 13 O2sat 98% RA GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits RESP: CTA b/l with good air movement throughout CV: RRR, S1 and S2 wnl, no m/r/g ABD: mild distension, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e, warm, good pulses SKIN: no rashes/no jaundice NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits. cog wheel rigidity RECTAL: guaic positive in ED- reportedly BRBPR from floor Pertinent Results: [**2111-1-18**] WBC-11.4* Hgb-8.8* Hct-26.4* MCV-95 RDW-13.1 Plt Ct-244 Neuts-82.3* Lymphs-14.9* Monos-2.1 Eos-0.5 Baso-0.2 Glucose-125* UreaN-34* Creat-2.2* Na-149* K-4.9 Cl-114* HCO3-25 AnGap-15 ALT-17 AlkPhos-69 Amylase-103* TotBili-0.2 [**2111-1-19**] Iron-100 calTIBC-235* Ferritn-39 TRF-181* URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub- NEG Urobiln-NEG pH-5.0 Leuks-NEG Brief Hospital Course: A/P: Pt is a 72 yo female with bipolar, h/o lithium use, who presents with LGIB likely from diverticulosis. . # LGIB- Patient with BRBPR, NG lavage negative in ED; likely lower GI source. She had a tagged RBC scan showing distal descending colon bleed at 5 minutes. Subsequently had angiography; however, no bleeding could be visualized. Following this procedure she had colonoscopy, showing diverticulosis without active bleeding. Briefly stable after colonoscopy, then had another bleed. At this time had another bleeding scan, showing bleeding in the same area at 60-90 minutes. IR declined to do subsequent angiography, given the length of time required to see bleeding, amount of contrast received with first angio, and patient's baseline CKD. Surgery was consulted. She is s/p 5 units PRBCs total this admit. She was last transfused on [**1-21**] and last had evidence of LGIB on [**1-22**]. Since that time she has had stable hematocrit. Has remained hemodynamically stable. If having further bleeding, will likely need surgical involvement for potential partial or full colectomy. Aspirin and subQ heparin were held. Bowel regimen added to minimize constipation. She should continue on bowel regimen as per d/c orders. . # Hypernatremia/diabetes insipidus: thought to be nephrogenic DI from chronic lithium use. At baseline in the 140's-150's. Initially received free water (1/2NS and D5W). She briefly went into the low 160's range at the time of her second MICU callout. This was in the setting of colonoscopy prep (likely volume depletion) and recieving Na bicarb IVFs for angiography hydration. Mental status did not appear significantly changed during this time. DDAVP was tried in case DI was only partially nephrogenic; unclear if this was of benefit. HCTZ was also added but D/Ced prior to discharge. She should have repeat chem 10 as per discharge orders. . # CKD- Patient in stage 4 CKD, creatinine at baseline upon admission. Had exposure to contrast with angiography as above; prehydrated with Nabicarb. However, she did experience creatinine bump associated with this. Cr improved with IVF. She should have repeat chem 10 as per discharge orders. . # Anemia- [**1-31**] acute blood loss anemia. Iron studies not c/w underlying abnormality, so likely just an acute process. PRBC transfusions as above. Folate and iron wre started. She should have follow-up HCT as per discharge orders. . #. HTN- She was not on any bp meds at home. She was normotensive to hypertensive on the floors at the beginning of her stay. HCTZ as above was started and D/Ced. Now normotensive with occasional SBP dips to 90-100, responsive to IVF. She should be encouraged to take PO and given IVF prn at inpatient rehab. . #. DM- well controlled. Covered with ISS. No sliding scale insulin at rehab given risk of hypoglycemia. . # H/O CVA- may benefit from ASA, but in light of recent GI bleed, will defer to outpatient PCP for decision to start aspirin or not. She will need follow-up with Dr. [**First Name (STitle) 14959**] in [**12-31**] weeks. . # Hyperlipidemia: continued statin. . # Bipolar disorder: continued clozaril and lamotrigine. . # Code Status:FULL CODE . # Communication: with daughter. [**Name (NI) **] not able to make own decisions. Medications on Admission: vitamin D 50,000 units every week, Clozaril 100 mg b.i.d. Ativan as needed Lamictil 100 mg b.i.d. Protonix 40 mg daily aspirin simvastatin 40 mg qd iron 325 mg daily. Discharge Medications: 1. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 2. Clozapine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO three times a day. 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. Desmopressin 10 mcg/spray Aerosol, Spray Sig: One (1) spray Nasal DAILY (Daily). 12. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed for constipation: please give scheduled until she stools, and then prn constipation. 13. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for agitation. 14. Outpatient Lab Work Please check WBC, HCT, Hgb, plts, sodium, potassium, chloride, bicarb, BUN, creatinine, magnesium, calcium, phosphate on [**2111-2-1**]. Please fax results to Dr. [**First Name (STitle) 14959**] (phone: [**Telephone/Fax (1) 14960**]) Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - LTC Discharge Diagnosis: Lower GI bleed Diverticulosis Anemia due to acute blood loss Hypernatremia Diabetes insipidus Diabetes mellitus Chronic kidney disease Discharge Condition: Stable, no bleeding x 72 hours with stable hematocrit. Discharge Instructions: You were admitted with blood in your stools. You had an evaluation for this including colonoscopy, bleeding scans, and an angiogram. We found that you had diverticulosis but were not able to intervene. Fortunately, you have stopped bleeding on your own. You required blood transfusions to keep your blood levels high enough. . Please return to the hospital or call your doctor if you have further blood in your stools, black or tarry stools, fever, abdominal pain, severe weakness or shortness of breath, or any new symptoms that you are concerned about. Followup Instructions: Please call your primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 14959**] ([**Telephone/Fax (1) 14960**]) to schedule a followup appointment in 2 weeks. . You should have a repeat hematocrit and chemistries checked in 5 days as per discharge orders - to be faxed to Dr. [**First Name (STitle) 14959**] as in orders.

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icd9cm

[ [ [] ] ]

[ "99.04", "88.47" ]

icd9pcs

[ [ [] ] ]

7761, 7826

2807, 6079

313, 406

8005, 8062

2370, 2784

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261, 275

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30,715

115,908

33549

Discharge summary

report

Admission Date: [**2133-3-26**] Discharge Date: [**2133-4-3**] Date of Birth: [**2088-3-23**] Sex: F Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 1**] Chief Complaint: Right foot swelling and pain, cellulitis Major Surgical or Invasive Procedure: debridement of Right dorsal foot in OR History of Present Illness: Mrs. [**Known lastname 185**] is a 45yo morbidly obese female who presented to OSH last Thursday with 3 days of spreading cellulitis from dorsum of foot up front calf. She reports increased edema, pain, and formation of bullae. She underwent an MRI at OSh which revealed liquification of Right dorsum of foot. She was transferred to [**Hospital1 18**] Surgical ICU for furhter management and possible debridement of area in OR. Past Medical History: morbid obesity, OSA, asthma, GERD, anxiety/panic disorder, sleep apnea, C/S x 2, post-partum depression Social History: Married. Lives with husband. Supportive mother & father. Family History: Type 2 diabetes Physical Exam: Vitals: 99.1, 78, 119/75, 20, RA-100% Blood sugars-97-133 Gen: NAD, A/O x3 CV: RRR, no m/r/g Resp: CTAB ABD: +BS, soft, NT/ND, obese Extrem: no edema RLE-erythema improving, clear yellow serous output, dressing intact, kerlix wrap Pertinent Results: [**2133-3-26**] 07:30PM BLOOD WBC-14.0* RBC-3.79* Hgb-10.0* Hct-30.9* MCV-82 MCH-26.5* MCHC-32.5 RDW-14.3 Plt Ct-237 [**2133-3-26**] 07:30PM BLOOD Neuts-90.1* Bands-0 Lymphs-8.1* Monos-1.5* Eos-0.2 Baso-0 [**2133-3-26**] 07:30PM BLOOD PT-13.5* PTT-30.4 INR(PT)-1.2* [**2133-3-26**] 07:30PM BLOOD Glucose-115* UreaN-15 Creat-0.8 Na-140 K-3.6 Cl-106 HCO3-24 AnGap-14 [**2133-3-26**] 07:30PM BLOOD CK(CPK)-152* [**2133-3-27**] 12:20AM BLOOD Calcium-7.2* Phos-3.0 Mg-2.0 [**2133-3-28**] 10:20AM BLOOD Vanco-41.0* [**2133-3-28**] 07:43PM BLOOD Vanco-8.1* . RADIOLOGY Final Report ANKLE (AP, MORTISE & LAT) RIGHT [**2133-3-26**] 7:38 PM [**Hospital 93**] MEDICAL CONDITION: 45 year old woman with severe infection of R foot/lower leg IMPRESSION: Diffuse leg edema without evidence of osteomyelitis or subcutaneous gas. . RADIOLOGY Final Report CHEST PORT. LINE PLACEMENT [**2133-3-27**] 4:43 AM HISTORY: 45-year-old woman with cellulitis with new placed central venous line. IMPRESSION: 1. New right central line in a satisfactory location ends in proximal SVC. 2. Small persistent left lower lobe atelectasis and small- to- moderate left pleural effusion. 3. Improved lung volume. . RADIOLOGY Preliminary Report PICC LINE PLACMENT SCH [**2133-3-30**] 10:37 AM Reason: please place picc for abx use [**Hospital 93**] MEDICAL CONDITION: 45 year old woman with nec cellulitis RLE IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 4 French single-lumen PICC line placement via the left brachial venous approach. Final internal length is 44 cm, with the tip positioned in SVC. The line is ready to use. Brief Hospital Course: Mrs.[**Known lastname 185**] was transferred from OSH. She was admitted to SICU in preparation for debridement of RLE cellulits in OR. Her operative course was uncomplicated. She remained intubated and transferred back to SICU overnight in case for need of further debridement. . Right foot wound remained stable POD1. No further deterioration of dermis. No further debridement required. Plastics team consulted, and agreed with assessment. Plan for placement of vacuum dressing once wound bed stable. Patient extubated, all IV vasopressors discontinued, vital signs remained stable. Afebrile. Blood cultures pending. . Transferred to 11 [**Hospital Ward Name 1827**] for further management. Wound RN consulted. Adjustments made to wound care. Physical therapy consulted-touch down on right foot only. Non-weight bearing. Patient ambulated well with walker. Occupational Therapy consulted. Right calf and foot continue to drain copius amounts of serous fluid. Vac dressing not appropriate at this time. . Nutrition consulted for education re: hight protein, [**Doctor First Name **], low-[**Doctor Last Name **] diet. Patient started on regular food. Blood sugars checked QID & HS, treated with Regular insulin sliding scale as indicated. Patient reports poor appetite. Encourage proper food choices to minimize hyperglycemia, and promote healing. . SL PICC line inserted due to poor peripheral access. Continued with IV antibiotics. Skin culture grew BETA STREPTOCOCCUS GROUP A. Antibiotic regimen switched to oral Levaquin. Remained afebrile with normal WBC. Plan to continue oral Levaquin for [**2-22**] weeks at rehab. PICC line removed prior to discharge. Screened for rehab placement by [**Hospital1 **] for complex wound care. Plan for vacuum dressing to be applied once surrounding epidermis around wound stops weeping, and able to adhere dressing to this area. Plastic surgeon will assume managment of antibiotics, and wound care after discharge. Plan for split-thickness skin graft to site in about 3 weeks. . Patient seen by social work during admission due to depressed appearance, and to provide support due to medical condition. Has been on antidepressants in past for post-partum depression, and has seen therapist. Stopped taking medication on her own, and has not been seeing therapist. Unable to remember names of therapist or medications. PCP [**Name (NI) 653**] to verify depression history and medications trialed. No medications of diagnosis of depression on file. Continue assessment & management of depressed symptoms during admission in rehab due to possible [**Hospital 4820**] hospital course. Consider involvement of Psych if and when appropritate. . Dermatitis: Generalized across back and back of calves. Possible related to hospital linen, or IV Morphine. Patient reports tolerating Levaquin in past without rash. Continue to assess skin. Continue PO Benadryl, Pepcid, Sarna Lotion for symptom relief. Consider involvment of Dermatology as indicated. Medications on Admission: Zyrtec Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheeze. 4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 7. Oxycodone 5 mg Tablet Sig: 2-3 Tablets PO Q4H (every 4 hours) as needed for pain. 8. Morphine 4 mg/mL Syringe Sig: One (1) Injection three times a day as needed for pain: Please give 10 minutes prior to dressing changes only . 9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 weeks: Continue until follow-up with Plastic surgeon. 10. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection QAC & HS: Refer to sliding scale. 11. Regular Insulin Sliding Scale 61-100 mg/dL 0 Units 101-120 mg/dL 2 Units 121-140 mg/dL 4 Units 141-160 mg/dL 6 Units 161-180 mg/dL 8 Units 181-200 mg/dL 10 Units 201-220 mg/dL 12 Units 221-240 mg/dL 14 Units 241-260 mg/dL 16 Units 261-280 mg/dL 18 Units 281-300 mg/dL 20 Units 301-320 mg/dL 22 Units > 320 mg/dL Notify M.D. Check blood sugars before each meal and at bedtime. 12. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety for 2 weeks. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**] Discharge Diagnosis: Primary: Righ lower extremity nectrotizing cellulitis Depression . Secondary: morbid obesity, OSA, asthma, GERD, C/S x 2, postpartum depression Discharge Condition: Stable Tolerating a regular diet Adequate pain control with oral medication 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 vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or 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. *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *Avoid driving or operating heavy machinery while taking pain medications. * 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. * Continue to ambulate several times per day. Followup Instructions: 1.Please make a follow-up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]([**Telephone/Fax (1) 77766**], in [**1-21**] weeks. 2.Make a follow-up appointment with your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 63252**] [**Telephone/Fax (1) **] in 1 week or as needed. Completed by:[**2133-4-3**]

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icd9cm

[ [ [] ] ]

[ "38.93", "86.22" ]

icd9pcs

[ [ [] ] ]

7600, 7700

2952, 5936

308, 349

7888, 7966

1306, 1939

9155, 9527

1023, 1040

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5962, 5970

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1055, 1287

228, 270

377, 806

828, 933

949, 1007

11,147

195,765

20716

Discharge summary

report

Admission Date: [**2173-3-26**] Discharge Date: [**2173-4-2**] Date of Birth: [**2117-1-11**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 613**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: EGD EUS History of Present Illness: 56 yo male with Hx of HTN, CAD and A-fib on anticoagulation who initially presented to the OSH today with a chief complain of progressive weakness, lightheadedness and tiredness. He was found to have a drop in HCT and was in Afib with RVR at 180, SBP of 90. Pt was given lopressor 5mg IV with good response in HR and BP, pt was then transferred to [**Hospital1 18**] and admitted to the MICU. Pt reports several episodes of unusually dark stools over the past 3-4 weeks with some intermittent epigastric pain. Pt also endorsed NSAID use prn pain (at most [**12-23**] Tylenol or Motrin/day) but denies any hx of GI bleed. . Pt received 1 L NS, vitamin K, IV PPI and one unit of pRBCs. Hct remained stable and pt remained hemodynamically stable with a heart rate in the 80s. Pt was transferred to the medicine floor on [**2173-3-27**]. Past Medical History: hypertension coronary artery disease hyperlipidemia ethanol abuse smoking Social History: significant for current tobacco use (approx 50 pack years). Pt has a history of significant alcohol use which he has decreased significant ly and now takes approx 2 glasses of wine or beer per day. No h/o IVDU Family History: Brother and father with CAD in 50s Physical Exam: Tm/c 100.3 115/69;97-126/31-82 RR 17-29 HR 89,70-89, 91-100% RA gen: well appearing, nad heent: mmm, mildly icteric sclera, eomi pulm: ctab, no w/r/r cv: hrrr, no m/r/g abd: s/nd/nabs. large palpable liver. mild ttp throughout extr: no c/c/e neuro: aox4, cn 2-12 intact grossly Pertinent Results: [**2173-4-2**] 06:15AM BLOOD WBC-14.8* RBC-3.04* Hgb-8.4* Hct-26.8* MCV-88 MCH-27.7 MCHC-31.4 RDW-16.4* Plt Ct-455* [**2173-3-26**] 01:05PM BLOOD WBC-16.0* RBC-2.70*# Hgb-6.8*# Hct-22.2*# MCV-82# MCH-25.0*# MCHC-30.4*# RDW-15.5 Plt Ct-595*# [**2173-3-26**] 01:05PM BLOOD PT-36.1* PTT-31.7 INR(PT)-3.8* [**2173-4-2**] 06:15AM BLOOD PT-16.0* PTT-27.5 INR(PT)-1.4* [**2173-3-26**] 01:05PM BLOOD Glucose-94 UreaN-32* Creat-1.3* Na-136 K-4.8 Cl-104 HCO3-21* AnGap-16 [**2173-4-2**] 06:15AM BLOOD Glucose-94 UreaN-18 Creat-0.9 Na-137 K-4.6 Cl-103 HCO3-24 AnGap-15 [**2173-3-26**] 01:05PM BLOOD ALT-49* AST-121* LD(LDH)-355* AlkPhos-363* TotBili-1.6* [**2173-4-1**] 06:20AM BLOOD ALT-52* AST-100* LD(LDH)-267* AlkPhos-286* TotBili-9.9* [**2173-4-2**] 06:15AM BLOOD ALT-53* AST-108* LD(LDH)-299* AlkPhos-271* TotBili-8.9* [**2173-3-30**] 06:30AM BLOOD GGT-367* [**2173-3-29**] 06:20AM BLOOD Lipase-30 [**2173-4-2**] 06:15AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.1 [**2173-3-29**] 06:20AM BLOOD Albumin-3.0* Calcium-8.7 Phos-3.3 Mg-1.9 [**2173-3-30**] 06:30AM BLOOD Hapto-159 [**2173-3-27**] 06:14AM BLOOD TSH-2.8 [**2173-3-30**] 06:30AM BLOOD HBsAg-NEGATIVE [**2173-3-26**] 01:05PM BLOOD HBsAb-POSITIVE HAV Ab-NEGATIVE [**2173-3-30**] 10:26AM BLOOD AMA-NEGATIVE . ABDOMEN U.S. (COMPLETE STUDY) Study Date of [**2173-3-27**] 8:07 AM IMPRESSION: 1. Echogenic and coarsened liver are consistent with chronic liver disease. 2. Thrombosis of the left portal vein; main and right portal veins as well as splenic vein are patent. 3. Small ascites. . CHEST (PORTABLE AP) Study Date of [**2173-3-26**] 4:39 PM IMPRESSION: No acute cardiopulmonary process identified. . CT ABD [**2173-3-31**] : 1. Large complex mass centered at the gastroesophageal junction with erosion into the gastric lumen. 2. Innumerable hepatic metastases. 3. Two 7-mm pulmonary nodules in the left lung are indeterminate. One or both may represent a small focus of infection, a benign nodule, or metastatic disease. 4. Severe coronary artery calcifications. . EGD on [**3-31**]: Mass in the gastroesophageal junction Normal mucosa in the stomach The duodenum was not entered due to the findings at the GE junction. Biopsies were not taken due to elevated INR. Otherwise normal EGD to pylorus. . EUS [**4-1**]: Mass in the gastroesophageal junction and cardia - this was biopised. EUS of the mass could not be performed due to constriction of esophageal lumen by tumor. EUS imaged of middle and upper third of the esophagus were normal. Brief Hospital Course: 56 yo male with PMHx of ETOH abuse, Afib on coumadin p/w anemia, RVR, hypotension with h/o melena. New mass seen at GE junction & e/o metastatic disease on CT scan. Biopsy results pending. . # GE junction mass/Anemia: Pt presented with hct drop and EGD performed on [**3-31**] revealed a large polyploid mass at the GE junction that was actively bleeding. Pt had a CT performed that revealed a large complex mass centered at the gastroesophageal junction with erosion into the gastric lumen and innumerable hepatic metastases. Patient, family and PCP were explained the results of these tests and biopsy was pending at time of discharge. Pt was eager to return home to family with plan for outpatient follow up with GI Onc. Hct has been essentially stable s/p transfusion with pRBCs but had trended down slightly with multiple transfusions of FFP. Pt had developped antibodies and blood bank was having difficulty finding an appropriate match for transfusion. Hct was 26.8 on day of discharge and pt agreed to have follow up labs drawn and followed up by his PCP [**Last Name (NamePattern4) **] [**4-7**]. . # Afib: Pt presented in A.Fib with RVR in setting of acute anemia. Pt was initially rate controlled with IV lopressor and admitted to the MICU where he remained hemodynamically stable on po BB. Pt was transferred to the floor and maintained good rate control with Metoprolol. Coumadin was held on admission due to GI bleed and supratherapeutic INR. Pt received Vitamin K for 5 days & a total of 7u FFP to correct his INR for EUS & biopsy. Pt was explained the risk of bleeding on Coumadin given his poor synthetic function and the ongoing bleeding seen in the esophageal mass. Pt was instructed to stop taking Coumadin and discuss this with his PCP in follow up. . # Cholestatic jaundice: Pt was noted to have a significant cholestasis with only mild transaminitis. CT abdomen revealed innumerable mets in the diffusely enlarged liver. The overwhelming burden of metastases is likely causing cholestasis & impaired synthetic function in setting of underlying ETOH cirrhosis. Pt was started on Ursodiol 300mg [**Hospital1 **] to help with pruritis and biopsy was taken of esophageal mass. Biopsy results were pending at time of discharge and pt was scheduled to follow up with GI onc as outpt. . # Chronic CHF: Pt has a significant CAD history s/p NSTEMI and ETOH abuse likely contributing to cardiomyopathy & EF 30%. Pt maintained his sats well on RA without any evidence of volume overload on exam. Pt was continued on Metoprolol and Lisinopril 5mg daily. Pt was instructed to continue taking Lasix prn as he was doing prior to admission. . # Leukocytosis: Pt was noted to have low grade fevers and significant leukocytosis on admission. ROS was negative and all blood/urine Cx were NGTD, CXR showed no evidence of infiltrate. CT scan showed large esophageal mass and it was thought likely that the leukocystosis was due his primary malignancy. . # ETOH abuse: Pt was a heavy drinker and now reports significantly less intake, currently drinking [**12-23**] glasses of wine or beer per day. Pt reports that last drink was 3 days PTA. Pt was monitored on CIWA for five days without any ativan requirements. Pt was given folate, thiamine, MIV daily and was counseled on the importance of complete cessation of alcohol intake. Social work was consulted. . # Hypothyroidism: TSH was in normal range and pt was continue home regimen of Levothyroxine 25mcg daily. Medications on Admission: - Lisinopril 10 mg - Levothyroxin 25 mcg - Coumadin 5 mg - Furosemide 40 mg - Metoprolol Succinate 50 mg - Folic acid 1 - Aspirin 81 mg - Magnesium 400 Discharge Medications: 1. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. 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* 8. Ativan 1 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety for 14 days. Disp:*14 Tablet(s)* Refills:*0* 9. Outpatient Lab Work Please draw a CBC and send results to Dr. [**First Name8 (NamePattern2) 4134**] [**Last Name (NamePattern1) 1022**] office #[**Telephone/Fax (1) 8506**] Discharge Disposition: Home Discharge Diagnosis: Primary: Gastrointestinal bleed Esophageal/Gastric Mass . Secondary: Coronary Artery Disease s/p MI Cirrhosis Discharge Condition: Good Discharge Instructions: You were admitted with low blood counts and found to have a bleeding mass between your esophagus & your stomach. A biopsy was taken and the results are pending. It is very important that you keep all of the scheduled follow up appointments below. . We have decreased your lisinopril to 5mg daily and you should not be taking any Coumadin anymore. We have started Ursodiol 300mg twice daily and Ativan 1mg up to twice daily as needed for anxiety. We have stopped the Aspirin & Lasix, but these may need to be restarted as an outpatient. Please discuss these with Dr. [**First Name (STitle) 1022**] in follow up. . You need to go into Dr.[**Name (NI) 2989**] office on Monday to have labs drawn to monitor your blood counts. Dr. [**First Name (STitle) 1022**] will let you know if you need additional transfusions. . If you develop any new chest pain, shortness of breath or any other general worsening of condition, please call your PCP or come directly to the emergency room. Followup Instructions: You have a follow up appointment with Dr. [**First Name8 (NamePattern2) 4134**] [**Last Name (NamePattern1) 1022**] on Wednesday [**4-7**] at 2:15pm. . You have a follow up appointment with Dr. [**Last Name (STitle) **] in GI Oncology on [**4-14**] at 10am. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

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icd9cm

[ [ [] ] ]

[ "45.13", "45.16" ]

icd9pcs

[ [ [] ] ]

9048, 9054

4359, 7840

279, 289

9208, 9215

1847, 4336

10245, 10627

1496, 1533

8043, 9025

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231, 241

317, 1154

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1268, 1480

79,585

179,104

41222

Discharge summary

report

Admission Date: [**2108-3-29**] Discharge Date: [**2108-4-8**] Date of Birth: [**2032-5-22**] Sex: M Service: MEDICINE Allergies: Penicillins / Azithromycin / furosemide Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Acute kidney injury Major Surgical or Invasive Procedure: balloon valvuloplasty History of Present Illness: 75 YOM with h/o severe AS ([**Location (un) 109**] 0.8), sCHF (EF of 20-25% on [**2108-2-14**]) and regular patient of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] presenting to [**Hospital1 18**] ED after routine labs showed [**Last Name (un) **]. He was last hospitalized here at [**Hospital1 18**] in [**1-/2107**] for NSTEMI, found to have 3VD and underwent CABG. Intraoperative assesment of his aorta revealed extensive calcification and he was felt to be extremely hig risk for open AVR. His AS has been managed medically since. 2 weeks ago he was admitted to OSH with SOB and found to be in CHF exacerbation. He was diuresed and on discharge his torsemide was increased to 40mg QD 2 weeks ago. He was seen yesterday in Dr.[**Name (NI) 12389**] office, where they agreed to pursue TAVI and a follow up appointment with Dr. [**Last Name (STitle) **] was planned. He underwent routine Lab check at that time which showed [**Last Name (un) **]. (Cr 7 base line 1.9) with hyperkalemia. He was telephoned this afternoon and sent to the ED. He is reportedly asyptomatic but had tenuous BP's (SBP in the 80's). Prior to [**2107-10-27**] it looks like his sBP's have been running in the 100's but since the new year he has been living in the 90's. Given his low EF, critical AS and dehydration he is being admitted to the CCU for fluid resuscitation and close monitoring. . Of note he had shingles during last hospitalization and was put on valcyclovir; he still c/o some residual intermittent pain on his L flank and back. Currently denies CP, SOB, abdom pain, F/C, D/C, N/V. Does report [**Month (only) **]'d PO intake recently; has been taking all his Rx as directed. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: - CABG: [**2107-2-4**] and underwent an off-pump coronary bypass grafting x1 with the left internal mammary artery to left anterior descending artery. - PERCUTANEOUS CORONARY INTERVENTIONS: NONE - PACING/ICD: NONE 3. OTHER PAST MEDICAL HISTORY: AS- [**Location (un) 109**] 0.8cm2 and EF 10% in [**1-/2107**] CAD- NSTEMI in [**1-/2107**] with 3VD chronic systolic heart failure CRI (baseline Cr 1.9) right foot w diabetic ulcer PVD Depression Past Surgical History Left CEA Right fem-[**Doctor Last Name **] bypass [**2-/2106**] Prostatectomy Partial colectomy for adenoma [**2104**] Social History: Race: Caucasian Lives with: wife Occupation: retired, sales Tobacco: 60 pack yrs, quit 1 year ago ETOH: denies Family History: Family History: Father, CHF, d. age 54 pneumonia Mother DM, d. age [**Age over 90 **] myocardial infarction Brother CA unknown Brother Bladder ca No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: T=98.1 BP=93/36 HR= 58 RR=17 O2 sat=100%RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP flat/not visualized. CARDIAC: RR, normal S1, S2. 4/6 systolic murmur loudest at RUS border heard throughout precordium. 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: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. SKIN: middle of L stomach, flank, and back in dermatomal distribution, are several scattered papules c/w healing vesicles/scabs NEURO: AAOx3, CNII-XII intact PULSES: DP and PT pulses b/l difficult to assess DISCHARGE EXAM: 98.1, 103/59, 90, 18, 99% RA, Weight 72.8kg GENERAL: NAD. Comfortable, appropriate and in NAD CARDIAC: RRR, S1, S2 but heart sounds faint. 1/6 systolic murmur loudest at RUS border. No thrills, lifts. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. SKIN: middle of L stomach, flank, and back in dermatomal distribution, are several scattered erythematous patches with healing scabs. rash is TTP. No other rashes noted. NEURO: AAOx3, PULSES: 1+ DP/PT, no pedal edema Pertinent Results: ADMISSION LABS: [**2108-3-29**] 12:00PM BLOOD WBC-8.2 RBC-3.59* Hgb-11.1* Hct-35.3* MCV-98 MCH-31.0 MCHC-31.5 RDW-14.3 Plt Ct-310 [**2108-3-29**] 12:00PM BLOOD PT-10.9 PTT-27.8 INR(PT)-1.0 [**2108-3-29**] 12:00PM BLOOD Glucose-113* UreaN-113* Creat-7.3*# Na-134 K-6.6* Cl-100 HCO3-15* AnGap-26* [**2108-3-29**] 12:00PM BLOOD Calcium-8.9 Phos-5.7*# Mg-2.6 [**2108-3-29**] 07:23PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008 [**2108-3-29**] 07:23PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG [**2108-3-29**] 07:23PM URINE RBC-1 WBC-7* Bacteri-NONE Yeast-NONE Epi-<1 [**2108-3-29**] 07:23PM URINE CastHy-25* [**2108-3-29**] 07:23PM URINE Hours-RANDOM UreaN-468 Creat-119 Na-65 K-23 Cl-57 . DISCHARGE LABS: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2108-4-8**] 06:00 7.8 2.83* 9.0* 28.4* 100* 31.8 31.7 14.5 268 DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas [**2108-4-5**] 00:14 83.1* 10.5* 5.9 0.3 0.2 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2108-4-8**] 06:00 123*1 27* 1.4* 139 4.6 107 21* 16 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2108-4-7**] 06:00 33 67* 386* 2501 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2108-4-8**] 06:00 7.9* 1.7* 2.5 . MICROBIOLOGY: -[**2108-3-29**] 7:59 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. C. difficile DNA amplification assay (Final [**2108-3-30**]): Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). -[**2108-4-5**] 7:42 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. C. difficile DNA amplification assay (Final [**2108-4-6**]): Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). FECAL CULTURE (Final [**2108-4-6**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2108-4-7**]): NO CAMPYLOBACTER FOUND. VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED. . IMAGING: -[**3-30**] Renal US: FINDINGS: The right kidney measures 10.7 cm and the left kidney measures 9.9 cm. No hydronephrosis or mass is seen in either kidney. No obstructing stone is present. Several echogenic foci in the renal sinus fat bilaterally may represent vascular calcifications. The bladder is moderately well distended and appears normal. IMPRESSION: Unremarkable renal ultrasound. No hydronephrosis. -[**2108-4-2**] Cardiac Catheterization: COMMENTS: 1. Selective coronary angiography of this right dominant system showed three vessel coronary artery disease. The LMCA had 30% stenosis. The LAD was patent with evidence of competative flow indicating a patent LIMA. The Lcx had a 90% origin stenosis. The RCA was occluded. 2. Resting hemodynamics showed normal RVEDP of 5 mmHg and mild LVEDP of 17 mmHg. There was mild PAHTN with PASP of 34/12 mmHG. There was severe AS with calculated [**Location (un) 109**] of 0.59 cm2. There was normal cardiac index of 2.5 L/min/m2. 3. Successful closure of left femoral arteritomy (has right fem-[**Doctor Last Name **] bypass) with 8F angioseal. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease including unrevascularized ostial Lcx disease. 2. Patent LIMA 3. Severe AS 4. Successful aortic valvuloplasty with two inflations of 22mm Tyshak II balloon. 5. Successful LFA angioseal. 6. If recurrent symptoms, CoreValve 7. Consider Lcx PCI [**2108-4-2**]: ECHO: Left ventricular wall thicknesses and cavity size are normal. There is moderate to severe global left ventricular hypokinesis with more pronounced hypokinesis of the inferolateral wall (LVEF = 25 %). No masses or thrombi are seen in the left ventricle. The aortic valve leaflets are moderately thickened. There is critical aortic valve stenosis (valve area <0.8cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with regional and global systolic dysfunction. Critical aortic valve stenosis. Mild mitral regurgitation. [**2108-4-3**] ECHO: There is severe regional left ventricular systolic dysfunction with akinesis of the basal inferior and inferolateral segments. There is moderate hypokinesis of the remaining segments (LVEF = 25-30%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is no pericardial effusion. IMPRESSION: Severe calcific aortic stenosis. Mild aortic regurgitation. Severe regional and global left ventricular systolic dysfunction, most c/w with multivessel CAD. Compared with the prior study (images reviewed) of [**2108-4-2**], measured transvalvular gradient is slightly lower, but overall - the findings are quite similar. Brief Hospital Course: BRIEF CLINICAL SUMMARY: 75 YOM with h/o severe AS ([**Location (un) 109**] 0.8), sCHF (EF of 20-25% on [**2108-2-14**]) and regular patient of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] admitted for [**Last Name (un) **] likely from over-diuresis and pre-renal azotemia. The patient underwent an aortic valvuloplasty. [**Last Name (un) **] improved throughout hospital course. . ACTIVE ISSUES: . # [**Last Name (un) **]: Cr on presentation 7.3 w/ a BUN of 113. Pre-renal etiology likely from recently increased Torsemide dose. FeUrea showed pre-renal etiology. Creatinine improved after IVF re-hydration. Pt remained euvolemic on exam. We held eplerenone, lisinopril and carvedilol to promote renal perfusion. His home torsemide was changed to 20mg qod dosing. Cr on discharge was 1.4, which was near the patient's baseline. He will get lytes checked on [**4-11**] and follow up with PCP [**Last Name (NamePattern4) **] [**4-12**]. . # Aortic Stenosis: [**Location (un) 109**] 0.8. Critical aortic stenosis, not amenable to aortic valve replacement. Patient evaluated by Dr. [**Last Name (STitle) **] who feels he is high risk for Cor Valve. He was planned to receive a balloon valvuloplasty, and received a valvuloplasty without complication on [**2108-4-2**]. He will be reevaluated in 6 months; if valvuloplasty fails then may proceed to Cor Valve . # CAD: Known 3VD S/P CABG. Chronic, stable without e/o ischemia at present. We cont [**Date Range **], atorvastatin 80mg qd, metoprolol succinate 12.5mg qd. His ACE was held in the setting of [**Last Name (un) **], as it was thought to be a contributor to his [**Last Name (un) **]. . # CHF: now euvolemic. Chronic, systolic CHF without acute exacerbation during this admission, LVEF 20-25%. Hypovolumic on admission with ARF improving after IVF hydration. The patient was continued on beta [**Last Name (LF) 7005**], [**First Name3 (LF) **], atorvastatin and torsemide 20mg qod. The patient also has an intermittent LBBB which does not seem to be rate related. This will likely transform to a permanent LBBB over the course of time. . # Shingles: had recent outbreak several wks prior to admission; he had healing skin lesions upon admission, but some residual pain (pt said he did not currently need pain Rx). We d/c'd his valcyclovir given that the treatment course if for 7 days. We continued Tramadol and Morphine PRN for pain. . #. Hyperkalemia: likely from holding diuretics. Off Torsemide in the course of the hospitalization, his potassium rose, but no concerning EKG changes. On the day of discharge the patient's K was 4.6. He will be restarting torsemide 20mg QOD on discharge so this will likely come down. He will be getting lytes checked on [**4-11**] and follow up with PCP [**Last Name (NamePattern4) **] [**4-12**]. . # HTN: some relative, asymptomatic hypotension, systolic mid-80s throughout hospitalization course. We gave periodic IVF infusions and held beta blockade intermittently. ACE-inhibitor held and beta [**Month/Year (2) 7005**] changed to metoprolol succinate on discharge. CHRONIC ISSUES: . # HLD: stable. continued statin. . # DM: stable; ISS in house. discharged on home metformin. . TRANSITIONS OF CARE 1. He will be reevaluated in 6 months; if valvuloplasty fails then may proceed to Cor Valve 2. Patient has intermittent LBBB, will likely become permanent; does not appear to be rate related 3. restarted torsemide at 20mg QOD on discharge to prevent volume overload when pt goes home - please follow up lytes on [**4-11**] and volume status and adjust torsemide as needed. 4. Discharge weight: 72.8kg; pt was euvolemic to slightly volume depleted on discharge. Medications on Admission: HOME MEDICATIONS: ATORVASTATIN [LIPITOR] - 80 mg [**Month/Year (2) 8426**] - 1 [**Month/Year (2) 8426**](s) by mouth once a day CARVEDILOL - 3.125 mg [**Month/Year (2) 8426**] - 1 [**Month/Year (2) 8426**](s) by mouth twice a day EPLERENONE - 25 mg [**Month/Year (2) 8426**] - 1 [**Month/Year (2) 8426**](s) by mouth daily LISINOPRIL - 5 mg [**Month/Year (2) 8426**] - 1 (One) [**Month/Year (2) 8426**](s) by mouth once a day METFORMIN - (Prescribed by Other Provider) - Dosage uncertain TORSEMIDE - (Prescribed by Other Provider) - 20 mg [**Month/Year (2) 8426**] - 1 (One) [**Month/Year (2) 8426**](s) by mouth twice daily TRAMADOL - (Prescribed by Other Provider) - Dosage uncertain VALACYCLOVIR - (Prescribed by Other Provider) - Dosage uncertain Medications - OTC ASPIRIN [ADULT LOW DOSE ASPIRIN] - (OTC) - 81 mg [**Month/Year (2) 8426**], Delayed Release (E.C.) - one [**Month/Year (2) 8426**](s) by mouth once a day Discharge Medications: 1. Outpatient Lab Work Please check Chem-7 on Wednesday [**2108-4-11**] with results to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 62**] phone or [**Telephone/Fax (1) 89795**].9 ICD-9 2. atorvastatin 80 mg [**Telephone/Fax (1) 8426**] Sig: One (1) [**Telephone/Fax (1) 8426**] PO DAILY (Daily). 3. aspirin 81 mg [**Telephone/Fax (1) 8426**], Chewable Sig: One (1) [**Telephone/Fax (1) 8426**], Chewable PO DAILY (Daily). 4. metoprolol succinate 25 mg [**Telephone/Fax (1) 8426**] Extended Release 24 hr Sig: 0.5 [**Telephone/Fax (1) 8426**] Extended Release 24 hr PO DAILY (Daily). Disp:*30 [**Telephone/Fax (1) 8426**] Extended Release 24 hr(s)* Refills:*2* 5. metformin 1,000 mg [**Telephone/Fax (1) 8426**] Sig: One (1) [**Telephone/Fax (1) 8426**] PO once a day. 6. torsemide 20 mg [**Telephone/Fax (1) 8426**] Sig: One (1) [**Telephone/Fax (1) 8426**] PO every other day. 7. Zofran 4 mg [**Telephone/Fax (1) 8426**] Sig: One (1) [**Telephone/Fax (1) 8426**] PO every 4-6 hours as needed for nausea for 1 weeks. Disp:*8 [**Telephone/Fax (1) 8426**](s)* Refills:*0* Discharge Disposition: Home With Service Facility: Steward Home care and Hospice Discharge Diagnosis: Primary Diagnosis: Acute Kidney Injury Ischemic colitis Secondary Diagnoses: Severe aortic stenosis Coronary artery disease Systolic congestive heart failure Shingles (resolving) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 28660**], It was a privilege to provide care for you here at the [**Hospital1 **] Hospital. You were admitted because you had blood tests which showed that you had some kidney damage. This was likely due to dehydration, due to decreased appetite and the torsemide water pills. You were treated with intravenous fluids and were monitored closely, and your kidney function has improved. You were also evaluated by Dr. [**Last Name (STitle) **], and you received a balloon valvuloplasty. Dr. [**Last Name (STitle) **] would like to re-evaluate you in 6 months and if you need another procedure he can discuss your options with you at that time. Your condition has improved and you can be discharged to home. During your stay, you had some loose stools with blood and were evaluated by Gastroenterology. This was felt to be related to "ischemic colitis," or bowel irritation in the setting of low blood pressures, which is resolving now. Your heart medications were changed during this admission but please note that management of your heart failure is an ongoing process, and doses will change based on food and fluid intake. Please weigh yourself every morning and call Dr. [**Last Name (STitle) **] if weight goes up more than 3 lbs in 3 days or 5 lbs in 2 days. (Your weight on discharge is 72.5kg, or 159.5lbs). Please keep your follow-up appointments as scheduled below. The following changes were made to your medications: -STOP Carvedilol -STOP Lisinopril -STOP Eplerenone -STOP VALACYCLOVIR (treatment of your zoster is complete) -START Toprol XL (for heart protection and heart rate control, instead of Carvedilol) -ADJUSTED torsemide: new dose is 20mg every other day Followup Instructions: PRIMARY CARE Name:[**Doctor Last Name **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],MD Specialty: Primary Care Location: ALL CARE MEDICAL Address: [**Location (un) 89384**], [**Hospital1 **],[**Numeric Identifier 40170**] Phone: [**Telephone/Fax (1) 55136**] When: Thursday, [**4-12**] at 2:15pm GASTROENTEROLOGY With: Dr. [**Last Name (STitle) 41033**] Time/Date: [**4-18**] (Wednesday) at 1:45pm Phone: [**Telephone/Fax (1) 89796**] CARDIOLOGY Department: CARDIAC SERVICES When: MONDAY [**2108-5-7**] at 8:40 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "557.0", "276.52", "401.9", "276.7", "V45.81", "428.0", "414.01", "272.4", "250.00", "584.9", "412", "053.9", "424.1", "428.22" ]

icd9cm

[ [ [] ] ]

