ChanBeDu/relevant_section_length · Datasets at Hugging Face

55,716

136,896

42739

Discharge summary

report

Admission Date: [**2119-2-13**] Discharge Date: [**2119-3-6**] Date of Birth: [**2071-10-1**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 30**] Chief Complaint: Altered mental status, drug overdose (?Flexeril) Major Surgical or Invasive Procedure: fasciotomy of LLE [**2119-2-15**] Anterior compartment debridement LLE [**2119-2-17**] Placement of tunneled HD catheter by IR Intubation History of Present Illness: 47yo female h/o depression with past suicide presenting s/p overdose of flexeril. Per report patient was found "asleep" on couch by boyfriend. Unclear how long had been unattended (~24hr). Boyfriends Empty flexeril bottle found next to patient. unclear how many pills were ingested. EMS administered narcanx3. Initially presented to an OSH. Intubated for airway protection. Started on levophed for persistent hypotension. Labs creatinine 3.9, K: 5.8, WBC 17 with 21% bandemia. CK 51K. Utox + methadone. R IJ as well as 3 peripherals placed for access. Received 9L of NS, vanc, zosyn for presumed aspiration. Started on nac bolus + ggt for planned 24hr though tylenol negative. Patient transferred to [**Hospital1 18**] ED, initial VS: afebrile, 112HR, 112/61 (MAP 73) on 0.5 levophed, 70% 400/14/30. Sedated on fentanyl and versed. Labs with K: 6.7. Kayxelate administered. No QT prolongation, no peak Twaves. NaBicarb not started. CXR c/w ARDs and patient started on ARDs net protocal. 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: Depression with past suicide attempts Social History: history of heavy alcohol abuse Smokes 1 ppd Lives with her boyfriend Family History: unknown Physical Exam: Admission exam: T 97.4 HR 110 BP 118/68 RR 24 O2 Sat 98% on CMV with PEEP of 15 Vt 400 Gen: intubated, non-responsive HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge exam: Afebrile, HR 90s; BP 130-150s; RR 18; 95%RA GENERAL - Well-appearing F in NAD, comfortable HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no JVD, no carotid bruits LUNGS - CTAB, no crackles, rhonchi, wheezes HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - LLE s/p fasciotomy, wound d/c/i, surrounding erythema and swelling decreased, wound healing, in cast with windows. Sutures taken out. Both lower extremities warm, well-perfused NEURO - No gross deficiency, AAOx3, appropriate SKIN - erythema surrounding suture overlaying HD line resolved, now only around suture, non-tender, no drainage Pertinent Results: ADMISSION LABS [**2119-2-13**] 02:00AM BLOOD WBC-6.9 RBC-4.18* Hgb-11.6* Hct-37.6 MCV-90 MCH-27.8 MCHC-30.9* RDW-14.8 Plt Ct-191 [**2119-2-13**] 02:00AM BLOOD Neuts-84* Bands-6* Lymphs-4* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-4* Myelos-0 [**2119-2-13**] 05:28AM BLOOD PT-11.5 PTT-22.3* INR(PT)-1.1 [**2119-2-13**] 05:28AM BLOOD Glucose-143* UreaN-39* Creat-3.5* Na-143 K-7.2* Cl-115* HCO3-16* AnGap-19 [**2119-2-13**] 02:00AM BLOOD ALT-138* AST-397* CK(CPK)-[**Numeric Identifier **]* AlkPhos-64 TotBili-0.2 [**2119-2-13**] 05:28AM BLOOD Lipase-18 [**2119-2-13**] 05:28AM BLOOD proBNP-1254* [**2119-2-13**] 03:18PM BLOOD CK-MB-GREATER TH cTropnT-0.03* [**2119-2-14**] 04:49AM BLOOD cTropnT-0.02* [**2119-2-13**] 05:28AM BLOOD Calcium-6.0* Phos-6.3* Mg-1.9 [**2119-2-13**] 02:00AM BLOOD Albumin-3.1* [**2119-2-13**] 08:29AM BLOOD Osmolal-310 [**2119-2-13**] 08:29AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2119-2-13**] 02:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-POS [**2119-2-13**] 08:29AM BLOOD HCV Ab-NEGATIVE [**2119-2-13**] 02:08AM BLOOD Type-ART Rates-24/0 Tidal V-500 PEEP-10 FiO2-70 pO2-66* pCO2-46* pH-7.12* calTCO2-16* Base XS--14 -ASSIST/CON Intubat-INTUBATED [**2119-2-13**] 02:20AM BLOOD Glucose-115* Na-143 K-6.7* Cl-118* calHCO3-14* PERTINENT RESULTS [**2119-2-13**] 02:00AM BLOOD ALT-138* AST-397* CK(CPK)-[**Numeric Identifier **]* AlkPhos-64 TotBili-0.2 [**2119-2-13**] 05:28AM BLOOD ALT-151* AST-435* CK(CPK)-[**Numeric Identifier 92360**]* AlkPhos-65 TotBili-0.2 [**2119-2-13**] 03:18PM BLOOD ALT-146* AST-481* CK(CPK)-[**Numeric Identifier 92361**]* AlkPhos-63 TotBili-0.4 [**2119-2-14**] 04:49AM BLOOD ALT-154* AST-492* LD(LDH)-871* CK(CPK)-[**Numeric Identifier 92362**]* AlkPhos-78 TotBili-0.3 [**2119-2-20**] 12:01AM BLOOD Fibrino-826* [**2119-2-14**] 04:49AM BLOOD cTropnT-0.02* [**2119-2-13**] 03:18PM BLOOD CK-MB-GREATER TH cTropnT-0.03* [**2119-2-18**] 03:09AM BLOOD Lipase-29 [**2119-2-13**] 05:28AM BLOOD Lipase-18 [**2119-3-2**] 08:46AM BLOOD calTIBC-260 Ferritn-201* TRF-200 [**2119-2-23**] 05:48AM BLOOD calTIBC-217* Ferritn-137 TRF-167* [**2119-2-19**] 03:40PM BLOOD Hapto-359* [**2119-3-1**] 03:03PM BLOOD Vanco-18.4 [**2119-2-28**] 07:00AM BLOOD Vanco-16.3 Discharge labs: [**2119-3-6**] 06:36AM BLOOD WBC-8.8 RBC-2.89* Hgb-8.3* Hct-24.9* MCV-86 MCH-28.7 MCHC-33.4 RDW-16.2* Plt Ct-340 [**2119-3-6**] 06:36AM BLOOD Glucose-92 UreaN-33* Creat-8.0*# Na-137 K-4.2 Cl-96 HCO3-27 AnGap-18 [**2119-3-6**] 06:36AM BLOOD Calcium-9.1 Phos-6.5* Mg-2.1 Micro: [**2119-2-13**] Blood Culture x2 PENDING [**2119-2-13**] Urine culture negative [**2119-2-13**] sputum culture negative CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2119-2-19**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). Imaging: CT Head [**2119-2-13**] 1. No evidence of hemorrhage, large vessel territorial infarction, or shift of normally midline structures. 2. The sulci are not clearly delineated. While this may be a normal finding in a brain without atrophy, given the patient's clinical status, diffuse cerebral edema cannot be excluded. The cerebellar tonsils are slightly low-lying. Correlate clinically. An MRI may be obtained for further characterization if necessary if there is no CI . CXR [**2119-2-14**] As compared to the previous radiograph, there is improvement with reduction of the bilateral parenchymal opacities. However, there is still evidence of moderate fluid overload, cardiomegaly, and likely a small left pleural effusion. The presence of an additional, aspiration related change at the right lung base cannot be excluded. No pneumothorax. The monitoring and support devices are in constant position. CXR [**2119-2-16**] An ET tube is present, 4.1 cm above the carina. An NG tube is present, extending beneath the diaphragm, off the film. There is cardiomegaly. There is increased retrocardiac density with air bronchograms and obscuration of the left hemidiaphragm, consistent with left lower lobe collapse and/or consolidation. There is some patchy right perihilar and infrahilar opacity and upper zone re-distribution. This may all represent CHF, though a superimposed pneumonic infiltrate on the right is difficult to exclude. Possible small left effusion. Right costophrenic sulcus clear. Compared with [**2119-2-15**], the right base consolidation is slightly improved. Left lower lobe consolidation slightly worse. Pulmonary edema is unchanged. Possible small left effusion, unchanged. CXR [**2119-2-18**] The ET tube is present, 5.0 cm above the carina. An NG tube is present, tip extending beneath the diaphragm, overlying the stomach. A dual-lumen right IJ catheter is present, with lead tips over distal SVC and upper right atrium. A left-sided PICC line is present, tip over proximal SVC. There are low inspiratory volumes, with pulmonary vascular plethora, consistent with CHF. There is increased retrocardiac density, consistent with left lower lobe collapse and/or consolidation. The possibility of small effusions cannot be excluded. CXR [**2119-2-22**]: INDINGS: In comparison with the study of [**2-19**], the nasogastric tube extends to the mid body of the stomach. Side hole is distal to the esophagogastric junction. There is continued enlargement of the cardiac silhouette with some decrease in pulmonary vascular congestion. The monitoring and support devices remain in place. CXR [**2119-2-24**]: Previous heterogeneous opacification in the right lung which improved from [**2-19**] through [**2-22**] has not improved subsequently, consistent with persistent multifocal pneumonia. Additionally, mild pulmonary edema most readily detected in the left lung, continues to improve. Heart is top normal size, decreased. Small right pleural effusion remains. No pneumothorax. Left PICC line ends alongside a dual-channel right supraclavicular central venous catheter in the mid-to-low SVC. No pneumothorax. Brain MRI [**2119-2-24**]: IMPRESSION: No significant abnormalities on MRI of the brain. No evidence of acute or subacute infarct seen. No evidence of mass effect or brain herniation identified. CT left leg w/o contrast [**2119-2-26**]: IMPRESSION: 1. Generalized ill defined low attenuation appearance of the muscles of the deep compartment of the left calf, likely the sequela of known previous compartment syndrome. Diffuse intramuscular hemorrhage interleaving between the soleus muscle fibers could also give this appearence although this is felt to be less likely. 2. No evidence of a localized hematoma or other discrete left lower extremity fluid collection. [**2119-3-1**]: HD line site ultrasound: IMPRESSION: Edematous soft tissues at the patient's HD tunnel line, consistent with cellulitis. No free fluid identified. Blood cultures from [**2-13**], [**2-19**], [**2-24**] negative Urine culture from [**2-13**] negative [**2119-2-13**] 9:00 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2119-2-16**]** GRAM STAIN (Final [**2119-2-13**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2119-2-16**]): SPARSE GROWTH Commensal Respiratory Flora. C. diff toxin negative on [**2-19**] Blood culture from [**3-2**] no growth at thte time of discharge. Brief Hospital Course: 47 y/o female with h/o depression found unresponsive, ? flexeril overdose (found empty bottle next to the bed), with renal failure requiring HD secondary to rhabdomyolysis or ATN, respiratory failure secondary to AMS and pneumonia s/p extubation, compartment syndrome s/p fasciotomy, waxing/[**Doctor Last Name 688**] delirium now resolved. # Delirium: Patient with waxing/[**Doctor Last Name 688**] mental status. Likely multifactorial, related to pain, ICU delirium and benzo-intoxication. CT head at time of admission showed potential cerebral edema, concerning for hypoxic injury while patient was unconsious. MRI brain w/o significant abnormalities. Also may have [**Last Name (un) 4897**] [**1-26**] EtOH abuse so treated with IV thiamine x 7 days, followed by PO thiamine. In the MICU, patient required precedex for ongoing delirum, started [**2-19**]. She had scheduled Ativan in case of withdrawal from benzos or alcohol, then transitioned to Valium which was tappered from 10mg q6h by 25% daily. Also received prn 5mg IV Haldol for agitation. Seroquel initially started at 25mg tid and uptitrated to 100mg tid, but eventually DCed once patients mental status improved to baseline after coming out of the ICU. Patient kept NPO while delirious. Mental status cleared a few days after leaving the MICU and was able to stop all benzodiazepines, haldol and seroquel. # Hypertension: SBP 140-160s on HD days, but as high as 170s on other days. Patient with no history of HTN. New HTN likely [**1-26**] CKD and some volume overload and anxiety. Started on amlodipine 5mg daily. # HD line infection vs cellulitis: Erythema overlying HD line tunnel. Initially started near suture site, now tracking along the tunnel. No drainage. ? cellulitis vs skin irritation. Patient has been on vanc or cefazolin since admission when erythema developed. Planned to cover with Keflex for cellulitis x1 week (starting [**3-2**]) and then stop and monitor site at HD center. Ultrasound HD tunnel area w/o abscess, c/w cellulitis. Keflex 500mg [**Hospital1 **] (last day [**3-8**]), to be taken after HD on HD days. # Alcohol Abuse/Withdrawal: patient has a long hx of alcohol abuse. Given non-responsiveness, give ativan throughout initial days in house based on vital signs, for tachycardia and hypertension. After extubation, she was very agitated and tachycardic, thought to be a component of alcohol withdrawal, and was thus treated with ativan, then converted to diazepam, then tappered (see above). # Hypoxic respiratory failure/Pneumonia. Possible etiology includes [**Doctor Last Name **]/ARDS secondary to opioids or naloxone vs aspiration (?RLL opacity) vs pulmonary edema vs infection. [**Doctor Last Name **] can occur with opioids, possibly with use of naloxone, which can cause a rapid surge of catecholamines occurs in the setting of withdrawal which leads to increased afterload and increased interstitial edema. Given the patient??????s leukocytosis and bandemia, (OSH labs notable for WBC 17 with 21% bands) also because of CXR findings concerning for ?aspiration or infection, the patient has been initiated on empiric vancomycin (renally dosed) and zosyn, which she received 5 days of. Her ventilator settings were set via ARDSnet protocol. Cultures were consistently negative and her abx were discontinued. She was subsequently extubated on [**2-17**]. On [**2-19**], she had episode of tachypnea, diaphoresis and fever, CXR revealed worsening bilateral opacifications and, although she had completed the initial empiric course of vanc/zosyn, she was continued on vanc and cefepime for coverage for VAP (extubated on [**2-18**]). Also likely component of fluid overload, which is being managed by HD. Completed vanc/cefepime x 8 days for VAP. # Flexeril overdose/suicide attempt- Events unwitnessed, but patient found down by her boyfriend with bottle of empty Flexeril. Does endorse depression and says she is not surprised taht she overdosed. Flexeril has similar toxicity to TCAs. The patient had EKGs and was monitored on telemetry for QRS widening and sodium bicarbonate was given. Patient evaluated by Psychiatry and initially placed on Section 12 with 1:1 sitter once patient extubated and awake. Towards discharge, patient denied SI, and psychiatry thought she was safe to be off section 12. BEST team set up partial day program in [**Location (un) 8973**], to start on [**3-8**]. # [**Last Name (un) **]. Unknown baseline creatinine, but no h/o CKD. Etiology likely multifactorial secondary to rhabdo/ ATN (initially presented with hypotension). Dialysis initiated on [**2-13**]. s/p tunneled line placement. Currently HD-dependant. Course unclear, patient may or may not recover kidney function. Started on sevelamer, nephrocaps, calcium acetate. Plan to start IV iron at HD center, followed by PO iron. Also getting Epo with HD. # Compartment Syndrome: pt had pain out of proportion (although she was sedated and not responsive, she became agitated) with palpation of her LLE in the am of [**2-15**]. Ortho consult was called and the patient was diagnosed with compartment syndrome. Fasciotomy on [**2-15**], complete resection of anterior compartment (secondary to extensive necrosis) on [**2-17**]. Patient likely will have permanent foot drop. Orthopedic tech saw patient and fitted [**Hospital1 **]-valve cast with foot in the neutral position to prevent foot drop, then re-made cast with windows for wound care. There was initially concern of bleeding (unexplained anemia), but CT LLE on [**2-26**] without evidence of bleed. Sutured DC'd on [**3-6**] prior to discharge. Follow up with orthopedic surgery on [**3-14**]. Follow up with outpatient PT on [**3-17**]. # Anemia: Hct low, with 3 unit pRBC transfused this admission. Likely 2/2 blood loss from OR, also from renal failure. Iron studies suggest iron deficiency. Hemolysis and DIC labs negative. CT LLE without evidence of hematoma. Started EPO with dialysis and IV iron to be started at outpatient HD, followed by PO iron. # Transitional issues: Follow up (see attached) - Psych Partial Program in [**Location (un) 8973**] (to start [**3-8**]) - Hemodialysis (to start [**3-7**]) - outpatient PT ([**3-17**]) - Orthopedics ([**3-14**]) - PCP Follow up final blood culture results Medications on Admission: None (previously on SSRIs, but no current meds) Discharge Medications: 1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 tab* Refills:*0* 2. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*270 Tablet(s)* Refills:*0* 3. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 2 days: last day [**3-8**]; On days of hemodialysis, take medication after dialysis session. Disp:*4 Capsule(s)* Refills:*0* 4. Outpatient Physical Therapy Please provide physical therapy for patient given recent left lower leg fasciotomy secondary from compartment syndrome. 5. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*180 Capsule(s)* Refills:*0* 6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Flexeril overdose Rhabdomyolysis Acute kidney injury Delirium Compartment syndrome Pneumonia Anemia Cellulitis Depression Suicide attempt Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname **] [**Known lastname 2152**], It was a pleasure participating in your care at [**Hospital1 18**]. You were admitted because you were found unconscious with a question of Flexeril overdose. Due to being unconscious for an unknown amount of time, you had muscle breakdown in your left leg, which was treated with surgerical debridement. You will continue with outpatient physical therapy. You also had kidney failure, and were started on hemodialysis, which will continue as an outpatient. We also treated you with several blood transfusions for anemia. You will continue treatment for depression at an outpatient psychiatric facility (see below) We made the following changes to your medications: STARTED Nephrocaps STARTED Sevelamer STARTED Calcium Acetate STARTED Keflex (last day [**3-8**]) STARTED Amlodipine You will received intravenous iron at dialysis, and after that, your nephrologist may start oral iron pills Followup Instructions: Tuesday [**2119-3-7**] [**Location (un) **]- [**Location (un) 5503**] Dialysis Center 237-[**Street Address(1) 49264**] [**University/College **] [**Numeric Identifier 49265**] Tel: [**Telephone/Fax (1) 49266**] Nephrologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (office 1-[**Telephone/Fax (1) 9674**]) After [**3-7**], you will have dialysis Tuesday, Thursday, Saturday at 3:00PM Wednesday [**2119-3-8**] 9:00 AM [**Hospital1 **]-Partial Program [**Street Address(2) 92363**], [**Location (un) 551**] [**Location (un) 8973**] ([**Telephone/Fax (1) 92364**] * In case of emergency, you can call [**Location (un) 5503**] Emergency Services [**Telephone/Fax (1) 74745**] or [**Telephone/Fax (1) 92365**] Name: NP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 86499**] Department: Womens Health Internal Medicine Location: GREATER [**Location (un) **] CHC Address: [**Street Address(2) 68461**], [**Location (un) **],[**Numeric Identifier 62441**] Phone: [**Telephone/Fax (1) 18050**] Appointment: Tuesday [**2119-3-7**] 2:00pm Department: ORTHOPEDICS When: TUESDAY [**2119-3-14**] at 11:40 AM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: TUESDAY [**2119-3-14**] at 12:00 PM With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Department: OBGYN Address: [**Location (un) 92366**], [**Location (un) **],[**Numeric Identifier 28653**] Phone: [**Telephone/Fax (1) 92367**] Appointment: Wednesday [**2119-3-15**] 2:30pm *Please arrive for this appointment at 2:00pm and remember to bring your insurance card as well as a photo ID with you. Department: REHABILITATION SERVICES When: FRIDAY [**2119-3-17**] at 11:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 31526**], MSPT [**Telephone/Fax (1) 44928**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2119-3-7**]

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Discharge summary

report+addendum

Admission Date: [**2162-11-5**] Discharge Date: [**2162-11-19**] Service: [**Hospital1 **] HISTORY OF PRESENT ILLNESS: Patient is an 86-year-old male with previous history of coronary artery disease, status post coronary artery bypass graft and hypertension who has had progressive decline and cognitive function over the past year. His family had noticed that he had developed progressive short-term memory loss, for example, he would forget where his bedroom was located and head to the garage. He would confuse his nieces and about six months ago, he would forget whether he took his medications and what day it was. Around this time, he stopped taking his daily walks and became more withdrawn. His nephew describes an event where he walked off away from home, came back 20 minutes later, stating that he went to the doctor's office, but he did not have an appointment that day and the office was to far away to access by foot. In [**2162-8-2**], he would wake up in the middle of the night and think people were in the house, however at that time he was still mowing the lawn and his primary care physician reports that he had 28 out of 30 on his mini mental status exam at that time. By [**2162-10-3**], the patient had had several violent episodes involving his sister with whom he lived and at that point, she said that she could no longer take care of him and placed him into a psychiatric [**Hospital3 **] facility. There, he was disoriented and wanted to leave and at one point struggled with the house staff. He was sent to [**Hospital6 33**] at that time where he was given Ativan. At one point, patient became violent with the staff and began hitting people at which point he was sedated and transfused to the [**Hospital1 **] for neuropsychiatric evaluation. He was then transferred to [**Hospital3 **] for unclear reasons, but at some point, he was unresponsive and hypotensive, either at [**Hospital1 **] or at [**Hospital3 **]. He was then transferred to [**Hospital6 256**]. At [**Hospital6 256**], he was lethargic, dehydrated and hypotensive and had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] coma scale of 4. On arrival to Emergency Department, patient was given Narcan without effect and was intubated for airway protection. CT of the head at the time was negative. The electrocardiogram was unremarkable and urine serum toxicology screen was negative. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post coronary artery bypass graft. 2. Hypertension. 3. Dementia. 4. Paranoia. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Cardura, Ecotrin, Zyprexa 7.5 mg q.h.s., Atenolol 25 mg, folate, Colace, Hytrin and a multivitamin. SOCIAL HISTORY: There is no tobacco or ethanol abuse. At the time of admission, he was a resident of [**Hospital1 **] [**Location (un) **]. FAMILY HISTORY: Noncontributory. PHYSICAL EXAM ON ADMISSION: Temperature was 96.9. Pulse was in the 70s. Blood pressure 110/palp. Respiratory rate 18. He was saturating 100% on nonrebreather mask. After Narcan and fluid resuscitation, his vitals were as follows: Temperature 96.9. Blood pressure 150/70. Pulse 80. Respiratory rate 18 and saturation 100% while on a ventilator. General appearance was unresponsive male who is intubated. Head, eyes, ears, nose and throat: Normocephalic, atraumatic. Pupils myotic, unresponsive. Mucous membranes moist. Neck was supple, soft and there was no jugular venous distention. Heart was regular rate and rhythm, normal S1, S2, no murmurs, rubs or gallops. Lungs were clear to auscultation bilaterally and the midline sternotomy scar was appreciated. Abdomen was soft, nontender, nondistended, positive bowel sounds. Extremities were cool. No cyanosis, clubbing or edema. Neurological exam revealed him unresponsive to verbal tactile or painful stimuli, bilateral Babinski, was indeterminate. There was no gag reflex. Corneal reflexes were present. There was a question of decerebrate posturing. LABORATORIES: White blood cell count of 8.0, hematocrit 38.9, platelet count 122,000. Sodium 142, potassium 3.3, chloride 118, bicarbonate 21, BUN 14, creatinine 1.1, glucose 131. Amylase 150, PT, PTT and INR was 13.9 PT, PTT 23, INR 1.3. Urinalysis showed 0-2 white blood cells. Urine tox screen negative. Serum tox screen negative. Chest x-ray showed deep sulcus sign on the left. HOSPITAL COURSE: Patient went thorough negative work-up which included a negative head CT times two; normal electrocardiogram. He ruled out for myocardial infarction by serial enzymes. His B12, folate and TSH were all within normal limits. His B12 was in the low ranges of normal, so he received B12 injections for one week. His urine serum toxicology was negative. Adrenal function was within normal limits. His LFTs were all normal. There was no infection found except for Staph aureus that grew from sputum. His lumbar puncture showed no remarkable findings including an HSV that was negative. He received an abdominal CT during the hospital course which showed no intraabdominal process. Patient was extubated on hospital day four and the extubation was successful and he was transferred to the floor. At that time, he spiked temperatures up to 102 degrees Fahrenheit and was placed on a course of levofloxacin and vancomycin for suspected pneumonia. Vancomycin was soon stopped, but he continued on a ten day course of levofloxacin. Patient continued to have waxing and [**Doctor Last Name 688**] mental status despite discontinuing all medications including cogentin that was started in the Medical Intensive Care Unit. On hospital day 14, patient received a physostigmine challenge test to rule out the possibility of anti-cholinergic syndrome and the results of which were equivocal. Patient remained confused although was a bit more alert after administration of 2 mg of physostigmine. During the hospital stay, patient received a PICC line and was began on TPN on hospital day 12. This dictation will be continued at a later date. [**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**] Dictated By:[**Doctor Last Name 45557**] MEDQUIST36 D: [**2162-11-19**] 14:16 T: [**2162-11-22**] 09:52 JOB#: [**Job Number 45558**] Name: [**Known lastname 8359**], [**Known firstname 8360**] Unit No: [**Numeric Identifier 8361**] Admission Date: [**2162-11-5**] Discharge Date: [**2162-12-2**] Date of Birth: [**2076-1-25**] Sex: M Service: [**Hospital1 767**] Addendum is to hospital course: 1. Infectious Disease: The patient became febrile to 101.8 degrees F on [**2162-11-21**]. Blood cultures from this date grew coagulase negative Staphylococcus as well as [**Female First Name (un) 1441**] on [**2162-11-23**]. The patient was treated with Vancomycin and fluconazole, and defervesced by [**2162-11-25**]. The PICC line was removed on [**2162-11-24**] and the tip culture was negative. Surveillance cultures from [**11-24**], [**11-25**], [**11-27**], and [**11-29**] all had no growth to date at the time of discharge. The patient was treated with Vancomycin and fluconazole until [**2162-12-1**] at which time a decision was made to withdraw care. Chest x-rays in the intervening period were clear with no active disease. 2. Gastrointestinal: Liver function tests were monitored while the patient was on fluconazole and remained normal throughout treatment. 3. F/E/N: The patient was discontinued on TPN on [**2162-11-24**] secondary to access issues. After the PICC line was removed, a peripheral intravenous catheter was inserted in his right lower extremity, and the patient's family wished to defer placement of a central venous catheter. The patient was continued on intravenous fluids until [**2162-12-1**]. 4. Neurologic: The patient's mental status continued to wax and wane, being responsive to questions on some days, and nonresponsive on others. Repeat imaging was deferred secondary to the family's wishes not to sedate the patient. At no time when the patient was fully awake, alert, and conversant. 5. Code: Throughout his hospitalization, the patient's status was DNR/DNI. Two family meetings with this [**Hospital 1325**] healthcare proxy, Mr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8362**], and the patient's sister, Ms. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8362**] appeared on [**2162-11-23**] and [**2162-11-30**] to discuss the treatment plan. Decision was made on [**2162-12-1**] by Mr. [**Name13 (STitle) 8362**] to change the treatment plan to comfort measures only. The patient was discharged in poor condition. He will be placed in a comfort-care facility close to [**Location (un) **], [**State 1145**]. Discharge diagnosis is dementia, NOS. OTHER DIAGNOSES: 1. Change in mental status. 2. Hypertension. 3. Coronary artery disease, status post coronary artery bypass graft. 4. Candidemia, partially treated with eight days of fluconazole. 5. Bacteremia, partially treated with eight days of Vancomycin. DISCHARGE MEDICATIONS: 1. Ativan 0.5 mg sublingual q8h prn agitation. 2. Morphine sulfate 5-10 mg po q6h prn pain. 3. Scopolamine patch one patch topically q72h prn excessive secretions. DISCHARGE PLAN: The patient was screened for placement at a facility for comfort care. No further followup is planned. [**First Name11 (Name Pattern1) 27**] [**Last Name (NamePattern1) 28**], M.D. [**MD Number(1) 29**] Dictated By:[**Last Name (NamePattern1) 3309**] MEDQUIST36 D: [**2162-12-6**] 21:37 T: [**2162-12-7**] 04:18 JOB#: [**Job Number 8363**]

[ "458.9", "V45.81", "486", "331.0", "790.7", "276.5", "294.11", "112.5", "401.9" ]

icd9cm

[ [ [] ] ]

[ "99.15", "38.93", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

2888, 2920

9192, 9357

2628, 2729

6654, 9169

129, 2423

2935, 4419

9374, 9756

2445, 2601

2746, 2871

22,671

182,499

417

Discharge summary

report

Admission Date: [**2116-7-3**] Discharge Date: [**2116-7-18**] Service: MEDICINE Allergies: Ticlid Attending:[**First Name3 (LF) 30**] Chief Complaint: Diarrhea and hypotension Major Surgical or Invasive Procedure: None History of Present Illness: This is a 86 y/o male with a h/o CAD, CHF (EF 30-40%), HTN, MDS, recent admission in [**7-13**] for diarrhea and treated presumptively for c diff given his past history of c diff enterocolitis, who now presents to the ED with n/v/weakness/dehydration/diarrhea/epigastric abd pain x 24 hours. Pt also had one episode of emesis (no blood) yesterday. He is still on his course of flagyl from recent admission, but has missed the last few doses due to outpt pharmacy issues. . In the [**Name (NI) **], pt was noted to have an elevated lipase and amylase of 557 and 900, respectively. He was also noted to have an elevated lactate of 3.2 and a positive u/a with 6-10 wbc's, trace leuks, neg nitrates. He was initially to be admitted to medicine, however pt dropped his SBP from 110 to 90, asymptomatic. Received 500 cc with good response and current SBP in the 100's. Received a total of 1 L NS. He was given Vanc/CTX/flagyl in the ED for h/o MRSA, positive u/a, and recent h/o c diff enterocolitis ([**4-10**]). . Currently, through aid of daughter translating, pt denies any f/c/s, dizziness/lightheadedness, chest pain, SOB, palpitations, n/v, abdominal pain, urinary symptoms. +generalized weakness, but not much different from baseline. +diarrhea, no BRBPR/hematochezia/melena. . The patient was transferred to the medicine service [**2116-7-6**]. His diarrhea was improving and he had no complaints at that time. Past Medical History: - HTN - CAD, 3VD s/p stents in [**11-8**] and [**7-10**] to LAD and OM1 - Ischemic Cardiomyopathy with EF 40% in [**7-10**] - C. difficile enterocolitis - CVA's with multiple infarcts of varying ages on MRI (bilateral frontal, L temporal, R cerebellar) baseline gait apraxia and frontal lobe affect. - Peripheral vascular disease - Myelodysplastic Syndrome vs. refractory anemia/thrombocytopenia, bone marrow [**2102**] - History of recurrent URI's Social History: Born in [**Country 3587**], retired x 20 yrs, lives at home with his wife who recently had a stroke. Sons live [**Name2 (NI) 3592**], but have a h/o alcoholism. One daughter involved in care. Quit tobacco many years ago, no EtOH or illicits. Bedridden at baseline and completely dependent for ADL's. Baseline bowel/urinary incontinence. Family History: Non-contributory Physical Exam: VS: Tc 100.2, BP 140/70, HR 96, RR 24, SaO2 100% RA General: Lying in bed, NG tube. Drowsy, responds to voice with hello/moan. Answers yes/no questions through interpretor with moan. NAD. HEENT: NC/AT, PERRL, EOMI. MM dry, OP clear. Neck: Supple, flat JVP, no nuchal rigidity Chest: CTA anteriorly; pt with trouble cooperating fully CV: RRR, s1 s2 normal, no m/g/r Abd: Soft, voluntary guarding, NABS, no HSM; no rebound. Ext: No c/c/e, pulses 2+ b/l Neuro: Moves all four extremities freely. Pertinent Results: Labs on admission: [**2116-7-3**] 10:20AM WBC-35.8* RBC-2.92* HGB-10.2* HCT-29.2* MCV-100* MCH-34.9* MCHC-35.0 RDW-17.4* [**2116-7-3**] 10:20AM PT-18.8* PTT-29.3 INR(PT)-1.8* [**2116-7-3**] 10:20AM NEUTS-69 BANDS-4 LYMPHS-8* MONOS-19* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2116-7-3**] 10:20AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL BURR-OCCASIONAL [**2116-7-3**] 10:20AM PLT SMR-VERY LOW PLT COUNT-64* LPLT-1+ [**2116-7-3**] 10:20AM GLUCOSE-105 UREA N-13 CREAT-1.2 SODIUM-135 POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-21* ANION GAP-17 [**2116-7-3**] 10:20AM ALT(SGPT)-17 ALK PHOS-83 AMYLASE-900* TOT BILI-0.5 [**2116-7-3**] 10:20AM LIPASE-557* [**2116-7-3**] 11:48AM LACTATE-3.2* [**2116-7-3**] 06:01PM ALBUMIN-2.4* . CT ABDOMEN W/CONTRAST [**2116-7-3**] IMPRESSION: 1. Diffusely swollen pancreas consistent with mild pancreatitis without peripancreatic fluid collections noted. 2. Mildly atrophic kidneys with diffuse calcification of the renal artery ostia are noted. MRA of the renal artery is recommended bilaterally if clinical suspicious for stenosis. 3. Diffuse rectal, sigmoid, and descending colon wall thickening suggestive of colitis. 4. Enlarged paraaortic lymph nodes noted on previous exam, unchanged and of unknown significance. . CHEST (PORTABLE AP) [**2116-7-3**] IMPRESSION: AP chest compared to [**2116-6-18**]: Lungs are clear. Heart size normal. No pleural abnormality or evidence of central adenopathy. Right hemidiaphragm is persistently elevated given part to interposition of the hepatic flexure of the colon between diaphragm and liver. . CT ABDOMEN W/CONTRAST [**2116-7-8**] IMPRESSION: 1. Again seen is stranding around the pancreas, consistent with pancreatitis. There appears to be some interval increase in the degree of stranding within the small bowel mesentery, and along the pericolic gutters. There is a small amount of fluid along the pericolic gutters and within the pelvis, which is slightly increased from the prior study. No focal abscesses are identified. 2. There are bilateral pleural effusions which also have increased slightly in comparison to the prior study. The remainder of the exam is unchanged. . Blood draws were discontinued when the decision was made for CMO. Brief Hospital Course: A/P: 86 yoM with PMH CAD, ischemic cardiomyopathy, MDS, recent admission for presumed C. difficile colitis, admitted to the MICU with diarrhea and hypotension admitted to floor [**7-6**]. After family meetings to address goals of care in this patient with chronic pain and MDS most likely with leukemic transformation, not likely a candidate for therapy per hematology, the patient was made DNR/DNI/CMO. . 1. Diarrhea. The diarrhea continued to improve with decreased stool number and volume on the floor. CT abdomen [**7-3**] showed diffuse rectal, sigmoid, and descending colon wall thickening suggestive of colitis. With the patient's elevated WBC, there was concern for an infectious source. His stool cultures were negative x2 and C. difficile toxin was negative x3, however, the patient had a history of recent antibiotic use. The original plan with the GI consult team was to perform a colonoscopy once the patient was stable to elucidate the cause of the diarrhea; this was no longer necessary as the patient is CMO. The patient's initial antibiotic treatment included levofloxacin and flagyl on admission. The patient continued to spike fevers despite antibiotic treatment. Levofloxacin was discontinued and ceftriaxone was started to broaden coverage [**7-8**]. Infectious disease was consulted to comment on antibiotic coverage. Flagyl was discontinued [**7-9**], with vancomycin IV started [**7-9**]. Vancomycin by mouth and imipenum was started [**7-10**]. The patient was continued on vancomycin IV and by mouth and imipenum until the decision was made for the patient to be CMO [**7-16**]. The patient was kept hydrated intravenously and with free water boluses through his feeding tube to replace his GI losses. . 2. Fever/leukocytosis. The patient was started on levofloxacin and flagyl for presumptive infectious colitis, with antibiotic changes as above per ID recommendations. Blood cultures taken [**7-3**], [**7-4**], [**7-5**], [**7-7**], [**7-8**] were negative. Urine cultures 7/28, [**7-4**], [**7-5**] were negative. Multiple chest x-rays were within normal limits. An echocardiogram did not show evidence of endocarditis. As above, the patient continued to spike low grade fevers despite treatment with antibiotics. The patient's white blood cells at baseline were 19-25 thought secondary to MDS. The white blood cell count elevated to 80s on this admission. Hematology felt that the patient's blood smears were concerning for leukemic transformation of the MDS. Cytology was sent prior to the decision for CMO and was pending at the time of discharge. . 3. MDS. Hematology/oncology followed the patient during hospitalization. The team confirmed the diagnosis of MDS from his original smear. This was an atypical presentation as the patient was diagnosed in [**2103**] and an extended lifespan is inconsistent with the diagnosis of MDS. As above, the team felt that the patient's blood smears during the end of his hospitalization were concerning for leukemic transformation. The patient was not a good candidate for chemotherapy. Cytology was sent prior to the decision for CMO and was pending at the time of discharge. . #) Thrombocytopenia. The patient had platelets in the 40s in the past. On this admission, the patient's platelets dropped as low as 12. The thrombocytopenia was likely secondary to acute illness and the patient's underlying bone marrow disorder. DIC/[**Doctor First Name **] were thought unlikely although there were occasional schistocytes on smear. The patient was given a platelet transfusion [**7-12**] at the time his platelets were 12. His platelets responded immediately afterwards but continued to drop and his last measurement was 31. . #) Anemia. The patient's hematocrit decreased during his hospital course. His baseline was low: 28-32. The anemia was macrocytic with recent normal B12, folate [**6-11**]. His low reticulocyte count was indicative of a hypoproliferative disorder, most likely secondary to MDS with likely leukemic transformation. He was given two transfusions [**7-8**] and [**7-11**] when his hematocrit dropped below 25. His hematocrit would respond appropriately immediately afterwards but continued to drop during hospitalization. . #) Shortness of breath. The shortness of breath was most likely secondary to pulmonary edema from the patient's congestive heart failure and bronchoconstriction. The patient was given lasix 10 mg as needed, ipratropium nebulizers as needed, and oxygen as needed. The patient was discharged with nebulizers as needed. . #) Mental status. The patient was alert and oriented on admission. The patient's mental staus waxed and waned throughout admission. His mental status was most likely secondary to underlying dementia with superimposed infection/hospitalization. CT head showed prior infarct. CT head [**7-6**] negative for increased ICP, hemorrhage. . #) Pancreatitis. The patient was found to have a chemical pancreatitis; he remained asymptomatic without complaints of epigastric pain. Amylase and lipase continued to trend down throughout admission. The patient was kept NPO with NJ tube placement [**7-9**] for feeding. A RUQ ultrasound was negative for gallstones. The NJ tube was removed when the decision was made for CMO. . #) Elevated INR. The patient had an increased INR to 1.8 in the MICU, likely in setting of nutritional deficiency from diarrhea. He was given vitamin K 5 mg SC x 3 doses in the MICU. His INR continued to remain elevated throughout hospitalization. . #) CAD. The patient had no active symptoms and remained stable. Initially he was continued on aspirin, plavix, metoprolol, and his ace-inhibitor. Aspirin and plavix were discontinued when the patient was thrombocytopenic and in anticipation of possible colonoscopy with biopsies. His antihypertensive treatment was discontinued when the decision was made for CMO. . #) Congestive heart failure. The patienet was initially hypovolemic secondary to diarrhea. The patient was continued on maintenance IVF and free water boluses through his NJ tube once placed. The patient's low albumin was counterproductive to keep fluids in the intravascular space. The patient became transiently fluid overloaded and given lasix 10 mg x2 with effective diuresis. IVF and free water boluses were stopped when the patient became CMO. . #) Pain. The patient at baseline had pain with movement of his extremities. There was increased pain with movement of the right upper extremity, films were taken of the wrist, elbow, and shoulder without evidence of destructive disease or any acute issues. The patient was treated with tylenol and morphine with good effect. The patient was continued morphone elixer upon discharge. . #) Hiccups. The patient at times complained of intractable hiccups. Thorazine was given with good effect. This was continued through the patient's CMO status. . #) F/E/N. The patient's tube feeds were continued through the NG tube from the MICU, transiently stopped for placement of an NJ tube per GI recommendations, and restarted. The patient's albumin continued to drop, although the patient was at goal tube feeds. Electrolytes were repleted as necessary. The NJ tube was discontinued when the decision was made for CMO. . #) Precautions. The patient was placed on MRSA precautions were a positive swab [**11-10**]. Medications on Admission: 1. Aspirin 81 mg qd 2. Metoprolol 50 mg [**Hospital1 **] 3. Clopidogrel 75 mg qd 4. Pantoprazole 40 mg qd 5. Calcium Carbonate 400 mg tid 6. Vit D 800 units qd 7. Flagyl 500 mg tid 8. Lisinopril 5 mg qd 9. Lipitor 40 mg qhs Discharge Disposition: Extended Care Facility: [**Hospital1 599**] of [**Location (un) 55**] Discharge Diagnosis: Primary: Colitis Myelodysplastic syndrome with likely leukemic transformation Thrombocytopenia Anemia . Secondary: History of cerebrovascular infarct Discharge Condition: Afebrile, vital signs stable. Comfortable. Discharge Instructions: After discussion with family members, the decision was made for the goal of patient care to be comfort measures only. The patient is being transferred to an extended care facility with hospice for comfort measures. Followup Instructions: None

[ "428.0", "276.52", "009.0", "V45.82", "414.01", "285.9", "238.7", "263.9", "577.0", "401.9", "287.5" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.6" ]

icd9pcs

[ [ [] ] ]

13013, 13085

5414, 12739

236, 242

13279, 13324

3077, 3082

13587, 13595

2529, 2548

13106, 13258

12765, 12990

13348, 13564

2563, 3058

172, 198

270, 1685

3096, 5391

1707, 2159

2175, 2513

44,468

177,637

42731

Discharge summary

report

Admission Date: [**2196-8-5**] Discharge Date: [**2196-8-14**] Date of Birth: [**2122-1-11**] Sex: F Service: CARDIOTHORACIC Allergies: Fosamax / Sulfa(Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 5790**] Chief Complaint: Shortness of breath on exertion, cough, tracheobronchomalacia Major Surgical or Invasive Procedure: Right thoracotomy, thoracic tracheoplasty with mesh, right main-stem bronchus and bronchus intermedius bronchoplasty with mesh, left main-stem bronchus bronchoplasty with mesh, bronchoscopy with lavage. History of Present Illness: A 74 y.o. female with restrictive lung disease due to scoliosis, reports prog worsening DOE and cough. She was diagnosed with TBM by CT and bronch. On [**2196-3-10**] she had a Y stent placed and noted significant improvement in her symptoms but not resolution. She presents for surgical treatment of TBM. Past Medical History: DVT/PE '[**67**], '[**85**] Scoliosis Restrictive lung disease severe TBM hiatal hernia fibromyalgia s/p right foot [**Doctor First Name **] OA evac hematoma right LE [**2192**] Social History: Does not smoke, occasional alcohol use. Acid exposure (worked in factory). Family History: non-contributory Physical Exam: VS: T 97.6, HR 70, BP 141/60, RR 18, O2-sat 96% General: Appears well, in NAD HEENT: MMM, no scleral icterus, trachea and tongue midline, no palpable lymphadenopathy Cardiac: RRR Pulmonary: CTAB Abdomen: Soft, non-tender, nondistended, positive bowel sounds, no palpable masses Extremities: no edema Skin: Right arm chemical irritation improving Brief Hospital Course: [**8-5**]: OR for R thoracotomy, tracheobrochoplasty, tracheobronchoplasty, thoracic epidural placed, extubated in SICU. Epidural split d/t referred shoulder pain unresponsive and mild hotn. [**8-6**]: better w/epidural/dil PCA, OOB, pulm toilet better, CK trending down, UO low overnight 10, 10, 500cc NS x 1, improved to 30-40/hr [**8-7**]: Chest tube, dc'ed CXR: right chest tube removed no ptx gross effusion; Continued chest pt, Lasix 10mg x2, Gauifenisen. Hep locked IV. Started clear liquids. AM Heparin [**8-8**] being held for epidural removal. [**8-8**]: CXR worsened this AM, SpO2 92-95 Lasix 20mg given. epidural d/c'd [**8-9**]: CXR displaced rib fracture noted. Desaturation, tachypnea, respiratory distress this AM, bronch stenosis noted to be improved no significan intervention. Respiratory status improved, Lasix 20mg IV x1. [**8-10**] afib with rvr, replete lytes lopressor 5mg x 2, dilt load dilt gtt started minimal response to max dilt for 30mins dilt gtt dc'ed. Pt started on amio load, amio gtt. Hold diuresis. metop 12.5'' increased to 25'' per thoracic, clears, oob/amb w/PT [**8-11**]: DC amio gtt at 1800. Restart coumadin. [**8-12**]: phlebitis in RUE, ? edema in LUE, stat UE u/s, transfer orders in, f/u daily INR level [**8-13**]: Tolerating PO, respiratory status improving, no pain Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Gabapentin 800 mg PO DAILY 2. Metoprolol Tartrate 25 mg PO BID 3. Warfarin 2.5 mg PO MONDAYS AND WEDNESDAYS 4. Warfarin 5 mg PO TUE, THURS, FRI, SAT, SUN 5. Guaifenesin 600 mg PO BID 6. Simvastatin 10 mg PO Frequency is Unknown 7. Montelukast Sodium 10 mg PO DAILY 8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **] 9. Metoclopramide 10 mg PO DAILY:PRN nausea 10. Omeprazole 20 mg PO DAILY 11. Calcium Carbonate 500 mg PO Frequency is Unknown 12. Sertraline 100 mg PO DAILY 13. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath Discharge Medications: 1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **] 2. Gabapentin 800 mg PO DAILY 3. Metoprolol Tartrate 50 mg PO BID RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth twice a day Disp #*40 Tablet Refills:*0 4. Guaifenesin 600 mg PO BID 5. Montelukast Sodium 10 mg PO DAILY 6. Omeprazole 20 mg PO DAILY 7. Sertraline 100 mg PO DAILY 8. Warfarin 2.5 mg PO MONDAYS AND WEDNESDAYS RX *Coumadin 2.5 mg 1 tablet(s) by mouth Mondays and Wednesdays Disp #*2 Tablet Refills:*0 9. Warfarin 5 mg PO TUE, THURS, FRI, SAT, SUN RX *Coumadin 5 mg 1 tablet(s) by mouth Tuesday, Thursday, Friday, Saturday, and Sunday Disp #*2 Tablet Refills:*0 10. Acetaminophen 1000 mg PO Q6H 11. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills:*0 12. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 13. Calcium Carbonate 500 mg PO HS:PRN unknown 14. Metoclopramide 10 mg PO DAILY:PRN nausea 15. Simvastatin 10 mg PO DAILY Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA 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 tracheobronchoplasty and you've recovered well. You are now ready for discharge. * Please keep your arm splint on for another 24 hours. Please follow-up with plastic surgery as needed. * 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. * Your chest tube dressing may be removed in 48 hours. If it starts to drain, cover it with a clean dry dressing and change it as needed to keep site clean and dry. * 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: Please call Dr.[**Name (NI) 2347**] office at [**Telephone/Fax (1) 2348**] to schedule an appointment in 2 weeks. Please follow up on Tuesday morning ([**2196-8-16**]) at your primary care physician's office to have an INR drawn. You have an appointment to follow up with Dr. [**First Name8 (NamePattern2) 4468**] [**Last Name (NamePattern1) **] at 2:45PM, [**2196-8-17**] for management of your coumadin. Location: [**Hospital **] CLINIC, INC. Address: [**Street Address(2) 71573**], [**Hospital1 **],[**Numeric Identifier 71574**] Phone: [**Telephone/Fax (1) **] Fax: [**Telephone/Fax (1) 92344**]

[ "553.3", "514", "427.31", "788.5", "327.23", "E849.7", "737.30", "E944.4", "518.89", "V12.55", "999.82", "519.19", "401.9", "453.81" ]

icd9cm

[ [ [] ] ]

[ "03.90", "33.48", "33.22", "96.05", "31.79" ]

icd9pcs

[ [ [] ] ]

4661, 4720

1621, 2938

368, 573

4786, 4786

6608, 7212

1218, 1236

3640, 4638

4741, 4765

2964, 3617

4937, 6585

1251, 1598

267, 330

601, 908

4801, 4913

930, 1110

1126, 1202

5,027

199,776

28657

Discharge summary

report

Admission Date: [**2137-8-29**] Discharge Date: [**2137-9-7**] Date of Birth: [**2076-1-8**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: [**2137-8-29**] - CABGx4 (Left internal mammary->left anterior descending artery, vein graft to diagonal, vein graft to obtsue marginal, vein graft to posterior descending artery) History of Present Illness: This is a 61 year old male with exercise intolerance and dyspnea on exertion. Nuclear stress testing showed inferolateral ST depressions with exercise. SPECT revealed an LVEF of 59% with reversible defects in the anterolateral, inferior and inferolateral regions. Subsequent cardiac catheterization was notable for severe three vessel disease and normal LV function. Based upon the above results, he was referred for surgical revascularization. Past Medical History: Coronary Artery Disease Diabetes mellitus type II Hypertension Hypercholesterolemia Chronic back pain Carotid bruits s/p Shoulder surgery Social History: 45 pack year history of tobacco, quit approximately 1 month prior to admission. Denies ETOH. He is a mechanic. Currently lives with his wife. Family History: Denies premature CAD. Physical Exam: Vitals: BP 114/58, HR 54, RR 12, SAT 98 on room air General: well developed male in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, bilateral carotid bruits noted Heart: regular rate, normal s1s2, no murmur or rub Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, trace edema, no varicosities Pulses: 1+ distally, bilateral femoral bruits noted Neuro: nonfocal Pertinent Results: [**2137-9-7**] 05:35AM BLOOD WBC-14.4* RBC-3.37* Hgb-10.6* Hct-31.0* MCV-92 MCH-31.5 MCHC-34.2 RDW-15.5 Plt Ct-362 [**2137-9-7**] 05:35AM BLOOD Glucose-92 UreaN-40* Creat-1.8* Na-134 K-4.6 Cl-97 HCO3-24 AnGap-18 Brief Hospital Course: Mr. [**Known lastname 69335**] was admitted and underwent coronary artery bypass grafting by Dr. [**Last Name (STitle) **]. The operation was uneventful and he was transferred to the CSRU in stable condition. For further surgical details, please see seperate dictated operative note. Within 24 hours, he awoke neurologically intact and was extubated. Due to persistent secretions and hypoxia, he required reintubation on postoperative day one. He concomitantly experienced an acute decline in renal function and postoperative leukocytosis. His creatinine peaked to 2.7. His white count peaked to 21K and he was started on empiric antibiotics. A TEE on postoperative day two was unremarkable. Over the next several days, his renal and respiratory function improved. His white count normalized. He was eventually extubated again on postoperative day four. Sputum cultures showed only normal flora. He continued to make clinical improvements and was intermittently transfused to maintain hematocrit near 30%. He stablized and transferred to the SDU on postoperative day six. He experienced brief periods of paroxsymal atrial fibrillation but remained mostly in a normal sinus rhythm. Beta blockade was advanced as tolerated, and he has had no further AFib. He remains hemodynamically stable and ready to be discharged home. Medications on Admission: Avapro 150 qd, Toprol XL 100 qd, Omeprazole 20 qd, Lipitor 80 qd, Tricor 145 qd, Avandia 8 qd, Aspirin 81 qd, Coenzyme Q10 Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 MDI* Refills:*2* 4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). Disp:*1 MDI* Refills:*2* 5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**4-18**] hours as needed. Disp:*40 Tablet(s)* Refills:*0* 6. Rosiglitazone 8 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 9. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 11. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day for 7 days. Disp:*14 Tablet Sustained Release(s)* Refills:*0* 12. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNA of So. eastern Ma Discharge Diagnosis: Coronary Artery Disease - s/p CABG Postop Acute Renal Insufficiency Postop Acute Respiratory Failure Postop Leukocytosis Hypercholesterolemia HTN Diabetes mellitus Chronic back pain Carotid bruits Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in one week. 4) No lifting greater then 10 pounds for 10 weeks. 5) No driving for 1 month. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in 4 weeks. Follow-up with primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) **] in 2 weeks. Follow-up with cardiologist Dr. [**Last Name (STitle) 45555**] in [**1-14**] weeks. Completed by:[**2137-9-7**]

[ "997.5", "584.9", "414.01", "518.5", "424.0", "E879.9", "724.5", "427.31", "272.0", "401.9", "250.00" ]

icd9cm

[ [ [] ] ]

[ "36.13", "39.61", "99.04", "96.04", "88.72", "38.93", "96.71", "36.15" ]

icd9pcs

[ [ [] ] ]

5114, 5166

2043, 3365

339, 521

5407, 5416

1807, 2020

5751, 6032

1331, 1354

3538, 5091

5187, 5386

3391, 3515

5440, 5728

1369, 1788

280, 301

549, 995

1017, 1156

1172, 1315

18,121

183,258

45804

Discharge summary

report

Unit No: [**Numeric Identifier 97580**] Admission Date: [**2199-5-20**] Discharge Date: [**2199-6-5**] Date of Birth: [**2144-12-18**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This 54 year old white male was noted to have tachycardia during an injection for chronic back pain. He was admitted for rule out myocardial infarction. During the rule out, he continued to have persistent tachycardia. An echocardiogram at that time revealed severe aortic stenosis and he was referred for cardiac catheterization. He is asymptomatic at rest and has dyspnea on exertion, extreme exertion like running. He has had chest pain a few times over the past six months. The echocardiogram revealed an aortic valve area of 0.5 centimeter squared and his peak gradient was 60 mmHg. He underwent cardiac catheterization at [**Hospital1 190**] on [**2199-5-6**], which revealed normal coronaries and an aortic valve area of 0.5 centimeter squared with a mean gradient of 60 and an ejection fraction of 40 to 45 percent and one to two plus mitral regurgitation. He is now admitted for elective aortic valve replacement. PAST MEDICAL HISTORY: History of chronic back pain. History of depression. History of aortic stenosis. History of gastroesophageal reflux disease. Status post excision of chest wall tumor in the left tenth rib space. Status post appendectomy. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg p.o. once daily. 2. Effexor 150 mg p.o. once daily. 3. Protonix 40 mg p.o. once daily. ALLERGIES: He has no known drug allergies. SOCIAL HISTORY: He lives with his wife and is a fire fighter. He quit smoking thirty years ago and drinks five to six drinks per week. FAMILY HISTORY: His family history is significant for coronary artery disease and valvular disease. REVIEW OF SYMPTOMS: As above. PHYSICAL EXAMINATION: On physical examination, he is a well- developed, well-nourished white male in no apparent distress. Vital signs are stable, afebrile. Head, eyes, ears, nose and throat examination is normocephalic and atraumatic. Extraocular movements are intact. The oropharynx is benign. The neck was supple with full range of motion, no lymphadenopathy or thyromegaly, carotids two plus and equal bilaterally without bruits. The lungs had bilateral scattered rhonchi. Cardiovascular examination - regular rate and rhythm with a III/VI systolic ejection murmur heard best at the apex. He had a well healed surgical scar on his left lateral chest. The abdomen was soft, nontender, with positive bowel sounds, no masses or hepatosplenomegaly. Extremities were without cyanosis, clubbing or edema. Pulses were two plus and equal bilaterally throughout with the exception of the femorals which were one plus bilaterally. HOSPITAL COURSE: He was admitted on [**2199-5-20**], and underwent an aortic valve replacement with a [**Street Address(2) 66683**]. [**Male First Name (un) 923**] mechanical valve. He tolerated the procedure well and was transferred to the CSRU on Neo-Synephrine and Propofol. He was extubated on his postoperative night and had his chest tubes discontinued on postoperative day number one. He was transfused two units of blood on postoperative day two for a hematocrit of 21.5. He was ready to transfer to the floor on postoperative day number two when he felt a [**Doctor Last Name **] in his chest and had severe subcutaneous emphysema across his chest and through his face. He had a right pneumothorax and had a right chest tube placed that had an air leak. On postoperative day number three, he was transferred to the floor. He continued to stay on suction with his chest tube and was otherwise in stable condition. He remained on suction and was beginning to be anticoagulated. He had his chest tube discontinued on postoperative day number five. On postoperative day number six, he had a slight pneumothorax on the right again and became acutely short of breath on postoperative day number seven with a large pneumothorax. He had a Cook catheter placed and had full expansion of his lung. He was then fully anticoagulated and had to have his INR drift down. His Cook catheter eventually became clotted off and he began to have a pneumothorax again. On [**2199-5-31**], he underwent a right VATS procedure with a bleb resection and talc pleurodesis. He tolerated this procedure well and had his chest tube discontinued three days following that and was anticoagulated again and his lung remained expanded following chest tube removal. On postoperative day number sixteen and five, he was discharged to home in stable condition. His laboratories on discharge showed a white blood cell count 12.6, hematocrit 26.6, platelet count 576,000. Sodium 136, potassium 4.0, chloride 98, CO2 30, blood urea nitrogen 12, creatinine 0.9, glucose 129. Prothrombin time 17.8, INR 2.1. MEDICATIONS ON DISCHARGE: 1. Colace 100 mg p.o. twice a day. 2. Aspirin 81 mg p.o. once daily. 3. Percocet one to two tablets q4-6hours p.r.n. pain. 4. Protonix 40 mg p.o. once daily. 5. Effexor 150 mg p.o. once daily. 6. Lasix 20 mg p.o. twice a day for seven days. 7. Potassium 20 mEq p.o. once daily for seven days. 8. Lopressor 75 mg p.o. twice a day. 9. Keflex 500 mg p.o. four times a day for ten days for an erythema where an intravenous had been. 10. Coumadin 5 mg p.o. tonight and on [**2199-6-6**], and then as directed by Dr. [**Last Name (STitle) 4127**] for an INR goal of 2.5 to 3.5. DISCHARGE DIAGNOSES: Aortic stenosis. Bullous emphysema. Gastroesophageal reflux disease. Depression. Chronic back pain. FO[**Last Name (STitle) 996**]P: He will be seen by Dr. [**Last Name (STitle) 4127**] in one to two weeks, by Dr. [**Last Name (STitle) 952**] in two weeks, and by Dr. [**Last Name (Prefixes) **] in four weeks. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern1) 18588**] MEDQUIST36 D: [**2199-6-5**] 17:27:16 T: [**2199-6-5**] 20:30:04 Job#: [**Job Number 97581**]

[ "424.1", "414.01", "512.1", "996.79", "E878.1", "998.81", "530.81", "492.0", "E879.8" ]

icd9cm

[ [ [] ] ]

[ "34.92", "32.29", "35.22", "99.04", "34.21", "39.61", "34.04" ]

icd9pcs

[ [ [] ] ]

