ChanBeDu/relevant_section_length · Datasets at Hugging Face

64,374

126,037

42253

Discharge summary

report

Admission Date: [**2131-11-29**] Discharge Date: [**2131-12-7**] Date of Birth: [**2056-2-26**] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion/Diminished exercise tolerance/ intermittent angina Major Surgical or Invasive Procedure: [**2131-11-29**] Aortic valve replacement (19mm St. Juse tisse), Coronary artery bypass graft x 1 (Saphenous vein graft to obtuse marginal) History of Present Illness: 75 year old female with a history of aortic stenosis which has been followed by serial echocardiograms. Recently she has become symptomatic with a markedly diminished exercie tolerance and dyspnea on exertion which were new symptoms. An echocardiogram was obtained which showed severe aortic stenosis with an increased mean gradient. A stress test earlier in the year showed poor exercise tolerance with slight ST depressions. In preparation for surgery, a cardiac catheterization was obtained which showed a 60% circumflex stenosis. Given the progression of her disease and symptoms, she has now been referred for aortic valve replacement and surgical revascularization. Past Medical History: Aortic Stenosis s/p Aortic valve replacement Coronary artery disease s/p Coronary artery bypass graft x 1 Hypertension Hyperlipidemia Hypothyroidism Temporal arteritis Polymyalgia rheumatica osteoarthritis Osteopenia Cataracts childhood asthma bronchiectasis BLE varicosities Social History: Race:Caucasian Last Dental Exam:1 yr ago Lives alone Contact: Phone # Occupation:retired Cigarettes: Smoked no [] yes [X] Hx: quit approx. [**2106**]; previously 1ppd for 30 years Other Tobacco use:none ETOH: < 1 drink/week [X] [**2-26**] drinks/week [] >8 drinks/week [] Illicit drug use:none Family History: No premature coronary artery disease. Family hx colon cancer. Physical Exam: Pulse:72 Resp: 16 O2 sat: 100% B/P Right:141/78 Left: 140/76 Height: 5'5 Weight: 145 lbs General:NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x]anicteric sclera; OP unremarkable Neck: Supple [x] Full ROM []no JVD Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [x] grade __4/6 SEM radiates throughout precordium to carotids Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x]; no HSM/CVA tenderness Extremities: Warm [x], well-perfused [x] Edema [] none_____ Varicosities: BLE L > R Neuro: Grossly intact [x];nonfocal exam;MAE [**5-24**] strengths Pulses: Femoral Right: 2+ Left: 2+ DP Right: NP Left: NP PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit: murmur radiates to carotids Pertinent Results: [**2131-11-29**] Echo: PRE-BYPASS: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. POST CPB: 1. Preserved [**Hospital1 **]-vewntricular systolic function. 2. Prosthetic valve identified in aortic position. It is well sr\eated and stable. Normal lealfet motion. There is mild perivalvular reguragitation. Unable to obtain gradients across the aortic valve due to poor transgastric windows. 3. No other change. [**2131-12-7**] 05:43AM BLOOD WBC-11.9* RBC-3.43* Hgb-10.0* Hct-30.9* MCV-90 MCH-29.2 MCHC-32.4 RDW-15.6* Plt Ct-275 [**2131-12-6**] 05:51AM BLOOD WBC-12.0* RBC-3.42* Hgb-10.0* Hct-30.4* MCV-89 MCH-29.1 MCHC-32.7 RDW-14.6 Plt Ct-332 [**2131-12-7**] 05:43AM BLOOD PT-14.2* INR(PT)-1.2* [**2131-12-6**] 05:51AM BLOOD PT-12.5 PTT-22.2 INR(PT)-1.1 [**2131-12-5**] 06:00AM BLOOD PT-11.6 INR(PT)-1.0 [**2131-12-7**] 05:43AM BLOOD Glucose-127* UreaN-18 Creat-0.7 Na-141 K-4.8 Cl-105 HCO3-30 AnGap-11 [**2131-12-6**] 05:51AM BLOOD Glucose-137* UreaN-16 Creat-0.7 Na-142 K-5.1 Cl-106 HCO3-30 AnGap-11 [**2131-12-4**] 01:20PM BLOOD CRP-82.9* [**2131-12-4**] 01:20PM BLOOD ESR-51* Brief Hospital Course: Ms. [**Known lastname 20677**] was a same day admit and on [**11-29**] was brought to the operating room where she underwent an aortic valve replacement and coronary artery bypass graft x Please see operative note for surgical details. Following surgery she was transferred to the CVICU for invasive monitoring in stable condition. She initially woke with some right sided neglect which resolved on POD1 with no residual focal deficits. She was agitated initially post op and self extubated on POD1. All narcotics were discontinued for lethargy and Zyprexa was given once for delirium. Her mental status slowly improved over the next several days and she was neurologically intact at the time of discharge. On POD 2 chest tubes were removed with some bleeding at chest tube sites requiring sutures in the right and middle site with resolution of the bleeding. On POD 3 she went into rapid atrial fibrillation with subsequent hypotension and was briefly started on Neosynephrine and converted to sinus rhythm on an Amiodarone drip. She was given a unit of blood for a hematocrit of 23 and weaned off pressors. AFib resumed and she was placed on Coumadin. On POD 4 the patient had an episode of amaurosis fugax of the right eye. This was associated with right temporal headache and jaw claudication. Additionally, ESR and CRP were elevated. She does have a history of temporal arteritis. Rheumatology, Ophthalmology and Vascular Surgery were consulted. High dose steroids were initiated. Vascular Surgery did not feel that temporal artery biopsy was warranted given the chronicity of her symptoms and that she's had a right sided temporal biopsy in the past. Rheumatology feels strongly that the patient should be treated empirically, and that she may have been incompletely treated for her previous episode. She was placed on PCP prophylaxis in the setting of high dose steroids. Visual symptoms resolved and the patient will follow up with her Ophthalmologist, Dr. [**First Name (STitle) **] as an outpatient. Medications on Admission: Levothyroxine 112mcg daily Pravastatin 40mg daily Aspirin 81mg daily Amlodipine 5mg daily Vitamin D 1000 mg daily Nevanac gtts to affected eye TID Discharge Medications: 1. Outpatient Lab Work Labs: PT/INR Coumadin for AFib Goal INR 2-2.5 First draw [**2131-12-8**] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by Provider 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 4. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): Continue 60mg daily until follow-up with Rheumatology. 8. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 9. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation . 10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. vitamin A 10,000 unit Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 15. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: MD to dose daily for goal INR 2-2.5, dx: afib. 16. atovaquone 750 mg/5 mL Suspension Sig: Two (2) PO DAILY (Daily): 1500mg Daily for PCP prophylaxis, until discontinued by Rheumatology. 17. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 18. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Location (un) **] Nursing & Rehabilitation Center - [**Location (un) **] Discharge Diagnosis: Aortic Stenosis s/p Aortic valve replacement Coronary artery disease s/p Coronary artery bypass graft x 1 Past medical history: Hypertension Hyperlipidemia Hypothyroidism Temporal arteritis Polymyalgia rheumatica osteoarthritis Osteopenia Cataracts childhood asthma bronchiectasis BLE varicosities Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with APAP Incisions: Sternal - healing well, no erythema or drainage Leg- Left - healing well, no erythema or drainage. Trace 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: **Ophthalmology: Dr. [**First Name (STitle) **], [**Location (un) 15749**] [**Location (un) 2274**], [**Telephone/Fax (1) 71774**], [**12-14**], 8:45am Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2132-1-9**] 1:15 in the [**Hospital **] medical office building, [**Doctor First Name **] [**Hospital Unit Name **] Rheumatolgy: [**Doctor First Name **] [**Doctor Last Name 1667**] [**Telephone/Fax (1) 2226**] (office will call you with appt.) Please call to schedule appointments with your Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23097**] in [**2-22**] weeks Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 58292**] [**Telephone/Fax (1) 58293**] in [**4-24**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR Coumadin for AFib Goal INR 2-2.5 First draw [**2131-12-8**] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by Provider **Please arrange coumadin/INR follow-up prior to d/c from rehab** Completed by:[**2131-12-7**]

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Discharge summary

report

Admission Date: [**2135-8-6**] Discharge Date: [**2135-8-12**] Date of Birth: [**2072-8-29**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5129**] Chief Complaint: Fever, chills, malaise Major Surgical or Invasive Procedure: IR guided drainage of right psoas fluid collection History of Present Illness: Ms. [**Known lastname 104688**] is a 62F with PMHx of aggressive urothelial cancer s/p nephroureterectomy in [**2133**] who presented to [**Doctor Last Name **] [**Last Name (un) 45902**] on [**8-4**] for several days of weakness, chills and reduced PO intake and more acutely difficulty ambulating on morning of ED visit. She has a complicated history of urothelial carcinoma which after nephroureteral resection was shown to recur in liver and ?rectus sheath for which she received 5 cycles cisplatin/gemcitabine starting [**12-28**]. Of note she has had profound leukocytopenia and thrombocytopenia with chemotherapy. Her last dose consisted of carboplatin/gemcitabine was completed [**7-14**]. Since last round she has become increasingly weak, confused, with worsening RLQ pain and RLE thigh pain, she also had some shaking of her UE bilaterally Tuesday night into Wednesday. She saw her Heme/Onc on Wednesday who sent her to the ED because of increased confusion, shaking and difficulty ambulating. In ED she was found to be febrile, pancytopenic, profoundly thrombocytopenic with hypotension and tachycardia. She was admitted to MICU for AMS and possible CNS infection. Head CT scan completed which revealed no evidence of metastatic disease or bleed. CT abdomen showed ?fluid collections concerning for possible abscess. She was treated empirically with Doripenem, Acyclovir, Doxycycline and Vancomycin. She was transferred to [**Hospital1 18**] for further work up/management and ?IR guided drainage of abdominal fluid collection. Of note also, she has a tick bite on RLE 4 weeks ago. . On the floor her vitals were: T: 100.0 HR:104 BP 105/48 (on levo) O2 100% on 3L NC. She was lethargic but arousable, she answered questions appropriately and was oriented x3. She knew the vice president of the USA and could spell WORLD backwards but demonstrated poor concentration only getting [**1-22**] in serial 7s. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - Uroepithelial Ca +peritoneal mets - RLE DVT, on Lovenox, [**2135-1-18**] - Malignancy associated hypercalcemia - Epilepsy (age 14), [**Doctor Last Name 11332**] mal - Skin graft s/p burn, right arm and hand [**2127**] - h/o Lyme Disease [**2132**] Social History: Married, lives with husband who is healthcare proxy and supportive. Two daughters who live in eastern [**State 350**]. Was working until [**2135-2-15**] as medical receptionist, previously lab work in biochemistry. - Tobacco: None - Alcohol: Rarely - Illicits: None Family History: - [**Name (NI) 5895**] (mother, maternal grandfather). No history of genitourinary tract malignancies. Physical Exam: ADMISSION Vitals: T:100.0 (PO) BP: 105/48 P:98 R:20 O2:100% 3L NC General: Lethargic but arousable, answers appropriately. Seems to have some increased work of breathing but is in NAD 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, S1 S2 clear and of good quality, no murmurs, rubs, gallops Abdomen: Distended with diffuse ecchymoses from SC anticoagulation. Tense but NT, no rebound and no guarding. There is a superficial hard round mass over RLQ which is not painful. She has active BS, tympanic to percussion GU: foley in place draining light urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. Diffuse petechiae over LE bilaterally R>L. RLE has [**12-19**]+ edema up to mid tibia. Neuro: Lethargic but arousable, falls asleep occasionally during questioning. Answers appropriately, Oriented to person, place, time, knows president and vice president. Correcetly spells WORLD backwards, [**1-22**] in serial 7s. Follows commands well, moves all extremities purposefully, 5/5 strength UE and LE bilaterally. CN 2-12 grossly intact, PERRL, EOMI. Exam on Discharge: ****** Pertinent Results: Labs on Admission: [**2135-8-7**] 12:09AM BLOOD WBC-2.1* RBC-3.07* Hgb-9.7* Hct-28.1* MCV-92 MCH-31.7 MCHC-34.6 RDW-25.0* Plt Ct-17* [**2135-8-7**] 12:09AM BLOOD Neuts-62 Bands-13* Lymphs-18 Monos-4 Eos-2 Baso-0 Atyps-1* Metas-0 Myelos-0 [**2135-8-7**] 12:09AM BLOOD PT-12.6 PTT-30.6 INR(PT)-1.1 [**2135-8-7**] 12:09AM BLOOD Glucose-129* UreaN-17 Creat-1.0 Na-134 K-4.1 Cl-109* HCO3-20* AnGap-9 [**2135-8-7**] 12:09AM BLOOD Albumin-2.3* Calcium-7.3* Phos-1.9* Mg-2.0 [**2135-8-7**] 12:29AM BLOOD Lactate-1.2 [**2135-8-7**] 11:03PM BLOOD Lactate-1.0 [**2135-8-7**] 12:29AM BLOOD freeCa-1.09* Imaging [**8-7**] CXR: There is a Port-A-Cath with distal lead tip in the distal SVC. Cardiac silhouette is within normal limits. There are bilateral pleural effusions and a left retrocardiac opacity. Minimal prominence of the pulmonary vascular markings are present. There is no pneumothorax. Bony structures are grossly intact. [**8-7**] CT guided IE drainage: IMPRESSION: Technically successful CT-guided drainage of fluid collection in the right psoas. The contents appeared to represent primarily hemorrhagic products so the collection is likely to represent a subacute or chronic hematoma, although superinfection would be a consideration. Fluid sent for gram stain and microbiology studies. [**2135-8-7**] 5:00 pm ABSCESS GRAM STAIN (Final [**2135-8-7**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. CULTURE (Final [**2135-8-10**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH TTE (Trans-Thoracic Echocardiogram) Done [**2135-8-9**] IMPRESSION: Normal global and regional biventricular systolic function. No pulmonary hypertension or clinically-significant valvular disease seen. CHEST (PORTABLE AP) Study Date of [**2135-8-9**] FINDINGS: In comparison with study of [**8-7**], the degree of pulmonary vascular congestion has substantially decreased. There also appears to be decreased pleural effusions with a thick band of atelectasis at the bases. No definite acute focal pneumonia, though an area of increased opacification at the right base, most likely reflecting atelectasis and crowding of vessels. LUNG (V/Q) SCAN Study Date of [**2135-8-9**] Low probability of pulmonary embolism. Ventilation images demonstrate central clumping consistent with airways disease. There is also patchy aeration at the bases, likely reflecting atelectasis as seen on chest radiograph. Perfusion images show subsegmental perfusion defects at the lung bases corresponding to areas of decreased ventilation. Lung perfusion is otherwise normal with no unmatched perfusion defects identified. VENOUS DOPPLER/DUPLEX ULTRASOUND BILAT LOWER EXT VEINS Study Date of [**2135-8-9**] IMPRESSION: No evidence of deep venous thrombosis in either right or left lower extremity. Labs on Discharge: [**2135-8-12**] 09:36AM BLOOD WBC-4.5 RBC-2.89* Hgb-9.1* Hct-27.5* MCV-95 MCH-31.4 MCHC-33.0 RDW-23.0* Plt Ct-15* [**2135-8-12**] 09:36AM BLOOD Neuts-74.9* Lymphs-17.8* Monos-4.3 Eos-2.8 Baso-0.2 [**2135-8-11**] 05:07AM BLOOD Glucose-133* UreaN-21* Creat-1.2* Na-141 K-4.4 Cl-105 HCO3-29 AnGap-11 [**2135-8-10**] 05:52AM BLOOD ALT-7 AST-15 LD(LDH)-112 CK(CPK)-5* AlkPhos-88 TotBili-0.4 [**2135-8-9**] 05:59AM BLOOD Calcium-9.8 Phos-3.5 Mg-1.6 [**2135-8-10**] 05:52AM BLOOD D-Dimer-1872* [**2135-8-10**] 05:52AM BLOOD Hapto-58 [**2135-8-9**] 10:15AM BLOOD Vanco-18.0 Brief Hospital Course: 62yo F PMHx aggressive urothelial Ca s/p right nephroereterectomy +chemo p/w AMS, fever, hypotension was initially admitted to MICU for management of sepsis. . #Sepsis: Patient initially treated empirically with Vancomycin and Zosyn, initially briefly requiring Levophed; likely source was thought to be abdominal abscess seen on CT abdomen however patient underwent IR guided drainage of the cyst and cultures were negative and the fluid collection was felt to NOT represent an abscess. ID consulted and recommended continuing vanco/zosyn for a total of 14 days. #Pancytopenia: She was leukopenic and thrombocytopenic, but her ANC never dropped below 500. Hematology/Oncology was consulted regarding both care of her chronic malignancy as well as possible neupogen to improve her cell lines, they did not recommend Neupogen. They felt the leukopenia and thrombocytopenia was secondary to chemotherapy (most recent dose of Carboplatin/Gemcitabine was [**2135-7-14**], 3wks prior to admission) and sepsis - both causing supression of her bone marrow. Both cell lines are recovering, with platelets lagging behind the WBC. Heme-Onc is aware of this and is not concerned. They feel she should receive a platelet transfusion is her platelets drop below 10,000 (should not happen since her PLTS are rising) or if she develops a significant bleed that cannot be cotrolled with conservative measures such as pressure. HER PLATELET COUNTS AND WBC WITH DIFFERENTIAL SHOULD BE CHECKED AT LEAST ONCE A WEEK AT THE [**Hospital1 1501**] to ensure they are continuing to head in the right direction. . #Urethelial Carcinoma: Pt w h/o aggressive malignancy s/p chemotherapy and right nephrouretectomy, with evidence of abdominal metastasis. The patient was seen here and requested an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], which was arranged for her. . #H/O DVT: She was initially continued on treatment doses of lovenox for treatment of prior DVT. She has been on this dose since [**2135-1-18**]. However, LE dopplers were negative for DVT here and V/Q scan was low probability, so since she had received 6 months of treatment for her first episode of DVT (arguably known source - CA), she was changed to prohylactic dose of Lovenox. Given her malignancy the risk-benefit of continuing prophylactic Lovenox indefinetely probably favors continuing it. However, if her bleeding risk increases (i.e. if she becomes thrombocytopenic again), this may need to be reconsidered. . #Pain: Pt w abd chronic pain [**1-19**] malignancy and resections, on chronic narcotics as an outpatient. Pain was exacerbated by IR drainage (see above), and pain was refratory to 5mg Oxycodone tabs, so pt was started on Morphine SR to improve basal control. . INACTIVE #Seizure disorder: Continued depakote, lacosamide, keppra. . After her ICU stay and severe illness, she is very weak and deconditioned and will require [**Hospital 3058**] rehabilitation before returning home. Medications on Admission: - Depakote 250mg PO TID - Lacosamide (anti-epileptic) 100mg PO BID - Remeron 2.5mg PO QHS - Keppra (unknown dose) - Ondansetron 8mg PO Q6hrs prn - Lovenox - Tylenol 1gm Q67hrs prn - Dulcolax supp - Senna 1 tab po Daily - Oxycontin 30mg PO QHS - Oxycodone 5mg PO Q4hrs prn Discharge Medications: 1. valproic acid 250 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 2. lacosamide 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. ondansetron 4 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain or fever >100.4. 6. mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 7. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-19**] Sprays Nasal TID (3 times a day) as needed for dry nose. 8. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q12H (every 12 hours). 9. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): On in the morning and off in the evening. 10. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 11. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [**Hospital1 **] (2 times a day) as needed for constipation. 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 13. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q24H (every 24 hours). 14. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 15. Heparin Flush (10 units/ml) 5 mL IV PRN line flush Indwelling Port (e.g. Portacath), heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN per lumen. 16. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port Indwelling Port (e.g. Portacath), heparin dependent: When de-accessing port, flush with 10 mL Normal Saline followed by Heparin as above per lumen. 17. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 24H (Every 24 Hours) for 6 days. 18. piperacillin-tazobactam 4.5 gram Recon Soln Sig: 4.5 grams Intravenous every eight (8) hours for 6 days. Discharge Disposition: Extended Care Facility: [**Hospital1 2670**] Care & Rehab Discharge Diagnosis: Sepsis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were transferred from [**Hospital6 7472**] with sepsis (severe infection). The source of the infection was not identified, but you improved with antibiotics and, per our infectious disease service, need to finish two full weeks of IV antibiotics. You were also seen by our Oncology service and they feel that your blood counts are rising as expected after chemotherapy and the infection, including the platelet count which is rising more slowly. You were found to not have any evidence of blood clots in your legs or your lungs so the dose of Lovenox was decreased to 30 mg per day in order to prevent further blood clots from forming. It is a blood thinner, so it needs to be held or stopped if you develop any significant bleeding. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2135-8-30**] at 1:30 PM With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 3217**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

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icd9pcs

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Discharge summary

report

Admission Date: [**2144-12-11**] Discharge Date: [**2144-12-21**] Date of Birth: [**2078-11-23**] Sex: M Service: SURGERY Allergies: Ephedrine / Adhesive Tape / Oxycodone Attending:[**First Name3 (LF) 695**] Chief Complaint: Metastatic renal cell carcinoma to the liver Major Surgical or Invasive Procedure: [**2144-12-11**]: Left lateral segmentectomy, partial resection of right hemidiaphragm and primary repair, resection of segment 6 mass. History of Present Illness: 66 y/o old male with a history of metastatic renal cell carcinoma to the liver and common bile duct. He is now 10 months after undergoing a common bile duct excision, cholecystectomy, Roux- en-Y hepaticojejunostomy, segment III (umbilical fissure) mass resection, segment III mass resection x2, segment III and IV mass resection, segment V mass resection, segment VII mass resection, and segment VI mass resection for metastatic renal cell carcinoma to the common bile duct as well as multiple liver metastases and a solitary surface implant that wasperformed on [**2144-2-14**]. A repeat CT scan of the abdomen demonstrated 2 new lesions in the liver. There was a lesion in the left lobe of the liver near the dome that is in the area of the previous lesion taken of the area of segment III and segment IV. The second lesion is in segment VI and somewhat exophytic abutting Gerota fascia. No other abnormalities in the abdomen noted. To OR with Dr [**Last Name (STitle) **] for resection. Past Medical History: RCC [**2140**]; MI [**2136**]; DM- diet controlled PSH: CABGx5 and AVR [**2136**]; Nephrectomy [**2140**]; ERCP x 3 with multiple stent placements [**2144-2-11**]: CBD excision with cholecystectomy, Roux-en-Y and segment III, IV, V, VI and VII mass resections [**2144-9-18**]: Wound revision and closure of incisional hernia with Prolene mesh Social History: N/[**Doctor First Name **] has no history of alcohol use. He has a smoking history but quit eight years ago. He has no history of IV drug use, marijuana use, tattoos, hepatitis, or piercing. He did have blood transfusions in [**2136**] and [**2140**]. He has one year of college. He has been married for 36 years. Family History: N/C Physical Exam: Post Op VS: 101.1, 79, 96/52, 16, 100% General: Sedated Card: RRR, no murmur noted Lungs: CTA bilaterally Abd: Dressing with serous staining. JP with serosanguinous drainageNeuro: Propofol for sedation Vanc and Gent for St Jude Valve Pertinent Results: On Admission: [**2144-12-11**] WBC-9.3 RBC-3.03*# Hgb-9.3* Hct-25.4*# MCV-84# MCH-30.8# MCHC-36.8* RDW-17.2* Plt Ct-136* PT-15.0* PTT-25.2 INR(PT)-1.3* Glucose-166* UreaN-19 Creat-1.1 Na-140 K-5.1 Cl-105 HCO3-27 AnGap-13 ALT-61* AST-101* CK(CPK)-501* AlkPhos-37* TotBili-5.3* Calcium-7.5* Phos-4.0 Mg-2.0 On Discharge [**2144-12-21**] WBC-8.8# RBC-3.52* Hgb-10.6* Hct-30.5* MCV-87 MCH-30.2 MCHC-34.9 RDW-15.9* Plt Ct-262 PT-31.9* PTT-34.2 INR(PT)-3.3* Glucose-144* UreaN-13 Creat-1.4* Na-135 K-4.2 Cl-98 HCO3-30 AnGap-11 ALT-39 AST-32 AlkPhos-95 TotBili-0.9 Calcium-7.8* Phos-3.3 Mg-2.2 Albumin-2.7* Brief Hospital Course: 66 y/o male well known to service who underwent Left lateral segmentectomy, partial resection of right hemidiaphragm and primary repair, resection of segment VI mass for recurrent renal cell carcinoma. He was taken to the OR with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. At the time of the surgery, he had a large mass in the left lateral segment at a site of previous resection that was densely adherent to the right diaphragm and required a left lateral segmentectomy and resection of a portion of the right hemidiaphragm. There was a second mass lateral that was originally by CT thought to be in segment VI but in fact, most likely represented a large metastatic deposit along the resection margin of the previous segment VI resection. This was a large necrotic tumor mass between the liver and the diaphragm and right side of the abdominal wall adjacent to Gerota fascia. This mass could not be resected in its entirety. He received 4,000 mL of crystalloid, 3 units of fresh frozen plasma, 9 units of packed red cells, 750 mL of albumin and made 800 mL of urine. He remained intubated through POD 3 and remained on O2 for low O2 sats for several more days His diet was advanced with good tolerance following extubation The Foley was d/c'd on POD 4. He was diuresed with Lasix. On POD 4 he had fever to 102.6. Blood cultures drawn at that time grew E coli. He had been started on Vanco and Gentamycin on POD 0 as he has a St Jude valve and previous known bacteremia. He received 10 days of Vanco and 7 days of Gentamycin. He was also felt to have pneumonia based on chest xray and O2 requirements and Gentamycin was discontinued and Ceftazadime added. A PICC line was placed on [**2144-12-18**] as per ID recomendations who saw patient throughout the hospitalization. It was determined he should receive antibiotics IV through [**2144-12-28**]. He was switched to IV Ceftriaxone for discharge. Other culture data from this admission showed E coli growing at the drain site and cultures were also sent from the JP drain fluid, both medial and lateral, which need outpatient follow up. These drains are to stay in until further evaluation with Dr [**Last Name (STitle) **]. Incision looked slightly reddened, but is intact and without drainage. Medications on Admission: amitriptyline 50', bisoprolol fumarate 5', Vicodin 1 tab'''' prn, Mobic 15', warfarin 10', Tylenol prn, chondroitin sulfate 1 tab'', iron sulfate 1 tab', glucosamine 1000', Keflex 500''' Discharge Medications: 1. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-8**] Puffs Inhalation Q6H (every 6 hours). 2. Insulin Regular Human 100 unit/mL Solution Sig: follow sliding scale Injection ASDIR (AS DIRECTED). 3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 4. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Warfarin 2 mg Tablet Sig: Four (4) Tablet PO Once Daily at 4 PM: for aortic valve replacement. 7. 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. 8. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig: One (1) dose Intravenous Q24H (every 24 hours) for 7 days: stop after [**2144-12-28**]. 9. bisoprolol patient usually takes Bisoprolol fumarate 5mg qd. On hold due to low bp's. Discharge Disposition: Extended Care Facility: [**Doctor Last Name 74930**]Nursing Discharge Diagnosis: Left lateral esegmentectomy, segment 6 mass resection, repair of diaphragm [**2144-12-11**] for recurrent renal cell CA Pneumonia E.coli bacteremia Discharge Condition: good Discharge Instructions: Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if fever, chills, nausea, vomiting, incision rednss, bleeding or drainage. Followup Instructions: [**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**], RN coordinator will call with follow up appointment with surgeon Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**1-8**] weeks [**Telephone/Fax (1) 673**] Office. [**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**], RN [**Telephone/Fax (1) 17195**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2144-12-21**]

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icd9cm

[ [ [] ] ]

[ "38.93", "34.81", "50.22" ]

icd9pcs

[ [ [] ] ]

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3118, 5397

345, 483

6895, 6902

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7096, 7624

2220, 2225

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743

133,099

13973+13974

Discharge summary

report+report

Admission Date: [**2111-1-16**] Discharge Date: [**2111-2-20**] Date of Birth: [**2034-6-19**] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 41752**] is a 76 year-old male who was admitted to the [**Hospital Unit Name 196**] Service originally on [**2111-1-16**] with complaint of progressively worse dyspnea on exertion over a period of years. He also had worsening lower extremity edema and orthopnea. He had a cardiac catheterization in [**2106**], which showed diffuse disease, which was medically managed. He had an echocardiogram recently before admission showing small ASD and moderate AS with an EF of 35% with posterior basal akinesis. He was referred to [**Hospital1 69**] for cardiac catheterization, which he had on [**1-17**] showing nonsignificant ASD, severe AS with a peak gradient of approximately 40 and a valve area of 0.6, 70% lesion in his left anterior descending coronary artery, 80% ramus lesion and other more diffuse disease. His wedge at the time of catheterization was 26. He was admitted to the [**Hospital Unit Name 196**] Service for further management and evaluation for aortic valve replacement versus valvuloplasty. PAST MEDICAL HISTORY: 1. Multinodular goiter. 2. Atrial fibrillation. SOCIAL HISTORY: The patient is surrounded by a very supportive family. He denies any history of tobacco, alcohol or drug use. FAMILY HISTORY: There is no history of coronary artery disease, diabetes, hypertension, or malignancy. ALLERGIES: Penicillin with an unknown drug reaction. MEDICATIONS ON ADMISSION: 1. Bisoprolol 2.5 mg q.d. 2. Coumadin 3 mg q.d. 3. Lasix 40 mg b.i.d. 4. Potassium chloride 10 mg b.i.d. PHYSICAL EXAMINATION: Vital signs on admission revealed a temperature of 96.1, heart rate of 72, respiratory rate 20, blood pressure 110/61, oxygen saturation of 100% on 4 liters. In general, he is alert, oriented times three, pleasant and in no acute distress. Neck revealed elevated JVD to the earlobe. Lung examination revealed crackles approximately [**1-31**] of the way up bilaterally. His abdomen was scaphoid, soft, nontender, nondistended. His heart was irregular and he had a 2 out of 6 systolic ejection murmur at the left upper sternal border, also audible at the apex. His extremities were warm and he had 2+ dorsalis pedis pulses and posterior tibial pulses bilaterally. HOSPITAL COURSE: Cardiovascular: Mr. [**Known lastname 41752**] is admitted with progressively worsening dyspnea on exertion, edema, and orthopnea with cardiac catheterization at the time of admission showing severe AS with a peak gradient of 40 and a valve area of 0.6. There was also evidence of coronary artery disease in his left anterior descending coronary artery and ramus. He was initially evaluated by cardiac surgery for aortic valve replacement, however, originally underwent aortic valvuloplasty instead with minimal results. He was then further reevaluated by cardiac surgery for aortic valve replacement. Prior to him going to surgery he had a fall in his platelets and was found to be HIT antibody positive. At this time it was felt it was unsafe to take him to surgery. It was conveyed by the surgeon that it may be possible at a later date to take him to surgery in approximately 60 days if he was retested and was HIT antibody positive. Throughout all of this time his congestive heart failure was worsening and he was attempted to be medically managed on the floor with Lasix for diuresis. This had minimal results, and on [**2111-2-15**] he was transferred back to the Coronary Care Unit for possible Swan placement and Swan guided hemodynamic therapy. A Swan could not immediately be placed due to an elevated INR and PTT. While awaiting for these numbers to normalize the patient expressed wishes not to have anything else done and stated he was tired and did not want any more interventions at this time. He was managed well in the Coronary Care Unit without a Swan with peripheral Dobutamine with an increase in urine output. He symptomatically did not improve, however. On [**2111-2-19**] a family meeting was held separate from and then a second family meeting with Mr. [**Known lastname 41752**] in which the options were conveyed to him and his family, being either pursue aggressive medical management with placement of a Swan and hemodynamic therapy with goals of optimizing him with a goal of getting to a possible aortic valve replacement date in several months or the option of going home with hospice and with mostly comfort care only. After much discussion these options were presented to Mr. [**Known lastname 41752**] and he stated "I just want to go home." At this time it was felt after much discussion that it was best for him to go home with hospice services. Mr. [**Known lastname 41753**] other cardiac issues including coronary artery disease, episodes of nonsustained ventricular tachycardia, atrial fibrillation, and a nonhemodynamically significant ASD. All of these were managed throughout admission. He will be sent home on cardiac medications as he tolerates, however, he will not be sent home on anticoagulation for his atrial fibrillation. He will be discharged home with hospice services. DISCHARGE CONDITION: At the time of discharge Mr. [**Known lastname 41752**] was very cachectic and ill appearing. He was frequently in much discomfort and sleeping throughout most of the day. He was taking in minimal po and was on 2 liters of oxygen by nasal cannula. DISCHARGE MEDICATIONS: 1. Fentanyl patch. 2. MS Contin. 3. Oxytrol patch. 4. Ativan 0.5 mg q 4 to 6 hours prn. DISCHARGE DIAGNOSES: 1. Congestive heart failure. 2. Atrial fibrillation. 3. Nonsustained ventricular tachycardia. 4. Severe aortic stenosis. 5. Heparin induced thrombocytopenia. 6. Acute renal failure. DISCHARGE STATUS: On the day of planned discharge with hospice home services Mr. [**Name14 (STitle) 41754**] passed away. [**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3812**] Dictated By:[**Last Name (NamePattern1) 9820**] MEDQUIST36 D: [**2111-2-20**] 08:46 T: [**2111-2-20**] 08:53 JOB#: [**Job Number 41755**] Admission Date: [**2111-1-16**] Discharge Date: [**2111-2-20**] Date of Birth: [**2034-6-19**] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 41752**] is a 77 year old male with a history of severe aortic stenosis, congestive heart failure, atrial fibrillation, and hypertension who originally presented to [**Hospital1 69**] with a several month history of progressive dyspnea on exertion, shortness of breath, orthopnea, and increased lower extremity edema. He underwent an aortic valvuloplasty on [**2111-1-27**]. There was minimal improvement in aortic gradient and aortic valve area, and no change in cardiac index. He had minimal diuresis and was started with Lasix and Natrecor. He was then, subsequently, on the Cardiac Care Unit Service for medical management while awaiting aortic valve replacement. While on the Cardiac Care Unit Service, his platelets began to fall, and he was found to be heparin-induced thrombocytopenia antibody positive. At this point, it was decided by CT Surgery that he would not currently be a candidate for a valve replacement due to the need to use heparin during the operation. It was felt that he could be re-tested in 60 days for possible resolution of his antibody, and at that time, may be a candidate for surgery. While awaiting surgery, and after discovery of the heparin-induced thrombocytopenia antibody, Mr. [**Known lastname 41752**] continued to deteriorate on the floor with an inability to diurese very well due to renal insufficiency and hypertension. He was then transferred to the Cardiac Care Unit for closer monitoring and possible Swan placement and hemodynamic guided therapy. A line originally could not be placed due to coagulopathy, and while awaiting his coags to return to baseline, Mr. [**Known lastname 41752**] expressed wishes for no more procedures or interventions. He expressed that he was fed up and tired and did not want anything else done. At this time, he was started on peripheral Dobutamine through an IV that had previously been placed. He had an improvement in urine output at this point, and maintenance of heart rate and blood pressure, however, no symptomatic improvement. Despite explanation of the risks and benefits of central line and PA catheter placement, Mr. [**Known lastname 41752**] insisted that he did not want anything else done and that he was tired and just wanted to go home. On the evening of [**2111-2-19**], a family meeting was held with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12101**] of the Ethics Service, Dr. [**First Name4 (NamePattern1) 3692**] [**Last Name (NamePattern1) 284**], the attending, the family, and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], a member of the health staff, to discuss options and possible goals and plans of therapy. These options included doing everything possible medically with a goal of getting Mr. [**Known lastname 41752**] to the possibility of an aortic valve replacement. The other option included comfort measures only with him going home with Hospice. It was felt that he was competent to make this decision. These options were presented to him and he decided that he would rather go home with Hospice care. On the morning of [**2111-2-20**], at approximately 10:15 a.m., he became bradycardic with respiratory distress and hypotension. He subsequently passed away at 10:35 a.m. His son, [**Name (NI) **] [**Name (NI) 41752**], was at his bedside, and the team was also present in the Cardiac Care Unit. No autopsy was desired. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-749 Dictated By:[**Last Name (NamePattern1) 9820**] MEDQUIST36 D: [**2111-2-22**] 12:45 T: [**2111-2-22**] 14:11 JOB#: [**Job Number 41756**]

[ "398.91", "707.0", "427.31", "396.2", "584.9", "414.01", "599.7", "427.1", "276.5" ]

icd9cm

[ [ [] ] ]

[ "37.23", "35.96", "88.56", "00.13" ]

icd9pcs

[ [ [] ] ]

5277, 5528

1421, 1564

5665, 6393

5551, 5644

1590, 1700

2411, 5255

1723, 2393

6422, 10078

1224, 1275

1292, 1404

32,742

166,117

51068

Discharge summary

report

Admission Date: [**2101-8-19**] Discharge Date: [**2101-8-30**] Date of Birth: [**2039-5-25**] Sex: F Service: SURGERY Allergies: Iron Dextran Complex / Heparin (Porcine) / Ibuprofen / Gadolinium-Containing Agents / Morphine / Vancomycin Attending:[**First Name3 (LF) 5569**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: right colectomy [**2101-8-23**] History of Present Illness: Ms. [**Known lastname **] is a 62 year old female with a PMH significant for ESRD on T,Thr,Sa HD [**1-31**] IgA nephropathy s/[**Name Initial (MD) **] failed CRT with transplant nephrectomy in [**7-7**] admitted for fever and diarrhea now transferred to the MICU for BRBPR. The patient was initially admitted to [**Hospital1 18**] on [**2101-8-19**] febrile to 103 with associated diarrhea and cough. She was initially covered with pip/tazo and linezolid for a possible HAP, which were held when the patient did not have a consolidation on CXR with BCx and rapid viral screen negative. Antimicrobials were held on [**2101-8-21**] given suspicion of bacterial HAP was low, and patient has remained afebrile since without dyspnea or productive cough since. She has continued to have persistent diarrhea, however, with C.diff toxin [**Doctor First Name **] negative x1, with further stool studies pending although felt by the floor team to be viral gastroenteritis. Of note, the patient underwent upper and lower endoscopy [**2101-5-4**] that demonstrated internal hemorrhoids and diverticulosis of the entire colon. . Tonight, the experience 500 cc BRBPR with continued passing of clots. The patient was then transferred to the MICU for further management. On initial transfer, the patient had PIV x1, and so a CVL was placed. An 500 cc OGL was negative for blood, but without return of bile. Currently, the patient continues to complain of passing clots, but denies any CP/SOB, f/c/s, n/v/d, abd pain, HA, palpitations. . Past Medical History: 1. Status post living unrelated renal transplant [**10/2093**] for IgA glomerular nephritis 2. Chronic renal insufficiency with baseline creatinine ~3.5-4.5 3. Asthma 4. Hypertension 5. Gastroesophageal reflux disease 6. Hypercholesterolemia 7. Coronary artery disease not otherwise specified: catheterization [**2087**] with 70% D1, 60% D2, echocardiogram [**2097**] WNL 8. Mild pulmonary hypertension 9. History of pericarditis with tamponade [**2090**] 10. Status post subtotal parathyroidectomy for primary hyperparathyroidism 11. Status post appendectomy 12. Status post Cesarean section 13. h/o pre-eclampsia in her last pregnancy 14. h/o ectopic pregnancy 15. [**2101-7-12**] renal transplant graft nephrectomy . Social History: Patient lives with her children and grandchildren. She is a former smoker, but has not used tobacco since she was a teenager. She denies alcohol and illegal substance use. . Family History: Mother died in her 70s of stroke. Sister with hypertension. No history of cancer or DM in the family. Physical Exam: VS: 96.3 70 158/64 20 100%RA Gen: Age appropriate female in NAD. HEENT: Perrl, eomi, sclerae anicteric. MMM, OP clear without lesions, exudate, or erythema. CV: Nl S1+S2, II/VI systolic murmur LUSB. No S3/4. Pulm: CTAB Abd: S/NT/ND +bs Ext: No c/c/e Skin: Hyperpigmented, no rashes . Pertinent Results: [**2101-8-19**] 05:45AM GLUCOSE-78 UREA N-13 CREAT-4.8* SODIUM-140 POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-31 ANION GAP-15 [**2101-8-19**] 05:45AM ALT(SGPT)-6 AST(SGOT)-16 ALK PHOS-156* TOT BILI-0.6 [**2101-8-19**] 05:45AM CALCIUM-9.8 PHOSPHATE-5.3* MAGNESIUM-2.6 [**2101-8-19**] 05:45AM WBC-7.5 RBC-4.30 HGB-9.8* HCT-34.5* MCV-80* MCH-22.8* MCHC-28.4* RDW-19.3* [**2101-8-19**] 05:45AM PLT COUNT-273 [**2101-8-18**] 10:37PM LACTATE-1.6 [**2101-8-23**] 10:03PM BLOOD Hct-32.0* [**2101-8-23**] 05:09PM BLOOD Neuts-59.4 Lymphs-23.9 Monos-4.2 Eos-12.0* Baso-0.5 [**2101-8-23**] 05:09PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+ Schisto-OCCASIONAL Burr-OCCASIONAL Stipple-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**2101-8-23**] 10:03PM BLOOD PT-PND PTT-PND INR(PT)-PND [**2101-8-23**] 12:55PM BLOOD Fibrino-179 [**2101-8-23**] 05:09PM BLOOD Glucose-81 UreaN-22* Creat-7.2* Na-140 K-4.1 Cl-107 HCO3-24 AnGap-13 [**2101-8-23**] 10:17PM BLOOD Type-ART pO2-192* pCO2-44 pH-7.39 calTCO2-28 Base XS-1 [**2101-8-23**] 10:17PM BLOOD Lactate-1.0 [**2101-8-23**] 02:48PM BLOOD freeCa-1.42* CXR, [**2101-8-23**] Preliminary Report !! WET READ !! ETT TERMINATING 3CM ABOVE CARINA.LEFT CVC TERMINATING IN MID SVC. RT CVC TERMINATING IN STABLE POSITION. NEW RETROCARDIAC OPACIFICATION. COULD REFLECT ATELECTASIS. CLINICAL CORRELATION IS RECOMMENDED. LEFT LUNG IS CLEAR. [**2101-8-23**] Preliminary Report !! PFI !! Superior mesenteric artery angiogram showing active extravasation of contrast from one of the branches of right colic artery. Unsuccessful selective catheterization of right colic artery and hence failed embolization. Brief Hospital Course: A surgery consult was obtained. It was noted that there was active LGIB w/ diverticular disease of entire colon. GI was unable to scope due to much blood. On [**8-23**], interventional radiology noted brisk arterial bleed from one of the branches of right colic artery was on superior mesenteric angiography. They were unsuccessful at selective catheterization of the right colic artery after several attempts and the procedure was abandoned. She recieved a total of 6 units of PRBC for hematochezia. On [**8-23**], she was then taken to the OR by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for right colectomy for lower GI bleed. Please refer to operative note for details. It was noted that a side-to-side functional end-to-end ileal colostomy was performed. Postop, hematocrit stabilized at 31-32. Aspirin was resumed at half dose daily. Postop, she spent one day in the SICU while intubated. She was successfully extubated and transferred out of the SICU. She was kept npo until passing flatus. Diet was slowly advanced. Supplements were started due hypoglycemia 59-74 due to po po intake. She did experience some diarrhea on [**8-28**]. Stool was sent for c.diff on [**8-30**]. Stool softners were held. Pain was controlled with dilaudid pca that was later switched to po dilaudid when diet was tolerated. She did experience intermittent confusion that was concerning for possible side effect of dilaudid. Dilaudid was switched to vicodin. Confusion was also likely secondary to her hypercalcemia (calcium increased to [**11-10**])that was managed with hemodialysis and adjustment of her meds. Calcium was elevated due to low phos and inability to take sensapar. Phoslo was stopped and renagel started. Cinacalcet was increased to 90mg. Calcitriol was stopped. She received Epogen and zemplar while at HD. Of note, the patient is allergic to heparin therefore she receives sodium citrate in place of heparin while on dialysis. She continued to receive dialysis, but due to need to dialyze on [**8-29**] for hypercalcemia, the Tues-Thursday-Sat schedule was thrown off. She will require dialysis on Wed [**8-31**]. Annti-hypertensives were held preop given GIB. Most of these were subsequently resumed. BP stabilized on valsartan, labetalol and amlodipine). She remained afebrile. WBC normalized. Abdomen appeared distended with the incision appeared mildly erythematous on [**8-29**] and keflex (renally dosed)was started for a 5 day course. PT evaluated and found the patient in need of rehab. The plan was for discharge to [**Hospital **] Rehab [**Telephone/Fax (1) 58445**] on [**8-30**]. Medications on Admission: Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Amlodipine 10 mg PO DAILY Aspirin 81 mg PO DAILY Calcium Acetate 1334 mg PO TID W/MEALS Cepacol (Menthol) 1 LOZ PO PRN Cinacalcet 60 mg PO DAILY Labetalol 800 mg PO BID Lorazepam 0.5 mg PO Q6H:PRN Loperamide 2 mg PO QID:PRN diarrhea Nephrocaps 1 CAP PO DAILY Omeprazole 20 mg PO DAILY Ondansetron 4 mg IV Q8H:PRN nausea Simvastatin 40 mg PO DAILY Valsartan 320 mg PO DAILY Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours) as needed for incision erythema for 3 days: started [**8-29**]. 11. Cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 12. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 13. Allergic to Heparin Dialysis uses sodium citrate in the lines at Hemodialysis instead of heparin Discharge Disposition: Extended Care Facility: [**Hospital **] Rehab Discharge Diagnosis: GI bleed-diverticuli right colectomy hypercalcemia esrd incision cellulitis Discharge Condition: stable Discharge Instructions: You are being discharged to [**Hospital **] Rehab in [**Hospital1 8**] Please call the Transplant Office [**Telephone/Fax (1) 673**] if fever, chills, nausea, vomiting, increased abdominal distension, increased abdominal/incision pain, incision redness/drainage, confusion Dialysis will continue at [**Hospital1 **] on Monday-Wednesday-Fridays Followup Instructions: Please keep the following appointments: Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2101-9-8**] 3:50 [**Last Name (NamePattern1) 439**], [**Location (un) 86**]. [**Location (un) **] Provider: [**Name10 (NameIs) 7158**] [**Last Name (NamePattern4) 7159**], M.D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2101-11-2**] 11:30 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] AV CARE AV CARE [**Location (un) **] (NHB) Phone:[**Telephone/Fax (1) 5537**] -this appointment for eval of access will need to be rescheduled Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13999**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2101-8-26**] 11:00 Provider: [**Name10 (NameIs) 7158**] [**Last Name (NamePattern4) 7159**], M.D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2101-11-2**] 11:30 Also, please call your PCP after your discharge and make an appointment to follow-up with her within the next two weeks. Completed by:[**2101-8-30**]

[ "403.91", "562.13", "585.6", "272.0", "996.81", "E849.7", "682.2", "E878.0", "414.01", "E849.8", "079.99", "493.90", "E878.8", "998.59", "275.42" ]

icd9cm

[ [ [] ] ]

[ "00.14", "88.47", "39.95", "38.95", "45.73" ]

icd9pcs

[ [ [] ] ]

9278, 9326

5047, 7683

376, 409

9446, 9455

3337, 5024

9847, 10916

2914, 3017

8150, 9255

9347, 9425

7709, 8127

9479, 9824

3032, 3318

328, 338

437, 1960

1982, 2706

2722, 2898

5,075

104,020

30334

Discharge summary

report

Admission Date: [**2109-3-5**] Discharge Date: [**2109-3-12**] Date of Birth: [**2051-9-26**] Sex: F Service: SURGERY Allergies: Protamine Attending:[**First Name3 (LF) 2597**] Chief Complaint: B/L Debilitating intermittent claudication Ischemic rest pain in her right foot Major Surgical or Invasive Procedure: Aortobifemoral bypass with 12 x 6 aortobifemoral femoral Dacron graft. History of Present Illness: This 57-year-old lady has had severe debilitating intermittent claudication of both her extremities for quite some time. She recently developed ischemic rest pain in her right foot. A CT angiogram was done which showed her infrarenal aorta to be open with total occlusion of her left iliac system from the aortic bifurcation to the groin, and a patent right common iliac artery, but a totally occluded right external iliac artery. She reconstituted common femoral arteries with patent superficial femoral arteries distally. Because of her young age and her severe symptoms, she has been recommended to have bypass surgery. Past Medical History: PMH HTN,(echo - nl EF), PVD, Murmur, s/p tubal ligation Social History: rare alcohol approximately Q month and denies other substances. Quit smoking 15 days ago after 40 years. Pt lives with husband and one of her 3 adult sons in [**Name (NI) **] MA. employed as a secratary Family History: n/c Physical Exam: VSS: 114/45, 62, 98.8, 97%RA, 18 GEN: NAD CARD: RRR, +SEM Lungs: CTA, diminished at bases ABD: +BS, soft Wound: Incisions C/D/I. Staples removed Pulses: palp B/L DP/PT Pertinent Results: [**2109-3-11**] 05:30AM BLOOD WBC-10.4 RBC-3.59* Hgb-11.9* Hct-34.3* MCV-95 MCH-33.0* MCHC-34.6 RDW-14.0 Plt Ct-427 [**2109-3-11**] 05:30AM BLOOD Plt Ct-427 [**2109-3-11**] 05:30AM BLOOD Glucose-87 UreaN-12 Creat-0.8 Na-137 K-4.2 Cl-99 HCO3-28 AnGap-14 [**2109-3-7**] 10:50AM BLOOD ALT-18 AST-22 AlkPhos-50 Amylase-37 TotBili-0.4 [**2109-3-6**] 05:09AM BLOOD CK(CPK)-370* [**2109-3-11**] 05:30AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.1 Brief Hospital Course: Pt underwent aortobifemoral bypass on [**3-5**]. During surgery she developed rapid SVT, hypotension and hypoxia, cardioverted with restoration of a sinus brady and stabilized- possible protamine rxn; she was kept intubated and sedated overnight. Cardiology-Dr. [**Last Name (STitle) **] consulted. Echo obtained POD 1: Patient extubated. Lopressor continued. Palpable DP pulses. Remained in ICU- metabolic acidosis and T wave inversion on ECG. Dr. [**Last Name (STitle) **] following patient for possible silent ischemia in setting of SVT/ operative procedure. T wave inversion resolved. POD 2: VSS, pain controlled with MSO4 PCA. Diet advanced to sips. Diuresis, OOB. POD 3: Transient desaturation to 87% on 3L NC. Denies SOB. Chest x-ray showing pulmonary congestion and right pleural effusion. Lasix X 2 given . CTA to r/o PE performed. Negative for PE. CTA showing mucous plug with total RLL collapse. Patient remained in VICU, aggressive pulmonary toilet. Bronchoscopy performed. POD 4: No overnight events, breathing improved. Psychiatry consulted as patient is requesting DNR/DNI. patient deemed competent and DNI ordered. Ambulating on oxygen with physical therapy. POD 5: VSS. No overnight events. Ambulating with physical therapy not requiring oxygen. O2 sats >93% on room air and while ambulating. Levaquin discontinued. POD 6: VSS. No overnight events. B/L palpable DP/PT pulses. Discharge to home with physical therapy. Staples removed. Will follow up with Dr. [**Last Name (STitle) **] in [**1-27**] weeks. Medications on Admission: ASA 81, plavix 75, atenolol 25, dyazide Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. [**Date Range **]:*1 1* Refills:*3* 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Obtain refill authorization from primary MD. [**Last Name (Titles) **]:*30 Tablet(s)* Refills:*0* 5. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. 7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**3-29**] hours as needed for pain. [**Month/Day (3) **]:*40 Tablet(s)* Refills:*0* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Month/Day (3) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: B/L Debilitating intermittent claudication Ischemic rest pain in her right foot Discharge Condition: Good. VSS. Cr 0.8, HCT 34.3 Palpable B/L DP pulses Discharge Instructions: Division of Vascular and Endovascular Surgery Endovascular Abdominal Aortic Aneurysm (AAA) Discharge Instructions Medications: ?????? Take Aspirin 81mg once daily ?????? Do not stop Aspirin unless your Vascular Surgeon instructs you to do so. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [**1-26**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [**3-29**] weeks for post procedure check and CTA What to report to office: ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: Call Dr.[**Name (NI) 5695**] office at [**Telephone/Fax (1) 3121**] to schedule post op visit to be seen in [**1-26**] weeks. Completed by:[**2109-3-12**]

[ "997.1", "486", "427.89", "788.5", "428.0", "933.1", "440.22", "E941.2", "285.9", "305.1", "997.3", "E849.7", "E878.2", "458.29", "E912", "518.0", "276.2" ]

icd9cm

[ [ [] ] ]

[ "39.29", "99.62", "96.05" ]

icd9pcs

[ [ [] ] ]

4703, 4758

2052, 3579

349, 422

4882, 4935

1598, 2029

7524, 7681

1390, 1395

3669, 4680

4779, 4861

3605, 3646

4959, 6944

6970, 7501

1410, 1579

229, 311

450, 1075

1097, 1154

1170, 1374

47,335

161,669

54681

Discharge summary

report

Admission Date: [**2173-8-11**] Discharge Date: [**2173-8-28**] Service: MEDICINE Allergies: aspirin / Percocet Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Shortness of Breath; transfer for Evaluation for CABG and AVR Major Surgical or Invasive Procedure: Intubation for Respiratory Failure Aortic Valve Balloon Angioplasty Right Heart Catheterization IABP placement History of Present Illness: Mr. [**Known lastname **] is a 88M w/ hx of CAD (100% ostial RCA occlusion, 90% D1 stenosis), critical AS (Aortic valve peak gradient 71 mm Hg, valve area <0.8cm2), systolic and diastolic CHF (LVEF 35% [**3-/2173**]) and DMII, who was transfered to [**Hospital1 18**] from [**Hospital3 12748**]. He presented to OSH on [**2173-8-10**] with several weeks of SOB. In [**Month (only) 958**], the patient had an echo and cardiac catheterization that demonstrated critical AS and severe three vessel disease not amenable to percutaneous intervention. It is not clear why a revascularization procedure or valve procedure was not brought up at that time. . He was recommended CABG and AVR by two cardiology consultants during hos admission at LGH. The patient and wife were agreeable and so he was transfered. . On admission to [**Hospital1 18**] he related that he has been having dyspnea for months, but has gotten worse in the past few weeks. He now gets out of breath just taking [**5-13**] steps. He has never blacked out or passed out. He denies any chest pain now or ever. He does have a cough, which he says is productive of occasional white/yellow sputum. He says he has gotten pneumonia twice in the past few months, but unclear when exact last time was. He denies orthopenea (sleeps with one pillow at night), but does endorse PND. He denies constipation or diarrhea. 1BM per day. He denies any palpitations. . The patient denies pain, chest pain, fevers, chills. The patient does note he has had some loose stools the past few days, and was admitted for a pneumonia, as recently as a few weeks ago. . On the floor the patient was doing well until the time of transfer. He was being activly diuresed with IV lasix but he initally did not make much urine in response. He was given additional IV Lasix on the morning of transfer to the CCU. Overnight he had been acutely desating but continually recovered his O2 sat on his own. He was empircally covered with Vanco/Cefepime for HCAP due to fever and respitory status. Shortly prior to transfer to the CCU at that time he acutely desaturated and required intubation due to inability to tolerate the BiPAP on the floor. He was transfered to the CCU. Past Medical History: CAD - (last c. cath in [**3-/2173**]) AS - Aortic valve peak gradient 60 w/ mean gradient of 37. Area of 0.5cm2 (echo [**3-/2173**]) HTN DMII chronic systolic CHF ischemic cardiomyopathy hypercholesterolemia HTN Social History: mother and sister both had severe coronary artery disease Family History: Lives w/ wife in [**Name (NI) 487**]. No current smoking but did in past. No current EtOH. Physical Exam: ADMISSION: 97.6 91/57 65 18 98% on RA FS 189 GENERAL: NAD lying in bed HEENT: PERRL, EOMI, MM mildly dry NECK: no carotid bruits appreciated, JVP 7cm at 30 degree angle LUNGS: mild crackles at bases, otherwise good air excursion HEART: RRR, no S2 heard, late peaking, soft I/VI holosystolic, squeaky murmur heard best at RUSB; soft heart sounds ABDOMEN: Soft, NT, NABS, no organomegaly EXTREMITIES: No c/c. Very trace edema b/l to ankles NEUROLOGIC: A+OX3, CN II-XII intact. Gross motor and sensation intact b/l. . Discharge: Pt expired Pertinent Results: ADMISSION: [**2173-8-12**] 12:07AM BLOOD WBC-5.2 RBC-3.89* Hgb-11.2* Hct-34.6* MCV-89 MCH-28.8 MCHC-32.3 RDW-16.4* Plt Ct-120* [**2173-8-12**] 08:10AM BLOOD PT-11.6 PTT-28.4 INR(PT)-1.1 [**2173-8-12**] 12:07AM BLOOD Glucose-208* UreaN-33* Creat-1.5* Na-135 K-4.4 Cl-101 HCO3-24 AnGap-14 [**2173-8-12**] 08:10AM BLOOD ALT-15 AST-16 LD(LDH)-159 AlkPhos-46 TotBili-0.5 [**2173-8-12**] 12:07AM BLOOD CK-MB-2 cTropnT-0.04* [**2173-8-12**] 12:07AM BLOOD Calcium-8.5 Phos-4.0 Mg-1.8 . PERTINENT: [**2173-8-14**] 04:40PM BLOOD CK-MB-2 cTropnT-0.06* [**2173-8-15**] 05:06AM BLOOD CK-MB-2 cTropnT-0.09* [**2173-8-14**] 12:27PM BLOOD Lactate-1.7 [**2173-8-14**] 04:00PM BLOOD Lactate-1.4 [**2173-8-14**] 12:27PM BLOOD Type-ART Temp-36.6 pO2-53* pCO2-34* pH-7.51* calTCO2-28 Base XS-3 Intubat-NOT INTUBA [**2173-8-15**] 12:24AM BLOOD Type-ART Temp-38.4 FiO2-100 pO2-135* pCO2-44 pH-7.38 calTCO2-27 Base XS-0 AADO2-533 REQ O2-89 Intubat-INTUBATED [**2173-8-15**] 09:48AM BLOOD Type-ART Temp-37.5 Tidal V-500 PEEP-10 FiO2-50 pO2-109* pCO2-37 pH-7.38 calTCO2-23 Base XS--2 -ASSIST/CON Intubat-INTUBATED . DISCHARGE: . STUDIES: Echo: [**2173-8-12**]: The left atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with inferolateral and anterior hypokinesis (multivessel CAD). The remaining segments contract normally (LVEF = 35%). The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Critical calcific aortic stenosis. Symmetric LVH with moderate regional left ventricular systolic dysfunction. Mild aortic regurgitation. Moderate mitral regurgitation. Moderate tricuspid regurgitation. Severe pulmonary hypertension. . Echo: [**2173-8-15**] Post-AV Valvuloplasty There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is moderately depressed (LVEF= 35%) with regional variation consistent with multivessel CAD. The right ventricular cavity is moderately dilated with normal free wall contractility. The aortic valve leaflets are severely thickened/deformed. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Symmetric LVH with moderate regional left ventricular systolic dysfunction. Moderately dilated RV with normal systolc function. Trivial mitral regurgitation, mild tricuspid regurgitation, mild aortic regurgitation. Compared with the findings of the prior study (images reviewed) of [**2173-8-12**], LV size and function are similar. The mitral regurgitation and tricuspid regurgitation are less apparent, but this could be related to sub-optimal imaging quality. The degree of aortic regurgitation appears similar, but assessment of the aortic valve is limited by sub-optimal imaging quality and severity of aortic stenosis was not directly assessed. . CXR: [**2173-8-12**] PA and lateral images of the chest demonstrate low lung volumes, likely due to low inspiratory effort. There are bilateral pleural effusions. Pulmonary vascular congestion is seen. The aorta is tortuous, and there is a prominent left pulmonary artery seen in the left hilum. There is nopneumothorax. Visualized osseous structures are unremarkable . CT Chest: [**2173-8-12**] 1. Patient is known with aortic stenosis and coronary artery disease : aortic valve and coronary arteries are heavily calcified. The aorta is mildly dilated in its ascending portion and is moderately calcified. The vast majority of upper portion of ascending aorta is not calcified. 2. Bilateral pleural effusion with septal thickening and ground-glass opacities are compatible with mild-to-moderate pulmonary edema. 3. Complex right kidney cyst is not completely included in this study. Because it has some calcified portion, an MRI is suggested. . Carotid US: [**2173-8-13**]: Findings are consistent with less than 40% stenosis bilaterally. Brief Hospital Course: 88M w/ hx of significant coronary artery disease and critical AS, COPD, HTN, HLD, DM2, who presented from OSH for evaluation of revascularization and/or valvular replacement procedures and subsequently developed acute hypoxic respiratory failure and needed to be intubated. #Goals of Care: On [**8-27**], pt became hypotensive with a SBP between 55-60 and was started on dopamine. He was brought to cath lab for IABP placement, was intubated, and maintained on pressors throughout the day. Pt's hemodynamics failed to improve and family decided to make him CMO. Balloon pump and pressors were discontinued. Pt expired on [**8-28**]. Active Issues During Admission: # Acute hypoxic respiratory failure: This was likely multifactorial in nature. Patient initially presented to inpatient cardilogy service where he appeared to be with pulmonary edema. He was gently diuresed in setting of AS. However, his respiratory status continued to decline despite nebulizers for management of COPD and heightened levels of diuresis. On HD3, he developed a cough and progressive hypoxia, rising from 2L to 4-5L with desaturations into the 70s. ABG showed profound hypoxemia and respiratory alkalosis. CXR showed pulmonary edema but it was felt that his edema may be hiding a potential PNA. Broad spectrum antibiotics (vanc, cefepime, levofloxacin) were initiated to treat HCAP. Sputum showed 4+ Gram + rods and 1+ Gram - rods. Patient ultimately required BIPAP but was unable to tolerate this, precipitating intubation and mechanical ventilation as well as transfer to the CCU. Aggressive diuresis and antibiotics were continued in the CCU. Dopamine and levophed were initially required to maintain mean arterial pressures. Swan was placed after patient developed oliguria as volume status was unclear. This demonstrated wedge pressure consistent with septic physiology (see below) which was managed with IVF and antibiotics. He was then taken to the cath lab and aortic balloon angioplasty was performed to augment cardiac output. However during the course of this hospitalization patient continued to have significant secretion with desats to 70s requiring deep suctioning of mucus plugs. Pulmonary was consulted who performed bronchoscopy with copious removela of secreations and mucus plugs. . # CHF: likely secondary to ischemic cardiomyopathy and also signficant critical AS. Patient was intially fluid recussictaed in the CCU for management of septic shock. Once his septic shock resolved, patient's CXR showed significant volume overload. He had valvuplasty to augment his cardiac output. He was intermittenly diuresed and kept euvolemic throughout majority of admission. . #Hypernatremia: Sodium elevated to 150 in the setting of diuresis. Free water defecit calculated and NG tube free-water bolus were given to correct. . # AS: critical AS (Aortic valve peak gradient 71 mm Hg, valve area <0.8cm2). Referred to this center for eval of percutaneous valve vs. cardiac [**Doctor First Name **] valve. Balloon Valvoplasty on [**2173-8-16**]. Intra-cath numbers showed LVEDP of 22 (correlated well with PADP), PCWP 18, SVO2 in 70s, CO [**5-9**], CI 3, SVR < 1000, mean valve gradient went from 50 to 30s after proceedure. . # Acute on Chronic renal insufficiency: Most recent Cr 1.2 at OSH. This was elevated to 4.2 and likely secondary to overaggressive diuresis and poor foward flow. [**Last Name (un) **] was held and diuresis was minimized to restore intravascular volume. . # CAD: patient w/ significant CAD per most recent cardiac cath (100% ostial RCA occlusion, 90% D1 stenosis). Patient was scheduled for CABG at time of admission but unable to perform surgery in setting of acute respiratory failure. #Thrombocytopenia- He had transient thrombocytopnia that self resolved. The nadir was 81 and had trended back to normal range. Uncertain etiology. . # DMII: on oral agents (metformin and glipizide) at home but was transitioned to insulin sliding scale while in house. HIs blood sugars ever elevated on the sliding scale to the mid 300s and he was placed on an insulin drip. His blood sugar was better controled and he was transitioned back to a sliding scale. . # Dyslipidemia: patient was continued on lipitor. . # hx of COPD: patient was continued on flovent and duonebs while in house. . Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from OSH records. 1. Allopurinol 300 mg PO DAILY 2. Nitroglycerin SL 0.3 mg SL PRN chest pain 3. Furosemide 20 mg PO DAILY 4. Atorvastatin 20 mg PO DAILY 5. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea 6. Atenolol 12.5 mg PO DAILY 7. Omeprazole 40 mg PO DAILY 8. Oxymetazoline 1 SPRY NU [**Hospital1 **] Duration: 3 Days 9. rivastigmine *NF* 3 mg Oral [**Hospital1 **] 10. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] 11. Gabapentin 600 mg PO DAILY 12. GlipiZIDE 10 mg PO BID 13. Losartan Potassium 50 mg PO DAILY 14. MetFORMIN (Glucophage) 1000 mg PO BID 15. meloxicam *NF* 7.5 mg Oral [**Hospital1 **] Discharge Medications: Pt expired Discharge Disposition: Expired Discharge Diagnosis: Primary: Pneumonia, Aortic Stenosis Secondary: Coronary Artery Disease, Hypertension, Hyperlipidemia, Diabetes Discharge Condition: Expired Discharge Instructions: Pt expired Followup Instructions: .

[ "414.01", "518.81", "403.90", "785.51", "785.52", "496", "486", "428.0", "E915", "511.89", "276.4", "274.9", "428.43", "287.5", "585.9", "E884.4", "424.1", "507.0", "276.0", "272.0", "V49.86", "038.9", "995.92", "272.4", "V66.7", "584.5", "250.00", "934.8", "414.8" ]

icd9cm

[ [ [] ] ]

[ "37.78", "96.72", "37.61", "35.96", "34.04", "37.23", "33.22", "33.24", "37.21", "88.56" ]

icd9pcs

[ [ [] ] ]

13335, 13344

8209, 12525

296, 409

13499, 13508

3630, 8186

13567, 13572

2965, 3057

13300, 13312

13365, 13478

12551, 13277

13532, 13544

3072, 3611

195, 258

437, 2639

2661, 2874

2890, 2949

59,592

166,933

39455

Discharge summary

report

Admission Date: [**2152-7-13**] Discharge Date: [**2152-7-21**] Date of Birth: [**2107-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins / Vicodin / Cefepime Attending:[**First Name3 (LF) 2009**] Chief Complaint: Osteomyelitis Major Surgical or Invasive Procedure: Right hallux debridement [**2152-7-14**], [**2152-7-17**], [**2152-7-20**] and closure [**2152-7-20**] History of Present Illness: The patient is a 44 year-old male with IDDM s/p crush injury to both feet in [**2151-3-10**] with ulceration of left and right great toes at nail bed and gangrene of left 3rd toe requiring amputation [**2151-7-10**]. Right great toe has had ulceration of nail bed since accident, with periodic worsening and improvement. Approximately one month ago, patient noted increased swelling of the right foot and the lower half of the leg, much more severe pain, "deepening of infection," as well as fevers to 102.8. Approximately two weeks prior to admission, the patient dropped a small popsicle on R great toe; one day later, he developed a blood blister along the lateral aspect of the toe. The day after, it opened and has been leaking thick, foul smelling fluid. Patient has been soaking it in Hibiclens. The patient has been followed by podiatry in [**Hospital3 **] for management of his bilateral foot ulcers since his accident. In the setting of his worsening erythema, pain, and new ulcer, he was started on IV vancomycin 12 days ago by his podiatrist and PCP. [**Name10 (NameIs) **] missed his dose the day prior to admission. Despite IV antibiotics, the toe is progressively worsening, with increasing pain and swelling. A culture in [**Hospital3 **] [**2152-7-1**] grew out staph aureus sensitive to vancomycin as well as prevotella species. Given the progression of the infection, the patient presented at [**Hospital1 18**] for further management and treatment. Past Medical History: - DMI: type I diagnosed age 3, last AIC 9 - HTN - Dyslipidemia - h/o renal insufficiency on NSAIDS diagnosed [**2152-6-8**] after taking Ibuprofen 800 mg Q8h Social History: Patient currently smokes 1-1.5PPD x 20 years. Social ETOH; denies IVDU and illicit drug use. Lives with mother on [**Location (un) **]. Works as a cook in the family restaurant. Has a 6 year-old son. Family History: - Father: gastric Ca - Uncle: type II DM - No significant family history of CAD Physical Exam: EXAM ON ADMISSION: - General: tired appearing, uncomfortable - HEENT: PERRL, EOMI, MMM, neck supple and without LAD - CV: tachycardic, regular rhythm, 2/6 SEM appreciated at RUSB - Lungs: clear to auscultation bilaterally - Abdomen: BS present, soft, non-distended, non-tender - Extremities: right lower leg edematous to below knee with mild erythema along shin and at base of great right toe; right great toe with two deep ulcerations, the first on the nail bed ~ 4 cm primarily white, the second ulceration along lateral aspect of toe ~4 cm, with outline of necrotic black tissue around erytematous central tissue; left foot missing 3rd toe, all nail beds scabbed over, erythematous blister on medial aspect of ball of left foot Pertinent Results: ADMISSION LABS: WBC-11.7* RBC-3.20* HGB-8.7* HCT-27.9* MCV-87 MCH-27.3 MCHC-31.3 RDW-14.6 NEUTS-75.0* LYMPHS-17.6* MONOS-3.8 EOS-3.1 BASOS-0.5 PLT COUNT-710* PT-12.8 PTT-29.6 INR(PT)-1.1 LACTATE-0.7 K+-4.3 GLUCOSE-137* UREA N-20 CREAT-0.8 SODIUM-136 POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-28 ANION GAP-14 ESR-87* CRP-130.4* ALT-169* AST-182* AlkPhos-359* TotBili-0.3 cTropnT-<0.01 Albumin-3.1* Calcium-8.7 Phos-3.0 Mg-2.0 URINE BLOOD-TR NITRITE-NEG PROTEIN-150 GLUCOSE-TR KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 FOOT XRAY PA, LATERAL, OBLIQUE: Interval progression of bony destruction secondary to progressive osteomyelitis of the right great toe. CHEST XRAY: No acute cardiopulmonary abnormality. MICRO DATA BLOOD CULTURES OBTAINED [**2152-7-13**]: NO GROWTH SWAB Right hallux ulcer: OBTAINED [**2152-7-13**] GRAM STAIN (Final [**2152-7-13**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. WOUND CULTURE (Final [**2152-7-17**]): CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH. STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. SPARSE GROWTH. ANAEROBIC CULTURE (Final [**2152-7-19**]): Mixed bacterial flora-culture screened for B. fragilis, C. perfringens, and C. septicum. None isolated. PREVOTELLA SPECIES. SPARSE GROWTH. BETA LACTAMASE POSITIVE. TISSUE BONE RIGHT HALLUX: OBTAINED [**2152-7-14**] GRAM STAIN (Final [**2152-7-14**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS. SMEAR REVIEWED; RESULTS CONFIRMED. TISSUE (Final [**2152-7-19**]): STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. SPARSE GROWTH. IDENTIFICATION PERFORMED ON CULTURE # [**Numeric Identifier 87175**] [**2152-7-13**]. ANAEROBIC CULTURE (Final [**2152-7-20**]): PREVOTELLA SPECIES. SPARSE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 303-1075C [**2152-7-13**]. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2152-7-17**]): NO FUNGAL ELEMENTS SEEN. SWAB RIGHT HALLUX: OBTAINED [**2152-7-14**] GRAM STAIN (Final [**2152-7-14**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. WOUND CULTURE (Final [**2152-7-20**]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. Work-up of organism(s) listed below discontinued (excepted screened organisms) due to the presence of mixed bacterial flora detected after further incubation. GRAM POSITIVE BACTERIA. RARE GROWTH. ANAEROBIC CULTURE (Final [**2152-7-20**]): PREVOTELLA SPECIES. SPARSE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 87175**], [**2152-7-13**]. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. SWAB RGT. FOOT WOUND: OBTAINED [**2152-7-17**] GRAM STAIN (Final [**2152-7-17**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2152-7-21**]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. ANAEROBIC CULTURE (Final [**2152-7-21**]): NO ANAEROBES ISOLATED. TISSUE RIGHT HALLOX: OBTAINED [**2152-7-20**] GRAM STAIN (Final [**2152-7-20**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [**2152-7-23**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. ANAEROBIC CULTURE (Final [**2152-7-24**]): NO ANAEROBES ISOLATED. DISCHARGE LABS WBC-15.1* RBC-3.25* Hgb-8.9* Hct-28.1* MCV-86 MCH-27.2 MCHC-31.6 RDW-15.4 Plt Ct-792* ESR-46* Glucose-247* UreaN-21* Creat-0.9 Na-133 K-4.8 Cl-97 HCO3-32 AnGap-9 ALT-42* AST-25 LD(LDH)-243 AlkPhos-186* TotBili-0.2 Calcium-8.8 Phos-3.0 Mg-2.1 CRP-36.9* Vanco-9.2* STUDIES FOOT XRAY PA, LATERAL, OBLIQUE: FINDINGS: Bandage overlies the foot. Mild dorsal soft tissue swelling and moderate plantar soft tissue swelling. Status post great toe transphalangeal amputation and status post right hallux debridement. The cortical margin appears clean. No fractures. No dislocation. Incidental note is made of a bipartite medial sesamoid and a type 2 os naviculare. IMPRESSION: Post-surgical changes of the right foot, as above. Brief Hospital Course: The patient is a 44 year-old male with DMI, smoker, s/p crush injury to both feet [**2151-3-10**] who presented with nonhealing osteomyelitis of right great toe despite 12 days of treatment with IV Vancomycin. The patient was admitted [**Date range (3) 87176**] for surgical and medical management of his osteomyelitis, the course of which was complicated by an anaphylactic reaction to cefepime on [**2152-7-14**]. The hospital course is as follows. 1. Osteomyelitis: upon presentation, the patient was afebrile, with a WBC of 11.7, and a lactate of 0.7. Foot x-rays were notable for osteomyelitis. No vascular insufficiency was found. Initial tissue cultures grew gram negative rods and gram positive cocci in pairs. The patient was started on cefepime, flagyl, and aztreonam to broaden coverage for gram negative organisms and pseudomonas. He was continued on vancomycin, which he had been receiving for 12 days prior to admission. Upon receiving cefepime, the patient developed an anaphylactic reaction, as described below. At that point, cefepime was stopped and ciprofloxacin was added to his regimen. The patient was taken to the OR [**2152-7-14**] for surgical debridement by podiatry, and the wound was left open. He was managed with antibiotics and daily dressing changes by podiatry and returned to the OR [**2152-7-17**] for further debridement. The wound was once again left open, and repeat foot x-rays showed no osteomyelitis. The patient returned to the OR [**2152-7-20**] for a third debridement and closure of the ulcer. Multiple cultures from the site revealed mixed flora, and patient was maintained on broad spectrum antibiotics at discharge; he is to follow-up with infectious disease and podiatry to follow-up with bone biopsy and for further antibiotic titration. During his course, the patient had a high narcotics requirement due to severe pain. His pain was managed with a morphine PCA. He was transitioned to oral MS Contin upon discharge. 2. Anaphylaxis: the night of admission, the patient developed throat swelling, tongue swelling, and rash to cefepime. He did not need to be intubated. He was transferred to the ICU and treated with epinephrine, H2 blocker, and steroids. He completed a three day course of steroids and was monitored on telemetry. When he stabilized, he was transfered back to the floor. Cefepime was added to his OMR allergy list. 3. Leukocytosis: throughout the patient's stay, his white blood count was persistently elevated, peaking at 21.2. This was attributed to both his infection and steroids. He was discharged with PCP and ID follow up for monitoring. 4. Transaminitis: At presentation, AST/ALT elevated to 100s. Unclear etiology. Liver function tests monitored and improved within normal range at discharge. He was recommended to have LFTs rechecked as outpatient to ensure continued resolution of transaminitis. 5. Diabetes mellitus, type I: The patient was persistently hyperglycemic, likely related to infection and steroid use. His Humalog sliding scale was increased from 8 (breakfast)/8 (lunch)/10 (dinner) to [**2152-9-17**] at discharge. His Lantus dose was maintained at home regimen, 42 units QHS. At discharge, blood glucose was well-controlled on the above regimen. 6. Hypertension: Due to persistently elevated blood pressure, lisinopril was increased from 10mg daily to 20mg daily. He was requested to have creatinine and potassium recheck within one week of discharge given increased dose. 7. Thrush: Likely related to underlying diabetes and recent infection. Improved with nystatin swish and swallow. 8. Tobacco use: Patient was maintained on a nicotine patch. He was counseled on the importance of quitting, particulary in the setting of wound healing. 9. Anemia: Patient was persistently anemic in the upper 20s. Patient reports he has had longstanding anemia. He was recommended to follow-up for formal anemia workup with his primary care provider. Medications on Admission: - Lantus 42U QPM - ISS: Novolog 8U breakfast, 8U lunch, 10U dinner - Lisinopril 5 mg QD - Oxycodone 15 mg [**Hospital1 **] prn pain - Oxycontin 20 mg Q12h prn pain - Lasix 40 mg QD given for swelling in leg/foot - Lamisil 250 mg QD - Bactroban 2% app TID - Vancomycin 1g IV Q12h - Ambien 10 mg QHS prn insomnia - Magnesium oxide 400 mg Discharge Medications: 1. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 2. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for sleep. 3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day): Use until thrush symptoms resolve. Disp:*300 ML(s)* Refills:*0* 5. Vancomycin 750 mg Recon Soln Sig: One (1) dose Intravenous every twelve (12) hours for 12 days: Take with 500mg solution for total dose 1250mg every 12 hours. Disp:*24 doses* Refills:*0* 6. Vancomycin 500 mg Recon Soln Sig: One (1) dose Intravenous every twelve (12) hours for 12 days: Take with 750mg solution for total dose 1250mg every 12 hours. Disp:*24 doses* Refills:*0* 7. Heparin Flush 10 unit/mL Kit Sig: Two (2) mL Intravenous once a day: Flush with 10mL Normal Saline followed by Heparin daily and as needed per lumen. . Disp:*100 mL* Refills:*2* 8. Normal Saline Flush 0.9 % Syringe Sig: Ten (10) mL Injection once a day: Flush with 10mL Normal Saline followed by Heparin daily and as needed per lumen. . Disp:*60 syringe* Refills:*0* 9. Insulin Lantus 42 units at bedtime Humalog 10 units breakfast, lunch, and dinner 10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 12 days. Disp:*24 Tablet(s)* Refills:*0* 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 12 days. Disp:*36 Tablet(s)* Refills:*0* 12. Morphine 30 mg Tablet Sustained Release Sig: Three (3) Tablet Sustained Release PO Q12H (every 12 hours): This medication will make you drowsy. Do not drive or operate machinery when taking this medication. Disp:*60 Tablet Sustained Release(s)* Refills:*0* 13. Morphine 15 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for Pain: This medication will make you drowsy. Do not drive or operate machinery when taking this medication. Disp:*60 Tablet(s)* Refills:*0* 14. Outpatient Lab Work Once per week have your primary doctor [**First Name (Titles) **] [**Last Name (Titles) **] nurse draw the following labs. Fax results to ([**Telephone/Fax (1) 4591**], phone number ([**Telephone/Fax (1) 6732**]. Attention Dr. [**First Name (STitle) **]. CBC with differential BUN/creatinine Vancomycin trough 15. Outpatient Lab Work Please have your primary care provider check the following at your next appointment. Chem-7 to assess potassium and kidney function on increased lisinpril dose; LFTs to ensure resolution of transaminitis; CBC to workup your anemia Discharge Disposition: Home With Service Facility: Home Solutions Discharge Diagnosis: Primary: Osteomyelitis Anaphylaxis (cefepime) Secondary: Hypertension Diabetes mellitus type I Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: right leg non-weightbearing Discharge Instructions: You were admitted to [**Hospital1 69**] for an infection in the bone of your right big toe. You were treated with antibiotics and pain medication. The podiatrists surgically removed dead tissue from your toe during three separate operations. During your hospital stay, you also had a severe allergic reaction to cefepime, an antibiotic. You were treated with steroids and anti-allergy medications. You should avoid all antibiotics in the cephalosporin class from now on. During your admission, we noted that your blood pressure was high and increased your lisinopril. Your liver function tests were slightly abnormal, and should be rechecked with your primary care doctor. You were noted to be anemic; this should also be rechecked by your primary care doctor. Please follow up with you primary care doctor to further address these issues. We have made the following changes to your medication: - STARTED flagyl - STARTED ciprofloxacin - STARTED vancomycin - STARTED nystatin mouth rinse - STARTED nicotine patch - STARTED MS Contin - STARTED MSIR (morphine immediate release) - INCREASED your Humalog insulin mealtime schedule to 10 units at breakfast, lunch, and dinner - INCREASED your lisinopril - STOPPED oxycontin - STOPPED oxycodone Followup Instructions: The following appointments have been made for you. Please keep these as scheduled. In addition, you will have daily dressing changes, weekly laboratory tests, and IV antibiotics. You will have a [**Hospital1 **] nurse to help with this. Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP (works with [**Last Name (LF) 31974**],[**First Name3 (LF) **] K.) Location: [**Hospital3 **], INC Address: 3130 STATE HWY,ROUTE 6, [**Location (un) 31977**],[**Numeric Identifier 31978**] Phone: [**Telephone/Fax (1) 31979**] Appt: [**7-26**] at 11:00am Department: PODIATRY When: TUESDAY [**2152-7-25**] at 11:10 AM With: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM [**Telephone/Fax (1) 543**] Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: Infectious Disease When: Tuesday, [**8-1**] at 3:00 pm With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 288**], MD Phone: [**Telephone/Fax (1) 457**] Location: [**Last Name (NamePattern1) 439**], basement level Completed by:[**2152-7-25**]

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Discharge summary

report

Admission Date: [**2125-3-1**] Discharge Date: [**2125-3-7**] Date of Birth: [**2058-1-29**] Sex: F Service: MEDICINE Allergies: Cephalosporins / Vancomycin / Codeine Attending:[**First Name3 (LF) 5266**] Chief Complaint: CHIEF COMPLAINT: Lower GI Bleed REASON FOR MICU ADMISSION: Hypotension Major Surgical or Invasive Procedure: Sigmoidoscopy History of Present Illness: Ms [**Known lastname 13275**] is a 67 year old woman with history of cervical cancer, s/p TAH/XRT, complicated by radition cystitis, short-gut syndrome from radiation enteritis, rectovesicular fistula, on home TPN via PICC with recurrent line infections, presenting with rectovaginal bleeding since 2 am on night prior to admission. Patient noted passage of bright red blood around 2 am, when she woke up to self cath. She describes being "covered in blood" and having severe, sharp pain in her left lower quadrant. Patien then placed a chux pad however this too became "soaked with blood". Patient also reported left hip / flank pain, reports she had a fall approximately one week PTA where she hit her left side. Reports fever up to 102 at home and shaking chills. Denies any vomiting but had nausea. She reports her ostomy output has remained stable and denies have any changes in her diet. In the ED, vital signs were initially: [**10-28**] pain, Temp 99.2 96 122/53 16 100. Patient noted to have small amount of "ooze-like" rectal bleeding and some vaginal bleeding. Ostomy bag with normal stool. Patient underwent CT scan which revealed likely infectious colitis of sigmoid. Blood cultures were collected and patient was noted to have decreasing systolic pressure into 80's and 90's. Patient received a total of 3L of fluid with minimal improvement, she was admitted to MICU for further management. No antibiotics were given. Past Medical History: 1. Cervical CA s/p TAH/XRT s/p hysterectomy [**2096**] with recurrence in [**2097**] 2. Radiation cystitis 3. Urinary Retention; straight catheterization ~8x per day 4. R ureteral stricture -- c/b recurrent infections -- s/p right nephrectomy ([**2123**]) 5. Recurrent UTIs: (Klebsiella (amp resistant) and Enterococcus (Levo resistant) 6. Short gut syndrome since [**2109**] s/p colostomy from radiation enteritis. 7. Osteoporosis 8. Hypothyroidism 9. Migraine HA 10. Depression 11. Fibromyalgia 12. Chronic abdominal pain syndrome 13. Multiple admits for enterococcus, klebsiella, [**Female First Name (un) **] infections 14. DVT / thrombophlebitis from indwelling central access 15. Lumbar radiculopathy 16. Multiple Prior PICC line / Hickman infections -- See multiple surgical notes [**2115**] to date 17. H/O SBO followed by surgery [**33**]. H/O STEMI [**2-20**] Takotsubo CM, with clean coronaries on cath in [**4-27**]. EF down to 20% in setting of illness, but EF recovered to 55-60%, in setting of klebsiella PNA. 19. Hyponatremia: previously attributed to hctz use Social History: She lives with her husband in an [**Hospital3 4634**] [**Last Name (un) **]. She reports a 80 PY smoking history but quit 18 years ago. Denies alcohol or drugs. Family History: Father with ETOH abuse, CAD. [**Last Name (un) **] with renal ca, CAD. 3 healthy children. Physical Exam: Vitals: T: 98.9 P: 72 BP: 162/88 R: 20 SaO2:100%RA General: Awake, alert to team entering room, NAD. HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP without erythema or exudate Neck: supple, trachea midline, no JVD or LAD. no thyromegaly. Pulm: NARD. CTAB. no w/r/r. Cardiac: RRR. normal S1 and S2. no m/r/g. Abdomen: normal bowel sounds. soft, non-distended. some TTP, especially in LLQ. no rebound. minimal guarding. no appreciable organomegaly. Extremities: MAE. Extremities are cool to touch but DPs and radials 2+ b/l. No C/C/E. Neurologic: Alert and orient x3. -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact -motor: normal bulk, strength and tone throughout. No abnormal movements noted. -sensory: decreased sensation to light touch in distal LEs consistent with known lumbosacral plexopathy Pertinent Results: Admission: [**2125-3-1**] 02:10PM BLOOD WBC-13.0*# RBC-3.98* Hgb-11.0* Hct-33.7* MCV-85 MCH-27.5 MCHC-32.6 RDW-13.6 Plt Ct-299 [**2125-3-1**] 02:10PM BLOOD Neuts-93.0* Lymphs-5.4* Monos-1.5* Eos-0 Baso-0.1 [**2125-3-1**] 02:10PM BLOOD PT-12.7 PTT-27.1 INR(PT)-1.1 [**2125-3-1**] 02:10PM BLOOD Glucose-90 UreaN-16 Creat-1.5* Na-124* K-4.9 Cl-94* HCO3-21* AnGap-14 [**2125-3-1**] 02:10PM BLOOD cTropnT-0.03* [**2125-3-1**] 02:10PM BLOOD Calcium-8.5 Mg-1.9 [**2125-3-2**] 01:35AM BLOOD Albumin-3.3* Calcium-7.5* Phos-2.7 Mg-1.8 [**2125-3-1**] 02:10PM BLOOD Osmolal-271* [**2125-3-1**] 05:05PM BLOOD Lactate-1.2 Discharge: [**2125-3-7**] 06:20AM BLOOD WBC-5.2 RBC-3.92* Hgb-10.7* Hct-32.9* MCV-84 MCH-27.3 MCHC-32.5 RDW-13.7 Plt Ct-285 [**2125-3-7**] 06:20AM BLOOD PT-15.0* PTT-29.5 INR(PT)-1.3* [**2125-3-7**] 06:20AM BLOOD Glucose-97 UreaN-19 Creat-1.4* Na-130* K-4.0 Cl-96 HCO3-25 AnGap-13 [**2125-3-7**] 06:20AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.5* Sigmoidoscopy: Findings: Lumen: Evidence of a previous subtotal colectomy was seen, as the lumen narrows at 12 cm. Impression: Previous intervention of the colon Otherwise normal sigmoidoscopy to 12 cm from anal verge Recommendations: Review CT scan abd/pelvis with radiologist. Question possibility of small bowel source. Additional notes: The attending was present for the entire procedure. The patient's reconciled home medication list is appended to this report. ECG [**2125-3-1**]: Normal sinus rhythm, rate 89. Normal tracing. Compared to the previous tracing of [**2125-2-6**] no significant change. 3 VIEWS HIP & LEFT HIP JOINT [**2125-3-1**]: There is an old healed fracture of the left superior and inferior pubic rami with surrounding callous. There are surgical clips in the pelvis. The sacrum has a mottled appearance which may be secondary to osteopenia or radiation treatment. Previously noted sacral fractures are not clearly seen on this study as overlying bowel obscures visualization. No new fractures are noted. IMPRESSION: Chronic fractures of the left superior and inferior pubic rami. No new fractures noted. CXR [**2125-3-1**]: COMPARISONS: [**2125-2-5**]. FINDINGS: Since prior examination, there is no significant interval change. The lungs are clear without consolidation, pleural effusions or pneumothorax. The patient is status post right calcified breast implantation and cholecystectomy. A right-sided PICC is seen with tip terminating within the low SVC. Cardiomediastinal contours are normal. The visualized osseous structures are unremarkable. IMPRESSION: No acute cardiopulmonary process. CT abdomen/pelvis [**2125-3-1**]: EXAMINATION: CT of the abdomen and pelvis with oral and intravenous contrast. COMPARISONS: Comparison is made to multiple prior examinations including [**2124-4-19**], [**2124-2-3**], [**2123-7-29**], and [**2123-7-12**]. TECHNIQUE: Helically acquired axial images were obtained from the thoracic inlet to the pubic symphysis after the administration of oral and 130 mL of Optiray intravenous contrast. Coronal and sagittal reformations were obtained. FINDINGS: CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: Other than mild linear atelectasis, the lung bases are clear without focal parenchymal consolidation, pleural effusions, or pulmonary nodules. There is stable appearance of central intrahepatic biliary dilatation and extrahepatic biliary dilatation with the common bile duct measuring up to 9 mm. No new focal liver lesions are identified. The spleen, both adrenal glands, pancreas, and left kidney are unremarkable. The patient is status post right nephrectomy. The patient is status post ileostomy. Multiple clips are noted within the pelvis. The patient is status post hysterectomy and bilateral oophorectomy. There is a significant amount of retained contrast seen within the cecum stable since multiple remote prior examinations dating back to [**2123-7-12**]. Contrast is seen to the ileostomy without evidence of obstruction. There is associated mesenteric stranding and fluid and bowel wall thickening and edema involving the rectum, sigmoid colon, transverse colon to the level of the cecum most compatible with a component of colitis, likely infectious in etiology. There is no evidence of associated pneumatosis. Transverse colon is noted to be in a stable but abnormal course with kinking and tethering adjacent to the deep left pelvic side wall. There is no intra-abdominal free air. There is no mesenteric or retroperitoneal lymphadenopathy. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The patient is status post multiple surgeries as described above. A Foley is seen with the bladder collapsed about it. Known fistulization not clearly apparent on this current study without administration of rectal contrast. Bowel wall thickening and edema with associated stranding as described above. No inguinal or pelvic lymphadenopathy. BONE WINDOWS: Stable appearance of extensive post-traumatic deformity. There is stable wedging of the L1 vertebral body. There is post-traumatic deformity with osseous remodeling of the left inferior and superior pubic rami and the left acetabulum. In addition, there is remodeling and extensive degeneration and demineralization involving the left hemisacrum. IMPRESSION: 1. Bowel wall thickening and edema with associated mesenteric stranding and fluid surrounding the entire colon and rectum, new from prior studies, most compatible with colitis, likely infectious in etiology. 2. Patient is status post extensive surgeries with ileostomy, all with stable appearance since prior examinations with retained contrast noted within the cecum. 3. Stable central intrahepatic and extrahepatic biliary dilatation. 4. Stable appearance with wedge compression of L1 and post-traumatic deformity involving the left hip and pelvis. CXR [**2125-3-2**]: FINDINGS: As compared to the previous examination, there is no relevant change. Unchanged course of the right-sided central venous access line. Unchanged normal to borderline size of the cardiac silhouette without evidence of pulmonary edema. No pleural effusions. No focal parenchymal opacities suggesting pneumonia. KUB [**2125-3-5**]: COMPARISONS: Comparison is made to CT examination from [**2125-3-1**]. FINDINGS: Nonspecific bowel gas pattern. No dilated loops of small or large bowel. No evidence of pneumoperitoneum. Clips are noted to overlie the pelvic inlet and the mid abdomen. The patient is noted to be status post right-sided breast implantation, which now demonstrates rim calcification. Lung bases are clear. Visualized osseous structures are unremarkable. An ileostomy is noted to overlie the right mid abdomen. IMPRESSION: No evidence of pneumoperitoneum. Brief Hospital Course: 67 year old woman with complicated medical history, including short gut syndrome, rectovaginal fistula, recurrent urinary tract and line infections, presenting with rectal/vaginal bleeding and hypotension. # HYPOTENSION: In setting of recurrent line infections, TPN via PICC line and active bleeding, concerning for sepsis vs volume depletion / dehydration. The patient was given IVF and transfused 1U pRBC and blood pressures improved. The cause was likely volume depletion in the setting of bleeding. Blood pressures were stable on the floor prior to discharge. # RECTAL/VAGINAL BLEEDING: Patient with ileostomy and blind rectal pouch with knwn vaginal fistula. Blood source difficult to elucidate, however given findings of colitis in CT with normal lactate, most likely due to infectious process. DDx changes in patient with blind loop, however pathogen most likely to be same as isolated strains in prior urinary infections (Cipro resistant e. coli, klebsiella) or c diff colitis, although less likely as food products are not processed through rectum. Would also keep high in differential radiation changes leading to bacterial infection. The patient underwent a sigmoidoscopy that showed normal mucosa and no evidence of fistula or active bleeding. The patient was continued on IV Cipro and flagyl, then converted to PO at discharge to complete a 10-day course for suspected infectious colitis. She received her home medications and additional dilaudid for pain control. # CHRONIC RENAL INSUFFICIENCY: Creatinine 1.5 on admission, (baseline creatinine 1.2 to 1.4), likely in setting of mild dehydration and volume depletion for bleeding. # SHORT GUT SYNDROME: Patient continued on chronic TPN throughout this admission. # HYPOTHYROIDISM: Continued on levothyroxine throughout this admission. # DEPRESSION: Continued on Prozac 30 mg divided in 3 doses per day. # FIBROMYALGIA: Patient with significant pain at baseline, requiring total of 30 mg of oxycodone and 10 mg of Methadone daily. In light of active colitis patient was maintained on dilaudid during this admission. Pain was improving back close to baseline at the time of discharge. # BLADDER SPASMS: Foley was removed ~72 hours prior to discharge. Patient developed the same bladder spasms that she typically experiences at home, which were associated with abdominal pain and relieved with catheterization. She was re-started on her home bladder medications which were held during the early part of the admission while the Foley was in place. Medications on Admission: ALPRAZOLAM - 0.5MG Tablet - ONE BY MOUTH AT BEDTIME FOR INSOMNIA LORAZEPAM [ATIVAN] - 0.5 mg Tablet Daily FLUOXETINE [PROZAC] - 60 mg Capsule TID GABAPENTIN - 300 mg Capsule QID FIORICET (BUTALBITAL-ACETAMINOPHEN-CAFF)- 50 mg-325 mg-40 mg Tablet - PRN headaches ZOLMITRIPTAN [ZOMIG] - 2.5 mg Tablet - 1 Tablet(s) by mouth at onset of headache . [**Month (only) 116**] take additional 1 tablet in 2 hours as needed. CYCLOBENZAPRINE [FLEXERIL] - 10 mg Tablet bedtime LIDOCAINE [LIDODERM] - 5 % patch OXYCODONE - 5 mg Tablet - one to two Tablet(s) by mouth every 4 hr as needed for pain may take up to 9 tabs per day - METHADONE - 5 mg Tablet - 1 Tablet(s) by mouth four times a day for pain PILOCARPINE HCL [SALAGEN] - 5 mg Tablet - one Tablet(s) by mouth every four (4) hours . CYANOCOBALAMIN - 1,000 mcg/mL Solution - 1000 mcg/ml IM once a month DARIFENACIN [ENABLEX] - 15 mg Tablet Sustained Release 24 hr ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit Capsule daily Mon thru Fri, skip Sat and Sun ESTRADIOL [VIVELLE-DOT] - 0.0375 mg/24 hour Patch Semiweekly - apply one patch twice weekly FEXOFENADINE [[**Doctor First Name **]] - 60 mg Tablet once a day HYOSCYAMINE SULFATE - 0.125 mg Tablet PRN bladder spasm IRON DEXTRAN - 100 mg IV every 2 weeks in TPN for 5 doses (started [**2-23**]) LEVOTHYROXINE - 50 mcg Tablet daily LISINOPRIL - 10 mg Tablet - 3 Tablet(s) by mouth once a day MVI-13 - - 10 mL IV once daily added to TPN PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day PHENAZOPYRIDINE [PYRIDIUM] - 100 mg Tablet - 1 Tablet(s) by mouth three times a day as needed for dysuria CALCIUM CARBONATE [TUMS] - 500 mg Tablet [**Hospital1 **] OPTICS MINI DROPS - 1.4 %-0.6 % Dropperette - [**1-20**] gtts ou every twelve (12) hours as needed. Discharge Medications: 1. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day. 3. Fluoxetine 20 mg Tablet Sig: Three (3) Tablet PO three times a day. 4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO four times a day. 5. Fioricet 50-325-40 mg Tablet Sig: One (1) Tablet PO once a day as needed for headache. 6. Zolmitriptan 2.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for headache. 7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12 hours on, 12 hours off . 8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 9. Methadone 5 mg Tablet Sig: One (1) Tablet PO four times a day. 10. Pilocarpine HCl 5 mg Tablet Sig: One (1) Tablet PO every four (4) hours. 11. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) Injection once a month. 12. Enablex 15 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO Mon-Fri. 14. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for back spasm. 15. Estradiol 0.0375 mg/24 hr Patch Semiweekly Sig: One (1) Transdermal as directed. 16. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO once a day. 17. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual QID (4 times a day) as needed for bladder spasm. 19. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 20. Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for dysuria. 21. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 22. Tums 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. 23. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 10 doses. Disp:*10 Tablet(s)* Refills:*0* 24. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 9 doses. Disp:*9 Tablet(s)* Refills:*0* 25. Outpatient Lab Work Please draw blood cultures on [**2125-3-26**] and fax results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**] at ([**Telephone/Fax (1) 16691**]. 26. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every four (4) hours: Take as needed for breakthrough pain if home regimen is ineffective. Please do not drive or operate machinery while using this medication. Disp:*30 Tablet(s)* Refills:*0* 27. TPN Resume previous home TPN order. Discharge Disposition: Home With Service Facility: [**First Name5 (NamePattern1) 189**] [**Last Name (NamePattern1) 269**] Discharge Diagnosis: Primary: - Colitis, likely infectious - Rectovaginal bleed (fistula present; suspect GI source) Secondary: - H/o cervical cancer s/p radiation - S/p multiple surgeries and bowel removal, s/p ileostomy - Radiation cystitis and proctocolitis - Short gut syndrome on TPN - Known rectovaginal fistula - Depression - Anxiety - Hypothyroidism - Anemia - Bladder dysfunction Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You were admitted to [**Hospital1 69**] with vaginal and rectal bleeding. Pelvic exam and sigmoidoscopy did not identify a clear source of bleeding. CT scan of the abdomen showed inflammatory changes consistent with infection, so you were started on antibiotics. We have made the following changes to your medication regimen: - BEGIN TAKING ciprofloxacin 500 mg by mouth twice daily until [**2125-3-11**] - BEGIN TAKING metronidazole 500 mg by mouth three times daily until [**2125-3-11**] Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Please arrange for follow up as recommended below. Followup Instructions: 1. PRIMARY CARE - Dr. [**First Name (STitle) 1022**] [**Telephone/Fax (1) 250**] - You have an appointment scheduled with Dr. [**First Name (STitle) 1022**] on Tuesday, [**3-13**] at 9:20AM. 2. Gastroenterology - Dr. [**First Name (STitle) 572**] [**Telephone/Fax (1) 463**] -You have an appointment scheduled with Dr. [**First Name (STitle) 572**] on [**First Name (STitle) 766**], [**4-2**] at 3:20PM. Other future appointments: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2125-4-26**] 2:20 Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2125-9-20**] 2:00 Completed by:[**2125-3-10**]

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Discharge summary

report

Admission Date: [**2200-1-20**] Discharge Date: [**2200-1-25**] Date of Birth: [**2151-12-23**] Sex: M Service: MEDICINE Allergies: Magnesium Citrate / Penicillins / Gabapentin Attending:[**First Name3 (LF) 10682**] Chief Complaint: Headache, hypoxia. Major Surgical or Invasive Procedure: Midline placement Mechanical ventilation History of Present Illness: 48 yo male with h/o multiple medical comorbidities, severe OSA s/p tracheostomy in [**2198**], triplegia secondary to electruciation, chronic pain syndrome s/p intrathecal [**Year (4 digits) **] with Bupivacaine pump implantation transferred from OSH for continued management of acute on chronic respiratory failure. Per patient had been in USOH when noted gradual onset of inability to properly use left hand, myoclonic jerking and confusion. He presented to OSH on [**1-15**] where he was noted to have increasing O2 requirement (at baseline FiO2: 35-40%) on arrival necessitating 100%. Regarding respiratory failure. Patient with a history of multifactorial respiratory failure secondary to severe OSA, COPD and neuromuscular weakness that culminated in tracheostomy 6mths prior. For the last 4mths he was required 24 ventilation with assist control. No documented hypoxia in OSH hospital only documentation of vent settings at 100% FiO2. Hypoxia work-up included upper and lower extremity ultrasounds: negative for DVT; TTE without intracardiac shunt. Patient was found to have increased secretions and questionable infiltrate on CXR. A bronchscopy was performed which demonstrated trachiobronchimalacia. Bronchial washings and sputum cultures were obtained which later grew out psuedomonas. Patient was initially treated with Levofloxacin and tigacylin, which was later transitioned to inhaled tobramycin based on sensitivites. Prior to transfer FiO2 had been weaned from 100% -> 70% with stable sats. Regarding altered mental status and myoclonic jerking. Patient with increasing confusion and myoclonus prior. Neurology consulted. CT head negative. EEG negative. Myoclonic jerking was attributed to [**Month/Year (2) **] toxicity as jerking resolved with initial [**Month/Year (2) **] dose reduction. AMS change was attributed to [**Month/Year (2) **] toxicity with contribution from hypoxia and UTI (urine cx + pseudomonas). Prior to transfer mental status returned to baseline. At time of transfer patient was oxygenating well on Assist Control: VT: 600 RR: 12 PEEP: 7.5 FiO2: 70%. VS: Tm 99.2 BP: 100-120s/50s-70s HR: 70s-80s On arrival to the [**Hospital Unit Name 153**], VSS. Patient reports mental status is back to baseline though reports persistent headache with associated left hand parathesias. Denies SOB though reports persistent chest heaviness and green secretions - though states he feels secretion amount has lessened since Abx initiation. ROS + sweats/chills, dysuria, + left hand numbness/tingling - nausea, vomiting, diarrhea - last BM 2 days prior Past Medical History: # Triplegia s/p electricution injury in [**2181**], has use of LUE. # Chronic multifactorial respiratory failure secondary to OSA, neuromuscular weakness, COPD s/p tracheostomy # Severe OSA, not able to tolerate CPAP and BiPAP, # COPD # Chronic Pain syndrome s/p [**Year (4 digits) **] intrathecal pump implantation in [**2196**] # Diabetes Mellitus type 2: last A1c: 7.9 # CAD s/p PCI with [**Year (4 digits) **] of distal RCA in [**2194**] [**1-6**] catherization: widely patent stent with mild to moderation (40-50%) stenosis of distal RCA beyond stent # Chronic atypical chest pain with borderline - mild elevations of troponins # Hypertension # GERD # History of GI bleed secondary to duodenal ulcer # Depression/Anxiety # s/p spinal fracture # Seizure Disorder Social History: [**Known firstname **] is single and lives with his mother and two brothers. [**Name (NI) **] is on medical disability, but used to work as a custodian. He has primarily daytime nursing care, but is able to get overnight care if necessary. He denies fear in any relationships, does not drink alcohol and uses no illicit drugs. Caffeine intake is two cups of coffee. He reports a 50-pack year history, quit in [**2193**]. Family History: His family history is positive for hypertension, diabetes, and depression. He has a brother with sleep apnea who is not on treatment. Physical Exam: Upon admission: GEN: obese male, comfortable, NAD HEENT: PERRL, EOMI, anicteric sclera, MMM, op without lesions Neck: thick, trach in place, no audible stridor RESP: anterior fields with bronchial/course breath sounds, quiet wheeze CV: distant heart sounds, RRR no appreciable murmurs, general anasarca ABD: distended, nontender, area of induration in RLQ secondary to pump, + BS EXT: warm, well perfused, general anasarca SKIN: multiple tattos, no rashes, no jaundice NEURO: AAOx3. Cn II-XII intact. Able to move LUE, increased tone in right upper and lower extremity Pertinent Results: OSH Data: OUTSIDE HOSPITAL Labs: see below creatinine: 1.21; peak 1.6 HgA1c: 7.9 BNP: 104 Trop: .18, .20 MICRO: Blood cx: no growth Sputum, bronch wash cx: + Pseudomonos - SENSITIVE to Ceftazidine 4 Gentamicin 4 Levofloxacin 2 Zosyn 16 Tobramycin <=1 Urine culture: Pseudomonas Legionella: negative Strep pneumo antigen: negative Outside Hospital Studies CXR ([**1-15**]): findings consisent with CHF and small left pleural effusion CT scan brain without contrast ([**1-15**]): no acute intracranial abnl EEG ([**1-16**]) no significant asymmetries or paroxysmal activiries suggestive of epilepsy Bronchoscopy ([**1-17**]): evidence of dynamic collapse as well as occlusion of the distal ET tube with forceful coughing; moderate quantity of purulent secretions TEE: [**1-16**] Normal with exception of trace MR, trace TR and trivial aorta atherosclerosis. Normal LV and RV size and function. No evidence of pulmonary hypertension though could not measure pulm artery pressure. No intrathoracic shunt. Admission Labs to [**Hospital1 18**]: [**2200-1-20**] 10:56PM WBC-7.7 RBC-3.92* HGB-10.7* HCT-31.0* MCV-79* MCH-27.3 MCHC-34.5 RDW-14.8 [**2200-1-20**] 10:56PM NEUTS-66.0 LYMPHS-21.3 MONOS-6.0 EOS-5.9* BASOS-0.9 [**2200-1-20**] 10:56PM PLT COUNT-249 [**2200-1-20**] 10:56PM PT-12.9 PTT-29.3 INR(PT)-1.1 [**2200-1-20**] 10:56PM GLUCOSE-165* UREA N-22* CREAT-1.4* SODIUM-141 POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-23 ANION GAP-18 [**2200-1-20**] 10:56PM CALCIUM-9.1 PHOSPHATE-3.4 MAGNESIUM-2.3 IRON-33* [**2200-1-20**] 10:56PM ALT(SGPT)-27 AST(SGOT)-37 ALK PHOS-70 TOT BILI-0.2 [**2200-1-20**] 10:56PM CK-MB-3 cTropnT-0.08* [**2200-1-20**] 10:56PM TSH-0.99 Discharge labs, [**2200-1-25**]: 6.6 >--------< 254 30.7 140 99 15 ----------------< 218 4.2 32 1.1 Micro: [**2200-1-22**] Urine cultures negative x2 [**2200-1-21**] 8:58 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2200-1-23**]** GRAM STAIN (Final [**2200-1-21**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [**2200-1-23**]): Commensal Respiratory Flora Absent. STAPH AUREUS COAG +. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S CHEST (PORTABLE AP) Study Date of [**2200-1-22**] FINDINGS: In comparison with the study of [**1-20**], there may be slight decrease in the persistent opacification at the right base. Left basilar opacification persists. Again, the appearance is consistent with pneumonia, though there may be some element of atelectasis. Tracheostomy tube remains in place. RENAL U.S. PORT Study Date of [**2200-1-22**]: The right kidney measures 9.8 cm and the left kidney measures 12.1 cm. There is mild hydronephrosis on the right. The left kidney is normal. No stones or focal masses identified. The bladder is substantially distended on the current examination. IMPRESSION: Mild right hydronephrosis. Substantially distended bladder. UNILAT UP EXT VEINS US RIGHT Study Date of [**2200-1-23**]: 1. No evidence of right upper extremity DVT. 2. Flattened waveforms in the internal jugular and subclavian veins; this may indicate a central obstructive process such as stenosis or extrinsic compression. CT chest may be useful Brief Hospital Course: 48 yo male with multiple medical comorbidities including triplegia secondary to electruciation, severe OSA s/p tracheostomy in [**2198**], chronic pain syndrome s/p intrathecal [**Year (4 digits) **] pump implantation transferred from OSH for continued management of acute on chronic respiratory failure in setting of pseudomonas pneumonia. # Acute on Chronic Respiratory Failure. Patient with baseline chronic multifactorial respiratory failure secondary to OSA, neuromuscular weakness, habitus and COPD. He is s/p tracheostomy 6months prior and upon admission had been ventilated for ~ 24hr/day. On presentation to OSH patient with FiO2 requirement of 100%. Likely worsening pulm function secondary to known PNA. Patient was quickly weaned off the ventilator and maintained on trach mask. Spoke with outpatient pulmologist who will follow him as outpatient. He was continued nebulizer treatments as well as antibiotics to cover his pneumonia. Per primary pulmonologist, patient can hold his own for a few days, but eventually will need some vent support. He recommends Ventilation at night/bedtime: SIMV Tv 500, RR 12, PEEP 5, 4L 02. Frequent suctioning. Patient/caretakers understand and this was ordered. # Pneumonia. Sputum culture and bronchial wash + pseudomonas at OSH. Legionella, Strep pneumo negative. Pseudomonas sensitive to ceftaz, zosyn, levofloxacin, gentamycin. Due to h/o of documented allergies unable to use ceftaz and zosyn secondary and gentamycin not ideal in setting of elevated creatinine. Patient arrived on inhaled tobramycin and levofloxacin. Patient clinically doing well. Decision made to stop inhaled tobramycin and continue pseudomonas coverage with levofloxacin for planned 14day course. Repeat sputum culture in house with MSSA. Started on Bactrim on [**1-23**] and will continue through [**1-31**]. # Altered mental status. At OSH attributed to [**Month/Day (4) **] toxicity exacerbated by relative hypoxemia and UTI. Work-up to date includes negative CT head, unremarkable EEG. Per patient mentation back to baseline however complains of continued frontal headache with associated parathesias of left hand. On presentation labs without significant metabolic derangements. No sign of encephalopathy, no asteristix on exam. Patient without h/o liver disease and LFTs within normal limit. + Tinels sign on exam. TSH within normal limits. Potential benefit from left wrist splint as question if parathesias is secondary to carpal tunnel in the setting of anasarca. Consider EEG as an outpatient if left upper extremity numbness does not improve. # Headache/Blurred vision. Assess by optho and neuro. Fundoscopic exam without obvious abnormality. Per neuro headache and blurred vision likely secondary to tension headache which can be treated with tyelnol. No further imaging or work-up persued in house. Patient will likely benefit getting new glasses. Symptomatic heat therapy or ice packs to the forehead/neck region to decrease discomfort from tension headache. Patient will need neurology follow up, which was scheduled, # Urinary retention. Chronic problem. In house decrease his [**Month/Day (4) **] dosage and stopped his anticholinergic medication nortriptyline. Differential includes heavy narcotic usage vs. medication induced vs. obstruction such as prostate hypertrophy or prostate cancer. Cauda equina syndrome or epidural abscess seem unlikely, given physical exam and overall symptoms. Yitamin B6, thiamine, copper levels, SPEP, UPEP, RPR, [**Doctor First Name **], rheumatoid factor, HIV test sent, should be followed up. Foley was placed and he started on tamsulosin. He was discharged with foley [**Last Name (un) **] to follow up with urology for ongoing care. # [**Last Name (un) **]. Baseline creatinine 0.8. OSH creatinine 1.2. On admission 1.4. Patient did not received any studies with contrast at OSH. Patient with no other medication changes. No history of GI losses though likely with sub-optimal PO intake. Fluctuated throughout admission. Lisinopril was held and he was hydrated. This stabilized by discharge. # Myoclonic jerks. Attributed to [**Last Name (un) **] toxicity at OSH. Jerks improved with lower dose of [**Last Name (un) **]. CT head negative. EEG read as unremarkable. Currently, patient without jerking movements. #Chronic Pain syndrome. Intrathecal [**Last Name (un) **] with buprivacaine pump in place. Of note per report there has been a 10% dose increase of his IT Pump on [**2199-12-25**] and [**2200-1-3**]. Per [**1-10**] note, plan was for pt to trial this regimen for two weeks; at time would reeval if another 10% increase is appropriate. Seen by outpatient pain physician. [**Name10 (NameIs) 12723**] transitioned to PO 4-8mg q6 prn, in addition to pump. Lyrica contiuned. Nortriptyline stopped. He will follow up with his Pain specialist as an outpatient. #CAD s/p PCI with [**Name10 (NameIs) **] of distal RCA in [**2194**]. He had reported chest heaviness on arrival. He had no signs of ischemia during admission. He was continued on his metoprolol, ASA. #Diabetes Mellitus II. His last A1c: 7.9. He was started and discharged home on Humalog ISS. #Depression/Anxiety: Continued home regimen with holding parameters for sedation. #Code Status: He was full code during this admission. Medications on Admission: ALBUTEROL SULFATE - (Prescribed by Other Provider) - Dosage uncertain B 12 - (Prescribed by Other Provider) - - 1 ml IM injection BACLOFEN - (Prescribed by Other Provider) - 20 mg Tablet - 2 Tablet(s) by mouth three times a day CLONAZEPAM [KLONOPIN] - (Prescribed by Other Provider) - 2 mg Tablet - 1 Tablet(s) by mouth twice a day [**Year (4 digits) **] WITH BUPIVACAINE INTRATHECAL PUMP - (Prescribed by Other Provider) - Dosage uncertain ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other Provider) - 50,000 unit Capsule - Capsule(s) by mouth X 12 weeks Then 1000mg QD HYDROMORPHONE - 8 mg Tablet - 1 Tablet(s) by mouth by mouth twice a day as needed for pain HYDROMORPHONE [[**Year (4 digits) **]] - (Dose adjustment - no new Rx) - 8 mg Tablet - 1 Tablet(s) by mouth twice a day as needed for prn pain three month supply IPRATROPIUM BROMIDE [ATROVENT HFA] - (Prescribed by Other Provider) - Dosage uncertain LACTULOSE - (Prescribed by Other Provider) - 10 gram/15 mL Solution - 2 tsp by mouth as needed LISINOPRIL - (Prescribed by Other Provider) - 2.5 mg Tablet - 1 Tablet(s) by mouth once a day METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 25 mg Tablet Sustained Release 24 hr - 0.5 (One half) Tablet(s) by mouth twice a day NORTRIPTYLINE - (Prescribed by Other Provider) - 50 mg Capsule - 1 Capsule(s) by mouth at bedtime PANTOPRAZOLE [PROTONIX] - (Prescribed by Other Provider) - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth twice a day PREGABALIN [LYRICA] - 100 mg Capsule - 1 Capsule(s) by mouth three times a day PREGABALIN [LYRICA] - 25 mg Capsule - 1 Capsule(s) by mouth three times a day QUETIAPINE [SEROQUEL] - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 200 mg Tablet - [**12-30**] Tablet(s) by mouth q am/ 600 mg Q PM SULFAMETHOXAZOLE-TRIMETHOPRIM [BACTRIM] - (Prescribed by Other Provider) - Dosage uncertain Medications - OTC ACETAMINOPHEN [TYLENOL EXTRA STRENGTH] - (Prescribed by Other Provider) - 500 mg Tablet - 1 Tablet(s) by mouth every six (6) hours as needed ASPIRIN - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day BISACODYL - (Prescribed by Other Provider) - 5 mg Tablet, Delayed Release (E.C.) - 2 Tablet(s) by mouth once a day DEXTRAN 70-HYPROMELLOSE [ARTIFICIAL TEARS (PF)] - (Prescribed by Other Provider) - Dosage uncertain DOCUSATE SODIUM [COLACE] - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 100 mg Capsule - 1 Capsule(s) by mouth three times a day MULTIVITAMIN - (Prescribed by Other Provider) - Dosage uncertain OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other Provider) - 1,000 mg Capsule - 1 Capsule(s) by mouth three times a day POLYETHYLENE GLYCOL 3350 [MIRALAX] - (Prescribed by Other Provider) - Dosage uncertain SENNA - (Prescribed by Other Provider) - 8.6 mg Tablet - 3 (Three) Tablet(s) by mouth twice a day SIMETHICONE - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 80 mg Tablet, Chewable - 1 Tablet(s) by mouth four times a day Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. baclofen 10 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 3. pregabalin 25 mg Capsule Sig: Five (5) Capsule PO TID (3 times a day). 4. clonazepam 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. quetiapine 200 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 9. quetiapine 200 mg Tablet Sig: Three (3) Tablet PO QPM (once a day (in the evening)). 10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 12. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily). 13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6 hours). 14. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours). 15. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 16. hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 17. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days: through [**2200-1-31**]. Disp:*14 Tablet(s)* Refills:*0* 18. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): through [**2200-2-1**]. Disp:*8 Tablet(s)* Refills:*0* 19. Ventilator at night/bedtime: SIMV, Tv 500ml, RR 12, PEEP 5, 4L 02 20. insulin lispro 100 unit/mL Solution Sig: 0-12 units Subcutaneous four times a day: Pls see sliding scale. Disp:*qs x 1 month * Refills:*0* 21. insulin syringe-needle,dispos. 0.3 mL 30 x [**5-12**] Syringe Sig: One (1) Miscellaneous four times a day: For insulin injections. Disp:*100 syringes* Refills:*2* Discharge Disposition: Home With Service Facility: New Century Home Care Discharge Diagnosis: Respiratory failure Healthcare acquired pneumonia Acute on chronic pain Urinary retention Headache, blurry vision Triplegia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: You were admitted for respiratory distress and respiratory failure. You were on mechanical ventilation. You were diagnosed with a pneumonia. With adequate treatment, your symptoms improved and you were taken off the ventilator. It is very important that you take your full course of antibiotics, follow your respiratory care instructions, and keep all follow up appointments. You were also seen by your pain doctors. Your pain is well controlled. You were also seen by the neurology team for a constellation of symptoms. It is very important that you follow up with them. Finally, you were found to have urinary retention, possibly due to your medications. A foley catheter was placed. It is very important that you follow up with urology in the outpatient setting. Medication changes: 1. metoprolol increased to 25mg twice daily 2. Lisinopril stopped 3. Tamsulosin 0.4mg daily started 4. Nortriptyline stopped 5. Humalog insulin injections four times a day started Followup Instructions: Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) 870**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Location (un) **] UROLOGY Address: [**Apartment Address(1) 66489**] [**Location (un) **],[**Numeric Identifier 59599**] Phone: [**Telephone/Fax (1) 46450**] Appt: [**1-29**] at 2pm Name: [**Last Name (LF) **],[**First Name3 (LF) **]-[**Doctor Last Name **] Address: [**Hospital1 25492**], [**Location (un) **],[**Numeric Identifier 66490**] Phone: [**Telephone/Fax (1) 60170**] Appt: [**2-11**] at 9:30am ****NOTE-Dr [**First Name (STitle) **] is out of the office for the next two weeks. If for any reason you feel you need to see the doc sooner than [**2-11**], please call his office and they can get you an appt with an on call physician covering for Dr [**First Name (STitle) **]. Department: PAIN MANAGEMENT CENTER When: FRIDAY [**2200-2-28**] at 1:50 PM With: [**Name6 (MD) 1089**] [**Name8 (MD) 1090**], MD [**Telephone/Fax (1) 1652**] Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Parking on Site ****NOTE: This was the first appt available with an afternoon time. If you want to be seen sooner than this, the appts will be in the morning. Please call the office if you would like to reschedule.

[ "300.4", "496", "041.7", "584.9", "414.01", "401.9", "345.90", "482.1", "V44.0", "788.20", "E929.8", "518.84", "V45.82", "530.81", "250.00", "591", "344.89", "784.0", "368.8", "519.19", "338.4", "327.23", "599.0", "285.9", "V15.82" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

19370, 19422

8796, 14102

326, 369

19590, 19590

4970, 8773

20727, 22061

4230, 4366

17243, 19347

19443, 19569

14128, 17220

19725, 20503

4381, 4383

20523, 20704

268, 288

397, 2982

4397, 4951

19605, 19701

3004, 3772

3788, 4214

4,786

164,322

1455

Discharge summary

report

Admission Date: [**2151-7-25**] Discharge Date: [**2151-8-7**] Service: Medicine, [**Hospital1 **] Firm HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old gentleman with a history of metastatic pancreatic cancer diagnosed in [**2150-7-26**], status post debulking and gastrojejunostomy surgery as well as radiation and chemotherapy. The patient presents with a 3-day history of dark black stools, lightheadedness, and shortness of breath for one day, and also a 1-day history of mild right upper quadrant pain. The patient has no previous history of melena. He has no chest pain, weakness, numbness, tingling, or dysuria. He has chronic constipation and distention. The patient is on chronic Coumadin therapy for a left lower extremity deep venous thrombosis. In the Emergency Department, the patient was hemodynamically stable. His hematocrit was found to be 25 (down from 34) one month ago. The patient had a nasogastric lavage which was positive for coffee ground material which did not clear with two liters. The patient was transfused one unit of packed red blood cells in the Emergency Department and admitted to the Medical Intensive Care Unit. The patient was also admitted from [**7-7**] to [**7-10**] for Klebsiella bacteremia which was treated with a 10-day course of levofloxacin. PAST MEDICAL HISTORY: (Past medical history is significant for) 1. Pancreatic cancer with known liver metastases treated in [**2150-7-26**] with debulking and gastrojejunostomy surgery as well as radiation and chemotherapy. 2. The patient has a history of gastric outlet obstruction secondary to surgery. 3. Benign prostatic hypertrophy. 4. Sick sinus syndrome; status post pacemaker placement. 5. Left lower extremity deep venous thrombosis (on Coumadin). 6. Melanoma with local excision. 7. Recent Klebsiella bacteremia; treated with a 10-day course of levofloxacin. PAST SURGICAL HISTORY: (Past surgical history is significant for) 1. Gastrojejunostomy. 2. Gastrojejunostomy tube placement in [**2150-7-26**]. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient denies tobacco, alcohol, and intravenous drug use. The patient lives with his wife. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed his temperature maximum was 99.5, his blood pressure was 100/49, his heart rate was 74, and his oxygen saturation was 96% to 99% on room air. In general, the patient was a well-nourished gentleman in no acute distress. Cardiovascular examination revealed a regular rate and rhythm. No murmurs, rubs, or gallops. The lungs were clear to auscultation bilaterally. The abdomen was tympanitic and distended, mildly tender in the right upper quadrant, with no rebound or guarding. Extremity examination revealed no clubbing, cyanosis, or edema. Neurologic examination was grossly nonfocal. Cranial nerves II through XII were intact. BRIEF SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The patient was admitted to the Medical Intensive Care Unit. 1. GASTROINTESTINAL BLEED ISSUES: The patient was transfused multiple units of packed red blood cells and fresh frozen plasma. The patient's Coumadin was held. His INR was 2.5 on admission. The patient was given intravenous vitamin K and intravenous Protonix q.12h. and was made nothing by mouth. An esophagogastroduodenoscopy done showed reflux from the duodenum/tumor area, but the scope could not be passed into the duodenum secondary to tumor. A nasogastric lavage was repeated which showed coffee-grounds followed by fresh clots of red blood. The patient was sent to Interventional Radiology for an angioembolization. An angioembolization was done to the gastroduodenal artery on [**7-25**]. This procedure was complicated with a right groin hematoma. On [**7-26**], the patient's hematocrit was still slowly dropping. Interventional Radiology and Surgery were consulted again. The patient was sent for a repeat embolization on [**7-28**]. This embolization was complicated with a left groin hematoma and pseudoaneurysm. Following the second angioembolization, the patient's hematocrit remained stable for 24 hours, and he was transferred to the medicine floor from the unit. The patient received a total of 14 units of packed red blood cells and 10 units of fresh frozen plasma in the unit. On [**7-30**], the patient had a prominent injection into the left femoral pseudoaneurysm. On [**7-31**], the patient had an ultrasound which showed a pseudoaneurysm still present in the left femoral area with flow through it. His hematocrit was stable at that time. On [**8-1**], the day following the patient being transferred to the floor, his hematocrit was dropping slowly to 28 with an expanding left femoral hematoma. The patient received 2 units of packed red blood cells, and 2 units of fresh frozen plasma, and 1 mg of intravenous vitamin K. Vascular Surgery was consulted again, and the patient was to go for repair of the left femoral pseudoaneurysm. The patient's hematocrit was stable for the next three days at approximately 32. His INR was corrected to 1.3. On [**8-3**], the patient was taken to the operating room for pseudoaneurysm repair. On [**8-4**], the patient was found to still have a slowly dropping hematocrit once again. He was transfused one unit of packed red blood cells. A repeat esophagogastroduodenoscopy was done on [**8-5**] which was negative. The patient's hematocrit remained stable at approximately 30 until discharge. 2. CARDIOVASCULAR ISSUES: The patient was ventricularly paced, and therefore ischemia was unable to be evaluated based on his electrocardiogram in the Emergency Department. The patient ruled out for a myocardial infarction, and his antihypertensive medications were held. The patient's blood pressure remained stable throughout his hospitalization. 3. GASTROINTESTINAL ISSUES: The patient has a history of chronic constipation. The patient was placed on a bowel regimen which included Senna and docusate. The patient was also placed on simethicone for complaints of bloating. The patient had regular bowel movements after being transferred to the floor and did not have any further gastrointestinal complaints. The patient was also started on Viokase with meals for possible pancreatic dysfunction. 4. COAGULOPATHY ISSUES: The patient was initially admitted on Coumadin with an INR of 2.5 following reversal of anticoagulation with fresh frozen plasma and vitamin K while the patient was in the Medical Intensive Care Unit. Once the patient was transferred to the floor, his INR continued to increase to a maximum level of 2.9. The patient again received 2 more units of fresh frozen plasma and 1 mg of intravenous vitamin K while on the floor and then placed on oral vitamin K to maintain his INR at less than 1.5. The patient was discharged with an INR of 1.3 which remained stable following the initial reversal with fresh frozen plasma and vitamin K. 5. PSEUDOANEURYSM ISSUES: The patient's angioembolization procedures were complicated with bilateral groin hematomas and a left groin pseudoaneurysm. The patient had bilateral ultrasounds initially done showing no pseudoaneurysm on the right, just a hematoma, and a pseudoaneurysm on the left. The patient had a thrombin injection performed and a repeat ultrasound which showed the pseudoaneurysm was still present that then began to expand with an expanding hematoma and a drop in his hematocrit. The patient went for repair of the pseudoaneurysm on [**8-3**] with no further complications. CONDITION AT DISCHARGE: Condition on discharge was good. DISCHARGE STATUS: Discharge status was to home. DISCHARGE DIAGNOSES: 1. Metastatic pancreatic cancer. 2. Gastrointestinal bleed. 3. Left femoral pseudoaneurysm. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up with Dr. [**Last Name (STitle) **] in one week. 2. The patient was instructed to follow up with Dr. [**Last Name (STitle) **] in 10 to 14 days. MEDICATIONS ON DISCHARGE: (Discharge medications included) 1. Clonazepam 0.5 mg by mouth at bedtime. 2. Doxazosin 2 mg two tablets by mouth at bedtime. 3. Pantoprazole 40 mg by mouth q.12h. 4. Viokase two tablets by mouth three times per day (with meals). [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**] Dictated By:[**Last Name (NamePattern1) 7586**] MEDQUIST36 D: [**2151-8-8**] 11:50 T: [**2151-8-10**] 07:49 JOB#: [**Job Number 8657**]

[ "578.1", "997.2", "197.4", "998.12", "157.0", "197.7", "276.6", "287.5", "285.1" ]

icd9cm

[ [ [] ] ]

[ "96.33", "45.13", "86.04", "39.52", "99.10", "88.47", "44.44" ]

icd9pcs

[ [ [] ] ]

7735, 7831

8081, 8594

7864, 8054

1923, 2101

2987, 7615

7630, 7714

143, 1321

1344, 1899

2118, 2952

24,992

170,217

49323

Discharge summary

report

Admission Date: [**2131-7-4**] Discharge Date: [**2131-7-28**] Date of Birth: [**2054-5-1**] Sex: M Service: GENERAL SURGERY BLUE HISTORY OF PRESENT ILLNESS: This 77-year-old man, who underwent an elective Whipple procedure on [**2131-7-6**]. He presented on [**7-4**], two days prior to his scheduled elective surgery with a complaint of a dizziness episode with questionable syncope outside the hospital. He had no prior episodes like this. He had denied any chest pain, palpitations, loss of consciousness, although the family acknowledges loss of consciousness. He denied bright red blood or any vomiting, although he had been having dark stools months prior to admission. He felt dizzy when she was sitting down in a chair. PAST MEDICAL HISTORY: 1. Atrial fibrillation. 2. Benign prostatic hypertrophy. 3. Choledocholithiasis. 4. Colon cancer. 5. Right cataract. PAST SURGICAL HISTORY: 1. Bilateral total knee arthroplasty. 2. Left sided total hip arthroplasty. 3. Earlier this year in [**2131-3-6**], he underwent a right colectomy with cholecystectomy. In addition, he was admitted to [**Hospital1 69**] in month of [**Month (only) 205**] for an upper GI bleed, was treated in the hospital for which he was an inpatient on the Hepatobiliary Service from [**6-22**] until [**2131-6-30**]. MEDICATIONS AT HOME: 1. Protonix 40 mg once a day. 2. Isosorbide dinitrate 10 mg twice a day. 3. Terazosin 5 mg once a day. 4. Celexa 20 mg once a day. 5. Quinidine 648 mg twice a day. ALLERGIES: 1. Sulfa. 2. Morphine. SOCIAL HISTORY: He does not smoke, but he does have a history of drinking that he quit six years ago. PHYSICAL EXAMINATION ON ADMISSION: Afebrile, pulse 72, blood pressure 102/64, 97% on room air. In no acute distress. Cardiovascular: Regular, rate, and rhythm without murmurs, rubs, or gallops. Lungs are clear to auscultation bilaterally. Abdomen is soft, nontender, nondistended with midline scar. Extremities: Positive edema, positive venous congestion. Rectal examination: Guaiac positive, good tone. ADMISSION LABORATORIES: White blood cells 5.8, hematocrit 28.6, platelets 167. Chem-10: Sodium 140, potassium 3.1, chloride 106, bicarb 21, BUN 42, creatinine 1.9, sugar 112, calcium 9.2, phosphorus 3.0, magnesium 1.7. Coagulation factors: PT 13.2, PTT 28.4, INR 12.2. LFTs: 123 ALT, AST is 39, alkaline phosphatase is 539, bilirubin 30.3, amylase was 343, and lipase was 805, and albumin was 3.0. The patient was transfused 1 unit of packed red blood cells and his K was repleted and he was prepared for surgery. Aside from the initial transfusion and the potassium repletion, Mr. [**Known lastname 103341**] preoperative course was unremarkable. On [**7-6**], he was brought down to the operating room and once consent was verified, he was put into general anesthesia, and underwent a pancreaticoduodenectomy by Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) **]. Please refer to the previously dictated operative note to hear the details of this operation. Briefly, once the dissection was brought down to the retroperitoneum, a large pancreatic head mass could be palpated and was excised. Once the mass was removed, a pancreaticojejunostomy and a choledochojejunostomy anastomoses were all performed. Two [**Location (un) 1661**]-[**Location (un) 1662**] drains were left behind as well as a central venous line. The patient was transferred postoperatively to the Surgical Intensive Care Unit, where his course was relatively unremarkable. He was given perioperative Lopressor to control his rate as well as dopamine, and given fluid resuscitation and monitored based on the central venous pressure. On [**7-9**], postoperative day three, the patient was transferred from the unit to the floor, but began having runs of atrial fibrillation that were not readily controlled with doses of Lopressor. It was decided to transfer him to a cardiac floor, where a diltiazem drip could be instituted. The diltiazem drip was able to control his rate under 100, although he remained in atrial fibrillation. On [**7-10**], a urine culture was sent off in the morning which showed E. coli that was already sensitive to the Zosyn that the patient was taking at this time. On [**7-11**], a Cardiology consult was obtained to help assess and treat his continued atrial fibrillation. As a result of this consult, a procainamide drip was begun at 3 mg/minute with good response. On [**7-14**], the patient returned back to normal sinus rhythm, and remained so for the rest of his hospital course. On [**7-13**], however, the [**Hospital 228**] hospital course was again complicated by two things, first a bile culture revealed the presence of E. coli and enterococcus as well as yeast in his bile. As a result of this, he was started on Diflucan in addition to the Zosyn he was already on. Moreover, a CT scan on the 8th also showed a failure of oral contrast past the stomach, and it was noted that he had a delayed gastric emptying presumably as a complication of his Whipple procedure. The patient was started on intravenous Reglan and intravenous erythromycin to help mobilize his stomach and increase his gastric emptying rate. Moreover, he was also started on hyperalimentation and his TPN was begun. Unfortunately, his triglyceride levels were 476, and he was not able to be started on lipids within his TPN mixture. On [**7-20**], the patient's course was complicated again. Because of lack of clinical improvement, another CT scan was obtained, and this showed a marked massive perihepatic, perisplenic and pelvic ascites. On [**7-21**], the patient underwent a paracentesis procedure during which 4 liters were removed from the patient's peritoneal cavity. Following this procedure, the patient improved clinically. His JP output gradually decreased, although at the time of discharge, it is still approximately 150 mL a day of output. However, he has recently tolerated a small amount of clear liquids by mouth without nausea or vomiting. As a result of his clinical improvement, he is being transferred to RHCI in [**Location (un) **] on [**7-28**]. CONDITION ON DISCHARGE: He is being discharged in good condition. DISCHARGE DIAGNOSES: 1. Pancreatic adenocarcinoma with one positive metastatic lymph node out of 11. 2. Status post Whipple procedure. 3. Hyperalimentation. 4. Atrial fibrillation. 5. Gastric outlet obstruction. 6. Anastomotic leak following Whipple procedure. 7. Urinary incontinence. 8. Hypokalemia. 9. Chronic blood loss anemia requiring blood transfusion. DISCHARGE MEDICATIONS: 1. Octreotide acetate 200 mg subQ every eight hours. 2. Atrovent inhaler every six hours. 3. Albuterol inhaler every four hours. 4. Procainamide 1500 mg extended release po bid. 5. Terazosin HCL 4 mg before bedtime. 6. Reglan 10 mg IV q6. 7. Erythromycin 200 mg IV 4x a day before each meal and before midnight. 8. Furosemide 40 mg once a day. 9. Fluconazole 400 mg once a day. 10. Potassium 40 mg once a day. FOLLOW-UP INSTRUCTIONS: He should have follow-up appointment with Dr. [**First Name (STitle) **] in [**12-7**] weeks, and he should also have a follow-up appointment with Dr. [**Last Name (STitle) 15521**] of Medical Oncology on [**8-14**]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**] Dictated By:[**Last Name (NamePattern1) 1179**] MEDQUIST36 D: [**2131-7-28**] 05:04 T: [**2131-7-28**] 06:19 JOB#: [**Job Number 103342**]

[ "427.31", "V10.05", "280.0", "157.0", "196.2", "997.4", "599.0", "600.0", "576.2" ]

icd9cm

[ [ [] ] ]

[ "52.7", "99.15", "38.93", "54.91" ]

icd9pcs

[ [ [] ] ]

6249, 6589

6612, 7023

1346, 1546

919, 1325

180, 756

1686, 6160

7048, 7539

778, 896

1563, 1671

6185, 6228

1,180

117,495

23027

Discharge summary

report

Admission Date: [**2127-2-8**] Discharge Date: [**2127-2-23**] Date of Birth: [**2047-9-1**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 759**] Chief Complaint: evaulation if pulmonary infiltrates - transfer from [**Hospital 11373**] Major Surgical or Invasive Procedure: none History of Present Illness: 79 yo femal with PMH of RA treated with pred and MTX, CAD, long h/o GERD, breat ca s/p left mastectomy and h/o pulm fibrosis presents from OSH for further eval of hypoxia in the setting of pregressice bilateral pulm infiltrates. In [**Month (only) **], the pat had RUL PNA that responded to abx by exam and CXR. In early [**Month (only) 1096**], she reported that she had weeks of fever around 101 associated with progressive SOB and cough, non-productive esp severe DOE. +sweat and chills/ no PND, sleeps on [**5-13**] pillows. Past Medical History: HTN, GERD, Pulm fibois, RA, ?PMR/TA, hypothroid, depression and anxiety, breast cancer s/p L mastectomy, OA, macular degeneration, s/p B TKR, chronic pain syndrome Social History: Lives near son. Moved here from, Flordia in [**Month (only) 205**] to be closer to children. Never smoked and rarely drinks ETOH. Able normally to walk around with a walker Family History: NC Physical Exam: Vitals: T= 98.8, HR = 96, BP = 133/71, RR = 24, SaO2 = 93-95% on 5L NC. General: Pleasant female, appears in slight distress. Speaks in short full sentances. no accessory muscle use HEENT: Normocephalic and atraumatic head, no nuchal rigity though holds head tilted toraed right. anicteric sclera, moist mucous membranes. Neck: No thyromegaly, no lymphadenopathy, no carotid bruits. Chest: Her chest rose and fell with equal size, shape and symmetry, her lungs had bronchial breath sounds thoughout all lung fields bilaterally. CV: PMI appreciated in the fifth ICS in the midclavicular line without heaves or thrills, RRR, normal S1 and S1 no murmurs rubs or gallops. Abd: Normoactive BS, NT, slightly distended. No masses or organomegaly Back: No spinal or CVA tenderness. Ext: NO cyanosis, no clubbing, trace pedal edema with 2+ dorsalis pedis pulses bilaterally. lateral deviation of all toes on both feet. Integument: no rash Neuro: CN II-XII symmetrically intact, PERRLA. Pertinent Results: Labs from OSH: [**10-14**]>__ < 311 31 [**Age over 90 **]|101|42<165 3.9|24|1.5 BNP 152 CT and Xrays were sent with patient. OSH CT of chest: bilateral upper lobe infiltrates, ground glass opacities. [**2127-2-9**] 06:02AM BLOOD WBC-8.7 RBC-3.10* Hgb-10.3* Hct-30.9* MCV-100* MCH-33.2* MCHC-33.3 RDW-17.9* Plt Ct-271 [**2127-2-9**] 06:02AM BLOOD Plt Ct-271 [**2127-2-9**] 06:02AM BLOOD PT-13.1 PTT-20.9* INR(PT)-1.1 [**2127-2-9**] 06:02AM BLOOD Glucose-105 UreaN-42* Creat-1.4* Na-134 K-3.7 Cl-97 HCO3-26 AnGap-15 [**2127-2-9**] 06:02AM BLOOD ALT-43* AST-35 LD(LDH)-442* AlkPhos-84 TotBili-0.4 [**2127-2-9**] 06:02AM BLOOD Albumin-3.2* Calcium-8.9 Phos-3.7 Mg-1.9 [**2127-2-8**] 06:55PM BLOOD Type-ART O2 Flow-2 pO2-67* pCO2-33* pH-7.49* calHCO3-26 Base XS-2 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**] Chest CT [**2127-2-11**]: Severe patchy ground glass opacity, reticulation, and traction bronchiectasis within both lungs, predominantly involving both upper lobes. This finding is non-specific in nature, but could represent atypical infection, hypersensitivity pneumonitis, or Acute Interstitial Pneumonia. Hand X-Ray [**2127-2-12**]: Findings most consistent with advanced osteoarthritis, though the second MCP joint is narrowed as described. Foot X-Ray [**2127-2-12**]: There are no fractures. There is marked medial subluxation of the second and third proximal phalanges on the metatarsals, and marked lateral subluxation of the fourth and fifth distal phalanges on the proximal phalanges. There are no focal osteolytic or sclerotic lesions. There are no marginal erosions. There is a posterior calcaneal spur. There is soft tissue prominence in the region of the MTPs. Chest CT [**2127-2-17**]: 1). Diffuse lung disease with upper lobe predominance (left greater than right). The areas of ground-glass opacity with traction bronchiectasis have increased in density when compared to [**2127-2-11**], but are otherwise unchanged. If the patient has a fever, these findings would consistent with pneumocystis carinii pneumonia or other atypical infectious processes. Other conditions that could be included on the radiographic differential diagnosis include chronic eosinophilic pneumonia, cryptogenic organizing pneumonia, vasculitis, drug toxicity, or acute interstitial pneumonia. CXR [**2127-2-21**]: Observed changes suggest improved aeration of the areas with less degree of ground-glass densities but persistent mostly interstitial infiltrates. No other significant interval change since [**2-14**]. Brief Hospital Course: 79 yo f with PMH sig for RA treated with pred/MTX, CAD, long h/o GERD, breast ca s/p left mastectomy presents from OSH for further eval of hypoxia (85% on RA) in the setting bilateral pulm infiltrates. 1.Pulm infiltrates. DDx includes PCP, [**Name10 (NameIs) **] other infectious cause (atypical PNA), vs MTX lung (dx of exclusion). She had 3 negative sputum cultures for PCP. [**Name10 (NameIs) **] was on levoflox/vanco on transfer from the OSH for CAP but they were d/c'd by they ICU team. Because po allergy to bactrim, pt was started on primaquine and clinda for a 3 week course for presumed PCP. [**Name10 (NameIs) **] has been on high dose steroids since admission. She received 3 days of IV Solu-Medrol and is currently on 60 mg of po Prednisone which she will continue until she is seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the pulmonary clinic in [**4-11**] weeks. She notes slight subjective improvement in SOB with exertion since admission. Bronch vs VATS were considered to get a tissue diagnosis given her repeat CT after two weeks of PCP treatment with continued ground glass opacities, however pulm/thoracics/cardiology felt that these procedures were too high risk given underlying cardiac disease (reversible defect on recent MIBI ([**10-12**])). She will be treated with high-dose steroids empirically for interstitial lung dz and followed closely by pulmonary. She will complete a 21 day course of Abx for PCP [**Name Initial (PRE) **]. She was given inhaled pentamidine for one month of PCP [**Name Initial (PRE) 1102**]. She had baseline PFTs done on [**2127-2-21**]. The results are currently pending. She will have a repeat CXR and PFT's in one month to monitor her lung function once PCP treatment has finished. She should have a CBC with diff checked in one week for concern of granulocytopenia with primaquine and RA. 2. CV. Positive stress test with reversible defect in [**10-12**] w/o intervention. Cardiology saw pt for pre-op evaluation and felt she was at moderate risk. She was started on Metoprolol 75 [**Hospital1 **] and hydralazine with adequate BP control. She was continued on Isordil and [**Hospital1 **] daily. Her LFT's were WNL. Her LDL was found to be 161, therefore she was started on 80 mg of Lipitor. 3. RA normally on prednisone and MTX once weekly. Rheumatology followed her during her stay. Her MTX was held. She is currently on high dose steroids for lung issues which is also controlling her RA. Alternative therapies may need to be considered once she is off steroids (TNF-inhib, etc). Her pain is currently controlled on a Fentanyl patch. She was continued on Ca/Vit D supplements. Her Alendronate was increased to full strength. 4. GERD: She was continued on Protonix 40 [**Hospital1 **]. 5. CRF. Cr at baseline of 1.5. She received Mucomyst and hydration prior to CT scan. She is normally on EPO injections for anemia. She did not receive EPO during her stay. 6. Hypothyroid: She was continued on Levoxyl. 7. Depression/Anxiety. She was continued on Effexor, trazodone prn, and Zyprexa. 8. Dementia. She notes short term memory impairment and should have an outpt evaluation. 9. PPX. She was on SC heparin during her stay. 10. Code Status. Full. Medications on Admission: Meds on transfer: advair, clinda, timentin, vanc, lovenox, lactinex, primaquine, alphaquan, fosamax, levothyroxine, MIV, [**Last Name (LF) 59392**], [**First Name3 (LF) **], nasonex, humibid, cardizem 120, duragesic patch, zyprexa, trazadone, cal, vit D, effoxor XR, nystatin s and swallow, solumedrol 30 QID, protonix, isordil 20 TID, [**Doctor First Name 130**] 180 outpatient: aranesp 200mcg every few weeks (last dose [**2127-1-23**]) Discharge Medications: 1. Brimonidine Tartrate 0.2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 2. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for coughing. 4. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO HS (at bedtime). 5. Trazodone HCl 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomina. 6. Venlafaxine HCl 75 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO BID (2 times a day). 7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 10. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever, pain. 12. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 16. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Transdermal Q72H (every 72 hours). 17. Senna 8.6 mg Tablet Sig: 1-5 Tablets PO BID (2 times a day) as needed. 18. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day): Please hold for Blood Pressure < 110 and Heart Rate < 60. . 19. Alendronate Sodium 70 mg Tablet Sig: One (1) Tablet PO QSUN (every Sunday). 20. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-9**] Sprays Nasal QID (4 times a day) as needed. 21. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 22. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 23. Hydralazine HCl 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours): Please hold for systolic blood pressure < 110. . 24. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 25. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 26. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 27. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): While on high dose steroids. . 28. Primaquine Phosphate 26.3 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 6 days. 29. Clindamycin HCl 150 mg Capsule Sig: Three (3) Capsule PO Q6H (every 6 hours) for 6 days. Discharge Disposition: Extended Care Facility: [**Hospital6 25759**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: Likely Pneumocystis carinii pneumonia Secondary Diagnoses: Rheumatoid Arthritis Coronary Artery Disease Discharge Condition: Stable Discharge Instructions: Please call your primary care physician or return to the hospital if you experience worsening shortness of breath or any other symptoms. Please do not take Methotrexate as there is concern that it is affecting your lungs. Please continue to take 60 mg of Prednisone until you see Dr. [**First Name (STitle) **] in 3 - 4 weeks. Followup Instructions: 1. Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the Pulmonology clinic in three to four weeks. Please call ([**Telephone/Fax (1) 513**] to make an appointment. 2. Pleaase follow-up with your primary care physician in one to two weeks. 3. Please follow-up with your rheumatologist in three to four weeks. You are no longer taking Methotrexate as there is concern that it is affecting your lungs.