[ "37.23", "88.56", "35.96" ]

icd9pcs

[ [ [] ] ]

15694, 15754

9915, 10323

327, 351

15978, 15978

4606, 4606

17861, 18629

2923, 3140

14588, 15671

15775, 15775

13635, 13635

7900, 9892

16129, 17838

5387, 7883

3155, 3165

15853, 15957

2179, 2393

13653, 14565

4010, 4587

3187, 3994

268, 289

10338, 13014

379, 2075

4622, 5371

15794, 15832

15993, 16105

2424, 2763

13030, 13609

2097, 2159

2779, 2891

27,436

112,243

31373

Discharge summary

report

Admission Date: [**2143-3-28**] Discharge Date: [**2143-4-11**] Date of Birth: [**2067-1-25**] Sex: M Service: CARDIOTHORACIC Allergies: Captopril Attending:[**First Name3 (LF) 165**] Chief Complaint: increasing fatigue Major Surgical or Invasive Procedure: [**2143-3-28**] MVRepair(28 CE Band)/AVR(21 mm CE pericardial)/CABG x3(Lima>lad,svg>pda,svg>om) [**2143-4-10**] right hemicolectomy, cholecystectomy, aortagram, SMA bypass graft from right common iliac artery, small bowel resection History of Present Illness: Patient was a 76 male complaining of increasing fatigue who had an echo showing worsening mitral reguritation. Cath showed subtotal occlusion of the LAD, mod-severe MR, EF 30-35%. Past Medical History: HTN, hyperlipidemia CAD with BMS x2 of RCA [**2137**]/instent restenosis [**7-25**] arthritis, anemia Social History: quit smoking 25 years ago, occasional alcohol, retired, lives with wife. Family History: Mother deceased from MI in late 80s. Physical Exam: (at exam [**3-13**]):HR 70 RR 15 157/49 NAD flat after cath skin unremarkable teeth in very poor repair neck supple with full ROM CTAB anteriorly RRR no murmur abd soft, NT, ND +BS extrems warm, well-perfused, no edema or varicosities noted neuro grossly intact no carotid bruits appreciated Pertinent Results: [**2143-4-11**] 03:03AM BLOOD WBC-7.3 RBC-3.07* Hgb-9.2* Hct-26.3* MCV-86 MCH-30.1 MCHC-35.1* RDW-15.4 Plt Ct-78* [**2143-4-10**] 03:57PM BLOOD Neuts-75* Bands-1 Lymphs-18 Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-2* Promyel-1* NRBC-2* [**2143-4-10**] 03:57PM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Ovalocy-1+ Schisto-OCCASIONAL Burr-1+ [**2143-4-11**] 03:03AM BLOOD PT-28.7* PTT-86.1* INR(PT)-2.9* [**2143-4-11**] 03:03AM BLOOD Plt Smr-VERY LOW Plt Ct-78* [**2143-4-11**] 03:03AM BLOOD Glucose-200* UreaN-55* Creat-2.2* Na-159* K-6.4* Cl-99 HCO3-19* AnGap-47* [**2143-4-11**] 03:03AM BLOOD ALT-586* AST-4466* LD(LDH)-4932* AlkPhos-177* Amylase-28 TotBili-2.7* [**2143-4-11**] 03:03AM BLOOD Lipase-36 [**2143-4-11**] 03:03AM BLOOD Albumin-1.6* Calcium-10.5* Phos-12.8* Mg-3.6* [**2143-4-11**] 05:15AM BLOOD Type-ART pO2-68* pCO2-35 pH-7.18* calTCO2-14* Base XS--14 [**2143-4-11**] 05:15AM BLOOD Glucose-234* Lactate-26.4* K-6.6* [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 73938**] (Complete) Done [**2143-4-10**] at 3:06:05 PM PRELIMINARY Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2067-1-25**] Age (years): 76 M Hgt (in): 63 BP (mm Hg): / Wgt (lb): 135 HR (bpm): BSA (m2): 1.64 m2 Indication: Intraop sternal debridement, ex lap ICD-9 Codes: 440.0, 396.9 Test Information Date/Time: [**2143-4-10**] at 15:06 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW1-: Machine: aw2 Echocardiographic Measurements Results Measurements Normal Range Mitral Valve - Mean Gradient: 3 mm Hg Findings LEFT ATRIUM: Mild LA enlargement. No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Mild symmetric LVH. Mildly depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Simple atheroma in ascending aorta. Normal aortic arch diameter. Complex (>4mm) atheroma in the aortic arch. Normal descending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR well seated, normal leaflet/disc motion and transvalvular gradients. No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mitral valve annuloplasty ring. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient appears to be in sinus rhythm. Conclusions Pre Bypass: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is mildly depressed (LVEF=40%). Septal motion is paradoxical, c/w post CABG. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. A mitral valve annuloplasty ring is present. Trivial mitral regurgitation is seen. There is no pericardial effusion. I certify that I was present for this procedure in compliance with HCFA regulations. Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting physician Brief Hospital Course: Mr [**Known lastname 1169**] was admitted on [**3-28**] after he underwent a mitral valve repair, CABG x 3, and aortic valve replacement. For details of the operation please see the operative report. Extubated on POD #1. Postoperatively he was on milrinone, levophed and epinephrine to maintain his cardiac output and blood pressure. He received multiple blood transfusions as well.Amiodarone started for A fib. Pressors/support weaned and then restarted for decreasing C.I. Chest tubes removed. C diff. positive with continuing diarhhea on POD #6 and flagyl started. Beta blockade titrated. Echo showed global hypokinesis. Sub Q heparin started for prophylaxis and mutiple BP agents added for hypertension. Gentle diuresis restarted on POD #7, pacing wires removed, and transferred to the floor to begin increasing his activity level. on POD #11, his WBC rose to 18 and he was pancultured. He c/o LLQ pain on POD #12. Cipro started for UTI. Left pleural effusion tapped on POD #12. At 6:30 AM on POD #13, he acutely decompensated with acute respiratory failure on the floor. He had agonal breathing, was bradycardic and had palpable pulses and was intubated by anesthesia emergently during the code. Transferred back to CVICU for stat TTE and left chest tube placed. Tamponade ruled out by echo. Sternum found to be unstable on exam (no CPR had been performed).Bronchoscopy done to rule out aspiration. Lactate rose to 11 and general surgery was urgently consulted.Creatinine rose to 2.2 and INR was 2.9. New subclavian accesss established.He was taken directly to the OR and Dr. [**First Name (STitle) **] debrided his sternum and re-wired it. The general surgery team then did an exploratory laparotomy to evaluate for acute mesenteric ischemia. He had a right hemicolectomy, cholecystectomy, aortagram with right common iliac artery to SMA bypass graft ( vascular team), and then a small bowel resection by Dr. [**First Name (STitle) **]. He was profoundly acidotic. He was aggressively resuscitated the rest of the night with multiple pressor support to maintain a BP. The family was consulted about his extremely grave prognosis and they agreed to continue the drips but no CPR or additional drug resuscitation. Made CMO by family with increasing pressor requirements and acidosis. Expired at 8:00 AM on [**4-11**]. Family declined autopsy. Medical Examiner elected to review the case. Medications on Admission: coreg 6.25 mg daily zetia 10 mg daily ASA 325 mg daily plavix 75 mg daily lovastatin 80 mg daily lasix 40 mg daily cozaar 50 mg [**Hospital1 **] Discharge Disposition: Extended Care Facility: TBA Discharge Diagnosis: CAd with BMS to RCA x2, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] [**7-25**] and instent restenosis HTN hyperlipidemia anemia arthritis Discharge Condition: Expired Discharge Instructions: patient expired Followup Instructions: expired [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2143-4-11**]

[ "427.31", "998.32", "997.1", "272.4", "998.11", "424.0", "997.4", "424.1", "511.9", "518.5", "008.45", "414.01", "V66.7", "599.0", "428.22", "V64.41", "401.9", "428.0", "V45.82", "557.0" ]

icd9cm

[ [ [] ] ]

[ "89.60", "33.22", "99.05", "45.73", "34.91", "96.04", "34.79", "45.62", "99.07", "38.93", "36.12", "39.26", "99.04", "88.42", "96.05", "96.71", "36.15", "51.22", "35.33", "39.61", "35.21", "77.61" ]

icd9pcs

[ [ [] ] ]

8349, 8379

5757, 8154

294, 528

8574, 8584

1335, 5734

8648, 8778

969, 1007

8400, 8553

8180, 8326

8608, 8625

1022, 1316

236, 256

556, 738

760, 863

879, 953

5,562

193,797

15719

Discharge summary

report

Admission Date: [**2109-9-24**] Discharge Date: [**2109-9-27**] Date of Birth: [**2058-3-5**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7934**] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: n/a History of Present Illness: 51M with metastatic NSC lung CA p/w dyspnea. Wife noted that pt has had dyspnea at home with walking around for the past week. No chest pain, no fevers, chills, does have a chronic cough. Today he went to clinic at PCPs office and was significantly SOB with walking. He was noted to be tachycardic to 150s and satting in low 90s was sent to ED. In the ED, T98.4 p 130 bp 90/60 satting 80%, was put on NRB. He was given 3L NS. WBC found to be 58, up from 30 2 wks ago and 18 the month prior. CXR showed R sided infiltrate vs RML collapse. pt was given levo/flagyl. HR was improved to 100, bp to 113/55. Patient was admitted to [**Hospital Unit Name 153**] for observation. Continued on antibiotics. Past Medical History: Past Medical History: COPD never on inhalers . Onc Hx: Dx in [**2106**]. s/p seventeen cycles of Navelbine chemotherapy between [**2107-6-17**] and [**2108-11-2**]. Developed progressive disease and brain mets His CEA was also rising. Seizure: episode of speech arrest on [**2107-11-24**] neuro-onc called it a seizure. 6 cycles of Taxotere chemotherapy. His treatments for brain metastases is summarized: (1) whole brain cranial irradiation from [**2107-1-17**] to [**2107-1-31**] to 3,000 cGy, (2) s/p X-knife stereotactic radiosurgery to a left frontal metastasis to 2,000 cGy on [**2108-1-25**], (3) s/p Cyberknife radiosurgery to right temporal metastasis to 1,800 cGy on [**2108-10-25**], and (4) s/p Cyberknife radiosurgery to 3 right brain metastases and a left frontal brain metastasis on [**2109-4-19**] to 1,800 cGy each. Tarceva from [**8-13**] to [**2109-9-3**] andstates that it made him feel much worse. His CEA which was 80 on [**7-16**] had risen to 145 on [**2109-8-13**]. Social History: Social History: Smoked sice age 16, no alcochol, drugs. now lives with wife. Family History: Family History: no CA in mom or dad. Physical Exam: Physical Exam: VS: Temp: BP: HR: RR: O2sat: L NC GEN: mild resp distress, alert, interactive, appropriate RESP: R sided bronchial breath sounds, otherwise fairly clear. CV: RR, S1 and S2 wnl, SEM ABD: soft, mild distension, nt EXT: no c/c/e Pertinent Results: [**2109-9-24**] 01:20PM PT-19.1* PTT-22.8 INR(PT)-1.8* [**2109-9-24**] 12:54PM LACTATE-4.2* [**2109-9-24**] 12:25PM K+-4.8 [**2109-9-24**] 11:45AM GLUCOSE-127* UREA N-26* CREAT-1.1 SODIUM-136 POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-19* ANION GAP-22* [**2109-9-24**] 11:45AM ALT(SGPT)-101* AST(SGOT)-56* ALK PHOS-744* AMYLASE-40 TOT BILI-0.8 [**2109-9-24**] 11:45AM CALCIUM-7.6* PHOSPHATE-2.2* MAGNESIUM-2.8* [**2109-9-24**] 11:45AM WBC-58.2*# RBC-4.27* HGB-13.2* HCT-39.3* MCV-92 MCH-30.9 MCHC-33.5 RDW-16.9* [**2109-9-24**] 11:45AM NEUTS-38* BANDS-40* LYMPHS-1* MONOS-3 EOS-17* BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [**2109-9-24**] 11:45AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL [**2109-9-24**] 11:45AM PLT SMR-LOW PLT COUNT-92* CXR [**9-24**]:IMPRESSION: More extensive parenchymal infiltrate in right mid lung field exceeding the previously described hilar prominence and densities related to patient's lung cancer shown by CT. The now present parenchymal infiltrates may represent the clinically suspected infection and followup chest examinations after treatment is recommended CXR [**9-25**]: FINDINGS: Compared with the study of [**9-24**], there has been further interval consolidation of the right mid lung infiltrate. LENIs:FINDINGS: Bilateral [**Doctor Last Name 352**]-scale and color Doppler son[**Name (NI) 1417**] of the lower extremities including the common femoral, superficial femoral, and popliteal veins were performed. Normal flow, augmentation and waveforms were demonstrated. Mid portion of the left superficial femoral was poorly compressible, but intraluminal thrombus was not identified. IMPRESSION: No acute DVT. Brief Hospital Course: 51M with metastatic NSC lung CA with mets to brain admitted with dyspnea. The patient was admitted for significant respiratory distress which worsened precipitously throughout the first 24-48 hours of his admission. He was on a nonrebreather mask breathing at 40-50 bpm, despite being treated with antibiotics for potential pulmonary infection. . He was DNR/DNI on admission, and his health care proxy (wife) transitioned his goals of care to comfort measures only in the afternoon of [**9-26**]. The patient was placed on a morphine drip and maintained on a NRB throughout the night. He desaturated over the course of 12 hours and passed away at 0514 on [**9-27**]. The family has declined autopsy. Medications on Admission: Medications: Keppra 1750 mg [**Hospital1 **] Vitamins; Dexamethasone 3.0 mg QD Fluconazole 100' Zonegran 100 [**Hospital1 **] tessalon perles ambien 10 qHS Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Cardiopulmonary arrest, made CMO for bilateral metastatic non small cell lung cancer. Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: Deceased

[ "197.7", "198.3", "780.39", "486", "162.8", "785.0", "198.5", "496", "E933.1", "355.8", "E849.8" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5210, 5219

4273, 4975

335, 340

5349, 5360

2525, 4250

5417, 5429

2216, 2238

5181, 5187

5240, 5328

5001, 5158

5384, 5394

2268, 2506

275, 297

369, 1075

1119, 2090

2122, 2184

27,199

113,196

33556

Discharge summary

report

Admission Date: [**2178-2-22**] Discharge Date: [**2178-3-4**] Date of Birth: [**2127-4-26**] Sex: M Service: SURGERY Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 148**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Cystgastrostomy History of Present Illness: the patient is a 50 year old male presented to [**Hospital3 3765**] with acute onset of left sided abdominal pain. He reports that he had 3 "attacks" of sharp pain on Friday night [**2-20**] which subsided and on Saturday morning had an attack which did not resolve. There was no nausea or vomiting associated with the pain. The pain is constant and radiates to his back and at times to his left shoulder. He reports that it is similar to previous attacks, although the pain in the past was more right sided. He reports that he first had gallstone pancreatitis in [**7-2**] and his gallbladder was removed. In [**2177-10-25**], he had another attack of pancreatitis which he was hospitalized for. A CT was done at this time, which showed a pancreatic pseudocyst. He had similar pain in [**2177-12-26**] which resolved and did not require hospitalization. On admission to [**Hospital1 **] on [**2-21**], his amylase was 288 and lipase was 324, WBC was 11.9, Hct 39.3. Repeat labs done at [**Hospital1 **] on [**2-22**] showed an amylase of 174 and lipase of 136, WBC 9.0 and Hct 36.4. Denies any chest pain, shortness of breath, fevers or chills. Last bowel movement was yesterday, no melena or BRBPR. No emesis and some mild nausea associated with dilaudid. Past Medical History: HTN Recurrent pancreatitis Social History: Denies tobacco use or current EtOH use, past hx of social EtOH use on business trips, which he stopped [**7-2**]. Family History: Non-contributory Physical Exam: (On presentation) Vitals: T 98.9 HR 83 BP 135/91 RR 18 94%RA NAD, A+O x 3 PERRLA, EOMI, Anicteric RRR, no m/r/g, No JVD CTA B, no r/r/c ABD +BS, soft, voluntary guarding, mild tenderness to palpation RLQ and LUQ EXT warm, well perfused, dp palp Pertinent Results: [**2178-2-24**] INTRAOP U/S: High-resolution linear array scans over the pancreas region were obtained demonstrating a large complex cystic collection measuring at least 5-6 cm in diameter and containing two components which are joined by a wide 5-mm neck. There was extensive echogenic material within the fluid including some floating debris. After surveying several sites, the best most proximate approach to the pseudocyst was through the stomach with the cyst approximately 3-5 mm deep to the stomach wall. After opening the anterior wall further, repeat ultrasound through the posterior wall of the stomach was performed, again to identify the closest site and this was confirmed by placement of a needle under direct ultrasound guidance into the cyst. Following visual confirmation of needle placement into the cyst, the ultrasound scan was ended and surgical cyst-gastrostomy was undertaken. . [**2178-2-23**] CTA ABD: IMPRESSION: 1. Necrotizing/hemorrhagic pancreatitis with pseudocyst formation. The extent of surrounding inflammatory change and size of the pseudocysts have increased since [**2178-2-22**]. There is no evidence for pdeudoaneurysm. The splenic vein is thrombosed. 2. Wall thickening involving the stomach, first/second portion of the duodenum and splenic flexure likely related to adjacent inflammatory change. 3. Rounded hypodense lesion within the interpolar region of the right kidney most consistent with cyst. 4. Multiple sub-cm hypodense lesions within the liver, incompletely characterized. . [**2178-2-22**] 08:58PM HCT-36.7* [**2178-2-22**] 02:29PM GLUCOSE-154* UREA N-9 CREAT-0.8 SODIUM-138 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-28 ANION GAP-11 [**2178-2-22**] 02:29PM estGFR-Using this [**2178-2-22**] 02:29PM ALT(SGPT)-13 AST(SGOT)-13 ALK PHOS-64 AMYLASE-153* TOT BILI-1.3 [**2178-2-22**] 02:29PM LIPASE-106* [**2178-2-22**] 02:29PM ALBUMIN-3.7 CALCIUM-8.4 PHOSPHATE-2.6* MAGNESIUM-1.8 IRON-17* [**2178-2-22**] 02:29PM calTIBC-298 FERRITIN-242 TRF-229 [**2178-2-22**] 02:29PM TRIGLYCER-77 [**2178-2-22**] 02:29PM WBC-10.0 RBC-4.23* HGB-12.6* HCT-36.6* MCV-86 MCH-29.9 MCHC-34.6 RDW-13.0 [**2178-2-22**] 02:29PM PLT COUNT-294 [**2178-2-22**] 02:29PM PT-14.6* PTT-25.4 INR(PT)-1.3* Brief Hospital Course: [**2178-2-22**] Patient evaluated in the [**Hospital1 18**] Emergency Department on transfer from [**Hospital3 **] with primary complaint of abdominal pain as detailed above. Patient was admitted to the SICU for monitoring, serial HCT's, made NPO, and given IV hydration and pain control. No acute events overnight. . [**2178-2-23**] Patient transferred from SICU to floor following stable exams and HCT's. CTA Abdomen performed to rule out bleeding into pseudocyst with results as detailed above. Pain control adequate with PCA. . [**2178-2-24**] Patient underwent open cystgastrostomy with Dr. [**Last Name (STitle) **] with intraop ultrasound as detailed above. There were no complications during the procedure. The patient was extubated in the OR and transferred to the PACU and ultimately [**Hospital Ward Name 121**] 9 for recovery. No acute events overnight. . [**2178-2-25**] POD1 Patient sat up in bed for 6 hours. Pain well controlled. NGT in place with PCA for pain control. No acute events. . [**2178-2-26**] POD2 Patient with difficulty with pain control, PCA dosing increased. Urine output stable. Patient OOB to chair. Remains NPO with NGT per plan. No acute events. . [**2178-2-27**] POD3 Patient OOB to hallway without assistance. Pain well controlled. NGT in place and good urine output overnight. No acute events. . [**2178-2-28**] POD4 PCA discontinued. Patient with good pain control with PO medication. NGT removed. Patient given sips and tolerating it well. Ambulating in halls without assistance. No acute events. . [**2178-3-1**] POD5 Patient given clear liquid diet and tolerating it well. Given Dulcolax PR x 1 for constipation with good result. All blood cultures from admission with NGTD. No acute events. . [**2178-3-2**] POD6 Patient given a regular diet. Excellent PO pain control. . [**2178-3-4**] POD7 At the time of discharge patient was afebrile with all vital signs within normal limits, tolerating a regular diet, with good pain control with PO medication, and ambulating without assistance. He was ruled out for C.diff after having some loose stool. He was discharged to home to follow up with Dr. [**Last Name (STitle) **] in 2 weeks. Medications on Admission: Amlodopine 5mg qd Quinapril 40mg qd Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed: Do not consume alcohol, drive, or operate machinery while taking this. Disp:*30 Tablet(s)* Refills:*0* 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for 1 months: Take this stool softener as long as you are taking narcotics. Disp:*60 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Pancreatic Pseudocyst Discharge Condition: Good 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 vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your 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. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to increase activity daily * No heavy lifting (>[**9-9**] lbs) for 6 weeks. * Continue with drain care and flushing of the left sided drain. * Monitor your incision for sign of infection (redness or increased drainage). * Keep incision clean and dry. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in 3 weeks. Please call [**Telephone/Fax (1) 1231**] to schedule an appointment.

[ "577.2", "577.1", "577.0", "572.3", "401.9" ]

icd9cm

[ [ [] ] ]

[ "52.4" ]

icd9pcs

[ [ [] ] ]

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101,921

35796

Discharge summary

report

Admission Date: [**2132-1-14**] Discharge Date: [**2132-1-28**] Date of Birth: [**2074-6-22**] Sex: F Service: SURGERY Allergies: Cyclobenzaprine / Codeine / Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 148**] Chief Complaint: Acute pancreatitis Major Surgical or Invasive Procedure: None History of Present Illness: Per OSh report (as patient is intubated and sedated on arrival to [**Hospital1 18**]) 57F with recurrent episodes of abdominal pain, nausea, and vomitting ove the at least the past several months. Would only last < 12 hours at each time with epigastric pain, radiating to the back. No prior evidence of gallstones on abdominal ultrasounds. She presented witha similar episode to [**Hospital6 **] on [**2132-1-5**] but with very severe pain and an episode of diarrhea. She had been afebrile, tender in epigastric area, with admission labs of lipase > 3500, amylase >1100, AST 428 AP 153 ALT 327 TB 1.5 Lactate 4.0 Cr 1.0 WBC 22.6, BE 9.1. CT at the time just showed acute pancreatitis, and was given a presumptive diagnosis of gallstone pancreatitis based on history and labs. Transferred to the ICu that day and subsequently intubated for worsening respiratory distress. The patient then spiked a fever, had positive blood cultures, and started on antibiotics. At some pont she was on pressors which have since been dicontinued. For nutrition got TPN for a few days, then enteral feeding, which is now stopped to due to vomitting yesterday. Had ERCP with sphinctertomy done before transfer; all biliary ducts filled normally as well as duodenum. WBC decreased and then began to [**First Name8 (NamePattern2) **] [**Last Name (un) 7162**], 35.6 on transfer. Pab [**Last Name (un) **] Klebsiella from FNA pancrease [**1-10**]. Urine Cx [**Female First Name (un) 564**], Blood culture [**1-4**] & 16 Klebsiella. OSH CT scans demonstrate no signs of gas aroudn the pancreas, just extensive edema and nonenhancement with some necrosis. Past Medical History: DM2, htn, hypothyroid, obesity Social History: married, banker, no smoking or etoh Physical Exam: intubated, sedated sclera nonicteric, no jaundice decreased bs, coarse, mild rhonchi b/l RRR obese, soft, nondistended +1 pedal edema Pertinent Results: 7.44 pCO2 37 pO2 69 HCO3 26 BaseXS 0 138 104 16 174 4.3 26 0.7 Ca: 7.7 Mg: 2.2 P: 3.5 ALT: 21 AP: 120 Tbili: 0.5 Alb: 2.0 AST: 29 LDH: 355 Dbili: TProt: [**Doctor First Name **]: 26 Lip: 63 wbc 28.7 8.1 494 hct24.7 N:82 . [**2132-1-23**] 06:45AM BLOOD WBC-19.7* RBC-2.85* Hgb-8.8* Hct-26.0* MCV-91 MCH-30.9 MCHC-33.8 RDW-14.6 Plt Ct-557* [**2132-1-23**] 06:45AM BLOOD Glucose-59* UreaN-18 Creat-0.6 Na-136 K-3.9 Cl-101 HCO3-27 AnGap-12 [**2132-1-14**] 10:45PM BLOOD ALT-21 AST-29 LD(LDH)-355* AlkPhos-120* Amylase-26 TotBili-0.5 [**2132-1-21**] 01:46AM BLOOD ALT-65* AST-73* LD(LDH)-254* AlkPhos-105 Amylase-48 TotBili-0.3 [**2132-1-14**] 10:45PM BLOOD Lipase-63* [**2132-1-23**] 06:45AM BLOOD Lipase-113* [**2132-1-23**] 06:45AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.5 [**2132-1-15**] 05:17PM BLOOD Lactate-0.9 . [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT GENERAL COMMENTS: The patient appears to be in sinus rhythm. Left pleural effusion. Conclusions The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. IMPRESSION: Preserved [**Hospital1 **]-ventricular systolic function. No evidence of vegitation on the aortic or mitral valves. . Radiology Report CT CHEST W/CONTRAST Study Date of [**2132-1-15**] 12:33 AM IMPRESSION: 1. Necrotizing pancreatitis involving greater than two-thirds of the pancreas. CT severity index is [**9-1**] . 2. Large acute fluid collection extending superiorly around the gastric fundus. 3. Splenic vein thrombosis, with development of collateral flow through a prominent left gastroepiploic vein. 4. No pseudoaneurysm identified. 6. Multifocal ground glass and airspace consolidations consistent with multifocal pneumonia. 7. Prominent right mammary lymph node. Correlation with mammography or history of breast cancer is recommended. This finding was entered into the radiology critical results reporting system on [**2132-1-16**]. 8. Fatty infiltration of the liver. . Radiology Report CT PELVIS W/CONTRAST Study Date of [**2132-1-25**] 12:48 PM IMPRESSION: 1. Progressively enlarging pancreatic collections and peripancreatic fluid in the setting of extensive pancreatic necrosis. 2. Gas within the gallbladder lumen, wich would be expected following instrumentation (ie. ERCP) though no documentation is on the OMR at time of dication. Differential would also include cholecystitis due to gas-forming organism. 3. Improved right pleural effusion and resolved abdominal ascites. Brief Hospital Course: 57 obese female with severe necrotizing pancreatitis, developing pseudocyst, intubated for almost 10 days with respiratory failure. No signs of gas on CT scan, pseudoaneursym or erosion into blood vessels. We will keep the patient intubated and sedated, likely bronch/BAL, introduce nutrition via enteral feeds after reassessment, continue antibiotics for positive blood cultures, urine culture, and presumptive pneumonias. Culture data: -OSH Urine Cx: [**Female First Name (un) 564**] -[**1-4**] & [**1-7**] OSH BCx: Klebsiella -[**1-10**] OSH FNA pancreas: Klebsiella -[**1-13**] BCx [**2-27**] GPCs in clusters--coag neg staph -[**1-14**] Sputum no orgs, no growth -[**1-15**] BCx pending . ID: Continue meropenem at 500mg q6h iv for likely polymicrobial process (at least 2 weeks given bacteremia at OSH, day 1 here [**1-14**], day 1 OSH [**1-6**]) -Continue fluconazole at 200mg q24h iv (prophylactic dose) [**1-22**]: afebrile, on floor doing well. -2 weeks total [**Last Name (un) 2830**] & fluco: END DATE [**2132-1-28**] . IMAGING: [**1-13**] CXR: Bilateral lower lobe atelectasis and small bilateral pleural effusions [**1-14**] CT torso: necrotizing pancreatitis with fluid collection and possible erosion into stomach. b/l pleural effusions and basilar atelectasis [**1-14**] TEE: wnl [**1-15**] CXR: improved b/l atelctasis [**1-16**] CXR: b/l pleural effusions, B atelectasis [**1-18**] CXR: mildly improved pleural effusions [**1-25**] CT PELVIS: Progressively enlarging pancreatic collections and peripancreatic fluid in the setting of extensive pancreatic necrosis. . [**1-13**]: admitted to TSICU. CT torso done [**1-14**]: Pt went to IR for placement of post-pyloric feeding tube. TF's were started and advanced toward goal. Attempt at esophageal balloon placement was made and failed. ID consult was obtained. Surgery was deferred. [**1-15**]: A-line switched [**2-25**] (+) culture [**1-16**]: attempted to wean PEEP and PS but did not tolerate well. [**1-17**]: attempt at aggressive diuresis lasix drip + diamox, goal negative 2-3L (-1866 on [**1-17**]), aggressive pulmonary toilet, goal=extubate sun/mon. A-line pulled [**2-25**] not working. vent pressure settings weaned but ABG with hypoxia to PO2 71: inc FiO2, inc pressure settings [**1-18**]: attempted to wean PS but again unsuccessful (increased WOB and tachypnea), placed new Aline, cont Lasix Gtt [**1-20**] extubated diuresis, goal 2-3L neg: overshot -4.4 L [**1-20**], -700 [**1-21**] . GI / ABD: pancreatitis, medical management. stable, no abd pain. Her pain improved and she was nontender on palpation. NUTRITION: replete with fiber via post-pyloric feeding tube, restarted 4hrs s/p extubation. consider speech/swallow c/s prior to advancing diet today given long intubation. The NJ feeding tube was D/C'd on [**1-21**] and her PO diet was advanced. She was tolerating a low fat diet on [**1-22**]. RENAL: UOP and Cr stable. lasix gtt -4.4 L neg [**1-20**], met alkalosis: s/p 2 doses diamox [**1-20**], Hco3 31. She was transited from lasix drip to lasix bolus on [**1-21**]. HEMATOLOGY: stable anemia ENDOCRINE: Insulin gtt, NPH 20/20: transition to RISS [**1-21**]; synthroid changed to PO dose ID: meropenem, fluconazole; ID following; WBC trending down She was discharged in good condition, tolerating a PO diet, reporting no abdominal pain and blood sugars well controlled on [**Hospital1 **] NPH. She will need a follow-up CT scan and pseudocyst drainage and cholecystectomy at the end of the month. Medications on Admission: levoxyl 100, prozac 20, lisinopril 20, metformin 1000", asa Discharge Medications: 1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 3. Levothyroxine 75 mcg Tablet Sig: Two (2) 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:*2* 5. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty (30) Units Subcutaneous twice a day. Disp:*1800 Units* Refills:*2* 7. Insulin Regular Human 100 unit/mL Solution Sig: Sliding Scale Injection four times a day: See Sliding Scale. Disp:*qs * Refills:*2* 8. One Touch Ultra System Kit Kit Sig: One (1) Miscellaneous four times a day. Disp:*qs * Refills:*2* 9. One Touch UltraSoft Lancets Misc Sig: One (1) Miscellaneous four times a day. Disp:*150 * Refills:*2* 10. One Touch Test Strip Sig: One (1) In [**Last Name (un) 5153**] four times a day. Disp:*150 * Refills:*2* 11. Insulin Syringe [**1-25**] mL 29 x [**1-25**] Syringe Sig: One (1) Miscellaneous four times a day. Disp:*150 * Refills:*2* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Acute severe pancreatitis Discharge Condition: Good 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 vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your 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. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to ambulate several times per day. * No heavy ([**11-6**] lbs) until your follow up appointment. Followup Instructions: Dr. [**Last Name (STitle) **] on [**2-15**]. Pt needs to have a repeat abdominal CT with PO and IV contrast with Pancreas protocol for evaluation of pseudocyst. His office will call you with a time for the appointment. Call [**Telephone/Fax (1) 1231**] with questions or concerns. Completed by:[**2132-1-28**]

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icd9cm

[ [ [] ] ]

