ChanBeDu/relevant_section_length · Datasets at Hugging Face

23,657

174,141

13528

Discharge summary

report

Admission Date: [**2147-2-24**] Discharge Date: [**2147-3-2**] Date of Birth: [**2112-11-14**] Sex: M Service: MEDICINE Allergies: Penicillins / Watermelon / Almond Oil / Hydralazine / cefepime Attending:[**First Name3 (LF) 603**] Chief Complaint: nausea, vomiting, shortness of breath Major Surgical or Invasive Procedure: [**2147-2-24**] - Central line placement in right IJ [**2147-2-24**] - Mechanical ventilation History of Present Illness: 34yo M PMHx DM1, ESRD (on HD [**Month/Day/Year **]/Thurs/Sat), severe gastroparesis with recurrent admissions for nausea/vomitting (most recent discharge [**2147-2-17**]), nonischemic cardiomyopathy (EF=30-35%), presenting with nausea, vomiting, and shortness of breath. History was initially obtained from the patient in the emergency department, and subsequently obtained from the patient's girlfriend by the ICU team. . Per ED, the patient reported that 3 days prior to day of admission, he developed nausea and NBNB emesis, consistent with prior episodes of gastroparesis. Symptoms were not initially associated with any fevers/NS/chills, shortnesss of breath, chest pain; beginning 1d prior to admission, he developed worsening pleuritic chest pain, non-exertional, along with shortness of breath and cough. Also reported poorly controlled finger sticks. . Per the patient's girlfriend, the patient has chronic issues with nausea/vomiting from gastroparesis. He was in his usual state of health until Tuesday, when he awoke with shortness of breath prior to dialysis. He felt okay after HD on Tuesday, then developed shortness of breath on Wednesday evening/Thursday morning. He felt better after HD yesterday, but awoke at 5 a.m. today with nausea, vomiting, shortnss of breath. His emesis was profuse and red, but the patient's girlfriend attributes this to red coolaid that he drank last night. No diarrhea. Last BM yesterday per girlfriend. Had mild coughing this morning. No recent travel or sick contacts. Had dental work and was on antibiotics 2-3 weeks ago. The patient's girlfriend is not sure the patient took his usual medications this a.m. but believes he probably did not. No recent med changes per girlfriend. [**Name (NI) **] fever/chills. No syncope. +abdominal pain, diffuse, this a.m. No dysuria. No rash. No myalgia/arthralgia. . On presentation to ED initial vital signs were 99.0 113 225/111 28 89% 3LNC. On exam patient was short of breath, appearing fatigued. He became hypoxic, requiring a non-rebreather. On further history taking, he reported that in setting of vomiting he may have aspirated small amount of vomitus. Labs were significant for WBC 11.8 (N87), Hct 29 (baseline 28), Na 131, K 4.2, glucose 678, Anion Gap 21, VBG 7.47/38, lactate 2.0. CXR significant for pulmonary edema (radiology read), felt to be consistent with pneumonia by ED. Patient was albuterol, ipratropium, NTG, labetalol 10 mg IV x 2, morphine, Zofran, vancomycin 1 gm, cefepime 2 gm. He was given succinylcholine, propofol, fentanyl, and midazolam prior to intubation. A central line and OGT were placed. After intubation, the patient reported to have red frothy secretions from ET tube. Vital signs prior to transfer were T 98.5 P 88, BP 160/91 Sat 100% on AC 500mL 22RR 10peep 100%. Past Medical History: - DM type I since age 19, followed at [**Last Name (un) **]. Complicated by nephropathy, neuropathy, gastroparesis, retinopathy. Multiple prior hospitalizations with DKA, nausea/vomitting [**2-9**] gastroparesis - ESRD on HD T/Th/S via right arm fistula @ [**Location (un) **] [**Location (un) **], dry weight 73kg - Hypertension - Nonischemic cardiomyopathy with EF 30-35% - Anemia: felt to be due to both iron deficiency and advanced CKD - Depression - Pulmonary hypertension - Migraines Social History: -Home: Lives with his GF. Mother lives in the area as well. -Tobacco: trying to quit; has relapsed and smokes 1 pack per week or week and a half -EtOH: previously drank heavily (30-40 drinks/week) but has not used alcohol since [**2144-11-14**] -Illicits: Denies other drugs. Family History: Paternal GF had DM2 but nobody with DM1. Hypertension in a few family members. Physical Exam: Admission exam: VS: T 98.4 BP 179/98 HR 92 RR 21 Sat 100%/vent Gen: Intubated, sedated. HEENT: Anicteric sclerae. Neck: RIJ in place. Chest: Clear ventilated breath sounds. CV: RRR. Normal s1, s2. No M/G/R. Abd: +BS. Soft. NT/ND. Rectal: Guaiac negative yellowish-brown stool. Ext: WWP. No edema. RUE fistula with good thrill. Neuro: Sedated. PERRL. Moves all extremities. Discharge exam - unchanged from above, except as below: Gen: Awake, interactive, comfortable Neck: supple, no RIJ Chest: CTAB aside from trace crackles in the lung bases bilat Neuro: A&Ox3, no focal neuro defecits Pertinent Results: Admission labs: [**2147-2-24**] 08:15AM BLOOD WBC-11.8*# RBC-3.11* Hgb-9.7* Hct-29.6* MCV-95 MCH-31.1 MCHC-32.6 RDW-13.9 Plt Ct-261# [**2147-2-24**] 08:15AM BLOOD Neuts-87.4* Lymphs-5.7* Monos-2.7 Eos-3.6 Baso-0.7 [**2147-2-24**] 02:02PM BLOOD PT-11.7 PTT-31.3 INR(PT)-1.1 [**2147-2-24**] 08:15AM BLOOD Glucose-678* UreaN-30* Creat-6.4* Na-131* K-4.2 Cl-90* HCO3-24 AnGap-21* [**2147-2-24**] 08:15AM BLOOD CK-MB-4 cTropnT-0.24* proBNP-GREATER TH [**2147-2-24**] 02:02PM BLOOD CK-MB-4 cTropnT-0.20* [**2147-2-24**] 08:15AM BLOOD Calcium-9.0 Phos-4.1 Mg-1.7 [**2147-2-24**] 08:41AM BLOOD Type-[**Last Name (un) **] Temp-37.2 pO2-138* pCO2-38 pH-7.47* calTCO2-28 Base XS-4 Intubat-NOT INTUBA [**2147-2-24**] 08:41AM BLOOD Lactate-2.0 Discharge labs: [**2147-3-2**] 05:39AM BLOOD WBC-5.6 RBC-2.82* Hgb-8.7* Hct-25.5* MCV-91 MCH-31.1 MCHC-34.3 RDW-14.1 Plt Ct-229 [**2147-3-2**] 05:39AM BLOOD Glucose-274* UreaN-40* Creat-10.2*# Na-137 K-3.6 Cl-94* HCO3-26 AnGap-21* [**2147-3-2**] 05:39AM BLOOD Calcium-8.7 Phos-5.0* Mg-1.9 Imaging: CXR [**2-24**]: Findings most consistent with pulmonary edema. CXR [**2-24**]: Right internal jugular vascular catheter terminates in the mid superior vena cava, with no visible pneumothorax. Other indwelling devices remain in standard position. Cardiac silhouette is enlarged but has slightly decreased in size, and widespread pulmonary edema has also slightly improved in the interval. Small pleural effusions have apparently slightly decreased in size but positional differences limit comparison. CXR [**2-27**]: 1. Right internal jugular central line continues to have its tip in the mid SVC. There is worsening bilateral airspace process most likely representing moderate-to-severe pulmonary edema. The heart is enlarged, which could reflect cardiomegaly, although pericardial effusion should also be considered. This is likely a layering left effusion. No pneumothorax is seen. CXR [**2-28**]: As compared to the previous radiograph, there is a marked improvement with decrease in extent of the pre-existing massive pulmonary edema. The radiograph currently shows only mild signs of fluid overload. Unchanged moderate cardiomegaly without pleural effusions. Mild retrocardiac atelectasis. Unchanged right internal jugular vein catheter. ECHO [**2-28**]: Mild symmetric left ventricular hypertrophy with mild cavity enlargement and normal regional/global systolic function. Pulmonary artery hypertension. Very small pericardial effusion. Compared with the prior study (images reviewed) of [**2147-2-10**], the left ventricular cavity is now smaller and systolic function is improved. The estimated PA systolic pressure is now lower. Brief Hospital Course: 34 yo M PMHx DM1, ESRD (on HD [**Year (4 digits) **]/Thurs/Sat), severe gastroparesis with recurrent admissions for nausea/vomitting (most recent discharge [**2147-2-17**]), nonischemic cardiomyopathy (EF previously 30-35%), presenting with nausea, vomiting, admitted to the ICU for respiratory failure. # Respiratory failure: Likely due to pulmonary edema in the setting of CHF exacerbation. Intubated in the ED due to worsening mental status. Extubated on [**1-25**], and able to saturate well on room air. On the floor he was initially on room air. However, on [**2-27**], patient became tachypneic and desatted into the 70-80s in the setting of severe HTN to 220/120s. Exam and CXR consistent with flash pulmonary edema. Patient initially on NRB, received urgent dialysis (-3L) and was able to be weaned to nasal cannula, he did not require intubation. His BP was controlled as below and he was transferred back to the floor where he remained on room air until discharge. # Acute on chronic systolic heart failure: Likely caused by severe HTN, with HTN possibly exacerbated by vomiting. Has non-ischemic cardiomyopathy for EF which was previously reported as 30-35%. MI ruled out with serial enzymes. He received extra sessions of hemodyalysis to remove volume, although these were often stopped early because he reported chest pain. A repeat echo showed an improved EF of 55% during this admission. # Alveolar hemorrhage - Bronchoscopy was performed in the [**Hospital Unit Name 153**] which was concerning for alveolar hemorrhage. This was performed because of blood in his endotracheal secretions. The cause was likely severe hypertension. Serologies were sent for [**Doctor First Name **], ANCA and anti-GBM, all of which were negative. He had no further obvious episodes of hemorrhage and had no hemoptysis after leaving the floor. # Hypertension: Patient has severe HTN, on multiple meds in setting of underlying ESRD. He was initially continued on home doses of [**Doctor First Name 40899**], carvedilol, lisinopril, amlodipine. On the floor, he remianed hypertensive and his [**Doctor First Name 40899**] patch was increased to 0.3mg/24h. On [**2-27**], developed BP into 220/120s with flash pulmonary edema. He was transferred to the ICU and started on nitro drip and also received IV labetalol to lower his BP. HTN thought to be related to fluid overload, he improved with an extra session of HD which removed 3L by ultrafultration. Patient has been recently skipping HD sessions and sometimes HD cut short due to crampy chest pain. His carvedilol was changed to labetalol to allow for more room to uptitrate. At discharge, he was on labetalol 300mg q8h with BP in the 160s. We wanted to monitor his BP for another 24 hours after this medication change but the patient insisted on leaving AMA, as described below. # Anemia: Chronic anemia related to ESRD. Transfused one unit during hospitalization. No source of acute bleed was identified aside from mild degree of pulmonary hemorrhage, as discussed below. # ESRD on HD (TuThSa): Renal was consulted and he continued to receive HD as an inpatient. Continued on sevelamer and nephrocaps. Had urgent dialysis on [**2-27**] for hypertensive emergency and pulmonary edema as described above. # DM1: Initially presented with severe hyperglycemia. Developed hypoglycemia on insulin gtt requiring D20 to maintain normoglycemia. After initial transfer to the floor, he remained hyperglycemic with multiple "critical high" blood sugars requiring additional doses of Lantus. At the time of his second MICU stay, he was again hyperglycemic to the 400s. Anion gap ~16-17, but also with ESRD. PH 7.45 on ABG. Does not make urine, so cannot measure urine ketone. No clear evidence of DKA. Patient restarted on insulin drip and transitioned to subcutaneous insulin once tolerating PO. Josline was consulted and his Lantus dose was increased to 14 units qAM and 12 units qPM. Again, we had hoped to monitor his glucose for longer after the most recent uptitration of his insulin, however he left AMA. #AMA: On [**3-2**], the patient was still mildly hypertensive to the 160s systolic and his labetalol had just been uptutrated. We had also recently increased his Lantus dose. We wanted to monitor him longer to ensure adequate BP and glycemic control after these medication changes. However, the patient was very frustrated with being in the hospital and chose to leave AMA. He understood and was able to repeat the risks of leaving, including worsening hypertension, fluid accumulation in the lungs, hyperglycemia and DKA and possible death. # Code status this admission: FULL CODE #Transitional issues -Will need BP closely monitored, antiypertensive regimen changed: carvedilol 25mg [**Hospital1 **] changed to labetalol 300mg q8h -Will need close monitoring of his blood sugar with uptitration of his Lantus this admission -Dry weight should be re-evaluated so that an appropriate amount of fluid is removed with each HD session -Would likely benefit from outpatient social work given that he is very frustrated and depressed about the state of his health, which may be contributing to his poor compliance. Medications on Admission: - amlodipine 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. - aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). - carvedilol 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day. - [**Hospital1 40899**] 0.2 mg/24 hr Patch Weekly [**Hospital1 **]: One (1) Patch Weekly Transdermal QSUN (every Sunday). - insulin glargine 100 unit/mL Solution [**Hospital1 **]: Fourteen (14) units Subcutaneous Every morning. - insulin lispro 100 unit/mL Solution [**Hospital1 **]: Sliding Scale units Subcutaneous Before meals and before bed - B complex-vitamin C-folic acid 1 mg Capsule [**Hospital1 **]: One (1) Cap PO DAILY (Daily). - lisinopril 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. - sevelamer carbonate 800 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). - sertraline 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. - hydromorphone 4 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day as needed for pain. - ondansetron 4 mg Tablet, Rapid Dissolve [**Hospital1 **]: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. Discharge Medications: 1. amlodipine 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 2. aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 3. [**Hospital1 40899**] 0.3 mg/24 hr Patch Weekly [**Hospital1 **]: One (1) Patch Weekly Transdermal QMON (every [**Hospital1 766**]). Disp:*4 Patch Weekly(s)* Refills:*0* 4. insulin glargine 100 unit/mL Solution [**Hospital1 **]: Fourteen (14) units Subcutaneous In the morning. 5. insulin lispro 100 unit/mL Solution [**Hospital1 **]: Sliding scale units Subcutaneous With meals and at bedtime: Please contnue to use your home sliding scale. 6. B complex-vitamin C-folic acid 1 mg Capsule [**Hospital1 **]: One (1) Cap PO DAILY (Daily). 7. lisinopril 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 8. sevelamer carbonate 800 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. sertraline 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 10. hydromorphone 4 mg Tablet [**Hospital1 **]: One (1) Tablet PO every twelve (12) hours as needed for pain. 11. ondansetron 4 mg Tablet, Rapid Dissolve [**Hospital1 **]: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 12. labetalol 300 mg Tablet [**Hospital1 **]: One (1) Tablet PO every eight (8) hours. Disp:*52 Tablet(s)* Refills:*0* 13. insulin glargine 100 unit/mL Solution [**Hospital1 **]: Twelve (12) units Subcutaneous at bedtime. Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Acute on chronic systolic heart failure Respiratory failure Uncontrolled type 1 diabetes Uncontrolled hypertension Secondary diagnoses: Gastroparesis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 21822**], It was a pleasure taking care of you during your admission to [**Hospital1 18**]. You were initially admitted to the intensive care unit where you were intubated for respiratory failure, thought to be due to an exacerbation of heart failure. You had fluid removed with dialysis and your symptoms improved. After transfer to the medicine floor, your blood pressure was severely elevated and fluid built up in your lungs, for which you were readmitted to the ICU. There, you received IV medications to lower your blood pressure and an insulin drip to control your blood sugar. Your blood pressure and blood sugar improved and were again transferred to the medicine floor. We stopped your carvedilol and added labetalol to help control your blood pressure. We also increased your [**Hospital1 40899**] patch to 0.3mg/24h. Labetalol was increased to 300mg every 8 hours. We wanted to watch your blood pressure after the most recent change to your medications, but you wanted to leave against medical advice. Please check your BP at home and call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], or return to the hospital if it is higher than 180/100 or if you have any headache, changes in vision, chest pain or shortness of breath. It is important that you go to each session of dialysis to remove fluid and help control your blood pressure. You will follow up with your nephrologist after discharge at your next dialysis session. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. The following changes were made to your medications: START labetalol 300mg by mouth three times per day STOP carvedilol CHANGE [**Name8 (MD) 40899**] patch 0.3mg/24h change every [**Name8 (MD) 766**] CHANGE Lantus 14 units in the morning and 12 in the evening Followup Instructions: Department: [**Hospital3 249**] When: FRIDAY [**2147-3-10**] at 10:10 AM With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Address: [**Location (un) 830**] [**Location (un) 86**], [**Numeric Identifier 718**] Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] [**Hospital Ward Name **] Ctr [**Location (un) 895**] Central [**Hospital **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor in follow up. [**Location (un) **] [**Location (un) **] Dialysis Center Schedule- Tuesday, Thursday and Saturdays Phone: [**Telephone/Fax (1) 5972**] Your nephrologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] will follow up with you for your hospitalization at your next scheduled dialysis day.

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Discharge summary

report

Admission Date: [**2109-1-10**] Discharge Date: [**2109-1-31**] Date of Birth: [**2064-2-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2024**] Chief Complaint: Abnormal labs Major Surgical or Invasive Procedure: PEG placement, diverting ileostomy, intubation, catheter placement into abdominal abscess History of Present Illness: Mr. [**Known lastname 73639**] is a 44 year old man with metastatic renal cell carcinoma, s/p R nephrectomy, who was sent to the ED by his oncologist after a routine, in clinic lab draw revealed ARF with Cr >7. He denies any urinary symptoms, shortness of breath or edema, but does endorse decreased appetite. Confirms he may have been mildly dehydrated upon arrival at his clinic visit. Denies any other localizing signs or symptoms of infection. He does endorse sleeping more in the last 2-3 weeks and that he's been taking more pain medication to keep his pain at his baseline level. At baseline he has pain in his right upper qaudrant and flank from his tumor progression. There is also rib involement adjoining the tumor site. His describes his pain as constant, pulsing in quality, worsening for last several weeks. Now feels skin over his R flank is warm to touch. His initial vitals in the ED were T98.6, HR 99, BP 142/91, RR 16, and Sat 98%RA. He rated his abdominal pain as [**4-13**]. His initial labs were remarkable for hyperkalemia (6.4), for which he received insulin/D50, kayexalate x 1 (did not tolerate second dose of kayexalate). EKG did not demonstrate peaked T waves. A renal ultrasound demonstrated no obstruction or hydronephrosis. He was seen by the renal consult service who were concerned for contrast nephropathy. He was given a total of 5L NS while in the ED with minimal Cr drop. Now being admitted to OMED for continued management of acute renal failure. Upon arrival to the floor, confirms history as above. Additionally c/o baseline dysphagia since emergency trach last [**Month (only) 116**]. Confirms poor pain management at baseline. He currently wakes himself up during the night to take more breakthrough medication. Past Medical History: Renal Cell Carcinoma (please see below) - h/o RLE DVT [**8-/2107**] - Colonic perforation - Hyponatremia - Anemia - Cervical surgery with rod-placement due to C2 met ONCOLOGIC HISTORY Mr. [**Known lastname 73639**] presented with hematuria and flank pain in [**1-/2107**] and was found to have a 5.1 x 5.8 cm R renal mass by CT scan and underwent partial R nephrectormy in 2/[**2106**]. In [**10/2107**], his renal cell carcinoma developed in the R subcostal region and was resected. In [**2108-4-3**], he was found to have a soft tissue mass (2.5 x 3.2 cm replacing the C2 vertebral body) and underwent posterior cervical fusion form the occiput to C5 as well as left sided C2 laminectomy and decompression. He had postop radiaion to the c-spine. In [**7-/2108**], he was treated with 1 cycle of high-dose IL-2, but a follow up CT showed progression, and this was stopped. In [**2108-11-3**], he was enrolled in a phase II trial evaluating sorafenib and concurrent bevacizumab. Monitored qMonth with CT scan. Last CT [**2109-1-3**] revealed decreased tumor size, but also colonic perforation which is currently encapsulated - not a surgical candidate until sorafenib & bevacizumab have cleared system given concern for poor wound healing. Social History: Married. Quit drinking alcohol. [**Doctor First Name **] tobacco and illicit drug use. Not currently emplyed, but worked as an electrician. Family History: Mother died of a brain tumor. Father diagnosed with prostate cancer in his 70s and is still living. He has 3 siblings and 2 children without medical concerns. Maternal aunt with lymphoma. Father and sister have had h/o "blood clots." Physical Exam: Admission Exam: VITALS: 97.8 126/76 95 16 97/RA Pain [**7-14**] Ht 5'7" Wght 12.5lb GENERAL: Thin, pale gentleman in NAD HEENT: NCAT, eyes disconjegate (baseline), PERRLA, MMM NECK: Very limited ROM [**1-5**] cervical fusion, without LAD CARD: RRR without m/g/r RESP: CTAB without wheeze/rale/rhonchi ABD: (+) BS, thin, flat with palpable mass R flank, warm to the touch with post-resection scar, very TTP with only slight touch BACK: R CVA tenderness, no left CVA tenderness, cervical midline scar EXT: WWP without c/c/e NEURO: A&O, appropriate Pertinent Results: [**2109-1-9**] 03:18PM WBC-12.6* RBC-4.29* HGB-11.6* HCT-36.3* MCV-85 MCH-27.1 MCHC-32.0 RDW-17.6* [**2109-1-9**] 03:18PM PLT COUNT-716*# [**2109-1-9**] 03:18PM ALT(SGPT)-38 AST(SGOT)-41* ALK PHOS-435* [**2109-1-9**] 03:18PM ALBUMIN-3.2* CALCIUM-9.5 [**2109-1-9**] 03:18PM GLUCOSE-106* UREA N-46* CREAT-6.7*# SODIUM-134 POTASSIUM-5.8* CHLORIDE-94* TOTAL CO2-27 ANION GAP-19 [**2109-1-14**] 4:40 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST 1. Interval increase in left nephrectomy bed fluid collection, including extravasated oral contrast, which has tumor seen at least along surrounding the inferior portions of this collection. 2. Right abdominal wall mass described above. 3. Diffusely fatty liver and distended gallbladder, as before. 4. Bibasilar atelectasis. Small foci of ill-defined opacity within both lungs are likely inflammatory or infectious in nature. Brief Hospital Course: 44 yo F metastatic renal cell cancer and known colonic perforation presenting five days after last admission with ARF and hyperkalemia. #) Acute renal failure. Noted to have Cr > 7 while in clinic. Baseline Cr approximately 1. Confirmed poor po intake but denied any other new nephrotoxic drugs, dysuria or difficulty urinating when has urge. Imaging revealed no evidence of hydronephrosis so unlikely to be post-renal etiology. AIN an additional consideration, but urine eosinophils netative. Other consideration would be progression of cancer but this seems unlikely to have occurred so quickly given no prior involvement of contralateral kidney. Ultimately attributed to contrast nephropathy from CT obtained during the prior admission when he may have also been dehydrated. Renal consult was obtained on admission and followed him throughout his his stay until clearly resolving. Treated with IVF hydration. Additionally avoided nephrotoxic medications and renally dose medications. Creatinine normalized to 1.1 by discharge. #) Hyperkalemia. Secondary to ARF and poor renal clearing. Given insulin/D50, kayexalate x 1 (did not tolerate second dose of kayexalate) while in ED. No peaked Ts observed on EKG. Stable K at 6. Continued monitoring on telemetry with daily EKGs and kayexelate PR for potasssium > 6. Resolved [**2109-1-14**] so telemetry and EKGs were discontinued. Continued to monitor electrolytes throughout stay. #) Renal cell carcinoma/Colonic Perforation: S/p R kidney resection with diffuse metastases. Most recently with colonic perforation on R flank. Last treatment was phase II trial evaluating sorafenib and concurrent bevacizumab. Both of these medications had been stopped with perforation. From the day following admission had worsening abdominal pain despite dramatic increases in both fentanyl patch and dilaudid pca. CT Abd/pelvis [**1-14**] with increased extravasation, as well as increased perinephric fluid at L kidney. Surgery consulted and discussed various options with patient. Plan was ultimately to have IR place a CT-guided drain [**1-16**] into the fluid collection. Mr. [**Known lastname 73639**], however, could not tolerate the pain of this procedure and was subsequently taken to the OR for surgery. Now s/p ileostomy & pigtail placement with decreased pain. Also started on TPN while in ICU. goals of care and hospice discussed with palliatve care consult. goal to dc home. CT Scan [**1-24**] to assess abscess with increased size of right middle lobe nodule from [**1-2**] and an increase in size of the right anterolateral abdominal wall metastasis since [**1-14**]. Pigtail in abscess putting aout 50-100 cc on discharge. He will f/u with his oncologist and Dr. [**Last Name (STitle) 519**] for this. #) Leukocytosis - Newly noted [**1-11**] AM. Denies any localizing symptoms/signs of infection beyond worsening R flank pain. Does have known colonic perforation which is concerning for occult bacteremia. Work-up for colonic perforation as above. Additionally obtained blood cultures which were pending and no growth to date. Started empirically on Cipro/Flagyl for GI pathogens. Newly increased [**1-23**], resolved [**1-29**]. No localizing symptoms of infection, but does have known colonic perforation with abscess. Afebrile. pancultured and restarted empiric flagyl/cipro for perforation. With lactobacillius in abscess so transitioned off cipro and have started Unasyn [**1-25**]. Unasyn continued for 7 days. Flagyl for total of 7 days. #) Pain - Only fairly well controlled on admission, stable on discharge. As an outpatient had recently increased Fentanyl patch from 75mcg to 125mcg. Still needed significant breakthrough dilaudid IV. Increased fentanyl patch [**1-14**] from 125 to 150mcg/72 hours. Started dilaudid pca for breakthrough. eventually was weaned off dilauded and was stable on 250mg fentanyl patch q72 hours. DNR/DNI Decided [**1-15**] with wife and patient after extensive discussion about current illness. Would still like to pursue palliative surgery and reversed code-status for OR. Medications on Admission: Fentanyl Patch 125mcg/hr q72H Colace 100mg [**Hospital1 **] Dulcolax 10mg QDaily PRN constipation Senna [**Hospital1 **] Tylenol Q6H PRN Lorazepam 1mg Q8H PRN Dilaudid 2-4mg Q3H PRN breakthrough Discharge Medications: 1. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl Topical QID (4 times a day) as needed. 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO TID (3 times a day) as needed. 3. Normal Saline Flush 0.9 % Syringe Sig: One (1) Injection three times a day: Please flush pigtail catheter three times a day. Thanks. . Disp:*90 flushes* Refills:*2* 4. Fentanyl 100 mcg/hr Patch 72 hr Sig: Two (2) Transdermal every seventy-two (72) hours: Please use two of the 100 mcg patches and one 50 mcg patch every three days, to make a total of 250 mcg every 3 days. . Disp:*20 patches* Refills:*2* 5. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Transdermal every seventy-two (72) hours: Please apply two 100 mcg patches and 1 50 mcg patch every 72 hours. . Disp:*10 patches* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 511**] Home Therapies Discharge Diagnosis: Primary: Metastatic renal cell carcinoma, colonic perforation, acute kidnedy failure Discharge Condition: Hemodynamically stable and afebrile. Discharge Instructions: You were admitted to the hospital with acute renal failure, infection surrounding your intestinal wall, and poor nutrition. Regarding your acute renal failure, your kidney function improved significantly and has now returned to its baseline. Upon admission, you were known to have a collection of fluid in your abdomen from your cancer communicating with your colon. To treat this, a drain was placed in the fluid collection and a diverting ileostomy was performed. You are being discharged with continued visiting nurse services to help you with your ileostomy, monitor your nutritional status, answer any questions you may have and monitor your weight. Your medications have changed while you were in the hospital. Take all medications as prescribed. You will be provided a list of the medications you should be taking and when to take them. Keep all outpatient appointments. Return to the hospital or consult a medical specialist if you notice fever, chills, worsening abdominal pain, vomiting, bloody vomit, inability to take in enough nutrition or fluid to keep yourself healthy, or for any other symptom which is concerning to you. Followup Instructions: Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2109-2-6**] 2:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9402**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2109-2-6**] 3:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2109-2-6**] 3:30 Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]/CUT. ONC. DERM Date/Time:[**2109-2-6**] 11:00 To follow-up with your ostomy care, please call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10132**] [**Telephone/Fax (1) 73642**] for a follow-up appointment for your ostomy care and for any further questions regarding your ostomy. Regarding your pigtail drain, your visiting nurse will continue to monitor its output. Once your drainage decreases to [**9-23**] mL per day, please call [**First Name8 (NamePattern2) 14735**] [**Last Name (NamePattern1) 5545**], the nurse [**First Name (Titles) 151**] [**Last Name (Titles) 73643**]l radiology for further follow-up. You will need an additional CT scan at this time before the drain can be pulled. Completed by:[**2109-2-13**]

[ "584.9", "E947.8", "285.22", "198.5", "197.6", "567.22", "V10.52", "197.0", "197.5", "V45.4", "276.0", "569.83", "276.7" ]

icd9cm

[ [ [] ] ]

[ "54.91", "96.6", "99.15", "46.01", "43.11" ]

icd9pcs

[ [ [] ] ]

10562, 10631

5399, 9482

329, 421

10760, 10799

4485, 5376

11991, 13249

3663, 3902

9727, 10539

10652, 10739

9508, 9704

10823, 11968

3917, 4466

275, 291

449, 2218

2240, 3487

3503, 3647

40,972

153,267

48953

Discharge summary

report

Admission Date: [**2129-6-21**] Discharge Date: [**2129-7-18**] Date of Birth: [**2066-9-15**] Sex: M Service: CARDIOTHORACIC Allergies: Bactrim Ds / Latex / Iodides / Shellfish Derived Attending:[**First Name3 (LF) 5790**] Chief Complaint: Tracheobronchomalacia. Major Surgical or Invasive Procedure: [**2129-6-22**] Flexible bronchoscopy with bronchoalveolar lavage, right thoracotomy, thoracic tracheoplasty with mesh, right main stem bronchus and bronchus intermedius bronchoplasty with mesh, and left main stem bronchus bronchoplasty with mesh. [**2129-7-6**] Right thoracentesis 60 cc heme [**2129-7-9**] Transthoracic ultrasound. Thoracentesis on the right side. 750 mL of serosanguineous fluid removed. History of Present Illness: Mr. [**Known lastname **] is a 62-year-old gentleman who has had severe tracheobronchomalacia which has manifest with dyspnea, cough and recurrent respiratory infections. His dyspnea was markedly improved with a silicone Y stent trial. The patient was evaluated by his cardiologist for preoperative clearance for this arduous procedure and was thought to be stable from a cardiac standpoint. Mr. [**Known lastname **] is at high-risk given the nature of the operation given his underlying significant lung impairment with a DLCO of around 50% in addition to his cardiac co-morbidity with questionable MI in [**2126**], [**2107**] and coronary artery bypass graft in [**2120**]. He also had a history of BOOP status post a VATS right lung biopsy nearly 4 years ago. We did discuss that this diffuse parenchymal lung disease can some times flare and hasten respiratory failure postoperatively. Past Medical History: Pneumonia Asthma/COPD: hospitalized no intubations Myocardial Infarction [**2126**] Shingles CABG [**2120**] Left Shoulder surgery Social History: Married, lives with family Tobacco: 20-60 pack year, quit [**2111**] ETOH: recovering alcoholic Family History: non-contributory Physical Exam: Vital Signs: Temp: 97.7 HR: 91 Resp: 20 BP: 114/74 O2 sat: 96% 2L NC General: A+O NAD Cardiac: atrial flutter, normal S1, S2 Lungs: occasional scattered rhonchi Abd: soft, NT, ND + BS EXT: no edema c/o shoulder pain with ROM no noted abnormalities. Incision: right thoracotomy site clean superior distal with minimal approximation. No discharge. mild erythema. steri-strips Neuro: at baseline Pertinent Results: [**2129-7-17**] WBC-11.7* RBC-3.15* Hgb-9.0* Hct-26.9* Plt Ct-452* [**2129-7-14**] WBC-10.9 RBC-3.24* Hgb-9.2* Hct-27.6* Plt Ct-528* [**2129-7-11**] WBC-12.6* RBC-3.02* Hgb-8.6* Hct-25.4* Plt Ct-436 [**2129-7-10**] WBC-16.5* RBC-2.97* Hgb-8.6* Hct-25.3* Plt Ct-417 [**2129-7-9**] WBC-20.2* RBC-2.79* Hgb-8.3* Hct-23.2* Plt Ct-428 [**2129-7-4**] WBC-13.8* RBC-3.20* Hgb-9.0* Hct-26.6* Plt Ct-339 [**2129-6-29**] WBC-24.5*# RBC-4.34* Hgb-12.4* Hct-37.5* Plt Ct-415 [**2129-6-24**] WBC-12.4* RBC-3.40* Hgb-9.7* Hct-29.1* Plt Ct-142* [**2129-7-17**] Glucose-89 UreaN-13 Creat-0.8 Na-132* K-4.0 Cl-94* HCO3-32 [**2129-7-11**] Glucose-88 UreaN-13 Creat-0.8 Na-134 K-4.5 Cl-95* HCO3-32 [**2129-7-5**] Glucose-87 UreaN-11 Creat-0.7 Na-133 K-4.6 Cl-98 HCO3-27 [**2129-6-21**] Glucose-85 UreaN-31* Creat-1.0 Na-138 K-4.7 Cl-102 HCO3-28 [**2129-7-15**] Calcium-8.6 Phos-3.7 Mg-1.9 Cx's [**2129-7-11**] Source: Nasal swab. MRSA SCREEN (Final [**2129-7-13**]):No MRSA isolated [**2129-7-4**] Source: Nasal swab. MRSA SCREEN (Final [**2129-7-13**]):No MRSA isolated Blood cultures x 10 no growth [**2129-7-5**] [**2129-7-5**] BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [**2129-7-5**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2129-7-9**]): OROPHARYNGEAL FLORA ABSENT. PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. 2ND MORPHOLOGY. PSEUDOMONAS AERUGINOSA | PSEUDOMONAS AERUGINOSA | | CEFEPIME-------------- =>64 R 32 R CEFTAZIDIME----------- =>64 R 4 S CIPROFLOXACIN--------- =>4 R 2 I GENTAMICIN------------ 4 S 4 S MEROPENEM------------- 0.5 S 1 S PIPERACILLIN---------- R =>128 R PIPERACILLIN/TAZO----- 16 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S [**2129-7-3**] [**2129-7-3**] 8:47 pm SPUTUM Site: EXPECTORATED Source: Expectorated. GRAM STAIN (Final [**2129-7-4**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 2+ (1-5 per 1000X FIELD): YEAST(S). RESPIRATORY CULTURE (Final [**2129-7-7**]): SPARSE GROWTH OROPHARYNGEAL FLORA. PSEUDOMONAS AERUGINOSA. Moderate GROWTH. PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- =>64 R CEFTAZIDIME----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I MEROPENEM------------- 4 S PIPERACILLIN---------- R PIPERACILLIN/TAZO----- 64 S TOBRAMYCIN------------ <=1 S CXR [**2129-7-16**] Since the prior study, there is no appreciable change in the appearance of the chest. There are bilateral pleural effusions, right greater than left and unchanged. There are multifocal airspace opacities with bibasilar consolidation. Heart is enlarged. Status post median sternotomy and CABG. Total shoulder replacement on the left. Echocardiogram [**2129-7-5**] The left atrium is mildly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is top normal/borderline dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is moderately depressed (LVEF= 35-40 %). The right ventricular cavity is mildly dilated with normal free wall contractility. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. [**2129-7-1**]: Nec CT 1. Multifocal airspace opacities in the lung, compatible with multifocal pneumonia. 2. Right pleural thickening, with a trace right pleural effusion. 3. Bow-shaped appearance of the trachea, with narrowing of the right bronchus intermedius and the left basal trunk. Of note, this study is not designed to elicit changes of tracheobronchomalacia. 4. Right-sided subcutaneous emphysema, likely post-surgical. Brief Hospital Course: Mr [**Name13 (STitle) 59821**] is a 62 yo male with PMH : of bronchiolitis obliterans with organizing pneumonia, TBM s/p Y stent [**7-/2128**]-[**2129**] and repeat Y stent placement [**2129-3-7**] second to severe dyspnea with the stent out. On [**2129-6-13**] Stent was removed Id consult pt with recurrent Pseudomonas aeruginosa infection. On [**2129-6-21**] admitted pre-op for antibiotics. On admission found to have an old PICC line in placed. Line removed tip sent for culture and a # 20 g placed. On [**2129-6-22**] patient to the operating room for a right thoracotomy and tracheo bronchoplasty. Cardiac: Admitted to ICU post op due to patients cardiac history. R/O negative for MI. Developed atrial fibrillation which was treated with Lopressor and amiodarone. he converted to NSR. Cardiology consult for Afib/flutter-recommended anticoagulation-digoxin and amiodarone. He was cardioverted but went back into atrial fibrillation/flutter. Cardiology recommends cardioversion in the future when patient can tolerate anticoagulation. He was discharged on Warfarin 2 mg with an INR Goal of 2.0-2.5. Respiratory: Admitted to ICU with face mask O2 40% Developed stridor and increased secretions on [**6-24**] I. P. performed a bronchoscopy and BAL sent. [**2129-6-27**] transferred med.[**Doctor First Name **] floor. midline chest tube d/DC'ed on [**6-30**] transferred to SICU for dyspnea, increased O2 requirement. On [**2129-7-14**] transferred to the floor ambulating in the halls. ID:[**2129-6-21**] Tip catheter from PICC line + klebsiella and BAL from OR [**2129-6-22**] >100,000 pseudomonas. Continue with Gent and meropenem x 2 weeks then tobramycin inhaling x 4 weeks. Sensitivities: pseudomonas sensitive to tobramycin. Continued with intermittent temperature spikes-negative blood cultures. Pain Control: Post op treated with epidural with fair to poor response Dilaudid added with pain reduction. Toradol added and epidural d/DC'ed. Physical Therapy: Evaluation of discomfort right shoulder recommends continue strengthing exercise. Medications on Admission: Aspirin 81mg po daily Lipitor 10mg po daily Avodart 0.5mg po qhs Lisinopril 2.5mg po daily Isosorbide "DN" 20mg po TID nitrolingual spray 0.4mg as needed Prednisone 5mg daily Singulair 10mg daily Spiriva inhl qAM Albuterol inhl [**Hospital1 **], PRN Albuterol neb 4x/day [**Doctor First Name **] 180mg daily Astelin nasal spray [**Hospital1 **] Flonase 2sprays [**Hospital1 **] mucinex 600 [**Hospital1 **] mucamyst [**Hospital1 **] Calcium + vitamin D daily Fosamax 70mg qFri Hycosamine 125mg po daily Protonix 40mg, 2tabs daily Flomax 1 tab qhs Docusate 2 tabs po qhs Clonazepam 1mg qAM, qPM Fluoxetine 40mg po qAM Trazadone 100mg, 2tabs qhs Wellbutrin SR 450mg daily Ambien 10mg po qhs Lyrica 75mg 2tabs daily Hydrocodone/APAP 500/5mg 1-2 tabs 4x/day IC 10 phen - CNR liquid qua" 1 tsp q4hrs PRN protosol-HC 2% PRN Carmol 40% lotion for feet Ciclapirox 8% to toes Floradil [**Hospital1 **] Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 5. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 6. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal [**Hospital1 **] (2 times a day). 7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 8. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 9. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 10. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours). 11. Bupropion HCl 150 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO QAM (once a day (in the morning)). 12. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO NOON (At Noon). 13. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 14. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 16. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Decrease dose to 81mg when INR 1.8 or greater. 17. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 18. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML(s)3-5mls Miscellaneous Q6H (every 6 hours) as needed for thickened secretions. 19. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb 0.083% Inhalation Q6H (every 6 hours) as needed for wheeze: mix with mucomyst to prevent bronchospasm. 20. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for afib. 21. Tobramycin 300 mg/5 mL Solution for Nebulization Sig: One (1) Inhalation [**Hospital1 **] (2 times a day): through [**2129-8-12**]. 22. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day): Hold HR < 50 or SBP < 100. 23. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 24. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 25. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 26. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for anxiety. 27. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 28. Lactulose 10 gram/15 mL Solution Sig: Thirty (30) ML PO three times a day as needed for constipation. 29. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 30. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 31. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: INR GOAL 2.0-2.5 Monitor closely. Discharge Disposition: Extended Care Facility: [**Hospital **] Health Care Center Discharge Diagnosis: Tracheobronchomalacia\ s/p:Flexible bronchoscopy with bronchoalveolar lavage, right thoracotomy, thoracic tracheoplasty with mesh, right main stem bronchus and bronchus intermedius bronchoplasty with mesh, and left main stem bronchus bronchoplasty with mesh. Discharge Condition: deconditioned Discharge Instructions: Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] with questions Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] [**7-26**] at 10:00am in the [**Hospital Ward Name 121**] Building [**Hospital1 **] I Chest Disease Center. Report to the [**Hospital Ward Name 517**] Clinical Center [**Location (un) **] Radiology Department for a Chest X-Ray 45 minutes before your appointment. Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4887**] for further Warfarin Dose. INR GOAL 2.0-2.5. Please call notify prior discharge to rehab. Completed by:[**2129-7-20**]

[ "E878.2", "041.7", "250.00", "412", "493.20", "999.2", "E884.4", "786.8", "451.82", "427.31", "V58.67", "V45.81", "E879.8", "785.6", "516.8", "V02.9", "482.1", "519.19", "427.32", "511.89", "790.7", "998.11", "997.1", "999.31" ]

icd9cm

[ [ [] ] ]

[ "38.93", "33.24", "99.62", "34.91", "31.79", "40.3", "88.72", "33.48" ]

icd9pcs

[ [ [] ] ]

13012, 13073

6899, 8869

339, 750

13376, 13392

2405, 6876

13520, 14046

1956, 1974

9915, 12989

13094, 13355

8997, 9892

13416, 13497

1989, 2386

8887, 8971

276, 301

778, 1672

1694, 1826

1842, 1940

41,332

167,698

52081

Discharge summary

report

Admission Date: [**2147-7-25**] Discharge Date: [**2147-7-25**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2972**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: None History of Present Illness: 88 yo male with a history of CHF (EF 40 to 45%)requiring admission in [**4-26**], moderate MR, mild AR, severe PR, moderate to severe pulmonary artery systolic hypertension and lymphoma now in remission was sent to the ED from clinic complaining of a one day history of dyspnea on exertion and nausea. The patient was confused at the time of admission so history was obtained from his wife, sons and daughter. [**Name (NI) **] the family the patient complained of general body aches, nausea without vomiting shortness of breath at rest and fatigue beginning the morning of admission. They also note a 3 month history of progressive L leg edema with a none healing ulcer. The family notes also he had missed his evenining medications the night before admission including his home lasix and lisinopril. He presented to his PCPs office where he was sent to the ED for evaluation for ACS. . In the ED he had a elevated troponin, BNP. EKG showed new ST depressions. It was felt the patient was likly having a CHF exacerbation with plan to admit to [**Hospital Unit Name 196**]. However while in the ED he had one episode of bradycardia to the 30s, hypotensive to the 70s/30s systolic and unresponsive. He was given atropine 1 mg with improvement in pressures to the 90-100s systolic, increase in HR to the 70s and improvement in responsiveness. EP was consulted for possible temporary pacemaker placement, they determined this was not needed given hemodynamic stability and the patient was transferred to the CCU for close monitoring. On admission the patient was denying chest pain and shortness of breath but was very confused. His family reports confusion has been present since the bradycardic episode. . On review of systems, his family denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, His family denies recent fevers, chills or rigors. 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, + 3 pillow orthopnea, + ankle edema, - palpitations, -syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS:Hypertension 2. CARDIAC HISTORY: - CABG: none - PERCUTANEOUS CORONARY INTERVENTIONS: none 3. OTHER PAST MEDICAL HISTORY: - HTN - Hypothyroidism - Lymphoma s/p rituximab in remission x 5 years (followed by Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) - Chronic systoloc CHF (LVEF 40% with regional anteroseptal and apical hypokensis) Social History: Lives with wife. -Tobacco history: Denies -ETOH: Reports occasional [**Country 6607**] Club consumption -Illicit drugs: Denies Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Exam on admission: GENERAL: confused but NAD. Oriented to name only following commands, grasping at the air over his bed. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 7 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 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. mild crackles at the bases, scarce wheezes. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c. 1+ pitting edema to the mid calf on the L and ankle on the R, 1 cm x 1 cm lesion on L calf with clear discharge. SKIN: + ulcers on LLE PULSES: Right: Carotid 2+ Femoral 2+ DP, PT dopplerable Left: Carotid 2+ Femoral 2+ DP, PT dopplerable Pertinent Results: Admission Labs: [**2147-7-25**] 10:45AM WBC-9.6 RBC-4.02* HGB-12.3* HCT-35.0* MCV-87 MCH-30.7 MCHC-35.2* RDW-14.8 [**2147-7-25**] 10:45AM NEUTS-89.0* LYMPHS-6.9* MONOS-3.6 EOS-0.3 BASOS-0.1 [**2147-7-25**] 10:45AM PLT COUNT-186 [**2147-7-25**] 10:45AM PT-11.8 PTT-23.6 INR(PT)-1.0 [**2147-7-25**] 10:45AM GLUCOSE-169* UREA N-49* CREAT-1.6* SODIUM-126* POTASSIUM-4.6 CHLORIDE-89* TOTAL CO2-21* ANION GAP-21* [**2147-7-25**] 10:45AM cTropnT-0.90* proBNP-[**Numeric Identifier 107794**]* [**2147-7-25**] 03:10PM cTropnT-1.48* Imaging: CXR PA and Lateral [**2147-7-25**]: FINDINGS: PA and lateral views of the chest were obtained demonstrating cardiomegaly without overt pulmonary edema. Mild pulmonary vascular congestion may be present though appears slightly improved from the prior exam. No large pleural effusion or pneumothorax is seen. Heart size is stably enlarged. Mediastinal contour is unchanged with an unfolded thoracic aorta containing faint atherosclerotic calcification. Bony structures appear intact. [**2147-7-25**] LENIs: IMPRESSION: No DVT in the bilateral lower extremities. [**2147-7-25**] Bedside TTE during CPR: Emergency study during a "code" while CPR is performed. Several subcostal images taken during CPR and during pulse check demonstrating cardiac stand-still. No cardiac function appreciated despite resuscitation efforts. Brief Hospital Course: On admission pt was noted to be delirious but initially had HR 70s and BP 110s/70s. EKG showed rate in 70s with P waves before most QRS complexes. At 20:35 pt developed sudden onset of bradycardia to the 50s and hypotension with BP 70s/40s. Atropine was given without significant effect and patient??????s mental status started to become more altered. Pt started to become very lethargic and anesthesia was called. Patient had a pulse and bag mask ventilation was initiated. After a few minutes pt became completely non-responsive and was intubated by anesthesia. Quickly after intubation patient became pulseless and PEA arrest algorithm was initiated with chest compressions. Pt was given multiple doses of epinephrine during code and bedside ECHO showed no pericardial fluid but an akinetic myocardium. After 15min resuscitation was ended due to medical futility. He was pronounced dead at approximately 21:15 on [**2147-7-25**]. Family was called by the CCU team and informed of his passing. They declined autopsy. Message was left with the covering service of Dr. [**Last Name (STitle) **] (PCP and primary cardiologist) to inform him of the passing. Medications on Admission: Travatan Z 0.004 % Eye Drops 1 drop in each eye at night Centrum Silver Tab 1 Tablet(s) by mouth daily Combigan 0.2 %-0.5 % Eye Drops 1 drop(s) in each eye twice daily Alprazolam 0.25 mg Tab one-half Tablet(s) by mouth daily as needed for anxiety Bisoprolol Fumarate 5 mg Tab 1 Tablet(s) by mouth daily Simvastatin 40 mg Tab 1 Tablet(s) by mouth once nightly at bedtime Senna-C Plus 187 mg-50 mg Tab 1 Tablet(s) by mouth daily as needed for constipation Levothyroxine 100 mcg Tab 1 Tablet(s) by mouth daily except Sundays Aspirin 162 mg Tab Oral Daily lisinopril 2.5 mg Tab Oral daily metoprolol tartrate 25 mg Tab Oral daily furosemide 120 mg Tab Oral daily spironolactone 12.5 mg Tab Oral daily Discharge Disposition: Expired Discharge Diagnosis: Cardiomyopathy Discharge Condition: Deceased

[ "293.0", "428.0", "244.9", "428.23", "202.80", "785.51", "425.4", "416.8", "401.9" ]

icd9cm

[ [ [] ] ]

[ "99.60" ]

icd9pcs

[ [ [] ] ]

7425, 7434

5516, 6678

271, 277

7492, 7503

4123, 4123

3055, 3172

7455, 7471

6704, 7402

3187, 3192

2568, 2626

212, 233

305, 2489

4139, 5493

3206, 4104

2657, 2895

2511, 2548

2911, 3039

27,949

115,801

31748

Discharge summary

report

Admission Date: [**2197-10-5**] Discharge Date: [**2197-10-11**] Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: My head hurts Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 83M s/p fall from standing. +LOC otherwise questionable hx. EMS notified daughter that her father had fallen and was en route to [**Hospital1 18**] for further evaluation, but she was unable to provide additional information. Pt denies use of Coumadin, ASA, or Plavix over past week. Past Medical History: PMHx: DM2, HTN, BPH Social History: Social Hx: married, lives in [**Location 10059**] Family History: Family Hx: noncontributory Physical Exam: On arrival PHYSICAL EXAM: afeb, 72 250/94 11 96%NRB Gen: comfortable, NAD. HEENT: PERRLA, 3->2mm bilaterally, EOMI scant blood from R external auditory canal Neck: Supple. Lungs: CTAB. Cardiac: RRR. nl S1/S2. Abd: +BS, soft, NT/ND. Extrem: Warm and well-perfused. No pelvic instability. Rectal: nl sphincter tone. Neuro: Mental status: AA+Ox2 (not to time), cooperative with exam, normal affect. Naming intact. No dysarthria or paraphasic errors. CNII - XII grossly intact. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors, or clonus. Strength full power [**6-17**] throughout. No pronator drift. Toes downgoing bilaterally. On discharge awake alert oriented x 3 speech clear, no facial asymetry, follows all commands, Perrla, EOMI, facial sensation intact, slight left pronation, small amount of dried blood to right ear with cerumen imapaction, unable to visualize membrane, motor exam seems to be 4+ throughout without focal deficit. Pertinent Results: Cardiology Report ECHO Study Date of [**2197-10-7**] PATIENT/TEST INFORMATION: Indication: Left ventricular function. Syncope. Height: (in) 64 Weight (lb): 130 BSA (m2): 1.63 m2 BP (mm Hg): 168/80 HR (bpm): 80 Status: Inpatient Date/Time: [**2197-10-7**] at 14:57 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007W040-0:39 Test Location: West SICU/CTIC/VICU Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] MEASUREMENTS: Left Atrium - Long Axis Dimension: 3.4 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 3.9 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *5.1 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: 4.6 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 3.2 cm Left Ventricle - Fractional Shortening: 0.30 (nl >= 0.29) Left Ventricle - Ejection Fraction: >= 55% (nl >=55%) Aorta - Valve Level: *3.8 cm (nl <= 3.6 cm) Aorta - Ascending: *3.6 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.8 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.8 m/sec Mitral Valve - A Wave: 1.2 m/sec Mitral Valve - E/A Ratio: 0.67 Mitral Valve - E Wave Deceleration Time: 160 msec INTERPRETATION: Findings: Patient unable to cooperate with Valsalva manuever; therefore unable evaluate for inducible outflow tract gradient. LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function (LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Transmitral Doppler and TVI c/w Grade I (mild) LV diastolic dysfunction. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta. AORTIC VALVE: ?# aortic valve leaflets. Mildly thickened aortic valve leaflets. No AS. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral annular calcification. Trivial MR. TRICUSPID VALVE: Tricuspid valve not well visualized. Indeterminate PA systolic pressure. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor subcostal views. Conclusions: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Mild (grade I) diastolic dysfunction. 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 number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Preserved global biventricular systolic function. Mild diastolic dysfunction. Mild aortic regurgitation. Mild aortic dilation. Inability to assess for inducible left ventricular outflow tract gradient given inability of patient to perform Valsalva manuever. No cardiac etiology of syncope identified. Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD on [**2197-10-7**] 15:21. [**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. ([**Numeric Identifier 74556**]) RADIOLOGY Final Report CT HEAD W/O CONTRAST [**2197-10-7**] 9:02 AM CT HEAD W/O CONTRAST Reason: interval change on CT. Please schedule for [**10-7**] at 0600 [**Hospital 93**] MEDICAL CONDITION: 83 M s/p fall, R frontal SAH, L parietal/frontal SDH, R temporal fx REASON FOR THIS EXAMINATION: interval change on CT. Please schedule for [**10-7**] at 0600 CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Trauma. COMPARISON: [**2197-10-6**]. FINDINGS: Contusions in the paramedian inferior frontal lobes have minimally increased in size. Subdural hematoma layering over the left frontal, parietal and temporal convexities as well as the left tentorium is relatively unchanged. Mild increase in extra-axial space overlying right frontal and parietal convexities. Bilateral subarachnoid hemorrhage is also stable. The ventricles are unchanged in size and there is mild layering interventricular hemorrhage. A non-displaced fracture of the right temporal bone is unchanged and the right mastoid air cells are moderately opacified. IMPRESSION: 1. Mild interval increase in paramedian bifrontal lower lobe contusion. 2. No new foci of hemorrhage are identified. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] [**Doctor Last Name **] DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**] Approved: SAT [**2197-10-7**] 3:03 PM Cardiology Report ECG Study Date of [**2197-10-5**] 4:50:34 PM Sinus rhythm. Right bundle-branch block. Left anterior hemiblock. The P-R interval is within normal limits. No previous tracing available for comparison. Read by: [**Last Name (LF) **],[**First Name3 (LF) **] F. Intervals Axes Rate PR QRS QT/QTc P QRS T 75 178 148 446/472 68 -58 51 ([**-8/4428**]) RADIOLOGY Final Report CAROTID SERIES COMPLETE [**2197-10-6**] 1:43 PM CAROTID SERIES COMPLETE Reason: SYNCOPAL EPISODE [**Hospital 93**] MEDICAL CONDITION: 83 year old man with ? syncopal episode REASON FOR THIS EXAMINATION: assess arterial blood flow, ? stenosis CAROTID SERIES COMPLETE REASON: Syncope. FINDINGS: Duplex evaluation was performed of both carotid arteries. Minimal plaque was identified. On the right peak systolic velocities are 93, 120, 102 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 106, 94, 139 in the ICA, CCA, ECA respectively. The ICA to CCA ratio is 1.1. This is consistent with less than 40% stenosis. There is antegrade flow in the right vertebral artery. The left vertebral artery is not visualized. IMPRESSION: Minimal plaque with bilateral less than 40% carotid stenosis. The left vertebral artery appears occluded. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: SUN [**2197-10-8**] 4:29 AM Brief Hospital Course: Pt was admitted through the emergency department. A syncope w/u was performed to include Echo and EKG as well as carotid duplex. The findings are in the pertinent results section of this summary. He was taken off telemetry monitoring and placed to floor status. He was seen by PT/OT and advanced in his diet and activity. He has serial head CT's which have been stable. He was screened for rehab placement. He had a swallow eval during his stay and their recommendations for a regular diet with thin liquids/ whole pills in puree, were followed. His family was updated throughout the hospitalization. His atenolol was increased to 50 mg po bid for better bp control. He is also on hydralazine PRN if his SBP goes over 160. The patient is neurologically intact on the day of discharge. Medications on Admission: Atenolol 50' Flomax 0.4' Detrol 2' HCTZ 12.5' finasteride 5' metformin 500' Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 8. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Outpatient Lab Work Please have your dilantin level checked within 2 weeks and have the results sent to your PCP. 11. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for SBP > 160: hold for SBP < 100 or HR < 60. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: right temporal fracture left parietal and left frontal sub dural hematoma Discharge Condition: neurologically stable Discharge Instructions: HEAD INJURY ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: Please return to the office in 4 weeks with a cat scan of the brain to be seen by Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) **]. You should follow up with your primary care physician [**Name Initial (PRE) 176**] 2 weeks of discharge - you had a 'syncope work up' while here and your PCP should review this results. Also we increased your atenolol to 50mg twice a day for better blood pressure control. Please have your PCP check your dilantin level as well. Completed by:[**2197-10-11**]

[ "250.00", "801.22", "E888.8", "E849.9", "401.9", "780.2", "600.00" ]

icd9cm

[ [ [] ] ]

[ "96.6" ]

icd9pcs

[ [ [] ] ]

10533, 10605

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281, 288

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746, 778

9474, 10510

7584, 7624

10626, 10702

9373, 9451

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820, 1115

228, 243

7653, 8532

316, 612

5497, 5778

1130, 1758

634, 659

675, 730

78,145

196,170

37552

Discharge summary

report

Admission Date: [**2150-9-25**] Discharge Date: [**2150-9-29**] Date of Birth: [**2087-5-31**] Sex: M Service: NEUROSURGERY Allergies: Penicillins / Darvocet A500 / Percodan / Morphine / Percocet Attending:[**First Name3 (LF) 1835**] Chief Complaint: Headache Major Surgical or Invasive Procedure: None History of Present Illness: This is a 63 yo M who presented to and OSH approximately 5 days after a fall. He had gotten out of bed and stood up and reported feeling dizzy. He states this occurs frequently when he stands from a lying position. He fell down on his left side and hit the left side of his head. He denied LOC. Since the fall, he had persistent bifrontal headache. He had drove himself to [**Hospital **] Hospital today at the recommendation of his PCP and had [**Name Initial (PRE) **] CT head which revealed IPH and was transferred to [**Hospital1 18**] for further care. He denied any visual changes, weakness, numbness, paresthesias, bowel or bladder changes on admission. He was on aspirin 81 mg daily. Past Medical History: -DM2 -HLD -Parkinson's disease -hx Ampullary carcinoma s/p Whipple's procedure -Hodgkins lymphoma -hx CCY, appy, inguinal herniopathy Social History: -social etoh, occasional tobacco Family History: NC Physical Exam: On admission: VS; P 100 BP 134/59 RR 20 100% RA Gen: lying in bed, NAD HEENT: MMM, oropharynx clear. Ecchymosis on left scalp. Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact horizontally. Decreased upgaze. No 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. Resting tremor, R arm > L. Mild cogwheeling at wrists. No pronator drift. 5/5 strength in R and L delt, bicep, tricep, WrE, IP, quad, ham, DF, PF. Sensation: Intact to light touch throughout Reflexes: B T Br Pa Ac Right 1 1 1 tr tr Left 1 1 1 tr tr Toes downgoing bilaterally Coordination: normal on finger-nose-finger bilaterally Gait: deferred On discharge: Bilateral UE tremor. Right tongue deviation. He was otherwise neurologically intact. Pertinent Results: [**2150-9-25**]: MRI brain 1. Hemorrhagic contusion in the inferior right frontal lobe with hemorrhagic contusion at the convexity in the right frontal lobe and a small right frontal subdural collection measuring no greater than 3 mm in size without mass effect. 2. Left parietal soft tissue hematoma. 3. No midline shift or hydrocephalus. 4. No acute infarcts or abnormal enhancement. [**2150-9-27**]:CT head No significant interval change of the multi-foci hemorrhagic contusion as described above. No developing hydrocephalus. Unchanged left parietal scalp hematoma. Unchanged small subarachnoid hemorrhage around the contusions sites. Brief Hospital Course: Mr. [**Known lastname 77792**] was admitted to [**Hospital1 18**] on [**2150-9-25**] under the care of Dr. [**Last Name (STitle) **] of the neurosurgery department. He was observed inthe SICU without any neurologic decline. Repeat CT imaging showed no progression of the Right frontal IPH. On [**9-26**] he was transfered to the floor. He was on phenytoin for seizure prophylaxis. He required a bolus of 500 mg x1 on [**2150-9-26**] and 300mg on [**9-27**]. He was seen by PT/OT. On [**9-28**] an IV nurse was called to evaluate his port which is no longer in use. they recommended TPA but this was deferred secondary to his ICH. We reommened that he follow up with is PCP for this port as an outpatient. On [**9-29**] his corrected Dilantin level was 17. He was cleared by PT/OT on [**2150-9-29**] and was discharged to home. Medications on Admission: -ASA 81 -primidone 50 prn (unknown dosing schedule) -zocor 20 mg daily -lisinopril 10 mg daily -lantus 20 units sc daily -fluoxetine 80 mg daily -levothyroxine 150 mcg -metformin 1000 mg [**Hospital1 **] Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY (Daily). 4. Levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 5. Primidone Oral 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 8. Dilantin Extended 100 mg Capsule Sig: One (1) Capsule PO three times a day. Disp:*21 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Right frontal contusion - traumatic Discharge Condition: Stable Discharge Instructions: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine. You will be required to take this medication for a total of ten days. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in 4 weeks. ??????You will need an MRI of the brain with contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. . Please follow up with your primary care provider or surgeon about the care of your portacath. Completed by:[**2150-9-29**]

[ "332.0", "250.00", "E885.9", "851.81", "V10.09", "201.90", "272.4" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5197, 5203

3453, 4283

334, 341

5283, 5292

2788, 3430

6302, 6759

1295, 1299

4538, 5174

5224, 5262

4309, 4515

5316, 6279

1314, 1314

2683, 2769

286, 296

369, 1070

1813, 2669

1328, 1561

1576, 1797

1092, 1228

1244, 1279

26,031

180,426

1975

Discharge summary

report

Admission Date: [**2148-9-3**] Discharge Date: [**2148-9-14**] Date of Birth: [**2092-11-2**] Sex: M Service: MEDICINE Allergies: Albumin Products / Lipitor / Mevacor / Ace Inhibitors / Amiodarone Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Abdominal swelling, leg swelling, fatigue Major Surgical or Invasive Procedure: None History of Present Illness: Mr [**Known lastname **] is 55 year old man with CHF (EF 25%) and multiple prior hospitalizations for decompensated heart failure, AFIB, CAD w/ MI in [**2132**], CABG in [**2140**], mitral valve repair in [**2142**], 3rd redo sternotomy in [**2148-4-26**] for tricuspid valvuloplasty, mitral valve replacement and biatrial maze procedure, now directly admitted from Dr.[**Name (NI) 3536**] office for repeat CHF exacerbation. Pt was in his usual state of health until ~ 1 wk ago when he started feel "bloated and filling up with fluid." Pt states that he has been very careful about his diet and especially his sodium intake. He has mildly increased shortness of breath and a dry cough. He also has fatigue and back pain that he attributes to his weight gain. He weighs himself daily and reports gaining at least 10 extra pounds, including 3 pounds yesterday. Pt was recently on vacation in [**State 1727**], and denies sick contacts or unusual exposures. He denies fever, chills, or changes in appetite. He has not had any chest pain, palpitations, nausea or vomiting, headaches, diarrhea, constipation, or urinary problems. Pt was recently discharged from [**Hospital1 18**] on [**2148-8-13**] after treatment for CHF exacerbation during which Pt was diuresed ~ 9 L w/ a furosemide iv drip titrated up to 30mg /hr and 3-4L urine output daily. Pt was underwent plasmapheresis ~2 wks prior but had to stop early due to lightheadedness. Pt believes this contributed to his weight-gain. In clinic, Pt's vitals were BP 128/72, HR 62, weighed 201 lbs, and Pt was directly admitted to [**Hospital1 18**]. Upon transfer to the floor, Pt was stable w/ little shortness of breath. Vitals were: 96.1F, 131/76, 88, 20, 100% RA, 90.7kg. Past Medical History: Past Medical History: - Mitral valve regurgitation s/p Mitral valve replacement in [**2142**] - Repeat Mitral valve replacement [**4-/2148**] - Tricuspid valve regurgitation s/p Tricuspid annuloplasty in [**4-/2148**] - Chronic Systolic Congestive Heart Failure - Coronary Artery Disease, s/p MI in [**2132**], s/p s/p CABG (LIMA to LAD, SVG to OM, SVG to PDA to PLV), RCA and LAD PCI's in [**2140**] - Paroxysmal/Persistent atrial fibrillation s/p five prior cardioversions, ablation in [**2146**] and biatrial MAZE in [**4-/2148**] - History of non-sustained VT s/p AICD implant in [**2142**], VT ablations [**10/2146**] - Moderate Pulmonary artery hypertension, AICD reimplant in [**4-/2148**] - Severe Hyperlipidemia(intolerant of statins, undergoes plasmapheresis every two weeks at [**Location (un) 5450**] Kidney Center with AV graft in the left arm [**2141**] - Mild Anemia - Obstructive sleep apnea (CPAP) - Chronic Renal Insufficiency - Carotid Disease - Chronic renal insufficiency Social History: The patient is married and lives in [**Location (un) 3844**]. He has two children 14 y/o girl, 17 y/o boy. He is a substitute teacher in a local elementary school and is currently retired. He was a salesman in the past. -Tobacco - 20 pack year history, quit [**2124**] -Alcohol - very rare beers / wine. -Drugs - never. Family History: Father - healthy Mother - atrial fibrillation + CAD, ?MI in her 70s 4 brothers, 1 sister healthy. DM on mother's side. Physical Exam: Physical Exam on admission: VS: 96.1F, 131/76, 88, 20, 100% RA, 90.7kg. GENERAL: middle aged man lying in bed in no acute distress. HEENT: PERL, EOMI, normal oropharynx, no lymphadenopathy. NECK: Supple, JVP was above his ear. CARDIAC: regular rate and rhythm with occasional premature beats, s1 obscured by [**3-31**] early systolic blowing murmur, s2, s4 gallop present. Large vertical mid-sternal scar. LUNGS: clear to auscultation bilaterally ABDOMEN: normal bowel sounds, distended, soft, non-tender to palpation, no masses. 6-7cm shifting dullness to percussion. GENITAL: marked scrotal edema EXTREMITIES: 2+ pulses throughout, fistulas w/ good bruit on L forearm. Bilateral 2+ pitting edema in lower extremities to scrotum. Physical Exam on discharge: VS: 98.0 94-103/50-55 70 16 95%RA Net neg 450. Weight 86.3kg GENERAL: middle aged man sleeping in bed, in no acute distress. HEENT: PERL, EOMI, normal oropharynx, no lymphadenopathy. NECK: Supple, JVP to chin. CARDIAC: regular rate and rhythm with occasional premature beats, s1 obscured by [**3-31**] early systolic blowing murmur, s2 normal, s3 gallop present. Large vertical mid-sternal scar. LUNGS: clear to auscultation bilaterally ABDOMEN: soft, distended, +BS GENITAL: scrotal edema improved EXTREMITIES: 2+ pulses throughout, fistulas w/ good bruit on L forearm. Bilateral 1+ pitting edema in lower extremities, trace to upper thighs. Pertinent Results: Admission Labs: [**2148-9-3**] 05:40PM BLOOD proBNP-[**Numeric Identifier 10873**]* [**2148-9-3**] 08:04PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2148-9-3**] 08:04PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013 [**2148-9-3**] 08:04PM URINE Hours-RANDOM UreaN-698 Creat-93 Na-24 K-69 Cl-31 [**2148-9-3**] 08:04PM URINE Osmolal-453 . Urine Analysis: [**2148-9-9**] 07:45PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.012 [**2148-9-9**] 07:45PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-TR [**2148-9-9**] 07:45PM URINE RBC-2 WBC-6* Bacteri-NONE Yeast-NONE Epi-0 TransE-<1 [**2148-9-9**] 07:45PM URINE CastGr-5* CastHy-56* [**2148-9-9**] 07:45PM URINE Mucous-RARE [**2148-9-9**] 07:45PM URINE Eos-NEGATIVE [**2148-9-9**] 10:05AM URINE Hours-RANDOM UreaN-290 Creat-250 Na-12 K-71 Cl-12 [**2148-9-9**] 10:05AM URINE Osmolal-312 Discharge Labs: [**2148-9-14**] 05:59AM BLOOD WBC-5.4 RBC-3.05* Hgb-9.0* Hct-26.3* MCV-86 MCH-29.5 MCHC-34.1 RDW-16.5* Plt Ct-174 [**2148-9-13**] 01:38PM BLOOD PT-18.7* INR(PT)-1.7* [**2148-9-14**] 05:59AM BLOOD Glucose-94 UreaN-55* Creat-2.4* Na-139 K-3.6 Cl-96 HCO3-34* AnGap-13 [**2148-9-14**] 05:59AM BLOOD Calcium-9.3 Phos-3.8 Mg-2.1 Brief Hospital Course: Mr [**Known lastname **] is 55 year old man with CHF (EF 25%) and multiple prior hospitalizations for decompensated heart failure, AFIB, CAD w/ MI in [**2132**], CABG in [**2140**], mitral valve repair in [**2142**], 3rd redo sternotomy in [**2148-4-26**] for tricuspid valvuloplasty, mitral valve replacement and biatrial maze procedure, directly admitted from Dr.[**Name (NI) 3536**] office for repeat CHF exacerbation. . ACTIVE ISSUES: . # Acute on chronic CHF - Pt's weight on admission 90kg (weight on previous discharge 84.8kg). Furosemide increased to 100mg PO bid, and he started metolozone at 5mg daily. Briefly added losartan 25mg po daily but Cr bumped to 2.8 and this was discontinued. Dialysis arranged in [**Hospital 10874**] Clinic w/ [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. On HD8, patient was transferred to the CCU for milrinone drip to assist with diuresis. He diuresed well with milrinone and torsemide. At the time of discharge he had diuresed a total of 3.5L and his weight was 86kg. On discharge, all of his home medications and doses were resumed, with the exception of carvedilol which was decreased to 12.5mg [**Hospital1 **]. He was not restarted on losartan due to his worsening renal failure (see below). He was scheduled to follow up with Dr. [**First Name (STitle) 437**] in clinic 2 days after discharge. . # Acute on chronic kidney disease: Creat elevated on admission to 2.8 (was 1.9 on prior hospital discharge), and continued to increase to 4.0. He had recently started losartan, which was discontinued. The patient's creatinine improved with initiation of milrinone. It trended downward and was 2.4 at the time of discharge. . # Hypokalemia: Patient was hypokalemic with ongoing diuresis. He was repleted as needed and on discharge his K was 3.6. . CHRONIC ISSUES: . # CORONARIES: CAD s/p CABG stable. Patient was continued on aspirin. His home carvedilol was decreased to 12.5 [**Hospital1 **] given his hypotension. . # Paroxysmal A-Fib: Pt remained in normal sinus rhythm for the duration of his stay. His was anticoagulated w/ warfarin, with goal INR [**2-29**] and carvedilol 12.5mg po bid. . # Low Back pain: Pt reported worsening back and abdominal due to fluid retention. His pain was well controlled with tylenol and tramadol. . #Insomnia: Continued home dose ambien. . TRANSITIONAL ISSUES: -Given multiple past admissions for CHF, had social work consult, who felt provided patient support throughout the procedure. -Arranged for outpatient diuresis clinic w/ [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. -Carvedilol decreased from 25/12.5 to 12.5 [**Hospital1 **]. -Not on ACEi or [**Last Name (un) **] [**2-28**] worsening renal failure likely [**2-28**] losartan. -All other home meds resumed. Medications on Admission: Digoxin 125mcg daily Spironolactone 25 mg daily carvedilol 25MG in the AM and 12.5MG PM aspirin 81 Zolpidem (ambien) 10 mg QHS Warfarin 3 mg daily Furosemide 100mg [**Hospital1 **] tadalafil 5 mg Tablet Sig: One (1) Tablet PO PRN erectile dysfunction. Discharge Medications: 1. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 5. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 6. furosemide 40 mg Tablet Sig: 2.5 Tablets PO twice a day. 7. tadalafil 5 mg Tablet Sig: One (1) Tablet PO as needed as needed for erectile dysfunction: DO NOT USE IN COMBINATION WITH NITROGLYCERIN. 8. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 9. carvedilol 25 mg Tablet Sig: [**1-28**] Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: acute on chronic systolic congestive heart failure exacerbation Secondary diagnoses: Paroxysmal atrial fibrillation Severe Hyperlipidemia (w/ biweekly plasmapheresis) Chronic Renal Insufficiency Coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname **], You were admitted to [**Hospital1 **] Hospital from Dr. [**Name (NI) 10875**] office because you were experiencing abdominal fullness and leg swelling, and you had gained approximately 11 lbs. This is most likely due to an acute worsening of your congestive heart failure, for which you have been hospitalized multiple times in the past. While you were in the hospital, you were given several medications to help your body get rid of this excess fluid. While we getting rid of your excess fluid, we had to replace the potassium that you were losing through your urine. We also closely monitored your kidney function through blood tests and they were improved throughout your hospital stay. By the time of your discharge from the hospital, your leg swelling was significantly improved, and your weight approached your normal "dry" weight. We have made the following changes to your medications: -REDUCE your carvedilol to 25mg, half tab by mouth twice daily We made no other changes to your home medications while you were here. Please continue to take the rest of your medications as prescribed. We have made appointments for you to see Dr. [**First Name (STitle) 437**] on [**9-16**] (please see below). You should discuss with Dr. [**First Name (STitle) 437**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] about regularly visiting the outpatient diuresis clinic that [**Doctor First Name **] runs. Please weigh yourself daily and let Dr. [**First Name (STitle) 437**] know if you gain more than 3 lb. You should also carefully monitor and restrict your daily salt intake to < 2 g daily and reduced your fluid intake to < 1.5 L daily. Followup Instructions: Department: CARDIAC SERVICES When: MONDAY [**2148-9-16**] at 2:30 PM With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: MONDAY [**2148-9-16**] at 2:00 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: MONDAY [**2148-9-16**] at 11:00 AM With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10249, 10255

6417, 6842

376, 383

10538, 10538

5075, 5075

12413, 13240

3516, 3637

9519, 10226

10276, 10276

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3680, 4384

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8251, 8765

2189, 3162

3178, 3500

76,988

145,946

22073

Discharge summary

report

Admission Date: [**2141-9-19**] Discharge Date: [**2141-10-4**] Date of Birth: [**2074-12-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4365**] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: Paracentesis History of Present Illness: 66 yo M with IDDM, HTN. hyperlipidemia presents with 2 week so fintermittant cramping abdominal pain with one episode of vomiting last week and no BM in 2 weeks. Pain feels like pressure, worse on left side, urinating improves it. Patient also reports an increase in urinary frequency, has PMH of BPH. He reports a weight loss of 5 lbs over last month unintentional and decreased po intake [**1-7**] to early satiety. No CP, minimal SOB as abd distension has increased. No fever, some ? of chills. . ED Course: Patient was treated with MOM and had a large BM which improved his symptoms. VSS, abd distension. Guaiac negative. CT showed innumerable omental masses and caking throughout abd. Surgery was consulted and recommened no acute intervention, tissue dx needed. Concern for cystadenocarcinoma. . ROS: As above. Also SOB which has worsened with increasing abdominal distension. Past Medical History: CVA [**2127**] on Coumadin HTN Hyperlipidemia Hyperplastic colon polyp removed in [**2137**] Social History: Former smoker, no EtOH, retired, one son, widowed x2, lives in [**Location 669**]. Former accountant. Family History: ? Pancreatic CA in Father Physical Exam: DISCHARGE PHYSICAL; VS: Tcuttent 99.9 BP 110/60 HR 82 RR 26 O2% oN RA GEN: NAS, comfortable HEENT: no OP lesions CV: regular rate s1/s2, no mrg PULM: end expiratory wheezes, good air movement, decreased bs at bases ABD: +bs, hypoactive bs, distended, dullness at flanks, non-tended EXT: 2+ pitting edema LE bilat NEURO: no focal deficits, a/o x3 PSYCH: appropriate Pertinent Results: IMAGING: [**2141-9-19**] CT OF THE ABDOMEN WITH CONTRAST: The visualized lung bases reveal mild bilateral dependent atelectasis. The remainder of the lungs are clear without nodules. There are no pleural effusions. The visualized heart is unremarkable without pericardial effusion. . There is a large volume of low density (approximately 20 [**Doctor Last Name **]) ascites in the abdomen, which fills the pelvis and paracolic gutters. Layering along the greater omentum is too numerous to count nodules adn stranding consistent with omental studding or "omental caking". In the splenic hilum, there is an ill- defined approximately 8 mm area of hypodensity which could represent a filling defect secondary to the phase of arterial opacification or a metastatic focus. Extrinsic to the splenic hilum, there is an ill- defined 3.1 x 2.1 cm area of isodense material in the splenic hilum. The pancreas is unremarkable. The adrenals and gallbladder are normal. There is a hypodensity within the dome of the liver (2:14) which is too small to characterize by CT. There is a 15 mm x 18 mm hypodensity within the interpolar region of the left kidney measuring 19 Hounsfield units and likely represents a simple cyst. The kidneys enhance and excrete contrast symmetrically and there is no hydronephrosis. The stomach is decompressed and there are no abnormalities appreciated. The remainder of the abdominal loops of small and large bowel are unremarkable. There are scattered mesenteric nodes. There is no retroperitoneal lymphadenopathy. There is no free air. . CT OF THE PELVIS WITH CONTRAST: The ascitic fluid present within the abdomen extends into the pelvis. In the area of the cecum and terminal ileum, there is a 1.8 x 1.4 cm mass extending into the lumen of the cecum (2:72). There is a partially air filled non- contrast opacified appendix (2:76). In the setting of extensive abdominal ascites and omental caking, this finding could represent a ruptured mucinous cystadenoma or cystadenocarcinoma of the appendix. The rectum, sigmoid colon, and remainder of the pelvic small and large bowel are unremarkable. The bladder is unremarkable. There are calculi present within the prostate which is otherwise unremarkable and the seminal vesicles are normal in appearance. . BONE WINDOWS: There are no suspicious sclerotic or lytic lesions identified. There are no fractures identified. . IMPRESSION: 1. Large volume of ascites. 2. Omental caking. 3. Cecal mass which could represent a colonic malignancy. 4. Appendix which is visualized but does not fill with contrast and in the setting of abdominal ascites and omental caking could represent a ruptured mucinous cystadenoma/cystadenocarcinoma of the appendix. Would recommend further evaluation with biopsy. 5. Ill-defined lesion in and around splenic hilum. Question metastatic foci. . . CXR [**2141-9-19**]: FINDINGS: There is rightward deviation of the trachea which could be secondary to patient's low lung volumes. There is further distortion of the mediastinum by these lung low volumes. The aorta is tortuous. The cardiac silhouette is grossly normal on this limited portable radiograph. There is mild distortion of the right and left costophrenic sulci to suggest possible small bilateral pulmonary effusions. The lungs, however, are clear without focal consolidation. There is no pneumothorax. The bony and soft tissue contours are normal. . IMPRESSION: Low lung volumes limit full evaluation on this portable chest radiograph. However, small bilateral pleural effusions appear present. . . LABS ON DISCHARGE: CBC: 12.7* 4.05* 10.8* 32.4* 80* 26.5* 33.2 14.1 522* Chem 7: 88 30* 1.3* 134 4.4 98 26 14 CEA: 1083 Brief Hospital Course: 66 yo M admitted with abd distension x2 weeks and 5lb weight loss found to have omental caking on CT. Diagnostic and therapeutic paracentesis performed. Cytology positive for maligant cells, indeterminate for GI malignancy based on staining. Oncology was consulted and felt to have a poor prognosis of less than 6 months. Pallitative care was consulted. Patient was discharged in faircondition, vitals stable, to a skilled nursing facility with scheduled out patient paracentesis 2 times a week at [**Company 191**]. Patient will eventually get an abdominal port for home management of his ascites and will be tranistioned to home hospice. His primary care doctor, Dr. [**Last Name (STitle) **] and [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**] from palliative care will be following him. . # Malignant Ascites: Patient presented to ED with abd pain and distension and was found to have omental caking on CT as well as a cecal mass. CEA was elevated at 1083. GI and oncology were consulted and it was recommended that a paracentesis be obtain for tissue diagnosis. A bedside paracentesis was performed with only 40 cc off. Patient was then sent for ultrasound guided paracentesis and 3L of fluid were removed. Cytology studies showed maliganct cells consistent with adenocarcinoma. Immunochemsitry staining was inconclusive. The malignant cells were positive for M0C31, B72.3, and cytokeratins 7 and 20; and are negative for CDX2; WT1 and calretinin. While the staining pattern is not entirely specific, combined with cytomorphology, the differential diagnosis includes pancreaticobiliary, gastric, and colonic origins for the adenocarcinoma. Oncology consult advised that Mr. [**Known lastname 57722**] prognosis was poor, less than 6 months, therefore definitive tissue diagnosis was not pursued further. Two additional ultrasound guided therapeutic paracentesis were performed. The second one had 600 PMNs indicating bacterial peritonitis and patient was treated with ceftriaxone (see below for treatment details). The third paracentesis got off 5.5 L and has 1750 PMN's. A fourth and final paracentesis was performed and showed 13 PMN's. Patient will be discharged to a skilled nursing facility. He is scheduled for out-patient therapeutic paracentesis at [**Company 191**] every Tuesday and Friday for the next 3 weeks. Dr. [**First Name8 (NamePattern2) 1528**] [**Last Name (NamePattern1) **] will be following, as [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**]. Plans for abdominal port placement after patient is d/c'ed from [**Hospital1 1501**]. . # Fever: Patient was afebrile on admission. He spiked a fever on HD 4 and became tachycardic. He met criteria for SIRS and was started on vancomycin and zosyn for empiric coverage and pan cultured. Blood cultures thus far have been negative and CXR at the time of spike showed no actue pulmonary process. Vanc/zosyn was discontinued after 4 days of treatment and ceftriaxone was started as above. The ceftriaxone was discontinued after the 4th paracentesis that showed resolution of his SBP. Patient remained afebrile until the day prior to discharge when he spiked to 101.9. He received one dose of ceftriaxone at the time of spike. He was again pan cultured and results of those cultures are pending at time of discharge. Vitals were stable through this last episode of fever and it was attributed to his tumor burden. The day of discharge his temperature rose to 100.6 but on repeat measurement was 98.6 and no intervention was done. Cultures and any necessary treatment will be followed up by his primary medicine team. . # Hypotension: Patient was normotensive on admission. Patient became hypotensive to 84/62 on HD 5 after spiking the night prior. His pressure increased to 90/58 after fluids and he required 4L by masal cannula for an O2 sat of 95%. Given his fever, elevated white count, hypotension and hypoxia, he met SIRS criteria and was transferred to the MICU where he was monitored overnight and transferred back to the floor. Patient's blood pressures were in the 100's/60's through the rest of his hospitalization. . # Shortness of Breath/Hypoxia: Thought to be multifactorial including increased abdominal pressure [**1-7**] ascites, infection and atelectasis. Patient was admitted on room air and was sating 97%. After his first bed side paracentesis during which he received 2 units FFP, he became acutely short of breath and required nebulizer treatments and O2 by masal cannula. This episode was attributed to TRALI. See below for more details. After this initial episode of hypoxia, patient was continued on 2L nc. After his second paracentesis, he spiked (as above) and became hypoxic. This episode was attributed to a SIRS picture and he was transferred to the MICU as above. Two dasy after returning to the floor, he again had an increasing oxygen requirement, sating at 89% on 4L nc and had no improvement in his oxygenation with nebulizer treatments. He was transferred back to the MICU for monitoring where he underwent a third paracentesis with improvement in his symptoms. He was stabilized on 2L nc and returned to the floor. He was eventually weaned off oxygen and was discharged sating 94% on room air. . # Sepsis: Patient spike to 101.9, was hypoxic, hypotensive and had an elevated white count. Therefore he met SIRS criteria and was transferred to the MICU. Upon arrival to the MICU the pt met SIRS criteria with potential sources including pulmonary, GI including ascites; of note was recently instrumented. U/A negative. No symtpoms to suggest CNS infection. Massive diarrhea [**1-7**] aggressive bowel regimen (or infection) possibly contributing. C. diff was negative. The patient was hemodynamically stable s/p 3L NS fluid resuscitation. The pt was given NS boluses prn for MAP>65 and was broadly covererd with vanco/zosyn/flagyl. Subsequent diagnostic tap revealed peritonitis. His vitals stabilized and he was transferred to the floor. . # Spontaneous Bacterial Peritonitis: Patient developed SBP found on his second paracentesis with 600 PMN's. He was treated with ceftriaxone. A repeat paracentesis showed 1750 PMN's and his treatment was continued. His fourth para showed 13 PMN's and his ceftriaxone was stopped. He does not need prophylaxis. # Question of TRALI: Patient was admitted with an elevated INR and received 2 units of FFP during his first paracentesis. One hour after, he had an increasing oxygen requirement. his chest Xray showed no acute process. His symptoms were initally attributed to transfusion-realted acute lung injury. He was treated supportively and symptoms resolved with oxygen and nebulizer treatments. This incident was investigated byt he blood bank and determined to be secondary to an allergic reaction not to TRALI. . # ARF: Patient was admitted with creatinine of 1.2. He bumped to 1.7 during his hospital stay. This bump was attributed to a pre-renal cause of renal failure as he was intravascularly volume depleted secondary to his malignany ascites. This resolved and his creatinine on discharge was 1.3. . # Anemia: Patient was admitted with a hct of 40 and developed a microcytic anemia which was attributed to iron deficency and anemia of chronic disease. He had flecks of blood in his vomitus early on in his hospital stay which was likley [**1-7**] to his elevated INR. . Elevated INR: 4.5 on admission, likely [**1-7**] to poor po intake for 2 weeks. Coumadin held and vitamin K given with normalization of INR to 1.2 on discharge. Patinet was not discharged on coumdain as he will be getting [**Hospital1 **]-weekly paracenteses. . # HTN: Well controlled on home meds. Anti-hypertensives were held intermittantly during episodes of hypotension. . # H/o remote CVA: Had been on coumadin as outpatient, being held in conjunction with PCP. [**Name10 (NameIs) 9766**] [**Name Initial (NameIs) **]/c'ed in preparation for an abdominal port. . # IDDM: The pt was continued on his home regimen and SSI. . # Hyperlipidemia: The pt was continued on his home meds. , # BPH: The pt's Flomax was held given concern for early sepsis during his hospitalization and restarted on discharge as his bps were stable. . # CODE STATUS: DNR/DNI confirmed with patient. Medications on Admission: ASA 81mg' Lisinopril 20mg' Coumadin 2mg' HCTZ 25mg' Flomax 0.4mg' Atenolol 25mg' Pravastatin 40mg' 70/30 insulin 15QAM 17QPM Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, headache. 2. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension Sig: as directed units Subcutaneous twice a day: Please take 15 units in the morning and 17 units with dinner. 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 12. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO at bedtime. Discharge Disposition: Extended Care Facility: [**Hospital 169**] Center Discharge Diagnosis: Primary Dx Adenocarcinoma unknown primary Ascites Bacterial peritonitis Secondary HTN h/o CVA Discharge Condition: Stable. Discharge Instructions: You were admitted with abdominal pain and distension and a CT scan of your abdomen showed fluid and a mass in your colon. The fluid was drained multiple times and a sample of the fluid showed that cancer cells were present. The oncologists were consulted and thought that chemotherapy or surgery would not be helpful. To make you more comfortable, we drained the fluid from your belly. One of the fluid samples was also positive for infection and you were treated with antibiotics. You were discharged to a skilled nursing facility and will return to the hospital for paracentesis twice weekly as long as you need this for comfort. Please take all medications as directed. We stopped your coumadin and [**Hospital **] so that you could have a paracentesis port placed next week if necessary. We also stopped your lisinopril and hydrocholorthiazide as your blood pressure was low and you did not require these medications anymore. Please follow-up with all outpatient appointments. You have a paracentesis scheduled on Friday, [**10-6**] at Please return to the hospital if you experience worsening fever, chest pain, difficulty breathing or any other concerning symptoms. It was a pleasure taking care of you. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] when you leave the nursing facility.

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icd9cm

[ [ [] ] ]

[ "99.07", "54.91" ]

icd9pcs

[ [ [] ] ]

15346, 15398

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331, 345

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1391, 1494

47,324

149,248

35315

Discharge summary

report

Admission Date: [**2197-10-19**] Discharge Date: [**2197-11-3**] Date of Birth: [**2142-1-10**] Sex: F Service: PLASTIC Allergies: Penicillins Attending:[**First Name3 (LF) 5667**] Chief Complaint: Left tonsillar squamous cell carcinoma Major Surgical or Invasive Procedure: Tracheostomy, oral/tonsillar resection via mandibulotomy, left radial forearm free flap, STSG to L forearm. History of Present Illness: 55-year-old female with a history of having what appears to be an unknown primary in the left neck in the past for which she has had her neck dissection as well as multiple biopsies and radiation for 60 sessions in [**2189**] as well as chemotherapy. Recently, on imaging, she had an area of concern in the left tonsillar fossa with a subsequent biopsy showing a new primary squamous cell carcinoma in the radiated area on [**2197-8-31**]. She has also had a PET scan confirming this. Past Medical History: osteoarthritis Carcinoma left neck, unknown primary s/p radiation Social History: She does not smoke, does not drink. She works as a food service manager Family History: breast cancer high blood pressure diabetes depression Physical Exam: Vitals: Afebrile, other vital signs stable Gen: alert, oriented and asks appropriate questions. Head: Flap in posterior mouth viable. OP otherwise clear. Neck: Flap viable with brisk cap refill, strong dopplerable pulses. Incisions healing, wick in place with serous drainage. Upper ext: Left forearm with skin graft site c/d/i. Dressings c/d/i. Splint in place. Lungs: CTAB Heart: RRR Abdomen: Soft, nontender, nondistended. G-tube in place, c/d/i. Lower ext: wwp Pertinent Results: [**2197-11-1**] 10:30AM BLOOD WBC-14.6* RBC-3.05* Hgb-9.2* Hct-28.4* MCV-93 MCH-30.0 MCHC-32.3 RDW-14.6 Plt Ct-832* [**2197-10-29**] 11:29AM BLOOD PT-13.0 PTT-23.8 INR(PT)-1.1 [**2197-11-1**] 10:30AM BLOOD Glucose-89 UreaN-7 Creat-0.5 Na-137 K-3.8 Cl-99 HCO3-28 AnGap-14 Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 80534**] [**Known lastname 80535**],[**Known firstname **] [**2142-1-10**] 55 Female [**-1/3685**] [**Numeric Identifier 80536**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 8090**]/dif SPECIMEN SUBMITTED: lateral, superior, lateral, inferior, medial, deep, Level 2A Left Neck, Resection left tonsilar carcinoma, Level 3 Left Neck, Level 1A Left Neck, Level 1B Left Neck Procedure date Tissue received Report Date Diagnosed by [**2197-10-19**] [**2197-10-19**] [**2197-10-25**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/ttl Previous biopsies: [**-1/3000**] FS BIOPSIES OF LEFT LATERAL ORAL-PHARYNGEAL WALL. DIAGNOSIS: 1. Superior margin (A): No malignancy identified. 2. Left lateral margin (B): No malignancy identified. 3. Left inferior margin (C): No malignancy identified. 4. Left medial margin (D): No malignancy identified. 5. Left deep margin (E): No malignancy identified. 6. Level 2A left neck dissection (F-G): Five nodes, no malignancy identified (0/5). 7. Level 3 left neck dissection (H-I): Three nodes, no malignancy identified (0/3). 8. Level 1A left neck dissection (J): Four minute nodes, no malignancy identified (0/4). 9. Level 1B left neck dissection (K-L): Minor salivary gland with fatty replacement. 10. Left tonsil resection (M-Y): 1. Invasive squamous cell carcinoma The tumor is moderately differentiated, focally involving skeletal muscle (deepest invasion = 0.7 cm, largest dimension is 2.3 cm). 2. No lymphatic vascular invasion. 3. Margins are negative for invasive carcinoma with distances of; Deep (black) = 2.5 mm Medial superior ([**Location (un) 2452**]) = 2 mm Medial inferior (yellow) = 4 mm Superior lateral (red) = 9 mm Lateral inferior (blue) = 5 mm 4. High grade dysplasia extends to medial-superior and medial-inferior margins. 5. Bone with no diagnostic abnormalities recognized Brief Hospital Course: The patient was admitted to the plastic surgery service on [**2197-10-19**] and had a redo radical neck dissection, tracheostomy, left radial forearm free flap reconstruction and split thickness skin graft. The patient tolerated the procedure well. Post-operatively, she was transfered on mechanical ventilation to the TICU. She was transferred to the floor on [**2197-10-26**]. She returned to OR on [**2197-10-30**] for G-tube placement as well as debridement and closure of open neck wound s/p fall. Neuro: Post-operatively, the patient remained sedated on fentanyl, propofol and cisatracurium drips. On POD 2, sedation was discontinued. Pain was treated with IV Dilaudid with good effect which was later changed to IV Morphine. After G-tube placement, pain was treated with Dilaudid PCA. Once G-tube was in use, liquid oxycodone was used for pain with good effect. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Low blood pressure was managed well with fluid boluses. She had blood pressures of 170/110 the last couple of days of her hospitalization. Medicine was consulted and started her on diltiazem which worked well. Her blood presssures were 120/80 afterwards. Medicine also recommended restarting her lorazepam before bed to treat possible benzo withdrawal and a renal ultrasound as an outpatient to look for renal artery stenosis. Her PCP, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] was contact[**Name (NI) **] for follow-up of this test and result. Pulmonary: The patient was maintained on mechanical ventilation for 48 hours after surgery. On POD 2, sedation was discontinued and the patient was changed to pressure support ventilation. Patient was transitioned to 35% trach collar and tolerated well. Able to clear secretions independently and spontaneously. GI/GU: Post-operatively, the patient was given IV fluids for 48 hours. On POD 2, tube feeds via NGT were started at 10cc/h with a goal of 80cc/h. Patient was maintained NPO for flap safety during entire hospital stay. PO status and swallow evaluation will be decided at outpatient clinic appointment by Dr. [**First Name (STitle) **]. On Post-op day #10, patient was sent for open G-tube placement with General Surgery service for long term tube feeds. Feeds were restarted via G-tube 48 hours after placement without issue. She was also placed on a bowel regimen to encourage bowel movement. Foley was removed on POD#12. Intake and output were closely monitored. ID: Post-operatively, the patient was started on IV Ancef which was continued for the duration of her stay. The patient's temperature was closely watched for signs of infection. She will be discharged on Duricef. Prophylaxis: The patient received subcutaneous heparin during this stay. She also was placed on aspirin for flap protection and was encouraged to get up and ambulate as early as possible. Pneumoboots while in bed. At the time of discharge on POD# 15, the patient was doing well, afebrile with stable vital signs, tolerating full tube feeds, ambulating, voiding without assistance, and pain was well controlled. Medications on Admission: Levoxyl 50mcg daily, Nexium, and lorazepam 1 mg two to three times a day PRN Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*45 Tablet(s)* Refills:*0* 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for puritis. Disp:*2 bottles* Refills:*3* 4. Duricef 500 mg Capsule Sig: One (1) Capsule PO twice a day for 14 days. Disp:*28 Capsule(s)* Refills:*0* 5. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 6. Levothyroxine 25 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Aspirin 81 mg Tablet Sig: 1.5 Tablets PO once a day: Through G-Tube. Disp:*45 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital **] rehab Discharge Diagnosis: Left tonsillar Invasive squamous cell carcinoma Discharge Condition: Stable Discharge Instructions: Nothing to eat or drink by mouth until seen and ok'd by Dr. [**First Name (STitle) **] Tube feeds via G-tube at 80 cc/hr Trach care - do not cap trach, clean or change inner cannula as needed for mucus and crusting. Neck wound care. Please place wick in neck wound, change [**Hospital1 **]. Important to clean crust off of wound, apply bacitracin. Left forearm care: xeroform and kerlix, splint JP drain care: please empty drains per instructions below Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * 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. DRAIN DISCHARGE INSTRUCTIONS You are being discharged with drains in place. Drain care is a clean procedure. Wash your hands thoroughly with soap and warm water before performing drain care. Perform drainage care twice a day. Try to empty the drain at the same time each day. Pull the stopper out of the drainage bottle and empty the drainage fluid into the measuring cup. Record the amount of drainage fluid on the record sheet. Reestablish drain suction. Followup Instructions: Follow up in with Dr. [**First Name (STitle) **]. Please call his office at [**Telephone/Fax (1) 6742**] to schedule the appointment. Pt should follow up with Dr. [**Last Name (STitle) 1837**] 10 days after discharge. Pt can reach his clinic at ([**Telephone/Fax (1) 6213**], and should schedule the appointment. Completed by:[**2197-11-3**]

[ "V15.3", "E849.7", "401.9", "146.1", "E878.6", "998.32", "E885.9", "244.9", "V87.41" ]

icd9cm

[ [ [] ] ]

[ "86.69", "76.43", "29.33", "54.21", "29.4", "40.41", "31.42", "43.11", "96.71", "31.1", "76.09", "86.74", "86.28", "86.89" ]

icd9pcs

[ [ [] ] ]

8325, 8373

4180, 7331

311, 420

8464, 8472

1690, 4157

10221, 10565

1134, 1189

7458, 8302

8394, 8443

7357, 7435

8496, 10198

1204, 1671

233, 273

448, 938

960, 1027

1043, 1118

16,709

182,260

52118

Discharge summary

report

Admission Date: [**2195-9-28**] Discharge Date: [**2195-10-13**] Service: HISTORY OF THE PRESENT ILLNESS: Ms. [**Known lastname **] is a [**Age over 90 **]-year-old female who was initially admitted to [**Hospital Unit Name 196**] and then the ICU and finally to the General Medicine Service. This is a [**Age over 90 **]-year-old with the past medical history of heart failure, and type 2 diabetes mellitus with multiple medical admissions for chest pain. The patient was admitted on the [**9-28**], complaining of increasing chest pain, which awoke her from her sleep. She also complained of increasing shortness of breath and diaphoresis. The chest pain was relieved with two tablets Tylenol #3. At no time did the pain radiate to her neck, upper extremities, or back. beats per minute, left axis deviation, Q waves in lead 3, which were old, along with delayed R wave progression. The chest x-ray in the emergency room showed a picture consistent with congestive heart failure with peribronchial cuffing and increasing left-side pleural effusion and a small right pleural effusion. The patient was given 25 mg Lopressor and ?????? tablet sublingual nitroglycerin in the emergency room. The patient went into respiratory distress requiring a nonrebreather and the blood pressure dropped to approximately 60 systolic. The patient was eventually intubated and started on dopamine drip. She was then transferred to the ICU for further evaluation. The patient's stay in the ICU was complicated by the development of aspiration pneumonia in the left lower lobe. Blood cultures grew out a gram positive rod cocci and she was started on Vancomycin and Levaquin. She was successfully extubated on the 8th day of her admission. She would not tolerate BiPAP. She refused to be intubated again. She had minor respiratory distress following extubation, which was treated with morphine, Lasix, and nitropaste. Of note, the patient and the patient's next of [**Doctor First Name **] both determined that the patient would be a Do Not Resuscitate/Do Not Intubate status. The patient also has refused any further evaluation or workup for her cardiovascular diseases. She was transferred to the floor on the [**2195-10-9**] for further treatment and placement in a rehabilitation facility. PAST MEDICAL HISTORY: 1. Severe aortic stenosis with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 109**] of 0.6 cm squared, peak gradient of approximately 127 mmHg and a mean of 71 mmHg Mercury. 2. Type 2 diabetes mellitus. 3. Coronary artery disease. 4. Paroxysmal atrial fibrillation. 5. Osteoporosis. 6. Lower GI bleed. 7. Left hip fracture. 8. Chronic constipation. ALLERGIES: The patient is allergic to PENICILLIN. MEDICATIONS ON ADMISSION: 1. Lasix 60 mg PO q.d. 2. Amiodarone 200 mg PO q.d. 3. Imdur 60 mg PO q.d. 4. Lopressor 12.5 mg PO b.i.d. 5. Colace 100 mg PO b.i.d. 6. Ultram 50 to 100 mg PO q.12h.p.r.n. chest pain not to exceed 200 mg q.d. 7. Amaryl 1 mg PO q.d. White blood count was 12. The hematocrit was 28.6 and the platelet count was 281,000. Chem 7 showed the sodium of 144, potassium 3, chloride 100, bicarbonate 33, BUN 34, creatinine of 1, and glucose 163, calcium 8.4, phosphate 3.6, magnesium 2.0. The iron study showed a TIBC of 198, haptoglobin of 344, ferritin level pending, TRF 152, and the Vancomycin level drawn on the [**10-9**] was 16.9, Multiple cultures were drawn during her stay in the ICU. A catheterized tip on the [**10-4**] grew out Staphylococcus aureus coagulase negative. Blood culture drawn on the [**2195-10-3**] grew out gram positive rods and MRSA. Chest x-ray showed bilateral pleural effusion left greater than right and a left lower lobe opacity. PHYSICAL EXAMINATION: Examination revealed the following: VITAL SIGNS: The patient was afebrile. Heart rate was 55 beats per minute. Blood pressure 104/3. Respiratory rate 18 beats per minute and she was saturating at 98% on two liters of nasal cannula. GENERAL: In general, this is a frail elderly woman lying in her bed. She is alert and oriented times three. She is in no apparent distress. Oropharynx was clear. Mucous membranes were moist. HEART: Heart was regular rate and rhythm with a 3/6 systolic crescendo decrescendo murmur best heard in the right upper sternal border. LUNGS: Lungs revealed diffuse crackles throughout and rales heard in the lower [**1-1**] of the lungs. ABDOMEN: Abdomen was protuberant, soft, nontender, and nondistended. There was no guarding or rebound. She had normoactive bowel sounds. EXTREMITIES: Extremities were warm with trace pitting edema. HOSPITAL COURSE: This is a [**Age over 90 **]-year-old female with a significant history of cardiac disease to include critical aortic stenosis, congestive heart failure, coronary artery disease, who has refused any further cardiac intervention. The patient was admitted initially to [**Hospital Unit Name 196**] for chest pain. She developed respiratory distress, which required intubation and an 11-day admission to the Intensive Care Unit. She was successfully extubated and transferred to the floor for placement. The brief stay on the General Medicine Team was relatively uneventful. #1. CARDIOVASCULAR DISEASE: The patient has a history of critical aortic stenosis, proximal atrial fibrillation, coronary artery disease, and congestive heart failure. She has refused any further cardiac intervention to include cardiac catheterization, valvuloplasty. We continued her on aspirin 325 mg PO q.d. We also continued her Amiodarone for history of paroxysmal atrial fibrillation. We also continued her on a low dose Lasix 40 mg PO q. 12 hours. #2. PULMONARY: The patient's pulmonary status improved throughout her stay and the supplemental oxygen requirement decreased. Chest x-ray showed stable bilateral pleural effusions, but the apices were improved. She remained on her Vancomycin and Levaquin. On discharge, she was saturating at 99% on two liters of oxygen. She received Ipratropium bromide and Albuterol as needed. #3. HEMATOLOGY: Iron studies showed that the patient had anemia of chronic disease. She did not require any transfusions and the hematocrit stay stable. She was discharged with a multivitamin. #4. ENDOCRINE: The patient has a history of diabetes mellitus. She was covered with regular insulin sliding scale. #5. GASTROINTESTINAL: The patient was covered with Protonix for prophylaxis. The patient was discharged to a rehabilitation home to improve strength. DISCHARGE DIAGNOSES: 1. Pneumonia. 2. Critical aortic stenosis. 3. Coronary artery disease. 4. Congestive heart failure. 5. Type 2 diabetes mellitus. 6. Proximal atrial fibrillation. 7. Osteoporosis. 8. Lower GI bleed. 9. Chronic constipation. 10. Left hip fracture. DISCHARGE MEDICATIONS: 1. Protonix 40 mg q.d. 2. Levofloxacin 250 mg PO q.d. for four more days. 3. Lasix 40 mg PO b.i.d. 4. Docusate sodium 100 mg PO t.i.d. as needed. 5. Tylenol 325 mg to 650 mg PO q.4h. to 6h.p.r.n. 6. Ipratropium bromide nebulizer treatments one nebulizer inhaled treatment every two hours as needed. 7. Albuterol nebulizer solution, one nebulizer treatment q.2 hours as needed. 8. Heparin 5000 units subcutaneously b.i.d.. 9. Senna one tablet PO q.h.s.p.r.n. 10. Milk of Magnesia 30 ml PO q.6h.p.r.n. 11. Tramadol 50 mg to 100 mg PO q.12h. P.r.n. pain not to exceed 200 mg in 24 hours. 12. Lactulose 30 ml PO q.d. as needed. 13. Amiodarone HCL 200 mg PO q.d. 14. Aspirin 325 mg PO q.d. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12175**], M.D. [**MD Number(1) 37596**] Dictated By:[**Name8 (MD) 6284**] MEDQUIST36 D: [**2195-10-12**] 15:00 T: [**2195-10-12**] 15:14 JOB#: [**Job Number **]

[ "427.31", "428.0", "507.0", "424.1", "511.9", "038.11", "518.81", "733.00", "250.00" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.72" ]

icd9pcs

[ [ [] ] ]

6583, 6839

6862, 7826

2777, 3748

4668, 6562

3771, 4650

2328, 2751

66,957

180,185

41570

Discharge summary

report

Admission Date: [**2173-10-8**] Discharge Date: [**2173-10-17**] Date of Birth: [**2121-1-17**] Sex: M Service: SURGERY Allergies: Augmentin Attending:[**First Name3 (LF) 4748**] Chief Complaint: Ischemic right foot Major Surgical or Invasive Procedure: Superficial Femoral Artery Stent Angio jet of Anterior Tibial Artery Cardiac Catheterization Right Below the Knee Amputation History of Present Illness: 52M with a PMH significant for CAD (s/p MI in [**2165**] with 3-stents; s/p 3-VD CABG ib [**2173-3-22**]), DM2 (with neuropathy), HTN, HLD, PVD, smoking history, obesity, chronic back pain, GERD and erectile dysfunction and CKD (baseline 1.0) who presents as an outside transfer from [**Hospital6 204**] for right ischemic foot. Two months prior the patient noted intermittent claudication symptoms with right-sided calf pain that then progressed to right foot pain. He said Tylenol relieved this. He saw his PCP last [**Name9 (PRE) 766**], who prescribed Vicodin, which offered some benefit. He started noticing that his leg was cold and that his foot had dry gangrene changes on the 1st and 3rd right toes last week. He urgently saw his Vascular surgeon (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from [**Hospital3 **]) who performed NIAS, ABIs 0.35 (R), PVRs. Patient presented to the [**Hospital 189**] hospital at around 1 pm on [**10-8**] after he experienced intense worsening of the right foot pain, burning. He underwent and angiogram which showed occulsion of the AT, tibioperoneal trunk, and distal PT. No intervention was performed. Patient did not have any signals below the level of the popliteal and had a cold foot. He had ability to move the foot, but had decreased sensation. He was transferred here for further management. Past Medical History: Myocardial infarction [**2165**] s/p 3 marginal stents [**2172**] Anterior MI, bare metal stent to LAD Diabetes with neuropathy Hypertension Dyslipidemia + tobacco use Obesity Back pain Depression Gastroesophageal gastric reflux Erectile dysfunction Chronic kidney disease (baseline crea 1.0) s/p Laminectomy L2-4 Social History: Lives with: mother Occupation: disabled, worked in receiving area of scuba company Tobacco: 10 ciagarettes/day x 2mo before that 1PPD x35 years ETOH: 1-2 drinks/week Family History: non-contributory Physical Exam: PE on Discharge: VS: Temp 98.2 HR 68 BP 109/59 RR 12 O2sat 98%2L NC General: in no acute distress, resting comfortably in bed. HEENT: mucus membranes moist, nares clear, no nasal flaring, no periorbital cyanosis, trachea at midline CV: regular rate, rhythm. Distant heart sounds secondary to body habitus. No appreciable murmurs/rubs, gallops. Pulm: CTAB, moderate inspiratory effort Abd: obese, soft, nontender, nondistended. MSK: L BKA site staple line clean,[**Year (4 digits) 5235**]. Minimal sero-sanguinous drainage. No fluctuance, no hematoma. Neuro: alert, oriented to person, place, time. Affect mildly flattened. Pertinent Results: [**2173-10-16**] 07:45AM BLOOD WBC-11.1* RBC-3.23* Hgb-7.7* Hct-25.6* MCV-79* MCH-23.9* MCHC-30.2* RDW-17.7* Plt Ct-472* [**2173-10-15**] 07:30AM BLOOD WBC-11.8* RBC-3.50* Hgb-8.3* Hct-28.0* MCV-80* MCH-23.8* MCHC-29.7* RDW-17.6* Plt Ct-473* [**2173-10-14**] 07:00AM BLOOD WBC-15.6* RBC-3.58* Hgb-8.9* Hct-29.0* MCV-81* MCH-25.0* MCHC-30.8* RDW-17.2* Plt Ct-378 [**2173-10-12**] 02:18PM BLOOD WBC-16.2* RBC-3.52* Hgb-8.3* Hct-27.6* MCV-78* MCH-23.7* MCHC-30.3* RDW-17.9* Plt Ct-355 [**2173-10-12**] 07:35AM BLOOD WBC-16.9* RBC-3.66* Hgb-8.8* Hct-27.9* MCV-76* MCH-24.0* MCHC-31.5 RDW-17.9* Plt Ct-316 [**2173-10-11**] 07:50AM BLOOD WBC-12.6* RBC-3.79* Hgb-8.9* Hct-29.2* MCV-77* MCH-23.6* MCHC-30.7* RDW-17.7* Plt Ct-331 [**2173-10-9**] 03:41AM BLOOD WBC-11.1* RBC-3.74* Hgb-9.3* Hct-27.7* MCV-74* MCH-24.7* MCHC-33.4 RDW-17.2* Plt Ct-373 [**2173-10-8**] 08:15PM BLOOD WBC-11.2* RBC-4.57*# Hgb-10.8* Hct-34.6*# MCV-76*# MCH-23.6*# MCHC-31.2 RDW-17.4* Plt Ct-384 [**2173-10-8**] 08:15PM BLOOD Neuts-72.1* Lymphs-20.2 Monos-5.3 Eos-1.7 Baso-0.6 [**2173-10-12**] 02:18PM BLOOD PT-14.7* PTT-30.3 INR(PT)-1.3* [**2173-10-12**] 07:35AM BLOOD PT-14.8* PTT-59.5* INR(PT)-1.3* [**2173-10-10**] 11:06PM BLOOD PTT-60.8* [**2173-10-10**] 04:20PM BLOOD PTT-66.6* [**2173-10-9**] 09:15PM BLOOD PTT-49.7* [**2173-10-8**] 08:15PM BLOOD PT-12.5 PTT-55.3* INR(PT)-1.0 [**2173-10-9**] 08:15AM BLOOD Fibrino-575* [**2173-10-9**] 03:41AM BLOOD Fibrino-551*# [**2173-10-15**] 07:30AM BLOOD Glucose-110* UreaN-18 Creat-1.3* Na-135 K-5.1 Cl-100 HCO3-24 AnGap-16 [**2173-10-14**] 07:00AM BLOOD Glucose-123* UreaN-15 Creat-1.2 Na-135 K-5.2* Cl-100 HCO3-22 AnGap-18 [**2173-10-13**] 06:06AM BLOOD Glucose-91 UreaN-12 Creat-1.1 Na-134 K-4.8 Cl-98 HCO3-24 AnGap-17 [**2173-10-12**] 02:18PM BLOOD Glucose-180* UreaN-13 Creat-1.2 Na-132* K-4.5 Cl-97 HCO3-27 AnGap-13 [**2173-10-10**] 07:00AM BLOOD Glucose-117* UreaN-12 Creat-1.0 Na-136 K-4.2 Cl-100 HCO3-29 AnGap-11 [**2173-10-8**] 08:15PM BLOOD Glucose-148* UreaN-16 Creat-1.3* Na-136 K-4.4 Cl-101 HCO3-25 AnGap-14 [**2173-10-13**] 06:06AM BLOOD ALT-17 AST-28 CK(CPK)-395* AlkPhos-82 TotBili-0.3 [**2173-10-14**] 07:00AM BLOOD CK(CPK)-223 [**2173-10-12**] 11:08PM BLOOD CK(CPK)-461* [**2173-10-12**] 02:18PM BLOOD CK(CPK)-912* [**2173-10-12**] 10:20AM BLOOD CK(CPK)-871* [**2173-10-11**] 11:37PM BLOOD CK(CPK)-1076* [**2173-10-11**] 08:40PM BLOOD CK(CPK)-1223* [**2173-10-11**] 09:10AM BLOOD CK(CPK)-1114* [**2173-10-11**] 07:50AM BLOOD CK(CPK)-1055* [**2173-10-10**] 07:00AM BLOOD CK(CPK)-689* [**2173-10-9**] 09:15PM BLOOD CK(CPK)-691* [**2173-10-9**] 01:37PM BLOOD CK(CPK)-813* [**2173-10-9**] 03:41AM BLOOD CK(CPK)-868* [**2173-10-14**] 07:00AM BLOOD CK-MB-4 cTropnT-0.28* [**2173-10-13**] 06:06AM BLOOD CK-MB-9 cTropnT-0.31* [**2173-10-12**] 11:08PM BLOOD CK-MB-10 MB Indx-2.2 cTropnT-0.28* [**2173-10-12**] 10:20AM BLOOD CK-MB-13* MB Indx-1.5 cTropnT-0.36* [**2173-10-11**] 11:37PM BLOOD CK-MB-16* MB Indx-1.5 cTropnT-0.31* [**2173-10-11**] 08:40PM BLOOD CK-MB-21* MB Indx-1.7 cTropnT-0.30* [**2173-10-11**] 09:10AM BLOOD CK-MB-18* MB Indx-1.6 cTropnT-0.25* [**2173-10-11**] 07:50AM BLOOD CK-MB-18* MB Indx-1.7 cTropnT-0.23* [**2173-10-10**] 11:06PM BLOOD cTropnT-0.18* [**2173-10-10**] 04:20PM BLOOD cTropnT-0.18* [**2173-10-10**] 07:00AM BLOOD CK-MB-16* MB Indx-2.3 cTropnT-0.25* [**2173-10-9**] 09:15PM BLOOD CK-MB-21* MB Indx-3.0 cTropnT-0.28* [**2173-10-9**] 01:37PM BLOOD CK-MB-22* MB Indx-2.7 cTropnT-0.14* [**2173-10-9**] 08:15AM BLOOD cTropnT-0.05* [**2173-10-15**] 07:30AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.0 [**2173-10-12**] 07:35AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.7 [**2173-10-9**] 03:41AM BLOOD Calcium-8.2* Phos-3.2 Mg-1.4* [**2173-10-13**] 06:06AM BLOOD Vanco-26.5* [**2173-10-11**] 07:55AM BLOOD Vanco-25.4* [**2173-10-17**] 08:05AM BLOOD WBC-10.8 RBC-3.82* Hgb-9.3* Hct-30.0* MCV-79* MCH-24.4* MCHC-31.0 RDW-17.8* Plt Ct-560* [**2173-10-16**] 07:45AM BLOOD WBC-11.1* RBC-3.23* Hgb-7.7* Hct-25.6* MCV-79* MCH-23.9* MCHC-30.2* RDW-17.7* Plt Ct-472* Brief Hospital Course: The patient was admitted to the General Surgical Service for evaluation and treatment of an ischemic right foot. On [**2173-10-9**] the patient underwent a ultrasound-guided puncture of left common femoral artery, contralateral second-order catheterization of right external iliac artery, serial arteriogram of right lower extremity, balloon angioplasty and stenting of right superficial, femoral artery, AngioJet mechanical and pharmacologic thrombolysis of tibioperoneal trunk and posterior tibial artery, and placement of 40 cm [**Location (un) **]-[**Doctor Last Name 6632**] thrombolysis catheter along the length of the posterior tibial artery, tibioperoneal trunk and popliteal artery. Postoperatively the patient experienced motor and sensory changes status post AngioJet thrombolysis and returned to the OR for Removal of [**Last Name (un) 73395**]-[**Doctor Last Name 6632**] catheter, serial arteriogram of right lower extremity, balloon angioplasty of right posterior tibial artery, and perclose closure of left common femoral arteriotomy (Reader referred to operative notes for details). Cardiac enzymes were elevated postoperatively given his extensive cardiac history patient was sent for cardiac catheterization on [**2173-10-11**] which revealed existing known blockages but patency of graft sites. The initial procedures on [**2173-10-9**] were unable to alleviate the right leg ischemia and the patient returned to the OR on [**2173-10-12**] for a Right Below Knee amputation. After arrival to the OR patient was noted to desaturate likely from a small amount of sedative and narcotic pain medication. It was felt that he likely obstructed his airway requiring placement of a nasal trumpet and a positive pressure ventilation. His oxygen saturations regained when his airway was controlled. A left axillary line was placed. The patient was intubated without complication. He did not become hypotensive or bradycardiac during this episode. Because it was felt that his profoundly ischemic right foot was contributing to his overall condition, it was felt that we should proceed with the operation to remove it. The procedure was otherwise uneventful and the patient was transferred to the ICU post operatively for continued monitoring. The patient did well overnight on just 02 via nasal cannula and was able to be transferred to the VICU the afternoon of POD1. Neuro: The patient received dPCA which malfunctioned and required IV dilaudid to cover his pain until dPCA functionality could be restored. Patient did not feel he was getting adequate pain control and was transitioned to intermittent IV dilaudid and PO oxycodone with good effect and adequate pain control. CV: The patient was closely monitored given his cardiac history and elevated Cardiac Enzymes. Elevated CK was likely due to ischemic right foot and Troponins and CK trended down during his stay. A TTE was performed of limited quality due to body habitus which showed mild hypokinesis of the apical and basalateral ventrical but with preserved EF of greater than 55%. IV lopressor was used for rate control and the patient's home atenolol was increased to 125mg with good effect and IV lopressor was discontinued. Vital signs were routinely monitored through hist stay. Pulmonary: After the respiratory concerns preoperatively during the BKA, the patient did well from a respiratory standpoint. He was comfortable on room air and vital signs were routinely monitored. Good pulmonary toilet, raised head of the bed and sitting upright and incentive spirometry were encouraged throughout hospitalization. Due to concerns for possible OSA patient was put in contact with the sleep clinic at [**Hospital1 18**]. GI/GU/FEN: Post-operatively, the patient was made NPO with IV fluids. Diet was advanced when appropriate, which was well tolerated. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. The patient was put on an aggressive bowel regimen with good effect. Patient had urinary retention on POD 3 from the Right BKA and the foley catheter had to be replaced. He was dishcaged with foley in place. ID: The patient's white blood count and fever curves were closely watched for signs of infection. Patient was put on IV Vancomycin, Ciprofloxacin, and Flagyl. His WBCs began to down trend after the BKA and he was transitioned to Bactrim PO. He remained afebrile. Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. Hematology: The patient's complete blood count was examined routinely; the patient received 1 unit of PRBCs on [**2173-10-10**], [**2173-10-12**], and [**2173-10-16**] for HCT less than 30 in light of evidence of heart strain via elevated cardiac enzymes. Thereafter, HCT remained stable and CE were downtrending. His hematocrit upon discharge was 30.0 The patient was otherwise asymptomatic, and hemodynamically stable. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; A knee immobilizer was used to prevent contracture of his right lower extremity. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, voiding via a foley [**Last Name (un) **], and pain was well controlled. He is being sent to a rehabilitation facility for continued work to improve mobility, endurance, and for amputation teaching and training. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: - pravastatin 80 mg daily - hydrocodone - ibuprofen 500 q6h - furosemide 40 mg daily - novolog 70/30 - gabapentin 900 mg tid - ASA 325 mg daily - omega 3 fa - nitroglycerin 0.4 mg prn chest pain - atenolol 100 mg daily - Prilosec 40 mg daily Discharge Medications: 1. amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 2. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3 times a day). 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*30 Patch 24 hr(s)* Refills:*2* 6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:*30 Tablet(s)* Refills:*0* 8. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for angina. 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*2* 11. atenolol 50 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily). Disp:*75 Tablet(s)* Refills:*0* 12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for constipation. Disp:*90 Capsule(s)* Refills:*2* 13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 14. oxycodone 5 mg Capsule Sig: [**12-28**] Capsules PO Q3H (every 3 hours) as needed for pain. Disp:*60 Capsule(s)* Refills:*0* 15. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: Willow Manor - [**Hospital1 189**] Discharge Diagnosis: Peripheral Vascualar Disease and Ischemic Right Foot Cardiac Ischemia Discharge Condition: Mental status: clear, coherent, cooperative with plan of care Ambulatory status: wheelchair-dependent, limited mobility with crutches Discharge Instructions: This information is designed as a guideline to assist you in a speedy recovery from your surgery. Please follow these guidelines unless your physician has specifically instructed you otherwise. Please call our office nurse if you have any questions. Dial 911 if you have any medical emergency. . ACTIVITY: . There are restrictions on activity. On the side of your amputation you are non weight bearing until cleared by your Surgeon. You should keep this amputation site elevated when ever possible. . You may use the other leg to assist in transferring and pivots. But try not to exert to much pressure on the amputation site when transferring and or pivoting. Please keep knee immobilizer on at all times to help keep the amputation site straight. . No driving until cleared by your Surgeon. . PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: . Redness in or drainage from your leg wound(s) . . Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. . Exercise: . Limit strenuous activity for 6 weeks. . . BATHING/SHOWERING: . You may shower immediately upon coming home. No bathing. A dressing may cover you??????re amputation site and this should be left in place for three (3) days. Remove it after this time and wash your incision(s) gently with soap and water. You will have sutures, which are usually removed in 4 weeks. This will be done by the Surgeon on your follow-up appointment. . WOUND CARE: . Sutures / Staples - an appointment will be made for you to return for staple removal. . When the sutures are removed the doctor may or may not place pieces of tape called steri-strips over the incision. These will stay on about a week and you may shower with them on. If these do not fall off after 10 days, you may peel them off with warm water and soap in the shower. . Avoid taking a tub bath, swimming, or soaking in a hot tub for four weeks after surgery. . MEDICATIONS: . Unless told otherwise you should resume taking all of the medications you were taking before surgery. You will be given a new prescription for pain medication, which can be taken every three (3) to four (4) hours only if necessary. . Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. . CAUTIONS: . NO SMOKING! We know you've heard this before, but it really is an important step to your recovery. Smoking causes narrowing of your blood vessels which in turn decreases circulation. If you smoke you will need to stop as soon as possible. Ask your nurse or doctor for information on smoking cessation. . Avoid pressure to your amputation site. . No strenuous activity for 6 weeks after surgery. FOLLOW-UP APPOINTMENT: . Be sure to keep your medical appointments. The key to your improving health will be to keep a tight reign on any of the chronic medical conditions that you have. Things like high blood pressure, diabetes, and high cholesterol are major villains to the blood vessels. Don't let them go untreated! . Please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. Normal office hours are 8:30-5:30 Monday through Friday. . PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE Followup Instructions: Please Call Dr.[**Name (NI) 1392**] office for a follow up visit: Phone: [**Telephone/Fax (1) 1393**]. Staples can be removed in about 4 weeks if still in a Rehabilitation Center. Otherwise, they will be removed at your office visit. During your stay we had concern for Obstructive Sleep Apnea. You will likely benefit from further work up for this condition. Please contact our sleep center. Sleep: ([**Telephone/Fax (1) 9525**] Please call to make an appointment for a sleep study followed by a sleep clinic visit. We also had to increase your dose of atenolol during your stay. Please follow up with your Primary Care Doctor in 1 week to manage your blood pressure medications.