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Discharge summary

report

Admission Date: [**2178-4-6**] Discharge Date: [**2178-4-13**] Date of Birth: [**2103-2-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2265**] Chief Complaint: epigastric burning, nausea Major Surgical or Invasive Procedure: transvenous pacer placement History of Present Illness: HISTORY OF PRESENTING ILLNESS: 75 M male with hx IDDM, HTN with 2 days nausea,GERD like symptoms, lack of appetite presented to ER today.On the night prior to admission he noted anterior chest discomfort very similar to prior episodes of heartburn and had emesis x1 with mild improvement with drinking gingerale. He denied any diaphoresis, weakness, light headedness, CP or SOB at the time. Of note he has had a left thumb paronychia which subsequently required surgical drainage and developed osteomyelitis with bactrim DS [**Hospital1 **] and clindamycin started on [**2178-4-3**] . Initially in triage his pulse with 57 with sinus bradycardia. On repeat vitals his pulse was in the 30s and found to be in CHB on ECG. Patient became diaphoretic and nauseous and had drop in BP from 130 systolic to 100s. He was externally paced and cardiolofy was called. On labs was found to have renal failure and hyperkalemia. Given K+ treatment with insulin, D50, calcium, and bicarbonate. No kayexalate was given. ECG with no concerning signs of ischemia. EP placed a transvenous pacer wire and being paced at 70. NPO at midnight for possible intervention. . In the ED, initial vitals were HR 60 BP 138/62 afebrile 100% RA RR:16 HR 36 feeling more fatigued. Repeat EKG at this point showed complete heart block HR dropped to 20 with 60/49 more symptomatic, nauseated diaphoretic, cards called. EP came, loaded pacer wire 9pm. Noted to have K of 7.9 Got ins, D5, switched fluids to D5. No kayexelate given. . Patient with known diabetes, HTN had never been to a hospital before. unclear how often he sees doctors. Patient also received Zofran and fentanyl and feeling much better after pacing at 70 as well. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . On arrival to the floor patient noted to be in 1st degree heart block on EKG. Kayexalate was administered given hyperkalemia in ED. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. macular Degeneratiopn 3. Anemia 4. Diabetic Retinopathy 5. Glaucoma Social History: Tobacco history: distant, 20ppy hx -ETOH: quit 3 years ago, liquor -Illicit drugs: none -lives with wife, retired building supervisor Family History: mother with diabetes, hx MI, brother diabetes. [**Name2 (NI) **] family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: T=98/7 BP=152/54 HR= 85 RR=16 O2 sat=99% GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple no JVP. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Transcutaneous pacer wire/pads in place. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2178-4-6**] 11:09PM URINE HOURS-RANDOM CREAT-80 SODIUM-105 POTASSIUM-49 [**2178-4-6**] 11:09PM URINE OSMOLAL-583 [**2178-4-6**] 11:09PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.019 [**2178-4-6**] 11:09PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2178-4-6**] 11:09PM URINE EOS-POSITIVE [**2178-4-6**] 11:08PM GLUCOSE-296* UREA N-27* CREAT-2.1* SODIUM-132* POTASSIUM-5.5* CHLORIDE-101 TOTAL CO2-22 ANION GAP-15 [**2178-4-6**] 11:08PM OSMOLAL-301 [**2178-4-6**] 10:12PM %HbA1c-10.2* eAG-246* [**2178-4-6**] 08:49PM K+-8.0* [**2178-4-6**] 08:40PM GLUCOSE-242* UREA N-28* CREAT-2.3* SODIUM-128* POTASSIUM-7.9* CHLORIDE-101 TOTAL CO2-17* ANION GAP-18 [**2178-4-6**] 08:40PM CK(CPK)-247 [**2178-4-6**] 08:40PM cTropnT-<0.01 [**2178-4-6**] 08:40PM CK-MB-3 [**2178-4-6**] 08:40PM CALCIUM-8.9 PHOSPHATE-3.4 MAGNESIUM-2.2 [**2178-4-6**] 08:40PM WBC-13.9* RBC-5.21 HGB-12.9* HCT-39.3* MCV-75* MCH-24.8* MCHC-32.9 RDW-13.8 [**2178-4-6**] 08:40PM NEUTS-78.8* LYMPHS-16.9* MONOS-3.5 EOS-0.6 BASOS-0.2 [**2178-4-6**] 08:40PM PLT COUNT-212 [**2178-4-6**] 08:40PM PT-13.3 PTT-25.4 INR(PT)-1.1 [**2178-4-6**] 06:55PM GLUCOSE-179* UREA N-26* CREAT-2.2* SODIUM-129* POTASSIUM-6.8* CHLORIDE-98 TOTAL CO2-20* ANION GAP-18 . [**2178-4-9**] 05:40AM BLOOD WBC-12.4* RBC-4.95 Hgb-11.8* Hct-37.0* MCV-75* MCH-23.9* MCHC-32.0 RDW-13.9 Plt Ct-161 [**2178-4-9**] 05:40AM BLOOD Neuts-67.2 Lymphs-24.6 Monos-6.0 Eos-1.6 Baso-0.5 [**2178-4-9**] 05:40AM BLOOD Plt Ct-161 [**2178-4-9**] 05:40AM BLOOD Glucose-111* UreaN-17 Creat-1.5* Na-136 K-4.3 Cl-103 HCO3-24 AnGap-13 [**2178-4-9**] 05:40AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.2 CXR: [**2178-4-6**] FINDINGS: Single AP upright portable view of the chest was obtained. The lungs are clear without focal consolidation. No appreciable pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. No overt pulmonary edema is seen. Possible [**Doctor Last Name **]-[**Doctor Last Name 3450**] deformity of the right shoulder is seen. IMPRESSION: 1. No acute cardiopulmonary process. 2. Possible right shoulder [**Doctor Last Name **]-[**Doctor Last Name 3450**] deformity. . [**2178-4-7**] -Echo The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The 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. No mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. . [**2178-4-7**]- Ultrasound of kidneys Ultrasound of the bilateral kidneys demonstrates no hydronephrosis, stones or concerning masses. The right kidney measures 10.2 cm and the left 9.7 cm. The bladder is well seen and normal in appearance. Brief Hospital Course: ASSESSMENT AND PLAN: 75 y/o man with hx DM, HTN admitted with nausea, indigestion found on EKG to have 3rd degree h/b s/p transvenous pacing. Pt now in 1st degree hb. Initially heart block thought to be secondary to hyperkalemia given his new bactrim use in conjunction with chronic lisinopril and acute renal failure. Ischemia was not thought to be the underlying etiology given that he did not have EKG evidence consistent with ischemia, and had negative troponins. Increased vagal tone in the setting of systemic infection was considered a possibility given his known osteomyeltis. # Heart block: His heart rate remained mostly above the intrinsic rate with HR in the 80s except in sleep. His heart block resolved with treatment of his hyperkalemia. An electrophysiology study was performed to evaluate the his-purkinje system which showed mild nodal disease and mild infranodal disease. His presentation was thought likely related more to increased vagal tone rather than his hyperkalemia and no pacemaker was indicated at that time. A TTE showed EF 50-65%, mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function but no evidence of endocarditis. If patient has symptoms with exertion related to AV conduction disease, then can consider elective pacemaker implantation. He will follow up with Dr [**First Name8 (NamePattern2) **] [**Name (STitle) **] in electrophysiology as an outpateient. His lisinopril has been held at time of discharge; amlodipine has been started in its place. # Osteomyelitis: He had osteomyelitis of the left thumb based on MRI by PCP prior to admission for which he had been started on bactrim and clindamycin. He also had leukocytosis on admission. Given his renal failure and hyperkalemia, these medications were discontinued and he was started on vancomycin. Infectious disease was consulted as was the hand service. I.D reviewed his o/p MRI with radiology and felt that it was consistent with osteomyelitis and started him on diflucan and IV vancomycin based on organisms on o/p culture and a PICC was placed for abx delivery. He was set up with home VNA services, and will follow up with Dr [**Last Name (STitle) 13895**] in I.D 2 weeks post discharge. # Renal Failure: Baseline is 1.5 and was 2.2 on admission. It was unclear whether this was nephrotoxicty of bactrim in combination with lisinopril, or due to poor forward flow in the setting of bradychardia due to a conduction delay. His FENA was 2.1 on admission, a renal ultrasound was unremarkable. His creatinine trended downwards and was slightly above his baseline on admission. His home lisinopril was stopped; amlodipine was started in its place. His metformin was held and his Cr was 1.2 on discharge. He should have close follow up of his renal function by his PCP as an outpatient. # Diabetes: poorly controlled with HgA1C 10.2. Continued on home dose of lantus of 50 units [**Last Name (STitle) **]. Medication eduction/compliance may be revisited as an outpatient with PCP and [**Name9 (PRE) 86587**] consulted as o/p. Medications on Admission: bactrim 800/160 DS started on [**2178-4-3**] clindamycin 150 2 tabs TID started on [**2178-4-3**] Novolog sliding scale Lisinopril 20 mg daily Lantus 50 units [**Name (NI) **] (pt unsure) metformin 500 [**Hospital1 **] zocor 20 daily ASA 81 daily xalatan eye drops 0.005% Timolol Maleate 0.5% lantoprost 0.005% Vitamin D 50,000 capsule ALLERGIES: NKDA Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 3. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. Timolol Maleate 0.5 % Drops Sig: One (1) drop each eye Ophthalmic twice a day. 5. Insulin Glargine 100 unit/mL Cartridge Sig: Fifty (50) units Subcutaneous at bedtime. 6. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 7. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 8. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*30 Tablet(s)* Refills:*0* 9. Outpatient Lab Work Check weekly (starting the week of [**2178-4-13**]) CBC with differential, BUN/Creatinine, vancomycin trough, and LFTs. Please fax the results to Dr. [**Last Name (STitle) 13895**] at ([**Telephone/Fax (1) 1353**]. 10. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 24H (Every 24 Hours). Disp:*30 gram* Refills:*0* 11. Normal Saline Flush 0.9 % Syringe Sig: [**6-8**] ML Injection twice a day: Flush PICC with 5-10 ML of normal saline before and after use. Disp:*60 qs* Refills:*0* 12. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: 2-5 MLs Intravenous PRN (as needed) as needed for line flush: Flush PICC with 2-5 ML heparin flush after access. Disp:*30 qs* Refills:*0* 13. Norvasc 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Primary Hyperkalemia Complete heart block Osteomyelitis of the left thumb Secondary Paronychia Diabetes Hypertension Discharge Condition: Stable, good, baseline ambulatory status, alert and oriented x 3. Discharge Instructions: You were admitted to the hospital because you were feeling nauseated and had heart burn. You were found to have an arrhythmia called heart block. You underwent an electrophysiology study that showed that you had mild heart conduction disease. You did not need a pacemaker right now but it is important that you follow up with Dr. [**First Name (STitle) **] at the scheduled time. Please return to the hospital if symptoms recur. You have a infection of your left thumb that is slowly improving. Our surgical and infectious disease teams feel that you have involvement of the bone that requires intravenous antibiotics. Medication changes: - We decreased the dose of the simvastatin to 10 mg daily from 20 mg daily - We stopped lisinopril because we were concerned that this was causing elevation of potassium in the blood - We started amlodipine (Norvasc) for blood pressure - Your metformin is being held because of your renal failure. Your primary care physician will decide when you can restart the metformin. - You are being started on fluconazole daily for the infection in your finger. - You will also need an intravenous antibiotic called vancomycin daily. While taking this medication you will need labs checked weekly. A lab slip will be included with your prescriptions. Please check your blood sugar before meals and keep a log of all your results. Discuss your blood sugars at your next appt with Dr. [**First Name (STitle) 3510**]. Your A1C shows that your blood sugars have been poorly controlled at home. Followup Instructions: Primary Care: Dr [**First Name (STitle) 3510**], Tuesday [**4-28**] at 4:30 PM at [**Location (un) **] Internal Medicine, [**Location (un) 4363**]. Tel [**Telephone/Fax (1) 11962**] Cardiology: Dr [**First Name8 (NamePattern2) **] [**Name (STitle) **] Phone: [**Telephone/Fax (1) 2258**] Date/time: [**5-11**] at 8:30am. Infectious Disease: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13895**] [**Hospital3 **] Deaconnes, [**Hospital **] Medical Office Building (LMOB), ground floor [**Last Name (NamePattern1) 439**] [**Location (un) 86**], [**Numeric Identifier 718**]. Please call [**Telephone/Fax (1) 457**] to schedule an appointment with Dr. [**Last Name (STitle) 13895**] for 2 weeks from your discharge date. We had made you an appointment with Dr [**First Name (STitle) **] [**Name (STitle) 86588**], however it was decided upon discussion between the ID departments to have you follow up with the [**Hospital1 18**] ID doctors since they had seen you while you were hospitalized. Please call [**Telephone/Fax (1) 39041**] and cancel the appointment which had been made for you on [**4-14**] at 4:00pm. [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2273**]

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icd9cm

[ [ [] ] ]

[ "38.93", "37.78" ]

icd9pcs

[ [ [] ] ]

12474, 12526

7541, 10611

340, 369

12688, 12756

4178, 7518

14327, 15578

3085, 3263

11014, 12451

12547, 12667

10637, 10991

12780, 13401

3278, 4159

13421, 14304

274, 302

397, 2761

2783, 2917

2933, 3069

17,149

125,751

4146

Discharge summary

report

Admission Date: [**2154-5-14**] Discharge Date: [**2154-5-24**] Date of Birth: [**2097-9-7**] Sex: M Service: SURGERY Allergies: Plavix / Simvastatin / Tape / Hydrochlorothiazide Attending:[**First Name3 (LF) 668**] Chief Complaint: ESRD here for living related kidney transplant Major Surgical or Invasive Procedure: living related kidney transplant [**2154-5-14**] Kidney Biopsy [**2154-5-20**]: Donor disease, no rejection History of Present Illness: ESRD secondary to Wegeners that was diagnosed in [**2143**], with recent progression of kidney disease. He recently started on hemodialysis in [**2153-10-17**]. He has had no significant complications of dialysis, although he does note that he feels fatigued for several hours after the treatments. He was felt to be a good candidate for transplant and will receive a kidney from his sister. Past Medical History: Atrial fibrillation-recently diagnosed, noted to be back in sinus on discharge (DCed on [**11-7**]) Acute on CRF - chronic proteinuria, baseline Cr 1.6-2.0 until last week when Cr acutely increased: at that time +rbc casts on sediment, renal ultrasound negative for hydronephrosis, Fe-urea = 33.53 <35% c/w pre-renal, ANCA/[**Doctor First Name **] negative, C3 wnl, C4 wnl, SPEP with IgG 474, other IgG's wnl, UPEP: multiple protein bands seen, no monoclonal bands, renal consulted and felt most confident this reflected progression of Wegener's CAD - multiple stent, most recent stent in [**10-21**] Chronic angina Hypertension Hypercholesterolemia Wegener's granulomatosis (renal/pulmonary involvement) diagnosed [**2143**] s/p cytoxan/prednisone x 1y initially, ANCA neg. since (chronic proteinuria, baseline Cr 1.6-2.0) Idiopathic pericarditis [**2150**] GERD Depression/anxiety Gout Umbilical hernia repair Social History: Married with 3 children, lives w/ wife and youngest daughter. [**Name (NI) **] two other children who live in [**Location (un) 86**]. Quit smoking 25 years ago. Rare etoh, denies illicit drugs. Family History: mother - CVA at 46, myasthenia [**Last Name (un) 2902**] father - CAD,died at 85 six siblings - one sister died of melanoma; a sister has scleroderma, and another sister has [**Name (NI) 18109**] Physical Exam: VS: 164/87, 60, 21, 95% Gen: NAD Card: Nl S1,S2 Lungs: CTA bilaterally Abd: Midline incision with dressing in place Extr: No edema R tunneleed hemodialysos catheter Pertinent Results: On Admission [**2154-5-14**] WBC-9.1# RBC-3.57* Hgb-10.1* Hct-30.7* MCV-86 MCH-28.3 MCHC-32.9 RDW-17.9* Plt Ct-177 Glucose-145* UreaN-29* Creat-5.5* Na-137 K-4.4 Cl-100 HCO3-27 AnGap-14 Calcium-8.6 Phos-4.6* Mg-1.6 On Discharge: [**2154-5-24**] WBC-5.8 RBC-2.99* Hgb-8.6* Hct-25.4* MCV-85 MCH-28.7 MCHC-33.7 RDW-17.1* Plt Ct-238 Glucose-121* UreaN-42* Creat-3.2* Na-127* K-3.7 Cl-101 HCO3-17* AnGap-13 ALT-26 AST-25 AlkPhos-99 TotBili-0.6 Calcium-7.9* Phos-2.3* Mg-1.7 FK506-8.4 Biopsy results from [**2154-5-20**]: There is no evidence of humoral rejection in this sample. 2. There is significant chronic donor vascular disease particularly in larger arteries. 3. While the infarct may relate to the ligated artery, clinical correlation is indicated to determine its significance. 4. The medullary changes are insufficient for a definite diagnosis of acute cellular rejection. Brief Hospital Course: Patient admitted following living related kidney transplant from his sister. This is reported as a perfect match HLA transplant. Please see the operative note for the surgical details. There was a large hernia defect just above the umbilicus that was included in the incision. Also, the kidney was a little sluggish to reperfuse and remained soggy and somewhat purplish in appearance but as hemostasis was maintained in the retroperitoneum, it eventually pinked up and began making urine. he received intra-op immunosuppression to include Simulect, (2 doses total, day 0 and 4), Cellcept and Solumedrol. Prograf was started on the evening of POD 0. Due to cardiac history with presence of stent, the Ticlid was restarted on POD 2. Dressing over incision required frequent changes due to bloody dressings. In addition he was becoming increasingly bloated and uncomfortable. An abdominal CT done on POD 3 showed no evidence of dilated loops of bowel. No CT finding to explain abdominal pain on this limited non-contrast evaluation. Unremarkable non- contrast appearance of transplant kidney in the right lower quadrant. On POD 4 his creatinine was noted to be rising (highest value on POD 6 of 5.5) Transplant U/S showed minimal simple-appearing perinephric fluid collection, with otherwise normal transplant ultrasound with appropriate arterial and venous waveforms and resistive indices. Patient was still continuing with distention and abdominal pain. KUB on POD 5 showed persistent air distention of the cecum and transverse colon with less distention of the distal colon and sigmoid compared to a day prior. This was concerning for Ogilvies Syndrome. Seen by GI service who felt the ileus was improving and initially recommended conservative management. However on [**2154-5-20**] it was decided to attempt neostigmine treatment, which was successful in alleviating the bowel distention. Biopsy also performed on [**5-20**] for the rising creatinine, it was determined that the kidney disfunction was a result of donor problems and was not rejection or TMA. Received 2 units PRBC's for slowly downward trending Hct. Patient transferred back to [**Hospital Ward Name 121**] 10 following the neostigmine. By POD 8 his bowel function returned. Abdominal incision was opened in two areas which will rewuire dressing changes upon discharge. Creatinine has improved to 3.2 on day of discharge with urine output of about 1300cc/day. Patient was never dialyzed, his HD catheter will remain in place for removal at future time in clinic. Medications on Admission: Labetalol 200" Isosorbide mononitrate/Imdur 30' Norvasc 10' Cozaar 50' ASA 325' Ticlopidine 250" Allopurinol 100' Furosemide 40' Protonix 20' Colace 100" Zoloft 50' Requip 3' Phoslo 1334 tid Lisinopril 40' Crestor 10' Tricor 145' Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 10. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO QOD (). 11. Ropinirole 1 mg Tablet Sig: Three (3) Tablet PO QPM (once a day (in the evening)). 12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Ticlopidine 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 15. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One (1) Packet PO TID (3 times a day). Disp:*90 Packet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: VNA of Greater [**Location (un) 5871**] Discharge Diagnosis: ESRD S/p kidney transplant [**2154-5-14**] Discharge Condition: Good Discharge Instructions: Please call the transplant office at [**Telephone/Fax (1) 673**] if you experience fever > 101.4, chills, nausea, vomiting, diarrhea or constipation. Monitor incision for redness, drainage or foul smelling discharge. Dressing change to abdominal incision twice a day. Pack two open areas VERY LIGHTLY with a single 2x2 and cover with gauze and paper tape. DO NOT USE OCCLUSIVE DRESSINGS or SILK TAPE. Have labs drawn every Monday and Thursday and faxed to [**Hospital 1326**] clinic at [**Telephone/Fax (1) 697**]. CBC, Chem 7, Ca, Phos, AST, T Bili, U/A, Trough Prograf level. Hold on showering until incisions are more well healed Do not drive if taking narcotic pain medications Continue colace and senna as long as on pain medication, or as long as needed Followup Instructions: [**Name6 (MD) **] [**Last Name (NamePattern4) 11082**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2154-5-28**] 10:50 [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2154-6-3**] 8:40 [**Name6 (MD) **] [**Last Name (NamePattern4) 11082**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2154-6-11**] 10:10 Completed by:[**2154-5-24**]

[ "311", "272.0", "285.9", "V45.82", "998.12", "300.00", "996.81", "585.6", "446.4", "997.4", "560.89", "274.9", "276.1", "401.9", "414.01" ]

icd9cm

[ [ [] ] ]

[ "99.04", "55.23", "86.04", "55.69", "00.91" ]

icd9pcs

[ [ [] ] ]

7596, 7666

3355, 5889

354, 464

7753, 7760

2449, 2664

8569, 8992

2051, 2249

6183, 7573

7687, 7732

5915, 6160

7784, 8546

2264, 2430

2678, 3332

268, 316

492, 887

909, 1823

1839, 2035

63,993

170,461

34200

Discharge summary

report

Admission Date: [**2118-12-5**] Discharge Date: [**2118-12-18**] Date of Birth: [**2079-6-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3913**] Chief Complaint: Scheduled admission for ATG to treat aplastic anemia. Major Surgical or Invasive Procedure: ATG treatment. BiPAP. PICC line placed. History of Present Illness: This patient is a 39 y/o M with history of aplastic anemia, admitted for ATG treatment. Patient diagnosed in [**2117-6-27**]; initially with complete response to ATG and cyclosporine and now with evidence of recurrence (pancytopenia). Patient has been taking cyclosporine as an outpatient, and now comes in for ATG treatment - 5 day course. Patient has generally been feeling well recently. Review of systems: Mild headaches recently (believes due to stress) - relieved with sleep Hematuria, he associates this with post-transfusion timing Legs swollen and achy (calf muscles) b/l Denies change in vision/hearing, difficulty swallowing, chest pain, abdominal pain, shortness of breath, diarrhea/constipation, rashes, fevers/chills. Past Medical History: Aplastic Anemia Seasonal allergies "Borderline" Hypertension . PAST SURGICAL HISTORY Hernia repair Sinus surgery Social History: Married, with twin girls 1 month old. Family is very involved in his care. Mr. [**Known lastname 78790**] has smoked a pack a pack-a-day for the past 23 years - wants to quit smoking. He drinks about two alcoholic beverages each evening but rarely exceeds this amount. Family History: His father has a history of ruptured abdominal aortic aneurysms but is alive at 61. His mother is healthy in her 60's. He has one great uncle who had leukemia as an old man. No other family history of hematologic illnesses. Physical Exam: Vitals: T: 98.2 BP: 174/108 P: 74 RR: 20 O2Sat: 99% on RA Weight: 245.5 pounds Gen: Obese male, NAD, conversational. HEENT: Oropharynx clear, MMM, EOM intact, PERRL, no sinus tenderness. NECK: No LAD. CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops. LUNGS: CTAB ABD: Soft, NT, ND. + BS. No HSM. EXTR: 1+ b/l non-pitting edema. No calf tenderness to palpation. SKIN: No petechiae, bruising, bleeding observed. NEURO: A&Ox3. Appropriate. CN 3-12 grossly intact. 5/5 strength throughout. Gait WNL. PSYCH: Listens and responds to questions appropriately, pleasant. Pertinent Results: Micro: [**12-9**]: 4/4 bottles GNR: Blood Culture, Routine (Final [**2118-12-12**]): ESCHERICHIA COLI. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 78791**] [**2118-12-9**]. Aerobic Bottle Gram Stain (Final [**2118-12-10**]): GRAM NEGATIVE ROD(S). Anaerobic Bottle Gram Stain (Final [**2118-12-10**]): GRAM NEGATIVE ROD(S). Blood Culture, Routine (Final [**2118-12-11**]): ESCHERICHIA COLI. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 2 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Aerobic Bottle Gram Stain (Final [**2118-12-9**]): GRAM NEGATIVE ROD(S). . [**12-9**] CXR: 1. Linear retrocardiac left lung base opacities, most likely represent atelectasis and are less likely to be due to pneumonia. 2. Moderate gastric dilatation. . [**12-9**] CT torso w/ contrast: 1. Markedly limited examination for evaluation of pulmonary embolus, although there is no large central pulmonary embolus. Since the patient has already recieved 200ml of IV contrast today, either a VQ scan or repeat CTA thorax in 24 hours can be obtained if high clinical suspicion remains. 2. Multiple pulmonary nodules identified throughout the lungs. These were not identified on the chest x-ray of 11:45 a.m. Therefore may represent septic emboli in the appropriate clinical setting. An echocardiogram may be warranted, given patient's clinical history of neutropenia and high susceptibility to infection. Additional etiologies in the differential diagnosis include fungal infection or other infectious process. 3. Free fluid within the pelvis is of unclear etiology . Echo [**12-10**]: 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) appear structurally normal with good leaflet excursion and no aortic regurgitation. The number of aortic valve leaflets cannot be determined. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . Discharge labs ([**12-18**]): WBC 3.9 Hb 8.7 Hct 24.7 Plt 31 Cr 0.9 TBili 0.8 LDH 232 ALT 75 AST 23 AlkPhos 77 Brief Hospital Course: 39 y/o male with recurrent aplastic anemia, admitted for 5-day course of ATG. Upon administration of the test-dose of horse ATG on day #1, the patient had a dermal reaction (erythema at the injection site) - as such, a test-dose of rabbit ATG was placed. This did not result in a reaction, and so the 5 day course of treatment ATG began. Patient tolerated days/doses # 1 through 4 without complication. On the day s/p treatment #4 and prior to treatment #5, the patient spiked a temperature to 103, and was started on cefepime. Later that day, he developed the relatively sudden-onset of tachypnea, mid-back pain (right greater than left, severe), abdominal tenderness to palpation of the right upper quadrant, tachycardia, hypertension and then subsequent hypotension with SBP in the 90s, febrile again to the 101's. He continued to maintain good oxygen saturation, but was placed on face-mask given his tachypneic mouth-breathing. He was given IV fluids, solumedrol, IV morphine, ativan, vancomycin, and the ICU was made aware. Differential diagnosis at that point included pneumonia, pulmonary embolism, aortic dissection, heart failure, TRALI, TACO, serum sickness or other type of allergic reaction to the ATG. CXR and CT torso were ordered STAT. CT demonstrated initial concern for a fungal infection, so started on voriconazole. Patient then generally stabilized and was feeling better and vital signs improved, so he remained on the floor. Then overnight, patient was hypotensive and refractory to IV fluids, had onset of acute renal failure, and vital signs worsening. Evidence for gram negative rod bacteremia and with pulmonary infiltrates, concern for gram negative rod pneumonia in immunosuppressed host. Patient transferred to the ICU overnight. . In the ICU, the patient was treated with IV fluids, cefepime, levofloxacin, vancomycin, and voriconazole. In the setting of high-grade bacteremia and a chest CT that showed multiple pulmonary nodules (possible septic PE), there was concern for a central venous line infection. The differential diagnosis included endocarditis, and spinal epidural abscess. TTE did not show any vegitation. Spinal epidural abscess was deemed unlikely as the patient's back pain was paraspinal rather than midline. Surgery was consulted, and the patient's port-a-cath was removed, with the tip sent for culture. The patient's ICU course was complicated by respiratory distress that was felt to be secondary to volume overload. For this, the patient briefly required BiPAP but not intubation. The patient's respiratory status improved with antibiotics and diuresis. In the ICU, the patient also had acute renal failure, for which cyclosporine and acyclovir were held. Back on the floor, patient's acute renal failure eventually resolved. . Back on the floor, patient's renal and liver function tests improved; he continued on IV ceftriaxone - per ID to complete a 14 day course, (PICC placed, so course could be completed as outpatient), and continued on voriconazole due to concern for fungal-type infection seen on CT chest, and acyclovir prophylaxis. Patient afebrile and without signs of infection s/p ICU stay. . Patient noted a visual deficity, fixed, in his right eye - ophthalmology was consulted and diagnosed with multiple peripheral retinal hemorrhages. They recommended keeping his platelets above a spontaneous bleeding threshold, we set that at >20, and to follow-up in [**3-2**] weeks in outpatient clinic. On discharge, the visual deficit was stable/improved, per patient report. Patient instructed to call immediately if vision were to change. . Cell counts: Patient with recurrent aplastic anemia, transfusion parameters set for Hct <24 and Plt <10. Patient appeared to be have either a consumptive or hemolytic process, as plastelet transfusion would result in immediate 1-hour post transfusion appropriate bump in platelet count, but then on re-check approximately 8 hours later, count would be back at approximately where it started. For blood transfusions, the Hct bump was typically not quite as robust as would be expected. Given patient's elevated bilirubin, concern for hemolysis reaction existed and/or consumptive process. Patient continued, after his ICU stay, to need almost daily platelet transfusions (perhaps because of platelets' role in inflammatory state) to meet his parameters, although his pRBC requirement significantly decreased. Patient discharged with instructions for close CBC monitoring follow-up. . Hypertension: On home metoprolol, when patient became hypotensive, metoprolol held. Then, on steroids, patient was hypertensive, so he ended up being discharged on an even higher dose than his admission metoprolol, and also on a low-dose calcium-channel blocker. . Secondary to high-dose steroids (prednisone taper), patient started with fingersticks and a regular insulin sliding scale. Insulin teaching occurred. . Edema: Patient with edema of left arm s/p IV contrast extravasation during CT scan. Patient seen by plastic surgery. Edema and pain improved. Issue was resolving on discharge. Patient with right arm bruising/edema due to frequent blood draws. PICC placed on right, edema improving on discharge. Bilateral lower extremity edema present - believed secondary to fluid retention in setting of high-dose steroids. On the few days prior to discharge, patient given doses of lasix for diuresis. Patient however without respiratory symptoms of volume overload. Medications on Admission: ACYCLOVIR - 400 mg Tablet - 1 Tablet(s) by mouth twice a day CYCLOSPORINE MODIFIED - 150mg q12h FOLIC ACID - 1 mg Tablet - 2 Tablet(s) by mouth once a day PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth twice a day MAGNESIUM OXIDE - 400 mg Tablet - 2 Tablet(s) by mouth three times a day Discharge Medications: 1. Glucocom Blood Glucose Kit Sig: One (1) kit Miscellaneous once. Disp:*1 kit* Refills:*0* 2. Lancets Misc Sig: One (1) lancet Miscellaneous as directed: Use 1 lancet each time you check your blood sugar. Disp:*1 box* Refills:*2* 3. Glucostix Test Strip Sig: One (1) strip In [**Last Name (un) 5153**] as directed: Use 1 strip each time you check your blood sugar. Disp:*1 box* Refills:*2* 4. Folic Acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 6. Prednisone 20 mg Tablet Sig: Four (4) Tablet PO once a day: for a total of 80 mg daily dose. Disp:*120 Tablet(s)* Refills:*2* 7. Cyclosporine Modified 25 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). Disp:*180 Capsule(s)* Refills:*2* 8. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. Disp:*90 Tablet(s)* Refills:*2* 9. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*2* 10. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 11. Insulin Glargine 100 unit/mL Solution Sig: Three (3) units Subcutaneous once a day. Disp:*5 ml* Refills:*2* 12. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 14. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig: Two (2) grams Intravenous Q24H (every 24 hours): last dose [**2118-12-24**]. Disp:*5 doses* Refills:*0* 15. Insulin Syringe-Needle U-100 29 x [**1-28**] Syringe Sig: One (1) syringe Miscellaneous once a day. Disp:*30 syringes* Refills:*2* Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Aplastic anemia. Gram-negative rod bacteremia. Retinal hemorrhages. Dermal skin reaction to horse ATG. Discharge Condition: Stable. Afebrile. Discharge Instructions: You were admitted to the hospital for a course of treatment with ATG to treat your aplastic anemia. You had a skin reaction to the test dose of the horse ATG, and so the treatment course was conducted with rabbit ATG. You tolerated 4 days of this regimen without complication. On the 5th day you became short of breath, your heart rate increased, you became febrile, and you were having back pain. Studies demonstrated bacteria (E.coli) in your bloodstream and concern for a fungal infection in the lungs. As a result, you were started on broad-spectrum antibiotics and antifungal therapy. You were transferred to the ICU because your blood pressure began to decrease. You were given IV fluids and closely monitored, and improved. Back on the floor, we continued the antimicrobials for bacterial and fungal infection, and we transfused you with platelets as needed. You will be on a 2-week course of antibiotics (ceftriaxone), so a PICC line was placed. You have needed frequent platelet transfusions, so you will need to have your blood counts checked daily. You were found to have retinal hemorrhages (bleeds in the blood vessels of your eye) - if you have any change in vision you must go to the emergency room immediately. Please call your doctor or return to the hospital if you develop fever >100.4, chills, sweats, difficulty breathing, rash, chest or abdominal pain, swelling, bleeding/bruising, lightheadedness, or other symptoms that concern you. Medication Instructions: 1. For Blood pressure: your blood pressure was elevated in the hospital and your regimen was adjusted. Please take metoprolol 50 mg twice daily and amlodipine 5 mg daily. 2. For Aplastic Anemia: please take Prednisone 80 mg daily. This dose will be tapered by your primary oncologist. Your Cyclosporine dose was decreased to 75 mg twice daily. Your cyclosporine level will be followed and your dose may need to be adjusted, again, as an outpatient. 3. For your infections: you will be given ceftriaxone 2 grams daily by IV for your bloodstream infection with E. coli. The last dose of this medication will be on [**2118-12-24**]. For the fungal infection, you will need to continue voriconazole 200 mg twice daily. 4. For your blood sugar: you had elevated blood sugar in the hospital related to the steroids we gave you. You will be started on a long-acting insulin. It is important for you to stay hydrated. Please obtain the Lantus (long-acting insulin), syringes and glucometer with test strips and bring it with you to your appointment on [**2118-12-19**] for teaching. Please check your blood sugar twice daily. 5. Otherwise, you will continue the pre-hospitalization medications: folate 2 mg daily, acyclovir 400 mg three times per day (note change in frequency from twice a day to three times per day), protonix 40 mg twice daily, and nicotine patch 21 mg. We stopped the magnesium supplementation as your magnesium was normal while in the hospital. We will check this value once you are discharged. Followup Instructions: Please come into [**Hospital Ward Name 1826**], [**Location (un) 436**] Provider: [**Name Initial (NameIs) 455**] 5-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F Date/Time:[**2118-12-19**] 9:00 Please call Dr. [**Last Name (STitle) **] on Monday [**12-19**], to schedule an appointment with him this week. Ophthalmology: (will be a couple hour appointment; both eyes will be dilated; will need someone to drive you home). [**1-3**], 3pm. Dr. [**First Name8 (NamePattern2) 3403**] [**Last Name (NamePattern1) **]. [**Hospital Ward Name 23**] building [**Location (un) 442**] eye clinic. [**Telephone/Fax (1) 253**]. Completed by:[**2118-12-20**]

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icd9cm

[ [ [] ] ]

[ "86.05", "38.93", "99.28" ]

icd9pcs

[ [ [] ] ]

13350, 13402

5731, 11190

370, 412

13549, 13569

2443, 5708

16622, 17259

1613, 1838

11557, 13327

13423, 13528

11216, 11534

13593, 15053

1853, 2424

850, 1174

277, 332

440, 831

15078, 16599

1196, 1310

1326, 1597

12,375

197,471

53831

Discharge summary

report

Admission Date: [**2107-7-23**] Discharge Date: [**2107-7-27**] Service: ID/CHIEF COMPLAINT: This is an 80-year-old male with history of congestive heart failure and coronary artery disease who presents with chest pain and pulmonary edema. PAST MEDICAL HISTORY: 1) Coronary artery disease. The patient is status post MI in [**2089**] and status post CABG times four in [**2101**] with LIMA to his LAD, sequential SVG graft to his [**Last Name (LF) 11641**], [**First Name3 (LF) **] and PDA. The patient had a most recent cath in [**2107-4-22**] which demonstrated left main mild diffuse disease, patent bypass grafts and LAD 80% in stent obstruction which was treated with rotablade and PTCA. A [**Year (4 digits) 11641**] 80% lesion, a left circ 90% lesion and RCA 80-90% lesion and a right PDA total occlusion. 2) Congestive heart failure with an EF of 24% and an increased left ventricular end diastolic pressure of 17 and an echocardiogram demonstrating inferior apical septal akinesis with [**Year (4 digits) 1192**] MR [**First Name (Titles) **] [**Last Name (Titles) 1192**] pulmonary hypertension. 3) History of sternal wound infection requiring debridement times three and a rectus flap. 4) Type 2 diabetes. 5) Hypertension. 6) Hypercholesterolemia. 7) Third degree heart block requiring DDD pacemaker in [**2099**]. 8) Stroke. 9) Neurosyphilis. 10) History of bright red blood per rectum. HISTORY OF PRESENT ILLNESS: Patient reportedly woke up with chest pain [**3-31**] without radiation. He took two tablets of sublingual Nitroglycerin with relief by the time the paramedics came to his home. The patient was given a dose of enteric coated Aspirin, oxygen and 20 mg of IV Lasix. The patient began developing extreme respiratory distress in the ambulance. In the Emergency Room the patient was noted to have a blood pressure of 220/120 and had admitted being non compliant with his medications. The patient was intubated in the Emergency Room and was started on IV Nitroglycerin, Heparin and given Morphine and Lasix. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: Vital signs showed that the patient was afebrile with a heart rate of 70-84, blood pressure 150/70 and was saturating 100% on an FIO2 of 100%. The patient was intubated and ventilated with assist control at a rate of 12. On head and neck examination the patient was noted to be intubated. He did not have any JVD on cardiovascular examination. He had regular rate and rhythm with normal S1 and S2 and no S3 or S4. He was noted to have a 2/6 systolic murmur at the right sternal border. On pulmonary examination the patient had crackles anteriorly and laterally. His abdomen was soft, nontender and his rectal exam showed stool that was guaiac negative. His extremities had 1+ edema and his pulses were palpable in his lower extremities. MEDICATIONS: ASA 81 mg po od, Lasix 20 mg po od, Lopressor 25 mg po bid, sublingual Nitroglycerin, Simvastatin 20 mg po od, Aldactone 25 mg po od and Captopril 50 mg po tid. SOCIAL HISTORY: Patient lives alone and does not have any history of alcohol use or tobacco use. FAMILY HISTORY: Unremarkable. PHYSICAL EXAMINATION: LABORATORY DATA: CBC demonstrated a hematocrit of 37.6, white count 11.0 and platelet count 249,000. His Chem 7 was remarkable for a BUN of 26 and creatinine of 1.4. His first set of cardiac enzymes showed a CK of 325 and an MB of 74 and troponin less than .3. On chest film the patient was noted to be in pulmonary edema. EKG, patient was noted to be paced. HOSPITAL COURSE: The patient had his Nitroglycerin gradually weaned off over the course of the next 24 hours. He also had aggressive diuresis during that first 24 hour period. The patient was extubated on [**2107-7-25**]. He was subsequently transferred to the floor following extubation. His cardiac drug regimen was simplified by changing his Captopril to Mavik 2 mg once a day and changing his Lopressor to Toprol XL 50 mg once a day. His Lasix dose was also increased to 80 mg once a day. On [**7-27**] the patient underwent a Persantine thallium which demonstrated an EF of 20% with global hypokinesis and an enlarged left ventricle. There was noted to be a moderately sized inferior wall defect which was predominantly fixed. This was noted to be essentially unchanged from the patient's previous Persantine thallium. On the date of discharge from the hospital the patient was in stable condition and his congestive heart failure had resolved. He was accepted to rehabilitation facility at [**Hospital1 2670**] and was transferred to [**Hospital1 2670**] on the following medications: Sliding scale insulin, Toprol XL 50 mg po once a day, Mavik 2 mg po once a day, Simvastatin 20 mg po once a day, Aldactone 25 mg po once a day, enteric coated Aspirin 325 mg po once a day, Plavix 75 mg po once a day, Colace 100 mg po bid and the patient's Lasix dose was decreased to 20 mg po q d following an increase in his creatinine from 2 to 2.6. The patient was discharged home on [**2107-7-27**]. DISCHARGE DIAGNOSIS: 1. Congestive heart failure. [**Name6 (MD) **] [**Last Name (NamePattern4) 5467**], M.D. [**MD Number(1) 5468**] Dictated By:[**Name8 (MD) 26201**] MEDQUIST36 D: [**2107-7-27**] 14:22 T: [**2107-7-28**] 08:20 JOB#: [**Job Number 44226**]

[ "412", "094.9", "428.0", "285.9", "250.00", "V45.81", "401.9", "425.4", "518.81" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

3162, 3177

5093, 5372

3583, 5072

3200, 3565

105, 253

1455, 2101

276, 1426

3063, 3145

46,692

164,676

38804

Discharge summary

report

Admission Date: [**2132-7-18**] Discharge Date: [**2132-7-25**] Date of Birth: [**2052-11-22**] Sex: M Service: CARDIOTHORACIC Allergies: Tetanus Attending:[**First Name3 (LF) 4679**] Chief Complaint: esophageal adenocarcinoma Major Surgical or Invasive Procedure: 1. [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagectomy. 2. Buttressing of intrathoracic anastomosis with pericardial fat. 3. Laparoscopic jejunostomy. 4. Esophagogastroduodenoscopy. History of Present Illness: 79 y.o. male with few year history of GERD and intermittent hoarseness that has been followed by Dr [**First Name4 (NamePattern1) 20765**] [**Last Name (NamePattern1) 86130**] (gastroenterology) with serial upper endoscopies and diagnosis of Barrett's esophagus. Recent serial endoscopies showed 4cm hiatal hernia and 6cm segment of Barrett's with biopsy on [**2132-4-16**] reporting adenocarcinoma arising in Barrett's, focally invasive. Patient has slightly worsening GERD and hoarseness in recent past but denies any new or other symptoms. Past Medical History: CAD (CABG x4), CVA (multiple), HTN, neuropathy BLE, BPH Social History: etoh [**3-12**] drinks per week remote h/o smoking Family History: NC Physical Exam: Discharge Vital signs and Physical Exam. VS: tempmax 98.2 HR69-SR 130/74 20 97RA gen: Pleasant in NAD, AAOx3 CV: RRR S1, S2 pulm: clear with slight rhonchi in RLL. abdomen: soft, ND, NT. J-tube intact with erythema. chest: incision C/D/I Ext: warm without edema. Pertinent Results: Labs: CBC: [**2132-7-18**] WBC-8.5 RBC-4.05* Hgb-11.7*# Hct-35.2 Plt Ct-126* [**2132-7-19**] WBC-6.9 RBC-3.85* Hgb-11.3* Hct-33.4* Plt Ct-116* [**2132-7-20**] WBC-9.3 RBC-3.93* Hgb-11.5* Hct-34.3* Plt Ct-108* [**2132-7-21**] WBC-9.4 RBC-3.81* Hgb-11.0* Hct-33.1* Plt Ct-114* [**2132-7-22**] WBC-8.0 RBC-3.81* Hgb-10.9* Hct-33.1* Plt Ct-135* [**2132-7-23**] WBC-7.4 RBC-4.08* Hgb-11.4* Hct-34.5 Plt Ct-169 [**2132-7-24**] WBC-7.3 RBC-4.10* Hgb-11.7* Hct-35.0 Plt Ct-192 chemistry: [**2132-7-18**] Glucose-143* UreaN-20 Creat-0.9 Na-140 K-4.2 Cl-106 HCO3-26 [**2132-7-19**] Glucose-122* UreaN-18 Creat-0.8 Na-140 K-4.1 Cl-107 HCO3-26 [**2132-7-20**] Glucose-135* UreaN-14 Creat-0.7 Na-140 K-3.8 Cl-110* HCO3-25 [**2132-7-21**] Glucose-138* UreaN-14 Creat-0.5 Na-139 K-3.8 Cl-104 HCO3-30 [**2132-7-22**] Glucose-118* UreaN-15 Creat-0.5 Na-138 K-3.8 Cl-103 HCO3-30 [**2132-7-23**] Glucose-134* UreaN-16 Creat-0.5 Na-135 K-3.7 Cl-100 HCO3-28 [**2132-7-24**] Glucose-136* UreaN-20 Creat-0.5 Na-134 K-3.9 Cl-101 HCO3-27 [**2132-7-21**] Calcium-7.8* Phos-1.8* Mg-2.1 [**2132-7-22**] Calcium-8.0* Phos-2.3* Mg-2.1 Radiology: [**2132-7-24**] IMPRESSION: Development of small apical pneumothorax following right-sided chest tube removal. Recommend followup. [**2132-7-25**] CXR: Stable right apical PTX. small RLL consolidation. Esophagus: [**2132-7-24**] Status post esophagectomy and gastric pull-through. Satisfactory postoperative appearance. No evidence for leak or obstruction. Brief Hospital Course: The patient was admitted to the Thoracic Surgical Service for elective [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagectomy for esophageal adenocarcinoma. After a brief, uneventful stay in the PACU, the patient was transferred to surgical ICU. He was kept NPO, on IV fluids, with a foley catheter, chest tube, JP drain and epidural for pain control. The patient was hemodynamically stable. He was transferred to the floor on POD 3. Neuro: The patient received epidural with good effect and adequate pain control. The epidural remained in place after the patient passed the barium swallow study. When tolerating oral intake, the patient was transitioned to oral pain medications. The patient experienced transient delirium in the ICU on POD 3. He continued to have some confusion but easily re-oriented and improving. He was maintained on a sleeping [**Doctor Last Name 360**] to normalize his sleep cycles. On discharge, pain was controlled with liquid roxicet. CV: The patient has a history of 1st degree AV block. He takes digoxin at home. Post-operatively he was maintained on IV lopressor. On POD 1 patient developed dropped beats and some bradychardia, also atrial fibrillation. Cardiology recomended holding digoxin, which was at time subtherapeutic. Metoprolol was held as well due to blood pressure parameters. Patient spontanously converted to sinus rythm and remained in sinus rythm since. He was continuously monitored. On [**2132-7-24**] he was started on low dose lopressor once his heart rate and blood pressure would tolerate. Medications were resumed with parameter indications. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. He had a chest tube until POD 6. The chest tube was to suction on POD 0 and was placed and remained on water seal until POD 6. There was no air leak, however CXR on [**2132-7-24**] revealed right apical pneumothorax which was stable on [**2132-7-25**]. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. His oxygen saturation was 95% on room air. GI/GU/FEN: Post-operatively, the patient was made NPO with IV fluids. Tube feeds were started on POD 1 at 20 cc/hr and advanced each day by 20 cc/hr up to a goal of 120 cc/hr. Patient tolerated the tube feeds well. His diet was advanced after barium swallow study on POD 6. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. He will be discharged on a full liquid diet along with cylced tubefeeds and to be advanced gradually to a soft mechanical diet. ID: The patient's white blood count and fever curves were closely watched for signs of infection. He remained afebrile. J tube site slightly erythematous on discharge. Will provide miconazole powder 2-3 times/day. Please continue to monitor for worsening infection. Endocrine: No issues. Hematology: The patient's complete blood count was examined routinely; no transfusions were required. On [**2132-7-24**] he was restarted on his Warfarin for multiple TIAs. INR Goal 2.0. Please adjust dosing and monitor INR. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a full liquid diet, ambulating, voiding without assistance, and pain was well controlled. Medications on Admission: ATENOLOL 25 mg daily, DIGOXIN 125 mg daily LISINOPRIL 2.5 mg daily OMEPRAZOLE 20 mg [**Hospital1 **] ROSUVASTATIN 20 mg daily TAMSULOSIN [FLOMAX] 0.4 daily, WARFARIN 2 mg Tablet once a day takes 3 mg every Tuesday Discharge Medications: 1. Replete Full Strengths Goal 120 mL/hr x 18 hours Flush with 100cc of water before starting and stopping feeds 2. Warfarin 2 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day: INR Goal 2.0- for hx of TIA. monitor INR closely until stable at goal. 3. Quetiapine 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO HS (at bedtime). 4. Acetaminophen 650 mg/20.3 mL Solution [**Hospital1 **]: Twenty (20) mL PO Q6H (every 6 hours) as needed for pain. 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Hospital1 **]: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 6. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Hospital1 **]: 2.5-5 MLs PO Q4H (every 4 hours) as needed for pain. 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 8. Lisinopril 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day: crush and take orally. 9. Crestor 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day: crush and take orally. 10. Digoxin 125 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 11. Atenolol 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day: hold if HR <60 or SBP <100. 12. Colace 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) ml PO twice a day as needed for constipation. 13. Aspirin 81 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 14. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Topical three times a day: near j-tube site. Discharge Disposition: Extended Care Facility: [**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**] Discharge Diagnosis: Esophageal Cancer GERD Coronary Artery Disease s/p CABG [**2118**] Hypertension Hyperlipidemia Multiple TIAs on Coumadin Bilateral Perpheral Neuropathy BPH Right Traumatic eye injury w/ decreased visual acuity Discharge Condition: Activity Status: Ambulatory - requires assistance or aid (walker or cane). Mental Status: Confused at times easily re-oriented. Level of Consciousness: Alert and interactive. Discharge Instructions: Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience: -Fevers > 101 or chills or shakes -Increased shortness of breath, cough or sputum production -Difficult or painful swallowing -Nausea, vomiting. Please take antinausea medication as needed -Monitor right wall incision. Call if this or any of the abdominal incisions become red or drain. -Monitor J-tube site for increased redness and call if this area does not improve with antifungal powder. Followup Instructions: Follow-up with Dr. [**First Name (STitle) **] [**0-0-**] Date/Time:[**2132-8-7**] 10:30 on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**] Get a chest X-Ray on the [**Location (un) 861**] Radiology Department 30 minutes before your appointment Completed by:[**2132-7-25**]

[ "530.81", "530.85", "427.31", "414.00", "426.11", "512.1", "997.1", "356.9", "V45.81", "401.9", "151.0", "427.89" ]

icd9cm

[ [ [] ] ]

[ "42.42", "96.6", "46.39", "45.13", "42.59" ]

icd9pcs

[ [ [] ] ]

8493, 8607

3058, 6642

301, 513

8861, 8936

1553, 3035

9564, 9891

1251, 1255

6908, 8470

8628, 8840

6668, 6885

9062, 9541

1270, 1534

236, 263

541, 1087

8951, 9038

1109, 1167

1183, 1235

7,671

159,061

10047+56103

Discharge summary

report+addendum

Admission Date: [**2197-4-2**] Discharge Date: [**2197-4-6**] Date of Birth: [**2148-4-6**] Sex: F Service: Neurosurgery HISTORY OF PRESENT ILLNESS: This is a 48-year-old lady with a complicated past medical history, transferred from [**Location (un) **], [**Location (un) 3844**] from the [**Hospital **] [**Hospital 107**] Hospital. She was admitted with a one-day history of the worse headache of her life which was gradually increasing in severity. On the day before admission (on [**2197-4-1**]), the patient lost consciousness in her bathroom and was found down by her relatives. Unsure whether the patient had seizures or not. The patient also had a two-week history of right ear block. She was seen both by her neurologist and primary care physician and was prescribed Medrol dose pack. The patient was found to have a hemotympanum on the same side. The patient was taken to the [**Hospital **] [**Hospital 107**] Hospital in Dairy, [**Location (un) 3844**], and CT scan was done. CT showed a right frontal subdural hemorrhage which was probably subacute. PAST MEDICAL HISTORY: (Past medical history is significant for) 1. Coronary artery disease, status post non-Q-wave myocardial infarction in [**2196-10-31**], status post a coronary artery bypass graft in [**2193**], and multiple percutaneous transluminal coronary angioplasties and stents; the last one was one month ago. 2. She also has a history of peripheral vascular disease, status post aortobifemoral and right subclavian femoral-femoral bypass graft. 3. She also has a history of hyperlipidemia. 4. Seizure disorder. 5. Hypertension. 6. Hypothyroidism. ALLERGIES: Her allergies are to HEPARIN; she has a history of HEPARIN-INDUCED thrombocytopenia. CODEINE, SULFA, and CECLOR. MEDICATIONS ON ADMISSION: Her medications include Neurontin, Depakote, Pepcid, Synthroid, Zocor, and TriCor, aspirin, Coumadin, metoprolol, Accupril, Isordil, Flexeril, and Plavix (which she had discontinued just the day before). PHYSICAL EXAMINATION ON PRESENTATION: On examination, her vital signs were stable. Respiratory rate was 12, heart rate was 74, blood pressure was 124/54, and oxygen saturation was 100%. On neurologic examination she was alert and oriented times three. Pupils were equal, round, and reactive to light; 2 mm in size. Extraocular movements were full. She followed commands. There was no facial droop. The tongue was midline. Shoulder shrug was [**6-4**]. There was a left-sided drift. She did have a prior left-sided Erb palsy in hands. Left upper extremity muscle strength was 4+. Right upper extremity muscle strength was 5; and all other muscle groups were 5. Fine touch was slightly decreased on the left side of the body. Her reflexes were bilateral and equal. RADIOLOGY/IMAGING: CT scan showed a subacute subdural hemorrhage with a midline shift. PERTINENT LABORATORY DATA ON PRESENTATION: INR was 2.05. These laboratories were done at the outside hospital. HOSPITAL COURSE: She was admitted to the Surgical Intensive Care Unit on [**2197-4-2**]. Her INR was corrected with fresh frozen plasma. Her ventricular drain was placed on [**2197-4-3**]. She was started on intravenous oxacillin. In the early morning of [**2197-4-4**], her neurologic status deteriorated, and she became unresponsive. She was taken to the operating room emergently. There, a craniotomy and drainage of the subdural hematoma was done. She was transferred to the Surgical Intensive Care Unit soon afterward and was extubated there. Post extubation she was moving all four limbs, was alert, awake, and oriented, and her status continued to improve. While she was in the Surgical Intensive Care Unit, she was also seen by the Vascular team and cardiologist in relation to her past medical issues. She was transferred to the floor on [**2197-4-4**]. She continued to improve neurologically. At the time of this Discharge Summary she was pending rehabilitation placement. DISCHARGE DIAGNOSES: Right-sided subacute subdural hematoma. [**Name6 (MD) 6911**] [**Name8 (MD) **], MD [**MD Number(1) 6913**] Dictated By:[**Name8 (MD) 33593**] MEDQUIST36 D: [**2197-4-6**] 09:18 T: [**2197-4-6**] 14:30 JOB#: [**Job Number 11834**] Name: [**Known lastname 5318**], [**Known firstname **] Unit No: [**Numeric Identifier 5882**] Admission Date: [**2197-4-2**] Discharge Date: [**2197-4-7**] Date of Birth: [**2148-4-6**] Sex: F Service: DISCHARGE SUMMARY ADDENDUM: This is an addendum to the summary done [**2197-4-6**]. The patient was discharged to rehab [**Hospital 5904**] Rehabilitation South Network at [**Hospital1 2314**], [**Location (un) 5905**]. She was discharged in stable condition. DISCHARGE MEDICATIONS: 1. Neurontin 600 milligrams three times daily. 2. Depakote 500 milligrams three times daily. 3. Pepcid 150 milligrams twice a day. 4. Synthroid 125 milligrams once a day. 5. Zocor 80 milligrams once a day. 6. Tricor 134 milligrams once a day. 7. Lopressor 100 milligrams three times a day. 8. Accupril 5 milligrams once a day. 9. Isordil 10 milligrams three times a day. 10. Folic Acid 1 milligram once a day. 11. Flexeril 10 milligrams three times a day. 12. Percocet 5 milligrams every four to six hours as needed. DISCHARGE CONDITION: The patient was discharged in stable condition to rehab. DR.[**Last Name (STitle) 5906**],[**First Name3 (LF) **] 14-120 Dictated By:[**Doctor Last Name 5907**] MEDQUIST36 D: [**2197-4-7**] 09:41 T: [**2197-4-7**] 09:57 JOB#: [**Job Number 5908**]

[ "780.39", "285.9", "244.9", "385.89", "V45.82", "432.1", "412", "V45.81", "443.9" ]

icd9cm

[ [ [] ] ]

[ "96.71", "38.93", "01.31" ]

icd9pcs

[ [ [] ] ]

5360, 5644

4016, 4788

4811, 5338

1810, 2996

3015, 3994

166, 1088

1111, 1783

23,977

157,858

12058

Discharge summary

report

Admission Date: [**2112-3-23**] Discharge Date: [**2112-3-27**] Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: This 81-year-old woman was a direct admission from an outside hospital for transfer for an inferior myocardial infarction complicated by a ventricular septal defect (also known as ventricular septal defect). She has a history of hypertension and mild dementia. She developed chest pain at [**Hospital3 1280**] Hospital and went to the hospital there after having pain while she was at church. She went to see her primary care physician and had an electrocardiogram there which showed inferior ST elevations and Q waves with a completed inferior myocardial infarction. She went to the Emergency Room at [**Hospital3 1280**] Hospital. She became hypotensive. Her enzymes were elevated. Her electrocardiogram changes were abnormal. She was started on aspirin and heparin. She had a transthoracic echocardiogram to evaluate a holosystolic murmur which showed the presence of a large ventricular septal defect and mitral regurgitation. She was transferred urgently to [**Hospital1 188**] for surgical repair of her ventricular septal defect. She came directly to the catheterization laboratory which showed a 90% right coronary artery lesion, a 50% left anterior descending artery lesion, a 50% first diagonal lesion. An intra-aortic balloon pump was placed, and left ventricular gram showed a large ventricular septal defect and moderate mitral regurgitation, and she was transferred up to the Coronary Care Unit for medical management prior to ventricular septal defect repair. MEDICATIONS ON ADMISSION: (Medications on admission were as follows) 1. Aldomet 500 mg p.o. b.i.d. 2. Hydrochlorothiazide 50 mg p.o. q.d. 3. Aspirin. 4. Norvasc 10 mg p.o. q.d. 5. Aricept 10 mg p.o. q.d. 6. Detrol 2 mg p.o. b.i.d. 7. Captopril 25 mg p.o. t.i.d. 8. Heparin (from the catheterization laboratory). ALLERGIES: She had no known drug allergies. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories from the outside hospital showed a white blood cell count of 12, hematocrit of 35.5, platelet count of 202,000. INR was 0.94, PT was 12, PTT was 25.3. Sodium of 138, potassium of 4.2, chloride of 98, bicarbonate of 25, blood urea nitrogen of 47, creatinine of 2.5, with a blood glucose of 119. Calcium of 9.2, albumin of 3.8, ALT of 106, AST of 155, elevated cardiac enzymes, with LDH of 526, and total bilirubin of 0.9. HOSPITAL COURSE: Her acute renal failure was noted. Her balloon pump remained in place, and she was referred to Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] for evaluation and repair of her ventricular septal defect. On examination by the cardiothoracic surgery fellow, the patient was mildly confused without any focal deficits. Mean arterial pressure was 62, pulmonary artery pressure was 46/14. She had no bruits in her neck. Her lungs were clear. She had a grade [**4-13**] holosystolic murmur. Her abdominal examination was benign. She had 1+ distal pulses and an right lower extremity intra-aortic balloon pump was in place. Her creatinine had dropped from 2.5 to 1.6. The determination was that she was in cardiogenic shock secondary to her ischemic ventricular septal defect and severe mitral regurgitation. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]sion was also held with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of Cardiology about the possibility of using a high-risk ventricular septal defect closure device. The patient was accepted as a surgical candidate; although high risk by Dr. [**Last Name (Prefixes) **]. The patient did have a right coronary artery stent in the catheterization laboratory without any other significant events, with the plan to possibly treat the left anterior descending artery lesion after ventricular septal defect repair or concurrently. The patient remained on aspirin therapy also. The patient continued to be monitored in the Coronary Care Unit over the next day to allow her to have some recovery time from her myocardial infarction. On [**3-25**], she went to the operating room with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] and had a coronary artery bypass graft times one with a saphenous vein graft to the left anterior descending artery and a patch repair for post infarct ventricular septal defect. The patient was transferred to the Cardiothoracic Surgery Intensive Care Unit in stable condition postoperatively. On postoperative day one, the patient was on propofol at 30, Neo-Synephrine at 0.5, insulin at 1.5, intra-aortic balloon pump at 1:1, and one other drug (unclear what that was). She was atrial paced at 70 with a blood pressure of 103/52, mixed venous at 70%, pulmonary artery was 28/16. Postoperative white blood cell count was 12, hematocrit of 29.4, platelet count of 50,000. INR was 1.3, PTT was 52.4, PT was 13.5. Sodium of 139, potassium of 5, chloride of 110, bicarbonate of 18, blood urea nitrogen of 39, creatinine of 1.4, with a blood glucose of 154. Lactic acid was 2.8 (up from 1.9). Her sternum was stable. Her lungs were clear bilaterally. Her heart was regular in rate and rhythm. She had dopplerable pulses in her extremities. Neurologically, she remained sedated. The need for increased products with a five pack of platelets and one unit of fresh frozen plasma to be able to pull the balloon was noted and ordered. Chest tubes remained in place. The patient was calm and alert and oriented, but she did require some gentle reminders as to where she was occasionally and also the plan of care. On postoperative day two, the balloon was discontinued. The patient was transfused one unit of packed red blood cells. Urine output was low. Neo-Synephrine was at 0.8. Milrinone at 0.3. The patient was in sinus rhythm with a blood pressure of 113/58. She remained intubated with a mixed venous of 72%, white blood cell count of 10.2, hematocrit of 24.2. Her platelet count rose to 111,000. Blood urea nitrogen and creatinine continued to climb with a blood urea nitrogen of 48 (up from 39) and a creatinine of 2.4 (up from 1.4). Blood sugar was 120. The patient remained intubated. The examination was otherwise benign. Plans were made to wean the ventilator and to keep chest tubes in place. Lactic acid on that day was 2, and plans were made to wean the Neo-Synephrine and hopefully discontinue the Milrinone. At 11:30 p.m. in the evening, the Cardiothoracic resident was called as the patient was having difficulty breathing. The patient had been suctioned and then had a flat wave on his electrocardiogram. A code was called. The patient was unresponsive. Cardiopulmonary resuscitation was started. Epinephrine was given. Chest tubes had greater than 500 cc of bright red blood. The fellow and the attending were notified. Pulmonary artery pressure shot up to 75, with the blood pressure dropping below 80, signally possibly tamponade. The chest was opened. A large amount of blood was suctioned. There was a large left ventricular perforation adjacent to the patch for the ventricular septal defect repair. Digital pressure was applied. Th[**Last Name (STitle) 1050**] was resuscitated with level I with packed red blood cells and intravenous fluids. Dr. [**Last Name (STitle) 14968**] and Dr. [**Last Name (STitle) 37826**] were present. They were unable to keep up the volume status and despite multiple ampules of epinephrine, bicarbonate, and internal massage. There was no intrinsic heart rhythm. The time of death of the patient was 10:45 p.m. in the Cardiothoracic Intensive Care Unit on [**3-27**]. Dr. [**Last Name (Prefixes) **] was called and made aware of all events. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass graft times one with patch repair of the ventricular septal defect. 2. Inferior myocardial infarction. 3. Cardiogenic shock. 4. Status post stent of the right coronary artery. 5. Hypertension. 6. Mild dementia. DISCHARGE STATUS: Again, the patient expired in the Cardiothoracic Intensive Care Unit on [**2112-3-27**]. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 76**] MEDQUIST36 D: [**2112-8-9**] 08:43 T: [**2112-8-9**] 17:46 JOB#: [**Job Number 37827**]

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Discharge summary

report

Admission Date: [**2111-12-23**] Discharge Date: [**2112-1-9**] Date of Birth: [**2061-3-4**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 545**] Chief Complaint: abdominal pain, n/v Major Surgical or Invasive Procedure: None History of Present Illness: Discussed case with ER physician. [**Name10 (NameIs) 9531**] [**Name11 (NameIs) **] notes. 50 y/o F w/ h/o DMII, HTN, HL, HOCM, h/o aflutter on coumadin, who presents with complaint of 2 weeks of nausea/vomiting, decreased PO intake, and abdominal pain. She reports that abdominal pain comes and goes and is generalized across her epigastrium without radiation. Pain is sharp and cramping in nature. She has been intolerant of PO's secondary to nausea, and reports that abdominal pain is worse with food. Emesis is non-bloody, non-bilious, and she denies any brbpr or melanotic stools. No recent fever, chills. No chest pain or shortness of breath. She had a cholecystectomy many years ago. ROS: as per HPI. otherwise negative. In ER, initial BP 194/108, afebrile. FSBG 129. Found to have elevated tbili (2.4), with increased alk phos (195). Also with renal insufficiency (cr 1.6), and anion-gap of 19 with bicarb on 30. Lactate elevated at 3.3. Given 2L NS IVF, zofran, morphine, 5mg IV lopressor and 325mg aspirin. Past Medical History: 1. DM2-last HgA1C 8.8% in [**6-20**]. On oral medication. 2. Hypertension 3. Hyperlipidemia 4. Asthma- PFTs in [**8-18**] c/w restrictive pattern: FEV 69%; FEV1 75; FEV/FEV1 106%. 5. Hypertrophic cardiomyopathy and diastolic dysfunction- Dry goal weight 183 lbs. Echo [**11-18**]: mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). [**2-17**]+ MR. Normal exercise MIBI [**10-19**]. 6. H/o a. flutter s/p cardioversion in [**5-20**] and on coumadin anti-coagulation 7. Depression 8. OSA- documented by sleep study, though pt not consistently using home BiPAP. Bipap was suggested over CPAP given noted hypoventilation during sleep study 9. s/p cholecystectomy Social History: Pt smokes ~10 cigarettes a day. No EtOH. No drugs. She does not work now but used to be a home health aide. She lives with her son and a friend. Family History: F: died of MI in 70s; Sisters:HTN, DM Physical Exam: vitals- 95.7, BP 170/120, HR 78, RR 16, 96% RA gen- lying in bed, sleepy but easily arousable, speech slow but appropriate heent- eomi, membranes moist neck- supple pulm- CTA b/l. no r/r/w cv- RRR. no m/r/g abd- soft, non-distended. RUQ and mid-epigastric tender to deep palpation w/o rebound or guarding. active bowel sounds. no flank echymosis. no caput. ext- trace edema; neuro- alert and oriented, motor strength full b/l, sensation intact to light touch. Rect- guaiac negative in ER Pertinent Results: Admission Labs: ------------ [**2111-12-23**] 04:00AM WBC-5.3 RBC-6.00* HGB-15.8 HCT-48.6* MCV-81* MCH-26.3* MCHC-32.5 RDW-17.5* [**2111-12-23**] 04:00AM NEUTS-70.4* LYMPHS-19.2 MONOS-5.7 EOS-0.7 BASOS-4.0* [**2111-12-23**] 04:00AM PLT COUNT-265 [**2111-12-23**] 05:35AM PT-20.6* PTT-34.1 INR(PT)-2.0* [**2111-12-23**] 05:35AM ACETONE-NEGATIVE [**2111-12-23**] 05:35AM CK-MB-5 cTropnT-0.01 [**2111-12-23**] 05:35AM LIPASE-18 [**2111-12-23**] 05:35AM ALT(SGPT)-27 AST(SGOT)-44* CK(CPK)-341* ALK PHOS-195* AMYLASE-61 TOT BILI-2.4* [**2111-12-23**] 01:25PM cTropnT-0.03* [**2111-12-23**] 01:25PM CK(CPK)-280* [**2111-12-23**] 04:11PM LACTATE-1.8 [**2111-12-23**] 05:35AM GLUCOSE-173* UREA N-21* CREAT-1.6* SODIUM-140 POTASSIUM-3.7 CHLORIDE-91* TOTAL CO2-30 ANION GAP-23* Studies: --------- EKG- Aflutter 3:1. no acute ST changes Abd CT [**2111-11-22**]- CT ABDOMEN: There is trace pericardial effusion and small right pleural effusion. Variable attenuation of the lung bases suggest underlying air trapping. Bibasilar atelectasis is also noted. Within the limitation of this non- contrast study, the spleen, liver, right adrenal gland and right kidney are unremarkable. A 1.5-cm hypodensity is seen in the lower pole of the left kidney which likely represents a cyst, unchanged. There is left adrenal gland thickening, unchanged. The pancreas is unremarkable. Loops of small bowel are collapsed. There is minimal calcification of the descending aorta. CT OF THE PELVIS: Multiple soft-tissue attenuation masses are seen in the pelvis which appear to be contiguous with the uterus on this limited non-contrast study and likely represent fibroids. The rectum, sigmoid colon, and appendix are unremarkable. The bladder is unremarkable. There is no free fluid or free air. BONE WINDOWS: There are no suspicious sclerotic or lytic lesions identified. IMPRESSION: 1. No acute intra-abdominal pathology identified. 2. Trace right pleural effusion and pericardial effusion. 3. Left kidney cyst and left adrenal gland thickening, unchanged. Pelvic ultrasound [**2111-11-22**]- FINDINGS: Transabdominal and transvaginal examinations were performed, the latter for better evaluation of the uterus and adnexa. The uterus is anteverted measuring 7.4 x 4.9 x 7.2 cm. Multiple fibroids are noted, the largest one in the right lateral fundus measuring approximately 4.3 cm. Left-sided exophytic fibroid is noted measuring approximately 3.2 cm. The right ovary measures 2.7 x 1.2 x 2.1 cm. The left ovary measures 3.7 x 1.8 x 2.0 cm. Free fluid is noted within the pelvis. Adjacent to the left ovary, there appear to be septations in one of the images that are not reproducible in real time. Doppler evaluation of the ovaries demonstrates no evidence of color flow or Doppler waveforms, which is thought to be artifactual given the normal appearance of the ovaries. The endometrial stripe is distorted by the presence of fibroids and cannot be accurately evaluated. IMPRESSION: 1. Fibroid uterus. 2. Bilateral normal ovarian size and echotexture. Doppler interrogation of the ovaries demonstrates no evidence of color flow or Doppler waveforms. Although the ovaries are normal in size and echotexture, cannot completely rule out torsion. Given the difficulty in the evaluation for blood flow, pelvic MRI could be obtained if clinically indicated. [**2111-11-22**] AP CHEST: The mediastinal silhouette is unchanged with enlargement of the cardiac silhouette again noted. The pulmonary vascularity is unremarkable. The lungs are clear without pleural effusion or pneumothorax. IMPRESSION: No acute cardiopulmonary process. Other Labs: TSH ([**1-3**]) - 6.2 Free T4 ([**1-3**]) - 1.2 ACE Level ([**1-3**]) - <1 SPEP ([**1-2**]) - negative UPEP ([**1-1**]) - no monoclona Ig, negative Bence [**Doctor Last Name **] Urine Protein/Cr ratio ([**1-1**]) - 3.5 Lipids ([**12-30**]) - Chol-158, TG-83, HDL-61, LDL-80 Micro Data: Urine ([**1-8**]) - negative [**Month/Year (2) **] ([**1-7**]) - >25 polys, heavy growth oropharyngeal fora. H. Flu (B-lactamase negative) - report finalized after d/c Urine Cx ([**1-4**]) - 1000/mL GP bacteria Urine ([**1-1**]) - mixed flora GC/Chlamyd ([**12-23**]) - negative Blood ([**12-23**]) - negative Other Studies: ECG ([**1-8**]): Regular tachycardia is probably atrial fibrillation. Left axis deviation. Probable anterior myocardial infarction, age undetermined. Low QRS voltage. Non-specific ST-T wave changes. Compared to tracing of [**2112-1-3**] the rhythm is now regular. There is loss of the anterior R wave and there is decreased QRS voltage. CHEST (PA & LAT) [**2112-1-7**] 12:48 PM FINDINGS: Two views of the chest were obtained. There is mild fluid overload with vascular engorgement, slightly worse than the prior examination dated [**2112-1-4**]. The cardiac silhouette remains enlarged. The bony thorax is grossly intact. CHEST (PORTABLE AP) [**2112-1-4**] 6:03 AM AP UPRIGHT CHEST: There is marked improvement of the bilateral pulmonary edema, now mild. No effusion is seen. The cardiac silhouette remains enlarged. IMPRESSION: Marked improvement of the bilateral pulmonary edema, now mild. CHEST (PA & LAT) [**2112-1-2**] 5:05 PM FINDINGS: TWO VIEWS OF THE CHEST WERE OBTAINED. Low lung volumes are again noted. Mild cardiomegaly is stable. There is no pneumothorax or pleural effusion. There is mild fluid overload with vascular engorgement. The bony thorax is grossly intact. RENAL U.S. [**2112-1-4**] 5:48 PM RENAL ULTRASOUND: The right kidney measures 10.8 cm, and the left kidney measures 9.7 cm. There is slight increased echogenicity of the renal cortex (on the right side when compared to the liver) indicating chronic renal disease. The left kidney demonstrates a 2.1 x 1.7 x 1.4 cm hypoechoic area with no internal flow consistent with a cyst. No hydronephrosis or renal calculus. IMPRESSION: 1. Evidence of chronic renal diseae. No calculus or hydronephrosis. 2. Small left kidney simple cyst. TTE ([**12-31**]): The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. The right atrial pressure is indeterminate. 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%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler and tissue velocity imaging are consistent with Grade III/IV (severe) LV diastolic dysfunction. The right ventricular free wall is hypertrophied. The right ventricular cavity is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. The pulmonic valve leaflets are thickened. Significant pulmonic regurgitation is seen. There is a small pericardial effusion. Compared with the prior study (images [**Month/Year (2) **]) of [**2110-12-22**], the left ventricular systolic function is somewhat improved. The findings of preserved left ventricular systolic function with severe diastolic dysfunction, biventricular hypertrophy, mild valvular abnormalities, and small pericardial effusion are suggestive of an infiltrative process such as amyloid. PERSANTINE MIBI [**2111-12-30**] PERSANTINE MIBI INTERPRETATION: This 50 year old type 2 IDDM woman with a history of [**Hospital1 **]-ventricular failure was referred to the lab for evaluation. The patient was infused with 0.142 mg/kg/min of dipyridamole over 4 minutes. No arm, neck, back or chest discomfort was reported by the patient throughout the study. There were no significant ST segment changes during the infusion or in recovery. The rhythm was atrial fibrillation/flutter throughout with rare isolated vpbs. Appropriate hemodynamic response to the infusion. The dipyridamole was reversed with 125 mg of aminophylline IV. IMPRESSION: No anginal type symptoms or ischemic EKG changes. Nuclear report sent separately. Reason: 50 Y/O WOMAN WITH AFIB, DIASTOLIC HEART FAILURE, AND FLASH PULMONARY EDEMA, EVAL REVERSIBLE WALL MOTION ABNORMALITIES SUMMARY OF DATA FROM THE EXERCISE LAB: Dipyridamole was infused intravenously for 4 minutes at a dose of 0.142 mg/kg/min. She had no ischemic symptoms or ECG changes. METHOD: Resting perfusion images were obtained with Tc-[**Age over 90 **]m sestamibi. Tracer was injected approximately 45 minutes prior to obtaining the resting images. Two minutes after the cessation of infusion of dipyridamole, approximately three times the resting dose of Tc99m sestamibi was administered IV. Stress images were obtained approximately 45 minutes following tracer injection. Imaging protocol: Gated SPECT. This study was interpreted using the 17-segment myocardial perfusion model. INTERPRETATION: The image quality is adequate but limited due to breast attenuation. Left ventricular cavity size is normal. Rest and stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 57% with an EDV of 69 ml. IMPRESSION: 1. Normal myocardial perfusion. 2. Normal left ventricular cavity size and systolic function Compared to the prior study of [**2110-12-19**], the prior lateral wall defect is no longer seen. CHEST (PORTABLE AP) [**2111-12-28**] 12:00 AM Mild cardiomegaly is stable. There is worsening of pulmonary edema, now severe. Small right pleural effusion is probably present. There is no pneumothorax. IMPRESSION: Pulmonary edema, worsening from [**12-26**]. LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2111-12-24**] 10:39 AM LIVER OR GALLBLADDER US (SINGL FINDINGS: The gallbladder is surgically absent. Limited views of the liver are unremarkable. There is no intra- or extra-hepatic biliary dilatation. The intra-hepatic portion of the common bile duct measures 5 mm, and the extra- hepatic portion of the common bile duct measures 3 mm. No ductal stones are present. Limited views of the head of the pancreas are unremarkable. IMPRESSION: Status post cholecystectomy. Unremarkable right upper quadrant ultrasound examination. No evidence of biliary dilatation. Brief Hospital Course: A/P: 50 y/o F w/ h/o DMII on oral agents, complains of 2 weeks of nausea/vomiting, decreased PO intake, and abdominal pain . # Acute on chronic diastolic heart failure Patient's volume status was continuously in flux. She had two episodes of flash pulmonary edema requiring transfer to the [**Hospital Unit Name 153**] for BiPAP therapy and aggressive diuresis. The etiology was likely A-flutter/A-fib with RVR versus hypoglyemia precipitating catecholamine surge causing htn vs anxiety provoking htn. During the second episode she was noted to be hypoglycemic prior to becoming short of breath. During the course of her hospitalization, she was ruled out for an MI and underrwent a P-MIBI which was negative for ischemia (showed resolution of previous lateral wall motion abnormalities). She also had a repeat echo as above. This raised the suspicion for an infiltrative process such as amyloid. She underwent an SPEP and UPEP which were negative. She had an ACE level sent (for possible sarcoid), however this was undetectable (pt on ACE inhibitor therapy). During the course of her hospitalization, she was seen by cardiology consult who helped with titration of her medications. After aggressive diuresis with IV lasix, her volume status improved and she was switched to PO lasix. Ultimately, she was discharged on B-blocker (Toprol XL 250), ACE-inhibitor (Lisinopril 60), Lasix (80mg [**Hospital1 **]), Hydralazine (50mg tid), and Imdur (60mg). She is to follow up in the heart failure clinic and was sent home with careful electronic monitoring of weight and blood pressure. . # Atrial flutter/Atrial Fibrillation Rate controlled varied during the course of her hospitalization. Her Toprol XL dose was ultimately uptitrated. She was maintained on coumadin with decrease of INR prior to discharge due to a decrease in her dose (secondary to hematuria). On discharge her coumadin dose was increased and she will have this monitored as an outpatient. After second transfer to the [**Hospital Unit Name 153**], she was placed on treatment dose Lovenox and Coumadin (given subtherapeutic INR). However she had hematuria and Lovenox was subsequently stopped. . # Hematuria As described above. Subsequently resolved. Should have UA checked after discharge. . # Hypertension Blood pressure varied as described above. Prior to discharge, blood pressure control was somewhat improved and she was discharged on regimen as above. Given the number of agents that she is on for blood pressure, it may be worth evaluating her for secondary causes of hypertension, including renal artery stenosis. . # Abdominal pain/[**Name (NI) 9532**] Unclear etiology, but evaulation in ER demonstrated no acute abdominal pathology on CT, and pelvic ultrasound showed only fibroid uterus with normal ovaries. u/a with few bacteria, but otherwise unremarkable. Other imaging (as above) unremarkable. AlkPhos persistently elevated. T. Bili had been elevated, but decreased by discharge. . # Acute on chronic renal failure Had major fluctuations in creatinine. Baseline of 1.2-1.3. Peaked as high as 2.3. Mostly pre-renal. Given IV fluids w/ some improvement. ACE inhibitor had been held, but then was restarted due to patient going into flash pulmonary edema. When dose was up-titrated to 40mg [**Hospital1 **], Cr increased, so was decreased again (ultimately changed to 60mg once daily). Renal consult team followed patient in initial phases. Urine Protein/Cr found to be 3.5 as above. . # acid-base disorder, mixed- anion gap of 19, with bicarb of 30 and hypochloremia. likely anion gap [**3-20**] to mild lactic acidosis and uremia from renal insufficiency. urine ketones negative. Lactate trended down. Elevated bicarb/hypochloremia in setting of diuresis and vomiting. . # DM-II, controlled- Initially held oral hypoglycemics in setting of renal insufficiency and recent CT. Sulfonylurea (Glucotrol XL) subsequently restarted, however pt had hypoglycemic episode as described above and this was stopped. Was ultimately covered with sliding scale insulin. Blood sugars remained well controlled on dietary modification. On discharge, Metformin was restarted. . # Depression/Anxiety - cont paroxetine initially, then psychiatry consulted and decided to cross taper paroxetine to fluoxetine given longer half-life which will be beneficial from a medical adherence standpoint. She was given Valium for anxiety, but was discharged on Ativan per psychiatry's recommendation. She will follow up with an outpatient therapist at [**Location (un) 686**] House. Her PCP will need to prescribe psychopharm, however psychiatry at [**Hospital1 18**] would be open to seeing her for this as well. . # Tobacco Use/Restrictive lung disease Was given a nicotine patch (which she was discharged on). Maintained on Advair and nebs as needed. . # Cough Patient reported upper respiratory symptoms during course of her hospitalization. She was afebrile with normal WBC count and no evidence of infiltrate on her chest x-ray. [**Hospital1 **] culture obtained showed oropharyngeal flora (initially). On discharge she reported resolution of cough and upper respiratory symptoms. After discharge, H. Flu was seen in [**Hospital1 **] cx. PCP to be [**Name (NI) 653**] since pt to follow up with her closely. . # Outstanding Issues: -consider fat pad biopsy for amyloid -consider w/u for secondary causes of htn -monitor INR -monitor HR/BP/weight -monitor response to Fluoxetine -repeat UA to ensure no microscopic hematuria -consider BiPAP for OSA -H. Flu in [**Name (NI) **], consider therapy vs. repeating. Medications on Admission: 1. Paroxetine HCl 20 mg PO DAILY 2. Pantoprazole 40 mg PO Q24H 3. Fluticasone-Salmeterol 250-50 Inhalation [**Hospital1 **] 4. Albuterol 90 mcg/Actuation 1-2 Puffs Inh Q6H prn 5. Simvastatin 10 mg PO DAILY 6. Lisinopril 20mg [**Hospital1 **] 7. Lorazepam 0.5 mg PO HS prn 8. Aspirin 325 mg PO DAILY 9. Furosemide 60mg PO once a day. 10. Warfarin 5 mg PO HS 11. Metoprolol 100mg daily 12. Nifedipine 60 mg PO DAILY 13. Potassium 20meq per day 14. Glucotrol XL 10 mg PO once a day 15. Metformin 500 mg PO BID Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Lisinopril 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 3. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 4. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day: Take as directed. Disp:*30 Tablet(s)* Refills:*0* 5. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*0* 6. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for anxiety. 7. Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily) for 2 weeks: Do not smoke while using patch. After 2 weeks, can stop using patch. Disp:*14 Patch 24 hr(s)* Refills:*0* 8. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) inhalation Inhalation twice a day. Disp:*1 inhaler* Refills:*2* 9. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing. Disp:*1 MDI* Refills:*0* 10. Atrovent HFA 17 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing. Disp:*1 MDI* Refills:*2* 11. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 12. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-17**] Sprays Nasal TID (3 times a day) as needed. Disp:*1 inhaler* Refills:*0* 13. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily): Take in addition to 50mg tablet (total 250mg daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 14. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day: Take in addition to 200mg tablet (total 250mg daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 15. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Unless directed otherwise. Disp:*60 Tablet(s)* Refills:*2* 16. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 17. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. Disp:*30 Tablet Sustained Release(s)* Refills:*2* 18. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary: Acute on chronic diastolic CHF with episodes of hypoxia Acute on Chronic Kidney Disease Secondary: Hypertension Atrial Flutter/Atrial Fibrillation Anxiety Diabetes Mellitus, Type II Obstructive Sleep Apnea Discharge Condition: Afebrile, vital signs stable. Ambulating w/o difficulty. Discharge weight - 153 lbs. Discharge Instructions: You were admitted because you initially had nausea, vomiting, and a change in your kidney function. You subsequently had worsening of your heart failure. You were given medications to remove fluid and control your blood pressure. . Weigh yourself every morning, call your doctor if your weight increases more than 3 lbs. You should follow a low salt (2g sodium) diet. You should also follow a diabetic, low fat, low cholesterol diet. . Many of your medications have been changed, deleted or added during this hospitalization. You should only take the medications you are being discharged with. Specifically, your Paroxetine was changed to Fluoxetine. Your Glucotrol XL is being held since you had low blood sugars. Your Nifedipine was discontinued. Your Lisinopril and Toprol XL doses were increased. You were started on Hydralazine and Imdur. Your lasix dose was increased and is now being given twice a day. Your [**Hospital **] nurse will need to follow your weight and blood pressure and breathing to adjust the dose. Your potassium level will also need to be watched very carefully (you are being given a potassium pill). Your coumadin dose is less than it was before. You will need to have your level checked very carefully to make sure it is appropriate. Your doctor [**First Name (Titles) **] [**Last Name (Titles) **] nurse will help you with this and adjust your dose accordingly. You are being given a nicotine patch. You should not smoke while using the patch since this could be dangerous to your heart. You are being given prescriptions for many of your medications, however you can continue taking those medications you were taking before. . You should keep all appointments as scheduled. You will need to follow up with your primary doctor, your cardiologist, your kidney doctor, and your psychiatrist. It is very important that you go to all these appointments and set up any necessary appointments as below. . You should talk to your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 9533**] your BiPAP for your sleep apnea. This will help your breathing and your heart. . If you should get worsening shortness of breath, chest pain, or palpitations, call your doctor or return to the emergency room. Followup Instructions: Primary Care: [**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2112-1-19**] 4:00 Cardiology: Please call [**Telephone/Fax (1) 3512**] to get an appointment in the heart failure clinic with Dr. [**First Name (STitle) 437**]. Nephrology (kidney): Dr. [**First Name4 (NamePattern1) 6930**] [**Last Name (NamePattern1) 3271**]. Please call ([**Telephone/Fax (1) 9534**] for a follow up appointment. Psychiatry: [**Location (un) 686**] House. Please call [**Telephone/Fax (1) 9535**]212 and speak with Ms. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to set up an intake appointment.

[ "428.33", "327.23", "428.0", "427.31", "403.90", "584.9", "250.02", "427.32", "518.81", "585.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

22234, 22292

13557, 19159

334, 341

22551, 22639

2872, 2872

24945, 25588

2309, 2348

19716, 22211

22313, 22530

19185, 19693

22663, 24922

2363, 2853

274, 296

369, 1393

2888, 6538

1415, 2130

2146, 2293

6549, 13534

4,123

129,193

48228

Discharge summary

report

Admission Date: [**2143-5-5**] Discharge Date: [**2143-5-9**] Date of Birth: [**2065-5-14**] Sex: F Service: MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 77 year old woman with a history of coronary artery disease status post myocardial infarction in [**2136**], status post recent left anterior descending stent with an ejection fraction of 25%, hypertension, known carotid stenosis, who was admitted to Trauma Surgical Intensive Care Unit on [**5-5**], after falling after a blackout and hitting her head. The patient had trauma to the head and face. The patient had one to two minutes of loss of consciousness. The patient denies preceding chest pain, shortness of breath, lightheadedness, dizziness, diaphoresis, visual loss and vertigo. She has no history of syncope or loss of consciousness although she had an episode of transient visual loss in the setting of taking sublingual Nitroglycerin on last admission. The patient had no post-ictal confusion. in the Emergency Department, a head CT scan was done which showed an intraparenchymal bleed on the medial portion of the right frontal lobe. A CT scan of the spine showed no fracture of subluxation. The patient was discharged recently on Coumadin. On admission, her INR was found to be 1.1. On last admission, the patient was evaluated by the Neurological Service after a transient visual loss. The patient was discharged with scheduled follow-up with Neurology, with results of the MRI and MRA still pending. PAST MEDICAL HISTORY: 1. Coronary artery disease status post myocardial infarction in [**2129**]. On [**2143-5-8**], the patient had a percutaneous transluminal coronary angioplasty stent of a 70% mid left anterior descending and was started on Plavix for nine months and Coumadin for a low ejection fraction, and questionable inferior apical aneurysm. 2. Hypertension. 3. Hypercholesterolemia. 4. History of breast cancer. 5. History of cerebrovascular accident. 6. Hypothyroidism. 7. Lumbar stenosis. 8. Status post total abdominal hysterectomy. 9. Carotid stenosis. 10. Status post appendectomy. 11. History of glaucoma surgery. 12. Likely posterior circulation hypoperfusion. 13. Chronic renal insufficiency. 14. Doppler done in [**3-/2143**], showed left common carotid stenosis between 60 to 70% and a right subclavian stenosis between 70 and 80%. MEDICATIONS ON ADMISSION: 1. Synthroid 25 micrograms p.o. q. day. 2. Coumadin. 3. Aspirin 325 mg q. day. 4. Atenolol 25 mg twice a day. 5. Elavil 25 mg q. h.s. 6. Fioricet p.r.n. 7. Lipitor 20 mg q. h.s. 8. Lisinopril 10 mg twice a day. 9. Multivitamin. 10. Valium 1 mg q. day. 11. Plavix 75 mg q. day. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION: On physical examination, the patient was alert and oriented. She had swelling over the right eye and forehead. The patient was able to follow commands. Pupils were symmetric and reactive. Cranial nerves II through XII intact. Strength of five out of five throughout. Sensation intact. No pronator drift. Neck had a cervical collar on. Lungs were clear to auscultation bilaterally. Heart was regular rate and rhythm, S1, S2. Abdomen soft, nontender, nondistended. Extremities with no edema. She had ecchymosis and abrasions of her shins bilaterally. Rectal: The patient had normal tone, heme negative. Back with no tenderness or deformities. LABORATORY: On admission, white blood cell count 5.9, hematocrit 32.2, platelets 169. Sodium 138, potassium 4.8, chloride 103, bicarbonate 28, BUN 35, creatinine 1.2, glucose 113. PT 12.9, INR 1.1, PTT 24.8, CK 143, MB 3, troponin less than 0.3. Electrocardiogram unchanged from prior. HOSPITAL COURSE: The patient was admitted to Trauma Surgical Intensive Care Unit for observation. Coumadin, aspirin and Plavix were held. The patient was felt stable and was transferred to Medicine. In terms of the syncopal work-up, it was unclear whether this was related to cardiac versus neurologic. Cardiology was consulted and recommended an electrophysiology study. Additionally, the patient was ruled out for a myocardial infarction. She had an electrophysiology study performed which showed normal sinus, no sinus dysfunction, normal per kg conduction, no inducible ventricular tachycardia. The patient was followed by Neurosurgery and Neurology. It was felt that her intracranial bleed was small. The patient initially had aspirin, Plavix and Coumadin withheld; then she was started on aspirin since her intracranial bleed seemed small and the patient had no neurological deficits. It was agreed upon between Neurology and Cardiology that she could be restarted back on Plavix, however, it is felt that restarting Coumadin is too risky at this time. During the hospital course, the patient had episodes of chest pain. There were no [**Year (4 digits) **] changes. The patient was ruled out for a myocardial infarction. It was felt that the patient's syncopal episode was not due to neurovascular causes, however, the MRI / MRA revealed a left CCA stenosis and no left vertebral artery was seen. Furthermore, a left subclavian stenosis was also noted. Due to these findings, it was felt that the patient should maintain a blood pressure of greater than 130 to maintain adequate perfusion to her brain. The syncopal event is most likely from vasovagal or orthostatic hypotension, however, if it recurs, further evaluation is warranted. The patient was noted to have a mass in the right upper lung on CT scan, however, this was seen on prior CT scans and the patient says it is related to radiation therapy from her radiation therapy when she had breast cancer. It was felt that further evaluation of this mass would not be followed up as an inpatient and will be deferred to outpatient management. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: 1. Syncope, most like vasovagal versus orthostatic hypotension. 2. Small intracranial hemorrhage. 3. Electrophysiology study with no evidence of inducible ventricular tachycardia, sinus dysfunction or conduction abnormalities. 4. Coronary artery disease, ruled out for myocardial infarction. 5. Carotid disease. 6. Hypertension. DISCHARGE INSTRUCTIONS: 1. The patient should follow-up with her Cardiologist. 2. The patient should follow-up with her Neurologist. 3. The patient should also follow-up with her primary care physician as scheduled as before. DISCHARGE MEDICATIONS: 1. Atenolol 50 mg twice a day. 2. Elavil 25 mg q. h.s. 3. Lisinopril 10 mg twice a day. 4. Lipitor 20 mg q. day. 5. Plavix 25 mg q. day. 6. Aspirin 325 mg q. day. 7. Levoxyl 25 micrograms q. day. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**] Dictated By:[**Name8 (MD) 101638**] MEDQUIST36 D: [**2143-5-10**] 15:15 T: [**2143-5-10**] 16:19 JOB#: [**Job Number 101639**]

[ "244.9", "414.01", "786.6", "401.9", "853.01", "424.0", "780.2", "272.0", "E888.9" ]

icd9cm

[ [ [] ] ]

[ "37.26" ]

icd9pcs

[ [ [] ] ]

5928, 6264

6517, 6988

2405, 2747

3735, 5842

6288, 6494

2771, 3716

169, 1514

1536, 2379

5868, 5907

6,741

100,191

26455

Discharge summary

report

Admission Date: [**2146-11-17**] Discharge Date: [**2146-11-25**] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8747**] Chief Complaint: Left sided weakness Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 65376**] is an 83 yo RHM who was in his USOH until this afternoon when he had the sudden-onset of left-sided weakness that led to him falling to the ground. He managed to have a couple of bystanders help him get back on his motor scooter and drive himself home. He went into his apartment and tried to go to the bathroom. He then fell off the toilet and found that he could not get up from the toilet and he called a neighbor. [**Name (NI) **] denies head trauma, HA, N/V, vertigo. An ambulance brought him to [**Hospital3 1443**] Hospital where a head CT revealed a right thalamocapsular hemorrhage and he was transferred to [**Hospital1 18**] for further management. His sister reported recent weight loss. No f/c/s/n/v/d, no changes in voice, difficulty swallowing, hearing, dizziness, vertigo, diplopia, blurry vision, headache, or head trauma. Past Medical History: Inguinal hernia ORIF of hip fx History of MVA where he was dragged by a car about 70 years ago Social History: Lives alone, previously able to care for himself. Unmarried. Has intermittent contact with two sisters and daughter. Denies smoking, drugs, or EtOH use. Family History: No neurological disease. No CA. Mother with diabetes died from CHF as complication of parathyroid abnormality. Father died at 87 in accident. Brother recently admitted to [**Hospital1 18**] for traumatic intracranial bleed. Physical Exam: PE: Gen, very thin HEENT AT/NC, MMM no lesions, no bruits Neck Supple, no thyromegaly, no [**Doctor First Name **], no bruits Chest Clear, with slightly decreased BS at right base CVS RRR w/o MGR ABD soft, NTND, + BS, large left sided inguinal hernia. EXT no C/C/E. no petechiae, no asterixis, rash over penis, and much of lower extremities. Severe nail disease. Neuro MS: AA&Ox3, appropriately interactive, normal affect, normal fund of knowledge [**Doctor Last Name 1841**] with errors, simple calculations intact, fluent without paraphrasic errors. Prosody slow flat. Naming, [**Location (un) 1131**], intact. 0/3 at 5 minutes,[**3-3**] with prompting No L/R confusion. Normal graphesthesia. Able to mimic brushing teeth with either hand. CN: I--not tested; II,III-PERRLA, VFF by confrontation, optic discs sharp with normal vasculature; III,IV,VI-EOMI w/o nystagmus, no ptosis; V--sensation intact to LT/PP, masseters strong symmetrically; VII-Left facial weakness with sparing of forehead; VIII-hears finger rub bilaterally; IX,X--voice normal, palate elevates symmetrically, uvula midline, gag intact; [**Doctor First Name 81**]--SCM/trapezii [**5-5**]; XII--tongue protrudes midline, slight apraxia Motor: Normal bulk and tone. No rigidity, no tremor, no bradykinesia Strength: Left sided hemiplegia. Coord: FFM slow on LEFT but accurate. Refl: [**Hospital1 **] Tri Brachio Pat [**Doctor First Name **] Toe R 2 2 2 2 2 down L 2 2 2 2 2 down [**Last Name (un) **]: LT, PP, temperature, vibration, and position sense intact. No evidence of extinction. Pertinent Results: [**2146-11-25**] 11:25AM BLOOD WBC-9.3 RBC-3.86* Hgb-12.5* Hct-36.0* MCV-93 MCH-32.4* MCHC-34.8 RDW-13.6 Plt Ct-180# [**2146-11-24**] 05:15AM BLOOD WBC-6.8 RBC-3.73* Hgb-11.9* Hct-34.9* MCV-93 MCH-32.0 MCHC-34.3 RDW-13.5 Plt Ct-115* [**2146-11-23**] 05:50AM BLOOD WBC-6.9 RBC-3.79* Hgb-12.3* Hct-35.3* MCV-93 MCH-32.4* MCHC-34.8 RDW-13.7 Plt Ct-85* [**2146-11-22**] 10:40AM BLOOD WBC-11.2* RBC-3.98* Hgb-12.7* Hct-35.8* MCV-90 MCH-31.9 MCHC-35.5* RDW-14.0 Plt Ct-77* [**2146-11-22**] 05:15AM BLOOD WBC-14.5* RBC-3.79*# Hgb-12.0*# Hct-34.3*# MCV-91 MCH-31.6 MCHC-34.9 RDW-14.2 Plt Ct-67* [**2146-11-21**] 01:57AM BLOOD WBC-15.4* RBC-2.91* Hgb-9.4* Hct-26.5* MCV-91 MCH-32.3* MCHC-35.5* RDW-13.9 Plt Ct-65* [**2146-11-20**] 03:00AM BLOOD WBC-19.6* RBC-2.98* Hgb-9.8* Hct-28.1* MCV-94 MCH-32.8* MCHC-34.8 RDW-13.4 Plt Ct-70* [**2146-11-19**] 02:30AM BLOOD WBC-25.1*# RBC-3.44* Hgb-11.2* Hct-32.3* MCV-94 MCH-32.6* MCHC-34.7 RDW-13.4 Plt Ct-106* [**2146-11-18**] 04:58AM BLOOD WBC-5.7 RBC-3.66* Hgb-12.4* Hct-34.2* MCV-93 MCH-33.9* MCHC-36.3* RDW-12.9 Plt Ct-118* [**2146-11-17**] 07:30PM BLOOD WBC-6.7 RBC-3.78* Hgb-12.4* Hct-34.0* MCV-90 MCH-32.7* MCHC-36.4* RDW-13.1 Plt Ct-117* [**2146-11-25**] 11:25AM BLOOD Plt Ct-180# [**2146-11-25**] 11:25AM BLOOD Glucose-110* UreaN-23* Creat-0.7 Na-138 K-4.6 Cl-104 HCO3-27 AnGap-12 [**2146-11-24**] 05:15AM BLOOD Glucose-111* UreaN-32* Creat-1.1 Na-139 K-4.4 Cl-106 HCO3-26 AnGap-11 [**2146-11-23**] 05:50AM BLOOD Amylase-53 [**2146-11-22**] 10:40AM BLOOD ALT-102* AST-52* Amylase-56 TotBili-0.6 [**2146-11-19**] 02:30AM BLOOD CK(CPK)-1600* [**2146-11-21**] 01:57AM BLOOD CK(CPK)-120 [**2146-11-25**] 11:25AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.8 [**2146-11-18**] 04:58AM BLOOD VitB12-786 [**2146-11-18**] 04:58AM BLOOD %HbA1c-5.6 [Hgb]-DONE [A1c]-DONE [**2146-11-18**] 04:58AM BLOOD Triglyc-40 HDL-98 CHOL/HD-2.1 LDLcalc-98 [**2146-11-22**] 10:40AM BLOOD Ammonia-20 [**2146-11-18**] 04:58AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Barbitr-NEG Tricycl-NEG Urine Culture KLEBSIELLA PNEUMONIAE | ENTEROBACTERIACEAE | | KLEBSIELLA PNEUMONIAE | | | AMPICILLIN/SULBACTAM-- 4 S 4 S <=2 S CEFAZOLIN------------- <=4 S <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S <=1 S CEFUROXIME------------ 2 S 2 S <=1 S GENTAMICIN------------ <=1 S <=1 S <=1 S IMIPENEM-------------- <=1 S 2 S <=1 S LEVOFLOXACIN----------<=0.25 S <=0.25 S <=0.25 S MEROPENEM-------------<=0.25 S <=0.25 S <=0.25 S NITROFURANTOIN-------- 32 S =>512 R <=16 S PIPERACILLIN/TAZO----- <=4 S <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S <=1 S Blood culture [**11-18**] KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 2 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN----------<=0.25 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S Repeat Urine culture <10,000 colonies Repeat Blood cultures negative for three days. Head CT [**11-17**]:Right basal ganglia 21 x 10 mm intraparenchymal hemorrhage with mild surrounding edema. No prior studies were available for comparison. Head CT [**11-18**]: stable hemorrhage MRI/MRA: MRI demonstrates the right thalamic hemorrhage, as visualized on the CT scan of [**2146-11-17**]. No additional areas of susceptibility artifact are detected. There are no signs of acute infarction. MRA demonstrates flow in the major branches of the circle of [**Location (un) 431**] and no abnormal vascularity. LEFT X-ray Knee and Hip: No fracture, dislocation, or evidence of hardware loosening. CXR:A feeding tube has been withdrawn slightly in the interval. Although the tip still terminates in the stomach, the most proximal portion of the radiodense tip is likely just above the GE junction level. Cardiac silhouette is stable in size and demonstrates left ventricular configuration. There has been interval marked improved aeration in the left retrocardiac region with only minimal residual atelectasis remaining. Bilateral pleural effusions are improved, resolved on the right and nearly resolved on the left. There are no new or worsening areas of opacification to suggest pneumonia. Echo/TTE:The left atrium is mildly dilated. A patent foramen ovale or small atrial septal defect could not be excluded by color Doppler study. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with probable distal septal hypokinesis. Overall left ventricular systolic function is borderline depressed. [Intrinsic left ventricular systolic function may be more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is a trivial/physiologic pericardial effusion. No cardiac source of embolus identifed. Brief Hospital Course: Neurology - Mr. [**Known lastname 65376**] was admitted to the ICU for monitoring once it was discovered that his left-sided was secondary to a right sided thalmocapsular hemorrhage. In the ICU, he remained hemodynamically stable however his neurological exam worsened from left sided hemiparesis to essentially, hemiplegia involving most of his left side, including face, arm, and leg. The differential included hypertensive hemorrhage, mass, aneurysm, or hemorrhagic conversion of an embolic. As the patient had little recorded or reportable medical history it is unclear that he had a history of HTN, but this was clearly the most likely diagnosis as no mass was observed and the MRA was negtive for vascular malformation. He was quite hypertensive at admission, with BPs 200/100s requiring IV hydralazine for control. The patient had a deterioration in his mental status after transfer out of the ICU. An encephalopathy work-up revealed bilateral pleural effusions thought to be secondary to possible aspiration pneumonia. His antibiotic regimen was changed to Levofloxacin and Metronidazole and he became alert and oriented within 24 hrs. He should complete another 6 days of Levofloxacin and Flagyl. Physical therapy has been involved with his care and he has been moved to and from his bed to a chair. HbA1C, Lipids were normal. His Trans-thoracic Echocardiogram revealed normal EF without vegetations. Respiratory - pt intermittently required oxygen by NC. He was diagnosed with bilateral pleural effusions and possible left sided pneumonia which on repeat CXR [**11-25**] showed interval resolution. He currently does not have an oxygen requirement. FEN/GI - the patient had difficulty swallowing and had been maintained with an NGT for adequate fluid and nutritional intake. Speech and swallow recommended: 1. Continue with NG tube feedings to maintain nutrition/hydration 2. PO diet consistency of nectar thick liquids and purees as a SNACK only 3. Basic aspiration precautions should be followed: a. Pt should be awake and alert while eating b. Pt should be seated upright in the bed during all meals. He will likely benefit from f/u with a nutrionist in Rehab. Pt. also with large left inguinal hernia. This is a [**Last Name 19390**] problem that has not presented acute issues for him. Renal/GU - Patient admitted with hyophosphatemia and hypomagnesemia which have responded well to both oral and IV supplementation. His recent Mg and Phos have normalized. He has [**Doctor First Name **] kept on Neuta Phos packets [**Hospital1 **]. Patient was evaluated by Urology service for difficulty with Foley catheter placement in the ICU. A catheter was placed by GU; they recommended a voiding trial and on [**11-25**] the catheter was pulled and the patient voided spontaneously. The patient has had microscopic hematuria and GU was made aware of this. Their recommendation was that this could be followed up as an outpatient. ID - The patient had Klebsiella pneumoniae urosepsis. He was initially placed on Gentamicin. He subsequently had a drop in his platelets. Because the bacteria was also sensitive to ceftriaxone he was switched as there was concern that the thrombocytopenia (low of 65) was secondary to gentamicin. Once the gent was discontinued, his platelets subsequently recovered to normal range. He has been treated with Levaquin IV and Flagyl for 2 days and should complete another 6 days of these two antibiotics for the Klebsiella and the pneumonia. HEME - Thrombocytopenia as mentioned above. Pt. had developed anemia and was tranfussed two units of PRBCs in the ICU. He has since had stable CBCs. His anemia was likely secondary to acute illness. He was placed on Heparin 5000 U SC for DVT prophylaxis. Musculoskeletal: Pt c/o pain in left knee. He underwent X-rays of both knee and left hip earlier in the hospitalization as he presented with a fall. These tests were negative for fracture or change in hardware (secondary to left hip ORIF in past). PODIATRY - the patient had severe nail fungus and Podiatry debrided the nails. He has been receiveing LacHydrin moisturizing cream to his feet for severe dryness. There has been much improvement during his hospital course. DISPO - Patient has no PCP and would definitely benefit from regular medical follow-up. A phone number for [**Hospital **] will be provided. The patient will have f/u appointments with Urology and Neurology/Stroke. Patient will require long-term assistance with ADLs and will benefit from inpatient rehabilitation. DIAGNOSIS: Right thalamocapsular hemorrhage likely secondary to hypertension Medications on Admission: None Discharge Medications: 1. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One (1) Packet PO BID (2 times a day). Disp:*60 Packet(s)* Refills:*2* 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for SBP<100 or HR<60. Disp:*60 Tablet(s)* Refills:*2* 3. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO DAILY (Daily). Disp:*900 mg* Refills:*2* 4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 6 days. Disp:*18 Tablet(s)* Refills:*0* 5. Ammonium Lactate 12 % Lotion Sig: One (1) application Topical [**Hospital1 **] (2 times a day). Disp:*60 applications* Refills:*2* 6. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). Disp:*600 mL* Refills:*2* 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day). Disp:*90 mL* Refills:*2* 8. Levofloxacin in D5W 500 mg/100 mL Piggyback Sig: One (1) Intravenous once a day for 6 days. Disp:*6 units* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Right thalamocapsular hemorrhage Left hemiplegia HTN BPH Discharge Condition: Fair Discharge Instructions: Please take your medications If you experience new wekaness, trouble speaking or swallowing, chest pain, or palpitations, please inform a physician Followup Instructions: Neurology/Stroke - Please call [**Telephone/Fax (1) 3767**] to schedule an apopointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Urology f/u for BPH [**Telephone/Fax (1) 164**] for appt. Patient will require referral for a PCP as an [**Name9 (PRE) 15973**]. The number for Helath Care Assocaites is:

[ "599.0", "285.9", "431", "396.3", "401.9", "995.91", "507.0", "038.49", "287.4", "110.1", "600.00", "E930.8" ]

icd9cm

[ [ [] ] ]

[ "99.04", "86.27" ]

icd9pcs

[ [ [] ] ]

14659, 14731

8971, 13577

285, 292

14832, 14839

3317, 8948

15035, 15373

1497, 1722

13632, 14636

14752, 14811

13603, 13609

14863, 15012

1737, 3298

226, 247

320, 1193

1215, 1311

1327, 1481

46,399

127,874

53239

Discharge summary

report

Admission Date: [**2191-7-13**] Discharge Date: [**2191-7-16**] Date of Birth: [**2131-12-13**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3256**] Chief Complaint: Presyncope/hypotension Major Surgical or Invasive Procedure: Central line placement and removal. History of Present Illness: 59 year old female with pmh of HTN, LBP, and depression who presents to the hospital status post pre-syncopal episode. She was at the train station when she began to feel weak and lightheaded. She denies any chest pain, shortness of breath, or palpitations. She denies any weakness, tingling, or any aura. Prior to the episode, she took Clonazepam today, 1mg x2 (she takes 1mg TID). She had a week of diarrhea prior to the event and was complaining of abdominal pain related to her diarrhea. She denied ever losing consciousness. She says that her "knees got weak". This has happened previously, though never this severe. She has not lost consciousness, she denies that she had any incontinence. Of note, she has had multiple trips to our ED for back pain and most recently in [**Month (only) 205**], for altered mental status. She had been prescribed benzos and narcotics at prior visits. At her most recent visit (AMS) it was thought to be secondary to benzodiazepines. She was given flumazenil and narcan with some improvement. Her BP's have ranged from 90s-130s systolic in these visits. In the ED, she was found to be hypotensive with initial vitals of 98.3, 65, 86/50, 13, and 95% on RA. Her BP reached as low as 69/42. Her HR ranged 52-71. She was given 7-8 liters of normal saline in the ED, and her hypotension was refractory. Peripheral dopamine was started and a left IJ was placed. She was started on levophed and at time of transfer she was on 0.02 of levophed. She was given Zosyn 4.5g, Vanco 1gm, and Tylenol 1gm. On the floor, she is awake, though appears drowsy. She is on 0.03 of levophed, answering questions appropriately. Her affect appears depressed. She tells me that she has chronic low back pain since her son past away in [**2162**]. She denies ever having SI/HI, and says she "has a daughter. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 20227**]'t do that to her." She says that she's not depressed because school is keeping her busy, and when she accomplishes things in school, she's proud of that. She is having some upper respiratory symptoms and currently is having some minor difficulty with full sentences. Past Medical History: Hypertension Low back pain Depression Social History: She was born and raised in [**Hospital1 8**], currently living in [**Hospital1 3494**]. She is divorced, has a daughter, and a son that passed away in [**2162**]. - Tobacco: former 1ppd, now very occassional - Alcohol: denies - Illicits: denies Family History: No history of sudden cardiac death. Physical Exam: Admission: General: Alert, oriented, no acute distress, drowsy, fatigued HEENT: Sclera anicteric, mildly dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Distant breath sounds throughout, Clear to auscultation bilaterally, few sparse inspiratory wheezes CV: Normal rate, regular rhythm, distant heart sounds normal S1 + S2, no murmurs, rubs, gallops that could be appreciated 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 Discharge: VS: 98.3, 124/76, 72, 16, 96% on RA Orthostats: 140/88 72 laying down, 148/90 76 standing after 3 minutes GENERAL: NAD, comfortable, appropriate. HEENT: MMM, OP clear. JVP flat HEART: RRR, no MRG, nl S1-S2. LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored. ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses. NEURO: Awake, A&Ox3, CNs II-XII intact bilaterally. Motor: [**3-31**] strength except for [**3-1**] on left foot press and illopsoas. Cerebellum: nl f-n-f, Reflexes 2+ bilaterally upper and lower, Sensory intact, Gait, mild unsteadiness. Pertinent Results: [**2191-7-13**] 01:00PM BLOOD WBC-10.8 RBC-3.56* Hgb-11.3* Hct-32.7* MCV-92 MCH-31.6 MCHC-34.4 RDW-13.2 Plt Ct-292 [**2191-7-16**] 09:00AM BLOOD WBC-5.7 RBC-3.27* Hgb-10.2* Hct-29.9* MCV-92 MCH-31.2 MCHC-34.1 RDW-13.1 Plt Ct-208 [**2191-7-13**] 01:00PM BLOOD Neuts-76.4* Lymphs-16.4* Monos-4.4 Eos-2.4 Baso-0.4 [**2191-7-13**] 01:00PM BLOOD PT-12.1 PTT-26.1 INR(PT)-1.0 [**2191-7-13**] 01:00PM BLOOD Glucose-94 UreaN-35* Creat-1.4* Na-136 K-5.4* Cl-103 HCO3-25 AnGap-13 [**2191-7-16**] 09:00AM BLOOD Glucose-135* UreaN-17 Creat-0.7 Na-143 K-3.9 Cl-108 HCO3-26 AnGap-13 [**2191-7-13**] 01:00PM BLOOD ALT-34 AST-26 AlkPhos-60 TotBili-0.2 [**2191-7-13**] 01:00PM BLOOD Lipase-20 [**2191-7-13**] 01:00PM BLOOD cTropnT-<0.01 [**2191-7-13**] 08:52PM BLOOD CK-MB-4 cTropnT-<0.01 [**2191-7-13**] 08:52PM BLOOD Calcium-7.4* Phos-4.0 Mg-1.7 [**2191-7-16**] 09:00AM BLOOD Calcium-8.9 Phos-2.9 Mg-1.7 [**2191-7-13**] 11:00PM BLOOD D-Dimer-2923* [**2191-7-13**] 08:52PM BLOOD Cortsol-5.4 [**2191-7-14**] 02:51PM BLOOD Cortsol-24.2* [**2191-7-14**] 03:22PM BLOOD Cortsol-28.7* [**2191-7-13**] 01:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2191-7-13**] 01:03PM BLOOD Lactate-1.2 [**2191-7-13**] 01:45PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2191-7-13**] 01:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2191-7-13**] 01:45PM URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG MRSA screen negative. Blood cultures x2 [**7-13**] no growth, final. [**2191-7-13**] EKG Normal sinus rhythm with borderline A-V conduction delay. Q waves in leads V1-V2 consistent with prior anteroseptal myocardial infarction. Compared to the previous tracing of [**2191-6-1**] the Q waves in leads V1-V2 are new. [**2191-7-13**] CT abdomen and pelvis: . Periportal edema with trace perihepatic and pericholecystic fluid with otherwise no evidence of acute cholecystitis. Overall, this is a nonspecific finding and given the lack of abdominal pathology, likely represents aggressive resuscitative efforts. 2. Foley catheter with a few centimeters of tubing identified within the bladder. Could be pulled back. 3. Multiple simple renal cysts, left greater than right. [**2191-7-14**] CT angio IMPRESSION NO evidence of pulmonary embolism Main pulmonary artery caliber is top normal. Apical predominant mild centrilobular emphysema. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: 59 year old female with a pmh of hypertension who presented post pre-syncopal episode, found to be hypotensive in the ED, admitted to the MICU for hypotension. 1. Hypotension: Thought to be from med effect (with multiple psychoactive medications such as ambien, Klonipin, flexeril and gabapentin) in the setting of dehydration from 4 days of watery stools. Other less likely possibilities considered included adrenal axis abnormality, vasovagal episode, and infection. However, infection is unlikely given her normal WBC, no fever, normal lactate, and lack of SIRS criteria. Vasovagal episode would likely not last as long as the patient's hypotension lasted (several hours despite fluid resuscitation of [**6-3**] L). She had a random cortisol drawn that was indeterminant for adrenal insufficiency and had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stimulation test, which was negative. Her lisinopril was held and she remained off pressors. Orhtostatics were negative. She was not given antibiotics and remained stable with BPs in the 90s-100s so she was called out of the ICU. 2. ARF, likely in the setting of dehydration and ACE-I. Improved with IV fluids. 3. Hyperkalemia: Also, likely high in the setting of ARF and ACE-I. Ressolved with IV fluids 4. EKG changes: The patient was noted to have new q waves in V1 and V2. Her cardiac enzymes were negative x 2. It is possible that the patient had a missed event. 5. Mental Status/Depression: The pt denied active SI, depression, or past SI attempts. Currently on several psychogenic medications. Her benzos, ambien, and gabapentin were all held in the setting of hypotension. Social work was consulted. Her medications were adjusted and she was discharged on amitriptyline and zoloft. Patient was scheduled to see her previous PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], who she had seen in the past as well as a psychiatrist, Dr. [**Last Name (STitle) 109593**]. 6. Chronic Back Pain: Patient takes flexeril Q6H prn for back pain. This was held in the setting of hypotension and her pain was treated with Tylenol. Patient was discharged on ibuprofen 800mg q8h x7 days to reduce pain and inflammation. 7. pulmonary nodue: The patient was noted to have a 3.0-mm solid non-calcified nodule in the middle lobe seen on her CTA. She has smoking history and therefore will need 3 month follow up of this nodule with repeat CT scan. This will need to be coordinated by her new PCP. Medications on Admission: Home Medications: Per health care alliance [**Hospital1 **]: Calcium Carbonate Vit D 1200 qd Pro air PRN Fioricet 2 tabs PO qHs Ceterizine 5mg qd Gabapentin 800mg QID Propranalol 80mg qd Sertraline 200mg qd Simvastatin 20mg qHs Lisinopril 20mg qd (historical) . Per Patient: Lisinopril 5mg PO daily Clonazepam 1mg PO TID Gabapentin 800mg QHS or TID (she takes PRN) Ambien 10mg PO QHS Flexeril unknown dose albuterol inhaler prn sertraline 200mg qd simvastatin 20mg. Medications on Transfer: Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Acetaminophen 650 mg PO/NG Q6H:PRN Pain Heparin 5000 UNIT SC TID Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Vitamin D 400 UNIT PO/NG DAILY Vitamin E 400 UNIT PO DAILY Zolpidem Tartrate 10 mg PO HS Discharge Medications: 1. calcium carbonate-vitamin D3 Oral 2. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**11-28**] puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 3. Fioricet 50-325-40 mg Tablet Sig: Two (2) Tablet PO at bedtime as needed for headache. 4. Zyrtec 10 mg Tablet Sig: [**11-28**] Tablet PO once a day. 5. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. 6. Zoloft 100 mg Tablet Sig: Two (2) Tablet PO once a day. 7. ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) for 7 days: Course: [**Date range (1) 109594**]. Please take with food and stay well hydrated. Disp:*0 Tablet(s)* Refills:*0* 8. simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 9. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Home Discharge Diagnosis: Primary: Hypotension, Presyncope, Depression Secondary: Hypertension, hyperlipidemia, chronic back pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 109595**], It was our pleasure taking care of you at [**Hospital1 18**]. You were admitted to the hospital for a low blood pressure and an inappropriately low heart rate. You were treated with intravenous fluids, and a medication to bring your blood pressure up. We also held some of the medications that you take that may have caused the low blood pressure. We found no explanation of the low blood pressure on CT scan of your belly and chest. We also found that you had a low blood count and were anemic. This is partally due to the fluids we gave you diluting your blood. Your blood levels were stable during discharge with no evidence of bleeding. Your anemia should be following up as an outpatient. We made the following changes to your medications: START ibuprofen 800 mg three times daily with meals for one week to decrease the inflammation in your back. Please stay well hydrated. HOLD lisinopril HOLD propranalol HOLD gabapentin Please only obtain medications from your PCP and your psychiatrist. Please discard all other medications that are not current. Followup Instructions: Please attend the following appointments: Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD Location: [**Hospital6 12736**] Address: [**Street Address(2) 5116**] [**Hospital1 3494**], [**Numeric Identifier 29455**] Phone: [**Telephone/Fax (1) 109596**] Appointment: Monday [**2191-7-18**] 3:20pm Name: [**Last Name (LF) **],[**First Name3 (LF) 2671**] J. Location: [**Location (un) **] OUTPATIENT CLINIC Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2900**] Phone: [**Telephone/Fax (1) 89646**] Appointment: Thursday [**2191-7-21**] 10:00am

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icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

[ [ [] ] ]