[ "96.6", "96.72" ]

icd9pcs

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8735, 9847

9966, 9994

8651, 8712

10046, 11475

2130, 2266

279, 300

373, 2006

2028, 2061

2077, 2115

72,886

189,614

7473

Discharge summary

report

Admission Date: [**2157-2-8**] Discharge Date: [**2157-2-14**] Date of Birth: [**2076-7-20**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Sulfa (Sulfonamide Antibiotics) / Percocet Attending:[**First Name3 (LF) 6743**] Chief Complaint: Endometrial mass Major Surgical or Invasive Procedure: hysteroscopy, submucosal myomectomy exploratory laparotomy supracervical hysterectomy, bilateral salpingo-oophorectomy small bowel resection, oversew of colon History of Present Illness: Ms. [**Known lastname 27356**] is an 80-year-old who was incidentally noted to have a 5cm irregular, vascular mass within the endometrial cavity on CT scan. She recently had a nephrectomy [**3-9**] renal cell carcinoma and the scan was done to evaluate for any residual or new disease. She denies vaginal bleeding and has no specific complaints. She had an endometrial biopsy which was negative. Past Medical History: OB/GYN: SVD x 5, postmenopausal, no h/o abn Paps PMH: HTN, arthritis, renal cell carcinoma PSH: pancreatectomy, nephrectomy, knee replacement surgery Social History: She does not smoke. She does not drink. She does not use recreational drugs. She lives with her son and reports feeling safe at home. Family History: noncontributory Physical Exam: Preop exam: NAD, appears stated age No cervical, supraclavicular, axillary, or inguinal adenopathy Lungs CTAB RRR Abdomen soft, NT, ND, surgical scars w/o evidence of herniation ext w/o edema/ tenderness Pelvic: Normal external genitalia. Inner labial folds normal. Urethral meatus normal. The wall of vagina are smooth. Cervix is normal. Bimanual exam reveals an enlarged but otherwise mobile and unremarkable uterus. There is no parametrial nodularity. There is no adnexal mass. Rectal exam reveals no mass, lesion, or irregularity. Postop exam: Vitals stable NAD, Alert/oriented x 3, gait steady RRR CTAB with exception of faint crackles at bases Abdomen soft, ND, NT, midline vertical incision c/d/i with staples Ext NE, NT Pertinent Results: [**2157-2-13**] 08:25AM BLOOD WBC-11.9* RBC-3.86* Hgb-11.4* Hct-33.6* MCV-87 MCH-29.5 MCHC-33.8 RDW-13.6 Plt Ct-256 [**2157-2-13**] 08:25AM BLOOD Neuts-73.7* Lymphs-14.9* Monos-6.2 Eos-4.8* Baso-0.4 [**2157-2-10**] 01:58AM BLOOD PT-12.6 PTT-27.0 INR(PT)-1.1 [**2157-2-13**] 08:25AM BLOOD Glucose-155* UreaN-9 Creat-0.9 Na-141 K-3.6 Cl-103 HCO3-29 AnGap-13 [**2157-2-10**] 01:58AM BLOOD ALT-24 AST-19 TotBili-0.6 [**2157-2-8**] 02:27PM BLOOD CK-MB-2 cTropnT-<0.01 [**2157-2-8**] 06:17PM BLOOD CK-MB-3 cTropnT-0.04* [**2157-2-8**] 09:25PM BLOOD CK-MB-4 cTropnT-0.05* [**2157-2-9**] 02:05AM BLOOD CK-MB-4 cTropnT-0.03* [**2157-2-8**] 12:21PM BLOOD Glucose-127* Lactate-2.0 Na-139 K-4.2 Cl-100 [**2157-2-8**] 04:12PM BLOOD Glucose-257* Lactate-8.1* Na-136 K-4.0 Cl-112 calHCO3-15* [**2157-2-10**] 05:06AM BLOOD Lactate-1.0 CXR [**2157-2-8**]: ET tube in standard placement, nasogastric tube passes into the stomach. No substantial subdiaphragmatic gas. Lung volumes are appreciably lower, exaggerating heart size and pulmonary vascular caliber. Mediastinal widening and vascular congestion suggest some cardiac decompensation and possibly mild edema surrounding the right hilus. There is no appreciable pleural effusion. Right jugular line ends in the upper SVC. Echo [**2157-2-9**]: The left atrium is dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal regional and global biventricular systolic function. Mild mitral regurgitation. CXR [**2157-2-10**]: NG tube tip is in the stomach. Cardiomediastinal silhouette is unchanged but there is interval development of bilateral perihilar opacities continuing toward the lower lungs, right more than left, finding consistent with interval development of at least moderate pulmonary edema accompanied by bilateral pleural effusions. Pathology: uterine polyp, uterine fibroids. tubes/ovaries/ uterus benign. Brief Hospital Course: Ms. [**Known lastname 27356**] [**Last Name (Titles) 1834**] emergent exploratory laparotomy secondary to hemoperitoneum after hysteroscopy complicated by uterine perforation into the uterine artery. During the procedure she had a supracervical hysterectomy, bilateral salpingo-oophorectomy, small bowel resection, oversew of colonic serosal tear, cystoscopy and proctoscopy. The case was complicated by brief intraop PEA arrest. Intraoperatively she was rescuscitated with 5 units PRBC's, 2units FFP, and 3L of crystaloid. She received 1 additional unit of PRBC's postoperatively. Following the case, the patient taken to the ICU where she initially remained intubated and sedated. She was extubated on POD 1 and weaned slowly to room air over the next several days. She did have pulmonary edema noted on CXR and thus was given 1 dose of IV lasix. She diuresed appropriately. She was hypotensive intraoperatively requiring a neo gtt for a brief period of time. Following fluid resuscitation this was weaned and turned off on postop day 0. She had a small troponin leak thought secondary to demand/ PEA arrest. She had an ECHO on POD 1 which demonstrated normal systolic function. Given small bowel resection, she had an NG tube placed intraoperatively and remained NPO. She was also was given 48 hours of vanc/cipro/ flagyl. The NG tube was discontinued on POD 2 and her diet was slowly advanced to regular. Ms. [**Known lastname 27356**] was discharged on POD # 6 in stable condition. She was ambulating without difficulty, voiding spontaneously, tolerating a regular diet, and had minimal pain. Medications on Admission: amlodipine, atenolol, ASA Discharge Medications: 1. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**7-13**] hours as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 2. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every six (6) hours as needed for pain. Discharge Disposition: Home Discharge Diagnosis: endometrial lesion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Do not drive while taking narcotics. No heavy lifting x 6 weeks Nothing in your vagina x 6 weeks You may shower and let water run over your incision however do not soak in a bath tub for 6 weeks. Call for: - increased pain not responsive to the medications prescribed - fevers, chills - redness, discharge, pain at incision - heavy vaginal bleeding - difficulty with urination - lower extremity swelling, pain - difficulty breathing, chest pain Followup Instructions: Please call Dr.[**Name (NI) 27357**] office to schedule an appointment to take your staples out at the end of this week or early next week. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 5777**] Date/Time:[**2157-3-3**] 11:10 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6753**] Completed by:[**2157-2-15**]

[ "427.5", "E878.8", "998.11", "E849.7", "E870.0", "998.2", "621.0", "218.2", "997.1", "568.0" ]

icd9cm

[ [ [] ] ]

[ "69.09", "68.39", "48.23", "57.32", "46.75", "54.19", "45.62", "65.61", "54.59", "99.60", "68.12" ]

icd9pcs

[ [ [] ] ]

6561, 6567

4501, 6116

332, 493

6630, 6630

2053, 4478

7252, 7692

1265, 1282

6193, 6538

6588, 6609

6142, 6170

6781, 7229

1297, 2034

276, 294

521, 921

6645, 6757

943, 1094

1110, 1249

9,963

133,903

12878

Discharge summary

report

Admission Date: [**2134-8-27**] Discharge Date: [**2134-9-4**] Date of Birth: [**2084-7-12**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6346**] Chief Complaint: Perianal fistulas with persistent drainage secondary to Crohn's disease Major Surgical or Invasive Procedure: Abdominal perineal resection History of Present Illness: The patient is a 50 year old man with Crohn's disease for 20 years last admitted [**2134-2-9**] for a diverting colostomy to treat severe perianal disease, who now presents for proctectomy to treat persistent drainage from his perianal fistulas. Past Medical History: Crohn's x20 yrs tx'd with Asulfadine/prednisone s/p perianal fistula Seton placement Social History: Lives alone No tobacco No EtOH No IVDA Family History: Father deceased prostate CA Mother deceased colorectal CA Physical Exam: Well-appearing man in no distress. Lungs clear bilaterally. Heart regular rate and rhythm. Abdomen soft, NTND, ostomy fuctioning well. Foley catheter in place with leg bag attached. Extremities warm and well-perfused, without edema. Some erythema under the scrotum, improving. Incision clean, dry and intact with packing in place posteriorly. JP drain in place with serosanguinous fluid. Pertinent Results: [**2134-8-27**] 09:00PM HCT-29.7* [**2134-8-27**] 03:37PM WBC-8.9 RBC-3.70* HGB-10.7* HCT-30.0* MCV-81* MCH-28.9# MCHC-35.7*# RDW-14.1 Brief Hospital Course: The patient was admitted to the Blue surgery service and underwent an abdominal perineal resection on [**2134-8-27**]. The patient remained intubated postoperatively and was transferred to the TSICU. He was extubated on post op day 2 and ventilated well on O2 via nasal cannula. The patient was transferred out of the ICU on post op day 3 and pain was controlled with a PCA. On post op day 4, the patient tolerated clear liquids and was given medications by mouth. On post op day 5, the patient's perineal drain began producing increased amounts of serosanguinous fluid. An CT abdomen/pelvis was obtained revealing a small ureteral leak, which should heal without intervention. The balloon of the Foley catheter was inflated another 10cc to facilitate tamponade of the leak. The other two JP drains were removed on post op day 7. Preliminary pathology results from the colon specimen demonstrated adenocarcinoma, however, the final report is pending. On post op day 8, the patient was ambulating, tolerating a regular diet, and felt comfortable taking care of his ostomy and Foley leg bag. He was deemed ready for discharge home on [**2134-9-4**]. Medications on Admission: None Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4-6H PRN as needed for pain. Disp:*90 Tablet(s)* Refills:*1* 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: Take as long as taking pain medication to avoid constipation. Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Crohn's disease, perianal fistulas, pathology of colon pending Discharge Condition: Ambulating, tolerating regular diet and medications by mouth, Foley catheter and JP drain in place, ostomy functioning well. Discharge Instructions: You may shower, no bath or swimming. Please call your doctor if you experience redness, warmth or tenderness at wound sites, fever >101.5 degrees, or severe pain. No heavy lifting ([**10-23**] pounds) for 6 weeks. Followup Instructions: Please follow up with Dr. [**First Name (STitle) 2819**] next Thursday, [**9-9**] at 4:00pm. His office number is [**Telephone/Fax (1) 2998**]. Completed by:[**2134-9-4**]

[ "997.5", "E878.6", "565.1", "154.0", "196.2", "998.11", "555.9" ]

icd9cm

[ [ [] ] ]

[ "99.04", "99.07", "48.5" ]

icd9pcs

[ [ [] ] ]

3018, 3024

1518, 2667

385, 416

3130, 3257

1354, 1495

3519, 3693

872, 931

2722, 2995

3045, 3109

2693, 2699

3281, 3496

946, 1335

274, 347

444, 691

713, 799

815, 856

80,442

112,809

54720+59627

Discharge summary

report+addendum

Admission Date: [**2120-7-29**] Discharge Date: [**2120-8-1**] Date of Birth: [**2064-7-18**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 11344**] Chief Complaint: Status Epilepticus Major Surgical or Invasive Procedure: Endotracheal Intubation with successful extubation History of Present Illness: Mr. [**Known lastname 37559**] is a 56-year-old right-handed man with history of seizure disorder, hypertension and depression who was transferred from an outside hospital, intubated for multiple seizures. At 5 a.m. yesterday, on [**7-28**], the patient woke up and felt that he might have a seizure soon because he had the urge to defecate, which often coincides with seizures. Because he felt that he was going to have a seizure, the patient took an extra 500 mg of Depakote. Usually, he takes 500 mg 3 times per day, but that morning, he took 1000 mg and he went back to sleep. At 7:30 in the morning, he woke up again. He was not feeling well. He felt confused and somewhat disoriented. He felt the urge to defecate again and went to the bathroom. His wife said that he was grabbing at the toilet paper, but seemed "out of it." At that time, his wife gave him another 500 mg of Depakote. So, by 7:30 in the morning, he had taken 1500 mg of Depakote. At 8:15, Mr. [**Known lastname 37559**] had a seizure, which lasted about 20 seconds. His wife states that his upper and lower extremities were both rigid without any shaking. He did not bite his tongue or have urinary incontinence. After the seizure ended, he was confused for about 1-2 minutes. His wife also notes that prior to the seizure, he made a yelping sound, which is typical before a seizure for him. The patient then returned to his baseline. At about 9 o'clock, he had another seizure. Again, his upper and lower extremities were rigid without any jerks. The second seizure lasted about 30 seconds and he was confused for 5 minutes. Again, no tongue biting, no urinary incontinence. He then slept for about 4 hours. At 1 in the afternoon, he woke up and had another seizure, same as the prior two. This one lasted about 1-1/2 minutes. He did bite his tongue and had urinary incontinence. His wife called 911. By the time, EMS arrived, the seizure had terminated on irs own. He was confused for the next 30 minutes or so. In the ambulance, the patient had a generalized tonic-clonic seizure. At that time, he was given 5 mg of IV valium. When he arrived at [**Hospital 8125**] Hospital ED, he was agitated and combative, so he was given another 5 mg of IV valium. Per outside hospital documentation, this patient is reported to often be combative and agitated when he is post ictal. They attempted to obtain a non-contrast head CT. However, he was too agitated for it. He was given another 5 mg of IV valium but continued to be combative. At that time, he was intubated for airway protection and given another 10 mg of IV valium. He was also given 4 mg of IV Ativan, 1000 mg of fosphenytoin, 2 g of ceftriaxone and then was maintained on propofol for sedation. His valproic acid level at [**Hospital 8125**] Hospital was 97. He was transferred to [**Hospital1 **] for further evaluation. In the ambulance ride on the way over, they ran out of propofol, so he was given 4 mg of midazolam. In the ED here, he was minimally responsive even off propofol, so no attempt was made at extubation, and he was admitted to the neurologic ICU. In the ED, he had a T-max of 101.6, which came down with Tylenol. Overnight, there was concern for an infectious process. He had an LP which showed 4 white cells and 3 RBCs. Prior to results of CSF coming back, he was empirically started on meningitis dosing of ceftriaxone 2 g, vancomycin and acyclovir for HSV. He had a chest x-ray, which did not show pneumonia and he had a UA which was negative for UTI. This morning, propofol was turned off for about 10-15 minutes and the patient woke up. He was quite agitated; however, he was alert, awake and following commands. The patient's wife [**Name (NI) **] was present today to provide more history. She said that Mr. [**Known lastname 37559**] has had cold and has been feeling unwell for the last week or so and on Saturday had subjective fevers and chills. He has not had a productive cough and has not complained of dysuria or frequency of urination. She said that at baseline, he drinks about [**1-12**] margaritas daily but has not consumed any alcohol for the last several days in the setting of feeling unwell. In terms of his seizure history, he had his first seizure at around age 16 or 18. He has only been treated with Depakote and has not been tried on any other anti epileptics. His seizures are quite well controlled and in the last 10 years, he has only had 3 seizures. His last seizure was 1 year ago and was in the setting of anti-epileptic drug noncompliance. Since then, he has been taking his medications regularly. He does not ever have myoclonic jerks and awakening or light sensitivity. Past Medical History: Seizure disorder, Hypertension, Depression Social History: Worked as contractor in construction, but has not been working very much recently. Tobacco, has smoked about one pack per week for many years since he was a teenager. Alcohol, drinks 2-3 margaritas daily. Illicits: Smokes marijuana daily. Family History: Has 5 siblings. None of them have seizure. Parents did not have seizures. No family history of migraines, stroke or MI. Physical Exam: ADMISSION EXAM: Vitals: T: 100.3 P: 95 R: 12 BP: 127/89 SaO2: 100% on 40% oxygen General: intubated, right after off propofol, patient can track the voice, nod his head, but unable to follow up commands. HEENT: ETT in place Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, 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: patient can track the voice, nod his head, but unable to follow up commands. -Cranial Nerves: I: Olfaction not tested. II: PERRL 1.5 to 1mm and brisk. III, IV, VI: unable to test V: unable to test VII: unable to assess with ETT in place VIII: unable to assess IX, X: per nursing report, gag intact [**Doctor First Name 81**]:unable to asess XII: unable to assess with ETT in place -Motor: Normal bulk, tone throughout. Spontaneous movement of bilateral upper extremities and lower extremities. -Sensory: withdraws somewhat to pain -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 1 1 1 1 0 R 1 1 1 1 0 Plantar response was mute bilaterally. -Coordination: unable to assess -Gait: Deferred DISCHARGE EXAM: *************** General: Awake, cooperative, NAD. HEENT: NC/AT Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: CTABL Cardiac: RRR, no murmurs Abdomen: soft, nontender, nondistended Extremities: no edema, pulses palpated Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, fluent language with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. The pt. had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 1 1 2 1 R 2 1 1 2 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Per PT/OT - Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. Pertinent Results: Labs on Admission: [**2120-7-31**] 05:00AM BLOOD WBC-7.8 RBC-4.09* Hgb-12.8* Hct-38.0* MCV-93 MCH-31.4 MCHC-33.8 RDW-13.0 Plt Ct-189 [**2120-7-31**] 05:00AM BLOOD Plt Ct-189 [**2120-7-31**] 05:00AM BLOOD Glucose-95 UreaN-7 Creat-0.9 Na-139 K-3.8 Cl-101 HCO3-30 AnGap-12 [**2120-7-29**] 09:35AM BLOOD CK(CPK)-9452* [**2120-7-31**] 05:00AM BLOOD CK(CPK)-7728* [**2120-7-29**] 05:00AM BLOOD CK-MB-11* MB Indx-0.3 cTropnT-0.03* [**2120-7-29**] 09:35AM BLOOD cTropnT-0.02* [**2120-7-30**] 02:03AM BLOOD Albumin-3.9 Calcium-8.2* Phos-2.4* Mg-1.9 [**2120-7-29**] 09:35AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.9 [**2120-7-31**] 05:00AM BLOOD Valproa-51 [**2120-7-30**] 02:03AM BLOOD Phenyto-5.0* Valproa-78 [**2120-7-29**] 06:27AM BLOOD Lactate-2.6* [**2120-7-28**] 09:13PM BLOOD Glucose-96 Lactate-3.7* Na-133 K-6.0* Cl-98 calHCO3-22 Imaging/Studies: CT head w/o contrast [**7-29**] FINDINGS: There is no evidence of infarction, hemorrhage, discrete masses, mass effect or shift of normally midline structures. The ventricles and sulci are normal in size and configuration. Bilateral mastoid air cells are clear. There are mucosal secretions within the sphenoid sinus as well the nasal cavity, likely representing intubation. There is mucosal thickening involving bilateral maxillary sinuses. The globes are intact. IMPRESSION: 1. No evidence of hemorrhage or infarction. 2. Mucosal thickening involving the sphenoid and maxillary sinuses as well as secretions within the nasal cavity likely representing intubation. EEG Read (ICU) - This telemetry captured no pushbutton activations. The initial diffuse beta activity and background suppression indicate moderate to severe encephalopathy which was possibly due to medication effect, e.g. propofol, or benzodiazepine. During the later half of the recording, the waking background was improved to [**5-16**] Hz indicating mild encephalopathy. There were no electrographic seizures or epileptiform discharges. Brief Hospital Course: Mr. [**Known lastname 37559**] is a 56-year-old right handed man with history of seizure disorder, hypertension and depression who was transferred from an outside hospital, intubated and sedated after having multiple seizures. # Neuro: Patient had 4 seizures the day of admission--3 tonic seizures at home and 1 GTCs on ambulance ride to the hospital. At OSH, he was loaded with dilantin prior to transfer. Per patient's wife, he had an upper respiratory tract infection for the last week with subjective fevers and chills. Infectious work up was negative for pneumonia, urinary tract infection, meningitis (see below). He has been compliant with his medications. Of note, the patient usually drinks 2-3 margaritas daily but has not consumed any alcohol for the last several days. Most likely his seizure was triggered by infection versus alcohol withdrawal. So, we did not feel there as a need to obtain further brain imaging with an MRI at this time or to adjust his home anti-epileptics. He was on long term EEG monitoring and did not have any epileptiform activity. Dilantin was tapered off slowly and he was continued on his home dose of Depakote 500mg Delayed Release PO BID. # Cardiac: Was monitored on telemetry and did not have any abnormal rhythms. Continued home metoprolol and lisinopril. Due to BP increases to 180s, Hydralazine IV was administered with good effect. Of note the BP increases were in the setting of likely alcohol withdrawl given his history of [**12-11**] hard liquor drinks per day for a considerable period. CIWA protocol was initiated and his lisinopril was increased to 30mg qDay with good effect 140-150mmHg SBP for the remainder of his hospitalization. # ID: Patient had a temperature to 101.6 in the ED. He was emperically started on Vancomycin/Ceftriaxone/Acyclovir in meningitis dosing. Chest x-ray with no pneumonia. UA with no UTI. CSF without elevated WBC or RBCs. No source of infection. Leukocytosis most likely in the setting of seizure and and trended down to normal. Discontinued all antibiotics. # Pulmonary: Was intubated prior to transfer. Extubated without difficulty. # RENAL: Cr was 1.3 on admission and CK peaked at ~9000. In setting of mild rhabdo after seizure. CK trended down with hydration. # PSYCH: Social work was consulted on Mr. [**Known lastname 37559**] for the concern for alcohol withdrawl during his time out of the ICU which was approximately 2-3 days after his last drink where he was noted to be diaphoretic, had increased blood pressure, and some tremor. He was placed on CIWA protocol which improved his symptoms considerably with blood pressures decreased to 140 from 180s. Social work noted there was no bed available for inpatient alcohol rehab which prompted us to offer the patient the option of taking a short course of ativan home for prophylaxis against withdrawl symptoms. The patient agreed to not drink over the course of the four days between discharge and presentation to the inpatient rehabilitation. TRANSITIONS OF CARE: -Code status: Full code Medications on Admission: - Depakote Delayed Release 500 mg [**Hospital1 **] - Metoprolol-XL 100 mg daily - Citalopram 40 mg daily - Lisinopril 20 mg daily Discharge Medications: 1. Divalproex (DELayed Release) 500 mg PO BID first now 2. Metoprolol Succinate XL 100 mg PO DAILY Hold sbp <100, hr <60 3. Azithromycin 250 mg PO Q24H Please take 2 pills the first day, then 1 pill each day for the following 4 days. RX *azithromycin 250 mg [**12-11**] tablet(s) by mouth daily Disp #*6 Tablet Refills:*0 4. Guaifenesin [**4-18**] mL PO Q6H:PRN sore throat / cough RX *guaifenesin 100 mg/5 mL [**12-11**] tablespoons by mouth every six (6) hours Disp #*1 Bottle Refills:*0 5. Citalopram 40 mg PO DAILY 6. Lorazepam 1 mg PO Q4H:PRN sweating, palpations Duration: 4 Days RX *lorazepam 1 mg 1 tablet(s) by mouth every four (4) hours for the first day, then at most every 6 hours for day 2, then at most every 8 hours for days [**2-11**] Disp #*24 Tablet Refills:*0 7. Lisinopril 30 mg PO DAILY hold sbp <100 RX *lisinopril 30 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Status Epilepticus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the ICU of [**Hospital1 1170**] for seizures which lasted an abnormal length of time, known as status epilepticus. On admission, you were intubated for protection of your airway; with improvement of your condition, we were able to extubate you safely. You were further monitored in our ICU then general floor with continuous EEG which did not show any seizures or epileptiform discharges. Please continue your Depakote Delayed Release twice a day as prescribed. You have also been prescribed medications to treat your sinus infection. Please complete your course of antibiotic treatment and follow up with your PCP next week. You were also provided information for alcohol cessation services and a course of medication to help bridge your care from here to rehabilitation services. Please take this medication as necessary for the next four days. It is IMPERATIVE that you do not drink alcohol while on this medication. Followup Instructions: Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 41415**] on Tuesday [**2120-8-6**] at 2:45pm You will also see Drs. [**Last Name (STitle) 851**] and [**Name5 (PTitle) 86863**] on the fourth floor of the [**Hospital Ward Name 860**] Building ([**Hospital Ward Name **]) at 9 a.m. on [**2120-8-13**]. If you have any problems in the meantime, please call them at [**Telephone/Fax (1) 857**]. Completed by:[**2120-8-1**] Name: [**Known lastname 18376**],[**Known firstname **] Unit No: [**Numeric Identifier 18377**] Admission Date: [**2120-7-29**] Discharge Date: [**2120-8-1**] Date of Birth: [**2064-7-18**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3824**] Addendum: Mr. [**Known lastname **] was seen by social work to offer rehabilitation services for his alcohol dependance issues which became more evident in light of his autonomic signs (diaphoresis, tremor) after 2-3 days of sobriety while inpatient which resolved with administration of benzodiazapines per CIWA protocol. The patient noted he was "fed up" with his alcohol use and endorsed his willingness to be managed inpatient at a rehab facility; however, per case management, no male bed was available at the projected time of discharge. After discussion, we determined providing a short course of benzodiazapine therapy over the course of the subsequent weekend prior to his presentation to rehabilitation in the coming week would be appropriate. The patient's visitor was asked to leave the room while guidelines were discussed with him regarding the use of Ativan as an outpatient, namely: - Alcohol cannot be used with this medication, whatsoever. - The medication should be only used if the patient felt any tremor, or experienced any diaphoresis. - If the symptoms experienced did not improve after taking this medication, immediate medical attention either in the ED, or with the patients PCP was necessary. The patient agreed to these guidelines. In order to maintain privacy, the guidelines and specific indications for taking Ativan were excluded from the discharge paperwork administered to the patient after verbal instructions were given by the house staff in detail alone with the patient. Of note, an appointment with the patients PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 18378**] on Tuesday [**2120-8-6**] at 2:45pm was scheduled prior to his discharge in which further evaluation for any withdrawl symptoms could be made. Social Work / Case Management also followed up with the patient regarding neurologic follow up, but were unable to arrange free transportation. As a result, the patient was either advised to obtain neurologic services within travel distance, or if accessable, to follow up with Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 18379**] on the fourth floor of the [**Hospital Ward Name 8742**] Building ([**Hospital Ward Name **]) at 9 a.m. on [**2120-8-13**]. Discharge Disposition: Home [**Name6 (MD) **] [**Last Name (NamePattern4) 3826**] MD [**MD Number(1) 3827**] Completed by:[**2120-8-2**]

[ "288.60", "305.1", "728.88", "345.70", "311", "303.90", "291.81", "473.9", "401.9" ]

icd9cm

[ [ [] ] ]

[ "89.19", "03.31", "96.71" ]

icd9pcs

[ [ [] ] ]

19517, 19661

11079, 14091

324, 377

15310, 15310

9098, 9103

16434, 19494

5459, 5583

14318, 15218

15268, 15289

14164, 14295

15461, 16411

7711, 9079

5598, 6170

6930, 7225

266, 286

405, 5117

9118, 11056

15325, 15437

14112, 14138

5139, 5184

5200, 5443

8,449

102,933

11330+11331

Discharge summary

report+report

Admission Date: [**2105-12-21**] Discharge Date: [**2106-1-15**] Date of Birth: [**2062-7-1**] Sex: F Service: TRAUMA SURGERY HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname **] is a 43 year-old female involved in a high speed rollover motor vehicle accident who was unrestrained. The patient was found unresponsive at the scene and was taken to an outside hospital where she was intubated, paralyzed and sedated. condition and was transferred to the [**Hospital1 **] Hospital for further management. Upon arrival here at the [**Hospital1 **] the patient was evaluated with multiple radiological studies, which in summary demonstrated a right frontal skull and sinus fracture, which was repaired on [**2105-12-25**]. The patient had a left distal humeral fracture along with a 1 cm punctate laceration on the lateral patient was also found to have a C2 to C7 fracture. The [**Hospital 228**] hospital course has been long and will only be detailed very briefly in summary. The patient was transferred to the Intensive Care Unit where she remained intubated for an extensive period of time. The patient developed several complications including C-difficile colitis, which was treated with Flagyl for a complete course of fourteen days. Repeat stool cultures were negative at the time of discharge. The patient also developed pressure ulcers on her chin and occiput due to her [**Location (un) 36323**] collar. These ulcers were treated initially just conservatively, but because they did not resolve the patient's collar eventually had to be custom made by the prosthetic company. The patient's ulcers were treated with Santyl ointment to the wounds. The patient's course was also complicated with thrombocytosis up to one million. The patient was started on aspirin for prophylaxis. The patient also had an IVC filter place during her hospital course, because of immobility. Because of the patient's inability to adequately wean off the vent, the patient was trached on the [**1-3**]. The patient also had a PEG tube placed at that time. Since that time the patient has been able to get off the vent without any difficulty and is tolerating trach mask. The patient now has a Passamuer valve which allows her to speak. The patient has been extensively followed by physical therapy and now is able to ambulate with assistance. Her other issue has been her glycemic control. This patient has a past medical history significant for very brittle diabetes and previous to her admission she was on an insulin pump. She was maintained for most of her hospital course on an insulin drip in the unit. Over the last week, the drip has been weaned to off and the patient has been started on Lantus insulin in increasing doses in order to provide a baseline glycemic control. The patient has been supplemented with sliding scale as needed. By the time of discharge the patient has been off her insulin regimen for almost 48 hours with adequate glycemic control. DISCHARGE MEDICATIONS: Aspirin 325 mg po q day, subQ heparin 5000 units b.i.d., Clonidine transdermal patch .2 mg q week, changed on Thursdays. Prevacid 30 mg once a day. Santal ointment to the chin also done once a day. Colace 100 mg b.i.d. Iron sulfate 325 mg once a day. Lantus insulin 50 units subQ q.h.s. Insulin sliding scale, which reads glucoses from 65 to 125 nothing, 125 to 175 2 units of regular insulin, 176 to 225 3 units of regular insulin, 226 to 275 5 units of insulin, 276 to 325 6 units of insulin, 326 to 375 7 units of insulin and greater then 376 8 units of insulin. The patient is also on vitamin C 500 mg twice a day and zinc 220 mg po once a day. FOLLOW UP: The patient is to follow up in trauma clinic in three to four weeks. DISCHARGE STATUS: Stable. DISCHARGE DIAGNOSES: 1. Hyperglycemia requiring insulin drip. 2. C-difficile colitis requiring treatment with antibiotics. 3. Thrombocytosis. 4. Deep venous thrombosis requiring placement of an IVC filter. 5. Right frontal skull and sinus fracture requiring operative repair. 6. Left open humeral fracture requiring open reduction and internal fixation. 7. C2 to C7 fracture requiring [**Location (un) 36323**] collar placement. 8. Ventilatory dependence requiring tracheostomy. 9. Inability to swallow requiring placement of PEG. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-205 Dictated By:[**Name8 (MD) 4729**] MEDQUIST36 D: [**2106-1-15**] 08:03 T: [**2106-1-15**] 08:57 JOB#: [**Job Number 36324**] Admission Date: [**2105-12-21**] Discharge Date: [**2106-1-26**] Date of Birth: [**2062-7-1**] Sex: F Service: Trauma ADDENDUM: The patient's general course continued to improve; however, with isolated low-grade fever spikes and problems with glucose control for which [**Last Name (un) **] Diabetes was consulted, and aggressive insulin measures were instituted by them. The patient also underwent repeat swallow study by Speech and Swallow which showed her to have adequate airway protection and ability to take regular foods. It was noted that the patient's left elbow appeared to be somewhat erythematous, and Orthopaedic Surgery was obtained which showed a previous elbow laceration to be infected and the likely source of the patient's low-grade fevers. The patient was started on antibiotics with some improvement of the elbow. The patient then made a trip to the operating room with Orthopaedic Surgery on [**1-18**], at which time a simple washout was conducted of the left elbow wound. Following this, as expected, the patient's blood sugar significantly improved and she became afebrile. Over the next few days the patient remained afebrile with stable vital signs. Her elbow wound was healing well, and she had no acute care issues. She remained in the hospital for approximately six additional days simply due to difficulty of placement, during which time her hematocrit slightly drifted down probably due to dilution and some blood loss during her orthopaedic procedure, for which she was given 2 units of blood on [**1-20**]. Her blood sugars continued to be under control. Her diet was advanced to soft solids, and her tube feeds were started. At one point, the patient's feeding tube became obstructed; however, this was quickly relieved with papaverine injection. For the remainder of the [**Hospital 228**] hospital stay she remained afebrile with stable vital signs with no acute care issues, just pending placement at a rehabilitation center that would adequately meet her needs. On [**1-26**], the patient was accepted and placed at a rehabilitation facility, and she will be discharged there. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: To rehabilitation. MEDICATIONS ON DISCHARGE: 1. Lentus insulin 36 units subcutaneous q.h.s. 2. Vitamin C 500 mg p.o. b.i.d. 3. Zinc 200 mg p.o. q.d. 4. Heparin 5000 units subcutaneous b.i.d. 5. Clonidine patch 0.2 mg per 24 hours; new patch every week. 6. Prophylaxis 40 mg p.o. q.d. 7. Flagyl 500 mg p.o. t.i.d. times five days. 8. Iron sulfate 325 mg p.o. q.d. 9. Aspirin 325 mg p.o. q.d. 10. ProMod with fiber via G-tube 50 cc per hour. 11. Vancomycin 1 g intravenously q.12h. times four days. 12. Collagenase ointment to chin q.d. 13. Serax 15 mg p.o. q.h.s. p.r.n. 14. Tylenol 650 mg to 1000 mg p.o. q.6h. p.r.n. 15. Morphine sulfate 2 mg to 4 mg intravenously/subcutaneous q.3-4h. p.r.n. 16. Percocet 5/325 one to two tablets p.o. q.4-6h. p.r.n. for pain. 17. Oxycodone elixir 5 mg per G-tube or p.o. q.4h. p.r.n. The patient should also have a premedicated Humalog sliding-scale with breakfast; blood sugar of less than 50 she should premedicate with no Humalog; 50 to 100 she gets 4 units; 101 to 150 she gets 9 units; 151 to 200 she gets 11 units; 201 to 250 she gets 13 units; 251 to 300 she gets 15 units; 301 to 350 she gets 17 units; and greater than 351 she gets 19 units. She should be on a 2200 kcal diabetic diet. The patient has a pre-meal Humalog sliding-scale with lunch and dinner that is different from her breakfast sliding-scale; less than 50 she should receive nothing; 50 to 100 she gets 4 units; 101 to 150 she gets 8 units; 151 to 200 she gets 10 units; 201 to 250 she gets 12 units; 251 to 300 she gets 14 units; 301 to 350 she gets 16 units; and greater than 351 she gets 18 units. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**] Dictated By:[**Last Name (NamePattern1) 22409**] MEDQUIST36 D: [**2106-1-26**] 16:20 T: [**2106-1-26**] 15:26 JOB#: [**Job Number 36325**]

[ "800.76", "801.26", "E816.0", "707.0", "812.51", "250.01", "518.5", "453.8", "805.02" ]

icd9cm

[ [ [] ] ]

[ "02.11", "16.52", "02.05", "02.02", "96.6", "31.1", "33.23", "46.32", "38.7" ]

icd9pcs

[ [ [] ] ]

3809, 6719

3021, 3678

6836, 8707

3690, 3788

6734, 6809

175, 2997

12,492

140,027

3275

Discharge summary

report

Admission Date: [**2187-5-29**] Discharge Date: [**2187-6-13**] Date of Birth: [**2114-8-11**] Sex: M Service: MEDICINE Allergies: Morphine Sulfate / Keflex / Penicillins / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 2186**] Chief Complaint: Hypoxia s/p intubation for Hip replacement Major Surgical or Invasive Procedure: total right hip replacement History of Present Illness: 72 M with Parkinson's Disease, h/o prostate CA s/p prostatectomy and urostomy with multiple revisions, and severe OA admitted for right total hip replacement by Dr. [**Last Name (STitle) **]. After non-traumatic easy intubation, he became hypoxic. He was suctioned and a large mucous plug was removed. Then further suctioning recovered green thick sputum which was sent for gram stain. The surgery was called off and the patient was transferred to the [**Hospital Unit Name 153**] because the aneasthesiologist did not feel he would be able to be extubated. . On arrival to ICU, VS: T 95.6 HR 85 BP 135/76 RR 16 O2 98% on PSV 10/5, FiO2 0.6. The ETT was noted to be further out of his mouth at 19 instead of 21cm. CXR showed that ETT high up, likely above vocal cords. Pt also noted to be difficult to ventilate, not getting significant tidal volumes. Propofol was discontinued and pt awoke quickly. He was extubated with good oxygen saturations on face mask. Past Medical History: Prostate CA s/p prostatectomy since [**2171**] Severe OA hips bilaterally Right wrist fracture s/p surgical repair Inability to walk [**12-20**] deconditioning after wrist fracture s/p right total knee arthroplasty that failed [**2176**] Knee contractures bilaterally ? DM (borderline per pt) Social History: Bedridden for past 4 months secondary to wrist fracture, Parkinson's Disease and OA. Has been living at home with wife as his primary caregiver. Did have home health services, but patient is often uncooperative with services. Wife feels she is no longer able to take care of him in this debilitated state. Quit tobacco "many" years ago. Used to be in the Army. No hx of asbestos exposure. Used to work in a paper mill. Is a retired plant manager for Wise potato chips. Family History: Not Contributory Physical Exam: VS 95.6 HR 85 BP 135/76 RR 16 O2 98% on PSV 10/5/0.6 Gen: elderly M intubated initially, open eyes to voice. HEENT: PERL. EOMI. MMM. CV: RRR. Nl S1, S2. no m/r/g. Lungs: + coarse rhonchi throughout and upper airway gurgling noises. No wheezes. Good air movement throughout. Abd: active BS. soft NT. ND. n oHSM Ext: no edema. babinski equivocal. Pertinent Results: [**2187-6-13**] 06:15AM BLOOD WBC-5.7 RBC-3.11* Hgb-9.5* Hct-28.6* MCV-92 MCH-30.6 MCHC-33.4 RDW-14.8 Plt Ct-133* [**2187-6-12**] 10:05PM BLOOD WBC-8.6 RBC-3.03* Hgb-9.4* Hct-27.5* MCV-91 MCH-31.1 MCHC-34.2 RDW-14.4 Plt Ct-137* [**2187-6-12**] 08:00AM BLOOD WBC-7.4 RBC-2.85* Hgb-8.7* Hct-26.6* MCV-93 MCH-30.4 MCHC-32.6 RDW-14.3 Plt Ct-118* [**2187-6-13**] 06:15AM BLOOD Plt Ct-133* [**2187-6-13**] 06:15AM BLOOD Ret Aut-2.6 [**2187-6-13**] 06:15AM BLOOD Glucose-136* UreaN-16 Creat-0.8 Na-136 K-3.8 Cl-101 HCO3-25 AnGap-14 [**2187-5-31**] 06:28AM BLOOD CK(CPK)-18* [**2187-5-31**] 06:28AM BLOOD CK-MB-2 cTropnT-<0.01 [**2187-6-13**] 06:15AM BLOOD Calcium-8.6 Phos-2.6* Mg-1.7 . CXR [**2187-5-29**]: 1. Endotracheal tube is above the level of the thoracic inlet and should be advanced. 2. Progression of opacity within the right upper lobe medially suggestive of volume loss and consolidation. 3. Increase in prominence of the interstitial markings may relate to volume overload versus congestive heart failure. 4. Asymmetric biapical pleural densities, more prominent on the right, may possibly relate to chronic lung disease with a potential additional component of volume loss and consolidation on the present examination, and could be further evaluated with CT of the chest if comparison prior chest x-rays are unavailable. . CXR [**2187-5-30**]: Mild pulmonary edema appears approximately unchanged. . EKG: pre op [**5-18**]: sinus tach 100 nl axis, no Q waves, no ST segment changes. . [**6-1**] Echo 1. The left atrium is mildly dilated. 2. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 3. The aortic valve leaflets are mildly thickened. 4. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Brief Hospital Course: 1. Hypoxia: The most likely cause was pneumonia [**12-20**] mucus plug, given his CXR, relative hypoxia, clinical exam, and sputum production. However, not febrile and no leukocytosis. His sputum gram stain shows G+C in pairs, [**9-11**] poly, <10 epi good sample. Culture grew oropharyngeal flora. Given one dose of vancomycin and then was started on levaquin and clindamycin for presumed aspiration pna. Speech and swallow evaluation was performed and they felt that pt was not an aspiration risk, so aspiration pneumonia was less likely. Repeated CXR on [**6-1**] which was much improved. Completed clinda x 7 day course. . 2. Diarrhea: Has intermittent episodes of diarrhea. He was started on Flagyl. However C.Diff. stool was negative and diarrheal episodes improved and so flagyl was discontinued. Was on Lomotil prn for any episodes of diarrhea. . 3. Osteo Arthritis: He had a total hip replacement surgery on [**6-9**]. Surgery went off well without any complications. His HCT dropped from 36.7 on day of [**Doctor First Name **] ([**6-9**]) to 26.6 on [**6-12**]. He received a unit of PRBC on [**6-12**]. His HCT on [**6-13**] was 28.6. Ortho was consulted-per ORtho, it was not unusual to have upto 10 pt HCT drop post hip replacement surgery. They were confortable discharging him around a HCT of 28-29. His vitals were stable on [**6-13**] (BP-110/60; HR-93; RR-18; O2sat-97/RA). . 4. Delirium/Confusion-Pt was delirious on [**7-31**]. most likely [**12-20**] taking percocet (past h/o delirium on taking percocet). Percocet was stopped and was put on Vicodin on discharge. . 5. Other conditions: Outside meds for Parkinson's, Depression and Psoriasis were continuted during this hospital stay. Medications on Admission: Sinemet 50/200 TID Folate 1 QD B1 QD Wellbutrin 150 QD Ibuprofen Percocet PRN Discharge Medications: 1. Carbidopa-Levodopa 50-200 mg Tablet Sustained Release Sig: One (1) Tablet PO TID (3 times a day). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 4. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day). 7. Hydrocortisone 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*1 applicator* Refills:*2* 8. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 9. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed. 10. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for dvt prophylaxis. Disp:*30 Tablet(s)* Refills:*0* 11. Vicodin Oral Discharge Disposition: Extended Care Facility: Life Care Center of [**Location 15289**] Discharge Diagnosis: Primary: 1. total right hip replacement 2. Hypoxemia. 3. Diastolic Heart Failure. Secondary: 1. Parkinson's Disease. 2. S/P Radical Prostatectomy. 3. Urostomy. 4. Severe Osteoarthritis. 5. Depression. 6. Biapical pleural thickening. Discharge Condition: All vitals are stable. Discharge Instructions: Please take all the medications and follow up with all the scheduled appointments. Please report to the ED or to your physician if you have fever, chest pain, shortness of breath, dizziness, severe abdominal pain or if there are any concerns at all. Followup Instructions: Please follow up with your PCP for an appointment in 2 weeks. Please follow up with Dr. [**Last Name (STitle) **] for an orthopedic appointment in [**5-27**] days. Call [**Telephone/Fax (1) 1228**] for an appointment. Please get your INR checked three times a week on Monday, Wednesday, Friday and make sure that it is around 2.0. Please report the INR to your PCP for monitoring the dose of Coumadin. Completed by:[**2187-6-13**]