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icd9cm

[ [ [] ] ]

[ "39.50", "00.45", "99.10", "84.15", "39.90", "37.22", "88.48", "88.56", "39.79", "00.40" ]

icd9pcs

[ [ [] ] ]

14863, 14924

7046, 12734

290, 417

15038, 15038

3032, 7023

18888, 19578

2355, 2373

13026, 14840

14945, 15017

12760, 13003

15198, 16787

2388, 2391

2406, 3013

231, 252

16799, 18273

18296, 18865

445, 1818

15053, 15174

1840, 2155

2171, 2339

68,464

146,491

35185

Discharge summary

report

Admission Date: [**2160-9-12**] Discharge Date: [**2160-9-25**] Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 78**] Chief Complaint: [**Hospital 80293**] Transfer from outside hospital for Neurosurgical evaluation Major Surgical or Invasive Procedure: None History of Present Illness: HPI: Patient is a 83 year old RHM with hx of HTN who was in his usual state of health (highly functioning, independently ambulating) until the past 1~2 days. She reports that he was behaving as if he was depressed for the past few days then had acute onset of ?vertigo plus possible chest pain hence went to [**Hospital1 **] in [**Location (un) 47**] early this morning around 6:30 where he was evaluated and found to have large L-sided IPH with blood in both ventricles plus R atria but minimal midline shift to the right. Past Medical History: 1. HTN 2. CAD - s/p stenting 11~12 yrs ago 3. BPH 4. Angina 5. ?Hyperlipidemia 6. Left cataract surgery Social History: Lives with girlfriend - habits unknown. Family History: N/C Physical Exam: Alert. Opens eyes to voice. Facial symmetry even. Not oriented to location or date. HEENT: Pupils: 3 --> 2.5mm but sluggish Lungs: CTA bilaterally. Cardiac: RRR. no M/R/G appreciated. Abd: Soft, NT, BS+ Motor: MAE's with 4-/5 motor strength throughout. DTR's Right 2 2 1 1 Left 2 2 1 1 Toes upgoing bilaterally Pertinent Results: [**2160-9-15**] 03:09AM BLOOD WBC-10.1 RBC-3.65* Hgb-11.2* Hct-31.8* MCV-87 MCH-30.8 MCHC-35.4* RDW-13.1 Plt Ct-145* [**2160-9-15**] 03:09AM BLOOD Plt Ct-145* [**2160-9-15**] 03:09AM BLOOD Glucose-155* UreaN-15 Creat-1.1 Na-138 K-3.8 Cl-103 HCO3-32 AnGap-7* [**2160-9-12**] 06:44PM BLOOD CK(CPK)-94 [**2160-9-12**] 06:44PM BLOOD Lipase-26 [**2160-9-12**] 10:45AM BLOOD CK-MB-3 cTropnT-<0.01 [**2160-9-15**] 03:09AM BLOOD Calcium-8.3* Phos-1.9* Mg-2.1 [**2160-9-14**] 04:14AM BLOOD Type-ART pO2-129* pCO2-49* pH-7.42 calTCO2-33* Base XS-6 Imaging: HCT [**9-12**]: IMPRESSION: 1. Large left intraparenchymal hemorrhage in the temporal-occipital lobe, possibly related to a hypertensive bleed. 2. Associated intraventricular extension of hemorrhage with small left temporal occipital subdural hematoma and subarachnoid hemorrhage is present. 3. 2 mm rightward shift, unchanged from prior study. No herniation. 4. Small vessel microvascular changes. MRA [**9-13**] IMPRESSION: 1. Left-sided temporal lobe intra-axial hemorrhage with mild surrounding edema and mass effect on the left lateral ventricle with extension to the ventricular system. 2. Thin rim of left-sided temporal occipital subdural. 3. Small vessel disease and brain atrophy. 4. Slightly hyperintense signal is seen in the left transverse sinus, which could be normal variation, but MRV is recommended to exclude sinus thrombosis. Findings were discussed with Dr. [**First Name (STitle) 34062**] [**Name (STitle) **] at the time of interpretation of this study. Brief Hospital Course: [**9-12**]: Admit to ICU intubated forairway protection and close neuologic monitoring. Poor Physical exam; PERRL, spontaneous movements of all limbs, but did not follow commands. No surgical intervention offered for this severe stroke given the high mortality rate associated within 1 month. Extubated [**9-13**]. MRI - stable except for a possible Left transverse sinus thrombus ->MRV, MRA showed no abnormalities. [**9-14**] Neurology consulted and have been in discussion with family regarding prognosis. Pt had previously signed a living will which the Health Care Proxy brought forth on [**2160-9-15**] on which date the patient was made CMO for comfort measures only. Palliative care medicine has been following for guidance and assistence with placing pt in outside hospice care or extended care facility. Medications on Admission: 1. Spironolactone 2. Doxazosin 3. Atenolol 4. ASA Discharge Medications: 1. Acetaminophen 160 mg/5 mL Solution Sig: [**11-21**] PO Q6H (every 6 hours) as needed for Fever. 2. Morphine Concentrate 5 mg/0.25 mL Solution Sig: [**11-21**] PO Q1H (every hour) as needed. 3. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed: [**Month (only) 116**] Crush if needed. 4. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for agitation. Discharge Disposition: Extended Care Facility: Carlyne House Discharge Diagnosis: Intraparenchymal hemorrhage Discharge Condition: Stable Discharge Instructions: Keep pt comfortable. Pt at high fall risk. Should be assisted by staff at all times for repositioning, meals and when out of bed. Support pillows should also be available for in bed positioning. Preventative skin care should be performed three times per day. ROM and measures to prevent contractures should also be employed. Followup Instructions: None Completed by:[**2160-9-25**]

[ "V45.82", "272.4", "V66.7", "431", "401.9", "600.00", "414.01", "413.9" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

4386, 4426

3029, 3847

345, 352

4498, 4507

1478, 3006

4880, 4916

1109, 1114

3948, 4363

4447, 4477

3873, 3925

4531, 4857

1129, 1459

225, 307

380, 907

929, 1035

1051, 1093

28,122

188,831

53381

Discharge summary

report

Admission Date: [**2169-4-27**] Discharge Date: [**2169-5-15**] Date of Birth: [**2110-3-8**] Sex: M Service: MEDICINE Allergies: Gluten Attending:[**First Name3 (LF) 943**] Chief Complaint: Upper GI Bleed Major Surgical or Invasive Procedure: EGDx2 Bone marrow biopsy History of Present Illness: 59 year old man with history of ESLD secondary to EtOH, hypertension who was referred to the hospital after having an elective EGD that showed significant amount of blood in the stomach. The patient noted that he was having black, loose stools and feeling dizzy when walking around for one week prior to presentation. He denied abdominal pain, chest pain, or headache. He had no nausea or vomiting prior the EGD. EGD showed a ? mass vs clotted blood in the antrum along the lesser curvature of the stomach and multiple lesions similar to a Dieulafoy's lesion. One cord of grade I varices was seen in the distal esophagus. Cold forceps biopsy was done of the mass. He was hypotensive to 80/45 following the endoscopy and again en route to the ED. . In the ED, vitals were: 98.7 106 99/64 18 100%2L. The patient's Hct was 20 and platelets were <5,000. He received 5 mg IV vitamin K and was transfered to the MICU where he required multiple transfusions. Additionally, on presentation his platelet count was <5K and hematology was consulted. . The patient was recently admitted to [**Hospital1 18**] from [**Date range (1) 109799**] for ascites control. During that admission he had a paracentesis for ~5 liters and started on spironolactone, lasix, and protonix. Past Medical History: EtOH abuse HTN Hypercholesterolemia Peripheral neuropathy [**12-24**] EtOH use Transaminitis Anemia Dermatitis herpetiformis Celiac disease MSM Social History: He is a lifetime nonsmoker. Until recently, he worked from [**Month (only) 116**] to [**Month (only) **] as a marketing director for farmer's markets. In the winter months, he worked in an office as a computer analyst. He has recently retired from both jobs. He was drinking [**12-25**] cocktails per night (mostly vodka). MSM. Family History: The patient's mother has [**Name (NI) 2481**] disease (she is 85 yo old); father died of prostate cancer at the age of 63; has one brother. Physical Exam: VS: 95.8 117 108/56 23 100%2L GEN: NAD, pale HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection, anicteric, OP clear, MMM, Neck supple, no LAD, no carotid bruits CV: RRR, nl s1, s2, no m/r/g PULM: CTAB, no w/r/r with good air movement throughout ABD: soft, NT, distended with ascites + BS, no HSM EXT: warm, dry, +2 distal pulses BL, no femoral bruits. numerous petechiae over lower legs. NEURO: alert & orientedx3, CN II-XII grossly intact, [**3-27**] strength throughout. No sensory deficits to light touch appreciated. No asterixis PSYCH: appropriate affect Pertinent Results: [**2169-4-27**] 04:59PM GLUCOSE-115* LACTATE-2.2* [**2169-4-27**] 05:00PM PT-16.7* PTT-32.6 INR(PT)-1.5* [**2169-4-27**] 05:00PM PLT SMR-RARE PLT COUNT-<5 [**2169-4-27**] 05:00PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL [**2169-4-27**] 05:00PM WBC-17.5* RBC-1.99*# HGB-6.9*# HCT-20.1*# MCV-101* MCH-34.9* MCHC-34.6 RDW-15.1 ****[**2169-4-27**] 05:00PM PLT SMR-RARE PLT COUNT-<5 [**2169-4-27**] 05:00PM GLUCOSE-144* UREA N-41* CREAT-0.8 SODIUM-128* POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-19* ANION GAP-14 [**2169-4-27**] 07:35PM PLT SMR-VERY LOW PLT COUNT-45*# [**2169-4-27**] 07:35PM HCT-28.5*# . STUDIES: EGD [**2169-4-27**] - Blood in the fundus and antrum Mass in the antrum (biopsy) Polyps in the antrum Varices at the distal esophagus Otherwise normal EGD to third part of the duodenum . Liver u/s [**2169-4-7**] - 1. Extremely echogenic liver which seriously limits evaluation for focal abnormalities (or intrahepatic biliary ductal dilatation). 2. Portal veins are patent, but with reversed flow. 3. Large ascites. 4. Gallbladder sludge, without evidence of cholecystitis Brief Hospital Course: 59 year old man with history of etoh cirrhosis presenting with upper GI bleed also found to be markedly thrombocytopenic, likely secondary to ITP. He was intially admitted to the ICU and then transferred to the hepatorenal floor. . Acute blood loss anemia secondary to GI bleed: He was transferred to the ED directly from endoscopy. The visible stomach lesions are the source of bleed, which was exacerbated by marked thrombocytopenia. He was relatively hypotensive on arrival to the ICU with HR>sbp, but still mentating and making urine. He was given 6 units of pRBC's and 4 units of platelets with 2 units of FFP. His Hct was stable and he was transferred to the floor at 29. He maintained his hct throughout the admission. He was intially NPO but quickly advanced to regular diet. His hct was checked [**Hospital1 **] at first and then daily. There was questionable mass on endoscopy whose pathology returned as normal gastric mucosa. PPI was held given it is a potential trigger to thrombocytopenia. He had a repeat endscopy on [**2169-5-15**] which showed multiple erosions but no active bleeding with pending biopsy results at time of discharge. . Thrombocytopenia/ITP: Patient with new onset thrombocytopenia and petechiae. Patient platelets were normal at >150 on last admit, 2 weeks prior to this one. DDx: destruction, sequestration, production error. No evidence of TTP. Heme has seen and reviewed smear and feel most c/w ITP. Also considering medication induced thrombocytopenia, since he was started on lasix and spironolactone on last admit. Initially patient was transfused for platelet goal of 50. PLTs continued to drop within hours of transfusion, so he was then tranfused for bleeding only. He only needed a transfusion on [**2169-5-3**] for a nose bleed and guaiac positive stool. Hematology followed him throughout the admission. Given his recent GI bleed and cirrhosis, steroids or splenectomy intially were not options for this patient. He was intitially treated with IVIG. He got 60gm total at first 30gm each on [**4-29**] and [**4-30**]. He then got more IVIG, for goal of 2gm/kg, so 45gm each on [**5-3**] and [**5-4**]. He did not bump his platelets to this, although they were consistently >5,000 after IVIG, though not above 10,000. Lasix was discontinued earlier in the admission since, in rare cases, it may cause thrombocytopenia. His aldactone was then increased from 100mg to 200mg. Bone marroy biopsy was attempted [**2169-5-8**], but at that point platelets began to improve, so it was not reattempted. since his Hct remained stable, a steroid trial was started on [**5-10**], 1mg per lb at dry weight. So he was given 70mg daily for 7 days with plan for quick taper on discharge. His platelets improved on this, and were 48 on discharge. He was started on a [**Hospital1 **] H2 blocker with the steroid to prevent gastritis. Hyponatremia: Had been trending down since admission, likely because on increasing dose of aldactone. discontinue aldactone was discontinued on [**2169-5-12**] with improvement of sodium. He was fluid restricted 1500cc. Will restart aldactone and possibly bumex when needed and, at discharge, it was thought the patient may be able to control/monitor his third-spacing by maintaining a low-sodium diet and weighing himself every day. ETOH Cirrhosis: MELD 14. With regard to synthetic function, INR chronically elevated 1.4-1.5; platelets previously normal range, however markedly low this admission as outlined above; albumin low at 2.8. Marked ascites on exam, has been stable on diuretics. discontinue lasix and aldactone as above. lactulose held because not encephalopathic. s/p cipro 500mg x3 days for prophylaxis for GI Bleed Leukocytosis: Now resolved. present since last admission. Max WBC count 18.1. Denies cough, dysuria. UA negative and CXR negative. Does have significant amount of ascites on exam however he is afebrile and without abdominal pain on exam which seems less consistent with SBP. EtOH abuse: No drink x1 month. No evidence of withdrawal this far out. - continue MVI, folate, thiamine Peripheral neuropathy: - Continue gabapentin 600 TID. Celiac disease: DH, stable, continue gluten free diet Medications on Admission: Gabapentin 600 mg Q8H Omeprazole 20 mg daily Thiamine HCl 100 mg DAILY Folic Acid 1 mg DAILY Miconazole Nitrate 2 % Powder Topical TID:prn Spironolactone 100 mg DAILY Furosemide 20 mg DAILY Discharge Medications: 1. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day). 6. Prednisone 10 mg Tablet Sig: Seven (7) Tablet PO once a day for 10 days. Disp:*70 Tablet(s)* Refills:*0* 7. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*3* Discharge Disposition: Home Discharge Diagnosis: Upper Gastrointestinal bleed secondary to Immune Thrombocytopenic Purpura Cirrhosis peripheral neuropathy Acute blood loss anemia Celiac disease Discharge Condition: stable Discharge Instructions: You were admitted to the hospital when you were found to have a GI bleed in the endoscopy suite. You were transfused a total of 6 units of RBCS in the MICU. Your blood level remained stable after that. You were found to have low platelets. You were treated with this intially with IVIG and then were put on steroids. Your platelet levels improved on the steroids. Your low platelet count may have been caused by one of the medications you were taking or by an infections. You should no longer take lasix, aldactone or protonix/pantoprazole. We started omeprazole to prevent gastro-intestinal bleeding. You should continue to take the steroids (prednisone 70 mg) until you see Dr. [**Last Name (STitle) **] in Hematology. Your sodium was also low while in the hospital. For this reason, we stopped your diuretics. You should no longer take aldactone or lasix. You should weigh yourself everyday and if your weight increased by 3 or more pounds, call your Liver doctor. Overall: stop taking aldactone, protonix, and lasix start taking prednisone and omeprazole Please call your doctor or return to the hospital if you have increased bruising, bleeding from your mouth or rectum, increasing abdominal girth, confusion or any other concerning symptoms. Followup Instructions: You have a follow up appointment for your low platelet count (ITP) with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] in Hematology on [**2169-5-19**] at 1:00 pm. (Phone:[**Telephone/Fax (1) 22**]) This appointment may be changed to an earlier date ([**5-17**]). If this does happen, the office will call you at home. You have a follow up appointment for your liver with Dr. [**Name (NI) **] on [**2169-5-29**] at 10:50 am. (Phone: [**Telephone/Fax (1) 2422**]). You have a follow up appointment with your primary-care physician [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 31804**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7405**] on [**2169-6-21**] at 2:30 pm. (Phone:[**Telephone/Fax (1) 250**])

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icd9cm

[ [ [] ] ]

[ "45.16", "99.05", "41.31", "99.07", "99.04", "99.14" ]

icd9pcs

[ [ [] ] ]

9122, 9128

4048, 8237

280, 307

9317, 9326

2874, 4025

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226, 242

335, 1600

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29,867

138,500

31678

Discharge summary

report

Admission Date: [**2180-10-27**] Discharge Date: [**2180-10-29**] Date of Birth: [**2123-9-11**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: Upper gastrointestinal bleed Major Surgical or Invasive Procedure: Esophageal duodenal upper endoscopy Colonoscopy Transfusion of 1 unit of packed red blood cells History of Present Illness: 57 year old female with history of MI s/p stent in [**5-20**] on aspirin/plavix presenting with single episode of lower GI bleed. The patient was in her usual state of health until the morning of admission when she developed acute onset cramping lower abdominal pain at a meeting. She got up to go to the bathroom and was incontinent of a large volume of bright red blood and diarrhea. The pain resolved after the BRBPR. She denied any other preceeding symptoms: fever, chills, chest pain, shortness of breath, nausea, preceeding diarrhea or constipation. She has never had a colonoscopy. . In the ED, initial vitals were: 97, 110/65, 87, 97% RA. She was hemodynamically stable throughout the ED course BP 107-113/71-83, HR 90s and her hematocrit was 38. She was given 1 liter Normal saline, NG lavage negative. The patient was evaluated by GI who recommended ICU monitoring for lower GI bleed. Past Medical History: CAD s/p MI [**5-20**]--PDA stent Hypertension s/p Cholecystectomy Social History: Divorced, 2 children, medical assistant for clinical research. Smoked [**4-16**] ppd X 40 years quit [**5-20**]. Occ EtOH. No IVDU Family History: Sister with [**Name (NI) 17095**], Father died from [**Name (NI) **] Lymphoma, Mother with pancreatic cancer. Physical Exam: T: 97.0 BP: 118/75 P: 82 RR: 18 O2 sats: 96% 2L NC Gen: well appearing female, no distress, no complaints HEENT: PERRL, OP clear, EOMI Neck: No JVD CV: RRR no murmur Resp: CTAB Abd: obese, soft, nontender, nondistended +BS Back: No lesions, no tenderness Rectal: ext hemorrhoids, non bloody, no palpable masses, guaiac positive Ext: No edema Pertinent Results: IMAGES/STUDIES . Tagged RBC scan - negative . EGD [**2180-10-27**] - normal Esophagus: Normal esophagus. Stomach: Normal stomach. Duodenum: Normal duodenum. . Colonoscopy [**2180-10-28**] - Multiple non-bleeding diverticula were seen in the sigmoid colon.Diverticulosis appeared to be severe. Multiple diverticula were seen in the whole colon.Diverticulosis appeared to be of moderate severity. No active bleeding seen. Likely diverticular source. . LABS . HCT TREND [**2180-10-27**] 10:33AM BLOOD Hgb-12.5 calcHCT-38 [**2180-10-27**] 10:20AM BLOOD WBC-13.3* RBC-4.21 Hgb-12.4 Hct-36.5 MCV-87 MCH-29.5 MCHC-34.0 RDW-13.7 Plt Ct-505* [**2180-10-27**] 02:13PM BLOOD Hct-30.9* [**2180-10-27**] 08:24PM BLOOD Hct-29.6* [**2180-10-28**] 12:03AM BLOOD Hct-28.7* [**2180-10-28**] 03:59AM BLOOD WBC-9.3 RBC-3.03*# Hgb-8.7*# Hct-26.0* MCV-86 MCH-28.7 MCHC-33.5 RDW-14.0 Plt Ct-356 [**2180-10-28**] 07:33AM BLOOD Hct-27.7* [**2180-10-28**] 12:32PM BLOOD Hct-30.6* [**2180-10-28**] 05:46PM BLOOD Hct-29.9* [**2180-10-29**] 01:05AM BLOOD Hct-28.0* [**2180-10-29**] 07:42AM BLOOD WBC-9.3 RBC-3.51* Hgb-10.5* Hct-30.4* MCV-87 MCH-29.8 MCHC-34.4 RDW-13.9 Plt Ct-378 . DIFF [**2180-10-27**] 10:20AM BLOOD Neuts-71.9* Lymphs-23.0 Monos-3.0 Eos-1.9 Baso-0.2 [**2180-10-28**] 03:59AM BLOOD Neuts-49.6* Lymphs-43.0* Monos-3.0 Eos-4.3* Baso-0.1 [**2180-10-29**] 07:42AM BLOOD Plt Ct-378 . CHEMISTRIES [**2180-10-27**] 10:20AM BLOOD Glucose-114* UreaN-24* Creat-0.8 Na-140 K-5.2* Cl-105 HCO3-24 AnGap-16 [**2180-10-29**] 07:42AM BLOOD Glucose-91 UreaN-6 Creat-0.6 Na-142 K-4.0 Cl-108 HCO3-26 AnGap-12 . OTHER LABS [**2180-10-27**] 10:20AM BLOOD ALT-17 AST-15 CK(CPK)-95 AlkPhos-82 Amylase-54 [**2180-10-27**] 10:20AM BLOOD Lipase-25 [**2180-10-27**] 10:20AM BLOOD CK-MB-NotDone cTropnT-<0.01 Brief Hospital Course: This is a 57 year old woman with history of CAD s/p MI and stent ([**5-20**]) presenting with BRBPR due to diverticulosis. Brief hospital course presented below by problem. . Briefly, this is a 57 year old female with history of MI s/p stent in [**5-20**] on aspirin/plavix presented on [**2180-10-27**] with single episode of lower GI bleed. She had acute onset of lower abdominal cramping, then was incontinent of a large volume of bright red blood and diarrhea. The pain resolved after the BRBPR. She denied any other preceeding symptoms: fever, chills, chest pain, shortness of breath, nausea, preceeding diarrhea or constipation. In the ED she was hemodynamically stable with BP 107-113/71-83, HR 90s and her hematocrit was 38. She was given 1 liter Normal saline, NG lavage negative. The patient was evaluated by GI who recommended ICU monitoring for lower GI bleed. . In the ICU, patient was continued on her PPI, given IVF, kept NPO for EGD and colonoscopy. No ischemic changes on EKG. The patient's beta blocker was held to not mask tachycardia. She received 1 unit of PRBC. On [**2180-10-27**], her tagged RBC scan was negative, her EGD was shown to be normal, and colonoscopy on [**2180-10-28**] showed diverticulosis as likely cause of GIB. Also showed multiple non-bleeding diverticula. During the whole hospital course, the patient was continued on asprin and plavix for recent drug eluting stent [**5-20**]. She was also continued on her statin for hyperlipidemia. Patient's Hct remained stable after the colonoscopy and patient was transferred to the general medicine floor for continued care in the evening of [**2180-10-28**]. On the day of discharge, the patient tolerated regular diet, had no more episodes of bleeding, and had a stable hematocrit. Patient was discharged on all her home medications including restarting her coreg CR for hypertension. She will need follow up with her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 74442**], within 1-2 weeks of discharge from the hospital. Also, she will need follow up with a local GI specialist for a full screening colonoscopy with better prep in the future to look for polyps and other colonic morphology. Medications on Admission: Aspirin 325 mg daily Plavix 75 mg daily Coreg CR 10 mg daily Crestor 10 mg daily Protonix 40 mg daily Discharge Medications: 1. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Coreg CR 10 mg Cap, Multiphasic Release 24 hr Sig: One (1) Cap, Multiphasic Release 24 hr PO once a day. 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Home Discharge Diagnosis: Final diagnosis Lower gastrointestinal bleed Secondary diagnosis Coronary artery disease with stent placement Hypertension Discharge Condition: Good, no bleeding for 24 hours, hematocrit blood levels stable. Discharge Instructions: You were admitted for active bleeding from your lower gastrointestinal tract that was likely due to bleeding from outpouchings in your colon, called diverticula. You were admitted to the intensive care unit for closer monitoring. While in the intensive care unit, they did a wash of your stomach contents showing no bleed, did a scan of active bleeding called a tagged red blood cell scan, that also did not show active bleeding. You received one unit of red blood cells for your loss of blood. Then, you had a upper endoscopy that was normal, and a colonoscopy that showed those outpouchings in your colon that were not actively bleeding but were likely the reason for your episode of bleeding. Your blood counts were stable and you were transferred to the general medical floor, where you did not have any episodes of bleeding and your blood counts and blood pressure remained normal. We continued your aspirin and plavix during your whole hospital course as you needed those for your heart stent. Your blood pressure medication called coreg was not given in the hospital but you can continue it when you are discharged from the hospital. We made no new changes to your medications so please continue all your medications from home, including the once a day dose of protonix. Please call your physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 74442**], or return to the hospital if you have any continued bleeding from below, lightheadness, fever, chills, chest pain, palpitations, or any other worrisome symptoms. Please make an appointment to see Dr. [**Last Name (STitle) 74442**] in [**State 5887**] within 1-2 weeks of discharge from the hospital. Also, please get a referral from your primary care physician to follow up with a gastrointestinal specialist for a full screening colonoscopy. Followup Instructions: Please make an appointment to see your primary care doctor [**First Name (Titles) **] [**State 74443**], Dr. [**Last Name (STitle) 74442**], within 1-2 weeks of discharge from the hospital. ([**Telephone/Fax (1) 74444**] Also, please get a referral from your primary care physician to follow up with a gastrointestinal specialist for a full screening colonoscopy.

[ "562.12", "285.1", "530.81", "V45.82", "414.01", "401.9" ]

icd9cm

[ [ [] ] ]

[ "45.13", "45.23" ]

icd9pcs

[ [ [] ] ]

6723, 6729

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345, 443

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277, 307

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14217

Discharge summary

report

Admission Date: [**2137-6-21**] Discharge Date: [**2137-6-25**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2962**] Chief Complaint: Abnormal stress test, s/p elective cardiac catheterization Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: Patient is an 88 year old woman with no prior known CAD, history of hypertension, hypercholesterolemia, descending thoracic aortic aneurysm, who presents for elective cardiac cath. The patient was in her USOH until 3 weeks PTA when she began experiencing SOB at rest and with exertion, fatigue. She experiences these symptoms primarily first thing in the morning when she wakes up. They occur at rest and with exertion. It is not associated with CP, nausea, diaphoresis, back pain. ROS otherwise notable for lower extremity edema over past few months, occasional palpitations for past couple years. She denies any chest pain or pressure, nausea, diaphoresis, claudication, orthopnea, PND, lightheadedness, any other symptoms. . She saw her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 24717**] for outpt stress. on [**6-11**], it showed basal to mid lateral wall infarct, EF 56%, mid lateral wall hypokinesis. Therefore, sent for elective cath. . Cath done today ([**2137-6-21**]) notable for 3VD. She received BM stent to the LAD. Cath was complicated by vagal response during radial approach. She became brady and hypotensive. Atropine 1mg x2 given. Dopamine gtt started. She went into afib/flutter. DCCV x2 without effect. Amio given and dopa stopped. Neo was started then she underwent DCCV x2 again with no effect. She spontaneously converted to NSR and her bp improved. Neo weaned to off. . Currently, she complains of bilateral leg pain. no SOB, CP, abd pain, headache, difficulty with speech. . Past Medical History: -atrial fibrillation: not on coumadin, rate controlled with toprol xl, prior treatment with digoxin. -Hypertension -Hypercholesterolemia -Breast cancer s/p right mastectomy 50 years ago -descending thoracic aortic aneurysm -> 4cm on last CT scan in fall, [**2137**] -infrarenal abdominal aortic aneurysm -> 3cm -appendectomy -hysterectomy -arthritis -pectus excavatum . Cardiac Risk Factors: Dyslipidemia, Hypertension Social History: Married, social EtOH, no tobacco, no drug use. Has supportive family with husband and twin daughters. [**Name (NI) 42275**] to read books. Family History: There is no known family history of premature coronary artery disease or sudden death. Physical Exam: VS: HR 62 RR 22 BP 95/63, 99% RA Gen: pleasant, NAD, AAOx3. mood appropriate HEENT: nc at. PERRLA, EOMI, MMM, no oral lesions neck: JVP 12 cm Cards: PMI 5th ICS. reg rate rhythm, nl s1s2 no MGR chest: pectus excavatum. trace crackles at bases. no wheeze, normal effort abd: soft, midline scar, ntnd no masses. no bruit ext: dopplerable pulses bilaterally radial, dp, pt. pressure dressing to right radial. groin site covered. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: dopplerable throughout Pertinent Results: EKG precath: sinus brady. nl axis. nl intervals. TW flattening aVL. EKG postcath: NSR, nl axis, nl intervals, TW flattening aVL, biphasic P waves V1 . ETT performed on [**6-11**] date demonstrated: abnormal perfusion c/w infarct involving the basal to mid lateral wall with mild degree of peri-infarct ischemia. Low noraml left ventricular systolic function with EF 56% and hypokinesis of the lateral to mid-lateral wall. Patient exercised on a modified [**Doctor First Name **] protocol to 78% of her maximum predicted heart rate. Nuclear imaging was significant for a basal to mid lateral wall infarct with a mild degree of peri-infarct ischemia. EF 56% with basal and mid lateral wall hypokinesis. . CARDIAC CATH: LMCA: mild plaques LAD: 99% heavy calcified prox stenosis with 70% mid LAD stenosis, D2 70% stenosis LCX: TO prox with collaterals RCA: 80% ostial stenosis s/p BM stent to LAD stenosis . ECHO: The left atrium is elongated. The right atrium is markedly dilated. The estimated right atrial pressure is 16-20 mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with inferolateral akinesis and inferior hypokinesis. Overall left ventricular systolic function is moderately depressed. The right ventricular cavity is dilated. Right ventricular systolic function is normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. . Brief Hospital Course: Pt is an 88 year old woman with no prior known CAD, history of hypertension, hypercholesterolemia, descending thoracic aortic aneurysm, who presents for elective cardiac cath. Cath showed 3VD and successful stenting of the LAD with a bare metal stent. She became transiently hypotensive and brady which was c/w vagal episode. She then went into afib/flutter in the setting of dopa gtt. She spontaneously converted after amio gtt started and after 4 rounds of DCCV. . #) CAD: no prior disease despite many risk factors. Cath as above shows 3VD now s/p stent x2 to LAD. continue ASA 325, plavix 75, metop at 25 [**Hospital1 **], statin, ACEi - Follow up with outpatient cardiologist . #) Rhythm: Had both atrial fibrillation with RVR and evidence for AVNRT during admission. Currently controlled with metoporolol [**Hospital1 **] and also began Amiodarone with anticoagulation. She tolerated the medications well. Her tachycardias were not associated with hypotension on the floor. She was discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-of-Hearts monitor and follow up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of EP. . #) Pump: Mildly overloaded on exam postcath. This improved with restarted normal lasix dose. Continued [**Last Name (un) **]. Post cath echo: moderate regional left ventricular dysfunction with inferolateral akinesis and inferior hypokinesis. Mod depressed function. Will continue with low dose outpaient Lasix. . She was discharged to extended care facility who will follow her INR in conjunction with her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 42276**]. She will follow up with EP here for her supraventricular tachycardias. Medications on Admission: ALLERGIES: NKDA . CURRENT MEDICATIONS: Hyzaar 50mg/12.5mg 1 pill daily Metroprolol XL 50mg 1 tablet daily Lasix 20mg 1 tablet daily Zetia 10mg daily in the PM Prednisone 5mg daily Aspirin 81mg daily Vitamin D 400 IU daily Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 3. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 days: Last Dose [**2137-6-28**]. 8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day for 1 weeks: Begin 200mg [**Hospital1 **] on [**2137-6-29**] and continue for 1 week. . 9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: Begin 200mg QDAY dosing on [**2137-7-6**] and continue indefinitely. 10. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) UNITS Injection TID (3 times a day). 11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 17. Outpatient Lab Work INR check [**2-16**] x weekly until INR therapeutic and stable Discharge Disposition: Extended Care Facility: watch [**Doctor Last Name **] care and rehab Discharge Diagnosis: 3 Vessel Coronary Artery Disease . atrial fibrillation Hypertension Hypercholesterolemia Breast cancer s/p right mastectomy 50 years ago descending thoracic aortic aneurysm -> 4cm on last CT scan in fall, [**2137**] infrarenal abdominal aortic aneurysm -> 3cm arthritis Discharge Condition: Ambulatory with assist, needs rehab. Discharge Instructions: You were admitted for a cardiac catheterization. The catheterization showed 3 vessel coronary artery disease. It was felt that stenting the Left Main would help provide some relief of your shortness of breath. During the procedure a cardiac arrhythmia was diagnosed, Atrial Fibrillation, which will require the use of a blood thinning medication, Coumadin. You will need your INR, or blood thinning level checked frequently by your doctors when [**Name5 (PTitle) **] leave the hospital. You were also started on an anti-arhythmic medication Amiodarone, to help keep your heart from going into atrial fibrillation. You will also be discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-of-Hearts heart monitor who's transmisions will be sent to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 42277**] office, with whom you have an appointment with on [**7-15**]. . Please attend all follow up appointments. Please take all medications as prescribed. IF you develop further chest pain, shortness of breath, or any signs of bleeding problems, please contact your health care proivders right away. Followup Instructions: Please have the rehab facility contact Dr.[**Name (NI) 24769**] office to set up outpatient INR checks and a follow up appointment. . Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2137-7-15**] 10:20 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2964**] MD, [**MD Number(3) 2965**]

[ "441.2", "427.31", "401.9", "427.89", "458.29", "414.01", "427.32", "V10.3", "441.4", "272.0", "428.0" ]

icd9cm

[ [ [] ] ]

[ "00.66", "88.56", "36.06", "00.46", "37.78", "99.20", "37.22", "00.40" ]

icd9pcs

[ [ [] ] ]

8441, 8512

4891, 6635

321, 346

8827, 8865

3149, 4868

10051, 10492

2509, 2597

6908, 8418

8533, 8806

6661, 6679

8889, 10028

2612, 3130

223, 283

6700, 6885

374, 1894

1916, 2337

2353, 2493

5,760

169,133

22009

Discharge summary

report

Admission Date: [**2108-12-29**] Discharge Date: [**2109-1-22**] Date of Birth: [**2056-10-18**] Sex: F Service: MEDICINE Allergies: Zosyn / Meropenem Attending:[**First Name3 (LF) 783**] Chief Complaint: Fever, abd pain Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 52 year old woman who originally presented to the [**Hospital6 6689**] Hospital in [**Month (only) **]. Her original complaints were abdominal pain, nausea, vomiting, anorexia and jaundice. She was admitted to the Intensive Care Unit at [**Hospital1 **] and noted to have an enterococcal urinary tract infection as well as enterococcal bacteremia. She did receive intravenous antibiotics, however her blood cultures remained positive. At the outside hospital she also required pressor treatment to maintain adequate blood pressure. She was transferred to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] on [**10-31**]. Here, she had an extensive liver work up that included a paracentesis on [**11-5**], liver biopsy on [**11-8**], endoscopy and colonoscopy on [**11-9**] and [**11-21**] respectively for persistent fevers, mental status change and questionable liver lesions. Her hepatic workup was consistent with non-alcoholic/alcoholic hepatitis. Following the colonoscopy she developed sharp abdominal pain and a CAT scan was obtained which showed retroperitoneal air presumably from a perforated left colon during the colonoscopy. She was taken to the operating Room by Dr. [**Last Name (STitle) **], Dr. [**First Name (STitle) 2819**] and was transferred to the surgical service. She underwent an exploratory laparotomy, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3379**] pouch and transverse colostomy. In addition a gastrostomy/ jejunostomy tube was placed. A wedge resection biopsy of the liver was also performed and an incidental jejunal mass was resected. Interestingly the jejunal mass was a heterotopic rest of pancreatic tissue. Mrs.[**Known lastname 57606**] postoperative course was complicated by multiple infections. She developed another episode of bacteremia which seeded her central line. Her course was notable for enterococcus bactermia in blood culture bottles. In addition she developed cellulitis surrounding the entry site of her GJ tube. She has a large abdominal wound which has been being treated by a vac dressing for a large mid abdominal wound. Also, there was concern for allergic reaction to meropenim and zosyn causing a blistering skin rash. She has had a persistent sinus tachycardia with unknown etiology despite extensive workup which was treated with lopressor. She went to the [**Hospital 57609**] rehab on [**2108-12-24**]. She was transfused 2 units pRBCs for a hct of 25 and received lasix. She also had an elevated TSH and her levoxyl dose was increased to 150. She decannulated her trach [**12-25**] and they were unable to replace and her respiratory status stable so left her decanulated. She was noted to have fever to 100.3, increasing leukocytosis to 24,000 and abdominal pain. Thus, she was transferred back to [**Hospital1 18**] for workup of her fevers. Past Medical History: Endometriosis, hypothyroidism. Left adrenal mass, gallstones 2.s/p ex lap, [**Doctor Last Name 3379**] pouch with left colonic resection and colostomy, jejeunal resection Social History: Lives in W Mass withhusband of 13 years. 10 year h/o smoking. College educated. Engineer. Family History: 2 sisters with hypothyroidism. Mother with DM and liver dx Physical Exam: Gen:Lethargic, confused , lying in bed Vitals: 101.4, 120, 108/60, 26 HEENT:NCAT. Sclera anicteric. Neck supple, No OP lesions CV:RRR nL S1S2. No MRG R TLC in place Pulm:CTA ant. Abd:Obese, soft, diffusely tender, colostomy bag in place Ext:[**2-14**]+ LE edema Derm:Diffuse erythematous rash on upper and lower body. Neuro:Alert to hospital(St Es), [**2108-12-12**], lethargic, doesn;t answer appropriately. Pertinent Results: [**2108-12-28**] 01:45PM BLOOD WBC-21.5* RBC-3.22* Hgb-9.7* Hct-30.0* MCV-93 MCH-30.0 MCHC-32.2 RDW-16.9* Plt Ct-257 [**2108-12-28**] 01:45PM BLOOD Neuts-76* Bands-5 Lymphs-10* Monos-3 Eos-1 Baso-0 Atyps-1* Metas-3* Myelos-1* [**2108-12-28**] 01:45PM BLOOD Plt Smr-NORMAL Plt Ct-257 [**2108-12-28**] 01:45PM BLOOD PT-14.4* PTT-37.0* INR(PT)-1.3 [**2108-12-28**] 01:45PM BLOOD Glucose-68* UreaN-19 Creat-0.6 Na-139 K-4.9 Cl-106 HCO3-25 AnGap-13 [**2108-12-28**] 01:45PM BLOOD ALT-15 AST-40 AlkPhos-427* Amylase-159* TotBili-1.1 [**2108-12-28**] 01:45PM BLOOD Lipase-443* [**2108-12-28**] 01:45PM BLOOD Calcium-8.2* Phos-3.3 Mg-1.6 [**2108-12-29**] 11:10AM BLOOD Albumin-1.9* Calcium-7.7* Phos-4.5 Mg-1.4* [**2108-12-31**] 10:15PM BLOOD VitB12-601 Folate-7.9 [**2108-12-28**] 01:45PM BLOOD Ammonia-31 [**2108-12-31**] 10:15PM BLOOD TSH-17* [**2108-12-29**] 11:10AM BLOOD T3-89 Free T4-0.9* [**2108-12-29**] 06:46PM BLOOD freeCa-1.04* [**2108-12-28**] 01:45PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.030 [**2108-12-28**] 01:45PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-40 Bilirub-SM Urobiln-0.2 pH-8.5* Leuks-NEG [**2108-12-28**] 01:45PM URINE RBC-0 WBC-0 Bacteri-RARE Yeast-NONE Epi-0 ---- Urine cx neg, blood cxs neg. C diff neg x4. Stool cx neg. ---- Abd CT [**12-28**]:IMPRESSION: 1) No focal fluid collections or bowel pathology appreciated. Overall marked improvement in amount of free abdominal fluid and anasarca since the previous exam. 2) Small bilateral pleural effusions, left greater than right. The right- sided effusion has decreased in size since the previous exam. 3) Stable known left adrenal adenoma. ---- CXR [**12-28**]:IMPRESSION: Moderate-size left pleural effusion ---- RUQ U/S [**12-29**]:IMPRESSION: No evidence of gallstones or cholecystitis ---- Head CT [**1-1**]:FINDINGS: There is no evidence of mass effect or hemorrhage. There is no displacement of normally midline structures. The ventricles and sulci are not remarkable. Grey and white matter are not unusual. There is no evidence of a focal extra-axial lesion or fluid collection. The visualized portions of the paranasal sinuses are clear. -------- IN-111 WHITE BLOOD CELL STUDY [**2109-1-15**] Following the injection of autologous white blood cells labeled with Indium-111, images of the whole body and lateral images of the abdomen obtained at 22 hours. These images show a focal area of tracer uptake in the left mid abdomen which likely represents the patient's colonic stoma. No other areas of focal abnormal uptake are identified. IMPRESSION: No abnormal areas of focal tracer uptake to suggest a focal infectious process. ---- ECG Study Date of [**2109-1-11**] 9:18:22 AM Sinus tachycardia. Since the previous tracing of [**2109-1-10**] no significant change. ---- CTA CHEST W&W/O C &RECONS [**2109-1-11**] 11:49 AM IMPRESSION 1. No large pulmonary embolus. 2. Interval improvement of the pleural effusion and improved aeration of the left lung. 3. Stable known left adrenal adenoma. 4. Small infected collection along the left flank. This collection is too small to be drained at the current time. 5. Right thyroid nodule. ---- [**2109-1-10**] [**-4/5000**] PLEURAL FLUID NEGATIVE FOR MALIGNANT CELLS. Reactive mesothelial cells and abundant lymphocytes. ----- ECHO Study Date of [**2109-1-8**] The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. ---- CT CHEST W/CONTRAST [**2109-1-8**] 9:30 AM IMPRESSION: 1) Moderate-sized left pleural effusion which has increased in size slightly since the prior CT of the abdomen dated [**12-28**]. Adjacent pulmonary opacity with intense, homogeneous enhancement most likely represents atelectasis. Trace right pleural effusion with atelectatic changes of the right lower lobe. 2) Stable appearance of 3 cm left adrenal adenoma. 3) 5 mm right middle lobe noncalcified pulmonary nodule, unchanged since the prior study. A three month follow up CT examination is recommended to ensure stability. ------------ MR HEAD W & W/O CONTRAST [**2109-1-6**] 9:57 AM IMPRESSION 1. New tiny area of abnormal low signal on the gradient echo images in the right frontal lobe, suggestive of blood products in this region of undetermination. 2. No acute territorial infarct seen within the brain. 3. No change in the scattered periventricular T2 hyperintensities suggestive of vascular chronic ischemic changes. 4. Fluid and/or mucosal thickening involving both mastoid air cells, the right maxillary, and the right sphenoid sinuses. The finding in the left mastoid air cells is new compared to the prior study. ------- Cytology Report SPINAL FLUID Study Date of [**2109-1-1**] NEGATIVE FOR MALIGNANT CELLS. Rare lymphocytes and monocytes present. ------ CT HEAD W/ & W/O CONTRAST [**2109-1-1**] 11:58 AM FINDINGS: There is no evidence of mass effect or hemorrhage. There is no displacement of normally midline structures. The ventricles and sulci are not remarkable. Grey and white matter are not unusual. There is no evidence of a focal extra-axial lesion or fluid collection. The visualized portions of the paranasal sinuses are clear. IMPRESSION: Negative study. LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2108-12-29**] 8:23 AM FINDINGS: The visualized portions of the liver are unremarkable. The gallbladder is unremarkable without evidence of stones. The common bile duct is not dilated. IMPRESSION: No evidence of gallstones or cholecystitis. ----- CHEST (PORTABLE AP) [**2108-12-29**] 10:49 AM FINDINGS: Examination is limited due to difficulty with patient's positioning. There has been interval placement of right IJ central venous catheter which terminates within the distal SVC. There is no pneumothorax. Cardiac and mediastinal contours appear grossly stable. There is an increased left retrocardiac density, consistent with atelectasis/effusion. IMPRESSION: Right IJ tip in distal SVC; no pneumothorax. ----- ABDOMEN (SUPINE & ERECT) [**2108-12-28**] 2:28 PM IMPRESSION 1. Nonspecific bowel-gas pattern with a few air-fluid levels, for which obstruction cannot entirely be excluded. No evidence for free air. ---- CT ABDOMEN W/CONTRAST [**2108-12-28**] 7:33 PM IMPRESSION: 1) No focal fluid collections or bowel pathology appreciated. Overall marked improvement in amount of free abdominal fluid and anasarca since the previous exam. 2) Small bilateral pleural effusions, left greater than right. The right- sided effusion has decreased in size since the previous exam. 3) Stable known left adrenal adenoma. Brief Hospital Course: 1. Fevers/leukocytosis/hypotension. Patient with multiple sources of possible infection initially. Blood and urine cultures all neg. Stool cxs neg. C diff neg x4. Following studies all wnL - [**12-29**] Liver ultrasound: No evidence of gallstones or cholecystitis. - [**12-28**] Abdominal CT: No focal fluid collections or bowel pathology. - [**12-28**] KUB: Nonspecific bowel-gas pattern - [**12-28**] CXR: Moderate-size left pleural effusion. Surgery evaluated her abdominal VAC dressing and felt no acute surgical issues She was initially empirically covered with broad spectrum antibiotics vanco/levo/clindamycin. The clinda was changed to flagyl in the MICU. However, no evidence of source was found. She did defervese on this regimen and her WBC trended down. ID was consulted for recs in treatment length, and they recommended continuing empiric levo and clinda for 10 days more. They then recommended changing this to levo/flagyl. HIV, SPEP, UPEP and PPD were negative. However, she did continue to have low-grade fevers on antibiotics and thus, antibiotics were discontinued on [**2109-1-9**] as there was no clear source that we were treating at the time. Her WBC continued to trend down. She did have a moderately sized left pleural effusion and this was tapped on [**2109-1-9**]. The pleural fluid did not show an impressive empyema, however, she did grew out levoquin-resistant Enterobacter in the pleural fluid. Therefore, we treated her for an enterobacterial empyema with Cefipime 2 gm IV Q12 which was started on [**2109-1-14**] and ID was asked to re-evaluate the patient to help us determine if the patient's lung infection was a primary source or if indeed, the patient was seeding from an other infected source. In addition, we obtained a tagged WBC scan to help us determine if there was an alternate source of infection. The tagged WBC scan showed no other source of infection and ID felt that this could either be secondary to her perforated bowel history or aspiration pneumonia. The recommended course for antibiotics is 2 weeks and a PICC was placed. Once the 2 week course has been completed, the patient should follow up with ID at [**Hospital1 18**] to re-assess the patient. 2. Hypotension: The patient received fluid in the ED (7 liters) and was shortly on levophed. Once her BP was stable in the MICU, she was sent to the floor and remained normotensive from 100-120s. Metoprolol 25 mg [**Hospital1 **] was started given the patient's unexplained but extensively worked up tachycardia. 3. Endocrine: Her synthroid was recently increased on [**12-26**] while at rehab given her elevated TSH to 150 mcg which was continued. She had a random cortisol checked which was normal in the setting of hypotension and an adrenal adenoma which appears stable. She appears to be subclinically hypothyroid but given her tachycardia and active infection, her Synthroid was not increased further at this time. 4. Dermatology: The patient initially presented with an erythematous rash on her trunk, lower and upper extremities. Dermatology felt it to be a drug rash probably due to meropenem. The rash resolved with the cessation of the drug. 6. Neuro: The patient has had an altered mental status since admission to [**Hospital **] Med center 3 months ago. She has a very odd thought pattern, with amnesias and very strange conversations. She does not wax and wane and therefore, we do not believe her mental status is delirium. Psychiatry was consulted, however, and believed she does have delirium. Neurology was consulted and believes that she possibly has Korsakoff's syndrome and thiamine, folate and B12 were initiated without any clinical improvement. Her thiamine level was noted to be low at the outside hospital. She had an extensive workup for structural/anatomical causes, toxic-metabolic causes, infection none of which provided a clear answer. Work-up included head CT, MRI, LP, multiple blood and urine cultures, cortisol and TSH. Per neuro, if truly Korsakoff's, may not improve despite thiamine replacement. Of note, the patient was able to read a book towards the end of her hospital stay, she is oriented x 3 and is witty. Her conversations although odd, appear to have a true basis to them and she appears to feed off of her environment. For example, on a floor with many pregnant nurses, the patient believed for a while that she, too, was pregnant. The patient apparently has tried to become pregnant in the past unsuccessfully. She has considered adoption but has no adopted children. With the recent tsunami in Southeast [**Female First Name (un) 8489**], she then believed that she had just been to Southeast [**Female First Name (un) 8489**] and picked up a "bug" from there. When told that none of her delusions were true, she accepted that and was aware that her stories were strange. She also had a delusion that she had bamboo tampons. Interestingly, the patient was found on a prior MRI to have blood products in the right posterior portion of her frontal lobe. This may explain her intact cognition and ability to converse but faulty thought processes, as illustrated on a mini-mental exam. However, these products were not visualized until months after her symptoms began and thus, it is unlikely the explanation for her symptoms. Neurology agreed. 7.FEN: She was continued on tube feeds once her abdominal pain resolved. She tolerated tube feeds without difficulty. Her albumin was low and nutrition was consulted for nutritional assessment. She had a speech and swallow eval and did well. They recommended soft solids and thin liquids which she was started on. She tolerated a PO diet without difficulty and her tube feeds were discontinued temporarily. However, she failed to meet her total nutritional needs and therefore, tube feeds were restarted and cycled overnight so as to encourage PO intake during the day. 7. Dressings: VAC dressing changed by surgery q3 days while she was here initially. They followed this closely. On [**2109-1-17**], hepatobiliary surgery assessed the patient's wounds and considered them to be stable. They recommended continued VAC, and once the wound flattens, to change to wet-to-dry dressings. The patient should follow up with Dr. [**Last Name (STitle) **] in [**3-15**] weeks. 8. Hypercalcemia - The patient developed unexplained hypercalcemia on the last 2 days of her admission. It is recommended that a PTH and Vitamin D level be checked at rehab. Medications on Admission: Duragesic 75 mcg Metoprolol 25 [**Hospital1 **] levoxyl 112 mcg protonix 40 sq hep reglan 10 q6h ativan 1 mg [**Hospital1 **] nystatin powder combivent prn neurontin 300 tid Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Enterobacter empyema Mental status changes/delirium Endometriosis Hypothyroidism Hypercalcemia Sinus tachycardia Discharge Condition: Stable. Alert and oriented x 3 with occasional strange delusions. Afebrile with mildly diffuse abdominal pain likely secondary to extensive surgical history, no acute issues. Has a left-flank small collection of fluid which is decreasing and likely post-operative. Discharge Instructions: Please tell the doctors at the rehab facility if you have any chest pain, shortness of breath, dizziness, lightheadedness, fevers, or chills. Also tell them if you are having increased nausea, vomiting, or abdominal pain. Last day of cefipime 2gm IV is [**1-29**] for a total of a 2 week course. Please check calcium and vitamin D while the patient is at rehab as the patient was noted to be hypercalcemic upon discharge. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **], your surgeon, in [**3-15**] weeks. Please call ([**Telephone/Fax (1) 2363**] to schedule an appointment. The patient had a noted right thyroid nodule on CT scan. This should be followed up on as an outpatient. The patient had unexplained hypercalcemia prior to discharge. Please check PTH and vitamin D levels at rehab. Please call ([**Telephone/Fax (1) 4170**] to schedule an appointment with your infectious disease doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23**], in 2 weeks after you have completed your antibiotic course to have a repeat CT scan to look for further indolent infection. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

[ "244.9", "693.0", "275.42", "510.9", "427.89", "263.9", "285.9", "780.09", "511.9" ]

icd9cm

[ [ [] ] ]

[ "96.6", "38.93", "03.31", "34.91" ]

icd9pcs

[ [ [] ] ]

17816, 17886

11124, 17591

295, 301

18043, 18309

4075, 11101

18782, 19594

3571, 3631

17907, 18022

17617, 17793

18333, 18759

3646, 4056

240, 257

329, 3254

3276, 3448

3464, 3555

26,241

195,908

12367

Discharge summary

report

Admission Date: [**2190-1-29**] Discharge Date: [**2190-2-27**] Date of Birth: [**2141-12-17**] Sex: F Service: Medicine HISTORY OF PRESENT ILLNESS: The patient was 47-year-old female Jehovah Witness initially brought to the Intensive Care Unit after transfer from [**Hospital3 **] Hospital for increasing bilirubinemia with multiple complex medical problems including systemic lupus erythematosus, antiphospholipid syndrome, multiple deep venous thromboses, cerebrovascular accident, and pulmonary embolism, no filter, end-stage renal disease (on hemodialysis since [**2187**]), and hypertension; who, while in the hospital, had progressive cholestatic liver disease, decreasing platelets, decreasing hematocrit, and refusing blood products; on hemodialysis, on broad spectrum antibiotics, and high-dose Epogen. HOSPITAL COURSE: The cause of the cholestatic liver disease was unclear due to not being able to perform a liver biopsy or endoscopic retrograde cholangiopancreatography from low platelets and low hematocrit. During hospital stay, Hematology, Infectious Disease, and Gastrointestinal consultations were all following. The patient could not receive any alternative products for blood or platelets. On [**2190-2-27**], [**Hospital6 733**] house staff cross-coverage was called to evaluate the unresponsive patient. The patient was not responsive to verbal name call. She did not respond to sternal rub. Her eyes were fixed and widely mid dilated, and unresponsive to light. The patient did not have heart or lung sounds, nor pulse, after evaluation for approximately two minutes. She did not have any deep tendon reflexes. She did not respond to second noxious stimuli. The family, particularly the husband, was comforted. The attending physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) **], was notified. An autopsy was declined by the family. The patient was pronounced dead at 12:30 a.m. on [**2190-2-27**]. [**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 34724**] Dictated By:[**Last Name (NamePattern1) 1183**] MEDQUIST36 D: [**2190-4-7**] 10:41 T: [**2190-4-7**] 10:44 JOB#: [**Job Number 38525**]

[ "459.0", "582.81", "285.21", "795.79", "573.8", "710.0", "789.5", "287.5", "585" ]

icd9cm

[ [ [] ] ]

[ "96.6", "39.95", "99.15" ]

icd9pcs

[ [ [] ] ]

850, 2254

167, 832

22,851

134,823

43082

Discharge summary

report

Admission Date: [**2113-9-19**] Discharge Date: [**2113-9-21**] Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 99**] Chief Complaint: Reason for Transfer: Sepsis CHIEF COMPLAINT: Diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is a 84 year old female transferred from [**Hospital1 112**] on the day of admission after presenting to their ED with vomiting and poor po intake for 2 days. She also complained abdominal pain with associated diarrhea. Per patient and family, she had been vomiting for 2 day, which was clear, nonbloody and occasionally resemble what she ait. She thinks this is [**3-4**] cabbage ingestion. The day of admission, she had [**2-1**] bowel of cereal and toast, which she immedicately vomited. She confirms hunger. Also with loose stool for two days, but only one BM daily. No BRBPR, no melena. She's felt warm, but states this is baseline and has not taken her temperature. Did have a insect bite 2 days ago, that developed a pustule that has since resolved. Has had cough for several weeks, minimally productive. Son confirms intermittent aspiration of fluids. No family members with illness, no renct travel, unclean water sources or eating raw meat. No recent antibiotics. Generally has one BM daily. No history of bowel obstruction though is s/p appy and ccy. No pain currently. Family states FS usually run 120-170, but were 300 this morning. . She was given 500cc NS and IV zofran. UA was reportedly negative though not in the BICS system on sign-out. Did have mild cough that was not productive. . Review of systems is positive for recent nausea, cough that started approx 2 week ago. Additionally she has had orthopnea and constipation at baseline. Her cough is mild and without phlegm. She has vomited a few times in the last few days. Negative for dizziness, syncope, presyncope, disorientation, hematuria, fever, chills, dysuria, sorethroat or palpitations. Reporst SOB that is improved with SL NTG at home. Past Medical History: 1. CAD s/p MI in '[**03**] 2. CHF with EF of 20-25%, severe global HK 3. DMII Insulin dependent 4. HTN 5. Hypercholesterolemia 6. PVD 7. PAF ?post op? not on anticoagulation 8. Anemia (Fe deficiency per report) 9. h/o CVA [**15**]. h/o cataracts 11. h/o fatty liver 12. s/p CCY 13. s/p ureteroscopy with stent '[**02**] 14. s/p appy 15. Nephrolithiasis . PAST SURGICAL HISTORY: 1. Cholecystectomy, remote. 2. Right ureteral stenting 3. Appendectomy, remote. 4. Bilateral cataract surgeries, remote. 5. Right axillary bifemoral bypass on [**2108-3-27**]. 6. Left AKA Social History: Social History: Tobacco: 1ppd x many years quit [**2093**] EtOH: Used to drink heavily, has quit for over 25+ years Illicit drugs: None . Family History: Family History: Diabetes in son, mother had TB Physical Exam: Physical Exam: VS 97.1, 170/80, 86, 18, 96/RA Gen - Elderly woman, mildly diaphoretic, appears fatigued, in no acute distress HEENT - OP clear, mmm, arcus senilis, pupils reactive but somewhat sluggish Neck: no thyromegaly, JVP approx 8-10 cm CV - regular rate, rhythm, soft systolic murmur at LLSB Lungs - occasional crackles at bases, poor air movement Abd - soft, nt, nd, + bs Back - no tenderness Ext - RLE no edema, no statis dermatitis Neuro - intact sensation RLE Skin - no rashes Pertinent Results: Per [**Hospital1 112**] [**2113-9-19**] records WBC 20.25, 87% PMN, 7% Lymp HCT 48.8 Platelets 300 . Na 142 BUN 45 Cr. 1.87 (baseline 0.9) Potassium 3.8 Chloride 100 Bicarbonate 25 gap 17 AST 52 ALT 66 AlkP 93 TB 1.9 Total protein 9.9 albumin 4.0 calcium 10.2 . EKG obtainted with SR, HR 90, mild LAD, LVH, old TWI AVL/I, STE V1-V4, and STD V5-V6. Similar to prior but more exagerated since [**2113-5-16**]. . TTE (Complete) Done [**2113-5-17**] at 3:08:38 PM FINAL The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. The right atrial pressure is indeterminate. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. There is severe global left ventricular hypokinesis (LVEF = 15-20 %). No masses or thrombi are seen in the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. The right ventricular cavity is dilated with depressed free wall contractility. The aortic valve leaflets (3) are thickened and mild AS is suggested (difficult to assess due to low cardiac output). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. ************ Compared with the prior study (images reviewed) of [**2111-4-20**], the overall LVEF appears lower. The severity of valvular regurgitation has increased. Brief Hospital Course: #. Sepsis/Shock: Patient was initially admitted to the floor with nausea/vomiting initially thought [**3-4**] viral gatroenteritis given acute onset and associated fever, mild abdominal cramping. However, patient became hypoxic and hypotensive with a lactate of 8 that increased over her stay and met severe sepsis criteria on basis of elevated WBCs, tachypnea, and HR >90 with suspected infection in abdomen. A CT abd/pelvis revealed thrombus in her aorta, renal infarcts, and bowel inflammation consistent with ischemia. Over her MICU course her labs indicated both shock liver and increasing ischemic bowel. She was bolused with NS (several liters) and unasyn/flagyl for antibiotic coverage of bowel flora. However, the lactate increased and her blood pressure decreased indicating progression of her shock. Surgery was consulted but felt the patient would not survive an operation on the bowel. Over the next two days the patient became increasingly hypotensive despite fluid boluses. A discussion with the family indicated that they would not like to pursue aggressive measures. The patient was kept comfortable with IV morphine and passed away at 1:10pm on [**2113-9-21**]. . # Transaminitis: Likely from shock liver. No sign of a gross infarct on CT, but small infarct could be contributing. Cholangitis also a concern, although Alk P not very high so less likely. Of note, patient with previous CCY. Treated with fluid resuscitation. . # ARF: Liklely from renal infarction. Shock/dehydration could have also contributed. UA negative. . # Metabolic acidosis: Likely due to lactic acidosis in the setting of showering clots causing infarction, and hypotension. Renal failure could also be contributing. Treated with fluid resuscitation. . # Coagulopathy: PT and INR became elevated, in addition to elevated PTT expect given heparin tx. Thought to likely represent DIC. Could also be affected by the high dose heparin. FFP was considered but never needed. . #. SOB: Patient with acute SOB on arrival to medical floor. ECG was unremarkable, cardiology consulted, cardiac enzymes cycled. SOB was likely from fluid boluses. Improved transiently until became acutely tachypnic and tachycardic with evolving shock. Was treated with IV morphine PRN to keep patient comfortable. . # Pump: EF 15-20% on last Echo in 4/[**2113**]. Thought that shock was likely being exacerbated by low EF and low cardiac output, monitored oxygenation with fluid resuscitation however patient never became hypoxemic and did not require lasix. . # Rhythm: Sinus rhythm on admission. Electrolytes were monitored. . # Diabetes: Patient with elevated glucose on arrival, no ketones in urine. Insulin gtt for [**Year (4 digits) **] glucose < 150 continued for duration of stay. . # Hypertension: Antihypertensive were held given shock. Medications on Admission: Medications upon Admission 1. Digoxin 125 mcg DAILY 2. Furosemide 60 mg PO DAILY - hold for now given diarrhea 3. Aspirin 81 mg Tablet PO once a day. 4. Metoprolol Succinate 75 mg PO DAILY 5. Rosuvastatin 10 mg PO DAILY 6. Isosorbide Mononitrate 30 mg Tablet PO DAILY 7. Lisinopril 12.5 mg PO DAILY 8. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: as directed units Subcutaneous twice a day: Take 23 units every morning and 7 units at dinner time. 9. Pantoprazole 20 mg Tablet daily 10. Spironolactone 25mg daily 11. Nitroglycerin 0.3 mg Tablet PRN as needed for chest pain / SOB 12. Humalog 100 unit/mL Solution Sig: as directed units Subcutaneous four times a day: Please follow sliding scale. Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Peripheral vascular disease leading to aortic thrombus leading to ischemic bowel leading to septic shock leading to cardiopulmonary arrest Discharge Condition: Death Discharge Instructions: None. Followup Instructions: None. Completed by:[**2113-9-21**]

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icd9cm

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Discharge summary

report

Admission Date: [**2114-10-7**] Discharge Date: [**2114-10-11**] Date of Birth: [**2048-10-3**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (un) 11220**] Chief Complaint: Overdose Major Surgical or Invasive Procedure: [**2114-10-7**] placement right internal jugular central line [**2114-10-7**] endotrachial intubation History of Present Illness: 67F w/ hx suicide attempts transferred from [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] to [**Hospital1 18**] w/ polysubstance overdose. Patient was found lethargic w/ multiple medication bottles (most recently filled trazadone and cyclobenzaprine). At [**Name (NI) **] pt was initially given Narcan but shortly thereafter became progressively more bradycardic and hypotensive with pulse dropping into the 30s and systolic blood pressure dropping into the 60s; responded to 1 mg of atropine and fluid bolus with return of pulse 90 and systolic of 115. Patient also given amp of calcium, and 1 mg of IV glucagon, as the nature of her ingestion was unknown and could involve antihypertensives. Given all the above, the patient was intubated with the Glidescope using 75 mg of succinylcholine and a #6 ET tube. Given the hemodynamic nature of this patient's overdose and the unknown complexity of her ingestion she was transferred to [**Hospital1 18**]. Head CT at [**Hospital1 **] reportedly normal. On arrival in [**Hospital1 18**] ED patient was intubated and sedated. She became briefly hypotensive during her initial ED course however this was thought due to a spurious blood pressure cuff [**Location (un) 1131**]. She received 1 dose of some narcan which didn't do much. She was seen by tox in the ED who thought OD was multifactorial, but suggested a beta blocker component given bradycardia/hypotension. GCS of 5 on transfer from the ED. Exam notable for normal tone no clonus. Pupils 3mm and reactive. Mucous membranes moist. CXR unremarkable. Of note pt recently admitted to [**Hospital3 4107**] and discharged on [**10-5**] with e.coli UTI with sepsis. VS on arrival to the ED: T97 P88 119/73 R17. Pt received 2 boluses of IV glucagon and a right IJ was placed for access VS on tx 36.7 81 73/40 18 100% Review of systems: unable to obtain Past Medical History: 1. Depression. 2. Congestive heart failure. 3. Coronary disease with ischemic cardiomyopathy and EF of 25%. 4. Chronic pain related to generalized osteoarthritis, degenerative disk disease. 5. Hyperlipidemia. 6. Hypertension. 7. GERD. 8. Long-term tobacco use. 9. Osteoarthritis with chronic pain as noted. 10. Pulmonary embolus [**13**]. Spontaneous pneumothorax Social History: (Obtained from OMR, confirmed after patient was extubated). Patient is married, lives with husband and daughter. Currently in rehab. Family stress due to death of her son from heroin overdose. Also has daughter w/ current substance abuse problems. [**Name (NI) **] a 60 pack year history and currently smokes about two pack per day, but has plans to quit. Family History: (Obtained from OMR, confirmed after patient was extubated). Mother had CHF, died from [**Name (NI) 11964**] at age 80. Father died from lung cancer. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 100.4 94 96/49 65 22 98% General: intubated and sedated, cachectic appearing HEENT: intubated, sclera anicteric Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation anteriorly Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: sedated, opens eyes and follows commands. no clonus Labs: see below DISCHARGE PHYSICAL EXAM VS: 97.6 100/50 60 18 97%RA Gen: well-appearing female in pajamas, eating breakfast HEENT: NCAT, MMM, anicteric sclera, EOMI Neck: Supple without LAD Pulm: CTA b/l without wheeze or rhonchi Cor: RRR (+)S1/S2 no m/r/g Abd: Soft, non-distended, non-tender to palpation, NABS LE: No edema, warm and well-perfused Psych: Limited affect, "fine" mood, denying SI/HI Pertinent Results: ADMISSION LABS: [**2114-10-7**] 10:34PM BLOOD WBC-8.5 RBC-4.52 Hgb-14.7 Hct-45.4 MCV-100* MCH-32.5* MCHC-32.3 RDW-13.8 Plt Ct-392 [**2114-10-7**] 10:34PM BLOOD Neuts-65 Bands-0 Lymphs-16* Monos-7 Eos-5* Baso-0 Atyps-6* Metas-1* Myelos-0 [**2114-10-8**] 12:00AM BLOOD PT-9.3* PTT-29.9 INR(PT)-0.9 [**2114-10-8**] 03:37AM BLOOD Fibrino-252 [**2114-10-7**] 10:34PM BLOOD Glucose-101* UreaN-10 Creat-0.6 Na-138 K-4.0 Cl-101 HCO3-27 AnGap-14 [**2114-10-7**] 10:34PM BLOOD ALT-31 AST-42* CK(CPK)-52 AlkPhos-85 TotBili-0.3 [**2114-10-7**] 10:34PM BLOOD Lipase-44 [**2114-10-7**] 10:34PM BLOOD cTropnT-<0.01 [**2114-10-8**] 03:37AM BLOOD CK-MB-4 cTropnT-0.04* [**2114-10-8**] 09:43AM BLOOD CK-MB-4 cTropnT-0.01 [**2114-10-7**] 10:34PM BLOOD Albumin-4.3 Calcium-10.0 Phos-5.7* Mg-1.9 [**2114-10-7**] 10:34PM BLOOD Osmolal-283 [**2114-10-7**] 10:34PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2114-10-8**] 12:46AM BLOOD Lactate-1.0 [**2114-10-8**] 12:00AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.003 [**2114-10-8**] 12:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2114-10-8**] 12:00AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG MICROBIOLOGY ============ MRSA SCREEN (Final [**2114-10-9**]): No MRSA isolated. Respiratory culture **FINAL REPORT [**2114-10-10**]** GRAM STAIN (Final [**2114-10-8**]): <10 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [**2114-10-10**]): SPARSE GROWTH Commensal Respiratory Flora. Blood culture **FINAL REPORT [**2114-10-14**]** Blood Culture, Routine (Final [**2114-10-14**]): NO GROWTH. IMAGING: ============== [**2114-10-8**] CXR: The patient is tilted towards the left. A new right jugular line ends in mid SVC, ET tube ends 7.2 cm above carina. NG tube is in the stomach. Left lower lobe atelectasis is unchanged. Changes related to severe emphysema is stable with high lung volumes and upper lobe oligemia. An electronic device is seen overlying the left upper lobe. CONCLUSION: New right-sided jugular line is in adequate position. There is no complication. Brief Hospital Course: Ms. [**Known lastname 53899**] is a 66 year old F with history of depression and suicide attempts who presented after her family found her overdosed at home. She was obtunded and bradycardic, hypotensive. She admitted suicidal attempt when she was extubated later and did not remember the medications she took, but said there were at least 3 different kinds. # Toxicology: Initial bradycardia and hypoglycemia were suggestive of beta blocker component to overdose. However, uncertain surrounding actual substances, likely included clopidogrel. Her QT interval was monitored with telemetry and serial EKGs. Acetaminophen and aspirin were both negative on serum toxicology. # Depression with Suicidal attempt via overdose with polysubstances: Medically managed as below. Seen by psychiatry who recommended that she go to an inpatient psych facility. All her psych meds were held because of their sedating effects initially. Also, psych consult agreed that none of her issues were acute and needed medication immediately. She was kept on a 1:1 observation for suicidal actions. # Respiratory failure due to altered mental status (AMS): Patient was inbutated at [**Hospital3 **] prior to transfer. AMS most likely related to intoxication, though the exact ingestion is unclear and likely polysubstance. Toxicology saw pt in the ED and felt that at least some of the overdose was beta blocker, and in fact pt did transiently increase BPs with administration of glucagon. Serum and Urine tox screens at [**Hospital1 18**] all negative, but doesn't rule out oxycodone use, trazodone, cyclobenzaprine, donepizil, gabapentin--all of which she is prescribed. Serum osmoles were normal and no metabolic acidosis pointing away from toxic alcohol ingestion. She was extubated on hospital day 2 and her bradycardia resolved. She continued to have blood pressures in the 90s systolic, which was baseline for her due to low ejection fraction heart disease (see below). # Hypotension: Transient, early in the course of her overdose. This resolved with time and she required vasopressors for only a few hours. The hypotension corresponded to bradycardia which resolved with glucagon (thought to be side effect of beta blocker overdose). Initially she had a rise in her troponin, however, the repeat showed a resolution of troponin to 0.01 and flat CKMB. It is possibly demand from bradycardia/hypotension. EKG were unchanged. # Leukocytosis: Up to 16.5 on admission. Likely from stress response. Urine is clean so unlikely related to recent UTI. No other localizing symptoms. Patient afebrile. Will need follow-up of final blood culture results. # Coronary disease with ischemic cardiomyopathy and ejection fraction (EF) of 25%. We initially continued her aspirin and clopidogrel because these were her most medically necessary medications. However, on further investigation, we found that her last [**Hospital1 **] was placed in [**2112**] and was a bare metal [**Last Name (LF) **], [**First Name3 (LF) **] clopidogrel was no longer indicated and further since this was one of the medications she ingested in a suicide attempt we felt it would be prudent to discontinue. Initially held beta blocker and nitrate due to the hypotension and bradycardia. These were restarted on discharge with hold parameters for blood pressure. Continued her statin. # Chronic obstructive Pulmonary Disease (COPD): Continued home advair, spiriva, albuterol. Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from webOMR. 1. Nicotine Patch 21 mg TD DAILY 2. Ranitidine 150 mg PO DAILY 3. Clopidogrel 75 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 6. Gabapentin 800 mg PO QID 7. Pantoprazole 40 mg PO Q24H 8. Rosuvastatin Calcium 5 mg PO DAILY 9. Donepezil 5 mg PO HS 10. Fluoxetine 60 mg PO DAILY 11. Metoprolol Tartrate 12.5 mg PO BID 12. BuPROPion 75 mg PO DAILY 13. traZODONE 50 mg PO HS:PRN insomnia 14. Carbidopa-Levodopa (25-100) 1 TAB PO TID 15. Lorazepam 0.5 mg PO BID:PRN anxiety 16. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **] 17. Tiotropium Bromide 1 CAP IH DAILY 18. Levofloxacin 500 mg PO Q24H 19. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 20. Cyclobenzaprine 5 mg PO TID Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain 2. Albuterol Inhaler [**1-8**] PUFF IH Q6H:PRN wheeze, SOB 3. Aspirin 81 mg PO DAILY 4. Famotidine 20 mg PO Q12H 5. Heparin 5000 UNIT SC TID 6. Rosuvastatin Calcium 5 mg PO DAILY 7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **] 8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 9. Lorazepam 0.5 mg PO BID:PRN anxiety 10. Metoprolol Tartrate 12.5 mg PO BID 11. Nicotine Patch 21 mg TD DAILY 12. Multivitamins 1 TAB PO DAILY 13. Tiotropium Bromide 1 CAP IH DAILY Discharge Disposition: Extended Care Facility: [**Hospital3 **] Discharge Diagnosis: Primary diagnoses- Polysubstance overdose CHF Depression HTN Secondary diagnoses- CAD HLD GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs. [**Known lastname 53899**], It was a pleasure taking care of you on the medicine service at [**Hospital1 69**]. You were admitted for overdose of multiple substances. Initially, these substances made your breathing slow and your blood pressure dropped, but you were put on mechanical ventilation and a medicine to increase your blood pressure and you improved. You tolerated extubation well and your blood work now appears normal. You will now be discharged to an inpatient psychiatric floor for further evaluation and treatment. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: The psychiatry team will arrange follow-up as an outpatient. [**Name6 (MD) **] [**Last Name (un) **] MD [**MD Number(2) 11224**]

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icd9cm

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Discharge summary

report

Admission Date: [**2150-10-10**] Discharge Date: [**2150-10-12**] Service: MEDICINE Allergies: Ampicillin Attending:[**First Name3 (LF) 4327**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: none History of Present Illness: [**Age over 90 **]M hx critical AS, dCHF, CAD s/p CABG and BMS on [**2150-9-1**]. He was admitted to [**Hospital1 1516**] from [**Date range (1) 23135**] for heart failure from severe AS and worsening CAD, and underwent stenting of RCA with BMS on [**9-1**] presents s/p mechanical fall landed on R ribcage/head. Pt was getting out of bed at approximately noon today when he tripped and landed on his right chest. Pt denies preceding SOB, chest pain, palpitations, dizziness, lightheadedness. After fall, went home, proceeded with his usual activities. On ascending stairs, however, pt was noted to have increased SOB. Also complained of some right-sided chest pain. Family noted that his breathing was "more labored" than usual so they called 911. Dry weight is 102, currently he is up in 1-teens. In the ED, initial VS were: 97.2 70 150/70 16 4L Nasal Cannula. Initially saturating well on 4L then dropped sats, CXR showed 4 continugous rib fxs, edema and effusions. Put on high-[**Last Name (un) **] 100% ventimask in order to maintain O2 sats. Given 80mg IV lasix x1 with ~600cc UOP and weaning of O2 from 100% to 75%. Ortho was consulted who recommended ICU admission for overnight observation due to the risk of splinting, especially in the setting of CHF exacerbation. On arrival to the MICU, he has no complaints and denies chest pain, palpitations or shortness of breath. He has no musculoskeletal pain to speak of. He was immediately weaned to nasal cannula and was saturating 100% on 6L at the time of admission. Past Medical History: - Coronary Artery Disease s/p CABG in [**2136**] and PCI w BMS to RCA in [**2150-8-19**] - Hypercholesterolemia - Hypertension - Critical aortic stenosis, moderate to severe aortic regurgitation (the aortic valve is fixed in one position with a similar antegrade and regurgitant orifice). He also has severe tricuspid regurgitation and severe pulmonary hypertension. The mitral regurgitation is at least moderate and possibly moderate to severe. - dCHF - s/p Pacemaker placement - Atrial Fibrillation, on coumadin - Mitral Regurgitation - T12 Compression Fracture - Gastric Ulcer - gout Social History: Home: Patient lives in [**Location 10059**] with his daughter, wife died approx 1 year ago. Born in [**State 4565**] and placed in internment camp during WWII where he met his wife; he moved from [**State 4565**] to [**State 8449**] to [**State 760**] to [**Location (un) 5622**] before relocating to [**Location (un) **] where he worked as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 23136**]; he retired 15-20 years ago and moved to [**Location (un) 86**] to be closer to his daughter and grandchildren Occupation: retired [**Doctor Last Name 23136**] EtOH: Denies Drugs: Denies Tobacco: Former tobacco use, quit 50 y. ago Family History: Unremarkable Physical Exam: ADMISSION EXAM: Vitals: afebrile 65 139/82 16 98%6L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP to angle of mandible CV: [**Last Name (un) **] [**Last Name (un) 3526**], normal S1 + S2, no murmurs, rubs, gallops Lungs: Diffuse bilateral rales with decr BS bilaterally 1/2 up Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, [**2-20**]+ peripheral edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact . DISCHARGE EXAM: Wt = 106lbs Vitals: afebrile 65 130s-140s/80s-90s 98% RA General: Alert, oriented x 3, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL Neck: supple, JVP flat. CV: [**Last Name (un) **] [**Last Name (un) 3526**], normal S1 + S2, no murmurs, rubs, gallops Lungs: Minimal bibasilar rales with decr bs Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, [**2-20**]+ peripheral edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Pertinent Results: [**2150-10-9**] 10:35PM WBC-3.6* RBC-3.10* HGB-10.4* HCT-32.7* MCV-106*# MCH-33.6* MCHC-31.8 RDW-19.4* [**2150-10-9**] 10:35PM NEUTS-74.3* LYMPHS-16.0* MONOS-6.7 EOS-2.4 BASOS-0.6 [**2150-10-9**] 10:35PM PLT COUNT-166 [**2150-10-9**] 10:35PM CK-MB-9 cTropnT-0.02* [**2150-10-9**] 10:35PM CK(CPK)-166 [**2150-10-9**] 10:35PM GLUCOSE-151* UREA N-37* CREAT-1.3* SODIUM-137 POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-24 ANION GAP-15 [**2150-10-10**] 02:34AM PT-15.5* INR(PT)-1.5* CXR [**2150-10-9**]: IMPRESSION: Moderate to severe pulmonary edema and bilateral pleural effusions. Multiple right posterior fractures as described above. CT HEAD [**2150-10-9**]: IMPRESSION: No acute intracranial process. Partial opacification of the right mastoid air cells. CT SPINE [**2150-10-9**]: IMPRESSION: Multilevel degenerative change. No acute fracture or malalignment. Partial opacification of right mastoid air cells. Pulmonary edema. Large bilateral pleural effusions. CT CHEST/ABDOMEN [**2150-10-9**]: IMPRESSION: 1. Large bilateral non-hemorrhagic pleural effusions. Mild pulmonary edema. 2. [**Hospital1 **]-apical scarring with calcification and mild bronchiectasis, likely sequela of prior granulomatous infection. 3. Stable mildly enlarged mediastinal lymph nodes, a nonspecific finding. 4. Stable high-grade compression fracture in the lower thoracic spine as well as a stable mild vertebral body height loss in the mid thoracic spine 5. Multiple right-sided rib fractures as described above including the fifth and sixth ribs, which are fractured both laterally and posteriorly. 8. Extensive atherosclerotic calcifications. RIGHT ELBOW XRAY [**2150-10-9**]: IMPRESSION: Stable right elbow radiograph. . DISCHARGE: [**2150-10-12**] 06:20AM BLOOD WBC-3.3* RBC-3.20* Hgb-10.7* Hct-33.0* MCV-103* MCH-33.4* MCHC-32.4 RDW-18.5* Plt Ct-173 [**2150-10-12**] 06:20AM BLOOD PT-14.2* PTT-41.8* INR(PT)-1.3* [**2150-10-12**] 06:20AM BLOOD Glucose-92 UreaN-28* Creat-1.1 Na-134 K-3.6 Cl-99 HCO3-31 AnGap-8 [**2150-10-12**] 06:20AM BLOOD Calcium-8.2* Phos-2.9 Mg-2.1 Brief Hospital Course: [**Age over 90 **]M hx critical AS, dCHF, CAD s/p CABG with recent BMS to RCA who presents from home s/p mechanical fall with 4 right sided contiguous rib fractures and florid pulmonary edema. . #CHF exacerbation: TTE [**8-30**] showed dCHF and critical AS, and he currently has the additional contribution from splinting from rib fractures: fall-> pain -> inc sympa tone -> less diastole -> pulm edema. EKG unchanged from baseline, pt not c/o chest pain so antecedent MI unlikely. He received 80IV lasix in the ED with good UOP and already started to wean O2. In the CCU, he continued to be diuresed with Lasix, and he was negative net 2L on the first day of admission. He was transitioned to torsemide on [**10-9**]. His admission weight was 54.6 kg, and his weight on [**10-11**] was 48.2 kg. He was transferred to the floors where diuresis continued with PO torsemide. . #CAD: s/p CABG and then with RCA BMS placed [**2150-8-30**]. Currently no c/o chest pain or discomfort. Cardiac enzymes were WML. Initially aspirin, Plavix, and beta blocker were continued. However, after consulting with the patient's primary cardiologist Dr. [**First Name (STitle) 437**], we stopped the Plavix given he was over a month out from BMS and given that we were starting warfarin for afib. . #Rib fractures: Orthopedic surgery team saw the patient and advised monitoring. His pain was controlled with Tylenol. He will follow up with his PCP on [**10-23**]. . #Atrial fibrillation: Patient had been on warfarin until he was admitted to the hospital in [**Month (only) 216**] for GI bleed. He was guaiac negative here, and after consulting with Dr. [**Last Name (STitle) **], warfarin was restarted on [**10-11**]. INR on discharge was 1.3. Caregroup VNA will coordinate INR follow up. . #[**Last Name (un) **]: Cr 1.3 on admission from baseline of 1, likely secondary to CHF exacerbation. On discharge, creatinine was 1.1. . Transitional Issues: - Patient will have follow up with Dr. [**First Name (STitle) 437**] and with Dr. [**Last Name (STitle) 5781**]. He will have VNA as well. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from [**Last Name (STitle) 23137**]. 1. Torsemide 10 mg PO DAILY:PRN weight gain > 3lbs 2. Pantoprazole 40 mg PO Q12H GI bleed, erosions 3. Vitamin D 400 UNIT PO BID 4. Metoprolol Succinate XL 12.5 mg PO BID 5. Clopidogrel 75 mg PO DAILY 6. Calcium Carbonate 600 mg PO BID 7. Atorvastatin 10 mg PO DAILY 8. Aspirin EC 81 mg PO DAILY Discharge Medications: 1. Aspirin EC 81 mg PO DAILY 2. Atorvastatin 10 mg PO DAILY 3. Calcium Carbonate 600 mg PO BID 4. Metoprolol Succinate XL 12.5 mg PO DAILY 5. Pantoprazole 40 mg PO Q12H 6. Vitamin D 400 UNIT PO BID 7. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q8H:PRN pain or fever 8. Warfarin 1 mg PO DAILY16 RX *warfarin [Coumadin] 2 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 RX *warfarin [Coumadin] 1 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 9. Torsemide 10 mg PO DAILY RX *torsemide 10 mg one tablet(s) by mouth DAILY Disp #*30 Tablet Refills:*2 10. Outpatient Lab Work Please check Chem-7 and INR on Wednesday [**2150-10-14**] with results to Dr. [**First Name (STitle) 437**] at Phone: [**Telephone/Fax (1) 62**] Fax: [**Telephone/Fax (1) 9825**] and [**Hospital 191**] [**Hospital3 **] at Office Phone:([**Telephone/Fax (1) 10844**] Office Fax:([**Telephone/Fax (1) 3053**] ICD9: 427.3 Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Acute on Chronic Diastolic CHF (EF 60%) Critical Aortic stenosis Mechanical fall with rib fractures Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You fell and broke 4 ribs. When you were transported to the hospital, we found that you were fluid overloaded and needed to get medicine to remove the extra fluid. We are going to ask you to take torsemide every day for a few days. You will see Dr. [**First Name (STitle) 437**] on Wedsnesday and he will decide what you should take from then on. Weigh yourself every morning, call Dr. [**First Name (STitle) 437**] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. Your weight at discharge is 106 pounds. Followup Instructions: Department: CARDIAC SERVICES When: WEDNESDAY [**2150-10-14**] at 9:00 AM With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: WEDNESDAY [**2150-10-14**] at 10:20 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: FRIDAY [**2150-10-23**] at 9:40 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2150-10-13**]

[ "428.33", "414.00", "V45.82", "272.0", "396.2", "V45.81", "V58.61", "V45.01", "873.42", "584.9", "799.02", "807.04", "E884.4", "397.0", "401.9", "V15.82", "427.31", "416.8", "V12.71", "E849.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10045, 10094

6548, 8471

229, 236

10258, 10258

4440, 6525

10955, 11899

3076, 3090

9100, 10022

10115, 10237

8659, 9077

10409, 10932

3105, 3772

3788, 4421

8492, 8633

181, 191

264, 1791

10273, 10385

1813, 2402

2418, 3060

19,769

142,028

22109

Discharge summary

report

Admission Date: [**2181-9-29**] Discharge Date: [**2181-10-12**] Service: MED Allergies: Shellfish Attending:[**First Name3 (LF) 2181**] Chief Complaint: Flank pain and epistaxis with dropping Hct, SOB, worsening edema. Major Surgical or Invasive Procedure: Hemodialysis started [**2181-10-4**] with tunneled catheter placement in right subclavian on [**2181-10-3**]. History of Present Illness: 83yo F with history of hypertension, chronic renal insufficiency, and right renal cystic mass, initially treated at [**Hospital 1474**] Hospital (admitted [**9-1**], dicharged [**9-3**] and readmitted on [**2181-9-4**]) for congestive heart failure, renal failure, and left upper lobe pneumonia with the chief complaint of shortness of breath, increasing pedal edema, and increasing fatigue. She was treated for congestive heart and worsening renal failure (baseline creatinine 2.0 in [**2179**]). At rehab, her hct dropped 37-->27 over 4-5 days. On [**2181-9-23**], she was noted to have had dark stool and significant epistaxis. On [**2181-9-24**], she was found to have a Hct of 16 which continued to drop despite multiple blood transfusions. She also began to complain of right flank pain. A CT of the abdomen and pelvis showed a right-sided retroperitoneal hematoma displacing the right renal artery anteriorly. At [**Hospital1 1474**], the patient received 10 units of packed RBCs, 2 units of FFP, and 2 doses ddAVP. She was started on dopamine IV drip .625 for renal insufficiency and was continued on lasix IV 80 tid and zaroxylyn. At the outside hospital, she was also being treated for a enterococcal pan-senstivie urinary tract infection. She was transferred to [**Hospital1 18**] on [**2181-9-29**] for the management of acute renal failure and retroperitoneal bleed. She was transferred from the MICU to the floor service on [**2181-9-30**]. Past Medical History: HTN, hypothyroid, gout, CRI (baseline Cr 2.0), diastolic dysfunction (EF 55% 7/04), 4 cm right renal mass (cystic RCC vs multiloculated cyst, seen on CT on [**11-11**], followed), hysterectomy, arthritis Social History: The patient is a non-smoker, does not drink alcohol. She had 2 prior pregnancies. Family History: Non-contributory Physical Exam: Vitals: T:96.9, BP: 156/64, HR: 96, RR:16, O2:98% 2L Gen: elderly woman, appears younger than stated age, in NAD. HEENT: EOMI, PERL, mild proptosis, OP clear, mmm, neck supple, not LAD, elevated JVD. CV: RRR, II/VI SEM at LLSB, no rubs Resp: decreased BS, + rales 2/3 up, scattered exp wheezing Abd: edema to mid abd, NDNT, +BS, soft Ext: [**3-13**]+ pitting edema to abd, good distal pulses. Skin: warm, no rash Neuro: grossly intact, A&O x3. GUIAC Neg Pertinent Results: [**2181-9-29**] 09:58PM GLUCOSE-102 UREA N-144* CREAT-4.2* SODIUM-141 POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-24 ANION GAP-20 [**2181-9-29**] 09:58PM ALT(SGPT)-25 AST(SGOT)-26 LD(LDH)-375* ALK PHOS-159* AMYLASE-540* TOT BILI-1.6* [**2181-9-29**] 09:58PM LIPASE-18 [**2181-9-29**] 09:58PM ALBUMIN-3.1* CALCIUM-9.3 PHOSPHATE-6.8* MAGNESIUM-2.3 URIC ACID-10.2* [**2181-9-29**] 09:58PM TSH-18* [**2181-9-29**] 09:58PM WBC-11.7* RBC-3.24* HGB-10.0* HCT-29.8* MCV-92 MCH-30.9 MCHC-33.6 RDW-15.1 [**2181-9-29**] 09:58PM NEUTS-93* BANDS-0 LYMPHS-4* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1* [**2181-9-29**] 09:58PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL STIPPLED-OCCASIONAL [**2181-9-29**] 09:58PM PLT COUNT-117* [**2181-9-29**] 09:58PM PT-14.0* PTT-39.8* INR(PT)-1.2 [**2181-9-29**] 09:58PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.010 [**2181-9-29**] 09:58PM URINE BLOOD-LG NITRITE-POS PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2181-9-29**] 09:58PM URINE RBC->50 WBC->50 BACTERIA-MOD YEAST-MANY EPI-[**4-13**] ECG: Normal sinus rhythm Possible anterior infarct - age undetermined Leftward axis - ? inferior myocardial infarction No previous tracing ECHO: ([**10-2**]): Conclusions: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity is small. Overall left ventricular systolic function is normal (LVEF 60%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic arch is mildly dilated. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but not stenotic. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Impression: small left ventricular cavity with severe concentric left ventricular hypertrophy and normal ejection fraction CXR: ([**9-29**]) Rotated positioning. There are moderate-to-moderately large bilateral layering pleural effusions with underlying collapse and/or consolidation. A right IJ central line is present, tip over distal SVC. No pneumothorax is identified. There is no upper zone redistribution to suggest CHF. Abd CT: ([**10-3**]) 1. Large retroperitoneal hematomas as described. 2. Gallstones. 3. Multiple buttock calcifications secondary to prior injections. 4. Anasarca/pleural effusions/ascites consistent with third spacing. Brief Hospital Course: The patient is a 83 year old female with retroperitoneal bleed likely secondary to right-sided renal mass, acute on chronic renal failure with anasarca, now HD dependent. HOSPITAL COURSE BY PROBLEM: 1. RETROPERITONEAL BLEED, likely [**3-12**] renal mass given proximity to R hematoma. - No further enlargement of retroperitoneal bleed during admission. Hct remained stable, no furhter transfusions required. - Coagulopathy reversed with FFP and Vit K suggestiong nutritional etiology. - Mixing studies performed at [**Hospital1 2025**] showed reversal of coagulopathy with the addition of factors, [**Last Name (un) 7162**] suggesting a nutritional etiology. 2. VOLUME OVERLOAD - CVP 15, tense edema to abd, pleural effusions on CXR - Overload most likely [**3-12**] RF and not cardiogenic (no ischemia on EKG, EF 55%-although does have known diastolic dysfunction) - Pt was taken off od dopamine on arrival from OSH and d/c'd all diuretics. - Pt started on dialysis for fluid removal and ultrafiltration on [**2181-10-4**]. Dialysis was successful and able to removel large amounts of fluid without change in BP. Beta blockers held. Much of the edema has resolved but not completely by the tiem of discharege and pt will most likely need lifelong HD. 3. ACUTE ON CHRONIC RENAL FAILURE - CT, MRI and U/S performed with ruled out obstruction and IVC thrombus. Renal mass could not be fully appreciated on imaging and would require bx for diagnosis. Pt does not want surgery and therefore refused bx. - Sent [**Doctor First Name **], ANCA, C3, C4 studied whcih were negative. - Urine studies initially showed achanthocytes, but nephritis later ruled out by follow-up analysis. 24 hr protien was 2.5, not nephrotic syndrome. - Final diagnosis is that pt had substantial chronic renal failure woth creat of 2.0 and had a second insult that placed her in acute renal failure. - Pt followed by Reanl team throughout admission. 4. RENAL MASS - Appears cystic on imaging. Has not increased in size since dx [**11-11**]. Supportive care only. 5. ENTEROCOCCUS UTI - Put on renally dosed amox 500 q24. D/c'd after 2 weeks course. No further + cx's for enterococcus. Pt did ahve yeast in urine and was treated for 3 days with Fluconazole. 6. RECENT PNA? - CXR with large bilateral pleural effusions. Difficult to assess for PNA. Most likely not a pna. Probable combination of colapsed lung within the pleural effusion and atelectasis. Pt did not spike fever and did not have a cough. O2sats improved with diuresis. 7: CV: Pt's Bp meds held initially while trying to take off large amounts of fluid. Pt then became hypertensive and was placed back on home medications. 8. Urinary retention: Foley removed and pt had difficulty urinating. No evidence of saddle numbness, no fecal incontinence. No other neurologic deficits. Urology consulted, but in light of the fact that the pt does not want any surgery, they recommended returning as an outpt for further treatment. 9. Psych: Throughout admission pt was very [**Last Name (un) 1425**] with good mood and appropriate affect. However, on day of discharge after pt realized that she would be unable to return home safely, her mood became depressed and she was withdrawn. Thsi is most likely transient and should improve as the pt makes progress at rehab, however, if it does not it should be addressed in the future possibly with a psych consult vs. anti-depresseants. Pt does not have a history of depression. 10. PROPH - Ranitidine, pneumoboots. No Heparin [**3-12**] recent coagulopathy. 11. ACCESS - R subclavian tunelled catherter. Foley 12. CODE: FULL Medications on Admission: Levobunolol HCl 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Allopurinol 100 mg Tablet Sig: One (1) Tablet PO QOD (every other day). Tablet ASA Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO QD (once a day). 4. Levobunolol HCl 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 5. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO QD (once a day). 6. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Calcium Acetate 667 mg Tablet Sig: 1.5 Tablets PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO QOD (every other day). Tablet(s) Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Right renal cystic mass with large right retroperitoneal bleed, acute on chronic renal failure with unclear etiology, anasarca Discharge Condition: Stable. Discharge Instructions: Please return to the ER or call your primary care physician if you experience worsening shortness of breath, chest pain, abdominal pain, increased swelling or start having nosebleeds or blood in your stool. Followup Instructions: Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6984**], in 1 week. Please follow up with a Urologist in your area if urinaru retention does not resolve.

[ "584.8", "518.0", "428.0", "599.0", "789.5", "459.0", "428.30", "403.91", "286.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

10321, 10418

5546, 5718

279, 391

10589, 10598

2726, 5523

10853, 11068

2218, 2236

9509, 10298

10439, 10568

9181, 9486

10622, 10830

2251, 2707

174, 241

5747, 9155

419, 1876

1898, 2103

2119, 2202

776

137,407

20909

Discharge summary

report

Admission Date: [**2184-10-11**] Discharge Date: [**2184-10-27**] Date of Birth: [**2123-2-22**] Sex: M Service: CSURG Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: DOE x several months Major Surgical or Invasive Procedure: redo MVR History of Present Illness: This is a 61 yo female s/p CABG x 3 adn MVR on [**2184-4-27**] with nes complaints od dyspnea on exertion. Finding of new murmur by PCP and echo finding 4+ MR. Past Medical History: MI [**4-4**] CAD/MR ischemia and valvular cardiomyopathy LV systolic dysfunction ^ lipids HTN S/P CABG x 3 and MV repair in [**4-4**] Social History: Lives alone in [**Location (un) 47**], MA. Works in real estate. + 80 pk year tob hx -- quit 1.5 years ago. Family History: No known CAD Physical Exam: On presentation: VS HR 84 regular, BP 124/66. Ht 5'8" Wt 200# General: Appears stated age in NAD -- anxious. Skin: Warm, dry, + rash on left knee. Neck: supple, no JVD, no lymphadenopathy. Chest: CTA bilat. CV: RRR. S1S2 with II/VI murmur in apex. Abd: NT. ND, + BS. Extremities: No varicosities. Neuro: CN II-XII intact. A+O x 3. Pertinent Results: [**2184-10-11**] 11:05PM WBC-15.3*# RBC-3.51* HGB-10.0*# HCT-30.2* MCV-86 MCH-28.6 MCHC-33.3 RDW-14.0 [**2184-10-11**] 11:05PM PLT COUNT-299 [**2184-10-11**] 11:05PM PT-14.1* PTT-32.4 INR(PT)-1.2 [**2184-10-11**] 06:20PM UREA N-15 CREAT-0.7 CHLORIDE-111* TOTAL CO2-23 [**2184-10-25**] 09:30AM BLOOD WBC-11.2* RBC-3.58* Hgb-10.6* Hct-31.9* MCV-89 MCH-29.5 MCHC-33.1 RDW-14.8 Plt Ct-676*# [**2184-10-25**] 09:30AM BLOOD Plt Ct-676*# [**2184-10-25**] 09:30AM BLOOD Glucose-204* UreaN-13 Creat-0.7 Na-137 K-4.8 Cl-100 HCO3-28 AnGap-14 Brief Hospital Course: Mr [**Known lastname 55627**] was admitted on [**2184-10-11**]. He proceeded to the OR and underwent a redo MVR with a 29mm mosiac porcine heart valve via right thoracotomy. Total cardio-pulmonary bypass time was 85 minutes. There was no cross clamp time as this operation was done with a bleeding heart approach. He was tranferred to the ICU in NSR rate 98, MAP 62, CVP 8, on neosynephrine, milrinone, insulin, and propofol drips. He was extubated on the evening of his operative day without any complications. His IV medications were weaned and both the milrinone and the neosynephrine being discontinued on the AM of POD 2. He had some post-op tachycardia for which is lopressor dose was increased and ace inhibitor adjusted. He was also followed by the cradiology team and their recommendations were followed. His chest tubes remained in longer than is typical because of ongoing drainage. On POD 3 he was noted to have crepitus in his right check and upper chest. His chest tubes x 3 remained on suction with an air leak. On [**10-18**] (POD 7) the chest tubes were put to water seal with a subsequent CXR showing a small pneumthorax and they were again put to suction. A persistent pneumothorax remined and on [**10-21**] (POD 9) a thoracic consult was obtained with rcommendations for doxycycline sclerosis. The chest tube was eft to water seal with an ongoing leak but minimal drainage. The chest tube was clamped for a 24-hour period without any respiratory distress and was eventually discontinued on [**10-26**] (POD 15) per the recommendations of the thoracic surgery team. Mr. [**Name14 (STitle) 55628**] was followed by the physical therapy team throughout his hospital stay with initial evaluation on POD 2 and on POD 7 he was found to be for for home. On [**10-27**] POD he was found to be safe for discharge home. Medications on Admission: lopressor 50 [**Hospital1 **] lipitor 80 daily aspirin 325 daily plavix 75 daily zestril 2.5 daily 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 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO QD (). Disp:*60 Tablet(s)* Refills:*2* 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO QD (). Disp:*30 Tablet(s)* Refills:*2* 5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours: Take with food. Disp:*120 Tablet(s)* Refills:*2* 6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO QD (). Disp:*15 Tablet(s)* Refills:*2* 8. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 10. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital **] Hospice and VNA Discharge Diagnosis: s/p redo MVR (#29 Mosaic porcine) vis right thoracotomy HTN, ^ chol, cardiomyopathy, s/p MVR/CABG '[**84**] persistent right pneumothorax Discharge Condition: good Discharge Instructions: keep wounds clean and dry. OK to shower, no bathing or swimming. Take all medications as prescribed call for any fever, redness or drainage from wound Followup Instructions: Dr [**Last Name (STitle) 349**] in [**2-3**] wks Dr [**Last Name (STitle) 27117**] in [**2-3**] wks Dr [**Last Name (STitle) **] in 4 wks Completed by:[**2184-10-27**]

[ "425.4", "272.0", "401.9", "424.0", "V45.82", "512.1", "V45.81", "428.0", "996.02", "414.01" ]

icd9cm

[ [ [] ] ]

[ "35.21", "34.92", "89.60", "39.61" ]

icd9pcs

[ [ [] ] ]

4929, 4991

1790, 3639

335, 346

5172, 5178

1226, 1767

5377, 5547

837, 851

3788, 4906

5012, 5151

3665, 3765

5202, 5354

866, 1207

275, 297

374, 537

559, 694

710, 821

31,755

105,833

49747+59204

Discharge summary

report+addendum

Admission Date: [**2169-10-25**] Discharge Date: [**2169-12-4**] Date of Birth: [**2116-10-8**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7760**] Chief Complaint: coffee-ground emesis Major Surgical or Invasive Procedure: 1) Ex-lap, ileocecectomy [**10-25**] 2) Return to OR for washout and ileostomy creation [**10-27**] 3) CVVHD [**10-26**] - [**11-6**] 4) Ex-lap, washout, resection of transverse and limited descending colon for ischemic segment of splenic flexure [**10-30**] 5) IVC filter placement [**10-31**] (for prophylaxis, h/o L subsegmental PE and multiple) 6) Abdominal closing at bedside (sutured [**Location (un) 5701**] bag to reduce abdominal opening by ~50%) 7) Ex-lap, washout, omentectomy, GJ tube placement, open tracheostomy, abdominal wall closure [**2169-11-3**] History of Present Illness: 53M with multiple medical problems, transported from nursing home to [**Hospital1 18**] ED for coffee-ground emesis, hypotension, and tachycardia noted after dialysis. He was found to have an upper GI bleed in the setting of fevers and sepsis. The upper GI bleeding resolved. Once stabilized, a CT scan was obtained which revealed free air and a dilated thickened cecum. Because of this, he was taken emergently to the operating room for exploration. Past Medical History: ESRD on HD, left AV fistula clotted DM Dementia Anemia Seizure disorder HTN Depression Pneumonias Social History: per daughter - no ETOH, "a lot" cigarettes Family History: noncontributory Physical Exam: On admission: T 96.1 HR 135 BP 79/52 RR 17 O2sat 88% Gen: intubated and sedated CV: reg rhythm, tachycardic Lungs: CTAB Abd: soft, mildly distended, no tenderness elicited, no masses Rectal: no tenderness elicited, no masses noted, heme neg . ON DISCHARGE: T: 98.1 HR: 81 BP: 149/63 RR: 19 Sat: 97% trach mask NAD, alert and awake RRR coarse bilateral breath sounds soft, mildly distended, wound healing well with grannulation tissue, clean no edema of extremities Pertinent Results: [**2169-10-25**] 05:19AM WBC-5.9 RBC-3.56* Hgb-12.6* Hct-38.8* MCV-109* MCH-35.5* MCHC-32.6 RDW-21.0* Plt Ct-457* [**2169-10-25**] 05:19AM Neuts-74* Bands-7* Lymphs-16* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* NRBC-2* [**2169-10-25**] 05:19AM PT-14.6* PTT-24.1 INR(PT)-1.3* [**2169-10-25**] 08:10PM Fibrino-449* D-Dimer-3084* [**2169-10-25**] 05:19AM Glucose-194* UreaN-29* Creat-5.1* Na-137 K-4.8 Cl-93* HCO3-21* AnGap-28* [**2169-10-25**] 07:21PM ALT-17 AST-59* AlkPhos-77 TotBili-0.2 [**2169-10-25**] 05:19AM CK(CPK)-184 CK-MB-4 cTropnT-0.08* [**2169-10-25**] 11:21AM CK(CPK)-404 CK-MB-6 cTropnT-0.06* [**2169-10-25**] 11:21AM ALT-17 AST-48* [**2169-10-25**] 11:21AM Calcium-7.8* Phos-1.1* Mg-1.8 [**2169-10-25**] 05:12AM Lactate-10.8* . ON DISCHARGE: [**2169-12-4**] 02:55AM BLOOD WBC-12.4* RBC-3.12* Hgb-9.2* Hct-28.5* MCV-91 MCH-29.5 MCHC-32.3 RDW-19.4* Plt Ct-501* [**2169-12-2**] 01:30AM BLOOD PT-14.7* PTT-30.6 INR(PT)-1.3* [**2169-12-4**] 02:55AM BLOOD Glucose-102 UreaN-92* Creat-7.5*# Na-141 K-4.4 Cl-98 HCO3-22 AnGap-25* [**2169-12-4**] 02:55AM BLOOD ALT-48* AST-63* AlkPhos-607* Amylase-221* TotBili-1.2 [**2169-12-4**] 02:55AM BLOOD Lipase-160* [**2169-12-4**] 02:55AM BLOOD Calcium-11.0* Phos-9.1*# Mg-2.5 . Brief Hospital Course: 53M with ESRD and multiple medical problems was transported from nursing home to [**Hospital1 18**] ED on [**10-25**] for coffee-ground emesis, hypotension to 70's, and tachycardia to 130's. NGT was placed, which returned coffee-ground colored liquid. He was intubated and sedated in ED for airway protection, and given 6U PRBC, 2U FFP, 2L crystalloid for presumed GI bleed. GI was consulted for possible EGD and intervention. Post-transfusion Hct was 38. Cultures were sent, and Vanc/Zosyn were started empirically. CT scan of the abdomen/pelvis was done, which showed free intraperitoneal air and fluid suggestive of perforation, and markedly dilated colon with a sharp transition in the region of the splenic flexure. Of note, he was also found to have LLL pulmonary emboli with bilateral ultrasound negative for DVTs. He was taken urgently to the OR for ex-lap, and ileocecectomy was performed, with plans to return to OR for washout and closure/maturing of ostomy at later date. . Postoperatively, he remained stable in the TICU - on CVVH, BP supported with pressors, Vanc/Zosyn continued, Fluc was added for broader coverage, PPI [**Hospital1 **] for prophylaxis. . On [**10-27**], he was taken back to the OR for exploratory laparotomy, removal of [**Location (un) 5701**] bag, ascending colectomy, abdominal wash-out, ileostomy maturation and reclosure with [**Location (un) 5701**] bag. Post-operatively, he became tachycardic to 200's, and was cardioverted. An ECHO was performed which demonstrated LVEF > 55% wuth grossly normal biventricular systolic function. A repeat ECHO on [**10-30**] showed similar findings. On [**10-29**], platelets were noted to be significantly decreased, so all heparin products were stopped, and HIT antibody was sent, which was ultimately came back negative. . On [**10-30**], he underwent ex-lap, washout, resection of transverse and limited descending colon for ischemic segment of splenic flexure. Exploratory laparotomy, washout, transverse colectomy, closure with a [**Location (un) 5701**] bag and left groin dialysis catheter placement. . On [**2169-10-31**] he had a IVC filter placed by Dr. [**Last Name (STitle) **] for prophylaxis, h/o L subsegmental PE. He underwent abdominal closure at the bedside (sutured [**Location (un) 5701**] bag to reduce abdominal opening by ~50%). He continued to have elevated LFTs and a RUQ ultrasound was performed for possible cholecystitis on [**2169-11-2**], it showed sludge without evidence of cholecystitis. On [**2169-11-3**], he returned to the OR for exploratory laparotomy, abdominal washout, abdominal wall closure with retention sutures, gastrostomy tube and tracheostomy. Infectious disease was consulted on [**2169-11-7**] for tailoring of his antibiotics towards [**Female First Name (un) 564**], Enterococcus, and Basteroides grown from his cultures. He continued on CVVH until [**2169-11-7**] whe he was transitioned to hemodialysis. . On [**2169-11-9**] A CT scan of his abdomen for persistent fevers found an 11 cm thick-walled fluid collection in the mid lower pelvis just beneath the intralesional scar, most likely representing abscess in this setting of cecal perforation and fever and he underwent drainage and placement of a pigtail catheter under CT guidance. The placement of the drain was complicated by a postop bleed with a decrease of his hematocrit to 23.6. He was managed conservatively with transfusions for the pelivc hematoma and was transfused a total of 10 units of PRBC and 2 units FFP up to [**2169-11-19**] when he finally stablized his hematocrit in the 27-30 range. Repeat CT scan on [**2169-11-13**] demonstrated stable size of the hematoma. A repeat ultrasound on [**2169-11-17**] for possible drainage found the large predominantly solidified pelvic hematoma not amenable to drainage. He continued to have fevers daily and his lines were changed. All cultures, except for his initial cultures from his OR swab, were negative. During the period of management of his pelvic hematoma, he also developed an ileus with decreased output from his ostomy and was provided nutrition via TPN. He stopped having fevers and his antibiotics(zosyn, flagyl, fluconazole, and daptomycin) were finally stopped on [**2169-11-27**]. His ileus resolved and he was restarted on tube feeds, slowly advanced to goal. His right subclavian quentin catheter used for dialysis was removed and a tunneled catheter was placed by interventional radiology on [**2169-11-30**] in the right internal jugular vein. . His retiention sutures were removed on [**2169-12-2**] with his wound healing well by secondary intention and essentially closed at the skin. His JP drain from his initial operation was also discontinued with minimal output. His pain has been well-controlled with Dilaudid prn. He has remained hemodynamically stable since his last operation on [**2169-11-3**]. His respiratory status has slowly improved with the ability to tolerate trach mask for the majority of the day, occasionally becoming tachypnic and diaphoretic when he tires. He continues to tolerate TF via his J-tube and his G-tube clamped. He received dialysis via his tunnel right IJ catheter on Monday, Wednesday, and Friday. He has been afebrile since [**2169-12-1**] and his hematocrit stable in the 27-28 range. He was deemed stable for discharge to an extended care facility and will follow-up with Dr. [**Last Name (STitle) **]. Medications on Admission: ASA, Lanthanum, Prozac, Lisinopril, Lopressor, Kayexalate, Nephrocap, Lopid, Estraderm Discharge Medications: 1. Metoprolol Tartrate 5 mg/5 mL Solution [**Last Name (STitle) **]: One (1) Intravenous Q4H (every 4 hours): SBP > 160. 2. Hydromorphone 2 mg/mL Syringe [**Last Name (STitle) **]: One (1) Injection Q3H (every 3 hours) as needed for pain. 3. Hydralazine 20 mg/mL Solution [**Last Name (STitle) **]: One (1) dose Injection Q6H (every 6 hours) as needed for SBP>160. 4. Acetaminophen 650 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6 hours) as needed for fever. 5. Influenza Tri-Split [**2169**] Vac Intramuscular 6. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Year (4 digits) **]: One (1) ML Intravenous DAILY (Daily) as needed. 7. Metoprolol Tartrate 25 mg Tablet [**Year (4 digits) **]: Two (2) Tablet PO TID (3 times a day): Hold for SBP < 100 or HR < 60. 8. Heparin (Porcine) 5,000 unit/mL Solution [**Year (4 digits) **]: One (1) Injection TID (3 times a day). 9. Gemfibrozil 600 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO BID (2 times a day). 10. Levothyroxine 125 mcg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily). 11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 12. Aluminum Hydroxide Gel 600 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty (30) ML PO TID (3 times a day). 13. Insulin sliding scale NPH 14 units Q12H . Scale Glucose Insulin Dose Regular 0-60 mg/dL [**1-3**] amp D50 61-120 mg/dL 0 Units 121-140 mg/dL 5 Units 141-160 mg/dL 8 Units 161-180 mg/dL 11 Units 181-200 mg/dL 14 Units 201-220 mg/dL 17 Units 221-240 mg/dL 20 Units 241-260 mg/dL 23 Units 261-280 mg/dL 26 Units 281-300 mg/dL 29 Units 301-320 mg/dL 32 Units 321-340 mg/dL 35 Units 341-360 mg/dL 38 Units > 361 mg/dL Notify M.D. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Cecal perforation LLL Pulmonary emboli Pelvic Hematoma Anemia ESRD on HD HTN DM Discharge Condition: Stable, to extended care facility. Discharge Instructions: Discharge Instructions: Please call your surgeon or return to the emergency department if you develop a fever greater than 101.5, chest pain, shortness of breath, severe abdominal pain, pain unrelieved by your pain medication, severe nausea or vomiting, severe abdominal bloating, inability to eat or drink, foul smelling or colorful drainage from your incisions, redness or swelling around your incisions, or any other symptoms which are concerning to you. . Diet: Please continue your tube feeds. . Medication Instructions: Please take all medications as prescribed. . Activity: No heavy activity until directed. Please continue physical therapy. . Renal: Please continue hemodialysis per renal. . Please follow-up as directed. Name: [**Known lastname 2654**],[**Known firstname **] Unit No: [**Numeric Identifier 16872**] Admission Date: [**2169-10-25**] Discharge Date: [**2169-12-4**] Date of Birth: [**2116-10-8**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 719**] Addendum: On [**2169-12-5**] patient was discharged to [**Hospital1 **]. He returned approximately 4 hours later with hypotension. He was started on low dose dopamine but was quickly taken off as he responded favorably to fluids and albumin. He has been stable since then afebrile and no longer hypotensive. Blood cultures obtained on [**2169-12-4**] are still pending. Last white count on [**2169-12-7**] 10.6. He will be transferred back to [**Hospital1 **] with previous orders with plan to be dialyzed tomorrow. Discharge Disposition: Extended Care Facility: [**Hospital3 14**] & Rehab Center - [**Hospital1 15**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 721**] MD [**MD Number(2) 722**] Completed by:[**2169-12-7**]

[ "458.29", "285.21", "560.9", "331.0", "995.92", "287.5", "998.12", "403.91", "997.4", "585.6", "038.9", "250.00", "427.89", "785.52", "294.10", "578.9", "518.81", "415.19", "540.0", "780.39" ]

icd9cm

[ [ [] ] ]

[ "99.61", "38.93", "45.73", "31.1", "99.07", "39.95", "96.6", "38.7", "54.72", "99.05", "96.33", "99.04", "54.4", "45.74", "45.72", "99.15", "43.19", "38.95", "46.21" ]

icd9pcs

[ [ [] ] ]

12723, 12959

3372, 8817

336, 904

11013, 11050

2115, 2864

1583, 1600

8954, 10787

10910, 10992

8843, 8931

11098, 11575

1615, 1615

2878, 3349

276, 298

932, 1385

11600, 12700

1629, 1869

1407, 1507

1523, 1567

18,477

186,476

573

Discharge summary

report

Admission Date: [**2189-9-30**] Discharge Date: [**2189-10-2**] Date of Birth: [**2127-4-7**] Sex: M Service: [**Hospital Unit Name 196**] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: ELECTIVE CAROTID ANGIOGRAPHY AND LEFT INTERNAL CAROTID STENTING Major Surgical or Invasive Procedure: Bilateral Carotid Angiography and Left Internal Carotid Stenting History of Present Illness: Pt is a 62 y.o man w/ h/o CAD s/p "multiple MI's" in [**2168**] w/o interventions, DM, HTN, known 3V CAD and 3+MR, awaiting CABG and MVR, EF 20-25%, presents for elective carotid angiography. He initially presented to the [**Hospital1 18**] from [**9-16**] - [**9-19**] with dyspnea on exertion, chest pain. Cath at that time revealed anterobasal, anterolateral, apical, inferior, posterobasal hypokinesis, 3+ MR, discrete 100% prox RCA w/ collateral flow, discrete 80% prox/mid LAD, 70% diag, 100% Prox Lcx, diffusely diseased otherwise. He was evaluated by CT surgery for CABG w/ MVR and a work up was started for pre-op clearance/eval. Carotid dopplers were c/w [**Country **] stenosis. He was discharged to home with follow up for carotid angiography today w/ Dr [**First Name (STitle) **]. He was admitted initially to the CMI service, awaiting his procedure and was then transferred to the CCU for post-stent care. His carotid angiography revealed: [**Country **] w/ string sign, 99% lesion. [**Doctor First Name 3098**] showed 70% stenosis w/ ulceration. A 7 x 30 mm precise stent was placed in the [**Doctor First Name 3098**]. Patient tolerated the procedure well but was mildly hypotensive (sbp 80's) post-procedure and was started on neo. He was transferred to the CCU for close observation. Past Medical History: 2 MIs 20 yrs ago (patient reports having cath, but w/o intervention DM dx in [**2179**] COPD shoulder surgery Social History: married with 3 children, lives with wife, smoking 2 ppd for 30yrs, no drinking. Family History: dad has HTN, CHF, grandparents have DM. Physical Exam: PE: (upon arrival from cath lab) T 97.0 BP 95/64 P 68 RR 20 95% 2L NC (neo at 0.53 drip) GEN: comfortable, laying supine [**1-19**] cath, no distress HEENT: MMM, OP clear NECK: JVP flat, no JVD, supple CHEST: anterior exam clear with bibasilar crackles around posterior (exam limited [**1-19**] supine position) CV: RRR, [**2-21**] blowing systolic murmur at apex ABD: soft, non-tender, NABS EXTRM: no edema, normal strength, small bruit on right side (unsure if new), minimal hematoma, non tender, 2+ DP pulses bilaterally NEURO: Intact CN exam, good historian Pertinent Results: [**2189-10-2**] 05:43AM BLOOD WBC-7.7 RBC-3.43* Hgb-11.6* Hct-33.9* MCV-99* MCH-33.8* MCHC-34.2 RDW-13.7 Plt Ct-200 [**2189-10-2**] 05:43AM BLOOD Plt Ct-200 [**2189-10-2**] 05:43AM BLOOD PT-12.9 PTT-26.0 INR(PT)-1.0 [**2189-10-2**] 05:43AM BLOOD Glucose-79 UreaN-16 Creat-0.8 Na-140 K-4.5 Cl-104 HCO3-27 AnGap-14 [**2189-10-2**] 05:43AM BLOOD Calcium-9.0 Phos-4.1 Mg-3.2* CAROTID ANGIOGRAPHY: PTCA COMMENTS: Initial angiography demonstrated a 70% lesion in the left ICA with a string sign of the right ICA. Heparin was initiated. A 7F Shuttle sheath was delivered to the left CCA over a Supracore wire. A Filterwire was advanced past the stenosis and deployed. The lesion was then pre-dilated with a 2.5 x 20 mm Crossail at 16 ATM and then stented with a 7.0 x 30 mm Precise stent. The stent was post-dilated with a 4.5 x 20 mm Crossail at 10 ATM. Final angiography demonstrated a 10% residual, no dissections and normal flow. The patient was evaluated by neurology on the table and was without deficits. COMMENTS: 1. Access was retrograde to the carotid and vertebral arteries. 2. Thoracic arch: Type I without significant disease. 3. Subclavian arteries: There was mild ostial left SCA disease. The right SCA had no disease. 4. Carotid/vertebral arteries: The RCCA was normal. The ECA had no disease. The ICA had a 99% lesion with a string sign. THe distal ICA filled only to the base of the skull with contralateral competitive flow from the [**Doctor First Name 3098**] through the ACOM. The intracerebral ICA/MCA and ACA were normal. There was flow from the vertebral to MCA. The LCCA was normal. The ICA had an eccentric 70% without ulceration. The ECA had no disease. The ICA filled the ipsilateral and contralateral ACA and MCA. The vertebral were normal bilaterally. The cerebellar and PCA vessels were normal. 5. Successful stenting of the [**Doctor First Name 3098**] was performed with a 7.0 x 30 mm Precise. FINAL DIAGNOSIS: 1. String sign of the [**Country **]. 2. Severe stenosis of the [**Doctor First Name 3098**]. 3. Stenting of the [**Doctor First Name 3098**]. Brief Hospital Course: Mr [**Known firstname 4580**] was transferred from the cath lab to the CCU in stable condition. 1. Carotid Stenosis: Pt with string sign on right (non-stentable lesion), but had stent placed in [**Doctor First Name 3098**] (due to 70% stenosis w/ ulceration). He tolerated the procedure well. He was loaded with plavix in the cath lab and was started on 75 mg daily for the next month (at least). He remained hypotensive overnight to sbp 80's-100's and remained on phenylephrine overnight (goal sbp was 100-120). He was asymptomatic of this blood pressure and his HR remained in the 60's. He mentated normally and denied any dizziness. We were able to wean the phenylephrine the morning after admission after the administration of several IVF boluses overnight to total approx 600 (200 x 3 over few hours). He ambulated without orthostatic hypotension, his sbp returned to the low 100's. It was thought that this hypotension was due to the procedure, carotid manipulation during procedure. His metoprolol, lisinopril, and lasix were held during admission and should be held until he follows up w/ Dr [**Last Name (STitle) **], 3 days after discharge. * 2. 3VD: awaiting CABG. Had viability study on [**10-1**] and [**10-2**]: prelim read was with good viability for CABG. Elective CABG to occur sometime in next month. On asa/bb (held for now)/statin/ace (held for now), now plavix. * 3. DM: held metformin peri cath. On glipizide and sliding scale. * 4. CHF/[**2-19**]+ MR: to have MVR w/ CABG. EF 20% but not in clinical failure except minor bibasilar crackles. * 5. bruit: doppler ordered to assess right sided bruit-- no recorded exam prior to cath. Doppler negative for pseudoaneurysm or fistula. * 6. dispo: home am after procedure w/ close follow up Medications on Admission: Repaglinide 1 mg TIDAC Rosiglitazone 8 mg daily glipizide 10 mg twice daily asa 325 mg once daily atorvastatin 80 mg daily lisinopril 2.5 mg once daily lasix 40 mg once daily metformin 1000 mg twice daily Discharge Medications: 1. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO QD (once a day): DO NOT TAKE THIS MEDICATION UNTIL YOU SEE DR [**First Name (STitle) **]. Disp:*30 Tablet(s)* Refills:*2* 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day). 4. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO QD (once a day). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): DO NOT TAKE THIS MEDICATION UNTIL YOU SEE DR [**First Name (STitle) **]. 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QD (once a day): DO NOT TAKE THIS MEDCIATION UNTIL YOU SEE DR [**First Name (STitle) **]. 7. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*3* 8. Metformin HCl 1,000 mg Tablet Sig: One (1) Tablet PO twice a day: RESTART THIS ON [**10-3**], AS BEFORE ADMISSION. Discharge Disposition: Home Discharge Diagnosis: 3 VESSEL CAD BILATERAL CAROTID STENOSIS S/P LEFT INTERNAL CAROTID ARTERY STENT CHF HYPERTENSION DIABETES COPD Discharge Condition: stable Discharge Instructions: Take all medications as prescribed. YOU HAVE A NEW MEDICATION, PLAVIX, THAT IS ESSENTIAL TO CONTINUE TO PROTECT YOUR NEW STENT (ALONG WITH ASPIRIN). **PLEASE DO NOT TAKE YOUR METOPROLOL, LISINOPRIL, OR LASIX UNTIL YOU SEE DR [**Last Name (STitle) **] ON MONDAY, [**2189-10-5**] at 1 pm, in his [**Location (un) 620**] office. HE WILL LIKELY RESTART THESE MEDICATIONS THEN IF YOUR BLOOD PRESSURE IS OK. **YOU SHOULD NOT START YOUR METFORMIN UNTIL TOMORROW, [**10-3**]. YOU [**Month (only) **] THEN RESUME THIS MEDICATION. **IF YOU DEVELOP DIZZINESS, LIGHTHEADEDNESS, CHEST PAIN, SHORTNESS OF BREATH, PLEASE CALL 911 AND RETURN TO THE NEAREST EMERGENCY ROOM **DO NOT DRIVE FOR 5 DAYS Followup Instructions: Please follow up w/ Dr [**Last Name (STitle) **] on Monday, [**2189-10-5**], at 1 pm, in his [**Location (un) 620**] office for a blood pressure check. Completed by:[**2189-10-4**]

[ "250.00", "414.01", "428.0", "401.9", "433.30", "424.0", "496", "458.29" ]

icd9cm

[ [ [] ] ]

[ "88.41", "00.63", "00.61" ]

icd9pcs

[ [ [] ] ]

7774, 7780

4830, 6593

398, 465

7934, 7942

2686, 4644

8672, 8855

2045, 2086

6848, 7751

7801, 7913

6619, 6825

4661, 4807

7966, 8649

2101, 2667

295, 360

493, 1799

1821, 1932

1948, 2029

27,049

156,584

25528

Discharge summary

report

Admission Date: [**2199-1-31**] Discharge Date: [**2199-2-15**] Date of Birth: [**2144-10-24**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2181**] Chief Complaint: Drop in Hematocrit, hypoxia Major Surgical or Invasive Procedure: Intubation History of Present Illness: 54 yo with anemia, COPD, h/o cirrhosis, PVD s/p recent AKA, recent admit for MSSA bacteremia and necrotizing LUL pneumonia now on course of CTX comes in from rehab for ?anemia vs increasing oxygen requirement. Pt reported to be desatting to 75-85% on RA (96% on 2L) and also to have Hct of 25, which was described as low; however, she was discharged from the hospital recently with a hct of 24. . Seeing the patient this morning [**1-/2120**] she looked extremely dyspneic, tachypneic w/ RR 40s, confused able to answer some questions, but mostly answering inappropriately. Denies recent fevers. Admits to increased thirst, shortness of breath in past 24 hours. Pt was discharged from [**Hospital1 18**] on [**1-25**] w/ MSSA PNA went to rehab on CTX for antibiotics. She was triggered for increased resp rate, ABG showed 7.32/32/78/17 on 4L oxygen . Of note: Her recent pulmonary history showed persistent hypoxia, she had a VATS procedure and biopsy that showed respiratory bronchiolitis with underlying interstitial lung disease (RB-ILD). After AKA, she represented with a LUL necrotizing PNA that is currently being treated with Ceftriaxone. Her hospital course was also complicated by MSSA bacteremia, which was also sensitive to Ceftriaxone . She was also anemic, with Hct of 24 on discharge, with a set transfusion threshold of 21. On anticoagulation for recurrent thromboses of unknown etiology. Past Medical History: 1. s/p AKA [**11-10**] (right) 2. s/p VATS and hypoxemia, biopsy c/w Respiratory Bronchiolitis-interstitial lung disease (RB-ILD) -- now on intermittent supplemental oxygen 3. PVD - s/p rt. ileo-fem bpg [**12-10**] complicated by lymphocele s/p drainage [**2198-1-11**],rt. ililac/femoral thrombectomy [**4-10**],rt. ileo-fem graft thrombectomy with bovine patchangioplasty [**2196**],rt. ileofem bpg with PTFE [**2195**], 4. chronic pancreatitis s/p Puestow,J-tube,ccy1998,Expl lap [**2189**] 5. ETOH cirrhosis/chronic pancreatitis 6. L breast cyst s/p excision 7. GERD, pud 8. esophagitis with stricture 9. small bowel obstruction 10. PV,SMV thrombosis; h/o DVT/PE 11. asthma/copd on inhalers 12. cervical ca s/p multiple d/c's 13. DM2 insulin dependent 14. entero-colonic fistula 15. cholecystectomy [**06**]. cdiff colitis 17. acute renal failure Social History: Recently discharged from [**Hospital3 **] to home. Married and lives at home generally with her husband, no children. Previously worked as a counselor in drug and alcohol programs. She quit smoking approximately [**12/2198**] with an over 80-pack year history of smoking. She quit drinking alcohol 23 years ago. She has no known exposure to tuberculosis. She was cleaning her husband's clothes during the time that he was working with asbestos for a three-month period. She has one dog at home and reports no allergies to animals. Years ago she had a parrot, a dove, and two parakeets. . Patient was transferred to [**Hospital1 18**] from NH East point [**Telephone/Fax (1) 63761**]. She otherwise lives at home generally with her husband, no children. . Family History: Noncontributory Physical Exam: VS: 98.6, 135/66, HR: 90s-100s, 24, 86% on RA -> 93% on 4L General - Somnolent, but arousable. Not always answering questions appropriately. HEENT - [**Last Name (un) **], MMM, no icteric sclera Neck - non elevated JVP CV - +s1+s2 Tachycardic Hyperdynamic. (thin chest wall) Chest - LUL - coarse. LLL - crackles. RLL with some crackles. Abdomen - mildly tender to deep palpation along RLQ, mildly distended, no dullness to percussin. Surgical scars, + BS. No rebound. No guarding. Ext - Left LE with 1+ edema, warm well perfused. R AKA with dressing, non tense, tender to palpation, no erythema above bandaged site. Palpable R,L fem pulse Pertinent Results: ADMISSION LABS: [**2199-1-31**] 04:00PM BLOOD WBC-7.8 Hgb-6.8* Hct-22.0* Plt Ct-690* [**2199-2-1**] 03:32AM BLOOD WBC-8.7 RBC-2.75* Hgb-8.1* Hct-26.5* MCV-96 MCH-29.5 MCHC-30.6* RDW-15.7* Plt Ct-643* [**2199-1-31**] 04:00PM BLOOD Neuts-82.7* Bands-0 Lymphs-12.6* Monos-3.5 Eos-1.0 Baso-0.2 [**2199-2-2**] 06:00AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL [**2199-1-31**] 04:00PM BLOOD Glucose-65* UreaN-35* Creat-1.1 Na-140 K-5.6* Cl-114* HCO3-20* AnGap-12 [**2199-1-31**] 07:40PM BLOOD ALT-15 AST-19 LD(LDH)-316* CK(CPK)-87 AlkPhos-282* TotBili-0.1 [**2199-1-31**] 07:40PM BLOOD Albumin-2.0* [**2199-2-1**] 03:32AM BLOOD Calcium-7.4* Phos-6.4* Mg-2.4 [**2199-2-1**] 09:40AM BLOOD Hapto-315* [**2199-2-3**] 02:45AM BLOOD Acetone-NEGATIVE [**2199-1-31**] 06:27PM BLOOD Type-ART pO2-92 pCO2-47* pH-7.27* calTCO2-23 Base XS--5 [**2199-1-31**] 06:27PM BLOOD Lactate-0.7 K-5.7* [**2199-2-6**] 02:18AM BLOOD freeCa-1.11* ROMI: . [**2199-2-1**] 09:40AM BLOOD CK-MB-3 cTropnT-0.04* proBNP-[**Numeric Identifier 63762**]* [**2199-1-31**] 07:40PM BLOOD CK-MB-NotDone cTropnT-0.04* LFTS: [**2199-1-31**] 07:40PM BLOOD ALT-15 AST-19 LD(LDH)-316* CK(CPK)-87 AlkPhos-282* TotBili-0.1 [**2199-2-1**] 03:32AM BLOOD ALT-14 AST-16 LD(LDH)-329* AlkPhos-290* TotBili-0.1 [**2199-2-9**] 02:42AM BLOOD ALT-10 AST-12 LD(LDH)-288* AlkPhos-171* TotBili-0.0 [**2199-2-14**] 06:04AM BLOOD ALT-7 AST-45* AlkPhos-386* TotBili-0.1 IN-111 WHITE BLOOD CELL STUDY [**2199-2-12**] . IMPRESSION: 1) Left upper lung pneumonia. 2) No evidence of vascular graft/stent infection, and no other site of infection. 3) Rectal tube balloon may be overinflated. CHEST (PORTABLE AP) [**2199-2-12**] 4:20 AM . CHEST AP: Cardiac, mediastinal and hilar contours are unchanged. Endotracheal and nasogastric tubes have been removed. Right-sided PICC tip is in the SVC. The left pulmonary opacities are not significantly changed from prior exam. There continues to be right lower lobe atelectasis. There are moderate bilateral pleural effusions which accounting for differences in technique are not significantly changed. Re-distribution of effusion along the left lateral chest is likely positional in nature. . IMPRESSION: Accounting for differences in technique, the bilateral pulmonary opacities and moderate pleural effusions are not significantly changed. TEE [**2-6**] 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. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the procedure. The patient was sedated for the TEE. Medications and dosages are listed above (see Test Information section). No TEE related complications. Conclusions LV systolic function appears depressed. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. There are filamentous strands on the aortic leaflets consistent with Lambl's excresences (normal variant). No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. Mild to moderate ([**12-5**]+) mitral regurgitation is seen. . IMPRESSION: No 2D echocardiographic evidence of endocarditis or abscess. Mild to moderate mitral regurgitation. Depressed LV function. TTE [**2199-2-4**] The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Systolic function of apical segments is relatively preserved. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. No patent ductus arteriosus is seen. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. . Compared with the prior study (images reviewed) of [**2198-12-13**], trace aortic regurgitation and low normal left venticular systolic function are seen on the current study (c/w diffuse process - toxin, metabolic, etc.). A PDA is not seen on review of the prior study nor on the current study. Brief Hospital Course: 54 yo F with multiple medical problems including COPD, EtOH cirrhosis, pancreatitis, PVD s/p AKA in [**11-10**] who initially presented with MSSA bacteremia and pneumonia, started improving on antibiotics then returned [**1-31**] with worsening oxygen requirement in the setting fo superimposed influenza B. She was being treated with broad antibiotics including cefazolin and clindamycin (vancomycin has been discontinued). The patient required intubation on [**2-6**], extubated [**2-11**], now on 4L oxygen requirement with o2 at 98%/4L. The Influenza B infection was treated with 5 day course of Oseltamivir [**Date range (1) 56769**]. MI was ruled out due to no ECG changes, no ST changes, no TWI, and Trops at 0.04. . In addition, given her MSSA bacteremia and worsened respiratory status, patient was investigated for possibility of endocarditis, TTE and TEE were negative although she did have [**Last Name (un) 1003**] lesions and [**Doctor Last Name **] spots identified. Pt also had a thigh CT to investigate possibility of R thigh graft infection, which was negative. A WBC scan showed a left upper lung pneumonia that we know about, and no evidence of vascular graft/stent infection, and no other site of infection . # Hypoxemia: Patient has persistent hypoxemia, most likely from necrotizing pneumonia, s/p Influenza B infection, also combination of CHF, COPD, persistent bilateral pleural effusion. She was placed on Ceftriaxone for her necrotizing PNA. A CT Chest questioned new infiltrates vs. worsening of ILD or PNA, and oxygen requirement increased to 4L. Patient also appeared fluid overloaded. Patient responded well to diuresis. Pt had to be transfered to the medical ICU for intubation, for hypoxic respiratory failure. She was intubated [**2-6**]-extubated [**2-11**]. She responded well to duonebs, chest PT, and incentive spirometry. . # Necrotizing pneumonia: CXR on [**2199-1-31**] showed dense left upper lobe consolidation consistent with known prior necrotizing pneumonia, loculated left pleural effusions due to the likely superimposed viral infection, and a left basilar atelectasis. A DFA tests was positive for influenza B virus. She received ceftriaxone, vancomycin clindamycin and cefazolin while in the hospital. Pt completed a 10 days course of clindamycin for any anaerobic causes of her PNA while in the hospital. She was started on cefapime [**2-2**]-d/c [**2-8**]. She was then placed on cefazolin 2gm q8h, for a 4week course. Pt transferred to rehab with picc, scheduled to finish her cefazolin on [**3-4**]. Pt is to get follow up CT in less than a month as listed in d/c instructions. She is to have CBC, LFTs and to have this information faxed to Dr. [**Last Name (STitle) 7443**]. Pt should also redceive Chest PT, incentive spirometry and Guafenison. . #Supratherapteutic INR: Patient was bridged from heparin back to coumadin for her history of venous and arterial clots, prior R illeo-fem graft clot. At discharge INR was 6.0. Indication to hold coumadin for 2 days. Check INR on [**2-16**], titrate up. #COPD: Patient continued to respond to duonebs standing at q6 hours albuterol, q6h ipratropium, and Q2 PRN Nebs. During hospital stay patient received one time dose of 125mg methyprednisolone. Pulmonary consultants were unconvinced that she had a copd exacerbation. . #RB-ILD: Disease monitored in house. Pulmonary consultants did not believe to be having worsening of this condition. . # Coccyx skin infection: Skin checks was ordered to prevent bed sores. Nursing skin/wound care was consulted for a minor coccyx skin infection and patient was placed in a buffy bed to prevent further wound care. . #Phlebitis/cellulitis: On admission prior Picc site was erythematous as was lower L leg. Concern for cellulitis. Picc tip no growth. Pt received IV vanco in house for treatment. Resolved at d/c. . # Influenza B infection: DFA-B positive, may have been insighting trigger to resp failure. Pt treated with 5 day course of oseltamivir. . # Ruled out for endocarditis: Negative TTE/TEE. Despite [**Doctor Last Name **] spots and jainway lesions. . # Aortic Atheroma: [**Month (only) 116**] be cause of [**Last Name (un) 1003**] lesions and [**Doctor Last Name **] spots. Needs to be monitored by PCP. . # Hypertension: A regimen was created during MICU course. At discharge patient was normotensive on metoprolol 75mg q8h, and lisinopril 20mg daily. . # Anemia: No active bleeding. Pt received PRN transfusions two units overall while in hospital. Discharge HCT was 24.5. All guaic stools negative. . # Pancreatitis: Chronic, thought to be [**1-5**] alcohol use in past, continues pancrease supplementation with diet. Not active admission. . # Cirrhosis: continue lactulose, titrate to 3 BMs daily, to prevent encephalopathy. Continue thiamine, folate, vitamins with PRN lasix. . #Phantom Limb pain: Discharge regimen Gabapentin 600mg TID, Amitriptyline 50mg, Lidocaine patch, Morphine SR 50mg Q12h, 2-4mg morphine IV q4-6h:prn. . # DM: Patient has finger sticks and sliding scale insulin. We titrated NPH as needed, pt had NPH standing doses at 7 units for breakfast and dinner. . # Hx of venous and arterial thrombi: Patient was on heparin gtt during her stay with an INR goal [**1-6**], and she was therapeutic [**Date range (1) 63763**]. She began to become supertherapeutic after she was restarted on Coumadin 3mg qhs and Coumadin/Heparin was discontinued . # Left hand dermatitis: Dr.[**Last Name (STitle) 63764**] was consulted from Dermatology on [**2-2**] and confirmed [**Last Name (un) 1003**] lesions, splinter hemorrhages, positive endocarditis stigmata. A biopsy was done and sutures were placed, specimen was demonstrated a negative gram stain/culture, fungal cx, anaerobic culture. . # Cholystasis: alk phos of 280 should be followed up with PCP. . # Depression: Continued Duloxetine . # Hypernatremia: Na of 151, responded to D5W. At discharge 146. . # FEN: Low Na/DM diet. . # Access: PICC . # Communication: Husband [**Name (NI) **] [**Name (NI) 7168**] [**Telephone/Fax (1) 63765**]. . # Code: Full code as discussed w/ Pt and HCP [**Name (NI) **] . # Dispo: Acute Rehab, pending clinical improvement. Patient will be followed by Primary Care physician and with Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7443**] from Infectious Disease. Medications on Admission: Ranitidine 150mg PO BID Zofran PRN Advair [**Hospital1 **] Atorvastatin 20 mg PO DAILY Lisinopril 5mg daily Metoprolol 25mg TID ISS Duloxetine 60mg daily Tiotropium Bromide 18 mcg daily inhalation ZnSO4 220mg daily Amitriptyline 50 mg PO HS Benzocaine 20 % Paste TID:PRN Dextromethorphan-Guaifenesin 10-100 mg/5 mL, Syrup Sig: 5-10ml PO Q6H PRN NPH 8 units qam and 5 units qpm Hexavitamin Tablet daily Folic Acid 1 mg daily Thiamine HCl 100 mg PO once a day. Albuterol PRN Fexofenadine 60mg PO BID Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule PO TID W/MEALS Gabapentin 400mg PO Q8H Medium Chain Triglycerides Oil 15ml TID Aspirin 325 mg daily Colace 100mg TID Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H PRN Morphine 45 mg Sustained Release PO Q12H Warfarin 3mg daily, Saturday/Sunday 2mg Ceftriaxone-Dextrose 1g Q24H (every 24 hours) for 18 days until [**2199-2-12**] Discharge Medications: 1. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q4-6H () as needed for pain: hold for sedation or RR below 12. 2. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 5. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO Q8H (every 8 hours). 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours). 9. Morphine 50 mg Capsule, Sust. Release Pellets Sig: One (1) Capsule, Sust. Release Pellets PO Q12H (every 12 hours). 10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 11. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 12. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: One (1) Subcutaneous twice a day: Patient has been receiving 7 units NPH at breakfast and 7 units NPH at dinner. 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 14. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Amitriptyline 25 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 16. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO QAM (once a day (in the morning)). 17. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 19. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 20. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [**4-13**] MLs PO Q6H (every 6 hours) as needed. 21. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 22. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 23. Medium Chain Triglycerides Oil Sig: Fifteen (15) ML PO TID (3 times a day). 24. Cefazolin in D5W 2 gram/100 mL Solution Sig: One (1) Intravenous every eight (8) hours for 19 days: 2grams cefazolin q 8H. Start date of therapy [**2-8**] end date [**3-4**]. Replacing Cefepime [**Date range (1) 23163**]. . 25. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q2H (every 2 hours) as needed for wheezing. 26. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours). 27. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 28. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 29. Outpatient Lab Work CBC, Chem7, Liver function tests, weekly basis and send the results by fax to Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7443**] at [**Telephone/Fax (1) 1419**]. 30. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO three times a day: TID w/ meals. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary: #. Hypoxemia #. Hypoxic Respiratory Failure #. Necrotizing Pneumonia #. MSSA Bacteremia #. COPD Secondary: #. Phlebitis/cellulitis Left arm #. Tacyhycardia #. Anemia #. Congestive heart failure #. Left hand dermatitis #. Altered Mental Status #. Acute renal faliure #. Cholecystasis #. Hyperkalemia #. Diabetes II #. Thrombocytosis- likely reactive #. GERD #. Hx of small bowel obstruction #. Hx of DVT/PE, SMV thrombosis #. Hx of Cervical Ca multiple d/cs #. Hx of Cdiff colitis #. Esophagitis w/ stricture #. AKA [**11-10**] (right) #. VATS in [**12-11**] #. Respiratory Bronchiolitis-interstitial lung disease #. PVD - s/p rt. ileo-fem bpg [**12-10**] complicated by lymphocele s/p drainage [**2198-1-11**],rt. ililac/femoral thrombectomy [**4-10**],rt. ileo-fem graft thrombectomy with bovine patchangioplasty [**2196**],rt. ileofem bpg with PTFE [**2195**]. #. Chronic pancreatitis s/p Puestow,J-tube. #. Hx of ETOH cirrhosis/chronic pancreatitis #. Hx of L breast cyst s/p excision Discharge Condition: Stable. HCT 24/5 at d/c. Needs home oxygen Saturating 93-94% on 2.5L n/c oxygen. Discharge Instructions: You were admitted for question of worsening anemia, severe dyspnea, tachypnea, and tachycardia. You were found to have a worsening of respiratory status. You had to be intubated to help support your breathing. You improved with antibiotics, diuretics and nebulizer treatments. You received several types of echocardiograms which failed to show any type of infection on any of your valves. You also received a WBC scan which did not show any other area of infection outside the area of your lung. You had a CT study of your leg which showed no abnormalities with your graft. . We modified your pain medication while you have been in the hospital. . Please continue to take your antibiotic Cefazolin until [**2199-3-4**]. . Please take all of your medications as below. . Please have your acute rehabilitation center at [**Hospital1 **] check your complete blood count, White Blood Cell Differential, Liver function tests, and BUN/Creatinine on a weekly basis and send the results by fax to Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7443**] at [**Telephone/Fax (1) 1419**]. He will be monitoring your laboratory values during your recovery . Please return to the emergency department or call your primary care provider if you experience mental status changes, difficulty breathing, fevers greater than 101.5 degrees F, somnolence, worsening pain, or any other symptoms that concern you. Followup Instructions: Please attend the following medical appointments: 1) Provider [**Last Name (NamePattern4) **]. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 5302**] Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2199-3-1**] 9:40AM . 2) Provider CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2199-2-27**] 1:45PM [**Hospital Ward Name 23**] Building [**Location (un) 861**] . 3) Provider PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2199-3-27**] 4:10PM . 4) Provider [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2199-3-11**] 10:00AM. [**Hospital **] Medical Office Building Suite GB.