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328, 365

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266, 290

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2575, 2615

2631, 2878

22,602

110,451

47837

Discharge summary

report

Admission Date: [**2135-4-13**] Discharge Date: [**2135-4-18**] Date of Birth: [**2085-8-16**] Sex: M Service: CARDIAC SURGERY HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is a 49 year-old gentelman who has a many year history of a heart murmur who was found to have mitral valve disease by echocardiogram with a recent onset of chest discomfort and diaphoresis with exertion. Echocardiogram in [**2134-12-6**] showed a moderately dilated left atria, mildly dilated left ventricle, ejection fraction of 60 to 70%, mildly thickened mitral valve leaflets, mild mitral valve prolapse, partial mitral leaflet flail with 3+ mitral regurgitation, 1+ tricuspid regurgitation and mild pulmonary hypertension. The patient underwent cardiac catheterization on [**2135-3-7**], which showed an ejection fraction of 60% with 2+ mitral regurgitation and no coronary disease. The patient was referred to Dr. [**Last Name (Prefixes) 411**] for mitral valve repair. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Mitral valve prolapse. 4. Depression. 5. Psoriasis. 6. Status post tonsillectomy. 7. Status post right knee arthroscopy. 8. Multiple orthopedic injuries. ALLERGIES: No known drug allergies. PREOPERATIVE MEDICATIONS: 1. Enteric coated aspirin 325 mg po q day. 2. Zestril 40 mg po q day. 3. Prozac 60 mg po q day. 4. Hydrochlorothiazide 25 mg po q day. 5. Multivitamins. HO[**Last Name (STitle) **] COURSE: The patient was taken to the Operating Room on [**2135-4-13**] with Dr. [**Last Name (Prefixes) **] for a minimally invasive mitral valve repair. Please see operative note for further details. The patient was transported to the Intensive Care Unit in stable condition on neo-synephrine and Propofol infusions. The patient was weaned and extubated from mechanical ventilation on his first postoperative night requiring low dose neo-synephrine. On the evening of postoperative day number one the patient was noted to have a moderate amount of chest tube drainage and a drop in hematocrit. Chest x-ray showed a right sided pleural effusion. A chest tube was inserted into the right pleural space with immediate drainage of about 500 cc of bloody fluid with fair resolution by chest x-ray. The patient continued to have a drop in hematocrit and a thoracic surgery consult was obtained. Thoracic surgery felt that the postoperative bleeding was self limiting. By postoperative day number two the patient's hematocrit had stabilized and there was no drainage of the chest tube, however, the patient continued to be anemic. The patient was again transfused packed red blood cells and given Lasix and the patient's hematocrit over the next several days began to climb. The patient was started on Lopressor. Repeat chest x-ray showed elevated right hemidiaphragm with little change between inspiratory and expiratory films, right middle and right lower lobe atelectasis. Coughing and deep breathing was encouraged as well as incentive spirometry. Postoperative day number four one of the patient's chest tubes were removed and the other was placed to water seal. Chest x-ray after this was done showed a small right apical pneumothorax unchanged from the previous films. On postoperative day number four the patient was transferred from the Intensive Care Unit to the regular part of the hospital where he began working with physical therapy. On postoperative day number five the patient's last remaining right pleural chest tube was removed and post removal chest x-ray showed unchanged from previous chest x-rays, which was small bilateral effusions right greater then left, elevated right hemidiaphragm, right middle and right lower lobe atelectasis and a small right apical pneumothorax. The patient ambulated with physical therapy and was able to climb one flight of stairs and walk 500 feet while remaining hemodynamically stable and without requiring oxygen and the patient was cleared for discharge to home. CONDITION ON DISCHARGE: Temperature max 100.1. Pulse 65 in sinus rhythm. Blood pressure 111/68. Respiratory rate 15. Room air oxygen saturation 95%. The patient's weight on [**4-18**] is 95.3 kilograms. Preoperatively the patient weighed 93 kilograms. Laboratory data, white blood cell count 7.9, hematocrit 27.3, platelet count 237, sodium 138, potassium 4.4, chloride 102, bicarb 30, BUN 14, creatinine 0.6, glucose 90, PT 12.4, INR 1.0, PTT 23.8. Neurologically the patient is awake, alert, and oriented times three, nonfocal. Heart is regular rate and rhythm without rub or murmur. Breath sounds are clear, decreased right. There is no rhonchi or rales. Abdomen positive bowel sounds, soft, nontender, nondistended. The patient is tolerating a regular diet. Right incisions are clean, dry and intact. There is no erythema. The chest tube site is covered with a dry sterile dressing, which is to be removed on [**4-19**]. Extremities are without edema. DISCHARGE DIAGNOSES: 1. Mitral regurgitation. 2. Status post minimally invasive mitral valve repair. 3. Postoperative right hemothorax. 4. Postoperative elevated right hemidiaphragm. 5. Postoperative anemia. DISCHARGE MEDICATIONS: 1. Percocet 5/325 one to two po q 4 to 6 hours prn. 2. Enteric coated aspirin 325 mg po q day. 3. Zantac 150 mg po b.i.d. 4. Colace 100 mg po b.i.d. 5. Lasix 20 mg po q day times seven days. 6. Potassium chloride 20 milliequivalents po q day times seven days. 7. Niferex 150 mg po q day. 8. Vitamin C 500 mg po b.i.d. 9. Multivitamin one po q day. 10. Lopressor 50 mg po b.i.d. DISCHARGE CONDITION: The patient is to be discharged to home in good condition. DI[**Last Name (STitle) 408**]E FOLLOW UP: The patient is to follow up with Dr. [**First Name (STitle) **] in one to two weeks. The patient is to follow up with Dr. [**First Name (STitle) 216**] in one to two weeks and the patient is to follow up with Dr. [**Last Name (Prefixes) **] in three to four weeks. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 1541**] MEDQUIST36 D: [**2135-4-18**] 12:13 T: [**2135-4-18**] 12:47 JOB#: [**Job Number 100959**]

[ "285.1", "424.0", "311", "401.9", "518.0", "696.1", "511.8", "272.0" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.12", "34.04" ]

icd9pcs

[ [ [] ] ]

5622, 5714

4995, 5188

5211, 5600

5726, 6260

1279, 4001

1007, 1253

4026, 4974

65,309

178,833

42693

Discharge summary

report

Admission Date: [**2115-10-21**] Discharge Date: [**2115-10-28**] Date of Birth: [**2034-9-6**] Sex: M Service: MEDICINE Allergies: Oxycodone Attending:[**First Name3 (LF) 1515**] Chief Complaint: Core Valve Major Surgical or Invasive Procedure: CoreValve/TAVR History of Present Illness: Patient is an 81yo caucasian male with known aortic stenosis, CAD s/p CABG x 3([**2088**]) and PCI-[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 11641**] ([**4-8**]), ischemic cardiomyopathy (EF20-25%),PPM/ICD, GI bleed (duodenal AVM), htn who was undergoing evaluation for aortic valve replacement. Serial echocardiograms demonstrated progressive aortic stenosis with ([**Location (un) 109**] 1.0cm2, mean gradient 27mmHG, reduced EF 23%). He reports shortness of breath walking less than 100feet, periods of shortness of breath at rest. He is able to go up six stairs before stopping due to shortness of breath. His daily activities have been greatly reduced. He denies light headedness or dizziness. He admits to occasional chest pressure, last episode this am. He was evaluated for aortic valve replacement and he was deemed not a surgical candidate for conventional AVR due to heavily calcified aorta. He was referred for TAVR evaluation. He met all inclusion criteria and did not meet any exclusion criteria. After informed consent, he was screened and accepted for the Corevalve/TAVR procedure. NYHA Class: III Past Medical History: 1. CARDIAC RISK FACTORS: +Hypertension, +Dyslipidemia 2. CARDIAC HISTORY: -CABG: CABG x3 in [**2088**] (SVG to RCA, LAD and OM1) -PERCUTANEOUS CORONARY INTERVENTIONS: [**3-/2115**]: DES x2 to the ramus -PACING/ICD: ICD placement [**2114-11-26**] -- Device: St. [**Hospital 923**] Medical Dual Chamber Fortify DR CD2231-40Q -- RA Lead: St. [**Hospital 923**] Medical Transvenous Tendril STS 2088TC/52 -- RV Lead: [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Transvenous Dual [**Last Name (un) **]/Pace-Send [**Last Name (un) **] IS-1 -Severe Aortic Stenosis ([**Location (un) 109**] 0.9 on TTE [**3-/2115**]) -NSTEMI [**3-/2115**] -Chronic Systolic CHF (EF 20-25%) from ischemic CMP 3. OTHER PAST MEDICAL HISTORY: -h/o Prostate cancer - [**2096**] -s/p CVA - [**2111**] - right sided weakness, resolved after rehab -Nasal Polyps -Torn Right Rotator Cuff - Macular Degeneration s/p bilateral lens implants ([**2104**], [**2109**]) -History tobacco use. Quit in [**2088**] -s/p Left Hand Surgery [**11/2110**] -s/p Bilateral Knee replacement -s/p Appendectomy -s/p Cholecystectomy -GI bleed from angioectasia s/p cauterization ([**3-/2115**]) Social History: Mr. [**Known lastname 11309**] lives with his wife [**Name (NI) 2411**] and used to work as a mechanic. He is currently retired. He does not exercise lately secondary to feeling fatigued. -Tobacco history: 60 pack-year history, quit in [**2088**] -ETOH: quit in [**2105**], heavy use for approx 30 years -Illicit drugs: None Family History: Family history of heart disease but no history of hypertension, diabetes, or stroke. His mother died at the age of 80 secondary to cardiac disease, and his father died at the age of 79 secondary to prostate cancer. Physical Exam: ADMISSION: Pulse: 71 B/P: 122/65 Resp: 18 O2 Sat: 100% (RA) Temp: 97.9 Height: Weight: 175 lbs General: Alert pale elderly male in NAD at rest. Skin: color pale, skin warm and dry. Scant hair growth below knees, no lesions noted. Turgor fair. HEENT: normocephalic, anicteric. Oropharynx moist, upper and lower dentures. Neck: supple, trachea midline, bruit vs. referred murmer Chest: no obvious deformity, surgical incisions well healed. LS decreased bases. No rales, wheeze. Heart: murmer RSB radiating throughout. Abdomen: soft, nontender, nondistended, (+)bowel sounds. Extremities: trace pedal edema bilat. lower extremities. Muscle atrophy. Neuro: alert and oriented, calm, receptive. Gross FROM. Pulses: (+)peripheral pulses. Discharge: Afebrile, non-tachycardic, normotensive, non-tachypneic, saturating well on RA PE similar as above except for: CV: RRR, no m/r/g Pertinent Results: ADMISSION: [**2115-10-21**] 05:19PM BLOOD WBC-3.8* RBC-3.88* Hgb-8.2* Hct-28.2* MCV-73* MCH-21.1* MCHC-29.1* RDW-17.1* Plt Ct-231 [**2115-10-21**] 05:19PM BLOOD PT-13.4* PTT-32.6 INR(PT)-1.2* [**2115-10-21**] 05:19PM BLOOD Glucose-102* UreaN-25* Creat-1.1 Na-144 K-3.8 Cl-107 HCO3-28 AnGap-13 [**2115-10-21**] 05:19PM BLOOD Glucose-102* UreaN-25* Creat-1.1 Na-144 K-3.8 Cl-107 HCO3-28 AnGap-13 [**2115-10-21**] 05:19PM BLOOD ALT-14 AST-23 CK(CPK)-63 AlkPhos-102 TotBili-0.8 [**2115-10-21**] 05:19PM BLOOD CK-MB-4 proBNP-3080* [**2115-10-21**] 05:19PM BLOOD Albumin-4.5 STUDIES: ([**10-21**]) CXR: Pacemaker leads terminate in right atrium and right ventricle. Cardiomegaly is moderate. Mediastinal position is stable. Diffuse interstitial opacities are unchanged since the prior study. There is no pleural effusion or pneumothorax. ([**10-22**]) CXR: Successful Core-Valve device placement without evidence of increasing pulmonary congestion or pneumothorax. [**2115-10-27**] The left atrium is markedly dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed (LVEF= 20-25 %) with global hypokinesis and regional thinning/akinesis of the mid to distal anterior wall, antero-septum, distal LV and apex. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with normal free wall contractility. The diameters of aorta at the sinus, ascending and arch levels are normal. An aortic CoreValve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**1-28**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2115-10-23**], no major change. ([**10-23**]) ECHO: The left atrium is markedly dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed (LVEF= 20-25%) secondary to dyskinesis of the distal septum and apex, akinesis of the basal-mid anterior septum and distal anterior wall and mild-moderate hypokinesis of the remaining segments. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. An aortic CoreValve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild mitral regurgitation. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2115-4-10**], there is a well seated aortic CoreValve prosthesis with normal transvalvular gradients and trace aortic regurgitation. The degree of mitral regurgitation has decreased. Moderate pulmonary artery systolic hypertension is now appreciated (pulmonary pressures could not be determined on the prior study). [**10-22**] Echo Pre valve Implant No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is severely depressed (LVEF= 20 %). with mild global RV free wall hypokinesis. There are simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. Poor image quality. Unable to visualize apex of LV: cant rule out apical thrombus. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2115-10-22**] at 830 am . Post valve Implant Corevalve seen in the aortic position. It appears well seated. Mild perivalvular and tarce central aortic insufficiency seen. Moderate mitral regurgitation. Rest of examination is unchanged from preimplant Discharge labs: [**2115-10-28**] 10:00AM BLOOD WBC-3.3* RBC-3.50* Hgb-7.7* Hct-26.3* MCV-75* MCH-22.0* MCHC-29.2* RDW-18.8* Plt Ct-167 [**2115-10-28**] 05:39AM BLOOD WBC-3.4* RBC-3.41* Hgb-7.6* Hct-25.5* MCV-75* MCH-22.2* MCHC-29.8* RDW-19.0* Plt Ct-181 [**2115-10-28**] 05:39AM BLOOD Glucose-88 UreaN-16 Creat-1.0 Na-139 K-3.9 Cl-105 HCO3-30 AnGap-8 [**2115-10-28**] 05:39AM BLOOD ALT-12 AST-21 LD(LDH)-185 AlkPhos-94 TotBili-0.9 [**2115-10-28**] 05:39AM BLOOD Calcium-8.3* Phos-3.8 Mg-2.2 Brief Hospital Course: 81yo male with symptomatic severe aortic stenosis. History of CAD, ICM, PPM/ICD, HTN, heavily calcified aorta. Active issues: # Severe aortic stenosis with CoreValve placement- Patient with severe aortic stenosis causing dyspnea on exertion and occasional chest pressure and leading to severe limitation of daily activities. Serial echocardiograms demonstrated progressive aortic stenosis with ([**Location (un) 109**] 1.0cm2, mean gradient 27mmHG, reduced EF 23%). Patient not a candidate for conventional AVR due to heavily calcified aorta. He was referred for TAVR evaluation. He met all inclusion criteria and did not meet any exclusion criteria. After informed consent, he was screened and accepted for the Corevalve/TAVR procedure. Corevalve done on [**10-22**]. Beta blocker and diuretics held day of procedure, given [**Month/Year (2) **] 325mg and [**Month/Year (2) 4532**] load 300mg dose day before, preop teaching, and Gerontology consulted. After CoreValve the patient required intermittent neo drip to maintain pressures in the first 24 hrs. He was then successfully weaned off pressors and remained stable. He was transferred to the floor on POD 2. An ECHO post-op showed well seated aortic CoreValve prosthesis with normal transvalvular gradients and trace aortic regurgitation. The degree of mitral regurgitation decreased. Pt remained hemodynamically stable in the ICU and on the general cardiology floor. # Anemia: Hct 23 pre-procedure, increased to 29 s/p 2 units PRBCs given at time of procedure. Iron profile with low ferritin and iron consistent with iron deficiency. Pt with hx of GI bleed in past, did have Guaiac positive stool but no grossly bloody stool or melena. He tolerated [**Month/Year (2) **]/[**Month/Year (2) 4532**]. Hct was trended and stable. Pantoprazole was continued. Hct trended and discharged with Hct of 26.3. # CAD - On [**Month/Year (2) **], statin. preop EKG unchanged. BB initially held and restarted on POD 2. Pt was discharged with dual antiplatelet therapy, metoprolol, Losartan and Lipitor. # ICM - PPM/ICD were interrogated and ICD was off for procedure. It was then again interrogated on POD 1 and functioning well. # HTN - [**Last Name (un) **] and beta blocker initially held, restarted on POD 2. ## TRANSITIONAL: -repeat Hgb/Hct [**2115-10-30**], follow-up iron deficiency anemia at appt on [**2115-10-31**] -f/u with PCP [**Name Initial (PRE) **]/u with cardiology Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Family/Caregiver. 1. Atorvastatin 80 mg PO HS 2. Ciprofloxacin HCl 250 mg PO Q12H Duration: 3 Doses 3. Clopidogrel 75 mg PO DAILY 4. Furosemide 40 mg PO DAILY 5. Losartan Potassium 25 mg PO DAILY 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Pantoprazole 40 mg PO Q12H 8. Aspirin 81 mg PO DAILY 9. Docusate Sodium 100 mg PO BID Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO HS 3. Clopidogrel 75 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Furosemide 40 mg PO DAILY RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 6. Losartan Potassium 25 mg PO DAILY RX *losartan 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*6 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Pantoprazole 40 mg PO Q12H 9. Ferrous Sulfate 325 mg PO DAILY 10. Acetaminophen 650 mg PO Q6H:PRN pain, temp>38.0 11. Outpatient Lab Work [**2115-10-30**] Hgb/Hct - please fax results to [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) 32655**] NP (fax)[**Telephone/Fax (1) 32656**] Discharge Disposition: Home Discharge Diagnosis: 1.Aortic Stenosis - s/p Corevalve/TAVR 2.Hypertension 3.CAD S/P MI, 3 vessel CABG [**2088**] 4.Chronic Systolic CHF 5.Ischemic Cardiomyopathy S/P ICD placement [**2114-11-26**] Device: St. [**Hospital 923**] Medical Dual Chamber Fortify DR CD2231-40Q RA Lead: St. [**Hospital 923**] Medical Transvenous Tendril STS 2088TC/52 RV Lead: [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Transvenous Dual [**Last Name (un) **]/Pace-Send [**Last Name (un) **] IS-1 7121/65 6.History of Prostate cancer [**2096**] 7.Stroke [**2111**] 8. GI bleed - Duodenal AVM s/p Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr [**Known lastname 11309**], It has been a pleasure assisting in your care here at [**Hospital1 18**]. You were admitted for treatment of your severe aortic stenosis. You were not a candidate for conventional surgical aortic valve replacement. Therefore you received a Corevalve transcatheter aortic valve replacement. Your procedure went very well. You received 2 units of blood. You had no complications. You have progressed nicely and are now ready for discharge. When you are at home, it is important to WEIGH YOURSELF DAILY. Notify the doctor if you gain more than 3 lbs in 2 days, or 5 lbs in 5 days. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] M. Location: [**Hospital1 **] [**Location (un) **] PHYSICIANS NETWORK, Address: [**Location (un) 10773**], [**Hospital1 **],[**Numeric Identifier 40170**] Phone: [**Telephone/Fax (1) 40171**] Appt: Thursday, [**10-31**] at 10am Completed by:[**2115-10-29**]

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icd9cm

[ [ [] ] ]

[ "37.23", "88.56", "88.42", "35.05" ]

icd9pcs

[ [ [] ] ]

12789, 12795

9186, 9298

282, 298

13421, 13421

4126, 8670

14309, 14622

2998, 3216

12086, 12766

12816, 13400

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232, 244

9313, 11620

326, 1455

13436, 13548

2211, 2639

1477, 1531

2655, 2982

4,668

140,989

26093+57481

Discharge summary

report+addendum

Admission Date: [**2109-12-21**] Discharge Date: [**2110-1-9**] Date of Birth: [**2073-5-27**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 297**] Chief Complaint: Respiratory failure Major Surgical or Invasive Procedure: tracheostomy tube placement central line placement transesophageal echocardiogram History of Present Illness: 36M with history of obesity, OSA, and cocaine use who presented to OSH with difficulty breathing and is now transferred to MICU at [**Hospital1 18**] after intubation for hypercarbic hypoxic respiratory failure. . According to the patient's girlfriend, he has apparently had a problem with fluid retention (primarily noted as enlarging pannus and inner thighs) which has gotten worse over the past two weeks. He saw his PCP one week ago and was told to double his Lasix dose. Over the past week he was noted by his girlfriend to be sleepy and confused. She has also noticed that his breathing has seemed more difficult and louder over the past several days, though she denies frank wheezing. He was brought into the ED at [**Hospital6 33836**] in [**Location (un) 16843**]. There, he denied fevers, cough, N/V though reported wheezing at home and "congestion". He is also supposed to be using BIPAP, but has not been using it frequently. No prior hospitalizations for dyspnea. his family reports a 15-year history of drug problems and has recently been using cocaine. . At the OSH ED, he had BP 152/76 HR 104 RR 32 89-90% NRB. He was given BIPAP, Lasix 80mg IV, an inch of nitro paste, 125mg Solumedrol, Rocephin 2g IV, and Azithromycin 500mg IV. The patient could not tolerate BiPAP in the ED and had an ABG of 7.17/109/62. He was intubated with 40mg etomidate, 200mg succinylcholine and ativan. Post-intubation, ABG was 7.27/81/137. Tox screen was negative. He is transferred to [**Hospital1 18**] for further evaluation. Past Medical History: 1. Obesity 2. OSA 3. Substance abuse, cocaine/crack 4. HTN 5. "Heart problems" 6. Arthritis Social History: Patient lives with his girlfriend in [**Name (NI) 1157**]. He is a trucker, but is "off for the season". Has a 15-year history of drug use, including crack and cocaine. Has been in Rehab in the past, but signed himself out. He drinks approximately a six-pack and a nip or two in a night, previously drank more. No smoking. Family History: HTN in father. [**Name (NI) **] diabetes, obesity, CAD, CA. Physical Exam: Vitals: T 98.7 BP 137/59 HR 103 95% on AC 1.0 600x18 PEEP 10 Gen: morbidly obese man, intubated and sedated, minimally responsive to painful stimuli HEENT: pupils 2mm and reactive bilaterally, moist mucous membranes Neck: short and thick, supple, could not visualize JVP Lung: coarse breath sounds bilaterally with inspiratory and expiratory wheezes Chest: round crusted papules across chest Cor: tachycardic, regular rhythm, no m/r/g appreciated Abd: obese abdomen, large panus, soft non-distended, NABS Ext: no clubbing or cyanosis, trace edema present in bilateral LEs up to knees Neuro: sedated, responsive to painful stimuli Pertinent Results: Admission labs: [**2109-12-21**] 04:35PM GLUCOSE-155* UREA N-18 CREAT-0.8 SODIUM-139 POTASSIUM-4.6 CHLORIDE-95* TOTAL CO2-36* ANION GAP-13 [**2109-12-21**] 04:35PM ALT(SGPT)-41* AST(SGOT)-25 LD(LDH)-399* CK(CPK)-278* ALK PHOS-63 TOT BILI-0.4 [**2109-12-21**] 04:35PM CK-MB-5 cTropnT-<0.01 [**2109-12-21**] 04:35PM ALBUMIN-4.0 CALCIUM-8.6 PHOSPHATE-3.8 MAGNESIUM-1.9 [**2109-12-21**] 04:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2109-12-21**] 04:35PM NEUTS-78* BANDS-5 LYMPHS-9* MONOS-7 EOS-0 BASOS-1 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-2* [**2109-12-21**] 04:35PM WBC-7.6 RBC-4.31* HGB-11.5* HCT-37.2* MCV-86 MCH-26.6* MCHC-30.8* RDW-16.0* [**2109-12-21**] 04:35PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-1+ [**2109-12-21**] 04:35PM PLT COUNT-189 [**2109-12-21**] 04:35PM PT-13.8* PTT-28.8 INR(PT)-1.3 [**2109-12-21**] 04:00PM URINE HOURS-RANDOM TOTAL CO2-<5 [**2109-12-21**] 04:00PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-POS amphetmn-NEG mthdone-NEG . DISCHARGE LABS [**2110-1-8**]: CBC: 8.1 > 8.1/26.7 < 433 . CHEM 7: 142 / 103 / 15 -------------< 118 4.0 / 30 / 0.8 . Ca: 8.3 Mg: 2.3 P: 3.8 . PT: 14.6 PTT: 65.2 INR: 1.5 . Pertinent studies: BILATERAL LOWER EXTREMITY ULTRASOUND: Grayscale and Doppler ultrasound of the left and right common femoral, superficial femoral, and popliteal veins was performed. Although this study was limited due to patient body habitus, flow and appropriate Doppler waveforms, and compressibility, and augmentation was seen within all of these vessels. No intraluminal thrombus is identified. IMPRESSION: No evidence of right or left lower extremity DVT. . TEE: Conclusions: No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers, though saline contrast injection was suboptimal due to long transit time to the heart. There is mild regional left ventricular systolic dysfunction with mild hypokinesis of the septum. Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. Trivial mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: No intracardiac shunt. Mild septal hypokinesis. . VQ Scan: INTERPRETATION: Ventilation images were obtained with Tc-[**Age over 90 **]m aerosol in only 3 views, limited by the patient body habitus. Perfusion images were obtained in the same 3 views. There is mild heterogeneity demonstrated with matched perfusion and ventilation.The patient is noted to be intubated. IMPRESSION: Limited study. No obvious evidence for pulmonary embolism. . RUQ U/S: FINDINGS: Focused ultrasound of the gallbladder was performed. The gallbladder is filled with echogenic material consistent with sludge, similar to the prior study. There is no gallbladder wall edema. The gallbladder is not tensely distended. No pericholecystic fluid is identified. IMPRESSION: Sludge-filled gallbladder without evidence for cholecystitis. The overall appearance is similar to the prior study. Brief Hospital Course: # Hypercarbic hypoxic respiratory failure: Pt has a history of OSA and presented to the OSH with dyspnea, confusion and hypercarbia on ABG, which prompted his intubation, he was then transferred to [**Hospital1 18**] for futher care. Etiology of respiratory failure was most likely PE worsened by obesity hypoventilation and CHF. Patient had negative LENIs and an indeterminate VQ scan (unable to obtain CT scan due to size/weight), but given significant risk factors, high A:a gradient, persistent elevated oxygen requirements after 10 L diuresis, and marked improvement of oxygenation after anticoagulation, PE was ultimately felt to be the primary cause of his respiratory failure. He is currently in the process of uptitrating coumadin for goal INR of [**2-28**]. Given his high PEEP requirements, a prolonged wean was anticipated and the patient had a trach placed in the OR. He continues to receive Albuterol and Ipratropium MDIs PRN and has the head of the bed elevated as much as tolerated to relieve the weight on his lungs. He was weaned from IV sedation and currently has a fentanyl patch, lorazapam via dophoff, and Haldol 50 mg PO TID with PRNs for agitation - QT interval has been 0.22-0.35. He will continue on Lasix via dophoff for further diuresis. He continues to wean from the ventilator and is currently on PS of 15, PEEP of 14 and FiO2 of 50% with oxygen saturation 91-95%. . # Fevers: Early in his hospital course he completed a course of Zosyn for ventilator associated pneumonia and associated septic shock during his first week of hospitalization. During his second week of his hospitalization he developed approximately one week of fevers up to 103.7. Etiology of the fevers was unclear, during these fevers he had multiple sets of blood/urine/sputum cultures with no growth, BAL with NGTD, he had no localizing symptoms, normal TSH, RUQ U/S x 2 not consistent with acalculous cholecystitis, and he was unable to be further imaged due to his size. A sputum culture from [**1-4**] grew pansensitive acenitobacter which was felt to be colonization and he was not started on any new antibiotics as his fever had improved and he was clinically well when the culture results returned. Fevers may have been due to drug fever from reglan and erythromycin with delayed clearance leading to fevers 3 days after the medications were stopped. He was afebrile for 36 hours prior to discharge. **Cultures pending at discharge: c. dif toxin, BAL fluid culture from [**1-6**], blood cultures from [**1-4**] and [**1-5**], line tip cx from [**1-7**]** . # Elevated CPK: Patient's CPK was found to be elevated with a peak of [**Numeric Identifier 64749**] on [**12-29**], the levels were trended and decreased to 1189 on [**1-7**]. Etiology unclear, NMS was felt to be unlikely given no muscle rigidity associated with his fevers. Renal function was preserved. Would recommend follow up with PCP to recheck CPK in [**2-28**] weeks to ensure it has normalized. . # HTN: Patient's outpatient medications were held on admission. He was started on captopril 12.5 TID for BP control with good results. . # ARF: Patient's Cr was elevated on admission, recovered to baseline with hydration, then he developed ARF again in the setting of hypotension and septic shock. He has since returned to a his baseline of Cr 0.8 at discharge. . # FEN: Patient is currently on tube feeds via dophoff, promote with fiber at 100 cc/hr. Patient had brief hypernatremia which resolved with increase fluid boluses and switch to promote tube feeds. . # Anemia: Pt had a decrease from his initial hct of 36, attributed to frequent labs and blood cultures. It has since been stable in the range 26-28. Stools were guaiac negative. . # PPX: Heparin gtt for PE treatment and DVT prophylaxis. PPI. Bowel regimen - currently held given loose stools. . # Full code . # Access: L PICC placed on [**1-7**] Medications on Admission: Lasix 40mg [**Hospital1 **] Albuterol prn Clonidine 0.1mg Procardia 30mg daily Naproxen 500mg Paxil Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. 2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for yeast overgrowth. 5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 6. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 9. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 11. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 12. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 13. Insulin Lispro (Human) 100 unit/mL Solution Sig: as directed Subcutaneous ASDIR (AS DIRECTED): per insulin flowsheet. 14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 15. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): goal INR [**2-28**]. 16. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 17. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 18. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours): may titrate patch to off as needed for pain. 19. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed. 20. Haloperidol 10 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day): Please check QTc daily, [**Name8 (MD) 138**] MD if > 450 before administering. . 21. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed. 22. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 23. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: titrate Intravenous infusion: Titrate to PTT 60-80. [**Month (only) 116**] discontinue 1 day after INR range 2-3. 24. Haloperidol Lactate 5 mg/mL Solution Sig: 5-15 mg Injection Q4H (every 4 hours) as needed for agitation. 25. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 23973**] Discharge Diagnosis: Hypercarbic respiratory failure Hypoxic respiratory failure Cannot rule out chronic pulmonary emboli Alcohol dependence hypertension hypernatremia obstructive sleep apnea morbid obesity B12 deficiency ventilator associated pneumonia with pan-sensitive acinetobacter colonization septic shock hyperthermia, likley reglan reaction Discharge Condition: ventilated through trach tube with 15 of pressure support, 12 of PEEP, 50% FiO2. Afebrile. Oriented to himself and place. Non-verbal due to high PEEP. Discharge Instructions: Please discharge to rehab at [**Hospital6 23973**] in [**Hospital1 **]. Please wean from ventilator per protocol. If the patient has fevers, chills, chest pain, uncontrolled fevers, shortness of breath, or other concerns, please return to the ED or call your PCP. Followup Instructions: With your PCP, [**First Name4 (NamePattern1) 717**] [**Last Name (NamePattern1) 11679**], phone [**Telephone/Fax (1) 64750**], fax [**Telephone/Fax (1) 64751**], in [**1-27**] weeks after discharge from rehab. Please follow up with the [**Hospital1 18**] pulmonary clinic 2-3 weeks after discharge from rehab. Call ([**Telephone/Fax (1) 513**] for an appointment. Completed by:[**2110-1-8**] Name: [**Known lastname 7867**],[**Known firstname 11432**] Unit No: [**Numeric Identifier 11433**] Admission Date: [**2109-12-21**] Discharge Date: [**2110-1-9**] Date of Birth: [**2073-5-27**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1225**] Addendum: Addendum to hospital course: Patient's ventilator was further weaned to PS 15, PEEP of 10, and FiO2 40%. . His coumadin was increased to 7.5 mg Qhs and will need to have his INR followed until therapeutic in range 2-3. . Patient's haldol was decreased to 25 mg PO TID. . C. dif toxin was negative. . Patient was given pneumovax and flu vaccine prior to discharge. Discharge Disposition: Extended Care Facility: [**Hospital6 6436**] [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 1226**] MD [**Last Name (un) 1227**] Completed by:[**2110-1-9**]

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icd9cm

[ [ [] ] ]

[ "89.38", "88.72", "89.64", "33.24", "96.6", "31.1", "38.93" ]

icd9pcs

[ [ [] ] ]

15050, 15257

6494, 8934

334, 418

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275, 296

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2113, 2442

26,281

110,579

7406

Discharge summary

report

Admission Date: [**2159-7-5**] Discharge Date: [**2159-7-29**] Date of Birth: [**2091-9-16**] Sex: F Service: HISTORY OF PRESENT ILLNESS: This is a 67-year-old female with a history of coronary artery disease (status post coronary artery bypass graft), also with a history of congestive heart failure, type 1 diabetes, hypothyroidism, and hypertension, who initially presented to the [**Hospital3 **] clearance because of a C2 fracture back in [**2158-12-23**]; status post a mechanical fall. She was cleared for surgery and switched from Coumadin to heparin at the time but requested to go home and have her surgery electively scheduled for [**2159-7-13**]. had a transoral resection of her odontoid and associated second soft tissues. She received 2 units of packed red blood cells and was extubated and given high-dose narcotics for pain management. On [**7-16**], she had a hypercarbic respiratory failure with an arterial blood gas demonstrating 7.02/99/134. She then had two episodes of bradycardia secondary to vagal stimuli, and a pulseless electrical activity/asystole arrest. She was brought back from both codes, and Electrophysiology was consulted. Electrophysiology placed a pacer wire (temporary). She was also maintained on broad spectrum antibiotics for lower extremity cellulitis. On [**7-24**], she was transferred from the Surgery Service to the Medical Intensive Care Unit for further management of renal failure as well as difficulty to wean. Her Medical Intensive Care Unit course was complicated by worsening mental status and ongoing acute renal failure. Her mental status was questionably attributed to narcosis versus uremia, and her narcotics were held at this time. On [**7-27**], a CT scan of her head was obtained for just ongoing mental status changes. A massive cerebral hemorrhage was noted at the time obstructing the fourth ventricle. Neurosurgery was consulted and a ventriculostomy drain was placed at the bedside. However, the patient remained in neurogenic shock and continued to demonstrate unresponsiveness by all objective clinical measures. She remained pressor-dependent to keep her mean arterial pressure greater than 70. Her code status was changed to do not resuscitate/do not intubate on [**2159-7-29**]. She remained in neurogenic shock. Her apnea test was positive for corneal reflexes and pupillary reflexes were absent. At 3:45 p.m., on [**7-29**], the patient was found to be unresponsiveness following a cardiac arrest. She expired at this time. The family denied postmortem examinations. [**First Name8 (NamePattern2) 900**] [**Last Name (NamePattern1) **], MD [**MD Number(1) 1908**] Dictated By:[**Name8 (MD) 17844**] MEDQUIST36 D: [**2159-11-13**] 14:55 T: [**2159-11-15**] 20:17 JOB#: [**Job Number 18711**]

[ "426.0", "806.00", "E888.9", "518.81", "357.2", "428.0", "707.0", "427.5", "250.61" ]

icd9cm

[ [ [] ] ]

[ "81.01", "39.64", "31.1", "77.99", "99.15", "96.04", "96.72", "03.09", "96.6" ]

icd9pcs

[ [ [] ] ]

154, 2842

79,422

185,645

40052

Discharge summary

report

Admission Date: [**2111-1-4**] Discharge Date: [**2111-1-20**] Date of Birth: [**2075-1-8**] Sex: M Service: NEUROLOGY Allergies: Tramadol Attending:[**First Name3 (LF) 2569**] Chief Complaint: found down with right upper extremity shaking Major Surgical or Invasive Procedure: PEG tube placement [**2111-1-18**]. History of Present Illness: The pt is a 35 year-old man with minimal PMH. He was transferred to [**Hospital1 18**] ED, intubated, from an OSH. We were consulted for seizure. By report, he had a trip-and-fall on his head yesterday (Sat [**1-3**]), with no LOC and no known sequelae. He was reportedly normal that evening and this morning ([**1-4**]), and went out with a friend. On returning home in the afternoon he told the friend he felt weak and sat down. When he did not get up hours later, EMS was called and they took him to the [**Location (un) 47**] ED where he was noted to have right-sided arm/leg weakness and expressive aphasia. According to their notes, he was able to give appropriate y/n head-nod/shake responses to questions and follow commands. He denied any h/o stroke, seizure or illicit substance abuse (he was MJ/THC+ on their Utox screen, however). He was taking Nexium for GERD and Xanax tid for mood Sx (I confirmed these Rx with [**Company 4916**], his pharmacy, and with his HCP/Aunt). Then, he was noted to exhibit myoclonic jerks of his right arm and leg. A Neurology assessment there was partial-complex seizure. He was given a total of 12mg LZP and loaded with 1gm PHT to stop the shaking/jerking, and consequently intubated with succ+etomidate for airway protection. He was bolused 200 of propofol, self-extubated, given 2mg/h LZP gtt, 50mcg/h propofol gtt, Phenobarbital 65mg IV, and then after re-intubation, was given 4mg more of LZP on transport-EMS on the way here due to Right-sided shaking. He arrived intubated and sedated on a propofol gtt at 50. He was again re-intubated on arrival (balloon above the vocal cords on arrival). He exhibited shaking of his right arm, and a MDZ gtt was started in the ED. A NCHCT here revealed a left-insular/opercular/subcortical hypodense region (completed infarct), and CTA revealed a left ICA large occlusion (just proximal to bifurcation) and decreased # of distal MCA branches on the Left. He has no known risk factors. I spoke on the phone with his HCP/aunt [**Name (NI) **] [**Telephone/Fax (1) 88058**]. [**Name2 (NI) **] was apparently in an OSH ED 5d PTA with cold Sx, normal CXR, negative flu swab, sent home. Past Medical History: -Mood/"depression" per OSH notes. On BDZ -GERD. On omeprazole. -PE in [**2105-11-12**] PT 20210G mutation NEG ([**2107**]) AT 3 activity 124 (NML) Protein S 131 cardiolipin <6 Factor V Leiden 3.4 Protein C 92 ALL NORMAL off coumadin (1 month) [**2107**] - drug seeking behavior had stopped coumadin Cardiomyopathy - Cardiologist ([**Doctor Last Name 6254**] [**Telephone/Fax (1) 6256**]) last seen - [**2108**] ([**Month (only) 958**]) Nonischemic CMY ED [**2-19**] - chest pain Pheochromocytoma [**2106-11-12**] - resected @[**Hospital1 2025**] was having stomach pains Social History: h/o learning disability (per aunt/HCP), which is why he has a HCP [**Doctor First Name **] [**Telephone/Fax (1) 88058**]). Special Ed, education through 8th grade. Cannot read or write well per aunt (small words only). Family History: unknown Physical Exam: ADMISSION EXAM VSS in ED (see ED record in chart), afebrile, normotensive (SBP 130s), HR 80s, RR 14 SaO2 100% (intubated, on vent/suppl O2) <<Exam was greatly limited by sedation not stopped [**1-14**] c/f sz.>> General: Sedated, intubated. HEENT: Intubated. Blood in ETT suction catheter after 3x intubations. Normocephalic. Mild bruise on Lt forehead. No scleral icterus. Mucous membranes are moist. Neck: Supple, with full range of motion and no nuchal rigidity. No carotid bruits appreciated, including specifically no bruit over Left ICA (clot location seen on CTA). No lymphadenopathy was appreciated. Pulmonary: Lungs CTA bilaterally. Non-labored breathing with vent. Cardiac: RRR, normal S1/S2, no M/R/G. Abdomen: Mildly obese. Soft, non-tender, and non-distended, + moderate bowel sounds. No masses or organomegaly were appreciated. Extremities: Warm and well-perfused, no clubbing, cyanosis, or edema. 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. DISCHARGE EXAM Eyes open, making eye contact, shakes head yes and no but not appropriately to simple questions, and does not follow axial or appendicular commands reliably or specifically. Moves left side spontaneously with apparent full strength. Not moving right side, but it withdraws purposefully to noxious stimuli. Pertinent Results: [**2111-1-4**] 08:50PM BLOOD WBC-11.6* RBC-4.38* Hgb-13.0* Hct-38.0* MCV-87 MCH-29.8 MCHC-34.3 RDW-13.5 Plt Ct-285 [**2111-1-5**] 05:58AM BLOOD Neuts-67.4 Lymphs-24.3 Monos-7.5 Eos-0.5 Baso-0.3 [**2111-1-4**] 08:50PM BLOOD PT-13.2 PTT-24.2 INR(PT)-1.1 [**2111-1-8**] 03:57AM BLOOD Thrombn-43.6* [**2111-1-4**] 08:50PM BLOOD Fibrino-238 [**2111-1-8**] 03:57AM BLOOD ACA IgG-2.6 ACA IgM-4.6 [**2111-1-8**] 03:57AM BLOOD ProtCFn-101 ProtSFn-81 [**2111-1-5**] 05:58AM BLOOD Glucose-99 UreaN-8 Creat-0.7 Na-139 K-4.0 Cl-108 HCO3-23 AnGap-12 [**2111-1-5**] 05:58AM BLOOD ALT-53* AST-28 CK(CPK)-204 AlkPhos-50 TotBili-0.3 [**2111-1-14**] 06:43PM BLOOD Cholest-288* [**2111-1-5**] 05:58AM BLOOD %HbA1c-6.2* eAG-131* [**2111-1-14**] 06:43PM BLOOD Triglyc-158* HDL-27 CHOL/HD-10.7 LDLcalc-229* [**2111-1-5**] 05:58AM BLOOD TSH-0.74 [**2111-1-4**] 08:50PM URINE bnzodzp-NEG barbitr-POS opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG marijua-PRESUMPTIV MICRO: SPUTUM CX: STAPH AUREUS COAG +, PAN-SENSITIVE BLOOD CX NGTD EKG: Sinus rhythm. Left axis deviation may be due to left anterior fascicular block. RSR' pattern with early precordial QRS transition is non-specific. Consider posterolateral myocardial infarction of indeterminate age, although is non-diagnostic. ST-T wave abnormalities are non-specific but cannot exclude myocardial ischemia. Clinical correlation is suggested. No previous tracing available for comparison. IMAGING: CTA HEAD AND NECK 1. Nonocclusive filling defect within the proximal left internal carotid artery, with occlusion of the distal left M1 segment and opercular and insular branches with a nonhemorrhagic infarct in the left MCA distribution. The atherosclerotic disease elsewhere is most compatible with a dissection of the proximal cervial [**Doctor First Name 3098**] with embolization to the left MCA. MRI BRAIN Acute infarct of the left MCA territory, likely secondary to dissection as proposed in the prior CTA - post-traumatic versus collagen vascular disease etiologies are diagnostic considerations. 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. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. EEG [**1-6**] This 16-hour recording showed only severe diffuse encephalopathic changes with loss of background and irregular high voltage delta with a little preservation of fast rhythms centrally in the right. This could be anoxic, ischemic, or possibly secondary to medication. No seizure activity or paroxysmal epileptic interictal discharges identified. EEG [**1-7**] This EEG shows an evolving encephalopathy going from an extremely severe marked attenuation of all activity which may have reflected drug effect to a still severe encephalopathy with diffuse delta activity and suppression of rhythms posteriorly but there were no ictal or interictal discharges identified. EEG [**1-8**] This EEG gives evidence for a severe diffuse encephalopathy that improved minimally during the course of the 24 hours. Over the course of 24 hours, however, activity over the left frontal central regions appeared to be more prominent and suggests lateralized difficulty superimposed upon the severe encephalopathy. No clear sustained epileptic activity was identified although an isolated left temporal discharge was seen. EEG [**1-9**] This EEG continues to show a severe diffuse encephalopathy that, as the record continued to the end, appeared to be slightly more abnormal broadly across the left hemisphere. Note is there is very poorly developed background rhythm in both hemispheres. No epileptic activity was identified. Brief Hospital Course: Left Middle Cerebral Artery Stroke The patient was admitted after being found down in a hallway with jerking movements of his right arm and an inability to understand commands. He was initially taken to [**Hospital **] hospital where he was given Ativan, Dilantin and Phenobarb which failed to stop the seizures. He was then transferred to [**Hospital1 18**] for further care. On arrival he was given Keppra, started on Versed and propofol drips which aborted the seizure. On imaging he was found to have a large thrombus v. dissection in his left common carotid artery, and MRI imaging revealed ischemia of most of the left MCA territiory. After careful review of his outside records it was discovered that he had a pulmonary embolism in [**2104**] and had been treated with coumadin until [**2107**]. In a cardiology note it was documented that he was lupus anticoagulant positive. It was unclear why he was taken off anticoagulation. His exam on discharge was notable for being alert, and attentive, globally aphasic and having a right hemiparesis. He was restarted on coumadin in hospital and on Lovenox 100 mg SubQ [**Hospital1 **] as bridge therapy until INR is between 2 and 3. Methicillin sensitive pneumonia The patient developed a culture positive (S. Aureus) pneumonia and was intially treated with vancomycin and zosyn which were switched when sensitivites returned. Antibiotics were started on [**2111-1-8**] and he should receive a 14-day course (end date [**2111-1-22**]). Seizures The patient was loaded with Keppra, Dilantin, Phenobarb as well as Versed and Propofol to stop his focal right arm seizures. EEG monitoring was performed which showed no epileptiform discharges. His medications were reduced to Keppra 1000 mg [**Hospital1 **] by time of discharge. no EPC noted on discharge form [**Hospital1 18**] Nutrition Patient was unable to tolerate PO intake and speech and swallow evaluation was performed twice. He received tube feeds, but required PEG tube placement on [**2111-1-18**]. The procedure was uncomplicated and the patient was given dilaudid for pain. Anticoagulation The patient was on a heparin drip after being admitted and was continued until after his PEG tube was placed. He was then started on coumadin with a goal INR of 2.0 - 3.0 with Lovenox as a bridge until this goal is reached. Medications on Admission: Xanax ?mg tid Nexium ?mg daily Discharge Medications: 1. docusate sodium 50 mg/5 mL Liquid Sig: [**12-14**] PO BID (2 times a day). 2. acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours) as needed for fever or pain. 3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 5. pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours) as needed for GERD. 6. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush: heparin flush 2ml IV PRN line flush PICC. Flush 10ml normal saline followed by heparin PRN per lumen use. 7. levetiracetam 500 mg/5 mL Solution Sig: Two (2) Intravenous [**Hospital1 **] (2 times a day). 8. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1) Intravenous Q6H (every 6 hours) for 3 days. 9. insulin lispro 100 unit/mL Solution Sig: per protocol Subcutaneous ASDIR (AS DIRECTED). 10. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. enoxaparin 100 mg/mL Syringe Sig: One (1) mg Subcutaneous Q12 HRS (): 90mg SC Q12hrs until INR goal of [**1-15**]. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at [**Hospital6 1109**] - [**Location (un) 1110**] Discharge Diagnosis: New - Left MCA stroke - Epilepsia partialis continua OLD - Lupus anticogulant positive - HLD Discharge Condition: Level of Consciousness: Alert and interactive. Mental Status: Confused - always. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted for a stroke and seizure. You had a stroke involving the left side of your brain and that led to language deficits. Because of this we have started you on coumadin to prevent future strokes. You were also placed on Keppra for seizure control. You had a PEG tube placed to ensure that you get adequate feedings. Followup Instructions: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. [**Location (un) **] of [**Hospital Ward Name **] center [**Hospital1 18**]. [**3-23**] at 2pm Call [**Telephone/Fax (1) 10676**] to ensure paperwork is in place 3 weeks prior to appointment. Please call ([**Telephone/Fax (1) 7394**] one week prior to appointment to ensure place and time. [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**] Completed by:[**2111-1-20**]

[ "289.81", "V12.51", "342.90", "781.94", "434.01", "263.9", "345.70", "482.41", "784.3", "530.81", "787.20" ]

icd9cm

[ [ [] ] ]

[ "96.72", "96.71", "38.97", "43.11", "96.04", "96.6" ]

icd9pcs

[ [ [] ] ]

12561, 12706

8975, 11308

314, 352

12844, 12891

4750, 8952

13372, 13874

3402, 3411

11390, 12538

12727, 12823

11334, 11367

13019, 13349

3426, 4731

229, 276

380, 2551

12906, 12995

2573, 3149

3165, 3386

9,402

175,168

2661

Discharge summary

report

Admission Date: [**2156-7-3**] Discharge Date: [**2156-7-8**] Date of Birth: [**2084-3-11**] Sex: F Service: MEDICINE Allergies: Aspirin / Aleve / Codeine / Depakote Attending:[**First Name3 (LF) 8104**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 13224**] is a 72F with a PMH s/f ESRD, chronic right sided HF, congestive hepatopathy, persistent hypoglycemia, and afib/flutter on digoxin who was found unresponsive at her NH for up to one hour. EMS was called, and the patient was found to be bradycardic to 30s, with a blood pressure of 80/palp. Per the patient's family, she had no new fevers, mental status changes, and had her usual chronic cough. In the emergency department the patients vitals were:97.6, 80/palp, 46, 40, 92% on 4LNC. She was intubated, and a right femoral line was placed. Her EKG showed a junctional bradycardia at 48, which was thought to be consistent with digoxin toxicity. A level was drawn, and the patient was administered 4 vials of digibind. She was noted to have a hematocrit of 21 (her baseline is 27-30), and a lactate of 8. She was started on levophed and given 750mg levofloxacin, 2g of cefepime, 1g of vancomycin, and 500mg of flagyl IV for presumed sepsis of unknown etilogy. Her blood sugars were in the 20s, for which the patient recieved two amps of D50. Past Medical History: 1. Chronic Gastric Angiodysplasia (GAVE) 2. DM type II: c/b nephropathy and neuropathy - currently not on diabetic meds secondary to persistent hypoglycemia 3. ESRD: HD MWF has fistula L arm 4. CAD 5. CHF: R-sided, diastolic EF 50-55% with 4+ TR 2+ MR [**8-/2155**] TTE 6. Anemia: multifactorial (ESRD + iron deficiency [**12-27**] GIB) 7. Gout 8. Chronic pleural effusions s/p thoracentesis [**8-/2153**] negative cytology, 9. H/O C. diff colitis 10. Atrial fib/flutter: currently undergoing amiodarone load, also on digoxin 11. Congestive Hepatopathy 12. Persistent hypoglycemia 13. Seizure disorder Social History: Pt lives at [**Location **]. No ETOH, tobacco, or drugs. Four children involved in her care. Family History: [**Name (NI) 1094**] son and daughter have DM. Her son also has HTN. Her mother had an MI in her 80s. Physical Exam: T=95.5 rectally... BP=112/60s... HR=90s... RR=23 GENERAL: Intubated, sedated HEENT: NCAT, Pupils minimally reactive bilaterally, +scleral icterus. Dry mucous membranes. No JVD appreciated. CARDIAC: Irregularly irregular rhythm, normal rate, no murmurs LUNGS: Coarse ventilated breath sounds, diminished at the left base ABDOMEN: Distended with an umbilical hernia. +BS, No HSM. EXTREMITIES: Cachectic extremities, non-palpable pulsed on BL LE's, 2+ pulses in radial arteries. Brief Hospital Course: Ms [**Known lastname 13224**] is a 72F with a PMH s/f ESRD, congestive hepatopathy, and afib/aflutter on digoxin who was found unresponsive at her NH. Admitted to the ICU on pressors and broad spectrum abx for presumed sepsis and dig toxicity (given digibind in ED), pt. was difficult to wean off pressors, given significant co-morbidities, a decision was made to focus on comfort. - continued morphine prn for pain/discomfort - sarna lotion for pruritis. Pt on [**Hospital1 **] Medicine service for one day, expired on [**2156-7-8**]. Medications on Admission: Digoxin 125 mcg QOD Amiodarone 400mg daily until [**7-10**], then 200mg daily Levetiracetam 250 mg [**Hospital1 **] Dextrose 600mg TID Actonel 35mg weekly Advair [**Hospital1 **] Albuterol prn ASA 81mg daily Combivent 18/103, two puffs q8H Fluoxetine 20mg daily Lasix 20mg daily Metoprolol tartrate 12.5mg [**Hospital1 **] Olanzapine 2.5mg daily Tylenol, sarna, miconazole powder prn Discharge Medications: - Discharge Disposition: Expired Discharge Diagnosis: Cardiopulmonary arrest secondary to end stage heart, kidney and liver failure Discharge Condition: deceased Discharge Instructions: - Followup Instructions: - Completed by:[**2156-7-8**]

[ "427.89", "410.41", "250.60", "280.0", "038.9", "427.32", "362.01", "572.8", "537.83", "428.32", "995.94", "427.31", "250.80", "518.81", "345.90", "357.2", "276.52", "250.50", "428.0", "E942.1", "585.6", "274.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

3794, 3803

2795, 3334

307, 313

3924, 3934

3984, 4015

2174, 2277

3768, 3771

3824, 3903

3360, 3745

3958, 3961

2292, 2772

256, 269

341, 1421

1443, 2047

2063, 2158

77,864

196,283

36386

Discharge summary

report

Admission Date: [**2198-6-30**] Discharge Date: [**2198-7-1**] Date of Birth: [**2118-3-1**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1271**] Chief Complaint: C1 burst fracture, odontois fracture with 9mm displacment of the superior fragment, spinal cord injury Major Surgical or Invasive Procedure: none History of Present Illness: 80 y/o male with PMH hypertension, went outside this am (witnessed by wife leaving house) to pick flowers. He clutched his chest and fell over railing into the garden. He was unresponsive, EMS was called and found to be in a PEA. He was given epinephrine and regained a pulse. He went to [**Hospital3 82437**] who scanned his neck and found C1/C2 burst fracture. Past Medical History: HTN, CAD Social History: Married lives in [**Hospital1 189**] area Family History: unknown Physical Exam: : T:96.5 BP:148/77 HR: 83 R 14 O2Sats 95% Gen: Intubated on Dopamine drip HEENT: Pupils: 2.5 min reactive Neck: In collar Extrem: Warm and well-perfused. Neuro: Eyes open, no commands, no corneal, no gag, no cough No heart rate fluctuation with pain No breathing over the vent Only response to pain in triple flexion in left lower extremity Toes mute Reflexes: unable to obtained Pertinent Results: [**2198-6-30**] 11:45PM TYPE-ART PO2-156* PCO2-32* PH-7.44 TOTAL CO2-22 BASE XS-0 [**2198-6-30**] 11:45PM LACTATE-1.6 [**2198-6-30**] 11:45PM freeCa-1.15 [**2198-6-30**] 11:24PM GLUCOSE-168* UREA N-23* CREAT-0.9 SODIUM-139 POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-21* ANION GAP-16 [**2198-6-30**] 11:24PM CK(CPK)-219* [**2198-6-30**] 11:24PM CK-MB-12* MB INDX-5.5 cTropnT-0.07* [**2198-6-30**] 11:24PM CALCIUM-9.0 PHOSPHATE-1.6* MAGNESIUM-1.4* [**2198-6-30**] 11:24PM WBC-16.4* RBC-4.10* HGB-12.5* HCT-35.6* MCV-87 MCH-30.4 MCHC-35.0 RDW-13.4 [**2198-6-30**] 11:24PM PLT COUNT-303 [**2198-6-30**] 11:24PM PT-13.6* PTT-29.7 INR(PT)-1.2* [**2198-6-30**] 09:07PM TYPE-ART PO2-410* PCO2-31* PH-7.45 TOTAL CO2-22 BASE XS-0 [**2198-6-30**] 09:07PM LACTATE-1.5 [**2198-6-30**] 09:07PM freeCa-1.10* [**2198-6-30**] 06:05PM GLUCOSE-205* UREA N-22* CREAT-1.0 SODIUM-137 POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-22 ANION GAP-16 [**2198-6-30**] 06:05PM ALT(SGPT)-66* AST(SGOT)-76* LD(LDH)-263* CK(CPK)-268* ALK PHOS-64 TOT BILI-0.7 [**2198-6-30**] 06:05PM CK-MB-12* MB INDX-4.5 cTropnT-0.09* [**2198-6-30**] 06:05PM ALBUMIN-4.3 CALCIUM-9.1 PHOSPHATE-1.6* MAGNESIUM-1.4* [**2198-6-30**] 06:05PM WBC-17.5* RBC-4.38* HGB-13.4* HCT-38.5* MCV-88 MCH-30.7 MCHC-34.9 RDW-13.3 [**2198-6-30**] 06:05PM PLT COUNT-280 [**2198-6-30**] 06:05PM PT-13.4 PTT-27.3 INR(PT)-1.1 [**2198-6-30**] 03:01PM TYPE-ART TIDAL VOL-500 PEEP-5 O2-100 PO2-349* PCO2-47* PH-7.32* TOTAL CO2-25 BASE XS--2 AADO2-317 REQ O2-58 INTUBATED-INTUBATED [**2198-6-30**] 02:07PM COMMENTS-GREEN TOP [**2198-6-30**] 02:07PM GLUCOSE-177* LACTATE-1.5 NA+-138 K+-4.1 CL--104 TCO2-23 [**2198-6-30**] 02:00PM UREA N-22* CREAT-1.0 [**2198-6-30**] 02:00PM estGFR-Using this [**2198-6-30**] 02:00PM CK(CPK)-229* [**2198-6-30**] 02:00PM LIPASE-40 [**2198-6-30**] 02:00PM LIPASE-40 [**2198-6-30**] 02:00PM cTropnT-0.08* [**2198-6-30**] 02:00PM CK-MB-9 [**2198-6-30**] 02:00PM WBC-18.7* RBC-4.61 HGB-13.8* HCT-40.8 MCV-89 MCH-30.0 MCHC-33.9 RDW-13.6 [**2198-6-30**] 02:00PM PLT COUNT-298 [**2198-6-30**] 02:00PM PT-13.1 PTT-26.7 INR(PT)-1.1 [**2198-6-30**] 02:00PM FIBRINOGE-356 Radiology Report MR CERVICAL SPINE W/O CONTRAST Study Date of [**2198-6-30**] 8:50 PM [**2198-6-30**] 8:50 PM MR CERVICAL SPINE W/O CONTRAST Clip # [**Clip Number (Radiology) 82438**] Reason: r/o spinal cord injury PRELIMINARY REPORT EU CRITICAL [**Doctor Last Name **] MR [**Name13 (STitle) **] # IMAGES:224 A known fracture of C2 is identified. There is tilting of the cranial portion of the fracture fragment, namely the dens, posteriorly. This indents the cord. There is cervical cord edema from the craniocervical junction to approximately the C3 level. There is a 5-mm focus of abnormal signal within the cervical cord at the C2 level, most likely representing a cord hemorrhage. Radiology Report MR HEAD W/O CONTRAST Study Date of [**2198-6-30**] 8:50 PM Reason: rule out anoxic brain injury. Found to be PEA in the field. Preliminary Report !! WET READ !! PRELIMINARY REPORT EU CRITICAL [**Doctor Last Name **] MRI BRAIN (C-) # IMAGES:199 No acute abnormality. No acute hemorrhage. No acute infarct. No shift Radiology Report CT CHEST W/CONTRAST Study Date of [**2198-6-30**] 2:09 PM [**Last Name (LF) **],[**First Name3 (LF) 7722**] EU [**2198-6-30**] 2:09 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST CT CHEST: There are bilateral posterior consolidations in both the right and left lungs, upper and lower lobes. This most likely represents contusion, although aspiration is also a consideration. There is no effusion. There is no pneumothorax. There is no hemothorax. Within the limits of respiratory motion, there are no lung nodules or masses identified. The heart is displaced to the left by a large pectus excavatum. There is no pericardial effusion. The aorta and great vessels are normal in caliber, contour, and configuration, with no evidence for acute aortic injury. There is atherosclerotic calcification of the aortic arch. Pulmonary artery is normal in caliber. There is no large central pulmonary embolus. The trachea and central airways are patent to the subsegmental level, with no endobronchial lesions identified. Endotracheal tube terminates above the carina. NG tube coursing through the mediastinum below the diaphragm. There is no mediastinal hematoma. There is no pathologic mediastinal or hilar adenopathy. The thyroid enhances normally. CT ABDOMEN: There is no free fluid or hemoperitoneum. There is no free air. The liver is homogeneous with no focal lesions identified. The spleen, pancreas, and adrenal glands are normal in appearance. There is bilateral nonspecific perinephric stranding. Within both kidneys, there are rounded low-attenuation lesions, most compatible with renal cysts. Kidneys demonstrate symmetric parenchymal enhancement and contrast excretion. There is no hydronephrosis. Left renal artery is relatively diminutive. The stomach, duodenum, and intra-abdominal loops of small and large bowel are unremarkable. There is a surgical suture line identified in the ileocecal region at the right lower quadrant. There is no mesenteric fluid. There is no bowel wall thickening. There is no bowel distension. There is atherosclerotic disease of the abdominal aorta, with ectatic dilatation of the infrarenal section just proximal to the bifurcation, with maximal dimension of 2.3 cm. The major mesenteric vessels appear patent at their origins. There is no pathologic retroperitoneal or mesenteric adenopathy. CT PELVIS: Urine opacifies the bladder. There is no extraluminal contrast identified. There is a Foley in the bladder, as well as a small focus of air in the dome, consistent with Foley placement. The rectum and sigmoid colon are unremarkable. There are scattered diverticula but no evidence for diverticulitis. There is no pelvic fluid. There is no pelvic adenopathy. Prostate is unremarkable. Postsurgical changes from bilateral inguinal herniorrhaphy are identified. BONE WINDOWS: There are no fractures. Degenerative changes are noted in the thoracolumbar spine with mild grade 1 anterolisthesis of L4 on L5, which is likely degenerative. There are no suspicious lytic or sclerotic osseous lesions. Marked left-convex focal scoliosis of the thoracic spine noted, with apex at T3-4. Changes at the shoulders suggest chronic rotator cuff disease. IMPRESSION: 1. Bilateral posterior consolidations in the right and left upper and lower lobes, most consistent with contusion, although aspiration is also in the differential. 2. No hemothorax, pneumothorax, or effusions. 3. Pronounced pectus excavatum causing displacement of the mediastinal structures to the left. 4. No solid abdominal organ injury. No free air or hemoperitoneum. 5. Bilateral nonspecific perinephric stranding. 6. Post-surgical changes from bilateral hernia repairs, as well as a suture line identified in the small bowel in the right lower quadrant. 7. Degenerative changes in the lumbar spine, with grade 1 anterolisthesis of L4 on L5, which is likely degenerative. Brief Hospital Course: 80 y/o male with PMH hypertension, went outside this am (witnessed by wife leaving house) to pick flowers. He clutched his chest and fell over railing into the garden. He was unresponsive, EMS was called and found to be in a PEA. He was given epinephrine and regained a pulse. He went to [**Hospital3 82437**] who scanned his neck and found C1/C2 burst fracture. On [**2198-6-30**], he was admitted to the trauma sicu. The patient was intubated prior to admission, right femoral central venous line and R radial a-line placed in the tsicu. discussion with family severity of injury based on CT scans and exam. MRI brain/cspine performed, pt is currently FULL CODE. On [**7-1**] pt heart rate went to 20 and pt was chemically recesitated. formal discussion with wife and son regarding patients prognosis and quadriplegia. pt was made CMO and expired 1416 Medications on Admission: Diovan 320mg QD, Lipitor 10mg QD, HCTZ 12.5mg, Prilosec 20mg [**Last Name (LF) 244**], [**First Name3 (LF) **] 81mg, Tylenol, MVI Discharge Medications: none- pt expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: none Followup Instructions: none [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2198-7-1**]

[ "414.01", "401.9", "754.81", "518.81", "952.03", "348.1", "336.1", "E882", "806.00" ]

icd9cm

[ [ [] ] ]

[ "38.91", "38.93" ]

icd9pcs

[ [ [] ] ]

9581, 9590

8500, 9359

420, 426

9641, 9650

1360, 8477

9703, 9832

926, 935

9540, 9558

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951, 1341

278, 382

454, 818

840, 851

867, 910

9,096

110,302

4365

Discharge summary

report

Admission Date: [**2160-1-28**] Discharge Date: [**2160-2-2**] Date of Birth: [**2104-7-14**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 949**] Chief Complaint: fever, hypotension Major Surgical or Invasive Procedure: Paracentesis x3 (Two diagnostic, one theraputic with removal of 6L) History of Present Illness: Mr. [**Known lastname 18823**] is a 55 year old man with PMH of alcoholic cirrhosis who presented to ED on [**2160-1-28**] with fever to 102, hypotension and cough x one month. According to patient and his wife he has theraputic paracentesis every two weeks and for the last 2 times he has had hypotension following paracentesis. Most recent paracentesis was [**2160-1-22**], 6 L was removed (2L less than usual given recent hypotension, in addition he has been holding his diuretics). In addition, 2 days PTA he noted erythema and pain of his left leg and on the day PTA he developed fevers 100-101. He also reported cough which has been present for one month, completed one week course of levofloxacin about two weeks prior to admission. . On admission he went to MICU [**1-5**] SBP in 80's, T101.7 elevated lactate to 3.6 which came down with IVF to 1.9. He had a right IJ placed, was ruled out for SBP with a diagnostic paracentesis, and blood and urine cultures remained negative; his diuretics were held. He was started on vancomycin and levofloxacin out of concern for a possible RLL pneumonia that the MICU team interpreted on CXR, however no infiltrate was read on CXR. His hematocrit trended down during admission, and he was transfused 6 units pRBCs [**1-5**] poor response to transfusion and 1 unit FFP. Due to failure of his HCT to bump appropriately with transfusion and as his ascites fluid was blood tinged he had a abdominal CT scan which showed no hemorrhagic component of his ascites to account for his blood loss. He has been persistently Guaiac positive, but per pt report this is baseline due to gastropathy. With IV fluid resuscitation and holding of his diuretics, his blood pressure improved and he has been net positive 3.4 liters since admission. Past Medical History: # Alcoholic cirrhosis # Grade 2 esophageal varices # Hepatic sarcoidosis # Asymptomatic cholelithiasis # Anemia, recent baseline around 25 # Alcohol abuse # Gout # History of Henoch-Schonlein purpura # Hypertension # Colon adenoma - 6mm adenomatous polyp by biopsy [**3-8**] # Bilateral herniorrhaphies Social History: No smoking. Prior alcoholic. No Etoh since [**Month (only) **]. No drug use. Lives w/ wife but is not working. Performs all ADLs but does not drive. He is married with a good social support system. He has two children living in [**State **]. Family History: Father, brother with alcoholism. Father with alcoholic cirrhosis and multiple bypass surgeries, unknown age. Mother with kidney disease. Physical Exam: VS: Temp: 98.3 BP: 96/59 HR: 83 RR: 18 O2sat 100% on RA. GEN: tired appearing but pleasant, comfortable, NAD HEENT: PERRL, EOMI, MMM, op without lesions RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: abdomen distended w/ + fluid wave, hypoactive bs, soft, nt, no masses or hepatosplenomegaly EXT: asymmetric LE edema L>R SKIN: icteric, petechial rash on LLE w/ mild erythema NEURO: AAOx3. Cn II-XII intact. . Pertinent Results: [**2160-1-28**] 12:40PM WBC-10.6# RBC-2.58* HGB-7.9* HCT-23.6* MCV-91 MCH-30.6 MCHC-33.5 RDW-15.9* [**2160-1-28**] 12:40PM NEUTS-83.8* LYMPHS-8.3* MONOS-7.5 EOS-0.3 BASOS-0.1 [**2160-1-28**] 12:40PM PLT COUNT-131* [**2160-1-28**] 12:40PM GLUCOSE-107* UREA N-17 CREAT-1.3* SODIUM-129* POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-20* ANION GAP-15 [**2160-1-28**] 12:40PM ALT(SGPT)-22 AST(SGOT)-65* ALK PHOS-149* TOT BILI-3.0* [**2160-1-28**] 12:40PM LIPASE-75* [**2160-1-28**] 01:22PM LACTATE-3.6* [**2160-1-28**] 03:15PM ASCITES WBC-54* RBC-265* POLYS-3* LYMPHS-64* MONOS-9* MESOTHELI-24* [**2160-1-28**] 03:15PM ASCITES TOT PROT-0.8 GLUCOSE-117 LD(LDH)-30 [**2160-1-28**] 09:01PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-TR [**2160-1-28**] 09:01PM URINE RBC-[**10-23**]* WBC-3 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2160-1-28**] 09:37PM LACTATE-1.7 . [**2160-1-28**] LLE Duplex - No DVT. . [**2160-1-28**] CXR - In comparison with the study of [**1-28**], there is no change in the appearance of the heart and lungs. Right IJ catheter has been introduced that extends to the level of the cavoatrial junction or into the upper portion of the right atrium itself. . [**2160-1-30**] CT ABD/PELVIS - 1. Moderate ascites without evidence of hemorrhagic component. 2. Cirrhosis with secondary signs of portal hypertension. 3. Gallstones are seen. . [**2160-2-2**] ABD U/S: Limited evaluation of the four quadrants demonstrates a moderate amount of ascites. A spot was marked in the left lower quadrant for paracentesis to be completed by the team. Brief Hospital Course: Mr. [**Known lastname 18823**] is a 55 year-old man with alcoholic cirrhosis initially admitted to MICU with fever, hypotension and concern for sepsis, treated with vancomycin and levofloxacin [**1-5**] concern for possible pneumonia. 1)fever, hypotension: Unclear etiology, very unlikely to be due to sepsis as no systemic/bacterial infection was identified during his admission. He was treated initially for pneumonia however his antibiotic course was stopped early as no infiltrate seen on several chest xrays. He may have had a minor cellulitis of left ankle, which also improved as he was on vancomycin during his MICU stay. He also may have had fever due to a viral illness. His hypotension may have been due to recent paracentesis and underlying liver disease. He was continued on vancomycin and levofloxacin during his ICU stay to cover for pneumonia, however this was stopped on tranfer to the liver service as he had no clear evidence of pneumonia on several chest xrays. He did not have any other evidence of bacterial infection on urine cultures, blood cultures, or peritoneal fluid analysis. He tested negative for influenza by nasal aspirate. He was afebrile with low/normal blood pressure prior to discharge. 2) Alcoholic cirrhosis: He has a history of persistant ascites requiring theraputic paracentesis every two weeks. Had 5 L paracentesis several days prior to admission which may have caused his hypotension possibly in the setting of a viral illness. He also has portal gastropathy and grade I esophageal varices seen on EGD 11/[**2158**]. He was continued on lactulose, rifaximin and nadolol during his admission. His diuretics were initially held but were restarted at home dose of lasix 20 and spironolactone 50mg prior to discharge. He also had a 6L theraputic paracentesis prior to discharge with 50 grams of albumin. His blood pressure was stable >95 following paracentesis. 3)Anemia: most likely due known portal gastropathy, seen on EGD [**10-10**] and continuous slow oozing. He was transfused a total of 6 units PRBC and 1 unit FFP during his hospital stay as his hematocrit was very slow to bump in response to transfusion. This may have been in part due to hemodilution in the setting of significant quantity of crystalloid that he was given for hypotension. His hematocrit was stable at 28 for three days prior to discharge. He was continued on ferrous sulfate, sucralfate and pantoprazole. 4) Left leg swelling, pain, erythema - possibly due to cellulitis, has improved since admission as he has been treated with vanc/levo for possible pneumonia. He had duplex which was negative for DVT. Resolved prior to discharge. 5) Non-gap metabolic acidosis - likely due to lactulose and resulting multiple loose stools daily, stable. 6) Code: full Medications on Admission: Rifaximin 400 mg tid Spironolactone 50 mg daily Sucralfate 1 g qid Mylanta 2 tabs [**Hospital1 **] Calcium Vit D Iron MVI Vit A Zinc Lactulose 30 mg tid Nexium 80 mg daily Nadalol 20 mg daily Tessalon pearles Colchicine 0.6 mg tab q am Lasix 20 mg daily Dry wt 185 lbs Discharge Medications: 1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 2. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 9. Vitamin A Oral 10. Zinc Oral 11. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO once a day. 12. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Tessalon Perles 100 mg Capsule Sig: One (1) Capsule PO every six (6) hours as needed for cough. 14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/ fever: do not exceed more than 2g/24 hours. 15. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Hypotension ESLD [**1-5**] Alcoholic Cirrhosis . Secondary Diagnoses: Hepatic sarcoidosis Abdominal hernia inguinal hernia chronic kidney disease HSP Discharge Condition: good blood pressure 105/60 on discharge Discharge Instructions: You were admitted to the hospital because you were having fever and low blood pressure and we were concerned that you had an infection. In addition, you had a low blood count. You were initially admitted to the ICU for close monitoring. You were initially treated with antibiotics for a presumed pneumonia however there was no evidence of pneumonia on either of the two chest xrays that you had so your antibiotics were stopped. You had two paracentesis to rule out infection and bleeding in your abdomen. There was no evidence of either. You also had a cat scan of your abdomen to evaluate for any source for your low blood count, there was no evidence of bleeding on the cat scan. It is most likely that the bleeding is due to your known gastropathy caused by the cirrhosis. It is likely that your fever was caused by a viral illness. Please continue to check your blood pressure daily as you have been doing. You were evaluated by the dermatologist for the rash on your feet. They were not concerned by the rash and think that it is tiny bruises due to your low platelet count. They recommended a cream for you to put on the inside of your ankle over the area of dry/skaly skin. You were given a prescription for this cream on discharge. On the day of discharge you had a paracentesis in order to improve your symptoms of abdominal fullness and distention. You had 6L of fluid removed and there was no evidence of infection on the fluid studies. You were also given 5g of albumin following this. Medications: 1. You were restarted on your diuretics on the day before discharge. 2. Your cholchicine was held during your admission and on discharge. Please discuss with Dr. [**Last Name (STitle) **] at your follow up appointment whether or not it is ok to restart this medicine. . Please call your doctor or return to the hospital if you experience any concerning symptoms including chest pain, persistant fevers, low blood pressure, fainting, difficulty breathing, bloody bowel movements. Followup Instructions: You have an appointment scheduled to see Dr. [**Last Name (STitle) **], MD on [**2160-2-5**], as discussed please cancel this appointment and [**Date Range **] one for the following week. Phone:[**Telephone/Fax (1) 2422**] Please call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] an appointment to be seen within one to two weeks of discharge. Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 7477**].

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icd9cm

[ [ [] ] ]

[ "99.07", "54.91", "99.04" ]

icd9pcs

[ [ [] ] ]

9432, 9438

5064, 7863

332, 402

9651, 9693

3428, 5041

11751, 12194

2807, 2945

8183, 9409

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274, 294

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32,536

133,891

54140

Discharge summary

report

Admission Date: [**2152-7-17**] Discharge Date: [**2152-7-28**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4891**] Chief Complaint: increased somnolence, AMS Major Surgical or Invasive Procedure: None History of Present Illness: This is an 89-year-old man with recently hospitalization here for L traumatic SAH, L frontal intraparenchymal hemorrhage, and R subarachnoid hemorrhage ([**Date range (1) 105348**]) who presented to the ED on [**7-17**] with altered mental status, was admitted to the MICU for 1 day given concern for extension of intracranial hemorrhage, now transferred to the floor for evaluation of his declining mental status and urinary tract infection. . Mr. [**Known lastname 110964**] was found and unresponsive on [**7-7**], after which he was brought to the ED and found to have extensive intraparenchymal hemorrhage. His hospitalization here from [**Date range (1) 105348**] was complicated by UTI (suspicious UA, ? UCtx, treated with 3 day course ciprofloxacin) and DVT of the L popliteal vein, for which he was started on Lovenox (originally on Lovenox 90mg SC BID, decreased to daily given elevated Factor Xa level). Upon discharge to [**Hospital3 **] on [**7-15**], his mental status was noted to be only somewhat alert and oriented (discharge summary states "A+Ox1.5"), responding intermittently to simple commands and dysarthric. His strength was [**4-13**] BUE, [**3-13**] RLE, [**2-13**] LLE. . Over the last 3 days, Mr. [**Known lastname 110964**] has been having increasing somnolence prompting him to be brought to the ED yesterday. . On arrival to the ED, VS were BP-140/67, HR-87, RR-28, O2-99% 2L NC. Temp was originally 102.2, was given Tylenol and 1g ceftriaxone, also nebulizers. Boroscope was done with visualization down to larynx which showed dried food particles. He had a catheter placed with returned 700cc of cloudy amber urine. EKG showed normal sinus rhythm, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 8730**] and T wave inversions in lateral leads. On transfer to the MICU, he was not following commands and non-verbal. . In the MICU, patient's vitals were stable and WNL. CT scan showed no change from prior (compared to [**2152-7-9**]), and dilantin for seizure prophylaxis was discontinued per neurosurgery. CXR negative for any acute intra-thoracic process. He was restarted on a statin (simvastatin) and beta blocker (metoprolol). He was given ceftriaxone and ampicillin for urinalysis (awaiting cultures, sensitivities not yet sent, ampicillin added given history VRE). He was NPO, not yet seen by speech and swallow. The patient was subsequently transferred to the hospital medicine service for ongoing care. Past Medical History: Past Medical History: Recent hospitalization: [**Date range (1) 105348**]/12 Patient was admitted to the neuro-ICU on [**2152-7-7**] after interval imaging in the ED revealed new left frontal intraparenchymal hemorrhage. Patient was admitted with dysarthria, confusion, and decreased hearing in his right ear, and no localizing or lateralizing signs. Urinalysis was suspicious for UTI and patient was started on a 3 day course of ciprofloxacin. . 1. Coronary artery disease: MI in [**2126**], STEMI in [**8-/2147**], most recent stress test WNL 2. History of hypertension. 3. Peptic ulcer disease. 4. Abdominal aortic aneurysm; status post repair. 5. Renal cell carcinoma; status post left nephrectomy. 6. Hyperlipdemia 7. Syncope in [**2143**] attributed to vasovagal reaction vs orthostatic hypotension . Past Surgical History 1) Popliteal aneurym excised/bypass [**9-13**] 2) Left iliac aa [**2-13**] 3) AAA repair w bilat iliac aa repair [**11/2135**], 4) Lt. thorocoabdominal Nephrectomy [**2-/2139**], 5) Angio [**2-13**] with embolization of left hypogastric artery 6) Left inguinal hernia repari 7) Vasectomy Social History: Retired, worked in chemical company mixing compounds. Lives alone. Widowed 9 years ago, but has 5 children, 4 of whom live locally, and 16 grandchildren. Pt was a smoker, but quit in [**2126**]. Never drank much alcohol and currently drinks none. Was a singer/son[**Name (NI) 110963**] in his freetime. Family History: Father had prostate CA, mother had MI. No strokes Physical Exam: Admission from the ICU: Vitals: T: BP: 112/67 P: 90 R: 30 O2: 98% shovel mask 35L General: tachypneic, eyes open, nonverbal, does not follow commands HEENT: Sclera anicteric Neck: supple, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley in place Ext: warm, well perfused, venodynes in place Neuro: does not follow commands, not verbal, +eye contact . Discharge: Vitals: Tm:99.5 (7 pm), Tc:98.3, BP:116/62(90-116/58-93), P:83(70-92), R:24, O2:98% on RA I/Os: ON: NS@75, 24hr: 765/760-Foley General: lying in bed, eyes open and awake, appears comfortable HEENT: sclera anicteric, no teeth, R facial droop, OP dry Neck: supple, JVP not elevated, no LAD Lungs: lungs clear posteriorly, anteriorly coarse expiratory sounds CV: low heart sounds, but appears to have regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, protuberant, non-tender Ext: improved, hands less red and puffy, warmer Neuro: awake, responds to being called "Happy." Still A+O x 0, able to squeeze fingers. Pertinent Results: ADMISSION [**Name (NI) **]: [**2152-7-17**] 09:30PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.015 [**2152-7-17**] 09:30PM URINE BLOOD-LG NITRITE-POS PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG [**2152-7-17**] 09:30PM URINE RBC-42* WBC->182* BACTERIA-FEW YEAST-NONE EPI-0 RENAL EPI-<1 [**2152-7-17**] 09:30PM URINE GRANULAR-7* [**2152-7-17**] 09:30PM URINE WBCCLUMP-MANY MUCOUS-FEW [**2152-7-17**] 06:58PM TYPE-[**Last Name (un) **] COMMENTS-GREEN TOP [**2152-7-17**] 06:58PM LACTATE-1.8 [**2152-7-17**] 06:55PM GLUCOSE-126* UREA N-33* CREAT-1.6* SODIUM-139 POTASSIUM-5.1 CHLORIDE-105 TOTAL CO2-26 ANION GAP-13 [**2152-7-17**] 06:55PM ALT(SGPT)-111* AST(SGOT)-76* ALK PHOS-103 TOT BILI-0.4 [**2152-7-17**] 06:55PM LIPASE-49 [**2152-7-17**] 06:55PM cTropnT-0.03* [**2152-7-17**] 06:55PM CALCIUM-8.6 PHOSPHATE-3.6# MAGNESIUM-2.4 [**2152-7-17**] 06:55PM PHENYTOIN-17.6 [**2152-7-17**] 06:55PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2152-7-17**] 06:55PM WBC-13.4* RBC-4.65 HGB-14.0 HCT-43.4 MCV-93 MCH-30.1 MCHC-32.2 RDW-13.2 [**2152-7-17**] 06:55PM NEUTS-80.3* LYMPHS-12.3* MONOS-5.4 EOS-1.7 BASOS-0.3 [**2152-7-17**] 06:55PM PLT COUNT-364# [**2152-7-17**] 06:55PM PT-10.4 PTT-19.7* INR(PT)-1.0 . DISCHARGE [**Month/Day/Year **]: [**2152-7-28**] 05:12AM BLOOD WBC-7.7 RBC-3.21* Hgb-9.7* Hct-30.1* MCV-94 MCH-30.4 MCHC-32.3 RDW-14.0 Plt Ct-293 [**2152-7-28**] 05:12AM BLOOD Glucose-185* UreaN-20 Creat-1.4* Na-137 K-3.7 Cl-108 HCO3-23 AnGap-10 [**2152-7-28**] 05:12AM BLOOD ALT-69* AST-66* AlkPhos-76 TotBili-0.3 [**2152-7-28**] 05:12AM BLOOD Calcium-8.0* Phos-2.4* Mg-1.8 [**2152-7-28**] 05:12AM BLOOD Phenyto-10.4 [**2152-7-26**] 05:24AM BLOOD Vanco-30.4* Head CT [**2152-7-17**]: IMPRESSION: Similar multicompartment hemorrhages with some decreased in acute blood products in the right anterior middle cranial fossa and subarachnoid hemorrhages; however, a small subdural effusion along the right frontal convexity has increased slightly, from 5 to 8 mm in thickness. Final report discussed with Dr. [**Last Name (STitle) **] on [**2152-7-19**], by telephone. . CXR [**2152-7-17**]: ONE VIEW OF THE CHEST: The lungs are low in volume but clear. The cardiac silhouette is mildly enlarged. The mediastinal silhouette and hilar contours are normal. No pleural effusion or pneumothorax is present. Evidence of a left radical nephrectomy is noted suggested by clips in the left upper quadrant. IMPRESSION: No evidence of acute intrathoracic process. . Spine CT: IMPRESSION: 1. Multilevel degenerative changes with grade 1 anterolisthesis of L4 on L5 and L5 on S1. Severe spinal stenosis at L4-5. 2. No acute fracture. Head CT [**7-22**]: IMPRESSION: No short interval change of complex multi-compartmental hemorrhage since recent preceding exam four days ago. Findings reported to Dr. [**Last Name (STitle) **] via phone at 8p on [**2152-7-21**]. NOTE ON ATTENDING REVIEW: There is minimal increase in the surrounding edema in the left frontal lobe around the hematoma with minimal increase in the rightward shift of midline structures (Likely related to evolution of hematoma) and slightly more conspicuous lobulated component of hemorrhage posteriorly. Consider close followup. [**7-28**] TTE: No valvular vegetations based on images, felt to be suboptimal in report. Brief Hospital Course: Assessment: 89-year-old man recently hospitalized for L traumatic SAH, L frontal intraparenchymal hemorrhage, and R subarachnoid hemorrhage ([**Date range (1) 105348**]) who presented to the ED on [**7-17**] with altered mental status, initially admitted to the MICU, found not to have extension of hemorrhage, then transferred to the floor for evaluation of his declining mental status and continued treatment of his staph urinary tract infection. . # Intraparenchymal hemorrhage complicated by continued cognitive decline: the patient had a fall on [**7-7**] resulting in traumatic hemorrhage and severe physical and cognitive decline. However, per his family, he was becoming even more somnolent during his short stay at [**Hospital1 **], prompting them to bring him to the [**Hospital1 18**] ED. We attributed the majority of his acute decline to his UTI, although he received an extensive work-up to exclude other reversible causes. Neurosurgery saw him on this admission and ruled out progression of bleed, thus dilantin was initially stopped for seizure prophylaxis. We thought the patient's poor mental status was likely chronic and representing cognitive decline [**2-10**] head bleed with acute exacerbation from urinary tract infection, as detailed below, and this information was discussed with his family. He was maintained on fall and aspiration precautions during his stay here. CT scan on admission showed no extension of head bleed thus dilantin was initially stopped but due to a spike seen on EEG without obvious seizure activity, dilantin was restarted despite the patient's transaminitis (switched to PO on discharge). On admission, the patient was lethargic, A+OxO, withdrawing to pain only. On discharge, his mental status had improved to the point that he was more awake and occasionally able to follow commands, but continued to be largely non-verbal. . # UTI: Patient had suspicious UA in the emergency department, prelim urine ctx showing coag+ staph. He was started on ceftriaxone and ampicillin in the MICU given that he has grown enterococcus in the past ([**2147**]) and concern for VRE. On the floor, he was switched to IV vancomycin for MRSA. Echo was obtained on day of discharge, given concern that MRSA UTIs are often associated with bacteremia. The TEE had suboptimal images by report, but did not reveal any vegetations. On discharge, WBC was 7.7. Repeat urine culture without growth. . # Edematous distal extremities: patient's hands were on occasion red, swollen and cold. Unlikely to be from clot given is on lovenox for DVT. ABG was unremarkable x 2, pulses palpable. [**Year (4 digits) **] surgery was consulted and felt that there were no acute issues. We gave the patient warm packs for his hands and upon discharge, his hands were warmer and less edematous. . # Hypoxia: Patient developed desaturation to 76% while on the floor. Respiratory therapy was called and this was felt to be due to tongue collapse. He was repositioned and put on non-rebreather, and his saturations immediately rose to 98%. We obtained an ABG which did not show any CO2 retention or hypoxia. . # DVT: Doppler on [**7-14**] showed DVT of the left popliteal vein that was partially occlusive. He was started on Lovenox with plan to continue for 6 months despite recent intracranial hemorrhage. Upon discharge on [**7-28**], was on Lovenox 90 mg daily (not [**Hospital1 **] given elevated anti-factor IX level). Lovenox level on this admission, drawn 6 hours after injection, was therapeutic at 0.97, and he was continued on Lovenox daily. . # Transaminitis: the patient's ALT on admission was > 111, AST >76. There were no LFTs in the system from recent hospitalization and all prior LFTs had been normal. Patient was on 2 medications with liver toxicity, namely simvastatin and dilantin. We held his simvastatin given potential for exacerbating hepatotoxicity. Dilantin was restarted on [**7-23**] based on neurosurgery recs. Upon discharge, LFTs were AST 69, ALT 66. . Chronic Issues . # CKD: had RCC, s/p L nephrectomy. Baseline Cr over past 10 years ranged from 1.7 - 2.5. On admission, Bun/Cr ratio was > 20 suggestive of pre-renal etiology. He was started on IVF and his Cr trended down. On discharge, BUN/Cr was 20/1.4. . # CAD: EKG on admission showed T-wave inversions in lateral leads, patient has history of STEMI. Troponins were negative (0.03, 0.22 this admission). Patient remained hemodynamically stable initially on the medicine floor, but due to hypotension when the patient was admitted to the MICU for the second time, his metoprolol was held. Metoprolol was restarted when he returned to the medicine floor. . Transitional Issues: will be going to [**Hospital1 **] [**Hospital1 8**] - f/u blood cultures ([**7-27**]) and urine electrolytes ([**7-28**]) - f/u echo ([**7-28**]) - Please f/u with PCP, [**Name10 (NameIs) **] [**Name Initial (NameIs) **] Medication changes: stopping simvastatin, IV vancomycin until [**8-2**]. - Check Vanc trough before evening vanc dose on [**7-28**]. Goal 15-20. - If rapidly changing renal function, please check lovenox level (factor Xa level) - If not eating or drinking, patient may need Dobhoff. Patient's family deferred this intervention when we discussed it in a family meeting during the admission, feeling it would not be in keeping with the patient's wishes. Also, patient may need IVFs depending on urine output, to enable time for further discussion with the family. - Patient had urinary retention when Foley removed, and failed attempted voiding trials. Will go to rehab with indwelling catheter. Medications on Admission: 1. Metoprolol Succinate XL 50 mg PO DAILY 2. Nitroglycerin SL 0.3 mg SL PRN chest pain 3. Simvastatin 40 mg PO QHS 4. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever 5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 6. Ciprofloxacin 0.3% Ophth Soln 4 DROP RIGHT EAR [**Hospital1 **] Duration: 10 Days 7. Dexamethasone Ophthalmic Soln 0.1% 4 DROP RIGHT EAR [**Hospital1 **] Duration: 10 Days 8. Docusate Sodium (Liquid) 100 mg PO BID 9. Enoxaparin Sodium 90 mg SC Q24H Duration: 6 Months First day = [**2152-7-14**]. 10. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain 11. Senna 1 TAB PO BID:PRN Constipation Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever 2. Senna 1 TAB PO BID:PRN constipation 3. Enoxaparin Sodium 90 mg SC Q24H Patient will need to continue this for at least 6 months 4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 5. Metoprolol Succinate XL 50 mg PO DAILY 6. Nitroglycerin SL 0.3 mg SL PRN chest pain 7. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain 8. Docusate Sodium (Liquid) 100 mg PO BID 9. Phenytoin (Suspension) 100 mg PO Q8H Please continue this until otherwise directed by your neurologist 10. Vancomycin 1000 mg IV Q 24H Duration: 5 Days Last Day is [**8-2**]. Please check a trough before the patient's evening dose on [**7-28**]. Discharge Disposition: Extended Care Facility: [**Hospital1 **] [**Hospital1 8**] Discharge Diagnosis: Urinary tract infection Traumatic intraparenchymal hemorrhage Deep venous thrombosis Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname 110964**], It was a pleasure taking care of you during your recent admission at [**Hospital1 18**]. As you know, you had a recent head bleed for which you were hospitalized here from [**Date range (1) 105348**] and discharged to [**Hospital3 **]. You were brought to the hospital from [**Hospital3 **] out of concern that you were becoming more sleepy. You had a CT scan of your head which showed that your head bleed was unchanged from prior scan. You were found to have a urinary tract infection for which you are now getting IV vancomycin. Your level of Lovenox was found to be stable, thus we continued you on daily dosing. Your mental status improved during your time here and upon discharge, you appeared more awake and were occasionally able to follow commands. Medication changes: -Please stop taking simvastatin, which can cause elevated liver enzymes Follow-up appointments: please see below Followup Instructions: [**2152-8-1**] 11:50a [**Last Name (LF) 1576**],[**First Name3 (LF) 2352**] [**Location (un) **] ([**Location (un) 2352**], MA), [**Location (un) **] [**Location (un) 2352**] - ADULT MEDICINE (SB) Please follow up with Dr. [**First Name (STitle) **] (Neurosurgery) as directed by him. Completed by:[**2152-7-28**]

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icd9cm

[ [ [] ] ]

[ "29.11", "38.93" ]

icd9pcs

[ [ [] ] ]

15894, 15955

8956, 13634

277, 284

16084, 16084

5533, 8933

17220, 17543

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47994

Discharge summary

report

Admission Date: [**2156-1-8**] Discharge Date: [**2156-1-20**] Service: MEDICINE Allergies: Aspirin Attending:[**Doctor First Name 1402**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Intubation. History of Present Illness: [**Age over 90 **] yo male with pmhx significant for Type 2 Diabetes Mellitus and coronary artery disease was admitted from the ED for [**2-14**] days of shortness of breath. Patient is a poor historian but reports that he has a [**2-14**] day history of shortness of breath, "wobbly on my feet," and generally "wasn't feeling good." He then called his PCP who recommended that patient call EMS to be taken to the hospital. On ROS, patient notes that he sleeps in a chair but denies leg swelling, PND, or palpitations. Patient reports that he takes his medications regularly but does occasionally "cheat" with his diabetic diet. On additional ROS, patient reports diffuse abdominal pain for 2-3 days, decreased appetite for several days, and URI 5 days ago which has improved. Patient otherwise denies dysuria, hematuria, diarrhea, constipation, fevers, chills, or night sweats. . Patient was brought to the ED by EMS where he was given 3x NTG and 180mg lasix IV. In the ED, VS were HR 120s / BP 125/72 / RR 28 / 98% on NRB / 1900 total UOP. Patient was initially placed on BiPap and then lowered to 4.5L NC. Received aspirin 325mg and was admitted. . Of note, patient was previously admitted to the hospital in [**2155-11-12**] with a similar episode of shortness of breath with dry cough. At that time, he was thought to have a CHF exacerbation secondary to medication noncompliance and underwent diuresis with improvement in SOB. Patient was discharged with outpatient cardiology follow-up but did not follow-up. Past Medical History: 1. Adult-onset diabetes mellitus. 2. Coronary Artery Disease - MI per report 3. Prostate cancer, [**Doctor Last Name **] 6 out of 10, diagnosed in [**Month (only) **] [**2141**], no metastases, status post XRT. 4. Hiatal hernia. 5. External hemorrhoids. Social History: No hx of drugs or EtOH. Did recently take codeine. Family History: n/c Physical Exam: PE: T 95.8 / HR 126 / BP 132/78 / RR 28 / PO2 96% on 4L Gen: lying comfortably in bed, no acute distress HEENT: Clear OP, MMM NECK: Supple; shoddy, nontender cervical LAD; JVP to jaw CV: tachycardic but regular rate. NL S1, S2. No murmurs, rubs or gallops LUNGS: bibasilar crackles with increased crackles on the left ABD: Soft, NT, ND. NL BS. No HSM EXT: No edema. 2+ DP/PT pulses BL SKIN: No lesions NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. alert and oriented x 3; hard of hearing with somewhat better hearing on the right side; slowed speech with difficulty with word-finding PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: Admission Labs: [**2156-1-8**] 10:13AM: GLUCOSE-155* UREA N-28* CREAT-1.1 SODIUM-141 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-26 ANION GAP-14 . WBC-11.4* RBC-3.83* HGB-11.3* HCT-32.4* MCV-85 MCH-29.5 MCHC-34.9 RDW-14.7 PLT COUNT-374 NEUTS-71.2* LYMPHS-22.3 MONOS-3.8 EOS-2.0 BASOS-0.6 . PT-12.1 PTT-24.4 INR(PT)-1.0 . [**2156-1-8**] 10:13AM CK(CPK)-78 CK-MB-NotDone proBNP-3382* cTropnT-0.02* [**2156-1-8**] 07:40PM CK(CPK)-60 CK-MB-NotDone cTropnT-0.04* [**2156-1-9**] 06:20AM CK(CPK)-64 CK-MB-NotDone cTropnT-0.03* . [**2156-1-8**] CXR: CHEST, ONE VIEW: Comparison with chest radiograph of [**2155-11-19**] and chest CT, [**2155-11-19**]. There are bilateral moderate pleural effusions, similar to the previous exam. Bilateral lower lobe opacities can represent atelectasis, aspiration, or pneumonia. Cardiac, mediastinal, and hilar contours are unchanged. No pneumothorax. Osseous structures are unchanged. IMPRESSION: Similar appearance of bilateral lower lobe atelectasis/aspiration/pneumonia and bilateral moderate pleural effusions. . [**2156-1-10**] Echo: Conclusions: The left atrium is normal in size. The estimated right atrial pressure is 11-15mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. An echodensity suggestive of a large apical mural thrombus is seen in the left ventricle. Overall left ventricular systolic function is severely depressed (ejection farction 20 percent) secondary to severe hypokinesis of all walls except the lateral wall. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2155-11-21**], the left ventricular ejection fraction is further reduced, the mitral regurgitation appears reduced (although it may not optimally have been displayed on the present study), and the presence of an echodensity in the left ventricle suggestive of an apical mural thrombus is now noted. . [**2156-1-19**] XRay right foot: IMPRESSION: 1. Curvilinear calcification located medially to the navicular bone could represent vascular calcification, but an avulsion injury cannot be excluded. 2. Os naviculare. . [**2156-1-20**] CT right foot: read from MS fellow: no fracture. Brief Hospital Course: [**Age over 90 **] yo male with CAD, DMII admitted with CHF exacerbation who had flash pulmonary edema requiring intubation. He improved, was extubated. Hospital course complicated by new tachycardia and delirium. Now with right foot pain. #. Cardiac A. Rhythm: Patient has a question of new diagnosis of atrial tachycardia, although P waves apear to be similar to old EKGs ddx also included benzo withdrawl despite family's insistence that he was not taking valium more than once a month. The tachycardia is thought to be the precipitating factor for this admission's CHF. His Toprolol was titrated up from 25mg to 200mg QD. We called his PCP's, Dr. [**Last Name (STitle) 172**], office for old EKGs; Old EKG showed rate in 70's with no obvious difference in P wave morphology. He had some ectopy thought to be a variant of this atrial tachycardia (SVT with aberrancy). . B. Cardiomyopathy: Pt with h/o CHF with EF 25-30% and 2+ MR. [**Name13 (STitle) **] had an acute CHF exacerbation with flash pulmonary edema. DDx flash edema includes includes worsening MR, atrial tach, HTN [**2-13**] holding lisinopril in setting of MR [**First Name (Titles) **] [**Last Name (Titles) **]. Pt ruled out for MI and had no new EKG changes suggestive of ischemia. Also lisinopril was restarted at a lower dose 2.5mg (home dose was 20mg QD) because of need to increase beta blocker for tachycardia. Patient had decreased intake because of clearing delirium at discharge. He was euvolemic at discharge. He is on 20mg lasix daily. - Patient needs to be weighed every day. If he gains more than 2 lbs he should take 40mg of lasix (his home dose). . C. Coronaries: Patient with a presumed CAD and prior MI, although no records here. No current chest pain or acute ischemic changes on EKG. CE neg. Medical management with home doses of atrovastatin 20mg, plavix 75mg. His metoprolol was increased for rate control with compensatory decrease in lisinopril to maintain blood pressure. Restarted aspirin 81mg (has listed GI bleed as allergy). . # ARF: Patient had episode of ARF with Creatinine bump to 1.4, from baseline 1.0, thought to be pre-renal from low CO. ACE I was held during renal failure. . # PNA: Completed a 7 day course on [**2156-1-16**] of zosyn for pneumonia. Patients white count and fevers decreased and he was afebrile at discharge. . #. Type 2 Diabetes Mellitus-- He was discharged on Lantus dose 22U (on half doses for NPO and poor PO intake). As he began eating we added back Humalog at meals (3U) and covered with insulin sliding scale. . # Right foot pain-- Patient with 3 days of right foot pain. redness and minimal swelling in medial ankle/foot arch. Thought to be secondary to a mechanical trauma. No break in the skin. Ddx is bruise/fracture/osteo. Right foot x-rays and CT showed no fracture. Continue tylenol for pain control. . 5. Anemia: Baseline--Unclear etiology for patient's anemia, thought likely secondary to iron deficiency anemia. Baseline Hct 32-35. Colonoscopy and EGD in [**4-15**] demonstrated no significant findings. Ferritin in [**3-15**] was 14 and most recent ferritin in [**8-15**] was 42. We continued ferrous sulfate 325mg PO daily. . 6. Delirium: Likely multifactorial from infection, age and ICU delirium, medications. He was treated for pneumonia. geriatrics was consulted. We encouraged normalizing behavior (OOB to chair), had his hearing aids brought in. We treated agitation with low dose ativan (0.25mg Q6PRN) preferentially then zyprexa 2.5mg PRN. He uses minimal-moderate diazepam at home and there was concern for withdrawl. Patient did not have any seizures or DT. For the last few days of admission, he had a clear sensorium and did not require any ativan or zyprexa. . 10. CODE: DNR. Agrees to intubation for reversible causes but would not like prolonged intubation. Confirmed with family on [**2156-1-19**]. . 11 COMM: Wife [**Name (NI) **] [**Name (NI) 101256**] - [**Telephone/Fax (1) 101257**] Daughter - [**First Name4 (NamePattern1) 717**] [**Last Name (NamePattern1) **] - [**Telephone/Fax (1) 101258**] PCP [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 172**] - [**Telephone/Fax (1) **] Medications on Admission: Aspirin 81mg PO daily Atorvastatin 20mg PO daily Lisinopril 20mg PO daily Clopidogrel 75mg PO daily Toprol XL 25mg PO daily Lasix 40mg PO daily Diazepam 5mg PO qhs Ferrous Sulfate 325mg PO daily Nitroglycerin .4mg SL prn Lantus 22U SC qhs Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 5. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily). 6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Insulin Glargine 100 unit/mL Solution Sig: 22U Subcutaneous at bedtime: This is his normal home dose. . 8. Insulin Lispro (Human) 100 unit/mL Solution Sig: Three (3) Units Subcutaneous QAS, with meals. 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Heparin (Porcine) 5,000 unit/mL Syringe Sig: One (1) Injection three times a day: if not ambulating. 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital 12414**] Healthcare Center - [**Location (un) 12415**] Discharge Diagnosis: Primary Atrial tachycardia CHF with EF of 30% Coronary artery disease Diabetes Mellitus type II Delirium Pneumonia acute renal failure Seconday Iron deficiency anemia Discharge Condition: Stable Discharge Instructions: You were admitted for congestive heart failure. You had to be intubated to help you breath. This was what you and your family agreed should be done during such circumstances. You must be weighed everyday. If you gain more than 2 lbs, you should take your 40mg of Lasix and call your doctor. Followup Instructions: Please follow up with the facility physician at the rehab facility. . After leaving there, please see your primary care doctor, Dr. [**Last Name (STitle) 172**], in the next week. . You should have your labs checked on Thursday [**2156-1-22**]- please check a potassium and magnesium and replace as needed. Completed by:[**2156-1-20**]

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icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

10879, 10972

5394, 9642

235, 249

11183, 11192

2856, 2856

11535, 11873

2159, 2164

9932, 10856

10993, 11162

9668, 9909

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2179, 2837

176, 197

277, 1795

2872, 5371

1817, 2073

2089, 2143

79,831

168,895

36821+58109

Discharge summary

report+addendum

Admission Date: [**2174-5-28**] Discharge Date: [**2174-6-4**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7333**] Chief Complaint: Syncope Major Surgical or Invasive Procedure: Pacemaker placement [**2174-5-30**] History of Present Illness: 88yo woman w hx of HTN, hypothyroidism, hyperlipidemia who came in with presyncope. She apparently fell 10d ago with unclear details. Again yesterday, she was walking to TV to change channel and suddnely felt LH/dizzy and hit the TV with her right side of ribs. She remembers falling and did not hit head/neck. She came to OSH ED for her rib pain. . At [**Location (un) 620**] she was noted to be in 2:1 heart block with bradycardia to 30s-40s and BP 170-200/40-60. She was given glucagon 3mg and zofran 4mg. HR had minimal response but blood pressure remained stable at SBP 160s. Patient transferred here for EP eval. . In our ED: VS: HR 40s, 188/56, 97% 2L, RR 20. EKG with intermittent 2:1 heart block noted w ventricular rate 50; LBBB (old) and prolonged QTc. CXR w ? pulm edema but no rib fractures. SL ntg x1 given for hypertension and she was admitted to CCU for EP eval. . Currently, she reports slight right rib pain which worsens with deep inspiration. She denies LH, dizziness, CP, palpitations, SOB. She reports taking normal amounts of PO intake and her meds over last week. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: hypothyroidism s/p ear surgery s/p hysterectomy neurocardiogenic vasovagal reaction [**9-6**] Social History: -Tobacco history: never -ETOH: prior social -Illicit drugs: no IVDU or other rec drugs -Bookkeeper for construction outfit (retired 10 yrs ago) - Lives at [**Location **] Crossing, an [**Hospital3 **] in [**Location (un) 620**]. Has had significant memory problems that she tries to hide. Earlier Mini mental score 20. Needs assist with medications. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: On admission - VS: HR 40 16 100% 2L 125/68 GENERAL: WDWN ** in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of *** 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. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: ========= Labs ========= Admission - [**2174-5-28**] 04:42AM BLOOD WBC-9.7 RBC-4.13* Hgb-11.7* Hct-35.0* MCV-85 MCH-28.2 MCHC-33.3 RDW-14.5 Plt Ct-243 [**2174-5-28**] 04:42AM BLOOD Glucose-110* UreaN-26* Creat-1.2* Na-139 K-4.6 Cl-104 HCO3-25 AnGap-15 [**2174-5-28**] 04:42AM BLOOD CK(CPK)-216* [**2174-5-28**] 04:42AM BLOOD CK-MB-5 cTropnT-<0.01 [**2174-5-28**] 01:20PM BLOOD CK-MB-4 cTropnT-<0.01 [**2174-5-28**] 01:20PM BLOOD CK(CPK)-200* [**2174-5-28**] 04:42AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.1 [**2174-5-28**] 04:42AM BLOOD TSH-10* URINE CULTURE (Final [**2174-5-29**]): NO GROWTH. . [**2174-6-4**] 06:35AM BLOOD WBC-9.6 RBC-3.40* Hgb-9.4* Hct-28.5* MCV-84 MCH-27.8 MCHC-33.1 RDW-14.1 Plt Ct-227 [**2174-6-4**] 06:35AM BLOOD Glucose-96 UreaN-30* Creat-1.0 Na-142 K-3.9 Cl-107 HCO3-23 AnGap-16 [**2174-6-4**] 12:55PM BLOOD Hct-31.5* ========== Cardiology ========== TTE [**5-30**] There is mild symmetric left ventricular hypertrophy with normal cavity size. Right ventricular chamber size is normal. There is no pericardial effusion. ECG [**6-2**] Sinus rhythm with atrial sensed and ventricular paced Since previous tracing of [**2174-5-31**], trate slower and atrial pacing not seen . =========== Radiology =========== CXR [**2174-5-28**] AP UPRIGHT RADIOGRAPH OF THE CHEST: The heart is moderately enlarged. Mild pulmonary vascular congestion is noted. Linear atelectasis is noted within the left lung base. Small left pleural effusion is visualized. Moderate degenerative changes of the thoracic and lumbar spine are noted. IMPRESSION: Mild pulmonary edema. CXR [**2174-6-2**]: REASON FOR EXAMINATION: Followup of a patient with heart block after recent pacemaker placement. PA and lateral upright chest radiograph was compared to [**2174-5-31**]. The pacemaker leads are in the right atrium and right ventricle. There is no pneumothorax. The cardiomediastinal silhouette is stable. Interval development of vascular engorgement is demonstrated, mild with still no overt pulmonary edema seen. The lung volumes are low, especially on the right. Head CT [**2174-6-1**] IMPRESSION: No evidence of acute hemorrhage or shift of normally midline structures. Brief Hospital Course: ASSESSMENT AND PLAN: 88yo woman w hx of HTN, hypothyroidism, hyperlipidemia who came in with syncope and found to have 2:1 AV block. . . RHYTHM:Newly diagnosed AV block. Atropine non diagnostic. Etiology initially throught to be from atenolol and slight worsening renal function, but HR did not improve with washout. The team also considered ischemic etiologies (accounts for 40% cases of AV block) but cardiac biomarkers were flat and no ischemic changes on EKG. Patient had [**Company 1543**] Sensia SEDR01 dual chamber pacer placed on [**2174-5-30**] because block was felt to be symptomatic. CXR showed proper lead placement and no PTX. . CORONARIES: no known CAD. EKG without ischemic changes. Biomarkers flat. Initially held atenolol. Continuee asa. . Rib Pain: No fracture and no effusion seen on CXR. . Hypertension: on atenolol and lisinopril as outpatient. Initially held ACE in setting of renal dysfunction but restarted on HD #2, increased to 40 mg because of high blood pressures. Held atenolol with bradycardia, restarted. . ARF: Baseline creatinine 1.1-1.3 was admitted with Cr 1.5 that downtrended. Likely due to poor forward flow from decreased CO due to bradycardia. . Hyperlipidemia: statin . Depression/Delerium: Fluoxetine inititially continued, but held when patient was delerious. Delerium felt to be due to poor sleep in house on top of underlying mod dementia, infectious and metabolic etiologies R/O'd. . Hypothyroidism: Levothyroxine 75. TSH 10. Plan to defer uptitration of synthroid to outpatient providers. . Code - DNR/DNI but reversed for 24 hrs peri-procedure Medications on Admission: lisinopril 20 daily atenolol 25 daily fluoxetine 20 daily lipitor 10 daily levothyroxine 75 daily ativan ? ASA 81 Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain or fever>101. Discharge Disposition: Extended Care Facility: [**Location (un) 1036**] - [**Location (un) 620**] Discharge Diagnosis: Primary: Second degree av block Secondary: Hypertension, Hypothyroidism Discharge Condition: stable Discharge Instructions: You were admitted to the hospital because after you fell at home, you were found to have a significant heart block. You had a pacemaker placed to prevent your heart rate from going to slowly. You will need to follow up with a heart rhythm specialist as an outpatient. . Please seek immediate medical attention if you experience chest pain, shortness of breath, abd pain, nausea, lightheadedness, palpitations, chest pain or any change from your baseline health status Followup Instructions: DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2174-6-7**] 3:00 . PCP: [**Name10 (NameIs) 357**] make an appt to see PCP 1-2 weeks after discharge from [**Location (un) **] . Completed by:[**2174-6-4**] Name: [**Known lastname 13265**],[**Known firstname **] Unit No: [**Numeric Identifier 13266**] Admission Date: [**2174-5-28**] Discharge Date: [**2174-6-4**] Date of Birth: [**2086-1-13**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1051**] Addendum: [**Hospital **] rehab stay will be less than 30 days. Discharge Disposition: Extended Care Facility: [**Location (un) 1132**] - [**Location (un) 407**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1052**] MD [**MD Number(2) 1053**] Completed by:[**2174-6-8**]

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icd9cm

[ [ [] ] ]

[ "37.72", "37.83" ]

icd9pcs

[ [ [] ] ]

9467, 9700

5658, 7253

269, 307

8259, 8268

3462, 5635

8784, 9444

2458, 2573

7418, 8043

8164, 8238

7279, 7395

8292, 8761

2588, 3443

1874, 1947

222, 231

335, 1780

1978, 2074

1802, 1854

2090, 2442

27,103

150,912

33093

Discharge summary

report

Admission Date: [**2127-6-26**] Discharge Date: [**2127-7-4**] Service: MEDICINE Allergies: Penicillins / Erythromycin Base / Naprosyn Attending:[**First Name3 (LF) 4975**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Left Heart Catheterization Colonoscopy History of Present Illness: The patient is an 84 year old man hx of CAD and likely prior IMI, HTN, AF (on coumadin,) hypercholesterolemia, s/p right fem-tib popliteal aneurysm transfered for cath after presenting w/ CP. the patient has a hx of CAD, s/p angioplasty 10 years prior. In [**3-21**], patinet underwent a EST as part of pre-op evalution, which showed inferior and lateral wall ischemia with an EF of 60%. Decision was made to treat with conservative medical manegment. The patient underwent a right proximal superficial femoral to distal posterior tibial bypass with non reversed saphenous vein angioscopy and ligation of femoral and popliteal aneurysms on [**2127-4-1**] complicated by PE. 4 days prior to presentation to [**Hospital1 18**] the patinet was at home in his usual state of health when he had sudden onset of substernal chest pressure while watching the red sox game. The pressure was described as [**7-22**] without radiation. He denies assoicated shortness of breath, n/v, diaphoresis, palpitations, or lightheadedness. The patient took his own blood pressure, and noted it to be 176 systolic. The chest pain continued for a few hours; he decided to activate EMS and was brought to [**Hospital **] hospital. Chest pain was relieved with SLNG. At the OSH, the patient reportendly had an unremarkable EKG and negative cardiac markers negative x 3. He was given ASA 325mg, metoprolol 75mg [**Hospital1 **], and plavix. Because of his elevated INR (1.9,) his coumadin was held, and the patient was transfered after his INR drifted down. The patient underwent cardiac catheterization upon transfer, showing 3VD, 80% mid LAD, 60% Lcx, 90% prox ramus, and 80% osial RCA. No intervention was taken. The patient admitted to [**Hospital Unit Name 196**] for futher manegment. ** On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools. He reports rectal bleeding suggestive of hemmeroidal origin, and has been by GI and the OSH. 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 paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: acute on chronic diastolic heart failure HTN, DJD of knees b/l, AF, PVD, hyperlipidemia, PE, CAD, R popliteal artery aneurism s/p bypass grafting with saphenous vein, hemerhoids, hernia Cardiac Risk Factors: - Diabetes, + Dyslipidemia, + Hypertension Social History: Worked as a stone [**Doctor Last Name 3456**]. Lives with Daughter and sister. [**Name (NI) **] hx of etoh, tobacco, or IVDU. No hx of SCD. Family hx of cancer, but unclear which type. Family History: No family history of sudden cardiac death or early MI. Physical Exam: VS - HR 78 BP 168/86 97% on RA Gen: WDWN middle aged 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 *** cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2127-6-26**] 12:00PM BLOOD WBC-4.5 RBC-3.61* Hgb-9.9* Hct-29.2* MCV-81* MCH-27.4 MCHC-33.8 RDW-15.9* Plt Ct-209 [**2127-7-4**] 05:55AM BLOOD WBC-6.3 RBC-3.57* Hgb-10.0* Hct-30.0* MCV-84 MCH-27.9 MCHC-33.2 RDW-16.2* Plt Ct-276 [**2127-6-26**] 12:00PM BLOOD Glucose-145* UreaN-12 Creat-0.7 Na-136 K-3.7 Cl-103 HCO3-25 AnGap-12 [**2127-7-4**] 05:55AM BLOOD Glucose-100 UreaN-14 Creat-1.0 Na-133 K-3.9 Cl-99 HCO3-27 AnGap-11 [**2127-6-26**] 12:00PM BLOOD ALT-15 AST-18 CK(CPK)-26* AlkPhos-71 Amylase-40 TotBili-0.5 DirBili-0.1 IndBili-0.4 [**2127-6-26**] 12:00PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2127-6-27**] 04:00AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.1 [**2127-6-30**] 05:35AM BLOOD Calcium-7.8* Phos-3.3 Mg-1.7 [**2127-6-26**] 12:00PM BLOOD VitB12-535 Cardiac catheterization: 1- Selective coronary angiography of this right-dominant systemdemonstrated severe diffuse three vessel disease. The LMCA had a 30-40% ostial taper. The LAD was a diffusely diseased and calcific vessel with 80% haxy mid segment stenosis. The LCX had a 60% proximal disease. The RI was a large vessel with serial stenosis including 90% proximal and 80% mid-vessel lesions. The RCA had a 70% ostial stenosis. 2- Limited resting hemodynamic assessment revealed normal systemic arterial pressure (114/62 mmHg). 3- Left ventriculography was deferred. FINAL DIAGNOSIS: 1. Severe diffuse three vessel coronary artery disease. 2. Consult cardiac surgery (Dr.[**Last Name (STitle) **] notified) Carotid u/s: Minimal plaque with bilateral less than 40% carotid stenosis. CT Abd/Pelvis: 1. Study limited by nonadministration of intravenous contrast. Concentric narrowing of the short segment of the distal descending colon, which may be due to underdistension, however, mass lesion cannot be excluded and further evaluation with colonoscopy is recommended. 2. Diverticulosis, no evidence of acute diverticulitis. TTE: The left atrium is moderately dilated. The right atrium is markedly dilated. There is mild (non-obstructive) focal hypertrophy of the basal septum. The left ventricular cavity is mildly dilated. 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 mildly dilated. 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. An eccentric, anteriorly directed jet of moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Brief Hospital Course: #. CAD: The patient has a history of CAD, status post POBA 10 years prior. A recent outpatient persantine MIBI revealed inferior and lateral wall ischemia. With a presentation of acute onset chest pain concerning for ACS, the patinet was ruled out for MI and had non-specific EKG changes. With the recent abnormal stress test, he underwent cardiac catheterization, which revealed three vessel disease. He had been started on heparin at the OSH and had been given plavix, but not loaded. Cardiothoracic surgery was consulted for likely bypass, and pre-op evaluation was performed, including carotid u/s, chest XR, and vein mapping. While on heparing, the patinet was noted to have BRBPR (work up discuss below.) Surgery was deffered in the acute setting, with plan to further addess as an outpaitn. He was continued to 81mg of ASA, high dose atorvastatin, and metoprolol. . #. Congestive Heart Failure: Again, complaints of chest pain consistent with unstable angina, and no evidence of cardiac damage. A TTE was optained, which showed 2+ MR/ 1+ AR / EF > 55%/ concentric LV hypertrophy. He was euvolemic on exam. His metoprolol dose was uptitrated. There were no formal indications for ACEi, and was not started. . #. Rhythm: On presenation, patinet showed his known AF with normal ventricular response. While on a heparing Gtt, had BRPBP, and was discontinued. While his CHADS score was calculated at 1, would have prefered to anticoagulated, and should be readdressed after stabilization of his acute GI bleed as an outpatinet. He was discuarged on 81mg of ASA and his metoprolol dose was uptitrated. . #. History of PE - Per OSH records, recent PE from post-op compliation from [**3-21**]. Was on coumadin, but now held on admission for cardiac catheterization. He was on a heparin gtt, but was stopped in the setting of GI bleed. His anticoagulation should be restarted as soon as possible. He had no O2 requirment. . #. BRBPR: The patinet reports a history of hemmeroids and complaints of BRPBR. Was seen by GI at the OSH, who felt was consistent with hemmeroidal bleeding. Was started on heparin, and had multiple episodes of BRBPR during the hospitalization with a 5 point HCT drop. He was taken to the CCU in order to undergo closer monitoring with continued bright red blood and plans for c-scope prep. The colonoscopy did not show evidence of bleeding, and the presumptive diagnosis is bleeding tics or AVMs. He was then restarted on anticoagulation, but continued bleed with drop of hct from 27 to 22.8. He was transfused with 1 U but inappropriate response. No further bleeding. His anticoagulation was discontinued, with plans to be re-initated as an outpatient once bleeding has stabilized. . # Upper Extremity Swelling. The patinet was noted to have a new swollon LUE swelling in this patinet with a history of DVT with heparin being stopped. Ultrasound examination did not reveal a DVT, and showed a hematoma. Anticoagulation, as described above, was stopped. Warm packs were applied, and resolving size should be confirmed as a outpatient. Medications on Admission: Lovenox 90mb [**Hospital1 **] Plavix 75mg dialy Lopressor 5mg q4h PRN Zocor 10mg dialy Lopressor 25mg PO bid Pepcid 20mg daily Colace Tylenol SLNG Aspirin 325mg. Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual PRN as needed for chest pain: If Chest pain does not resolve after 3 doses 5 min apart, call 911. Disp:*1 vial* Refills:*2* 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Primary Diagnosis: Unstable Angina Three vessel CAD Lower GI Bleed Left arm hematoma . Secondary Diagnosis: Atrial Fibrillation Pulmonary Embolishm Hypertension Discharge Condition: Stable Discharge Instructions: You are being discharged from the hospital after admission for chest pain. You were found to have occlusion of three of your coronary arteries. While bypass surgery was planned, you hospitalization was complicated by GI bleeding. Surgery is being delayed, with planned follow up with your cardiologist to readdress. Because of bleeding, your coumadin is also being stopped. If you develop chest pain, shortness of breath, palpitations, bloody stool, call your PCP or go to the emergency room. . You developed a hematoma in your left arm, which will take time to resolve. Keep warm packs on your arm. If you develop pain, weakness, or numbness in the arm call 911. . Take all medication as prescribed and keep appointments listed below. Followup Instructions: Dr.[**Name (NI) 76923**] office will call you to schedule follow up for next week. . You have an appointment with Dr. [**Last Name (STitle) 7047**] of cardiology on [**7-8**] at 12:20pm. 15 [**Name (NI) **] Brothers [**Name (NI) **] in [**Location (un) **], MA ( [**State 76924**], [**Location (un) **], MA) . Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2127-8-21**] 1:45 . Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2127-8-21**] 2:15

[ "425.8", "562.12", "272.4", "411.1", "V45.82", "427.89", "E879.0", "715.90", "997.2", "415.19", "427.32", "V12.51", "414.01", "427.31", "E878.8", "E849.7", "428.0", "998.12", "428.30", "402.91", "442.3" ]

icd9cm

[ [ [] ] ]

[ "37.22", "88.57", "88.72", "99.04", "45.23" ]

icd9pcs

[ [ [] ] ]

11144, 11199

6838, 9928

260, 301

11404, 11413

4077, 5405

12204, 12778

3152, 3208

10140, 11121

11220, 11220

9954, 10117

5422, 6815

11437, 12181

3223, 4058

210, 222

329, 2657

11328, 11383

11239, 11307

2679, 2934

2950, 3136

50,089

184,615

41100

Discharge summary

report

Admission Date: [**2157-8-22**] Discharge Date: [**2157-9-8**] Date of Birth: [**2096-10-8**] Sex: F Service: MEDICINE Allergies: atorvastatin Attending:[**First Name3 (LF) 4327**] Chief Complaint: Weight gain and shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 89581**] is a 60 y/o female with htn, CAD, COPD, DM and HL who presented to [**Hospital3 **] following increased weight gain and sob. She explains that she has gained some 28 lbs since [**Month (only) 205**]. She was first diagnosed with CHF in [**2151-8-5**]. She endorses PND, orthopnea and sleeps elevated in a hospital bed on 2 or more pillows. She has significant DOE and she can only walk about 25 feet with her wheeled walker before she gets SOB. She also endorses palpitations and rare chest pain "when she gets upset." She denies fevers, chills, nasea, vomiting, cough, hemoptysis or changes in bowels. Her last BM was 2 days ago. . She was transferred to [**Hospital1 18**] for cardiac cath. Cath showed elevated right and left heart cath, wedge of 35. Cuff pressures 30-40 mm hg less than central pressures. No intervention. She was then transferred to the floor. . On the floor she feels tired and thirsty. Past Medical History: 1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: STEMI [**2156**] BMS to LAD -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: # CAD - NSTEMI and STEMI ([**2156**]) # Hypertension # Hyperlipidemia # Diabetes Mellitus # PAD # AAA # Diverticulosis # A Fib on Coumadin # Cholecystitis # Pneumococall Meningitis in [**2130**] # Nasal Polyps # Hidradenitis Suppurativa # Hypothyroidism # Anemia # Congestive Heart Failure with echo on [**2157-7-26**] showing EF of 40-45% with MR, TR and PR. Social History: -Tobacco history: Smokes 1 ppd for 40 years -ETOH: Rare -Illicit drugs: None Family History: She has extensive history for CAD with father and three brothers with known CAD; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: 96.4, 109/63, 104, 18, 100% 4L GENERAL: Sleeping. NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. MMM. NECK: Supple. Unable to assess JVP given body habitus. CARDIAC: Very distant heart sounds. Sounded RRR w/o MRG. LUNGS: Very distant lung sounds with bibasilar crackles. No wheezes. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. C-Section scar noted. EXTREMITIES: [**12-5**]+ Pitting edema in b/l LE's PULSES: Right: Carotid 2+ brachial 2+ radial/DP/PT's all non palpable Left: Carotid 2+ brachial 2+ radial/DP/PT's all non palpable . DISCHARGE PHYSICAL EXAMINATION: Vitals - Tm 97.7/Tc97.4; HR 77; BP 130/99 (84-130/49-99) RR: 20 02 sat: 100% 2L In/Out: 24H: [**Telephone/Fax (1) 89582**] (-3800cc); 8H [**Telephone/Fax (1) 89583**] (-980cc) Weight: 114kg (130kg on admission) FS: 150 Gen: Obese, NAD,. Drowsy this AM, sleeping comfortably, CV: Very distant heart sounds, irregularly irregular, no murmurs appreciated Lungs: CTAB Abd: BS+, obese, edematous, soft, non-tender, non-distended. Extr: 2+ edema in lower extremities below knees, 3+ above knees. 2+ b/l radial pulses, pulses found by Doppler in b/l LE??????s. Ulcers on heals are clean and appear to be healing. Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+), (Right DP pulse: + by doppler), (Left DP pulse: + by doppler) Skin: No rashes. Small circular lesions on bilateral hands. Some excoriations on bilateral lower extremities, wrapped in bandages Neurologic: drowsy this AM, hard to arouse, consistent with prior mornings Pertinent Results: Admission Labs: [**2157-8-23**] 07:30AM BLOOD WBC-11.0 RBC-3.90* Hgb-10.1* Hct-32.5* MCV-83 MCH-25.8* MCHC-30.9* RDW-19.2* Plt Ct-289 [**2157-8-23**] 07:30AM BLOOD Plt Ct-289 [**2157-8-23**] 12:35PM BLOOD PTT-120.9* [**2157-8-23**] 07:30AM BLOOD Glucose-81 UreaN-67* Creat-1.8* Na-132* K-6.3* Cl-93* HCO3-29 AnGap-16 [**2157-8-23**] 12:35PM BLOOD Glucose-PND UreaN-PND Creat-PND Na-130* K-6.9* Cl-92* HCO3-PND [**2157-8-23**] 07:30AM BLOOD Calcium-9.2 Phos-5.4*# Mg-3.1* [**2157-8-23**] 12:55PM URINE Color-DkAmb Appear-Cloudy Sp [**Last Name (un) **]-1.022 [**2157-8-23**] 12:55PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-5.5 Leuks-LG [**2157-8-23**] 12:55PM URINE RBC->182* WBC->182* Bacteri-MANY Yeast-NONE Epi-0 . Discharge Labs [**2157-9-7**] 05:55AM BLOOD WBC-7.5 RBC-3.47* Hgb-8.7* Hct-30.9* MCV-89 MCH-25.0* MCHC-28.1* RDW-18.1* Plt Ct-193 [**2157-9-7**] 05:55AM BLOOD Glucose-107* UreaN-66* Creat-1.6* Na-134 K-4.0 Cl-88* HCO3-38* AnGap-12 [**2157-8-30**] 02:33PM BLOOD calTIBC-416 VitB12-1116* Folate-11.3 Ferritn-51 TRF-320 Reports: [**2157-8-22**] Cardiac Cath FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Severely elevated left- and right-sided filling pressures. 3. Severe pulmonary hypertension. [**2157-8-23**] Echo Conclusions: Very poor image quality. The left ventricle is not well seen. There is no pericardial effusion. . Microbiology: [**2157-8-23**] 12:55 pm URINE Source: Catheter. **FINAL REPORT [**2157-8-25**]** URINE CULTURE (Final [**2157-8-25**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. OF TWO COLONIAL MORPHOLOGIES. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. AMPICILLIN ON REQUEST ONLY. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: 60 yo F with Hx of CAD, CHF (EF 40-45%), DM, HTN, HL, COPD presenting with major CHF exacerbation, at least 50lbs up, and hypotension. . # Acute on Chronic Sytolic and Diastolic Congestive Heart Failure: Patient presented with SOB, PND, Orthopnea, crackles on exam, LE edema. Most recent echo per report showed EF or 40-45% per report. Cath showed CO 3.5 L/min. Of note, her cuff systolic BP's are 40 points lower than central BP measured in cath lab. Initially diuresed with lasix drip on the floor, but this was complicated by hypotension to SBP of 40. This value is of unclear significance, given it was a cuff pressure and may have been 40 points higher. She was transferred to the CCU for diuresis with central BP monitoring. She was briefly on dopamine but this was promptly stopped once it became clear that a SBP of 80's is normal for her. She was diuresed a total of ~35L negative during admission, using a combination of lasix, acetazolamide, and metolazone. She was also anemic (see below), and was transfused 2 units pRBCs, which likely helped mobilize fluid. Her edema is improved, but still has 2+ pitting edema up to her waist. She has a ways to go for her diuresis but is now on a stable regimen of lasix 80gm IV BID and spironolactone 25mg PO daily. She should have her electrolytes checked twice daily while she is being diuresed by IV doses (has a PICC line in). Not currently on an ACEi as has been having problems with hypotension but should be started after diuresis is finished. Should be on a heart healthy, 2g sodium, 1.5L fluid restricted, diabetic diet. . # Hypotension: Pt has extensive peripheral arterial disease, and as such her systolic blood pressure measured with a cuff is abotu 40mmHg LOWER than that measured centrally in the cardaic cath lab. Systolic blood pressures in the 70's are tolerable for her because of this. . # Hypokalemia: pt has been persistently hypokalemic during diuresis, and is now on potassium 40mEq PO TID. She should have her electrolytes checked [**Hospital1 **] while diuresing. Of note, she was hyperkalemic on admission. She was put on spironolactone to help maintain a normal K+, increase diuresis, and to help treat her CHF. Potassium should continue to be checked daily at her rehab facility. . # Coronary Artery Disease: as evidenced by prior STEMI and NSTEMI. Patient had elevated troponins at OSH but unclear if this is [**1-5**] NSTEMI or [**Last Name (un) **]. CK-MB flat. Cath showed occluded R, newly occluded LAD since [**Month (only) **] stent (no intervention done) collateralized from diag and circ. ASA was decreased to 81mg PO daily (from 325), Plavix 75 mg daily continued, Metoprolol tartrate changed to 12.5mg [**Hospital1 **] (from 50 [**Hospital1 **]) [**1-5**] hypotension, continued pravastatin 80mg daily. . # Atrial Fibrillation: Remained in A-fib throughout admissiion. Metoprolol mostly held [**1-5**] hypotension, with rates remaining in the 70's-80's. Now on metoprolol 25mg XL for rate control (changed from 50 [**Hospital1 **]). On coumadin at home, was held for most of admission [**1-5**] anemia with GI bleed (see below). Restarted on [**2157-9-4**], at lower than home dose at present. . # Anemia: hct dropped to 22.1 at low point, baseline in high 20's. She had some blood-tinged sputum and melena, in the setting of wretching likely secondary to congestion. She was transfused 2 units pRBCs without incidence, and hct remained stable in the low 30's. Coumadin was restarted on [**9-4**], she continues on plavix 75mg daily, and ASA was decreased to 81mg from 325mg daily. . # Metabolic alkalosis: [**1-5**] diuresis. Should continue to improve as euvolemia is achieved and diuresis can be scaled back. . # Acute Kidney Injury: Likely [**1-5**] vascular congestion and poor forward flow, exacerbated by intravascular volume depletion [**1-5**] diuresis. Baseline is cr 1.2-1.3, she went up to Cr 2.2 at one point, and has now been trending back down to Cr 1.7. . # Chronic Obstructive Pulmonary Disease: No evidence of exacerbation at this time. No wheezes on exam. Pt continued on Albuterol and Ipratropium nebs and O2 as needed. . # Diabetes Mellitus: Pt was on 74 units glargine qPM, had some issues with hypoglycemia so now on 30 units glargine. FBS running in high 100's. . Transitional issues: 1. Please make appt with Dr. [**Last Name (STitle) **] (outpt cardiologist) upon discharge 2. New appt with Dr [**First Name (STitle) 437**], heart failure specialist at [**Hospital1 18**] 3. Assess fluid status and change IV lasix to PO once pt appears dry, Dr. [**First Name (STitle) 437**] can assist with heart failure management 4. Start lisinopril for afterload reduction as BP allows 5. Uptitrate glargine as needed per fingersticks 6. Pt will need intensive teaching regarding CHF management at home 7. Check lytes regularly while on IV lasix Medications on Admission: MEDICATIONS (Admission Meds): # O2 3-4L # Tylenol 650 mg q 4 PRN # Mucomyst 20% 600 mg [**Hospital1 **] # Aspirin 325 mg daily # Vitamin D3 800 units daily # Plavix 75 mg daily # Colace 100 mg [**Hospital1 **] # Lasix 40 mg IV daily (held recently) # SSI Novolog # Levemir insulin 74 units subQ at bedtime # Xopenex 1.25 mg inhalation q 6 hours PRN # Synthroid 75 mcg daily # Lopressor 25 mg [**Hospital1 **] # Niacin 500 mg QHS # Nicotine Patch 21 mg topically daily # Nitrostat 0.4 mg SL q5 mins up to 3 doses # Percocet 1 tab PO q 4 as needed # Senna 1 tab PO at bedtime # Silver gel topically # Pravastatin 80 mg qhs # Ocean Nasal spray q4 hours as needed # Spiriva 1 puff daily # Coumadin (held recently) # Heparin gtt Discharge Medications: 1. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for back pain. 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 4. 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. 5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. insulin lispro 100 unit/mL Solution Sig: 0-12 units Subcutaneous four times a day: as per sliding scale. 8. insulin glargine 100 unit/mL Solution Sig: Thirty (30) units Subcutaneous at bedtime. 9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) vial Inhalation Q6H (every 6 hours) as needed for wheeze. 10. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day: Hold SBP <90, HR<55. 12. niacin 500 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO at bedtime. 13. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 15. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 16. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily). 17. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for fungal infection for 3 days. 18. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 20. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for heartburn . 21. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 22. furosemide 10 mg/mL Solution Sig: Eight (8) ml Injection twice a day: 80 mg total [**Hospital1 **]. 23. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Acute on Chronic Congestive Heart Failure Acute on chronic Kidney Injury Coronary Artery disease Atrial fibrillation on warfarin Chronic Obstructive Pulmonary disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 89581**], You were admitted to the hospital with worsening of your congestive heart failure. You were initially admitted to the floor where we started you on IV lasix. Because your blood pressures dropped when we started this medication we transferred you a floor where they could watch you more closely. We have adjusted your medicines to help your heart work better and get rid of extra fluid. You were anemic and received a blood transfusion. The following changes were made to your medications: 1. Discontinue mucomyst, Xopenex, nicotine patch 2. Decrease glargine to 30 units at night 3. Decrease aspirin to 81 mg daily 4. Decrease metoprolol to 25 mg once daily 5. Start Miralax for constipation 6. STart miconazole powder for your rash 7. Start iron for your anemia 8. Start pantoprazole and ranitidine as needed for your heartburn 9. Start spironolactone to help with your heart failure 10. Increase the lasix to 80 mg IV twice daily 11. Decrease your warfarin to 3mg daily Thank you for letting us participate in your care. We wish you a speedy recovery. Followup Instructions: Please make an appt with Dr [**Last Name (STitle) **] when pt is discharged. . Department: CARDIAC SERVICES When: MONDAY [**2157-9-26**] at 1:30 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

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icd9cm

[ [ [] ] ]

[ "38.93", "88.56", "37.23" ]

icd9pcs

[ [ [] ] ]