[ "599.0", "V64.1", "428.31", "E935.2", "428.0", "292.81", "519.1", "787.91", "V10.46", "507.0", "696.1", "715.35" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7271, 7338

4460, 6171

367, 397

7615, 7639

2605, 4437

7937, 8373

2207, 2225

6299, 7248

7359, 7594

6197, 6276

7663, 7914

2240, 2586

284, 329

425, 1387

1409, 1704

1720, 2191

22,942

115,682

18235

Discharge summary

report

Admission Date: [**2196-2-29**] Discharge Date: [**2196-3-4**] Date of Birth: [**2132-5-26**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 922**] Chief Complaint: Shortness of breath, Dyspnea on exertion Major Surgical or Invasive Procedure: [**2196-2-29**] Pericardiectomy [**3-3**] Paracentesis by Hepatology service History of Present Illness: This is a 63 yo male with cirrhotic liver disease, atrial fibrillation and known pericardial calcification/constriction referred for evaluation for pericardial stripping and possible Maze procedure. Denies orthopnea and PND. No history of chest pain. His shortness of breath does improve following paracentesis. Past Medical History: - Liver Cirrhosis, complicated by Ascites. Liver bx [**10-29**] showed chronic venous outflow obstruction/constrictive pericarditis. - Alcoholism, quit [**2187**] - Hypertension - Chronic Atrial Fibrillation - Chronic Venous Insufficiency - History of Gout(resolved when quit ETOH) - External Hemorrhoids Past Surgical History: - s/p Paracentesis on frequent basis, currently Q3-4 weeks - s/p Bilateral Inguinal Hernia - s/p Umbilical Hernia - Polypectomy(complicated by GI Bleed) Social History: Race: Caucasian Lives with: Alone in [**Location (un) 39908**]. Partner is [**Name2 (NI) **]. Occupation: Retired Machinist Tobacco: Denies ETOH: None since [**2187**]. History of heavy use. Family History: Father died of liver disease at age 69. Mother died of stroke at age 83. No premature CAD. Physical Exam: Pulse: 87 Resp: 20 O2 sat: 99% B/P Right: 115/81 Left: 115/84 Height:6'0" Weight:175 lbs General: Non-toxic, No acute distress middle aged male Skin: Dry [x] intact [x] ?jaundice HEENT: PERRLA [x] EOMI [x] - sclera anicteric Neck: Supple [x] Full ROM [x] - no JVD Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur - none Abdomen: +distended, very firm - significant ascites noted, large ventral hernia noted Extremities: Warm [x], well-perfused [x] Edema 1+ pitting edema bilaterally, chronic venous changes Varicosities: GSV without varicosities Neuro: Grossly intact Pulses: Femoral Right: 2 Left: 2 DP Right: 1 Left: 1 PT [**Name (NI) 167**]: 1 Left: 1 Radial Right: 2 Left: 2 Carotid Bruit -- none Pertinent Results: [**2196-2-29**] Echo: PREBYPASS: The left atrium is dilated. No atrial septal defect is seen by 2D or color Doppler. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Transgastric view could not be obtained. The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened. There are filamentous strands on the aortic leaflets consistent with Lambl's excresences (normal variant). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). The pericardium appears thickened. There are pericardial calcifications. The echo findings are suggestive but not diagnostic of pericardial constriction. POST BYPASS: Biventricular systolic function remains preserved. Pre-op [**2196-2-29**] 12:10PM BLOOD WBC-17.8*# RBC-3.99*# Hgb-11.5*# Hct-34.4*# MCV-86 MCH-28.7 MCHC-33.3 RDW-15.6* Plt Ct-353 [**2196-2-29**] 01:45PM BLOOD UreaN-31* Creat-1.1 Cl-99 HCO3-25 [**2196-3-2**] 11:55AM BLOOD ALT-18 AST-38 LD(LDH)-221 AlkPhos-114 TotBili-0.9 Post-op [**2196-3-3**] 05:45AM BLOOD WBC-7.8 RBC-3.05* Hgb-8.6* Hct-26.3* MCV-86 MCH-28.4 MCHC-32.8 RDW-16.2* Plt Ct-200 [**2196-3-3**] 05:45AM BLOOD Plt Ct-200 [**2196-3-3**] 05:45AM BLOOD PT-12.2 INR(PT)-1.0 ASCITES ASCITES ANALYSIS WBC RBC Polys Lymphs Monos Mesothe Macroph [**2196-3-3**] 06:12PM 400* 3750* 48* 36* 0 3* 13* PERITONEAL ASCITES CHEMISTRY TotPro Albumin Triglyc [**2196-3-3**] 06:12PM 3.9 2.2 169 [**2196-3-3**] 05:45AM BLOOD Glucose-91 UreaN-25* Creat-1.0 Na-127* K-4.9 Cl-92* HCO3-28 AnGap-12 [**2196-3-2**] 11:55AM BLOOD ALT-18 AST-38 LD(LDH)-221 AlkPhos-114 TotBili-0.9 Radiology Report CHEST (PORTABLE AP) Study Date of [**2196-3-2**] 11:55 AM Final Report HISTORY: Chest tubes removed. Rule out pneumothorax. IMPRESSION: AP chest compared to [**3-2**]: Since [**3-2**], major cardiopulmonary support devices have all been removed, left lower lobe atelectasis has worsened, though the small overall lung volumes are unchanged. A slight interval increase in the cardiomediastinal diameter is a common finding after cardiac surgery. No pneumothorax. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] Approved: WED [**2196-3-2**] 7:47 PM Chest CT [**2196-3-4**]: Preliminary Report !! WET READ !! A 9.6 x 8 cm loculated left pleural high density collection represents hematoma, possibly with moderate mass effect on the left ventricle - Dr [**Last Name (STitle) 914**] reviewed and spoke with radiologist - left pleural hematoma noted -patient cleared for discharge [**2196-3-4**]: Right femoral US: small hematoma at cannulation site with no vessel compression - WET REAS Brief Hospital Course: Mr. [**Known lastname 50343**] was a same day admit after undergoing pre-operative work-up as an outpatient. On day of admission he was brought directly to the operating room where he underwent a pericardiectomy with a bypass time of 105 minutes. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-operative day one he remained hemodynamically stable and was transferred to the step-down floor for further care. Coumadin was restarted for atrial fibrillation. Chest tubes and epicardial pacing wires were removed per cardiac surgery protocols. He was seen by the hepatology service and had a paracentesis for 3500 cc's during his hospital stay. He complained post operatively of right leg stabbing pain and right thigh paresthesia. He was started on Neurontin. Neurology was consulted and it was thought that the paresthesia was a direct result of the femoral vein cannulation. A right femoral ultrasound was performed which revealed only a small hematoma with no pseudoaneurysm or fistula noted. The pain was improving at the time of discharge. Neurology recommended continuing Neurontin with follow up in clinic in 4 weeks if symptoms persist. He continued to progress with activity level and was discharged home with visiting nurses on [**3-4**]. He is to have his INR checked by VNA on [**3-6**] with results called to Dr[**Name (NI) 670**] office. Follow up with Dr [**Last Name (STitle) 914**] in 1 month. Medications on Admission: Ciprofloxacin 250mg po daily since [**4-29**] Furosemide 20mg po TID Spironolactone 100mg po BID **Warfarin 7.5mg po daily** STOPPED [**2196-2-23**] Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): resume preop schedule. 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain, fever. 5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for dermititis. Disp:*1 bottle* Refills:*0* 6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4 hrs as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:*45 Tablet(s)* Refills:*2* 8. Warfarin 5 mg Tablet Sig: 1.5 Tablets PO once a day as needed for a-fib: for target INR 2-2.5. resume preop schedule. 9. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day. 10. FerrouSul 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day for 1 months. Disp:*30 Tablet(s)* Refills:*0* 11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO twice a day for 1 months. Disp:*60 Tablet(s)* Refills:*0* 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day for 1 months. Disp:*30 Tablet(s)* Refills:*0* 13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 14. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). Disp:*180 Capsule(s)* Refills:*1* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Constrictive Pericarditis s/p Pericardiectomy Past Medical History: - Liver Cirrhosis, complicated by Ascites. Liver bx [**10-29**] showed chronic venous outflow obstruction/constrictive pericarditis. - Alcoholism, quit [**2187**] - Hypertension - Chronic Atrial Fibrillation - Chronic Venous Insufficiency - History of Gout(resolved when quit ETOH) - External Hemorrhoids Past Surgical History: - s/p Paracentesis on frequent basis, currently Q3-4 weeks - s/p Bilateral Inguinal Hernia - s/p Umbilical Hernia - Polypectomy(complicated by GI Bleed) Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Sternal wound healing well, no drainage or erythema 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**] Coumadin to be followed by [**Hospital 197**] Clinic at PCP's office (Dr. [**First Name (STitle) **] Followup Instructions: Surgeon Dr. [**Last Name (STitle) 914**] on [**3-29**] @ 1:00 PM [**Telephone/Fax (1) 170**] Please call to schedule appointments Primary Care Dr. [**First Name (STitle) **] in [**1-23**] weeks Cardiologist Dr.[**Name (NI) 3733**] in [**1-23**] weeks [**Hospital 878**] Clinic in 4 weeks if right leg pain persists Wound check appointment -[**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse [**First Name (Titles) **] [**Last Name (Titles) 10542**]e prior to discharge Coumadin to be followed by [**Hospital 197**] Clinic at PCP's office (Dr. [**First Name (STitle) **] - phone #[**Telephone/Fax (1) 24713**] Completed by:[**2196-3-4**]

[ "789.59", "459.81", "276.7", "998.12", "V58.66", "571.5", "423.2", "429.1", "401.9", "427.31", "276.1" ]

icd9cm

[ [ [] ] ]

[ "37.31", "54.91", "39.61" ]

icd9pcs

[ [ [] ] ]

8594, 8649

5198, 6805

317, 396

9241, 9389

2362, 5175

10030, 10694

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Discharge summary

report+report

Admission Date: [**2182-3-30**] Discharge Date: [**2182-4-4**] Date of Birth: [**2148-4-23**] Sex: M Service: [**Doctor Last Name **] HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is an unfortunate 33-year-old male with a history of type 1 diabetes for 12 years with multiple complications including severe gastroparesis requiring recent jejunostomy tube placement on [**2182-3-8**]. The patient was sent to the Emergency Room by his primary care physician secondary to purulent drainage from the jejunostomy tube site and relative hypotension with a blood pressure of 93/80. Of note, the patient's normal blood pressure ranges from 130 to 180 systolic. The patient had recently been admitted from [**3-6**] to [**3-9**] with complaints of nausea, vomiting, abdominal pain, and an increased blood pressure. Initially, the patient had a gastroesophageal tube placed and then he had a gastrojejunostomy tube placed Interventional Radiology on [**3-8**]. By discharge, the patient was tolerating liquids and toast. The patient noted discharge starting on [**3-11**]. Per the patient, the discharge has progressively become worse. He was on a course of oral antibiotics of an unknown name for eight days which finished two days ago with improvement. The discharge was yellow with some blood. There was notable pain around the jejunostomy tube site, but no abdominal pain. The patient denied nausea and vomiting, was tolerating thick liquids, and had a good appetite. He also denied fevers or chills. Furthermore, the patient denied shortness of breath. No chest pain. He denied melena or bright red blood per rectum. In the Emergency Department, Surgery removed the jejunostomy tube. Blood cultures were sent, and a would culture was sent. In the Emergency Department, he was given normal saline, Flagyl, levofloxacin, Ancef, Reglan, and insulin. PAST MEDICAL HISTORY: 1. Type 1 diabetes for 12 years; complicated by autonomic dysfunction, gastroparesis, and nephropathy. 2. Gastroparesis; of note, the patient had a gastric emptying study that showed that the patient's stomach had not emptied even two hours after the administration of contrast. 3. Labile hypertension. 4. Autonomic dysfunction with orthostatic blood pressure. 5. Gastroesophageal reflux disease. 6. Coronary artery disease; catheterization in [**2181-7-14**] demonstrated the patient had a 50% stenosis of the first diagonal. 7. An echocardiogram in [**2181-12-14**] showed an ejection fraction of 50% to 55% and 1+ mitral regurgitation. MEDICATIONS ON ADMISSION: 1. Hydrochlorothiazide 12.5 mg p.o. once per day 2. Labetalol 400 mg p.o. twice per day. 3. Lantus 20 units subcutaneously q.h.s. 4. Regular insulin sliding-scale. 5. Lisinopril 20 mg p.o. q.h.s. 6. Clonidine 0.1-mg patch every five days. 7. Xanax 0.5 mg p.o. as needed. 8. Norvasc 10 mg p.o. once per day. 9. Protonix 40 mg p.o. once per day. 10. Reglan 10 mg p.o. four times per day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is a nonsmoker. He does not drink and does not use drugs. FAMILY HISTORY: Father with diabetes. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed temperature was 99.7, blood pressure was 100/58, heart rate was 91, respiratory rate was 16, and oxygen saturation was 98% on room air. In general, the patient appeared tired but in no acute distress. Head, eyes, ears, nose, and throat examination revealed mucous membranes were dry. Pupils were equal, round, and reactive to light and accommodation. Extraocular muscles were intact. Neck revealed right jejunostomy tube in place. No lymphadenopathy. Cardiovascular examination revealed a regular rate and rhythm. A 2/6 systolic murmur at the right upper sternal border and the left upper sternal border. The lungs were clear to auscultation bilaterally. The abdomen was soft, nontender, and nondistended. Gauze on abdomen soaked with serosanguineous fluid. Extremity examination revealed no edema. Pedal pulses were 2+. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratory data on admission revealed hematocrit was 24 (baseline of 23 to 26), white blood cell count was 7.3, and platelet count was 453,000. Differential on the white count revealed 71% neutrophils, 19% lymphocytes, 8% monocytes, and 2% eosinophils. Creatinine was 2.8 (baseline creatinine of 1.6) and blood urea nitrogen was 51. Glucose was 610. PERTINENT RADIOLOGY/IMAGING: A computed tomography of the abdomen showed a large phlegmon of the anterior abdominal tissue superficial to the external oblique aponeuroses with question an area of less than 1 cm of gas. HOSPITAL COURSE BY ISSUE/SYSTEM: 1. ABSCESS AROUND JEJUNOSTOMY TUBE SITE: The patient was seen by the Surgery Service who removed the jejunostomy tube and felt that for initial management the patient would not require debridement. They did place drains within the wound and recommended that if the area drained appropriately the patient may not need debridement. The patient was started on vancomycin and Zosyn, per Surgery request, and a dry gauze was applied to the area. Blood cultures showed no growth. Wound cultures showed greater than three colony types. Therefore, there was no further workup per the Laboratory. The colony types included streptococcus and lactobacillus. The patient was continued on empiric antibiotic treatment with vancomycin and Zosyn. He continued to improve clinically, and Surgery continued to follow the patient. It was ultimately determined that he would not require a trip to the operating room for debridement. A peripherally inserted central catheter line was placed so that the patient could be discharged on intravenous antibiotics. However, by the time of discharge the patient was tolerating oral intake and was therefore discharged on oral levofloxacin and Flagyl for a total of a 14-day course. The final wound culture was moderate growth of Streptococcus milleri in addition to moderate growth of lactobacillus species. The patient was to have home [**Hospital6 1587**] for help with his three times per day Nu-Gauze dressing changes. He was to follow up with Dr. [**Last Name (STitle) **] from Surgery in two weeks after discharge. The [**Hospital6 1587**] was going to help with twice per day dressing changes. 2. LABILE BLOOD PRESSURE ISSUES: The patient continued to have his baseline labile blood pressure while in house. He was continued on Norvasc, labetalol, and lisinopril. The clonidine was initially held but then added back just prior to discharge. The patient transiently required hydralazine 10 mg intravenously q.6h. for blood pressure control, but this was discontinued one day prior to discharge. 3. ANEMIA ISSUES: In anticipation of surgical debridement, the patient was given one unit of packed red blood cells to have him better prepared for the operating room and possible further blood loss. His hematocrit went to 29 after the blood transfusion and remained at 29 until discharge. 4. GASTROPARESIS ISSUES: The patient continued to have nausea and vomiting during his hospital course. However, with the help of Reglan and antiemetics the patient was tolerating oral intake by the time of discharge. DISCHARGE DIAGNOSES: 1. Jejunostomy tube infection; status post jejunostomy tube removal. 2. Type 1 diabetes with multiple complications. 3. Gastroparesis. 4. Labile hypertension. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to follow up with his primary care physician (Dr. [**Last Name (STitle) **] one week status post discharge. 2. The patient was to continue antibiotics for a full 2-week course. 3. He was also given a new prescription for Paxil (an antidepressant). 4. He was instructed to eat multiple small meals per day and to avoid large meals to help with his gastroparesis. 5. The patient was also to follow up with Dr. [**Last Name (STitle) **] in two weeks after discharge. 6. The patient was to have home [**Hospital6 407**] for dressing changes and for frequent blood pressure checks. MEDICATIONS ON DISCHARGE: 1. Protonix 40 mg p.o. once per day. 2. Norvasc 10 mg p.o. once per day. 3. Labetalol 400 mg p.o. twice per day. 4. Lisinopril 10 mg p.o. once per day. 5. Regular insulin sliding-scale. 6. Paxil 20 mg p.o. once per day. 7. Clonidine 0.1-mg patch one patch every five days. 8. Reglan 10 mg p.o. four times per day (with meals). 9. Flagyl 500 mg p.o. three times per day (for a 2-week course). 10. Levofloxacin 500 mg p.o. once per day (for a 2-week course). [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. Dictated By:[**Last Name (NamePattern1) 5851**] MEDQUIST36 D: [**2182-6-12**] 19:27 T: [**2182-6-13**] 06:38 JOB#: [**Job Number 93187**] Admission Date: [**2182-4-5**] Discharge Date: [**2182-4-11**] Date of Birth: [**2148-4-23**] Sex: M Service: CHIEF COMPLAINT: Hypertensive emergency. HISTORY OF PRESENT ILLNESS: The patient is a 33-year-old African-American male with a longstanding history of type 1 diabetes mellitus and hypertension. The patient came to the Emergency Department with complaints of nausea, vomiting, and noted to have an increased blood pressure. The patient had been discharged from [**Hospital1 346**] on [**4-4**] after he was admitted for treatment of an infected jejunostomy tube. The patient was placed on levofloxacin and Flagyl for treatment of the jejunostomy tube infections. On the morning of [**3-5**], the patient took his morning medication and had breakfast and subsequently developed nausea and vomiting. The patient denies chest pain, headache, visual changes, of fevers. He does report some lightheadedness and shortness of breath. He came to the Emergency Department and was found to be hypertensive with a blood pressure of 235/141. He was given 10 mg of intravenous hydralazine, 40 mg of intravenous labetalol, and then placed on intravenous nitroprusside. His systolic blood pressure decreased to 180. He was given 2 mg of Ativan times two. He received another dose of 10 mg intravenously of hydralazine. The patient was admitted to the Intensive Care Unit for further management. PAST MEDICAL HISTORY: 1. Type 1 diabetes mellitus times 12 years. 2. Orthostatic hypotension with episodes of hypertensive urgency. 3. Gastroparesis. 4. Gastroesophageal reflux disease. 5. Coronary artery disease; most recent catheterization in [**2181-7-14**] revealed 50% occlusion of first diagonal. An echocardiogram in [**2181-12-14**] showed an ejection fraction of 50% to 55%, enlarged left atrium, mild left ventricular hypertrophy, moderately dilated aortic root. 6. Status post jejunostomy tube placement; jejunostomy tube removed during last hospitalization due to infection. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Levaquin 500 mg p.o. q.d. 2. Flagyl 500 mg p.o. t.i.d. 3. Norvasc 10 mg p.o. q.d. 4. Labetalol 200 mg p.o. b.i.d. 5. Protonix 40 mg p.o. q.d. 6. Lisinopril 10 mg p.o. q.d. 7. Hydrochlorothiazide 25 mg p.o. q.d. 8. Reglan 10 mg p.o. q.i.d. 9. Clonidine patch 0.2 mg every week. 10. Lantus and sliding-scale with Humalog. SOCIAL HISTORY: The patient denies the use of tobacco and alcohol. He is a former truck driver. He is married. FAMILY HISTORY: Family history is significant for diabetes mellitus. PHYSICAL EXAMINATION ON PRESENTATION: General physical examination revealed cachectic-appearing male with malaise. Temperature was 97.1, heart rate was 108, blood pressure was 235/141, respiratory rate was 18, and oxygen saturation was 98% on room air. Head, eyes, ears, nose, and throat examination revealed pupils were equally round and reactive to light. Extraocular movements were intact. Mucous membranes were moist. The oropharynx was clear. Neck examination revealed no lymphadenopathy and soft. Lungs were clear to auscultation bilaterally. Heart revealed normal first heart sounds and second heart sounds, tachycardic. A 3/6 systolic murmur, a palpable heave. Fourth heart sound was present. Abdominal examination revealed bowel sounds were present. Soft, nontender, and nondistended. Left upper quadrant exit site was warm with a dressing, clean, dry, and intact. No erythema. Extremity examination revealed no clubbing, cyanosis, or edema. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratory data revealed white blood cell count was 10, hematocrit was 34, and platelets were 364. Differential with 77% neutrophils, 14% lymphocytes, 5% monocytes and 3% eosinophils. Chemistry-7 revealed sodium was 136, potassium was 4, chloride was 101, bicarbonate was 24, blood urea nitrogen was 14, creatinine was 1.3, and blood glucose was 225. Urinalysis showed trace blood, and 30 protein, and 500 glucose. Prothrombin time was 11.2, partial thromboplastin time was 24.8, and INR was 0.8. PERTINENT RADIOLOGY/IMAGING: Electrocardiogram revealed a normal sinus rhythm, rate was 98 beats per minute, normal P-R and QRS axis and intervals. No ST-T wave changes. No change from prior electrocardiogram of [**2182-3-6**]. A chest x-ray revealed no cardiopulmonary abnormalities. ASSESSMENT AND PLAN: This is a 33-year-old male with diabetes mellitus and a history of severe autonomic instability who presented with a hypertensive urgency. The patient was admitted to the Medical Intensive Care Unit for management of hypertension. No signs on admission of end-organ damage. HOSPITAL COURSE BY ISSUE/SYSTEM: 1. CARDIOVASCULAR SYSTEM: As noted above, the patient has had multiple episodes of hypertensive urgency. Most recent admission led to placement of jejunostomy tube to allow medications to be administered when the patient has nausea and vomiting. Due to the patient's initial inability to take oral medications, he was treated with intravenous blood pressure medications including hydralazine, Lopressor, and enalapril. In addition, the patient was maintained on his Clonidine patch. When the patient was able to take oral medications, he was transitioned to his outpatient regimen which included Norvasc 5 mg p.o. q.d., labetalol 200 mg p.o. b.i.d., hydrochlorothiazide 25 mg p.o. q.d., and lisinopril 10 mg p.o. q.d. The lisinopril was ultimately titrated up to 20 mg p.o. q.d. due to the patient's persistent hypertension. 2. GASTROINTESTINAL ISSUES: (a) HEME-POSITIVE EMESIS: The patient had an episode of heme-positive emesis on admission. A Gastroenterology consultation was obtained. The Gastroenterology Service recommended control of the patient's nausea and vomiting with Ativan and Reglan. An endoscopy was deferred. The patient was administered an H2 blocker, and serial hematocrit levels were followed. The patient did not have further episodes of heme-positive emesis. (b) GASTROPARESIS: The possibility of a gastric pacemaker was discussed with the patient. The [**Last Name (un) **] Service also recommended considering acupuncture as a treatment for gastroparesis. These issued will be addressed in the outpatient setting. 3. INFECTIOUS DISEASE ISSUES: As noted above, the patient was recently treated for an infection of his jejunostomy tube on his last hospitalization. The jejunostomy tube had been removed. The patient was continued on his levofloxacin and Flagyl for this infection. He was to complete a 2-week course. The patient remained afebrile during this hospitalization. 4. RENAL SYSTEM: The patient has chronic renal insufficiency at baseline. His renal function remained stable during this hospitalization. 5. ENDOCRINE SYSTEM: The patient was followed closely by the [**Last Name (un) **] Service during his hospitalization. Initially, in the Intensive Care Unit, he was maintained on an insulin drip and his blood sugars were followed hourly. Ultimately, he was transitioned to his outpatient insulin regimen which included Lantus and a Humalog sliding-scale. 6. NUTRITION ISSUES: Initially, the patient was nothing by mouth due to his inability to tolerate oral intake. Due to his persistent nausea and vomiting, the patient was administered intravenous fluids, and a Nutrition consultation was obtained for assistance with the patient's diet. As the patient improved, he was able to tolerate a diabetic diet. 7. PSYCHIATRIC ISSUES: During his hospitalization, the patient expressed feelings of depression. He was seen by the Psychiatry Service. Dr. [**Last Name (STitle) 10166**] evaluated the patient and believed that he had a mild depression, yet difficult to separate his symptoms from the patient's discouragement about his medical illness. The patient was started on Celexa 10 mg p.o. q.d. 8. PROPHYLAXIS ISSUES: The patient was maintained on subcutaneous heparin and Pepcid during his hospitalization. CONDITION AT DISCHARGE: Condition on discharge was good. DISCHARGE STATUS: Discharge status was to home. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to follow up with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] (telephone number [**Telephone/Fax (1) 16315**]). 2. The patient was to follow up with his endocrinologist, Dr. [**Last Name (STitle) 978**] (telephone number [**Telephone/Fax (1) 2490**]). 3. The patient was also to follow up with his psychiatrist, Dr. [**Last Name (STitle) 57179**]. MEDICATIONS ON DISCHARGE: 1. Clonidine patch 0.2 mg every week. 2. Reglan 10 mg p.o. q.i.d. 3. Levofloxacin 500 mg p.o. q.d. (times five days). 4. Flagyl 500 mg p.o. t.i.d. (times five days). 5. Lantus 18 units subcutaneously q.h.s. 6. Norvasc 5 mg p.o. q.d. 7. Labetalol 200 mg p.o. b.i.d. 8. Hydrochlorothiazide 25 mg p.o. q.d. 9. Protonix 40 mg p.o. q.d. 10. Celexa 10 mg p.o. q.d. 11. Lisinopril 20 mg p.o. q.d. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 24755**] Dictated By:[**Last Name (NamePattern1) 5092**] MEDQUIST36 D: [**2182-4-16**] 18:06 T: [**2182-4-17**] 07:44 JOB#: [**Job Number **]

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45233

Discharge summary

report

Admission Date: [**2147-4-18**] Discharge Date: [**2147-5-5**] Date of Birth: [**2065-4-28**] Sex: F Service: MEDICINE Allergies: Aspirin / Milk Attending:[**First Name3 (LF) 898**] Chief Complaint: retroperitoneal bleed Major Surgical or Invasive Procedure: -Abdominal angiogram with IR guided embolization of pseudoaneursym of L3 aorta branch ([**2147-4-25**]) -Abdominal angiogram with IR guided embolization of pseudoaneursym of L3 aorta branch ([**2147-4-29**]) -PICC line placement on left arm and then exchange by IR with power PICC line -Transesphageal echocardiogram History of Present Illness: Ms. [**Known firstname **] [**Known lastname **] is a 81 yo female with hx of RA, with recent L4-L4 back laminectomy in [**12-17**], with chornic back pain, who had 5 recent kyphoplasties in Flordia, after which deveoloped a RP bleed when being restarted on her anticoagulation for her St. [**Male First Name (un) 923**] MVR. She was transfered from [**State 108**] today to be further treated. She had her vertebroplasty procedure in [**State 108**] on [**4-2**]. Hemaglobin was before the procedure was 12 per son, then fell and she was given 2 units of blood on [**2147-4-9**]. She then had a upper and lower GI scope that found inflammation per son, but no bleeding in colon, duodeunum, and stomach. She was discharged on [**2147-4-13**] with stable blood counts. Then felt severe abdominial pain the next day. She was taken to ER and had a CT of the abdomen ([**2147-4-14**]) that found a large PR bleed and a L3 fracture of the transverse process. She had been off anticaoguation during her kyphoplasty, and was restarted on 5mg for 2 days, then had an INR of 2.7 on [**2147-4-13**]. On the day of the RP bleed the INR was 5.1. She was given vitamin K IV and FFP. She had a repeat CT scan in 12 hours with no change. She was transfused 5 units over two days. Then requested transfer to [**Hospital1 18**], where she has her regular care. (MD # in FLA is [**Telephone/Fax (1) 96676**]). On the floor, minimal abdominal pain, no SOB, no CP. Would like to eat. Understands risk of bleeding vs stroke. 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. No recent change in bowel or bladder habits. No dysuria. Past Medical History: 1. Rheumatoid arthritis. Chronically on steriods 2. Atrial fibrillation. 3. St. [**Male First Name (un) 923**] mechanical valve mitral valve replacement in [**2145**]. for HOCM, 4. High cholesterol. 5. Gastroesophageal reflux disease. 6. Depression. 7. Laminectomy of L4-L5 [**12-17**] 8. Diastolic HF, EF 70% 9. Osteoprerosis, multiple recent compression fractures Social History: She lives alone, alternating here and in floridia. Son [**Name (NI) **] is HCP. Nonsmoker, no etoh, no drugs. Able to do ADLs prior to admission. Family History: non-contributory Physical Exam: On admission: Vitals: T: 96 BP: 143/71 P: 80 R: 18 18 O2:98% 2LNC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry membranes, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, no murmurs, loud click of heart valve throughout Abdomen: soft, tender right side, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Changes on discharge: -hematoma on right thigh, medial and posterior, decreasing in size, tender -PICC in place in left arm Pertinent Results: Admission labs- [**2147-4-18**] 09:05PM BLOOD WBC-11.6* RBC-3.92* Hgb-11.5* Hct-34.0* MCV-87 MCH-29.2 MCHC-33.8 RDW-14.5 Plt Ct-261 [**2147-4-18**] 09:05PM BLOOD PT-13.1 PTT-26.6 INR(PT)-1.1 [**2147-4-18**] 09:05PM BLOOD Glucose-69* UreaN-10 Creat-0.4 Na-135 K-3.9 Cl-98 HCO3-26 AnGap-15 [**2147-4-18**] 09:05PM BLOOD Calcium-8.5 Phos-2.8 Mg-1.8 Urine Studies- [**2147-4-22**] 10:20PM URINE RBC-2 WBC-30* Bacteri-MOD Yeast-NONE Epi-0 [**2147-4-22**] 10:20PM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.0 Leuks-MOD [**2147-4-22**] 10:20PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.007 [**2147-4-22**] 10:20 pm URINE Source: Catheter. **FINAL REPORT [**2147-4-25**]** URINE CULTURE (Final [**2147-4-25**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Other labs- [**2147-4-26**] 02:08AM BLOOD WBC-14.6* RBC-3.44* Hgb-10.2* Hct-29.8* MCV-87 MCH-29.8 MCHC-34.4 RDW-15.6* Plt Ct-254 [**2147-4-26**] 03:55PM BLOOD Hct-30.6* [**2147-4-28**] 07:05AM BLOOD WBC-13.8* RBC-3.06* Hgb-9.1* Hct-27.9* MCV-91 MCH-29.8 MCHC-32.8 RDW-15.5 Plt Ct-314 [**2147-4-24**] 04:44PM BLOOD WBC-22.0* RBC-3.94* Hgb-12.0 Hct-34.0* MCV-86 MCH-30.3 MCHC-35.2* RDW-15.1 Plt Ct-331 [**2147-4-29**] 07:30AM BLOOD WBC-14.3* RBC-2.48* Hgb-7.5* Hct-22.4* MCV-91 MCH-30.3 MCHC-33.5 RDW-16.0* Plt Ct-316 [**2147-5-4**] 04:09PM BLOOD Hct-31.4* [**2147-5-4**] 11:22PM BLOOD Hct-29.8* [**2147-5-5**] 06:15AM BLOOD WBC-7.3 RBC-3.42* Hgb-10.3* Hct-30.5* MCV-89 MCH-30.2 MCHC-33.8 RDW-16.0* Plt Ct-330 BASIC COAGULATION PT PTT INR(PT) Source: Line-PICC [**2147-5-5**] 06:15AM 14.1* 69.2* 1.2* RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2147-5-5**] 06:15AM 80 8 0.5 137 3.3 101 28 11 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos TotBili DirBili [**2147-5-2**] 05:57AM 19 26 477* 97 0.8 CPK ISOENZYMES CK-MB cTropnT [**2147-4-26**] 02:08AM 3 <0.011 CHEMISTRY TotProt Calcium Phos Mg [**2147-5-5**] 06:15AM 8.7 3.4 2.2 URINALYSIS Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks [**2147-4-30**] 11:37AM SM NEG NEG NEG NEG NEG NEG 6.0 NEG MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi [**2147-4-30**] 11:37AM 6* 1 FEW NONE 0 [**2147-4-24**] 4:44 pm BLOOD CULTURE Source: Line-PICC #1. **FINAL REPORT [**2147-5-1**]** Blood Culture, Routine (Final [**2147-4-30**]): STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. ISOLATED FROM ONE Bottle of one set only SENSITIVITIES REQUESTED BY [**Doctor First Name **] [**Doctor Last Name 1447**] #[**Numeric Identifier 81549**] [**2147-4-28**]. FINAL SENSITIVITIES. Sensitivity testing performed by Sensititre. CLINDAMYCIN = SENSITIVE ( <=0.12 MCG/ML ). SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP | CLINDAMYCIN----------- S ERYTHROMYCIN----------<=0.25 S PENICILLIN G----------<=0.06 S VANCOMYCIN------------ <=1 S [**2147-4-26**] 4:14 pm CATHETER TIP-IV Source: right picc line. **FINAL REPORT [**2147-4-28**]** WOUND CULTURE (Final [**2147-4-28**]): No significant growth. Reports- Ultrasound right lower extremity IMPRESSION: No evidence for DVT in the right lower extremity. EKG [**4-20**] Cardiology Report ECG Study Date of [**2147-4-20**] 10:04:44 AM Sinus rhythm. There are non-diagnostic Q waves in the lateral leads. Non-specific ST-T wave changes. Compared to the previous tracing ST-T wave changes are less marked. Intervals Axes Rate PR QRS QT/QTc P QRS T 75 140 82 422/448 36 2 -10 CT Abd and Pelvis without contrast [**2147-4-23**] IMPRESSION: 1. More extensive retroperitoneal hematoma. 2. Similar evidence of a focal dissection in the lower abdominal aorta, but most likely chronic and unlikely to relate to the recent retroperitoneal hemorrhage. u/s doppler LE [**2147-4-19**] IMPRESSION: No evidence for DVT in the right lower extremity. [**2147-4-25**] Aortagram IMPRESSION: 1. Abdominal aortogram demonstrating a 2.6 x 1.6 cm pseudoaneurysm originating from the L3 lumbar artery. In addition, note was made of a focal 8 mm x 7 mm dissection involving the infrarenal abdominal aorta without evidence of extravasation corresponding with the patient's preprocedure CTs. The CT of the chest from [**2147-4-5**], which was performed prior to the kyphoplasty and showed similar appearance of the focal aortic dissection as seen on the recent exam of [**2147-4-23**]. 2. Uncomplicated embolization of pseudoaneurysm using coils, Gelfoam, and thrombin as described above. 3. Completion abdominal aortogram demonstrating no flow to the pseudoaneurysm. [**2147-4-26**] TEE The left atrium is normal in size. There is asymmetric left ventricular hypertrophy. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Diastolic function could not be assessed. 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. A bileaflet mitral valve prosthesis is present. The mitral prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. Trivial mitral regurgitation is seen. The degree of mitral regurgitation seen is normal for this prosthesis. There is no pericardial effusion. IMPRESSION: Normally functioning mitral prosthesis. Asymmetric septal hypertrophy. Normal regional and global left ventricular systolic function. [**2147-4-29**] CTA abd/pelvis/LE . IMPRESSION: 1. New extensive right thigh hematoma with possible tiny focus of active extravasation. This hematoma appears separate from the retroperitoneal hematoma and may relate to the patient's anticoagulation. 2. Unchanged appearance of iliopsoas hematoma. No definite opacification or extravasation from the known lumbar pseudoaneurysm status post coiling. 3. Progressive thrombosis within the false lumen of the focal infrarenal aortic dissection. Aortogram [**2147-4-29**] IMPRESSION: 1. Selective right third lumbar angiogram demonstrating residual filling of the previously embolized pseudoaneurysm. 2. Successful coil re-embolization along the length of the L3 lumbar artery with complete stasis seen on follow-up post embolization angiography. 3. Right common femoral angiogram demonstrating no evidence for contrast extravasation. Incidental note made of moderate stenosis involving approximately 1-cm segment of the distal SFA near its junction with the popliteal artery. A small focal dilation in a peripheral medial profunda branch is noted corresponding to the findings on the CT from [**2147-4-29**] but unlikely to be related to the patient's hematoma. Transesophogeal echo [**2147-5-1**] No spontaneous echo contrast is seen in the body of the left atrium. Overall left ventricular systolic function is normal (LVEF>55%). There are complex (>4mm) atheroma in the aortic arch and descending aorta. There are three aortic valve leaflets with moderate thickening and calcification but no vegetations. There is no significant aortic regurgitation. A bileaflet mitral valve prosthesis is present. No mass or vegetation is seen on the mitral valve. Mild mitral regurgitation is seen that is normal for this type of prosthesis. The tricuspid and pulmonic valves were not well seen. There is no pericardial effusion. IMPRESSION: No evidence of endocarditis on the bileaflet mechanical mitral valve or the native aortic valve. CT without contrast abd/pelvis [**2147-5-3**] IMPRESSION: 1. Stable to slightly decreased size of right psoas, right pelvic sidewall, and right thigh hematoma. No new hematomas are seen. 2. Multiple embolization coils seen along the right psoas muscle at the L3 level. 3. Extensive atherosclerotic calcification of the abdominal aorta and iliac arteries. 4. Status post mitral valve replacement with sternal cerclage wires. 5. Stable calcified pulmonary nodule, which may be related to prior granulomatous disease. 6. Stable-appearing multilevel vertebral body compression fractures status post kyphoplasty. 7. Diverticulosis without diverticulitis. Brief Hospital Course: Ms. [**Known firstname **] [**Known lastname **] is a 81 year old female with history of rheumatoid arthritis, with recent L4-L4 back laminectomy in [**12-17**], with chronic back pain, who had 5 recent kyphoplasties in [**State 108**], after which developed a retroperitoneal bleed from a pseudoaneurysm of the L3 artery and was transferred to [**Hospital1 18**] to be started on anticoagulation for her St. [**Male First Name (un) 923**] MVR. # Retroperitoneal bleed: Based on imaging, likely from a pseudoaneurysm of the L3 artery branch of the aorta, which bleed in the setting of a supratheraputic INR after procedure. At the OSH she required a total of 7 units of blood, and was transferred off anticoagulation with a stable hct. She was restarted on the heparin drip and her hct slowly trended down from 34 to 29 over 2 days, and given 1 unit of blood. Repeat CT scan showed increased size of bleed. IR was consulted and on [**4-25**] performed embolization with multiple coils of aneurysm. During this she had hypertension and some ST changes consistent with demand ischemia. She was monitored in the MICU overnight and restarted on heparin 6 hours post op. On [**4-29**] she was noted to have increasing pain in her thigh, and her hct fell to 22.4. Repeat CTA showed increased bleeding from the same area and now the hematoma expanded into her thigh. She was given 2 units of blood and returned for a second IR guided embolization with additional coils, gel foam, and thrombin placed again. She was kept off heparin for 2 and half days post procedure. Her hct had a slight decrease to 26 from 28 (thought to be from dilution from PICC line), given one additional unit of blood. Then heparin was restarted on [**2147-5-3**], since then hct has been stable. . Will need daily hematocrit check, and if concern for bleeding heparin drip should be stopped and consider CT with contrast. Can have contrast with power PICC that is in place. . # Mitral valve replacement with mechanical St. [**Male First Name (un) 923**]: She requires long term anticoagulation from high risk of stroke and valve thrombosis. However, also has risk for RP bleed to worsen. See above for bleeding course. Now restarted on heparin on [**2147-5-3**]. Goal PTT of 50-70 to prevent rebleeding, Q6H PTT checks, follow sliding scale. Once stable for 1 week, consider restarting [**Date Range 197**] at rehab. Patient is very sensitive to [**Date Range 197**] (was on 1.5 as out pt) and will likely need slow bridging on low doses. . # Rheumatoid arthritis: Patient on long term prednisone, was given 2 bursts of steroids during her admission due to increased knee pain and concern for possibility of adrenal insufficiency. Was on 20mg for 3 days, then back to 5 mg per day; then after IR procedure had 2 days of 20mg, then 10mg x 1 day, and then back to 5 mg. During these times she had a leukocytosis of 22, and it was unclear if it was from the steroids vs the UTI. Improved by discharge with decreased steroids and antibiotics. . # Pain: Has pain in back and right thigh from chronic issues and from bleed. However, is very sensitive to pain medications. Very easily over sedated and becomes delirious with narcotics. Initially she was treated with morphine, this was then stopped, and her mental status and pain improved. She is now on tramadol TID and standing Tylenol. Also lidocaine patches. . # Osteoporosis: multiple fractures, s/p kyphoplasty on 5 vertebral fractures. She has not been on a bisphosphonate and will need to be started on one. She was started on calcium and vitamin D. Recommend out pt bone scan. . # ST depressions with HOCM: She developed ST depressions with hypertension in setting of IR procedure, also had similar depressions in precordial and lateral leads in FL with initial bleed. She had no chest pain. Resolved with treatment of blood pressure with metoprolol IV and labetalol IV. Was ruled out for MI. Likely from increased stress in setting of HOCM. If hypertensive in the future cardiology recommends to treat with BB or CCB, and avoid agents that decrease preload due to her HOCM. . # Bacteremia: On [**4-24**] she had [**2-12**] culture bottles positive with STREPTOCOCCUS ANGINOSUS in setting of elevated WBC (also on high dose steroids). She was afebrile and also had a klebsiella UTI at that time. She had 3 sets of negative cultures on vancomycin and was transitioned to ceftriaxone. Due to hx of mechanical valve, TEE was done to rule out endocarditis, was negative study. Per infectious disease recommendations, pt to complete course of ceftriaxone on [**2147-5-10**] for 2 week course. . # UTI: Klebsiella Pneumonia, had Foley from outside hospital. Also had elevated WBC as noted above. Was first treated with Cipro, then once on ceftriaxone this was stopped. She completed a 10 day course and had Foley removed. No bladder obstruction. . # Diastolic heart failure: Chronic, no heart failure sx during admission. . # Hypertension: Only had increased BP during IR procedure to 160s. Otherwise controlled on metoprolol 25 [**Hospital1 **]. . # Hyperlipidemia: Was continued on statin . # Gastritis: seen on recent EGD at OSH, may be secondary to chronic steroids. She was placed on PPI and continued at discharge. No epigastric pain. . # Nutrition: very poor PO intake during admission. Seen by nutrition. Once bleed was treated and narcotics stopped. Pt was more responsive and has started to have more PO intake. Passed a swallowing study. Needs encouragement to eat and assistance in feeding. Supplement drinks between meals. . # Communication: Patient, son [**Name (NI) **] is HCP day [**Telephone/Fax (1) 96677**] night [**Telephone/Fax (1) 96675**] cell [**Telephone/Fax (1) 96674**] . # She is being discharged to [**Hospital 100**] Rehab for further care and physcial therapy. Medications on Admission: Acetaminophen Docusate Sodium Ferrous Sulfate Fluoxetine Lansoprazole Oral Disintegrating Tab Ondansetron PredniSONE Simvastatin Vitamin D Zolpidem Tartrate Discharge Medications: 1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 5. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours): max 4g per day. 6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for pain: hold for sedation. 7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain: on for 12 hours, off for 12 hours . 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for loose stool. 9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day): apply to buttocks rash. 10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for painful tongue. 11. 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. 12. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 13. Heparin (Porcine) in NS 10 unit/mL Kit Sig: One (1) Intravenous drip: drip as per d/c instructions, goal PTT 50-70. 14. Ceftriaxone 1 gram Recon Soln Sig: One (1) Intravenous once a day for 6 days: last day [**2147-5-10**]. 15. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 17. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for SBP<100, HR<60. 18. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 19. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day). 20. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 21. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary- Retroperitoneal bleed from 3rd Lumbar pesudoaneursym Secondary- Demmand Ischemia in setting of Hypertrophic Obstructive Cardiomyopathy Bacteremia with Strep anginosus Urinary tract infection Mitral valve replacement requiring anticoagulation Hypertension Discharge Condition: Hemdynamically stable, afebrile, on heparin drip Discharge Instructions: You were admitted to [**Hospital1 18**] due to needing to restart your anticoagulation in a setting of a bleed after your kyphoplasty. You had two procedures to stope the bleeding. You have now been restarted on your heparin. You will start your [**Hospital1 **] next week. You also were treated with anitbiotics for a bladder infection and a possible blood infection. Your last day of antibiotics will be [**2147-5-10**]. It is improtant that you eat in order to heal. You will be going to a rehab to gain your strength and improve your eating. Please call to make an appointment with you primary care docotor once you leave the rehab center. If you have chest pain, shortness of breath, new abdominal pain, new weakness, problems with [**Name2 (NI) 16019**], fainting, or other concerning symtpoms please seek medical attention or go to the ER. Followup Instructions: Please call to make an appointment with you primary care docotor once you leave the rehab center. PCP: [**Name10 (NameIs) **],[**First Name3 (LF) 2946**] S. [**Telephone/Fax (1) 2205**] Completed by:[**2147-5-5**]