1705, 1822

5489, 6067

4879, 5467

1398, 1550

2774, 4853

1845, 2756

190, 1122

1145, 1372

1567, 1688

65,894

198,734

35471

Discharge summary

report

Admission Date: [**2196-2-15**] Discharge Date: [**2196-2-19**] Service: MEDICINE Allergies: Coumadin Attending:[**First Name3 (LF) 613**] Chief Complaint: Syncope, Fall, altered Mental Status Major Surgical or Invasive Procedure: Endotracheal intubation History of Present Illness: This is an 89 y.o. female with history of hypertension and syncope admitted status post witnessed fall where she struck her head and intubated for agitation and altered mental status. Per report, the patient was walking in a public place when she was noted to lose consciousness and collapse. Those who noted her falling thought she struck her head on the pavement when she fell. Her blood glucose in the field was 156. On arrival to the ED, her vitals were BP 190/83, HR 100 (atrial fibrillation), T 98.6. Her mental status was altered and she was extremely combative. The patient was intubated in the ED using etomidate and succinycholine and then was started on propofol drip for sedation. Her lactate was initially elevated to >8 but she was fighting violently when arrived and after hydration this descreased to 4.4. She was afebrile with a white count of 11.3. Urinalysis, head CT, chest radiograph, and ECG all failed to suggest an acute process to explain her altered mental status. After intubation she continued to remain quite agitated but was eventually fully sedated with propofol. She was admitted to the ICU. Past Medical History: -Hypertension -Hyperlipidemia -Chronic Obstructive Pulmonary Disease -Tobacco abuse -History of DVT -Recurrent syncope last workup in [**5-/2190**] at which time carotid ultrasounds, head CT and EEG were reported as normal -B12 deficiency -Pneumonia in [**4-/2192**] and [**2195**] -Old right basal ganglia lacunar infarct Social History: She has smoked a bit more than a pack per day for 70 years and continues to smoke. She doesn't use alcohol. She is widowed and lives alone in [**Hospital1 8**]. Though she is generally independent for her ADL's she has a great deal of help from her son and [**Name2 (NI) 9259**] who check in multiple times per day. Family History: Brother died of a myocardial infarction at age 52. Sister died of [**Name (NI) 2481**] disease. Physical Exam: Vitals: 98.2 124/51 69 15 100% on PS 10/5 .50 Gen: Elderly female, cachectic, intubated, temporal wasting HEENT: Abrasion above left orbit, dried blood around mouth, no teeth, pinpoint pupils Neck: in C-collar, no carotid bruit on left, unable to assess right [**1-11**] collar Chest: Lungs clear to auscultation bilaterally CV: Regular rate and rhythm ABD: Soft, NT, ND, BS+ EXT: DP 2+, WWP, abrasion on bilateral knuckles, diffuse ecchymosis on bilateral upper extremities Pertinent Results: LABORATORY =========== On Presentation: WBC-11.3* RBC-3.82* Hgb-11.2* Hct-34.7* MCV-91 RDW-15.0 Plt Ct-234 ---Neuts-33.2* Bands-0 Lymphs-59.3* Monos-5.4 Eos-1.5 Baso-0.6 -PT-11.9 PTT-23.4 INR(PT)-1.0 Glucose-101 UreaN-14 Creat-0.6 Na-145 K-3.3 Cl-110* HCO3-28 Calcium-7.7* Phos-2.6* Mg-1.6 ALT-118* AST-156* AlkPhos-85 TotBili-0.4 Lipase-15 ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG On Discharge: WBC-7.6 RBC-3.54* Hgb-10.7* Hct-30.9* MCV-87 RDW-14.9 Plt Ct-187 Glucose-96 UreaN-6 Creat-0.5 Na-139 K-3.5 Cl-104 HCO3-27 AnGap-12 Calcium-8.1* Phos-1.5* Mg-1.5* Lactate-8.2*-->4.4*-->1.8-->1.1 Cardiac Enzymes: CPK: 50-->448*-->631*-->596*-->128 CK-MB: ND--> 7--> 9--> 8--> 2 TropT: <0.010-->0.02-->0.04-->0.03-->0.02 URINE: BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 RADIOLOGY RESULTS ================= ECG [**2196-2-15**]: Sinus tachycardia. Consider right atrial abnormality. Low limb lead voltage. ST segment depression. Clinical correlation is suggested. No previous tracing available for comparison. Chest and Pelvis Radiograph [**2196-2-15**]: IMPRESSION: 1. No evidence of acute intrathoracic abnormality. 2. Distal tip of endotracheal tube at the inferior margin of the clavicles, 4.7 cm above the carina. 3. Emphysema. 4. Limited view of the pelvis without overt fracture. If there is concern for pelvic fracture, repeat radiograph is recommended. Pelvis Radiograph [**2196-2-15**]: IMPRESSION: No evidence of fracture. CT Head w/o Contrast [**2196-2-15**]: 1. No fracture, hemorrhage, or edema. 2. Chronic small vessel ischemic disease. 3. Age-related parenchymal involutional change. CT C-Spine [**2196-2-15**]: IMPRESSION: No evidence of traumatic injury to the cervical spine. Severe emphysema. Carotid Ultrasound [**2196-2-16**]: IMPRESSION: No hemodynamically significant stenosis in the internal carotid arteries bilaterally. Chest Radiograph [**2196-2-16**]: There is mild cardiomegaly. The lungs are hyperinflated. Atelectases are in the left base. Right lower lobe opacity could be due to pneumonia or aspiration. There is no pneumothorax or large pleural effusions. MR [**Name13 (STitle) 430**] w/ and w/o Contrast [**2196-2-19**]: IMPRESSION: No evidence of mass. Moderate small vessel ischemic changes. Brief Hospital Course: This is an 89 year old female with history of hypertension, hyperlipidemia, and unexplained syncope who was brought to the ED after a witnessed fall where her head struck the ground. 1) Syncope - The patient has had multiple episodes of syncope and the etiology of these episodes remains unclear despite an extensive work-up at another hospital. The cause of this particular event is similarly unclear. The patient has had previous echocardiograms, holter monitors, and a stress test, which have all been negative for a source of syncope. The patient was ruled out for MI at her presentation here (despite elevated CK's and borderline elevated troponin, MB remained flat and these other elevations considered more consistent with fall and struggle). Cerebrovascular causes of syncope could include TIA though this would be extremely rare unless there was bilateral disease. Given concern unilateral disease could cause brief hemiparesis and fall, carotid ultrasounds (previously performed at [**Hospital3 **]) were repeated and remained negative. Although she had a previous benign EEG at an outside hospital there was also some concern the patient could be having seizures given post-fall confusion with elevated CPKs. In an elderly woman most likely causes of new seizure would be infection or new mass lesion vs anatomic abnormality. As her picture was not consistent with infection and she had no fever, leukocytosis, or meningismus, her brain was imaged with CT and MRI. Neither imaging modality revealed an acute process. Orthostasic hypotension could be another common etiology of loss of conscious in elderly individuals but these episodes do not sound consistent with orthostasis as they do not happen just on standing but after she has been walking for some time. Ultimately, etiology of syncope is unclear but the patient does have severe COPD and despite being recommended home O2 in the past she has refused this. In the hospital the patient was noted to become hypoxemic on ambulation without supplementary oxygen. It was considered likely the patient has had hypoxemia at home and this may explain her syncopal episodes. The patient was discharged on supplementary O2. 2) Altered Mental Status - Per the patient's son her baseline mental status is generally alert and oriented *3 with mild memory deficits but the patient is able to take care of herself. At presentation she was extremely agitated and combative with minimal awareness. CT head ruled out acute intracranial bleed, and infectious work-up was ultimately negative, except for small infiltrate possibly consistent with pneumonia. The patient was never febrile and lactate trended down quickly with hydration, making severe infection less likely. She was extubated on hospital day 2 and at that time was at her baseline mental status. Most likely etiology of altered mental status was considered to be post-concussion syndrome vs persistent hypoxemia. B12 and tox screen were both within normal limits ruling out other possible metabolic causes of altered mental status. 3) Pneumonia v Pneumonitis: Repeat chest radiograph on the second hospital day revealed new right lower lobe infiltrate. The patient was noted to have an episode of emesis while intubated so this infiltrate was considered most likely to be due to aspiration pneumonia vs pneumonitis. She was started on a course of levofloxacin and remained afebrile without worsening cough or sputum production. 4) Emphysema: The patient has known emphysema and has met criteria for home O2 in the past. Imaging during this hospitalization also showed emphysema and physical exam after her extubation revealed extremely poor air movement, which improved with inhaled bronchodilators. Per the patient's son she has met criteria for home oxygen therapy during past hospitalizations and has consistently refused this. Given her inpatient team thought it extremely likely that part of her symptomatology was due to untreated COPD we attempted to start measures to better treat her emphysema. The patient was started on scheduled ipratroprium inhalers during her hospitalization and after prolonged discussion she was discharged with home oxygen and bronchodilators. The patient was counseled that she absolutely can not smoke in her home while she has oxygen. She expressed understanding of this and repeatedly expressed her understanding of the consequences of smoking around the oxygen including fire, burns, or death. 5) Hypertension: The patient is on metoprolol, hydrochlorathiazide, and amlodipine as an outpatient for hyptertension. These were held initially as orthostatic hypotension was considered one possible mechanism of her syncope. Eventually, her metoprolol was restarted and as she was observed and continued to have adequate blood pressure control with only this [**Doctor Last Name 360**] so the other agents were not restarted. 6) Hyperlipidemia - The patient is on fluvastatin at home and this was held initially but restarted on discharge. 7) Poor PO intake: The patient appeared somewhat cachectic and her son reported that she eats very poorly at home. Her son and others have been working on obtaining support with meal preparation and encouraging her eating. We reiterated the importance of good nutrition and deferred this issue to her outpatient treaters. The patient was fed a soft, regular diet. She received heparin SC for DVT prophylaxis. She was full code. Medications on Admission: Lescol 40mg qd Metoprolol 25 mg [**Hospital1 **] Amlodipine 5mg qd HCTZ 12.5 mg qd Discharge Medications: 1. Oxygen Therapy Oxygen therapy at continuous 3 L/min. Pulse dose for portable administration. 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. 3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) puff Inhalation four times a day. Disp:*1 MDI* Refills:*2* 4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation Q4hr:PRN. Disp:*1 MDI* Refills:*2* 5. Lescol 40 mg Capsule Sig: One (1) Capsule PO once a day. 6. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 2 days. Disp:*2 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnoses: Syncope Status post fall Emphysema/ Chronic Obstructive Pulmonary Disease Secondary Diagnoses: Hypertension History of cerebral vascular disease Discharge Condition: Good, tolerating PO's Discharge Instructions: You were admitted because you had a fall. We did tests and could not find any concerning causes for the fall in your brain or from your heart. We are not sure what caused you to pass out but we think it may have to do with your blood pressure medications or the fact that you have low oxygen levels due to your lung disease. Your medications have been changed. You have been started on IPRATROPRIUM inhalers, a medication to help your breathing. You should take this medication four times a day every day. You may also use ALBUTEROL inhalers as needed to help your breathing. It will also be important to use your home oxygen to protect your heart from the effects of low oxygen levels and this may prevent future episodes of passing out. PLEASE DO NOT SMOKE IN THE HOUSE WITH YOUR OXYGEN. IF YOU MUST SMOKE PLEASE GO OUTSIDE AND LEAVE YOUR OXGYEN INSIDE. We have also stopped your AMLODIPINE (NORVASC) and HCTZ as these medications could contribute to you passing out and your blood pressures were normal in the hospital so you do not need them. Finally, you will need to finish two days of the antibiotic LEVOFLOXACIN at home in order to treat a possible pneumonia. Please return to your local ED or call your doctor if you have fevers, chills, chest pain, increasing shortness of breath or any other concerning changes in your health. Followup Instructions: Please follow up with your regular [**First Name8 (NamePattern2) **] [**Last Name (Titles) 9655**] S. BELOK next week to discuss this hospitalization. You can reach Dr.[**Name (NI) 12083**] office at [**Telephone/Fax (1) 12071**]. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "787.20", "276.52", "276.2", "401.9", "790.5", "269.8", "496", "799.02", "272.4", "E885.9", "V12.51", "305.1", "266.2", "910.0", "507.0", "780.39", "780.09", "V12.54", "780.2" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

11347, 11405

5154, 10610

252, 277

11614, 11638

2750, 3161

13033, 13389

2137, 2234

10743, 11324

11426, 11520

10636, 10720

11662, 13010

2249, 2731

11541, 11593

3175, 3371

3388, 5131

176, 214

305, 1438

1460, 1785

1801, 2121

40,477

179,736

41679

Discharge summary

report

Admission Date: [**2155-8-4**] Discharge Date: [**2155-8-7**] Date of Birth: [**2099-8-18**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5167**] Chief Complaint: Generalized seizure Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 3646**] is a 55 y/o man with known long time epilepsy with hx of right temporal lobectomy who presented on [**2155-8-4**] as an [**Hospital 90601**] transfer from [**Hospital3 26615**] hospital. Per wife he was in usual state of health, complaining of "auras" over the past few days but was found at 08:00 [**2155-8-4**] actively seizing. His seizure was described as whole body shaking, unresponsiveness and eyes upturned. EMS was called and he was taken to the OSH where he continued to show signs of seizures (not documented what they saw). He was given ativan, loaded with fosphenytoin and then intubated for airway protection. He was sent here by air on propofol gtt. During the flight he was hypotensive to the 70's and the propofol was decreased. On arrival he was on propofol gtt, agitated, moving his right side, reaching for the tube with the right hand with no purposeful movement of the left hand noted. This was also noted at the OSH that he was not moving his left hand as much. His wife states that he was not complaining of fever, chills, pain within the last couple of days. He also has not missed any medications and has not had any changes to his med's recently. She states his last big sizure was in [**2146**]. Past Medical History: Paranoid schizophrenic Epilepsy s/p R temporal lobectomy Vertigo thought to be BPPV HTN HLD Social History: Lives with his wife. [**Name (NI) **] alcohol, smoking or illicit drug use Family History: No family hx of sz. Physical Exam: ON ADMISSION [**2155-8-4**] Vitals: T:98 P:71 R: 18 BP: 110/60 SaO2:100% General: Seen right before paralization. Was agitated thrashing right arm. Pulm; CTA CV: Distant RRR Abd: Soft Ext: no edema Skin: No lesions or rashes. Neurologic: Initubated. Seen right before given paralytic. Was thrashing around the right arm, reaching for the tube (restraints). Not opening eyes, had them shut tightly. PERRL. Not following commands. His face looked symmetric. Withdraws ext to pain. Right side more then left. Right leg flexed at the hip and knee. The left one was flat. reflexes were brisk. Cross abduction at the knees. Toes down going. NEW FINDINGS SINCE ADMISSION: [**2155-8-5**] GEN: Obese, appears older than stated age, in NAD Neurological Examination: Mental Status: Awake, alert and oriented to day, date and situation. Able to provide a good history. Reaction time is a little delayed, speech is slow but nondysarthric. No aphasia or anomia. Cranial Nerves: PERRL, EOMI without nystagmus, face is symmetric without ptosis or facial droop, tongue is midline, and palate elevates symmetrically. Hearing is grossly intact and sensation is intact and symmetric. Motor: Full strength throughout except for bilateral IP weakness. Reports some abdominal and groin tenderness on strength testing of large proximal muscle groups. No pronator drift or asterixis. He does have some intention tremor bilaterally. - Sensory: Grossly intact to light touch -Coordination: No intention tremor. -Gait: Deferred Pertinent Results: [**2155-8-4**] 11:04PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006 [**2155-8-4**] 11:04PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-MOD [**2155-8-4**] 11:04PM URINE RBC-3* WBC-9* BACTERIA-NONE YEAST-NONE EPI-0 [**2155-8-4**] 02:44PM CK(CPK)-1770* [**2155-8-4**] 02:44PM CALCIUM-9.5 PHOSPHATE-2.5* MAGNESIUM-2.0 [**2155-8-4**] 02:44PM TSH-0.91 [**2155-8-4**] 01:09PM GLUCOSE-142* LACTATE-2.6* NA+-130* K+-3.8 CL--94* [**2155-8-4**] 12:55PM GLUCOSE-137* UREA N-9 CREAT-1.0 SODIUM-131* POTASSIUM-3.9 CHLORIDE-96 TOTAL CO2-21* ANION GAP-18 [**2155-8-4**] 12:55PM CARBAMZPN-6.0 [**2155-8-4**] 12:55PM WBC-11.1* RBC-4.75 HGB-14.7 HCT-39.8* MCV-84 MCH-31.0 MCHC-37.0* RDW-12.6 [**2155-8-4**] 12:55PM NEUTS-81.6* LYMPHS-13.6* MONOS-4.2 EOS-0.4 BASOS-0.2 [**2155-8-4**] 12:55PM PLT COUNT-132* CK: [**2155-8-4**] 02:44PM BLOOD CK(CPK)-1770* [**2155-8-5**] 02:25PM BLOOD CK(CPK)-1740* [**2155-8-6**] 06:10AM BLOOD CK(CPK)-1091* [**2155-8-7**] 05:50AM BLOOD CK(CPK)-95 Imaging studies: EEG [**2155-8-5**] IMPRESSION: Abnormal EEG due to the mildly slow background for the early portions of the tracing. This suggests a widespread encephalopathy. There were no prominent focal abnormalities. There were no epileptiform features. Brief Hospital Course: Mr. [**Known lastname 3646**] presented to the ED as a transfer from an OSH for status where he was intubated for airway protection received dilantin and placed on propofol gtt on transfer. He was airlifted to [**Hospital1 18**] ED where he was admitted to the neurology ICU. On intial exam, there was a concern for asymmetric movements of the right compared to the left side but right before going to the NeuroICU was noted to have symmetric movements. He was weaned off propofol gtt and extubated without further evidence of seizures On the morning after admission, he was note to be doing well, complaining of some slight bilateral lower extremity weakness on our examination of his strength and some nonfocal headache. He was out of bed and in his chair tolerating breakfast without difficulties. On transfer to the floor, he continued to complain of lower extremity weakness but was able to walk without difficulty or assistance. His elevated CKs continued to downtrend and were attributed to his seizure. He was deemed stable for discharge home without further workup. Transitional issues: Seizures: He will follow up with Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **] at the [**Location (un) 4368**] Neurological institute for further management of his AEDs. Medications on Admission: LaMOTrigine 500 mg PO/NG QAM LaMOTrigine 400 mg PO/NG QPM LeVETiracetam 1500 mg IV BID Lisinopril 20 mg PO/NG DAILY Atenolol 100 mg PO/NG DAILY Clonazepam 1 mg PO/NG QID Fluoxetine 20 mg PO/NG DAILY Olanzapine 20 mg PO DAILY Niacin 100 mg PO TID Triamterene-Hydrochlorothiazide 1 CAP PO DAILY Discharge Medications: 1. olanzapine 10 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet, Rapid Dissolve PO DAILY (Daily). 2. lamotrigine 100 mg Tablet Sig: Four (4) Tablet PO twice per day (once in the morning and once at night). Disp:*240 Tablet(s)* Refills:*2* 3. atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 5. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 6. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. carbamazepine 200 mg Tablet Extended Release 12 hr Sig: Two (2) Tablet Extended Release 12 hr PO BID (2 times a day). 9. Keppra 500 mg Tablet Sig: 3.5 Tablets PO twice a day: (total 1750mg twice every day). Disp:*210 Tablet(s)* Refills:*2* 10. niacin 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for temp>100.4 or mild pain. Discharge Disposition: Home Discharge Diagnosis: seizure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for a seizure episode and concern for status epilepticus. You were intubated to protect your airway and had a brief stay in the ICU. The breathing tube was then removed, you were transfered to the floor and did not have any more seizures while you were in the hospital. Some changes were made to your medications: You should take the following: - Keppra to 1750mg twice every day - LaMOTrigine 400 mg twice every day - Clonazepam 1 mg PO/NG four times per day - Carbamazepine (Extended-Release) 400 mg PO twice every day Followup Instructions: please follow up with Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **] at the [**Location (un) 511**] Neurological Institute.

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icd9cm

[ [ [] ] ]

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183,157

50304

Discharge summary

report

Admission Date: [**2105-3-3**] Discharge Date: [**2105-3-18**] Date of Birth: [**2028-6-13**] Sex: M Service: MEDICINE Allergies: Lasix Attending:[**First Name3 (LF) 898**] Chief Complaint: SOB, CP Major Surgical or Invasive Procedure: central line placement History of Present Illness: Mr. [**Known lastname **] is a 76 year old male with a history of ALS, CAD s/p CABG, CHF (EF of 35 %) who initially presented from home with acute onset shortness of breath, epigastric pain and arm pain. Of note the patient was recently admitted to this hospital between [**2105-2-14**] and [**2105-2-23**] for rectal pain. During that admission the patient was found to be impacted and also to have a urinary tract infection. He was disimpacted and started on stool softeners. He received a two week course of ciprofloxacin for his UTI which was scheduled to end on [**2105-2-27**]. He was also started on digoxin for better rate control of his atrial fibrillation and imdur for recurrent chest pain. The patient reports that since that admission he was been experiencing cough and congestion for approximately 8 days. On this presentation he complained of acute worsening shortness of breath, epigastric pain and bilateral arm pain. The pain was described as dull and in his epigastrium without radiation. It was not associated with movement or eating. He has had similar pain before but it has not been persistent. The arm pain was described as going down both arms without an aching sensation. He denied chest pain, lightheadedness or syncope. He did report nasal and sinus congestion and cough since his last discharge. He denied fevers, chills, nausea, vomiting or fatigue. He was transported here by EMS who noted that he was rhonchorous and diaphoretic. His epigastric pain and dyspnea did not improve with nitroglycerin. In the ED his vitals were 98.6, 135, 137/86, 26, 100% on NRB. He received 2mg IV morphine for chest pain. He was given 10mg IV diltiazem for afib w/ RVR with decrease in HR to 80s-90s. Blood cultures were drawn and Vanc/Zosyn (for HAP as he has recently been hospitalized) and IVF were given. The patient had a large bowel movement in the ED. Labs were notable for lactate of 2.7, repeat K (first hemolyzed) of 4.7, WBC 10.9 with mild left shift, INR of 1.4, BNP 1376, troponin 0.04/CK 239 with negative MB. His O2 supplementation was weaned to face tent. A CXR was interpreted as CHF. Additionally he was given PR ASA. A RIJ CVL was placed. CVP readings were [**10-25**]. His SBP dropped to the 70s while HR was in the 60s-70s and dopamine and levophed were started. She received a partial dose of 0.5mg IV Dilaudid for pain control. He received ~2.5L NS while in the ED. He was transferred to the MICU for further management. In the MICU he continued to have shortness of breath as well as atypical chest pain. His CXR was consistent with pulmonary edema nad he recieved lasix for diuresis. He had a repeat echocardiogram which showed 3+ mitral regurgatation and he was started on lisinopril for afterload reduction. He had a speech and swallow evaluation which was notable for moderate to severe dysphagia. A PEG tube was discussed with the patient who declined, prefering to take POs despite the aspiration risk. Goals of care were discussed with the patient and his sister [**Name (NI) **]. [**Name2 (NI) 227**] his unstable cardiac status, repeated hospitalizations and dysphagia the decision was made to focus on comfort measures. His dyspnea and chest pain improved with subsequent administration of PRN morphine. Per this discussion the patient would still prefer around the clock care in a rehab setting as opposed to hospice. He was transferred to the floor for further management. Review of systems is difficult to obtain secondary to the patient's severe dysarthria. He complains of abdominal pain and consiptation but does not want any medications. He denies dyspnea or chest pain currently. Past Medical History: ALS HTN chronic systolic CHF (EF 35%-40%) CAD s/p MI Afib Gout, currently inactive Hyperlipidemia Social History: Resides in Brookside Home. Sister lives with him and assists with some IADLs. Gets privately-hired HHA as well as VNA twice a week. Has been seen by palliative care during previous admissions, but while he wants to focus on comfort, he also wants to be treated and hospitalized if necessary for acute illness. Has considered [**Hospital 100**] Rehab although has declined to go there during last admission in order to minimize spending. Denies tobacco, EtOH, illicit drug use. Family History: Father with Stomach Ca Physical Exam: VS: Temp: 97.3 BP: 105/59 HR: 80 RR: 17 O2sat 97% on face tent, CVP 9 GEN: pleasant, comfortable, NAD, dysarthria (at baseline per HCP) [**Name (NI) 4459**]: PERRL, [**Name (NI) 3899**], anicteric, MMM, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: coarse breath sounds bilaterally CV: irreg irreg, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e, cool extremities with chronic venous stasis changes SKIN: abrasions on left shin (from transfer via ambulance per HCP) NEURO: AAOx3 Pertinent Results: Hematology: [**2105-3-3**] 02:25AM WBC-10.9 RBC-4.50* HGB-13.5* HCT-41.7 MCV-93 MCH-29.9 MCHC-32.3 RDW-17.0* PLT COUNT-260 [**2105-3-13**] 05:50AM WBC-14.1*# RBC-4.34* Hgb-12.6* Hct-39.3* MCV-91 MCH-29.0 MCHC-32.0 RDW-16.3* Plt Ct-269 . Coags: [**2105-3-3**] 02:25AM PT-15.6* PTT-41.9* INR(PT)-1.4* [**2105-3-13**] 05:50AM PT-27.7* PTT-48.5* INR(PT)-2.8* . Chemistries: [**2105-3-3**] 02:25AM GLUCOSE-181* UREA N-18 CREAT-1.0 SODIUM-135 POTASSIUM-10.0* CHLORIDE-102 TOTAL CO2-24 ANION GAP-19 [**2105-3-3**] 02:33AM LACTATE-2.4* K+-4.7 [**2105-3-3**] 12:20PM DIGOXIN-0.4* [**2105-3-13**] 05:50AM Glucose-112* UreaN-26* Creat-0.7 Na-148* K-3.0* Cl-107 HCO3-33* AnGap-11 . Urinalysis: [**2105-3-3**] 02:54PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-4* PH-5.0 LEUK-NEG [**2105-3-3**] 02:54PM URINE RBC-[**12-3**]* WBC-[**6-23**]* BACTERIA-NONE YEAST-NONE EPI-0 TRANS EPI-0-2 [**2105-3-3**] 02:54PM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.029 Cardiac Enzymes: [**2105-3-3**] 02:25AM BLOOD CK(CPK)-239* CK-MB-6 cTropnT-0.04* proBNP-1376* [**2105-3-3**] 12:20PM BLOOD CK(CPK)-148 CK-MB-25* MB Indx-16.9* cTropnT-0.30* [**2105-3-4**] 12:13AM BLOOD CK(CPK)-104 CK-MB-13* MB Indx-12.5* cTropnT-0.19* . Admission EKG: Probable atrial flutter with rapid ventricular response. Left ventricular hypertrophy and intraventricular conduction delay. Compared to the previous tracing of [**2105-2-22**] ventricular response has increased. There is left axis deviation. No diagnostic interim change. Imaging: . [**3-3**] Echocardiogram: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly to moderately depressed (LVEF= 40 %) with inferior and inferolateral akinesis. [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 aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . [**3-3**] AP UPRIGHT CHEST: Tip of a right IJ central venous catheter terminates at the cavoatrial junction. The patient is status post median sternotomy and CABG. Mild cardiomegaly is stable. The aorta is unfolded. There is unchanged moderate pulmonary edema. New airspace abnormality within the right upper and right infrahilar regions is concerning for aspiration or evolving pneumonia. There are small bilateral effusions, right greater than left. Left basilar atelectasis with accompanying elevation of the hemidiaphragm is again seen. Visualized osseous structures are unremarkable. . [**3-4**] CXR IMPRESSION: Persistent pulmonary edema with no focal opacities to suggest pneumonia. . Microbiology: Blood Cultures [**2105-3-3**] x 2 - final no growth Urine Culture [**2105-3-3**] - final (yeast) Brief Hospital Course: A/P: Mr. [**Known lastname **] is a 76 year old male with a history of ALS, CAD s/p CABG, CHF (EF of 35 %) who initially presented from home with acute onset shortness of breath, epigastric pain and arm pain. Found to have had an NSTEMI with resultant pulonary edema. Initially admitted to [**Hospital 2571**] transferred to floor to focus on comfort care. . Acute on chronic systolic heart failure: Felt to be secondary to severe ischemic heart disease and exacerbated by his heart attack. Repeat echocardiogram on this admission revealed an EF of < than 40%, as well as 3+ mitral regurgitation. Given the MR, his EF is likely overestimated, and thus he was felt to have very poor forward flow. For his CHF, he was started on lasix 10 mg IV daily, then switched to 20mg po daily, which he tolerated well. Of note the patient has a reported allergy to lasix (hypotension and gout flares) but it was felt that the benefits of continued diuresis for his pulmonary status outweighed this risk. He was also started on lisinopril 10 mg daily for afterload reduction. finally, he was maintained on metoprolol for additional treatment of heart failure. On this regimen he had improvement in his cardiopulmonary status. Shortness of Breath: Dyspnea likely secondary to congestive heart failure exacerbation as above with component of cardiac ischemia. During this hospitalization goals of care were discussed extensively and the patient decided to focus on comfort measures including using morphine for his dyspnea and ativan for his anxiety. He was started on standing atrovent for bronchospasm in the setting of likely recurrent aspiration events and was started on standing lorazepam and PRN morphine for comfort and anxiety. His CHF was managed as above. NSTEMI: On presentation the patient complained of atypical chest pain which was thought to be his anginal equivalent. His troponins peaked at 0.3 with an elevated MB-index, consistent with a heart attack. The decision was made to continued to medically manage his cardiac disease with aspirin, plavix, metoprolol, and lisinopril. A statin was not felt to be of any benefit given his poor short term prognosis. His atrial fibrillation was aggressively rate controlled to reduce myocardial demand. He was continued on SL nitroglycerin and morphine PRN for chest pain. Atrial Fibrillation/Flutter: The patient appeared to have increased tachycardia with agitation and discomfort. It was felt that anxiety was contributing to his tachycardia. He was continued on digoxin and metoprolol for rate control. Given change in goals of care his coumadin was discontinued. We attempted to aggressively control exertional and adrenergic stimuli with bowel medications, mouth care and ativan for anxiety. Constipation: The patient was recently hospitalized for fecal impaction. He was continued on an aggressive bowel regimen which he often opted not to take. He should be encouraged to take his bowel medications to avoid severe constipation. Benign Prostatic Hypertropy: these medications were discontinued for comfort. He remains with a foley catheter in place. Gout: No active inpatient issues. Given goals fo care, allopurinol was discontinued. Should his gout recur this could be reinstituted. ALS: The patient's ALS has reached end stage. Per his primary neurologist Dr. [**Last Name (STitle) **] his prognosis is quite poor. During this admission he had a swallowing evaluation which demonstrated moderate to severe dysphagia. PEG tube placement was discussed with the patient who opted to continued PO intake despite aspiration risks. He was given hyoscyamine and ipratropium nebs for secretion management. He was given ativan tid for anxiety management, without which he would become agitated. Due to his chronically bedbound status, he was noted to have multiple sacral pressure ulcers which were cared for locally, and were stage 1 at discharge. FEN: He was placed on a pureed, thin liquid diet to minimize aspiration risk. Aspiration precautions were taken. Code status: DNR/DNI, clarified with pt and family. He would NOT want to be admitted to an ICU nor have a central line inserted again. Goals of care: Extensive discussions took place with the patient, his family and the medical staff. He would prefer to focus on comfort measures over life prolonging measures but would also prefer to maintain his currently level of care. His coumadin was discontinued. Labs were not checked regularly and only significant abnormalities were treated. He was started on PRN morphine and standing ativan for comfort. He will be transferred to rehab for further care. Contact: [**Name (NI) **] and sister [**Name (NI) **] [**Name (NI) **], HCP and primary caretaker ([**Telephone/Fax (1) 104913**]. Medications on Admission: colace [**Hospital1 **] Lactulose 30ML PO TID prn Lisinopril 10 mg qdaily Aspirin 325 mg po daily Allopurinol 100 mg [**Hospital1 **] Clopidogrel 75 mg PO DAILY Finasteride 5 mg PO DAILY Pantoprazole 40 mg qdaily Tamsulosin 0.4 mg qhs Warfarin 2 mg PO HS Hydrocortisone Acetate 1 % Ointment (hemorrhoids) Bisacodyl 10mg prn Atorvastatin 80 mg qdaily nasal spray Miralax [**Hospital1 **] Digoxin 125 mcg PO QOD. Senna 8.6 mg PO TID Hydrocortisone 2.5 % Cream [**Hospital1 **]: One (1) Appl Rectal [**Hospital1 **] (2 times a day). Metoprolol Tartrate 25 mg Tablet tid Hyoscyamine Sulfate 0.125 mg, Sublingual tid Isosorbide Mononitrate 30 mg qdaily SL NTG prn Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 2. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 3. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2 times a day). 4. Lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO TID (3 times a day). 5. Aspirin 325 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 7. Sodium Chloride 0.65 % Aerosol, Spray [**Hospital1 **]: [**1-14**] Sprays Nasal [**Hospital1 **] (2 times a day) as needed. 8. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet [**Hospital1 **]: One (1) Powder in Packet PO bid (). 9. Hydrocortisone 2.5 % Cream [**Hospital1 **]: One (1) Appl Rectal [**Hospital1 **] (2 times a day). 10. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual [**Hospital1 **]: One (1) Tablet, Sublingual Sublingual TID (3 times a day). 11. Lisinopril 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 12. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours). 13. Digoxin 125 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 14. Nitroglycerin 0.3 mg Tablet, Sublingual [**Hospital1 **]: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 15. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 16. Furosemide 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 17. Simethicone 80 mg Tablet, Chewable [**Hospital1 **]: [**1-14**] Tablet, Chewables PO QID (4 times a day) as needed. 18. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 19. Morphine Concentrate 20 mg/mL Solution [**Last Name (STitle) **]: 5-10 mg PO Q3H (every 3 hours) as needed for pain. 20. Guaifenesin 100 mg/5 mL Syrup [**Last Name (STitle) **]: 5-10 MLs PO Q6H (every 6 hours) as needed. 21. Lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO three times a day. Discharge Disposition: Extended Care Facility: [**Hospital3 2732**] & Retirement Home - [**Location (un) 55**] Discharge Diagnosis: Primary: ALS, end-stage . Secondary: Hypertension Acute on Chronic Systolic Heart Failure Atrial Fibrillation NSTEMI Coronary Artery Disease Hyperlipidemia Discharge Condition: Fair. Able to make sounds but having difficulty communicating. Incontinent. Requiring significant nursing care. Discharge Instructions: You were seen and evaluated for your epigastric pain and shortness of breath. Your symptoms were due to worsening of your heart failure as well as a heart attack. You were treated with diuretics and medications for your heart. A number of conversations took place between you and your familiy and the physicians here and it was decided that your medical care would focus on comfort measures. You will receive lasix and ativan to make sure that you remain comfortable in your rehba institution. . The following changes were made to your medication regimen: 1. Your coumadin was discontinued 2. Your Isosorbide Mononitrate was discontinued . Please take all medicines as prescribed. Please call your doctor if you are experiencing pain or any other symptoms which disturb you. Followup Instructions: Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2204**] if you have any concerns about your medical care. His office phone number is [**Telephone/Fax (1) 2205**]. . You have an appointment with your neurologist as below: Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 1038**], M.D. Phone:[**Telephone/Fax (1) 558**] Date/Time:[**2105-3-19**] 12:00

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icd9cm

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icd9pcs

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Discharge summary

report

Admission Date: [**2178-12-14**] Discharge Date: [**2178-12-19**] Service: CARDIOTHORACIC Allergies: Latex / Codeine / Oxycodone / Percocet / Sulfa (Sulfonamide Antibiotics) / Vicodin Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2178-12-14**] Aortic Valve Replacement (21mm St. [**Male First Name (un) 923**] tissue) History of Present Illness: 85 year old female with known aortic stenosis complaining of progressively woserning dyspnea on exertion. Echocardiograms have also shown worsening aortic valve area. Most recent 0.5cm2. Referred for aortic valve surgery. Past Medical History: Aortic Stenosis, Hypertension, Hypothyroidism, s/p Left knee meniscus repair, s/p bilateral eyelid surgery Social History: Lives with husband and son Quit smoking 30 years ago. Admits to glass of wine with dinner 2x/wk. Family History: Mother with myocardial infarction. Sister with coronary artery disease and valve surgery. Father with heart disease. Physical Exam: Admission VS: HR 85 RR 16 BP 145/80 HT 5'1" Wt 125# Skin: Unremarkable HEENT: Unremarkable Neck: Supple, Full range of motion Chest: Clear to auscultation bilaterally Heart: Regular rate and rhythm with 3/6 systolic ejection murmur radiation to neck Abd: Soft, non-tender, non-distended, +bowel sounds Ext: Warm, well-perfused, -edema Neuro: Grossly intact Discharge VS: HR 58 BP 123/77 RR 20 O2sat 96 RA WT 61 kgs Skin:MSI incision C/D/I, sternum stable Chest: Clear to auscultation bilaterally Heart: RRR Abd:soft, non-tender, non-distended, +bowel sounds Ext: warm, well-perfused, +1 edema lower extremity Neuro: grossly intact Pertinent Results: [**2178-12-14**] 12:26PM GLUCOSE-138* NA+-133* K+-4.3 [**2178-12-14**] 12:18PM UREA N-9 CREAT-0.7 CHLORIDE-111* TOTAL CO2-22 [**2178-12-14**] 12:18PM WBC-9.1 RBC-3.51*# HGB-10.8*# HCT-30.4*# MCV-87 MCH-30.7 MCHC-35.5* RDW-12.8 [**2178-12-14**] 12:18PM PLT COUNT-193 [**2178-12-14**] 12:18PM PT-14.8* PTT-62.9* INR(PT)-1.3* ECG Study Date of [**2178-12-14**] 12:43:20 PM Normal sinus rhythm. Possible anteroseptal myocardial infarction of unknown age but with ST segment elevation in leads V1-V3. Non-specific ST segment depression in leads II, III, aVF and V5-V6. Compared to the previous tracing of [**2178-12-8**] the changes are similar. Clinical correlation is suggested. Read by: [**Last Name (LF) **],[**First Name3 (LF) 125**] M. Intervals Axes Rate PR QRS QT/QTc P QRS T 72 150 92 404/425 78 -20 85 [**2178-12-19**] 07:00AM BLOOD WBC-8.4 RBC-3.29* Hgb-10.0* Hct-29.0* MCV-88 MCH-30.4 MCHC-34.5 RDW-14.1 Plt Ct-290# [**2178-12-19**] 07:00AM BLOOD Plt Ct-290# [**2178-12-19**] 07:00AM BLOOD Glucose-95 UreaN-15 Creat-1.0 Na-138 K-5.0 Cl-105 HCO3-27 AnGap-11 Brief Hospital Course: Mrs. [**Known lastname 6955**] was a same day admit, and on [**12-14**] she was brought to the operating room where he underwent an aortic valve replacement. Please see operative note for surgical details. In summary she had an Aortic valve replacement with a 21mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] tissue valve. Her bypass time was 72 minutes with a crossclamp time of 50 minutes. She tolerated the surgery well and following surgery he was transferred to the CVICU for invasive monitoring in stable condition. She remained hemodynamically stable in the immedicate post-op period and was extubated on the day of surgery. On post-op day one she was started on beta blockers and diuretics and gently diuresed towards her pre-op weight. Later on this day she was transferred to the telemetry floor for further care. Chest tubes and epicardial pacing wires were removed per protocol. In the evening of post-op day 2 she went into rapid atrial fibrillation. She was given an Amiodarone bolus, IV Lopressor and started on PO Amiodarone. She remained in atrial fibrillation requiring increasing doses of Metoprolol to control her rate. She was started on Coumadin on POD 3 for more than 24 hours of continuous atrial fibrillation. She gradually improved while working with physical therapy for strength and mobility. On post-op day five she was discharged to home with the appropriate follow-up appointments. Medications on Admission: Synthroid, Morvasc, Aspirin, Alprazolam, Estradiol/Progeterone Discharge Medications: 1. 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* 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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for chest pain. Disp:*30 Tablet(s)* Refills:*0* 5. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): take 400 mg (2 tablets) for 7 days, then taper down to 200 mg (1 tablet) daily. Disp:*60 Tablet(s)* Refills:*0* 7. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0* 8. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day: take 40 mg (2 tablets) for 5 days and then taper down to 20 mg (1 tablet) for 5 days. Disp:*30 Tablet(s)* Refills:*0* 9. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: do not take any coumadin [**12-19**] and then resume on [**12-20**] with 1 mg (1 tablet). Adjust further doses per the office of Dr. [**Last Name (STitle) 8051**]. Disp:*50 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital **] Hospice and VNA Discharge Diagnosis: Aortic Stenosis s/p Aortic Valve Replacement PMH: Hypertension, Hypothyroidism, s/p Left knee meniscus repair, s/p bilateral eyelid surgery Discharge Condition: Good Discharge Instructions: no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks shower daily, no baths or swimming no lotions, creams or powders to incisions report any drainage from, or redness of incisions report any fever greater than 100.5 report any weight gain greater than 2 pounds a day or 5 pounds a week take all medications as directed Followup Instructions: Wound check and post-op visit with: Dr. [**Last Name (STitle) **] at [**Hospital3 1280**] in [**2-22**] weeks. Call ([**Telephone/Fax (1) 26917**] for appt Dr. [**Last Name (STitle) 8051**] in [**2-22**] weeks. Please call to schedule appt. INR checked on [**12-21**] with results sent to the office of Dr. [**Last Name (STitle) 8051**] ([**Telephone/Fax (1) 80078**]. Completed by:[**2178-12-19**]

[ "E878.1", "715.90", "244.9", "997.1", "401.9", "733.00", "424.1", "427.31" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.21" ]

icd9pcs

[ [ [] ] ]

5836, 5898

2829, 4268

318, 410

6081, 6087

1720, 2806

6491, 6892

921, 1039

4381, 5813

5919, 6060

4294, 4358

6111, 6468

1054, 1701

259, 280

438, 661

683, 791

807, 905

281

111,199

2177

Discharge summary

report

Admission Date: [**2101-10-18**] Discharge Date: [**2101-10-25**] Date of Birth: [**2041-10-12**] Sex: F Service: MED Allergies: Penicillins Attending:[**First Name3 (LF) 1850**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 60 yo F with RA (only on plaquenil), HTN, pulm fibrosis, PVD, OA, tobacco use presents to ED with 2-3 wk h/o malaise, dry cough, and progressive SOB. Denies any F/C/NS. Nearly intubated in the ED for hypoxic respiratory failure (O2 sats 80s, RR 40s), with significant wheeze. However, with IV steroids and continuous albuterol nebs, improved and stablilized, though still tachypnic with wheeze. CTA demonstrated no PE, though large mass (taking up much of RUL, some of RML that compresses the RUL and RML bronchi, with ?extension into the pretrachial/subcarinial space vs associated lymphadenopathy, innumerable bilateral nodules and thick interstitial markings. In addition, hypodensities were visualized in the liver. Started on empiric levo/azithro in the ED. ED course also notable for MAT as high as 170 bpm, in part exacerbated by albuterol, with rate-related lateral ischemic changes (st dep V3-V6, lateral TWI). ruling out for MI with serial neg cardiac enzymes. Past Medical History: RA pulmonary fibrosis PVD tobacco use (>20 years) OA HTN prior Cardiomyopathy, with EF now 55% (was 30-40% [**2095**], etiology unknown) Recent p-mibi, with no perfusion defects, no [**Last Name (LF) **], [**First Name3 (LF) **] 58% s/p appy s/p cervical fusion [**2095**] s/p lumbar fusion OA Social History: Very relgious, former heavy smoker. Family History: N.C. Physical Exam: T 97.9 HR 127 BP 138/63 RR 25 98% NRB Gen: Female, sitting up, tachypnic, w/ acc muscle use HEENT/Neck: +JVD, +cervical LAD, EOMI, MM dry, CV: irregular, tachy, no m/r/g Pul: diffuse wheezes, poor a/m b/l abd: soft, nt, nd. Ext: no edema, from Pertinent Results: [**2101-10-18**] 02:22PM TYPE-ART TEMP-37.0 RATES-/30 O2-60 PO2-118* PCO2-40 PH-7.36 TOTAL CO2-24 BASE XS--2 INTUBATED-NOT INTUBA [**2101-10-25**] 03:02AM BLOOD WBC-17.2* RBC-3.61* Hgb-9.9* Hct-31.9* MCV-88 MCH-27.5 MCHC-31.1 RDW-15.0 Plt Ct-95* [**2101-10-25**] 03:02AM BLOOD Glucose-150* UreaN-56* Creat-1.2* Na-145 K-4.5 Cl-111* HCO3-25 AnGap-14 [**2101-10-25**] 09:40AM BLOOD Type-ART Temp-36.4 O2 Flow-4 pO2-70* pCO2-51* pH-7.26* calHCO3-24 Base XS--4 Intubat-NOT INTUBA Brief Hospital Course: Pt was admitted to the [**Hospital Unit Name 153**] in respiratory distress. CT/angiogram results showed a large right lung mass, likely to be lung cancer, with metastasis to the left lung and liver. The prognosis of this cancer was discussed with the patient and her sister, [**Name (NI) **], her healthcare proxy. [**Name (NI) **] the patient's respiratory distress seemed to improve, her blood gases demonstrated that she was tiring out. On [**10-24**] and [**10-25**] family meetings were held to discuss the patient's progress and dismal prognosis. At this time the patient was made DNR/DNI but treatment was continued. Later on in the night, the patient became hypotensive and increasingly short of breath. After speaking with [**Doctor Last Name **], her healthcare proxy, comfort measures were started with morphine. Shortly thereafter, she became more hypoxic and bradycardic. The patient had no corneal reflexes, and had no heart sounds or breath sounds for one minute. Time of death was 7:10pm. The family was present. Autopsy consent was granted. Medications on Admission: lopressor oxycontin vioxx plaquenil fosamax mvi Discharge Medications: expired Discharge Disposition: Home Facility: expired Discharge Diagnosis: pneumonia metastatic lung cancer Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased [**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**] MD [**MD Number(2) 1851**]

[ "235.6", "425.4", "162.8", "428.0", "401.9", "515", "197.0", "443.9", "518.81", "714.0", "584.9", "485", "197.7" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

3682, 3707

2481, 3552

290, 296

3783, 3793

1979, 2458

3850, 3977

1691, 1697

3650, 3659

3728, 3762

3578, 3627

3817, 3827

1712, 1960

231, 252

324, 1305

1327, 1622

1638, 1675

4,979

114,218

5103

Discharge summary

report

Admission Date: [**2109-7-7**] Discharge Date: [**2109-7-24**] Date of Birth: [**2037-10-9**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Hypotension, Encephalopathy Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: 71 male with EtOH cirrhosis brought to the ED by his wife for 1 week of increased abdominal girth, LE edema, confusion. Prior to this, the pt had good functional status, working up until last week at which time, the pt started to c/o "dizziness." At PCPs office, BP was 90s/60s, so his nadolol was D/Cd. Pt also noted increased weight. Otherwise, the pt denies melena, BRBPR, fevers/chills. Because of continued weight gain along with confusion, he was brought in to the ER. . In the ER, labs showed Cr 1.3. BP 82/68, HR 125, T 94.6, 96% RA, BP increased to 100s/60s with 500ml NS. Pt received kayexalate for K of 6. RUQ U/S showed no pocket to perform paracentesis so empiric CTX was given for presumed SBP. Lactulose was also given for encephalopathy. Lopressor 5mg IV was given for ? atrial flutter, new-onset. He was then admitted to the MICU for tachycardia Past Medical History: 1. Alcoholic cirrhosis complicated by portal hypertension, nonocculsive portal vein clot, grade II esophageal varices 2. Splenomegaly 3. Diabetes mellitus 4. Anemia status post EGD in [**4-16**] showing ulcers (H pylori +) and varices and colonoscopy showing internal hemorrhoids and diverticula 5. Thalassemia minor, no history of transfusions 6. H. pylori positive status post treatment 7. Pancytopenia, status post bone marrow biopsy showing MDS versus sideroblastic anemia 8. Cataracts 9. Status post hernia repair 10. Status post appendectomy Social History: The patient has a 50+ pack per year smoking history, quit four years ago. Past heavy alcohol use, now none. Patient is married. Family History: Italian descent - mom died of appendicitis when he was young - father had atherosclerosis, but the patient does not know if he had an MI (myocardial infarction) or stroke - brother did die of an MI (myocardial infarction) at age sixty - denies any colon cancer or liver disease in his family. Physical Exam: VS: Tc 96.1 BP 98/60 P 71 RR 20 99% 3L NC, FS 180, 197; wt 217.9# (baseline wt 81kg or 178# per report) Gen: elderly bronzed man lying flat in bed, appearing comfortable, answering questions appropriately, with wife at bedside [**Name (NI) 4459**]: [**Name (NI) 3899**], mild icteris, no nystagmus, MM moist Neck: supple, JVD to mandible Lungs: crackles halfway up on the right from ant exam, no wheeze CV: distant heart sounds, irregularly irregular, [**3-19**] holosyst murmur at LLSB with rad to axilla Abd: distended, nontender, not tense, hyperactive bs, no palpable liver or spleen Groin: R cath site with dressing c/d/i, minimal dried blood, no fluid collection or ecchymosis Ext: 3+ bilateral LE edema to groin; +palmar erythema; unable to palpate DP or PT pulses Neuro/Psych: approp affect, no evid of encephalopathy; no asterixis Pertinent Results: [**2109-7-7**] 10:21AM AMMONIA-125* [**2109-7-7**] 10:26AM PT-16.2* PTT-33.3 INR(PT)-1.5* [**2109-7-7**] 10:26AM PLT COUNT-160 [**2109-7-7**] 10:26AM HYPOCHROM-2+ ANISOCYT-3+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-2+ POLYCHROM-1+ TARGET-2+ SCHISTOCY-1+ STIPPLED-1+ TEARDROP-2+ ELLIPTOCY-1+ [**2109-7-7**] 10:26AM NEUTS-54.6 BANDS-0 LYMPHS-34.8 MONOS-6.6 EOS-3.2 BASOS-0.8 [**2109-7-7**] 10:26AM WBC-6.3 RBC-4.51* HGB-11.4* HCT-35.7* MCV-79* MCH-25.3* MCHC-32.0 RDW-23.7* [**2109-7-7**] 10:26AM CALCIUM-9.5 PHOSPHATE-5.0* MAGNESIUM-2.1 [**2109-7-7**] 10:26AM CK-MB-NotDone cTropnT-0.09* [**2109-7-7**] 10:26AM LIPASE-21 [**2109-7-7**] 10:26AM ALT(SGPT)-23 AST(SGOT)-43* LD(LDH)-233 CK(CPK)-24* ALK PHOS-78 AMYLASE-31 TOT BILI-2.5* [**2109-7-7**] 10:26AM GLUCOSE-175* UREA N-43* CREAT-1.3* SODIUM-131* POTASSIUM-6.0* CHLORIDE-93* TOTAL CO2-32 ANION GAP-12 [**2109-7-7**] 11:58AM LACTATE-1.7 [**2109-7-7**] 12:32PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2109-7-7**] 12:32PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017 [**2109-7-7**] 03:04PM HGB-12.0* calcHCT-36 [**2109-7-7**] 03:04PM K+-5.0 [**2109-7-7**] 03:04PM COMMENTS-GREEN [**2109-7-7**] 06:49PM URINE OSMOLAL-465 [**2109-7-7**] 06:49PM URINE HOURS-RANDOM CREAT-132 SODIUM-11 [**2109-7-7**] 08:27PM ALBUMIN-3.8 CALCIUM-8.8 PHOSPHATE-5.4* MAGNESIUM-2.1 [**2109-7-7**] 08:27PM GLUCOSE-188* UREA N-40* CREAT-1.2 SODIUM-130* POTASSIUM-4.9 CHLORIDE-94* TOTAL CO2-26 ANION GAP-15 . RUQ US ([**7-7**]): LIMITED ULTRASOUND OF THE ABDOMEN: Comparison is made to the prior ultrasound dated [**2109-2-7**]. There is moderate amount of ascites surrounding the liver in the upper abdomen, slightly increased since prior study. Small amount of free fluid is seen in the lower abdomen; however, there is no fluid pocket sufficient for marking. Again note is made of cirrhotic liver. IMPRESSION: Moderate amount of ascites surrounding the liver and small amount of ascites in the lower abdomen. No spot is marked. . CXR ([**7-7**]): FINDINGS: There is a new left IJ central catheter with tip in the left brachiocephalic vein. The right pleural effusion has increased in size, now moderate-to-large. Persistent shift of the heart to the right indicates partial collapse of the right lower and possibly middle lobes. There is a small left pleural effusion. Diffuse opacity of the abdomen suggests ascites. IMPRESSION: 1. Worsening right pleural effusion and associated collapse of the right lower and probably right middle lobes. 2. Ascites. . RUQ US w/ Doppler ([**7-8**]): LIMITED ABDOMINAL ULTRASOUND: The liver is diffusely hyperechoic and has a nodular contour, compatible with cirrhosis. The main, left, anterior right portal veins are patent. Since the prior study, the posterior right portal venous flow has diminished noticeably, and it is difficult to get flows within this structure. The splenic, SMV are patent as is the IVC. There is marked splenomegaly. Additionally, ultrasound in the four quadrants of the abdomen was performed, and a spot was marked in the right lower quadrant. IMPRESSION: 1. Diminished flow in the posterior right portal vein since the prior study of [**Month (only) 1096**]. The main, left, and anterior right portal veins have similar flows to the prior study. 2. Cirrhosis. Splenomegaly. 3. Moderate ascites. A position for paracentesis was marked in the right lower quadrant. . Echo ([**7-9**]): Conclusions: The left atrium is mildly dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The right atrium is moderately dilated. The estimated right atrial pressure is 16-20 mmHg. Left ventricular wall thicknesses and cavity size are normal. There is moderate global hypokinesis without regionality. The right ventricle is mildly dilated with moderate global free wall hypokinesis. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened. No aortic stenosis is seen. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a very small, primarily anterior pericardial effusion withtout echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2109-2-7**], there has been a decline in left and right ventricular systolic function. The severity of tricuspid regurgitation has increased, the effusion is more prominent (but remains very small) and atrial fibrillation is now present. Ascites was also present on the prior study. An atrial septal defect is not seen on the current study (may be related to technical differences). . CXR ([**7-10**]): There is stable cardiomegaly. The aorta is calcified and tortuous. Pulmonary vasculature is unremarkable. The moderate-sized right pleural effusion has slightly decreased in size. There continues to be associated compressive atelectasis. A small left pleural effusion is also noted. Osseous and soft tissue structures are stable. IMPRESSION: No radiographic evidence of pneumonia or CHF. Slight decrease in size of moderate right pleural effusion. Small left pleural effusion. . CXR ([**7-12**]): The cardiomegaly is moderate and stable. The tortuous aorta is unchanged. Pulmonary vasculature is unremarkable. Bilateral pleural effusions are demonstrated, right more than left, grossly unchanged. The bibasal atelectasis is unchanged as well. There is new linear opacity in the left lower lobe representing additional plate-like atelectasis. Brief Hospital Course: 71 yo M with alcoholic cirrhosis, grade II varices, non-occlusive portal vein thrombosis with recannulization admitted to the MICU with hypotension and atrial flutter/fibrillation with resolution s/p fluids and rate control subsequently called out to the floor for continued management. The following issues were investigated during this hospitalization: . # Hypotension: Etiology thought to be secondary to cirrhosis vs Afib/flutter with RVR, resolved with IVF and HR control. Sepsis was considered initially, but seemed unlikely. While on the general medicine floor, the patient was continued on Ceftriaxone and Azithromycin for possible PNA and or presumed SBP. Additionally, he was aggressively diuresed for new CHF. In the setting of diuresis, the patient at one point became hypotensive to 80/50. At this time he received a small bolus with good effect. Diuresis thereafter for obvious fluid overload was difficult given the tenuous blood pressure. While the etiology of the tenuous blood pressure was felt to be from 3rd spacing while being intravascularly depleted it was also thought that the patient might be becoming symptomatic in his continued atrial fibrillation/atrial flutter. For this reason, the electrophysiology cardiology team was consulted and Digoxin was loaded for rhythm control. The patient's blood pressure remained low, but stable for the remainder of his hospitalization. . # Arrhythmia: New-onset Afib/Aflutter on presentation was thought to be related to discontinuation of Nadolol as an outpatient. He was loaded with Digoxin in the MICU, which was not continued on the floor because of rate control with Nadolol (for varices). However, because of hypotension as detailed above, additional rate control agents could not be added and yet the patient was intermittently tachycardic to the 140s. He was not symptomatic, but continued management, mainly of his heart failure became complicated. For this reason, additional mechanisms for control of the arrythmia were considered, to include cardioversion and anti-arrhythmics. Cardioversion was not an option given the patient's relative contraindication to anticoagulation given known grade 2 esophageal varices. For this reason, the patient was loaded with Digoxin again and continued on Nadolol for both rhythm and rate control. . # Heart Failure: Patient's echo on [**7-9**] showed biventricular heart failure, changed from prior imaging, with no evidence of infarct on EKG. Most likely etiology was overall fluid overload from decompensated cirrhosis, worsened by atrial fibrillation/flutter. The CHF service was consulted in house and recommended diuresis with Lasix and Aldactone. This was initiated reaching a maximum of Aldactone 50 mg and Lasix 40 mg IV BID, before the patient's blood pressure proved to be problem[**Name (NI) 115**]. With this diuresis, the patient's creatinine bumped predictably and he had a contraction alkalosis on daily labs. Additionally, his O2 requirement decreased from 3 liters to 1 liter. However, he continued to have 3+ pitting edema beyond his knees in both LEs with a normal albumin. For this reason, the CHF service was reconsulted and the patient was taken for a right and left heart cardiac catheterization, after which he was transferred to the acute cardiac floor for continuous diuresis with a Lasix drip. Unfortunatelty due to hypotension he was unable to be furtehr diuresed and the gtt discontinued. # Decompensated cirrhosis: RUQ U/S revealed diminished flow in the posterior right portal vein since the prior study of [**Month (only) 1096**]. AFP was normal. Tbili was elevated, but stable. The patient's encephalopathy resolved with Lactulose, which was continued PRN for a goal of [**4-14**] BMs/day. Given documented esophageal varices in house, the patient was continued on Nadolol. Prophylactic treatment of presumed SBP was continued with Ceftriaxone and he was maintained on a PPI. Patient was diuresed as tolerated with Lasix and Aldactone as detailed above until complicated by hypotension. . # ARF: Creatinine was elevated initially to 1.3, which was likely in the setting of poor forward flow from cirrhosis. This resolved with diuresis but then in the setting of further diuresis, hypotension and worsening decompensated liver failure complicated by CHF his Cr started to rise most likely mised ATN amd pre-renal azotemia. . # Thrombocytopenia: Patient's platelet count continued to drop from admission reaching 70,000. While this was thought to be most likely from his liver disease, his prophylactic, subcutaneous Heparin was discontinued and HIT antibodies were sent off. He was given TEDS instead for DVT prophylaxis as well as for LE edema. He never had any obvious bleeding or signs of bleeding. . # Goals of Care: Due to worsening decompensated liver failure and CHF discussion as to goals of care were had between patient, wife and primary team. Decision made to concentrate on comfort and means to get patient home with family. He was discharged to home with hospice on [**2109-7-24**]. Medications on Admission: Neurontin 300 daily Omeprazole 20 daily Aldactone 50mg [**Hospital1 **] Lasix 60 AM, 40 PM Humalog sliding scale Discharge Medications: 1. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. Disp:*1 tube* Refills:*0* 2. Cortisone 1 % Cream Sig: One (1) Appl Topical TID (3 times a day) as needed. Disp:*1 tube* Refills:*0* 3. morphine Sig: 5-10 mg Sublingual every four (4) hours as needed for pain. Disp:*1 bottle* Refills:*0* 4. ativan Sig: One (1) mg Sublingual every 4-6 hours. Disp:*60 tabs* Refills:*2* 5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q4H (every 4 hours) as needed. 6. Nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Hospice Care Discharge Diagnosis: cirrhosis chf AFIB hyponatremia Discharge Condition: poor Discharge Instructions: please take medications as prescribed call your pcp if you have any discomfort or other concerns Followup Instructions: please call your PCP and update him on your clinical status

[ "425.5", "401.9", "584.5", "427.31", "789.5", "284.8", "456.21", "572.2", "570", "428.41", "572.3", "452", "486", "535.50", "282.49", "572.4", "303.00", "571.2", "250.00", "276.1" ]

icd9cm

[ [ [] ] ]

[ "88.56", "99.04", "45.16", "34.91", "37.23", "54.91" ]

icd9pcs

[ [ [] ] ]