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icd9cm

[ [ [] ] ]

[ "96.72", "96.04", "33.24", "86.11", "88.72", "96.6" ]

icd9pcs

[ [ [] ] ]

19280, 19359

8870, 15210

301, 313

20400, 20483

4101, 4101

21941, 22663

3410, 3427

16144, 19257

19380, 20379

15236, 16121

20507, 21918

3442, 4082

234, 263

341, 1746

4117, 8847

1768, 2621

2637, 3394

16,371

136,139

16762+16763+16764+56802

Discharge summary

report+report+report+addendum

Admission Date: [**2112-1-12**] Discharge Date: [**2112-1-14**] Service: MEDICAL ICU CHIEF COMPLAINT: Tremors. HISTORY OF PRESENT ILLNESS: The patient is an 81 [**Hospital **] nursing home resident brought to the Emergency Department for tremors and found to have electrocardiogram changes and a potassium of 9.6. She was brought emergently to dialysis for hyperkalemia. While on dialysis she had a drop in her blood pressure to 79/56, which responded well to 1.3 liters of intravenous fluid boluses. Per nursing home records she has mild chronic renal insufficiency with a baseline creatinine of approximately 1.5. A urinalysis was performed, which showed greater then 50 white blood cells, many bacteria and pus in appearance. Per report from nursing home she has complained of dysuria for approximately the last week. At baseline the patient is severely demented and per family at baseline she is about alert and oriented times one. She has had frequent falls at the nursing home over the last month and additionally has had chronic diarrhea. She had stool incontinence times one on the day of admission. Per report she has had no fevers or chills, nausea, vomiting or abdominal pain. Although she frequently cries out in discomfort she does not pinpoint any area of pain. PAST MEDICAL HISTORY: 1. Dementia, Alzheimer's type. 2. Hypothyroidism. 3. Left breast carcinoma status post mastectomy. 4. Depression. 5. Anemia. 6. Chronic obstructive pulmonary disease. 7. Congestive heart failure with an EF of 20% as measured in [**2109-11-20**]. 8. History of left hip fracture. 9. ITP, which appears to have been diagnosed by a bone marrow biopsy as the patient has known pancytopenia. 10. Chronic pulmonary fibrosis. MEDICATIONS ON ADMISSION: 1. Zestril 10 mg po q day. 2. Digoxin 0.125 q.d. 3. Lasix 60 mg po q day. 4. Aldactone 25 mg q.d. 5. Celexa 20 mg q.d. 6. Synthroid 0.05 mg q day. 7. Aricept 5 mg po q day. 8. Oxycodone started one day prior to admission. 9. Multivitamin. 10. Calcium with vitamin D 600 mg b.i.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is a nursing home resident at [**Hospital3 **] Center. She is widowed and has two daughters, which are active in her health care decision making. Her son-in-law is a hematologist. The patient is DNR/DNI. PHYSICAL EXAMINATION ON PRESENTATION TO THE EMERGENCY DEPARTMENT: Temperature 96.0. Blood pressure 90/58, which improved to 112/50 with fluids. Heart rate 60. Respiratory rate 20. Oxygen saturation 98% on room air. Vital signs on presentation to the MICU temperature 100.4, blood pressure 141/93, heart rate 107, respiratory rate 19, oxygen saturation 97% on room air. On physical examination the patient is a thin elderly woman lying flat in bed. She has occasional myoclonic jerks. On HEENT jugulovenous pulsations was not elevated. Her left eye was closed with some minor difficult opening. Her mucous membranes were very dry. Pupils are equal, round and reactive to light. Her neck was supple. On lung auscultation her lungs were clear to auscultation with decreased inspiratory effort and limited secondary to patient cooperation. Cardiovascular examination heart was regular rate and rhythm with a 3/6 systolic murmur at the left upper sternal border, which radiated to the carotids. Abdominal examination soft, nontender, mild distention with decreased bowel sounds. Extremity examination right Quinton catheter is in place without signs of hematoma. Her bilateral dorsalis pedis pulses and posterior tibial pulses were 2+. She had no pain with axial loading of the lower extremities and there is no pain on palpation of the hip. There is no ecchymosis or rashes. On neurological examination she was alert and oriented times zero. She moved all four extremities without difficulty. Cranial nerves II through XII intact. LABORATORY VALUES: White blood cell count 8.9 with a normal differential. Hematocrit 29.9, platelets 120, sodium 135, potassium 9.6, chloride 109, bicarb 14, BUN 87, creatinine 4.0, glucose 154, calcium 8.9, phosphorus 6.9, magnesium 2.3, PT 14.3, PTT 31.5, INR 1.5. Digoxin level is 1.0. CK was 71. PERTINENT STUDIES DURING HOSPITALIZATION: 1. Urinalysis specific gravity 1.025, moderate blood, protein 100, trace ketones, moderate leukocyte esterase, nitrite negative, 3 to 5 red blood cells, greater then 50 white blood cells, many bacteria. 2. Urine culture pan sensitive E-Coli. 3. Electrocardiogram on admission showed wide QRS complex and a left bundle branch block morphology with peak T waves. No acute ST or T wave changes when compared with electrocardiogram date [**2111-9-15**]. 4. Chest x-ray no evidence of congestive heart failure or pneumonia. 5. Plain film of the hip no acute fracture, status post open reduction and internal fixation on the left. IMPRESSION: The patient is an 81 [**Hospital **] nursing home resident presenting with hyperkalemia brought emergently to hemodialysis complicated by urinary tract infection. HOSPITAL COURSE: 1. Renal: The patient's initial presentation was for tremors and a potassium was checked and found to be 9.6, which was confirmed on duplicate analysis. She was given Kayexalate, insulin along with D50, bicarb and Lasix while in the Emergency Department. A Quinton catheter was placed in her right groin and she was taken emergently to hemodialysis. Dialysis was complicated with mild hypertension with a systolic blood pressure in the 80s, which responded well to fluid boluses. Her creatinine also increased from a baseline of 1.5 to 4.0 on admission. Both of her creatinine and hyperkalemia improved after hemodialysis and potassium remaining stable around 4.5 for the remainder of her hospital course. A renal ultrasound was performed secondary to acute on chronic renal failure and was notable for atrophic right kidney with a large renal cyst in the right kidney as well. The etiology of her acute renal failure was not completely clear, however, it was felt to be multifactorial with a urinary tract infection, dehydration and cardiac medications including ace inhibitor and spironolactone as well as questionable non-steroidal anti-inflammatory drugs use at the nursing home being the most likely source for renal failure. The Quinton catheter was pulled prior to discharge without incident. 2. Cardiovascular: On admission the patient with a history of congestive heart failure from an echocardiogram performed [**2109-11-20**] with an EF of 20%. During her Medical Intensive Care Unit stay she had an episode of atrial fibrillation with rapid ventricle response with heart rates around 100 to 130s. The atrial fibrillation broke with 5 mg of Lopressor intravenous and 12.5 of Lopressor po. A set of cardiac enzymes were checked and she was found to have a mild increase in her CK from 100 to 300 and there was a slight troponin leak to 1.2. The troponin leak was thought secondary to demand ischemia as the patient was not only tachycardic, but had a hematocrit of 23 during the episode. Her cardiac enzymes trended down for the remainder of her hospital course and it was felt that no further intervention was necessary. In working up the atrial fibrillation a repeat echocardiogram was performed, which showed a normal ejection fraction of greater then 55% with no wall motion abnormalities and a trivial pericardial effusion. As this echocardiogram is not consistent with a diagnosis of congestive heart failure her cardiac medications were simplified during this admission. She was continued on her ace inhibitor, but discontinued Lasix and Spironolactone and Digoxin. She was started on beta blocker for rate control secondary to atrial fibrillation and given Lipitor and a baby aspirin. It was felt that the previous echocardiogram, which showed an EF of 20% may have been during a peri myocardial infarction and the patient had recovery of functio with reperfusion. 3. Hematology: Patient with known pancytopenia at baseline, which was evaluated by a bone marrow biopsy while at [**Hospital 100**] Rehab. The complete results of bone marrow biopsy were not known and per report it was felt that biopsy was consistent with ITP. On presentation her hematocrit was 29, which fell to 23 with fluid hydration. She received 1 unit of packed red blood cells with an appropriate bump in her hematocrit. Of note her INR was slightly increased, which was felt to be secondary to possible nutritional deficiency. The option of starting Coumadin secondary to atrial fibrillation was discussed, however, given the patient's frequent falls at nursing home it was felt that anticoagulation should not be started at this time. 4. Infectious disease: On admission the patient had a urinalysis consistent with urinary tract infection. Urine culture grew out E-coli at greater then 100,000 organisms, which was pan sensitive to all antibiotics except Ampicillin. A gram positive bacteria growing at 10 to 100,000 organisms was also identified, but not speciated. She was started on Levaquin250 mg po q day to be continued for seven to ten days. 5. Neurology: At baseline the patient is severely demented secondary to Alzheimer's. On admission she was found to be agitated and frequently cried out without any provocation. She did not identify any sources of pain. After hemodialysis and initiation of antibiotic therapy her mental status cleared significantly and at the time of dictation she had waxing and [**Doctor Last Name 688**] mental status, however, overall she appeared to be alert and oriented times two and at times alert and oriented times three. She had impairment of opening the left eye on admission, however, this seemed to resolve without any intervention. Cranial nerves were intact and there were no focal neurological deficits noted on examination. 6. Orthopedics: Due to frequent falls at the nursing home and an ill defined pain complaints a hip film was performed. They showed no signs of acute fracture and open reduction and internal fixation of the left femur. On physical examination she had no findings suggestive of hip fracture either. DISCHARGE CONDITION: Stable and improved. DISCHARGE DIAGNOSES: 1. Acute on chronic renal failure likely secondary to dehydration, urinary tract infection, nephrotoxic medications. 2. Urinary tract infection. 3. Paroxysmal atrial fibrillation. 4. Anemia. 5. Thrombocytopenia. 6. Demand induced cardiac ischemia. 7. Hypothyroidism. 8. Altered mental status, improved. 9. History of Alzheimer's dementia. 10. Chronic obstructive pulmonary disease. DISCHARGE MEDICATIONS: 1. Zestril 10 mg po q day. 2. Metoprolol 25 mg po b.i.d. 3. Aspirin 81 mg po q day. 4. Lipitor 10 mg po q day. 5. Celexa 20 mg po q day. 6. Synthroid 50 micrograms po q day. 7. Aricept 5 mg po q day. 8. Multivitamin one tab po q day. 9. Calcium with vitamin D one tab po b.i.d. 10. Levaquin 250 mg po q day times seven days, last dose on [**2112-1-21**]. DISCHARGE INSTRUCTIONS: The patient is to be discharged to [**Hospital 100**] Rehab facility and follow up by attending physician [**Name Initial (PRE) **]. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2112-1-14**] 12:58 T: [**2112-1-14**] 13:04 JOB#: [**Job Number 47362**] Admission Date: [**2112-1-12**] Discharge Date: [**2112-1-23**] Service: [**Hospital1 **] HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 47363**] is an 81[**Hospital 4622**] nursing home resident who was brought to the Emergency Department for tremors and found to have a potassium of 9.6 and brought emergently to dialysis. While in dialysis, she had a decrease in her blood pressure to 79/56 which responded to a 1.3-liter intravenous fluid boluses. Per records, she has had mild chronic renal insufficiency (with a baseline creatinine of 1.5). A urinalysis was performed and was found to have greater than 50 white blood cells and many bacteria with puffs. Per report, dysuria has occurred for one week prior to admission. At baseline, the patient is demented; and per the family she is alert and oriented to person. She frequently has falls at the nursing home and cries out for mother. The patient has been noted to have chronic diarrhea at the nursing home. She was incontinent of stool on admission. She denies any pain currently. She stated that she did not have an nausea, vomiting, fevers, or chills. On admission, she frequently screamed out in pain; however, she could not point to any area that hurt more another. The patient was admitted to the Medical Intensive Care Unit for hypovolemia, renal failure, and hyperkalemia. The patient was emergently dialyzed. In the interim, her potassium had corrected to a value of 4.5, and her creatinine to a value of 1.8 prior to transfer. She has been treated for a urinary tract infection. On [**1-12**], she had an episode of atrial fibrillation potentially secondary to anemia which precipitated demand ischemia (troponins were elevated at 1.2). An echocardiogram was performed which revealed a normal ejection fraction. She was transferred complaining of some buttock pain, but otherwise was without complaints. Her mental status had returned to baseline prior to being transferred to the medical floor. She denied chest pain, nausea, vomiting, diarrhea, shortness of breath, orthopnea, lower extremity edema, and pain in hips or pelvis. PAST MEDICAL HISTORY: 1. Chronic renal insufficiency. 2. Dementia. 3. Hypothyroidism. 4. Left breast cancer; status post mastectomy. 5. Depression. 6. Anemia. 7. Chronic obstructive pulmonary disease. 8. Congestive heart failure (with an ejection fraction of 20% in [**2109-11-20**]). 9. History of left hip fracture. 10. Idiopathic thrombocytopenic purpura. MEDICATIONS ON TRANSFER: 1. Levofloxacin 250 mg p.o. q.24h. 2. Levothyroxine 750 mcg p.o. q.d. 3. Multivitamin one tablet p.o. q.d. 4. Pantoprazole 40 mg p.o. q.24h. 5. Acetaminophen 500 mg to 1000 mg p.o. q.4-6h. as needed. 6. Aspirin 81 mg p.o. q.d. 7. Atorvastatin 10 mg p.o. q.d. 8. Metoprolol 12.5 mg p.o. b.i.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient resides at [**Hospital3 **] Center. She is widowed. She has two daughters. FAMILY HISTORY: Family history was noncontributory. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed temperature was 98.4, heart rate was 64, blood pressure was 160/62, respiratory rate was 20, oxygen saturation was 99% on room air. In general, an elderly woman in no acute distress. Head, eyes, ears, nose, and throat examination sclerae were anicteric. Pupils were 2 mm. Reactive to light. Mucous membranes were moist. Neck examination revealed normal jugular venous pressure and supple. No lymphadenopathy. Lungs were clear to auscultation bilaterally. Heart examination revealed a regular rate and rhythm. Normal first heart sound and second heart sound. A 26holosystolic murmur at the apex radiating to the axilla. The abdomen was soft, nontender, and nondistended. Bowel sounds were normoactive. Extremity examination revealed no peripheral edema. Dorsalis pedis pulses were not palpable, but her feet were warm, well perfused. Neurologically, alert, oriented to hospital and month. Impaired short-term memory. Did not remember the year after five minutes. Did not know she was ..................... PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on admission revealed white blood cell count was 8.9, hematocrit was 29.9, and platelets were 120. Sodium was 135, potassium was 9.6, chloride was 109, bicarbonate was 14, blood urea nitrogen was 87, creatinine was 4, and blood glucose was 154. Calcium was 8.9, phosphate was 6.9, and magnesium was 2.3. PT was 14.3, PTT was 31.5, and INR was 1.4. Urinalysis demonstrated a specific gravity of 1.025, moderate blood, 100 protein, moderate leukocyte esterase, negative nitrites, 3 to 5 red blood cells, and greater than 50 white blood cells. A digoxin level was obtained and was 1. PERTINENT LABORATORY VALUES ON DISCHARGE: Laboratory values prior to discharge revealed white blood cell count was 4.1, hematocrit was 31.9, and platelets were 68. Blood urea nitrogen was 20, creatinine was 1.1, and potassium was 4. RADIOLOGY/IMAGING STUDIES DURING ADMISSION: A renal ultrasound on [**2112-1-13**] demonstrated right kidney which was atrophic (measuring 6 cm). The left kidney appeared normal without hydronephrosis (measuring 10.9 cm). A left hip film on [**2112-1-12**] demonstrated no acute fracture. A right hip film obtained on [**2112-1-15**] demonstrated a right iliac bone which was abnormal with loss of the usual trabecular pattern and fracture of the anterior superior iliac spine. There was no fracture of the right proximal femur. Moderate degenerative changes were seen in the right hip. A computed tomography scan of the pelvis on [**2112-1-16**] demonstrated extensive lytic lesions within the right iliac bone with several superimposed areas of nondisplaced pathology fractures in the right iliac [**Doctor First Name 362**], displaced fracture at the tip of the right iliac [**Doctor First Name 362**]. There was a large soft density tissue mass adjacent to the right iliac bone. A long bone series on [**2112-1-17**] demonstrated the fracture involving the anterior superior aspect of the right iliac spine; however, there were no other fractures, dislocations, lytic, or sclerotic lesions. A magnetic resonance imaging without gadolinium was performed on [**2112-1-19**] which demonstrated expansion of the medullary cavity of the right ilium with abnormal decreased T1 and increased STIR signal identified within the right iliac [**Doctor First Name 362**] and extending inferiorly into the right acetabular roof. The increased STIR signal identified within the right iliac muscle and the right gluteus minimus muscle likely represented a reactive change with the exact amount of soft tissue extension into these muscles difficult to assess without gadolinium. A small sacral nerve root diverticulum was noted on the left. Splenomegaly was noted. A magnetic resonance imaging with gadolinium was scheduled and complained on [**2112-1-22**] with results pending. An echocardiogram performed on [**2112-1-14**] demonstrated left atrium was normal in size. The left ventricular wall thickness, cavity size, and systolic function were normal. Mild pulmonary artery systolic hypertension was noted. An electrocardiogram on [**2112-1-12**] demonstrated a regular rate and rhythm, rate was 51, left bundle-branch morphology. ST-T wave abnormalities with marked T waves. Electrocardiogram on [**2112-1-20**] demonstrated a sinus rhythm with bradycardia. Broad QRS interval. Left bundle-branch block. HOSPITAL COURSE: 1. CARDIOVASCULAR SYSTEM: The patient was transferred to the Medicine Service with mildly elevated troponins; likely secondary to demand ischemia precipitated by anemia. Her peak troponin was 1.2 and decreased to 0.7 promptly on [**2112-1-15**]. The patient was continued on metoprolol and aspirin; however, diuretics and digoxin were discontinued secondary to the echocardiogram results. 2. RENAL SYSTEM: The patient's potassium improved rapidly with dialysis. On admission, potassium was 9.6 and decreased to 4.9 on the day of admission status post dialysis. On the day of discharge, the patient's potassium was 4. Ms. [**Known lastname 47363**] also presented with an acute-on-chronic renal failure. Her admission creatinine was 4; and with aggressive hydration, her creatinine quickly returned to baseline. The patient's creatinine on [**2112-1-21**] was 1.1. Prior to discharge, the patient was taking adequate oral fluids and no longer required maintenance intravenous fluids. 3. INFECTIOUS DISEASE: On admission, the patient's urinalysis was consistent a urinary tract infection. A urine culture was obtained and was positive for Escherichia coli with greater than 100,000 organisms per mL. This organism was sensitive to levofloxacin. 4. HEMATOLOGIC SYSTEM: Ms. [**Known lastname 47363**] was noted to have pancytopenia. Thrombocytopenia was previously described as idiopathic thrombocytopenic purpura, status post a bone marrow biopsy. Ms. [**Known lastname 47363**] was also noted to be anemic during this admission. Her hematocrit was 26.4 at its lowest on [**2112-1-14**]. She received 2 units of packed red blood cells with an appropriate increase in her hematocrit to 32.8 on the following day. The patient's hematocrit on discharge was 31.9. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**] Dictated By:[**Last Name (NamePattern1) 20054**] MEDQUIST36 D: [**2112-1-23**] 04:34 T: [**2112-1-23**] 05:59 JOB#: [**Job Number 47364**] Admission Date: [**2112-1-12**] Discharge Date: [**2112-1-23**] Service: ADDENDUM: This discharge addendum is to continue where a previous discharge summary ended. HEMATOLOGY/ONCOLOGY: After resolution of Ms. [**Known lastname 47365**] acute on chronic renal failure, she was transferred to the medical floor in good condition. It was at this time that she had noted some right hip pain, and as she has a history of multiple falls, plain films were obtained to further evaluate this symptom. The x-rays demonstrated a fracture of the right iliac bone involving the anterior superior iliac spine. The Orthopedic Service was contact[**Name (NI) **] regarding possible stabilization of this fracture, however, they admitted that there was nothing that could be done with this type of fracture. A follow-up CT scan was recommended secondary to some pathologic fractures and lytic lesions demonstrated at that area. The follow-up CT scan showed a lytic lesion involving the right iliac bone and the sacrum with several areas of pathologic fractures. There were soft tissue masses noted to be surrounding the right iliac bone. A skeletal survey demonstrated no other areas of fractures, dislocations, lytic or sclerotic lesions. An MRI without contrast was obtained to further delineate the possibility of soft tissue involvement. These results were consistent with expansion of the medullary cavity of the right ileum. The multiple fractures within the iliac [**Doctor First Name 362**] were visualized. The Hematology/Oncology Service was contact[**Name (NI) **] and agreed with obtaining tissue from the soft tissue lesion prior to making a decision regarding aggressiveness of care. This was discussed with the family and the family was in agreement with this plan. The CT-guided biopsy was unable to be performed while the patient was admitted. Further workup for this soft tissue mass will be determined by the patient's primary care physician. [**Name10 (NameIs) **] note, an SPEP and UPEP were sent and the results were negative. Although the right hip pain was not present at rest, this area gave the patient significant discomfort. PHYSICIAN [**Last Name (NamePattern4) **]: Ms. [**Known lastname 47363**] will need to be followed by her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], while she is at [**Hospital3 **]. The remainder of the workup for this soft tissue mass can occur at that time. A CT-guided biopsy will be the next step in the patient's overall evaluation. DISCHARGE DIAGNOSIS: 1. Acute on chronic renal failure likely secondary to dehydration, urinary tract infection, nephrotoxic medications. 2. Urinary tract infection. 3. Paroxysmal atrial fibrillation. 4. Anemia. 5. Thrombocytopenia. 6. Demand-induced cardiac ischemia. 7. Hypothyroidism. 8. Altered mental status, improved. 9. History of Alzheimer's dementia. 10. Chronic obstructive pulmonary disease. 11. Soft tissue mass of unknown etiology. DISCHARGE MEDICATIONS: 1. Metoprolol 25 mg p.o. b.i.d. 2. Amlodipine 10 mg p.o. q.d. 3. Percocet one to two tablets p.o. q. 4-6 hours p.r.n. 4. Lipitor 10 mg p.o. q.d. 5. Levothyroxine sodium 50 micrograms p.o. q.d. 6. Celexa 20 mg p.o. q.d. 7. Aricept 5 mg p.o. q.d. DISCHARGE CONDITION: Good. DISCHARGE STATUS: The patient is being discharged to [**Hospital3 1761**] Center. DISCHARGE INSTRUCTIONS: Ms. [**Known lastname 47363**] will require a higher level of care at [**Hospital3 **] Center until the hip lesion can be addressed. PHYSICIAN [**Last Name (NamePattern4) **]: ms. [**Known lastname 47363**] is to follow-up with her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in one to two weeks. Ms. [**Known lastname 47363**] will require a CT-guided biopsy of the soft tissue lesion. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1636**] Dictated By:[**Last Name (NamePattern1) 20054**] MEDQUIST36 D: [**2112-1-23**] 08:14 T: [**2112-1-23**] 08:22 JOB#: [**Job Number 47366**] Name: [**Known lastname 8760**], [**Known firstname 8761**] Unit No: [**Numeric Identifier 8762**] Admission Date: [**2112-1-12**] Discharge Date: [**2112-1-27**] Date of Birth: [**2030-3-21**] Sex: F Service: [**Hospital1 1098**] This discharge addendum is continued with a previous discharge summary. Hematology/Oncology: Mrs. [**Known lastname **] had MRI with gadolinium demonstrating a soft tissue mass infiltrating the right iliac [**Doctor First Name **] and extending out beyond the bone anteromedially and posterolaterally. It was determined that this soft tissue mass was amenable to a CT-guided biopsy, and this was performed by Interventional Radiology on [**2112-1-26**]. Pathology is pending at the time of this dictation. Dr. [**Last Name (STitle) **], the patient's primary care physician, [**Name10 (NameIs) **] to followup with the pathology results to guide future evaluation and therapy. Of note, the patient was found to have a radiographic splenomegaly on the MRI measuring 15 cm. An abdominal ultrasound was performed demonstrating splenomegaly with dilatation of the entire portal venous system, but normal hepatopetal flow. The liver demonstrated normal echotexture and size with no masses identified. The hepatic venous system was dilated as well, but there was no extrahepatic biliary ductal dilatation. The right kidney was found to be atrophic and the left kidney was without hydronephrosis. Hepatitis serologies were pending at the time of discharge, liver function tests were within normal limits during this admission. The Hematology/Oncology service is following along with this patient and previous records from [**Hospital3 8763**] were obtained. These records include a bone marrow biopsy performed in [**2111-7-20**] and the Hematology/Oncology consult service notes during that admission. Secondary to the negative bone marrow performed during that time period and the unchanged clinical status, the patient's thrombocytopenia/anemia, a bone marrow biopsy was not further pursued. A potential explanation for the patient's thrombocytopenia and anemia may be the patient's portal system hypertension with splenomegaly. Further evaluation for the portal system and dilatation and splenomegaly will be pursued by the patient's primary care physician as felt indicated. DISCHARGE DIAGNOSES: 1. Acute and chronic renal failure secondary to dehydration, urinary tract infection, nephrotoxic medications. 2. Urinary tract infection. 3. Paroxysmal atrial fibrillation. 4. Anemia. 5. Thrombocytopenia. 6. Demand induced cardiac ischemia. 7. Hypothyroidism. 8. Altered mental status improved. 9. History of Alzheimer's dementia. 10. Congestive obstructive pulmonary disease. 11. Soft tissue mass of unknown etiology - pathology results pending. 12. Splenomegaly. 13. Portal venous system dilation. DISCHARGE MEDICATIONS: 1. Metoprolol 25 mg po bid. 2. Amlodipine 10 mg po q day. 3. Percocet 1-2 tablets po q4-6 prn. 4. Lipitor 10 mg po q day. 5. Levothyroxine 50 mcg po q day. 6. Celexa 20 mg po q day. 7. Aricept 5 mg po q day. DISCHARGE CONDITION: Good. DISCHARGE STATUS: The patient is being discharged to [**Hospital3 6278**] Center. DISCHARGE INSTRUCTIONS: Ms. [**Known lastname **] will require higher level of care at [**Hospital3 643**] Center until the hip lesion can be addressed. This includes higher level of rehabilitation. PHYSICIAN [**Name Initial (PRE) 2467**]: Ms. [**Known lastname **] is to followup with her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], upon return to [**Hospital6 8764**]. Pending laboratories and studies include a CA-27.29, hepatitis serologies, and the pathology results from the right pelvis soft tissue mass. These studies will require followup by the patient's primary care provider. Dictated By:[**Last Name (NamePattern1) 2469**] MEDQUIST36 D: [**2112-1-27**] 15:43 T: [**2112-1-28**] 12:18 JOB#: [**Job Number 8765**]

[ "276.5", "585", "276.7", "584.9", "599.0", "427.31", "428.0", "496", "287.3" ]

icd9cm

[ [ [] ] ]

[ "39.95", "83.21" ]

icd9pcs

[ [ [] ] ]

28303, 28394

14470, 16272

27547, 28049

28072, 28281

23618, 24052

1790, 2127

19017, 23597

28419, 29178

16287, 18999

115, 125

11602, 13602

14006, 14346

13625, 13981

14363, 14453

6,115

105,047

660

Discharge summary

report

Admission Date: [**2194-2-21**] Discharge Date: [**2194-3-1**] Date of Birth: [**2146-9-1**] Sex: M Service: Transplant [**Doctor First Name **] HISTORY OF PRESENT ILLNESS: Patient is a 47 year-old male with polycystic kidney disease and impending renal failure. PHYSICAL EXAMINATION: He is a well-developed male in no acute distress. He is 268 pounds with a blood pressure of 133/86. Heart rate is 106. Neck is supple without masses. Heart is regular rate and rhythm with S1 and S2 clearly heard. No murmur, rub or gallop were appreciated. His lungs were clear to auscultation bilaterally. His abdomen was soft, distended and the kidneys and liver are easily palpable bilaterally. Bowel sounds are normal and present. Extremities are with 1 to 2+ edema bilaterally. LABORATORY DATA: Hemoglobin is 10.8 with a hematocrit of 34.2. His potassium is 5.2; BUN is 54 and creatinine is 4.7. HOSPITAL COURSE: The patient was admitted to the operating room for an elective bilateral nephrectomy and right Perma- cath placement. He tolerated the procedure well and was taken to the postoperative care unit where he was noted to have postoperative potassium of 7.4. It should also be noted that his bilateral kidneys, each kidney weighed about 35 pounds and the total amount of fluid loss during the procedure, secondary to removal of the kidneys, was estimated to be roughly 5 liters. Renal was consulted in the PACU. The patient was maintained intubated, at which time he was dialyzed to remove the potassium which was performed on postoperative day number zero. After the dialysis was completed, his potassium had dropped down to 6.0 and patient was being maintained at this time in the surgical intensive care unit. On the morning of postoperative day number 1, the patient was extubated. He did well. He was also dialyzed again and this brought his potassium down on postoperative day number 2 to 4.7. On postoperative day number 2, it was also noted that his hematocrit had dropped to 24 from a previous level of 30.5. He was followed for this. His value remained stable. It was 25.2 on the following day. By postoperative day number 3, pressors had been weaned off. The patient was tolerating clears. On postoperative day number 4, the patient was transferred to the floor. On postoperative day number 5, the patient was noted to be passing flatus and had 2 bouts of emesis on the previous evening while taking in clears. The patient was made n.p.o. again. Urinalysis was continued and his hematocrit was followed. On postoperative day number 6, one of the [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drains was discontinued. He was advanced to a regular diet which he tolerated well. His hematocrit was still stable. Now it was slowly increasing and it was up to 26.2 on postoperative day number 7. Patient was still receiving dialysis. Hematocrit remained stable. The patient was discharged home on postoperative day number 8, tolerating a regular diet, after both of his [**Location (un) 1661**]-[**Location (un) 1662**] drains had been removed. DISCHARGE STATUS: To home. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSES: Status post bilateral nephrectomy (open) complicated by hyperkalemia. DISCHARGE MEDICATIONS: Calcium acetate 667 mg, take 2 caps p.o. t.i.d. with meals. Dilaudid 2 mg take one tablet p.o. q. 3 to 4 prn. Colace 100 mg take one p.o. b.i.d. B-complex vitamins. Vitamin C and Folic acid capsules, take one p.o. q. Day. Panprazolol 40 mg delayed released, take one p.o. q. Day. FOLLOW UP: The patient is to follow-up with Dr. [**First Name (STitle) **] in his office. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**] Dictated By:[**Last Name (NamePattern1) 5032**] MEDQUIST36 D: [**2194-5-12**] 21:17:32 T: [**2194-5-13**] 05:50:36 Job#: [**Job Number 5033**] cc:[**Last Name (NamePattern4) 3433**]

[ "585.6", "753.12", "530.81", "285.9", "403.91" ]

icd9cm

[ [ [] ] ]

[ "38.95", "39.95", "55.54" ]

icd9pcs

[ [ [] ] ]

3236, 3307

3331, 3618

936, 3180

3630, 4015

309, 918

195, 286

3205, 3214

78,570

156,307

37360

Discharge summary

report

Admission Date: [**2189-1-28**] Discharge Date: [**2189-2-15**] Date of Birth: [**2107-3-24**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: Pneumocephalus Major Surgical or Invasive Procedure: Lumbar Drain History of Present Illness: 81 yo male who was transferred to [**Hospital1 18**] Neurosurgery from [**Hospital6 16029**]. Daughter reports that patient hit his head on basement ceiling on [**2189-1-1**] and a day or two later complained of a headache and feeling "fuzzy." They continued to monitor him, and felt he was worsening in regards to headaches. The day after [**Holiday 1451**] [**1-9**], they brought him to the ER because of worsening headaches and CT showed a skull fracture, but no blood. Patient began to have depth perception issues and was able to go up and down the [**Last Name (LF) 5927**], [**First Name3 (LF) **] outpatient Head CT was done which was stable on [**1-16**] morning. On [**1-16**] eve, the patient became lethargic and disoriented, and unable to follow directives. A repeat head CT showed worsening pneumocephalus and he was admitted. Per OSH CT reads some pneumocephalus was seen on the [**2189-1-9**] scan. A right sided EVD was placed on [**1-17**] with Ancef for prophylaxis. ENT was consulted for suspicion that there was dehiscence of the tegmen tympani within the floor of the right middle cranial fossa as a source of air to the subarachnoid space; thus the concern was that with forcible extravasation of air, air would be further pushed into the subarachnoid space. ENT then placed a right myringotomy tube. On [**1-21**] a head CT showed some resolution of his pneumocephalus and the EVD was clamped. A few hours post-clamping, the patient had an episode of unresponsiveness, a repeat head CT was done which still showed some mild decrease in the pneumocephalus. The EVD was reopened and per family he improved. Over the next few days the family reports that he was doing well and on [**1-24**] the EVD was removed. Post-removal, the patient began to worsen and on [**1-26**] he became less verbal and was unable to ambulate, a repeat head CT showed worsening pneumocephalus. At that time, the patient's family requested a transfer to another facility. Past Medical History: Hypothyroidism Irregular heart rate with hx of ectopy, Afib and V-tach. Cardioversion x1 Cataracts Subdural Hematomas x3 (per family) Osteoporosis Compression fracture which was cemented BPH GERD Exposure to Asbestos type organism in soil while in [**State 5170**] during military service Social History: Primary caretaker for wife who suffered a aneurysmal bleed many years ago that required surgery and subsequently a CSF leak. Lives with wife, and has three daughters. Nonsmoker. Family History: Noncontributory Physical Exam: On Admission: O: T: 98.2 BP: 105/64 HR: 66 R 16 O2Sats 96% RA Gen: WD/WN, comfortable, NAD. HEENT: Normacephalic Neck: Supple. Lungs: CTA bilaterally. Cardiac: HR irregular Extrem: Warm and well-perfused. Neuro: Mental status: Awake. On observation without interaction, patient is muttering to himself, grabbing at the [**Hospital Ward Name **], pointing at the ceiling. With interaction, he is able to follow simple commands but at times needs prompting. Orientation: Oriented to person and date. Recall: Was able to recall what state he lives in, DOB, wife's name, what he did for a living prior to retirement. Unable to recall what he ate for breakfast or what hospital he came from. Language: Speech hesitant at times, but clear. Naming intact. Able to name pen, flashlight, and TV. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2.5 to 2.0 mm bilaterally. Visual fields unable to be assessed secondary to patient's ability to follow complex commands. 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. Tremor noted to bilateral upper extremities, L>R. Right bicep and tricep -[**6-17**], otherwise full motor strength. Sensation: Intact to light touch. Coordination: Unable to assess. On Discharge: Patient expired Pertinent Results: Labs on Admission: [**2189-1-29**] 05:45AM BLOOD WBC-8.0 RBC-4.37* Hgb-14.9 Hct-44.1 MCV-101* MCH-34.1* MCHC-33.8 RDW-14.7 Plt Ct-250 [**2189-1-29**] 05:45AM BLOOD Neuts-70.8* Lymphs-19.5 Monos-4.7 Eos-4.3* Baso-0.7 [**2189-1-29**] 05:45AM BLOOD PT-13.6* PTT-23.9 INR(PT)-1.2* [**2189-1-29**] 05:45AM BLOOD Glucose-95 UreaN-14 Creat-0.9 Na-140 K-4.1 Cl-103 HCO3-27 AnGap-14 [**2189-1-29**] 05:45AM BLOOD ALT-31 AST-36 LD(LDH)-209 AlkPhos-50 Amylase-46 TotBili-0.6 [**2189-1-29**] 05:45AM BLOOD Lipase-19 [**2189-1-29**] 05:45AM BLOOD Albumin-3.7 Calcium-8.8 Phos-3.1 Mg-2.1 Imaging: Head CT [**1-29**]: HEAD CT WITHOUT IV CONTRAST: There has been recent right frontal burr hole, with small amount of air and fluid in the tract (2:31). There has also been previous bilateral parietal mini-craniectomy (2:25) and a previous frontal site of burr hole is seen (2:28). There is extensive pneumocephalus, most severely in the bifrontal extraaxial space (2:24, and 300B:26). However, there is also a large amount of air in the frontal horns of the lateral ventricles, in the right frontal lobe near the recent burr hole, and additional smaller locules in a parafalcine and posterior fossa as well as sella and parasellar distribution. There is no hemorrhage, edema, mass effect, shift of midline structures or evidence of major vascular territorial infarction. However, there is severe encephalomalacia in the right temporal lobe. There is severe volume loss and periventricular hypodensity consistent with small vessel ischemic change. However, there are also bilateral convexity low-density collections which may represent chronic subdural hematomas, although these may also represent subdural hygromas. The visualized paranasal sinuses appear unremarkable, except for a small mucous retention cyst on the roof of the left maxillary sinus (300B:38). IMPRESSION: 1. Extensive pneumocephalus, most severely in the bifrontal extraaxial CSF space, but also other locations as described. 2. No hemorrhage or shift of midline structures. 3. Severe volume loss, enlargement of ventricles and sulci, and bilateral chronic subdural hematomas or subdural hygromas. TTE [**2189-2-2**]: The left and right atria are moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). 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 appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be quantified. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. CLINICAL IMPLICATIONS: Based on [**2186**] 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. [**2-2**] ECG Sinus rhythm with ventricular premature beats including a six beat run of ventricular tachycardia. Consider left atrial abnormality. ST-T wave abnormalities are non-specific. Clinical correlation is suggested. Since the previous tracing of [**2189-1-29**] sinus bradycardia is absent, ventricular ectopy is now present and further ST-T wave changes are seen. Rate PR QRS QT/QTc P QRS T 107 154 98 374/456 43 42 -69 [**2-2**] LE U/S: IMPRESSION: No evidence of deep vein thrombosis in either leg. [**2-2**] CXR: IMPRESSION: No acute intracranial process. Irregular reticular opacities represent chronic interstitial changes such as pulmonary fibrosis. A CT can be considered for further evaluation if clinically indicated. [**2-2**] Bilateral Knee, Bilateral Hip and Pelvis Plain Films: no fracture [**2-3**] CT MYELOGRAM: IMPRESSION: Successful lumbar myelogram. Please see the sinus CT which follows this examination and is reported separately [**2-3**] CT SINUS/HEAD post MYELOGRAM: IMPRESSION: Post-myelographic head CT demonstrates no leakage of contrast to identify a continued source of pneumocephalus. The tegmen tympani are markedly thin bilaterally, with additional thinning of the cribriform plate, though no contrast or fluid is present within the paranasal sinuses, nor middle ear cavities. Please note that during the fluoroscopic phase of the myelogram, the patient sneezed some fluid on a guage, which when viewed under fluoroscopy, demonstrated contrast in the gauge suggesting there could be a leak anteriorly most probably via the sino-nasal cavities. [**2-4**] CT HEAD: 1. Interval overall decrease in multicompartmental pneumocephalus, particularly within the bifrontal extra-axial spaces, frontal horns of the lateral ventricle, within the right temporal [**Doctor Last Name 534**] and in the left frontovertex parenchyma. 2. Bilateral subdural collections are again noted, unchanged in size from [**2189-2-1**]; the overall appearance is suggestive of hygromas. 3. No new focus of hemorrhage. [**2-5**] Right Elbow Plain Film: Two views of the right elbow demonstrate mild spurring at the lateral epicondyle at the origin of the common extensor tendon consistent with tendinopathy or lateral epicondylitis. No fracture or malalignment is detected. There is a small joint effusion which may represent an occult fracture. No fracture is identified on these limited portable views. [**2-6**] Right Forarm Plain Films: FINDINGS: No abnormal calcifications or gas collections in the soft tissues. No evidence of cortical disruptions indicative of fracture. No evidence of chronic inflammatory disease. [**2-6**] Right Upper Extremity Ultrasound: IMPRESSION: No evidence DVT. MICROBIOLOGY [**2189-2-2**] 12:00 pm Blood Culture, Routine (Final [**2189-2-8**]): NO GROWTH. ================= Time Taken Not Noted Log-In Date/Time: [**2189-2-5**] 5:46 pm CSF;SPINAL FLUID Site: LUMBAR PUNCTURE CSF FLC,GST,VIC ADDED AT 5:45PM ON [**2189-2-5**] FROM [**2189-2-4**]. GRAM STAIN (Final [**2189-2-5**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2189-2-8**]): NO GROWTH. VIRAL CULTURE (Preliminary): ================= Brief Hospital Course: 81 year old male who was transferred to [**Hospital1 18**] from Bay State Hospital in [**Location (un) 5583**] on [**1-28**] for treatment of Pneumocephalus s/p hitting head on ceiling with subsequent temporal bone fracture and decline of neurological function in [**Month (only) **]. While at Bay State he had an EVD, myringotomy tube, and lumbar drain placed. The EVD and lumbar drain were removed prior to transfer to [**Hospital1 18**]. He was evaluated by NSURG for potential intervention. ENT was consulted to assist in management. During his hospitalization he experienced episodic periods of bigeminy and trigeminy for which cardiology was consulted and gave input on continuation of his beta-blocker in the setting of his history of ectopy and arrhythmias. At that time his dosage was changed from Metoprolol XL 50mg daily to Metoprolol 25mg [**Hospital1 **]. In relation to the course of his pneumocephalus, the Head CT on [**2-1**] showed slight interval decrease in frontal [**Doctor Last Name 534**] pneumocephalus, but no significant change in bifrontal pneumocephalus. On [**2-2**] he began experiencing 8-10 beat runs of ventricular tachycardia with associated periods of decreased responsiveness which was treated with administration of magnesium and fluids, as well as repeat consultation of cardiology and increase of his Metoprolol to 25mg TID. At that time it was determined to transfer him to medicine while keeping him on [**Hospital Ward Name 121**] 11 to allow for close following of his neuro status, while optomizing his medical treatment. Upon transfer to the medicine service the patient's course was as follows: Ectopy: Cardiology notes were reviewed. The patient was continued on metoprolol TID. A TTE showed normal LVEF and no dilation of RV cavity size, however, the cardiology attending re-read the TTE and thought the RV looked dilated. He recommended CTA to r/o PE. The patient was not hypoxic, on room air, stable without hypotension or tachycardia, and without symptoms of PE so it was felt this was not an emergent procedure. He did undergo LENIs which revealed no DVT. Pneumocephalus: Head CTs up until time of transfer to medicine were unchanged as was neurologic exam. The patient remained alert and oriented only to self. On [**2-3**], he underwent CT myleogram which showed no obvious leak. The patient at reecommendation of Neurosurgery underwent a Lumbar drain [**2-4**]. He was maintained flat while the drain was open until Monday [**2-9**] when he was reassessed with a Head CT that showed ------------. While the lumbar drain was in place the patient had to be maintained in restraints because out of restraints he disconnected the drain 3 times and this poised an immediate danger to his health. AMS: It was thought this was likely [**3-17**] his pneumocephalus. An extensive infectious workup revealed no infection. ID was consulted and felt there was no need for empiric antibioitcs and vanc/gent/flagyl that had been started prophylactically by the neurosurgery team were discontinued. The patient remained afebrile. He was empirically treated with cefazolin 2 gram q8h while the lumbar drain was in place. His mental status improved after placement of lumbar drain such that he was intermittently alert and oriented *3. He was felt to have a delirium likely from prolonged confusion in the setting of his pneumocephalus. He was monitored and ---------. Right Arm Pain: The patient complained of right arm pain [**2-6**]. Arm x-rays were negative for fracture, right upper extremity ultrasound revealed no evidence of deep vein thrombosis. Given the location of the tenderness patient was felt to have strained his right brachioradialis. He was treated with standing tylenol, ice packs and flexion of arm at elbow. At the time of discharge, the patient's arm pain -------------. Hypothyroidism: The patient was maintained on his home synthroid dose. TSH checked during his illness was mildly elevated at 4.9. It was felt that his mental status was not being influenced by his hypothyroidism and that as an outpatient he can follow -up with repeat TFTs. No dosage adjustment was made. Possible Interstitial lung disease: In midst of fever workup CXR was done which revealed no acute process but did reveal possible interstitial disease. A CT was recommended to better evaluate his lungs. Given no symptoms and not an acute issue further workup of this was deferred and can be pursued as an outpatient. He was transfered to the neurosurgery service once again on [**2189-2-12**]. A nuclear medicine study was performed. The pledgits were removed and read as negative for CSF leak on [**2189-2-12**] and the lumbar drain was removed on this date. He developed signs of obstructive apnea on [**2-13**] and a nasal airway and CPAP were initiated. His code status was DNR/DNI. On [**2189-2-14**], patient was observed to have more difficulty breathing has increased use of BiPAP. Family was made aware of his respiratory status and made the decision to make the patient CMO. At approximately 0340, patient expired. Medications on Admission: Levoxyl 88 mcg PO Daily Metoprolol XL 50mg Daily Flomax Daily Nexium Fosamax 70mg Q Thursday MEDICATIONS ON TRANSFER: Metoprolol Tartrate 25 mg PO/NG TID Senna 1 TAB PO/NG HS Docusate Sodium 100 mg PO BID Gentamicin 80 mg IV Q8H MetRONIDAZOLE (FLagyl) 500 mg PO/NG TID Vancomycin 1000 mg IV Q 12H Acetaminophen 325-650 mg PO/NG Q6H:PRN Pain Levothyroxine Sodium 88 mcg PO/NG DAILY Heparin 5000 UNIT SC TID Tamsulosin 0.4 mg PO HS Pantoprazole 40 mg PO Q24H Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Pneumocephalus Altered Mental Status Cardiac Ectopy Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Completed by:[**2189-2-15**]

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Discharge summary

report

Admission Date: [**2158-7-28**] Discharge Date: [**2158-7-31**] Date of Birth: [**2088-4-11**] Sex: F Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 106**] Chief Complaint: Hypertensive urgency Major Surgical or Invasive Procedure: Diagnostic Cardiac Catheterization History of Present Illness: Ms. [**Known firstname 29585**] is a 70 year-old female with a history of hypertension and diabetes who presents with hypertensive urgency. . Over the past 3 weeks, the patient has had dyspnea on exertion. She noted that after 2 blocks she is very short of breath; there is no associated chest pain, nausea/vomiting. . The patient gets her routine medical care in [**Country 29586**] and is currently visiting family in the [**Location (un) 86**] area. She has previously been seen at [**Company 191**]; given her disatisfaction with her blood pressure management, she presented for evaluation in [**Hospital Ward Name 23**] today. Exam at that time showed a blood pressure of 250/108; she was oriented to person, time but thought she was in [**Location (un) 29587**]. Given the degree of hypertension noted, she was sent to the ED for further evaluation. . In the ED, vitals showed a temperature of 97.7, HR 60, initial blood pressure of 164/90 and a RR of 20. The blood pressure increased to 224/94. Finger stick was 234. An EKG showed ST-elevations in V2-V3; given these findings, the cath lab was activated and she was taken for angiography. IV heparin, plavix 600mg and 5mg IV lopressor were given; aspirin was held given her allergy. . In the cath lab blood pressures was 258/92 with a HR of 56; nitroprusside was started (0.194 mcg/kg/min) and titrated up to 1.613 mcg/kg/min. The blood pressure remained elevated to >250 systolic with MAPs >150. 10mg of IV hydralazine was given at the end of the case. . Currently, the patient denies any headache, blurry vision, chest pains. She is generally feeling well. . Upon review of her OMR record, she has a note from [**2149**] that notes a BP of 240/110. At that time, she was on lisinopril 40mg daily. On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . Past Medical History: Cardiac Risk Factors: (+)Diabetes, (-)Dyslipidemia, (+)Hypertension Cardiac History: CABG, PCI, Pacemaker/ICD: None. . OTHER PAST HISTORY: 1. Hypertension: Patient says she's been hypertensive "forever". She cannot recall any prior BP meds other than the lisinopril or hydralazine. She occasionally check her BP and noted it to regularly be >200 systolic. 2. Diabetes 3. Dementia . Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse; she drinks an occasional glass of wine on special occasions. There is no family history of premature coronary artery disease or sudden death. Her mother and one sister have high blood pressure. Physical Exam: Blood pressure was 158/58 mm Hg while lying flat. It decreased to 130 systolic and the nitride was shut off. Soon thereafter, it increased back to 230s systolic. Pulse was 65 beats/min and regular, respiratory rate was 20 breaths/min with an 02 of 98% on room air. Generally the patient was well developed, well nourished and well groomed. . There was no thyromegaly. The respirations were not labored and there were no use of accessory muscles. The lungs were clear to ascultation bilaterally with normal breath sounds and no adventitial sounds or rubs. . The heart sounds revealed a normal S1 and the S2 was normal. There were no rubs, murmurs, clicks or gallops. There was an audible S4. . The abdominal aorta was not enlarged by palpation. There was no hepatosplenomegaly or tenderness. The abdomen was soft nontender; there was mild distension/obesity. The extremities had no pallor, cyanosis or cyanosis; there was 1+ edema bilaterally. There were no abdominal, femoral or carotid bruits; a right femoral sheath was in place. Inspection and/or palpation of skin and subcutaneous tissue showed no stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: [**2158-7-28**] 12:36PM COMMENTS-GREEN TOP [**2158-7-28**] 12:36PM K+-3.9 [**2158-7-28**] 12:15PM GLUCOSE-249* UREA N-13 CREAT-0.9 SODIUM-139 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-25 ANION GAP-15 [**2158-7-28**] 12:15PM estGFR-Using this [**2158-7-28**] 12:15PM CK(CPK)-46 [**2158-7-28**] 12:15PM cTropnT-<0.01 [**2158-7-28**] 12:15PM CK-MB-NotDone proBNP-954* [**2158-7-28**] 12:15PM CALCIUM-9.3 PHOSPHATE-3.3 MAGNESIUM-1.9 [**2158-7-28**] 12:15PM WBC-8.2 RBC-4.68 HGB-14.5 HCT-43.0 MCV-92 MCH-30.9 MCHC-33.6 RDW-13.6 [**2158-7-28**] 12:15PM NEUTS-59.7 LYMPHS-31.7 MONOS-4.9 EOS-2.3 BASOS-1.5 [**2158-7-28**] 12:15PM PLT COUNT-386 . . EKG showed a normal sinus rhythm with a rate in the 60s. The PR interval was slightly prolonged. There was evidence of LVH. ST-elevations were noted in V3-V4. . PROCEDURE: Right Heart Catheterization: was performed by percutaneous entry of the right femoral vein, using a 7 French pulmonary wedge pressure catheter, advanced to the PCW position through a 7 French introducing sheath. Cardiac output was measured by the Fick method. Left Heart Catheterization: was performed by percutaneous entry of the right femoral artery, using a 5 French left [**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 5 French JL4 and a 5 French JR4 catheter, with manual contrast injections. Conscious Sedation: was provided with appropriate monitoring performed by a member of the nursing staff. HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.87 m2 HEMOGLOBIN: 14.5 gms % FICK **PRESSURES RIGHT ATRIUM {a/v/m} 14/18/12 RIGHT VENTRICLE {s/ed} 53/14 PULMONARY ARTERY {s/d/m} 51/16/28 PULMONARY WEDGE {a/v/m} 24/19/18 AORTA {s/d/m} 258/92/147 **CARDIAC OUTPUT HEART RATE {beats/min} 56 RHYTHM SINUS O2 CONS. IND {ml/min/m2} 125 A-V O2 DIFFERENCE {ml/ltr} 55 CARD. OP/IND FICK {l/mn/m2} 4.3/2.3 **RESISTANCES SYSTEMIC VASC. RESISTANCE 2512 PULMONARY VASC. RESISTANCE 186 **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM **RIGHT CORONARY 1) PROXIMAL RCA NORMAL 2) MID RCA DISCRETE 80 2A) ACUTE MARGINAL NORMAL 3) DISTAL RCA TUBULAR 40 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 6) PROXIMAL LAD NORMAL 6A) SEPTAL-1 NORMAL 7) MID-LAD DISCRETE 30 8) DISTAL LAD NORMAL 9) DIAGONAL-1 NORMAL 12) PROXIMAL CX NORMAL 13) MID CX DISCRETE 70 13A) DISTAL CX NORMAL 14) OBTUSE MARGINAL-1 NORMAL TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 0 hour41 minutes. Arterial time = 0 hour37 minutes. Fluoro time = 9.4 minutes. Contrast injected: Non-ionic low osmolar (isovue, optiray...), vol 55 ml, Indications - Renal Premedications: ASA 325 mg P.O. Plavix 600 mg Fentanyl 25 mcg iv Hydralazine 10 mg iv Nitrprusside iv drip at 4.431 mcg/kg/min Versed 0.5 mg iv Anesthesia: 1% Lidocaine subq. Anticoagulation: Heparin 0 units IV Cardiac Cath Supplies Used: - ALLEGIANCE, CUSTOM STERILE PACK - GUIDANT, PRIORITY PACK 20/30 COMMENTS: 1. Coronary angiography of this right dominant system revealed a LMCA without angiographically significant coronary artery disease. The LAD had a 30% mid-segment stenosis. The LCX had a 70% discrete stenosis in the mid portion. The RCA had an 80% mid-vessel stenosis with a 40% distal stenosis. 2. Resting hemodynamics revealed severe systemic arterial hypertension with an SBP of 259 mm Hg for which a nitroprusside IV drip was started. Left and right sided filling pressures were mildly elevated with an RASP of 12 mm Hg, RVEDP of 14 mm Hg and a wedge of 18 mm Hg suggestive of diastolic dysfunction. PASP was 51 mm Hg. Cardiac output was 4.3 and index 2.3 suggestive of normal systolic function. 3. Left ventriculography was deferred. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Mild diastolic ventricular dysfunction. 3. Severe systemic arterial hypertension. RENAL US ([**2158-7-28**]): 1. Delayed upstokes and acceleration of renal artery waveforms on both sides (left greater than right ) that may reflect renal artery stenosis. MRA of renal arteries may be helpful for further evaluation. 2. No evidence of hydronephrosis. . CXR ([**2158-7-28**]): No acute cardiopulmonary disease. Brief Hospital Course: 1. Hypertension: The patient's blood pressure was contontrolled at first with IV nitro, then transitioned over to PO meds. Pressures remained elevated, but improved at time of dischrage. There were no signs/symptoms to suggest hypertensive emergency (no chest pain, headache, blurry vision, nausea, decreased urine output). She has been markedly hypertensive for many years and was only on a single [**Doctor Last Name 360**] at time of admission. Regarding causes, essential hypertension remains the most likely etiology. Renal artery stenosis is possible and the renal ultrasound could not rule this out. Hyperaldo was considered unlikely given her normal potassium. Other etiologies ([**Initials (NamePattern4) **] [**Location (un) **], OSA, thyroid disease, etc.) remain on the differential, though unlikely. The patient showed improved BP at time of discharge on PO med regiment, that will need to be followed up as an outpatient to continue to titrate. . 2. Dyspnea: The etiology of this is unclear. She has evidence of LVH on EKG and mild LE edema --heart failure (likely diastolic) is possible. Outpatient echo is recommended. . 3. ST-elevations: Given LVH and hypertension, these changes are much less likely ischemic, especially in light of no abnormal findings on cardiac cath. Medications on Admission: 1. Hydralazine 25mg [**Hospital1 **] 2. Metformin 1000mg [**Hospital1 **] 3. Glipizide 7.5mg [**Hospital1 **] 4. Oxybutynin 5mg 1-2x daily 5. Inhaler (unclear name or use) Discharge Medications: 1. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(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. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 5. Glipizide 5 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Stable Discharge Condition: Stable Discharge Instructions: You are being discharged from the hospital after an admission an admission for hypertensive urgency. You were found to have dangerously high blood pressures, and you now being started on a battery of medications to control your blood pressure. It is essential that you take your prescribed medications every day. You were also found to have a possible abnormality of the blood supply to your kidneys, which may be the cause of your current difficulty in managing your hypertension. You will require follow up as an outpatient for additional testing to evaluate for the significance of this potential abnormality. If you develop severe headache, changes in your vision, chest pain, or shortness of breath, call your doctor. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11771**], M.D. Phone:[**Telephone/Fax (1) 26488**] Date/Time:[**2158-8-1**] 10:30 Call to make an appointment with [**Company 191**] primary care clinic within one weeks time to have them check your blood pressure and adjust your medication: ([**Telephone/Fax (1) 1300**]

[ "794.31", "272.4", "250.00", "401.9", "414.01", "429.3", "293.1" ]

icd9cm

[ [ [] ] ]

[ "88.52", "88.56", "37.23" ]

icd9pcs

[ [ [] ] ]

11372, 11378

9048, 10348

288, 325

11429, 11438

4554, 7156

12219, 12570

10571, 11349

11399, 11408

10374, 10548

8572, 9025

11462, 12196

3377, 4535

7175, 8555

228, 250

353, 2631

2653, 3041

3057, 3362

77,609

134,799

37660

Discharge summary

report

Admission Date: [**2127-10-10**] Discharge Date: [**2127-10-17**] Date of Birth: [**2108-10-3**] Sex: M Service: MEDICINE Allergies: Cefaclor / Unasyn Attending:[**First Name3 (LF) 2641**] Chief Complaint: Unresponsiveness; overdose Major Surgical or Invasive Procedure: Intubation History of Present Illness: 19M with history of bipolar disorder, ADHD, found unreponsive by mother at 6 am this morning with empty clozaril and robitussin bottles next to him. He was last seen normal at 1 or 2 am. He seemed to be in good spirits last night, did not seem depressed or suicidal per brother, though mother thought he seemed somewhat sad. Mother recalls hearing him breathing heavy (as he usually does) at 6am, but when she went in to wake him for school, he was breathing but unresponsive. Pill bottles next to him, ?suicide note. EMS called. Intubated in field with 9.0 tube. Bottles: Clozaril 50 mg (1 tab [**Hospital1 **]) #14 on [**2127-8-25**] Clozaril 100 mg (3 tabs HS) #21 on [**2127-8-25**] Robitussin (details unknown); mother does note that she has seen several empty robitussin bottles in his room lately, which she states was for a bad cough as a result of smoking. . Brought to OSH. Seized GTC x 1 minute and intubated for airway protection. Got benzos for seizure. Got levaquin for pneumonia and activated charcoal. Li level negative. Serum - APAP, salicylates negative. Urine - negative for PCP, [**Name10 (NameIs) 84449**], cocaine, amphetamines, THC, opiates, barbs, methadone. fT4 0.74 with TSH 2.26. Glucose 243. ABG 7.23/35/586. Head CT performed. Transferred to [**Hospital1 18**]. . In the [**Hospital1 18**] ED, initial vitals T99.4, 115/50, HR 130, R20, 99% on AC 600 x 14, 0.30, PEEP 5. Became febrile to 103.8. ECG with sinus tach at 111 STE V2-V4, terminal R wave in aVR, QRS 108, QTc 427. Patient was given ceftriaxone 2 gram, vancomycin, and acetominophen PR. Written for acyclovir but was not given. Bicarb gtt - 3 amps in 1L D5W started. Cards consulted for ECG abnls, wanted to see post bicarb gtt ECG. Toxicology consulted and recommended labs, stopping bicarb with monitoring of ECG, supportive care, and LP - has not yet received. Access 18g x3, 20g x1. . Review of systems: (+) Per HPI. Mother also notes he had been experiencing a vibrating/screeching sensation in his ears x 3 weeks. (-) Unable to obtain from patient; per mother no recent fever, chills, headache, shortness of breath, chest pain, nausea, vomiting, diarrhea, constipation or abdominal pain. Past Medical History: - Bipolar disorder vs. schizoaffective disorder. 1.5 year at [**Hospital1 **], 2 years with DYS Program in [**Location (un) 686**]. Denies past history of suicidal attempts, though did frequently have cutting behaviors leading to inpatient stay as above. Has been tried on Risperdal, Zyprexa, Seroquel, Depakote, Trileptal, Naltrexone, Clonidine, Tenex, Concerta, Strattera in addition to most recent regimen of Clozaril, Lithium, Lamictal, Inderal. Adherence in question. - ADHD - Conduct disorder - Hypothyroidism - Exercise-induced asthma - s/p eye operation as child Social History: Adopted. Lives with adopted mother and brother. [**Name (NI) 84450**] vocational/behavioral school. Has smoked since age 8 - 0.5 to 1.5 PPD. Reports alcohol use on weekends, unable to quantify amount. Reports occasional marijuana use. Family History: Unknown; patient is adopted. Physical Exam: On admission... General: Intubated and sedated. HEENT: Sclera anicteric, pupils reactive but minimally so (3.5->3). No nystagmus. ETT and NGT in place. MMM. Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation anterolaterally CV: Tachycardic, regular, S1 S2, soft SM at LUSB 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. Healed scars on upper extremities from past cutting. Neuro: Sedation limiting exam. Currently nonresponsive to all stimuli, does not withdraw to pain. No clonus. Tone normal Pertinent Results: CXR 1V ([**2127-10-16**]): AP single view of the chest has been obtained with patient in upright position. The heart size is normal. Pulmonary vasculature is unremarkable. No signs of acute infiltrate and the lateral pleural sinuses are free. No evidence of pneumothorax. When comparison is made with the next previous chest examination of [**2127-10-13**], the patient has been extubated. The previously identified bilateral pulmonary parenchymal densities that existed at that time when the patient was taking care of for status post overdose intoxication, have cleared up completely and the findings now are within normal limits. EKG ([**2127-10-16**]): Sinus rhythm. Since the previous tracing precordial T waves improved. [**2127-10-16**] WBC-9.5 Hgb-15.3 Hct-46.3 Plt Ct-341 [**2127-10-12**] PT-13.7* PTT-26.4 INR(PT)-1.2* [**2127-10-15**] Glucose-103 UreaN-11 Creat-0.7 Na-143 K-4.1 Cl-105 HCO3-26 Calcium-8.7 Phos-4.2 Mg-2.1 [**2127-10-13**] ALT-14 AST-24 LD(LDH)-404 CK(CPK)-122 AlkPhos-76 TotBili-0.5 [**2127-10-10**] cTropnT-<0.01 [**2127-10-11**] cTropnT-<0.01 [**2127-10-10**] BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Brief Hospital Course: 19 year-old male with bipolar disorder vs. schizoaffective disorder admitted [**2127-10-10**] following suicide attempt by clozaril overdose. At outside hospital prior to transfer, patient was also noted to have tonic-clonic seizure. Hospital course was as follows. 1. Overdose. Suicidal gesture. Clozaril overdose. Tox screen negative. Also with lithium in past, though level negative. Toxicology was consulted, and did not feel that the patient's clinical exam was consistent with NMS or serotonin syndrome (no clonus, rigidity). He was placed on bicarb gtt, and serial ECG's after bicarb was stopped were stable. Patient initially endorsed suicidal ideation after extubation. He was placed on 1:1 observation. He was given haldol for PRN agitation while monitoring for QTc prolongation. Psych meds were still being held upon transfer from the MICU. 2. Seizure. In setting of overdose, fever, and leukocytosis. Likely overdose related. No prior seizure history. LP, culture data, and HSV PCR were without indication of meningitis. 3. Aspiration pneumonia vs. pneumonitis. Febrile to 102F with infiltrates on CXR, bands on diff. Likely related to altered mental status/somnolence due to overdose. Likely due to aspiration. Bronchoscopy showed erythema without evidence of active infection. BAL showed 1+ PMNs, and was without active growth (although patient was on antibiotics prior to broncoscopy). Unasyn was discontinued due to rash. Patient was started on levaquin for aspiration pneumonia coverage. On transfer to the medical floor, patient continued to do well. He completed a 5-day course of levofloxacin for aspiration pneumonia. He did not have recurrence of fevers. Given his asthma history and wheezing on exam, he was started on fluticasone standing and albuterol inhaler as needed. He was noted to have hematuria. Urology was consulted given pain with urination and hematuria, and felt that this was due to Foley trauma. Patient should ensure good oral hydration. Pyridium was started for short course. If patient continues to have visible blood in urine on [**2127-10-22**], he should contact urology for further follow-up. If bleeding persists on [**2127-10-21**], please call [**Hospital1 18**] urology for follow-up appointment at ([**Telephone/Fax (1) 10797**]. Psychiatry followed the patient closely. He was not started on any psychiatric medications during the hospital course. **Communication: [**Name (NI) **] [**Name (NI) **] (mother), ([**Telephone/Fax (1) 84451**] Medications on Admission: Medications: (per [**Location (un) 535**], mother unsure of what he was on) Lithium 600 mg [**Hospital1 **] (last had 300 mg tabs #120 filled on [**8-5**]) Lamictal 50 mg QAM (last had 25 mg tabs #60 on [**8-11**]) clozapine 50 mg [**Hospital1 **] (#28 on [**9-4**]), 200 mg QHS (last 100 mg tabs, #28 on [**9-4**]) propanolol 10 mg TID (last #90 on [**2127-7-23**]) synthroid on OSH list, has not taken since [**2121**] Discharge Medications: 1. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 2. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed) as needed for cough. 3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 4. Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 days. 5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for Shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: [**Hospital3 26615**] Hospital - [**Location (un) 5028**] Discharge Diagnosis: Primary: - Suicide attempt, Clorazil overdose Secondary: - Aspiration pneumonitis vs. pneumonia, now resolved - Hematuria - Asthma Discharge Condition: Hemodynamically stable. O2 saturation >95% on room air. Ambulatory. Without suicidal or homicidal ideations. Discharge Instructions: You came in to the hospital after an overdose on medications. We performed testing and given you treatment to support your breathing in the beginning. You recovered on your own to baseline. During your admission you developed blood in your urine secondary to foley trauma. The urologist was not concerned. If it does not resolve in one week contact them and follow up as an outpatient. Please follow-up with your physicians as listed below. Please follow up with your outpatient psychiatrist/psychiatric facilty regarding psychiatric medications. Please return to the hospital if you feel chest pain, fatigue, short of breath, depression, thinking about hurting yourself or others, or any symptoms that is of concern to you. Followup Instructions: Please be sure to follow-up with your primary care physician [**Name Initial (PRE) 176**] 1-2 weeks after discharge from the inpatient psychiatric facility. If you continue to have bleeding with urination on [**2127-10-22**], please schedule an appointment with [**Hospital1 18**] urology at ([**Telephone/Fax (1) 10797**].

[ "401.9", "E950.3", "314.01", "969.3", "296.89", "E930.0", "307.9", "305.1", "693.0", "312.9", "E879.6", "276.52", "867.0", "788.1", "507.0", "293.0", "975.5", "244.9", "493.92", "599.71", "295.75", "276.6", "780.39", "518.81" ]

icd9cm

[ [ [] ] ]

[ "38.91", "03.31", "96.04", "96.6", "96.71", "33.24" ]

icd9pcs

[ [ [] ] ]

8851, 8935

5307, 7809

307, 319

9111, 9222

4110, 5284

10000, 10327

3396, 3426

8282, 8828

8956, 9090

7835, 8259

9246, 9977

3441, 4091

2245, 2533

241, 269

347, 2226

2555, 3128

3144, 3380

10,114

167,957

11207+11208+11209

Discharge summary

report+report+report

Admission Date: [**2171-10-30**] Discharge Date: [**2171-11-6**] Date of Birth: [**2099-3-17**] Sex: F Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old female with a past medical history of coronary artery disease with one vessel disease, hypercholesterolemia, hypertension, remote tobacco, diabetes mellitus, hypothyroidism, and chronic renal insufficiency, who was recently discharged from [**Hospital1 69**] on [**2171-10-20**]. On that admission, she presented with shortness of breath and underwent a cardiac catheterization which revealed a 70 to 80% obtuse marginal I lesion which was angioplastied but not stented. The patient had a TTE, which revealed an ejection fraction of greater than 55%, with no regional wall motion abnormality. The patient did well until [**10-29**], when she presented to an outside hospital complaining of chest heaviness at home for a duration of 20 minutes. She reportedly took one sublingual nitroglycerin, and experienced pre-syncopal episode when she stood. She stated that the chest pain lasted throughout the previous evening and was associated with nausea and shortness of breath. She denied diaphoresis. The patient was admitted to [**Hospital3 3834**] for rule out myocardial infarction. On [**10-29**], she experienced a sudden worsening of her respiratory status. Her oxygen saturation was 81% on room air. A blood gas at that time revealed a pH of 7.19, PCO2 74, and PO2 of 92. The patient was intubated at this time. A Swan-Ganz catheter was placed, which revealed a pulmonary capillary wedge pressure of 20. The patient was diuresed with Bumex, which reduced the wedge pressure to 15. The patient's CKs were negative, but her troponin reportedly went from less than 0.04 to 1.08. A TTE was obtained and, by report, had a new inferior wall motion abnormality. The patient was transferred to [**Hospital1 188**] for further management of her congestive heart failure. Upon arrival, the patient was intubated, anxious, but without any complaints. PAST MEDICAL HISTORY: 1. Diabetes mellitus, Type 2, for five years. 2. Chronic obstructive pulmonary disease with an FEV-1 of 1.43 and pulmonary hypertension on her last echocardiogram 3. Coronary artery disease with one vessel disease, status post obtuse marginal I percutaneous transluminal coronary angioplasty in [**10-14**] 4. Hypertension 5. Obesity 6. Congestive heart failure 7. Chronic renal insufficiency 8. Interstitial cystitis 9. Hypercholesterolemia 10. Hypothyroidism 11. Anxiety disorder 12. Status post cholecystectomy ALLERGIES: The patient is allergic to contrast dye, iodine, penicillin and seafood. MEDICATIONS AT HOME: Lopressor 25 mg by mouth twice a day, Actos 30 mg by mouth once daily, Lipitor 10 mg by mouth daily at bedtime, Alphagan eyedrops 0.2% to right eye twice a day, Bumex 1 mg by mouth once daily, Imdur 30 mg by mouth once daily, Colace 100 mg by mouth twice a day, Ativan 1 mg by mouth twice a day as needed, percocet as needed, Norvasc 10 mg once daily, Cogentin 1 mg once daily, Trilafon 2 mg by mouth once daily, Prozac 40 mg by mouth once daily, Synthroid 125 mcg by mouth once daily, Lopid 600 mg by mouth once daily, Glucophage 850 mg by mouth once daily. PHYSICAL EXAMINATION: The patient had a blood pressure of 107/60, pulse 82, she was breathing at 27, oxygen saturation 95% on room air. The ventilator was set on SIMV with an FIO2 of 50%, tidal volume of 750, and PEEP of [**5-18**]. In general, the patient was an alert, elderly female. She was intubated but in no acute distress. On head, eyes, ears, nose and throat examination, her pupils were equal, round and reactive to light, her extraocular movements were intact. She was intubated. On neck examination, her neck was supple, without any jugular venous distention. On cardiovascular examination, regular rate and rhythm, heart sounds were distant and difficult to auscultate. Respiratory examination showed bibasilar rales. Abdominal examination was soft, with some mild right upper quadrant tenderness, positive bowel sounds, no hepatosplenomegaly. Extremity examination: The patient had no cyanosis, clubbing, and trace edema. Her extremities were warm, and her pedal pulses were not palpable. LABORATORY DATA: On admission, revealed a white blood cell count of 11.4, hematocrit 29.6, platelets 223. Sodium 142, potassium 3, chloride 103, CO2 29, BUN 17, creatinine 1.2, glucose 170. She had a calcium of 8.2, a phosphate of 2.7, a magnesium of 1.8. CK was 53. She had a pH of 7.46, PCO2 40, PO2 70 on FIO2 of 50. Electrocardiogram from [**10-29**] revealed normal sinus rhythm at 72, with normal axis, normal intervals, no ischemic changes. Chest x-ray revealed pulmonary edema. HOSPITAL COURSE: The patient arrived at the Coronary Care Unit intubated but hemodynamically stable. Despite negative enzymes and a lack of ischemic electrocardiogram changes, we were concerned about ischemia as a precipitant, since obtuse marginal lesions can be electrically silent. The patient was monitored on 24 hour telemetry, and was continued on Lopressor, aspirin and Lipitor. She was started on Captopril for afterload reduction. The patient was initially diuresed with lasix to reach a 24 hour fluid balance of .5 to 1 liter negative per day. The patient had a transthoracic echocardiogram which revealed the following: The left atrium is enlarged. The left ventricular cavity size is normal. Global left ventricular systolic function appears preserved due to suboptimal technical quality. A focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mitral regurgitation is present but cannot be quantified, likely at least moderate in severity. Compared to the prior study of [**2171-10-16**], there is no definite change. The patient was taken to the cardiac catheterization laboratory on [**10-31**]. The following was discovered: 1. The left main was normal. The left anterior descending had a 70% stenosis in its D1 branch. The left circumflex had a 70% stenosis in its obtuse marginal II branch. The right coronary artery had a 40% mid-vessel lesion. 2. Successful percutaneous transluminal coronary angioplasty of D1 and obtuse marginal II branches without dissection, without residual stenosis and TIMI-III flow. The final diagnoses at cardiac catheterization included two vessel coronary artery branch disease and successful percutaneous transluminal coronary angioplasty of D1 and obtuse marginal II branches. The patient tolerated the procedure well, without any complications. She was continued on her prior cardiac regimen with the addition of Captopril, which was titrated upwards as tolerated. The decision was also made to maintain her on Plavix for an extended time period given the recurrence of her obtuse marginal disease. From a pulmonary standpoint, the patient was slowly weaned off the ventilator until she was successfully extubated on [**11-2**]. Her oxygenation improved daily, with her most recent oxygen requirement to date approximately 5 liters of oxygen by nasal cannula, which is approaching her home oxygen requirement of 2 liters. Would continue to diurese her gently with fluid goals of even to slightly negative. She was maintained on a standing dose of 40 mg of oral lasix, with good effect. During her hospital stay, the patient was very agitated and anxious, requiring restraints to keep her from removing any equipment. We initially sedated her with Ativan, which she takes at home. We continued her on her home dose of Trilafon. Still, we had trouble calming the patient. We consulted the Psychiatry service, who were concerned that she might be undergoing benzodiazepine intoxication. They did not think that she was in any danger of acute withdrawal, given that she only had increased dosages for a few days. The Ativan was held, and the patient's agitation was treated with supplemental Trilafon as needed. The Psychiatry service recommended resuming the patient's home dose of Ativan at 1 mg twice a day once the patient's mental status clears. After the resolution of her acute medical problems, the patient was seen by the Physical Therapy service, which felt that she would benefit from an acute rehabilitation stay prior to returning home. CONDITION AT DISCHARGE: The patient will be discharged to an inpatient rehabilitation facility. DISCHARGE DIAGNOSIS: 1. Two vessel coronary artery disease status post successful percutaneous transluminal coronary angioplasty 2. Diabetes mellitus 3. Hypertension 4. Hypercholesterolemia 5. Chronic obstructive pulmonary disease 6. Chronic renal insufficiency 7. Anxiety disorder DISCHARGE MEDICATIONS: Aspirin 325 mg by mouth once daily, Protonix 40 mg by mouth once daily, Lipitor 10 mg by mouth daily at bedtime, lasix 40 mg by mouth once daily, Imdur 30 mg by mouth once daily, Synthroid 125 mcg by mouth once daily, atenolol 25 mg by mouth once daily, Zestril 10 mg by mouth once daily, Combivent metered dose inhaler two puffs four times a day, K-Dur 10 mEq by mouth once daily, Plavix 75 mg by mouth once daily, percocet one to two tablets by mouth every four to six hours as needed, Colace 100 mg by mouth twice a day, Cogentin 1 mg by mouth once daily, Trilafon 2 mg by mouth once daily, Prozac 40 mg by mouth once daily, Trilafon 2 mg by mouth/intravenously every six hours as needed for agitation, Actos 30 mg by mouth once daily, Glyburide 10 mg by mouth twice a day, Lopid 600 mg by mouth once daily, Glucophage 850 mg by mouth once daily. FOLLOW UP: The patient will see her primary care provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20585**], for an initial evaluation. She will then either be referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 346**] or with a local cardiologist, depending upon the family's preference. Rehabilitation potential is good. [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 5219**] Dictated By:[**Last Name (NamePattern1) 11732**] MEDQUIST36 D: [**2171-11-6**] 00:07 T: [**2171-11-6**] 01:23 JOB#: [**Job Number 36041**] Admission Date: [**2171-10-30**] Discharge Date: [**2171-11-6**] Date of Birth: [**2099-3-17**] Sex: F Service: ADDENDUM DISCHARGE MEDICATIONS: There was a medication listed as Trilafon at 2 mg p.o. q.d. This should be changed to 2 mg p.o. b.i.d. HOSPITAL COURSE: Additional Psychiatry recommendations were made to obtain a head CT in the future if the patient's mental status changes recur. DR.[**First Name (STitle) **],[**First Name3 (LF) 870**] 12-464 Dictated By:[**Last Name (NamePattern1) 11732**] MEDQUIST36 D: [**2171-11-6**] 08:16 T: [**2171-11-6**] 08:08 JOB#: [**Job Number 36042**] Admission Date: [**2171-10-30**] Discharge Date: [**2171-11-6**] Date of Birth: [**2099-3-17**] Sex: F Service: ADDENDUM: Given the severity of the patient's chronic lung disease, we were concerned about chronic pulmonary emboli as a possible cause. The patient underwent a CT angiogram of her chest, which revealed extensive emphysematous disease, but no pulmonary emboli. There has been a change in the patient's discharge status. The patient and her family have decided that she should be discharged to home with VNA and physical therapy assistance at home. DR.[**First Name (STitle) **],[**First Name3 (LF) 870**] 12-464 Dictated By:[**Last Name (NamePattern1) 11732**] MEDQUIST36 D: [**2171-11-6**] 14:44 T: [**2171-11-6**] 14:50 JOB#: [**Job Number 36043**]

[ "E939.4", "593.9", "285.9", "411.1", "492.8", "428.0", "292.81", "424.0", "250.00" ]

icd9cm

[ [ [] ] ]

[ "88.56", "99.20", "36.05", "96.71", "88.43", "37.22" ]

icd9pcs

[ [ [] ] ]

10661, 10766

8620, 8889

10784, 11984

2710, 3270

9777, 10637

3294, 4784

8526, 8599

167, 2055

2077, 2688

21,000

188,959

4377

Discharge summary

report

Admission Date: [**2112-10-11**] Discharge Date: [**2112-10-15**] Date of Birth: [**2050-10-1**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This 62-year-old white male has a known history of coronary disease and had a cardiac catheterization in [**2089**]. He had medical management at that time and had a percutaneous transluminal coronary angioplasty of the right coronary artery in [**2104**]. He had a recent stress test for exertional chest pain which was positive and underwent cardiac catheterization on [**2112-9-21**] which revealed a right dominant system with a 99 percent RCA stenosis and 99 percent LAD stenosis with 40 percent diagonal 1 stenosis, 99 percent diagonal 2 stenosis and a normal left circumflex. His ejection fraction was 59 percent. He had mild left atrial enlargement, mild mitral regurgitation and he is now admitted for elective coronary artery bypass graft. PAST MEDICAL HISTORY: Significant for a question of transient ischemic attacks in the past. History of coronary artery disease, status post cardiac catheterization in [**2089**], status post angioplasty of the RCA in [**2104**], status post benign lump removal in the posterior right thigh, status post right femur fracture, status post bilateral ankle fractures, history of hypertension, history of gastroesophageal reflux disease, history of hypercholesterolemia. MEDICATIONS: 1. Lipitor 80 mg p.o. once a day. 2. Norvasc 10 mg p.o. once a day. 3. Atenolol 25 mg p.o. once a day. 4. Aspirin 325 mg p.o. once a day. 5. Pepcid p.r.n. 6. Viagra 25 mg p.r.n. He has no known allergies. FAMILY HISTORY: Significant for coronary artery disease. SOCIAL HISTORY: He works as a consultant and lives with his wife. Quit smoking in [**2089**] and drinks two glasses of wine per day. REVIEW OF SYSTEMS: Unremarkable. PHYSICAL EXAMINATION: He is a well-developed, well-nourished white male in no apparent distress. Vital signs stable. Afebrile. HEENT examination: Normocephalic, atraumatic. Extraocular muscles are intact. Oropharynx benign. Neck was supple. Full range of motion. No lymphadenopathy or thyromegaly. Carotids 2 plus and equal bilaterally without bruits. Lungs clear to auscultation and percussion. Cardiovascular: Regular rate and rhythm, normal S1, S2 with no rubs, murmurs or gallops. Abdomen was obese, soft, nontender with positive bowel sounds. No masses or hepatosplenomegaly. Extremities were without clubbing, cyanosis or edema. Pulses were femoral, 2 plus bilaterally, DP and PT 1 plus bilaterally, radial 2 plus bilaterally. Neurological examination was nonfocal. He was admitted on [**2112-10-11**] and underwent coronary artery bypass graft times three with LIMA to the LAD, reverse saphenous vein graft to diagonal and PVA. Cross clamp time was 71 minutes. Total bypass time 99 minutes. He was transferred to the CSRU on Neo-Synephrine and Propofol in stable condition. He had a stable postoperative night. He was extubated. He had a right pneumothorax postoperatively which was stable. On postoperative day no. 1 he was transferred to the floor in stable condition. He had his chest tubes and wires discontinued on postoperative day no. 3, and on postoperative day no. 4 he was discharged to home in stable condition. His laboratories on discharge were hematocrit 30.8, white count 8,400, platelets 138,000, sodium 135, potassium 4, chloride 98, CO2 30, BUN 16, creatinine 0.6, blood sugar 115. DISCHARGE MEDICATIONS: 1. Lasix 20 mg p.o. for 7 days. 2. Potassium 20 mEq p.o. twice a day for 7 days. 3. Colace 100 mg p.o. twice a day. 4. Zantac 150 mg p.o. twice a day for one month. 5. Lipitor 80 mg p.o. once a day. 6. Tylenol no. 3 one to two p.o. q.4-6h. p.r.n. pain. 7. Lopressor 25 mg p.o. twice a day. 8. Aspirin 81 mg p.o. once a day. DISCHARGE DIAGNOSES: Coronary artery disease, hypertension, hypercholesterolemia. He will follow-up with Dr. [**Last Name (STitle) 18872**] in one to two weeks and Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **], M.D. in four weeks. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern1) 18588**] MEDQUIST36 D: [**2112-10-15**] 15:29:01 T: [**2112-10-15**] 16:55:57 Job#: [**Job Number 18873**]

[ "414.01", "401.9", "V45.82", "512.1", "272.0", "530.81" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

1633, 1675

3858, 4342

3503, 3836

1869, 3480

1831, 1846

167, 923

946, 1616

1692, 1811

6,682

177,023

28286

Discharge summary

report

Admission Date: [**2122-9-15**] Discharge Date: [**2122-9-25**] Date of Birth: [**2041-10-30**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7760**] Chief Complaint: Right lower quadrant pain, severe R-sided chest pain, altered mental status and anorexia of 2 days duration. Major Surgical or Invasive Procedure: Appendectomy ([**2122-9-15**]) History of Present Illness: The patient is an 80-year-old female who presented to our ED with the above complaints. She denied nausea, vomiting, diarrhea, hematochezia and melena. Past Medical History: Mesenteric ischemia Diabetes mellitus type II Peripheral vascular disease Hypertension Thyroid hormone dependent Past Surgical History: Placement of inferior mesenteric artery stent for mesenteric ischemia Total thyroidectomy Social History: Lives in [**State 15946**], MA, denies tobacco or alcohol use and history. Has a son who is a nurse. Family History: Non-contributory Physical Exam: VS: T99.5 P65 BP112/39 R20 sat 96%RA Gen - ill-appearing, slightly confused HEENT - anicteric, dry MM Cor - RRR without m/g/r Lungs - CTA bilat. [**Last Name (un) **] - bowel sounds present, tense at RLQ, distended, quite tender, +guarding Ext - no edema, cool toes Pertinent Results: [**2122-9-14**] 11:45PM WBC-19.7* RBC-3.33* HGB-10.6* HCT-30.9* MCV-93 MCH-31.6 MCHC-34.2 RDW-14.1 [**2122-9-14**] 11:45PM NEUTS-86.4* LYMPHS-9.0* MONOS-3.9 EOS-0.7 BASOS-0.1 [**2122-9-14**] 11:45PM PLT COUNT-174 LPLT-1+ [**2122-9-15**] 02:20AM URINE RBC-0 WBC-[**6-13**]* BACTERIA-FEW YEAST-NONE EPI-[**6-13**] [**2122-9-15**] 02:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [**2122-9-15**] 02:20AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013 Brief Hospital Course: The patient was admitted to the Platinum Surgery service under Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6633**]. Both her physical exam and her CT scan confirmed the presence of appendicitis. Specifically, she had a 13mm appendix with an appendicolith, and marked inflammatory stranding in the right lower quadrant centered about the appendix. The appendix was dilated but filled proximally with air and stool. The appearance was consistent with uncomplicated distal acute appendicitis. She was also noted to have a ventral hernia containing fat. She was administered levofloxacin, metronidazole, hydrated and was taken to the operating room for a laparoscopic appendectomy and ventral herniorrhaphy, and her appendix was noted to be gangrenous. Please refer to the operative note for further details of the operation. A drain was left in the surgical bed. In the immediate post-operative period, she was given 1 unit of packed red blood cells (PRBCs). Ampicillin was added to her antibiotic regimen to broaden gram-negative coverage given the state of her appendix. Her pain was controlled adequately and her urine output was adequate. On POD#2, she worked with physical therapy. Leter in the day, she was noted to have slightly decreased breath sounds and mild shortness of breath (SOB). She was administered a diuretic and nebulizer therapy with vast improvement in her pulmonary status. Later the same evening, she developed asymptomatic atrial fibrillation that ceased with 5mg intravenous metoprolol. Work-up for acute coronary syndrome was negative. On POD#3 ([**2122-9-18**]), the patient again manifested atrial fibrillation and SOB, and began to have oliguria, with a urine output of 40ml over 4 hours. She was transferred to the intensive care unit for close monitoring. A central venous line was placed, and she was given a unit of PRBCs for a hematocrit of 29.3. A nasogastric tube was placed for decompression of the stomach, and this yielded 300ml of contents straightaway. After stabilization and conversion to normal sinus rhythm, the patient was transferred back to the floor on POD#5. She had two bowel movements and was allowed a clear liquid diet, which she tolerated well. On POD#6 overnight, the patient again had atrial fibrillation but was asymptomatic. On the morning of POD#7, she again suffered dyspnea, and a chest x-ray showed cephalization. She responded well to intravenous furosemide. Later in the day, she complained of nausea. Evaluation for acute coronary syndrome proved negative. She was seen by the cardiology service for evaluation of her atrial fibrillation and dyspnea. Her metoprolol dosage was optimized over the next day. The cardiology service recommended a trial of beta blocker in the absence of albuterol and a trans-thoracic echocardiogram. The former was quite successful in preventing her paroxysmal atrial fibrillation, and the latter showed mild L atrial dilatation, LVEF of 70%, and 1+MR. On POD#8, her [**Location (un) 1661**]-[**Location (un) 1662**] drain was removed, and she was advanced to a regular diet. Her antibiotics were discontinued. She felt quite well, and expressed a desire to be discharged. She did have a few bouts of diarrhea, but laboratory tests were negative for clostridium difficile colitis. On POD#9, the patient was discharged to the [**Hospital1 10151**] Center in good condition. She was afebrile, tolerating a regular diet, able to walk about and manage most of her activities of daily living, and was pain-free. She is to follow up in clinic with Dr. [**Last Name (STitle) 6633**] in 2 weeks for evaluation and outpatient treatment. Medications on Admission: bisporolol-HCTZ 2.5/6.25mg QD ASA 81mg QD clopidogrel 75mg QD glipizide 5mg [**Hospital1 **] ezetimibe-simvastatin 10/20mg QD lisinopril 10' levothyroxine 125mcg q TWTSaSu, 62.5mcg q MF Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Levothyroxine 125 mcg Tablet Sig: 0.5 Tablet PO MONDAY AND FRIDAY (). 9. Hydrochlorothiazide 25 mg Tablet Sig: 0.26 Tablet PO DAILY (Daily). 10. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO TUES THROUGH THURSDAY, SAT & SUNDAY (). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer treatment Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: Acute appendicitis/gangrenous appendix Congestive heart failure Discharge Condition: Vital signs stable, afebrile, alert/oriented, tolerating po, ambulant with assistance. Overall, very good. Discharge Instructions: Please call for fever greater than 101, nausea/vomiting, inability to eat, wound redness, warmth, swelling, foul smelling drainage, abdominal pain that is not controlled by medication or any other concerns. You may resume your regular diabetic diet. You may resume your normal activities. Please resume taking all medications you were taking prior to this surgery and pain medications. Please follow up as directed. No heavy lifting for 4-6weeks or until directed otherwise. [**Month (only) 116**] leave wound open to air, please leave the steristrips intact until they fall off. Followup Instructions: Please follow up with your primary care physician in [**State 15946**], MA. Call for an appointment to be seen the week you get discharged from [**Hospital3 **]. Call Dr. [**Last Name (STitle) 17477**] office for an appointment in 2 weeks. Her phone number is: (81) [**Telephone/Fax (1) **]. Completed by:[**2122-9-25**]

[ "560.1", "997.1", "540.9", "428.0", "427.31", "443.9", "401.9", "552.1", "244.0", "788.5", "250.00", "997.4" ]

icd9cm

[ [ [] ] ]

[ "53.49", "99.04", "38.93", "96.07", "47.01" ]

icd9pcs

[ [ [] ] ]

6901, 6986

1905, 5561

424, 457

7094, 7203

1342, 1882

7836, 8159

1022, 1040

5798, 6878

7007, 7073

5587, 5775

7227, 7813

797, 888

1055, 1323

276, 386

485, 638

660, 774

904, 1006

16,535

192,341

8633

Discharge summary

report

Admission Date: [**2167-6-8**] Discharge Date: [**2167-7-14**] Date of Birth: [**2097-10-8**] Sex: M Service: TRANSPLANT SURGERY SERVICE Attending:[**Last Name (NamePattern4) 30250**] ADMISSION DIAGNOSIS: End stage liver disease secondary to hepatitis C. End stage liver disease secondary to hepatitis C status post orthotropic cadaveric liver transplant. HISTORY OF PRESENT ILLNESS: This patient is a 69 year-old male who is a patient of both the liver team and Dr. [**Last Name (STitle) **] who had a past medical history significant for hepatitis C, hypertension, psoriasis and chronic low back pain secondary post TIPS procedure on [**4-/2166**] with revision on 11/[**2166**]. His other surgeries are status post umbilical hernia repair. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Spironolactone 200 b.i.d., Lasix 40 q day, Protonix 40 q day, Lactulose, vitamin E, vitamin D, iron and calcium. He was admitted and underwent a cadaveric liver transplant on [**2167-6-8**] after having been appropriately assessed by the Transplant Surgical Service. It should be notable that during the case the patient's procedure had several notable findings. One was that there was a arterial branch patch in the recipient to the donor. The patient's transplant was portal vein to portal vein. The patient's duct was duct to duct anastomosis over a 5 French T tube and the patient's MELD score at the time of transplant was 29. He had a warm ischemic time of 52 minutes completed by Dr. [**Last Name (STitle) **]. The patient's intraoperative fluids were noted for having received 36 units of packed red blood cells, 29 units of fresh frozen platelets, 10 of cryo and 11 packs of platelets. He had 5 liters of Cell [**Doctor Last Name **] and 3500 of crystalloid in the form of Plasma-Lyte. His urine output was 3500 cc during the case and it was completed with the patient being brought to the Intensive Care Unit in hemodynamically stabilized yet critical condition. Over the following 24 hours the patient became more hemodynamically stable and required additional blood transfusion. On [**2167-6-9**] he was returned to the Operating Room for an exploration and was found to have an area of bleeding from the posterior vena cava. This was repaired and the patient was again returned to the Intensive Care Unit. Over the next several days in the Intensive Care Unit the patient became much more hemodynamically stable. He was not on any pressors at this time or drips and was maintained with antibiotics including Unasyn, Ampicillin, bactrim and Ganciclovir. His immunosuppressive regimen included CellCept, Solu-Medrol and Cyclosporin. It should be noted that during this time the patient did, however, rule in positive for myocardial infarction by perioperative troponins elevated to 5.7. The thought by cardiology evaluation to be a non Q wave myocardial infarction versus an isolated troponin leak and the patient was maintained on Lopressor. He had an echocardiogram evaluation that showed an EF function of 30% with an akinetic anterior wall during this acute period. This was repeated several days later and it showed that the patient's EF had returned to 50% and he had no thrombus in his atrium. The patient continued to be in guarded condition until postoperative day seven and five during which time he had a repeat CAT scan, which showed there was a significant amount of blood approximately 1 liter in an area behind the liver. The patient at this time was concerning hemodynamically and again was returned to the Operating Room on [**2167-6-16**]. At this time the patient was found to just have a significant intra-abdominal hematoma on exploration. He underwent a biopsy of his liver at this time as well and it was thought to not be a complicated case. When he returned to the Intensive Care Unit from this point on he became hemodynamically stable without further concerns. The patient's biopsy revealed that there was no rejection and no ductal cholestasis. On primary evaluation in the Operating Room he did not appear to have any ductal leak, but the surgeons were maintaining a close eye for this finding. In the Intensive Care Unit the patient's hemodynamics were no longer a concern, but his mental status was as he began to be awakened and expected to be more interactive with a concern. For this reason neurology was consulted and he was thought to have a electroencephalogram not consistent with seizure activity and MRI with old periventricular white matter changes. He was not thought to have had any acute neurological event. In the next several days as the patient continued in the Intensive Care Unit he recovered from his Intensive Care Unit psychosis/confusion and although communication was difficulty as he was predominantly Italian speaking he did become somewhat more oriented. It should be noted that Infectious Disease was consulted at this time and was following the patient closely for potential signs of infection. He did from cultures grow out E-coli from wound fluid and was treated with appropriate antibiotics, Levofloxacin, but since he had a distant sensitivity to such Ceftazidine per infectious disease. He did not hve any fungal cultures that were positive. The patient also had nutrition consulted at this time and this was to be a big issue in terms of his recuperation and his recovery and was started on total parenteral nutrition, again with close following for potential signs of infection and close maintenance of wound and continued line care. The patient was transferred out of the Intensive Care Unit when it was deemed that he indeed had maintained hemodynamic stability on [**2167-6-22**]. At this point it should be noted that he was tolerating po at increased amounts up to approximately a liter a day in supplement to his total parenteral nutrition. At this point it should also be noted that his total bili had trended downward from a high of 5.1 during the returning perioperative time to 1.9. This was associated with transaminases of AST of 20, ALT of 30, alkaline phosphatase of 251 and an albumin of 2.4. The patient's coags were significant at this time for an INR of 1.4 and a PTT of 27 and his white blood cell count had indeed come down as well from a high of 16.8 to 11.3. His hematocrit at this time was stable in the 27 to 28 range with platelets of 124. The patient's BUN and creatinine were 38 and .9 respectively with controlled potassium at 4.4. His hospital course outside of the Intensive Care Unit was characterized by continued surveillance of his liver function. On [**2167-6-29**] the patient underwent an ultrasound, which revealed that he had normal pulsatile flow through the porta and on [**7-2**] he had a cholangiogram, which indicated that he had a dilated proximal duct with some extravasation. This was followed up by a CAT scan and also evidenced extravasation of contrast. This was concerning and the patient was continued with his T tube. At this point the approximate T tube drainage was 200 to 400 cc a day. It should also be noted that on all imaging formats the hepatic artery was viewed as patent as well and it was not thought that ischemia was a concern at this point contributing to the patient's status. He underwent an endoscopic retrograde cholangiopancreatography on [**2167-7-7**], which showed that he had an anastomotic leak and evidenced such clearly enough to place a stent that was 7 cm by 10 French Cotton-[**Doctor Last Name **] biliary stent through the site of anastomosis. They believed that adequate result would be achieved from this placement. Follow up ultrasound the following day again noted normal arterial flow and that the portal vein was patent. The biliary system was slightly dilated. Cholangiogram repeated on [**2167-7-8**] evidenced no leak at the anastomosis. This was a very encouraging sign given the recent endoscopic retrograde cholangiopancreatography and stent placement. The patient had this followed by a HIDA scan, which again evidenced no leak and had minimal 16 minute normal transient time of contrast to the small bowel. The patient clinically looked very well at this point and he had liver function tests that were trending downward. On [**2167-7-11**] his T bili was 1.1 with an alkaline phosphatase of 424, AST of 39 and ALT of 80. This was accompanied by white blood cell count of 11, hematocrit now 31.9 and platelets of 164. His chemistry was significant for a BUN and creatinine at his baseline. Discharge planning was seriously discussed and initiated for rehab in the patient's family's area. At this point the patient's immunosuppressive regimen included Prednisone at 15 mg po q day, CellCept at 1 gram po b.i.d. and Cyclosporin. It should be noted that during the time the patient was having these resolving liver function issues his Cyclosporin level was elevated as high as 563. On [**2167-7-6**] he had his dose held and then reduced to 175, 125 and finally to 75 mg po b.i.d. for which he had a therapeutic level on 260 on [**2167-7-11**]. With these findings the patient was discussed in depth with Dr. [**Last Name (STitle) **] and thought to be both hemodynamically and immunosuppressively stable enough to transfer to a rehab at this point. He was taking in an adequate amount of nutrition po as documented by calorie counts and had his total parenteral nutrition discontinued. The patient had also tolerated his T tube being clamped for greater then 48 hours without any temperature spikes or any abdominal discomfort. He was ambulating with a walker and was seen regularly by physical therapy. The patient was discharged to rehab on [**2167-7-14**]. DISCHARGE DIAGNOSES: 1. Hepatitis C significant for his Child's B cirrhosis and hepatocellular carcinoma status post OLT with postoperative course as noted above. He had perioperative encephalopathy, which had resolved. 2. Hypertension. 3. Psoriasis. 4. He has an L1 compression fracture. 5. Status post umbilical hernia repair. 6. He is status post TIPS in [**4-/2166**] and then revised again on 11/[**2166**]. DISCHARGE MEDICATIONS: Protonix 40 mg po b.i.d., Salicylate 450 mg po q day, vitamin D 400 international units po q day, Calcium carbonate 600 mg po b.i.d., Risperdal .5 mg po q.h.s. for sleep, Fluconazole 400 mg po q day and Bactrim single strength one tab po q day for his chronic immunosuppressive needs, but he had completed all perioperative and infectious antibiotics as per the infectious disease consultation service. He took Actigall 300 mg po t.i.d., Univasc 7.5 mg po q day to be held for SBP less then 100, Lopresor 12.5 mg po b.i.d. to be held for SBP less then 100 and a heart rate less then 60, aspirin 81 mg po q day. His immunosuppression regimen at the time of discharge was CellCept [**Pager number **] mg po b.i.d., Prednisone 15 mg po q day and Cyclosporin 75 mg po b.i.d. He was on a regular insulin sliding scale, but had finger sticks that were very well controlled and have been tapered to b.i.d. finger sticks. He took Colace during the times of constipation, but had been having regular soft bowel movements without any need for additional stool softeners. He was to be seen by physical therapy and was full weight bearing, ambulated for stability with a walker, but this could be transitioned as per the consult service. He was tolerating po greater then a liter a day without any intravenous supplementation. He should get nutrition shakes and strict Is and Os to be accounted for at the rehabilitation facility. He has a medication list that will be provided by the transplant surgical service to accompany the patient and he should follow up with Dr. [**Last Name (STitle) **], calling the office on the day following arrival to confirm his appointment. The [**Hospital 228**] rehabilitation potential is very good and he was discharged to rehab hemodynamically completely stable and doing very well. He had the above noted imaging studies that confirmed that he no longer had any biliary system leak and his hematocrit had been stable for some time. He was to maintain his T tube, which is to be secured to the skin without any tension and this would stay in place until follow up and further evaluation by Dr. [**Last Name (STitle) **]. The patient was discharged to rehab on [**7-14**], which for him was postoperative days number thirty six, thirty four and twenty eight. Please contact Dr.[**Name2 (NI) 1369**] office at the [**Hospital1 **] [**First Name (Titles) 21293**] [**Last Name (Titles) 4869**] with any questions. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366 Dictated By:[**Name8 (MD) 15477**] MEDQUIST36 D: [**2167-7-13**] 09:46 T: [**2167-7-13**] 10:02 JOB#: [**Job Number 30251**]

[ "285.1", "998.11", "576.8", "570", "410.11", "070.54", "998.12", "293.0", "996.82" ]

icd9cm

[ [ [] ] ]

[ "99.15", "39.1", "44.14", "50.12", "38.93", "39.59", "54.0", "51.87", "50.59" ]

icd9pcs

[ [ [] ] ]

9748, 10148

10172, 12879

833, 9727

225, 378

407, 806

29,866

132,173

26394

Discharge summary

report

Admission Date: [**2115-12-31**] Discharge Date: [**2116-1-10**] Date of Birth: [**2054-6-13**] Sex: F Service: MEDICINE Allergies: Codeine / Lipitor Attending:[**First Name3 (LF) 30**] Chief Complaint: Hypertensive emergency Major Surgical or Invasive Procedure: TTE [**1-2**] EGD [**1-8**] TEE [**1-9**] Fluoroscopic guided LP Bedside LP History of Present Illness: Ms. [**Known lastname 64426**] is a 61yo female with PMH significant for CAD, ESRD on HD, and Type 2 DM who presents with mental status changes. The patient completed dialysis treatment yesterday morning and was waiting for a ride home. Five minutes later the dialysis technician found the patient confused, standing in the middle of the floor, in a gaze, and not answering questions. Per her daughter, she had spoken to her mother earlier that morning. The patient had no complaints at that time. She denied any fevers, chills, chest pain, SOB, abdominal pain, or any other concerning symptoms. She does take her medications but does miss doses at times. Per records from her dialysis facility, her BP's pre- and post-dialysis have been labile. . In the ED initial vitals were T 98.3 BP 270/90 AR 103 RR 16 O2 sat 85% RA. She received Labetolol 20mg x1, 40mg x1, 40mg x2, and Hydralazine 10mg IV x1. He was then started on a nitroglycerin gtt given persistently elevated blood pressures. She also received Ativan 1mg x2, Zofran 8mg IV, Protonix 40mg IV, and regular insulin 10 units SQ. The patient also had an episode of coffee ground emesis. An NGT was placed at this time. She was then transferred to the MICU for further management of her blood pressure. Past Medical History: 1)CAD s/p cath ([**8-24**]): Mild epicardial disease, collalateral flow to distal inferior wall, no intervention 2)Hypertension 3)Hyperlipidemia 4)Type 2 Diabetes: complicated by retinopathy, neuropathy, and nephropahy 5)Chronic kidney disease (stage IV) 6)Stroke 7)Impaired memory s/p MVA 8)Anemia Social History: Patient lives alone. Independent. No current history of tobacco, alcohol, or IVDA. Family History: # F, d70s: Heart disease # Siblings (two sisters): DM2 Physical Exam: vitals T 101.6 BP 166/63 AR 118 RR 18 O2 sat 97% on 4L Gen: Patient difficult to arouse, moves all extremities HEENT: L surgical pupil, R pupil minimally responsive Heart: RRR, no audible m,r,g Lungs: CTAB Abdomen: soft, NT/ND, +BS Extremities: 1+ bilateral edema, 2+ DP/PT pulses Pertinent Results: CT head: No evidence of hemorrhage or mass effect. Chronic small vessel ischemic changes. . MRI/MRA head: 1. Moderate-sized acute infarct in the left frontal lobe corresponding to left middle cerebral artery territory, and smaller acute infarct in the left caudal occipital lobe, corresponding to left PCA territory. These findings likely represent sequelae of an embolic event. 2. MRA: Apparent filling defects within peripheral branches of left MCA, which could represent emboli. No aneurysm or dissection in the anterior posterior circulation. . EEG: This is an abnormal portable EEG due to intermittent but, at times, prolonged bursts of moderate amplitude mixed theta and delta frequency slowing seen broadly over the right side, most prominently in the right fronto-central and fronto-temporal regions, consistent with underlying cortical and subcortical dysfunction. In addition, the background was disorganized, slow, and demonstrated admixed bursts of moderate amplitude generalized mixed theta and delta frequency slowing. These latter findings are consistent with a moderate encephalopathy which suggests dysfunction of bilateral subcortical or deep midline structures. Medications, metabolic disturbances, and infection are among the common causes of encephalopathy but there are others. There were no clearly epileptiform features. No electrographic seizure activity was noted. . Transthoracic echocardiogram: No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast at rest. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . Transesophageal echocardiogram: The left atrium is normal in size. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. The left ventricle is not well seen. 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 to 40 cm from the incisors. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. No masses or vegetations are seen on the pulmonic valve or tricuspid valve. There is no pericardial effusion. . Ultrasound of AV fistula: No sizeable thrombus identified within the left AV graft. . Carotid dopplers: No stenosis of the right ICA. Less than 40% stenosis of the left ICA. . Lumbar puncture: Gram stain, cultures negative. Viral cultures no growth to date. . HSV PCR: negative . Blood cultures: No growth to date . Labs on admission: [**2115-12-30**] 10:00PM TSH-1.9 [**2115-12-30**] 10:00PM VIT B12-[**2013**]* [**2115-12-30**] 10:00PM CK-MB-3 cTropnT-0.02* [**2115-12-30**] 10:14PM K+-4.7 [**2115-12-31**] 03:00AM PLT COUNT-328 [**2115-12-31**] 03:00AM NEUTS-90.7* LYMPHS-7.7* MONOS-1.3* EOS-0.3 BASOS-0 [**2115-12-31**] 03:00AM WBC-9.7 RBC-3.94* HGB-12.2 HCT-36.4 MCV-92 MCH-30.9 MCHC-33.5 RDW-13.2 [**2115-12-31**] 03:00AM GLUCOSE-371* UREA N-22* CREAT-3.2* SODIUM-132* POTASSIUM-6.4* CHLORIDE-94* TOTAL CO2-27 ANION GAP-17 Labs on discharge: WBC: 7.3 Hematocrit: 27.8 Plt: 510 Na 141, K 3.6, Cl 104, bicarb 26, BUN 20, Cr 4.7, glu 104 Ca 9.0, Mg 1.7, Phos 5.0 Vanco level 17.7 Brief Hospital Course: BRIEF HOSPITAL COURSE: . 61F PMH CAD, ESRD, Type 2 DM presented with mental status changes on [**2115-12-31**] at dialysis, and was found to have a BP 270/90. She was transferred to the MICU where she required a nitro gtt. She also had a fever, leukocytosis, and coffee-ground emesis. Her current diagnosis is stroke likely embolic in nature. . 1. Embolic stroke: Confirmed on MRI where an embolic stroke in the left frontal and occipital lobs (Left MCA and PCA territories) was found. AV fistula ultrasound, TTE, TEE, and carotid ultrasound showed no obvious source of embolus. While on the floor, mental status improved, although patient is not yet back to baseline. Given fevers and stroke, endocarditis was suspected. TEE was done 10 days after initiating antibiotics and this may have contributed to the negative result. She was monitored on telemetry with no evidence of atrial fibrillation so a thrombus from arrhythmia seems unlikely. Patient is being treated for endocarditis and will continue 4-week course of ceftriaxone and vancomycin, with treatment scheduled to end on [**1-29**]. There is no clear indication for coumadin and she will be treated with Aggrenox [**Hospital1 **]. She is also on Dilantin for seizure prophylaxis for a two week course followed by a one week taper. She has follow up scheduled with Dr. [**Last Name (STitle) **] in Neurology Stroke. . 2. HTN: She was initially transitioned to a labetolol drip in the MICU with stabilization of blood pressure. Upon BP control in the MICU, her MS did not clear. She was transferred to the floor where her blood pressure was controlled with metoprolol 37.5 mg po three times daily with blood pressure. . 3. Fevers: Given fevers and mental status changes, meningitis vs endocarditis was suspected. CXR, urine, and blood cultures were negative. A bed-side LP was unsuccessful, so the patient was empirically covered with ceftriaxone, vancomycin, ampicillin, and acyclovir in the setting of fevers and leukocytosis. A flouroscopy-guided LP was performed after 36 hours of antibiotics. A CSF pleocytosis was seen on LP although this is hard to interpret in the setting of acute infarcts. Broad-spectrum coverage was continued. CSF gram stain, fluid cultures, and viral cultures are negative. HSV 1 and 2 DNA PCR was negative so acyclovir was discontinued on [**1-6**]. Ampicillin was discontinued on [**1-10**]. Patient is being discharged on ceftriaxone and vancomycin (with hemodialysis) for a four week course. 4. Coffee ground emesis: Patient had episode of coffee ground emesis in emergency room. Stool was guaiac negative. Hematocrit remained stable during admission. Per daughter, patient has not had colonoscopy or endoscopy in past. EGD on [**1-8**] revealed mild gastritis and duodenitis. GI recommended a PPI two times daily. Medications on Admission: Aspirin 325mg PO daily Sevelamer 800mg PO TID Colace 100mg 2 tablets PO BID PRN Humalog insulin sliding scale Metoprolol 150mg PO daily Vitamin D Folic Acid Discharge Medications: 1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 2. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr [**Last Name (STitle) **]: One (1) Cap PO BID (2 times a day). 3. Phenytoin Sodium Extended 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO TID (3 times a day): Started on [**1-1**]. On [**1-15**] begin taper. Continue 100mg [**Hospital1 **] x 2 days, then 100mg daily for 2 days. Then stop the medication. Last dose should be on [**1-19**]. 4. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: 5000 (5000) units Injection TID (3 times a day). 5. Metoprolol Tartrate 25 mg Tablet [**Month/Day (2) **]: 1.5 Tablets PO TID (3 times a day). 6. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Month/Day (2) **]: One (1) gram Intravenous HD PROTOCOL (HD Protochol) for 19 days: Course complete on [**2116-1-29**]. 7. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback [**Date Range **]: One (1) gram Intravenous Q12H (every 12 hours) for 19 days: Course complete on [**2116-1-29**]. 8. PICC line care per protocol 9. Insulin Regular Human 100 unit/mL Cartridge [**Date Range **]: as directed by sliding scale Injection four times a day. 10. Docusate Sodium 100 mg Capsule [**Date Range **]: One (1) Capsule PO BID (2 times a day). 11. Senna 8.6 mg Tablet [**Date Range **]: One (1) Tablet PO BID (2 times a day). 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Date Range **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] TCU - [**Location (un) 86**] Discharge Diagnosis: Primary: - Acute left frontal MCA and occipital PCA stroke - Malignant hypertension - Presumptive meningitis/endocarditis - Upper GI bleed NOS, gastritis, non-bleeding DU Secondary: - CKD stage V on HD - DM II - Peripheral neuropathy - Hypertension - Post-traumatic memory deficits - Non-flow limiting coronary artery disease Discharge Condition: Stable Discharge Instructions: You were admitted with fevers and a stroke. We were unable to find a clear source of your stroke. We are treating you for presumed meningits/endocarditis with a total of 4 weeks of antibiotics through your PICC line. . Please follow up as indicated below. . Please take all of your medications as directed. 1. You are now taking Aggrenox. Your aspirin has been discontinued. You should not take aspirin in addition to Aggrenox. 2. You are taking an anti-seizure medication called Dilantin three times daily which is to prevent seizures. You will take 100 mg three times daily for 2 weeks and then taper the medication off. After two weeks, take 100mg twice daily for two days then take 100mg daily for two days, then stop the medication. 3. You will be on antibiotics until [**1-29**] for a total of four weeks. . If you develop any new weakness, confusion, fevers, loss of consiousness or any other concerning symptoms, please return to the emergency room to be evaluated. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) 20141**], M.D. Phone:[**Telephone/Fax (1) 4022**] Date/Time:[**2116-1-16**] 10:20 . Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**] Date/Time:[**2116-2-11**] 2:30 . Continue with dialysis on MWF schedule. You will receive Vancomycin at hemodialysis. . Follow up with your primary care doctor when you are discharged from the rehab facility.

[ "434.11", "250.40", "250.60", "583.81", "357.2", "322.9", "362.01", "535.51", "348.31", "585.6", "421.0", "535.60", "250.50", "403.01", "285.21" ]

icd9cm

[ [ [] ] ]

[ "39.95", "03.31", "88.72", "45.13" ]

icd9pcs

[ [ [] ] ]

11114, 11188

6493, 9304

300, 378

11559, 11568

2482, 2482

12596, 13072

2109, 2165

9512, 11091

11209, 11538

9330, 9489

11592, 12573

2180, 2463

238, 262

6311, 6447

406, 1669

2491, 5767

5781, 6292

1691, 1992

2008, 2093

15,810

161,437

19594

Discharge summary

report

Admission Date: [**2120-11-30**] Discharge Date: [**2120-12-3**] Date of Birth: [**2057-10-1**] Sex: M Service: CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: The patient is a 63 year-old male who presented to an outside hospital with stuttering chest pain, began at 9:30 on the morning of admission. By the afternoon the pain continued. The pain did not radiate, no shortness of breath or palpitations. He was found to have ST elevations in the inferior leads and transferred to catheterization, which showed right coronary artery disease and stented times two. The patient remained hemodynamically stable post catheterization, but the patient had a poor history of aspirin allergy so was transferred to the Coronary Care Unit for aspirin desensitization and further monitoring. The patient was started on Lopressor, Plavix, morphine, nitroglycerin and heparin at the outside hospital and also Integrilin. At the time of evaluation post catheterization he is chest pain free without shortness of breath, palpitations. Nitro drip had been weaned off in the catheterization laboratory. REVIEW OF SYSTEMS: Negative for any paroxysmal nocturnal dyspnea, orthopnea, lower extremity edema. The patient reports he has no change in his activity level. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hiatal hernia. ALLERGIES: Aspirin, which causes facial swelling as a young adult. Denies shortness of breath with this. MEDICATIONS: None at home. SOCIAL HISTORY: He denies tobacco or alcohol abuse. FAMILY HISTORY: Negative for coronary artery disease. PHYSICAL EXAMINATION: At the time of admission the patient is afebrile. Blood pressure 136/72. Pulse 90. Respiratory rate 14. 98% 2 liters nasal cannula. In general, he is well developed, well nourished and in no acute distress. HEENT negative for any JVD. Cardiovascular examination S1 and S2. No murmurs, rubs or gallops appreciated. Lungs are clear to auscultation anteriorly. Abdominal examination was benign. Extremities shows a right groin without hematoma or any bruit. LABORATORIES ON ADMISSION: White blood cell count 9.8, hematocrit 35.5, platelets 240, chemistries show sodium 137, potassium 3.5, chloride 106, bicarb 23, BUN 15, creatinine 0.8. His initial CK was 1038 with an MB of 198 and troponin of 1.72. Electrocardiogram from the outside hospital showed normal sinus rhythm at 80 beats per minute, left axis deviation, ST elevations, 3 mm in the inferior leads, right sided leads with no ST elevations or no ST changes and positive Q waves also in the inferior leads. Electrocardiogram at [**Hospital1 69**] shows sinus tachy to 101 with Q waves in leads 3, 2 and AVF. Cardiac catheterization shows three vessel coronary disease with left main carotid with 20% lesion distally, left anterior descending coronary artery with tubular 50% lesion proximally and diffuse 70% lesion distal to the major diagonal. Left circumflex had a large obtuse marginal one with 50% stenosis and a moderate obtuse marginal two with 80% lesion. Finally right coronary artery had a proximal 40% lesion and was totally occluded in the mid portion with thrombus present. His hemodynamics showed mildly elevated left and right filling pressures with mean capillary wedge of 15, cardiac index of 2.9, right ventricular and diastolic pressure of 12. The patient underwent stenting to mid to distal right coronary artery times two. HOSPITAL COURSE: 1. Cardiovascular: Coronary artery disease, the patient was admitted for inferior ST elevation myocardial infarction. Cardiac catheterization at the time of admission did show multivessel coronary artery disease, but was felt that his right coronary artery lesion was his culprit vessel. He subsequently underwent successful right coronary artery stenting times two and his CPKs ended up trending down. There was concern in the post catheterization settings about his history of aspirin allergy. The reason he was in the Coronary Care Unit for aspirin desensitization, which he tolerated quite well. At the time of discharge he was taking aspirin 325 once a day without difficulties or signs of allergies. He was also started on Plavix and started empirically on Lipitor. He was started on beta blocker and also on a low dose ace inhibitor. At the time of discharge he was on Atenolol 50 mg q day and Lisinopril 5 mg q day. As mentioned above the patient now has known two vessel coronary artery disease. He is currently asymptomatic. He will follow up with Dr. [**Last Name (STitle) **] in several weeks time at which time possible discussions can be made whether the patient will require additional revascularization to his stenotic vessels. Pump, on cardiac catheterization the patient was found to have mildly elevated filling pressures. He subsequently underwent an echocardiogram, which show an ejection fraction of 50 to 55% with distal inferior and apical hypokinesis. There was also a suggestion of an impaired relaxation possibly suggestive of diastolic dysfunction. Although the patient's catheterization showed mildly elevated filling pressures he remained stable from a volume standpoint. He was autodiuresing at the time of his discharge. He was started on beta blockade and low dose Lisinopril as mentioned above. Hemodynamics, the patient remained hemodynamically stable during his hospital course. Rhythm, the patient remained in sinus rhythm during his hospital course. 2. Pulmonary: The patient remained stable during his hospital course sating well on room air. 3. Renal: The patient's electrolytes remained stable during hospital course with additions of an ace inhibitor tolerated well. 4. Gastrointestinal: No issues. 5. Hematology: The patient's hematocrit remained stable during hospital course. He seemed to tolerate his aspirin desensitization to aspirin without any evidence of allergic reaction. DISCHARGE DIAGNOSES: 1. Inferior ST elevation myocardial infarction status post successful right coronary artery stent times two. 2. Two vessel coronary artery disease stable. 3. History of aspirin allergy status post successful desensitization. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg po q day. 2. Lipitor 10 mg po q day. 3. Lisinopril 5 mg po q day. 4. Plavix 75 mg q day. 5. Atenolol 50 mg q day. 6. Zantac 150 mg b.i.d. 7. Senokot and Colace prn. 8. Nitroglycerin prn. FOLLOW UP: He is scheduled to follow up with Dr. [**Last Name (STitle) **] in three to four weeks time. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], M.D. [**MD Number(1) 9615**] Dictated By:[**Last Name (NamePattern1) 5539**] MEDQUIST36 D: [**2120-12-4**] 03:03 T: [**2120-12-5**] 10:33 JOB#: [**Job Number 53118**]

[ "410.71", "401.9", "V07.1", "V14.6", "414.01", "429.9" ]

icd9cm

[ [ [] ] ]

[ "37.23", "99.20", "36.01", "36.06", "88.56" ]

icd9pcs

[ [ [] ] ]

6182, 6191

1553, 1592

5931, 6160

6214, 6428

3451, 5910

6440, 6814

1615, 2093

1142, 1285

146, 159

188, 1122

2108, 3433

1307, 1482

1499, 1536

53,441

167,823

15869

Discharge summary

report

Admission Date: [**2145-3-22**] Discharge Date: [**2145-4-2**] Date of Birth: [**2090-1-18**] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest pain and palpitations Major Surgical or Invasive Procedure: [**2145-3-26**] Coronary bypass grafting x3 with left internal mammary artery to left anterior descending coronary; reverse saphenous vein single graft from the aorta to the posterior descending coronary artery; reverse saphenous vein single graft from the aorta to the first obtuse marginal coronary artery. [**2145-3-22**] Cardiac cath History of Present Illness: Ms. [**Known lastname **] is an 54-year-old Latin American woman with a past history of type 2 diabetes, hypertension, and coronary artery disease diagnosed at age 47. She has had daily episodes of chest pain accompanied by palpitations over the past several months despite taking nitroglycerin, isosorbide mononitrate and beta-blockers. The patient was being evaluated by her outpatient cardiologist, Dr. [**First Name (STitle) **], who advised a cath to evaluate her coronaries. Cath on [**2145-3-22**] showed severe three vessel coronary artery disease and she was admitted for surgery. Past Medical History: Diabetes Mellitus II Hypertension Hyperlipidemia Coronary Artery Disease s/p NSTEMI x2 PCI-LAD in [**2135**](BX Velocity Hepacoat stent) Asthma GERD Anxiety Arthritis Tubal ligation 28 years ago Social History: Separated from her husband. [**Name (NI) **] husband lives in [**Male First Name (un) 1056**] with her 5 children. The youngest child is 20 years old. She is living currently in the home of her niece in [**Location (un) 86**]. . She came to the United States in [**2135**] in order to receive cardiac care. -Tobacco history: None -ETOH: None -Illicit drugs: None Family History: Notable for father, brother with significant coronary artery disease and mother with diabetes. Physical Exam: Temp 98 Pulse: 72 Resp: 24 O2 sat: 100%-RA B/P Right: 133/77 Left: 136/70 Height: 5 feet 3 inches Weight: 141 lbs/64kg General: NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] MMM- normal oropharynx Neck: Supple [x] Full ROM [x] no [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] JVD Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur-no Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x] Extremities: Warm [x], well-perfused [x] Edema: none Varicosities: None [] Neuro: Grossly intact-nonfocal exam Pulses: Femoral Right: 1+ cath site Left:1+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: dop Left: dop Radial Right: 2+ Left: 2+ Carotid Bruit -none Pertinent Results: [**2145-3-22**] Cath: 1. Selective coronary angiography in this right dominant system demonstrated three vessel coronary artery disease. The LMCA was a short vessel. The LAD was totally occluded with a clear channel (technically subtotally occluded) from the ostium to the proximal edge of the previously placed bare metal stent. It fills beyond via (mostly) right to left collaterals and some LCx-septal collaterals. The LCx was a large vessel with mild proximal disease. It gives rise to a major bifurcating OM with critical disease at the ostium of the first branch. The AV groove circ has moderate proximal disease and gives rise to 4 small, diseased branches distally. The RCA was a small caliber vessel with mild ostial disease, ~40%, and spasm upon initial catheter engagement. Intracoronary nitroglycerine was given with improvement. The distal RCA had a 70% focal lesion and gave rise to a long RPDA with serial mild to moderate focal lesions. 2. Limited resting hemodynamics revealed normotension. [**2145-3-23**] Carotid U/S: Right ICA no stenosis. Left ICA no stenosis. [**2145-3-26**] Echo PRE-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. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is mildly depressed(LVEF= 40 %). With regional wall m otion abnormalities in the anterior and inferior septal walls at the base, mid and apical regions. Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-13**]+) mitral regurgitation is seen. There is no pericardial effusion. POST-BYPASS: Normal RV systolic function. Overall LVEF 40%. There is some improvement in the previously hypokinetic regions. Intact thoracic aorta. Mild MR [**First Name (Titles) **] [**Last Name (Titles) **]. [**2145-3-22**] 03:20PM BLOOD WBC-6.9 RBC-4.38 Hgb-13.6 Hct-36.7 MCV-84 MCH-31.1 MCHC-37.1* RDW-13.4 Plt Ct-262 [**2145-3-26**] 01:19PM BLOOD WBC-11.9* RBC-3.26* Hgb-10.0* Hct-27.6* MCV-84 MCH-30.6 MCHC-36.3* RDW-13.6 Plt Ct-177 [**2145-3-30**] 04:07AM BLOOD WBC-7.7 RBC-2.94* Hgb-9.2* Hct-25.3* MCV-86 MCH-31.2 MCHC-36.2* RDW-13.7 Plt Ct-225 [**2145-3-22**] 03:20PM BLOOD PT-12.7 INR(PT)-1.1 [**2145-3-26**] 01:19PM BLOOD PT-14.1* PTT-26.8 INR(PT)-1.2* [**2145-3-27**] 02:13AM BLOOD PT-13.2 PTT-23.3 INR(PT)-1.1 [**2145-3-22**] 03:20PM BLOOD Glucose-170* UreaN-14 Creat-0.6 Na-139 K-3.5 Cl-104 HCO3-27 AnGap-12 [**2145-3-30**] 04:07AM BLOOD Glucose-153* UreaN-9 Creat-0.6 Na-141 K-3.7 Cl-102 HCO3-30 AnGap-13 [**2145-3-29**] 06:19AM BLOOD Calcium-8.0* Phos-2.3* Mg-1.9 Brief Hospital Course: As mentioned in the HPI, Mrs. [**Known lastname **] is a 55 year old pleasant Spanish speaking female with known history of CAD (s/p BMS to LAD [**2135**]), DM, HL, HTN with progressive chest pain and palpitations. She presented for evaluation with cardiac catheterization which revealed three vessel disease. She underwent usual surgical work-up and received medical management prior to surgery. On [**3-26**] she was brought to the operating room where she underwent a coronary artery bypass graft x 3 by Dr. [**Last Name (STitle) 914**]. Please see operative report for surgical details. Following surgery she was transferred to the CVICU in stable condition, titrated on phenylephrine and propofol drips. Later that day she was weaned from sedation, awoke neurologically intact and extubated. On post-op day one she was started on beta blockers and diuresed towards his pre-op weight. Later this day she was transferred to the telemetry floor for further care. Chest tubes and pacing wires were removed per protocol. Physical therapy assisted patient with strength and mobility. She continued to make good progress while receiving minor adjustments in her medical care. On post-op day 7 she was discharged home with VNA services and the appropriate medications and follow-up appointments. Medications on Admission: ALBUTEROL SULFATE [**12-13**] puff inhaled every 4 hours as needed ALPRAZOLAM 0.25 mg at bedtime as needed for Anxiety or Insomnia AMLODIPINE Not Taking as Prescribed) - 10 mg daily ATENOLOL 100 mg daily CLOPIDOGREL [PLAVIX] - 75 mg daily ISOSORBIDE MONONITRATE (Not Taking as Prescribed) 60 mg daily LISINOPRIL 40 mg daily METFORMIN 850 mg three times per day NITROGLYCERIN Sublingual -PRN PHENYLTOLOXAMINE-ACETAMINOPHEN [RELAGESIC] - Dosage uncertain RANITIDINE 150mg twice daily SIMVASTATIN 40 mg daily LORATADINE - 10 mg daily Discharge Medications: 1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*1* 5. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 7. metformin 850 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*1* 8. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*7 Tablet(s)* Refills:*0* 9. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO DAILY (Daily). Disp:*7 Tablet Extended Release(s)* Refills:*0* 10. glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Coronary Artery Disease, s/p Coronary Artery Bypass Graft x 3 Past Medical History: Diabetes Mellitus II Hypertension Hyperlipidemia PCI-LAD in [**2135**](BX Velocity Hepacoat stent) Asthma GERD Anxiety Arthritis Past Surgical History: Tubal ligation 28 years ago Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Trace edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery [**Hospital Ward Name **] 2A Office [**Telephone/Fax (1) 170**] Tuesday [**4-5**] @ 1:15 pm Surgeon Dr.[**Last Name (STitle) 914**] [**Name (STitle) **] [**4-20**] @ 1:30 pm [**Telephone/Fax (1) 170**] Cardiologist Dr. [**First Name (STitle) **] Phone:[**Telephone/Fax (1) 62**] [**4-30**] @ 3:00 pm Please call to schedule the following: Primary Care Dr. [**Last Name (STitle) 1789**] [**Telephone/Fax (1) 1792**] in [**3-16**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2145-6-21**] 8:45 Completed by:[**2145-4-2**]

[ "414.2", "414.01", "401.9", "V70.7", "412", "250.00", "V45.82", "428.21", "300.00", "780.52", "530.81", "428.0", "272.4", "285.9", "493.90", "411.1" ]

icd9cm

[ [ [] ] ]

[ "36.15", "88.56", "36.12", "88.53", "39.61", "37.22" ]

icd9pcs

[ [ [] ] ]