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icd9cm

[ [ [] ] ]

[ "88.42", "38.86", "88.72", "38.93" ]

icd9pcs

[ [ [] ] ]

21222, 21288

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295, 613

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197+55193

Discharge summary

report+addendum

Admission Date: [**2136-4-4**] Discharge Date: [**2136-4-9**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: fatigue Major Surgical or Invasive Procedure: R IJ placement History of Present Illness: This is a 84 year-old Russian speaking female with a history of systemic hypertension, pulmonary arterial hypertension, chronic diastolic CHF, who presents with hypotension, drop in hematocrit and guaiac positive stools. She reportedly collapsed 3 times today. Per son, patient felt lightheaded every time she stood up and had to sit back down to the floor. She has never had a problem like this in the past. Denies any NSAID or alcohol use. Denies hematemesis. Occasional blood-tinged stool when she strains, but denies hematochezia. Denies any fevers. Denies black or bloody stools, but stool always black because of iron. Of note, patient was recently admitted and discharged on [**2136-4-2**] with multifocal pneumonia. In the ED, initial vitals were T:98.3, BP:81/20, HR:79, O2 Sat 100% on 4L. NG lavage was negative. Patient received 2 units PRBC and right IJ placed for persistent hypotension. . ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, diarrhea, constipation, chest pain, orthopnea, PND, lower extremity oedema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: #. Pulmonary HTN on 2 litres home O2 #. CHF - last echo [**8-1**]: ef > 55% with Symmetric LVH with preserved global and regional biventricular systolic function. No pulmonary hypertension seen. #. HTN #. Type II DM #. Hyperlipidemia #. Low back pain #. Obesity #. h/o heart murmur - ? PDA #. Anemia (baseline ~ 26-30) #. Urinary incontinence #. Syncope Social History: The patient lives alone and has VNA help. She denies etoh and smoking, and for ambulation wears a back support corset(belt), compression stocking and uses a walker. She is on 2L home oxygen Family History: NC Physical Exam: Vitals: T:97.3 BP:105/37 HR:88 RR:21 O2Sat:96% on RA GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, pale conjunctiva, no epistaxis or rhinorrhea, dry MM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, 3/6 systolic murmur, normal S1 S2, radial pulses +2 PULM: Lungs CTAB ABD: Soft, Superficial subcutaneous firm area, NT, ND, +BS, no HSM, EXT: No peripheral oedema. NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. SKIN: Pale Pertinent Results: Laboratories: Notable for Hematocrit of 22 down from baseline 30, WBC 22.5, and creatinine 3.9 up from baseline 1.4. See below for rest. . ECG: Sinus rhythm at 76 bpm with evidence of RVH, normal axis and intervals, no ST-T changes. . Imaging: [**2136-4-4**] Chest x-ray: FINDINGS: Portable AP upright chest radiograph is obtained. Evaluation is somewhat limited by underpenetrated technique. There is no definite evidence of pneumonia. Heart size is stable. Pulmonary arterial prominence is noted compatible with patient's given history of pulmonary hypertension. Atherosclerotic calcification at the aorta is noted. There is no pneumothorax. Diffuse demineralized bone is noted with post-surgical changes of the right proximal humerus. . Abdominal CT:Large right rectus muscle hematoma approximately 10.1x4.4x15.2 cm. . Echocardiogram on [**2136-3-26**]: The left atrial volume is markedly increased (>32ml/m2). The left atrium is dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. 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 left ventricular inflow pattern suggests impaired relaxation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Brief Hospital Course: This is a 84 year-old female with a history of pulmonary hypertension, diastolic CHF, who presented with weakness, hypotension, Guaiac positive stools. . # Hypotension - Her hypotension and anemia were felt to be due to blood loss from rectus sheath hematoma. Unknown exactly how the hematoma occurred (?secondary to heparin injection while recently hospitalized)but was well visualized on the abdominal CT that she had in the ER. She was evaluated by GI (due to anemia and guaiac positive stools), who found external hemorrhoids on exam and stated there was little or no concern regarding duodenal angioectasia as source of hematocrit drop. They followed and plans for c-scope if she started bleeding again. Her Hct was 22 on admission, microcytic. She received 3 units of blood in total and her hematocrit stablized at 29-30 for several days. Her blood pressure was 80/40 on admission and she was admitted to the MICU, but did not require pressors, her BP increased with blood and fluids (2L). In the ICU she was on a po PPI, had two large bore IVs, as well as central access. Her Hct was checked q6 hours and transfusion parameter was 26. Her aspirin was held. Her BP increased to teens over 80's and she was transferred to the medical floor after one day in the MICU. On the medical floor her blood pressure remained in the 120's/80's initially but then increased to 140's. Her lisinopril, valsartan, metoprolol and furosemide were held initially due to her relatively low blood pressure and increased creatinine (see below). Her furosemide was restarted on the last day of hospitalization due to blood pressure that would tolerate it and signs of hypervolemia. In addition she had several bowel movements on the day prior to admission, likely due to many laxatives she was receiving. She did not have a leukocytosis, fever. The stool was guiaic negative. Her laxatives were discontinued except docusate. . # Acute renal failure - Pre-renal secondary to hypotension/hypovolemia. C Her electrolytes and volume status were stable. Her lisinopril, lasix and valsartan were held and continue to be held as her blood pressure is in the 130's. Her creatinine was 3.4 on admission with a baseline of 1.6. Her creatinine decreased to 1.4 after hydration and her lasix was restarted at her home dose of 80mg po bid. . # Leukocytosis - WBC on admission was very high, likely reactive, given hypotension, and acute blood loss. Blood and urine cultures were negative and she had no diarrhea. Her CXR was unremarkable and antibiotics were deferred as there was no source of infection, she was afebrile and her leukocytosis resolved (WBC was 7 for the last two days of admission). . # Hyperlipidemia - She continued to take atorvastatin . # Chronic pain - She continued to take gabapentin . # Diabetes mellitus - insulin sliding scale while in house, once creatinine normalized glipizide 2.5mg q daily was re-started. . # Psych - Continued paroxetine . # PPx: She had pneumoboots . # Code: Full code . # Comm: [**Name (NI) 1961**],[**Name (NI) **] (Son) [**Telephone/Fax (1) 1976**] Medications on Admission: #. Atorvastatin 20mg #. Aspirin 81mg #. Docusate 200mg [**Hospital1 **] #. Gabapentin 300mg qHS #. Paroxetine 20mg daily #. Prilosec 20mg daily #. Diovan 160mg daily #. Glipizide 2.5mg SR daily #. Lisinopril 20mg daily #. Niferex-150 Forte 150-25-1 mg-mcg-mg [**Hospital1 **] #. Metoprolol Tartrate 12.5mg [**Hospital1 **] #. Senna 8.6mg [**Hospital1 **] #. Clindamycin 300mg q6H x 4 days #. Lasix 80mg [**Hospital1 **] #. Albuterol q4-6 hours Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 4. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection ASDIR (AS DIRECTED). 6. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 9. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Location (un) 582**] of [**Location (un) 583**] Discharge Diagnosis: Primary: - Acute blood loss anemia - Acute renal failure - Hypovolemic shock - Rectus sheath hematoma - GI bleed NOS - Acute on chronic renal failure - Acute on chronic diastolic heart failure - Pulmonary hypertension on home O2 Secondary: - Hypertension - Diabetes mellitus type II - Chronic pain - Upper GI bleed - Depression Discharge Condition: stable, ambulatory, afebrile, good po intake, stable hematocrit Discharge Instructions: You were admitted with low blood pressure, anemia. You were treated in the medical intensive care unit. You received blood transfusions and IV fluids. You were evaluated by the gastroenterologists that felt that your low blood count was due to the collection of blood in your abdominal wall and possibly some bleeding from your small intestine. You blood counts remained stable and your blood pressure improved. You were transferred to the medical floor where you remained stable. Physical therapy evaluated you, worked with you. . Please continue to take your medication as prescribed. You should call your doctor if you feel weak, dizzy, have abdominal pain, nausea, vomiting, black or red stool. . It is important that you follow up as outlined below. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 544**], M.D. Date/Time:[**2136-5-4**] 11:10 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2136-9-5**] 10:00 Completed by:[**2136-4-10**] Name: [**Known lastname 172**],[**Known firstname 173**] Unit No: [**Numeric Identifier 174**] Admission Date: [**2136-4-4**] Discharge Date: [**2136-4-9**] Date of Birth: [**2052-3-7**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 175**] Addendum: [**Location (un) 176**] of [**Location (un) 177**] [**Name (NI) 178**], spoke [**Name (NI) 179**] [**Last Name (NamePattern1) 180**] was discharged on 50,000 units vit D per day in error, [**Name (NI) 178**] Ms. [**Name13 (STitle) **] that the correct dose is vitamin D 1600 units a day. Discharge Disposition: Extended Care Facility: [**Location (un) 176**] of [**Location (un) 177**] [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 181**] MD [**MD Number(1) 182**] Completed by:[**2136-4-10**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

11234, 11468

4461, 7560

266, 282

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79,195

181,626

37643

Discharge summary

report

Admission Date: [**2187-8-23**] [**Month/Day/Year **] Date: [**2187-8-31**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 974**] Chief Complaint: s/p Fall down 11 stairs Major Surgical or Invasive Procedure: [**2187-8-28**] Vertebroplasty History of Present Illness: 85 yo female s/p fall down 11 stairs. She was taken to an area hospital where found to have a T3 burst fracture and L5 compression fracture. She was then transferred to [**Hospital1 18**] for further care. Past Medical History: HTN Shingles Social History: Married and lives with husband Family History: Noncontributory Pertinent Results: [**2187-8-23**] 05:23PM GLUCOSE-167* UREA N-15 CREAT-0.9 SODIUM-139 POTASSIUM-5.6* CHLORIDE-102 TOTAL CO2-26 ANION GAP-17 [**2187-8-23**] 05:23PM WBC-14.9* RBC-4.59 HGB-13.7 HCT-41.8 MCV-91 MCH-30.0 MCHC-32.9 RDW-13.1 [**2187-8-23**] 05:35PM PT-11.8 PTT-21.8* INR(PT)-1.0 [**2187-8-23**] 05:23PM PLT COUNT-206 [**2187-8-23**] 05:35PM FIBRINOGE-401* [**2187-8-23**] 05:40PM LACTATE-2.4* TCO2-26 [**2187-8-23**] 08:00PM URINE RBC-[**2-15**]* WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0-2 CT head [**2187-8-23**] IMPRESSION: No acute intracranial process, including no hemorrhage, edema or mass. No fracture CT C-spine [**2187-8-23**] 1. T3 burst fracture incompletely evaluated, described in detail on dedicated thoracic spine CT. 2. No other fracture. 3. Multilevel degenerative changes in the cervical spine, most pronounced at C5-6 level, leading to spinal canal stenosis, which predisposes to spinal cord injury. CT T-spine [**2187-8-23**] IMPRESSION: Acute T3 burst fracture with approximately 50% loss of vertebral body height and mild retropulsion into the spinal canal. CT does not provide sufficient soft tissue detail to evaluate the spinal cord, and if clinically indicated, MR may be obtained to evaluate for acute spinal cord edema. Cardiology Report ECG Study Date of [**2187-8-25**] 12:16:02 PM Sinus rhythm. Compared to the previous tracing of [**2187-8-23**] there is no change. Intervals Axes Rate PR QRS QT/QTc P QRS T 90 186 86 362/414 70 0 46 MR CERVICAL SPINE W/O CONTRAST; MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST [**2187-8-25**] IMPRESSION: Compression of L5 vertebra is noted with increased signal on inversion recovery images which could be due to acute/subacute compression. Mild retropulsion of the posterior superior portion is seen which in combination of disc degenerative change and facet degenerative changes result in moderate spinal stenosis at L4-5 level. Mild degenerative changes at other levels in the lumbar region. Repeat head CT [**2187-8-28**] IMPRESSION: No evidence of acute intracranial abnormalities. Brief Hospital Course: She was admitted to the trauma service. Orthopedic Spine surgery was consulted given her spine fractures. After discussion with patient's family the decision was made for patient to undergo a vertebroplasty vs surgical intervention. She was taken to Interventional Radiology where the procedure was performed; there were no complications. Post procedure she was monitored closely. It was felt that she did not require a TLSO brace and that her activity could be advanced. Physical and Occupational therapy were the consulted; she is being recommended for rehab after her acute hospital stay. Treatment for a UTI was started early, she will continue on Ampicillin for another 3 days after hospital [**Month/Day/Year **]. Geriatric Medicine was consulted given her age and mechanism of injury. Several recommendations pertaining to her medications were made. calcium and Vitamin D were added as prophylaxis. She was placed on around the clock Tylenol and prn Ultram. The Amitriptyline was weaned and discontinued as it was felt could be contributing to her delirium. She was evaluated by Speech for a bedside swallow; she is being recommended for a soft diet and thin liquids. She was noted to complain of right shoulder pain and an xray was done which showed no fracture or dislocations. Medications on Admission: Lovastatin 20', HCTZ 25', Atenolol 25', Amitriptiline 50' qhs [**Month/Day/Year **] Medications: 1. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5,000 Units Injection TID (3 times a day). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Erythromycin 5 mg/g Ointment Sig: One (1) Appl Ophthalmic QID (4 times a day) as needed for conjuntivitis for 4 days: Apply OU. 6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime): Apply OS. 7. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 12. Ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 3 days. 13. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as needed for constipation. 14. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's PO twice a day as needed for constipation. [**Month/Day/Year **] Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] [**Location (un) **] Diagnosis: s/p Fall T3 burst fracture L5 compression fracture Urinary tract infection Delirium [**Location (un) **] Condition: Hemodynamically stable, tolerating a regular diet, pain adequately controlled. Followup Instructions: Follow up in 2 weeks with Dr. [**Last Name (STitle) 1352**], Orthopedic Spine Surgery; call [**Telephone/Fax (1) 3736**] for an appointment. Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from rehab. Completed by:[**2187-8-31**]

[ "780.09", "372.30", "041.04", "805.2", "E880.9", "401.9", "805.4", "599.0" ]

icd9cm

[ [ [] ] ]

[ "81.65" ]

icd9pcs

[ [ [] ] ]

2816, 4108

296, 328

699, 2793

5799, 6076

663, 680

4134, 5547

5579, 5664

233, 258

5696, 5776

356, 563

585, 599

615, 647

28,566

197,334

45862

Discharge summary

report

Admission Date: [**2108-9-6**] Discharge Date: [**2108-9-11**] Date of Birth: [**2059-9-20**] Sex: M Service: CARDIOTHORACIC Allergies: Epoetin Alfa Attending:[**First Name3 (LF) 165**] Chief Complaint: asymtomatic with + ETT and known CAD Major Surgical or Invasive Procedure: CABG X 6 [**2108-9-6**] (LIMA to LAD, SVG to DIAG, SVG to RAMUS, SVG to OM, SVG to PDA, sequentially to PLV) History of Present Illness: 48 yo male currently being evaluated for renal transplant. Had a + persantine stress test and cath revealed severe 3VD. Referred for CABG. Past Medical History: 1. Diabetes mellitus type I-retinopathy, neuropathy 2. ESRD on Hemodialysis Tu/Th/Sa - started [**8-2**] 3. Peripheral vascular disease 4. History of syncopal episodes. 5. s/p left toe amputation. 6. Autonomic neuropathy. 7. Degenerative joint disease 8. Anemia of chronic inflammation 9. History of orthostatic hypotension. 10. Hypertension 11. Chronic diarrhea thought [**3-2**] diabetic enteropathy. 12. HCV (per note in [**2106**], stage I fibrosis c grade [**1-31**] inflammation, VL 2.5 million, never on treatment) 13. Left TKR secondary to trauma, [**2105**] at [**Hospital1 112**]. 14. enterobacter line infection, enteroccous bacteremia, enterococcus septic prosthetic knee (TTE negative) 15. Left knee washout [**11-2**] 16. Left knee prosthesis removal and I+D [**11-2**] 17. Erectile dysfunction s/p penile implant. Social History: Married, owns a shoe store. Denies EtOH Quit tobacco 6 years ago, previously smoked 1 PPD X 15 yrs Denies current drug use. History of IVDA (heroin) and cocaine 5 years ago. Family History: Mom died of MI in her early 50's Sister with DM Physical Exam: 81.8 kg 6'1" HR 64 RR 12 183/93 NAD lying flat after cath pt. refused further exam Pertinent Results: [**2108-9-11**] 07:05AM BLOOD WBC-5.0 RBC-2.39* Hgb-7.0* Hct-19.9* MCV-83 MCH-29.1 MCHC-35.0 RDW-17.4* Plt Ct-194 [**2108-9-6**] 12:03PM BLOOD WBC-7.5 RBC-2.85* Hgb-8.2* Hct-23.4* MCV-82 MCH-28.7 MCHC-35.0 RDW-15.8* Plt Ct-151 [**2108-9-7**] 04:35AM BLOOD PT-13.1 PTT-33.4 INR(PT)-1.1 [**2108-9-6**] 12:03PM BLOOD Plt Ct-151 [**2108-9-6**] 12:03PM BLOOD PT-15.8* PTT-31.3 INR(PT)-1.4* [**2108-9-11**] 07:05AM BLOOD Glucose-176* UreaN-56* Creat-9.3* Na-136 K-3.7 Cl-95* HCO3-26 AnGap-19 [**2108-9-7**] 04:35AM BLOOD Glucose-109* UreaN-34* Creat-8.2* Na-134 K-5.7* Cl-98 HCO3-23 AnGap-19 [**2108-9-11**] 07:05AM BLOOD Calcium-7.6* Phos-5.2* Mg-2.5 [**2108-9-7**] 04:35AM BLOOD Calcium-8.9 Phos-5.8* Mg-3.0* RADIOLOGY Final Report CHEST (PA & LAT) [**2108-9-10**] 8:47 AM CHEST (PA & LAT) Reason: evalaute effusion [**Hospital 93**] MEDICAL CONDITION: 48 year old man with s/p cabg REASON FOR THIS EXAMINATION: evalaute effusion TWO VIEWS OF THE CHEST ON [**9-10**] The sternal sutures and change from coronary artery surgery noted. There is still a small left pneumothorax. Air is seen at the anterolateral lung base and some air over the apex as well as a small amount of mediastinal reaction and fluid. There is also atelectasis at the left base and additional effusion. CONCLUSION: Minimal change is present but the overall appearance of the chest is good postoperatively. DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Approved: MON [**2108-9-10**] 9:54 AM RADIOLOGY Final Report KNEE (AP, LAT & OBLIQUE) LEFT [**2108-9-10**] 2:51 PM KNEE (AP, LAT & OBLIQUE) LEFT Reason: warmth and swelling [**Hospital 93**] MEDICAL CONDITION: 48 year old man with REASON FOR THIS EXAMINATION: warmth and swelling LEFT KNEE CLINICAL HISTORY: Warmth and swelling. AP and lateral views were obtained. Since the study of [**2107-9-3**], the patient has undergone another revision of the total knee arthroplasty. New metallic femoral and tibial components are seen, and there appears to have been further resection of the distal femur. The patella is quite osteopenic and poorly defined. No hardware loosening or fracture is seen. There are multiple bony fragments medially and laterally, more extensive than on the study from roughly one year previously. IMPRESSION: The patient has undergone additional revision of the total knee arthroplasty with more resection of bone. No fracture or loosening of the prosthetic components is seen. There is diffuse soft tissue swelling and osteopenic bony fragments. No studies after the most recent surgery are available for comparison and obviously infection cannot be excluded. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: MON [**2108-9-10**] 7:28 PM Cardiology Report ECG Study Date of [**2108-9-6**] 2:13:58 PM Sinus rhythm. Axis to the left. Prominent intrinsicoid deflection in leads V2-V4. Normal P-R interval. Compared to the previous tracing of [**2108-8-29**] left axis deviation and prominent intrinsicoid deflections have newly appeared. Terminal T wave inversions in leads V5-V6 are no longer present. Read by: [**Last Name (LF) **],[**First Name3 (LF) **] I. Intervals Axes Rate PR QRS QT/QTc P QRS T 73 126 98 [**Telephone/Fax (2) 97675**] -48 42 Cardiology Report ECHO Study Date of [**2108-9-6**] PATIENT/TEST INFORMATION: Indication: Coronary artery disease Status: Inpatient Date/Time: [**2108-9-6**] at 07:56 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW02-7:56 Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Name (STitle) **] MEASUREMENTS: Left Ventricle - Ejection Fraction: 55% to 60% (nl >=55%) Aorta - Ascending: 3.2 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.0 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave Deceleration Time: 260 msec INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic function (LVEF>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. The patient appears to be in sinus rhythm. Results were personally Conclusions: PRE-BYPASS: The left atrium is normal in size. 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 mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Post-bypass: Patient has preseved biventricular function, mild mitral regurgitaion. Aortic contours are intact. Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD on [**2108-9-10**] 12:50. [**Location (un) **] PHYSICIAN: Brief Hospital Course: Admitted on [**9-6**] and underwent cabg x6 with Dr. [**First Name (STitle) **]. Transferred to the CSRU in stable condition on phenylephrine and propofol drips. Followed by the renal service for management of dialysis timing. Extubated that afternoon, and transferred to the floor on POD #1 to begin increasing his activity level. Had dialysis on [**9-7**], he continued to progress. Physical therapy worked with him on mobility. Orthopedics was consulted for swelling and warmth left knee, xray obtained, and to follow up with Dr [**Last Name (STitle) 7111**]. He was had hemodialysis [**9-11**] and was transfused with PRBC for decreased hematocrit. He continued to do well and was ready for discharge home with services on POD 5. Medications on Admission: lopressor 50 mg TID hydralazine 25 mg TID ASA 81 mg daily zocor 10 mg QHS clonidine 0.1 mg [**Hospital1 **] renagel 1 tab daily lisinopril 10 mg daily loperamide 2 mg TID humulin NPH 12 units QAM regular insulin 10 units QAM percocet 2 tabs [**Hospital1 **] oxycontin Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:*60 Tablet(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Oxycodone 5 mg Tablet Sig: 2-4 Tablets PO Q4H (every 4 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 6. insulin please resume insulin regime and follow up with Dr [**Last Name (STitle) **] at [**Last Name (un) **] NPH 12 units qam Regular 10 units qam 7. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Three (3) Tablet Sustained Release 12 hr PO twice a day for 1 weeks. Disp:*42 Tablet Sustained Release 12 hr(s)* Refills:*0* 8. Zocor 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Coronary Artery Disease s/p CABG x6 IDDM retinopathy autonomic neuropathy ESRD/HD T-Th-SAT HTN PVD DJD chronic diarrhea with DM enteropathy ED s/p penile implant Hep. C L TKR with mult. knee surgs for infections L toe amp Discharge Condition: good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Please follow up with PCP and Dr [**Last Name (STitle) **] in relation to pain management Followup Instructions: Please call to schedule all appointments see Dr. [**Last Name (STitle) 1789**] in 1 week [**Telephone/Fax (1) 1792**] see Dr. [**Last Name (STitle) 1016**] in [**3-3**] weeks see Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] see Dr [**Last Name (STitle) **] in 2 weeks Continue with hemodialysis Tuesday/Thrusday/Saturday Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE Date/Time:[**2109-1-4**] 2:30 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2108-9-11**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

9983, 10038

7877, 8616

314, 428

10305, 10312

1829, 2651

10913, 11574

1657, 1706

8934, 9960

3498, 3519

10059, 10284

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1721, 1810

238, 276

3548, 5191

456, 596

7854, 7854

618, 1449

1465, 1641

24,646

196,959

52757

Discharge summary

report

Admission Date: [**2198-7-24**] Discharge Date: [**2198-8-2**] Service: MEDICINE Allergies: Metoprolol / Cozaar Attending:[**First Name3 (LF) 14145**] Chief Complaint: direct admission; ECG changes and global hypokinesis on echo at cardiology clinic Major Surgical or Invasive Procedure: cardiac catheterization with DES to LAD placement and removal of right internal jugular line History of Present Illness: [**Age over 90 **]yo man with history of atrial flutter and recurrent SVT s/p [**Age over 90 4448**] placement, hypertension, referred to [**Hospital1 18**] ED for evaluation for cardiac catheterization by his cardiologist when he was found to have ECG changes and new global hypokinesis and depressed ejection fraction on echocardiogram at his clinic visit. At the visit, the patient noted dyspnea on exertion over the past one to two months when he exercises. He walks three times per week on the treadmill. He also noted a 30 minute episode of left substernal chest pressure that developed about one week ago and resolved after three sublingual nitroglycerin tabs. This pain was not associated with shortness of breath, nausea, diaphoresis, and did not radiate. He does not get chest pressure when he exercises. Over the past month he has developed some shortness of breath with laying flat at night. He has been told he has lower extremity swelling, but he did not note this. He denies fevers, chills, sweats, cough, palpitations, abdominal pain, nausea, vomiting, dysuria or hematuria. He has occasional consitpation, denies bloody or black stools. In the ED he was treated with clopidogrel, aspirin, and metoprolol. . Previous work-up has included cardiac cath at OSH in [**2186**] demonstrating mild mid-LAD stenosis, no interventions done. He had a stress test in [**10/2197**] showing no ischemia. Past Medical History: Coronary artery disease- s/p cath [**2186**] with mild-mid LAD stenosis; Stress [**10-14**]: no ischemia Postural Hypotension Aflutter s/p cardioversion in [**2190**] s/p pacemaer placement; 1st degree AV block Hypertension Moderate MR [**First Name (Titles) 8304**] [**Last Name (Titles) **] insufficiency with baseline creat 1.6 s/p R carotid endarterectomy s/p B/L cataract surgery Thrombocytopenia s/p hip fracture Anemia Prostate cancer Neuropathy Tonsillectomy Rheumatoid Arthritis Myelodysplasia Neuropathy Bradycardia Social History: patient lives with his wife. [**Name (NI) **] is a retired shoe-part factory owner Tob: previous 30yrs x 1ppd, quit 30yrs ago EtOH: none Exercises at the gym 3-4x/week on bicycle for 10-15 minutes and walks [**2-11**] mile a day Family History: non-contributory Physical Exam: T 96.4 HR 54 BP 152/72 RR 20 100%2Lnc Gen: lying flat on back at 15degrees elevation, NAD HEENT: left pupil scarred, reaction bilaterally, anicteric, left eyelid swelling with mild erythema, no discharge, OP clear, MMM Neck: supple, no LAD, JVP 7cm CV: PMI nondisplaced, RRR, distant heart sounds, II/VI SEM Resp: CTAB Abd: +BS, soft, NT, ND, no masses, no HSM Ext: [**2-10**]+ edema Neuro: A&Ox3, motor and sensation intact grossly Pertinent Results: Brief Hospital Course: [**Age over 90 **] yo man with history of coronary artery disease, found to have ST-depressions and echo with global hypokinesis and reduced EF at cardiologist's office, admitted for cardiac cath, with hospitalization complicated by bleeding hematoma necessitating brief CCU stay. During his hospitalization the following issues were addressed:. 1. Coronary artery disease: Patient was admitted for cardiac catheterization. On admission he creatinine was elevated above baseline and his INR was elevated on coumadin. Coumadin was held, and acute [**Age over 90 **] failure was treated with gentle hydration. He underwent cardiac cath with PCI DES to LAD on [**2198-7-27**]. After cath, coumadin was resumed heparin gtt continued for a subtherapeutic INR in the setting of history of Afib and recurrent SVT. On [**2198-7-29**] he developed a large right groin hematoma, and Hct dropped acutely from 27 to 19. He was taken to the CCU, a central line placed, and transfused 4units PRBC. The hematoma stabilized with clamp pressure. He was called out of the CCU the following day, and required one subsequent unit PRBC during his hospitalization to maintain a Hct greater than 30. Heparin and coumadin was discontinued. Coumadin will likely be restarted as an outpatient by Dr. [**Last Name (STitle) **] when he is stable. He was continued on aspirin and Plavix for secondary prevention. He is not on a beta-blocker or ACE-I due to adverse reactionsin past (wheezing to former, ARF to latter). His troponins did rise during the period of acute blood and hypotension loss due to demand ischemia. No further interventions were done. He was started on imdur for BP control. 2. CHF: EF is reported at 35%. The patient remained euvolemic throughout. He was diuresed briefly after the blood transfusions. 3. Afib: Patient has a h/o Afib maintained on Rhythmol. This was changed to sotolol, which he tolerated well. Anticoagulation will be restarted as an outpatient as discussed above. 4. Acute [**Last Name (STitle) **] failure on [**Last Name (STitle) **] [**Last Name (STitle) **] insufficiency: Baseline creatinine is 1.6. The patient was admitted wit an elevated creat 2.4 that corrected with hydration. It remained stable throughout the remainder of his hospitalization. All medications were renally dosed. 5. PVD with [**Last Name (STitle) **] ulcer. He was evaluated by [**Last Name (STitle) 1106**] in house and will f/u with Dr. [**Last Name (STitle) **] as an outpatient. Dressing changes qd per VNA. 5. Dispo: Patient was discharged to home with services. He will follow-up with Dr. [**Last Name (STitle) **]. Medications on Admission: Coumadin Folate 3 mg [**Hospital1 **] Atorvastatin 10 mg po daily Propafenone 225 tid Clocein for SBP ppx Finsasteride 5 mg po daily Modafinil 200 mg po daily Tamsulosin 0.4 mg po daily Mirtazapine 7.5 mg po qhs Torsamide 2.5 mg po daily Pentoxyfylline 400 tid Darvocet 1 tab daily Oxybutynin XL 5 daily Vitamin C 1g daily Discharge Medications: 1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Modafinil 100 mg Tablet Sig: Two (2) Tablet PO qd (). 4. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 5. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO TID (3 times a day). 6. Ascorbic Acid 500 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 9. Bimatoprost 0.03 % Drops Sig: One (1) drop Ophthalmic [**Hospital1 **] () as needed for glaucoma. 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 30 days. Disp:*30 Tablet(s)* Refills:*0* 11. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 12. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 13. Imdur 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Primary: Coronary artery disease Hematoma PVD with [**First Name3 (LF) **] ulcer . Secondary: Hypertension Myelodysplasia h/o recurrent SVT Discharge Condition: stable Discharge Instructions: Please hold your coumadin until you follow-up with Dr. [**Last Name (STitle) **]. Please take all other medications as prescribed. . If you develop chest pain, shortness of breath, palpitations, or any other concerning symptom, please contact Dr. [**Last Name (STitle) **] and/or return to the emergency department. Followup Instructions: 1. Please follow-up with Dr. [**Last Name (STitle) **] within the next two weeks. You can call [**Telephone/Fax (1) 108812**] to schedule an appointment. Provider: [**Name10 (NameIs) **] CALL Where: NONE CARDIAC SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2198-10-16**] 11:15 2. Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2199-1-16**] 10:30 3. Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY Where: [**Last Name (NamePattern4) **] SURGERY Date/Time:[**2198-8-23**] 10:15