15057, 15100

9021, 14067

350, 375

15176, 15183

3174, 8998

15329, 15392

2002, 2297

14231, 15034

15121, 15155

14093, 14208

15207, 15306

2312, 3155

283, 312

403, 1268

1290, 1839

1855, 1986

15,046

168,616

50748

Discharge summary

report

Admission Date: [**2191-1-28**] Discharge Date: [**2191-2-13**] Date of Birth: [**2124-2-1**] Sex: F Service: MEDICINE Allergies: Tetracyclines / Zinc Attending:[**First Name3 (LF) 2160**] Chief Complaint: SOB Major Surgical or Invasive Procedure: GJ tube placement by interventional [**First Name3 (LF) **] PICC line placement History of Present Illness: The pt is a 66F w/ multiple medical problems including chronic respiratory disease, multiple admissions for aspiration pneumonia, brought in by EMS after her home health aide said she "can't watch her like this". She has a PEG tube for feeding and had been NPO for her chronic aspiration, but per her home health aide her PCP has allowed her to try pudding by mouth which she has been doing for about a month. Her aide thinks she may have aspirated on Wednesday, as afterwards she started have some shortness of breath and fever and has not been able to cough up secretions. The patient initially refused to go the hospital but her aide finally called EMS this am to bring her to the ED. Per ED staff, she had decreased mental status and was unable to provide any history. She was febrile to ~103 and had stable SBPs in the 100s. She was covered with Vanc/Ceftaz/Clinda in the ED. She appeared to be in respiratory distress, but the decision was made not to intubate her in the ED due to medical futility. The ED staff was only able to reach a sister in [**Name (NI) 19061**] who states she was not her HCP and provided little other information. She was transferred to the [**Hospital Unit Name 153**] on humidified facemask with O2 sats in the low 90s. Past Medical History: 1. Castleman's disease: unicentric. Found incidentally on splenectomy done for "splenic pain" around [**2176**]. Has had lymph nodes sampled in past to r/o lymphoma but all have shown reactive lymph tissue only. Followed here in Heme/Onc by Dr. [**Last Name (STitle) 410**]. Last saw him [**3-7**] at which time they were thinking about pursuing bronchoscopy. 2. Hx anaplastic thyroid cancer s/p radical neck dissection, at age 15 3. Esophageal webs and esophageal dysmotility. Has had numerous esophageal dilatations. 4. Recurrent aspiration pneumonias: has been admitted for this approximately 10 times over the past year. Is now strictly NPO and s/p PEG placement. Last admission for aspiration PNA with sputum Cx growing Pseudomonas, MRSA 5. Chronic pulmonary disease: Abnormal repeat chest CTs in past: Is followed in pulmonary clinic for numerous abnl findings: has centrilobular nodular opacities with mild GGO as well as bronchiectasis. Restrictive physiology on PFTs. At time of her last visit to Pulmonary Clinic, there were ongoing discussions re: bronchoscopy to figure out her pulmonary process. Also has one sputum cx positive for [**Month/Year (2) **]. 6. MRSA osteomyelitis of olecranan s/p multiple debridements 7. Hx Bipolar d/o 8. GERD 9. Osteoporosis: has broken both hips, left in [**11-7**], right with failed ORIF and redo at [**Hospital1 2025**] 10. Hx zoster 11. Hx depression, chronic pain 12. HTN Social History: Pt is retired social worker, most recently employed at [**Name (NI) 86**] VA 10 yrs ago. When working, reported no known occupational exposures that may have contributed to chronic pulmonary disease. Pt has lived in [**Location 86**] her entire life, has never been married, and has no children. She currently lives at home w/ a 24 hr health aide. Pt has reportedly refused further placement in the past. Habits: Denied smoking, alcohol, recreational and IV drug use. Some previous smoking history, but details unclear. Family History: Family History: 1. Father: HTN, DM, depression, died MI, age 59. 2. Mother: HTN, hypercholesterolemia, died MI, age 82. 3. Sister: HTN [**Name (NI) **] additional extended family history of heart disease, cancer, diabetes, alcoholism, or mental illness/depression of which pt was aware. No family history of respiratory dx, including CF. Physical Exam: VS: 96.5, 77, 122/67, 24, 100% on 35% facemask Gen: drowsy but arousable, frail, cachectic woman in NAD HEENT: PERRL, EOMI, MM dry Neck: supple, large right-sided scar tissue (thyroidectomy), no JVD Lungs: diffuse rhonchi and crackles throughout, worse at bases CV: RRR, nl S1S2, II/VI HSM Abdomen: hypoactive BS, soft, non-distended, mild diffuse TTP, G-tube site mildly erythematous with small amount of oozing. Ext: WWP, no c/c/e Neuro: AAOx3, CN II-XII intact, increased tone Pertinent Results: CT ABDOMEN: There continued to be extensive nodular and tree-in-[**Male First Name (un) 239**] opacities in the right middle and lower lobes. Dependent atelectasis and mild bronchiectasis are noted at the right base. Overall, the appearance is improved compared to the prior chest CT. [**Male First Name (un) **] low attenuation focus in liver is stable. Small stones are noted in the gallbladder. The common bile duct remains prominent, but stable. Again noted is an atrophic pancreas with a somewhat prominent pancreatic duct. Patient is status post splenectomy. The gastrojejunostomy tube appears in good position. No associated fluid collections are identified. The bowel loops are unremarkable. Small nonobstructing stone is noted in the left kidney. The kidneys are otherwise unremarkable. The adrenal glands are within normal limits. There is no free air or free fluid. No mesenteric or retroperitoneal lymphadenopathy is identified. CT PELVIS: The bladder, sigmoid colon, and rectum are unremarkable. There is no free fluid and no pelvic or inguinal lymphadenopathy. Vascular calcifications are identified. [**Male First Name (un) **] WINDOWS: There are no suspicious lytic or sclerotic osseous lesions. Left hip prosthesis, lumbar dextroscoliosis and degenerative changes, and deformed right femur are stable. IMPRESSION: 1. Well-positioned gastrojejunostomy tube without evidence of abscess or free air. 2. Right middle and lower lobe tree-in-[**Male First Name (un) 239**] and nodular opacities consistent with bronchiolitis. Overall, the appearance is improved compared to [**2191-1-28**]. Likely due to chronic aspiration or remote infection. 3. Cholelithiasis and stable prominence of the common duct. 4. Nonobstructing left ureteral calculus. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 5004**] THAM DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**] Approved: TUE [**2191-2-8**] 9:49 PM [**Numeric Identifier **] REPOSITION GASTRIC TUBE INTO DUODENUM [**2191-2-7**] 10:24 AM Reason: Please place GJ tube. Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 67 year old woman with hiatal hernia, recurrent aspiration, has G tube. Would like GJ tube. Pt NPO since ~ 8 a.m. REASON FOR THIS EXAMINATION: Please place GJ tube. INDICATION: 67-year-old female with hiatal hernia and recurrent aspiration with G-tube. Please place GJ tube. RADIOLOGISTS: Dr. [**Last Name (STitle) 18936**] and Dr. [**First Name (STitle) 3175**] performed the procedure. Dr. [**First Name (STitle) 3175**], the attending radiologist, was present and supervising. PROCEDURE AND FINDINGS: The risks and benefits were explained to the patient and written informed consent was obtained. The patient's abdomen was prepped and draped in sterile fashion. Lidocaine jelly and 10 cc of 1% lidocaine were applied at the PEG site. Under fluoroscopic guidance, approximately 5 cc of Optiray contrast were injected into the G-tube with free spill of contrast into the stomach. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**] wire was then advanced under fluoroscopic guidance into the stomach. The existing PEG tube was removed and an MP catheter was advanced into the stomach. The MP catheter and [**Last Name (un) 7648**] wire were used to navigate into the duodenal loop and beyond the ligament of Treitz. An 18 French peel-away sheath was placed over the [**Last Name (un) 7648**] wire into the stomach. An 18 French MIC feeding jejunostomy tube was then placed over the wire and the peel- away sheath removed. Under fluoroscopic guidance, this was advanced into the jejunum. Contrast was instilled into the feeding tube under fluoroscopic guidance with free spill of contrast into the proximal jejunum, beyond the ligament of Treitz, The 20cc gastric retention balloon was then inflated with 15 cc of normal saline. The patient tolerated the procedure well and there were no immediate complications. IMPRESSION: Successful placement of 18 French gastrojejunostomy feeding tube. The tube is now ready for use. CHEST, AP UPRIGHT [**2191-2-8**]: Comparison to [**2191-2-3**]. There is volume loss in soft tissue in the right supraclavicular area, making the right apex appear relatively lucent, as before. This appearance is related to prior neck dissection. The cardiac and mediastinal contours are unchanged. A PICC line terminates in the superior vena cava, in an unchanged position. Bibasilar opacities have almost fully resolved. IMPRESSION: Resolution of bibasilar opacities with only minimal residua. CT Chest ([**1-28**]): 1. Widespread tree-in-[**Male First Name (un) 239**] appearance suggesting active infectious process such as bronchiolitis. 2. Persistent right lower lobe consolidation with some worsening representing most likely a combination of atelectasis and aspiration. 3. Persistent but stable mediastinal lymphadenopathy. 4. Nine-mm incompletely characterized hypodensity in the right lobe of the liver, most likely a simple cyst. 5. Unchanged pancreatic ductal dilatation. 6. The patient is after splenectomy. 7. The patient is after insertion of percutaneous gastrostomy. . CXR ([**1-28**]): 1. Increasing bibasilar atelectasis. 2. Prominent air filled esophagus consistent with patient's known esophageal dysmotility. [**2191-2-13**] 06:17AM BLOOD WBC-10.8 RBC-3.53* Hgb-11.4* Hct-33.5* MCV-95 MCH-32.3* MCHC-34.0 RDW-15.9* Plt Ct-567* [**2191-2-12**] 05:08AM BLOOD WBC-10.4 RBC-3.46* Hgb-11.1* Hct-33.2* MCV-96 MCH-32.0 MCHC-33.3 RDW-16.2* Plt Ct-547* [**2191-2-9**] 05:31AM BLOOD WBC-14.6* RBC-3.62* Hgb-11.5* Hct-34.6* MCV-96 MCH-31.7 MCHC-33.1 RDW-15.7* Plt Ct-542* [**2191-2-8**] 07:30AM BLOOD WBC-11.7* RBC-3.85* Hgb-12.4 Hct-36.0 MCV-94 MCH-32.1* MCHC-34.3 RDW-15.6* Plt Ct-526* [**2191-2-6**] 11:48AM BLOOD WBC-10.6 RBC-3.78* Hgb-12.1 Hct-35.1* MCV-93 MCH-32.0 MCHC-34.5 RDW-15.1 Plt Ct-502* [**2191-2-3**] 09:00AM BLOOD WBC-13.8* RBC-3.90* Hgb-12.3 Hct-36.1 MCV-93 MCH-31.7 MCHC-34.2 RDW-14.9 Plt Ct-433 [**2191-2-2**] 07:00AM BLOOD WBC-15.1* RBC-4.15* Hgb-13.1 Hct-38.5 MCV-93 MCH-31.5 MCHC-34.0 RDW-14.8 Plt Ct-466* [**2191-1-31**] 09:00AM BLOOD WBC-14.9* RBC-3.85* Hgb-12.0 Hct-35.8* MCV-93 MCH-31.1 MCHC-33.4 RDW-14.5 Plt Ct-447* [**2191-1-28**] 03:00AM BLOOD WBC-18.6*# RBC-4.03* Hgb-13.0 Hct-38.8 MCV-97 MCH-32.4* MCHC-33.5 RDW-14.8 Plt Ct-379 [**2191-2-4**] 11:42AM BLOOD PT-13.3* PTT-33.9 INR(PT)-1.2* [**2191-2-13**] 06:17AM BLOOD UreaN-22* Creat-0.7 Na-138 K-4.6 Cl-103 HCO3-30 AnGap-10 [**2191-2-7**] 04:55AM BLOOD Glucose-110* UreaN-17 Creat-0.7 Na-140 K-4.5 Cl-108 HCO3-25 AnGap-12 [**2191-1-28**] 03:00AM BLOOD Glucose-117* UreaN-34* Creat-1.2* Na-134 K-5.4* Cl-99 HCO3-28 AnGap-12 [**2191-2-11**] 07:03AM BLOOD ALT-13 AST-17 AlkPhos-88 Amylase-73 TotBili-0.2 [**2191-2-2**] 07:00AM BLOOD ALT-19 AST-44* CK(CPK)-20* AlkPhos-108 TotBili-0.2 [**2191-2-2**] 07:00AM BLOOD Lipase-71* [**2191-2-11**] 07:03AM BLOOD Lipase-48 [**2191-2-2**] 07:00AM BLOOD CK-MB-2 cTropnT-<0.01 [**2191-1-28**] 03:00AM BLOOD cTropnT-<0.01 [**2191-2-13**] 06:17AM BLOOD Calcium-10.7* [**2191-1-28**] 03:00AM BLOOD Albumin-3.8 Calcium-10.6* Phos-2.5* Mg-2.6 [**2191-2-3**] 09:00AM BLOOD Triglyc-242* [**2191-1-28**] 03:00AM BLOOD TSH-0.056* [**2191-1-28**] 03:00AM BLOOD PTH-57 [**2191-1-28**] 03:00AM BLOOD Free T4-0.90* [**2191-2-12**] 05:08AM BLOOD Vanco-21.6* [**2191-1-28**] 03:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2191-1-28**] 12:11PM BLOOD Type-ART pO2-56* pCO2-50* pH-7.37 calTCO2-30 Base XS-1 [**2191-2-8**] 03:33PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020 [**2191-2-8**] 03:33PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG Date 6 Specimen Tests Ordered By All [**2191-1-28**] [**2191-1-29**] [**2191-2-3**] [**2191-2-4**] [**2191-2-7**] [**2191-2-8**] [**2191-2-9**] All BLOOD CULTURE BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) SPUTUM STOOL URINE All EMERGENCY [**Hospital1 **] INPATIENT [**2191-2-9**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE-PENDING; BLOOD/AFB CULTURE-PENDING INPATIENT [**2191-2-8**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING INPATIENT [**2191-2-8**] URINE URINE CULTURE-FINAL INPATIENT [**2191-2-8**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING INPATIENT [**2191-2-7**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL INPATIENT [**2191-2-4**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {GRAM NEGATIVE ROD #1, PSEUDOMONAS AERUGINOSA, GRAM NEGATIVE ROD #3, GRAM NEGATIVE ROD #4} INPATIENT [**2191-2-3**] URINE URINE CULTURE-FINAL INPATIENT [**2191-2-3**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL INPATIENT [**2191-2-3**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL INPATIENT [**2191-2-3**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL INPATIENT [**2191-2-3**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL INPATIENT [**2191-2-3**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL INPATIENT [**2191-1-29**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {STAPH AUREUS COAG +, KLEBSIELLA PNEUMONIAE, STAPH AUREUS COAG +} INPATIENT [**2191-1-29**] URINE URINE CULTURE-FINAL INPATIENT [**2191-1-28**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL EMERGENCY [**Hospital1 **] [**2191-1-28**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL EMERGENCY [**Hospital1 **] RESPIRATORY CULTURE (Final [**2191-2-2**]): OROPHARYNGEAL FLORA ABSENT. STAPH AUREUS COAG +. MODERATE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. KLEBSIELLA PNEUMONIAE. SPARSE GROWTH. Trimethoprim/Sulfa sensitivity testing available on request. STAPH AUREUS COAG +. SPARSE GROWTH. SECOND COLONIAL MORPHOLOGY. 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. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | KLEBSIELLA PNEUMONIAE | | STAPH AUREUS COAG + | | | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ <=1 S CIPROFLOXACIN--------- <=0.25 S CLINDAMYCIN----------- =>8 R =>8 R ERYTHROMYCIN---------- =>8 R =>8 R GENTAMICIN------------ <=0.5 S <=1 S <=0.5 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- =>8 R <=0.25 S =>8 R MEROPENEM------------- <=0.25 S OXACILLIN------------- =>4 R =>4 R PENICILLIN------------ =>0.5 R =>0.5 R PIPERACILLIN/TAZO----- <=4 S RIFAMPIN-------------- <=0.5 S <=0.5 S TETRACYCLINE---------- <=1 S <=1 S TOBRAMYCIN------------ <=1 S VANCOMYCIN------------ <=1 S <=1 S Brief Hospital Course: Aspiration Pneumonia: Was admitted to the ICU due to hypoxia and poor resp status. started on ceftazidime, Flagyl, vancomycon - completed total of 15 days. Sputum culture in ICU showed 2 species of MRSA and Kleb pneumoniae, psuedomonas. Stabilised and transferred ot the floor for further care. She has been eating pureed foods intermittently for several months, despite being told she should stay NPO to prevent aspiration. At discharge she did not reuire O2 therapy, good saturation but uses home @ 2 lit for chronic lung disease. CX R showed improvement in the pneumonia. She was afebrile prior to discharge. Extensive discussions were held with speech/swallow team. Pt has failed multiple evaluations and is well know to the swallow team here. They recommended considering fundoplication (laparoscopic vs endoscopically by [**Doctor Last Name **]), but needs to recover from current pneumonia first. The patient was instructed and advised onmany occasions to remain strictly NPO to avoid the risk of aspiration. Her case has been discussed at ethics rounds in the past for this reason. Aspiration precautions should be maintained. Leucocytosis: A thorough work up was done which did not reavl any other source other than the asp pneumonia. Rx as above. H/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] in spputum - based on ID reccs, pulmonary was consulted who did not think this patient needed a bronchoscopy as she was not likely candidate for Rx even if [**Doctor First Name **] was found. G tube leakage: GI put more water in the balloon, which worked for a while, but tube continued to leak. Likely due to poor wound healing (malnutrition). G/J tube was replaced by IR with good results. The homecaregiver was taught appropriate dressing changes. . Other med problems [**Name (NI) 105571**] stable. She is advised to follow up in the [**Hospital 105572**] clinic as below. Full Code The patient was advised by many members of the medical staff that she should NOT take anything orally, given the risk if aspiration. Medications on Admission: 1. docusate 2. Zofran 4mg q8h prn nausea 3. Oxycodone 10mg Solution q4-6h pain 4. Lorazepam 1 mg q6h prn 5. Fentanyl 75 mcg/hr Patch 72HR 6. Carbidopa-Levodopa 25-100 mg tid 7. omeprazole 20 mg suspension qd 8. Cholecalciferol (Vitamin D3) 400 unit [**Hospital1 **] 9. Ipratropium inh q6h prn 10. Tylenol 325 mg prn 11. Levothyroxine 100 mcg qd 12. Albuterol inh prn 13. Ferrous Sulfate 300 (60) mg qd 14. Lamictal 100 mg qd 15. Quetiapine 200 mg qhs 16. Venlafaxine 150 mg qd 17. Metoprolol Tartrate 25 mg [**Hospital1 **] 18. Alendronate 70 mg qweek 19. Gabapentin 400 mg qhs 20. Aspirin 81 mg qd Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2 times a day): To be given by feeding tube. 2. Acetaminophen 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed: To be given by feeding tube. 3. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as needed. 4. Carbidopa-Levodopa 25-100 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day): To be given by feeding tube. 5. Levothyroxine 112 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily): To be given by feeding tube. Disp:*30 Tablet(s)* Refills:*0* 6. Nutren Nutren 1.5 with fibre 50 ml per hour for 24 hours 7. Ferrous Sulfate 300 mg/5 mL Liquid [**Hospital1 **]: One (1) PO DAILY (Daily): To be given by feeding tube. 8. Lisinopril 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily): To be given by feeding tube. 9. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day): To be given by feeding tube. Disp:*60 Tablet(s)* Refills:*0* 10. Albuterol Sulfate 0.083 % Solution [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as needed. 11. Lamotrigine 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily): To be given by feeding tube. 12. Quetiapine 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO QHS (once a day (at bedtime)) as needed: To be given by feeding tube. 13. Alendronate 70 mg Tablet [**Hospital1 **]: One (1) Tablet PO QWED (every Wednesday): To be given by feeding tube. 14. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical QID (4 times a day) as needed. 15. Prochlorperazine 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6 hours) as needed: To be given by feeding tube. 16. Venlafaxine 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day): To be given by feeding tube. 17. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily): To be given by feeding tube. 18. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily): To be given by feeding tube. 19. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Last Name (STitle) **]: [**1-4**] Drops Ophthalmic PRN (as needed). 20. Gabapentin 400 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO HS (at bedtime): To be given by feeding tube. 21. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Month/Day (2) **]: One (1) Tablet PO twice a day: via feeding tube. 22. Oxycodone 5 mg/5 mL Solution [**Month/Day (2) **]: One (1) PO Q4H (every 4 hours) as needed. Discharge Disposition: Home With Service Facility: Gentiva/[**Location (un) 86**] Discharge Diagnosis: Aspiration pneumonia h/o atypical Mycobacterium positive sputum culture Leaking G-J tube Leucocytosis - resolved Secondary diagnoses: 1. Castleman's disease: unicentric. 2. Hx anaplastic thyroid cancer s/p radical neck dissection 3. Esophageal webs and esophageal dysmotility. Has had numerous esophageal dilatations. 4. Recurrent aspiration pneumonias 5. Chronic pulmonary disease: centrilobular nodular opacities, restrict physiology, has had sputum positive for [**Location (un) **]. 6. MRSA osteomyelitis of olecranan s/p multiple debridements 7. Hx Bipolar d/o 8. GERD 9. Osteoporosis: has broken both hips, left in [**11-7**], right with failed ORIF and redo at [**Hospital1 2025**], pelvic fracture [**9-8**] 10. Hx zoster 11. Hx depression, chronic pain 12. HTN Discharge Condition: stable Discharge Instructions: Return to the hospital or call your primary doctor if you notice worsening cough, shortness of breath, chest pain or any other symptoms concerning to you. You are advised not to eat or drink anything by mouth to avoid the risk of aspiration and lung infections. All your medications should be given thru the PEG tube. Followup Instructions: Please make an appointment to follow up with Dr [**Last Name (STitle) 2903**] within 10 days. Please follow up with Neurology regarding treatment of your parkinsons diease. ([**Telephone/Fax (1) 2528**]. Please make an appointment with your endocrinologist, Dr [**Last Name (STitle) **] [**Name (STitle) 7711**]. Call ([**Telephone/Fax (1) 74299**] to schedule an appointment to discuss the high calcium levels and also the thyroid medication and to follow-up for the results of lab work done in the hospital. Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 2936**] - Call to make an appointment in the next 2 weeks. Endocrinology - Dr [**Last Name (STitle) **] [**Last Name (NamePattern4) 7711**]. Call ([**Telephone/Fax (1) 74299**] to schedule an appointment to discuss the high calcium levels and also the thyroid medication and to follow-up for the results of lab work done in the hospital. Follow up with your GI doctor for further concerns about the feeding tube - Dr [**Last Name (STitle) **],[**First Name3 (LF) 2671**] ([**Telephone/Fax (1) 10499**] or ([**Telephone/Fax (1) 70399**]

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icd9cm

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42801

Discharge summary

report

Admission Date: [**2126-12-14**] Discharge Date: [**2126-12-18**] Date of Birth: [**2047-5-16**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1943**] Chief Complaint: Sepsis Major Surgical or Invasive Procedure: None History of Present Illness: PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**State 19827**]) Mrs. [**Known lastname **] is a 79 year old woman with a past medical history significant for CHB s/p PPM, DM, dementia, and a recent admission for a fall s/p ORIF hip fracture now admitted for pneumonia, UTI, and sepsis. The patient was admitted to [**Hospital1 18**] from [**Date range (1) **] after presenting with a fall, [**Date range (1) 1834**] ORIF right intertrochanteric hip fracture repair on [**12-4**], and was discharged to rehab with complications. Since discharge, she has had increasing confusion, agitation, and a productive cough, for which she was transferred tonight to [**Hospital1 18**] for further evaluation. Prior to transfer, the patient had a CXR that, per report, was negative for consolidation, as well as a negative UA. In the [**Hospital1 18**] ED, initial VS 97.2 80 127/58 16 100%. Labs were notable for a lactate of 3.5, UA with 54 WBC, and a chest CT with a multifocal left-sided pneumonia. She received CTX 1 gm, vanco 1 gm, azithromycin 500 mg, 2L IVF, and was admitted to the MICU for further management. Past Medical History: - s/p pacer placement for complete heart block and asystole in [**2123**] - Dementia - DM - PVD - Parathyroid adenoma Social History: - Lives in [**State 19827**] with husband as primary caregiver, severe dementia - Came to [**Name (NI) 86**] to visit her son Family History: Noncontributory Physical Exam: On admission to ICU: Gen: Elderly frail woman in NAD HEENT: PERRL, sclerae anicteric. MM dry, OP clear, poor dentition. Neck supple without lymphadenopathy. CV: Nl S1+S2, JVP <10 cm Pulm: Crackles at right base, diffuse left-sided rales, bronchial breath sounds with dullness to percussion. End expiratory wheezes bilaterally Abd: S/NT/ND +bs Ext: 1+ edema bilaterally Neuro: Oriented to person, otherwise non-focal Skin: Right hip staples in place. On transfer from ICU to floor: Vitals: 97.9 129/45 68 11 97%2L Gen: Elderly frail woman in NAD HEENT: PERRL, sclerae anicteric. MM dry, OP clear, poor dentition. Neck supple without lymphadenopathy. CV: Nl S1+S2, JVP <10 cm Pulm: Crackles at right base, diffuse left-sided rales, no wheezes Abd: soft, nondistended, nontender, ecchymoses on RLQ Ext: 1+ edema bilaterally Neuro: Oriented x 1, moving all extremities Skin: Right hip staples in place. Mild sacral ulcer. On discharge: Vitals: 98.1 148/50 75 18 96%RA Gen: Elderly frail woman in NAD HEENT: PERRL, sclerae anicteric. MM dry, OP clear, poor dentition. Neck supple without lymphadenopathy. Right lip droop CV: Nl S1+S2, JVP <10 cm Pulm: Crackles at right base, diffuse left-sided rales, no wheezes Abd: soft, nondistended, nontender, ecchymoses on RLQ Ext: 1+ edema bilaterally Neuro: Oriented x 1, moving all extremities Skin: Right hip staples removed. Mild sacral ulcer. Pertinent Results: On admission: [**2126-12-13**] 11:00PM BLOOD WBC-16.2*# RBC-3.13* Hgb-9.2* Hct-28.8* MCV-92 MCH-29.4 MCHC-31.9 RDW-14.8 Plt Ct-550* [**2126-12-13**] 11:00PM BLOOD Neuts-94.4* Lymphs-4.2* Monos-1.1* Eos-0.1 Baso-0.1 [**2126-12-13**] 11:00PM BLOOD PT-12.1 PTT-27.4 INR(PT)-1.1 [**2126-12-13**] 11:00PM BLOOD Glucose-261* UreaN-56* Creat-1.8* Na-142 K-4.0 Cl-103 HCO3-26 AnGap-17 [**2126-12-15**] 04:05AM BLOOD LD(LDH)-166 [**2126-12-13**] 11:00PM BLOOD cTropnT-<0.01 [**2126-12-14**] 05:18AM BLOOD Calcium-8.4 Phos-5.0* Mg-2.4 [**2126-12-15**] 04:05AM BLOOD calTIBC-208* Hapto-318* Ferritn-167* TRF-160* [**2126-12-13**] 11:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-5* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2126-12-13**] 11:06PM BLOOD Lactate-3.5* [**2126-12-13**] 10:50PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.022 [**2126-12-13**] 10:50PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [**2126-12-13**] 10:50PM URINE RBC-1 WBC-54* Bacteri-MANY Yeast-NONE Epi-2 [**2126-12-13**] 10:50PM URINE CastGr-10* CastHy-6* [**2126-12-13**] 10:50PM URINE Mucous-RARE [**2126-12-13**] 10:50PM URINE Hours-RANDOM Creat-150 Na-<10 K-72 Cl-<10 [**2126-12-13**] 10:50PM URINE Osmolal-438 [**2126-12-13**] 10:50PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG On discharge: [**2126-12-18**] 07:55AM BLOOD WBC-11.0 RBC-3.06* Hgb-8.8* Hct-28.8* MCV-94 MCH-28.9 MCHC-30.7* RDW-14.5 Plt Ct-614* [**2126-12-18**] 07:55AM BLOOD Glucose-170* UreaN-20 Creat-0.9 Na-138 K-4.4 Cl-101 HCO3-31 AnGap-10 [**2126-12-18**] 07:55AM BLOOD ALT-12 AST-19 [**2126-12-18**] 07:55AM BLOOD Calcium-9.8 Phos-3.6 Mg-2.1 [**2126-12-17**] 05:41AM BLOOD Triglyc-134 HDL-36 CHOL/HD-5.1 LDLcalc-119 [**2126-12-15**] 05:44PM BLOOD Lactate-1.1 Microbiology: URINE CULTURE (Final [**2126-12-16**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- 32 R CEFTAZIDIME----------- 16 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R [**2126-12-13**] 11:00 pm BLOOD CULTURE #1. Blood Culture, Routine (Pending): [**2126-12-13**] 11:10 pm BLOOD CULTURE #2. Blood Culture, Routine (Pending): Legionella Urinary Antigen (Final [**2126-12-14**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. MRSA SCREEN (Final [**2126-12-16**]): No MRSA isolated. ECG [**2126-12-13**]: Sinus rhythm. Possible old inferior myocardial infarction. ST-T wave changes in the anterolateral leads suggest ischemia. Compared to the previous tracing of [**2126-12-3**] no clear change. Portable CXR [**2126-12-13**]: FINDINGS: Single semierect frontal view of the chest demonstrates a left pectoral pacer/AICD with leads terminating in the right atrium and right ventricle. The lung volumes are low, accentuating cardiomegaly. There is no vascular congestion. Equivocal opacity in the left costophrenic angle correlates with consolidation on subsequent CT. The right lung is clear. IMPRESSION: Equivocal opacity in the left base, where there is confluent and increased consolidation on subsequent CT. CT head w/o contrast [**2126-12-14**]: FINDINGS: There is no intracranial hemorrhage, mass effect, edema, or shift of normally midline structures. The [**Doctor Last Name 352**]-white matter differentiation is preserved. A tiny right basal ganglia lacune versus prominent Virchow-[**Doctor First Name **] space appears unchanged. Ventricles and sulci are prominent, consistent with age-related involution. Bifrontal extra-axial spaces are prominent, unchanged empty sella. Paranasal sinuses and mastoid air cells are well aerated. Vascular calcifications are seen in the cavernous carotid and vertebral arteries. Globes and soft tissues are unremarkable. IMPRESSION: 1. No acute intracranial process. 2. Age-related involution changes. CT chest/abdomen/pelvis w/o contrast [**2126-12-14**]: CT CHEST: A left pectoral cardiac pacer/AICD is in place with leads terminating in the right atrium and right ventricle. The heart is normal in size without pericardial effusion. There is calcified disease involving the LAD. No mediastinal, hilar, or axillary lymphadenopathy by size criteria. There is dense consolidation in the left upper and lower lobes, consistent with pneumonia. The right lung is relatively clear. Central airways are not well assessed allowing for motion. CT ABDOMEN: Visceral assessment is highly limited by lack of contrast. Allowing for such, the liver demonstrates no focal lesion. The gallbladder is moderately distended but without pericholecystic fluid or evidence of stone. The spleen, pancreas, and right adrenal gland appear unremarkable. Slight thickening is present in the left adrenal gland without focal lesion. Bilateral kidneys are small in size but without hydronephrosis or hydroureter. There is atherosclerotic disease in the infrarenal aorta, without aneurysm formation. The spleen measures 13 cm, top normal in size. Small and large bowel loops are normal in caliber without evidence of obstruction. The appendix is normal. There is a large amount of fecal material distending the cecum and rectum. No overt colitis or diverticulitis. CT PELVIS: The bladder is collapsed, with an indwelling Foley catheter. The uterus and adnexa appear age appropriate. No inguinal or pelvic sidewall adenopathy. No free fluid in pelvis. BONE WINDOW: Allowing for significant motion, no evidence of fracture or concerning focal lesion. Patient is status post screw fixation of the right hip. Diffuse osteopenia is present. There is mild loss of height in T12 vertebral body, age indeterminate. IMPRESSION: 1. Left upper and lower lobe pneumonia. 2. No small-bowel obstruction. 3. Large amount of fecal material in the rectal vault. Right upper extremity ultrasound: FINDINGS: There is normal respirophasic waveform in the left subclavian vein. The waveform in the right subclavian vein is blunted. There is normal compressibility and flow within the right internal jugular, right axillary, paired brachial, basilic, and cephalic veins. IMPRESSION: 1. No DVT of the right upper extremity. 2. Blunted waveform in the right subclavian vein which can be seen in more central obstruction such as stenosis/more proximal thrombus. Right hip x-ray [**2126-12-17**]: FINDINGS: Comparison is made to previous study from [**2126-12-4**]. There is a dynamic compression screw with lateral plate fixating an intertrochanteric fracture of the right femur. There is lucency between the greater trochanter and the superior aspect of the hardware laterally; however, this is likely within normal limits for the post-operative state. The dynamic compression screw is well centered within the femoral head. Lateral surgical skin staples are present. No additional fractures are seen. There are degenerative changes of the lumbar spine with scoliosis. Joint space narrowing of both hips are also seen consistent with osteoarthritis. CTV chest w/ contrast [**2126-12-17**]: (preliminary read) No filling defect to suggest central venous clot. Decreased opacity in the lingula and left lower lobe c/w improved pna. Small mediastinal lymph nodes, presumed reactive. 10 mm right thyroid nodule could be better assessed by ultrasound as indicated. Indeterminate 13 x 9 mm right adrenal nodule. 5 mm hypodensity in segment VIII/V of the liver which is too small to further characterize, most likely a cyst or hemangioma (103:547). Degenerative change of the T-spine. Brief Hospital Course: Mrs. [**Known lastname **] is a 79 year old woman with a past medical history significant for CHB s/p PPM, DM, dementia, and a recent admission for a fall s/p ORIF hip fracture now admitted for pneumonia, UTI, and sepsis. # Sepsis: Pt was admitted initially to the ICU for concerns for sepsis. She was hypotensive (lowest systolic BP documented in the 70s) with a lactate of 3.5. CT chest showed left upper and lower lobe pneumonia. U/A was also consistent with UTI. She responded well to IV fluids and hypotension as well as elevated lactate resolved. Lactate was 1.1 by time of discharge. She had one temperature of 100 in the ICU but remained afebrile throughout remainder of hospital course. She was treated for HCAP and UTI per below. # HCAP: CT with evidence of multifocal left-sided consolidations. She was treated for healthcare associated pneumonia as she was from a rehab facility. Pt reportedly with cough at nursing home and with leukocytosis (WBC 15 on admission). She had low grade temp of 100 at ICU but remainded afebrile through remainder of hospital stay. She was unable to provide a sputum specimen for further evaluation. She was initially started on vancomycin, cefepime, and ciprofloxacin at the ICU. This was narrowed to vancomycin and meropenem after consulting with infectious disease. She will have a total course of 7 days of HCAP treatment with vancomycin. Her dosing is IV 1g vancomycin every 48 hours; a morning trough showed be checked prior to her dose on [**2126-12-20**]. ID recommended Meropenem for 14 day course. Patient was briefly on 2L oxygen by nasal cannula but was weaned to room air by time of discharge. She was discharged with a single lumen PICC for continued antibiotic therapy at rehab. # Aspiration risk: Pt was noted to have some coughing with meals. While awaiting swallow evaluation, a discussion was held with the family regarding option of keeping patient NPO until she was cleared by swallow therapy. Risks and benefits of keeping pt NPO and swallow evaluation were discussed with family. Family decided to allow the patient to eat, understanding the risks. An initial swallow evaluation found that pt was aspirating thin liquids. A repeat swallow assessment the next day at the bedside showed no overt aspiration with regular solids and thin liquids. The family was informed that we could not rule out silent aspiration and were informed that a video swallow could be performed for further evaluation. The family declined the video swallow and opted to monitor symptoms while optimizing aspiration precautions. She can follow up with swallow assessment at her LTAC if concerns for aspiration arise. A repeat chest x-ray prior to discharge did not show consolidations worrisome for aspiration pneumonia. # UTI: Patient had a foley catheter at rehab. Urine culture grew klebsiella sensitive only to meropenem and gentamicin. ID recommended meropenem. Her foley was discontinued. Foley catheterization should be avoided despite patient being incontinent. Skin integrity should be preserved with frequent diaper changes and washings. # Facial droop: Pt was noted to have a right facial droop that per family had been present for 1 week at rehab. Pt had prior hx of strokes. Discussed with family option of pursuing head MRI to formally diagnose stroke but informed them that management would be secondary prevention. Pt was continued on her aspirin. Lipid panel was checked and LDL was 116, LFTs wnl. She was started on a small dose of simvastatin. She should have her LFTs monitored while on the statin. # Question of central thrombus: Pt had right arm swelling at site of PICC in right arm, which pt had pulled out herself. A RUE ultrasound did not show DVT in the arm. However, there was some blunted waveform in the right subclavian vein which can be seen in more central obstruction such as stenosis/more proximal thrombus. This was discussed with radiology who felt that f/u CTV would help delineate if she had proximal DVT. Pt [**Date Range 1834**] CTV after discussion with family about risks/benefits of testing. The preliminary read of the CTV showed no central thrombus. It showed decreased opacity in the lingula and left lower lobe to suggest improved pneumonia. Also showed a 10mm thyroid nodule, indeterminate 13x9mm right adrenal nodule, and 5mm hypodenxity in liver (most likely cyst or hemangioma). Final [**Location (un) 1131**] of CTV was pending at time of discharge. # Hyperglycemia/Diabetes: Pt had underlying diabetes in setting of active infection which resulted in poorly controlled blood glucose levels. She had been on only oral agents at home and later placed on insulin with her oral agents at rehab. Her metformin and sulfonylurea were held and she was given lantus and HISS. Lantus was uptitrated to 15 units daily. Blood glucose control had improved with fingersticks mostly in the 100s at time of discharge. Her insulin regimen should be adjusted according to her fingersticks at rehab. # Acute renal failure: Creatinine on admission was elevated to 1.8 from prior 1.1-1.3, likely pre-renal azotemia in setting of sepsis. Cr downtrended to her baseline with IV hydration, Cr was 0.9 by time of discharge. # Anemia: Hct was 32 on prior discharge. Hct fluctuated between low and high 20s during this admission, lowest at 22. However, Hct stabilized to high 20s and was 28 by time of discharge. There was no evidence of bleed; coags were wnl. She was started on iron supplementation as her iron was low at 12. # Encephalopathy [**2-6**] sepsis on baseline chronic dementia. Per family, mental status had been worsening prior to admission to hospital. Likely delirium with underlying dementia worsened due to sepsis. CT head was negative for acute process. Mental status fluctuated throughout the day c/w delirium. She was largely A & O x 1 (self only) and recognized family members. Donepezil was held initially but restarted at time of discharge. Of note, family stated that pt had previously been on citalopram for depression. This should be held due to delirium. Re-initiation of citalopram may be considered upon return of mental status to baseline. # HTN: BP meds were initially held due to hypotension/conern for sepsis. Her home HCTZ and amlodipine were restarted. Despite this, SBP was 170s. Her PCP Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] was contact[**Name (NI) **] who stated that she had done better on [**Last Name (un) **] (benicar) than on acei in the past. She was started on losartan 25mg daily. She was also started on metoprolol tartrate 12.5mg [**Hospital1 **] as she had CAD (had been on nebivolol previously). These BP medications can be uptitrated at her rehab according to her BPs. She will need electrolytes checked within 1-2 weeks given the addition of losartan. # Hip fracture: Pt s/p recent right ORIF on [**2126-12-4**] after mechanical fall. She was seen by orthopedics who removed her staples on [**2126-12-17**]. Repeat hip x-ray was performed during hospital stay. She will follow up with ortho as outpatient. She was continued on SC lovenox for DVT prophylaxis which should be continued until [**2127-1-3**]. # Skin: Pt had small sacral decubitus ulcers, stage II, covered with meplex. She also had blister on right heel. She should have waffle boots to prevent worsening of blister and also frequent repositioning. Medications on Admission: HOME MEDS (per patient) Amaryl 8 mg PO QHS Aricept 10 mg PO QHS ASA 81 mg PO twice weekly Bystolic 5 mg PO QHS Glucophage 750 mg PO BID HCTZ 25 mg PO QHS Norvasc 10 mg PO QHS Plavix 75 mg PO QHS TRANSFER MEDICATIONS Lantus 15 units QHS and HISS Donepizil 10 mg daily Oxycodone 5 mg Q4H prn Duoneb Q4H prn Tramadol 25 mg PO TID Colace Senna MVI Nebivolol 5 mg QHS Glimepiride 4 mg QHS ASA 81 mg daily Plavix 75 mg daily Amlodipine 10 mg daily HCTZ 25 mg daily Lovenox 30 mg QHS PPI Alendronate weekly Ca-Vit D Trazodone 50 mg Q4H prn agitation Metformin 850 mg [**Hospital1 **] 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. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. donepezil 10 mg Tablet Sig: One (1) Tablet PO once a day. 8. multivitamin Capsule Sig: One (1) Capsule PO once a day. 9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. ferrous sulfate 325 mg (65 mg iron) Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO once a day. 11. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 12. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: Two (2) Tablet, Chewable PO once a day. 14. enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mL Subcutaneous Q24H (every 24 hours). 15. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 16. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) Inhalation every four (4) hours as needed for shortness of breath or wheezing. 17. tramadol 50 mg Tablet Sig: 0.5 Tablet PO three times a day as needed for pain. 18. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week: Sunday. 19. insulin glargine 100 unit/mL Solution Sig: Fifteen (15) Subcutaneous once a day. 20. Humalog 100 unit/mL Solution Sig: see attached Subcutaneous four times a day: please see attached sheet on sliding scale. 21. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 22. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 23. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 24. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q48H (every 48 hours) for 2 doses: To be given [**2126-12-20**] and [**2126-12-22**]. 25. meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours): Continue until [**2126-12-30**]. 26. nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): Apply to rash. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: Healthcare associated pneumonia Urinary tract infection Encephalopathy Secondary: Right hip fracture status post repair Dementia Coronary artery disease Diabetes mellitus type 2 Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: It was a pleasure taking care of you in the hospital. You were admitted with pneumonia and a urinary tract infection. You were treated with antibiotics for this. You will need to complete a few more days of these antibiotics at your rehab facility. During your hospital stay, you were seen by our orthopedics team to re-assess your hip fracture. Your staples were removed and a repeat hip x-ray was performed. You will need to continue to follow-up with orthopedics as an outpatient. You were also seen by our swallow therapist to assess for risk of aspiration. Initially there was concern that you may be aspirating thin liquids but a repeat assessment showed that you could tolerate a regular diet with thin liquids. At rehab, you should continue to have supervision when eating and to re-assess with swallow therapy if you show signs of aspiration. The following changes were made to your medications: 1) Start IV vancomycin 1 gram every 48 hours (to be given [**2126-12-20**] and [**2126-12-22**]) 2) Start IV meropenem 500mg every 8 hours (continue until [**2126-12-30**]) 3) Start metoprolol tartrate 12.5mg twice a day 4) Stop nebivolol 5) Start losartan 25mg daily 6) Start ferrous sulfate (iron) 325mg daily 7) Start simvastatin 10mg daily 8) Stop glimepiride 9) Stop metformin Followup Instructions: Department: ORTHOPEDICS When: THURSDAY [**2127-1-16**] at 9:40 AM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: THURSDAY [**2127-1-16**] at 10:00 AM With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2126-12-19**]

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Discharge summary

report

Admission Date: [**2170-10-9**] Discharge Date: [**2170-10-18**] Service: CCU HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old female with coronary artery disease. The patient is status post cardiac catheterization during [**2170-8-31**] admission for right femoral-popliteal bypass when the patient developed an episode of chest pain while at dialysis. She went to catheterization during which a cypher stent was placed in her right coronary artery. The patient had no further cardiac symptoms following this until four days prior to her current admission when she developed an episode of chest pain. The patient was at dialysis and was briefly hypotensive, requiring cessation of dialysis. Several hours following this she developed chest pain which was accompanied by weakness and lethargy. Her weakness continued over the next few days. She also noted dyspnea with walking and presented to the Emergency Department for further evaluation. PAST MEDICAL HISTORY: 1. Hypertension. 2. Depression. 3. End-stage renal disease (on hemodialysis). 4. Hypercholesterolemia. 5. Type 2 diabetes mellitus. 6. History of transient ischemic attack. 7. Coronary artery disease; status post myocardial infarction. 8. Glaucoma. 9. Cataracts. 10. Peripheral vascular disease; status post right femoral-popliteal bypass; status post left femoral-tibial bypass graft; status post right coronary artery stent. MEDICATIONS ON ADMISSION: Home medications included aspirin, Plavix, Pravastatin, captopril, Prilosec, Lopressor, Renagel, Vicodin, insulin, and eyedrops. ALLERGIES: PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed the patient's temperature was 96.7 degrees Fahrenheit, her blood pressure was 142/38, her heart rate was 84, and her respiratory rate was 23. In general, the patient was a pale elderly female in no acute distress. Head, eyes, ears, nose, and throat examination revealed surgical pupils. Left pupil was dilated and nonreactive. The right pupil was minimally reactive; thought from surgical. Extraocular movements were intact. The oropharynx was clear. The mucous membranes were dry. Cardiovascular examination revealed a regular rate. Normal first heart sounds and second heart sounds. There was a holosystolic murmur heard loudest at the apex. The lungs were clear to auscultation anteriorly. The abdominal examination revealed positive bowel sounds. The abdomen was soft, nontender, and nondistended. Extremity examination revealed pulses were dopplerable. The right was bandaged. No edema. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories revealed the patient's white blood cell count was 11.6, her hematocrit was 28.6, and her platelets were 245. Her sodium was 142, potassium was 3.9, chloride was 102, bicarbonate was 28, blood urea nitrogen was 41, creatinine was 4.6, and blood glucose was 100. Creatine kinase was 179, CK/MB was 20, MB index was 11.2, and troponin was 5.95. PERTINENT RADIOLOGY/IMAGING: Electrocardiogram revealed a normal sinus rhythm at a rate of 70, left ventricular hypertrophy. There were 1-mm to 2-mm ST elevations in leads II, III, and aVF. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1. CARDIOVASCULAR ISSUES: (a) Coronaries: Given electrocardiogram changes and cardiac history, the patient went to the Catheterization Laboratory upon arrival to the Emergency Department. Cardiac catheterization showed a thrombus in her proximal right coronary artery stent. During catheterization, this was successfully re-stented with a 3.5-mm X 23-mm Hepacoat stent. The catheterization also showed elevated filling pressures with an elevated wedge pressure. The patient was transiently hypotensive during cardiac catheterization and briefly required a dopamine drip, but her procedure was otherwise uncomplicated. The patient was then transferred to the Coronary Care Unit for close monitoring. She was loaded on Plavix and received Integrilin for 18 hours. She was continued on a daily regimen of aspirin, Plavix, and statin. She was heparinized until an echocardiogram was obtained. She was started back on a beta blocker and ACE inhibitor which were titrated up throughout her hospitalization. The patient developed a cough with the ACE inhibitor and was instead switched to an angiotensin receptor blocker. (b) Pump: The patient had a post myocardial infarction echocardiogram which showed an ejection fraction of 40%. She was put back on an ACE inhibitor for afterload reduction which was then changed over to an angiotensin receptor blocker as she developed a cough. She received regular hemodialysis for management of her volume status. (c) Rhythm: The patient was monitored on telemetry throughout her hospitalization. She did not have any arrhythmia complications. (d) Valves: The patient was admitted with a history of mitral regurgitation. Her post myocardial infarction echocardiogram showed 2+ mitral regurgitation. She was continued on an ACE inhibitor. 2. PULMONARY ISSUES: No active issues. The patient saturated well on room air throughout her hospitalization. 3. RENAL ISSUES: The patient with end-stage renal disease (on hemodialysis). She was followed by the Renal Service throughout her hospitalization and continued to receive dialysis three times per week (per her regular schedule). She was also continued on Renagel for her elevated phosphate. 4. ENDOCRINE ISSUES: The patient with a history a type 2 diabetes mellitus. She was continued on NPH insulin with regular insulin supplementation at meals (per her home regimen). 5. PERIPHERAL VASCULAR DISEASE ISSUES: The patient was status post a right femoral-popliteal bypass. He wound was monitored and dressed throughout her hospitalization. Her surgical followup was verified. 6. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was placed on a cardiac, diabetic, American Diabetes Association diet which she tolerated well. Her electrolytes were monitored. 7. OPHTHALMOLOGIC ISSUES: The patient with a history of glaucoma and cataracts. The patient was continued on her glaucoma eyedrops (per her home regimen). 8. NEUROLOGIC ISSUES: The patient was admitted with complaints of fatigue and somnolence. These symptoms quickly resolved following cardiac catheterization and were thought to be due to her cardiac problems. She had a thyroid-stimulating hormone sent which was normal. She did not have any further episodes of lethargy or other neurological issues during her hospitalization. 9. INFECTIOUS DISEASE ISSUES: The patient with urinalysis showing asymptomatic bacteruria. Her Foley catheter was removed, and she remained asymptomatic. Per consultation with the Renal Service, the patient was not treated for her asymptomatic bacteruria. 10. PROPHYLAXIS ISSUES: Proton pump inhibitor for gastrointestinal prophylaxis and subcutaneous heparin for deep venous thrombosis prophylaxis. Colace and Senna were given for a bowel regimen. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: Discharge status was to rehabilitation. DISCHARGE DIAGNOSES: 1. Right coronary artery stent thrombosis with successful restenting of thrombosed stent. 2. End-stage renal disease (on hemodialysis). 3. Non-ST-elevation myocardial infarction. 4. Urinary tract infection. MEDICATIONS ON DISCHARGE: 1. Losartan 25 mg by mouth once per day. 2. Heparin 5000 units subcutaneously q.12h. 3. Metoprolol 50 mg by mouth twice per day. 4. Renagel 800 mg by mouth three times per day. 5. Pantoprazole 40 mg by mouth q.24h. 6. Nephrocaps one tablet by mouth once per day. 7. Pramipexole 0.25 mg by mouth at hour of sleep. 8. Timolol 0.5% ophthalmologic eyedrops one drop both eyes twice per day. 9. Prednisolone 1% ophthalmologic suspension one drop both eyes twice per day. 10. Pilocarpine 2% one drop both eyes at hour of sleep. 11. Levobunolol 0.5% one drop both eyes at hour of sleep. 12. Dorzolamide 2%/Timolol 0.5% one drop twice per day (to right eye only). 13. Brimonidine tartrate 0.15% ophthalmologic eyedrops q.8h. 14. Quinine sulfate 325 mg by mouth every Monday, Wednesday, and Friday. 15. Pravastatin 10 mg by mouth at hour of sleep. 16. Senna one tablet by mouth twice per day as needed. 17. Colace 100 mg by mouth twice per day. 18. Plavix 75 mg by mouth once per day. 19. Aspirin 325 mg by mouth once per day. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up with Surgery on [**10-23**] with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] as previously scheduled. 2. The patient was instructed to follow up with her primary care physician in one week. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15176**], M.D. [**MD Number(1) 15177**] Dictated By:[**Last Name (NamePattern1) 5212**] MEDQUIST36 D: [**2170-10-18**] 16:16 T: [**2170-10-18**] 16:37 JOB#: [**Job Number 101053**]

[ "403.91", "588.0", "285.21", "599.0", "410.71", "996.72", "250.40", "428.0", "458.21" ]

icd9cm

[ [ [] ] ]

[ "88.56", "36.06", "36.01", "37.23", "39.95", "39.64", "99.20" ]

icd9pcs

[ [ [] ] ]

7170, 7382

7409, 8455

1469, 3196

8488, 9035

3231, 7037

7052, 7149

119, 973

996, 1442

19,326

135,961

4003

Discharge summary

report

Admission Date: [**2112-3-29**] Discharge Date: [**2112-4-21**] Date of Birth: [**2055-4-13**] Sex: M Service: [**Last Name (un) **] CHIEF COMPLAINT: End stage renal disease. HISTORY OF PRESENT ILLNESS: The patient is a 56 year old male admitted to the [**Hospital1 69**] on [**2112-3-29**] for kidney transplant. The patient had suffered renal failure due to Indocin toxicity and had been on hemodialysis for four years prior to transplant, using a left arm AV fistula. PAST MEDICAL HISTORY: Diabetes mellitus Coronary artery disease status post coronary artery bypass graft in [**2104**] and redo CABG in [**2110**]. Chronic renal insufficiency progressing to renal failure. Sleep apnea. Ankle surgery for gout. Status post gastric bypass 30 years ago. Status post corrective surgery for sleep apnea in [**2104**]. ALLERGIES: The patient had no known drug allergies. SOCIAL HISTORY: The patient is married and lived in [**Location **]. HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] on [**2112-3-29**] and taken to the Operating Room where he underwent cadaveric renal transplant. The procedure was performed without complication and the patient thereafter transferred to the PACU for continued observation. The patient suffered bleed graft function with his urine output on postoperative day number one being 471 ml of urine, on postoperative day two 255 ml of urine and on postoperative day three 350 ml of urine, decreasing to 7 ml of urine on postoperative day number four. In the postoperative period, the patient also developed nausea and vomiting requiring placement of a nasogastric tube on postoperative day number four. An abdominal x-ray revealed a dilated right colon. This was followed by a physical examination and also imaging and the decision was finally made to attempt Neostigmine therapy. The patient was transferred to a monitored setting. CT scan of his abdomen was obtained to rule out mechanical obstruction prior to treatment with the Neostigmine. Within a few seconds of the Neostigmine infusion, the patient became somnolent and with increasing respiratory distress. The patient was emergently intubated. The patient also went in to rapid atrial fibrillation with his heart rate in the upper 100s during this event. Some Lopressor was given but the patient's blood pressure was noted to decrease and he was therefore started on Levophed and Neo-Synephrine. The patient converted back to normal sinus rhythm just prior to cardioversion. The patient was on Propofol for comfort. The patient was transferred to the Trauma SICU from the Recovery Room for continued monitoring. On the day following the Neostigmine therapy, which was postoperative day number five, revealed that the patient's physical examination and his labs raised concern for an intra- abdominal pathologic process. The patient's white blood cell count was increased to 12. The decision was made to take the patient for an exploratory laparotomy. Intra-operatively, the patient was noted to have gangrenous right colon with two small microperforations. The patient underwent an exploratory laparotomy, lysis of adhesions, extended right hemicolectomy with takedown of the hepatic flexure and a diverting ileostomy. Estimated blood loss was 600 ml. The patient was returned back to the Intensive Care Unit following the procedure. The patient had been started on Vancomycin, Zosyn and Flagyl. On the evening of surgery, the patient was dialyzed. At the end of the dialysis session, the patient went into rapid atrial fibrillation. Treatment of the rapid rhythm was attempted with two boluses of Lopressor but the patient's blood pressure was noted to decrease into the 80s and 90s. Given the hemodynamic instability, the decision was made to initiate amiodarone therapy and plans made for cardioversion. Immediately prior to cardioversion, the patient reverted to sinus rhythm. On [**4-6**], the patient remained on the amiodarone drip but continued to have recurrent atrial fibrillation. The patient was weaned off the mechanical ventilator and extubated. On [**2112-4-7**], the patient was noted to have increased secretions and was also becoming tachypneic. A chest x-ray revealed left lower lobe collapse. The patient was ultimately electively intubated. Following the intubation, the patient's blood pressure was noted to decrease and the patient was started on a Levophed drip. On [**2112-4-8**], the patient required some increasing doses of Levophed. On [**2112-4-8**], the patient also underwent CT scan of his abdomen to evaluate for obstruction. The CT scan revealed contrast to the colostomy bag. There was, however, some free extravasation of contrast at the inferior and lateral margins of the liver as well as anteriorly to the left lobe of the liver. There was no free air identified in the abdomen. The patient's transverse descending and sigmoid colon were appropriately decompressed. The transplanted kidney showed no evidence of hydronephrosis and there was no peri-renal fluid collection. The decision was made to continue clinically monitoring the patient with no immediate return to the Operating Room for exploration. On [**2112-4-10**], a followup CT scan was obtained revealing an unchanged distribution of intraoperative peritoneal oral contrast. There was no evidence of active contrast extravasation. The patient was noted to have a right lower lobe consolidation. While at CT scan, the patient did have an episode of rapid atrial fibrillation with a decrease in his systolic blood pressure to the 70s and 80s. This was managed with an increase in the patient's Levophed drip. This was later titrated down. On [**2112-4-11**], the patient was noted to have a decreased cardiac output and an increased systemic vascular resistance and the patient was started on vasopressins in an attempt to support his cardiac output. Note some concern for cardiac events. The patient's propofol infusion was changed to Fentanyl. The patient did have some episodes of atrial fibrillation and required cardioversions. The patient also became febrile to 102.2 F. The patient remained arousable to voice. The patient was, however, not following commands. He was moving all extremities. Because of worsening acidosis and decreasing cardiac output, the patient was also started on a Milrinone drip. An Infectious Disease consultation was requested. Based on the Infectious Disease input, the patient was started on meropenem and continued on Vancomycin. The patient's Levaquin and Zosyn was discontinued. Given the deterioration of the patient's condition and unclear etiology, the patient was taken for an exploratory laparotomy on [**2112-4-12**]. Please refer to the dictated operative note for details. There was no evidence of purulence in the peritoneal cavity. The ileostomy and bowel appeared viable. The kidney was also biopsied. The kidney appeared pink and viable. The patient was transferred back to the Intensive Care Unit. On [**2112-4-14**], the patient underwent a transesophageal echocardiogram to evaluate for endocarditis. No visitation was noted of the patient's spouse. The patient's urine output remained minimal, ranging from 38 to 571 between the [**4-9**] and [**4-15**]. The patient's blood urea nitrogen was noted to be increasing and was 218 on [**4-16**]. The decision was made to resume the patient's VVHB which had been discontinued with the patient's increasing vasopressor requirement. On [**2112-4-16**], cultures from the patient's midline abdominal wound which was open and was being packed came back with vancomycin resistant enterococcus. The patient was switched from Vancomycin to linezolid. The patient continued on Levophed vasopressin for blood pressure support. The patient also remained on an amiodarone drip. While being turned in his bed on the night of [**2112-4-17**], the patient's right upper arm was noted to bend in a manner suggestive of a humerus fracture. This was confirmed on an x-ray obtained on [**2112-4-18**]. An Orthopedic Surgery consultation was requested. The Orthopedic Service was of the opinion that external splinting would be more appropriate than surgical intervention, given the patient's critical clinical condition. On [**2112-4-19**], the patient was started on ciprofloxacin when cultures from his abdominal wound on the [**4-15**] grew pseudomonas. The patient remained critically ill, requiring multiple pressor support and requiring increasing oxygen through the ventilator. The patient's serum lactate was also noted to be increasing. On [**2112-4-20**], the patient had a decrease in his cardiac output. An echocardiogram was ordered. Although the quality of the images obtained were poor, the study was able to verify that the patient had no pericardial effusion to explain the decreased cardiac output. The patient's right ventricular function did appear depressed. By [**2112-4-21**], the patient was unimproved. Given the overall gradual deterioration in the patient's function and unclear prognosis, discussions were held with the family on the patient's plans for further care. The patient's midline abdominal wound was debrided at the bedside on [**2112-4-21**], with no evidence of fasciitis noted. The patient's fractured humerus was placed in a cast by the Orthopedic Surgery Service. This was expected to remain in place for four weeks. On the evening of [**2112-4-21**], following discussions between the health care providers on the transplant end and Intensive Care Unit teams as well as the patient's family, the decision was made to change the patient's code status to COMFORT MEASURES ONLY. Consistent with these wishes, all medications except morphine for the patient's comfort were discontinued. The patient died shortly after. The patient's family members were present in the room at the time of the patient's death. . DISPOSITION: The patient's family was approached regarding the possibility of post mortem autopsy. The final decision is unavailable at this time. DISCHARGE DIAGNOSES 1.Multiple Organ Failure 2.Acute colonis pseudoobstruction 3.S/P Kidney Transplant 4.ESRD 5.CAD 6.Obesity [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 4841**] Dictated By:[**Last Name (NamePattern1) 17694**] MEDQUIST36 D: [**2112-4-21**] 22:46:39 T: [**2112-4-21**] 23:55:51 Job#: [**Job Number 17695**]

[ "038.9", "997.4", "996.81", "585", "560.89", "995.92", "567.2", "557.0", "569.83" ]

icd9cm

[ [ [] ] ]

[ "54.12", "00.14", "38.93", "96.04", "99.15", "55.24", "96.6", "55.69", "96.71", "38.95", "45.73", "88.72", "46.21" ]

icd9pcs

[ [ [] ] ]