9029, 9087

5787, 7082

336, 675

9394, 9561

2786, 5764

10432, 11245

1911, 2007

7666, 9006

9108, 9170

7108, 7643

9585, 10409

9344, 9373

2022, 2767

269, 298

703, 1294

9192, 9321

1528, 1895

41

101,757

26891+57517

Discharge summary

report+addendum

Admission Date: [**2132-12-31**] Discharge Date: [**2133-1-27**] Date of Birth: [**2076-5-13**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2186**] Chief Complaint: Progressive signs of dizziness, visual difficulties, unsteady gait Major Surgical or Invasive Procedure: Right-sided high frontal stereotactic biopsy, CT-guided target point, definition and MRI-guided intraoperative imaging. History of Present Illness: The patient is a 56-year-old male with a history of colon cancer, as well as testicular cancer, who presents with progressive signs of dizziness, visual difficulties, unsteady gait for approximately 12 months. He was worked up including an MRI scan that showed a brainstem lesion. He was referred to the brain tumor clinic for consideration of a biopsy. The patient has been followed at the [**Hospital6 **] at [**Location 10050**]. He had been treated for a number of medical issues. He was examined by Dr. [**Last Name (STitle) 66170**] whose physical exam reportedly showed bilateral facial numbness and swaying, and a MRI of the head was preformed. This demonstrated expansion of the brainstem without significant contrast enhancement. The patient was thus considered to have a brainstem glioma and started on Decadron. The patient now presents for a surgical opinion. In the office, the patient complains about dizziness, blurred vision, double vision, occasional headaches, and unsteady gait. He feels better with medications. He takes at baseline 2 Tylenol a day. Has a history of arthritis in the lower back, otherwise, he reports that the numbness in his hands has disappeared since starting the Decadron. The patient has tapered his Decadron to a dose of 2 mg p.o. b.i.d. The patient is otherwise feeling himself stable. He was told that he had a left lazy eye at baseline, but the patient is not quite sure about the symptoms. He denies otherwise any extreme fatigue, weight loss or other symptoms. Past Medical History: Hypertension Hypercholesterolemia Sigmoid colon cancer [**2125**] Testicular cancer s/p Left orchiectomy and was found to be a germ cell tumor T1, N0.was treated with adjuvant chemotherapy no radiation. Hemorrhoids Recurrent bouts of thrush Social History: He is a high school graduate. He is an electrician. He is divorced. He has no other people in the household. He has a 40-pack-year history of smoking. He drinks about three drinks a week, and he denies any recreational drug use. Family History: His mother died at 63 of a heart attack. His father died at 44 after a MVA. He has two sisters 58 and 54, the 54-year-old has gallbladder stones. Other than that, they both are healthy. There are two brothers, one brother at 47 who has hypertension and two daughters that are in good health. Physical Exam: GENERAL: He is alert, pleasant, middle-aged man in no acute distress. Weight was 170 pounds, height was 74 inches, blood pressure was 154/90, pulse of 96, respirations 20, temperature of 97.4. HEENT: The patient did have a head tilt to the left. CARDIOVASCULAR: Regular rate and rhythm. No murmurs, gallops or rubs. LUNGS: Clear to auscultation. EXTREMITIES: No clubbing, cyanosis or edema. NEUROLOGIC: The patient is awake, alert and oriented. He has bilateral reactive pupils. Eye movements are full and we cannot detect a clear deficit of a particular muscle, at current, the patient has no diplopia. Visual fields seem to be fully intact. He has non-exhaustible end gaze nystagmus with rotatory component. Face is symmetric. Tongue is midline. No fasciculations. He has a hoarse voice. He has full strength bilaterally. He has intact sensation and symmetric reflexes. The patient does not have any memory problems, blackouts, nausea, concentration, or speech problems, as well as hearing problems. On motor examination, he was [**4-24**] bilaterally, normal tone, no drift. I found no evidence of any weakness in his hands. Upper sensory, he was intact to light touch throughout, and he was intact to pinprick over in the hands Reflexes were 2+ throughout. Cerebellar: He had bilateral intention tremor in the hands as well as finger tapping and rapid alternating movements were fine. Foot tapping and heel-knee-shin was normal. Gait: He had a wide based gait, he is unable to toe tandem or heel walk. Pertinent Results: [**2132-12-31**] 09:40AM GLUCOSE-116* LACTATE-1.2 NA+-132* K+-4.0 CL--95* [**2132-12-31**] 09:40AM TYPE-ART PO2-83* PCO2-35 PH-7.50* TOTAL CO2-28 BASE XS-3 INTUBATED-INTUBATED VENT-SPONTANEOU COMMENTS-RM AIR [**2132-12-31**] 09:48AM PT-11.1* PTT-21.2* INR(PT)-0.8 [**2132-12-31**] 09:48AM PLT COUNT-241 [**2132-12-31**] 09:48AM WBC-17.9* RBC-4.30* HGB-12.2* HCT-34.0* MCV-79* MCH-28.4 MCHC-35.9* RDW-17.9* [**2132-12-31**] 09:48AM GLUCOSE-115* UREA N-16 CREAT-0.5 SODIUM-133 POTASSIUM-3.9 CHLORIDE-95* TOTAL CO2-26 ANION GAP-16 [**2132-12-31**] 11:21AM freeCa-1.12 [**2132-12-31**] 11:21AM HGB-11.1* calcHCT-33 O2 SAT-97 CARBOXYHB-1 [**2132-12-31**] 11:21AM GLUCOSE-129* LACTATE-1.7 NA+-133* K+-3.9 CL--98* . Pathology [**2132-12-31**]: MIDDLE CEREBELLAR PEDUNCLE/PONS STEREOTACTIC BRAIN BIOPSY (including intraoperative smear): DIFFUSELY INFILTRATING FIBRILLARY ASTROCYTOMA. WHO ([**2126**]) grade II out of IV. . Brief Hospital Course: 56 M with PMH sigmoid and testicular ca in [**2125**], HTN, COPD, admitted for new diagnosis pontine glioma s/p posterior fossa decompression and necrotizing pna. . # Pontine glioma: 56 year-old man initially seen and discussed in brain tumor clinic. Patient taken to OR on [**12-31**] for brainstem lesion biopsy under general anesthesia. Postoperatively stayed in the PACU 6 hours then transferred to floor. On postop day one patient demonstrated difficulty of swallowing which he failed his speech and swallow evaluation. Patient kept NPO, started IV fluids. On [**2133-1-2**] patient taken back to OR for a suboccipital chiari decompression. Patient tranferred to neuro ICU for hemodymanic and neurologic monitoring. Due to postoperaive respiratory secretion extubated on [**2133-1-4**] after bronchcospy. . Brain stem biopsy pathology result is significant for infiltrative astrocytoma. Radiation oncology decided not to perform radiation mapping and to hold off for another several weeks before planning to start XRT, since patient has a slow growing glioma, and XRT could exacerbate pna. Patient known by Dr [**Last Name (STitle) 4253**] will follow up with him as scheduled. Patient was transferred to Step-down unit on [**2132-1-7**]. His speech continued to become more articulate and clear, and his mental status continued to become more clear. The patient stated that his dizziness has improved. . # Necrotizing pneumonia: Patient has a known pulmonary process that been followed in [**Hospital 669**] [**Hospital **] hospital in MA. In house repeat CT of the chest significant for left lower lobe, consolidative opacity, with central area of necrosis, an air-fluid level, and low-attenuation material. Additionally, there are several areas within the right and left lungs peripherally, with patchy opacity and tree-in-[**Male First Name (un) 239**] opacities, concerning for multifocal opacity. There is also a wedge-shaped opacity in the right lower lung zone, some of which may represent atelectasis.There is a 3.3 x 2.6 cm nodule with multiple foci of calcification within the left lower lobe. Attempt to obtain images from [**Hospital **] hospital regarding pulmonary lesions for comparison, [**Name (NI) 653**] with MEdical records to sent ua CD images. Medicine and interventional pulmonary services recommended continue antibiotics, and follow up with chest CT with and with out contrast in 4 weeks in pulmonary clinic. In the mean time [**Name (NI) 653**] with Dr [**First Name (STitle) **] at the [**Hospital **] hospital regarding tranfering him over to VA regarding his known pulmonary process, and colon carcinoma for further work up which he was agreed with the transfer. . Pleural fluid culture grew out positive to MSSA, GNR, [**Female First Name (un) 564**] albicans, staph coag neg. BAL culture grew out Stenotrophomonas maltophila and Klebsiella sensitive to almost all abx tested. ID was consulted and created antibiotic regimen of clindamycin, bactrim, ceftriaxone, to be continued for 4-6 weeks. Levo was completed for 2 weeks (last date [**2133-1-27**]). Patient should be reassessed to refine abx regimen within 2-4 weeks. The patient greatly improved on suctioning and chest PT, maintaining >95% RA on the floor. . The following labs will need to be followed up after discharge: LFTs, mycolytic/fungal cx, Cdiff x3, legionella urinary antigen . # Urinary retention: Patient had no urine output after foley was d/ced. Straight cath released 980 ml of urine. After 2 days of straight caths, patient recovered normal urination, and does not have a foley upon discharge. . # Skin lesions: Dermatology consulted in reference to his left deltoid skin lesion, non-bleeding which is present for 5 year according to patient. Dermotalogy recommended excision of the lesion to rule out melanoma once acute issues resolved with Derm Surgery ([**Telephone/Fax (1) 2977**]). . # Anemia: Patient's Hct was around 25 during admission. . # HTN: Controlled. Diltiazem and captopril were continued as per her outpt regimen. . # Access: Picc placed [**2133-1-9**]. Medications on Admission: The patient is a 56 y/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4746**] with a PMH significant for sigmoid and testicular cancer in '[**25**], HTN, and COPD who was admitted to the neurosurgery service on [**2132-12-31**] with a new diagnosis of a pontine mass after 1yr of progressive dizziness and ataxia. He underwent a stereotactic bx on [**12-31**] showing a low grade glioma and received a palliative posterior fossa expansion on [**1-2**]. . Routine pre-op CXR revealed multiple opacities and a 3x3 cm well demarcated cavitary lesion with an air/fluid level in left posterior lung. Following his surgery, he was extubated w/out event but required reintubation later that evening [**1-22**] desaturation. On [**1-3**], a chest CT was done which showed a multifocal pneumonic process with LLL necrotizing PNA. He underwent a bronch on [**1-4**] with BAL revealing MSSA and stenotrophamonas and was started on Levofloxacin (now d10/14), Vanco (since d/c), and Clinda (d10/42) at this time. Bactrim (d5/14) was added on [**1-8**] when BAL grew stenotrophamonas. . During this time, he has been intermittantly hypoxic with thick secretions requiring frequent suctioning. Over the past 2d, he has been afebrile and his secretions have cleared appreciably. He has maintained his O2 sats on 4L NC. Other than this, the patient has been intermittantly hypertensive requiring the addition of captopril to his outpatient regimen. He has also failed numerous speech and swallow evaluations requring NG tube feeds to maintain his nutritional status. From an oncologic standpoint, his pontine lesion is not amenable to resection and the plan is to initiate palliative radiation therapy. Per neurosurgery, his prognosis is extremely poor. Finally, the patient has requested transfer to the [**Location 1268**] VA system over the past several days as he has received much of his care at this hospital. Discussions are still ongoing to facilitate this transfer. . PMH: 1. Colon cancer 2. testicular cancer 3. Hemorrhoids 4. Hypertension. 5. Thrush. 6. Hypercholesterolemia. . Transfer Meds: Acetaminophen Albuterol Bisacodyl Captopril Clindamycin Dexamethasone Diltiazem Docusate HSQ Sulfameth/Trimethoprim Oxycodone Nystatin Nicotine Patch Levofloxacin Lansoprazole Ipratropium ISS . PE: 97.0 (98.5), 124/72, 81, 21, 95% 4L NC Gen: Cachetic [**Male First Name (un) 4746**] sitting up in a chair in NAD HEENT: MMM, PERRLA, EOMI, O/P clear w/ NGT in posterior oropharynx Neck: No LAD, No JVD CV: RRR, S1/S2 wnl, -M/R/G appreciated Lungs: Decreased breath sounds bilaterally L>R w/ coarse inspiratory sounds bilaterally and anteriorly, -wheezes appreciated, dullness to percussion at the L base Abd: S/NT/ND, +BS Ext: -C/C/E, 2+ peripheral pulses bilaterally Neuro: CN 2-12 grossly intact, dysarthric, strength 5/5 in the RLE, on the LLE he has decreased dorsal flexion in the foot/flexion and extension at the knee/flexion at the hip, mildly decreased L grip strength compared to R hand ================ Micro: - Sputum [**1-3**]: E. coli (pan-sensitive), Coag + staph (pansensitive) - BAL [**1-4**]: Stenotrophamonas (sensitive bactrim), Coag + staph (MSSA), sparse GNR - MRSA/VRE swab: negative ================ CTA [**2133-1-9**]: 1. Some improvement in the consolidation in the left lower lobe, although the large 4-cm cavitary lesion with an air-fluid level persists, consistent with slight overall improvement in necrotizing pneumonia. 2. New small cavitary lesion in the left upper lobe, possibly related to aspiration. Of note, the patient has a small hiatal hernia. 3. Improvement in some of the ground-glass opacities in the right middle and upper lobes, with persistent 4-mm lung nodule. 4. Similar slightly prominent right hilar and mediastinal lymph nodes. 6. No evidence of pulmonary embolism. 7. Similar calcified lung mass, possibly a hamartoma, although metastatic colon cancer cannot be excluded. . CT Head ([**2133-1-9**]): No definite change in the mass effect associated with the brainstem glioma. Interval development of a small left frontal region subdural collection. . CXR [**2133-1-10**]: No interval change. Persistent opacity at the left base. There is a 3.6-cm parenchymal opacity within the left base as well which is also unchanged. There is no evidence for overt pulmonary edema. The lines and tubes are stable in position. ================ A/P: 56 yo M admitted for dizziness/weakness. Found to have a pontine glioma now s/p posterior fossa decompression complicated by necrotizing PNA and multiple episodes of hypoxia requiring MICU level care. Called out to medicine service for further management of his infection and pulmonary status. . # Hypoxia: He has been stable over the past few days w/ better maintained SpO2. He has improved in the past w/with deep suctioning. Chest CT c/w necrotizine PNA. He is on levo ([**1-9**] -> 2 weeks), and clinda ([**1-9**] -> 6 weeks). Bactrim was started on [**1-8**] (x 2 weeks): BAL + for stenotrophamonas. - wean O2 as tolerated on the floor - Per thoracic staff ([**2133-1-10**]) pt will need CT guided drain placement this week; ? if best to schedule PEG at same time to minimize procedures - continue levaquin, clindamycin, and bactrim for full course - will need repeat CT in 1 month - continue nebs prn - continue aggressive pulmonary toilet - incentive spirometry on the floor . # Lung nodule. Chest CT from the VA on [**8-25**] demonstrated 2 lesions in LLL (anterior and posterior) both of which were felt to be stable compared to prior CT [**2-/2127**]. - await old films being mailed from the VA - f/u IP/thoracic recs . # Brainstem glioma. Prognosis estimated at a couple of months per neurosurg. ? palliative radiation - continue Decadron [**Hospital1 **] per neurosurgery - continue prn pain meds - Neurosurg following - pt full code - monitor CN exam, mental status, and strength exams . # Anemia. 4pt Hct drop on [**2133-1-9**], transfused on [**1-11**] w/ appropriate Hct elevation and has been stable overnight - repeat Hct when called out to floor - guaiac stools x3 then d/c if negative - transfuse for Hct < 25 - continue PPI while on decadron . # HTN. BP well controlled on current regimen - Continue diltiazem and captopril - monitor BP and titrate prn . # Left deltoid lesion. - f/u in Dermatologic surgery clinic on [**2133-1-15**] at 11am . # Communication: VA Chief - [**Telephone/Fax (3) 66171**]. Mrs. [**Name (NI) 66172**] (aunt) [**Telephone/Fax (1) 66173**] is HCP. . # FEN. TF's through NGT (failed video swallow again on [**2133-1-12**]) - continue aspiration precautions - patient has decline PEG placement x2 per notes in chart - will reevaluate patient's wishes once transferred to floor; would be best to place PEG when placing drainage so as to minimize procedures - replete lytes prn . # Access: PICC line placed [**2133-1-9**] . # PPX. SC heparin, PPI, bowel regimen, ISS while on decadron, replete lytes . # Code: Full . # Dispo: Patient would like to be transferred to [**Location 1268**] VA. [**Name (NI) 1094**] aunt has a scheduled meeting today with Dr. [**Last Name (STitle) **] Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed: Hold for lose stool. 3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 5. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-22**] Puffs Inhalation Q6H (every 6 hours). 7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 10. Hydromorphone 2 mg/mL Syringe Sig: One (1) Injection Q4-6H (every 4 to 6 hours) as needed. 11. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 12. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO BID (2 times a day). 13. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-22**] Drops Ophthalmic PRN (as needed). 14. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 15. Levofloxacin in D5W 500 mg/100 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours): Started on [**1-2**] Total of 14 days then d/c. . Discharge Disposition: Extended Care Facility: VA Discharge Diagnosis: Right brainstem lesion Discharge Condition: Neurologically stable Discharge Instructions: Monitor suboccipital staple sites for drainage, erthyma, swelling, fever greater than 101.5, seizure activity, visual changes, weakness, numbness or any other neurologic symptoms that may be concerning. Keep your all appointments as sheduled. Followup Instructions: Follow up with Dr [**Last Name (STitle) **] in 10 days from [**1-2**] for wound check and staple removal or can be removed at the [**Hospital **] hospital. Follow up with Dr [**Last Name (STitle) 4253**](neurooncology) and Dr [**Last Name (STitle) 3929**](Radiation oncology) in brain tumor clinic on [**2133-1-26**] at 1300 [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Building [**Location (un) **]. Follow up with Pulmonary Clinic in 4 weeks with a Chest CT with and without contrast. Follow up with Dr [**First Name (STitle) **], Dermatologic surgery clinic([**Telephone/Fax (1) 2977**]for left deltoid lesion on [**2133-1-15**] at 1100. Follow up with VA infectious disease for possible repeat CT chest in 4 weeks. Completed by:[**2133-1-27**] Name: [**Known lastname 11567**],[**Known firstname **] Unit No: [**Numeric Identifier 11568**] Admission Date: [**2132-12-31**] Discharge Date: [**2133-1-27**] Date of Birth: [**2076-5-13**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 406**] Addendum: a Chief Complaint: a Major Surgical or Invasive Procedure: a History of Present Illness: a Past Medical History: a Social History: a Family History: a Physical Exam: a Pertinent Results: a Brief Hospital Course: a Medications on Admission: a Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) 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. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) injection Injection ASDIR (AS DIRECTED): Standard insulin sliding scale, no standing insulin needed. 5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 7. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 8. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 9. Diltiazem HCl 30 mg Tablet Sig: 1.5 Tablets PO QID (4 times a day). 10. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 12. Oxycodone 5 mg/5 mL Solution Sig: 5-10 mg PO every four (4) hours as needed for pain. 13. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 14. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-22**] Sprays Nasal QID (4 times a day) as needed. 15. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day) as needed. 16. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Three Hundred (300) mg PO DAILY (Daily). 17. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for indigestion. 18. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO DAILY (Daily). 19. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 6 weeks: Last date to give: [**2133-3-6**]. 20. Dexamethasone Sodium Phosphate 4 mg/mL Solution Sig: One (1) mg Injection QAM (once a day (in the morning)) for 7 days: Last date to give: [**2133-1-30**]. 21. Dexamethasone Sodium Phosphate 4 mg/mL Solution Sig: Two (2) mg Injection QPM (once a day (in the evening)) for 7 days: Last date to give: [**2133-1-30**]. 22. Lorazepam 2 mg/mL Syringe Sig: 0.5-1 mg Injection Q6H (every 6 hours) as needed for anxiety. 23. Sulfameth/Trimethoprim 320 mg IV Q8H Duration: 3 Days Last date to give: [**2133-1-29**] 24. Ceftriaxone 1 gm IV Q24H Duration: 4 Weeks Last date to give: [**2133-2-18**] 25. Dexamethasone 1 mg IV QAM Duration: 7 Days Start: [**2133-1-31**] Last date to give: [**2133-2-6**] 26. Dexamethasone 1 mg IV QPM Duration: 7 Days Start: [**2133-1-31**] Last date to give: [**2133-2-6**] 27. Dexamethasone 1 mg IV QD Duration: 7 Days Start: [**2133-2-7**] Last date to give: [**2133-2-13**] Discharge Disposition: Extended Care Facility: [**Hospital6 11569**] [**Location 205**] Discharge Diagnosis: a Discharge Condition: a Discharge Instructions: a Followup Instructions: a [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 408**] MD [**MD Number(2) 409**] Completed by:[**2133-1-27**]

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icd9cm

[ [ [] ] ]

[ "33.26", "43.11", "01.13", "01.24", "96.71", "33.24", "38.93", "99.04", "96.6" ]

icd9pcs

[ [ [] ] ]

22847, 22914

19956, 19959

19796, 19799

22959, 22962

19930, 19933

23012, 23170

19890, 19893

20011, 22824

22935, 22938

19985, 19988

22986, 22989

19908, 19911

19755, 19758

19827, 19830

19852, 19855

19871, 19874

47,430

186,726

39993

Discharge summary

report

Admission Date: [**2125-3-13**] Discharge Date: [**2125-3-28**] Date of Birth: [**2096-2-3**] Sex: M Service: CARDIOTHORACIC Allergies: Advil / Aspirin Attending:[**First Name3 (LF) 165**] Chief Complaint: transfer for aortic valve abscess on TTE Major Surgical or Invasive Procedure: [**2125-3-16**] Redo sternotomy/Bentall procedure ( [**Street Address(2) 6158**]. [**Male First Name (un) 923**] mechanical valve/graft composite)/removal MV vegetation History of Present Illness: Patient is a 29M with IVDU, MV and AV strep viridans endocarditis, s/p mitral and aortic valve replacement 6/[**2124**]. He is transferred from [**Hospital1 **] after a potential aortic valve abscess was seen on surveillance TTE. Since having his valves replaced, he denies further IVDA. He was hospitalized "weeks ago" at LGH for cellulitis, and again about 4-5 weeks ago presumably for another episode of IE. No records accompany this patient who is admittedly unclear about the details of his complicated course. He was feeling weak with sores on his feet and hands which prompted this recent treatment course. He has been at [**Hospital1 **] for 4 of a projected 6-8wk course of ampicillin/rifampin, though we do not know the bug. Today, a TTE showed questionable mitral regurgitation and a possible aortic valve abscess. He denies ongoing IVDA, and feels at his baseline. . He initially had strep viridans MV IE [**9-/2123**] treated with parenteral antibiotics. He was hospitalized at [**Hospital1 18**] from [**Date range (1) 85496**]/11 with streptococcus viridans blood stream infection found to later be MV and AV endocarditis. While iniitally planning for conservative management with antibiotics, he developed complete heart block, respiratory and heart failure, necessitating AVR/MVR with St. [**Male First Name (un) 923**] mechanical valves. Completed 4 weeks of post op ceftriaxone and 2 weeks gentamycin. Felt to be initiated by IV cocaine abuse. Cardiac surgery was consulted for evaluation of redo sternotomy/Bentall. Past Medical History: -Aortic and mitral valve endocarditis s/p Aortic and Mitral valve replacement -Viridin streptococcal endocarditis -PICC line infection - Stenotrophomonas/Enterobacter cloacae -Anxiety -Depression -Asthma -surgery for pilonidal cyst -s/p Hernia repair Social History: Was living with his mother prior to hospitalization. Smoking about 1/2PPD, no ETOH or drugs. Trying to get SSI Family History: Father died at age 57 of an abdominal aortic aneurysm (heavy smoker). Mother had [**Name2 (NI) 499**] cancer with a colectomy, GF died of asbestos Physical Exam: Pulse: 87 Resp:14 O2 sat:96%RA B/P 119/45 Height: 73 inches Weight: 101kg General:A&Ox3, NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [x] grade II/VI Sternum: well healed sternotomy scar evident. Sternum stable. Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x] Extremities: Warm [x], well-perfused [x] Edema-none Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Radial Right:2+ Left:2+ Carotid Bruit -none Right:2+ Left:2+ Pertinent Results: Admission labs: [**2125-3-12**] 11:20PM BLOOD WBC-5.2 RBC-3.99*# Hgb-11.0*# Hct-32.9*# MCV-83 MCH-27.7 MCHC-33.5 RDW-14.2 Plt Ct-199 [**2125-3-12**] 11:20PM BLOOD Neuts-60.3 Lymphs-22.6 Monos-5.6 Eos-9.7* Baso-1.7 [**2125-3-13**] 04:27AM BLOOD PT-25.5* PTT-46.2* INR(PT)-2.4* [**2125-3-12**] 11:20PM BLOOD ESR-20* [**2125-3-12**] 11:20PM BLOOD Glucose-86 UreaN-11 Creat-0.8 Na-137 K-4.6 Cl-105 HCO3-23 AnGap-14 [**2125-3-13**] 04:27AM BLOOD ALT-18 AST-26 AlkPhos-107 TotBili-0.2 [**2125-3-13**] 04:27AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.1 [**2125-3-12**] 11:20PM BLOOD CRP-68.6* [**2125-3-12**] 11:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2125-3-12**] 11:39PM BLOOD Lactate-0.8 Tee [**2125-3-16**]:PRE-BYPASS: This study is limited due to acoustic shadowing from mechanical valves in the aortic & mitral positions.No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No spontaneous echo contrast is seen in the body of the right atrium. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The sinuses of Valsalva are dilated. A mechanical aortic valve prosthesis is present and not well seated. Abnormal rocking motion is noted. A paravalvular aortic valve leak is present. The aortic valve prosthesis appears abnormal. An aortic annular abscess is seen. Significant aortic regurgitation is present, but cannot be quantified. A bileaflet mitral valve prosthesis is present. The motion of the mitral valve prosthetic leaflets appears normal. A small paravalvular mitral prosthesis leak is present in what appears to be originating behind the posterior leaflet. This is more than the typical washing jet seen in this type of mechanical valve. A typical washing jet is noted originating behind the anterior leaflet. A 1.1 x 1.5cm echodensity is seen in junction with the ventricular side of the anterior leaflet of the mechanical mitral valve prosthesis.There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results in the operating room. POSTBYPASS: The patient is AV paced on a phenylephrine infusion. Biventricular function is maintained. EF 55%. There is a well seated mechanical valve in the mitral position. Peak and Mean Gradients across the mitral prosthesis are 7mmHg & 3mmHg, respectively with a cardiac output of 7.8L/m. There are characteristic washing jets noted. The echodensity noted prebypass is no longer present.There is a well seated mechanical valve in the aortic position. The study is limited due to the presence of acoustic shadowing from the aortic valve conduit & mechanical valve in the mitral position. There is no AI. Peak & mean gradients across the valve are 28 & 14mmHg, respectively.The remaining aorta is intact.The remaining valves are unchanged. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2125-3-16**] 14:49 [**2125-3-28**] 03:50AM BLOOD WBC-7.0 RBC-2.93* Hgb-7.6* Hct-23.0* MCV-79* MCH-26.1* MCHC-33.3 RDW-14.3 Plt Ct-408 [**2125-3-28**] 03:50AM BLOOD PT-36.3* INR(PT)-3.5* [**2125-3-28**] 03:50AM BLOOD PT-36.3* INR(PT)-3.5* [**2125-3-28**] 03:50AM BLOOD Glucose-97 UreaN-24* Creat-1.6* Na-139 K-4.3 Cl-102 HCO3-29 AnGap-12 [**2125-3-16**] 10:45 am TISSUE EXPLANTED AORTIC VALVE TISSUE. GRAM STAIN (Final [**2125-3-16**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Final [**2125-3-20**]): ENTEROCOCCUS SP.. Isolated from broth media only, INDICATING VERY LOW NUMBERS OF ORGANISMS. Reported to and read back by [**Doctor Last Name 87957**],D (X42950) [**2125-3-18**] AT 1055. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S PENICILLIN G---------- 4 S VANCOMYCIN------------ 1 S ANAEROBIC CULTURE (Final [**2125-3-22**]): NO ANAEROBES ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2125-3-19**]): NO FUNGAL ELEMENTS SEEN. [**2125-3-17**] 12:21 pm BLOOD CULTURE Source: Line-right tlc. **FINAL REPORT [**2125-3-23**]** Blood Culture, Routine (Final [**2125-3-23**]): NO GROWTH. Brief Hospital Course: 29 y/o man with hx of IV drug use and endocarditis requiring mechanical MV and AV replacment [**7-16**] found to have persistent endocarditis of both prosthetic valves with near frank dehiscence of AV; currently hemodynamically stable and feeling well. . # AORTIC AND MITRAL VALVE ENDOCARDITIS: Patient with large mitral valve vegetation and "near-frank" dehiscence of aortic valve on TEE/TTE, with at least moderate valvular AR. He had no evidence of acute on chronic CHF on admission. Blood cultures returned positive for enterococcus faecium (sensitive to vancomycin), coag-negative staph (sensitive to vanco and gentamycin), gram negative rods, and yeast. On admission, his PICC line was pulled. He was started on vancomycin, gentamycin, cefepime, and ambisome, per infectious disease recommendations. On day 3 of admission, he underwent Bentall Aortic Root replacement with a mechanical composite graft and removal of vegetation from mechanical mitral valve. . Underwent surgery with Dr. [**First Name (STitle) **] on [**3-16**], please see operative report for further details. He was transferred to the CVICU in stable condition on titrated phenylephrine and propofol drips. Extubated early the following morning and transferred to the floor on POD #2 to begin increasing his activity level. Gently diuresed toward his preop weight. Beta blockade titrated and coumadin resumed for his double mechanical heart valves. Chest tubes and pacing wires removed per protocol. PICC line in place for continued abx therapy for endocarditis.Seen daily by ID service as well as consult by chronic pain service. Postoperative renal dysfunction followed closely along with drug monitoring of antibiotics. His creatnine was 1.6 prior to discharge and Gentamicin frequency had been decreased per ID recommendations the day prior to discharge. Lab monitoring and length of duration of antibiotics per ID. Cleared for discharge by Dr.[**First Name (STitle) **] to [**Hospital **] rehab on POD # 12. All f/u appts advised. Target INR 2.5-3.5 for mechanical heart valves. Medications on Admission: - buprenorphin/naloxone [**9-6**] SL [**Hospital1 **] - ativan 0.5mg qh8prn, hs - ampicillin 2000mg q4hr - nicotine patch 21 daily - colace 100BID - tylenol 650mg q4hr - rifampin 600mg QD - buspirone 20mg daily - warfarin13mg daily Discharge Medications: 1. metoprolol tartrate 25 mg [**Hospital1 8426**] Sig: 0.5 [**Hospital1 8426**] PO BID (2 times a day). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. ranitidine HCl 150 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO BID (2 times a day). 4. warfarin 1 mg [**Hospital1 8426**] Sig: daily [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] DAILY (Daily). 5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. hydromorphone 2 mg [**Last Name (Titles) 8426**] Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*40 [**Last Name (Titles) 8426**](s)* Refills:*0* 7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 8. lorazepam 0.5 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO Q8H (every 8 hours) as needed for severe anxiety. Disp:*40 [**Last Name (Titles) 8426**](s)* Refills:*0* 9. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 10. acetaminophen 325 mg [**Last Name (Titles) 8426**] Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 11. morphine 30 mg [**Last Name (Titles) 8426**] Extended Release Sig: One (1) [**Last Name (Titles) 8426**] Extended Release PO Q8H (every 8 hours). 12. cyclobenzaprine 10 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO TID (3 times a day). 13. buspirone 10 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO BID (2 times a day). 14. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 15. micafungin 100 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours) for 1 doses: last dose [**2125-3-28**]. 16. warfarin 5 mg [**Month/Day/Year 8426**] Sig: One (1) [**Month/Day/Year 8426**] PO ONCE (Once) for 1 doses. 17. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 18. ampicillin sodium 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q4H (every 4 hours): End date= [**2125-4-27**] per ID. 19. Outpatient Lab Work WEEKLY: CBC with diff, BUN/Creatinine, LFTs Twice weekly: Gent Peak and Trough 1/2 hour prior to dosing 20. gentamicin in NaCl (iso-osm) 80 mg/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours): Gent trough goal<1. Once Creatnine <1, please increase dosing to q 12h. Last dose= [**2125-4-27**]. Discharge Disposition: Extended Care Facility: [**Hospital1 **] State Hospital Discharge Diagnosis: s/p redo sternotomy/ Bentall procedure/ rem. MV vegetation Viridin streptococcal endocarditis PICC line infection - Stenotrophomonas/Enterobacter cloacae Anxiety Depression Asthma left leg cellulitis 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 ............ 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: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Last Name (Titles) **] 2A, [**Telephone/Fax (1) 170**] [**2125-4-17**] @ 1:15 pm Cardiologist:Dr. [**Last Name (STitle) 23097**] [**4-10**] @ 2:15 pm ID: [**First Name11 (Name Pattern1) 3049**] [**Last Name (NamePattern4) 14666**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2125-4-3**] 1:30 ID: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4091**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2125-4-24**] 10:00 Eye clinic(for glasses) [**Telephone/Fax (1) 253**] [**4-12**] @ 1:00 pm, [**Hospital Ward Name 23**] 5 Please call to schedule appointments with your : Primary Care Dr. [**Last Name (STitle) 67391**] in [**5-10**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication mechanical AVR/MVR Goal INR 2.5-3.5 First draw day is first day at rehab [**2125-3-29**] *** please arrange for coumadin/INR Atrius followup prior to discharge from rehab laboratory monitoring required: WEEKLY: CBC with diff BUN/Creatinine LFTs Gentamicin twice weekly: Peak and Trough 1/2 hour prior to dose All laboratory results should be faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**] All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2125-3-28**]

[ "421.0", "305.1", "285.9", "E879.8", "041.85", "041.04", "276.69", "414.01", "424.1", "493.90", "300.4", "996.61", "112.89", "682.6", "427.41", "999.31", "041.09", "304.00", "E878.1", "287.5" ]

icd9cm

[ [ [] ] ]

[ "35.21", "88.72", "38.93", "99.62", "39.61" ]

icd9pcs

[ [ [] ] ]

12863, 12921

7988, 10055

321, 492

13165, 13349

3238, 3238

14273, 15930

2478, 2626

10337, 12840

12942, 13144

10081, 10314

13373, 14250

2641, 3219

7645, 7965

241, 283

520, 2059

3254, 7612

2081, 2334

2350, 2462

64,067

117,620

37330

Discharge summary

report

Admission Date: [**2181-6-7**] Discharge Date: [**2181-6-22**] Date of Birth: [**2101-5-18**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: Cholangiocarcinoma of the distal common bile duct. Major Surgical or Invasive Procedure: [**2181-6-7**]: 1. Pylorus preserving Whipple's resection. 2. Open cholecystectomy. 3. J-tube placement. 4. Placement of gold fiducial seeds for CyberKnife therapy. History of Present Illness: The patient is an 80-year-old gentleman who presented with obstructive jaundice. On endoscopic US and CT scan a 3 cm stricture of the distal bile duct was noted. He underwent stent placement via ERCP. He is being admitted for a Whipple resection. Past Medical History: 1. Gastroesophageal reflux disease. 2. Anemia. 3. Vitamin B12 deficiency. 4. Barrett's esophagus with intramural adenocarcinoma. 5. Prostate cancer with radiation therapy in [**2167**]. 6. Osteoarthritis, primariy of the knees Social History: Lives with his wife in [**Hospital3 **]. Has two sons and one daughter who is estranged. He is retired and worked in the press room at the [**Location (un) 86**] Globe. Family History: His father died at age 55 of lung cancer. His mother lived until age [**Age over 90 **]. Physical Exam: On Discharge: Gen:NAD CVS:RRR, no m/r/g Resp: CTA b/l Abd:soft, NT/ND, subcostal surgical incision with steri strips, JP drain in place, J tube in place. Ext: well perfused, no e/c/c Pertinent Results: [**2181-6-7**] 05:50PM WBC-11.2*# RBC-3.41* HGB-8.7* HCT-27.3* MCV-80* MCH-25.4* MCHC-31.8 RDW-19.9* [**2181-6-7**] 05:50PM PT-12.9 PTT-24.9 INR(PT)-1.1 [**2181-6-7**] 05:41PM TYPE-ART PO2-237* PCO2-36 PH-7.42 TOTAL CO2-24 BASE XS-0 INTUBATED-INTUBATED [**2181-6-7**] 10:10PM GLUCOSE-214* UREA N-21* CREAT-1.1 SODIUM-138 POTASSIUM-4.6 CHLORIDE-107 TOTAL CO2-21* ANION GAP-15 [**2181-6-7**] 05:50PM PHOSPHATE-3.9 MAGNESIUM-1.6 PATHOLOGY: Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 83973**],[**Known firstname 275**] R [**2101-5-18**] 80 Male [**-8/2854**] [**Numeric Identifier 83974**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] Gross Description by: DR. [**Last Name (STitle) **]. WENSON/mtd SPECIMEN SUBMITTED: FS Bile Duct Margin, Gallbladder, PORTAL VEIN MARGIN, Jejunum, WHIPPLE SPECIMEN. Procedure date Tissue received Report Date Diagnosed by [**2181-6-7**] [**2181-6-7**] [**2181-6-12**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/aas?????? Previous biopsies: [**Numeric Identifier 83975**] G I BIOPSY (1 JAR). [**Numeric Identifier 83976**] GI BX ( 1 JAR) [**-7/4754**] G I BIOPSIES (13 JARS). DIAGNOSIS: I. Gallbladder, cholecystectomy (A): Chronic cholecystitis with cholesterolosis. II. Bile duct margin (B): No carcinoma seen. III. Portal vein margin (C): Adenocarcinoma present within fibrous tissue. IV. Jejunum, resection (D-G): Small intestinal segment, within normal limits. V. Whipple specimen, pancreaticoduodenectomy (H-AF): A. Adenocarcinoma, moderately differentiated, see synoptic report. B. Adenocarcinoma involving 3 of 12 peripancreatic lymph nodes ([**2-2**]). C. Duodenal segment with focal periampullary foveolar metaplasia, acute inflammation and reactive epithelial changes. RADIOLOGY: [**2181-6-7**] CHEST PORT: FINDINGS: In comparison with the study of [**5-24**], there are substantially lower lung volumes with atelectatic changes at the left base. Endotracheal tube is now in place with its tip approximately 7 cm above the carina. Nasogastric tube extends well into the stomach. Right IJ catheter appears displaced somewhat to the midline. The tip lies just below the level of the carina. The resident reports that the line was bringing back venous blood. However, if the precise position of the catheter is critical, a lateral view could be obtained. [**2181-6-13**] ABD CT: IMPRESSION: 1. Free air likely consistent with recent surgery. Free fluid within the abdomen. 2. Peripancreatic fluid collections and stranding adjacent to the surgical site may represent post-operative fluid; however, pseudocyst and leak cannot be completely excluded. 3. Minimal dilation of proximal loops of small bowel measuring up to 4 cm, with transition point not clearly identified may represent post-operative ileus; however, cannot rule out small bowel obstruction. 4. Small segment of small bowel appears thickened within the left upper quadrant and may represent underdistension or may be secondary to post-operative changes. 5. Wall thickening at the gastrojejunal anastomosis likely represents post-operative edema. Additionally, an area of lobulated thickened gastric fold at the GE junction is noted. Recommend attention on follow up CT. If this persists then endoscopy is recommended. 6. Surgical drain is noted within the right upper quadrant. The J-tube is not clearly visualized. An NG tube is in place. [**2181-6-14**] J TUBE EVAL: IMPRESSION: 1. Multiple dilated loops of small bowel in conjunction with poor forward flow of contrast following injection of the J-tube are consistent with small bowel ileus. There does not appear to be an obstruction at the entry site of the J-tube. 2. Poor gastric emptying with esophageal reflux. MICROBIOLOGY: [**2181-6-8**] 10:25 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2181-6-10**]** MRSA SCREEN (Final [**2181-6-10**]): No MRSA isolated. Brief Hospital Course: The patient was admitted to the General Surgical Service on [**2181-6-7**] for treatment of cholangiocarcinoma. On the same day, the patient underwent pylorus-preserving pancreaticoduodenectomy (Whipple) and open cholecystectomy, which went well without complication (reader referred to the Operative Note for details).He was transferred to the SICU for postoperative respiratory insufficiency. The patient was kept on a ventilator, extubated on [**6-8**]. He was then transferred to [**Hospital Ward Name 121**] 9 and started on clears on POD4. He had an episode of nausea and vomiting immediately after lunch, with persistent hiccupping. The patient also experienced an episode of sinus tachychardia >130bpm, for which he was triggered. A fluid bolus was given, along with lopressor for rate control.Tachycardia remitted and HR stabilized in the 90s. Abdominal distention was also noted and an NG tube was placed, with significant bilous return (approximately 2L). A CT scan was performed on [**6-13**] (POD6) to evaluate for bowel obstruction which showed "minimal dilation of proximal loops of small bowel with transition point not clearly identified, questionable small bowel obstruction. Small segment of small bowel appears thickened, wall thickening at the gastrojejunal anastomosis likely representing post-operative edema". An UGI with small bowel follow through performed on [**6-14**] (POD7) showed multiple dilated loops of small bowel in conjunction with poor forward flow of contrast following injection of the J-tube, consistent with small bowel ileus. The NGT was taken ou the following morning after return of bowel function. A KUB was done done on [**6-18**] (POD11) to assess for obstruction:"persistent dilation of the small bowel, most likely representing ileus". The JP drain fluid was sent for gram stain and cultures which showed 4+ GNR, heavy growth, and 1+ GPC, moderate growth and sparse growth of probable enterococcus. The patient was started on ciprofloxacin 500mg [**Hospital1 **]. Reglan was discontinued on POD 12 because the patient experienced neurological side effects (absence-like episodes) that promptly remitted after the medication was stopped. On POD12 a CT scan of the abdomen with PO and IV contrast was ordered for persistent failure to thrive and ileus on KUB with high JP amylase levels (2400): "thickening of a loop of small bowel just posterior to the [**Doctor Last Name 406**] drain and adjacent to the anastomotic site with the pancreas is minimally increased since [**2181-6-13**] and may represent postoperative changes". Tubefeeds were re-started on POD12 (Fibersource HN Full strength; starting rate: 20 ml/hr, goal rate: 80 ml/hr) and the patient was started on clears the following day. The patient continued to do well, ambulating and taking adequate PO. At the time of discharge on POD15 ([**6-22**]), the patient was doing well, afebrile with stable vital signs. The patient was tolerating a clear liquid diet, tube feeds were up to the goal rate of 80 mL/hr, he was ambulating, voiding without assistance, and pain was well controlled. Staples were removed, and steri-strips placed. The patient was discharged to a rehab facility. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Lexapro, B12, omeprazole and Zantac Discharge Medications: 1. Octreotide Acetate 100 mcg/mL Solution Sig: One (1) injection Injection Q8H (every 8 hours). 2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 3. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. Erythromycin 250 mg Tablet Sig: One (1) Tablet PO every six (6) hours for 10 days. 6. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Discharge Disposition: Extended Care Facility: Life Care Center of [**Location 15289**] Discharge Diagnosis: 1. Cholangiocarcinoma of the distal common bile duct. 2. Postoperative respiratory insufficiency Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid. Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**4-2**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery J tube care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *Wash the area gently with warm, soapy water or 1/2 strength hydrogen peroxide followed by saline rinse, pat dry, and place a drain sponge. Change daily and as needed. *Keep the insertion site clean and dry otherwise. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. *Flush with 30 cc of water Q8H JP Drain Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *Maintain suction of the bulb. *Note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or VNA nurse if the amount increases significantly or changes in character. *Be sure to empty the drain frequently. Record the output, if instructed to do so. *You may shower; wash the area gently with warm, soapy water. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2181-7-2**] 4:00 . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 1231**] Date/Time:[**2181-7-6**] 8:45 [**Hospital Ward Name 23**] 3, [**Hospital Ward Name **] Completed by:[**2181-6-22**]

[ "196.2", "276.51", "715.36", "576.2", "560.1", "263.9", "530.81", "427.89", "584.9", "E878.6", "156.1", "478.75", "518.5", "V10.03", "574.10" ]

icd9cm

[ [ [] ] ]

[ "96.6", "51.22", "46.39", "52.7" ]

icd9pcs

[ [ [] ] ]

9653, 9720

5637, 8973

364, 531

9861, 9861

1577, 5614

12375, 12765

1267, 1359

9059, 9630

9741, 9840

8999, 9036

10027, 10605

10620, 12352

1374, 1374

1388, 1558

273, 326

559, 807

9876, 10003

829, 1064

1080, 1251

79,585

113,455

41221+58428

Discharge summary

report+addendum

Admission Date: [**2107-1-28**] Discharge Date: [**2107-2-14**] Date of Birth: [**2032-5-22**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Azithromycin Attending:[**First Name3 (LF) 1406**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2107-2-4**] Off-pump coronary bypass grafting x1 with the left internal mammary artery to left anterior descending artery History of Present Illness: 74M p/t OSH w chest pain, exertional dyspnea. Ruled in for NSTEMI. Echo revealed decline in EF to 10% (from 30% in [**2099**]) and AS with [**Location (un) 109**] 0.8cm2. He has a h/o 2vessel CAD on cath in [**2099**]. Cardiac cath will be performed on Monday, [**2107-1-31**]. Cardiac surgery is asked to evaluate for AVR, CABG. Past Medical History: Past Medical History: CAD chronic systolic heart failure DM CRI (baseline Cr 1.9) ^lipids htn 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 Last Dental Exam: 50 yrs. ago Lives with: wife Occupation: retired, sales Tobacco: 60 pack yrs, quit 2 weeks 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: Pulse: 63 Resp: 18 O2 sat: 98%RA B/P Right: Left: 90/50 Height: Weight: 79kg General: NAD, appears stated age Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema: 1+pedal edema bilaterally Varicosities: None [x] well healed incision of RLE fem-[**Doctor Last Name **] bypass right lateral foot w 3mm round ulcer- no erythema, minimal drainage on dressing, does not appear infected Neuro: Grossly intact x Pulses: Femoral Right: Left: DP Right: NP Left: NP PT [**Name (NI) 167**]: NP Left: NP Radial Right: 1+ Left: 1+ Carotid Bruit Right: Left: no bruits Pertinent Results: [**2107-2-4**] Introp TEE Pre-Procedure: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is severely depressed (LVEF= 10 - 15 %). with moderate global free wall hypokinesis. There is significant calcification of the ascending aorta. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. The patient was started on NTG and his PA pressures came down from 70/35 to 55/30 with modest improvement of RV fxn. LV remained severely depressed. Based on the epi-aortic scan and the surgeon's assessment of the ascending aorta, the procedure was changed to an off-pump LIMA - LAD CABG only. The plan was to refer the patient for a trans-vascular aortic valve replacement. Post-procedure:: The patient is on low-dose phenylephrine. RV systolic fxn remains mildly depressed. LV systolic fxn is severly depressed. AI remains trace. MR is trace. [**2107-2-10**] 04:27AM BLOOD WBC-13.6* RBC-3.18* Hgb-10.0* Hct-29.3* MCV-92 MCH-31.5 MCHC-34.2 RDW-14.1 Plt Ct-496* [**2107-2-10**] 08:15AM BLOOD PT-45.0* PTT-37.4* INR(PT)-4.8* [**2107-2-10**] 04:27AM BLOOD Glucose-82 UreaN-25* Creat-1.5* Na-135 K-4.5 Cl-100 HCO3-27 AnGap-13 [**2107-2-13**] 05:08AM BLOOD WBC-11.5* RBC-3.05* Hgb-9.5* Hct-28.3* MCV-93 MCH-31.3 MCHC-33.7 RDW-13.9 Plt Ct-615* [**2107-2-14**] 05:24AM BLOOD PT-22.2* INR(PT)-2.1* [**2107-2-14**] 05:24AM BLOOD UreaN-24* Creat-1.3* Na-134 K-4.8 Cl-99 Brief Hospital Course: This is a 74-year-old male who presented to an outside hospital with chest pain, exertional dyspnea, and ruled in for non-ST-elevated myocardial infarction. He had an echocardiogram that revealed a decline in his ejection fraction to 10% from 30% in [**2099**]. He also had aortic stenosis with an aortic valve area of 0.8 cm2. Cardiac catheterization demonstrated 3-vessel coronary artery disease with 60% left anterior descending artery stenosis, 70-95% left circumflex artery stenosis, an occluded right coronary artery with poor left-to-right collaterals. He was taken to the operating room on [**2107-2-4**] and underwent an off-pump coronary bypass grafting x1 with the left internal mammary artery to left anterior descending artery. The aorta was palpated and found to be heavily calcified throughout the entire ascending aorta all the way down to the annulus. Intraoperatively Dr. [**Last Name (STitle) **] was asked to evaluate the level of calcific anatomy, and confirmed Dr[**Doctor Last Name **] findings. A discussion was carried out as to what options the patient had. It was felt that it would be a prohibitively high risk to replace the aortic valve, since there was no safe place to clamp on the aorta. At this point, it was elected to do the left internal mammary artery to left anterior superior descending artery bypass off pump. See operative note for full details. Post operatively he was extubated and epinephrine was slowly weaned. He went into rapid atrial fibrillation on POD#1 and dropped his systolic blood pressure into the 70's. He was cardioverted x 3 with 200/360/360 Joules and converted to sinus rhythm. He was weaned from all vasoactive medications over the next 3 days and was hemodynamically stable in sinus rhythm. He did have post operative acute renal failure with a peak creatinine of 2.0 and this was decreasing at the time of discharge. He was started on Coumadin for paroxysmal atrial fibrillation and received 2 doses of 5 mg and INR went to 4.8. He was resumed with Coumadin at a lower dose and INR was therapurtic at the time of discharge. He was evaluated by physical therapy for strength and mobility and cleared for home. He was transferred to the step down floor on post operative day 5. Chest tubes and pacing wires were removed per cardiac surgery protocol. He was tolerating a full oral diet, ambulating with assistance and his wounds were healing well. It was felt that he was safe for discharge home with services on POD # 8. The patient will be advised to follow up with Dr [**Last Name (STitle) **] in 3 weeks and at that time discuss Corevalve options for aortic stenosis. All follow up appointments were advised. Medications on Admission: Aspirin 325mg daily Atenolol 50mg Daily Glyburide 5mg daily Lovastatin 40mg daily Metformin Lisinopril Discharge Medications: 1. amiodarone 200 mg [**Last Name (STitle) 8426**] Sig: Two (2) [**Last Name (STitle) 8426**] PO BID (2 times a day): x 3 days, then decrease to 1 tab twice daily x 7 days, then dcrease to 1 tab daily . Disp:*120 [**Last Name (STitle) 8426**](s)* Refills:*2* 2. atorvastatin 80 mg [**Last Name (STitle) 8426**] Sig: One (1) [**Last Name (STitle) 8426**] PO DAILY (Daily). Disp:*60 [**Last Name (STitle) 8426**](s)* Refills:*2* 3. glyburide 2.5 mg [**Last Name (STitle) 8426**] Sig: One (1) [**Last Name (STitle) 8426**] PO BID (2 times a day). Disp:*60 [**Last Name (STitle) 8426**](s)* Refills:*2* 4. aspirin 81 mg [**Last Name (STitle) 8426**], Delayed Release (E.C.) Sig: One (1) [**Last Name (STitle) 8426**], Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 [**Last Name (STitle) 8426**], Delayed Release (E.C.)(s)* Refills:*2* 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. furosemide 20 mg [**Last Name (STitle) 8426**] Sig: One (1) [**Last Name (STitle) 8426**] PO BID (2 times a day) for 14 days. Disp:*28 [**Last Name (STitle) 8426**](s)* Refills:*0* 7. potassium chloride 10 mEq [**Last Name (STitle) 8426**] Extended Release Sig: Two (2) [**Last Name (STitle) 8426**] Extended Release PO Q12H (every 12 hours) for 14 days. Disp:*56 [**Last Name (STitle) 8426**] Extended Release(s)* Refills:*0* 8. warfarin 1 mg [**Last Name (STitle) 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] Once Daily at 4 PM: INR goal=[**12-30**] for Atrial Fibrillation. Disp:*150 [**Month/Day (3) 8426**](s)* Refills:*2* 9. carvedilol 3.125 mg [**Month/Day (3) 8426**] Sig: One (1) [**Month/Day (3) 8426**] PO BID (2 times a day). Disp:*60 [**Month/Day (3) 8426**](s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: 1. Coronary artery disease. 2. Aortic valve stenosis. 3. Calcified ascending aorta. Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - 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**] **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:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2107-3-9**] 1:30 Cardiologist: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2107-3-21**] 8:00 Please Draw INR for Coumadin dosing to be called into Dr. [**Last Name (STitle) **] #[**Telephone/Fax (1) 55136**], Fax # [**Telephone/Fax (1) 55139**] Coumadin indication:postoperative Atrial Fibrillation INR goal=[**12-30**] 1st INR draw on [**2107-2-15**] Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **] in [**3-1**] weeks [**Telephone/Fax (1) 55136**] **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:[**2107-2-14**] Name: [**Known lastname 14212**],[**Known firstname 126**] L Unit No: [**Numeric Identifier 14213**] Admission Date: [**2107-1-28**] Discharge Date: [**2107-2-14**] Date of Birth: [**2032-5-22**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Azithromycin Attending:[**First Name3 (LF) 135**] Addendum: For discharge medications the following changes were made: Lipitor 40 QD replaced with Lovastatin 40 QD (preop med) Metformin 850mg [**Hospital1 **] resumed per pre-op schedule Discharge Disposition: Home With Service Facility: [**Hospital 1397**] Home Health Care [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**] Completed by:[**2107-2-14**]

[ "428.0", "707.14", "584.9", "585.9", "458.29", "424.1", "403.90", "V64.1", "443.9", "440.0", "427.31", "599.0", "410.71", "276.1", "523.40", "428.23", "414.01", "250.80" ]

icd9cm

[ [ [] ] ]

[ "23.09", "37.23", "36.15", "38.97", "88.56", "99.62" ]

icd9pcs

[ [ [] ] ]

11483, 11707

4121, 6817

313, 440

8970, 9126

2385, 4098

9966, 11460

1297, 1514

6971, 8756

8863, 8949

6843, 6948

9150, 9943

1529, 2366

254, 275

468, 803

847, 1105

1121, 1265

71,698

115,429

39149+58262

Discharge summary

report+addendum

Admission Date: [**2109-2-1**] Discharge Date: [**2109-2-11**] Date of Birth: [**2036-2-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 425**] Chief Complaint: Right sided weakness Major Surgical or Invasive Procedure: [**2109-2-2**]: Left Burr Hole evacuation of SDH History of Present Illness: 72 yo left handed male w/ PMHx [**Month/Day/Year 65**] for CAD s/p MI, CABG, CHF w/ EF 15% who presents as transfer from OSH for SDH. The history is obtained through wife as patient appears fatigued and in slight resp distress. His wife found him outside a couple of months ago crawling to the house. He said that he had fallen. She then noticed 1-2 days ago that he had trouble walking. He stayed in bed almost all of yesterday. Today she notice that his R arm and leg were not working very well. He also saying things that did not make sense at times like he was "going back to [**State 108**]" when there were no plans to do so. He could only walk [**1-25**] steps with a walker yesterday. He was brought to an OSH today where head CT showed a large 3 cm L SDH with 1 cm midline shift. . The patient was given Vitamin K, FFP, and platelets prior to transfer to [**Hospital1 18**]. Upon arrival he was note to have erythema of his skin concerning for rash and he was given benadryl and Solu-Medrol out of concern for a transfusion reaction. Past Medical History: DM, CAD s/p MI, CABG, Afib, CHF w/ EF 15% s/p ICD, sleep apnea on BIPAP Social History: Retired, lives with wife. In dependant of ADLs. Smoker in past. Family History: non-contributory Physical Exam: Vitals: T 99.8; BP 110/70; P 98; RR 22; O2 sat 88% . General: lying in bed, wearing face mask, appears in mild distress. HEENT: NCAT, dry mucous membranes Pulmonary: upper airway rhonci, shallow breath sounds Cardiac: irreg irreg Abdomen: soft, nontender, non distended, normal bowel sounds Extremities: cool no edema. . Neurological Exam: Mental status: awake, states name, place - [**Hospital1 **], year [**2108**], month [**Month (only) **]. Does not repeat no ifs ands or buts. Names thumb but cannot name tuning fork. Some L/R confusion. . Cranial Nerves: I: Not tested II: R pupil surgical, L pupil 4-->2mm with light. III, IV, VI: does not comply formally with eye movements. VII: R NLF flattening XII: Tongue midline slightly clumsy side to side movements. . Motor: Normal bulk. Normal tone. Difficulty lifting R arm off bed. Does not comply with formal testing but appears to have right hemiparesis. . Sensation: intact to light touch . Reflexes: 1+ throughout Pertinent Results: Labs on Admission: [**2109-2-2**] 12:00AM BLOOD WBC-10.4 RBC-5.85 Hgb-14.5 Hct-45.8 MCV-78* MCH-24.7* MCHC-31.6 RDW-16.7* Plt Ct-247 [**2109-2-2**] 12:00AM BLOOD Neuts-86.5* Lymphs-8.5* Monos-4.5 Eos-0.2 Baso-0.3 [**2109-2-2**] 12:00AM BLOOD PT-13.4 PTT-26.6 INR(PT)-1.1 [**2109-2-2**] 12:00AM BLOOD Glucose-193* UreaN-33* Creat-1.3* Na-139 K-4.1 Cl-97 HCO3-30 AnGap-16 [**2109-2-2**] 12:00AM BLOOD CK(CPK)-85 [**2109-2-2**] 12:00AM BLOOD CK-MB-2 cTropnT-0.02* [**2109-2-2**] 12:00AM BLOOD Calcium-9.3 Phos-3.6 Mg-2.2 . Labs on Discharge: [**2109-2-11**] 03:59AM BLOOD WBC-10.6 RBC-6.52* Hgb-16.3 Hct-54.1* MCV-83 MCH-24.9* MCHC-30.1* RDW-18.6* Plt Ct-175 [**2109-2-11**] 03:59AM BLOOD PT-18.4* PTT-33.2 INR(PT)-1.7* [**2109-2-11**] 03:59AM BLOOD Glucose-208* UreaN-156* Creat-3.4* Na-143 K-5.0 Cl-101 HCO3-24 AnGap-23* [**2109-2-10**] 03:19AM BLOOD ALT-64* AST-185* AlkPhos-126 TotBili-1.4 [**2109-2-11**] 03:59AM BLOOD Calcium-9.1 Phos-5.6* Mg-3.2* [**2109-2-11**] 03:59AM BLOOD Digoxin-1.2 . --------------- IMAGING: --------------- CT head w/o contrast [**2109-2-2**]: There is a large 3.3 x 7.8 x 11.7 cm lentiform predominantly low-density extra-axial fluid collection overlying the left cerebral hemisphere, which has high density rim and internal septations, compatible with chronic subdural hematoma. This causes substantial mass effect on the adjacent sulci, as well as effacement of the left occipital [**Doctor Last Name 534**], and 13-mm rightward shift of normally midline structures, resulting in rightward subfalcine herniation. There is mild left uncal herniation and relative widening of the cerebellomedullary cistern on the left compared to the right. These findings are not changed from one day prior. Also not changed is area of low density with loss of [**Doctor Last Name 352**]-white matter differentiation along the posterior right temporoparietal lobe, consistent with evolving subacute infarct. No evidence of acute intracranial hemorrhage, edema, mass effect, hydrocephalus, or acute large vascular territory infarction is seen compared to one day prior. Note is made of stranding within the right occipital scalp (2:18). The patient has left lens replacement. No skull fracture is seen. 6-mm round well-circumscribed focus in the left frontal bone (3:36) is well circumscribed and has nonaggressive features. Mild mucosal thickening is noted at the left frontoethmoid junction. Vascular calcifications are noted along the cavernous carotid arteries. IMPRESSIONS: 1. Large lentiform predominantly hypodense extra-axial collection along the left cerebral hemisphere, with hyperdense rim and internal septations, compatible with chronic subdural hematoma. This collection causes substantial mass effect, including rightward subfalcine herniation and early left uncal herniation. Findings not changed from one day prior. 2. Hypodense evolving subacute-to-chronic posterior right temporoparietal lobe infarct, unchanged. . CT head w/o contrast [**2109-2-3**]: Substantial reduction in size of the subdural hemorrhage, but with presence of what is likely an acute component along its superficial aspect, as noted above. . CT head w/o contrast [**2109-2-4**]: Little change in comparison to one day prior, with persistent presence of likely acute subdural hematoma along the superficial aspect of the subdural collection. . CT head w/o contrast [**2109-2-7**]: No significant interval change with persistent left subdural extra-axial collection with some residual acute hemorrhage, with grossly stable mass effect on the left hemisphere, and stable shift of midline structure. . CXR [**2109-2-6**]: The moderate cardiomegaly with associated pulmonary edema is unchanged. Right lower lobe collapse persists. There are mild small bilateral pleural effusions. Pacer/defibrillator wires terminate appropriately, unchanged. Sternal wires are intact. IMPRESSION: Unchanged moderate cardiomegaly with mild pulmonary edema. Persistent right lower lobe collapse. . Echocardiogram [**2109-2-3**]: The left atrium is elongated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is severely depressed (LVEF= 15 %). The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. There is a very small pericardial effusion. Brief Hospital Course: Neurosurgery Intensive Care Unit Course: He was initially admitted to the neurosurgical ICU with confusion. Head imaging showed a subacute subdural hematoma. He underwent evacuation of the subdural hematoma with burrhole. The procedure was uncomplicated. The evening following the extubation he was found to be in worsened respiratory distress. He had pre-existing central sleep apnea for which he used bipap however he had worsened from his baseline. He had gone into afib with RVR in the setting of his rate controlling metoprolol for his PAF being held. His home lasix had also been held. A chest x-ray showed evidence of flash pulmonary edema. He was transferred to the Cardiology Cricitcal Care Unit (CCU). . CCU Course: . Acute on chronic systolic congestive heart failure: On transfer to the CCU service he was found to be in respiratory distress with evidence of volume overload. His apneic episodes from his central sleep apnea worsened due to [**Last Name (un) **] [**Doctor Last Name 6056**] respirations from heart failure and he required frequent bipap. He was switched from lasix boluses to lasix gtt,diurel, and then subsequently metolazone with vigorous urine output. His CVP was initially 24 and trended into the normal range. He initially had a FENA of 0.8. His Cr worsened initially from 1.8 to 2.8 with lasix drip, then improved to 2.4 with IV fluids but began to worsen, reaching 3.4 at the time of transfer. . Cheynes-[**Doctor Last Name **] Respirations: The patient developed alternate tachypnea and apnea, consistent with Cheynes-[**Doctor Last Name **] respirations. This was felt to be due to the patient's central . He should follow up his outpatient cardiologist Dr [**Last Name (STitle) **] on discharge. It is very important that that the patient use BIPAP at night AND during the day when less alert. . Acute kidney injury: The patient creatinine rose with diuresis, then improved with small boluses of IV fluids, then continued to rise. The patient's creatinine had reached 3.4 by the time of transfer. . Anion gap: The patient was noted to have an anion gap of 23 on the day of transfer. A peripheral venous lactate was 3.0 at the time of discharge. The patient's gap acidosis was thought to be multifactorial, related renal failure and to lactic acidosis. Following transfer, attention should be given to maintaining adequate perfusion without compromising the patient's respiratory status. . Atrial fibrillation: The patient's atrial fibrillation was initally rate controlled with carvedilol which was subsequently switched switched to metoprolol. Anticoagulation was held in the setting of the patient's subdural hematoma. The patient cannot restart anticoagulation with warfarin or heparin until she follows up with neurosurgery and is cleared for anticoagulation. . Subdural hematoma: Serial CT scans were stable, although the patient's mental status remained altered. The patient was continued on Keppra for seizure prophylaxis. The neurology service was consulted and recommended doing a routine EEG if the patient's mental status changes persist. Neurosurgery was consulted regarding anticoagulation and felt that it was safe to restart aspirin. Per neurosurgery, the patient should not start heparin or Coumadin until at least [**2109-2-27**], and only after being seen in follow-up by neurosurgery. The neurology service should be consulted at [**Hospital 8641**] hospital for management of the patient's seizure prophylaxis. . Delirium: The patient would become agitated at night. Benzodiazepines were avoided and frequent reorientation was encouraged. Neurology was consulted and recommended checking an EEG. This should be done if the patient's altered mental status persists. Medications on Admission: ASA 81mg Carvedilol 12.5m [**Hospital1 **] Lisinopril 10mg daily Plavix 75mg daily Lasix 40m [**Hospital1 **] Zocor 40mg daily KCl 20meq daily Prilosec 20mg daily MVI Novolog 70/30. Discharge Medications: 1. Simvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 3. Digoxin 125 mcg Tablet [**Hospital1 **]: One (1) Tablet 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. Metoprolol Tartrate 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO three times a day. 6. Keppra 1,000 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day. 7. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge [**Last Name (STitle) **]: Ten (10) units Subcutaneous qam. 8. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge [**Last Name (STitle) **]: Six (6) units Subcutaneous at bedtime. Discharge Disposition: Extended Care Discharge Diagnosis: Left Chronic subdural hematoma Cardiomyopathy(LEVF<20%) Acute on chronic kidney injury Discharge Condition: Hemodynamically stable; not oriented to person, place, or time; intermittently responsive to simple commands; intermittently apneic tachypneic, with cheynes-[**Doctor Last Name 6056**] respirations Discharge Instructions: You came to the hospital because of bleeding in your head. You had a neurosurgical procedure to remove some blood from your head. Your heart failure worsened post-operatively, requiring transfer to the cardiac intensive care unit. You were treated with diuretic medications. . Your family requested transfer to [**Hospital 8641**] Hospital, closer to home. At the time of discharge, there were several active issues that still needed attention: 1. Your kidney function was getting worse. This should be followed closely at [**Hospital 8641**] Hospital. 2. You were not as alert as you usually are. Consideration should be to doing an EEG if this persists. 3. You have staples in your head from the neurosurgical procedure. These should be removed on [**2109-2-12**]. . You will be transferred to [**Hospital 8641**] Hospital for further care. . You will need to follow up with neurosurgery (Dr. [**First Name (STitle) **] in 4 weeks for further evaluation. You should not start anticoagulation with Coumadin or heparin until you are seen by Dr. [**First Name (STitle) **]. Followup Instructions: Dr. [**Last Name (STitle) **]: Monday [**2109-2-18**], 10:40am. [**Location (un) 8641**] Cardiology, [**Apartment Address(1) **] [**Street Address(2) 86734**] [**Location (un) 8641**] Newhampshire, [**Numeric Identifier **]. Tel: [**Telephone/Fax (1) 86735**] . Dr [**First Name (STitle) **] (neurosurgery): Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7746**], MD Phone:[**Telephone/Fax (1) 3666**] Date/Time:[**2109-3-7**] 11:15 Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 13716**] Admission Date: [**2109-2-1**] Discharge Date: [**2109-2-11**] Date of Birth: [**2036-2-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 296**] Addendum: Correction to discharge summary: Under subdural hematoma, the d/c summary states that the patient should not take warfarin or heparin until at least [**2109-2-27**] AND being evaluated by neurosurgery. The discharge summary should state that the patient should NOT take heparin or warfarin until being evaluated on neurosurgery, which will be one [**2109-3-7**]. Discharge Disposition: Extended Care [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 297**] MD [**MD Number(1) 298**] Completed by:[**2109-2-11**]

[ "425.4", "276.2", "293.0", "585.9", "V45.81", "427.31", "428.23", "V45.02", "584.9", "327.23", "412", "342.92", "E888.9", "428.0", "852.21", "414.00", "250.00" ]

icd9cm

[ [ [] ] ]

[ "01.31", "93.90" ]

icd9pcs

[ [ [] ] ]

15132, 15302

7628, 11354

334, 385

12594, 12794

2685, 2690

13915, 15109

1658, 1676

11586, 12425

12484, 12573

11380, 11563

12818, 13892

1691, 2012

2031, 2031

274, 296

3224, 7605

413, 1466

2255, 2666

2704, 3205

2046, 2239

1488, 1561

1577, 1642

12,337

106,345

48518

Discharge summary

report

Admission Date: [**2136-1-12**] Discharge Date: [**2136-1-23**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5880**] Chief Complaint: Fever Major Surgical or Invasive Procedure: None History of Present Illness: 85 yo male s/p recent hospitalization for colectomy and splenectomy complicated by anastomotic leak and treated with a diverting ileostomy with g-j tube placement and appendectomy. He was discharged to rehab and returned less than 1 week later with fever and acute renal failure. Past Medical History: HTN Hiatal hernia TIA (on Plavix) Asthma Spinal stenosis AR and MR (requires SBE prophylaxis) Social History: Married and lives with wife [**Name (NI) **] in [**Name (NI) 108**] during winter months Family History: Noncontributory Physical Exam: Gen: NAD, AAOx3 CV: RRR Pulm: some coarse BS bilat Abd: soft, NT, wound open and packed, ostomy intact Ext: no c/c/e Pertinent Results: [**2136-1-12**] 06:10PM GLUCOSE-98 UREA N-49* CREAT-1.5* SODIUM-134 POTASSIUM-5.3* CHLORIDE-105 TOTAL CO2-20* ANION GAP-14 [**2136-1-12**] 06:10PM CALCIUM-9.4 PHOSPHATE-4.1 MAGNESIUM-2.2 [**2136-1-12**] 06:10PM WBC-13.9* RBC-3.75* HGB-11.9* HCT-35.0* MCV-94 MCH-31.7 MCHC-33.9 RDW-17.1* [**2136-1-12**] 06:10PM PLT COUNT-418 Cardiology Report ECHO Study Date of [**2136-1-13**] PATIENT/TEST INFORMATION: Indication: Left ventricular function. Pulmonary embolus. Right ventricular function. Height: (in) 67 Weight (lb): 185 BSA (m2): 1.96 m2 BP (mm Hg): 129/54 HR (bpm): 56 Status: Inpatient Date/Time: [**2136-1-13**] at 10:41 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007W006-0:13 Test Location: West SICU/CTIC/VICU Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] MEASUREMENTS: Left Atrium - Long Axis Dimension: *4.2 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *5.7 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *5.1 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: *1.5 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: *1.5 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.1 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 2.3 cm Left Ventricle - Fractional Shortening: 0.44 (nl >= 0.29) Left Ventricle - Ejection Fraction: 60% to 65% (nl >=55%) Aorta - Valve Level: *3.7 cm (nl <= 3.6 cm) Aorta - Ascending: *3.7 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.7 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.8 m/sec Mitral Valve - A Wave: 0.9 m/sec Mitral Valve - E/A Ratio: 0.89 Mitral Valve - E Wave Deceleration Time: 368 msec TR Gradient (+ RA = PASP): 19 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: This study was compared to the report of the prior study (images not available) of [**2134-6-29**]. LEFT ATRIUM: Mild LA enlargement. Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. The IVC is normal in diameter with >50% decrease collapse during respiration (estimated RAP [**4-12**] mmHg). LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Normal regional LV systolic function. Overall normal LVEF (>55%). Transmitral Doppler and TVI c/w Grade I (mild) LV diastolic dysfunction. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta. AORTIC VALVE: Moderately thickened aortic valve leaflets. No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Trivial MR. LV inflow pattern c/w impaired relaxation. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor apical views. The patient appears to be in sinus rhythm. Conclusions: The left atrium is mildly dilated. The left atrium is elongated. The estimated right atrial pressure is 5-10 mmHg. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened with focal calcification of the noncoronary cusp. There is no aortic valve stenosis.Trace aortic regurgitation is seen. Trivial mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. IMPRESSION: Moderate symmetric LVH. Normal left ventricular systolic function. Compared with the report of the prior study (images unavailable for review) of [**2134-6-29**], there is no significant change. CTA CHEST W&W/O C&RECONS, NON- Reason: r/o PE Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 85 year old man with concern for PE. REASON FOR THIS EXAMINATION: r/o PE CONTRAINDICATIONS for IV CONTRAST: None. EXAMINATION: CT of the chest with and without contrast dated [**2136-1-13**]. COMPARISON: CT of the abdomen dated [**2136-1-12**]. INDICATION: Question pulmonary embolism. TECHNIQUE: Axial imaging was obtained through the chest before and after the administration of IV contrast. FINDINGS FOR CT OF THE CHEST WITH AND WITHOUT IV CONTRAST: There is heavy atherosclerotic calcification of the thoracic aorta and great vessels. There is cardiomegaly and coronary artery calcification. There is no pericardial effusion. After administration of IV contrast there is evidence of thrombus in the right main pulmonary artery as well as segmental and subsegmental branches of the right upper lobe pulmonary arteries. No thrombus is seen within the left pulmonary arteries. Small mediastinal lymph nodes are demonstrated which are numerous but not enlarged by CT criteria. Scattered air space disease is seen within the right middle lobe and right lower lobe which may represent atelectasis, infection, or infarction given evidence of pulmonary embolism. There is bibasilar atelectasis. There is no evidence of pneumothorax or pleural effusion. Limited imaging of the upper abdomen demonstrates evidence of splenectomy with small fluid collection in the left upper quadrant measuring 3 cm which contains gas consistent with post-surgical changes. Small amount of fluid measuring 2.4 cm x 1.6 cm is seen adjacent to the pancreatic tail. IMPRESSION: 1. Evidence of pulmonary embolism on the right as described with air space consolidation within the right middle and right lower lobes which may represent atelectasis, infection, or pulmonary infarction given evidence of pulmonary embolism. 2. Limited evaluation of post-surgical changes in the left upper quadrant as seen on prior CT abdomen and pelvis. Findings were discussed with the resident taking care of the patient at completion of the examination. Reason: S/P RECENT SURGERY NOW TACHYPNEIC EVAL FOR PE RADIOPHARMECEUTICAL DATA: 7.1 mCi Tc-[**Age over 90 **]m MAA ([**2136-1-12**]); 44.0 mCi Tc-99m DTPA Aerosol ([**2136-1-12**]); HISTORY: S/P RECENT SURGERY NOW TACHYPNEIC EVAL FOR PE INTERPRETATION: Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views demonstrate marked central clumping consistent with airways disease. There is diffuse irregularity of tracer uptake within the lung parenchyma. Perfusion images in the same 8 views show multiple large peripheral wedge-shaped defects in the right lung. Perfusion irregularity of the left lung is much less pronounced than the right. Chest x-ray shows a left lower lobe opacity. While the above findings may in part be attributed to airways disease, they are concerning for pulmonary embolism and consistent with a moderately high probability for pulmonary embolism. IMPRESSION: Moderate-High Likelihood for pulmonary embolism. Brief Hospital Course: He was admitted to the Surgery Service under the care of Dr. [**Last Name (STitle) **]. He underwent a lung scan which revealed moderate to high probability of pulmonary embolus. CTA of the chest was done following the lung scan which revealed a thrombus in the right pulmonary artery. He was started on a Heparin drip and later started on Coumadin and Lovenox as a bridge until his INR becomes therapeutic. On HD #5 he experienced episode of increased shortness of breath and chest pressure after performing morning ADL's; EKG and CXR were all normal; his CK and troponin were flat. He again experienced a similar episode on HD #7, EKG without change compared to previous one; chest radiograph performed and pending at time of this dictation. This episode was proceeded by a session of chest physiotherapy and resolved shortly after that. His supplemental oxygen was discontinued at that time as his room air saturations were 95%. On HD #8 he was noted to have guaiac positive stool via his ileostomy. His Coumadin was stopped; the Lovenox was changed to Heparin and he remained on the Plavix. His hematocrits were as follows: [**2136-1-20**] 01:20AM 32.6* [**2136-1-19**] 09:00PM 34.6* [**2136-1-19**] 07:14PM 32.6* [**2136-1-19**] 09:30AM 33.5* A GI consult was obtained and recommendations for scoping were made. The scope showed: The first stoma was examined. We reached 50 cm and found no blood and normal ileal mucosa with bile. The second the stoma was examined and initially normal ileal mucosa was seen aprox 15 cm. Following 15 cm, colonic mucosa was observed. Multiple polyps were seen. Polyp in the 25 cm Polyp in the 30 cm Otherwise normal colonoscopy to anastomosis Recommendations: Pt will need a repeat colonscopy once he is off his coumadin Monitor hct Physical therapy was consulted and have recommended rehab stay following his acute hospitalization. The patient has continued to progrss well, tolerating a normal diet and having O2 sats in the high 90's on room air. His HCt has remained stable and he is discharged in stable condition to rehab to followup with Dr. [**Last Name (STitle) **] and with Dr. [**First Name (STitle) 679**] of gastroenterology. He will remain on lovenox until his INR is at a therapeutic range of [**1-7**] at which point the lovenox will be stopped and he will be continued on coumadin only for anticoagulation. Medications on Admission: Plavix 75' Flomax 0.4' Cozaar 50' Lipitor 10' Lopressor 25" Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol [**Date Range **]: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 2. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Date Range **]: Two (2) Puff Inhalation QID (4 times a day). 3. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR [**Date Range **]: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 4. Atorvastatin 10 mg Tablet [**Date Range **]: One (1) Tablet PO at bedtime. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Date Range **]: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Acetaminophen 325 mg Tablet [**Date Range **]: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 7. Warfarin 2 mg Tablet [**Date Range **]: One (1) Tablet PO HS (at bedtime): Adjust daily dose based on INR. 8. Metoprolol Tartrate 50 mg Tablet [**Date Range **]: Two (2) Tablet PO TID (3 times a day): hold for HR <60; SBP <110. 9. Losartan 50 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 10. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup [**Date Range **]: Five (5) ML PO Q6H (every 6 hours) as needed for cough. 11. Clopidogrel 75 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 12. Colace 100 mg Capsule [**Date Range **]: One (1) Capsule PO twice a day as needed for constipation. 13. Milk of Magnesia 800 mg/5 mL Suspension [**Date Range **]: Ten (10) ML's PO twice a day as needed for constipation. 14. Enoxaparin 100 mg/mL Syringe [**Date Range **]: Seventy (70) mg Subcutaneous Q12H (every 12 hours): discontinue after therapeutic INR ([**1-7**]) reached on warfarin. Discharge Disposition: Extended Care Facility: [**Hospital **] rehab [**Location (un) 3915**] Discharge Diagnosis: Pulmonary embolus Discharge Condition: Stable Discharge Instructions: Please call or return if you have a fever >101.5, severe pain, inability to pass gas or stool, nausea/vomiting, chest pain, shortness of breath, drainage from the wound, or any other concerns. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] in 2 weeks, call [**Telephone/Fax (1) 6439**] for an appointment. Please call for a followup with GI, Dr. [**First Name (STitle) 679**], ([**Telephone/Fax (1) 16940**] for a repeat ileoscopy. Completed by:[**2136-1-23**]

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icd9cm

[ [ [] ] ]

[ "45.22" ]

icd9pcs

[ [ [] ] ]

12441, 12514

8280, 10684

267, 274

12576, 12585

992, 1386

12826, 13094

823, 840

10794, 12418

5271, 5308

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302, 583

605, 700

716, 807

32,555

124,587

23344

Discharge summary

report

Admission Date: [**2177-10-24**] Discharge Date: [**2177-10-25**] Date of Birth: [**2110-9-2**] Sex: M Service: MEDICINE Allergies: Shellfish Attending:[**First Name3 (LF) 458**] Chief Complaint: hypotension following a-flutter ablation Major Surgical or Invasive Procedure: A flutter ablation. EP testing. History of Present Illness: Mr. [**Known lastname 59921**] is a 67M with PMH of CAD s/p CABG in [**2155**], numerous MI's most recent in [**2167**], and complete heart block with pacer/ICD implantation in [**2174-11-7**], who presented to the hospital today for elective ablation of atrial flutter. The patient first began to notice symptoms such as fatigue, shortness of breath, lightheadedness, and dyspnea on exertion in [**2177-2-6**]. In [**2177-5-6**] the patient was seen in the device clinic for routine follow-up, and was noted to have atrial flutter with complete heart block. In early [**Month (only) 216**], he underwent TEE and DC cardioversion at [**Hospital3 1443**] Hospital, and since that time his symptoms have markedly improved. However, in susequent outpatient cardiology visits, it was decided that he should undergo atrial flutter ablation to prevent recurrent arryhthmia. Since the patient has not undergone defibrillation threshold testing since device implantation in [**2174**], he was scheduled for a combined ICD testing and TEE/atrial flutter ablation procedure in the EP lab for today, [**2177-10-24**]. His coumadin has been discontinued since Saturday and he has been bridged with Lovenox. . Prior to presenting for his study, the patient states that he was in his USOH, with his only complaint being chronic hip pain. The patient felt generally well and denied any chest pain or dyspnea. He also denies palpitations, lightheadedness or syncope. He reports that he has never been shocked by his device. He denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, cough, or hemoptysis. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . In the EP lab, TEE showed no throbmus, and AFL isthmus ablation was performed. Subsequently he underwent an EP study (DFT testing) x 2. After the second test he had prolonged hypotension to SBP in 50's for 10-15 minutes. Also had hypoxia with poor airway security, desta to 80s. Briefly given neo and dopa with resolution of hypotension, and an LMA was placed for airway protection, which was d/c'ed on recovery. His L femoral arterial line was left in place, and he was admitted to the CCU for further monitoring. Past Medical History: CAD, s/p CABG in [**2155**], 5 MI's from [**2155**]-[**2167**] Cardiomyopathy (?ischemic), with EF documented at 30% in [**2174**] Complete heart block s/p pacer/ICD in [**11-9**] Atrial flutter Hypertension Dyslipidemia Moderate aortic stenosis Diabetes Type 2 with peripheral neuropathy Bilateral carotid artery disease, s/p right CEA Rectal bleeding 2-3 years ago BPH Bilateral osteoarthritis Appendectomy as a child Social History: Married, semi-retired masonry teacher at [**Location (un) 1121**] Vocational tech. Does not drink alcohol. Remote history of very brief tobacco use. Family History: Family history is significant for extensive coronary artery disease, with multiple male relatives having [**Name (NI) 5290**] in their 50-60s. Mother died of MI in her 70's. Physical Exam: VS: T 96.2, BP 105/60, HR 80, RR 21, O2 97% on 5L NC Gen: obese middle aged male in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: R lateral cervical surgical scar. Supple with JVP of 10 cm. CV: Quiet precordium. PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. No m/r/g. Chest: well healed midline sternotomy scar. No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: Obese and protuberant, soft, NT/ND, no HSM or tenderness. No abdominial bruits. Ext: L groin with arterial line still in place, no hematoma or bruit. R groin puncture site also with no hematoma or bruit. Extermities with bileteral 2+ pitting edema to below the knee, Skin: chronic venous stasis changes and hyperemia bilaterally LE Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP MEDICAL DECISION MAKING Pertinent Results: creatinine 2.3, baseline 2.2 INR 1.6 . ECHO [**10-24**] The left atrium is dilated. Mild spontaneous echo contrast is seen in the body of the left atrium. Mild spontaneous echo contrast is present in the left atrial appendage. No thrombus is seen in the left atrial appendage. The right atrium is dilated. No atrial septal defect is seen by 2D or color Doppler. LV systolic function appears depressed. Right ventricular systolic function appears depressed. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. IMPRESSION: No atrial thrombus seen. Borderline low left atrial appendage velocities and mild spontaneous echo contrast in the left atrium/LAA. Brief Hospital Course: 67M with CAD, CHB s/p pacer/ICD [**2174**], and recent development of atrial flutter, admitted for defibrillation threshold testing and a-flutter ablation c/b brief hypotension and airway compromise, admitted to the ICU for closer monitoring post procedure. . 1. Hypotension: Patient became hypotensive after procedure, and was briefly on dopamine and neosynephrine. Was weaned off prior to being transferred to CCU for overnight monitoring. Hypotension likey related to propofol administered during anesthesia for DFT testing, or a transient effect of induced arrhythmia. Patient with stable blood pressure in the CCU. His SBP fell temporarily to high 60's after morning administration of antihypertensives. He is been told to stagger daily BP meds by taking Cozaar at night. Other than that change, he is to continue his home regimen. . 2. CAD/angina: continued medical management with Isosorbide MN 120mg daily, Lipitor 40mg daily, valsartan 50mg daily, carvedilol 12.5mg [**Hospital1 **]. Also started on ASA 81 mg daily. Will continue this at home. . 3. CHF - no documented EF, but likely chronic systolic CHF. Continued BB and [**Last Name (un) **] as above, and bumetanide 4 mg am, and 2mg pm) . 4. Rhythm - s/p flutter ablation, currently in ventricularly paced rhythm. Underlying rhythm is CHB. Patient is to follow up with Dr. [**Last Name (STitle) **] in 3 weeks, and the device clinic as per scheduled appt. He will continue amiodarone 200 mg daily. He is to restart coumadin tonight, and get INR checked on monday. The result will be sent to his PCP's office. He was also given Lovenox day of discharge, and was given a prescription for 1 dose day after discharge. . 5. Hyperlipidemia: continued statin . 6. DM: continue glypizide held in the hospital, FSG qid, RISS. will restart glypizide upon discharge. Medications on Admission: Coumadin, last dose [**2177-10-19**] Lovenox 60mg SQ [**2177-10-22**] and [**2177-10-23**] Naproxen 250mg TID Lipitor 40mg daily Cozaar 50mg daily Isosorbide MN120mg daily Bumetanide 2mg TID Klor con 10meq daily Glipizide XL 10mg [**Hospital1 **] Amiodarone 200mg daily Coreg 12.5mg [**Hospital1 **] Discharge Medications: 1. Naproxen 250 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Take in evening. 4. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 5. Bumetanide 2 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 6. Bumetanide 2 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 8. Glipizide 10 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO BID (2 times a day). 9. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 11. Isosorbide Mononitrate 120 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Lovenox 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous once a day for 1 days. Disp:*1 1* Refills:*0* 14. Outpatient Lab Work INR check for [**2177-10-26**]. Please fax results to Dr.[**Name (NI) 59922**] office. fax: [**Telephone/Fax (1) 59923**] 15. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: atrial flutter hypotension . Secondary: CAD HTN DMII obesity hyperlipidemia Discharge Condition: stable. Discharge Instructions: You came to the hospital for ablation of an abnormal heart rhythm and testing of your heart. During the procedure, your blood pressure was low, and you were admitted to the CCU, and have been stable since. . Some medication changes: 1. We recommend that you take your Cozaar at night, to stagger it from your other antihypertensive medications. 2. You should also take an Aspirin 81 mg everyday. Prescription is included with your discharge work. 3. Restart your coumadin tonight. 4. Take one dose of Lovenox at home tomorrow ([**2177-10-26**]). a prescription is included. . Please call your doctor or return to the hospital if you have chest pain, worsening shortness of breath, lightheadedness, or any other concerning symptoms. Completed by:[**2177-10-25**]

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icd9cm

[ [ [] ] ]

[ "37.34", "89.49", "88.72" ]

icd9pcs

[ [ [] ] ]

9210, 9216

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311, 345

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3495, 4622

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231, 273

373, 2679

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50,626

151,037

41808

Discharge summary

report

Admission Date: [**2118-7-21**] Discharge Date: [**2118-8-4**] Date of Birth: [**2034-3-10**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Vytorin [**9-26**] / Neosporin Attending:[**First Name3 (LF) 165**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2118-7-26**] AVR ( [**Street Address(2) 6158**]. [**Male First Name (un) 923**] Epic Supra porcine)/CABG x1 (SVG to dRCA) History of Present Illness: This 84 year old female has been followed for a history of aortic stenosis. An echo on [**2118-7-12**] showed heavily calcified aortic valve leaflets with a mean aortic valve gradient of 60 mm Hg and [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.8 cm2. She has had increasing shortness of breath over the past week with occasional episodes of dizziness and increased leg edema. She underwent cardiac cath at [**Hospital6 5016**] today which revealed severe AS, 80% ostial RCA lesion, and normal LV function. She was transferred to [**Hospital1 18**] for surgery. Past Medical History: CAD- s/p cardiac cath [**5-26**] aortic stenosis probable rheumatic heart disease HTN mitral valve prolapse anxiety colon cancer NIDDM Past Surgical History: s/p appy s/p choley s/p s/p partial colectomy for colon ca [**2108**] s/p bilat cataract surgery Social History: Lives with: daughter Contact: [**Name (NI) **] Phone #([**Telephone/Fax (1) 90798**] Occupation:housewife Cigarettes: Smoked no [x] yes [] last cigarette _____ Hx: Other Tobacco use:noen ETOH: < 1 drink/week [x] [**1-24**] drinks/week [] >8 drinks/week [] Illicit drug use none Family History: no premature CAD Physical Exam: Pulse:30s-40s Resp:10 O2 sat: 96%on RA B/P Right:160/90 Left: Height:65" Weight: 155 Five Meter Walk Test #1_______ #2 _________ #3_________ General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur [x] grade _4/6_____ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [x] _Tr____ Varicosities: None [x] Neuro: Oriented to person only-daughter states patient was confused after she received versed, but is oriented and intact at baseline, exam is non-focal Pulses: Femoral Right:fem stop-no hematoma Left:2+ DP Right:2+ Left:2+ PT [**Name (NI) 167**]:2+ Left:2+ Radial Right:2+ Left:2+ Carotid Bruit Right:transmitted murmur Left:transmitted murmur Pertinent Results: Conclusions PRE-BYPASS: No spontaneous echo contrast is seen in the body of the left atrium. No spontaneous echo contrast is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the ascending aorta. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. 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 moderately thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results prior to incision. POST-BYPASS: The patient in on a phenylephrine infusion. There is a well-seated, well-functioning bioprosthetic valve in the aortic position. No aortic regurgitation is seen. There is a mean gradient of 14 mmHg across the aortic valve. Biventricular function is unchanged. There is no mitral regurgitation. The ascending aorta, aortic arch, and descending aorta are intact. Surgeon notified in person of the results at time of study. I certify that I was present for this procedure in compliance with HCFA regulations. Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting physician [**2118-8-4**] 05:50AM BLOOD WBC-11.1* RBC-3.51* Hgb-11.4* Hct-34.3* MCV-98 MCH-32.5* MCHC-33.3 RDW-14.1 Plt Ct-451* [**2118-8-3**] 08:10AM BLOOD WBC-11.6* RBC-3.78* Hgb-12.0 Hct-35.9* MCV-95 MCH-31.8 MCHC-33.4 RDW-14.1 Plt Ct-419 [**2118-8-4**] 05:50AM BLOOD Glucose-136* UreaN-30* Creat-0.7 Na-148* K-3.4 Cl-108 HCO3-33* AnGap-10 [**2118-8-3**] 08:10AM BLOOD Glucose-117* UreaN-27* Creat-0.5 Na-148* K-4.0 Cl-107 HCO3-34* AnGap-11 [**2118-8-4**] 05:50AM BLOOD Mg-2.4 [**2118-8-3**] 08:10AM BLOOD Calcium-8.9 Phos-4.4 Mg-2.5 Brief Hospital Course: Admitted [**7-21**] from OSH and pre-op work-up completed. Carotid ultrasound revealed less than 40% stenosis in the [**Country **], 60-69% stenosis on the left with antegrade vertebral flow. The patient was noted to have second degree heart block with bradycardia that evening and was transferred to the CVICU for close monitoring. EP was consulted and noted Wenckebach rhythm, beta blockers were held. Noted to have periods of confusion and agitation. L carotid disease noted on duplex. Dental extraction completed [**7-24**]. On [**2118-7-26**] she was taken to the operating room and underwent Aortic valve replacement with a size 21-mm St. [**Male First Name (un) 923**] Epic tissue valve/Coronary artery bypass graft x1 with saphenous vein graft to right coronary artery/Aortic endarterectomy with Dr. [**First Name (STitle) **]. She tolerated the procedure well and was transferred to the CVICU in critical but stable condition, intubated and sedated requiring pressor support. POD 1 found the patient extubated and breathing comfortably. The patient was sleepy, but easily arousable and oriented to person and place. She was hemodynamically stable, weaned from vasopressor support. Beta blocker was not initited due to high grade heart block. EP evaulated the patient and is following postoperatively. Diuretics were initiated and the patient was gently diuresed toward the preoperative weight. Norvasc and Lisinopril were added for hypertension. All lines and drains were discontinued in a timely fashion with criteria met. On POD#4 she transferred to the step down unit for further monitoring. Physical Therapy was consulted for evaluation of strength and mobility. Her mental status remained oriented to person and place, she follows verbal commands, however she makes no effort to interact and progress. All offending medications were discontinued so that her mental status would not possibly be affected by narcotics. On [**8-1**] she failed a speech and swallow study. A dobhoff tube was placed for nutrition. Diet was advanced to nectar thick liquids and pureed solids with subsequent swallowing evaluations. She will remain on tube feeds until PO intake improves. The patient does have a history of a lacrimal duct disorder and she does not open her eyes- this is her pre-operative baseline. She will maintain her Foley Catheter to rehab. Heart rhythm recovered and she was in sinus rhythm by the the time of discharge. Discussed with EP- and recommendation is to follow up with her regular cardiologist. On POD 9 she was cleared by Dr.[**First Name (STitle) **] for discharge to [**Hospital **] in [**Hospital1 3597**], NH. Medications on Admission: Nitro patch 0.4 mg top Diltiazem CD 300 mg PO daily Lescol XL 80 mg PO daily Metformin 500 mg PO daily ASA 81 mg PO daily MVI 1 PO daily Lisinopril 20 mg PO daily Lasix 20 mg PO daily KCl 10 mEq PO daily Vitamin D 50,000 u PO once a week for 8 weeks Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. fluvastatin 80 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 7. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. chlorhexidine gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 11. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. 13. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 14. potassium chloride 20 mEq Packet Sig: One (1) Packet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: coronary artery disease aortic stenosis s/p aortic valve replacement,coronary artery bypass graft x1 probable rheumatic heart disease hypertension mitral valve prolapse anxiety h/o colon cancer non-insulin dependent diabetes mellitus s/p appendectomy s/p cholecsytectomy s/p s/p partial colectomy for colon carcinoma [**2108**] s/p bilateral cataract surgery Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema minimal 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) **] ([**Telephone/Fax (1) 170**]) on [**2118-9-5**] at 1:45pm Cardiologist:Dr. [**Last Name (STitle) 5017**] on [**2118-8-24**] at 9:15am Please call to schedule appointments with: Primary Care Dr.[**Last Name (STitle) **] [**Name (STitle) **] ([**Telephone/Fax (1) 83705**]) in [**3-22**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2118-8-4**]

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icd9cm

[ [ [] ] ]

[ "35.21", "00.40", "39.61", "38.14", "36.11", "96.6", "23.09" ]

icd9pcs

[ [ [] ] ]

9005, 9052

4850, 7506

329, 456

9455, 9691

2615, 4827

10615, 11281

1678, 1696

7807, 8982

9073, 9434

7532, 7784

9715, 10592

1250, 1349

1711, 2596

270, 291

484, 1070

1092, 1227

1365, 1662

5,525

133,906

52674

Discharge summary

report

Admission Date: [**2116-6-18**] Discharge Date: [**2116-6-26**] Date of Birth: [**2050-4-3**] Sex: M Service: MEDICINE Allergies: Neupogen / Neurontin / Dilaudid Attending:[**First Name3 (LF) 905**] Chief Complaint: Altered mental status, hypoglycemia. Major Surgical or Invasive Procedure: -Placement of femoral line. History of Present Illness: Mr. [**Known lastname **] is a 66 year old male with Obesity hypoventilation syndrome, possible COPD, atrial fibrillation, status-post cardioverson (not on Coumadin), ESRD on HD (s/p failed renal tx, T,Th,Sa), PVD with recent admission for TMA ulcer s/p debridement who presents altered mental status in the setting of hypoglycemia. In the ER his initial VS were: T 97.8 HR 81 irreg. BP 108/72 RR 18 O2 sat 96% BG 30s in the nursing home, given glucagon IM x 2. Transferred to the ER, BG upon arrival to the ER was 120. In the ER he was normotensive but then began more obtunded and his BG was in the 30s and he was given D50 and his BG improved to 66 and was given 1 additional amp of D50. The patient has been intermittently hypotensive- with systolics between 70-80. His obtundation slightly improved with D50 but still with altered mental status. L femoral line placed, 1L NS given, also given vanc / zosyn. Some periumbilical abd pain so underwent CT abd / pelvis which was prelim negative, renal fellow contact[**Name (NI) **]. Cultures drawn from HD line. Prior to his transfer to the floor his VS were: BP 105/59, 79 RR 12 O2 100% on non rebreather. The patient was unable to provide a history upon initial evaluation due to his obtundation. Past Medical History: -Obesity Hypoventilation syndrome -Possible COPD -Atrial Fibrillation - s/p cardioversion in [**10-13**]. Was maintained on coumadin for 6 months. Currently not anticoagulated due to fall risk. -Pericardial effusion - s/p drainage, unclear etiology -ESRD from ATN in setting of acute gastroenteritis, s/p failed cadaveric kidney transplant in [**2109**]. Dialyzed at [**Location (un) **] Tues, Thurs, Sat. -Abdominal wall hernia - s/p repair after transplant -Multiple knee surgeries 20 years ago -Poor access, Right Tunnelled line -Baseline SBP's in 90s -Hypercapnia due to obesity hypoventilation syndrome -non-melanoma skin cancer -septic knee -TMA ulcer/ganrene x2 s/p debridement [**2116-5-11**] -PVD s/p angioplasty/stent of R popliteal artery Social History: Denies any history of Tobacco use, no EtOh use for [**Last Name (un) **] than 20 years, no drug use. Lives with his wife normally- since last discharge living at [**Hospital3 **], now on disability. Used to work as a spray painter. Has 3 children and multiple grandchildren. Family History: History of CAD (mother died at age 70), cancer Physical Exam: On admission: VS: 97.9 (axillary) HR 90 BP 106/64 O2 sat 92% on 1L Gen: somnolent, minimal responsiveness to verbal stimuli HEENT: anicteric sclera, MM dry, PERRL Neck: large, supple, no LAD Heart: Irregularly irregular, soft heart sounds, no m/rg Lung: Coarse BS anteriorly bilaterally Abd: obese, soft NT/nD +BS no rebound or guarding Ext: s/p R foot amp with VAC in place, no pitting edema Skin: diffuse ecchymosis in upper ext Neuro: somnolent, arousable, moving arms Pertinent Results: Labs: [**2116-6-18**] 11:25AM WBC-13.4*# RBC-2.79* HGB-8.6* HCT-29.0* MCV-104* MCH-30.9 MCHC-29.7* RDW-17.9* [**2116-6-18**] 11:25AM NEUTS-86.1* LYMPHS-10.8* MONOS-1.5* EOS-1.3 BASOS-0.2 [**2116-6-18**] 11:25AM PLT COUNT-263 [**2116-6-18**] 11:25AM PT-13.4 PTT-31.1 INR(PT)-1.2* [**2116-6-18**] 11:25AM CALCIUM-8.1* PHOSPHATE-4.0 MAGNESIUM-1.8 [**2116-6-18**] 11:25AM ALT(SGPT)-21 AST(SGOT)-34 CK(CPK)-110 ALK PHOS-86 TOT BILI-0.3 [**2116-6-18**] 11:25AM GLUCOSE-25* UREA N-30* CREAT-4.7* SODIUM-141 POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-30 ANION GAP-15 [**2116-6-18**] 12:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-150 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2116-6-18**] 12:30PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 [**2116-6-18**] 05:22PM LACTATE-0.8 Studies: 1. LUE U/S: No evidence of left upper extremity DVT, in the limited study. Right subclavian DVT, extent unknown. If necessary for management, consider dedicated right upper extremity US. 2. [**6-18**] New edema. Left upper lung opacity is difficult to assess due to low lung volumes and may represent asymmetric edema, though a focus of infection cannot be excluded. Reassessment following diuresis is recommended. CT head [**2116-6-21**]: No intracranial hemorrhage or edema. Brief Hospital Course: This is a 66 year old male with obesity hypoventilation, possible COPD, afib, ESRD on HD, PVD with recent TMA ulcer, presents with confusion in the setting of hypoglycemia and hypotension. #. Altered mental status: The patient initally had a dramatic response to Narcan, likely due to accumulation due to renal dysfunction and standing morphine. His narcotics were initially held, however given his pain and decision to be CMO, he was placed on a morphine drip (see below). His hypoglycemia was initially treated with D10 which was also discontinued. #. ESRD: Previous HD on T/Th/Sa; did not have [**Month/Day/Year 2286**] since admission. Renal has seen the patient however [**Month/Day/Year 2286**] was discontinued after family meeting with patient in agreement (see below). #. Hypoglycemia: The patient was known to have episodes of hypoglycemia. This has been worked up before and no endogenous source has been found. The most likely scenario is that the patient has reduced insulin clearance without [**Month/Day/Year 2286**] and for this reason became hypoglycemic without continued glucose infusion. #. Goals of care: On transfer out of the ICU, the patient was alert though remained somewhat disoriented. With family, the issue was readdressed and the patient was clearly not interested in further [**Month/Day/Year 2286**]. He was focused on comfort and ideally would not want further interventions if they could not allow him to return to home. Due to his multiple medical issues, it is unlikely that he would have been able to leave a skilled nursing facility. The patient and family decided to defer [**Month/Day/Year 2286**] and discontinue the D10 drip. He was made CMO, placed on inpatient hospice, and passed at 21:50 on [**2116-6-26**]. Medications on Admission: Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Atrovent two puffs q 6hrs Q4H (every 4 hours) Clopidogrel 75 mg PO DAILY Omeprazole 20 mg PO DAILY (Daily). Prednisone 5 mg PO at bedtime. Simvastatin 10 mg PO DAILY Vitamin A 10,000 unit (1) Tablet PO once a day. Heparin (5000 Units) Injection TID Digoxin 125 mcg PO EVERY OTHER DAY Aspirin 325 mg PO DAILY (Daily). Cyanocobalamin 1000 mcg PO DAILY Docusate Sodium 100 mg PO BID Senna 8.6 mg PO BID Bisacodyl 10 mg PO DAILY (Daily) Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H Morphine 15 mg PO Q8H (every 8 hours) as needed for pain. Nephro-Vite 0.8 mg PO once a day. Metoprolol Tartrate 12.5 mg PO twice a day Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: -Renal failure Discharge Condition: NA Discharge Instructions: Mr. [**Known lastname **] was admitted for hypoglycemia, altered mental status, and renal failure. He was initially treated in the ICU where he responded to Narcan, a medicine that reverses the effect of opiates (pain medication). He was also found to have low blood sugar due to continued action of insulin. This is most likely because he was unable to remove insulin without [**Known lastname 2286**]. As a result, he was placed on a D10 (sugar) drip to maintain blood glucose. He and family have made the decision to discontinue [**Known lastname 2286**], and decided to pursue comfort only measures. Followup Instructions: NA [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**] Completed by:[**2116-6-27**]

[ "453.8", "995.91", "585.6", "427.31", "251.2", "038.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "39.95" ]

icd9pcs

[ [ [] ] ]

7143, 7152

4622, 4823

327, 357

7210, 7214

3297, 4599

7866, 7994

2736, 2786

7116, 7120

7173, 7189

6408, 7093

7238, 7843

2801, 2801

251, 289

385, 1654

2815, 3278

4838, 6382

1676, 2427

2443, 2720

14,627

111,466

12556

Discharge summary

report

Admission Date: [**2148-2-11**] Discharge Date: [**2148-3-7**] Date of Birth: [**2098-9-16**] Sex: F Service: HISTORY OF PRESENT ILLNESS: This is a 50-year-old female with a history of hypertension and increasing headache over six days who then developed some neck and back and lower extremity pain on approximately the sixth day. The headache was defined as diffuse, rated at 5/10 in intensity, and not very responsive to pain medication. She went to an outside hospital two days prior to admission where she was evaluated and felt to have symptoms consistent with migraine headache. A CT scan of the head was not obtained at that time. Neck films were obtained at that time but were normal per report and she was given naproxen and discharged home. At the time of admission to the [**Hospital6 256**], she stated that her headache awoke her from a sleep with increasing headache, as well as some nausea and vomiting on the morning of admission. There was no diplopia or visual changes. She did complain of mild neck pain. Denied any weakness and numbness or tingling. PREVIOUS MEDICAL HISTORY: Includes a history of hypertension and she is status post appendectomy as a 15 year old. ALLERGIES: She has no known drug allergies. CURRENT MEDICATIONS: Vasotec, Atenolol, Flexeril and Naprosyn. PHYSICAL EXAMINATION: She was afebrile. Vital signs: Blood pressure 157/86. Heart rate 85. Respiratory rate 17. 02 saturation 100% on room air. She was awake and in no acute distress. The neck showed bilateral bruises along the lateral aspects of the neck and shoulders, but was supple to motion. Chest was clear to percussion and auscultation. There were no carotid bruits. There was a 2/6 systolic ejection murmur but the heart was otherwise normal sinus rhythm. Abdominal exam was unremarkable. Extremity exam was unremarkable. Neurological exam showed mental status, the patient was awake, alert and oriented times three with fluent speech, normal naming of objects and normal repetition. She was drowsy with her eyes closed sporadically throughout the exam. Cranial nerves were intact. Muscles were normal bulk and tone with full strength 5/5 throughout. There was no drift and no asterixis and a sensory exam showed light touch to be intact throughout. Deep tendon reflexes were equal bilaterally. Toes appeared to be upgoing bilaterally and there were slightly clumsy dystonia for finger to nose and rapid alternating movements on the right. At the time of admission, her white blood cell count was 13.4, hematocrit 35.5, platelet count 285,000. Coags: PT was 11.8, PTT 21.9, INR 1.0. Chem-7 and urinalysis were negative and a head CT showed a subarachnoid hemorrhage with evidence to suggest an aneurysmal rupture. The patient was seen in consultation by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of Interventional Neuroradiology who felt that a diagnostic angiogram was indicated and the patient was taken to the Angiogram Suite for diagnostic angiogram. A aneurysm was seen at that time and the patient underwent a coiling of an anterior communicating artery aneurysm during the initial procedure. The patient tolerated the procedure well. She went to the Neurological Intensive Care Unit for recovery in stable condition. On the morning following the angiogram, the groin sheath was removed and tolerated well. A vent drain was placed at the time of the angiogram and the vent drain drained clear cerebral spinal fluid for several days. On attempts to wean the patient from the vent drain, her mental status would deteriorate, therefore, the vent drain was continued for several days. On [**2-29**], cerebrospinal fluid cultures from [**2-27**], grew out one colony of gram positive rods in one plate and due to this, the patient was begun on vancomycin and cephalexin for meningitis and seen in consultation by the Infectious Disease Service. The patient tolerated the remainder of her hospitalization. The drain was slowly elevated as the patient could tolerate as clinically and the drain was clamped on the [**3-4**] and removed on the [**3-5**]. An lumbar puncture was done on the [**3-6**] to measure opening pressure and the opening pressure was 12 (closing pressure was 10). The patient tolerated the procedure well and showed no further mental status changes throughout the remainder of the hospitalization. She was subsequently discharged home on the morning of the [**2148-3-7**] with follow-up to see Dr. [**Last Name (STitle) 1132**] in the Clinic in approximately two to three weeks time. It is important to note, that the patient was followed throughout her hospitalization by the Psychiatry Service for history of anxiety and for dealing with her recent illness. CONDITION ON DISCHARGE: Stable and improved. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Name8 (MD) 5474**] MEDQUIST36 D: [**2148-6-9**] 14:05 T: [**2148-6-9**] 14:05 JOB#: [**Job Number 38882**]

[ "780.6", "430", "401.9", "112.2", "435.8", "331.4", "300.00" ]

icd9cm

[ [ [] ] ]

[ "39.79", "03.31", "02.2", "38.91", "88.41" ]

icd9pcs

[ [ [] ] ]

1346, 4778

1280, 1323

155, 1258

4803, 5069

81,491

198,528

52051

Discharge summary

report

Admission Date: [**2164-10-2**] Discharge Date: [**2164-10-11**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2610**] Chief Complaint: Respiratory Distress Major Surgical or Invasive Procedure: Intubation and Mechanical ventilation History of Present Illness: This is a [**Age over 90 **] year-old (by record though actually 86 years-old per brother) male with history of Afib, HTN, CVA's and severe dememntia (nonverbal at baseline) who presented with respiratory failure. Per nursing home documentation the patient was short of breath on the morning of admission AM and received azithromycin and and furosemide at his facility. In the evening he looked worse and was noted to be acutesly short of breath so he was taken by EMS to [**Hospital1 18**]. There he was in some extremis with mottled skin, a heart rate in the 180's in and hypoxia. He was intubated almost immediately for hypoxia and then had a central venous line placed after becoming hypotensive. HR improved to 80's with a single dose of diltiazem. He received 2L of fluid, vancomycin, levofloxacin, and metronidazole after a CXR showed multifocal pneumonia. Conversation with the brother and next of kln revealed he wished the patient to be full code. The patient was transferred to the MICU for further treatment, vitals prior to tx were T: 101.2 P 96 rr 20 bp 109/72 sa 02 100%. On arrival to MICU pt intubated and nonverbal at baseline so ROS not obtainable. Moves a small amount on own. Past Medical History: -Atrial Fibrillation -R MCA embolic stroke [**8-22**] -Cerebellar hemorrhage s/p craniotomy [**2126**] -Alzheimers dementia and nonverbal / PEG fed since stroke in [**2161**] -Colon CA stage III s/p resection -Coronary Artery Dementia -Hypertension -Mitral Regurg -Left Ventricular Hypertropy -Cervical radiculopathy/myelopathy -T12 compression fracture -Gastroesophageal Reflux -Liver hemangioma -Chronic Kidney Disease -BPH s/p TURP -History of bowel obstruction -History of multiple falls -History of ETOH abuse -Remote History of Pulmonary TB ([**2103**]'s) Social History: Immigrated from [**Country 532**] in [**2134**], at baseline speaks & understands limited English - translator needed. Positive h/o alcohol abuse, none for >1 yr. He does not smoke. Previously employed as a photographer. Brother states patient is a Holocaust survivor. Has lived in facility >1 yr. Nonverbal and fed by PEG. Family History: Both parents died in [**2095**] in the [**Location (un) 25508**] ghetto. Physical Exam: VS: 97.3, BP 106/47, HR 106, RR 22, O2 99%(AC 500, 20, 15/5, 80% FiO2) General Appearance: Thin, chronically ill appearing Eyes / Conjunctiva: Pupils dilated Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal tube, OG tube Lymphatic: Cervical WNL Cardiovascular: Tachycardic, normal S1 and S2 Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: Bilateral rhonchi L>R Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent Skin: Warm Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds to: Verbal stimuli, Movement: Purposeful, Tone: Not assessed Pertinent Results: =================== LABORATORY RESULTS =================== Admission labs: WBC-19.1* RBC-4.87 Hgb-12.1* Hct-40.6 MCV-83 RDW-16.0* Plt Ct-252 ---Neuts-89.7* Lymphs-5.4* Monos-3.8 Eos-0.6 Baso-0.5 PT-15.6* PTT-28.3 INR(PT)-1.4* Glucose-138* UreaN-40* Creat-1.4* Na-148* K-5.3* Cl-106 HCO3-33* ALT-17 AST-28 LD(LDH)-229 AlkPhos-64 TotBili-0.5 cTropnT-0.01 proBNP-8748* Calcium-8.8 Phos-3.8 Mg-2.4, ABG: pO2-102 pCO2-76* pH-7.26* calTCO2-36* lactate 2.8* Urine Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.007 Blood-NEG Nitrite-NEG Protein-75 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG RBC-0-2 WBC-0-2 Bacteri-RARE Yeast-NONE Epi-0-2 Other significant lab results: Pleural fluid WBC-1100* RBC-[**Numeric Identifier **]* Polys-36* Bands-0 Lymphs-21* Monos-41* Eos-2* TotProt-2.0 Glucose-136 Creat-1.2 LD(LDH)-94 Albumin-1.4 Polys-93* Lymphs-0 Monos-0 Macro-7* Cultures: No growth ============= MICROBIOLOGY ============= [**10-2**] BCx *2: Negative [**10-2**] BAL: RESPIRATORY CULTURE: ~3000/ML Commensal Respiratory Flora. LEGIONELLA CULTURE (Final [**2164-10-9**]): NO LEGIONELLA ISOLATED. NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2164-10-3**]): NO AFB SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. [**10-2**] RSV Screen/culture: negative [**10-2**] Bronchial washings: RESPIRATORY CULTURE: ~4000/ML Commensal Respiratory Flora. LEGIONELLA CULTURE (Final [**2164-10-9**]): NO LEGIONELLA ISOLATED. NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2164-10-3**]): NO AFB SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. [**10-3**] Sputum GS/culture: >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2164-10-5**]): SPARSE GROWTH Commensal Respiratory Flora. =========================== RADIOLOGY & OTHER STUDIES =========================== [**10-1**] ECG: Atrial fibrillation with rapid ventricular response. Consider left ventricular hypertrophy. ST-T wave abnormalities. No previous tracing available for comparison. Clinical correlation is suggested. [**10-2**] CHEST RADIOGRAPH: IMPRESSION- 1. Mild cardiomegaly. 2. Diffuse opacities throughout both lungs, worst in the perihilar region and left base, concerning for multifocal pneumonia. Effusion is also likely present on the left. 3. Multiple calcified pulmonary nodules. 4. Adequate positioning of endotracheal and nasogastric tube, though the ETT cuff is overinflated. [**10-2**] CT Chest: IMPRESSION- 1. Dense consolidation of the left lower lobe with associated volume loss, and multiple additional scattered consolidative and ground-glass opacities throughout the lungs bilaterally are most compatible with multifocal pneumonia. Massive aspiration could also have this appearance. 2. Cardiomegaly, bilateral effusions, and subtle septal thickening suggest mild volume overload. 3. Aortic valve and coronary calcifications are noted. 4. Attenuated caliber of the central airways, without obstruction, compatible with bronchomalacia. Mosaic attenuation of the lung parenchyma suggests a degree of airtrapping, which may also reflect this process. 5. Hyperinflation of the endotracheal tube cuff, with a slightly low position of the endotracheal tube. 6. Nasogastric tube extends to the stomach, though should be advanced for optimal positioning. 7. Distention of the gallbladder is noted in the upper abdomen. Clinically correlate, and consider right upper quadrant ultrasound for further evaluation if indicated. [**10-2**] CT Head: IMPRESSION- 1. No evidence of acute intracranial abnormalities. MRI would be more sensitive for an acute infarction or global hypoxic injury. 2. Extensive cystic encephalomalacia in the right MCA territory, likely related to prior infarction. 3. Extensive cystic encephalomalacia in the left cerebellar hemisphere and bilateral mid to inferior vermis, with partially visualized suboccipital postsurgical changes, which could be related to prior hemorrhage or infarct. [**10-2**] TTE: The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is moderate global left ventricular hypokinesis (LVEF = 30 %). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is dilated with depressed free wall contractility. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-17**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. [**10-8**] CHEST RADIOGRAPH: IMPRESSION: Esophageal tube has been removed. Mild pulmonary edema, worse in the right lung and moderate right pleural effusion have decreased. Moderate cardiomegaly stable. Right internal jugular line ends in the mid SVC. No pneumothorax. Brief Hospital Course: [**Age over 90 **] y.o. male with history of cerebrovascular disease and severe dementia presenting dyspnea and found to have extensive pulmonary infiltrates and septic physiology. 1) Hypoxic respiratory failure: The patient presented with acute hypoxia requiring intubation. At the time of presentation patient was suffering from multifocal pneumonia, acute exacerbation of chronic systolic CHF likely precipitated by RVR, and large effusion with compressive atelectasis; all of these processes likely contributed to hypoxic respiratory failure at time of presentation. The patient underwent broad spectrum treatment for pneumonia, thoracentesis, and once hemodynamically stable was diuresed allowing extubation on [**2164-10-7**]. The patient was extubated without incident and weaned to progressively lower amounts of supplementary oxygen. He is discharged on 2 liters of O2 by nasal canula and O2 sats in the high 90s. 2) Shock: The patient presented in shock with a somewhat mixed picture suggestive of septic but also potentially an element of cardiogenic shock. Blood cultures remained negative though he did have multifocal pneumonia. His echocardiogram revealed diminshed ejection fraction of 30% but likely had further depressed EF on admission due to RVR and decreased ventricular filling time. He initially intermittently required norepeinephrine but this was stopped on [**2164-10-5**] and pressors were not restarted. Home lisinopril for blood pressure was held on transfer to the floor in the setting of elevated creatinine and was stable with systolics from 110s-120s. 3) Multifocal Pneumonia: The patient was started on vancomycin, cefepime, metronidazole, and azithromycin on presentation for broad empiric coverage of health care associated pneumonia (as he came from a facility). Unfortunately bronchoalveolar lavage cultures, sputum, and blood cultures all failed ot reveal an organism. The patient received five days of azithromycin and a total of eight days of vancomycin, cefepime, and metronidazole for empiric coverage of pneumonia. He remained afebrile and initial leukocytosis of 19 improved. His respiratory support requirements improved and he was extubated. He should have a follow up chest radiograph in [**3-20**] wks to document resolution of his infiltrate. 4) Acute on Chronic Systolic CHF: The patient presented with elevated BNP and signs of volume overload. Further, when his pleural effusion was tapped it appeared transudative and cultures remained negative consistent with an effusion due to heart failure. He had an echocardiogram that revealed globally diminished contractility but no wall motion abnormalities and troponin negative making acute ischemia unlikely. Patient's exacerbation likely due to RVR as well as possible hypokinesis in the context of systemic infection/ sepsis. After hemodynamic instability resolved the patient was diuresed with net ICU fluid balance of approximately -500 ml of fluid. On discharge, CXR showed improvement in fluid status and a decrease in his lower extremity edema. Prior to admission, pt was on lasix 80 mg daily, which we stopped on discharge because he appeared to be euvolemic both by exam and on chest xray and will follow up to determine further need for lasix as outpatient. 5) Afib with RVR: The patient had intermittent spells of RVR in the ICU that appeared to negatively affect his hemodynamics. His beta blocker was held due to hypotension so he was amiodarone loaded to try and achieve better rate control with good effect. After hypotension resolved his beta blocker was restarted with good effect. He has 5 more days of amiodarone loading with 400 mg [**Hospital1 **] and should f/u with a cardiologist to determine continued need for amiodarone. 6) Hypertension: As sepsis resolved the patient become somewhat hypertensive so after being restarted on his home metoprolol he was also started on captopril, which was then switched to lisinopril for easier dosing with good control of blood pressure. Lisinopril was stopped on transfer to the floor in the setting of elevated creatinine, with systolic BP 110s-120s. 7) Goals of Care: The [**Hospital 228**] health care proxy is his brother and next of [**First Name8 (NamePattern2) **] [**Name (NI) **] [**Name (NI) 107750**]. Given the patient is nonverbal and demented at baseline [**First Name5 (NamePattern1) **] [**Known lastname 107750**] makes all health care decisions and initially insisted the patient remain full code. This was despite repeatd overtures by the health care team that given the patient's underlying morbidity and poor baseline function his odds of surviving a resusciation or recovering to even his baseline poor functional were poor. This was also discussed with the proxy's daughter and [**Name2 (NI) 802**] (both nieces of the patient as well) who were understanding of the patient's poor prognosis and very insistent they did not want him to suffer. After discussion of all three of these parties the patient's brother agreed to a code status of DNR/DNI and agreed he should not be reintubated if he failed extubation. Medications on Admission: 1. Aspirin 325 mg Tablet [**Name2 (NI) **]: One (1) Tablet PO DAILY (Daily). 2. Brimonidine 0.15 % Drops [**Name2 (NI) **]: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 3. Latanoprost 0.005 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic HS (at bedtime). 4. Calcitrate-Vitamin D 315-200 mg-unit Tablet [**Hospital1 **]: One (1) Tablet PO twice a day. 5. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed. 6. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Ten (10) mL PO BID (2 times a day) as needed for constipation. 7. Amiodarone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day: in the morning. 8. Amiodarone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day for 10 days: in the evening. 9. Omeprazole 20 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1) Tablet, Delayed Release (E.C.) PO once a day. 10. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: [**10-3**] mL PO Q6H (every 6 hours) as needed. Discharge Medications: 1. amiodarone 200 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO BID (2 times a day): Please take 400mg twice daily for 5 additional days until [**10-16**], then decrease your dose to 200mg daily until followup with a cardiologist. 2. docusate sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: One (1) PO BID (2 times a day). 3. ipratropium bromide 0.02 % Solution [**Month/Day (2) **]: One (1) Inhalation every four (4) hours as needed for SOB, Wheezing. 4. senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. metoprolol tartrate 50 mg Tablet [**Month/Day (2) **]: 2.5 Tablets PO TID (3 times a day). 6. nystatin 100,000 unit/mL Suspension [**Month/Day (2) **]: Five (5) ML PO QID (4 times a day) as needed for oral thrush for 1 months: Please discontinue when oral thrush resolves. 7. mirtazapine 15 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO HS (at bedtime). 8. heparin (porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1) Injection TID (3 times a day). 9. brimonidine 0.15 % Drops [**Month/Day (2) **]: [**12-17**] Ophthalmic twice a day. 10. latanoprost 0.005 % Drops [**Month/Day (2) **]: [**12-17**] Ophthalmic at bedtime. 11. bisacodyl 10 mg Suppository [**Month/Day (2) **]: [**12-17**] Rectal qM,W,F. 12. acetaminophen 650 mg Suppository [**Month/Day (2) **]: One (1) Rectal every four (4) hours as needed for pain. 13. aspirin 325 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day. 14. cholecalciferol (vitamin D3) 1,000 unit Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day. 15. Tylenol 325 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO every four (4) hours as needed for pain: through NG tube. 16. brimonidine 0.2 % Drops [**Month/Day (2) **]: One (1) Ophthalmic twice a day. 17. Ativan 0.5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO twice a day as needed. 18. Ambien 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO at bedtime. 19. sorbitol 70 % Solution [**Month/Day (2) **]: Thirty (30) ml Miscellaneous once a day. 20. magnesium citrate Solution [**Month/Day (2) **]: One [**Age over 90 1230**]y (150) ml PO qM,W,F. 21. Maalox Maximum Strength 400-400-40 mg/5 mL Suspension [**Age over 90 **]: One (1) PO every six (6) hours as needed. 22. albuterol sulfate 2.5 mg/0.5 mL Solution for Nebulization [**Age over 90 **]: One (1) Inhalation every four (4) hours as needed for shortness of breath or wheezing. 23. albuterol sulfate 0.63 mg/3 mL Solution for Nebulization [**Age over 90 **]: One (1) Inhalation three times a day. 24. ipratropium bromide 0.02 % Solution [**Age over 90 **]: 0.5 mg Inhalation three times a day. 25. omeprazole (bulk) 100 % Powder [**Age over 90 **]: Twenty (20) Miscellaneous once a day. 26. Levsin/SL 0.125 mg Tablet, Sublingual [**Age over 90 **]: Two (2) Sublingual every four (4) hours as needed. 27. scopolamine base 1.5 mg Patch 72 hr [**Age over 90 **]: One (1) Transdermal every seventy-two (72) hours. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - LTC Discharge Diagnosis: pneumonia congestive heart failure Discharge Condition: Mental Status: Nonverbal, noncommunicative Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted to the hospital for respiratory failure which was likely caused by pneumonia. You also accumulated too much fluid in your body due to your heart failure. In the intensive care unit, you were supported by a breathing tube until your breathing improved with antibiotics and the removal of fluid with medications. You developed rapid heart rates in the hospital and you were started on two medications called metoprolol and amiodarone for your atrial fibrillation. It is very important to follow up with a cardiologist as an outpatient to adjust your dose of this medication. The following changes were made to your medications: - Amiodarone was STARTED. Please take 400mg twice daily for 5 additional days until [**10-16**], then decrease your dose to 200mg daily until followup with a cardiologist. - Metoprolol was STARTED - Stop taking lisinopril - Furosemide was STOPPED for now, as adequate fluid was removed in the hospital. Please discuss re-starting this medication with your primary care physician. Followup Instructions: Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 250**]) within 1-2 weeks after you are discharged from [**Hospital 100**] Rehab. Completed by:[**2164-10-11**]

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26025

Discharge summary

report

Admission Date: [**2179-5-21**] Discharge Date: [**2179-5-26**] Date of Birth: [**2111-10-10**] Sex: M Service: CARDIOTHORACIC Allergies: Statins-Hmg-Coa Reductase Inhibitors Attending:[**First Name3 (LF) 165**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: [**2179-5-21**] Cardiac catheterization with intra aortic balloon pump placement [**2179-5-21**] Urgent Coronary artery bypass graft x3 (left internal mammary artery > left anterior descending, saphenous vein graft > obtuse marginal, saphenous vein graft > right coronary artery) History of Present Illness: 67 year old male with known coronary artery disease s/p stents to the RCA and OM in [**2172**], an active smoker, and GERD. He presented to his cardiologist's office for an episodic visit due to exertional chest burning that started few days prior to office visit. His pain occurred with mowing his lawn or working in his yard. He presented to [**Hospital1 18**] for outpatient catheterization that revealed significant left main disease with active chest pain requiring IABP insertion. Cardiac surgery was consulted and he was taken to the operating room emergently from the catheterization lab due to chest pain. Past Medical History: Coronary artery disease Non ST elevation myocardial infarction [**2172**] Chronic obstructive pulmonary disease Gastroesophageal reflux disease RCA and OM stents [**2172**] Abdominal surgery [**07**] years ago Social History: He lives with his spouse [**Name (NI) **] is a retired truck driver He smokes [**6-13**] cigarettes a day and drinks a couple beers a day. Family History: non contributory Physical Exam: Pulse: 83 Resp: 12 O2 sat: 100% B/P Right: 136/82 Left: 130/72 Height: 5'7" Weight: 71.7 kg General: On cath lab table with chest pain no respiratory distress Skin: Dry [x] intact [x] unable to exam posterior skin HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] anteriorly Heart: RRR [x] Irregular [] Murmur - none Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema none Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: IABP Left: unable to access DP Right: +1 Left: +1 PT [**Name (NI) 167**]: +1 Left: +1 Radial Right: +2 Left: +2 Carotid Bruit no bruit bilateral Pertinent Results: Date/Time: [**2179-5-21**] Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1510**], MD Left Ventricle - Ejection Fraction: 40% to 45% >= 55% Aorta - Ascending: 3.3 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 4 mm Hg < 20 mm Hg Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. Left-to-right shunt across the interatrial septum at rest. Small secundum ASD. LEFT VENTRICLE: Mild regional LV systolic dysfunction. Mildly depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Simple atheroma in aortic arch. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Mild [1+] TR. Conclusions Prebypass A left-to-right shunt across the interatrial septum is seen at rest. A small secundum atrial septal defect is present. There is mild regional left ventricular systolic dysfunction with hypokinesia of the apical and mid portions of the inferior and anteroseptal walls. Overall left ventricular systolic function is mildly depressed (LVEF= 40- 45% %). Right ventricular chamber size and free wall motion are normal. 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. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Post bypass Patient is AV paced and receiving an infusion of phenylpephrine. Biventricular systolic function is unchanged. Aorta is intact post decannulation. [**2179-5-26**] 06:15AM BLOOD WBC-10.4 RBC-4.04* Hgb-12.4* Hct-36.9* MCV-91 MCH-30.7 MCHC-33.6 RDW-12.8 Plt Ct-169 [**2179-5-21**] 09:15AM BLOOD WBC-7.2 RBC-4.55* Hgb-14.2 Hct-41.4 MCV-91 MCH-31.3 MCHC-34.3 RDW-13.1 Plt Ct-163 [**2179-5-26**] 06:15AM BLOOD Plt Ct-169 [**2179-5-22**] 04:13AM BLOOD PT-12.8 PTT-26.3 INR(PT)-1.1 [**2179-5-21**] 09:15AM BLOOD Plt Ct-163 [**2179-5-21**] 09:15AM BLOOD PT-12.7 PTT-28.6 INR(PT)-1.1 [**2179-5-26**] 06:15AM BLOOD Glucose-107* UreaN-16 Creat-0.9 Na-137 K-4.3 Cl-97 HCO3-32 AnGap-12 [**2179-5-21**] 09:15AM BLOOD Glucose-119* UreaN-13 Creat-0.8 Na-137 K-4.3 Cl-106 HCO3-24 AnGap-11 [**2179-5-21**] 09:15AM BLOOD ALT-15 AST-16 CK(CPK)-79 AlkPhos-54 TotBili-0.5 [**2179-5-21**] 09:15AM BLOOD CK-MB-4 cTropnT-<0.01 [**2179-5-26**] 06:15AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.0 [**2179-5-21**] 09:15AM BLOOD Albumin-3.8 [**2179-5-23**] 06:35AM BLOOD Mg-2.2 [**2179-5-21**] 09:15AM BLOOD %HbA1c-5.4 eAG-108 COMPARISON: Chest radiographs dating back to [**2179-5-21**], most recent from [**2179-5-23**]. PA AND LATERAL CHEST RADIOGRAPHS: New ill-defined opacities are identified in the lung bases, left greater than right, findings suggestive of subsegmental atelectasis. There are small bilateral pleural effusions. The upper lung zones appear clear. There is no pneumothorax, vascular congestion, or overt pulmonary edema. Cardiomediastinal and hilar contours are within normal limits. Median sternotomy wires are intact. On the lateral projection, there are small rounded lucencies in the inferior retrosternal region, likely residual post-operative air. The clicking sound on physical examine may actually be from mild crepitus due to residual air. IMPRESSION: 1. Bibasilar opacities, left greater than right, probable atelectasis. 2. Small bilateral pleural effusions. 3. Intact median sternotomy wires. 4. Retrosternal foci of air secondary to recent surgery. Brief Hospital Course: On [**5-21**] Mr. [**Known lastname 64660**] [**Last Name (Titles) 1834**] a cardiac catheterization which revealed muti-vessel disease including significant left main stenosis. He was having active chest pain during the procedure so an intra-aortic balloon pump was placed and he was brought urgently to the operating room for a coronary artery bypass grafting. Please see the operative note for details. He received cefazolin for perioperative antibiotics and was transferred to the intensive care unit for post operative manamgent. That evening he was weaned from sedation, awoke neurologically intact and was extubated without complications. Post operative day one his intra aortic balloon pump was removed and he was started on betablockers and diuretics. Later that day he was transferred to the floor. Physical therapy worked with him on strength and mobility. His chest tubes and epicardial wires were removed per protocol. He was started on wellbutrin for smoking cessation and provide education, and currently denied any urges to smoke. He continued on inhalers for pulmonary and mucinex was added to help with mucous clearance. On post operative day three he developed a sternal click with no drainage, chest xray revealed wires intact. He was monitored and repeat Chest Xray [**5-26**] wires remained intact. He was ready for discharge home on post operative day five with services. Medications on Admission: TIOTROPIUM BROMIDE 18 mcg Capsule, w/Inhalation Device - 1 (One) puff inhaled daily ASPIRIN 81 mg daily, OMEGA-3 FATTY ACIDS-FISH OIL 360 mg-1,200 mg Capsule - 3 Capsule(s) daily OMEPRAZOLE 20 mg daily Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). Disp:*15 Tablet(s)* Refills:*0* 4. guaifenesin 600 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO BID () for 5 days. Disp:*20 Tablet Extended Release(s)* Refills:*0* 5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*qs Cap(s)* Refills:*0* 6. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. Disp:*qs qs* Refills:*0* 8. bupropion HCl 150 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO twice a day: start twice a day [**5-27**]. Disp:*60 Tablet Extended Release(s)* Refills:*0* 9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 10. potassium chloride 10 mEq Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day for 7 days. Disp:*7 Tablet Extended Release(s)* Refills:*0* 11. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen (17) gram PO DAILY (Daily). Disp:*30 gram* Refills:*0* 12. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: 1.5 Tablet Extended Release 24 hrs PO DAILY (Daily). Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*0* 13. acetaminophen-codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA, [**Hospital1 1559**] Discharge Diagnosis: Coronary artery disease s/p CABG Chronic obstructive pulmonary disease Gastric esophageal reflux disease Tobacco abuse Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Codiene as needed Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage Edema none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Smoking cessation: it has been discussed with you that you should quit smoking and you have been started on Wellbutrin, please call PCP if you find this not effective for further options to assist with quiting smoking **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 Wound check in Dr [**First Name (STitle) **] Clinic - to evaluate sternum [**5-31**] at 2:45 pm [**Telephone/Fax (1) 170**] Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**6-21**] at 1pm Cardiologist:Dr. [**Last Name (STitle) 1911**] [**Telephone/Fax (1) 11767**] on [**6-14**] 10am Liver function test in 1 month with Dr [**Last Name (STitle) 1911**] due to statin Please call to schedule appointments with your Primary Care Dr.[**Last Name (STitle) 17029**] [**Telephone/Fax (1) 17030**] in [**3-9**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2179-5-26**]

[ "412", "V45.82", "996.72", "414.01", "272.0", "305.1", "745.5", "411.1", "E879.8", "401.9", "V65.49", "496", "530.81" ]

icd9cm

[ [ [] ] ]

[ "36.15", "38.91", "88.72", "88.56", "39.61", "36.12", "37.61" ]

icd9pcs

[ [ [] ] ]

9876, 9949

6307, 7716

314, 597

10112, 10339

2461, 6284

11398, 12267

1651, 1669

7969, 9853

9970, 10091

7742, 7946

10363, 11375

1684, 2442

264, 276

625, 1244

1266, 1477

1493, 1635

70,563

186,080

7294

Discharge summary

report

Admission Date: [**2116-7-3**] Discharge Date: [**2116-7-9**] Date of Birth: [**2067-7-28**] Sex: M Service: MEDICINE Allergies: Bactrim Attending:[**First Name3 (LF) 1936**] Chief Complaint: fevers, malaise, cough Major Surgical or Invasive Procedure: R IJ placement and removal Rash-biopsy [**7-9**] History of Present Illness: 48 year-old [**Country **] Rican male with HIV (dx '[**01**], last CD4 370 in [**3-/2116**], VL ~9000) self-discontinued antiretrovirals (b/c he felt depressed on them), who was in his USOH until around 3 days ago when he began to experience drenching night sweats, low-grade fevers, chills and dry non-productive cough. He felt the night sweats were occuring because it was hot outside, so did not seek medical attention. He had URI Sx a few weeks ago and was told by a friend to see a doctor at the time but he declined. He also endorses losing 20 lbs in the past month or so, but believes this has to do with moving from the 2nd to the [**Location (un) **] of his building. Additionally, he reports nocturia, frequent urination that began the night prior to admission and dysuria at the end of his stream, which is new. Denies urethral/penile discharge although has hx STIs in the past as continues unprotected intercourse w/ male partners. Denies nausea, vomiting, decreased PO intake, bloody stools, chest pain and hemoptysis. He presented to the ED due to worsening fever, dizziness, difficulty breathing, dry cough and upper back pain. . In the ED, initial VS: 99.5 82/51 132 20 100% RA- CXR showed a dense opacity in the right apex. Worsening O2 sats in ED, led him to be on 4L NC prior to transfer to [**Hospital Unit Name 153**]. He was given 2L NS, Vanc/ Zosyn/ Levo for HAP, and started on levophed due to SBPs in the 80s. CVL was placed and he was sent to the [**Hospital Unit Name 153**] for further mgt. Past Medical History: -HIV diagnosed in [**2101**]; no ARVs for many years. Sees Dr. [**Last Name (STitle) 724**] [**Name (STitle) 26955**] b/l MRSA + buttock abscesses -Right epididymo-orchitis w/ assoc right pyocele Social History: Born in [**Male First Name (un) 1056**], moved to the US 27 yrs ago. Sexually active with males, contracted HIV in [**2101**] from unprotected intercourse. Has a HIV+ boyfriend with whom he is currently sexually active (without protection), who may not be monogamous. Denies tobacco use, occasional EtOH ([**4-16**] drinks/wknd) and marijuana use. Last crystal meth use 3 yrs ago. No IVDU. Used to work in a hotel. Never been in prison, never been homeless. Last PPD negative in [**2116-3-16**] per patient w/ Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] at [**Location (un) 12091**]. Family History: no h/o HIV Physical Exam: VS: afebrile, HR 103 BP 113/64 SaO2 99% 4L NC GEN: thin chronically-ill appearing Hispanic M in mild respiratory distress, on 4L NC, diaphoretic, warm, flushed HEENT: EOMI, PERRLA, no scleral icterus LUNGS: CTAB/L no wheeze B/L CV: tachycardic, nl S1, S2 no murmurs appreciated ABD: +BS soft, non-tender, non-distended EXT: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema NEURO: alert, oriented, limited medical knowledge, no focal neurologic deficits . on discharge Vitals: 97.7 99.9 98/59 93 18 97%RA Pain: denies Access: PIV Gen: nad HEENT: no thrush, mmm CV: RRR, no m Resp: CTAB, no crackles, no wheezing Abd; soft, nontender, +BS Ext; no edema Neuro: A&OX3, nonfocal Skin: circular erythematous patches RLE>LLE are now hyperpigmented, no blister. L forearm with well demarkated erythema improved psych: appropriate . Pertinent Results: wbc 32-->8ss hgb [**12-25**] stable plt wnl . BUN/creat 13/0.7 (1.6 on [**7-3**]) . LDH 1193-->227 . AST/ALT 540/392->344/252 (fluctuating levels), new since [**12-22**] alk phos 108->199 t bili 1.4 albumin 2.7 . INR 1.5->1.1 . B2 glucan [**7-4**] pending . sputum cx [**7-5**] >10epis . AFB [**7-5**] negative poor quality [**7-6**] negative poor quality [**7-7**] negative . Cath tip negative . UA neg, Ucx neg . RPR NR Hep C Ab postiive and VL 899K HCV genotype pending Hep B sAg and VL negative monospot negative crypto ag neg hep A neg Urine legionella neg blood cx X2 [**7-3**] NTD . . Imaging/results: CXR [**7-3**] IMPRESSION: Dense opacity in the right apex. Underlying pulmonary mass is favored, although infectious consolidation is also considered in light of clinical symptoms. Given the apical location, tuberculosis must be excluded and appropriate precautions taken. CT scan is recommended for further characterization. . CXR [**7-4**] Pa/Lat The infiltrate in the right upper lung is less pronounced, but somewhat more spread suggesting that some reexpansion has occurred. Air bronchograms can still be seen. Atelectasis is present at the left base. The rounded shadow overlying the left lower lobe is considered to be a nipple shadow. Small bilateral effusions may be present. . RUQ US 1. No evidence for biliary ductal dilatation. Gallbladder collapsed, thus excluding acute cholecystitis. 2. 3-cm vascular lesion with apparent large feeding vessel from right portal vein, and large draining vessel emptying into IVC. Findings consistent with portosystemic shunt, possibly congenital if the patient has not had prior procedure of the liver. Dynamic study is recommended for further assessment, such as multiphasic CT or MRI. . . Brief Hospital Course: 48 year old man with uncontrolled HIV (CD4 370 in [**3-/2116**], VL ~9000) off ARVs admitted [**7-3**] with fevers, sweats, cough X 3days. Was found to have RUL PNA in ER, febrile, hypoxic, hypotensive. Started on broad Abx with Vanc/Ctx/Azithro. Was hypotensive in ER and initially admitted to [**Hospital Unit Name 153**]. Improved with broad IV Abx over next couple days. Transfered to floor on [**7-5**]. Wbc improved from 32-->8 on discharge, pt was afebrile for many days, blood cx all negative, no good sputum sample sent. Was changed to Levo only on [**7-7**] and completed total 7days of Antibiotics. Given RUL distribution, radiology felt he needed to be ruled out for TB, had AFB smears X3 done (poor quality), however ID felt given acute history, recent negative PPD and no new exposure, this was very unlikely so respiratory isolation stopped. He did well from this perspective. We did not check CD4 count or viral load in setting of acute infection. We have arranged follow up with Dr. [**Last Name (STitle) 724**], who follows this patient at [**Hospital1 **]. . However, he was found to have new transaminitis (200-400s AST, ALT) since [**12-22**]. NOt on any meds at home. He endorsed a hisotry of significant daily etoh abuse but would have expected LFTs to come down after several days of hospitalization. Same thing with shock liver (and would have expected more severe elevation). He was ruled out for HAV and EBV. He has a h/o clearing Hep B and his hep B sAg was negative. He had a negative hep C in [**6-20**] but repeat hep C here was POSITIVE and VL high reflecting likely acute hep C (pt later admitted to IVDU). His liver function was otherwise okay. HCV genotype pending. Dr. [**Last Name (STitle) 724**] will see him as outpt to discuss treatment of both HIV and Hep C. Of note, he had circular erythematous pruritic nonpainful nonblistering rash develop in his LE after admisison. Initially patient and MICU felt this was secondary to the one dose of bactrim he reiceved (now listed as an allergy), however, ID did not feel this was a typical drug rash. We considered secondary sphyllis in setting of transamnitis and rash, but RPR negative. Later, when his test revealed positive HCV, they wanted to r/o hep C related rash. Derm was consulted and they performed biopsy of this rash on the day of discharge [**7-9**]. They will contact patient with results and appropriate follow up. . Of note, in the work up of his transaminitis, he had a RUQ US which showed RUQ with 3-cm vascular lesion with apparent large feeding vessel from right portal vein, and large draining vessel emptying into IVC->consistent with portosystemic shunt, possibly congenital if the patient has not had prior procedure of the liver. Unlikey this is causing acute elevation in LFTs as pt likely has had this for long time. We reccommend a dynamic study is recommended for further assessment, such as multiphasic CT or MRI Medications on Admission: (self discontinued anti-HIV medications) terbinafine Discharge Medications: 1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: RUL pneumonia Acute Hep C Untreated HIV Rash in legs-unclear etiology (for now listed as bactrim allergy but not clear)-biopsy done Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: you were admitted with fevers, cough and found to have pneumonia. you improved with 7 days of antibiotics. Your liver tests were elevated. this is because of your alcohol use. you were also found to have new hepatitis C infection. These two things together can be very very dangerous for your liver. Stop drinking! please see Dr. [**Last Name (STitle) 724**] on [**7-16**] to discuss treatment for your HIV and Hepatitis C. You had a rash on your legs that we were not sure about. Dermatology saw you before you left hospital and biopsied. they will call you with hte results of this biopsy and for follow up. Please keep this area clean. Please discuss getting MRI or your liver with Dr. [**Last Name (STitle) 4888**] Followup Instructions: Appointment When: THURSDAY, [**2117-7-16**] AM Where: [**Hospital3 26956**], [**Hospital1 26957**], [**Location (un) 669**], [**Numeric Identifier 18406**] With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] ([**Telephone/Fax (1) 9256**]

[ "790.4", "486", "V08", "782.1", "070.51" ]

icd9cm

[ [ [] ] ]

[ "38.93", "86.11" ]

icd9pcs

[ [ [] ] ]