[ "593.9", "414.01", "V45.01", "V10.46", "410.71", "428.0", "285.1", "238.7", "401.9", "584.9", "997.1", "998.12", "707.14", "272.0", "440.23", "427.89" ]

icd9cm

[ [ [] ] ]

[ "37.23", "36.07", "36.01", "88.56", "99.04", "99.20" ]

icd9pcs

[ [ [] ] ]

7496, 7579

3191, 5831

309, 404

7763, 7771

3168, 3168

8135, 8799

2665, 2683

6204, 7473

7600, 7742

5857, 6181

7795, 8112

2698, 3148

188, 271

432, 1850

1872, 2400

2416, 2649

78,415

194,041

47034

Discharge summary

report

Admission Date: [**2112-1-11**] Discharge Date: [**2112-1-24**] Service: MEDICINE Allergies: Ether Attending:[**First Name3 (LF) 1257**] Chief Complaint: CC:[**CC Contact Info 99728**] Major Surgical or Invasive Procedure: None History of Present Illness: EAST HOSPITAL MEDICINE ATTENDING ADMISSION NOTE Date: [**2112-1-13**] Time: 05:35 The patient is a [**Age over 90 **] yo F recently discharged [**2111-12-23**] after admission initially to the [**Hospital Unit Name 153**] [**2111-12-20**] with hypercarbic respiratory acidosis who presented to the ED with 3 days of AMS. She has been home from rehab for about 6 days. Per family, did not "do well" and was unhappy at rehab. Has been comnplaining of abdominal pain for the past 2-3 days. She presented to scheduled follow up at her PCP's office this morning, where it was reported that she was hypotensive. She was brought to the ED from her PCP's office given concern for her BP and mental status. Per daughters, no fevers, no CP, no SOB although not very active. Has suspected sleep apnea and desats with sleep, but family felt that pt would not cooperate with CPAP titration last admission. Ms. [**Known lastname 99729**] Lasix had been d/ced last admission, but family noted that she was recently started back on a daily dose of Lasix (had previously been on 40mg [**Hospital1 **]). In ER: VS: 98.1 61 136/48 18 99% RA CXR was consistant with CHF exascerbation. She had a CT AP for nonspecific abdominal pain which showed bilateral pleural effusions with atelectasis, R > L, but was otherwise no acute pathology. 1st trop 0.03. UA unremarkable. VBG 7.31/67/39/35. She recieved 20mg IV furosemide. Given increased lethargy and somnulence in the ED, she was placed on BiPAP with improvement in her mental status. Per family report, she was on BiPAP for about one hour and tolerated it well. Vitals prior to transfer to the [**Hospital Unit Name 153**] were HR 54, BP 130/42, RR 20, Sat 99% on [**10-26**] FiO2 40% In ICU, she was on non-rebreather and was A&O x 1. She was managed conservatively for 24 hours and then transfered to the floor. On the floor, she is on 4L NC and has no complaints, although she is still only A&O x 1. Review of Systems: (+) Per HPI (-) Unable to assess due to patient's altered mental status Past Medical History: Past Medical History: - Alzheimer's dementia with delusions and sundowning (Pt's family confirms confusion and sundowning, but denies Dx of Alzheimer's or dementia) - arteriosclerotic heart disease - mitral regurgitation - hypertension - h/o UTI's with Klebsiella and E.coli - depression - lower extremity edema, ? CHF (Per family, pt was admitted to [**Location (un) 745**]-[**Location (un) 3678**] a few years ago and was Dx with CHF. No Echo in our system). - diffuse degenerative arthritis of the spine and arthritis of the right knee - S/p radical thyroidectomy for cancer of the thyroid - S/p left knee replacement - hearing aide in her left ear - GERD - varicose veins with venous stasis - hypercholesterolemia - s/p cataract surgery in her left eye. - Chronic renal insufficiency, baseline 1.4-1.7. Social History: Lives in nursing home, [**Last Name (un) **] [**Last Name (un) 43131**] House, walks with walker. She does not smoke or drink alcohol. Family History: Not relevant Physical Exam: VS: 97.7 100/42 75 20 96% 4L NC GEN: Alert to person only; no apperent distress HEENT: no trauma, pupils round and reactive to light and accomodation, no LAD, oropharynx clear, no exudates CV: regular rate and rhythm, no murmurs/gallops/rubs PULM: clear to auscultation bilaterally, no rales/crackles/rhonchi GI: soft, non-tender, non-distended; no guarding/rebound EXT: no clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV present DERM: no lesions appreciated Pertinent Results: Admission Results: [**2112-1-11**] 11:15AM BLOOD WBC-4.1 RBC-3.40* Hgb-10.9* Hct-33.5* MCV-98 MCH-32.0 MCHC-32.5 RDW-14.7 Plt Ct-156 [**2112-1-11**] 11:15AM BLOOD Neuts-54.7 Lymphs-35.2 Monos-6.3 Eos-2.1 Baso-1.6 [**2112-1-11**] 11:15AM BLOOD PT-12.7 PTT-24.9 INR(PT)-1.1 [**2112-1-11**] 11:15AM BLOOD Glucose-109* UreaN-28* Creat-1.8* Na-142 K-4.6 Cl-104 HCO3-29 AnGap-14 [**2112-1-11**] 11:15AM BLOOD proBNP-5053* [**2112-1-11**] 11:15AM BLOOD cTropnT-0.03* [**2112-1-11**] 05:05PM BLOOD Type-[**Last Name (un) **] pO2-39* pCO2-67* pH-7.31* calTCO2-35* Base XS-4 Comment-GREEN TOP [**2112-1-11**] 11:39AM BLOOD Glucose-107* Lactate-2.3* Na-143 K-4.5 Cl-99* calHCO3-31* . Microbiology: 1. Urine Culture ([**1-10**]): pending as of [**1-12**] 2. Blood Culture ([**1-10**]): pending as of [**1-12**] . CXR (PA, Lateral) ([**1-10**]): 1. Findings compatible with mild congestive heart failure with small bilateral pleural effusions and mild bibasilar atelectasis. 2. Cardiomegaly. Please note, a small pericardial effusion is seen on today's CT. CT Abdomen and Pelvis ([**1-10**]): 1. No specific acute intra-abdominal CT findings. 2. Bilateral small pleural effusions with associated atelectasis, right greater than left. 3. Small pericardial effusion. 4. Diverticulosis. 5. Coronary artery and vascular atherosclerotic disease. 6. Fibroid uterus. CXR ([**1-11**]): 1. Increased mild pulmonary edema. 2. Stable bilateral pleural effusions and associated atelectasis. . Urine cx [**1-13**]: Pansensitive E coli Brief Hospital Course: This is a [**Age over 90 **] year old woman who was recently admitted for hypercarbia secondary to suspected sleep apnea not on CPAP who presented with lethargy, pulmonary edema as well as diarrhea. Her lethargy was suspicious for hypercarbia encephalopathy. She was initially treated with BIPAP for one hour in the ED, and then admitted to the ICU. In the ICU, she was treated with only oxygen as well as diuresis, and discharged to the floor. She had a sleep study on the floor, which showed severely disordered breathing with desaturation, [**Last Name (un) **] [**Doctor Last Name **] breathing, and apnea. She was started on low dose Provigil 50 mg in the morning, and this was titrated up to 50 mg twice daily and then to 100 in AM and 50 at noon with some improvement in her daytime sleepiness. Before Provigil titration, she had severe apnea with desaturation on the floor and was transferred back to the ICU for a trial of BiPAP which she failed. In regards to her diastolic CHF exacerbation, her CXR findings were from flash pulmonary edema which also could be related to mitral regurgitation (no echo in our system; Echo was not done because of her advanced age and no surgical options). BNP in the ED was 5053. Troponin's were negative for ACS. She was treated with 20 mg IV Lasix and a short course of BiPAP as above. She developed mild worsening of renal function in the setting of diuresis. Her Lasix was decreased to 20 mg every other day and then 40 mg daily and her creatinine was stable on this oral Lasix. In regards to her acute encephalopathy, it was related to hypercapnia and poor sleep from sleep apnea/obesity hypoventilation syndrome. This has resolved completely. She, however, developed catheter associated UTI. On hospital day 4, after discontinuation of her Foley catheter, she developed incontinence and foul smelling urine. It grew out pan sensitive E coli, and she was treated with ciprofloxacin 250 mg po daily for 7 days. Despite initial diarrhea, C Diff was negative and she subsequently developed formed stools. I spent more than 30 minutes with her daughter daily to discuss prognosis, short life expectancy, and appropriate discharge plans. Family decided for home discharge with 24 hour care and strong consideration for hospice. She is at high risk for rehospitalization unless she is in a hospice program because of short life expectancy, advanced age, and very poor functional status. She was DNR/DNI and her emergency contact was [**Name (NI) **],[**First Name3 (LF) **] her DAUGHTER and HCP. Phone: [**Telephone/Fax (1) 99730**] Medications on Admission: CITALOPRAM 10 MG PO DAILY FOLIC ACID 1MG PO DAILY LOVASTATIN 20 MG PO DAILY OMEPRAZOLE 20 MG PO DAILY CALCIUM/VITAMIN D 500MG/400 UNITS DAILY MULTIVITAMINS ONE DAILY VITAMIN E SUPPLEMENTS -ONE PO DAILY furosemide 40 mg po BID potassium chloride 20 mEq S.R. po BID OTC: Calcium 500 mg / Vit D 1 po daily MVI 1 po daily Vitamin E 200 units po daily Discharge Medications: 1. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. 5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for affected area. 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Provigil 100 mg Tablet Sig: 1 tab at 8 AM and [**1-24**] tab at 12 noon Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 11. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2 times a day) as needed for hemorrhoids. 14. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Hospital1 100**] Senior Life Home Health Care Discharge Diagnosis: Hypercarbic respiratory failure Acute encephalopathy Urinary tract infection Acute renal failure Chronic kidney disease, stage III Sleep apnea Discharge Condition: Level of Consciousness: Lethargic but arousable. Mental Status: Clear and coherent. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted with confusion related to retention of carbon dioxide (CO2) from your breathing/slepping disorder. We did a sleep study to evaluate the cause, and tried you on a breathing machine which was uncomfortable for you to wear. You also had a urinary tract infection and some kidney injury. You received antibiotics and Provigil. The last medication is to keep you awake and for you to breath betther. We discussed hospice with you family but they decided for discharge home with 24 hour care. You can hold Lasix for 1-2 days but you need to restart it. Please consult with your PCP regarding future dose. Followup Instructions: Department: INTERNAL MEDICINE When: MONDAY [**2112-1-25**] at 3:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 143**], MD [**Telephone/Fax (1) 142**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

[ "327.23", "041.4", "414.01", "403.90", "459.81", "996.64", "272.0", "584.9", "287.5", "428.33", "424.0", "311", "599.0", "530.81", "V49.86", "276.2", "294.8", "454.8", "715.96", "721.90", "278.00", "348.39", "428.0", "112.89", "585.3", "E879.6" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9569, 9648

5367, 7952

244, 250

9834, 9883

3829, 5344

10660, 10966

3309, 3323

8350, 9546

9669, 9813

7978, 8327

10018, 10637

3338, 3810

2237, 2310

174, 206

278, 2218

9898, 9994

2354, 3141

3157, 3293

59,349

190,504

35282

Discharge summary

report

Admission Date: [**2193-3-5**] Discharge Date: [**2193-3-11**] Date of Birth: [**2120-5-9**] Sex: M Service: NEUROSURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 3227**] Chief Complaint: Right Frontal Mass Major Surgical or Invasive Procedure: [**2193-3-6**] Craniotomy for tumor resection History of Present Illness: This is a 72 y.o. M with widely metastatic melanoma including involvement of liver, lung, bone, subcutaneous nodules and multiple cerebral metastasis. He is s/p IL therapy and currently undergoing CTLA4 therapy. The therapy is complicated by colitis requiring steroid treatment. The steroid was tapered to off in late [**12-21**]. While most of the systemic metastasis responded to CTLA4, the right frontal mass increased in size from [**2193-1-8**] MRI (4 x 2.8 x 3 cm) to the [**2193-3-2**] MRI (5.5 x 3.5 x 3.5 cm). Neurosurgery is consulted with regard to surgical resection of the lesion Past Medical History: Metastatic melanoma (see below for oncologic history) HTN DM2 . Past oncologic history: Mr. [**Known lastname 21207**] originally presented in [**2189-6-12**] with a 5-mm malignant melanoma of stage IIC (T4, N0, M0, [**Doctor Last Name **] level IV), at which time he had an excision and then he received interferon for 11 months. Four months later, he went in for follow up at the VA and he developed a new right preauricular mass at the excision site and underwent reexcision as well as parotidectomy at the VA, followed by involved-field radiation with 5000 cGy in [**2191-7-13**] in Central [**State 1727**]. In [**2192-4-12**], he developed lesions on his lips, right leg, left occiput, and left temple. All the lesions were excised and pathology revealed incompletely excised metastatic melanoma. He additionally underwent a CT scan of the torso on [**2192-8-15**] which revealed lung, liver, soft tissue, bone, and adrenal metastasis. On [**2192-8-23**], he underwent a CT scan of the brain that showed three lesions, two 15 mm lesions in the right and left frontal lobes with associated edema, but no evidence of shift and a third lesion in the right frontoparietal lobe. Social History: The patient works repairing small engines. He smokes small cigars about eight to ten a day over the last several years and used to be a cigarette smoker, but quit 15 years ago. He used to smoke about a pack a day for several years. He very rarely drinks alcohol. He is married and has two children and seven grandchildren. Family History: His father had melanoma with extensive disease on his nose which required essentially entire excision of his nose and then he believes he developed metastatic disease. He died of an MI at age 72. His mother is 96 and still alive. He has no siblings. His children are all healthy. Physical Exam: Upon admission: On examination, the patient is awake, alert, and appropriate His speech appear fluent and comprehension intact He does not appear in any acute distress. VFF. mild papilledema. EOMI. FS. hearing and SCM symmetric. tongue and uvula midline. Normal tone and bulk. No abnormal movements. Full strength except LLE (5-/5). Able to stand without the use of his arms. Sensation intact to LT. Diffusely hyporeflexic. No Hoffmans or Clonus. Rhomberg negative. Normal gait. Normal FTN and [**Doctor First Name **]. On Discharge: XXXXXXXXXXXX Pertinent Results: Labs on Admission: [**2193-3-5**] 12:13PM BLOOD WBC-3.3* RBC-4.37* Hgb-13.4* Hct-38.7* MCV-89 MCH-30.6 MCHC-34.6 RDW-14.7 Plt Ct-271 [**2193-3-5**] 12:13PM BLOOD Neuts-63.3 Lymphs-25.0 Monos-9.1 Eos-2.2 Baso-0.3 [**2193-3-5**] 12:13PM BLOOD PT-12.9 PTT-22.7 INR(PT)-1.1 [**2193-3-5**] 12:13PM BLOOD ESR-18* [**2193-3-5**] 12:13PM BLOOD UreaN-20 Creat-1.0 Na-140 K-4.2 Cl-106 HCO3-29 AnGap-9 [**2193-3-5**] 12:13PM BLOOD ALT-20 AST-25 LD(LDH)-220 AlkPhos-82 Amylase-39 TotBili-0.3 DirBili-0.1 IndBili-0.2 [**2193-3-5**] 12:13PM BLOOD TotProt-7.2 Albumin-4.7 Globuln-2.5 Calcium-9.6 Phos-3.8 UricAcd-4.2 Labs on Discharge: XXXXXXXXXXXXX MRI HEAD [**2193-3-8**]: FINDINGS: Since the previous study the patient has undergone resection of right frontal enhancing mass lesion. Blood products are seen at the surgical site with a small area of slow diffusion involving the brain at the margin of surgical resection and most likely related to the surgical procedure. Following gadolinium there is no evidence of a definite area of residual enhancement identified in the right frontal region. The previously noted right posterior frontal enhancing lesion is also no longer visible. This lesion was also not visualized on the MRI of [**2193-3-6**] and [**2193-3-2**]. There remains some mass effect on the right lateral ventricle and corpus callosum. There is no hydrocephalus. IMPRESSION: Status post resection of right frontal tumor. Marginal slow diffusion could be related to surgical procedure. Blood products at the surgical site are seen without definite residual enhancement. Small bilateral subdurals appear related to the recent surgery. Pneumocephalus. Small areas of susceptibility as before. CT Head [**2193-3-7**]: FINDINGS: Multiple postoperative changes are notable in the brain including osseous defects consistent with right frontal craniotomy. Subjacent to this site is what is likely postoperative pneumocephalus. Right frontal defects are consistent with surgical mass excision. There is adjacent right frontal hypodensity, indicating edema, which was present on preoperative studies. A small amount of hyperdense fluid is seen layering posteriorly within the occipital horns of the lateral ventricles bilaterally consistent with a small amount of hemorrhage. There is no other evidence of large intracranial bleeding. There is no shift of normal midline structures. Apart from the surgical defects, visualized osseous structures are unremarkable. The paranasal sinuses are notable for mucosal thickening in the maxillary sinuses bilaterally, more prominently on the left. The mastoid air cells are clear. IMPRESSION: Multiple postoperative changes as detailed above. There is no evidence of large postoperative intracranial bleeding. EKG [**3-6**]: Sinus bradycardia Normal ECG except for rate Since previous tracing of [**2193-3-5**], heart rate slower Intervals Axes Rate PR QRS QT/QTc P QRS T 55 164 86 424/415 -5 -10 16 Brief Hospital Course: 72 y.o. M with widely metastatic melanoma including involvement of liver, lung, bone, subcutaneous nodules and multiple cerebral metastasis. He is s/p IL therapy and currently undergoing CTLA4 therapy. The therapy is complicated by colitis requiring steroid treatment. The steroid was tapered to off in late [**12-21**]. While most of the systemic metastasis responded to CTLA4, the right frontal mass increased in size from [**2193-1-8**] MRI (4 x 2.8 x 3 cm) to the [**2193-3-2**] MRI (5.5 x 3.5 x 3.5 cm). Neurosurgery is consulted with regard to surgical resection of the lesion. Review of system is notable for increased frequency of HA as well as difficulty negotiating stairways. The wife states that the patient has a tendency to lean to one side. He was admitted on [**3-5**] to begin work up for planned surgical resection of said frontal lesion. He went to the OR on [**3-7**] for surgical resection. Post-operatively he was maintained in the ICU for 24h of observation. On POD#1, he was transferred to neurosurgery floor. Decadron taper to off was started. Neurological examination after surgery was intact, without focal deficit. He was seen and evaluated by physical and occupational therapy who determined he would be appropriate for home discharge with appropriate supervision. Medications on Admission: Atenolol, Doxazosin, Gemfibrozil, Insulin, Lisinopril, Simvastatin Discharge Medications: 1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 3. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed: Please continue to take Colace/Docusate; while you require narcotic pain medication. Disp:*40 Tablet(s)* Refills:*0* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 9. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) for 4 doses. Disp:*4 Tablet(s)* Refills:*0* 10. Dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) for 4 doses: to start after 2mg dosing completed. Disp:*8 Tablet(s)* Refills:*0* 11. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 12. Outpatient Occupational Therapy 13. Outpatient Physical Therapy Discharge Disposition: Home With Service Facility: Androscoggin Home Care & Hospice Discharge Diagnosis: Right frontal mass Discharge Condition: Neurologically stable Discharge Instructions: General Instructions/Information ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ??????You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? You are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: increasing redness, increased swelling, increased tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: -Please return to the office in [**6-21**] days(from your date of surgery) for a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. -You have a Brain [**Hospital 341**] Clinic appointment with [**Name6 (MD) 5005**] [**Name8 (MD) 78783**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2193-3-18**] 2:00 pm. This located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], on [**Hospital Ward Name 23**] [**Location (un) **]. Please call [**Telephone/Fax (1) 44**] if you require additional directions, or must change your appointment. -You have an appointment for a MRI of your head immediately before on [**2193-3-18**] at 12:35pm. This will also occur on the [**Hospital Ward Name 5074**], please call [**Telephone/Fax (1) 327**] if you require additional directions or must change your appointment. Completed by:[**2193-3-11**]

[ "197.7", "250.00", "348.5", "327.23", "197.0", "272.4", "198.7", "198.5", "431", "198.89", "401.9", "V10.82", "198.3" ]

icd9cm

[ [ [] ] ]

[ "01.59" ]

icd9pcs

[ [ [] ] ]

9073, 9136

6367, 7669

293, 341

9199, 9223

3401, 3406

11106, 12141

2529, 2810

7787, 9050

9157, 9178

7695, 7764

9248, 11083

2825, 2827

3367, 3382

235, 255

4023, 6344

369, 968

3420, 4004

990, 2172

2188, 2513

17,125

117,486

4498

Discharge summary

report

Admission Date: [**2102-12-10**] Discharge Date: [**2102-12-16**] Service: [**Hospital Ward Name 19217**] CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: This is an 80 year old woman with chronic obstructive pulmonary disease on home O2 at a basal rate of three liters per minute on nasal cannula admitted for shortness of breath of a few days duration. The patient was admitted to the Medical Intensive Care Unit for hypercarbia and respiratory acidosis, intubated for two days, and then extubated and started on steroids, bronchodilators and Levofloxacin empirically for pneumonia/bronchitis. Vital signs were stable, and the patient was transferred to the ACOVE Service. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease. The patient was intubated twice. She is normally on home O2 at three liters per minute and has an FEV1 of 0.66 liters. 2. The patient also has history of hypertension. 3. History of partial deafness. 4. History of colon cancer; status post resection in [**2098**]. 5. History of osteoarthritis. 6. History of a stroke. OUTPATIENT MEDICATIONS: 1. Albuterol. 2. Atrovent. 3. Serevent. 4. Ranitidine 150 mg twice a day. 5. Clonidine 0.25 mg twice a day. 6. Ritalin. ALLERGIES: Doxycycline. HOSPITAL COURSE: After the patient was transferred from the Unit, the goal was to bring her back to her baseline oxygen requirement. Nebulizer treatments were continued and gradually transitioned with the aide of respiratory therapy with metered dose inhalers. The patient was continued on the p.o. Levaquin antibiotic. Over the next few days, the patient's course gradually improved and oxygen requirement decreased so that she returned to her baseline. The patient was evaluated by Physical Therapy and any final evaluation of rehabilitation potential versus home with assistance. The patient will be discharged home on the following medications. DISCHARGE MEDICATIONS: 1. Prednisone 30 mg p.o. q. day for three days followed by 20 mg p.o. q. day times three days followed by 10 mg p.o. q. day times three days, then 10 mg every other day for three days, and then finally stopping. 2. Ipratropium two puffs inhaled three times a day. 3. Albuterol two puffs inhaled q. four to six hours. 4. Levofloxacin 250 mg p.o. q. day times ten days. 5. Insulin on regular sliding scale. 6. Clonazepam 0.25 mg p.o. twice a day. 7. Calcium carbonate, or TUMS, three tablets p.o. q. day. 8. Protonix 40 mg p.o. q. day. 9. Lorazepam 1 to 2 mg intravenous q. two to four hours p.r.n. agitation. 10. Alendronate 5 mg p.o. q. day. 11. Vitamin D 400 International Units daily. DISCHARGE INSTRUCTIONS: 1. Diet is regular soft diet. 2. No restrictions on activity as tolerated for weight bearing. 3. Anticipated goal is to return the patient to maximum semblance of independent activities of daily living. DISCHARGE DIAGNOSES: Chronic obstructive pulmonary disease exacerbation. CONDITION ON DISCHARGE: Stable. [**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**] Dictated By:[**Last Name (NamePattern1) 8442**] MEDQUIST36 D: [**2102-12-15**] 17:41 T: [**2102-12-15**] 18:45 JOB#: [**Job Number 19218**]

[ "491.21", "518.81", "401.9", "V10.05", "458.9", "715.98", "733.00", "438.9" ]

icd9cm

[ [ [] ] ]

[ "96.71", "38.93", "96.04" ]

icd9pcs

[ [ [] ] ]

2911, 2964

1961, 2658

1301, 1938

2682, 2889

1128, 1282

137, 159

189, 712

734, 1104

2990, 3245

21,460

146,318

51199

Discharge summary

report

Admission Date: [**2136-10-23**] Discharge Date: [**2136-11-14**] Date of Birth: [**2095-4-26**] Sex: F Service: TRANSPLANT SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 41 year old female patient, status post an orthotopic liver transplant in [**2136-5-31**], secondary to alcoholic cirrhosis, complicated by a hepatic artery stenosis, status post stenting in [**2136-8-31**]. She has been ask to return for another angiogram to evaluate increasing liver function tests on her surveillance laboratories. She denies any fever, chills, nausea, vomiting, upper respiratory symptoms, shortness of breath, chest pain, abdominal pain, change in appetite, change in bowel habits, change in color of stool, dysuria or hematuria. PAST MEDICAL HISTORY: 1. Alcoholic cirrhosis. 2. Hemachromatosis. 3. Antiphospholipid syndrome. 4. Neuropathy and myopathy. 5. Hyponatremia. 6. Orthotopic liver transplant in [**2136-5-31**], complicated by a myocardial infarction. 7. Cesarean section. ALLERGIES: She has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Protonix 40 mg once daily. 2. Bactrim single strength one once daily. 3. Gabapentin 300 mg p.o. three times a day. 4. Lopressor 50 mg p.o. twice a day. 5. Fludrocortisone 0.1 mg once daily. 6. Norvasc 10 mg once daily. 7. CellCept 1 mg twice a day. 8. Plavix 75 mg once daily. 9. Aspirin 325 mg p.o. once daily. 10. Cyclosporin 175 mg twice a day. 11. Prednisone 10 mg once daily. SOCIAL HISTORY: The patient does smoke one pack of cigarettes a day and she does still currently use alcohol. PHYSICAL EXAMINATION: On physical examination, she has a low grade temperature of 99.8. Her pulse is 70, blood pressure 108/62, respiratory rate 18, and her oxygen saturation is 96% in room air. On general examination, she is somnolent and jittery with a flat affect. Her neurologic examination, cranial nerves II through XII are intact. Cardiovascular is regular rate and rhythm. The lungs are clear to auscultation bilaterally. The abdomen is soft, nontender, nondistended, well healed abdominal scar. Extremities - no cyanosis, clubbing or edema. She has palpable dorsalis pedis pulses. LABORATORY DATA: On admission, her laboratory values are significant for a sodium of 128, potassium 5.3, creatinine 1.9, ALT 54, AST 29, alkaline phosphatase 412 and total bilirubin of 0.9. Her hematocrit on admission was 29.0. HOSPITAL COURSE: Because of the length of the stay, we will evaluate the patient's admission with a system spaced approach. Neurologically, the patient's main neurologic problem was her pain control. She would use Oxycontin and Oxycodone to control her pain and would need Benadryl to help sleep at night. Ambien and other benzodiazepines were avoided due to the risk of hepatotoxicity. In addition, the patient while admitted continued to smoke cigarettes at a feverish pace both by walking downstairs and outside of the hospital as well as smoking within her room surreptitiously. Cardiovascularly, the patient was continued on Metoprolol and Norvasc throughout her admission. Pulmonary - The patient developed some pulmonary infiltrates on several chest x-rays. A bronchoscopy was performed with bronchoalveolar lavage on [**2136-12-2**]. This yielded positive cultures of [**Last Name (LF) 23087**], [**First Name3 (LF) 564**] Albicans and cytomegalovirus for which she was subsequently treated. FEN - The patient remained well hydrated throughout her admission and was given a regular diet basically throughout her stay, se the nights of NPO prior to various procedures. Gastrointestinal - The patient's [**Last Name **] problem is her gastrointestinal issues. She presented with hepatic artery stenosis/thrombosis. As evidenced by the [**2136-10-24**], angiography which revealed a significant pressure gradient in the hepatic artery as well as a dilated tortuous hepatic artery course, these areas of hepatic artery were ballooned open and an arterial stent was placed on [**2136-10-24**]. However, a subsequent cholangiography revealed a necrotic area within the parenchyma of the liver with proximal dilated biliary trees. These were subsequently stented with external drainage in interventional radiology on [**2136-10-25**], and various upsizing were performed to the PTCs. A final cholangiogram was performed on [**2136-11-8**], which revealed that the collection was in a very difficult position, about two to three centimeters above the bifurcation of the biliary tree. This irregular collection did communicate with both the right and left biliary systems. Moreover, as if that were not problem[**Name (NI) 115**] enough, biliary culture grew out not only fungus but [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 10577**] which is notoriously resistant to Diflucan. She was started on AmBisome and subsequently discharged on [**Last Name (NamePattern1) 106245**] which was not as nephrotoxic. Genitourinary - There were no issues. Hematologically, the patient did require one unit of packed red blood cells for a chronic blood loss anemia. Infectious disease - The patient was started on empiric antibacterials of Zosyn, Vancomycin, and Levofloxacin. Gradually, the need for the Zosyn and Vancomycin was obviated by the negative bacterial cultures and the patient only remained on Levofloxacin at the time of her discharge. She also was treated with AmBisome which caused her to have increasing creatinine and other nephrotoxic problems so she was switched over to [**Name (NI) 106245**] which is less nephrotoxic. A PICC line was placed on [**2136-11-7**], to enable her to undergo home intravenous antibiotic therapy. Transplant - The patient throughout her admission was maintained in immunosuppressed state with Cyclosporin, CellCept and Prednisone. DISPOSITION: On [**2136-11-14**], the patient was discharged home with VNA care for her bilateral percutaneous drains. On discharge physical examination, the patient was afebrile with stable vital signs. She was alert and oriented times three in no apparent distress. Her lungs were clear to auscultation bilaterally. The abdomen was soft, nontender, and her percutaneous transhepatic catheters had bilious output. Her laboratory values were significant only for an alkaline phosphatase of 751. DISCHARGE DIAGNOSES: 1. Status post orthotopic liver transplant [**2136-6-4**]. 2. Hepatic artery thrombosis. 3. Hepatic abscess. 4. Candidal cholangitis. 5. CMV pneumonia. 6. Ethanol cirrhosis. 7. Hematochromatosis. 8. Antiphospholipid syndrome. 9. Neuropathy. 10. Myopathy. MAJOR SURGICAL PROCEDURES: 1. Bilateral biliary stent placement. 2. Biliary stent upsizing and manipulation. 3. Bronchoscopy. 4. Percutaneous transhepatic cholangiogram. 5. Hepatic artery balloon dilatation and hepatic artery stenting. MEDICATIONS ON DISCHARGE: 1. CellCept [**Pager number **] mg twice a day. 2. Prednisone 5 mg once daily. 3. Neoral 150 mg p.o. twice a day. 4. Valcyte 900 mg once daily. 5. [**Pager number 106245**] 70 mg intravenously once daily for two weeks. 6. Oxycontin 20 mg q12hours. 7. Percocet one to two tablets q4-6hours as needed for pain. 8. Bactrim one single strength tablet once daily. 9. Protonix 40 mg once daily. 10. Gabapentin 600 mg three times a day. 11. Metoprolol 25 mg twice a day. 12. Levofloxacin 500 mg p.o. once daily. 13. Norvasc 10 mg once daily. 14. Vancomycin one gram once daily for two weeks. Outpatient laboratory work to include complete blood count, differential, Chem10, liver function tests, Cyclosporin and Vancomycin levels. FOLLOW-UP: She has follow-up appointment with Dr. [**First Name (STitle) **] [**Name (STitle) **] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] as directed by the discharge planning sheet. [**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**] Dictated By:[**Last Name (NamePattern1) 1179**] MEDQUIST36 D: [**2137-1-1**] 13:15 T: [**2137-1-1**] 18:51 JOB#: [**Job Number 106246**]

[ "584.9", "576.1", "078.5", "996.82", "572.0", "447.1", "576.8", "112.4", "275.0" ]

icd9cm

[ [ [] ] ]

[ "39.50", "51.87", "39.90", "97.05", "33.24", "87.54", "38.93", "88.47", "50.91", "51.98", "87.51" ]

icd9pcs

[ [ [] ] ]

6355, 6862

6888, 8094

1082, 1476

2437, 6334

1612, 2419

178, 749

771, 1056

1494, 1589

1,321

139,634

20755

Discharge summary

report

Admission Date: [**2113-10-15**] Discharge Date: [**2113-10-25**] Date of Birth: [**2095-10-21**] Sex: M Service: NEUROLOGY Allergies: Vancomycin / Fluorescein Attending:[**First Name3 (LF) 7575**] Chief Complaint: ongoing confusion, agitation Major Surgical or Invasive Procedure: video EEG monitoring History of Present Illness: CC:[**CC Contact Info 55377**] HPI: 17 year old RH boy with history of PANDAS s/p strep infection, cognitive decline over several years, junvenile rheumatoid arthritis, multiple seizures and autoimmune diseases in the family who is being transferred from the MICU to neurology service to rule out epilepsy as a cause of hallucinations and episodes of pain/emesis. Patient was born full term, normal spontaneous vaginal delivery. Mom had UTI and was treated with bactrim x 2 weeks at the beginning of her pregnancy. He had Rh incompatibility, hyperbilirubin, treated with phototherapy. Developmental milestones met on time, although he never learned to tie shoes or ride bicycle. Did well all through childhood into high school- intelligent, popular, athletic. Diagnosed with junvenile RA [**2103**] when he presented with fever, swollen joints. Treated with naprocen. During the summer of [**2109**], obtained long bout of sinusitis, + strep, fever 104 daily, "red palms". In [**2110-10-2**] developed complications of the strep infection (PANDAS) with OCD, ?myoclonus, sydenhams chorea, frequent PVCs on cardiac tele, and "painless limp." Found to have high ASO titers by Dr. [**Last Name (STitle) 55378**] at [**Hospital3 **] [**Location (un) **]. Treated with two courses of IVIG with improvement in ruminations and chorea. However, developed aseptic meningitis as a complication of IVIG thus treatment was stopped. Slowly developed neurocognitive decline, neuropsych testing showed poor cognition. For the poor cognition, headache, limp, had LP [**2111-5-2**] but no opening pressure was done. Unremarkable per mother. Metabolic workup was undertaken including muscle biopsy for possibly mitochondrial disease (Dr. [**Last Name (STitle) **], however, biopsy was "lost for months" thus testing was inconclusive. Treated with co-Q. Had eye exam in [**2111-7-2**] with florecien angiogram and diagnosed with papilledema [**2-1**]. LP at this time with opening pressure of 24, 28 cm H2O. VP shunt was placed for presumed pseudotumor cerebri [**10-4**]. Afterwards limp/headache/cognition improved. Of note, mom notes AM erections have ceased, and per her the patient is very perturbed by this. They are seeking urological input on this issue. One and a half months ago he again had a sinus infection with rhinorrhea, cough, fevers up to 101.5 daily. With a fever he would have cough, burning red swollen hands, back pain, dizziness, sweating, projectile emesis wihtout nausea. These episodes occur every 4 days and last 7-10 minutes, afterwhich he is lethargic, sleepy, "disoriented." last episode was on [**2113-10-13**]. Additionally, he was recently admitted to [**Hospital1 2025**] for these episodes, given ativan for sleep, and began hallucinating ("they are performing neuropsych testing on me, the projector is behind my head") , strange behavior. Mom would find him wrapped up in the telephone cord. He was discharged after improvement with ativan. mom gave ativan as directed for sleep at night and again began acting strangely: muttering to himself, seeing "gremlins on the walls." Visual changes upon standing (lights dimming). Mom wanted him to be reevaluated, and since he did see Dr. [**Last Name (STitle) **] in clinic a few months ago for transfer of his care to the [**Hospital1 18**], they decided to present to the [**Hospital1 18**]. In the ED, he became aggressive when the discussion re: doing an LP arose. He pulled his IV, cursed, yelled, ran down the hallway, requiring security action. He was admitted to the MICU for observation and security guard/behavior management. Has been on multiple AEDs for mood stabilization. Also, mom states, "I'm not a munchausen mom" out of the blue. Past Medical History: As above+ juvenile arthritis raynaud's h/o sydenham's chorea s/p strep infection EEG [**2110**] negative, no seizure activity has seen Dr [**Last Name (STitle) **] in Neurology at [**Hospital1 18**] PCP is Dr [**Last Name (STitle) 3265**] at [**Hospital1 2025**] Social History: Dad is a psychiatry epidemeiologist, mom is a PHD in clinical psychology. Has 16 yo sister, and twin siblings 15 yo. Has had to go to a "step down" school for the past 2 years. Previously was smart, athletic, "most popular." Family History: Mom: MVP, PFO, pericarditis, febrile seizures, TIA (couldn't speak) while on OCPs, migraine with visual changes Mat GF: died of hypokalemia, [**Doctor Last Name 11332**] mal seizures, microangiopathy of the brain, catasil (DNA abnormality) Dad: sleep apnea on CPAP, 100's of lipomas [**Name (NI) **] cousin: downs syndrome [**Name (NI) **] GM: childhood stoke 16 yo sister: + [**Doctor First Name **] 1:160, + antiribonucleic ab, FUO, elevated ESR and CRP, anemia, joint pain, memory disturbances 15 yo female twin: drop seizures with abnormal EEG, + tilt table, cognitive problems. 15 [**Name2 (NI) **] male twin: healthy Physical Exam: VITALS: AF, 82-115, 117/85, 97% on RA, +1.7L I/O GEN: follows commands but speaks very few words, almost mute SKIN: no rash HEENT: NC/AT, anicteric sclera, mmm NECK: supple CHEST: normal respiratory pattern, CTA bilat, pectus excavatum CV: regular rate and rhythm without murmurs ABD: soft, nontender, nondistended, +BS, no HSM EXTREM: no edema NEURO: Mental status: Patient is awake. Almost mute, would answer very few questions and only in one word sentences. Would not or could not name objects. No left/right mismatch. Could not test memory. Cranial Nerves: I: deferred II: Visual acuity: unable to test. Visual fields: full to left/right/upper/lower fields. Fundoscopic exam: disk margins NOT crisp. Pupils: 6->4mm, consenual constriction to light. III, IV, VI: EOMS full, gaze conjugate. No nystagmus or ptosis. V: facial sensation intact over V1/2/3 to light touch VII: symmetric smile VIII; hearing intact to finger rubs IX, X: Symmetric elevation of palate. [**Doctor First Name 81**]: SCM [**4-5**] bilaterally XII: tongue midline without atrophy or fasciulations. Sensory: was able to say "yes" when I tickled each extremity Motor: Normal bulk, tone. No fasciculations or drift. + shaking of left leg which was supressible. Turned over in bed quickly without difficulty. Strength: Delt Tri [**Hospital1 **] WE WF FE FF IP QD Ham DF PF Toe Reflexes: [**Hospital1 **] BR Tri [**Hospital1 **] Ach Toes RT: 2 2 2 3 2 beats clonus down LEFT: 2 2 2 3 2 beats clonus down * crossed adductors* Coordination: Slow but normal finger-to-nose, no dysmetria Gait: unable to test on my exam, but on chief residents exam was able to ambulate without difficulty however was VERY slow. HR shot up to 130's + dizziness with arising. * Upon discharge, patient's exam MUCH improved. Interactive, fluent without aphasia, normal and nonfocal neuro exam. Remains with flat/constricted affect.* Pertinent Results: [**2113-10-14**] 07:35PM URINE HOURS-RANDOM [**2113-10-14**] 07:35PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2113-10-14**] 07:35PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-<1.005 [**2113-10-14**] 07:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-7.5 LEUK-NEG [**2113-10-14**] 07:35PM URINE RBC-0 WBC-0 BACTERIA-RARE YEAST-NONE EPI-0 [**2113-10-14**] 07:35PM URINE AMORPH-OCC [**2113-10-14**] 01:24PM GLUCOSE-93 UREA N-11 CREAT-1.3* SODIUM-139 POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-27 ANION GAP-16 [**2113-10-14**] 01:24PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2113-10-14**] 01:24PM WBC-6.3 RBC-5.04 HGB-16.3 HCT-43.9 MCV-87 MCH-32.3* MCHC-37.1* RDW-12.2 [**2113-10-14**] 01:24PM NEUTS-67.3 LYMPHS-23.3 MONOS-6.0 EOS-3.4 BASOS-0.1 [**2113-10-14**] 01:24PM PLT COUNT-190 UA negative + ASO titers AM cortisol, ESR, TSH, RF, C4 NORMAL. [**Doctor First Name **] and Stox negative. Cereloplasmin and copper PENDING at time of discharge. NONCONTRAST HEAD CT: Again seen is a right frontal approach reticular catheter with the tip near the foramen of [**Location (un) 9700**], unchanged in location. There is no ventricular dilatation. There is no acute intra- or extraaxial hemorrhage. There is no evidence of acute major vascular territorial infarction. Again noted, are prominent cerebral veins over the tentorium. Osseous structures are unremarkable. The visualized paranasal sinuses are clear. Note that the visualized portions of the shunt tubing appear continuous. IMPRESSION: No acute intracranial hemorrhage, hydrocephalus, or change from [**2113-9-26**]. CXR: clear Brief Hospital Course: Mr. [**Known lastname 10675**] was originally admitted to the MICU for behavior control, close monitoring by security. Neurology was consulted for hallucinations (visual, responding to internal stimuli) and abnormal behavior (he was almost mute on original neuro consultation). It was decided to transfer him to the neurology service to rule out temporal lobe epilepsy as a cause of these symptoms. He was monitored via video EEG for 4 days and had multiple push button events for odd sensatations, none of which were epileptiform. He had no seizures. All medications were discontinued (lamictal and neurontin, originally started for mood stabilization.) Originally we felt an MRI was indicated, but after transfer to the neurology floor he became more interactive, with completely normal neurological exam and thus MRI of the brain was no longer indicated. Also, he has a VP shunt and although it is MRI safe (up to 1.5 tesla), it requires immediate reprogramming after MRI and this service is unavailable here at [**Hospital1 18**]. (Ventricular shunt placed by Dr. [**Last Name (STitle) 16471**] at [**Hospital1 2025**], current setting is 1.0, [**Company **] strata shunt). Contact was maintained with patient's new neurologist, Dr. [**First Name8 (NamePattern2) 9485**] [**Last Name (NamePattern1) **], and she agreed with plan. Psychiatry followed closely and felt his acute delirium vs. brief psychotic episodes cleared and was safe for discharge home. He continues to have a flat/constricted affect. His primary psychiatrist was contact[**Name (NI) **] and he too felt he was safe to go home. His goal for this patient is to get him back to school. Regarding positive ASO titers, mother was told to followup with her Mr. [**Known lastname 55379**] PCP [**Last Name (NamePattern4) **]: the need for PCN to treat these titers. In addition, the family is in contact with the leading expert in PANDAS and treatment regimen is still being debated. Medications on Admission: lamictal 75 mg each morning, 50 mg in evening neurontin 800 mg twice daily Discharge Medications: none Discharge Disposition: Home Discharge Diagnosis: Brief psychotic episode of unclear etiology (fever? medication induced?) + ASO titers Discharge Condition: stable - no hallucinations or delusions, ambulating, eating well, no nausea Discharge Instructions: Please discontinue all home medications at this time. Please return to the emergency department if you experience visual or auditory hallucinations, aggressive behavior or other worrisome symptoms. Followup Instructions: Please followup with Dr. [**Last Name (STitle) 55380**] (primary psychiatrist) within the next 2 months.