14158, 14230

6218, 10506

308, 314

14441, 14441

3841, 3841

15713, 16100

2002, 2113

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57,490

102,978

42699

Discharge summary

report

Admission Date: [**2130-2-3**] Discharge Date: [**2130-2-12**] Date of Birth: [**2083-1-5**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5790**] Chief Complaint: Tracheobronchomalacia Major Surgical or Invasive Procedure: [**2130-2-3**] Redo right thoracotomy, thoracic tracheoplasty with mesh, right mainstem bronchus bronchoplasty with mesh, left mainstem bronchus bronchoplasty with mesh, repair of bronchus intermedius laceration, bronchoscopy with bronchoalveolar lavage, pericardial fat pad buttress History of Present Illness: 47yo male with ongoing dyspnea with exertion mostly and severe bouts of dry high-pitch cough for years. He was evaluated for on multiple occasions but only about 9 months ago underwent bronchoscopy showing tracheomalacia in the distal trachea. Further work up was complicated by a trial of stent resulting in R bronchial tear needing surgical repair with a muscle flap, tracheostomy and prolonged ICU course, rehab, eventual trach removal. On presentations he is bothered by a severe dry cough, DOE and decreased activity toleraNCE. He had a trial stent placedin early [**January 2130**] which improved his symptoms dramatically. The stent was removed for yeast laryngitis and he had completed a course of Diflucan. Past Medical History: PMH Tracheomalacia HTN obesity anxiety/depression mild GERD Hx of portal vein thrombosis which resolved sinusitis s/p Right thoracotomy with repair of bronchial tear with intercostal muscle flap Social History: From [**State 4260**] Married, supportive family. No A/T/D Family History: Noncontributory Physical Exam: BP: 130/73. Heart Rate: 92. Weight: 197. Height: 65.5. BMI: 32.3. Temperature: 98.7. Resp. Rate: 16. Pain Score: 0. O2 Saturation%: 99. Chest:CTAB, incisions healing well COR RRR Abd lg soft, NT Ext calves soft, no edema Pertinent Results: [**2130-2-10**] 09:25AM BLOOD WBC-11.1* RBC-3.35* Hgb-9.8* Hct-29.0* MCV-87 MCH-29.3 MCHC-33.9 RDW-14.9 Plt Ct-182 [**2130-2-10**] 09:25AM BLOOD Plt Ct-182 [**2130-2-10**] 09:25AM BLOOD Glucose-91 UreaN-15 Creat-0.8 Na-136 K-3.9 Cl-96 HCO3-28 AnGap-16 [**2130-2-6**] 01:53AM BLOOD CK(CPK)-4430* [**2130-2-5**] 01:49PM BLOOD CK-MB-12* MB Indx-0.2 [**2130-2-10**] 09:25AM BLOOD Calcium-9.4 Phos-3.7 Mg-2.0 [**2130-2-7**] 09:40PM BLOOD Type-ART pO2-107* pCO2-47* pH-7.44 calTCO2-33* Base XS-6 [**2130-2-6**] 01:12PM BLOOD Lactate-0.8 [**2130-2-6**] 10:19AM BLOOD O2 Sat-87 [**2130-2-7**] 09:40PM BLOOD freeCa-1.08* Brief Hospital Course: The patient was admitted to the surgical service following Redo right thoracotomy, thoracic tracheoplasty with mesh, right mainstem bronchus bronchoplasty with mesh, left mainstem bronchus bronchoplasty with mesh, repair of bronchus intermedius laceration, bronchoscopy with bronchoalveolar lavage, pericardial fat pad buttress. Please see the dictated operative note for further details of the patient's procedure. Postoperatively the patient was taken to the surgical intensive care unit. Intensive care Unit Course: [**2-3**]: Admitted to the Surgical Intensive Care Unit status post redo tracheobronchoplasty for tracheobronchomalacia. He was extubated, weaned off pressor support. He continued to have sinus tachycardia overnight. His CK was increased to 7,000, his Creatinine was 1.3, he was making adequate urine [**2-4**]: Chest tube put to water seal. Repeat CXR showed increased pleural effusion on the right side, chest tube was put back to suction. He was started on ativan as needed for agitation, which is a home medication. His hematocrit had slow decline, unclear source as no evidence of active bleeding. His creatine kinase was downtrending from 8000 to 6000 with fluids. [**2-5**]: Poor pain control in AM, was evaluated by the acute pain service. The epidural was still working well and hence was adjusted to Bupivicaine+Dilaudid rate 12 (max) with good effect. CK from 7000->4500 in pm, his urine output was sufficient. [**2-6**]: Pt became increasingly tachypneic, with increased oxygen requirement. He received IV Lasix with good response and was placed on BiPAP w/ subsequent improvement in CXR, oxygenation, and symptoms. O2 sats remained stable on shovel mask overnight. Hct trend 21.8-->21.7--19.8 w/ complaints of dizziness. Transfused 1u PRBC w/ Hct increase to 23. Pain control tenuous; epidural rate to 14, split and dilaudid PCA added. [**2-7**]: Lasix given in the AM, with good UOP of about 600cc. Chest tube pulled in AM, repeat CXR showed no reaccumulation of effusion. HIs diet was advanced per thoracics attending. Lasix repeated in the evening, with overall negative -400. Hct stable. ABG stable. can most likely be transferred to the floor today. [**2-8**]: Epidural DC'd, HSQ increased to TID. Not using Dilaudid PCA (only took 0.5mg overnight), started Oxycodone w/ Dilaudid IV PRN for breakthrough, made bowel regimen standing. He was transferred to the floor. Upon transfer to the floor,the patient was doing well. He had no acute events, and hisoxygen was gradually weaned. His pain was controlled with oral pain medication. He was tolerating a regular diet. He was able to ambulate and void. A trending ambulatory pulse oximetry was done on [**2130-2-11**] which demonstrated that he was able to maintain his oxygenation at 93-96% on room air. His mental status was clear and coherent at his baseline. Hid home medications were restarted. He will be discharged and will remain in the area at a nearby hotel until seen in follow up, at which time he may be medically cleared to travel back to [**State 4260**] with his wife. Medications on Admission: Nasonex 50 mg 2 puffs [**Hospital1 **] Lipitor 40 mg PO Daily Cymbalta 60 mg 1 tab PO daily Nexium 40 mg 1 tab PO daily Divalproex 500 mg 1 tab PO daily Febofibrate 200 mg PO daily Notriptyline 25 mg PO Daily Lorazepam 1 mg POI Daily Discharge Medications: 1. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 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 at bedtime. 4. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. Nasonex 50 mcg/actuation Spray, Non-Aerosol Sig: Two (2) nasal sprays Nasal once a day. 6. fenofibrate 160 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 8. lorazepam 1 mg Tablet Sig: One (1) Tablet PO once a day as needed for anxiety. 9. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 11. Oxycodone 5-10mg PO Q4H prn pain Discharge Disposition: Home Discharge Diagnosis: tracheobronchomalacia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: * You were admitted to the hospital for lung surgery and you've recovered well. You are now ready for discharge. * Continue to use your incentive spirometer 10 times an hour while awake. * Check your incisions daily and report any increased redness or drainage. Cover the area with a gauze pad if it is draining. * You will continue to need pain medication once you are home but you can wean it over a few weeks as the discomfort resolves. Make sure that you have regular bowel movements while on narcotic pain medications as they are constipating which can cause more problems. Use a stool softener or gentle laxative to stay regular. * No driving while taking narcotic pain medication. * Take Tylenol 650 mg every 6 hours in between your narcotic. If your doctor allows you may also take Ibuprofen to help relieve the pain. * Continue to stay well hydrated and eat well to heal your incisions * Shower daily. Wash incision with mild soap & water, rinse, pat dry * No tub bathing, swimming or hot tubs until incision healed * No lotions or creams to incision site * Walk 4-5 times a day and gradually increase your activity as you can tolerate. Call Dr.[**Name (NI) 5067**]/Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience: -Fevers > 101 or chills -Increased shortness of breath, chest pain or any other symptoms that concern you. Followup Instructions: As you know, you should remain in the area until seen in follow up in Dr.[**Name (NI) 2347**] clinic. At that time you may be cleared for travel back to [**State 4260**]. Please call Dr.[**Name (NI) 92303**] Clinic at [**Telephone/Fax (1) 92304**] to schedule your follow up appointment. Completed by:[**2130-3-9**]

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icd9cm

[ [ [] ] ]

[ "03.90", "33.48", "31.79", "96.56", "33.23" ]

icd9pcs

[ [ [] ] ]

6862, 6868

2587, 5674

330, 616

6934, 6934

1951, 2564

8478, 8796

1677, 1694

5959, 6839

6889, 6913

5700, 5936

7085, 8455

1709, 1932

269, 292

644, 1365

6949, 7061

1387, 1584

1600, 1661

6,475

154,622

447

Discharge summary

report

Admission Date: [**2113-5-10**] Discharge Date: [**2113-5-14**] Date of Birth: [**2035-11-8**] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 77 year old gentleman with past medical history of asthma, recent Group A Streptococcus, non-necrotizing fasciitis, Dr. [**Last Name (STitle) **] for his recent infection the day of admission. At the appointment, Dr. [**Last Name (STitle) **] noted that the patient had a significant cardiac rub. A chest x-ray was ordered which documented that there was significant cardiomegaly compared to his previous chest x-ray one week prior to admission. Dr. [**Last Name (STitle) **] referred the patient to the [**Hospital6 256**] Emergency Department for echocardiogram to evaluate for a possible pericardial effusion. In the Emergency Department the patient was noted to have significant accumulation of pericardial fluid and physiological evidence of cardiac tamponade. The patient was admitted from the Emergency Department to the Cardiac Intensive Care Unit for hemodynamic monitoring. The cardiology fellow was consulted regarding the need for pericardiocentesis. Given the patient's blood pressure was stable, the decision was made to hold off on pericardiocentesis until the morning following admission, so the patient could have the full attention of all members of the Cardiac Catheterization Laboratory. PAST MEDICAL HISTORY: 1. Asthma. 2. Gout. 3. Gastroesophageal reflux disease. 4. Mild anemia. MEDICATIONS ON ADMISSION: 1. Amoxicillin 500 q. 8 hours. 2. Singulair. 3. Albuterol. 4. Salmeterol. 5. Fosamax 70 q. Tuesday. 6. Calcium with Vitamin D. 7. Fluticasone. PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.1, heart rate 55, blood pressure 151/56, respiratory rate 22, oxygen saturation 98% on room air. In general, she was a well-appearing elderly male in no apparent distress. Head, eyes, ears, nose and throat was anicteric. Facial muscles were symmetric. Mucous membranes were moist. Cardiovascular, borderline tachycardia, notable soft, vocal-like rub at the left lower sternal border. The patient had a pulsus paradoxus at 22. Pulmonary, the patient was noted to have basilar crackles, no wheezes or rhonchi. The abdomen with active bowel sounds, soft, nontender. The patient had mild mid epigastric tenderness as well as right upper quadrant tenderness. There was no apparent guarding, no rebound, no evidence of acute abdomen. Extremities, he had mild 1+ peripheral edema, isolated only to his feet bilaterally. Feet were warm. He has had some notable conjunctival pallor. HOSPITAL COURSE: 1. Cardiac - The patient was noted to have tamponade physiology on his transesophageal echocardiogram in the setting of recent pericarditis. The patient was taken to the Cardiac Catheterization Laboratory on [**2113-5-11**] for pericardiocentesis. The procedure drained approximately 550 cc of bloody fluid. On post procedure the patient's pulsus paradoxus decreased to less than 10. The patient did have some pain post procedure, for which she was treated with Toradol and Morphine with good effect. The drain was removed after 24 hours. The patient was followed with serial echocardiograms which did not reveal reaccumulation of the fluid. He had three separate echocardiograms performed. There was some notation of increased density on the perimeter of his pericardium which could be possible. Dr. [**Last Name (STitle) 284**] discussed with the patient that this may place him at risk for developing a constrictive etiology in the future. The patient was informed that if he develops worsening shortness of breath or lower extremity edema, he should call Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) 284**] for further evaluation immediately. 2. Rhythm - The patient was in normal sinus rhythm on admission. Initially he was noted to have short runs of nonsustained ventricular tachycardia no greater than 5 beats in a row. This resolved with drainage of the pericardial fluid. 3. Ischemia - The patient had his cardiac enzymes cycled. There was no evidence of coronary artery disease by cardiac enzymes. The patient had no history of coronary artery disease. 4. Heme/infectious disease - The patient had a recent Group A Streptococcus non-necrotizing fasciitis for which he had been treated with Amoxicillin for a ten day course. The patient completed a ten day course during this hospitalization with the last day being [**2113-5-14**]. In addition, the patient was noted to have a history of chronic anemia which had been described as sideroblast anemia by Dr. [**Last Name (STitle) 2148**]. The patient also was noted to have Vitamin B12 deficiency during the hospital stay. He was started on B12 supplementations during his hospital stay and will be started on Vitamin B12 p.o. 100 q.d. 5. Pulmonary - The patient has a history of asthma, which appears well controlled. He was continued on his home asthma medications which include Fluticasone, Salmeterol, Albuterol and Montelukast without any exacerbations during his hospital stay. In addition, the patient had some history of lung nodules and has been recommended to have a repeat computerized tomography scan which had not been done. During this hospital stay, the patient did have a repeat chest computerized tomography scan which showed moderate pericardial effusion, moderate bilateral pleural effusions left greater than right and bibasilar atelectasis. Computerized tomography scan was able to comment on the tiny nodule in the lingula which was unchanged as well as the 2 mm left upper lobe nodule which appeared unstable. They were unable to comment on the previous 6 mm nodule in the left lower lobe given this was obscured by pleural fluid. Based on the chest computerized tomography scan though, it appears that none of the nodules have changed in size. If there is concern, then a repeat chest computerized tomography scan can be performed as an outpatient in the future. 6. Fluids, electrolytes and nutrition - The patient was noted to have the bilateral pleural effusions and had been given a significant amount of hydration prior to having the pericardiocentesis to maintain adequate preload. The patient was diuresed with Lasix with good effect prior to discharge. DISCHARGE CONDITION: Stable. The patient's pain with deep inspiration has resolved. The patient is tolerating a full p.o. diet. The patient is ambulating without difficulty. DISCHARGE DIAGNOSIS: 1. Cardiac tamponade. 2. Idiopathic pericarditis. 3. Pericardial effusion. 4. Asthma, mild. 5. Anemia of chronic disease. 6. B12 deficiency. DISCHARGE FOLLOW UP: The patient should follow up with Dr. [**Last Name (STitle) **] within one to two weeks of discharge. In addition he was informed he should call Dr.[**Name (NI) 3811**] office the day following discharge to make an appointment. He was advised to schedule an echocardiogram approximately one week prior to his next appointment with Dr. [**Last Name (STitle) 284**]. DISCHARGE MEDICATIONS: 1. Salmeterol 1 puffs b.i.d. 2. Montelukast 1 tablet p.o. q.d. 3. Fluticasone 2 puffs b.i.d. 4. Nexium 40 mg p.o. q.d. 5. Albuterol 1 to 2 puffs q. 6 hours prn. 6. Tylenol prn. 7. Calcium carbonate with Vitamin D. 8. Fosamax 70 q. Tuesday. 9. Vitamin B12 100 mcg p.o. q.d. 10. Multivitamin one tablet p.o. q.d. 11. Amoxicillin 500 mg p.o. q. 8 hours, today is the last day. 12. Ibuprofen 200 mg tablet, three tablets p.o. t.i.d. prn arthritic pain. [**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3812**] Dictated By:[**Name8 (MD) 3482**] MEDQUIST36 D: [**2113-5-14**] 12:45 T: [**2113-5-14**] 19:12 JOB#: [**Job Number 3813**]

[ "285.29", "729.4", "423.9", "511.9", "493.90" ]

icd9cm

[ [ [] ] ]

[ "37.0" ]

icd9pcs

[ [ [] ] ]

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1506, 1678

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158,528

12937

Discharge summary

report

Admission Date: [**2140-7-11**] Discharge Date: [**2140-7-25**] Date of Birth: [**2098-9-9**] Sex: F Service: NEUROLOGY Allergies: Ciprofloxacin Hcl / Epinephrine / Pentothal / Flagyl Attending:[**First Name3 (LF) 618**] Chief Complaint: HA, unsteady gait Major Surgical or Invasive Procedure: None History of Present Illness: 41yo RH F h/o HTN, hyperlipidemia, smoking and recent mesenteric ischemia s/p iliocecectomy and R colectomy with course c/b cholecystitis and possible generalized seizure (thought to be [**2-5**] ativan withdrawal) who presents with several days of excruciating headache and one day of unsteady gait. Headache began on Thursday behind the right cheek and spread to between her eyes this weekend. It built to excruciating pain over the course of days and today was a/w nausea/vomiting x 1. The pain is constant and non-throbbing and she cannot identify exacerbating or relieving factors; she denies upon questioning worsening with prone position, straining, cough or sneezing. She denies changes in her vision. No photo/phonophobia. She had no other deficits until today. She went out for breakfast and was able to walk. She returned home and stayed in bed. This early afternoon, around 1pm, she got up to walk and her husband says she was "walking like she was drunk"; she endorses falling to the left side and on questioning, says that side feels weak. This apparently had a sudden onset, as she was able to walk with no difficulty this morning. She denies other deficits, such as changes in her vision or diplopia, incoordination, vertigo, numbness/tingling, dysarthria or dysphagia. She has no neck pain or back pain. In the ED, she received morphine 2mg IV at 21:17pm, zofran 4mg IV at 21:19pm and labetalol 10mg IV at 21:28pm and 21:45 for HTN up to systolic bp 220's, as well as hydralazine 10mg IV at 22:00pm. ROS: On review of systems, the pt denied recent fever or chills. No recent travel or leg pain. No night sweats; she does have recent weight loss due to her recent bowel surgery. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Denied rash. Past Medical History: -HTN -MVP (takes abx prophylactically and no recent dental manipulations) -Hyperlipidemia -Chronic fatigue -Chronic headaches (migraines, a/w P/P, N/V and unlike this HA) -Fibromyalgia -Depression/Anxiety -Talus fracture -Cervical cancer (no further details) -GERD -Hydronephrosis -Mild COPD -Appendectomy [**2131**] No h/o blood clots or miscarriages Social History: Works as proofreader. Smoked 1.5-2ppd since age 14, quit one month ago. No etoh/drugs. History of heavy alcohol use, stopped in [**2136**]. Denies illicits. Family History: Mother and aunt with coronary artery disease and carotid disease. Parents died of cancer (she is unable to provide further details). No h/o clots. Physical Exam: VS 98.7 106 228/131 18 98% Gen Awake, cooperative, in obvious discomfort holding her eyes and head HEENT NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck Supple, no carotid bruits appreciated. No nuchal rigidity Lungs CTA bilaterally CV RRR, nl S1S2, no M/R/G noted Abd soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted Ext No C/C/E b/l Skin no rashes or lesions noted. No splinter hemorrhages. NEURO MS Awake, alert but requires frequent prompting to cooperate with interview. Fully oriented. MOYB intact but slow. Speech fluent, with normal naming, comprehension and repetition. Normal prosody. There were no paraphasic errors. Able to follow both midline and appendicular commands. When asked to name objects on the NIH stroke card, she was unable to point to them or even the card; she has optic ataxia as well on both sides of space. Appears to be able to guide her gaze to find objects in space. Interprets cookie theft picture appropriately. No dysarthria. She denies visual deficits and confabulates when [**Location (un) 1131**]. Names colors. CN CN I: not tested CN II: Possible RHH more inferior quadrant, no extinction. Pupils 3->2 on the left, 4->3 on the right. Can count fingers in all quadrants and answer questions such as whether I am wearing a tie or glasses. Fundi unable to visualize due to lack of cooperation. CN III, IV, VI: EOMI no nystagmus or diplopia CN V: intact to LT throughout CN VII: full facial symmetry and strength CN VIII: hearing intact to FR b/l CN IX, X: palate rises symmetrically CN [**Doctor First Name 81**]: shrug [**5-7**] and symmetric CN XII: tongue midline and agile Motor Normal bulk and tone. L pronator drift. Does not cooperate fully with power testing but is clearly [**4-7**] in left triceps and finger extensors, as well as 4-/5 in left IP's, [**4-7**] left hamstrings and [**4-7**] in dorsiflexors and toe extensors. [**5-7**] on the right in these muscle groups. Sensory intact to LT, PP, JPS, vibration throughout. No extinction. Reflexes 2+ in UE's, 1+ in legs b/l. Toes down on right and up on left. Coordination unable to assess FTN as she cannot find the target visually on either side or with either arm. Can tap rhythmically with either heel. Gait refused. Can sit unassisted on the edge of the bed. Pertinent Results: WBC 17.4 (higher than baseline) with 81.2 PMNs; hct 34, plts 428 Coags normal Na 128, K 4.7, Cl 85, HCO3 33 (AG 15), BUN 10, Cr 0.9, Glu 151 Ca/Mg/Phos normal Amylase 123 (trending down) Lipase 61 (also trending down) ALT 41/AST 79; Alk P 290 CE's neg x 2 A1c 5.4 [**2140-7-19**] 06:30AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2140-7-19**] 02:45PM BLOOD ANCA-NEGATIVE B [**2140-7-22**] 06:20AM BLOOD CRP-30.6* [**2140-7-18**] 09:08PM BLOOD CRP-275.3* [**2140-7-19**] 02:45PM BLOOD [**Doctor First Name **]-NEGATIVE dsDNA-NEGATIVE [**2140-7-19**] 02:45PM BLOOD [**Doctor First Name **]-NEGATIVE dsDNA-NEGATIVE [**2140-7-19**] 06:30AM BLOOD C3-163 C4-31 [**2140-7-12**] 01:33PM BLOOD HIV Ab-NEGATIVE [**2140-7-11**] 04:54AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2140-7-19**] 06:30AM BLOOD HCV Ab-NEGATIVE [**2140-7-12**] 02:44AM BLOOD ANGIOTENSIN 1 - CONVERTING [**Last Name (un) **]-Test [**2140-7-12**] 01:33PM BLOOD FACTOR V LEIDEN-PND [**2140-7-12**] 01:33PM BLOOD PROTHROMBIN MUTATION ANALYSIS-PND [**2140-7-12**] 01:33PM BLOOD Metanephrines (Plasma)- TEST [**2140-7-21**] 03:40PM BLOOD BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA, IGM, IGG)-PND [**2140-7-21**] 03:40PM BLOOD Beta-2-Glycoprotein 1 Antibodies IgG-PND TSH 5.1 HIV [**Doctor First Name 1059**] and VLNegative Serum and Urine Tox negative Fibrinogen 331 Lupus anticoagulant: Negative [**Doctor First Name **]: Negative C3: 112; C4: 16 Rheumatoid Factor: 5 ACA abs: Pending Homocysteine: 9.4 CSF Tube 1: WBC 3; RBC 80; 32 polys, 42 lymphs, 26 monos Tube 4: WBC 3; RBC 310; 22 polys, 51 lymphs, 27 monos Protein: 143 Glucose: 65 CSF: Gram stain, HSV PCR, Lyme, VZV PCR, VDRL, Cryptococcal ag, [**Male First Name (un) 2326**] virus all negative Tests TEE [**2140-6-14**]: trivial MR, trivial TR. No ASD/PFO. Normal EF. No aortic atheroma. Imaging NCHCT [**2140-7-10**]: Multifocal hypoattenuating regions, bilaterally, in a non- arterial distribution, much of which is consistent with vasogenic edema. With considerations of cerebral venous thrombosis, vasculitis, PRES, toxic (including drug effect) and infection, including viral (particularly, HSV) or septic emboli, gadolinium-enhanced MRI, with cerebral MRA and MRV, was recommended for further characterization and has been obtained. CXR [**2140-7-10**]: No, evidence of acute cardiopulmonary process. CTA Head/Neck [**2140-7-11**]: 1. Evidence of large vessel disease in the neck, with moderate stenoses of the left subclavian artery proximal to the vertebral origin, and of the left internal carotid artery just distal to its origin. 2. No definite evidence of small vessel disease, although evaluation of the intracranial vessels is limited by suboptimal technique. If further evaluation of the intracranial vessels is needed, cerebral angiography would be the most appropriate diagnostic test. 3. Unchanged CT appearance of multifocal cortical and subcortical hypodensities, better characterized by prior MRI. MRI/A Head/Neck [**2140-7-11**]: 1. New areas of abnormal increased diffusion signal, in multiple vascular territories, including bilateral PCA, right ACA, and right MCA territories. Most likely, these areas represent subacute infarctions. Enhancement of these areas may be consistent with evolving infarction, given the gyriform enhancement pattern; other etiologies including vasculitis, and infection such as septic emboli and viral infection such as herpes simplex should be considered. This would be a very unusual pattern for reversible leukoencephalopathy, but followup imaging will be helpful to determine if there is any reversible component. 2. No evidence of dural sinus thrombosis. Carotid U/S [**2140-7-11**]: Bilateral less than 40% carotid stenosis. Echocardiogram [**2140-7-11**]: 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 or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular systolic function is normal. There are simple atheroma in the arch and descending aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. No aortic valve abscess is seen. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. Hip film [**2140-7-12**]: Joint spaces are preserved. There are no signs of acute fractures. There is normal osseous mineralization. Sacroiliac joints are unremarkable. Abdominal U/S [**2140-7-12**]: 1. No evidence of underlying bowel obstruction or pneumoperitoneum. Single loop of dilated small bowel of unclear [**Name2 (NI) 39728**]. 2. Increased density likely within the left renal collecting system suggestive of recently administered IV contrast in this patient with known long-standing left hydronephrosis and UPJ obstruction. Please correlate clinically. Brief Hospital Course: Ms. [**Known lastname 39729**] is a 41 year old woman with a history of HTN, hyperlipidemia, and recent mesenteric ischemia s/p R hemicolectomy who p/w bifrontal headache who was admitted with N/V and left sided hemiplegia and unsteady gait. Her hospital course by problem is as follows: 1. NEURO: Her initial neuro exam showed a left hemiplegia, as well as elements of [**Doctor First Name **] syndrome (denial of blindness or visual disturbance) and [**Doctor Last Name **] syndrome (optic ataxia and possible optic apraxia). MRI obtained in the ED showed multiple areas of enhancement, more likely hypertensive encephalopathy but possibly areas of stroke. Posterior reversible encephalopathy syndrome was considered most likely. Vasculitis was also considered, given her elevated ESR. However, the LP and CTA were not consistent with this. Hypercoagulability work up was also initiated given her mesenteric ischemia and concern for cerebral embolic events (esp. that she had lesions in multiple vascular distributions). A rheumatology consult was placed to try to help identify the underlying etiology of her multiple intracranial lesions and recent mesenteric ischemia. She had an extensive vasculitis work-up, excluding angiogram or biopsy. Aside from an elevated ESR and CRP her work-up was negative for HSV [**1-5**] and VL, HHV 6, CMV, Lyme, ANCA, [**Male First Name (un) 2326**], EBV, VDRL, ds DNA, [**Doctor First Name **], hyperhomocysteinemia, HCV and HBV. Endocarditis was considered, but blood cultures were negative and echo was normal. Her symptoms improved over the course of the next few days to the point of having only mild Left sided weakness and mild confusion, and she was called out to the step down unit. There she was monitored and her blood pressure medications were gradually titrated up. She was then transferred to the floor where her mental status began to improve and her strength returned to [**Location 213**]. She did have persistent labile affect. A repeat MR prior to discharge showed improvement of the intracranial lesions. The mechanism of stroke was felt to be likely hypertension. 2. ID: Her initial leukocytosis resolved however late in her hospital course she developed a Klebsiella UTI. She completed a course of Bactrim and her symptoms of dysuria and frequency resolved. 3. CV: HTN. BP was controlled initially with nicardipine drip and then nimodipine po for a goal SBP 140-180. She was then switched to verapamil, HCTZ and metoprolol with good results. She was also monitored on telemetry without events. 4. GI: h/o mesenteric ischemia with abdominal pain. Surgery followed and found no acute pathology. Abdominal CT was obtained which showed no abscesses or evidence of inflammation. Her path report from the initial surgery were also reviewed without evidence of vasculitis. 5. She was discharged with home PT and OT and will follow-up with her primary care doctor for follow-up of her Factor V Leiden and Prothrombin gene mutation results as well as Neurology. CODE - full code Medications on Admission: Fluoxetine 10 mg PO DAILY Metoprolol Tartrate 12.5 mg PO BID Hydrochlorothiazide 25 mg Tablet PO DAILY Aspirin 325 mg Tablet PO once a day Simvastatin 20 mg PO once a day. Bentyl 10 mg PO three times a day. Ranitidine HCl 150 mg PO twice a day Prilosec 20 mg PO twice a day Nortriptyline 10 mg PO once a day No OCPs. Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*0 Tablet(s)* Refills:*0* 2. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*1* 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*1* 4. Dicyclomine 10 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*1* 5. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*1* 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 11. Hydrochlorothiazide 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as needed for HTN. Disp:*60 Tablet(s)* Refills:*2* 12. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. Disp:*120 ML(s)* Refills:*0* 13. Verapamil 80 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:*2 Tablet(s)* Refills:*2* 14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day) as needed for HTN. Disp:*60 Tablet(s)* Refills:*1* Discharge Disposition: Home With Service Facility: Nurses PRN Discharge Diagnosis: 1. Stroke 2. Hypertension 3. UTI Discharge Condition: Stable Discharge Instructions: 1. Please see your doctor [**First Name (Titles) 3**] [**Last Name (Titles) 1988**] 2. Please take all your medications as prescribe 3. Please call your doctor or come to the nearest ED if you have new symptoms Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2140-8-2**] 3:45 Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2140-9-27**] 2:15 [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

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icd9cm

[ [ [] ] ]

[ "99.04", "88.72", "03.31" ]

icd9pcs

[ [ [] ] ]

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521

Discharge summary

report

Admission Date: [**2186-12-11**] Discharge Date: [**2186-12-13**] Date of Birth: [**2136-6-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1711**] Chief Complaint: CHEST PAIN Major Surgical or Invasive Procedure: Catheterization History of Present Illness: Mr. [**Known lastname 4318**] is a 50 yo M with history of prior anterior MI s/p DES to LAD in [**8-29**] who presented to ED after experiencing CP since 9am and found to have inferior STE. He was working on his truck this am when he started to have chest tightness and diaphoresis that felt similar to his prior heart attack. He rated it as a [**8-4**]. The night prior he said he took an antacid for what he thought was gas pain. He says he had not taken any of his medications in 6 months except his aspirin. He had co-workers call 911. . In the ED, initial vitals were 78 118/87 16 100%NRB. Given nitro, morphine, plavix 600mg, and started on integrillin. He was taken to cath where he has near occlusion of OM and underwent export thrombectomy followed by direct stenting with a 3.0x15mm Endeavor, post-dilated to 3.25mm. An LVgram showed EF in 40% marked LV dysfunction 40% (anterior, apical, and posterolateral HK). LVEDP ~35-40mmHg. He was started on intergrillin and had a perclose. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, borderline Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: Cypher drug-eluting stent (3.5 x 18 mm) to LAD at [**Hospital **] in [**8-29**], prior to discharge he had stress testing performed during which he exercised for 12 minutes 20 seconds on a modified [**Doctor First Name **] protocol, achieving a heart rate of only 104. With this he had no symptoms except for fatigue and no ischemic ECG changes. -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: -COPD/emphysema, pulm nodule documented on CTA [**7-3**] -systolic CHF post LAD infarct/ischemia that had resolved on echo [**7-3**] Social History: -works as truck dispatcher -Tobacco history: He has been a heavy smoker, up to three packs/day, but currently one pack/week. He has no known history of hypertension. -ETOH: 6 beers/week -Illicit drugs: none Family History: There is a family history of cardiac disease with his father having had an MI and CVA in his 60s and his mother an MI at approximately age 70. Otherwise, no family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: T=97.3 BP=140/87 HR= 89 RR=22 O2 sat= 95% on RA GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. 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. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2186-12-12**] 03:14AM BLOOD WBC-9.7 RBC-5.00 Hgb-15.7 Hct-44.8 MCV-90 MCH-31.3 MCHC-35.0 RDW-15.2 Plt Ct-183 [**2186-12-11**] 06:45PM BLOOD WBC-11.0 RBC-5.04 Hgb-15.1 Hct-44.6 MCV-89 MCH-30.0 MCHC-33.9 RDW-15.0 Plt Ct-209 [**2186-12-11**] 10:30AM BLOOD WBC-11.0 RBC-4.82 Hgb-14.8 Hct-42.9 MCV-89 MCH-30.7 MCHC-34.5 RDW-14.9 Plt Ct-229 [**2186-12-11**] 10:30AM BLOOD PT-12.0 PTT-24.3 INR(PT)-1.0 [**2186-12-11**] 10:30AM BLOOD Plt Ct-229 [**2186-12-11**] 06:45PM BLOOD Plt Ct-209 [**2186-12-12**] 03:14AM BLOOD Glucose-110* UreaN-13 Creat-0.7 Na-137 K-4.9 Cl-107 HCO3-22 AnGap-13 [**2186-12-11**] 06:45PM BLOOD Glucose-163* UreaN-15 Creat-0.8 Na-141 K-3.7 Cl-106 HCO3-27 AnGap-12 [**2186-12-11**] 10:30AM BLOOD Glucose-122* UreaN-16 Creat-0.8 Na-142 K-4.1 Cl-113* HCO3-20* AnGap-13 [**2186-12-11**] 06:45PM BLOOD CK-MB-138* MB Indx-14.8* [**2186-12-12**] 03:14AM BLOOD CK-MB-152* MB Indx-16.1* cTropnT-2.00* [**2186-12-12**] 07:33AM BLOOD CK-MB-109* MB Indx-15.6* cTropnT-1.57* [**2186-12-11**] 06:45PM BLOOD Calcium-8.3* Phos-4.3 Mg-2.1 [**2186-12-12**] 03:14AM BLOOD Calcium-8.2* Phos-3.2 Mg-2.1 [**2186-12-11**] 10:30AM BLOOD %HbA1c-5.7 [**2186-12-11**] 10:30AM BLOOD Triglyc-277* HDL-21 CHOL/HD-8.7 LDLcalc-106 [**2186-12-11**] 10:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG CXR: IMPRESSION: AP chest compared to [**2185-6-28**]: Heart size normal. Mild peribronchial opacification in the left mid lung is chronic, probably scarring. No pulmonary edema, focal pulmonary abnormality or pleural effusion. Pleural thickening along the left costal margin could be due to fat deposition or previous trauma. TTE [**2186-12-12**]: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with focal hypokinesis of the mid to distal anterior septum, inferior wall, and apex. Overall left ventricular systolic function is moderately depressed (LVEF= 40 %). The remaining segments contract normally. Right ventricular chamber size and free wall motion are normal. The right ventricular cavity is mildly dilated The diameters of aorta at the sinus, ascending and arch levels are normal. There are simple atheroma in the ascending aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Moderate regional systolic dysfunction c/w multivessel CAD. Cath [**2186-12-11**]: Official report is not availible - but in summary: subtotally occluded LCx s/p successful intervention with DES. LV gram suggests EF 40% with regional HK (anterior, apical, and posterolateral), which compared to most recent echo [**2185**] was normal. Brief Hospital Course: Mr. [**Known lastname 4318**] is a 50 yo M with history of prior anterior MI s/p DES to LAD in [**8-29**] who presented to ED after experiencing CP found to have inferior STE now s/p DES to OM1. . # CORONARIES: Patient has history of LAD disease and prior anterior infarct. Prior to the event, patient was not adherent to medications. He has risk factors of prior MI, HL, HTN, and smoking. After stentingn to the LCx, he was hemodynamically stable and was to CCU for monitoring. He was started on aspirin 325mg, plavix 75mg, Lisinopril 10mg, metoprolol 25 [**Hospital1 **] and atorvastatin 80mg. His cardiac enzymes were downtrending. # Pump: Patient has LV dysfunction 40% with anterior, apical, and posterolateral hypokinesis. No symptoms of heart failure and was euvolemic on exam. He was given instructions on his diet and was given consulting for smoking cessation. # RHYTHM: Patient was in sinus for the duration of his hospitalization. # Tranaminitis: Likely [**2-27**] myocardial injury, although patient also says he drinks 6 beers on sundays and with a ratio of 2:1 (ast:alt) may be hepatic injury [**2-27**] alcohol. His LFT's were trended during the hospitalization. # HL: He was not compliant with his home lipitor regimen. During the hospitalization, he was placed on atorvastatin 80mg. FEN: follow and replete elytes, regular heart healthy diet ACCESS: PIV's PROPHYLAXIS: -DVT ppx with subQhep -Pain management with tylenol -Bowel regimen with senna/colace -stress ulcer not indicated Medications on Admission: -atenolol 25 mg daily -lisinopril 20 mg daily -Lipitor 40 mg daily -gemfibrozil 600 mg twice daily -aspirin 325 mg daily***only one he is currently adhering too Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] . Disp:*30 Tablet(s)* Refills:*11* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 6. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 7. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual every 5 minutes for total of 3 [**Last Name (Titles) 4319**]: call 911 if you still have chest pain after 3 [**Last Name (Titles) 4319**]. . Disp:*30 tablets* Refills:*0* 8. Chantix 0.5(11)-1(3X14) mg Tablets, Dose Pack Sig: as directed Tablets, Dose Pack PO as directed on package. Disp:*1 dose pack* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: ST Elevation Myocardial Infarction Dyslipidemia Hypertension chronic Obstructive Pulmonary disease Coronary Artery Disease Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You had a heart attack and a drug eluting stent was placed in one of your coronary arteries. You will need to take Plavix and aspirin every day for at least one year. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking Plavix unless Dr. [**Last Name (STitle) **] tells you to. You must take all of your medicines every day to prevent another heart attack and help your heart to recover. . Medication changes: 1. Continue to take Aspirin every day 2. Increase your Atorvastatin to 80 mg daily 3. Start Metoprolol succinate 100 mg daily 4. Stop taking Atenolol 5. Start taking Plavix (Clopidigrel)to prevent the stent from clotting off and causing another heart attack. 6. Decrease your Lisinopril to 10 mg daily. 7. Chantix dose pack: take per package directions to help you quit smoking. . Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. Follow a low sodium diet. Followup Instructions: Cardiology: Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2187-1-1**] 11:20 . Primary Care: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for Dr. [**First Name8 (NamePattern2) 4320**] [**Last Name (NamePattern1) 4321**]. Date/time: 2:50pm [**2186-12-20**] Phone: [**Telephone/Fax (1) 608**]

[ "410.41", "305.1", "518.89", "492.8", "V45.82", "790.4", "412", "V15.81", "272.4", "428.0", "305.01", "401.9", "428.42", "414.01" ]

icd9cm

[ [ [] ] ]

[ "99.20", "88.56", "00.40", "88.53", "37.22", "00.66", "00.45", "36.07" ]

icd9pcs

[ [ [] ] ]

9845, 9851

6989, 8498

328, 345

10018, 10018

3970, 6966

11169, 11578

2839, 3109

8709, 9822

9872, 9997

8524, 8686

10163, 10587

3124, 3951

2015, 2432

10607, 11146

278, 290

373, 1898

10032, 10139

2463, 2598

1920, 1995

2614, 2823

10,167

102,448

6301

Discharge summary

report

Admission Date: [**2196-1-15**] Discharge Date: [**2196-1-20**] Service: Neurology HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old right-handed man with a history of coronary artery disease, insulin dependent diabetes mellitus, hypertension, peripheral vascular disease, atrial fibrillation status post stroke with left leg weakness. He had recurrent episodes of confusion shaking for the past four years. He was evaluated extensively at [**Hospital3 417**] Hospital for these spelss of transient ischemic attack versus seizure. He had several EEGs said to have been not suggestive of epileptic activity. He has been tried on AEDs without improvement. He was last seen at [**Hospital3 417**] Hospital on [**12-31**] for evaluation of a 20- minute episode of garbled speech and "confusion" and was transferred to [**Hospital1 69**] Neurosurgery service for further evaluation and management. As part of the work-up, the Neurosurgery Service performed a conventional angiogram which reportedly showed bilateral vertebral artery stenosis, right side 70%, left side 75%. Therefore, the Neurosurgery Service decided to proceed with stent angioplasty of the left vertebral artery. He was then discharged to rehabilitation on [**1-12**]. He did well until this morning when he was found again to have a spell of "being confused". His wife indicates that he was not answering questions appropriately. He was brought to the emergency room where he was noted by emergency room staff to have a 15-minute episode of moaning and garbled speech. The patient then returned to baseline. Dr. [**Last Name (STitle) 1132**] asked us to evaluate the patient for question of transient ischemic attack versus further management options. REVIEW OF SYSTEMS: His wife indicates that he had gradual cognitive decline which became more pronounced during the past year. He also has urinary incontinence at baseline, no headache, he has recurrent falls. The patient denies vertigo, diplopia, tinnitus. He has left leg weakness since [**2195-10-16**] status post stroke. MEDICATIONS ON ADMISSION: Tylenol; vitamin D; atenolol; paroxetine; calcium carbonate; quinidine; lisinopril and allopurinol. He is not on aspirin. ALLERGIES: Dilantin and Aricept. SOCIAL HISTORY: He is a retired iron worker. He is married and lives with his wife. [**Name (NI) **] quit smoking 30 years ago. He has three children. His wife indicates a history of alcohol abuse in the past. She always handled the finances at home. FAMILY HISTORY: Coronary artery disease. A brother has [**Name (NI) 5895**] disease. PHYSICAL EXAMINATION: The patient was afebrile, pulse 64 with occasional irregularities, blood pressure 140/75. In general he was a well-nourished, mildly overweight older man lying in the Emergency Department bed. He did not appear to be in any distress. HEENT was normocephalic, atraumatic. Mucous membranes were moist. On lung examination he was clear to auscultation bilaterally. Cardiac was irregular with no murmurs. Abdomen was soft, nontender, nondistended, positive bowel sounds x 4. Extremities had 2+ pulses, no edema. Neurologically he was awake, alert, oriented to place, month and year, oriented to personal information, date of birth, address and phone number. He stated that he was here because he didn't feel well but could not elaborate, unable to provide driving directions from his home to the [**Location (un) **] Building where he worked for years. He was unable to name all grandchildren and had difficulty with son's age. Speech and language were intact. There was no neglect, no apraxia. Right pupil was status post surgery at 2 mm. On the left it was 3 mm. He had decreased adduction of the left eye and nystagmus of the right eye on right gaze. There was no field cut, no Horner's, no ptosis. He had flattened right nasolabial fold. His palate went up symmetrically. He had normal tone and strength in both upper extremities, no drift. He had drift of the left lower extremity. He had tremulous finger-nose-finger bilaterally. Rapid alternating movements were intact. Deep tendon reflexes were 2+ in the upper extremities, 1+ at the knees. Right toe was down, left toe was up. He had normal cortical sensation, no bruits and positive glabellar and snout. LABORATORY STUDIES: White count was 8.2, hematocrit 38.6, platelet count 213, INR 1.1, PTT 32.8, sodium 140, potassium 4.6, chloride 104, bicarbonate 27, BUN 21, creatinine 1.4, glucose 125, CK 59, troponin negative, calcium, magnesium and phosphate were normal. B12, TSH, folate from [**1-3**] were within normal limits. RPR was negative. EKG showed normal sinus rhythm. Magnetic resonance angiography from [**2196-1-3**] did not demonstrate any diffusion abnormalities. There was a T2 and flail segment abnormality in the periventricular white matter. He had increased ventricular size and cerebral atrophy. Magnetic resonance angiography of his head was normal. There was no evidence of vertebral stenosis. Left vertebra was dominant. Magnetic resonance angiography of the neck showed mild right internal carotid artery stenosis, normal flow in both vertebral arteries. CT angiography on the day of admission showed normal results. HOSPITAL COURSE: The patient was admitted to the neurology service initially to the intensive care unit. He was transferred out of the intensive care unit on hospital day two, placed on telemetry and no cardiac events were noted. He was placed on EEG monitoring and no seizures were noted. The patient did not have his usual spells. In addition there were no interictal spikes suggestive of a seizure disorder. The patient was taken off video EEG monitoring on [**1-19**]. He was empirically started on Keppra at 250 mg p.o. b.i.d. which will be titrated up as an outpatient to a goal of 1,500 mg p.o. b.i.d. The patient will be discharged on [**2196-1-20**] to rehabilitation. DISCHARGE CONDITION: Stable. DISCHARGE DIAGNOSES: 1. Seizure disorder, although transient ischemic attacks cannot be ruled out. 2. Dementia. 3. Diabetes mellitus. 4. Degenerative joint disease. 5. Atrial fibrillation. 6. Peripheral vascular disease. 7. Depression. 8. Hypertension. FOLLOW UP: The patient will follow up as an outpatient with Dr. [**Last Name (STitle) 1132**] and an appointment will be made for him to see a behavioral neurologist. DISPOSITION: The patient is being discharged to rehabilitation. [**Name6 (MD) 725**] [**Name8 (MD) 726**], M.D. [**MD Number(1) 727**] Dictated By:[**Last Name (NamePattern1) 5476**] MEDQUIST36 D: [**2196-1-20**] 10:48 T: [**2196-1-20**] 10:58 JOB#: [**Job Number 24435**]

[ "780.39", "433.10", "401.9", "427.31", "250.00", "435.9", "414.01" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5971, 5980

2540, 2611

6001, 6234

2106, 2265

5283, 5949

6246, 6725

2634, 5265

1768, 2079

123, 1748

2282, 2523

21,552

195,378

9909

Discharge summary

report

Unit No: [**Numeric Identifier 33222**] Admission Date: [**2155-5-2**] Discharge Date: [**2155-5-11**] Date of Birth: [**2097-3-27**] Sex: M Service: ENT PRIMARY DIAGNOSIS: Invasive thyroid cancer. PRIMARY PROCEDURE: Total thyroidectomy, central neck dissection, resection of cricothyroid membrane. HISTORY OF PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname 216**] is a 58-year- old gentleman with a large anterior neck mass, known to be a thyroid cancer. This mass is invasive into his cricothyroid membrane. He presents for surgical correction. PAST MEDICAL HISTORY: 1. Urinary stricture. 2. Type 2 diabetes. MEDICATIONS: None ALLERGIES: No known drug allergies. COURSE IN HOSPITAL: Mr. [**Known lastname 216**] was taken to the operating room on [**2155-5-2**]. He underwent a total thyroidectomy with central lymph node dissection, as well as cricotracheal resection. The start of the case was delayed as the nurses and residents were unable to place a Foley catheter. Intraoperative urology consultation was obtained. The patient underwent a rigid cystoscopy in order to place a Foley catheter. Dense strictures throughout his urethra were found. Postoperatively, Mr. [**Known lastname 216**] was observed in the PAC unit for two nights. He was kept intubated until postoperative day #3. No NG tube was placed for fear of damaging the area of the cricotracheal resection and reconstruction. On postoperative day #1 Mr. [**Known lastname 216**] was noted to have some runs of supraventricular tachycardia. An EKG was done and was normal. His electrolytes were managed and this spontaneously resolved. On postoperative day #2 Mr. [**Known lastname 18082**] calcium was noted to trend down. He was started on calcium intravenously, as he was still intubated. On postoperative day #3 Mr. [**Known lastname 216**] was weaned off the ventilator, however, after extubation he became stridorous with increasing work of breathing. He required reintubation. For this reason he underwent a tracheostomy on the same day. Hematology oncology consultation was requested given the invasive nature of the patient's thyroid carcinoma. On postoperative day #4 Mr. [**Known lastname 216**] was successfully weaned off the vent and onto a tracheostomy collar. As his calcium started to drop further, he was started on calcium twice a day, as well as Rocaltrol 0.5 mcg daily. On postoperative day #5 the patient's cuff was taken down and he was started on calcium, as well as Rocaltrol for dropping calcium. He was seen by the speech and swallow team. The patient was noted to have gross aspiration on his first few days of swallow on [**2155-5-7**]. However, the speech and swallow team had a Passy-Muir valve placed for the patient, which he did well with while awake and not eating. The patient was given a Passy-Muir valve by the speech and swallow team, which he did well with when he was awake. On postoperative day #6 the patient was started on p.o. He could also be started on p.o. medication including liothyroxine 50 mcg p.o. daily and his calcium was increased to 2 gm twice a day. His Rocaltrol was also increased to 0.5 mcg p.o. daily. On postoperative day #6 urology was reconsulted to see if there was any further recommendations to be made about his Foley catheter. They recommended discontinuing his Foley and catheterizing himself once per day. The patient received adequate teaching in hospital and was prepared to do this task by the time he went home. On [**5-8**], the endocrine service was consulted because of Mr. [**Known lastname 18082**] hypocalcemia. They recommended increasing his calcium carbonate to 500 mg p.o. four times daily and continue his Calcitrol at 0.5 mcg daily. They also recommended changing the parathyroid hormone level. On postoperative day #7, Mr. [**Known lastname 216**] did have his Foley removed and was taught to straight catheterize. His blood sugars came under better control as he was started on metformin. A radiation oncology consultation was obtained to see if radiation would be of benefit for Mr. [**Known lastname 216**], given the aggressiveness of his cancer. On [**2155-5-9**], Mr. [**Known lastname 216**] was seen by speech and swallow again. His speech and swallow examination revealed minimal penetration with liquids and trace aspiration. They recommended him receiving an oral diet, which he did successfully. He was able to have his nasogastric tube removed and was discharged home in stable condition on [**2155-5-10**]. CONDITION ON DISCHARGE: Afebrile. Vital signs stable. Patient was tolerating a full soft solid diet. His neck was flat. His incision was clean, dry and intact. The tracheostomy site was clean. Cranial nerves V-VII and [**Doctor First Name 81**]-XII were intact. INSTRUCTIONS ON DISCHARGE: Mr. [**Known lastname 216**] is to followup with Dr. [**Last Name (STitle) 1837**]. He was instructed to call and make an appointment. He is to call Dr.[**Name (NI) 20390**] office or proceed to the closest emergency room if he experiences fever, wound redness or drainage or any other significant problems. Mr. [**Known lastname 216**] is to straight catheterize himself once per day in order to keep his urethra patent. He is to followup with a urologist, which will be coordinated by his primary care physician. [**Name10 (NameIs) **] is also to followup with Dr. [**Last Name (STitle) 3929**], of radiation oncology. The patient also has his own private endocrinologist, whom he is to followup with. MEDICATIONS ON DISCHARGE: 1. Levoxyl 100 mcg p.o. daily 2. Calcitrol 0.25 mcg p.o. twice a day 3. Percocet 1-2 tablets p.o. q.4-6h p.r.n. for pain. 4. Famotidine 20 mg p.o. twice a day. 5. Metformin 500 mg p.o. q.a.m. 6. Calcium carbonate 1250 mg p.o. twice a day. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 30193**] Dictated By:[**Last Name (NamePattern4) 33223**] MEDQUIST36 D: [**2155-6-3**] 10:14:44 T: [**2155-6-3**] 15:05:13 Job#: [**Job Number 33224**]

[ "478.33", "193", "197.3", "197.1", "598.2", "E878.9", "252.1", "198.89", "287.3", "250.00", "196.0", "V46.11" ]

icd9cm

[ [ [] ] ]

[ "06.4", "31.69", "31.41", "96.72", "96.04", "96.6", "31.1", "58.5", "31.42", "40.42", "33.23", "34.3", "40.3" ]

icd9pcs

[ [ [] ] ]

5552, 6068

4821, 5526

338, 573

180, 309

595, 4529

4554, 4806

62,284

126,960

46370

Discharge summary

report

Admission Date: [**2149-6-3**] Discharge Date: [**2149-6-9**] Date of Birth: [**2069-8-1**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7651**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname **] is a 79-year-old man with a history of CAD s/p CABG with unknown anatomy, aortic stenosis (1.3 cm2), AF, and recent prolonged hospitalization at OSH complicated by pneumonia requiring intubation, pulmonary hemorrhage (on Plavix and Coumadin), and ?amiodarone-induced pulmonary fibrosis who presents with dyspnea. He has been home from rehab for approximately six weeks and was in his usual state of health until several days ago when he noted an increasing O2 requirement and worsening dyspnea on exertion. He is on 1.5L O2 at baseline (this has been weaned gradually since his last discharge) and typically sats 94%, but his O2 sat fell to the 80s on multiple occasions during the past few days. His lasix was increased from 40mg PO daily to 80mg PO daily during this time but his dyspnea persisted. He was seen by his PCP today and was noted to be in afib with RVR, and he was referred to the ED. . In the ED, initial VS were: 98.4 150 98/73 18 100%o2 83%ra. He was given Dilt 5 mg IV x 2 followed by a Dilt gtt to 15 mg/hr with improvement of his heart rate to the 100s-120, and SBP fell to the low 90s. EKG was notable for mild ST depressions in the lateral leads and trop was mildly elevated at 0.15. Cardiology was consulted and felt that increased trop represented demand ischemia and EKG changes were rate-related. He was thought to be clinically dry/over-diuresed and was given 1L NS. At 6 pm, he converted to sinus spontaneously at a rate of 60. . On arrival to CCU, vitals were 99.3 76 118/53 20 91% on 2L NC. His O2 sat improved to 97-98% on 3L NC. He denied any CP, and felt his SOB had improved. He denied any lightheadedness, diaphoresis, abdominal pain, or N/V. He remained in normal sinus rhythm. . Of note, the patient's family reports that he has also had a recent short hospital course for a fib with RVR in which he had elevated cardiac enzymes, thought to be secondary to demand ischemia. They have a pulse oximeter at home to monitor his O2 sats, and have noted several episodes of increased HR recently. The patient has generally been asymptomatic during these episodes. Also of note, the patient recently spent 4 days in the car, traveling. . On review of systems, he denies any prior history of stroke or TIA. He has a h/o DVT, but no h/o pulmonary embolism. He denies recent fevers, chills or rigors. He has occasional cough, non-productive. On cardiac review of systems, he denies chest pain, paroxysmal nocturnal dyspnea, or orthopnea. Past Medical History: #. Coronary artery disease, s/p MI, s/p coronary artery bypass grafting in [**2125**], anatomy unknown, no interventions since. #. CHF, systolic, LVEF 40% [**9-/2148**] #. Aortic stenosis (valve 1.3 cm2 on [**6-22**]) #. Paroxysmal atrial fibrillation #. Hypertension. #. Hyperlipidemia. #. Pulmonary fibrosis ? secondary to amiodarone #. DVT [**2146**] #. Testicular cancer #. Colon cancer s/p left hemicolectomy #. Corticosteroid-induced hyperglycemia #. Post-herpetic neuralgia #. h/o back pain, T7 compression fracture Social History: He lives with his wife in [**Name (NI) 86**] for five months of the year and is in [**State 2690**] for the remainder. He is a retired chemistry teacher. He does not smoke, rarely drinks. He has three children and grandchildren. Family History: No family history of early MI or arrhythmias. Father with history of heart disease. Physical Exam: VS: T=99.3 BP=118/53 HR=76 RR= 20 O2 sat= 91% on 2L NC --> 97% on 3L NC GENERAL: WDWN male in NAD. Alert. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink. MMM. NECK: Supple, no appreciable JVD. Symmetric bilateral soft tissue swelling above clavicle, non-tender to palpation and without any erythema or fluctuance. Right side of neck tender to palpation/light touch secondary to post-herpetic neuralgia. CARDIAC: Normal Sl, S2. RRR. III/VI SEM heard best at left sternal border and radiating to carotids. Well-healed sternotomy incision. LUNGS: Resp were unlabored. Inspiratory crackles bilaterally, half-way up lung fields. These sounded like a combination of both wet and dry crackles. No wheezes. ABDOMEN: Normal bowel sounds. Soft. Non-tender. Mild-moderately distended, but no appreciable fluid wave. No HSM. Stool palpable in lower abdomen. Well-healed vertical incision scar from previous surgery. EXTREMITIES: Warm, well-perfused. 1+ lower ext edema bilaterally. SKIN: No rashes. PULSES: DP pulses 2+ bilaterally. NEURO: Cranial nerves intact. Normal tone and sensation. Pain in dermatomal distribution Pertinent Results: [**2149-6-3**] 02:00PM BLOOD WBC-10.1# RBC-4.07* Hgb-11.0* Hct-33.9* MCV-83# MCH-27.1# MCHC-32.5 RDW-16.9* Plt Ct-204 [**2149-6-3**] 02:00PM BLOOD Neuts-91.1* Lymphs-5.2* Monos-3.1 Eos-0.4 Baso-0.2 [**2149-6-8**] 07:45AM BLOOD WBC-7.6 RBC-4.07* Hgb-11.0* Hct-33.8* MCV-83 MCH-26.9* MCHC-32.4 RDW-16.9* Plt Ct-214 [**2149-6-3**] 02:00PM BLOOD PT-20.7* PTT-29.2 INR(PT)-1.9* [**2149-6-8**] 07:45AM BLOOD PT-15.9* PTT-71.3* INR(PT)-1.4* [**2149-6-3**] 02:00PM BLOOD Glucose-166* UreaN-38* Creat-1.1 Na-141 K-3.9 Cl-99 HCO3-31 AnGap-15 [**2149-6-8**] 07:45AM BLOOD Glucose-99 UreaN-37* Creat-1.4* Na-141 K-4.0 Cl-98 HCO3-34* AnGap-13 [**2149-6-4**] 06:00AM BLOOD ALT-14 AST-28 AlkPhos-66 TotBili-0.5 [**2149-6-3**] 02:00PM BLOOD proBNP-[**2059**]* [**2149-6-3**] 02:00PM BLOOD cTropnT-0.15* [**2149-6-5**] 04:30AM BLOOD CK-MB-2 cTropnT-0.30* [**2149-6-5**] 04:03PM BLOOD CK-MB-2 cTropnT-0.23* [**2149-6-4**] 06:00AM BLOOD Albumin-3.6 Calcium-8.9 Phos-3.0 Mg-2.4 [**2149-6-8**] 07:45AM BLOOD Calcium-9.5 Phos-4.0 Mg-2.4 [**2149-6-4**] 12:34PM BLOOD Type-ART pO2-62* pCO2-41 pH-7.54* calTCO2-36* Base XS-10 Intubat-NOT INTUBA [**2149-6-3**] 02:51PM BLOOD Lactate-1.9 Microbiology: [**2149-6-3**] Blood cultures: pending at time of discharge, no growth to date MRSA SCREEN (Final [**2149-6-6**]): No MRSA isolated. Cardiology: ECG [**2149-6-3**]: Atrial fibrillation. Left bundle-branch block. ECG [**2149-6-3**]: Sinus rhythm. Intraventricular conduction delay. Compared to the previous tracing the rate and rhythm have changed. TTE [**2149-6-4**]: Findings: The left atrium is moderately dilated. The right atrium is markedly dilated. A left-to-right shunt (passage of bubbles) across the interatrial septum is seen with Valsalva manuever which is consistent with probable atrial septal defect. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Mild global hypokinesis is present, with more severe hypokinesis of the inferior, inferolateral, and inferoseptal walls (EF 40-45%Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). The right ventricular cavity is mildly dilated with borderline normal free wall function. There is abnormal septal motion/position. The ascending aorta is mildly dilated. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). 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 no pericardial effusion. IMPRESSION: Probable atrial septal defect. Mild global left ventricular hypokinesis with more severe inferior hypokinesis. Mild right ventricular dilation with borderline normal function. Moderate aortic stenosis. Mild mitral regurgitation. Compared with the prior study (images reviewed) of [**2147-6-16**], left ventricular function is less vigorous. More regional dysfunction is apparent. The severity of aortic stenosis has progressd. TTE [**2149-6-9**]: After intravenous injection of agitated saline at rest and post-Valsalva, there was premature appearance of a very small amount of saline contrast in the left heart suggestive of a small atrial septal defect/patent foramen ovale. ECG [**2149-6-8**]: Sinus bradycardia. Occasional atrial ectopy. Probable left atrial abnormality. Left axis deviation. Inferior wall myocardial infarction of undetermined age. Left ventricular hypertrophy. Lateral ST-T wave changes likely related to left ventricular hypertrophy. Compared to the previous tracing of [**2149-6-5**] there is no significant diagnostic change. Radiology: CXR [**2149-6-3**]: Lung volumes are profoundly diminished relative to the prior exam. There is mild vascular indistinctness and interstitial prominence predominantly in the lung bases. There is evidence of prior CABG and median sternotomy. A markedly tortuous aorta with calcified plaque at the arch is seen. The cardiac silhouette is enlarged but stable. Minimal blunting of the right costophrenic angle may indicate a small pleural effusion. There is no pneumothorax. The bones are diffusely osteopenic. IMPRESSION: Limited examination. No definite focal consolidation or florid edema noted. There may be mild interstitial edema present CTA CHEST W&W/O C&RECONS, NON-CORONARY Study [**2149-6-4**]: There are diffuse coronary artery calcifications in this patient who is status post CABG and median sternotomy. The heart is enlarged. There is no pericardial effusion. There are aortic valvular calcifications of indeterminate hemodynamic significance. Atherosclerotic calcifications are also present along the aorta and its major branches, without aneurysmal dilatation. There is mild enlargement of the main pulmonary artery which measures 3.6 cm in diameter, suggesting pulmonary hypertension. There is good opacification of the main and lobar pulmonary arteries as well as some segmental pulmonary arteries, which show no pulmonary embolism. However, there is suboptimal assessment of some segmental branches as well as the subsegmental branches of pulmonary arteries due to motion, limiting assessment for smaller pulmonary embolism. Multiple mediastinal lymph nodes are all subcentimeter, not meeting CT size criteria for adenopathy. There are tiny bilateral pleural effusions. The central airways are patent to the subsegmental levels. There are areas of traction bronchiectasis (3:31), a finding which can be seen in pulmonary fibrosis. As seen on chest radiographs, there are extensive bilateral increased interstitial markings, particularly in the lung bases. However, detailed assessment of the lung parenchyma is not possible due to poor inspiratory effort on both phases of imaging. There is also diffuse heterogeneous ground-glass opacification of the lungs bilaterally which in part may be due to imaging during expiration, however, together with enlarged heart and pleural effusions raises concern for CHF. While the current study is not tailored for subdiaphragmatic diagnosis, no focal abnormality is seen in the visualized upper abdomen except to note vascular calcifications along the aorta, celiac artery, and splenic artery. There are severe compression deformities of T5 and T7, and milder compression deformity along the inferior endplate of T8, which were not present on PA and lateral chest radiographs from [**2146-4-26**]. IMPRESSIONS: 1. No central pulmonary embolism seen in main or lobar branches. Small pulmonary embolism in some segmental branches and in subsegmental branches cannot be excluded due to motion artifact. 2. Combined CT and serial CXR findings favor acute superimposed upon chronic interstitial lung disase. The acute process is likely CHF (less likely atypical infection or acute exacerbation of chronic lung disease) and the chronic process could reflect UIP or NSIP but is not fully characterized on this limited assessment. (The patient is currently unable to prone to assess for lung fibrosis. Per discussion with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], patient has clinical symptoms which may be referable to pulmonary edema. We suggest initial treatment for the acute process, and when the patient has improved clinical status, high- resolution chest CT may be reattempted for further assessment of underlying interstitial lung disease. Other differential considerations for acute processes include acute exacerbation of interstitial lung disease, less likely atypical diffuse infection such as viral infection.) 3. Suspect pulmonary hypertension. 4. Multiple compression deformities in the mid thoracic spine are new [**Last Name (un) 2675**] chest radiographs of [**2146-4-26**]. CXR [**2149-6-6**]: In comparison with the study of [**6-4**], there is little overall change. Diffuse interstitial prominence persists, consistent with known chronic pulmonary disease. In view of the enlargement of the cardiac silhouette and tortuosity of the aorta, some of this could reflect elevated pulmonary venous pressure. No evidence of acute focal pneumonia. CXR [**2149-6-9**]: Coarse basilar predominant interstitial abnormalities are present consistent with pulmonary fibrosis, and more acute superimposed interstitial opacities evident on to the [**2149-6-4**] radiograph have apparently resolved. Stable cardiomegaly. Brief Hospital Course: 79-year-old man with a history of CAD s/p CABG with unknown anatomy, aortic stenosis (1.3 cm2), AF, and recent prolonged hospitalization at OSH complicated by pneumonia requiring intubation, pulmonary hemorrhage, and potential amiodarone-induced pulmonary fibrosis who presented with dyspnea and increasing O2 requirement in setting of AF with RVR, concomitant demand ischemia and congestive heart failure exacerbation. Dyspnea likely multifactorial, and initially thought to be related to arrhythmia, systolic heart failure exacerbation, possible PE, and subacute/chronic pulmonary disease. #) A fib with RVR and demand ischemia - Patient in a fib with RVR and rate of 150 on presentation to ED. Received several boluses of IV diltiazem and was started on diltiazem gtt. ECG was notable for mild ST depressions in the lateral leads, felt to be rate-related. Troponin was mildly elevated at 0.15 (peaked at 0.30), and this was felt to represent demand ischemia. He appeared clinically dry/over-diuresed and was given IV fluids. After a few hours, he spontaneously converted to sinus rhythm while on the diltiazem gtt. BP mildly compromised in setting of rapid HR, but stabilized following rate conversion. Patient's SOB improved, and patient was otherwise asymptomatic. He was weaned off diltiazem drip overnight, transitioned to oral diltiazem, and later started on metoprolol for rate control. He was also continued on his outpatient dose of Dronedarone for rate control. We considered his pulmonary disease, infection, PE, or thyroid disease as possible etiologies of recurrent a fib. Thyroid disease unlikely given normal TSH. PE considered given h/o long car ride and previous h/o DVTs while on coumadin. Patient started on heparin gtt, however no large PE seen on chest CTA. No clinical signs of PNA, as patient afebrile, no leukocytosis, and no focal infiltrate noted on CXR. Pulmonary etiology remained on differential. Patient was monitored on telemetry and was d/c'd on metoprolol, dronederone, and warfarin. Diltiazem was stopped. Heparin gtt was stopped, and patient will be bridged to therapeutic INR on enoxaparin in outpatient setting. #) Demand Ischemia - Cardiac enzymes elevated, likely secondary to demand ischemia in setting of a fib with RVR. Troponin elevated at 0.15 on admission, and peaked at 0.30. ECG showed <1mm ST segment depressions in I, avL, and III; not significantly changed from past. Patient has not had cardiac cath since CABG in [**2125**], could consider repeat cath once more medically stable for evaluation of cornary anatomy/progression of CAD. No immediate intervention necessary at this time. Echo obtained [**2149-6-4**] revealed mild global hypokinesis, with more severe hypokinesis of the inferior, inferolateral, and inferoseptal walls (EF 40-45%). Patient was continued on aspirin, statin, and Coumadin. # Systolic heart failure - Considered acute pulmonary edema/CHF exacerbation in setting of a fib with RVR. Additionally, patient received 1 liter IVF in ED for hypotension in setting of rapid HR, which may have contributed to worsening pulmonary edema. Echo in [**9-/2148**] demonstrated LVEF of 40%, as well as AS. Repeat echo this admission revealed mild global LV hypokinesis with more severe inferior hypokinesis, LVEF 40-45%, moderate AS and mild MR. CXR on admission did not show florid edema, but noted there may be mild interstitial edema. Clinical exam revealed bilateral crackles and lower extremity edema, although it was unclear if crackles were secondary to pulmonary edema or chronic interstitial changes within the lungs. Diagnostic possibilities included h/o pulmonary fibrosis secondary to amiodarone toxicity or to remote bleomycin treatment vs. scarring s/p alveolar hemorrhage vs other etiology). Given hypotension prior to CCU presentation, diuretics were initially held, but with stabilization of SBPs patient was aggressively diuresed with furosemide. His O2 requirement was gradually weaned, and he was back to near baseline at time of discharge, with sats >90% on 2L NC and sats about 92% on 2L NC with ambulation. Desats on exertion had improved with diuresis. CXR also showed radiographic evidence of improvement in pulmonary edema, with resolution by discharge on [**2149-6-9**]. Given the benefits of rhythm control of his a fib against any possible side-effects, the decision was made to continue dronedarone despite systolic CHF and low EF. Patient was also d/c'd on regimen of furosemide, spironolactone, metoprolol. His lisinopril had been held in setting of rising Cr, and he was not started on an ACE/[**Last Name (un) **] prior to discharge because of reduced GFR. This should be started as an outpatient once renal function has improved. Of note, repeat echo [**2149-6-9**] showed insignificant ASD with just a few bubbles traveling intra-atria. . #) Chronic interstitial lung disease - Patient has h/o possible amiodarone-induced pulmonary toxicity, also possibly due to bleomycin toxicity and also had recent prolonged hospitalization at OSH complicated by pneumonia requiring intubation and diffuse alveolar hemorrhage. His [**State 2690**] pulmonologist was [**Name (NI) 653**], and it appeared his pulmonary hemorrhage occurred in setting of treatment with ASA and plavix. In [**State 2690**], he was investigated by bronchoscopy but patient declined biopsy at the time. Autoimmune workup was negative. He was weaned from initially 40 mg prednisone to his current dose of 15mg on admission to the CCU. Of note, he had a second hspitalization at OSH for steroid myopathy causing a fall and pulmonary contusions. The patient was again discharged on steroids and travled to NY on 5-10mg of prednisone/day with improved CXR and 2-3L O2 at home. The feeling was that the most likely diagnosis was that of amiodarone-induced pulmonary fibrosis, complicated by alveolar hemmorhage and residual scarring. CTA chest on [**2149-6-4**] demonstrated acute process, likely CHF, superimposed on chronic interstitial lung disease, which was present on [**2146-4-26**] chest radiograph but not present on CT chest of [**2138-8-8**]. Patient seen by pulmonary consult, who felt CTA appearances could represent early IPF given the distribution and his age, however, the presence of this scarring prior to starting amiodarone did not make amiodarone pulmonary toxicity less likely as he could just have easily had a further amiodarone-induced pulmonary insult on top of presexisting IPF. Pulmonary team also considered BOOP in the differential, and recommended continuing Prednisone 15 mg PO daily and continuing diuresis. They will repeat CT chest in [**2-18**] weeks as outpatient, with pulmonary follow-up to be scheduled. No clear evidence of pulmonary toxicity from Dronederone, and medication was continued. . #. Hypertension - Patient hypotensive in setting of a fib with RVR, but remained generally normotensive during rest of hospital course once rate controlled. Furosemide 20mg PO daily, spironolactone 25mg PO daily, and metoprolol succinate 75mg PO daily on discharge. . #. Hyperlipidemia - Continue statin. . #. Constipation - Chronic issue per patient/family. Abdominal exam on admission revealed stool palpable in lower quadrants, but was otherwise benign: soft, non-tender, and distended but without appreciable fluid wave. No HSM appreciated. He had normal LFTs. He was continued on Miralax prn constipation. . #. Steroid-induced hyperglycemia - He was on a regimen of Lantus, insulin s/s during his admission, and will resume his home insuline regimen on discharge. . #) Thoracic spine compression fractures - New since [**2145**], but per patient's history have been previously diagnosed. Likely secondary to chronic steroid use. He was started on calcium and vitamin D, and may benefit from having DEXA scan as an outpatient given his risk of osteoporosis on steroid therapy. . # New anisocoria but reactive bilaterally. Currently no focal neurological deficits otherwise. Need to watch this especially given warfarin therapy. . # Renal dysfunction: Cr on admission 1.1, and rose to peak of 1.4 on [**8-4**] in setting of diuresis. Cr trending back down on day of discharge, and can be monitored in outpatient setting. Furosemide dose reduced to 20mg PO daily prior to discharge. . #. Diabetes, steroid-induced - Patient treated with Lantus, insulin s/s during admission, and will resume home insulin regimen on discharge. Stable blood glucose measurements during admission. . #) Patient discharged to home with PT services. Medications on Admission: MEDICATIONS (confirmed with wife): 1. Lyrica 75mg PO QAM, 150mg PO QPM 2. Alpha lipoic 400mg 2 tabs PO QAM, 1 tab PO QPM 3. Aspirin 81mg PO daily 4. Lasix 40mg PO daily 5. Protonix 40mg PO daily 6. Prednisone 15mg PO daily 7. Diltiazem 120mg PO daily 8. Multaq 400mg PO BID 9. Potassium 40 mEq daily 10. Zocor 20mg PO daily 11. Warfarin 2.5mg PO daily 12. Darvocet QPM prn pain 13. Levemir 4 units QHS 14. Novalog sliding scale 15. Xopenex nebulizers prn (not using) 16. Miralax one packet daily Discharge Medications: 1. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) packet packet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)). 4. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO QPM (once a day (in the evening)). 5. Outpatient Lab Work Please check INR, Chem-7 on Wednesday [**6-11**] and fax results to Dr. [**Last Name (STitle) 2204**] at [**Telephone/Fax (1) 7922**] and call Dr.[**Name (NI) 3733**] at [**Telephone/Fax (1) 62**] 6. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 7. Dronedarone 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day. Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2* 11. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 13. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 14. Calcium 600 + D(3) 600-400 mg-unit Tablet Sig: One (1) Tablet PO twice a day: take with meals. 15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours). Disp:*6 syringe* Refills:*2* 17. Insulin Glargine 100 unit/mL Solution Sig: Four (4) units Subcutaneous at bedtime. 18. Insulin Aspart 100 unit/mL Solution Sig: as per sliding scale units Subcutaneous three times a day. 19. EMLA 2.5-2.5 % Cream Sig: One (1) application Topical once a day: stop using as soon as possible. . Disp:*1 tube* Refills:*2* Discharge Disposition: Home With Service Facility: Community VNA Discharge Diagnosis: Acute on chronic Congestive heart failure Rapid atrial fibrillation Chronic lung fibrosis Thoracic spine compression deformities Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you during your stay at the [**Hospital1 18**]. You presented following increasing shortness of breath and requiring more oxygen at home. Your oxygen levels were low and you were found to be in rapid atrial fibrillation (a rapid irregular heartbeat). You were given medication to help slow the heart intravenously and your heart tracings (ECGs) showed that your heart was under strain and this was borne out with changes in blood tests. You then went back into a normal heart rhythm spontaneously. You had an echocardiogram (ultrasound of the heart) to assess heart and valve function which was similar to your previous scan in [**2148-9-15**] in addition to similar narrowing of the aortic valve. You seemed to have a much lower oxygen level on moving and we felt that this may be due to fluid on the lungs and this improved when we used medication to help you lose water from the body. You had a CT scan which showed evidence of fluid on the lungs (pulmonary edema) in addition to chronic changes in your lungs which were likely stiffening (fibrosis). This scan also shoewd no evidence of a blood lcot on the lungs as a cause for your shortness of breath in addition to some old fractures of your spine which may be due to thin bones. You should have a bone mineral density exam arranged by Dr. [**Last Name (STitle) 2204**] as an outpatient. We started you on a heparin drip in case we had to do a procedure and held your warfarin. We felt that no repeat angiogram (test to determine if there is any narrowing in the main blood vessesl supplying to the heart) was required and that no other procedure was warranted at the present and your warfarin was restarted. You were also started on calcium and vitamin D for your potentially thin bones. Being on steroids (prednisone) can also thin your bones. You were seen by the pulmonary doctors who [**Name5 (PTitle) 2985**] that your lung condition may have appeared by itself (what we call idiopathic) or may have been the result of being on your amiodarone or that being on amiodarone worsened a previously present condition. You were seen by the physical therapist who was happy with your progress and you were deemed fit to go home with oxygen after a repeat echoccardiogram scan. We reduced your water tablets prior to discharge. . Medication changes: 1. Stop taking ditiazem and Potassium 2. Start taking Metoprolol to lower your heart rate 3. Start taking spironolactone to get rid of extra fluid 4. Start taking Calcium and Vitamin D to help your bones get stronger. 5. STart Enoxaparin to prevent blood clots until your warfarin is therapeutic. Use twice daily until Dr.[**Name (NI) 2935**] office tells you it is OK to stop. 6. Decrease Furosemide to 20 mg daily 7. Continue Warfarin at your previous dosing. You will get an INR checked by the VNA on Wednesday [**2149-6-11**]. 8. continue Insulin at your previous dosing. Weigh yourself every morning, call Dr.[**Name (NI) 3733**] if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. Followup Instructions: Name: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 6564**],MD Location: [**Hospital1 **] HEALTHCARE - [**State 3753**]GROUP Address: [**State **], [**Apartment Address(1) 3745**], [**Location (un) **],[**Numeric Identifier 809**] Phone: [**Telephone/Fax (1) 2205**] We are working on a follow up appointment with Dr. [**Last Name (STitle) 2204**] for sometime next week. You will be called at home with the appointment. If you have not heard or have questions, please call Dr. [**Last Name (STitle) 98544**] office at number provided above. Department: CARDIAC SERVICES When: FRIDAY [**2149-7-11**] at 9:20 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4511**], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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6209

Discharge summary

report

Admission Date: [**2151-3-4**] Discharge Date: [**2151-3-14**] Date of Birth: [**2093-8-28**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 106**] Chief Complaint: Weakness/vomiting/diarrhea Major Surgical or Invasive Procedure: Intubation, central venous catheter placement with swan catheter. History of Present Illness: 57 woman with h/o CABG (emergent in [**2139**] w/ VG's to OM and LAD), stenting of SVG to LAD in [**2141**] who initially presented to [**Hospital1 18**] [**1-13**] w/ acute STEMI ([**Doctor First Name **] was SVG - LAD that was stented) complicated by severe cardiogenic shock requiring IABP and triple pressors, LCx with 90% stenosis unable to be intervened on, 3+MR, apical akinesis with mural thrombus, recently d/c'd from [**Hospital1 18**] ([**Date range (1) 24213**]) for hypotension and NSVT now s/p ICD placement. She was discharged to rehab at [**Hospital1 **] but has been feeling unwell for ~1 week with vomiting, watery diarrhea, decreased po intake, and progressive weakness. She collapsed today at rehab after using the bathroom and was sent to the ED. She has not had chest pain, worsening shortness of breath, fevers, abdominal pain or cough since d/c. . In the ED, she has a low-grade temp of 100.1. SBP initially in the mid 50's. Right IJ placed under sterile conditions. She was bolused ~ 1 liter total over a couple hours and started on Neo. CVP ranged from [**6-26**] after fluids. UO minimal. She became tachypnic and placed on CPAP 5/5 with good effect. Neo was weaned off prior to transfer to the CCU. . She was noted to have a new transaminitis (ALT 933, TB 1.0), acute renal failure (creat elevated at 2.4 from 0.8 on [**2-27**]), leukocytosis (WBC 20.1), and lactate of 6.8. Her RUQ was minimally tender; RUQ U/S revealed normal hepatic flow c/w congestion. Guaiac negative on exam. [**Doctor First Name **] consult felt transaminitis likely secondary to low flow state and unlikely ischemic bowel given soft belly. Past Medical History: -[**Last Name (un) 24206**] [**Last Name (un) 24206**] syndrome -CVA in [**2122**] and [**2132**] with mild dysphagia -seizure disorder -CAD s/p emergent CABG (SVG to LAD, SVG to OM) after failed PTCA (attempted to LAD; LMCA occlusion) [**2139**]; stenting of SVG to LAD in [**2141**] -CHF s/p AICD placemnt [**2-24**] -Aorto-bifemoral bypass -GI bleed Social History: She worked as a secretary but hasn't for some time due to health problems. Lives with her husband in [**Name (NI) **], daughter nearby. [**Name2 (NI) **] been at [**Hospital3 **]. She had been smoking 1 pack per week. Rare etoh. Family History: Father died of an MI at 78, mother healthy. Physical Exam: Afebrile 97po, HR 100 sinus tach with episodes of RAF 13-160's occ PVC. SBP 54-66/30's o nlevophed infusion to be d/c'd upon arrival to Sisters home. [**Name2 (NI) 8389**] draining 10-20cc/hr, rectal bag for loose stools. Coccyx decubitus covered with aquacel wet/DSD. Pertinent Results: [**2151-3-4**] 08:20PM BLOOD WBC-20.1*# RBC-2.98* Hgb-9.2* Hct-28.2* MCV-95 MCH-30.9 MCHC-32.7 RDW-18.3* Plt Ct-277# [**2151-3-4**] 08:20PM BLOOD Neuts-87.4* Bands-0 Lymphs-9.1* Monos-3.2 Eos-0 Baso-0.3 [**2151-3-4**] 08:20PM BLOOD PT-25.8* PTT-35.7* INR(PT)-2.6* [**2151-3-6**] 10:23AM BLOOD Fibrino-260 [**2151-3-6**] 10:23AM BLOOD FDP-40-80 [**2151-3-7**] 04:47AM BLOOD Fibrino-320 [**2151-3-7**] 04:47AM BLOOD FDP-40-80 [**2151-3-8**] 04:18AM BLOOD FDP-10-40 [**2151-3-4**] 08:20PM BLOOD Glucose-115* UreaN-37* Creat-2.4*# Na-130* K-5.1 Cl-89* HCO3-23 AnGap-23* [**2151-3-4**] 08:20PM BLOOD ALT-933* AST-942* CK(CPK)-75 AlkPhos-158* Amylase-25 TotBili-1.0 [**2151-3-5**] 04:21AM BLOOD ALT-1053* AST-1247* LD(LDH)-1510* CK(CPK)-96 AlkPhos-148* TotBili-1.2 [**2151-3-6**] 05:28AM BLOOD ALT-3820* AST-5128* LD(LDH)-3370* AlkPhos-195* TotBili-1.1 [**2151-3-8**] 04:18AM BLOOD ALT-1900* AST-594* LD(LDH)-486* AlkPhos-174* TotBili-1.4 [**2151-3-9**] 04:22AM BLOOD ALT-1273* AST-223* AlkPhos-163* TotBili-1.4 [**2151-3-11**] 04:10AM BLOOD ALT-626* AST-72* LD(LDH)-397* AlkPhos-122* TotBili-1.4 [**2151-3-4**] 08:20PM BLOOD CK-MB-NotDone [**2151-3-5**] 04:21AM BLOOD CK-MB-NotDone cTropnT-0.31* Brief Hospital Course: A/P: 57 F with CAD s/p CABG ('[**39**]), massive STEMI [**12-23**] c/b cardiogenic shock s/p AICD p/w vomiting, diarrhea, poor po intake, leukocytosis, acute renal failure, transaminitis and coagulopathy. Status-post code/intubation for hypotension/hypoxia, on 3 pressors, in multisystem organ failure with a.fib with RVR. . ## Cardiogenic Shock: She has class IV HF, EF 10-15%. CVP, PAD, PCWP elevated, end organ damage. Now stabilized on dopamine, after discussion with family and patient will not escalate care, DNR/DNI. Will not withdraw current pressor support but will not add. She has elected to go home with hospice services to be comfortable and be with her family. She will go with levophed at its current dose until she is out of the ambulance at which point the levophed will be turned off. . # Atrial fibrilations with RVR: occured [**3-11**] with no decrease of BP, broke with metoprolol, attempted cardioversion with her pacer and externally with no success, will turn her pacer off with EP as she is now DNR/DNI. . # Acute renal failure: Initially likely pre-renal azotemia in setting of poor renal perfusion secondary to cardiogenic shock but then developed dense ATN, likely secondary to shock. Small improvement with lasix gtt and metolazone. Given goals of care no CVVH. . # Mural thrombus on previous TTE and severe apical AK. Initially coagulopathic due to hypotensive liver injury, now improved INR but given goals of care no further anticoagulation. . # Ischemia: CAD: Pt w/ CABG (VG's to LAD and OM in [**2139**]), PCI of OM-LAD '[**41**] and PCI of acute MI (VG to LAD) [**12-23**]. She still has very tight consecutive 90% lesions in prox and mid LCx w/ occluded VG-OM. D/c Plavix since BMS was placed >1 month ago; aspirin 81mg daily stopped given goals of care . ## Valves: known 4+ MR. . ## ID: Presented from rehab with diarrheal illness, rising WBCs; reportedly a Norovirus outbreak at rehab, stool now + for c.diff, on precautions, started flagyl for 14 day course but stopped this on discharge given goals of care. . # Pulmonary: successfully extubated, maintaining sat with minimal oxygen, maintain O2 sat >90, prn morphine for air hunger. Medications on Admission: Clopidogrel 75 mg PO DAILY ToprolXL 12.5 mg PO DAILY Pantoprazole 40 mg PO Q24H Acetaminophen 325 mg PO Q4-6H prn Atorvastatin 80 mg PO DAILY Miconazole Nitrate 2 % Powder [**Hospital1 **] as needed Trazodone 25 mg PO HS as needed for insomnia Tramadol 50 mg PO Q4-6H as needed for pain Aspirin 162 mg PO DAILY Ipratropium 0.02 % Q6H as needed for wheezing, dyspnea Docusate Sodium 100 mg PO BID Senna 8.6 mg PO BID as needed for constipation Lisinopril 2.5 mg PO DAILY Warfarin 5 mg Tablet PO HS Oxycodone-Acetaminophen 5-325 mg PO Q4-6H as needed for pain Dolasetron 12.5 mg Q8H as needed Prochlorperazine 10 mg Q6H as needed for nausea. Lasix 80 mg PO qdaily prn Discharge Medications: 1. ativan Sig: 0.5-2.0 mg Sublingual q 4 hours as needed for anxiety, shortness of breath: Please give 2mg/mL concenctration. Disp:*60 mL* Refills:*2* 2. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO q [**1-19**] hours as needed for shortness of breath or wheezing. Disp:*60 mL* Refills:*2* 3. Levsin/SL 0.125 mg Tablet, Sublingual Sig: 1-2 tabs Sublingual four times a day as needed for secretions. Disp:*120 tabs* Refills:*2* 4. Trazodone 50 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed for insomnia. Disp:*60 Tablet(s)* Refills:*2* 5. Levophed 1 mg/mL Solution Sig: 0.1 mcg/kg/min Intravenous continuous: to be used in ambulance, administered by RN of [**Hospital1 18**] and terminated on arrival to private home. Discharge Disposition: Home with Service Discharge Diagnosis: Congestive heart failure, coronary artery disease. Discharge Condition: Stable. Discharge Instructions: You have been discharged home with hospice services to focus on spending time with your family and be as comfortable as possible. Followup Instructions: None.

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icd9cm

[ [ [] ] ]

[ "93.90", "96.6", "96.72", "38.93" ]

icd9pcs

[ [ [] ] ]

7938, 7957

4287, 6463

340, 408

8052, 8062

3072, 4264

8240, 8249

2722, 2767

7180, 7915

7978, 8031

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2782, 3053

274, 302

436, 2082

2104, 2459

2475, 2706

20,247

148,030

24716

Discharge summary

report

Admission Date: [**2124-3-2**] Discharge Date: [**2124-3-15**] Date of Birth: [**2072-10-6**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: chronic abdominal pain and recurrent pancreatitis Major Surgical or Invasive Procedure: 1. Staging laparoscopy. 2. Pylorus-preserving Whipple pancreaticoduodenectomy. 3. Open cholecystectomy. 4. Open liver biopsy. History of Present Illness: This 51-year-old gentleman presented to me within the last month with a 9-year history of abdominal pain and recurrent bouts of pancreatitis. His workup for this never took him to the extent of advanced imaging nor an ERCP until recently. He was referred to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for an endoscopic ultrasound and that examination showed gross cystic disease of the head of the pancreas. A CT scan confirmed this with macroscopic cystic disease in the head, inflammatory changes of the whole pancreas and a dilated pancreatic duct distally as well with lymphadenopathy. All these features put together were very suggestive of intraductal papillary mucinous tumor. Past Medical History: pancreatic cystic dz., pancreatitis, GERD, multiple fractures, cataracts. Sz associated with alcohol withdrawal. PSH: rotator cuff rep air, R knee arthroscopy, EUS Social History: heavy ETOH abuse, smoking Physical Exam: NAD AOx3 CTA b/l RRR soft, mild TTP, no distension +bs no c/c/e Pertinent Results: [**2124-3-2**] 12:40PM BLOOD WBC-6.1 RBC-2.98* Hgb-11.7* Hct-32.0* MCV-107*# MCH-39.1* MCHC-36.5* RDW-15.0 Plt Ct-178 [**2124-3-4**] 03:58AM BLOOD WBC-11.3* RBC-1.99*# Hgb-8.0*# Hct-23.2* MCV-117* MCH-40.1* MCHC-34.4 RDW-14.3 Plt Ct-115* [**2124-3-5**] 03:14AM BLOOD WBC-6.0 RBC-1.74* Hgb-6.7* Hct-19.0* MCV-109*# MCH-38.4* MCHC-35.2* RDW-14.7 Plt Ct-88* [**2124-3-5**] 05:04PM BLOOD WBC-7.1 RBC-2.71*# Hgb-9.4*# Hct-26.7* MCV-98# MCH-34.6* MCHC-35.1* RDW-21.5* Plt Ct-86* [**2124-3-14**] 07:10AM BLOOD WBC-8.1 RBC-2.84* Hgb-10.3* Hct-29.4* MCV-104* MCH-36.4* MCHC-35.1* RDW-19.1* Plt Ct-660* [**2124-3-2**] 12:40PM BLOOD PT-13.2* PTT-32.4 INR(PT)-1.2* [**2124-3-11**] 07:00AM BLOOD PT-14.9* PTT-32.3 INR(PT)-1.3* [**2124-3-2**] 11:21PM BLOOD Glucose-147* UreaN-10 Creat-0.5 Na-138 K-4.2 Cl-108 HCO3-22 AnGap-12 [**2124-3-5**] 03:14AM BLOOD Glucose-164* UreaN-16 Creat-0.6 Na-135 K-3.8 Cl-107 HCO3-24 AnGap-8 [**2124-3-6**] 11:24AM BLOOD Glucose-108* UreaN-10 Creat-0.5 Na-135 K-4.0 Cl-104 HCO3-27 AnGap-8 [**2124-3-12**] 06:35AM BLOOD Glucose-96 UreaN-5* Creat-0.5 Na-139 K-3.9 Cl-102 HCO3-24 AnGap-17 [**2124-3-4**] 03:58AM BLOOD ALT-14 AST-61* LD(LDH)-144 AlkPhos-63 Amylase-27 TotBili-1.1 [**2124-3-11**] 07:00AM BLOOD ALT-13 AST-22 AlkPhos-71 Amylase-24 TotBili-0.3 [**2124-3-2**] 11:21PM BLOOD Calcium-7.1* Phos-4.0 Mg-0.8* [**2124-3-5**] 01:29PM BLOOD Calcium-6.9* Phos-1.5* Mg-1.6 [**2124-3-12**] 06:35AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.5* [**2124-3-3**] 11:52AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEG [**2124-3-3**] 11:52AM BLOOD HCV Ab-NEGATIVE [**2124-3-2**] 12:51PM BLOOD Type-ART Temp-36.4 Rates-/10 Tidal V-700 pO2-219* pCO2-49* pH-7.40 calHCO3-31* Base XS-4 Intubat-INTUBATED Vent-CONTROLLED [**2124-3-2**] 11:37PM BLOOD Type-ART Rates-12/ Tidal V-600 PEEP-5 FiO2-50 pO2-200* pCO2-44 pH-7.32* calHCO3-24 Base XS--3 Intubat-INTUBATED [**2124-3-4**] 04:45PM BLOOD Type-ART pO2-56* pCO2-53* pH-7.29* calHCO3-27 Base XS--1 [**2124-3-8**] 09:23PM BLOOD Type-ART Temp-37.8 pO2-102 pCO2-36 pH-7.43 calHCO3-25 Base XS-0 GRAM STAIN (Final [**2124-3-8**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. 4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S). DUE TO LABORATORY ERROR, UNABLE TO REVIEW SMEAR.. RESPIRATORY CULTURE (Final [**2124-3-9**]): OROPHARYNGEAL FLORA ABSENT. MORAXELLA CATARRHALIS, PRESUMPTIVE IDENTIFICATION. MODERATE GROWTH. HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. MODERATE GROWTH. Beta-lactamse negative: presumptively sensitive to ampicillin. Confirmation should be requested in cases of treatment failure in life-threatening infections.. STREPTOCOCCUS PNEUMONIAE. SPARSE GROWTH. PRESUMPTIVELY PENICILLIN SENSITIVE BY OXACILLIN SCREEN. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STREPTOCOCCUS PNEUMONIAE | PENICILLIN------------ S SPECIMEN SUBMITTED: GALLBLADDER, LIVER BX, PANCREATIC NECK MARGINS FS, WHIPPLE (JEJUNUM) & PANCREATIC BODY. Procedure date Tissue received Report Date Diagnosed by [**2124-3-2**] [**2124-3-3**] [**2124-3-13**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **],DR. [**Last Name (STitle) **]. [**Doctor Last Name 18795**]/cma?????? DIAGNOSIS 1. Gallbladder, cholecystectomy (A-B): Chronic cholecystic. Cholelithiasis, pigment-type. One lymph node (0/1), no malignancy identified. 2. Liver, wedge biopsy (C): Prominent steatosis; micro- and macrovesicular, no intracellular hyaline. Portal fibrosis with periportal extension. No cirrhosis identified (trichrome stain). Marked increase in iron deposition (3+/4+, chiefly in hepatocytes with accentuation of deposition in acinar zone 1). The findings are consistent with toxic/metabolic syndrome. The amount and distribution of iron deposition raises the possibility of a genetic iron storage disease. 3. Pancreatic neck margin (D): Chronic pancreatitis with marked fibrosis and no malignancy identified. 4. Pancreas and duodenum, Whipple resection (E-X, AB-AH): Chronic pancreatitis with severe fibrosis and multiple dilated pancreatic ducts. The ductal linings show inflammation and focal erosions, as well as reactive epithelial changes. No neoplasia is identified. Nine lymph nodes with no malignancy identified. 5. "Pancreatic body, final margin" (Y-AA): Chronic pancreatitis with no malignancy identified. One lymph node with no malignancy identified. Brief Hospital Course: Patient was taken to the OR for a pylorus preserving Whipple procedure and diagnostic laparoscopy which went well. Patient was kept intubated and brought to the ICU in anticipation of acute alcohol withdrawal. Patient was thus kept intubated and sedated for a week and treated with benzodiazepines for alcohol withdrawal. He was slowly weaned and was successfully extubated on POD7. He continued to do well. Patient developed post-operative fever. Sputum cultures ([**2124-3-5**]) grew out MORAXELLA CATARRHALIS, STREPTOCOCCUS PNEUMONIAE and HAEMOPHILUS INFLUENZAE and was thought to be ventilator associated pneumonia. He was started on antibiotics. Patient's respiratory symptoms resolved and he continued to do well. He was transferred to the floor. His diet was advanced without complication. Throughout his stay, the benefits and importance of abstinence from alcohol were continually stressed by multiple members of the team, including residents, case and social workers, and Dr. [**Last Name (STitle) **]. It was our hope that Mr. [**Known lastname 12262**] would go to an alcohol rehab facility after the surgery to help him recover and continue to stay alcohol free. He adamantly insisted that he needed to go home first to take care of personal matters. He was given strict instructions for follow up and instructions for admission to rehab facilities. It is hoped that Mr. [**Known lastname 12262**] will continue to stay abstinent from alcohol and will seek assistance dealing with his alcohol abuse. He was discharged home on [**2124-3-15**] in good condition. Discharge Medications: 1. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 2. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). Disp:*25 Patch 24HR(s)* Refills:*2* 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Discharge Disposition: Home Discharge Diagnosis: head of pancreas mass Discharge Condition: good Discharge Instructions: please seek medical attention if you experience fever > 101.5, severe nausea, vomitting, or pain do driving while on narcotic pain meds PLEASE CHEACK IN TO REHAB AS SOON AS POSSIBLE NO DRINKING ALCOHOL Followup Instructions: please follow up with Dr [**Last Name (STitle) **] in [**3-10**] weeks. call ([**Telephone/Fax (1) 15807**] fro an appointment. Completed by:[**2124-3-17**]

[ "303.91", "577.1", "486", "574.10", "285.9", "997.3" ]

icd9cm

[ [ [] ] ]

[ "52.7", "50.12", "51.22" ]

icd9pcs

[ [ [] ] ]

8816, 8822

6381, 7959

362, 490

8888, 8895

1561, 6358

9148, 9307

7982, 8793

8843, 8867

8919, 9125

1477, 1542

273, 324

518, 1231

1253, 1419

1435, 1462

12,878

140,965

28514

Discharge summary

report

Admission Date: [**2127-11-18**] Discharge Date: [**2127-11-28**] Date of Birth: [**2055-9-9**] Sex: M Service: MEDICINE Allergies: Shellfish Attending:[**First Name3 (LF) 2078**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Cardiac cath x2 arterial line History of Present Illness: 72 M with h/o COPD, HTN, seizure disorder, cardiomyopathy (EF 15-30%), transferred from OSH after admission for worsening SOB, +enzyme leak on [**11-13**], treated for CHF exacerbation with diuresis, subsequently +persantine-stress showing global hypokinesis. Cath was apparently deferred [**3-6**] increased creatinine and ?need for CABG. . Pt presented on [**11-13**] with ~3-4d history of worsening SOB. Pt describes gradual onset over past ~1 year history of worsening SOB. +smoker, quit ~10 yrs ago. +cough, non-productive. no fever/chills. pt denies cp/palpitations. His SOB is elicited by exertion only, does not occur at rest. he denies orthopnea, pnd, lower extremity edema. . Upon admission to OSH, VS: 109/81 93, 22, 90%2L. CK 140, cre 1.2, INR 1.4, BNP 2081. pt noted to have troponin 1.24 (0-0.1 range nl), ?pulmonary edema on CXR. Pt started on lovenox, diuresed with lasix, with subsequent BNP decrease to 1040. EKG showed ?lateral TWI per report (on review shows ?STD V2-V5 with TWI). Plan had been to cath pt at OSH, however initially deferred because of rising crt with diuresis. TTE showed global hypokinesis. Stress test on [**11-17**] also showed depressed EF. Pt was trasnferred to [**Hospital1 18**] for ?Cath with or without CABG. His SOB has improved since his admission on [**11-13**], and he denies any repeat occurence of chest tightness, pressure, pain. Past Medical History: recent NSTEMI - no intervention at osh [**3-6**] ?cabg. ischemic CM (per report) CHF (EF 15-20%) ?DM (pt denies) COPD (dx ~6 mo ago) HTN (50+ yrs) seizure disorder ([**3-6**] head trauma) Social History: Lives with wife in [**Name2 (NI) **]. Smoked 20 years 4 ppd, quit ~10 years ago, denies alcohol presently, was drinking ~1 case / day x 10 years, quit ~20 years ago, denies IVDU. Used to work with heavy machinery. Family History: no premature CAD or SCD, mother "big heart", died in 80s, father died of leukemia. Physical Exam: VS: 97.2 110/72 68 30 99%2L 70kg GEN: NAD HEENT: EOMI, sclera anicteric, OP clear, MMM, no LAD, no carotid bruits. ~8-10 cm JVD. CV: distant, regular, nl s1, s2, no m/r/g. PULM: crackles bilaterally, R>L ~[**2-3**] way up, no r/w. ABD: soft, NT, ND, + BS, no HSM. EXT: warm, 2+ dp/radial pulses BL, no femoral bruits r/l. NEURO: alert & oriented x 3, CN II-XII grossly intact. [**6-6**] strength symmetric @ triceps, biceps, delts, hip flexion, dorsoflexion, plantarflexion Pertinent Results: . . OSH Labs: [**11-13**] admit labs: chem7 141/5.1 105/25.9 23/1.2 , inr 1.4 tropI 1.0 -> 1.24 / 1.45 / 0.97 / 0.45 ck 10 ([**11-14**]) ck mb 6.62 -> 3.47 . . . . STUDIES: . [**2127-11-19**] Cardiac Cath FINAL DIAGNOSIS: 1. Severe three vessel coronary artery disease. 2. Moderately elevated right sided filling pressures. 3. Moderate pulmonary hypertension. 4. Severely elevated left sided filling pressures. 5. Moderately severe depression of cardiac output. 6. Severe left ventricular systolic dysfunction. 7. 2+ mitral regurgitation. . [**2127-11-25**] Cardiac Cath COMMENTS: 1. The mid RCA lesion was predilated with 1.5 and 2.0 mm balloons, stented with two 2.25 mm bare metal stents and post dilated with the stent balloon.( See PTCA comments) 2. The proxmal RCA lesion was direcly stented with a 2.25 mm balloon and post dilated with a 2.5 mm balloon. Distally we deployed a trapped 2.25 X 12 Mini vision stent, originally intended to the distal RCA lesion. The stents were post dilated with a 2.75 mm balloon,.(see PTCA comments) 3. The distl RCA lesion was stented with a 2.25 X 08 mm MIcrodriver stent. (see PTCA comments) The final angiogram showed TIMI III flow with no residual stenosis, no dissection, no perforation and no embolisation. The patient left the lab in a stable condition. (see PTCA comments) FINAL DIAGNOSIS: 1. Successful stenting of the RCA (bare metal) . [**2127-11-26**] CXR: Mild interstitial edema and small right pleural effusion have increased. Moderate cardiomegaly is stable. Hyperinflation indicates severe COPD and diaphragmatic calcification probably due to asbestos exposure. . [**2127-11-17**] CXR (OSH): mild congestive changes cannot be excluded, no definte infiltrates, no pleural effusions. . [**2127-11-18**] EKG: ?STE V2, unchanged from [**11-13**] EKG, STD V3-V5, Q's in inferior leads, ?R v1. [**2127-11-13**] EKG (OSH): STD v1, v2, v4, v5. ?sI, qIII, tIII. . . [**2127-11-14**] TTE - limited study, LV dilated, normal thikcness, globally hypokinetic, EF 15-20%, no segmental WMA. RV dilated, hypokinetic, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6878**], RA dilated. moderate MR, no AS/AI. mild TR, RVSP 53mmhg. . . [**2127-11-17**] - persantine myoview nuclear study (OSH): large inferior wall infarct, reversible ischemia affecting the anterior wall, marked LV dilation with global hypokinesia. EF 17%. . . [**2127-7-24**] ([**Hospital1 **]) MyoView stress test - dilated LV at rest & stress. large inferior wall infarct without ischemia. significant inferior wall hypokinesis with diffuse global hypokinesis of the remaining walls. EF 32%. Brief Hospital Course: Pt was admitted to the [**Hospital1 1516**] medicine service in hemodynamically stable condition, without chest pain, with ongoing shortness of breath. . . # CAD - pt reports no known prior h/o CAD. Stress test from [**7-8**] showed depressed EF (15-30%). TTE on [**11-17**] showed EF 15-20% with global hypokinesis. Etiology of cardiomyopathy initially unclear: most likely ischemic though alcohol-related also possible given alcohol history. Disease burden on cardiac cath--90% disease LAD, LCX, RCA--made ischemic etiology even more probable. Because pt's diffuse disease, he was evaluated by cardiothoaric surgery service. He and his family ultimately declined CABG given the high risk of the procedure. Pt underwent percutaneous intervention with revascularization. Post-cath, the pt was transferred to the CCU for hypotension--cause unclear (?[**Name2 (NI) 69085**] vs cardiogenic). He was transferred back to the floor pre-discharge. He was continued on a regimen of aspirin, plavix, coreg and lisinopril. Spirinolactone was discontinued. His rythym was normal sinus during his hospital course. . # CHF: Pt initially presented with florid CHF to OSH. Troponin was 1.24, BNP 2080. He was diuresed with significant symptomatic improvement. As above, echocardiogram showed an EF 15-20%, bilateral ventricle dilation & hypokinesis, but no significant valvular disease. He was started on lisinopril pre-cath; however, this was discontinued post-cath secondary to relative hypotension--with plans to restart as an outpatient. Similiarly, the pt was not discharged with lasix as his blood pressure had been low post-cath and he did not seem overloaded. Pt did tolerate Toprol. . # anemia - pt noted to have hct 38-41 @ OSH, dropped to 34 after heparin started. no obvious source of bleeding, guaiac negative pre-cath. iron studies suggest some component of iron deficiency. smear and hemolysis labs (ldh, hapto, LFTs) (-). hct was stable cath. . ## htn: pt has long h/o htn, apparently controlled previously with lisinopril only. Pt became relatively [**Name2 (NI) 69086**] post-cath, able to tolerate only b-blocker. . # NEURO - ?right carotid pulse absent on admission, however carotid doppler shows patent vessel, <40% stenosis. no h/o TIA/CVA. pt family noted [**11-19**] pt is a bit more confused, speech a little more garbled than usual. No neurological deficits previously, or on current exam [**11-22**] (5/5 strength triceps, biceps, delts, wrists, dorsoflexion, plantarflexion, toes downgoing. 28/30 on mini-mental status exam (can't count back [**Hospital1 **] from 100 by 7s). no new meds. Transient confusion thought to be most likely [**3-6**] sundowning as is worse in PM, and subsequently stabilized. . # COPD - unclear if pt has underlying COPD. Pt had long h/o smoking. CXR The lungs showed lungs hyperexpanded bilaterally. Pt started on combivent/albuterol inhalers as he was thought to likely have some COPD. . # seizure disorder - apparently [**3-6**] head trauma from heavy machinery incident ~20 years ago, with seizures occuring after second fall ~1 yr later. pt on dilantin and phenobarbital as outpt. . . # gerd - pt on zantac as outpatient, which was continued here. Medications on Admission: HOME MEDS: combivent 1 puf in h qid phenobarbital 64.8 po qhs folic acid 1 mg po qd prinivil/zetril 20 mg po qdilay dilantin zantac asa prednisone 20 mg po bid (started ~1wk ago for COPD flare) . . Medications on Transfer: aldactone 25 mg po qd asa 162 po qd atrovent 2.5ml INH q6h prn coreg 6.25 mg po qd dilantin 100mg po q8h lovenox 70 mg sc q12h phenobarbital 64.8 mg po bid (prev sz d/o) lisinopril 10mg po qdaily zocor 10 mg po qhs . Discharge Medications: 1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-3**] Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. Disp:*1 INHALER* Refills:*3* 2. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*11* 7. Phenobarbital 30 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). Disp:*60 Tablet(s)* Refills:*2* 8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO twice a day for 2 days: Start on [**11-29**]. Disp:*4 Tablet(s)* Refills:*0* 9. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: Start on [**12-1**]. Disp:*2 Tablet(s)* Refills:*0* 10. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day: Take in the evening. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 11. Rehab Cardiac rehab to begin after [**12-27**] Discharge Disposition: Home Discharge Diagnosis: NSTEMI hypotension Discharge Condition: good, ambulating without pain. not short of breath Discharge Instructions: You were in the hospital because you had a mild heart attack. Cath showed that you had very bad [**First Name9 (NamePattern2) 69087**] [**Last Name (un) **] disease. You were taken to the cath lab for stents. You have been started on many new medications. Take these as prescribed. You may not stop the asprin or plavix under any circumstance unless told to by a cardiologist. If you have any questions about your medications, call Dr. [**Name (NI) 69088**] office (number below). You should refrain from heavy activity for 1 month. You have been given numbers for cardiac rehab. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet You are on a short steroid taper because you recieved steroids in the intensive care unit. Followup Instructions: You have an appointment with Dr. [**Last Name (STitle) **] at Friday [**1-2**] at 9:20AM. This is in the [**Hospital Ward Name 23**] building. Call ([**Telephone/Fax (1) 1987**] for directions or to change this appointment.

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icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

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5416, 8635

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10515, 10567

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7829

Discharge summary

report

Admission Date: [**2156-1-27**] Discharge Date: [**2156-2-5**] Date of Birth: [**2077-10-5**] Sex: F Service: MEDICINE Allergies: Erythromycin Base / Heparin Agents Attending:[**First Name3 (LF) 1377**] Chief Complaint: nausea,vomitting, generalized weakness Major Surgical or Invasive Procedure: 2 Central Venous Catheters History of Present Illness: 78 y/o lady with hypertension and supraventricular tachycardia presented to the Emergency Department with 3 to 4 days of nausea, vomitting and generalized weakness. Patient was seen at [**Hospital1 18**] ED on [**2156-1-14**] with right ureteral stone. She was suppose to have an elective cardioversion as out patient prior to surgical removal of this stent. Since getting home, patient has felt generally weak and decreased appetite. She has had on and off of abdominal pain and back pain. Her husband has a hard time quantifying or qualifying the pain. . Patient continued to have nausea, nonbloody, nonbilious vomitting and generalized weakness, and husband decided to bring the patient to the Emergency Department. On arrival to [**Hospital1 18**] ED patient was walking and talking without any difficulty. Her inital vitals in ED were T 96 BP 96/64 HR 96 RR 16 unable to check oxygen saturation. Her SBP trended down to 40s and she was started on pressors (initally phenyphrine which was switched to levophed). Patient also received 7L of IVF. She was started on dobutamine drip after a bedside TTE showed depressed LV function. Her oxygen saturation also decreased to 60s and she was intubated. Patient also received vancomycin, ceftriaxone and levaquin in ED for possible pneumonia on CXR. CT torso with contrast shows PE, Aortic/celiac thormbus, and infarcted spleen. There was also concern for shock bowel. Vascular surgery and General surgery were consulted. Acute medical management for DIC was recommended. Hematology was consulted for coagulopathy. Urology was also consulted for ureteral stone. . On arrival to the floor patient was on levophed and dobutamine drip, sedated and intubated. Most of the history was obtained from the chart and with husband. . ROS: Patient has experienced on and off palpitations. No fevers, chills, or night sweats. Past Medical History: - Hypertension - Supra ventricular Tachycardia - Dyslipidemia Social History: Retired, had her own business. Never smoked. No ETOH, street drugs. Lives with her husband. [**Name (NI) **] children per husband. Family History: grandmother had kidney stones. Physical Exam: On Presentation: Gen: intubated and sedated HEENT: pupils equally round and minimally reactive to light, MMM Heart: S1S2 RRR Lungs: CTAB in anterior lung fields Abd: BS absent, soft, ND Ext: WWP, no edema Neuro: Limited by sedation On Discharge: VSS GEN: NAD HEENT: EOMI, PERRL, MMM, no OP lesions Heart: regular rate, s1/s2, no mrg PULM: CTAB EXT: 1+ non pitting edema UE to mid forearm and [**Doctor Last Name **] with ankle, 2+ DP pulses PSYCH: appropriate NEURO: CN 2-12 intact, UE/LE stength [**3-30**], sensation intact Pertinent Results: Admit Labs: [**2156-1-27**] 07:05AM BLOOD WBC-15.0*# RBC-5.22 Hgb-15.6 Hct-47.1 MCV-90 MCH-29.8 MCHC-33.0 RDW-16.3* Plt Ct-145* [**2156-1-27**] 07:05AM BLOOD Neuts-75.7* Lymphs-19.1 Monos-3.9 Eos-1.0 Baso-0.2 [**2156-1-27**] 08:25AM BLOOD PT-19.5* PTT-26.5 INR(PT)-1.8* [**2156-1-27**] 08:42PM BLOOD ACA IgG-2.0 ACA IgM-6.3 [**2156-1-27**] 07:05AM BLOOD Glucose-125* UreaN-37* Creat-1.4* Na-138 K-5.7* Cl-99 HCO3-20* AnGap-25* [**2156-1-27**] 07:05AM BLOOD ALT-290* AST-257* CK(CPK)-146* AlkPhos-87 TotBili-2.1* [**2156-1-27**] 07:05AM BLOOD Lipase-33 [**2156-1-27**] 07:05AM BLOOD Albumin-4.1 Calcium-9.3 Phos-4.7*# Mg-2.7* [**2156-1-27**] 10:25AM BLOOD D-Dimer-[**Numeric Identifier **]* [**2156-1-27**] 09:55AM BLOOD Hapto-31 [**2156-1-27**] 02:38PM BLOOD PEP-HYPOGAMMAG IgG-410* IgA-64* IgM-22* IFE-NO MONOCLO [**2156-1-27**] 07:15AM BLOOD Lactate-5.1* [**2156-1-27**] 11:19AM BLOOD freeCa-0.89* . TTE [**2156-1-27**]: The left atrium is dilated. The right atrium is dilated. There is moderate regional left ventricular systolic dysfunction with focal hypokinesis of the inferior and inferolateral walls. Right ventricular chamber size is normal. with borderline normal free wall function. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. IMPRESSION: Suboptimal image quality. Moderate regional left ventricular systolic dysfunction. Borderline reduced right ventricular function. Moderate mitral regurgitation. Mild aortic regurgitation. Mild pulmonary hypertension. Small circumferential effusion with no echocardiographic signs of tamponade. . CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST; CT CHEST W/CONTRAST [**2156-1-27**] CHEST: There is a large but nonobstructing thrombus at the bifurcation of the right middle lobe vessels and the right interlobar artery. Given the delayed nature of the scan, there is suboptimal opacification of the pulmonary arterial tree and the more distal segmental and subsegmental branches are difficult to fully evaluate. There are no associated findings suggestive of right heart strain. The heart itself is enlarged with predominantly left atrial enlargement. Scattered coronary calcifications are evident. The ascending aorta is approximately 36 mm in diameter 1 cm distal to the sinotubular ridge. At the level of the main pulmonary artery, the descending thoracic aorta is approximately 25 mm in diameter. At the aortic hiatus, the thoracic aorta is approximately 23 mm in diameter. Further comment on the aorta is reserved to the following section on the abdomen/pelvis. There are large bilateral pleural effusions. Extensive dependent consolidations are noted likely due to relaxation atelectasis although aspiration or small foci of infection cannot be entirely excluded. There is interlobular septal lines likely due to edema. An endotracheal tube is present with the distal tip at the ostium of the right mainstem bronchus. A nasogastric tube is also present. There is a leftward deviation of the trachea at the thoracic inlet of indeterminate cause due to incomplete scanning of the thyroid and neck region. Enlarged lymph nodes are noted throughout the mediastinum. ABDOMEN/PELVIS: There is a large mural thrombus occupying over 50% of the lumen of the descending thoracic aorta starting at approximately the level of the left superior pulmonary vein. This long mural thrombus extends to the aortic hiatus. Intimal calcifications are noted posteriorly without displacement. Near the aortic hiatus, a second focus of mural thrombus along the anterior aspect of the aorta is seen extending into the abdomen and terminating at the level of the superior mesenteric artery. This thrombus occludes the ostium of the celiac axis which is completely thrombosed. The appearance of this extensive mural thrombus is interval given its lack of appearance on the chest CT dated [**2156-1-14**]. There are corresponding large infarctions involving the spleen. There is a heterogeneous attenuation at predominantly the left hepatic lobe which is presumably due to the vascular compromise. As best can be determined it somewhat normalizes on the later chest CT. There is appropriate contrast opacification of the superior mesenteric artery. Collateralization is identified through the gastroduodenal and pancreaticoduodenal arcades. There is periportal edema noted in the liver. A well-defined low-attenuation lesion is identified within segment V anteriorly measuring approximately 8 mm in diameter. This is indeterminate but likely represents a simple cyst. There is marked gallbladder wall edema. A significant amount of mesenteric edema and ascites is present. Majority of the ascites is in the perihepatic distribution as well as deep within the pelvis. The kidneys enhance and excrete contrast symmetrically. The adrenal glands are appropriately perfused. There is edema of the pancreas. The distal tip of the nasogastric tube is noted within the gastric pylorus. The bowel is largely collapsed. There is wall thickening involving the ascending and proximal transverse colon. No small bowel dilatation is identified. Although heavily calcified, the remainder of the aorta is well opacified and nonaneurysmal. No dissection flap is identified. A right femoral central line is present. Small locules of air identified in the extraperitoneal soft tissues of the right groin likely due to the placement of the femoral line catheter. The bladder is collapsed around a Foley catheter balloon. A small uterus is present. Ovaries are not definitively identified. Mild degenerative changes are noted throughout the thoracolumbar spine. No suspicious osseous lesions are identified. Normal thoracolumbar spinal alignment is evident. A vertebral hemangioma is incidentally identified in the L2 vertebral body. Transitional segmentation is incidentally noted at the lumbosacral junction. IMPRESSION: 1. Acute pulmonary embolism in the right interlobar artery as above. No specific signs of right heart strain noted. There are large bilateral pleural effusions. 2. Interval nonocclusive thrombosis of the descending aorta and upper abdominal aorta resulting in the apparent interval thrombosis of the celiac axis and branch vessels further resulting in splenic infarctions and vascular perfusion abnormalities of the liver. While the superior mesenteric artery is patent, there is wall edema of the ascending and proximal transverse colon which may be due to distal embolic phenomenon. There is a large amount of accompanying ascites. 3. Retraction of the endotracheal tube is recommended as the distal tip is at the ostium of the right mainstem bronchus. Retraction by approximately 3 cm would be optimal. DISCHARGE LABS: CBC: WBC:8.8, Hgb:9.2, Hct:27.8, Plt Ct:448 CHEM 7: Glucose:73, BUN:10, Creat: 0.6, Na:139, K: 4, Cl:104, HCO3: 26 HIT AB: pending SSA: pending Brief Hospital Course: 78 y/o lady supraventricular tachycardia presented to ED with cardiogenic with shock. Found to have multiple thrombi thought to be secondary to heparin-induced thrombocytopenia. Treated with argatroban drip and stabilized. Transitioned to coumadin. On floor had multiple AVNRT episodes on diltiazem. EP consulted and changed to quinidine. Discharged in stable condition with hematology follow up. # Shock: Patient was in cardiogenic shock with depressed EF wall motion abnormality and decreased cardiac out put on admission. Was treated broadly with vanocmycin/zozyn given recent history of nephrolithiasis, and argatroban for coagulopathy. Stabilized after several days in the ICU and transferred to the floor. Hematology consult advised that coagulopathy likely secondary to heparin-induced thrombocytopenia. Treatment as below. # Coagulopathy: Concern for HIT given recent exposure on [**1-14**]% drop in plt since then. Howevere heparin-dependant antibody was negative making HIT less likely. Other possibilities included DIC from infection though cultures were negative and malignancy given patient has refused age appropriate cancer screenings [**Last Name (un) **] PCP. [**Name10 (NameIs) **] had multiple thrombus including PE, arotic/celiac thrombus and most likely emboli leading to splenic infarct and possible bowel infarct. At this time, a seconf heparin-dependant antibody and SSA is pending. Hematology was consulted and per their recommendations, argatroban was continued and patient was transitioned to coumadin. She has hematology follow up next month and her PCP will follow her INR. # Tachycardia: Patient with known history of AVNRT. Had initially been amiodarone loaded but was then transition to diltiazem 360mg a day. This did not control her tachycardia and she continued to be tachy intermittently though her pressures remained stable. EP was consulted and recommended quinidine 600 qam and qpm and 300 at lunch and metoprolol 50mg [**Hospital1 **] which adequately controlled her tachycardia. Patient may have ablation in future and will contact Dr. [**Last Name (STitle) 28264**] to follow up. # Hypoxia: Oxygen sats dropped to 60s on presentation to the emergency room and patient was intubated. Found to have PE. Treated as above and successfully extubated. On room air prior to discharge. # Right Ureteral Stone: Known upon prior hospital admission. Initially treated with vancomycin and zosyn given concern for septic shock. These were discontinued as cultures were all negative and there were no localizing symptoms. # Hematuria: Had after discontinuation of foley. Hct stable. # Leukocytosis: Ranged 13,000-18,000, likely in setting of cardiogenic shock from pulmonary embolus and likely HIT. Initially treated with antibiotics which were disconintued as patient had no localizing symptoms and had negative cultures. # Anemia: Decreased from baseline to low-mid 30's. Had left groin hematoma and small jugular hematoma after line attempts. No other signs of bleeding. # # Hematomas: Occurred in left groin and jugular in setting of line attempts. Stable, no increase in size, no respiratory compromise. # Mediastinal Lymphadenopathy: See on CT chest. Has follow up with pulmonology for further evaluation. Concern for malignacy. # Contact: [**Name (NI) 4906**], Mr.[**First Name8 (NamePattern2) 122**] [**Known lastname 28265**], [**Telephone/Fax (1) 28266**] # Code: FULL Medications on Admission: Husband will verify the dose 1. Aspirin 81 mg PO Daily 2. Atorvastatin 20 mg PO Daily 3. MVI 4. Alprazolam 0.25 mg PO TID prn anxiety. 5. Docusate Sodium 100 mg PO BID 6. Metoprolol Tartrate 50 mg PO Q6 hours 7. Morphine 15 mg Tablet Sig: 1-2 Tablets PO every [**3-1**] prn pain. Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. Disp:*90 Tablet(s)* Refills:*2* 3. Quinidine Sulfate 200 mg Tablet Sig: Three (3) Tablet PO Q12H (every 12 hours): Take 600 mg (2 tablets) in the morning and at night. . Disp:*180 Tablet(s)* Refills:*2* 4. Quinidine Sulfate 200 mg Tablet Sig: 1.5 Tablets PO LUNCH (Lunch): Take 300 mg at lunch (one and a half tablets). Disp:*45 Tablet(s)* Refills:*2* 5. Aspirin 81 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Coagulopathy AVNRT Pulmonary Embolus Aortic Thrombus Secondary: Hyperlipidemia Discharge Condition: Vitals stable. Ambulating without difficulty or pain. Discharge Instructions: You were admitted to the ICU after coming to the emergency room and required intubation and blood pressure support. You were found to have numerous clots that could have been from severe infection, a heparin allergy (though the test was negative for this) or from a cancer. You were treated with an iv medication for the clots and then started on an oral medication called coumadin which is a blood thinner that you can take at home. You should continue this medication and will be followed by hematology as an out patient. They will determine how long you need to be on this medication. Additionally, you continued to have a fast heart rate while you were here - the same fast heart rate that you have intermittently at home. The cardiologists saw you and you were started on: QUINIDINE 600 mg in the morning, 300mg at lunch and 600mg at night METOPROLOL 50 mg twice a day COUMADIN 3mg in the evening Your cholesterol medicine was stopped because lab tests showed that your liver had some dysfunction - probably in the setting of being critically ill. Dr. [**First Name (STitle) 679**] may restart this in the future. Patients taking coumadin need very close monitoring of their INR (a lab test that indicates how thin the blood is). You will need to have your INR checks the day after you are discharged and the Monday after you are discharged. Dr. [**First Name (STitle) 679**] will follow that and contact you regarding the results. Your fast heart rate as resolved with the new medication regimen you were started on. No other medication changes were made. You should continue all your other home medications as previously directed. Finally, some enlarged lymph nodes were seen on your CT scan. It is unclear what the significance of these are, but you have an appointment with a pulmonologist to have this followed up on. You have several follow up appointments listed below. Please be sure to go to these or change them as necessary. Please follow up with Dr. [**First Name (STitle) 679**] next week. You can call Dr.[**Name (NI) 7914**] office at [**Telephone/Fax (1) 62**] to make an appointment in several weeks. You have an appointment with the hematologists in [**Month (only) 547**] as below. If you have bleeding that won't stop, shortness of breath, abdominal pain, chest pain, fever, dizziness or lightheadedness, severe nausea/vomiting, or any other concerning symptoms, please seek medical care immediately. It was a pleasure meeting you and participating in your care. Followup Instructions: Hematology: Dr. [**First Name11 (Name Pattern1) 569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] & Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 22**] [**2156-3-3**] 2:00pm Pulmonology: Dr. [**Last Name (STitle) **] [**2156-2-10**] at 1pm Primary Care: Please call Dr. [**First Name (STitle) 679**] to schedule an appointment at [**Telephone/Fax (1) 682**] Cardiology: Please call Dr. [**Last Name (STitle) **] to schedule an appointment in several weeks at [**Telephone/Fax (1) 62**]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]

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icd9cm

[ [ [] ] ]

[ "38.91", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

14702, 14708

10296, 13751

333, 362

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2503, 2535

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338

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24908

Discharge summary

report

Admission Date: [**2135-10-26**] Discharge Date: [**2135-11-3**] Date of Birth: [**2059-10-6**] Sex: M Service: MEDICINE Allergies: Opioid Analgesics Attending:[**First Name3 (LF) 2641**] Chief Complaint: Left flank pain Major Surgical or Invasive Procedure: s/p catheterization and tpa thrombolysis History of Present Illness: 76 yo man with PMH significant for afib and recent subtherapuetic INR, who presented to PCP's office on [**2135-10-26**] with left flank pain. The pain started suddenly on [**2135-10-25**], was described as sharp "like a knife", and was located in left flank region without radiation. Mr. [**Known lastname 62631**] also had significant nausea, concommitant with the flank pain, which he attempted and failed to relieve through self-induced vomiting. He had no hematuria, fever, or diarrhea. No recent trauma. The pain persisted, constant in intensity at 10/10, and he saw his PCP [**Last Name (NamePattern4) **] [**10-26**] where he was found to have microscopic hematuria by UA and was referred to the [**Hospital 1474**] Hospital ED. CT there showed a left renal artery obstruction c/w thrombosis vs. thromboembolism. He was transferred to [**Hospital1 18**]. Past Medical History: Coronary artery disease status post angioplasty ~ 15 yrs ago Atrial fibrillation Prostate condition - unspecified Hypertension Hypercholesterolemia Asthma - pt unaware of PFTs in past Social History: 60 pack yr smoking hx, quit 30 yrs ago Alcohol occasionally No drug use Lives with wife retired, former [**Name (NI) 62632**] worker Family History: Father with unknown type cancer Mother with MI Physical Exam: VS: T 98.6 HR 99 BP 161/94 RR 15 O2sat 96%RA Genl: NAD HEENT: PERRLA, EOMI Neck: no carotid bruits, no LAD, no JVD CV: Irregularly irregular, nl s1s2, no mrg Pulm: Lungs clear Abdomen: soft, tender at left flank, nondistended, normoactive bowel sounds, no abdominal bruit, no pulsating mass to suggest AAA Back: left CVa tenderness, no ecchymosis Ext: LE without edema, 1+DP pulses/ 1+[**Doctor Last Name **] pulses, no cyanosis Pertinent Results: Admission labs: CBC: WBC-9.4 RBC-5.07 Hgb-12.5* Hct-37.8* Plt Ct-164 Diff: Neuts-85.0* Bands-0 Lymphs-10.8* Monos-3.8 Eos-0.1 Baso-0.3 Coags: PT-14.0* INR(PT)-1.3 Chem10: Glucose-118* UreaN-20 Creat-1.5* Na-137 K-4.8 Cl-96 HCO3-28 Calcium-8.7 Phos-2.8 Mg-1.8 Fe studies: Iron-21* calTIBC-365 Ferritn-54 TRF-281 Anemia studies: VitB12-496 Folate-15.8 Ret Aut-1.3 Fibrino-667* Discharge labs: Chem10: Glucose-157* UreaN-13 Creat-1.3* Na-140 K-4.6 Cl-106 HCO3-23 Calcium-8.8 Phos-3.3 Mg-2.2 CBC: WBC-4.8 RBC-4.03* Hgb-10.2* Hct-30.7* Plt Ct-232 Coags: PT-18.8* PTT-115.7* INR(PT)-2.5 Micro: Blood cx x 2 - negative Urine cx - negative Studies: . UA at OSH with 0-2 rbc, 0-2 wbc, creat 1.3 Stool guaiac negative . CT abd/pelvis at OSH with essentially complete absence of flow to the left kidney other than min flow to some portions of ant mid pole and lower pole, contrast in prox left renal aa with lack beyong that point suggests in situ thrombus or embolism; cysts in both kidneys, aorta diffusely calcified but nl in caliber, no aortic dissection, prostate enlarged, no LAD, diverticuli, enlarged heart; otherwise nl . EKG at [**Hospital1 18**] with afib, normal axis, no LVH, q in III, no ST/T wave abnormalities. ECHO ([**10-27**]): Left Atrium - Long Axis Dimension: *5.0 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *7.5 cm (nl <= 5.2 cm) Left Ventricle - Septal Wall Thickness: 0.9 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 0.8 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 5.2 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 45% (nl >=55%) Aorta - Valve Level: 2.9 cm (nl <= 3.6 cm) Aorta - Ascending: *4.1 cm (nl <= 3.4 cm) Aorta - Arch: *3.1 cm (nl <= 3.0 cm) Aortic Valve - Peak Velocity: 1.2 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 1.1 m/sec Mitral Valve - E Wave Deceleration Time: 181 msec TR Gradient (+ RA = PASP): *22 to 30 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. LEFT VENTRICLE: Normal LV cavity size. Mildly depressed LVEF. RIGHT VENTRICLE: Mildly dilated RV cavity. RV function depressed. AORTA: Normal aortic root diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild [1+]TR. PERICARDIUM: No pericardial effusion. Conclusions: 1. The left atrium is moderately dilated. The right atrium is moderately dilated. 2. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed. Inferior hypokinesis is present. 3. The right ventricular cavity is mildly dilated. Right ventricular systolic function appears depressed. 4. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. 5. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Cath [**10-27**]: Selective renal angiography demonstrated a large blood clot present within the left main renal artery extending into the peripheral branches. Perfusion of the left renal parenchyma was significantly reduced. Catheter-directed intrathrombus pulse spray infusion of 10 mg of TPA was performed via a multisidehole infusion catheter. The multisidehole infusion catheter positioned within the thrombosed was connected to a continuous drip of TPA at 1 mg per hour during the first hours of the infusion and 0.5 mg per hour continuous infusion of TPA thereafter. Followup angiogram was planned to be performed in approximately 15 hours. Cath [**10-28**]: Followup left renal angiography demonstrated significantly reduced amount of thrombus within the left renal artery. Perfusion to the left renal parenchyma has significantly improved. Areas of the left renal parenchyma in its lower lateral pole demonstrated persistent hypoperfusion. Pulse spray catheter-directed infusion of 6 mg of TPA into the left renal artery was performed. The catheter was connected to the continuous infusion of TPA at 1 mg per hour for 4 hours. A followup left renal angiography will be then performed. Follow-up 10/28: Marked improvement of the left renal artery thrombus with only small residual filling defects, predominantly in the lower renal artery branch. Overall, improved parenchymal perfusion compared with the prior study with still some areas of hypoperfusion in the interpolar region and lower pole. Arterial duplex, right lower extremity, [**11-3**]: No evidence of right inguinal pseudoaneurysm or AV fistula. Brief Hospital Course: 76yo man with afib, CAD, HTN, BPH, w/ left renal artery occlusion, renal failure, s/p catheter guided TPA lysis to restore flow. . History is detailed below by problem: . 1) Left renal artery occlusion: The patient was found to have a left renal artery thrombus [**1-2**] cms distal to origin of aorta with occlusion of the tributaries extending into renal pelvis. Renal arteriography was performed with injection of TPA x 3. Adequate flow was restored and patient received heparin bridging to coumadin over 5 days. On the night following his TPA therapy, He had bleeding from a hematoma at the right groin catheter site. Bleeding was stopped with pressure and the hematoma was monitored closely; it resolved throughout his hospital course. 2) Renal insufficiency: Mr. [**Known lastname 62633**] creatinine was 1.5 on admission, up from baseline of 1.0, believed secondary to renal artery occlusion. With restoration of arterial perfusion, his creatinine trended down to 1.3 at discharge. Per the interventional radiology service, this would be analagous to slow recovery from ATN and would expect for it to continue to fall. 3) Anemia: Pt has Fe deficiency anemia. His hematocrit dropped from 37 on admission to 29 to a low of 27.1 on [**10-28**]. Guaiac exams were negative, and no active sources of bleeding were idenitified. His hematocrit stabilized in the low 30s prior to discharge. 4) Hypertension: he was normotensive throughout his course, received lasix home med dose of 40 mg po qd and continued on verapamil SR 240 mg PO Q24H. [**Last Name (un) **] was held given the ACE inhibitor component. Medications on Admission: [**Last Name (un) **] 180 mg po qd Furosemide 40 mg po qd Zocor 40 mg po qd Coumadin 5 mg po qd Discharge Medications: 1. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day. 2. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). Disp:*30 Tablet Sustained Release(s)* Refills:*2* 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 4. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:*10 Tablet(s)* Refills:*0* 7. Atrovent 18 mcg/Actuation Aerosol Sig: One (1) INH Inhalation twice a day. Discharge Disposition: Home Discharge Diagnosis: Renal artery embolus and renal infarct s/p thrombolysis Discharge Condition: good Discharge Instructions: Please call your primary care doctor if you have fevers > 101.5, severe chest pain, shortness of breath, worsening back pain, blood in your urine or if your symptoms worsen. Take your coumadin as prescribed and have your INR checked by your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 766**] at clinic. Followup Instructions: Follow up appointment w/ PCP on [**Name9 (PRE) 766**], [**11-7**], at 215pm Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2135-11-29**] 10:00 Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2135-11-17**] 2:00

[ "600.00", "272.0", "427.31", "593.81", "V58.61", "V45.82", "401.9", "599.7", "493.90", "724.5", "592.0" ]

icd9cm

[ [ [] ] ]

[ "88.42", "88.45", "99.10" ]

icd9pcs

[ [ [] ] ]

9288, 9294

6800, 8410

295, 338

9394, 9401

2124, 2124

9778, 10116

1610, 1659

8556, 9265

9315, 9373

8436, 8533

9425, 9755

2516, 6777

1674, 2105

240, 257

366, 1234

2140, 2500

1256, 1443

1459, 1594

51,108

109,513

32225

Discharge summary

report

Admission Date: [**2177-5-26**] Discharge Date: [**2177-5-30**] Date of Birth: [**2123-5-28**] Sex: M Service: CARDIOTHORACIC Allergies: Lipitor Attending:[**First Name3 (LF) 1505**] Chief Complaint: Angina Major Surgical or Invasive Procedure: [**2177-5-26**] Coronary artery bypass graft x 3 LIMA-> LAD, RSVG-> Diagonal, PLV History of Present Illness: Mr. [**Known lastname 1511**] is a 53 year old man with stable angina found to have multi-vessel disease. Cardiac Catheterization: Date:[**2177-4-17**] Place:MW subtotal occlusion od LAD, 80% stenosis of ostium of PDA, occluded PDA, patent [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 10157**] in obtuse marginal and mid RCA Cardiac Echocardiogram:[**2176-3-25**] EF 55% with no wall motion abnormalities, 1+MR, trace AI, 1+TR, 1+PI Other diagnostics:ETT:angina at 9 minutes w associated diagnostic ST changes Past Medical History: Coronary artery disease s/p cypher DES to LCx and R-PLV in [**2172**] Hyperlipidemia Ulcerative colitis Lumbar disc disease s/p lumbo-sacral surgery [**2176**] s/p Appendectomy s/p Hernia repair [**2172**] Social History: Race:caucasian Last Dental Exam:>1 year ago Lives with:alone, has girlfriend Occupation: repair diesel engines at a golf course Tobacco:denies EtOH:4 beers/month Family History: Father w CABG in his 70's Physical Exam: Pulse:72 Resp:16 B/P Left: 126/90 Height:5'9" Weight:82 kgs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:1+ Left:1+ DP Right:2+ Left:2+ PT [**Name (NI) 167**]:2+ Left:2+ Radial Right:2+ Left:2+ Carotid Bruit Right:- Left:- Pertinent Results: [**2177-5-26**] Echo: 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. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). 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. There are three aortic valve leaflets. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person of the results. Post CPB: The patient is in sinus rhythm. The biventricular systolic function is unchanged. The visible contours of the thoracic aorta are intact. [**2177-5-29**] 10:45AM BLOOD WBC-8.5 RBC-3.19* Hgb-10.3* Hct-29.5* MCV-93 MCH-32.2* MCHC-34.8 RDW-13.7 Plt Ct-156 [**2177-5-29**] 10:45AM BLOOD Na-139 K-4.5 Cl-101 [**2177-5-28**] 04:13AM BLOOD Glucose-133* UreaN-16 Creat-0.8 Na-136 K-4.2 Cl-103 HCO3-27 AnGap-10 Brief Hospital Course: Mr. [**Known lastname 1511**] was a same day admit after undergoing pre-operative work-up as an outpatient. On [**5-26**] he was brought to the operating room where he underwent a coronary artery bypass graft x 3. See operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one he was started on beta-blockers and diuresed towards his pre-op weight. Later this day he was transferred to the step-down floor for further care. Chest tubes and epicardial pacing wires were removed per protocol. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home with VNA serives in good condition with appropriate follow up instructions. Medications on Admission: Asacol 800 mg [**Hospital1 **] Aspirin 325 mg daily Pravastatin 40 mg daily Metoprolol tartrate 25 mg [**Hospital1 **] Fish oil Multivitamin Discharge Disposition: Home With Service Facility: tba Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass graft x Past medical history: s/p cypher DES to LCx and R-PLV in [**2172**] Hyperlipidemia Ulcerative colitis Lumbar disc disease s/p lumbo-sacral surgery [**2176**] s/p Appendectomy s/p Hernia repair [**2172**] Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Dilaudid Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. 1+ Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [**Last Name (STitle) **] on [**6-19**] at 1:30pm Cardiologist: Dr. [**Last Name (STitle) 6254**] on [**7-1**] at 9:00am Please call to schedule appointments with your Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 70216**] in [**4-15**] weeks [**Telephone/Fax (1) 72189**] **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:[**2177-5-30**]