8675, 8681

5422, 8354

289, 340

8857, 8857

3646, 5399

9753, 10021

2754, 2766

8457, 8652

8702, 8836

8380, 8434

9008, 9730

2781, 3627

227, 251

368, 1889

8872, 8984

1911, 2108

2124, 2738

6,954

124,167

48625

Discharge summary

report

Admission Date: [**2117-7-10**] Discharge Date: [**2117-7-13**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 21990**] Chief Complaint: Blood in diaper Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] yr old female with past medical hx of bladder cancer, rectal cancer s/p resection and colostomy and B12 deficiency who was sent to ED for evaluation after found to have 5-10cc of blood in her diaper. In [**Name (NI) **], pt complained of nausea and vomited x 1, coffee ground emesis. NG lavage done after the emesis and was negative. She was noted to be tachycardic to the 130s but BP stable. A hct was 32 (hct on [**7-7**] of 37) and she received 2 units of PRBCs. Per pt report, she has not been feeling well for the past few days; she denies pain but states that she felt weak and tired. She denies any hx of ulcers or bleeding from her rectum. She denies pain and refuses to report further hx. She states that she fell recently, hit her head and twisted her right ankle and has had difficulty walking since that time. She is confused at baseline per her PCP. Past Medical History: Bladder cancer Rectal cancer s/p chemo/XRT and resection with colostomy in [**2103**] Depression B12 deficiency Cataracts Social History: Patient has no close family, and lives at [**Location 2299**] house nursing home. Her power of attorney is a distant relative, [**Name (NI) **] [**Name (NI) 102287**], [**Telephone/Fax (1) 102288**] Family History: NC Physical Exam: VS: temp 99, BP 128/55, HR 105 (90s-130s), R 16, O2 98% RA Gen: NAD, AO x 3,irritated at being woken up HEENT: MM dry, EOMI Neck: supple, no JVD CV: regular, tachy, no murmurs Chest: clear bilaterally, no wheezes Abd: +BS, soft, NTND, colostomy bag in place with brown liquid stool; guaic positive per ED report Pelvic: blood noted in perinuem, pt uncooperative with exam Ext: no edema, warm, 2+ DP; pain on palpation of right hip with decreased ROM Neuro: grossly intact, moves all ext Pertinent Results: Admission labs: [**2117-7-9**] 08:45PM BLOOD WBC-15.2* RBC-3.68* Hgb-10.8* Hct-32.4* MCV-88 MCH-29.4 MCHC-33.3 RDW-14.0 Plt Ct-441*# [**2117-7-9**] 08:45PM BLOOD Neuts-86.1* Lymphs-10.7* Monos-2.4 Eos-0.6 Baso-0.1 [**2117-7-9**] 08:45PM BLOOD PT-13.1 PTT-23.4 INR(PT)-1.1 [**2117-7-9**] 08:45PM BLOOD Glucose-126* UreaN-38* Creat-1.7* Na-135 K-5.3* Cl-102 HCO3-20* AnGap-18 [**2117-7-10**] 05:56PM BLOOD Calcium-9.7 Phos-3.2 Mg-2.4. . CTA abd: Inflammation of splenic flecture, left hydronephrosis/hydroureter to uretervesicular junction. No visualized stone (although artifact from arthroplasty). . [**2117-7-9**] CXR: Mild cardiomegaly . [**2117-7-9**] LE U/S: no DVT . [**2117-7-9**] Right hip XR: No fractures . EKG: sinus tach at 127; left axis deviation; Q waves in III, aVF; stable 1st degree AV block; no change from prior EKG ([**2-/2109**]) . [**2117-7-10**] CT Abdomen and Pelvis: IMPRESSION: 1. No masses are identified. 2. No evidence for retroperitoneal hematoma or intra-abdominal free fluid or free air. 3. Left hydronephrosis with left hydroureter extending down to the left ureterovesicular junction. No stone or UVJ mass identified definitively. 4. Right adrenal lesion measuring 2.2 x 1.3 cm which, given its low Hounsfield units, is most likely an adrenal adenoma. Please correlate with prior outside imaging, if available. 5. Cholelithiasis without evidence for acute cholecystitis. . Urine cytology - pending . Discharge labs: [**2117-7-13**] 06:14AM BLOOD WBC-6.4 RBC-3.65* Hgb-10.9* Hct-32.3* MCV-89 MCH-29.8 MCHC-33.7 RDW-13.5 Plt Ct-414 [**2117-7-13**] 06:14AM BLOOD Plt Ct-414 [**2117-7-13**] 06:14AM BLOOD Glucose-103 UreaN-18 Creat-1.0 Na-140 K-3.9 Cl-108 HCO3-19* AnGap-17 [**2117-7-12**] 06:14AM BLOOD Calcium-9.5 Phos-3.8 Mg-2.0 [**2117-7-10**] 11:13AM BLOOD Hgb-12.1 calcHCT-36 Brief Hospital Course: Hospital course by problem: . #1. Bleed: Patient had Hct of 32 on admission to MICU, which was felt to be below her baseline, so she received 2 units PRBC. Her Hct increased to 37, and she was hemodynamically stable and transferred to the regular medical floor the next day. Serial Hcts were checked, and the value drifted down to 33 over the 4 days in the hospital. She was never symptomatic. The source of bleed was never found, as she never had another episode of bloody emesis nor visible blood in her ostomy or per rectum or vagina. The stool in her ostomy bag was only slightly guaiac positive. Ct of the adbomen and pelvis showed no obvious source of bleed, and pelvic exam was not tolerated by the patient. She did not receive any further transfusions. . The GI team had planned to do colonoscopy and endoscopy on [**2117-7-13**], but patient's PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] felt that this test could be postponed, as the patient was stable, could be monitored with qd hcts in the nursing home. Also, the patient would not be likely to have any intervention that may be indicated to treat her bleed. The plan is for the patient to return to [**Hospital3 **], where she will have qd hcts for 1 week, and be closely monitored by Dr. [**First Name (STitle) **]. . #2. Fall on right hip: Patient had a fall at the nursing home prior to admission, and was very tender on the right hip. No no fracture was seen on X ray or CT. The images, however, were sub-optimal, as the patient has a right hip prosthesis. An MRI was attempted to rule out fracture, but the patient refused this procedure. The radiologists feel that with the plain film and CT rule out fracture fairly well. . #3. Possible UTI: Patient had large blood and moderate leuks on UA, and culture is still pending. The plan is for 5 days of empiric therapy with Bactrim double strength [**Hospital1 **] at [**Female First Name (un) 12660**] house. . #4. Left kidney hydronephrosis on CT No masses or stones were seen on the CT. The patient was seen by urology, who recommended a CT urogram and cystoscopy which can be done in the outpatient setting. Urine cytology was sent which is still pending. . #5. Acute renal failure On admission, the patient's creatinine was 1.7. This was likely prerenal ARF due to dehydration, and improved with IV fluids. Medications on Admission: B12 1000mcg SC q month ASA 325mg qd MVI with iron, 1 tab qd Tylenol prn Discharge Medications: 1. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin EC 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 3. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. 4. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every [**4-14**] hours as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: Guaiac positive stools Acute blood loss anemia UTI Discharge Condition: Stable Discharge Instructions: NOTE TO [**Female First Name (un) **] HOUSE STAFF: Please check patient's Hct daily for 7 days. Please give patient Bactrim double strength BIF for 5 days Please follow up with [**Hospital1 18**] about results of patient's urine culture and urine cytology. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] is aware of this patient. Please call him if Hct is dropping or if there are any worrisome events. Followup Instructions: NOTE TO [**Female First Name (un) **] HOUSE STAFF: Please check patient's Hct daily for 7 days. Please give patient Bactrim double strength BIF for 5 days Please follow up with [**Hospital1 18**] about results of patient's urine culture and urine cytology. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] is aware of this patient. Please call him if Hct is dropping or if there are any worrisome events. Completed by:[**2117-7-26**]

[ "599.0", "584.9", "V44.3", "591", "276.7", "V10.06", "276.2", "V10.51", "285.1" ]

icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

6821, 6894

3941, 3941

279, 285

6989, 6997

2105, 2105

7472, 7932

1577, 1582

6432, 6798

6915, 6968

6335, 6409

7021, 7449

3555, 3918

1597, 2086

224, 241

3969, 6309

313, 1196

2121, 3539

1219, 1344

1360, 1561

56,757

185,520

52462

Discharge summary

report

Admission Date: [**2122-8-15**] Discharge Date: [**2122-8-20**] Date of Birth: [**2042-1-17**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 800**] Chief Complaint: clogged G tube Major Surgical or Invasive Procedure: Endotracheal Intubation Arterial line placement History of Present Illness: 80-year-old man with PMHx of CAD, COPD, dementia and seizure disorder who was transferred from [**Hospital1 **] for complaint of clogged G-tube. Per [**Hospital1 **] records, pt was at baseline but wasn't able to receive po meds due to clogged G-tube and was sent in for evaluation. On arrival to [**Hospital1 18**], pt was uncomfortable with increasing oxygen requirement. . In the ED, initial vitals were: T 100.0 P 60 BP 188/85 R 24 O2 sat 98% on NRB and RA sat in the 80s%. Pt was notably tachypneic and in mild respiratory distress. ABG revealed acute on chronic respiratory acidosis 7.41/74/67. Portable CXR was concerning for right sided PNA and he received vanc/pip-tazo for empiric coverage of HAP. He did not tolerate BiPAP trial due to beard and discomfort. It was felt that the hypercarbia was not acute given his alert and agitated mental status with intermittent yelling. . On arrival to the ICU, pt was yelling intermittently but denying any pain when questionned. He reports shortness of breath which began approximately 3 days ago and occaisional cough that is non-productive. He denies fevers, chills, nausea, vomiting or chest pain. He reports feeling hungry and thirsty, though further review of symptoms difficult to obtain due to MS. Past Medical History: CAD (h/o of IMI) COPD (baseline O2 requirement of 1-2L NC) B/L hip fx s/p R hip replacement BPH with obstructive uropathy Mood d/o PVD Osteoporosis HTN GERD Anemia Mild dementia Hyperthyroid Persistent R pleural effusion Social History: (+) tobacco, 5 cigarettes per day x 60 years, quit 1 yr ago. Social EtOH. No drugs. Formerly in Marines. Now lives at [**Location **]. Family History: noncontributory Physical Exam: PHYSICAL EXAM AT ADMISSION: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Physical Exam at discharge: Vitals: 98 97 120/62 72 18 93%CPAP 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. G tube intact without drainage, erythema, or tenderness. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: LABS ON ADMISSION: Lactate:1.2 . Trop-T: <0.01 CK: 20 MB: Notdone . 135 89 23 BS 125 AGap=8 ------------- 4.6 43 0.7 . WBC 11.9 Hgb 11.2 Hct 35.2 Plts 189 N:91.1 L:3.7 M:4.8 E:0.1 Bas:0.3 . PT: 13.1 PTT: 31.4 INR: 1.1 . LABS at discharge: [**2122-8-20**] 05:45AM BLOOD WBC-3.8* RBC-3.02* Hgb-9.2* Hct-29.9* MCV-99* MCH-30.5 MCHC-30.8* RDW-14.9 Plt Ct-177 [**2122-8-20**] 05:45AM BLOOD Glucose-110* UreaN-20 Creat-0.6 Na-140 K-3.5 Cl-99 HCO3-36* AnGap-9 [**2122-8-20**] 05:45AM BLOOD Calcium-8.4 Phos-2.2* Mg-2.1 . Micro: Blood Cx sent x 2 on [**8-15**]: No growth . GRAM STAIN (Final [**2122-8-16**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2122-8-19**]): OROPHARYNGEAL FLORA ABSENT. ESCHERICHIA COLI. MODERATE GROWTH. PROTEUS MIRABILIS. QUANTITATION NOT AVAILABLE. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | PROTEUS MIRABILIS | | AMPICILLIN------------ =>32 R =>32 R AMPICILLIN/SULBACTAM-- =>32 R 16 I CEFAZOLIN------------- 8 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CEFUROXIME------------ 4 S <=1 S CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ =>16 R 4 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN---------- =>128 R 16 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ 4 S 2 S TRIMETHOPRIM/SULFA---- <=1 S =>16 R . Images: CXR [**2122-8-15**]: IMPRESSION: Diffusely increased pulmonary opacity, particularly on the right. Bilateral pleural effusions. . CXR [**2122-8-16**]: Findings are consistent with right lung multifocal opacities that might be worrisome for infectious process accompanied by bilateral pleural effusion. The percutaneous gastrostomy tube is noted. . CXR [**2122-8-17**]: IMPRESSION: Improved right upper/lower lung opacities; bilateral pleural effusions, right greater than left, show no change. . CXR [**2122-8-18**]: (extubated) Lower lung volumes post-extubation with no interval change, stable moderate right pleural effusion and left lower lobe atelectasis. . Echo [**2122-7-23**]: IMPRESSION: Regional left ventricular systolic dysfunction consistent with coronary artery disease. Moderate aortic stenosis. Mild to moderate aortic regurgitation. Moderate eccentric mitral regurgitation. . EKG [**2122-8-15**]: NSR with HR of 79, peaked T waves essentially unchanged from prior tracings, no other acute ST-T wave changes . EKG [**2122-8-18**]: Atrial fibrillation with rapid ventricular response. Left ventricular hypertrophy with ST-T wave changes. Compared to the previous tracing of [**2122-8-17**] atrial fibrillation with rapid ventricular response and lateral ST-T wave changes have appeared and marked increase in rate. Clinical correlation is suggested. . Brief Hospital Course: 80-year-old man with PMHx of CAD, COPD, dysphagia and seizure disorder who was transferred from [**Hospital1 **] for clogged G-tube but found to be in respiratory distress with pneumonia. . # Pneumonia: Pt was found to be in repiratory distress in the ED and was admitted to the MICU for possible pneumonia with pulmonary edema seen on CXR. Empiric vancomycin and piperacillin-tazobactam were started. When he got to the MICU he was yelling intermittently but denying any pain when questioned. At one point on his first night in the ICU, he became very quiet with O2 saturation dropping; he then stopped breathing and became apneic. He was emergently intubated, with post-intubation hypotension requiring pressors briefly. Furosemide was given intermittently with good urine output and improvement of respiratory status. Acetezolamide was given to waste bicarb and stimulate respiratory drive. Neurology was consulted and thought that the episode was not a seizure. Neurology was convinced that he may have had a stroke in the past and this is the reason for his swallowing difficulty. The patient was extubated within 30 hours. The patient's antibiotic regimen was changed to cefepime and ciprofloxacin, but after the sputum culture grew out E. coli and Proteus sensitive to cephalosporins and resistant to ciprofloxacin, the regimen was changed to ceftriaxone. The 14-day course of antibiotics will end on [**2122-8-26**]. . # History of CAD: has been followed by cardiology. Echo in [**2122-7-4**] showed focal wall motion abnormality, LVEF 40%. He had no chest pain. CE negative and EKGs at baseline. Suspected acute on chronic pleural effusions [**1-5**] heart failure. He was started on aspirin 81mg daily (as per PCP, [**Name10 (NameIs) **] contraindication to starting). He was continued on simvastatin and lisinopril. Due to his episodes of hypotension in the MICU, his acetutolol was discontinued and was held at discharge as his heart rate remained in the low 60s and SBP in the 120s. Closely follow-up is needed to consider restarting the beta blocker. . # Atrial fibrillation: On [**2122-8-18**] in the ICU, patient developed atrial fibrillation with rapid ventricular rate, quickly controlled with metoprolol 5 mg IV x 1. The rhythm spontaneously converted to sinus, which has persisted until discharge. He was discharged on ASA 81mg daily with further anticoagulation to be considered by PCP. . # Hypertension: continued on home regimen of lisinopril. Acebutolol was discontinued due to hypotensive episodes and heart rate in the low 60s. . # Dementia: continued on home regimen of Actonel/Ca q week. Held trazodone as concerned about mental status. . # Seizure disorder: continued valproic acid 750 mg qam and 1000 mg qhs. Neurology was consulted and did not feel as though his history was consistent with seizure and that he was mentating well after extubation. Medications on Admission: Tamsulosin 0.4 mg daily Lisinopril 20 mg daily Acebutolol 200 mg [**Hospital1 **] Valproic Acid 750 mg qam Valproic Acid 1000 mg qhs Donepezil 10 mg Tablet qhs Trazodone 25 mg Tablet qhs Actonel With Calcium 35 mg-500 mg (1250 mg) q monday Simvastatin 10 mg daily Fluticasone 110 mcg/Actuation [**Hospital1 **] Ipratropium Bromide 0.02 % q6hrs Nitroglycerin 0.3 mg Tablet SL prn Ferrous Sulfate 325 mg daily Albuterol Nebs q6hr prn Lansoprazole 30 mg daily Heparin 5000u sc tid MIV daily Senna qhs Docusate Sodium 50 mg/5 mL Liquid daily Acetaminophen 325 mg Tablet q6hr prn Bisacodyl 10 mg Tablet daily prn Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) Injection TID (3 times a day). 2. Lisinopril 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Hospital1 **]: One (1) Capsule, Sust. Release 24 hr PO daily. 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: One (1) Inhalation Q4H (every 4 hours) as needed for wheeze. 5. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours). 6. Valproic Acid (as Sodium salt) 250 mg/5 mL Syrup [**Hospital1 **]: Three (3) PO QAM (once a day (in the morning)). 7. Valproic Acid (as Sodium salt) 250 mg/5 mL Syrup [**Hospital1 **]: Four (4) PO HS (at bedtime). 8. Donepezil 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at bedtime). 9. Simvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 10. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2 times a day). 11. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime). 12. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 13. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 14. Ceftriaxone 1 gram Recon Soln [**Hospital1 **]: One (1) gram Intravenous once a day for 8 days: last day [**2122-8-26**]. 15. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Pneumonia Discharge Condition: vital signs were stable upon discharge Discharge Instructions: You were admitted to the hospital because you were thought to have a clogged gastric tube. You were found to have pneumonia and were treated with antibiotics. Because of a brief episode of not breathing, you were intubated but then extubated the following day. Your respiratory status improved on the antibiotic. You were discharged to [**Hospital1 **] in stable condition. You were started on a new medication called aspirin. Please continue to take this medication as directed. Your antibiotic will be given until [**2122-8-26**] to complete a 14-day course. The following medications were stopped: acebutolol because of low blood pressure and trazodone because of confusion. If you develop fevers, chills, shortness of breath, chest pain, or any other concerning symptom, please seek medical care immediately. Followup Instructions: Please keep the following appointments or contact the provider to cancel/reschedule. Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 43**] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2122-9-24**] 4:30 Please contact your PCP: [**Name (NI) **],[**First Name3 (LF) **] S. [**Telephone/Fax (1) 608**] for a follow up appointment in [**12-5**] weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]

[ "599.69", "296.90", "428.0", "787.20", "424.0", "041.4", "733.00", "285.9", "530.81", "041.6", "424.1", "518.81", "401.9", "345.90", "V55.1", "458.29", "242.90", "496", "294.8", "414.01", "507.0", "443.9", "600.91" ]

icd9cm

[ [ [] ] ]

[ "96.04", "38.91", "93.90", "38.93", "96.71", "96.6" ]

icd9pcs

[ [ [] ] ]

11523, 11602

6381, 9261

329, 379

11656, 11697

3184, 3189

12561, 13082

2076, 2093

9920, 11500

11623, 11635

9287, 9897

11721, 12538

2108, 2604

2618, 3165

275, 291

3423, 6358

407, 1664

3203, 3404

1686, 1908

1924, 2060

47,693

188,536

36645

Discharge summary

report

Admission Date: [**2121-10-2**] Discharge Date: [**2121-10-7**] Service: MEDICINE Allergies: Neomycin/Bacitrac Zn/Polymyxin Attending:[**First Name8 (NamePattern2) 812**] Chief Complaint: Shortness of breath and palpitations Major Surgical or Invasive Procedure: Placement of IVC filter. History of Present Illness: [**Age over 90 **] year old female with hypertension, dementia, presenting to ED with acute onset of palpitations and dyspnea. Started at 4:30pm after drinking a cup of coffee, which caused her to cough, and continued afterwards. Thought perhaps was aspiration or irritation related. Denies chest pain, back pain, nausea, diaphoresis. In the ED, initial vs were: T98.2, HR130, BP 95/67, R24, 96% on NRB. Still requiring NRB (though 99% on this, appears to desat with lower amounts of O2). Lowest SBP 93. CXR with large hiatal hernia. CTA with multi-focal PEs. NGT was placed to decompress hernia. Guaiac negative. BNP 4700 and troponin 0.09. Patient was started on IV heparin. In the MICU, patient notes feeling tired without other complaints. States her breathing is still difficult, though better than before. No palpitations currently. Unsure if she has had any recent weight loss. Does not recall recent mammography or other cancer screenings. Review of systems: (+) Per HPI (-) Denies fever, headache, cough, chest pain or tightness, nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: - Hyperlipidemia - Hypertension - Hypothyroidism - History of cellulitis of leg [**8-/2120**] - Dementia - Bipolar illness - History of hernia repair - Constipation - Osteoporosis - compression fx seen on xrays - AAA s/p repair Social History: Lives in dementia unit at [**Last Name (un) 35689**] House, daughter actively involved in her care. Formerly worked as a dental assistant No current smoking or EtOH. Family History: Son was [**Name2 (NI) 82909**], committed suicide. Daughter deceased from pancreatic cancer. One other daughter currently alive and well. Physical Exam: T 98.4 BP: 121/54 P: 75 R: 18 O2: 95% on 3L General: Sleepy though easily arousable, cachectic elderly female. HEENT: Sclera anicteric, PERRL. MM slightly dry, oropharynx clear Neck: supple, JVD to 2 cm ASA, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused UEs, slightly cool LEs, 2+ pulses, no clubbing, cyanosis. Trace to 1+ bilateral LE edema. Pertinent Results: Images: CT chest: extensive bilateral filling defects in main and lobar arterial branches. CT evidence of possible R heart strain. Large hiatal hernia. LLL compressive atelectasis. CXR: Hiatal hernia with compressive atelectasis. Lungs clear. EKG: Sinus tach at 124, NANI, 1mm ST depression in I and aVL, no prior. Hematology: [**2121-10-1**] 07:25PM BLOOD WBC-14.0* RBC-4.50 Hgb-13.1 Hct-41.7 MCV-93 MCH-29.2 MCHC-31.5 RDW-14.5 Plt Ct-253 [**2121-10-1**] 07:25PM BLOOD Neuts-87.0* Lymphs-9.4* Monos-3.2 Eos-0.3 Baso-0.2 [**2121-10-2**] 04:35AM BLOOD PT-12.8 PTT-124.9* INR(PT)-1.1 Chemistries: [**2121-10-1**] 07:25PM BLOOD Glucose-227* UreaN-20 Creat-0.9 Na-139 K-5.4* Cl-104 HCO3-21* AnGap-19 [**2121-10-1**] 07:25PM BLOOD CK(CPK)-76 [**2121-10-1**] 07:25PM BLOOD cTropnT-0.09* [**2121-10-1**] 07:25PM BLOOD CK-MB-NotDone proBNP-4736* [**2121-10-2**] 04:35AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.1 ABG: [**2121-10-2**] 08:22AM BLOOD Type-ART pO2-226* pCO2-37 pH-7.44 calTCO2-26 Base XS-1 Brief Hospital Course: [**Age over 90 **] year old female with hypertension, hyperlipidemia, hypothyroidism; presenting with extensive bilateral PE and high O2 requirement. #Pulmonary embolism. CTA showed massive bilateral filling defects and R heart strain. Trigger unknown, but given cachexia and age would be concerned for malignancy. Ambulatory at facility at baseline. Unlikely to be primary hypercoaguable state at her age. No identified meds that would put her at risk. She was hemodynamically stable with high O2 requirements. She was started on IV heparin drip. LENI's showed nonocclusive thrombus involving the left superficial femoral vein. TTE showed LEF 55% and most significant for markedly dilated and hypokinetic RV, mod-severe TR, and mod pulm HTN. An IVC filter was placed to prevent further clot burden. IV heparin was transitioned to lovenox for faciliation of outpatient therapy. #UTI - Patient was note dto have a positive urine culture for pansensitive Ecoli. She denied urinary symptoms, but due to her incontinence and inability to assess dementia from baseline was treated with at 3 day course of clinidamycin. #Dysphagia - Patient was noted to have coughing with po intake of nectar thick liquids. It is unclear if her dysphagia is a consequence of deconditioning from her acute illness and/or a chronic change due to her dementia. Speech and swallow was consulted and recommended a video study. Prior to the study, patient and daughter discussed what they would want if patient was aspirating on food and/or liquids, and pt wanted to be allowed to eat anyway. She was discharged to rehab with instruction to include swallow therapy during her stay with supervision during meals. #Weakness - Pt was noted to be deconditioned due to her PE during her hospitalization. #Tachycardia/palpitations. In setting of acute PE. Her heart rate and her symptoms inproved with gentle hydration and initiation of anticoagulation. #Leukocytosis. Initial WBCs 14K which improved to 8 without intervention. Likely stress response to PE and hypoxia. #Dementia/bipolar. She was continued on home risperdal and mirtazepine. #Hiatal hernia. NGT placed in ED for decompression out of concern that this was leading to symptoms. This was discontinued on arrival to the MICU. #Code: Pt and daughter both confirm DNR/DNI status Communication: Patient and daughter [**Name (NI) **] [**Name (NI) 14164**] [**Telephone/Fax (1) 82910**] Medications on Admission: Aspirin 81 mg daily Levothyroxine 75 mcg daily Simvastatin 10 mg daily Risperdal 0.5 mg QAM, 1.5 mg QPM Mirtazepine 22.5 mg daily Ranitidine 150 mg daily Calcium plus D [**Hospital1 **] Multivitamin daily B12 1000 mcg daily B6 100 mg daily Folate 0.4 mg daily mag citrate prn lactulose prn eucerin cream Discharge Medications: 1. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pyridoxine 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Risperidone 1 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 10. Risperidone 1 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 11. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) teaspoon PO BID (2 times a day). 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 17. Mirtazapine 45 mg Tablet Sig: half Tablet PO at bedtime. 18. Magnesium Citrate 1.745 g/30mL Solution Sig: Three (3) teaspooon PO once a day as needed for constipation. 19. Lactulose 10 gram/15 mL Solution Sig: One (1) tablespoon PO once a day as needed for constipation. 20. Eucerin Cream Sig: apply liberally Topical three times a day as needed for dry or itchy skin. 21. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 22. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 1 days: through [**10-7**] evening. Tablet(s) Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: Primary: Pulmonary embolism Secondary: Deep vein thrombosis Discharge Condition: Stable, afebrile, 96% on 2L oxygen Discharge Instructions: You were seen at the [**Hospital1 18**] ED for heart palpitations and shortness of breath. CT imaging in the ED revealed large blood clots in your pulmonary arteries, and you were started on blood thinners to prevent worsening of the blood clots. An ultrasound examination of your legs showed a clot in your left leg, and a IVC filter was placed to prevent further clots from travelling to your lungs. Due to deconditioning you were sent to rehab for continued physical therapy. During your hospitalization it was noted that you cough with nectar thick liquids. You should receive swallow therapy during your rehab stay. Medications changed on this admission: -->You are being sent home on lovenox and coumadin. Lovenox acts as a blood thinner that you should continue to use until your coumadin levels are therapeutic. Your goal INR is [**12-24**]. It should be rechecked in one week. --> Please take ciprofloxacin for a urinary tract infection, please complete course as directed Please call your doctor or go the nearest emergency room if: -You have new shortness of breath -You have chest pain -You become lightheaded or faint -You develop blood in the stool -Any other concerning symptom Followup Instructions: Please follow up with your primary care physician after you are discharged from rehab. Dr. [**First Name8 (NamePattern2) 4320**] [**Last Name (NamePattern1) 4321**] [**Telephone/Fax (1) 82911**] [**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, DMD [**MD Number(2) 821**] Completed by:[**2121-10-7**]

[ "272.4", "397.0", "288.60", "787.20", "401.9", "285.9", "296.80", "733.00", "453.41", "244.9", "415.19", "416.8", "599.0", "428.0", "041.4", "553.3", "294.8" ]

icd9cm

[ [ [] ] ]

[ "38.7" ]

icd9pcs

[ [ [] ] ]

8471, 8556

3773, 6210

284, 310

8660, 8697

2754, 3750

9948, 10305

1995, 2134

6565, 8448

8577, 8639

6236, 6542

8721, 9925

2149, 2735

1321, 1544

208, 246

338, 1302

1566, 1796

1812, 1979

11,728

147,122

27080

Discharge summary

report

Admission Date: [**2178-9-3**] Discharge Date: [**2178-9-28**] Date of Birth: [**2116-2-19**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2751**] Chief Complaint: A.Fib RVR, hemodynamically unstable s/p mediastinoscopy Major Surgical or Invasive Procedure: mediastinoscopy History of Present Illness: 62 year old female with history of HTN, CAD s/p DES to LCx/LAD in [**10/2177**], severe PAH, biventricular diastolic dysfunction, and mediastinal lymphadenopathy electively admitted to thoracic surgery s/p mediastinoscopy yesterday with persistent hypoxia and lactic acidosis. . Right and left heart cath in [**10/2177**] showed pulmonary artery pressures of 67/23/46. Nuclear stress last month showed uninterpretable ECG for ischemia due to abnormal baseline, with appropriate hemodynamic response to Persantine. No anginal type symptoms, a fixed mild decrease in septal activity may be related to LBBB. Normal LV wall motion and systolic function, with hyperdynamic LVEF of 85%. . During this admission, she was noted to have an oxygen saturation of 90% in pre-op and was hypotensive during the case, to the 60s systolic, and required ephedrine and neo to maintain her BPs. Bronchoscopy showed clear secretions. In the PACU she was extubated and continued to have low O2 sats 88-90% on 3 liters N/C, although both the patient and her daughter explained that this is her baseline and she does not use home oxygen. She reported taking her home lisinopril and atenolol the morning of the mediastinoscopy. She did not take her Lasix. She was also unable to void in the PACU and when a foley was placed she urinated 200cc. Her urine output in PACU reached a low of 17 cc/hour but averaged 20-30 cc/hour overnight. She had an initial VBG that was 7.29/35/26 and a lactate of 5. On repeat VBG four hours later it was 7.30/34/43 and lactate was 5 again. She was transferred to Medicine for management of her lactic acidosis and hypoxia. Past Medical History: Past Medical History: DM CAD s/p LAD cypher stenting occult SBE with aortiv valve vegetation severe pHTN HTN HLD . Past Sx History: Rt Fem-[**Doctor Last Name **] bypass Rt CEA following CVA prior to [**2173**] Lt CEA following TIA [**2173**] Stenting of LCx DPromus [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] of Prox/Mid LAD with Promus Stent Social History: Pt livers with two daughters at home. Tob: 0.5ppd x40years (since age 17) EtOH: social - 2 beers every 2 weeks Illicit drug use: denies Family History: Father had MI in his 50's and stroke in his 60's. Siblings with DM. Physical Exam: Admission Physical Exam: Vitals: T: 98.3 BP: 108/91 (rechecked at 7 AM 89/61) P:158 (rechecked 134) R: 24 on NRB (19 on BiPAP) O2: 96% on 50% o2 General: Alert, oriented, on NRB HEENT: Sclera slightly icteric, MMM, oropharynx clear Neck: Mediastonsocpy site near jugular notch appears CDI. JVP elevated to below jaw line at 75 degrees. Lungs: Coarse rhonchi/crackles in lower lung fields bilaterally left worse than right. 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, 1+ pulses, no clubbing, cyanosis 1+ edema surgical scars consistent with revascularization procedures. . Discharge Physical Exam: Pertinent Results: [**2178-9-3**] 11:58PM TYPE-[**Last Name (un) **] PO2-43* PCO2-34* PH-7.30* TOTAL CO2-17* BASE XS--8 [**2178-9-3**] 11:58PM LACTATE-5.0* K+-5.4* [**2178-9-3**] 11:41PM GLUCOSE-174* UREA N-34* CREAT-1.2* SODIUM-130* POTASSIUM-5.7* CHLORIDE-96 TOTAL CO2-15* ANION GAP-25* [**2178-9-3**] 11:41PM cTropnT-0.02* [**2178-9-3**] 11:41PM CALCIUM-8.6 PHOSPHATE-5.9* MAGNESIUM-1.9 [**2178-9-3**] 06:58PM TYPE-ART TEMP-36.1 RATES-/20 PO2-26* PCO2-35 PH-7.29* TOTAL CO2-18* BASE XS--9 INTUBATED-NOT INTUBA COMMENTS-O2 DELIVER [**2178-9-3**] 04:46PM CK(CPK)-56 [**2178-9-3**] 04:46PM CK-MB-4 cTropnT-<0.01 [**2178-9-3**] 03:40PM OTHER BODY FLUID CD23-DONE CD45-DONE HLA-DR[**Last Name (STitle) 7735**] [**Name (STitle) 7736**]7-DONE KAPPA-DONE CD10-DONE CD19-DONE CD20-DONE LAMBDA-DONE CD5-DONE [**2178-9-3**] 03:40PM OTHER BODY FLUID CD3-DONE [**2178-9-3**] 03:40PM OTHER BODY FLUID IPT-DONE . MICRO: . IMAGING: [**2178-9-3**] CXR - Lungs are well expanded. Compared to prior radiograph, there is decrease in interstitial markings, upper vascular redistribution and hilar engorgement. A right lower lung radiopacity likely due to aspiration pneumonia persists. Small bilateral pleural effusions are present, no evidence of pneumothorax. Cardiomediastinal contour is stable with a dilated pulmonary artery, unchanged from prior radiograph . [**2178-9-7**] RUQ ultrasound 1. Mild intra-abdominal ascites. 2. Gallbladder wall thickening and pericholecystic fluid, likely secondary to 3rd spacing and underlying cardiac disease. No cholelithiasis or evidence of acute cholecystitis. 3. Limited evaluation of the pancreas and abdominal aorta due to overlying bowel gas. . PATHOLOGY [**2178-9-3**] LN biopsy: FRAGMENT OF LYMPH NODE WITH REACTIVE FEATURES, INCLUDING FOLLICULAR HYPERPLASIA, FOCAL PARACORTICAL HYPERPLASIA AND SINUSOIDAL HISTIOCYTOSIS. THERE IS NO EVIDENCE OF LYMPHOMA. Non-specific T cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by non-Hodgkin B-cell lymphoma are not seen in specimen. Correlation with clinical findings and morphology is recommended. Flow cytometry immunophenotyping may not detect all lymphomas as due to topography, sampling or artifacts of sample preparation. Brief Hospital Course: 62 yo F with hx of severe of pulm HTN and CAD s/p DES to Lcx/LAD in [**10/2177**] prior CVA s/p b/l CEA's, PVD who was transferred to medicine after mediastinoscopy complicated by hypotension, hypoxia, and lactic acidosis in the immediate post op period. In brief, she came to medicine service on [**2178-9-4**] with lactic acidosis and hypoxia, and was transferred to the medical ICU early on [**2178-9-5**] after triggering for hypoxia and atrial flutter with rates to 170s. On review, she had experienced 1-2 months of progressive shortness of breath, > 20 lb weight gain, and worsening lower extremity edema, likely representing worsening congestive heart failure. # Hypotension: She was hypotensive during the mediastinoscopy, to the 60s systolic, and required ephedrine and neo to maintain her BPs. She reported taking her home lisinopril and atenolol the morning of the mediastinoscopy. Her pressures recovered in the PACU. Home beta blocker and lisinopril were held. Echo ([**2178-9-4**]) showed signs of severe pulmonary artery hypertension with right ventricle dilatation and moderate global free wall hypokinesis, and septal motion consistent with increased RV pressures. On exam, she had evidence of RHF including elevated JVP, pulsatile liver, and bilat lower extremity edema. Thus, it was assumed that intraoperatively she had poor forward flow from RV overload and impairment of LV filling. Because of concern for intraoperative MI, troponins were sent, which were initially elevated and peaked to 0.67, but trended down, consistent with demand ischemia. On [**2178-9-5**], she went into atrial flutter with rates to the 170s and was transferred to the unit (see below). Her rate was initially controlled on esmolal drip, with subsequent hypotension to MAPS 50s with HR 100s. A RIJ was placed and she was supported on neosyn. The esmolal drip was stopped and she was loaded with amiodarone; her pressures quickly responded and she was taken off of neosyn after a few hours. Her SBPs have since been greater than 90. # Lactic acidosis: Post-op, VBG was 7.29/35/26 and on repeat 4 hrs later 7.30/34/43. Lactate was 5, attributed to hypotension and poor forward flow during the procedure, with potential contribution of Metformin. Her home metformin was held and she was started on Lasix 20 mg IV bid. The metabolic acidosis quickly improved over the post op day 1. # Hypoxia: In retrospect, was likely multifactorial with components of pneumonia, pulmonary edema secondary to CHF, and likely COPD / emphysema with long smoking history. Pre-procedure, she was noted to have an oxygen saturation of 90%, but post-op in the PACU continued to have low O2 sats 88-90% on 3 liters N/C after extubation. CXR showed new consolidation in the RLL concerning for pulmonary edema with overlapping right lower lobe consolidation likely secondary to aspiration pneumonia and she had WBCs 15.3. She was started empirically on Levofloxacin. Shortly after transfer to medicine on [**9-4**], she triggered for hypoxia, O2 sats 86% on 6L (as well as tachycardia and afib, discussed below) and was transferred to the MICU where she was started on BiPAP. Considering her tachycardia, hypoxia, and TTE showing R sided overload and pulmonary HTN, there was some concern for a PE. However, lack of chest pain, negative LENIs and evidence of PNA on CXR to explain her symptoms supported low suspicion for pulmonary embolism. [**Doctor Last Name 3012**] score was 1.5 for tachycardia. Therefore, there was not sufficient evidence to warrant Heparinization in a patient newly s/p mediastinoscopy with high risk of medistinal bleeding. She was switched to Vancomycin and Zosyn treated for HCAP with 8 day course with improvement in her WBC and symtpoms. She was continued on albuterol / ipratropium / Advair nebulizers with symptomatic improvement. Her pulmonary edema was aggressively treated with Lasix (see congestive heart failure below) with improvement of her O2 sats until she was sating well at 92-100% on RA. She continued to have intermittent O2 sats to 88-89% on RA and used 1 L NC to keep her O2 saturation > 92%. By the time of discharge, her oxygen saturation was 97-100% on 1L NC. # Atrial fibrillation: Early on the morning of [**2178-9-5**], the patient triggered for tachycardia to the 170's with systolic blood pressures in the low 100s. Her beta blocker had been held the day before because of her hypotension. EKG appeared to be atrial flutter with 2:1 conduction. She was not complaining of any symptoms of SOB, chest pain, or palpitations. She received 10 mg IV diltiazem, and 20 mg IV lasix 2-3 hours prior to ICU evaluation (total 40 mg IV on day of transfer from thoracic surgery). She was transferred to the ICU for rate control and hemodynamic monitoring. Atrial fibrillation with RVR was thought most likely secondary to developing PNA and recent mediastinoscopy. She was loaded with Amiodarone and converted to sinus rhythm with improvement in hemodynamic status. After load she was started on Amiodarone 400mg PO BID for 7 days. After 4 days in sinus on amiodarone, she was switched to metoprolol after consultation with her cardiologist, Dr. [**Last Name (STitle) **]. The patient remained in sinus rhythm for the remainder of her hospitalization, with the exception of 3 runs of VT, no more than 15 beats at a time. # Elevated LFTs: She had a mild LFT elevation that coincided an with initiation of Amiodarone, however after consultation with pharmacy appeared too early to be attributed to amiodarone. In retrospect, the LFT elevation also coincided with her Afib and profound hypotension in the unit, and thus may have been secondary to poor perfusion. RUQ ultrasound was unremarkable. LFTs were followed for more than two weeks and returned nearly to baseline levels but should be rechecked at PCP visit this week. #Elevated INR: As above, seen in the setting of hypotension and atrial fibrillation, however, may have been multifactorial with contribution of malnutrition and initiation of broad spectrum antibiotics. She received Vitamin K x 1 and her coags slowly improved to baseline. Pt will need LFTs followed up as an outpatient. Consider MRCP to evaluate bilairy tree if persistently elevated. # Rash: She developed a cluster of [**7-10**] non-vesicular, round, ~ 1 cm diameter, pruritic pink papules, at midline on her back; each papule had a small, black eschar at the center. There was no associated pain. The skin lesion was treated initially with 0.5% hydrocortisone cream with some symptomatic improvement, and then a 7 day empiric course of Valtrex given concern for shingles. The lesions resolved over the course of ~ 10 days. # Right heart failure: The patient presented with significant weight gain and lower extremity edema to the knees, with evidence of right heart failure on TTE, likely secondary to pulmonary hypertension. She also had evidence of left-sided diastolic failure with pulmonary edema, likely from impaired LV filling in the setting of RV overload. She was diuresed aggressively with increasing Lasix dose to a maximum of 80 mg IV tid, with average output of roughly 2 L / day for the space of two weeks, and then a single dose of Metolazone. At this point, she had a contraction alkalosis with Cr bump to 1.1 (from 0.5-0.6 baseline). She diuresed to a dry weight of 79.9 kg (173 lbs), which is 8 kg from her admission weight, and 16 kg from her max recorded weight during this admission (may be some discrepancy in scales). She says that at home (before gaining weight), her dry weight was between 185-190 lbs. Symptomatically, she was much improved, and her O2 sat improved as described above. Dry weight on discharge was 81.1 kg. # Pulmonary HTN: Pulmonary was consulted and recommended right heart catheterization and pulmonary function tests were recommended as an outpatient. # Mediastinal lymphadenopathy - Her mediastinal biopsy showed only non-specific proliferative changes. Pulmonary recommended that she follow up with them as an outpatient. #CAD s/p stents: She was continued on home clopidogrel and ASA. #DM: She was treated with SSI while in house. #HLD: She was continued on her home statin. #HTN: As discussed above her antihypertensives were held during her hypotensive episodes. TRANSITIONAL ISSUES: - consider decreasing aspirin dose from full strength to baby aspirin 81mg daily in setting of being on both cilastazol and clopidogrel - recheck LFTs and chemistries in [**4-3**] days - consider MRCP in setting of transient LFT elevations - consider PFTs - consider Right Heart Cath Medications on Admission: 1. ALENDRONATE 70 mg weds - (pt does not taking this medication) 2. CILOSTAZOL 100 mg [**Hospital1 **] 3. CLOPIDOGREL 75 mg qd 4. GLYBURIDE 5 qd 5. LISINOPRIL 20 qd 6. METFORMIN 1,000 [**Hospital1 **] 7. METOPROLOL SUCCINATE [TOPROL XL] 200 qd 8. NIACIN 500 [**Hospital1 **] 9. OMEPRAZOLE 20 qd 10. PREGABALIN 100 [**Hospital1 **] 11. SIMVASTATIN 40 qd Discharge Medications: 1. Home Oxygen O2 via nasal cannula 2 Liters Dx: CAD/pulmonary hypertension Sats: low 80s on room air today 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. cilostazol 100 mg Tablet Sig: One (1) Tablet PO twice a day. 4. glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. 5. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 6. niacin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 9. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 10. pregabalin 100 mg Capsule Sig: One (1) Capsule PO twice a day. 11. torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 12. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 13. Outpatient Lab Work Please follow up with Primary Care Physician and get blood drawn on [**2178-10-1**] to get the following labs drawn: Chem 10 AST, ALT, Alk Phos, T Bili Discharge Disposition: Home With Service Facility: Home Care [**Location (un) 511**] Discharge Diagnosis: Primary: - Pulmonary hypertension - Congestive heart failure Secondary: - Atrial flutter Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname **], You were admitted to the hospital for a procedure to sample lymph nodes in your chest. After the procedure, you had very low blood pressure and a difficult time breathing. You had to be treated in the intensive care unit for an abnormal heart rhythm. You were then transferred to the regular medicine service, where you received medication to help remove fluid and to control your heart rate. You lost more than 25 lbs of fluid weight and your breathing greatly improved. Your liver function tests were found to be slightly increased, we would recommend following up with your primary care physician for an [**Name9 (PRE) 60478**]. Changes made to your medications: - Please STOP Lisinopril 20 mg for now until your primary care physician feels it is safe to restart - Please DECREASE Metoprolol Succinate to 100mg daily - Please START torsemide 20mg daily - Please STOP lasix Please ask your cardiologist whether or not you may decrease your aspirin full strength to the baby aspirin dose (81mg) daily. Please follow up with your primary care physician later this week. Please be sure to follow up your liver function tests and kidney function with him and consider getting an MRCP. You will also need to get Pulmonary Function Tests and follow up with your cardiologist for a potential Right Heart Catheterization. Followup Instructions: * Please be sure to call your primary care doctor's office when you go home to set up an appointment with him in the next [**4-3**] days to recheck your labs* Name: [**Last Name (LF) **],[**First Name3 (LF) **] A Location: [**Location (un) **] FAMILY PRACTICE Address: [**Location (un) 66508**], [**Location (un) **],[**Numeric Identifier 28669**] Phone: [**Telephone/Fax (1) 41186**] Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Doctor Last Name **] BLDG, [**Apartment Address(1) 17383**] Address: [**Last Name (NamePattern1) 8541**], [**Location (un) **],[**Numeric Identifier 8542**] Phone: [**Telephone/Fax (1) 7960**] Appointment: Wednesday [**2178-10-7**] 11:15am

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Discharge summary

report

Admission Date: [**2191-8-22**] Discharge Date: [**2191-8-27**] Date of Birth: [**2127-5-5**] Sex: F Service: MEDICINE Allergies: Penicillins / Codeine / Dilaudid / Keflex / citalopram / Erythromycin Base Attending:[**First Name3 (LF) 3556**] Chief Complaint: Respiratory failure, shock Major Surgical or Invasive Procedure: Right video-thorascopic lung biopsy Right Heart Catherization arterial line History of Present Illness: 64-year-old woman with a very complicated past history presents with hypoxemic respiratory failure, shock, and acute renal failure. She had a similar presentation recently and had improved with steroids. She was transferred from rehab to OSH with desaturations. She received lasix and was placed on Bipap in OSH ED. Due to falling Hct and hypoxemia, she was intubated and transferred to [**Hospital1 18**]. She arrived intubated, on pressors, and oliguric. Past Medical History: PMH: - ITP ([**2176**], requiring IVIG and steroids) - Hypogammaglobulinemia - managed with monthly IVIG - Pancytopenia of unclear etiology (with bone marrow biopsies reporting hypercellular marrow) - Splenomegaly of unclear etiology - Colonic mucinous adenoCA, s/p right hemicolectomy ([**4-/2190**]) and chemotherapy (FOLFOX x6 cycles, last dose [**1-/2191**]) - Hyperbilirubinemia initially suspected secondary to hemolytic anemia, however, etiology less clear currently - Recurrent bronchitis with bronchiectasis - Hypertension; Hypercholesterolemia - Type 1 DM c/b retinopathy - Hx parapsoriasis - Hx of pericardial effusion - Hx left transudative pleural effusion s/p thoracentesis ([**2191-4-2**], path: mesothelial cells, macrophages, and lymphocytes) PSH: - Right hemicolectomy for colon cancer ([**4-/2190**]) - Right chest port-a-cath placement ([**5-/2190**]) - Colonoscopy ([**2191-3-9**]) - Left thoracentesis ([**2191-4-2**]) Social History: Lives with husband in [**Name (NI) 5110**], no smoking, EtOh, IVDU, Husband [**Name (NI) **] is HCP Family History: Mother - thyroid dz - still living, father - prostate cancer and "lung dz" Physical Exam: Physical Exam: Vitals: T:98.8 BP:109/39 P:54 R: 21 O2:98% General: intubated HEENT: Sclera anicteric, MMM, pupils nonreactive Neck: no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Crackles heard BL lung bases Abdomen: soft, , non-distended, bowel sounds present, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, BL LE edema Neuro: Pt sedated and intubated . Pertinent Results: ADMISSION Labs: [**2191-8-22**] 05:42PM BLOOD WBC-15.5* RBC-3.95*# Hgb-12.8# Hct-40.5# MCV-103* MCH-32.5* MCHC-31.6 RDW-17.1* Plt Ct-103* [**2191-8-22**] 05:42PM BLOOD PT-13.8* PTT-50.9* INR(PT)-1.3* [**2191-8-22**] 05:42PM BLOOD Glucose-266* UreaN-62* Creat-1.8*# Na-150* K-5.9* Cl-113* HCO3-29 AnGap-14 [**2191-8-22**] 05:42PM BLOOD ALT-29 AST-33 LD(LDH)-477* AlkPhos-383* TotBili-1.5 [**2191-8-22**] 05:42PM BLOOD cTropnT-0.02* [**2191-8-22**] 06:29PM BLOOD Type-MIX pO2-186* pCO2-72* pH-7.19* calTCO2-29 Base XS--2 Intubat-INTUBATED PERTINENT: [**2191-8-24**] 03:10AM BLOOD WBC-12.9* RBC-3.91* Hgb-12.9 Hct-38.4 MCV-98 MCH-33.0* MCHC-33.5 RDW-16.4* Plt Ct-79* [**2191-8-25**] 04:07AM BLOOD WBC-11.3* RBC-3.95* Hgb-12.9 Hct-39.4 MCV-100* MCH-32.8* MCHC-32.8 RDW-16.2* Plt Ct-52* [**2191-8-26**] 03:39AM BLOOD WBC-10.8 RBC-3.86* Hgb-12.5 Hct-37.7 MCV-98 MCH-32.4* MCHC-33.1 RDW-16.4* Plt Ct-31* [**2191-8-26**] 12:46PM BLOOD WBC-7.5 RBC-3.07* Hgb-10.1* Hct-30.6* MCV-100* MCH-33.0* MCHC-33.0 RDW-16.2* Plt Ct-29* [**2191-8-26**] 04:53PM BLOOD WBC-9.1 RBC-2.59* Hgb-8.5* Hct-26.2* MCV-101* MCH-32.8* MCHC-32.5 RDW-16.5* Plt Ct-24* [**2191-8-27**] 04:38AM BLOOD PT-15.8* PTT-48.5* INR(PT)-1.5* [**2191-8-25**] 09:26AM BLOOD Thrombn-23.9* [**2191-8-26**] 08:40PM BLOOD Fibrino-106* [**2191-8-27**] 04:38AM BLOOD Fibrino-135* [**2191-8-25**] 04:07AM BLOOD Fact II-38* Fact V-125 FactVII-69 Fact X-68* [**2191-8-26**] 12:46PM BLOOD ACA IgG-PND ACA IgM-PND [**2191-8-26**] 03:39AM BLOOD Glucose-272* UreaN-73* Creat-1.2* Na-145 K-4.5 Cl-111* HCO3-27 AnGap-12 [**2191-8-27**] 04:38AM BLOOD LD(LDH)-917* TotBili-3.2* DirBili-1.8* IndBili-1.4 [**2191-8-26**] 12:46PM BLOOD Hapto-<5* [**2191-8-26**] 05:11PM BLOOD Lactate-6.2* [**2191-8-27**] 04:50AM BLOOD Glucose-263* Lactate-3.5* K-4.4 PORTABLE UPRIGHT SEMI-ERECT CHEST RADIOGRAPH ON [**2191-8-23**] AT 5:30 A.M. CLINICAL HISTORY: Hypoxemic respiratory failure. Evaluate interval change. TECHNIQUE: Single portable chest radiograph was performed with comparison to the examination from one day previous. FINDINGS: There is interval development of a right apical pneumothorax, measuring approximately 1.8 cm on maximum measurement. The right hemithorax remains relatively well aerated, but with diffuse alveolar opacities, similar in extent and degree to the prior examination. There appears to be slight increased volume loss in the left retrocardiac region, which may represent slight worsening atelectasis, although the possibility of a worsening alveolar process cannot be excluded. The cardiac silhouette remains enlarged. Endotracheal tube remains in place, with the tip approximately 4 cm above the carina. Left-sided subclavian central venous catheter is again seen, with the tip at the junction of the brachiocephalic veins. Right-sided implanted catheter is present with the tip at the cavoatrial atrial junction. A feeding tube remains in place, NG type, extending beyond the inferior confines of this film. IMPRESSION: Interval development of right apical pneumothorax. CT head [**8-23**] Final Report INDICATION: Dilated right pupil. Evaluation for hemorrhage. TECHNIQUE: Contiguous axial images were obtained through the brain without IV contrast. COMPARISON: NECT of the head, [**2191-8-12**]. FINDINGS: There is no acute hemorrhage, edema, mass effect, or evidence of acute major vascular territory infarction. The ventricles and sulci are mildly prominent, suggesting atrophy. The basilar cisterns are patent. The bones are unremarkable. The nasopharynx and mastoid air cells are opacified, likely due to endotracheal intubation. IMPRESSION: No evidence of an acute intracranial abnormality. LENI [**8-23**] INDICATION: 64-year-old woman with respiratory distress, rule out DVT. COMPARISON: None available. FINDINGS: Duplex evaluation was performed on the bilateral lower extremity veins. There is normal compression and augmentation of the common femoral, proximal femoral, mid femoral, distal femoral and popliteal veins. The calf veins are not seen bilaterally. There is normal phasicity of the common femoral veins bilaterally. There is subcutaneous edema in the calves bilaterally greater on the right than the left. IMPRESSION: 1. No evidence of deep vein thrombosis in the bilateral lower extremities. The calf veins were not visualized bilaterally, due to the marked edema. 2. Bilateral subcutaneous edema in the calves, right greater than left. [**8-23**]-CTA INDICATION: Respiratory failure. TECHNIQUE: Multidetector helical CT scan of the chest was obtained before and after the administration of 100 cc IV Visipaque contrast. Coronal, sagittal and oblique reformations were prepared. COMPARISON: Prior CT examinations, most recent dated [**8-21**], [**2190**] and review of chest radiograph dated [**2191-8-23**]. DLP: 373 mGy-cm. FINDINGS: No pulmonary arterial filling defect to suggest pulmonary embolism is identified. The aorta is normal in caliber and configuration without evidence of acute aortic syndrome. Within the lung parenchyma, there are extensive widespread airspace and ground-glass opacities as well as patchy areas of consolidation and septal thickening. Overall, the findings are highly suggestive of edema, though the denser consolidation in the left lower lobe could represent a developing infection. There are underlying changes of chronic interstitial lung disease including traction bronchiectasis with corkscrewing which have progressed from the examination of [**2191-3-31**]. There are small pleural effusions, left greater than right. On the right, there is a chest tube coursing predominantly along the major fissure. There is tiny residual right pneumothorax. There are coronary artery, aortic arch and mitral valve calcifications. The heart appears mildly enlarged and the main pulmonary artery is prominent measuring 3.1 cm suggestive of pulmonary hypertension. An esophageal catheter is in place coursing towards the stomach with tip out of the field of view. There are three central lines. One is a right-sided port, a left-sided internal jugular catheter and a left-sided PICC all with tips in the SVC. An endotracheal tube is in appropriate position. No lymphadenopathy is identified. There is diffuse anasarca. Limited views of the upper abdomen demonstrate ascites as previously seen. The patient is status post splenectomy. No concerning osseous lesion is seen. IMPRESSION: 1. No evidence of pulmonary embolism. 2. Widespread bilateral airspace and ground-glass opacities with septal thickening consistent with edema. Patchy more confluent consolidations particularly at the left base are present such that pneumonia cannot be excluded. 3. Right-sided chest tube with trace residual right pneumothorax. 4. Underlying chronic pulmonary disease appears progressed from the exam of [**2191-3-6**]. The study and the report were reviewed by the staff radiologist. [**8-24**] ECHO Conclusions The left atrium is mildly dilated. A small secundum atrial septal defect is present. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size is mildly dilated 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. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Small secundum atrial septal defect. Preserved biventricular systolic function. Mild mitral regurgitation. Moderate pulmonary hypertension. [**8-27**] CT- Abd/ chest Final Report INDICATION: Acute hematocrit drop status post VATS and biopsy right side yesterday, also with coagulopathy and thrombocytopenia, unclear source of bleeding. COMPARISON: Comparison is made to CT chest performed [**8-23**], [**2190**]. TECHNIQUE: Non-contrast axial images were obtained from thoracic inlet to the pelvic outlet. Coronal and sagittal reformations were provided. FINDINGS: The patient is status post a right video-assisted thorascopic lung biopsy with sutures evident along the right lung base. There is interval development of large right hemorrhagic pleural effusion with high-density organizing content, likely reflecting developing hematoma as well as degree of active extravasation. Of note, there is an associated leftward shift of mediastinum with apparent collapse of the right atrium (2:35). There is slightly increased fluid within the pericardium, which is measuring 27 Hounsfield units, however, the pericardial effusion is grossly unchanged compared to prior studies in size and the density measurements are likely falsely elevated due to artifact from patient's arms being down her side. Heart size is decreased compared to prior study, likely representing the pressure effects of the right-sided hemorrhage. Differential density noted between the interventricular septum and the intracardiac blood, indicating anemia. There are diffuse ground-glass opacifications with smooth septal thickening, likely representing pulmonary edema. More confluent areas of dense opacification in the basilar segments of the right upper lung as well as in the right mid and lower lung and left lower lung likely represent pneumonia. Endotracheal tube is well positioned. Nasogastric tube terminates in the body of the stomach. Left-sided PICC line terminates in the upper SVC. Right-sided Port-A-Cath terminates in the right atrium. Central airways are clear. No lymphadenopathy identified. Atherosclerotic calcifications are noted within the aorta and coronary arteries. Large volume nonhemorrhagic intra-abdominal ascites evident. Kidneys are without hydronephrosis or masses. There appears to be delayed excretion of the contrast, which is likely related to right heart catheterization performed [**2191-8-24**], suggestive of ATN. There is the appearance of interval development of diffuse rounded hypodensities throughout the liver, predominantly more central than peripheral. Findings are of unclear etiology and may relate to delayed excretion, though multiple abscesses is a less likely consideration. The gallbladder is minimally distended. Given ascites and lack of intravenous contrast, assessment of the abdomen is extremely limited. No small or large bowel dilatation identified. Oral contrast is noted in the bowel. Rectal tube in place, Foley catheter in place. No fractures are identified. No suspicious lytic or blastic lesions evident. IMPRESSION: 1. Patient status post right-sided VATS biopsy with interval development of a large tension hemorrhagic pleural effusion with leftward shift of mediastinum and collapse of the right atrium and overall small-appearing heart. Right-sided chest tube in place. 2. Diffuse ground-glass opacities noted throughout the lung with smooth septal thickening as well, likely related to pulmonary edema with additional more focal opacification concerning for pneumonia. 3. Diffuse rounded hypodensities throughout the liver with central hilar predilection are of unclear etiology, may represent delayed contrast excretion versus indicating multiple abscesses. 4. Large volume simple ascites. 5. Retained intravenous contrast within the kidneys likely related to cardiac catheterization two days prior, suggestive of ATN. 6. Anasarca. [**2191-8-26**] 10:28 pm BLOOD CULTURE Source: Line-port. Blood Culture, Routine (Pending): __________________________________________________________ [**2191-8-26**] 9:22 pm BLOOD CULTURE Source: Line-aline. Blood Culture, Routine (Pending): __________________________________________________________ [**2191-8-26**] 8:40 pm BLOOD CULTURE Source: Line-aline. Blood Culture, Routine (Pending): __________________________________________________________ [**2191-8-26**] 8:36 pm URINE Source: Catheter. **FINAL REPORT [**2191-8-27**]** URINE CULTURE (Final [**2191-8-27**]): NO GROWTH. __________________________________________________________ [**2191-8-26**] 8:30 pm SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2191-8-26**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Preliminary): Further incubation required to determine the presence or absence of commensal respiratory flora. YEAST. SPARSE GROWTH. __________________________________________________________ Time Taken Not Noted Log-In Date/Time: [**2191-8-25**] 5:27 pm TISSUE RIGHT LUNG. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary): VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Preliminary): CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Preliminary): Direct Antigen Test for Herpes Simplex Virus Types 1 & 2 (Final [**2191-8-26**]): SPECIMEN NOT PROCESSED DUE TO: NOT ACCEPTABLE FOR TISSUE BIOPSY. PLEASE REFER TO HERPES CULTURE FOR RESULT. TEST CANCELLED, PATIENT CREDITED. __________________________________________________________ Time Taken Not Noted Log-In Date/Time: [**2191-8-25**] 5:27 pm TISSUE RIGHT LUNG. GRAM STAIN (Final [**2191-8-25**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2191-8-26**]): NO FUNGAL ELEMENTS SEEN. ACID FAST SMEAR (Final [**2191-8-26**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): __________________________________________________________ [**2191-8-24**] 8:03 pm URINE Source: Catheter. **FINAL REPORT [**2191-8-25**]** Legionella Urinary Antigen (Final [**2191-8-25**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. __________________________________________________________ [**2191-8-23**] 5:30 pm BLOOD CULTURE Source: Line-a line . Blood Culture, Routine (Pending): __________________________________________________________ [**2191-8-23**] 5:30 pm BLOOD CULTURE Source: Line-cvl. Blood Culture, Routine (Pending): __________________________________________________________ [**2191-8-23**] 5:14 pm URINE Source: Catheter. **FINAL REPORT [**2191-8-24**]** URINE CULTURE (Final [**2191-8-24**]): NO GROWTH. __________________________________________________________ [**2191-8-22**] 8:32 pm BRONCHOALVEOLAR LAVAGE BRONCHOALVEOLAR LAVAGE. GRAM STAIN (Final [**2191-8-23**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2191-8-25**]): NO GROWTH, <1000 CFU/ml. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2191-8-23**]): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Preliminary): YEAST. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Final [**2191-8-25**]): HERPES SIMPLEX VIRUS TYPE 1. CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY.. CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final [**2191-8-25**]): Negative for Cytomegalovirus early antigen by immunofluorescence. Refer to culture results for further information. __________________________________________________________ [**2191-8-22**] 5:43 pm SWAB Source: Rectal swab. **FINAL REPORT [**2191-8-25**]** R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2191-8-25**]): No VRE isolated. __________________________________________________________ [**2191-8-22**] 5:43 pm MRSA SCREEN Source: Rectal swab. **FINAL REPORT [**2191-8-25**]** MRSA SCREEN (Final [**2191-8-25**]): No MRSA isolated. __________________________________________________________ [**2191-8-22**] 5:42 pm BLOOD CULTURE Source: Line-tlc. Blood Culture, Routine (Pending): __________________________________________________________ [**2191-8-22**] 5:42 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2191-8-25**]** MRSA SCREEN (Final [**2191-8-25**]): No MRSA isolated. __________________________________________________________ [**2191-8-7**] 1:19 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE. GRAM STAIN (Final [**2191-8-7**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2191-8-9**]): NO GROWTH, <1000 CFU/ml. POTASSIUM HYDROXIDE PREPARATION (Final [**2191-8-7**]): Test cancelled by laboratory. PATIENT CREDITED. This is a low yield procedure based on our in-house studies. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (7-2306). Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2191-8-8**]): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Final [**2191-8-22**]): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2191-8-9**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. __________________________________________________________ [**2191-8-6**] 4:19 pm SPUTUM Source: Expectorated. **FINAL REPORT [**2191-8-22**]** GRAM STAIN (Final [**2191-8-6**]): <10 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final [**2191-8-6**]): TEST CANCELLED, PATIENT CREDITED. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2191-8-7**]): SPECIMEN NOT PROCESSED DUE TO: IMPROPER SPECIMEN COLLECTION. Induced sputum required. PLEASE SUBMIT ANOTHER SPECIMEN. TEST CANCELLED, PATIENT CREDITED. Reported to and read back by DR [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **] [**2191-8-7**] AT 15:48. FUNGAL CULTURE (Final [**2191-8-22**]): GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS. Specimen is only screened for Cryptococcus species. New specimen is recommended. Brief Hospital Course: 64-year-old woman with very complex past history now presents with severe hypoxemic respiratory failure, shock, and oliguric renal failure after a recent admission for the same overall syndrome, which improved with time, antibiotics, and steroids. The overall impression at that admission had been that she was likely to have immunologically mediated disease. BAL and serologic examinations were non-diagnostic. In this admission, bronchoscopy on the night of admission was consistent with alveolar hemorrhage. She was treated with broad-spectrum antibiotics and pulse-dose steroids. She came off pressors and did not grow bacterial pathogens. BAL was negative for bacterial pathogens but did grow HSV. Although the literature supports that this is often just reactivation, rather than than a causal pathogen, she was treated with systemic acyclovir. The principal differential was felt to be idiopathic ARDS (i.e., acute interstitial pneumonia or recurrent Hamman-[**Doctor First Name **] syndrome) vs. a potentially treatment-responsive lung disease (such as DIP or PAP). PE protocol CT excluded PE. Her chest CT had been interpreted as potentially consistent with pulmonary edema. To exclude a cardiac etiology of her pulmonary findings, she underwent both echocardiogram and right heart catheterization. This excluded hydrostatic pulmonary edema as the etiology. We therefore recommended lung biopsy, and her family wished to proceed. The results of her VATS lung biopsy showed: "The findings are consistent with organizing stage of ARDS/DAD (adult respiratory distress syndrome/diffuse alveolar damage). The nature of the preexisting interstitial lung disease is unclear." HSV stains on tissue were negative. The diagnosis was therefore felt to be recurrent Hamman-[**Doctor First Name **] syndrome, which is associated with a dismal prognosis and no effective therapy. She was treated with Meduri-protocol steroids. However, she became thrombocytopenic and began to bleed from her chest tube. Thoracic surgery offered operative exploration, but her family elected to transition to comfort-focused care given her overall comorbidities and prognosis, and the patient died on [**2191-8-27**] at 10:46am. Medications on Admission: 1. BuPROPion 100 mg PO TID 2. Glargine 14 Units Bedtime Insulin SC Sliding Scale using REG Insulin 3. Nadolol 20 mg PO DAILY 4. Simvastatin 20 mg PO DAILY 5. Furosemide 20 mg PO BID 6. Docusate Sodium (Liquid) 100 mg PO BID 7. PredniSONE 20 mg PO DAILY Duration: 6 Days 20mg x3 days [**Date range (1) **] 10mg x3 days [**Date range (1) 17940**] Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: recurrent Hamman-[**Doctor First Name **] syndrome (idiopathic ARDS) respiratory failure shock acute renal failure acute blood loss anemia Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]

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icd9cm

[ [ [] ] ]

[ "34.04", "96.6", "32.20", "38.91", "89.64", "96.72", "33.24", "38.93" ]

icd9pcs

[ [ [] ] ]

24680, 24689

22035, 24255

361, 439

24871, 24880

2594, 2594

24936, 25075

2028, 2106

24651, 24657

24710, 24850

24281, 24628

24904, 24913

2137, 2575

20799, 22012

18427, 19436

15310, 16375

19470, 20763

295, 323

467, 927

2610, 14297

16411, 16426

949, 1894

1910, 2012

73,612

135,460

54632

Discharge summary

report

Admission Date: [**2195-8-6**] Discharge Date: [**2195-8-9**] Date of Birth: [**2122-10-10**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 4327**] Chief Complaint: Chest Pain, SOB Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 72 y/o male with PMHx of CAD (3 vessel disease with 100% occlusion of the right coronary artery but good collateralization), CHF, PVD with R stent leg, HTN, DM2, carotid artery disease, recent PEA arrest (hospitalized at [**Hospital1 18**]) and mod-severe AS (peak gradient of 40mmHg and an estimated valve area of 1.0cm2) who is admitted for chest pain and shortness of breath. History is gathered from the patient's two daughters, as he is too obtunded to give a history. Per his daughters, he had been experiencing increasing CP all week since being discharged from rehab on [**7-31**]. Has had multiple episodes of chest pain that came on with both rest and exertion, as well as while sitting on the toilet trying to have BM. Associated with diaphoresis and radiation of pain to left arm. Episodes lasted less than an hour usually and were relieved with multiple doses of nitro. He also was complaining of worsening shortness of breath, which became signficantly worse last night. Has been sleeping sitting up in a chair, becomes dyspneic and has chest pain when lying flat. Daughters also endorse PND and worsening lower extremity edema. Given all these symptoms, his daughters have called 911 a few times this week, but thus far the patient had refused to go. Today they mentioned his symptoms at a pre-op visit for CABG planning, and they were told to call their cardiologist, who recommended they bring him to the ER. They brought him to [**Hospital3 **], where he was tachypneic and tachycardic, so he was started on BiPAP. Nitro paste was applied, resulting in hypotension, so paste was removed. Cardiac enzymes at that time were negative and ECG showed baseline LVH with "strain" pattern. Given that his providers were at [**Hospital1 18**] and he is scheduled to undergo CABG here next week, he was transferred to [**Hospital1 18**] ED via med-evac flight. While en route he started to not tolerate the BiPAP, was given ativan 2mg IV, and subsequently became obtunded. On arrival to [**Hospital1 18**], initial vitals were HR: 99, BP: 179/70, and his GCS was 7, he was satting 90% on NRB. He was switched back onto BiPAP given his belly breathing, poor breath sounds at bases with crackles. He was started low dose nitro gtt with drop in pressures again, so this was stopped. No lasix was given in the ED. Labs and imaging significant for Trop negative, CK: 37 MB: 2, Lactate:2.3, CXR showing volume overload from comparision 12 hours ago. On arrival to the floor, patient was on BiPAP, sedative and minimally responsive, GCS 12. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension . 2. CARDIAC HISTORY: -CABG: In pretesting first seen [**2195-8-6**] in Dr.[**Name (NI) 11272**] clinic. -PERCUTANEOUS CORONARY INTERVENTIONS: none (3 VD) -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: PEA arrest in [**2195-6-5**] Mitral Regurgitation Moderate to severe Aortic Stenosis Severe primary pulmonary hypertension COPD on home O2 Peripheral vascular disease Bilateral Carotid Stenosis - Occluded right ICA Benign neck tumors Social History: Lived independently until recent hospitalization, was in rehab until 1 week ago. Back at home now with VNA -Tobacco history: 1 ppd for many years, current smoker -ETOH: unknown -Illicit drugs: none Family History: Father and 2 brothers with CAD Physical Exam: Admission Physical Exam: VS: T=97.8 BP=142/95 HR=60 RR=18 O2 sat= 98% GENERAL: WDWN male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of [**8-13**] cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. . Loud, late-peaking SEM with radiation to carotids. No r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. accessory muscle use and belly breathing. Bibaliar crackles with expitory wheeze. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. 1+ lower extermity pitting edema SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Left: Carotid 2+ Pertinent Results: CXR [**2194-8-5**]: Mild pulmonary edema, not definitely changed given differences in inspiratory effort and portable technique since exam earlier the same day. [**2195-8-6**] 01:40PM BLOOD WBC-10.3 RBC-3.49* Hgb-10.3* Hct-31.9* MCV-91 MCH-29.3 MCHC-32.2 RDW-15.9* Plt Ct-220 [**2195-8-9**] 08:40AM BLOOD WBC-10.1 RBC-3.64* Hgb-10.4* Hct-32.5* MCV-89 MCH-28.6 MCHC-32.1 RDW-16.8* Plt Ct-220 [**2195-8-9**] 08:40AM BLOOD Glucose-226* UreaN-24* Creat-1.0 Na-138 K-4.3 Cl-94* HCO3-37* AnGap-11 [**2195-8-8**] 03:25PM BLOOD UreaN-25* Creat-1.1 Na-138 K-4.5 Cl-94* [**2195-8-8**] 07:15AM BLOOD Glucose-154* UreaN-21* Creat-1.0 Na-137 K-4.6 Cl-95* HCO3-37* AnGap-10 [**2195-8-7**] 03:35PM BLOOD Glucose-292* UreaN-29* Creat-1.0 Na-137 K-4.3 Cl-94* [**2195-8-7**] 07:44AM BLOOD Glucose-203* UreaN-28* Creat-1.0 Na-136 K-4.0 Cl-95* HCO3-38* AnGap-7* [**2195-8-6**] 01:40PM BLOOD UreaN-29* Creat-1.0 Na-137 K-5.1 Cl-95* HCO3-37* AnGap-10 [**2195-8-7**] 07:44AM BLOOD CK-MB-2 cTropnT-<0.01 [**2195-8-6**] 08:50PM BLOOD CK-MB-2 proBNP-7575* [**2195-8-6**] 08:50PM BLOOD cTropnT-<0.01 Brief Hospital Course: Mr. [**Known lastname 111747**] is a 72 year old male with PMHx of CAD (3 vessel disease undergoing CABG work up), CHF, HTN, DM2, and severe AS who presented with chest pain and shortness of breath and found to have an acute CHF exacerbation. Active Diagnoses: #Acute on chronic diastolic CHF: The patient presented to an OSH with chest pain and increased oxygen requirements and was transferred to [**Hospital1 18**] for further care. On presentation to [**Hospital1 18**] he was sedated (given Ativan at OSH), on BiBAP, poor O2 saturation on 100% non-re breather. He was admitted to the CCU where his mental status improved. He was aggressively diuresed and over the course of his hospitalization was negative 6.5L. His oxygenation improved and he was weaned off BiPAP. He was continued to be diuresed and was transitioned to oral medication. It was felt that the chest pain and SOB was due to this volume overload and his cardiac markers were negative. His case was discussed with the cardiothoracic surgeons who felt that he was stable to be discharged home and could represent to the hospital on Thursday [**2195-8-13**] for definitive treatment (CABG and AVR). He was discharged on 80mg PO BID of furosemide with lab work follow-up on Tuesday [**2195-8-13**]. Chronic Diagnoses: #CAD: He is known to have 3 vessel disease and at time of admission was undergoing pre-surgery evaluation with a scheduled surgery date of [**2195-8-13**]. Given his clinical improvement of his chest pain and SOB on medical therapy it was not felt that he needed emergent CABG. He will keep his scheduled surgery date of [**2195-8-13**] for definitive therapy. #HTN: The patient is known to have this diagnosis and he had several episodes of hypertension following diuresis. His Lisinopril was increased to 20mg PO daily and his metoprolol was decreased to 100mg PO BID. On this oral regimen his SBP was in the 120s-130s. He was discharged on this regimen. #DM2: He is known to have this diagnosis and is only on oral metformin at home. THis was held on admission over concern that he may require a procedure with contrast. He was maintained on a insulin sliding scale while in the hospital and was discharged home on his home oral medication. #Aortic Stenosis: He is known to have this diagnosis and this complicated his care as on presentation at the OSH and [**Hospital1 18**] ed he was given nitro (paste at OSH and drip at [**Hospital1 18**]) which caused a drop in his blood pressure. His pressures normalized following discontinuation of these medications. He will undergo definitive treatment for this at his planned CABG on [**2195-8-13**]. Transitional Issues: # He is planned to have surgery with Dr. [**First Name (STitle) **] on [**2195-8-13**]. In preparation for surgery given his recent hospitalization and aggressive diuresis he will have Chem-7 drawn with his out-patient cardiologist on [**2195-8-11**]. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Family/Caregiver[**Name (NI) 581**]. 1. MetFORMIN (Glucophage) 1000 mg PO BID 2. Lisinopril 10 mg PO DAILY 3. Metoprolol Tartrate 125 mg PO BID 4. Furosemide 40 mg PO BID 5. Atorvastatin 20 mg PO DAILY 6. Aspirin 325 mg PO DAILY 7. DiphenhydrAMINE 50 mg PO QHS:PRN insomnia Not currently taking 8. Acetaminophen 650 mg PO HS Discharge Medications: 1. Acetaminophen 650 mg PO HS 2. Aspirin 325 mg PO DAILY 3. Atorvastatin 20 mg PO DAILY 4. Lisinopril 20 mg PO DAILY hold for sbp<100 RX *lisinopril 10 mg 2 tablet(s) by mouth Daily Disp #*60 Tablet Refills:*0 5. Metoprolol Tartrate 100 mg PO BID RX *metoprolol tartrate 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 6. MetFORMIN (Glucophage) 1000 mg PO BID 7. DiphenhydrAMINE 50 mg PO QHS:PRN insomnia Not currently taking 8. Outpatient Lab Work Dx: Acute on chronic diastolic congestive heart failure Please draw chem 7 panel (Na, K, Cl, CO2, BUN, Cr) on Tuesday [**2195-8-11**] and send results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 111748**] at fax [**Telephone/Fax (1) 111749**], phone [**Telephone/Fax (1) 45283**]. 9. Furosemide 80 mg PO BID RX *furosemide 40 mg 2 tablet(s) by mouth twice a day Disp #*120 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [**Hospital3 **]Hospice Discharge Diagnosis: Acute on chronic congestive heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 111747**], You were hospitalized for acute shortness of breath and chest pain. You were found to have too much fluid and that was the cause of your shortness of breath. You were given lasix (a water pill) to take off the extra fluid. We talked with your surgeons and we decided that you are safe to go home until your surgery on Thursday [**2195-8-13**]. You should continue to take your home medications. You should also have your labs checked (electrolytes and creatinine) on Tuesday [**2195-8-11**]. Medication Changes: INCREASE lisinopril to 20mg daily DECREASE metorpolol to 100mg daily INCREASE Furosemide to 80mg twice a day. Followup Instructions: Please check a Chem 7 (Na, K, Cl, Bicarb, Cr, BUN, glucose) on [**2195-8-11**] and fax results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 86177**]. Fax: ([**Telephone/Fax (1) 92239**], Phone: ([**Telephone/Fax (1) 86181**]. Please follow up with Dr.[**Name (NI) 111750**] for surgery on Thursday.

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9946, 10000

5656, 5900

287, 294

10086, 10086

4558, 5633

10917, 11243

3651, 3684

9035, 9923

10021, 10065

8597, 9012

10237, 10763

3724, 4539

2999, 3152

8318, 8571

10783, 10894

232, 249

322, 2889

10101, 10213

3183, 3419

5918, 8297

2911, 2979

3435, 3635

12,954

150,007

1515

Discharge summary

report

Admission Date: [**2137-1-15**] Discharge Date: [**2137-2-12**] Date of Birth: [**2077-7-8**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Zestril / Heparin Agents / Heparin,Beef Attending:[**First Name3 (LF) 1267**] Chief Complaint: 59 year old male with 6-9 months of increased DOE. Major Surgical or Invasive Procedure: AVR (21mm CE Magna tissue valve) [**2137-1-16**] Tracheostomy PEG History of Present Illness: This 59 year old white male has a history of severe COPD and aortic stenosis has had significant deterioration in his breathing over the past 6-9 months. He started using oxygen at home 4 weeks prior to admission. He underwent cardiac echo on [**2136-12-25**] which showed an EF of 60% and a bicuspid aortic valve with severely thickened and deformed leaflets and [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.7 cm2 and a peak gradient of 43 mmHg. He is now admitted for cardiac cath prior to AVR. Past Medical History: Hypertension Aortic stenosis Osteomyelitis of hip, s/p L hip replacement in [**2132**] s/p septic arthritis of the L wrist in [**11-2**] Severe COPD s/p L knee surgery s/p vasectomy s/p rhinoplasty as a child because of fx s/p GIB several years ago h/o adrenal mass s/p removal of skin cancers Social History: Married, retired fire fighter. Cigs: smoked [**2-3**] ppd x 30-40 years and quit in [**8-5**] ETOH: weekend beer drinker Family History: + CAD Physical Exam: Gen: Thin white male in NAD AVSS HEENT: N/C,A/T, PERLA, EOMI, oropharynx benign. Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids 2+= bilat. w/ radiating murmurs. Lungs: clear to A+P CV: RRR without R/G, 3/6 SEM Abd: + BS, soft, nontender without masses or hepatosplenomegaly Ext: without C/C/E, no varicosities. Neuro: nonfocal Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2137-2-12**] 02:43AM 9.9 3.75* 9.1* 30.7* 82 24.3* 29.7* 17.7* 399 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [**2137-2-12**] 02:43AM 399 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2137-2-12**] 02:43AM 138* 51* 1.3* 139 4.5 101 29 14 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2137-2-11**] 06:00AM 52* 76* 624* 101 124* 0.5 OTHER ENZYMES & BILIRUBINS Lipase [**2137-2-11**] 06:00AM 238* CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2137-2-11**] 06:00AM 3.2* 8.6 3.9 2.0 RADIOLOGY Final Report CHEST (PORTABLE AP) [**2137-2-9**] 8:41 AM CHEST (PORTABLE AP) Reason: eval for consolidation [**Hospital 93**] MEDICAL CONDITION: 59 year old man with AS s/p AVR. REASON FOR THIS EXAMINATION: eval for consolidation INDICATION: Effusion, followup. PORTABLE CHEST: Comparison is made to prior film from 2 days earlier. A tracheostomy tube remains in place. Cardiac and mediastinal contours are stable. There is increased density in both lung bases, left greater than right, consistent with bilateral pleural effusions. These appear more conspicuous today, although it is uncertain whether this reflects differences in patient's positioning (i.e. with more posterior layering of effusions currently). Note that superimposed parenchymal abnormality, including pneumonia, cannot be excluded. More cephalad portions of each lung field are clear. IMPRESSION: Bilateral pleural effusions left greater than right (see above). DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 8889**] Approved: SAT [**2137-2-9**] 3:26 PM Brief Hospital Course: The patient was admitted on [**2137-1-15**] and had a cardiac cath on [**1-14**] which revealed: severe AS, mild pulm HTN, diffuse plaquing with ostial and prox. 30-40% stenosis, toherwise clean coronaries. LVEF: 40% and 1+MR. On [**1-16**] Dr. [**Last Name (STitle) **] performed an AVR with a 21mm [**Company 1543**] Mosaic valve. Cross clamp time was 73 mins. and total bypass time was 91 minutes. He tolerated the procedure well and was transferred to the CSRU in stable condition on Propofol and Neo. He was extubated on the post op night and remained on Neo on POD #1. His chest tubes were d/c'd on POD#2. POD #3 he had decreased urine output with a creat. of 2.8 and markedly elecated LFTs. He was swanned and seen by the renal and hepatology services. He was started on Natracor. He also had several episodes of PAF, which he did not tolerate well and was followed by EP. He was treated at that time with Procainamide because of his liver issues. On POD#5 he was reintubated for respiratory distress. He continued to require agressive respiratory therapy and continued to have arrythmia issues. Eventually he was briefly extubated and required reintubation. He underwent tracheostomy and PEG placement on [**1-29**] and has been stable since that time. He is now on trach collar, but has secretions and requires frequent suctioning. His renal and liver issues have resolved. He grew out staph aureus in his sputum and has been treated with Vanco. on POD# 27 he was discharged to rehab in stable condition. Medications on Admission: Diovan/HCTZ 160/2.5 [**2-3**] tab PO daily Protonix 40 PO daily Albuterol 2 puffs QID Spiriva daily Discharge Medications: 1. Acetaminophen 160 mg/5 mL Elixir Sig: One (1) Elixir PO Q4H (every 4 hours) as needed for temperature >38.0. 2. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Albuterol 90 mcg/Actuation Aerosol Sig: Eight (8) Puff Inhalation Q4H (every 4 hours). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Eight (8) Puff Inhalation QID (4 times a day). 7. Olanzapine 10 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO DAILY (Daily). 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 9. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: Two (2) Drop Ophthalmic TID (3 times a day). 10. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4 times a day). 11. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation every 4-6 hours as needed. 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 15. Diltiazem HCl 60 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 16. Valsartan 80 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 17. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO twice a day for 7 days: Decrease dose to 400 mg PO daily for 7 days after [**Hospital1 **] dose completed, and then decrease to 200 mg PO daily after that. 18. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day. 19. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) Intravenous twice a day for 6 days. 20. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 21. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 22. Nystatin 100,000 unit/mL Suspension Sig: Five (5) cc PO four times a day. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Aortic stenosis Severe COPD Respiratory failure Discharge Condition: Fair. Discharge Instructions: Follow medications on discharge instructions. You may not drive for 4 weeks. You may not lift more than 10 lbs for 3 months. Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 4127**] for 1-2 weeks after d/c from rehab Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks. Completed by:[**2137-2-12**]

[ "303.90", "291.81", "458.29", "401.9", "427.31", "584.5", "934.1", "571.2", "424.1", "570", "V43.64", "518.5", "286.7", "428.0", "496" ]

icd9cm

[ [ [] ] ]

[ "88.53", "99.62", "96.6", "31.1", "00.17", "96.05", "88.56", "88.72", "43.11", "39.61", "96.72", "89.64", "96.04", "37.23", "35.21" ]

icd9pcs

[ [ [] ] ]

7407, 7486

3647, 5182

370, 438

7578, 7585

1844, 2647

7759, 7952

1456, 1463

5332, 7384

2684, 2717

7507, 7557

5208, 5309

7609, 7736

1478, 1825

280, 332

2746, 3624

466, 985

1007, 1302

1318, 1440

27,109

103,103

34182

Discharge summary

report

Admission Date: [**2195-5-11**] Discharge Date: [**2195-6-2**] Date of Birth: [**2166-9-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 99**] Chief Complaint: jaundice and fatigue Major Surgical or Invasive Procedure: Paracentesis, diagnostic Paracentesis, therapeutic History of Present Illness: 28 year old man with hx of chronic etoh use presenting with fatigue, jaundice and found to be anemic. He stated that ~[**12-10**] months ago he noticed that he was more fatigued with increasing abdominal girth, leg swelling and fatigue. He denies abdominal pain, chest pain, cough, dysuria, rash, or headache. He denied bloody or black stools, as well as no grey stools. He was encouraged by his mother to come to the hospital for evaluation. He initially presented to [**Hospital3 **] where he was hemodynamically stable with markedly elevated bilirubin and Hct ~15. He was guaiac negative x1. Prior to transfer he received vitamin K po, and lactulose 30 g as well as a banana bag of IVF . In the ED, his initial vital signs were 101.5 122 144/63 30 95%RA. He received zosyn IV x1 and motrin 600 mg po x1. He had a diagnostic para that showed no evidence of SBP. He was guaiac negative x 1. He received 1 unit of pRBCs and admitted to the ICU. In ICU he was continued on CTX because of fevers x 24 hours and defervesced. Past Medical History: tooth abscess ([**8-16**]) car accident at age 17 (received blood transfusion) Social History: divorced. 5 kids (10 year old son and 8 year fraternal twins (boy and girl) with ex-wife. 5 year old son, 2 year old girl with present girlfriend. works small construction jobs. incarcerated in [**2194-7-9**]. Family History: sister with HepC. dad with heavy etoh use. mom with anxiety/depression Physical Exam: VS: 99.7 118 138/57 32 100%NRB GEN: marked jaundice and distended abdomen HEENT: AT, NC, PERRLA (5->2mm bilat), EOMI, no conjuctival injection, icteric, OP clear, dental depression in left 2nd mandibular molar, MMM, Neck supple, no LAD, no carotid bruits CV: regular tachy, nl s1, s2, no m/r/g PULM: CTAB, no w/r/r with good air movement throughout ABD: marked distension with ascites, NT, + BS, no HSM, no caput. marked penile and scrotal swelling EXT: warm, +2 distal pulses BL, no femoral bruits, marked peripheral edema NEURO: alert & oriented x3, coherent response to interview, CN II-XII intact, 5/5 strength throughout. No sensory deficits to light touch appreciated. asterixis PSYCH: appropriate affect Pertinent Results: [**2195-5-11**] 05:15PM WBC-15.6* RBC-1.28* HGB-5.2* HCT-14.8* MCV-116* MCH-41.0* MCHC-35.3* RDW-23.5* [**2195-5-11**] 05:40PM HGB-5.2* calcHCT-16 O2 SAT-90 [**2195-5-11**] 07:10PM WBC-19.7* RBC-1.39* HGB-5.5* HCT-15.7* MCV-113* MCH-39.7* MCHC-35.1* RDW-25.5* [**2195-5-11**] 05:15PM ASA-NEG ETHANOL-193* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2195-5-11**] 05:15PM NEUTS-77* BANDS-15* LYMPHS-2* MONOS-3 EOS-1 BASOS-0 ATYPS-0 METAS-2* MYELOS-0 NUC RBCS-2* [**2195-5-11**] 05:15PM HYPOCHROM-3+ ANISOCYT-3+ POIKILOCY-1+ MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-1+ TARGET-1+ SCHISTOCY-1+ BURR-1+ TEARDROP-1+ ACANTHOCY-1+ [**2195-5-11**] 05:15PM PT-26.4* PTT-43.6* INR(PT)-2.6* [**2195-5-11**] 05:15PM ALBUMIN-2.5* CALCIUM-7.7* PHOSPHATE-3.3 MAGNESIUM-1.9 [**2195-5-11**] 05:15PM calTIBC-142* VIT B12-GREATER TH FOLATE-14.9 HAPTOGLOB-<20* FERRITIN-1374* TRF-109* [**2195-5-11**] 05:15PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc Ab-NEGATIVE HAV Ab-POSITIVE IgM HAV-NEGATIVE [**2195-5-11**] 05:15PM GLUCOSE-104 UREA N-22* CREAT-0.8 SODIUM-122* POTASSIUM-5.7* CHLORIDE-90* TOTAL CO2-22 ANION GAP-16 [**2195-5-11**] 06:10PM ASCITES TOT PROT-0.5 GLUCOSE-135 LD(LDH)-177 AMYLASE-18 ALBUMIN-LESS THAN [**2195-5-11**] 06:10PM ASCITES WBC-13* RBC-4100* POLYS-95* BANDS-0 LYMPHS-5* MONOS-0 EOS-0 [**2195-5-11**] 07:10PM RET MAN-15.0* . RUQ ultrasound: IMPRESSION: 1. Constellation of findings, consistent with longstanding liver disease, including splenomegaly and portal vein flow reversal. 2. Gallbladder contains sludge, no evidence of acute cholecystitis. . CXR: IMPRESSION: No acute cardiopulmonary process. . CT abd/pelvis: IMPRESSION: 1. Extremely limited exam due to lack of IV and oral contrast. 2. Splenomegaly and shrunken liver consistent with cirrhosis. Multiple varices are incompletely identified on this study. 3. Extensive amount of intra-abdominal and pelvic ascites with a small layering fluid level. 4. Extensive anasarca and scrotal edema. 5. Large ill-defined left gluteal hematoma as described above. 6. Multiple ground-glass nodules at the lung bases. This may be infectious etiology. Brief Hospital Course: 28 year old man with history of chronic etoh use presenting with fatigue found to have marked hepatic dysfunction and gastrointestinal bleed. Hepatic failure most likely secondary to alcoholic cirrhosis. Patient not a transplant candidate due to continued EtOH use. Patient with signs of worsening hepatic function including increasing abdominal girth, leg swelling, fatigue and jaundice for which he presented to [**Hospital3 3583**]. He was transferred from [**Hospital3 **] for his markedly elevated bilirubin and Hct ~15. He received 1 unit of pRBCs in the ED and was admitted to MICU Green, where he received 3 units pRBCs, Hct improved to 21. Got therapeutic tap of 8L performed on [**5-14**] without complications or signs of infection. Transferred to [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] on [**5-14**]. Started on prednisone; furosemide increased to 80 qday; albumin 50 gm started [**2195-5-16**]. On [**2195-5-18**] patient experienced hematemesis of 700 ml on the floor, was transferred to MICU [**Location (un) **], where NG suctioned out 1.5 L of blood. Patient was emergently intubated. Given 5 units of pRBCs, 4 units of FFPs, 1 bag of platelets, vasopressin, octreotide. Patient felt to have fulminant hepatic failure with poor prognosis as after his transfer to MICU [**Location (un) **] he remained he hemodynamically unstable with active bleeding at oropharynx/UGI, IV sites, via Foley and lower gastrointestinal tract bleeding requiring several units blood and FFP daily. The patient was also felt to have hepatic encephalopathy. Patient also had a fever with no clear source of infection, but was treated empirically with ceftriaxone. In this setting patient required intubation for airway protection. He also developed hepatorenal syndrome non responsive to fluids, octreotride, or midrodrine. The patient also developed a lactic acidosis likely from his liver failure with global hypoperfusion. Given the patient's multisystem organ failure and the fact that he was not a candidate for a transplant, a family meeting was held with his mother. The decision was made to shift the patient's goals of care to comfort measures. He was started on iv morphine. Organ bank notified and will intervene and meet with family to discuss organ donation in more detail. The patient died from complications of his liver disease. Medications on Admission: none Discharge Medications: Discharge due to death Discharge Disposition: Expired Discharge Diagnosis: Fulminant Hepatic Failure due to Alcoholic Cirrhosis Hepatorenal syndrome with renal failure Hepatic Encephalopathy Hematemesis due to Variceal Bleed Coagulopathy with lower gi bleed due to liver failure Respiratory Failure Discharge Condition: Dead Discharge Instructions: Discharge due to death Followup Instructions: Discharge due to death Completed by:[**2195-6-12**]

[ "286.7", "578.1", "570", "682.2", "518.81", "572.4", "276.6", "285.1", "584.9", "507.0", "790.7", "456.20", "695.9", "117.9", "572.2", "572.3", "571.2", "303.01", "578.0" ]

icd9cm

[ [ [] ] ]

[ "45.13", "39.95", "39.1", "96.72", "54.91", "39.79", "38.95", "96.6", "96.06", "38.91", "38.93", "96.04" ]

icd9pcs

[ [ [] ] ]

7213, 7222

4755, 7111

333, 385

7490, 7496

2602, 4732

7567, 7620

1783, 1855

7166, 7190

7243, 7469

7137, 7143

7520, 7544

1870, 2583

273, 295

413, 1437

1459, 1540

1556, 1767

28,744

108,474

31453

Discharge summary

report

Admission Date: [**2120-9-17**] Discharge Date: [**2120-12-5**] Date of Birth: [**2078-5-10**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: s/p Motor vehicle crash Major Surgical or Invasive Procedure: [**2120-9-18**] 1. Open treatment and fracture/dislocation of C2-3. 2. Open treatment and fracture/dislocation of C6-7. 3. Open treatment and fracture/dislocation of C7-T1. 4. Posterior cervical arthrodesis, C2-3. 5. C2 laminectomy. 6. C5-6, C6-7, C7-T1 posterior cervical arthrodesis. 7. Posterior cervical instrumentation, C5-6, C6-7, C7-T1. 8. Left iliac crest bone graft. 9. Application of local allograft. [**9-19**] 1. Open reduction and internal fixation of left maxillary sinus fracture. 2. Closed reduction of nasal bone fracture. [**2120-9-19**] 1. Open treatment of fracture dislocation C2-C3. 2. Anterior cervical diskectomy C2-3. 3. Anterior cervical arthrodesis/fusion C2-C3. 4. Application of anterior cervical plate C2-C3. 5. Right iliac crest bone graft. [**2120-9-19**] 1. Tracheostomy. 2. [**Last Name (un) **] gastrostomy. [**2120-9-20**] 1. Tracheostomy exchange day 1 post prior tracheostomyplacement. 2. Right femoral inferior vena cava filter (Bard G2 type) 3. Fluoroscopic control of IVC filter placement History of Present Illness: 42 yo male, unrestrained driver who was +EtOH; s/p high speed motor vehicle crash hit jersey barrier and was then hit from behind by a truck and ejected from the car. He had a period of asystole and was resuscitated with epinephrine and atropine. He was taken to an area hospital where found to have multiple traumatic injuries and was then immediately transferred to [**Hospital1 18**] for further care. Past Medical History: Unknown Social History: Has a mother who is very involved in his care; 2 sisters and a 10 yo daughter [**Name (NI) **] in [**Name (NI) 3844**] Family History: Noncontributory Physical Exam: Exam on admission: P: 70 BP 116/45 RR: 17 O2: 90% intubated GCS 9T HEENT: bilat pupils 6 mm, minimally reactive with divergent gaze; proptosis of left eye with eccymosis. Lacs on left and midline occiput, as well as the L pinna. Blood in the nares Resp: breathsounds bilat CV: heart sounds heard ab: soft ext: open fx of L forarm; LLE deformity and laceration Neuro: nl rectal tone; moves bilat LE spont, will move deltoids of BUE with noxious stimuli Pertinent Results: head CT [**9-17**]: 1. Extensive intracranial injury including right frontal and parietal subarachnoid hemorrhage, frontal contusions, small subdural collections and scattered foci of increased attenuation at the [**Doctor Last Name 352**]-white matter junction concerning for diffuse axonal injury. Further characterization with MR [**First Name (Titles) **] [**Last Name (Titles) **] echo sequences may be helpful for further characterization. 2. Incompletely imaged facial bone fractures as above for which a maxillofacial CT is recommended for further evaluation. 3. Metallic foreign body of unclear etiology in the region of the nasopharynx. Clinical correlation is recommended. CT sinus [**9-17**]: 1. Multiple fractures of the left frontal and parietal bones. Comminuted fracture of the left orbital walls and comminuted fractures of the left maxillary sinus walls. 2. Comminuted fracture of the left parasymphyseal region of the mandible as well as fractures of the alveolar ridge of the central-to-right body of the mandible as well as the left maxillary alveolar ridge. 3. Additional fractures of the anterior wall of the right maxillary sinus and the pterygoid plates bilaterally. Fracture of the left hard palate and right nasal bone. 4. Comminuted fracture of the right lamina of C2 and the left pedicle and body of C2. Please refer to concurrent CT of the cervical spine for additional findings. 5. Tiny left subdural hematoma and right subarachnoid hemorrhage. Please refer to the concurrent CT of the head as well as head MR for additional significant findings. MR head [**9-17**]: 1. Multiple small areas of slow diffusion in teh cortex suspicious for contusions, although embolic infarction could present a similar appearance. 2. Enlarged extra- axial CSF space over the frontal and temporal lobes bilaterally, which may represent with intensity slightly greater than CSF. These likely represent subdural hygromas. No significant change in size of a thin T2 hyperintense extra- axial hemorrhage over the left frontal, temporal and parietal lobes. 3. Bilateral subarachnoid hemorrhages. C-spine CT [**9-17**] The skull base through the superior endplate of T2 is well visualized on the lateral view. An endotracheal tube is noted in place. Multiple fractures are identified. There is a comminuted fracture of the C2 left body lamina junction which extends to the vertebral foramen. A comminuted fracture of the right C2 lamina is seen extending into the pars inferior facet. There is clockwise rotation of C2 in relation with the C1 vertebral body. The right inferior articulating facet of C2 appears subluxed lying anterior to the inferior facet of C3. Additional fractures include a comminuted C5 spinous process fracture, a comminuted fracture of the C6 spinous process extending slightly into the bilateral laminae, a distracted fracture of the C7 pedicle and a nondisplaced fracture of the right C7 lamina. Nondisplaced fractures are also noted involving the anteroinferior C7 and anterosuperior T1 vertebral bodies. There is a unilateral "jumped" left facet, C6 on C7. CT does not provide intrathecal detail comparable to MR. [**First Name (Titles) **] [**Last Name (Titles) **] material within the spinal canal at C6-C7 likely compresses the cord and may represent hematoma or disk material. Bullous changes are present at the lung apices. A metallic foreign body is noted in the nasopharynx of unclear origin. Please refer to the accompanying CT facial bone regarding numerous skull fractures. MR [**Name13 (STitle) 2853**] [**9-17**] 1. Edema and/or contusion of the cervical cord at the C2/3 level. 2. T2 and STIR hyperintensity of the disc at the C2/3 level with disruption of the disc margin posteriorly. Similar findings at the C7/T1 level. 3. Disruption of the ligamentum flavum at the C6/7 level. 4. Edema and/or hemorrhage of the interspinous ligaments extending from C3 through T1. 5. Left C6/7 unilateral interfacet dislocation and right C2/3 and left C7/T1 facet joint disruption. 6. For full description of the cervical spinal fractures, please refer to the concurrent CT of the cervical spine. 7. No large epidural hematomas. No cord compression. 8. Prevertebral hematoma suspicious for anterior longitudinal ligament injury. CT C/A/P [**9-17**] 1. Focal irregularity of the intima in the descending aorta concerning for minimal aortic injury. As the location is not classic differential diagnosis includes atherosclerotic plaques, although this is considered less likely. Follow-up CT in 24 hours is recommended to ensure stability. 2. No mediastinal hematoma. 3. Patchy airspace opacity likely representing pulmonary contusion with aspiration in the right mid lower lobes. Dense consolidation at the lung bases, greater than left, may represent atelectasis versus effusion. 4. Fractures of the fourth and fifth ribs with tiny amount of subpleural air. 5. Fractures of the lumbar spine as described above. 6. Thickening of the bladder wall extending into the distal left ureter with proximal dilatation of the ureter. The constellation of findings is comcerning for transitional cell carcinoma and atypical for traumatic injury. Follow- up CT with delayed images of the ureter and a filled bladder are recommended for better delineation of the process. ADDENDUM: Upon further review, it was noted that the patient had a nondisplaced fracture of the medial right scapula. Findings were discussed with Dr. [**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) **] [**2120-9-18**]. L femur XR/L tib fib XR [**9-17**]: Minimally displaced fracture through the distal fibula. Soft tissue defect anterior to the tibia containing foci of linear hyperdensity consistent with retained foreign bodies. LUE XR [**9-17**]: no fx LENI [**9-18**]: neg CT head/sinus [**9-22**] 1. Overall unchanged appearance of the brain with diffuse subarachnoid hemorrhage, subdural hematoma, and contusion. Slightly decreased [**Doctor Last Name 352**]-white differentiation, which can be technical. Please correlate clinically. 2. Numerous comminuted fractures of the skull and facial bones as described above post-surgery. Fractures of the cervical spine, only partially visualized. SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT PORT [**2120-11-15**] 4:40 PM SHOULDER (AP, NEUTRAL & AXILLA Reason: r/o fracture or other processes [**Hospital 93**] MEDICAL CONDITION: 42 year old man s/p fall out of bed now with increased right shoulder pain and point tenderness. REASON FOR THIS EXAMINATION: r/o fracture or other processes EXAMINATION: Right shoulder. INDICATION: Pain. Fall out of bed. Views of the right shoulder show no evidence of acute displaced fracture. There is, however, inferior subluxation of the humeral head by approximately 1-1.5 cm. IMPRESSION: Inferior subluxation of right humeral head from glenoid. CT HEAD W/O CONTRAST [**2120-11-14**] 7:52 PM CT HEAD W/O CONTRAST Reason: eval for fx, interval change in ICH [**Hospital 93**] MEDICAL CONDITION: 42 year old man with chronic subdural, s/p fall out of bed, no LOC, unknown head trauma REASON FOR THIS EXAMINATION: eval for fx, interval change in ICH CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Chronic subdural hematoma, status post fall off bed, no loss of consciousness. Evaluate for change. COMPARISON: [**2120-11-7**]. TECHNIQUE: Non-contrast head CT scan. FINDINGS: There is no evidence of acute hemorrhage. Again seen are bilateral frontal extra-axial collections, not significantly changed compared to prior studies, again consistent with subdural hematomas. Maximum thickness again measures upwards of 9 mm, not significantly changed from prior study. There is no shift of normally midline structures. Ventricles appear stable. [**Doctor Last Name **]- white matter differentiation appears preserved. Likely mucous retention cyst within the right maxillary sinus, not significantly changed from prior. Post- surgical sinus changes also again seen. IMPRESSION: No evidence of acute hemorrhage. Bifrontal subdural hematomas versus hygromas are again seen, not significantly changed in appearance from prior. CHEST (PA & LAT) [**2120-11-11**] 10:52 AM CHEST (PA & LAT) Reason: eval for PNA [**Hospital 93**] MEDICAL CONDITION: 42 year old man with multiple traumatic injuries, central cord syndrome, trach + PEG w/ increasing sputum production REASON FOR THIS EXAMINATION: eval for PNA INDICATION: 42-year-old man with multiple traumatic injury, central cord syndrome, tracheostomy tube and PEG tube placement with increasing sputum production. COMPARISON: AP upright portable chest x-ray dated [**2120-10-22**]. AP UPRIGHT PORTABLE CHEST X-RAY: A tracheostomy tube is in place. The PEG tube catheter is not clearly seen. The cardiac silhouette and mediastinal contours are normal and stable. Atelectasis at both lung bases has increased. There is a small left pleural effusion, which appears stable in size. An underlying pneumonia is not excluded. The surrounding soft tissue and osseous structures are unchanged, with cervical plates in the lower neck. IMPRESSION: Increased bibasilar atelectasis. Pneumonia, particularly at the left lung base, may be obscured. C-SPINE (AP, FLEX & EXT) 3 VIEWS Reason: assess for any cervical spine postoperative changes/processe [**Hospital 93**] MEDICAL CONDITION: 42 year old man s/p MVC with cervical spine fractures; s/p spine stabilization on [**9-18**] REASON FOR THIS EXAMINATION: assess for any cervical spine postoperative changes/processes CERVICAL SPINE HISTORY: 42-year-old man status post motor vehicle collision with cervical spine fractures status post stabilization. Assess for any postop change. TECHNIQUE: Four views of the cervical spine were obtained including lateral flexion and extension views. FINDINGS: Comparison is made to prior films of the cervical spine from [**2120-10-17**]. Again seen is anterior fixation plate and screws spanning C2 and C3 with apparent bony fusion across the disc space. There is also posterior spinal fusion extending from C5-T1. No evidence of hardware breaks. The lower pedicle screws are not well evaluated on the lateral films. There is no evidence of loosening of the superior pedicle screws. There is no abnormal alignment of the visualized cervical spine down to the C6 level upon flexion or extension. The atlantoaxial interval is maintained. Also again seen is a tracheostomy as well as multiple fixation plates, screws, and cerclage wires of the mandible and maxilla. Periapical lucencies are seen around the roots of a few mandibular teeth, which may represent periodontal disease. IMPRESSION: No abnormal alignment of the cervical spine upon flexion or extension down to the C6 level. The lower portion of the posterior cervical fusion is not well visualized due to the overlying shoulders. Brief Hospital Course: He was admitted to the Trauma Service. Orthopedic Spine surgery was consulted given his spine fractures; he was taken to the operating room on [**9-18**] for posterior instrumentation and on [**9-19**] was taken back for anterior instrumentation; during this time he underwent placement of tracheostomy and gastrostomy tube by Trauma Surgery. His multiple facial fractures were also repaired on the 9th in the operating room by Oral Maxillo Facial Surgery. Behavioral Neurology was consulted for anoxic brain injury. Several recommendations were made pertaining to his medications. He was loaded with Dilantin, and remained on this for 10 days for seizure prophylaxis. There was no evidence of any seizure activity. He remained in the Trauma ICU for several weeks; he was difficult to wean from the ventilator despite early tracheostomy placement. He would eventually be weaned; is currently tolerating a trach mask. Transfer to the regular nursing unit took place on HD #30. Throughout his hospital stay he had episodes of diarrhea; he did have a positive C-Diff culture on [**10-5**]; this was treated with Flagyl course and resolved. Subsequent stool cultures were obtained and were negative (most recent on [**11-1**]); he did continue to have intermittent loose stools. His tube feeding formula was adjusted; Imodium and DTO were added which has significantly decreased his amount of stools to 1-2x/day. As a result of his loose stools he did have some altered skin integrity in his peri-anal region. The Wound Nurse Specialist was consulted; several recommendations were made and his skin has improved. He was placed on a First Step Mattress as well; tube feeding nutrients were optimized. A Speech consult was placed for evaluation of Passy Muir valve; he was unable to tolerate this on the initial try. Subsequent trials were not as successful given copious upper airway secretions. He was started on a Scopolamine patch to help with drying some of the secretions; this did seem to help some. His trach was eventually removed on [**12-1**]. His voice is strong, he is able to communicate his needs. He was seen in follow up by Oral Maxillo Facial Surgery for removal of his jaw wires; his oral screws were removed 2 weeks later at bedside by OMFS without difficulty. He was also seen in follow up by Spine Surgery; follow up flexion & extension cervical spine films were done; his cervical collar was removed. He may wear a soft collar for comfort if needed. Orthopedics was re-consulted for a right shoulder dislocation; this injury was non operative; he was placed in a sling for comfort. He will follow up in about 1 month in [**Hospital 5498**] clinic. Nutrition was closely involved in his care throughout his stay; tube feedings were initiated early on and are now being cycled given that he is now on an oral diet. The rate of the tube feeding should be decreased as his appetite improves. He is also being treated for a UTI with Ciprofloxacin 7 day course; he has 3 more days left in this course. His foley catheter was changed as well. Physical and Occupational therapy were consulted; he will require a rehab stay post acute hospital discharge. Medications on Admission: Unknown Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day). 2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for constipation. 3. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day): hold for SBP <110; HR <60. 4. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) ML Inhalation Q8H WITH MUCOMYST (). 5. Acetylcysteine 10 % (100 mg/mL) Solution Sig: One (1) ML Miscellaneous Q8H (every 8 hours). 6. Opium Tincture 10 mg/mL Tincture Sig: Five (5) Drop PO BID (2 times a day). 7. Haloperidol 1 mg Tablet Sig: Two (2) Tablet PO twice a day. 8. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Loperamide 2 mg Capsule Sig: One (1) Capsule PO 8X/DAY () as needed for diarrhea. 10. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 12. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 13. Ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q12H (every 12 hours) for 3 days. 14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: s/p Motor vehicle crash 1) C2,5,6,7,T1,L4,5 fractures 2) Ant/Post Maxillary Sinus fracture 3) Fractures 4,5 Ribs 4) Pulmonary Contusion 5) Nasopharynx-Foreign Body 6) Non-displaced Left frontal/parietal fx 7) Left Lateral wall of orbit fracture 8) Mandibular fracture 9) Nasal Bone fracture 10) Left Fibula fracture 11) Right SAH 12) Right medial scapula fracture 13) Game Keeper's thumb 14) Inferior subluxation of right humeral head from glenoid (nonperative) 15) UTI Discharge Condition: Good Followup Instructions: Follow up in Trauma Clinic with Dr. [**Last Name (STitle) **] in 4 weeks, call [**Telephone/Fax (1) 6429**] for an appointment. Follow up in [**Hospital 5498**] Clinic in 4 weeks, cal [**Telephone/Fax (1) 1228**] for an appointment.

[ "802.20", "811.00", "807.02", "806.03", "E849.7", "873.73", "519.00", "518.0", "285.9", "831.03", "806.23", "V09.0", "824.8", "305.40", "839.03", "518.5", "305.00", "806.08", "707.8", "802.4", "E812.0", "879.9", "933.0", "860.0", "482.41", "839.04", "800.24", "E884.4", "550.90", "008.45", "599.0", "802.8", "305.60" ]

icd9cm

[ [ [] ] ]

[ "96.04", "81.03", "43.19", "34.04", "34.91", "96.72", "38.7", "76.76", "81.63", "76.74", "96.05", "33.21", "81.05", "93.55", "31.74", "21.71", "77.79", "81.02", "80.51", "81.62", "31.1", "96.6" ]

icd9pcs

[ [ [] ] ]

17884, 17931

13391, 16566

338, 1382

18445, 18452

2510, 8880

18475, 18712

2002, 2019

16624, 17861

11863, 11956

17952, 18424

16592, 16601

2034, 2039

275, 300

11985, 13368

1410, 1819

2053, 2491

1841, 1850

1866, 1986

4,992

172,965

21968

Discharge summary

report

Admission Date: [**2199-9-17**] Discharge Date: [**2199-9-26**] Date of Birth: Sex: Service: HISTORY OF PRESENT ILLNESS: The patient is a 24-year-old male, Irish citizen, who sustained a mechanical fall from the first story of a roof while working. There was positive loss of consciousness. It is unclear the distance of the fall and how the patient landed. His [**Location (un) 2611**] Coma Scale, however, on admission was 15 and on the scene was 15. He was noted to be hemodynamically. In the Emergency Room he was complaining of bilateral forearm pain, right-sided chest pain. The fast ultrasound scan was fairly positive in the Emergency Department. He remained hemodynamically stable and was admitted to the Trauma Surgery Intensive Care Unit. He has no past medical history. No past surgical history. He is on medications and has no known drug allergies. PHYSICAL EXAMINATION: On physical examination, he had a temperature of 99.8 degrees. Blood pressure was 127/53. Heart rate 66. He was breathing at 20 respirations a minute and 95 percent oxygen saturation on room air. He was in no acute distress. He had a cervical spine collar on and was uncomfortable appearing. His pupils were equal, round, reactive to light and accommodation. His extraocular movements were intact. His bilateral nares appeared to have some dried blood on them. His tympanic membranes were clear. His oropharynx also had some dried blood. His trachea was midline. His lungs were clear to auscultation bilaterally. His heart was regular rate and rhythm with no murmurs or rubs. His abdomen was soft, nontender, nondistended, with normal active bowel sounds. He had normal rectal tone. He had lacerations on the volar aspect of his right hand. His left hand had a Colles deformity with positive laceration on the volar aspect and a positive hematoma and three second capillary refill. His right hand also had a Colles deformity and had a 2 second capillary refill. On neurological examination, he was alert and oriented times three. His cranial nerves were intact. He was moving all extremities. LABORATORY DATA: Notable for hematocrit of 38, a white blood cell count of 13, 380,000 platelets. His chemistry-10 panel was largely unremarkable. He had a lactate of 3.1, amylase of 35, liver antigen of 175, urinalysis with 0 to 2 red blood cells. His serum and urine toxicology screens were negative. The CT of his head had no bleed, no mass effect, no shift. A CT of his face showed a right maxillary sinus fracture, an orbital floor fracture without depression and a hard palate fracture. CT of his chest showed no traumatic injury. CT of the abdomen showed a grade 5 liver laceration and a splenic laceration as well as an adrenal hematoma. His bilateral arm x-rays showed bilateral distal radius fractures with intra- articular extension and a CT of his cervical spine showed no fracture but a C5-6 congenital fusion. HOSPITAL COURSE: He was initially admitted to the Surgical Intensive Care Unit. [**Location (un) 5498**] was consulted as was Plastic Surgery, the Trauma Surgery Service was managing his liver and splenic lacerations. The Orthopedic service treated his bilateral distal radius fracture. There initially was a closed reduction done in the Emergency Room. However, on hospital day number 4, the patient was taken to the Operating Room by the Orthopedic Surgery Service where open reduction and internal fixation as well as external fixation of the left distal radius was performed. An open reduction and internal fixation of his right distal radius was performed. The Orthopedic Service continued to follow the patient throughout the remainder of his hospital admission. The Plastic Surgery Service did not plan any emergent fixation or surgical intervention to treat his facial fractures. His liver and splenic laceration were treated nonoperatively with serial hematocrits and serial physical examinations and close monitoring of his vital signs. The patient remained in the Surgical Intensive Care Unit with stable serial hematocrits and was transferred out on hospital day number three. The patient did well on the floor, did have some intermittent temperatures which were believed to be related to his surgeries. Physical Therapy and Occupational Therapy Services continued to work with the patient throughout his admission and he continued to improve his functional status throughout the admission. The patient was discharged home on hospital day number 10 with very strict instructions to avoid any vigorous activity. Percocet was given for pain. The patient had orthoplast hand splints and was instructed not to carry any heavy weights with his hands and was given strict instructions on how to clean his pin sites as well as some physical therapy exercises to do for his wrists, and he was given phone numbers and follow-up appointments with the Trauma Service as where a repeat CT scan and examination will be performed as well as follow-up with Dr. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD [**First Name (Titles) **] [**Last Name (Titles) 5498**], and Plastic Surgery as well as Physical Therapy. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home with outpatient Physical Therapy. DISCHARGE MEDICATIONS: Percocet. FOLLOW-UP PLANS: He had follow-up with the Trauma doctors at the Trauma Clinic several days after discharge. He had a follow-up with Dr. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD [**First Name (Titles) **] [**Last Name (Titles) 5498**] 10 to 14 days following discharge. He was given the phone number of Plastic Surgery to follow-up. In addition, he was given the phone number of Physical Therapy to call for an outpatient physical therapy appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 13037**] Dictated By:[**Last Name (NamePattern1) 39725**] MEDQUIST36 D: [**2199-11-17**] 18:30:20 T: [**2199-11-17**] 20:48:57 Job#: [**Job Number 57532**]

[ "802.4", "813.41", "864.05", "998.89", "780.6", "E882", "868.01", "865.03", "802.8", "780.09" ]

icd9cm

[ [ [] ] ]

[ "79.02", "79.32", "78.13" ]

icd9pcs

[ [ [] ] ]

5344, 5355

2990, 5226

927, 2972

5373, 6114

152, 904

5251, 5320

24,990

127,853

48203+59067

Discharge summary

report+addendum

Admission Date: [**2105-6-29**] Discharge Date: [**2105-7-9**] Date of Birth: [**2041-12-26**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: 63M with +ETT referred for cardiac cath. Major Surgical or Invasive Procedure: Left ICA stent placement s/p CABGx3(LIMA->Diag, SVG->LAD, PDA) [**7-3**] History of Present Illness: This 63WM had a +ETT and was referred for cardiac cath. He was found down in his apartment in [**2-15**] and was found to be hyperkalemic, in DKA, and had lithium toxicity. MRI at that time revealed a L frontal infarct with bilateral carotid artery stenoses. He was eventually discharged to rehab. He was readmitted to NEBH in [**Month (only) 547**] with increasing pedal edema. An echo showed an EF of 25-30% and he had a persantine MIBI which showed reversible lateral and apical ischemia. He was then transferred to [**Hospital3 **] for further cardiac and carotid evaluation. Past Medical History: -IDDM : complicated by retinopathy, nephropathy, peripheral neuropathy - Stroke: left frontal CVA [**2-15**] - Hypertension - Hyperlipidemia - PVD - Carotid disease: bilateral critical carotid stenosis per recent MRA - Chronic kidney disease: baseline creat 1.3 - Bipolar disorder - Glaucoma - Diabetic retinopathy - Peripheral neuropathy - s/p tonsillectomy - +smoker Social History: significant for current tobacco use, 2ppd, 40 pack-years total. There is no history of alcohol abuse. Walks with cane at baseline. Family History: There is no family history of premature coronary artery disease or sudden death. Mother had MI in her 60s. Physical Exam: VS: BP 109/62, HR 84, RR 12, O2 98% on RA Gen: obese man lying flat in bed, pleasant and conversational, in NAD. HEENT: NCAT. Anicteric. PERRL, EOMI, OP clear w/ MMM. Neck: Supple with JVP of 8 cm. CV: irreg irreg S1/S2, + 1/6 systolic murmur at LUSB, no s3/s4/r. Chest: CTAB anteriorly. Abd: obese, +BS, soft, NTND. Ext: warm; 2+ pitting edema to mid-leg RLE>LLE; faint but palpable DP b/l. Neuro: a/o x 3, strength 5/5 throughout. Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT dopplerable Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT dopplerable Pertinent Results: [**2105-7-8**] 11:09AM BLOOD WBC-5.9 RBC-3.45* Hgb-11.1* Hct-31.7* MCV-92 MCH-32.1* MCHC-34.9 RDW-15.2 Plt Ct-158 [**2105-7-7**] 10:55AM BLOOD PT-12.2 PTT-27.1 INR(PT)-1.0 [**2105-7-8**] 11:09AM BLOOD Glucose-170* UreaN-49* Creat-1.4* Na-139 K-3.9 Cl-104 HCO3-29 AnGap-10 Date: [**2105-7-8**] Signed by [**First Name8 (NamePattern2) 2620**] [**Last Name (NamePattern1) 2621**], CCC-SLP on [**2105-7-8**] Affiliation: [**Hospital1 18**] BEDSIDE SWALLOWING EVALUATION: HISTORY: Thank you for consulting on this 63 y/o male with HTN, hyperlipidemia, DM, and tobacco use referred for a cardiac cath after an abnormal ETT and decreased LV function. He was found with 3VD, now s/p CABG x 3 on [**7-3**]. He also had a left ICA stent placed during this admission. He was extubated [**7-4**]. He had a recent admission after being found on the floor at home in [**Month (only) 404**] at which time he was found hypercalcemic in DKA with lithium toxicity. He also had a left frontal infarct. PMH includes PVD, carotid disease, CRI, bipolar d/o, glaucoma, diabetic retinopathy, peripheral neuropathy, s/p tonsillectomy, GERD He was advanced to a diet of thin liquids and ground consistency solids while in the ICU, [**3-13**] poor dentition. Per chart review he has tolerated well, We were consulted to evaluate for diet upgrade to tougher solids now that the pt is on the floor. EVALUATION: The examination was performed while the patient was seated upright in the chair on Far 2. Cognition, language, speech, voice: Pt was A&O x 3 with fluent language. Speech and voice were wfl, but initiation of speech and prosody were altered and were slow. He was able to follow all basic commands. Teeth: remaining teeth in poor condition - several teeth were loose or missing Secretions: wfl in the oral cavity, mild baseline cough / throat clearing ORAL MOTOR EXAM: Symmetrical facial appearance with adequate lip seal and buccal tone. Tongue was at midline with functional strength and ROM. Palatal elevation was symmetrical. Gag deferred to maintain rapport. SWALLOWING ASSESSMENT: The pt was seen during lunch with thin liquids (cup, straw, consecutive), purees, chicken noodle soup, ground meat, crackers and pills whole with liquid. Oral transit was mildly prolonged with the cracker only, but oral cavity residue was seen after any consistency. He had throat clearing after one bite of ground meat and after 2 sips of liquid, but reported it was from phlegm and the "stent" and denied any sensation of residue or aspiration. No overt coughing or changes in vocal quality was observed after any consistency. Laryngeal elevation was mildly delayed, but adequate to palpation. SUMMARY / IMPRESSION: The pt appears to be tolerating the current diet well. While his dentition is poor, he is able to manage regular consistency solids and his diet can be upgraded to thin liquids and regular consistency solids. Pills can be taken whole with liquids without difficulty. The pt was observed to have difficulty self- feeding, in part [**3-13**] tremor and spilled a good portion of his lunch. He may benefit from an OT evaluation for possible adaptive devices available for feeding. This swallowing pattern correlates to a Dysphagia Outcome Severity Scale (DOSS) rating of 6, modified independence. RECOMMENDATIONS: 1. Suggest the pt be upgraded to a diet of thin liquids and regular consistency solids. 2. Pills whole with thin liquids. 3. Consider OT consult to evaluate for potential adaptive devices for feeding. These recommendations were shared with the patient, nurse and medical team. ____________________________________ [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.S., CCC-SLP Pager #[**Numeric Identifier 2622**] RADIOLOGY Preliminary Report CHEST (PA & LAT) [**2105-7-8**] 11:40 AM CHEST (PA & LAT) Reason: evaluate effusion [**Hospital 93**] MEDICAL CONDITION: 63 year old man s/po CABG REASON FOR THIS EXAMINATION: evaluate effusion INDICATION: CABG, effusion. Followup. CHEST, TWO VIEWS: Cardiac shadow has improved in size. Lung fields appear clear. However, bilateral posteriorly loculated pleural effusions are seen, small in size. Right internal jugular vein line is again identified in the right atrium, and should be retracted at least 5 cm to be at the cavoatrial junction. Midline sternotomy wires and vertical staple line noted. IMPRESSION: 1. Bilateral small posteriorly loculated pleural effusions. 2. Right internal jugular vein line in right atrium, which should be retracted. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name (STitle) 16722**] [**Name (STitle) **] D' [**Doctor Last Name **] Cardiology Report ECHO Study Date of [**2105-7-3**] *** Report not finalized *** PRELIMINARY REPORT PATIENT/TEST INFORMATION: Indication: Intra-op TEE for CABG Status: Inpatient Date/Time: [**2105-7-3**] at 09:41 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW209-9:4 Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) 1112**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] MEASUREMENTS: 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: *5.9 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 25% (nl >=55%) Aorta - Valve Level: 2.9 cm (nl <= 3.6 cm) Aorta - Descending Thoracic: 2.3 cm (nl <= 2.5 cm) Aortic Valve - LVOT Diam: 2.1 cm INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: Lipomatous hypertrophy of the interatrial septum. PFO is present. Left-to-right shunt across the interatrial septum at rest. LEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Severe regional LV systolic dysfunction. Severely depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size. Moderate global RV free wall hypokinesis. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: No AS. Trace AR. MITRAL VALVE: No MS. Trivial MR. TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. The patient appears to be in sinus rhythm. Results were personally post-bypass data The post-bypass study was performed while the patient was receiving vasoactive infusions (see Conclusions for listing of medications). Conclusions: PRE-BYPASS: 1. The left atrium is moderately dilated. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is severe regional left ventricular systolic dysfunction of the lateral, inferior and anterior apical walls and the inferior and lateral mid walls.. Overall left ventricular systolic function is severely depressed. 3. Right ventricular chamber size is normal. There is moderate global right ventricular free wall hypokinesis. 4. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 5. There is no aortic valve stenosis. Trace aortic regurgitation is seen. 6. Trivial mitral regurgitation is seen. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine 1. Biventricular function is slightly improved. 2. Aorta is intact post decannulation 3. Other findings are unchanged [**Location (un) **] PHYSICIAN: Brief Hospital Course: The patient was admitted on [**2105-6-29**] and underwent cardiac cath which revealed: LMCA with distal taper and moderate calcification, diffuse disease and distal 90% lesion of the LAD, moderate disease of D1, 90% LCX lesion, and RCA has 90% lesion with heavy calcification. He had an echo which showed an EF of 25-30%, LAE, trace MR and trace TR. On [**6-30**] he had a L carotid stent placed by Dr. [**First Name (STitle) **] and tolerated the procedure well. Dr. [**Last Name (STitle) **] was consulted and on [**7-3**] he had a CABGx3(LIMA->Diag, SVG->LAD and PDA). The cross clamp time was 58 mins., total bypass time was 71 mins. He tolerated the procedure well and was transferred to the CSRU on Epi., Neo., and Propofol in stable condition. He was extubated on POD#1 and also had his chest tubes d/c'd. He had high glucoses post op which stabilized and was transferred to the floor on POD#5. He passed a swallowing evaluation. He progressed slowly and was discharged to rehab in stable condition on POD#6. Medications on Admission: ASA 325mg once daily Plavix 75mg daily Toprol XL 50mg once daily Zocor 10mg once daily Tricor 45mg once daily Lasix 40mg twice a day Lantus insulin 34 units QHS Regular insulin sliding scale Omeprazole 20mg once daily Clonazepam 0.5mg twice a day Risperdal 0.25mg QAM and 0.5mg QPM Depakote 500mg three times a day Travatan 0.004% one gtt each eye QHS Refresh eye drops one gtt each eye twice a day MVI one tablet daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for temperature >38.0. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 5. Risperidone 0.25 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO QD (). 9. Travoprost 0.004 % Drops Sig: One (1) Ophthalmic QHS (once a day (at bedtime)). 10. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 11. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 7 days: Decrease the dose to 200 mg PO daily after 7 day dose completed. 14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. 15. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 16. Ciprofloxacin 500 mg Tablet Sig: 1.5 Tablets PO Q12H (every 12 hours) for 5 days. 17. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO ONCE (Once) for 7 days. 18. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-10**] Drops Ophthalmic PRN (as needed). 19. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital **] health care center Discharge Diagnosis: Coronary artery disease IDDM s/p L CVA HTN ^chol. PVD CRI bilat. carotid stenoses bipolar disorder Discharge Condition: Good Discharge Instructions: Follow medications on discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs. for 2 months. Shower daily, let water flow over wounds, pat dry with a towel. Call our office for temp>101.5, sternal drainage. Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 35275**] for 1-2 weeks. Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2105-10-20**] 8:30 Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2105-10-20**] 9:00 Provider: [**Last Name (NamePattern5) 7224**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2105-10-20**] 10:30 Completed by:[**2105-7-9**] Name: [**Known lastname **],[**Known firstname 389**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 201**] Unit [**Name2 (NI) **]: [**Numeric Identifier 16351**] Admission Date: [**2105-6-29**] Discharge Date: [**2105-7-9**] Date of Birth: [**2041-12-26**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4551**] Addendum: The pt. is also on Lantus 34 units at dinner and a regular insulin sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital **] health care center [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 358**] MD [**MD Number(1) 359**] Completed by:[**2105-7-9**]

[ "285.29", "428.0", "296.80", "433.30", "796.3", "412", "250.40", "365.9", "681.11", "250.50", "443.9", "496", "414.01", "V12.59", "305.1", "272.0", "713.5", "V17.3", "403.91", "250.60" ]

icd9cm

[ [ [] ] ]

[ "36.15", "37.23", "00.40", "39.61", "88.61", "88.56", "36.12", "99.04", "00.63", "00.61", "00.45", "89.60", "38.93" ]

icd9pcs

[ [ [] ] ]

15309, 15524

10471, 11496

362, 437

13937, 13944

2334, 6203

14222, 15286

1613, 1722

11967, 13710

6240, 6266

13815, 13916

11522, 11944

13968, 14199

7189, 10402

1737, 2315

282, 324

6295, 7163

465, 1051

10448, 10448

1073, 1447

1463, 1597

6,580

143,585

23657

Discharge summary

report

Admission Date: [**2134-4-14**] Discharge Date: [**2134-4-18**] Date of Birth: [**2108-3-11**] Sex: F Service: TRA HISTORY OF PRESENT ILLNESS: The patient was a 26-year-old female who was involved in a motor vehicle accident as an unrestrained passenger at high speed with rollover and prolonged extrication of approximately 20-30 minutes. The patient was initially seen at an outside hospital where she was found to have a severe scalp laceration of the left frontal region, as well as splenic laceration and a liver laceration. The patient was subsequently transferred. The patient denied any loss of consciousness. It was unclear if the patient had a head injury. [**Location (un) 2611**] coma scale on admission was 15, and there was some evidence of tachycardia. PAST MEDICAL HISTORY: Hepatitis C, IV drug abuse. She is status post a tubal ligation. MEDICATIONS ON ADMISSION: None. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: Vital signs: Temperature 99.4, heart rate 119, blood pressure 116/50, respirations 16/min, oxygen saturation 100% on room air. General: She had a GCS of 15. HEENT: She had an approximately 8 cm left frontal parietal laceration. Pupils equal, round and reactive to light and accommodation. Extraocular movements intact. Tympanic membranes clear. Neck: Her trache was noted to be midline. Chest: She had a right breast contusion. Lungs: Clear to auscultation bilaterally. Cardiovascular: Regular rate with tachycardia. Abdomen: The subxiphoid region was noted to be tender; however, the abdomen was soft and nondistended. There was a left upper quadrant ecchymosis. Rectal: She had normal tone, no stool, guaiac negative. Pelvis: Stable. Back: There was severe left thoracolumbar abrasion. There was no deformity. There was some tenderness from T8 to the sacrum. Extremities: She had a right wrist laceration, approximately 1 cm. She had 2+ dorsalis pedis, posterior tibial, and radial pulses bilaterally. LABORATORY DATA: Initial laboratories were significant for a white blood cell count of 22.6, hematocrit 33, platelet count 268,000; PT 14.3, PTT 22.7, INR 1.3, fibrinogen 153; chemistry showed a sodium of 145, potassium 4.8, chloride 112, bicarbonate 26, BUN 11, creatinine 0.7, glucose 145; serum toxicology screen was positive for barbiturates and at the outside hospital was positive for cocaine. EKG showed sinus tachycardia. Chest x-ray showed no fracture or pneumothorax. Pelvis showed no fracture and no dislocation and some presence of some old contrast. CAT scan from the outside hospital revealed her head to be negative. Cervical spine showed no fracture or dislocation including reconstructed images. CT of her abdomen showed an upper pole contained splenic laceration, as well as a left lobe liver laceration in segment IV. CT of her abdomen and pelvis at [**Hospital3 **] was significant for liver laceration, a splenic laceration extending into the hilum, small high attenuation focus in the right lower quadrant with surrounding hematoma which may represent active extravasation of the small vessel, perihepatic and perisplenic hemorrhage with hemorrhage seen tracking along the pericolic gutters and into the pelvis which is increased compared to the outside hospital CAT scan, a tiny stable pneumothorax, a left adnexal cyst, and no evidence of bladder rupture. HOSPITAL COURSE: The patient was admitted to the surgical intensive care unit for serial hematocrits and close monitoring. She remained in the intensive care unit until [**2134-4-17**], post injury date #3, at which time she was transferred to the floor in stable condition. She was ultimately discharged on [**2134-4-18**]. 1. Contained splenic and liver lacerations: These two injuries were managed nonoperatively with serial hematocrits and close hemodynamic monitoring. Of note, the patient did receive 1 unit of packed red blood cells and 2 units of fresh frozen plasma initially, as well as 5 units of intravenous fluids, and her hematocrits were noted to trend down despite this resuscitation and transfusion from a high 33 on admission on [**2134-4-14**], down to 24.4 on post injury day #1, [**2134-4-15**]. Hematocrits ultimately stabilized, and at the time of discharge, her hematocrit was 28.4 on [**2134-4-18**], in the morning. She did have some abdominal tenderness from these injuries. This was initially managed with patient-controlled analgesia. The patient was ultimately converted to oral Dilaudid, on which she was sent out with. 1. Scalp laceration: The patient had a scalp laceration which was treated with stapling and appeared non-infected and to be clean, dry, and intact. The patient was discharged with strict instructions to return to the trauma clinic for removal of staples. 1. Neck pain: Despite having a CAT scan from the outside hospital which was negative for any fractures or dislocations, the patient did have continued cervical spine pain and ultimately underwent a flexion/extension examination which demonstrated only grade I retrolisthesis of C4 and C5 on extension which reduced with flexion. The patient's cervical spine was then cleared clinically, and the collar was removed, and the patient was discharged without the collar. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSIS: 1. Splenic laceration. 2. Liver laceration. 3. Scalp laceration. 4. Hepatitis C. DISCHARGE MEDICATIONS: Colace 100 mg twice a day, Dilaudid 2 mg [**1-3**] tab every 4-6 hours, Fioricet 325 40 and 50 mg [**1-3**] tab every 4-6 hours as needed for migraine headaches. DISCHARGE INSTRUCTIONS: The patient was instructed to follow- up in the trauma clinic in [**7-11**] days for removal of staples and follow-up with her splenic and liver lacerations. She was given phone number [**Telephone/Fax (1) 60496**] to call for both an appointment and directions. In addition, the patient was instructed to follow-up with her primary care provider or hepatologist concerning her hepatitis C and any possible repercussions or complications of her liver laceration. In addition, the patient was instructed to be involved in no contact sports, heavy lifting, or do any strenuous activity until directed otherwise by the trauma surgeons. [**First Name11 (Name Pattern1) 518**] [**Last Name (NamePattern4) **], [**MD Number(1) 17554**] Dictated By:[**Last Name (NamePattern1) 39725**] MEDQUIST36 D: [**2134-4-20**] 20:17:10 T: [**2134-4-21**] 09:38:33 Job#: [**Job Number 60497**]

[ "070.70", "865.09", "E812.1", "864.00", "873.0", "305.60" ]

icd9cm

[ [ [] ] ]

[ "99.07", "38.91", "86.59", "99.04" ]

icd9pcs

[ [ [] ] ]

5473, 5636

5366, 5449

908, 953

3384, 5311

5661, 6567

976, 3366

165, 792

815, 881

5336, 5345

71,599

192,984

39514

Discharge summary

report

Admission Date: [**2123-10-16**] Discharge Date: [**2123-10-23**] Date of Birth: [**2044-1-1**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Respiratory Distress Major Surgical or Invasive Procedure: PEG tube exchange [**10-19**] History of Present Illness: 79y/o F w/ dementia, non-verbal p/w respiratory distress and diarrhea. Pt. was recently treated for recurrent respiratory infection w/ augmentin and then developed diarrhea. She had been having diarrhea for several days and then today her son noted respiratory distress and brought her to [**Location (un) 620**] ED. At [**Location (un) **] her VS were initially 116/66, 89, 21 and 100%. Labs came back w/ bicarb of 10 and then lactate of 9. She was given 5L NS, levo and flagyl. U/A had >100 WBCs. WBC was 19 w/ 26% bands. Hct 36. She was intubated after discussion w/ son re: goals of care transferred to [**Hospital1 18**] ED and started on levophed at 0.8 for SBP 76. she got 2L more NS, cefepime and vanc IV. At [**Location (un) 620**] she had hyperkalemia w/o EKG changes and got insulin, D50. Past Medical History: Dementia, nonverbal at baseline Left hip decubitus ulcer Sacral decubitus ulcer diabetes urinary retention CVA 8 years ago Recurrent pulmonary infections Old necrotic left great toe Social History: Living at home with the son. Immigrated from [**Country 651**] 18 years ago. Dependent on all ADLs. No smoking, no alcohol known. Family History: NC Physical Exam: Vitals: T: BP: 110/55 P: 98 R: 22 O2: 97% FiO2 100%, CMV TV 400, PEEP 5 General: Unresponsive to stimuli, on vent and levophed drip at 0.8mcg/min. Extremities contracted. HEENT: Sclera anicteric, MMM, oropharynx clear, TMs impacted w/ wax. Pupils equal and reactive to light. Neck: Left triple lumen 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: foley present w/ cloudy urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, large decubitus ulcer/burn wound on L hip. L foot w/ necrotic great toe. Pertinent Results: [**2123-10-17**] 1:33 am URINE Source: Catheter. **FINAL REPORT [**2123-10-20**]** URINE CULTURE (Final [**2123-10-20**]): PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. GRAM NEGATIVE ROD(S). ~6OOO/ML. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 4 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- 2 I GENTAMICIN------------ 8 I MEROPENEM------------- 0.5 S PIPERACILLIN/TAZO----- 16 S TOBRAMYCIN------------ <=1 S [**2123-10-17**] 1:39 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2123-10-21**]** GRAM STAIN (Final [**2123-10-17**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2123-10-21**]): Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. OF THREE COLONIAL MORPHOLOGIES. YEAST. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 4 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- 0.5 S GENTAMICIN------------ 8 I MEROPENEM------------- 1 S PIPERACILLIN/TAZO----- 16 S TOBRAMYCIN------------ <=1 S [**2123-10-17**] 1:33 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2123-10-18**]** MRSA SCREEN (Final [**2123-10-18**]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. [**2123-10-23**] 03:38AM BLOOD WBC-6.1 RBC-2.83* Hgb-8.3* Hct-23.9* MCV-85 MCH-29.5 MCHC-34.8 RDW-16.7* Plt Ct-339 [**2123-10-22**] 03:32AM BLOOD Neuts-75.4* Lymphs-18.3 Monos-4.3 Eos-1.8 Baso-0.2 [**2123-10-23**] 03:38AM BLOOD Glucose-181* UreaN-11 Creat-0.5 Na-140 K-4.2 Cl-106 HCO3-28 AnGap-10 [**2123-10-23**] 03:38AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.8 [**2123-10-22**] 03:58AM BLOOD Type-ART Temp-37.7 Rates-/16 O2 Flow-3 pO2-74* pCO2-35 pH-7.50* calTCO2-28 Base XS-3 Intubat-NOT INTUBA [**2123-10-20**] 02:34AM BLOOD Lactate-0.9 [**2123-10-22**] 03:58AM BLOOD freeCa-1.16 Brief Hospital Course: #Sepsis: Ms [**Known lastname **] was hypotensive and hypoxic on admission and was intubated and required pressors. Lactate was 9.1. She was treated empirically for hospital-acquired pneumonia with cefepime and vancomycin; this was narrowed to cefepime after sputum cultures returned positive for pseudomonas aeruginosa. UA was positive and culture also grew pseudomonas. A 14-day course of cefepime was planned. For some concern of c. diff colitis she was initially treated with PO vancomycin, but this was discontinued after toxin assays returned negative. Other sources of infection considered included her various decubitus ulcers, her burn-related ulcer, and her necrotic great toe. Pressors were weaned after 48 hours; her BP remained stable throughout the remainder of her hospitalization. Her ventilator settings were gradually weaned and she was extubated on HD#7, which she tolerated. She was discharged with the plan to continue her IV antibiotics via PICC for a 14-day course. #Left upper extremity DVT: Ms. [**Known lastname **] was noted to have an edematous left arm during hospitalization in the setting of a left internal jugular catheter. Ultrasound demonstrated a cephalic vein DVT. Heparin was begun and changed to lovanox on HD#7, but it was then decided that the risks of anticoagulation exceed the benefits, and this was discontinued. #Nutrition: Ms. [**Known lastname 87266**] gastric tube was clogged after her son administered a tube feeding. The tube then fell out when it was flushed. It was then replaced by a gastrojejunal tube, selected to decrease aspiration risk, which was sutured into place. #[**Last Name (un) **]: Ms. [**Known lastname **] originally had a creatinine of 1.2 on admission which was attributed to prerenal factors. Creatinine decreased to 0.4 with blood pressure support and fluids. #Anemia: Hct trended down from 30 to 26, where it stabilized, during hospitalization. #DM: Ms. [**Known lastname **] was managed on an ISS, which was decreased on HD#3 following an episode of hypoglycemia. On discharge, she was returned to her home regimen of metformin. #Goals of care: Ms. [**Known lastname **] was eventually made DNR/DNI after discussions with her sons, and was discharged to home with hospice services. Medications on Admission: Metformin 500mg QD Jenuvia tube feed MVI Vit C oral [**Name (NI) 10687**] MOM Artificial Tears Tylenol Discharge Medications: 1. cefepime 1 gram Recon Soln Sig: One (1) Recon Soln Injection Q12H (every 12 hours) for 7 days: continue for 7 more days until [**10-29**]. Disp:*14 Recon Soln(s)* Refills:*0* 2. sodium chloride 0.9 % 0.9 % Parenteral Solution Sig: Ten (10) ML Intravenous PRN (as needed) as needed for line flush: non-heparin-dependent PICC. Disp:*1000 ML(s)* Refills:*0* 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 4. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. 5. Januvia continuing at previous home dose (dose not known to us at this time) Discharge Disposition: Home With Service Facility: VistaCare Discharge Diagnosis: 1. Sepsis 2. Respiratory failure 3. Dementia 4. Acute renal failure Discharge Condition: Mental Status: Not interactive. Level of Consciousness: Lethargic and not arousable. Activity Status: Bedbound. Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure taking care of your mother in the ICU. She has now been extubated and is going home with hospice services. She should receive IV antibiotics at home through her PICC line and nutrition through her PEG tube. Because she is [**Hospital 66537**] hospice care, it is very important that if you are concerned about any symptoms, you call Vistacare, the hospice company, for assistance, rather than bringing her to the hospital. Followup Instructions: Home hospice services through VistaCare.