994, 10490

172, 198

227, 497

520, 905

922, 976

9,279

135,145

4110

Discharge summary

report

Admission Date: [**2191-3-24**] Discharge Date: [**2191-3-28**] Date of Birth: [**2143-7-29**] Sex: F Service: [**Last Name (un) **] PREOPERATIVE DIAGNOSIS: Left breast cancer. HISTORY OF PRESENT ILLNESS: This is a 47-year old female with a history of left breast cancer diagnosed in [**2190-7-4**]. She also has a history of low back pain and a history of 4 herniated discs, esophageal reflux disease with H. pylori, and a Bartholin cyst in [**2184**]. The patient has been doing well. She has been tolerating her chemotherapy. She initially underwent a lumpectomy at the [**Hospital 882**] Hospital but had positive margins. She was started on chemotherapy with a plan for a mastectomy. The patient completed a course of Adriamycin and Cytoxan. Her last dose was [**2191-2-18**]. The plan for the patient is to undergo bilateral mastectomies with [**Last Name (un) 5884**] (deep inferior epigastric perforator) flaps by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] just after the patient undergoes bilateral mastectomies. PAST MEDICAL HISTORY: To review the patient's past medical history; left breast cancer diagnosed in [**2190-10-4**]. Status post lumpectomy and chemotherapy with Adriamycin and Cytoxan. The patient refused Taxol given her borderline need for chemotherapy. She had a sentinel lymph node which was negative, and the mass was 2.2 c (per the patient's report). The patient has a history of a Bartholin cyst marsupialization in [**2184**] and a history of low back pain with 4 herniated discs. A history of arthritis in both her hands. PAST SURGICAL HISTORY: Was previous mentioned. She also has a history of 2 C-sections at the ages of 19 and 17 years old. MEDICATIONS AT HOME: Protonix 40 mg p.o. daily, multivitamin, and as mentioned the patient has completed a course of Adriamycin and Cytoxan on [**2-18**]. ALLERGIES: The patient has no known drug allergies. FAMILY HISTORY: Her mother died at the age of 75 of gastric cancer. Her father is alive at the age of 84. He has a past medical history of benign prostatic hypertrophy, congestive heart failure, COPD, and a history of a stroke 2 years ago. The patient has 1 older sister and 2 [**Name2 (NI) 1685**] brothers. One of her brothers has a history of hypertension, and hypercholesterolemia, and GERD. SOCIAL HISTORY: The patient does not smoke tobacco. She occasionally drinks alcohol. She works as a home care nurse. She is a registered nurse, however she is currently not working. She immigrated from [**Location (un) 6847**] 15 years ago. She is married with 2 children; ages 17 and 19. PHYSICAL EXAMINATION ON ADMISSION: The patient is afebrile with a temperature of 98, a blood pressure of 112/87, a heart rate of 87, respirations of 18, and 98% on room air. She is in no acute distress. The extraocular motions of her eyes are intact bilaterally. Her neck is supple with no lymphadenopathy and no jugular venous distention. Her cardiovascular exam is the following; a regular rate and rhythm, S1 and S2 are appreciated. No murmurs, rubs, or gallops. Her lung exam was the following; the chest is clear to auscultation bilaterally. There is no wheezing. There are no rhonchi. There are no coarse breath sounds in any of the lung fields. Her abdomen is soft. It is nontender and nondistended. Her bowel sounds are positive. Her extremities are without cyanosis, without clubbing, and without edema. She has 2+ bilateral dorsalis pedis pulses. Her cranial nerve exam reveals cranial nerves II through XII are grossly intact. She is awake, alert, and oriented x 3. BRIEF SUMMARY OF HOSPITAL COURSE: She underwent bilateral mastectomies and bilateral [**Last Name (un) 5884**] reconstruction. Postoperatively, she was intubated on SIMV and transferred to the ICU for flap monitoring q. 15 minutes initially with a Doppler probe to assess for flap viability with both the probe and a clinical examination from the nurse on call along with plastic surgery residents and general surgery residents covering the breast service. The patient had 4 drains; 1 axillary drain on each side and 2 donor site drains from her abdominal incision. The plan for the patient overnight after surgery was to extubate sometime later in the morning. The patient did very well overnight and had no issues. She was afebrile. Her respiratory status was very good. She was on SIMV of 500 x 12 with a PEEP of 5 and an FiO2 of 50. Her breath sounds were clear to auscultation. Her labs were all normal. Her hematocrit did not trend down too much, and she looked good and able to be extubated on postoperative day 1. Again, her flaps were checked rigorously overnight. They were warm and well perfused. Capillary refill was roughly 2 seconds, and signals were dopplerable throughout the night, per the routine of the plastic and breast surgery services when doing these cases. On postoperative day 1, the patient had no untoward events. She had a very average output from her JP's that was not concerning for any hematoma. Her flaps, again, looked very good. They looked healthy. She was doing very well. She was changed to a p.r.n. analgesia. She was started on a clear liquid diet. On postoperative day 2, the patient had an episode of an elevated temperature. She tolerated her liquids very well. The patient was not transfused a unit. The plastic surgery service thought that she was deemed to be somewhat dilutional in her hematocrit, and that they would take a wait-and-see approach. They ordered to have diet advanced as tolerated, and she could be out of bed to a chair. Her A-line was discontinued. She was changed from IV to p.o. analgesia. She was transferred to the floor. Upon transferring to the floor, the patient's Foley was discontinued. Again the patient had no active bleeding, and it was decided that she not be transfused on postoperative day 2. On postoperative day 3, the patient was seen and examined. Found to be doing very well. Her pain was controlled. She was ambulating on her own. She was afebrile. Vital signs were stable. Her flaps looked excellent. Her JP's were appropriate. She was able to be controlled on oral medications. Her p.o. intake was very good. On postoperative day 4, the patient was seen. She was again afebrile. Her flaps looked excellent. Her donor site also looked excellent. Her drains, again, were appropriate. The plan was that the patient - given that her pain was tolerated on oral pain medications, she was taking a regular diet, she was able to go to the bathroom on her own - she was ready to be discharged to home. Since she was a nurse, she was able to monitor her JP drainage output. She had minimal teaching from the nurses on the floor and felt very comfortable with being able to provide that function for herself. MEDICATIONS ON DISCHARGE: She was discharged on Protonix 40 mg p.o. daily, on oxycodone 5 q.6h. (for pain). She was also discharged on Keflex 500 mg p.o. q.i.d. until her drains were removed. DISCHARGE INSTRUCTIONS AND FOLLOWUP: She was given followup to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. She was given instructions to call his office upon discharge and see him in 1 week. She was also given instructions to call Dr. [**Last Name (STitle) 11635**] and to schedule a follow-up appointment upon discharge. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSES: Left breast cancer. SURGERY PERFORMED: Bilateral mastectomies with immediate reconstruction using deep inferior epigastric perforator flaps. DISCHARGE DISPOSITION: To home. [**Name6 (MD) 17486**] [**Name8 (MD) 11635**], [**MD Number(1) 18026**] Dictated By:[**Last Name (NamePattern1) 18027**] MEDQUIST36 D: [**2191-3-28**] 04:45:47 T: [**2191-3-28**] 10:11:02 Job#: [**Job Number 18028**]

[ "530.81", "174.4", "401.9" ]

icd9cm

[ [ [] ] ]

[ "93.90", "85.7", "85.42", "99.04" ]

icd9pcs

[ [ [] ] ]

7574, 7831

1959, 2340

7406, 7550

6828, 7350

1753, 1942

1631, 1731

3645, 6801

229, 1074

2667, 3616

1097, 1607

2357, 2652

7375, 7384

15,646

102,898

557

Discharge summary

report

Admission Date: [**2145-11-14**] Discharge Date: [**2145-11-18**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Found Down Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] yo male with chronic kidney disease who presents to the ED after being found down at apt. Pt found by landlord after not being seen in 2 days and found in own feces. . ED: While in the ED, found to have K of 7, creat of 10, trop of 3 with nl CK. Received 10 U Insulin/ 1 amp D 50, Haldol/ativan, Kayexalate PR, Calcium gluconate 1 g x 2. Patient pulled foley catheter and NGT was unable to be placed. . When arrived on MICU floor, patient agitated and not responsive to questions. Withdraws to pain. Past Medical History: 1. Hypertension. 2. Chronic renal insufficiency (with a baseline creatinine of 4 documented as far back at [**2140**]). The patient has refused a workup for this in the past. Social History: Patient living alone, wife in rehab/[**Hospital1 1501**]. Per OMR: He is a former [**Company 2318**] worker. He use to drink heavily in his youth. No alcohol at all in the last 10 years. No tobacco. Family History: NC Physical Exam: t 97 BP 122/71 RR 19, 02 91-100%, HR 111 GEN: Arousable, agitated HEENT: MM dry, PERRL, EOMI Neck: JVP 6 cm CV: RRR, [**2-15**] murmur at LLSB Pulm: occ exp wheezes, otherwise clear bilaterally Abd: + bs-hypoactive, soft, non-distended, no masses Ext: [**1-11**] + pulses, no edema Skin: excoriations of LE and UE Neuro: moves all extremities Pertinent Results: [**2145-11-14**] 05:15PM WBC-7.8 RBC-2.90* HGB-10.0* HCT-31.1* MCV-107* MCH-34.3* MCHC-32.0 RDW-14.6 [**2145-11-14**] 05:15PM NEUTS-81.1* LYMPHS-11.0* MONOS-3.8 EOS-3.8 BASOS-0.3 [**2145-11-14**] 05:15PM PLT COUNT-292 [**2145-11-14**] 05:15PM PT-13.2* PTT-25.3 INR(PT)-1.2* [**2145-11-14**] 05:15PM TSH-0.26* [**2145-11-14**] 05:15PM ALBUMIN-3.4 CALCIUM-9.4 PHOSPHATE-9.3*# MAGNESIUM-3.0* [**2145-11-14**] 05:15PM cTropnT-3.02* [**2145-11-14**] 05:15PM GLUCOSE-128* UREA N-204* CREAT-10.0*# SODIUM-157* POTASSIUM-7.1* CHLORIDE-127* TOTAL CO2-8* ANION GAP-29* [**2145-11-14**] 05:15PM AST(SGOT)-25 CK(CPK)-98 ALK PHOS-234* AMYLASE-197* TOT BILI-0.2 [**2145-11-14**] 05:43PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG Brief Hospital Course: [**Age over 90 **] yo male with acute on chronic renal failure with severe electrolyte disturbances and azotemia. . ARF- Patient with longstanding renal failure with current azotemia and electrolyte disturbance consistent with acute worsening. The cause of the acute worsening was unclear but may have been partially due to hypovolemia causing a prerenal worsening of the function. Per renal recommendations, the patient was not immediately a candidate for dialysis treated with IV fluids and electrolytes were monitored. . Elevated troponin- no clear signs of cardiac ischemia, but does have significantly elevated troponin. No CK increase. Either purely due to ARF or recent ischemic event. . Social Issues - the patient had no health [**Doctor First Name 4540**] proxy upon admission, and we managed to contact a next of [**Doctor First Name **] ([**Name (NI) **] [**Name (NI) 4541**], nephew) after three days. Until that point, patient was deemed full code and was evaluated by both renal and orthopedics for hemodialysis and fractured femur respectively. We also contact[**Name (NI) **] the patient's PCP, [**Name10 (NameIs) 1023**] provided us with ample documentation of the patient's history of refusing treatments, including blood draws, colonoscopy, and chronic dialysis. Upon contacting the next of [**Doctor First Name **], the patient was made DNR/DNI, but preparations were made to proceed with dialysis. On the morning of [**11-18**], the patient became apneic and subsequently went into cardiopulmonary arrest with no obvious etiology. He was pronounced at 12:29pm, and the next of [**Doctor First Name **] was alerted. Medications on Admission: Nicardipine and toprol Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased

[ "276.7", "584.9", "276.52", "585.9", "276.0", "403.90", "410.71" ]

icd9cm

[ [ [] ] ]

[ "38.95", "39.95" ]

icd9pcs

[ [ [] ] ]

4206, 4215

2466, 4105

275, 281

4267, 4277

1645, 2443

4334, 4345

1261, 1265

4178, 4183

4236, 4246

4131, 4155

4301, 4311

1281, 1626

225, 237

309, 829

851, 1028

1044, 1245

64,645

198,615

4944

Discharge summary

report

Admission Date: [**2189-8-11**] Discharge Date: [**2189-8-13**] Date of Birth: [**2109-3-28**] Sex: M Service: MEDICINE Allergies: Ativan / OxyContin Attending:[**Doctor Last Name 10493**] Chief Complaint: Bilateral foot pain and hypotension Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 2491**] is an 80 year old man with DJD, ? gout, kidney disease, nonspecific interstitial pneumonitis (?amio toxicity), dilated cardiomyopathy with EF of 20-25% s/p ICD placement presenting with bilateral foot pain and falls for 3 weeks. The patient believes his symptoms began suddenly, and progressed over a 2 week time. He noted increasing pain, swelling in his ankle and 1st MTP joints bilaterally. Today, he got up out of bed felt light headed and nearly fell but quickly sat down without trma. He also noticed slightly worsening dyspnea on exertion and generalized weakness. He denied recent foot/leg trauma, fevers, chills, sweats, rash, other joint pains, recent travel, tick or insect exposure, sick contacts. Of note, he was recently admitted to an OSH for "dehydration" after steroid dose reduction. He was recently seen in pulmonology clinic on [**2189-8-5**] and had his steroids reduced from 10mg daily to 5mg daily in the setting of higher doses before this. After his fall, he decided to come to the ED after talking with his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1007**]. . In the ED, initial vitals were 98.2 97/65 76 24 98%RA. He denied SOB but looked dyspneic and upon further questioning admitted to dyspnea. He was noted to have increased pain and swelling of his ankles and MCP joints bilaterally and was given cefazolin 1gm IV ONCE for suspected septic arthritis. He was given 1 5/325 tab of percocet for his pain. He was subsequently noted to be hypotensive to 82/43. He was given 1L of NS wide open. Subsequently his saturation dropped to 94% on RA and he was placed on 2LNC. For the low blood pressure he was broadened to vancomycin 1gm IV ONCE. His pressures rose to 92/50 with his last vitals 99.3 61 18 99%2L. . On the floor, he remained asymptomatic but continued to be transiently hypotensive occasionally to the 80s, and at one point down to the 60s, and fortunately responded to a 250cc bolus of NS. He was given dexamethasone 4mg IV ONCE for presumed adrenal crisis. Ortho was consulted who recommended rheumatology consultation. Podiatry was consulted who offered to tap the joint, which a small amount of serosanguinous fluid was sent to the lab. The patient was subsequently started on vanc/cefepime/levofloxacin. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, 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) ILD/NSIP ? in setting of prior amiodarone use -[**2189-8-5**] outpatient PFTs: FVC of 2.86 liters, which is 73% predicted, an FEV1 of 1.96 liters to 79% predicted with an FEV1/FVC ratio of 68, which is 108% predicted. Compared to his last testing two and a half weeks ago there is a marked decline in both his forced vital capacity (about 400 mL) and a drop in his FEV1 by about 400 mL as well 2) Idiopathic DCM, chronic LBBB, sp ICD implantation for primary 3) Hypothyroidism 4) Bilateral TKR 5) T12 compression fracture in [**2188-3-3**] 6) Right peroneal nerve injury [**2189**],now improving 7) CKD . Social History: Happily married, retired, formerly involved in magazine advertising. - Tobacco: None - Alcohol: 1 drink of liquor daily, no excess beyond this - Illicits: None No h/o STIs, recent travel, tick exposures, etc. Family History: No history of autoimmune dz such as Lupus, RA Physical Exam: On admission: General: Alert, oriented, pleasant elderly man mildly dyspneic HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally except right basilar rales, no wheezes, 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 Rectal: Guiac negative brown stool. GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Musculoskeletal: Bilateral MTP joints with swelling, R>>L, On discharge: VS: T 96.9 BP 130/75 P 65 RR 18 SaO2 96% RA General: AAOx3, pleasant elderly man NAD HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: CTAB, no wheezes, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Rectal: Guiac negative brown stool. GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Musculoskeletal: Bilateral MTP joints with swelling, R>>L, no erythema/tenderness/warmth Pertinent Results: On admission: [**2189-8-11**] 10:15AM BLOOD WBC-15.9* RBC-3.34* Hgb-11.2* Hct-32.0* MCV-96 MCH-33.4* MCHC-34.9 RDW-14.2 Plt Ct-230 [**2189-8-11**] 10:15AM BLOOD Neuts-89.4* Lymphs-4.5* Monos-5.7 Eos-0.2 Baso-0.2 [**2189-8-11**] 08:21PM BLOOD ESR-52* [**2189-8-11**] 10:15AM BLOOD Glucose-147* UreaN-55* Creat-2.4* Na-128* K-5.5* Cl-97 HCO3-20* AnGap-17 [**2189-8-11**] 08:21PM BLOOD LD(LDH)-229 CK(CPK)-32* [**2189-8-11**] 10:15AM BLOOD proBNP-2288* [**2189-8-11**] 08:21PM BLOOD Calcium-8.6 Phos-3.5 Mg-1.7 [**2189-8-11**] 10:15AM BLOOD TSH-1.9 [**2189-8-11**] 10:15AM BLOOD Cortsol-31.9* [**2189-8-11**] 10:15AM BLOOD CRP-37.9* [**2189-8-11**] 10:21AM BLOOD K-5.4* . [**8-11**] CXR: Increased interstitial markings bilaterally, most noted in the periphery and at the lung bases, mildly increased since the prior study. Findings consistent with interstitial lung disease, which may have progressed. Overlying acute component not entirely excluded. . [**8-11**] foot films: No acute fracture or dislocation. Brief Hospital Course: 80 year old man with DJD, ? gout, kidney disease, chronic pneumonitis (?amio toxicity), dilated cardiomyopathy with EF of 20-25% and ICD placement for primary prevention and chronic pneumonitis presenting with bilateral foot pain and falls for 3 weeks with hypotension, [**Last Name (un) **], leukocytosis, worsening intestitial infiltrates. . #) Hypotension: Given low grade fever, leukocytosis, left shift, persistent pressures, chief concern was initially sepsis; however sx resolved rapidly after only 1 day on abx so infection was less likely. Cardiogenic shock due to CHF exacerbation/MI was also considered but EKG and physical exam ___and echo?___ made this less likely. CXR showing increased interstitial infiltrate density in setting of steroid-induced immunosuppression made atypical PNA a concern, and numerous studies for legionalla,PCP,[**Name10 (NameIs) 3019**],beta galactoman,glucan were all negative. Given increasing density of interstitial infiltrates on CXR and dyspnea, would be concerned about a an atypical pulmonary infection, although patient arrived with normal rest saturations. Ultimately, because pt presented with hyponatremia, hyperkalemia and recent steroid dose reduction, and because sx resolved rapidly after IV dexamethasone, it was concluded that adrenal crisis was most likely etiology of hypotension. On Day #2 he was transferred from MICU to floors where he received prednisone PO and remained afebrile with stable VS. Cortisol stim test and random cortisol both were elevated but this is because pt was being treated with steroids during test. . #) Arthritis: Given podagra in left MTP in setting of elevated serum uric acid, acout gout was diagnosed. There was also concern for septic arthritis given fever, white count etc so pt was initially started on broad spectrum abx but synovial fluid cx were negative. Sample was too small to send for light microscopy so crystal study could not be performed. Prednisone treatment ([**Last Name 788**] problem #1) helped treat gout and symptoms rapidly resolved. Lyme Ab, ESR, CRP, [**Doctor First Name **] were all negative/WNL. . #) Acute kidney injury: Creatine bump to 2.4 on admission; normalized to baseline of 1.8 during stay. Thus was most likely prerenal etiology from hypotension. . #) Dilated cardiomyopathy: Echo on hosp day #3 (done to R/O CHF as etiology of hypotension) showed no progression of CHF (severe systolic, EF 20-25%). . #) Hypothyroidism: TSH normal when checked to R/O hypothyroid as etiology of hypotension. Home levothyroxine continued. . #) GERD: Omeprazole Medications on Admission: 1) Azathioprine 100mg PO daily 2) Prednisone 5mg PO daily 3) Atorvastatin 10mg PO daily 4) Carvedilol 25mg PO BID 5) Enalapril 5mg PO daily 6) Levothyroxine 125mcg PO daily 7) Omeprazole 40mg PO daily 8) Tramadol 50-100mg PO BID PRN Pain 9) Aspirin 81mg PO daily 10) Bactrim DS tab PO 3x per week 11) folate 1 tab PO daily 12) Vitamin D 1 tab PO daily Allergies: 1) Oxycontin - agitated delerium 2) Ativan - agitated delerium Discharge Disposition: Home Discharge Diagnosis: 1. Adrenal insufficiency from stopping steroids 2. Acute gout flare Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital yesterday with low blood pressure and swollen feet. We determined that these problems had been caused by two different issues: being tapered too quickly off your steroids, and having a flare-up of your gout. There is a small chance that you have a joint infection; cultures of your joint fluid have been negative so far but you should follow up with your PCP about these results and/or if your symptoms worsen. You should go to all the appointments scheduled below to follow up on these problems and decide whether you should be started on medication for your gout. We have written you a prescription for Prednisone: 60 milligrams/day for 2 days, 40 milligrams/day for 3 days, 20 milligrams/day for 3 days, and then then 10 milligrams/day every day after that. We also wrote you a prescription for Colchicine 0.6 milligrams three times/day, which you should take as needed if you have another gout flare. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Department: PRIMARY CARE When: Thursday [**8-20**] at 2:30PM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**], M.D. ([**Telephone/Fax (1) 10492**]) Department: RHEUMATOLOGY WHEN: within 4-6 weeks. Dr.[**Name (NI) 20529**] office will call you with date of appointment. With: Dr. [**Name (NI) 9620**] ([**Telephone/Fax (1) 2226**]) Department: REHABILITATION SERVICES When: WEDNESDAY [**2189-8-19**] at 8:45 AM With: [**Name (NI) 2482**] [**Name (NI) 2483**], PT, CCS [**Telephone/Fax (1) 2484**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: WEDNESDAY [**2189-8-26**] at 10:20 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: MONDAY [**2189-8-31**] at 11:00 AM With: ICD CALL TRANSMISSIONS [**Telephone/Fax (1) 59**] Building: None None Campus: AT HOME SERVICE Best Parking: None [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]

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icd9cm

[ [ [] ] ]

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Discharge summary

report

Admission Date: [**2126-9-14**] Discharge Date: [**2126-9-18**] Date of Birth: [**2092-7-19**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2569**] Chief Complaint: severe headache Major Surgical or Invasive Procedure: [**2126-9-15**] Cerebral angiogram with verapamil injection to bil ICAs History of Present Illness: Mr. [**Known lastname 111912**] is a 34 yo RHM with a history of GERD and vitiligo who presented to [**Hospital1 18**] as a transfer from OSH for headache with SAH on NCHCT. Patient was in his usual state of health until Friday evening when he developed a sudden rapidly progressive b/l R sided frontal headache with 10/10 intensity followed by nausea and several episodes of vomiting (at the end of which he noted some coffee ground emesis). Of note, headache came on at a time when he was having an intense argument with his girlfriend. [**Name (NI) **] notes that after 2-3 hours, that his headache quickly dissipated (he also had taken 2 naproxen at that time)and continued to decrease in severity since that time. On Saturday morning, he woke up with a hint of a headache which he thought worsened only with valsalva, coughing and rapid shaking of his head from side-to-side. . He had a very similar episode 1 month prior with sudden onset [**11-13**] headache. That episode lasted only 10 seconds and dissipated on its own without intervention. He had never experienced anything prior to that beforehand. . His headache history is otherwise unremarkable. He does not have headaches very often. He does notice that sometimes when he drinks beer, he has a mild b/l posterior headache. He has never been so inebriated that he would have been unaware of a severe headache. Upon arrival to the ER, a CTA head was performed which showed vasospasm in the distal ICA/proximal MCA as well as L ACA, raising concern for Reversible Cerebral Vasoconstriction Syndrome. He was admitted to the ICU for monitoring. . He otherwise denies neurological symptoms on ROS. He has no significant family history of neurological disease. He denies cocaine use or other stimulants. Past Medical History: GERD vitiligo Social History: Quit smoking 1 year ago, drinks 1 drink per day, no illicits. Family History: No aneurysm, strokes, intracerebral bleeds in family Physical Exam: PHYSICAL EXAM ON ADMISSION: Hunt and [**Doctor Last Name 9381**]: 1 [**Doctor Last Name **]: 2 GCS 15 O: T:97.8 BP:134/86 HR:106 R14 O2Sats 100% RA Gen: WD/WN, comfortable, NAD. HEENT: NC/AT Neck: Supple.no nuchal rigidity Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4to3 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally with extinquishing nystagmus on leftward gaze. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to finger rub bilaterally. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**6-8**] throughout. No pronator drift Sensation: Intact to light touch, propioception bilaterally. Reflexes: B T Br Pa Ac Right 2 2 2 2 1 Left 2 2 2 2 1 Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin . PHYSICAL EXAM ON DISCHARGE: -Vitals: 98.1 110/68 [110-135/68-99] 81-90 20 100% RA -Neuro: completely intact Pertinent Results: Labs on Admission: [**2126-9-14**] 05:59PM estGFR-Using this [**2126-9-14**] 05:59PM NEUTS-69.2 LYMPHS-22.5 MONOS-6.4 EOS-1.6 BASOS-0.3 [**2126-9-14**] 05:59PM PT-10.8 PTT-29.6 INR(PT)-1.0 [**2126-9-14**] 05:58PM LACTATE-1.7 [**2126-9-14**] 05:59PM GLUCOSE-105* UREA N-12 CREAT-1.0 SODIUM-140 POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-25 ANION GAP-14 [**2126-9-14**] 10:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG Relevant Labs: [**2126-9-15**] 04:34AM BLOOD ANCA-NEGATIVE B [**2126-9-15**] 04:34AM BLOOD [**Doctor First Name **]-NEGATIVE [**2126-9-15**] 04:03AM BLOOD RheuFac-8 CRP-0.7 [**2126-9-15**] 04:03AM BLOOD ESR-4 Imaging: NCHCT: hyperdensity in the quadrigeminal cistern CTA head/neck: 1. Diffuse subarachnoid hemorrhage identified in the non-contrast head CT, more conspicuous at the right ambient cistern. There is no evidence of hydrocephalus or intraventricular hemorrhage. 2. The 3D rendering reconstructions of the intracranial vessels, demonstrate vasospasm at the M1 and A1 segments with no definite aneurysm identified or vascular malformation. MRI OF THE HEAD: Trace of subarachnoid hemorrhage is redemonstrated with high signal intensity in the sulci evident on the FLAIR sequence (image #9, series #14, image #15, #16, series #14). There is no evidence of hydrocephalus or shifting of the normally midline structures. The diffusion-weighted sequences demonstrate a questionable cortical area with high signal intensity on the DWI sequence with no definite restricted diffusion, possibly related with T2 shining-through effect from diffuse subarachnoid hemorrhage. The major vascular flow voids are patent. The orbits are unremarkable, the paranasal sinuses and the mastoid air cells are clear. IMPRESSION: Evidence of subarachnoid hemorrhage, previously demonstrated by CT of the head, there is no evidence of intraventricular hemorrhage or hydrocephalus. No definite areas with restricted diffusion are identified, there is possible T2 shining-through effect along the left parietooccipital region, possibly related with subarachnoid hemorrhage. MRV OF THE HEAD. The major dural venous sinuses are patent, the superior longitudinal sinus, straight sinus and transverse sinuses are patent with no evidence of venous sinus thrombosis. IMPRESSION: Essentially normal MRV of the head. MRA BRAIN WITHOUT CONTRAST ([**9-16**]): There is evidence of vascular flow in both internal carotid arteries as well as the vertebrobasilar system, the supraclinoid carotid arteries are notable for bilateral vasospasm involving the A1 and M1 segments, no aneurysms larger than 3 mm in size are seen. The basilar artery and the posterior cerebral arteries are grossly unremarkable, the anterior cerebral arteries are patent and appear grossly normal. IMPRESSION: Bilateral vasospasm involving the supraclinoid carotid arteries, extending at the level of M1 and A1 segments as described above, no aneurysms larger than 3 mm in size are seen, the visualized vascular structures of the posterior circulation are unremarkable. Brief Hospital Course: 34yo M without significant pmh, presents with sudden intense headache and found to have SAH in the basal cistern on NCHCT. # Neuro: Patient was initially admitted to Neurosurgical service who took care of him during first two days in ICU. He was started on Dilantin for seizure prophylaxis and Nimodipine for prevention of vasospasm. His SBP goal was 100-160. He remained stable overnight. On HD#2, patient underwent angiogram with Dr. [**Last Name (STitle) **], revealing moderate narrowing of both ICAs. Prednisone 100mg x3 doses was ordered as precaution given concern for vasculitis. MRI head did not show any evidence of acute or prior infarcts and MRV head showed patent sinuses. Patient was transferred to neurology service on HD #3. Nimodipine was d/c'ed and started Verapamil 80mg PO tid instead presumptively for vasospasm. Dilantin was discontinued, as SAH was quite small and not in location typically associated with seizures. Imaging revealed vasospasm of the distal ICA/proximal MCA as well as L ACA, raising concern for Reversible Cerebral Vasoconstriction Syndrome. Neuro exam did not demonstrate any abnormality. CTA with no evidence of aneurysm. MRA head with no acute infarct. MRV brain with patent sinuses. Angiogram showed b/l moderate narrowing of ICAs. TCD was normal. The etiology of his bleed was likely small vessel extravasation secondary to vasospasm as no aneurysms were visualized on multiple imaging modalities. Differential also included vasculitic process; however, ESR/CRP, ANCA and RF, [**Doctor First Name **] are all normal. . On HD #4 patient was transferred to the neurology floor, where his neurologic exam remained normal and nonfocal. On discharge he was switched to Verapamil LA 180mg PO daily. His neuro exam on discharge remained completely nonfocal. He declined outpatient angiogram, so will instead have outpatient CT in one month to follow up on his vasospasm and see whether it has resolved. . ==================== TRANSITIONS OF CARE: -Needs outpatient CT angiogram in 4 weeks -Will follow up with Dr. [**First Name (STitle) **] and Dr. [**First Name (STitle) **] Medications on Admission: Naproxen 500 mg PO Q8H:PRN pain Zantac prn Discharge Medications: 1. Verapamil SR 180 mg PO Q24H RX *verapamil 180 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 Discharge Disposition: Home Discharge Diagnosis: Subarachnoid hemorrhage Vasospasm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with a severe headache followed by nausea and vomiting. You were found to have a subarachnoid hemorrhage (bleeding on the surface of the brain), and cerebral artery vasospasm (constriction/spasm of the arteries supplying your brain). We believe that you may have a condition called Reversible Cerebral Vasoconstriction Syndrome, which is a temporary narrowing of the cerebral arteries that results in bleeding. However, you will need further brain imaging as an outpatient to confirm this diagnosis. . Please attend the outpatient follow-up appointments with neurologist Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] (see below). You will need a CT angiogram (CTA) in FOUR WEEKS, prior to your appointment with Dr. [**First Name (STitle) **] (see below for information on how to schedule this). . We made the following changes to your medications: 1. STARTED verapamil 180mg by mouth daily 2. STOPPED naproxen (increases risk for bleeding) -- for headache in the future, you should take Tylenol if needed. Followup Instructions: -You will be called by the radiology department to schedule an outpatient CT angiogram (CTA) in FOUR WEEKS. If you do not hear from them within one week, please call ([**Telephone/Fax (1) 111884**] to schedule the appointment. Department: NEUROLOGY When: MONDAY [**2126-11-18**] at 2:00 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**] Building: [**Hospital6 29**] [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

[ "435.9", "709.01", "530.81", "V15.82", "430" ]

icd9cm

[ [ [] ] ]

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35545

Discharge summary

report

Admission Date: [**2182-3-16**] Discharge Date: [**2182-3-22**] Date of Birth: [**2135-9-29**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6346**] Chief Complaint: Post-operative abdominal pain, surgical abdominal wound Major Surgical or Invasive Procedure: None at this institution. Patient underwent small bowel resection and primary closure of the wound on [**2182-3-14**] at outside hospital prior to transfer to [**Hospital1 18**] on [**2182-3-16**]. History of Present Illness: 47 year old smoker who underwent an elective laparascopic assisted sigmoid colectomy for diverticulitis on [**2-27**]. His postoperative course was complicated by an anastomotic leak and on [**3-4**], he was taken back to the OR for a reversal of his coloproctostomy and creation of a diverting colostomy. Subsequent to that, he developed a wound infection that was opened at the bedside and packed. He was discharged home on [**3-14**], but coughed on the way home and noted a gush of fluid at that time from the abdomen. He called his PCP's office and when examined there, he was found to have a rupture of a small bowel. On [**3-14**], he underwent a small bowel resection and primary closure of the wound. He was transferred to [**Hospital1 18**] late on [**2182-3-16**]. Past Medical History: Past Medical History: Diverticulitis, Hypertension, C.O.P.D., Alcohol (6 pack/day) and tobacco abuse (45 pk. yrs), G.E.R.D, Left clavicle fracture Past Surgical History: s/p lap sigmoidectomy [**2182-2-27**] for recurrent diverticulitis complicated by anastomotic leak, then s/p resection, end colostomy [**2182-3-4**] c/b evisceration, small bowel perforation s/p small bowel resection and primary closure of wound [**2182-3-14**]. Removal of lymph node left breast in [**2164**] Social History: Unemployed. Previously worked in construction. Married with three children. Smokes 1.5 PPD x 30 years. Drinks 6 beers daily. Denies illicit substance use. Family History: Father with skin cancer, mother with angina. Five brothers and three sisters alive and well. Physical Exam: VS: T:98.7, BP:154/96, HR:88, RR:18, SaO2: 97% RA GEN: Well appearing male in NAD. HEENT: Sclerae anicteric. O-P moist, intact. NECK: Supple. No lymphadenopathy. LUNGS: CTA(B). CARDIAC: RRR; nl S1/S2 w/o m/c/r. ABD: Protuberant. (L)LQ stoma pinkish-red, intact, patent. Ostomy intact. Hourglass-shaped surgical wound 17cm x 6cm x 3.5cm granulating, no exudate. Wet-to-Dry dressing in place for discharge home, then VAC dressing will be replaced. Normoactive BSx4. Appropriate minimal wound area tenderness, soft, ND. EXTREM: Mild dependent lower extremity non-pitting edema w/o erythema, pallor, cyanosis. Negative [**Last Name (un) 5813**] sign. No knots. NEURO: A+Ox3. Non-focal/grossly intact. SKIN: As above, otherwise intact. Pertinent Results: [**2182-3-21**] Lower extremity Duplex Venous U/S (bilateral): No DVT of the bilateral lower extremity veins. Brief Hospital Course: 46 male s/p lap sigmoid resection complicated by anastomotic leak, s/p ex-lap with anastomotic resection and end colostomy complicated by wound dehiscence and bowel perforation, s/p ex-lap with [**Hospital 80929**] transferred to [**Hospital1 18**] SICU from [**Hospital **] hospital early on [**2182-3-17**]. He was made NPO, an NGT was placed, and TPN via a (L) subclavian CVL and IV Zosyn and Fluconazole continued. He was placed on a Dilaudid PCA, and given toladol and tylenol for pain control with good effect. A VAC dressing was placed to the adbominal wound. The patient remained hemodynamically stable during the SICU stay. On [**2182-3-18**], the patient was transferred to the floor NPO, with the NG tube in place, continued of IV fluids, same IV antibiotics, and TPN. A foley catheter was placed. Pain Service was consulted to augment the patient's pain control regimen; adjustment to the patient's Dilaudid PCA in addition to the use of Toradol resulted in improved pain control. On [**2182-3-19**], the NGT and foley were discontinued. Patient was started on clear liquids, which he tolerated well. Pain remianed well controlled. He remained stable. On [**2182-3-20**], flatus was present in ostomy; his diet was further advanced to regular with continued good tolerability. He was weaned off the TPN. VAC dressing was changed with noted improvement of the wound. He was placed on Diludid PO with round-the-clock tylenol for pain control with excellent effect. On [**2182-3-21**], the patient complained of mild lower extremity non-pitting edema with faint, diffuse patchy erythema. Swelling symmetrical; no knots or calf pain. Negative [**Last Name (un) 5813**] sign. Sent for bilateral lower extremity duplex venous U/S study, which did not reveal a DVT. Ambulated frequently. On [**2182-3-22**], IV antibiotics and the CVL were discontinued. VAC dressing was taken down with a wet-to-dry dressing placed for discharge home. Local [**Date Range 269**] will then replace VAC dressing for continued wound care. He remained stable during his stay on the floor. At the time of discharge, the patient was doing well, afebrile with stable viral signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Local [**Date Range 269**] will manage the patient's VAC dressing at home. The patient will follow-up with Dr. [**Last Name (STitle) 80930**] and his PCP in the next 2 weeks. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Atenolol 75mg PO daily, Percocet 5/325mg 1-2 tabs PO q4-6 prn pain, Nicotine transdermal patch 7 mg, Albuterol MDI 2 puffs QID PRN Discharge Medications: 1. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*14 Patch 24 hr(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): Attn Pharmacist: [**Month (only) 116**] substitute Zantac 150mg 1 tab PO BID (#60 2RF) if Famotidine not covered by insurance. Disp:*60 Tablet(s)* Refills:*2* 5. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO every four (4) hours as needed for pain. Disp:*70 Tablet(s)* Refills:*0* 6. Atenolol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* Discharge Disposition: Home With Service Facility: [**Hospital 269**] Home Health and Hospice Services Discharge Diagnosis: Post-operative anastomotic leak followed by surgical site dehiscence. Discharge Condition: Good. Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**4-28**] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. . VAC Dressing: * Your [**Month/Year (2) 269**] Nurse will manage the VAC dressing settings, change the dressing, monitor the wounds healing progress, and interact with your provider to make any changes. * Please call your [**Name6 (MD) 269**] [**Name8 (MD) **], MD, or go to the ER if you experience significant new pain at the dressing site, the dressing comes undone or the vacuum seal fails, you experience a malfunction in the equipment, or there a prolonged power loss affecting the VAC system. is pus present, significantly increased output, or a change in the consistency or appearance of the drainage. Followup Instructions: Please call ([**Telephone/Fax (1) 80931**] to schedule a follow-up appointment with Dr. [**Last Name (STitle) 80932**] (PCP) in 2 weeks. You have an appointment with Dr. [**Last Name (STitle) 80930**] on Thursday, [**4-4**] at 1:35pm for post-hospital follow-up. Location: 3 Alumni Dr # 201 [**Location (un) 8641**], [**Numeric Identifier 59342**]. Telephone:([**Telephone/Fax (1) 80933**]. Office fax: ([**Telephone/Fax (1) 80934**]. Completed by:[**2182-3-22**]

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icd9cm

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593

Discharge summary

report

Admission Date: [**2137-11-6**] Discharge Date: [**2137-11-20**] Date of Birth: [**2065-8-18**] Sex: F Service: MEDICINE Allergies: Adhesive Tape Attending:[**First Name3 (LF) 4654**] Chief Complaint: Altered mental status, hypotension, hypoxia. Major Surgical or Invasive Procedure: CT-guided drainage of left gluteal abscess ([**2137-11-15**]). History of Present Illness: Mrs. [**Known lastname 4636**] is a 72 y/o woman with PMH notable for paraplegia [**1-5**] anterior spinal artery infarct, indwelling suprapubic catheter with frequent UTIs admitted with altered mental status and hypoxia. Per nursing facility notes, the patient was noted to be unresponsive to voice commands but responsive to tactile stimuli. Vitals at the time were BP 100/50, HR 100, RR 20, O2 80% on RA which increased to 97% on 6 L NC. Reportedly, she is alert & oriented X 3 at her baseline. Of note, she is currently on nitrofurantoin 100 mg PO BID for a UTI (? culture result) which she started on [**2137-10-29**] for a planned 10 day course. She apparently also complained of nausea and may have vomited so lactulose was held today. . On arrival to the ED, initial vitals were T 102.1, HR 100, BP 132/56, RR 24, 97% on 15 L via nasal cannula. Blood pressure trended down to 80s systolic. She was originally on peripheral dopamine for BP improvement but as this was not effective, it was changed to peripheral levophed with subsequent improvement in blood pressures to 120s systolic. Blood and urine cultures were sent. She was treated with PR tylenol, levofloxacin 750 mg IV X 1, vancomycin 1 g IV X 1, and 1 g ceftriaxone X 1. She received a total of 6 L NS in the ED. . On arrival to the MICU, the patient denies any pain. She is alert and speaking a few words at a time though they are difficult to interpret. She specifically denies any shortness of breath or any abdominal pain. Past Medical History: Past Medical History: (from OMR) - Paraplegia [**1-5**] Anterior Spinal Infarct ([**2128**]) - Thoracic Aneurysm Repair ([**2128**]) - COPD (? on home O2). With history of LLL Collapse/PNA s/p mucous plug removal via bronchoscopy. - HTN - Hyperlipidemia - GERD - Suprapubic Catheter Placement / UTIs on Ppx Bactrim - Fecal Incontinence - Depression - Atraumatic comminuted L intertrochanteric femur fracture - Chronic sacral decubitus ulcers with past bilateral ischial tuberosity osteomyelitis Social History: The patient admits 2-3ppd x 40+ years, but has smoked intermittently for the past five years. The patient denies alcohol or illicit drug use. Her son, [**Name (NI) **], is listed as her HCP ([**Telephone/Fax (1) 4635**]); however, he tells me that she "has made it clear she wants nothing to do with him" and he defers to his other brother [**Name (NI) 1704**], [**Telephone/Fax (1) 4655**]. Family History: Son has DM. Physical Exam: VS T 101.3, HR 84, BP 153/42, RR 23, O2 97% on 4L NC Gen: obese elderly woman lying in bed, eyes open, no acute distress HEENT: PERRL, EOMI, OP clear, MMM Neck: no JVD, no lymphadenopathy, no meningismus CV: RRR, no appreciable murmur Chest: grossly clear with occasional expiratory wheezing Abd: obese, distended but soft, normoactive bowel sounds, no tenderness to palpation; suprapubic catheter in place with dressing; + erythematous yeast infection inferior to both breasts and in groin around to back Ext: upper extremities with > tone than lower extremities, bilateral lower ext in multipodus boots, no peripheral edema Back: sacral ulcer which probes to bone, some thick tan discharge in wound but tissue appears beefy red; bilateral ischial ulcers 2 cm in size Neuro: face symmetric, CN II-XII grossly intact, bilateral hand grip [**3-9**], shoulder shrug symmetric bilaterally, does not move either leg, DTRs not elicited at bilateral biceps, patellae; speaking short sentences & seems to appropriately answer yes/no questions; denies any pain; toes mute bilaterally; upper extremities stiff. Pertinent Results: Labs at admission [**2137-11-6**] 11:00AM BLOOD WBC-16.7*# RBC-4.56 Hgb-12.1 Hct-36.8 MCV-81* MCH-26.6* MCHC-32.9 RDW-17.6* Plt Ct-416 [**2137-11-6**] 11:00AM BLOOD Neuts-88.5* Lymphs-7.6* Monos-3.1 Eos-0.3 Baso-0.4 [**2137-11-6**] 07:37PM BLOOD PT-17.8* PTT-25.6 INR(PT)-1.6* [**2137-11-6**] 11:00AM BLOOD Glucose-141* UreaN-9 Creat-0.5 Na-145 K-2.8* Cl-104 HCO3-29 AnGap-15 [**2137-11-6**] 07:37PM BLOOD Albumin-2.4* Calcium-6.6* Phos-1.4*# Mg-1.7 . Culture data . [**2137-11-15**] ABSCESS GRAM STAIN-FINAL; WOUND CULTURE-FINAL {STAPH AUREUS COAG +}; ANAEROBIC CULTURE-PRELIMINARY INPATIENT [**2137-11-15**] BLOOD CULTURE negative [**2137-11-14**] BLOOD CULTURE negative [**2137-11-13**] BLOOD CULTURE negative [**2137-11-13**] BLOOD CULTURE negative [**2137-11-12**] BLOOD CULTURE negative [**2137-11-12**] BLOOD CULTURE negative [**2137-11-11**] BLOOD CULTURE negative [**2137-11-11**] BLOOD CULTURE negative [**2137-11-10**] BLOOD CULTURE MRSA [**2137-11-10**] BLOOD CULTURE negative [**2137-11-9**] BLOOD CULTURE negative [**2137-11-9**] BLOOD CULTURE negative [**2137-11-8**] BLOOD CULTURE MRSA [**2137-11-8**] URINE CULTURE YEAST [**2137-11-8**] BLOOD CULTURE negative [**2137-11-7**] BLOOD CULTURE negative [**2137-11-7**] BLOOD CULTURE negative [**2137-11-7**] BLOOD CULTURE negative [**2137-11-6**] URINE CULTURE YEAST [**2137-11-6**] BLOOD CULTURE MRSA . Studies . Chest x-ray ([**2137-11-6**]) There is bilateral atelectasis. There is no evidence of focal consolidation that would be indicative of pneumonia. There is no evidence of congestive heart failure. The mediastinal and cardiac contours are stable. There is again evidence of post-surgical changes. There is no pleural effusion and no evidence of pneumothorax. The visualized osseous structures are stable. IMPRESSION: No evidence of pneumonia. . Transthoracic echocardiogram ([**2137-11-9**]) The left atrium and right atrium are normal in cavity 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. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). 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 a trivial/physiologic pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Compared with the prior study (images reviewed) of [**2136-9-12**], the findings are similar. . CT head without contrast ([**2137-11-9**]) 1. No evidence of acute intracranial abnormalities. 2. Fluid in the right maxillary sinus, which may indicate acute sinusitis. . MR pelvis ([**2137-11-10**]) IMPRESSION: 1. Large sacral/coccygeal decubitus ulcer extending up to the inferior sacrum. Abnormal signal involves both sides of the inferior sacrum, likely from a combination of osteomyelitis. Te possibility of a superimposed nondisplaced left sacral alar insufficiency fracture cannot be excluded. 2. 2.6- cm rim-enhancing high T2 structure in the left gluteal soft tissues lateral to and apparently communicating with the ulcer tract -- ? abcess collection vs packing material in recess of ulcer. Please see comment above. 3. Stable appearance of the ulcer tracts extending up to the ischial tuberosities bilaterally with abnormal signal and enhancement about the posterior aspect of the ischial tuberosities, consistent with osteomyelitis. 4. Old left intertrochanteric fracture only partially imaged on today's study. 5. Prominent sacral Tarlov's cysts. 6. Suprapubic catheter seen approaching the bladder; it is difficult on the images performed today to determine if the balloon and tip are in fact within the bladder lumen. Clinical correlation is therefore requested -- is this tube draining urine?. 7. Distended large bowel most consistent with ileus. . MR brain ([**2137-11-10**]) 1. Unchanged bilateral white matter foci of hyperintensities on T2-weighted and FLAIR images may correspond to chronic microvascular ischemia. 2. No evidence of acute infarction, masses, or other lesions. 3. Limited MRA evaluation of the brain due to a significant image degradation from motion artifact demonstrates no identifiable stenosis, occlusion, aneurysm in the visualized vessels. The MCAs and the left vertebral artery are poorly visualized. . EEG ([**2137-11-12**]) IMPRESSION: This is a normal routine EEG in the waking and drowsy states. There is no evidence of focal slowing or epileptiform discharges. . CT-guided drainage of left gluteal abscess ([**2137-11-15**]) 1. Successful CT-guided aspiration of approximately 1 cc of bloody pus from the left parasacral/left gluteal collection. 2. Sclerosis of both ischial tuberosities, highly suggestive of osteomyelitis. 3. Persistent left intertrochanteric fracture. . Chest x-ray PA and lateral ([**2137-11-16**]) There are multiple healed rib fractures from prior thoracotomy on the left, with residual osseous deformity. Right PICC terminates in the superior vena cava. There is bibasilar atelectasis. IMPRESSION: No appreciable change from the prior study. Brief Hospital Course: A 72 year-old woman with past medical history notable for paraplegia secondary to spinal artery infarct, COPD, and indwelling suprapubic catheter admitted with mental status change, fever, and leukocytosis. . 1. Septic shock. She presented with low blood pressure, elevated white count, fever, and mental status change. She was bolused with 6L normal saline in the ED and started on dopamine. When she arrived to the ICU levophed was running peripherally with systolic blood pressures in the 130s. This was quickly weaned off and her systolic BP stablized in the 90-110s. Overnight, she was started on vancomycin and cefepime for empiric coverage of sepsis from UTI versus other source, such as large stage IV sacral decubitus ulcer. A blood culture from this first hospital day later grew out methicillin resistent staph aureus. A urine culture grew out [**Female First Name (un) **] but no significant bacteria. Thus the vancomycin was continued and cefepime discontinued on hospital day 3. Her suprapubic catheter was changed in the ICU. Infectious disease was consulted for treatment recommendations. They agreed that sacral decubitus ulcer was the likely source for bacteremia and recommended MR [**First Name (Titles) **] [**Last Name (Titles) 4656**] for sacral osteomyelitis as well as TTE to [**Last Name (Titles) 4656**] for valvular vegetations. Blood cultures were followed serially. The echocardiogram, as above, was negative for endocarditis. Three subsequent blood cultures grew out MRSA; the last was on [**11-10**]. Vancomycin was continued. Surveillance cultures were followed through [**11-14**] and all returned negative. Once therapeutic on vancomycin, she defervesced and her white count returned to [**Location 213**]. She will need to complete a six-week course of vancomycin (last day will be [**12-24**]) for treatment of osteomyelitis. A right PICC line has been placed for this purpose. . 2. Altered mental status. On admission, she was minimally interactive, somnolent, and disoriented. Overnight in the ICU, her mental status improved such that she was talking and interactive, with improved speech, following commands and oriented x3 by the first hospital day. This is how she appeared when she was transferred to the medicine floor. It was believed at the time that her altered mental status was due to fever and infection. However, when she did not make significant improvement over the first weekend, neurology was consulted. Per their note, the altered mental status was likely secondary to toxic/metabolic encephalopathy in the context of infection. However, they recommended MR [**First Name (Titles) **] [**Last Name (Titles) 4656**] for stroke and consideration of lumbar puncture. MR brain showed no acute abnormalities. Her mental status continued to improved during the week, although she still has periods of waxing and [**Doctor Last Name 688**] alertness. Her oxygen sats have been fine on RA, CXR was negative for infiltrate, and MR as above was negative. . 3. Urinary tract infection / leakage around suprapubic catheter. Her first urine culture grew out >100,000 colonies of [**Female First Name (un) **]. She had been started on fluconazole in the unit and her suprapubic catheter changed. However, given that she was not symptomatic, infectious disease offered that she did not need to continue the fluconazole. She was noted to have leakage around her suprapubic catheter. [**Female First Name (un) 159**] was called and instructed us to restart her oxybutynin which had been stopped for concern of mental status change. She has follow-up planned in [**Female First Name (un) **] clinic as outlined in discharge instructions. . 4. Sacral decubitus ulcer and ischial ulcers. She presented with a stage IV sacral decubitus ulcer and two stage III ulcers over the ischial tuberosities. Plastics, consulted in the ED, recommended wet-to-dry dressing changes three times daily, with frequent turning and kinair bed. Patient was started on zinc/vitamin c/mvi and nutritional supplements to ensure adequate wound healing. As above, MR sacral spine was ordered to [**Female First Name (un) 4656**] for osteomyelitis. This showed a small fluid collection in the left gluteal soft tissue concerning for abscess. Interventional radiology drained this abscess percutaneously under CT-guidance. One cc of bloody pustular fluid was drained that later grew out MRSA. She will continue IV vancomycin as above for a total six week course. Dressing changes should continue as outlined in the discharge orders. . 5. Hypoxia. Initially she required oxygen in the ED and overnight in the ICU. Chest x-ray showed volume overload but no infiltrate. With treatment of her infection her oxygen requirements gradually improved. We continued her home COPD regimen of inhaled steroids and bronchodilators, and her oxygen saturation steadily improved. . 6. Fungal infections. We treated superficial fungal infections under the breast and in the groin with miconazole powder. . 7. Paraplegia s/p spinal artery infarct. We continued her outpatient baclofen. . 8. Abdominal distension/nausea. This improved overnight in the ICU and was no longer a problem at time of transfer to the floors. LFTs were within normal limits. . 9. Osteoporosis. We continued her outpatient calcium, vitamin D, and fosamax. . Her diet was progressed to normal diet with ensure supplements. She was kept on subcutaneous heparin for venous thrombosis prophylaxis. Her code status is DNR/DNI. Medications on Admission: * alendronate 70 mg weekly on Thursday * protonix 40 mg daily * zincate 220 mg daily * MVI daily * vitamin D 800 U daily * ASA 81 mg daily * buspar 10 mg [**Hospital1 **] * baclofen 40 mg TID * lactulose 30 mL daily * heparin 5000 U sc tid * bisacodyl 10 mg daily * nortriptyline 50 mg qhs * combivent 1 puff q6h prn * tylenol 650 mg po prn * ensure tid with meals * milk of mag 30 mL daily prn * bisacodyl 10 mg pr daily prn * fleet's enema prn * macrobid 100 mg [**Hospital1 **] X 10 days (last day [**11-7**]) * advair 250/50 [**Hospital1 **] * vitamin c 500 mg [**Hospital1 **] * senna [**Hospital1 **] * colace 100 mg [**Hospital1 **] * gabapentin 900 mg q8h * oxybutynin 5 mg tid * calcium carbonate 1000 mg tid Discharge Medications: 1. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week: Take one pill every Thursday. 2. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours) for 7 weeks: Continue through [**2137-12-25**]. 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for yeast. 4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 6. Baclofen 10 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Buspirone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 13. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO Q8H (every 8 hours). 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 17. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 19. Nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 20. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 21. Heparin, Porcine (PF) 5,000 unit/0.5 mL Syringe Sig: One (1) Injection three times a day. 22. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO once a day. 23. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: [**Hospital6 4657**] - [**Location 1268**] Discharge Diagnosis: Primary Diagnosis Sepsis secondary to osteomyelitis . Secondary Diagnoses Chronic sacral and ischial decubitus ulcers Paraplegia secondary to anterior spinal artery infarct Hypertension Hyperlipidemia Gastroesophageal reflux disease Chronic obstructive pulmonary disease Fecal incontinence Discharge Condition: Vital signs stable. Afebrile. Discharge Instructions: You were hospitalized for treatment of sepsis. We believe the source of the infection was the ulcer over your lower back. Cultures we took of the blood grew out bacteria that likely originated from this ulcer. You were treated with intravenous antibiotics for the infection. Please continue to take the antibiotics for a period of 6 weeks. Because the antibiotics were started on [**11-6**], the last dose should happen on [**12-24**]. . Your follow-up appointments are listed below. . Please call your doctor or return to the emergency room if you have fever, change in mental status, or any other symptoms that are concerning to you. Followup Instructions: 1. Follow-up with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**Last Name (STitle) **] clinic [**11-25**], [**Hospital Ward Name 23**] [**Location (un) **] at 3PM: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD Phone: [**Telephone/Fax (1) 921**] Date/Time:[**2137-11-25**] 3:00 . 2. Follow-up in infectious disease clinic with Dr. [**First Name (STitle) **]: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2137-12-20**] 10:30 . 3. Follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1266**], as needed: [**Telephone/Fax (1) 608**]. [**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**] Completed by:[**2137-11-20**]

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icd9cm

[ [ [] ] ]

[ "38.93", "83.95" ]

icd9pcs

[ [ [] ] ]

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11422

Discharge summary

report

Admission Date: [**2205-6-21**] Discharge Date: [**2205-7-10**] Date of Birth: [**2150-9-2**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1234**] Chief Complaint: L. foot infection Major Surgical or Invasive Procedure: 1) Debridement of left lower extremity fifth toe/ray amputation. 2) Serial arteriogram of the left lower extremity. 3) Left superficial femoral artery to anterior tibial artery bypass graft using reversed greater saphenous vein, angioscopy, vein inspection and valve lysis. 4) Debridement of wound including bone and partial closure of wound over left fifth ray, left foot. History of Present Illness: This is a 54 y/o male with a known vascular pathology history, who presents with a L. lateral foot infection since 7 days ago. The patient noticed redness and swelling 7 days ago and then noticed the ulcer and odor over the past three days. Over the past three days, the pain increased and the patient self-treated the wound with alcohol swabs and bacatracin. The patient states some neuropathy, but has foot sensation. The patient denies chills/fever, constitutional symptoms, nausea/vomitting, rest pain, LLE pain on ambulation, or wound drainage. His last vascular procedure was an angioplasty of the RLE trifurcation for ischemic pain at [**Hospital1 2025**] this past [**Month (only) 404**]. Past Medical History: VASCULAR RISK FACTORS: Diabetes, Hypercholesterol, Hypertension, Obesity, Smoking History. VASCULAR HISTORY: Stent Placement: ? LE, cardiac. PAST MEDICAL HISTORY: HTN, DM, Hypercholesterolemia, CAD, PVD, psoriatic arthritis PAST SURGICAL HISTORY: CABGx5 [**2197**] Cerebral Angiogram [**3-/2204**] Multiple cardiac and LE angioplasties and stents (last angioplasty LE [**2-/2205**]) Social History: Former IS consultant, now on disability. Lives with sister. Former [**Name2 (NI) 1818**] quite about 9yrs ago 40ppy history; Drinks 1-2 drinks/day Family History: Several uncles on his father's side had strokes in their 50's, Father CAD Physical Exam: On Admission: Vital Signs: Temp: 98.7 RR: 16 Pulse: 96 BP: 162/92 Neuro/Psych: Oriented x3, Affect Normal, NAD. Neck: No masses, Trachea midline, No right carotid bruit, No left carotid bruit. Skin: Abnormal: L. dorsum of foot psoriatic lesion, abd psoriatic lesion. Heart: Regular rate and rhythm. Lungs: Clear, Normal respiratory effort. Gastrointestinal: Abnormal: Obese, NT. Rectal: Not Examined. Extremities: Abnormal: LLE mid-Calf 2+ edema. Pulse Exam (P=Palpation, D=Dopplerable, N=None) RUE Radial: P. LUE Radial: P. RLE Femoral: P. Popiteal: P. DP: D. PT: D. LLE Femoral: P. Popiteal: P. DP: D. PT: D. DESCRIPTION OF WOUND: L. lateral foot: 2cm diameter gangrenous eschar over metatarsal head, fluctuant with no drainage, mildly tender, L. lateral foot erythema/swelling, odorous On Discharge: AFVSS Gen: NAD, AOx3 CVS: reg Pulm: no resp distress Abd: S/NT/ND Wound: LLE staples intact, c/d/i LLE: graft dop, DP dop, PT dop Pertinent Results: Admission labs: [**2205-6-22**] 02:01AM BLOOD WBC-10.3 RBC-4.06* Hgb-11.9*# Hct-36.3* MCV-89 MCH-29.3 MCHC-32.8 RDW-13.9 Plt Ct-334 [**2205-6-21**] 10:43PM BLOOD PT-13.0 PTT-27.1 INR(PT)-1.1 [**2205-6-21**] 10:43PM BLOOD ESR-90* [**2205-6-22**] 02:01AM BLOOD Glucose-105* UreaN-25* Creat-1.6* Na-139 K-4.1 Cl-99 HCO3-29 AnGap-15 [**2205-6-22**] 02:01AM BLOOD Calcium-9.5 Phos-3.2 Mg-1.9 [**2205-6-21**] 10:43PM BLOOD CRP-88.4* Discharge labs: [**2205-7-10**] 04:29AM BLOOD WBC-9.3 RBC-3.28* Hgb-9.7* Hct-28.4* MCV-87 MCH-29.5 MCHC-34.0 RDW-16.8* Plt Ct-315 [**2205-7-10**] 04:29AM BLOOD Plt Ct-315 [**2205-7-7**] 01:40AM BLOOD PT-13.5* PTT-25.6 INR(PT)-1.2* [**2205-7-10**] 04:29AM BLOOD Glucose-133* UreaN-23* Creat-1.6* Na-138 K-3.9 Cl-103 HCO3-26 AnGap-13 [**2205-7-10**] 04:29AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.0 Path: L fifth toe [**2205-6-22**]: - Skin and subcutaneous tissue with necrosis, acute and chronic inflammation, abscess formation, and granulation tissue. - Bone margin free of acute inflammation. Non-invasive Arterial Studies [**2205-6-24**]: On the right, essentially normal study except for noncompressible vessels. On the left, there is significant popliteal/tibial artery occlusive disease. LE Doppler [**2205-6-25**]: Patent left greater saphenous vein with suitable diameters. ECHO [**2205-6-27**]: Poor technical quality due to patient's body habitus. Left ventricular function is probably mildly depressed with global hypokinesis, a focal wall motion abnormality cannot be fully excluded (even after the addition of echo contrast). The right ventricle is not well seen but is probably normal. No pathologic valvular abnormality seen. Moderate pulmonary artery systolic hypertension is seen. LVEF = 45-50%. Stress test [**2205-6-28**]: 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 sinus with rare isolated vpbs and 1 apb. 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. Cardiac perfusion scan [**2205-6-28**]: 1. Enlarged left ventricle. Calculated LVEF 51%. 2. Severe fixed perfusion defect in the distal anterior wall. 3. Moderate reversible perfusion defect at the apex. L foot xray [**2205-7-3**]: There has been amputation of the fifth ray at the mid metatarsal shaft level. Brief Hospital Course: Mr. [**Known lastname 36509**] was admitted on [**2205-6-21**] with a left lateral foot infection of 1 week duration. He was started on triple antibiotics (vancomycin, cipro, flagyl), and was made NPO for a procedure. On [**2205-6-22**], the patient underwent a left 5th toe amputation. Pathology showed skin and subcutaneous tissue with necrosis, acute and chronic inflammation, abscess formation, and granulation tissue. The bone margin was free of acute inflammation. The wound was initially managed with wet-to-dry dressings, then a wound vac, and then wet-to-dry dressings again. On [**2205-6-24**], the patient underwent ABIs/PVRs, which showed an essentially normal study on the right except for noncompressible vessels and significant popliteal/tibial artery occlusive disease on the left. On [**2205-6-24**], the patient underwent a LLE angiogram, which showed the following: ANGIOGRAPHIC FINDINGS: 1. Normal-appearing distal abdominal aorta without evidence of being aneurysmal or stenotic disease. 2. Patent bilateral common iliac arteries. 3. Patent bilateral hypogastric arteries. 4. Patent bilateral external iliac arteries. 5. The left common femoral and profunda femoris artery were patent. 6. The left superficial femoral artery was patent. 7. The above-knee popliteal artery was patent. However, the below-knee popliteal artery was occluded. There are large geniculate branches and collaterals that reconstituted the anterior tibial artery and peroneal arteries. 8. The anterior tibial artery was occluded proximally, however, it did reconstitute with in-line flow to the foot through the dorsalis pedis artery. The midportion of artery was heavily diseased. 9. The peroneal artery was occluded proximally but reconstituted and proceeded down to the ankle where it provided the posterior branch. 10.The posterior tibial artery was occluded. It was decided to perform a femoral to distal pedal bypass. Given the significant psoriatic plaques on the dorsum of the left foot, dermatology was consulted. They recommended applying urea 40% cream over psoriatic plaques at night under occlusion and clobetasol 0.05% ointment to the plaques each morning. There was no contraindication to surgery. This advice was followed with good result. Shortly after the angiogram, the patient experienced a gout flare in his right knee. Rheumatology was consulted and suggested avoiding colchicine and indomethacin given his ARF. The knee was tapped, confirming gout, and intraarticular steroids were administered. The patient was also started on prednisone 30mg PO daily with good effect. Also following the angiogram, the patient experienced a small rise in his Cr to 1.9 from his baseline of 1.1. Renal was consulted, and they felt that this was a combination of contrast nephropathy, transient hypotension in the operating room, and intrinsic kidney disease. His vancomycin and cipro doses were adjusted with a decrease in his Cr over time. The patient was evaluated by cardiology during this time to assess his candidacy for surgery. ECHO showed that his left ventricular function is mildly depressed with global hypokinesis and EF 45-50%. The stress test did not show any ischemic changes. A nuclear scan showed the following: 1. Enlarged left ventricle. Calculated LVEF 51%. 2. Severe fixed perfusion defect in the distal anterior wall. 3. Moderate reversible perfusion defect at the apex. Cardiology deemed him a candidate for surgery. On [**2205-7-2**], the patient underwent a left superficial femoral artery to anterior tibial artery bypass graft using reversed greater saphenous vein, angioscopy, vein inspection and valve lysis. He tolerated the procedure well and was taken to the PACU in good condition. His left PT and DPs were dopplerable. He received 2 uPRBC postoperatively. He was then transferred to the VICU for further recovery. While in the VICU he recieved monitered care. He followed the distal bypass pathway with initial bedrest, followed by activity as appropriate. When he was stabilized from the acute setting of post operative care, he was transfered to floor status. His diet was advanced, which was tolerated well. His foley catheter was removed, and he voided successfully. He experienced ARF as described above. After the Cr began to fall, the patient's lasix was restarted and he diuresed well. His ASA and plavix were restarted on POD1. He required intermittent blood transfusions for hct < 30. There was an ooze from the medial edge of the bypass wound but no large bleed. The ooze was controlled with a stitch. Triple antibiotics were continued until the day of discharge. Antibiotics were switched to a course of Augmentin for 2 weeks upon discharge since the wound culture grew out group B strep. All other cultures were negative. Endocrine-wise, his blood glucose was controlled with an insulin sliding scale with good effect. On [**2205-7-7**], the patient underwent a debridement and partial closure of the left foot wound. Podiatry cleared him for full-weight bearing on the heel. Physical therapy saw the patient throughout his stay and recommended rehabilitation. Final consult service recommendations: Renal: Expect full renal recovery, no additional recommendations. Dermatology: Continue applying creams as directed. [**Month (only) 116**] resume enbrel treatment per outside dermatologist after discharge. Cardiology: Switch amlodipine to imdur for edema. Please speak with your cardiologist about this. Podiatry: Heel weight bear LLE; follow up with Dr. [**Last Name (STitle) **] in 1 week. Rheum: Decrease dosage of prednisone by 10mg every three days starting today until you are taking no prednisone. On the day of discharge, the patient was in good condition. His pain was well-controlled with PO pain medications, and he was eating, voiding, and out of bed with assistance. Medications on Admission: Avandia 4mg PO BID, Glypizide 5mg PO Daily, Metoprolol 100mg PO BID, Amlopdipine 7.5mg PO daily, moxipril 15mg PO daily, lasix 40mg PO daily, crestor 10mg PO daily, Enbrel 50mg SQ qweek, Plavix 75mg PO daily, ASA 325mg PO qdaily Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Amlodipine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) sliding scale Injection ASDIR (AS DIRECTED). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Urea 20 % Cream Sig: One (1) application Topical qPM (). 9. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 10. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical QAM (once a day (in the morning)). 13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 14. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 15. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 17. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 2 weeks. Tablet(s) 18. Avandia 4 mg Tablet Sig: One (1) Tablet PO twice a day. 19. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. 20. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) Discharge Disposition: Extended Care Facility: [**Location (un) 582**] at [**Location (un) 620**] Discharge Diagnosis: Left lower extremity ischemia and left foot infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ??????You should get up out of bed every day and gradually increase your activity each day ??????Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ??????Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ??????Elevate your leg above the level of your heart (use [**3-6**] pillows or a recliner) every 2-3 hours throughout the day and at night ??????Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ??????You will probably lose your taste for food and lose some weight ??????Eat small frequent meals ??????It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ??????To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ??????No driving until post-op visit and you are no longer taking pain medications ??????Unless you were told not to bear any weight on operative foot: ??????You should get up every day, get dressed and walk ??????You should gradually increase your activity ??????You may up and down stairs, go outside and/or ride in a car ??????Increase your activities as you can tolerate- do not do too much right away! ??????No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ??????You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ??????Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ??????Take all the medications you were taking before surgery, unless otherwise directed ??????Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ??????Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ??????Redness that extends away from your incision ??????A sudden increase in pain that is not controlled with pain medication ??????A sudden change in the ability to move or use your leg or the ability to feel your leg ??????Temperature greater than 100.5F for 24 hours ??????Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2205-7-19**] 1:00 Please see your private cardiologist within 1 week. Discuss the pros and cons of switching amlodipine to Imdur. Please see your primary care physician [**Name Initial (PRE) 176**] 1 week. Discuss restarting embrel.