[ "556.9", "413.9", "272.4", "V45.82", "414.01" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

4513, 4547

3298, 4322

281, 365

4853, 5070

1992, 2862

5993, 6555

1342, 1369

4568, 4627

4348, 4490

5094, 5970

1384, 1973

235, 243

393, 918

4649, 4832

1163, 1326

2872, 3275

9,770

144,773

8997

Discharge summary

report

Admission Date: [**2130-3-23**] Discharge Date: [**2130-4-4**] Service: CARDIOTHORACIC Allergies: Codeine Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Coronary Artery Bypass Graft x3 (Left internal mammary artery > left anterior descending, Saphenous vein graft > Obtuse marginal, Saphenous vein graft > right coronary artery) [**2130-3-30**] Cardiac Catherization [**2130-3-23**] History of Present Illness: [**Age over 90 **] year-old woman with paroxysmal atrial fibrllation, hypertension, and hyperlipidemia who initially presented to the [**Hospital3 **] ED on [**2130-3-20**] complaining of chest pain. She ruled in for an NSTEMI by cardiac enzymes with a peak troponin I of 1.37 (CK on admission noted to be 111). Chest pain relieved by Nitroglycerin and she was admitted to OSH CCU. She continued to have post MI angina and was transferred to [**Hospital1 18**] for cardiac cath. Past Medical History: Atrial fibrillation; never on warfarin, per patient Hypertension Hyperlipidemia Hypothyroidism History of an left acoustic neuroma surgically removed several decades ago; residual left-sided deafness Glaucoma Left [**Hospital Ward Name 4675**] cyst s/p T&A s/p bilat cataract surgery Social History: Social history is significant for the absence of current/past tobacco use. There is no history of alcohol abuse. She is independent in her ADLs and lives in [**Location (un) 5481**] Independent Living. Family History: There is no family history of premature coronary artery disease or sudden death. Her mother and several siblings had ischemic heart disease in their elder years. Physical Exam: Temperature was 97.3. Blood pressure was 197/56 mm Hg while supine. Pulse was 47 beats/min and regular, respiratory rate was 16 breaths/min with an O2Sat of 100% on 2 L/min nasal cannula. Generally the patient was well developed, well nourished and well groomed. The patient was oriented to person, place and time. The patient's mood and affect were appropriate. . There was no xanthalesma and conjunctiva were pink with no pallor or cyanosis of the oral mucosa. The neck was supple with JVP of 8cm cm. The carotid waveform was normal with no bruits. There was no thyromegaly. The were no chest wall deformities, scoliosis or kyphosis. 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. . Palpation of the heart revealed the PMI to be located in the 5th intercostal space, mid clavicular line. There were no thrills, lifts or palpable S3 or S4. The heart sounds revealed a normal S1 and the S2 was normal. There was a III/VI There were no rubs, clicks or gallops. . The abdominal aorta was not enlarged by palpation. There was no hepatosplenomegaly or tenderness. The abdomen was soft nontender and nondistended. The extremities had no pallor, cyanosis, clubbing or edema. There were no abdominal, femoral or carotid bruits, though her systolic aortic murmur . Inspection and/or palpation of skin and subcutaneous tissue showed no stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 2+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+ Pertinent Results: [**2130-3-23**] CNIS: 1. Less than 40% stenosis of the right internal carotid artery. 2. 40-59% stenosis of the left internal carotid artery [**2130-3-23**] Cath: 1. Coronary angiography of this right dominant system revealed severe three vessel and left main coronary artery disease. The left main coronary artery had a 80% heavily calcified stenosis in the distal segment. The LAD had a 50% stenosis at the bifurcation of the 2nd diagonal which itself had a 40% shelf-like plaque. The LCX had an 80%stenosis proximally with a 70% stenosis in the first OM. The RCA was totally occluded at its ostium. 2. Limited resting hemodynamics revealed severely elevated systemic arterial pressures (aortic pressure was 168/46 mm Hg). A widened pulse pressure was noted. 3. Contrast aortography revealed mild to moderate aortic regurgitation. [**2130-3-23**] Echo: The left atrium is dilated. The estimated right atrial pressure is 0-5mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF 70%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are focal calcifications in the aortic arch. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is mild 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. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The left ventricular inflow pattern suggests impaired relaxation. The estimated pulmonary artery systolic pressure is normal. There is a small to moderate sized pericardial effusion subtending the posterior wall and right atrial free wall. There are no echocardiographic signs of tamponade. No right ventricular diastolic collapse is seen. There is brief right atrial diastolic invagination [**2130-3-24**] Head CT: No acute intracranial hemorrhage. Bifrontal small chronic subdural hematomas. [**2130-3-24**] Head MRA: 1. No acute infarct. 2. White matter chronic microvascular ischemic changes. 3. Generalized atherosclerosis without occlusions, hemodynamically significant stenosis, or aneurysms within the circle of [**Location (un) 431**] or its major tributaries. 4. Fetal left PCA. [**2130-3-24**] EEG: This is an abnormal EEG due to the frequent triphasic waves and the slow and disorganized background rhythm. Both of these abnormalities suggest a mild to moderate encephalopathy, which may be seen with infections, toxic metabolic abnormalities or medication effect. No epileptiform features or electrographic seizures were noted. [**2130-3-28**] Abd CT: 1. Subcentimeter lung nodules as described above. In a low risk patient, 12 months follow up scan is recommended to assess stability. 2. Small hypodense focus within the left lobe of the liver could represent an atypical hemangioma. 3. Cystic lesions within the pancreatic head and pancreatic body that may represent sidebranch IPMT. Consider MRI for further characterization or alternatively six months follow-up to assess stability. 4. Cholelithiasis without evidence of cholecystitis. 5. Fusiform infrarenal aortic aneurysm. 6. Severe atherosclerotic changes involving the aorta and its branches. 7. Findings, the spleen could represent hemangioma. This can also be evaluated with MRI or in a 6 months follow-up scan. 8. Fibroid uterus. 9. Small right-sided pleural effusion and pericardial effusion. 10. 2.8 x 2.6 cm rounded focus in the right adnexa could represent para- ovarian cyst which can be confirmed with pelvic ultrasound if needed. [**2130-3-28**] Abd U/S: 1. Normal flow in the mesenteric arterial and venous vasculature with no evidence for significant stenoses or thrombosis. 2. Uncomplicated gallstones. 3. A small 3 cm mid abdominal aortic aneurysm. 4. 2 cm cystic nodular pancreatic mass in the neck suspicious for possible cystic pancreatic neoplasm. This could be further evaluated with MRI. 5. Solid 3.5 cm lesion in the inferomedial aspect of the spleen of unclear etiology, but also worrisome for neoplasm. Again this could be further evaluated with MRI. [**2130-4-2**] CXR: Left-sided chest tube has been removed, with no pneumothorax. There is improving aeration at the left base likely due to a combination of improving atelectasis and effusion. Small right pleural effusion with adjacent basilar atelectasis is unchanged. [**2130-3-23**] 11:25AM BLOOD WBC-9.1 RBC-3.36* Hgb-11.1* Hct-32.0* MCV-95 MCH-33.0* MCHC-34.6 RDW-12.6 Plt Ct-225 [**2130-4-1**] 02:55AM BLOOD WBC-17.6* RBC-3.79* Hgb-12.2 Hct-35.5* MCV-94 MCH-32.2* MCHC-34.4 RDW-14.0 Plt Ct-236 [**2130-4-4**] 05:25AM BLOOD WBC-11.7* RBC-2.94* Hgb-9.5* Hct-28.0* MCV-95 MCH-32.4* MCHC-34.1 RDW-14.0 Plt Ct-275 [**2130-3-24**] 02:40AM BLOOD PT-13.1 PTT-31.5 INR(PT)-1.1 [**2130-4-1**] 02:55AM BLOOD PT-12.5 PTT-33.9 INR(PT)-1.1 [**2130-3-23**] 11:25AM BLOOD Glucose-155* UreaN-14 Creat-0.7 Na-134 K-3.7 Cl-95* HCO3-33* AnGap-10 [**2130-4-4**] 05:25AM BLOOD Glucose-106* UreaN-35* Creat-1.1 Na-137 K-4.4 Cl-103 HCO3-30 AnGap-8 [**2130-4-4**] 05:25AM BLOOD Calcium-7.6* Phos-3.7 Mg-2.5 Brief Hospital Course: Ms [**Known lastname **] was transferred from the outside hospital straight to the cardiac catheterization suite. During the cath, she was found to have 80% stenosis of her left main coronary artery as well as severe 3-vessel disease. Cardiac surgery was consulted for possible CABG on hospital day #2. As part of the pre-op workup, a TTE was done (due to concern for aortic regurgitation given her wide pulse pressure) but this showed only 1+ AR. A pre-op UA was suggestive of a UTI and she was initially started on empiric ciprofloxacin. Due to this infectious concern, cardiac surgery initially held off on the CABG. With improvement, she was scheduled for the OR [**2130-3-30**]. . On hospital day #2, she was noted to have an acute change in her mental status. Whereas she had initially had a completely normal neurologic exam, she was suddenly somnolent, intermittently calling out for her "Mama", and noted to be weak on the left side of her body. A stat neuro consult was obtained along with MRI/MRA of the brain due to concern for an acute stroke; given her history of atrial fibrillation, she was also put on a heparin drip given the likelihood of embolic stroke. The MRI/MRA showed no evidence of any acute or old infarct. Her ciprofloxacin was also changed to ceftriaxone given the concern that the fluoroquinolone could be contributing to her altered mental status. An EEG was obtained to rule out seizure with [**Doctor Last Name 555**] paralysis (and she was placed on seizure precautions), but this showed only diffuse slowing and no evidence of epileptiform activity. . By hospital day #3, she was substantially more awake than the prior day. She had 5/5 strength in all extremities and normal cranial nerve exam, though she remained mildly disoriented to date and recent events. Due to concern for dehydration, she received gentle IV fluids, especially since her PO intake was limited by nausea. . On hospital day #4, her mental status was back to baseline and her neuro exam was completely normal. Her PO intake was substantially improved. Her urine culture was found to be growing out ceftriaxone-sensitive E. coli. . For her CAD, she was afterload reduced with her home regimen of lisinopril. She was also kept on her home dose of Toprol XL, though it was intermittently held due to asymptomatic bradycardia. Given her wide pulse pressure, her blood pressure was controlled with goal SBPs 130s-150s (she was 200s upon admission and required prn hydralazine initially for improvement). . She continued to be medically managed for several more days and on [**3-30**] was brought to the operating room where she underwent a coronary artery bypass graft x 3. Please see operative report for surgical details. Following surgery she was transferred to the CSRU for invasive monitoring in stable condition. Within 24 hours she was weaned from sedation, awoke neurologically intact and extubated. Late on post-op day one she had an episode of atrial fibrillation which was treated with Lopressor. . On post-op day two she was started on beta blockers and diuretics. She was gently diuresed towards her pre-op weight. Later on this day she was transferred to the telemetry floor for further care. . By post-op day three her epicardial pacing wires and chest tubes were removed. Post-operatively she worked with PT for strength and mobility. She continued to make clinical improvements and on post-op day five she was discharged to rehab with appropriate medications and follow-up appointments. Medications on Admission: CURRENT MEDICATIONS: nitropaste 0.5" q4h, atorvastatin 20mg qhs, aspirin 162mg daily, levothyroxine 88mcg daily, timolol eye drops, isosorbide mononitrate 30mg daily, Toprol XL 25mg daily, lisinopril 40mg daily, HCTZ 12.5mg daily, clopidogrel 75mg daily (last given [**3-22**]; stopped due to hematuria), amlodipine 5mg daily HOME MEDICATIONS: Patient is unsure of exact medication list/doses; paperwork from [**Hospital3 **] shows only medications upon transfer atorvastatin ? 20mg daily, aspirin 81mg daily, prn SL nitro, levothyroxine 88mcg daily, HCTZ, eye drops for glaucoma Discharge Medications: 1. Bimatoprost 0.03 % Drops Sig: One (1) gtt Ophthalmic HS (at bedtime): both eyes. 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day): Both eyes. 7. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. 10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 10 days. Capsule, Sustained Release(s) Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 Myocardial Infarction (NSTEMI) Atrial Fibrillation PMH: Hyperlipidemia, Hypertension, Hypothyroidism, Left side deafness, Glaucoma Discharge Condition: Good Discharge Instructions: [**Month (only) 116**] shower, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns Followup Instructions: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment Dr. [**First Name8 (NamePattern2) 1312**] [**Last Name (NamePattern1) **] after discharge from rehab ([**Telephone/Fax (1) 1803**]) please call for appointment Dr. [**Last Name (STitle) 10165**] [**Name (STitle) 31187**] after discharge from rehab ([**Telephone/Fax (1) 31188**]) please call for appointment Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse ([**Telephone/Fax (1) 3633**]) Completed by:[**2130-4-4**]

[ "276.1", "414.01", "780.39", "365.9", "401.9", "789.30", "041.4", "423.9", "427.31", "599.0", "V45.61", "244.9", "410.71", "272.0" ]

icd9cm

[ [ [] ] ]

[ "99.04", "37.22", "89.60", "36.12", "88.56", "38.93", "36.15", "39.61" ]

icd9pcs

[ [ [] ] ]

13825, 13891

8717, 12239

230, 461

14126, 14132

3362, 5465

14597, 15186

1512, 1676

12869, 13802

13912, 14105

12265, 12265

14156, 14574

1691, 3343

12609, 12846

180, 192

12286, 12591

489, 969

5474, 8694

991, 1276

1292, 1496

20,075

175,728

17761

Discharge summary

report

Admission Date: [**2105-9-26**] Discharge Date: [**2105-9-29**] Date of Birth: [**2055-5-18**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3705**] Chief Complaint: alcohol withdrawal Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a 50 y/o male with PMHx EtOH abuse with withdrawal symptoms and DTs, depression, HTN who presents to the ED with suicidal ideations after an episode of binge drinking, called EMS on self with SI. Did not actually harm himself. Was recently admitted to dual diagnosis center for ~1 week starting on [**9-16**], after discharge began drinking 1 pint of vodka nightly and reports he drank [**1-3**] gallon of vodka today. . In the ED, initial vs were: Temp:99.3 HR:124 BP:135/88 Resp:16 Sat:95 Patient received thiamine, folate, multivitamin, 2L fluid and was started on CIWA scale with valium and received a total of 80mg PO with 2mg Ativan due to withdrawal symptoms - agitation, tachycardia, and tremulousness that resolved with treatment. Psych was consulted and did not feel that a section 12 was necessary at this time. . Of note, patient does admit to an admission at [**Hospital1 2025**] where he experienced seizures and self reports a diagnosis of delirium tremens. . On the floor, the patient feels shaky, anxious and tremulous. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. . Past Medical History: (from OMR, confirmed with patient) PAST MEDICAL HISTORY: - PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 49342**] at [**Hospital **] Medical Associates in [**Location (un) 5110**], MA - s/p R nephectomy in [**2096**] [**2-3**] renal mass, HTN, dyslipidemia PAST PSYCHIATRIC HISTORY: (from OMR, confirmed with patient) - Unclear psychiatric diagnosis separate from his alcoholism. Historical diagnosis of MDD, anxiety, bipolar disorder. - Multiple past dual diagnosis hospitalizations, two at [**Hospital1 1680**] JP in the past month. - Medication trials include prozac, seroquel and benzos. - Pt reports one prior SA/SBI by stabbing himself once in [**2099**] in the RLQ, sought medical treatment at [**Hospital1 2025**]. Patient has scar on RLQ, but appears to be surgical incision, possibly from nephrectomy. Social History: - Tobacco: 1 pack/week - Alcohol: 1 qt of vodka daily, reportedly [**1-3**] gallon today; multiple in/outpatient detoxes; self-reported h/o withdrawal seizure at [**Hospital1 2025**] ([**2100**]), self-reported DT's (tremors and VHs, no ICU stays), and blackouts. Longest period of sobriety for three months ending a couple months ago (similar to past evaluations, patient vague about time frame.) - Illicits: denies IVDU, remote h/o benzo and cocaine abuse Family History: Father died of MI at age 70. Physical Exam: Vitals: T: 98.0 BP: 142/794 P:70 R: 16 O2: 98% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, 2x2 erythematous scaly patch on right thigh since last hospitalization Skin: Diffuse erythematous macules on back and chest, some excoriated, blanching. Erythematous face. Neuro: AAOx3, 5/5 strength all extremities, +tremor, no nystagmus Pertinent Results: Labs on Admission: [**2105-9-26**] 02:55PM BLOOD WBC-7.8 RBC-4.60 Hgb-14.8 Hct-42.5 MCV-92 MCH-32.3* MCHC-35.0 RDW-14.4 Plt Ct-313 [**2105-9-26**] 02:55PM BLOOD Neuts-59.3 Lymphs-31.9 Monos-5.6 Eos-1.2 Baso-2.0 [**2105-9-26**] 02:55PM BLOOD Glucose-147* UreaN-15 Creat-1.1 Na-144 K-3.8 Cl-102 HCO3-23 AnGap-23* [**2105-9-26**] 02:55PM BLOOD ALT-52* AST-60* LD(LDH)-197 AlkPhos-105 TotBili-0.5 [**2105-9-26**] 02:55PM BLOOD Albumin-4.3 Calcium-9.2 Phos-1.3*# Mg-1.9 [**2105-9-26**] 02:55PM BLOOD ASA-NEG Ethanol-277* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG . Labs on Discharge: [**2105-9-29**] 08:50AM BLOOD WBC-4.9 RBC-4.34* Hgb-13.6* Hct-40.7 MCV-94 MCH-31.3 MCHC-33.4 RDW-14.0 Plt Ct-209 [**2105-9-29**] 08:50AM BLOOD Glucose-94 UreaN-9 Creat-1.0 Na-140 K-4.5 Cl-104 HCO3-28 AnGap-13 [**2105-9-29**] 08:50AM BLOOD UricAcd-4.8 Brief Hospital Course: In the MICU [**Date range (3) 49343**]: 50 y/o male with known history of EtOH withdrawal and DTs who presents after SI while intoxicated, now with EtOH withdrawal symptoms. In the [**Name (NI) **], Pt received diazepam 80mg PO with lorazepam 2mg and a banana bag and another 20mg of diazepam with 1mg lorazepam overnight in the CCU. He felt better the following morning and was transferred to the medical floor. Psych did not recommend section 12. Pt also had an anion gap acidosis - (Gap of 19 on admission) that had closed by morning. . Called out to the medical floor, [**9-27**] - [**9-29**]: . # ETOH withdrawal, dependence - On folate, thiamine, CIWA. Continued to receive Valium through day 2 on medical floor for CIWA > 10. When patient's symptoms of withdrawal had resolved, he was discharged home with instructions for close follow-up. . # gout - Patient developed pain in right toe on the medical floor. Presentation consistent with acute gout. Started on naproxen and colchicine with significant improvement. . # depression with suicidality - Suicidal ideation resolved by the time of discharge. Patient was seen by psych who recommended dual diagnosis, however the patient refused. . # hepatitis, NOS - Mild elevation in ALT, AST. Most likely fatty liver vs. alcohol induced. . # follow-up: Consider HIV testing and would vaccinate for HAV and HBV. Medications on Admission: Zoloft Trazodone Norvasc "Cholesterol medication" Discharge Medications: 1. Outpatient Meds Patient does not know doses of home medications. Please continue taking trazodone and amlodipine as you have been directed. 2. Naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 5 days: Please take for five days following discarge. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Alcohol withdrawal 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 the hospital with alcohol intoxication and withdrawal. You were given medication for your symptoms of withdrawal. By the time of discharge, your symptoms had resolved. Please do not drink alcohol. . You were also treated for pain that you experienced in your toe. We believe this was related to a condition called gout. Please take the Naprosyn (naproxen) 500 mg every twelve hours for the next five days for this pain in your toe. Followup Instructions: Please follow-up at the following time/place: . Department: [**Hospital3 249**] When: FRIDAY [**2105-10-16**] at 2:45 PM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage ******PLEASE NOTE: YOU HAVE A MANAGED CARE INSURANCE PLAN AND YOU MUST CALL YOUR INSURANCE TO TELL THEM WHO YOUR PRIMARY CARE DOCTOR IS. DR [**Last Name (STitle) **] WORKS CLOSELY WITH DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. PLEASE LIST DR [**First Name (STitle) **] AS YOUR PCP WITH YOUR INS. QUESTIONS PLEASE CALL NUMBER ABOVE.

[ "782.1", "401.9", "311", "274.9", "303.01", "V62.84", "573.3", "291.81" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6703, 6709

4908, 6274

334, 340

6791, 6791

4048, 4053

7454, 8155

3235, 3265

6374, 6680

6730, 6730

6300, 6351

6942, 7431

3280, 4029

1439, 1889

276, 296

4633, 4885

368, 1420

6749, 6770

4067, 4614

6806, 6918

1968, 2741

2757, 3219

24,573

184,883

1116

Discharge summary

report

Admission Date: [**2128-1-30**] Discharge Date: [**2128-2-9**] Date of Birth: [**2070-7-15**] Sex: M Service: MEDICINE Allergies: Cefepime Attending:[**First Name3 (LF) 1190**] Chief Complaint: worsening dyspnea on exertion, diarrhea, abdominal pain Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 57 year old Guatemalan man with hx. CAD (3 vessel cabg [**2-28**],), CHF (EF:50, impaired relaxation on echo), NIDDM (diet controlled but c/b neuropathy and nephropathy), ESRD ([**Hospital1 **]-weekly HD started in [**Country 7192**] and last done there on Sat (6 dd ago; by LT. subclav line placed there [**2127-12-5**] and still in place) who has had fatigue, dyspnea on exertion worse than baseline, and 10 loose bm yesterday with RUQ abdominal pain since yesterday. He denies chest pain, denies LH, denies nausea or diaphoresis. He denies fever. He denies vomiting. He did not notice any blood in his bowel movements. Yesterday he presented to his pcp with these complaints and was found to have some new TWI in II, III, AVF, and V1-5. He was sent to the ED. In the ED he is found to be hemodynamically stable and afebrile, complaining of RUQ pain. His K is 6.3, BUN 125, and Cr. 12. By the time of his arrival in the EW, he is noted only to have TWI (that is significantly changed) in III, and a trop elevated but at baseline. His MBI is elevated, however (this has not been documented recently, and may represent a significant change). RUQ U/S reveals cholecystitis and a small gall bladder. Surgery, Cardiology, and Renal were all consulted. He is guaiac positive, with a hematocrit of 27.5 (approximately at baseline, which is widely variable from 24 to 38). At the time of my evaluation, only surgery had evaluated the patient and recommend Surgery vs. perc. drainage is possible by IR pending an abdominal CT. He was given 1 gram vanco and 2.25 g of Zosyn in the ED. Past Medical History: 1. CAD- s/p 3v CABG [**2-/2126**] (LIMA to LAD, SVG to OM, SVG to PDA) 2. Type II diabetes mellitus- HgbA1c 6.5 [**12/2126**]; c/b retinopathy, neuropathy, nephropathy 3. Hypertension 4. Chronic kidney disease- baseline creast 2.4-2.8 5. Hyperlipidemia- last FLP [**7-/2126**] (TChol 100, LDL 39, HDL 44) 6. Peripheral [**Year (4 digits) 1106**] disease 1) CAD: s/p CABG [**2-28**] LIMA-> LAD, SVG -> RCA/PDA, SVG -> OM1 -- [**2126-3-1**] cardiac cath: LMCA 40%, LAD mid 80% tubular lesion with prox D2 lesion, LCx 70%, OM1 tubular 90%, RCA dominant with proximal 99% 2) Type II DM (diet controlled) c/b retinopathy and nephropathy 3) HTN 4) Hyperlipidemia 5) CHF: [**2-28**] Echo: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated, LVEF 30-35%, [**12-29**]+ MR 6) PVD: s/p stent to bilateral CIAs (Genesis) and steft to [**Female First Name (un) 7195**] ([**Location (un) 6647**]) 6/0. -- s/p POBA and atherectomy of L SFA [**2126-7-17**] 7) CRI: baseline Cr 1.5-1.9 8) COPD 9) Tracheomalacia 10) C. diff colitis 11) UGI bleed [**2126-5-25**]: EGD showed non-bleeding [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Tear, gastropathy, and gastritis Social History: patient is originally from [**Country 7192**] and travelled there this year. he lives with his brother. he is on disability. no tob, EtOH, illicits Family History: father d. CAD, mother and brother with [**Name (NI) 7199**]. Physical Exam: 98.6 53 166/43 16 100% RA (on admission) 96.5 80 155/46 17 98% RA ([**2128-2-1**] transfer to medicine service) NECK: harsh bruit b/l neck. JVP at 6cm. No LAD, no thyromegaly, trachea midline. HEENT:ROMI PERRL Face symmetric PULM: [**Month (only) **] breath sounds b/l CV: S1/S2 with II/VI holosystolic murmur at base ABD:tender RUQ, with palpation, no masses or HSM, EXT: Trace [**Last Name (un) **] but no rash NEURO: UE/LE symmetric motion RECTAL: Guaiac positive per ED. Pertinent Results: [**2128-1-30**] 07:50AM BLOOD WBC-8.2 RBC-3.06*# Hgb-9.0*# Hct-27.5*# MCV-90 MCH-29.3 MCHC-32.7 RDW-16.2* Plt Ct-175 [**2128-1-30**] 03:04PM BLOOD WBC-8.5 RBC-2.73* Hgb-8.4* Hct-25.2* MCV-93 MCH-31.0 MCHC-33.5 RDW-16.5* Plt Ct-172 [**2128-1-30**] 08:46PM BLOOD WBC-11.8* RBC-3.00* Hgb-8.9* Hct-25.5* MCV-85# MCH-29.7 MCHC-34.8 RDW-16.4* Plt Ct-167 [**2128-1-31**] 03:18AM BLOOD WBC-15.3* RBC-2.82* Hgb-8.4* Hct-24.2* MCV-86 MCH-29.6 MCHC-34.5 RDW-16.4* Plt Ct-162 [**2128-1-31**] 08:24PM BLOOD WBC-12.3* RBC-3.72*# Hgb-10.8*# Hct-30.8*# MCV-83 MCH-29.2 MCHC-35.2* RDW-17.0* Plt Ct-171 [**2128-2-1**] 03:36AM BLOOD WBC-9.8 RBC-3.50* Hgb-10.6* Hct-29.9* MCV-86 MCH-30.3 MCHC-35.5* RDW-17.4* Plt Ct-178 [**2128-2-2**] 05:30AM BLOOD WBC-9.3 RBC-3.75* Hgb-10.8* Hct-31.5* MCV-84 MCH-28.9 MCHC-34.4 RDW-16.9* Plt Ct-197 [**2128-2-3**] 05:16AM BLOOD WBC-7.6 RBC-4.35* Hgb-12.6* Hct-37.3* MCV-86 MCH-29.0 MCHC-33.8 RDW-17.0* Plt Ct-223 [**2128-2-4**] 05:20AM BLOOD WBC-8.6 RBC-4.33* Hgb-12.6* Hct-36.3* MCV-84 MCH-29.1 MCHC-34.7 RDW-16.7* Plt Ct-231 [**2128-1-30**] 03:04PM BLOOD Neuts-87.9* Bands-0 Lymphs-6.5* Monos-2.7 Eos-2.6 Baso-0.2 [**2128-1-30**] 03:04PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Burr-1+ Fragmen-OCCASIONAL [**2128-1-30**] 07:50AM BLOOD PT-12.6 PTT-25.9 INR(PT)-1.1 [**2128-2-4**] 05:20AM BLOOD PT-12.9 PTT-23.6 INR(PT)-1.1 [**2128-1-30**] 07:50AM BLOOD Glucose-108* UreaN-125* Creat-12.0*# Na-147* K-6.3* Cl-116* HCO3-14* AnGap-23* [**2128-1-30**] 03:04PM BLOOD Glucose-69* UreaN-128* Creat-11.9* Na-144 K-6.7* Cl-115* HCO3-12* AnGap-24* [**2128-1-30**] 08:46PM BLOOD Glucose-81 UreaN-60* Creat-6.7*# Na-144 K-3.8 Cl-108 HCO3-23 AnGap-17 [**2128-1-31**] 03:18AM BLOOD Glucose-71 UreaN-65* Creat-7.4* Na-142 K-4.2 Cl-107 HCO3-23 AnGap-16 [**2128-1-31**] 08:24PM BLOOD Glucose-143* UreaN-24* Creat-3.8*# Na-142 K-3.4 Cl-103 HCO3-28 AnGap-14 [**2128-2-1**] 03:36AM BLOOD Glucose-73 UreaN-27* Creat-4.7* Na-143 K-3.4 Cl-103 HCO3-28 AnGap-15 [**2128-2-2**] 05:30AM BLOOD Glucose-61* UreaN-37* Creat-6.6*# Na-142 K-3.7 Cl-102 HCO3-25 AnGap-19 [**2128-2-3**] 05:16AM BLOOD Glucose-76 UreaN-21* Creat-5.3*# Na-140 K-3.8 Cl-100 HCO3-30 AnGap-14 [**2128-2-4**] 05:20AM BLOOD Glucose-90 UreaN-37* Creat-7.4*# Na-143 K-4.0 Cl-100 HCO3-27 AnGap-20 [**2128-2-3**] 05:16AM BLOOD ALT-13 AST-17 AlkPhos-218* TotBili-0.6 [**2128-1-30**] 07:50AM BLOOD ALT-20 AST-13 CK(CPK)-129 AlkPhos-322* Amylase-117* TotBili-0.3 [**2128-1-30**] 07:50AM BLOOD Lipase-42 [**2128-1-31**] 08:24PM BLOOD CK-MB-NotDone cTropnT-0.42* [**2128-1-31**] 03:18AM BLOOD CK-MB-NotDone cTropnT-0.34* [**2128-1-30**] 08:46PM BLOOD CK-MB-NotDone cTropnT-0.31* [**2128-1-30**] 03:04PM BLOOD CK-MB-9 cTropnT-0.27* [**2128-1-30**] 11:20AM BLOOD cTropnT-0.27* [**2128-1-30**] 11:20AM BLOOD cTropnT-0.27* [**2128-1-30**] 11:20AM BLOOD CK-MB-10 MB Indx-8.3* [**2128-1-30**] 07:50AM BLOOD cTropnT-0.28* [**2128-1-30**] 07:50AM BLOOD cTropnT-0.28* [**2128-1-30**] 07:50AM BLOOD CK-MB-10 MB Indx-7.8* [**2128-2-4**] 05:20AM BLOOD Calcium-8.3* Phos-5.7* Mg-2.0 [**2128-1-30**] 07:50AM BLOOD Calcium-7.9* Phos-5.9* Mg-2.9* [**2128-1-31**] 08:24PM BLOOD Hapto-185 [**2128-1-30**] 04:42PM BLOOD PTH-266* [**2128-2-2**] 04:00PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE [**2128-1-30**] 07:50AM BLOOD Digoxin-<0.2* [**2128-2-2**] 04:00PM BLOOD HCV Ab-NEGATIVE [**2128-1-30**] 04:17PM BLOOD Type-ART pH-7.13* [**2128-1-30**] 08:19AM BLOOD Lactate-1.1 [**2128-1-30**] 04:17PM BLOOD freeCa-1.08* ==================== STUDIES: CT ABDOMEN [**2128-1-30**] IMPRESSION: 1. Mild thickening of gallbladder wall with distention or intramural edema. MInimal pericholecystic fluid. No definite radiopaque gallstones visualized. Gallstones are seen on ultrasound from same day. Given history of end-stage renal disease and fluid stranding throughout the retroperitoneum and mesentery, gallbladder wall edema is probably secondary to third spacing. 2. Right lower lobe consolidation, which in the appropriate clinical context can represent pneumonia. 3. Small right pleural effusion. . CXR [**2128-1-30**] (portable) IMPRESSION: Unchanged cardiomegaly with mild congestive heart failure. . CTA Chest [**2128-1-30**] IMPRESSION: 1. No PE. 2. Right lower lobe consolidation most consistent with pneumonia. Aspiration and round atelectasis are less likely possibilities. . Ultrasound Gallbladder/Liver: [**2128-1-30**] IMPRESSION: 1. Gallbladder wall edema, pericholecystic fluid, gallstones stones and positive son[**Name (NI) 493**] [**Name2 (NI) 515**] sign consistent with acute cholecystitis. Other causes for gallbladder wall edema include hypoalbuminemia, hepatitis, pancreatitis and CHF. 2. Small right pleural effusion. . ECHO [**2128-1-31**] Left Ventricle - Ejection Fraction: 55% (nl >=55%) TR Gradient (+ RA = PASP): *26 mm Hg (nl <= 25 mm Hg) Conclusions: 1. The left atrium is mildly dilated. 2. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF=55%). Regional left ventricular wall motion is normal. 3. The aortic valve leaflets (3) are mildly thickened. 4. Compared with the findings of the prior study (images reviewed) of [**2127-10-14**], there has been no significant change. . Venography [**2128-2-3**] IMPRESSION: 1) Bilateral mild apparent narrowing at the junctions of the subclavian and brachiocephalic veins, without associated collateral formation. 2) Very mild narrowing of the right cephalic vein above the elbow. 3) Otherwise unremarkable bilateral upper extremity venograms. . Carotid ultrasound [**2128-2-2**] IMPRESSION: Moderate right-sided plaque with a 60-69% carotid stenosis. On the left, there is less than 40% carotid stenosis. Brief Hospital Course: Mr. [**Known lastname 7203**] is a 57 year old Guatemalan man with history of significant coronary artery disease who is status post 3 vessel CABG and who has diastolic dysfunction, NIDDM, end-stage renal disease (on hemodialysis in [**Country 7192**]) who presented to the emergency department with uremia, cholecystitis, demand ischemia and right lower lobe pneumonia after experiencing worsening dyspnea on exertion, diarrhea, abdominal pain at home. . UREMIA: The pt has a history of rapid decline in renal function (Creatinine 2.1 in [**7-/2126**] to 4.0 in [**5-/2127**] to 12.0 on presentation during this admission). The patient's constellation of symptoms were likely explained by the acute onset of uremia in the setting of no dialysis for 6 days prior to presentation. Per history, the pt has end stage renal disease and was recently initiated on hemodialysis. During this hospitalization, the pt was emergently dialyzed with existing left subclavian access (placed in [**Country 7192**]). He subsequently had at least 3 dialysis sessions prior to discharge. Cultures drawn from the line did not show any growth to date and the renal team felt comfortable proceeding with dialysis via the existing access. It was determined that the pt will need a permanent dialysis access, hence the pt was seen by transplant surgery. The transplant surgery team has planned the pt for an out-patient Left brachiocephalic AV-fistula placement on [**2128-3-3**]. The pt has also been set up to get regular dialysis at [**Location (un) **] [**Location (un) **] Dialysis Center every Tuesday-Thursday-Saturday. The pt showed an appropriate response to the dialysis with decrease in creatinine to 6.8 after the first dialysis session. The pt did, however, have several episodes of hypotension in the post-dialysis setting, which were treated with fluid boluses (with appropriate hemodynamic response). The pt was instructed to hold his Imdur, Lisinopril, Pletal and Digoxin after discussion with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. The pt was also instructed to follow-up with Dr. [**Last Name (STitle) **] to discuss if/when these medications were to be restarted. . HEMODIALYSIS: The pt has been evaluated by [**Last Name (STitle) **] Surgery and has been planned for an out-patient AV-fistula placement next week (for a more permanent access). In the interim he will receive dialysis through his left subclavian line (placed [**2127-12-5**] in [**Country 7192**]) every Tuesday-Thursday and Saturday at [**Location (un) **] [**Location (un) **] Dialysis Center. . CORONARY ARTERY DISEASE: On presentation the pt was noted to have questionable T-wave inversions in lead III. His troponin was noted to be 0.28 with an MBI 7.8 , CK MB 10 and CK of 129. The pt's troponin initially trended up but his CK trended down. These findings were difficult to interpret in light of acute on chronic renal failure but it was determined that the pt did not likely have a myocardial infarction, but rather more likely had demand ischemia in the setting of anemia, infection, hypertension and congestive heart failure with slight volume overload. The pt also denied chest pain but is diabetic (diet controlled per pt) and likely has an anginal equivalent of DOE. The Cardiology Service saw and evaluated the patient and was in agreement with the diagnosis and plan for treatment. They noted that despite bypass grafting, there are likely myocardial territories with little flow reserve which are causing persistent stable angina and demand ischemia when stressed. The Cardiology service also felt that the pt's CAD would likely not be amenable to percutaneous intervention (not likely to be very different from [**5-/2127**], when all grafts were patent). The pt's diffuse EKG changes were initially thought to be concerning but were also thought to be nonspecific and the anterior PR segment depression could likely represent mild pericarditis. On admission the pt was medically managed with aspirin, Plavix, beta-blocker (with a BP goal: 100-13/50-80) and a statin. . HYPOTENSION: The pt was noted to become hypotensive (SBP 70-80s) after starting Isordil with concurrent administration of Nifedipine. The pt was given two 250cc boluses of normal saline with appropriate blood pressure response to the 90s. The pt's nifedipine was held. The primary team will defer to the patient's primary care physician about when (and if) to restart the pt on nifedipine (a sustained release form will likely be tolerated better). The pt was maintained on Isosorbide Dinitrate, Lisinopril, Metoprolol and Hydralazine. The hydralazine and Lisinopril were discontinued on the recommendations of the renal team because of fluid adjustment during dialysis. . ?CHOLECYSTITIS: The pt was noted to have a 4mm thickened gall bladder wall with some fluid and a positive son[**Name (NI) 493**] [**Name2 (NI) 515**] sign on presentation. He was empirically started on Zosyn and Vancomycin (discontinued [**2128-1-31**]). The pt was evaluated by Surgery and it was thought that the pt was stable and did not need emergent gall bladder drainage or cholecystectomy. It was thought that the patient's right upper quadrant pain was likely the result of a right lower lobe pneumonia and the pt had an excellent response to medical therapy with resolution of right upper quadrant pain. . PNEUMONIA (RIGHT LOWER LOBE): The pt was noted to have right lower lobe pneumonia on abdominal CT. He was not noted to be in any respiratory distress. The pt was started on Levofloxacin for a total 14 day antibiotic course. . ANEMIA: The pt was noted to have a hematocrit of 27.5 on admission (baseline mid-20s to mid-30s). Due to concern for gastritis, the pt was started on pantoprazole. The pt likely has anemia of chronic renal disease and has been started on erythropoietin by the renal team (given during dialysis). . Diabetes Mellitus Type (unknown): Per pt he was diagnosed with diabetes as a child and has maintained blood glucose control with diet. During the hospitalization the pt was noted to have most blood glucose [**Location (un) 1131**] within normal range and rarely required the insulin sliding scale. The pt was also seen by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] endocrinologist and was recommended continuation of diet control with an out-patient follow-up with an endocrinologist and a nephrologist. . DIARRHEA: The pt was noted to have diarrhea during this hospitalization. All his stool cultures were negative for C.difficle. . CAROTID BRUIT: The pt was noted to have a bilateral carotid bruit on clinical exam. He underwent a carotid doppler which showed the right carotid artery to have a 60-70% stenosis and the left carotid to have a 40% stenosis. The pt will follow with Dr. [**First Name (STitle) **] as an out-patient. . FEN: The pt was maintained on a cardiac, renal and diabetic diet. . PROPHYLAXIS: Pt was maintained on prophylaxis with pneumoboots, pantoprazole. . CODE STATUS: Full code Medications on Admission: Plavix Lasix (? dose) Lipitor 80 Metoprolol 50 [**Hospital1 **] Hydral 50 q 6 hours Nifed 90 CR Protonix 40 81 mg ASA Dig 0.125 Sodium bicarb 1300 tid Pletal 100 [**Hospital1 **] Imdur 120 Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 5. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:*14 Tablet(s)* Refills:*0* 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Do NOT take on the days you have dialysis. Disp:*30 Tablet(s)* Refills:*2* 10. Paricalcitol 2 mcg IV QHD 11. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H for 6 days. Disp:*3 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1) CAD: s/p CABG [**2-28**] LIMA-> LAD, SVG -> RCA/PDA, SVG -> OM1 -- [**2126-3-1**] cardiac cath: LMCA 40%, LAD mid 80% tubular lesion with prox D2 lesion, LCx 70%, OM1 tubular 90%, RCA dominant with proximal 99% 2) Type II DM (diet controlled) c/b retinopathy and nephropathy 3) HTN 4) Hyperlipidemia- last FLP [**7-/2126**] (TChol 100, LDL 39, HDL 44) 5) CHF: [**2-28**] Echo: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated, LVEF 30-35%, [**12-29**]+ MR 6) PVD: s/p stent to bilateral CIAs (Genesis) and steft to [**Female First Name (un) 7195**] ([**Location (un) 6647**]) 6/0. -- s/p POBA and atherectomy of L SFA [**2126-7-17**] 7) CRI: baseline Cr 2.4-2.8 8) COPD 9) Tracheomalacia 10) h/o C. diff colitis 11) UGI bleed [**2126-5-25**]: EGD showed non-bleeding [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Tear, gastropathy, and gastritis 12) RLL pneumonia 13) End stage renal disease Discharge Condition: Stable Discharge Instructions: Please report to the nearest emergency department if you have chest pain, nausea, vomiting, diarrhea, fever, chills, lightheadedness, loss of consciousness, abdominal pain or headache. . You have been scheduled for a follow-up appointment with Dr. [**Last Name (STitle) **]. Please ask him when you need to restart the following medications: Imdur, Pletal and Digoxin. . There has been a change in your medications. Please see attached changes carefully; you should not take your lisinopril on the morning you have dialysis (to prevent your blood pressure from becoming too low). . You will need hemodialysis every Tuesday-Thursday-Saturday. This hemodialysis has been set up for you at [**Location (un) **] [**Location (un) **] Dialysis Center, starting [**2128-2-10**]. . You will have a small surgery to place your arterio-venous fistula (for hemodialysis) on [**2128-3-3**] at 8:00am. Please arrive at the Clinical Center and go to the [**Location (un) **]. You should not eat or drink anything after midnight on [**2128-3-2**]. Your surgery will be done by Dr. [**Last Name (STitle) **]. If you have any questions, call [**Doctor First Name 5969**] at [**Telephone/Fax (1) 7207**]. . Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD. Phone: [**Telephone/Fax (1) 608**]. Date/Time: [**2128-2-12**] at 2:10pm. . [**Last Name (un) **] DIABETES CENTER APPOINTMENTS **ENDOCRINOLOGIST (Diabetes doctor): Dr. [**First Name8 (NamePattern2) 7208**] [**Last Name (NamePattern1) 978**] [**2128-5-13**] at 3:30am You will need to bring his glasses (if any), referral from Dr. [**Last Name (STitle) 7209**], list of medications and your insurance card. . **NEPHROLOGIST (Kidney doctor): Dr. [**First Name (STitle) 4102**] [**Name (STitle) 4090**]. Phone: [**Telephone/Fax (1) 3637**]. Date/Time: [**2128-2-11**] at 3:00pm. Go to [**Location (un) **]. Sign in at front desk. . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2128-5-10**] 4:00pm . Completed by:[**2128-2-9**]

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icd9cm

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icd9pcs

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324, 339

19158, 19167

3920, 9651

20405, 21277

3347, 3409

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367, 1945

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3178, 3331

65,854

137,145

50824

Discharge summary

report

Admission Date: [**2107-5-24**] Discharge Date: [**2107-5-31**] Date of Birth: [**2028-4-19**] Sex: F Service: NEUROSURGERY Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Amiodarone / Prilosec / Spironolactone / Epinephrine / Shellfish Derived / Valium / Lipitor / Fish Product Derivatives / Lidocaine / trimethoprim-polymyxin B / Amiodarone / Benadryl Decongestant / Iodine Attending:[**First Name3 (LF) 1835**] Chief Complaint: speech difficulty Major Surgical or Invasive Procedure: [**2107-5-26**] left parietal crani for tumor biopsy History of Present Illness: [**Known firstname 1123**] [**Known lastname 51820**] is a 79-year-old right-handed woman, with remote history of stage I breast cancer in the right breast, status post lumpectomy, and radiotherapy [**2092**], who presented to BTC yesterday with Dr. [**Last Name (STitle) 724**] for new finding of left parietal mass on workup for speech difficulty. Her neurological problem began during [**Name (NI) **] time in [**2106-12-16**] when she experienced non-specific headache. A head CT showed no abnormality and her headache was thought to be from shingles. Her headache resolved over time. In mid-[**2107-4-17**], she developed subacute onset of "mixing her words" as noted by her family members. She saw Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2107-5-12**] and a head MRI performed elsewhere on [**2107-5-13**] showed a mass in the left inferior parietal brain. On [**2107-5-18**], she experienced lightheadedness and lost the ability to stand. Her family called 911 and the ambulance brought her to the emergency department at [**Hospital1 69**]. She was hospitalized and a gadolinium-enhanced head MRI from [**2107-5-20**] showed a cystic enhancing mass in the inferior left parietal brain. CT of the torso was negative for masses. During her hospitalization she became agitated and anxious. Oxazepam helped but sons are reporting that it wears off in mid-day. She was discharged home on [**2107-5-20**] for follow up in BTC [**2107-5-23**] and she was referred to Dr [**Last Name (STitle) **] on [**5-24**]. She has been without evidence of breast cancer disease since lumpectomy and radiation therapy in [**2092**]. Past Medical History: 1. Recently-diagnosed brain lesions, as above (clinical deficit = mild language abnormalities, word-finding, paraphasic errors) 2. Breast cancer s/p 0.4 cm grade I invasive ductal carcinoma. ER+, PR+, HER-2/neu -ve in [**2100**]. s/p chemo(Tamoxifen), XRT, 2x lumpectomy. Thought to be in remission. 3. CAD s/p CABG [**2090**] 4. Hypertension on BB and [**Last Name (un) **] 5. High cholesterol, now off statin due to Adverse reaction 6. GERD w/ hiatal hernia, frequent symptoms 7. Esophagitis 8. S/p CCY 9. s/p appy 10. s/p hysterectomy 11. DJD / Chronic Low back pain 12. Thyroid nodule 13. Macular degeneration 14. pancreatic cysts 15. history of multiple prior UTIs, most recently in [**2106-4-16**] (E coli, treated with Cipro). Social History: She lives alone in [**Location (un) 2312**]. Husband died of cancer in [**2103**]. Smoked 10 yrs but quit [**2055**], no EtOH, no illicit drugs. Family History: Her parents are deceased; her mother had diabetes and [**Name (NI) 2481**] disease while her father had stroke or myocardial infarction. Three of her sisters died of breast cancer while one is alive with coronary artery disease and kidney cancer with pulmonary metastasis. Physical Exam: Physical Examination: Temperature is 97.8 F. Her blood pressure is 140/72. Heart rate is 68. Respiratory rate is 20. She has no pain. Her skin has full turgor. HEENT examination is unremarkable. Neck is supple and there is no bruit or lymphadenopathy. Cardiac examination reveals regular rate and rhythms. Her lungs are clear. Her abdomen is soft with good bowel sounds. Her extremities do not show clubbing, cyanosis, or edema. Neurological Examination: She is awake, alert, and able to follow some but not all commands. She has a receptive aphasia with intact fluency but poor repetition and comprehension. She can name a watch but not a tie. There is no right-left confusion. Cranial Nerve Examination: Her pupils are equal and reactive to light, 3 mm to 2 mm bilaterally. Extraocular movements are full; there is no nystagmus or saccadic intrusion. Visual fields are full to confrontation. Her face is symmetric. Facial sensation is intact bilaterally. Her hearing is intact bilaterally. Her tongue is midline. Palate goes up in the midline. Sternocleidomastoids and upper trapezius are strong. Motor Examination: She does not have a drift. She can move all 4 extremities well and symmetrically. Her muscle tone is normal. Her reflexes are 0-1 and symmetric bilaterally. Her ankle jerks are absent. Her toes are down going. Sensory examination is intact to touch and proprioception. Coordination examination does not reveal appendicular dysmetria or truncal ataxia. Her gait is waddling but not from muscle weakness. She cannot do tandem gait. Discharge Exam: Pt is alert oriented x2, incisionis c/d/i with monocrylsutures superficially. face symmetric, PERRL, mild global aphasia, motor [**5-21**], sensory intact Pertinent Results: [**2107-5-26**] MR HEAD W/ CONTRAST *************** [**2107-5-25**] CHEST (PRE-OP PA & LAT) PA AND LATERAL CHEST RADIOGRAPHS: The cardiomediastinal and hilar contours are stable, with top normal heart size. The lungs are well expanded and clear, without consolidation, pleural effusion or pneumothorax. There is no pulmonary edema. Multiple mediastinal surgical clips and intact sternotomy wires relate to prior CABG. IMPRESSION: No acute cardiopulmonary pathology. [**2107-5-25**] MR FUNCTIONAL BRAIN BY No significant changes are demonstrated in the left temporal and parietal lesions with associated vasogenic edema. Limited study as only language paradigm could be obtained. One of the language activation areas is in close proximity to the lesion along its anterosuperior extent. The other language activation areas are not adjacent to the lesion. There is mild medial displacement of the arcuate fascicle by the lesion. [**2107-5-25**] CTA HEAD W&W/O C & RECO 1. Centrally-necrotic enhancing masses in the left posterior temporal and parietal lobes, unchanged from the recent MR of [**2107-5-20**], supplied by distal branches of the left MCA and drained by tributaries to the left vein of [**Last Name (un) 70890**]. 2. Mild perilesional edema and local mass effect upon the occipital [**Doctor Last Name 534**] of the left lateral ventricle, but no associated hemorrhage, unchanged from the recent MR. 3. Significantly decreased caliber of the basilar artery with 2.5 mm non-enhancing proximal-mid-basilar segment, new from [**2097-3-8**], likely representing interval development of severe steno-occlusive disease. [**2107-5-25**] Cardiovascular ECHO The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. 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. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. No clinically-significant valvular disease seen. [**5-27**] Echo The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. 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. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. No clinically-significant valvular disease seen. [**5-27**] CT head - 1. Stable centrally necrotic masses in the left posterior temporal and parietal lobes, unchanged from [**2107-5-26**], without evidence of hemorrhage. No post-operative changes are seen. 2. Mild perilesional edema with local mass effect on the occipital [**Doctor Last Name 534**] of the left lateral ventricle, but no shift of normally midline structures. ADMISSION LABS: [**2107-5-24**] 12:40PM BLOOD WBC-6.9 RBC-4.22 Hgb-12.7 Hct-38.7 MCV-92 MCH-30.1 MCHC-32.7 RDW-13.0 Plt Ct-185 [**2107-5-24**] 12:40PM BLOOD PT-12.4 PTT-27.8 INR(PT)-1.1 [**2107-5-24**] 12:40PM BLOOD Glucose-177* UreaN-15 Creat-0.8 Na-138 K-3.5 Cl-100 HCO3-28 AnGap-14 [**2107-5-24**] 12:40PM BLOOD Calcium-9.6 Phos-2.8 Mg-1.9 DISCHARGE LABS: [**2107-5-30**] 06:50AM BLOOD WBC-10.7 RBC-4.16* Hgb-12.7 Hct-38.3 MCV-92 MCH-30.5 MCHC-33.1 RDW-13.0 Plt Ct-179 [**2107-5-30**] 06:50AM BLOOD Glucose-133* UreaN-32* Creat-0.8 Na-136 K-4.2 Cl-100 HCO3-26 AnGap-14 [**2107-5-30**] 06:50AM BLOOD Calcium-9.0 Phos-2.7 Mg-2.3 Brief Hospital Course: Patient was admitted to [**Hospital1 18**] on [**5-24**] with a left parietal brain lesion. On [**5-25**] she underwent a CTA of the head as well as a functional MRI of the brain. She was seen by medicine for operative clearance who felt she needed no additional workup. On [**5-26**] she underwent MRI WAND study and there was a family dicussion with Dr [**Last Name (STitle) **] regarding the surgery. She arrived in pre-op and was complaining of chest pain. A cardiac consult was called and the surgery was aborted. She was transferred to cardiology for futher management. Serial enzymes were obtained which showed no evidence of elevation. She was optimized for surgery. On [**5-27**] a repeat echo showed no evidence of hypokiness with EF > 55%. She was then taken to OR on [**5-27**]. Post op CT showed expected post op changes. She c/o of left shoulder pain and enzymes were again negative. She did well postoperatively and remained stable during her floor course. PT/OT were consulted and they recommended home with 24-hour supervision. She also will be set up with VNA for medication management. She was deemed fit for discharge on the afternoon of [**5-31**]. She was given instructions for followup and prescriptions for all required medications. PENDING RESULTS: Left brain mass pathology final report [**2107-5-27**] TRANSITIONAL CARE ISSUES: Patient will need to follow up in Brain [**Hospital 341**] Clinic for further recommendations regarding possible treatment of her L brain mass. This appointment has already been arranged for her. Medications on Admission: Medications - Prescription 6 MASTECTOMY BRAS FOR BREAST CANCER - - ICD# 174.8 ALPRAZOLAM - 0.5 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth daily ATENOLOL - 50 mg Tablet - 1 Tablet(s) by mouth twice a day manufactor TEVA per patient request DEXAMETHASONE - 1 mg Tablet - [**1-17**] Tablet(s) by mouth twice daily IRBESARTAN [AVAPRO] - 75 mg Tablet - 1 Tablet(s) by mouth twice a day LANSOPRAZOLE [PREVACID] - (Dose adjustment - no new Rx) - 30 mg Capsule, Delayed Release(E.C.) - one Capsule(s) by mouth twice a day - No Substitution MYLICON - - use 2 drops after each meal NITROGLYCERIN [NITROSTAT] - 0.3 mg Tablet, Sublingual - 1 Tablet(s) sublingually q5 minutes as needed for chest pain OXAZEPAM - (Dose adjustment - no new Rx) - 10 mg Capsule - 1 Capsule(s) by mouth twice a day as needed PARTIAL BREAST PROSTHESIS - - wear as needed daily ICD9: 174.9 POTASSIUM CHLORIDE [KLOR-CON M20] - (Dose adjustment - no new Rx) - 20 mEq Tablet, ER Particles/Crystals - 0.5 (One half) Tablet(s) by mouth daily TRIAMTERENE-HYDROCHLOROTHIAZID - 37.5 mg-25 mg Tablet - [**1-17**] Tablet(s) by mouth daily Medications - OTC ASPIRIN - 81 mg Tablet - one Tablet(s) by mouth daily CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) - 400 unit Capsule - 1 Capsule(s) by mouth twice a day CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - (Prescribed by Other Provider) - Dosage uncertain DEXTRAN 70-HYPROMELLOSE [TEARS NATURALE] - Drops - one eye four times a day ERGOCALCIFEROL (VITAMIN D2) - (Prescribed by Other Provider) - 400 unit Capsule - one Capsule(s) by mouth three times a day --------------- --------------- --------------- --------------- Discharge Medications: 1. simethicone 80 mg Tablet, Chewable [**Month/Day (2) **]: One (1) Tablet, Chewable PO QID (4 times a day) as needed for indigestion. Disp:*120 Tablet, Chewable(s)* Refills:*0* 2. nitroglycerin 0.3 mg Tablet, Sublingual [**Month/Day (2) **]: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 3. triamterene-hydrochlorothiazid 37.5-25 mg Capsule [**Month/Day (2) **]: 0.5 Cap PO DAILY (Daily). 4. cholecalciferol (vitamin D3) 400 unit Tablet [**Month/Day (2) **]: One (1) Tablet PO twice a day. 5. acetaminophen 325 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain or fever > 101.5: Do not exceed 4,000mg of tylenol in a 24 hour period. Disp:*240 Tablet(s)* Refills:*0* 6. irbesartan 150 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO BID (2 times a day). 7. potassium chloride 10 mEq Tablet Extended Release [**Month/Day (2) **]: One (1) Tablet Extended Release PO DAILY (Daily). 8. atenolol 50 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day. 9. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 10. hydromorphone 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 11. levetiracetam 500 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 12. quetiapine 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day) as needed for agitation. Disp:*90 Tablet(s)* Refills:*1* 13. oxazepam 10 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q6H (every 6 hours) as needed for anxiety. Disp:*60 Capsule(s)* Refills:*0* 14. dexamethasone 2 mg Tablet [**Last Name (STitle) **]: taper Tablet PO per instruction: 4mg PO TID x 1 days, 3mg PO TID x 2 days, 2mg po TID x 2 days, 2mg po BID and continue on current dose. Disp:*120 Tablet(s)* Refills:*0* 15. Outpatient Physical Therapy Eval and treat 16. dextran 70-hypromellose Drops [**Last Name (STitle) **]: One (1) drop Ophthalmic every six (6) hours. 17. ergocalciferol (vitamin D2) 400 unit Tablet [**Last Name (STitle) **]: One (1) Tablet PO three times a day. 18. cyanocobalamin (vitamin B-12) Oral 19. aspirin 81 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: One (1) Tablet, Delayed Release (E.C.) PO once a day. 20. hospital bed Please provide that patient with one [**Hospital 105700**] hospital bed for home use. Patient has a brain tumor ICD-9 784.20 Length of need: 1 year [**16**]. docusate sodium 100 mg Capsule [**Year (2 digits) **]: One (1) Capsule PO twice a day as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Left parietal tumor angina anxiety aphasia leukocytosis HTN GERD Discharge Condition: Mental Status: Clear and coherent, mild global aphasia Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General Instructions/Information ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin (do not take extra aspirin, you may take your daily baby aspirin), Advil, and Ibuprofen etc. ?????? You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: increasing redness, increased swelling, increased tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. We made the following changes to your medications: 1) We STOPPED your ALPRAZOLAM. 2) We STOPPED your MYLICAN. 3) We INCREASED your OZAZEPAM to 4 times per day as needed for anxiety. 4) We INCREASED your DEXAMETHASONE. On [**5-31**] you will take 4mg three times a day. On [**4-13**] you will take 3mg three times a day. On [**4-15**] you will take 2mg three times a day. On [**6-5**] and onwards you will take 2mg two times a day. 5) We STARTED you on SIMETHICONE 80mg four times a day as needed for indigestion or gas. 6) We STARTED you on TYLENOL 650mg every 6 hours as needed for pain or fever. Do not exceed 4,000mg of tylenol in a 24 hour period as this can cause fatal liver damage. 7) We STARTED you on HYDROMORPHONE 2mg every 6 hours as needed for pain. Do not drive, operate heavy machinery, drink alcohol or take any sedating medications until you know how this medication effects you as it can cause dangerous sleepiness. 8) We STARTED you on KEPPRA 1,000mg twice a day. 9) We STARTED you on SEROQUEL 25mg twice a day as needed for anxiety. Please continue to take your other medications as previously prescribed. It was a pleasure taking care of you on this hospitalization. Followup Instructions: Follow-Up Appointment Instructions ??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**6-6**] at 1pm. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your appointment, or require additional directions. Completed by:[**2107-5-31**]

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icd9cm

[ [ [] ] ]

[ "01.59", "02.12" ]

icd9pcs

[ [ [] ] ]

15388, 15446

9350, 10688

534, 589

15555, 15555

5289, 8693

18850, 19319

3223, 3498

12635, 15365

15467, 15534

10938, 12612

15726, 17653

9055, 9327

3513, 3513

5113, 5270

3536, 5097

17682, 18827

477, 496

10714, 10912

617, 2287

8710, 9038

15570, 15702

2309, 3044

3060, 3207

31,608

152,365

28505

Discharge summary

report

Admission Date: [**2133-1-9**] Discharge Date: [**2133-2-3**] Date of Birth: [**2075-4-28**] Sex: F Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 5893**] Chief Complaint: hemoptysis Major Surgical or Invasive Procedure: Endotracheal intubation IVC filter placement Chest tube placement Tracheostomy PEG placement History of Present Illness: 57yoF w/extensive CA burden in lungs from metastatic cervical adenocarcinoma, on 4L of O2 at home, who p/w acute SOB and hemoptysis after cyberknife treatment. Two hours into her treatment the day of admission, she experienced worsening dyspnea and coughed up phlegm and approximately 30cc of blood. She apparently had been having episodes of hemoptysis every few days. A respiratory code was called, and she was stabilized on a NRB mask sating in 90s. In the ED, she was tachycardic to 120s-130s (sinus tachycardia) on EKG. She was otherwise hemodynamically stable w/sbp 116-120. She required intubation due to hypoxia. A CT chest was performed showing multiple bilateral subsegmental PEs. IP was consulted for PEs and recent h/o hemoptysis. They felt that the risks were greater than benefits in anticoagulating pt. Thus, she was not heparinized. She did receive stress dose steroids and Ceftriaxone/Flagyl/Levofloxacin for empiric treatment of postobstructive PNA. She was admitted to the ICU for further care. Past Medical History: Primary oncologist- Dr. [**Last Name (STitle) 69068**] at MSK - mesonephric adenocarcinoma dx [**2125**] s/p TAHBSO - [**2125**] chemotherapy with platinum and 5-FU and with radiation therapy to the pelvis - [**2126**] VATS wedge resections of the right middle lobe and left lower lobe for pulmonary mets - [**2128**]-[**2130**] several different chemotherapeutic regimens including avastin and gemcitabine most recently in [**3-16**] - PET-CT [**8-15**] showed at least 5 FDG avid lung nodules compatible with metastases - cyberknife therapy for palliation of SOB [**6-15**] - most recent chest imaging [**2133-1-5**] CT chest showed worsened mediastinal and pulmonary disease with 6x12cm right hilar mass that invades the posterior [**Last Name (un) **] of the left main PA. Other PAST MEDICAL HISTORY: [**Doctor Last Name 13534**]-Parkinson-White syndrome hepatitis C diagnosed in [**2104**] ganglion cyst removed many years ago laparoscopic fallopian tube surgery many years ago Social History: Married with two teenage boys, one of whom is adopted. No smoking or EtoH. Family History: Non contributory Physical Exam: VS: T: 97.8 ??????F HR: 116 BP: 99/57 RR: 24 SpO2: 94% on vent AC/550/15/5/40% Gen: intubated, sedated HEENT: PERRL, Endotracheal tube in place Cardiovascular: tachycardic S1 S2 no m/r/g Respiratory: (Breath Sounds: Wheezes : bilateral, Rhonchorous: bilateral) Abdominal: Soft, Non-tender, Bowel sounds present Extremities/Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Skin: Warm Pertinent Results: [**2133-1-9**] ADMISSION LABS: WBC-10.9# RBC-4.35 Hgb-11.6* Hct-35.6* MCV-82 MCH-26.6* MCHC-32.5 RDW-15.6* Plt Ct-368# Neuts-88* Bands-7* Lymphs-4* Monos-0 Eos-0 Baso-0 . PT-14.2* PTT-28.7 INR(PT)-1.2* . Glucose-175* UreaN-14 Creat-0.8 Na-137 K-5.0 Cl-98 HCO3-25 AnGap-19 Calcium-9.6 Phos-4.1 Mg-2.1 . ABG: pO2-86 pCO2-42 pH-7.42 calTCO2-28 Base XS-2 Lactate-2.6* . Significant labs during hospital course: Hct 34 on admission, down to 26 after hemoptysis. Drifted down to 22 and has been stable. INR 1.2 Platelets 170-270 up until [**2133-1-16**]. Labs not checked for several days, then platelets noted to be 95 on [**2133-1-20**]. WBC 9.4 on admission, drifted down to 3.9, was never neutropenic in house. PF4 sent, found to be positive. Cr 0.8 on admission, down to 0.5 but then acutely increased to 1.0 [**1-22**], renal function otherwise normal in house. *************RADIOLOGY [**2133-1-9**] CT-A 1. Stable large metastatic lesions throughout the lungs. 2. Left lower lobe segmental pulmonary emboli. 3. New left lingular atelectasis. 4. Worsened right upper lobe ground-glass and airspace patchy opacity which could represent developing infection, post-inflammatory changes, or atelectasis. 5. Nasogastric tube tip coiled within the esophagus. Recommend replacement. 6. Endotracheal tube tip approximately 8 cm from the carina. Recommend advancing approximately 4 cm. 7. No evidence of pulmonary hemorrhage. CHEST (PORTABLE AP) [**2133-1-9**] IMPRESSION: Endotracheal and nasogastric tubes as above. Consider advancing endotracheal tube at least 4 cm for optimal placement. Nasogastric tube needs repositioning. CT Head [**2133-1-9**]: Limited evaluation due to recirculation of intravenous contrast from previous CTA chest. Cannot exclude small subarachnoid or extraaxial hemorrhages. No obvious evidence of intracranial hemorrhage or mass effect. [**1-10**] IVCgram: Successful placement of OptEase IVC filter immediately below renal veins. Renal US [**1-23**]: The right kidney measures 10.5 cm in its long axis and the left kidney measures 12.7 cm. The left collecting system shows mild hydronephrosis. The ureter could not be assessed being obscured by overlying bowel gas. Right kidney is normal. No focal mass lesions or calculi identified. There is an indwelling Foley catheter in the urinary bladder which was empty at the time of the examination. CXR [**1-27**]: Comparison with [**2133-1-23**]. A new large left pneumothorax causes some tension as evidenced by slight tracheal buckling to the right and hyperlucency of the right medial costophrenic angle. The massive pulmonary metastases are unchanged; right lung shows no evidence of pleural effusion or pneumothorax. Tracheostomy tube is unchanged in position. Osseous structures appears similar. CT Chest w/o contrast [**1-29**]: 1. Slight decrease in the overall size of the multiple soft tissue masses with multiple areas of internal air within the mass, most likely related to recent treatment. 2. Small loculated left apical pneumothorax that might be related to air- collections in the left upper lobe mass. 3. New small left pleural effusion. 4. Unchanged mediastinal lymphadenopathy. 5. Splenomegaly. Mild left hydronephrosis. CXR [**2-1**]: Small left pneumothorax may be present, but not appreciably changed. Subcutaneous emphysema in the adjacent left chest wall is stable. Left pleural catheter unchanged in position. Aside from the large masses in both lungs, the lungs are grossly clear. Heart size normal. Tracheostomy tube in standard placement. No right pleural abnormality. CXR s/p chest placed to water seal [**2133-2-2**]: There is no appreciable pneumothorax or pleural effusion. Subcutaneous emphysema in the left chest wall is stable. Large lung masses show little interval change except for recent cavitation. Tracheostomy tube in standard placement. Left PIC line tip projects over the junction of the brachiocephalic veins. Heart size normal. Patient had multiple blood, sputum, BAL, and urine cultures sent during her admission. She never grew a clinically significant pathogen from any of her cultures. Brief Hospital Course: 57yoF w/ adenocarcinoma of the cervix w/known extensive lung metastases who p/w respiratory failure in the setting of hemoptysis at cyberknife therapy, found to have new bilateral subsegmental pulmonary emboli. #. Respiratory failure Felt to be multifactorial, including very large pulmonary masses with possibility of bleeding or inflammation from radiation, PE, post obstructive pneumonia, and anxiety. Bandemia on presentation suggestive of possible infection. Ms. [**Known lastname 69069**] was treated with a burst of steroids for possible post-radiation edema as well as a course of antibiotics (vanc, zosyn, and flagyl) for possible post-obstructive pneumonia; antibiotics were stopped when the team decided she did not have an infectious picture. Multiple cultures were never positive. She was not a candidate for systemic anticoagulation because of the concern that her tumor might erode into her pulmonary artery, making her a high bleeding risk. The patient could not be weaned from the vent, and after discussing the matter with the patient and her family, the team proceeded with a PEG and trach to allow her to be on mechanical ventilation chronically. She receives frequent lidocaine to suppress her cough, and she has done well for extended periods on her trach collar using the passy muir valve. #. Pulmonary emboli No anticoagulation as discussed above. Patient has been tachycardic throughout her admission with a baseline HR of 100-110. Her blood pressures are chronically in the 90s/50s. An IVC filter was placed. #. Hemoptysis Hct decreased after acute presentation, but eventually stabilized around 22. She did not continue hemoptysizing. The team set a Hct of 21 as a parameter for RBC transfusion; she received a total of 1 unit of PRBCs during her course. Hct stable at 22.1 on day of discharge. #. Metastatic Mesonephric cervical adenocarcinoma Patient was followed by Dr. [**Last Name (STitle) **], who had been coordinating her XRT. A hematology oncology consult did not recommend further chemotherapy. The patient will pursue the possibility of further chemotherapy at NY Presbyterian. # Heparin Induced Thrombocytopenia: Patient had an acute drop in her platelets from 200s to 95 about 10 days after admission. All heparin products were held. PF4 antibody came back positive, and the patient's platelets recovered several days after the heparin was stopped. Pt was started on prophylactic Fondaparinux 2.5mg sc daily. Pt was not felt to be a candidate for systemic anticoagulation because of the high risk of bleeding from her pulmonary mass as discussed above. Her PICC was left in because it is not coated with heparin. # Tension Pneumothorax: Patient developed worsening of her tachycardia, with HR in 130s. CXR revealed a left-sided pneumothorax with evidence of some tension. She had pigtail catheter placed by IP with improvement in pneumothorax. Repeat imaging after catheter was clamped was difficult to interpret because of her extensive tumor burden, and a chest CT was obtained to better clarify the extent of her pneumothorax. The read is suggestive of a fistula from the tumor creating a pathway for air to extend into her pleural space. Chest tube was placed to water seal on [**2-2**] for transfer and follow up CXR was stable. (see results section for details) # Leukopenia: Patient developed leukopenia late in her course. Nadir WBC was 3300 with no evidence of neutropenia. In the setting of worsening tachycardia, there was concern that she might be developing sepsis, and a pulmonary source of infection was felt to be most likely. She was empirically treated with vanc/cipro/zosyn for 3 days. Once culture data came back negative, antibiotics were stopped. Moreover, the tachycardia improved with the placement of the pigtail catheter for her pneumothorax. At the time of transfer, her white count was stable at 4200. # Renal failure: During her second week of admission, patient had decreased urine output and Cr increased from 0.6 to 1.0. Renal ultrasound demonstrated mild left hydronephrosis. She was given some IV fluids and managed expectantly, and her urine output and Cr improved. # LE edema: Patient has developed b/l pitting LE edema during her course due to a positive fluid balance every day over 3 weeks. Because of her tenuous blood pressures, the team is deferring diuresis for now with the hope that she will be able to tolerate lasix at another time. # Nutrition: Patient receives tube feeds (replete with fiber) at 65ml/hr through her PEG tube. Residuals checked Q4H and held for residual > 150cc. She is also able to take soft foods when she is on her trach collar using the Passy Muir Valve. # Access: left sided PICC (not heparin coated) # Code: DNR Medications on Admission: Benzonatate 100 mg Capsule by mouth three times a day Fluticasone-Salmeterol [Advair Diskus] Levalbuterol Tartrate Prednisone 5 mg daily Dexamethasone 4mg was routinely given during chemo treatment Discharge Medications: 1. Senna 8.8 mg/5 mL Syrup [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a day) as needed. 2. Chlorhexidine Gluconate 0.12 % Mouthwash [**Month/Year (2) **]: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 3. Sodium Chloride 0.65 % Aerosol, Spray [**Hospital1 **]: [**12-10**] Sprays Nasal QID (4 times a day) as needed. 4. Oxycodone 5 mg/5 mL Solution [**Month/Day (2) **]: One (1) ml PO Q4H (every 4 hours) as needed for pain. 5. Albuterol 90 mcg/Actuation Aerosol [**Month/Day (2) **]: Six (6) Puff Inhalation Q4H (every 4 hours) as needed. 6. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Day (2) **]: Six (6) Puff Inhalation QID (4 times a day). 7. Acetaminophen 650 mg Suppository [**Month/Day (2) **]: [**12-10**] Suppositorys Rectal Q6H (every 6 hours) as needed. 8. Bisacodyl 10 mg Suppository [**Month/Day (2) **]: One (1) Suppository Rectal DAILY (Daily) as needed. 9. Lidocaine HCl 1 % (10 mg/mL) Solution [**Month/Day (2) **]: 2.5 MLs Injection Q2H (every 2 hours) as needed for ETT ajdustment or discomfort. 10. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: Two (2) ml PO BID (2 times a day) as needed for constipation. 11. Fondaparinux 2.5 mg/0.5 mL Syringe [**Month/Day (2) **]: 0.5 ml Subcutaneous DAILY (Daily). 12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 13. Lorazepam 2 mg/mL Syringe [**Last Name (STitle) **]: Two (2) mg Injection Q2H PRN (). Discharge Disposition: Extended Care Discharge Diagnosis: Primary Diagnosis: Respiratory Failure Secondary Diagnoses: Cervical cancer, Pulmonary embolism, Heparin induced thrombocytopenia, Tension Pneumothorax Discharge Condition: With trach, on mechanical ventilator but able to tolerate periods on her trach collar. Tachycardic in 100-110 range with BP 90s/50s. Extravascular volume overload with bilateral pitting edema. With trach, on mechanical ventilator but able to tolerate periods on her trach collar, currently satting well on 50% FiO2. Tachycardic in 100-110 range with BP 90s/50s. Extravascular volume overload with bilateral pitting edema. Discharge Instructions: Ms. [**Known lastname 69069**] was admitted with respiratory failure from her underlying pulmonary metastases. Her care is being transitioned to NY Presbyterian. Please continue her medications as recorded below. Feel free to contact [**Hospital3 **] with any questions or concerns. Followup Instructions: With her primary doctor and with NY Presbyterian.

[ "E934.2", "786.3", "V10.41", "486", "512.1", "287.4", "415.19", "518.81", "288.50", "197.0" ]

icd9cm

[ [ [] ] ]

[ "96.04", "34.04", "43.11", "31.1", "33.24", "45.13", "38.7", "38.91", "96.72", "88.51", "38.93", "96.6" ]

icd9pcs

[ [ [] ] ]

13772, 13787

7212, 11982

284, 378

13985, 14411

3061, 3076

14745, 14798

2538, 2556

12231, 13749

13808, 13808

12008, 12208

3468, 7189

14435, 14722

2571, 3042

13870, 13964

234, 246

406, 1423

3092, 3451

13828, 13848

2250, 2430

2446, 2522

27,694

172,676

13232

Discharge summary

report

Admission Date: [**2166-10-19**] Discharge Date: [**2166-10-31**] Date of Birth: [**2112-10-13**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 358**] Chief Complaint: found unresponsive Major Surgical or Invasive Procedure: Central IV catheter (right IJ) Upper Endoscopy History of Present Illness: 54 yo male with past medical history of Type 1 Diabetes Mellitus, CAD, ESRD on HD, and alcohol abuse was admitted from the ED after being found unresponsive and with a blood glucose elevated to 1425. . He was reportedly found down at home surrounded by emesis and small pools of fresh and old blood. He was brought to [**Hospital1 **] [**Location (un) 620**] where his vital signs were HR 121, RR 22, BP 213/99, and pulse ox 100% NRB. His labs were notable for WBC 23, Na 126, K 5.4, CO2 30.6, and blood glucose of 1425. He was started on an insulin gtt at 10 units per hour and received 1 gram ceftriaxone IV x 1. He was intubated for airway protection and was then transferred to [**Hospital1 18**] for further management. At [**Hospital1 18**] ED, temp 96.9, HR 114, BP 164/86, RR 20, Pulse ox 100% vent. His NG tube was notable for dark fluid residuals, although hemoccult was not performed. He received 40mg IV pantoprazole, 1gram IV vancomycin, flagyl 500mg IV, propofol, and midazolam. Per report, he received approximately 4L NS between [**Hospital1 **] [**Location (un) 620**] and [**Hospital1 18**]. Past Medical History: PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Name (STitle) 1022**] ([**Telephone/Fax (1) 40328**]) Primary Nephrologist: Dr. [**Last Name (STitle) **] ([**0-0-**]) . Type 1 Diabetes Mellitus Failure to Thrive Coronary Artery Disease s/p MI in [**2149**] and CABG in [**2165**] Right Eye Blindness GERD End Stage Renal Disease on HD (qMWF at [**University/College **] Dialysis Center) Alcohol Abuse Social History: Home: lives with daughter, independent of ADLs Occupation: unknown Tobacco: 2 PPD EtOH: previous history of alcohol use, pt denies recent use Drugs: denies Per patient's dialysis nurse ([**Doctor First Name **]), he has been very depressed since his wife passed away several years ago. He is very withdrawn and often comes to dialysis unwashed wearing clothes he has not changed for several days. Brother-in-law: [**Name (NI) 4468**] [**Name (NI) **] [**Telephone/Fax (1) 40329**]; [**Telephone/Fax (1) 40330**] Daughter: [**Doctor First Name **] [**Telephone/Fax (1) 40331**] Family History: Not contributory Physical Exam: T 95.5 / HR 118 / BP 108/42 / RR 32 / Wt 57 kg Gen: sedated and intubated, dissheveled HEENT: OP not visualized secondary to intubation, dry mucous membranes with dried blood on chin, no scleral icterus, pupils round and minimally reactive to light, normocephalic, atraumatic NECK: Supple, No LAD, No JVD CV: tachycardic but regular rhythm. NL S1, S2. No murmurs, rubs or gallops LUNGS: CTA, BS BL, No W/R/C ABD: scaphoid, soft, NT, ND. NL BS. No HSM EXT: No edema. 2+ DP pulses BL SKIN: scattered .25-1cm areas of hyperkeratosis without evidence of bleeding, discharge, erythema, or fluctuance; decreased skin turgor; no spider angiomas, no jaundice NEURO/Psych: intubated and sedated Pertinent Results: [**2166-10-19**] 09:50PM BLOOD WBC-8.1 RBC-2.77* Hgb-8.6* Hct-27.5* MCV-99* MCH-31.0 MCHC-31.2 RDW-15.0 Plt Ct-279 [**2166-10-20**] 03:45AM BLOOD WBC-2.6*# RBC-2.15* Hgb-6.6* Hct-19.9*# MCV-93 MCH-30.7 MCHC-33.1 RDW-15.3 Plt Ct-179 [**2166-10-21**] 03:39AM BLOOD WBC-8.5# RBC-3.09*# Hgb-9.3*# Hct-26.7* MCV-87 MCH-30.1 MCHC-34.8 RDW-17.4* Plt Ct-174 [**2166-10-31**] 05:56AM BLOOD WBC-7.5 RBC-3.76* Hgb-11.5* Hct-33.8* MCV-90 MCH-30.5 MCHC-34.0 RDW-15.8* Plt Ct-284 [**2166-10-19**] 09:50PM BLOOD PT-13.1 PTT-114.1* INR(PT)-1.1 [**2166-10-19**] 09:50PM BLOOD Glucose-1088* UreaN-76* Creat-6.9* Na-133 K-4.0 Cl-89* HCO3-25 AnGap-23 [**2166-10-31**] 05:56AM BLOOD Glucose-162* UreaN-14 Creat-4.9*# Na-138 K-4.1 Cl-99 HCO3-31 AnGap-12 [**2166-10-19**] 09:50PM BLOOD ALT-13 AST-13 LD(LDH)-207 CK(CPK)-88 AlkPhos-102 Amylase-76 TotBili-0.2 [**2166-10-19**] 09:50PM BLOOD CK-MB-5 cTropnT-0.10* [**2166-10-20**] 01:21AM BLOOD CK-MB-5 cTropnT-0.08* [**2166-10-31**] 05:56AM BLOOD Glucose-162* UreaN-14 Creat-4.9*# Na-138 K-4.1 Cl-99 HCO3-31 AnGap-12 [**2166-10-20**] 07:23AM BLOOD CK(CPK)-68 [**2166-10-20**] 01:21AM BLOOD CK(CPK)-74 [**2166-10-19**] 09:50PM BLOOD ALT-13 AST-13 LD(LDH)-207 CK(CPK)-88 AlkPhos-102 Amylase-76 TotBili-0.2 [**2166-10-27**] 04:23AM BLOOD Lipase-22 [**2166-10-20**] 03:45AM BLOOD calTIBC-131* Ferritn-754* TRF-101* [**2166-10-19**] 09:50PM BLOOD Osmolal-371* [**2166-10-22**] 03:45AM BLOOD Osmolal-303 [**2166-10-19**] 09:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2166-10-19**] 09:52PM BLOOD Type-ART Rates-20/0 Tidal V-500 PEEP-5 FiO2-100 pO2-216* pCO2-70* pH-7.26* calTCO2-33* Base XS-2 AADO2-433 REQ O2-74 -ASSIST/CON Intubat-INTUBATED [**2166-10-26**] 09:27AM BLOOD Type-ART Rates-/25 Tidal V-454 PEEP-5 FiO2-40 pO2-136* pCO2-40 pH-7.39 calTCO2-25 Base XS-0 Intubat-INTUBATED . CXR [**10-19**]: 1. Findings indicating underlying obstructive lung disease. 2. ET tube and right IJ catheter in good position, NG tube looped in the stomach with its tip pointing towards the GE junction, which should be repositioned. . [**10-21**] TEE: The left atrium is normal in size. 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 valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. No vegetation seen (cannot definitively exclude). . CT Head [**10-22**]: 1. No evidence for intracranial hemorrhage or abscess. 2. Paranasal sinus opacification as described. 3. Mild brain atrophy and evidence for prior microvascular ischemia. . EGD [**10-24**]: Esophagitis in the middle third of the esophagus, lower third of the esophagus and gastroesophageal junction compatible with severe reflux or [**Female First Name (un) **] (biopsy). Erythema in the duodenal bulb and first part of the duodenum compatible with duodenitis. Recommendations: Continue [**Hospital1 **] PPI x 2 weeks, then daily PPI therapy. Reasonable to treat with fluconazole 200mg daily x 14 days for possible [**Female First Name (un) **], at least until path/micro results are confirmed. Patient should have eventual outpatient colonoscopy because over 50 yrs old and anemic. . Esophageal Biopsy: Granulation tissue with fibrinopurulent exudate. Scant detached squamous cells. GMS stain is negative for fungal forms. Multiple levels are examined. . MRI Head [**10-24**]: No definite acute infarct. Moderate brain atrophy and mild-to- moderate changes of small vessel disease with left corona radiata lacune. Lacunes in the left thalamus. Soft tissue changes in the paranasal sinuses, which appear to be secondary to intubation. . CXR [**10-27**]: The patient is extubated and the right internal jugular line is removed in the meantime interval. The right PICC line tip terminates in mid low SVC. The cardiomediastinal silhouette is stable as well as post-sternotomy wires. There is no hilar enlargement. Slight increase in interstitial markings, especially in the perihilar and right lower lobe areas might represent mild volume overload. There is no pneumothorax or sizable pleural effusion. Brief Hospital Course: 54 yo M with DM, CAD, and ESRD on HD admitted with hyperosmolar nonketotic state after being found unresponsive. . # Altered mental status. Patient was admitted with poor mental status in the setting of hyperglycemia. Head CT and MRI were only significant for chronic small vessel ischemic disease. On [**10-26**], he was extubated and his mental status appeared to be back at baseline after discussing with his long-term dialysis nurse. He remained alert and oriented throughout the rest of his hospital stay. . # Hyperglycemia: It was unclear whether the patient had type 1 DM or insulin-dependent type 2 DM. His BS were elevated to 1400 in the ED with a significant anion gap, suggestive of DKA. Urine was not available to test ketones as patient has ESRD. However, the MICU team had the impression that the patient had hyperosmolar nonketotic coma given that the patient only developed diabetes in his 30s. There was concern that the causal event was infectious, although blood cultures and urine cultures were negative. Further infectious work-up is discussed below. Alternatively, there was concern that the patient was not faithfully taking his home medications. Patient's hyperglycemia was treated in the ICU and then he was transitioned to fixed and sliding scale insulin. His glucose control is made difficult by poor and inconsistent dietary intake. . # Infection/Sinusitis. Patient's initial presentation was significant for tachycardia and leukocytosis concerning for septic picture. He was started on broad spectrum antibiotics. ID was consulted, and he was given a 10 day course of vancomycin (completed), as well as 2 weeks total of ceftriaxone and metronidazole. There was no definite source discovered; blood and urine cultures, including fungal blood cultures, were negative at the time of discharge. CXR did not show infiltrate. Pt was noted to have opacified sinuses on head CT. Seen by ENT on [**10-24**] who did not see signs of invasive fungal infection; culture of sinuses negative, although antifungals were given because pt had budding yeast forms on his gram stain. . # Esophagitis. Patient had episode of bloody emesis at time of presentation. An upper endoscopy was performed and he was found to have severe esophagitis. It was unclear whether the esophagitis was due to [**Female First Name (un) **] or severe reflux disease. He was placed on antifungals (initially caspofungin, then switched to fluconazole) for a 2 week course. In addition, he was given PPI [**Hospital1 **] x 2 weeks, to be continued once daily thereafter. Of note, his biopsy did not show fungal forms. He had no further episodes of bloody emesis, and his Hct was stable at the time he was discharged. . # Resp Failure: Patient was intubated in the MICU for airway protection and increased secretions in the setting of poor mental status. Following extubation, he was assessed by speech and swallow, who put him on a soft diet with thin liquids. . # ESRD on Hemodialysis. Patient was followed by renal and dialyzed Monday, Wednesday, Friday per his normal routine. His phosphate binders were stopped given persistently low phosphorous. Nephrocaps should be continued. Given his poor nutritional state, it was felt to be appropriate to put him on a consistent carbohydrate diet. . # History of CAD s/p CABG, hypertension. Patient's clonidine, lisinopril, Norvasc, and toprol were continued. Although he was admitted with minoxidil, he did not need it for control of his BP and it was stopped. . # Depression. Patient was admitted on mirtazapine, although there was concern that he might not have been taking it at home. His mirtazapine was held in the setting of his poor mental status. After discussing with his home dialysis nurse, it appeared that his mood was improved in the hospital as compared with his baseline. Thus, his mirtazapine was not restarted. The team was concerned that he has significant depressive symptoms over the last several months (worse since his wife died a few years ago) interfering with his ability to care for himself. It is recommended that he get help from psychiatry for possible medication/counseling. . # History of alcohol abuse. Tox screen negative for alcohol. Patient denied recent use of alcohol. He was discharged on thiamine (gets folate in his nephrocaps) since it was unclear whether alcohol continues to be a problem for him. . # Medication changes: - Lantus decreased for AM hypoglycemia - Minoxidil stopped as not needed for BP control - Phoslo stopped as phosphorous too low - Reglan stopped for loose stools - Mirtazapine stopped for altered mental status, as above - PPI started for severe esophagitis - Antibiotics as discussed above . # COMM: [**First Name8 (NamePattern2) **] [**Known lastname 40332**] [**Telephone/Fax (1) 40331**] Medications on Admission: Aspirin 81mg PO daily Clonidine .3mg PO bid Lantus 16 units qhs Lisinopril 40mg PO daily Minoxidil 2.5mg PO bid Nephrocaps 1 tablet daily Norvasc 10mg PO dialy Phoslo 2 tabs wid Prilosec 20mg PO daily Reglan 10mg PO qid Remeron 50mg PO qhs Simvastatin 10mg PO daily Toprol XL 100mg PO daily Thiamine 100mg PO daily Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary diagnosis: Mental status change, hyperglycemia with possible hyperosmolar coma, Esophagitis Secondary Diagnosis: Hematemesis, DM, ESRD on dialysis, CAD, HTN, Sinusitis, Depression Discharge Condition: Patient's mental status had returned to baseline and his hyperglycemia had resolved. His vital signs were stable and he was afebrile. Discharge Instructions: You were admitted with high blood sugars with mental status change and concern for infection. You were treated in the MICU, where your sugars were controlled and your mental status improved. You were given antibiotics and antifungals to treat your infection, which was felt to involve your sinuses. 1. Please take all medications as prescribed. It is important for you to monitor your blood sugar regularly and take your insulin as directed. 2. Please attend all follow-up appointments listed below. 3. Please call your doctor or return to the hospital if you develop fevers, chills, decline in mental status, blood sugar > 350, pain with swallowing, or any other concerning symptom. Followup Instructions: Please see your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 1022**] within 2-3 weeks of your discharge. It is recommended that you have a colonoscopy in the near future. You may also need to be evaluated by a psychiatrist. Completed by:[**2166-10-31**]

[ "486", "999.9", "261", "530.10", "530.82", "V45.81", "518.81", "250.23", "707.03", "250.43", "473.9", "585.6" ]

icd9cm

[ [ [] ] ]

[ "38.93", "45.16", "96.04", "99.04", "96.72", "39.95" ]

icd9pcs

[ [ [] ] ]

12922, 13001

7735, 12145

293, 342

13235, 13372

3276, 7712

14107, 14378

2536, 2554

13022, 13022

12583, 12899

13396, 14084

2569, 3257

12165, 12557

235, 255

370, 1481

13145, 13214

13042, 13123

1503, 1924

1940, 2520

7,809

114,247

48886

Discharge summary

report

Admission Date: [**2134-9-30**] Discharge Date: [**2134-10-5**] Date of Birth: [**2078-12-5**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 1253**] Chief Complaint: DKA. Major Surgical or Invasive Procedure: Right inguinal CVC placement [**9-30**] History of Present Illness: Ms. [**Known lastname 18741**] is a 55 year-old woman with DMI, severe gastroparesis, HTN, Grave's Disease and Hepatitis C who presented to the ED [**9-30**] with hyperglycemia. She has had multiple admissions to [**Hospital1 18**] for DKA, most recently discharged [**2134-8-11**]. She initially c/o fevers, dysuria, thirst, and nausea and [**Year (4 digits) **]. PTA her blood glucose readings were 300-600. She had no cough or sputum production. She did have one episode of diarrhea. She also is bothered by chronic lower leg and back pain, both of which also prompted her ED presentation. She reports some mild abdominal pain which is typical for her when she has DKA. She reports she has been compliant with taking her Lantus and sliding scale. In the ED, her initial vital signs were: temperature of 98.8, blood pressure of 124/65, heart rate of 95, respiratory rate of 20, and oxygen saturation of 98% on RA. A finger stick glucose was critically high at triage. The ED team had a difficult time obtaining access, so a right femoral central line was placed. She was started on an insulin drip at 7 units per hour and she was started on intravenous fluids, on her first liter at time of transfer. In the ICU she was transitioned off the insulin gtt, back to bolus insulin [**10-1**]. She was given 6L IVF. Her nausea improved. She had no clear infctious etiology, with clear urine, so was given 1 dose of cipro but this was stopped. She was thought to have a viral syndrome as etiology of her DKA. Currently she feels generally unwell, with global achiness, but overall improved from admission. She continues to have dysuria despite negative UA/CX. She has a dry cough but no shortness of breath. She c/o bilateral lower back pain, which is not normal for her and started prior to admission. She has not been out of bed since admission. ROS: 10 point review of systems negative except as noted above. Past Medical History: 1. DM Type 1: Years w/ DM: 5 Age of Diag: 48 Year Diag: [**2127**]. Several episodes of DKA, managed on 28U Lantus [**Hospital1 **] plus HISS 2. Diabetic polyneuropathy and gastroparesis 3. Hypertension 4. Grave's disease s/p RAI [**2129**] 5. Reactive airway disease 6. Seronegative arthritis, followed in rheumatology 7. Hepatitis C, genotype 1A, biopsy with grade 1 inflammation, never been on antiviral therapy, acquired via blood transfusion during surgery in [**2110**] 8. GERD 9. Migraines 10. Bilateral knee arthroscopy in [**5-24**] 11. s/p TAH and pelvic floor surgery with bladder lift 12. Depression 13. Bone spurs in feet 14. Bilateral foot drop requiring wheelchair use Social History: Patient lives in a multi apartment building in the same apartment with a daughter, grandaughter, and grandson. She has a son, daughter and another brother who live on another floor. She is a never smoker and does not use alcohol or drugs. She has not worked for many years. She uses a wheelchair at baseline. Family History: Her mother died of colon cancer. There are multiple family members with DM Physical Exam: VS: T 98.1 HR 91 BP 107/58 RR 11 Sat 99% RA; BG 308 (1700), 219 (2100) Gen: Well appearing woman in NAD Eye: extra-occular movements intact, pupils equal round, reactive to light (2.5mm->2mm), sclera anicteric, not injected, no exudates ENT: mucus membranes moist, no ulcerations or exudates Neck: no thyromegally, JVD: flat Cardiovascular: regular rate and rhythm, normal s1, s2, no murmurs, rubs or gallops Respiratory: Clear to auscultation bilaterally, no wheezes, rales or rhonchi Abd: Soft, non tender, non distended, no heptosplenomegally, bowel sounds present Extremities: Trace pedal edema bilaterally, no cyanosis, clubbing, joint swelling Neurological: Alert and oriented x3, CN II-XII intact, normal attention, speech fluent Integument: Warm, moist, no rash or ulceration Psychiatric: appropriate, pleasant, not anxious Hematologic: no cervical or supraclavicular LAD Pertinent Results: Admission labs: WBc 5.6 hct 36.5, hgb 10.9, plt 389->25.2. BMP: 125/5.7/89/18/20/1.3 UA: negative ECG [**9-30**]: NSR (96), nl axis/intervals, no acute ST-T changes. CXR [**9-30**]: Normal chest radiograph. [**2134-10-5**] 07:00AM BLOOD WBC-4.8 RBC-3.48* Hgb-9.3* Hct-30.1* MCV-87 MCH-26.8* MCHC-30.9* RDW-15.7* Plt Ct-272 [**2134-10-5**] 07:00AM BLOOD Glucose-232* UreaN-15 Creat-0.8 Na-131* K-4.3 Cl-99 HCO3-28 AnGap-8 [**2134-10-5**] 07:00AM BLOOD Phos-3.7 Mg-1.7 [**2134-10-2**] 05:37AM BLOOD TSH-0.54 [**2134-10-1**] 08:45PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.004 [**2134-10-1**] 08:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2134-10-1**] 10:42AM URINE RBC-2 WBC-4 Bacteri-FEW Yeast-NONE Epi-1 Micro: [**2134-10-1**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2134-10-1**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2134-10-1**] URINE URINE CULTURE-FINAL INPATIENT Brief Hospital Course: 55 year old female with type 1 diabetes mellitus with many admissions for DKA, who presented with DKA. 1. Diabetic Ketoacidosis, type I DM with complications: Patient has history of many admissions for DKA. It is not entirely clear what prompted this episode, likely viral syndrome as no evidence of UTI, pulmonary infection, no evidence of cardiac ischemia. Patient improved with IV fluids, and insulin. Pt initially received insulin drip, converted to SQ insulin, with fair control. At time of discharge, glucose 100-259; but generally in mid to high 100's. Pt was returned to her home insulin regimen, and will follow up with [**Last Name (un) **] the day following discharge. 2. Global achiness: suspect viral syndrome as no clear evidence of other infection. Pt also with some localization to sacroiliac joints bilaterally. Pt was briefly given tramadol to treat pain, but this was not continued at discharge. 3. Hypertension: continued losartan, well-controlled. 4. [**Doctor Last Name 933**] disease: TSH 0.54. Methimazole continued at home dose. 5. Asthma: Asymptomatic. - Contiued home medications 6. Anemia: Normocytic. Near baseline. 7. GERD: Continued protonix 8. Depression, anxiety: Continue amitriptyline and diazepam 9. Chronic pain: Continue home regimen of percocet, neurontin, amitriptyline. Briefly treated with Tramadol as well, not continued at discharge. 10. Seronegative arthritis: continued sulfasalazine. Dispo: to home. F/u with [**Last Name (un) **] as outpt. Medications on Admission: At home: - Amitriptyline 25 mg - Cozaar 50 mg - Diazepam 5 mg [**Hospital1 **] - Colace 100 mg - Flovent - Humalog sliding scale TID - Lantus 28 units [**Hospital1 **] - Naprosyn 500 mg [**Hospital1 **] - Neurontin 900 mg TID - Percocet q6H PRN Pain - Protonix 40 mg daily - Reglan 10 mg daily - Singulair 10 mg daily - Serevent diskus - Sulfasalazine 1000 mg [**Hospital1 **] - Tapazole 10 mg TID - Zocor 10 mg - Zomig 2.5 mg - ASA 81 mg On transfer: Amitriptyline 25 mg PO HS Metoclopramide 10 mg PO QIDACHS Aspirin 81 mg PO DAILY Methimazole 10 mg PO TID Diazepam 5 mg PO BID Montelukast Sodium 10 mg PO DAILY Docusate Sodium 100 mg PO BID Oxycodone-Acetaminophen 1 TAB PO Q6H:PRN pain Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] Pantoprazole 40 mg PO Q24H Gabapentin 600 mg PO TID Heparin 5000 UNIT SC TID Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose: Glargine 28units, humalog sliding scale Simvastatin 10 mg PO DAILY Losartan Potassium 50 mg PO DAILY Discharge Medications: 1. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Diazepam 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 6. Insulin Glargine 100 unit/mL Solution Sig: as dir units Subcutaneous twice a day: 28 units [**Hospital1 **]. 7. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3 times a day). 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 11. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation Q12H (every 12 hours). 13. Sulfasalazine 500 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 14. Methimazole 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 15. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Zomig 2.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for headache. 17. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 18. Humalog 100 unit/mL Solution Sig: as dir units Subcutaneous as dir: Insulin SC Fixed Dose Orders Breakfast Bedtime Glargine 28 Units Glargine 28 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-70 mg/dL [**1-22**] amp D50 [**1-22**] amp D50 [**1-22**] amp D50 [**1-22**] amp D50 71-120 mg/dL 0 Units 0 Units 0 Units 0 Units 121-180 mg/dL 5 Units 5 Units 5 Units 0 Units 181-240 mg/dL 7 Units 7 Units 7 Units 0 Units 241-300 mg/dL 9 Units 9 Units 9 Units 2 Units 301-360 mg/dL 11 Units 11 Units 11 Units 3 Units 361-420 mg/dL 13 Units 13 Units 13 Units 4 Units 421-480 mg/dL 15 Units 15 Units 15 Units 5 Units 481-540 mg/dL 17 Units 17 Units 17 Units 6 Units >541 mg/dL 19 Units 19 Units 19 Units 7 Units . Discharge Disposition: Home With Service Facility: Uphams Corner Home Care Discharge Diagnosis: # Diabetic Ketoacidosis # Type I diabetes, poorly controlled, with complications # Sacroilitis # Hypertension # [**Doctor Last Name 933**] disease # Chronic pain syndrome; peripheral neuropathy Discharge Condition: stable Discharge Instructions: You were admitted with another episode of DKA. You were provided IV fluids and insulin to improve your glucose control. You have been converted back to your previous home insulin regimen. Please follow up with your [**Last Name (un) **] appointment tomorrow. Please seek medical attention if you develop nausea, [**Last Name (un) **], persistent poor glucose control, fevers, chills, or any other concern. Followup Instructions: Please follow up with your [**Last Name (un) **] appointment tomorrow. Please follow up with your primary care doctor within the next several weeks. Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2134-10-19**] 9:15

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

10369, 10423

5309, 6814

277, 318

10661, 10670

4302, 4302

11126, 11419

3311, 3387

7905, 10346

10444, 10640

6840, 7882

10694, 11103

3402, 4283

233, 239

346, 2260

4318, 5286

2282, 2968

2984, 3295

63,515

103,490

36963

Discharge summary

report

Admission Date: [**2171-5-13**] Discharge Date: [**2171-5-16**] Date of Birth: [**2128-7-23**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 358**] Chief Complaint: accidentally swallowed cleaner Major Surgical or Invasive Procedure: EGD History of Present Illness: 42 year old man with h/o depression, ADD, and who is otherwise healthy, who reportedly accidently swallowed a mouth full of ammonium chloride on day of admission. He was storing the cleaner in a diet coke can, and accidently took a sip of of the cleaner. He immediately spit the cleaner out and then repeatedly washed his mouth out with tap water for about a half an hour. After "one to two hours" he went to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], where he did not receive endoscopy. . He was transferred to [**Hospital1 18**], where he was seen by ORL, GI, and then transferred to the ICU for observation. While in the ICU, he was made NPO, had daily scopes to assess airway and an EGD that showed grade 2 burn (desquamation of superficial layer). He was advanced to clears but still complaining of pain on swallowing. Has a cough that causes pain in throat area too. Tolerated a milk shake prior to being transferred. Psychiatry saw him to rule out suicide. No previous history of suicide. . Transferred to the floor with AVSS. Past Medical History: GERD Attention deficit disorder Depression ?Asthma Social History: no tob/etoh history One of 4 sibs. Sister and mother have visited. Works currently as night auditor at a hotel. Lives alone and has a cat. Family History: noncontributory Physical Exam: AVSS GENERAL: Well appearing, no acute distress HEENT: EOMI, PERRL, OP non erythematous, no oral lesions. NECK: No cervical lymphadenopathy, no JVD, no carotid bruit CARD: RRR, normal S1/S2, no m/r/g RESP: CTA bilaterally, no wheezes/rales/rhonchi ABD: Soft, nontender, nondistended, normoactive bowel sounds, no hepatosplenomegaly BACK: No spinal tenderness, no CVA tenderness EXT: No clubbing/cyanosis/edema, 2+ DP pulses NEURO: CN II-XII, A&O x 3, Strength 5/5 in both upper and lower extremities bilaterally, no sensory deficits, ambulates well PSYCH: Feels fine but is anxious about "the plan is" Pertinent Results: [**2171-5-13**] 04:19PM BLOOD WBC-17.7* RBC-5.37 Hgb-16.5 Hct-47.1 MCV-88 MCH-30.7 MCHC-35.0 RDW-14.1 Plt Ct-290 [**2171-5-14**] 04:14AM BLOOD WBC-12.7* RBC-4.62 Hgb-14.4 Hct-43.1 MCV-93 MCH-31.2 MCHC-33.5 RDW-14.3 Plt Ct-256 [**2171-5-14**] 06:42AM BLOOD WBC-13.7* RBC-4.98 Hgb-15.3 Hct-46.5 MCV-93 MCH-30.8 MCHC-33.0 RDW-14.2 Plt Ct-271 [**2171-5-15**] 04:50AM BLOOD WBC-8.6 RBC-5.31 Hgb-16.2 Hct-46.6 MCV-88 MCH-30.5 MCHC-34.8 RDW-14.1 Plt Ct-264 [**2171-5-16**] 06:40AM BLOOD WBC-6.3 RBC-5.02 Hgb-15.4 Hct-44.8 MCV-89 MCH-30.7 MCHC-34.3 RDW-14.0 Plt Ct-246 [**2171-5-13**] 04:19PM BLOOD Neuts-92.8* Lymphs-4.2* Monos-2.4 Eos-0.3 Baso-0.2 [**2171-5-13**] 04:19PM BLOOD Plt Ct-290 [**2171-5-13**] 04:19PM BLOOD Glucose-120* UreaN-17 Creat-1.1 Na-144 K-3.9 Cl-104 HCO3-24 AnGap-20 [**2171-5-14**] 06:42AM BLOOD Glucose-103 UreaN-11 Creat-0.9 Na-140 K-3.6 Cl-106 HCO3-25 AnGap-13 [**2171-5-15**] 04:50AM BLOOD Glucose-88 UreaN-9 Creat-0.9 Na-142 K-3.6 Cl-103 HCO3-26 AnGap-17 [**2171-5-16**] 06:40AM BLOOD Glucose-91 UreaN-9 Creat-1.0 Na-141 K-3.7 Cl-101 HCO3-28 AnGap-16 [**2171-5-14**] 06:42AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.1 [**2171-5-14**] 06:42AM BLOOD ALT-21 AST-22 LD(LDH)-139 AlkPhos-69 TotBili-0.5 EGD: Indications: Caustic ingestion of ammonium salts Procedure: The procedure, indications, preparation and potential complications were explained to the patient, who indicated his understanding and signed the corresponding consent forms. A physical exam was performed. The patient was administered conscious sedation. Supplemental oxygen was used. The patient was placed in the left lateral decubitus position and an endoscope was introduced through the mouth and advanced under direct visualization until the second part of the duodenum was reached. Careful visualization of the upper GI tract was performed. The procedure was not difficult. The patient tolerated the procedure well. There were no complications. Findings: Esophagus: Lumen: A small size hiatal hernia was seen, displacing the Z-line to 38cm from the incisors, with hiatal narrowing at 40cm from the incisors. Mucosa: Erythema with sloughing/ulceration of the superficial layer of the esophagus was noted in the lower third of the esophagus, most significant at the GE junction. There was intermittent patchy sloughing in the upper third of the esophagus and pharynx. There was one small discrete ulcer in the midesophagus. Findings are consistent with a grade 2 injury/burn. Stomach: Mucosa: Normal mucosa was noted. Duodenum: Normal duodenum. Impression: Erythema in the lower third of the esophagus and upper third of the esophagus Small hiatal hernia Normal mucosa in the stomach Otherwise normal EGD to second part of the duodenum Recommendations: Clear liquids for 24 hrs. Hold PPI overnight. Carafate prn discomfort. There is no evidence for steroids in caustic injestions as related to the esophagus, regardless of the severity of the burn. Advance to soft solids in 24 hrs. Additional notes: The attending physician was present during the entire procedure. _________________________________ [**First Name4 (NamePattern1) 450**] [**Last Name (NamePattern1) 79**], M.D. _________________________________ [**First Name4 (NamePattern1) **] [**First Name8 (NamePattern2) 3037**] [**Name8 (MD) 349**], MD Brief Hospital Course: Mr. [**Name13 (STitle) **] is a 42 year old man with h/o depression, ADD, and who is otherwise healthy, who reportedly accidently swallowed a mouth full of ammonium chloride on day of admission. He was initially treated in the ICU as there was concern for airway compromise given the significant esophageal burns he suffered after this toxic ingestion. He was seen by GI and ENT/ORL with daily endoscopic evaluations of his esophagus. On his 2nd hospital day he was transferred to floor. He was tolerating a clears/liquid diet and had AVSS. His medical course is as follows: 1. accidental alkali ingestion/Esophageal caustic injury: Patient reportedly accidently swallowed an alkaline based cleansing [**Doctor Last Name 360**]. There was initial concern for airway compromise and esophageal perforation so he was treated initially in the ICU. His EGD showed superficial caustic burns to esophagus. Patient's course in [**Hospital Unit Name 153**] was significant for tolerating clears and not requiring intubation for airway management. He was started on Clindamycin for a 2 week course prophylactically for possible superficial infection. He tolerated soft solids on the floor, remained afebrile, and was discharged home with close follow up to Dr. [**First Name (STitle) **], ENT/ORL. He was advised about short and long term consequences of his toxic ingestion-namely that he is at risk esophageal perforation, infection in the short term and in the long term, stricture, dysphagia, and possibly cancer. 2. Depression/Anxiety/ADD: The patient was evaluated by psychiatry and reported no suicidal ideation or previous suicide attempts or thoughts. He was continued on his home medications and has close follow up with his outpatient therapist. #) Prophylaxis: Patient was given Subcu hep; bowel regimen; and his home PPI. Medications on Admission: Protonix 40 mg daily Wellbutrin XR 150 mg [**Hospital1 **] Adderall 30 mg [**Hospital1 **] Klonipin 1 mg [**Hospital1 **] Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*14 Tablet(s)* Refills:*0* 2. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 13 days: two week course . Disp:*52 Capsule(s)* Refills:*0* 3. Amphetamine-Dextroamphetamine 5 mg Tablet Sig: Six (6) Tablet PO BID (2 times a day). 4. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 5. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) as needed for GERD. 7. Lidocaine HCl 2 % Solution Sig: Twenty (20) ML Mucous membrane TID (3 times a day) as needed for pain. Disp:*1 unit* Refills:*0* 8. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for esophageal discomfort/pain. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Toxic ingestion Secondary: Depression Attention Deficit Disorder Discharge Condition: Stable, tolerating normal food. Discharge Instructions: You were admitted for treatment of toxic ingestion of an alkaline liquid (cleaning [**Doctor Last Name 360**]). You were evaluated by doctors who [**Name5 (PTitle) **] in the gastrointestinal system and ear, nose, and throat. You had studies done that showed how you suffered burns of your esophagus. You were given medications and put on a diet to minimize the effects of this ingestion. Your medications have been modified in the following manner: 1. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours): two week course (first dose was [**5-15**]). 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 3. Lidocaine HCl 2 % Solution Sig: PRN ML Mucous membrane TID (3 times a day) as needed for pain. 4. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for esophageal discomfort/pain You should follow up with the ear, nose and throat specialist on [**Last Name (LF) 766**], [**2171-5-20**]. Should you feel any worsening of your symptoms such as increasing pain on swallowing, difficulty breathing, shortness of breath, or fevers, chills please seek medical attention. Additionally, you should be aware of the long term consequences that could occur to you. For example, you are increased risk for esophageal scarring, perforation, and cancer. You should see a gastrointestinal specialist in 10 to 15 years to follow up for these potential consequences. Followup Instructions: Please keep the following appointments: Follow up with Dr. [**First Name (STitle) **], on [**Last Name (LF) 766**], [**5-20**], at 1:00 PM. Please call [**Telephone/Fax (1) 31733**] for directions to her office. Outpatient therapist appointment on [**Last Name (LF) 766**], [**First Name3 (LF) **] 1s at 1130 AM Completed by:[**2171-5-16**]

[ "E924.1", "947.2", "948.00", "300.4", "530.81", "314.00" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

8629, 8635

5622, 7465

302, 308

8753, 8787

2305, 5599

10319, 10664

1650, 1667

7638, 8606

8656, 8732

7491, 7615

8811, 10296

1682, 2286

232, 264

336, 1402

1424, 1477

1493, 1634

73,059

124,602

54811

Discharge summary

report

Admission Date: [**2106-6-8**] Discharge Date: [**2106-6-20**] Date of Birth: [**2025-4-12**] Sex: F Service: NEUROLOGY Allergies: aspirin / Levaquin / Penicillins / Sulfa(Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 2569**] Chief Complaint: L MCA stroke Major Surgical or Invasive Procedure: tPA administration History of Present Illness: Mrs. [**Known lastname 112027**] is an 81-year-old probably right-handed woman presenting with the above on a background of paroxysmal atrial fibrillation, not anticoagulated, likely coronary artery disease, end-stage renal disease, on hemodialysis. Per OSH notes, the patient woke and went to the bathroom at about 7 AM. Shortly afterward, she was found slumped on the toilet, was found to be mute and with a right hemiplegia. She was taken to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], where stroke was suspected. Non-contrast head CT did not reveal hemorrhage, and tPA was started at 9:30 AM. She was then transferred to [**Hospital1 18**], arriving at 10:50. She likely got about 20 cc too much tPA - it was still running during transport and was supposed to be stopped at 10:30, but was stopped on arrival at 10:50. At baseline she is ambulatory with a walker and is "A&Ox3". Review of systems was not possible. Past Medical History: - ICD placement, about 10 days ago - Paroxysmal atrial fibrillation, not on Coumadin (patient apparently refused), also ventricular pauses per call-in - ESRD on hemodialysis, percutaneous right chest line - On Plavix, presumed coronary disease - Possible further medical history - Hypertension (on arrival and on dialysis, so probable) - Prednisone taper for unknown reason (husband says no oxygen or inhalers at home, so this will need to be verified) Social History: Lives with her husband. Further not obtainable. Family History: Not obtainable. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: Afebrile, 76 BPM, 152/65 mmHg, 97% 2L General Appearance: Comfortable, no apparent distress. HEENT: NC, OP clear, MMM. Neck: Supple. No bruits. Lungs: CTA bilaterally. Cardiac: RRR. Normal S1/S2. No M/R/G. Abdominal: Soft, NT, BS+ Extremities: Warm and well-perfused. Peripheral pulses 2+. Neurologic: Mental status: Awake and alert, cooperative with exam. Mute. Tracks examiner, but clear left gaze and spacial preference. Intermittently following commands (sometimes shows two fingers, sometimes not), reliably opening and closing eyes and gripping and releasing left hand. Later somnolent. Cranial Nerves: I: Not tested. II: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. Conjugate. Needs strong stimulus to get eyes past midline to right. V, VII: Right facial palsy, mostly lower. VIII: Hearing intact to voice. IX, X: Not evaluable. [**Doctor First Name 81**]: Trapezius flaccid on right. XII: Tongue midline, but not fully evaluable. Tone - occasional intermittent resistance with passive movements of right arm and leg, left side normal. Power Left appears full and right is paretic. Reflexes: B T Br Pa Ac Right 2 1 2 0 0 Left 1 1 1 0 0 Toes downgoing on left and up on right. Sensation intact to pain in all limbs. No ataxia on left, accurate reach. PHYSICAL EXAM AT TIME OF DEATH 5:30am on [**6-20**]. GEN: lying in bed, pale, not moving HEENT: pupils bilaterally fixed and dilated CV: no heart beat ausculatated or palpated PULM: no breath sounds auscultated or palpated EXT: cold, pale, no peripheral pulses palpated Pertinent Results: ADMISSION LABS: [**2106-6-8**] 11:00AM BLOOD WBC-38.4* RBC-3.10* Hgb-10.3* Hct-33.2* MCV-107* MCH-33.3* MCHC-31.1 RDW-18.6* Plt Ct-365 [**2106-6-8**] 11:05AM BLOOD PT-12.2 PTT-27.4 INR(PT)-1.1 [**2106-6-8**] 11:05AM BLOOD Fibrino-540* [**2106-6-8**] 11:05AM BLOOD UreaN-74* [**2106-6-12**] 01:50PM BLOOD %HbA1c-5.1 eAG-100 [**2106-6-12**] 01:50PM BLOOD Triglyc-113 HDL-49 CHOL/HD-2.9 LDLcalc-71 [**2106-6-8**] 11:08AM BLOOD Glucose-109* Na-136 K-4.3 Cl-96 calHCO3-22 DISCHARGE LABS: None were drawn as pt expired on [**6-20**] at 5:30am REPORTS: CT/CTA [**2106-6-8**]: IMPRESSION: 1. Left MCA infarction. No evidence of hemorrhage. 2. Focal ulceration at the origin of the right common carotid artery. 3. Extensive atherosclerosis involving the arotic arch, left common carotid artery, and carotid bifurcations. CXR [**2106-6-9**]: IMPRESSION: Moderate right pleural effusion. Retrocardiac opacity may represent pneumonia, atelectasis or other pulmonary process. ECHO [**2106-6-9**]: Conclusions The left atrium is mildly dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The interatrial septum is aneurysmal. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Physiologic mitral regurgitation is seen (within normal limits). There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal biventricular systolic function. No evidence of left atrial mass/thrombus although TTE cannot exclude this. If clinically indicated, a TEE will better assess for LAA thrombus. CT HEAD [**2106-6-9**]: IMPRESSION: 1. Extensive cytotoxic edema and hyperdensity throughout the left MCA distribution, in an evolving territorial infarct. This likely represents abnormal parenchymal enhancement (related to the contrast given for the CTA,roughly 17 hours earlier), in the setting of blood-brain barrier breakdown in the acutely ischemic brain. 2. Old left PCA territorial infarct, with encephalomalacia. CT HEAD [**6-11**]/!2: IMPRESSION: Evolving left MCA infarct. No evidence of hemorrhage. CXR [**2106-6-12**]: FINDINGS: The NG tube tip is in the stomach. The dual-lead pacemaker and right supraclavicular double-lumen catheter is again visualized. Small left pleural effusion is again visualized and is unchanged. There continues to be dense retrocardiac opacity likely due to a combination of volume loss and effusion, although an infiltrate cannot be excluded. Brief Hospital Course: On Admission: [**Known firstname 8797**] [**Known lastname 112027**] is an 81 year old female with a history of atrial fibrillation not on anticoagulation, ESRD (on dialysis) who presented as a transfer from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital for L MCA infarct. She was brought to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital where her exam was notable for aphasia and right-sided hemiparesis. She had a head CT scan performed which showed an acute/subacute left MCA distribution infarct. Neurology evaluated the patient and she received t-PA. She was transferred to [**Hospital1 18**]-ICU for further care. On arrival she had ecchymoses/hematoma over her left chest at the site of pacemaker placement and right upper arm (prior bruise from fall). Compressive dressings were placed on both these sites. ICU course: ([**2106-6-8**]- [**2106-6-11**]) # Neuro: CTA after tPA showed recanalized flow through the MCA however she continued to have significant R sided weakness and productive aphasia. At first, her BP was allowed to autoregulate, however she went into afib with RVR with subsequent relative hypotension (SBP<120) and there was an empiric concern for inadequate cerebral blood flow. She was placed on Neosynephrine and given lopressor/digoxin to control arrhythmias. Neo was then stopped at 48hrs and she was allowed to autoregulate once again. Lipid profile showed an LDL of 72 and a HgA1C of 5.1. In terms of anticoagulation for afib, she had refused coumadin in the past (personal preference) despite being advised to start the medication. She had received a peripheral iliac stent for PAD in [**2106-1-10**] and was taking plavix on admission. Plavix was continued after ensuring -with NCHCT- that she had not had hemorrhagic conversion. However after discussion with her Cardiologist who had placed the stent, she was no longer at risk for in-stent thrombosis and she was switched to aspirin bridge to coumadin. . # Cardiovascular: She demonstrated afib with RVR and was loaded with digoxin and received several doses of lopressor without effect. She was started on PO metoprolol which was uptitrated and amiodarone gtt. Given the hemorrhage over the pacemaker device site, EP was consulted. Pacer was interrogated and appeared to be working appropriately. . # Renal and genitourinary: initially she continued on her dialysis in the ICU at her regular schedule. . # Endocrine: Prednisone taper was continued as per outpatient regimen, . # Musculoskeletal, Rheumatologic: Standing Tylenol for pain . # Hematology, Oncology: WBC was >40 on admission and then trended down which was thought to reflect infection/stroke/steroids and ?possible underlying hematological malignancy. Floor Course [**Date range (1) 4859**] # NEURO: patient continued to have dense R hemiplegia and only followed commands to open and close her eyes. After it became clear that she would require a PEG tube, her family decided to make her CMO on [**6-17**]. Her medications were stopped and she was started on dilaudid PRN and ativan PRN through her NGT, which was then discontinued on [**6-19**] and she was transitioned to concentrated morphine solution. She passed away on [**6-20**] at 5:30am. Her family was notified. Medications on Admission: - Plavix - Verapamil - Neurontin - Metoprolol - Nephrocaps - Prednisone taper (?) Discharge Medications: N/A pt expired on [**6-20**] at 5:30am Discharge Disposition: Expired Discharge Diagnosis: Left MCA infarct Discharge Condition: N/A pt expired Discharge Instructions: N/A pt expired Followup Instructions: N/A pt expired [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

[ "585.6", "V49.86", "458.21", "285.21", "V45.11", "V45.88", "434.11", "342.01", "496", "276.8", "008.45", "V45.02", "E879.8", "443.9", "427.31", "998.12", "403.91", "784.3" ]

icd9cm

[ [ [] ] ]

[ "96.6", "39.95" ]

icd9pcs

[ [ [] ] ]

10152, 10161

6657, 6657

339, 360

10222, 10238

3667, 3667

10301, 10429

1890, 1907

10089, 10129

10182, 10201

9983, 10066

10262, 10278

4153, 6634

1947, 2260

287, 301

388, 1333

2568, 3648

3684, 4136

6672, 9957

2275, 2552

1355, 1809

1825, 1874

14,467

104,642

28548

Discharge summary

report

Admission Date: [**2118-11-29**] Discharge Date: [**2118-12-10**] Date of Birth: [**2069-10-26**] Sex: F Service: SURGERY Allergies: Zantac 75 / Lipitor Attending:[**First Name3 (LF) 371**] Chief Complaint: Fatigue, nausea/vomiting, left neck swelling and pain Major Surgical or Invasive Procedure: CT guided drainage of abdominal abscess History of Present Illness: The patient is a 49 y/o female with h/o diverticulitis and multiple abdominal surgeries presents with increasing lethargy for 3-4 days. She began to notice swelling of her left neck 4 days ago accompanied by ear pain and pain on swallowing. Her husband has noticed increased drainage from her abdominal wound. The patient has also had frequent episodes of nausea and vomiting. She denies fever, chills, shortness of breath, chest pain, or abdominal pain. Her ostomy output has remained constant. Past Medical History: PMH: 1.)Colocutaneous Fistula 2.)Aspiration pneumonia with MRSA 3.)Diverticulitis 4.)Anxiety 5.)Depression 6.)afib PSH: 1.)[**2118-7-21**]- Exploratory laparotomy with total colectomy 2.)[**2118-7-23**]- Takedown of ileorectal anastomosis, [**Doctor Last Name **] pouch, ileostomy 3.)[**2115**]- Sigmoid Colectomy 4.)[**2109**]- Cholecystectomy Social History: Mrs. [**Known lastname 69147**] lives in [**Location **] with her husband and four kids (7,9, 17, and 19 years of age). This is her second marriage and she stays at home and cares for the children. Before her first marriage, she worked at a nursing home. She has a 16 pack-year smoking history, quitting in [**Month (only) 216**] due to her hospitalization. She drinks alcohol occassionally and has no history of illicit drug use. She buckles up when she drives and does not own a gun. She does not bike and has no history of felonies or misdemeanors. She is on a limited hospital diet and does not actively exercise. She has not been sexually active due to her hospitalizations but otherwise, only has sex with her current husband. Family History: Mother passed away of lung cancer and was a heavy smoker. Her father is alive and well. There is no history of diverticulitis, diabetes, cancer or cardiac problems. Physical Exam: T 95 P 70 BP 100/60 R 20 SaO2 100% Gen - no acute distress Heent - no scleral icterus, tympanic membranes clear; fullness, warmth, and erythema along left sternocleidomastoid muscle Lungs - clear Heart - regular rate and rhythm Abd - soft, nontender, nondistended, bowel sounds audible; ostomy patent; purulent material draining from abdominal wound Extrem - no lower extremity edema Pertinent Results: [**2118-11-29**] 12:19AM BLOOD WBC-13.0* RBC-3.10* Hgb-8.7* Hct-25.7* MCV-83 MCH-28.2 MCHC-34.0 RDW-14.1 Plt Ct-363 [**2118-11-29**] 12:19AM BLOOD PT-32.6* PTT-54.6* INR(PT)-3.5* [**2118-11-29**] 12:19AM BLOOD Glucose-97 UreaN-22* Creat-1.1 Na-133 K-3.1* Cl-100 HCO3-23 AnGap-13 [**2118-11-29**] 12:19AM BLOOD ALT-9 AST-14 AlkPhos-302* Amylase-108* TotBili-0.2 [**2118-11-29**] 12:19AM BLOOD Lipase-16 [**2118-11-29**] 11:00 am ABSCESS RIGHT RETRO PERITONEAL . **FINAL REPORT [**2118-12-4**]** GRAM STAIN (Final [**2118-11-29**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. SMEAR REVIEWED; RESULTS CONFIRMED. WOUND CULTURE (Final [**2118-12-4**]): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for Pseudomonas aeruginosa, Staphylococcus aureus and beta streptococcus). WORK UP OF GRAMNEGATIVE RODS REQUESTED BY DR [**First Name (STitle) **] [**2118-12-2**]. ESCHERICHIA COLI. HEAVY GROWTH. Trimethoprim/Sulfa sensitivity testing available on request. ESCHERICHIA COLI. HEAVY GROWTH. SECOND STRAIN. Trimethoprim/Sulfa sensitivity testing available on request. ESCHERICHIA COLI. HEAVY GROWTH. THIRD STRAIN. Trimethoprim/Sulfa sensitivity testing available on request. ENTEROCOCCUS SP.. QUANTITATION NOT AVAILABLE. STAPH AUREUS COAG +. QUANTITATION NOT AVAILABLE. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. Please contact the Microbiology Laboratory ([**6-/2418**]) immediately if sensitivity to clindamycin is required on this patient's isolate. KLEBSIELLA PNEUMONIAE. SPARSE GROWTH. Trimethoprim/Sulfa sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | ESCHERICHIA COLI | | ESCHERICHIA COLI | | | ENTEROCOCCUS SP. | | | | STAPH | | | | | K | | | | | | AMPICILLIN------------ =>32 R =>32 R =>32 R <=2 S AMPICILLIN/SULBACTAM-- =>32 R =>32 R 16 I 4 S CEFAZOLIN------------- <=4 S <=4 S <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S <=1 S <=1 S CEFUROXIME------------ 8 S 16 I 4 S <=1 S CIPROFLOXACIN--------- =>4 R =>4 R =>4 R 1 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=1 S <=1 S <=1 S <=0.5 S <=1 S IMIPENEM-------------- <=1 S <=1 S <=1 S <=1 S LEVOFLOXACIN---------- =>8 R =>8 R =>8 R =>8 R 1 S MEROPENEM-------------<=0.25 S <=0.25 S <=0.25 S <=0.25 S OXACILLIN------------- =>4 R PENICILLIN------------ 8 S =>0.5 R PIPERACILLIN---------- =>128 R PIPERACILLIN/TAZO----- <=4 S <=4 S <=4 S <=4 S RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ <=1 S <=1 S <=1 S <=1 S VANCOMYCIN------------ <=1 S <=1 S ANAEROBIC CULTURE (Final [**2118-12-3**]): NO ANAEROBES ISOLATED. Brief Hospital Course: The patient presented to the ED and had an abdominal CT scan which showed a large right sided peritoneal fluid collection despite an appropriately placed drainage catheter. She presented with a clinical picture of sepsis as she was hypotensive with SBP in the 80s. She was transferred to the SICU for intensive monitoring and was started on broad spectrum antibiotics of Vancomycin and Zosyn. A levophed drip had to be started for the patient's hypotension. The patient had been on coumadin for a history of atrial fibrillation and came in with an INR of 3.5. The patient was given FFP to bring the INR down so that she could have CT guided drainaged of her abscess. 450cc was able to aspirated during the procedure and the loculations were broken up. The aspirated fluid was sent for cultures, which grew back E. coli and MRSA. ENT was consulted for the patient's neck pain which was diagnosed to be parotitis, This was treated with sialogues, hot compresses, aggressive parotid massage, and IV antibiotics. These measures were successful in treating her parotitis. The patient was transfused one unit of packed RBCs for a Hct of 22.6. The patient was able to be weaned off the Levophed drip and was stable enough to be transferred to the floor on hospital day 2. The patient's diet was able to be advanced and she was able to tolerate a regular diet. However, the patient continued to feel lethargic and nauseous and have a low level of activity. On hospital day 6, she vomited and she was made NPO. She continued to have good ostomy output and drainage from her abdominal drain at this point. Another CT scan was obtained to assess the abscess drainage which revealed near-complete resolution of right lower quadrant fluid collection with pigtail catheter in place. There was also decrease in size of posterior fistulous tract through the right flank muscles. Given these findings, the patient's nausea likely was not due to insufficient abscess drainage. The patient had another episode of nausea and vomiting on hospital day 10. Her diet was gradually advanced and the patient was able to tolerate a regular diet on discharge. Physical therapy was consulted to assist the patient with ambulation and she was able to ambulate independently. Coumadin was restarted and the patient's INR closely monitored. The patient had a PICC placed so that she could receive IV antibiotics after discharge. The [**Hospital 228**] hospital course was complicated by acute renal failure due to a high Vancomycin level. As her Vancomycin level trended down, her Cr trended down as well and was stable at on discharge. The patient had adequate urine output throughout her admission. She was discharged to home with services in stable condition. Medications on Admission: warfarin 1mg qHS Protonix 40mg qDay trazodone 100mg qHS citalopram 20mg qDay alprazolam 1mg TID prn Discharge Medications: 1. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 5. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*20 Capsule(s)* Refills:*0* 7. Reglan 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours. Disp:*120 Tablet(s)* Refills:*2* 8. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 3 days. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Abdominal abscess Discharge Condition: Stable Discharge Instructions: Call your doctor or seek immediate medical attention if you experience fever, chills, lightheadedness, dizziness, chest pain, shortness of breath, severe abdominal pain, nausea/vomiting, or bleeding, increased drainage, or redness from drain site. Activity as tolerated. Try to walk at least three times a day. You may resume your home medications. No driving while taking pain medications. No tub baths or swimming. Followup Instructions: Call [**Telephone/Fax (1) 1864**] to schedule an appointment with Dr. [**Last Name (STitle) **] in [**12-6**] weeks.