[ "276.51", "038.9", "707.03", "599.0", "276.2", "788.20", "V49.86", "041.7", "285.9", "787.91", "294.8", "707.04", "518.81", "995.92", "707.23", "584.9", "569.62", "482.1", "453.81", "276.50" ]

icd9cm

[ [ [] ] ]

[ "38.97", "96.72" ]

icd9pcs

[ [ [] ] ]

7883, 7923

4824, 7105

337, 368

8035, 8035

2334, 4801

8673, 8717

1565, 1569

7258, 7860

7944, 8014

7131, 7235

8173, 8650

1584, 2315

277, 299

396, 1197

8050, 8149

1219, 1402

1418, 1549

53,787

174,772

2628

Discharge summary

report

Admission Date: [**2160-10-7**] Discharge Date: [**2160-10-11**] Date of Birth: [**2089-9-14**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 905**] Chief Complaint: cough, hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: 71 F with a h/o COPD who has had multiple admissions for COPD in the past who presented to her PCP [**Name Initial (PRE) **] 5 days of nasal congestion, rhinorrhea and cough. Her cough was productive of sputum, but she had not noted the color. Her SOB was slightly worse than baseline, but she has been able to do all of her ADLs. She denies chest pain or pressure. She reports a minor chronic daily cough at baseline. At her PCP's office she was noted to desat to the mid-80s and she was send to ED for further evaluation. She has been on home O2 in the past but not recently. She denies HA, sinus pressure, or sore throat. She denies sick contacts, recent long travel or swelling in her legs or PND. She does report that she cannot breathe as easily when laying flat. . In the ED, initial vs were: T 97.3 P 99 BP 160/84 R 18 O2 sat 92 on room air. Patient was given albuterol and ipratropium nebs, methylpred 125mg and azithromycin 500mg IV x1. Her CXR was negative for infiltrates or pulm edema. Her O2 sats decrease to 85% occasionally on 3.5L and then O2 sats increase without intervention. Her current VS are 93 153/63 18 95% on 3.5L. . On the floor, she is not in any respiratory distress and is able to speak in full sentences. She reports that she feels well currently. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, or congestion. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: #1 COPD - last PFTs [**3-9**] FVC/FEV1 68, FVC 82% pred, FEV1 81% pred. stage I, mild COPD. She reports being on Home O2 for a period of [**4-2**] months in the past. Her last COPD flare requiring steroids and admission was 1.5 years ago. #2 current tobacco use #3 DM II - hgb A1c 6.9, on oral agents #4 Obesity #5 Hyperlipidemia #6 Diverticulosis #7 h/o adrenal adenoma #8 herpes simplex #9 hx PE in setting of OCPs 30+ years ago #10 Chronic kidney diease - baseline Cr 1.5-2.0 Social History: She reports smoking 2PPD x 60 years. She has quit in the past for 6 months at a time and she has been smoking [**2-1**] ppd recently. She denies EtOH or drugs. She lives alone and reports that she is able to complete all of her ADLs. She is able to walk for 15 min to and from the grocery store without getting SOB. Family History: father died in 60's - EtOH mother died @ 36 - MI. obese, smoked sister - DM, renal failure brother - mentally retarded had 4 children, 1 son died @ 42 - EtOH, hemochromatosis, seizure father died in 60's - EtOH mother died @ 36 - MI. obese, smoked sister - DM, renal failure brother - mentally retarded had 4 children, 1 son died @ 42 - EtOH, hemochromatosis, seizure 1 son 2 daughters 9 grandchildren 5 great-grandchildren Physical Exam: ADMISSION: Vitals: afebrile BP: 117/49 P: 92 R: 20 18 O2: 94% on 3L NC General: Alert & oriented x3, no acute distress, no accessory muscle use. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP @ 7cm, no LAD Lungs: poor airflow, + inspiratory and expiratory wheezes diffusely, no rales, ronchi. no dullness to percussion CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema DISCHARGE: General: Alert & oriented x3, NAD, appears comfortable, no accessory muscle use. Speaking full sentences without difficulty. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, no LAD Lungs: good airflow, CTAB, no wheezes, rales or 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 Pertinent Results: Labs on admission: [**2160-10-7**] 07:05PM GLUCOSE-120* UREA N-27* CREAT-1.8* SODIUM-143 POTASSIUM-4.7 CHLORIDE-104 TOTAL CO2-29 ANION GAP-15 [**2160-10-7**] 07:05PM WBC-9.2 RBC-4.33 HGB-12.8 HCT-38.7 MCV-89 MCH-29.5 MCHC-33.0 RDW-13.0 [**2160-10-7**] 07:05PM PLT COUNT-300 [**2160-10-7**] 07:05PM NEUTS-72.1* LYMPHS-21.2 MONOS-4.7 EOS-1.4 BASOS-0.6 [**2160-10-7**] 05:12PM GLUCOSE-145* [**2160-10-7**] 05:12PM ALT(SGPT)-17 AST(SGOT)-23 [**2160-10-7**] 05:12PM CHOLEST-154 [**2160-10-7**] 05:12PM TRIGLYCER-180* HDL CHOL-43 CHOL/HDL-3.6 LDL(CALC)-75 Micro: MRSA swab PENDING 1/2 bottles blood culture with gram positive cocci in clusters. Imaging: CXR FINDINGS: The cardiomediastinal silhouette appears unchanged. The hilum appears unremarkable bilaterally. There is flattening of the diaphragm and irregular distribution of pulmonary vessels consistent with COPD. No lobar consolidation is noted. No pleural abnormalities are seen. The osseous structures appear unremarkable. IMPRESSION: COPD with no acute cardiopulmonary process. LABS AT DISCHARGE: [**2160-10-11**] 06:45AM BLOOD WBC-9.5 RBC-3.84* Hgb-11.5* Hct-35.0* MCV-91 MCH-30.0 MCHC-32.9 RDW-12.9 Plt Ct-277 [**2160-10-11**] 06:45AM BLOOD Glucose-160* UreaN-51* Creat-2.0* Na-144 K-4.8 Cl-106 HCO3-33* AnGap-10 [**2160-10-11**] 06:45AM BLOOD Calcium-9.2 Phos-4.8* Mg-2.3 [**2160-10-7**] 05:12PM BLOOD %HbA1c-6.9* Brief Hospital Course: MICU COURSE: This 71 yo female patient with history of mild COPD and current tobacco use presented with a cough and hypoxia, and admitted for COPD exacerbation. She was observed for 48 hours in the MICU. She did not require intubation; her vital signs were closely monitored. She received albuterol and ipratropium nebs Q2, as well as advair inhaler. Prednisone 60mg daily for COPD exacerbation was also started. She received azithromycin 250mg x 4 days. She was advised to stop smoking but refused a nicotine patch. Her symptoms improved with this treatment. The patient's symptoms were most likely secondary to a COPD exacerbation in setting of URI in a patient with current tobacco use and untreated COPD. She was transferred to the medicine wards in stable condition. MEDICINE [**Hospital1 **] COURSE: On the wards, the patient was slowly weaned off of nebulizer treatments of albuterol and ipratropium and changed to inhalers. Her Advair inhaler was continued. She was continued on azithromycin to complete a 5 day course, she was also continued on prednisone 60 mg po x 5 days and discharged on a prednisone taper. Her blood pressure remained wnl during admission, and her home medications were continued. She was found to have acute on chronic renal failure, with Cr elevated from her baseline of 1.5 to 1.8 on admission. As a result of her bump in creatinine, the patient's home Metformin was discontinued *******ADD LISINOPRIL IF D/Cd*****. These will be restarted as an outpatient only if advised by her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 410**]. On prednisone, the patient was found to have a leukocytosis and elevated serum glucose levels, as expected. Her high serum glucose levels were treated on a regular insulin sliding scale. Her glyburide, which was temporarily held in the MICU, was restarted on the medical wards. The patient was evaluated by PT and deemed stable for discharge to home with services on [**2160-10-11**]. Her oxygen was found to desaturate to less than 88% with ambulation and no oxygen on. As a result, she was sent home with VNA and continuous home oxygen. In addition, blood glucose levels were found to be elevated due to prednisone. We started 5 units of NPH nightly on [**2160-10-10**], and the patient was discharged on this medication, after having teaching by nursing in the hospital. She will have VNA services at home for teaching regarding her new medications and home oxygen. She will also be evaluated for home physical therapy. It was recommended that she follow-up with her primary care physician within one week of discharge from the hospital. Medications on Admission: 1.Albuterol 90 mcg HFA 2 puffs(s) INH q4-6 hrs PRN - not taking 2.Fluticasone-Salmeterol 250 mcg-50 mcg 2 discs once daily - not taking 3.Furosemide 20 mg PO daily 4.Glipizide 15 mg PO q AM and 10mg PO qPM 5.Lisinopril 20 mg by mouth once a day 6.Metformin 1,000 mg Tablet by mouth twice a day 7.Nifedipine 30 mg by mouth once a day 8.Simvastatin 80 mg Tablet by mouth once a day 9.Aspirin 81 mg Tablet by mouth once a day Discharge Medications: 1. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO once a day for 2 days. 2. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). Disp:*14 Tablet Sustained Release(s)* Refills:*0* 3. Nifedipine 30 mg Tablet Extended Rel 24 hr (b) Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Glipizide 5 mg Tablet Sig: Three (3) Tablet PO QAM (once a day (in the morning)). 7. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO Q PM (). 8. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 11 days: Six (6) Tablets daily for 2 days, then Four (4) Tablets daily for 3 days, then Two (2) Tablets daily for 3 days, then One (1) Tablet daily for 3 days. Disp:*33 Tablet(s)* Refills:*0* 9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every eight (8) hours as needed for shortness of breath or wheezing. 11. Home oxygen Patient required continuous home oxygen, 2-3 liters nasal cannula. Off oxygen, desaturates to less than 88% RA. 12. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. Disp:*1 inhaler* Refills:*2* 13. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for shortness of breath, wheezing. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Chronic Obstructive Pulmonary Disease Acute Exacerbation Acute on Chronic Renal Failure Discharge Condition: Stable. Discharge Instructions: Mrs. [**Known lastname 13204**], you were admitted to the hospital because of an exacerbation, or worsening of your COPD. Your primary care doctor had noticed your oxygenation to be very low during your last visit. In addition, you had new symptoms of cough, increased shortness of breath, and trouble breathing. We think that this occurred because you had not been taking all of your COPD medications, and also caught a cold that caused inflammation in your airway and affected your breathing. At first, you were observed and treated in the medical intensive care unit. Your course in the medical intensive care unit was uncomplicated, shortly after you were transferred to a regular medical [**Hospital1 **] for further management. During this admission, you were treated with COPD medications like albuterol, Advair, and ipratropium inhalers. You were also started on oral prednisone and an antibiotic called azithromycin. You were also kept on oxygen during your hospital stay. Your symptoms improved with this regimen, you were evaluated by physical therapy, were found to be stable and fit for discharge to home with visiting nursing services to monitor your oxygen levels and blood sugars. During this admission, you were also found to have slightly higher kidney blood tests than normal, also called acute on chronic renal failure. This likely occurred at first because you were dehydrated as a result of decreased fluid intake prior to admission. Your Metformin and Furosemide were stopped while you were in the hospital, because of the elevation of the kidney blood tests. Dr. [**Last Name (STitle) 410**] will decide whether or not you should restart this medication when you see her in follow-up. You may notice that your blood sugars are a bit higher when you leave the hospital. This is due to the prednisone that you are taking and should resolve once this medication course is completed. We started you on 5 units of NPH in the hospital twice daily, which you were taught to give yourself in the hospital, and should take this before breakfast and at night while you are on the prednisone. You should continue the insulin while on the prednisone and then follow up with you PCP about further blood sugar control as your blood sugars will be lower once you stop the steroids. You are also going home on continuous oxygen. The reason for this is that we found that your oxygen in your blood got to very low levels when walking when you did not have the oxygen on. It is VERY IMPORTANT that you do not smoke while you have the oxygen on as this is a fire [**Doctor Last Name 13205**] and can be VERY dangerous. It is very important that you adhere to the medication regimen that is prescribed for you. Please make a follow-up appointment with Dr. [**Last Name (STitle) 410**] within ONE WEEK OF DISCHARGE by calling her office at: [**Telephone/Fax (1) 1144**]. Should you experience any fevers, shortness of breath, lightheadedness, or other concerning symptom, you should report these symptoms to a health care provider immediately or go to an emergency room immediately. There have been several changes to your medications during this hospital stay as outlined below: MEDICATIONS THAT HAVE BEEN STOPPED: Metformin 1000 mg po twice daily Furosemide 20 mg PO daily These medications should be re-started only if advised by Dr. [**Last Name (STitle) 410**]. NEW MEDICATIONS: Prednisone 60mg PO once daily for 2 days, then 40 mg po once daily for 3 days, then 20 mg once daily for 3 days, then 10 mg once daily for three days then stop Mucomyst 600mg PO twice daily Fluticasone nasal spray, 2 sprays per nostril twice per day as needed for nasal congestion Ipratropium inhaler, 2 puffs every 8 hours as needed for shortness of breath or wheezing 5 units NPH insulin injected subcutaneously before breakfast and at night CHANGED MEDICATIONS: Fluticasone-Salmeterol 500mcg-50 mcg 2 puffs once daily changed to two puffs twice daily. It was a pleasure caring for you and we wish you the best! Followup Instructions: Please make a follow-up appointment with Dr. [**Last Name (STitle) 410**] within ONE WEEK OF DISCHARGE by calling her office at: [**Telephone/Fax (1) 1144**]. [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**] Completed by:[**2160-10-12**]

[ "V12.51", "493.22", "585.9", "276.51", "305.1", "562.10", "465.9", "584.9", "403.90", "278.00", "250.02", "272.4" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10581, 10638

5819, 8478

330, 336

10770, 10780

4403, 4408

14852, 15137

2832, 3260

8953, 10558

10659, 10749

8504, 8930

10804, 14829

3275, 4384

1664, 1980

276, 292

5475, 5796

364, 1645

4423, 5456

2002, 2483

2499, 2816

61,153

120,365

37927

Discharge summary

report

Admission Date: [**2175-11-6**] Discharge Date: [**2175-11-8**] Date of Birth: [**2104-7-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1943**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 84779**] is a 71 year old man with a recent admission to NEBH for right total hip replacement, who at [**Hospital3 2558**] was found to have low blood pressure and sent to the [**Hospital1 18**] for further evaluation. Mr. [**Known lastname 84780**] stay at [**Hospital **] Hospital was marked by a right hip replacement without operative or peri-operative complications, but with an extended post-operative course complicated by apparent alcohol withdrawal; an episode of brief unresponsiveness/syncope while getting out of bed to chair, thought to be secondary to hypovolemia and Wenckebach rhythm; delirium; and an E. coli UTI treated with levofloxacin and then bactrim, with the concern that levofloxacin could contribute to confusion. A CT scan was done which by report showed generalized cerebral atrophy with ventriculomegaly and prominence of the sulci; as well as likely mild microvascular ischemic changes in the white matter and lower attenuation of the right lower basal ganglia thought to be related to a prominent perivascular space, but with subacute or old lacunar infarct a possibility that could not be ruled out. Note was also made of a macrocytic anemia. Alcohol withdrawal symptoms were evidently treated with ativan. Intermittent hypotension was treated with IV fluids. He was discharged to [**Hospital3 2558**] with improvement in his mental status but still with some memory problems (did not know what surgery he had). On [**10-23**], day of discharge from NEBH, his hematocrit was 29.7 and his platelets 591. He was discharged on 1 mg PO coumadin, 40 mg Accupril (quinapril), and 5 mg Norvasc, as well as the medications listed below. While at [**Hospital3 2558**] from [**10-23**] until today, his physical rehabilitation was apparently going well and his wife reports there had been discussion of discharge planning for discharge to home in the near future. However, today, he had hypotension to 80/50 there by report; and apparently also having urinary retention; and he was transferred to the [**Hospital1 18**] for further management. In the ED, initial vs were recorded as: T 97.8 P 55 BP 170/132 (likely in error; all BPs recorded thereafter are in 80s-100s); R 20 O2 sat 100% RA. Patient was given 3L of NS and vancomycin In the [**Hospital Unit Name 153**], Mr. [**Known lastname 84779**] was comfortable without any particular complaints. His blood pressure was normotensive. A review of systems was mostly negative as detailed below. Past Medical History: HTN "Abnormal heart rhythm", apparently not on coumadin recently urinary frequency nocturia spondylolisthesis chronic back pain arthritis prior history of post-op delirium in [**12-3**] Social History: Occupation: Accountant Drugs: deferred Tobacco: Past smoking hx 25 yrs x2 ppd= 50 pack years. quit [**2147**] Alcohol: EtOH: claims [**3-29**] drinks per night though ongoing questions reveal slightly inconsistent answers. Other: lives with wife. Drugs, sexual activity outside of marriage: deferred with wife nearby. Family History: Half brothers DM2; another half brother of [**Name (NI) 83430**] causes; no cardiac history. Physical Exam: General Appearance: Well nourished Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, oropharynx clear Cardiovascular: (S1: Normal), (S2: Normal, Distant), distant quiet heart sounds Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTAB Abdominal: Soft, Non-tender, Bowel sounds present Extremities: No edema or cyanosis Skin: Warm, Rash: thin skin; rhinophyma; seborrheic dermatitis Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented (to): [**Month (only) **], hospital (gets hospital wrong initially, long explanation of why this was), person, Movement: Purposeful, Tone: Normal, hand flip intact; serial 7s w/o error; WORLD forwards and backwards accurately; [**1-28**] 3 item recall at 1 minute Pertinent Results: [**2175-11-6**] 11:55AM GLUCOSE-121* UREA N-12 CREAT-0.8 SODIUM-135 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-22 ANION GAP-13 [**2175-11-6**] 11:55AM ALT(SGPT)-17 AST(SGOT)-17 ALK PHOS-55 TOT BILI-0.3 [**2175-11-6**] 11:55AM LIPASE-65* [**2175-11-6**] 11:55AM CALCIUM-8.4 PHOSPHATE-3.3 MAGNESIUM-1.9 IRON-17* [**2175-11-6**] 11:55AM calTIBC-173* VIT B12-369 FOLATE-18.8 FERRITIN-796* TRF-133* [**2175-11-6**] 11:55AM WBC-4.6 RBC-2.74* HGB-8.9* HCT-26.0* MCV-95 MCH-32.4* MCHC-34.1 RDW-14.8 [**2175-11-6**] 11:55AM PT-12.8 PTT-25.4 INR(PT)-1.1 [**2175-11-6**] 11:55AM RET AUT-1.9 Brief Hospital Course: Mr. [**Known lastname 84779**] is a 71 year old man status post right hip replacement and lengthy post-operative and rehab course, who presented with hypotension, mild cognitive impairment. # HYPOTENSION: Blood pressure initially with systolic in the 80's. After administration of 3L NS, the blood pressure improved to the 100's. All HTN meds held and blood pressure remained normal throughout the hospital admission. No acute infections evident on history or physical. # HYPERTENSION: The patient's need for HTN medications have probably decreased due to cessation in alcohol consumption. The patient was on 3 anti-HTN agents upon admission to hospital. He will be discharged on only one [**Doctor Last Name 360**]. The blood pressure should be rechecked after discharged and medications adjusted accordingly. # ANEMIA: Labs suggest anemia of chronic disease (high ferritin, low Iron). MCV down from [**Month (only) **] OSH value >100, now 96, B12 and Folate normal. Other potential etiologies include occult bleed, residual effects of high alcohol intake. # ARRYTHMIA: Appears to be wenckebach with variable 2:1 and 3:2 conduction. C/w past records. Benign appearing for now. Cardiology reviewed the EKG and agreed that rhythm is wenckebach. - Telemetry consistent with wencheback with variable conduction. # S/P RIGHT TOTAL HIP REPLACEMENT: On 1 mg Coumadin for apparent post-op anticoagulation. Consider lovenox which some analyses suggest is superior. Emailed primary orthopedist at NEBH (Dr. [**Last Name (STitle) 18097**] to see what intended course of anticoag was, not clear from d/c summary. # MEMORY LOSS/MENTAL STATUS: Poor 3 item recall, [**1-28**] on admission at 1 minute, [**2-28**] at 5 minutes on d/c. OSH CT c/w atrophy, which is c/w CT head repeated here. Etiology not definitively determined, possibilities include: early dementia, long-term effects of EtOH (korsakoff syndrome), possible hypoperfusion effect when BP is low. Gave thiamine and folate. Head CT showed no acute issues. # URINARY RETENTION likely [**2-27**] prostatism. His symptoms were reported to have improved since his last hospitalization. His symptoms were urinary retention and urinary frequency. He reports that these symptoms have improved. Bladder scanner measured a post-void residual of 180cc. The patient is asymptomatic and has normal renal function. Flomax was increased to 0.8mg daily. Outpatient followup is warranted by PCP or urologist. Medications on Admission: Medications: Prior home medications: Vicodin PRN HCTZ 25 daily quinapril 40 daily allopurinol 300 daily amlodipine 5 mg daily oxybutynin ER tylenol PR MVI . [**Hospital3 2558**] transfer medications: . ativan 0.5 mg po q 2 hrs for EtOH w/d colace senna prilosec 20 daily accupril 40 mg daily, changed to 20 mg daily Niferex 150 mg daily amlodipine 5 mg daily coumadin 1 mg seroquel 50 mg po q4hrs prn seroquel 100 mg HS apap 650 mg po tid allopurinol 300 mg tid flomax 0.4 mg [**Hospital1 **] MVI daily robitussin Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Tablet(s) 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 4. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 6. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 7. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 8. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: 1. Hypotension 2. Urinary retention (likely from Prostatism) 3. Anemia, normocytic 4. Short-term memory loss Discharge Condition: Stable for discharge, blood pressure normal and stable, patient able to ambulate with the assistance of a walker. Discharge Instructions: You were admitted with low blood pressure. With administration of 3 liters of IV fluids and not giving you blood pressure medications, your blood pressure became normal. There were no signs that you had any acute infections. During the entire hospitalization your blood pressure was normal and now at the level where an anti-hypertension medication can be started again. We also found you to have urinary retention of 180mL by bladder scanner. You have reported having symptoms of urinary retention and urinary frequency in the past. Since then you were started on Tamsulosin (also called Flomax) and your symptoms have improved. We are going to increase your dose of Flomax and recommend that if your symptoms return of urinary retention or urinary frequency, then you should speak to your primary care physician about whether [**Name Initial (PRE) **] urology consultation would be helpful. We are making the following changes to your medications: STOP HCTZ (hydrochlorthiazide), a blood pressure med STOP Accupril, a blood pressure med CHANGING dose of Amlodipine to 2.5mg once daily INCREASE Tamsulosin (Flomax) to 0.8mg once daily, for urine retention If you develop worsening of your condition, have fever, chills, low blood pressure, urinary symptoms, or other concern, then please seek medical attention. Followup Instructions: You should follow up with your primary care physician or general medicine doctor within the next 1 week to have your blood pressure rechecked to see if your anti-hypertension medications need to be adjusted. You should also speak with your doctor about your urinary retention and whether a urology consultation would be helpful.

[ "724.5", "V43.64", "788.41", "401.9", "458.9", "600.91", "716.90", "788.20", "285.9", "426.13" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8811, 8881

5065, 6694

327, 333

9034, 9150

4451, 5042

10520, 10853

3425, 3519

8097, 8788

8902, 9013

7558, 7577

9174, 10103

3534, 4432

7595, 7736

10132, 10497

276, 289

7758, 8074

361, 2860

6710, 7532

2882, 3070

3086, 3409

7,107

148,024

8816+55979

Discharge summary

report+addendum

Admission Date: [**2145-4-18**] Discharge Date: [**2145-4-23**] Date of Birth: [**2067-11-11**] Sex: F Service: MICU/[**Hospital1 **] INPATIENT MEDICINE HISTORY OF THE PRESENT ILLNESS: Ms. [**Known lastname **] is a 76-year-old female with a history of emphysema, obstructive sleep apnea, dysphagia, diastolic CHF, prerenal ARS, who presents with diffuse weakness and hand tremors times one to two days. When asked, the patient states that her symptoms have been going on for several weeks. On the day prior to admission, the patient had dizziness upon standing and weakness. She called EMS who took her to the Emergency Department. In the ED, she was found to be in acute renal failure with a creatinine elevated to 2.3 from 0.9 and hypotensive with a systolic blood pressure in the 60s. She was given 2 liters of normal saline without response in blood pressure (her systolic blood pressure was still in the 70s-80s). The patient then spiked a temperature to 102 and she was started on sepsis protocol. She was transferred to the Medical Intensive Care Unit for further management. In the MICU, the patient was given 1 liter normal saline and her CVP was found to be at 20 with an SB02 of 72%. Therefore, she was started on Levophed. PAST MEDICAL HISTORY: 1. Dysphagia, motility study in [**2144-1-29**] showed no esophageal contraction. 2. Prerenal acute renal failure in [**2144-3-28**] secondary to poor p.o. intake. 3. Obstructive sleep apnea, on CPAP at 8-10 cm of water. 4. Emphysema, on home 02. 5. Bronchiectasis. 6. Pulmonary hypertension. 7. Symptomatic bradycardia, status post DDD pacemaker in [**2143-11-29**]. 8. GERD. 9. History of MRSA in her sputum, status post hernia repair. 10. Diastolic CHF with an echocardiogram from [**2143-6-29**] showing EF greater than 60%, right ventricular hypokinesis and 1+ MR. 11. Coronary artery disease. 12. Hypertension. 13. Status post appendectomy. 14. Status post TAH. 15. Status post back surgery. 16. Status post right total hip. 17. Chronic lower back pain. ALLERGIES: Penicillin, codeine, and Bactrim. ADMISSION MEDICATIONS: 1. Colace 100 mg p.o. b.i.d. 2. MS Contin 30 mg p.o. b.i.d. 3. Lipitor 20 mg p.o. q.d. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**] Dictated By:[**Name8 (MD) 4993**] MEDQUIST36 D: [**2145-4-23**] 03:22 T: [**2145-4-25**] 16:52 JOB#: [**Job Number 30776**] Name: [**Known lastname 5378**], [**Known firstname **] Unit No: [**Numeric Identifier 5379**] Admission Date: [**2117-3-29**] Discharge Date: [**2145-4-23**] Date of Birth: Sex: F Service: ADDENDUM: Please add to previous dictation of discharge summary list of medications continued. Vitamin E. Flovent 110 micrograms per actuation, one puff twice a day. Neurontin 800 mg in the morning, 400 mg in the afternoon and 800 mg in the evening. Reglan. Serevent two puffs inhaled twice a day. Diovan 60 mg p.o. q. day. Evista which was recently stopped. Lasix 40 mg p.o. twice a day. FAMILY HISTORY: The patient has a father and brother with chronic obstructive pulmonary disease. She has a sister with breast cancer. SOCIAL HISTORY: History of tobacco use, rare alcohol use. She lives with her cousin. PHYSICAL EXAMINATION: On admission, temperature of 102.0 F.; blood pressure ranging from 79 to 96 over 26 to 45; heart rate of 89; oxygen saturation 96% on four liters by nasal cannula. In general, the patient is an elderly female sitting in bed in no apparent respiratory distress. HEENT: Extraocular movements intact. Pupils are equal, round and reactive to light. Mucous membranes were dry. Heart is regular rate and rhythm. Lung examination with slight crackles at the bases, but otherwise clear. Abdominal examination is obese, soft, nontender, with some distention. Extremities with one to two plus pitting edema bilaterally. Positive for asterixis. Alert and oriented times three and able to follow commands. LABORATORY: On admission are notable for a white blood cell count of 12.6 with 78% neutrophils. Her hematocrit is 30.4 down from 36.1. Her creatinine is 2.3 up from 0.9. Urinalysis was negative. Liver function tests within normal limits. EKG shows possible atrial arrhythmia with a rate at 70 to 80 beats per minute. There is left axis deviation and a right bundle branch block. There are diffuse T wave inversions in the anteroseptal leads which is new. Chest x-ray shows peri-hilar haziness but no definite infiltrate or pulmonary vascular congestion. HOSPITAL COURSE: 1. HYPERTENSION: The patient was hypotensive with a systolic blood pressure in the 60s on admission that was not fluid responsive. She was enrolled in a MUST protocol for presumed sepsis given the temperature spike to 102.0 F.; however, in the Medical Intensive Care Unit it was felt that the etiology of her hypertension was most likely multifactorial. They felt that she probably had an early pneumonia causing poor p.o. intake in the setting of underlying dysphagia, causing prerenal acute renal failure which, in turn, decreased clearance of her MS-Contin. They also felt that her acute renal failure was then exacerbated by Lasix causing hypovolemia and hypotension in a patient who is preload dependent secondary to her right ventricular dysfunction and increased pulmonary artery pressures. The patient was aggressively fluid resuscitated and after three liters of normal saline her central venous pressure was approximately 17 to 20 and further intravenous fluid boluses were stopped. Her SVO2 was greater than 70, however, the patient remained hypotensive and so she was started on low dose of Levophed. The patient was taken off sepsis protocol since sepsis at that time was not suspected. The patient was started on Levofloxacin for a presumed community acquired pneumonia. Urinalysis was negative. Blood cultures were obtained but they were no growth to date. In the Medical Intensive Care Unit, her O2 remained stable and the patient did not require any intubation. Eventually, the patient was able to be taken off Levophed the following day and her blood pressure remained stable throughout the remainder of the hospitalization. Sputum cultures were obtained which grew Methicillin resistant Staphylococcus aureus. Chest x-ray was now showing a left lower lobe opacity with a persistent left pleural effusion. Given these findings, the patient was started on Vancomycin, initially at one gram intravenously q. day based on age. A trough of Vancomycin level was drawn prior to the third dose and was found to be low at 5.9. Following curbside with Infectious Disease, her Vancomycin dose was increased to 1.5 mg q. 24 hours. The patient, according to Infectious Disease, should be continued on the Vancomycin dose for at least two weeks. Since her blood cultures showed no growth, there was no need to prolong the course of Vancomycin for greater than two weeks. An echocardiogram was obtained to determine her ventricular function as well as to look for endocarditis. It showed a left atrium that was moderately dilated, a right atrium that was moderately dilated, a left ventricular cavity size that was borderline dilated, left ventricular ejection fraction of greater than 55%, right ventricular cavity was mildly dilated, right ventricular systolic function was borderline normal. She had one to two plus mitral regurgitation and three plus tricuspid regurgitation. There was moderate pulmonary artery systolic hypertension and no pericardial effusion. There was no evidence for endocarditis seen on transthoracic echocardiogram. The patient was also continued on Levofloxacin which was started empirically in the Medical Intensive Care Unit for fevers, for possible community acquired pneumonia and will be treated with a total of a two week course. Upon transfer to the Floor, the patient developed diarrhea. Three separate samples on three separate days were sent for Clostridium difficile which all returned as negative. The diarrhea improved throughout the course of the hospitalization. It is felt that her initial fever was likely from this pneumonia and there was no other infectious etiology found. 2. CARDIOVASCULAR: The patient has a history of diastolic congestive heart failure. An echocardiogram was obtained to determine her systolic function. Left ventricular ejection fraction was greater than 55% although she had a borderline normal right ventricular systolic function with one to two plus mitral regurgitation, three plus tricuspid regurgitation and moderate pulmonary artery systolic hypertension. The patient ruled out for myocardial infarction on admission with three sets of negative enzymes. Following transfer to the Floor after the patient had been hemodynamically stable for greater than 24 hours, the patient was restarted back on her home doses of Diovan for blood pressure control. The patient remained hemodynamically stable throughout the remainder of the hospitalization. The patient, however, was not started on Lasix due to persistent diarrhea. The patient was asked to weigh herself at home. She was told not to take Lasix for now but should she gain more than two pounds, she should call her primary care physician for recommendations on whether to restart Lasix. The patient is scheduled for a follow-up in three days following discharge to see her primary care physician. 3. PULMONARY: The patient has a history of emphysema and is on home O2. She also has obstructive sleep apnea and uses BiPAP at home. The patient's O2 saturation remained stable throughout the remainder of the hospitalization and she did not require intubation. She was also continued on her home inhalers and given nebulizers as needed. 4. ACUTE RENAL FAILURE: The patient was admitted with a creatinine of 2.3. Following aggressive fluid resuscitation, her creatinine returned to baseline and it was felt that her acute renal failure was likely prerenal in etiology. 5. DISPOSITION: The patient was seen by Physical Therapy and they recommended home with home Physical Therapy. The Medicine Team recommended pulmonary rehabilitation to the patient, however, the patient declined pulmonary rehabilitation stating that she had been discharged previously to pulmonary rehabilitation and that they had not been able to do anything for her. The patient wished to go home with home services. CONDITION ON DISCHARGE: Hemodynamically stable, ambulating, O2 saturations stable on two liters of oxygen by nasal cannula during the day and BiPAP overnight, pain free. DISCHARGE STATUS: The patient is discharged to home with home services including home oxygen and home Physical Therapy. DISCHARGE DIAGNOSES: 1. Dysphagia. 2. Prerenal acute renal failure. 3. Obstructive sleep apnea on CPAP 8 to 10 centimeters of water. 4. Emphysema on home O2. 5. Bronchiectasis. 6. Pulmonary hypertension. 7. Borderline right ventricular dysfunction. 8. Symptomatic bradycardia status post DDD pacemaker. 9. Gastroesophageal reflux disease. 10. Methicillin resistant Staphylococcus aureus pneumonia. 11. Diastolic congestive heart failure. 12. Coronary artery disease. 13. Hypertension. 14. Multi-factorial hypotension including hypovolemia from poor p.o. intake in the setting of dysphagia, acute renal failure, MS-Contin, pneumonia. DISCHARGE MEDICATIONS: 1. Docusate 100 mg p.o. twice a day. 2. Fluticasone four puffs inhaled twice a day. 3. Salmeterol one disc inhaled q. 12 hours. 4. Metoclopramide 5 mg p.o. four times a day a.c. and h.s. 5. Senna 8.6 mg p.o. twice a day. 6. Levofloxacin 250 mg p.o. q. 24 hours times ten days. 7. Valsartan 160 mg p.o. q. day. 8. Atorvastatin 40 mg p.o. q. h.s. 9. Calcium carbonate 500 mg p.o. three times a day. 10. Vitamin D 400 units p.o. q. day. 11. Gabapentin 800 mg in the morning and 400 mg in the afternoon and 800 mg at night. 12. Vancomycin 1.5 grams intravenously q. 24 hours times ten days. 13. Combivent two puffs inhaled twice a day. 14. The patient was given a prescription for Lasix but was asked not to take it due to her diarrhea. She was asked instead to weigh herself daily and if she gains more than two pounds she should call her primary care physician to determine whether she should restart Lasix. DISCHARGE INSTRUCTIONS: 1. The patient is scheduled to follow-up with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 5380**] [**Name (STitle) **] on Monday, [**4-26**], which is three days following discharge. Dr. [**Last Name (STitle) **] was notified as to the patient's admission. She was also asked to follow-up on the patient's Vancomycin level as requested by Infectious Disease. 2. The patient is scheduled to follow-up with Dr. [**First Name4 (NamePattern1) 55**] [**Last Name (NamePattern1) **] on [**5-5**]. 3. The patient is scheduled to follow-up with Dr. [**First Name (STitle) **] [**Name (STitle) 5381**], from Ophthalmology on [**5-13**]. 4. The patient is scheduled to follow-up with Nurses [**Last Name (un) 5382**] and Spivac from the Cardiac Center on [**9-8**]. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-207 Dictated By:[**Name8 (MD) 1433**] MEDQUIST36 D: [**2145-4-23**] 15:40 T: [**2145-4-25**] 17:08 JOB#: [**Job Number 5383**]

[ "492.8", "276.5", "482.41", "584.9", "397.0", "424.0", "428.32", "428.0", "780.57" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

3134, 3254

10834, 11456

11479, 12396

4649, 10517

12420, 13443

2124, 3116

3366, 4632

1284, 2101

3272, 3342

10543, 10813

62,586

180,027

5399

Discharge summary

report

Admission Date: [**2174-6-7**] Discharge Date: [**2174-6-21**] Date of Birth: [**2125-6-18**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1406**] Chief Complaint: sent for catheterization after found to have dilated CM on ECHO Major Surgical or Invasive Procedure: [**2174-6-7**] - Left heart catheterization, coronary angiogram [**2174-6-14**] - Coronary artery bypass grafting times 5 with the left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the right acute marginal, first and second obtuse marginal artery and first diagonal artery. History of Present Illness: Mr. [**Known lastname **] is a 48 y/o M with diabetes (diagnosed in [**1-/2174**]), hyperlipidemia, HTN, and newly diagnosed dilated cardiomyopathy who is s/p catheterization. The patient was initially supposed to have shoulder surgery done this past [**Month (only) 958**], but was found to have elevated sugars and diagnosed with DM. The surgery was rescheduled for earlier this month, and pre-operative ECHO was done showing biventricular dilation and severe hypokinesis, with mild mitral and moderate tricuspid regurgiation. There was also evidence of moderate pulmonary artery systolic HTN. An EF of [**9-3**]% was reported. Despite this EF, the patient denies any shortness of breath, dyspnea on exertion, chest pain, or decreased exercise tolerance due to fatigue. He does have some decreased exercise tolerance, but attributes it to R hip pain not fatigue. The patient also denies any history of PND or sleep orthopnea. The only symptoms that the patient does report is leg swelling since [**Month (only) 205**]. On cath, LMCA had distal 50% disease, diffuse LAD disease with 80-90% occlusions in small vessel at mid and distal segments, total occlusion of L cx after large OM1 and diffuse disease in RCA marginal branches. Wedge pressure was 32, PA pressues in 70s, pt was given 40 mg IV Lasix. . On arrival to the floor, patient was stable and CP free. Past Medical History: DM type 2, recently diagnosed [**1-/2174**] high cholesterol hypertension Social History: -Tobacco history: denies -ETOH: used to drink heavily on weekends in 20-30s, [**11-2**] beers/day -Illicit drugs: denies The patient lives with his second wife and two children. He has three children from previous marriage. He used to play soccer a lot when he as younger, but stopped playing regularly six years ago. He still reports playing soccer now on occassion. Originally from [**Country 7192**]. Family History: grandmother had throat cancer (was a smoker) aunt had DM No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission PE: VS 114/80 pulse 94 100 on RA GENERAL: well appearing, pleasant gentleman, NAD, alert and appropriate HEENT: NCAT. Sclera anicteric NECK: Supple CARDIAC: RRR, S1, S2 LUNGS: clear to auscultation b/l, no wheezes/crackles ABDOMEN: soft, non-tender, non-distended EXTREMITIES: warm, well perfused, 1+ DP/PT pulses, confirmed with Doppler, 2+ pitting edema b/l 3/4 up the shin Pertinent Results: [**2174-6-11**] 07:05AM BLOOD Glucose-133* UreaN-22* Creat-0.8 Na-138 K-4.8 Cl-99 HCO3-27 AnGap-17 [**2174-6-8**] 07:45AM BLOOD %HbA1c-8.7* eAG-203* [**2174-6-7**] 10:00AM BLOOD Triglyc-87 HDL-45 CHOL/HD-3.8 LDLcalc-108 2D-ECHOCARDIOGRAM: [**2174-5-25**] The left atrium is dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is severely depressed (LVEF= 15-20%). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] 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 structurally normal. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Biventricular dilatation and severe hypokinesis. Mild mitral and moderate tricuspid regurgitation. Moderate pulmonary artery systolic hypertension. . . CARDIAC CATH: [**2174-6-7**] Coronary angiography: left dominant LMCA: Distal 50% LAD: Diffuse disease with serial 80-90% occlusions in a small vessel (2.0 mm) at the mid and distal segments. Small diagonal branches have diffuse disease. LCX: Total occlusion mid Cx after large OM1. OM2 fills via collaterals. RCA: Likely nondominant with diffuse diseas in marginal branches and serial 80% lesions. Assessment & Recommendations 1. CSURG consult 2. Admit for management of decompensated CHF and titration of medical therapy. 3. Secondary prevention CAD and CHF. . Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2174-6-7**] for a cardiac catheterization. This revealed severe dilated cardiomyopathy with three vessel disease. The cardiac surgery service was consulted for surgical evaluation. He was worked-up in the usual preoperative manner including and viability study and carotid ultrasound. The carotid ultrasound showed a 60-69% right internal carotid artery stenosis and a 40% left internal carotid artery stenosis. The viability study revealed a fixed defect in the distal anterior and apical region. Given his high risk for surgery, a tranplant consutation was obtained. Workup revealed that he appeared to be an acceptable transplant/VAD candidate should the need arise. On [**2174-6-14**], Mr. [**Known lastname **] was taken to the operating room where he underwent coronary bypass grafting to five vessels. Please see operative note for details. Postoperative he was taken to the intensive care unit for monitoring. He was transfused with red blood cells for postoperative anemia. He required several days of pressors prior to extubation for blood pressure and cardiac output support. He was also noted to aggitated as sedation was weaned and was thus switched to precedex. He was ultimately extubated on [**2174-6-15**]. He developed a fever however work-up was negative. As his atelectasis improved, his fever went away. Coreg and lisniopril were started given his heart failure. On [**2174-6-20**] he was transferred to the step down unit for further recovery. He continued to be gently disuresed towards his preoperative weight. He was noted to be fatigued, nauseated and jaundiced and a liver ultrasound showed no evidence of acute cholecystitis, some ascites and a poorly visualized pancreas. His total bilirubin was elevated at 5 however trended down and was 3.9 on discharge. His lipase was elevated at 85. His nausea improved. He continued to wrok daily with the physical therapy service. Mr. [**Known lastname **] continued to make steady progress and was discharged home on [**2174-6-21**]. He will follow-up with Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) 171**] and Dr. [**Last Name (STitle) **] as an outpatient. Medications on Admission: Glimepiride 4 mg [**Hospital1 **] Lisinopril 5 mg daily Metformin 850 mg [**Hospital1 **] Simvastatin 20 mg daily Discharge Medications: 1. 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* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 3. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 4. glimepiride 4 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 6. metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS. Disp:*30 Tablet(s)* Refills:*2* 9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 10. potassium chloride 10 mEq Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO once a day for 5 days. Disp:*5 Capsule, Extended Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: coronary artery disease dilated cardiomyopathy noninsulin dependent diabetes mellitus s/p coronary artery bypass graft x 5 hypertension hypercholesterolemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage 2) Please NO lotions, cream, powder, or ointments to incisions 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart 4) No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns [**Telephone/Fax (1) 170**] 7) Take lasix and potassium once daily for 5 days then stop. **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2174-7-14**] 1:15 Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2174-6-29**] 1:20 WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2174-6-28**] 11:00 [**Hospital **] Medical Building 2A Please call to schedule appointments with: Primary Care Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] ([**Telephone/Fax (1) 1144**]) in [**2-22**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2174-6-21**]

[ "272.0", "250.50", "401.9", "425.4", "428.0", "518.0", "285.9", "250.40", "414.8", "362.01", "414.01", "782.4", "583.81", "E878.2", "428.23" ]

icd9cm

[ [ [] ] ]

[ "88.56", "39.61", "37.23", "36.14", "36.15" ]

icd9pcs

[ [ [] ] ]

8766, 8837

5198, 7414

373, 699

9038, 9038

3234, 5175

10083, 10906

2640, 2813

7578, 8743

8858, 9017

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9189, 10060

2828, 3215

270, 335

727, 2100

9053, 9165

2122, 2197

2213, 2624

52,967

134,043

8420

Discharge summary

report

Admission Date: [**2200-3-31**] Discharge Date: [**2200-4-15**] Date of Birth: [**2139-6-28**] Sex: F Service: MEDICINE Allergies: Penicillins / Lamictal Attending:[**First Name3 (LF) 99**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: Tracheostomy Mechanical ventilation History of Present Illness: 60 F with history of ILD (likely IPF), DM type I; admit from ED with dyspnea, fever, and pneumonia. Patient has been feeling unwell x 3-4 days with fevers up to 103, rigors, and severe productive cough. Sputum [**Doctor Last Name 352**] in color with possible few flecks ?blood. Normally does not produce sputum. + HA x few days, no neck pain or stiffness. No pleuritic CP but does report pain after bouts of coughing. No vomiting or diarrhea or abd pain, but +nausea after coughing fits. No dysuria, rash, leg swelling. Was at outpatient CT today, techs thought she was wheezing and coughing and thus recommended she go to her PCP. [**Name10 (NameIs) **] PCP, sats in high 80s. In the ED, vitals 100.4, HR 84, BP 133/46, R 24-48, 88-90% on RA with 94% on 4L. Received nebs, tylenol, NS, levaquin and ordered vanco but does not appear that she has gotten this yet. CXR with bibasilar opacities concerning for pneumonia. Mild leukocytosis, elevated glucoses, and mildly elevated lactate on labs.Triaged to MICU for respiratory distress and tachypnea. Review of systems: Constitutional: Reports fatigue and fever Eyes: Denies blurry vision Cardiovascular: Denies chest pain, palpitations, and edema Respiratory: Reports cough, dyspnea, tachypnea, and wheeze Gastrointestinal: Reports nausea. Denies abdominal pain, emesis, diarrhea, and constipation Genitourinary: Denies dysuria Musculoskeletal: [**Doctor First Name **] joint pain Integumentary (skin): Denies jaundice and rash Endocrine: Reports hyperglycemia Neurologic: Reports headache Past Medical History: - ILD (UIP on lung biopsy [**2199-4-25**]) - type I diabetes, has insulin pump - sarcoidosis, diagnosed via a LN biopsy in the [**2160**]'s - depression - carpal tunnel syndrome - s/p appendectomy, hysterectomy, cholecystectomy - hypothyroidism Social History: She works as a mechanical engineer though in an office setting, no unusual exposures. Lives with her partner, [**Name (NI) **] [**Name (NI) **]. She does not drink any alcohol. She quit smoking last year. Family History: Multiple family members with various cancers, including lung. Physical Exam: Vitals: T: 97.9, HR: 78, BP: 111/98, RR: 30, O2Sat 92% on 3L NC General Appearance: Well nourished, Anxious, No(t) Diaphoretic, mild respiratory distress, sitting up in bed, +rigors Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Lymphatic: No(t) Cervical WNL, Supraclavicular WNL, Cervical adenopathy, bilat 1+cm tender anterior cervical nodes Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), ?apical murmur, difficult to appreciate behind rhonchi Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles : few at R base, Wheezes : rare, Rhonchorous: very rhonchorous throughout) Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended Extremities: no edema Skin: Warm, No(t) Rash: , No(t) Jaundice Neurologic: Attentive, Follows simple commands, Responds to: Not assessed, Oriented (to): , Movement: Not assessed, Tone: Not assessed Pertinent Results: CT CHEST W/O CONTRAST [**2200-3-31**]: IMPRESSION: 1. Significant increase in multifocal ground-glass opacity, which could be due to a multifocal infection superimposed on known interstitial lung disease (ILD), progression of alveolitis related to ILD, or acute exacerbation of ILD. If the ground glass is directly related to the ILD, it is not typical of UIP. Differential diagnosis includes NSIP, LIP and chronic hypersensitivity pneumonitis given the air trapping and distribution. 2. Unchanged nodules since [**2199-3-26**], do not warrant further followup. 3. Increase mediastinal lymph nodes, likely reactive. 4. Minimal aortic valve calcifications, of unknown hemodynamic significance. 5. 10 mm soft tissue between the stomach and the liver, could be gastrohepatic lymph node or stomach diverticulum. 6. Increase in bronchial wall thickening and moderate airtrapping, related to small airway disease. CHEST (PORTABLE AP) [**2200-3-31**]: IMPRESSION: New bibasilar ill-defined opacities superimposed upon chronic interstitial lung disease. Findings may represent an acute infectious etiology, but an inflammatory process such as acute exacerbation of the patient's underlying interstitial lung disease is not excluded. BILAT LOWER EXT VEINS PORT [**2200-4-7**]: IMPRESSION: No lower extremity DVT. CHEST (PORTABLE AP) [**2200-4-11**]: Portable AP chest radiograph was compared to prior study obtained on [**2200-4-10**]. The tracheostomy tip is about 5.5 cm above the carina. The NG tube tip is in the stomach. The cardiomediastinal silhouette is stable. There is slight interval increase in widespread parenchymal opacity that giving its rapid change might represent some degree of superimposed pulmonary edema. Two areas of lucencies in the mid left and mid lung zones are again noted, unchanged. Small pleural effusion cannot be excluded. The right PICC line tip is in mid SVC. CT HEAD W/O CONTRAST [**2200-4-13**]: NON-CONTRAST HEAD CT: There is no evidence of intracranial hemorrhage, mass effect, shift of midline structures, hydrocephalus, or acute major vascular territorial infarction. [**Doctor Last Name **]-white matter differentiation appears preserved. Bones and soft tissues appear unremarkable. Please refer to dedicated CT sinus study for evaluation of the sinuses. IMPRESSION: No acute intracranial pathology. CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2200-4-13**]: IMPRESSION: Multifocal sinus disease with aerosolized secretions within the frontal sinus and sphenoid sinuses as described above as well as partial opacification of the mastoid air cells bilaterally. In the appropriate clinical setting, this suggests underlying acute sinusitis. CHEST (PORTABLE AP) [**2200-4-15**]: FINDINGS: As compared to the previous examination, there is no relevant change. The monitoring and support devices are in unchanged position. Unchanged is the extent and severity of the bilateral diffuse parenchymal opacities. There is no evidence of newly occurred pneumothorax or of pleural effusions. MICROBIOLOGY: [**2200-4-15**] MRSA SCREEN MRSA SCREEN-FINAL NEGATIVE [**2200-4-15**] BLOOD CULTURE Blood Culture, Routine-PENDING NEGATIVE [**2200-4-14**] BLOOD CULTURE Blood Culture, Routine-PENDING NEGATIVE [**2200-4-13**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {YEAST} [**2200-4-13**] URINE URINE CULTURE-FINAL NEGATIVE [**2200-4-13**] BLOOD CULTURE Blood Culture, Routine-PENDING NEGATIVE [**2200-4-11**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL NEGATIVE [**2200-4-11**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2200-4-10**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL NEGATIVE [**2200-4-10**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2200-4-8**] SPUTUM GRAM STAIN-FINAL NEGATIVE [**2200-4-6**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL NEGATIVE [**2200-4-6**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2200-4-6**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2200-4-6**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL NEGATIVE [**2200-4-5**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2200-4-5**] URINE URINE CULTURE-FINAL NEGATIVE [**2200-4-5**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2200-4-4**] URINE URINE CULTURE-FINAL NEGATIVE [**2200-4-4**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2200-4-4**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2200-4-3**] Rapid Respiratory Viral Screen & Culture Respiratory Viral Culture-FINAL NEGATIVE [**2200-4-3**] Rapid Respiratory Viral Antigen Test-FINAL NEGATIVE [**2200-4-3**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL; LEGIONELLA CULTURE-FINAL; Immunoflourescent test for Pneumocystis jirovecii (carinii)-FINAL NEGATIVE [**2200-4-3**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2200-4-3**] URINE URINE CULTURE-FINAL NEGATIVE [**2200-4-3**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL NEGATIVE [**2200-4-1**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL NEGATIVE [**2200-4-1**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL NEGATIVE [**2200-3-31**] URINE Legionella Urinary Antigen -FINAL NEGATIVE [**2200-3-31**] MRSA SCREEN MRSA SCREEN-FINAL NEGATIVE [**2200-3-31**] URINE URINE CULTURE-FINAL NEGATIVE [**2200-3-31**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2200-3-31**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE Brief Hospital Course: 60 year old female with ILD, DM I; admit with cough, dyspnea and evidence of pneumonia on CXR, admitted to MICU with persistent tachypnea and relatively high oxygen requirements on [**2200-3-31**]. Was subsequently trached and as prognosis worsened, [**Hospital 228**] health care proxy ([**Name (NI) **] [**Name (NI) **]) per patient's perceived wishes decided to pursue comfort measures on evening of [**2200-4-15**]. # Hypoxia: With history of interstitial pulmonary fibrosis and baseline abnormal lungs she likely has poor pulmonary reserve. Initially was managed with high flow oxygen and bronchodilators; however, 3 days after admission had acutely worsened respiratory status requiring emergent intubation. Intubation was complicated and a tracheostomy was performed shortly following attempted intubation due to inability to secure her airway. Multiple urine, blood, and sputum cultures were sent and were negative during the hospitalization. Urine legionella antigen was negative. PCP stain was negative. Had rapid viral antigens return as negative. Regardless, she completed a 10 day antibiotic course of vancomycin and levofloxacin as well as an 8 day course of metronidazole without great change in her respiratory status. All antibiotics were stopped on [**2200-4-9**] due to persistently negative culture data. High dose steroid burst for 6 days was discontinued on [**2200-4-10**] and there was no noted improvement in overall respiratory status. Patient was ventilated on several different modes of ventilation; however, desaturation was an issue with every mode. She required large doses of a variety of sedating medications (was on fent patch, fent drip, methadone, olanzapine, midazolam drip, diazepam oral) to keep her from becoming dys-synchronous with the ventilator. Patient was having more frequent periods of agitation, which were became associated with hypertension and bradycardia overnight on [**2200-4-12**]. The bradycardia was severe enough (HR in the 20s) to elicit a ventricular escape rhythm. We discontinued methadone, as it was a new medication that was started around same time as beginning of bradycardic episodes. Bradycardia was still present during periods of agitation following discontinuation of methadone; however, HR sunk only to 50s instead of to the 20s. Patient in her final days began having worsening hypoxia and had to be manually bagged with 100% FiO2 with slow resolution in her oxygen sats. On [**4-15**] she was moved to APRV ventilation as it was only strategy able to keep her oxygen sats gretaer than 90%. Family decided to pursue comfort measures on afternoon of [**4-15**] due to worsening oxygenation and inability to ventilate the patient. Patient died within 30 minutes of removal of ventilator support. # Mental status: Patient had intact mental status at presentation; however, had unknown underlying mental status once trached as sedation wean was limited by oxygen desaturations. Had concerning number of depressions in oxygen sats surrounding her attempted intubation. Head CT was obtained to rule out anoxic brain injury and appeared to be negative. Underlying mental status was not determined prior to patient's death. # Fever: Had fevers daily throughout admission. Had total of 14 negative blood cultures this admission. All urine cultures negative. Is c. diff negative for 3 samples. LFTs normal. All abx discontinued on [**4-9**] due to unclear source of treatment and continued fevers despite adequate course and selection of empiric antibiotics. Persistently elevated LDH likely from underlying lung disease. BUE U/S shows RUE DVT, heparin drip started, however not clear if this is source of fever. CT sinuses consistent with acute sinusitis on [**4-13**] and NG tube was removed and an OG tube was placed. Saline nasal rinses were initiated on [**4-14**]. No exact cause for fevers was determined prior to patient's death. # Upper extremity DVT: ??????Nonocclusive thrombus in the right basilic vein extending through the right axillary vein and into the right subclavian vein.?????? Right PICC was discontinued and left PICC was inserted. Patient was started on a heparin drip on [**2200-4-10**]. # Diabetes/hyperglycemia: Patient came into hospital on insulin pump. Was managed on insulin drip for several days prior to switch to glargine and sliding scale insulin. Was nourished with Boost Glucose Control via NG then OG tube while hospitalized. # Depression: Continued home meds throughout hospitalization. Medications on Admission: Depakote 250 mg twice daily Fluoxetine 80 mg daily Pravastatin 20 mg daily Levothyroxine 100 mcg daily Lisinopril 5 mg daily Omeprazole 20 mg daily Topiramate 25 mg before bedtime Wellbutrin 100 mg daily Insulin pump Folic acid 1 mg daily Centrum Silver 1 tab daily Discharge Medications: None, patient expired. Discharge Disposition: Expired Discharge Diagnosis: Primary: Idiopathic Pulmonary Fibrosis Respiratory Failure Secondary: Diabetes Mellitus Type 1 Discharge Condition: Patient expired Discharge Instructions: Admitted with low oxygen saturations and subsequently required ventilatory support. Hypoxia worsened and was eventually moved to comfort measures per the request of health care proxy. Died shortly after removal of ventilator support. Followup Instructions: None Completed by:[**2200-4-17**]

[ "244.9", "311", "250.01", "V45.85", "276.0", "V58.67", "453.8", "276.2", "518.81", "135", "515", "486", "V15.82" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.72", "33.24", "31.29", "96.05" ]

icd9pcs

[ [ [] ] ]

13832, 13841

8971, 11743

289, 327

13980, 13998

3531, 5474

14280, 14316

2405, 2468

13785, 13809

13862, 13959

13495, 13762

14022, 14257

2483, 3512

1426, 1898

242, 251

355, 1407

5483, 8948

11758, 13469

1920, 2167

2183, 2389

4,242

186,065

6912

Discharge summary

report

Admission Date: [**2173-5-20**] Discharge Date: [**2173-6-7**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5880**] Chief Complaint: fall Major Surgical or Invasive Procedure: none History of Present Illness: 82 y/o Male with dementia who was transferred from [**Hospital3 **] after falling from a 2nd story window onto concrete at nursing home. At [**Hospital 487**] hospital Left shoulder was found to be dislocated and was reduced. Head CT was done showing bilateral SDH. The patient was transferred to [**Hospital1 18**] for further medical treatment. Past Medical History: at baseline patient's mental status is A&Ox1. dementia, Parkinsons, with bilateral nerve stimulator placement, CAD HTN bladder CA rheumatic fever atrial septal defect Social History: Retired printer. Married. Family History: Noncontributory Pertinent Results: [**2173-5-20**] 05:48PM BLOOD WBC-13.9*# RBC-4.44* Hgb-13.9* Hct-40.9 MCV-92 MCH-31.3 MCHC-34.0 RDW-13.0 Plt Ct-167 [**2173-5-27**] 05:15AM BLOOD WBC-9.5 RBC-4.02* Hgb-12.4* Hct-35.2* MCV-88 MCH-31.0 MCHC-35.3* RDW-13.0 Plt Ct-180 [**2173-5-20**] 05:48PM BLOOD PT-13.3 PTT-22.5 INR(PT)-1.2 [**2173-5-21**] 02:16AM BLOOD Glucose-149* UreaN-24* Creat-0.7 Na-145 K-4.1 Cl-114* HCO3-25 AnGap-10 [**2173-5-23**] 02:10PM BLOOD Glucose-98 UreaN-15 Creat-0.6 Na-139 K-4.1 Cl-104 HCO3-28 AnGap-11 [**2173-5-20**] 05:48PM BLOOD CK(CPK)-181* Amylase-85 [**2173-5-20**] 05:48PM BLOOD CK-MB-2 [**2173-5-20**] 05:48PM BLOOD cTropnT-<0.01 [**2173-5-20**] 05:48PM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2173-5-20**] 05:48PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]->1.035 [**2173-5-27**] 03:44PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2173-5-27**] 03:44PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.019 URINE CULTURE (Final [**2173-5-31**]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SECOND MORPHOLOGY. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | ENTEROCOCCUS SP. | | AMPICILLIN------------ <=2 S <=2 S LEVOFLOXACIN---------- =>8 R 0.5 S NITROFURANTOIN-------- <=16 S <=16 S VANCOMYCIN------------ <=1 S 2 S CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2173-5-27**]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. Reference Range: Negative. AEROBIC BOTTLE (Final [**2173-5-29**]): REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 26029**] CC6A [**2173-5-28**] AT 1000. ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES. HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of gentamicin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details. HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to 1000mcg/ml of streptomycin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECALIS | AMPICILLIN------------ <=2 S LEVOFLOXACIN---------- 1 S PENICILLIN------------ 2 S VANCOMYCIN------------ 2 S ANAEROBIC BOTTLE (Final [**2173-6-1**]): NO GROWTH. Imaging: Head CT [**2173-5-20**] IMPRESSION: 1) Right frontal lobe parenchymal contusion with hemorrhage and surrounding edema. 2) Subarachnoid hemorrhage, most prominent across the frontal lobes bilaterally, but also within the occipital horns of the lateral ventricles. 3) Bilateral subdural collections in the frontotemporal parietal regions, slightly greater on the left. 4) Longitudinal fracture of the skull base. 5) Fracture of the sphenoid at the left inferior orbital fissure. Given that several nerve structures pass through this area, an ophthalmologic consult is recommended and further coronal high resolution imaging should be considered. [**2173-5-21**] CT Abd/Pelvis IMPRESSION: 1. No acute intra-abdominal pathology/injury. 2. A 6.5 cm renal cyst arising off the superior pole of the left kidney. [**2173-5-21**] TL spine IMPRESSION: No evidence of fracture or dislocation [**2173-5-20**] CT cspine IMPRESSION: 1. No fracture or malalignment of the cervical spine. 2. Extensive degenerative changes within the cervical spine, most prominent at the C4-7 levels. 3. Focal areas of decreased attenuation within both lobes of the thyroid. Clinical correlation is recommended, and further evaluation with ultrasound can be obtained if indicated. [**2174-5-31**] interval head CT FINDINGS: Study is being compared to prior examination dated [**2173-5-23**]. Evolving bilateral frontal contusions are seen with no interval increase in intraparenchymal, subarachnoid, and subdural hemorrhage. The amount of intraventricular hemorrhage has decreased and the subdural hemorrhages are smaller compared to prior study. No new areas of hemorrhages are identified. Midline structures are normal in position. Ventricles and subarachnoid spaces are stable in size. Bilateral stimulator devices within the thalami are again seen. Nondisplaced longitudinal skull base fracture is again visualized. Small left sphenoid [**Doctor First Name 362**] fracture is again noted. INTERPRETATION: Evolving contusions, smaller subdural hemorrhages bilaterally. No new intracranial hemorrhage is seen. Decrease in the amount of intraventricular hemorrhage. Brief Hospital Course: Mr. [**Known lastname **] was transferred from and outside hospital to [**Hospital1 18**] after he fell out a second story window at a nursing home. A full trauma resusciation was done upon his arrival. Neurosurgery was immiediatly consulted for bilateral subarachnoid hemorfhages, subdural hematomas, intracranial hemorrhage and basilar skull fracture. He was admitted to the ICU for careful observation and neurological monitoring. Opthamology was consulted for a left sphenoid fracture. There was no impingement of the nerve or muscles, and thus required no acute treatment. He was followed with repeat head CTs which were stable, and slowly improved during his hospital course. His basilar skull fracture did not require treatment. Once stabilized, he was transferred to the floor. His mental status was slighly below baseline and he had several days of fevers. A urine culture and one set of blood cultures were positive for enterococcus which was sensitive to ampicillin. One antibiotic therapy was started, he began to improve clinically. His sedating medications were weaned, and he became more alert. He worked with physical therapy throughout his hospital course. Early in his hospital course, Mr. [**Known lastname **] pulled out his foley catheter with the balloon still inflated. His outpatient urologist was [**Name (NI) 653**], and he advised replacing the foley and leaving it in for several weeks to allow the inflammation to decrease. Several discussions took place between his family and various members of the healthcare team to try to place him in an appropriate rehab facility or skilled nursing facility. Due to his underlying Parkinsons and dementia, and with the addition of his closed head trauma, he will require extensive rehab and reconditioning to get back to his baseline. Medications on Admission: ativan, celexa, zyprexa, colace, haldol, memantine Discharge Medications: 1. Memantine HCl 5 mg Tablet Sig: One (1) Tablet PO Q PM (). 2. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 7. Haloperidol 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 8. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 10. Ampicillin Sodium 2 g Recon Soln Sig: Two (2) grams Injection Q6H (every 6 hours) for 2 weeks: Last dose [**2173-6-11**]. 11. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: right intracranial hemorrhage bilateral subarachnoid hemorrhages bilateral subdural hemorrhages basilar skull fracture left L sphenoid fracture left shoulder dislocation hypertension dementia Parkinsons coronary artery disease Discharge Condition: good Discharge Instructions: Take all your medications as prescribed [**Name8 (MD) **] MD if you have increased headache, vomitting, fever to 101F, change in speach, coordination, strength, or any other concerns. Followup Instructions: Follow up with Dr. [**Last Name (STitle) 739**] of neurosugery in 2 weeks. Please call for an appointment [**Telephone/Fax (1) 1669**]. Follow up with [**Hospital **] clinic in [**2-19**] weeks. Call [**Telephone/Fax (1) 253**]. Talk to your primary care doctor regarding an incidental finding on your CT scan. We found decreased attenuation of both lobes of your thyroid which should be further investigated. If you wish, you can follow-up with Dr. [**Last Name (STitle) 26030**] at [**Hospital1 18**]. You can call [**Telephone/Fax (1) 9**] for an appointment. Follow up with your primary urologist, Dr. [**Last Name (STitle) 26031**] [**Telephone/Fax (1) 26032**] in the next 2-3 weeks. Completed by:[**2173-6-7**]

[ "599.0", "V10.51", "831.00", "041.04", "401.9", "414.01", "E849.7", "801.21", "883.0", "707.8", "E882", "790.7" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

8932, 9002

5939, 7758

265, 272

9273, 9279

935, 5916

9511, 10238

899, 916

7859, 8909

9023, 9252

7784, 7836

9303, 9488

221, 227

300, 648

670, 839

855, 883

5,308

146,190

6891

Discharge summary

report

Admission Date: [**2152-2-28**] Discharge Date: [**2152-3-10**] Service: MEDICINE Allergies: Cephalexin / Nsaids / Phenergan / Codeine Attending:[**First Name3 (LF) 7202**] Chief Complaint: transferred from OSH for STEMI Major Surgical or Invasive Procedure: Cardiac Catheterization TEE Cardioversion Pacemaker/Defibrillator Placement History of Present Illness: Ms. [**Known lastname 7749**] is a 83 year old woman with a history of CAD s/p cath [**12-24**] with stent LCX and RCA, ESRD on HD for the past 5 weeks, Hep B cirrhosis and COPD who is transferred from [**Hospital1 25986**] and Rehab Center with STEMI. . She was recently hospitalized at [**Hospital1 18**] from [**1-19**] to [**2-2**] with left lower lobe pneumonia and ESRD and started on HD. She was discharged to [**Hospital1 **] for treatment of her pneumonia. Over the past week, she was noted to have increasing cough with white sputum production, bronchospasm, shortness of breath and orthopnea. She was treated with IV solumedrol and biaxin which was changed to prednisone 60 mg on [**2-25**]. She was continued on levaquin and vancomycin and nebulizers. She was seen by pulmonary and they felt her wheeze and sob were due to CHF rather than COPD exacerbation. On [**2-25**] they were unable to complete dialysis due to clotted access catheter. On [**2-25**] she was started on 100 mg IV Lasix [**Hospital1 **] and zaroxyln with good response. ECG done [**2-25**] elevation in the inferior leads which were new compared to ECG from [**2152-2-2**]. ECG was repeated on [**2-28**] and showed similar ST elevation that was slightly decreased. CK was 115, CK-MB was 41 and TnI was 14.88. She was transfered to the [**Hospital1 18**] ED for further evaluation. Of note her aspirin was discontinued one week prior to admission due to platelet count of [**Numeric Identifier 17445**]. . In the ED the patient reported that she has been having chest pressure for several days. The pressure is worse with inspiration and expiration and worse with cough. She has had cough and shortness of breath for one month. She reported [**5-31**] chest pain, radiating to her right shoulder. In the ED she received aspirin 325 mg, heparin 5000 bolus and 300 mg plavix. She was brought to the cath lab. . Cath: findings notable for mod LMCA calcification, LAD mod calc with diffuse disease, LCX with non dom vessel, RCA occ mid segment with L --> R collaterals, RCA lesion dilated and then Taxus stent x 5. . Admitted to [**Hospital Unit Name 196**]. . ROS: Reports 5/10 chest pain that is slightly better than prior to cath. Worse with inspiration and expiration. She feels short of breath and feels like she has sputum that she cannot get up. She denies abdominal pain, diaphoresis, nausea, vomiting. Feels her legs are restless. Past Medical History: 1. COPD 2. Hepatitis B cirrhosis 3. Low back pain s/p laminectomy 4. Chronic renal insufficency - baseline Cr 2.9-3.3-> Being followed by renal (Dr. [**Last Name (STitle) 3271**] who feels this may be either hypertensive vascular disease or membranous glomerulonephritis secondary to hepatitis 5. rheumatoid arthritis 6. chronic renal insufficiency 7. recurrent urinary tract infections 8. right total knee replacement 9. anemia of chronic disease 10. coronary artery disease 11. hypothyroid 12. right ORIF of hip 13. Depression 14. Gout Social History: lives with daughter Family History: non contributory Physical Exam: PE: VS: T 96.8 HR 74 BP 123/55 RR 22 O2 sat 92-97% 2L GEN: Elderly woman, lying in bed flat, with some tachypnea and complaining of chest pain. HEENT: PERRL, EOMI, sclera anicteric, MMM. Neck: JVP at 10 cm. No lymphadenopathy. Lungs: Crackles at left base with wheezes throughout. CV: Regular, no murmurs, rubs or gallops appreciated. Abd: Soft, obese, non tender and non distended, active bowel sounds. Ext: No edema, no rash. vascular: 2+ DP pulses. Groin: no hematoma, no bruit, good pulse. Neuro: Alert and oriented. Pertinent Results: ECG: [**2152-2-25**]: Sinus at 72 bpm, normal intervals. Normal axis. 1mm STE in II, III, avf, (III>II) TWI and ST depressions I, AVL, new since [**2152-2-2**]. . [**2152-2-28**] prior to cath: 1mm STE in II, III, AVF, slightly improved. TWI I, Avl, ST depressions I AVL. . [**2152-2-28**] post cath: Sinus 68 bpm. Normal intervals and axis. STE II, III, AVF, with TWI and ST depressions I and AVL. . Labs: see below, notable for elevated BUN/Cr, low plts, elevated MB/trop [**2152-2-28**] 01:40PM PT-11.6 PTT-32.8 INR(PT)-1.0 [**2152-2-28**] 01:40PM PLT SMR-LOW PLT COUNT-93* [**2152-2-28**] 01:40PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+ SCHISTOCY-1+ [**2152-2-28**] 01:40PM NEUTS-93.3* BANDS-0 LYMPHS-3.1* MONOS-3.1 EOS-0.2 BASOS-0.3 [**2152-2-28**] 01:40PM WBC-6.8 RBC-4.54# HGB-14.7# HCT-43.4# MCV-96 MCH-32.4* MCHC-33.9 RDW-15.9* [**2152-2-28**] 01:40PM CALCIUM-8.9 PHOSPHATE-3.5 MAGNESIUM-2.1 [**2152-2-28**] 01:40PM CK-MB-35* MB INDX-31.0* cTropnT-5.12* [**2152-2-28**] 01:40PM CK(CPK)-113 [**2152-2-28**] 01:40PM GLUCOSE-189* UREA N-36* CREAT-4.1* SODIUM-138 POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-26 ANION GAP-20 [**2152-2-28**] 08:55PM PT-11.7 PTT-25.5 INR(PT)-1.0 [**2152-2-28**] 08:55PM PLT COUNT-91* [**2152-2-28**] 08:55PM WBC-5.7 RBC-4.57 HGB-14.5 HCT-43.0 MCV-94 MCH-31.8 MCHC-33.7 RDW-15.5 [**2152-2-28**] 08:55PM ALBUMIN-3.9 [**2152-2-28**] 08:55PM CK-MB-25* MB INDX-24.0* cTropnT-5.25* [**2152-2-28**] 08:55PM ALT(SGPT)-59* AST(SGOT)-54* LD(LDH)-407* CK(CPK)-104 ALK PHOS-117 TOT BILI-0.3 [**2152-2-28**] 08:55PM GLUCOSE-154* UREA N-44* CREAT-4.3* SODIUM-136 POTASSIUM-4.5 CHLORIDE-96 TOTAL CO2-22 ANION GAP-23* [**2152-2-28**] 10:30PM PLT COUNT-81* [**2152-2-28**] 10:30PM CK-MB-NotDone [**2152-2-28**] 10:30PM CK(CPK)-88 [**2152-2-28**] 10:30PM POTASSIUM-4.3 [**2152-2-28**] 11:01PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [**2152-2-28**] 11:01PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.034 [**2152-2-28**] C.Cath: COMMENTS: 1. Selective coronary angiography showed a right dominant system with calcified LMCA but no critical stenosis. LAD had some moderate diffuse disease. LCX was a non-dominant vessel without critical lesions. RCA was totally occluded through its mid-vessel course with some distal flow to the PDA territory via L->R collaterals. 2. Left ventriculography was deferred given CRI. 3. Hemodynamic assessment showed mildly elevated right-sided filling pressures consistent with volume overload. There was mild to moderate pulmonary hypertension. 4. The acute total occlusion of the mid RCA was predilated with 1.5 X 6mm Sprinter and 2.5 X 30mm maverick balloons, stented with 2.5 X 20mm, 3.0 X 20mm, 3.0 X 15mm and 3.5 X 32mm Taxus stents and post dilated with 3.0 X 15mm NC ranger balloon with lesion reduction from 100% to 0%. The final angiomgram showed TIMI flow with no dissection and no embolisation. (see PTCA comments) 5. R femoral arteriotomy site was closed with a 6Fr angioseal. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Normal ventricular function. 3 Successful stenting of the mid RCA lesion in the setting of an Acute inferior STEMI [**2152-3-2**] CXR: HISTORY: Shortness of breath and cough. Recent MI. Please evaluate for CHF versus pneumonia. AP upright and left lateral views of the chest show interval clearing of pleural effusion seen on the patient's prior portable study from [**2152-1-26**]. No focal consolidation is seen to suggest pneumonia and the pulmonary vasculature is not congested. Moderate cardiomegaly appears stable and soft tissue mass at the right upper mediastinum has been shown to be vascular on previous cross sectional imaging studies. Tunneled dialysis tubing is seen with distal tip at the level of the right atrium and the proximal tip at the level of the SVC/right atrial junction. Calcified atherosclerotic plaque is seen in the arch of the aorta. CONCLUSION: No CHF or pneumonia. [**2152-2-29**] Echo: Conclusions: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50%) secondary to hypokinesis of the basal inferior wall. An apical intracavitary gradient is identified. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size is normal. Right ventricular systolic function appears depressed. 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 left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2152-1-26**], inferobasal hypokinesis is now present. Brief Hospital Course: 83 year old woman with history of CAD, hep B cirrhosis, ESRD on HD, recent pneumonia, s/p sTMEI with stent who developed post MI AF. S?p DCCV with brief stay in the CCU for observation. Bradycardia concerning for sick sinus syndrome. . . 1. s/p STEMI: patient experienced an ST Elevation MI. the patient tolerated catheterization well, and was pain free afterwards. She is s/p RCA stents with continued STE on ECG, which gradually resolved, evolving into q waves. Patient was started on usual post-MI care with ASA, BB, statin, plavix, and ACEIs. Patient does have diastolic [**Last Name (LF) 25987**], [**First Name3 (LF) **] 50%. Since diuresis would have been ineffective (patient has ESRD), HD was used to take off fluid . c. Rhythm: patient was in NSR post MI. On [**3-1**], she spontaneously converted to afib with RVR. She required IV diltiazem and IV lopressor to control her rate. She was also started on anti-coagulation with heparin and coumadin. The decision was made to cardiover the patient. s/p DCCV, in sinus, cont to hold BB to observe rate for 24 hrs. Patient then became bradycardic to 40s, and was transferred to CCU with a temp pacing wire. TEE showed: No evidence for intracardiac ( and in particular left atrial )thrombus. Severely hypokinetic right ventricle. HR stable in the CCU, but did have one episode of atrial tachycardia, ?wandering pacemaker, followed by a pause, junctional escape rhythm and return of sinus rythym. Tolerated full course of HD prior to transfer. Transferred back to [**Hospital Unit Name 196**] for monitoring and placement. Pt felt ok. Has some difficulty breathing, + cough but unable to get much up. She developed a small left forarm bleed from an IV. Then, the decision was made in consult with EP to place a DDD pacemaker. Pt was given 2 doses of vancomycin pre and post-procedure. The procedure was w/o complications. Post-pacemaker, the patient's HR alternated between 60s (paced) and 100s (afib). BB blocker was adusted to control HR. The patient has an appointment to follow up in Device clinic. . 2. ESRD on HD: renal consult was called, HD was initiated. Initially had some difficulty due to hypotension associated with atrial fibrillation. Post DCCV+pacemaker placement, the patient tolerated HD ok. The patient is to have hemodialysis while at rehab on a schedule of HD MWF. All meds were renally dosed, and the patient was continued on sevelamer, and nephrocaps. Patient needs her eletctrolytes to be checked 3 times a week with dialysis. Electrolytes should be adjusted and sevelamer dosing (phosphate binder) should be adjusted according to phosphate levels. . 4. Pneumonia: s/p levofloxacin for 14 days. The patient initially had some cough, but clear CXR, afebrile. Expectorants were given, the patient continued to remain afebrile, and symptoms improved. . 5. COPD: s/p steroid taper. The patient's lungs were without wheezes. We continued inhalers, nebs PRN. . 6. UTI: patient was discovered to have VRE on [**3-2**] cx. Of note, the patient was started on vancomycin for "urinary infection" while at rehab, though there was no clear documentations regarding what was cultured from that urine. The patient was started on linezolid for 14 days, started on [**3-6**]. . 7. Thrombocytopenia: Chronic and likely related to cirrhosis. Albumin only slightly decreased and INR normal. will monitor while on heparin, platelets did not drop greater than 50%, stayed stable. . 8. Anti-coagulation. Patient has atrial fibrillation and was started on anticoagulation with heparin and coumadin. Heparin was d/c'd and patient was therapeutic on her INR throughout her hospital stay. During the last day, the patient was supratherapeutic on her INR, but here was no evidence of bleeding, mental status changes or agitation. PO Vitamin K was given. At rehab, coumadin needs to be HELD for [**2152-3-11**] and [**2152-3-12**]. PT/INR needs to be re-checked on [**2152-3-11**]. If INR > 7, 5mg of PO vitamin K should be given, and PCP needs to be notified for further guidance (and coumadin dosing needs to be held). Medications on Admission: Calcitonin 3.7 ml nasal daily Calcium/Vitamin D 500 mg [**Hospital1 **] Docusate 100 mg [**Hospital1 **] Epoetin 8000 U MWF Esomeprazole 40 mg daily Fluticasone/Salmeterol 250/50 [**Hospital1 **] Folic acid 1 mg daily Lasix 100 mg IV bid Hydralazine 50 mg q 8 hours Iron Sucrose 100 mg IV MWF Isosorbide Mononitrate SR 120 mg daily Lactulose 10 ml tid Levalbuterol inhaled qid Levofloxacin 250 mg po every other day, next due [**2-29**], last dose [**3-4**] Levothyroxine 25 mcg daily Lorazepam 0.5 mg MWF 1/2 hour prior to dialysis Zaroxyln 10 mg po bid Lopressor 50 mg po bid Miconazole powder [**Hospital1 **] Nephrocaps 1 daily Prednisone 60 mg daily Requip 1 mg qhs for RLS Senna 1 [**Hospital1 **] Sevelamer 1200 mg with meals tid Spiriva one daily Vancomycin 1 gm IV MWF with dialysis (level 9.7 on [**2152-2-28**]) Ambien 5 mg qhs PRN: Tylenol 650 mg po q4 hours prn bisacodyl 10 mg daily prn Sarna qid prn levalbuterol (xopenex) q 6 hrs prn ativan 0.5 mg tid prn Fioricet qid prn simethicone 80 mg qid prn Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig: One (1) Nasal DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation [**Hospital1 **] (2 times a day). 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 9. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO QMOWEFR (Monday -Wednesday-Friday): give prior to dialysis. 11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 12. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 13. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 14. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 15. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 16. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO TID (3 times a day) as needed for anxiety. 17. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 19. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 20. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): take with meals. adjust according to Chem 7 results. 22. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO qhs (). 23. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 24. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 12 days. 25. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 26. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 27. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime): please dose according to INR. INR should be [**2-25**]. Call PCP for further guidance on warfarin dosing. 28. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day: please hold if SBP < 90. 29. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): please hold for HR < 50, SBP < 90. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: ST Segment Elevation Myocardial Infarction New Onset Atrial Fibrillation, on anti-coagulation s/p TEE Cardioversion S/P pacemaker/ICD placement End Stage Renal Disease Rheumatoid arthritis Anemia Thrombocytopenia Discharge Condition: stable, afebrile, ambulatory, chest pain free Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500ccs/day -please follow up with all outpatient appointments -please take all your medications as directed -please attend dialysis as scheduled--Monday, Wednesday, Friday -if you should feel more chest pain, palpitations, lightheadedness, dizziness, please let your doctor know immediately. -please re-check INR on Saturday, [**2152-3-11**]. Please watch for mental status changes, acute overt bleeding. Continue to hold coumadin on [**2152-3-11**] and [**2152-3-12**]. If INR > 7 on Saturday [**2152-3-11**], give 5mg of Vitamin K PO, recheck INR on Sunday. Please call PCP [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 2936**] to adjust Warfarin dosing based on INR and further guidance. INR should be [**2-25**] Followup Instructions: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2152-3-15**] 10:30 -please call your PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **]. at [**Telephone/Fax (1) 2936**] to arrange a follow/up appointment as soon as possible -patient needs hemodialysis MWF for removal of fluid as well [**Hospital 25988**] clinic -PCP for adjustment of anti-coagulation Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 2936**] Appointment should be in [**7-31**] days Completed by:[**2152-3-10**]

[ "599.0", "491.21", "427.31", "285.21", "287.4", "426.0", "486", "427.5", "790.92", "410.41", "997.1", "571.5", "428.0", "440.0", "458.29", "041.04", "427.81", "428.30", "414.01", "V09.80", "786.59", "585.6" ]

icd9cm

[ [ [] ] ]

[ "88.72", "99.20", "89.45", "37.72", "37.78", "37.22", "39.95", "37.83", "88.56", "36.07", "00.66", "00.40", "99.61", "00.48" ]

icd9pcs

[ [ [] ] ]

17156, 17228

9289, 13394

280, 358

17485, 17533

3998, 7109

18426, 19028

3423, 3441

14460, 17133

17249, 17464

13420, 14437

7126, 9266

17557, 18403

3456, 3979

210, 242

386, 2807

2829, 3369

3385, 3407

50,734

175,945

39883

Discharge summary

report

Admission Date: [**2105-11-20**] Discharge Date: [**2105-11-27**] Date of Birth: [**2044-10-28**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1505**] Chief Complaint: Shortness of breath, dyspnea on exertion Major Surgical or Invasive Procedure: [**2105-11-20**] Redo sternotomy, mitral valve replacement (31mm St. [**Male First Name (un) 923**] mechanical) History of Present Illness: Mr. [**Known lastname 87733**] is a 60 year old male who underwent single vessel coronary artery bypass to the acute marginal and a mitral valve repair in [**2097**] at the [**Hospital1 2025**] by Dr. [**Last Name (STitle) **]. Over the last several months, he has developed worsening dyspnea on exertion and even shortness of breath at rest. He currently denies chest pain, orthopnea, PND, pedal edema and syncope. Recent echocardiogram revealed severe mitral regurgitation with flail posterior leaflet. Given the above findings, he was referred for redo operation. Past Medical History: Coronary artery disease Hypercholesterolemia Hypertension Osteoarthritis Gout Varicose Vein Past Surgical History: s/p CABG, MV Repair [**2097**] Left Hip Pinning at age 13 Social History: Race: Caucasian Last Dental Exam: "many years ago" Lives: Alone Occupation: Car Sales, currently on disability Tobacco: Quit 8 years ago, approx 30PYH ETOH: Rare Family History: Father with MI at age 61. Sister with MI at age 59. Physical Exam: Pulse: 63 Resp: 18 O2 sat: 100% BP Right: 128/80, Left: 130/85 General: WDWN male in no acute distress Skin: Warm[x] Dry [x] intact [x] HEENT: NCAT[x] PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] - no JVD Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [**3-7**] holosytolic murmur best heard at apex, left lower sternal border Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema - trace Varicosities: GSV varicosed left thigh, both lower legs without significant 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: [**11-20**] Echo: PRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Moderate to severe (3+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on Mr.[**Known lastname 87733**] by Dr.[**First Name (STitle) 6507**] [**Name (STitle) 60351**]: Patient is on epinephrine 0.02mcg/kg/min. Normal Right ventricular systolic function. LVEF 55%. The mitral mechanical prosthesis is well placed and stable with transvalvular gradients (mean of 8mm of Hg) and conveyed by Dr.[**First Name (STitle) 6507**] to Dr.[**Last Name (STitle) **]. Intact thoracic aorta. [**2105-11-20**] 02:40PM BLOOD WBC-42.0*# RBC-3.48* Hgb-10.0* Hct-30.9* MCV-89 MCH-28.8 MCHC-32.4 RDW-14.3 Plt Ct-317 [**2105-11-22**] 04:24AM BLOOD WBC-16.6* RBC-2.93* Hgb-8.4* Hct-25.7* MCV-88 MCH-28.7 MCHC-32.7 RDW-14.4 Plt Ct-171 [**2105-11-27**] 05:00AM BLOOD WBC-10.7 RBC-2.92* Hgb-8.6* Hct-25.6* MCV-88 MCH-29.3 MCHC-33.4 RDW-14.7 Plt Ct-270 [**2105-11-20**] 02:40PM BLOOD PT-13.1 PTT-39.6* INR(PT)-1.1 [**2105-11-23**] 12:14PM BLOOD PT-28.8* INR(PT)-2.8* [**2105-11-24**] 05:15AM BLOOD PT-45.6* PTT-39.0* INR(PT)-4.9* [**2105-11-24**] 09:20AM BLOOD PT-46.0* INR(PT)-5.0* [**2105-11-25**] 05:30AM BLOOD PT-33.9* INR(PT)-3.4* [**2105-11-26**] 05:05AM BLOOD PT-29.1* INR(PT)-2.9* [**2105-11-27**] 05:00AM BLOOD PT-25.4* INR(PT)-2.4* [**2105-11-20**] 03:03PM BLOOD UreaN-22* Creat-1.3* Na-142 K-3.9 Cl-115* HCO3-22 AnGap-9 [**2105-11-27**] 05:00AM BLOOD Glucose-96 UreaN-29* Creat-1.8* Na-138 K-5.1 Cl-105 HCO3-27 AnGap-11 [**2105-11-21**] 01:27AM BLOOD ALT-12 AST-40 LD(LDH)-384* AlkPhos-53 Amylase-42 TotBili-0.4 [**2105-11-24**] 05:15AM BLOOD Calcium-8.1* Phos-3.8 Mg-2.2 Brief Hospital Course: Mr. [**Known lastname 87733**] was a same day admit after undergoing all pre-operative work-up as an outpatient. On [**11-20**] he was brought directly to the operating room where he underwent a redo-sternotomy, mitral valve replacement. Please see operative note for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-operative day one he was started on beta blockers and diuretics and diuresed towards his pre-op weight. In addition Coumadin was started and titrated for a goal INR 3-3.5. He remained in the ICU receiving aggressive pulmonary toilet for several days and on post-op day three was transferred to the telemetry floor for further care. He had an episode of atrial fibrillation and was given additional beta blockers and started on Amiodarone. His rhythm at discharge was sinus regular. Chest tubes and epicardial pacing wires were removed per protocol. Cipro was started for post-op UTI. On post-op day five he received 2 units of red blood cells for low HCT. His HCT at discharge was 25. While awaiting a therapeutic INR he worked with physical therapy for strength and mobility. He was discharged home with VNA services on post-op day seven with the appropriate medications and follow-up appointments. Dr. [**Last Name (STitle) 35055**] will follow his INR and adjust his Coumadin accordingly. Medications on Admission: Aspirin 325 daily Allopurinol 150 daily Lovastatin 20 daily Lisinopril 10 daily Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. lovastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 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. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 6. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:*10 Tablet(s)* Refills:*0* 7. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Take two 200 mg tablets twice daily x 5. Then one 200mg tablets twice daily x 7 days. Then 1 200mg tablet until stopped by cardiologist. Disp:*60 Tablet(s)* Refills:*2* 10. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: Goal INR 3-3.5 for mechanical MVR. Dr. [**Last Name (STitle) 35055**] to adjust dose depending on INR. Disp:*30 Tablet(s)* Refills:*2* 11. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*1* 12. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: tba Discharge Diagnosis: Mitral regurgitation s/p Mitral valve Replacement s/p mitral annuloplasty/coronary artery bypass [**2097**] Hypertension Hypercholesterolemia Degenerative joint disease Gout s/p left hip pinning Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema 2+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**12-17**] at 1PM Please call to make appointments with: PCP/Cardiologist:Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 35055**] ([**Telephone/Fax (1) 87734**]) **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication mechanicla valve Goal INR 3-3.5 First draw [**11-29**] Results to:Dr. [**Last Name (STitle) 35055**] phone:[**Telephone/Fax (1) 87734**] fax:781- Completed by:[**2105-11-27**]

[ "272.0", "V45.81", "427.31", "599.0", "276.2", "274.9", "424.0", "401.9" ]

icd9cm

[ [ [] ] ]

[ "35.24", "39.61" ]

icd9pcs

[ [ [] ] ]

7743, 7777

4545, 6015

322, 435

8015, 8228

2273, 4522

9068, 9784

1422, 1475

6145, 7720

7798, 7994

6041, 6122

8252, 9045

1168, 1227

1490, 2254

242, 284

463, 1031

1053, 1145

1243, 1406

66,109

144,234

44744

Discharge summary

report

Admission Date: [**2180-6-1**] Discharge Date: [**2180-6-4**] Date of Birth: [**2103-12-15**] Sex: F Service: MEDICINE Allergies: Augmentin / Simvastatin Attending:[**Last Name (un) 7835**] Chief Complaint: chills Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 95725**] is a 76 yo F with h/o asthma and CLL (not currently undergoing treatment), type 1 DM (insulin pump) with recent admission for PNA in late [**Month (only) 547**] treated with levofloxacin, who presents to [**Hospital1 18**] with shaking chills. Today pt notes being very cold and having shaking chills. Denies fevers, nausea, vomiting, CP, SOB, abd pain, dysuria. States that this feels similar to when she had her prior pneumonia. Initial VS in the ED: 102.8 83 106/45 20 100% RA. Labs notable for WBC 14.3 (N42.8, L55.1, no bands), platelets 102 (baseline), lactate 1.7, creatinine 0.7. Blood cultures were obtained. CXR showed probable mild bibasilar atelectasis. Pt was given vancomycin 1g and levoflox 750mg and tylenol 500mg. While pt was febrile, she had a narrow complex tachycardia (likely AFib with RVR, rates 150s). She received 2L IVF with improvement in rates to 100-110s. She was admitted to the [**Hospital Unit Name 153**] for AFib with RVR in the setting of infection with borderline blood pressures. Vitals on transfer: 93/49, 73, 22, 100% RA 3L IVF just voided 800cc . In the MICU, vitals are: . sinus 84, NA/NI, no STE Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: 1. CLL/lymphoma of the eyes: diagnosed in [**2157**], self treated cadmium and semicarbazide, with excellent baseline PS 2. Asthma 3. Hypercholesterolemia 5. Diabetes 6. Left shoulder fracture (traumatic) 7. Osteoporosis 8. right vocal fold hypomobility, resolving left vocal fold hemorrhage, and laryngeal hyperfunction CLL history: CLL diagnosed in [**2157**], followed by Dr [**Last Name (STitle) 2036**] in the past, self treated with cadmium and semicarbazide (a Russian patented formulation studies in the 60s for multiple cancers) for many years at least intermittently since [**2169**] or [**2170**], last seen by Dr [**Last Name (STitle) 2036**] in 1/[**2176**]. She then transferred her care to the [**Hospital1 2025**]. Previously there had been discussion of treatment of her CLL given her diffuse LAD, but she refused. Whether or not treated at [**Hospital1 2025**] is unknown. Not all of the information is available from Dr[**Name (NI) 13339**] original assessment, which apparently stretches back to early [**2157**], but as early as [**2162**] she had WBC 27 with marked lymphocytic predominance. WBC peaked at 40, and it was sometime around [**2167**] that she began her Russian self treatment program, which remarkably has decreased her WBC to normal with no toxic side effects per the documentation from Dr [**Last Name (STitle) 2036**]. PLT have largely been in the range of 100-150. Social History: Patient is bilingual. Was a Neurologist in [**Country 532**]. Worked with a lot of TB patients. Since she has been here she has been retired. Married. Has 2 daughters who are both here in the US. One is a pediatrician and one is a nurse. Family History: Parents are both deceased. Father (30, killed); Mother (75, heart problems, diabetes). She has 1 brother (80 - CABG in his 60's). She has two daugthers ages 38 and 48 (well). Physical Exam: ADMISSION EXAM General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: right basilar crackles CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: grossly intact Pertinent Results: ADMISSION LABS [**2180-6-1**] 04:20PM BLOOD WBC-14.3*# RBC-4.72 Hgb-13.7 Hct-42.3 MCV-90 MCH-29.1 MCHC-32.4 RDW-13.7 Plt Ct-103* [**2180-6-1**] 04:20PM BLOOD Neuts-42.8* Lymphs-55.1* Monos-0.7* Eos-0.7 Baso-0.7 [**2180-6-1**] 04:20PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2180-6-1**] 04:20PM BLOOD Glucose-151* UreaN-17 Creat-0.7 Na-135 K-3.9 Cl-100 HCO3-26 AnGap-13 [**2180-6-1**] 04:20PM BLOOD CK(CPK)-99 [**2180-6-1**] 04:20PM BLOOD CK-MB-3 [**2180-6-1**] 04:20PM BLOOD cTropnT-<0.01 [**2180-6-2**] 04:53AM BLOOD Calcium-7.0* Phos-2.7 Mg-1.8 [**2180-6-2**] 04:53AM BLOOD TSH-1.2 [**2180-6-2**] 04:53AM BLOOD Free T4-0.85* [**2180-6-2**] 04:53AM BLOOD Cortsol-4.8 [**2180-6-1**] 04:29PM BLOOD Lactate-1.3 . URINE STUDIES [**2180-6-1**] 10:14PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009 [**2180-6-1**] 10:14PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG . MICROBIOLOGY [**2180-6-1**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] [**2180-6-1**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] . IMAGING CXR UPRIGHT AP AND LATERAL VIEWS OF THE CHEST: The cardiac silhouette size is top normal. The mediastinal and hilar contours are relatively unchanged with mild unfolding of the thoracic aorta. Pulmonary vascularity is not engorged. There is crowding of the bronchovascular structures. No overt pulmonary edema is present. There is minimal streaky atelectasis at the lung bases. No focal consolidation, pleural effusion or pneumothorax is identified. Mild loss of height of a mid thoracic vertebral body appears unchanged. IMPRESSION: Low lung volumes with probable mild bibasilar atelectasis. Brief Hospital Course: 76 yo F history of CLL, DM1, recent pneumonia 2 months ago (treated with ceftriaxone/azithro then switched to levo), who presents with chills, fever, leukocytosis. # FEVER: There was initial concern for PNA and she was started on broad spectrum antiobiotics. CXR was not felt to be consistent with PNA and therefore antibiotics were discontinued once cultures were negative x 48 hrs. Other sources of infection were considered including urinary source (U/A normal), GI source (patient denied diarrhea). Her CLL was also considered as a possible source of fever however her smear was not consistent with active disease. Lyme titer was requested by family and sent, and this was pending upon discharge to be followed up by PCP. [**Name10 (NameIs) **] have been viral syndrome. #TACHYCARDIA: EKG looks like A flutter with variable conduction, although the other 2 EKGs in NSR. Tachcyardia likely stimulated by fever/inflammatory state. Pt also complained of chest pressure during this event. Could have been experiencing some demand ischemia through troponin was negative x 1. TSH was normal. # Hypotension - likely secondary to hypovolemia. She responded well to bolus IV fluids. As above it was felt that she was unlikely to have an infection. Blood cx showed no growth at the time of transfer. # THROMBOCYTOPENIA: Patient's baseline platelet count is 100-150. Differential: ITP (can be seen in CLL), viral infection, DIC (PTT INR fine, less likely), B12/folate deficiency, HIV. Was noticed on prior admission, plt then 65, now 100. Smear on prior admission showed platelet clumping. -acute thrombocytopenia likely effect of underlying inflammatory state or viral syndrome, had returned to baseline at discharge. # DM type I: Has insulin pump. She was continued on her home settings. # HTN: her home moexepril with held in the setting of hypotension, it will be restarted upon discharge. # Asthma: stable, continued on montelukast, fluticasone-salmeterol, albuterol nebs TRANSITIONAL ISSUES: -Follow up CT Chest pending for end of [**Month (only) 205**] to follow up small area of consolidation in upper right lower lobe. Medications on Admission: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H wheezing/SOB 2. Aspirin 81 mg PO DAILY Start: In am 3. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **] 4. Guaifenesin [**4-27**] mL PO Q6H:PRN cough 5. Glargine 10 Units Breakfast + 3 Units Bedtime 6. Insulin SC Sliding Scale using HUM Insulin 6. Moexipril 7.5 mg PO DAILY 7. Polyethylene Glycol 17 g PO DAILY:PRN constipation Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) inhalation Inhalation Q6H (every 6 hours) as needed for wheeze. 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. Insulin Pump IR1250 Misc Sig: as needed units Miscellaneous qac. 6. moexipril 7.5 mg Tablet Sig: One (1) Tablet PO once a day. 7. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) packet PO once a day as needed for constipation. Discharge Disposition: Home Discharge Diagnosis: Fever Atrial Fibrillation/Flutter with RVR (resolved) Chronic Lymphocytic Lymphoma Asthma, stable Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with a fever, hypotension and tachycardia and admitted to the ICU for monitoring. Infectious workup has been negative, including CXR, U/A, Blood cultures to date. You initially received antibiotics but these were stopped as there was no bacterial source found and this was felt to be more consistent with a viral syndrome. Followup Instructions: Please make an appt and see your PCP within one week for post discharge follow up. You will need a follow up CT scan of the chest, which will be scheduled by your PCP at the end of [**Month (only) 205**]. . Follow up with your hematologist Dr. [**Last Name (STitle) **], as scheduled [**2180-7-19**]

[ "458.9", "204.10", "285.9", "250.01", "478.5", "493.90", "287.5", "079.99", "427.32", "733.00", "427.31", "V45.85" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9369, 9375

6086, 8076

288, 294

9516, 9516

4263, 6063

10049, 10351

3599, 3776

8666, 9346

9396, 9495

8255, 8643

9666, 10026

3791, 4244

8098, 8229

1513, 1893

242, 250

322, 1494

9531, 9642

1915, 3327

3343, 3583

74,869

123,152

37906

Discharge summary

report

Admission Date: [**2150-9-5**] Discharge Date: [**2150-9-12**] Date of Birth: [**2076-7-18**] Sex: F Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 338**] Chief Complaint: Serotonin Syndrome Major Surgical or Invasive Procedure: Expired History of Present Illness: The patient is a 74 yo woman with h/o depression, Hep C, and Parkinson's disease, who presented to OSH on [**9-3**] with fatigue, anorexia, s/p mechanical fall, and decreased urinary frequency. Per OSH records, the patient was started on Azilect for a new diagnosis of Parkinson's disease on [**2150-8-11**]. She had reportedly been taking Prozac for depression prior to starting Azilect, and she continued this medication until six days prior to admission. . On admission to [**Hospital 1281**] Hospital, the patient was found to have a UTI, so she was given IVFs and one dose of Ceftriaxone. She had a CT head which was normal. Shortly thereafter, she spiked a fever to > 106, became rigid and obtunded, and was admitted to the MICU. Given the fact that the patient was on an SSRI and an MAOI, she was thought to be in serotonin syndrome. . In the ICU, the patient was intubated, sedated, and paralyzed given her severe myoclonus. She was initially given Dantrolene and Bromocriptine, and was then started on Cryoheptadine. She became hypotensive after intubation and was started on Neosynepherine. This morning, the patient was noted to have new ST elevations in I, II, V3-V6, and her troponin increased from 0.14 on admission to 8.7. She had a TTE, which showed a new wall motion abnormality. She was started on a heparin gtt. Her sedation was held this morning, and the patient's mental status did not improve. She had an LP performed and was transferred to [**Hospital1 18**] for further workup and possible cardiac catheterization. . On arrival to the MICU, the patient remains unresponsive. Per the patient's family, she was able to open her eyes to commands prior to leaving [**Hospital 1281**] Hospital. Past Medical History: Parkinson's Disease (diagnosed 3 weeks ago) Hepatitis C (contracted from blood transfusion. Genotype 1B, untreated) Thrombocytopenia Mild asthma Cirrhosis c/b esophageal varice Social History: Patient is a widow. She is of Japanese heritage, having married an American in [**Country 14635**] and moved to this country. She has seven children. She does not drink or smoke or use IV drugs. Family History: Liver disease Physical Exam: Vitals: T: 96.5, BP:114/60, P:119, R:18 O2: 95% on CMV. VT 400, r 16, FiO2 50% General: Intubated and sedated. Not responsive to verbal or painful stimuli. HEENT: PERRL, Right pupil > left pupil (3 cm v 2 cm). Sclera anicteric, MMM, blood around ET tube site Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: Foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: . [**2150-9-5**] 05:57PM BLOOD WBC-10.2 RBC-3.36* Hgb-11.8* Hct-35.2* MCV-105* MCH-35.2* MCHC-33.6 RDW-14.5 Plt Ct-66* [**2150-9-5**] 05:57PM BLOOD Neuts-84.1* Lymphs-12.7* Monos-3.0 Eos-0.1 Baso-0.1 [**2150-9-5**] 05:57PM BLOOD PT-18.9* PTT->150* INR(PT)-1.7* [**2150-9-5**] 05:57PM BLOOD Plt Smr-VERY LOW Plt Ct-66* [**2150-9-5**] 05:57PM BLOOD Glucose-124* UreaN-19 Creat-0.4 Na-137 K-3.7 Cl-109* HCO3-20* AnGap-12 [**2150-9-5**] 05:57PM BLOOD ALT-111* AST-364* LD(LDH)-737* CK(CPK)-3257* AlkPhos-38* TotBili-2.1* [**2150-9-5**] 05:57PM BLOOD CK-MB-122* MB Indx-3.7 cTropnT-1.11* [**2150-9-5**] 05:57PM BLOOD Albumin-2.5* Calcium-7.0* Phos-2.0* Mg-1.7 [**2150-9-5**] 07:53PM BLOOD Type-ART Rates-16/ Tidal V-400 PEEP-5 FiO2-50 pO2-94 pCO2-38 pH-7.38 calTCO2-23 Base XS--1 -ASSIST/CON Intubat-INTUBATED [**2150-9-5**] 07:53PM BLOOD Lactate-1.5 . PERTINENT LABS/STUDIES: . CXR ([**9-5**]): ETT 1.7cm from carina. left pleural effusion layers superiorly. retrocardiac opacity. NGT in stomach. . CT Head: No intracranial hemorrhage, edema, or mass effect. Prominant frontal extraxial CSF space, incidental finding. Slight air fluid levels pleasant in left sphenoid sinus and left maxillary sinus, which may be secondary to patient's intubated status. EKG: NSR with rate of 69 bpm. Nl axis. ST elevation in I, II, V3-V6. Brief Hospital Course: The patient is a 74 yo woman with h/o depression, HepC, and recently diagnosed Parkinson's syndrome, who presents with hyperthermia, rigidity, and clonus, consistent with serotonin syndrome. . #. ACS: The patient was found to have ST changes on ECG and an increase in TroponinI from 0.14 to 8.7. The patient was intubated and thus unable to verbalize potential chest pain. Heparin gtt was started at OSH, and cardiology was C/S upon arrival. Given the fact that her ECG appeared to be more consistent with demand ischemia, the heparin gtt was discontinued and the patient was not placed on Plavix or ASA. Per cardiology the troponin leak was most likely secondary to demand. The pt's troponin trended down until [**2150-9-12**]. On [**2150-9-12**] the pt was found to be hypotensive (requiring multiple pressors), hypoxic, and with a lactate of 7, which was presumed to be due to ischemia in the setting of cardiogenic shock. The pt's troponin was noted to be 0.22. The patient's family was notified, and came to the bedside. After discussions with the attending physician, [**Name10 (NameIs) **] pt's family decided to change goals of care to comfort, and pressors were stopped. Later the patient's family requested that the patient be extubated, and the pt expired shortly afterward. . # Ventilator-associated pneumonia: The pt was noted to have new secretions and worsening oxygen requirement, so vancomycin and cefepime were initiated for ventilator-associated pneumonia. The pt developed an increased oxygen requirement on [**9-11**], and was found to have a pneumothorax. Thoracic surgery saw the patient and placed a chest tube to relieve the pneumothorax. On [**2150-9-12**], the pt was noted to be more hypotensive and hypoxic, which was attributed to worsening septic shock and likely new cardiogenic shock. #. Serotonin Syndrome: The patient presented with hyperthermia, posturing, and rigidity in the setting of MAOI and SSRI use. This was thought to be [**2-9**] serotonin syndrome, so she was started on Bromocriptine, Dantrolene, and Cryoheptadine at OSH. On arrival to [**Hospital1 18**], Neurology was consulted, and she was restarted on Cyproheptadine. The pt continued on cyproheptadine for rigidity for the duration of her hospitalization. The pt was followed by neurology during this hospitalization and had two EEGs during this time to evaluate persistently altered mental status. . Medications on Admission: Admission Medications: Azilect 1 mg daily Transfer Medications: Versed gtt at 0.01 mg/kg/h Zemuran gtt at 0.5 mg/kg/h Ceftazidime 2 g IV q8h Gentamicin 140 mg Heparin gtt Ibuprofen prn Neo-synepherine gtt . Discharge Disposition: Expired Discharge Diagnosis: Cardiogenic Shock Discharge Condition: Expired Followup Instructions: Expired

[ "332.0", "287.5", "785.51", "070.54", "997.31", "333.99", "411.1", "E947.8", "571.5", "512.8", "584.9", "599.0", "311" ]

icd9cm

[ [ [] ] ]

[ "34.04", "33.22", "96.72", "38.93", "88.91" ]

icd9pcs

[ [ [] ] ]

7214, 7223

4542, 6956

285, 295

7285, 7295

3178, 3178

7318, 7329

2485, 2500

7244, 7264

6982, 6982

7005, 7025

2515, 3159

227, 247

7047, 7191

323, 2052

4198, 4518

3194, 4189

2074, 2253

2269, 2469

20,880

197,075

21454

Discharge summary

report

Admission Date: [**2150-8-24**] Discharge Date: [**2150-9-8**] Date of Birth: [**2150-8-24**] Sex: F Service: NB HISTORY: This twin is 34-2/7-weeks gestational age admitted to the NICU for prematurity. She was delivered by C section to a 32-year-old gravida 1, para 0-2 mother with the following prenatal screens. Blood type A positive, DAT negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune, group B Strep unknown. Estimated date of delivery was [**2150-10-3**]. Estimated gestational age therefore at 34-2/7 weeks. This spontaneously conceived twin pregnancy was complicated by preterm labor refractory to tocolysis. Betamethasone course was completed four days prior to delivery. Spontaneous rupture of membranes 10 hours prior to delivery yielded clear amniotic fluid. Mother experienced an intrapartum therapy to 100.7 degrees for which she received intrapartum antibiotic therapy administered five hours prior to delivery. This infant was vigorous at the time of delivery and required bulb suctioning, drying, and free-flow oxygen to improve her color. She had Apgars of 7 at 1 minute and 8 at 5 minutes. PHYSICAL EXAMINATION UPON ADMISSION: Well-appearing infant. Birth weight of 2315 (50th percentile). Head circumference 32.5 cm (75th percentile). Length 43.5 cm (50th percentile). Temperature 99.8. Heart rate 72. Respiratory rate 60. O2 saturation 92 percent in room air. Blood pressure at the 60/39 with a mean of 45. HEENT: Anterior fontanel is soft and flat, nondysmorphic. Palate intact. Neck and mouth normal. Normocephalic. No nasal flaring. Chest: No retractions. Good bilateral breath sounds. No crackles. Cardiovascular: Well perfused, regular rate and rhythm, normal S1 and S2. Femoral pulses equal, no murmur. Abdomen is soft, nondistended, no organomegaly, no masses, and bowel sounds active, and anus patent. GU: Normal female genitalia. CNS: Active, alert, responds to stimulus. Tone: Appropriate for gestational age and symmetric. Moves all extremities symmetrically. Suck, root, and gag are intact. Grasp and morrow are symmetric. Skin is intact. Musculoskeletal: Normal spine, limbs, hips, and clavicles. HOSPITAL COURSE BY SYSTEMS: Cardiovascular: This baby required normal saline bolus x2 for transient hypotension, which corrected following fluid resuscitation. During the hospital course the heart rate varied from 140s-160s with blood pressure means 40s-mid 50s. Respiratory: This baby demonstrated mature pulmonary function and has had a comfortable respiratory pattern breathing 30s-50s without evidence of periodic breathing. Fluid, electrolytes, and nutrition: Initially an IV was placed with a low blood sugar of 25. This improved to 66 with D10W bolus and a running IV. Feeds were initiated on day of life one with breast feeding supplemented with Similac 20 calories. Feeds were by breast or gavage tube through day of life 12. Baby has been by mouth feeding for the last 48 hours with breast milk 24 calories enhanced with Similac powder or Similac 24 calories/ounce. Infant was started on Vi-Daylin the day prior to discharge. Weight at time of discharge is 2310 grams. There has been a normal urine and stooling pattern. Infant has remained euglycemic on enteral feeds as well. GI: [**Known lastname 319**] has experienced physiologic jaundice with a peak bilirubin of 6.9/0.3. On day of life three, she did not require phototherapy. Heme/ID: Initially upon admission to the NICU, CBC and blood culture were obtained revealing a white count of 8.8 with 12 polys, 0 bands, and 70 lymphocytes, hematocrit 55.8 percent and platelets of 309,000. Blood culture remained sterile and antibiotics were discontinued after 48 hours in view of negative cultures and improved clinical course. Neurologically: Her examination is reassuring. Baby required [**Name2 (NI) **] for neutral thermal environment, and was weaned to an open crib by day of life and has been cobedding in a crib with her twin sister. Sensory: Hearing screening was performed with automated auditory brain stem responses and baby passed her hearing screen. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home with family. NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 45938**] of [**Hospital1 6687**]. FEEDS AT TIME OF DISCHARGE: Breast feeding being supplemented with 24 calories/ounce breast milk with Similac 24 calorie formula. MEDICATIONS: Vi-Daylin 1 cc by mouth each day. CAR SEAT POSITION SCREENING: Was performed prior to discharge and infant passed without problems. STATE NEWBORN SCREENING: Obtained at the recommended intervals and results are pending at the time of discharge. IMMUNIZATIONS RECEIVED: Hepatitis B vaccine given on [**9-4**]. IMMUNIZATIONS RECOMMENDED: i. Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following three criteria: 1) born at <32 wks; 2) born between 32 and 35 wks with 2 of the following: daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school age siblings; or 3) with chronic lung disease. ii. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age (and for the first 24 months of the child??????s life), immunization against influenza is recommended for household contacts and out-of-home caregivers. FOLLOW-UP APPOINTMENTS: Dr. [**Last Name (STitle) 45938**] upon return to [**Hospital1 6687**]. DISCHARGE DIAGNOSES: 1. Prematurity at 34-2/7 weeks, twin number two. 2. Sepsis suspect ruled out. 3. Transient hypoglycemia, resolved. 4. Transient hypotension, resolved. [**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2150-9-8**] 02:02:46 T: [**2150-9-8**] 04:31:37 Job#: [**Job Number 41446**]

[ "V05.3", "775.6", "765.18", "V29.0", "765.27", "796.3", "V31.01" ]

icd9cm

[ [ [] ] ]

[ "99.55", "96.6" ]

icd9pcs

[ [ [] ] ]

4232, 4805

5628, 6030

2255, 4176

5534, 5607

4832, 5509

1211, 2227

4201, 4208

18,637

102,954

29445

Discharge summary

report

Admission Date: [**2131-11-22**] Discharge Date: [**2131-11-29**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4748**] Chief Complaint: L. carotid stenosis Major Surgical or Invasive Procedure: Left carotid endarterectomy History of Present Illness: This is an 85 y/o M with a history of bilateral carotid stenosis and a history of prior stroke. The patient has a R. hand TIA and critical L. carotid stenosis. Past Medical History: 70-80% R carotid stenosis R MCA stroke '[**10**] w residual slight L sided weakness excision of neck mass gout HTN Type 2 DM gastritis Social History: lives with wife and son, retired salesman, no current or past tobacco use, no EtOH Family History: no family hx of stroke, CAD, cancer, DM, or other neurologic disease Physical Exam: T=97.6 P=68 BP=167/58 RR=16 100%RA HEENT: no icterus, MMM CHEST: CTA B/L HEART: S1, S2, RRR ABD: soft, NT, ND, +BS EXT: no edema Neuro: baseline dysarthria, diff. enunciating words, strength R>L Pertinent Results: [**2131-11-21**] 08:55AM GLUCOSE-130* UREA N-30* SODIUM-143 POTASSIUM-4.6 [**2131-11-21**] 08:55AM PT-12.6 PTT-31.9 INR(PT)-1.1 [**2131-11-21**] 08:45AM WBC-8.7 RBC-3.88* HGB-11.7* HCT-33.2* MCV-86 MCH-30.2 MCHC-35.2* RDW-14.7 [**2131-11-21**] 08:45AM PLT COUNT-224 [**11-22**] MRI Brain: 1. Late subacute right parafalcine subdural hematoma with maximal thickness of [**5-9**] mm. 2. No acute infarcts. 3. Moderate small vessel ischemic changes and an old infarct of the right medulla. 4. 1.3 x 0.9 cm calcified meningioma versus degenerative pseudo mass posterior to the body of C2. This can be further evaluated by CT of the cervical spine. [**11-22**] MRA Brain: Short segment narrowing of the V4 segment of the left vertebral artery. Brief Hospital Course: The patient was admitted to the Vascular surgery A team on [**2131-11-22**] for a left carotid endarterectomy with a Dacron patch. There were no surgical complications and the patient was hemodynamically stable in the PACU. During the post-operative course in the PACU, the patient develped a 3cm hematoma at the incision site. There was no blood drainage, gentle pressure was applied for 10 minutes, and a pressure dressing was applied to the wound. The patient was transferred to the VICU. During the evening of POD0, the patient developed worsening dysarthria. Neurology was consulted and a stat MRI Head with stroke protocol was ordered. In addition, neurology recommended that the HOB remain flat and to maintain a goal SBP 120-130 to maximize cerebral perfusion pressure. MRI and MRA of the brain showed a R frontal parafalcine stroke (no acute changes). On POD1, the patient's speech was improved and he remained hemodynamically stable. The patient's POD1 HCT=25.0. The patient received 2u PRBCs. [**Date range (3) 70697**] patient remained in hospital for continued observation and physical thearphy.Patient was assesed by PT and will require rehab prior to discharge home.Rehab screening in progress. family agreeable to plans. [**2131-11-29**] d/c to rehab. stable Medications on Admission: ecotrin 81' metoprolol 25" folic acid 1' plavix 75 (held) simvastatin 20' Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Ciprofloxacin 500 mg Tablet Sig: 1.5 Tablets PO Q48H (every 48 hours) for 2 weeks. 6. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 HR Sig: One (1) Cap PO DAILY (Daily). 7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 8. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection four times a day. Discharge Disposition: Extended Care Facility: Maples Nursing & Retirement Center - [**Location (un) 6151**] Discharge Diagnosis: L. carotid stenosis history of right middle cerebral artery stroke [**2110**] residual rt. sided weakness history of hyperlipdemia history of presumed pneumonia by cxr on admission-Cipro Dm2 uncontrolled chronic anemia-transfused chronic renal insuffiency 2.0 old subdural hematoma by CT [**11-7**] perioperative dysarthria,improving Discharge Condition: Good Followup Instructions: Please call Dr.[**Name (NI) 1392**] office at ([**Telephone/Fax (1) 4852**] to schedule a follow-up appointment Completed by:[**2131-11-29**]

[ "486", "E878.8", "998.12", "585.9", "285.21", "250.02", "274.9", "403.90", "433.30" ]

icd9cm

[ [ [] ] ]

[ "00.40", "99.04", "38.12" ]

icd9pcs

[ [ [] ] ]

3976, 4064

1851, 3136

283, 313

4443, 4450

1077, 1828

4473, 4617

777, 847

3262, 3953

4085, 4422

3162, 3237

862, 1058

224, 245

341, 502

524, 661

677, 761

4,489

175,073

9044

Discharge summary

report

Admission Date: [**2159-7-30**] Discharge Date: [**2159-8-13**] Date of Birth: [**2130-2-24**] Sex: M Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 562**] Chief Complaint: Fever, cough and progressive SOB x 2weeks Major Surgical or Invasive Procedure: None. History of Present Illness: 29yo male with hx of childhood asthma presents reports that approximatley 2 weeks ago he began noticing a productive cough. Spiked fever to 103F @ home. Went to see PCP, [**Name10 (NameIs) **] was late and told that he would have to come back. Patient continued to feel fatigued, and began noticing some difficulty catching his breath. Returned to PCPs office and found to be tachypneic, tachycardic, with sats of low 80% on 2liters nasal cannula. Transported via EMS to ED for further eval and treatment. Received 1 gram ceftriaxone and 500mg Levaquin in ED with total of 4mg of morphine. CXR showed LLL pna. Evaled by MICU and admitted for pulmonary monitoring/treatment. No acute episodes in MICU, sating in high 90% on Nonrebreather mask. Called out for transfer to CC7 floor bed. [**7-31**] onset of non-bloody diarrhea, ova/parasites sent along with urine legionel antigen. Patient sating well on floor. Desats to 90-92% on room air, and to 85% with any ambulation so MICU called to evaluate. ABG was 7.47/40/47 Past Medical History: 1.Asthma (as a child, no episodes in past 2-3years, no prior intubations or hospitilizations for attacks) Pertinent Results: [**2159-7-30**] 06:15PM LACTATE-1.2 [**2159-7-30**] 04:08PM LACTATE-2.9* [**2159-7-30**] 03:20PM GLUCOSE-97 UREA N-11 CREAT-0.8 SODIUM-139 POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-28 ANION GAP-16 [**2159-7-30**] 03:20PM ALT(SGPT)-52* AST(SGOT)-60* CK(CPK)-49 ALK PHOS-148* TOT BILI-0.5 [**2159-7-30**] 03:20PM WBC-10.0 RBC-5.13 HGB-15.0 HCT-43.1 MCV-84 MCH-29.2 MCHC-34.8 RDW-11.9 [**2159-7-30**] 03:20PM NEUTS-77.5* LYMPHS-16.4* MONOS-5.8 EOS-0.2 BASOS-0.2 [**2159-7-30**] 03:20PM PLT COUNT-338 Liver: [**2159-8-5**] 04:15AM BLOOD ALT-132* AST-118* LD(LDH)-774* AlkPhos-264* TotBili-0.3 [**2159-8-5**] 04:15AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE HAV Ab-POSITIVE [**2159-8-5**] 04:15AM BLOOD HCV Ab-NEGATIVE On Discharge: [**2159-8-13**] 11:03AM BLOOD WBC-7.5 RBC-4.24* Hgb-12.1* Hct-36.8* MCV-87 MCH-28.6 MCHC-32.9 RDW-13.1 Plt Ct-366 [**2159-8-7**] 03:40AM BLOOD Neuts-89.5* Lymphs-6.8* Monos-3.1 Eos-0.4 Baso-0.2 [**2159-8-13**] 11:03AM BLOOD Glucose-126* UreaN-22* Creat-1.0 Na-136 K-4.2 Cl-100 HCO3-26 AnGap-14 [**2159-8-13**] 11:03AM BLOOD Calcium-8.8 Phos-5.2*# Mg-1.7 Brief Hospital Course: [**Hospital Unit Name 153**] course: Patient transfered from floor to [**Hospital Unit Name 153**] on [**8-1**] secondary to decreased O2 sat despite NRB mask. A CT scan was done on [**8-1**] which showed bilateral pneumonia left > right. Patient also had serial CXRs which showed minimally improving left lower lobe PNA. Patient refused HIV testing but a CD4 count that was drawn came back as 60. Patient was continued on treatment for hospital acquired PNA with vancomycin, azithromycin, and ceftriaxone which was later switched to just azithro and caftriaxone for CAP. Since patient had low CD4 count was started on treatment for PCP PNA with prednisone and bactrim (21 day treatment). Induced sputum was done which confirmed PCP. [**Name10 (NameIs) **] also with thrush so started on nystatin. During [**Hospital Unit Name 153**] stay he had a run of [**Last Name (LF) 6059**], [**First Name3 (LF) **] cardiology consulted. A TTE was ordered to rule out seeding of heart valve; there were no masses or vegetations seen. He did not have another episode of [**First Name3 (LF) 6059**]. He also had a complaint of headache "the worst headache he has ever had" so LP and CT head were done which both came back negative. Patient continued to remain stable and slowly improve in [**Hospital Unit Name 153**] so was transferred to floor on NRB mask on [**8-5**] On Floor 1) PNA - Continued Bactrim 400mg IV q8 (eventually switched to PO Bactrim DS 2tabs q8) and prednisone. Prednisone was tapered from 80mg after 5 days to 40mg for 5 days and then 20mg for remaining 11 days. Patient for first few days on floor remained on NRB mask but slowly improved and gradually tansitioned to nasal cannula with weaning of oxygen as tolerated. Patient remianed afebrile on floor and WBC remained within normal limits. He will be discharge with another 8 days of Bactrim and prednisone to complete 21 day courses, along with home oxygen for ambulation. 2) Oral Thrush - Continued nystatin swish and swallow, gradually improved while on floor. 3) Low back pain - Patient complaining of low back pain while on floor. Initially treated with IV morphine, ibuprofen and oxycodone, then transitioned to flexerol and ibuprofen with oxycodone for breakthrough. Patient never had any symptoms of weakness or numbness in his lower extremeties. No gait disturbances. 4) HIV testing - While on floor patient asked again by Housestaff about being tested for HIV, patient continued to refuse. However with continued discussion with attendings patient stated willing to follow up outpatient. Medications on Admission: none Discharge Medications: 1. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day): Swish and spit for thrush in your mouth. Disp:*40 mL* Refills:*2* 2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) for 8 days. Disp:*24 Tablet(s)* Refills:*0* 3. Prednisone 20 mg Tablet Sig: One (1) Tablet PO QD (once a day) for 8 days. Disp:*8 Tablet(s)* Refills:*0* 4. Ventolin 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:*1 canister* Refills:*2* 5. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain for 6 doses. Disp:*6 Tablet(s)* Refills:*0* 6. Cyclobenzaprine HCl 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 6 days. Disp:*18 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 6549**] Medical Discharge Diagnosis: Pneumocystis carninii pneumonia Community acquired pneumonia Thrush Discharge Condition: Good, stable. Discharge Instructions: Call Dr. [**Last Name (STitle) **] if you experience a fever, increased shortness of breath, develop a cough, or feel worse. Drink plenty of fluids. Try to rest, walking slowly, stopping if you feel short of breath. Follow up with your PCP in two days. Followup Instructions: Follow up appointment with Dr. [**Last Name (STitle) **] on [**8-15**] at 11:20.