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icd9cm

[ [ [] ] ]

[ "39.29", "81.91", "84.11", "77.68", "88.48", "88.42" ]

icd9pcs

[ [ [] ] ]

13495, 13572

5695, 11614

332, 711

13670, 13670

3080, 3080

16544, 16917

2032, 2108

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2,344

113,411

14426

Discharge summary

report

Admission Date: [**2200-8-3**] Discharge Date: [**2200-8-16**] Date of Birth: [**2169-3-15**] Sex: M Service: BLUE GENERAL SURGERY Attending:[**Last Name (NamePattern4) **] HISTORY OF PRESENT ILLNESS: The patient is a 31 year old male recently diagnosed with hepatocellular carcinoma and hepatitis B in [**2200-7-5**]. He presented to the Emergency sweats, headache and worsening right upper quadrant abdominal pain. It was unclear how high the patient's temperature was as he did not take his temperature at home. The patient denied nausea, vomiting, diarrhea or cough or cold symptoms. The patient denied having any sick contacts. Furthermore, the patient complains of new right lower quadrant abdominal pain at times radiating to his flank. He also complains of his abdominal pain. The patient also had a poor appetite. PAST MEDICAL HISTORY: 1. Hepatitis B. 2. Hepatocellular carcinoma diagnosed [**2200-7-5**]. PAST SURGICAL HISTORY: Status post appendectomy in [**2194**]. ALLERGIES: Optiray 320, CT scan intravenous contrast causes rash, itching. Levaquin causes itching and redness. MEDICATIONS ON ADMISSION: 1. Epivir HBV 100 mg once daily. 2. Famotidine 20 mg q.h.s. 3. Percocet q4-6hours p.r.n. for pain. SOCIAL HISTORY: The patient lives with his girlfriend in [**Name (NI) 1474**], [**State 350**]. He works as a custodian in a nursing home. He denied a history of tobacco, intravenous drug use and recreational drug use. He drinks alcohol socially. PHYSICAL EXAMINATION: On admission, the patient is a healthy appearing pleasant gentleman, appropriate for his stated age, in no apparent distress, laying on a stretcher. The head and neck examination showed extraocular movements are intact. The pupils are equal, round, and reactive to light and accommodation. He has oral thrush and cervical lymphadenopathy. There is no thyromegaly. His chest examination revealed bilaterally clear to auscultation. His heart has a regular rate and rhythm, normal heart sounds, no murmurs. His abdomen was soft, nondistended, right upper quadrant/epigastric/right lower quadrant abdominal tenderness. Bowel sounds active. Surgical scar from previous appendectomy. Burn scar infraumbilically. Rectal examination showed no masses with guaiac negative stools. He has no peripheral edema. His extremities were warm and well perfused. His neurologic examination was grossly intact. LABORATORY DATA: Pertinent laboratory results revealed a white count of 8.0, hematocrit 37.8, platelet count 150,000. His blood electrolytes were within normal limits. His liver function tests revealed AST of 155, ALT 226, alkaline phosphatase 167, total bilirubin 1.0, amylase 78 and lipase of 15. RADIOLOGIC STUDIES: Chest x-ray revealed clear lungs, no effusions. CT scan with p.o. contrast revealed large mass in the left hepatic lobe. In comparison to [**2200-7-18**], the mass was larger. No lesions in the right lobe. No biliary dilatation. Right upper quadrant ultrasound showed extension of portal venous clot to include the entire main portal vein to the level of the pancreatic head. The right portal vein remains preserved. There was a known 6.0 centimeter hepatic lobe mass consistent with hepatocellular carcinoma. HOSPITAL COURSE: The patient was admitted for scheduled hepatic lobectomy, cholecystectomy and removal of portal vein thrombosis. At the time of presentation, he noted to have two day history of fever and was found to have a temperature of 102.8. Blood culture was sent and failed to identify organism. A chest x-ray was negative. The patient was started on Ampicillin, Gentamicin and Flagyl for empiric treatment. A heparin drip was initiated in attempt to prevent further extension of the thrombus in the portal vein. Fever was thought to be of tumor origin and the patient was brought to the operating room on [**2200-8-8**]. He underwent a left hepatic lobectomy, cholecystectomy and removal of portal vein clot with placement of two [**Location (un) 1661**]-[**Location (un) 1662**] drains. Pathology report confirmed hepatocellular carcinoma with tumor thrombosis in the portal vein. Surgical margins were positive at the junction of the left portal vein and main portal vein. Because this was viewed as a palliative resection we did not consider resection of the entire portal vein with interposition graft. He received 18 units of packed red blood cells, three units of platelets and 11 units of fresh frozen plasma intraoperatively and postoperatively. The patient remained intubated postoperatively and was transferred to the Surgical Intensive Care Unit in stable condition with epidural in place for pain control. He required Propofol to maintain systolic blood pressure less than 180. The patient was weaned from Propofol and extubated postoperative day number one and transferred to the floor on postoperative day number two. The patient continued to spike fevers postoperatively despite antibiotic treatment. Blood, urine and sputum cultures were obtained on postoperative day number two. Sputum cultures were positive for pansensitive Klebsiella. Chest x-ray showed possible right middle lobe pneumonia. Gentamicin was discontinued when the patient began to experience ringing in his ears. Ampicillin and Flagyl were replaced with Ceftriaxone. Fevers resolved. The patient was discharged with one [**Location (un) 1661**]-[**Location (un) 1662**] drain in place. He was given a prescription for two weeks of Bactrim and instructed to follow-up with Dr. [**Last Name (STitle) **] within one week. MEDICATIONS ON DISCHARGE: 1. Bactrim DS one tablet p.o. twice a day times ten days. 2. Epivir HBV 100 mg p.o. once daily. 3. Percocet 5/325 one to two tablets p.o. q4-6hours p.r.n. for pain. 4. Famotidine 20 mg p.o. q.h.s. 5. Colace 100 mg p.o. twice a day. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To home without services. DISCHARGE DIAGNOSIS: Hepatocellular carcinoma, status post left hepatic lobectomy and portal vein thrombectomy. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366 Dictated By:[**Name8 (MD) 27821**] MEDQUIST36 D: [**2200-8-16**] 19:13 T: [**2200-8-19**] 19:49 JOB#: [**Job Number 42713**]

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icd9cm

[ [ [] ] ]

[ "38.07", "51.22", "50.12", "50.3" ]

icd9pcs

[ [ [] ] ]

5974, 6319

5634, 5872

1148, 1251

3289, 5608

966, 1122

1526, 3271

218, 847

869, 942

1268, 1503

5897, 5952

73,257

195,203

36339

Discharge summary

report

Admission Date: [**2160-3-4**] Discharge Date: [**2160-3-10**] Service: MEDICINE Allergies: Sotalol / Amiodarone / Digoxin Attending:[**First Name3 (LF) 7333**] Chief Complaint: S/P Pacemaker placement with pericardial effusion Major Surgical or Invasive Procedure: -RA isthmus ablation for atypical atrial flutter -Implantation of pacemaker History of Present Illness: (per admission note and patient): 87 yo female with history of HTN, atrial flutter, tachy/brady syndrome, rheumatoid arthritis, who was transferred from an OSH for atrial flutter ablation as she had failed sotalol and amiodarone in the recent past. The patient initially presented with chest pain and near syncope, found to be in 2:1 conduction at a rate of 150 on [**2160-2-29**] to an OSH. Rate control was attempted with digoxin which made her nauseous, and then Toprol. She has complained of lightheadedness related to bradyarrhythmia. At that time she spontaneously converted to sinus rhythm/brady with HR's ranging between 45-55. There she ruled out for an MI and her beta blocker was increased to 25 [**Hospital1 **]. She was transfered to [**Hospital1 18**] for RA isthmus ablation for atrial flutter. After the procedure she had a brief deterioration into AF. She was started on dofetilide on [**2160-3-5**]. The plan was to monitor her for 6 doses of dofetilide, decrease her beta blocker secondary to bradycardia and restart coumadin, then discharge from [**Hospital Ward Name 121**] 3. Today, she became persistently bradycardic into the 40's with a prolonged QT on dofetelide. A pacemaker was then placed to treat her bradycardia. After the procedure she developed chest pain on the lower left chest wall, worse with inspiration, reproducible to palpation. When asked how long the pain has been present for, she states intermittently for "days to weeks, maybe even months." The pain is mostly located in the upper left abdomen, but sometimes migrates to her lower left chest, but does not radiate. The pain is not associated with SOB, nausea, or diaphoresis. The patient's vital signs were stable during the episode in the EP lab. A stat TTE was done in the EP lab which showed questionable evidence of a small pleural effusion. She was transferred to the CCU for monitoring. Past Medical History: 1. CARDIAC RISK FACTORS: HTN 2. CARDIAC HISTORY: Atrial flutter Tachy/brady syndrome 3. OTHER PAST MEDICAL HISTORY: Rheumatoid arthritis Anemia Osteoporosis Social History: Pt lives with her brother -[**Name (NI) 1139**] history: none -ETOH: None -Illicit drugs: None Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: T 97 HR 73 BP 135/64 RR 11 O2 100% on RA GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. Hard of hearing HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no elevation of JVP. CARDIAC: RRR, normal S1, S2. 2/6 systolic murmur at apex, no rubs/gallops. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi in anterior lung fields ABDOMEN: NABS. Soft, NTND. EXTREMITIES: No edema. ulnar deviation of BL hands, swan neck deformity, swelling of MCP joints. WWP. 2+ DP, tibial pulses. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: [**2160-3-4**] 12:56PM GLUCOSE-98 UREA N-21* CREAT-1.0 SODIUM-135 POTASSIUM-5.0 CHLORIDE-93* TOTAL CO2-30 ANION GAP-17 [**2160-3-4**] 12:56PM MAGNESIUM-2.3 [**2160-3-4**] 12:56PM WBC-6.2 RBC-4.01* HGB-13.1 HCT-37.8 MCV-94 MCH-32.8* MCHC-34.8 RDW-14.4 [**2160-3-4**] 12:56PM NEUTS-77.7* LYMPHS-18.5 MONOS-2.7 EOS-0.7 BASOS-0.4 [**2160-3-4**] 12:56PM PLT COUNT-188 [**2160-3-4**] 12:56PM PT-14.9* PTT-26.1 INR(PT)-1.3* EKG: Atrial pacing at 70 beats per minute, early repolarization of V5, V6, present on old EKG, no T wave changes, no QT prolongation. ECHO [**2160-3-7**]: (by cardiology fellow) The estimated right atrial pressure is 0-5 mmHg. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size is normal. with normal free wall contractility. There is a trivial/physiologic pericardial effusion. There is an anterior space which most likely represents a fat pad. There are no echocardiographic signs of tamponade. IMPRESSION: Trivial pericardial effusion no signs of tamponade. CXR: no acute cardopulmonary process Brief Hospital Course: # Chest pain: Chronic issue. Pleuritic, reproducible, located in left lower chest, left upper abdomen. Initial differential included pneumothorax, pericarditis, pericardial effusion given recent pacemaker placement, however the pain predated the procedure and was later linked to patient throwing out the garbage a few days ago. Pulsus was wnl and tte showed only trivial pericardial effusion. Thought pain was most likely either musculoskeletal or GI in origin. On further review of the chest xray following pacemaker placement a small pneumothorax was appreciated. The patient also had a Hct drop, which pointed towards a hemothorax. Likely pain was secondary to both musculoskeletal and worsened by hemothorax. The patient was given ibuprofen which alleviated the pain. The patient was discharged to an acute rehab facility for physical therapy. # Tachy/Brady Syndrome: S/P pacemaker placement with questionable chest pain that was likely a chronic issue. The patient does not have any physicial or echocardiographic signs of cardiac tamponade. A CXR taken after PPM placement showed a small PTX and small pleural effusion. Repeat CXR showed small progression of the PTX, likely with hemothorax as patient had decrease in Hct as well. A TTE was done as well to confirm placement of leads. This showed proper placement of the pacemaker leads. Coumadin was held during this time, and the patient was instructed not to restart coumadin dosing until her appointment with Dr. [**Last Name (STitle) 23246**] next week. Cephalexin was to be continued for a total of 5 days post pacemaker placement # A flutter: S/P right atrial isthmus ablation. The patient was initially restarted on coumadin, but then discontinued when taken to the EP lab for pacemaker placement. She was continued on metoprolol and dofetilide, and discharged on this regimen. QT was monitored with daily EKGs. She was started on daily magnesium replacement. Coumadin was not restarted this admission as complication of hemothorax. She was instructed to discuss restarting coumadin with Dr. [**Last Name (STitle) 23246**] as an outpatient next week. # HTN: Continued metoprolol as above # RA: Continued prednisone and resumed methotrexate at discharge FEN: Heart healthy diet ACCESS: PIVs PROPHYLAXIS: -DVT ppx with heparin SC TID CODE: Full Code Medications on Admission: HOME MEDS: Folic acid 1 mg daily Methotrexate 2.5 mg (5 tabs) po daily Metoprolol tartrate 25 mg [**Hospital1 **] Prednisone 2.5 mg daily Warfarin 2.5 mg QOD Cclcium carbonate 500 mg po BID MVI 1 daily Medications on Transfer: Maalox PRN Calcium Carb 500mg [**Hospital1 **] Cefazolin 2gm and 1gm X1 (start [**2160-3-7**]) Cephalexin 500mg PO Q8H X 3 days Dofetilide 125mcg [**Hospital1 **] Folic acid 1mg daily Magnesium Oxide 400mg [**Hospital1 **] Metoprolol tartrate 12.5mg [**Hospital1 **] MVI PO daily Prednisone 2.5mg daily Simethicone 40-80mg QID PRN Ambien 5-10mg QHS PRN Discharge Medications: 1. FoLIC Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. PredniSONE 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Calcium Carbonate 500 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO DAILY (Daily). 5. Methotrexate Sodium 2.5 mg Tablet Sig: Five (5) Tablet PO once a week: every thursday. 6. Dofetilide 125 mcg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 7. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) for 3 days. Disp:*8 Capsule(s)* Refills:*0* 9. Protonix 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Ibuprofen 200 mg Capsule Sig: [**11-30**] Capsules PO once a day. Discharge Disposition: Extended Care Facility: [**Location (un) 931**] House Discharge Diagnosis: Primary Diagnoses: Atrial flutter Right atrial isthmus ablation Tachy/Brady Syndrome s/p pacemaker implantation Small hemothorax Secondary Diagnoses: Hypertension Rheumatoid arthritis Discharge Condition: Ambulatory with cane. Patient was afebrile and hemodynamically stable prior to discharge. Discharge Instructions: You were admitted to [**Hospital1 18**] for evaluation of a fast heart rate. You were found to be in atrial flutter. You underwent a procedure to ablate this rhythm. You then had a very slow heart rate, therefore a pacemaker was placed. You had a complication of blood collecting around your lung following the procedure. It is important that you keep the incision and dressing dry until you are evaluated in one week in the Device Clinic. New medications: - Dofetilide 125mg twice a day - A prescription for this medication has been faxed to your CVS in [**Location (un) **] and your mail-away pharmacy. - Protonix 20mg daily - to protect your stomach from ulcers while you are on prednisone. - Cephalexin 500mg every eight hours for 3 more days - Magnesium oxide 400mg twice a day Please DO NOT take coumadin until you are seen by Dr. [**Last Name (STitle) 82344**]. Recheck your INR lab on Monday [**2160-3-14**]. You can take the rest of your prescribed medications as directed. If you experience worsening chest pain, shortness of breath, lightheadedness, dizziness, fever, chills or any other worrisome symptoms please seek medical attention. Followup Instructions: Please follow up with your cardiologist, Dr. [**Last Name (STitle) 23246**], in [**Location (un) **] on Tuesday [**3-18**] at 11:00am. The phone number of the office is [**Telephone/Fax (1) 82345**]. Please also follow up with the device clinic, if your cardiologist recommends, on [**2160-3-20**] 1:00pm. The phone number of their office is [**Telephone/Fax (1) 62**] Completed by:[**2160-3-10**]

[ "998.11", "733.00", "786.59", "V58.69", "427.81", "285.9", "427.31", "V58.65", "511.89", "512.1", "714.0", "427.32", "401.9", "V58.61" ]

icd9cm

[ [ [] ] ]

[ "37.26", "99.69", "37.34", "37.83", "37.72", "99.29" ]

icd9pcs

[ [ [] ] ]

8628, 8684

4637, 6976

287, 365

8913, 9006

3487, 4614

10210, 10613

2612, 2728

7607, 8605

8705, 8835

7002, 7205

9030, 10187

2743, 3468

8856, 8892

2373, 2410

198, 249

393, 2300

2441, 2484

7230, 7584

2322, 2353

2500, 2596

25,016

100,805

1181+55266

Discharge summary

report+addendum

Admission Date: [**2146-2-7**] Discharge Date: [**2146-2-9**] Service: ICU HISTORY OF PRESENT ILLNESS: This is an 86-year-old male nursing home resident with advanced dementia, coronary artery disease, cerebrovascular accident since [**2141-8-1**], PEG placed in [**2144-8-1**] in the setting of pneumonia and sepsis who presents status post PEA arrest. The patient was noted to be lethargic on the [**8-8**] and chest x-ray was done at that time which showed a question of a right lower lobe pneumonia. He was started on Levaquin. By report, the patient improved the next day and became more verbal. On the morning of admission, the patient was found to be again lethargic and less responsive. At that time, temperature was normal. His blood pressure is 104/76, heart rate 118, respiratory rate was increased with an oxygen saturation of 86% on room air. Fingerstick was 326 and he was given insulin and EMS was called. He was brought to the Emergency Room. On arrival, the patient was unresponsive and cyanotic. His temperature was 98 and his oxygen saturation was 30% and he had no blood pressure. Rhythm was pulseless electrical activity. CPR was started. Atropine and Epinephrine were given with restoration of his pulse. Pressors were started for hypotension. Patient was intubated. There is an unclear duration of arrest prior to the code being called. The code itself lasted nine minutes. CT angiogram of the chest revealed no pulmonary embolism. Hematocrit was noted to be 20 and he was transfused 1 unit of packed red blood cells, and was admitted to the Intensive Care Unit for further management. PAST MEDICAL HISTORY: 1. Coronary artery disease with coronary artery bypass graft in [**2136**]. 2. Dementia. 3. Cerebrovascular accident with left sided weakness resulting. 4. Diabetes mellitus type 2. 5. Peptic ulcer disease. 6. Atypical psychosis. 7. Prostate cancer. 8. Hypercholesterolemia. 9. Ejection fraction of 40-50% with left ventricular hypertrophy, moderate mitral regurgitation, and moderate AS with global hypokinesis. 10. AVR for aortic insufficiency. 11. PEG tube for feeding placement [**2144-8-1**]. 12. Aspiration pneumonia and sepsis with no identified source in [**2144-8-1**]. 13. Upper gastrointestinal bleed. 14. Abdominal aortic aneurysm. 15. Seizure disorder. 16. Gout. MEDICATIONS: 1. Norvasc 5 mg po q day. 2. Prevacid 30 mg po q day. 3. Risperdal 0.25 mg po bid. 4. Allopurinol 100 mg po q day. 5. Aspirin 81 mg po q day. 6. Dilantin 300 mg po q am, 400 mg po q pm. 7. NPH insulin 3 units q am, 4 units q pm. 8. Cardura 4 mg po q day. 9. Lipitor 10 mg po q day. 10. Trazodone 25 mg po bid prn. 11. Tramadol 25-50 mg po q6h prn. 12. Lactulose 20 cc po prn. 13. Levaquin 500 mg po q day since [**2-6**]. 14. ProMod with fiber at 95 cc per hour. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Nursing home resident x2.5 years at the [**Hospital3 2558**]. No tobacco or ethanol. PCP is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7514**] and Dr. [**Last Name (STitle) **] from [**Hospital3 4262**] Group. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: Not able to obtain. VITAL SIGNS ON ADMISSION: Temperature 95.0, blood pressure 109/43 with a MAP of 65, heart rate is 97, and oxygen saturation of 99%. He was mechanically ventilated on SIMV plus pressure support of 600 cc tidal volume with a respiratory rate of 12 and a FIO2 of 1.0. No spontaneous respirations, PEEP of 5, and pressure support of 10. He was on dopamine at 21 mcg/kg/minute. PHYSICAL EXAMINATION: In general he was unresponsive and intubated. Pupils were fixed and dilated. There is no response to confrontation. Jugular venous pressure was not seen. The chest was clear anteriorly. Heart has a normal S1, S2 without murmur, and is regular, rate, and rhythm. Abdomen was obese with a G tube in place with no surrounding erythema or pus. He is guaiac positive according to the exam in the Emergency Room. Extremities were without edema and were warm. Distal pulses were not felt in the feet, but there were 1+ radial pulses. Skin was intact without rash. There is no response to voice, and he did withdraw to pain. Toes were upgoing bilaterally. Tone was increased with flaccid tone noted on the left and decreased but flaccid on the right. PERTINENT LABORATORIES: Hematocrit was 20.5, white count 7.0, platelets 182. INR is 1.3. Sodium is 139, potassium 4.4, chloride 103, bicarb 13, BUN 62, creatinine 1.1, and glucose of 609. Anion gap was 23. Transaminases were normal. Amylase and lipase 103 and 22. CK was 44 with a troponin of 0.3. Albumin 1.9. Calcium 7.1, phosphate 6.3, magnesium 2.2. Arterial blood gas showed a pH of 7.13, pCO2 of 40, and a pO2 of 252. Lactate was 5.7. Chest x-ray showed ET tube 7 cm above the carina with heart size within normal limits and low lung volumes. There is normal pulmonary vasculature and a widen mediastinum. CT angiogram of the chest showed a right lower lobe aspiration pneumonia. No pulmonary embolism. A right lower lobe mass 3.2 x 2.9 cm encasing the right lower lobe bronchus and pulmonary artery. Mediastinal lymphadenopathy including pericarinal and AP window lymphadenopathy. An anterior 8 mm nodule and ascites with intraabdominal hemorrhage. Electrocardiogram showed atrial fibrillation at 127 beats per minute with ST depressions 1 mm in leads V3 to V6 with T-wave inversions in those leads. There was also T-wave inversions seen in leads I, aVL, II, III, and aVF. CT scan of the abdomen showed a layering hematoma adjacent to the liver extending down the right pericolic gutter. A 5.1 x 4.8 cm exophytic simple cyst in the right kidney in the lower pole, a large 8.8 x 12 cm infrarenal abdominal aortic aneurysm just above the bifurcation concerning for recent expansion and no obvious liver disease or injury. CT scan of the head showed a large chronic right middle cerebral artery territory infarct that was felt to be old as well as right cerebral watershed infarct also felt to be old. There is also an old left caudate lacune. There was no new mass effect or intracranial hemorrhage. IMPRESSION: This is an 86-year-old male with advanced dementia, abdominal aortic aneurysm, coronary artery disease, who presented with pulseless electrical activity, cardiac arrest, and was successfully resuscitated, but now with examination suggestive of anoxic brain injury. HOSPITAL COURSE: The cause of the patient's PEA arrest was not clear. It was felt to most likely be multifactorial secondary to anemia, pneumonia, and hypovolemia. PE and tamponade were effectively ruled out on CT angiogram. The patient's troponin rose to over 50, which was felt to be consistent with the patient's cardiac arrest. There is no intervention that was felt to be required according to the Cardiology consult service. In terms of the patient's abdominal aneurysm, there was radiographic evidence of recent expansion, but rupture was ruled out by the abdominal CT scan. Patient received packed red blood cells for a hematocrit less than 28. Blood sugar was managed with insulin drip initially and changed to regular insulin-sliding scale. The patient's new lung mass was not known prior to this admission and this was felt to worsen the patient's overall prognosis. This was communicated to the family, who understood. It was felt that the appearance of the mass was most consistent with malignancy. In terms of the patient's pneumonia, he was given Levaquin and Flagyl. The Neurology Service was consulted and agreed to the Intensive Care Unit's assessment that the patient had a very poor prognosis given his multiple comorbidities and the prolonged arrest. On [**2-8**], the patient developed new anisocoria and repeat CT scan of the head revealed massive left sided edema with subfalcial herniation and probable uncal herniation. Mannitol was given as per the Neurology and Neurosurgery consultants. Vancomycin was added to the patient's antibiotic regimen once blood cultures returned positive for gram-positive cocci. On [**2-9**], the family meeting was held with patient's wife, son, daughter, and several of the physicians. The grave prognosis was communicated to the family. The family decided to withdraw the ventilator which was done. Morphine was given and titrated for comfort. The patient died that night at 11:35 pm. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**] Dictated By: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. MEDQUIST36 D: [**2146-3-25**] 15:00 T: [**2146-3-29**] 06:34 JOB#: [**Job Number 7515**] Name: [**Known lastname 956**], [**Known firstname 957**] Unit No: [**Numeric Identifier 958**] Admission Date: [**2146-2-7**] Discharge Date: [**2146-2-9**] Date of Birth: [**2059-2-17**] Sex: M Service: ADDENDUM: DISCHARGE DIAGNOSES: 1. Cardiac arrest; status post resuscitation. 2. Aspiration pneumonia. 3. Abdominal aortic aneurysm; unstable. 4. Right lung mass. 5. Subfalcine herniation. 6. Probable uncal herniation. 7. Intracerebral edema. 8. Sepsis. 9. Hypotension (resulting from sepsis). 10. Anemia (requiring transfusion). 11. Renal failure. [**First Name4 (NamePattern1) 963**] [**Last Name (NamePattern1) 964**], M.D. [**MD Number(1) 965**] Dictated By:[**Name8 (MD) 305**] MEDQUIST36 D: [**2146-3-27**] 22:28 T: [**2146-3-27**] 23:19 JOB#: [**Job Number 966**]

[ "276.2", "162.8", "780.39", "276.5", "507.0", "348.1", "789.5", "427.5", "518.81" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

3113, 3131

8966, 9564

6454, 8944

3573, 6436

3151, 3184

114, 1640

3199, 3550

1662, 2854

2871, 3096

19,334

155,858

19371+19372+19373

Discharge summary

report+report+report

Admission Date: [**2101-12-10**] Discharge Date: [**2101-12-26**] Date of Birth: [**2041-6-11**] Sex: F Service: BMT HISTORY OF PRESENT ILLNESS: This is a 60-year-old female with no significant past medical history, who presented to an outside hospital on [**2101-12-8**] with complaints of dyspnea on exertion and increasing pallor, and was found to be pancytopenic with a white blood cell count of 2.2, hematocrit of 18.5, and platelet count of 15,000. She had a bone marrow aspirate that showed an overwhelming cell type of dysplastic red cell maturation. The patient received 2 units of packed red blood cells overnight at the outside hospital and her hematocrit rose to 28.4. She did have a fever to 101.5 overnight. No antibiotics were started. A chest x-ray was clear. On admission here, the patient describes a history of worsening dyspnea on exertion over a [**12-27**] week period to the point of being intolerant of five steps upstairs. She has no shortness of breath at rest. No chest pain, no lightheadedness, no visual changes. No nausea, vomiting, or diarrhea. Patient notes a history of easy bruising throughout her life. She notes a weight gain of 15 pounds in the past few months. No night sweats, no prior fevers. Patient did have some mild URI symptoms three weeks ago, but now only notes a dry cough for the past three days. PAST MEDICAL HISTORY: Patient denies any significant past medical history. She has not seen a primary care physician for many years. She has a history of right knee injury. ALLERGIES: Citrus fruit causes a rash. Otherwise, no known drug allergies. MEDICATIONS: None. She rarely takes aspirin prn. SOCIAL HISTORY: She lives in [**Location 1468**]. She has never been married. She has brothers in [**Name (NI) **] and [**Name (NI) 10478**], and a cousin in [**Name (NI) 1110**], with whom she is close. She works as a bank teller. She quit tobacco 15 years ago after a history of one pack per week. She has rare alcohol use, and denies any history of IV drug use. FAMILY HISTORY: Mother died from a CVA, and her brother had a heart attack at about 60 years of age. Her father passed away from lung cancer. PHYSICAL EXAM ON ADMISSION: Well-nourished, pale, and tired-appearing female in no distress. Vital signs: Temperature 99.5, heart rate 64, blood pressure 124/76, respiratory rate 24, and 92% on room air. HEENT: Midline herpetic lesion above her lip. Oropharynx clear. Moist mucosal membranes. Pale conjunctivae. Neck: No lymphadenopathy, supple. Lungs are clear to auscultation bilaterally. Heart: Regular rate and rhythm, normal S1, S2. Abdomen is soft, nontender, nondistended, positive bowel sounds, obese, no masses, and no hepatosplenomegaly. Extremities: No edema, clubbing, or cyanosis, 2+ distal pulses. Cranial nerves II through XII are intact. Alert and oriented times three. Strength 5/5. Gait within normal limits. LABORATORY DATA ON ADMISSION: White count 1.6, hematocrit 29.5, platelet count 16. White count differential: 60% neutrophils, 4% bands, 28% lymphocytes, 3% monocytes, 3% eosinophils, 0% basophils, 1 atypical, 1 metamyelocyte, 1 myelocyte, 333 nucleated RBCs. Chem-7 as well as renal function was unremarkable as well as LFTs, which were within normal limits with the exception of a T bilirubin, which was elevated at 1.8, albumin was 3.7. Uric acid was 5.9. INR is 1.2. Bone marrow biopsy at the outside hospital showed hypercellular marrow with only a rare megakaryocyte, infrequent white blood cell overwhelming cell type. He has dysplastic red cell maturation with frequent megacaryocyte blasts with well-defined nuclei, having frequent clover leaved and binucleate appearance. HOSPITAL COURSE: 1. Hematology/Oncology: On hospital day #1, Dr. [**Last Name (STitle) **] performed a bone marrow biopsy, the results did not confirm a M6 AML, erythroleukemia. FISH chromosome and flow cytometry studies were done. Patient had a Hickman central line placed, and subsequently a chemotherapy protocol was initiated including idarubicin and cytarabine. Initially patient tolerated this regimen well, but did subsequently develop febrile neutropenia at which point her antibiotic regimen was changed from empiric levofloxacin and fluconazole to cefepime, Vancomycin, and then AmBisome in addition. Patient continued to spike fevers despite this broad-spectrum coverage. Patient received blood cell transfusions for hematocrit less than 25, and also received platelet transfusions for platelet count less than 20,000. She received an additional unit of platelets in the setting of a fall from her bed that resulted in a large left orbit hematoma superficially. 2. Infectious disease: As described above, the patient was started on levofloxacin and fluconazole empirically. She did develop fevers on hospital day #8 in the setting of neutropenia with an ANC of 120. Cefepime and then Vancomycin were added on her regimen on this day, and then on [**12-22**], AmBisome was initiated for broader spectrum coverage. Cultures were sent including blood, both central and peripheral, urine and stool cultures. Patient did have diarrhea during this time as well. Serial Clostridium difficile tests were done, but were negative. However, given the high suspicion, Flagyl IV was added to her regimen for broader spectrum coverage. Patient had continued to spike fevers despite this broad-spectrum coverage, and was receiving Tylenol for fever control at the time of this dictation. 3. Fluids, electrolytes, and nutrition: The patient had poor p.o. intake from hospital day six onward. Because of her concerns about her nutritional status, TPN was initiated on [**12-24**]. 4. Intravenous access: Patient had a Hickman placed on [**12-13**]. Hickman was not successfully placed by Surgery, and therefore the Interventional Radiology team was consulted for immediate placement of a Hickman by fluoroscopy, which was successful. However, the patient did have subsequent hematomas in her upper chest bilaterally, which were tender throughout her hospital stay. She continued on prn oxycodone for control of her discomfort. 5. GI: Patient did develop diarrhea during her hospital stay. Clostridium difficile tests were negative x3. However, Flagyl was initiated out of concerns for this possibility. Patient continued bowel regimen early on in her hospital stay with the use of oxycodone. Peridex, Gelclair, and Nystatin were used for mouth care. 6. Status post fall: On the morning of [**12-24**], the patient fell from her bed and sustained a left orbit hematoma. The patient had received a unit of platelets overnight, and at the time of the fall her platelet count was 70,000. Patient was sent for an immediate head CT noncontrast, which did rule out any intracranial hemorrhage, but did show a significant left orbit hematoma superficially. A followup CT of the orbits was done, which revealed no bleeding behind the globe or any compression of the globe. The patient had no associated visual symptoms. Ice was applied to the patient's hematoma and an additional bag of platelets was transfused for bleeding control. Serial neuro examinations were within normal limits. 7. Urologic: The patient did develop hematuria on [**12-21**]. This discolored urine was controlled after a platelet transfusion. It is likely related to the patient's chemotherapy regimen. The patient's subsequent hospital course as well as discharge status, medications, and follow-up plans will be addended. [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 31111**], M.D. [**MD Number(1) 31112**] Dictated By:[**Last Name (NamePattern1) 1615**] MEDQUIST36 D: [**2101-12-26**] 11:14 T: [**2101-12-27**] 05:27 JOB#: [**Job Number 52691**] Admission Date: [**2102-1-2**] Discharge Date: [**2102-1-27**] Date of Birth: [**2041-6-11**] Sex: F Service: This is a continuation of prior discharge summary for patient's course in the Intensive Care Unit. HOSPITAL COURSE: 1. Pulmonary: On [**1-2**] the patient developed worsening respiratory distress with tachypnea and hypoxia. She also had a temperature of 105 and chest x-ray revealed bilateral diffuse infiltrates. She had worsening respiratory distress with continued hypoxia, which required intubation and transferred to the Intensive Care Unit. In the Intensive Care Unit she had a very complicated course from a respiratory standpoint. She has a clinical diagnosis of adult respiratory distress syndrome with diffuse bilateral alveolar infiltrates and low PO2. She required extremely high PEEPs up to the mid 20s to adequately oxygenate her. The ______________ was unclear and ________ multifactorial. The most likely culprit was a hypersensitive reaction to numerous antibiotics, which the patient received in the past. She was maintained on the ___________ protocol with low tidal volumes with high respiratory rate and in about three weeks we able to wean off her PEEP slowly. The patient slowly improved and was able to transition to pressure support ventilation and eventually extubated about four weeks off intubation without any problems. 2. Infectious disease: The patient had a complicated course of antibiotics with multiple side effects. She is believed to have adverse reactions to Meropenem, Levofloxacin, Penicillins, and Cephalosporins. Those side reactions include a rash, high fevers, as well as hypersensitivity reaction that may have been contributing to her adult respiratory distress syndrome. In the beginning of her Intensive Care Unit course she had no significant infections. Toward the middle of her Intensive Care Unit course she developed a ventilator associated pneumonia and grew Enterobacter cloacae, which was gram sensitive and was being treated with Gentamycin. About a week prior to discharge from the Intensive Care Unit she developed _______________ staph line infection. The central line was discontinued. One day prior to leaving the Intensive Care Unit she developed a gram positive cocci bacteremia with 4 out of 4 blood cultures positive for gram positive cocci. She is currently on Vancomycin for gram positive cocci bacteremia and Gentamycin for Enterobacter cloacae __________ associated pneumonia. 3. Vitamin insufficiency: Upon arrival to Intensive Care Unit the patient failed cord stim test and was therefore started on Hydrocortisone for seven days. Upon completion of the course Hydrocortisone was stopped when she developed hypotension following that and required restarting of the Hydrocortisone. The decision was made to continue steroids until she clinical improves and given that she is now doing much better she will have the steroids weaned. 4. Hypotensive: The patient remained hypotensive for a considerable period of time. This was believed to be secondary to a possible infection even though none was documented in the beginning or a part of her hypersensitivity reaction to numerous medications. She required pressors for about two to three weeks, but those subsequently weaned off without any difficulty. Adrenal insufficiency was another etiology that may have contributed to her hypotension. 5. AML: The patient believed in remission during Intensive Care Unit stay. No blast on peripheral smears. Unable to perform bone marrow biopsy secondary to current illnesses. She had transient leukocytosis during her hospital stay. This was believed to be secondary to stress reaction, leukemoid reaction and oral steroid doses. 6. Elevated liver function tests: The patient had elevated transaminase, which remained persistent, though relatively stable. We followed those about every other day and showed no significant change. 7. Volume overload: The patient received about 20 liters of fluid in the context of initial hypotension believed to be part of multiple septic picture. She became significantly volume overloaded. Echocardiogram showed no EF. She was able to diurese on herself and with the help of diuretics. DISCHARGE CONDITION: The patient is awake and alert, but significantly decondition from prolonged Intensive Care Unit course. DISCHARGE STATUS: Discharged to BMT Floor. DISCHARGE DIAGNOSES: 1. Adult respiratory distress syndrome. 2. Hypersensitive reaction to multiple antibiotics. 3. Enterobacter cloacae. 4. Ventilator associated pneumonia. 5. Staph epidermis line sepsis. 6. Gram positive cocci bacteremia. 7. Adrenal insufficiency secondary to possible sepsis. 8. AML. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**] Dictated By:[**Name8 (MD) 5094**] MEDQUIST36 D: [**2102-1-27**] 12:32 T: [**2102-1-27**] 12:38 JOB#: [**Job Number 52692**] Admission Date: [**2101-12-10**] Discharge Date: [**2102-2-2**] Date of Birth: [**2041-6-11**] Sex: F Service: Bone Marrow Transplant This discharge summary will cover the dates of [**2102-1-27**] to [**2102-2-2**], during which time I assumed care of the patient. HOSPITAL COURSE: 1. Pulmonary failure - The patient was extubated in the Intensive Care Unit on [**2102-1-25**]. She tolerated extubation very well with normal oxygenation on room air. She was transferred from the Intensive Care Unit to the Bone Marrow Transplant Unit on [**1-27**]. The patient did not have any further pulmonary issues throughout her hospital stay. Of note, a sputum culture from [**1-20**] was positive for Enterobacter Cloacae which was thought to be due to ventilator-associated pneumonia. Therefore the patient was started on Vancomycin which was continued for a seven day course and then discontinued. 2. Acute myelogenous leukemia - On discharge the patient will be day 51 after induction chemotherapy with Idarubicin and Cytarabine, for acute myelogenous leukemia. The patient did not undergo consolidation due to her acute respiratory illness and persistent fevers. The patient did have a bone marrow biopsy on [**1-25**], and the preliminary results revealed no leukemic cells. The patient will follow up with her primary oncologist, Dr. [**Last Name (STitle) **] to discuss further consolidation treatment after she has recovered physically from her long Intensive Care Unit stay. 3. Infectious disease - As mentioned earlier, the patient's cultures drawn during her period of febrile neutropenia were all negative, however, sputum cultures from [**1-20**] grew Enterobacter Cloacae and the patient was treated with a course of seven days of Gentamicin. In addition, blood cultures from [**1-25**] grew 4 out of 4 bottles of coagulase negative Staphylococcus aureus. Therefore the patient was started on Vancomycin. At that time her subclavian catheter and arterial catheters were both removed. The catheters did not grow out any bacteria. A subsequent blood culture from [**1-28**] did not grow any bacteria. The patient was maintained on Vancomycin for a 13 day course and then it was discontinued. The patient did not have any recurrent fevers while she was on the Bone Marrow Transplant Unit. 4. Nutrition - The patient had been on total parenteral nutrition during her stay on the Bone Marrow Transplant Floor in [**Month (only) 404**] entering her Intensive Care Unit stay, however, she was transitioned to tube feeds at the end of her unit stay. On arrival to the floor, the patient was tolerating a full diet and did not need total parenteral nutrition or tube feeds, however, she was supplemented with Boost. 5. Abscess - The patient had a mid line was placed on [**1-25**] which was converted to a PICC line on [**1-30**] in order to facilitate blood draws and intravenous fluids. 6. The patient did have transiently elevated liver function tests, however, these improved when her Atovaquone was stopped. 7. Endocrine - The patient had been started on Hydrocortisone in the Intensive Care Unit for adrenal insufficiency. This was being weaned when the patient was transferred to the floor. We continued to wean her Hydrocortisone and by the time of discharge she was off of Hydrocortisone. However, it should be noted that if the patient develops sepsis bacteremia or any severe infection she should be started on stress dose steroids as she had recently been on steroids. The patient had no further issues during her stay and will be transferred to a rehabilitation facility for strengthening and nutrition needs. DISCHARGE STATUS: To extended care facility. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSIS: 1. Acute myelogenous leukemia, status post chemotherapy with Idarubicin and Cytarabine. 2. Adult respiratory distress syndrome secondary to an allergic reaction to Meropenem. 3. Neutropenic fever. 4. Enterobacter cloacae pneumonia. 5. Coagulase negative Staphylococcus intravenous catheter-related bacteremia. 6. Hypoxic respiratory failure. 7. Simple cyst of the right kidney. DISCHARGE MEDICATIONS: 1. Colace 100 mg one p.o. b.i.d. 2. Acetaminophen 325 mg one to two tablets p.o. q. 4-6 hours prn 3. Oxycodone 5 mg one p.o. q. 3 hours prn 4. Protonix 40 mg one p.o. q.d. 5. Lorazepam 0.5 mg p.o. q. 4-6 hours prn 6. Multivitamin one p.o. q.d. 7. Heparin sodium 5000 units subcutaneously q. 8 hours, discontinue once the patient is ambulating fully. 8. Megesterol acetate 400 mg p.o. b.i.d. FOLLOW UP: The patient is to follow up with Dr. [**Last Name (STitle) **] on [**2102-2-8**] at 2:30 PM at the Hematology/Oncology Unit on the ninth floor of the [**Hospital Ward Name 23**] Center. MAJOR SURGICAL OR INVASIVE PROCEDURES: Hickman catheter was placed [**2101-12-14**] and removed [**2101-12-27**]. A PICC line was placed on [**2102-1-30**]. The patient was intubated on [**2102-1-2**] and extubated on [**2102-1-26**]. A bone marrow biopsy was performed on [**2102-1-31**]. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-438 Dictated By:[**Last Name (NamePattern1) 5615**] MEDQUIST36 D: [**2102-2-1**] 19:47 T: [**2102-2-1**] 21:08 JOB#: [**Job Number 52693**]

[ "428.0", "518.81", "E930.8", "288.0", "008.45", "482.39", "038.11", "205.00", "996.62" ]

icd9cm

[ [ [] ] ]

[ "99.15", "38.93", "41.31", "99.25", "96.72", "86.11", "96.04", "33.24", "38.91", "99.04" ]

icd9pcs

[ [ [] ] ]

12125, 12276

2072, 2214

12297, 13137

17041, 17441

16632, 17018

13155, 16577

17453, 18162

162, 1376

2976, 3735

1399, 1683

1700, 2055

16602, 16611

3,826

122,846

24950

Discharge summary

report

Admission Date: [**2103-4-25**] Discharge Date: [**2103-5-3**] Date of Birth: [**2066-6-16**] Sex: F Service: MEDICINE Allergies: Viramune / Atazanavir Attending:[**First Name3 (LF) 2297**] Chief Complaint: transferred from [**Hospital3 **] for PNA and hepatic encephalopathy Major Surgical or Invasive Procedure: -Central line -Arterial line -Bronchoscopy/BAL History of Present Illness: 36 yo F admitted to OSH with dyspnea, bilateral PNA, DOE. She had greyish whit sputum, bilateral infiltrates on PNA. Placed on levoquin, remained afebrile. Pt found to be hypoNa and hyper K. HyperK treated with calcium/insulin/kayexalate. A renal consult felt the pt's hypoNa to be SIADH, pt placed on a fluid restriction and given NS 50 cc/hr, spironolactone also stopped. LFTs elevated on admission which continued to rise. Total bili from 6.3 to 9. On the day of transfer, pt was noted to be encephalopathic, transferred to the OSH ICU for intubation. . On transfer to this hospital, pt was intubated and sedated. . Recent admission on [**2103-4-10**] for GIB, EGD with large varices, ? [**Doctor First Name **]-[**Doctor Last Name **] tear. . Admitted for further mgmt of liver failure. Past Medical History: 1. Hep C dx in [**2097**], genotype 1A -tried on pegIFN/ribavirin, some response, but stopped [**3-15**] side effects -cirrhosis -portal hypertension 2. HIV dx in [**2088**], dx during prenatal screening -H/o ARV intolerance -initial regimen was CBV/IDV on which she did well, but developed kidney stones. IDV- kidney stones/ DDC- myopathy nevirapine- rash/ Abacavir- rash -CD4 490 [**1-15**] 3. Elevated AFP 4. sciatica 5. 2 C-sections 6. bronchitis 7. Cervical dysplasia in [**2091-6-10**] (per ID note) 8. Asthma (no intubations) 9. peripheral neuropathy 10. L4/5 radiculopathy on R 11. h/o CA-MRSA skin infection 12. s/p tubal ligation after last pregnancy 13. h/o polysubstance abuse and has been sober for 1 year; in group and maintanence programs 14. ETOH abuse in past Social History: She currently lives in a halfway house (wrap house). She has 3 children age 14, 5 and 3. She is not drinking any alcohol and she plans to move in with her boyfriend and live in [**Name (NI) 5503**] when she graduates from her halfway house. Engaged. Family History: 1. F- colon cancer 2. M- pancreatic cancer, died at 53 . Physical Exam: 91, 113/44, 94 % 5 PEEP, 60% FiO2, temp 99.4 intubated, sedated, not answers to commands PEERLA, +icterus RRR nl s1/s2, no m/r/g coarse BS, no crackles protuberant abd, umbilical hernia, +BS, DTP, liver not palpable 2+-3+ pitting edema to knees, cool extremities, warm hands . Pertinent Results: [**2103-4-25**] 08:32PM TYPE-ART PO2-78* PCO2-28* PH-7.38 TOTAL CO2-17* BASE XS--6 [**2103-4-25**] 08:32PM LACTATE-10.8* K+-5.7* [**2103-4-25**] 08:32PM freeCa-1.06* [**2103-4-25**] 07:49PM GLUCOSE-51* UREA N-65* CREAT-3.7* SODIUM-132* POTASSIUM-6.0* CHLORIDE-98 TOTAL CO2-15* ANION GAP-25* [**2103-4-25**] 07:49PM CALCIUM-8.8 PHOSPHATE-5.4* MAGNESIUM-3.0* [**2103-4-25**] 06:02PM OTHER BODY FLUID WBC-1650* RBC-1650* POLYS-77* LYMPHS-0 MONOS-13* MESOTHELI-1* MACROPHAG-9* [**2103-4-25**] 05:56PM PT-23.0* INR(PT)-2.3* [**2103-4-25**] 05:39PM TYPE-ART TEMP-38.3 RATES-14/20 TIDAL VOL-550 PEEP-10 O2-50 PO2-101 PCO2-27* PH-7.38 TOTAL CO2-17* BASE XS--7 -ASSIST/CON INTUBATED-INTUBATED VENT-SPONTANEOU [**2103-4-25**] 05:39PM GLUCOSE-115* LACTATE-10.9* K+-5.0 [**2103-4-25**] 05:39PM freeCa-0.95* [**2103-4-25**] 03:15PM TYPE-ART TEMP-38.3 PO2-137* PCO2-30* PH-7.43 TOTAL CO2-21 BASE XS--2 [**2103-4-25**] 03:15PM LACTATE-9.8* K+-6.0* [**2103-4-25**] 03:03PM PT-26.5* PTT-35.9* INR(PT)-2.7* [**2103-4-25**] 12:30PM TYPE-ART TEMP-38.3 RATES-14/22 TIDAL VOL-550 PEEP-5 O2-50 O2 FLOW-5 PO2-128* PCO2-31* PH-7.39 TOTAL CO2-19* BASE XS--4 INTUBATED-INTUBATED [**2103-4-25**] 11:50AM TYPE-[**Last Name (un) **] TEMP-37.8 PO2-49* PCO2-32* PH-7.38 TOTAL CO2-20* BASE XS--4 [**2103-4-25**] 11:50AM GLUCOSE-85 LACTATE-8.8* NA+-131* K+-6.3* [**2103-4-25**] 11:14AM GLUCOSE-81 UREA N-61* CREAT-3.0* SODIUM-130* POTASSIUM-6.1* CHLORIDE-95* TOTAL CO2-17* ANION GAP-24* [**2103-4-25**] 11:14AM CALCIUM-9.0 PHOSPHATE-4.7* MAGNESIUM-3.1* [**2103-4-25**] 11:14AM URINE HOURS-RANDOM SODIUM-47 [**2103-4-25**] 11:14AM URINE OSMOLAL-315 [**2103-4-25**] 11:14AM URINE EOS-NEGATIVE [**2103-4-25**] 05:44AM UREA N-59* CREAT-2.4* POTASSIUM-5.9* [**2103-4-25**] 05:44AM HCG-<5 [**2103-4-25**] 04:47AM URINE HOURS-RANDOM CREAT-54 SODIUM-45 [**2103-4-25**] 04:47AM URINE COLOR-LtAmb APPEAR-Clear SP [**Last Name (un) 155**]-1.020 [**2103-4-25**] 04:47AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-NEG [**2103-4-25**] 04:47AM URINE RBC-30* WBC-0 BACTERIA-NONE YEAST-NONE EPI-<1 [**2103-4-25**] 02:42AM TYPE-[**Last Name (un) **] PH-7.41 [**2103-4-25**] 02:42AM LACTATE-4.5* [**2103-4-25**] 02:42AM freeCa-1.08* [**2103-4-25**] 02:15AM GLUCOSE-86 UREA N-55* CREAT-2.0* SODIUM-128* POTASSIUM-6.2* CHLORIDE-98 TOTAL CO2-20* ANION GAP-16 [**2103-4-25**] 02:15AM ALT(SGPT)-147* AST(SGOT)-298* LD(LDH)-770* ALK PHOS-165* AMYLASE-81 TOT BILI-10.0* [**2103-4-25**] 02:15AM LIPASE-30 [**2103-4-25**] 02:15AM ALBUMIN-2.1* CALCIUM-8.2* PHOSPHATE-4.3 MAGNESIUM-3.0* IRON-87 CHOLEST-91 [**2103-4-25**] 02:15AM calTIBC-182* FERRITIN-719* TRF-140* [**2103-4-25**] 02:15AM TRIGLYCER-108 HDL CHOL-30 CHOL/HDL-3.0 LDL(CALC)-39 [**2103-4-25**] 02:15AM OSMOLAL-303 [**2103-4-25**] 02:15AM CORTISOL-24.7* [**2103-4-25**] 02:15AM WBC-21.6*# RBC-2.61*# HGB-9.6*# HCT-29.5*# MCV-113* MCH-36.6* MCHC-32.4 RDW-18.7* [**2103-4-25**] 02:15AM NEUTS-81* BANDS-2 LYMPHS-4* MONOS-2 EOS-0 BASOS-0 ATYPS-3* METAS-3* MYELOS-5* [**2103-4-25**] 02:15AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+ MACROCYT-3+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+ STIPPLED-OCCASIONAL [**2103-4-25**] 02:15AM PLT COUNT-163 [**2103-4-25**] 02:15AM PT-35.7* PTT-40.9* INR(PT)-3.9* [**2103-4-25**] 02:15AM FIBRINOGE-164 [**2103-4-25**] 02:15AM WBC-21.6* LYMPH-7* ABS LYMPH-1512 CD3-81 ABS CD3-1227 CD4-38 ABS CD4-576 CD8-44 ABS CD8-671 CD4/CD8-0.9 Brief Hospital Course: MICU COURSE: The patient was admitted to the MICU directly from the OSH. A CVL was placed in the L IJ, and an A-line was placed in the L radial artery. Levophed was started to support the blood pressure. The K+ was elevated, with peaked T waves on EKG, and she was treated with calcium gluconate and insulin/dextrose and kayexalate. She was started on Unasyn initially for broad antimicrobial coverage for presumed sepsis [**3-15**] PNA, then switched to Vancomycin and Zosyn; she was ventilated with lung-protective ventilation; a bronchoscopy was performed with BAL on [**2103-4-25**]: negative cx data. The patient was evaluated and followed by the Transplant Service but was not a candidate for transplantation [**3-15**] sepsis. She was maintained on pressors for most of her hospital course, at one point weaned down only to vasopressin. An ECHO revealed a normal EF. The bilirubin consistently rose from 10.0 on admission to as high as 33. The patient had a significant ileus on admission and was treated with neostigmine with good results; however, the ileus returned later in her course, with significant abdominal distension. Her mental status remained consistently poor, with no purposeful response to stimuli. Pupillary exam remained intact. A head CT showed diffuse loss of sulci prominence w/o herniation. An EEG showed + triphasic waves and no epileptiform activity and was c/w hepatic encephalopathy; she was treated with lactulose, rifamixin, and flagyl. The patient was repeatedly pan-cultured w/o significant yield. She was transfused one U pRBCs for a Hct of 21. The patient was in acute renal failure on arrival; a FeNa was 1.3%. The patient was started on mitodrine and ocreotide and the urine output briefly improved but then declined. The patient had episodes of hypoglycemia to the 50s and was given D50 and started on D5 maintenance. The coagulopathy progressively worsened. On HD 9 ([**2103-5-3**]) the patient spiked to 102.9, was tachycardic, on vasopressin, with minimal-to-no urine output, increased abdominal distension, and worsening coagulopathy, with an INR of 7.0 and fibrinogen of 46. At this point, there was discussion with the HCP regarding the patient's grim prognosis, and the decision was made to make the patient CMO. Pressors were discontinued, the patient was extubated, and within 2 hours the patient was noted to become agonal with a junctional rhythm that quickly deteriorated to asystole. The patient was pronounced at 8:19 PM; a post-mortem was declined by the HCP. Medications on Admission: Meds on transfer: albuterol proventil 2.5 mg q6 amytriptylene 25 mg po qhs CTZ 1 gm qd (d#1) flovent 2 puff IH lasix 40 mg IV bid ([**4-24**]) lactulose 60 ml q6 kayexalate enema 60 gm tid paxil 20 mg qd trazadone 50 mg qhs dilaudid 1-1.5 mg IV q6 regular insulin truvada (held) propofol gttdopamin gtt . Meds at home (from transplant documents): videx Ec (didanosine) 250 mg qd truvada (emticitabine/tenofovir) 1 tab qd reyataz (atazanavir) 150 mg qd MVI norvir (ritonavir) 100 mg qd amitryptilene 20 mg qd trazadone 50 mg qd paxil 20 mg qhs lactulose 15 ml qd clotrimazole 10 ml qd spironolactone 200 mg qd lasix 20 mg qd . Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: 1. Cardiopulmonary arrest 2. Hepatic failure 3. Sepsis Discharge Condition: Deceased