[ "V44.2", "E930.8", "584.9", "567.22", "038.9", "427.31", "V58.61", "527.2", "562.11", "276.51", "995.92" ]

icd9cm

[ [ [] ] ]

[ "99.04", "99.07", "54.91" ]

icd9pcs

[ [ [] ] ]

10739, 10810

7024, 9782

335, 377

10872, 10881

2644, 7001

11348, 11468

2052, 2220

9932, 10716

10831, 10851

9808, 9909

10905, 11325

2235, 2625

242, 297

405, 907

929, 1278

1294, 2036

41,441

149,099

43539

Discharge summary

report

Admission Date: [**2153-2-2**] Discharge Date: [**2153-2-5**] Date of Birth: [**2083-11-6**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 949**] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: Endoscopy with variceal banding x4 History of Present Illness: This is a 69 yo F w/ past medical history of autoimmune hepatitis, cirrhosis, known grade II varices who was admitted for hematemesis and was found to have a variceal bleed. She reports being in her usual state of health until the day prior to admission. She reports feeling bloated and nausead that evening with a sense of fullness. She became increasingly nauseated over the course of the night and at around 4am she went to the bathroom to vomit. As she was running to the bathroom she bumped into the door, hit her head and fell. She then vomited a large amount of bright red blood with dark clots. She called EMS and was sent to [**Hospital3 3765**]. There, she was found to have a Hct of 29.4. She also had a head laceration from hitting her head on the bathroom door which was cleaned and dressed. She received NS 2L IV as well as Zofran 4mg IV for nausea. A CT head was negative per report, though there is currently no documentation in her transfer paperwork. She was transferred to the [**Hospital1 18**] ED for further management. Of note, she takes low dose prednisone for AI hepatitis as well as a PPI. She has no history of GIB. . In the ED, her vital signs were T 98.2, BP 121/49, HR 62, 97% on room air. She was given pantoprazole 40 mg IV x1 and octreotide 100 mg IV x1. She was hemodynamically stable throughout her ED stay. Her HCT here was down to 26.9 after IVF. She was transferred to the MICU for further management. . In the MICU she was started on Octreotide 50 mcg/hr IV DRIP, Sucralfate 1 gm PO TID, and CeftriaXONE 1 g IV Q24H x3 days and continued on Pantoprazole 40 mg IV Q12H. She underwent EGD which found 4 cords of grade II varices in the middle third of the esophagus and lower third of the esophagus. The varices were not bleeding and all were banded. Her HCT remained stable overnight and she was transfered to the [**Doctor Last Name 3271**] [**First Name4 (NamePattern1) 679**] [**Last Name (NamePattern1) 4869**] for further management. . At this time, she denies any melena, BRBPR, diarrhea, abdominal pain or other symptoms, see below. She has not felt lightheaded since being at the OSH. She has no current complaints. Past Medical History: 1. Autoimmune hepatitis 2. Cirrhosis - 2 cords of grade II and 3 cords of grade I varices ([**10-30**]) 3. Hypertensive gastropathy 4. Connective tissue disorder 5. Fibrocystic disease 6. Asthma 7. Recurrent pericarditis 8. Arthritis Social History: Denies alcohol, tobacco or illicit drug use. She is a retired management consultant. Family History: Negative for underlying lung disease, CAD Physical Exam: Vitals: T: 98.3 BP: 118/65 P: 63 R:18 O2: 95% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, scalp w/staples in place from lac 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 Pertinent Results: Admission labs: [**2153-2-2**] 08:36AM BLOOD WBC-6.1# RBC-3.19* Hgb-9.2* Hct-26.9* MCV-84 MCH-28.8 MCHC-34.1 RDW-16.0* Plt Ct-107* [**2153-2-2**] 08:36AM BLOOD PT-15.9* PTT-27.8 INR(PT)-1.4* [**2153-2-2**] 08:36AM BLOOD Glucose-94 UreaN-35* Creat-0.6 Na-141 K-4.1 Cl-106 HCO3-30 AnGap-9 [**2153-2-2**] 08:36AM BLOOD ALT-59* AST-55* AlkPhos-135* Amylase-48 TotBili-0.6 [**2153-2-2**] 08:36AM BLOOD Albumin-3.6 . Discharge labs: [**2153-2-5**] 05:15AM BLOOD WBC-3.5* RBC-3.24* Hgb-9.3* Hct-27.3* MCV-85 MCH-28.8 MCHC-34.2 RDW-15.9* Plt Ct-83* [**2153-2-5**] 05:15AM BLOOD PT-15.3* PTT-27.5 INR(PT)-1.4* [**2153-2-5**] 05:15AM BLOOD Glucose-101 UreaN-11 Creat-0.5 Na-141 K-3.7 Cl-107 HCO3-27 AnGap-11 [**2153-2-4**] 05:05AM BLOOD ALT-39 AST-33 AlkPhos-109 TotBili-0.7 [**2153-2-5**] 05:15AM BLOOD Calcium-8.0* Phos-2.2* Mg-2.1 . EGD [**2153-2-2**]: Esophagus: Protruding Lesions 4 cords of grade II varices were seen in the middle third of the esophagus and lower third of the esophagus. The varices were not bleeding. 4 bands were successfully placed. Stomach: Contents: Small amount of clotted blood was seen in the stomach body. Mucosa: Patchy erythema of the mucosa was noted in the antrum and stomach body. These findings are compatible with mild gastritis. Duodenum: Normal duodenum. Impression: Varices at the middle third of the esophagus and lower third of the esophagus (ligation) Erythema in the antrum and stomach body compatible with mild gastritis Blood in the stomach body Otherwise normal EGD to second part of the duodenum Recommendations: No definitive source of bleeding found; bleeding presumed secondary to varices. Continue octreotide drip. Ceftriaxone 1 g qd . EGD [**2152-11-10**]: 2 cords of grade II and 3 cords of grade I varices were seen in the lower third of the esophagus. The varices were not bleeding. Erythema, congestion and mosaic appearance of the mucosa were noted in the whole stomach. These findings are compatible with portal hypertensive gastropathy. A probabale small non bleeding varix were seen in the cardia. . EKG: Sinus, rate of 63, normal axis and intervals, TWI in V1 and TWF in V2, no ischemic changes. No priors for comparison Brief Hospital Course: 69F with cirrhosis [**12-25**] AI hepatitis and known varices who presented with hematemesis and was found to have a variceal bleed. She is now s/p banding of 4 varices, IV PPI, octreotide drip, and 2U pRBCs with stabilization of her condition. HCT stable for >48 hrs so DCed home with repeat EGD in 3 weeks. . # Variceal bleed: Patient had known grade I and II varices as of EGD on [**2152-11-10**] and was on nadolol. Hct at that time was 34.7. Admission HCT was 26.9 and EGD showed 4 grade II varices, all of which were banded. HCT stabilized but pt initially had orthostatic hypotension. She was bolused with NS and BP improved. Discontinued Octreotide after 48hrs. Treated with Pantoprazole 40 mg IV Q12H. Will DC on PO PPI [**Hospital1 **]. Also given Sucralfate 1 gm PO TID this admission. Restarted Nadolol on [**2153-2-4**] once no longer bleeding. Will continue as an outpatient. Received ceftriaXONE 1 g IV Q24H x 3 days for PPx against infection in a GIB. Will DC on ciprofloxacin 250mg PO daily for SBP PPx as has had a variceal bleed for 4 more days. Scheduled to have repeat EGD in 4 weeks with Dr. [**Last Name (STitle) **]. . # AIH cirrhosis: Chronic issue. Continued home prednisone 5mg PO daily. . # Syncope: Appears to have been in the setting of nausea/vomiting and acute blood loss anemia. Patient had a negative CT of her head at the OSH, though no report on file. She was accompanied by images, however. No longer orthostatic s/p IVF. Will need staples removed from head on [**2153-2-8**] after 7 days. . # Asthma: Continued home tiotropium daily . # Insomnia: Continued trazodone, ativan at home doses. Medications on Admission: Asacol 800mg [**Hospital1 **] Ativan 0.5mg QHS Citracal + D TID Fioricet PRN Flaxseed oil 3 capsules TID Glucosamine 3 tabs daily Nadolol 20mg daily Omeprazole 40mg daily Prednisone 5mg daily Singulair 10mg daily Trazodone [**Age over 90 **]m QHS Vagifem 25mcg 2x week vaginally Valtrex 2000mg [**Hospital1 **] prn herpes outbreak Vitamin C 250mg daily Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 3. Trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 4. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*5* 6. Asacol 400 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 7. Citracal + D 315-200 mg-unit Tablet Sig: One (1) Tablet PO three times a day. 8. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day. 9. Vagifem 25 mcg Tablet Sig: One (1) tablet Vaginal once a week. 10. Vitamin C 250 mg Tablet Sig: One (1) Tablet PO once a day. 11. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Disp:*4 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Variceal bleed . Secondary: Autoimmune hepatitis Discharge Condition: Stable CBC, stable vital signs, at baseline Discharge Instructions: You were admitted for vomiting blood. You were found to have a variceal bleed, a complication of your chronic liver disease. We did an endoscopy and banded 4 varices. You also were transfused blood. Your bleeding stabilized. You will need a repeat endoscopy in [**1-24**] weeks to re-check your varices in your esophagus. . Please take your medications as ordered. We have made the following changes: * Take ciprofloxacin 250 mg by mouth daily X 4 more days. * Take omeprazole 40 mg twice per day. . Please attend your follow up appointments. . Please call your doctor or come to the emergency room if you experience bleeding, vomiting, ongoing nausea, passing out, extreme fatigue, confusion, chest pain, shortness of breath, palpitations, or other concerning symptoms. Followup Instructions: [**2153-2-21**] 09:30a [**Doctor Last Name **] [**Doctor Last Name **], EAST PROCEDURES [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **] ENDOSCOPY SUITES [**Telephone/Fax (1) 2422**] * Do not eat or drink after midnight prior to this appointment. . [**2153-3-13**] 08:45a [**Last Name (LF) **],[**First Name3 (LF) **] H [**Hospital Unit Name **], [**Location (un) **] LIVER CENTER (SB) [**Telephone/Fax (1) 2422**] Completed by:[**2153-6-20**]

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Discharge summary

report

Admission Date: [**2146-6-26**] Discharge Date: [**2146-7-10**] Date of Birth: [**2063-5-28**] Sex: F Service: MEDICINE Allergies: Codeine / Lasix / Diltiazem / Ativan Attending:[**First Name3 (LF) 3556**] Chief Complaint: respiratory failure Major Surgical or Invasive Procedure: ET intubation Arterial line Femoral line Bronchoscopy History of Present Illness: This is a 83 year old female with h/o asthma, COPD, HTN, diastolic dysfunction, and trachobronchomalacia s/p Y stent with recent admission for COPD and CHF exacerbations who initially presented from rehab on [**6-26**] with worsening SOB and respiratory failure. Noted to be more SOB that evening at rehab and transferred to [**Hospital 882**] Hospital where SBP 189/53, HR 110, O2 sat 99-100% on NRB. Started on nitro gtt, R femoral line placed, and intubated for ABG of 7.17/92/86. Labs notable for WBC 17.0 (67.2N, 0B), Hct 27.9, BNP 1555, Cr 1.7, CK 31, tropI 0.06 (nl < 0.10). EKG with J point elevation in V1-2 that was initially concerning for STEMI. Transferred to [**Hospital1 18**]. . In the ED, Tm 99.2, BP initially 178/78 which improved after 1 inch nitropaste and uptitrating nitro gtt, O2 sat 100% on AC vent. Given ASA 325 mg X 1, cardiology called to review EKGs who thought EKGs were unremarkable for ACS. Admitted to MICU for further management after receiving solumedrol 125 mg IV X 1. Past Medical History: 1. Asthma/COPD - Recently admitted for a flare on [**2146-3-29**] and treated with nebulizers, steroids, and a course of azithromycin. Last seen by Dr. [**Last Name (STitle) 1632**] in Pulmonology in [**Month (only) 547**], when he thought she was deconditioned from her time in the hospital although adequately medicated. Recommended a Cardiology consult at this time for what he believed to be significant diastolic dysfunction secondary to long-standing hypertension. 2. Paralyzed left hemidiaphragm s/p pericardial window procedure, performed per old cardiology notes for recurrent pericardial effusions. Pericardial biopsy c/w inflammation with no evidence of malignancy. [**Doctor First Name **] 1:40, dsDNA and RF negative. 3. Severe hypertension with diastolic dysfunction - Per PCP notes typically controlled in the 160's unless patient experiences an asthma flare when it shoots to 170's-180's. Notably systolic pressures were in the 130's during her last hospital admission, presumably the reason why her HCTZ and enalapril doses were halved. Patient is poorly compliant and most recently has not been taking her antihypertensives due to her ill son-in-law, unable to pick up her meds from the pharmacy. 4. Hyperlipidemia 5. Chronic renal insufficiency (creatinine around 1.4). 6. Polymyalgia rheumatica. 7. Osteoporosis. 8. Trigeminal neuralgia - reportedly seen by Optometry [**2146-4-26**] and referred to Dr. [**Last Name (STitle) **] of [**Last Name (STitle) 878**]. 9. Iron-deficient anemia 10. Gastritis Social History: Ms. [**Known lastname 12129**] is a widow of many years and a mother of three. She lives in the bottom unit of a shared home with her daughter and son-in-law, who provide her with a large amount of care and support. Although Ms. B is able to complete most of her ADL's, she relies on her daughter for shopping and cooking. While she doesn't specifically say it, her increasing dependence on her children has taken a bit of its toll on her. This may be partially responsible for her decreased med compliance - the patient relies on others to go to CVS to pick up her meds. Her daughter had the flu prior to Ms. [**Known lastname 12129**]' hospitalization, and because of this, she was unable to pick up her medications on time. Additionally, it sounds as if the patient doesn't leave her house very often. She comments on how she doesn't like to walk outside or to sit on her porch. Ms. [**Known lastname 12129**] would rather watch television, socializing with friends infrequently. Family History: Diabetes mellitus in siblings and children. No bleeding or clotting disorders. Mom with ?MI Physical Exam: VS: Tm 99.4 HR77-104 BP111-160/36-61 RR18-20 O2: 93-99% 2L NC 24 hr Is/Os: 683/915 8hr Is/Os 260/474 [**Location 10226**]3.7L GEN: elderly female HEENT: EOMI, PERRL, sclera anicteric NECK: Supple, JVD approximately 12 cm above sternal notch CV: distant heart sounds, reg rate, normal S1, S2. No m/r/g. CHEST: Resp were unlabored, no accessory muscle use while on vent. fair air mvmt b/l with faint expiratory wheezing and diffuse rhonchorous sounds ABD: Soft, NT, obese, no HSM or other palpable masses EXT: [**2-6**]+ pitting edema bilaterally over LEs, WWP SKIN: No rash Pertinent Results: INITIAL ADMISSION: [**2146-6-26**] 10:33PM TYPE-ART PO2-345* PCO2-58* PH-7.35 TOTAL CO2-33* BASE XS-4 INTUBATED-INTUBATED [**2146-6-26**] 09:27PM K+-5.6* [**2146-6-26**] 09:08PM CK(CPK)-45 [**2146-6-26**] 09:08PM cTropnT-0.12* [**2146-6-26**] 09:08PM CK-MB-NotDone proBNP-[**Numeric Identifier 17378**]* [**2146-6-26**] 09:08PM CALCIUM-9.4 PHOSPHATE-4.1 MAGNESIUM-2.2 [**2146-6-26**] 09:08PM URINE HOURS-RANDOM [**2146-6-26**] 09:08PM URINE GR HOLD-HOLD [**2146-6-26**] 09:08PM WBC-14.6*# RBC-2.81* HGB-8.2* HCT-26.2* MCV-94 MCH-29.4 MCHC-31.4 RDW-15.0 [**2146-6-26**] 09:08PM NEUTS-91.4* LYMPHS-4.9* MONOS-3.5 EOS-0.1 BASOS-0.1 [**2146-6-26**] 09:08PM PLT COUNT-386 [**2146-6-26**] 09:08PM PT-12.4 PTT-23.0 INR(PT)-1.0 [**2146-6-26**] 09:08PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011 [**2146-6-26**] 09:08PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2146-6-26**] 09:08PM URINE RBC-0-2 WBC-[**3-9**] BACTERIA-FEW YEAST-NONE EPI-[**3-9**] SECOND MICU ADMISSION ([**Date range (1) 17379**]): BLOOD: [**2146-7-4**] 08:52AM BLOOD WBC-10.4 RBC-2.55* Hgb-7.4* Hct-23.2* MCV-91 MCH-29.0 MCHC-31.8 RDW-14.7 Plt Ct-342 [**2146-7-5**] 03:38AM BLOOD WBC-6.9 RBC-2.35* Hgb-7.0* Hct-21.0* MCV-90 MCH-29.9 MCHC-33.5 RDW-15.2 Plt Ct-271 [**2146-7-6**] 03:54AM BLOOD WBC-7.3 RBC-2.43* Hgb-7.3* Hct-21.1* MCV-87 MCH-30.0 MCHC-34.4 RDW-14.9 Plt Ct-198 [**2146-7-7**] 01:24AM BLOOD WBC-8.7 RBC-2.85* Hgb-8.6* Hct-24.5* MCV-86 MCH-30.2 MCHC-35.1* RDW-15.4 Plt Ct-186 [**2146-7-8**] 02:44AM BLOOD WBC-11.2* RBC-3.09* Hgb-9.1* Hct-26.8* MCV-86 MCH-29.5 MCHC-34.2 RDW-15.8* Plt Ct-262 [**2146-7-9**] 02:12AM BLOOD WBC-16.0* RBC-3.46* Hgb-10.0* Hct-29.8* MCV-86 MCH-29.0 MCHC-33.8 RDW-14.6 Plt Ct-319 [**2146-7-9**] 10:35AM BLOOD WBC-12.7* RBC-3.05* Hgb-9.2* Hct-26.7* MCV-88 MCH-30.0 MCHC-34.3 RDW-15.7* Plt Ct-261 [**2146-7-10**] 03:30AM BLOOD WBC-10.0 RBC-3.11* Hgb-9.0* Hct-27.7* MCV-89 MCH-29.0 MCHC-32.6 RDW-15.5 Plt Ct-269 MICRO: Blood Culture, Routine (Final [**2146-7-10**]): NO GROWTH. URINE CULTURE (Final [**2146-7-5**]): GRAM NEGATIVE ROD(S). ~9000/ML. URINE CULTURE (Final [**2146-7-9**]): NO GROWTH. GRAM STAIN (Final [**2146-7-4**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2146-7-6**]): 10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA. _ _ _ ________________________________________________________________ IMAGING: CT pelvis 6/23/08:1) No retroperitoneal hematoma or fluid in the pelvis. Soft tissue anasarca. 2) Soft tissue density nodules along anterior abdominal wall, probably injection sites. CXR [**7-1**]: An ET tube and NG tube have been removed. A bronchial stent is identified. Right- sided PICC line tip terminates in the mid SVC. Enlargement of the cardiac silhouette persists. There is mild leftward mediastinal shift, persistent elevation of the left hemidiaphragm, and retrocardiac opacity likely representing atelectasis. Consolidation cannot be excluded. Small right- sided pleural effusion and basilar atelectasis are unchanged. Upper extremity U/S [**7-2**]: No evidence of DVT in the right upper extremity. Limited evaluation of the peripheral segment of the right brachial vein due to overlying bandage. ECHO [**2146-7-4**]: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is severe global left ventricular hypokinesis (LVEF = 20 %). No masses or thrombi are seen in the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size is normal. with severe global free wall hypokinesis. 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. There is borderline pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with severe global biventricular hypokinesis c/w diffuse process. Mild mitral regurgitation. Borderline pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [**2146-2-7**], biventricular systolic function is new. CT Abdomen/Pelvis [**2146-7-6**]: 1. Interval development of moderate amount of pelvic free simple fluid. 2. No evidence of retroperitoneal hematoma. 3. Multiple renal cysts, some of which are simple and others which are hyperdense, as described above. These need follow up with US or MR in 6 months. 4. Aortic and vascular calcifications with focal displacement of aortic calcifications just above the aortic bifurcation which could represent calcified mural thrombus or intramural hematoma, unchanged. 5. Pneumopericardium. 6. Small right pleural effusion. ECHO [**2146-7-9**]: The left atrium is dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is moderate to severe global left ventricular hypokinesis (LVEF = 30 %). There is no ventricular septal defect. Right ventricular chamber size is normal. with borderline normal free wall function. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2146-7-4**], the left ventricular ejection fraction is increased. Brief Hospital Course: OVERALL SUMMARY: 83 yo F with h/o COPD, asthma, HTN, diastolic CHF with recent admission for respiratory failure thought to be [**2-5**] COPD and CHF exacerbation who presented from rehab with SOB and respiratory failure requiring intubation and MICU admission. Initially extubated and weaned down to 2L NC. On day of planned discharge ([**2146-7-4**]) she had a PEA arrest. She was resuscitated with chest compressions and epinephrine, reintubated, and transferred back to the MICU. She was briefly hypotensive with intubation, but became hypertensive to the 170s-180s later during her hospital course which was managed with multiple oral and IV medications including nicardipine, labetalol (PO and IV), clonidine patch, nitro drip. She was extubated on [**7-7**] and continued to complained of significant anxiety, chest pain [**2-5**] compressions, and difficulty coughing up secretions. She had persistent respitatory difficulty requiring high flow mask on [**7-8**] and [**7-9**]. When initially admitted her code status was full. After family meeting on [**7-8**] she was switched to DNR/DNI. During the night of [**7-9**] she had an episode of bradycardia to the 30s, which resolved spontaneously. On the morning of [**7-10**], she was agitated and called for decreasing O2 saturation and increasing bradycardia. Nasal airway was placed and supplemental O2 was given but these did not increase O2 sats. Her O2 sat and heart rate continued to drop and she became bradycardic. The bradycardia transitioned to asystole, and she expired at 8:45am on [**2146-7-10**]. . Respiratory failure: Initial respiratory failure at presentation most likely [**2-5**] COPD/asthma exacerbation and worsening of underlying diastolic CHF, especially as BPs elevated. Required intubation from [**6-27**] to [**6-28**]. Was treated for asthma/COPD/CHF exacerbation, extubated, and transferred to the floor. However on [**2146-7-4**] she had a PEA arrest likely [**2-5**] hypercarbic respiratory failure (ABG showed pH of ~7) and was resusciated, re-intubated and transferred back to the MICU. In the MICU she had persistent difficulty passing SBTs; a trial on [**7-6**] showed that she had small tidal volumes and extubation was delayed. On [**7-7**] she had a RISB of 67 and passed a SBT. She was extubated without difficulty. Post-extubation she complained of significant R chest pain which was treated with a lidocaine patch and fentanyl. She also complained of respiratory secretions which she had difficulty coughing up; she was treated with guaifenicin. She did well on a shovel mask most of the day [**7-7**] but in the evening desatted to the high 80s and was placed on a high flow mask with FiO2 of 40%. On [**7-8**] she complained of persistent difficulty coughing up secretions and also complained of significant anxiety. Respiratory difficulty continued through [**7-9**], though her O2 sats were generally in the 90s throughout this period. On [**7-10**] AM, her O2 sat dropped over the course of 15 minutes before she expired as per above. COPD/Asthma: She was treated for COPD/asthma exacerbation throughout her hospital course (beginning on [**6-27**]) with a slow steroid taper. Her nebs, fluticasone, and cromolyn were continued during hospitalization. She had no other evidence of acute COPD exacerbation during her hospital course. . HTN: She had a very labile BP in the setting of discontinuation of ACE-I due to ARF, hyperkalemia. Was controlled with increased dose of PO nicardipine and prn hydralazine, stabilized HD 3 on nifedipine 60mg q8h. At the time of re-intubation on [**7-4**] was briefly hypotensive, and her clonidine patch was discontinued, but then blood pressure continued to rise and she became hypertensive to the 170s-180s systolic. She was put back on her home clonidine patch as well as a nitro drip and nicardipine. Her blood pressures continued to spike intermittently to the 180s+ and a labetalol drip was started. She continued to exhibit intermittent episodes of hypertension and nitro and labetalol drips were needed intermittently, though the overall goal was to decrease the nitro drip as much as possible. Her ACEI was not able to be restarted as her creatinine was persistently above the baseline (her baseline is 1.6-2 and she ranged from 2.2-2.6 during second MICU admission). Her HTN had a significant anxiety component and she was given morpine once as well as ativan 0.5mg IV on 2 occasions to decrease anxiety. This did appear to help as when her anxiety was better controlled her BPs were also better controlled, but in general she was extremely labile. . Cardiac: 1) CAD: Innitially she had EKG changes concerning for NSTEMI. Cardiology reviewed EKGs and felt she was not having ACS. Cardiac enzymes were stable from [**Date range (1) 7154**]. It was thought that EKG changes were likely due to LVH and J point elevation. Slightly increased troponin and CK post chest compressions on [**7-4**] later trended downwards on [**7-5**] and she was ruled out for MI. ASA and statin were continued throughout hospital course. 2) Pump: Known diastolic CHF, last baseline TTE in [**2-11**] revealed LVEF > 55%, PCWP > 18mmHg. Admitted and diuresed in MICU. After PEA, an echo showed a LVEF ~20% likely [**2-5**] the PEA. She was given lasix initially with the goal to keep a negative fluid balance. When she no longer showed clinical evidence of volume overload, lasix was used to keep fluid balance even. A repeat echo on [**7-9**] showed an LVEF of ~30% with global LV hypokinesis and significant pulmonic regurgitation. Her persistent low EF after PEA arrest is indicative that cardiac failure was likely one of the primary reasons for her death. 3) Rate: Remained in NSR. Slightly tachycardic as well as bradycardic at different points. Episode of bradycardia to the 30s on the night of [**7-9**], spontaneously resolved. Bradycardia starting the morning of [**7-10**] persisted until time of death. . Trachobronchomalacia s/p Y stent placement on [**6-18**]. ETT tube was placed b/w stent and trachea, causing dyspnea / wheezes. Interventional pulmonary consulted after re-intubation on [**7-4**] and felt that the stent should be left in place until she was more stable. . Acute on chronic renal failure Baseline Cr 1.6 - 1.9, was slightly elevated at initial [**6-27**] admission and at time of second MICU admission [**7-4**]. On [**7-5**] - [**7-6**] Cr continued to be elevated at 2.2. [**Date range (1) 1164**] Cr was elevated to 2.3. On [**7-9**] and [**7-10**] Cr was increasingly elevated at 2.6. Her ACEI was held at admission and was not restarted during her hospital course. Anemia Has baseline iron deficiency of anemia and anemia of chronic disease. Hct was in mid 20s until [**7-5**], when it was 21 in the AM and 20.1 in the PM. She was transfused 1 unit of PRBC. Repeat Hct post-transfusion was 22.2. Hct morning of [**7-6**] was 21.1; repeat Hct in the PM was 20.9. She was transfused another 1 unit of PRBC. A CT of the abdomen showed moderate free fluid in the dependent pelvis but no retroperitoneal hematoma. Guaiacs were negative and labs showed no evidence of hemolysis. Hematocrit stabilized and rose to around 25-26 during the rest of her hospital stay. FEN/GI NGT was placed, lytes were repleted PRN. Patient complained of abdominal pain on [**7-5**] which resolved by [**7-6**], though still complained of gas pains. Was given simethicone and pains resolved. Tube feeds were started on [**7-8**]. Osteoporosis: Home Calcium, vitamin D, and bisphosphonates were continued Access: Femoral line was placed during the code [**7-4**] and removed on [**7-5**]. PICC line was placed on [**7-5**]. R Aline was placed on [**7-4**]. PPX: Heparin SC/pneumoboots, colace, PPI, insulin SS Code: FULL starting at initial admission; changed to DNR/DNI after family meeting on [**7-8**]. Medications on Admission: 1. Atorvastatin 10 mg qd 2. Nifedipine 180 qd 3. Cholecalciferol 800mg qd 4. Calcium Carbonate 500 mg tid 5. Docusate Sodium 100 mg [**Hospital1 **] 6. Detrol LA 2 mg q24 7. Aspirin 325 mg qd 8. Carbamazepine 100 mg [**Hospital1 **] 9. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMONDAY: with 0.3mg patch for 0.4mg total. 10. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMONDAY: with 0.1mg patch for 0.4mg total. 11. Alendronate 70 mg qthurs 12. Cromolyn 800 mcg/Actuation 2 puffs q6 13. Ferrous Sulfate 325 mg qd 14. Omeprazole 20 mg [**Hospital1 **] 15. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID 16. Sodium Chloride 0.65 % aerosol 17. Fexofenadine 60 mg [**Hospital1 **] 18. Guaifenesin 1200mg [**Hospital1 **] 19. Acetaminophen 650mg q6 20. Lidocaine HCl 1 % (10 mg/mL) nebs prn 21. Budesonide 0.25 mg/2 mL 1 neb q6 22. Albuterol Sulfate 2.5 mg q6hrs 23. Ipratropium Bromide 0.02 q6hrs 24. Albuterol Sulfate 2.5 mg q2hrs prn 25. Bisacodyl 10 mg qd 26. Prednisone 5 mg Tablet Sig: TAPER Tablet PO once a day: 20mg daily for 3 more days, then 15mg daily for 5 days, then 10mg daily ongoing until pulmonary appointment with Dr. [**Last Name (STitle) 575**] on [**2146-7-14**]. 27. Enalapril Maleate 20 qd 28. Debrox 6.5 % [**Hospital1 **] Discharge Medications: NONE Discharge Disposition: Expired Discharge Diagnosis: Chronic obstructive pulmonary disease complicated by hypercarbic respiratory failure and PEA arrest. Congestive heart failure Hypertension Discharge Condition: Expired Discharge Instructions: This patient expired at 8;45 am on [**2146-7-10**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**] Completed by:[**2146-7-15**]

[ "428.33", "403.00", "585.9", "584.9", "518.81", "493.22", "428.0", "285.9", "725" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.72", "38.93", "33.23", "96.04" ]

icd9pcs

[ [ [] ] ]

20016, 20025

10674, 18631

317, 372

20207, 20217

4695, 10651

3994, 4087

19987, 19993

20046, 20186

18657, 19964

20241, 20453

4102, 4676

258, 279

400, 1408

1430, 2978

2994, 3978

43,774

105,720

37202

Discharge summary

report

Admission Date: [**2146-1-1**] Discharge Date: [**2146-1-19**] Date of Birth: [**2094-7-30**] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 11415**] Chief Complaint: s/p pedestrian vs. car with resultant polytrauma Major Surgical or Invasive Procedure: [**2146-1-1**]: 1. Irrigation and debridement of soft tissue, muscle including bone of the right distal tibia open fracture. 2. Application of multiplanar external fixator to the right lower extremity. [**2146-1-5**]: 1. Inferior vena caval filter placed by the right femoral route. [**2146-1-5**]: 1. Open reduction, internal fixation left supracondylar femur fracture. [**2146-1-12**]: 1) Irrigation and debridement open right tibia fracture 2) adjustment of external fixator with the addition of calcaneal tibial pins and 3) closed reduction of the distal tibia fracture and distal fibular fracture with traction and manipulation. History of Present Illness: Mr. [**Known lastname 15273**] is a 51 year old gentleman who was struck by a car while intoxicated. There was no LOC. He was transferred from an OSH for further management of his injuries, which influded a comminuted left femur fracture, an open right ankle fracture, and right lateral 2nd and 3rd rib fractures. Past Medical History: none Social History: homeless smokes cigarettes drinks ~12 beers a day, long history of alcohol abuse Family History: not applicable Physical Exam: Upon Admission: General Evaluation Exam BP: 120/73 HR: 93 RR:14 Temp:97.3 Sensorium: Awake () Awake impaired (x) Unconscious () Airway: Intubated () Not intubated (x) Breathing: Stable () Unstable (x) Circulation: Stable (x) Unstable () Musculoskeletal Exam Neck Normal () Abnormal () Comments: in C-collar Spine Normal (x) Abnormal () Comments: Clavicle R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Shoulder R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Arm R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Elbow R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Forearm R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Wrist R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Hand R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Pelvis R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Hip R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Thigh R Normal (x) Abnormal () Comments: L Normal () Abnormal (x) Comments: swelling distal femur Knee R Normal () Abnormal (x) Comments: L Normal () Abnormal (x) Comments:swelling/deformity Leg R Normal () Abnormal (x) Comments: L Normal () Abnormal (x) Comments: Grade IIIa open fx Ankle R Normal () Abnormal (x) Comments: open distal tib/fib L Normal (x) Abnormal () Comments: Foot R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Urethral Bleeding Yes () No (x) Vascular: Radial R Palpable (x) Non-palpable () Doppler () L Palpable (x) Non-palpable () Doppler () DP R Palpable () Non-palpable () Doppler (x) L Palpable () Non-palpable () Doppler (x) PT R Palpable (x) Non-palpable () Doppler () L Palpable (x) Non-palpable () Doppler () Neuro: (not following commands) Ant Tib R (weakly fires) L () [**Last Name (un) 938**] R (-) L (-) Peroneal R (-) L (-) GS R (-) L (-) On discharge: AVSS NAD, A&O x3 CV: RRR PULM: CTAB ABD: soft, nt/nd RLE: exfix in place, pin sites c/d/i, brisk capillary refill, sensation intact to light touch, motor intact - moving all toes LLE: knee immobilizer in place, incision c/d/i, brisk capillary refill, sensation intact to light touch, [**6-1**] [**Last Name (un) 938**]/GS/TA Pertinent Results: [**2146-1-1**] 12:55AM BLOOD WBC-11.6* RBC-3.78* Hgb-11.8* Hct-35.9* MCV-95 MCH-31.3 MCHC-33.0 RDW-14.7 Plt Ct-223 [**2146-1-1**] 04:17AM BLOOD WBC-8.9 RBC-3.71* Hgb-11.5* Hct-35.1* MCV-95 MCH-31.0 MCHC-32.8 RDW-14.6 Plt Ct-204 [**2146-1-2**] 08:15AM BLOOD WBC-10.1 RBC-3.12* Hgb-9.6* Hct-28.8* MCV-92 MCH-30.7 MCHC-33.3 RDW-14.6 Plt Ct-156 [**2146-1-3**] 04:50AM BLOOD WBC-9.3 RBC-2.79* Hgb-8.7* Hct-26.0* MCV-93 MCH-31.3 MCHC-33.7 RDW-14.7 Plt Ct-152 [**2146-1-4**] 04:13AM BLOOD WBC-6.6 RBC-2.24* Hgb-7.0* Hct-21.3* MCV-95 MCH-31.4 MCHC-33.0 RDW-14.1 Plt Ct-153 [**2146-1-4**] 11:04AM BLOOD WBC-8.3 RBC-2.74* Hgb-8.4* Hct-25.5* MCV-93 MCH-30.8 MCHC-33.0 RDW-15.4 Plt Ct-164 [**2146-1-4**] 06:45PM BLOOD WBC-8.7 RBC-3.23* Hgb-9.8* Hct-29.5* MCV-92 MCH-30.3 MCHC-33.1 RDW-16.2* Plt Ct-141* [**2146-1-4**] 08:17PM BLOOD WBC-7.5 RBC-3.26* Hgb-9.7* Hct-29.8* MCV-91 MCH-29.9 MCHC-32.8 RDW-16.3* Plt Ct-154 [**2146-1-5**] 02:17AM BLOOD WBC-8.7 RBC-3.20* Hgb-9.9* Hct-28.7* MCV-90 MCH-31.0 MCHC-34.6 RDW-15.9* Plt Ct-169 [**2146-1-5**] 08:16PM BLOOD Hct-26.8* [**2146-1-8**] 01:03AM BLOOD WBC-8.0 RBC-2.83* Hgb-8.7* Hct-25.8* MCV-91 MCH-30.6 MCHC-33.6 RDW-15.1 Plt Ct-226 [**2146-1-8**] 05:00AM BLOOD WBC-8.1 RBC-2.92* Hgb-8.9* Hct-26.6* MCV-91 MCH-30.4 MCHC-33.3 RDW-15.0 Plt Ct-259 [**2146-1-9**] 02:41AM BLOOD WBC-7.8 RBC-2.87* Hgb-8.7* Hct-25.4* MCV-89 MCH-30.4 MCHC-34.3 RDW-14.9 Plt Ct-307 [**2146-1-10**] 01:53AM BLOOD WBC-7.1 RBC-2.95* Hgb-9.0* Hct-27.0* MCV-91 MCH-30.4 MCHC-33.3 RDW-15.0 Plt Ct-327 [**2146-1-11**] 01:50AM BLOOD WBC-8.6 RBC-3.05* Hgb-9.1* Hct-27.7* MCV-91 MCH-30.0 MCHC-33.0 RDW-15.0 Plt Ct-390 [**2146-1-12**] 10:58AM BLOOD WBC-12.3* RBC-3.31* Hgb-9.7* Hct-30.2* MCV-91 MCH-29.5 MCHC-32.3 RDW-15.0 Plt Ct-455* [**2146-1-13**] 02:30AM BLOOD WBC-9.6 RBC-2.92* Hgb-8.8* Hct-27.2* MCV-93 MCH-30.2 MCHC-32.5 RDW-15.1 Plt Ct-433 [**2146-1-13**] 08:13AM BLOOD Hct-29.1* [**2146-1-14**] 06:40AM BLOOD WBC-8.5 RBC-3.17* Hgb-9.5* Hct-28.6* MCV-90 MCH-29.9 MCHC-33.2 RDW-14.9 Plt Ct-454* [**2146-1-15**] 06:45AM BLOOD WBC-9.2 RBC-3.23* Hgb-9.8* Hct-29.2* MCV-91 MCH-30.3 MCHC-33.4 RDW-14.4 Plt Ct-511* [**2146-1-17**] 03:44AM BLOOD WBC-12.1* RBC-3.31* Hgb-9.8* Hct-29.8* MCV-90 MCH-29.5 MCHC-32.8 RDW-14.7 Plt Ct-504* [**2146-1-18**] 04:31AM BLOOD WBC-6.7 RBC-3.47* Hgb-10.1* Hct-30.6* MCV-88 MCH-29.1 MCHC-32.9 RDW-14.5 Plt Ct-474* [**2146-1-1**] 12:55AM BLOOD PT-13.3 PTT-24.2 INR(PT)-1.1 [**2146-1-2**] 08:15AM BLOOD PT-12.8 PTT-27.1 INR(PT)-1.1 [**2146-1-5**] 02:17AM BLOOD PT-12.0 PTT-26.5 INR(PT)-1.0 [**2146-1-1**] 04:17AM BLOOD Glucose-120* UreaN-11 Creat-0.6 Na-138 K-4.3 Cl-104 HCO3-26 AnGap-12 [**2146-1-2**] 08:15AM BLOOD Glucose-120* UreaN-10 Creat-0.8 Na-136 K-4.2 Cl-100 HCO3-28 AnGap-12 [**2146-1-3**] 04:50AM BLOOD Glucose-124* UreaN-9 Creat-0.7 Na-138 K-3.8 Cl-102 HCO3-28 AnGap-12 [**2146-1-4**] 04:13AM BLOOD Glucose-83 UreaN-13 Creat-0.6 Na-137 K-5.1 Cl-105 HCO3-28 AnGap-9 [**2146-1-5**] 02:17AM BLOOD Glucose-104 UreaN-9 Creat-0.7 Na-141 K-3.8 Cl-108 HCO3-27 AnGap-10 [**2146-1-6**] 01:55AM BLOOD Glucose-121* UreaN-9 Creat-0.6 Na-141 K-4.0 Cl-108 HCO3-28 AnGap-9 [**2146-1-8**] 05:00AM BLOOD Glucose-120* UreaN-9 Creat-0.5 Na-138 K-3.9 Cl-103 HCO3-28 AnGap-11 [**2146-1-10**] 01:53AM BLOOD Glucose-119* UreaN-13 Creat-0.6 Na-142 K-3.9 Cl-107 HCO3-26 AnGap-13 [**2146-1-12**] 10:58AM BLOOD Glucose-125* UreaN-16 Creat-0.8 Na-143 K-4.4 Cl-109* HCO3-25 AnGap-13 [**2146-1-17**] 03:44AM BLOOD Glucose-105 UreaN-14 Creat-0.8 Na-138 K-4.2 Cl-105 HCO3-23 AnGap-14 [**2146-1-18**] 04:31AM BLOOD Glucose-111* UreaN-10 Creat-0.7 Na-141 K-4.1 Cl-109* HCO3-24 AnGap-12 [**2146-1-1**] 04:17AM BLOOD ALT-55* AST-70* AlkPhos-78 Amylase-141* TotBili-0.1 [**2146-1-2**] 07:11PM BLOOD CK(CPK)-569* [**2146-1-3**] 04:50AM BLOOD ALT-25 AST-46* AlkPhos-60 Amylase-27 TotBili-1.0 [**2146-1-1**] 12:55AM BLOOD Lipase-427* [**2146-1-1**] 04:17AM BLOOD Lipase-177* [**2146-1-2**] 08:15AM BLOOD Lipase-17 [**2146-1-3**] 04:50AM BLOOD Lipase-15 [**2146-1-1**] 04:17AM BLOOD Calcium-7.8* Phos-3.8 Mg-1.8 [**2146-1-5**] 02:17AM BLOOD Calcium-8.2* Phos-3.5 Mg-2.0 [**2146-1-5**] 10:00PM BLOOD Calcium-7.6* Phos-3.4 Mg-1.7 [**2146-1-9**] 02:41AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.1 [**2146-1-10**] 01:53AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.1 [**2146-1-10**] 01:53AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.1 [**2146-1-11**] 01:50AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.1 [**2146-1-12**] 10:58AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.1 [**2146-1-17**] 03:44AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.0 [**2146-1-18**] 04:31AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.4 [**2146-1-9**] 02:41AM BLOOD T4-6.2 [**2146-1-9**] 02:41AM BLOOD TSH-4.0 [**2146-1-1**] 12:55AM BLOOD ASA-NEG Ethanol-275* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2146-1-1**] CT torso: IMPRESSION: 1. Rib fractures, appearing both chronic and with acute rib fractures seen at the second and third ribs on the right as well as in the twelfth rib. There is no pneumothorax. 2. Bilateral spondylolysis, without spondylolisthesis at L5. 3. Bilateral dependent atelectasis as well as a poorly marginated opacity in the right upper lobe. Considerations for the latter finding include nodule or, less likely aspiration. Followup is recommended to document resolution/progression when clinically stable. [**2146-1-1**] CT RLE: IMPRESSION: 1. Comminuted displaced left distal femur fracture without intra-articular extension. 2. Segond fracture concerning for anterior cruciate ligament injury. 3. Fracture through the fibular head which may signify posterolateral corner injury. Further evaluation can be performed with MRI if indicated. [**2146-1-1**] Left tib/fib xray: IMPRESSION: Comminuted fractures of the distal tibia and fibula Brief Hospital Course: The patient arrived in the [**Hospital1 18**] ED on [**2146-1-1**]. On primary and secondary survey, the patient was intoxicated but was otherwise hemodynamically stable and following commands with a GCS of 15. Imaging studies ultimately revealed the following injuries: Comminuted L femur fx Open right ankle fx / near amputation R lateral 2nd and 3rd rib fxs The patient's admission labs also revealed pancreatitis with a lipase of 427 and an alcohol level greater than 400. The patient was admitted to the trauma service. The orthopedic team was consulted and the patient was brought to the OR [**2146-1-1**] for washout and ex fix placement of the R ankle. He was started on lovenox. Ortho intended to take the patient back to the OR for ORIF of his R tib/fib fractures. However, on POD1, the patient was noted to have fevers and tachycardia. He was also diaphoretic, agitated and disoriented. He was put on CIWA protocol for alcohol withdrawal and later transferred to the ICU on because he was developing delirium tremens. While in the ICU, the patient required large amounts of valium. He was also receiving haldol and dilaudid with little effect. An NGT was used to decompress his stomach and reduce the risk of aspiration. Because of his worsening progression and increased somnolence, he was later intubated by the SICU team [**2146-1-3**]. He was noted to have a Hct of 21 and was therefore received 4 units of pRBCs. On [**2146-1-5**], the patient was again brought to the OR for ORIF of his left femur fracture. At the same time, an IVC filter was placed by the trauma surgery service. Post-op, the patient was left intubated and transferred back to the SICU. He was noted to have fevers overnight and was therefore pancultured and started on broad-spectrum antibiotics. His sputum eventually grew out GNRs. His antibiotics were adjusted appropriately. The patient was eventually started on tube feeds. His vent was weaned and he was extubated [**2146-1-8**]. He continued to have altered mental status, delirium and agitation, which was controlled with Zyprexa. He was seen by physical therapy, who recommended discharge to rehab. On [**2146-1-12**], ortho again took the patient to the OR for washout of the right ankle, adjustment of the ex fix, and closed reduction of the tib fib fractures. He was intubated a few hours prior to the OR for increased agitation. It was determined to keep the patient intubated post-op and obtain a head CT to assess for any potential etiology of his prolonged agitation and delirium. This was ultimately negative. The patient was then extubated and transferred to the floor. After this, the patient's mental status was noted to improve markedly. He was then transferred to the orthopedics service for continued management. On [**1-16**], he was confused and agitated for most of the day. He received many doses of haldol, zyprexa, valium with no avail. He tried to get OOB many times and despite mutiple restraints, he fell onto his left side suffering a small left eyebrow abrasion. Xrays were taken of his left femur. The hardware was intact, with slighly more displacement compared to the fluoroscopic images taken in the OR. He was transferred back to the SICU for more close supervision an medical management of his agitation/delirium. He became stable and oriented thereafter. In the AM of [**1-18**] he was alert and oriented to person, time, and place. All antibiotics and IV medications were stopped prior to discharge. He is being discharged to [**Hospital1 **] today in stable condition, with a knee immoblizer on his left leg and an ex-fix to the right. His staples from his left leg were removed just prior to discharge. Medications on Admission: none Discharge Medications: 1. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 3. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 5. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection [**Hospital1 **] (2 times a day). 7. Haloperidol 5 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8 Hours). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Folic Acid 400 mcg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: Primary diagnosis S/P pedestrian v. car 1. Comminuted left femur fracture 2. Open right ankle fracture/near amputation 3. Right lateral rib fractures 2&3 4. Delirium tremens 5. Acute blood loss anemia Secondary diagnoses 1. ETOH abuse 2. Pancreatitis Discharge Condition: Stable. Ex-fix to RLE, KI to LLE Discharge Instructions: Do NOT drink alcohol. You had life threatening delirium tremens during your hospitalization. A good addictions program will help you to stay sober after your discharge, maybe AA. You suffered a broken left leg which was surgically repaired and you have a broken right ankle which needs surgery in a few weeks. You can get up but do not bear weight on the right leg. The left leg can be touch down weight bearing. The Orthopedic service will re evaluate you in a few weeks. Call Dr. [**Last Name (STitle) 1005**] if you have any fevers > 101 or increased redness or swelling over the right leg. Physical Therapy: Activity: Bedrest Right lower extremity: Non weight bearing Left lower extremity: Touchdown weight bearing Knee immobilizer: At all times Treatments Frequency: Site: RLE ex-fix Type: Surgical Comment: pin care - 50/50 mix of NS and peroxide [**Hospital1 **] Site: R shin Type: Surgical Dressing: Nonadherent Dsg (Adaptic) Comment: change daily, reinforce as needed with ABD Site: left knee Type: Surgical Dressing: Gauze - dry Comment: cover only for drainage Followup Instructions: Call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 6429**] for a follow up appointment in 2 weeks Call the [**Hospital **] Clinic at [**Telephone/Fax (1) 1228**] for a follow up appointment in 2 weeks with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**] Completed by:[**2146-1-19**]

[ "E814.7", "303.01", "285.1", "E001.0", "821.23", "E000.9", "577.0", "V60.0", "824.9", "807.09", "291.81", "E849.5" ]

icd9cm

[ [ [] ] ]

[ "38.7", "79.35", "38.93", "78.17", "96.6", "79.66", "79.06" ]

icd9pcs

[ [ [] ] ]

14355, 14428

9890, 13585

368, 1016

14723, 14758

4190, 9867

15907, 16353

1502, 1518

13640, 14332

14449, 14702

13611, 13617

14782, 15377

1533, 1535

15395, 15542

15565, 15884

3844, 4171

280, 330

1044, 1359

1550, 3830

1381, 1387

1403, 1486

43,633

168,124

38762

Discharge summary

report

Admission Date: [**2106-2-22**] Discharge Date: [**2106-2-24**] Date of Birth: [**2054-9-27**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 443**] Chief Complaint: Substernal chest pain radiating to right shoulder and down right arm. Major Surgical or Invasive Procedure: Cardiac catheterization and subsequent angioplasty with stents to right coronary artery. Proximal RCA was stented for 60-70% stenosis with drug eluting stent. 90% stenosed distal RCA was stented also with a DES and the subsequently jailed RPL branch was rescued with a balloon. LMCA was noted as normal and the LAD demonstrated 40-50% stenosis. History of Present Illness: 51yo gentleman past smoker w/ hyperlipidemia C/O chest pain beginning at 7am. Symptoms began after he woke up, letting his dog out in the morning. He began to feel pain over his "whole chest" radiating to his right shoulder and down his right arm. He also endorsed nausea, sweating, SOB, and "clamy" sensation. He took an aspirin. He waited and took a shower, but as symptoms presisted he drove himself to the [**Hospital3 **] ER. EKG showed evloving ST elevations inferiorly. Pain at presentation was [**3-31**]. In the OSH ED, initial vitals were HR 48, RR 20, POx 100%, BP 129/81. Troponin I <0.01, CPK 91. Patient received 600mg clopidrogrel, heparin, morphine, IV NTG, and ?ativan. Patient was transfered to [**Hospital1 18**] with ETA for catheter procedure listed as 930am. On ROS patient endorsed intermittent chest pain for the past 2 weeks, sometimes while sitting, recently diminished excercise tolerance, and right shoulder pain for the past month. Patient also noted several other past ED visits for chest pain that were much less severe. He denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery or past, cough, hemoptysis. Patient noted one episode of dark stools 2 weeks ago. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. Denies weakness, aphasia, LOC, fall, parasthesias. All of the other review of systems were negative. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia 2. CARDIAC HISTORY: Patient describes past minimal symptoms and normal stress EKG and Echo ~5yrs ago. 3. OTHER PAST MEDICAL HISTORY: Asthma, Migraines, "normal colonoscopy 2 yrs ago" Social History: -Tobacco history: 48 pack yr history, stopped 10yrs ago. -ETOH: 2-6 beers/day, none for past month. -Illicit drugs: no IVDU, no cocaine -4 healthy daughters, wife is living and supportive. -Patient works with scaffolding, physical labor. Family History: Father deceased, MIx4 (first in 40s) and CVA/TIA x5-6. Mother died of diabetes related disease, had CABGx3 at 62yo. Denies arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: At admission: VS: T=94.6...BP=112/77...HR=85...RR=14-20...O2 sat=100% GENERAL: WDWN man in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. No pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 7 cm. No bruits. CARDIAC: PMI faintly palpated 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. Bibasilar crackles otherwise CTAB. No wheezes, no rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. Cap refill<2s. R Femoral insertion sight without hematoma, active bleeding or bruit. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral deferred DP 2+ PT 1+ Left: Carotid 2+ Femoral 1+ DP 2+ PT 1+ Neuro: CNs II-XII intact, motor and light touch grossly intact. Discharge exam unchanged. Pertinent Results: - [**2106-2-22**] EKG: post PCI (11:07) Rate 80, Rhythm Sinus, Axis normal, Intervals wnl, Q waves in II, III, and AvF. Compared to prior, pre-intervention, STE in inferior leads have improved. - CK peak on [**2106-2-22**] at 20:47. CK declined to 943 on [**2106-2-23**] at 05:45. - CK MB at peak was 126 on [**2106-2-22**] at 12:40 - Hematocrit remained stable throughout admission around 40. - Fasting lipid profile: Chol 213, Triglyc 220, HDL 43, LDL 130 - [**2106-2-23**] TransThoracic Echocardiogram demonstrated EF 45% as well as mild regional left ventricular systolic. TTE also showed mild dilation of the LA, RA, and aorta. Trace AR and MR noted. No pericardial effusion. Brief Hospital Course: 51 year old man transferred from outside hospital to [**Hospital1 18**] with inferior ST-elevation myocardial infarction. #STEMI - the patient was transferred to [**Hospital1 18**] catheter laboratory with ETA listed as 930am, symptom-to-balloon time of 3 hrs 15 min. On arrival, patient's BP 112/71, HR 76. In the cath lab results notable for LMCA normal, LAD 40-50% stenosis, RCA 90% stenosis of distal RCA, 60-70% of proximal RCA stenosis. Patient's distal RCA was stented w/ a DES and rescued the subsequently jailed RPL branch with a balloon. Proximal RCA was also stented w/DES. The patient's ST elevations improved markedly prior to discharge, with evolution of inferior Q waves. He was discharged on atorvastatin, metoprolol, aspirin and plavix, with follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3321**]. #NSVT - the patient had multiple runs of NSVT in the 24 hours post-MI, the longest of which was 20 beats. This was thought to be normal re-perfusion arrythmias. The patient had no further runs of NSVT after 24 hours. Medications on Admission: Albuterol inhaler, 2 puffs as needed. Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*11* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*1* 5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Inferior ST Elevation Myocardial Infarction Hyperlipidemia Asthma Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You had an heart attack caused by a blockage in your right coronary artery. These blockages were opened and a drug eluting stent was placed to keep the artery open. You will need to take a 325 mg aspirin and Plavix every day for at least one year. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking Plavix or aspirin for one full year unless your cardiologist tells you to. other medication changes: 1. Start Metoprolol 25 mg daily to slow your heart rate down and help your heart recover from the heart attack 2. Start Aspirin and Plavix as noted above to prevent the stent from clotting off. 3. Start Atorvastatin (Lipitor) to lower your cholesterol and prevent further blockages 5. Followup Instructions: Primary Care: [**Last Name (LF) **],[**First Name3 (LF) **] E. Phone: [**Telephone/Fax (1) 5317**] Date/time: Please call tommorrow for an appt to be seen in [**3-25**] weeks. . Cardiology: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3321**] [**Last Name (un) 34851**] [**Location (un) 3320**], [**Numeric Identifier 34852**] Wednesday [**2106-3-3**] at 2:20pm. Phone:([**Telephone/Fax (1) 73315**] Ext.3822 Completed by:[**2106-2-24**]

[ "414.01", "427.1", "410.41", "429.9", "272.4", "493.90" ]

icd9cm

[ [ [] ] ]

[ "88.52", "88.55", "99.20", "00.66", "00.41", "37.22", "36.07", "00.46" ]

icd9pcs

[ [ [] ] ]

6596, 6602

4740, 5817

384, 734

6712, 6712

4031, 4717

7602, 8063

2734, 2943

5905, 6573

6623, 6691

5843, 5882

6857, 7273

2958, 4012

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7293, 7579

275, 346

762, 2213

6726, 6833

2408, 2460

2235, 2273

2476, 2718

66,657

119,195

38987

Discharge summary

report

Admission Date: [**2148-5-5**] Discharge Date: [**2148-5-15**] Date of Birth: [**2088-10-8**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: [**2148-5-5**] Scalp stapled (Removed [**2148-5-14**]) History of Present Illness: 59 yr old male who was found down in driveway unconscious. The fall was unwittnessed and it was unknown how long the patient was down on the ground. On presentation to the emergency department, the patient could not recall the event. He was not able to converse and his exam was limited related to intoxication, ETOH level was 419. He was transported to [**Hospital1 18**] for further care. Scalp laceration was stapled in the emergency department. Past Medical History: EtOh Cirrhosis Social History: Significant history of alcohol abuse. Currently lives with parents. Physical Exam: Upon admission: O: INR 1.2 PT 13.6, PTT 29.4. NA 137 Gen: comfortable, NAD. HEENT: Pupils: [**4-16**] EOMs pt non compliant with exam Neck: hard cervical collar on Extrem: Warm and well-perfused. Neuro: Mental status:GCS=14 E=4, v=4, M=6 Awake and alert, able to follow simple commands with repeated requests. Orientation: Oriented to person only. Recall: unable to recall objects Language: Speech slow, one word answers after multiple questions. pt able to name "watch" slowly. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields- pt non compliant with exam. III, IV, VI: Extraocular movements- non compliant with exam. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength appears full and symmetric- patient does not cooperate with full motor exam. No pronator drift Sensation: Intact to light touch. Toes downgoing bilaterally Coordination: normal on finger-nose-finger Pertinent Results: [**2148-5-12**] 09:40AM BLOOD WBC-5.9 RBC-3.74* Hgb-12.9* Hct-35.9* MCV-96 MCH-34.6* MCHC-36.1* RDW-12.9 Plt Ct-138* [**2148-5-11**] 06:50AM BLOOD WBC-7.0 RBC-3.87* Hgb-12.9* Hct-37.9* MCV-98 MCH-33.3* MCHC-34.0 RDW-13.0 Plt Ct-175 [**2148-5-10**] 06:17AM BLOOD Neuts-83.4* Lymphs-10.6* Monos-4.8 Eos-1.1 Baso-0.2 [**2148-5-11**] 06:50AM BLOOD PT-12.5 PTT-27.6 INR(PT)-1.1 [**2148-5-12**] 09:40AM BLOOD Plt Ct-138* [**2148-5-14**] 06:15AM BLOOD Glucose-77 UreaN-12 Creat-0.8 Na-126* K-4.1 Cl-91* HCO3-22 AnGap-17 [**2148-5-13**] 07:15AM BLOOD Glucose-86 UreaN-9 Creat-0.8 Na-127* K-4.3 Cl-90* HCO3-26 AnGap-15 [**2148-5-12**] 09:40AM BLOOD Glucose-99 UreaN-10 Creat-0.7 Na-128* K-4.1 Cl-92* HCO3-25 AnGap-15 [**2148-5-11**] 06:50AM BLOOD Glucose-105* UreaN-11 Creat-0.7 Na-128* K-3.9 Cl-95* HCO3-22 AnGap-15 [**2148-5-10**] 03:55PM BLOOD Glucose-116* UreaN-10 Creat-0.7 Na-128* K-4.9 Cl-96 HCO3-20* AnGap-17 [**2148-5-9**] 09:36PM BLOOD Glucose-113* UreaN-16 Creat-1.0 Na-130* K-3.6 Cl-96 HCO3-23 AnGap-15 [**2148-5-9**] 04:40PM BLOOD Glucose-113* UreaN-17 Creat-0.9 Na-128* K-3.8 Cl-95* HCO3-21* AnGap-16 [**2148-5-9**] 06:05AM BLOOD Glucose-98 UreaN-12 Creat-0.8 Na-130* K-3.8 Cl-95* HCO3-20* AnGap-19 [**2148-5-8**] 01:40AM BLOOD Glucose-93 UreaN-10 Creat-0.9 Na-132* K-3.9 Cl-99 HCO3-22 AnGap-15 [**2148-5-7**] 11:35AM BLOOD Glucose-135* UreaN-8 Creat-0.7 Na-132* K-4.3 Cl-98 HCO3-23 AnGap-15 [**2148-5-7**] 02:28AM BLOOD Glucose-137* UreaN-8 Creat-0.8 Na-132* K-4.1 Cl-96 HCO3-25 AnGap-15 [**2148-5-6**] 01:49AM BLOOD Glucose-135* UreaN-6 Creat-0.8 Na-134 K-5.4* Cl-100 HCO3-19* AnGap-20 [**2148-5-5**] 04:40PM BLOOD Glucose-129* UreaN-8 Creat-0.8 Na-137 K-4.5 Cl-101 HCO3-18* AnGap-23* [**2148-5-11**] 06:50AM BLOOD ALT-9 AST-20 AlkPhos-64 Amylase-53 TotBili-0.7 [**2148-5-14**] 06:15AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.2 [**2148-5-13**] 07:15AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.1 [**2148-5-12**] 09:40AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.8 [**2148-5-11**] 06:50AM BLOOD Calcium-8.4 Phos-2.6* Mg-2.0 [**2148-5-10**] 03:55PM BLOOD Calcium-8.6 Phos-3.0 Mg-2.0 [**2148-5-10**] 06:20AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.3 [**2148-5-5**] 04:40PM BLOOD ASA-NEG Ethanol-419* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Imaging: [**5-6**] CT Head: Non displaced occipital fx into skull base, LSAH, LSDH [**5-6**] CT C-spine: No acute fx of C-spine. Right occipital fx extends into R skull base/clivus, close proximity to right vert artery. multi-level degnerative changes. [**5-6**] CT Torso: Bilat dependent atelectasis. Nonspecific mildly enlarged mediastinal LNs measure up to 1.1 cm in short axis. gynecomastia. HH. incomplete fxs of right lateral 4th-7th ribs of indetermin age. nondisplaced fx of lateral right 10th rib. no ptx. no ev of acute visceral inj in abdomen or pelvis. Large fat containing right inguinal hernia. [**5-6**]: CTA Head/Neck: Intraparenchymal, subarachnoid and subdural hemorrhage, in a distribution likely representing the sequela of prior trauma. There is no evidence of an underlying vascular malformation, aneurysm, dissection or hemodynamically significant stenosis of either the CTA of the head or neck. . Stable skull base fracture, nondisplaced. . Approximately 50% stenosis of the right internal carotid artery at its origin by NASCET criteria. [**5-7**]: CT Head: Mildly increased edema surrounding the left temporal and frontal hemorrhagic contusions. Stable extent of subarachnoid, subdural and intraventricular hemorrhage. . Brief Hospital Course: The patient was found to have a Subarachnoid hemorrhage involving the left frontal, parietal, temporal, and right frontal regions, left subdural hematoma, and areas of probable intraparenchymal hemorrhage in bilateral temporal lobes. 2.5 mm rightward midline shift, a nondisplaced right occipital fracture extending into the right skull base, and large right parietal soft tissue hematoma and edema with overlying skin staples on CT scan. His C-spine was cleared by CT scan. Several rib fractures were seen on CT scan as well, however the age of the fractures was unable to be determined. The patient was admitted from the emergency department to the TSICU for closer monitoring. The patients neurological status was monitored carefully by trauma surgery as well as neurosurg while in the TSICU. Dilantin therapy was initiated to prevent siezure. The patients neurological status varied during his stay in the unit from being cooperative with care to having difficulty answering questions and combative. Given history of alcohol abuse, CIWA scale was initiated. There was a concern for possible continued intercranial bleeding and he was followed by CT scan which showed no changes. These changes in mental status were contributed to acute alcohol withdrawal at which time standing valium was ordered. His mental status slightly improved, he was able to take food and medications by mouth, and he was transfered to the inpatient floor. The patient was noted to have hyponitremia [**2148-5-9**] with a sodium of 130. On admission the patients sodium level was 137 and over time, continued to drop as low as 126. These values were treated with intervals of normal saline IV, sodium tablets three times daily, and fluid restriction. Urine chemistries from [**2148-5-9**] showed normal urine sodium at 41. A mass insidentally found in the lower pole of the right kidney was evaluated by ultrasound and was found to be a simple cyst. [**2148-5-14**] endocrinology was consulted and recommended strict I&O, continued fluid restriction, and to monitor labs. The patients sodium level was 133 on day of discharge. CIWA scale and standing valuim was continued on the floor, the patients neuro status continued to improve. Social work and nursing case managment were consulted and the patient's disposition was complicated by lack of inurance. Physical therapy was consulted and cleared the patient to return home. Medications on Admission: Aldactone Lasix Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 5. Spironolactone 25 mg Tablet Sig: Three (3) Tablet PO Q 8H (Every 8 Hours). 6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 days. Disp:*12 Tablet(s)* Refills:*0* 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 9. Sodium Chloride 1 gram Tablet Sig: Four (4) Tablet PO TID (3 times a day). Disp:*360 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: s/p Fall Subarachnoid/Intraparenchymal/Subdural hemorrhages Hyponatremia Urinary tract infection Discharge Condition: Mental Status: Confused - sometimes Level of Consciousness: Alert and interactive Activity Status: Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: You were admitted to the hospital after you were found down on the ground unconscious. You were found to have mulitple areas of bleeding in your brain. You were admitted to the Trauma ICU for close monitoring; head CT scans were repeated and remained stable. Because of your high blood alcohol level you experienced withdrawal symptoms during your stay requiring medications to help control these symptoms. Your sodium was also very low in the hospital felt to be related to an alteration in one of the body's regulatory hormones. To treat this you were given salt tablets which you should continue as prescribed. Your fulid intake was also restricted so that you should be careful to not drink more than 1 liter of fluid in a day. Your diuretic (Lasix) was also stopped as this can make the condition of low sodium worse. The Endocrine doctors saw [**Name5 (PTitle) **] [**Name5 (PTitle) 1028**] you were in the hospital and made these recommendations. *IT IS IMPORTANT THAT YOU FOLLOW UP WITH YOUR PCP THIS WEEK TO HAVE YOUR SODIUM LEVEL CHECKED*. You were prescribed antibiotics for a urinary tract infection. It is important to finish all of this medication as written on the bottle until the bottle is empty. IT IS VERY IMPORTANT THAT YOU DO NOT DRINK ALCOHOL OR TAKE ILLICT DRUGS AS THIS PUTS YOU AT RISK FOR FURTHER TRAUMA. Followup Instructions: Follow up this Friday [**5-17**] with Dr. [**Last Name (STitle) 86480**] [**Telephone/Fax (1) 86481**], your primary care doctor to have your Na (Sodium)level checked. It is very important that you have this checked regularly. Completed by:[**2148-5-20**]

[ "873.0", "550.91", "291.81", "599.0", "571.2", "348.5", "253.6", "041.04", "E888.9", "801.26", "593.2", "807.01" ]

icd9cm

[ [ [] ] ]

[ "86.59" ]

icd9pcs

[ [ [] ] ]

9088, 9094

5741, 8150

322, 379

9235, 9235

2252, 4488

10776, 11034

8216, 9065

9115, 9214

8176, 8193

9417, 10753

998, 1000

274, 284

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5552, 5718

1014, 1209

9250, 9393

879, 897

913, 983

2,622

145,404

12213+56341

Discharge summary

report+addendum

Admission Date: [**2196-7-26**] Discharge Date: [**2196-8-4**] Date of Birth: [**2120-1-19**] Sex: M Service: VASCULAR CHIEF COMPLAINT: Blue toe syndrome. HISTORY OF PRESENT ILLNESS: This 76 year-old nondiabetic white male with no coronary artery disease status post coronary artery bypass graft AVR in [**2196-4-18**] with a history of paroxysmal atrial fibrillation, hypertension, hypercholesterolemia, polio with residual changes in the right leg developed blue toes times one month. He was admitted to CT Surgery and had an echocardiogram, which was negative for vegetation or thrombus. The patient was transferred to Dr.[**Name (NI) 1392**] [**Name (STitle) 4869**] and had an arteriogram with bilateral leg run off, which showed extensive disease of the aorta and the proximal plaque and common iliac arteries bilaterally. The patient was started on Plavix and scheduled for follow up with Dr. [**Last Name (STitle) 1391**]. The patient was seen by his primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 13057**] last week while Dr. [**Last Name (STitle) 1391**] was on vacation and Prednisone was started 20 mg b.i.d. was "five days ago." The patient was mowing his lawn and developed dry gangrene at the tip of the right second toe. He is now admitted for further evaluation and treatment. ALLERGIES: No known drug allergies. MEDICATIONS: Prednisone 20 mg po t.i.d., Amiodarone 20 mg q day, Plavix 75 mg q day, Synthroid .025 mg q day, Zestril 2.5 mg q day, Norvasc 5 mg q day, Lipitor 40 mg q day, aspirin 325 mg q day, Lasix 20 mg q day. PAST MEDICAL HISTORY: 1. Coronary artery disease with an inferior wall myocardial infarction in 3/96. Status post coronary artery bypass graft, AVR in [**2196-4-18**]. 2. Paroxysmal atrial fibrillation most recent episode was post coronary artery bypass graft. He is treated with Lopressor and Amiodarone. 3. Aortic stenosis status post AVR. 4. Hypertension. 5. Hypercholesterolemia. 6. Hypothyroidism. 7. History of polio. 8. History of benign prostatic hypertrophy. 9. Right pleural effusion status post thoracentesis secondary to coronary artery bypass graft. 10. History of migraines. PAST SURGICAL HISTORY: 1. Coronary artery bypass graft times three with an AVR #25 [**Last Name (un) 3843**]-[**Doctor Last Name **] Bovine pericardial valve [**2196-5-5**]. 2. Mastoid surgery remote. 3. Nephropexy on the right remote. 4. Left PICC line in [**2196-4-18**]. SOCIAL HISTORY: Retired travel [**Doctor Last Name 360**], married, former sixty pack year smoker. Nonsmoker since [**Month (only) 547**] of this year. Denies alcohol. PHYSICAL EXAMINATION: Temperature 97.2, 68, 16, blood pressure 140/90, O2 sat 99% on room air. General appearance, alert, cooperative white male complaining of foot pain. HEENT examination was unremarkable. Carotids were palpable without bruits. Pulse examination shows intact radials, femorals, popliteals, dorsalis pedis pulses and posterior tibial pulses bilaterally. Abdominal aorta was nonprominent. The chest was clear to auscultation bilaterally. He has severe scoliosis. A well healed mediastinotomy incision. Heart is regular rate and rhythm with a soft systolic ejection murmur heard at the upper left chest. Abdominal examination was unremarkable. Rectal examination was deferred. Bone joint examination shows mild edema at the ankles and feet. There is purple modeling discoloration of the toes and the plantar surface of the feet bilaterally. The right second toe tip is with dry gangrene. The right medial knee saphenectomy incision is open with necrotic base. There is no odor or cellulitis. ADMISSION LABORATORIES: White blood cell count 17.0, hematocrit 35.1, BUN 33, creatinine 0.8, K 4.2, glucose 410, PT/INR/PTT were normal. Urinalysis was unremarkable. Chest x-ray was unremarkable. Electrocardiogram showed a sinus rhythm with marked left axis deviation, right bundle branch block, left anterior fascicular block, old lateral infarct. HOSPITAL COURSE: The patient was admitted to the Vascular Unit. He was begun on intravenous heparinization. He underwent on [**2196-7-29**] a aortobifemoral bypass graft with an 18 by 9 mm graft with a right second toe amputation. He tolerated the procedure well and was transferred to the PACU in stable condition. Postoperatively, he was hemodynamically stable. He had a dorsalis pedis pulse and posterior tibial pulse, which were palpable bilaterally. The patient required in the PACU neo-synephrine and Dopamine to maintain cardiac index greater then 2.0. He was transferred to the CICU for continued monitoring and care. The patient had an epidural placed during surgery for analgesic control. The patient continued to show improvement, although he still had some lower extremity modeling. Hematocrit was 28.4 down from 31.4. BUN and creatinine remained stable. He had a right IJ and a right radial line. Antibiotic wise he was covered with Flagyl and Levofloxacin. Dopamine and Levophed were continued for maintaining cardiac index. He was weaned from his pressors and was transferred to the VICU for continued monitoring and care. Postoperative day three he continued to do well and he was transferred to the regular nursing floor. He remained NPO. Serial CKs were obtained. He peaked his CKs over 1400, which gradually over the next 48 hours showed decline in the total CKs with improvement of his symptoms. He was evaluated by physical therapy and the patient was hesitant to begin walking secondary to extensive lower extremity pain. His analgesic control was readjusted. He was begun on Zantac for anxiety, which he had been on at home and this was restarted here. He did require transfusion of packed red blood cells times one. His PCA was discontinued on postoperative day number five after 24 hours off the epidural. Foley was discontinued. He had no difficulty with voiding. Toradol was begun 15 mg intravenous q 6 hours times 48 hours for improvement in analgesic control. With continued encouragement both by physical therapy and the staff and the patient did begin ambulation. The remaining of the hospital course was unremarkable. The patient was discharged in stable condition. His wounds were clean, dry and intact and he is to follow up with Dr. [**Last Name (STitle) 1391**] in a weeks time. DISCHARGE MEDICATIONS: Xanax 0.5 mg t.i.d. prn, Hydromorphone 2 mg q 2 to 4 hours prn, Lasix 40 mg b.i.d., Lisinopril 2.5 mg q.d., Metoprolol 25 mg b.i.d. hold for systolic blood pressure of less then 100 and heart rate less then 60. Amlodipine 5 mg q day, Amiodarone 200 mg q.d., Levothyroxine 25 mcg q.d., Lisinopril 2.5 mg q.d., Atorvastatin 40 mg q day, aspirin 325 mg q day, Dulcolax tabs ten prn or Dulcolax suppository prn. Acetaminophen 325 to 650 mg q 4 to 6 hours. Metamucil two packets q.d., Plavix 75 mg q day, _____________ 40 mg q.d. DISCHARGE DIAGNOSES: 1. Blue toe syndrome status post aortic bifemoral bypass graft. 2. Hypotension corrected. 3. Blood loss anemia corrected. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2196-8-4**] 10:59 T: [**2196-8-4**] 12:03 JOB#: [**Job Number **] Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 6893**] Admission Date: [**2196-7-26**] Discharge Date: [**2196-8-9**] Date of Birth: [**2120-1-19**] Sex: M Service: Vascular ADDENDUM: Discharge was deferred awaiting peaked T assessment. The patient needed skilled nursing facility, short term to maximize his mobility and independence. The patient also had significant pain issues which were dealt with by adding Toradol 15 mg IV q 6 hours times 48 hours to his analgesic regime with improvement of his symptoms. He was then placed on Ibuprofen 400 mg to 600 mg tid prn for pain. The remainder of the hospital course was unremarkable. The patient was discharged with abdominal staples removed to follow-up with Dr. [**Last Name (STitle) **] in two weeks for removal of the femoral skin clips. [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**], M.D. [**MD Number(1) 238**] Dictated By:[**Last Name (NamePattern1) 145**] MEDQUIST36 D: [**2196-8-8**] 07:47 T: [**2196-8-10**] 14:53 JOB#: [**Job Number 6895**]

[ "412", "V43.3", "440.24", "285.1", "272.0", "427.31", "V45.81", "458.2", "244.9" ]

icd9cm

[ [ [] ] ]

[ "84.11", "39.25" ]

icd9pcs

[ [ [] ] ]

6967, 8521

6417, 6946

4064, 6393

2241, 2499

2693, 4046

157, 177

206, 1609

1632, 2217

2516, 2670

71,576

145,166

31752

Discharge summary

report

Admission Date: [**2144-11-12**] Discharge Date: [**2144-12-10**] Date of Birth: [**2103-3-13**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8850**] Chief Complaint: Urosepsis and hypotension. Major Surgical or Invasive Procedure: Endotracheal intubation [**2144-11-13**] to [**2144-11-16**]. History of Present Illness: [**Known firstname **] [**Known lastname **] is a 41-year-old right-handed man, with a history of anaplastic astrocytoma of the spine complicated by severe lower extremity weakness and urinary retention, s/p Foley catheter, high-dose steroids, hypertension, chronic pain, who presented to the emergency room at [**Hospital1 18**] on [**2144-11-12**] with increased weakness. The patients sister reports that he had been having fecal incontinence and diarrhea over the last week, and then developed SOB and acute onset abdominal pain the day of admission. There were no fevers or CP, but were some chills. But he was on high-dose dexamethasone. ED COURSE: He was noted to be somnolent and hypotensive. He was intubated for airway protection. CVL was placed and started on neosynephrine and Levophed drips. Given 8L NS fluids and broad spectrum antibiotics with vanco/zosyn. Labs were notable for elevated lactate 7.1 and acute renal failure (creatinine 1.8). Scans of head and torso with evidence of possible pneumonia (aspiration) but no other source. Urinalysis was grossly positive. Cardiology and surgery were consulted for questionable cardiogenic shock and acute abdomen, respectively. He was then admitted to the MICU. MICU COURSE: He was weaned off vasopressors with repeated fluid boluses. Levoflox and Flagyl added to vancomycin and Zosyn. C. difficile and legionella urine Ag were negative. Urine and blood cultures from the ED eventually grew E. coli sensitive to cephalosporins and antibiotics were tailored to cefazolin and flagyl. He was extubated on [**2144-11-15**]. But he developed CHF with echocardiogram suggestive of Takotsubos. He was auto-diuresed and started on ACE inhibitor per Cardiology; no beta-blocker given chronically bradycardic (HR 40-50s, asymptomatic). Troponin peaked at 0.3 with flat CKs. Anticoagulation was discussed given apical akinesis but deferred due to risk of bleeding with underlying malignancy. His dexamethasone were continued at Q12H. But he developed thrombocytopenia and heparin products stopped but HIT negative so restarted and platelet counrs have subsequently improved. He had been holding chronic pain medications given recent intubation. He was transferred to OMED for further care. Currently the patient complains of mild abdominal pain and loose stools. Denies SOB but notes low O2 sats occasionally. No other pain including no chest pain. Denies nausea or vomiting. He feels below baseline strength overall and fatigued. Past Medical History: Anaplastic astrocytoma of the T-L spinal cord. Hypertension Pain (flexor spasms and neurogenic pain) Past Oncological History: [**3-13**]-RLE weakness 07/07-Right knee gave out with difficulty walking and right anterior thigh numbness OSH MRI showed a spinal cord conus mass He had a myelotomy-Dr. [**Last Name (STitle) 548**] [**2143-9-13**]=anaplastic astrocytoma involved in field ratdiation t10-l1 [**2143-9-19**] to [**2143-10-28**] to 4860 cGy followed by 11 cycles of temozolomide 7 days on and 7 days off. This was followed by CPT-11 Weekly x4 with Avastin Q2 weeks/ 2 weeks rest and repeat cycle [**11-6**]= C1D22 CPT-11/Avastin (D15 was held). Social History: Patient lives at home with his parents and sister. [**Name (NI) **] was wheelchair bound. He does not smoke cigarettes, drink alcohol, or use illicit drugs. Family History: His grandmother has [**Name2 (NI) 499**] cancer. His mother has non-[**Name (NI) **]??????s lymphoma. His father has coronary artery disease. One of his brothers is a diabetic. Physical Exam: on presentation to [**Hospital Unit Name 153**]: VITAL SIGNS: Temperature 97.6 F, blood pressure 115/69, heart rate 125, repiration 21, saturation 99% on AC FIO2 100%, TV 680, RR 14, PEEP 5 GENERAL: intubated, sedated, overweight, NAD SKIN: Positive for macular purpuric rash on trunk and arms, blanching.HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline CARDIOVASCULAR: distant heart sounds, s1s2 no audible m/r/g PULMONARY: b/l ae coarse inspiratory breath sounds, +scant exp wheezing, c/r ABDOMEN: no BS, soft, distended, TTP (evidenced by wincing on exam), no guarding. EXTREMITIES: No C/C, 1+E, no palpable cords NEUROLOGICAL EXAMIANTION: intubated, sedated, +rigors, squeezes hands, opens eyes on command. Pertinent since extubation; EXTREMITIES: 3+ edema at hands and feet NEUROLOGICAL EXAMINATION: His Karnofsky Performance Score is 60. He is awake, alert, and oriented times 3. His language is fluent with good comprehension. His short-term memory is intact. Cranial Nerve Examination: His pupils are equal and reactive to light, 4 mm to 2 mm bilaterally. Extraocular movements are full; there is no nystagmus. Visual fields are full to confrontation. His face is symmetric. Facial sensation is intact bilaterally. His hearing is intact bilaterally. His tongue is midline. Palate goes up in the midline. Sternocleidomastoids and upper trapezius are strong. Motor Examination: He does not have a drift. His muscle strengths are [**5-11**] at all muscle groups in the upper extremities. In the lower extremities, his right foot has no movement, while his right quadriceps and right ileopsoas have 2/5 strength. In his left lower extremity, there is weakness at his left [**Last Name (un) 938**] and left tibialis anterior at 4-/5, as well as 4/5 strength at left quadriceps. His muscle tone is spastic in the right lower extremity. His reflexes are 2- at biceps, triceps, and brachioradialis bilaterally. His right knee jerk is 0 while his right ankle jerk is 5+. His left knee jerk is 2+, while the left ankle jerks is absent. His right toe is mute. Sensory examination is notable for decreased sensation in both of his lower extremities up to T11 level. He can stand but he cannot walk. Pertinent Results: [**2144-11-12**] 11:40AM WBC-2.1*# RBC-3.84* HGB-12.8* HCT-36.8* MCV-96# MCH-33.2* MCHC-34.7 RDW-14.4 [**2144-11-12**] 11:40AM NEUTS-73* BANDS-7* LYMPHS-10* MONOS-9 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [**2144-11-12**] 11:40AM PLT SMR-LOW PLT COUNT-143* [**2144-11-12**] 11:40AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL [**2144-11-12**] 11:40AM GLUCOSE-150* UREA N-18 CREAT-1.8*# SODIUM-132* POTASSIUM-3.8 CHLORIDE-91* TOTAL CO2-24 ANION GAP-21* [**2144-11-12**] 11:40AM ALT(SGPT)-74* AST(SGOT)-28 CK(CPK)-35* ALK PHOS-98 TOT BILI-1.2 [**2144-11-12**] 11:50AM LACTATE-7.1* [**2144-11-12**] 11:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2144-11-12**] 11:40AM CK-MB-NotDone [**2144-11-12**] 11:40AM cTropnT-0.08* [**2144-11-12**] 09:05PM CK-MB-6 cTropnT-0.05* [**2144-11-12**] 09:05PM CK(CPK)-92 [**2144-11-12**] 05:10PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2144-11-12**] 05:10PM URINE RBC-[**11-26**]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-0 [**2144-11-12**] 5:10 pm URINE Site: CATHETER **FINAL REPORT [**2144-11-15**]** URINE CULTURE (Final [**2144-11-15**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC ______________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- 32 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [**2144-11-13**] 4:30 am BLOOD CULTURE Source: Line-central. Blood Culture, Routine (Preliminary): ESCHERICHIA COLI. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 261-5711B [**2144-11-12**]. Anaerobic Bottle Gram Stain (Final [**2144-11-14**]): GRAM NEGATIVE ROD(S). Aerobic Bottle Gram Stain (Final [**2144-11-15**]): GRAM NEGATIVE ROD(S). Rapid Respiratory Viral Antigen Test (Final [**2144-11-16**]): Respiratory viral antigens not detected. SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA A,B AND RSV. C. Diff negative x 3 ECG: Sinus tachycardia @118, no acute st/t changes. Imaging: CXR: IMPRESSION: No acute intrathoracic process. KUB:IMPRESSION: Limited examination. Nonspecific bowel gas pattern. Evaluation for free air is limited. CT Head: IMPRESSION: No acute intracranial process. CT chest/abd/pelvis: IMPRESSION: Limited study given lack of intravenous contrast. 1. Bibasilar consolidations. 2. Properly positioned endotracheal tube, nasogastric tube, and right internal jugular central venous catheter. 3. No acute intra-abdominal or pelvic findings. Oral contrast material is noted within the stomach and has not progressed throughout the bowel, and thus evaluation of the bowel is somewhat limited. 4. Status post laminectomy T11-12 through T12-L1. 5. Inflammatory changes of the right inguinal canal of uncertain significance or etiology ECHO: The left atrium is normal in size. The estimated right atrial pressure is 10-20mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate to severe regional left ventricular systolic dysfunction with mid to distal LV akinesis. The estimated cardiac index is borderline low (2.0-2.5L/min/m2). Right ventricular chamber size is normal. with mild global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. IMPRESSION: Severe regional left ventricular systolic dysfunction consistent with Takatsubo cardiomyopathy. Mild mitral regurgitation. No vegetations identified. If clinically suggested, the absence of a vegetation by 2D echocardiography does not exclude endocarditis. CXR: One portable upright view. Comparison with [**2144-11-14**]. Lung volumes are somewhat low. There is minimal streaky density consistent with subsegmental atelectasis. Ill-defined increased density in the retrocardiac area may represent atelectasis or consolidation. Mediastinal structures are unchanged. An endotracheal tube, nasogastric tube, and right internal jugular catheter remain in place. IMPRESSION: Limited study demonstrating retrocardiac density consistent with atelectasis or consolidation unchanged. Shoulder X-ray:Right shoulder x-ray examination within normal limits, except for tiny clavicular spur. Brief Hospital Course: Assessment/Plan: The patient is a 41-year-old right-handed man with a history of progressive anaplastic astrocytoma of the spine on high-dose steroids presented with urosepsis. (1) Urosepsis: Initially in shock. E. coli grew from blood and urine cultures. Required vasopressors and aggressive fluid resuscitation initially. Resolved and transfered out of [**Hospital Unit Name 153**]. Since transfer to the flow there have been o further fevers or signs of infection. Initially on IV [**Hospital 74560**] transfered to PO cipro (D1 = [**11-18**]) to complete 14 day course given bacteremia, finish [**12-2**] Urosepsis likely secondary to LE paralysis, patient required significant effort to urinate and has poor sensation of a full bladder. (2) Acute Renal Failure: Prerenal due to hypotension from septic shock. Resolved with correction of sepsis and aggressive IVF. On the floor lisinipril was resumed.HCTZ and lasix were used to correct volume overload, but subsequently discontinued [**2-8**] hyponatremia. Volume status stable. (3) Cardiomyopathy/NSTEMI: Due to sepsis. Troponin leak from hypotension rather than ruptured plaque. Echo with Takotsubos. Volume overload resolved after diuresis. Cardiology was following and started ACE. Continue to monitor for signs of CHF. (4) Hyponatremia: He developed during diuresis with lasix and HCTZ, corrected with discontining diuretics. He later downtrending again, responed to IVF therefore likely hypovolemic hyponatremia. (5) Thrombocytopenia: Platlets trended down to 46, then recovered to 97 on day of transfer from ICU. HIT negative. Likely [**2-8**] to GNR septicemia. (6) Right shoulder pain: increasing after PT, with movement last 2 days. Tender over right AC joint. x-ray negative, continue Oxycodone, tylenol prn. (7) Diarrhea: Possibly due to chemotherapy. Considered C. diff although stools negative x 3. Bowel movements are diminished prior to d.c. Continue anti-motility agents prn. (8) Anaplastic Astrocytoma: Located in the T-L spine, unresectable anaplastic astrocytoma s/p radiation. Complicated by progressive lower extremity weakness and urinary retention. Patient also has fecal incontanance. This is likely the cause of urosepsis. After discussion between Dr. [**Last Name (STitle) 724**] and family decided to pursue hospice, no longer getting treatment for tumer. Continue narcotic regimen and Decadron 4 mg [**Hospital1 **]. (9) Hypertension: Currently normotensive. Continue lisinopril, Diuretics d/c [**2-8**] hyponatremia, beta blocker d/c for bradycardia. (10) Anemia: This is likely secondary to chemotherapy +/- ACD. Hct stable at baseline. (11) Code: Now DNR/DNI. (12) Disposition: Per Dr [**Last Name (STitle) 724**], family agrees to hospice. Code status changed to DNR/DNI on [**11-23**]. (13) Communication: Per patient and his sisters. Medications on Admission: dexamethasone 4mg [**Hospital1 **] diphenoxylate-atropine 2.5mg/0.025mg 2 tabs QID prn fluoxetine 20mg daily HCTZ 25mg, 1-2 tabs daily prn pedal edema lisinopril 10mg daily morphine concentrate 20mg/ml 0.5mg Q8hprn pain MS contin 30mg [**Hospital1 **] oxcarbazepine 300mg, 1.5mg [**Hospital1 **] oxycodone 5mg q6h breakthrough pain prochlorperazine 10mg prn prior to chemo ambien 5mg HS PRN colace 50mg TID Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. 3. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 5. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 6. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for heartburn. 7. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 8. Oxcarbazepine 300 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 9. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insominia. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 12. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for greater than 2 episodes of diarrhea per day. 13. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-8**] Sprays Nasal QID (4 times a day) as needed. 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for shoulder pain. 15. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 16. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). Discharge Disposition: Extended Care Facility: [**Location (un) 14468**] Nursing & Rehabilitation Center - [**Location (un) 1456**] Discharge Diagnosis: Urosepsis Pneumonia Acute renal failure cardiomyopathy and NSTEMI Anaplastic astrocytoma of the T-L spine Secondary dx: Hypertension Hypercholesterolemia Anemia Discharge Condition: Comfortable and alert, afebrile. Discharge Instructions: You were admitted to the hospital for increased weakness and urinary retention. Upon arrival to the hospital you entered septic shock from massive infection. You were intubated and sent to the intensive care unit for intensive management. You were found to have a urinary tract infection as well as an pneumonia. These were treated with a course of antibiotics. During your treatment course you had a heart attack which weakened your heart. After much discussion with the oncology team and your family it was decided that your spine cancer is progressing and is not curable. Focus was transfered to making you comfortable and planning was made to transition to hospice care The following changes were made to your medication regimen: Stopped: 1)Diphenelexate-atropine 2)Hydrochlorothiazide 3)Lisinopril Started: 1)Maalox 2)Famotidine 20mg [**Hospital1 **] 3)Ambien 5mg for sleep 4)Bactrim DS 1 tab on M/W/F Please follow up with your doctors as detailed below. If you have worsening weakness, fevers, chills, abdominal pain, increased diarrhea, headache, shortness of breath, cough, chest pain, or any other worrisome symptom please seek urgent medical attention. Followup Instructions: Please follow-up with your Neuro-Oncologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] as needed: ([**Telephone/Fax (1) 6574**].

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

16371, 16482

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345, 408

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44957

Discharge summary

report

Admission Date: [**2172-10-10**] Discharge Date: [**2172-10-12**] Date of Birth: [**2092-5-30**] Sex: M Service: SURGERY Allergies: Iodine-Iodine Containing Attending:[**First Name3 (LF) 4691**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: 80M discharged today s/p R frontal meningioma resection c/b R MCA infarct. Was only at [**Hospital3 **] a few hours when began complaining of abdominal/chest pain and SOB. Presented to [**Hospital1 18**] ED for evaluation, and CT showed large amount of free air associated with subcutaneous emphysema around G-tube insertion site and lack of apposition of stomach with abdominal wall. Received vanc/zosyn in ED as empiric coverage. Admitted to ICU out of concern for respiratory status. On admission to ICU, he has no current complaints. He denies pain or SOB, and his respiratory status appears to be around his baseline. Past Medical History: CAD, PVD, MR, spinal stenosis, HTN, HLD, DMII, AAA (non-op), CVA [**2169**] (residual LUE weakness), [**2153**] - RCA stent, re-stenosed - placed [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] in [**2164-5-22**] Social History: He stopped smoking many years ago. He does not drink alcohol or use drugs. He is right handed Family History: unknown Physical Exam: Physical Exam: Vitals: T 101.8 P 97 BP 131/51 RR 24 O2 99% GEN: A&Ox2 (baseline), NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: moderate wheeze b/l, No W/R/R ABD: Soft, nondistended, minimally tender at G-tube site and in epigastrum. tympanic, no rebound or guarding, normoactive bowel sounds, no palpable masses. G-tube 5cm at flange. Ext: No LE edema, LE warm and well perfused Pertinent Results: Laboratory: CBC - 9.0 > 30.6 < 251 N:81.7 L:12.9 M:3.9 E:1.2 Bas:0.2 Lactate:1.4 135 | 102 | 20 ----------------< 227 3.7 | 19 | 0.9 AST: 18 ALT: 20 AP: 74 Tbili: 0.5 Alb: 3.0 Lip: 33 Imaging: CXR - free air under diaphragm, maybe worse than yesterday G-tube study - no contrast leak CT abd/pelvis - no contrast leak. stomach wall fallen away from abdominal wall. Brief Hospital Course: He was admitted to Surgical ICU and underwent abdominal CT imaging which did not show any leaks. His tube feedings and home meds were restarted with exception of his Norvasc due to low blood pressures with systolic in low 100's. An abdominal binder was also ordered. Once hemodynamically stable he was transferred to floor. Upon transfer to floor there were no further active issues during his stay for the malfunctioning gastric tube. He continued to tolerate his tube feedings. He is being discharged back to rehab on hospital day 3 and will return for his Neurosurgical and Neurology follow up as previously scheduled. Evaluation of resuming his Norvasc should be ongoing upon return to rehab to determine when can be restarted. Medications on Admission: Plavix 75mg daily, Aspirin 325mg, daily, colace 100mg [**Hospital1 **], proscar 5mg Daily, hydrochlorothiazide 25mg daily, Novolog 70/30 23 units SC BID, lisinopril 20mg daily, Oxybutynin 5mg daily, KCl 10meq daily, Zocor 40mg daily, Flomax Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) ML Injection TID (3 times a day). 2. aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 3. oxybutynin chloride 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 4. tamsulosin 0.4 mg Capsule, Ext Release 24 hr [**Hospital1 **]: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 5. simvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 6. hydromorphone 2 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 7. hydrochlorothiazide 12.5 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY (Daily). 8. trazodone 50 mg Tablet [**Hospital1 **]: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 9. clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 10. Protonix 40 mg Susp,Delayed Release for Recon [**Hospital1 **]: Forty (40) MG PO once a day. 11. Heparin Flush (10 units/ml) 2 mL IV PRN picc line 12. ipratropium bromide 0.02 % Solution [**Hospital1 **]: One (1) Neb Inhalation every six (6) hours as needed for shortness of breath or wheezing. 13. insulin NPH & regular human 100 unit/mL (70-30) Suspension [**Hospital1 **]: Twenty Three (23) units Subcutaneous twice a day: to be given at breakfast and dinner time. 14. Humalog 100 unit/mL Solution [**Hospital1 **]: One (1) dose Subcutaneous four times a day as needed for per sliding scale: See attached sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Gastric feeding tube malfunction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital for evaluation of your malfunctioning feeding tube. The tube was repositioned and is now functioning properly - the tube feedings have been resumed. Followup Instructions: ?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) 739**], to be seen in 4 weeks. ?????? You have follow-up at the Brain [**Hospital 341**] Clinic on [**10-19**] at 4 pm. [**Location (un) 858**] [**Hospital Ward Name 23**] Building. Phone: Phone: [**Telephone/Fax (1) 1844**]. You will need an MRI of the brain with and without gadolinium contrast. Department: NEUROLOGY When: MONDAY [**2172-10-19**] at 4:00 PM With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 1844**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2172-10-12**]

[ "272.4", "V45.89", "V12.54", "401.9", "250.00", "443.9", "V58.67", "496", "536.42", "414.01", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "96.6" ]

icd9pcs

[ [ [] ] ]

4716, 4786

2199, 2936

302, 308

4862, 4862

1801, 2176

5244, 6000

1341, 1350

3228, 4693

4807, 4841

2962, 3205

5037, 5221

1380, 1782

247, 264

336, 966

4877, 5013

988, 1213

1229, 1325

23,098

134,689

46024

Discharge summary

report

Admission Date: [**2107-8-8**] Discharge Date: [**2107-8-18**] Date of Birth: [**2031-6-16**] Sex: M Service: SURGERY Allergies: Percocet Attending:[**First Name3 (LF) 301**] Chief Complaint: recurrent umbilical hernia Major Surgical or Invasive Procedure: open repair of umbilical hernia with mesh History of Present Illness: He is a 75-year-old gentleman with a history of umbilical hernia that was repaired primarily. He has since had multiple recurrences. He reports five to six recurrences that have been repaired. He reports that his last repair was about two years ago and was done with mesh via open technique. During that admission, his course was complicated by an abscess and bowel injury. His current recurrence was noted approximately a year and half ago. Since then, the hernia has increased in size. He currently has complaints of intermittent nausea and vomiting as well as some discomfort at the site of the hernia. Past Medical History: hypertension, ulcer disease, and arthritis. His past surgical history is as above. Social History: Social history is significant for a past smoker but quit several years ago. He denies any alcohol use. Family History: His family history is noncontributory Physical Exam: Physical examination, he is afebrile with normal vital signs. He is in no acute distress. He is alert and oriented x3. His HEENT exam is unremarkable. His lungs are clear to auscultation bilaterally. His heart is regular without murmurs, rubs, or gallops. His abdomen is soft, nontender, and nondistended. He has multiple incisional scars from his prior repair. His examination is consistent with some degree of loss of domain. He has a recurrent hernia in his left flank region. The defect measures between 3-5 cm. With degree of Valsalva maneuver, the hernia sac easily fills up with intestinal contents but is reducible. Pertinent Results: [**2107-8-8**] 10:39AM HCT-40.8 [**2107-8-8**] 10:39AM MAGNESIUM-2.0 [**2107-8-8**] 10:39AM POTASSIUM-4.7 [**2107-8-8**] 10:39AM BLOOD Hct-40.8 [**2107-8-10**] 09:35AM BLOOD Glucose-170* UreaN-11 Creat-0.9 Na-136 K-4.0 Cl-99 HCO3-27 AnGap-14 CT Abd/Pelvis: 1. Ventral abdominal wall hernia with findings consistent with small-bowel obstruction with transition point at the inferior aspect of the ventral hernia on the right. 2. 11.5 cm x 2.5 cm fluid collection deep to the surgical bed in the left lower abdominal wall. Small foci of free intraperitoneal gas and subcutaneous stranding consistent with recent surgery. 3. Sigmoid diverticulosis without evidence of diverticulitis. 4. Emphysema. 5. Right lower lobe and right middle lobe patchy airspace opacities consistent with aspiration Vs. frank pneumonia. 6. Limited examination for pulmonary embolus due to bolus timing. However, no large central pulmonary emboli are demonstrated. Brief Hospital Course: On POD0, the patient was admitted to surgery and was brought to the OR for open repair of a umbilical hernia. The patient was transferred from the PACU to the floor with an epidural, NGT, foley, and left NPO. On POD1, epidural, NGT, and foley were d/c'ed. On POD2, patient was awaiting bowel function and diet was advanced to clear liquids. On POD3, the patient had two episodes of emesis with a decrease in O2 sat. Patient was transferred to the MICU for aspiration, as seen on CT. Levo/flagyl/vanc were started, NGT was placed, and the patient was made NPO. On POD4, the patient was transferred back to the floor. On POD5, the foley was d/c'ed, and the patient remained NPO. On POD6 the patient's vital signs and physical exam remained stable. On POD7 his NGT was d/ced, and ID saw him and recommended 10-14 days of empiric antibiotics. He was placed on levo, flagyl, plus vanco for wound erythema. On POD8 his diet was advanced to full, JP was d/ced. Ond POD9 his wound erythema improved in color and decreased in size. On POD9 he remained stable and was discharged for home. Medications on Admission: aspirin 81, diltiazem ER 180, Prilosec 20, and metoprolol 50. Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain, [**Month/Day/Year **]. Tablet(s) 2. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2 hours) as needed. Disp:*20 Tablet(s)* Refills:*0* 3. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet 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. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): please continue taking until last dose on [**8-26**]. Disp:*15 Tablet(s)* Refills:*0* 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Please continue taking until last dose on [**8-26**]. Disp:*30 Tablet(s)* Refills:*0* 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: recurrent incisional hernia Discharge Condition: good Discharge Instructions: Please call doctor [**First Name (Titles) **] [**Last Name (Titles) **] greater than 101, nausea/vomiting, inability to eat, wound redness/warmth/swelling/foul smelling drainage, abdominal pain not controlled by pain medications or any other concerns. Please observe the wound closely for these things. Please resume taking all medications as taken prior to this surgery and pain medications and stool softener as prescribed. Please follow-up as directed. No heavy lifting for 4-6 weeks or until directed otherwise. [**Month (only) 116**] leave wound open to air, please leave steri-strips intact until they fall off. Followup Instructions: Please call Dr. [**Last Name (STitle) 15645**] clinic early next week to set up an appointment. The phone number is [**Telephone/Fax (1) 2723**]. Completed by:[**2107-8-24**]

[ "491.20", "552.21", "998.59", "E878.8", "560.1", "507.0", "682.2", "401.9" ]

icd9cm

[ [ [] ] ]

[ "53.61" ]

icd9pcs

[ [ [] ] ]

5075, 5081

2885, 3975

293, 336

5153, 5160

1917, 2862

5832, 6010

1216, 1255

4087, 5052

5102, 5132

4001, 4064

5184, 5809

1270, 1898

227, 255

364, 972

994, 1078

1094, 1200

44,706

151,305

817

Discharge summary

report

Admission Date: [**2157-11-20**] Discharge Date: [**2157-11-25**] Service: MEDICINE Allergies: lisinopril Attending:[**First Name3 (LF) 3256**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: [**2157-11-20**] endotracheal intubation History of Present Illness: Mr. [**Known lastname **] is an 88 yo M with h/o dCHF, COPD, DM2, CKD presents with acute shortness of breath. . Per family, patient had become increasingly short of breath at home over the last few days. This morning he felt so short of breath that he insisted on coming to the ED. Also complaining of burning chest pain. Has been taking meds as prescribed, reports "maybe a few pounds" of weight gain in the last few weeks. Per records, his dry weight is about 200 lbs and upon admission his weight was 218 lbs. . Of note, the family denies that he has been having increasing symptoms of PND, orthopnea, peripheral edema, weight gain, increasing amounts or change in quality of his daily sputum, recent illness. . On arrival to the ED, VS were RR 30, HR 80s, SBP 180, SpO2 67% on RA. On exam, he was tachypneic, tight breathing with expiratory wheezes, giving one word answers to questions. Given nebulizers and solumedrol. CXR showed pulmonary edema. Started on NTG drip, given ASA. Started on BiPAP, but vomited. Place on NRB, but only satting up to 80. Intubated for hypoxia, given etomidate and succ. Stopped NTG, started propofol gtt, given 4 midaz bolus. Given 20 IV lasix and azithro/ceftraixone. Vent settings on transfer 550/16/5/100. VS on transfer 100.8 81 99/ra 16 115/48. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1.) Mild obstructive pulmonary disease: Last PFTs [**9-/2157**], FEV1 1.24 2.)? Coronary artery disease: [**8-/2152**] Stress test negative, but frequent atrial irritability. MIBI revealed normal myocardial perfusion. 3.)Diastolic congestive heart failure: [**6-27**] LVEF = 65%, E/e' > 15, MR [**First Name (Titles) **] [**Last Name (Titles) **] 4.)Hyperlipidemia 5.)Chronic renal insufficiency: baseline creatinine 1.2-1.4 6.)Diabetes mellitus, type 2 7.)GERD: on high dose PPI, h/o H.pylori gastritis 8.)Gynecomastia 9.)Hypertension 10.)Constipation 11.)Left knee osteoarthritis 12.)Pulmonary nodule 13.)Atrial ectopy- [**2146**] had atrial tach and APCs seen by Zimmetbaum- thought secondary to his lung disease. 14.) Chronic sinusitis 15.)Dysphagia 16.)Peripheral neuropathy 17.)Sexual dysfunction 18.)Elevated PSA 19.)Cataract surgery [**65**].)Dyslipidemia 21.)S/P right eye injury and blindness since childhood Social History: 40 pack year somking history but stopped in [**2124**]. Never used alcohol/illicits. He lives with his wife in a senior home and has sons in the area. Previously, he worked as a longshoreman, worked in a hardware store, and worked in a security. Originally from [**State 5111**], moved to [**Location (un) 5770**] and met his wife in [**Name (NI) 5771**]. Has 8 living children, many grandchildren and a few great-grandchildren. Family History: reviewed and Not contributory Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 98.8, BP: 140/63, P: 75, R: 18 O2: 99% vented General: intubated, sedated HEENT: PERRLA, oropharynx clear and moist Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, + SEM murmur best at left sternal border without radiation to the carotids or axillae Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . DISCHARGE PHYSICAL EXAM: Vitals: afebrile, VSS, O2 sats mid 90s on 2L O2 (on O2 at baseline) CV: Regular rate and rhythm, normal S1 + S2, + SEM murmur best at left sternal border without radiation to the carotids or axillae Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Ext: no cyanosis, no edema Pertinent Results: ADMISSION LABS: [**2157-11-21**] 12:40AM BLOOD WBC-7.2 RBC-3.87* Hgb-9.6* Hct-30.4* MCV-79* MCH-24.9* MCHC-31.7 RDW-18.1* Plt Ct-330 [**2157-11-21**] 12:40AM BLOOD Neuts-88.6* Lymphs-7.9* Monos-2.3 Eos-1.1 Baso-0.2 [**2157-11-20**] 11:10PM BLOOD PT-12.0 PTT-34.0 INR(PT)-1.1 [**2157-11-20**] 11:10PM BLOOD Glucose-158* UreaN-21* Creat-1.4* Na-138 K-4.2 Cl-98 HCO3-28 AnGap-16 [**2157-11-21**] 05:59AM BLOOD ALT-10 AST-17 LD(LDH)-243 AlkPhos-103 TotBili-0.5 [**2157-11-20**] 11:10PM BLOOD proBNP-1530* [**2157-11-20**] 11:10PM BLOOD cTropnT-<0.01 [**2157-11-21**] 11:01AM BLOOD CK-MB-2 cTropnT-<0.01 [**2157-11-21**] 05:59AM BLOOD Calcium-9.0 Phos-2.9 Mg-1.5* [**2157-11-21**] 12:36AM BLOOD Type-ART PEEP-5 pO2-151* pCO2-53* pH-7.36 calTCO2-31* Base XS-3 Intubat-INTUBATED [**2157-11-21**] 12:36AM BLOOD Hgb-9.8* calcHCT-29 O2 Sat-99 [**2157-11-21**] 12:36AM BLOOD Lactate-2.4* [**2157-11-20**] 11:00PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005 [**2157-11-20**] 11:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG . MICRO: [**11-20**], 12/5 BLOOD CULTURES NGTD [**11-21**] URINARY LEGIONELLA ANTIGEN NEGATIVE . IMAGING: [**11-20**] CXR COMPARISON: [**2157-8-30**]. FINDINGS: Single frontal view of the chest demonstrates interval increase of bilateral fluffy perihilar and infrahilar opacities as well as obscured and prominent cardiac silhouette, compatible with moderate congestive heart failure. There is persistent opacity involving the cardiophrenic angles. Supervening pneumonia and or aspiration cannot be excluded in the appropriate clinical setting. Small effusions cannot be excluded. There is no pneumothorax. Atherosclerotic calcifications are seen in the aortic arch. IMPRESSION: 1. Findings compatible with moderate congestive heart failure, with interval worsening since [**2157-8-30**]. 2. Supervening lower lobe infection and/or aspiration cannot be excluded in the appropriate clinical setting. . [**11-22**] CXR: FINDINGS: In comparison with the study of [**11-20**], there is continued enlargement of the cardiac silhouette with decreasing pulmonary vascular congestion. Confluent lower lobe opacities are consistent with regions of pneumonia, especially at the right base. The endotracheal and nasogastric tubes have been removed. . Labs on Discharge: . [**2157-11-25**] 06:07AM BLOOD WBC-8.5 RBC-4.07* Hgb-10.0* Hct-31.9* MCV-79* MCH-24.7* MCHC-31.4 RDW-17.5* Plt Ct-340 [**2157-11-25**] 06:07AM BLOOD Glucose-114* UreaN-26* Creat-1.2 Na-140 K-3.9 Cl-97 HCO3-35* AnGap-12 [**2157-11-25**] 06:07AM BLOOD Calcium-8.7 Phos-4.0 Mg-2.0 Brief Hospital Course: This is an 88 year old male with a history of COPD and diastolic CHF who is admitted with 1 day of shortness of breath and intubated in the ED for hypoxia found to have CHF exacerbation and community acquired pneumonia. . # CHF exacerbation: On admission, patient was in severe respiratory distress requiring intubation in the ED for hypoxia. CXR demonstrated fluid overload. BNP was elevated only mildly, to 1530. Per family and patient, he did not make any diet changes and was compliant with medications, thus cause of exacerbation is unclear. However, he was up 18 lbs from his dry weight. ACS was ruled out as a cause of CHF exacerbation with 2 sets of neg cardiac enzymes. Patient responded well to diuresis with Lasix 40mg IV and was transitioned to Lasix 40mg PO qd and finally to home dose of Lasix 20mg PO qd. On discharge, patient was at his dry weight of 200 lbs. Symptom control with albuterol and ipratroprium nebs. Continued diltiazem, losartan for BP control. On discharge, patient was set up with VNA services as well as telemonitoring for daily weights. . # Pneumonia: On admission, CXR consistent with a bilateral pneumonia given the fluffy bases which have a slight nodularity. This could be consistent with a bacterial or viral illness. However, he did not initially have leukocytosis and his family denied recent increase in sputum, fevers, muscle aches, or generalized illness. Urine legionella was negative. Patient was treated for CAP with Ceftriaxone/Azithromycin. Patient was then transitioned to Levofloxacin 750mg PO qd and was discharged with a prescription to complete a 7 days course of antibiotics. . #CAD: Continue statin, ASA for CAD primary prevention . # Chronic obstructive pulmonary disease (COPD): History of non-compliance with his advair due to costliness and also trouble getting his oxygen at home. Continued albuterol/ipratroprium, advair when extubated. Because he was not wheezing on exam and his CXR was more consistent with volume overload than hyperinflation, the steroids that were started in the ED were not continued in the ICU. . # Chronic kidney disease: Admission Creatinine was at baseline. . # Diabetes mellitus, type 2 (DMT2): Maintained on sliding scale. . # GERD: Continued PPI . TRANSITIONAL ISSUES: - FULL CODE Medications on Admission: ALBUTEROL SULFATE - 90 mcg qid ALBUTEROL SULFATE - 2.5 mg/3 mL neb q6h CITALOPRAM - 20 mg daily DILTIAZEM HCL 240 mg daily ERYTHROMYCIN - 5 mg/gram Ointment right eye at bedtime FLUTICASONE - 50 mcg Spray [**Hospital1 **] nasal FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose [**Hospital1 **] FUROSEMIDE - 20 mg daily GLIPIZIDE - 10 mg [**Hospital1 **] IPRATROPIUM BROMIDE - 0.2 mg/mL neb q6 LOSARTAN - 50 mg daily LOVASTATIN - 10 mg daily OMEPRAZOLE - 40 mg daily PIOGLITAZONE [ACTOS] 15 mg daily RANITIDINE HCL - 300 mg bedtime ASPIRIN - 81 mg daily Discharge Medications: 1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Inhalation four times a day. 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 3. citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1) Ophthalmic at bedtime: apply to right eye. 5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Nasal twice a day. 6. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 7. glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day. 8. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 9. losartan 50 mg Tablet Sig: One (1) Tablet PO once a day. 10. lovastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 11. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 12. pioglitazone 15 mg Tablet Sig: One (1) Tablet PO once a day. 13. ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO at bedtime. 14. diltiazem HCl 240 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day. 15. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 1 days. Disp:*1 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: PRIMARY DIAGNOSIS Acute diastolic heart failure exacerbation Pneumonia . SECONDARY DIAGNOSIS Chronic obstructive pulmonary 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 the hospital because you were having difficulty breathing. We think that you had an exacerbation of your chronic heart failure. You were treated by removing fluid from your lungs with furosemide (lasix) at higher doses than you take at home. You also had a breathing tube in to breathe for you. The tube was removed and you did very well. You were also found to have a pneumonia which was treated with antibiotics. You will need to finish taking the antibiotics at home. . The following changes were made to your medications: -START Levofloxacin 750mg; take it ONCE on SUNDAY, [**11-28**] . It is very important that you keep all of the follow-up appointments listed below. . It is also very importan that you weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. . It was a pleasure taking care of you in the hospital! Followup Instructions: Department: [**Hospital3 249**] When: WEDNESDAY [**2157-11-30**] at 10:40 AM With: [**Doctor First Name **] FERN, RNC [**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: [**Hospital3 249**] When: TUESDAY [**2158-1-10**] at 10:40 AM With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**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: PULMONARY FUNCTION LAB When: MONDAY [**2158-3-20**] at 11:40 AM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2157-11-27**]

[ "585.9", "491.21", "564.00", "250.00", "518.81", "428.0", "428.33", "403.90", "530.81", "715.96", "369.60", "482.9", "424.0", "356.9", "272.4", "397.0", "285.9", "584.9" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

11454, 11511

7083, 9343

240, 283

11686, 11686

4423, 4423

12774, 13641

3488, 3519

9993, 11431

11532, 11665

9403, 9970

11837, 12751

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1634, 2082

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6778, 7060

311, 1615

4439, 6759

11701, 11813

2104, 3025

3041, 3472

4109, 4404

81,692

181,596

52716

Discharge summary

report

Admission Date: [**2184-3-5**] Discharge Date: [**2184-3-20**] Service: MEDICINE Allergies: Penicillins / Ciprofloxacin / Cefazolin / Adhesive Tape / Ceftriaxone Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Primary Care Physician: [**Name Initial (NameIs) 141**] . Chief Complaint: elevated INR Major Surgical or Invasive Procedure: none. History of Present Illness: [**Age over 90 **]M with extensive pmhx including CAD, CHF EF 30%, MR, HTN, gout, on coumadin for afib found to have INR >6 at PCP earlier this week and on repeat today INR 9.5. He has remained asymptommatic denying bruising or bleeding. Has home caretaker who is with him 24hours and administers medications. Coumadin had been held for 3 days prior to presentation today and despite this, INR continued to climb in the absence of any other changes. . In the ED, initial VS were: 97.0 70 115/70 18 99. Labs were notable for INR 8.4, Creatinine of 3.4 up from baseline around 1.5. Patient was given po vitamin K 5mg x1 and NS at 75cc/hr due to known EF. Active type and screen was sent. Abdomen distended but typical per care taker. Very hard of hearing. Alert but not good historian. Vitals on transfer were 96.7 76 115/65 18 100% on RA. . On the floor, home health assistant reported no recent changes in activity, urine output, intake, diarrhea, new complaints, fevers, chills. Approximately 3 weeks ago metoprolol and imdur we readded to his medication regimen w/ subsequent brief hypotension to 70s that was treated at home w/ po liquids and salt and discontinuation of metoprolol/imdur. His lasix has recently been increased to 20mg/40mg every other day. Otherwise nothing at all has been out of the ordinary. The patient reports darkening of his urine and some mild increase in work of breathing and fatigue with mild abdominal distention and bloating over last 3 days but otherwise denies ROS. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough. 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: Cardiomyopathy with EF 30%, no evidence for CAD on cath [**2176**] Mitral regurgitation S/p right knee replacement, complicated by numerous infections, now s/p removal of knee, spacer in place, needs to wear knee immobilizer HTN Afib on coumadin CHF (Echo done in [**2178-11-4**] in [**State 108**] showed marked [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 13385**], moderately severe LV dilatation and global hypokinesis with inferolateral akinesis and estimated EF of 25% to 30% with moderate MR. [**First Name (Titles) **] [**Last Name (Titles) 29817**] at that time showed no significant CAD with severe systolic LV dysfunction with 2+ mitral regurgitation) Status post DDDR pacemaker in [**2176**] Aspiration pneumonia [**2180**] per family at the [**Hospital 11461**] hospital, pt had g tube placed for feeding for a period of time. H/o DVT of the right lower extremity in [**2177**] Gout BPH H/o parotitis treated with antibiotics H/o of chronic diarrhea (pancreatic insufficiency) H/o C diff colitis ([**2179**]) DJD Inguinal hernia remote CCY Psoriatic arthritis Social History: Lives at home, with an occupational therapist who lives with him. His wife has [**Name (NI) 2481**] disease, and resides in [**Location (un) 67583**]. At baseline patient uses motorized wheelchair. Health care proxy: [**Name (NI) **] (son) [**Telephone/Fax (1) 108757**] (cell) and [**Telephone/Fax (1) 108758**] (home) [**Doctor First Name 19948**] (daughter) [**Telephone/Fax (1) 108759**] (cell) and [**Telephone/Fax (1) 108760**] (home) Occupational Therapist who lives w/ him: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17**] [**Telephone/Fax (1) 108754**] (cell) and [**Telephone/Fax (1) 108761**] (home)and his son [**Name (NI) **] [**Name (NI) 108752**] of [**Name (NI) 745**] as his joint HCPs. Family History: Non-contributory Physical Exam: Vitals: T 96.7 HR 72 BP 132/59 RR 22 POx 93 % on RA. General: Alert, oriented, mildly tachypnic but speaking in full sentences HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP at 6cm, no LAD Lungs: Decreased BS at bases b/l w/ occassional inspiratory rhochi, no wheezes, rales, no cough CV: Irreg, irreg, HS distant normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, + distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 1+ pulses, no clubbing, cyanosis, 1+ woody edema to knees Pertinent Results: ADMISSION LABS: [**2184-3-5**] 05:40PM WBC-6.3 RBC-3.81* HGB-8.8* HCT-30.0* MCV-79* MCH-23.1* MCHC-29.3* RDW-19.4* [**2184-3-5**] 05:40PM NEUTS-65.5 LYMPHS-22.9 MONOS-8.0 EOS-3.4 BASOS-0.2 [**2184-3-5**] 05:40PM PLT COUNT-133* [**2184-3-5**] 12:30PM PT-79.3* INR(PT)-9.5* [**2184-3-5**] 05:40PM GLUCOSE-100 UREA N-90* CREAT-3.5*# SODIUM-139 POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-22 ANION GAP-18 . REPORTS: [**2184-3-5**] CXR AP: Comparison is made with the prior chest x-ray. On today's film the lung volumes are slightly lower. Some upper zone re-distribution is present but the costophrenic angles are sharp. Heart remains enlarged. Appearances suggest mild failure. RENAL U/S [**2184-3-6**]: IMPRESSION: 1. No evidence of hydronephrosis. 2. Left renal cyst. 3. New small-to-moderate ascites throughout the abdomen. ECHO [**2184-3-8**]: The left atrium is markedly dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed (LVEF= XX %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The right ventricular cavity is dilated with depressed free wall contractility. The ascending aorta is mildly dilated. There are three aortic valve leaflets. The aortic valve leaflets are moderately 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. Moderate to severe (3+) 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 no pericardial effusion. IMPRESSION: Moderately dilated left ventricle with severe global hypokinesis. Dilated and hypokinetic right ventricle. Moderate to severe mitral regurgitation. Moderate pulmonary hypertension and tricuspid regurgitation. Brief Hospital Course: [**Age over 90 **] yo M with CAD, CHF EF30%, HTN, afib on coumadin who presents with elvated INR to 9.5 and new acute on chronic renal failure. He was originally admitted to [**Hospital1 1516**] for diuresis with IV lasix, but required transfer to the CCU for milrinone drip after IV lasix failed to achieve adequate diuresis. He is being discharged on metolazone and torsemide for diuresis. In addition, his congestive heart failure medication regimen was optimally managed to also include the initiation of digoxin and metoprolol. . CCU Course: Patient was admitted to the CCU for acute on chronic heart failure and failure to diurese on lasix drip. He was started on lasix drip, milrinone, and metolazone with excellent response. He diuresed a net negative 8.5 liters length of stay and his perepheral edema has resolved and his renal failure improved. The patient also was treated for a UTI for 5 days with vancomycin and meropenem from [**2184-3-14**] until [**2184-3-18**]. As a result he developed thrombocytopenia from 100s to the 50s over the past 4 days probably from the antiobiotics, PLTs were stable at ~100 at the time of discharge. ID was curbsided who recommended dc'ing the antibiotics as the original U/A was not significantly dirty and the cultures were thought to be likely contaminant. The antibiotics were discontinued just prior to transfer to the floor. Finally the patient also had nightly episodes of delerium/agitation, most likely secondary to ICU delerium and disturbed sleep-wake cycle. This resolved after reorientation. The patient was transferred back to the [**Hospital1 1516**] service on a PO regimen of torsemide 60mg daily and metolazone with the eventual goal to discharge the patient in [**12-6**] days. . # Acute on Chronic Renal Failure - Creatinine rose to 3.5 from baseline of 1.5-2.0. It was initially felt that his acute on chronic renal failure was secondary to poor forward flow from heart failure. He was diuresed with some improvement in her creatinine to 3.4 (peak of 4.1). His urine studies were more consistent with an intrinsic process. The renal team was consulted and felt that this was prerenal etiology. Renal ultrasound was negative for hydronephrosis. Creatinine was 3.4 at time of discharge. SPEP/UPEP were normal. The patient had a mild anion gap acidosis from renal failure which resolved with improvement with creatinine. . # Atrial fibrillation: The patient was anticoagulated for atrial fibrillation. The reason for his INR elevation to 9.4 in the setting of holding his warfarin is uncertain except for possible medication interactions in the setting of renal failure. He was given vitamin K and his INR trended down to a therapeutic range. His warfarin was restarted. He remained in atrial fibrillation throughout his course. He was not on any rate controlling medications on admission, but a low dose beta blocker was started. He was restarted on his warfarin at 2.5 mg daily. INR will need to be monitored as an outpatient and dose adjusted accordingly. . # Anemia/Thrombocytopenia - At baseline dating back to [**2183-12-5**]. Likely secondary to chronic disease. Started on ferrous sulfate supplementation as iron noted to be low. HCT stable at 30 at time of discharge. . # Hypothyroidism: Thyroid function tests were done on admission and TSH was found to be elevated. The patient's dose of levothyroxine was increased from 75 mcg daily to 100 mcg daily. He will need repeat TFTs to monitor as an outpatient. . # The following medical issues remained stable during this hospitalization: coronary artery disease, and depression. He was continued on his home medications. He was also started on trazodone for treatment of his insomnia. . # Code: DNR/DNI (confirmed this admission). # Emergency Contact: Health care proxy: [**Name (NI) **] (son) [**Telephone/Fax (1) 108757**] (cell) and [**Telephone/Fax (1) 108758**] (home) [**Doctor First Name 19948**] (daughter) [**Telephone/Fax (1) 108759**] (cell) and [**Telephone/Fax (1) 108760**] (home) Occupational Therapist who lives w/ him: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17**] [**Telephone/Fax (1) 108754**] (cell) and [**Telephone/Fax (1) 108761**] (home)and his son [**Name (NI) **] [**Name (NI) 108752**] of [**Name (NI) 745**] as his joint HCPs. . He will have close outpatient follow-up with Dr. [**Last Name (STitle) 141**] within 1-2 weeks post discharge. Medications on Admission: Dovonex 0.005% top [**Hospital1 **] Flomax 0.4mg HS levothyroid 75mcg daily lexapro 10mg daily ALLOPURINOL 100 mg QHS PANTOPRAZOLE 40 mg AM QUETIAPINE 25 mg QHS WARFARIN 2.5mg M/W/F, 5mg all other CAMPHOR-MENTHOL 0.5 %-0.5 % Lotion TID prn itching DOCUSATE SODIUM 100mg twice a day Simvastatin 10mg daily **recent d/c of imdur and metoprolol last 2 weeks Discharge Medications: 1. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Quetiapine 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily) as needed for constipation. 5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:*45 Tablet(s)* Refills:*2* 9. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:*30 Tablet(s)* Refills:*2* 10. Torsemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): Take 30 minutes after metolazone. Disp:*90 Tablet(s)* Refills:*2* 11. Metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Take 30 minutes before torsemide. Disp:*30 Tablet(s)* Refills:*2* 12. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day. Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* 14. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. Disp:*30 Tablet(s)* Refills:*0* 15. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO at bedtime. Disp:*30 Capsule(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Acute on chronic congestive heart failure. Anemia of chronic disease. Hypothyroidism. Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname 108752**], you were admitted to the hospital because of shortness of breath and swelling caused by your known congestive heart failure. You were treated with diuretic medications and your condition improved. During your hospital stay, your thyroid function tests were noted to be abnormal. As a result, we increased your thyroid medication dose. You will need to have your thyroid tests checked again as an outpatient in about one month. In addition, your pacemaker settings were changed during this admission to better pace your heart. You are now deemed medically stable for discharge to home. . The following changes have been made to your medications: 1. STOP SIMVASTATIN. 2. STOP FLOMAX. 3. STOP ALLOPURINOL. 4. STOP LASIX (FUROSEMIDE). 5. STOP SPIRINOLACTONE. 6. START TRAZODONE 25 mg by mouth at bedtime as needed for insomnia. 7. START Potassium Chloride 40 mEq by mouth daily. 8. START Metolazone 5 mg by mouth daily; take 30 minutes prior to torsemide for diuresis. 9. START Torsemide 60 mg by mouth daily for diuresis. 10. START Metoprolol 12.5 mg by mouth three times per day for heart disease and blood pressure control. 11. START Digoxin 0.0625 mg by mouth daily for heart disease. 12. START Ferrous Sulfate 325 mg by mouth daily for anemia. 13. WARFARIN (COUMADIN) 2.5 mg by mouth MWF and 5 mg all other days CHANGED TO WARFARIN (COUMADIN) 2.5 mg by mouth daily. 14. Levothyroxin (Synthroid) 75 mcg by mouth daily CHANGED TO Levothyroxin (Synthroid) 100 mcg by mouth daily. 15. START Oxazepam (Serax) 10 mg by mouth at bedtime . Please weigh yourself every morning, and call your doctor if your weight goes up more than 3 pounds. It has been a pleasure caring for you during this hospital stay. Followup Instructions: Please schedule an appointment with Dr. [**Last Name (STitle) 141**] within [**12-6**] weeks of discharge from the hospital. His office phone number is: ([**Telephone/Fax (1) 100950**]. Completed by:[**2184-3-21**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

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373, 380

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188,301

43877

Discharge summary

report

Admission Date: [**2142-9-16**] Discharge Date: [**2142-10-6**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 134**] Chief Complaint: chest pain, dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: . HPI: 84yo man with PMH of s/p colostomy for UC, presents with dyspnea x several days associated with cough and increasing episodes of chest pain relieved by sl NTG. Per the pt's family, he has had several years of dyspnea on exertion. He was in his USOH until several weeks ago, when they noticed increasing dyspnea with little exertion and cough productive of white phlegm, which is new for him. Beginning several days prior to admission, he began to have episodes of chest pain which were relieved with one sublingual NTG. Per the ED note, these episodes of SSCP, occurring at rest, had no radiation and lasted several minutes. Today, he had an episode witnessed by his family, when he had dyspnea and looked [**Last Name (LF) **], [**First Name3 (LF) **] they brought him to the emergency room. Per the family, he has never used NTG prior to the past several days. They are unaware of any heart problems he may have or why his PCP prescribed NTG in the first place. Family denies PND, edema, palpitations. Notes recent PCP visit [**Name Initial (PRE) **]/ ECHO, unclear results. . In the ED, the pt was noted to be tachycardic and in mild respiratory distress. He had JVP to his jaw and crackles at bilateral lung bases. A CXR showed mild CHF and an EKG showed atrial flutter with ventricular rate to 130s. He was also noted to have positive cardiac enzymes with troponin 3.16, CK 302, MB 27, MBI 8.9. Heparin was initiated. His BP fell to 70s/50s, and he was cardioverted at 150J with successful conversion to NSR (after attempting with 1 amp calcium, D50, and insulin for hyperkalemia to 5.5). He was noted to have increased dyspnea and sats 85% on [**Last Name (LF) 597**], [**First Name3 (LF) **] he was given 40mg IV lasix x 2. He was started on a nitro gtt to decrease preload and placed on BIPAP with resulting sats of 100%. . Past Medical History: s/p colostomy placement for ulcerative colitis ?HTN ?hiatal hernia no hypercholesterolemia per family no DM, CVA Social History: Non-contributory Family History: Non-contributory Physical Exam: PE: VS: T 95.5, HR 81, BP 90/64, RR 25, SaO2 97%/BIPAP Genl: pt sitting up in chair, BIPAP in place, anxious, wants to take off mask HEENT: NCAT, MMM, BIPAP in place Neck: JVP up to jawline CV: RRR, no S1, S2, no m/r/g Pulm: bilateral rales approx [**12-10**] way up lungs, no wheezes Abd: soft, NTND, BS+, colostomy bag Ext: warm, dry, no pitting edema, PP 2+ Neuro: appropriate, difficult to assess w/ pt in resp distress Pertinent Results: [**2142-9-16**] 11:00AM BLOOD WBC-16.2* RBC-3.49* Hgb-10.5* Hct-31.1* MCV-89 MCH-30.0 MCHC-33.8 RDW-14.4 Plt Ct-199 [**2142-10-3**] 06:45AM BLOOD WBC-12.8* RBC-3.75* Hgb-11.2* Hct-34.5* MCV-92 MCH-29.8 MCHC-32.4 RDW-14.5 Plt Ct-369 [**2142-10-4**] 12:50PM BLOOD Hct-43.2# [**2142-9-16**] 11:00AM BLOOD PT-14.7* PTT-34.1 INR(PT)-1.5 [**2142-10-3**] 06:45AM BLOOD Plt Ct-369 [**2142-9-16**] 11:00AM BLOOD Glucose-117* UreaN-75* Creat-3.5*# Na-135 K-5.5* Cl-104 HCO3-12* AnGap-25* [**2142-10-5**] 06:35AM BLOOD Glucose-117* UreaN-94* Creat-4.3* Na-148* K-6.8* Cl-112* HCO3-19* AnGap-24* [**2142-9-28**] 03:55AM BLOOD ALT-27 AST-47* LD(LDH)-455* AlkPhos-146* Amylase-270* TotBili-1.0 [**2142-9-16**] 11:00AM BLOOD CK-MB-27* MB Indx-8.9* cTropnT-3.16* [**2142-9-17**] 05:20AM BLOOD Calcium-9.0 Phos-5.0* Mg-1.8 [**2142-10-4**] 06:49PM BLOOD Mg-2.9* [**2142-9-24**] 04:45AM BLOOD Cortsol-20.0 [**2142-10-4**] 06:18PM BLOOD Type-ART Temp-36.1 pO2-46* pCO2-23* pH-7.48* calHCO3-18* Base XS--3 Intubat-NOT INTUBA [**2142-10-4**] 06:18PM BLOOD freeCa-1.51* . Creatinine [**10-3**]: 1.8->1.8-> [**10-4**]: 2.3->3.1->3.6->3.7-> [**10-5**]: 4.3 . Potassium [**10-3**]: 5.2->5.3-> [**10-4**]: 5.6->hemolyzed->6.5->6.2-> [**10-5**]: 6.8 . BRAIN MRI IMPRESSION: 1. Large subacute borderzone distribution infarct. Small subacute right distal anterior cerebral artery distribution infarct. 2. Evidence of hemorrhagic transformation on right near cranial vertex. 3. Abnormal flow-related signal in petrous portion of right internal carotid artery. Evaluation was severely limited secondary to patient motion. Focal areas of stenosis, or even dissection, cannot be excluded. 4. Both middle cerebral arteries and anterior cerebral arteries are grossly patent on this limited MRA. . Brief Hospital Course: The patient was admitted with cardiogenic shock to the CCU. He was supported with pressors and fluids. The patient had an acute on chronic renal failure with oliguria. Echo revealed a very low EF of <20%. CCU care at the time focused on reducing the afterload to allow forward flow. Subsequent diuresis caused a reduction in creatinine. It was subsequently determined that the patient had been volume overloaded and diuresis was continued. He had output from his ostomy and c dif was checked and negative. He also developed weakness of his L side and hemineglect, which MRI subsequently showed to be due to a massive MCA and ACA thrombotic/embolic stroke with subsequent hemorrhagic conversion at the apex of the brain. The patient never received anticoagulation for this reason. The patient's family knew that he would have prefered not to live with a PEG, but the patient was temporarily outfitted with a dobhoff tube and fed tube feeds. The patient appeared to be temporarily stable and discussions regarding his future placemnt were initiated with the family. During this period he began to have a rising creatinine. It was not clear at this time whether his voume status was increased or decreased. He then developed large volume outputs through his ostomy after receiving kayexalate for an increased potassium in the setting of rising creatinine. At this point it was felt that he was volume depleted and volume resuscitation was initiated. The patient's potassium continued to rise despite multiple kayexalate rounds. The patient became anuric. Palliative care was consulted to help with decision making. In the face of rising potassium despite kayexalate and anuria, it was discussed with the patient's family that the chances of recovery was slim. HD was not felt to be a reasonable option and the patient was made CMO. He died comfortably at 4:41am on [**2142-10-6**]. Family was contact[**Name (NI) **] immediately. Medications on Admission: Toprol XL 200mg qd Avodart 0.5mg qd Diovan 320mg qd Zetia 10mg qd Fosamax 40mg qd Tums [**Hospital1 **] Ecotrin qd Flonase qd Caduet 40mg qd Glucosamine & Chondroitin Discharge Disposition: Expired Discharge Diagnosis: Cardiogenic Shock MCA/ACA Stroke ARF Hyperkalemia Secondary HTN Hypercholesterolemia Colostomy for UC. Discharge Condition: Death Discharge Instructions: The patient was admitted for cardiogenic shock and developed a large MCA/ACA stroke and renal failure. He became anuric and hyperkalemic. His family declined hemodialysis and his goals of care were changed to comfort care. Followup Instructions: N/A Completed by:[**2142-10-8**]

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icd9cm

[ [ [] ] ]

[ "99.61", "97.49", "99.04", "96.04", "93.90", "96.08", "89.64", "96.72", "38.93" ]

icd9pcs

[ [ [] ] ]

6778, 6787

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281, 287

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315, 2156

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3048

Discharge summary

report

Admission Date: [**2128-11-30**] Discharge Date: [**2128-12-13**] Date of Birth: [**2052-7-24**] Sex: F Service: Medicine. #58 HISTORY OF PRESENT ILLNESS: The patient is a 76 year old female with a past medical history significant for coronary artery disease, status post coronary artery bypass graft in [**2121**]; diabetes mellitus, type II, insulin dependent; congestive heart failure and a four month history of progressive dementia with psychosis since a toe amputation surgery in [**2128-7-20**]. She presented with decreased p.o. intake, decreased responsiveness times three days, at the nursing home. Of note, the patient has chronic Foley, sacral decubitus ulcers and foot ulcers. PAST MEDICAL HISTORY: Coronary artery disease, status post four vessel coronary artery bypass graft in [**2111**]; diabetes mellitus, type II; hypertension; hypothyroidism; dementia; congestive heart failure, stage IV; back surgery; history of cellulitis; status post right total knee replacement. SOCIAL HISTORY: The patient is a nursing home resident. The patient has a close relationship with her husband and daughter. 20 pack year tobacco history but has quit. No history of alcohol use. FAMILY HISTORY: Noncontributory. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Nitropatch 0.4 mg. Aspirin 81 mg q. day. Toprol XL 50 mg q. day. Lasix 40 mg p.o. twice a day. Neurontin 600 mg three times a day. Fentanyl patch 25 mg q. three days. Oxycontin 10 mg twice a day. Levoxil 137 mcg q. day. Trazodone 50 mg q.i.d. Trazodone 50 mg q. four hours prn. Risperdal 1 mg p.o. q h.s. Risperdal 0.5 mg p.o. q. six hours prn. Ativan 1 mg q. six hours prn. NPH 24/12 plus regular insulin sliding scale. Senna q h.s. PHYSICAL EXAMINATION: Initial examination revealed a temperature of 103.4; heart rate of 116; blood pressure of 130/28; respiratory rate of 30 and oxygen saturation of 91% on room air. The patient was an ill-appearing female, in no acute distress; minimally responsive to painful stimuli. She had diffuse coarse breath sounds with a 2 out of 6 systolic murmur. She had normal bowel sounds without rebound or guarding. She had a sacral decubitus ulcer. LABORATORY DATA: CBC was significant for white blood cell count of 19.6 with 70 neutrophils, 25 bands, 3 lymphocytes; hematocrit of 31. Chemistry 7 was significant for BUN of 50 and creatinine of 1.4. Lactate was 5.9. Cardiac enzymes were sent and were sent for a troponin of 0.17. Urinalysis was significant for positive nitrites, moderate leukocyte esterase. Electrocardiogram: Normal sinus rhythm at 67 beats per minute with a left axis deviation; old Q wave in V1 and V2 with T wave inversions in 3, AVF and V1 through V3. HOSPITAL COURSE: Since the patient had fever, tachycardia, increased white blood cell count with pronounced left shift and increased lactate, tachypnea and hypoxia, the patient was felt to be experiencing sepsis. Sepsis protocol was activated. The right internal jugular was placed and the patient received intravenous hydration, empiric antibiotic coverage (Levofloxacin, Gentamycin, Vancomycin) and was intubated for airway protection. The patient was then transferred to the Medical Intensive Care Unit for intensive monitoring. The rest of the hospital course is described by systems: 1.) Pulmonary: The patient was initially intubated for airway protection. Chest x-ray revealed no focal consolidation or pleural effusion. The patient was extubated on hospital day number two without complications. The patient's pulmonary status remained stable for the rest of the admission. 2.) Cardiac: As stated previously, initial cardiac enzymes were significant for a troponin of 0.17. Electrocardiogram was significant for some new T wave inversions. These changes were felt to be in the setting of demand ischemia. The patient had an echocardiogram done during the admission which revealed moderate mitral regurgitation and a left ventricular ejection fraction of 35%. 3.) Infectious disease: The patient's blood cultures were positive for Proteus, making a urine source of infection most likely. The patient was initially started on Zosyn to cover Proteus bacteremia as well as possible anaerobes in the sacral decubitus ulcer. The patient was continued on Zosyn and became afebrile on hospital day number seven. At this time, the sacral decubitus ulcer culture was found to be positive for Proteus as well and plastic surgery felt that coverage for anaerobes was no longer necessary. As a result, the patient was switched to Ceftriaxone. On hospital day number nine, Vancomycin was added when it was found that blood cultures drawn on hospital day number 5 grew out coagulase negative Staphylococcus, resistant to Oxacillin in two out of four bottles, including one drawn through the PICC line and one drawn through a peripheral site. At this time,l the patient was still afebrile. Cultures drawn through the porta-cath and culture of the discontinued PICC line catheter tip were negative. The patient was continued on both Ceftriaxone and Vancomycin through discharge. MENTAL STATUS CHANGES: Initially, the patient was minimally responsive to even painful stimuli. The patient had a CT scan that was significant for mild hypodensity in the periventricular white matter bilaterally that was consistent with chronic microvascular infarction. The ventricles and sulci were also prominent, consistent with moderate brain atrophy. There was no evidence of acute intracranial hemorrhage or mass effect. Neurology was consulted who felt that her change in mental status reflected underlying dementia, exacerbated by a toxic metabolic encephalopathy, most likely of infectious origin. They recommended treating her multiple infections, attempting to limit her sedating medications, discontinuing the Fentanyl patch, having a well lit room and using a low dose Haldol as needed for extreme agitation. Sedating medications were limited and the infection was treated. The patient continued to improve over the course of her admission. The the patient went from minimal responsiveness to being able to answer yes and no questions to eventually being able to hold a minimal conversation with use of complete sentences. At the time of her discharge, she was oriented to person and place but not time. There was consideration of having magnetic resonance scan performed to further evaluate central nervous system pathology. However, the patient was taken down to the magnetic resonance scan suite and began screaming, which was felt to preclude the ability to obtain adequate magnetic resonance scan images. The family was consulted and treating team explained to the family that magnetic resonance scan was unlikely to provide information that could provide therapeutic benefit but was rather for diagnostic interest. As a result, the family agreed to forego magnetic resonance scan. Ulcers: Plastics was consulted for evaluation of the sacral decubitus ulcer. They debrided the ulcer and treated with a Dakin's treatment as well as wet to dry dressing changes three times a day. At the time of discharge, they felt that dressing changes could be changed to normal saline wet to dry dressing changes three times a day along with discontinuation of the Dakin's. They encouraged optimization of nutrition as well as keeping the patient rotated to decrease pressure in the sacral area. Podiatry was also consulted for evaluation of foot ulcers. They recommended bilateral multi-poultice splints to prevent further heel break-down. They recommended non invasive arterial studies when the patient is medically stable. They recommended considering a vascular surgery consult as a result of non invasive arterial studies which were poor. They did not recommend operative intervention during the current admission. Endocrine: Diabetes mellitus. The patient was managed on NPH as well as regular insulin sliding scale. At the time of discharge, the patient's insulin were 30 units of NPH at breakfast as well as 16 units of NPH at dinner. Thyroid: The patient was continued on Synthroid during her admission. Fluids, electrolytes and nutrition: The patient was maintained on a diet of ground food with supplementation of food brought by family. Hematology: The patient received transfusion of one unit packed red blood cells during her admission. Iron studies were consistent with anemia of chronic disease. DISCHARGE MEDICATIONS: Insulin sliding scale, NPH 30 units at breakfast, 16 units at dinner; Humilog insulin sliding scale. Vancomycin 1000 mg intravenous q. 12 hours. Ceftriaxone 1 gram intravenous q. 12 hours. Fentanyl patch 25 mcg per hour transdermally q. 72 hours. Metoprolol 12.5 mg p.o. twice a day; held for heart rate less than 60 or systolic blood pressure less than 100. Trazodone hydrochloride 50 mg p.o. q h.s. prn. Gabapentin 300 mg p.o. twice a day. Risperidone 0.5 p.o. q. six hours prn. Captopril 6.25 mg p.o. three times a day. Heparin 5000 u8nits subcutaneous q. 8 hours. Bowel regimen. Levothyroxine sodium 137 mcg p.o. q. day. Aspirin 81 mg p.o. q. day. Acetaminophen liquid 650 mg p.o. q. four to six hours prn. DISPOSITION: To long term care facility. DISCHARGE STATUS: Non ambulatory; able to tolerate ground diet; oriented times two; able to answer direct questions and express simple requests in a logical manner. DISCHARGE DIAGNOSES: Sepsis, likely secondary to Proteus urinary tract infection. Myocardial infarction, without ST elevation. Coronary artery disease. Sacral decubitus ulcer. Heel eschar. Dementia. Toxic metabolic encephalopathy. Hypertension. Congestive heart failure. Cardiomyopathy with left ventricular ejection fraction of 35%. Anemia of chronic disease. Diabetes mellitus, type II, insulin dependent. Hypothyroidism. Coagulase negative staph bacteremia. Diabetic neuropathy. CODE STATUS: "Do Not Resuscitate", "Do Not Intubate." DISCHARGE FOLLOW-UP: Appointment to be made for follow-up with Dr. [**First Name (STitle) 679**]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1379**] Dictated By:[**Last Name (NamePattern1) 14513**] MEDQUIST36 D: [**2128-12-13**] 03:28 T: [**2128-12-13**] 17:10 JOB#: [**Job Number 14514**]