[ "486", "724.2", "112.0", "427.89", "136.3" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6154, 6212

2681, 5267

351, 359

6324, 6339

1554, 2288

6643, 6727

5322, 6131

6233, 6303

5293, 5299

6363, 6620

2302, 2658

270, 313

387, 1406

1428, 1535

32,572

137,413

33345

Discharge summary

report

Admission Date: [**2144-7-30**] Discharge Date: [**2144-8-2**] Date of Birth: [**2069-4-18**] Sex: F Service: MEDICINE Allergies: Tetracycline Attending:[**First Name3 (LF) 3556**] Chief Complaint: chest pain x 1 day Major Surgical or Invasive Procedure: none History of Present Illness: This is a 75 y/o w/ MMP including recent CABG and AVR [**2144-6-5**], ex lap and [**Location (un) **] patch for duodenal perforation who p/w chest pain x 1 day and new RBBB. Pt notes that she had 1 hour of sharp SSCP that was sudden in onset, but gradually subsided on its own over 1 hour time. She notes that it was similar to "gas pain" that she has [**2-12**]/x month but did not go away with rubbing of her belly as it usually does and was associated w/SOB and palpitations which her gas pain usually is not. She notes that at the time of her CABG, she did not have angina and is unable to relate this as an anginal equivalent. She is bedridden at this time and thus this was not exertional in nature. Also unable to assess positional pain b/c she does not move much. She was resting, not eating or exerting herself otherwise at the time of onset. She denies associated N/V/diaphoresis/visual changes. Also denies cough/fever/chills/HA/dizzyness. Is depressed but denies recent new onset fatigue. . Per OSH records, she has had guiac + stool on and off since the beginning of her stay at NESH. She has been transfused for HCT drops in the setting of guiac + stool on multiple occassions. She takes iron supplements and her stool is often dark. She denies . In the [**Name (NI) **], pts vitals on presentation were T 98 HR 77 BP 126/54 RR 14 100% on her home vent settings. EKG showed a new RBBB, CK was negative, but TNI was up from baseline. CT surgery was notified of her admission. She received Aspirin 325mg, Morphine 4mg IV x 1 for lower back pain, not for chest pain. While in the ED, she was CP free. . Currently, she denies pain, notes that she did have an episode of pain en route from the ED, sharp, lasting for minutes, associated w/SOB. Resolved on its own once she arrived in the unit. EKG was done and was unchanged from the ones prior, still revealing new RBBB. Notes that had severe edema weeks ago but it has greatly improved. Denies any LE cramping/pain. She has chronic LBP. . Past Medical History: - Aortic valve replacement([**Street Address(2) 6158**]. [**Hospital 923**] Medical Biocor tissue valve)[**2144-6-5**] for severe AS - Coronary artery bypass grafting x2(left internal mammary artery graft to left anterior descending and reversed saphenous vein graft to the posterior descending artery) [**2144-6-5**] - Respiratory failure s/p tracheostomy [**2144-6-23**] full vent at NESH is SIMV 12/500 PEEP 8 50%FIO2, but was in process of weaning - jejunostomy [**2144-6-23**] - Perforated duodenal ulcer s/p exploratory laparotomy, [**Location (un) **] patch [**2144-7-7**] - hypertension - hypercholesterolemia - sleep apnea (CPAP dependent) - diabetes mellitus type 2 - diverticulosis - poor balance - frequent falls - fractured vertebrae (L2, L5) - recent subdural hematoma ([**12-18**]) - s/p cholecystecomy - s/p appendectomy - s/p partial colectomy for diverticulitis - knee arthroscopy x3 - s/p pilonidal cyst removal - Depression Social History: retired lab tech no tobacco no etoh Family History: father deceased from MI at age 41 Physical Exam: VS: T 99.6 BP 117/52 HR 102 sat 100% 40%FIO2, PS 10, PEEP 5 GEN: obese, NAD, awake, alert, appropriate HEENT: EOMI, PERRL, sclera anicteric, conjunctivae clear, OP moist and without lesion NECK: Supple, difficult to asses JVP- lying flat and with trach collar. Trach in place. CV: Reg rate, normal S1, S2. +systolic murmur w/soft diastolic click. CHEST: Sternotomy scar noted, still two small open areas w/packing, Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi, diminished BS at bases. ABD: large midline scar w/multiple open areas w/small amount of serous drainage, packing inside; Obese Soft, NT, ND, no HSM EXT: 1+ edema noted, no clubbing/cyanosis SKIN: unable to assess known sacral decubitus ulcer b/c of pt's size, no rashes noted Neuro: CN 2-12 grossly in tact, she has difficulty writing but has good strength in both upper and lower extremities. She is oriented x 3. . Pertinent Results: [**2144-7-30**] 08:51PM GLUCOSE-124* UREA N-39* CREAT-0.6 SODIUM-142 POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-33* ANION GAP-10 [**2144-7-30**] 08:51PM HCT-29.0* [**2144-7-30**] 12:20PM GLUCOSE-180* UREA N-40* CREAT-0.7 SODIUM-142 POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-29 ANION GAP-15 [**2144-7-30**] 12:20PM CK(CPK)-19* [**2144-7-30**] 12:20PM CK-MB-NotDone cTropnT-0.14* [**2144-7-30**] 12:20PM ALBUMIN-2.7* CALCIUM-10.0 PHOSPHATE-2.7 MAGNESIUM-2.3 [**2144-7-30**] 05:25AM CK(CPK)-11* [**2144-7-30**] 05:25AM CK-MB-NotDone cTropnT-0.15* [**2144-7-29**] 10:50PM CK(CPK)-11* [**2144-7-29**] 10:50PM cTropnT-0.17* [**2144-7-29**] 10:50PM CK-MB-NotDone [**2144-7-29**] 10:50PM WBC-12.3*# RBC-3.31* HGB-9.6* HCT-30.4* MCV-92 MCH-29.0 MCHC-31.6 RDW-16.1* [**2144-7-29**] 10:50PM PT-12.1 PTT-23.8 INR(PT)-1.0 CXR: Moderate cardiomegaly is unchanged. There is increased opacity in the left, filling half of the hemithorax, likely representing an accumulation of pleural fluid. A tracheostomy tube, median sternotomy wires, and left subclavian catheter are unchanged. IMPRESSION: Large left pleural effusion increased in size since the most recent study dated [**2144-7-8**]. . There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. A bioprosthetic aortic valve prosthesis is present. The transaortic gradient is normal for this prosthesis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. Limited study. Brief Hospital Course: This is a 75 y/o w/CABG and AVR [**2144-6-5**] who p/w sharp chest pain associated w/dyspnea and palpitations x 1 day w/new RBBB, and TNI elevation. EKGs: Review of EKGs from [**7-29**] - [**7-30**] reveal NSR w/new RBBB morphology not present on [**7-9**] - [**7-12**]. Cardiology was consulted and felt that the pt's EKGs were c/w prior IMI and upon consultation of the cardiac surgery service, both services felt that there was need for heparinization and that with TTE w/o focal wall motion abnormalities, no indication for surgical intervention. She was CP free throughout her course though she did have epigastric tenderness around the site of her healing wound from the perforated duodenal ulcer. General surgery was consulted and evaluated the wound. The wound was repacked and dressed. She had guiac + stools, but stable HCTs, GI was consulted and recommended outpt colonoscopy. She was J tube lavage negative upon arrival. She was weaned off of the vent and did well on 40%FiO2 via trach mask. Medications on Admission: Acetaminophen Paroxetine HCl 10 mg/5 mL PO DAILY Atorvastatin 20 mg PO DAILY Amitriptyline 25 mg PO HS Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (4) **]: [**2-12**] PO BID (2 times a day). Zestril 5 mg PO DAILY Hydrochlorothiazide 25 mg PO DAILY Spironolactone 25 mg PO DAILY Metoprolol Tartrate 50 mg PO TID Insulin Glargine 25 units Subcutaneous BREAKFAST Nexium 40mg once daily Bumex 2 mg PO once a day Roxicodone 10 mg Q6 hours prn pain Nystatin swish and swallow Xopenex 1.25 Q8h MOM [**Name (NI) 77399**] powder iron supplementaion vitamin C Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid [**Name (NI) **]: One (1) PO BID (2 times a day). 2. Acetaminophen 160 mg/5 mL Solution [**Name (NI) **]: One (1) PO Q6H (every 6 hours) as needed. 3. Aspirin 325 mg Tablet [**Name (NI) **]: One (1) Tablet PO DAILY (Daily). 4. Chlorhexidine Gluconate 0.12 % Mouthwash [**Name (NI) **]: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 5. Insulin Glargine 100 unit/mL Solution [**Hospital1 **]: One (1) 25 Subcutaneous once a day. 6. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: One (1) Injection QACHS: please see attached sliding scale. 7. Lisinopril 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 9. Ascorbic Acid 90 mg/mL Drops [**Hospital1 **]: One (1) PO DAILY (Daily). 10. Nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO QID (4 times a day) as needed. 11. Paroxetine HCl 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 12. Atorvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 13. Amitriptyline 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime). 14. Ibuprofen 100 mg/5 mL Suspension [**Hospital1 **]: One (1) PO Q8H (every 8 hours) as needed. 15. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 16. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization [**Last Name (STitle) **]: One (1) ML Inhalation TID (3 times a day). 17. Maalox 200-200-20 mg/5 mL Suspension [**Last Name (STitle) **]: One (1) ML PO QID (4 times a day) as needed. 18. Spironolactone 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 19. Hydrochlorothiazide 12.5 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY (Daily). 20. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 21. Bumetanide 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 22. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1) Injection TID (3 times a day). 23. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) for 4 days. 24. Oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: One (1) PO Q6H (every 6 hours). Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Chest Pain EKG changes RBBB Discharge Condition: stable Discharge Instructions: You were admitted for chest pain, while you were here, your EKGs showed evidence of possible ischemia. However, there was no evidence that intervention was indicated while you were here. You were evaluated by the cardiac and general surgery services. You were weaned off of your ventilator and you did well. Please follow up with your primary care physician and present to the hospital or call your PCP if you have chest pain/shortness of breath, fever/chills, Nausea/vomiting/headache/dizzyness. Followup Instructions: Please follow up with your primary care physician within the next 1-2 weeks. Please call PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 1955**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) **] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]

[ "578.9", "707.05", "429.3", "599.0", "410.91", "V58.67", "426.4", "V43.3", "401.9", "493.20", "V44.0", "V58.66", "311", "250.00", "V44.1", "272.0", "V45.81", "414.00", "998.83", "041.4", "562.11", "E878.8", "E849.7", "780.57" ]

icd9cm

[ [ [] ] ]

[ "88.72" ]

icd9pcs

[ [ [] ] ]

10247, 10319

6194, 7199

292, 298

10391, 10400

4356, 6171

10945, 11276

3368, 3403

7803, 10224

10340, 10370

7225, 7780

10424, 10922

3418, 4337

233, 254

326, 2331

2353, 3298

3314, 3352

14,598

164,179

10480

Discharge summary

report

Admission Date: [**2145-2-1**] Discharge Date: [**2145-2-5**] Date of Birth: [**2083-5-28**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 61 year-old male with a history of coronary artery disease status post multiple RCA intervention who was referred for one vessel CABG. His most recent cardiac catheterization was in [**2144-9-17**] which demonstrated no significant LAD or circumflex disease, 30% proximal RCA in stent restenosis, 50% diffuse disease mid RCA, total occluded distal RCA stents, 70% stenosis distal to the RCA stents extending into the proximal PDA. The patient was status post PCC of the proximal and distal RCA, status post stenting of the mid RCA and distal RCA, status post beta radiation to the proximal RCA and gamma radiation to the mid and distal RCA. Approximately three weeks prior to presentation the patient developed recurrent, exertional angina symptoms similar to what he was experiencing prior to the last intervention. He had chest pain after walking approximately one quarter of a mile. He was referred for re-cardiac cath and consult for RCA bypass. PAST MEDICAL HISTORY: Includes 1. Coronary artery disease status post MI, status post multiple PTCA. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Aspirin 325 milligrams po q day. 2. Mevacor 80 milligrams po q HS. 3. Atenolol 100 milligrams po q day. 4. Imdur 30 milligrams po q day. 5. Altace 2.5 milligrams po q day. 6. Plavix 75 milligrams po q day. LABORATORY DATA: White count 4.5, crit 39,1, platelet count 192,000. Chem 7 141, 4.6, 104, 30, 11, 1.0 and 141. PHYSICAL EXAMINATION: Neuro - intact. HEENT - no bruits. Lungs are clear to auscultation bilaterally. Cardiovascular - regular rate and rhythm, normal S1, S2. Abdomen - soft, nontender, nondistended. Extremities - good veins, no cyanosis, clubbing or edema. HOSPITAL COURSE: The patient was admitted to the hospital on [**2145-2-1**] and underwent CABG times two with LIMA to the LAD and saphenous vein graft to PDA. The patient did well postoperatively and was transferred to the CSRU. On postoperative day one the patient's chest tubes were removed and the patient was transferred to the floor. The patient did very well on the floor and on postoperative day one was out of bed ambulating. On postoperative day two the patient continued to work with Physical Therapy who stated that he was already at a level IV by postoperative day two. The patient's Foley catheter was removed on postoperative day two. On postoperative day three the patient's wires were removed. The patient reached a level Versus with Physical Therapy on postoperative day three. The patient was started on Vancomycin for a small amount of serious drainage that was noticed on his wound. A dry dressing was placed over night and on postoperative day four there was no drainage left on his dressing. The Vancomycin was discontinued and the patient was discharged to home in good condition. DISCHARGE DIAGNOSIS: 1. Status post CABG times two. DISCHARGE MEDICATIONS: 1. Lopressor 50 milligrams po bid. 2. Lasix 20 milligrams po bid times seven days. 3. KCL 20 milliequivalents po bid times seven days. 4. Colace 100 milligrams po bid. 5. Aspirin 325 milligrams po bid. 6. Mevacor 80 milligrams po q HS. 7. Tylenol 650 milligrams po q four hours prn. 8. Percocet one to two tablets po q four to six hours prn. 9. Ibuprofen 400 milligrams po q six hours prn. 10. Imdur 60 milligrams po q day. 11. Plavix 75 milligrams po q day. DI[**Last Name (STitle) 408**]E INSTRUCTIONS: The patient was to follow up with Dr. [**Last Name (Prefixes) **] in four weeks. The patient also is suppose to follow up with his primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 34593**] in three to four weeks. DISCHARGE STATUS: Good. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 6067**] MEDQUIST36 D: [**2145-2-5**] 08:59 T: [**2145-2-5**] 09:07 JOB#: [**Job Number 34594**]

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

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

3068, 4155

3012, 3045

1895, 2991

1635, 1876

158, 1129

1152, 1612

55,440

195,768

35364

Discharge summary

report

Admission Date: [**2178-2-6**] Discharge Date: [**2178-2-13**] Date of Birth: [**2108-7-16**] Sex: F Service: MEDICINE Allergies: Codeine / Azithromycin / Morphine Attending:[**First Name3 (LF) 1936**] Chief Complaint: transferred from OSH for GIB, hypoxemia Major Surgical or Invasive Procedure: Blood transfusion at NEBH EGD [**2-11**] History of Present Illness: The patient is a 69F w/ h/o afib on coumadin, PUD, COPD, CKD, h/o CVA, HTN, hyperlipidemia who presented to [**Hospital3 **] on [**2-3**] with SOB, lightheadedness, and black stools. She was found to have an INR of 11 and was given 4 units of FFP and 10mg vitamin K. She received 3 units PRBC to bring her Hct up to 37.5. Last INR showed correction to 1.3. She was seen by GI with plans for endoscopy, but on arrival to the endoscopy suite she was found to be hypoxic while lying flat. The procedure was cancelled and she was given Solumedrol 125mg IV. She was reportedly in sinus tach to 104. Because of clinical evidence of volume overload, she received 80mg IV Lasix. She was later found to be afib to 150 at which point Diltiazem 10mg IV was given as well as digoxin 0.5mg IV. She reportedly converted to sinus rhythm. The patient's family requested transfer to a [**Location (un) 86**] area hospital at which point the referral to [**Hospital1 18**] was made. At that time the patient was reportedly on 3L NC satting 93% with HR in the 100s (sinus tach) and systolic BP in the 120s. The patient arrived on the floor on a NRB mask satting 90% with a HR in the 140s. EMS reported that overnight she had triggered the rapid response team again for hypoxemia and was sent to their ICU where she was on BiPAP. She was reportedly given another 80mg IV lasix this am and 10mg IV dilt per EMS (although this was not reflected in the discharge summary, which did not recount any of these events after the call-in to [**Hospital1 18**]). Her SBP was in the 130s during transfer and HR and O2 sat were as they were on arrival. The patient was alert and able to answer questions but only with 1-2 word answers. She was in significant respiratory distress with SBP in the 140s-150s and HR in the 120s-140s. O2 sat was 88-95% on NRB. She triggered immediately for these vital signs and the [**Hospital Unit Name 153**] was called immediately on arrival. Past Medical History: atrial fibrillation on coumadin since [**2173**], on rythmol/dilt COPD/asthma, not oxygen or steroid dependent chronic kidney disease, baseline creatinine 1.3 (?) CVA X2 ([**9-20**], [**10-20**])-emoblic, with residual minimal aphasia and right leg weakness L VATS procedure [**2175**] for ?hemothorax (s/p fall)-unclear of details hypertension dyslipidemia remote history of peptic ulcer disease DJD and L sciatica Fibromyalgia s/p TAH Social History: Divorced, retired, lives alone. Has three kids. Quit smoking 2 years ago. Dose not abuse alcohol. Family History: Mother with lung cancer. Physical Exam: Vitals: 98.6 R 110/56 L 82/54 78 18 95%2Lnc Tele: sinus Pain: 0/10 Access: PIV Gen: nad, sitting up HEENT: mmm CV: RRR, no m appreciated Resp: CTAB, slight basilar crackles, rhonchi upper lobes unchanged, no wheezing Abd; soft, nontender, +BS Ext; no edema Neuro: A&OX3, grossly nonfocal Skin: no changes psych: appropriate . Pertinent Results: wbc 7.3 (was 23K on admission) hgb stable 10s, hct 30s (s/p 3U prbc at OSH) BUN/creat 25/1.0-stable (was 2.0 at OSH) INR 1.1 Trops peak 0.39, last 0.14 . . EKG [**2-11**]: sinus, diffuse STD/TWI in strain pattern (present in EKGs from [**2-8**] and [**2-9**]) . . Imaging/results: CXR [**2-6**]: Interstitial moderate-to-severe pulmonary edema. Bilateral pleural effusions. . CXR [**2-9**]: Decrease in bilateral pleural effusions, which are small in size. Emphysema. Stable cardiomegaly. . CXR [**2-12**]: Small bilateral pleural effusions persist, right greater than left. No airspace consolidation or edema. Prominent pulmonary arterial contour suggests underlying pulmonary arterial hypertension possibly due to known emphysema. Prior to patient discharge evaluation with PA and lateral radiographs recommended to confirm enlarged pulmonary artery and to exclude a mediastinal mass. . . CXR PA/Lat [**2-13**] REASON FOR EXAM: 69-year-old woman with abnormal portable x-ray. Evaluate enlarged pulmonary contour versus mediastinal mass. Impression: Since [**2178-2-12**] and other priors back to [**2178-2-6**], all done with a portable AP technique, moderate cardiomegaly and hyperinflation are unchanged. [**Hospital1 **]-apical scarring is significant with bilateral apical thickening, up to 1.4 cm on the left. Traction bronchiectasis in both upper lobes and superior hilar retraction, mostly on the left are present, all consistent with prior granulomatous exposure such as tuberculosis. Hilar retraction could explain the mediastinal abnormality, although no prior study is available for comparison. Bilateral pleural effusions decreased, now minimal. *First, comparison with prior studies from elsewhere is recommended. If not available, a chest CT for further characterization and followup in six months by chest x-ray are recommended . . ECHO [**2-9**] The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . EGD [**2-11**]: Small hiatal hernia, Normal mucosa in the esophagus Erythema and granularity in the antrum compatible with gastritis (biopsy), Erythema and atrophy in the stomach body compatible with gastritis, Otherwise normal EGD to third part of the duodenum--biopsy c/w chemical gastritis. Brief Hospital Course: 69 female w/ h/o afib on coumadin, h/o embolic CVA, remote PUD not on PPI, COPD, CKD II, admitted to OSH [**2-3**] with melena/[**Hospital 80627**] hospital course there complicated by Afib/RVR resulting in acute distolic CHF and hypoxemic resp failure. Was tranfered to [**Hospital1 18**] MICU [**2-6**]. As for GIB, INR 11 on admission, given ffp/VitK and transfused 3U at OSH and no more GIB after arrival to [**Hospital1 18**]. While in MICU sercie, rate controlled (had some difficulty likely because overwhelming adrenergic response to GIB-->amio, dig, BB, dilt gtt-->finally controlled). As a result of Afib/RVR, developed Acute diastolic heart failure, diuresed (needed lasix gtt), now near euvolemia. Was transfered to Gen Med [**2-11**]. Underwent EGD that day, showed gastritis (biopsy with chemical gastritis), keep on PPI [**Hospital1 **] X6weeks, then qd while on coumadin. no more celebrex. Coumadin restarted with heparin 5000U SC TID for bridging (not full bridging given recent bleed, but need some coverage given h/o recent embolic strokes). From cardiac standpoint, doing well overall, remained in sinus back on home meds, but still requiring O2. This is likely combo of mild CHF and COPD/bronchits (large part). Plan is to d/c home with short course of lasix/nebs/O2 with close VNA follow up to titrate off. Needs PCP, [**Name10 (NameIs) **], cards follow up. . . Please see detailed plan below according to problem list: . Acute Diastolic heart failure/Hypoxia: in setting of Afib RVR on admission. s/p lasix gtt and rate control. Though near euvolemic, still with crackles and O2 requirement and last CXR with small effusions. Strict HR control. -start lasix 40mg PO qd for short time, monitor BP, urine outpt, creat. Repeat Chem in 1week. Home VNA for CHF nursing to wean off lasix (does NOT need chronically so long as HR controlled) -note BP unequal in arms and should be checked only R arm (too low L arm) -cont BB as below . . UGIB/melena: insetting of INR 11/asa/celebrex, no PPI. s/p 3U prbc, INR reversal at OSH, HCT stable here 30s. EGD delayed [**2-16**] cardiopulm issues. -EGD [**2-11**] with only gastritis, no ulcer or bleeding. biopsy showing chemic gastritis -PPI [**Hospital1 **] -HCT stable, resumed coumadin [**2-11**] (with heparin [**Hospital1 **] for bridging) -no more celebrex. okay to resume ASA 81 after 1week. Cont PPI [**Hospital1 **] on discharge for atleast 6weeks, then qd should be okay. . . Afib/Fluttter: complicated by embolic CVA X2 '[**75**]. developed refractory RVR in setting of stress (GIB) c/b acute diastolic heart failure. s/p amio/dig/dilt gtt/BB Finally converted to sinus o/n [**2-9**] and has been controlled since (monitored on tele while here) -converted back to dilt 60mg QID (cardizem 240 on d/c), rhytmol 225mg [**Hospital1 **] -resumed coumadin 7.5mg qhs [**2-11**] (no full bridging given GIB), f/u INRs per VNA . . CVA, embolic [**9-20**], [**10-20**]. off coumadin X8days for GIB, but also high risk stroke. -given EGD with only gastritis, resumed coumadin [**2-11**], will bridge with heparin [**Hospital1 **] only since recent GIB. monitor INRs closely. . . CKD II: need to clarify baseline with daughter (1.0-1.2). Creat here mostly 1.2 (with diuresis). Initially had some ARF (creat 2.0) in setting of above illness (Afib RVR), now resolved. -monitor with diuresis, will have VNA do chem check in 1week, wean off lasix when possible -avoid nephrotoxins, no more celebrex/NSAIDs . . COPD/bronchiectasis: Has some cough/rhonchi with CXR PA/Lat showing emphysema and bronchiectasis. Likely contributing to hypoxia (poor [**Hospital1 **] reserve). -will cont mucomyst/albuterol nebs q6 at home for short time. guaifenesin for cough as well. -will d/c on O2 as well, NEEDS outpt PFTs, repeat CXR/CT in 3months, would benefit from [**Hospital1 **] follow up. -cont advair, spiriva, incentive spirometer . . NSTEMI: had demand related trop leak to 0.39 on admission. EKG with LV strain pattern suggesting microvascular ischemia. No h/o documented CAD and no exertional symptoms at baseline (though not very active). Echo unremarkable. Can get outpt stress if none recently or can just medically manage. -cont BB/statin, asa on discharge, no ACE given hyperK -f/u outpt cardiologist . . Pneumonia: OSH CXR with PNA, none here. s/p levaquin X7days (last [**2-10**]). CXR does show bronchiectasis b/l UL, explains chronic cough -manage with nebs/mucomyst/guaifenesin as above . . Insomnia/fibromyalgia: cont flexeril 10mg qhs, xanax 0.75mg qhs at home doses. tylenol prn. celexa 20mg qd . . dyslipidemia: cont lipitor 80mg, resume ASA 81 in 1week . . HTN: on cardizem 240 and hctz 12.5 at home. dilt at above. hctz can be resume on d/c once off lasix. Note, EKG with diffuse STD/TWI suggestive of LV strain. . . FEN/proph: HLIV, monitor lytes, low Na diet, heparin [**Hospital1 **]/coumadin, PPI [**Hospital1 **], bowel regimen. PT following . . dispo/code: full code. Qualifies for home O2. Will continue short course of diuresis/nebs. D/c home with CHF VNA services. Daugther updated in detail. Will arrange PCP follow up in 1week, also reccommend [**Hospital1 **] and cardiology following. VNA to follow INRs, and chem check in 1 week. Hopefully can wean off O2 in couple weeks. . Updated patient and daughter [**Name (NI) 717**] [**Name (NI) **], today. [**Telephone/Fax (1) 80628**] (h), [**Telephone/Fax (1) 80629**] . Medications on Admission: Meds at home: Reconciliated on [**2-11**] (after transfer from ICU) coumadin 7.5 MWF, 5mg rest of days Rythmol (propafenone) 225mg tid diltiazem ER 240mg qd Lipitor 80mg qhs aspirin 81mg qd hctz 12.5mg qd spiriva 1 puff daily pro-air 2 puffs qid prn advair 500/50 1 puff [**Hospital1 **] celexa 20mg qd xanax 0.75mg qhs flexeril 10mg qhs propoxyphene prn pain celebrex 200mg qd Vicodin prn-? colace 100mg [**Hospital1 **] tylenol 1000mg q6h prn . . Meds on transfer: Protonix gtt 8mg/hr rythmol 225mg tid digoxin 0.25mg qd diltiazem 90mg q6h Solu-Medrol 125mg IV bid combivent nebs q6h standing and q2h prn Levaquin 250mg IV qod Flagyl 500mg IV q8h morphine prn Advair 500/50 1 puff [**Hospital1 **] spiriva 1 puff qd tylenol prn lipitor 80mg qhs flexeril 10mg qhs prn Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 5. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: [**1-16**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day). 8. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS PRN () as needed for insomnia. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: dose may change . 12. Cardizem CD 240 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 13. Propafenone 225 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO once a day: only restart after OFF lasix. 15. Guaifenesin 200 mg Capsule Sig: One (1) Capsule PO every [**6-22**] hours. 16. Propoxyphene 65 mg Capsule Sig: One (1) Capsule PO twice a day as needed for pain. 17. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**1-16**] Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 18. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day: start after [**2-15**]. 19. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): you can likely d/c this after 1week or so. Disp:*7 Tablet(s)* Refills:*0* 20. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation every six (6) hours: with mucomyst nebs. Disp:*qs qs* Refills:*2* 21. N-Acetyl-L-Cysteine Powder Sig: One (1) Miscellaneous every six (6) hours: with albuterol nebs. Disp:*qs qs* Refills:*2* 22. Heparin (Porcine) 5,000 unit/mL Syringe Sig: One (1) Injection three times a day for 5 days. Disp:*15 syringes* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Upper GIB in setting INR 11, s/p 3U prbc, EGD with gastritis Afib c RVR Acute diastolic heart failure COPD, chronic bronchietaosis Hypoxia requiring O2, multifactorial PNA s/p Abx h/o embolic strokes Discharge Condition: STABLE Discharge Instructions: You were admitted for black stools secondary to bleeding from your GI tract. Your INR/coumadin level on admission was very high. You underwent EGD which showed gastritis. YOu were given total 3U blood and you had no further bleeding. You are started on protonix twice a day for 6weeks, then once a day indefinately while you are on coumadin. please stop celebrex and dont take other NSAIDs. . YOur coumadin was restarted on [**2-11**]. You will get heparin injections until you coumadin is within goal. You need close follow up to make sure your coumadin level gets to goal [**2-17**] and stays there and doesnt get too high. YOu can restart aspirin 3days after discharge. . You had complications while your were in the hospital. Your heart rate (atrial fibrillation) was very fast which caused fluid to build up in your lungs and breathing problems. Your heart rate was controlled and now you are back on your previous medications, rythmol and cardizem. You still have a small amount of fluid build up in your lungs and you will go home on short course of lasix. You will be set up with VNA services to follow you and take the lasix off in about a week or so. Please do not resume the HCTZ until you are OFF the lasix . You still required oxygen on discharge. It is likely that your oxygen level is borderline at baseline due to COPD and now you have some worsening because of the heart failure and some bronchitis. You did have a pneumonia on admisison for which you finished antibiotics. You will continue nebulizer treatment to help with the cough. You should have a PULMONARY follow up for CT scan and pulmonary function tests after discharge. . . Your blood pressure is unequal in both arms and should be checked only on your Right arm (left arm is too low). Followup Instructions: Please follow up with your doctor within one week after discharge. please take all paperwork from this hospital with you. Please follow up with a cardiologist and a pulmonologist Please resume your previous coumadin monitoring system

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icd9cm

[ [ [] ] ]

[ "45.16" ]

icd9pcs

[ [ [] ] ]

14887, 14938

6254, 7684

333, 376

15181, 15189

3335, 6231

17005, 17241

2944, 2970

12479, 14864

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52,214

175,323

39059

Discharge summary

report

Admission Date: [**2106-12-8**] Discharge Date: [**2106-12-10**] Date of Birth: [**2054-12-5**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 10488**] Chief Complaint: Dyspnea and Syncope Major Surgical or Invasive Procedure: Tracheal Stenting History of Present Illness: 51 yo male with h/o HIV, SCC of larynx recently discharged on [**2106-12-2**] for evaluation of hemoptysis now here for increasing dyspnea. Pt was in downtown earlier today, paying a traffic ticket when he experienced a violent cough with SOB while climbing stairs. Pt states he then felt dizzy and passed out for 2 min, was then taken to [**Hospital1 2025**] initially where a CTA and CXR were done and were both neg. He was then transferred here. . In the ED, VS were stable. Pt denied CP, was breathing comfortably. States that he feels much better. No further imaging was pursued in the ED. First TnT was neg here. Pt is being admitted for syncope w/u and symptomatic treatment. On transfer, VS were HR 60 BP 110/80 RR 15 O2 sat 96% on RA. . On the floor, pt is comfortable, denies any dizziness. States cough is better now, feeling much better in general. Past Medical History: HIV (on HAART) laryngeal cancer s/p chemo, radiation hypertension seizure disorder hypothyroidism depression Social History: Ex smoker, smoked <5 cigarette /day for 10 years, no EtOH/drugs. He lives with his family , wife and two daughters. Contracted HIV sexually when young from a female partner. Family History: No family history of cancer per the patient. Physical Exam: General: alert, oriented, no acute distress HEENT: sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: good air movement bilat, rhonchorous CV: RRR, no murmurs, rubs, gallops Abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: 5/5 strength in all ext, sensation intact Pertinent Results: [**2106-12-8**] 08:50AM GLUCOSE-89 UREA N-16 CREAT-1.5* SODIUM-141 POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-23 ANION GAP-16 [**2106-12-8**] 08:50AM cTropnT-<0.01 [**2106-12-8**] 08:50AM TSH-1.6 [**2106-12-8**] 08:50AM TSH-1.6 [**2106-12-8**] 08:50AM WBC-6.5 RBC-4.92 HGB-15.4 HCT-44.3 MCV-90 MCH-31.4 MCHC-34.8 RDW-15.5 [**2106-12-8**] 08:50AM PLT COUNT-255 [**2106-12-8**] 01:55AM GLUCOSE-94 UREA N-14 CREAT-1.4* SODIUM-140 POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-21* ANION GAP-14 [**2106-12-8**] 01:55AM estGFR-Using this [**2106-12-8**] 01:55AM cTropnT-<0.01 [**2106-12-8**] 01:55AM cTropnT-<0.01 [**2106-12-8**] 01:55AM WBC-5.3 RBC-4.67 HGB-14.7 HCT-41.6 MCV-89 MCH-31.4 MCHC-35.3* RDW-15.4 [**2106-12-8**] 01:55AM NEUTS-54.0 LYMPHS-33.7 MONOS-5.7 EOS-5.6* BASOS-1.1 [**2106-12-8**] 01:55AM PLT COUNT-229 [**2106-12-8**] 01:15AM URINE HOURS-RANDOM [**2106-12-8**] 01:15AM URINE GR HOLD-HOLD [**2106-12-8**] 01:15AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017 [**2106-12-8**] 01:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG Brief Hospital Course: The patient yesterday was at the parking office, and then had a syncopal episode after he had a coughing spell. The patient was transferred to [**Hospital1 2025**] initially where he had a CTA of the chest done which was negative for PE however showed that there was only a 4mm opening of the trachea. The patient was transferred to [**Hospital1 18**] for further care. Syncope: The patient had syncope secondary to a vasovagal/possible hypoxemic episode after a coughing fit. It is unlikely to be seizure as the patient states that he has had seizures in the past that presented differently. He states that he had chest pain after the syncopal episode however he stated that this was secondary to CPR performed at parking office after his syncopal event. Ishcemia is also unlikely given that he had a stress test done on prior admission which was negative for ischemia. The diagnosis was confirmed when the patient had two additional syncopal episodes while in the presence of the interventional pulmonary fellows who agreed that the patient would need to be taken to the OR for stenting and debridment so the patient does not have any further episodes of syncope. Cough: The patient had a cough which is likely secondary to the SCC of the larynx that the patient has. He was given guaifenesin-dextromethorphan Tracheal Narrowing: The patient has laryngeal SCC which has narrowed the trachea to 4mm per the report from [**Hospital1 2025**]. Interventional pulmonary service was called and agreed that since the patient is poorly compliant that he would likely need to have a stent placed. Since he had lunch, he was added onto the OR schedule for tomorrow. However while the IP fellow was in the room, the patient had a coughing fit and syncopized. At this time the decision was made to transfer to the patient to the ICU and take him to the OR for an emergent intervention. IP placed a stent following coughing fit and procedure went well. He did not have any complications from his procedure. Patient maintained excellent ventilatory status during and after procedure, and felt well overnight. He was transferred to the floor where he was observed for an additional 24 hours. Subsequently the patient developed some hemoptysis consisting of blood tinged sputum. Initially the sputum was red colored, however subsequently it became brown colored. IP fellow was made aware of this and saw the sputum and agreed that he was ready for discharge. The patient states that at discharge his breathing was normal and much better than it has ever been. He was not complaining of shortness of breath or chest pain. The patient was made aware of the importance of following up at [**Hospital1 2177**] for cyberknife treatments. Fever: Overnight on [**2107-12-9**] the patient had a temperature of 100.4. A chest x-ray was checked, urine analysis was checked both of which were negative. Blood cultures were drawn and sent off to be followed up by his primary care doctor. The patient also did not have any additional fevers after the low grade temp of 100.4. Increased Creatinine: The patient had creatinine checked on a daily basis and it remained stable throughout his hospitalization. The patient will follow up with his primary care doctor for this. Medications on Admission: 1. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. atazanavir 300 mg Capsule Sig: One (1) Capsule PO once a day. 3. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO once a day. 4. fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day. 5. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 6. ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. zonisamide 100 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). Discharge Medications: 1. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 5. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. zonisamide 100 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 8. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. Disp:*100 ML(s)* Refills:*0* 9. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*20 Tablet(s)* Refills:*0* 11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*20 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Syncope Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Syncope/ Transient Loss of Consciousness Syncope or fainting is a [**Last Name **] problem caused by inadequate blood flow to the brain. There are many serious reasons for fainting, including internal bleeding, irregular heartbeat, and diseases of the heart muscle or valves or circulation. Other causes include diseases of the central nervous system, medications, low blood sugar, or dehydration. Vasovagal Syncope is the most common cause of syncope and can occur in healthy people at the sight of blood, hearing unexpected news, or while experiencing pain During your stay in the hospital, we did not find an immediately life-threatening cause for your loss of consciousness. Rarely, serious symptoms can develop later. Therefore it is <B>very important</B> to carefully monitor your condition at home and return to the Emergency Department immediately if you have any of the warning signs listed below. Treatment: * Drink plenty of liquids (unless your doctor has told you not to.) Do not consume alcohol until you are completely better. * Be sure to take any prescribed medications as you were instructed. Continue your previously prescribed medications unless you were instructed to do otherwise. Warning Signs: Call your doctor or return to the Emergency Department right away if any of the following problems develop: * You have recurrent loss of consciousness in the next 6 months. * You are not getting better in 24 hours, or you are getting worse in any way. * You experience new chest pain, pressure, squeezing, tightness, a rapid heartbeat or palpitations. * You have shaking chills, or a fever greater than 102 degrees (F). * You have new or worsening difficulty breathing. * You develop abdominal (belly) pain, vomiting, black or bloody stool. * You develop severe headache, dizziness, confusion or change in behavior. * Any serious change in your symptoms, or any new symptoms that concern you. Followup Instructions: Department: RADIATION ONCOLOGY [**Hospital **] [**Hospital6 **] Name: DR. [**Last Name (STitle) 4498**] When: [**2106-12-13**] Address: [**Location (un) 86592**], [**Location (un) 86**], MA Phone ([**Telephone/Fax (1) 86593**] Department: [**Hospital3 249**]- Primary Care When: MONDAY [**2106-12-13**] at 2:35 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: Otolaryngology Name: Dr. [**Last Name (STitle) 86594**] [**Name (STitle) 86595**] When: Wednesday [**2106-12-22**] at 1:35 PM Address: [**Location (un) 86592**], [**Location (un) 86**], MA Phone [**Telephone/Fax (1) 86596**] Department: Chest Disease Center Name: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] When: We are working on a follow up appt with Dr. [**Last Name (STitle) **] for 2 weeks after your hospital discharge. You will be called at home with the appointment time and date. If you have not heard from the office in 2 business days, please call the number listed below. Location: [**Hospital1 18**] - DIVISION OF PULMONARY MEDICINE Address: [**Location (un) **], [**Hospital1 **] 116, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3020**]

[ "786.2", "403.90", "V10.21", "780.39", "V08", "585.9", "162.0", "300.4" ]

icd9cm

[ [ [] ] ]

[ "33.23", "31.99", "31.5" ]

icd9pcs

[ [ [] ] ]

8053, 8059

3283, 6535

337, 357

8111, 8111

2119, 3260

10210, 11592

1589, 1635

7063, 8030

8080, 8090

6561, 7040

8262, 10187

1650, 2100

278, 299

385, 1247

8126, 8238

1269, 1380

1396, 1573

28,127

172,426

33933

Discharge summary

report

Admission Date: [**2182-5-9**] Discharge Date: [**2182-5-12**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 458**] Chief Complaint: Syncope vs pulseless arrest Major Surgical or Invasive Procedure: None History of Present Illness: 83yo man with h/o lung ca s/p lobectomy, CABG ([**2168**]), DM type 2, who presented after a pulseless arrest at [**Hospital1 778**]. He relates that he was walking to leave the Red Sox game and the next thing he remembers is being held done. His grandson lowered him to the ground; he did not fall. He was pulselss for a maximum of 3 minutes. AED was applied to the patient but said no shock (did not have rhythm). CPR was initiated and continued for 2 mintues. Glucose was given as he is on a hypoglycemic for DM; he has sz hx, but no sz for 30yr). After recovering from the ? pulseless arrest with CPR, the patient vomited. He reports struggling as staff were trying to resuscitate him. Prior to his LOC, he denies any chest pain, palpitations, nausea, vomiting, lightheadness, fever, chills, or vertigo. He did report some gastrocnemius pain at baseline when he exercises more than 10 minutes and has a known diagnosis of PVOD with h/o one stent. Upon presentation to the [**Hospital1 18**] ED, the patient felt well, with HR 60 SBP 120. His lactate 4.3. Heparin was initiated. . At baseline, the patient works out 3 times a week on various cardio machines (treadmill, eliptical) as part of a cardiac rehabilitation program which he began shortly after his CABG in [**2168**]. He denies any dyspnea on exertion but notes that he has started a new medication, ranexa, within the last month for dyspnea. He denies orthopnea, sleeps on a stable amount of pillows, denies PND or peripheral edema. He denies any symptoms presyncope or recent episodes of syncope. He relates that prior to his CABG in [**2168**], his MI associated symptoms were in fact chest pain, shoulder pain, and arm pain, dissimilar to his presentation currently. . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: 1. CABG (3vd) in [**2168**], [**Hospital 78383**] [**Hospital3 **] 2. Lung Cancer [**2175**] s/p lobectomy- no radiation or chemotherapy 3. DM2 4. HTN 5. Hyperlipidemia 6. CHF 7. PVOD s/p stent to right leg within the past year 8. Bilateral cataracts 9. Cholecystectomy [**83**]. Hemorrhoids 11. Knee surgery, unknown type 12. Seizure disorder, unknown focus. No seizure in 35 years on 2 antiepileptics, phenytoina and phenobarbitol. Social History: SOCIAL HISTORY: Lives in [**Location **] state, here visiting family. Has cardiologist in NY. Social history is significant for the [**11-29**] ppd cigarettes for 50 years. He endorses the absence of current tobacco use and stopped smoking in [**2157**]. He endorse a history of moderate alcohol use but denies abuse. . Family History: FAMILY HISTORY: Father MI (deceased). Physical Exam: VS: T94.6, BP 122/38, HR 44 with PACs, RR 14, 100 O2 % on 2L Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with no appreciable JVP. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: Crackles at bilateral bases. No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No wheeze, rhonchi. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: 1+ peripheral edema. No clubbing or cyanosis. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP MEDICAL DECISION MAKING Pertinent Results: CXR: The heart remains enlarged. There is no evidence of failure. The costophrenic angles are sharp. Comparison with the prior chest x-ray of [**5-9**] shows resolution of the interstitial edema present at that time. ECHO: The left atrium is mildly dilated. 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 severe hypokinesis/near akinesis of the basal and mid-inferolateral wall. The remaining segments contract normally (LVEF = 45-50%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. Mild mitral regurgitation. Moderate pulmonary hypertension. Brief Hospital Course: Syncope: While the etiology of the patient's syncope was uncertain, the most likely etiology appeared to be bradycardia. His EKG showed LAFB and RBB which is not new per primary cardiologist. DUring telemetry monitoring he was noted to have sinus bradycardia, sinus pauses, and episodes of junctional rhythms. He was found to have an elevated digoxin level (3.1) which was felt to have contributed to his syncopal epiosde. He was monitored on telmetry in the CCU and his HR improved and was no longer significantly bradycardic as the digoxin level came down. He had no other events on telemetry during his stay. Nodal blocking agents were held. EF was mildly reduced (better than prior testing per his cardiologist). The pt did not wish to pursue invasive diagnostic testing (such as EP study) given the likely diagnosis of bradycardia induced syncope. Since the bradycardia improved with discontinuation of the digoxin, permanent pacemaker was not required. . # CAD/Ischemia: Pt was not felt to have any evidence of ischemia. His cardiac enzymes were flat and he never had any ischemic changes on EKG. He was started on aspirin 81mg and continued on his home plavix and statin. Nodal blocking agents were held. . # Pump:ECHo showed EF 45-50%; Pt was continued on his home lasix. Pts ace inhibitor was initially held secondary to ARF but restarted prior to discharge. . #ARF-Pts baseline Cr 1.2; was 1.8 on admission but improved to 1.4 on day #2; it was ultimately fel to be related to dehydration or bradycardia causing poor renal perfusion. Once his HR improved his renal function returned to baseline. . Medications on Admission: 1. Ranexa 500 mg PO BID * new medication started 3 months ago 2. Terazosin 1 mg PO daily 3. Captopril 50 mg PO BID 4. Digoxin 0.125 mg daily 5. Norvasc 10 mg PO daily 6. Lasix 40 mg PO daily 7. Glucophage 500 mg PO TID before meals 8. Carvedilol 3.125 mg PO BID 9. Plavix 75 mg PO daily 10. Lopid 600 mg PO BID 11. Ibuprofen 800 mg PO BID 12. Zocor 40 mg PO daily 13. Dilantin 200 mg PO qHS 14. Phenobarbital 60 mg PO qHS 15. Vitamin C 500 mg PO daily 16. Vitamin E 200 IU PO daily Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 5. Phenobarbital 30 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Vitamin E 100 unit Capsule Sig: Two (2) Capsule PO DAILY (Daily). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Captopril 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 12. Ranexa 500 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO twice a day. Tablet Sustained Release 12 hr(s) 13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 14. Glucophage 500 mg Tablet Sig: One (1) Tablet PO three times a day: please administer before meals. Discharge Disposition: Home Discharge Diagnosis: Primary Digoxin toxicity Syncope . Secondary Coronary artery disease Lung cancer Diabetes mellitus type II Hypertension Hyperlipidemia Congestive heart failure Peripheral venous disease Bilateral cataracts Seizure disorder Discharge Condition: Hemodynamically stable, afebrile Discharge Instructions: You were admitted to the hospital with after a syncopal episode (fainting event) in which a pulse could not be detected. When you arrived at the hospital, you heart rate was found to be low. This was most likely due to digoxin toxicity, which is digoxin blood levels which were dangerously elevated. You were monitored on the heart monitor, and your heart rate improved as you body cleared the digoxin. An ultrasound of your heart was performed and showed improved systolic ("pumping) function of your heart. In addition to the risk for repeat digoxin toxicity in the future, it was felt that you clinically no longer required digoxin. It is recommended that you discontinue this medication permanently. . As your heart function had improved, you were felt to no longer require the same dosage of furosemide (lasix). Your home lasix dosage was decreased by half. In addition, two (2) medications were held during this hospital stay due to your slow heart rate, amlodipine (norvasc) and carvedilol. It is recommended that you hold both amlodipine and carvedilol medications until you followup with your outpatient cardiologist so that he can reassess your need for these at their current dosages. . In summary, please note the following medication changes: 1. DISCONTINUED MEDICATION: Digoxin 2. MEDICATION DOSAGE CHANGE: The furosemide (lasix) dosage was decreased by half (40mg daily to 20 mg daily). 3. HOLD THESE MEDICATIONS UNTIL YOU SEE YOU CARDIOLOGIST IN ONE WEEK: Amlodipine (norvasc) and Carvedilol 4. Please resume all other regular home medications which are not specified above. . Please keep all followup appointments. . Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * 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. Followup Instructions: 1. Followup with your outpatient cardiologist, Dr. [**Last Name (STitle) 78384**] [**Name (STitle) 78385**], ([**Telephone/Fax (1) 78386**]) in one week. Please call his office on Monday to schedule a followup appointment. . 2. Please also followup with your PCP at the VA hosptial within 1-2 weeks of discharge.

[ "414.00", "272.4", "428.0", "E942.1", "584.9", "440.20", "V45.81", "401.9", "V10.11", "250.00", "780.2", "440.4", "427.89", "345.90" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8695, 8701

5376, 7000

288, 295

8968, 9003

4218, 5352

11595, 11912

3241, 3264

7533, 8672

8722, 8947

7026, 7510

9027, 10272

3279, 4197

10292, 11572

221, 250

323, 2411

2433, 2870

2902, 3209

30,977

183,457

162

Discharge summary

report

Admission Date: [**2192-8-7**] Discharge Date: [**2192-8-21**] Date of Birth: [**2130-11-19**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1234**] Chief Complaint: left lower leg extremity ischemia Major Surgical or Invasive Procedure: s/p Left femoral-below knee popliteal bypass History of Present Illness: This is a 61-year-old female who has a history of a left femoral to above-knee popliteal bypass with prosthetic due to a previous harvesting for CABG of her saphenous vein. The patient also has a history of stenting and angioplasty of the distal popliteal artery. The patient presented to the hospital with increasing left foot pain and was found on angiography to have a completely thrombosed prosthetic graft. She had suitable runoff from the below-knee popliteal artery and the decision was made to perform a redo bypass operation. Past Medical History: PVD (Fem stent [**6-12**]), B CEA, IDDM, RAS, HTN, CAD (MI '[**70**], CABGx3 '[**71**]), CRI, Breast implants, Depression Social History: 80 pack year history, quit in [**2170**] no alcohol Family History: non contrib Physical Exam: On day of discharge, patient was feeling well without complaints, vital signs stable. T 98.3, Pulse 74, BP 140/40, RR 18, O2 sats 96% RA The patient was not in any acute distress, alert and oriented x 3 and not in any pain. CVS- regular rate and rhythm Pulm- clear to auscultation, bilaterally Abd- non distended, soft, non tender Wound- left leg- clean, dry and intact Pulses palpable bilaterally fem, [**Doctor Last Name **], dp, pt Pertinent Results: [**2192-8-17**] 03:40AM BLOOD WBC-15.0* RBC-3.22* Hgb-9.9* Hct-29.8* MCV-93 MCH-30.6 MCHC-33.1 RDW-14.4 Plt Ct-495* [**2192-8-7**] 07:45PM BLOOD Neuts-63 Bands-0 Lymphs-27 Monos-5 Eos-4 Baso-1 Atyps-0 Metas-0 Myelos-0 [**2192-8-17**] 03:40AM BLOOD Plt Ct-495* [**2192-8-17**] 03:40AM BLOOD PT-14.0* PTT-33.0 INR(PT)-1.2* [**2192-8-19**] 06:10AM BLOOD Glucose-118* UreaN-54* Creat-1.5* Na-136 K-4.0 Cl-100 HCO3-28 AnGap-12 [**2192-8-19**] 06:10AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.5 Blood culture all negative Brief Hospital Course: The patient was admitted on [**2192-8-7**] for a left lower extremity bypass on [**2192-8-8**]. The patient underwent a left fem-bk [**Doctor Last Name **] with right arm vein (cephalic + basilic) and venovenostomy. Intraop fluids- 5.6 L crystalloid, 4 units RBC, urine output 475cc, estimated blood loss 600 cc. The patient remained intubated to the PACU with a palpable L DP, dopplerable L PT. The patient remained intubated on [**2192-8-9**], sedated in the PACU. She was then extubated and transferred to the VICU on [**8-9**]. Her vital signs were continually monitored throughout. [**2192-8-10**]-patient began a regular diet and treated with nebulizers, had nausea and dry heaving. The patient transferred from chair to bed, had difficulty maintaining O2 sats >90% and was transferred to the CSRU. [**2192-8-11**] Patient treated in CSRU for pulmonary edema secondary to CHF. Patient was intubated due to increasing shortness of breath. Transfused one unit of red blood cells and diuresed. The patient continued to be monitored in the CRSU through [**8-17**]. She was shortly extubated on [**8-13**] but intubated later that night for pulmonary edema. Tube feeds were started on [**2192-8-13**]. [**2192-8-14**]- CPAP as tolerated, nebs, wean PS as tolerated, extubated and chest PT. [**8-15**]- Swallow evaluation performed-cleared [**8-16**]-diuresis held, dispo to VICU. [**8-17**]- transferred to the floor, regular diet, ambulating, nebs. Seen by PT- recommend 2-4x/wk and rehab disposition. 8/11,[**8-19**]- continued pulm toilet, diuresis, PO home meds. [**Last Name (un) **] consult for sugars >400. Patient started on standing insulin dose + sliding scale. OT consulted to help with right arm function. [**8-20**]- d/c central line, peripheral line inserted, PT eval, oral home meds, lasix 40 po. [**8-21**] VSS, no events. [**Last Name (un) **] in to evaluate- will continue current BS medications. Staples removed prior to discharge. F/U Dr. [**Last Name (STitle) **] 3-4 weeks with duplex Medications on Admission: [**Last Name (un) 1724**]: ASA 81', Lipitor 5', Citolapram 20', Metoprolol 50", Norvasc 10', Lasix 40', Humalog, Lantus 18 U HS, Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 9. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 11. Humalog SLiding Scale Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Glucose Insulin Dose 0-60 mg/dL [**1-10**] amp D50 61-80 mg/dL 0 Units 0 Units 0 Units 0 Units 81-120 mg/dL 3 Units 3 Units 4 Units 0 Units 121-160 mg/dL 6 Units 6 Units 7 Units 1 Units 161-200 mg/dL 9 Units 9 Units 10 Units 3 Units 201-240 mg/dL 11 Units 11 Units 11 Units 5 Units 241-280 mg/dL 13 Units 13 Units 13 Units 7 Units 281-320 mg/dL 15 Units 15 Units 15 Units 8 Units > 320 mg/dL Notify M.D. 12. Lantus 100 unit/mL Solution Sig: 20 units QHS Subcutaneous at bedtime: Continue Humalog SS. Discharge Disposition: Extended Care Facility: [**Location (un) 1725**] Nursing Center Discharge Diagnosis: Left lower leg ischemia- occluded femoral to above knee popliteal bypass graft PMH: PVD (Fem stent [**6-12**]), B CEA, IDDM, RAS, HTN, CAD (MI '[**70**], CABGx3 '[**71**]), CRI, Breast implants, Depression Discharge Condition: patient in good condition, vital signs stable Discharge Instructions: Division of [**Year (2 digits) **] and Endovascular Surgery Lower Extremity Bypass Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [**2-11**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2192-9-11**] 1:45 Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2192-9-11**] 1:00 Completed by:[**2192-8-21**]

[ "V45.81", "440.22", "996.74", "250.01", "427.31", "997.1", "428.0", "410.71", "414.00" ]

icd9cm

[ [ [] ] ]

[ "39.29", "96.6" ]

icd9pcs

[ [ [] ] ]

5890, 5956

2207, 4227

348, 395

6207, 6255

1675, 2184

9112, 9398

1191, 1204

4407, 5867

5977, 6186

4253, 4384

6279, 8680

8706, 9089

1219, 1656

275, 310

423, 960

982, 1105

1121, 1175

16,754

108,483

7436

Discharge summary

report

Admission Date: [**2112-9-17**] Discharge Date: [**2112-9-28**] Date of Birth: [**2037-10-1**] Sex: M Service: Cardiothoracic Surgery . HISTORY OF PRESENT ILLNESS: Briefly, this is a 75 year old male with type 2 diabetes mellitus and hypertension, positive smoking history, who presented with dyspnea during the night and some minimal chest discomfort. The patient denied any nausea, vomiting, diaphoresis, and was brought to an outside hospital and found to be in congestive heart failure. He desaturated to 88% on three liters. The EKG showed sinus tachycardia and chest x-ray showed left atrial enlargement. The patient was given Lasix and the EKG showed flipped T waves. He has been on heparin, Nitroglycerin and Lopressor and was transferred here. PAST MEDICAL HISTORY: 1. Diabetes mellitus type 2. 2. Hypertension. 3. High cholesterol. 4. Mild COPD ALLERGIES: He had no known drug allergies. MEDICATIONS: 1. Nifedipine 300 mg q. day. 2. Avandia 4 mg q. day. 3. Metformin 800 mg three times a day. 4. Lisinopril 10 mg q. day. 5. Glyburide 5 mg twice a day. 6. Lipitor 10 mg q. day. PHYSICAL EXAMINATION: On physical examination he was afebrile. His vital signs were stable. He was rhonchorous breath sounds throughout. His heart was regular rate and rhythm with a positive murmur at the apex. His abdomen was soft, nontender and nondistended. He had no calf tenderness or swelling. LABORATORY: His labs at the outside hospital were white blood cell count 13.0, hematocrit of 39, platelets 254, troponin was 0.4. EKG showed normal sinus rhythm with flipped T's in V3 through V6. The patient was admitted for Telemetry and followed. HOSPITAL COURSE: The patient ruled in for a heart attack and Cardiothoracic was consulted. He was found to have multi-vessel disease. The patient was taken to the Operating Room on [**2112-9-22**], where a coronary artery bypass graft times three and a aortic valve replacement was performed. The patient did well postoperatively and was transferred to the CSRU for recovery. The patient was slowly extubated and chest tubes were discontinued. The patient was transferred to the Floor. Wires were removed and Foley catheter was also removed. The patient continued to do well, however, prior to chest tube removal, the patient had a slow air leak which required prolonged suction. The patient was transferred to the floor with the chest tube in place and continued to do well. Physical Therapy was consulted for mobility and for strength and he continued to improve on the floor. He handled a regular diet and chest tube was put on water-seal. After repeated chest x-rays, he still showed continued expansion of the lung. The chest tube was discontinued on [**2112-9-26**] after chest x-ray examination post pull chest x-ray which showed no pneumothorax and the patient continued to do well. The patient was discharged to a rehabilitation facility in stable condition. DISCHARGE INSTRUCTIONS: 1. He was instructed to follow-up with Dr. [**Last Name (STitle) 27267**] in one to week weeks. 2. He is also instructed to follow-up with Dr. [**Last Name (STitle) 1911**] from Cardiology in two to four weeks. DISCHARGE MEDICATIONS: 1. Lopressor 12.5 mg p.o. twice a day. 2. Metformin 500 mg p.o. three times a day. 3. Protonix 40 mg p.o. q. day. 4. Lipitor 10 mg p.o. q. day. 5. Glyburide 2.5 mg p.o. twice a day. 6. Vicodin one to two tablets p.o. q. four hours p.r.n. 7. Enteric coated aspirin 325 mg p.o. q. day. 8. Lasix 20 mg twice a day. 9. Potassium 40 mEq p.o. twice a day. DISCHARGE STATUS: The patient is discharged to rehabilitation in stable condition and instructed to follow-up with Dr. [**Last Name (STitle) **] in one to two weeks. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern4) **] MEDQUIST36 D: [**2112-9-27**] 15:21 T: [**2112-9-27**] 16:46 JOB#: [**Job Number 27268**]

[ "780.6", "491.21", "424.1", "285.9", "250.00", "428.0", "996.59", "414.01", "410.71" ]

icd9cm

[ [ [] ] ]

[ "36.12", "37.23", "88.56", "35.21", "36.15", "89.68", "39.61" ]

icd9pcs

[ [ [] ] ]

3229, 4030

1706, 2968

2992, 3206

1150, 1688

185, 779

801, 1127

68,457

115,923

51428

Discharge summary

report

Admission Date: [**2129-8-9**] Discharge Date: [**2129-8-12**] Date of Birth: [**2062-6-28**] Sex: F Service: MEDICINE Allergies: Aspirin / Compazine Attending:[**First Name3 (LF) 7651**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: PICC placement [**2129-8-11**] History of Present Illness: 67F with h/o of CVA (L hemiparesis), NIDM, CRI, HTN, HLD, CAD s/p CABG with LIMA-LAD, SVG-OM1, SVG-OM2 with Dr. [**First Name (STitle) **] on [**2129-7-27**] and was discharged to [**Hospital **] rehab on [**2129-8-4**]. She was improving at rehab but developed left substernal chest pain around 9 pm last night of sudden onset and was sent to [**Hospital1 18**] ED. . Last night at 9pm, the patient was watching TV when she noticed sudden onset of left shoulder pain that eventually radiated to her sternum and became substernal chest pain. The pain was at first stabbing in sensation but later became a dull pressure that reminded her of her previous MI. Her pain worsened with a cough as well as inspiration. It did not seem to worsen with exertion, although she is primarily bedbound since the surgery. She also reports the pain worsens with lying flat and improves while leaning forward. She denies any associated SOB, diaphoresis, nausea, vomitting, dizziness, numbness/tingling of her extremities. She reports 6-pillow orthopnea and feels uncomfortable while lying flat currently. She denies recent PND, palpitations, lightheadedness, edema. . In the ED, initial vs were: T 98.5 P 58 BP 115/68 R20 O2 sat100% on 2L. Patient was found to have an elevated WBC to 13.8, with increased b/l pleural effusions and a possible new infiltrate on CXR. Her troponin is 0.5 x2 and she has slight t wave inversions in V3-V6 which are new from previous EKG. BNP was noted to be [**Numeric Identifier 106637**]. Cr. is stable at 2.1. She was given vanco/levoflox for treatment of presumed HAP. Chest pain responded to nitro gtt, given plavix as patient is allergic to aspirin. Currently, chest pain free. On review of her micro, noted to have had recent pan-sensitive pseudomonas UTI. Consulted Cards and CT surgery. . On the floor, she was found to be in [**4-30**] chest pain and [**8-30**] when she takes a deep breath. She was on a nitro gtt. She was actively orthopneic. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. 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. Past Medical History: Past Medical History: Coronary Artery Disease s/p Cerebrovascular accident with L hemiparesis noninsulin dependent Diabetes mellitus Chronic renal insufficiency with microalbuminuria Hyperlipidemia Hypertension Asthma Morbid obesity Past Surgical History: s/p Bilateral carpal tunnel release s/p CABG [**2129-7-27**]: LIMA-LAD, SVG-OM1, SVG-OM2 Social History: Lives alone, currently at [**Hospital **] rehab s/p CABG on [**2129-7-27**] Occupation: nurse No history of smoking, no EtoH, no ilicit drug use, including no cocaine. Family History: Mother had DM. No known CAD. No history of early MI or blood clot. Physical Exam: Vitals: 97.7 59 141/55 16 100%2LNC General: Alert, oriented, obese, looks uncomfortable but in no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated but difficult to discern given habitus, no LAD Lungs: Reduced breath sounds at the right lower and mid fields, positive egophony on the right, no wheezes, rhales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley catheter in place Ext: 1+ edema L>R however recent SVG harvest was on the left. +LLE calf tenderness but no pain. warm, well perfused, 2+ pulses, no clubbing, cyanosis. Pertinent Results: Labs on Admission: [**2129-8-9**] 12:08AM BLOOD WBC-13.8* RBC-2.97* Hgb-9.2* Hct-27.0* MCV-91 MCH-31.1 MCHC-34.2 RDW-15.2 Plt Ct-265 [**2129-8-9**] 12:08AM BLOOD Neuts-80.4* Lymphs-12.8* Monos-2.3 Eos-4.3* Baso-0.2 [**2129-8-9**] 12:08AM BLOOD Glucose-245* UreaN-54* Creat-2.3* Na-137 K-4.5 Cl-102 HCO3-27 AnGap-13 [**2129-8-9**] 12:08AM BLOOD CK(CPK)-87 [**2129-8-9**] 12:08AM BLOOD CK-MB-2 proBNP-[**Numeric Identifier 106637**]* [**2129-8-9**] 12:08AM BLOOD cTropnT-0.05* [**2129-8-9**] 12:08AM BLOOD Calcium-9.1 Phos-2.4*# Mg-2.1 Other Labs: [**2129-8-11**] 04:30PM BLOOD PT-13.1 PTT-34.4 INR(PT)-1.1 [**2129-8-11**] 04:30PM BLOOD ALT-43* AST-52* AlkPhos-120* TotBili-0.5 [**2129-8-11**] 04:30PM BLOOD Albumin-3.5 Calcium-9.2 Phos-3.9 Mg-2.0 Cardiac Enzymes: [**2129-8-9**] 12:08AM BLOOD CK-MB-2 proBNP-[**Numeric Identifier 106637**]* [**2129-8-9**] 12:08AM BLOOD cTropnT-0.05* [**2129-8-9**] 07:50AM BLOOD cTropnT-0.05* [**2129-8-9**] 03:42PM BLOOD CK-MB-2 cTropnT-0.05* [**2129-8-11**] 04:30PM BLOOD cTropnT-0.05* Discharge Labs: [**2129-8-12**] 11:00AM BLOOD WBC-5.9 RBC-5.09# Hgb-15.7# Hct-46.5# MCV-91 MCH-30.8 MCHC-33.8 RDW-15.3 Plt Ct-106*# [**2129-8-12**] 11:00AM BLOOD Glucose-284* UreaN-66* Creat-2.7* Na-137 K-5.0 Cl-99 HCO3-30 AnGap-13 [**2129-8-12**] 11:00AM BLOOD Mg-1.9 ECG [**2129-8-8**]: Sinus bradycardia. Consider inferior myocardial infarction of indeterminate age. RSR' pattern in lead V1 with early R wave progression. Other ST-T wave abnormalities. Since the previous tracing of [**2129-7-27**] the axis is less right inferior. The QRS complex is narrower. T wave abnormalities are probably more prominent. Clinical correlation is suggested. CXR [**2129-8-9**]: PA AND LATERAL VIEWS OF THE CHEST: Lung volumes are low. There are bilateral small pleural effusions which are slightly increased in size since the previous study. There is bibasilar atelectasis which as slightly improved at the left base since the prior study. Mild cardiomegaly is unchanged. Mild central pulmonary vascular prominence is again seen, unchanged. There is no pneumothorax. Midline sternotomy wires remain intact. IMPRESSION: Bilateral pleural effusions have slightly increased in size since the previous study. TTE [**2129-8-9**]: The left atrium is dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF 75%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2129-7-22**], the findings are similar. Bilateral Lower Ext Veins US [**2129-8-10**]: No evidence of DVT in the lower extremities. Unilateral Upper Ext Veins US (Left): No evidence of DVT of the left upper extremity. Brief Hospital Course: The patient is a 67yo female with h/o of CVA (L hemiparesis), DM, CRI, HTN, HLD, CAD s/p CABG [**2129-7-27**], admitted from [**Hospital **] rehab after the acute onset of sharp, substernal chest pain on the night of [**2129-8-8**]. #) Chest pain: Patient c/o sharp substernal chest pain, non-radiating, and worse with inspiration. ECG revealed diffuse T wave inversions, which were concerning for possible cardiac ischemia. However, pain seemed more consistent with pleuritic chest pain than with angina, and patient ruled out for an MI after cardiac enzymes were negative x3. Other differential diagnoses for chest pain included PE, pericarditis, pneumonia, and infection of her sternotomy incision. She had bilateral lower extremity venous ultrasounds, which did not reveal any evidence of DVT, as well as a left upper extremity venous ultrasound, which also did not reveal any DVT. The patient was started on vancomycin and cefepime for possible HAP, as she had an elevated WBC on admission and possible focal consolidation on CXR. An sternotomy incision infection seemed unlikely, as her incision was without any erythema, pus, or fluctuance. CT surgery was following, and felt her pain may be incisional but did not feel the incision site was infected. Pericarditis remained on the differential, given the timing of her recent CABG and diffuse, non-specific ECG changes. An echo on [**2129-8-9**] did not reveal any evidence of pericardial effusion. The patient's pain had generally resolved within the first day of her admission, after being placed on a nitro gtt and receiving morphine. Given her renal disease, she was not started on ibuprofen or colchicine for presumed pericarditis, but rather will be discharged on Tylenol and oxycodone as needed for her chest pain. Her tramadol was stopped. . #)PNA: The patient was started on vancomycin and cefepime for possible HAP, as she had an elevated WBC on admission and possible focal consolidation on CXR. She remained afebrile throughout her hospital course. A PICC line was placed on [**2129-8-11**], and she will continue on an 8-day course of antibiotics for presumed HAP. [**2129-8-16**] will be the last day of her antibiotic therapy. A vanc trough on [**2129-8-12**] was 22.5, and the patient's vanc dose was decreased to 500mg daily. She should have a repeat vanc trough on [**2129-8-14**] prior to her dose of vancomycin. #) Diastolic heart failure: Patient felt to be in mild acute on chronic congestive heart failure, possibly secondary to HAP, as well as her Lasix being held. She was gently diuresed with Lasix, with cautious monitoring of her electrolytes, fluid balance, and renal fucntion. She was continued on Ramipril, but her dose was decreased in setting of her rising Cr. Dose will be further decreased to 5mg PO daily on discharge. She was ordered for metoprolol 12.5mg PO BID, but this was held for most of her admission as her HR was in the 40s-50s. She was continued on a low sodium diet. The patient was not felt to be significantly volume overloaded, and aggressive diuresis was not pursued given her elevated Cr. Her oxygen sats remained 100% on 2L nasal cannula, and remained in the 90s off oxygen. . #) Coronary artery disease: The patient's chest pain was not thought to be secondary to ACS after her cardiac enzymes remained negative, and her ECG did not significantly change over the course of her admission. She was continued on Plavix, and not given ASA given her h/o ASA hypersensitivity. She was weaned off the nitro drip within the first 24 hours of admission, and remained generally chest pain free. She was continued on a statin and metoprolol, but metoprolol was frequently held in setting of bradycardia. . #) Rising Cr - The patient's Cr was 2.3 on admission, down from 2.9 on [**2129-8-4**] (the day of discharge following her CABG). Her Cr rose to 2.8 on [**2129-8-10**], in the setting of diuresis for mild pulmonary edema. Additional Lasix was then held, with Cr trending back down to 2.6-2.7. It is unclear what the patient's baseline Cr will be, as she had an episode of ATN secondary to hypotension during her recent hospitalization, and as she also has underlying chronic renal insufficiency secondary to diabetic nephropathy. Her BUN/Cr and renal function should be closely monitored. . #) Hypertension - Her BPs were stable, and generally normotensive during her hospital course. Her hydralazine was stopped, and she was continued on Ramipril, Metoprolol, Amlodipine, Clonidine, and several doses of Lasix. As above, her metoprolol was held secondary to bradycardia. . #) Asthma - The patient had several brief episodes of SOB, which she felt may be secondary to her asthma. She was ordered for ipratropium and albuterol nebs as needed for dyspnea. . #) Sleep apnea - The patient reported having a previous diagnosis of OSA, for which she has been on BiPap in the past. A respiratory consult was ordered, and the patient may benefit from a sleep study and CPAP in the outpatient setting. . #) H/o CVA: She was continued on Crestor, plavix. . #) DM Type 2: She was on Lantus 16 units QHS, as well as an insulin s/s. She will not be discharged on pioglitazone, and her regular insulin will be changed to aspart. . #) Prophylaxis: She was on SC heparin for DVT prophylaxis. She was on colace, senna, miralax prn constipation, and lactulose prn constipation. Medications on Admission: Ranitidine HCl 150 mg PO daily Docusate Sodium 100 mg PO BID Clopidogrel 75 mg PO daily Amlodipine 10 mg PO daily Lidocaine 5 %(700 mg/patch) Adhesive Patch one DAILY (Daily) as needed for back pain. Tramadol 50 mg q 4 hours PRN pain Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) u SC Injection TID (3 times a day). Metoprolol Tartrate 12.5 mg PO BID Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen (17) gram/dose powder PO DAILY (Daily). Clonidine 0.2 mg PO TID Rosuvastatin 40 mg PO daily Ciprofloxacin 500 mg PO daily (last dose [**2129-8-5**]) Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever or pain. Bisacodyl 5 mg Tablet Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Saline nasal spray Lactulose 30cc PO q 12 hours PRN constipation Trazadone 25 mg Po qhs Insulin regular sliding scale QID Glargine 16 units qhs Zolpidem 5 mg po qhs Lorazepam 1mg Po q 4 hours PRN anxiety Hydralazine 25 mg Po q6 hours nitroglycerin 0.4 mg SL q 5 minutes x3 for chest pain Discharge Medications: 1. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day: Hold SBP < 10. 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Hold for diarrrhea. 4. Cefepime 1 gram Recon Soln Sig: One (1) Recon Soln Injection Q24H (every 24 hours) for 5 days. 5. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q 24H (Every 24 Hours) for 5 days. 6. Lantus 100 unit/mL Solution Sig: Sixteen (16) units Subcutaneous at bedtime. 7. Insulin Aspart 100 unit/mL Solution Sig: as per sliding scale units Subcutaneous four times a day. 8. Ramipril 5 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)): Hold SBP < 100. Capsule(s) 9. Rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): Hold HR < 55. SBP < 100. 13. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 14. 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. 15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) syringe Injection TID (3 times a day). 16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 18. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) patch Topical once a day: on for 12 hours during the day. 19. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. 20. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): Please give ATC for chest pain. 21. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for chest pain: Please give for breakthrough pain. 22. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as needed for insomnia. 23. Lactulose 10 gram/15 mL Solution Sig: Thirty (30) cc PO twice a day as needed for constipation. 24. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for anxiety. 25. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab Sublingual every 5 minutes x 3 doses as needed for chest pain. 26. Saline Nasal 0.65 % Aerosol, Spray Sig: One (1) spray Nasal every 6-8 hours as needed for dry nose. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Chest pain Coronary Artery disease s/p cornary artery bypass grafting diabetes Mellitus Type 2 Hypertension Hyperlipidemia history of Cerebrovascular accident Asthma Obstructive sleep apnea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had chest pain and was admitted for evaluation. We did not find any evidence for a heart attack. We think that the chest pain could be due to pericardial irritation from the surgery or possibly from a pneumonia. You were started on IV antibiotics and a PICC line was placed for the antibiotics and to draw blood. You will have a total of 8 days of the antibiotics. You heart rate has been low and we have been holding your metoprolol. You had an exacerbation of your congestive heart failure and some Lasix was given. Your kidney function worsened and is now improving. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. . Medication changes: 1. Stop taking Hydralazine, Tramadol, Zolpidem, Pioglitizone and gabapentin 2. Start taking Ramapril 5 mg in the am 3. Start Vancomycin and Cefepime to treat a pneumonia. You will have an eight day course. 4. Start oxycodone and tylenol to treat the chest pain 5. Start senna to treat constipation . Weigh yourself every day and call Dr. [**First Name (STitle) **] if your weight increases more than 3 poounds in 1 day or 6 pounds in 3 days. Followup Instructions: Department: CARDIAC SERVICES When: MONDAY [**2129-8-22**] at 2:40 PM With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: WEDNESDAY [**2129-8-24**] at 2:10 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 815**], MD [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SURGERY When: MONDAY [**2129-9-5**] at 2:15 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 170**] Building: LM [**Hospital Unit Name **] [**Location (un) 551**] Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE

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Discharge summary

report

Admission Date: [**2115-12-3**] Discharge Date: [**2116-1-1**] Date of Birth: [**2045-1-27**] Sex: F Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 52022**] Chief Complaint: Bilateral knee pain / osteoarthritis Major Surgical or Invasive Procedure: Bilateral total knee arthroplasy Placement of IVC filter History of Present Illness: 70 year old woman with a history of hypertension, osteoarthritis, herpes simplex encephalitis w/ secondary seizure disorder and memory loss with a history of increasing bilateral knee pain and difficulty with ambulation presents to [**Hospital1 18**] for elective bilateral total knee replacement. Past Medical History: 1. Hypertension 2. Osteoarthritis 3. Seizures and memory loss due to encephalitis 4. HSV encephalitis [**2108**] Social History: Mandarin speaking, lives with husband and has daughters who assist with her care. No history of tobacco or alcohol. Family History: non-contributory Physical Exam: PE: VS: T 94.2 ax 95.7 po HR 75 BP 100/63 RR O2 sat 100% Gen: Intubated and sedated. HEENT: PERRLA EOMI MM pink and moist CV: RRR no m/r/g Lungs: CTA anterior exam soft, NT, ND normoactive BS Bilateral knee incisions clean, dry, and intact. Pertinent Results: [**2115-12-16**] 06:05AM BLOOD WBC-9.9 RBC-3.88* Hgb-11.6* Hct-34.8* MCV-90 MCH-29.8 MCHC-33.3 RDW-15.2 Plt Ct-559* [**2115-12-15**] 06:00AM BLOOD WBC-9.9 RBC-3.80* Hgb-11.4* Hct-33.8* MCV-89 MCH-30.0 MCHC-33.7 RDW-15.4 Plt Ct-499* [**2115-12-14**] 06:10AM BLOOD WBC-11.3* RBC-3.68* Hgb-11.5* Hct-33.2* MCV-90 MCH-31.3 MCHC-34.7 RDW-16.8* Plt Ct-408 [**2115-12-13**] 07:30PM BLOOD Hct-34* [**2115-12-13**] 01:00PM BLOOD Hct-34.9* [**2115-12-13**] 06:00AM BLOOD Hct-29.0* [**2115-12-13**] 06:00AM BLOOD WBC-11.3* RBC-3.61* Hgb-11.3* Hct-32.2* MCV-89 MCH-31.3 MCHC-35.1* RDW-17.1* Plt Ct-358 [**2115-12-12**] 11:50PM BLOOD Hct-32.6* [**2115-12-12**] 04:42AM BLOOD WBC-10.0 RBC-3.72* Hgb-11.3* Hct-31.6* MCV-85 MCH-30.3 MCHC-35.7* RDW-16.1* Plt Ct-280 [**2115-12-11**] 09:01PM BLOOD Hct-31.9* Plt Ct-263 [**2115-12-11**] 01:24PM BLOOD WBC-10.3 RBC-3.67* Hgb-11.5* Hct-32.1* MCV-88 MCH-31.4 MCHC-35.9* RDW-17.0* Plt Ct-235 [**2115-12-11**] 05:45AM BLOOD WBC-10.3 RBC-3.67* Hgb-11.3*# Hct-31.8* MCV-87 MCH-30.8 MCHC-35.5* RDW-17.0* Plt Ct-208 [**2115-12-11**] 12:18AM BLOOD Hct-30.6* [**2115-12-10**] 05:14PM BLOOD Hct-31.3*# [**2115-12-10**] 05:01AM BLOOD WBC-9.0 RBC-2.98* Hgb-8.8* Hct-24.9* MCV-84 MCH-29.5 MCHC-35.3* RDW-16.3* Plt Ct-170 [**2115-12-10**] 02:09AM BLOOD Hct-25.4* [**2115-12-9**] 06:22PM BLOOD Hct-27.0* [**2115-12-9**] 05:45AM BLOOD WBC-9.7 RBC-2.94* Hgb-9.2* Hct-25.4*# MCV-86 MCH-31.2 MCHC-36.1* RDW-16.0* Plt Ct-165 [**2115-12-8**] 11:43PM BLOOD Hct-18.7* Plt Ct-154 [**2115-12-8**] 04:47PM BLOOD Hct-21.2* [**2115-12-8**] 10:55AM BLOOD WBC-8.0 RBC-3.26* Hgb-9.9* Hct-27.8* MCV-84 MCH-30.3 MCHC-36.0* RDW-15.6* Plt Ct-105* [**2115-12-8**] 12:26AM BLOOD Hct-22.4* [**2115-12-7**] 07:35PM BLOOD WBC-8.0 RBC-2.88* Hgb-9.0* Hct-24.7* MCV-86 MCH-31.3 MCHC-36.4* RDW-16.5* Plt Ct-107* [**2115-12-7**] 01:39PM BLOOD Hct-26.9* [**2115-12-7**] 05:35AM BLOOD WBC-9.0 RBC-3.10* Hgb-9.5* Hct-26.5* MCV-86 MCH-30.6 MCHC-35.7* RDW-16.6* Plt Ct-106* [**2115-12-6**] 12:11PM BLOOD Hct-30.7* [**2115-12-6**] 05:20AM BLOOD Hct-29.3* [**2115-12-6**] 03:00AM BLOOD WBC-10.5 RBC-3.46* Hgb-11.0* Hct-30.0* MCV-87 MCH-31.7 MCHC-36.7* RDW-16.2* Plt Ct-96* [**2115-12-5**] 07:55PM BLOOD Hct-30.9* Plt Ct-96* [**2115-12-5**] 03:42PM BLOOD Hct-28.1* [**2115-12-5**] 11:47AM BLOOD Hct-30.1* [**2115-12-5**] 08:20AM BLOOD Hct-29.4* [**2115-12-5**] 06:18AM BLOOD WBC-12.7* RBC-3.40*# Hgb-10.7*# Hct-29.3* MCV-86 MCH-31.7 MCHC-36.7* RDW-16.0* Plt Ct-103* [**2115-12-5**] 01:35AM BLOOD Hct-26.9* [**2115-12-4**] 05:45PM BLOOD Hct-27.4* [**2115-12-4**] 01:02PM BLOOD Hct-28.7*# [**2115-12-4**] 05:48AM BLOOD WBC-11.6* RBC-2.56* Hgb-8.3* Hct-22.8* MCV-89 MCH-32.2* MCHC-36.2* RDW-16.1* Plt Ct-202# [**2115-12-4**] 12:21AM BLOOD WBC-14.5* RBC-3.28* Hgb-10.2* Hct-29.3* MCV-89 MCH-31.2 MCHC-35.0 RDW-15.9* Plt Ct-92* [**2115-12-3**] 03:51PM BLOOD WBC-13.7*# RBC-3.27* Hgb-10.5* Hct-29.9* MCV-91 MCH-32.1* MCHC-35.1* RDW-15.3 Plt Ct-85*# [**2115-12-16**] 06:05AM BLOOD Plt Ct-559* [**2115-12-13**] 06:00AM BLOOD PT-12.5 PTT-23.4 INR(PT)-1.0 [**2115-12-12**] 04:42AM BLOOD Plt Ct-280 [**2115-12-12**] 04:42AM BLOOD PT-12.5 PTT-21.3* INR(PT)-1.0 [**2115-12-11**] 09:01PM BLOOD Plt Ct-263 [**2115-12-11**] 05:45AM BLOOD PT-12.7 PTT-22.2 INR(PT)-1.1 [**2115-12-11**] 12:30AM BLOOD PT-12.8 PTT-23.6 INR(PT)-1.1 [**2115-12-10**] 05:14PM BLOOD PT-13.4* PTT-26.2 INR(PT)-1.2 [**2115-12-10**] 05:01AM BLOOD PT-13.8* PTT-25.4 INR(PT)-1.3 [**2115-12-9**] 06:22PM BLOOD PT-15.1* PTT-43.4* INR(PT)-1.6 [**2115-12-9**] 05:45AM BLOOD PT-14.5* PTT-30.6 INR(PT)-1.4 [**2115-12-9**] 02:27AM BLOOD PT-14.6* PTT-36.4* INR(PT)-1.5 [**2115-12-8**] 10:55AM BLOOD PT-16.6* PTT-56.4* INR(PT)-1.9 [**2115-12-7**] 05:35AM BLOOD PT-14.5* PTT-39.7* INR(PT)-1.4 [**2115-12-6**] 03:00AM BLOOD PT-14.7* PTT-40.0* INR(PT)-1.5 [**2115-12-5**] 06:18AM BLOOD PT-15.6* PTT-33.2 INR(PT)-1.7 [**2115-12-4**] 05:48AM BLOOD PT-14.8* PTT-31.4 INR(PT)-1.5 [**2115-12-3**] 07:50PM BLOOD PT-13.9* PTT-27.6 INR(PT)-1.3 [**2115-12-3**] 03:51PM BLOOD Plt Smr-LOW Plt Ct-85*# [**2115-12-3**] 03:51PM BLOOD PT-14.7* PTT-37.3* INR(PT)-1.5 [**2115-12-12**] 04:42AM BLOOD Fibrino-663* [**2115-12-9**] 10:39AM BLOOD Fibrino-631*# D-Dimer-3171* [**2115-12-7**] 05:35AM BLOOD Fibrino-785* D-Dimer-2280* Thrombn-70.1* [**2115-12-6**] 03:00AM BLOOD Fibrino-691*# [**2115-12-5**] 06:18AM BLOOD Fibrino-524*# [**2115-12-4**] 05:48AM BLOOD Fibrino-292# [**2115-12-3**] 07:50PM BLOOD Fibrino-97* [**2115-12-13**] 06:00AM BLOOD Glucose-123* UreaN-19 Creat-0.6 Na-136 K-4.2 Cl-103 HCO3-24 AnGap-13 [**2115-12-11**] 05:45AM BLOOD Glucose-120* UreaN-20 Creat-0.6 Na-141 K-4.1 Cl-109* HCO3-24 AnGap-12 [**2115-12-10**] 05:01AM BLOOD Glucose-111* UreaN-17 Creat-0.6 Na-141 K-3.6 Cl-108 HCO3-26 AnGap-11 [**2115-12-8**] 04:27AM BLOOD Glucose-113* UreaN-11 Creat-0.6 Na-141 K-3.5 Cl-108 HCO3-25 AnGap-12 [**2115-12-6**] 03:00AM BLOOD Glucose-138* UreaN-9 Creat-0.6 Na-142 K-3.7 Cl-110* HCO3-24 AnGap-12 [**2115-12-4**] 05:45PM BLOOD Glucose-162* UreaN-18 Creat-0.9 Na-139 K-3.8 Cl-108 HCO3-21* AnGap-14 [**2115-12-3**] 03:51PM BLOOD Glucose-235* UreaN-17 Creat-0.8 Na-139 K-4.5 Cl-106 HCO3-19* AnGap-19 [**2115-12-15**] 06:00AM BLOOD ALT-82* AST-89* AlkPhos-166* TotBili-1.3 [**2115-12-13**] 06:00AM BLOOD ALT-49* AST-59* AlkPhos-145* TotBili-1.4 [**2115-12-12**] 04:42AM BLOOD LD(LDH)-437* TotBili-1.4 [**2115-12-11**] 05:45AM BLOOD TotBili-1.6* DirBili-0.7* IndBili-0.9 [**2115-12-11**] 12:18AM BLOOD ALT-50* AST-73* LD(LDH)-434* AlkPhos-135* TotBili-1.7* [**2115-12-9**] 06:22PM BLOOD ALT-57* AST-62* LD(LDH)-444* TotBili-2.2* [**2115-12-8**] 11:43PM BLOOD CK-MB-2 cTropnT-<0.01 [**2115-12-8**] 04:47PM BLOOD CK-MB-2 cTropnT-<0.01 [**2115-12-5**] 10:16AM BLOOD Type-ART Temp-36.9 Rates-/16 Tidal V-400 PEEP-5 FiO2-40 pO2-114* pCO2-39 pH-7.42 calHCO3-26 Base XS-1 Intubat-INTUBATED [**2115-12-4**] 06:00PM BLOOD Type-ART pO2-107* pCO2-35 pH-7.43 calHCO3-24 Base XS-0 [**2115-12-4**] 06:19AM BLOOD Type-ART Temp-37.6 pO2-139* pCO2-35 pH-7.37 calHCO3-21 Base XS--3 [**2115-12-3**] 07:54PM BLOOD Type-ART pO2-221* pCO2-33* pH-7.36 calHCO3-19* Base XS--5 [**2115-12-3**] 02:35PM BLOOD Type-ART FiO2-40 pO2-130* pCO2-46* pH-7.29* calHCO3-23 Base XS--4 Intubat-INTUBATED Vent-CONTROLLED [**2115-12-3**] 12:44PM BLOOD Type-ART FiO2-40 pO2-171* pCO2-36 pH-7.44 calHCO3-25 Base XS-1 Intubat-INTUBATED Vent-CONTROLLED Comment-ETT [**2115-12-3**] 11:36AM BLOOD Type-ART FiO2-40 pO2-182* pCO2-42 pH-7.39 calHCO3-26 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED Comment-ETT Brief Hospital Course: 70 F s/p bilateral total knee arthoplasty (see operative report for details) for osteoarthritis [**2115-12-3**]. Patient developed postoperative hypotension and transfusion requirement necessitating an ICU admission. Postop, patient was hypotensive in PACU, required pressors and was transfered to ICU for close monitoring. Postoperative hematocrit was unresponsive to repeated transfusions of PRBC. Patient was taken to the interventional radiology suite on [**2115-12-5**] for suspicion of arterial vs. venous bleed into the surgical bed of the right knee. Arteriographic imaging of popliteal and genicular circlution revealed "No active extravasation, pseudoaneurysm or other evidence for arterial bleeding was identified from the arteries around the knees on either side." Per interventional radiology, the decision was made to image the venous system around the knees by ultrasonography given the edema in the patient's lower extremities which would make cannulation for venography difficult. Ultrasonography on the same date showed " 1. Partially-occlusive thrombus within the right common femoral and right popliteal veins. 2. No deep venous thrombosis within the left upper extremity. 3. No evidence of a hematoma within the right knee." Patient was treated for DVT with therapeutic Lovenox (1mg/kg). -IVC filter was inserted on [**2115-12-9**] CT scan on [**12-9**] showed "within the musculature of both thighs, particularly the quadriceps, evidence of bilateral hematoma, with expansion of the musculature as well as high- and low-attenuation collections. There are hematocrit levels within both thighs. The hematoma on the left is greater than right, and extends to the height of the quadriceps musculature, and measures approximately 4.5 x 7 cm." Follow-up CTA on [**12-11**] showed "1. Bilateral hematomas around the recent knee joint surgery, larger on the left side. These are stable compared to recent CT. No evidence of pseudoaneurysm or active extravasation of contrast on the CTA. 2. Right lower limb deep venous thrombosis extending to the upper common femoral vein level. The patient has had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] filter placed." Patient's INR was reversed with fresh frozen plasma, Hct was stable for 48 hours, and was cleared by the ICU team for transfer to the floor. Patient subsequently continued to improve and made progress with physical therapy. She was treated with a heparin drip for DVT and continued on coumadin. Her pain was adequately controlled, she tolerated a Cardiac/Heart healthy /Pureed/Honey prethickened liquids diet. She was discharged to follow-up with Dr. [**Last Name (STitle) **] in the orthopaedic surgery clinic. *** This discharge summary (hospital stay [**2115-12-3**] - [**2116-1-1**]) was completed--from the inpatient chart-- by the house officer who was off service after [**2115-12-13**]. For further details about the hospital course after [**2115-12-13**] please contact [**Name (NI) 1022**] [**Name (NI) **], the discharging PA*** Medications on Admission: 1. Aspirin 81 mg daily 2. Atenolol 100 mg daily 3. Hydrochlorothiazide 25 mg daily 4. Norvasc 5 mg daily 5. Phenytoin 100 mg tid 6. glucosamine 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. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 3. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: Goal INR 2.0-2.5 for Tx of DVT. -Please check 2x weekly -Please call result to [**Telephone/Fax (1) 9118**] Attn. [**Doctor Last Name **] Brown. Disp:*30 Tablet(s)* Refills:*2* 4. Outpatient Lab Work Please Check INR 2x weekly. Goal INR 2.0-2.5 for Tx of DVT. Please call results to [**Telephone/Fax (1) 9118**]. Attn [**Doctor Last Name **] Brown. Discharge Disposition: Home Discharge Diagnosis: s/p bilateral total knee replacement Bilateral OA of knees DVT R popliteal vein pharyngeal dysphagia Discharge Condition: stable Discharge Instructions: [**Name8 (MD) **] M.D. for increase in severity of symptoms, breakdown of surgical wound, fever, pain, questions or other concerns. Continue with weight bearing as tolerated bilateral lower extremities. Continue to take Coumadin for treatment of DVT. Keep brace on right leg at all times when ambulating. Please call/return if any fevers, increased discharge from incision or trouble breathing. Continue with out-patient physical therapy. Please have INR checked 2x weekly while taking Coumadin. Please call results to [**Telephone/Fax (1) 9118**] attn. [**Doctor Last Name **] Brown. Goal INR 2.0-2.5 Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in the Orthopaedic Surgery clinic in [**11-8**] days, please call clinic to schedule @ [**Telephone/Fax (1) 1228**]. Provider: [**Name (NI) **] [**Name (NI) 6724**], PT Phone:[**Telephone/Fax (1) 2484**] Date/Time:[**2116-1-3**] 8:00 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 1228**] Call to schedule appointment for 10-14 days after discharge Completed by:[**2116-2-26**]

[ "998.12", "453.8", "458.29", "285.1", "790.4", "276.6", "287.5", "401.9", "276.2", "715.96", "780.39", "286.9", "139.0", "275.41" ]

icd9cm

[ [ [] ] ]

[ "38.91", "38.7", "81.54", "88.48", "99.04", "99.06", "99.05", "99.07", "38.93", "96.71", "00.17" ]

icd9pcs

[ [ [] ] ]

11711, 11717

7819, 10863

356, 415

11862, 11870

1323, 7796

12522, 13010

1029, 1047

11058, 11688

11738, 11841

10889, 11035

11894, 12499

1062, 1304

280, 318

443, 742

764, 879

895, 1013

2,904

167,954

24464

Discharge summary

report

Admission Date: [**2130-6-9**] Discharge Date: [**2130-6-17**] Date of Birth: [**2069-9-8**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 60 y/o man with PMH significant for mesothelioma and COPD presenting to the ED from [**Hospital6 17032**] with concern for a hemothorax. Pt had experienced two to three days of increasing SOB. He reports that before this time he could move around the house and climb one flight of stairs without significant SOB. He has slept propped up on the couch for several years. However, over the last three days, he has noted an increased SOB. Pt reports that he could not even walk to the bathroom or hold a long conversation without significant SOB by yesterday. Pt has had mild cough. His daughter [**Name (NI) 653**] his PCP who started him on home oxygen but this did not provide any real relief. Today, when he went in for a previously scheduled CT scan at the OSH, the SOB had continued to worsen. CT scan showed a large presumed hemothorax on the right with air in it suggestive of loculation. There was also a slight shift in the mediastinum. Labs were significant for a WBC count of 17.7 and Hct of 32.5. . In further discussion, pt denies fevers and chills. Pt has had five weeks of right sided chest pain and lower right back pain that is worse with deep inspirations. He reports that this is completely unchanged over the last several days. Pt reports that his abdomen feels "hard" to him but denies any abdominal pain. No nausea or vomiting. His appetite is severely decreased and he has lost approximately 25 pounds in the last four months. Pt reports that he moves his bowels every 3 or 4 days. No blood in the stools. No difficulty with urination. No LE pain but did develop tenderness over the top of his right foot over the last two days. He attributes this to slippers which are "too tight". Past Medical History: 1. Mesothelioma- Diagnosed approximately 5 weeks ago when the pt presented to his PCP with right sided chest and back pain. He has not yet started any sort of treatments but reports that he was scheduled to do so next week. 2. COPD 3. S/P appendectomy Social History: Pt is currently living with his daughter. His wife died three years ago. He works as a printer. Pt smoked one pack per day for 42 years and quit 5 weeks ago when he was diagnosed with the mesothelioma. No ETOH or drugs Family History: Noncontributory. Physical Exam: 96.7 102 154/76 19 94% 8L NC ---> 100% mask Gen- Ill, cachectic appearing man resting on the strecher. Able to speak in full sentences without real SOB but does appear fatigued by the effort. Sitting upright in attempt to make his breathing more comfortable. HEENT- NC AT. Face mask in place. PERRL. Anicteric sclera. EOMI. Cardiac- Tachycardic. Regular rhythem. No m,r,g. Pulm- Coarse breath sounds at the very top of the right lung but otherwise on breath sounds on the right. Coarse breath sounds throughout the left lung. Abdomen- Soft. NT. ND. Positive bowel sounds. Extremities- No c/c/e. 2+ DP pulses bilaterally. Pertinent Results: [**2130-6-9**] 07:25PM GLUCOSE-120* UREA N-15 CREAT-0.7 SODIUM-134 POTASSIUM-4.6 CHLORIDE-94* TOTAL CO2-28 ANION GAP-17 [**2130-6-9**] 07:25PM WBC-17.9* RBC-4.23* HGB-11.0* HCT-33.9* MCV-80* MCH-25.9* MCHC-32.3 RDW-14.5 [**2130-6-9**] 07:25PM PLT COUNT-561* CHEST (PORTABLE AP) [**2130-6-15**] 7:54 AM FINDINGS: There has been no change in the extent of opacification of the right hemithorax and left basilar atelectasis/consolidation. An endotracheal tube and NG tube remain in place. No clear pneumothorax is seen on this study. Pulmonary vasculature in the visualized portion of the left lung appears normal. CHEST (PORTABLE AP) [**2130-6-9**] 7:26 PM IMPRESSION: Near complete opacification of the right hemithorax with small amount of air seen at the right apex. This is most likely due to a large pleural effusion. A chest CT is recommended for further characterization. CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST [**2130-6-10**] 3:59 PM 1) No definite evidence of pulmonary embolism on this limited exam. 2) Multifocal ground glass opacity, most prominent in the basal segments of the left lower lobe, representing multifocal pneumonia vs. aspiration. 3) Irregular circumferential right pleural thickening, consistent with the patient's known history of mesothelioma. There may be extension to the right lateral chest wall musculature. 4) Large multiloculated right pleural effusion with pockets of air, resulting in compressive atelectasis of the right middle and lower lobes. The majority of the pleural fluid measures simple fluid. Study Date of [**2130-6-11**] 11:29:32 PM ECG Regular narrow complex tachycardia - mechanism uncertain - consider AV nodal reentry Left ventricular hypertrophy with repolarization changes Clinical correlation is suggested No previous tracing for comparison Brief Hospital Course: A/P: 60 y/o man with PMH significant for mesothelioma transferred from OSH for management of hemothorax who was intubated for respiratory failure #respiratory failure - likely from combination of progressive right sided hemothorax, progreessive lung cancer and right sided atelextasis, diffuse ground glass in lungs(CHF vs pneumonia) - tried diuresis with no improvement in respiratory status, likely not CHF - The patient was treated empirically for pneumonnia with Cefepime/Vanco/Flagyl. - As the patient did not improve despite intubation and antibiotics, palliative care was consulted and the patient ultimately passed away from respiratory failure. . #right sided hemothhorax s/p thoracentesis by IP - CT chest to assess size of hemothorax post tap:complete atelectasis RML and RLL from hemothorax, ground glass opacity in LLL - Thoracic surgery was consulted and felt the patient was not a candidate for pleurodesis. . #pneumonia - Afebrile with cefepime, vanco, and flagyl. . #Mesothelioma(sarcomatoid type)-diagnosed [**4-8**] with recurrent right pleural effusion, underwent bronchoscopy, VATS and decortication iwth residula pleural thickening. Planned to be referred to [**Company 2860**] for chemo vs additional surgery as outpatient. - spoke to oncologist at [**Hospital1 **] - palliative care was consulted and the patient later died of respiratory failure . #AVNRT: Occured likely related to hypoxia prior intubation . . #hyponatremia - likely from SIADH - will not fluid restrict since patient has terminal disease - sent for urine lytes . . #Code status- Pt reports that he is willing to be intubated/recussitated. However, he would never want to be on life support over a few days if there is no hope of recovery.reiterated with family in ICU and confirmed full code. Sister is health care proxy. The patient ultimately understood his very poor prognosis and the patient passed away. . #Communication- Outpt Oncologist: Dr. [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) 61872**] [**Telephone/Fax (1) 61873**] Discharge Disposition: Expired Discharge Diagnosis: Mesothelioma. Discharge Condition: Death [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "253.6", "276.3", "496", "162.8", "305.1", "511.8", "518.0", "427.89", "518.81", "486" ]

icd9cm

[ [ [] ] ]

[ "93.90", "96.04", "34.91", "96.71" ]

icd9pcs

[ [ [] ] ]

7206, 7215

5133, 7183

340, 346

7272, 7416

3284, 5110

2608, 2626

7236, 7251

2641, 3265

281, 302

374, 2080

2102, 2356

2372, 2592

53,683

148,572

38646

Discharge summary

report

Admission Date: [**2112-3-10**] Discharge Date: [**2112-3-16**] Date of Birth: [**2072-12-24**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1390**] Chief Complaint: transferred from outside hospital after being found to have a liver laceration, acute renal failure, and possible colitis s/p fall at home Major Surgical or Invasive Procedure: [**2112-3-11**] 1. Exploratory laparotomy. 2. Near complete small bowel resection. 3. Damage control open abdomen dressing. [**2112-3-11**] 1. Ultrasound-guided puncture of left common femoral artery. 2. Placement of a catheter into the aorta. 3. Abdominal aortogram. 4. Perclose closure of left common femoral arteriotomy. [**2112-3-12**] 1. Exploratory laparotomy. 2. Abdominal washout. 3. Extended right colectomy. 4. 10 cm small bowel resection. [**2112-3-14**] 1. Exploratory laparotomy. 2. Abdominal washout. 3. A 2 cm small bowel resection. 4. Wedge liver biopsy. 5. Gastrostomy tube placement. 6. Primary closure of the anterior abdominal wall. 5. Cholecystectomy. 6. Damage control open abdominal dressing placement. History of Present Illness: 39F transferred from OSH w/ liver laceration after fall at home several days ago. Came to OSH ED on [**3-9**] w/ [**4-14**] d abd pain, n/v/d and [**Month (only) **] po intake. Had brady episode to 20-30 and was admitted to CCU on levo, found to be in acute renal failure (Cr =9, K = 7.6) and received dialysis on [**12-18**]. CT CAP showed multiple hypodensities through R and L lobe along w/ perihepatic fluid/blood as well as L sided colitis. White counts were elevated to ~15 throughout admission and she had gram positive cocci in her blood cultures. Past Medical History: PMH: spinal cord stenosis, cervical radiculopathy, UGIB [**3-15**] gastritis, htn, hx of EtOH abuse (resolved), eczema, arthritis, depression, HLD, Raynaud's Social History: unknown Family History: non-contributory Physical Exam: On admission: 96.9 88 127/76 75 94% 5L NC NAD, uncomfortable in bed OP Clear, NCAT CTAB -cwr RRR -mgr Abd: Firm, +guarding/+rebound. Diffusely tender, no clear areas of discrete pain. Ext: -CCE Pertinent Results: RADIOLOGY: CT torso [**2112-3-11**]: 1. Complete occlusion of the celiac axis and SMA resulting in ischemia to the entire small bowel and the proximal half of the colon. 2. The devascularization also results in no arterial flow to the liver or the spleen. The liver does maintain some blood supply from the portal vein. 3. Complex liver laceration with small subcapsular hematoma but no significant hemoperitoneum. 4. Markedly attenuated renal arteries bilaterally with some residual perfusion of the kidneys but in an abnormal fashion suggestive of early acute cortical necrosis. RUQ U/S [**2112-3-13**]: This is an incomplete study. Two limited Doppler images of the liver were obtained, which demonstrate color flow and appropriate vascular waveforms within the right hepatic vein and middle hepatic veins. This study was then terminated per clinician's request. ECHO [**2112-3-15**]: preserved [**Hospital1 **]-ventricular systolic function. small non-circumferential pericardial effusion with no evidence of tamponade. Large left-sided pleural effusion and moderate right-sided pleural effusion LABS: [**2112-3-16**] 02:06AM BLOOD WBC-47.4* RBC-2.70* Hgb-7.8* Hct-24.7* MCV-92 MCH-29.0 MCHC-31.6 RDW-20.6* Plt Ct-134*# [**2112-3-15**] 01:48AM BLOOD WBC-39.6* RBC-3.39* Hgb-9.7* Hct-30.3* MCV-90 MCH-28.7 MCHC-32.0 RDW-20.6* Plt Ct-50* [**2112-3-14**] 05:18PM BLOOD WBC-38.2* RBC-3.48* Hgb-9.8* Hct-30.3* MCV-87 MCH-28.3 MCHC-32.4 RDW-19.9* Plt Ct-52* [**2112-3-14**] 04:13AM BLOOD WBC-30.4* RBC-3.22* Hgb-9.2* Hct-27.6* MCV-86 MCH-28.7 MCHC-33.4 RDW-19.3* Plt Ct-65* [**2112-3-13**] 10:21PM BLOOD WBC-36.5* RBC-3.36* Hgb-9.8* Hct-28.6* MCV-85 MCH-29.1 MCHC-34.3 RDW-18.8* Plt Ct-63* [**2112-3-13**] 01:48PM BLOOD WBC-35.5* RBC-3.42* Hgb-9.9* Hct-28.6* MCV-84 MCH-28.8 MCHC-34.5 RDW-18.9* Plt Ct-64* [**2112-3-13**] 09:18AM BLOOD WBC-30.9* RBC-3.35* Hgb-9.4* Hct-27.9* MCV-83 MCH-28.1 MCHC-33.8 RDW-19.0* Plt Ct-66* [**2112-3-13**] 05:34AM BLOOD WBC-32.9* RBC-3.39* Hgb-9.7* Hct-28.5* MCV-84 MCH-28.7 MCHC-34.2 RDW-18.2* Plt Ct-77* [**2112-3-13**] 12:01AM BLOOD WBC-30.9* RBC-3.51* Hgb-10.1* Hct-29.5* MCV-84 MCH-28.8 MCHC-34.3 RDW-18.4* Plt Ct-82* [**2112-3-12**] 07:00PM BLOOD WBC-27.0* RBC-3.58* Hgb-10.5* Hct-29.9* MCV-84 MCH-29.2 MCHC-35.0 RDW-18.5* Plt Ct-80* [**2112-3-12**] 08:19AM BLOOD WBC-32.1*# RBC-3.94* Hgb-10.9* Hct-33.1* MCV-84 MCH-27.7 MCHC-32.9 RDW-18.1* Plt Ct-95* [**2112-3-12**] 04:55AM BLOOD WBC-20.9* RBC-3.86*# Hgb-10.7*# Hct-32.4*# MCV-84 MCH-27.7 MCHC-33.0 RDW-17.7* Plt Ct-97*# [**2112-3-12**] 01:45AM BLOOD WBC-23.0* RBC-3.05* Hgb-8.5* Hct-25.8* MCV-85 MCH-27.8 MCHC-32.8 RDW-19.1* Plt Ct-37* [**2112-3-11**] 08:49PM BLOOD WBC-20.7* RBC-3.85* Hgb-10.8* Hct-32.7* MCV-85 MCH-28.0 MCHC-33.0 RDW-18.7* Plt Ct-53* [**2112-3-11**] 04:00PM BLOOD WBC-21.4* RBC-4.03* Hgb-11.4* Hct-34.8* MCV-86 MCH-28.2 MCHC-32.7 RDW-18.8* Plt Ct-55* [**2112-3-11**] 11:30AM BLOOD WBC-29.2* RBC-3.60* Hgb-9.5* Hct-31.3* MCV-87 MCH-26.5* MCHC-30.5* RDW-19.4* Plt Ct-86* [**2112-3-11**] 09:20AM BLOOD Hct-29.8* [**2112-3-11**] 04:12AM BLOOD WBC-23.7* RBC-3.74* Hgb-10.5* Hct-33.8* MCV-90 MCH-28.1 MCHC-31.1 RDW-19.2* Plt Ct-108* [**2112-3-10**] 09:42PM BLOOD WBC-21.9* RBC-3.83* Hgb-10.9* Hct-32.9* MCV-86 MCH-28.4 MCHC-33.0 RDW-19.2* Plt Ct-115* [**2112-3-10**] 09:42PM BLOOD Neuts-83* Bands-11* Lymphs-1* Monos-1* Eos-2 Baso-0 Atyps-0 Metas-1* Myelos-1* NRBC-31* [**2112-3-10**] 09:42PM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-OCCASIONAL Macrocy-1+ Microcy-1+ Polychr-1+ Ovalocy-OCCASIONAL Target-OCCASIONAL [**2112-3-16**] 02:06AM BLOOD Plt Ct-134*# LPlt-3+ [**2112-3-16**] 02:06AM BLOOD PT-16.2* PTT-63.6* INR(PT)-1.4* [**2112-3-15**] 01:48AM BLOOD Plt Smr-VERY LOW Plt Ct-50* [**2112-3-15**] 01:48AM BLOOD PT-12.9 PTT-38.3* INR(PT)-1.1 [**2112-3-14**] 05:18PM BLOOD Plt Smr-VERY LOW Plt Ct-52* LPlt-3+ [**2112-3-14**] 05:18PM BLOOD PT-12.4 PTT-38.2* INR(PT)-1.0 [**2112-3-14**] 04:13AM BLOOD Plt Ct-65* [**2112-3-14**] 04:13AM BLOOD PT-12.9 PTT-40.9* INR(PT)-1.1 [**2112-3-13**] 10:21PM BLOOD Plt Ct-63* LPlt-3+ [**2112-3-13**] 10:21PM BLOOD PT-14.2* PTT-47.4* INR(PT)-1.2* [**2112-3-13**] 01:48PM BLOOD Plt Smr-VERY LOW Plt Ct-64* LPlt-3+ [**2112-3-13**] 01:48PM BLOOD PT-13.2 PTT-49.1* INR(PT)-1.1 [**2112-3-13**] 09:18AM BLOOD Plt Smr-VERY LOW Plt Ct-66* LPlt-2+ [**2112-3-13**] 05:34AM BLOOD Plt Ct-77* [**2112-3-13**] 05:34AM BLOOD PT-14.7* PTT-52.5* INR(PT)-1.3* [**2112-3-13**] 12:01AM BLOOD Plt Smr-LOW Plt Ct-82* [**2112-3-13**] 12:01AM BLOOD PT-15.3* PTT-57.0* INR(PT)-1.3* [**2112-3-12**] 07:00PM BLOOD Plt Ct-80* [**2112-3-12**] 07:00PM BLOOD PT-16.1* PTT-61.0* INR(PT)-1.4* [**2112-3-12**] 08:19AM BLOOD Plt Ct-95* [**2112-3-12**] 08:19AM BLOOD PT-16.3* PTT-59.4* INR(PT)-1.4* [**2112-3-12**] 04:55AM BLOOD Plt Ct-97*# [**2112-3-12**] 01:45AM BLOOD Plt Smr-VERY LOW Plt Ct-37* [**2112-3-12**] 01:45AM BLOOD PT-20.0* PTT-91.4* INR(PT)-1.8* [**2112-3-11**] 08:49PM BLOOD Plt Smr-VERY LOW Plt Ct-53* LPlt-1+ [**2112-3-11**] 08:49PM BLOOD PT-19.2* PTT-82.9* INR(PT)-1.8* [**2112-3-11**] 04:00PM BLOOD Plt Ct-55* [**2112-3-11**] 04:00PM BLOOD PT-20.4* PTT-89.6* INR(PT)-1.9* [**2112-3-11**] 11:30AM BLOOD Plt Smr-LOW Plt Ct-86* [**2112-3-11**] 11:30AM BLOOD PT-19.5* PTT-70.8* INR(PT)-1.8* [**2112-3-11**] 04:12AM BLOOD Plt Smr-LOW Plt Ct-108* [**2112-3-11**] 04:12AM BLOOD PT-17.8* PTT-58.4* INR(PT)-1.6* [**2112-3-10**] 09:42PM BLOOD Plt Smr-LOW Plt Ct-115* LPlt-1+ [**2112-3-10**] 09:42PM BLOOD PT-15.4* PTT-46.6* INR(PT)-1.4* [**2112-3-11**] 04:00PM BLOOD Fibrino-438* [**2112-3-11**] 04:12AM BLOOD Fibrino-550* [**2112-3-11**] 04:00PM BLOOD Ret Man-2.1* [**2112-3-11**] 04:12AM BLOOD Ret Man-2.2* [**2112-3-16**] 12:23PM BLOOD Glucose-89 UreaN-20 Creat-1.4* Na-135 K-4.6 Cl-103 HCO3-19* AnGap-18 [**2112-3-16**] 07:42AM BLOOD Glucose-90 UreaN-18 Creat-1.4* Na-134 K-4.6 Cl-102 HCO3-21* AnGap-16 [**2112-3-16**] 02:06AM BLOOD Glucose-102* UreaN-18 Creat-1.4* Na-136 K-5.2* Cl-105 HCO3-20* AnGap-16 [**2112-3-15**] 07:48PM BLOOD Glucose-94 UreaN-17 Creat-1.4* Na-136 K-5.5* Cl-103 HCO3-16* AnGap-23* [**2112-3-15**] 01:29PM BLOOD Na-135 K-5.7* Cl-103 HCO3-15* AnGap-23* [**2112-3-15**] 07:35AM BLOOD Glucose-119* UreaN-18 Creat-1.2* Na-136 K-5.3* Cl-110* HCO3-18* AnGap-13 [**2112-3-15**] 01:48AM BLOOD Glucose-123* UreaN-17 Creat-1.1 Na-135 K-5.3* Cl-108 HCO3-20* AnGap-12 [**2112-3-14**] 05:18PM BLOOD Glucose-95 UreaN-16 Creat-1.1 Na-135 K-4.8 Cl-106 HCO3-21* AnGap-13 [**2112-3-14**] 04:13AM BLOOD Glucose-105* UreaN-13 Creat-1.0 Na-135 K-3.6 Cl-102 HCO3-26 AnGap-11 [**2112-3-13**] 10:21PM BLOOD Glucose-116* UreaN-14 Creat-1.0 Na-134 K-3.5 Cl-101 HCO3-29 AnGap-8 [**2112-3-13**] 01:48PM BLOOD Glucose-84 UreaN-13 Creat-1.2* Na-135 K-3.7 Cl-102 HCO3-28 AnGap-9 [**2112-3-13**] 09:18AM BLOOD Na-134 K-3.4 [**2112-3-13**] 05:34AM BLOOD Glucose-88 UreaN-16 Creat-1.3* Na-135 K-3.6 Cl-102 HCO3-27 AnGap-10 [**2112-3-13**] 12:01AM BLOOD Glucose-86 UreaN-17 Creat-1.3* Na-135 K-3.7 Cl-102 HCO3-26 AnGap-11 [**2112-3-12**] 07:00PM BLOOD Glucose-87 UreaN-20 Creat-1.6* Na-135 K-3.4 Cl-102 HCO3-25 AnGap-11 [**2112-3-12**] 08:19AM BLOOD Glucose-77 UreaN-23* Creat-1.7* Na-137 K-3.6 Cl-102 HCO3-26 AnGap-13 [**2112-3-12**] 01:45AM BLOOD Glucose-94 UreaN-29* Creat-2.0* Na-137 K-3.6 Cl-103 HCO3-26 AnGap-12 [**2112-3-11**] 08:49PM BLOOD Glucose-110* UreaN-37* Creat-2.6* Na-138 K-3.7 Cl-102 HCO3-25 AnGap-15 [**2112-3-11**] 04:00PM BLOOD Glucose-150* UreaN-46* Creat-3.4* Na-139 K-3.9 Cl-105 HCO3-20* AnGap-18 [**2112-3-11**] 11:30AM BLOOD Glucose-164* UreaN-48* Creat-3.8* Na-136 K-4.2 Cl-95* HCO3-21* AnGap-24 [**2112-3-11**] 04:12AM BLOOD Glucose-81 UreaN-47* Creat-3.8* Na-138 K-5.0 Cl-97 HCO3-13* AnGap-33* [**2112-3-10**] 09:42PM BLOOD Glucose-71 UreaN-41* Creat-3.4* Na-138 K-4.6 Cl-99 HCO3-21* AnGap-23* [**2112-3-16**] 02:06AM BLOOD ALT-627* AST-3139* AlkPhos-360* TotBili-6.7* [**2112-3-15**] 01:48AM BLOOD ALT-228* AST-686* AlkPhos-199* TotBili-5.5* [**2112-3-14**] 05:18PM BLOOD ALT-234* AST-731* AlkPhos-188* TotBili-5.4* [**2112-3-14**] 04:13AM BLOOD ALT-274* AST-973* LD(LDH)-567* AlkPhos-184* TotBili-4.8* [**2112-3-13**] 05:34AM BLOOD ALT-376* AST-1599* AlkPhos-178* Amylase-34 TotBili-4.8* [**2112-3-13**] 12:01AM BLOOD ALT-395* AST-1688* AlkPhos-179* Amylase-34 TotBili-4.9* [**2112-3-12**] 07:00PM BLOOD CK(CPK)-224* [**2112-3-12**] 08:19AM BLOOD ALT-556* AST-2610* AlkPhos-180* TotBili-5.2* [**2112-3-12**] 01:45AM BLOOD ALT-555* AST-2917* AlkPhos-165* TotBili-4.1* [**2112-3-11**] 08:49PM BLOOD ALT-835* AST-4872* LD(LDH)-3040* AlkPhos-215* TotBili-5.1* [**2112-3-11**] 04:00PM BLOOD ALT-900* AST-5570* LD(LDH)-4038* AlkPhos-201* Amylase-58 TotBili-4.5* [**2112-3-11**] 11:30AM BLOOD ALT-919* AST-4974* AlkPhos-223* TotBili-4.2* [**2112-3-11**] 04:12AM BLOOD ALT-872* AST-4744* LD(LDH)-3088* AlkPhos-244* Amylase-54 TotBili-3.8* [**2112-3-10**] 09:42PM BLOOD ALT-926* AST-5569* LD(LDH)-3865* CK(CPK)-946* AlkPhos-228* Amylase-47 TotBili-3.7* DirBili-2.5* IndBili-1.2 [**2112-3-14**] 04:13AM BLOOD Lipase-75* [**2112-3-10**] 09:42PM BLOOD CK-MB-16* MB Indx-1.7 cTropnT-0.01 [**2112-3-16**] 12:23PM BLOOD Calcium-7.7* Phos-5.0* Mg-2.0 [**2112-3-16**] 07:42AM BLOOD Calcium-8.3* Phos-4.7* Mg-2.3 [**2112-3-16**] 02:06AM BLOOD Albumin-1.6* Calcium-8.7 Phos-4.9* Mg-1.8 [**2112-3-15**] 07:48PM BLOOD Calcium-10.1 Phos-5.3* Mg-1.9 [**2112-3-15**] 01:29PM BLOOD Calcium-8.1* Phos-4.5 Mg-2.1 [**2112-3-15**] 07:35AM BLOOD Calcium-7.8* Phos-3.6 Mg-2.0 [**2112-3-15**] 01:48AM BLOOD Calcium-7.9* Phos-3.1 Mg-2.0 [**2112-3-14**] 05:18PM BLOOD Calcium-8.0* Phos-2.9 Mg-1.9 [**2112-3-14**] 04:13AM BLOOD Calcium-7.9* Phos-1.4* Mg-2.0 [**2112-3-13**] 10:21PM BLOOD Calcium-8.1* Phos-1.3* Mg-2.2 [**2112-3-13**] 01:48PM BLOOD Calcium-7.7* Phos-1.3* Mg-1.9 [**2112-3-13**] 09:18AM BLOOD Mg-2.0 [**2112-3-13**] 05:34AM BLOOD Calcium-7.6* Phos-1.4* Mg-2.0 [**2112-3-13**] 12:01AM BLOOD Calcium-7.8* Phos-1.7* Mg-2.3 [**2112-3-12**] 07:00PM BLOOD Calcium-7.9* Phos-1.9* Mg-1.8 [**2112-3-12**] 08:19AM BLOOD Albumin-1.8* Calcium-7.6* Phos-1.8* Mg-2.0 [**2112-3-12**] 01:45AM BLOOD Calcium-6.8* Phos-2.8 Mg-2.4 [**2112-3-11**] 08:49PM BLOOD Albumin-2.0* Calcium-7.7* Phos-3.8# Mg-1.7 [**2112-3-11**] 04:00PM BLOOD Albumin-2.1* Calcium-7.8* Phos-5.5* Mg-1.9 Iron-143 [**2112-3-11**] 11:30AM BLOOD Albumin-2.4* Calcium-7.2* Phos-6.5* Mg-2.0 [**2112-3-11**] 04:12AM BLOOD Albumin-2.9* Calcium-8.2* Phos-7.6*# Mg-2.4 Iron-131 [**2112-3-10**] 09:42PM BLOOD Albumin-3.1* Calcium-7.7* Phos-5.0* Mg-2.1 Iron-126 [**2112-3-11**] 04:00PM BLOOD calTIBC-195* Ferritn-1274* TRF-150* [**2112-3-11**] 04:12AM BLOOD calTIBC-273 Ferritn-402* TRF-210 [**2112-3-10**] 09:42PM BLOOD calTIBC-282 Ferritn-293* TRF-217 [**2112-3-16**] 02:06AM BLOOD Triglyc-105 [**2112-3-12**] 01:45AM BLOOD Ammonia-39 [**2112-3-16**] 07:42AM BLOOD Vanco-20.1* [**2112-3-16**] 02:06AM BLOOD Vanco-25.3* [**2112-3-15**] 07:35AM BLOOD Vanco-21.5* [**2112-3-14**] 06:08AM BLOOD Vanco-8.8* [**2112-3-12**] 08:19AM BLOOD Vanco-18.2 [**2112-3-10**] 09:42PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2112-3-16**] 12:35PM BLOOD Type-ART Temp-36.7 Rates-16/ Tidal V-521 PEEP-12 FiO2-60 pO2-71* pCO2-39 pH-7.34* calTCO2-22 Base XS--4 Intubat-INTUBATED Vent-IMV [**2112-3-16**] 07:58AM BLOOD Type-ART pO2-78* pCO2-37 pH-7.37 calTCO2-22 Base XS--3 [**2112-3-16**] 02:16AM BLOOD Type-ART pO2-108* pCO2-40 pH-7.33* calTCO2-22 Base XS--4 [**2112-3-15**] 10:20PM BLOOD Type-ART pO2-100 pCO2-35 pH-7.29* calTCO2-18* Base XS--8 [**2112-3-15**] 08:50PM BLOOD Type-ART pO2-197* pCO2-35 pH-7.26* calTCO2-16* Base XS--10 [**2112-3-15**] 08:15PM BLOOD Type-ART pO2-47* pCO2-36 pH-7.29* calTCO2-18* Base XS--8 [**2112-3-15**] 04:40PM BLOOD Type-ART Temp-38.3 pO2-75* pCO2-35 pH-7.21* calTCO2-15* Base XS--13 [**2112-3-15**] 01:47PM BLOOD Type-ART pO2-82* pCO2-38 pH-7.21* calTCO2-16* Base XS--12 [**2112-3-15**] 11:48AM BLOOD Type-ART PEEP-10 pO2-66* pCO2-38 pH-7.20* calTCO2-16* Base XS--12 Intubat-INTUBATED Vent-IMV [**2112-3-15**] 07:55AM BLOOD Type-ART pO2-67* pCO2-38 pH-7.28* calTCO2-19* Base XS--7 [**2112-3-15**] 06:31AM BLOOD Type-ART Temp-36.9 Rates-16/ Tidal V-500 PEEP-10 FiO2-50 pO2-97 pCO2-35 pH-7.28* calTCO2-17* Base XS--9 Intubat-INTUBATED [**2112-3-15**] 01:57AM BLOOD Type-ART Temp-36.8 Rates-16/ Tidal V-500 PEEP-10 FiO2-50 pO2-84* pCO2-35 pH-7.32* calTCO2-19* Base XS--7 Intubat-INTUBATED [**2112-3-14**] 08:14PM BLOOD Type-ART Temp-35.9 Rates-16/ Tidal V-500 PEEP-10 FiO2-50 pO2-88 pCO2-36 pH-7.38 calTCO2-22 Base XS--2 -ASSIST/CON Intubat-INTUBATED [**2112-3-14**] 05:28PM BLOOD Type-ART Temp-36.9 Rates-16/ Tidal V-500 PEEP-8 FiO2-50 pO2-76* pCO2-40 pH-7.35 calTCO2-23 Base XS--3 Intubat-INTUBATED Vent-CONTROLLED [**2112-3-14**] 04:01PM BLOOD Type-ART pO2-110* pCO2-42 pH-7.36 calTCO2-25 Base XS--1 [**2112-3-14**] 03:34PM BLOOD Type-ART pO2-101 pCO2-45 pH-7.36 calTCO2-26 Base XS-0 Intubat-INTUBATED [**2112-3-14**] 09:38AM BLOOD Type-ART pO2-88 pCO2-39 pH-7.42 calTCO2-26 Base XS-0 [**2112-3-14**] 04:30AM BLOOD Type-ART pO2-91 pCO2-42 pH-7.44 calTCO2-29 Base XS-3 [**2112-3-13**] 10:30PM BLOOD Type-ART pO2-123* pCO2-45 pH-7.41 calTCO2-30 Base XS-3 [**2112-3-13**] 05:15PM BLOOD Type-ART Temp-36 pO2-100 pCO2-36 pH-7.45 calTCO2-26 Base XS-1 Intubat-INTUBATED [**2112-3-13**] 01:59PM BLOOD Type-ART Temp-36.1 pO2-117* pCO2-29* pH-7.45 calTCO2-21 Base XS--1 Intubat-INTUBATED [**2112-3-13**] 09:33AM BLOOD Type-ART Temp-36.5 Rates-16/ Tidal V-500 PEEP-5 FiO2-60 pO2-105 pCO2-37 pH-7.46* calTCO2-27 Base XS-2 -ASSIST/CON Intubat-INTUBATED [**2112-3-13**] 05:40AM BLOOD Type-ART pO2-141* pCO2-42 pH-7.42 calTCO2-28 Base XS-3 [**2112-3-13**] 12:31AM BLOOD Type-ART pO2-125* pCO2-44 pH-7.42 calTCO2-30 Base XS-4 [**2112-3-12**] 07:06PM BLOOD Type-ART Temp-35.5 Rates-16/ Tidal V-500 PEEP-5 FiO2-60 pO2-103 pCO2-38 pH-7.44 calTCO2-27 Base XS-1 -ASSIST/CON Intubat-INTUBATED [**2112-3-12**] 02:02PM BLOOD Type-ART Temp-36.6 Rates-16/ Tidal V-500 PEEP-5 FiO2-60 pO2-146* pCO2-43 pH-7.41 calTCO2-28 Base XS-2 -ASSIST/CON Intubat-INTUBATED [**2112-3-12**] 08:45AM BLOOD Type-ART Temp-36.5 pO2-154* pCO2-42 pH-7.39 calTCO2-26 Base XS-0 [**2112-3-12**] 05:07AM BLOOD Type-ART pO2-150* pCO2-51* pH-7.33* calTCO2-28 Base XS-0 [**2112-3-12**] 01:47AM BLOOD Type-ART pO2-291* pCO2-47* pH-7.36 calTCO2-28 Base XS-0 [**2112-3-11**] 08:58PM BLOOD Type-ART pO2-261* pCO2-43 pH-7.37 calTCO2-26 Base XS-0 [**2112-3-11**] 04:05PM BLOOD Type-ART pO2-277* pCO2-45 pH-7.28* calTCO2-22 Base XS--5 [**2112-3-11**] 01:26PM BLOOD Type-ART pO2-296* pCO2-39 pH-7.35 calTCO2-22 Base XS--3 Intubat-INTUBATED [**2112-3-11**] 12:17PM BLOOD Type-ART pO2-282* pCO2-48* pH-7.31* calTCO2-25 Base XS--2 [**2112-3-11**] 09:51AM BLOOD pO2-110* pCO2-36 pH-7.22* calTCO2-16* Base XS--12 [**2112-3-11**] 04:29AM BLOOD Type-[**Last Name (un) **] pH-7.18* Comment-GREEN TOP [**2112-3-10**] 10:40PM BLOOD Type-[**Last Name (un) **] pH-7.36 [**2112-3-16**] 12:35PM BLOOD Lactate-4.8* [**2112-3-16**] 07:58AM BLOOD Lactate-4.1* [**2112-3-16**] 02:16AM BLOOD Glucose-96 Lactate-4.5* [**2112-3-15**] 10:20PM BLOOD Lactate-4.9* [**2112-3-15**] 08:50PM BLOOD Glucose-83 [**2112-3-15**] 08:15PM BLOOD Lactate-6.8* [**2112-3-15**] 04:40PM BLOOD Lactate-5.0* K-4.5 [**2112-3-15**] 01:47PM BLOOD Lactate-5.6* [**2112-3-15**] 11:48AM BLOOD Lactate-4.5* [**2112-3-15**] 07:55AM BLOOD Glucose-108* Lactate-3.6* [**2112-3-15**] 06:31AM BLOOD Glucose-97 Lactate-2.7* Na-133* K-4.3 [**2112-3-15**] 01:57AM BLOOD Lactate-2.3* [**2112-3-14**] 08:14PM BLOOD Glucose-111* Lactate-2.4* Na-135 K-4.5 [**2112-3-14**] 05:28PM BLOOD Glucose-91 K-4.8 [**2112-3-14**] 04:01PM BLOOD Glucose-80 Lactate-2.3* Na-132* K-4.4 Cl-104 [**2112-3-14**] 03:34PM BLOOD Glucose-81 Lactate-2.2* Na-131* K-4.5 Cl-103 [**2112-3-14**] 09:38AM BLOOD Glucose-89 K-3.3* [**2112-3-14**] 04:30AM BLOOD Glucose-100 Lactate-2.4* [**2112-3-13**] 10:30PM BLOOD Lactate-2.3* [**2112-3-13**] 05:15PM BLOOD Glucose-69* K-3.7 [**2112-3-13**] 01:59PM BLOOD Glucose-73 Lactate-1.6 [**2112-3-13**] 09:33AM BLOOD Glucose-85 Lactate-1.9 [**2112-3-13**] 05:40AM BLOOD Glucose-81 Lactate-2.0 [**2112-3-13**] 12:31AM BLOOD Glucose-78 Lactate-2.5* [**2112-3-12**] 07:06PM BLOOD Glucose-79 Lactate-2.4* Na-131* K-3.2* [**2112-3-12**] 02:02PM BLOOD Glucose-83 Lactate-2.3* Na-131* K-3.5 [**2112-3-12**] 08:45AM BLOOD Glucose-71 Lactate-2.1* [**2112-3-12**] 05:07AM BLOOD Glucose-85 Lactate-2.4* [**2112-3-12**] 01:47AM BLOOD Lactate-2.5* [**2112-3-11**] 08:58PM BLOOD Lactate-2.2* [**2112-3-11**] 01:26PM BLOOD Glucose-150* Lactate-5.4* Na-134* K-4.0 Cl-99* [**2112-3-11**] 09:51AM BLOOD Lactate-11.4* K-4.6 [**2112-3-11**] 04:29AM BLOOD Lactate-12.1* [**2112-3-10**] 10:40PM BLOOD Lactate-7.0* [**2112-3-14**] 04:01PM BLOOD Hgb-9.7* calcHCT-29 [**2112-3-14**] 03:34PM BLOOD Hgb-10.0* calcHCT-30 [**2112-3-12**] 02:02PM BLOOD Hgb-11.4* calcHCT-34 [**2112-3-11**] 01:26PM BLOOD Hgb-10.8* calcHCT-32 [**2112-3-16**] 12:35PM BLOOD freeCa-1.13 [**2112-3-16**] 07:58AM BLOOD freeCa-1.19 [**2112-3-16**] 02:16AM BLOOD freeCa-1.19 [**2112-3-15**] 08:15PM BLOOD freeCa-1.25 [**2112-3-15**] 04:40PM BLOOD freeCa-0.90* [**2112-3-15**] 01:47PM BLOOD freeCa-0.87* [**2112-3-15**] 07:55AM BLOOD freeCa-1.22 [**2112-3-15**] 06:31AM BLOOD freeCa-1.06* [**2112-3-15**] 01:57AM BLOOD freeCa-1.09* [**2112-3-14**] 08:14PM BLOOD freeCa-1.14 [**2112-3-14**] 05:28PM BLOOD freeCa-1.22 [**2112-3-14**] 04:01PM BLOOD freeCa-1.20 [**2112-3-14**] 03:34PM BLOOD freeCa-1.20 [**2112-3-14**] 09:38AM BLOOD freeCa-1.16 [**2112-3-14**] 04:30AM BLOOD freeCa-1.25 [**2112-3-13**] 10:30PM BLOOD freeCa-1.26 [**2112-3-13**] 05:15PM BLOOD freeCa-1.03* [**2112-3-13**] 01:59PM BLOOD freeCa-1.07* [**2112-3-13**] 09:33AM BLOOD freeCa-1.09* [**2112-3-13**] 05:40AM BLOOD freeCa-1.17 [**2112-3-13**] 12:31AM BLOOD freeCa-1.18 [**2112-3-12**] 07:06PM BLOOD freeCa-1.15 [**2112-3-12**] 02:02PM BLOOD freeCa-1.27 [**2112-3-12**] 08:45AM BLOOD freeCa-1.05* [**2112-3-12**] 05:07AM BLOOD freeCa-1.04* [**2112-3-12**] 01:47AM BLOOD freeCa-1.01* [**2112-3-11**] 08:58PM BLOOD freeCa-1.05* [**2112-3-11**] 01:26PM BLOOD freeCa-0.96* [**2112-3-11**] 09:51AM BLOOD freeCa-1.05* [**2112-3-11**] 04:29AM BLOOD freeCa-1.00* [**2112-3-10**] 10:40PM BLOOD freeCa-0.86* Brief Hospital Course: From the ICU, a repeat CT torso was performed which showed complete occlusion of the celiac axis and SMA resulting in ischemia to the entire small bowel and the proximal half of the colon. The patient was therefore taken to the OR and resection of nearly all of the small bowel was performed. The proximal margin of resection was approximately 20 cm distal to the ligament of Treitz. The distal margin resection was approximately 10cm proximal to the ileocecal valve. The vascular team was consulted for assessment of residual mesenteric blood flow with possibility of preserving viability to the upper GI tract if the celiac artery could be revascularized. However, they found could only see a stump of the superior mesenteric artery and no evidence of distal reconstitution. The celiac artery was not visualized and there was no evidence of flow in the distal branch of the celiac artery. The [**Female First Name (un) 899**] was patent. The patient returned to the OR the next day for a second look and washout. Because they looked non-viable, more of the proximal small bowel was resected (10cm) and an extended R hemicolectomy and cholecystectomy were also performed. Post-operatively, the patient was maintained on pressors. She was started on CVVHD. The transplant team was consulted for consideration of small bowel transplantation. However, this procedure was not performed by the transplant surgeons and the patient's family was referred to other programs that offered adult small bowel transplant. However, after a family meeting in which the patient's prognosis was discussed, it was decided to make the patient CMO. The patient was taken off the ventilator and expired shortly after. Medications on Admission: atenolol 50mg qam and 25mg qpm, biotin 1mg''', clondidine patch 0.5mg qwk, flexeril 5mg'''prn, hctz', lisinopril 40mg', norvasc 10mg', percocet 1-2 tabs q6h prn, protonix 40mg', xanax 0.25mg''prn, zoloft 100mg' Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: grade III liver laceration acute renal failure mesenteric ischemia Discharge Condition: expired Discharge Instructions: none Followup Instructions: none

[ "575.8", "401.9", "864.14", "276.2", "785.52", "E888.9", "584.9", "303.93", "286.7", "E849.0", "995.92", "038.9", "571.0", "511.9", "443.0", "557.0" ]

icd9cm

[ [ [] ] ]

[ "39.95", "88.42", "96.04", "38.95", "54.12", "88.47", "38.91", "51.22", "50.12", "96.72", "45.73", "45.61", "43.19", "38.93" ]

icd9pcs

[ [ [] ] ]

22376, 22385

20383, 22085

454, 1190

22495, 22504

2247, 20360

22557, 22564

1999, 2017

22347, 22353

22406, 22474

22111, 22324

22528, 22534

2032, 2032

276, 416

1218, 1776

2046, 2228

1798, 1958

1974, 1983

51,039

172,813

38463

Discharge summary

report

Admission Date: [**2129-6-5**] Discharge Date: [**2129-6-24**] Date of Birth: [**2077-8-8**] Sex: M Service: CARDIOTHORACIC Allergies: Lipitor Attending:[**First Name3 (LF) 922**] Chief Complaint: Unstable angina Major Surgical or Invasive Procedure: [**2129-6-5**] 1. Emergent coronary artery bypass grafting x4 on intra- aortic balloon pump of the left internal mammary artery to left anterior descending coronary; reverse saphenous vein single graft from aorta to the first diagonal coronary; reverse saphenous vein single graft from aorta to first obtuse marginal coronary; as well as reverse saphenous vein single graft from aorta to posterior descending coronary artery. 2. Endoscopic left greater saphenous vein harvesting. 3. status post percutaneous tracheostomy with #8 Portex/PEG placement on [**2129-6-17**] History of Present Illness: Jaw and right shoulder pain developed at rest [**6-3**] night,resolving after few minutes.Recurrent pain right shoulder yesterday prompting trip to [**Hospital 9464**] Hospital where troponins were positive (8.4). Also new Q waves apparant on ECG. Stuttering pain through last night led to cath today which revealed severe multivessel coronary disease. Past Medical History: fatty liver DM Social History: Occupation:computer tech analyst Tobacco:denies ETOH:social Family History: negative Physical Exam: Pulse: Resp:18 O2 sat: 99 on 4 L B/P Right:80/50 Left:82/50 Height:70" Weight:220# General:WDWN in NAD> c/o [**1-2**] rt shoulder pain Skin: Dry [x] intact []macular rash w/scabs from itching dorsum hands HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur n Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right:2 Left:2 DP Right:2 Left:2 PT [**Name (NI) 167**]:2 Left:2 Radial Right:2 Left:2 Carotid Bruit Right:n Left:n Pertinent Results: [**2129-6-22**] 02:02AM BLOOD WBC-13.2* RBC-3.80* Hgb-10.8* Hct-32.0* MCV-84 MCH-28.4 MCHC-33.7 RDW-14.0 Plt Ct-420 [**2129-6-21**] 02:45AM BLOOD WBC-10.1 RBC-3.94* Hgb-11.2* Hct-32.7* MCV-83 MCH-28.4 MCHC-34.2 RDW-14.1 Plt Ct-373 [**2129-6-22**] 02:02AM BLOOD PT-23.1* PTT-49.1* INR(PT)-2.2* [**2129-6-21**] 02:45AM BLOOD PT-18.4* PTT-57.3* INR(PT)-1.7* [**2129-6-20**] 01:21AM BLOOD PT-16.9* PTT-63.6* INR(PT)-1.5* [**2129-6-19**] 08:09AM BLOOD PT-15.2* PTT-62.9* INR(PT)-1.3* [**2129-6-19**] 02:03AM BLOOD PT-14.9* PTT-63.6* INR(PT)-1.3* [**2129-6-18**] 08:04PM BLOOD PT-13.8* PTT-60.1* INR(PT)-1.2* [**2129-6-22**] 02:02AM BLOOD Glucose-189* UreaN-24* Creat-0.7 Na-137 K-3.8 Cl-95* HCO3-31 AnGap-15 [**2129-6-21**] 02:45AM BLOOD Glucose-194* UreaN-18 Creat-0.7 Na-133 K-3.6 Cl-94* HCO3-30 AnGap-13 [**2129-6-20**] 01:21AM BLOOD Glucose-201* UreaN-15 Creat-0.7 Na-135 K-3.7 Cl-97 HCO3-27 AnGap-15 Left ventricular wall thicknesses and cavity size are normal. There is moderate to severe regional left ventricular systolic dysfunction with near akinesis of the distal half of the left ventricle and inferior wall with an apical aneurysm and a likely 1cm apical thrombus. .The right ventricular cavity is dilated with free wall hypokinesis. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. There is no pericardial effusion. IMPRESSION: Extensive regional left ventricular systolic dysfunction with apical aneurysm and likely apical 1cm mural thrombus. Brief Hospital Course: The patient arrived on a heparin drip and IABP. He had chest pain en route which was relieved with SL NTG. Mr.[**Known lastname **] was consented and taken emergently to the OR, where he [**Known lastname 1834**] emergent CABG x 4 as detailed in Dr.[**Name (NI) 9379**] operative report. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in critical but stable condition requiring milrinone and epinephrine to optimize his cardiac function. Vancomycin was used for surgical antibiotic prophylaxis, given his inpatient preoperative stay of greater than 24 hours. [**Last Name (un) **] was consulted for management of untreated diabetes with a preop HgbA1c of 12. He was extubated on POD# 1, and subsequently demonstrated EtOH withdrawal. CIWA scale was initiated. He developed weakness and lethargy/unresponsiveness on [**6-7**] and was re-intubated. Head CT [**6-8**] revealed embolic shower with a TEE revealing left apical thrombus. An MRI on [**6-9**] confirmed multiple acute infarcts , compatible with embolic phenomena. Heparin drip was initiated. Neurology was consulted. Heme was consulted for hypercoagulable workup. Heme recommended systemic anti-coagulation for [**2-26**] months and did not recommend familial/genetic hypercoagulable workup at this time. Vancomycin and Cefepime were initiated for turbid pericardial fluid/fever/leukocytosis. Cefepime was continued for GNR in the sputum. MRSA grew from sputum as well, likely colonized. Line tip cx revealed coag negative staph. He was extubated again on [**2129-6-11**]. He went into RAF and converted to SR with amio gtt. He remained hemodynamically stable. However, his secretions worsened and on [**6-15**] he required reintubation for airway protection /bronchial hygiene management prior to repeating a Head CT scan. Post procedure he was bronched. Ultimately due to his difficulty with secretion clearance, Mr.[**Known lastname **] [**Last Name (Titles) 1834**] a percutaneous tracheostomy and PEG placement on [**6-17**]. Tube feedings were resumed. He was weaned to trach collar trials and was evaluated for PMV trials, which were deemed inappropriate at this time due to increased secretions vs. trach size too large for trachea per the speech language pathologist. His secretions did somewhat improve and all antibiotics were discontinued as infection was no longer an issue. Mr.[**Known lastname 85599**] anticoagulation was transitioned to Coumadin, for INR goal of [**1-26**] for the LV apical thrombus/Paroxysmal Afib. His INR was therapeutic on day of discharge. His progress remained stable and on POD# 19 Mr.[**Known lastname **] was cleared by Dr.[**Last Name (STitle) 914**] for discharge to [**Hospital3 **] in [**Location (un) **]. All follow up appointments were advised. Medications on Admission: none Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2 times a day). 5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Warfarin 1 mg Tablet Sig: MD to dose Tablet PO DAILY (Daily): PAF/Thromboembolic event, INR goal 2-3.0. 8. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr Transdermal DAILY (Daily). 9. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for aggitation. 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses: *given. 13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Four (4) Puff Inhalation Q6H (every 6 hours). 15. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 16. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 17. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 19. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO DAILY (Daily). 20. Potassium Chloride 20 mEq / 50 ml SW IV PRN K<4.4 and CR<2.0 ** Concentrated KCL must be given via central line only ** 21. Insulin Regular Human 100 unit/mL (3 mL) Insulin Pen Sig: One (1) Subcutaneous every six (6) hours: per SS protocol. 22. Lantus 100 unit/mL Cartridge Sig: As directed Subcutaneous twice a day. 23. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Discharge Disposition: Extended Care Discharge Diagnosis: 1. Acute myocardial infarction refractory to all medical therapy including intra-aortic balloon pump. 2. Cardiomyopathy. 3. Severe 3-vessel coronary disease. 4. Diabetes. 5. Diminished left ventricular function. Ejection fraction of 30%. PMH: DM, fatty liver Discharge Condition: Alert and oriented x [**12-25**] nonfocal Deconditioned right shoulder deficit left lid lag Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: 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**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: Provider: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2129-7-11**] 1:00 Please call to schedule appointments Cardiologist Dr. [**Last Name (STitle) 39975**] in [**2-24**] weeks Neurologist Dr.[**First Name (STitle) **] # [**Telephone/Fax (1) 2574**], appointment arranged for [**Last Name (LF) 2974**], [**7-29**] at 12pm **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:[**2129-6-24**]