[ "572.2", "571.5", "070.70", "785.52", "518.81", "995.92", "584.9", "560.1", "507.0", "038.9", "570" ]

icd9cm

[ [ [] ] ]

[ "99.15", "96.6", "33.24", "38.93", "38.91", "96.72" ]

icd9pcs

[ [ [] ] ]

9433, 9442

6206, 8728

350, 399

9541, 9552

2678, 6183

2305, 2364

9405, 9410

9463, 9520

8754, 8754

2379, 2659

242, 312

427, 1220

1242, 2021

2037, 2289

8772, 9382

27,030

121,548

17468

Discharge summary

report

Admission Date: [**2147-1-11**] Discharge Date: [**2147-1-19**] Date of Birth: [**2086-10-7**] Sex: M Service: CARDIOTHORACIC Allergies: Levaquin / Midazolam Attending:[**First Name3 (LF) 922**] Chief Complaint: 60 year old with 3VDs and aortic stenosis. Major Surgical or Invasive Procedure: [**1-13**] AVR (25mm porcine) CABGX3 (LIMA-LAD, SVG-OM, SVG-PDA) History of Present Illness: 60 y.o. male with AS and 3VDs now s/p AVR(25mm Porcine)/CABGX3 (LIMA-LAD, SVG-OM, SVG-PDA. Past Medical History: PMH: CAD, S/P MI w/ RCA stenting (BMS) [**4-/2142**], AS, Reactive Airway Disease, Hodgkin's lymphoma, S/P Rads/Chemo '[**12**], Hypothyr, RIH [**10-20**] Social History: Works as a pastor and lives at home wife his wife. Denies ETOH and recreational drug use. Family History: Mother, alive 86y.o. s/p MVR, hemorragic CVA Father alive 89 y.o. no cardiac history Two brother alive with no cardiac history Physical Exam: Admission physical exam [**1-12**] Pulse: 87 Resp: 18 B/P right 173/82 left 155/72 Ht: 5'7" Wgt 81.6kg General: NAD Skin: Unremarkable well healed biopsy site L clavicle HEENT: Unremarkable Neck: Supple, Full ROM Chest: Slight decreased air at L base Heart: RRR IV-VI systolic murmur radiating to carotids Abdomen: Benign Extremities: Warm, well-perfused, no edema Varicosities: None Neuro: Intact Pulses: Femoral, DP, PT, radial, equal bilaterally 2+ Carotid Bruit: right and left radiating murmur Pertinent Results: [**2147-1-11**] 09:58PM PT-13.5* PTT-25.0 INR(PT)-1.2* [**2147-1-11**] 07:13PM HGB-13.8* calcHCT-41 O2 SAT-97 [**2147-1-11**] 06:30PM GLUCOSE-144* UREA N-14 CREAT-0.8 SODIUM-139 POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-25 ANION GAP-15 [**2147-1-11**] 06:30PM ALT(SGPT)-8 AST(SGOT)-20 CK(CPK)-124 ALK PHOS-68 AMYLASE-38 TOT BILI-0.5 [**2147-1-11**] 06:30PM cTropnT-<0.01 [**2147-1-11**] 06:30PM ALBUMIN-3.8 [**2147-1-11**] 06:30PM %HbA1c-5.9 [**2147-1-11**] 06:30PM WBC-7.0 RBC-4.43* HGB-13.2* HCT-37.7* MCV-85 MCH-29.7 MCHC-34.9 RDW-13.9 [**2147-1-11**] 06:30PM PLT COUNT-214 [**2147-1-17**] 07:00AM BLOOD WBC-10.1 RBC-3.35* Hgb-10.3* Hct-28.7* MCV-86 MCH-30.7 MCHC-35.8* RDW-15.0 Plt Ct-163 [**2147-1-17**] 07:00AM BLOOD Glucose-133* UreaN-13 Creat-0.7 Na-132* K-3.6 Cl-96 HCO3-27 AnGap-13 [**2147-1-17**] 07:00AM BLOOD Calcium-7.6* Phos-1.3*# Mg-2.2 RADIOLOGY Final Report CHEST (PA & LAT) [**2147-1-17**] 3:49 PM CHEST (PA & LAT) Reason: s/p ct d/c [**Hospital 93**] MEDICAL CONDITION: 60 year old man with REASON FOR THIS EXAMINATION: s/p ct d/c HISTORY: Status post removal of chest tube. FINDINGS: In comparison with the study of [**1-13**], there has been removal of the endotracheal tube, nasogastric tube, mediastinal drains, and Swan-Ganz catheter. The left chest tube has been removed and there is no evidence of pneumothorax. Elevation of the left hemidiaphragm persists as does some atelectatic change at the left base. Sternal sutures remain in place and without fracture. DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**] Approved: WED [**2147-1-18**] 10:14 AM [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 48783**] (Complete) Done [**2147-1-13**] at 3:41:13 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 177**] [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2086-10-7**] Age (years): 60 M Hgt (in): 67 BP (mm Hg): 119/73 Wgt (lb): 180 HR (bpm): 64 BSA (m2): 1.94 m2 Indication: Intraoperative TEE for CABG/AVR ICD-9 Codes: 786.05, 786.51, 440.0, 424.1 Test Information Date/Time: [**2147-1-13**] at 15:41 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], 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: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *6.0 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 60% to 65% >= 55% Aorta - Annulus: 2.3 cm <= 3.0 cm Aorta - Sinus Level: 3.1 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.4 cm <= 3.0 cm Aorta - Ascending: 2.8 cm <= 3.4 cm Aorta - Descending Thoracic: 2.2 cm <= 2.5 cm Aortic Valve - Peak Velocity: *2.7 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *28 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 15 mm Hg Aortic Valve - Valve Area: *0.6 cm2 >= 3.0 cm2 Mitral Valve - E Wave: 0.9 m/sec Mitral Valve - A Wave: 0.4 m/sec Mitral Valve - E/A ratio: 2.25 Mitral Valve - E Wave deceleration time: 210 ms 140-250 ms Findings LEFT ATRIUM: Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity. Overall normal LVEF (>55%). 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. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Severe AS (AoVA <0.8cm2). Moderate (2+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve 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. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is normal (LVEF>55%) with noted inferior wall hypokinesis from the mid-papillary level to apex. 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Moderate (2+) aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. POST-BYPASS: I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2147-1-15**] 11:33 Brief Hospital Course: Mr [**Known lastname **] is a 60 y.o male who was transferred from [**Hospital1 **] on [**1-11**] for cardiac catheterization and an echo that revealed an EF of 55%, LM: 60-70%, LAD 30%, LCX:50% RCA:30%, [**Location (un) 109**] 0.77 with peak 50. He was then referred for cardiac surgery. On [**1-13**] he was brought to the operating room and underwent AVR (25mm Porcine) and CABGX3 (LIMA-LAD, SVG-OM, SVG-PDA). He received 48 hours of perioperative Vancomycin because he was inpatient prior to his surgery. He was brought to the intensive care unit in stable condition for recovery. He did well during the immediate post-operative period. His anesthesia was reversed and he remained on precedex for his ventilatory wean until POD1 when he was extubated. On POD 1 he had a self limited episode of AF. His Neosinephrine was weaned off and he was started on beta-blockers and lasix. On POD 2 he was stable enough to transfer to F6 to continue his perioperative care management. On POD4 his chest tubes were removed. He developed more atrial fibrillation and he was started on amiodarone and coumadin. He was ready for discharge home on POD 6. Medications on Admission: Levothyroxine 0.1', ASA 325', Atorvastatin 40' Folic Acid 1' Toprol XL 50' Co-Q-10 200' VitC 500' Omega 3' VitE' MVI' NTG SL prn Fiber supplement daily Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 weeks. Disp:*30 Tablet(s)* Refills:*0* 2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Packet PO Q12H (every 12 hours) for 2 weeks. Disp:*30 Packet(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain for 10 days. Disp:*50 Tablet(s)* Refills:*0* 6. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*0* 7. Warfarin 2 mg Tablet Sig: As directed Tablet PO ONCE (Once): 3 mg (1.5 tabs) [**1-19**], Check INR [**1-20**] with results called to Dr. [**Name (NI) 48784**] office at [**Telephone/Fax (1) 48785**]. . Disp:*75 Tablet(s)* Refills:*0* 8. Amiodarone 200 mg Tablet Sig: As directed below Tablet PO As directed: Sig: 400mg [**Hospital1 **] for 4 days Then 400mg daily for 7 days Then 200mg daily until dc'd by cardiologist. Disp:*50 Tablet(s)* Refills:*0* 9. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: while taking narcotic pain medicine. Disp:*60 Capsule(s)* Refills:*0* 12. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day for 1 months. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: 60 y.o. with AS and CAD now s/p AVR (25mm porcine) CABGX3 (LIMA-LAD, SVG-OM, SVG-PDA) PMH: CAD, s/p MI w/RCA stenting, AS, Reactive Airway Disease, Hodgkin's lymphoma, s/p Rads/Chemo in [**2112**], Hypothyroidism, RIH [**10-20**] Discharge Condition: Good Discharge Instructions: 1. Keep wound clean and dry. OK to shower, no bathing or swimming. 2. Call for any redness or discharge from wounds 3. Take all medication as prescribed at discharge 4. No heavy lifting or driving for 6 wks 5. Coumadin - Check INR [**1-20**] with results called to Dr.[**Name (NI) 48786**] office at [**Telephone/Fax (1) 48785**]. Followup Instructions: 2 weeks to Dr [**First Name8 (NamePattern2) 31011**] [**Name (STitle) 1611**], PCP - [**1-19**] Spoke to [**Doctor First Name 17563**] at Dr. [**Last Name (STitle) 48787**] office who agreed to follow coumadin after discharge. Dr [**First Name8 (NamePattern2) 565**] [**Last Name (NamePattern1) **], Cardiologist in 2 weeks [**Hospital Ward Name 121**] 6 for wound check in 2 weeks Dr. [**Last Name (STitle) 914**] in 4 weeks Completed by:[**2147-1-19**]

[ "427.31", "V58.66", "V15.3", "414.01", "V58.61", "412", "244.9", "493.90", "424.1", "V10.72" ]

icd9cm

[ [ [] ] ]

[ "88.72", "39.61", "36.12", "39.64", "88.56", "37.23", "35.21", "89.64", "36.15" ]

icd9pcs

[ [ [] ] ]

10439, 10494

7400, 8543

329, 396

10768, 10775

1480, 2456

11154, 11611

817, 945

8746, 10416

2493, 2514

10515, 10747

8569, 8723

10799, 11131

960, 1461

247, 291

2543, 7377

424, 516

538, 694

710, 801

2,093

168,482

46005

Discharge summary

report

Admission Date: [**2145-2-4**] Discharge Date: [**2145-2-9**] Date of Birth: [**2065-3-17**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 134**] Chief Complaint: substernal chest pain Major Surgical or Invasive Procedure: none History of Present Illness: This is a 79yo F with history of AAA repair 4 months ago, hypertension, hyperlipidemia who presented to the ED with substernal chest pain. According to her, the pain started suddenly at 8PM on the night of admission. She describes a [**9-6**] sharp substernal chest pain that radiates to the back. SHe denies nausea/vomiting/diziness/fever/chills. She denies previous occurence(not even before her AAA repair). On arrival to [**Hospital1 18**] ED, her BP was 211/90 on the right and 119/90 on the left and P60. CTA was done which showed type B aortic dissection 3cm off left subclavian and extends for 4-5cm, confined to the thorax. Her AAA repair was intact. She was started on esmolol, morphine and nipride. Past Medical History: 1. h/o atrial ectopy and tachycardia- previous stress and holter monitor testing 2.spinal stenosis 3. AAA- currently stable at 5 x4 cm by CT 4. neuropathy 5. h/o bronchitis 6. HTN 7.hyperlipidemia 8.asthma 9.barrett's esophagus 10.Antral ulcer [**1-1**] 11. s/p AAA repair [**10-1**] 12. diverticulosis Social History: Lives at home with son, who is a teacher.Denies Tobacco or ETOH use.She has a daughter, who is active in her health care and is a nurse [**First Name8 (NamePattern2) **] [**Last Name (Titles) 9012**] Family History: noncontribitory Physical Exam: Gen-uncomfortable and in obvious pain HEENT-anicteric, oral mucosa dry, neck supple CV-rrr, no r/m/g resp-CTAB(anterior exam) [**Last Name (un) 103**]-active BS, NT/ND, soft neuro-PERL, move all 4 limbs symmetrically extremities-DP 1+b/l, no femoral bruit, no pitting edema Pertinent Results: [**2145-2-3**] 11:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2145-2-3**] 09:30PM GLUCOSE-131* UREA N-9 CREAT-0.8 SODIUM-142 POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-31* ANION GAP-10 [**2145-2-3**] 09:30PM CK(CPK)-85 [**2145-2-3**] 09:30PM cTropnT-<0.01 [**2145-2-3**] 09:30PM WBC-5.0 RBC-4.47 HGB-13.0 HCT-40.2 MCV-90 MCH-29.1 MCHC-32.4 RDW-14.9 [**2145-2-3**] 09:30PM PLT COUNT-177 [**2145-2-3**] 09:30PM PT-13.2 PTT-27.9 INR(PT)-1.1 EKG [**2-3**]:NSR at 60bpm with LAD and 1st degree AVB Brief Hospital Course: 79yo F with history of abdominal aortic aneurysm repair 4 months ago, hypertension and hyperlipidemia presents with type B aortic dissection. CT abdomen done in the ED showed aortic dissection about 3cm off left subclavian vein and extend 4cm confined to the thorax. CT surgery was consulted and agrees to just medical manegement. SHe was transferred to the CCU for blood pressure monitoring. She was initially on esmolol and nipride and was weaned off the next day to oral blood pressure medication. She was transitioned to labetolol, captopril and norvasc which were titrated up to control her blood pressure. Upon discharge, her blood pressure was better controlled. She would need close follow up as outpatient to make sure her blood pressure is well controlled. SHe has no end organ damage during her hospital stay. There was no new heart murmur, her renal function remained stable, good peripheral pulses, serial lactate level was normal, serial neuro exam normal. Echocardiogram was performed on [**2-4**] which showed EF>75%, no mass/thrombi, no VSD, wall motion normal, no aortic stenosis and 1+Aortic regurgitation. CT chest/abdomen was repeated on [**2-8**] for complain of chest pain radiating to the back. That showed no progression of aortic dissection and no bowel ischemia. She has diffuse pain complain while in the hospital . This included headache, periumbilical pain, back pain and knee pain. These are all chronic pain and patient is on neurontin. She would follow up with her PCP for that. She remained on aspirin and lipitor for coronary artery disease. Her CXR was consistent with left lower lobe pneumonia and since she was febrile, she was started on levofloxacin for a course of 10 days. Discharge Medications: 1. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 2. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 3. Brimonidine Tartrate 0.15 % Drops Sig: One (1) Ophthalmic QHS (once a day (at bedtime)). 4. Pilocarpine HCl 1 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 5. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)). 7. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO QPM (once a day (in the evening)). 8. Betaxolol HCl 0.25 % Drops, Suspension Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 9. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 11. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 12. Labetalol HCl 200 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital3 537**]- [**Location (un) 538**] Discharge Diagnosis: type II aortic dissection hypertension chronic pain Discharge Condition: good Discharge Instructions: Take all your home medications. Take your blood pressure each day and record it for your doctor. Please return to the hospital if you experience more chest pain/severe abdominal pain or if there are any concerns at all. Followup Instructions: Provider: [**Name10 (NameIs) **] FIELD SCREENING Where: [**Hospital6 29**] [**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2145-3-17**] 1:00 Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Where: [**Hospital6 29**] [**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2145-3-17**] 3:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2145-3-24**] 1:30 Completed by:[**2145-2-9**]

[ "719.46", "447.2", "365.9", "272.0", "486", "441.01", "401.9", "562.10", "356.9", "789.05", "493.90", "414.01", "724.5", "530.85" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5739, 5810

2561, 4283

334, 340

5906, 5912

1965, 2538

6181, 6777

1639, 1656

4306, 5716

5831, 5885

5936, 6158

1671, 1946

273, 296

368, 1080

1102, 1406

1422, 1623

21,687

198,216

6360

Discharge summary

report

Admission Date: [**2181-2-21**] Discharge Date: [**2181-3-2**] Service: NEUROLOGY HISTORY OF PRESENT ILLNESS: This is an 88-year-old woman, with past medical history significant for past subdural hemorrhage and left occipital stroke, who presents with imbalance for the past 2-3 months and has been using a cane since then. She says there is no lightheadedness, vertigo, chest pain, shortness of breath, weakness, numbness, or visual problems. She says that 2 weeks prior to admission, she tripped over a cord on the floor and fell on her knees (no injuries) and went to her PCP who ordered [**Name Initial (PRE) **] head CT which was negative for acute pathology. She also says that for the past week or so she has been "confused," which consists of being distracted, not being able to focus, and leaving items in the wrong place (normally she is very organized), and has also had a short temper. She says there is no numbness or weakness, no speech or comprehension problems. On the day prior to admission, she was at home and the girl who helps her out came to help her with her laundry, and then she said "I could not do the laundry" and could not make "quick decisions." She then called her PCP who sent her to the Emergency Department for further management, and an MRI showed evidence of subacute strokes and right ICA stenosis. PAST MEDICAL HISTORY: 1. Right subdural hemorrhage in [**4-6**] status post evacuation. She had presented with ataxia at that time 2. Left occipital stroke which occurred at the same time as the subdural hemorrhage. 3. Hypertension. 4. Status post left wrist fracture. 5. Status post right total knee replacement. 6. Sciatica. 7. Osteoarthritis. 8. Glaucoma. 9. History of Bell's palsy. 10.History of UTIs. 11.History of 3 miscarriages. ALLERGIES: 1. Sulfa which caused hepatitis. 2. Lasix. MEDICATIONS: 1. Dyazide. 2. Premarin. 3. Cozaar. 4. Timoptic eyedrops. 5. Xalatan eyedrops. 6. Donnatal. 7. Tylenol. 8. Amoxicillin for prophylaxis against UTIs. SOCIAL HISTORY: Lives alone. Son is a pediatrician. Husband was a cardiologist. A 60-pack year smoking history, now quit. No ETOH. FAMILY HISTORY: CAD, CHF, kidney carcinoma, pancreatic carcinoma. PHYSICAL EXAM: She is afebrile with a blood pressure of 102-138/78-88, heart rate 60-64, O2 sat 97% on room air. GENERAL MEDICAL EXAM: Unremarkable with no carotid bruits appreciated. NEUROLOGIC EXAM: Alert and oriented x 3. Able to say the months of the year backwards. Registration intact. Recall intact to 3 objects at 5 minutes. Repetition and naming intact. Speech fluent without paraphasic errors or hesitancy. Able to relate full HPI. No neglect or apraxia. Cranial nerves - pupils equal, round and reactive to light. Extraocular eye muscles intact without nystagmus. There is a right homonymous hemianopsia which is old. Facial sensation and movement are intact bilaterally. Hearing intact to finger rub. Tongue protrudes midline without fasciculations. Sternocleidomastoids intact bilaterally. Shoulder shrug intact bilaterally. Motor - normal bulk and tone throughout. No fasciculations. No pronator drift. There is minor 4+/5 weakness in the left biceps and triceps, and bilaterally in the finger extensors. Otherwise, she has full strength in the right and left upper and lower extremities throughout. Reflexes slightly brisker on the left in the upper and lower extremities. Toes downgoing bilaterally. Sensation - decreased sensation to vibration and temperature in the lower extremities to the knees, and in the upper extremities to the elbows. Impaired proprioception in the lower extremities bilaterally. No extinguishing to double-simultaneous stimulation. Coordination slightly ataxic on finger-to-nose on the right and heel-to-shin on the right. Rapid alternating movements and fine finger movements intact bilaterally. Gait normal. Narrow-based gait, not unsteady. Positive Romberg. LABS AND STUDIES: White count 5.0, hematocrit stable at 33.5, platelet count 173, INR 1.1. Chem-10 normal. Ruled out for MI by enzymes. MRI shows restricted diffusion in the right frontal, right superior parietal and posterior temporal lobes consistent with subacute infarct. The GRE images show some susceptibility in the right superior parietal lobe which could represent hemorrhage. The T2 and FLAIR sequences showed increased signal in these regions, as well as the left insular and left posterior parietal lobes which correspond to regions of prior infarction, as seen on a prior study of [**2179-4-18**]. There is no shift. The ventricles and cisterns are normal in appearance. There is no hydrocephalus. On the MRA of the brain, there is irregularity and decreased signal of the right vertebral artery consistent with atherosclerotic narrowing. In addition, there is decreased flow in the left carotid artery, raising the possibility of a proximal stenosis. Of the MRA of the cervical vasculature is recommended. Carotid ultrasound showed an 80-99% stenosis in the right carotid artery and 40% in the left carotid artery. Angiogram revealed greater than 95% stenosis at the origin of the right cervical cord bifurcation, treated successfully using stent angioplasty with distal protection. CT of the head without contrast on [**2-28**] showed no interval change. TTE showed no ASD or PFO. There was mild symmetric left ventricular hypertrophy. There was mild regional left ventricular systolic dysfunction, resting wall motion abnormalities, inferior akinesis and septal hypokinesis. Right ventricle was normal. There was mild 1+ AR and 2+ MR. The left ventricular inflow pattern suggests impaired relaxation. EF is about 45%. HOSPITAL COURSE: The patient was admitted to the neurology service for her subacute strokes, and a full stroke work-up was completed, including transthoracic echocardiogram and carotid artery ultrasound. It was found that the patient had a severe stenosis in the right carotid artery, and this was stented without incident. The patient remained in the PACU for a day after the angiogram, as she was briefly on dopamine. She was eventually able to be weaned off the dopamine, and she returned to the floor and felt well. She had no exacerbation of her symptoms throughout the hospital course, and there were no complications of the procedure. For a couple of days after the angiogram was done, the patient did have some sun-downing and confusion at night with agitation and did require 25 mg of Seroquel for this. The patient is now being discharged to rehab in good condition. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg qd. 2. Plavix 75 mg qd. 3. Timolol eyedrops 0.5% 1 drop OU qd. 4. Latanoprost 0.005% eyedrops 1 drop OU q hs. 5. Famotidine 20 mg po bid. 6. Colace 100 mg po bid. 7. Tylenol prn. 8. Seroquel 25 mg po bid prn agitation. FOLLOW-UP: She is scheduled to follow-up with Dr. [**Last Name (STitle) **] in ENT on [**2181-4-5**] at 2:00 pm, and in the [**Hospital **] Clinic on [**2181-5-3**] at 9:30 am. She will be scheduled for a follow-up appointment with Dr. [**First Name (STitle) **] [**Name (STitle) **], and with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2148**] prior to her discharge. [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], M.D. [**MD Number(1) 4269**] Dictated By:[**Last Name (NamePattern1) 10034**] MEDQUIST36 D: [**2181-3-2**] 13:13 T: [**2181-3-2**] 14:00 JOB#: [**Job Number 24612**]

[ "V13.09", "715.90", "311", "365.9", "V12.59", "599.0", "433.11", "401.9" ]

icd9cm

[ [ [] ] ]

[ "39.50", "88.41", "39.90", "88.91" ]

icd9pcs

[ [ [] ] ]

2165, 2216

6613, 7510

5723, 6590

2232, 2402

123, 1356

2420, 5705

1378, 2012

2029, 2148

76,827

151,035

51281

Discharge summary

report

Admission Date: [**2195-11-16**] Discharge Date: [**2195-11-21**] Date of Birth: [**2134-10-3**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 594**] Chief Complaint: Dyspnea, cough, LE edema. Major Surgical or Invasive Procedure: None. History of Present Illness: 61F w/ pulm fibrosis on 12L NC at home, presenting to ED with 2d h/o cough, SOB and b/l LE swelling. History provided by patient and husband. Pt has had increased cough and SOB for 2 days. Cough occasionally productive of clear sputum, mucus plus occasionayll tinged with blood. No fevers or chills. No CP. No nausea or vomiting or abdominal pain. ROS + for loose stools, no blood or melena. Just found out someone she was in contact with yesterday called in to work sick today, but symptoms precede this exposure. Has been in contact with sister whose [**Name2 (NI) 802**] had a cold recently, but not [**Name2 (NI) 802**] herself. LE swelling is chronic per husband - she is largely immobile and sits in her chair all day. She has been getting her pulm care at [**Hospital1 2177**] for the past year, last hosp there 3 weeks ago. She has discussed getting lung transplant with [**Hospital1 112**] but has been non-compliant with PT and, due to her poor mobility, is no longer a candidate for transplant. She is attempting a chemotherapeutic infusion in a few weeks to treat her lung disease. . In the ED she triggered upon arrival for low O2 sat in the low 80%. Other VS were: 95.1, 100, 136/89, 22, 91% on 15L NC. She was A&Ox3, had b/l pitting edema to knees, fine crackles 50% up her lungs (per a note, these crackles may be her baseline). CXR was done which showed new moderate bibasilar opacities, may represent superimposed effusion/infiltrate, last CXR [**2192**]. BNP >6000 (no baseline in OMR). Was given combivent, solumedrol, and azithromycin for possible pna. After these interventions pt felt she was at her baseline. Obtained PA/Lateral CXR prior to transfer to MICU. At the time of transfer vitals were 101, bp 118/77, 92% NRB, rr 25. . On arrival to the MICU, VS 96.1, 125/60, 90% on NRB, 106. Pt appears uncomfortable and deferring most questions to husband. . 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. Lung fibrosis, history of hypersensitivity pneumonitis - diagnosed 12 years ago. See HPI. 2. History of tobacco use. 3. Severe anxiety on benzodiazepines. 4. Severe gastroesophageal reflux disease (GERD). 5. Question of arthritis/myositis - status post muscle biopsy that was nonspecific, showing nonspecific collagen vascular disease with elements of RA, SSc, polymyositis under the care of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 92003**] (? mixed connective tissue disease) followed by Rheumatology. 6. Severe needle phobia. 7. Status post lung biopsy in [**2192**] and [**2183**]. Social History: Ms. [**Known lastname 976**] is married. She worked as a secretary in the past. She has no work-related exposures that she knows about. She has no alcohol. She quit cigarettes after smoking 3 packs per day for 20 years, quitting at the age of 35. She reports possible exposure to tuberculosis from her cousin in the past. She has no animals or birds at home. There is an extensive note from Dr. [**Last Name (STitle) **] from [**2187**] regarding her home mold exposure and cleaning. She is still living in the same place. Family History: Her family history is notable for a grandfather with diabetes,father with congestive heart failure (CHF), mother with dementia, and brother with prostate cancer. No family history of lung disease. Physical Exam: Admission Physical Exam: Vitals: 96.1, 125/60, 90% on NRB, 106, 31 General: Alert, oriented, uncomfortable but in NAD, breathing unlabored HEENT: Sclera anicteric, MMM; facemask on CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: dependent early inspiratory crackles in right lung Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley placed Ext: warm, TTP, 2+ edema; skin firm and thickened, no erythema Discharge Physical Exam: Patient expired. No heart or lung sounds for 2 minutes upon auscultation. Negative corneal reflex, dolls eye, and gag reflex. Pertinent Results: Labs on Admission: [**2195-11-16**] 11:45AM BLOOD WBC-16.7* RBC-4.41 Hgb-14.0 Hct-43.2 MCV-98 MCH-31.6 MCHC-32.3 RDW-15.2 Plt Ct-271 [**2195-11-16**] 11:45AM BLOOD Neuts-82.1* Lymphs-12.4* Monos-4.3 Eos-0.8 Baso-0.4 [**2195-11-16**] 11:45AM BLOOD PT-11.0 PTT-23.7* INR(PT)-1.0 [**2195-11-16**] 11:45AM BLOOD Glucose-139* UreaN-18 Creat-0.8 Na-139 K-4.0 Cl-97 HCO3-36* AnGap-10 [**2195-11-16**] 11:45AM BLOOD ALT-32 AST-27 LD(LDH)-433* AlkPhos-75 TotBili-0.9 [**2195-11-16**] 09:57PM BLOOD Mg-1.9 [**2195-11-16**] 12:19PM BLOOD Lactate-1.9 Pertinent Labs: [**2195-11-19**] 11:55AM BLOOD WBC-16.1* RBC-4.79 Hgb-15.3 Hct-47.3 MCV-99* MCH-32.0 MCHC-32.4 RDW-14.7 Plt Ct-265 [**2195-11-19**] 11:55AM BLOOD Glucose-372* UreaN-24* Creat-0.9 Na-132* K-5.2* Cl-88* HCO3-33* AnGap-16 [**2195-11-19**] 11:55AM BLOOD Calcium-9.8 Phos-4.4 Mg-2.4 Radiology: CHEST (PA & LAT) Study Date of [**2195-11-16**] 3:03 PM FINDINGS: As compared to the previous examination, there is a further mild increase in extent and severity of the pre-existing bilateral peripheral opacities. In light of the history of pulmonary fibrosis, these findings could indicate progressing exacerbation, overlying edema or pneumonia. The size of the cardiac silhouette is constant. [**11-16**] CTA chest: 1. Progression of widespread interstitial lung disease. 2. Increased centrilobular ground-glass opacity and reticular markings in right and left upper lobes most likely represent progression of interstitial lung disease, but cannot exclude superimposed pneumonia or edema 3. Pulmonary arterial hypertension with enlarged right heart and bowing of interatrial septum into the left atrium and reflux in to IVC. Brief Hospital Course: 61 yo female with pulm fibrosis [**12-24**] hypersensitivity pneumonitis on 12L NC at home, presenting to ED with 2d h/o cough, SOB and b/l LE swelling with hypoxia/increased oxygen requirement from baseline. This was felt to be most likely progression of her interstitial lung disease, so she was started on high dose methylprednisolone. She was also empirically started on vanc/cefepime/levo for HCAP coverage, Bactrim as well for PCP coverage since pt chronically on steroids, heparin drip, nebs, and lasix IV for diuresis. Blood, urine, sputum, and nasopharyngeal cxrs were obtained. No evidence of PE so heparin was stopped the evening of admission. CT showed worsening in areas of prior disease which was consistent with progression of existing lung disease. No focal consolidation to suggest PNA and no diffuse ground glass opacities suggesting PCP PNA, so [**Name9 (PRE) 621**] also stopped. PCP was negative so bactrim was decreased to a prophylactic dose. Pt diuresed over three liters the first night of admission but there was no significant change in O2 status; in fact, she was mildly worsened. Discussed care with husband who wanted to pursue transplant in [**Location (un) 5622**]. Call made on behalf of family but transplant center refused patient as transplant candidate due to her poor respiratory status. Pt remained stable in unit but with unremitting high O2 requirement. Discussion began regarding end of life care and palliative care was consulted. Patient and husband informed of poor prognostic status. Patient and husband voiced their preferences for end of life care including no needle sticks, finger sticks, or lab draws moving her to comfort measures only. She was given lorazepam and morphine for comfort during this time period. Patient wanted oxygen mask removed secondary to discomfort knowing the risk of poor oxygen delivery. She expired on [**2195-11-21**] at 0950 with her husband at her bedside. Autopsy was declined. Medications on Admission: ACETYLCYSTEINE [N-ACETYL-L-CYSTEINE] - (Prescribed by Other Provider) - Dosage uncertain ALBUTEROL SULFATE - 2 puffs QID AZATHIOPRINE - 50mg po BID CODEINE-GUAIFENESIN - Entered by MA/[**Name2 (NI) **] Staff - 100 mg-10 mg/5 mL Liquid - one to two tsps by mouth q 4 hours prn FLUTICASONE - 50 mcg Spray, Suspension - 2 SPRAYS INTRANASALLY once a day IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation HFA Aerosol Inhaler - 1-2 puffs po once a day LORAZEPAM [ATIVAN] - 3-4mg po TID OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day PREDNISONE - 50mg po daily RANITIDINE HCL [ZANTAC] 150mg po BID Vitamin C 500mg daily Vitamin D 1000mg daily Discharge Medications: Patient expired. Discharge Disposition: Expired Discharge Diagnosis: Patient expired. Discharge Condition: Patient expired. Discharge Instructions: Patient expired. Followup Instructions: Patient expired.

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

9211, 9220

6463, 8440

331, 338

9280, 9298

4763, 4768

9363, 9382

3905, 4104

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366, 2246

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2734, 3349

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4615, 4744

12,949

192,577

16077+16105

Discharge summary

report+report

Admission Date: [**2126-2-4**] Discharge Date: [**2126-2-21**] Service: SOCIAL HISTORY: The patient is married and lives at home. Denies any history of alcohol abuse. He has a distant history of tobacco use, which has long since quit. INITIAL PHYSICAL EXAMINATION: The patient was afebrile with a heart rate of 53 in sinus rhythm, blood pressure of 117/45 and an oxygen saturation of 96% on room air. In general, he was lying flat in bed in no acute distress. His neck was supple with no jugulovenous distention or carotid bruit. His heart revealed a regular rate and rhythm with no murmurs, rubs or gallops. Lungs were clear to auscultation bilaterally. Adomen was obese, soft, nontender, nondistended with no hepatosplenomegaly or other palpable masses. His extremities were warm and well perfuse, however, he did have 1+ peripheral edema to the knee bilaterally. Neurologically, his gross motor examination showed to be intact, however, there was some evidence of peripheral neuropathy in the distal lower extremities as from his diabetes mellitus type 2. LABORATORIES ON ADMISSION: White blood cell count was 9.7, hematocrit 41.5, platelet count 206. Sodium 141, potassium 4.7, chloride 102, bicarbonate 28, BUN 35, creatinine 1.7, glucose 126. His PTT was 33.5 and INR 1.1. An electrocardiogram showed sinus rhythm with a rate of 55 and some left axis deviation with right bundle branch block and increased PR interval. He did not have any ST or T segment changes. HOSPITAL COURSE: Mr. [**Known lastname **] was admitted to the Cardiac Catheterization Laboratory on [**2126-2-4**] where a cardiac catheterization showed disease in multiple coronary arteries. He was found to have a 30% distal occlusion of his left main, 10% ostial occlusion of his left anterior descending coronary artery, and 60% at the mid left anterior descending coronary artery, left circumflex with diffuse disease and 80% occlusion at the obtuse marginal, and a right coronary artery with a 90% proximal lesion. In the catheterization laboratory, the right coronary artery lesion was attempted to be crossed and stented without success, and at the time some subintimal dye staining was noticed, which was suspicious for possible perforation. However, bedside echocardiogram revealed no effusion at the time. He was subsequently admitted to the Coronary Care Unit where he was experiencing 1 to 2 out of 10 chest pain typical of the anginal symptoms, which he came in complaining of. Further studies showed the right coronary artery perforation was contained and that the patient was stable. His ejection fraction from the catheterization was estimated to be approximately 40%. The patient remained stable and on [**2126-2-6**] was taken to the Operating Room where he underwent a coronary artery bypass graft times four. Please refer to the dictated operative note for full details of this procedure, but in summary, the patient had a left internal mammary coronary artery graft to the diagonal, saphenous vein graft to the left anterior descending coronary artery, saphenous vein graft to the obtuse marginal and a saphenous vein graft to the posterior descending artery. The patient tolerated the procedure well, and was transferred to the Cardiac Surgical Intensive Care Unit, A paced at a rate of 88 beats per minute and on a neo-synephrine drip at 1 microgram per kilogram per minute. Once in the Cardiac Surgical Intensive Care Unit, the patient's hemodynamics were seemed to be somewhat compromised with an SVO2 of less then 60%. He was at this time given packed red blood cells and lactated Ringers and his pacing rate was increased for an underlying rhythm of sinus bradycardia in the 50s with minimal improvement. At this time Dopamine drip was started at 3 micrograms per mg per minute, an additional volume was given, however, there is minimal improvement seen in the SVO2 or cardiac index via the Swan-Ganz catheter. However, when calculated by the Fick method, the cardiac index was found to be greater then two. The Dopamine drip at this time was increased to 5 and the patient was carefully monitored. He was unable to be weaned from his propofol for sedation as well at this time. Later on that day he appeared to be doing slightly better with warm and well perfuse extremities and no acidosis via his laboratory values. He continued to have a low cardiac index/cardiac output via his Swan-Ganz catheter, however, the Fick method continued to show better values. On postoperative day number one the patient was continued to require a neo-synephrine drip as his blood pressure would drop precipitously when he was awake or agitated. He was also on Dopamine at 5, insulin at 3, and Propofol at 30. He required continual A pacing at this time as although his underlying sinus rate was up to the mid 60s, he was not able to maintain an adequate blood pressure with his rate. Over the next couple of days he required repeated blood transfusions for persistently low hematocrit. He also required continued Dobutamine and insulin drips to maintain his cardiac output. An echocardiogram was done to rule out cardiac tamponade and was found to be negative for tamponade. The pacing was finally able to be stopped, as the patient's heart rate climbed into the low 70s in sinus rhythm, and he was able to maintain his blood pressures without precipitous drops. At this time diuresis was begun as well. His cardiac index at this time did steadily improve and on postoperative day number five the patient was found to have a cardiac index greater then 2.5 with a low amount of Dobutamine drip. At this time the Dobutamine was slowly weaned. He was extubated later on postoperative day number five, which he tolerated fairly well. Serial arterial blood gases showed reasonable numbers. At this time he continued to be on an insulin drip at 1 unit per hour. On postoperative day number six the Dobutamine had been weaned off completely, and the patient continued only on an insulin drip. He had developed a slight fever and a low grade white blood cell count elevation and sputum cultures showed gram negative rods for which he was started on Levofloxacin. He did demonstrate some confusion, requiring Haldol from time to time. He was doing well on postoperative day number eight except for some episodes of oxygen desaturation, as well as continued heavy secretions since the time of extubation. His confusion was slowly improving, as was his ability to take a diet. He had remained mostly in bed, however, as he had been unable to tolerate much physical activity. His hematocrit was remaining stable in the low 30s. By postoperative day number eleven his respiratory status and confusion had improved enough for him to be transferred to the floor. At this time, his heart rate was in the low 80s and sinus rhythm with a blood pressure of 114/50, and his oxygen requirement had dropped down to 3 liters of nasal cannula at which he had an oxygen saturation of 96%. He tolerated transfer to the floor without difficulty. He did continue to exhibit some baseline confusion and disorientation, which had been present all along. His po intake improved slightly, however, he did continue to require assistance in order to eat properly. On postoperative day number fifteen, he was stable from a cardiopulmonary standpoint and he was deemed ready for transfer from the hospital to an extended care rehabilitation facility, where he could build strength and mobility, which had been issues for him during his hospitalization. At the time of discharge he was afebrile with a heart rate in the low to mid 90s in sinus rhythm and a blood pressure of 142/60 with oxygen saturation of approximately 94% on room air and up to 96 to 97% on 2 liters of nasal cannula. He was incontinent of urine owing largely to confusion and showed a regular rate and rhythm with no murmurs, rubs or gallops. His lungs were clear to auscultation bilaterally. He had significant decrease in the amount of his respiratory secretions. His abdomen was soft, nontender, nondistended with no hepatosplenomegaly. his white blood cell count was [**Numeric Identifier 890**] with a hematocrit of nearly 33%, and a platelet count of 335. His chem 7 showed a sodium of 142, potassium 4.1 and a BUN and creatinine of 37 and 1.5 around his baseline BUN and creatinine. MEDICATIONS ON DISCHARGE: 1. Felodipine 10 mg po q day. 2. Lansoprazole oral solution 30 mg q day. 3. Levofloxacin 250 mg po q day for seven more days. 4. Albuterol ipratropium inhaler two puffs q four hours. 5. Plavix 75 mg po q day. 6. Colace 100 mg po b.i.d. 7. Enteric coated aspirin 325 mg po q day. 8. A regular insulin sliding scale. 9. Lopressor 50 mg po b.i.d. 10. Haldol 1 mg po b.i.d. 11. Ipratropium bromide nebulizer one nebulizer treatment q 6 hours prn. 12. Albuterol nebulizer solution one nebulizer q 6 hours prn. DISPOSITION: To an extended care rehabilitation facility. CONDITION ON DISCHARGE: Stable, from a cardiopulmonary standpoint, however, he will require aggressive nutritional and physical therapy support to help build his strength, mobility and nutritional status. The patient's diet should be a diabetic and cardiac heart healthy diet. The patient's activities should be as tolerated with aid in order to be able to ambulate and move from bed to chair. DISCHARGE DIAGNOSES: 1 . Coronary artery disease status post coronary artery bypass grafting times four on [**2126-2-6**]. 2. Diabetes mellitus type 2. 3. Chronic renal insufficiency with a baseline creatinine of 1.7. 4. Hypercholesterolemia. 5. Peripheral neuropathy as related to his diabetes. 6. Gram negative rods in his sputum for which he is on Levofloxacin. FOLLOW UP: Follow up should be with Mr. [**Known lastname 45990**] cardiologist in the next one to two weeks and with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in approximately three to four weeks time. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Name (STitle) 45991**] MEDQUIST36 D: [**2126-2-21**] 10:26 T: [**2126-2-21**] 10:35 JOB#: [**Job Number **] Admission Date: [**2126-2-4**] Discharge Date: [**2126-2-21**] Service: Cardiothoracic Surgery CHIEF COMPLAINT: Worsening exertional angina. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is an 80-year-old man with a past medical history significant for coronary artery disease, diabetes mellitus type 2 and chronic renal insufficiency. He states that he had had coronary artery disease for approximately 15 years, which has been medically managed. He presented to the hospital as he had been noticing increasing symptoms, frequency, and duration of his exertionally induced angina. He reports having been catheterized approximately 10 years prior showing severe right coronary artery disease, but that no intervention was done at that time. He also notes increasing amounts of dyspnea and shortness of breath with activity. He notes that his symptoms would resolve within approximately 30 minutes and with taking of one sublingual nitroglycerin tablet. He had also recently been experiencing increased symptoms of paroxysmal nocturnal dyspnea and orthopnea. PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Coronary artery disease. 3. Hypertension. 4. Diabetes mellitus type 2. 5. Chronic renal insufficiency with a baseline creatinine of 1.7. PAST SURGICAL HISTORY: Status post herniorrhaphy. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg once per day. 2. Lasix 40 mg once per day. 3. Lipitor 10 mg once per day. 4. Plendil 10 mg once per day. 5. Neurontin 300 mg three times per day. 6. Nadolol 40 mg once per day. 7. Naprosyn. 8. Potassium chloride. ALLERGIES: The patient has no known drug allergies. INCOMPLETE DICTATION. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**] Dictated By:[**Name8 (MD) 17704**] MEDQUIST36 D: [**2126-2-21**] 09:58 T: [**2126-2-21**] 10:13 JOB#: [**Job Number 46051**]

[ "414.01", "593.9", "357.2", "998.2", "414.19", "272.0", "250.60", "401.9", "411.1" ]

icd9cm

[ [ [] ] ]

[ "36.15", "39.61", "88.56", "36.13", "37.23" ]

icd9pcs

[ [ [] ] ]

9417, 9767

8413, 8998

11625, 12218

1517, 8386

11570, 11598

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280, 1095

10390, 10420

10449, 11353

1110, 1499

11376, 11546

100, 257

9023, 9396

58,156

148,674

45897

Discharge summary

report

Admission Date: [**2189-1-2**] Discharge Date: [**2189-1-14**] Service: MEDICINE Allergies: Shellfish Derived Attending:[**First Name3 (LF) 2145**] Chief Complaint: fall with intracranial bleed Major Surgical or Invasive Procedure: none History of Present Illness: [**Age over 90 **] year old female with history of Afib on warfarin, DMII, PVD, HTN, TIAx2, HL, CKI, severe pulmonary HTN presents s/p fall with head trauma resulting in bitemporal IPH and SAH. Patient reports that she was reaching for something while seated in her wheelchair and fell forward striking the left side of her face on a table and then the floor. She reports no loss of consciousness. Felt slightly dizzy prior to the fall, had some sensations of palpitations. Denies any headache, LOC, n/v, chest pain or blurred vision. . In the ED, initial vs were: 98.5, 81, 156/83, 20, 98% RA. Patient received CT of head which showed bilateral sylvian fissure SAH. CT maxilla found a non displaced fracture of the left anterior maxilla. Patient was initially collared, but C-spine was subsequently cleared with CT. Neurosurgery evaluated the patient in the ED, did not recommend emergent neurosurgical intervention. Patient was loaded with dilantin 1 g IV. For a supratherapeutic INR of 3.6, patient was given 2 units of FFP as well as vitamin K 10 mg IV. Patient was admitted to the MICU for close monitoring. Per ED report, patient was speaking clearly, awake, not confused, prior to transport. Vital signs prior to transfer were: 88, 137/77, 19, 95% 2L. . In the MICU, patient is awake but fatigued, alert and oriented to person place and time. Complains of a little bit of pain in her left face, but says that it does not bother her unless she presses on it. Past Medical History: - Atrial fibrillation, on Coumadin - Type 2 diabetes, on insulin Lantus with hemoglobin A1c 8.6 in [**5-4**] - PVD status post transmetatarsal amp in [**2184**] for ischemic ulcer and high-grade right RAS and included left internal iliac artery with occlusion noted in the SFA as well as at the popliteal trifurcation. - Hypertension - History of breast cancer, status post left mastectomy - MGUS followed by Dr. [**Last Name (STitle) 2539**] - History of TIA in [**2179**] and likely TIA in [**3-/2185**] - Hyperlipidemia - Obesity - Chronic Renal Insufficiency - baseline creatinine ~2 recently - Severe pulmonary hypertension with RV hypertrophy by TTE [**10-4**] - s/p left BKA - s/p bilateral cateract surgery Social History: The patient lives with daughter and granddaughter. She does not smoke nor use any alcohol. She has skilled nursing and home health aides. Family History: HTN, DMII Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 96.4, 120/49, 92, 18, 85% RA General: AAOx3, NAD, comfortable, fatigued but easily arousable, cooperative with exam HEENT: bilateral surgical pupils, EOMI, left periorbital swelling, slight tenderness to palpation over left maxilla, poor dentition, clotted blood in left upper mouth, no active bleeding, neck supple, no C-spine tenderness, no JVD, no LAD CV: S1S2, irregularly irregular, no m/r/g Chest: CTA b/l, no w/r/r Abdomen: soft, ND, NT, +BS Ext: left BKA, no e/c/c, 1+ peripheral pulse in right LE Neuro: normal affect, AAOx3, good recall, able to recall 3 objects at 5 minutes, fluent speech. CN II-XII intact, with exception of poor hearing in left ear. Unable to evaluate pupillary response as they are surgical. 5/5 strength in UEs and RLE. Sensation intact Pertinent Results: ADMISSION LABS: . [**2189-1-2**] 03:50PM PT-34.9* PTT-33.4 INR(PT)-3.6* [**2189-1-2**] 03:50PM PLT COUNT-279 [**2189-1-2**] 03:50PM NEUTS-77.0* LYMPHS-14.2* MONOS-5.7 EOS-1.5 BASOS-1.5 [**2189-1-2**] 03:50PM WBC-6.7 RBC-4.22 HGB-12.6 HCT-38.5 MCV-91 MCH-29.9 MCHC-32.8 RDW-14.9 [**2189-1-2**] 03:50PM cTropnT-0.01 [**2189-1-2**] 03:50PM GLUCOSE-167* UREA N-47* CREAT-1.8* SODIUM-136 POTASSIUM-9.3* CHLORIDE-106 TOTAL CO2-26 ANION GAP-13 [**2189-1-2**] 05:54PM K+-4.7 [**2189-1-2**] 05:57PM URINE RBC-[**2-28**]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-0 [**2189-1-2**] 05:57PM URINE BLOOD-SM NITRITE-POS PROTEIN-75 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2189-1-2**] 05:57PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.013 . MICROBIOLOGY: . [**2189-1-2**] URINE CX: > 100.000 organisms E. coli SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I 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 . [**2189-1-7**] URINE CX: No growth . [**2189-1-7**] BLOOD CX: STAPHYLOCOCCUS, COAGULASE NEGATIVE | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- =>32 R TETRACYCLINE---------- 2 S VANCOMYCIN------------ 1 S . [**2189-1-8**] BLOOD CX: No growth to date. . [**2189-1-9**] BLOOD CX: Gram Positive cocci (see above for speciation and sensitivities). . IMAGING: . [**2189-1-2**] CT head w/o contrast: Bilateral Sylvian fissure subarachnoid hemorrhages. No fractures. . [**2189-1-8**] CT head w/o contrast: 1. Multiple areas of subarachnoid hemorrhage that appeared to be resolving. This is most pronounced at the site of hemorrhage seen in the perimesencephalic cistern. 2. No evidence of new foci of hemorrhage. . [**2189-1-2**] CT sinus/mandible: Non-displaced fracture of the anterior left maxilla with possible involvement of the root of the corresponding canine tooth. There is associated with soft tissue swelling. . [**2189-1-2**] CT C-spine: No fractures or malalignments. Mild degenerative change with posterior osteophytes causing mild narrowing of the central canal. This increases the risk of cord injury, not assessed by noncontrast CT. If clinical concern for such injury is maintained, MRI is indicated. . [**2189-1-2**] CXR: Marked aortic tortuosity with widening of the superior mediastinum as noted previously. If there is clinical concern for aortic injury based upon mechanism or other clinical signs, cross-sectional imaging is advised. . [**2189-1-8**] R lower extremity ultrasound: No evidence of DVT. . [**2189-1-14**] ECHO: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The right ventricular cavity is mildly dilated with borderline normal free wall function. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . Compared with the prior study (images reviewed) of [**2187-10-19**], right ventricular function appears mildly reduced. There is no evidence of endocarditis on this technically limited study. The severity of mtiral regurgitation and tricuspid regurgitation are reduced. . Brief Hospital Course: [**Age over 90 **] F with Afib on warfarin, HTN, DMII, HL, PVD, presents s/p fall with bitemporal SAH . #. Intracranial bleed: Patient found to have bilateral subarachnoid hemorrhages in setting of fall and supratherapeutic INR. INR 3.6 on admission to ED, written to receive 2 units of FFP and 10 mg IV vitamin K for INR reversal, with goal <1.4. Evaluated by neurosurgery, no need for urgent surgical intervention. On admission, patient with clear mental status, no neurological defects. Was loaded with dilantin 1000 mg in ED for seizure prophylaxis, and continued on dilantin 100mg TID x 7 days (completed on [**2189-1-9**]). SBP was maintained < 160. Repeat CT head on [**2189-1-8**] showed resolving bleed. Patient is instructed to hold all anticoagulation and antiplatelet therapy until her scheduled follow up with Dr. [**First Name (STitle) **] in [**Hospital 4695**] clinic. . # Fevers: Patient developed fever of 101.2 F on [**2189-1-7**]. She proceeded to have low grade temperatures of 99-100 F over the next two days. Repeat UA and urinalysis were negative, CXR showed no focal consolidation, lower extremity ultrasound was negative for DVT. She denied any localizing symptoms. Her blood cultures from [**2189-1-7**] returned with coagulase negative Staph and empiric Vancomycin was started. Surveillance cultures showed an additional blood culture from [**2189-1-9**] positive for Coagulase negative staph. Due to two positive blood cultures on different days this was deemed to be a true bacteremia. She was continued on vancomycin. After four days of negative blood cultures a PICC line was placed on [**2189-1-13**]. Echo was performed on [**2189-1-14**] showing no evidence of endocarditis. Vancomycin trough was measured on [**2189-1-13**] and was subtherapeutic. Her vancomycin dose was increased on [**2189-1-14**] to 1 gram IV q24h. Patient should continue vancomycin for a total of 14 days with last day being [**2189-1-24**]. Please recheck vancomycin level prior to dose on [**2189-1-16**] to ensure patient is receiving adequate levels. Her CBC and renal function should be monitored once a week while on this medication. . # Lethargy: Likely multifactorial: initiation of phenytoin (completed 7 day course on [**2189-1-9**]), infection (though CXR, UA, and physical exam were unrevealing), sequellae from recent head bleed, daytime somnolence from OSA, or hypoactive delirium given age, prolonged immobility, hospitalization, and underlying dementia. Daughter is very concerned that her elevated glucose during admission is responsible for her lethargy (blood glucose 150-300) though this seems unlikely. ABG ruled out hypercapnea. Her lack of focal neurologic deficits makes embolic stroke less likely. CT head performed on [**2189-1-8**] without evidence of new bleeding. No witnessed convulsions or involuntary movements to suggest seizures. Glucose and electrolytes within normal range during episodes. Patient's concurrent fevers and bacteremia (see above) were likely major contributors as her mental status intermittently improved with antibiotics. Patient continues to have extended periods of somnolence when in bed during the day, but with loud voice and tactile stimuli she arouses and oriented x 3. Strongly recommend getting patient out of bed during the day and using her glasses and hearing aids at all times to help prevent delirium. . # A fib: INR supratherapeutic on admission at 3.6. Not on any rate control agents at home. Per neurosurg recs, INR kept <1.4 given intracranial bleed. Warfarin and aspirin held. Patient is not to restart these medications until she has been fully reevaluated in follow up at [**Hospital 4695**] clinic. . # Maxillary fracture: nondisplaced left maxilla fracture. Also left upper teeth slightly loose. Without much discomfort on exam. Plastic surgery team evaluated the patient at admission, nothing to do acutely. Dental consult obtained, said recommended Oral surgery referral for diffusely poor dentition to discuss option of tooth extraction. Recommend that patient readdress the option of tooth extraction with her primary care provider who can refer her to local oral surgeons. . # HTN: Patient's blood pressure remained stable on home lisinopril 10 mg daily. Patient's blood pressure was monitored closely to maintain pressures < 160/100 to prevent rebleeding. . # UTI: Patient described symptoms of dysuria for 2-3 days prior to presentation.. UA with bacteria and >50 WBC, urine culture grew pansensitive E. coli. Patient was treated with three days of ciprofloxacin. Follow up urine culture showed no growth of bacteria. . # DMII: HbA1c 7.3 in 3/[**2187**]. Per daughter she has not taken any insulin at home for the last 4 months as she is managed with a strict diabetic diet at home. Patient had persistently elevated sugars during this admission and required sliding scale insulin for coverage. Recommend close monitoring and continued sliding scale during her rehabilitation. Her daughter is adamant that patient should not receive any juice or fruit (despite carbohydrate counting). . # Hyperlipidemia: Continued on home simvastatin. . # CKD: Baseline creatinine 1.7-1.8. Patient's creatinine remained stable throughout admission and was 1.6 on day of discharge. . # OSA: No formal diagnosis prior to admission. ICU monitoring on presentation showed intermittent apnea and desatting to mid 70s while asleep. Habitus also strongly suggestive of OSA. Patient's facial fracture prohibits CPAP. She was maintained on supplemental oxygen via nasal cannula overnight while sleeping. . # CODE STATUS: FULL (confirmed with [**First Name4 (NamePattern1) 19904**] [**Last Name (NamePattern1) 228**] health care proxy) . # EMERGENCY CONTACT: [**First Name8 (NamePattern2) 19904**] [**Last Name (NamePattern1) 4135**] [**Telephone/Fax (1) 97746**] . # DISPO: [**Hospital **] Rehabilitation. Medications on Admission: ALBUTEROL SULFATE neb q6h prn SOB, wheezing AMMONIUM LACTATE 12 % Cream [**Hospital1 **] ASPIRIN 81 mg daily LISINOPRIL 10 mg daily SIMVASTATIN 40 mg daily TIMOLOL [BETIMOL] 0.5 % drop 1 drop each eye [**Hospital1 **] WARFARIN 2.5 mg qMonday, 5 mg qSun,Tues,Wed,Thurs,Fri,Sat ASCORBIC ACID 500 mg daily Discharge Medications: 1. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for SOB, wheezing. 4. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 5. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO once a day. 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 7. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 24H (Every 24 Hours). 8. heparin, porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML Intravenous PRN (as needed) as needed for line flush. 9. Insulin Please continue sliding scale Humalog insulin with meals and before bed. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] Senior Healthcare of [**Location (un) 55**] Discharge Diagnosis: Subarachnoid Hemorrhage Hypertension Fall Bacterial urinary tract infection DM2 Coagulase negative Staph Bacteremia Discharge Condition: Hemodynamically stable, afebrile, fluent speech, extremely poor hearing (must yell to communicate with her even with her earring aids in place) and visual acuity, oriented to person, 'hospital', and month. Requires assistance for all mobilization. Discharge Instructions: You presented to the [**Hospital1 18**] Emergency Department after falling out of your wheelchair. You were found to have bleeding in your brain and a broken bone in your face. You were admitted to the ICU and monitored closely overnight. Your blood thinning medications were stopped and you remained stable. You were evaluated by the Neurosurgery team who determined that there was no need for surgical intervention at this time. You were transferred to the Medicine floor where you were closely monitored. . You were also found to have a urinary tract infection when you presented. You were treated with antibiotics and your infection resolved. . You developed increased drowsiness while on the Medicine floor and were occasionally very difficult to wake from sleep. A repeat CT scan showed no worsening of your brain bleed. There were likely many things that contributed to your new drowsiness. This is likely due to your immobility, your elevated sugars, dehydration, seizure medications and your blood stream infection. . You also developed fevers several days into your admission. Your evaluation showed no evidence of a new urinary tract infection, pneumonia, or blood clots that could be responsible for your fever. You were found to have a blood stream infection. It remains unclear how bacteria entered your blood. You will require 2 weeks of antibiotic treatment to ensure that the infection has cleared. . . You were found to have several loose teeth when you presented to the hospital. You were seen by a dentist who recommended that you be evaluated by a oral surgeon to discuss the option of having your teeth extracted. We were unable to schedule this follow up appointment with you as there is no oral surgeon at [**Hospital1 69**]. Please discuss this with your primary care provider and they will help you arrange any needed follow up. . The following changes were made to your home medications. 1) STOP aspirin. It is very important that you do not restart this medication until instructed to do so by your neurosurgeon. 2) STOP coumadin (warfarin). Do not restart this medication unless instructed to do so by your physician. 3) START Acetaminophen (Tylenol) 325 mg tablet, take 2 tablets every 6 hours as needed for pain. 4) START Vancomycin 1 gram IV daily for two weeks (last dose [**2189-1-24**]) . It is very important that you keep all follow up appointments as listed below. Followup Instructions: Please follow up with your primary care provider [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 250**] within one week of discharge from your rehab facility. . Department: RADIOLOGY When: THURSDAY [**2189-2-5**] at 10:15 AM With: CAT SCAN [**Telephone/Fax (1) 327**] Building: CC CLINICAL CENTER [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage . Department: NEUROSURGERY When: THURSDAY [**2189-2-5**] at 11:00 AM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7746**], MD [**Telephone/Fax (1) 3666**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]