[ "790.99", "298.9", "V45.2", "293.0", "714.30" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11167, 11173

9045, 11012

318, 341

11304, 11381

7279, 8394

11628, 11736

4653, 5279

11138, 11144

11194, 11283

11038, 11115

11405, 11605

5294, 5655

250, 280

369, 4105

5870, 7260

8403, 9022

5670, 5854

4127, 4393

4409, 4637

26,866

181,340

32736

Discharge summary

report

Admission Date: [**2115-3-12**] Discharge Date: [**2115-3-18**] Date of Birth: [**2045-11-7**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: DOE and fatigue Major Surgical or Invasive Procedure: [**2115-3-12**] Mitral Valve Repair utilizing a 30mm [**Doctor Last Name **] Annuloplasty Band History of Present Illness: 69 yo male with known MVP since [**2093**]. Episode of DOE and pre-syncope this past fall and escho showed severe MR with a flail chord and P2 cusp. There was significant LVH and a normal EF. Referred for surgical intervention. Past Medical History: MVP prostate cancer environmental allergies allergic rhinitis shingles eosinophilia ( allergies) prior bronchitis ? reactive airway disease PSH: herniated disc repair appy I and D 5th right phalange prostatectomy [**9-19**] Social History: retired physician never used tobacco never uses ETOH lives with wife in [**State 48158**] Family History: father expired MI at age 67 mother with CVA at 88 brother with CAD/PCI stent Physical Exam: 72" 225# HR 70 RR 14 right 155/98 left 148/90 98% RA sat. WDWN , NAD multiple excoriations of skin/folliculitis (legs); no c/c NCAT,PERRL,mild erythema and posterior pharynx lymphadenopathy (known prior) neck supple, full ROM, no JVD CTAB well-healed small unbilical incision RRR 3-4/6 late systolic murmur soft, NT, ND + BS; mild pulsatility of abd aorta, slightly enlarged abd. warm, well-perfused extrems; 1+ LE edema;left small finger with past fx neuro alert and oriented x 3;gait slow but [**Last Name (LF) 4374**], [**First Name3 (LF) 2995**]; strengths [**6-17**] 2+ bilat. fems/DP/PT/radials right carotid transmitted murmur versus quiet bruit Pertinent Results: [**2115-3-17**] 06:15AM BLOOD WBC-5.3 RBC-3.40* Hgb-10.9* Hct-32.8* MCV-96 MCH-31.9 MCHC-33.1 RDW-13.5 Plt Ct-186 [**2115-3-17**] 06:15AM BLOOD Plt Ct-186 [**2115-3-12**] 12:16PM BLOOD PT-15.0* PTT-40.0* INR(PT)-1.3* [**2115-3-17**] 06:15AM BLOOD Glucose-92 UreaN-20 Creat-1.0 Na-137 K-5.1 Cl-103 HCO3-24 AnGap-15 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 76279**] (Complete) Done [**2115-3-12**] at 9:48:00 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2045-11-7**] Age (years): 69 M Hgt (in): 74 BP (mm Hg): 135/78 Wgt (lb): 225 HR (bpm): 67 BSA (m2): 2.29 m2 Indication: Intraoperative TEE for MVR ICD-9 Codes: 786.05, 440.0, 424.1, 424.0 Test Information Date/Time: [**2115-3-12**] at 09:48 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5740**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW1-: Machine: [**Pager number 5741**] Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.3 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 60% to 65% >= 55% Aorta - Annulus: 2.3 cm <= 3.0 cm Aorta - Sinus Level: *4.1 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.9 cm <= 3.0 cm Aorta - Ascending: *3.9 cm <= 3.4 cm Aorta - Descending Thoracic: *2.7 cm <= 2.5 cm Findings Posterior leaflet 1.1cm Anterior leaflet 2.1cm C-[**Month (only) **] distance 2.1cm LEFT ATRIUM: Dilated LA. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall normal LVEF (>55%). [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Moderately dilated aortic sinus. Mildly dilated ascending aorta. Simple atheroma in aortic arch. Mildly dilated descending aorta. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Mild to moderate ([**2-13**]+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate/severe MVP. Partial mitral leaflet flail. Mild mitral annular calcification. Eccentric MR jet. Severe (4+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions PRE-BYPASS: 1. The left atrium is dilated. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] 3. Right ventricular chamber size and free wall motion are normal. 4. The aortic root is moderately dilated at the sinus level. The ascending aorta is mildly dilated. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. 5. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Mild to moderate ([**2-13**]+) aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. There ismild mitral valve prolapse of the anterior leaftlet (A2) with retraction. There is posterior (P1, P2) mitral leaflet flail. An eccentric, anteriorly directed jet of severe (4+) mitral regurgitation is seen. 7. There is moderate tricuspid regurgitation. 8. Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] present in OR to confirm AI is 2+. Hence minimally invasive MVR converted to open sternotomy MV repair Post-Bypass: 1. Patient is being AV paced and receiving an infusion of Phenylephrine. 2. Annuloplasty ring seen in the mitral position. Appears well seated.Mild mitral regurgitation present. Chordal Systolic Anterior Motion present. No LVOT obstruction. Mean gradient across the mitral valve is 3 mm Hg. 3. Aortic intact post deacnnulation. 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) **] [**2115-3-14**] 09:56 RADIOLOGY Final Report CHEST (PORTABLE AP) [**2115-3-16**] 12:48 PM CHEST (PORTABLE AP) Reason: Evaluate for consolidation / infiltrates [**Hospital 93**] MEDICAL CONDITION: 69 year old man s/p MV repair REASON FOR THIS EXAMINATION: Evaluate for consolidation / infiltrates CHEST, SINGLE VIEW ON [**3-16**] HISTORY: Status post MV repair. Question infiltrate. REFERENCE EXAM: [**3-15**]. FINDINGS: There is a small left pleural effusion similar in size compared to the prior study. Otherwise, there is no significant interval change. DR. [**First Name (STitle) **] [**Doctor Last Name **] Approved: SUN [**2115-3-17**] 7:15 AM Brief Hospital Course: Admitted [**3-12**] and underwent MVRepair with Dr. [**Last Name (STitle) 1290**]. Transferred to the CVICU in stable condition on titrated phenylephrine and propofol drips. Extubated that afternoon. Transferred to the floor on POD #1 and chest tubes removed.on POD #2. Developed a fever and pancultured. Cipro started for ? UTI and vanco started for continued fevers. Went into A fib on POD #4 and had intermittent junctional rhythm. Cardiology consult done after amiodarone started, and then discontinued.Low dose beta blockade recommended. Pacing wires removed on POD #5.WBC remained normal. Vanco discontinued on POD #6 and pt. will go home on 5 more days of cipro.Cleared for discharge to home with services. Pt. is to make all followup appts as per discharge instructions. Medications on Admission: ASA 81', claritin 10', asmanex 220" Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*90 Tablet, Delayed Release (E.C.)(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. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 5 days. Disp:*10 Tablet(s)* Refills:*0* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for pain. Disp:*45 Tablet(s)* Refills:*0* 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. Disp:*30 Tablet(s)* Refills:*0* 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 1 weeks. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*1* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 weeks. Disp:*14 Tablet(s)* Refills:*1* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Mitral Valve Prolapse, Mitral Regurgitation - s/p MV Repair Postop Atrial Fibrillation Postop Fevers Discharge Condition: Good Discharge Instructions: 1)Please shower daily. No baths. Pat dry incisions, do not rub. 2)Avoid creams and lotions to surgical incisions. 3)Call cardiac surgeon if there is concern for wound infection. 4)No lifting more than 10 lbs for at least 10 weeks from surgical date. 5)No driving for at least one month. Followup Instructions: Dr. [**Last Name (STitle) 1290**] in [**5-18**] weeks, call for appt [**Telephone/Fax (1) 170**] Dr. [**Last Name (STitle) 76280**] in [**3-17**] weeks, call for appt Dr. [**Last Name (STitle) **] in [**3-17**] weeks, call for appt Completed by:[**2115-3-18**]

[ "427.31", "E878.8", "998.89", "780.6", "V10.46", "997.1", "396.2" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.12" ]

icd9pcs

[ [ [] ] ]

9932, 9990

7958, 8738

337, 434

10135, 10142

1842, 7439

10477, 10740

1062, 1140

8825, 9909

7476, 7506

10011, 10114

8765, 8802

10166, 10454

1155, 1823

282, 299

7535, 7935

462, 691

713, 939

955, 1046

12,619

175,719

21350

Discharge summary

report

Admission Date: [**2100-8-10**] Discharge Date: [**2100-8-21**] Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1055**] Chief Complaint: Fever, mental status change Major Surgical or Invasive Procedure: Angiogram of Left lower extremity with successful angioplasty of distal bypass graft. History of Present Illness: 86yo M with MMP including ESRD on HD, CAD (known reversible defect that pt has refused intervention for), severe PVD with h/o OM of L heel who was sent from [**Location (un) 1036**] NH to [**Hospital1 **]-[**Last Name (un) 4068**] for fevers and lethargy. At OSH found to have T 103, WBC 38, bld cxs drawn and pt was transferred to [**Hospital1 18**]. In [**Name (NI) **] pt had LP which was negative, CXR showed R pleural effusion (unchanged from prior studies), Head CT neg for acute bleed. Pt was transferred to MICU where he got HD. He was continued on Vanc and Ctx was added. The next day blood cultures from [**Hospital1 **]-[**Last Name (un) 4068**] grew Proteus Mirabilis sensitive to amp, levoflox. He was transferred to floor. Past Medical History: CAD s/p recent admission in [**4-27**] where he had NSTEMI and found to have reversible defect on MIBI but refused intervention s/p CABG, S/p PCIs CHF CMML x2 years with chronic thrombocytopenia and anemia Ischemic colitis, ESRD on HD with r av fistula, PVD s/p L bypass OM s/p debridement [**5-28**] (MRSA rx with vanco)-> followed by Podiatry Dr. [**Last Name (STitle) **] R pleural effusion (exudative but cytology negative for malignancy) HTN Aspiration PNA Social History: no current etoh/tob/drug use. Family History: NC Physical Exam: T 97.8 BP 118/70 P72 R18 96%RA Thin elderly man in NAD grey sclera with arcus senilis, semi-dry MM with white patches on tongue RRR 2/6 SM at LUSB decreased BS on R with dullness to percussion [**12-25**] way up on R soft, slight epigastric tenderness, soft superficial masses on abdomen, diminished BS stable R 2nd digit foot ulcer without signs of infection L heel with increased tenderness and erythema surrounding ulcer which probed to bone. Pertinent Results: Hematologic: [**2100-8-10**] 04:50PM WBC-36.9* RBC-3.10* HGB-9.5* HCT-27.9* MCV-90 MCH-30.6 MCHC-34.0 RDW-20.3* [**2100-8-10**] 04:50PM BLOOD Neuts-74* Bands-0 Lymphs-12* Monos-10 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-4* [**2100-8-18**] 09:24AM BLOOD WBC-57.7* RBC-2.90* Hgb-9.1* Hct-25.9* MCV-89 MCH-31.4 MCHC-35.2* RDW-17.3* Plt Ct-102*# [**2100-8-19**] 09:15AM BLOOD Neuts-61 Bands-2 Lymphs-4* Monos-17* Eos-0 Baso-1 Atyps-0 Metas-2* Myelos-13* NRBC-1* [**2100-8-20**] 05:56AM BLOOD WBC-57.6* RBC-3.27* Hgb-10.3* Hct-28.9* MCV-88 MCH-31.5 MCHC-35.6* RDW-16.8* Plt Ct-78* Chemistry: [**2100-8-10**] 04:50PM BLOOD Glucose-100 UreaN-82* Creat-5.6*# Na-135 K-6.3* Cl-90* HCO3-27 AnGap-24* [**2100-8-20**] 05:56AM BLOOD Glucose-65* UreaN-39* Creat-2.8*# Na-143 K-3.5 Cl-95* HCO3-34* AnGap-18 [**2100-8-10**] 04:50PM BLOOD Calcium-10.2 Phos-4.2 Mg-1.7 [**2100-8-20**] 05:56AM BLOOD Calcium-9.0 Phos-3.0 Mg-1.6 Coags: [**2100-8-10**] 04:50PM BLOOD PT-14.2* PTT-32.9 INR(PT)-1.3 [**2100-8-20**] 05:56AM BLOOD PT-13.9* PTT-34.1 INR(PT)-1.2 Cardiac: [**2100-8-10**] 04:50PM BLOOD CK-MB-NotDone cTropnT-0.29* [**2100-8-11**] 04:14AM BLOOD CK-MB-NotDone cTropnT-0.28* Misc: [**2100-8-13**] 09:00AM BLOOD VitB12-1406* Folate-GREATER TH [**2100-8-13**] 09:00AM BLOOD TSH-4.7* Brief Hospital Course: 1. Proteus [**Name (NI) 11646**] Pt was continued on ceftriaxone for proteus bacteremia. He defervesced after first day. His cultures from L heel ulcer also grew dense proteus so this was felt to be the source. The patient will be continued on IV 1g QD ceftriaxone for 4 weeks from [**2100-8-13**] and Vancomycin 750mg QHD for 2more weeks (given history of MRSA OM) for osteomyelitis but duration will be determined by outpatient Podiatry Dr. [**Last Name (STitle) **] and will depend on how wound is heeling. 2. PVD- The worsening of his heel ulcer over the prior 2 weeks was found to be secondary to decreased flow in his L bypass graft. Vascular was consulted and arteriogram was performed on [**8-17**] by Dr. [**Last Name (STitle) **] and angioplasty was successfully performed on distal graft. Given the improvement in his distal blood flow it was felt that the L heel osteomyelitis might respond to conservative treatment with abx and wound care. The patient is to follow up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] to assess progression of wound and vascular status. 3. Rectus sheath hematoma- During hospital course pt developed rectus sheath hematoma at sight of heparin injections. ASA which had briefly been started was d/c'd for good along with hep sq inj. Pt's Hct drifted down to 25 so he required several blood transfusions to aim for Hct >30. Given his thrombocytopenia (plts as low as 30) he was transfused several bags of plts to keep count >100. The hematoma stabilized so pt was felt stable for d/c with plans to recheck Hct and plts at HD and transfuse to keep Hct>30 and Plts>50. 4. [**Name (NI) 5964**] Pt was continued on HD MWF. All medications were renally dosed. He was continued on Epo at HD. 5. [**Name (NI) 298**] Pt was admitted with mental status change that improved with treatment of infection. He had a MRI of his head which revealed diffuse microvascular dz but no acute CVA. Currently holding antiplatelet agents given low plt count. Patient with 90% stenosis of R carotid artery, however refusing surgical intervention. 6. Pain - The patient has some pain from the ulcer, as well as from the rectus sheath hematoma. We have started oxycodone 2.5 mg QID, as well as PRN, which is keeping his pain well-controlled. He may be switched to longer acting meds once at rehab. We found that a dose of 5 mg of oxycodone q 6 hours caused confusion. 7. Code status- Code status was discussed with patient and family. He again affirmed that he was DNR/DNI. Given his poor prognosis, goals of care were discussed and patient and family agreed to current treatment plan which included antibiotics and transfusions as necessary but avoiding major surgical interventions. Things should be discussed with patient and family as they arise on a situational basis. Medications on Admission: Metoprolol 75 mg PO TID Ambien 5 mg PO qhs Isosorbide dinitrate 30 mg xr losartan 50 mg PO qd famotidine 20 mg PO qd Lipitor 20 mg PO qd Sevelamer 800mg PO TID MVI qd Folic acid 1 mg PO qd Gabapentin 100 mg PO qhs Albuterol nebs q 6 hours sertraline 50 mg PO qd Colace 100mg PO BID Collagenase ointment qd Percocet 5-325 mg 1-2 tabs PO q4-6 hours Tylenol 325 mg PO q4-6 hours Heparin SQ TID Discharge Medications: 1. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) injection Injection at HD. 2. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO QD (once a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 7. Lidocaine 5 % Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q12HR (). 8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO QD (once a day). 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 11. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO QAM (once a day (in the morning)). 12. Phytonadione 5 mg Tablet Sig: One (1) Tablet PO QD (once a day). 13. Oxycodone HCl 5 mg Tablet Sig: 0.5 Tablet PO QID (4 times a day). 14. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a day). 15. Oxycodone HCl 5 mg Tablet Sig: 0.5 Tablet PO QID (4 times a day) as needed for breakthrough pain. 16. Ceftriaxone Sodium in D5W 20 mg/mL Piggyback Sig: One (1) gram Intravenous Q24H (every 24 hours) for 4 weeks. 17. Vancomycin HCl 1,000 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750) mg Intravenous Q hemodialysis for 2 weeks. Discharge Disposition: Extended Care Facility: [**Location (un) 1036**] - [**Location (un) 620**] Discharge Diagnosis: L heel ulcer infected with proteus, MRSA Proteus bacteremia PVD Right Rectus sheath hematoma Discharge Condition: Good, stable. Discharge Instructions: Take all medications as directed. Continue wound care. Return to the hospital if his hct is unable to be stablized with ocasional transfusion. Followup Instructions: 1) Call Dr. [**Last Name (STitle) **] (vascular) to schedule f/u appt in [**12-25**] weeks. [**Telephone/Fax (1) 1784**]. 2) Call Dr. [**Last Name (STitle) **] (podiatry) to schedule f/u appt in [**12-25**] weeks. [**Telephone/Fax (1) 543**]. 3) Provider: [**Name10 (NameIs) 454**],ONE DAY CARE [**Hospital Ward Name **] 8 Where: DAY CARE [**Hospital Ward Name **] 8 Date/Time:[**2100-9-13**] 7:00 4) Provider: [**Name10 (NameIs) 6122**] WEST OUTPATIENT RADIOLOGY Where: [**Hospital 273**] RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2100-9-13**] 8:30 5) Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**] Date/Time:[**2100-9-27**] 3:00

[ "428.0", "496", "707.0", "998.12", "707.15", "038.49", "440.24", "276.7", "434.91" ]

icd9cm

[ [ [] ] ]

[ "38.93", "88.48", "39.50", "86.22", "39.95", "99.04" ]

icd9pcs

[ [ [] ] ]

8309, 8386

3476, 6325

285, 372

8523, 8538

2181, 3453

8731, 9469

1693, 1697

6766, 8286

8407, 8502

6351, 6743

8562, 8708

1712, 2162

218, 247

400, 1145

1167, 1630

1646, 1677

31,852

197,965

32107

Discharge summary

report

Admission Date: [**2142-7-31**] Discharge Date: [**2142-8-10**] Date of Birth: [**2075-2-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: s/p fall, unresponsive Major Surgical or Invasive Procedure: Placement IVC filter History of Present Illness: Pt is a 67M with end stage jaw cancer receiving paliative chemo therapy who was found by his wife at the bottom of his stairs. She had last seem him 8-10 hrs earlier prior to her going to sleep. His clothes were strewn around the house (unusual for him). He was unresponsive and his G tube had been pulled out. EMS were called and he was brought to the [**Hospital1 18**] ED via another hospital as a truma basic. His SBP when EMS found him was 80. He was reportedly hypotensive upon arrival to the OSH. In the [**Hospital1 18**] ED the pt's GSC was 3T with stable vital signs. He had severe facial swelling and was only postured to painful stimuli. Head CT in the ED showed a Right frontal SAH, small hemorrhagic contusions in the the posterior right temporal lobe. No significant mass effect or intraventricular extension noted. No CT evidence of acute cortical stroke. Possible nondisplaced fracture over the left orbital roof. There was a nondepressed left frontal bone fracture extending over the left orbit. . Patient was admitted to the trauma ICU. Past Medical History: Oral CA x/ XRT and mandible necrosis, cadaver bone and muscle/skin graft reconstruction 25 yrs ago, CA recurrence [**Month (only) 547**] [**2141**]. s/p trach & peg approx 1 month ago for concerns of airway compromise & ongoing weight loss. Social History: lives at home with his wife, visiting hospice care, chemo at [**Hospital1 336**] Family History: . Physical Exam: PHYSICAL EXAM on date of [**8-9**] VSTm=98.3 Tc=97.8 BP (115/69-129/72) HR 77-101 RR 20, sat 99% on 35% TM GEN: alert able to follow compands, cachectic HEENT: eomi, constricted pupils, laceration on left head, stiches, perrla, portion of right jaw missing, swelling around OP, NECK: Tracheostomy noted, NO hematoma near old IJ site CV: tachy regular, no murmurs, no gallops LUNGS: difficult lung exam unable to exam much post, scatter rales ABD: PEG in place, clean dressing no signs of infection, BS present, nontender Fem cath site some ecchymosis, small hematoma, no bruit EXT: ecchymosis lower ext, good pulses, no edema, in pneumoboots, Neuro: exam is limited, due to patients mobility Pertinent Results: ADMISSION LABS: [**2142-7-31**] 08:00AM BLOOD WBC-5.0 RBC-3.04* Hgb-9.6* Hct-29.4* MCV-97 MCH-31.7 MCHC-32.8 RDW-16.6* Plt Ct-194 [**2142-7-31**] 07:28PM BLOOD WBC-7.1 RBC-2.68* Hgb-8.3* Hct-25.4* MCV-95 MCH-31.2 MCHC-32.8 RDW-17.1* Plt Ct-214 [**2142-8-1**] 02:06AM BLOOD Neuts-84.5* Bands-0 Lymphs-12.3* Monos-2.7 Eos-0.3 Baso-0.3 [**2142-8-1**] 02:06AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2142-8-1**] 02:06AM BLOOD PT-16.2* INR(PT)-1.5* [**2142-7-31**] 08:00AM BLOOD PT-15.3* PTT-30.5 INR(PT)-1.4* [**2142-7-31**] 08:00AM BLOOD UreaN-16 Creat-0.5 [**2142-7-31**] 07:28PM BLOOD Glucose-137* UreaN-9 Creat-0.5 Na-142 K-4.0 Cl-108 HCO3-26 AnGap-12 [**2142-7-31**] 08:00AM BLOOD estGFR-Using this [**2142-7-31**] 08:00AM BLOOD CK(CPK)-468* Amylase-15 [**2142-7-31**] 08:00AM BLOOD CK-MB-13* MB Indx-2.8 cTropnT-<0.01 [**2142-7-31**] 07:28PM BLOOD Calcium-8.0* Phos-2.6* Mg-1.4* [**2142-7-31**] 07:28PM BLOOD Osmolal-294 [**2142-8-1**] 02:06AM BLOOD TSH-6.3* [**2142-8-1**] 02:06AM BLOOD Cortsol-40.4* [**2142-7-31**] 08:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2142-7-31**] 11:48AM BLOOD Type-ART Temp-37.0 Rates-/16 Tidal V-500 PEEP-5 FiO2-100 pO2-468* pCO2-39 pH-7.52* calTCO2-33* Base XS-8 AADO2-209 REQ O2-43 Intubat-INTUBATED Vent-SPONTANEOU [**2142-7-31**] 08:09AM BLOOD Glucose-107* Lactate-2.3* Na-141 K-3.6 Cl-102 calHCO3-31* . DISCHARGE LABS: . [**2142-8-10**] 07:15AM BLOOD WBC-10.4 RBC-3.64* Hgb-11.4* Hct-35.7* MCV-98 MCH-31.3 MCHC-31.9 RDW-20.4* Plt Ct-294 [**2142-8-9**] 05:50AM BLOOD WBC-10.8 RBC-3.62* Hgb-11.1* Hct-34.1* MCV-94 MCH-30.6 MCHC-32.5 RDW-20.1* Plt Ct-284 [**2142-8-10**] 07:15AM BLOOD Plt Ct-294 [**2142-8-10**] 07:15AM BLOOD PT-15.2* PTT-30.4 INR(PT)-1.4* [**2142-8-10**] 07:15AM BLOOD Glucose-116* UreaN-10 Creat-0.6 Na-141 K-4.1 Cl-104 HCO3-28 AnGap-13 [**2142-8-9**] 05:50AM BLOOD Glucose-126* UreaN-7 Creat-0.5 Na-139 K-3.4 Cl-102 HCO3-29 AnGap-11 [**2142-8-7**] 01:17PM BLOOD CK(CPK)-50 [**2142-8-10**] 07:15AM BLOOD Calcium-9.5 Phos-2.7 Mg-2.4 . RADIOLOGY MRA BRAIN W/O CONTRAST [**2142-8-5**] 5:13 PM MR HEAD W/ CONTRAST; MRA BRAIN W/O CONTRAST [**Hospital 93**] MEDICAL CONDITION: 67 year old man with fall subdural bleed REASON FOR THIS EXAMINATION: Looking to r/o posterior stroke with MRA/MRI brain. Also would like MRI brain w/ gadolinium r/o brain mets, hx of jaw ca recurrence. MRI AND MRA BRAIN INDICATION: 67-year-old man with fall and subdural hematoma. Rule out posterior stroke with MRI/MRA of the brain, rule out brain metastasis with history of jaw carcinoma recurrence. TECHNIQUE: Multiplanar T1-weighted images were obtained following administration of [**Hospital 3173**] gadolinium. 3D high-resolution time-of-flight sequence was performed. No diffusion DWI or GRE sequences were performed. COMPARISON: Head MR [**First Name (Titles) 27533**] [**2142-8-2**]. BRAIN MR [**First Name (Titles) **] [**Last Name (Titles) **] CONTRAST: Right subdural hematoma has not appreciably changed in size since the previous examination. Subarachnoid hemorrhage and intraventricular blood products are not definitely appreciated on this study due to limited examination. There is an area of enhancement involving cortex and subcortical white matter of the right inferior temporal lobe, corresponding to an area of contusion on the previous examination. There is an area of surrounding edema. There is no mass effect or shift of normally midline structures. The ventricles are normal in size. BRAIN MRA: As on the previous study, there is absent flow in most of the internal carotid artery, with a short segment flow in the supraclinoid left internal carotid artery. There is collateral or retrograde filling from the segment through the anterior and posterior communicating arteries. The anterior cerebral and middle cerebral arteries are patent. The vertebral, basilar arteries are patent, with codominant vertebral arteries. Major branches of the basilar artery are patent. IMPRESSION: 1. Absent flow in the major part of the left internal carotid artery, with collateral or retrograde flow to a short supraclinoid segment of the left internal carotid artery. Complete circle of [**Location (un) 431**]. Patent ECA, MCA, and PCA and major branches. Diffusion-weighted imaging was not performed. 2. Area of enhancement in the right anterior temporal lobe, corresponding to an area of contusion seen on previous examination with surrounding edema. This finding may reflect a post-traumatic etiology; however, underlying enhancing brain lesion cannot be entirely excluded. Short-term two-week followup is recommended to document resolution of this finding. 3. Unchanged right subdural hematoma. 4. Subarachnoid and intraventricular hemorrhage not evaluated on this study, as gradient echo imaging was not performed. Findings were discussed with Dr. [**Last Name (STitle) **] at 5:30pm on [**2142-8-6**]. This study was reviewed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. DR. [**First Name (STitle) **] [**Name (STitle) **] DR. [**First Name8 (NamePattern2) 11136**] [**Last Name (NamePattern1) 11137**] DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**] . CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2142-8-7**] 11:08 AM CT CHEST WITH AND WITHOUT [**Month/Day/Year **] CONTRAST: The scan is of limited diagnostic quality due to artifact from breathing during the examination. Within these limitations, there are new bibasilar effusions and atelectasis at the lung bases. There has been improvement in the multifocal ill-defined consolidation in both lungs. There is no significant intrathoracic lymphadenopathy. There is no pericardial effusion. There are small filling defects in the branches of the right upper lobe pulmonary artery as well as branches of the bilateral lower lobe pulmonary arteries suggestive of subsegmental pulmonary emboli. CT ABDOMEN POST-ADMINISTRATION OF [**Month/Day/Year **] CONTRAST: There is free fluid present in the upper abdomen, particularly around the liver and spleen. There is a gastrostomy tube seen in situ. The abdominal images are compromised due to artifact from breathing. Within these limitations, the visualized liver and spleen appear unremarkable. The kidneys perfuse normally. There is minimal thickening of the left adrenal gland. The right adrenal gland and pancreas appear unremarkable. The gallbladder appears unremarkable. CT PELVIS POST-ADMINISTRATION OF [**Month/Day/Year **] CONTRAST: The images are again compromised due to artifact from breathing. There is a filling defect in the right femoral vein likely a DVT. There is a left- sided inguinal hernia containing loops of bowel within it. There is a urinary catheter seen in the bladder with air likely representing recent bladder instrumentation MUSCULOSKELETAL: There are multiple left-sided rib fractures. Fractures are also present involving the left iliac [**Doctor First Name 362**], the left superior pubic ramus and the left inferior pubic ramus. There may also be a fracture through the right iliac bone. CONCLUSION: The entire examination is suboptimal due to artifact from breathing throughout the examination. 1. Interval development of bibasilar effusions and atelectasis at the lung bases. There are small filling defects in the branches of the right upper lobe and right and left lower lobe branches of the pulmonary arteries suggestive of pulmonary emboli. 2. There has been interval improvement with significant resolution of the consolidative opacities in both lungs seen on the prior study. 3. Abdominal pelvic ascites is present. 4. Gastrostomy tube is seen within the stomach. 5. Left inguinal hernia containing loops of bowel within it. 6. Fractures involving the left ribs, left iliac [**Doctor First Name 362**], left superior pubic ramus, the left inferior pubic ramus and a probable fracture through the right iliac bone. 7. A filling defect in the right femoral vein is consistent with a thrombus and may be further assessed with a Doppler ultrasound. The findings were discussed with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**] at 2:20 pm on [**2142-8-7**]. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 28783**] [**Name (STitle) 28784**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: TUE [**2142-8-7**] 6:09 PM RADIOLOGY Final Report MR HEAD W/O CONTRAST [**2142-8-2**] 9:04 PM MR HEAD W/O CONTRAST Reason: ischemic injury [**Hospital 93**] MEDICAL CONDITION: 67 year old man s/p fall REASON FOR THIS EXAMINATION: ischemic injury INDICATION: Head trauma, status post fall. COMPARISON: No previous brain MRI. Head CT scans dated [**7-31**] and [**2142-8-1**] are available for correlation. TECHNIQUE: Sagittal T1-weighted and axial T1-weighted, T2-weighted, FLAIR, gradient echo, and diffusion-weighted images of the brain were obtained. FINDINGS: There is a right subdural hygroma, measuring approximately 6 mm in maximal thickness, with small amount of subacute subdural hematoma layering posteriorly in its dependent portion (best seen on FLAIR images). Subarachnoid blood is present in multiple sulci of the right cerebral hemisphere, and in a few sulci of the left cerebral hemisphere. There are multiple small cortical foci of high signal on FLAIR and diffusion-weighted images in the superior medial aspects of the frontal and parietal lobes, most consistent with hemorrhagic contusions. There is an area of high T2 signal involving the cortex and subcortical white matter of the right inferior temporal lobe. Due to its proximity to the mastoid air cells, this area is not well evaluated on gradient echo and diffusion-weighted images, and it is not clear whether blood products are present within this contusion. There is a small linear focus of high T2 signal in the subcortical white matter of the posterior left frontal lobe, without any associated signal abnormalities on diffusion-weighted or gradient echo images, which appears non-specific, and may or may not be related to the patient's trauma. Small amount of blood is layering in the occipital horns of the lateral ventricles, left more than right. The ventricles are normal in size. The major vascular flow voids appear unremarkable. The left frontal sinus, bilateral ethmoid air cells, and the nasal cavity have fluid signal. There is moderate circumferential mucosal thickening in both maxillary sinuses, and mild circumferential mucosal thickening in the sphenoid sinus. Multiple foci of soft tissue swelling are noted in the posterior scalp. IMPRESSION: 1. Small right subdural hygroma, which contains a small amount of posteriorly layering subacute blood products. 2. Subarachnoid hemorrhage in the hemispheric sulci, right greater than left. 3. Multiple small hemorrhagic contusions in the superior medial aspects of bilateral frontal and parietal lobes. Larger right inferior temporal contusion, which may or may not be hemorrhagic. 4. Intraventricular blood as before. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) 95**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 96**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: SAT [**2142-8-4**] 10:56 AM CT HEAD W/O CONTRAST [**2142-7-31**] 7:54 AM CT HEAD W/O CONTRAST Reason: evaluate for ICH [**Hospital 93**] MEDICAL CONDITION: 74 year old man found down REASON FOR THIS EXAMINATION: evaluate for ICH CONTRAINDICATIONS for IV CONTRAST: None. HEAD CT WITHOUT CONTRAST [**2142-7-31**] at 0813 hours. HISTORY: Found down at base of stairs. TECHNIQUE: Serial transverse images were acquired sequentially through the brain and reconstructed at stacked 5 mm transverse sections. Images were reconstructed utilizing bone and soft tissue window algorithms. COMPARISON: None. FINDINGS: There is a large subgaleal hematoma extending over the left frontal convexity with a large laceration extending to the skull surface. No embedded radiopaque foreign bodies are identified. Soft tissue swelling extends over the lateral aspect of the included left face superficial to the left zygoma and in the preseptal soft tissues. There is a linear lucency extending over the left orbital roof which may represent a nondisplaced fracture. Subcutaneous air in an extraconal distribution is identified, particularly medially. There is possibly an inferior orbital wall fracture. The globe itself is intact with lens in place. The right orbit is unremarkable. There is extensive opacification of the ethmoid air cells and near-complete opacification with a small amount of layering high-attenuation fluid around more chronic appearing mucosal thickening in the left maxillary antrum. The right maxillary antrum demonstrates similar but less severe thick mucosa likely due to chronic sinusitis. The mastoid air cells are clear. The skull base is intact. Intracranially, the ventricles are midline with no intraventricular hemorrhage identified. There is layering subarachnoid hemorrhage over the right frontal convexity. Two small punctate rounded hyperattenuated foci are noted in the right posterior temporal lobe likely due to contusions. A small focus of subarachnoid hemorrhage is also noted in the perimesencephalic cisterns posterior to the right colliculi. No CT evidence of acute cortical stroke is noted. IMPRESSION: Small hemorrhagic contusions in the posterior right temporal lobe and subarachnoid hemorrhage overlying the posterior right frontal lobe and perimesencephalic cistern. No significant mass effect or intraventricular extension noted. No CT evidence of acute cortical stroke. Question of possible nondisplaced fracture over the left orbital roof. Likewise, the left inferior orbital wall or medial wall of the left maxillary sinus cannot be cleared of fracture definitively. Consider detailed maxillofacial CT scan for further evaluation. Review with the trauma team at time of initial interpretation. Wet read posted to ED dashboard. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**] Approved: TUE [**2142-7-31**] 2:10 PM Brief Hospital Course: Patient is a 67 y/o male, prior trach and peg, with advance SCC jaw cancer(dx [**2114**], s/p XRT with brachytherapy, recurrence [**3-3**]) who follows at [**Hospital1 336**] was admitted to [**Hospital1 18**] after a fall down a flight of stairs on [**7-31**]. GCS of 3T in ED, with a SBP originally in the 80s. Reported to have shown decorticate posturing. . The patient was pan-scanned in the ED revealing the following injuries: 1. Hemorrhagic contusion R temp, R frontal SAH, coup-contra-coup 2. L [**7-6**] rib fxs 3. L inferior and superior public rami fx w/ involvement of iliac [**Doctor First Name 362**], sacral ala 4. open L temoporal lac 5. B/L PNA, R>L 6. left frontal bone fracture He was admitted to the TSICU. Neurosurgery, plastics, neurology, spine, orthopedics, and ENT were all consult. The rest of this summary is by systems at the time of transfer from the trauma service to the medical serivce on [**2142-8-4**]: . Patient was transferred out to the general medical floor on [**8-4**], with saturating 99% on 35% oxygen by trach mask. . On morning of [**2142-8-6**] pt had been sat'ing 99% on 35% trach mask, was having peg dressing changed, and was noted to have labored breathing (RR=30s), and desat to 84% on 35% trach mask, up to 92% on 100% trach mask. ABG = 7.45/40/102. CXR was concerning for pneumothoraax, and pt was tnrasfered to MICU for AC ventilation via trach and closer monitoring. . Upon arrival to MICU [**8-8**] pt breathing comfortably on AC ventilation (98.7 109 134/77 100% AC 450x12 50% PEEP 5). repeat CXR showed reexpansion of LLL, and acute event felt [**12-29**] mucus plug. Given concern for thickened secretions, pt continued on zosyn empirically ?new/ongoing pna. pt was stable on AC ventilation throughout [**8-8**] and was transitioned to PS then back to trach mask without difficulty. ddx also included PE given onc history/pelvic fracture, however given acute improvement, and recent dye loads, plan made for CTA on following morning which did show new PE and right femoral DVT. IVC was placed in interventional radiology on [**8-9**], though plan made not to anticoagulate pt given SAH and contusion. Pt was otherwise gradually weaned from AC ventilation to PS then to 35% trach mask with sats 90-100%. Goals of care discussed at length with wife, and decision made to make pt DNR, though ok to intubate/ventilate via trach. neurologic and orthopedic issues stable, no intervention made. phenytoin level was noted to be subtherapeutic, but per neuro only needs 10d course, and given lack of seizures, ok to d/c after day 10 ([**8-10**]). pain control maintained with morphine and fentanyl patch. Pt called out to medical floor on [**8-8**]. . Patient called out to floor [**8-8**]. Patient was stable on the general medical floor. Did have one episode of bleeding from his tongue/tumor erosion. Patient has remained in 2 point restraints and belt, out of concern that he would pull out his trach or lines. Patient did slide out of bed night of [**8-9**] but did not hit head, normal neuro exam decision made to not repeat head scan. SYSTEMS BASED COURSE. . Neurologic: small head bleeds were stable on repeat CT and deemed non-operative by neurosurgery. He was started on dilantin for seizure prophylaxis. He completed 10 days. Slowly, the patient's neurologic exam improved; he began following commands, moving all extremities, and communicating. At times he is still confused. Neurology did not feel this was event was caused by a stroke. His cervical c-spine CT was highly abnormal, but it was unclear what, if any of these findings were related to his trauma. An MRI of the C spine was performed and his neck was cleared by the ortho spine staff on [**2142-8-4**]. He is to follow-up with Dr. [**Last Name (STitle) 548**] (neurosurgery) with a repeat head CT 6 weeks after fall. He received an MRI of the brain w/ & w/o to r/o brain mets, no obvious mets were seen but could not be ruled out in the setting of brain contusion. . Respiratory: Patient was started on the ventillator in the ED. His trach was changed in the TSICU to a cuffed trach; he was bronched upon admission to the TSICU given the PNA on CT scan. BAL ultimately grew pseduomonas. He was quickly weaned off the vent in the first 24 hours of his admission. Saturating well on TM. In on zosyn for PNA c tobramycin nebs. Patient did become hypoxic on [**8-6**] transferred to MICU, as noted before, noted to have attelectasis of LLL, new PEs, (RUL and LLL) decision made not to anticoagulate. IVC filter placed. Patient now stable 99% on 35%o2 by trach mask. ABx course for PNA will be with zosyn, on [**8-11**]. Patient still requires frequent trach suctioning. . Cardiac: initally patient was hypotensive in the TSICU requiring pressors. A CVL was placed and his CVP monitored. He was weaned from pressors with in 48 hours of admit. No similar episodes of hypotension since that occurence. Left internal carotid found to be incidentally blocked on MRI/MRA, but this appears stable from prior studies, other vessels noted to have good flow. Patient . GI: Pt is NPO given his advanced oral cancer. His GT was replaced in the TSICU. TF were started and quickly advanced to goal. . ID: see all respiratory. Blood and urine cultures are negative. . MSK: pelvix fractures deemed non-operative by orthopedics. His activity is TDWB on the LLE and WBAT on the RLE. He is to have inlet and outlet pelvic films once he is moving about. He should follow-up with orthopedics in 4 weeks. L forehead laceration was sutured by the trauma team. . HEME:HCT stable at 35. no signs of active bleeds.' . RENAL: No renal issues foley is in place. . ONC: Patient has end stage jaw cancer. Patient Dr. [**Last Name (STitle) 75139**] [**Telephone/Fax (1) 75140**] @ [**Hospital1 **] is patients oncologist. Patient is end stage jaw cancer s/p recurrence. Poor prognosis 4 month estimation. . #Code status: DNR, but mechanical ventilation through trach is okay. Follow up CT of head scan in 4 weeks Follow up with orthopedics in 4 weeks for leg fractures Continue Zosyn IV antibiotics until [**8-11**] for completion of Pseudomonas Pneumonia treatment . Medications on Admission: Augmentin 875-125, Prochlorperazine 10mg PO q6h, Seroquel 12.5mg q6h, Ambien 10mg qHS, Diazepam 1-2mg qHS, Vicodin, Zofran 8mg PO qday, Calcium Discharge Medications: 1. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: [**11-28**] Inhalation Q6H (every 6 hours) as needed. 2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 3. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO BID (2 times a day). 4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 5. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 7. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 10. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours). 13. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) Injection Q4H (every 4 hours) as needed for agitation. 14. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon Soln [**Month/Day (2) **] Q8H (every 8 hours): Stop after [**8-11**]. 15. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q6H (every 6 hours): Hold for sedation and RR below 12. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) **] Discharge Diagnosis: Primary Diagnosis Hypotension Hemorrhagic contusion right temporal lobe Right frontal subarachnoid hemorrage Left Rib fractures [**7-6**] Left inferior and superior public rami fracture w/ involvement of iliac [**Doctor First Name 362**] Open left temoporal laceration Left orbital fracture Bilateral upper lobe pneumonia Hypoxia Right upper lobe and left lower lobe pulmonary embolism R leg deep vein thrombosis . Secondary Recurrence of oral/jaw cancer, s/p failure of repeated chemo/XRT treatments Discharge Condition: Stable, Tracheostomy in place breathing on his own with 35% trach mask, requiring qshift suctioning, PEG in place receiving tube feeds. Discharge Instructions: You were admitted to the hospital for a fall, you were found to have a Subarachnoid hemorrage, and temporal brain contusion on imaging of your head. You were started on medications to keep your blood pressure elevated during the beginning of your hospital stay. . You were diagnosed with a pelvic fracture of your left inferior and superior pubic rami and your left iliac [**Doctor First Name 362**] of your pelvis. You are touch down weight bearing on the the left leg and weight bearing on the right lower extremity. . You were found to have a pneumonia. Treatment for this will be completed [**8-11**]. You were also found to have blood clots in your lungs and in your leg, because you had a bleed in your head you can not be on blood thinners. You had a filter placed in your inferior vena cava to prevent any more clots from moving to your lungs. Please follow up with neurology for a repeat CT of the head in 4 weeks to make sure that your intracranial bleed has not progresed. Please follow up for an MRI to make sure there are not metastases to the brain. Call your doctor or return to the emergency room if you experience any of the following: fever > 101, shortness of breath, sudden change in mental status. Followup Instructions: Forehead Stitches should be removed sometime between 9/13-15/07. Please follow up with orthopaedics in 4 weeks from your discharge in the hospital. Please repeat a head CT in 4 weeks to assess for interval change/improvement of your known head bleeds and contusions. You will also follow-up with Dr. [**Last Name (STitle) 548**] of neurosurgery at that time. His telephone number is ([**Telephone/Fax (1) 18865**]. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