[ "453.6", "250.00", "291.0", "423.9", "349.82", "427.31", "453.41", "410.71", "414.01", "414.2", "342.90", "434.11", "425.4", "112.0", "429.79", "303.91" ]

icd9cm

[ [ [] ] ]

[ "39.61", "96.71", "36.15", "96.72", "31.1", "88.72", "36.13", "33.23", "96.07", "39.63", "43.11", "38.93", "38.91", "96.04" ]

icd9pcs

[ [ [] ] ]

8777, 8792

3658, 6487

287, 887

9104, 9297

2142, 3635

9961, 10552

1402, 1413

6542, 8754

8813, 9083

6513, 6519

9321, 9938

1428, 2123

232, 249

915, 1270

1292, 1308

1324, 1386

9,344

116,730

27209

Discharge summary

report

Admission Date: [**2199-5-21**] Discharge Date: [**2199-6-26**] Date of Birth: [**2172-2-15**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: s/p multiple gunshot wounds to chest and back Major Surgical or Invasive Procedure: [**2199-5-21**] Exploratory Laparotomy; Right tube thoracostomy; Distal pancreatectomy; splenectomy; small bowel resection; gastostomy tube; enteroenterostomy; repair left renal laceration; repair transverse colon laceration History of Present Illness: 27-year-old male who sustained a number of gunshot wounds and presented to an area hospital where he was intubated and bilateral chest tubes were placed. He was transferred to [**Hospital1 346**] for definitive management. On arrival, he was hypotensive with a systolic blood pressure in the 70s and tachycardic. He was taken directly to the operating room for exploration of his injuries. Past Medical History: Unknown Social History: Has girlfriend who is expecting Family History: Noncontributory Physical Exam: Upon admission to trauma bay: Intubated/sedated/paralyzed Chest: decreased BS on right; bullet wound on right; supraxyphoid wound Back: wound at right scapula tip; wound lower thoracic spine Cor: tachy Abd: distended GU: + hematuria Extr: right arm deformity; bullet wound visible RUE Pertinent Results: [**2199-5-21**] 07:46PM GLUCOSE-166* UREA N-14 CREAT-1.0 SODIUM-136 POTASSIUM-4.9 CHLORIDE-107 TOTAL CO2-20* ANION GAP-14 [**2199-5-21**] 07:46PM CALCIUM-7.9* PHOSPHATE-4.2 MAGNESIUM-2.0 [**2199-5-21**] 07:46PM WBC-10.5 RBC-3.80* HGB-11.4* HCT-31.5* MCV-83 MCH-30.1 MCHC-36.2* RDW-17.6* [**2199-5-21**] 07:46PM PLT COUNT-170 [**2199-5-21**] 07:46PM PT-12.9 PTT-27.0 INR(PT)-1.1 [**2199-5-21**] 08:58AM ALT(SGPT)-127* AST(SGOT)-149* ALK PHOS-26* AMYLASE-73 TOT BILI-1.9* HUMERUS (AP & LAT) RIGHT [**2199-6-18**] 1:38 PM HUMERUS (AP & LAT) RIGHT; ELBOW (AP, LAT & OBLIQUE) RIGH Reason: ? interval change [**Hospital 93**] MEDICAL CONDITION: 27 year old man with R arm fx s/o ORIF REASON FOR THIS EXAMINATION: ? interval change HISTORY: Status post ORIF, question interval change. RIGHT HUMERUS, TWO VIEWS. RIGHT ELBOW, THREE VIEWS. RIGHT FOREARM, 2 VWS . RIGHT HUMERUS: There is a comminuted fracture of the distal humerus, transfixed by two plates and multiple screws. There is marked comminution. Fracture lines remain visible. No definite hardware loosening is identified. There is callus formation/heterotopic bone formation to some degree between the fractured fragments, but more pronounced in the soft tissues surrounding the humeral fracture. Innumerable small pieces of shrapnel are also present. RIGHT ELBOW: The lateral view is obliqued, limiting assessment for joint effusion. However, there is a probable joint effusion. There is a fracture or osteotomy of the proximal ulna, which is secured by a screw, in overall anatomic alignment. The fracture/osteotomy site remains visible with minimal articular irregularity. I suspect slight widening of the radiocapitellar and ulnar trochlear articulations, but this appearance may be accentuated by the atypical positioning. No hardware loosening is identified. RIGHT FOREARM: Allowing for the proximal humeral fracture/osteotomy site, the right forearm is otherwise within normal limits. PORTABLE ABDOMEN [**2199-6-17**] 3:41 PM PORTABLE ABDOMEN Reason: ? ileus/obstruction [**Hospital 93**] MEDICAL CONDITION: 27M s/p multiple gsw to [**Last Name (un) 103**] s/p PEG recent emesis REASON FOR THIS EXAMINATION: ? ileus/obstruction INDICATION: Multiple gunshot wounds to the abdomen, status post PEG tube, recent emesis. COMPARISON: CT of the abdomen and pelvis from [**2199-6-11**]. FINDINGS: No dilated loops of small or large bowel are identified. Contrast is seen throughout the colon. One left sided abdominal drain is visible. An IVC filter is seen in place. IMPRESSION: No evidence of small or large bowel obstruction. CHEST (PORTABLE AP) [**2199-6-12**] 12:51 PM CHEST (PORTABLE AP) Reason: ? aspiration, pt with emesis trach cuff deflated at time [**Hospital 93**] MEDICAL CONDITION: 27M s/p trach REASON FOR THIS EXAMINATION: ? aspiration, pt with emesis trach cuff deflated at time PORTABLE CHEST AT 1 P.M. ON [**6-12**] INDICATION: Vomiting while tracheostomy cuff deflated. Evaluate for aspiration. FINDINGS: Compared with [**2199-5-31**], the left lung now appears almost completely reexpanded and clear. A pigtail drainage catheter is seen in the left upper quadrant of the abdomen. The right pleural effusion has decreased somewhat, but there is still residual fluid present at the lung base as well as what appears to be fluid loculated in the fissure overlying the right mid lung field. The visualized portions of the right lung appear clear. Position of the tracheostomy tube is unremarkable. IMPRESSION: No large volume aspiration detected. Sinus rhythm, rate 70. The tracing is within normal limits. No previous tracing available for comparison. Read by: [**Last Name (LF) **],[**First Name3 (LF) 1730**] Intervals Axes Rate PR QRS QT/QTc P QRS T 70 162 74 [**Telephone/Fax (2) 66740**] 33 31 \ VIDEO OROPHARYNGEAL SWALLOW [**2199-6-7**] 2:52 PM VIDEO OROPHARYNGEAL SWALLOW Reason: ? aspiration [**Hospital 93**] MEDICAL CONDITION: 27 year old man s/p GSW REASON FOR THIS EXAMINATION: ? aspiration INDICATION: 27-year-old with gunshot wound. Question aspiration. VIDEO-OROPHARYNGEAL FLUOROSCOPIC EXAMINATION. FINDINGS: A video swallow examination was performed under fluoroscopic guidance in collaboration with speech pathology. Barium of varying consistencies including barium mixed with solids, and a barium tablet was administered. There was no evidence of residual, penetration, or aspiration. IMPRESSION: 1. No evidence of penetration or aspiration. US EXTREMITY NONVASCULAR RIGHT [**2199-6-6**] 10:36 AM US EXTREMITY NONVASCULAR RIGHT Reason: assess for RUE collection [**Hospital 93**] MEDICAL CONDITION: 27 year old man s/p gsw to R humerus, s/p ORIF now with erythema at elbow, fever, wbc REASON FOR THIS EXAMINATION: assess for RUE collection ULTRASOUND SCAN OF RIGHT ARM CLINICAL DETAILS: Right upper limb edema post-reduction internal fixation. Evaluation collection FINDINGS: Focused ultrasound over the area of swelling in the lateral right elbow region shows an ovoid heterogenous collection measuring up to 3.2 cm sagittal x 3.2 cm transverse. It is mainly anechoic (cystic) with some lattice-like internal echogenicity. The appearance on ultrasound are most suggestive of a localized postoperative hematoma. Infection cannot be excluded by imaging. CONCLUSION: 1. Small (3.2cm) collection in the right lateral elbow subcutaneous tissues. CT GUIDANCE DRAINAGE [**2199-6-4**] 9:55 AM CT GUIDANCE DRAINAGE; CT GUIDANCE DRAINAGE Reason: CT quided Drainage of peripancreatic fluid collection. [**Hospital 93**] MEDICAL CONDITION: 27 year old man with multiple gun shot wound traumas, s/p partial pancreatectomy currently with fluid collection seen on CT. REASON FOR THIS EXAMINATION: CT quided Drainage of peripancreatic fluid collection. CONTRAINDICATIONS for IV CONTRAST: None. CT GUIDANCE DRAINAGE HISTORY: 27-year-old man with multiple gunshot wound traumas, S/P partial pancreatectomy with multiple intra-abdominal fluid collections. Needs drainage of peripancreatic and upper left quadrant fluid collections. Comparison is made with prior study dated [**2199-6-3**]. ABDOMEN CT WITHOUT CONTRAST: Images obtained throughout the bases of the lungs show bilateral lower lobe consolidations and small bilateral pleural effusions. Left hepatic laceration is unchanged. Adrenal glands, gallbladder, and right kidney are unremarkable. Stable upper pole contusion in the left kidney. Again seen is a fluid collection in the splenic fossa that shows interval increase in size now measuring 5.4 x 13 cm. Again visualized is another fluid collection in the pancreatic tail resection site measuring approximately 70 x 39 mm. Stable collection/hematoma posterior to the left kidney. Gastrostomy tube is seen in the stomach. A surgical drain is seen along the anterior left abdomen. PROCEDURE: The risks and benefits of the procedure were explained to the patient. The patient was prepped and draped in the usual sterile fashion. The patient received conscious sedation during the procedure and local lidocaine 1%. A preprocedure timeout was performed to verify the patient identity. CT fluoroscopy was used to identify the sites over the left lateral upper and mid abdomen for insertion of the needles. After localization of the first collection located in the upper left quadrant and standard technique for cleansing, and local anesthesia infiltrated in the soft tissues, an 18-gauge spinal needle was inserted into the fluid collection under continuous fluoroscopic guidance. With parallel technique, a 10-French pig tail catheter was inserted into the fluid collection and approximately 30 cc of pus were aspirated. Using CT fluoroscopy, the second fluid collection located at the site of the pancreatic tail resection was localized. After cleansing and local anesthesia infiltrated, an 18- gauge spinal needle was inserted into the fluid collection under continuous fluoroscopic guidance. Using parallel technique, a 10-French pigtail catheter was inserted into the fluid collection and approximately 20 cc of pus were aspirated with no complications. IMPRESSION: Satisfactory CT-guided insertion of catheters into two fluid collections in the left upper quadrant and left mid abdomen with no complications. Brief Hospital Course: He was admitted to the Trauma service and taken immediately to the operating room for an exploratory laparotomy and the following: 1. Right chest thoracostomy tube placement. 2. Exploratory laparotomy. 3. Distal pancreatectomy. 4. Splenectomy. 5. Resection of small intestine (25-cm). 6. Enteroenterostomy. 7. Gastrostomy tube placement. 8. Suture repair of left renal laceration. 9. Suture repair of transverse colon laceration. Orthopedic surgery was consulted for his right humerus fracture; he underwent closed reduction for this initially and was later taken to the operating room for an ORIF. He has remained NWB through his RUE since the surgery. He will need to follow up with Orthopedics in 2 weeks. Thoracic surgery was consulted because of the injuries to his chest from the gunshot wound; recommendations to continue with chest tubes to suction. His chest tubes were later discontinued. He was fitted for a TLSO brace which will need to be worn while out of bed. Vascular Surgery was consulted for IVC filter placement; this was placed on [**2199-6-3**]. Infectious Disease was consulted because of persistent fevers; he was already being treated for a pneumonia. He also underwent repeat radiologic scanning of his abdomen, a fluid collection was identified (see Pertinent results CT abdomen); CT guided drainage catheters were placed x2 on [**2199-6-4**]. The output from these drains were monitored closely; he was started on Octreotide on [**6-18**]; the output began to decrease. The Octreotide should be continued for another 7 days then discontinued His first drain was pulled on [**6-22**] and the second was pulled on [**6-26**].The Octreotide should be continued for another 7 days then discontinued. He was also treated for a UTI with Ciprofloxacin; this has been discontinued. Orthopedic Spine Surgery was consulted as well because of his spinal injuries. He was fitted for a TLSO brace. Psychiatry was consulted because of increased episodes of anxiety and depression; he was started on an SSRI; dose increased from Zoloft 25 QD to 50 QD after 5 days. It was recommended that prn Ativan be used for his anxiety. His Zoloft dose should be increased as tolerated per recommendations of Psychiatry. A Speech and Swallow evaluation was also performed. He was changed to a Passy Muir valve and passed his swallow study. He was already receiving tube feedings via his PEG tube; he was given an oral diet in addition to this. His appetite has remained poor; calorie counts were initiated. His tube feedings which were being cycled over 12 hours at night were increased to 16 hours. Physical and Occupational therapy have also worked very closely with him and have recommended spinal cord injury rehab. Medications on Admission: None Discharge Medications: 1. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO BID (2 times a day). 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. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once a day. 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Hold for HR <60 and SBP < 100. 9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 10. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 17. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 18. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 19. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 20. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed for UTI for 7 days. 21. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 22. Octreotide Acetate 100 mcg/mL Solution Sig: One (1) Injection Q8H (every 8 hours). Continue for 7 days. 23. Metoclopramide 5 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours). Discharge Disposition: Extended Care Facility: [**Hospital6 **] - Rehab and SCI Discharge Diagnosis: s/p Multiple Gunshot Wounds to Chest and Back Liver Laceration Left Kidney Laceration Transverse Colon Laceration Bullet Deformity Right Humerus Discharge Condition: Stable Discharge Instructions: Follow up with Orthopedics in 2 weeks. Follow up in Trauma Clinic in 2 weeks. Followup Instructions: Call [**Telephone/Fax (1) 1228**] for an appointment in [**Hospital **] Clinic in 2 weeks. Call [**Telephone/Fax (1) 6439**] for an appointment in Trauma Clinic in 2 weeks. Completed by:[**2199-6-26**]

[ "682.3", "806.39", "567.22", "285.1", "998.59", "958.4", "E922.0", "866.12", "863.93", "518.81", "812.31", "300.4", "863.52", "864.13" ]

icd9cm

[ [ [] ] ]

[ "38.7", "54.91", "52.52", "41.5", "34.04", "31.1", "96.6", "46.75", "79.31", "45.62", "33.23", "55.81", "79.01", "83.02", "79.61", "42.23", "43.19" ]

icd9pcs

[ [ [] ] ]

14527, 14586

9741, 12480

360, 587

14775, 14784

1440, 2059

14912, 15117

1103, 1120

12535, 14504

7025, 7150

14607, 14754

12506, 12512

14808, 14889

1135, 1421

275, 322

7179, 9718

615, 1007

1029, 1038

1054, 1087

13,033

132,307

43044

Discharge summary

report

Admission Date: [**2187-7-11**] Discharge Date: [**2187-7-14**] Date of Birth: [**2148-4-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: hypertensive urgency Major Surgical or Invasive Procedure: HD History of Present Illness: Mr. [**Known lastname **] is a 39 yo man with DM1 c/b ESRD and severe gastroparesis, HTN, CAD s/p STEMI, and multiple line infections who is transferred from [**Hospital3 1196**] with abdominal pain and hypertensive urgency. Patient was transferred to [**Hospital1 **] from [**Hospital1 1501**] yesterday at MN after developing severe abdominal pain, sweating, nausea, and vomiting, which he reported to be typical of his usual exacerbations of gastroparesis. AT [**Location (un) 745**]-Nellesley ER, 193/124, HR 97, T 99.9, RR 20, SpO2 100% on RA. He received 1 amp D50 for hypoglycemia (BG 48), Dilaudid 1 mg IV x4, Ativan 1 mg IV, and Morphine 4 mg IV. Patient requested transfer to [**Hospital1 18**]. Past Medical History: 1. Diabetes Mellitus Type I - Gastroparesis with chronic hospitalizations - ESRD on HD since [**2-/2184**] - Autonomic dysfunction, frequent HTN emergency & orthostatic hypotension - Peripheral neuropathy 2. Coronary artery disease - STEMI [**2186-12-17**] in setting of cocaine, s/p BMS to LAD 3. Aortic valve endocarditis ([**4-21**]) - In the context of coag neg staph bacteremia ([**Month (only) 404**] and [**2187-3-16**]) and positive intravenous catheter tip [**2187-4-6**] had his HD catheter changed over a wire. 4. Hypertension 5. History of line sepsis with coag negative staph [**2187-1-10**], and priors with klebsiella and enterobacteremia 6. Esophageal ulceration: H pylori neg, active esophagitis seen on EGD [**2187-4-18**], h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear 7. History of substance abuse (cocaine, marijuana, alcohol) 9. History of thrombosed AV fistula in LUE [**4-20**], [**Doctor Last Name **]-tex in place 10. multiple line infections (MRSE) and fungemia Social History: Patient has a prior history of tobacco and marijauna use, but he does not currently smoke. He has a prior history of alcohol abuse and has been sober for 9 years. He has a past history of cocaine use. He currently denies illicit drugs. Currently lives with his mother and brothers. Family History: Father deceased of ESRD and DM. Mother aged 50's with hypertension. Two sisters, one with diabetes. Six brothers, one with diabetes. There is no family history of premature coronary artery disease or sudden death. Physical Exam: Vitals: T: 98.2 BP: 162/100 P: 80 R: 12 SaO2: 100% on 2L General: Awake, alert, NAD, pleasant, appropriate, cooperative. HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM, no lesions noted in OP Neck: supple, no significant JVD or carotid bruits appreciated Chest: tunnelled HD catheter with dressing intact on right anterior chest; Lungs CTA bilaterally, no wheezes, ronchi or rales Cardiac: RR, nl S1 S2, [**3-21**] murmur best heard at LUSB, radiates to apex; no rubs or gallops appreciated Abdomen: soft, NT, ND, hypoactive bowel sounds, no masses or organomegaly noted Extremities: PICC in RUE without induration or surrounding erythema; No edema, 2+ radial, DP pulses b/l Lymphatics: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted Skin: no rashes or lesions noted. Neurologic: Alert, oriented x 3. Able to relate history without difficulty. Cranial nerves II-XII intact. Normal bulk, strength and tone throughout. No abnormal movements noted. No deficits to light touch throughout. No nystagmus, dysarthria, intention or action tremor. 2+ biceps, triceps, brachioradialis, patellar reflexes and 2+ ankle jerks bilaterally. Plantar response was flexor bilaterally. Pertinent Results: Labs at discharge: [**2187-7-14**] 05:37AM White Blood Cells 5.0 K/uL 4.0 - 11.0 Red Blood Cells 3.65* m/uL 4.6 - 6.2 Hemoglobin 9.1* g/dL 14.0 - 18.0 Hematocrit 31.7* % 40 - 52 MCV 87 fL 82 - 98 MCH 24.8* pg 27 - 32 MCHC 28.6* % 31 - 35 RDW 19.9* % 10.5 - 15.5 Platelet Count 288 K/uL 150 - 440 [**2187-7-14**] 05:37AM Glucose 77 mg/dL 70 - 105 Urea Nitrogen 31* mg/dL 6 - 20 Creatinine 9.6*# mg/dL 0.5 - 1.2 Sodium 140 mEq/L 133 - 145 Potassium 4.3 mEq/L 3.3 - 5.1 Chloride 97 mEq/L 96 - 108 Bicarbonate 29 mEq/L 22 - 32 Anion Gap 18 mEq/L 8 - 20 Calcium, Total 9.9 mg/dL 8.4 - 10.2 Phosphate 5.2* mg/dL 2.7 - 4.5 Magnesium 1.7 mg/dL 1.6 - 2.6 Iron 22* ug/dL 45 - 160 Iron Binding Capacity, Total 280 ug/dL 260 - 470 Ferritin 151 ng/mL 30 - 400 Transferrin 215 mg/dL 200 - 360 Vancomycin 18.0 ug/mL 10 - 20 Brief Hospital Course: Patient is 39 yo man with DM1 c/b ESRD - on HD - and severe gastroparesis, HTN, CAD s/p STEMI, and multiple line infections who was transferred from NWH on [**7-10**] with abdominal pain and hypertensive urgency. Patient was transferred to NWH from nursing facility on [**7-10**] after developing severe abdominal pain, sweating, N/V, consistent with usual exacerbations of gastroparesis. He requested transfer from NWH to [**Hospital1 18**]. . During his most recent course in the ED and MICU, patient received Dilaudid, Ativan, labetalol, hydralazine, clonidine and Zofran. He was also on a labetalol gtt for a period of time - which was weaned off quickly and changed to regular po regiment. He had been having abdominal pain early through his hospital course, but it responded to Dilaudid. Hospital course by problem: . ** Hypertensive urgency: Initially started Labetalol gtt which was discontinued shortly after arrival to ICU. BP was then subsequently well controlled on home regiment: clonidine TD, labetalol, lisinopril. . ** Nausea/vomiting: Secondary to chronic gastroparesis, slight elevation in alk Phos but remainder of LFTs and lipase WNL. Controlled with IV Ativan, Dilaudid, Reglan, Zofran PRN. Regiment was changed to PO Ativan, Dilaudid, Reglan, Zofran and diet was advanced to regular. . ** [**Street Address(1) **] on HD: Secondary to severe, uncontrolled DM and hypertension. On HD Tues, Thurs, Saturday. Continued calcium acetate, Lanthanum and received IV iron replacement as thought to have iron deficiency anemia. . ** Bacteremia: known MRSE bacteremia for which he completed a course of vancomycin for possible endocarditis on [**5-18**]. On more recent admission, patient grew 2/2 bottles with MSSE and was started on vancomycin per HD protocol. [**Month/Day (4) **] on [**6-27**] was negative for evidence of endocarditis. His HD catheter was resided to a new subcutaneous tunneled catheter within the RIJ during that admission. The HD catheter tip grew MRSE and he was continued on Vanc at HD until end date [**7-16**]. . ** Fungemia: Blood cultures from [**6-26**] grew TRICHOSPORON species, and had finished his 10-day course of Caspofungin prior to admission. Day 1 = [**7-1**] last day [**7-11**]. . ** DM1: Continued Lantus 6 units qHS + Lispro sliding scale. . ** CAD s/p STEMI: Continued ASA, [**Month/Year (2) **], Statin, beta-blocker. . ** Peripheral neuropathy: Continued Neurontin. . ** Anemia: Chronic and secondary to ESRD. Currently at baseline HCT 27-30. Continued EPO with HD. . Medications on Admission: Aspirin 325 mg daily Clopidogrel 75 mg daily Atorvastatin 80 mg daily Labetalol 100 mg tid Lisinopril 20 mg daily, hold on [**Month/Year (2) 2286**] days Clonidine 0.3 mg/24 hr Patch qFriday Metoclopramide 5 mg PO QIDACHS Gabapentin 200 mg Sun, Mon, Wed, Fri Gabapentin 100 mg Tues, Thurs, Sat Pantoprazole 40 mg [**Hospital1 **] Calcium Acetate 667 mg tid with meals Lanthanum 1,000 mg tid with meals Lantus 6 units qhs Insulin Lispro sliding scale Hydromorphone 4 mg q6hrs prn Lorazepam 1-2 mg q6-8hrs prn Caspofungin 50 mg IV daily (start date [**7-1**], end date [**7-14**]) Vancomycin qHD (end date [**7-16**]) Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Insulin Glargine 100 unit/mL Solution Sig: Six (6) units Subcutaneous at bedtime. 4. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 5. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO 3X/WEEK (TU,TH,SA). 7. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO 4X/WEEK ([**Doctor First Name **],MO,WE,FR). 8. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 11. Labetalol 100 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 12. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): please take after hemodialyis on [**Doctor First Name 2286**] days. Disp:*30 Tablet(s)* Refills:*2* 13. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*120 Tablet(s)* Refills:*2* 14. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 15. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 16. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: 1000 (1000) mg Intravenous HD PROTOCOL (HD Protochol) for 2 days: Last day [**2187-7-16**]. Discharge Disposition: Home Discharge Diagnosis: It is very important that you take all of your medications as directed and keep all your follow up appointments. You have been scheduled an appointment as below with the [**Month/Day/Year **] team. It is also very important that you attend this meeting in order to be further considered from transplantation. Please do not miss [**First Name (Titles) **] [**Last Name (Titles) 2286**] appointments. If you develop abdominal pain, nausea or vomiting, chest pain, shortness of breath, facial swelling, pain at the site of your [**Last Name (Titles) 2286**] catheter or any other symptom that concerns you, please proceed to the Emergency Room as soon as possible. Discharge Condition: Patient toleratin po well, BP well controlled, no nausea or vomiting Discharge Instructions: You were admitted with nausea and vomiting. You were treating with anti-nausea and pain medications which controlled your symptoms, and you have been able to eat a regular diet. Followup Instructions: It is very important that you keep the following appointment: Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER - NON BILLING Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2187-7-19**] 9:00 It is also very important that you continue to follow with Dr. [**Last Name (STitle) 1366**] and attend [**Last Name (STitle) 2286**]. Please do not miss [**First Name (Titles) 9278**] [**Last Name (Titles) 85236**]s. Please call to arrange an appointment with your primary care physician within two weeks of discharge. Please call [**Telephone/Fax (1) 250**] to arrange this appointment

[ "536.3", "250.43", "250.63", "V45.1", "285.21", "790.7", "403.91", "414.01", "585.6" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

9618, 9624

4738, 5532

335, 340

10334, 10405

3900, 3900

10633, 11304

2452, 2667

7934, 9595

9645, 10313

7293, 7911

10429, 10610

2682, 3881

275, 297

3919, 4715

5560, 7267

368, 1075

1097, 2136

2152, 2436

49,575

131,536

42478

Discharge summary

report

Admission Date: [**2109-1-19**] Discharge Date: [**2109-1-19**] Date of Birth: [**2039-6-7**] Sex: F Service: NEUROLOGY Allergies: No Allergies/ADRs on File Attending:[**First Name3 (LF) 2569**] Chief Complaint: H/A, R-sided weakness Major Surgical or Invasive Procedure: None History of Present Illness: 69 y/o female on ASA and Plavix for a coronary stent who woke up this morning complaining of headache and then developed right sided weakness. Patient was taken to an outside hospital, CT scan of the head revelaled a 2.5 X5 cm left temporal ICH and diffuse SAH around the circle of [**Location (un) **] and contralateral sylvian fissure. Pt was intubated, and transferred to [**Hospital1 18**], where she was admitted to the ICU. Her family gathered, and decided that the pt should be [**Hospital1 3225**] (based on her previously voiced wishes if this situation were to ever arise). She was terminally extubated with her family at the bedside and was pronounced dead at 7:40pm on [**2109-1-19**]. Past Medical History: HTN,Hyperlipidemia, CAD Social History: lives with her husband of 40 years. She speaks portuguese. No history of smoking, drinking or drug use. Family History: There is no family history of stroke, exessive bleeding, or unexplained death. Physical Exam: EXAM AT THE TIME OF ADMISSION: Gen: WD/WN, comfortable, NAD. HEENT: NCNT Lungs: CTA bilaterally. Cardiac: RRR. Abd: Soft Extrem: Warm and well-perfused. No C/C/E. Neuro: Intubated, unresponsive Cranial Nerves: I: Not tested II:Pupils 3mm and non reactive, No corneals Weak cough. Motor: Extensor posturing with bilateral lower extremities spontaneously,decorticate EXAM AT THE TIME OF DEATH: GEN: pale woman lying in bed not moving HEENT: pupils fixed and dilated, no carotid pulse felt CV: no heartbeat auscultated PULM: no breaths auscultated EXT: cool, no radial pulse felt Pertinent Results: LABS (admission labs and labs at the time of expiration are the same time): [**2109-1-19**] 11:00AM BLOOD WBC-17.6* RBC-4.02* Hgb-13.3 Hct-37.4 MCV-93 MCH-33.1* MCHC-35.6* RDW-12.1 Plt Ct-246 [**2109-1-19**] 11:00AM BLOOD Neuts-70 Bands-12* Lymphs-10* Monos-8 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2109-1-19**] 11:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2109-1-19**] 11:00AM BLOOD Plt Smr-NORMAL Plt Ct-246 [**2109-1-19**] 11:00AM BLOOD Glucose-271* UreaN-18 Creat-0.6 Na-134 K-4.8 Cl-106 HCO3-19* AnGap-14 [**2109-1-19**] 11:00AM BLOOD cTropnT-0.07* [**2109-1-19**] 11:00AM BLOOD Calcium-8.4 Phos-2.7 Mg-2.1 [**2109-1-19**] 11:59AM BLOOD pO2-385* pCO2-39 pH-7.36 calTCO2-23 Base XS--2 -ASSIST/CON Intubat-INTUBATED REPORTS: CTA HEAD [**2109-1-19**]: IMPRESSION: 1. Larger left frontotemporal intraparenchymal hemorrhage with associated vasogenic edema and increased midline shifting deviation towards the right, now measuring up to 12 mm. 2. Narrowing of the left perimesencephalic cistern as described above. 3. Diffuse subarachnoid hemorrhage overlying the cerebral hemispheres and intraventricular system. 4. Lobulated saccular formation identified in the bifurcation of the left middle cerebral artery at the M1-M2 segment, measuring approximately 6 x 9 mm in size. 5. There is an infundibulum the right PCOM insertion in the right internal carotid artery. 6. There is a small outpouching at the left extracranial internal carotid artery at the level of C2 superior endplate, possibly representing a small aneurysm versus possible vascular tortuosity. No flow-stenotic lesions are identified. Brief Hospital Course: [**Known firstname 91945**] [**Known lastname **] was admitted to the hospital at 5:12pm on [**2109-1-19**] to the ICU for her IPH. Given her poor prognosis, her family gathered and decided to make her [**Date Range 3225**]. She was terminally extubated and died with her family at the bedside at 7:40pm on [**2109-1-19**]. Her family declined an autopsy, as did the medical examiner. Medications on Admission: Lisinopril 5mg QD Metoprolol 50 mg TID Plavix 5mg QD Discharge Medications: N/A pt expired. Discharge Disposition: Expired Discharge Diagnosis: Intraparenchymal hemorrhage Discharge Condition: Please see discharge summary for full exam at time of death. Pt pronounced dead at 7:40pm on [**2109-1-19**]. Family at the bedside. Discharge Instructions: N/A pt expired on [**2109-1-19**] at 7:40pm after being admitted for an IPH. Her family decided to make the pt [**Name (NI) 3225**] and terminally extubate her shortly after her arrival in the ICU. Followup Instructions: N/A, pt expired. [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

[ "V45.82", "348.5", "431", "272.4", "401.9", "V58.69", "V58.66" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

4156, 4165

3624, 4012

308, 315

4237, 4374

1933, 3601

4621, 4752

1235, 1316

4116, 4133

4186, 4216

4038, 4093

4398, 4598

1331, 1527

247, 270

343, 1046

1543, 1914

1068, 1094

1110, 1219

26,492

125,102

25270

Discharge summary

report

Admission Date: [**2166-11-20**] Discharge Date: [**2167-4-15**] Date of Birth: [**2112-1-3**] Sex: F Service: SURGERY Allergies: Iodine; Iodine Containing / Heparin Agents Attending:[**First Name3 (LF) 371**] Chief Complaint: 54 F s/p MVC w/ multi-trauma Major Surgical or Invasive Procedure: [**2166-11-20**] -Laparoscopic gastrostomy tube placement. [**2166-11-20**] -Closed reduction of splinting of left distal radius and ulna fracture. -Irrigation debridement, extensive of left supracondylar femur fracture. -Irrigation debridement, extensive to bone of left Schatzker 6 tibial plateau fracture. -Closed reduction application external fixator left supracondylar femur fracture. -Closed reduction application external fixator left Schatzker 6 tibial plateau fracture -Closed reduction left metacarpal fractures and CMC joint. [**2166-11-24**] -Removal of external fixation left lower extremity. -Irrigation and debridement down to bone open left femur fracture. -Irrigation and debridement down to bone open left tibia fracture. -Open reduction and internal fixation left femur with [**Last Name (un) 101**] plate, 13 hole. -Open reduction and internal fixation tibia with [**Last Name (un) 101**] plate. -Open reduction and internal fixation right distal radius. -Open reduction and internal fixation right distal ulna. -Open reduction and internal fixation left fourth, fifth and third metacarpocarpal dislocations. [**2166-11-25**] IVC filter placement. Left femoral thrombectomy and bovine patch angioplasty/intraoperative angiogram. [**2166-12-12**] Removal of femoral bovine patch and replacement with saphenous vein patch after artery debridement. Left lower extremity angiography. [**2166-12-23**] Evacuation of left groin hematoma, debridement of subcutaneous tissue and placement of a VAC dressing. [**2166-12-26**] 1. Debridement of necrotic wounds of left abdomen, groin and thigh. 2. Debridement of right wrist wound. [**2167-1-14**]: 1. Irrigation and debridement down to bone of open wounds. 2. Removal of fixation hardware, radial and ulnar plates. 3. Placement of expanding external fixator, right wrist. [**2167-1-21**]: Irrigation, debridement and part layered closure as well as VAC change to wounds of right arm and left abdomen and leg. [**2167-1-25**]: Exploration of left groin wound, evacuation of clot. Examination and then repacking of left groin wound. [**2167-2-11**]: Irrigation and debridement of left knee wound. [**2167-2-24**]: 1. Incision and drainage of left knee wound with exploration of left knee joint. 2. Removal of implant, left knee. 3. Removal of external fixator, right wrist. [**2167-3-2**]: 1. Irrigation and debridement left wound dehiscence down to bone with removal of necrotic bone areas. 2. Removal of hardware from distal femur and proximal tibia in the form of 3.5 mm screws and locking screws. [**2167-3-6**]: Irrigation and debridement and replacement of vacuum dressing. [**2167-3-11**]: 1. Irrigation and debridement, left wound. 2. Removal of femoral [**Last Name (un) 101**] plate. 3. Placement of external fixator. 4. Placement of vacuum dressing. [**2167-3-20**]: 1. Irrigation and debridement left leg (irrigation and debridement of skin, muscle and bone). 2. Adjustment of external fixator left leg. [**2167-3-30**] 1. Irrigation and debridement left leg (irrigation and debridement of skin, muscle and bone). History of Present Illness: Ms. [**Known lastname **] is an unfortunate woman who was involved in a high-energy MVC. She was an unrestrained driver who drove head-on into a tractor [**Last Name (un) 28523**] at high speed (50-55mph). Her immediate injuries included: -aortic transection -Left distal femur fracture -left ischial fracture -right distal radius/ulna fracture -left metacarpal fractures -open left tib/fib fracture. Past Medical History: DM2, CAD w/ + stress test, obesity Social History: Lives alone. Physical Exam: Pt was medflighted from [**Location (un) 3844**] and was intubated and sedated on arrival. Pertinent Results: [**2166-11-20**] 06:55PM FIBRINOGE-244 [**2166-11-20**] 06:55PM PT-12.7 PTT-23.4 INR(PT)-1.1 [**2166-11-20**] 06:55PM PLT COUNT-286 [**2166-11-20**] 06:55PM WBC-17.3* RBC-4.27 HGB-13.0 HCT-37.1 MCV-87 MCH-30.4 MCHC-35.0 RDW-13.9 [**2166-11-20**] 06:55PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2166-11-20**] 06:55PM AMYLASE-45 [**2166-11-20**] 06:55PM UREA N-27* CREAT-1.2* [**2166-11-20**] 06:58PM GLUCOSE-481* LACTATE-3.5* NA+-138 K+-4.2 CL--101 TCO2-24 [**2166-11-20**] 06:58PM GLUCOSE-481* LACTATE-3.5* NA+-138 K+-4.2 CL--101 TCO2-24 [**2166-11-20**] 07:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2166-11-20**] 07:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.035 Brief Hospital Course: This is the discharge summary of a patient who expired under the care of the Trauma Service after a prolonged hospitalization for multiple severe injuries. On [**2166-11-20**] she was a restrained driver in a head-on [**Last Name (un) 8886**] between her car and a tractor-[**Last Name (un) 28523**]. After a prolonged extrication she was transferred to the [**Hospital1 18**] where she was found to have the following injuries: -thoracic aortic tear at the level of the proximal descending aorta -R [**9-20**] rib fracture -L ischium fracture -R distal radius & distal ulna fractures -L 4th metacarpal fracture -L femur fracture -L open tibia/fibula fractures She had multiple surgical procedures throughout her hospital stay. These included: [**11-20**]: endovascular stent placed in thoracic aorta. ex-fix L femur/L tibia, CRPP L metacarpal. closed reduction/splint R radius/ulna [**11-24**]: [**Last Name (un) 101**] plate L tibia, [**Last Name (un) 101**] plate L femur, ORIF R distal radius/ distal ulna, CRPP R MC fx's, R volar orthoplast, L ulnar gutter orthoplast. [**11-25**]: IVC filter [**11-26**]: iliac artery stented. L femoral embolectomy and bovine patch angioplasty [**11-28**]: open trach. No PEG [**2-12**] body habitus. [**12-12**]: removal of femoral bovine patch and replacement with saphenous vein patch [**12-23**]: I&D L knee and primary closure, I&D R wrist [**12-26**]: I&D L abdomen/groin and R wrist [**1-14**]: I&D L groin, [**Last Name (un) **] and exfix of R wrist [**1-21**]: partial closure L groin. I&D R wrist. Washout L knee. [**1-24**]: exploration L groin wound & evacuation of clot. [**Date range (1) 63248**]: multiple washouts L knee, with ultimate removal of all hardware and placement of a spanning external fixator, VAC placement. Her hospital course was complicated by the following events: -SEPTIS/PNEUMONIA: Multiple episodes of enterococcal bactermia and pseudomonal pneumoniam treated with appropriate antibiotics and resolved. -HIT+ --found on [**12-2**]. --Received 9 week course of lepirudin gtt anticoagulation. --Maintained on fondaparinux prophylaxis afterwards. -POSTERIOR CIRCULATION CVA --found on [**12-15**] --neurology consulted, no intervention performed other than continued anti-coagulation. -RISING DIRECT BILIRUBIN. --[**12-4**]: hepatology consulted --us dopplers: patent vessels, hyperechogenic liver --[**12-6**]: CT & RUQ US showed no dilated ducts, s/p choly, no abscesses --ERCP? --[**12-7**] GI consulted. Poor ERCP candidate, likely cholestatic from drug rxn. --Resolved. -ATRIAL FIBRILLATION. --early in hospital course had rapid AF --> cardioversion --> bradycardic arrest --> atropine --[**2-15**] transferred to SICU for rapid AF with resulting hypotension. Chemically cardioverted with Amiodarone, transferred back to floor. She was maintained on amiodarone and instructed to follow-up with cardiology as an outpatient. -L KNEE WOUND INFECTION: her left knee wound had prolonged drainage and multiple I+D's after the original ORIF on [**2166-11-24**]. The organisms found on multiple wound cultures were pseudomonas (ceftazadime sensitive) and MRSA. She had multiple courses of antibiotics and VAC dressing changes to treat these infections. Eventually all hardware was removed and she was placed back in a spanning external fixator ([**2167-3-11**]). VAC dressing treatment was continued. -R WRIST WOUND DEHISCENCE: The patient's R wrist wound dehisced after her original ORIF. The hardware was removed for concern of infection (though all intra-op cultures were negative) and an external fixator was placed. This was later removed on [**2167-2-24**]. The wound was treated with prolonged VAC dressing. -L GROIN WOUND-- During her original stent grafting of her thoracic aorta, she sustained an injury to her left femoral artery during access, which led to thrombosis. This required thrombectomy and stenting in the cardiac catheterization laboratory. Ultimately she also required a thrombectomy and a bovine patch repair of her left femoral artery, but unfortunately this became infected and was replaced with a vein patch (for details see above and dictated operative notes). The soft tissue over the patient's left groin eventually became necrotic due to her morbid obesity and her tenous cardiovascular status when she presented. She underwent multiple debridements and VAC placements. Femoral vessels were never exposed. She was brought to the operating room once on [**2167-1-25**] for concern of increased bleeding around the VAC, but the femoral vessels were intact and no source of vigorous bleeding was identified. She was maintained on bleeding precautions and her VAC dressing outputs were monitored carefully throughout her course. This wound has been stable and treated with a VAC since exploration on [**2167-1-25**]. -PROLONGED ICU COURSE: A tracheostomy ([**2166-11-28**]) and laparoscopic G-tube ([**2167-12-15**]) were placed. She was maintained on tube feeds and followed by the nutritional service. Ms. [**Known lastname **] continued to require frequent wound care and washouts of her left leg wound. On [**2167-3-31**] she became acutely confused, bradycardic, hypotensive and hypothermic and required transfer to the ICU. She required broad spectrum antibiotics, mechanical ventillation and pressor support. At the time of her admission to the ICU, her left leg grew pseudomonas, VRE, and enterococcus. After more than a week reequiring norepinephrine for blood pressure support, amputation of the left leg was discussed. Ms. [**Known lastname **] had very explicit advanced directives against this very procedure. After many discussions with her healthcare proxy, it was determined that Ms. [**Known lastname **] would not want amputation even if it meant that it would save her life. On [**2167-4-15**] she still required norepinephrine and was making no clinical improvement. She was made CMO by her healthcare proxy. Medications on Admission: Insulin, ASA. Discharge Disposition: Expired Discharge Diagnosis: -Thoracic aorta tear, s/p stent graft. -Left groin pseudoaneurysm and infected bovine patch angioplasty. -Left Grade III open Schatzker 6 tibial plateau fracture--> VAC. -Left Grade III open supracondylar femur fracture--> VAC. -Right distal radius ulnar fracture, w/ wound dehiscence--> VAC. -Left fourth, third and fifth metacarpocarpal dislocations in the hand. -Non-healing necrotic left groin wounds--> VAC. -DM2 -atrial fibrillation -prolonged ventilator dependence s/p tracheostomy -prolonged poor nutrition s/p g-tube placement Discharge Condition: expired Discharge Instructions: none Followup Instructions: none

[ "V45.01", "901.0", "482.1", "996.67", "038.9", "427.31", "707.07", "958.4", "998.31", "E812.0", "823.10", "682.6", "996.62", "E934.2", "903.1", "278.01", "815.00", "813.44", "821.33", "998.11", "008.45", "250.00", "287.4", "401.9", "444.22", "997.02", "112.5", "808.42", "518.5", "995.92", "997.2", "807.02" ]

icd9cm

[ [ [] ] ]

[ "77.63", "78.17", "80.13", "38.93", "39.73", "79.65", "79.36", "38.7", "43.19", "39.90", "39.50", "78.15", "80.16", "84.72", "79.35", "31.1", "79.33", "39.49", "00.14", "83.39", "93.59", "39.56", "86.22", "54.0", "78.63", "79.66", "78.65", "79.32" ]

icd9pcs

[ [ [] ] ]

10948, 10957

4934, 10884

330, 3448

11537, 11546

4093, 4911

11599, 11606

10978, 11516

10910, 10925

11570, 11576

3981, 4074

262, 292

3476, 3878

3900, 3936

3952, 3966

21,675

165,623

13361

Discharge summary

report

Admission Date: [**2124-9-16**] Discharge Date: [**2124-9-17**] Date of Birth: [**2049-12-20**] Sex: F Service: CHIEF COMPLAINT: Decreased p.o. intake, hypoxia and arrhythmia. HISTORY OF PRESENT ILLNESS: This is a 77 year old female with a complex past medical history including nonsmall cell lung cancer, status post right middle lobe and right lower lobe resection, post debulking and recurrent pseudomonas pneumonia, right lung pseudomonas abscess and chronic respiratory failure, status post tracheostomy. The patient has been at [**Hospital1 1319**] for three months and was referred after two days of decreased p.o. intake and decreased baseline oxygen saturations, went from FIO2 of 20% to 35% and question of brady-arrhythmia with junctional rhythm and need for temporary pacemaker placement. Recent history is significant for pseudomonas pneumonia about five weeks ago, treated with three antibiotics, Gentamicin, Vancomycin and another antibiotic which is not clear. This was complicated by Clostridium c difficile infection as well as acute renal failure with creatinine of 3.2. Her pneumonia resolved, Clostridium difficile was refractory to Flagyl and changed to p.o. Vancomycin. The patient was maintained on tracheostomy mask, weaning trial since three weeks, baseline settings, pressure support of 12 and 5, FIO2 .21, respiratory rate 14 and title volumes of 360 to 500. The patient tolerated this quite well and went from 1 to 2 hours to six hours in the past week on tracheostomy mask. During weaning trial a question on prophylactic antibiotics, this week also with urinary tract infection but interim antibiotics. Also started Prednisone for pseudogout. Per the daughter, patient this week with increased lethargy, decreased p.o. intake, bilious emesis, and a headache. The patient also had intermittent chest tightness and dyspnea. On the day of admission the patient was having her usual six hour weaning trial and desated to 88% on FIO2 of 21% and then increased to 100% on .35 FIO2. Heartrate decreased to the 40s and there was a question of a junctional rhythm. Hence, the patient was referred to [**Hospital6 256**]. At the [**Hospital6 256**] the patient's high blood pressure was 15/72, pulse 69, temperature 97.9, she was sating at 100% with an FIO2 of 0.5%, arterial blood gases of 7.38, 50 and 322. She was given Ativan 1 mg times one and Morphine Sulfate. In Medicine Intensive Care Unit the patient was maintained on pressure support of 15 and 5 FIO2, 0.4 and had a volume of 450. PAST MEDICAL HISTORY: Significant for chronic obstructive pulmonary disease, nonsmall cell lung cancer, status post right middle lobe and right lower lobe resection, history of melanoma in the past. The patient's pathology of the nonsmall cell lung cancer, consistent with adenomatous features. Lymph nods were all negative. History of recurrent pneumonia including pseudomonas. History of respiratory failure and chronic tracheostomy. Multiple right lung pseudomonas abscesses, status post multiple chest tube drains, multiple rib resections, perioperative atrial fibrillation resolved in Amiodarone, chronic asthmatic bronchitis, hypertension, diverticulitis status post sigmoid resection in [**2092**], history of BCA, patient is status post radiation therapy as well as chemotherapy, status post bilateral axillary node dissection in [**2116**] and [**2118**], severe osteoarthritis. Status post cholecystectomy, appendectomy, total abdominal hysterectomy, history of anxiety and depression, functional dependency, history of urinary tract infection and urosepsis and melanoma. History of pseudogout and Methicillin-sensitive resistant Staphylococcus aureus. ALLERGIES: Levaquin causes a rash, Bactrim causes a rash, Codeine causes nausea and intravenous dye as well as shellfish. SOCIAL HISTORY: No ethyl alcohol, no intravenous drug use, positive tobacco use for 60 years, quit in [**2113**]. Married. Has lived in the [**Location (un) 3844**] area. FAMILY HISTORY: Significant for coronary artery disease, hypertension, diabetes, cancer and hemochromatosis. MEDICATIONS ON ADMISSION: Zofran 4 mg intravenously q.i.d. prn; Prednisone 20 mg one p.o. q. day; Maxzide 400 mg b.i.d.; Loperamide 2 mg b.i.d. prn; Propoxyphene 1 mg one prn; Nitroglycerin q. 6 hours prn; Protonix 40 mg one p.o. q. day; Clonazepam 0.5 mg one p.o. b.i.d.; sodium bicarbonate 20 mEq one p.o. q. day; Ranitidine 150 mg one p.o. q.h.s.; Colace 10 mg p.o. prn; Sorbitol 30 mg q.h.s.; Simethicone 80 mg one p.o. q.i.d. prn; Montelukast 10 mg one p.o. q. day; Bupropion b.i.d.; Densitron 4 mg p.o. q.i.d.; Tylenol prn; Wellbutrin prn; Atrovent 3 puffs q.i.d.; Flovent 220 mcg two puffs b.i.d.; Salmeterol 2 puffs b.i.d.; Multivitamin; Reglan 10 mg one p.o. q.i.d.; Atenolol 25 mg one p.o. b.i.d. PHYSICAL EXAMINATION: In the Emergency Room the patient was generally ill-appearing, sedated but appeared comfortable. Head, eyes, ears, nose and throat, pupils equal, round and reactive to light. Oropharynx was clear, moist mucous membranes. Chest, left lung clear to auscultation. Right distant rhoncherous breathsounds. Chest wall after rib resection, site is clean dry and intact with no drainage. Cardiovascular, regular rate and rhythm, normal S1, normal S2, no murmurs. Abdomen is soft, normoactive bowel sounds, nontender, nondistended. Extremities, PICC line site is clean, dry and intact in the left upper extremity. There is no cyanosis, clubbing or edema. 1+ pedal edema bilaterally. Neurological, alert and oriented times three. The patient was too sedated to comply with neurological examination but moved all extremities spontaneously. Skin: Right upper chest wound, no erythema, no drainage. LABORATORY DATA: The patient's data revealed white count 22.1, hematocrit 30.4, platelet count 672, neutrophils 88, lymphocytes 5.4, monocytes 5.8, eosinophils 0.6. Arterial blood gases 7.3, 850 and 229. Sodium 136, potassium 4.6, chloride 98, bicarbonate 25, BUN 24, creatinine 1.9, glucose 138. Creatinine kinase is 187, troponin 0.04, ALT 63, AST 29, LD is 214, albumin 4.1, alkaline phosphatase 178, total bilirubin 0.2, amylase 26, lipase 15. Chest x-ray, post surgical changes in the right upper lobe area, status post right lower lobe and right middle lobe resection and mediastinal shift. No pneumothorax. Questionable of interstitial markings increased bilaterally. Positive right small effusion, no infiltrates. Electrocardiogram, normal sinus rhythm at 68 beats/minute normal axis. Early repolarization. HOSPITAL COURSE: The patient was maintained on FiO2 of 0.40 and positive end-expiratory pressure of 5 and pressure support of 12. On the second day the patient was on her baseline of 0.21% FIO2 sating very well on this. Otherwise the patient was maintained on Albuterol, Atrovent, Flovent, Salmeterol with good response. Cardiac - Throughout her admission in the hospital, the pt remained in normal sinus rhythm. She ruled out for an myocardial infarction. A repeat electrocardiogram revealed the patient was in sinus rhythm. Otherwise an electrophysiology consult was obtained and the electrophysiology cardiology team felt that pacemaker placement was currently not indicated as the patient was in sinus rhythm with no evidence of syncope, hypertension or other symptoms. Infectious disease - The patient has a history of recurrent pseudomonas pneumonia, Clostridium difficile, Methicillin-sensitive resistant Staphylococcus aureus and urinary tract infection. Her count was elevated on admission but then normalized to 14 on the second day. It was felt most likely secondary to steroid response as there was no other systemic signs of infection. The patient was pancultured with blood cultures, sputum cultures, urine cultures and a repeat chest x-ray was also performed which revealed interval improvement of her prior chest examination. The patient was maintained on aspiration precautions. On day #2, the sputum gram stain revealed gram negative rods and final sputum culture was pending. This was probably consistent with colonization for pseudomonas. Renal insufficiency - Acute versus chronic. It was noted that the patient's creatinine was improving with hydration. Creatinines fell from 1.8 to 1.7. Recent nausea, vomiting and diarrhea - Clostridium difficile was checked times three. The patient was also maintained on Reglan. No antibiotics given that there was no focal sign of infection. On day #2 of hospitalization the patient remained free of any nausea, vomiting or diarrhea. Her stool cultures remained pending at that time. Fluids, electrolytes and nutrition - The patient was maintained on intravenous fluids and was started on tube feeds. Her electrolytes were replaced and the patient tolerated tube feeds well. The patient has a left PICC Line which is midline and three weeks old. It appears clean, dry and intact. DISPOSITION: Back to [**Hospital 1319**] Hospital. The team here has communicated with the medicine team there and they are willing to accept the patient given that her reason for admission has resolved. FOLLOW UP: The patient is to set up a follow up appointment with her primary care physician within one weeks time. DISCHARGE MEDICATIONS: Zofran 4 mg intravenously q.i.d. prn Prednisone 20 mg one p.o. q. day Maxzide 400 mg p.o. t.i.d. Protonix 40 mg one p.o. q. day Clonazepam 0.5 mg one p.o. b.i.d. Ranitidine 150 mg one p.o. q.h.s. Lorazepam 0.5 mg one p.o. prn Albuterol nebulizers prn Atrovent nebulizers prn Flovent 220 mcg one puff b.i.d. Salmeterol 2 puffs b.i.d. Atenolol 25 mg one p.o. b.i.d. DISCHARGE STATUS: Stable. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-948 Dictated By:[**Last Name (NamePattern1) 5843**] MEDQUIST36 D: [**2124-9-17**] 17:52 T: [**2124-9-17**] 18:13 JOB#: [**Job Number 40615**]

[ "V10.3", "518.84", "496", "V46.1", "427.89", "593.9", "V10.11", "427.31", "274.9" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

4041, 4135

9302, 9927

4162, 4844

6609, 9162

9174, 9279

4867, 6591

150, 198

227, 2554

2577, 3850

3867, 4024

28,808

131,259

13020

Discharge summary

report

Admission Date: [**2138-3-9**] Discharge Date: [**2138-4-1**] Date of Birth: [**2077-10-31**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1493**] Chief Complaint: Delerium, hepatitis, concern for biliary obstruction Major Surgical or Invasive Procedure: Endoscopic Retrograde Cholangiopancreatography (ERCP) with sphincterotomy; intubation with successful extubation; Esophagogastroduodenoscopy History of Present Illness: Mr [**Known lastname 39868**] is a 60 year-old man with history of active alcohol abuse, previously normal mental status, who was admitted to [**Hospital 6451**] Hospital on [**2138-2-22**] with 4 day h/o hematemasis and black/tarry stools found to have Hct of 13.5 on admission, EGD showed [**Doctor First Name 329**] [**Doctor Last Name **] tear which was actively bleeding and was clipped. EGD was otherwise unremarkable no varices were seen in esophagus or stomach. He was transfused 6 units PRBC. His course was complicated by an [**Doctor Last Name 7792**] in the setting of his anemia, and this was managed medically with beta blockade. In addition, he developed SVT with respiratory distress, pulmonary edema on CXR, and was reportedly electively intubated and started on an amiodarone gtt and diuresed. During this episode, he was also transiently hypotensive requiring vasopressors (first dopamine, then phenylephrine) which were weaned off after an unclear duration. Following extubation, the patient was noted to be markedly delirious with disorientation and agitation; per his wife. During his admission at [**Hospital3 **], he was noted to have new jaundice with worsening bilirubinemia/transminitis; a RUQ ultrasound on [**2138-2-27**] showed a distended gallbladder with sludge, mild GB wall thickening, small amounts of pericholecystic fluid, and a mildly prominent CBD. A percutaneous cholecystostomy tube was inserted on [**2138-2-28**] out of concern for cholecystitis. A followup ultrasound showed an increasing amount of abdominal ascites and continued evidence of acalculous cholecystitis (as well as echogenic liver texture with fatty infiltration) and he was transferred to [**Hospital1 18**] on [**2138-3-9**] for ERCP. Past Medical History: - alcohol abuse with reported history of delirium tremens (circumstances unclear) - CAD with [**Name (NI) 7792**] in [**2123**], then two others; denies stenting but says he had a 'balloon' procedure - HTN (stopped medications in [**2123**]) - Hyperlipidemia (stopped medications in [**2123**]) - H/o tobacco abuse (quit [**2123**]) Social History: Alcohol abuse, drank 1 pint with 2-3 beers daily since [**2121**]; prior to that drank about half as much. Quit [**2123**], (+) Tobacco use 3 ppd x 25 years. Without h/o of IVDU. Previously stocked shelves. Lives with wife, [**Name (NI) **], in [**Name (NI) 39869**]. One daughter. Family History: CAD Physical Exam: T 99 BP 114/82 HR 92 RR 18 Sat 100% RA General: awake, alert, talkative, no acute distress HEENT: pale sclera, PERRL, mildly jaundiced CV: slightly tachycardic but regular, no murmur appreciated Lungs: clear anteriorly ABD: abdomen distended but soft, BS +, not TTP; dull to percussion approximately [**1-15**] from bed; (+) fluid wave Extremities: 2+ LE edema, extremities warm Skin: no facial rash Neuro: alert & oriented X 2, no asterixis Pertinent Results: [**2138-3-9**] 09:05PM WBC-14.7* RBC-3.57* HGB-10.7* HCT-33.3* MCV-93 MCH-29.8 MCHC-32.0 RDW-17.3* PLT COUNT-312 [**2138-3-9**] 09:05PM PT-14.8* PTT-31.4 INR(PT)-1.3* [**2138-3-9**] 09:05PM GLUCOSE-109* UREA N-24* CREAT-1.4* SODIUM-150* POTASSIUM-3.7 CHLORIDE-114* TOTAL CO2-28 ANION GAP-12 [**2138-3-9**] 09:05PM ALBUMIN-2.7* CALCIUM-8.7 PHOSPHATE-3.1 MAGNESIUM-2.2 [**2138-3-9**] 09:05PM ALT(SGPT)-110* AST(SGOT)-161* LD(LDH)-287* ALK PHOS-862* AMYLASE-236* TOT BILI-4.2* [**2138-3-9**] 09:05PM LIPASE-425* [**2138-3-28**] 05:00AM BLOOD WBC-10.8 RBC-2.83* Hgb-9.0* Hct-26.4* MCV-93 MCH-31.8 MCHC-34.1 RDW-18.2* Plt Ct-270 [**2138-3-28**] 05:00AM BLOOD PT-15.0* PTT-32.1 INR(PT)-1.3* [**2138-3-28**] 05:00AM BLOOD Glucose-84 UreaN-8 Creat-0.5 Na-131* K-3.4 Cl-99 HCO3-23 AnGap-12 [**2138-3-28**] 05:00AM BLOOD ALT-67* AST-107* LD(LDH)-171 AlkPhos-381* TotBili-2.4* [**2138-3-26**] 04:48PM BLOOD Calcium-8.3* Phos-2.4* Mg-2.1 [**2138-3-14**] 05:30AM BLOOD VitB12-774 Folate-18.0 [**2138-3-10**] 03:52PM BLOOD calTIBC-157 Hapto-291* Ferritn-1519* TRF-121* [**2138-3-14**] 05:30AM BLOOD TSH-5.4* [**2138-3-11**] 05:20PM BLOOD IgM HAV-NEGATIVE [**2138-3-11**] 01:00PM BLOOD IgM HAV-NEGATIVE [**2138-3-10**] 03:52PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-POSITIVE [**2138-3-10**] 03:52PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE [**2138-3-10**] 03:52PM BLOOD [**Doctor First Name **]-NEGATIVE [**2138-3-10**] 03:52PM BLOOD IgG-1314 [**2138-3-10**] 03:52PM BLOOD CERULOPLASMIN-Test [**2138-3-12**] 10:30AM ASCITES WBC-500* RBC-[**Numeric Identifier 16351**]* Polys-3* Lymphs-26* Monos-15* Mesothe-3* Macroph-53* Albumin-1.3 CLOSTRIDIUM DIFFICILE TOXIN: NEGATIVE FOR C. DIFFICILE x 5 RAPID PLASMA REAGIN TEST (Final [**2138-3-17**]): NONREACTIVE. [**2138-3-12**] 11:10 am PERITONEAL FLUID GRAM STAIN (Final [**2138-3-12**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2138-3-15**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2138-3-18**]): NO GROWTH. ABDOMEN U.S. (COMPLETE STUDY) [**2138-3-10**] 10:24 AM 1. Diffusely echogenic liver consistent with fatty changes. More severe forms of hepatic disease such as fibrosis cannot be excluded. 2. Splenomegaly. 3. A moderate amount of sludge is noted within the gallbladder. There is no evidence of acute cholecystitis. 4. Small amount of ascites in the right lower quadrant ascites, not deemed sufficient for therapeutic drainage. ERCP BILIARY&PANCREAS BY GI UNIT [**2138-3-11**] 2:35 PM FINDINGS: Eleven fluoroscopic images were obtained without a radiologist present. These were submitted for review. Fluoroscopic images demonstrate slight tapering of the intrahepatic biliary ducts. This may be consistent with cirrhosis. There is no biliary dilatation identified. Per report, sludge was removed from the common hepatic duct. IMPRESSION: Tapering of intrahepatic biliary ducts without dilatation. This suggests cirrhosis. CT HEAD W/O CONTRAST [**2138-3-13**] 1:20 PM A round hypodensity likely represents a chronic lacune in the deep white matter (2A:14). Mild prominence of the sulci is indicative of age- inappropriate brain parenchymal atrophy. There are dense calcifications of the intracranial carotid and vertebral arteries. There is no evidence of hemorrhage, edema, masses, mass effect, or acute infarction. No fractures are identified. IMPRESSION: Age-inappropriate prominence of sulci and chronic deep white matter lacune. No evidence of acute intracranial hemorrhage or ischemia. CHEST (PORTABLE AP) [**2138-3-15**] 7:31 PM 1. Supporting lines in satisfactory positions. 2. Stable bilateral upper lobe opacities may be secondary to an acute pneumonia, however, cannot exclude a chronic underlying interstitial abnormality including pneumoconiosis. If clinically warranted, consider CT for further evaluation. EEG Study Date of [**2138-3-16**] This is an abnormal portable EEG in the waking and drowsy states as the majority of the tracing demonstrated a poorly organized and slow background interrupted with brief bursts of moderate amplitude generalized mixed frequency slowing. With stimulation, a poorly sustained low voltage fast background appeared briefly. This constellation of findings is indicative of a mild encephalopathy due to dysfunction of bilateral subcortical or deep midline structures. Medications, metabolic disturbances, and infection are among the common causes of encephalopathy. There were no areas of prominent focal slowing, althought encephalopathic patterns can sometimes obscure focal findings. There were no epileptiform features and no electrographic seizure activity was noted. CT CHEST W/CONTRAST [**2138-3-21**] 5:13 PM 1. Bilateral opacities within the upper lobes and superior segment of the right lower lobe in a bronchovascular distribution. Given patient's history, this finding is most consistent with infection. Underlying bronchiolectasis/fibrosis appear to be present, which together with the presence of loss of volume would suggest chronicity of these changes, however superimposed infection may be present. No hilar mass identified. 2. Bilateral moderate simple pleural effusions with associated relaxation atelectasis. 3. Coronary artery calcifications. 4. Mild upper abdominal ascities with a partially visualized enlarged periportal lymph node. 5. Tiny sub-centimeter nodules within the thyroid gland. US ABD LIMIT, SINGLE ORGAN [**2138-3-22**] 10:21 PM 1. Gallbladder sludge. Gallbladder wall thickening is likely explained by low albumin state. No evidence for acute cholecystitis. 2. No intra- or extra-hepatic biliary ductal dilation. 3. Ascites. VIDEO OROPHARYNGEAL SWALLOW [**2138-3-24**] 12:30 PM Moderate oropharyngeal dysphagia without evidence of aspiration. Brief Hospital Course: Mr [**Known lastname 39868**] is a 60 year-old man with a history of active alcohol abuse, previously normal mental status, who was admitted to [**Hospital3 417**] Hospital on [**2138-2-22**] with a 4 day h/o hematemesis and black/tarry stools found to have HCT of 13.5 on admission, EGD showed [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear which was actively bleeding and was clipped. EGD was otherwise unremarkable no varices were seen in esophagus or stomach. He was transfused 6 units PRBC. His course was complicated by an [**Last Name (NamePattern1) 7792**] in the setting of his anemia, and this was managed medically with beta blockade. In addition, he developed SVT with respiratory distress, pulmonary edema on CXR, and was reportedly electively intubated and started on an amiodarone gtt and diuresed. During this episode, he was also transiently hypotensive requiring vasopressors (first dopamine, then phenylephrine) which were weaned off after an unclear duration. Following extubation, the patient was noted to be markedly delirious with disorientation and agitation; per his wife. During his admission at [**Hospital3 **], he was noted to have new jaundice with worsening bilirubinemia/transaminitis; a RUQ ultrasound on [**2138-2-27**] showed a distended gallbladder with sludge, mild GB wall thickening, small amounts of pericholecystic fluid, and a mildly prominent CBD. A percutaneous cholecystostomy tube was inserted on [**2138-2-28**] out of concern for cholecystitis. A follow-up ultrasound showed an increasing amount of abdominal ascites and continued evidence of acalculous cholecystitis (as well as echogenic liver texture with fatty infiltration) and he was transferred to [**Hospital1 18**] on [**2138-3-9**] for ERCP. Since admission to [**Hospital1 18**], he had an ultrasound that showed no evidence of biliary obstruction, cholecystitis, or pancreatitis, small amount of ascites, and a fatty liver. He underwent ERCP on [**3-11**] to rule out biliary obstruction, and this showed biliary sludge which was extracted from the CBD; a sphincterotomy was performed; on cholangiogram, the biliary contour was thought to be consistent with cirrhosis. He had persistent altered mental status and was started on lactulose for potential hepatic encephalopathy. Autoimmune liver disease serologies were negative, ceruloplasmin normal, his discriminant factor remained below 32, Hep A, B and C serologies negative. He had a diagnostic paracentesis [**3-12**] negative for SBP (500 WBC 3% polys). UA [**3-12**] had 11 WBC few bacteria, trace leukocyte esterase, blood and nitrite negative. CXR on admission showed a possible aspiration pneumonia with extensive opacification in both lungs, primarily upper lobes and hazy opacification at the right lung base. He was started on levofloxacin/metronidazole on [**2138-3-9**] for a planned 10-day course; he had a low-grade fevers but never an overt fever spike. Blood and urine cultures with no growth to date. Head CT done today showed no acute hemorrhagic or ischemic infarct. He was transferred to the west liver service on [**2138-3-13**] given his persistant altered mental status. He was evaluated by the neurology service on [**2-/2059**] who felt this was most likely due to toxic/metabolic encephalopathy. The following day [**3-15**], a code blue was called for decreased responsiveness. On evaluation, he appeared to be having a seizure and was given IV Ativan and IV dilantin. His condition deteriorated, developed agonal respirations and bilious vomit on OG suction and he was intubated for airway protection and transferred to the ICU for further care. In the ICU, post intubation he developed hypotension requiring pressor support. He was also transfused 2 units PRBC. He was continued on ceftriaxone and Flagyl initially but then changed to Vanc/Zosyn for concern for development of VAP vs ASP pneumonia. Cardiac enzymes were negative x 3. He developed Atrial fibrillation with rapid ventricular response and was treated with amiodarone drip, which was discontinued prior to transfer out of ICU as patient stable. Antiepileptics were stopped as seizure thought [**2-15**] toxic/metabolic process, EEG c/w encephalopathy. He continued to improve and was extubated and transferred back to the medical floor on [**2138-3-20**]. Patient remained on hospital floor until [**3-24**]. He was noted to have a decrease in his hematocrit on the AM of [**3-24**] (28-->24), and a repeat HCT check revealed another 5 point drop. He was noted to have a BP drop to 98 mm Hg systolic, but denied chest pain, abdominal pain, shortness of breath. Received 2U PRBCs 19 --> 27, scope showed post bulbar ulcer which was injected with epinephrine. Received 2 more units [**3-25**] and HCT stable to 31-29-29. He is still having dark stools but had been hemodynamically stable. H.pylori was sent and negative. Upon admission to the floor [**3-26**], denied any current complaint. No abdominal pain, lightheartedness, shortness of breath, chest pain or palpitations. He initially continued to have persistent diarrhea, up to five bowel movements daily, despite decreased lactulose dosing. Clostridium difficile was checked x 5 and was persistently negative. He was started briefly on po Flagyl, but given multiple negative C.diff toxins, this was discontinued. Diarrhea improved and he was continued on lactulose as treatment for his alcohol cirrhosis and potential hepatic encephalopathy. Preventative treatment for acalculous cholecystitis was continued with ursodiol. For his recent [**Month/Year (2) 7792**], he was started on beta blockade but was not started on an antiplatelet therapy given recent GI bleeding. He was then discharged to a rehabilitation facility for continued recuperation from his prolonged illness. Plan to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 39870**], Phone:[**Telephone/Fax (1) 463**] on [**2138-4-22**] at 1:00 pm. Medications on Admission: mvi 1 daily timentin 3.1g q6h duoneb q6h metoprolol 5mg iv q6h nexium 40mg [**Hospital1 **] lorazepam 1-2mg iv q12h prn Discharge Medications: 1. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Three (3) Puff Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 6. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day): Titrate for 3 bowel movements daily . 7. Papain-Urea 830,000-10 unit/g-% Ointment Sig: One (1) Appl Topical DAILY (Daily): Please apply to coccyx. 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain or fever > 101. 10. Metoprolol Tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2 times a day): Hold for SBP < 100 or HR < 60 . 11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): [**Month (only) 116**] discontinue if patient increasingly active. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 701**] Discharge Diagnosis: Primary: Alcohol abuse, cirrhosis, small intestine ulcer with bleeding, pneumonia Discharge Condition: Stable, without fever and no further bleeding. Discharge Instructions: You were admitted with concern for infection in your bile duct. You were evaluated with imaging and your bile duct sphincter was surgically opened. Your course was complicated by infection, including pneumonia, that necessitated intubation. You were extubated but then had bleeding from your small intestine. This was treated via an EGD. Now that you are stable and have no further evidence of bleeding or infection, you are being discharged to a rehabilitation facility for continued recovery. Please take all medications as prescribed. Your facility will be provided with a list of medications you should be taking. Please keep all outpatient appointments. Seek medical advice if you notice fever, chills, abdominal pain, difficulty breathing, black or bloody stools, worsening of your overall condition or for any other symptom which is concerning you. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2138-4-22**] 1:00

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Discharge summary

report

Admission Date: [**2143-12-31**] Discharge Date: [**2144-1-18**] Date of Birth: [**2078-8-16**] Sex: M Service: CARDIOTHORACIC Allergies: Morphine Sulfate / Fentanyl / Indocin / Keflex / Adhesive Tape Attending:[**First Name3 (LF) 1283**] Chief Complaint: DOE and decreased exercise tolerance Major Surgical or Invasive Procedure: [**2144-1-6**] redo sternotomy/ AVR/MVR/ TV repair ( 23mm St. [**Male First Name (un) 923**] mechanical aortic, [**Street Address(2) 11599**]. [**Male First Name (un) 923**] mechanical mitral, 30 mm CE tricuspid annuloplasty band) History of Present Illness: 65 yo male who enderwent AVR with [**Male First Name (un) **]. valve in [**2135**]. He had a CVA at that time, but has no residual deficits. He has had increasing DOE and decreasing exercise tolerance for the past 1-2 months. Pt. had been prviously informed that his St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 71102**] valve had been recalled. Echo done [**9-29**] revealed [**Last Name **] problem with the prosthetic valve function, but did show severe TR, pulm. HTN, mild MS, moderate MR. Cath then showed normal coronaries, cardiac index of 1.6, dilated aortic root and ascending aorta, ? mild paravalvular AI, PA 57/25. referred for reoperation to Dr. [**Last Name (STitle) 1290**]. Past Medical History: mechanical AVR [**2135**] CVA [**2135**] chronic A fib RHD DJD GERD NIDDM DVT recent hosp. [**10-29**] (subtherapeutic INR for heparinization) PSH: AF ablation VVI pacer for brady [**2140**] back [**Doctor First Name **]. [**2123**] appy tonsillectomy RIH repair [**2139**] umb. hernia repair Social History: retired window maker quit smoking [**2106**]; smoked 2.5 ppd for 10 years no ETOH lives with wife Family History: no premature CAD Physical Exam: PERRLA, EOMI, right eye with baseline congenital drift alert and oriented x3, MAE [**3-28**] strengths, steady gait RRR, crisp valve click, ? murmur CTAB soft, NT, ND, obese abd, no palpable masses, + BS extrems warm with bil LE varicosities no carotid bruits 2+ bil. fem/radials 1+ bil. DP/PTs neck full ROM, supple, no lymphadenopathy skin brown discoloration LE calves 6'3" 288 # Discharge vitals 98.6, 60 afib, 110/56, 18 RA sat 97% wt 126.6kg Neuro a/o x3 nonfocal Pulm CTA ant/post Cardiac Irregular no m/r/g Abd soft nt, nd +BS Ext Warm +2 edema lle, +1 edema rle pulses palpable Inc sternal stable with staples no erythema/drainage Left groin with staples slow healing no erythema no drainage Pertinent Results: [**2144-1-18**] 04:20AM BLOOD WBC-10.9 RBC-3.35* Hgb-9.2* Hct-27.8* MCV-83 MCH-27.4 MCHC-33.0 RDW-16.3* Plt Ct-510* [**2143-12-31**] 06:27PM BLOOD WBC-6.8 RBC-4.27* Hgb-12.3* Hct-35.6* MCV-83 MCH-28.7 MCHC-34.5 RDW-16.4* Plt Ct-218 [**2144-1-18**] 04:20AM BLOOD Plt Ct-510* [**2144-1-18**] 04:20AM BLOOD PT-24.9* PTT-77.8* INR(PT)-2.5* [**2143-12-31**] 06:27PM BLOOD Plt Ct-218 [**2143-12-31**] 06:27PM BLOOD PT-15.2* PTT-37.8* INR(PT)-1.4* [**2144-1-18**] 04:20AM BLOOD Glucose-102 UreaN-20 Creat-1.3* Na-131* K-4.5 Cl-96 HCO3-26 AnGap-14 [**2144-1-6**] 08:03PM BLOOD Glucose-175* UreaN-21* Creat-1.4* Na-136 K-6.7* Cl-109* HCO3-19* AnGap-15 [**2143-12-31**] 06:27PM BLOOD Glucose-107* UreaN-19 Creat-1.1 Na-138 K-4.4 Cl-102 HCO3-26 AnGap-14 [**2143-12-31**] 06:27PM BLOOD ALT-21 AST-26 LD(LDH)-297* AlkPhos-66 TotBili-1.4 [**2144-1-14**] 06:20AM BLOOD Calcium-8.3* Phos-4.4 Mg-2.3 [**2143-12-31**] 06:27PM BLOOD %HbA1c-6.9* [Hgb]-DONE [A1c]-DONE CHEST (PA & LAT) [**2144-1-17**] 8:22 AM CHEST (PA & LAT) Reason: evaluate pleural effusions [**Hospital 93**] MEDICAL CONDITION: 65 year old man s/p AVR/MVR/TVrepair REASON FOR THIS EXAMINATION: evaluate pleural effusions INDICATION: A 65-year-old man status post trivalve repair. Evaluate pleural effusions. COMPARISON: PA and lateral chest x-ray dated [**2144-1-15**]. PA AND LATERAL CHEST X-RAY: A small left pleural effusion is stable. A tiny right pleural effusion is either new or slightly increased since prior exam. The appearance of the lungs is otherwise unchanged and unremarkable. The patient is status post median sternotomy with trivalve repair. A left chest wall single-lead pacemaker is positioned in the coronary sinus. The surrounding soft tissue and osseous structures are unremarkable. IMPRESSION: Stable left, and slightly increased tiny right pleural effusions. PATIENT/TEST INFORMATION: Indication: Intra-op TEE for re-do AV Replacement, MV Replacement, TV Repair Height: (in) 75 Weight (lb): 280 BSA (m2): 2.53 m2 BP (mm Hg): 126/45 HR (bpm): 60 Status: Inpatient Date/Time: [**2144-1-6**] at 09:41 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW1-: Test Location: Anesthesia West OR cardiac Technical Quality: Suboptimal REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**] MEASUREMENTS: Left Atrium - Four Chamber Length: *6.0 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *7.4 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: *1.4 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 5.4 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 3.9 cm Left Ventricle - Fractional Shortening: *0.28 (nl >= 0.29) Left Ventricle - Ejection Fraction: 45% to 50% (nl >=55%) Aorta - Valve Level: *4.0 cm (nl <= 3.6 cm) Aorta - Ascending: *4.2 cm (nl <= 3.4 cm) Aorta - Arch: 2.9 cm (nl <= 3.0 cm) Aorta - Descending Thoracic: *2.9 cm (nl <= 2.5 cm) Mitral Valve - Mean Gradient: 7 mm Hg Mitral Valve - Pressure Half Time: 200 ms Mitral Valve - MVA (P [**11-26**] T): 1.1 cm2 Mitral Valve - MVA (2D): 1.0 cm2 INTERPRETATION: Findings: LEFT ATRIUM: Marked LA enlargement. Mild spontaneous echo contrast in the body of the LA. No spontaneous echo contrast is seen in the LAA. Depressed LAA emptying velocity (<0.2m/s) No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Mildly depressed LVEF. [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] RIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall hypokinesis. AORTA: Mildly dilated aortic sinus. Focal calcifications in aortic root. Moderately dilated ascending aorta. Focal calcifications in ascending aorta. Normal aortic arch diameter. Simple atheroma in aortic arch. Mildly dilated descending aorta. Simple atheroma in descending aorta. AORTIC VALVE: Mechanical aortic valve prosthesis (AVR). Cannot exclude AS. Mild (1+) AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild mitral annular calcification. Moderate MS (MVA 1.0-1.5cm2) Moderate (2+) MR. TRICUSPID VALVE: Moderate [2+] TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. The rhythm appears to be atrial fibrillation. Results were Conclusions for post-bypass data Conclusions: PRE-BYPASS: 1. The left atrium is markedly dilated. Mild spontaneous echo contrast is seen in the body of the left atrium. 2. No spontaneous echo contrast is seen in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No thrombus is seen in the left atrial appendage. 3. The right atrium is markedly dilated. No atrial septal defect is seen by 2D or color Doppler. 4. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is mildly depressed. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] 5. The right ventricular cavity is mildly dilated. There is mild global right ventricular free wall hypokinesis. 6. The aortic root is mildly dilated at the sinus level. The ascending aorta is moderately dilated at 4.2 cm and the distal Ascending aorta tapers down to about 3.6 cm. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. 7. A mechanical aortic valve prosthesis is present. The study is inadequate to exclude significant aortic valve stenosis, But a mean gradient of only 12 mm of Hg is obtained. Trace to Mild (1+) aortic regurgitation is seen. 8. The mitral valve leaflets are moderately thickened. There is moderate mitral stenosis (area 1.0-1.5cm2). Moderate (2+) mitral regurgitation is seen. 9. Moderate [2+] tricuspid regurgitation is seen. 10. There is a trivial/physiologic pericardial effusion. POST-BYPASS: Pt is AV paced and is on an infusion of epinephrine and phenylephrine 1. A mechanical valve is well seated in the Aortic position. Leaflets open well. Washing jets are seen, no significant AI is seen. Mean gradient across the valve is 12 mm of Hg. 2. A mechanical valve is well seated in the Mitral position. Leaflets open well. Washing jets are seen, no significant MR is seen. A mean gradient of [**1-26**] mm fo Hg is obtained across the valve. 3. An annuloplasty ring is well seated in the Tricuspid position. Trace TR is seen. No significant gradient is obtained across the valve. 4. RV function is slightly worse compared to pre bypass. LV function is unchanged 5. Aorta is intact post decannulation. 6. Other findings are unchanged Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD on [**2144-1-10**] 14:49. [**Location (un) **] PHYSICIAN: Brief Hospital Course: Admitted [**12-31**] after stopping coumadin at home on [**12-26**]. IV heparinization started after labs were drawn and preoperative work-up was completed over the next several days. His INR took several days to normalize for surgery. On [**2144-1-6**], Mr. [**Known lastname 13220**] was taken to the operating room where he underwent a redo sternotomy with an aortic and mitral valve replacement as well as a tricuspid valve repair. Postoperatively he was transferred to the CSRU on epinephrine, phenylephrine and propofol drips. An additional left chest tube was placed at the bedside that afternoon for large pleural effusion. Mr. [**Known lastname 13220**] [**Last Name (Titles) **] extubated later that night. His chest tubes and epicardial pacing wires removed after his permanent pacer was interrogated by electrophysiology service. Mr. [**Known lastname 13220**] was transferred to the floor on POD #2 for further recovery. Gentle diuresis was started and coumadin was resumed. The physical therapy service worked with him daily to help increase his strength and mobility. As it took a few days for his INR to increase, intravenous heparin was started as a bridge until his INR was therapeutic. He was transfused with 2 units of packed red blood cells due to postoperative anemia. Mr. [**Known lastname 13220**] continued to make steady progress and was discharged home on postoperative day 13. Plan for INR to be checked [**1-20**] in the am with results to Dr [**Last Name (STitle) 20222**]. Medications on Admission: coumadin 7.5 mg Tues/Thurs, 10 mg other 5 days atenolol 50 mg daily lisinopril 40 mg daily norvasc 5 mg daily avandia 4 mg [**Hospital1 **] aldactone colace 100 mg [**Hospital1 **] ASA 81 mg daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 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:*1* 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 7. Rosiglitazone 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*1* 8. Metoprolol Succinate 50 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:*1* 9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q2-3H (every 2-3 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 11. Warfarin 5 mg Tablet Sig: Three (3) Tablet PO ONCE (Once): please take 15mg [**1-18**] and [**1-19**] - have INR checked [**1-20**] and check with MWHC for further dosing. Disp:*90 Tablet(s)* Refills:*0* 12. Outpatient [**Name (NI) **] Work PT/INR as needed first draw [**1-20**] Results to Dr [**Last Name (STitle) 20222**] at MWHC ([**Telephone/Fax (1) 26917**] goal INR 3-3.5 No statin started d/t allergy (stomach and leg cramps) Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Mitral and Tricuspid Regurgitation s/p Redo Aortic and Mitral Valve Replacement and Tricsupid Valve Repair PMH: Rheumatic heart disease s/p AVR [**2144**]. [**First Name4 (NamePattern1) 923**] [**Last Name (NamePattern1) **] valve, Chronic Atrial Fibrillation s/p AF ablation, Degenerative Joint Disease, Gastroesophageal Reflux Disease, h/o Deep Vein Thrombosis, CVA [**2135**] ( s/p AVR with no residual), Diabetes Mellitus, s/p AVR [**2135**]. [**First Name4 (NamePattern1) 923**] [**Last Name (NamePattern1) **] valve, VVI pacer for bradycardia [**2140**],s/p back surgery [**2123**], s/p appy, s/p tonsillectomy, s/p RIH repair [**2139**], s/p umb. hernia repair Discharge Condition: Good. Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5)No lifting greater then 10 pounds for 10 weeks. 6)No driving for 1 month. Followup Instructions: see Dr. [**Last Name (STitle) 349**] in [**11-26**] weeks see Dr. [**Last Name (STitle) 20222**] in [**12-28**] weeks see Dr. [**Last Name (STitle) 1290**] in 4 weeks [**Telephone/Fax (1) 170**] Please send INR results to the Heart Center of [**Hospital **] [**Hospital 197**] Clinic ([**Telephone/Fax (1) 26917**] goal INR 3.0-3.5 Completed by:[**2144-1-18**]

[ "416.8", "530.81", "401.9", "397.0", "427.31", "997.3", "511.9", "996.02", "V45.01", "396.8", "250.00", "285.1" ]

icd9cm

[ [ [] ] ]

[ "35.14", "35.22", "39.61", "99.04", "35.24", "34.04" ]

icd9pcs

[ [ [] ] ]

13469, 13518

10053, 11558

367, 602

14230, 14238

2553, 3599

14749, 15113

1794, 1812

11806, 13446

3636, 3673

13539, 14209

11584, 11783

14262, 14726

4421, 9994

1827, 2534

291, 329

3702, 4395

630, 1345

10030, 10030

1367, 1663

1679, 1778

29,406

164,432

31932

Discharge summary

report

Admission Date: [**2159-8-19**] Discharge Date: [**2159-9-11**] Date of Birth: [**2087-8-21**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: # Intra-parenchymal hemorrhage # Intraventricular hemorrhage Major Surgical or Invasive Procedure: # Right craniotomy # Left EVD placement # Left EVD removal # Intubation History of Present Illness: 71M h/o HTN, CAD s/p CABG, PVD, AAA, fell while exercising on treadmill, unclear whether fall was mechanical or secondary to syncope/LOC. Patient initially admitted to [**Hospital 1559**] Medical Center, where head CT demonstrated large IPH/IVH. Initial SBP = 170. At OSH, pt reported headache and nausea, vomited, and became confused. Pt received atenolol and mannitol 50 g, and then was sedated with benzodiazepines and vecuronium for intubation prior to transfer to [**Hospital1 18**]. Past Medical History: # Hypertension # Coronary artery disease s/p CABG # Abdominal aortic aneurysm # Peripheral vascular disease # Cataracts # Benign prostatic hypertrophy Social History: Lived at home with wife. Family History: Noncontributory Physical Exam: PE on admission: VS: Afebrile, HR 73, BP 177/90, RR 20 100% on vent Gen: Intubated, sedated. HEENT: Pupils 1.5mm round/nonreactive, no corneal response bilaterally. Positive gag/cough. Neck: Intubated. Lungs: CTA bilaterally. Cardiac: RRR, S1/S2. Abd: Soft, NT, BS+ Extrem: ?L knee surgery, warm and well-perfused. Mental status: Intubated/sedated. Cranial Nerves: CNII: See above. Unable to assess the rest of cranial nerves. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. No withdrawal of extremities to noxious stimuli. Reflexes: [**12-31**] throughout except left knee (s/p knee surgery). Toes upgoing bilaterally. . PE on transfer to MICU: VS: T 101, BP 142/64, HR 83, RR 16, SaO2 100/vented Gen: Lying in bed, intubated, off sedation. HEENT: NC/AT, moist oral mucosa. Neck: Intubated Back: NA CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally Abd: +BS soft Ext: No edema Vasc: 1+ DP pulses Neuro: Opens eyes to voice, but does not track or appear to have purposeful movements. Moves all extremities. Pertinent Results: Notable admission labs: . [**2159-8-19**] 11:20AM WBC-10.2 RBC-4.05* HGB-13.7* HCT-39.1* MCV-97 MCH-33.8* MCHC-35.0 RDW-13.3 [**2159-8-19**] 11:20AM NEUTS-91.0* BANDS-0 LYMPHS-6.5* MONOS-2.3 EOS-0.1 BASOS-0.2 [**2159-8-19**] 11:20AM PLT SMR-NORMAL PLT COUNT-169 [**2159-8-19**] 11:20AM PT-14.5* PTT-23.1 INR(PT)-1.3* . Notable imaging: . [**8-19**] CT head: R. frontal intracranial hemorrhage with extension into the third and fourth ventricles with layering of blood within the occipital poles of the lateral ventricles, stable shift of the midline leftward and subfalcine herniation of approximately 8 mm. . [**8-21**] CT head: Unchanged [**8-24**] CT Head: Unchanged [**8-24**] LE U/S: No DVT b/l [**8-24**] CXR: RLL, LLL opacity [**8-25**] CT head: Unchanged [**8-27**] CXR: RLL opacity . [**2159-9-4**] Head CT -- IMPRESSION: Interval decrease in density of the hemorrhage along the left frontal catheter tract, intraventricular hemorrhage, as well as right frontal lobe hemorrhage, consistent with evolution of blood products. Unchanged degree of rightward shift of septum pellucidum. No new foci of intracranial hemorrhage. Minimal increase in size of right frontal extraaxial collection. . [**2159-9-4**] BILATERAL DUPLEX VENOUS LOWER EXTREMITY: Grayscale, color, and Doppler son[**Name (NI) 1417**] of the bilateral common femoral, superficial femoral, popliteal and calf veins were performed. There is normal flow, compression, and augmentation demonstrated in these vessels. The greater saphenous vein demonstrates pulsatile flow that may be related to reflux secondary to worsening CHF. . [**2159-9-4**] AP chest compared to [**8-29**] through 7: Lungs remain essentially clear following resolution of the left lower lobe atelectasis, no pleural effusion is seen. Lung apices are partially excluded from the examination. No evidence of pneumothorax elsewhere. Heart size normal. ET tube in standard placement. Brief Hospital Course: 72M h/o CAD s/p CABG, AAA, HTN, [**Hospital 15134**] transferred from [**Hospital 2586**] on [**2159-8-19**] with traumatic ICH s/p fall (?mechanical v syncope), admitted to Neurosurgery on [**2159-8-19**] for large IPH/IVH. Underwent emergent right decompressive craniotomy and left EVD placement on [**2159-8-19**], with stable repeat CT after EVD clamped and removed. # Respiratory distress: [**Name (NI) 5601**], pt febrile and started on vancomycin and zosyn for pneumonia. His neuro exam slowly improved and he was transferred to stepdown unit [**8-31**]. He had respiratory decompensation and required re-intubation [**9-4**] and was transferred to MICU. On [**2159-9-4**], pt again reported to be in respiratory distress, RR = 50's with accessory muscles, 02 sats in mid-90s. ABG 7.46/33/185 on non-rebreather. A large amount of thick sputum removed with suctioning, with RR reportedly improved into the 30's, but with periods of apnea. Pt was re-intubated for "airway protection," and transferred to the MICU. Respiratory distress suspected to be primarily related to mucus plugging. CXR improved. LENIS negative. ABG suggestive of hyperventilation: low CO2, nml 02. Pt required minimal vent settings and was extubated shortly after arriving to MICU, but require pulmonary toilet via suctioning to be continued at rehab. . # Altered mental status: On [**2159-9-4**] in early AM, pt described as "obtunded" & non responsive per notes in chart, compared to previously improving MS. BP at the time of MS change 110/60's. Emergent head CT done, which showed no change. For duration of admission, mental status improved where he would open his eyes to voice, speak a few words, and move his R extremities (pt has expected dense left hemiplegia). No toxic or metabolic cause of his MS change was discovered besides mucus plugging and possible pneumonia. Pt expected to have slow course of improvement for MS change [**12-29**] ICH. . # ICH: ICH slightly improved on repeat head CT on [**9-4**]. Pt continued on levetiracetam and was instructed to follow up with neurosurgery as an outpatient. Pt was instructed to remain off clopidogrel but was restarted on ASA 81mg daily for CAD. . # HTN: Pt required multiple anti-HTN agents during his admission, including nicardipine, metoprolol, lisinopril, and hydralazine. Per neurosurgery, pt was instructed to maintain SBP with no specific requirement, and was continued on metoprolol 75mg PO Q8H. . # CAD: Pt was restarted on ASA 81mg daily per neurosurgery recommendations. . # Fevers: Pt became febrile on [**8-23**] & continued to have fevers ~daily through [**8-29**]. He was started on vanco and zosyn for empiric tx of pneumonia as CXR showed retro-cardiac opacity. CSF was negative (showed 1+ PMNs, negative Gram-stain and cx). Urine cx's negative. Intermittent low grade fevers considered likely [**12-29**] ICH, as he completed a full abx course for PNA. Pt was afebrile x24hrs at discharge. . # Nutrition: Pt was unable to swallow food due to his mental status and received a post-pyloric Dobhoff via IR placement. Tube feeds were begun with no complications. . # Full code Medications on Admission: Medications on transfer: . Levetiracetam 1500 mg PO BID Vancomycin 1000 mg IV Q 12H Piperacillin-Tazobactam Na 4.5 gm IV Q8H (started [**2159-8-24**]) Heparin 5000 UNIT SC BID Tamsulosin HCl 0.4 mg PO HS Nystatin Oral Suspension 5 ml PO QID:PRN Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Insulin SC Famotidine 20 mg IV Q12H . Medications at home: Atorvastatin ASA Ezetimibe Indapamide Lisinopril Tamsulosin Atenolol . ALL: NKDA Discharge Medications: 1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 2. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 3. Docusate Sodium 50 mg/5 mL Liquid Sig: Two Hundred (200) MG PO BID (2 times a day): Hold for diarrhea. 4. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed: Hold for diarrhea. 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed: Hold for diarrhea. 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO every eight (8) hours. 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary diagnosis: # Intracranial hemorrhage # Pneumonia # Respiratory distress [**12-29**] mucus plugging # Hypertension . Secondary diagnosis # Coronary artery disease s/p CABG # Abdominal aortic aneurysm # Cataracts # Peripheral vascular disease # Benign prostatic hypertrophy Discharge Condition: Stable, residual left-sided neurological deficits Discharge Instructions: You were admitted to the hospital because you had sustained an intracranial hemorrhage. You underwent a craniotomy with evacuation and ventriculostomy, which was removed. You then experienced respiratory difficulties because you were unable to clear your secretions, which required you to be transferred to the intensive care unit so you could be suctioned. We found that you also had likely developed a pneumonia, and you completed a course of antibiotics. . To control your blood pressure, we have started you on a new medication: # Metoprolol 75 mg every eight hours. Please follow-up with your primary care provider so that you can adjust this metoprolol dose, and also possibly consider changing to a long acting medication. . To control the possibility of seizures, we have also started you on a new anti-seizure medication: # Levetiracetam 1500 mg [**Hospital1 **] (twice daily) . Because you have coronary artery disease (clogged arteries), we have resumed your aspirin at a low dose (neurosurgery felt this would not make your bleeding worse): # Aspirin 81mg daily . We have ***stopped*** certain medications you had been taking: # Do not continue taking Plavix (clopidogrel), because you have an intracranial hemorrhage currently, and this can make bleeding worse. # Also, unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Advil, or Ibuprofen. . Otherwise, please continue taking your home medications. . To care for your craniotomy, you need to have your incisions checked daily for signs of infection. You should limit your exercise to walking, with no lifting, straining, or excessive bending. Continue to take your pain medication as prescribed, but make sure you increase your fluid and fiber intake to avoid constipation. . CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F . You have several follow-up appointments. See below. Followup Instructions: You need to make an appointment to see Dr. [**Last Name (STitle) **] (tel. [**Telephone/Fax (1) **]) in three weeks. You also need to schedule a CT scan of your head before your appointment with Dr. [**Last Name (STitle) **] (please call the same number). . Please also make an appointment with your primary care provider in one week. Completed by:[**2159-9-11**]

[ "E884.9", "440.20", "401.9", "441.4", "331.4", "414.01", "853.01", "486", "V45.81", "518.81" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.6", "01.39", "96.04", "02.39" ]

icd9pcs

[ [ [] ] ]

8930, 9000

4289, 5642

377, 451

9324, 9376

2328, 2336

11715, 12082

1204, 1221

7959, 8907

9021, 9021

7466, 7466

9400, 11692

7854, 7936

1236, 1239

276, 339

479, 972

1602, 2309

3089, 4266

2352, 2685

9040, 9303

1253, 1551

5657, 7440

7491, 7833

994, 1146

1162, 1188

64,560

120,267

29143

Discharge summary

report

Admission Date: [**2107-5-12**] Discharge Date: [**2107-5-16**] Date of Birth: [**2042-9-8**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1406**] Chief Complaint: Chief Complaint: Asymptomatic ascending aortic aneurysm Major Surgical or Invasive Procedure: Ascending aortic aneurysm repair (#32mm graft)/[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 70128**] on [**2107-5-12**] History of Present Illness: This is a 64 year old male with known ascending aortic aneurysm. Please see full H&P from [**2107-4-1**]. Recent CT scan shows increasing dimensions, now measuring 5.2cm x 5.5cm. He is completely asymptomatic, denying chest pain, dyspnea, and light-headedness. He is scheduled for ascending aortic aneurysm repair on [**2107-5-2**]. Past Medical History: Past Medical History: Ascending aortic aneurysm Mild Aortic Insufficiency Chronic atrial fibrillation(Aspirin only) Hypertension Hypercholesterolemia Past Surgical History: s/p Excision of Parathyroid adenoma s/p Tonsillectomy Social History: Race: Caucasian Last Dental Exam: 1 month ago, Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 70129**], [**Location (un) **], MA Lives with: wife Occupation: runs IT organization Tobacco: denies ETOH: [**2-3**] wine/day Family History: Father had an MI in his early 50s, lived until his early 80s. Physical Exam: Physical Exam Pulse: 59 Resp: 16 O2 sat: 100%RA BP: 141/103 Height: 5'[**06**]" Weight: 210lb General: WD WN male in NAD. Appears stated age Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur none 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: mynx Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Pertinent Results: [**2107-5-16**] 04:17AM BLOOD WBC-6.5 RBC-3.41* Hgb-10.5* Hct-29.7* MCV-87 MCH-30.9 MCHC-35.4* RDW-13.6 Plt Ct-225 [**2107-5-14**] 04:20AM BLOOD WBC-8.0 RBC-3.49* Hgb-10.9* Hct-29.9* MCV-86 MCH-31.2 MCHC-36.4* RDW-13.7 Plt Ct-171 [**2107-5-16**] 04:17AM BLOOD UreaN-20 Creat-0.8 Na-137 K-4.1 Cl-99 [**2107-5-15**] 04:26AM BLOOD UreaN-15 Creat-1.0 Na-135 K-3.6 Cl-97 [**2107-5-14**] 04:20AM BLOOD Glucose-128* UreaN-12 Creat-0.9 Na-138 K-4.1 Cl-101 HCO3-29 AnGap-12 [**2107-5-14**] 04:20AM BLOOD WBC-8.0 RBC-3.49* Hgb-10.9* Hct-29.9* MCV-86 MCH-31.2 MCHC-36.4* RDW-13.7 Plt Ct-171 [**2107-5-12**] 11:29AM BLOOD WBC-8.9 RBC-3.50*# Hgb-11.0*# Hct-29.8*# MCV-85 MCH-31.4 MCHC-36.9* RDW-13.2 Plt Ct-166 [**2107-5-13**] 03:18AM BLOOD PT-13.3 PTT-48.5* INR(PT)-1.1 [**2107-5-12**] 11:29AM BLOOD PT-16.3* PTT-36.0* INR(PT)-1.4* [**2107-5-15**] 04:26AM BLOOD UreaN-15 Creat-1.0 Na-135 K-3.6 Cl-97 [**2107-5-12**] 12:59PM BLOOD UreaN-17 Creat-0.9 Na-141 K-3.9 Cl-112* HCO3-21* AnGap-12 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 70130**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 70131**] (Complete) Done [**2107-5-12**] at 9:16:40 AM PRELIMINARY Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 18**] - Department of Cardiac S [**Last Name (NamePattern1) 439**], 2A [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2042-9-8**] Age (years): 64 M Hgt (in): 70 BP (mm Hg): / Wgt (lb): 215 HR (bpm): BSA (m2): 2.15 m2 Indication: Aortic valve disease. Atrial fibrillation. Mitral valve disease. Thoracic aorta aneurysm. Intraoperative TEE for ascending aorta replacement and MAZE. ICD-9 Codes: 402.90, 427.31, 441.2, 424.1, 424.0 Test Information Date/Time: [**2107-5-12**] at 09:16 Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2011AW000-0:00 Machine: ie 33 u/s 3 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.4 cm Left Ventricle - Fractional Shortening: 0.29 >= 0.29 Left Ventricle - Lateral Peak E': 0.12 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 7 < 15 Aorta - Annulus: 2.7 cm <= 3.0 cm Aorta - Sinus Level: *4.8 cm <= 3.6 cm Aorta - Sinotubular Ridge: *3.6 cm <= 3.0 cm Aorta - Ascending: *5.0 cm <= 3.4 cm Aorta - Arch: *3.5 cm <= 3.0 cm Aorta - Descending Thoracic: *2.9 cm <= 2.5 cm Aortic Valve - LVOT diam: 2.5 cm Mitral Valve - E Wave: 0.9 m/sec Findings LEFT ATRIUM: No spontaneous echo contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Moderately dilated aorta at sinus level. Moderately dilated ascending aorta Mildly dilated aortic arch. Mildly dilated descending aorta. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. No AS. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No MS. Mild (1+) MR. TRICUSPID VALVE: Tricuspid valve not well visualized. Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The rhythm appears to be atrial fibrillation. Results were personally reviewed with the MD caring for the patient. Conclusions Pre CPB: No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is moderately dilated. The aortic arch is mildly dilated. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen between the LEFT and NON coronary cusps. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results. POST CPB 1. Preserved [**Hospital1 **]-ventricular systolci function 2. Tube graft identified in aortic position. 3. Trace aortic regurgitation,with good leaflet excursion 4. Unchanged mitral regurgitation. 5. No echocardiographic evidence of dissection in the arch/descending aorta I certify that I was present for this procedure in compliance with HCFA regulations. Interpretation assigned to [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting physician ?????? [**2098**] CareGroup IS. All rights reserved. Brief Hospital Course: On [**2107-5-12**] Mr.[**Known lastname **] was taken to the operating room and underwent Ascending aortic aneurysm repair with (#32mm graft)/[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 70128**] with Dr.[**Last Name (STitle) 914**]. Please see operative report for further surgical details. Cross clamp time:99 minutes. Cardiopulmonary Bypass time:122 minutes. Hypothermic Circulatory Arrest Time:24 minutes. He tolerated the procedure well and was transferred to the CVICU intubated and sedated. He weaned off pressor support, awoke neurologically intact and was extubated without incident. He was started on Beta-blocker/Statin/ASA and diuresis. POD#1 He was transferred to the step down unit for further monitoring. Physical Therapy was consulted for evaluation of strength and mobility. The remainder of his postoperative course was essentially uneventful. On POD 4 he was cleared for discharge to home. All follow up appointments were advised. Medications on Admission: ATENOLOL - 25 mg Tablet - 1 Tablet(s) by mouth at bedtime ROSUVASTATIN - 40 mgTablet - 1 Tablet(s) by mouth at bedtime ASPIRIN 325 mg Tablet - 1 Tablet(s) by mouth daily MULTIVITAMIN - 1 Capsule(s) by mouth daily Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 2. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 3. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 5. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. Disp:*7 Tablet(s)* Refills:*0* 6. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 1 weeks. Disp:*14 Tablet Extended Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) **] Nursing Services Discharge Diagnosis: Ascending aortic aneurysm (#32mm graft)[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 70128**] on [**2107-5-12**] Secondary: Past Medical History: Ascending aortic aneurysm Mild Aortic Insufficiency Chronic atrial fibrillation(Aspirin only) Hypertension Hypercholesterolemia Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesia Incisions: Sternal - 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: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2107-6-8**] 1:00 Cardiologist: [**Name6 (MD) 1918**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2107-6-23**] 3:00 Wound Check: [**5-25**] at 10:00am with [**Doctor First Name **], at Dr.[**Name (NI) 10342**] office Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 12203**],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 35783**] in [**4-5**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2107-5-16**]

[ "401.9", "441.2", "458.29", "272.0", "424.1", "427.31" ]

icd9cm

[ [ [] ] ]

[ "39.61", "38.45", "37.36" ]

icd9pcs

[ [ [] ] ]

9806, 9874

7893, 8854

334, 465

10200, 10364

2067, 7870

11288, 12074

1339, 1403

9119, 9783

9895, 10027

8880, 9096

10388, 11265

1025, 1081

1418, 2048

255, 296

493, 829

10049, 10179

1097, 1323

8,900

145,955

8510

Discharge summary

report

Admission Date: [**2195-8-8**] Discharge Date: [**2195-8-14**] Date of Birth: [**2113-1-13**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3326**] Chief Complaint: altered mental status, aspiration PNA Major Surgical or Invasive Procedure: PICC placement History of Present Illness: Mr. [**Known lastname 29963**] is an 82y/o gentleman with myasthenia [**Last Name (un) 2902**] and advanced Parkinson's disease whose wife brought him to the [**Name (NI) **] because he was having difficulty swallowing at home, and he is transferred to the ICU with concerns that he may not be able to protect his airway and that he might have aspirated. He was recently admitted for altered mental status, and per Neurology his decreased responsiveness, stiff posture, and agitation were likely due to advancing Parkinson's Disease. This morning, the patient's wife reports that he has been more lethargic, and that when she was feeding him an Ensure, the liquid dribbled out of his mouth. She is unsure if he aspirated. . In the ED, initial vs were: T 98, P 100, BP 148/78, R 34, O2 sat 90%2L NC. He was given 1L IVF. CXR was suggestive of mild volume overload and also revealed a possible opacity; aspiration could not be excluded. The patient was given Levaquin and Ceftriaxone. Wife refused CT, and also expressed that the patient is DNI. Vitals on transfer: T 87, BP 112/68, RR 32, SaO2 98% 2L NC . In the ICU, the patient is somnolent bit arousable but hedoes not comply with exam and cannot answer Review of Systems. Past Medical History: -advanced Parkinson's Disease (bradyphrenia, dysarthria, slumping) Has been on Sinemet x 5 yrs. Has significant dementia and reported hallucinations. Followed by Dr. [**Last Name (STitle) **]. -[**First Name9 (NamePattern2) **] [**Last Name (un) 2902**] -Afib: on coumadin -CAD s/p angioplasty -CHF (LVEF ~35% by TTE [**1-31**]) -HTN -Myasthenia [**Last Name (un) **] (mainly ocular symptoms, has been on pyridostigmine in the past) stable) -Choledocholithiasis -GI bleed in setting of [**Last Name (un) **] [**2190**] -BPH -hx of prostate cancer s/p XRT [**4-2**] yrs ago -s/p L hip replacement at [**Hospital3 **] [**2187**] -cervical spondylosis Social History: Married, wife [**Name (NI) **] is primary care provider, [**Name10 (NameIs) **] assistance during the day when at home, distant pipe smoker, no current ETOH. No history or IV or illicit drug use. He used to own a business making [**Holiday **] decorations. Family History: No Parkinson's disease in family - Mom had Alzheimer's and Dad died of esophageal cancer. Physical Exam: Vitals: T: 96.8, BP: 108/62, P: 93, R: 12, O2: 91% 2L NC General: somnolent but arousable; no acute distress, breathing fast but is not using accessory muscles (patient states that this is his baseline) HEENT: Sclera anicteric, MM dry Neck: supple, no JVD, no LAD Lungs: Clear to auscultation bilaterally from the front, with crackles at bilarteral bases CV: tachycardic, irregularly irregular, no murmurs Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: LABS: [**2195-8-7**] 09:05PM BLOOD WBC-15.0*# RBC-4.40* Hgb-13.3* Hct-40.0 MCV-91 MCH-30.2 MCHC-33.3 RDW-14.1 Plt Ct-268# [**2195-8-7**] 09:05PM BLOOD PT-55.5* PTT-57.5* INR(PT)-6.2* [**2195-8-14**] 04:10AM BLOOD WBC-8.8 RBC-3.63* Hgb-11.1* Hct-33.7* MCV-93 MCH-30.5 MCHC-32.8 RDW-14.1 Plt Ct-160 [**2195-8-14**] 04:10AM BLOOD PT-19.2* PTT-37.0* INR(PT)-1.8* [**2195-8-14**] 04:10AM BLOOD Glucose-150* UreaN-22* Creat-0.7 Na-137 K-4.2 Cl-106 HCO3-25 AnGap-10 MICRO: [**2195-8-8**] 12:24 pm BLOOD CULTURE Source: Line-piv SET#2. Blood Culture, Routine (Preliminary): ENTEROCOCCUS SP.. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 305-7306S [**2195-8-8**]. STAPHYLOCOCCUS, COAGULASE NEGATIVE. REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 29967**] [**2195-8-11**] 11AM. ISOLATED FROM ONE SET ONLY. SENSITIVITIES PERFORMED ON REQUEST.. Anaerobic Bottle Gram Stain (Final [**2195-8-9**]): GRAM POSITIVE COCCI IN PAIRS AND CHAINS. [**2195-8-8**] 12:24 pm BLOOD CULTURE Source: Line-piv. Blood Culture, Routine (Preliminary): ENTEROCOCCUS SP.. POSSIBLE ENTEROCOCCUS RAFFINOSUS. FINAL SENSITIVITIES. Sensitivity testing performed by Sensititre. Penicillin = RESISTANT ( >=8 MCG/ML ). Daptomycin = SENSITIVE ( 1 MCG/ML ). PROBABLE ENTEROCOCCUS. POSSIBLE SECOND TYPE. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ 16 R DAPTOMYCIN------------ S LINEZOLID------------- 2 S PENICILLIN G---------- R VANCOMYCIN------------ <=1 S Anaerobic Bottle Gram Stain (Final [**2195-8-9**]): GRAM POSITIVE COCCI IN PAIRS AND CHAINS. REPORTED BY PHONE TO DR [**Last Name (NamePattern4) 29968**] [**Numeric Identifier 29969**] [**2195-8-9**] 910AM. **FINAL REPORT [**2195-8-11**]** [**2195-8-10**] 10:19 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2195-8-11**]** MRSA SCREEN (Final [**2195-8-11**]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. IMAGING: [**2195-8-7**] CXR 1. Mild fluid overload. 2. Left retrocardiac opacities, may reflect atelectasis. However, aspiration or pneumonia is not excluded. [**2195-8-10**] CXR Improved pulmonary edema, particularly left lung. Worsening right lower lobe pneumonia. Brief Hospital Course: Mr. [**Known lastname 29963**] is an 82y/o gentleman with advanced Parkinson's Disease brought to the [**Hospital1 18**] ED by his wife for possible aspiration and admitted to the ICU given concern of possible airway compromise and need for intubation. #PNA: Patient admitted with tachypnea, increasing respiratory requirements, elevated WCC, and question of a new opacity on CXR, in the setting of a AMS and question of aspiration. The team considered aspiration PNA to be the most likely diagnosis, although PE was also considered (but patient's INR was supratherapeutic). At time of arrival to the [**Hospital Unit Name 153**], he was able to swallow his oral secretions and was believed to be able to protect his airway. He was started on Levofloxacin+Flagyl to cover CAP and aspiration, which was then broadened to CTX+flagyl. He briefly spiked a fever to 102 with rigors, but remained hemodynamically stable. The gram stains on his blood cultures came back with GPCs in [**3-1**] bottles. His coverage was broadened to cover MRSA with Vanco. He remained stable from hemodynamic and respiratory perspectives. He was then transfered to the floors, but was transferred back to the [**Hospital Unit Name 153**] a day later in the setting of fevers, decreased arouseability, and low urine output. At that time, his blood cultures were growing enterococcus (Vanc-sensitive). CXR showed progressing PNA. Patient was stabilized, was satting well with a shovel mask and humidified air (he is a mouth breather and does not sat well with nasal cannula). At the time of discharge, his WBC had stabilized and he had been afebrile for >24H. He was discharged with a PICC line with plans for Vancomycin (14 day course for bacteremia), and Ceftriaxone/Flagyl (7 day course for aspiration pneumonia). Discharged home on O2 by face tent. . #. Parkinson's Disease: Patient with a history of progressive [**Last Name (un) 3562**], with dementia, bradykinesia, paucity of speech, and pill-rolling tremor. Recently discharged after an episode of "slumping over," with decreased arousability. He was continued on his Sinemet and Entacapone. When he was made NPO for concern of aspiration, an NG tube was placed so that he could receive his Parkinson's medications. Family was aware that his neuro disease had progressed, and that his decreased interactiveness likely represented a new baseline for him. Considering his airway compromise and likelihood that he had aspirated and would continue to do so, his family came in for a meeting with Palliative Care. They decided to make him CMO, and he was discharged home with hospice care. NG tube was d/c'd and he went home with only medications for comfort and his aspiration pneumonia. . #. Atrial Fibrillation: Patient had a longterm history of Afib, but was not in RVR during his [**Hospital Unit Name 153**] stay. His INR was supratherapeutic at 6.2, and his coumadin was held. Coumadin was restarted at 1mg daily (home dose), and at the time of discharge, his INR was 1.8. At the time of discharge, however, his Coumadin was held because he was made CMO. . # CAD/CHF: Repeat TTE yest shows little change from prior. Still with some LV hypokinesis and mod decrease in LV function with EF 40-45%. Not grossly volume overloaded to exam and breathing issues/hypoxia seem more likely pulmonary in origin. Valves okay. His fluid status was monitored and he was continued on his home Aspirin 81mg daily. His medications were discontinued at the time of discharge when he was made CMO. . #. Anemia: chronic disease, with low iron. No obvious source of blood loss. Patient's Hct was stable throughout stay. . #. Bladder dysfunction: chronic issue, on two medications for bladder function at home. Likely worsened in setting of acute illness. Had foley in place during admission, so Flomax & Darifenacin were held in house. He is being discharged with a foley. Medications on Admission: Sinemet 25mg/100mg TID Entacapone 200mg TID Clozapine 25mg daily Sertraline 100mg daily Klonopin 0.5mg qHS ASA 81mg daily Coumadin 1mg daily HCTZ 12.5mg daily Darifenacin 15mg daily Flomax 0.4mg daily Multivitamin daily Antacid daily Ascorbic acid 500mg daily Colace 100mg [**Hospital1 **] Discharge Medications: 1. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) grm Intravenous Q 24H (Every 24 Hours) for 8 days: day 1 was [**8-9**], last day is [**8-22**] (total of 14 day course). Disp:*8 doses* Refills:*0* 2. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 4 days: day 1 was [**8-8**], last day is [**8-17**] (total of 10 day course). Disp:*12 doses* Refills:*0* 3. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig: One (1) gm Intravenous Q24H (every 24 hours) for 4 days: day 1 was [**8-8**], last day is [**8-17**] (total of 10 day course). Disp:*4 doses* Refills:*0* 4. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 5. Morphine 10 mg/5 mL Solution Sig: 1-2 drops PO Q1-2HRS as needed for pain. Disp:*1 bottle* Refills:*0* 6. Lorazepam 2 mg/mL Solution Sig: One (1) Mg Injection Q4 Hours. Disp:*1 bottle* Refills:*0* 7. Heparin Lock Flush 10 unit/mL Syringe Sig: Two (2) Intravenous twice a day: 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. Disp:*1 month supply* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Aspiration Pneumonia Secondary: Parkinson's disease Dementia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted with trouble swallowing and you were found to have an infection, which is most likely in your lungs due to aspiration. In addition, you had one positive blood cultutre. We treated you with antibiotics. Your Parkinson's disease has progressed, and this contributes to the likelihood of aspiration events. After discussion with you and your family, you are being sent home with hospice care so you can be with your family. You will be able to finish the antibiotic course there. . We made the following changes to your medications: -STOP Hydrochlorothiazide (HCTZ) -STOP Metoprolol -STOP Darifenacin and Flomax (you are going home with a foley in place) -START ON MORPHINE SL as needed for pain -START lorazepan 1 mg IV as needed every 4 hours as needed for anxiety/agitation -START ON Antibiotics: vancomycin for your blood infection for a total of 14 days (this medication should finished by [**8-21**]). You were also started on ceftriaxone and flagyl for possible aspiration infection and you will need a total of 10 days ( this will be finished [**8-17**]) Followup Instructions: You should call the hospice, Care Alternative: [**First Name5 (NamePattern1) 1785**] [**Last Name (NamePattern1) 29970**] [**Telephone/Fax (1) 29971**] for any concerns or questions.

[ "276.0", "V43.64", "358.00", "790.7", "185", "507.0", "401.9", "V45.82", "285.9", "V58.61", "332.0", "428.0", "596.59", "414.01", "427.31", "584.9", "041.10" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.6" ]

icd9pcs

[ [ [] ] ]

11447, 11453

5916, 9831

352, 368

11568, 11568

3321, 3860

12814, 13000

2593, 2684

10171, 11424

11474, 11547

9857, 10148

11707, 12231

2699, 3302

4475, 5893

12260, 12791

275, 314

396, 1628

11583, 11683

1650, 2303

2319, 2577

271

173,727

21643

Discharge summary

report

Admission Date: [**2120-8-7**] Discharge Date: [**2120-8-20**] Date of Birth: [**2074-11-30**] Sex: F Service: [**Doctor First Name 147**] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: gallstone pancreatitis Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a 45 year old female transferred from [**Hospital3 **] on [**2120-8-7**] for treatment of pancreatitis. Patient presented to [**Hospital1 **] after a syncopal episode. Postive reports of R abdominal and back pain after eating fatty meals in the past. At [**Hospital1 **], lipase 7474m antkase 2,490, ALT 402, AST 463, bili 1.5, Alk Phos 130, WBC 17. CT demonstrated cholecystitis, cholelithiasis, intrahepatic ductal dilatation and pacreatitis with surrounding phlegmon. She improved on cefotetan, imopenem and hydration. On [**8-6**], patient symptoms became acutely worse and developed grey-[**Doctor Last Name **] sign. Repeat CT demonstrated increase in abdominal fluid, increase in pancreatic inflamation, increase [**Last Name (un) **] of phlegman, new pleural effusions. Patient arrived to [**Hospital1 18**] intensive care unit [**2120-8-7**]. Past Medical History: none Social History: Denies EtOH, Tobacco or IDU Family History: Denies CAD, cancer, or gallstones Physical Exam: 99.2 158/70 89 24 94% 5L diaphoretic dry MMM tachy regular dull @ bases bilaterally, poor inspiratory effort tense echymosis over flanks bilaterally, tender, distended, no rebound mild lowere extremity edema Pertinent Results: [**2120-8-7**] 08:06PM LACTATE-1.0 [**2120-8-7**] 07:12PM GLUCOSE-155* UREA N-19 CREAT-0.5 SODIUM-153* POTASSIUM-3.8 CHLORIDE-113* TOTAL CO2-30* ANION GAP-14 [**2120-8-7**] 07:12PM ALT(SGPT)-42* AST(SGOT)-21 ALK PHOS-90 AMYLASE-80 TOT BILI-0.4 [**2120-8-7**] 07:12PM LIPASE-33 [**2120-8-7**] 07:12PM CALCIUM-7.9* PHOSPHATE-2.1* MAGNESIUM-2.5 [**2120-8-7**] 07:12PM WBC-14.9* RBC-3.35* HGB-8.4* HCT-27.3* MCV-81* MCH-25.1* MCHC-30.8* RDW-16.8* [**2120-8-7**] 07:12PM NEUTS-75* BANDS-0 LYMPHS-15* MONOS-8 EOS-2 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2120-8-7**] 07:12PM PT-14.2* PTT-19.7* INR(PT)-1.3 Brief Hospital Course: On arrival to medical intensive care unit, patient was stable and supportive measures were continued. Imipenan was continued. Patient remained stable and was started on TPN and transferred to the surgical intensive care unit on [**8-8**]. Patient continue to improve in both clinical appearance and in lab values and was transferred to the floor [**8-10**]. Sugars were monitored and patient required insulin. Patient was advanced low fat diet on [**8-16**] which she tolerated well. A [**Last Name (un) 387**] consult was obtained for patients new onset of diabetes. A cholecystectomy was planned during the hospital admission was but then cancelled secondary to a large pseudocyst demonstrated on CT. Patient was discharged on [**8-20**] with surgical and [**Last Name (un) 387**] follow upl Medications on Admission: none Discharge Medications: 1. Lantus 100 unit/mL Solution Sig: Eight (8) units Subcutaneous at bedtime. Disp:*30 * Refills:*2* 2. Humalog 100 unit/mL Solution Sig: per sliding scale unit Subcutaneous with meals. Disp:*100 * Refills:*2* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: insulin dependent diabetes gallstone necrotizing pancreatitis cholelithiasis Discharge Condition: good Discharge Instructions: Take medications as perscribed. Call doctor or report to emergency if develop abdominal pain, naseau or vomiting Followup Instructions: Patient to call and make appointment with Dr.[**Name (NI) 2829**] office in one month. Office will arrange for patient to have repeat CT scan that AM. [**Hospital **] Clinic- [**2120-9-11**] 10 am with Dr.[**Last Name (STitle) **] [**Telephone/Fax (1) 55107**] Patient to follow up with Dr.[**Name (NI) 56952**] office regarding diabetic nutrition education classes.

[ "574.10", "577.0", "574.00", "577.2", "250.01" ]

icd9cm

[ [ [] ] ]

[ "99.15", "38.93" ]

icd9pcs

[ [ [] ] ]

3476, 3482

2258, 3054

356, 363

3603, 3609

1622, 2235

3770, 4145

1344, 1379

3109, 3453

3503, 3582

3080, 3086

3633, 3747

1394, 1603

294, 318

391, 1255

1277, 1283

1299, 1328

61,857

101,897

36124

Discharge summary

report

Admission Date: [**2160-11-13**] Discharge Date: [**2160-11-18**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2901**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: Mr. [**Known lastname 22656**] is an 85 year-old man with a history of hypertension and coronary artery disease who presented with angina, now being transferred to the CCU after bieng found to have left main coronary artery disease. Six months prior to admission, began experiencing "palpatations", described as chest pressure over the left nipple. It would occur in the morning and occasionally throughout the day and would be worsened by his morning weight lifting. Each episode would last ~5-10 minutes. They were not associated with SOB, diapheresis or nausea. He contact[**Name (NI) **] his PCP he referred him to a cardiologist (Dr. [**Last Name (STitle) **]. A stress MIBI was performed and reportedly positive per the patient though we do not have the report. He was then prescribed SL nitro which he took twice daily, with or without symptoms though he does believe that taking it with symptoms did help. Four months ago he underwent cataract surgery, at which time he stopped aspirin. The surgery was uneventful. Three months prio to admission, the angina resolved and he ran out of nitro. Two weeks prior to admission he stopped aspirin in preparation for spinal stenosis surgery. Five days prior to admission, he again began to experience palpatations. He was in [**State 108**] for his surgery and, upon describing his symptoms to the anesthiologist, was cancelled. He flew back to [**Location (un) 86**] on [**11-13**] and called his PCP who referred him to the ED for further evaluation. In the ED VSS, EKG showed old LBBB per his PCP. [**Name10 (NameIs) **] CP resolved with SL NTG x1. He was given ASA 325mg and started on a heparin gtt. Overnight, he was continued on nitro and heparin gtts and had stuttering chest pain. On the morning of transfer he was loaded with Plavix 600mg and sent for cardiac cath where he was found to have a 80% ulcerated left main lesion. ROS (-) PND/orthopnea (+) Edema, chronic (-) Fevers/chills/weight change (+) Sinus congestion with Flomax (-) Cough (+) Occasional heart burn (+) Constipation (BM every 2-3 days) (-) Nausea/vomiting/diarrhea (-) Bloody stools (+) "Black stools" (+) Chronic leg pain, anteriorly, though secondary to spinal stenosis Negative colonoscopy in [**2155**], per patient PSA normal, per patient Past Medical History: 1. CARDIAC RISK FACTORS: (-) Diabetes (-) Dyslipidemia (+) Hypertension 2. CARDIAC HISTORY: -CABG: None. -PCI: None. -PACING/ICD: None. 3. OTHER PAST MEDICAL HISTORY: - Old LBBB (old per PCP) - History of paroxysmal atrial fibrillation (patient denies) - BPH - Spinal Stenosis - Cataracts, s/p surgery - History of nephrolithiasis - History of bilateral hip fracture, s/p repair (right in [**10-3**]; left in [**12-4**]) Social History: Orginially from [**Country 2784**]. Retured from teaching mechanical engineering at [**University/College **]. Quit smoking 45 years ago, rare EtOH, no drugs. Married. Family History: (+) HTN, (+) CAD. Physical Exam: VS: Afebrile, 127/55, 56, 12, 95% on room air GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: MMM. NCAT. Sclera anicteric. Right pupil 3mm --> 2mm and left faintly reactive, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of 8 cm. CARDIAC: Regular rate, normal S1, S2. II/VI systolic murmur at LUSB LUNGS: Anteriorly clear. ABDOMEN: Soft, NTND. EXTREMITIES: 2+ edema bilaterally; 2+ DP pulses BUTTOCK: 4x3cm tan discolorated area on right buttock; blanches; skin intact. SKIN: No rashes. PULSES: Right: Carotid 2+ DP 2+ Left: Carotid 2+ DP 2+ Pertinent Results: Laboratory values: [**2160-11-13**] 06:05PM BLOOD WBC-6.2 RBC-4.64 Hgb-13.8* Hct-39.2* MCV-85 MCH-29.9 MCHC-35.3* RDW-14.2 Plt Ct-142* [**2160-11-16**] 04:09AM BLOOD WBC-6.3 RBC-4.13* Hgb-12.5* Hct-35.4* MCV-86 MCH-30.4 MCHC-35.4* RDW-14.2 Plt Ct-144* [**2160-11-13**] 06:05PM BLOOD PT-13.0 PTT-30.5 INR(PT)-1.1 [**2160-11-16**] 07:59AM BLOOD PT-12.8 PTT-50.3* INR(PT)-1.1 [**2160-11-16**] 07:59AM BLOOD FDP-0-10 [**2160-11-16**] 07:59AM BLOOD Fibrino-344 D-Dimer-As of [**10-28**] [**2160-11-15**] 11:12AM BLOOD ESR-10 [**2160-11-13**] 06:05PM BLOOD Glucose-121* UreaN-15 Creat-0.9 Na-140 K-4.0 Cl-107 HCO3-26 AnGap-11 [**2160-11-16**] 04:09AM BLOOD Glucose-119* UreaN-19 Creat-0.9 Na-140 K-4.2 Cl-107 HCO3-26 AnGap-11 [**2160-11-14**] 04:00PM BLOOD ALT-11 AST-15 CK(CPK)-51 AlkPhos-60 Amylase-38 TotBili-0.9 [**2160-11-13**] 06:05PM BLOOD CK(CPK)-71 [**2160-11-14**] 02:39AM BLOOD CK(CPK)-57 [**2160-11-14**] 10:33AM BLOOD CK(CPK)-50 [**2160-11-13**] 06:05PM BLOOD cTropnT-0.02* [**2160-11-14**] 02:39AM BLOOD CK-MB-NotDone cTropnT-0.03* [**2160-11-14**] 10:33AM BLOOD CK-MB-NotDone cTropnT-0.03* [**2160-11-14**] 04:00PM BLOOD cTropnT-0.03* [**2160-11-15**] 02:28AM BLOOD Calcium-8.7 Phos-4.0 Mg-1.9 [**2160-11-16**] 07:59AM BLOOD D-Dimer-476 [**2160-11-14**] 04:00PM BLOOD VitB12-277 [**2160-11-15**] 11:12AM BLOOD Triglyc-44 HDL-60 CHOL/HD-3.0 LDLcalc-109 [**2160-11-15**] 11:12AM BLOOD CRP-15.3* [**2160-11-14**] 10:11PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.050* [**2160-11-14**] 10:11PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG Imaging/Studies: CXR - 1.2 cm nodular opacity in the left upper lung zone, concerning for lung mass. Followup imaging is recommended. ECG - Sinus rhythm with a first degree A-V block. Old left bundle-branch block. ECHO - The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%), mostly secondary to left bundle branch block-related septal motion. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are three aortic valve leaflets. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. IMPRESSION: Symmetric LVH with borderline global systolic function. Mild mitral regurgitation. Mild pulmonary hypertension. CT head w/o - IMPRESSION: Loss of [**Doctor Last Name 352**]-white matter differentiation in the medial right frontal lobe, MR [**First Name (Titles) 151**] [**Last Name (Titles) 4639**]n-weighted imaging is recommended to rule out acute infarction. MRI/A head: IMPRESSION: 1. Acute right anterior cerebral artery territorial infarct. 2. Tiny small areas of slow diffusion in the right parietal, right medial occipital, left parietal and the left frontal regions indicate multiple small infarcts, which could be embolic in nature. MRA OF THE HEAD: Head MRA demonstrates normal flow signal within the arteries of anterior and posterior circulation. IMPRESSION: Normal MRA of the head. Brief Hospital Course: 85M presenting with chest pain admitted initially to cardiology service. Patient continued to have chest pain and underwent emergent catheterization and found to have left main disease. He was transferred to the CCU to await CABG, but had a R ACA stroke and CBAG was deferred. He was discharged to rehab in stable condition. # Coronary Artery Disease: Initially presented with concern for unstable angina; ruled out by cardiac enzymes; ECG was difficult to interpret in setting of LBBB. Medically managed overnight with heparin gtt, nitro gtt, ASA, BB, statin. Caridac cath on [**11-14**] showed LMCA ulcerated lesion of 70% and tortuous aorta. Given LMCA lesion and its nature, patient was transferred to CCU for further observation prior to possible CABG. He was continued on ASA, heparin gtt and metoprolol and high dose statin. Nitro gtt was started to maintain patient symptom free and maintain BP <120. ASA was decreased to 81 mg QD. Patient was also started on Integrillin drip on [**11-15**] which was discontinued on [**11-16**], given no further catheterization. Metoprolol was started low dose, and he is charged on 25mg toprol daily. ACEI held for now. Can start amlodipine 5mg if neeeded at rehab. # CVA: On [**11-15**] patient was noted to have LLE paresis and LUE weakness, urinary incontinence on routine vitals check. VS were stable. Given that these findings were new, neurology consultation was immediately obtained. Last normal exam was 3 hrs prior to observation of symptoms. Heparin was temporarily stopped given concern for intracranial hemorrhage (ICH). CT head confirmed no ICH and heparin gtt was restarted. Given unclear timing of the event, tPA was not administered. MRI of head showed acute infarct in the Right ACA territory consistent w/ exam. Given relatively small size of infarction and being outside of 5hr window, pt did not undergo MERCI retrieval. By [**11-16**], patient's exam markedly improved w/ [**3-1**] distal and 4+/5 proximal LLE. At time of discharge pt's exam was [**3-1**] upper and lower extremity strength. Per Neurology recommendations patient was started on coumadin for total duration of at least 3mo. Patient discharged on Lovenox as bridge to therapeutic INR on coumadin. Patient discharged to rehab and has neurology follow up in 3 months. . # Acute on Chronic Diastolic Heart Failure: On admission, patient had 2+ lower extremity edema dn elevated JVP to 10cm, no prior history of heart failure. Echo showed symmetric LVH with borderline global systolic function, EF 50-55%, likely secondary to LBBB. Mild mitral regurgitation and mild pulmonary hypertension were also noted. Given CVA, no lasix was admininistered to maintain pressures > 120 systolic. ACE-I was also held due to concern for hypotension, and betablocker dose dose was decreased temporarily while hypotetnsive, but was titrated back up to 12.5 mg [**Hospital1 **]. Patient was provided with [**Male First Name (un) **] stockings. . # Sinus bradycardia: Bradycarid to the 50's throughout admission. Patient has reported history of PAF but patient denies this. Patient remained in sinus rhythm throughout hospitalization. Given history of Atrial fibrillation, patient will require 2wk monitoring of HR to assess for duration of anticoagulation. If goes into atrial fibrillation, will likely need life-long anticoagulation, to be determined by out patient cardiologist. . # Acute Anemia: Patient was found to have Hct decreased from 39 to 34 post cath. No active sources of bleeding were identified, however pt had one guiac positive stool on [**11-17**]. HCT improved to 35 by [**11-16**] and remained stable for the remainder of hospitalization. . # Spinal Stenosis: Surgery was delayed until cardiac disease issues were resolved. Patient was treated w/ oxycodone/acetaminphen and IV morphine prn for pain control. . # Hypertension: Patient was hypertensive on admission. He was continued on home regimen of norvasc, quinopril and motoprolol prior to catheterization w/ SBPs in 140-150 range. ACE-I and CBB were held in setting of relative hypotension. amlodipine can be restarted as needed. . # Lung Nodule: Noted on CXR as incidental finding, no priors for comparison. Patient will require CT as outpatient for further evaluation. . # Right Buttock Prior Decub Ulcer Site: Patient reports this is site of prior decub which occured during hip fracture surgery. Per his report, was difficult to heal. On exam, a well healed, erythematous area was noted. Skin care w/ frequent repositioning and dry dressings was performed. . # Propylaxis: DVT - lovenox 90mg sq [**Hospital1 **] transitioned to warfarin. Continue lovenox until therapeurtic INR ([**12-30**]) for 2 days. Protonix 40mg PO daily while in ICU, discontinued on discharge. . # Code: FULL CODE Medications on Admission: Norvasc 10mg daily flomax quinapril 20mg daily Aspirin 81mg daily Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: dose adjust for goal INR [**12-30**]. x 3 months (until [**2160-2-9**]). 8. Enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg Subcutaneous Q12H (every 12 hours): 90 mg sq [**Hospital1 **]. Continue until therapeutic on coumadin (INR [**12-30**]) for 2 days. 9. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 10. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary Diagnoses: Unstable Angina Left Main Coronary Artery Disease Right Anterior Cerebral Artery Stroke Secondary Diagnoses: Left Bundle Branch Block Hypertension Spinal Stenosis Possible history of Atrial Fibrillation BPH Discharge Condition: Good, vitals stable. Discharge Instructions: You were admitted with chest pain and you had a cardiac catheterization which showed a blockage the main left artery of the heart which cannot be fixed with a stent. The cardiac surgeons saw you and determined that you would be a candidate for bypass surgery. Unfortunately, you had a small stroke as a complication of the catheterization. Because of this, you will need to go to rehab to regain your strength before considering heart surgery. Several medications were adjusted: - Atorvastatin 80mg daily should be taken every day - Toprol 25mg daily - You were started on Coumadin for your stroke, this is a blood thinner that prevents clots from forming. Lovenox will be administered until the coumadin levels are therapeutic - Quinipril has been held. If you have chest pain, shortness of breath, high fever, pain at your groin, severe abdominal pain, dizziness or lightheadedness or any other concerning symptom, please seek medical care immediately. It was a pleasure meeting you and participating in your care. Followup Instructions: CARDIOLOGY: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2160-12-5**] at 10:30AM NEUROLOGY: Dr. [**First Name (STitle) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 2574**] [**2161-2-17**] at 2:00pm CARDIAC SURGERY: Dr. [**Last Name (STitle) 81943**] [**Name (STitle) **] ([**Telephone/Fax (1) 6876**] on [**12-18**] (thursday) at 1:30 [**Initials (NamePattern4) **] [**Hospital Unit Name **], [**Location (un) **], suite A at [**Hospital1 18**] on the [**Hospital Ward Name **]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

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