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Discharge summary

report

Admission Date: [**2163-3-2**] Discharge Date: [**2163-3-23**] Date of Birth: [**2102-7-13**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2297**] Chief Complaint: Liver Failure Major Surgical or Invasive Procedure: [**2163-3-4**] Transjugular liver biopsy [**2163-3-7**] EGD [**2163-3-7**] Attempted colonoscopy [**2163-3-19**] Thoracentesis [**2163-3-23**] IR guided percutaneous cholecystostomy tube placement and drainage of ascitic fluid History of Present Illness: Mr. [**Known lastname 392**] is a 60 year old gentleman with a history of alcohol consumption, who is being admitted with acute onset of decompensated cirrhosis. Patient developed right leg weakness in [**2162-11-28**]. This grew progressively worse, until right leg "buckled out" from under him (attributed to subsequently found iliopsoas hematoma). When he was picked up by EMS at that time, they noticed that he was floridly jaundiced. Since then, he has had two admissions to [**Hospital3 **] Hospital for new onset, decompendated cirrhosis. His MELD was 28 on [**2-8**]. Now, per advice of his outpatient Hepatologists, he is being admitted from [**Hospital 38380**] Rehab ([**Location 30150**]; Phone: ([**Telephone/Fax (1) 110577**]). He was still on prednisone until [**3-1**] (when it was discontinued in clinic). His LFT's were in the 900 in mid [**Month (only) 958**], and are coming down. From outpatient clinic on [**3-1**], labs on [**3-1**] showed that LFTs trended down from previous, but patient was clinically worse with MELD 30. Patient then admitted for expedited work-up. Biopsy has not been done previously. . Patient reports that he has never been jaundiced before. He denies any abdominal distention, episodes of confusion, hematochezia, melena or hematemesis. He has been drinking [**11-29**] glasses of white wine per day since [**2152-8-8**]. Prior to that, he had alternating periods of alcohol consumption and sobriety. He denies any past IV drug use, tattoos, blood transfusions, or surgeries. He has never been told that he has high blood pressure in the past. He has not been sexually active for the past 25 years, but never checked for any sexually transmitted diseases. He is unaware of any iron disorders. He denies any family history of any liver diseases or cancers. He is of English decent. . Today, he just notes that he has pain on his coccyx from a couple of ulcers that were being treated with special dressings at rehab. . . REVIEW OF SYSTEMS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: - EtOH consumption: no apparent periods of abuse - Cirrhosis - Stress test in [**2137**] for chest pain, revealed no CAD - hiatal hernia - Iliopsoas Hematoma - flu in [**2140**] - question of asthma (prescribed an inhaler but never used it) - has never had a colonoscopy or EGD Social History: He has been drinking [**11-29**] glasses of white wine per day since [**2152-8-8**]. Prior to that, he had alternating periods of alcohol consumption and sobriety. Had occasional beer. Never any hard alcohol. Reports last drink was [**2162-12-1**]. Quit smoking in [**2129**]. He denies any past IV drug use. He is not married, and has no children. He has not been sexually active for the past 25 years, but never checked for any sexually transmitted diseases. He is retired, and used to work in commercial real estate. He is of English decent. He has many close relatives near him on [**Location (un) 21541**]. He also has some relatives around [**Name (NI) 86**]. His HCP is his cousin, [**Name (NI) **] [**Name (NI) 1391**] ([**Telephone/Fax (1) 110578**]). Family History: No family history of liver disease or iron storage disorders. One brother with mental retardation. One brother with [**Name2 (NI) **]. Physical Exam: ADMISSION PHYSICAL EXAM: VS - Temp 100.2F, BP 101/61, HR 71, R 18, O2-sat 100% RA GENERAL - Alert, interactive, well-appearing in NAD HEENT - PERRLA, EOMI, sclerae icteric NECK - Supple, HEART - 2/6 systolic murmur heard throughout LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use ABDOMEN - NABS, soft/NT/ND, no masses, liver edge 2cm below costal margin EXTREMITIES - WWP, 2+ pitting edema in the bilateral LE's, no calf tenderness SKIN - icteric NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**4-2**] throughout except for [**3-3**] in the right hip flexor, no asterixis . DISCHARGE PHYSICAL EXAM: EXPIRED Pertinent Results: ADMISSION LABS: [**2163-3-1**] 01:40PM BLOOD WBC-15.0* RBC-2.60* Hgb-9.8* Hct-28.6* MCV-110* MCH-37.9* MCHC-34.4 RDW-20.2* Plt Ct-38* [**2163-3-1**] 01:40PM BLOOD Neuts-85* Bands-1 Lymphs-4* Monos-10 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2163-3-1**] 01:40PM BLOOD PT-33.9* INR(PT)-3.3* [**2163-3-1**] 01:40PM BLOOD UreaN-27* Creat-0.8 Na-125* K-5.7* Cl-91* HCO3-24 AnGap-16 [**2163-3-1**] 01:40PM BLOOD ALT-161* AST-143* CK(CPK)-76 AlkPhos-220* TotBili-24.0* DirBili-6.8* IndBili-17.2 . DISCHARGE LABS: [**2163-3-23**] 03:05PM BLOOD WBC-11.1*# RBC-0.75*# Hgb-2.7*# Hct-9.1*# MCV-120* MCH-36.5* MCHC-30.6* RDW-23.0* Plt Ct-44*# [**2163-3-23**] 03:05PM BLOOD PT-23.7* PTT-54.5* INR(PT)-2.3* [**2163-3-23**] 03:05PM BLOOD Glucose-366* UreaN-78* Creat-2.2* Na-138 K-5.6* Cl-102 HCO3-19* AnGap-23* [**2163-3-23**] 03:05PM BLOOD ALT-17 AST-41* LD(LDH)-312* AlkPhos-46 TotBili-9.3* [**2163-3-22**] 07:09PM BLOOD Lipase-70* [**2163-3-23**] 03:05PM BLOOD Calcium-8.3* Phos-6.6* Mg-2.2 [**2163-3-23**] 05:11PM BLOOD Type-ART pO2-133* pCO2-40 pH-7.29* calTCO2-20* Base XS--6 [**2163-3-23**] 05:11PM BLOOD Lactate-7.8* . PERTINENT LABS: [**2163-3-6**] 06:12AM BLOOD Fibrino-134* [**2163-3-4**] 05:44AM BLOOD Hapto-<5* [**2163-3-4**] 05:44AM BLOOD Triglyc-85 HDL-107 CHOL/HD-1.4 LDLcalc-30 [**2163-3-1**] 01:40PM BLOOD TSH-1.7 [**2163-3-3**] 05:45PM BLOOD 25VitD-12* [**2163-3-1**] 01:40PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV Ab-POSITIVE [**2163-3-3**] 05:45PM BLOOD HBsAb-NEGATIVE HBcAb-NEGATIVE [**2163-3-3**] 05:45PM BLOOD AMA-NEGATIVE [**2163-3-3**] 05:45PM BLOOD [**Doctor First Name **]-NEGATIVE [**2163-3-3**] 05:45PM BLOOD CEA-12* PSA-0.2 AFP-1.8 [**2163-3-3**] 05:45PM BLOOD IgG-1240 IgA-674* IgM-271* [**2163-3-3**] CA [**69**]-9 504 H [**2163-3-3**] CERULOPLASMIN 15 L [**2163-3-3**] 05:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2163-3-3**] 05:45PM BLOOD HCV Ab-NEGATIVE [**2163-3-5**] 07:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-MOD Urobiln-NEG pH-6.5 Leuks-NEG [**2163-3-5**] 07:00PM URINE Hours-RANDOM TotProt-6 [**2163-3-5**] Urine PEP: no protein [**2163-3-6**] Free kappa and lambda light chains: FREE KAPPA, SERUM 20.1 H (ref range 3.3-19.4 mg/L) FREE LAMBDA, SERUM 30.2 H (ref range 5.7-26.3 mg/L) FREE KAPPA/LAMBDA RATIO 0.67 (ref range 0.26-1.65) [**2163-3-6**] Serum PEP: polyclonal [**2163-3-10**] Urine porphyrins: Test Result Reference Range/Units UROPORPHYRIN 53.7 H 22.0 OR LESS mcg/g creat HEPTACARBOXYPORPHYRIN 12.3 H 4.6 OR LESS mcg/g creat HEXACARBOXYPORPHYRIN NOT DETECTED NOT DETECTED mcg/g creat PENTACARBOXYPORPHYRIN 2.9 H 1.7 OR LESS mcg/g creat COPROPORPHYRIN 575.4 H 23.0-130.0 mcg/g creat TOTAL PORPHYRINS 644.3 H 31.0-139.0 mcg/g creat . [**2163-3-4**] IRON, LIVER TISSUE Test Name Flag Result Units Reference --------- ---- ------ ----- --------------- Iron, Liver Tissue H 3497 mcg/g dry wt [**Telephone/Fax (1) 110579**] Hepatic Iron Index H 1.0 mcmol/g/yr <1.0 . [**2163-3-16**] 05:35AM BLOOD proBNP-986* [**2163-3-15**] 03:27PM BLOOD Type-[**Last Name (un) **] pO2-34* pCO2-39 pH-7.45 calTCO2-28 Base XS-2 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**] [**2163-3-19**] 08:41AM BLOOD Type-ART Temp-36.2 pO2-57* pCO2-38 pH-7.48* calTCO2-29 Base XS-4 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**] [**2163-3-19**] 08:41AM BLOOD Glucose-102 Lactate-2.8* Na-137 K-5.0 Cl-103 [**2163-3-19**] 08:41AM BLOOD freeCa-1.29 [**2163-3-19**] 06:54PM PLEURAL WBC-375* RBC-[**Numeric Identifier 110580**]* Polys-8* Lymphs-39* Monos-6* Atyps-2* Meso-5* Macro-40* [**2163-3-19**] 06:54PM PLEURAL TotProt-1.4 Glucose-224 Creat-1.5 LD(LDH)-163 Amylase-17 Albumin-1.1 Cholest-18 [**2163-3-20**] 01:30PM PLEURAL TotProt-1.7 Glucose-160 LD(LDH)-482 Cholest-21 . MICROBIOLOGY: [**2163-3-3**] RPR: non-reactive [**2163-3-3**] Rubella IgG/IgM: positive [**2163-3-3**] Varicella IgG: positive [**2163-3-3**] CMV IgG: negative [**2163-3-3**] EBV antibody panel: [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2163-3-7**]): POSITIVE BY EIA. [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2163-3-7**]): POSITIVE BY EIA. [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2163-3-7**]): NEGATIVE <1:10 BY IFA. INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION. [**2163-3-3**] 05:45PM BLOOD HIV Ab-NEGATIVE [**2163-3-11**] Urine culture: no growth [**2163-3-11**] Blood cultures x2: no growth [**2163-3-17**] C. diff PCR: negative [**2163-3-19**] Blood cultures x2: no growth to date [**2163-3-19**] Pleural fluid: gram stain with no PMNs, no microorgansims. Fluid culture with no growth to date [**2163-3-23**] [**2163-3-23**] 11:09 am SWAB Source: Biliary fluid. **FINAL REPORT [**2163-3-27**]** GRAM STAIN (Final [**2163-3-23**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). FLUID CULTURE (Final [**2163-3-25**]): A swab is not the optimal specimen collection to evaluate body fluids. KLEBSIELLA PNEUMONIAE. MODERATE GROWTH. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMIKACIN-------------- <=2 S AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- 2 S CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I MEROPENEM-------------<=0.25 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R ANAEROBIC CULTURE (Final [**2163-3-27**]): NO ANAEROBES ISOLATED. [**2163-3-23**] 11:01 am PERITONEAL FLUID **FINAL REPORT [**2163-3-29**]** GRAM STAIN (Final [**2163-3-23**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2163-3-26**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2163-3-29**]): NO GROWTH. . PATHOLOGY: [**2163-3-4**] Tranjugular liver biopsy (right lobe): 1. Established cirrhosis (trichrome stain) with mild septal and periseptal mononuclear inflammatory infiltrate composed predominantly of lymphocytes. No significant plasma cell infiltrate identified. 2. Iron overload, severe (grade 4); within hepatocytes, Kupffer cells and bile duct epithelial cells (Iron stain). 3. Bile ductular proliferation and cholestasis are also present. 4. No steatosis, [**Doctor First Name 68085**] hyalin or granulomas are seen. . IMAGING: [**2163-3-3**] CXR PA/lat: Small right-sided pleural effusion is present. There is no pleural abnormality on the left side. Lungs are clear. There are no lung opacities concerning for nodules or consolidation. Heart size, mediastinal and hilar contours are normal. IMPRESSION: Small right pleural effusion. No nodules or lung consolidation. . [**2163-3-4**] Transjugular liver biopsy: Pressures were obtained in the following locations: RIGHT ATRIUM: 7 mmHg, FREE RIGHT HEPATIC VEIN PRESSURE: 8 mmHg, WEDGED RIGHT HEPATIC VEIN PRESSURE: 24 mmHg The patient tolerated the procedure well and there were no immediate post-procedure complications. IMPRESSION: 1. Successful fluoroscopic-guided transjugular liver biopsy via the right internal jugular vein. Three core samples of the right hepatic lobe were obtained via the right hepatic vein and sent to pathology. 2. Portosystemic gradient measures 16 mmHg consistent with portal hypertension. . [**2163-3-5**] Multiphase CT abd/pelvis: In the lung bases, note is made of a moderate-sized right pleural effusion with adjacent compressive atelectasis. There are no pulmonary nodules or masses seen. ABDOMEN AND PELVIS: There is abnormal morphology to the hepatic parenchyma consistent with the patient's known cirrhosis. There is a small low-attenuation lesion in the segment VIII of the liver measuring less than a centimeter in size and is too small to characterize. There is no enhancement within this lesion. Additional tiny subcentimeter-sized low-attenuation lesions are seen in the liver, which are too small to characterize. There is no intra- or extra-hepatic biliary ductal dilatation. The portal and hepatic veins are patent. The patient has an aberrant hepatic arterial anatomy, with replaced right hepatic artery originating from the superior mesenteric artery. No hyper-enhancing lesions are seen in the liver. The gallbladder is slightly distended without wall thickening. There is high density within the gallbladder measuring 32HU. The spleen is enlarged measuring 13.5 cm in the largest dimension. There are lower esophageal and paraesophageal varices. Note is made of prominent splenorenal shunting. The splenic and superior mesenteric veins appear within normal limits. There is perihepatic ascites, which measures about 2.5 Hounsfield units in density representing simple fluid. There are no hematomas seen in the abdomen or pelvis. There is evidence of mild fat stranding involving the mesentary suggestive of ascites. The pancreas, adrenal glands appear within normal limits. The kidneys enhance contrast symmetrically and are seen excreting contrast without focal abnormalities. Nonspecific perinephric fat stranding is seen. The abdominal aorta is normal in caliber. There is no mesenteric or retroperitoneal lymphadenopathy. The urinary bladder is well-distended without any obvious focal abnormalities. There are coarse calcifications within the prostate gland. There is no pelvic lymphadenopathy. There is [**Hospital1 **]-lenticular-shaped low-attenuation lesion within the right iliacus muscle (series 6, image 61) measuring approximately 6.1 x 2.0 cm in size, which extends upward up to the level of the iliopsoas insertion into the lesser trochanter of the right femur. It measures approximately 39 Hounsfield units in density. Please note that he images of the pelvis were not obtained on the non-contrast CT images and the visualized abnormality within the right iliacus muscle is noted only on the three-minute delayed view through the pelvis. It is unclear if this is an enhancing lesion or not. Multilevel degenerative changes are seen in the spine, without suspicious osteolytic or osteoblastic lesions. Evaluation of bowel is limited due to lack of enteric contrast. IMPRESSION: 1. No evidence of active extravasation. 2. [**Hospital1 **]-lenticular shaped low-density lesion within the right iliacus muscle likely represents patient's known hematoma. 3. Nonspecific findings of high density contents within the gallbladder could be secondary to hemobilia, inspissated bile or vicarious contrast excretion. 4. Cirrhosis with sequela of portal hypertension. 5. Small hypodense lesions within the liver which are too small to characterize. No hyper-enhancing lesions to suggest HCC. 6. Moderate right pleural effusion with adjacent compressive atelectasis. . [**2163-3-7**] EGD: Findings: Esophagus: Normal esophagus. Stomach: Normal stomach. Duodenum: Normal duodenum. Recommendations: No varices No evidence of portal hypertension on EGD . [**2163-3-8**] TTE: The left atrium is dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF 80%). There is a moderate resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . [**2163-3-9**] CT Abd/pelvis (attempted CTC Virtual Colonoscopy): A moderate right pleural effusion is again with adjacent compressive atelectasis (3:4) is minimally changed since [**Month (only) 547**] [**2163-3-5**]. The heart size is normal, and there is no pericardial effusion. Severe mitral annulus calcifications are unchanged (3:6). Non contrast-enhanced images of the liver demonstrate a mildly nodular contour, in keeping with known history of cirrhosis. Massive parasplenic varices denote chronic portal hypertension (3:29). The pancreas, stomach, adrenal glands, kidneys, and intra-abdominal loops of small and large bowel are within normal limits. No large colonic polyps or masses are seen, although this assessment is limited due to obscuration from incomplete insufflation and obscuring fluids. There is no mesenteric or retroperitoneal lymphadenopathy, and no free air or free fluid. CT OF THE PELVIS WITHOUT IV CONTRAST: Coarse calcifications reside within the prostate (3:89). The urinary bladder and rectum are normal. There is no intrapelvic free fluid. OSSEOUS STRUCTURES: There is no acute fracture. There are no bony lesions concerning for malignancy or infection. IMPRESSION: 1. This should not be considered as a virtual CT colonography examination. 2. Unchanged moderate right pleural effusion with adjacent compressive atelectasis. 3. Cirrhotic liver. Massive parasplenic varices denote chronic portal hypertension. . [**2163-3-10**] CXR PA/lat: There are lower lung volumes. Cardiac size is top normal, is accentuated by the low lung volumes. Moderate right pleural effusion is unchanged. New diffuse alveolar opacities are likely consistent with pulmonary edema. There is no pneumothorax. The aorta is tortuous. . [**2163-3-10**] LUE U/S: No evidence of deep vein thrombosis in the left arm. . [**2163-3-11**] Abdominal ultrasound: Multiple son[**Name (NI) 493**] images were obtained. The liver is nodular and coarse in appearance, consistent with cirrhosis. A small pocket of ascites is seen near the dome of the liver. No ascites was seen in the remaining quadrants. The pocket was deemed too small to mark for aspiration without real-time ultrasound guidance. IMPRESSION: Small pocket of fluid for which realtime ultrasound-guided aspiration would be required. . [**2163-3-11**] CXR PA/lat: There are low lung volumes. There are developing opacities within the lung bases. These may represent atelectasis or more likely developing pneumonia or aspiration. Heart size is upper limits of normal but stable. There are no pneumothoraces. . [**2163-3-16**] CTA Chest: There is no central PE. The subsegmental and distal branches of the pulmonary arteries are difficult to evaluate secondary to respiratory motion. The great vessels are unremarkable. There is no pericardial effusion. There are mitral valve calcifications along with coronary calcifications most notably in the LAD. There are also aortic annulus calcifications. There is no mediastinal or axillary lymphadenopathy by CT criteria. Within the lungs, there are dense peribronchial opacities surrounded by ground-glass opacities in bilateral upper lobes. There is also a moderate-sized nonhemorrhagic layering right-sided pleural effusion with adjacent atelectasis. There is also left-sided opacity consistent with atelectasis, less likely infectious process. The tracheobronchial tree is patent to the subsegmental level. This study is not intended for subdiaphragmatic evaluation; however, moderate amount of ascites as well as prominent splenorenal shunting is seen. BONES: No suspicious osseous or lytic lesions are seen. A bony island is seen within the posterior approximately tenth rib. IMPRESSION: 1. No evidence of central PE. 2. Moderate right-sided pleural effusion with adjacent atelectasis. 3. Peribronchial opacities representative of pulmonary edema diffusely in bilateral upper lobes. 4. Coronary calcifications along with mitral and aortic annulus calcifications as described above. . [**2163-3-18**] Cardiac MRI: ***pending final read*** . [**2163-3-18**] Abdominal ultrasound: Small amount of ascites only seen in the perihepatic space. There is no suitable pocket to mark. Also noted there is splenomegaly, a right pleural effusion, and sludge within the gallbladder. . [**2163-3-19**] CXR PA/lat: There are low inspiratory volumes. Even allowing for this, there is probable cardiomegaly. There is opacity at the right base obscuring the right hemidiaphragm, new compared with [**2163-3-11**]. The most likely etiology is a small effusion with underlying collapse and/or consolidation. Mild prominence of vascular markings could reflect mild vascular plethora; doubt overt CHF. There is atelectasis at the left base. No left effusion. . [**2163-3-19**] CXR portable: Compared with [**2163-3-19**] at 8:44 a.m., a catheter has been placed at the right base. There is a persistent right pleural effusion, probably slightly smaller, with underlying collapse and/or consolidation. There is slight rightward positioning of the mediastinum and trachea, ? due to rotation. There are low inspiratory volumes, with vascular plethora and patchy opacity at the left base. No left-sided effusion. No pneumothorax is detected. IMPRESSION: 1. Interval placement of right-sided (pleural) catheter. A portion of the catheter is indistinct, ? related to site of entry. No pneumothorax detected. 2. Right effusion again seen, possibly slightly smaller, with underlying right base collapse and/or consolidation. 3. Confluent opacity in the left midzone and base medially, which could represent an additional focal pneumonic infiltrate. 4. Mild prominence of the cardiomediastinal silhouette with slightly rightward positioning. Please see comment. 5. Probable CHF, even allowing for low lung volumes. . [**2163-3-20**] CXR portable: Compared with [**2163-3-19**] at 21:59 p.m., there has been improvement at the right base. No effusion is identified at the right base on the current exam. Some residual atelectasis and/or focal infiltrate at the right base medially is again seen, better visualized due to improvements in the effusion. Patchy retrocardiac opacity has also improved. Slight vascular plethora remains present, but has improved. No left-sided effusion. IMPRESSION: Patchy opacities at both bases are improved. Right pleural effusion has resolved on the frontal view. CHF has also improved. No new area of infiltrate or consolidation identified. [**2163-3-22**] CT abdomen/pelvis: IMPRESSION: 1. Progressive increased distention of the gallbladder, now measuring 7.1 cm in transverse diameter. Evaluation for gallbladder wall edema/enhancement cannot be performed secondary to lack of intravenous contrast. Acute cholecystitis cannot be excluded on this examination. If further imaging confirmation is needed, a gallbladder scan could be performed. 2. Cirrhotic liver with sequelae of portal hypertension. Small volume ascites. 3. Increased density of the kidneys may be a sign of renal insufficiency in the setting of prior contrast administration. [**2163-3-23**] IR guided paracentesis: IMPRESSION: Technically successful ultrasound-guided drainage of 1.8 L of dark straw-colored slightly thickened fluid. Hemorrhagic ascitic fluid noted within paracentesis tubing at the end of percutaneous cholecystostomy procedure. Brief Hospital Course: Mr. [**Known lastname 392**] is a 60 year old gentleman, with PMHx significant for alcohol consumption but not abuse, now presenting with decompensated cirrhosis (for jaundice) of unknown origin for expedited transplant work-up. Hospital course complicated by acute on chronic anemia, encephalopathy, hypoxia, acute kidney injury, coccygeal ulcers and depression. . #Septic shock: He presented to ICU with hypotension and unresponsiveness. Elevated white count concerning for sepsis of unidentified source. Leukocytosis, tachypnea, and hypotension were concerning for septic shock. Right IJ was placed on admission to the ICU with initiation of pressors. Initially, phenylepherine was chosen given history of LVOT in attempts to avoid tachycardia. He was bolused several liters of fluid with good response as well. However, he continued to become hypotensive requiring initiation of vasopressin then norepinepherine to maintain MAPs in the 60s range. He was empirically started on vancomycin and cefepime, with broadening to fluconazole given continued decompensation. CT scan of the abdomen was pursued, which identified a >7 cm gallbladder concerning for cholecystitis. Necessity for intervention prompted elective intubation on MICU day #2. IR was consulted and a bedside percutaneous paracentesis and cholecystostomy tube placement was performed. He received FFP and cryoprecipitate prior to the procedure as his INR was high and platelet count low due to underlying liver disease. The procedure was complicated by bleeding and hypotension. Ascitic fluid was also sent for culture. Following the procedure, HCP made the decision to change code status from full code to DNR. Soon after the procedure, blood pressures continued to drop despite being on pressors. Abdomen was found to be increasingly distended. Hct was checked and had fallen to 9 (from 29 prior to the procedure). He was transfused two units PRBCs. HCP was informed of likelihood that pt was hemorrhaging into intra-abdominal cavity. Possible options were discussed, including IR guided intervention to stop the bleeding. Given overall poor prognosis, HCP made the decision to not pursue aggressive management. BPs continued to drop and he was pronounced dead on [**2163-3-23**] at 17:40pm. HCP was informed and declined autopsy. # Cirrhosis: Patient with cirrhotic liver noted on OSH imaging, with jaundice and MELD 23. Only known risk factors for cirrhosis are alcohol consumption (family contributed that it is a "jumbo bottle" of wine per day), ongoing poor diet/overweight, and family history of porphyria cutanea tarda. Cirrhosis etiology is most likely a combination of alcoholic cirrhosis, with contribution from NAFLD and porphyria (based on family history and porphyrin labs). At OSH, HFE gene was negative, making hemochromatosis less likely. Other possible etiologies, including viral and autoimmune were ruled out on labs and serologies. During this admission, the patient had a transjugular liver biopsy, which demonstrated elevated portal pressures consistent with portal hypertension, with pathology showing cirrhosis and severe iron overload. For his transplant evaluation, patient had EGD showing normal esophagus, stomach and duodenum without varices or portal gastropathy. He had a virtual colonscopy, but the study was limited and non-diagnostic. Also, his TTE was done; this showed hyperdynamic LV with EF 80%, moderate resting LVOT obstruction, and mildly thickened aortic valve leaflets. He was continued on furosemide, spironolactone, lacutlose and rifaxmin. . # Acute on chronic anemia: Hematocrit stabilized in the low 20s, with several blood transfusions intermittently during this admission for Hcts below 21. There were no active signs of bleeding on exam on CT imaging. Patient's labs were consistent with ongoing hemolysis that was probably secondary to both cirrhosis and porphyria. . # Encephalopathy: Throughout the latter half of this hospitalization, the patient had waxing and [**Doctor Last Name 688**] somnolence. Differential for encephalopathy was broad, including pulmonary edema, hypoxia, deconditioning, atelectasis and infection. Work-up for infection was negative (no UTI, PNA, infectious diarrhea, skin infection or SBP). Likely not attributable hepatic encephalopathy, given frequent BMs on lactulose. No sedating meds. Most likely etiology was from chronic disease and deconditioning from long hospital stay, with some contribution from pulmonary edema and atelectasis. . # Hypoxia: Following attempted colonoscopies, the patient was noted to have a new oxygen requirement of 2L supplemental oxygen. ABG on [**3-19**] demonstrated hypoxia with pO2 57. Etiology was unclear, but it was most likely mutlifactorial from pleural effusion, LVOT obstruction, atelectasis, and possible silent aspiration. Diuretics were initially discontinued to allow more BP room for metoprolol for rate control and better preload. Patient had a thoracentesis for 800 cc transudative fluid on [**3-19**]. He was uptitrated to metoprolol tartrate 25 mg PO BID for improvement of preload. Lasix at low dose was restarted. Patient was evaluated by speech and swallow, who noted to overt aspiration, but recommended HOB elevation, and diet with thin liquids and soft solids. . # Acute kidney injury: Creatinine was initially 0.8 and rose to 1.3 several days prior to discharge, which it remained stable. This [**Last Name (un) **] was likely related to diuretic medications and decreased PO intake, along with some decreased cardiac output from LVOT obstruction. Patient's diuretics were adjusted. . # Coccygeal ulcers: Noted to have several ulcers, from exfoliative stress and pressure. At rehabilitation, he should continue commercial cleansing, Duoderm and Mipelex per nursing care recommendations. There were no signs of infection. . # Depression: Patient expressing hopelessness, and sadness about his father's death on [**3-17**]. This probably contributed to some lack of motivation during inpatient physical therapy and rehab process. . # Alcohol consumption: Based on patient report, it did not seem that he has alcohol abuse beyond what is recommended for his gender ([**11-29**] glasses of wine per night); however, family input that he was actually drinking a "jumbo" bottle of wine per day. He was deemed not a transplant candidate . # Iliopsoas Hematoma: Patient developed weakness in his right leg in [**Month (only) 404**] of this year, with right iliopsoas hematoma demonstrated on CT scan. During this admission, repeat CT scan showed a slight improvement in the size of the iliopsoas hematoma. . Medications on Admission: - folic acid 1 mg daily - furosemide 20 mg daily - nadolol 40 mg daily - prednisone 40 mg daily (d/c'ed [**2163-3-1**]) - senna 8.6 mg daily - spironolactone 100 mg daily - thiamine 100 mg daily - lactulose 10 mg [**Hospital1 **] - xifaxan 550 mg [**Hospital1 **] - vitamin d 1000 units daily - nystatin swish and swallow - ursodiol 500 mg [**Hospital1 **] Discharge Medications: EXPIRED Discharge Disposition: Expired Facility: [**Hospital 38380**] [**Hospital **] Nursing and Rehab Discharge Diagnosis: EXPIRED Discharge Condition: EXPIRED Discharge Instructions: EXPIRED Followup Instructions: EXPIRED Completed by:[**2163-3-30**]

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Discharge summary

report

Admission Date: [**2123-6-21**] Discharge Date: [**2123-7-13**] Date of Birth: [**2060-9-24**] Sex: M Service: NEUROSURGERY Allergies: Dilantin Attending:[**First Name3 (LF) 1835**] Chief Complaint: Transfer from OSH with L parietal brain mass Major Surgical or Invasive Procedure: External Ventricular drain- Right External Ventricular drain- Left tracheostomy Peg Tube PICC line Subclavian Central line History of Present Illness: Pt is a 62m who was at work when he developed nausea today. This was accompanied by 1 episode of vomiting. His co-workers called his wife when he began acting different and wasn't his usual self. He was taken to OSH where CT head showed L parietal brain mass. Currently he denies headache, visual changes, motor weakness or speech difficulty. Past Medical History: HTN, High cholesterol Social History: Lives with wife at home, non smoker Family History: NC Physical Exam: BP: 136/80 HR: 96 R 12 O2Sats 99 Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRLA EOMs full Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**3-20**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light,4 to 3 mm bilaterally.visual fields show L inferior quadrant visual field cut III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-22**] throughout. No pronator drift Sensation: Intact to light touch Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Handedness Right Pertinent Results: HEAD CT [**2123-6-21**] OSH L parietal lesion with significant vasogenic edema, no midline shift MRI head [**2123-6-22**] incomplete study d/t movement, L parietal mass with vasogenic edema seen [**6-23**] CT TORSO: IMPRESSION: 1. Small bilateral pleural effusions. 2. No acute process of the chest, abdomen or pelvis. 3. Small hypoattenuating liver and renal lesions are too small to characterize, likely simple cysts. 4. Significantly distended urinary bladder. [**6-23**] CXR: Left lung is clear. Mild volume loss and heterogeneous opacification at the right lung base could be due to hypoventilation alone or alternatively recent aspiration. The stomach is mildly-to-moderately distended with gas. Upper lungs are clear. Ascending thoracic aorta is tortuous or minimally dilated. [**6-24**] EEG: [**6-24**]: Head CT: IMPRESSION: 1. Post ventriculostomy catheter placement with new small amount of subarachnoid hemorrhage in the right frontal lobe. 2. Left parietal vasogenic edema has increased and there is slightly increased midline shift to the right by about 5 mm, new from the CT from [**2123-6-21**]. 3. Ventricles are normal in size, but slightly more prominent than on [**2123-6-21**] predominantly involving the temporal horns. NOTE ADDED AT ATTENDING REVIEW: I agree with the above interpretation and note that the involvement of the corpus callosum and the fast diffusion seen in the nonenhancing core of the lesion on the MR study argue that a primary malignant neoplasm, such as a glioblastoma, is more likely than abscess or metastatic disease. [**6-24**] Head CT: 1. Rapidly progressive ventricular enlargement, particularly right greater than left occipital horns, since nine hours ago. Interval increased cerebral edema nad rightward midline shift, now by 7 mm. Increased effacement of right ambient cistern, suggesting uncal herniation. 2. Stable position of a right frontal approach intraventricular shunt catheter. 3. Stable right frontal subarachnoid hemorrhage with new intraventricular component in the right occipital [**Doctor Last Name 534**]. Alternatively, new right intraventricular density could represent pus, in the setting of ventriculitis. 4. Substantial edema about a left parietal lesion, better seen on preceding MRI. [**6-24**] CXR:NG tube tip is in the stomach. ET tube tip is 6 cm above the carina. Left subclavian catheter tip is in the upper SVC. There is no pneumothorax. Bilateral pleural effusions are small. MR [**Name13 (STitle) **] W& W/O CONTRAST [**2123-6-25**] 1. Again areas of edema are demonstrated in the cerebellum with associated subependymal enhancement along the fourth ventricle, likely related with the previously demonstrated intraventricular abscess. 2. The signal intensity throughout the cervical spinal cord is normal with no evidence of focal or diffuse lesions. 3. Mild-to-moderate multilevel degenerative changes throughout the cervical spine, more significant at C5/C6 and C6/C7 levels MRI OF THE THORACIC SPINE 1. Mild degenerative changes in the thoracic spine as described above involving the T7, T8, and T8/T9 levels. No focal or diffuse lesions are noted throughout the thoracic spinal cord or areas with abnormal enhancement. 2. Areas of edema are noted along the right musculature with no evidence of fluid collections. 3. Bilateral pleural effusions, slightly right greater than left. MRI OF THE LUMBAR SPINE 1. Mild thickening of the nerve roots at the level of L5/S1, concerning for arachnoiditis. 2. Mild disc degenerative changes identified at L4/L5 with bilateral joint effusions, disc degenerative changes are also present at L5-S1 with no evidence of spinal canal stenosis. [**6-26**] ECHO: no vegetations, EF > 50%, no ASD [**6-27**] CT head AM: worsening left edema, and rightward shift enlarged temporal horns bialt [**6-27**] CT head 6PM: enlarging left ventricular system. Interval progression of rightward shift of the normally midline structures by 18 mm (previously 9 mm). [**6-28**] MRI Brain with and without contrast: IMPRESSION: Interval evolution of the previously noted left parietal lesion, with increase in the nonenhancing necrotic central portion. Areas of slow diffusion and abnormal enhancement noted in the lateral, the third, and the fourth ventricles related to the presence of purulent material; obliteration of cerebral aqueduct. Small foci of slow diffusion in the left parietal lesion and splenium and right centrum semiovale- ? infarcts/purulent material. Assessment for infarction is limited given the confounding effects of possible purulent material based on the clinical details. There are extensive areas of increased signal intensity in the cerebellar hemisphere, vermis, and in the brainstem. There is mild meningeal enhancement noted along the surface of the brain, predominantly on the left side. Subependymal enhancement is noted in the lateral, third and 4th ventricles. Extensive FLAIR hyperintense signal in the cerebral parenchyma and in the brainstem structures as described above related to surrounding edema and parenchymal changes along with some degree of CSF seepage. However, the etiology of these changes is not clear. Correlate clinically A small enhancing focus in the left temporal lobe, attention on close followup. Mucosal thickening in the ethmoid and the mastoid air cells bilaterally and diffusely. [**6-28**] AM CT head: IMPRESSION: 1. Decompression of the left lateral ventricle after new external ventricular drain has been placed. 2. Decrease in rightward shift of the normal midline structures from 18 mm to 8 mm. 3. Stable extensive vasogenic edema in the left parieto-occipital lobe with stable appearance of small hyperdense abscess. 4. No evidence of new hemorrhage. [**6-28**] CXR: There is bibasilar atelectasis. Lungs are otherwise clear. Small bilateral pleural effusions are unchanged. Hilar and cardiomediastinal contours are normal. There is no pneumothorax. The endotracheal tube and left subclavian central venous catheter are in unchanged and appropriate position. A feeding tube passes through the expected course of the esophagus and enters the left upper quadrant of the abdomen. [**6-30**] EEG:nonconvulsive status [**7-1**] CXR: Unchanged bibasilar atelectasis and trace left effusion. [**7-2**] Bilateral lower extemity ultrasound venous studies: No evidence of deep venous thrombosis in bilateral lower extremities. [**7-3**] CXR: Tracheostomy tube whose distal tip is 4 cm above the carina. There is a left-sided PICC line whose distal tip is in the mid SVC. Heart size is within normal limits. Tortuosity of the thoracic aorta. There is a small amount of free air underneath the right hemidiaphragm which after discussion with the clinical team is related to recent PEG tube placement. [**7-4**] MRI Head: 1. Overall improvement with decrease in size of left parietal ring-enhancing lesion, amount of intraventricular fluid and complete resolution of FLAIR signal abnormality involving brainstem and cerebellum. 2. Mild decrease in ventricular size with stable position of bifrontal ventriculostomy catheters. 3. Unchanged partial opacification of the bilateral mastoid air cells. CT Head [**7-6**] 1. Unchanged position of the external ventricular drain. The ventricles are unchanged in size when compared to the exam performed approximately 24 hours. 2. No evidence of hemorrhage. 3.. Stable appearance of vasogenic edema surrounding the known abscess in the left temporal lobe [**7-7**] CT Head: 1. Status post removal of the left external ventricular drain, with a small amount of air layering in the left lateral ventricle. 2. Unchanged ventricular size. 3. No evidence of hemorrhage. [**7-7**] Mandible Xray: There are no signs for acute fractures or dislocations. Mineralization is within normal limits. There is subtlelucency surrounding the left second molar within the mandible which corresponds to the abnormality seen on the prior CT study. The paranasal sinuses are within normal limits. The nasal bone is unremarkable. Portion of the cervical spine is within normal limits aside from some spurring at the articulation of C1 and C2. [**7-9**]: Bilateral lower extremity dopplers: No evidence of deep venous thrombosis in bilateral lower extremities Brief Hospital Course: 62 y/o M n/v at work and change in personality presented to OSH where head CT revealed large L parietal mass. He was transferred to [**Hospital1 18**] for further neurosurgical evaluation. On examination, patient was nonfocal. He was admitted to neurosurgery and awaiting MRI of head for further evaluation and keppra was added. On [**6-22**], patient was unable to tolerate MRI scanner and imaging was incomplete. Neuro and rad onc were consulted. Infectious workup was also initiated, labs were sent. On [**6-23**] Mr. [**Known lastname **] was found in distress in his room having projectile vomited and was complaning of severe pain. His Temperature was noted to be 102 rectaly and he was slightly more lethargic. He was transfered to the ICU for close monitoring, nausea control and more frequent neuro checks. Upon arrival in the ICU he was further worked up for possible causes of his hematemsis, fevers, and lab abnormalities. The decision was made to perform a lumbar puncture which showed an openign pressure of 28 and was yellow and cloudy in appearance. The fluid also was viscous and only 2-3ml were able to be removed. The fluid was sent and found to have protein in the 800's a glucose of 1, and 99% polys. As such ID was consulted for cocnerns for intracranial bacterial infection. The decision was made to place an external ventricular drain on [**6-24**] for intrathecal administration of antibiotics. Later in the evening his condition worsened and he was intubated and EVD was placed at the bedside. On the morning of [**6-24**] his exam continued to worsen and there was question of seizure activity so an EEG was placed. He was started on additional antiseizure agents. His ICP was noted to be increasing so he recieved 23% saline x 1 dosage. This worked temporarily but then the ICP increased again. Due to the location of shift and risk of herniation he was given decadron, mannitol and started on 3% saline gtt. After his physical exam remained stable throughout he was restarted on propofol, and subsequent ICP's were well controlled as well as his blood pressure. He was started on intrathecal antibiotics per ID's recommendations. On [**6-25**]: patient remained stable, somewhat improved as compared to [**6-24**]. ICPs stable and less than 10. His Decadron was decreased to 6mg Q6 hours. A repeat CT showed persistant hydrocephalus, but less mass effect on the brain stem. EVD was lowered to 10 to allow for more drainage. An Echo cardiogram was performed which ruled out endocarditis and showed EF of > 50%. On [**6-26**], patient's exam showed new disconjugate gaze, but was otherwise unchanged. His ICP were stable overnight ranging from [**5-25**] and his EVD had an output of 106cc and 29cc. He continues to recieve IT antibiotics. CSF culture is pending. EEG remains in place. EVD was lowered to 5cm in an attempt to reduce occipital and temporal [**Doctor Last Name 534**] ventriculomegaly. Overnight he developed transient ICPs to the low to mid 20s and became transiently bradycardic to the 40s. Blood pressure remained stable. ICPs normalized after increasing hypertonic saline gtt to 15cc/hour. Repeat Head CT on [**6-27**] demonstrated increase rightward shift and continued bilateral enlarged temporal horns. The EVD was raised to 15cm above the tragus in an effort to not overdrain the lateral ventricles and improve the rightward shift. He received the morning doses of IT Gent and Vanco. CSF Cultures returned demonstrating speciation to STREPTOCOCCUS ANGINOSUS with pansensitivites. Both IV and IT antibiotics were narrowed and he continued on only IV Flagyl and IV PCN with only IT Vancomycin [**Hospital1 **]. His exam remained unchanged. Repeat Head CT at 6pm demonstrasted *** On [**6-28**], The external ventricular drain on right stopped working at 0300am and was discontinued. The left external ventricular drain patent and open at 5 H2Ocm above the tragus. At approximately 3 pm the EVD stopped draining and TPA was administered and clamped x 30 mins. The drain was opened and the was again draining CSF with a good waveform. The continuous EEG was consitent with 3-4 seizures in the morning and Keppra was restarted at 1000mg [**Hospital1 **] with a loading dose of 1400mg. A non contrast Head Ct was performed which was consistent with decompression of the left lateral ventricle after new external ventricular drain has been placed. decrease in rightward shift of the normal midline structures from 18 mm to 8 mm.Stable extensive vasogenic edema in the left parieto-occipital lobe with stable appearance of small hyperdense abscess.No evidence of new hemorrhage. The 3% sodium chloride gtt was discontinued. The serum sodium was 142. Per infectious disease, as the patient was experiencing seizures penicillin was discontinued and ceftriaxone 2 gm q 12 hours. On exam, the patient was intubated. He was spontaneously opening his eyes. There was no tracking noted and sluggish pupillary response bilaterally. There was no movement in the 4 extremities to noxious. The patient did not follow commands. a MRI was performed which was consistent with edema within the pons and brainstem but no clear stroke and showed a small increase in the size of the left parietal brain abscess. On [**6-29**] the patient's neurological exam remained the same. Eye opening was spontaneous and he had positive corneals and positive blink to threat. Discussion was held with ID and due to the lack of a sizeable abscess to drain, there is no role for surgical intervention aside from current EVD. He continued to received IT vancomycin [**Hospital1 **] in addition to IV Ceftriaxone. On [**6-30**] his neurologic exam was stable however he was noted to be febrile o/n and was cultured except CSF. His EEG was reviewed and it was found that he had been in non-convulsive status on [**6-29**]. In the setting of fevers ID recommended addition of IV Vancomycin and requested CSF be sent the evening of [**6-30**]. On [**7-1**], patient continued to be febrile with an increase in his WBC, CSF gram stain showed no growth to date, sputum and blood cultures are still pending. On exam, there was no EO or movement in all extermities to noxious stimuli. IT vanco was adminitistered at 10am. His NA level was 128, standing salt tabs were added and labs were ordered to follow up the level. On [**7-2**], the patient began to follow commands. He developed a rash believed to be due to Dilantin. Dilantin was subseqently discontinued, and he was started on Lacosamide per the Epilepsy team. The EEG leads were temporarily removed. LENIs studies were performed and were negative. The patient was able to tolerate trach mask. On [**7-3**], MRI Head showed decrease in size of abcess and resolving ventriculitis. EEG showed no seizures. The Infectious Diseases team recommended a likely time period of 2 more weeks of IV antibiotics. He continued to follow commands. On [**7-4**], the patient was noted to have a normal sleep/active pattern on EEG and continued to follow commands. He worked with Physical Therapy and was able to sit up at the side of the bed and dangle his feet. EEG was discontinued due to lack of seizures for the previous 48 hours. On [**7-5**] his intrathecal abx were discontinued and he went for a baseline CT head prior to having his EVD clamped. His EVD was clamped at noon. On [**7-6**] a repeat CT head showed no change in ventricular size and it was decided to continue his clamping for 24 more hours and if his exam was unchanged to take it out on [**7-7**]. His serum Na dropped to 128 and he was started on NaCl tabs. On [**7-7**] his neuro exam remained stable. He was AOx2, MAE and following commands. His left EVD was discontinued without complication as well as the right EVD staples. Post removal CT revealed no hemorrhage. His trach was capped with a passe muir valve which he tolerated well. Na was improved to 129 but still low so we also started on florinef. On [**7-8**] he was neurologically stable. Na was up to 131. PT/OT and social work continued to work on his discharge plan. He was transferred to step-down. OMFS plan to take him to OR [**7-9**] for extraction of lower left 2nd molar. On [**7-9**], patient alert, EO to voice, nods his head appropriately and follows commands. His sodium level has improved from 128 to 133 with the addition of salt tabs and florinef per renal. They also recommended urine lytes and osm be sent for further evaluation. He was taken to the OR for tooth extraction. He toelrated the tooth extraction well under MAC and went to the PACU post-operatively. On [**7-10**] he was seen again by renal and they recommended continuign his florinef at the same dose and signed off. He remained stable on [**7-11**] and on [**7-12**] was evalauted by speech and swallow and transfer orders were written for him to go to the floor from step down. Speech and swallow recommended a video swallow to be completed. On [**7-13**], video swallow was cancelled. Patient remained stable on examination and was discharged to rehab in stable condition. Medications on Admission: Simvastatin, Lisinopril Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain or fever 2. Artificial Tears Preserv. Free 1-2 DROP BOTH EYES PRN dry eyes 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 4. CeftriaXONE 2 gm IV Q 12H 5. Dexamethasone 1 MG IV QD Duration: 1 Days 6. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 7. DiphenhydrAMINE 25 mg IV Q6H:PRN itching 8. Docusate Sodium (Liquid) 200 mg PO BID 9. Fludrocortisone Acetate 0.1 mg PO DAILY 10. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 11. Heparin 5000 UNIT SC TID 12. HydrALAzine 10 mg IV Q6H:PRN SBP > 160 13. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 14. LeVETiracetam Oral Solution 1500 mg PO BID 15. Lacosamide 200 mg PO BID 16. MetRONIDAZOLE (FLagyl) 500 mg IV Q6H per ID recs 17. Ondansetron 4 mg IV Q4H:PRN nausea 18. Pantoprazole 40 mg IV Q24H 19. Promethazine 12.5 mg IV Q6H:PRN n/emesis 20. Sarna Lotion 1 Appl TP TID:PRN pruritis 21. Senna 2 TAB PO BID 22. Simvastatin 20 mg PO DAILY 23. Sodium Chloride 2 gm PO TID 24. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 25. Outpatient Lab Work CBC w/ diff, LFTs, ESR, CRP Please have this information faxed to the [**Hospital **] clinic at [**Telephone/Fax (1) 1419**] Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**] ([**Hospital3 1122**] Center) Discharge Diagnosis: L parietal Mass intracranial abscess Meningitis Coma Elevated ICP Cerebral Edema Respiratory failure Electrolyte imbalance Protien/Calorie malnutrition Hydrocephalus 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: ?????? 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 was closed with staples then you must wait until after they are removed to wash your hair. You may shower before this time using a shower cap to cover your head. These staples can be removed on [**7-14**]. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? **You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. ?????? **You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Staples can be removed on [**7-14**]. This can be done at your rehab facility. If there are any questions please call [**Telephone/Fax (1) 1669**]. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen 4 weeks after your antibiotic have been discontinued. ??????You will need an MRI of the brain with and without gadolinium contrast. ?????? You should follow up in the infectious disease clinic in 4 weeks with an MRI of the head. This appointment can be scheduled by calling [**Telephone/Fax (1) 457**]. Completed by:[**2123-7-13**]

[ "780.01", "518.81", "780.39", "522.5", "320.2", "276.1", "401.9", "324.0", "348.5", "054.9", "331.4", "263.9", "272.4", "437.2" ]

icd9cm

[ [ [] ] ]

[ "02.22", "02.21", "23.19", "96.72", "43.11", "03.31", "96.6", "31.1" ]

icd9pcs

[ [ [] ] ]

20946, 21082

10447, 19539

319, 444

21292, 21292

2094, 2920

23358, 24009

933, 937

19614, 20923

21103, 21271

19565, 19591

21468, 23335

952, 1077

234, 281

472, 817

1370, 2075

9651, 10424

3698, 7513

21307, 21444

839, 863

879, 917

60,668

180,373

39528

Discharge summary

report

Admission Date: [**2175-11-1**] Discharge Date: [**2175-11-2**] Date of Birth: [**2153-2-17**] Sex: F Service: MEDICINE Allergies: Rituximab Attending:[**First Name3 (LF) 3984**] Chief Complaint: Rituxan Desensitization Major Surgical or Invasive Procedure: None History of Present Illness: [**Doctor Last Name **] is a 22 Y transgender male with history of refractory ITP since [**2171**], medical non-compliance, major depressive disorder who presents electively for Rituxan desensitization. Pt most recent presented to clinic on [**11-1**] to Dr. [**Last Name (STitle) 3638**] his hematologist and was noted to have Plt count of 5000. He was reporting intemittent "red spots" on his face and chest, occassional epistaxis, and transient bleeding from the gums with tooth brushing. Denied menses. He has had multiple such episodes that have been well managed with pulse steroids and rituxan treatment with densitization protocol. As such, he was started on prednisone 60 daily per his oncologist and presented the next day for repeat check which was 31,000. He presents today for scheduled densitization. Also took montelukast yesterday evening in compliance of the desensitization protocol. Typically desensitization has been done on the oncology floor, however due to requirement of extra staffing and history of patient non-compliance patient now presents for directly observed desensitization in the MICU. . Presently he denies any bruising, "red spots", or bleeding. He denies any other complaints. . . . 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: HPI for ITP: --Diagnosed with ITP in [**8-/2172**] at [**Hospital1 2177**] after presenting with petechiae and large ecchymotic area. Subsequently treated with high dose corticosteroids, IVIG, rituximab to which he had an allergic reaction (throat swelling), WinRho, all without sustained response. In [**2173-3-17**], laporascopic splenectomy was performed. In [**2173-7-17**], he was placed on N-plate at [**Hospital1 2177**] with response though he was only intermittently adherent about receiving it. Last dose was administered in early [**2174-6-16**]. In mid-[**2174-6-16**], he was seen in [**Hospital1 2177**] ER for heavy menstrual bleeding and found to have platelets of 63K. He was subsequently lost to follow up at [**Hospital1 2177**]. --On [**2174-10-8**], admitted to [**Hospital1 18**] after a suicidal attempt with Wellbutrin and alcohol. Found to have a platelet count of <5K without bleeding other than menses. He received platelet transfusions and placed on started prednisone 90 mg daily with improvement in thrombocytopenia. Subsequently admitted to Psychiatry. A prednisone taper was attempted but platelet count began declining, prompting an increase in the dose of his prednisone back up to 90 mg daily. At discharge on [**2174-10-21**], platelet count was 50,000. --Prednisone tapered slowly to 70 mg daily by [**2174-11-9**]. Subsequently lost to follow up. --Resurfaced [**2175-1-4**] with complaints of increased bruising. Off all medications for several weeks. Platelet count 48K. Admitted bruises may have been from a fight. Subsequently lost to follow up. --Resurfaced [**2175-2-10**] with epistaxis and heavier more sustained menses. Platelet count declined to <5000. Placed on a 4 day pulse of dexamethasone 40 mg daily. After three days, platelet count rose to 102K. Again lost to follow up; did not keep scheduled appointments and unable to reach by phone. --Hospitalized [**2175-2-23**] - [**2175-2-26**] after presenting to ER with persistent epistaxis. Platelet count 5000. Did not respond to IV dexamethasone. Transferred to ICU for rituximab desensitization which reportedly was uneventful. During the post-infusion observation period, he became upset, and left AMA. Again lost to follow up; unable to reach despite leaving numerous phone messages to call us regarding on-going care. --Contact[**Name (NI) **] us on [**2175-3-8**] reporting heavy menses, epistaxis, petechiae, and vomiting possible coffee-ground material. Refused hospitalization. Transfused with platelets, given single dose of aminocaproic acid. --On [**2175-3-16**], received second dose of rituximab as an outpatient using the desensitization protocol. Infusion was uneventful. Platelet count prior to rituximab was 10,000. Again did not keep followup appointments. --Scheduled to have more Rituxan as OP on [**2175-9-7**] Additional PMH: MDD EtOH abuse Obesity [**Hospital 5550**] Medical non-compliance of note patient is a transgender male (female -> male) Social History: Lives in an apt by himself in [**Country **] town. Drinks heavily about twice a month. No history of withdrawal symptoms or seizures. Smokes marijuana 1-2 times monthly. No tobacco, other illicits. Family History: Mother with asthma. Brother with paranoid schizophrenia. Sister who identifies as male. No history of ITP or other blood disorders in the family. Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2175-11-1**] 11:52AM BLOOD WBC-7.5 RBC-4.36 Hgb-12.4 Hct-38.3 MCV-88 MCH-28.4 MCHC-32.4 RDW-14.4 Plt Ct-76*# [**2175-11-1**] 11:52AM BLOOD Glucose-113* UreaN-16 Creat-0.7 Na-140 K-4.1 Cl-106 HCO3-26 AnGap-12 Brief Hospital Course: Ms. [**Known lastname 87292**] is a 22 year old transgendered (female-->male) male with history of refractory ITP here for rituxan desensitization. . #. Rituxan Desensitization - The patient was pretreated with Montelukast the day prior to admission. While in the MICU he was pre-medicated with diphenhydramine, famotidine, and lorazepam. During his MICU admission, Mr. [**Known lastname 87292**] [**Last Name (Titles) 35325**] 3 doses of Rituxan in increasing concentrations (1/100, [**12-26**], standard dosing). The patient tolerated these medications well without complication, with no hemodynamic compromise, respiratory distress, clinical signs of allergic reaction or anaphylaxis. Discharge with plans to follow up with hematology ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) tomorrow for further management. Medications on Admission: citalopram 10mg daily abilify 10mg daily ranitidine 150bid prednisone 60mg, started on [**10-27**] montelukast, one dose 11/14 Discharge Medications: 1. citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. Abilify 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day. 4. prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Rituxan desensitization Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you at [**Hospital1 18**]! You were admitted so that you could be desensitized to Rituxan which will be used to treat your ITP. The desensitization went well and was without complication. You are now ready for discharge. There were no changes made to your home medication regimen. Please see below for instructions regarding follow-up care: Followup Instructions: Please follow-up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP. She will call you tomorrow regarding an appointment time. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

[ "530.81", "296.20", "V14.8", "302.50", "V15.81", "V07.1", "305.00", "287.31" ]

icd9cm

[ [ [] ] ]

[ "99.12" ]

icd9pcs

[ [ [] ] ]