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Discharge summary

report+addendum

Admission Date: [**2113-12-18**] Discharge Date: Date of Birth: [**2036-12-24**] Sex: F Service: [**Location (un) 259**] HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old female with multiple medical problems who was transferred from [**Hospital3 **] for management of congestive heart failure, acute on chronic renal failure, and mental status changes. The patient originally presented on [**12-11**] with complaints of increasing shortness of breath, nonproductive cough, and altered mental status. The husband stated that the patient was well until two days prior to admission to [**Hospital3 **] when she began feeling weak. Per report, she was unable to arise from the chair. She had increased pain at her decubitus ulcer site and some watery diarrhea from her colostomy site. This was associated with some shortness of breath, but the husband denied any focal pain in the chest or abdomen of the wife. The patient had a baseline creatinine of 1.4 in early [**Month (only) 1096**], and her creatinine was 1.9 on admission to [**Hospital3 21232**] which bumped to a high of 2.9 on [**12-15**] (discontinued Lasix on [**12-15**]) after aggressive diuresis and then fell back to 2.5 on transfer. Renal consult was obtained on [**12-14**] who suggested a prerenal azotemia secondary to dehydration versus congestive heart failure. They recommended stopping diuresis with Lasix, stopping the patient's ACE inhibitor, and providing gentle hydration. The patient was noted to have a urinary tract infection at the time of discharge and was started empirically on Rocephin at [**Hospital3 **]. It did not appear that she demonstrated an increase white blood cell count nor did she become febrile. Her original chest x-ray at [**Hospital1 **] demonstrated a left lower lobe consolidation (atelectasis versus pneumonia), and she was continued on Rocephin therapy. Neurology was consulted for mental status changes who suggested checking a head CT which was without evidence of bleed or mass. Other suggestions including an EEG and MRI were not performed at the time. In addition, the patient was noted to have a low hematocrit at [**Hospital3 **] with normal iron studies, normal B12, and folate. Her hematocrit stayed stable at 26-27. She had an elevated INR of 6.0 on [**12-14**], and therefore, her Coumadin was held. The patient was subsequently transferred to [**Hospital6 1760**] as it became difficult to manage her congestive heart failure in the setting of acute on chronic renal failure and secondary to mental status changes. PAST MEDICAL HISTORY: 1. Fournier's gangrene in [**2113-3-12**] (complicated by a diverting colostomy, complicated with cerebrovascular accident, right-side clot, right toe gangrene, right BKA). 2. Diabetes mellitus. 3. Coronary artery disease. 4. Congestive heart failure. 5. Chronic renal insufficiency. 6. Chronic anemia. 7. MRSA. 8. Small bowel obstruction with subsequent colostomy. 9. Chronic atrial fibrillation. 10. Patent foramen ovale. 11. Right BKA. ALLERGIES: HEPARIN, PERCOCET, OXYCODONE. Of note, the patient is exquisitely sensitive to narcotics with significant decrease in respiratory drive with as little as 1 mg Morphine IV. SOCIAL HISTORY: The patient is a resident of the nursing home of ................. She is married with no children and has a very attentive husband. She denied any alcohol or tobacco use. REVIEW OF SYSTEMS: On transfer, the patient reported generalized weakness times a few days but had somewhat improved. She denied any headache, dizziness, but was very thirsty. She denied rhinorrhea, sore throat, but complained of dry cough. She had no pleuritic chest pain. She had some shortness of breath but improved. She had no abdominal pain. She had some watery stool over the last few days. No dysuria. No lower extremity edema. She had a positive weight gain within the last few days. PHYSICAL EXAMINATION: Vital signs: Temperature 97.0??????, heart rate 84, respirations 20, oxygen saturation 91% on room air, 99% on 3 L oxygen by nasal cannula. General: The patient was lying still. She was moderately ill appearing. She was in no acute distress. HEENT: Normocephalic, atraumatic. Extraocular movements intact. Pupils equal, round and reactive to light. Oropharynx dry. No wheezing. Neck: Supple. No lymphadenopathy. JVP at 7 cm. Cardiovascular: Irregularly, irregular. There was a 2/6 systolic murmur heard best at the sternal border. Lungs: Few crackles at the bilateral bases. Abdomen: Positive bowel sounds. Colostomy in place. Soft, nontender, nondistended. No masses. No hepatosplenomegaly. Extremities: There were 2+ pulses in the upper extremities. She had decreased pulse in left lower extremity. Right BKA clean and intact. No erythema. Skin: Occasional ............... No rash. Neurological: The patient was alert and oriented times three. She was sleepy but easily arousable. She moved all four extremities. Back: There was a grade 3 sacral decubitus, packed, good granulation tissue. There was a single area of 1.5 cm of mild redness around the sacral decubitus. No discharge. No palpable abscess. Perineum: No discharge. No erythema. No palpable fluid collection or abscess. MEDICATIONS AT HOME: NPH 18 U subcue q.a.m., 10 U subcue q.p.m., Coumadin 5 mg p.o. q.d., Epogen 5000 U subcue twice a week, Imdur 60 mg p.o. q.d., Paxil 20 mg p.o. q.d., Xanax 0.25 mg p.o. b.i.d., Prevacid 30 mg p.o. q.d., Multivitamin 1 tab p.o. q.d., Duragesic 15 mcg transdermal patch to be changed q.72 hours, Accupril 10 mg p.o. q.d. MEDICATIONS ON TRANSFER: Paxil 20 mg p.o. q.d., Multivitamin 1 tab p.o. q.d., Calcium Carbonate 500 mg p.o. t.i.d., Vitamin C 500 mg p.o. q.d., Vitamin D 400 mg p.o. q.d., Senna 1 tab p.o. q.d. p.r.n., Epogen 5000 U twice a week, Imdur 30 mg p.o. q.d., Duragesic patch 50 mcg transdermal to be changed q.72 hours, Rocephin 1 g q.24 hours, Milk of Magnesia p.r.n., Dulcolax p.r.n., regular Insulin sliding scale. LABORATORY DATA AT THE OUTSIDE HOSPITAL: On [**12-17**] sodium was 143, potassium 5.6, chloride 109, bicarb 24, BUN 119, creatinine 2.5, glucose 114, calcium 10.1; hematocrit 26.6, white count 6.7, platelet count 198, differential of 71 neutrophils, 2 bands, 19 lymphs, 6 monos, 2 eos; iron 274, TIBC 439, B12 930, folate 11.3; INR 3.4; albumin 3.2. Urinalysis 1.015, nitrite positive, protein 100, few white blood cells; urine culture on [**12-11**] demonstrated Citrobacter greater than 100,000 colonies sensitive to Ceftriaxone; blood cultures on [**12-12**] without growth. Echocardiogram in [**2113-6-11**] showed normal left ventricle, normal right ventricle, ejection fraction 60%, [**12-13**]+ mitral regurgitation, 3+ tricuspid regurgitation, moderate pulmonary artery hypertension. Echocardiogram in [**2113-11-11**] showed left atrial enlargement, trace mitral regurgitation, [**12-13**]+ tricuspid regurgitation, moderate pulmonary hypertension, increased right ventricular size, increased left ventricular size, ejection fraction 40%. HOSPITAL COURSE: The patient is a 76-year-old female with multiple medical problems who was transferred from an outside hospital for further management of acute on chronic renal failure, congestive heart failure, and mental status changes. 1. Cardiovascular: The patient was known to have a history of coronary artery disease and known congestive heart failure; however, the patient had never undergone a catheterization. Echocardiogram obtained at the outside hospital in [**Month (only) 1096**] showed a decrease ejection fraction compared to her echocardiogram at our facility in [**2113-6-11**]. On original presentation to the outside hospital, the patient was thought to be in congestive heart failure and underwent significant diuresis with perhaps some component of overdiuresis. At the time of discharge to [**Hospital6 1760**], the patient was felt to be rather dry, and therefore her Lasix dose was held, and she was given a gentle fluid challenge of 500 cc. The patient responded to this with an increase in her urine output and improvement in her creatinine. A chest x-ray obtained at the time of discharge did not demonstrate any signs of heart failure, and urine electrolytes checked at the time of admission also suggested that the patient was likely dry. The patient was continued on her Imdur, and a daily Aspirin was added to her regimen given the likelihood of coronary artery disease. Given that the patient had not tolerated reinitiation of her ACE inhibitor at the outside hospital, this medication was also initially held. The patient was found to be in atrial fibrillation which is a chronic arrhythmia for her. She was therefore continued on her Coumadin once her INR had fallen to appropriate levels. Over the next few days, it was felt that the patient was likely peripherally but centrally volume overloaded. An attempt was made to provide the patient with enough fluid to adequately perfuse her kidneys and therefore correct her prerenal azotemia and yet not overload her poorly functioning hear to worsen her congestive heart failure. Therefore over the next few hospital days, the patient was treated with a low dose of Lasix, and her p.o. intake was encouraged. On the morning of [**12-20**], the patient was noted to have an acute episode of shortness of breath with a desaturation to the upper 80s on her 3 L nasal cannula. The patient was felt to suffer from diastolic cardiac dysfunction leading to flash pulmonary edema in the setting of fluid from a past red blood cell infusion. The patient was treated with Lasix, Nitropaste, and Lopressor IV to treat her tachycardia. In addition, it was felt important to restart the patient's ACE inhibitor in an effort to improve her renal perfusion. An echocardiogram was repeated which demonstrated a dilated left and right atrium, symmetric left ventricular hypertrophy, [**12-13**]+ mitral regurgitation, 3+ tricuspid regurgitation, and new left ventricular and right ventricular systolic dysfunction, with a small pericardial effusion, and an ejection fraction of 40-45%. Given the patient's evidence of systolic dysfunction, her crackles on examination, and increased oxygen requirement, she was treated with low doses of Lasix, and her ACE and Imdur were continued. Over the next few hospital days, the balance was obtained between Lasix IV and fluids in an effort to balance the patient's fluid status; however, on [**12-22**], the patient had significant abdominal pain with a fairly benign physical examination. It was thought that the patient was likely experiencing mesenteric ischemia, and an effort was made to obtain an abdominal CT scan in order to verify this possibility; however, in the setting of her rising creatinine, the patient was pretreated with fluid hydration and Mucomyst prior to obtaining the CT scan. In the setting of this fluid therapy, the patient developed increasing shortness of breath, low oxygen saturations, and increasing acidosis. At the same time, the patient was also being treated with narcotic medication including three doses of Oxycodone 5 mg p.o. in an effort to provide pain control for the patient's sacral decubitus ulcer. In the setting of fluid hydration and narcotic use, the patient had an acute episode of hypocarbic respiratory distress and was subsequently transferred to the MICU. Over the next four days in the MICU, the patient was gently diuresed to treat her pulmonary edema and was placed on a Narcan drip requiring three days of continuous Narcan therapy for reversal of her narcotic induced mental status changes and decreased respiratory drive. While in the MICU a Renal consult was obtained who suggested that given the patient's poor cardiac function, she could not maintain her baseline creatinine of 1.4, as well as clear lungs and recommended tolerating a higher creatinine in order to keep her lungs dry. It was also suggested that the patient's ACE inhibitor be discontinued and not restarted given that she had demonstrated multiple times in the past the inability to tolerate the ACE based on increasing creatinine. While in the MICU, the patient's cardiovascular status improved. She maintained a systolic blood pressure of approximately 130 to 140 and tolerated aggressive diuresis of approximately 1 L/day. On transfer back to the floor, the patient was felt to be euvolemic and was continued on her Imdur, Metoprolol 12.5 b.i.d. which was started for presumed diastolic dysfunction, Nitro transdermal patch of 0.2 mg/hr, Hydralazine 10 mg q.i.d., and a daily Lasix dose of 20 mg p.o. per day. It was clear that part of the patient's problem resulting in transfer to the MICU were secondary to narcotic overdose and subsequent hypercarbic respiratory distress; however, given the increased lactate, significant abdominal pain, and history of severe vascular disorder, it was felt likely that the patient may have experienced an intermittent mesenteric ischemia which may have also precipitated her respiratory distress. However, the patient's abdominal pain resolved in the MICU, and this was never further evaluated. On transfer back to the floor, a Cardiology consult was obtained in order to request aid in balancing the patient's congestive heart failure and poor cardiac function with her acute renal failure. Cardiology also suggested that the patient's fluid status had been difficult to ascertain and manage over the past several weeks. They recommended obtaining a stress exam with a Persantine thallium in order to assess for coronary ischemia which may be able to be reversed through catheterization. They also recommended titrating up her Hydralazine and nitrates as tolerated. A Persantine thallium was therefore obtained which demonstrated a moderately reversible defect in the inferior wall, an ejection fraction of 42%, significantly enlarged right ventricle, and global hypokinesis. Review of the stress thallium with cards in the setting of the patient's overall functional status and chronic illness, it was felt that she would not likely benefit from a cardiac catheterization, and the best course of action was to resume medical management of the patient's coronary artery disease. Over the next five or six hospital days, the patient was treated with cardiac medications including Imdur, Atenolol, Hydralazine as tolerated, as well as continuing her Nitro patch and continuing on a daily Lasix dose of 20 mg p.o. q.d. The patient maintained systolic blood pressures in the 120s and demonstrated adequate urine output during this period; Following placement of a PEG tube on [**1-4**], the patient demonstrated an acute episode of respiratory distress and hypoxia. This responded to intravenous Lasix, as well as 50-100% non-rebreather. By the morning, the patient's respiratory distress had significantly improved, and it was felt this was most likely secondary to an aspiration event resulting in aspiration pneumonitis which has since resolved. In addition, the patient's hypotension during this episode responded well to fluids, and her blood pressure was back at baseline by the next morning. Over the few days following, on [**1-4**], the patient was treated with her continued gentle diuresis of Lasix 20 mg p.o. q.d.; however, on [**1-7**], the patient demonstrated a drop in her blood pressure to a systolic of the high 90s to low 100s accompanied by a decrease in her urinary output. Reevaluation suggested that the patient was likely dry and had been overdiuresed at this point. She was therefore treated with gentle fluids including 1 U of packed red blood cells, as well as small boluses of 250 cc a piece. When these small boluses did not demonstrate a significant increase in the patient's blood pressure nor urinary output, she was then placed on maintenance fluids in addition to her tube feeds. The patient received approximately 1 L/day over the 28th and 29th. Subsequently on the morning of 30th, the patient had an acute onset of shortness of breath with an acute desaturation to 84% on her usual 3 L oxygen. This was felt to be likely in the setting of fluid overload, and therefore, the patient's maintenance fluids were stopped. She was given Lasix 40 mg IV with some increase in her urinary output. In addition, the patient was tachycardiac; however, given her continued low blood pressure at the upper 90s, it was not felt prudent to give Lopressor to slow her rate. Given that the patient looked so uncomfortable, she was given Morphine 1 mg IV. Over the next few hours, the patient's mental status decreased significantly as did her respiratory rate. A blood gas obtained a few hours after administration of the Morphine demonstrated impending acidosis of 7.27, CO2 58, and an O2 of 90. The patient was treated with 0.4 Narcan with significant increase in her mental status and respiratory rate. Therefore, the patient was placed on a Narcan drip, and given persistent hypercarbia and acidosis, she was placed on BIPAP therapy and transferred to the MICU. Therefore in summary, the patient was thought to have coronary artery disease with significant systolic and diastolic function based on echocardiogram results. This was felt to be best managed medically with Hydralazine, nitrates, and beta-blockers, and there was felt to be no benefit from a cardiac catheterization; however, the patient's fluid status proved to be difficult to control as the patient persistently vacillated between being too wet and too dry. The overall plan was to maintain the patient's blood pressure with a systolic of approximately 130 in order to obtain adequate renal perfusion but to also provide her the benefit of cardiac medications including beta-blocker therapy, Hydralazine, and nitrates. Finally the patient was started on Digoxin q.o.d. in an effort to improve her systolic function and therefore improve her renal perfusion. 2. Pulmonary: At the time of admission the patient's initial chest x-ray demonstrated left lower lobe consolidation versus atelectasis which had been present since her chest x-rays in [**2113-6-11**]. The patient had been treated with one week of Rocephin therapy, and on transfer, was afebrile with a normal white blood cell count and no pulmonary symptoms. It was therefore felt prudent to discontinue her antibiotic therapy and follow her pulmonary exam clinically. She was also encouraged to use incentive spirometer as tolerated in an effort to improve her left lower lobe atelectasis. During the hospital stay, as detailed in the cardiovascular system, the patient vacillated between pulmonary edema and dry lungs. The patient demonstrated her best pulmonary function when treated with Lasix on a daily basis despite a bump in her creatinine to a baseline of 2.0. Over the first two hospital days, the patient was treated with gentle fluid therapy, and just prior to transfer to the MICU, the patient demonstrated an acute desaturation, as well as hypercarbic respiratory failure in the setting of narcotic therapy. The patient was diuresed effectively while in the MICU and then transferred back out to the floor and maintained on a daily dose of Lasix for her congestive heart failure; however, over the next few days, it was felt that the patient was likely being overdiuresed, as her systolic pressure began to drop. Her Lasix and other cardiac medications were discontinued, and the patient was treated with fluids including small fluid boluses and packed red blood cells. However, once again in the setting of small amounts of fluid therapy, the patient demonstrated an acute onset of shortness of breath with flash pulmonary edema and was therefore treated with further diuresis, and in this instance, placed on BIPAP therapy and transferred to the MICU. 3. Infectious disease: The patient was noted to have a Citrobacter urinary tract infection on presentation to the outside hospital and completed a 7-day course of Rocephin therapy at that hospital. Urinalysis and culture obtained at the time of transfer demonstrated a normal urinalysis with no growth in the culture, and therefore, her Rocephin therapy was held. However a few days following admission, the patient began complaining of burning with urination, and urinalysis was repeated which demonstrated significant candidal growth. The patient was therefore treated with Fluconazole therapy and Peridium with resolution of her urinary tract infection symptoms. The patient had no further urinary tract symptoms until the 29th at which time she once again began complaining of burning with urination through the catheter. A urinalysis was resent which demonstrated significantly elevated white blood cell count, as well as nitrite positive and leukocyte esterase positive. The patient was therefore started on Levaquin pending final results of the urine culture. The patient demonstrated no evidence of pulmonary infection on the multiple chest x-rays obtained during her hospitalization. The left lower lobe consolidation versus atelectasis was felt to most likely represent some kind of mass or atelectasis as apposed to an infectious infiltrate. The patient demonstrated diarrhea during her hospital stay, and a C-difficile toxin was found to be positive. Therefore, the patient was treated with a 21-day course of Flagyl while in the hospital. The patient had no further signs or symptoms of infection up until the time of her transfer to the MICU. During the entire course, the patient remained afebrile with a normal white blood cell count. 4. Renal: The patient demonstrated an elevated creatinine on admission to the outside hospital which increased further with diuresis at the outside hospital and improved somewhat with hydration therapy. The patient was also felt to have possibly developed an interstitial nephritis secondary to Rocephin therapy, and this antibiotic was discontinued at the time of transfer. Over the course of the hospital stay, the patient's creatinine was elevated to approximately 1.9 to 2.0 which was felt to be required in order to keep the patient's lungs dry enough to decrease her oxygen requirement; however, following the PEG tube placement when the patient began to experience lower systolic blood pressures, it was felt that her renal perfusion had decreased, and her urinary output began to decrease as well. A Renal consult was reobtained, and a urinalysis was sent with sediment consistent with interstitial nephritis despite the fact that the patient had not undergone any medication changes recently. It was recommended to start Levaquin therapy for a urinary tract infection and to attempt to maintain her systolic blood pressure greater than 130 to improve renal perfusion. Following the episode of acute shortness of breath and desaturation on [**1-10**], it was recommended to attempt diuresis, and some thought was given towards the possibility that dialysis may need to be an option in the future. Therefore, it was determined to begin initiation of discussion of dialysis with the patient and her husband should this become an issue. At the time of transfer to the MICU, the patient's creatinine had increased on a daily basis up to 3.8 with an increasing BUN up to 128. 5. Gastrointestinal: The patient had no complaints of abdominal pain or suggestion of pathology at the time of admission; however, her stool was sent for C-diff which was positive, and the patient was therefore treated with a 21-day course of Flagyl; however, approximately four days into the hospital stay, the patient began complaining of significant abdominal distress; however, her abdominal exam remained benign. Although the patient's stool remained guaiac negative, she did demonstrate significant diarrhea, and given her history of significant peripheral vascular disease, it was felt that the patient might be experiencing an intermittent mesenteric ischemia. An attempt was made to obtained a CT scan to verify this thought; however, in the setting of fluid therapy and narcotic therapy for pain management, the patient developed significant hypercarbic respiratory distress and was transferred to the MICU with subsequent resolution of her gastrointestinal symptoms. During the remainder of the hospital course, the patient maintained excellent colostomy output with no complaints of abdominal pain and benign abdominal exams. On [**1-4**], a PEG tube was placed without complications, and tube feeds were initiated. The patient had no further gastrointestinal issues leading up to her MICU transfer. 6. Hematologic: The patient had been on Coumadin for her chronic atrial fibrillation; however, this had been held secondary to elevated INR at the outside hospital. Once the patient's INR had fallen below 3, her Coumadin was restarted, and an attempt was made to maintain her INR between 2 and 3 during the course of the hospital stay. The patient also demonstrated a low hematocrit at the time of admission, however, had normal iron studies, B12, and folate at the outside hospital. It was felt that the patient's anemia was most likely secondary to chronic illness, and she was continued on her Epogen shots. The patient was transfused 1 U packed red blood cells on three different occasions during the hospital stay prior to her transfer to the MICU. The patient's stool remained guaiac negative during the hospital stay. 7. FEN: The patient was attempted on a p.o. diet with Boost supplement at the time of admission; however following transfer to the MICU, a swallow study was obtained which demonstrated that the patient was aspirating significantly. Follow-up studies continued to demonstrate aspiration, and therefore a PEG tube was placed on [**1-4**]. The patient's electrolytes were checked on a daily basis and repleted as needed. The patient will likely need continuation of her tube feeds until she has attained adequate strength in oropharyngeal control in order to refrain from aspirating. 8. Wound care: The patient demonstrated a stage 3 sacral decubitus wound at the time of admission which was followed by Dr. [**First Name (STitle) **] in Plastic Surgery. A Plastic consult was obtained at the time of admission who suggested that the patient's wound was healing appropriately with good granulation tissue and that no surgical intervention would be necessary at this time. The patient's wound was packed with Duoderm gel and normal saline gauze b.i.d. throughout the course of the hospital stay and continued to demonstrate good granulation tissue without evidence of infection. 9. Neurological: The patient demonstrated a fluctuating mental status over the course of the hospital stay which was significantly altered by the administration of any narcotics or benzodiazepine therapy. Approximately four days into the hospital stay, the patient was treated with Oxycodone 5 mg p.o. q.6 hours times three doses in an attempt to help her gain control over her significant abdominal pain and sacral decubitus pain. Following this, the patient developed an acute respiratory distress with hypercarbia and was transferred to the MICU and placed on a Narcan drip. Following this episode, the patient was not administered any further narcotics until her acute episode of shortness of breath with desaturations [**1-10**]. At this time 1 mg Morphine was provided to the patient in an effort to provide comfort, and she subsequently developed, once again, a hypercarbic respiratory distress and increasing acidosis. She was therefore placed on a Narcan drip with great improvement in her mental status. In addition in retrospect, it was found that the patient's mental status was most clear when her lungs were dry and her oxygen saturations were high. [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**] Dictated By:[**Dictator Info 35355**] MEDQUIST36 D: [**2114-1-10**] 18:26 T: [**2114-1-10**] 19:36 JOB#: [**Job Number 35356**] Name: [**Known lastname **], [**Known firstname 3591**] Unit No: [**Numeric Identifier 6287**] Admission Date: [**2113-12-18**] Discharge Date: [**2114-1-16**] Date of Birth: Sex: F Service: . ADDENDUM TO DISCHARGE SUMMARY: HOSPITAL COURSE (continued): Over the next few days in the Medical Intensive Care Unit, the patient's significant systolic and diastolic cardiac dysfunction continued to be managed with Hydralazine, nitrites and beta blocker. The patient's fluid status persistent in being difficult to control. Given that the patient did not desire any further interventions, a cardiac catheterization was not performed. Persistent efforts at medical management were maintained with continuation of beta blocker therapy, Hydralazine and nitrates for improved forward flow, however, the patient's blood pressure did not always tolerate the continuation of these medications. The patient continued to be alternately treated with small fluid challenges for intermittent hypotension which had to be subsequently followed with efforts at diuresis, given the initiation of shortness of breath and decreasing oxygen saturations. Given the patient's significant cardiac dysfunction which has persisted for a long time and which had resulted in the significant decrease in her baseline functional capacity, as well as her associated renal insufficiency and sacral decubitus wound complications, a family meeting was held with the patient as well as her husband to discuss goals of care. Given that the patient was responding poorly to optimal medical management, no further interventions were requested at that time. The patient and her husband agreed that she should be made "DO NOT RESUSCITATE", "DO NOT INTUBATE", and that the focus should be changed from optimal management to comfort measures. The patient was subsequently transferred from the Medical Intensive Care Unit back to a more private room on the wards. She was provided with morphine and Ativan as needed for dyspnea as well as complaints of air hunger. Over the next few hospital days, an attempt was made to maintain the patient's blood pressure at appropriate levels, however, inotropics were not to be used. The patient required increasing doses of morphine therapy, both for pain in her sacral decubitus wound as well as for increasing dyspnea and severe air hunger. The patient subsequently passed away on [**2114-1-16**]. Her husband was present at the time and refused an autopsy at the time of death. The appropriate attending was notified and Death Certificate forms were filed with the Admissions Office. [**Name6 (MD) **] [**Last Name (NamePattern4) 424**], M.D. [**MD Number(1) 425**] Dictated By:[**Name8 (MD) 6288**] MEDQUIST36 D: [**2114-6-13**] 16:46 T: [**2114-6-21**] 14:46 JOB#: [**Job Number 6289**]

[ "008.45", "584.9", "585", "707.0", "276.0", "428.0", "599.0", "518.81", "486" ]

icd9cm

[ [ [] ] ]

[ "44.32", "96.6" ]

icd9pcs

[ [ [] ] ]

7114, 26062

5309, 5629

3961, 5287

3455, 3938

26075, 30973

170, 2576

5655, 7096

2599, 3243

3260, 3435

27,398

118,698

34558

Discharge summary

report

Admission Date: [**2133-5-21**] Discharge Date: [**2133-5-22**] Date of Birth: [**2078-7-16**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3984**] Chief Complaint: DKA Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname **] is a 54yo M with type I DM presented to the ED with N/V x 3 days. He states that after he got off work [**Known lastname 766**] he started feeling very unwell with malaise and nausea. He had to pull his car over [**Known lastname 766**] afternoon to vomit. FSG in the 300s, and per pt, he is typically able to keep his FSGs in the 100s. He tried to increase his po fluid intake at home, but was unable to [**1-8**] N/V. He states that he has only been taking his home lantus and novolog intermittently since [**Month/Day (2) **]. He called EMS this morning, FSG was greater than assay when they arrived. FSG on arrival to the ED 400s. The patient has had multiple episodes of emesis since then all of green and yellow, no BRB or black, tarry emesis. No emesis was observed in the ED. He denied adominal pain but endorsed cough which is only slightly worse than his baseline, dry cugh with is attributed to smoking. The patient also denied any urinary symptoms including dysuria or urinary frequency, fevers or chills, chest pain and shortness of breath. + constipation. Of note, pt states that this feels like his prior episodes of DKA. He feels generally unwell, but better since arrival to the ED. In the ED, initial VS were: 97.5 107 178/94 18 96% 2L Labs were notable for anion gap of 30, Na 126, Hct 56 VBG 7.19/15/126/6 lactate 2.1 His exam in the ED was notable for dry mucous membranes. Pt was given 1.75L NS prior to transfer and started on an insulin drip at 5 units/hour. Vitals prior to transfer: HR 110s, RR 15-16, 100% RA, BP 165/93 On arrival to the MICU, patient's VS 91 168/86 16 100% RA. Pateint denies any current complaints and is asking for food. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies shortness of breath, dyspnea or wheezing. Denies chest pain, chest pressure, palpitations. Denies constipation, abdominal pain, diarrhea, dark or bloody stools. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Diabetes Mellitus, Type 1: diagnosed in [**2126-2-5**]. Hypertension Hypercholesterolemia PAD s/p fem-[**Doctor Last Name **] on [**2129-12-13**] Social History: Social History: Firefighter. Lives with wife. Denies IVDU. Smokes [**2-8**] cig/day. 30 yr smoking hx per records. Drinks 2-3 beers most nights. Admits to drinking up tp 5-6 beers at night at times. . Family History: Family History: Mom - cancer history on mom's side + HX of SCD: Dad - deceased from MI at age 42 Physical Exam: ADMISSION EXAM General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear, [**Month/Day (3) 3899**], PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Pertinent Results: ADMISSION LABS [**2133-5-21**] 08:00AM BLOOD WBC-10.6 RBC-5.50# Hgb-17.4# Hct-56.0*# MCV-102* MCH-31.7 MCHC-31.0 RDW-13.4 Plt Ct-230 [**2133-5-21**] 08:00AM BLOOD Neuts-83* Bands-2 Lymphs-7* Monos-7 Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0 [**2133-5-21**] 08:00AM BLOOD Glucose-473* UreaN-28* Creat-1.3* Na-126* K-5.3* Cl-89* HCO3-7* AnGap-35* [**2133-5-21**] 08:00AM BLOOD Calcium-9.1 Phos-4.4# Mg-2.3 [**2133-5-21**] 08:00AM BLOOD %HbA1c-10.5* eAG-255* [**2133-5-21**] 12:42PM BLOOD [**Month/Day/Year **]-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2133-5-21**] 09:55AM BLOOD Type-[**Last Name (un) **] pO2-126* pCO2-15* pH-7.19* calTCO2-6* Base XS--20 Comment-GREEN TOP [**2133-5-21**] 08:11AM BLOOD Lactate-2.1* . DISCHARGE LABS [**2133-5-22**] 12:39AM BLOOD WBC-7.6 RBC-4.09*# Hgb-12.9*# Hct-39.0*# MCV-95# MCH-31.6 MCHC-33.1 RDW-13.4 Plt Ct-151 [**2133-5-22**] 04:47PM BLOOD Glucose-265* UreaN-11 Creat-0.6 Na-130* K-3.6 Cl-99 HCO3-21* AnGap-14 [**2133-5-22**] 04:47PM BLOOD Calcium-8.0* Phos-1.3* Mg-2.0 . URINE STUDIES [**2133-5-21**] 10:55AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.019 [**2133-5-21**] 10:55AM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2133-5-21**] 10:55AM URINE CastGr-3* CastHy-5* . MICROBIOLOGY [**2133-5-21**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2133-5-21**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2133-5-21**] URINE URINE CULTURE-PENDING INPATIENT . IMAGES CXR FINDINGS: Frontal and lateral views of the chest were obtained. The heart is of normal size with normal cardiomediastinal contours. The lungs are clear without focal or diffuse abnormality. The pulmonary vasculature is unremarkable. No pleural effusion or pneumothorax. The osseous structures are unremarkable. No radiopaque foreign bodies. IMPRESSION: No acute cardiopulmonary process. . Brief Hospital Course: 54yoM with Hx of type I DM and prior episodes of DKA who presents with N/V and feeling unwell for 3 days, found to have elevated glucose and AG, c/w DKA. . # DKA: Patient presented with an initial anion gap of 30. The precipitating event for DKA was unclear. Infectious w/u including CXR, UA was unrevealing. EKG was without signs of ischemia. It is likely there was a component of non compliance with insulin therapy. He was started on an insulin gtt with agressive fluid resuscitation. Anion gap was noted to close and he was given 22 units of lantus. Insulin gtt was discontinued 2 hourse later. The patient was noted to tolerate a regular diet. He was transitioned to an HISS with adjustments [**First Name8 (NamePattern2) **] [**Last Name (un) **]. The patient was discharged home with plan to follow-up with [**Last Name (un) 387**] and his PCP. . # [**Last Name (un) **]- Creatine was elevated at 1.3 on admission from baseline of 0.8. Likely pre-renal in nature due to dehydration. Creatinine improved to baseline with administration of IVF. His home lisiopril was initially held but was restarted prior to discharge. . STABLE ISSUES # [**Name (NI) 12329**] Pt with hypertension at baseline. Is mildly hypertensive here likely [**1-8**] the fact that patient has been unable to tolerate his oral medications for the past few days. His home lisiniopril was initially held given elevated creatinine this was restarted prior to discharge. . # HL- Patient was restarted on his home crestor when he was able to tolerate PO. . Transitional issues - Patient was full code throughout this admission - Patient will follow-up with his PCP and [**Name9 (PRE) **] - Blood and urine cultures were pending at the time of discharge Medications on Admission: Aspirin 81 mg Tab, Delayed Release 1 Tablet(s) by mouth DAILY (Daily) Cilostazol 100 mg Tab 1 Tablet(s) by mouth twice a day Crestor 20 mg Tab 1.5 Tablet(s) by mouth DAILY (Daily) (total dose 30mg) Ferrous Gluconate 325 mg Tab 1 Tablet(s) by mouth daily Humalog 100 unit/mL Sub-Q sliding scale with meals Lantus 100 unit/mL Sub-Q 22 units daily Solution(s) once a day Lisinopril 10 mg Tab 1 Tablet(s) by mouth daily Metoprolol 25 mg Tab one Tablet(s) by mouth twice a day Multivitamin Cap 1 Capsule(s) by mouth daily Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS Diabetic Ketoacidosis Secondary Diagnosis Diabetes type 1 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname **] It was a pleasure participating in your care while you were admitted to [**Hospital1 69**]. As you know you were admitted because you were having high blood sugars which caused you to go into diabetic ketoacidosis or DKA. We are not sure what caused this but it is very important that you take your insulin as instructed and follow up with the [**Last Name (un) **] doctors. We did increase the amount of insulin you take with meals and you will be provided with a print out with this information. Tho following changes have been made to your medications: CHANGED: Lantus 22 units at bedtime Please feel free to call with any questions or concerns. Followup Instructions: Please call [**Last Name (un) **] at ([**Telephone/Fax (1) 19850**] to make an appointment to be seen within 1 week. You should also call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 766**] to make an appointment to be seen within 1 week of your discharge. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

[ "272.4", "276.1", "V45.89", "V15.81", "443.9", "285.9", "250.13", "584.9", "V15.82", "276.52", "V58.67", "401.1" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7942, 7948

5634, 7367

308, 314

8069, 8069

3676, 5611

8929, 9346

2895, 2977

7969, 8048

7393, 7919

8220, 8906

2992, 3657

2059, 2473

265, 270

342, 2040

8084, 8196

2495, 2643

2675, 2863

23,038

179,247

43851

Discharge summary

report

Admission Date: [**2104-1-30**] Discharge Date: [**2104-2-13**] Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 425**] Chief Complaint: Hypoxia. Major Surgical or Invasive Procedure: Status post pacemaker lead removal. Temporary wire placement. History of Present Illness: 87 year-old male with CAD s/p CABG, CHF (EF 30% with BiV ICD), AF (on coumadin), diet-controlled DM, s/p recent admission for sepsis, who now presents s/p fall with hypoxia and hypotension. The patient fell x2 the night prior to admission at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] stating he felt "weak". He denies dizzines, lightheadedness, LOC, or head trauma. He was subsequently dyspneic, found to have an oxygen saturation in mid 70's, and noted to be cyanotic. EMS was then called. . Review of systems positive for increased SOB over past several days. The patient denies chest pain. He also denies fevers, chills, nausea, vomiting, abdominal pain, or diarrhea. He has had some minor dysuria recently with increased frequency. . In the ED, patient had SBP in 70's and lactate 4.0. A CVL was placed, and he was given 1L NS, vancomycin 1g IV, levofloxacin 500mg IV, and flagyl 500mg IV. BP improved to 80/44. CVP noted to be 24 and levophed was started instead of further fluid bolus. Oxygen saturations were 95-98% on 100% NRB. He had oral temperature of 99.5. He was then transferred to the MICU for further treatment. Past Medical History: 1. Coronary artery disease status post CABG in [**2089**] 2. Congestive heart failure, EF 30% 3. Atrial fibrillation 4. Status post pacemaker/AICD placement 5. History of idiopathic intrinsic lung disease, on 3L O2 at home 6. Diabetes mellitus type II, diet-controlled 7. Benign prostatic hyperplasia 8. Gastrointestinal bleeding without clear etiology and resulting anemia 9. Hypothyroidism 10. Right ear melanoma status post excision Social History: Used to deliver milk for job. Lives by himself but son is in same house, widower, retired. Denies tobacco past or present, previous moderate EtOH use, no IVDU. Family History: Father>>Tb Physical Exam: Vitals: T 98 BP 133/72 HR 104 RR 24 O2 97% on 100% NRB Gen: Mild respiratory distress, but able to speak a [**2-28**] word sentences comfortably. Lying flat. HEENT: OP dry. Circular area of hypopigmentation medial to right ear (s/p melanoma surgery). Neck: R IJ in place. Cardio: RRR, nl S1S2, [**1-29**] sys murmur at LUSB. Resp: Crackles [**1-27**] way up on left, crackles [**11-27**] way up on right. Abd: Soft, mildly distended, +BS (somewhat hypoactive), non-tender Ext: 2+ pitting edema BL LE Neuro: A&Ox3. Pertinent Results: CT Head on [**2104-1-30**]: IMPRESSION: 1. No evidence of intracranial hemorrhage. 2. Dilated superior ophthalmic veins (right greater than left). This may be related to differences in section location on current study v. the prior examination. It is likely not clinically significant but suggest correlation for bruits on auscultation. . CHEST (PORTABLE AP) [**2104-1-30**] FINDINGS: Compared with [**2103-12-28**], the left lower lobe is now clear. There is now bilateral perihilar and right lower lobe edema consistent with CHF/fluid overload. No obvious consolidating pulmonary infiltrates. . Echocardiogram on [**2104-1-31**]: IMPRESSION: No valvular vegetations seen. Dilated and hypertrophied left ventricle with moderate global systolic dysfunction. Dilated right ventricle with moderate systolic dysfunction. Moderate to severe tricuspid regurgitation. Moderate pulmonary hypertension. Compared with the prior study (images reviewed) of [**2103-12-24**], the left ventricle appears slightly more dilated. The other findings are similar. . Chest Ultrasound [**2104-2-1**]: IMPRESSION: No abscess identified around the pacemaker pocket. . ECG Study Date of [**2104-2-6**] 8:09:30 AM Atrial fibrillation and ventricular paced rhythm with capture. Occasional ventricular ectopy. Compared to the previous tracing of [**2104-2-5**] there is occasional ventricular ectopy. Otherwise, no diagnostic interim change. . [**Numeric Identifier **] PICC W/O PORT [**2104-2-6**] IMPRESSION: Successful placement of PICC line via the left basilic vein, terminating in the superior vena cava. Ready for use. . Labwork on admission: [**2104-1-30**] 06:50AM WBC-30.0*# RBC-3.58* HGB-10.0* HCT-31.5* MCV-88 MCH-28.0 MCHC-31.8 RDW-16.9* [**2104-1-30**] 06:50AM PLT COUNT-285 [**2104-1-30**] 06:50AM NEUTS-94.5* LYMPHS-2.6* MONOS-2.7 EOS-0.1 BASOS-0.1 [**2104-1-30**] 06:50AM PT-20.8* PTT-32.5 INR(PT)-2.0* [**2104-1-30**] 06:50AM GLUCOSE-94 UREA N-36* CREAT-2.3*# SODIUM-138 POTASSIUM-4.6 CHLORIDE-99 TOTAL CO2-23 ANION GAP-21* [**2104-1-30**] 06:50AM CK(CPK)-48 [**2104-1-30**] 06:50AM CK-MB-NotDone proBNP-[**Numeric Identifier 43211**]* [**2104-1-30**] 06:50AM cTropnT-0.08* [**2104-1-30**] 07:03AM LACTATE-4.0* K+-4.6 . Labwork on discharge: [**2104-2-13**] 06:50AM BLOOD WBC-7.3 RBC-3.45* Hgb-9.6* Hct-30.4* MCV-88 MCH-27.9 MCHC-31.6 RDW-17.5* Plt Ct-307 [**2104-2-13**] 06:50AM BLOOD PT-20.3* PTT-38.3* INR(PT)-2.0* [**2104-2-13**] 06:50AM BLOOD Glucose-90 UreaN-29* Creat-1.5* Na-138 K-3.6 Cl-94* HCO3-35* AnGap-13 Brief Hospital Course: 87 year-old male with coronary artery disease s/p CABG, congestive heart failure, atrial fibrillation, diabetes mellitus, with recent admission for sepsis, who now presents status post fall with hypoxia and hypotension secondary to sepsis. . 1. Sepsis: The patient had a recent admission for sepsis and was found to have MRSA bacteremia and Pseudomonas UTI at that time. The patient's recurrent sepsis on this admission was thought to be secondary to infected ICD leads and the patient went to the operating [**2104-2-3**] for lead removal and temporary lead placement. The differential initially included endocarditis, recurrent UTI, pneumonia, and C. difficile infection. These diagnoses were excluded as there were no vegetations noted on intraoperative TEE, the patient's urinalysis was negative, chest X-ray negative for pneumonia, and C. difficile cultures negative. The patient was followed by Infectious Disease during admission. The patient was started on vancomycin [**2104-1-30**] and will continue to complete a four-week course from [**2104-2-3**], the date of pacer lead removal. The patient will have a permanent pacemaker placed once the antibiotic course is completed. The patient was transiently on cefepime and metronidazole empirically but these were discontinued. The patient initially required levophed but this was weaned the second day of admission. Lactate 4.0 on presentation but subsequently normalized. . 2. Hypoxia: The patient has a history of lung disease of unclear etiology (restrictive and diffusion defects by last pulmonary function testing). The patient has a history of amiodarone use, but CT chest in [**2101**] did not show definitive signs of amiodarone toxicity. The patient has a baseline oxygen requirement 2-3L. The patient's increased oxygen requirement on admission was believed secondary to hypoxia secondary to sepsis and/or CHF. The patient's BNP was elevated on admission. There were no signs of pneumonia on imaging or sputum culture. The patient's oxygen requirement decreased during admission with diuresis and treatment of sepsis. On discharge, the patient was saturating 93% on 3L at rest, but required higher levels of oxygen on ambulation from severe deconditioning. The patient should be given nebulizers and increased oxygen prior to exertion. The patient also intermittently desaturated during sleep, likely secondary to intermittent hypoventilation. The patient responds to brief use of increased oxygen or non-rebreather mask as needed. . 3. Acute renal failure: The patient had creatinine 2.3 on admission, from baseline 0.9. This was likely pre-renal in setting of sepsis and congestive heart failure. The patient's creatinine improved with diuresis and treatment of sepsis. The patient's renal failure subsequently remained stable 1.4-1.5 and this may represent a new baseline. . 4. Status post fall: The patient suffered a fall prior to admission likely secondary to hypotension and/or hypoxia in the setting of sepsis. No obvious syncope or trauma. Head CT negative for acute intracranial pathology. . 5. Atrial fibrillation: There is no need for rate control. The patient is on coumadin as an outpatient and was therapeutic on admission. Anticoagulation was held prior to the pacemaker removal but restarted prior to discharge. The patient was started on low-dose amiodarone for rhythm control. The patient's pacemaker was removed with temporary pacemaker placement. The patient will have a permanent pacemaker placed once his course of antibiotics is complete. . 6. Congestive heart failure: LVEF 30%, 1+ MR, 3+ TR from last echocardiogram. The patient had a BiV ICD/pacer on admission which was removed as above and replaced with a temporary screw-in pacemaker. A permanent pacemaker will be placed once the patient has completed a course of antibiotics. The patient had an elevated BNP on admission and crackles on exam consistent with a CHF exacerbation. The patient responded to diuresis with improved oxygenation. The patient's beta-blocker and ACE-inhibitor were initially held secondary to hypotension. The patient was started on carvedilol prior to discharge. ACE-inhibitors were held secondary to relative hypotension and persistently elevated creatinine. An ACE-inhibitor can be restarted as an outpatient if blood pressures remain stable and the patient's creatinine is believed to be at a new baseline. The patient's digoxin was held for supratherapeutic levels with renal failure and initiation of digoxin. The patient's digoxin can be restarted as an outpatient for symptoms. . 7. Coronary artery disease: No signs or symptoms of active ischemia. Status post CABG in [**2089**] (LIMA -- D1, SVG-- LAD, SVG -- Ramus; SVG -- OM; SVG-- PDA). CK/troponins negative on admission. The patient was continued on beta-blocker and atorvastatin. The patient has an allergy to aspirin. . 8. Diabetes mellitus, type II: Diet-controlled as an outpatient. The patient was maintained on sliding scale insulin. . 9. Anemia: History of B12 deficiency and gastrointestinal losses. Recent baseline hematocrit 27-29. The patient was continued on B12 supplementation. . 10. Benign prostatic hypertrophy: No active issues. The patient was continued on finasteride. . 11. Code: Full. . 12. MACU for IV antibiotics, telemetry monitoring until permanent pacemaker placement. Medications on Admission: Doxycycline 100mg [**Hospital1 **] Atorvastatin 10 mg qd Levothyroxine 25 mcg qd MVI qd Prilosec 20mg qd Carvedilol 6.25 mg [**Hospital1 **] Finasteride 5 mg qd Cyanocobalamin 1000 mcg qd Albuterol/atrovent nebs q6h Warfarin 5 mg qhs Lisinopril 10mg qd Furosemide 40 mg [**Hospital1 **] NaCl nasal spray [**Hospital1 **] prn Digoxin 125 mcg qd Advair 250/50 1 puff [**Hospital1 **] Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day. 5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) Injection DAILY (Daily). 7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q2H (every 2 hours) as needed for shortness of breath or wheezing. 10. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-27**] Sprays Nasal [**Hospital1 **] (2 times a day) as needed. 11. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever or pain. 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 15. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 16. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Outpatient Lab Work Please monitor weekly CBC with differential, BUN/creatinine, vancomycin trough, and liver function tests and fax results to [**Hospital **] clinic at [**Telephone/Fax (1) 1419**]. 19. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): Please follow insulin sliding scale as provided. 20. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 21. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day: Titrate to goal even fluid balance. 22. Vancomycin 500 mg Recon Soln Sig: 1.5 Recon Solns Intravenous Q 24H (Every 24 Hours): 750 mg QD started [**2104-2-3**] for four-week course . 23. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary: 1. MRSA bacteremia 2. Hypoxemia, back to baseline oxygen requirement 2-3L NC 3. Acute renal failure, new baseline creatinine 1.5 . Secondary: 1. Coronary artery disease status post CABG in [**2089**] 2. Congestive heart failure, EF 30% 3. Atrial fibrillation 4. Status post pacemaker/AICD placement 5. History of idiopathic intrinsic lung disease, on 3L O2 at home 6. Diabetes mellitus type II, diet-controlled 7. Benign prostatic hyperplasia 8. Gastrointestinal bleeding without clear etiology and resulting anemia 9. Hypothyroidism 10. Right ear melanoma status post excision Discharge Condition: Afebrile, vital signs stable. Satting 96% on 3L at rest (requires much higher levels of oxygen with ambulation). Creatinine 1.5. INR 2.0. Discharge Instructions: You were hospitalized with bacteria in your blood, likely from an infected pacemaker wire. You are on antibiotics for infection. Your pacemaker was removed and you now have a temporary pacemaker wire. You will have a permenant pacemaker placed once you have finished your antibiotics. . You have a history of congestive heart failure. Please follow the below instructions regarding your heart: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1 liter . Please take your medications as prescribed. - You were started on amiodarone to help control your heart rhythm. You will likely need to take this for one month and can reassess the need for this medication with Dr. [**Last Name (STitle) **]. - Your digoxin was discontinued for levels that were too high with kidney failure. Please discuss future use of this medication with your primary care physician or cardiologist. - Your lisinopril was discontinued for acute kidney failure. Please discuss future use of this medication with your primary care physician or cardiologist. . Please keep your follow-up appointments as below. Followup Instructions: Follow-up in Electrophysiology Device Clinic for pacemaker interrogation and left pacer lead dressing change: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2104-2-18**] 10:30 . Follow-up in Cardiac Surgery clinic regarding your chest wound: Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2104-2-20**] 02:00p . The office of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] will contact you regarding a follow-up appointment in four weeks for permenant pacemaker placement. Please call the office at [**Telephone/Fax (1) 285**] if you do not hear from a representative by Friday, [**2-15**]. . Please contact the office of your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], at [**Telephone/Fax (1) 608**] to schedule a follow-up appointment within two weeks of discharge from the rehab facility. You should discuss restarting digoxin and lisinopril with your primary care physician or cardiologist. . Follow-up in Infectious Disease clinic: Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name 9406**] Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2104-3-11**] 11:30a . Previously scheduled appointments: Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]/CUT. ONC. DERM Date/Time:[**2104-2-13**] 10:45a . Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 19848**] CUTANEOUS ONCOLOGY Date/Time:[**2104-2-13**] 11:00a

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icd9cm

[ [ [] ] ]

[ "37.77", "37.78", "99.21", "37.79", "38.93", "99.04" ]

icd9pcs

[ [ [] ] ]

13315, 13394

5249, 10625

223, 287

14025, 14165

2688, 4307

15364, 17035

2125, 2137

11058, 13292

13415, 14004

10651, 11035

14189, 15341

2152, 2669

4949, 5226

175, 185

315, 1472

4321, 4935

1494, 1931

1947, 2109

26,470

159,207

10781

Discharge summary

report

Admission Date: [**2159-7-1**] Discharge Date: [**2159-7-8**] Date of Birth: [**2090-7-31**] Sex: M Service: CARD [**Doctor First Name 147**] CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 68 year old gentleman with a history of coronary artery disease status post stent and left anterior descending in [**2158-10-12**]. He developed restenosis for which he was treated with percutaneous transluminal coronary angioplasty brachy therapy in [**2159-1-12**]. He now presents with chest pain. Cardiac catheterization was performed which revealed re-stenosis in his left anterior descending stent and tight stenosis of the right coronary artery and obtuse marginal 30%. He was subsequently evaluated for cardiac surgery. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Hypertension. 3. Status post knee surgery in [**2131**]. 4. Status post appendectomy in [**2110**]. MEDICATIONS: 1. Captopril 6.25 mg three times a day. 2. Aspirin 325 mg q. day. 3. Atorvastatin 20 mg q. day. 4. Docusate 100 mg twice a day. 5. Ambien 5 mg q. h.s. 6. Tylenol p.r.n. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient smoked for 20 years. PHYSICAL EXAMINATION: Vital signs were heart rate 68; blood pressure 138/65. Mr. [**Known lastname **] is a pleasant gentleman in no apparent distress. His head is normocephalic, atraumatic. His neck is supple with no carotid bruits. His heart is regular rate and rhythm, no murmurs. His lungs are clear to auscultation bilaterally. Abdomen is soft, nontender, nondistended with normoactive bowel sounds. Extremities are without cyanosis, clubbing or edema. HOSPITAL COURSE: Mr. [**Known lastname **] was taken to the Operating Room on [**2159-7-2**], for a coronary artery bypass graft times two. Grafts included [**Doctor First Name 4796**] to [**Doctor First Name **] and RIMA to distal right coronary artery. The procedure was performed without complication and Mr. [**Known lastname **] was subsequently transferred to the CSRU. A couple of hours after surgery, Mr. [**Known lastname **] was found to have ST segment elevations on EKG. He was taken back to the Cardiac Catheterization Laboratory for further evaluation. Catheterization was remarkable for coronary spasm. He was monitored closely back in the CSRU and was fluid resuscitated and hemodynamically stabilized. Mr. [**Known lastname **] was extubated on postoperative day two successfully. On postoperative day two, Mr. [**Known lastname **] also developed rapid atrial fibrillation. This was treated with intravenous Lopressor and Amiodarone and Mr. [**Known lastname **] was started on oral amiodarone. He converted to a sinus rhythm with these medications and has remained in sinus rhythm since. Mr. [**Known lastname **] was then transferred to the floor on postoperative day three. His condition continued to improve. On postoperative day five, Mr. [**Known lastname **] was tolerating an oral diet and his pain was controlled with oral medications. He was able to ambulate well without assistance. He was then felt stable for discharge home. PHYSICAL EXAMINATION: At discharge, temperature 98.3 F.; pulse 67; blood pressure 132/60; respirations 18; O2 saturation 94% on room air. His heart is regular rate and rhythm. Lungs are clear to auscultation bilaterally. Incisions are clean, dry and intact. His abdomen was soft, nontender, nondistended, with normoactive bowel sounds. Extremities are without cyanosis, clubbing or edema. DISCHARGE MEDICATIONS: 1. Pantoprazole 40 mg q. day. 2. Clopidogrel 75 mg q. day. 3. Aspirin 325 mg q. day. 4. Captopril 12.5 mg three times a day. 5. Amiodarone 400 mg three times a day for five days, then twice a day times seven days, then q. day. 6. Imdur 60 mg q. day. 7. Metoprolol 25 mg twice a day. 8. Docusate 100 mg twice a day. 9. Percocet one to two tablets q. four to six hours p.r.n. for pain. DISCHARGE INSTRUCTIONS: 1. Mr. [**Known lastname **] will follow-up with Dr. [**Last Name (STitle) 2472**] in three to four weeks. 2. To follow-up with Dr. [**Name (STitle) **] in four weeks. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Mr. [**Known lastname **] is to be discharged home. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass graft times two. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 11235**] MEDQUIST36 D: [**2159-7-8**] 11:58 T: [**2159-7-8**] 17:33 JOB#: [**Job Number 35219**]

[ "272.0", "V45.82", "996.72", "427.31", "413.9", "V15.82", "997.1", "401.9", "414.01" ]

icd9cm

[ [ [] ] ]

[ "88.56", "39.61", "37.22", "89.64", "36.01", "36.16", "89.69" ]

icd9pcs

[ [ [] ] ]

4297, 4602

3579, 3973

1709, 3161

3997, 4168

3185, 3556

182, 195

225, 787

809, 1173

1191, 1225

4194, 4276

8,464

185,142

46967

Discharge summary

report

Admission Date: [**2114-3-29**] Discharge Date: [**2114-4-5**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7055**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: pericardiotomy with drain History of Present Illness: Ms. [**Known lastname 99606**] is a 82 year old female with history of asthma, atrial fibrillation, who is referred from an ophthalmology clinic after reporting increased shortness of breath over [**12-24**] days. The patient is moderately demented and history is obtained through chart review in addition to patient interview. Over the past 1-2 days, the patient has noted increasing dyspnea upon exertion, previously able to climb approximately one flight of stairs, and now with shortness of breath with minimal level ground ambulation. She did not seek medical attention. At a routine ophthalmology appointment today she was found to have marked dyspnea and referred to the emergency room. . In the ER the patient received an EKG demonstrating low voltage, and CXR demonstrated a grossly enlarged heart. Bedside echo demonstrated large cardiac effusion, and the patient was transferred to CCU for further management. The patient recalls that she has been told that she has ??????fluid around the heart?????? approximately 8-10 years ago. On ROS she denies any fever, chills, night sweats. No change in diet. Patient reports rare chest pain with exertion, no history of (pre)syncope. . The patient recalls that she has been told that she has ??????fluid around the heart?????? approximately 8-10 years ago. On ROS she denies any fever, chills, night sweats. No change in diet. Patient reports rare chest pain with exertion, no history of (pre)syncope. Past Medical History: Hypertension, Coronary artery disease s/p myocardial infarction, Hyperlipidemia, CHF, Chronic AF, Dementia, Asthma, Cataracts, Glaucoma, Gastritis tx for H.Pylori [**2109**], Iron deficiency anemia, Hypokalemia, Ankle Fx [**2100**]. Social History: Patient lives alone, although she notes that she has family in the area. She is widowed. Patient has a 1 ppd smoking history, quit 30 years ago. No current alcohol use. Family History: Unknown Physical Exam: VS: T98, BP 136/60, P78 reg. Gen: Alert to person, pleasant and conversant female in no distress. Moderate dementia present. CV: Pulsus 136->118 = 18 mm Hg. S1 S2 with II/VI HSM maximal over RUSB without radiation. No carotid bruit bilaterally. JVD 16 cm, to angle of jaw. Lungs: Bilateral crackles at posterior bases. Anterior fields clear. Abd: Soft, NT/ND. Ext: No C/C/E x4. ??????Trace?????? guaiac positive stools Pertinent Results: Admission Labs: [**2114-3-29**] WBC-2.5* RBC-3.47* HGB-7.5*# HCT-24.3*# MCV-70*# MCH-21.6*# MCHC-30.8* PLT COUNT-226 NEUTS-69.2 LYMPHS-15.9* MONOS-11.0 EOS-3.2 BASOS-0.7 PT-14.6* PTT-44.0* INR(PT)-1.3 GLUCOSE-94 UREA N-5* CREAT-0.8 SODIUM-130* POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-24 ANION GAP-13 ALT(SGPT)-19 AST(SGOT)-41* LD(LDH)-406* CK(CPK)-210* ALK PHOS-89 TOT BILI-0.8 CK-MB-7 cTropnT-<0.01 ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG FIBRINOGE-199 RET AUT-1.9 CK(CPK)-218* CK-MB-8 cTropnT-0.02* . Admission Studies: [**2114-3-29**] CXR ?????? Grossly enlarged cardiac silhouette consistent with effusion. No acute signs PNA. EKG ?????? Small evidence electrical alternans lead II. Atrial fibrillation, low voltage across limb and precordial leads. Echo ?????? Large pericardial effusion, est ~1L. No RV nor LV collapse. Severely dilated RA and LA. . Discharge Labs: [**2114-4-5**] WBC-6.0 RBC-3.72* Hgb-8.7* Hct-27.8* MCV-75* MCH-23.4* MCHC-31.3 RDW-19.3* Plt Ct-199 Glucose-109* UreaN-18 Creat-0.9 Na-125* K-4.2 Cl-98 HCO3-22 AnGap-9 Calcium-8.5 Phos-3.1 Mg-1.5* . Other: [**2114-3-31**] ALT-15 AST-29 CK(CPK)-159* AlkPhos-66 TotBili-1.3 [**2114-3-31**] CK-MB-5 cTropnT-0.04* [**2114-3-30**] CK-MB-8 cTropnT-0.01 [**2114-3-29**] CK-MB-7 cTropnT-<0.01 [**2114-3-29**] CK-MB-8 cTropnT-0.02* [**2114-3-30**] VitB12-1710* Folate-GREATER TH Hapto-77 [**2114-3-29**] calTIBC-508* Hapto-78 Ferritn-8.6* TRF-391* [**2114-3-30**] Osmolal-267* [**2114-3-29**] TSH-7.0* T4-7.1 [**2114-3-30**] [**Doctor First Name **]-NEGATIVE [**2114-3-29**] ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2114-3-30**] URINE UreaN-518 Creat-131 Na-98, UA negative . Blood cultures [**2114-4-1**] [**12-26**] likely contaminated with skin flora (GPC) otherwise no growth to date. . Pericardial fluid transudative, gram stain negative for organisms, no growth of organisms in culture, no malignant cells on cytologic exam . Echo [**2114-4-4**] The left atrium is normal in size. The right atrium is markedly dilated. The inferior vena cava is dilated (>2.5 cm). The right ventricular cavity is dilated with severe global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) are mildly thickened. The mitral valve leaflets are mildly thickened. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. There is a small to moderate (0.5-1cm) sized circumferential pericardial effusion. No right atrial or right ventricular diastolic collapse is seen. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. Compared with the prior study (tape reviewed) of [**2114-4-2**], the pericardial effusion is slightly larger. . Echo [**2114-4-2**] There is a small pericardial effusion. The effusion appears circumferential. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. . Echo [**2114-3-30**] 1. The left atrium is mildly dilated. The right atrium is markedly dilated. The inferior vena cava is dilated. 2. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 3. The right ventricular cavity is markedly dilated. There is severe global right ventricular free wall hypokinesis. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. 4. The aortic valve leaflets (3) are mildly thickened. 5. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. 6. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. 7. There is a moderate sized pericardial effusion. . ECG Study Date of [**2114-4-3**] Atrial fibrillation. Rightward axis. Low QRS voltage. Right bundle branch block. Poor R wave progression. Diffuse nonspecific ST-T wave changes . C.CATH Study Date of [**2114-3-30**] Subxiphoid [**Date Range 99607**] was performed with one pass, draining approximately 450ml of sero-sanguinous fluid. The initial pericardial pressures were elevated with significant respiratory variation. The mean pressure was approximately 24mm Hg. A post-procedure echocardiogram demonstrated a moderate residual effusion and successful [**Date Range 99607**] of large pericardial effusion. . CHEST (PORTABLE AP) [**2114-3-30**] The cardiac shadow is again grossly enlarged, however, there has been interval decrease in size. There is left lower lobe atelectasis, which in retrospect, was previously present. No pleural effusions or pneumothorax is seen. These structures are unremarkable. The pericardial drain tip can be seen over the left superior cardiac border.IMPRESSION: Interval placement of pericardial drain, without pneumothorax; drain appears to be quite advanced along the superior aspect of the heart. Persistently enlarged but decreased cardiac shadow. Persistent left lower lobe atelectasis. . CHEST (PA & LAT) [**2114-3-29**] There are no prior studies for comparison. The cardiac silhouette is grossly enlarged with extension beyond the aortic knob, concerning for pericardial effusion. Cardiac silhouette occupies approximately 3 quarters of the left hemithorax. The aorta contains mural calcifications. The right lung is grossly clear. The surrounding soft tissue and osseous structures are unremarkable.impression: Grossly enlarged cardiac silhouette concerning for pericardial effusion/tamponade, much less likely multichamber cardiac enlargement. Brief Hospital Course: 82 year old female with increasing dyspnea upon exertion, found to have large cardiac effusion on CXR and echocardiography. At presentation in the ED, the patient had elevated pulsus paradoxus (20 mm Hg), but no echocardiographic or electrocardiographic evidence of tamponade. There was estimated 1-2 L of pericardial fluid present with severely dilated right atrium and ventricle, suggestive of a chronic accumulation process. The morning after admission, the patient underwent [**Year/Month/Day 99607**] without complication at which time a drain was placed. Over the next 2.5 days, about 2-3L of serous fluid was eluted. Drain removal was required to prevent infectious complications and 3 days of kefzol was given for prophylaxis. She was afebrile without leukocytosis. The patient had serial echocardiograms showing gradual reaccumulation of the pericardial fluid. The etiology of the effusion was unclear. Fluid analysis revealed a transudate without evidence of infection or malignant cells. Mammography was negative in [**2109**]. PPD was negative. Other possibilities include idiopathic, collagen vascular disease related (h/o inflammatory arthritis but [**Doctor First Name **] negative), drug induced, or metabolic (thryoid function within normal). No recent trauma. Chest xray did not suggest presence of parechymal disease. Outpatient routine cancer screening is recommended. . Echocardiogram at admission demonstrated a large effusion approx 3cm in diameter, EF>55% with normal LV function, global RV hypokinesis & dilation as well as LA/IVC dilation. She has 4+TR and 2+MR. [**First Name (Titles) **] [**Last Name (Titles) 99607**], the pericardial effusion was "small" by echocardiogram on [**4-2**]; however, the RA/RV/IVC dilation and valvular dysfunction remained. Repeat echo on [**4-4**] indicated the expansion of the effusion to about 1cm in diamter, appearing to be chronically accumulating (but not large enough to merit acute surgical intervention). Per report, echo in [**2109**] had 4+TR, mod MR, moderately dilated RV with moderate hypokinesis, and a minimally dilated LA. LV size and function was normal; no effusion was seen. . Medical management for heart failure included metoprolol, aspirin, and atorvastatin. Her ACE inhibitor was discontinued in order to prevent reduction in preload in light of her significant diastolic dysfunction. . For chronic atrial fibrillation, rate control with metoprolol was recommended. Anticoagulation was held given the patient's significant fall risk. . ***FOLLOW UP: The patient is scheduled for surveillance echocardiogram on [**4-11**], and results were requested to be faxed to the PCP's office. If evidence of significant accumulation of pericardial effusion, the patient should be quickly referred for cardiothoracic surgery evaluation for possible pericardial window procedure to reduce risk of tamponade. Also, screening of 5HIAA level to rule out carcinoid as a cause for effusion was still pending at discharge. . Anemia -For chronic anemia and history of iron deficient anemia, the patient received 2 units PRBC at admission that raised her hematocrit from 24 to above 30 where it then remained stable. Stool was trace guaiac positive in the ED. Iron studies were consistent with iron deficiency and retic count was appropriate. She did not have B12 or folate deficiency. Hematocrit was stable in range of 27-30. She was provided an H2 blocker for gastric prophylaxis. Per her PCP, [**Name10 (NameIs) 2792**] in [**2106**] revealed diverticulosis and hemorrhoids. Outpatient followup and continued treatment is recommended. . Dementia - The patient was consistently disoriented to place and time, displaying severe defects in short term memory. Also, she lacked ability to independantly care for herself or safely take medications. She required promting to swallow food at meals as she tended to pocket the food with extended chewing time. For chronic, severe sundowning with risk to safety, the patient was treated successfully with standing olanzapine. She did not require additional haldol at discharge. . History of asthma - No wheezing occurred during the hospital stay. The patient routinely had dyspnea on exertion thought secondary to the heart failure. If needed, therapy using atrovent, but not albuterol, is recommended with the heart failure condition. . Renal - The patient was incontinent and did not tolerate foley placement. . Chronic hyonatremia - Her sodium ranged in the high 120s and was thought chronically reduced in the setting of loop diuretic use and possibly SIADH after analysis of urine electrolytes and osmolality. Fluid restriction was recommended for both hyonatremia and heart failure. . FEN - Heart healthy, pureed diet. Prompting for swallowing. Fluid restriction of 1.5L daily. . Prophylaxis ?????? SC heparin, Mylanta, Zantac . Code-full . Dispo-Physical and occupational therapy was recommended at rehabilitation facility. The patient's 2 daughters were involved to assume health care decisionmaking responisbilities and were aware that the patient was not safe to live alone. She will require placement or continual assistance long term. Medications on Admission: none taken Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 3. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 8. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 9. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 12. Donepezil Hydrochloride 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Brimonidine Tartrate 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 15. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 16. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). 17. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)) as needed. 18. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 19. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: pericardial infusion atrial fibrillation congestive heart failure iron deficiency anemia chronic hyponatremia hypokalemia hypomagnesemia dementia secondary: gastritis s/p treatment for H. pylori hyperlipidemia asthma arthritis depression cataract glaucoma Discharge Condition: in usual state of health, tolerating an oral diet, hemodynamically stable Discharge Instructions: Please take medications as prescribed. Since you have chronic pericardial effusion, it is important to monitor your symptoms. Call your doctor of go to the ED if you have worsening shortness of breath, chest pain, dizziness or lightheadedness, palpitations, or other concerning symtpoms. For congestive heart failure, follow a low <2g sodium diet and weigh yourself daily. For weight increased above 2kg, call your doctor. For disorientation and dementia, consider outpatient psychometric testing. It is not recommended to continue to live by yourself. Anticoagulation is not recommended for atrial fibrillation due to fall risk. Followup Instructions: Please follow up with your primary care physician. [**Name10 (NameIs) **] will need a follow up echocardiogram to check for recurrence of pericardial effusion. Also, testing for 5HIAA level is still pending at time of discharge. Echocardiogram: [**Hospital1 18**] [**Hospital Ward Name 517**] [**Location (un) 470**] [**Hospital Unit Name 723**] [**Apartment Address(1) 99608**]. [**4-11**] at 11AM. It is essential to keep this appointment. Please try not to reschedule; however, if necessary, call [**Telephone/Fax (1) 3312**]. PCP [**Name Initial (PRE) **]: You have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at the [**Location (un) 538**] Health Center ([**Telephone/Fax (1) 18768**] on [**4-16**] at 11:30AM. A copy of this discharge information was faxed to Dr.[**Name (NI) 99609**] office at [**Telephone/Fax (1) 99610**].

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icd9cm

[ [ [] ] ]

[ "37.0", "99.04" ]

icd9pcs

[ [ [] ] ]

15413, 15486

8516, 11047

281, 309

15786, 15861

2719, 2719

16542, 17426

2255, 2264

13740, 15390

15507, 15765

13705, 13717

15885, 16519

3621, 8493

2279, 2700

11058, 13679

222, 243

337, 1795

2735, 3605

1817, 2051

2067, 2239

7,536

159,457

292

Discharge summary

report

Admission Date: [**2164-11-21**] Discharge Date: [**2165-1-1**] Date of Birth: Sex: F Service: HISTORY OF PRESENT ILLNESS: Ms. [**Name14 (STitle) 2765**] is a 63-year-old lady who was initially admitted to the Medical service at [**Hospital6 256**] after being transferred from an outside hospital. She has a long history of end-stage renal disease and is status post cadaveric kidney transplant. She has recently been diagnosed with gastric B cell lymphoma and presents here for further workup. This was prompted by symptoms of abdominal pain and diagnosed after EGD-obtained biopsy. She has had a history of weight loss, night sweats, pruritus, and feeling fatigued over the last few months. PAST MEDICAL HISTORY: 1. Underwent cadaveric renal transplantation in [**5-/2156**] for end-stage renal disease secondary to hypertension. 2. Osteoporosis. 3. Total abdominal hysterectomy with bilateral salpingo-oophorectomy. 4. Peripheral vascular disease and was scheduled to undergo peripheral vascular bypass. 5. Congestive heart failure. 6. Appendectomy. 7. Lumbar disc surgery. PHYSICAL EXAMINATION: She is an elderly lady in some distress. She is afebrile. Blood pressure is 100/70, heart rate is 96. Chest and abdomen are clear to auscultation. Abdomen is distended and somewhat tender. Extremities are within normal limits. HOSPITAL COURSE: She was admitted to the hospital for further management. During the next 24 hours her abdominal pain and tenderness worsened. Nasogastric tube was placed for decompression. After CAT scan and surgical evaluation it was decided that she had an acute abdomen, and we decided to do a laparotomy. On the laparotomy she was found to have extensive ganglion of her small bowel. Most of her small bowel was resected, and an SMA thrombectomy was performed by the Vascular Surgery service at the same time. A second-look laparotomy was performed the next day, and more small bowel resected. Two days later a third look was performed, and small bowel reanastomosed. This left her with about 50 cm of small intestine. She was kept in the Intensive Care Unit postoperatively, and extensive discussions were had with the family, and her poor prognosis explained to them. She was kept on total parenteral nutrition and low-dose immunosuppression. Hematology/Oncology consultation was obtained, and it was felt she was not stable enough to tolerate treatment for her lymphoma. She briefly developed peritonitis which resolved with antibiotic therapy. She was gradually started on orals, which she tolerated surprisingly well. She was also able to take all of her oral medication. As expected, we were not able to wean her off the TPN. She continued to be followed by the Renal and Hematology/Oncology, and Transplant services during this admission. Finally, due to lack of improvement in her condition, and as per her and the family's wishes, she was transferred to Hospice care. DISPOSITION: Transferred for palliative Hospice care. DISCHARGE DIAGNOSES: 1. Acute mesenteric ischemia. 2. End-stage renal disease. 3. Hypertension. 4. Gastric B cell lymphoma. 5. Status post cadaveric kidney transplant. [**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. Dictated By:[**Name8 (MD) 2766**] MEDQUIST36 D: [**2165-4-1**] 16:18 T: [**2165-4-3**] 22:38 JOB#: [**Job Number 2767**]

[ "403.91", "579.3", "567.2", "518.5", "571.5", "428.0", "202.83", "996.81", "557.0" ]

icd9cm

[ [ [] ] ]

[ "45.61", "00.14", "45.91", "39.50", "45.62", "88.42", "50.11", "99.25", "54.91", "96.72", "38.06", "39.57", "99.15" ]

icd9pcs

[ [ [] ] ]

3051, 3412

1392, 3030

1142, 1374

151, 727

749, 1119

18,214

138,720

10346

Discharge summary

report

Admission Date: [**2146-8-3**] Discharge Date: [**2146-8-10**] Date of Birth: [**2084-5-9**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old male who was in postoperative day 11 from cadaveric kidney transplant who presented to the Emergency Department complaining of sudden onset of abdominal pain that developed overnight. The patient became short of breath and over the course of the night pain worsened as per his report. His pain was diffuse and not well localized. The patient also complained of some chills with no temperature reported at home. The patient came to the Emergency Department of [**Hospital1 1444**] for evaluation. PAST MEDICAL HISTORY: 1. Type 2 diabetes mellitus. 2. End-stage renal disease status post cadaveric kidney transplant. 3. Congestive heart failure. 4. Hypertension. 5. Retinopathy. 6. Neuropathy. 7. Charcot's foot. PAST SURGICAL HISTORY: Includes: 1. Cadaveric renal transplantation on [**2146-7-23**] on steroid-free protocol. 2. Status post appendectomy. ALLERGIES: None. MEDICATIONS ON ADMISSION: 1. Prograf. 2. ____________ 3. Bactrim. 4. Nystatin. 5. Protonix. 6. Colace. 7. Lopressor. 8. Avandia. PHYSICAL EXAMINATION: Patient was afebrile and his vital signs were stable. He was satting at 100% on two liters nasal cannula. Generally, he was alert and oriented times three with moderate distress. His HEENT examination showed a normocephalic, atraumatic male with pupils equal and reactive to light and accommodation and the sclerae anicteric. Neck supple without lymphadenopathy and no jugular venous distention. Cardiac was a regular rate and rhythm with no murmurs, rubs or gallops. Respiratory was clear to auscultation bilaterally with breath sounds bilaterally. Abdomen showed obese, mildly distended, moderately tender abdomen over the transplantation site in the right lower quadrant with peri-incisional tenderness. There was mild fullness to palpation. Extremities warm without edema. Neurological examination was intact. LABORATORY ON ADMISSION: White count 14.2, hematocrit 24.3, platelet count 385,000. Sodium 130, potassium 6.3, chloride 93, bicarb 16, BUN 83, creatinine 5.3, glucose 330, calcium, magnesium and phos was 8.5, 1.5 and 3.9 respectively. Urinalysis showed [**3-9**] white blood cell count, occasional bacteria and nitrite positive. The patient had liver function tests with AST and ALT of 28 and 28, alk phos of 82, total bilirubin of 0.6, albumin of 3.6, amylase of 52 and lipase 46. RADIOLOGY: A chest x-ray on admission showed no evidence of pulmonary disease or congestive heart failure without free air under the diaphragm. HOSPITAL COURSE: The patient was admitted to the Transplant Surgery Service with intravenous Zosyn and was continued to be followed. Nephrology began to follow the patient on [**2146-8-3**], the date of admission, and recommended no changes to his immunosuppression and agreed with the plan of volume repletion. CT of the abdomen on [**8-3**] also showed fluid collection around the right transplant kidney. On hospital day one overnight patient was transferred to the SICU for decreased hematocrit and decreasing oxygen saturation and for further one on one monitoring. While in the unit patient was transfused four units packed red blood cells and patient's tachypnea also improved. The patient was taken to the Operating Room on the [**8-4**] for evacuation of hematoma that was found around his perinephric area of the right cadaveric kidney transplant. The patient tolerated the procedure well and was transferred back to the Surgical Intensive Care Unit after having perinephric hematoma evacuation, exploratory laparotomy washout procedure. On postoperative day No. 13 and one from hematoma evacuation patient was continued on Zosyn as he had been two days prior and patient remained stable overnight with temperatures of 99.8, heart rate of 90-100, blood pressure 100/60, respiratory rate 20 and 97% and CVP of 14. The patient was awake and alert in the unit. Lungs were clear to auscultation bilaterally with decreased breath sounds at the bases. Chest x-ray showed atelectatic changes postoperatively. The patient continued to have good renal output and was transferred to the floor on the afternoon of [**2146-8-5**]. The patient continued to do well on [**2146-8-6**], only complaining of tenderness of the right lower quadrant area. However, in the afternoon of [**2146-8-6**], the patient noted that his left arm began swelling and the patient had ultrasound to rule out left upper extremity deep venous thrombosis which was found to be negative. On [**2146-8-7**], the patient continued to do well. The left arm swelling went down and renal function began to improve with creatinine from 2.9 to 2.4. The Renal team continued to follow the patient during his hospital course and patient was changed from valacyclovir q. 8h. to valacyclovir q. day. The patient had continued improvement. Saturations on ambulation with physical therapy improved from the 80's prior to admission to 95 to 99%. Pulmonary team was consulted for patient's history of sleep apnea and prior desaturations on ambulation, however, was found to be clear by Pulmonary at this time and suggested that the desaturations were attributed to atelectatic type changes postoperatively. Patient was discharged on the [**2146-8-10**] to [**Hospital6 7068**] in good condition. DISCHARGE MEDICATIONS: 1. ___________ 500 mg two tablets p.o. b.i.d. 2. Bactrim 400/80 mg tablets one p.o. q. day. 3. Prilosec 40 mg tablets one p.o. q. day. 4. Colace 100 mg capsule one p.o. q. day. 5. Avandia 4 mg tablet two p.o. q. day. 6. Lopressor 50 mg tablet 0.5 p.o. b.i.d. 7. Ambien 5 mg one p.o. q. hs. p.r.n. 8. ___________ 450 mg tablet one p.o. q. day. 9. ___________ 1 mg capsule three p.o. b.i.d. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain put out scant output of 15 on day of discharge and was removed, however, was still oozing after the drain was pulled and needed to have dressing changed three times a day p.r.n. until oozing subsides, however, wound looked clean and intact. CONDITION AT DISCHARGE: Good. DISCHARGE STATUS: To [**Hospital6 310**]. DISCHARGE DIAGNOSES: Status post cadaveric kidney transplant with perinephric fluid collection and perinephric hematoma evacuation. [**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**] Dictated By:[**Name8 (MD) 6297**] MEDQUIST36 D: [**2146-8-10**] 14:01 T: [**2146-8-10**] 14:02 JOB#: [**Job Number 34337**] cc:[**Location (un) 34338**]

[ "250.60", "250.40", "E878.0", "518.0", "996.81", "584.9", "998.12", "250.50", "428.0" ]

icd9cm

[ [ [] ] ]

[ "55.24", "54.19" ]

icd9pcs

[ [ [] ] ]

6327, 6705

5490, 6239

1102, 1214

2710, 5467

935, 1076

1237, 2071

6254, 6305

158, 688

2086, 2692

710, 911

79,804

172,959

36555

Discharge summary

report

Admission Date: [**2119-5-8**] Discharge Date: [**2119-5-12**] Date of Birth: [**2088-12-21**] Sex: M Service: SURGERY Allergies: Lactose Attending:[**First Name3 (LF) 6088**] Chief Complaint: Thrombosed AV fistula Major Surgical or Invasive Procedure: [**5-8**]: OPERATIONS: 1. Ultrasound-guided puncture of the right common femoral artery. 2. Second-order catheterization of the left radial artery. 3. Serial arteriogram of the left upper extremity. 4. Rheolytic thrombolysis of the left brachial and radial arteries. 5. Ultrasound-guided puncture of the left common femoral vein [**5-8**]: PROCEDURES: Thrombectomy, fistulogram, arteriogram, attempted embolectomy during thrombectomy, administration of t-PA. [**5-9**]: OPERATIONS: 1. Serial arteriogram of the left upper extremity. 2. Export catheter thrombectomy of the left radial artery. 3. Exchange of lysis catheter and rheolytic thrombolysis of the left brachial and ulnar arteries. History of Present Illness: 30M with ESRD on HD since [**2118-4-15**], admitted for thrombosed L upper extremity AV graft . Pt was diagnosed with CKD in late [**2116**], which progressed rapidly to ESRD. He has been on HD since [**2118-4-15**] via multiple IJ tunneled catheters on both sides. Most recently he had a graft placed in fall [**2117**], but subequently has had recurrent issues with thrombosis requiring thrombectomies. Pt was doing well until recent saturday when he went to his outpatient HD unit and could not be dialyzed as graft had thrombosed. His last HD was on Thursday and was normal as described prior. Pt came in saturday for as above - was set up for AV Care today for thrombectomy and with noted complication today with showering of emboli, sent to [**Hospital1 18**] Past Medical History: 1. History of hypertension x one to two years. 2. History of hospitalization for bipolar disorder, also in [**Month (only) 116**] [**2117**]. He says he was never hospitalized while on medications before that and is now well controlled on Abilify. 3. ESRD on HD (T/Th/Sat) of unclear cause who started [**Year (4 digits) 2286**] in [**Month (only) 116**]. No prior catheter infections. He is currently dialyzed through a left HD catheter that he had for ~3 months. The pt. had a left AV fistula that closed off. 4. +PPD, on Isoniazid, Pyridoxine. Social History: The patient lives with wife and wife's daughter who is 5 years old, quit smoking marijuana in 05/[**2117**]. Denies any alcohol use currently, denies any IV drug use in the past. He was incarcerated in [**2116**] for five months after being accused of domestic violence. Last worked in [**2118-1-16**] as personal assistant. Family History: His parents are both alive and healthy. His mother is 52 and father 62. He does have two sisters and two brothers, all of whom are healthy. No family history of hypertension, DM2, renal disease. Physical Exam: Physical Exam: VS 96.2 85 160/90 100% CMV 1.0/16x500/5 General: intubated and sedated CV: RRR Pulm: intubated, CTAB, transmitted upper airway sounds, rales LUL Abd: OGT, soft, non-distended, foley in place Ext: LUE cool dopplerable radila. ulnar and [**Location (un) **] arch RUE cool hand, 1+ radial pulse, no edema Pulse exam: F DP PT R p p p L p p p Pertinent Results: [**2119-5-12**] 05:10AM BLOOD WBC-5.9 RBC-3.01* Hgb-9.4* Hct-28.1* MCV-93 MCH-31.1 MCHC-33.3 RDW-15.1 Plt Ct-271 [**2119-5-12**] 05:10AM BLOOD PT-21.1* PTT-48.6* INR(PT)-2.0* [**2119-5-12**] 05:10AM BLOOD Glucose-92 UreaN-30* Creat-11.0*# Na-139 K-3.8 Cl-98 HCO3-28 AnGap-17 [**2119-5-12**] 05:10AM BLOOD Calcium-8.6 Phos-6.5* Mg-1.9 Brief Hospital Course: Pt admitted, An attempted thrombectomy was carried out, but emboli showered to the L hand, resulting in a cold hand. He was emergently taken to the OR, where catheters for lysis and heparinization were placed. An LMA was converted to an ETT in the OR for bronchospasm. The patient left the OR in stable condition with TPA and heparin infusing through the catheters. He was then taken to the CVICU. The following cases were then performed [**5-8**]: OPERATIONS: 1. Ultrasound-guided puncture of the right common femoral artery. 2. Second-order catheterization of the left radial artery. 3. Serial arteriogram of the left upper extremity. 4. Rheolytic thrombolysis of the left brachial and radial arteries. 5. Ultrasound-guided puncture of the left common femoral vein Follow-up Lysis check as below. [**5-9**]: OPERATIONS: 1. Serial arteriogram of the left upper extremity. 2. Export catheter thrombectomy of the left radial artery. 3. Exchange of lysis catheter and rheolytic thrombolysis of the left brachial and ulnar arteries. All sheaths pulled. Heparin / Coumadin started. [**Hospital 197**] clinic to follow INR. INR on DC 2.0. Heparin stopped. Pt had Tunneled line in IR, femoral temporary HD line DC Pt discharged home in table condition. Groin Line Pulled. ON DC. Medications on Admission: cinacalcet 60 mg daily, epo with HD, INH, lisinopril 15 mg po daily, sevelamer 2400 mg po tid, pyridoxine prn, MVI Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. Disp:*2 Tablet(s)* Refills:*0* 3. Coumadin 2 mg Tablet Sig: Two (2) Tablet PO once a day: Your INR goal is [**1-18**]. Your total dose is 5 mg per day you have 1 mg tablets. Disp:*60 Tablet(s)* Refills:*6* 4. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: your INR goal is [**1-18**]. You are taking 5 mg a day. take with the 2 mg tablets. Disp:*30 Tablet(s)* Refills:*6* 5. Home Medications Please take all home medications as ordered by PCP 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 7. Sevelamer Carbonate 800 mg Tablet Sig: Two (2) Tablet PO three times a day. 8. Isoniazid 100 mg Tablet Sig: One (1) Tablet PO once a day. 9. Lisinopril 5 mg Tablet Sig: Three (3) Tablet PO once a day. 10. Epogen 2,000 unit/mL Solution Sig: One (1) Injection once a week: per PCP, [**Name10 (NameIs) 82744**] uncertain. 11. Sensipar 60 mg Tablet Sig: One (1) Tablet PO at bedtime. 12. Pyridoxine 25 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Left upper extremity ischemia with rest pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: What is warfarin? Warfarin is the generic name for Coumadin?????? (brand or trade name). Warfarin belongs to a class of medications called anticoagulants, which help prevent clots from forming in your blood and or keep grafts open. Why am I taking warfarin? You are taking warfarin because you have a medical condition that puts you at risk for forming dangerous blood clots, or to keep open vessels that have stents and or vessels that allow blood to flow for ischemic leg symptoms. How do I take warfarin? Warfarin is taken once daily at the same time every day, preferably in the evening, with or without food. If you miss a dose of warfarin, take the missed dose as soon as possible on the same day. If you forget, do not double up the next day! Write the day of your missed dose on your calendar and let your health care provider know at your next visit. Why is warfarin use monitored so carefully? Warfarin is a medication that requires careful and frequent monitoring to make sure that you are being adequately treated, but not over- or under-treated. If you have too much warfarin in your body, you may be at risk for bleeding. If you have too little warfarin in your body, you may be at risk for forming dangerous blood clots. Medications, food and alcohol can also interfere with warfarin, making close monitoring even more important. What is INR? INR, which stands for International Normalized Ratio, is a blood test that helps determine the right warfarin dose for you. The INR tells us how much warfarin is in your bloodstream and is a measure of how fast your blood clots. A high INR means you are more likely to bleed (your blood does not clot very fast). A low INR means you are more likely to form a clot (your blood clots very fast). All patients will have an INR goal depending on their medical condition(s), yours is [**1-18**]. What are the possible side effects of warfarin? The major side effect of warfarin is bleeding (especially when your INR is too high). Here are some symptoms of bleeding to look for and to report to your health care provider: Unusual bruising or bruises that won't heal Bleeding from your nose or gums Unusual color of urine or stool (including dark brown urine, or red or black/tarry stools) What do I need to know about drug interactions with warfarin? Many drugs can potentially interfere with warfarin and may cause your INR to change, putting you at risk for bleeding or a clot. These drugs include prescription medications, over-the-counter medications (like aspirin, ibuprofen, naproxen), and dietary and herbal supplements. They should be avoided unless otherwise directed by health provider. [**Name10 (NameIs) **] should take your Aspirin as directed. What role does my diet play? The amount of vitamin K in your diet may affect your response to warfarin. Certain foods (like green, leafy vegetables) have high amounts of vitamin K and can decrease your INR. You do not have to avoid foods high in vitamin K, but it is very important to try to maintain a consistent diet every week. What about alcohol? Alcohol use also may affect your response to warfarin. Excessive use can lead to a sharp rise in your INR. It is best to avoid alcohol while you are taking warfarin. Safety Tips Carry a wallet ID card and/or wear an emergency alert bracelet Tell all health care providers (physicians, nurses, pharmacists, dentists, etc.) that you are taking warfarin, especially if you have any planned surgeries or procedures. Alert your health care provider if you are pregnant or become pregnant while taking warfarin. Plan ahead when traveling by having enough warfarin and arrange for follow-up blood tests. It is also important to keep your diet consistent. Avoid any sport or activity that may result in a serious fall or injury. Use a soft-bristled toothbrush to protect your gums. Use an electric razor if you are prone to cut yourself when shaving. Call Dr[**Name (NI) 5695**] office if you have any questions regarding your new medication. PLEASE GET YOUR [**Name (NI) **] AS ORDERED Followup Instructions: Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2119-5-19**] 1:30 Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2119-7-12**] 10:45 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17081**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2119-8-28**] 1:45 You are on coumadin The [**Company 191**] Anticoagulation management service will moniter your cINR level. They will contact you on [**2119-5-16**]. You must be available to come in that day so your INR can be checked. If you do not hear from them there number is Phone: [**Telephone/Fax (1) 2173**]. Completed by:[**2119-5-12**]

[ "E878.8", "285.21", "453.89", "512.1", "444.89", "997.79", "276.7", "795.5", "519.11", "403.91", "996.73", "271.3", "V58.61", "599.0", "296.80", "585.6" ]

icd9cm

[ [ [] ] ]

[ "96.71", "39.95", "99.10", "38.95", "39.79", "88.49", "96.04" ]

icd9pcs

[ [ [] ] ]

6318, 6324

3709, 4998

289, 1003

6413, 6413

3344, 3686

10657, 11439

2728, 2924

5163, 6295

6345, 6392

5024, 5140

6564, 10634

2954, 3325

228, 251

1031, 1798

6428, 6540

1820, 2370

2386, 2712

23,710

178,196

24548

Discharge summary

report

Admission Date: [**2183-7-20**] Discharge Date: [**2183-7-28**] Date of Birth: [**2139-2-11**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Paroxysmal Nocturnal Dyspnea Major Surgical or Invasive Procedure: [**2183-7-22**] - Mitral Valve Repair (28mm [**Last Name (un) 3843**] [**Doctor Last Name **] Ring)and repair of anterior mitral leaflet tear. History of Present Illness: Mr. [**Known lastname 12262**] is a 44-year-old gentleman with a history of paroxysmal nocturnal dyspnea. He underwent evaluation which showed a severely depressed LV function in the 20% to 30% range along with severe mitral regurgitation. He also underwent a cardiac MRI which confirmed the findings, and had a very low effective forward left ventricular output. He therefore was referred for surgery. Past Medical History: Hypertension Sleep Apnea Hernia Repair Social History: Lives with wife and 1 child. Works in fire protection. Drinks occassionally Family History: HTN and diabetes in parents Physical Exam: GEN: WDWN in NAD SKIN: Unremarkable HEENT: Unremarkable LUNGS: Bibasilar rales HEART: RRR, 4/6 systolic murmur apex->axilla ABD: Benign EXT: 2+ pulses. No varicosities Pertinent Results: [**2183-7-25**] 06:05AM BLOOD WBC-9.6 RBC-3.09* Hgb-8.3* Hct-25.3* MCV-82 MCH-26.9* MCHC-33.0 RDW-13.6 Plt Ct-187 [**2183-7-25**] 06:05AM BLOOD Plt Ct-187 [**2183-7-25**] 06:05AM BLOOD Glucose-138* UreaN-18 Creat-1.0 Na-139 K-4.3 Cl-104 HCO3-28 AnGap-11 [**2183-7-20**] CXR No evidence for CHF. [**2183-7-24**] CXR There has been interval removal of the endotracheal tube, nasogastric tube, right internal jugular venous access sheath and pulmonary artery catheter, and mediastinal drains. There is stable cardiomegaly. The mediastinal contours appear unchanged. Sternal suture wires in unchanged configuration, and valvular prosthesis. Small bilateral pleural effusions, new since the previous examination. No congestive heart failure. Minimal atelectasis at the left base. No pneumothorax. The osseous structures appear unchanged. [**2183-7-21**] Abdominal Ultrasound Normal abdominal ultrasound. No abdominal aortic aneurysm [**2183-7-22**] EKG Sinus rhythm at 93 Long QTc interval Since previous tracing of [**2183-7-20**], the rate has increased [**Last Name (NamePattern4) 4125**]ospital Course: Mr. [**Known lastname 12262**] was admitted to the [**Hospital1 18**] on [**2183-7-20**] for surgical management of his mitral valve disease. He was worked-up in the usual preoperative manner including an abdominal ultrasound which was negative for an abdominal aortic aneurysm. His renal arteries were normal as well and not a factor in his hypertension. On [**2183-7-22**], Mr. [**Known lastname 12262**] was taken to the operating room where he underwent a mitral vale repair utilizing a 28mm [**Last Name (un) 3843**] [**Doctor Last Name **] annuloplasty band. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, Mr. [**Known lastname 12262**] [**Last Name (Titles) 5058**] neurologically intact and was extubated. He was then transferred to the cardiac surgical step down unit for further recovery. Mr. [**Known lastname 12262**] was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. His drains and wires were removed per protocol. An ace inhibitor was started for afterload reduction. Beta blockade was titrated for optimal heart rate and blood pressure control. Mr. [**Known lastname 12262**] continued to make steady progress and was discharged home on postoperative day eight. He will follow-up with Dr. [**Last Name (Prefixes) **], his cardiologist and his primary care physician as an outpatient. Medications on Admission: Labetolol 300mg twice daily Lisinopril 25mg twice daily Norvasc 10mg daily Lasix 40mg daily Potassium 40mEq daily Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for 2 weeks. Disp:*120 Tablet(s)* Refills:*2* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain for 2 weeks. Disp:*80 Tablet(s)* Refills:*0* 5. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 8. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*120 Tablet(s)* Refills:*2* 9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 10. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). Disp:*360 Tablet(s)* Refills:*2* 11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*30 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] home care Discharge Diagnosis: Mitral regurgitation Discharge Condition: Good Discharge Instructions: you may take a shower and wash your incisions with mild soap and water do not swim or take a bath for 1 month do not apply lotions, creams, ointments or powders to your incisions do not lift anything heavier than 10 pounds for 1 month do not drive for 1 month Followup Instructions: Provider: [**Last Name (Prefixes) 413**],[**First Name3 (LF) 412**] [**Telephone/Fax (1) 170**] Follow-up appointment should be in 1 month Provider: [**Name10 (NameIs) 17010**] cardiologist Appointment should be in [**8-3**] days Completed by:[**2183-8-20**]

[ "428.20", "429.5", "478.29", "780.57", "424.0", "401.9", "425.4" ]

icd9cm

[ [ [] ] ]

[ "35.12", "88.72", "35.32", "39.61" ]

icd9pcs

[ [ [] ] ]

5626, 5732

350, 494

5797, 5803

1330, 2388

6111, 6375

1098, 1127

4078, 5603

5753, 5776

3940, 4055

5827, 6088

1142, 1311

2439, 3914

282, 312

522, 927

949, 989

1005, 1082

60,699

138,366

48057

Discharge summary

report

Admission Date: [**2171-10-3**] Discharge Date: [**2171-10-7**] Date of Birth: [**2109-6-7**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2724**] Chief Complaint: back and leg pain Major Surgical or Invasive Procedure: [**2171-10-3**]: L3-5 Laminectomy, facetectomy and fusion History of Present Illness: A 62-year-old woman who suffered from neurogenic claudication and lumbar stenosis. Conservative therapy had been unsuccessful in ameliorating his symptoms. Past Medical History: fibromyalgia, arthritis, HL, glaucoma, lyme disease Social History: nonsmoker , [**4-22**] EtOH per week Family History: non-contributory Physical Exam: per medical record Exam upon discharge: motor full incision cdi with staples foley in place Brief Hospital Course: Pt electively presented for lumbar decompression and fusion. Surgery was without complication and the patient tolerated it well. She was admitted for close monitoring and pain control to the ICU post op. She was kept flat until the morning for intra-op dural leak and repair. On POD#1 she required pain medication titration. On POD#2 ambulation was encouraged and PT was consulted for assistance with discharge planning. Her incision was clean dry and intact with staples. Her foley was removed but she required multiple straight catheterization and foley was replaced. her pain was managed and she was ambulating with walker. She was seen by PT and recommedned home with services. She received instructions for leg bag and will get VNA at home for support. Medications on Admission: wellbutrin eye drops Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 5. Methocarbamol 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 7. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 8. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**1-19**] Tablets PO Q8H (every 8 hours) as needed for headache. Disp:*30 Tablet(s)* Refills:*0* 9. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 10. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette Ophthalmic daily (). 11. Bupropion HCl 100 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO BID (2 times a day). 12. Simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: Community Nurse [**First Name (Titles) **] [**Last Name (Titles) **] Care,Inc Discharge Diagnosis: lumbar stenosis urinary retention Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: DISCHARGE INSTRUCTIONS FOR SPINE CASES ?????? Do not smoke ?????? Keep wound clean / No tub baths or pools until seen in follow up/ begin daily showers [**2171-10-7**] ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting for two weeks. ?????? Limit your use of stairs to 2-3 times per day ?????? Have a family member check your incision daily for signs of infection ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake if you experience muscle stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. for 3 months to promote bone fusion. ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation Followup Instructions: PLEASE RETURN TO THE OFFICE IN [**10-31**] DAYS FOR REMOVAL OF YOUR STAPLES PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR. [**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS. You will need xrays prior to your appointment. You will need to follow up with urologist for removal of your catheter in approximately 1 week - call PCP to get local urologist or call [**Hospital 18**] [**Hospital 159**] clinic : [**Telephone/Fax (1) 101341**] Completed by:[**2171-10-7**]

[ "738.4", "530.81", "788.29", "E878.1", "296.20", "729.1", "349.31", "721.3", "272.0" ]

icd9cm

[ [ [] ] ]

[ "84.51", "80.51", "81.62", "03.59", "81.08" ]

icd9pcs

[ [ [] ] ]

2966, 3074

878, 1641

336, 396

3151, 3151

4207, 4698

727, 745

1712, 2943

3095, 3130

1667, 1689

3333, 4184

760, 780

279, 298

424, 582

3166, 3309

604, 657

673, 711

801, 855

45,342

185,148

7712

Discharge summary

report

Admission Date: [**2156-3-15**] Discharge Date: [**2156-3-19**] Date of Birth: [**2104-6-7**] Sex: M Service: MEDICINE Allergies: Penicillins / Maalox / Pepto-Bismol / Tylenol-Codeine #3 Attending:[**First Name3 (LF) 2736**] Chief Complaint: post-arrest Major Surgical or Invasive Procedure: internal jugular dialysis catheter placement History of Present Illness: This is a 50 yo M with a history of CAD s/p multiple stents (anatomy unknown), PVD, DM, HTN, HLD, recent ICD removal for pocket infection that was found unresponsive at home today. Patient went for a walk, was found 20 minutes later by wife after he did not return. It was unknown how long he was unconscious. Family called EMS. Pre-hospital rhythm was VTACH s/p defibrillation x 2, epinephrine 1 mg x 2, narcan 2 mg, amiodarone 150 mg IV x 1. After about ?10 minutes of downtime, he had ROSC with NSR. He was intubated in the field for airway protection. He was brought to OSH with CXR confirming tube placement. He was in PEA per OSH code sheet but uncertain. He had ROSC after 3 minutes with epinephrine 1 mg x 1. ECG showed LBBB, troponin 0.06. No other overt abnormalities on labs. No ECG strips are available for review. Initial troponin was 0.06. . Per family, he has reported over the last couple of months with worsening lower extremity edema. He sleeps with two pillows at night, and this has been stable. He has not been complaining of much lately including chest pain or other cardiac symptoms. Also, he was recently admitted to [**Hospital1 **] for unknown reasons and fell during hospitalization with cervical spine strain. . He was transferred to [**Hospital1 18**]. ECG showed STEMI in II, III, aVF. Cardiology was consulted in ER. Decision was made not to perform c. cath. He was given a PR aspirin. He was admitted to the CCU for further management s/p arrest. . On exam, the patient did not have spontaneous movements. He had corneal reflex bilaterally. Pupils were sluggish. He was started on fentanyl/versed. He has been hemodynamically stable with HR < 100, lowest SBP < 90. He was placed on volume control ventilation, FiO2 100 %, 500x12, PEEP 6. Access included IO on arrival. He has 18G PIV x 2. Head CT showed ? mild transient hypoperfusion. . ROS unable to be obtained. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: - all stents have been placed [**Hospital1 1774**] in [**Location (un) 8985**], MA. He has five in his heart, three in his legs - Last stress test at [**Hospital1 **] 1-2 months. Per reports, was not abnormal 3. OTHER PAST MEDICAL HISTORY: per records: Diabetes PND MI/stents neuropathy colitis dermatitis arthritis Social History: - Tobacco history: [**1-5**] ppd Unknown regarding illicit drugs and alcohol Family History: - Mother: [**Name (NI) **], has history of MI and DM - Father: Died at age 57 of MI Physical Exam: On Admission: Vitals: T: 35.2 P: 74 R: 18 BP: 135/68 SaO2: 100% on CMV General: intubated, paralyzed and sedated. Pulmonary: Lungs coarse bilaterally Cardiac: regular, no murmurs appreciated. Abdomen: soft, non-distended. Extremities: cold, mildly edematous throughout Neuro: unresponsive to voice, sternal rub or pain. Pupils 2mm and minimally reactive bilaterally. Pupils midline and conjugate. No corneal reflex, no VOR, no blink to threat. No cough, no gag. Paralyzed without response to deep nailbed pressure. Areflexic, toes mute. Intermittently has brief myoclonic jerks of his head and eyelids despite paralysis. Pertinent Results: On admission: [**2156-3-15**] 11:07PM BLOOD WBC-20.5* RBC-4.50* Hgb-10.3* Hct-31.9* MCV-71* MCH-22.8* MCHC-32.1 RDW-14.9 Plt Ct-290 [**2156-3-15**] 11:07PM BLOOD PT-11.4 PTT-29.9 INR(PT)-1.1 [**2156-3-15**] 11:07PM BLOOD Fibrino-349 [**2156-3-15**] 11:07PM BLOOD UreaN-27* Creat-2.1* [**2156-3-16**] 02:48AM BLOOD Glucose-241* UreaN-30* Creat-2.1* Na-140 K-3.6 Cl-108 HCO3-16* AnGap-20 [**2156-3-15**] 11:07PM BLOOD ALT-98* AST-87* CK(CPK)-989* AlkPhos-108 TotBili-0.2 [**2156-3-15**] 11:07PM BLOOD Lipase-32 [**2156-3-15**] 11:07PM BLOOD cTropnT-0.46* [**2156-3-15**] 11:07PM BLOOD CK-MB-26* MB Indx-2.6 [**2156-3-15**] 11:07PM BLOOD Albumin-3.3* Calcium-8.2* Phos-6.6* Mg-1.7 [**2156-3-16**] 02:48AM BLOOD %HbA1c-9.7* eAG-232* [**2156-3-16**] 01:24PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2156-3-15**] 11:07PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2156-3-16**] 01:24PM BLOOD HCV Ab-POSITIVE* [**2156-3-15**] 11:25PM BLOOD Type-[**Last Name (un) **] Temp-36.1 Rates-16/ Tidal V-500 PEEP-5 FiO2-100 pO2-465* pCO2-29* pH-7.36 calTCO2-17* Base XS--7 AADO2-219 REQ O2-45 -ASSIST/CON Intubat-INTUBATED [**2156-3-15**] 11:09PM BLOOD Glucose-240* Lactate-6.9* Na-140 K-4.1 Cl-106 calHCO3-17* [**2156-3-15**] 11:09PM BLOOD freeCa-1.08* LFT's: [**2156-3-15**] 11:07PM BLOOD ALT-98* AST-87* CK(CPK)-989* AlkPhos-108 TotBili-0.2 [**2156-3-16**] 02:48AM BLOOD ALT-104* AST-110* LD(LDH)-392* CK(CPK)-1692* AlkPhos-104 TotBili-0.3 [**2156-3-16**] 10:00AM BLOOD CK(CPK)-[**2063**]* [**2156-3-17**] 05:40AM BLOOD ALT-188* AST-315* CK(CPK)-2410* [**2156-3-18**] 01:50AM BLOOD ALT-773* AST-862* CK(CPK)-1287* [**2156-3-18**] 06:00AM BLOOD ALT-1487* AST-1772* LD(LDH)-2550* CK(CPK)-1206* AlkPhos-88 TotBili-0.6 [**2156-3-18**] 02:08PM BLOOD CK(CPK)-1248* [**2156-3-19**] 06:15AM BLOOD ALT-2532* AST-2112* LD(LDH)-1501* AlkPhos-100 TotBili-1.3 Cardiac Enzymes: [**2156-3-15**] 11:07PM BLOOD cTropnT-0.46* [**2156-3-15**] 11:07PM BLOOD CK-MB-26* MB Indx-2.6 [**2156-3-16**] 02:48AM BLOOD CK-MB-75* MB Indx-4.4 cTropnT-2.41* [**2156-3-16**] 10:00AM BLOOD CK-MB-204* MB Indx-10.6* cTropnT-3.52* [**2156-3-16**] 06:45PM BLOOD CK-MB-467* cTropnT-4.52* [**2156-3-16**] 11:31PM BLOOD CK-MB-GREATER TH cTropnT-4.88* [**2156-3-17**] 04:00AM BLOOD CK-MB-GREATER TH cTropnT-5.41* [**2156-3-17**] 08:03PM BLOOD CK-MB-365* cTropnT-7.48* [**2156-3-18**] 01:50AM BLOOD CK-MB-267* MB Indx-20.7* cTropnT-9.06* [**2156-3-18**] 06:00AM BLOOD CK-MB-195* MB Indx-16.2* cTropnT-10.29* [**2156-3-18**] 02:08PM BLOOD CK-MB-139* MB Indx-11.1* cTropnT-12.78* Brief Hospital Course: This is a 51 year old male with a history of CAD s/p multiple DES, found down outside his house for an unclear amount of time and found by EMS to be in VT/VF arrest s/p defibrillated x 2, epi given with ROSC to PEA s/p amiodarone and epi transferred to [**Hospital1 18**] in NSR, unresponsive, intubated, sedated to initiate post-cardiac arrest hypothermia protocol. . # s/p VF/VT cardiac arrest. He had been found unresponsive by his wife and EMS was called. He was found to be in v-tach/vfib and was debrillated twice with return of spontaneous circulation after approx 10 minutes of resuscitation. It was unclear how long he had been down for. He was intubated in the field and brought to an OSH where he had a PEA arrest with return of spontaneous circulation after epinephrine. The patient reportedly had ICD which was though to be due to low EF, but was reportedly removed for a pocket infection. The cause of the VT/VF was unclear, but thought possibility secondary to an MI given STE on EKG (see below). Initiation of artic sun therapeutic cooling protocol for neuroprotection s/p arrest on started in the ED. The patient intubated and sedated with fentanyl and midazolam. He was paralyzed with cisatracurium. He was monitored for hypokalemia and hyperglycemia during cooling and hyperkalemia and hypoglycemia during rewarming. He was started on an insulin gtt for initial hyperglycemia during the initial 24 hours of cooling. Neuro was consulted to monitor for seizure activity. The patient was monitor with video EEG, and was found to have seizure activity requiring antiseizure medications for suppression, as advised by neurology. The patient was in sinus with runs of atrial tachycardia on admission. On hospital day 2 until the patient expired, the patient would go between NSR and accelerated idioventricular rhythm. His BP would drop in the AIVR. Moreover, the patient's blood pressure was very labile independent of his rhythm. He would range from hypotension requiring norepinephrine to maintain a MAP>65 to 200/110 requiring nitro gtt for BP reduction. The patient was warmed and sedation/paralytic were discontinued. His exam was significant for corneal reflexes but no other brainstem activity. Given the extremely poor prognosis based on his initial myoclonic status on admission, EEG pattern and clinical exam, the patient's family decided to make the patient CMO. The patient was extubated at 6pm on [**2156-3-19**] and died at 7:20 PM on [**2156-3-19**]. . # STEMI- The patient presented an EKG concern for STE in III>II and AvF with STD in I, aVL, V2-V5 with q-waves in the inferior leads. Likely RCA/posterior territory. Given the uncertainty of the situation such as unknown amount of down time, ? drug overdose among other factors, it was thought that risks of c. cath could potentially outweight benefits of urgent cardiac cath. The patient was given asa 300 pr, plavix loading dose and 75mg daily and started on a heparin gtt. . # [**Last Name (un) **]: The patient presents with oliguria and hyperkalemia in the setting of presumed [**Last Name (un) **] from hypoperfusion during his cardiac arrest. Urine microscopy was unrevealing. Given that he was hyperkalemic in the setting of oliguria and [**Last Name (un) **], a temp dialysis line was placed and HD was initiated. . # Diabetes- The patient uses concentrated insulin at home and a sliding scale for meal time coverage. He was started on an insulin sliding scale. . # Leukocytosis- The patient presented with a leukocytosis in the setting of cardiac arrest, which is likely secondary a stress response. Per family the patient was not recently ill. Blood cultures were negative. The patient was empirically started on cefepime and vancomycin. . Medications on Admission: A. Cardiac - plavix 75 mg PO qD - ASA 325 mg PO qD - Lipitor 20 mg PO qHS - nitroglycerin prn B. Other - diazepam 5 mg PO qHS - gabapentin 600 mg PO TID - trazodone 50-100 mg PO qHS - humalin R500 20 units qAM and qHS - Humalog 100 SSI 3x daily starting at 6 units, starting at 100-150 - oxycodone 30 mg PO q 4 hr - oxycondone 15 mg PO q 2 hr prn pain - nicotine patch 21 mg TD Discharge Medications: patient expired Discharge Disposition: Expired Discharge Diagnosis: *patient expired 7:20 PM on [**2156-3-19**] Discharge Condition: *patient expired 7:20 PM on [**2156-3-19**] Discharge Instructions: *patient expired 7:20 PM on [**2156-3-19**] Followup Instructions: *patient expired 7:20 PM on [**2156-3-19**], family declined autopsy

[ "401.9", "276.2", "V66.7", "305.1", "410.41", "785.50", "427.5", "780.01", "357.2", "584.9", "250.62", "276.1", "250.42", "714.0", "333.2", "348.1", "427.1", "427.41", "414.01", "583.81", "272.4", "V58.67", "V49.86", "780.39", "276.7", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "96.71", "38.97", "39.95", "38.91", "38.95" ]

icd9pcs

[ [ [] ] ]

10399, 10408

6172, 9931

328, 374

10495, 10540

3575, 3575

10632, 10703

2834, 2919

10359, 10376

10429, 10474

9957, 10336

10564, 10609

2934, 2934

2407, 2616

5476, 6149

277, 290

402, 2300

3590, 5458

2647, 2724

2322, 2387

2740, 2818

8,322

105,062

27612

Discharge summary

report

Admission Date: [**2128-5-23**] Discharge Date: [**2128-6-1**] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8747**] Chief Complaint: Right sided weakness and difficulty speaking. Major Surgical or Invasive Procedure: None History of Present Illness: The pt is a 76 year old woman of unknown handedness who was brought to the hospital unaccompanied by ambulance and is unable to relate a history at this time. She was reportedly found sitting on a sidewalk this afternoon at about 2PM, alert awake and non-verbal with right-sided weakness. According to the EMS notes, the patient was able to give her name but had a right facial, right arm, and leg flaccidity. She was taken to [**Hospital 1474**] Hospital where her BP at 3:15 was 238/100 with HR of 52. A NC head CT showed a 2x3 LEFT subcortical hemorrhage. The patient received 10mg Labetalol and by 4:30 BP 133/66 with HR 37. She also received a bolus of dilantin. She was then transferred to [**Hospital1 18**] for management. Past Medical History: No known PMH, but pt does not see doctors. She has fallen twice in the last year, but has not seen a doctor after these events Social History: Pt lives with her mentally retarded daughter. She has a friend who drives her to the store, etc. Her daughter has a guardian who makes her medical/financial decisions. Family History: Unknown Physical Exam: T 98.9 HR 41 BP 102/62 RR 16 Sat 100 FiO2 100% Gen Lying in gurney, eyes open. Left gaze preference. HEENT AT/NC, MMM no lesions, no bruits Neck Supple, no thyromegaly, no [**Doctor First Name **], no bruits Chest CTA B, breathing is labored. CVS RRR w/o MGR ABD soft, NTND, + BS EXT no C/C/E. no rashes or petechiae, no asterixis Neuro Opens eyes to voice. Lifts left hand up to command to show two fingers. No blink to threat on right. There is a right facial. The right arm is flaccid. She squeezes with the left hand to command. The RIGHT leg is externally rotated and flaccid. The RIGHT ankle is in plantar flexion. The LEFT leg moves to foot tickles. Both legs internally rotate toward noxious stimuli. The left ankle is in plantar flexion. Pertinent Results: [**2128-5-23**] 06:05PM BLOOD WBC-5.7 RBC-5.00 Hgb-14.7 Hct-42.7 MCV-85 MCH-29.5 MCHC-34.5 RDW-14.9 Plt Ct-168 [**2128-5-23**] 06:05PM BLOOD PT-12.7 PTT-26.9 INR(PT)-1.1 [**2128-5-23**] 06:05PM BLOOD Glucose-147* UreaN-15 Creat-0.6 Na-138 K-4.4 Cl-106 HCO3-20* AnGap-16 [**2128-5-24**] 02:58AM BLOOD ALT-13 AST-18 LD(LDH)-189 CK(CPK)-59 AlkPhos-74 Amylase-157* TotBili-0.4 [**2128-5-23**] 06:05PM BLOOD cTropnT-0.11* [**2128-5-23**] 08:21PM BLOOD CK-MB-NotDone cTropnT-0.10* [**2128-5-23**] 06:05PM BLOOD CK(CPK)-86 [**2128-5-23**] 08:21PM BLOOD CK(CPK)-70 [**2128-5-23**] 06:05PM BLOOD CK-MB-NotDone [**2128-5-24**] 02:58AM BLOOD CK-MB-NotDone [**2128-5-24**] 02:31PM BLOOD CK-MB-NotDone [**2128-5-23**] 06:05PM BLOOD Calcium-8.7 Phos-2.8 Mg-2.0 [**2128-5-24**] 02:58AM BLOOD Albumin-3.2* Calcium-8.4 Phos-3.1 Mg-2.0 Cholest-144 [**2128-5-24**] 02:58AM BLOOD Triglyc-121 HDL-47 CHOL/HD-3.1 LDLcalc-73 [**2128-5-24**] 02:58AM BLOOD TSH-2.5 [**2128-5-24**] 02:57PM URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG [**2128-5-24**] 02:57PM URINE RBC-[**11-8**]* WBC-[**2-22**] Bacteri-FEW Yeast-NONE Epi-0 [**2128-5-23**] 08:21PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020 [**2128-5-23**] 08:21PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG CT head [**5-23**]:IMPRESSION: Stable appearance of an area of increased attenuation in the left basal ganglia consistent with intraparenchymal hemorrhage, with slight shift of normally midline structures to the contralateral side and mass effect on the left lateral ventricle. CT head [**5-24**]:Again seen is evidence of intraparenchymal hemorrhage in the left putamen, measuring just slightly larger compared to prior study, however, not appearing significantly changed. No significant change in mass effect on left lateral ventricle or slight rightward shift. No new areas of hemorrhage identified. ------- CXR [**5-25**] 1. New pulmonary edema. 2. Left lower lobe consolidation/atelectasis with small left pleural effusion. 3. Dislocation of the left shoulder. TTE: The left atrium is elongated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue velocity imaging E/e' is elevated (>15) suggesting 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. There is a minimally increased gradient consistent with minimal aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Brief Hospital Course: 1. Left putaminal hemorrhage: Her exam stayed fairly stable thoroughout her course, except that her mental status improved significantly. Her ICH was stable on repeat neuroimaging, with no significant mass effect. It was measured as roughly 2x1.3 cm and appeared to originate in the left putamen. There was no intraventricular spread. The location was very typical for hypertensive hemorrhage, and her admission blood pressure was extremely elevated. She does not regularly seek medical care so she may be chronically experiencing uncontrolled hypertension. She had a repeat CT 24 hours after admission which showed a stable bleed and amount of edema. Her BP was treated initially with a nicardipine drip. This was quickly weaned and she was treated with IV hydralazine. This was transitioned to oral hydralazine and captopril with aggressive titration. She had received a dose of labetalol at the OSH and presented extremely bradycardic in the high 30s. This was a sinus bradycardia. It was either due to her hypertension(no evidence of high ICP to suggest [**Location (un) 3484**] repsonse) or to the beta blockade. We decided not to use further beta blockers given this response. The bradycardia resolved on day 1 of her stay. She continued to have right arm weakness, but started to regain some use of her right leg. Her speech was extremely dysarthric, but she was able to tell us her name and other short answers, but did not speak fluently. She was following commands. 2.Pulmonary: She was initially intubated for airway protection. She was quickly weaned from the ventilator and extubated. She later developed pulmonary edema on chest X-ray. She was given several doses of lasix during her stay and responded well. As she has possibly long standing HTN and an enlarged heart on CXR, she likely has some element of CHF. An echo was performed and demonstrated a normal ejection fraction, but evidence of diastolic dysfunction. 3.Cardiac: As above, she had BP controlled with a goal SBP of less than 150 given her bleed. This was achieved as above without problems. [**Name (NI) 227**] her probable CHF and bradycardia with labetalol, she was put on an ACE-I with good tolerance. She was found to have diastolic dysfunction as discussed above. 4.Ortho: The patient was found to have a dislocated left shoulder on CXR. The ortho service felt this was likely chronic given lack of pain and good ROM, and no operative management was recommended. 5.GI: She had a post-pyloric feeding tube placed and tolerated tube feeds well. She refused placement of a PEG tube. A repeat speech and swallow evaluation, including videoswallow evaluation. Final recommendations were: 1. Remain NPO at this time, with NG tube in place for nutrition, hydration & meds. 2. Speech therapy at rehab for: a. aphasia remediation b. Po trials of purees (no more than [**2-21**] oz) with deep pressure to tongue to trigger repeat swallows. c. Repeat video swallow within 1-2 weeks, according to treating clinician, prior to po diet advancement or d/c of NG tube. 6. GNR in eyes: The pt developed a purulent discharge from her eyes. Swab revealed GPC and GNR. She was started on cipro ophth gtt. Medications on Admission: None Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4-6H (every 4 to 6 hours) as needed. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 7. Captopril 25 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 8. Ciprofloxacin 0.3 % Drops Sig: 1-2 Drops Ophthalmic Q4H (every 4 hours) for 5 days. 9. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: -left putaminal intraparenchymal hemorrhage -hypertension Discharge Condition: Stable. Neurologic examination notable for anterior aphasia, right-sided hemiplegia. Discharge Instructions: Please continue all medications as prescribed. Please attend all follow-up appointments. If the pt experiences fever, worsening weakness, or other concerning symptoms, have her return to the emergency department for evaluation. Followup Instructions: Neurology: Please call [**Telephone/Fax (1) 1694**] to schedule a follow-up appointment in [**Hospital 878**] Clinic with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]. The clinic will have to be contact[**Name (NI) **] so that demographic information may be updated prior to scheduling of the appointment. Primary Care Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time: [**2128-6-29**] 1:30

[ "V64.2", "518.0", "372.30", "428.30", "276.51", "416.8", "431", "428.0", "427.89", "718.31", "511.9", "401.9" ]

icd9cm

[ [ [] ] ]

[ "38.91", "96.6", "96.71", "88.72" ]

icd9pcs

[ [ [] ] ]

9316, 9388

5238, 8447

308, 314

9490, 9576

2231, 5215

9852, 10335

1429, 1438

8502, 9293

9409, 9469

8473, 8479

9600, 9829

1453, 2212

223, 270

342, 1075

1097, 1226

1242, 1413

433

141,626

47327

Discharge summary

report

Admission Date: [**2163-10-8**] Discharge Date: [**2163-10-28**] Date of Birth: [**2112-11-10**] Sex: F Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 1148**] Chief Complaint: fever, hypotension Major Surgical or Invasive Procedure: RSC dialysis cath Endotracheal intubation History of Present Illness: 50 yo F with h/o ESRD on HD, chronic PEs, PVD, AR/MR medically treated, CHF p/w fever, hypotension. Pt reported to the ED after dialysis catheter accidentally "fell out." Found by the ED to have mental status changes. Fever to 103.6, SBPs in the 60s. Pt noted to have a lactate of 3.3, wbc 7. Pt was intubated given concern over airway protection (pt alternately somnolent/ agitated) and a R femoral TLC was placed. Levophed started. Given 3 L NS. Pt given vanc 1000 mg X1 and cefepime 2 gm IV X1. In the [**Name (NI) **] pt defervesced and systolics stabilized to 100s on pressor/fluid as above. In the ED no clear source of infxn identified. CXR negative, pt unable to make urine. . Transferred to MICU for further management. Past Medical History: 1. CHF--AR and MR [**First Name (Titles) 767**] [**Last Name (Titles) 100137**] endocardidtis ([**2162**]) with medical tx, not surgical candidate for valve repair. Echo [**2162-10-1**] showed LAE, dilated RV/LV, LVEF >60% (intrinsic depression given regurg). 4+ AR, 3+ MR, 2+ TR. PA systolic HTN. 2. ESRD on HD qT, R, Sat --due to mixed gent and contrast-induced nephrotoxicity 3. Chronic PE s/p IVC filter [**11-3**] on lifelong coumadin 4. PVD s/p fem-post tib nonreversed saphenous vein graft [**11-3**]-- c/b wound hematoma --> exploration /evacuation, IVC filter placed; chronic venous stasis ulcers 5. HBV and HCV 6. Hypothyroidism 7. OA s/p bilateral TKR ([**2157**]) c/b R septic joint --> redo 8. Multiple psych issues including bipolar d/o with psychosis, narcotic dependence, anxiety d/o 9. Hx of pericardial effusion with tamponade [**2-3**] - resolved 10. MRSA carrier Other PSH: 1. s/p CCY 2. s/p C-section Social History: Lives at home in [**Location (un) 669**] with her husband, who spends his time taking care of her. She is on SSI. She is not able to walk, is transported in wheelchair by her husband, whom she cites as a strong support. No alcohol or drugs. [**1-31**] ppd x 40 years tobacco. She says she feels that "life is not worth living" and has thought about comitting suicide, although she has never formulated a plan. She is Catholic and says she prays a lot, and that is why she is "still here." She does not have a therapist she sees regularly. Family History: NC Physical Exam: T 100 BP 150-160/60-70 P 55-80 R 23 O2 97 on FiO2 40% Vent: PS 10/5 on rate of 23 TV 375 Gen: Intubated, obtunded Eyes: PERRL, sclerae anicteric Mouth: MMM, intubated Neck: Supple, no lymphadenopathy Chest: Scattered crackles at bases, fair air movement Heart: RR, no murmur Abd: Obese, no bowel sounds. Ext: No edema Neurol: Toes mute, some spontaneous movement of lower extremities. Could not elicit reflexes, no clonus Skin: No rash. Pertinent Results: Admit Labs: ======== [**2163-10-8**] WBC-7.3 RBC-3.88* HGB-11.9* HCT-36.1 MCV-93 MCH-30.6 MCHC-32.8 [**2163-10-8**] NEUTS-84* BANDS-0 LYMPHS-12* MONOS-2 EOS-1 BASOS-0 [**2163-10-8**] PT-43.2* PTT-40.7* INR(PT)-4.9* [**2163-10-8**] GLUCOSE-66* UREA N-32* CREAT-5.4*# SODIUM-138 POTASSIUM-5.0 CHLORIDE-97 TOTAL CO2-24 ANION GAP-22* . Admission to floor: 147 107 12 -------------< 101 AGap=16 4.2 28 3.3 Ca: 9.1 Mg: 2.1 P: 2.7 Vanco: 23.7 WBC 9.5 Hgb 9.7 HCT 29.8 PLT 177 PT: 41.8 PTT: 38.0 INR: 4.7 . MICRO: ===== [**2163-10-8**]- Blood Cx NGTD [**10-10**] Urine Cx yeast < 10,000 [**2163-10-15**]- Blood Cx NGTD [**2163-10-15**]- O&P, Cdiff Negative [**2163-10-10**]- Urine Cx <10,000 Yeast [**2163-10-15**]- Sputum: GRAM STAIN (Final [**2163-10-16**]): negative [**10-15**] RPR pending . RADIOLOGY: ========= [**2163-10-8**] CXR : The ET tube is 2.8 cm above the carina. NG tube tip is in the stomach. There continues to be volume loss/infiltrate in the left lower lobe in the retrocardiac region. There are also patchy areas of volume loss/infiltrate obscuring the right hemidiaphragm and right heart border. . [**10-10**] CXR: 1. Retraction of endotracheal tube, now located 5.8 cm above the carina. 2. Stable left lower lobe and right hilar opacities, which may represent atelectasis or less likely consolidation. . [**2163-10-13**]- Portable CXR: Acutely occurring left-sided total pulmonary whiteout most likely related to mucous plugging and atelectasis . [**10-21**] Head CT: There is no evidence of an intracranial hemorrhage. There is no midline shift, mass effect or hydrocephalus. The [**Doctor Last Name 352**]-white matter differentiation is preserved. . [**10-27**] TTE: The left atrium is moderately dilated. The right atrium is moderately dilated. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. There is a large vegetation on the aortic valve (right cusp). Severe (4+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2162-10-1**], findings are similar. Brief Hospital Course: 50 yo F with h/o ESRD on HD, chronic PEs, PVD, AR/MR medically treated, CHF p/w SIRS/sepsis from presumed line infection and persistent mental status changes. . # SIRS/Sepsis: On admission presented with fever, hypotension (SBP 60's), lactate of 3.3. CXR showed an infiltrate in LLL, UA shows many white cells, positive nitrites, < 1 epi, but UCx was negative. Line infection was thought to be most likely possibility. Line had been removed by patient at home. She was started on antibiotics with vanco/cefepime for presumed sepsis and volume resucitated with NS IVF. Admitted to ICU, where she was transiently placed on pressors. A new dialysis catheter was placed, in addition to a PICC to complete a 2 week course of vanco/cefepime. She subsequently remained hemodynamically stable and afebrile. Blood cultures have been negative this entire admission. Patient is afebrile with normal white count. SBP at baseline low 90s to low 100's. C. diff and ova/parasites, RPR, and sputum gram stain were negative. Blood cultures have remained negative. Vancomycin and cefepime were given for a 14-day course. . # Mental status changes: During MICU course and after admission to floor, patient was noted by staff and husband to have waxing and [**Doctor Last Name 688**] mental status, most notably decreased attention and perseverative/repetitive speech. Although she was oriented x 3, she would repeat "the 20th" several times before being able to move on the next question. Her mental status was observed for several days to determine if there was any improvement, with the thought that resolving infection may have been a factor. Other possible etiologies included ischemia/hypoperfusion from poor cardiac output or uremia from renal failure. Oversedation with drugs was also considered--pain medications were held, trazodone was d/c'ed. Hypothyroidism was considered as well, and levothyroxine was increased from 25 -> 50 -> 100 mcg daily. This should be checked in 2 weeks. Additionally head CT was done that showed no abnormalities. The patient had some improvement in mental status, though not completely at baseline per husband. Pt was alert and oriented x 3 on day of discharge and appropriate. . # ESRD on HD: Secondary to gentamicin-induced renal failure during endocarditis admission. New HD catheter placed. Currently on MWF HD schedule, although recommended 4x/weekly (as outpatient due to the fact that she does not fluid restrict). On renal diet with 1.5L fluid restriction, although noncompliant. Not currently on lanthanum, sevelamer. Nephrocaps, epogen given at HD . # CHF: severe MR/AR [**3-3**] [**Month/Day (2) 100137**] endocarditis, LVEF >55% by echo ([**10-4**] and [**2162-10-27**]) but physiologically decreased given severe AI. No fluid overload on last CXR or on clinical exam, although patient has felt subjectively short of breath that improves with dialysis. Her BP was consistently hypotensive with baseline SBP 90s. . # Chronic pain: Stable on methadone 20 mg PO TID, hydromorphone prn, and topamax, although these meds were held temporarily for oversedation, but then restarted. She is currently on them and still complains of pain. . # Chronic PEs: IVC filter in place since [**2162**], came in supratherapeutic on coumadin. Coumadin was restarted at home dose of 5 mg PO daily when INR was within goal 2.0-3.0, at goal. . # PVD: Stable, has non-healing wound over left thigh and shins b/l. s/p vein graft in [**2162**]. Baby aspirin was continued. She was seen by vascular surgery on admission in early [**Month (only) 462**] and by wound care nursing during her last admission, who recommended continuing her current regimen of duoderm/moistened gauze/4x4/Hy tape/ABD. . # Hypothyroidism: TSH was elevated, but significance in setting of acute illness was unclear. ICU team increased levothyroxine from 25 to 50. On the floor, given her lethargy, hypothyroidism was thought to be a potential contributing factor. Levothyroxine was further increased to 100 mcg daily for this reason, despite having only been on 50 mcg daily for several weeks. Will need TSH check in 2 weeks . # Psych issues--Stable. Bipolar with psychotic features, narcotic dependence, anxiety d/o. Her psych meds were held while in the ICU, then restarted on admission to the floor at her outpatient doses of topirimate, citalopram, and quetiapine. As mentioned above, trazodone was d/c'ed secondary to concerns of oversedation. . # PPx: Coumadin, pneumoboots, PPI were given. . # FEN/GI-She was tolerating POs well, kept on a renal diet with 1.5L fluid restriction, and given a bowel regimen. # Access: Picc . # Communciation: with husband . # FULL CODE Medications on Admission: 1.Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID 2.Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY . 3.Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY 4.Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID 5.Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID 6.Lanthanum 250 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID 7.Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID 8.Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID prn 9.Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 10.Simethicone 80 mg Tablet, Chewable Sig: [**1-31**] Tablet, Chewables PO QID prn 11.Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY 12.Warfarin 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 13.Topiramate 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14.Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 15.Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 16.Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed for pain for 7 days. 17.Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day) as needed for pain, fever. 18.Methadone 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Topiramate 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 7. Hydromorphone 2 mg Tablet Sig: Two (2) Tablet PO Q3-4H (Every 3 to 4 Hours) as needed for pain. 8. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 16. Methadone 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 17. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1) Appl Rectal [**Hospital1 **] (2 times a day) as needed for hemorrhoid pain. 18. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 19. Dolasetron Mesylate 12.5 mg IV Q8H:PRN nausea Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital Discharge Diagnosis: Sepsis, likely HD catheter infection CHF Severe valvar disease ESRD on HD Chronic pain Chronic PE PVD Nonhealing left thigh wound Hypothyroidism Bipolar disorder Discharge Condition: Stable, afebrile, continued HD requirement Discharge Instructions: Please take all your medications as directed. We have not added any new medications. . Please follow up with [**First Name8 (NamePattern2) 1743**] [**Last Name (NamePattern1) **], your NP, after you leave your rehab facility. . If you experience fever > 100.5, shaking chills, nausea, vomiting, lightheadedness, dizziness, or any other symptoms, or if your mental status worsens, please contact your health care provider. Followup Instructions: Please follow up with [**First Name8 (NamePattern2) 1743**] [**Last Name (NamePattern1) **], [**MD Number(3) 17036**] you leave your rehab facility.