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Discharge summary

report

Admission Date: [**2166-11-25**] Discharge Date: [**2166-12-17**] Date of Birth: [**2087-4-9**] Sex: F Service: MEDICINE Allergies: Penicillins / Cephalosporins Attending:[**First Name3 (LF) 8487**] Chief Complaint: knee pain, fever Major Surgical or Invasive Procedure: Incision and drainage of left septic knee on [**2166-11-26**]. History of Present Illness: Ms. [**Known lastname **] is a 79 yo female with a history of CAD and CHF with EF of 20%, CKD who presents wtih left knee pain. . Patient was recently admitted [**Date range (1) 40856**] with MSSA sepsis with unknown source. TEE was negative for vegetations, but since she has a pacemaker she was treated with 6 weeks of oxacillin. She was discharged to [**Hospital 599**] rehab but readmitted [**10-20**] with fevers. Blood cultures were negative. PICC line was changed and did not grow any bacteria. TEE showed fibrinous material on the pacer lead, but this was not felt to be the cause of the fevers. CT showed pleural effusion but this was thought to be due to CHF and not infection. There was some thought that the fevers were due to beta lactam allergy. The patient was treated with vancomycin for two weeks. . Patient reports that four days prior to admission she began to participate in physical therapy and two days prior to admission she began to note left knee pain. This has been progressing over the past day. On the day of admission she developed a temperature of 99.2 and shaking chills. ESR was 79 and a portable X ray showed mild arthritis. She was sent to the ED for evaluation. . In the ED she was afebrile. Knee was visibly swollen, erythematous and warm. Arthrocentesis was performed which yielded 10 cc of yellow fluid. LDH 1167, glucose 63, wbc [**Numeric Identifier 40857**] rbc 1250, 78 PMN. Gram stain: 4+ pmn, 1+ Gram positive cocci. culture pending. . She received tylenol, vancomycin one gram, ceftriaxone one gram and 3 [**Location **]. . Upon admission to the floor patient was without any localizing symptoms. Past Medical History: 1. Coronary artery disease; s/p CABG X4 [**2161**]; s/p PCA with stent to D1 - [**1-9**] ETT: 8.75 min [**Doctor Last Name 4001**] protocol (~5.5 METS). LV dysfunction in the absence of angina or ischemic EKG 2. CHF- EF 20% [**2166-9-22**] Echo : [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated, RA moderately dilated, severe global LV hypoK, RV sys fxn borderline normal, trace AR, 3+ MR, 3+ TR, no mass/vegetation visualized. 3. HTN 4. Hypercholesterolemia -- 5. DM2- c/b nephropathy and retinopathy - [**2166-9-19**] HgbA1C 6.1% 6. H/o AF w/ RVR in post-op period; s/p cardioversion 7. Anemia: HCT 28-31 - iron studies [**2-6**] low iron, TIBC/ferritin nl - [**9-10**] vit B12/folate wnl 8. Chronic renal insufficiency: baseline Cr 1.4-1.6 9. GERD 10. s/p CCY 11. s/p hernia repair. 12. History of E alloantibody with hemolytic reaction to blood transfusions requiring E negative blood. 13. s/p AICD 14. Afib Social History: Lives at [**Hospital1 599**] [**Location (un) 16007**] Quit smoking 40 years ago EtOH: occasional Daughter is involved with pt's care Family History: Noncontributory Physical Exam: VS- 99.4 68 130/60 23 93% ra [**Name (NI) **] Pt. lying supine with eyes closed at 30 degrees HOB, NAD HEENT- PERRL, EOMI, anicteric, MMM, OP clear, white film on tongue removable by patient with teeth NECK- no [**Doctor First Name **], supple, non tender, JVP 12cm. CV- Irregular, +s1/s2, no s3/s4, II/VII late diastolic murmur at RUSB and III/VI SEM at LLSB. LUNGS- Decreased BS at left base, otherwise clear. ABD- Soft,+BS, NT/ND/NR, mild bruising over abd with hyperpigementation over lower abdomen, no flank tenderness, no mass, no pulsation EXT- Left knee with swelling, mild erythema, significnat warmth, pain with active and passive ROM, evidence of effusion. Sensation intact. 2+ DP pulses bilaterlly. 1+ pitting edema left leg, trace edema right leg NEURO- A&Ox2 (not date) Pertinent Results: . HEME . [**2166-11-25**] 03:30PM BLOOD WBC-7.1 RBC-2.59* Hgb-9.0* Hct-26.6* MCV-103* MCH-34.6* MCHC-33.7 RDW-18.5* Plt Ct-113* [**2166-11-26**] 06:05AM BLOOD WBC-8.8 RBC-2.48* Hgb-8.4* Hct-25.4* MCV-103* MCH-33.8* MCHC-32.9 RDW-18.2* Plt Ct-100* [**2166-11-28**] 06:45AM BLOOD WBC-7.2 RBC-3.44*# Hgb-11.1*# Hct-33.7* MCV-98 MCH-32.3* MCHC-33.0 RDW-20.8* Plt Ct-83* [**2166-11-28**] 06:45AM BLOOD Neuts-64.6 Bands-0 Lymphs-27.1 Monos-3.9 Eos-3.8 Baso-0.6 [**2166-11-28**] 06:45AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL Target-OCCASIONAL Burr-OCCASIONAL . CHEM . [**2166-11-25**] 03:30PM BLOOD Glucose-144* UreaN-40* Creat-1.7* Na-135 K-5.2* Cl-102 HCO3-23 AnGap-15 [**2166-11-26**] 06:05AM BLOOD Glucose-190* UreaN-41* Creat-1.8* Na-134 K-5.2* Cl-103 HCO3-22 AnGap-14 [**2166-11-28**] 06:45AM BLOOD Glucose-117* UreaN-40* Creat-1.7* Na-136 K-5.3* Cl-104 HCO3-19* AnGap-18 . LFT . [**2166-11-27**] 05:35AM BLOOD ALT-14 AST-18 LD(LDH)-382* AlkPhos-127* TotBili-0.7 . LYTES / IRON / CRP / TSH . [**2166-11-28**] 06:45AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.1 [**2166-11-27**] 05:35AM BLOOD calTIBC-156* VitB12-607 Folate-12.8 Hapto-205* Ferritn-1702* TRF-120* [**2166-11-27**] 05:35AM BLOOD TSH-7.5* [**2166-11-26**] 06:05AM BLOOD CRP-230.1* . CXR . UPRIGHT AP CHEST: A pacemaker ICD device overlies the left chest, with leads overlying the right atrium and right ventricle. The patient is post-median sternotomy. There is unchanged cardiomegaly. Mediastinal and hilar contours are normal. Since the prior exam, there is no significant change in the amount of interstitial pulmonary edema. The right pleural effusion may be slightly enlarged. There is a small left effusion, unchanged. IMPRESSION: Unchanged degree of congestive failure. . KNEE XRAY . LEFT KNEE, TWO VIEWS: There is normal mineralization of the depicted osseous structures. Osteophytes are seen along the medial tibial plateau as well as the superior aspect of the patella. There are no definite cortical erosions. Surgical clips are seen in the medial aspects of the calf. IMPRESSION: No definite evidence for osteomyelitis. Please note that bone scan or MRI is more sensitive for this diagnosis. . TTE . Conclusions: 1. The left atrium is moderately dilated. The right atrium is markedly dilated. 2. The left ventricular cavity size is normal. There is severe global left ventricular hypokinesis. Overall left ventricular systolic function is severely depressed. 3. The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. 4. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. . the rest is per OMR... Brief Hospital Course: 79 year old woman with history of CAD and CHF, recent MSSA sepsis s/p 6 weeks IV antibiotics presents with septic arthritis, anemia, thrombocytopenia. She was treated with IV vancomycin, had I&D of left knee and washout. During the MICU course, patient was grossly volume overloaded to her resuscitation for sepsis. Volume management ws attempted with natrecor drip and other means of diuresis as it was primarily due to CHF. No HD was offered as patient as there was no clinical indication. Patient was DNR/DNI and she was not intubated. As her respiratory status worsened, family meeting was held and it was decided to make the patient CMO. She expired on [**2166-12-17**]. . RESPIRATORY: Distress: Most likely due to fluid overload for CHF EF 15-20% with 2+MR, she had minimal diuresis on floor and was given IVF for her worsening renal failure. Patient on CXR also had evidence of conolidation/atelctasis on RLL and possible RUL septic emboli which could be source of resp symptoms. Pacer rate adjusted by EP and increased to 70. Patient intially improved with afterload reduction with hydralazine along with improved diuresis. Patient continued to be in worsening respiratory dispress requiring prn BiPap despite natrecor drip started with cardiology consulting service. On [**12-14**] after family meeting it was agreed to move towards DNR/DNI care. Patient was subsequently made CMO and expired on [**2166-12-17**]. . ID: She had a recent bacteremia of unknown source, for which she completed 6 weeks of appropriate antibiotic therapy. She presented to the ED with knee pain, redness, warmth, and was found to have a septic arthritis with significant leukocytosis in the aspirated synovial joint. SHe was intially given ceftriaxone in the ED with vancomycin. On admission to the floor, the ceftriaxone was stopped and the vancomycin was continued (renally dosed). Orthopaedics was consulted and took the patient to the OR on [**2166-11-26**] for incision and drainage of the left knee. Significant pus was drained from the knee. Cultures showed methicillin sensitive staphylococcus aureus. Infectious disease was consulted, who agreed with initial choice of antibiotics. The only source of recurrent bacteremia identified was her pacemaker wires, which on TEE in [**Month (only) 359**] had fibrinous material noted. She had no other obvious source. A repeat TTE was done on [**2166-11-27**], which did not show evidence of endocarditis. . Despite continued vancomycin therapy (goal trough 15-20), pt continued to have low grade fevers to 100.5 daily, and chest xray revealed a possible consolidation in the lower lobe. Therefore, pt was started on levofloxacin in addition to vancomycin. . Pt was taken to OR on [**2166-12-4**] for pacer extraction by the electrophysiology service. All anticoagulants except aspirin were discontinued prior to this date. . # Basilic vein thrombosis: On hospital day 7, pt was noted to have upper extremity swelling in left>right, and vascular ultrasound revealed a thrombosis of the basilic vein. Despite this, anticoagulation was discontinued given the severe risks of anticoagulation in the setting of pacer extraction. . # CHF: EF 15-20% Initially diuretics held given renal insufficiency, however, as renal function stabilized, home dose furosemide was restarted, then increased as needed for gentle diuresis. Pt did develop pleural effusions as a result of mild-moderate volume overload. She was not a hemodialysis candidate after discussion with the family, with respect to patient's wishes and her prognosis. Patient's diuresis was attempted with standing diuretics and natrecor drip. Cardiology service was consulted to help manage her CHF. Patient despite the natrecor drip continue to remain volume overloaded with a progressively compromised pulmonary status. . # AFIB: NSR. On amiodarone with ICD / pacer. Continue amiodarone. TSH was checked as monitor on drug, and was found to be elevated at 7. She is clinically euthyroid, and decision to treat this will be made as outpatient. EP was consulted regarding pacer wires, and the pacer was interrogated. Pacer was removed on [**2166-12-4**] due to bactermia. . CAD / HTN: Continued beta blocker, aspirin, plavix, imdur, lipitor. She did not have any chest pain or difficulty breathing during hospitalization. . CKD: Creatinine at baseline. Clearance 19 on admission. . ANEMIA: thought to be due to CKD with decreased epogen, and iron studies revealed an anemia of chronic disease. We continued procrit, and she was transfused on [**2166-11-27**]. She responded well to the transfusion. . THROMBOCYTOPENIA: She has a chronically low level of platelets. They usually are around low 100s. On [**2166-11-28**] her platelets were measured as 80s. The platelets were remeasured in a yellow top tube to verify a true drop in platelets, and the repeat was 105. . COAGULOPATHY: Chronically elevated INR or unclear etiology. This was felt to likely be due to either nutritional deficiencies or to a factor deficiency. There was no evidence of bleeding, so nothing was done. . DM 2: Continued lantus and humalog sliding scale. . PREOPERATIVE RISK: In terms of the patient's preoperative risk, she has had recent revascularization in the last 5 years with a stress test in [**2163**] that showed no ischemic changes with exercise. She is currently unable to exercise, but based on these previous tests she does not require further testing prior to surgery. The surgery is an intermediate risk. However, she does have severe CHF with EF of 20%, CKD and diabetes which put her at risk for perioperative complications such as hypoxia, elevated blood sugars and further kidney dysfunction. Medications on Admission: colace 100 mg [**Hospital1 **] Amiodarone 200 mg daily Imdur 30 mg daily Procrit 4000 U MWF ASA 81 mg daily MVI with minerals daily Lsix 40 mg daily, hold Wt < 175 KCL 20 mEq with lasix lipitor 10 mg daily Prilosec 20 mg daily Plavix 75 mg daily tylenol 650 mg [**Hospital1 **] lopressor 50 mg tid hydralazine 10 mg qid calcium 600 mg [**Hospital1 **] lantus 20 U sc qhs Discharge Medications: expired Discharge Disposition: Extended Care Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired Completed by:[**2167-3-18**]

[ "507.0", "453.8", "427.31", "711.06", "428.0", "117.9", "996.61", "429.4", "790.7", "707.05", "584.5", "250.00", "425.4", "424.0", "599.0", "518.81" ]

icd9cm

[ [ [] ] ]

[ "93.90", "37.99", "99.04", "81.91", "37.78", "96.6", "80.76", "80.86", "00.13", "38.93" ]

icd9pcs

[ [ [] ] ]

12894, 12909

6730, 12440

307, 371

12960, 12969

4008, 6707

13025, 13063

3171, 3188

12862, 12871

12930, 12939

12466, 12839

12993, 13002

3203, 3989

251, 269

399, 2042

2064, 3003

3019, 3155

18,048

189,340

52722

Discharge summary

report

Admission Date: [**2114-9-6**] Discharge Date: [**2114-9-10**] Date of Birth: [**2049-7-21**] Sex: M Service: MEDICINE HISTORY OF PRESENT ILLNESS: This is a 65 year-old male with a past medical history of severe chronic obstructive pulmonary disease and baseline O2 requirement at home who was rushing this a.m. for an early morning pulmonary clinic appointment, felt short of breath and used 2 liters of oxygen portable in car without relief. In arrival to the office with continued shortness of breath. He denies cough or sputum at that time. He denies fevers or chills. No chest pain. No recent illnesses. He denies other symptoms. No nausea, vomiting, bowel movement changes, no constipation. No change in urinary habits or no urinary symptoms. No change in appetite. No lower extremity edema. No recent upper respiratory infection. No orthopnea. No change in shortness of breath greater then baseline until [**9-6**]. No paroxysmal nocturnal dyspnea. The patient was evaluated by Dr. [**Last Name (STitle) **] in the Pulmonary Clinic who felt the patient would benefit from biPAP. Vital signs, pulse 94. Blood pressure 129/74. Respiratory rate 23. Pulse ox 97% on 2 liters. Arterial blood gases revealed 7.31/702/67. There was no baseline available in the last 100 days. In the Emergency Department the patient received Levofloxacin 500 mg po, Xanax, Solu-Medrol 125 mg IV, Albuterol nebulizers. Chest x-ray at the time showed hyperinflated lungs bilaterally. Electrocardiogram was normal sinus rhythm at a ventricular response rate of 95, normal axis, normal intervals. No ST T changes. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease, FEV1 .4, FEV1 of FVC of 36%, FVC of 40%. 2. Anxiety. 3. Twenty pound weight loss for the past one year. ALLERGIES: No known drug allergies. MEDICATIONS AS AN OUTPATIENT: Albuterol MDI two puffs q.i.d., Atrovent MDI two puffs q.i.d., Albuterol nebulizers two q.i.d., Serevent two puffs q.i.d., Claritin 10 mg po q.d., Xanax 1 mg po q.i.d. SOCIAL HISTORY: Lives at daughters home. [**Name2 (NI) **] alcohol. No drugs. Current smoker, two to three cigarettes per day, two packs per day times fifty years previously. FAMILY HISTORY: Stomach CA. PHYSICAL EXAMINATION ON ADMISSION: Vital signs, pulse 94. Blood pressure 129/72. Pulse ox 67% on 2 liters nasal cannula. Respiratory rate 16. General, this is an older then stated age male, fatigued breathing with pursed lips bending over bed. Oropharynx clear. Face without erythema. Neck was supple. No lymphadenopathy. Accessory muscles being used. No JVD. Lungs distant breath sounds, coarse rhonchi, scattered. Poor air movement. Positive barrel chest appearance. Cardiac regular rate and rhythm. S1 and S2. No murmurs, rubs or gallops. Distant heart sounds. Abdomen was soft, nontender, nondistended. Positive bowel sounds. Positive paradoxical movement. Extremities, no clubbing, cyanosis or edema. Neurological 5 out of 5 strength bilateral upper extremity and lower extremity. LABORATORY ON ADMISSION: White count 9.9, hematocrit 45.7, platelets 285, 70 neutrophils, 23 lymphocytes, 5 monocytes, 2 eosinophils. Sodium 140, K 4.8, chloride 98, CO2 34, BUN 7, creatinine .7, glucose 101. Arterial blood gases revealed 7.31/38/72. Chest x-ray marked emphysema. No pneumonia. Pulmonary function tests [**2-18**] severe obstructive defect probably gas trapping, FEV1 15% predicted, FEV1/FVC 36%, PVC 40% predicted. HOSPITAL COURSE: 1. Chronic obstructive pulmonary disease: The patient was transitioned from Solu-Medrol 125 mg intravenous q.d. to the next day 60 mg po Prednisone q.d. The patient was continued on Levofloxacin 500 mg q.d. the patient has no history of cardiac disease and was not thought that cardiac disease attributed to acute chronic obstructive pulmonary disease exacerbation. The patient was put on BIPAP on the night of [**9-7**] and continued throughout his hospital stay to use BIPAP. The patient was sent home on BIPAP. The patient noticed improvement in breathing ability after nightly BIPAP treatment. The patient was treated with Albuterol and Atrovent nebulizers q 4 hours as well as Serevent. The patient was discharged home on a steroid taper of twenty days, home O2 BIPAP to be used at night, Levofloxacin to finish a fourteen day course as well as Albuterol and Atrovent nebulizers. The patient did complain of mild runny nose at the time of discharge. This was treated with Flonase and nasal inhaler as well as continuing Claritin q.d. 2. Anxiety: The patient exhibited occasional symptoms of anxiousness. The patient was continued on Xanax 1 mg po q.i.d. as well as Serax 15 mg po q.h.s. This appeared to satisfy the patient's anxiety needs. DISCHARGE CONDITION: Fair. DISCHARGE STATUS: No change in discharge status. The patient is full code. DISCHARGE DIAGNOSES: 1. Chronic obstructive pulmonary disease, severe. 2. Anxiety disorder. DISCHARGE MEDICATIONS: 1. Prednisone 60 mg to complete a twenty day taper. 2. Levofloxacin 500 mg po q.d. to complete a fourteen day course. 3. Albuterol MDI two puffs q.i.d. 4. Atrovent MDI two puffs q.i.d. 5. Claritin 10 mg po q.d. 6. Xanax 1 mg po q.i.d. 7. Serax 15 mg po q.h.s. prn. 8. BIPAP at night. 9. Home O2 as needed. 10. Flonase two puffs inhaled through each nostril q.d. FOLLOW UP: The patient is to follow up with Dr. [**Last Name (STitle) **] in the Pulmonary Clinic. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 103528**] Dictated By:[**Last Name (NamePattern1) 1324**] MEDQUIST36 D: [**2114-9-10**] 15:44 T: [**2114-9-11**] 11:03 JOB#: [**Job Number **]

[ "305.1", "300.00", "491.21" ]

icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

4805, 4890

2245, 2279

4911, 4985

5009, 5390

3522, 4783

5402, 5793

165, 1636

3091, 3504

1659, 2048

2065, 2228

59,485

108,441

36018

Discharge summary

report

Admission Date: [**2115-1-28**] Discharge Date: [**2115-2-5**] Date of Birth: [**2051-5-30**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3376**] Chief Complaint: sigmoid carcinoma, umbo hernia Major Surgical or Invasive Procedure: 1. Laparoscopy. 2. Flexible sigmoidoscopy and tattooing of tumor. 3. Laparoscopic sigmoidectomy with #31 stapled coloproctostomy. 4. Incarcerated umbilical hernia repair History of Present Illness: The patient is a morbidly obese gentleman with multiple medical problems who was diagnosed with sigmoid colon cancer. After cardiac clearance, and no evidence of metastatic disease by CT scan, he was taken to the operating room for definitive resection. Past Medical History: DM2, HTN, hyperchol, anxiety Social History: quit tobacco > 20 years ago, drinks 4-6 beers daily, retired from [**Last Name (un) **] [**Doctor Last Name 20728**]. Married, wife recently broke ankle. Family History: His family history is negative for cancer. There is no family history of premature coronary artery disease, unexplained heart failure, or sudden death. Father died in his 70's, had Parkinson disease. Physical Exam: At time of dscharge: Tm:98.1 Tc: 98.1 P76 BP:138/73 RR:20 SaO2:98% at 4L Gen: NAD Card: RRR No M/R/G Lung: CTAB with distant breath sounds Abd: +BS, soft, obese, nontender, nondistended, no reboung or guarding Wound: C/D/I Ext: pedal edema Pertinent Results: [**2115-2-2**] 01:10PM BLOOD WBC-15.1* RBC-3.81* Hgb-12.0* Hct-37.7* MCV-99* MCH-31.5 MCHC-31.7 RDW-14.2 Plt Ct-384 [**2115-1-31**] 04:12AM BLOOD Neuts-90* Bands-1 Lymphs-3* Monos-3 Eos-2 Baso-1 Atyps-0 Metas-0 Myelos-0 [**2115-1-31**] 04:12AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-NORMAL Macrocy-2+ Microcy-NORMAL Polychr-NORMAL [**2115-2-2**] 01:10PM BLOOD PT-13.8* PTT-22.0 INR(PT)-1.2* [**2115-2-5**] 06:50AM BLOOD Creat-1.5* K-4.5 [**2115-2-4**] 07:20AM BLOOD Creat-1.5* K-4.0 [**2115-2-3**] 07:25AM BLOOD Creat-1.2 K-3.4 [**2115-1-29**] 07:40AM BLOOD Glucose-138* UreaN-13 Creat-0.9 Na-135 K-4.6 Cl-103 HCO3-29 AnGap-8 [**2115-1-30**] 05:37AM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-1129* [**2115-2-5**] 06:50AM BLOOD Mg-2.1 [**2115-1-28**] 05:18PM URINE Hours-RANDOM Creat-573 Na-27 . MRSA SCREEN (Final [**2115-2-1**]): No MRSA isolated . Path:Primary Tumor: pT3: Tumor invades through the muscularis propria into the subserosa or the nonperitonealized pericolic or perirectal soft tissues. Regional Lymph Nodes: pN0: No regional lymph node metastasis. Lymph Nodes Number examined: 14. Number involved: 0. . STUDIES: [**1-29**] ECHO: LA normal in size. LV wall thickness, cavity size, global [**Month/Year (2) 16631**] function normal (LVEF>55%). RV chamber size, free wall motion normal. AV not well seen. No AR. MV not well seen. No MR. [**First Name (Titles) **] [**Last Name (Titles) 16631**] pressure not determined. anterior space which most likely represents a prominent fat pad. . [**1-30**] CTA: No evidence of PE. B/L ground-glass opacities with central distribution, sparing the lung bases, no intralobular septal thickening (aspiration pneumonia >> fluid overload). Mild dilatation of the main pulmonary artery suggestive of PA HTN. B/L small pleural effusions (L > R). Gallstones, no cholecystitis. . Brief Hospital Course: Mr. [**Known lastname 8071**] is a 63-year-old man who underwent a screening colonoscopy and was found to have several polyps and a mass at 25 cm. This was biopsied positive for moderately differentiated adenocarcinoma. He underwent a CT scan of the abdomen, which showed no evidence of metastatic disease. He had no GI symptoms referable to the colon cancer. After cardiac clearance, and no evidence of metastatic disease by CT scan, he was taken to the operating room for definitive resection. Patient underwent laparoscopic sigmoidectomy with stapled coloproctostomy and umbilical hernia repair. . He returned to [**Location **] 5 from the PACU. He was made NPO and had IV hydration, IV medications, foley and oxygen via NC. He started to show evidence of fluid overload, initially O2 sats's the mid 90s on 5L NC, but had desated to mid 80s requiring NRB. A CTA was done - negative for PE. He also had an ECHO, which showed a normal EF. He had been persistently hypertensive and tachycardic despite hydralazine IV and metoprolol IV. After stabilizing diurisis and blood pressure control in the ICU, he returned to the surgical floor requiring oxygen by nasal cannula. . The patient's serum creatinine increased from 0.9 to 1.5 his PO lasix will be held for a total of 3 days. The pt will follow up with his PCP [**Last Name (NamePattern4) **] [**2115-2-7**]. Prior to his visit the VNA will draw a serum creatinine and fax to PCP [**Name Initial (PRE) 3726**]. A discharge summary was faxed to the office. . The pt's blood sugar was 50 on [**2115-2-5**] without any signs or symptoms of hypoglycemia. This was treated and the pt was educated on the s/s of hypoglycemia. He was advised to check his blood sugar before meals and at bedtime and to continue with his oral diabetic medications. He was advised to call his PCP if his blood sugar is less than 90 or more than 250. The patient's staples were removed and steri strips were applied. . The patient is currently on home oxygen 2L via NC. He will continue with this at home. He was evaluated per Physical Therapy, and cleared for home with oxygen. He was able to ambulate up and down stairs in hospital prior to discharge with sats remaining over 95% on 2 liters with minimal assist. It was recommended he be discharged to a rehabilitation facility secondary to his acute renal failure and hypoglycemia, but he refused this. The risks of this were explained to the patient. Discharge paperwork was reviewed with the patient and he will follow up with Dr. [**Last Name (STitle) 1120**] in [**1-22**] weeks and his PCP [**Last Name (NamePattern4) **] [**2115-2-7**] . Medications on Admission: lisinopril 40 mg, Lasix 80 mg, Toprol XL 50 mg, metformin 1000 mg [**Hospital1 **], glyburide 5 mg [**Hospital1 **], Zoloft 40 mg, Xanax 0.5 mg TID PRN, Zocor 80 mg, Betoptics drops [**Hospital1 **] Discharge Medications: 1. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for 2 weeks. Disp:*45 Tablet(s)* Refills:*0* 2. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 5. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 10. Xanax 0.5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety. 11. Zocor 80 mg Tablet Sig: One (1) Tablet PO once a day. 12. Sertraline 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Trusopt 2 % Drops Sig: One (1) Ophthalmic twice a day. Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Primary: Sigmoid colon cancer Incarcerated umbilical hernia. Post-op Hypoxia secondary to fluid over load Hypercarbia Post op ventricular tachycardia Hypertension Acute renal failure . Secondary: DM2, HTN, hyperchol, anxiety Discharge Condition: Stable Tolerating regular diet Pain well controlled with oral medicaitons 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 vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or 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. *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *Avoid driving or operating heavy machinery while taking pain medications. * 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. * Continue to ambulate several times per day. . Incision Care: -Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. . Oxygen: -Please continue with your home oxygen therapy. Titrate oxygen to maintain resting saturations over 93%. . Medications: Lasix: -Please continue to hold your lasix until your follow up your PCP [**Last Name (NamePattern4) **] [**2115-2-7**]. . Blood sugars: -Please continue to check your blood sugars before meals and at bedtime. -Please call your PCP if your blood sugars are under 90 and over 250. -Continue your metformin and glyburide unless otherwise instructed per yor PCP. Followup Instructions: 1) Please call Dr.[**Name (NI) 77999**] office for a followup appointment in [**12-21**] weeks ([**Telephone/Fax (1) 3378**] 2. A follow up appointment was made for you at your PCP's office, [**Last Name (un) **],[**Doctor Last Name **] M. [**Telephone/Fax (1) 27541**], on [**2115-2-7**] at 11:00 AM. Please call if you can not make this appointment. It is very important for you to keep this appaointment to follow up with your lab results. NEITHER DICTATED NOR READY BY ME Completed by:[**2115-2-5**]

[ "997.5", "311", "327.23", "153.3", "428.0", "584.9", "428.33", "997.1", "518.0", "250.00", "278.01", "305.01", "E878.8", "427.89", "552.1" ]

icd9cm

[ [ [] ] ]

[ "45.94", "17.36", "45.24", "54.21", "53.43" ]

icd9pcs

[ [ [] ] ]

7348, 7431

3379, 6007

345, 521

7700, 7776

1523, 3356

9795, 10300

1045, 1247

6257, 7325

7452, 7679

6033, 6234

7802, 8944

8959, 9772

1262, 1504

274, 307

549, 805

827, 857

873, 1029