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icd9cm

[ [ [] ] ]

[ "96.04", "38.91", "39.95", "96.71", "38.95", "38.93" ]

icd9pcs

[ [ [] ] ]

13460, 13515

5801, 10469

289, 332

13721, 13766

3090, 4568

14237, 14389

2613, 2617

11749, 13437

13536, 13700

10495, 11726

13790, 14214

2632, 3071

231, 251

360, 1091

4578, 5778

1113, 2041

2057, 2597

76,547

171,643

41747

Discharge summary

report

Admission Date: [**2100-9-1**] Discharge Date: [**2100-9-13**] Date of Birth: [**2021-9-24**] Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2569**] Chief Complaint: leaning to the left Major Surgical or Invasive Procedure: N/A History of Present Illness: HPI: Ms [**Known lastname **] is a 78 year-old right-handed woman on coumadin and asa for history of CVA, 4 years ago who presents from an OSH s/p fall last night with a new IPH. History obtained from Son and [**Name2 (NI) 90692**]. Patient has expressive aphasia and R hemiplegia from a stroke in [**2096**]. Last night around 1:30 pm she got up to use the bathroom. Son found her propped between wall and comode. He helped her back to bed and she seemed only to complain of her right elbow. This morning when the health aides arrived they noted her listing to the left which was her former strong side. With this concern they took her to an OSH. Head CTwas done at OSH which showed a 3cm IPH. She was given 2 units of FFP and 5mg vitamin K and then transferred to [**Hospital1 18**] for further managment. Otherwise she has had no other complaints. She did fall, injuring her back 3-4 months ago. She also had a significant pneumonia over the winter, but otherwise has been recently healthy. She denies headache, visual changes. Denies focal numbness, parasthesiae. No bowel or bladder incontinence or retention. Uses a hemiplegic walker for ambulation. She also eats normal foods, without aspiration. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: [] Neurologic - Ischemic Stroke (L MCA w/residual R hemiplegia, Broca's aphasia) [] Cardiovascular - CAD/MI (no stents), CHF, HTN, HL, s/p PPM placement (for sick sinus syndrome) [] Endocrine - DM2 (on insulin), Hypothyroidism [] Psychiatric - Depression [] Other - recurrent falls Social History: former smoker, 25 years ago, has home health aids and a visiting nurse twice a week NO etoh or illicit drugs Family History: Stroke (mother) Physical Exam: At Admission: Physical Exam: Vitals: T:98.9 P:74 R:18 BP:138/40 SaO2:98% General: Awake, cooperative, NAD. HEENT: NC/AT, MMM, no lesions noted in oropharynx Neck: Supple, Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: paced rhythm, Abdomen: soft, NT/ND, Extremities:warm and well perfused Skin: multiple purpura Neurologic examination: GCS:15 level of arousal -4 best verbal -5 best motor -6 Mental Status exam: Awake and alert [spontaneously to voice]. Oriented to month, date, hospital ( by nodding) Attentive, and able to complete tasks Speech was nonsensical Language is nonfluent, unable to repeat, but able to comprehend. Could point to the appropiate picture on stroke card Able to follow both midline and appendicular commands. There was no evidence of left-right confusion as the patient was able to accurately follow the instruction to tough right ear with left hand. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. she reacted to threat bilaterally. III, IV, VI: EOMI without nystagmus. V: Facial sensation intact to light touch. VII: Right facial droop. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: RUE: minimal movement of bicep in plane of gravity RLE: can get IP up against gravity about [**4-3**]. However, unable to sustain LUE. appears weak 5- in delt, tricep LLE: 4 in IP -Sensory: felt noxious and vibration in all 4 extremities -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was extensor bilaterally. -Coordination: No dysmetria on FNF on left ___________________________________________________________ Pertinent Results: NCHCT [**2100-9-1**] IMPRESSION: 1. Interval mild increase in the size of a right parenchymal hemorrhage as described above. A few small hypodense foci within may relate to ongoing hemorrahage. Causes may include trauma, coagulopathy, amyloid angiopathy, underlying lesion, etc. 2. Changes in the left frontal lobe can be subacute-chronic. These can be better assessed with MR, MRA if not contra-indicated after clinical correlation. 3. Diffuse sclerosis of the bones- correlate with metabolic parameters. CXR [**2100-9-1**] FINDINGS: The lung volumes are normal. There are no pleural effusions. Borderline size of the cardiac silhouette. The slightly increased vascular diameter and the multiple interstitial bilateral markings suggest mild-to-moderate pulmonary edema. No focal parenchymal opacity suggesting pneumonia. Valvular ring calcifications. Right pectoral pacemaker in situ. NCHCT [**2100-9-2**] 1. No significant interval change from prior study. Foci of parenchymal hemorrhage in the right temporoparietal region and right inferior insular cortex, unchanged from prior study with no areas of new hemorrhage. 2. Area of hypodensity in the left frontal lobe likely representing prior infarcts. 3. Correlate clinically for need of further workup for underlying cause of hemorrhage, that is possibly best evaluated via MRI. TTE [**2100-9-3**] - The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated given small body size. Regional left ventricular wall motion is normal. There is mild global left ventricular hypokinesis (LVEF = 40-45%). There is no ventricular septal defect. 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. There is no aortic valve stenosis. Trace aortic regurgitation is seen. There is moderate thickening of the mitral valve chordae. Severe (4+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is no pericardial effusion. IMPRESSION: Severe mitral regurgitation. Mildly dilated left ventricle with at least mild global systolic dysfunction. Moderate tricuspid regurgitation. Moderate to severe pulmonary hypertension. NCHCT [**2100-9-4**] IMPRESSION: No interval change in known right temporoparietal and inferior insular cortex intraparenchymal hemorrhages. No new hemorrhage. Sputum Cx - MSSA Urine Cx - Klebsiella Brief Hospital Course: 78 yo W h/o prior L MCA stroke (residual Rhemiplegia, aphasia), DM2, past tobacco use, s/p PPM p/w L-sided weakness s/p fall on [**8-31**], resulting in a R IPH and small SAH. [] Intraparenchymal Hemorrhage - She was noted the next morning to be leaning primarily to her left (her strong side) and was subsequently brought to the hospital where the hemorrhage was found on imaging. She was awake and oriented (could nod yes or no) and had new mild left sided weakness ([**5-4**]) with her prior residual productive aphasia and R face, arm, and leg weakness. She was transferred to [**Hospital1 18**] for further care after receiving FFPs and Vitamin K. Her INR was 2.7 prior to 2 units of FFPs and 1.9 after, so she was given an additional 2 units of FFPs. While in the ED, she experienced a brief 2 minute convulsive seizure and was subsequently started on Levetiracetam 500 q12h. Her repeat NCHCT at that time showed a very small amount of expansion from her prior outside hospital NCHCT. Her repeat NCHCTs on [**9-2**] and [**9-4**] showed no further expansion of the IPH/hematoma or SAH. Her INR has remained stable in the 1.2-1.3 range. Her neurologic exam had been challenging as she was originally very hyperactive and agitated off sedation and subsequently has been more lethargic (possibly due to quetiapine 50 [**Hospital1 **] which was administered to reduce agitation); she does not attend to the examiner or follow commands reliably and may have had a component of delirium. Her hemorrhage and neurologic exam remained stable throughout the rest of her hospitalization, but her overall mental status was very poor with regards to interactivity with her environment. Her multiorgan failure were the primary determinants of her prognosis. [] Systolic Heart Failure and Hypoxic Respiratory Failure - She was given Furosemide when being infused with FFPs to help prevent volume overload but her UOP did not respond appropriately; she became hypoxic later in the evening of [**9-1**] while in the ICU and was intubated for respiratory support. A TTE performed on [**9-3**] showed an LVEF of 40-45% with 4+ MR and 2+ TR; the EF was felt to be an overestimate in the setting of her severe valvular disease. She was treated with IV Furosemide boluses and vasodilated with amlodipine and PRN hydralazine. [] Cardiac Ischemia - The patient has had elevation of her cardiac troponins from 0.06 to a maximum of 4 in the setting of her IPH and metabolic abnormalities, possibly suggesting demand ischemia versus NSTEMI. However, given her hemorrhage, we were unable to thrombolyse or anticoagulate her, so she was medically optimized with aspirin, beta blockade, statin therapy, and oxygenation. [] Acute on Chronic Renal Failure - In the setting of the patient's systolic heart failure, the patient's CKD worsened with a maximum Cr of 3.8. Optimization of her systolic function stabilized her renal dysfunction. Of note, the patient had expressed that she would not want to go on dialysis. [] Hyperglycemia/Hypoglycemia/Diabetes - She was hyperglycemic to the 300s-400s on the first night of admission and was treated with insulin which brought her glucose down to the 40s transiently; she was started on D5NS to maintain her glucose levels in the 100-200 range. She has intermittently been hyperglycemia and has intermittently required insulin infusions. [] Goals of Care - Multiple discussions have taken place with [**Doctor First Name **] (the patient's son), [**Name (NI) 1439**] (the patient's daughter), and the patient's grandchildren regarding her hemorrhage, her multi-organ system dysfunction, and the possibility of tracheostomy and gastrostomy placement in the context of the patient's wishes for goals of care (which unfortunately are not known). The patient had expressed the willingness to go to a long term care facility (nursing home) but also had declined dialysis, making it difficult to tell whether she would want long-term or permanent mechanical ventilation or enteral feeding through a PEG if it allowed her to live. After further discussion and time with the patient, the family decided to make her CMO on [**2100-9-12**]. She was transferred to the Neurology floor on a morphine infusion, and she passed overnight on [**2100-9-12**]. Medications on Admission: -levoxyl 125 mcg QD -colace -MVI lantus 16 units at bedtime, humalog 5 units at breakfast humalog 8 units at dinner, ?Simvastin 10mg [**Name (NI) 244**] (son doesn't think she takes this) norvasc 10mg QD imdur 90mg QD coumadin 7mg QD metoprolol 25mg [**Hospital1 **] ASA 81mg QD rocaltrol 0.5mcg QD proair 2 puffs Q6H prn SOB ferrous sulfate 325mg [**Hospital1 **] procrit [**Numeric Identifier 389**] units every 2 weeks. Missed last dose on [**8-21**] lasix 40mg QM, W, F lidoderm patch QD zoloft 125mg QD Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Intracerebral hemorrhage Acute on chronic systolic heart failure Mitral regurgitation/Mitral valve disease Acute on Chronic renal failure Diabetes Mellitus type 2, uncontrolled Hypoxic respiratory failure Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

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12042, 12159

2394, 2411

11695, 11700

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2776, 3321

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55,973

159,695

4028

Discharge summary

report

Admission Date: [**2181-11-6**] Discharge Date: [**2181-11-11**] Date of Birth: [**2120-10-31**] Sex: F Service: MEDICINE Allergies: Penicillins / Imuran / Cephalosporins / Sulfa (Sulfonamide Antibiotics) / Reglan / Latex / Ampicillin / Lactose / Soy, Lentils, Beans / Neomycin Attending:[**First Name3 (LF) 5037**] Chief Complaint: fever during dialysis Major Surgical or Invasive Procedure: interventional radiology hemodialysis catheter removal interventional radiology tunneled hemodialysis catheter placement History of Present Illness: 61 yo F child psychiatrist w/ complicated PMH significant for type 1 IDDM (s/p revision renal and pancreas transplants, [**2160**] and [**2174**]), diastolic CHF (Echo 35-40%, [**7-/2181**]), recurrent MDR E coli UTIs, chronic anemia, currently on dialysis for repeated hyperkalemia, who developed fevers during dialysis on [**2181-11-5**]. . Pt states that she was feeling completely normal up until dialysis. Over the last three months, she has had a complicated course w/ multiple admissions, most recently [**Date range (1) 17774**], w/ HCAP and worsening CHF during which she was intubated. Pt has since been at [**Hospital3 **] since than and recently discharged to [**Hospital 10246**] Rehab in [**Location 1268**], where she has slowly been making progress in her recovery. . Pt received dialysis on Monday, [**2181-11-5**], as usual and was found to be febrile and have chills. Dialysis was terminated early. Per her most recent nephrology note from [**2181-10-29**], her renal graft seemed to be working better, with Cr 2.0, and a tentative plan to wean off dialysis. Pt denies any localizing symptoms prior to Monday. . In the [**Name (NI) **], Pt was initially not very responisve and triggered on arrival for altered mental status with fever 103 and HR 130. UA was bland, UCx and Blood Cx pending. Pt was given Vancomycin 1g, Levofloxacin 750mg, and Metronidazole 500mg, stress dose steroids (methylprednisolone 125mg) and fluid bolus (amount not documented). Pt had a good response w/ lactate correcting from 2.9 to 2.2, HR 90, and marked improvement in mental status. By report, she had nausea, lower abdominal pain and dysuria. Pt's CXR was significnat for small bilateral pleural effusions and interval marked enlargement of the cardiac silhouette. Bedside Echo did not show any significant pericardial effusion. Pt had a non-contrast CT abd which showed dilated fluid-filled loops of small bowel in RLQ and midline pelvis w/ some fecalized loops concerning for partial small bowel, colon full of stool, and normal appearing LLQ transplanted kidney. Transplant surgery was called and had low suspicion for obstruction w/ recommendation of serial abdominal exams and repeat imaging w/ po contrast if worsening exam or symptoms. Pt was admitted for fever of unknown origin workup. . On arrival to the floor, Pt's vitals were 99.2F, 117/60, HR 94, RR 18, sat 100% 2L. Pt has no pain at all, except for a "sharp pain" near her urethra. ROS: No fevers, no chills (aside from dialysis session on Monday), no night sweats, no changes in weight. No cough, no SOB, no chest pain, no palpitations. No nausea, no vomiting, no diarrhea or constipation. Pt states that she normally has 3 BM daily and that she has been regular. Her last BM was 4pm 1d prior to admission. Past Medical History: 1. diastolic CHF (preserved EF 35%, moderate regional systolic dysfunction, [**9-/2181**]) 2. s/p renal transplant ([**2157**], complicated by chronic rejection, second transplant [**2160**]) 3. s/p pancreas transplant (with allograft pancreatectomy [**5-/2174**], redo transplant [**6-/2175**], acute rejection [**7-/2180**] which resolved with increased immunosuppresion) 4. diabetes mellitus type I (complicated by neuropathy, retinopathy, dysautonomia, no longer requires regular insulin after pancreas transplant) 5. autonomic neuropathy 6. sleep-disordered breathing (on 2L NC nighttime, unable to tolerate CPAP) 7. osteoporosis 8. hypothyroidism 9. pernicious anemia 10. cataracts 11. glaucoma 12. anemia from chronic kidney disease (on Aranesp previously) 13. Right foot fracture, complicated by RLE DVT 14. chronic LLE edema 15. Reucrrent MDR E.coli pyelonephritis 16. s/p anal polypectomy ([**5-/2176**]) 17. s/p bilateral trigger finger surgery ([**8-/2178**]) 18. s/p left [**Year (4 digits) 6024**] ([**8-/2179**]) 19. CAD s/p DES to LAD [**9-/2181**] Social History: Child psychiatrist, on disability. Lives alone in [**Hospital1 8**], MA, but has been in various rehabs since her 3 wk hospitalization in [**2181-9-22**] (see HPI), most recently [**Hospital 17775**] Rehab. Mobilizes w/ wheelchair but has a new prosthesis that doesn't fit well. Denies tobacco use or alcohol use; no recreational substance use. Family History: Father with MI at 57 year old; denies family history of arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Physical Exam: Vitals: 99.2F, 117/60, HR 94, RR 18, sat 100% 2L General: sickly looking woman in bed in no acute distress HEENT: PERRL, EOMI, normal oropharynx Neck: no JVD, no LAD Heart: RRR, nl S1, S2, 4/6 systolic blowing murmur heard best at apex dialysis port site looks normal. Lungs: CTAB Abdomen: soft, non-tender, normal bowel sounds, Extremities: L below the knee amputation, R leg erythematous and very tender to palpation over R shin. No obvious skin breaks, no pus, no pedal edema. 2+ pulses. Neurological: intermittently falling asleep during conversation. A&O x 3. CN2-12 grossly intact. Pt 4/5 strength throughout. . Pertinent Results: [**2181-11-5**] 09:00PM BLOOD WBC-1.8* RBC-4.18*# Hgb-12.0# Hct-38.5# MCV-92 MCH-28.8 MCHC-31.2 RDW-16.2* Plt Ct-176 [**2181-11-5**] 09:00PM BLOOD Neuts-66.1 Lymphs-31.1 Monos-1.0* Eos-1.8 Baso-0.1 [**2181-11-5**] 09:54PM BLOOD PT-11.9 PTT-22.8 INR(PT)-1.0 [**2181-11-5**] 09:00PM BLOOD Glucose-100 UreaN-37* Creat-1.6*# Na-141 K-7.6* Cl-104 HCO3-27 AnGap-18 [**2181-11-5**] 09:00PM BLOOD ALT-25 AST-86* LD(LDH)-962* AlkPhos-62 TotBili-0.4 [**2181-11-6**] 08:02AM BLOOD Lipase-13 [**2181-11-6**] 08:02AM BLOOD Albumin-3.0* Calcium-8.3* Phos-2.1* Mg-1.6 Iron-9* [**2181-11-6**] 08:02AM BLOOD calTIBC-239* Ferritn-53 TRF-184* [**2181-11-6**] 08:02AM BLOOD TSH-0.45 [**2181-11-6**] 05:20PM BLOOD Cortsol-15.1 [**2181-11-6**] 08:02AM BLOOD Vanco-22.4* [**2181-11-6**] 08:02AM BLOOD tacroFK-2.3* rapmycn-3.1* [**2181-11-6**] 05:44PM BLOOD Type-[**Last Name (un) **] Temp-38.3 pH-7.42 [**2181-11-5**] 09:12PM BLOOD Lactate-2.9* [**2181-11-5**] 10:43PM BLOOD Glucose-96 Lactate-2.2* K-3.4 [**2181-11-6**] 05:44PM BLOOD Lactate-1.9 [**2181-11-8**] 05:35AM BLOOD tacroFK-9.3 [**2181-11-5**] 09:15PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011 [**2181-11-5**] 09:15PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR [**2181-11-5**] 09:15PM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-0 [**2181-11-5**] 09:15PM URINE CastHy-1* [**2181-11-5**] 9:00 pm BLOOD CULTURE (2 of 2 bottles) **FINAL REPORT [**2181-11-8**]** Blood Culture, Routine (Final [**2181-11-8**]): ESCHERICHIA COLI. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Aerobic Bottle Gram Stain (Final [**2181-11-6**]): GRAM NEGATIVE ROD(S). Reported to and read back by DR. [**Last Name (STitle) **] ([**Numeric Identifier 17776**]) @ 0914 [**2181-11-6**]. [**2181-11-5**] URINE URINE CULTURE-FINAL Anaerobic Bottle Gram Stain (Final [**2181-11-6**]): GRAM NEGATIVE ROD(S). [**2181-11-6**] BLOOD CULTURE Blood Culture, Routine-FINAL {ESCHERICHIA COLI} ( 2 of 4 bottles) [**2181-11-6**] CATHETER TIP-IV WOUND CULTURE-FINAL No significant growth [**2181-11-7**] BLOOD CULTURE Blood Culture, Routine-no growth to date [**2181-11-8**] BLOOD CULTURE no growth to date [**2181-11-5**] Radiology CHEST (PORTABLE AP) Small bilateral pleural effusions. Interval marked enlargement of the cardiac silhouette relative to the most recent prior exam. However, other more remote exams have demonstrated enlargement of the silhouette, thereby suggesting the possibility of waxing and [**Doctor Last Name 688**] pericardial effusion. Correlate clinically. . [**2181-11-6**] Radiology CT ABD & PELVIS W/O CON 1. Fluid-filled dilated loopss of small bowel in the right lower quadrant and midline pelvis with areas of fecalized small bowel concerning for partial small-bowel obstruction, of uncertain etiology. Clear transition point is difficult to identify given the lack of both oral and intravenous contrast. 2. Small right pleural effusion. 3. Normal appearance of the appendix. 4. Normal appearance of the transplanted kidney in the left lower quadrant. . [**2181-11-7**] Cardiology ECHO 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. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is moderately depressed (LVEF= XX %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] 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. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Severe (4+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. IMPRESSION: No vegetation seen. Moderately dilated left ventricular cavity with moderate global hypokinesis - the anterior wall and septum have the worst function. Severe mitral regurgitation. Small ASD/stretched PFO present with left to right shunting at rest. . [**2181-11-7**] Radiology ART [**Month/Day/Year **] (REST ONLY) FINDINGS: The Doppler waveform in the right common femoral, superficial femoral, and popliteal arteries is triphasic with monophasic Doppler waveform at the level of the posterior tibial and dorsalis pedis artery. The pressures are falsely elevated due to calcified vessels; therefore, ABI index could not be obtained. IMPRESSION: Findings consistent with significant posterior tibial disease in the right lower extremity. . [**2181-11-8**] Radiology CHEST (PORTABLE AP) FINDINGS: Removal of dialysis catheter with no evidence of pneumothorax. Heart is mildly enlarged and is accompanied by vascular engorgement and new septal lines consistent with interstitial edema. Small pleural effusions have increased in size in the interval. Brief Hospital Course: 61 yo F child psychiatrist w/ complicated PMH significant for type 1 IDDM (s/p revision renal and pancraes transplants, [**2160**] and [**2174**]), diastolic CHF (Echo 35-40%, [**7-/2181**]), recurrent MDR E coli UTIs, chronic anemia, currently on dialysis for repeated hyperkalemia, who developed fevers during dialysis and later septic shock. . Active issues: . # Fever: UA bland, UCx pending. CXR w/out infiltrates or opacities. Blood Cx growing gram negative rods. CT abdomen concerning for possible obstruction, but Pt currently completely asymptomatic. No diarrhea, pain or discomfort. R shin initially concerning for cellulitis, but no obvious skin breaks, and now completely painless and no longer inflamed. Suspect line infection but site initially looked clean and uninfected. Tunneled HD line was removed by IR on [**2181-11-6**], and Pt has remained afebrile. [**11-5**] blood cultures growing E coli, sensitive to cephalosporins. Pt was treated w/ meropenem ([**Date range (1) 17777**]) at 500mg [**Hospital1 **] (Pt still making urine) given absence of clear source and tenuous clinical condition, but this was discontinued once sensitivities were finalized on [**11-9**] and switched to ceftazidime per HD protocol. Pt had a replacement HD catheter placed by IR w/ no complications on [**2181-11-9**]. Although Pt has a stated allergy to cephalosporins, the purported allergy is neutropenia, and happened over 20 years ago. Infectious disease feels that although a marrow suppressive response w/ cephalosporins is not impossible, it is rare, and Pt will be on a two week course from the day the HD line was removed, [**Date range (1) 17778**], w/ 2-2-3g dosing w/ HD. Pt can get CBC checks to ensure she is not having any marrow suppressive effects during treatment, at which time her antibiotic may be switched back to meropenem. Avoiding gent to avoid further damage to kidneys. Pt will need to continue ceftazidime on a 2-2-3g schedule w/ HD until [**11-20**]. She should continue to have CBCs drawn prior HD to monitor for neutropenia while on ceftazidime. . # dyspnea: likely fluid overload from ICU course vs worsening mitral regurgitation seen on Echo. CXR on [**11-9**] shows increased pulmonary vasculature. Attempted diuresis w/ furosemide 80mg iv but poor response. Pt had complete resolution of symptoms and exam findings w/ HD. . # ? R lower extremity cellulitis: Pt has very tender and erythematous R shin. No obvious skin breaks, no other signs of infection. Question of vascular cause. Arterogram shows poor tibial perfusion. Pt's symptoms have completely resolved without intervention. Pain and symptoms could have been caused by hypotension during sepsis exacerbating pre-existing poor perfusion from peripheral artery disease. . # ? SBO: CT abdomen w/out contrast concerning for possible SBO, but Pt currently w/out any abdominal pain or nausea. Also reports having had BM recently. Will continue to monitor clinically. -consider CT abd w/ po contrast if clinically worsening . # peripheral neuropathy of amputation stump: intermittently symptomatic. Gabapentin 300mg po q48hrs PRN (renally dosed). . # CAD/CHF: repeat echo on [**2181-11-7**] shows no vegetations, moderately dilated left ventricular cavity with moderate global hypokinesis, especially the anterior wall and septum, severe mitral regurgitation, and small ASD/stretched PFO present with left to right shunting at rest. In comparison to echo of [**2181-10-9**], the degree of mitral regurgitation has increased to severe. Estimated pulmonary systolic pressures are significantly higher. Pt's prior medications of atorvastatin 80mg daily, clopidogrel 75mg daily, and aspirin 325 mg daily were continued without issue. . # Hyperglycemia: likely secondary to steroid dosing. Required only a small amount of insulin as an inpatient. Continue QID finger sticks for now with insulin sliding scale coverage. . # Diarrhea: Patient had a few loose bowel movements. C diff was negative and the diarrhea resolved on its own prior to discharge. . Chronic Issues: . # s/p renal transplant: Pt received continue stress dose methylprednisolone 100mg iv q8hrs for 2 doses, then 60 prednisone mg x 1 d, then 30mg x1, then 15mg x 1d, back to home dose of prednisone 5mg daily. Pt's other medications including sirolimus 1.5mg daily, tacrolimus 3mg [**Hospital1 **], sevelamer carbonate 1600mg po tid, and calcium citrate-vitamin d were continued without issue. . # s/p pancreas transplant: Pt's home meds of lipase-protease-amylase[Creon] 12k, 38k 60k, [**1-25**] capsules tid, folic acid 1mg daily, famotidine 20mg daily, and acyclovir 200mg q12hrs were continued without issue. . # glaucoma: Prior meds continued, including brimonidine 0.15% drops tid, cyclosporine 0.05% drops daily, Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES QD, and Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS. . # hypothyroidism: levothyroxine 112mcg M, W, F, Sat. 100mcg Tues Thurs Sun . # anemia: darbepoetin alpha 200mcg/mL iv q 28 days . TRANSITIONAL ISSUES: -Pt should continue to have CBC checks prior to HD to monitor for neutropenia while on ceftazidime (until [**11-20**]). Medications on Admission: Medications - Prescription ACYCLOVIR - (Prescribed by Other Provider) - 200 mg Capsule - 1 Capsule(s) by mouth every twelve (12) hours ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 80 mg Tablet - 1 Tablet(s) by mouth once a day BRIMONIDINE [ALPHAGAN P] - (Prescribed by Other Provider) - 0.15 % Drops - 1 drop both eyes tid CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg Tablet - 1 Tablet(s) by mouth once a day CYCLOSPORINE [RESTASIS] - (Prescribed by Other Provider) - 0.05 % Dropperette - one drop both eyes daily DARBEPOETIN ALFA IN POLYSORBAT [ARANESP (POLYSORBATE)] - (Prescribed by Other Provider) - 200 mcg/mL Solution - iv q 28 days DORZOLAMIDE-TIMOLOL - (Prescribed by Other Provider) - 0.5 %-2 % Drops - one drop both eyes twice daily ELBOW PADS - - use as tolerated FAMOTIDINE - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day FOLIC ACID - (Prescribed by Other Provider) - 1 mg Tablet - 1 Tablet(s) by mouth once a day GRAB BARS - - to be installed HEPARIN (PORCINE) - (Prescribed by Other Provider) - 5,000 unit/mL Cartridge - SC three times a day HYDROCORTISONE-PRAMOXINE - 2.5 %-1 % Cream - apply to itchy skin as needed LATANOPROST [XALATAN] - (Prescribed by Other Provider) - 0.005 % Drops - 1 gtt ou at bedtime LEVOTHYROXINE - (Prescribed by Other Provider) - 112 mcg Tablet - 1 Tablet(s) by mouth every other day MWFsat LEVOTHYROXINE [LEVOXYL] - 100 mcg Tablet - 1 Tablet(s) by mouth qod alternating with 112 mcg qd LIPASE-PROTEASE-AMYLASE [CREON] - 12,000 unit-[**Unit Number **],000 unit-[**Unit Number **],000 unit Capsule, Delayed Release(E.C.) - [**1-25**] Capsule(s) by mouth three times a day METHAZOLAMIDE - (Prescribed by Other Provider) - 50 mg Tablet - 1 Tablet(s) by mouth three times a day PERSONAL EMERGENCY RESPONSE SERVICE ([**Last Name (un) **]) - - PATIENT LIVES ALONE, FREQUENT HYPOGLYCEMIA AND FREQUENT FALLS; FOR HOME USE FOR AT LEAST 12 MONTHS PREDNISONE - (Dose adjustment - no new Rx) - 5 mg Tablet - 1 Tablet(s) by mouth once a day SEVELAMER CARBONATE [RENVELA] - (Prescribed by Other Provider) - 800 mg Tablet - 1 Tablet(s) by mouth three times a day SIROLIMUS [RAPAMUNE] - (Prescribed by Other Provider) - 1 mg Tablet - 1.5 Tablet(s) by mouth once a day SMOOTH EMOLIENT LUBRICANT FOR EYES - (Prescribed by Other Provider) - Dosage uncertain TACROLIMUS - (Dose adjustment - no new Rx; update) - 1 mg Capsule - 3 Capsule(s) by mouth twice a day TERIPARATIDE [FORTEO] - 20 mcg/dose (600 mcg/2.4 mL) Pen Injector - 20 mcq sq every evening TRAVOPROST [TRAVATAN Z] - (Prescribed by Other Provider) - Dosage uncertain TRAZODONE - (Prescribed by Other Provider) - 50 mg Tablet - 0.5 (One half) Tablet(s) by mouth at bedtime TRIAMCINOLONE ACETONIDE - 0.1 % Cream - apply to itchy skin as needed do not use longer than 2 weeks at a time Medications - OTC ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1 Tablet(s) by mouth once a day BLOOD SUGAR DIAGNOSTIC [FREESTYLE LITE STRIPS] - Strip - check finger stick blood sugar four times a day before meals and at bedtime CALCIUM CITRATE-VITAMIN D3 [CITRACAL + D] - (Prescribed by Other Provider) - Dosage uncertain LANCETS - Misc - test finger stick blood sugar four times a day before meals and at bedtime LOPERAMIDE [IMODIUM A-D] - (Prescribed by Other Provider) - 2 mg Tablet - 3 Tablet(s) by mouth PRN MULTIPLE URINE TESTS [MULTISTIX 10 SG] - Strip - prn urinary symptoms SENNOSIDES - (Prescribed by Other Provider) - 8.6 mg Tablet - 2 Tablet(s) by mouth at bedtime SYRINGE WITH NEEDLE (DISP) [SYRINGE 3CC/25GX1"] - 25 gauge X 1" Syringe - use for vitamin B12 injection as directed Discharge Medications: 1. acyclovir 200 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 3. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic three times a day. 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette Ophthalmic daily (). 6. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic twice a day. 7. famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. hydrocortisone-pramoxine 2.5-1 % Cream Sig: One (1) Topical once a day as needed for itching. 11. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 12. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day): MWF Sat. 13. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day): Tu, Th, Sun. 14. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule, Delayed Release(E.C.) Sig: [**1-25**] Caps PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 15. methazolamide 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 16. prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day. 17. sirolimus 1 mg Tablet Sig: 1.5 Tablets PO q am. 18. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO twice a day. 19. travoprost 0.004 % Drops Sig: One (1) drop Ophthalmic once a day. 20. trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as needed for insomnia. 21. triamcinolone acetonide 0.1 % Cream Sig: One (1) Topical once a day: apply to itchy skin, no longer than 2 wks at a time. 22. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every 48 hours) as needed for peripheral neuropathy. 23. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 24. Citracal + D 315-200 mg-unit Tablet Sig: One (1) Tablet PO twice a day. 25. senna 8.6 mg Capsule Sig: Two (2) Capsule PO at bedtime: hold for loose stool. 26. ceftazidime 1 gram Recon Soln Sig: [**1-25**] g Intravenous with dialysis for 9 days: Pt is to receive 2/2/3g w/ HD until [**11-20**]. Disp:*qs g* Refills:*0* 27. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 28. insulin regular human 100 unit/mL Solution Sig: as directed Injection four times a day. Discharge Disposition: Extended Care Facility: Roscommon on the Parkway - [**Location 1268**] Discharge Diagnosis: Primary: E coli septicemia (suspected HD line infection) Secondary: s/p pancreas and renal transplant chronic renal failure diastolic and systolic congestive heart failure severe mitral regurgitation peripheral neuropathy glaucoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital for fevers and rigors during dialysis. You were found to have a bacterial infection in your blood and were started on broad-spectrum antibiotics. You then became septic, had low blood pressure, and were transferred briefly to the ICU, where you were given fluids and started on high-dose steroids. Your dialysis line was also pulled because it may have been the cause of your infection. Your urine did not show any sign of infection, nor did your chest X-ray. Your echocardiogram did not show any signs of endocarditis, but your prior mitral regurgitation has worsened to severe and your pulmonary hypertension is also worse. When you first came, you developed right leg pain of unclear etiology. This may have been due to low blood pressure from sepsis worsening your baseline poor leg perfusion from your peripheral vascular disease. You also developed some shortness of breath, likely because you were fluid overloaded. Your symptoms resolved after you had a new dialysis catheter placed and were dialyzed. Your blood cultures eventually grew E coli. You were initially treated with meropenem, but this was switched to ceftazidime with hemodialysis to avoid putting another line and potential source of infection. Although you had a potential drug reaction to a cephalosporin causing neutropenia, our infectious disease experts felt that treatment with ceftazidime was the preferred option due to your brief treatment course of 2 weeks, no need of another line, and no renal toxicity (as with gentamicin). Your blood levels will be closely monitored to ensure that you do not develop neutropenia. Your stool sample was negative for C diff infection. We have made the following changes to your medications: -START ceftazidime 2g/2g/3g with hemodialysis until [**11-20**]. -INCREASE sevelamer to 1600mg three times daily with meals Please continue to take your other medications as previously prescribed. Followup Instructions: Department: CARDIAC SERVICES When: WEDNESDAY [**2181-11-14**] at 9:20 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: TRANSPLANT CENTER When: THURSDAY [**2181-11-29**] at 3:00 PM With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]

[ "365.9", "E930.5", "428.40", "E879.1", "414.01", "348.31", "585.6", "560.9", "355.8", "V45.11", "403.91", "995.92", "038.42", "244.9", "V42.83", "424.0", "790.29", "682.6", "733.00", "999.31", "V49.75", "996.81", "428.0", "V45.82", "E878.0", "288.03" ]

icd9cm

[ [ [] ] ]

[ "97.49", "39.95", "38.94", "38.95" ]

icd9pcs

[ [ [] ] ]

23021, 23094

11699, 12046

429, 552

23370, 23370

5639, 11676

25512, 26256

4825, 4966

20582, 22998

23115, 23349

16883, 20559

23546, 25262

4996, 5620

16736, 16857

25291, 25489

368, 391

12061, 15736

580, 3357

23385, 23522

15752, 16715

3379, 4446

4462, 4809

31,973

102,040

9812+56070

Discharge summary

report+addendum

Admission Date: [**2180-2-12**] Discharge Date: [**2180-2-28**] Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 1556**] Chief Complaint: [**Age over 90 **] year old female admitted with abdominal pain and no BM x 8 days. Major Surgical or Invasive Procedure: Status Post exploratory laparotomy with lysis of adhesions. History of Present Illness: Ms. [**Known lastname 14936**] is a [**Age over 90 **]-year-old woman who presents from an outside institution ([**Hospital3 2558**]) with a several-day history of increasing constipation, nausea without vomiting. She has noted that her abdomen has been increasingly distended over the last several days. Her most recent bowel movement was days ago. She has received a number of enemas in an effort to relieve this. She has had no flatus in the last day or so. Per her recollection, no change in stool caliber or hematochezia. She has had diminished oral intake and at this point is n.p.o. She denies any abdominal pain or cramping. Past Medical History: Depression Shortness of breath associated with pectus carinatum and age appropriate obstructive ventilatory deficit - seen in pulmonary clinic Colon Ca and small bowel Ca/resected in past History of falls Hypothyroidism Glaucoma Cataracts ? some short term memory loss Social History: Smoking: 60 pack year no alcohol use. Lives at home iwth a 24 hr aide Family History: patient denies any med issues in family Physical Exam: VITAL SIGNS: Temperature is 97.3, pulse is 82. Blood pressure 124/68, respirations 21, saturation on 2 liters is 97. GENERAL: She is alert, oriented, and in no acute distress. HEENT: Sclerae are anicteric. Oropharynx is clear. There is a plaque on the soft palate of a whitish hue. NECK: Supple. Trachea midline. No lymphadenopathy. No bruits. LUNGS: Clear with few wheezes bilaterally. HEART: Regular. ABDOMEN: Markedly distended. There are no obvious hernias, no organomegaly. She does have active high pitched bowel sounds. She has some discomfort to palpation. No peritoneal signs. EXTREMITIES: Without edema. Feet are warm. No ulcers. Pertinent Results: Admission Labs --------------- [**2180-2-11**] 08:15PM WBC-15.5* RBC-4.61 Hgb-14.6 Hct-41.4 MCV-90 MCH-31.8 MCHC-35.4* RDW-13.4 Plt Ct-417 Neuts-85.6* Lymphs-8.2* Monos-5.6 Eos-0.2 Baso-0.4 Plt Ct-417 Glucose-125* UreaN-16 Creat-0.7 Na-122* K-4.9 Cl-86* HCO3-30 AnGap-11 . [**2180-2-22**] 05:55AM BLOOD WBC-26.2*# RBC-3.55* Hgb-10.7* Hct-32.4* MCV-91 MCH-30.2 MCHC-33.1 RDW-14.3 Plt Ct-387 . [**2180-2-23**] 09:15AM BLOOD Neuts-90.0* Lymphs-5.6* Monos-3.5 Eos-0.8 Baso-0.1 . [**2180-2-24**] 05:25AM BLOOD WBC-14.2* RBC-3.19* Hgb-9.6* Hct-30.1* MCV-94 MCH-30.1 MCHC-32.0 RDW-14.3 Plt Ct-412 Glucose-112* UreaN-28* Creat-0.4 Na-139 K-4.1 Cl-107 HCO3-28 AnGap-8 [**2180-2-23**] 09:15AM BLOOD CK-MB-NotDone cTropnT-0.03* . Radiology --------- [**2180-2-11**] 9:22 PM ~ ABDOMEN (SUPINE & ERECT) INDICATION: [**Age over 90 **]-year-old female with possible small-bowel obstruction on outside film. IMPRESSION: Multiple, relatively proportionately gas-distended loops of large and small bowel extending to the rectum, without free intraperitoneal air. Appearance is suggestive of adynamic ileus, though early or incomplete SBO cannot be completely excluded; correlate clinically, with imaging follow- up as indicated. . [**2180-2-12**] 9:46 PM ~CHEST PORT. LINE PLACEMENT HISTORY: Right IJ line. Assess placement, evaluate for pneumothorax. IMPRESSION: Tube and line placement as described. . [**2180-2-12**] 4:50 AM ~ CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST INDICATION: [**Age over 90 **]-year-old female with history of colon CA status post resection, presenting with abdominal distention and nausea. IMPRESSION: 1. Multiple dilated loops of fluid-filled small bowel with fecalized material in the distal ileum extending to the ileocolonic anastomosis in the mid abdomen. Findings are consistent with partial small- bowel obstruction. No evidence for free intraperitoneal fluid or air. 2. Cystic mass in the right adnexa and fluid filled endometrial cavity are both concerning findings given the patient's age. Further characterization with pelvic ultrasound is recommended on a non-emergent basis if additional followup is warranted. 3. Small bilateral pleural effusions and bibasilar atelectasis. 4. Dilatation of the aortic root to 4.5 cm. Coronary artery calcifications and enlargement of the pulmonary artery suggestive of pulmonary arterial hypertension. 5. Left adrenal adenoma. 6. Severe degenerative changes in the thoracolumbar spine with numerous wedge compression deformities of unknown chronicity. . [**2180-2-17**] 6:29 PM ~FOOT 2 VIEWS RIGHT [**Hospital 93**] MEDICAL CONDITION:R foot pain and bruising FINDINGS: No previous images. Frontal and lateral view show no definite fracture. There is apparent dislocation of the third PIP and subluxed fourth PIP. Question of a well-corticated bone fragment at the distal fourth proximal phalanx. This could be a sequela of previous injury, though an acute fracture cannot be unequivocally excluded. . [**2180-2-17**] 2:57 PM ~ CHEST (PORTABLE AP) [**Hospital 93**] MEDICAL CONDITION: Rales and crackles FINDINGS: In comparison with the study of [**2-13**], there has been the development of substantial pleural effusions bilaterally. The pulmonary vessels are less sharply seen, consistent with increasing pulmonary venous pressure. The endotracheal tube has been removed and the right IJ catheter remains. . [**2180-2-18**] 2:21 PM ~FOOT AP,LAT & OBL RIGHT INDICATION: Pain in the third and fourth right toes. IMPRESSION: Overall unchanged appearance when compared to [**2180-2-17**]. Dislocation of the third and fourth proximal interphalangeal joint. Subluxation/dislocation of the second and fifth metatarsophalangeal joint. A fracture at the base of the fourth middle phalanx cannot reliably be excluded. . [**2180-2-20**] 11:28 AM ~CHEST (PORTABLE AP) Reason: increased white count, please eval for acute pulmonary proce FINDINGS: Again noted are large bilateral pleural effusions and right IJ line with tip in the SVC. The upper lungs are clear. The lower lungs cannot be assessed due to the overlying effusions. . [**2180-2-21**] 7:47 PM ~PORTABLE ABDOMEN INDICATION: Recent small bowel obstruction status post LOA, presenting with nausea and vomiting. IMPRESSION: Limited examination. Recommend upright and supine views to further assess bowel as indicated. No definite evidence of obstruction. Dense material of the colon is probably from CT evaluation nine days prior. . [**2180-2-22**] 9:00 PM ~CHEST PORT. LINE PLACEMENT PROCEDURE: Chest portable for line placement on [**2180-2-22**]. IMPRESSION: 1. Right PICC line in a fairly satisfactory location at the SVC/atrial junction. 2. New bilateral mild interstitial pulmonary edema. . [**2180-2-22**] 11:52 AM ~CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST INDICATION: Status post exploratory laparotomy, [**2-12**], now with elevated white blood cell count. Evaluate for abscess. IMPRESSION: 1. Dilated loops of small bowel and moderate amount of stool in the colon. Findings are most suggestive of ileus. 2. Focal area of peripheral circumferential gas within the colon, just adjacent to the ileocolic anastomosis, most likely represents gas trapped around luminal contents, as no other signs to suggest bowel ischemia are present. 3. Increased bilateral pleural effusions and atelectasis. 4. Small amount of fluid in the pelvis without evidence of abscess. 5. Left adrenal gland prominence could relate to adenoma as previously suggested, although a focal nodule is not definitely visualized on today's examination. . [**2180-2-24**] 10:00 AM ~CHEST (PORTABLE AP) Reason: pulm edema, ? increasing effusions INDICATION: Followup. IMPRESSION: No relevant changes as compared to [**2-22**]. . . Cardiology ---------- TTE (Complete) Done [**2180-2-18**] at 11:48:15 AM FINAL IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Moderate aortic stenosis. Mild-moderate aortic regurgitation. Moderate mitral regurgitation. Moderate pulmonary hypertension. Dilated thoracic aorta. . Pathology --------- SPECIMEN SUBMITTED: right ovary. Procedure date Tissue received Report Date Diagnosed by [**2180-2-12**] [**2180-2-14**] [**2180-2-17**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/cma?????? Previous biopsies: [**-6/3243**] EGD (2). DIAGNOSIS: Right ovary, exploratory laparotomy: 1. Fallopian tube with paratubal cyst and reactive mesothelial cells. 2. Ovary with simple cyst. Dr. [**Last Name (STitle) **] [**Last Name (NamePattern5) 16189**] reviewed slide B. Clinical: Small bowel obstruction. Gross: The specimen is received fresh labeled with "[**Known lastname 14936**], [**Known firstname 2127**]" the medical record number and "right ovary." It consists of a fallopian tube and ovary. The fallopian tube measures 5.5 cm in length and 0.3 cm in diameter and the ovary measures 2.5 x 2.0 x 1.5 cm. At the junction of the fallopian tube and the ovary is what appears to be a paratubal cyst which measures 3.5 x 3.0 x 2.0 cm. The surface of the specimen is inked in black and the specimen is serially sectioned to reveal a biloculated cyst with a smooth lining and contains approximately 15 cc of clear fluid. The ovary is also serially sectioned to reveal a simple cyst with approximately 5 cc of yellow fluid. The cyst wall has a smooth lining and measures 0.1 cm in thickness. No solid component is identified. Representative sections are submitted as follows: A = fallopian tube, B-C = paratubal cysts. D-E = ovary with cyst. . Brief Hospital Course: This is a [**Age over 90 **] year old female admitted on [**2180-2-12**] with small bowel obstruction. Underwent exploratory laparotomy. Postoperative Issues: 1. Cardiac - Has been tachycardic intermittently. Ekg confirms sinus rhythm to sinus tach. Troponin checked with normal to slight elevations. [**Date Range **] [**2-18**]: IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Moderate aortic stenosis. Mild-moderate aortic regurgitation. Moderate mitral regurgitation. Moderate pulmonary hypertension. Dilated thoracic aorta. Acute on chronic heart failure. 2. Respiratory - Pulmonary consult called for management of CHF, COPD and pectus carinatum. Chest x-rays have showed bilateral pleural effusions with some CHF. Diuresised with lasix multiple times. Albuterol nebulizers given for expiratory wheezes. Currently respiratory status stable. Daily advair and spiriva. 3. Infectious Disease - WBC up to 26 on [**2180-2-22**] Pancultured with negative cultures for blood, urine, sputum. Stool sent for c. diff. negative times four. Central line discontinued, negative growth of culture tip. Started on vancomycin and flagyl. White count trending down to 11.6 on [**2180-2-28**]. Flagyl discontinued. Will continue oral vancomycin for 14 more days per Infectious Disease. 4. Abdomen/GI - Patient has been getting a fleets enema daily with colace. Her abdomen is now soft, positive bowel sounds, slightly distended. Incision line dry and intact without erythema. Has been tolerating a soft diet with fluid intake approx. 1 liter a day. As oral intake good will discontinue TPN today. 5. GU - Foley discontinued on [**2180-2-26**]. Incontinent at times. Baseline bun 15-20, creatinine .3 -.8. 6. Mobility - Out of bed with assistance. She has been ambulating with physical therapy with walker with much assistance. 7. Discharge plans - She will be discharged to rehab. at [**Hospital1 **] today. She is to follow up with Dr. [**Last Name (STitle) **] in 2 weeks. Medications on Admission: Advair Spiriva ASA Levoxyl 75' Diltiazem XL 180' Remeron 7.5 mg daily and 15 mg QHS Lisinopril 7.5' Trosopt eye drops TID rt eye Centrum silver Discharge Medications: 1. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic TID (3 times a day). 2. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: 1-2 puffs Inhalation Q6H (every 6 hours) as needed. 3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO QAM (once a day (in the morning)). 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever or pain. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 9. Lisinopril 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 10. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): continue until [**2180-3-8**]. 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Location 12243**] Senior Care - [**Hospital1 189**] Discharge Diagnosis: High grade small bowel obstruction Post-operative Ileus Post-operative Leukocytosis Discharge Condition: Stable Discharge Instructions: Please call Dr. [**Last Name (STitle) **] or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * If you are nauseous and vomiting; cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * Your pain is not improving within 8-12 hours or becoming progressively worse, or inadequately controlled with the prescribed pain medication. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Abdominal pain and/or tenderness * Abdominal fullness * Abdominal distention * Increase in cramping and/or bloating sensation * Failure to pass gas or stool (constipation) * Changes in bowel habits ?????? such as constipation or diarrhea * Any serious change in your symptoms, or any new symptoms that concerns you. Followup Instructions: Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in clinic on [**3-17**] at 1:15. Completed by:[**2180-2-28**] Name: [**Known lastname 5749**],[**Known firstname 1194**] Unit No: [**Numeric Identifier 5750**] Admission Date: [**2180-2-12**] Discharge Date: [**2180-2-28**] Date of Birth: [**2087-1-14**] Sex: F Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 3524**] Addendum: This patient has preserved systolic function via echo. Therefore she has chronic dystolic heart failure. [**Last Name (NamePattern4) 5751**] NP Discharge Disposition: Extended Care Facility: [**Hospital6 609**] for the Aged - MACU [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2207**] MD [**MD Number(1) 3525**] Completed by:[**2180-3-13**]

[ "428.32", "754.82", "511.9", "518.0", "614.6", "560.81", "428.0", "496", "620.2", "416.8", "599.0", "V10.05", "244.9", "560.1", "997.4", "008.45", "396.8", "V10.09" ]

icd9cm

[ [ [] ] ]

[ "54.59", "99.15", "65.49", "38.93", "54.11" ]

icd9pcs

[ [ [] ] ]

14982, 15205

9746, 11794

302, 363

13293, 13302

2167, 4724

14314, 14959

1431, 1472

11988, 13061

5210, 9723

13186, 13272

11820, 11965

13326, 14291

1487, 2148

179, 264

391, 1033

1055, 1326

1342, 1415

65,562

171,920

20646

Discharge summary

report

Admission Date: [**2109-5-10**] Discharge Date: [**2109-5-11**] Date of Birth: [**2042-9-7**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3984**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: Endoscopy with clip placement after biopsy History of Present Illness: 66 Mandarin-speaking F presents from GI suite after endocscopy for removal of large pedunculated stomach polyp [**5-10**]. Today she had an uncomplicated removal of large pedunculating stomach polyp with use of a loop snare. There was a large artery feeding the polyp with approximately 200ml of EBL after cautery and hemostasis. MAC was used during procedure. She remained hemodynamically stable and has 2 PIV, 16 and 20G. . She was started on 1L of NS, given Zofran 4mg IV, Dilaudid 1mg IV in procedure. She received Versed and Fentanyl for sedation. . On the floor, the patient is sleepy but arousable. Past Medical History: Osteoarthritis Social History: Lives with husband. [**Name (NI) 1403**] as a home caretaker for the elderly. Denies tobacco or etoh use. Family History: Non-contributory Physical Exam: PEx on admission to ICU: Vitals:96, 49, 171/88, 13, 97%/RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP to mandible Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Bradycardic with reg rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, mildly distended (patient states baseline), 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: ADMISSION LABS: [**2109-5-10**] 04:28PM WBC-8.1# RBC-4.10* HGB-12.3 HCT-37.2 MCV-91 MCH-30.0 MCHC-33.1 RDW-12.7 [**2109-5-10**] 04:28PM PLT COUNT-199 [**2109-5-10**] 11:57AM GLUCOSE-103* UREA N-17 CREAT-0.7 SODIUM-139 POTASSIUM-5.0 CHLORIDE-105 TOTAL CO2-26 ANION GAP-13 [**2109-5-10**] 11:57AM estGFR-Using this [**2109-5-10**] 11:57AM CALCIUM-7.8* PHOSPHATE-3.2 MAGNESIUM-2.0 [**2109-5-10**] 11:57AM PT-12.7 PTT-32.4 INR(PT)-1.1 [**2109-5-10**] 10:00AM WBC-3.8* RBC-4.00* HGB-12.3 HCT-36.2 MCV-90 MCH-30.7 MCHC-34.0 RDW-12.7 [**2109-5-10**] 10:00AM PLT COUNT-191 [**2109-5-10**] 10:00AM PT-UNABLE TO INR(PT)-UNABLE TO DISCHARGE LABS: [**2109-5-11**] 04:42AM BLOOD WBC-5.4 RBC-4.05* Hgb-12.6 Hct-36.7 MCV-91 MCH-31.1 MCHC-34.4 RDW-12.9 Plt Ct-199 [**2109-5-11**] 04:42AM BLOOD Plt Ct-199 [**2109-5-11**] 04:42AM BLOOD Glucose-88 UreaN-15 Creat-0.8 Na-141 K-3.6 Cl-106 HCO3-27 AnGap-12 [**2109-5-11**] 04:42AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.2 IMAGING: None Brief Hospital Course: 66 yo F s/p gastric polyp removal admitted to ICU for monitoring of GI bleed. . Ms. [**Known lastname **] was transferred to the ICU for monitoring for GI bleed after she had a gastric polyp removal that was fed by a large artery. In the ICU, she was started on a protonix drip. Her HCT was trended and remained stable. She was monitored on telemetry without hemodynamic irregularities. She denied any abdominal pain and was able to tolerate a clears diet prior to discharge. She was discharged with [**Hospital1 **] Protonix but no other changes to her medications. She had slightly elevated blood pressure during her stay, ranging in the 130s-160s post procedure that trended down to 120s prior to discharge. Her blood pressure should be followed as an outpatient. Medications on Admission: Fosamax Calcium Fish Oil Discharge Medications: 1. Fish Oil Oral 2. Fosamax Oral 3. calcium carbonate Oral 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: -gastric polyp removal Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**Known lastname **], It was a pleasure to take care of you at [**Hospital1 18**]. You were admitted to the ICU for monitoring after your biopsy procedure because of bleeding during the procedure. The gastrointestinal physicians wanted to monitor your heart rate, blood counts, and blood pressure overnight; all of these things were stable. Please make an appointment to see your primary physician to evaluate your blood pressure. Please call the hospital and ask for the on-call ERCP fellow if you have any questions. The following changes were made to your medications: -START Pantoprazole Followup Instructions: Please call to make an appointment with your primary physician. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

[ "998.11", "401.9", "427.89", "300.00", "211.1", "E878.8" ]

icd9cm

[ [ [] ] ]

[ "88.74", "43.41", "44.43" ]

icd9pcs

[ [ [] ] ]

3881, 3887

2778, 3550

312, 356

3963, 3963

1773, 1773

4741, 4934

1170, 1188

3625, 3858

3908, 3942

3576, 3602

4114, 4718

2431, 2755

1203, 1754

264, 274

384, 993

1790, 2414

3978, 4090

1015, 1031

1047, 1154

32,613

183,046

31651

Discharge summary

report

Admission Date: [**2111-4-9**] Discharge Date: [**2111-4-15**] Date of Birth: [**2035-8-11**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 495**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Thoracentesis, Left side [**2111-4-12**] History of Present Illness: Mr. [**Known lastname 9464**] is a 75 yo M w/ metastatic papillary thyroid cancer s/p XRT 19 sessions who presented on [**2111-4-9**] with 2 days of worsening dysphagia for solids, poor oral intake, weight loss 20 pounds over last several weeks and some lethargy. . On admission, in the ED T 96.7, Hr 133, BP 102/73 and RR 20 sats 93% on RA. His WBC was 26.5, with 87% Neutrophils. Calcium 11.9, alb 3.2. His chest x ray was read as multifocal pneumonia, predominately affecting the lingula and left lower lobe. He was transfer to the floor. . On the floor, he was started on Levofloxacine/Flagyl. He was also given Zoledonic Acid and IV fluids to treat his hypercalcemia. GI was also consulted but they have not seen him until he recovers from his multifocal pneumonia. He had an esophageal x ray that showed no evidence of esophageal perforation but aspiration of contrast material into the airway. he was also evaluated by Speech and swallow who recommended an esophageal video swallow to assess him better. . Overnight his O2 saturation started to drop. this morning he was on 6 L NC sats into the 88%, increased work of breathing. i/o over 24 H 3 L positive. He received 40 Iv lasix, and had 600 cc urine out. Chest x ray revealed worsening Left pleural effusion. ABG 7.49,27, 68 compatible with acute repiratory alcalosys and hypoxemia. Past Medical History: Papillary thyroid cancer dx fall [**2109**] right neck mass --s/p neck mass resection [**7-13**]; unable to perform thyroidectomy [**2-7**] high bleed risk, proximity to trachea and recurrent laryngeal nerve and large tumor size --s/p XRT to neck [**11-13**] --s/p RAI ablation --Metastatic to lymph nodes and adrenal glands * s/p hernia repair * s/p tonsillectomy Social History: Remote tobacco use, smoked 1.5 packs/week x 20 years. Retired engineer. Married. Family History: Son with Grave's disease Physical Exam: HR 135, Bp 115/68, HR 79, Sats 95% on 10L Gen: Thin elderly, in moderate distress HEENT: moist oral mucose Neck: surgical scar, skin changes secondary to radiation. small tumors in the anterior part of his neck. Hrt: Regular rate S1 S2 no m/r/g Chest vesicular cluster erhthematous rash over R anterior hemithorax Lungs: decrease BS and dullness to percussion over left hemithorax Abd: Soft, nontender +bowel sounds Ext: Warm, well perfused Neuro: Alert, interactive Pertinent Results: [**2111-4-12**] 10:20AM BLOOD WBC-33.5* RBC-4.64 Hgb-13.5* Hct-40.8 MCV-88 MCH-29.1 MCHC-33.0 RDW-16.3* Plt Ct-264 [**2111-4-12**] 10:20AM BLOOD Glucose-99 UreaN-23* Creat-0.9 Na-152* K-3.1* Cl-114* HCO3-19* AnGap-22* [**2111-4-9**] 10:55AM BLOOD ALT-57* AST-30 AlkPhos-147* TotBili-0.5 [**2111-4-12**] 10:20AM BLOOD LD(LDH)-296* CK(CPK)-70 [**2111-4-12**] 10:20AM BLOOD TotProt-5.5* Albumin-2.7* Globuln-2.8 Calcium-11.7* Phos-2.4* Mg-2.1 [**2111-4-12**] 11:30AM BLOOD Type-ART pO2-68* pCO2-27* pH-7.49* calTCO2-21 Base XS-0 . RADS [**2111-4-9**] chest x ray: IMPRESSION: New multifocal pneumonia, predominately affecting the lingula and left lower lobe. Stable widened mediastinum consistent with known right thyroid mass with tracheal deviation to the left. . [**2111-4-9**] Abdomen: IMPRESSION: No evidence of obstruction . 4/3/08Esophagous: 1. No evidence of esophageal perforation. 2. Aspiration of contrast material into the airway. 3. Small hiatal hernia. . [**2111-4-12**]: Chest x ray MARKED INTERVAL INCREASE IN LT EFFUSION, NOW MODERATE TO LARGE RESULTING IN INCREASE OPACIFICATION OF LESS AERATED LT HEMITHORAX. INTERVAL INCREASE IN mULTIFOCAL RT OPACITIES. THYROID MASS STABLE. [**Doctor Last Name **] D/W [**Doctor Last Name **] [**Numeric Identifier 74372**] Brief Hospital Course: Mr. [**Known lastname 9464**] is a 75 yo M w/PMHx sx for metastatic papillary thyroid cancer with local invasion and tracheal deviation who presents with worsening o2 requirment and chest x ray showed worsening left pleural effusion #. Respiratory distress: patient admitted 3 days ago, with leukocytosis, no fevers and x ray that showed multifocal pneumonia. X ray this morning showed worsening pleural effusion that could definitely explain his shortness of breath. He has not spike fevers but his WBC continues to trend up despite a/b which is concerning for underlying infection either viral, bacterial. Other posibilites will include PE given tachycardia and underlying malignancy. On the other hand, he was definitely positive in fluid balance given hydration for hypercalcemia. Patient underwent thoracentesis for diagnosis. Patient's respiratory status worsened. Palliative care was consulted and eventually it was decided to make the patient CMO. He expired on [**2111-4-15**] of respiratory arrest. # Leukocytosis: no documented fever. likely secondary to his pulmonary process. He also has his zoster lesions with no clear evidence of superinfection. There was no evident source of his infection. # Hypernatremia: patient presented with normal sodium on admission. Looks normovolemic on exam. He received about 5 L last 24 hours. ddx includes DI which might be due to his hypercalcemia, or given high cloride and low bicarb it could also be due to NS hydration. # hypercalcemia: patient with prior normal calcium, likely hypercalcemia of malignancy. Received zolindronic acid. Patient was initially full code, but his respiratory status continued to worsen. He eventually was seen by palliative care, and was made CMO. He expired secondary to respiratory arrest likely from complications of his malignancy. #. Communication. Wife [**Name (NI) **] [**Name (NI) 9464**] HCP [**Telephone/Fax (1) 74373**] Medications on Admission: Levoxyl 88 mcg PO daily Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Expired Metastatic Papillary Carcinoma Respiratory failure Pleural Effusion Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired

[ "197.2", "196.0", "276.0", "196.1", "244.1", "197.0", "193", "275.42", "198.7", "276.3", "507.0", "197.1" ]

icd9cm

[ [ [] ] ]

[ "34.91" ]

icd9pcs

[ [ [] ] ]

6121, 6130

4088, 6015

341, 383

6249, 6258

2788, 4065

6314, 6324

2260, 2286

6089, 6098

6151, 6228

6041, 6066

6282, 6291

2301, 2769

282, 303

411, 1757

1779, 2146

2162, 2244

1,795

189,051

21481

Discharge summary

report

Admission Date: [**2128-7-29**] Discharge Date: [**2128-8-24**] Date of Birth: [**2081-1-23**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2597**] Chief Complaint: fever, hypotension, diarrhea, r/o sepsis Major Surgical or Invasive Procedure: Open left fourth and fifth transmetatarsal amputation of the toes Left lower extremity arteriography and tibial angioplasty. Angioplasty of left anterior tibial artery. Left below-the-knee amputation. History of Present Illness: 47yo woman with h/o type II diabetes mellitus, ESRD on hemodialysis, CAD, CHF (EF 20%), PVD presenting with fever, hypotension, diarrhea, and left toe pain. The patient presented to [**Hospital1 18**] ED on [**2128-7-20**] with left toe pain, and was discharged to home on a course of Augmentin for concern of developing cellulitis and infected laceration. She continued to have sharp pain in her left foot. She did not complete the 7day course, however, developing worsening diarrhea and nausea after four days of antibiotics. Diarrhea was more frequent than her baseline loose stools, and was nonbloody. She denies having had fevers or chills. She continued to take her Coreg and Imdur despite decreased po intake. She has had chronic diarrhea at baseline since starting hemodialysis in [**2125**] (MWF). She missed dialysis on Monday of this week, but was dialyzed Tuesday and Wednesday. She presented to [**Hospital 191**] clinic today and was found to have temp of 101.7, pulse 104, and BP 86/62. She was referred to the ED for further evaluation. On presentation to the ED, T 102.9 HR 112 BP 104/66 RR 16 98%RA. Her blood pressure dropped to 86/54, and she was treated with 3L NS. She continued to be hypotensive and was started on dopamine; however, he heart rate was 120s. A right IJ was placed, and she was started on levophed. Blood pressure stabilized at 110/64. She also received vancomycin, levofloxacin, and metronidazole. On review of records, baseline blood pressure for this patient ranges (80-100/60s). She also denies having had recent chest pain or tightness, shortness of breath, orthopnea, or PND. At baseline she is able to walk from one room to another without becoming short of breath. . ROS: significant for cough productive of yellow sputum. She denies headaches, dizziness, chest pain, tightness, palpitations, SOB, orthopnea, PND, abdominal pain. Past Medical History: 1. CHF - EF 20-25% 2, h/o osteomyelitis 3. h/o VRE bacteremia 4. hypertension 5. hypercholesterolemia 6. ESRD from poorly controlled DM. 7. DM type 2- complicated by neuropathy, vascular disease, retinopathy, gastropathy, and renal insufficiency; she does not know her blood sugar ranges, although her A1C has been low at 5.8 mg/dL. 8. PVD- s/p PTCA of R superficial femoral and posterior tibial arteries, complicated by VRE bacteremia. S/p TMA of R 5th metatarsal with prolonged healing; + claudication symptoms. 9. CAD with ischemic cardiomyopathy- s/p MI in [**2124**] severe 3 vessel disease 1. Selective coronary angiography of this right dominant system revealed diffuse three vessel disease. The LMCA contained mild, diffuse disease. The LAD contained moderate disease with total occlusion of the distal vessel. The LCX contained moderate diffuse disease and supplied the distal LAD via collaterals. The RCA contained severe, small vessel diffuse disease. 2. Limited resting hemodynamics revealed a central aortic pressure of 133/74. TTE [**1-/2127**]: The left atrium is moderately dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is severe global left ventricular hypokinesis (ejection fraction 20-30 percent). 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 is borderline 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 structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. 10. Hx of VRE in BCx in [**12-18**]- sensitive to linezolid. 11. Osteoporosis Social History: Came to US from [**Country **] in [**2116**]. Lives with her elderly husband. Their children are in [**Country **]. Very involved with her church and is devout [**Doctor First Name **]. Denies tobacco, alcohol, or illicit drug use Family History: significant for diabetes, CAD Physical Exam: Pt deseased Pertinent Results: RADIOLOGY Final Report CT HEAD W/O CONTRAST [**2128-8-24**] 7:57 AM CT HEAD W/O CONTRAST Reason: ? bleed [**Hospital 93**] MEDICAL CONDITION: 47 year old woman with ESRD/DM/CAD, coagulopathy now unresponsive REASON FOR THIS EXAMINATION: ? bleed CONTRAINDICATIONS for IV CONTRAST: None. NON-CONTRAST HEAD CT SCAN HISTORY: End-stage renal disease, diabetes and coronary artery disease, coagulopathy, now unresponsive. TECHNIQUE: Non-contrast head CT scan. COMPARISON STUDIES: None. FINDINGS: There is a 2.5 x 4.2 cm lesion in the right frontal lobe with hyperdense material, presumably hemorrhage, sedimenting in the dependent portion as well as hyperdense material marginating the lesion. This abnormality causes extensive compression of the right frontal [**Doctor Last Name 534**]. There is a moderately large quantity of blood sedimenting in the occipital horns. The fourth ventricle is filled with blood and grossly dilated as well. Blood is also seen in the region of the vallecula, posterior to the medulla. Finally, there is probably a small amount of blood within the posterior aspect of the third ventricle. Though the scans are degraded by motion artifact, there is likely a small quantity of subarachnoid blood overlying the cerebral convexities bilaterally. There is no shift of normally midline structures. Within the limitations of this study, no definite major vascular territorial infarction is noted. The right globe is shrunken and hyperdense, presumably representing end-stage diabetic damage. CONCLUSION: Probable unclotted right frontal hemorrhage with extensive intraventricular hemorrhage, as well as hydrocephalus and subarachnoid hemorrhage. BRAIN SCAN Reason: BRAIN HEMMORRHAGE BRAIN DEATH RADIOPHARMECEUTICAL DATA: 24.7 mCi Tc-[**Age over 90 **]m Neurolite; History: 47 year old woman with brain hemorrhage and absent gag and corneal reflexes on exam. FINDINGS: Following injection of tracer, flow and static images of the brain were obtained in multiple projections showing no evidence of perfusion to the cerebral cortex. The perfusion abnormalities noted above are consistent with brain death. IMPRESSION: No demonstrable intracerebral perfusion consistent with brain death. Brief Hospital Course: 47yoW with h/o TIIDM, 3vCAD, CHF (EF 20-25%), ESRD on HD presenting with fever, left toe pain, diarrhea, and septic shock. . Admitted to the MICU: . On admission hypotension was felt likely to be due to septic shock given concurrent fever, leukocytosis, infected toe. infection source likely necrotic left 4th/5th toes, concerning for osteomyelitis and bactermia. Less likely GI source with diarrhea but lack of abdominal pain. . NSTEMI: Likely demand ischemia in setting of hypotension in patient with known 3v disease. ECG showed lateral ST-depressions. No heparin gtt was started as not likely due to plaque rupture. She was continued on ASA, atorvastatin 80mg daily. Carvedilol and lisinopril were held given hypotension. An echo was performed to evaluate for wall motion abnormalities, assess cardiac function. An echo on [**7-30**] demonstrated interval improvement in left ventricular systolic function (40%) from prior studies (20-25%). . Diarrhea: Patient reports having diarrhea at baseline, but worsening this week. Given concern for C.difficile, the patient was treated empirically with metronidazole. C diff studies have been negative. Stool cultures negative. . ESRD: The patient was continued on M,W,F Hemodialysis untill death Hospital Course: . On [**7-30**] pt received TMA of her left 4th/5th digits. Pt initially placed on levophed as above, switch to vasopressin [**7-31**]. Has now been off pressors for > 36 hours. initially pt placed on [**Month/Year (2) **] and zosyn. However, cultres have now grown out enterobacter and klebsiella, both sensitive to levofloxacin, as well as Coag pos staph and entercoccus ([**Last Name (un) 36**] pending). [**First Name9 (NamePattern2) **] [**Doctor Last Name **] been continued. Per ID, who has been following, flagyl added to regimen. Pt has been afebrile since [**7-31**]. . Underwent angiogram with interventions x 2 to restore blood flow. plavix started. It was decided that pt foot was source of sepsis s/p TMA. It was decided to to a BKA. Patient thenhad L BKA [**8-19**] and was transferred to the SICU for cont. fevers and SBP in 60's. Patient was AAOx3 until [**8-24**] when she had acute worsening of mental status at 6:15am. A stat NS consult obtained. She was subsequently intubated for airway protection. On review of labs, PT 21.1, PTT 150, INR 2.0. Unclear etiology as patient was only on SQ hep and hep flushes for CLs. Patient was also on ASA and plavix. Stat head CT showed large 4-5 cm intraparenchymal right frontal bleed with bilateral intraventricular blood and in 3rd and 4th ventricles. Initial exam after aforementioned event: PHYSICAL EXAM: O: T: 99.3 BP: 96/52 HR: 99 R 14 99% O2Sats vented CMV 14x500 FiO2 100% PEEP 5 CVP 27 Gen: Lying in bed bleeding from right ear from BS, oozing from mouth, not awake. HEENT: Pupils: L pupil sluggish 3mm -> 2.5mm EOMs Neck: Supple Lungs: breath sounds bilaterally. Cardiac: tacyhcardic, regular rate. S1/S2. Abd: Soft, NT, BS+ Extrem: left BKA staples c/d/i, right toe resection staples c/d/i. hands warm, no cyanosis or edema. Neuro: Exam performed without sedation. Patient intubated, not awake or alert. Not responding to painful stimuli in all 4 extremities, Left pupil sluggish 3->2.5mm and eye midline, no corneal reflex, no gag. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Reflexes: no DTRs . Pt made CMO . Pt deseased shortly after Medications on Admission: Coreg 12.5mg [**Hospital1 **] Imdur 60mg daily Lipitor 80mg daily Nephrocaps Protonix 40mg daily Neurontin 600mg QHS Lisinopril 20mg daily Calcium carbonate Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: n/a Discharge Condition: n/a Discharge Instructions: n/a Followup Instructions: n/a Completed by:[**2129-5-21**]

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icd9cm

[ [ [] ] ]

[ "39.95", "88.48", "00.40", "84.11", "37.23", "96.04", "38.93", "39.50", "99.04", "88.56", "84.15", "88.53" ]

icd9pcs

[ [ [] ] ]

10866, 10875

7213, 8463

355, 561

10922, 10927

4966, 5077

10979, 11013

4887, 4918

10838, 10843

5114, 5180

10896, 10901

10656, 10815

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10951, 10956

9856, 10630

275, 317

5209, 7190

589, 2487

2509, 4619

4635, 4871

5,077

105,470

10109

Discharge summary

report

Admission Date: [**2138-8-1**] Discharge Date: [**2138-8-7**] Date of Birth: [**2065-10-30**] Sex: F Service: GSURG-GOLD HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 33749**] is a 72 -year-old woman who is followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of the UMG who was admitted to Dr. [**Last Name (STitle) 519**] on [**8-2**] in the early morning with a probable gallstone pancreatitis. Mrs. [**Known lastname 33749**] underwent a left carotid endarterectomy by Dr. [**Last Name (STitle) 1476**] on [**7-31**]. At home, on [**2138-8-1**], Mrs. [**Known lastname 33749**] experienced sudden onset of an upper abdominal pain with limited emesis. REVIEW OF SYSTEMS: She had nausea, vomiting, fever or chills, and sweats. She complains of diarrhea, but denies any melena, hematochezia, or bright red blood per rectum. She has not had any prior history of a right upper quadrant pain or indigestion. There were no relieving factors; however, the pain was exacerbated by food ingestion. There were no urinary symptoms described by the patient. PAST MEDICAL HISTORY: 1. Coronary artery disease status post myocardial infarction, congestive heart failure, and on [**2138-2-20**], percutaneous transluminal coronary angioplasty with stent. 2. History of Helicobacter pylori positive upper gastrointestinal bleed. 3. Cerebrovascular accident with right sided hemiparesis. 4. Chronic obstructive pulmonary disease and 30 pack year smoking history. 5. A question of chronic renal failure. PAST SURGICAL HISTORY: 1. Left carotid endarterectomy. 2. Appendectomy. 3. Right ankle open reduction and internal fixation. ADMITTING MEDICATIONS: Lasix, Prevacid, lisinopril, Albuterol, Atrovent, Flovent, aspirin, Paxil, and Diltiazem. ALLERGIES: She has allergies to Levaquin and penicillin which cause a rash. PHYSICAL EXAMINATION: On admission, her temperature was 98.1 F and she was afebrile without chills. Her blood pressure was 168/77, heart rate was 106, respiratory rate was 23, and saturations were 95% on four liters. She was alert and oriented times three. Her lung examination was clear to auscultation bilaterally. Heart examination was regular rate and rhythm. The abdominal examination showed a soft, obese abdomen with positive right upper quadrant tenderness, including a positive [**Doctor Last Name 515**] sign. She also had percussion tenderness. There was a question of a palpable gallbladder in the right upper quadrant. The rectal examination was heme positive with good rectal tone. The pulses were palpable bilaterally equally. PERTINENT LABORATORY VALUES: On admission, the CBC showed an elevated white count of 20.2 with a hematocrit of 35.8 and platelets of 33.8. She had 71% neutrophils and a bandemia of 14%. Sodium was 137, potassium 5.5, chloride 102, bicarbonate 19, BUN of 32, and creatinine was elevated to 1.7, with a baseline of 1.0 to 1.4. Her glucose at the time was 143. Liver function tests showed an ALT of 13, AST of 29, and alkaline phosphatase of 79, and a total bilirubin of 0.5. Amylase was elevated significantly to 571 and lipase was 1,365. A urinalysis showed 3 to 5 white blood cells with moderate bacteria, and less than 1.0 epithelial cells per high power field. CT scan as per Dr.[**Name (NI) 1745**] review with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] showed moderately dilated gallbladder with a vascule over the liver, mild diffusely intrahepatic ductal dilation, generous common bile duct at 6.0 mm. The pancreatic head looked questionably enlarged with atrophy otherwise. The ducts were normal. The colon was probably normal with or without focal thickening. There was nothing to suggest cholecystitis. HOSPITAL COURSE: The patient was admitted to the General Surgery team into the Intensive Care Unit for IV hydration, antibiotics, and for a decision as to whether or not the gallbladder would receive a percutaneous drain, versus an endoscopic retrograde cholangiopancreatography sphincterotomy, versus a laparoscopic cholecystectomy. In addition, Dr. [**Last Name (STitle) 1476**] and the Vascular service team will be following the patient in house as well. Overnight in the Unit, the patient was stable, but was continued with tender, right upper quadrant pain. She had one episode of nausea. By hospital day two, her white count had decreased to 14 and her lipase had significantly decreased to 28. The liver function tests were still normal when repeated, as per the previous day, and amylase was down to 45 as well. Mrs.[**Known lastname 33756**] urine output on postoperative day two was approximately 30-70 cc/hr and she had two bowel movements. She continued to be NPO. She was started at Flagyl and ceftriaxone at the time because of her Levaquin allergy, as prophylaxis and treatment for a potential gallstone pancreatitis. Because the patient was felt to still be somewhat unstable, the decision to perform an interventional procedure was delayed until postoperative day three. On [**8-4**], an ultrasound was performed to reevaluate the gallbladder which showed a mildly distended gallbladder with sludge. However, there were no gallbladder stones or thickening, and there was no pericholecystic fluid. Mrs.[**Last Name (un) 33756**] vital signs continued to be stable and her white count continued to fall from 14.3 to 13 by hospital day four. The panel 7 continued to be normal and the amylase and lipase continued to be also within normal limits at 51. Stool was sent for Clostridium difficile that was negative and a urinalysis was also negative at this time. Because of the recent carotid endarterectomy, there was much discussion as to the appropriate management of her condition. Because she had become stable in the Intensive Care Unit on [**8-5**], she was transferred to the floor. There was a coughing spell on transfer and respiratory therapy helped. In addition, Mrs. [**Known lastname 33749**] was to have a laparoscopic cholecystectomy on [**8-5**]. Her laparoscopic cholecystectomy occurred at approximately 03:00 PM on [**8-5**] and was uneventful. Mrs. [**Known lastname 33749**] remained on perioperative antibiotics and had a postoperative hematocrit of 29.5. By hospital day six, her hematocrit had returned to 35.3 and she was recovering bowel function, such that her diet was advanced. Case manager had screened her for rehabilitation and on hospital day seven, her antibiotics were discontinued and she was advanced to a full diet. She will be discharged to home with a home nursing care for taking care of her today, on [**2138-8-7**]. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: To home with nursing care. FOLLOW-UP: She will follow-up with Dr. [**Last Name (STitle) 519**] in two weeks and with Dr. [**Last Name (STitle) 1476**] from Vascular in approximately three weeks. DISCHARGE MEDICATIONS: Percocet one to two tablets po q four to six hours prn, Colace 100 mg po bid, Serevent two puffs po bid, Combivent two puffs po tid, Flovent two puffs po bid, Lasix 40 mg po q day, Ativan 0.5 mg q six hours po prn nausea, metoprolol 50 mg po bid, Protonix 40 mg po q 24 hours, Paxil 20 mg po q day, and Flomax 0.4 mg po bid. DISCHARGE DIAGNOSES: 1. Status post right carotid endarterectomy. 2. Status post laparoscopic cholecystectomy for treatment of a presumed gallstone pancreatitis. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**] Dictated By:[**Last Name (NamePattern1) 9800**] MEDQUIST36 D: [**2138-8-7**] 09:27 T: [**2138-8-11**] 11:10 JOB#: [**Job Number 33757**]

[ "576.1", "574.10", "428.0", "577.0", "412", "496", "414.01" ]

icd9cm

[ [ [] ] ]

[ "51.23" ]

icd9pcs

[ [ [] ] ]

6690, 6916

7287, 7705

6940, 7266

3790, 6668

1577, 1876

1899, 3772

730, 1109

167, 710

1131, 1554

27,732

114,363

32256+57792

Discharge summary

report+addendum

Admission Date: [**2149-11-28**] Discharge Date: [**2149-12-9**] Date of Birth: [**2076-12-16**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: s/p Coronary Artery Bypass Graft x3 (Left internal mammary artery > Left anterior descending, saphenous vein graft > RAMUS, saphenous vein graft > obtuse marginal) and mitral valve replacement with 27mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] bicor tissue valve [**2149-12-1**] History of Present Illness: 72 year old male with increasing shortness of breath at rest and exertional chest pain increasing over the last 3-4 days. Admitted to OSH and underwent cardiac catherization that revealed CAD. Transferred to [**Hospital1 18**] for surgical evaluation Past Medical History: Hypertropic obstructive cardiomyopathy Coronary artery disease mitral regurgitation Social History: owner of food company Tobacco denies ETOH 1 drink/week Lives with spouse Family History: Father CAD deceased age 77 Brother CAD deceased age 75 Physical Exam: Vitals 69, 18, RT B/P 104/45 Skin unremarkable Neck Full ROM, supple HEENT unremarkable Chest CTA bilat Heart RRR SEM [**3-18**] at LSB > apex Abd soft, NT ND Ext warm well perfused no edema Pertinent Results: [**2149-12-8**] 06:10AM BLOOD WBC-9.1 RBC-3.38* Hgb-9.6* Hct-28.9* MCV-85 MCH-28.4 MCHC-33.3 RDW-16.0* Plt Ct-331# [**2149-12-9**] 06:15AM BLOOD PT-27.0* INR(PT)-2.7* [**2149-12-8**] 06:10AM BLOOD PT-21.5* INR(PT)-2.0* [**2149-12-9**] 06:15AM BLOOD UreaN-32* Creat-1.6* K-4.9 [**2149-12-8**] 06:10AM BLOOD UreaN-33* Creat-1.8* K-4.7 [**2149-12-7**] 06:30AM BLOOD Glucose-123* UreaN-30* Creat-1.5* Na-135 K-4.4 Cl-96 HCO3-30 AnGap-13 RADIOLOGY Final Report CHEST (PA & LAT) [**2149-12-7**] 11:40 AM CHEST (PA & LAT) Reason: evaluate effusion [**Hospital 93**] MEDICAL CONDITION: 72 year old man s/p cABG and MVR REASON FOR THIS EXAMINATION: evaluate effusion STUDY: PA and lateral chest. [**2149-12-7**]. HISTORY: 72-year-old man status post CABG with mitral valve replacement. Evaluate effusion. FINDINGS: Comparison is made to previous study from [**2149-12-5**]. The right-sided venous catheter has been removed. There is improvement of the pulmonary edema since the previous study. There remains a left-sided pleural effusion and left retrocardiac opacity. Atelectasis within the right mid lung zone is again seen. Median sternotomy wires are seen. There is air-filled colon interposed between the diaphragm and the liver. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 75407**] (Complete) Done [**2149-12-1**] at 1:27:23 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. Division of Cardiothoracic [**Doctor First Name **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2076-12-16**] Age (years): 72 M Hgt (in): 67 BP (mm Hg): 140/60 Wgt (lb): 200 HR (bpm): 70 BSA (m2): 2.02 m2 Indication: Intraoperative TEE for MVR/CABG ICD-9 Codes: 440.0, 424.1, 424.0 Test Information Date/Time: [**2149-12-1**] at 13:27 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5740**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2007AW3-: Machine: 3 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: *1.7 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.9 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *5.9 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 55% to 60% >= 55% Left Ventricle - Peak Resting LVOT gradient: 5 mm Hg <= 10 mm Hg Aorta - Annulus: 2.5 cm <= 3.0 cm Aorta - Sinus Level: *3.7 cm <= 3.6 cm Aorta - Sinotubular Ridge: 3.0 cm <= 3.0 cm Aorta - Ascending: *3.5 cm <= 3.4 cm Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm Mitral Valve - Mean Gradient: 3 mm Hg Findings LEFT ATRIUM: Dilated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Severe symmetric LVH. Mildly dilated LV cavity. Overall normal LVEF (>55%). [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild (1+) AR. MITRAL VALVE: Severely thickened/deformed mitral valve leaflets. Partial mitral leaflet flail. Severe mitral annular calcification. Severe thickening of mitral valve chordae. [**Male First Name (un) **] of mitral valve leaflets. Calcified tips of papillary muscles. Eccentric MR jet. Severe (4+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions PRE-BYPASS: 1. The left atrium is dilated. No atrial septal defect is seen by 2D or color Doppler. 2. There is moderate to severe symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 5. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. 6. The mitral valve leaflets are severely thickened. There is posterior leaflet flail. There is severe mitral annular calcification. There is severe thickening of the mitral valve chordae. There is systolic anterior motion of the mitral valve leaflets. An eccentric, anteriorly and posteriorly directed jet of Severe (4+) mitral regurgitation is seen. There is systolic reversal as noted by pulse wave doppler of both sided pulmonary veins. 7. Pt has a hypertrophied septum measuring 1.9 cm to 2.2cm. Peak velocity across the LVOT is 2.4cm/s. 8. The tricuspid valve leaflets are mildly thickened. POST-BYPASS: 1. Biventricular function is maintained, LVEF >50%. 2. A bioprosthetic prosthetic valve is noted in the mitral position. The valve is well seated; there is good leaflet excursion and there is no paravalvular leak or mitral regurgitations. Peak gradient across the valve is 11mmHg, mean gradient is 5mmHg, MVA is 1.7cm2. 3. There is no change in the velocity across the LVOTat rest and measures 2.4 cm/s. 4. Aortic contours are intact post-decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2149-12-3**] 10:02 Brief Hospital Course: Transferred in from outside hospital for surgical evaluation. He underwent preoperative workup and plavix washout. On [**12-1**] he went to the operating room and underwent coronary artery bypass gradt and mitral valve replacement. Please see operative report for further details. He was transferred to the CVICU on neo, epi, and propofol. In the first 24 hours he awoke neurologically intact and was extubated. He was started on amiodarone for ventricular ectopy and continued for atrial fibrillation. He continued to require vasoactive medications for blood pressure management and were weaned off post operative day 3. He continued to improve and was transferred to the floor post operative day 4. He continued to progress slowly and had a gout flare in the L knee and ankle. He was treated with colchicine, was seen by rheumatology. He had a slight increase in his creat which imporved with a decrease in his lasix. He was discharged home in stable condition on POD #8. Medications on Admission: [**Doctor First Name **] ASA Diovan 80/12.5 Flonase Prilosec Toprol 100 Vytorin Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 4. Prilosec 20 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* 5. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg daily x 7 days then 200mg daily until discontinued by Dr. [**Last Name (STitle) 5017**]. Disp:*37 Tablet(s)* Refills:*0* 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily) for 2 weeks. Disp:*14 Capsule, Sustained Release(s)* Refills:*0* 9. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*0* 10. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day): to tape burns on left leg. Disp:*QS 1 month* Refills:*0* 11. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day. Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*0* Discharge Disposition: Home with Service Facility: TBA Discharge Diagnosis: Coronary Artery Disease s/p CABG Mitral Regurgitation s/p MVR Hypertrophic obstructive cardiomyopathy Unstable Angina Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment Dr [**Last Name (STitle) 5017**] in [**1-14**] weeks ([**Telephone/Fax (1) 5424**]) please call for appointment Please follow up with outpatient dentist for evaluation of implant lower left side Wound check [**Hospital Ward Name 121**] 6 as instructed by nurse ([**Telephone/Fax (1) 3633**]) [**Hospital 2225**] clinic(Dr. [**Last Name (STitle) 12434**], Ermana or Raychandhur) in 3 weeks - [**Telephone/Fax (1) 2226**] Completed by:[**2149-12-9**] Name: [**Known lastname **],[**Known firstname 12380**] Unit No: [**Numeric Identifier 12381**] Admission Date: [**2149-11-28**] Discharge Date: [**2149-12-9**] Date of Birth: [**2076-12-16**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 741**] Addendum: Coumadin follow up confirmed with [**Doctor Last Name **] at Dr. [**Last Name (STitle) 12382**] office. D/c paperwork faxed. Discharge Disposition: Home With Service Facility: Amedisys [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2149-12-9**]

[ "997.1", "425.1", "424.0", "411.1", "782.3", "427.31", "274.0", "416.0", "414.01", "V17.3", "427.69" ]

icd9cm

[ [ [] ] ]

[ "35.23", "99.07", "99.04", "36.12", "88.72", "39.61", "36.15", "89.60" ]

icd9pcs

[ [ [] ] ]

12385, 12547

7867, 8852

343, 648

10771, 10778

1425, 1973

11290, 12362

1142, 1198

8982, 10552

2010, 2043

10630, 10750

8878, 8959

10802, 11267

1213, 1406

284, 305

2072, 7844

676, 929

951, 1036

1052, 1126

76,527

192,338

26035

Discharge summary

report

Admission Date: [**2172-6-9**] Discharge Date: [**2172-6-10**] Date of Birth: [**2118-6-24**] Sex: F Service: MEDICINE Allergies: Penicillins / Nifedipine / Verapamil Hcl / Morphine / Codeine / Percocet / Dilaudid / Optiray 350 / Nsaids / Iodine; Iodine Containing Attending:[**First Name3 (LF) 338**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: - Elective cholangiogram - Tube was exchanged for a small 6F tube History of Present Illness: Mrs. [**Known lastname 24698**] is a 53 year old female with a history of chronic pancreatitis s/p whipple x 2, multiple biliary strictures s/p dilation and tube changes who presented this morning for elective IR cholangiogram to assess stricture. The procedure was uncomplicated. She was noted to have persistent stricture at the hepatojejunostomy site with some improvement since her previous preocedure with free passage of contrast into the jejunum without delay. Her previous tube was exchanged for a small 6F tube. Immediately post-procedure she developed some pruritis and received 25 mg IV benadryl with improvement. At approximately 1 PM she developed acute onset right upper quadrant pain which radiated to her back and felt similar ot the pain which she previously has experienced with pancreatitis. Of note, the pain for which she has been undergoing the stricture dilations has been on the left side. The pain was [**9-5**] and associated with nausea, vomiting of bilious material. She received vicodin and valium with minimal improvement. She subsequently developed rigors but was afebrile and received demerol 25 mg IV x 1. her baseline blood pressures range in the 100s to 110s systolic. Her pressure was noted to decrease to 94/68 and she received a 250 cc bolus and started on maintenance fluids at 150 cc/hr. Her repeat blood pressure was 86/35. No additional IVF were given for her hypotension. She was asymptomatic. Blood cultures were sent and she was started on ciprofloxacin and flagyl. She was admitted to the MICU for further management. . On arrival to the MICU she continues to complain of right upper quadrant pain which radiates to her back. She endorse nausea, vomiting. She denies fevers, chills, lightheadedness, dizziness, hematemasis, constipation, diarrhea, melena, hematochezia, dysuria, hematuria, decreased urine output, leg pain or swelling. All other review of systems is negative in detail. Past Medical History: 1. Status post cholecystectomy '[**46**] 2. History of recurrent biliary strictures requiring stents 3. Status post whipple in [**2166-1-25**] in [**Location 8398**]for chornic pancreatitis 4. History of what ampullary stricture status post percutaneous dilation. 5. GERD. 6. herniated cervical disk 7. osteopenia . Past Surgical History - s/p c/section x 3 ([**2142**], [**2144**], [**2148**]) - s/p whipple [**2-/2166**], Redo pancreaticojejunostomy [**5-4**] - s/p open cholecystectomy in [**2146**] Social History: She is married. She is a nonsmoker and non-drinker. Works as nurse. Family History: Family history is notable for heart disease in her father, mother with asthma, hypertension and cancer. Brother with pancreatitis. Physical Exam: Vitals: T: 98.6 BP 91/52: P: 98 R: 22 O2: 99% on RA General: Alert, oriented, appears uncomfortable HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, tender diffusely with voluntary guarding, no rebound tenderness, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2172-6-9**] 08:40AM BLOOD WBC-6.3 RBC-4.17* Hgb-11.1* Hct-35.0* MCV-84 MCH-26.7* MCHC-31.7 RDW-14.3 Plt Ct-338 [**2172-6-9**] 02:20PM BLOOD Neuts-81.0* Lymphs-17.0* Monos-0.6* Eos-1.2 Baso-0.3 [**2172-6-9**] 08:40AM BLOOD PT-11.7 INR(PT)-1.0 [**2172-6-9**] 06:44PM BLOOD Glucose-132* UreaN-9 Creat-0.7 Na-141 K-3.4 Cl-106 HCO3-24 AnGap-14 [**2172-6-9**] 06:44PM BLOOD Calcium-8.8 Phos-2.1*# Mg-1.6 [**2172-6-9**] 02:20PM BLOOD ALT-18 AST-18 AlkPhos-112 Amylase-28 TotBili-0.4 DirBili-0.1 IndBili-0.3 [**2172-6-9**] 02:20PM BLOOD Lipase-18 . [**2172-6-9**] Blood cultures x 2... . [**2172-6-9**] Biliary catheter check: . [**2172-6-9**] Abdominal x-ray: Brief Hospital Course: 53 year old female with a history of chronic pancreatitis s/p whipple complicated by multiple biliary strictures s/p dilation and tube changes who presented this morning for elective IR cholangiogram to assess stricture and developed mild hypotension post procedure. . Hypotension: Patient's blood pressures primarily in the 90s systolic with good urine output, no lightheadedness or dizziness and mentating well. No evidence of bleeding post-procedure. Most likely related to medications given periprocedure. We feel that instrumentation infection (?transient bacteremia) versus hemorrhage are much less likely given that her Hct was stable and WBC trended down. She is currently afebrile and abdominal pain is well controlled. She does not need antibiotics as of now. - She will follow up with her gastroenterologist and PCP [**Last Name (NamePattern4) **] 2 weeks. . Abdominal Pain: Patient developed pain post-procedure which is different from her typical pain. Is worse on the right side and radiates to the back. This rapidly corrected and was well controlled on home regimen for pain. - She should not drive on narcotics and we recommended colace while taking narcotics for pain. . Code: Full (discussed with patient) Communication: Patient, [**Name (NI) **] [**Name (NI) 24698**] (husband) [**Telephone/Fax (1) 64668**] Disposition: Home Medications on Admission: Lansoprazole 30 mg PO BID Darvon 100-200 mg Po Q6-8H:PRN Vicodin Q6H:PRN Tylenol PRN Calcium Multivitamin Soy for hot flashes 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. Propoxyphene N-Acetaminophen 100-650 mg Tablet [**Last Name (STitle) **]: [**11-29**] Tablets PO every 6-8 hours as needed for pain: Do not drive while on narcotics. 3. Hydrocodone-Acetaminophen 5-500 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: Do not drive while on narcotics. 4. Docusate Sodium 100 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO BID (2 times a day): Please take for regular bowel movements while on narcotics. 5. Multivitamins Tablet, Chewable [**Month/Day (2) **]: One (1) Tablet, Chewable PO once a day. 6. Calcium 500 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: - Elective cholangiogram showing persistent stricture at the hepatojejunostomy - Assymptomatic hypotension Discharge Condition: good. tolerating PO and ambulating without dizzyness or palpitations. Discharge Instructions: You came to the hospital for an elective IR cholangiogram to assess stricture. The procedure was uncomplicated but after the procedure you may have had an allergic reaction and your blood pressure was very low. Despite a low blood pressure, all of your symptoms improved including urine output of > 2 liters. You will need to see your interventionalist and primary care physicians in the next 2 weeks. . Medication changes: none . Please call your doctor or return to the ED if you have dizziness, lightheadedness, falls, chest pain, increased abdominal pain, nausea, vomiting, diarrhea. Followup Instructions: Please call your Primary care physician: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 2936**] for an appointment in the next 2 weeks. Provider: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2172-6-15**] 2:45 Provider: [**Name10 (NameIs) 454**],ONE [**Name10 (NameIs) 454**] Date/Time:[**2172-6-24**] 8:30 Provider: [**Name10 (NameIs) 6122**] WEST Phone:[**Telephone/Fax (1) 8243**] Date/Time:[**2172-6-24**] 10:00 Completed by:[**2172-6-10**]

[ "789.01", "733.90", "338.18", "530.81", "V45.79", "780.62", "V14.8", "493.90", "693.0", "576.2", "722.0", "577.1", "458.29", "E937.8" ]

icd9cm

[ [ [] ] ]

[ "87.54", "51.98" ]

icd9pcs

[ [ [] ] ]

6778, 6784

4438, 5787

405, 473

6944, 7016

3758, 4415

7654, 8226

3065, 3197

5963, 6755

6805, 6923

5813, 5940

7040, 7446

3212, 3739

7466, 7631

354, 367

501, 2436

2458, 2964

2980, 3049

21,658

191,808

9049

Discharge summary

report

Admission Date: [**2171-10-30**] Discharge Date: [**2171-11-9**] Date of Birth: [**2111-12-2**] Sex: M CHIEF COMPLAINT: A tense headache (times three to four days); increasing in severity. HISTORY OF PRESENT ILLNESS: This is a 59-year-old male with The patient was most recently treated with Taxotere (finished last dose approximately two weeks prior to presentation). He has a history of a headache for over the last month since starting Taxotere therapy; which was originally intermittent. Over the last week, his headache had been progressively worse with the intensity increasing over the last three to four but they were no longer effective over the last four days. A CT scan was done as an outpatient which showed no evidence for an acute disease process. His pain has been progressively worse. He was scheduled for a magnetic resonance angiography for further evaluation. The magnetic resonance angiography showed multiple enhancing fossae of the thalamus, cerebellum, and surface of the frontal lobes with enhancement of the meninges; consistent with carcinoma dysmeningitis. Magnetic resonance imaging also noted enlarged third ventricle; consistent with communicating hydrocephalus. The patient also noted neck pain associated with a headache with some nausea. He denies photophobia, visual changes, emesis, fevers, or chills. He has no focal weakness, sensory deficits, back pain or incontinence of bowel or bladder. He has not noted any change in speech or difficulty swallowing. He has had some constipation secondary to Percocet for which he was treated with lactulose. PAST MEDICAL HISTORY: 1. Non-small-cell lung cancer; stage III-B, diagnosed in [**2169-5-18**] now with bony liver metastases. 2. Chemotherapy has included Auguron, MMP inhibitor with concurrent gemcitabine and cisplatin times six cycles, Iressa from [**2170-5-18**] to [**2171-7-18**], Taxotere times four cycles from [**2170-8-18**] to [**2170-11-17**], radiation therapy in [**2171-7-18**], and most recently Taxotere times two cycles (with the last approximately two weeks ago). 3. Gastrointestinal bleed secondary to nonsteroidal antiinflammatory drugs. MEDICATIONS ON ADMISSION: (Medications at home included) 1. OxyContin 20 mg p.o. b.i.d. 2. Percocet p.o. as needed. 3. Lactulose p.o. as needed. 4. Ativan p.o. as needed (for sleeplessness). 5. Colace. 6. Senna. 7. Protonix. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives with his wife who is a former nurse. He is a small business owner. He smoked two packs per day times 30 years. He drinks approximately six beers per night. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on presentation to the Emergency Department revealed temperature was 97, blood pressure was 108/52, pulse was 78, respiratory rate was 18. In general, the patient was in some noticeable pain but was awake and alert and nontoxic-appearing. Head, eyes, ears, nose, and throat examination revealed his pupils were equal, round, and reactive to light and accommodation. He had mild photophobia with anicteric sclerae. His oropharynx was without thrush or ulcerations. On neck examination, he had slight meningismus with no cervical lymphadenopathy. His lungs were clear to auscultation bilaterally. His heart was regular in rate and rhythm. Normal first heart sound and second heart sound. No murmurs, rubs, or gallops. On abdominal examination, he was soft, nontender, and nondistended with normal active bowel sounds. Extremities revealed no cyanosis, clubbing, or edema. Neurologic examination revealed cranial nerves II through XII were intact. His sensation was intact to light touch; symmetrically in the upper extremities and lower extremities. His motor strength was [**4-21**] and symmetric in the upper extremities and lower extremities. He had no reflexes in the biceps or patella bilaterally. Finger-to-nose was intact bilaterally. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory values on admission revealed white blood cell count 6.6, hemoglobin was 11.7, hematocrit was 33.2, platelet count was 395, and mean cell volume was 86. Differential revealed neutrophils of 63%, lymphocytes of 28%. Sodium was 137, potassium was 4.7, chloride was 105, bicarbonate was 21, blood urea nitrogen was 13, creatinine was 0.7, and blood glucose was 110. ALT was 37, AST was 27, alkaline phosphatase was 147, amylase was 36, total bilirubin was 0.3, lipase was 25, albumin was 3.8. Calcium was 9.4, phosphorous was 3.3, magnesium was 2. RADIOLOGY/IMAGING: Electrocardiogram done on [**2171-11-4**] showed a normal sinus rhythm at a rate of 67, normal axis and intervals; with no change compared to electrocardiogram of [**2170-11-19**]. IMPRESSION: The patient is a 59-year-old male with non-small-cell lung cancer with metastases to liver and bone now with magnetic resonance imaging consistent with carcinomatous meningitis with metastases to left cerebellum, left thalamus, and frontal lobes. HOSPITAL COURSE BY SYSTEM: 1. NEUROSURGERY: The patient was admitted to the Medical Oncology Service with a diagnosis of new brain metastases and carcinomatous meningitis. A lumbar puncture was performed which showed an elevated open pressure of 31, and only 2 cc could be removed. The cytology revealed malignant cells. On hospital day four, the patient was noted to have bradycardia with a heart rate in the 30s to 40s, as well as some hypertension, which raised concern for [**Location (un) **] triad and increasing intracranial pressure. Fortunately, no respiratory depression was noted. A head CT was repeated at that time which showed no change in ventricular dilatation. He was then transferred to the Medication Intensive Care Unit for monitoring of bradycardia. He was started on Decadron at that point. The following morning, he was brought to the operating room (per Neurosurgery), and a ventriculoperitoneal shunt/Ommaya was placed on [**2171-11-4**]. He tolerated the procedure well and had a uneventful Surgical Intensive Care Unit course. He was then transferred back to the Medicine/Oncology Service on [**2171-11-5**]. For the remainder of the patient's hospitalization, the patient had no recurrence of headache or meningeal signs. His Decadron was tapered to 2 mg p.o. t.i.d. with plans to taper down to a maintenance level of 2 mg p.o. b.i.d. as an outpatient. A cerebrospinal fluid flow study examining the shunt was to be performed on [**2171-11-12**] as an outpatient. 2. ALTERED MENTAL STATUS: Postoperatively, the patient was noted to be delirious with persistent altered mental status for approximately 48 hours to 72 hours. As he had some difficulty with opiates causing mental status changes prior to surgery, opiate pain medications were limited at this point. His mental status began to clear approximately three days postoperatively, and it was felt that the etiology of his altered mental status was multifactorial; including Decadron, postsurgical anesthesia, brain metastases, and possible alcohol withdrawal. He was continued on a CIWA scale; however, he did not require any Ativan per protocol. At the time of discharge, the patient was alert and oriented times three for greater than 48 hours; and although he had some difficulty remembering events immediately prior to the surgery, the patient was felt to be back at baseline. 3. INFECTIOUS DISEASE: Due to Decadron use, he had an elevated white blood cell count which normalized by the time of discharge and was tapered from steroids. Cerebrospinal fluid cultures were negative as well as blood cultures. One of two of his urine culture grew Streptococcus bovis; which, given its association with colon cancer, an outpatient colonoscopy may be necessary. 4. ONCOLOGY: Per Neurosurgery, the Ommaya may be used for intrathecal chemotherapy which will be coordinated by Dr. [**Last Name (STitle) 724**] in Neurology/Oncology. 5. FLUIDS/ELECTROLYTES/NUTRITION: The patient was hypoglycemic secondary to steroid use and was monitored on q.i.d. fingersticks with a regular insulin sliding-scale. At the time of discharge, his fingersticks were trending down. He was able to tolerate an oral diet without difficulties at the time of discharge. CONDITION AT DISCHARGE: Condition on discharge was stable and improved. DISCHARGE DIAGNOSES: 1. Non-small-cell lung cancer with newly diagnosed brain metastases. 2. Increased intracranial pressure; status post ventriculoperitoneal shunt. 3. Status post repeat ventriculoperitoneal shunt placed on [**2171-11-4**]. 4. Delirium; resolved. MEDICATIONS ON DISCHARGE: 1. Decadron 2 mg p.o. t.i.d. (times three days) and 2 mg p.o. b.i.d. (ongoing thereafter). 2. Protonix 40 mg p.o. q.d. 3. Colace liquid 100 mg p.o. b.i.d. 4. Lactulose 30 cc p.o. q.d. 5. Senna one tablet p.o. q.d. DISCHARGE INSTRUCTIONS: 1. The patient was to follow up with Dr. [**Last Name (STitle) 724**] in Neurology/Oncology. The patient was to schedule an appointment. 2. Cerebrospinal fluid flow study; per Nuclear Medicine, was scheduled for [**2171-11-12**]. 3. The patient was to follow up with Dr. [**Last Name (STitle) 24028**] and Dr. [**First Name (STitle) **] as well. 4. The patient was discharged to home after clearance by Physical Therapy and was to receive two sessions of [**First Name (Titles) 3429**] [**Last Name (Titles) 11807**] for ventriculoperitoneal shunt wound care. [**First Name11 (Name Pattern1) 24029**] [**Last Name (NamePattern4) 31283**], M.D. [**MD Number(1) 31284**] Dictated By:[**Last Name (NamePattern1) 31285**] MEDQUIST36 D: [**2171-11-10**] 15:28 T: [**2171-11-12**] 13:18 JOB#: [**Job Number 31286**]

[ "162.8", "331.4", "198.4", "198.3", "197.7", "198.5" ]

icd9cm

[ [ [] ] ]

[ "02.34", "03.31" ]

icd9pcs

[ [ [] ] ]

8386, 8635

8661, 8881

2206, 2451

8905, 9759

5059, 6550

8316, 8365

137, 207

236, 1615

6566, 8301

1637, 2179

2468, 5031

15,141

129,833

17004

Discharge summary

report

Admission Date: [**2138-6-10**] Discharge Date: [**2138-6-17**] Service: CARDIOTHORACIC SURGERY HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 4223**] is an 81-year-old white male with a vague history of chest discomfort over the past few months. He lives in [**Location **] and was here for his sister's funeral and had chest pain with nausea, dyspnea, diaphoresis on [**2138-6-5**]. He initially refused treatment. His symptoms resolved, but recurred the following morning. He presented to [**Hospital **] Hospital and ruled-in for an MI with a peak CPK of 1,200. He had a cardiac cath which revealed a tight distal left main, two-vessel coronary artery disease, with an ejection fraction of 25%. He was transferred to [**Hospital6 1760**] for CABG. PAST MEDICAL HISTORY: Significant for a history of 1) Hypertension, 2) History of type 2 diabetes, 3) History of nephrolithiasis, 4) Status post subdural hematoma. MEDICATIONS ON ADMISSION: 1) aspirin 81 mg po qd, 2) metformin 850 mg po bid, 3) Glucotrol 10 mg po qd, 4) Toprol XL 100 mg po qd, 5) Flomax 0.4 mg po qd, 6) Lo-Trol 50/20 po qd. ALLERGIES: He has no known allergies. FAMILY HISTORY: Unremarkable. REVIEW OF SYSTEMS: Unremarkable. PHYSICAL EXAM: He was a well-developed elderly white male in no apparent distress. Vital signs stable, afebrile. HEENT exam - normocephalic, atraumatic. Extraocular movements intact. Oropharynx benign. Neck was supple, full range of motion, no lymphadenopathy or thyromegaly. Carotids 2+ and equal bilaterally without bruits. Lungs were clear to auscultation and percussion. Cardiovascular exam - 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 2+ and equal bilaterally throughout. Neuro exam was nonfocal. HOSPITAL COURSE: On [**6-11**], the patient underwent a CABG x 3 with LIMA to the LAD, reversed saphenous vein graft to OM and PDA. Crossclamp time was 77 minutes. Total bypass time 92 minutes. He was transferred to the CSRU on epinephrine, insulin drip and aprotinin. He was transfused 2 units of blood on the first night, and remained intubated, as he would get agitated with weaning. His epinephrine was DC'd on postop day #1. He was extubated and started on Lopressor. He did have some slight confusion and was treated with Haldol. On postop day #2, his chest tubes were DC'd. He was transferred to the floor in stable condition. He did require some Haldol at night prn, but his confusion resolved. On postop day #3, his epicardial pacing wires were DC'd. He did have a slight bump in his creatinine to 1.6, but we think his baseline might have been around 1.5, so his lasix was DC'd, and his preop metformin was DC'd as well. On postop day #6, he was discharged to home in stable condition. LABS ON DISCHARGE: Hematocrit 32.8, white count 10,000, platelets 168, sodium 142, potassium 4.6, chloride 107, CO2 25, BUN 82, creatinine 1.5, blood sugar 81. DISCHARGE MEDICATIONS: 1) colace 100 mg po bid, 2) glipizide 10 mg po qd, 3) Flomax 0.4 mg po qd, 4) Ecotrin 325 mg po qd, 5) Lopressor 100 mg po tid, 6) Lipitor 10 mg po qd, 7) Plavix 75 mg po qd--he is on the Plavix for poor distal targets. FOLLOW-UP: He will be seen by Dr. [**Last Name (STitle) 1537**] in one week, and then will travel back to [**Location (un) **] by plane, and should be seen by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 47832**] in [**Location (un) 2716**], [**State **] in one to two weeks. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern1) 11726**] MEDQUIST36 D: [**2138-6-17**] 10:27 T: [**2138-6-17**] 10:34 JOB#: [**Job Number 47833**]

[ "278.00", "414.01", "401.9", "593.9", "410.91", "424.0", "V13.01", "250.00" ]

icd9cm

[ [ [] ] ]

[ "39.61", "36.15", "36.12", "88.72", "39.64" ]

icd9pcs

[ [ [] ] ]

1177, 1192

3134, 3937

966, 1160

1955, 2948

1243, 1937

1212, 1227

2968, 3110

137, 773

796, 939

79,262

183,195

36355

Discharge summary

report

Admission Date: [**2157-8-28**] Discharge Date: [**2157-9-2**] Date of Birth: [**2076-1-15**] Sex: M Service: MEDICINE Allergies: Lisinopril Attending:[**First Name3 (LF) 1943**] Chief Complaint: High blood pressure Major Surgical or Invasive Procedure: Central line placement History of Present Illness: 81 y/o Spanish only speaking man with PMhx of DM, CAD, poorly controlled HTN, diastolic HF and aortic stenosis who presented [**8-28**] with HA and chest pain after being non-compliant with BP meds for last 24-48hrs (he states was unable to get rx filled at time of discharge). Of note, pt was discharged on [**2157-8-26**] after admission hypertensive urgency, c/b bp lability prompting w/u that is still pending. He a headache in the evening [**2157-8-27**] with worsening chest pressure at which time, he took his BP and decided to come to the ED because it was very high. In the ED, initial vs were: T 97.3 P 85 BP 230/130 R 24 Sats 100% on RA O2. There was difficulty obtaining IV access and pt was initially treated with oral home regimen including Losartan 100mg, Carvedilol 25mg, Hydralazine 37.5mg and Percocet x 2. SBP initially responded coming down to 180s but rebounded quickly to 240s. CVL was placed in the left IJ and pt was started on a nitro gtt. EKG was essentially unchanged, CT head without ICH and CXR without pulm edema. Nitro gtt was maxed out with minimal change in BP and pt was started on labetalol gtt (nitro weaned off). In the ICU his labetolol gtt was weaned off on [**8-29**] and he was resumed on his home medications. His BP [**8-30**] was 120-170 but increased at night to 211/98 associated with some agitation (though fully oriented). He was given hydralazine 10mg iv with improvement in his blood pressure to 170. He continues to have a HA ([**8-29**]) but denies chest pressure, sob, palpitations, nausea, vomiting, abdominal pain. His vision is at baseline. He notes diarrhea (non-bloody) in the icu ([**2-22**] BM's/day). He denies fevers. Also of note in the icu on [**8-28**] he had aggitation with paranoia requiring restraints, 3mg iv ativan and 10mg iv haldol. Psychiatry was consulted and thought he was acutely delerious due to hypertension and that withdrawal for etoh was very unlikely. 10 point review of systems otherwise negative. Past Medical History: Diabetes Mellitus type II without complicatoins Aortic Stenosis with valve area of 1.0 Afib/flutter (not anticoagulated due to fall risk & non-compliance) Diastolic CHF (EF of 55%) CAD s/p cath in [**5-28**] with 2VD and BMS placed to distal RCA Orthostatic hypertension Obstructive Sleep Apnea: uses cpap at home Peptic Ulcer Disease History of prostate cancer Anxiety L ACA CVA: hypotensive washout stroke Neurocysticercosis: dx on CT with with mult extra calcifications. LE neuropathy S/P left ACL tear H/o Seizure d/o, last episode [**2147**], maintained on Carbamazepine LLL lung nodule [**2151**] Fe deficiency anemia Restless leg syndrome, insomnia, nightmares Vit D deficiency Remote h/o etoh abuse Social History: Lives with wife and grandson, [**Name (NI) **]. [**Name2 (NI) 3003**] heavy etoh with withdrawal seizures but quit 30 years ago (son confirmed not actively drinking). Prior cocaine and morphine but quit 30y ago. Tobacco: quit 40 years ago. Family History: Father w CAD; died of MI age 41. Mother died of 'sepsis' in 30s. 5 brothers & sisters died at very young age(kids), but he does not know etiology. Physical Exam: VS: T 99.0 HR 83 BP 184/100 RR 20 Sat 95% RA Gen: Well appearing elderly man in NAD Eye: extra-ocular movements intact, pupils equal round, reactive to light, sclera anicteric, not injected, no exudates ENT: mucus membranes moist, no ulcerations or exudates Neck: no thyromegaly, JVD: flat Cardiovascular: regular rate and rhythm, normal s1, s2, no murmurs, rubs or gallops Respiratory: Clear to auscultation bilaterally, no wheezes, rales or rhonchi Abd: Soft, non tender, non distended, no hepatosplenomegally, bowel sounds present Extremities: Trace edema, no cyanosis, clubbing, joint swelling Neurological: Alert and oriented x3, CN II-XII intact, normal attention, sensation normal, asterixis absent, speech fluent Integument: Warm, moist, no rash or ulceration Psychiatric: appropriate, not anxious Hematologic: no cervical or supraclavicular LAD Left IJ in place, foley catheter in place Pertinent Results: On admission: WBC-8.1 RBC-4.21* Hgb-11.8* Hct-33.6* MCV-80* MCH-28.0 MCHC-35.0 RDW-16.8* Plt Ct-342 PT-12.6 PTT-26.5 INR(PT)-1.1 Glucose-140* UreaN-14 Creat-0.8 Na-139 K-3.4 Cl-100 HCO3-25 AnGap-17 Ethanol-NEG Urine tox screens: [**2157-8-28**] 06:11PM URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG [**2157-8-28**] 11:40PM URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-POS mthdone-NEG Cardiac enzymes: [**2157-8-28**] 04:30AM BLOOD CK(CPK)-461* CK-MB-6 cTropnT-<0.01 [**2157-8-28**] 05:04PM BLOOD CK(CPK)-303* CK-MB-5 cTropnT-<0.01 [**2157-8-29**] 02:12AM BLOOD CK(CPK)-336* CK-MB-6 cTropnT-<0.01 [**8-28**] EKG: Atrial fibrillation. Non-specific lateral ST-T wave changes [**8-28**] CXR: IMPRESSION: Interval left-sided internal jugular catheter placement with tip terminating at the azygocaval junction. No evidence of pneumothorax. [**8-29**] CT head: 1. No acute intracranial process or change compared to the prior study dated one day earlier. 2. Partial opacification of the anterior ethmoid cells, not significantly unchanged. Brief Hospital Course: 81 yo man with labile poorly controlled hypertension admitted with hypertensive emergency, delirium, CAD, diastolic heart failure, seizure d/o, DM and anxiety/depression. 1. Hypertensive Emergency: The patient has admitted with systolic's >>200's. He was initially admitted to the ICU where BP control was attempted. Secondary causes were considered. Once the BP was in better control, the patient transferred to floor. On occasion, the SBP would be in 120's when patient was resting, but it was noticed that the patient's mood plays a significant role in raising the SBP to >210's. Without significant medical intervention, the systolics could spontaneously drop back down to 120's. We determined that this patient has severe anxiety and depression. One of the practices that he does at home is check his BP >30x/day and when he notices that it is high, his pressure increases... then it is self-escalating. These psychiatric issues also lead him to having poor sleep and thus further exacerbates his BP. We found that it was very important to use Spanish interpreters frequently when interacting with him. 2. Anxiety/Depression: Psychiatry consulted during admission. They assisted with recommendations on how to manage these issues while avoiding delirium from benzodiazapine use. These issues are deeply ingrained and will require further outpatient management. The patient is also dealing with significant home stressors---his geriatric wife has cancer, one of his sons was killed in an accident, another son is an alcoholic, etc... 3. CAD, native vessel: continue aspirin, [**Last Name (un) **], bb, statin. 4. Chronic diastolic heart failure, not exacerbated: continue antihypertensive regimen as above, monitor for pulmonary edema. 5. Seizure Disorder: Stable, his last seizure was in [**2138**]. Continued his home Carbamazepine 300mg [**Hospital1 **] and lyrica 100mg TID. 6. Afib/Flutter: Continue BB, aspirin. He is not anticoagulated at baseline due to fall risk and lack of compliance. 7. Diabetes mellitus, type II, without complications: Restart metformin, continue ssi with qid bg checks and dm diet, on aspirin, [**Last Name (un) **]. 8. OSA: treat with cpap in house. 9. PUD: continue ranitidine. 10. Dispo: He will be discharged home with several services: Nursing, Physical Therapy, Social Work, and whatever Psych services are available. Medications on Admission: Medications on recent discharge-(pt reports non-compliance as unable to obtain meds from pharmacy until monday [**8-29**]) Potassium Chloride 20 mEq daily Losartan 100 mg Tablet [**Hospital1 **] Carvedilol 25 mg Tablet [**Hospital1 **] Atorvastatin 40 mg Tablet daily Clonidine 0.2 mg/24 hr Patch QTHUR Amlodipine 10 mg Tablet daily Hydralazine 37.5 mg Tablet po q6hr Ranitidine HCl 300mg daily Nitroglycerin 0.3 mg Tablet SL prn Sertraline 125mg daily Pregabalin 100 mg Capsule TID Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS Aspirin, Buffered 325 mg daily Metformin 500 mg Tablet [**Hospital1 **] Carbamazepine 300mg [**Hospital1 **] Ferrous Sulfate 325 mg daily Isosorbide Mononitrate 60 mg daily Discharge Medications: 1. Aspirin 325 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* 2. Isosorbide Mononitrate 60 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:*0* 3. Carbamazepine 100 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO BID (2 times a day). Disp:*180 Tablet, Chewable(s)* Refills:*0* 4. Losartan 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 5. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*0* 6. Sertraline 50 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily). 7. Quetiapine 50 mg Tablet Sig: One (1) Tablet PO twice a day as needed for Insomnia. Disp:*60 Tablet(s)* Refills:*0* 8. Pregabalin 100 mg Capsule Sig: One (1) Capsule PO three times a day. Disp:*90 Capsule(s)* Refills:*0* 9. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 10. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). Disp:*qs 1 month* Refills:*0* 11. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTHUR (every Thursday). Disp:*4 Patch Weekly(s)* Refills:*0* 12. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain: Take under tongue as needed for chest pain every 5 minutes, up to 3 doses total. If chest pain persists, seek medical attention. Disp:*20 Tablet, Sublingual(s)* Refills:*0* 13. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO once a day. Disp:*30 Packet* Refills:*0* 14. Coreg 12.5 mg Tablet Sig: Two (2) Tablet PO twice a day. Disp:*120 Tablet(s)* Refills:*0* 15. Atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO at bedtime. Disp:*60 Tablet(s)* Refills:*0* 16. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*0* 17. Hydralazine 25 mg Tablet Sig: 1.5 Tablets PO every six (6) hours. Disp:*180 Tablet(s)* Refills:*0* 18. Ranitidine HCl 150 mg Capsule Sig: Two (2) Capsule PO once a day. Disp:*60 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: PRIMARY DIAGNOSES: 1. Hypertension 2. Anxiety SECONDARY DIAGNOSES: 1. Obstructive sleep apnea 2. Atrial fibrillation and flutter 3. Type 2 diabetes mellitus 4. Coronary artery disease 5. Diastolic congestive heart failure 6. Peptic ulcer disease Discharge Condition: You are in fair condition. Discharge Instructions: You have been treated for both your hypertension and your anxiety during this hospital admission. We have found that the increase in your blood pressure is in some part related to your stresses and anxiety. You should continue in being managed for these conditions as well as your other medical problems. Among the many factors contributing to your anxiety, one of them is the status of your blood pressure. You should usually limit the checking of your blood pressure to no more than once a day. For your condition called congestive heart failure it is important that you monitor your weight each day. Weigh yourself every morning, call your doctor if your weight increases by more than 3 pounds from your regular weight. You should also limit your salt (sodium) to 2 grams a day. Limit fluids to less than 1.5 liters a day. MEDICATION CHANGES: 1. Quetiapine 50mg one tablet by mouth twice a day (for anxiety and sleeping problem) 2. Hydrochlorthiazide 12.5mg one tablet by mouth once a day (for high blood pressure) Seek medical attention if you have worsening of your condition or have other concern. Followup Instructions: Please follow up with your primary care provider within the next 1-2 weeks. Please also make an appointment to follow up with your psychiatrist. Call Dr. [**Last Name (STitle) 60521**] at [**Telephone/Fax (1) 82398**]. Other appointments you have scheduled already: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2157-10-10**] 1:30 GI [**Apartment Address(1) 3921**] (ST-3) GI ROOMS Date/Time:[**2157-10-10**] 1:30 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2157-11-3**] 2:00

[ "293.0", "V10.46", "414.01", "424.1", "428.32", "305.03", "345.90", "327.23", "357.2", "300.4", "427.31", "272.0", "V15.82", "V12.54", "533.90", "V17.3", "V15.81", "250.60", "427.32", "428.0", "402.01" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

10919, 10976

5523, 7901

290, 314

11267, 11296

4411, 4411

12458, 13096

3332, 3480

8666, 10896

10997, 11044

7927, 8643

11320, 12155

3495, 4392

11065, 11246

4863, 5310

12175, 12435

231, 252

342, 2328

5319, 5500

4425, 4846

2350, 3059

3075, 3316

15,751

107,030

24482

Discharge summary

report

Admission Date: [**2201-6-18**] Discharge Date: [**2201-6-24**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: DOE Major Surgical or Invasive Procedure: AVR(21mm CE) [**2201-6-18**] History of Present Illness: 80 y/o male with 2 yr h/o SOB. Had Echo that revealed AS. Has had serial Echo's since, with the last done on [**4-28**] which showed worsening AS. Past Medical History: Aortic stenosis Hypertension Hypercholesterolemia Diabetes Mellitus Type 2 Left Eye Glaucoma Severe LE Varicosities h/o Bilat. Renal Calculi s/p bilat. cataract surgery s/p appendectomy s/p tonsillectomy s/p lithotripsy Social History: Lives with wife, retired. Quit smoking 20yrs ago (40-50 pk yrs). ETOH: 1 glass wine/day. Family History: Sister with RHF/valve [**Doctor First Name **]. Physical Exam: VS: 76 14 154/78 5'[**06**]" 165# General: Well-appearing, well-nourished elderly man Skin: Unremarkable, -lesions HEENT: PERRLA, EOMI, NC/AT Neck: Supple, FROM, -JVD, Murmur radiating to carotids Chest: CTAB, -w/r/r Heart: RRR, +S1S2, 2/6 SEM Abd: Soft, NT/ND +BS Ext: Warm, well-perfused, -c/c/e, +severe bilat varicosities (L>R) 2+ pulses bilat. Fem, PT, and L DP. No pulse on R DP. Neuro: CN 2-12 intact, non-focal, MAE [**4-28**] strengths Pertinent Results: [**2201-6-18**] 10:16AM BLOOD WBC-15.2*# RBC-2.89*# Hgb-9.6*# Hct-26.3*# MCV-91 MCH-33.3* MCHC-36.5* RDW-13.8 Plt Ct-175 [**2201-6-23**] 06:25AM BLOOD WBC-8.5 RBC-3.44* Hgb-11.0* Hct-31.5* MCV-92 MCH-32.0 MCHC-34.9 RDW-14.2 Plt Ct-228 [**2201-6-18**] 10:16AM BLOOD PT-16.1* PTT-40.3* INR(PT)-1.7 [**2201-6-22**] 02:40AM BLOOD PT-13.3 PTT-26.3 INR(PT)-1.2 [**2201-6-18**] 11:25AM BLOOD UreaN-15 Creat-0.8 Cl-105 HCO3-27 [**2201-6-18**] 07:55PM BLOOD Glucose-111* K-3.3 [**2201-6-23**] 06:25AM BLOOD Glucose-167* UreaN-34* Creat-0.9 Na-140 K-3.4 Cl-101 HCO3-28 AnGap-14 [**2201-6-24**] 06:25AM BLOOD K-3.9 Brief Hospital Course: As stated in the HPI, he is a 80 y/o male with a h/o AS who was initially seen as an outpt. He was a same day admit and brought to the operating room, where he underwent an aortic valve replacement. Please see op note for full surgical details. He tolerated the procedure well with a total bypass time of 71 minutes and cross clamp time of 58 minutes. He was transferred to CSRU in stable condition with a MAP of 60, CVP 7, PAD 13, [**Doctor First Name 1052**] 18, HR 87 NSR and being titrated on Neo, Propofol, and Insulin. Pt was weaned from propofol and mechanical ventilation and was extubated later on op day. He was awake, alert, MAE, and following commands. On POD #1 he was recovering well. Swan Ganz catheter was removed. Diuretics and B-blockers were started per protocol. His chest x-ray showed bibasilar atelectasis and small r. pleural effusion which was matched with bibasilar rales and dimished bs on exam. POD #2 his chest tubes were removed, but cont. to have decreased breath sounds with CXR showing cont. atelectasis and effusion. He was cont. to be aggressively diuresed along with aggressive cpt w/ postural drainage. Also received flovent and combivent and Levaquin was started for poss. pneumonia. POD #3 his epicaridal pacing wires and foley were removed. He remained in the CSRU and repeat cxr showed cont. r. effusion and atelectasis w/ poss. superimposed pnuemonia. POD #4 he appeared to be improved, but had cont. decreased bs right base. He was transferred to telemetry floor. CXR showed decreased atelectasis. By POD #5 he appeared to be doing quite well. Cont. to ambulate and get OOB. O2 sats remained alittle low depsite O2 via NC. Exam unremarkable. He was d/c'd on POD #6. Exam was unremarkable, incisions stable, breath sounds clear. Labs were stable and he would follow-up as directed. Medications on Admission: 1. HCTZ 50mg qd 2. Atenolol 50mg qd 3. Glucophage 500mg qd 4. KCL ER 600mg qd 5. Gemfibrozil 600mg qd 6. Omeprazole 20mg qd 7. Vit. E qd 8. Omega 5 Oils 9. Allphagan [**First Name9 (NamePattern2) **] [**Male First Name (un) **] 10. B-Complex Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Brimonidine Tartrate 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). Disp:*1 bottle* Refills:*2* 5. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 inhaler* Refills:*2* 6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-25**] Puffs Inhalation Q4H (every 4 hours). Disp:*1 inhaler* Refills:*2* 7. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. Disp:*3 Tablet(s)* Refills:*0* 9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). Disp:*1 bottle* Refills:*2* 10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily) for 7 days. Disp:*14 Capsule, Sustained Release(s)* Refills:*0* 11. Lopressor 50 mg Tablet Sig: 1.5 Tablets PO three times a day. Disp:*135 Tablet(s)* Refills:*2* 12. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 14. Zocor 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 8300**] VNA NH Discharge Diagnosis: Aortic stenosis s/p Aortic Valve Replacement Hypertension Hypercholesterolemia Diabetes Mellitus Type 2 Left Eye Glaucoma Severe LE Varicosities h/o Bilat. Renal Calculi Discharge Condition: Good Discharge Instructions: Follow medications on discharge instructions. You may not drive for 4 weeks. You may not lift more than 10 lbs. for 3 months. You should shower, let water flow over wounds, pat dry with a towel Do not put lotions or creams on incisions. Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) **] for 1-2 weeks. Make an appointment with Dr. [**Last Name (STitle) 5017**] for 2-3 weeks. Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks. Completed by:[**2201-6-25**]

[ "250.00", "401.9", "424.1", "997.3", "486" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.21" ]

icd9pcs

[ [ [] ] ]

5930, 5992

2001, 3825

272, 303

6205, 6211

1373, 1978

6496, 6738

844, 893

4118, 5907

6013, 6184

3851, 4095

6235, 6473

908, 1354

229, 234

331, 479

501, 722

738, 828

9,195

113,157

27125

Discharge summary

report

Admission Date: [**2198-5-7**] Discharge Date: [**2198-5-10**] Date of Birth: [**2157-11-3**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3984**] Chief Complaint: respiratory failure Major Surgical or Invasive Procedure: bronchoscopy with stenting to L main bronchus History of Present Illness: 40 year old female with recent dx of metastatic esophageal cancer with R main bronchus stent and esophageal stent, transferred from OSH ED with resp failure since home O2 ran out this AM. Husband states that pt respiratory distress occured acutely and did not improve with new O2 tanks. He states that she did not complain of any chest pain but he states that she did have fevers and cough earlier that day. Intitially at OSH patient was T 103, BP 99/35, HR 130s-170s (sinus)95% NRB. Pt was intubated and given imimpenem, solumedrol. Her ABG at OSH was 7.25/75/75 before intubation. Transferred to [**Hospital1 18**] for further care. In the ED at [**Hospital1 18**] patient afebrile [**Company 5249**] 99 rectal and CXR showed stable RML/RLL collapse. Past Medical History: esophogeal cancer (poorly diff adenocarcinoma of distal esophogas), s/p esophageal stent with mets to adrenal, pancreas and T12 vertebrae anxiety disorder, HTN, Chronic obstructive pulmonary disease, ?Non small cell lung cancer with 80% stenosis of R main bronchus, s/p stent. Social History: Mr.and Mrs.[**Last Name (STitle) 66599**] have no children and are each other's support system. She is a homemaker and he is employed at [**Company **]. Quit smoking in [**Month (only) 404**] Family History: NC Physical Exam: PE: T 97.9 BP 116/67 HR 95 RR 31 O2Sat 100% on CMV 450x16 PEEP 5 FiO2 0.6 Gen: Patient sedated but responsive to verbal stimuli Heent: PERRL, sclera anicteric, pt with ETT and OG tube Neck: no LAD Lungs: Diffuse ronchi with hyperresonance at RLL Cardiac: RRR S1/S2 no murmurs, difficult to hear given BS Abdomen: soft, NT, decreased BS Ext: no edema, warm, DP +2 Neuro: sedated but responsive to verbal stimuli Pertinent Results: [**2198-5-7**] 05:23PM PLT SMR-HIGH PLT COUNT-554*# [**2198-5-7**] 05:23PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL [**2198-5-7**] 05:23PM NEUTS-94.7* BANDS-0 LYMPHS-3.2* MONOS-1.6* EOS-0.2 BASOS-0.3 [**2198-5-7**] 05:23PM WBC-16.4* RBC-3.72* HGB-10.2* HCT-31.1* MCV-84 MCH-27.3 MCHC-32.7 RDW-16.6* [**2198-5-7**] 05:23PM ALBUMIN-3.1* [**2198-5-7**] 05:23PM ALT(SGPT)-16 AST(SGOT)-28 LD(LDH)-398* ALK PHOS-103 TOT BILI-0.4 [**2198-5-7**] 05:23PM GLUCOSE-140* UREA N-8 CREAT-0.8 SODIUM-137 POTASSIUM-4.0 CHLORIDE-93* TOTAL CO2-29 ANION GAP-19 [**2198-5-7**] 05:25PM LACTATE-2.2* [**2198-5-7**] 11:16PM LACTATE-1.9 [**2198-5-7**] 11:16PM TYPE-ART TEMP-36.6 PO2-283* PCO2-44 PH-7.42 TOTAL CO2-30 BASE XS-4 . Chest CT [**5-8**]: IMPRESSION: 1) No pulmonary embolism. 2) Extensive tumor involving the mid and distal esophagus invading into the right hilum and intimately associated with the left atrium. This tumor narrows and encases the right-sided pulmonary arteries and occludes the right middle and right lower lobe bronchi. 3) Interval placement of an esophageal stent as well as an apparent right- sided bronchial stent which is now located within the fistulous tract connecting the residual esophageal lumen and the right lower lobe bronchi. It is possible that this stent has migrated from its intended location in the bronchus intermedius. 4) Persisting total collapse of the right middle lobe and right lower lobe. 5) Persisting fluid-filled cavitary lesion in the right middle lobe, which may be superinfected. 6) Persisting ground glass and tree-in-[**Male First Name (un) 239**] opacities in the right upper and left lower lobes, likely infectious. 7) Lytic lesion in the T12 vertebral body, likely metastasis. Brief Hospital Course: A/P: 40 y/o F with PMHx significant for metastatic esophageal CA, ? NSCLC s/p R bronchus and esophageal stents who presents from OSH with fever and respiratory distress. . 1. Respiratory Distress: The intial suspicion was that the patient had developed a pneumonia which led to a decompensation on the backgroudn of her poor baseline with R lung atelectasis from her tumor. She was treated empirically with Zosyn and vanco given recent hospitalization. However, a bronch was performed to evaluate her airways and the stent placement. This unfortunately showed very severe anatomical defects caused by the urdelying cancer. There was obstruction noted of both L and R mainstem bronchus. The esophageal stent was noted to be eroding through the esophageal wall into the R mainstem bronchus. The patient returned for another bronch by interventional pulmonary with a plan to make an aggressive attempt to treat the lesions as best as possible. However, removal of the esophageal stent which was eroding into the R bronchus was not possible. The L mainstem bronchus was stented. Discussions were held with the family and with the patient who remained awake, alert and fully aware of her surroundings and able to communicate (non-verbally given that she was intubated). It was explained to the patient and the family that she would never be able to be safely extubated given the severity of the disease and that her prognosis from the aggressive cancer was one of terminal progression likely over weeks to a few months. The patient ultimately elected for comfort measures only. She was extubated on [**2198-5-10**] in the company of her family. She soon passed away quietly and comfortably with her friends and family present Medications on Admission: Atenolol Paxil Wellbutrin Albuterol Norvasc Pulmacort Discharge Medications: not applicable Discharge Disposition: Expired Discharge Diagnosis: End stage metastatic CA respiratory failure post-obstructive pneumonia sepsis Discharge Condition: deceased Discharge Instructions: not applicable [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

[ "198.5", "496", "197.0", "485", "518.0", "198.7", "401.9", "197.8", "150.5", "518.81" ]

icd9cm

[ [ [] ] ]

[ "96.04", "98.15", "96.71", "45.13", "33.22", "96.05", "33.91" ]

icd9pcs

[ [ [] ] ]

5820, 5829

3954, 5677

334, 381

5950, 5960

2144, 3931

1694, 1698

5781, 5797

5850, 5929

5703, 5758

5984, 6127

1713, 2125

275, 296

409, 1167

1189, 1467

1483, 1678