7436, 7442

6137, 6979

294, 301

7510, 7510

5902, 6114

8062, 8342

5254, 5402

7157, 7413

7463, 7489

7005, 7134

7661, 8039

5417, 5883

1575, 2023

231, 256

329, 1556

7525, 7637

2045, 5020

5036, 5238

46,953

197,960

33952

Discharge summary

report

Admission Date: [**2179-8-10**] Discharge Date: [**2179-8-19**] Date of Birth: [**2111-12-16**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Penicillins Attending:[**First Name3 (LF) 6743**] Chief Complaint: pelvic mass Major Surgical or Invasive Procedure: Exploratory laparotomy Lysis of adhesions Right salpingo-oophorectomy Drainage of ascites Total abdominal hysterectomy Infragastric omentectomy Appendectomy Cystoscopy Repair of ventral hernia History of Present Illness: Ms. [**Known lastname 19075**] is a 67-year-old gravida 0 woman with a past medical history significant for diabetes, hypertension, hypercholesterolemia, and morbid obesity, who noted postmenopausal bleeding. An ultrasound was performed on the [**2179-7-6**], and this revealed, in a fairly limited study, a large complex right adnexal cystic mass, ovarian in origin. The endometrium was not clearly visualized; however, the uterus measured 12.3 x 10.6 x 8.3 cm and multiple fibroids were noted. The kidneys were unremarkable and there was a small amount of free fluid noted within the posterior cul-de-sac. A followup CT scan of the abdomen and pelvis was then performed on [**2179-7-8**], and this revealed once again the solid cystic and right adnexal mass measuring 15 x 12 x 8 cm. There was no significant free fluid or irregularities suggestive of ascites. The CA-125 level was elevated at 395 and a CEA level of 44.3 was noted. Ms. [**Known lastname 19075**] in the past week has been hospitalized for pulmonary embolism. She developed a blood clot in her leg and was admitted to [**Hospital3 **] for evaluation. A CTA of the chest revealed ascites with bilateral pulmonary emboli. A IVC filter was placed. She has been started on low-molecular-weight heparin. Past Medical History: PAST MEDICAL HISTORY: As mentioned, the patient suffers from diabetes, hypertension, hypercholesterolemia, and recently was diagnosed with a DVT and pulmonary embolism. . PAST SURGICAL HISTORY: She had her left ovary removed through a vertical midline incision in [**2160**]. She believes it was for benign disease. . OB/GYN HISTORY: Her last menstrual cycle "years and years ago." She denies any history of pelvic infections or abnormal Pap smears. Her last Pap smear was obtained in 10/[**2177**]. Social History: She denies tobacco, drug, or alcohol use. She is retired. She worked for an astronomy magazine called [**Hospital Ward Name **] & Telescope, and she worked there for years and years. Family History: She reports her father had [**Name2 (NI) 499**] cancer at the age of 59. Physical Exam: GENERAL: She appears her stated age, in no apparent distress. HEENT: Normocephalic, atraumatic. Oral mucosa without evidence of thrush or mucositis. Eyes, sclerae are anicteric. NECK: Supple, no masses, no thyromegaly identified. LYMPHATICS: Lymph node survey, negative cervical, supraclavicular, axillary, or inguinal adenopathy. CHEST: Lungs clear bilaterally. HEART: Regular rate and rhythm. I appreciate no murmurs. BACK: No spinal or CVA tenderness. ABDOMEN: Soft, obese, nontender, nondistended. A large vertical midline incision is noted. I am unable to palpate any mass or irregularity. EXTREMITIES: No clubbing, cyanosis, or edema. PELVIC: Normal external genitalia. The inner labia minora is normal. Urethral meatus is normal. There is no bleeding identified on speculum exam, the cervix is normal in appearance. Bimanual exam is dominated by a pelvic mass that extends over to the right side. It is nonmobile. RECTAL: Reveals good sphincter tone without mass or lesion. Pertinent Results: HEMATOLOGY ========== [**2179-8-11**] 01:16AM BLOOD WBC-25.3*# RBC-3.89* Hgb-9.5* Hct-31.4* MCV-81* MCH-24.4* MCHC-30.3* RDW-16.0* Plt Ct-326 [**2179-8-11**] 11:26AM BLOOD WBC-21.0* RBC-3.90* Hgb-9.3* Hct-30.8* MCV-79* MCH-23.8* MCHC-30.1* RDW-16.4* Plt Ct-338 [**2179-8-11**] 09:38PM BLOOD WBC-19.7* RBC-3.36* Hgb-8.2* Hct-26.4* MCV-79* MCH-24.3* MCHC-31.0 RDW-16.5* Plt Ct-330 [**2179-8-11**] 09:38PM BLOOD Neuts-87.7* Bands-0 Lymphs-7.5* Monos-4.5 Eos-0.1 Baso-0.2 [**2179-8-12**] 07:30AM BLOOD WBC-22.3* RBC-3.30* Hgb-8.2* Hct-25.7* MCV-78* MCH-24.8* MCHC-31.8 RDW-16.7* Plt Ct-319 [**2179-8-12**] 07:30AM BLOOD Neuts-90.0* Bands-0 Lymphs-5.1* Monos-4.7 Eos-0.1 Baso-0.2 [**2179-8-13**] 06:55AM BLOOD WBC-19.9* RBC-3.18* Hgb-7.7* Hct-25.7* MCV-81* MCH-24.1* MCHC-29.8* RDW-16.3* Plt Ct-318 [**2179-8-14**] 04:56AM BLOOD WBC-13.0* RBC-3.54* Hgb-8.8* Hct-28.6* MCV-81* MCH-24.9* MCHC-30.8* RDW-15.8* Plt Ct-314 [**2179-8-14**] 09:21AM BLOOD Hct-28.3* [**2179-8-15**] 06:10AM BLOOD WBC-11.0 RBC-3.82* Hgb-9.5* Hct-31.3* MCV-82 MCH-24.8* MCHC-30.2* RDW-15.9* Plt Ct-345 [**2179-8-16**] 09:42AM BLOOD WBC-9.0 RBC-3.86* Hgb-9.5* Hct-31.5* MCV-82 MCH-24.7* MCHC-30.2* RDW-16.0* Plt Ct-349 [**2179-8-16**] 09:42AM BLOOD Neuts-80* Bands-0 Lymphs-7* Monos-7 Eos-4 Baso-0 Atyps-0 Metas-0 Myelos-2* [**2179-8-17**] 07:40AM BLOOD WBC-8.9 RBC-3.55* Hgb-9.0* Hct-28.5* MCV-80* MCH-25.4* MCHC-31.7 RDW-16.1* Plt Ct-323 . CHEMISTRY ========= [**2179-8-13**] 01:15PM BLOOD Glucose-121* UreaN-25* Creat-1.2* Na-136 K-4.2 Cl-99 HCO3-24 AnGap-17 [**2179-8-13**] 01:15PM BLOOD Calcium-8.6 Phos-3.0 Mg-1.7 [**2179-8-14**] 04:56AM BLOOD Glucose-92 UreaN-26* Creat-1.2* Na-139 K-4.4 Cl-102 HCO3-27 AnGap-14 [**2179-8-14**] 04:56AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.8 [**2179-8-15**] 06:10AM BLOOD Glucose-108* UreaN-22* Creat-1.1 Na-142 K-3.4 Cl-101 HCO3-32 AnGap-12 [**2179-8-15**] 06:10AM BLOOD Calcium-9.1 Phos-3.1 Mg-1.7 [**2179-8-16**] 09:42AM BLOOD Glucose-112* UreaN-14 Creat-0.8 Na-140 K-3.1* Cl-99 HCO3-33* AnGap-11 [**2179-8-16**] 09:42AM BLOOD Calcium-8.4 Phos-1.9* Mg-1.8 [**2179-8-17**] 07:40AM BLOOD Glucose-118* UreaN-10 Creat-0.8 Na-142 K-2.9* Cl-99 HCO3-36* AnGap-10 [**2179-8-17**] 07:40AM BLOOD Calcium-8.1* Phos-2.1* Mg-1.7 [**2179-8-17**] 04:10PM BLOOD Glucose-125* UreaN-10 Creat-0.9 Na-144 K-3.4 Cl-100 HCO3-35* AnGap-12 [**2179-8-17**] 04:10PM BLOOD Calcium-8.7 Phos-1.8* Mg-2.1 [**2179-8-18**] 07:50AM BLOOD Glucose-124* UreaN-9 Creat-0.9 Na-145 K-3.9 Cl-101 HCO3-36* AnGap-12 [**2179-8-18**] 07:50AM BLOOD Calcium-8.7 Phos-2.3* Mg-2.1 . BLOOD GAS ========= [**2179-8-13**] 04:39PM BLOOD Type-ART FiO2-35 pO2-87 pCO2-53* pH-7.31* calTCO2-28 Base XS-0 Intubat-NOT INTUBA . URINANALYSIS ============ [**2179-8-12**] 05:10AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005 [**2179-8-12**] 05:10AM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2179-8-12**] 05:10AM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-<1 [**2179-8-12**] 05:10AM URINE Mucous-RARE . MICROBIOLOGY ============ [**2179-8-12**] 5:10 am URINE Source: Catheter. **FINAL REPORT [**2179-8-15**]** URINE CULTURE (Final [**2179-8-15**]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 2 S . [**2179-8-12**] 12:06 pm SPUTUM Site: EXPECTORATED Source: Expectorated. **FINAL REPORT [**2179-8-16**]** GRAM STAIN (Final [**2179-8-12**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [**2179-8-14**]): MODERATE GROWTH OROPHARYNGEAL FLORA. GRAM NEGATIVE ROD(S). SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES. . [**2179-8-17**] 10:58 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [**2179-8-18**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2179-8-18**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). . . RADIOLOGY ========= Radiology Report CHEST (PA & LAT) Study Date of [**2179-8-11**] 10:36 PM In comparison with study of [**8-4**], there is increased opacification at the right base silhouetting the hemidiaphragm. This could represent acute pneumonia, atelectasis, pleural effusion, or some combination of these conditions. Prominence of the pulmonary vessels could reflect elevated pulmonary venous pressure, although it also could be a manifestation of substantially lower lung volumes. Mild atelectatic changes are seen at the left base. . CARDIOLOGY ========== Cardiology Report ECG Study Date of [**2179-8-12**] 12:13:10 AM Sinus tachycardia. Early R wave progression. ST-T wave abnormalities. Low precordial lead voltage. Since the previous tracing of [**2179-8-4**] the rate is faster. ST-T wave abnormalities are new. Clinical correlation is suggested. . Cardiology Report ECG Study Date of [**2179-8-13**] 4:11:34 PM Sinus tachycardia. Non-specific repolarization abnormalities. Compared to the previous tracing of [**2179-8-12**] there is no significant difference. . Cardiology Report ECG Study Date of [**2179-8-17**] 10:16:26 AM Sinus rhythm. Possible prior inferior myocardial infarction, age undetermined. Anterolateral ST-T wave changes raise consideration of myocardial ischemia. Clinical correlation is suggested. Compared to the previous tracing of [**2179-8-13**] the anterior ST segment depressions and T wave inversions are more apparent. . TTE (Complete) Done [**2179-8-17**] at 11:48:32 AM FINAL The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%) There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The aortic arch 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 (area 1.2-1.9cm2). Trace 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. Brief Hospital Course: Ms. [**Known lastname 19075**] was admitted after undergoing exploratory laparotomy, lysis of adhesions, right salpingo-oophorectomy, drainage of ascites, total abdominal hysterectomy, infragastric omentectomy, appendectomy, cystoscopy, and repair of ventral hernia. Her intra-operative course was complicated by blood loss anemia and she was transfused 2 units of PRBC. Her hematocrit increased appropriately. Please see the operative report for complete details. Her post-operative course was complicated by the following issues: . *) Cardiovascular She had no cardiac events during this hospital course. She was maintained on home antihypertensives with holding parameters. . *) Pulmonary On post-operative day 1, Ms. [**Known lastname 19075**] [**Last Name (Titles) 12368**] to high 80s - low 90s while on room air in the setting of fever. Chest radiograph demonstrated findings suggestive of pneumonia, and she had a leukocytosis. She was started empirically on levofloxacin and metronidazole for pneumonia. She maintained oxygen saturations in the mid-90s on 2L NC until post-operative day 3 when she [**Last Name (Titles) 12368**] to the low 70s on 2L NC. She was asymptomatic. Arterial blood gas revealed an acute respiratory acidosis. Chest radiograph revealed bilateral pulmonary effusions. She was admitted overnight to the ICU and given IV furosemide prn. She was transferred back to the floor where she continued to diurese with furosemide and was eventually weaned of oxygen. She had no significant EKG changes during her hospital course. . *) FEN/GI Ms. [**Known lastname 19075**] was started on a regular diet post-operatively which she tolerated well until post-operative day 3 when she experienced nausea and emesis. She was made NPO with IVF for presumed ileus. Her diet was cautiously advanced after resolution of nausea and passing of flatus. She was able to tolerate regular food by post-operative day 6. Her electrolytes were checked and repleted appropriately. . *) Hematology Due to concern for bleeding in the setting of blood loss anemia requiring transfusion, Ms. [**Known lastname 19075**] was kept on prophylactic heparin until post-operative day 3 when her home lovenox dose was started. She was transfused another 2 units of PRBC in the ICU to maximize oxygenation, as her Hct had drifted to 25.7. It increased appropriately to 31.5. She was transfused a total of 4 units of PRBC during her hospital course. . *)ID: Ms. [**Known lastname 78430**] leukocytosis trended down after initiation of antibiotic therapy. Initial work-up of her fever revealed urine culture significant for enterococcus and sputum culture demonstrating oropharyngeal flora. She received a total of 4 days of metronidazole. She was discharged on levofloxacin for a 14 day course. . Of note, on post-operative day [**7-3**], she had multiple loose bowel movements. She had no fever or abdominal pain. Her stool tested negative for C. difficile. . *) Endocrine She was maintained on home sulfonylurea and covered with insulin on a sliding scale. . *) Wound On post-operative day 8, Ms. [**Known lastname 78430**] staples were removed from the incision. She then experienced superficial wound separation. There was no evidence of fascial dehiscence or infection. A wet to dry dressing was placed. She was discharged with VNA with daily wet to dry dressing changes. . Ms. [**Known lastname 19075**] was eventually discharged on post-operative day 9 in stable condition: afebrile, able to eat regular food, under adequate pain control with oral medications, and ambulating and urinating without difficulty. Medications on Admission: ATENOLOL - (Prescribed by Other Provider) - 50 mg Tablet - Tablet(s) by mouth ENOXAPARIN [LOVENOX] - (Prescribed by Other Provider) - Dosage uncertain EZETIMIBE-SIMVASTATIN [VYTORIN [**10/2151**]] - (Prescribed by Other Provider) - 10 mg-80 mg Tablet - Tablet(s) by mouth GLIPIZIDE - (Prescribed by Other Provider) - 5 mg Tablet - Tablet(s) by mouth HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 25 mg Tablet - Tablet(s) by mouth LISINOPRIL - (Prescribed by Other Provider) - 20 mg Tablet - Tablet(s) by mouth POTASSIUM CHLORIDE [KLOR-CON M10] - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H () as needed: maximum daily Tylenol (acetaminophen) is 4000mg, each Percocet contains 325mg Tylenol (acetaminophen). Disp:*50 Tablet(s)* Refills:*0* 3. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 7. Enoxaparin 150 mg/mL Syringe Sig: One [**Age over 90 10973**]y (130) mg Subcutaneous Q12H (every 12 hours). 8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Klor-Con 10 10 mEq Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) 1514**] Regional VNA Discharge Diagnosis: primary: pelvic mass pneumonia pulmonary edema post-operative ileus . secondary: deep vein thrombus pulmonary embolism hypertension type 2 diabetes Discharge Condition: stable Discharge Instructions: Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * No strenuous activity, nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. **if no cervix p LSC hyst, nothing in vagina for 3 months * You may eat a regular diet. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have staples, they will be removed at your follow-up visit. Followup Instructions: Please follow up at the clinic for a wound check with Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7613**], MD Phone:[**Telephone/Fax (1) 5777**] Date/Time:[**2179-8-26**] 1:30 Please follow with Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 5777**] Date/Time:[**2179-9-15**] 1:30 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6753**]

[ "278.01", "285.1", "218.1", "486", "511.9", "276.2", "183.0", "518.4", "560.1", "568.0", "599.0", "518.0", "250.01", "997.3", "401.1", "198.1", "276.6", "789.51" ]

icd9cm

[ [ [] ] ]

[ "47.19", "57.32", "54.59", "65.62", "68.49", "99.04", "54.4" ]

icd9pcs

[ [ [] ] ]

15943, 16011

10726, 14336

298, 492

16203, 16212

3661, 10703

17051, 17535

2548, 2623

14999, 15920

16032, 16182

14362, 14976

16236, 16828

16843, 17028

2017, 2329

2638, 3642

247, 260

520, 1799

1844, 1993

2345, 2532

20,140

119,827

24090

Discharge summary

report

Admission Date: [**2117-4-9**] Discharge Date: [**2117-5-20**] Date of Birth: [**2059-1-14**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2181**] Chief Complaint: Fever, tachycardia Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 58 year old male with a recent admission for abdominal pain s/p negative exploratory laparotomy for suspected intussuception now returns on day of discharge with fever and tachycardia. Patient has a history for terrible vasculopathy s/p recent right BKA with dry gangrene of the distal stump. Patient's last admission was significant for a negative ex-lap. Post-operatively, his course was complicated by respiratory distress necessitating an urgent return to the ICU and was intubated. After multuple failed attempts at extubation, the patient was trached. Patient then did well on a trach mask and was transferred to rehab on the day of admission but now returns with tachycardia to the 120's, and fever to 102 degrees F. Past Medical History: PVD s/p multiple failed femoral distal bypass Diabetes mellitus CAD s/p CABG [**2102**] s/p ex lap [**3-16**] Physical Exam: T 101 HR 120 BP 144/90 RR 18 SpO2 99% on 70%TM Moderately distressed Coarse breath sounds b/l Tachycardic, nl S1 and S2 Abd soft, NT/ND Right AKA stump with dry gangrene Left lower extremity warm and well-perfused Pertinent Results: MRI HEAD: The diffusion images demonstrate no evidence of slow diffusion to indicate acute infarct. There is moderate prominence of ventricles and sulci, inappropriate for the patient's age. There is no midline shift, mass effect, hydrocephalus, or territorial infarct. Following gadolinium, no evidence of abnormal parenchymal, [**Month/Year (2) 1106**], or meningeal enhancement seen. Gastric biopsy: negative for H. pylori. Brief Hospital Course: The patient was re-admitted to the surgical service and taken to the SICU. A chest x-ray on admission showed effusions consistent with CHF along with overlying pnumonia. Urine cultures were significant for Klebsiella UTI and sputum cultures were significant for MRSA. He was placed on vancomycin, levofloxacin and fluconazole. He underwent PICC line placement on [**4-11**]. A trach collar was placed on [**4-12**]. GI was consulted for colonoscopy. Patient was transferred to the floor on [**4-13**]. He was seen by respiratory therapy and suctioned continually throughout his hospital course. His respiratory status improved. He tolerated his trach collar, and tube feeds at goal. The fluconazole was discontinued. On [**4-14**] the patient was seen by physical therapy. A nutrition consult was obtained on [**4-15**]. He underwent a failed bedside swallow study. Based on a chest x-ray that showed a small hydro-pneumothorax on the left lower lobe of the lung, a thoracic surgery consult was obtained, though no specific interventions were warranted at the time. On [**4-16**] the patient's tube feed were changed from Respalor to Deliver 2.0 to give increased calories. On [**4-18**], urine cultures grew out VRE, and a C diff was negative. He experienced low grade fevers. He was pan-cultured on [**4-19**] for continued fevers. On [**4-20**], his nutrition regimen was changed to Deliver 2.0 at 70cc/hr with 15g ProMod. On [**4-21**], the patient experienced PVC's. An EKG showed ST segment depression along the lateral pre-cordial leads. Serial enzymes showed mild elevation of troponins. A cardiology consult was obtained. The cardiology service simply recommended increasing the beta-blockade and maximizing the patient's electrolyte status. On [**4-22**], the patient was transferred to the medical service. . Pt's vancomycin was stopped after 14 days of treatment. HIV test was found to be negative. MRI head was obtained to further w/u patient's apparent cognitive decline. MRI showed prominent sulci and enlarged ventricles abnormal for the patient's age. Due to concerns for dementia, neurology consult was obtained. Neurology felt that the patient's cognitive symptoms were consistent w/ metabolic encephalopathy due to his multiple medical problems. They felt that his mental status would improve as his health improved. Underlying dementia was possible but difficult to assess with an overlying delerium. The patient continued to pull out his doboff tube. Pt had EGD performed to evaluate his poor nutritional status. He was found to have a large gastric ulcer and high dose PPI was started. The gastric biopsy and the serology were both negative for H. pylori. PEG placement was unsuccessful by GI due to the patient's anantomy. [**4-28**] the patient had a J tube placed in interventional radiology for nutritional support. He was re-started on tube feeds. [**4-29**] patient failed a repeat swallow evaluation due to discoordinated swallow. [**4-30**] the patient was taken for colonoscopy and found to have a normal colon to cecum. [**5-5**] the patient was found to be C diff positive and was started on 14 day course of Flagyl. On [**5-11**], as his mental status improved, he did well at the bed side swall evaluation. On [**5-12**], he underwent video swallow evaluation and was able to tolerate ground consistent food and thin liquids. His meds should be crushed and mixed with puree thick liquid. He has gained 30 lb since the tubefeed was initiated (70 lb to 100 lb) during this admission. He will still need to be on tubefeed to support his nutrition until he is cleared by a nutritionist. In terms of his mental status, he continued to improve steadily over the last few weeks of his hospital stay. He was more alert and engaged with activity. He did much better with PT and OT at the end after his mental status improved. As noted above, his mental status change was likely toxic-metabolic from acute infection. He started to develop more pain around the right stump since [**5-10**]. He was seen by the [**Month/Year (2) 1106**] surgery who felt that he is too medically sick and malnourished to have surgery at this time. He will follow up with Dr. [**Last Name (STitle) 3407**] as outpatient. Initially, his pain was controlled with titrating up the Oxycontin. However, it was titrated too quickly from 10 mg [**Hospital1 **] to 30 mg [**Hospital1 **]. He then developed urinary retention requiring foley placement. After he passed the video swallowing, he was tolerating ground consistent solids. On [**5-17**], he had an emesis x 1, and had aspiration pneumonia (+interstital markings on the left on CXR, fever, leukocytosis). His Flagyl course was extended, and Vanc/Levo were added. His sputum showed many GPC which later grew Staph aureus. Given his recent MRSA pneumonia, he will be treated with 2 week course of Vanc/Levo/Flagyl. He was seen by the pain service who recommended to discontinue Oxycontin, and start Neurontin, MSIR, and lidocaine patch in addition to the standing Tylenol. On [**5-18**], his J-tube was noted to be obstructed but was able to be flushed by IR on [**5-19**]. Tubefeed was resumed without any difficulty since. Since oxycontin was discontinued, the foley was removed on [**5-20**] and was able to void without any difficulty. Medications on Admission: Lopressor 50mg [**Hospital1 **] percocet nebulizer lipitor klonopin 0.5mg TID RISS heparin sc lasix 40mg TID prevacid milk of mag multivitamin papain zinc Discharge Medications: 1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-13**] Puffs Inhalation Q6H (every 6 hours) as needed. 2. Multivitamins Tablet, Chewable Sig: One (1) Cap PO DAILY (Daily). 3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 5. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Papain-Urea 830,000-10 unit-% Spray, Non-Aerosol Sig: One (1) Appl Topical DAILY (Daily). 8. Insulin Regular Human 100 unit/mL Solution Sig: Sliding scale Injection ASDIR (AS DIRECTED): See the sliding scale. 9. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 6 days: Last day [**2117-5-18**]. 15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 16. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for confusion. 17. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 18. Morphine Sulfate 15 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 19. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): Last day [**5-31**]. 20. Vancomycin HCl in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours): Last day [**5-31**]. 21. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 22. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QD (). 23. Morphine Sulfate 2 mg/mL Syringe Sig: [**12-13**] Injection Q12H (every 12 hours) as needed. 24. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary: 1)Gangrenous leg 2)Urinary tract infection 3)MRSA pneumonia 4)Failure to thrive and weight loss 5)Altered mental status 6)Gastric ulcer 7)C.diff colitis Secondary: 1)Coronary artery disease 2)Anemia 3)Congestive heart failure 4)Peripheral [**Location (un) 1106**] disease 5)Diabetes mellitus 6)Hypertension Discharge Condition: Hemodynamically stable, pt doing much better with physical therapy, passed video swallow evaluation tolerating po. Discharge Instructions: Patient needs to take all of the medications as directed. Patient needs to continue the tube feed nutrition until re-assessed by the nutrionist. He can also take oral food as directed below. He needs to seek medical attention if he develops fever, chills, nausea, vomiting, worsening pain, worsening wound, or any other concerning symptoms. Followup Instructions: Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3407**] ([**Telephone/Fax (1) 1241**]) on [**2117-6-1**] 10:45 Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY Where: [**Last Name (NamePattern4) **] SURGERY Date/Time:[**2117-6-1**] 10:45 Completed by:[**2117-5-20**]

[ "531.90", "V09.0", "783.21", "707.03", "V55.0", "482.41", "997.69", "263.9", "569.62", "041.3", "008.45", "E935.2", "783.7", "507.0", "349.82", "440.24", "428.0", "788.29", "599.0" ]

icd9cm

[ [ [] ] ]

[ "96.6", "38.93", "96.72", "99.04", "45.23", "86.28", "45.16", "46.32" ]

icd9pcs

[ [ [] ] ]

9728, 9800

1943, 7274

333, 339

10161, 10277

1491, 1920

10668, 11066

7479, 9705

9821, 10140

7300, 7456

10301, 10645

1253, 1472

275, 295

367, 1105

1127, 1238

8,436

139,998

27517

Discharge summary

report

Admission Date: [**2107-4-25**] Discharge Date: [**2107-4-28**] Date of Birth: [**2053-7-17**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: stroke Major Surgical or Invasive Procedure: min. inv. PFO closure/patch repair right fem. art. [**2107-4-25**] History of Present Illness: 53 yo caucasian female with CVA on [**2-24**] and now resolving aphasia. Multiple embolic foci were found with scanning. ASD/PFO/interatrial septal aneursym diagnosed by TTE/TEEs which showed EF 60-65%, trace AI, ASD with bidirectional flow. Cath revealed nl. cors. Referred for surgical repair to Dr. [**Last Name (STitle) 1290**].Pre-op US of right femoral bruit ruled out AV fistula or pseudoaneurym. Past Medical History: CVA [**2-17**] anemia asthma (secondary to cat allergy) nephrolithiasis Social History: office manager lives alone rare ETOH never used tobacco Family History: non-contributory Physical Exam: HR 64 128/63 RA sat 100% 5'4" 120# NAD skin/HEENT unremarkable neck supple, full ROM, no carotid bruits CTAB RRR S1 S2, no murmur or rub soft, NT, ND, + BS extrems warm and well-perfused with 2+ bil. fem/DP/PT/radials right femoral bruit present no varicosities neuro grossly intact Pertinent Results: [**2107-4-27**] 01:10AM BLOOD WBC-14.1* RBC-3.54* Hgb-9.3* Hct-27.6* MCV-78* MCH-26.3* MCHC-33.9 RDW-20.7* Plt Ct-250 [**2107-4-27**] 01:10AM BLOOD Plt Ct-250 [**2107-4-27**] 01:10AM BLOOD Glucose-108* UreaN-12 Creat-0.7 Na-142 K-4.3 Cl-106 HCO3-27 AnGap-13 [**2107-4-27**] 01:10AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.8 Brief Hospital Course: Admitted [**2107-4-25**] and underwent minimally invasive PFO closure and patch repair of her small right femoral artery post-cannulation. Transferred to the CSRU in stable condition on neosynephrine and propofol drips. Extubated successfully and off all drips on POD #1. Transferred to the floor to begin increasing her activity level. Chest tubes removed on POD #2 and beta blockade started. Neuro consulted about restarting coumadin postop, and they recommended aspirin only. She made excellent progress and was discharged to home with VNA services on POD #3. Medications on Admission: advair prn albuterol prn ASA 81 mg daily FeSO4 325 mg daily coumadin 5 mg daily (LD [**4-19**]) Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*0* 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Disp:*10 Tablet(s)* Refills:*0* 3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 5 days. Disp:*20 Capsule, Sustained Release(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 2 weeks. Disp:*28 Capsule(s)* Refills:*0* 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day): one puff IH [**Hospital1 **]. Disp:*2 Disk with Device(s)* Refills:*2* 10. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed. Disp:*2 MDI* Refills:*2* 11. Motrin 600 mg Tablet Sig: One (1) Tablet PO every 6-8 hours for 2 weeks. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital **] Hospice and VNA Discharge Diagnosis: s/p Min. inv. PFO closure/patch repair of right femoral artery CVA anemia asthma nephrolithiasis Discharge Condition: stable Discharge Instructions: may shower over incisions and pat dry no lotions, creams or powders on any incision no driving for 2 weeks Followup Instructions: follow up with Dr. [**First Name (STitle) 4640**] in [**11-15**] weeks follow up with Dr. [**Last Name (STitle) 32255**] in [**11-15**] weeks follow up with Dr. [**Last Name (STitle) 1290**] [**Telephone/Fax (1) 170**] Completed by:[**2107-5-16**]

[ "285.9", "V13.01", "745.5", "447.1", "V12.59", "493.90" ]

icd9cm

[ [ [] ] ]

[ "99.04", "35.71", "39.56", "39.61" ]

icd9pcs

[ [ [] ] ]

3930, 3992

1696, 2261

328, 398

4133, 4142

1356, 1673

4297, 4547

1016, 1034

2408, 3907

4013, 4112

2287, 2385

4166, 4274

1049, 1337

282, 290

426, 831

853, 927

943, 1000

75,114

170,450

42591

Discharge summary

report

Admission Date: [**2125-4-4**] Discharge Date: [**2125-4-14**] Date of Birth: [**2053-10-22**] Sex: F Service: CARDIOTHORACIC Allergies: Amoxicillin / Naproxen Attending:[**First Name3 (LF) 5790**] Chief Complaint: Right pleural effusion Major Surgical or Invasive Procedure: [**2125-4-4**] Right VATS total pulmonary decortication, parietal pleurectomy, flexible bronchoscopy. History of Present Illness: Patient is a very pleasant 71F with h/o MDS (stable) who presents with a recurrent right pleural effusion. Patient initially presented with nausea and without pulmonary complaints. CXR at that time revealed large right pleural effusion. Thoracentesis performed [**2125-3-15**] with 1200cc sanguinous fluid moved. Gram stain was negative. Cell analysis showed lymphocytes concerning for a malignant effusion. Cytology was ultimately negative by flow cytometry. Patient was referred to our clinic for VATS pleural bx, ?pleurodesis. Patient notes DOE over the past 2.5 weeks after 1 flight of stairs. She also has a dry cough. Otherwise she is in her usual state of health. She denies hemoptysis, chest pain, abdominal pain. Past Medical History: MDS, followed by Dr. [**Last Name (STitle) **], last BMB was in [**6-30**] with stable disease Osteoporosis Hyponatremia Abdominal pain, w/u as above, currently initiated PT appointments Social History: Lives at home with husband. Denies alcohol or tobacco use. Family History: N/C Pertinent Results: [**2125-4-14**] WBC-7.9 RBC-2.86* Hgb-8.3* Hct-25.3* Plt Ct-492* [**2125-4-12**] WBC-9.2 RBC-2.81* Hgb-8.2* Hct-24.7* Plt Ct-384 [**2125-4-5**] WBC-16.6* RBC-3.18* Hgb-10.1* Hct-27.4* Plt Ct-397 [**2125-4-4**] WBC-20.9*# RBC-3.15* Hgb-9.0* Hct-28.1* Plt Ct-393 [**2125-4-14**] Glucose-102 UreaN-12 Creat-0.5 Na-126* K-4.8 Cl-93* HCO3-25 [**2125-4-12**] Glucose-110* UreaN-13 Creat-0.5 Na-129* K-5.1 Cl-96 HCO3-29 [**2125-4-4**] Glucose-112* UreaN-21* Creat-0.6 Na-131* K-4.3 Cl-100 HCO3-17 [**2125-4-14**] Calcium-8.4 Phos-3.6 Mg-2.2 [**2125-4-4**] TISSU RIGHT SUPERIROR POSTERIOR PLEURAL BIOSPY. GRAM STAIN (Final [**2125-4-4**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [**2125-4-7**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2125-4-10**]): NO GROWTH. ACID FAST SMEAR (Final [**2125-4-5**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2125-4-5**]): NO FUNGAL ELEMENTS SEEN. [**2125-4-4**] TISSUE POSTERIOR PLEURAL BIOPSY RIGHT. GRAM STAIN (Final [**2125-4-4**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [**2125-4-7**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2125-4-10**]): NO GROWTH. ACID FAST SMEAR (Final [**2125-4-5**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Final [**2125-4-17**]): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2125-4-5**]): NO FUNGAL ELEMENTS SEEN. [**4-4**]/ PLEURAL FLUID RIGHT. GRAM STAIN (Final [**2125-4-4**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2125-4-7**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2125-4-10**]): NO GROWTH. ACID FAST CULTURE (Preliminary): ACID FAST SMEAR (Final [**2125-4-5**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2125-4-5**]): NO FUNGAL ELEMENTS SEEN. CXR: [**2125-4-13**] Since yesterday, right basilar chest tube was removed. One right chest tube is still in place, ending at the apex. Loculated right hydropneumothorax is unchanged. Aeration at the right base slightly improved. Tiny left pleural effusion is unchanged. Left linear atelectasis improved. The left lung is otherwise clear. The cardiomediastinal silhouette and hilar contours are unchanged. [**2125-4-12**] Persistent loculated right hydropneumothoraces with two chest tubes in place. [**2125-4-9**] FINDINGS: One of three right-sided chest tubes has been removed. Slight increase in number of multifocal loculated hydropneumothoraces in the right hemithorax, but overall similar amount of loculated pleural fluid and adjacent parenchymal opacification in the right lung except for slight improved aeration in the right upper lobe. Linear atelectasis is present at the left lung base as well as a questionable small left pleural effusion. Brief Hospital Course: Mrs. [**Known lastname 92146**] was admitted on [**2125-4-4**] for Right VATS total pulmonary decortication, parietal pleurectomy, flexible bronchoscopy. She transferred to the unit intubated and extubated the next day. She was transfused 2 units PRBC. Three chest tubes remained to suction with a persistent airleak. She was followed by serial chest films which confirmed Loculated right hydropneumothorax. Pulmonary toilet continued nebs, oxygen supplements and gentle diuresis. Once her respiratory status was stable she transferred to the floor. The chest tubes continued on suction then placed to water-seal. A persistent airleak remained. Two of the chest-tube were removed with a the 3rd placed to pneumostat. Her pain was well controlled. She tolerated a regular diet. Her labs were monitored and repleted. She was seen by physical therapy. Continued to do well and was discharged to home with VNA. She will follow-up with Dr. [**Last Name (STitle) **] as an outpatient. Medications on Admission: RISEDRONATE [ACTONEL] - 35 mg Tablet - one Tablet(s) by mouth weekly as directed Medications - OTC CALCIUM CARBONATE-VIT D3-MIN [CALTRATE 600+D PLUS MINERALS] - (OTC) - 600 mg (1,500 mg)-400 unit Tablet, Chewable - 1 Tablet(s) by mouth twice a day MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 2. Actonel 35 mg Tablet Sig: One (1) Tablet PO once weekly (). 3. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a day. 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*70 Tablet(s)* Refills:*0* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Outpatient Lab Work Chem 7 (sodium, potassium, chloride, bicarbonate, BUN, creatine, glucose) Please fax results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 3382**] Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Right fibrothorax Osteoporosis Hyponatremia Abdominal pain, w/u as above, currently initiated PT appointments h/o colon polyps, nl colonoscopy in [**2119**] hyperlipidemia squamous cell in situ removed from shoulder adnexal cysts chronic abdominal pain (likely MSK) Discharge Condition: stable Discharge Instructions: Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if experience: -Fever > 101 or chills -Increased shortness of breath, cough or sputum production -Incision develops drainage -Chest pain -Chest-tube bandage remove Saturday PM and cover with a bandaid -Pneumostat: change dressing daily. Empty daily Should Chest Tube fall out cover site immediately with a dressing and call the office [**Telephone/Fax (1) 2348**] or come to the Emergency Room for a Chest X-Ray. Followup Instructions: Please call the office of Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 1504**] and Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 17398**], to set up a follow up appointment with Dr. [**First Name (STitle) **] for Thursday, [**4-19**]. This will be on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**]. Report to the [**Location (un) 861**] Radiology Department for a Chest X-Ray 45 minutes before your appointment. Follow-up with Dr. [**Last Name (STitle) **] your PCP [**Telephone/Fax (1) 250**] Completed by:[**2125-4-23**]

[ "276.1", "512.1", "733.00", "511.89", "272.4", "998.11", "E878.8", "276.3", "238.75", "458.29", "511.0", "V10.83", "789.09", "V12.72" ]

icd9cm

[ [ [] ] ]

[ "33.22", "34.20", "34.52", "96.71", "34.04" ]

icd9pcs

[ [ [] ] ]

6933, 6991

4728, 5716

313, 417

7301, 7310

1507, 2444

7837, 8430

1483, 1488

6071, 6910

7012, 7280

5742, 6048

7334, 7814

3512, 3604

3637, 4705

250, 275

445, 1179

1201, 1390

1406, 1467

68,533

149,460

46990

Discharge summary

report

Admission Date: [**2193-10-4**] Discharge Date: [**2193-10-10**] Service: MEDICINE Allergies: Lipitor Attending:[**Doctor First Name 2080**] Chief Complaint: Mechanical fall Major Surgical or Invasive Procedure: Central line placement History of Present Illness: Ms. [**Known lastname 656**] is an 89yo female with PMH notable for HTN, HL, prior upper GI bleed, colonic polyps and diverticulosis who presents after being found down at home by EMS. [**Name (NI) **] cousin became concerned when she hadn't been able to reach patient for several days; called EMS who found patient down on her kitchen floor covered in feces. Per report, she was cold, shivering, but AAOx3, denying any CP or SOB. She had a vague recollection of being awake that morning, but could not recall eating lunch. Exact timing of fall unclear. EMS did not find any pill bottles at the home. Was brought to ED for further evaluation. . In ED, patient was hypothermic with temp 34.6, tachy to 110s, and BP was 80/p. She was AAOx3. Neuro exam was non-focal. Had melena on exam but good rectal tone. Also noted to have necrotic appearing sacral ulcer. Labs notable for WBC 8.8 but with 92% neutrophils and 2 bands, CK 1217, K 5.5, Cr 2.3 (from baseline 0.8). Patient had a anion gap of 24. UA likely contaminated given 8 epis. CT head and C-spine were negative, and CXR not suggestive of pulmonary edema or consolidation. ECG did not show peaked T waves or changes concerning for ischemia. The patient received 3L fluid, and was rewarmed with warm IVF and bear hugger. She refused NGT placement. . On arrival to the MICU, patient AAOx3. Denied any CP or SOB. During interview, SBP dropped to 60s, and patient was noted to have pulsatile abdominal mass on exam. Stat abdominal ultrasound ordered and did not show e/o AAA. Vascular surgery consulted, and recommended urgent CTA abdomen. Patient got additional 1L NS, and urgent R IJ CVL placed. Also started levophed for persistent hypotension. . Of note, patient had an admission to [**Hospital1 18**] in [**2188**] after an unwitnessed fall at home. During that admission she was treated for [**Last Name (un) **] presumed secondary to rhabdomyolysis, and during a work-up for anemia was found to be guiac positive and underwent an EGD demonstrating erosive gastritis, duodenal ulcers, duodenitis. Was treated with PPI. H. pylori testing was negative at time. Past Medical History: HTN (not on medication) HL (not on statin s/p prior episode of rhabdomyolysis) Colonic polyps Diverticulosis Osteoporosis h/o upper GI bleed (erosive gastritis, duodenal ulcers, duodenitis; H. pylori antigen negative [**2188**]) Microscopic hematuria (s/p negative cystoscopy [**2189**], has left upper pole renal cyst on ultrasonography) s/p mechanical [**2189**] with facial hematoma and small CNS bleed OA Social History: Lives alone in an apartment. She's had a number of different careers to include dietician, teacher and guidance counselor and accountant. She denies any smoking, alcohol or illicit drug history. Family History: Noncontributory Physical Exam: ADMISSION EXAM Vitals: T: 96.8 BP: 86/34 P: 89 R: 18 O2: 94% RA General: AAOx3 initially, shivering, more lethargic as pressures dropped HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley draining yellow urine Ext: warm, well perfused, 2+ pulses, no edema Skin: 2 unstage-able ulcers-> ~4cm diameter sacral ulcer and ~2cm diameter R scapular ulcer; multiple non-pruritic linear erythematous lesion on abdomen DISCHARGE EXAM 96.5, 118/54, 85, 18, 95% RA Gen: AOx3, but fogetful HEENT: dry MM CV: soft systolic murmur at RUSB, RRR, normal S1, S2 Lungs: CTAB, no wheezes, no crackles Ext: 1+ pitting edema bilaterally, RUE still edematous, weakness due to edema, intact pulses Neuro: nonfocal Pertinent Results: ADMISSION LABS [**2193-10-4**] 12:00AM BLOOD WBC-8.8# RBC-4.00* Hgb-12.3 Hct-38.8 MCV-97# MCH-30.8 MCHC-31.8 RDW-13.9 Plt Ct-100* [**2193-10-4**] 12:00AM BLOOD Neuts-92* Bands-2 Lymphs-2* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2193-10-4**] 12:00AM BLOOD PT-13.3 PTT-25.4 INR(PT)-1.1 [**2193-10-4**] 12:00AM BLOOD Glucose-265* UreaN-95* Creat-2.3*# Na-143 K-5.5* Cl-102 HCO3-17* AnGap-30* [**2193-10-4**] 12:00AM BLOOD ALT-44* AST-66* CK(CPK)-1217* AlkPhos-71 TotBili-0.8 [**2193-10-4**] 12:00AM BLOOD Calcium-8.0* Phos-7.0*# Mg-2.7* [**2193-10-4**] 06:45AM BLOOD Type-ART pO2-114* pCO2-35 pH-7.35 calTCO2-20* Base XS--5 . DISCHARGE LABS . [**2193-10-10**] 05:55AM BLOOD WBC-7.6 RBC-2.95* Hgb-9.3* Hct-28.0* MCV-95 MCH-31.6 MCHC-33.4 RDW-14.4 Plt Ct-73* [**2193-10-10**] 05:55AM BLOOD Glucose-89 UreaN-11 Creat-0.8 Na-142 K-4.0 Cl-111* HCO3-27 AnGap-8 [**2193-10-9**] 06:00AM BLOOD ALT-21 AST-18 AlkPhos-49 TotBili-0.4 [**2193-10-10**] 05:55AM BLOOD Calcium-8.1* Phos-3.3 Mg-2.1 PERTINENT STUDIES ECHO [**10-4**] Conclusions The left atrium is normal in size. 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. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is a very mild resting left ventricular outflow tract obstruction. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . US [**10-4**] There are moderate atherosclerotic calcifications of the abdominal aorta but no evidence of abdominal aortic aneurysm formation. The abdominal aorta measures about 1.4 cm at its mid section. The aortic bifurcation is normal. IMPRESSION: No evidence of abdominal aortic aneurysm. . CT ABD/PELVIS (no contrast) [**10-5**] IMPRESSION: 1. Anasarca. 2. Bibasilar atelectasis and pleural effusions. 3. Left kidney cyst, no evidence of hydronephrosis. 4. Extensive diverticulosis without diverticulitis. 5. No evidence of aortic aneurysm. . Xray Right Shoulder/elbow [**10-6**] RIGHT ELBOW: There is no evidence of fracture, dislocation, or soft tissue abnormality. RIGHT SHOULDER: A lateral view was not obtained. There is deformity of the humeral head with large medial spurs and narrowing of the glenohumeral joint. There are cystic changes within the humeral head suggesting old trauma with superimposed degenerative change. No acute fracture is demonstrated. There are no findings suggestive of dislocation; however, if this is suspected clinically, additional views would be indicated. . RUE US [**10-9**]: Superficial thrombus in the right cephalic vein. No right upper extremity DVT. Brief Hospital Course: 89yo female with PMH of HTN, HL, prior upper GI bleed, and diverticulosis presents now s/p unwitnessed fall at home brought in by ambulance after a call by a family member concern about her safety and found to have hypothermia, bandemia, [**Last Name (un) **], elevated CK, and hypoglycemia. . #. Hypotension: The patient presented in the ED with profound hypovolemia after being found down for an unclear period of time, but was normotensive. The patient was hypothermic and exhibited a left shift (2% band and 92% polys) in the ED. Blood cultures were obtained, but were negative. A UA revealed 32 hyaline casts, but also many epithelial cells. A urine culture obtained in the ED grew skin flora. A repeat cath UA (obtained in the MICU) revealed WBC-11, a few bacteria, but urine cultures were unable to be obtained because the lab did not receive sufficient quantity of urine. Her subsequent urine cultures have been negative. . The patient was volume resuscitated with 6L of NS in the ED. On arrive to the ICU, the patient became hypotensive to the 60/30's. An additional 1L bolus was given, a R triple lumen CVL was placed, norepinephrine gtt was started to maintain MAP>60. Empiric antibiotics were started - vancomycin and zosyn with renal dosing. The patient had multiple sources of infection including a UTI vs. translocation of skin flora from 2 large unstagable ulcers located on her sacrum and on her L scapula, however, we had no positive cultures. The vancomycin and zosyn were doscontinued when the patient was transfered to the floor. She remained afebrile, with a normal WBC count, and non signs or symptoms of infection. . An a-line was placed for continued BP monitoring. The patient remained on norepiphrine gtt from [**10-4**] through [**10-8**]. An Echo was also obtained on [**10-4**] which reveal a hyperdynamic left ventricular systolic function with an EF at 75%, making cardiogenic shock very unlikely. Before being transferred to the floor, the A-line was removed. While on the floor, the patient was normotensive without any episodes of hypotension. . # [**Last Name (un) **] from hypovolemia. The patient presented with a Cr 2.3 which down-trended to her baseline of around 0.8 after 7L of NS. Etiology likely [**1-30**] prerenal ischemia especially given significant improvement with IVF. Despite initial CK elevation to the 1200's, no evidence of rhabdomyolysis based on sedmient which would have contributed to renal dysfunction. Based on her initial BUN of 95, the patient has likely being hypovolemia and in renal failure for multiple days prior to her presentation. All medication were renally dosed. Her Cr remained stable on the floor. . # GIB- There was initial concern for GIB given a pos guiaic in the ED and in the mICU and HCT drop from 38 to 31 over 8 hours. This HCT drop was in the setting of 6L of fluid resuscitation. The HCT remained stable, but below her prior baseline of around 38-40. There was also a concern for AAA given a abdominal palpable mass, HCT drop and hypotension. A CTA and ultrasound of the Abdominal Aorta was negative for a AAA. The patient had no episodes of bleeding while on the floor. Her Hct remained low, but stable. Iron studies were consistent with an inflammatory anemia, negative for hemolysis, and an appropriate reticulocyte count. . #. Fall- The patient has had 2 prior falls- in [**2188**] and [**2190**]. The cause of those falls were deemed to be mechanical. The etiology of this 'fall' was unclear given the patient was found down without a clear memory of the 'fall'. She had fecal material on her clothing. A CT head and C-spine in the ED was negative. She developed pain in her right arm, but did not recall if she fell on to it. X-rays were negative for fractures. Social work and case management was involved to evaluate better options for her home situation. The patient will be discharged to rehab. . # Superficial RUE clot: The patient had unilateral right upper extremity swelling. Xrays of the arm were negative. An UE US showed a superficial cephalic clot. This was treated with elevation and compresses. . # Unstageable ulcers: The patient has skin breakdown on her back and sacrum, likely from immobilization. Wound care was consulted and performed dressing changes. The patient will continue dressing changes at rehab. . # Fungal groin infection: The patient has probable dermatophytic infection of intertriginous groin area. The patient will continue Micaconazole powder to area three times a day. . TRANSITIONAL ISSUES: The patient's platelet count was 100K on admission and this trended down slightly. We attributed this to a possible medication effect and think that this should improve after discharge. We have ordered a CBC to be ordered on [**10-12**] at rehab and then another CBC should be drawn at her first PCP [**Name Initial (PRE) 648**]. These results will be followed up by her PCP. Medications on Admission: MVI Vitamin D Discharge Medications: 1. Vitamin D Oral 2. M-Vit Oral 3. naproxen 500 mg Tablet Sig: One (1) Tablet PO twice a day as needed for pain. 4. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for groin rash. 5. Outpatient Lab Work Please draw a CBC on [**10-12**] and have results faxed to the patient's PCP at Fax: [**Telephone/Fax (1) 4004**]. Discharge Disposition: Extended Care Facility: [**Hospital3 537**]- [**Location (un) 538**] Discharge Diagnosis: Mechanical Fall at home Acute Kidney Injury secondary to dehydration Lower GI bleed of unknown source 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 a fall at home. While it is unclear what caused your fall, we do not think that you had a seizure or heart attack, or irregular heart rhythm. You were brought to the hospital and initially treated in the ICU for a low blood pressure and minor GI bleed. You were stabilized in the ICU and then transfered to the floor for further management. On the floor, you did not have any bleeding. Your BP was stable and we took you off of antibiotics. Physical therapy evaluated you and recommended that you go to rehab before going home. . There are no medication changes to note. Followup Instructions: Department: [**Hospital3 249**] When: THURSDAY [**2193-10-17**] at 11:10 AM With: DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]/[**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] South [**Hospital **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage **This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor in follow up.**

[ "V15.88", "287.5", "276.1", "251.2", "707.03", "275.3", "562.10", "728.88", "272.4", "578.1", "285.1", "785.52", "V12.72", "453.81", "276.7", "707.02", "079.99", "715.90", "707.22", "995.92", "401.9", "733.00", "584.5", "V85.0", "038.9" ]

icd9cm

[ [ [] ] ]

[ "38.91", "38.97" ]

icd9pcs

[ [ [] ] ]

12662, 12733

7298, 11817

233, 258

12879, 12879

4094, 7275

13699, 14328

3087, 3104

12279, 12639

12754, 12858

12241, 12256

13064, 13676

3119, 4075

11838, 12215

178, 195

286, 2426

12894, 13040

2448, 2859

2875, 3071

4,104

199,806

55791

Discharge summary

addendum

Name: [**Known lastname 4439**], [**Known firstname 4440**] M Unit No: [**Numeric Identifier 4441**] Admission Date: [**2156-8-25**] Discharge Date: Date of Birth: [**2111-11-29**] Sex: F Service: ADDENDUM: The patient is a 44 year old female who was admitted to the Medical Intensive Care Unit for monitoring and intubation for airway protection in the setting of unresponsiveness. After an extensive workup, it was still unclear as to what the inciting event was leading to the obtundation. The patient's acid base status on admission suggested a primarily respiratory alkalosis with concurrent metabolic acidosis of unclear etiology. A possible contributing factor could have been diabetic ketoacidosis as the patient's blood sugar was elevated to the 300s on admission, with acetone and ketones in the serum. A toxicology panel was negative. The patient was then transferred to the medicine service after she became stable. On admission to the medicine service, the patient was stable off antibiotics, afebrile, with her mental status at baseline. A chest x-ray showed a resolved infiltrate. Given the patient's history, she was deemed to be at risk for aspiration pneumonitis, while an ongoing aspiration pneumonia or community acquired pneumonia were doubtful. The plan on discharge to the floor from the Medical Intensive Care Unit was to hold off on antibiotics and to aggressively manage the patient's blood sugars, which were much improved since admission to the Unit. The plan was also to monitor the patient closely for any evidence of infection and to encourage activity and physical therapy. 1. Diabetes mellitus: On admission to the floor, the patient was on a regular insulin sliding scale. As the patient's morning sugars were noted to be elevated, she was started on NPH 4 units subcutaneously in the evening. Subsequently, the patient's morning blood sugars were still noted to be elevated, in the high 100s, however, the patient's overall glucose control appeared to be much better. The morning NPH was increased to 14 units from 10 units on admission to the floor and evening NPH was increased to 10 units. On discharge, the patient's insulin regimen consisted of a regular insulin sliding scale in addition to 14 units NPH in the morning and 4 units of NPH in the evening. 2. Cardiovascular: The patient was noted to have persistently elevated blood pressure upon transfer to the floor. The patient's Lopressor was increased from 25 mg twice a day to 50 mg twice a day to 75 mg twice a day, with continued inadequate blood pressure control, with systolic blood pressures in the 160s to 180s range. On discharge, the patient was given a prescription for Lopressor 100 mg twice a day for adequate blood pressure control. 3. Gastrointestinal: On admission to the floor, the patient was seen to have fecal incontinence, with soft formed stools. The patient was noted to defecate in her gown with lack of awareness of the event. Gastroenterology consulted the patient and suggested that this phenomenon may be secondary to a proximal area of compaction with leakage of stool around that area. The patient was placed on Peri-Colace. Stool studies were done which showed no polymorphonuclear leukocytes in stool, with Clostridium difficile toxin pending. A fecal culture was not performed, as the patient had been in the hospital for more than three days. On the day of discharge, the patient was noted to have normal bowel movements, with awareness of her bowel movements. 4. Respiratory: The patient was noted to have an improving cough, with decreased sputum production. The patient was instructed report to her primary care physician for increasing cough, sputum production, fevers or chills on discharge. DISCHARGE MEDICATIONS: Lopressor 100 mg p.o.b.i.d. NPH 14 units s.c.q.a.m. and 10 units s.c.q.p.m. Regular insulin sliding scale. Nephrocaps. Zoloft 100 mg p.o.q.d. Protonix 40 mg p.o.q.d. Pravachol 10 mg p.o.q.d. Lasix 40 mg p.o.b.i.d. CONDITION AT DISCHARGE: Stable. DISCHARGE STATUS: The patient was discharged to home. DISCHARGE DIAGNOSIS: Obtundation with acid base disturbance of unclear etiology. DR.[**Last Name (STitle) **],[**First Name8 (NamePattern2) **] [**Doctor First Name 2**] 12-875 Dictated By:[**Name8 (MD) 1212**] MEDQUIST36 D: [**2156-9-6**] 21:46 T: [**2156-9-9**] 10:42 JOB#: [**Job Number 4442**]

[ "414.00", "412", "585", "250.11", "996.81", "276.3", "276.2", "401.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

3816, 4041

4142, 4457

4056, 4121

9,981

148,945

30283

Discharge summary

report

Admission Date: [**2130-3-24**] Discharge Date: [**2130-4-26**] Date of Birth: [**2073-11-7**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: decreased speech output, impaired comprehension, lethargy Major Surgical or Invasive Procedure: External ventricular drain (now Internalized to VPS) PICC line placement by interventional radiology [**2130-4-26**] Tracheostomy [**4-10**] PEG placement [**4-10**] VPS placement [**4-10**] PICA aneurysm coiling [**2130-3-29**] History of Present Illness: 56 year old woman recently discharged from [**Hospital1 18**] after treatment for endocarditis and possible brain abscess. She was re-admitted on [**3-24**] with fever and altered mental status. On [**2-21**], one week after a vomiting/diarrheal illness, she developed a mainly expressive aphasia and was found to have a subacute infarction in the left parietal lobe. Initial general examination was notable for fever (104.6) and new systolic and diastolic murmurs; elevated WBC (15.4) also present. Echocardiogram showed severe aortic stenosis and aortic insufficiency. Subsequent MRIs showed not only the left parietal lesion visualized on CT, but also an evolving left frontal lesion. Workup included evaluation by Neuro-Oncology (question of glioma raised) and brain biopsy, which showed reactive cells, no evidence of malignant process, and negative gram stain/culture. Although the cultures were negative, the ring-enhancing lesions were thought to be most consistent with brain abscesses related to septic emboli. She was discharged to [**Hospital 38**] rehab on [**2130-3-11**]. She was treated with Vancomycin, Ceftriaxone, Gentamicin, and Flagyl for presumed polymicrobial endocarditis (6 weeks of therapy planned). She developed acute renal failure on [**3-15**], thus the Gentamicin was discontinued and the Vancomycin dose was decreased. Over the past few days prior to admission, she has had fever, hypertension, headache, NBNB emesis, and decreased appetite. On the day of admission, her speech output decreased, her comprehension appeared to be more impaired, and she was more somnolent. Past Medical History: Endocarditis, septic emboli as above Heart murmur as a child Did not see physician [**Name Initial (PRE) **] 20 years Social History: Social history is significant for smoking 1 ppd. denies any alcohol use or IV drug use. Lives with her husband at home who also smokes. Family History: Father died at 76 and mother who died of alzheimer's in her 80s. One sister who is healthy in her 40s. Physical Exam: On initial neurology consult [**3-25**]: VS: T 99.3 HR 80 BP 120/66 RR 12 Sat 100% on AC 40%FIO2, TV 600, rate 10, PEEP 5 GEN intubated, sedated w/Propofol (20) HEENT EVD in place Chest CTAB CVS RRR, harsh systolic and diastolic murmurs ABD soft, NT, ND, +BS EXT no c/c/e, distal pulses strong, no rash NEURO Mental status - sedated with Propofol as above, but somewhat agitated, requiring two point soft restraints. Opens eyes to loud voice, squeezes hands on command, but shakes head no and does not follow other commands. Cranial nerves - II,III--pupils asymmetric (baseline) L 5 to 3, R 3 to 2, blinks to threat bilaterally; III,IV,VI-full horizontal eye movements, no ptosis appreciated; V, VII--+corneals bilaterally, difficult to assess facial asymmetry d/t EVD, ETT; IX,X--weak gag Motor - moves arms and legs antigravity, more spontaneous movement on the left compared to the right, normal bulk and tone, no tremor or other involuntary movement observed Coordination - difficult to assess, but no gross ataxia when reaching to pull out lines/tubes Reflexes - brisk throughout with crossed adductors. toes mute bilaterally (question of left upgoing toe) |[**Hospital1 **] |tri |bra |pat |[**Doctor First Name **] | toe | L | 2 | 2 | 2 | 3 | 2 | mute | R | 2 | 2 | 2 | 3 | 2 | mute | Sensation - withdraws to noxious stimuli x 4 extremities Pertinent Results: Laboratory values on admission: CBC 15.9>27.3<334 Na 136 K 3.7 Cl 101 CO2 20 BUN 17 Cr 2.7 glu 140 Ca 9.0 Mg 1.4 Ph 3.3 CRP 9.3 ESR 73 PT 13.9 PTT 27.0 INR 1.2 Serum toxicology screen negative Micro: Blood culture [**2-21**] - coag negative staph, micrococcus Blood culture [**2-28**] - S.viridans, coag negative staph, micrococcus BLOOD CULTURES NEGATIVE [**3-24**] x2, [**3-25**] x2, [**3-27**] x2, [**3-28**], [**3-29**], [**3-30**] x3, [**4-2**] x2 BLOOD CULTURES coag neg staph x 1 - [**4-7**]; NGTD [**4-8**] BLOOD FUNGAL CULTURES NGTD [**4-3**] URINE CULTURES - YEAST on [**3-16**], [**3-30**], [**4-2**], [**4-8**] SPUTUM CULTURES - YEAST on [**4-10**] CSF CULTURES - NEGATIVE [**3-25**], [**3-28**], [**3-30**], [**3-31**], [**4-7**] CSF CULTURES - YEAST [**4-9**] CSF FUNGAL CULTURES - NGTD [**3-28**] STOOL C DIFF - NEGATIVE [**4-4**], [**4-6**], [**4-9**] CSF cryptococcus [**3-28**] - negative RPR - negative Pending cultures: CSF [**4-11**], catheter tip [**4-10**] Imaging: Please see OMR records for reports of prior MRIs and head CTs. Head CT [**3-24**] - 1. Interval development of moderate-to-severe hydrocephalus w/dilatation of the lateral, 3rd & 4th ventricles. 2. Interval development of hemorrhage within the suprasellar and basilar cisterns, cisterna magna, & surrounding proximal cord. Brain MRI [**3-25**] - 1. Signal changes at the basal cisterns suggestive of blood as seen on the previous CT. 2. Moderate hydrocephalus with mild periventricular edema. 3. Signal changes in the left parietal lobe and frontal lobe with a focus of slow diffusion in the left subcortical white matter indicative of a tiny suspected abscess. 4. Slow diffusion in the posterior fossa most likely due to blood products. 5. Slow diffusion in left sylvian fissure due to blood or high protein material. MRA head/neck [**3-25**] - Diminished flow signal in the L MCA branches with a small area of narrowing in the proximal portion of the anterior division of R MCA. These findings could be secondary to surrounding inflammatory changes in the sylvian fissure, more pronounced since the previous MRA of [**2130-2-21**]. Neck MRA limited by motion artifact. The flow signal gap at the right carotid bifurcation could be due to artifacts from motion or due to stenosis. MRI c-spine [**3-26**] - 1. Posterior fossa subdural hematoma extending between down the level of C2-3, posteriorly. 2. No evidence of cord compression or intrinsic cord signal abnormalities. 3. Lacunar infarcts in the right cerebellar hemisphere as above. Angio [**3-28**] - 1. 4.7-mm broad-based superiorly directed aneurysm at the origin of the right PICA. 2. Mild ectasia in the cavernous portion of the right ICA. 3. Shallow broad-based aneurysms/ectasia in the cavernous portion of the left ICA. Angio [**3-29**] - 1. Three millimeter right vertebral artery V4 segment aneurysm, with associated narrowing of the distal V4 segment extending to the vertebrobasilar junction, suggestive of a dissection. Following GDC embolization, the dome of the aneurysm was well secured. Small residual filling at the aneurysmal neck was seen. The parent vessel was preserved. 2. Moderate narrowing of the distal left vertebral artery V4 segment extending to the vertebrobasilar junction, moderate vasospasm of the bilateral proximal superior cerebellar arteries and bilateral P1 segments, and mild narrowing of the basilar artery. 3. Narrowing and vessel wall irregularities of the left MCA superior division M2 segment. 4. Two to three millimeter laterally and inferiorly projecting aneurysm at the anterior genu of the right ICA cavernous segment. 5. Bilateral AICA-PICA complex. Angio [**3-31**] - 1. Moderate spasm of bilateral posterior cerebral arteries, for which 5 mg of verapamil was given on each side. 2. Spasm of bilateral A1 segments and left M2 segment, for which 5 mg of verapamil was given on the left. 3. No apparent filling of the recently coiled aneurysm at the origin of the right PICA. The images were, however, degraded by motion artifact. MRI/A [**3-31**] - Interval evolution of acute right PICA infarction. New tiny foci of ischemia in the left parietal lobe could represent tiny areas of watershed infarction. Stable focus of restricted diffusion in the left frontal lobe, which corresponds to a suspected abscess in this location. Diffuse subarachnoid hemorrhage, intraventricular hemorrhage, and left parietotemporal intraparenchymal hemorrhage, likely an evolving hemorhhagic infarction. There is diffuse leptomeningeal enhancement which could be related to shunting but superimposed infection is not entirely excluded. On MRA note is made of vasospasm in bilateral vertebral arteries, basilar artery,bilateral PCA's and possibly the left superior M2 Angio [**4-2**] - 1. Minimal improvement noted in the previously noted vasospasm in the posterior cerebral arteries bilaterally. 2. Residual spasm is noted in the distal vertebral arteries bilaterally. Five milligrams of Verapamil was given into each vertebral artery. 3. Residual spasm is noted in the distal A2 and M2 segments of the left internal carotid artery which appears to be not significantly changed since the prior examination. Five milligrams of Verapamil was also given into the distal left internal carotid artery. Angio [**4-4**] - Injection of the left vertebral artery demonstrates moderate residual vasospasm in the distal left vertebral artery with minimal interval improvement from the prior study. 5 mg of verapamil was injected for treatment. In addition, it is noted that the anterior spinal artery arises from the left vertebral artery in this region of spasm. Injection of the right vertebral artery demonstrates minimal residual vasospasm which is minimally improved from the prior study. 5 mg of verapamil was injected for treatment. Injection of the left internal carotid artery demonstrates minimal spasm involving the left A2 and M2 segments. 5 mg of verapamil was infused for treatment. Injection of the right internal carotid artery demonstrates no significant vasospasm. CTA [**4-7**] - Mild improvement in left distal vertebral artery and M2 vasospasm, otherwise no significant change from prior angiogram accounting for differences in technique. HCT [**4-11**] - Status post repositioning of right frontal ventriculostomy catheter with the tip now terminating in the frontal [**Doctor Last Name 534**] of the right lateral ventricle. There is no change in the size and configuration of the lateral ventricles. Unchanged amounts of intraventricular blood present. EEG [**3-27**] - This is an abnormal routine EEG due to the slow and disorganized background and bursts of generalized slowing, suggestive of mild encephalopathy. CT torso [**4-1**] - 1. Bilateral large pleural effusions that have increased in the interval, with consolidation and atelectasis of both lower lung lobes. 2. New periportal edema. 3. Splenic infarct that has increased in interval. ECHO [**4-3**] - The left atrium is dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed with mid septal hypokinesis (LVEF 50%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. There is moderate to severe aortic valve stenosis. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is a trivial/physiologic pericardial effusion. Suboptimal image quality - patient unable to cooperate. No vegetation seen (cannot exclude). Compared with the prior study (images reviewed) of [**2130-2-23**], the mid septum now appears more hypokinetic. [**4-6**] - LUE u/s - No deep vein thrombosis. Brief Hospital Course: 56yo woman with recent admission for endocarditis and septic emboli who represents with lethargy, found to have hydrocephalus and right cerebellar infarct secondary to posterior subdural hemorrhage and right PICA aneurysm. Hospital course is reviewed below by system. 1. Neurology: On arrival, Mrs. [**Known lastname 9381**] had placement of an extraventricular drain by neurosurgery. She then had an MRI showing a posterior fossa subdural hemorrhage extending down to C2-3 posteriorly, as well as lacunar cerebellar infarcts. Angiography showed a right PICA aneurysm. On [**3-29**], this was coiled and she was admitted to the ICU for post-operative HHH therapy, with goal SBP>160 and Hct<30. She went for repeat angiography on [**4-11**], and [**4-4**]. This showed bilateral vertebral artery vasospasm, as well as left A2/M2 vasospasm. She was given intraarterial verapamil during each angiogram. She was also started on nimodipine. The HHH therapy and nimodipine were limited beginning on [**4-7**] due to cardiac issues (see below). The EVD was internalized on [**4-10**]. During this time, Mrs. [**Known lastname 9381**] became less responsive. She was initially mouthing words and following commands intermittently, but then stopped responding entirely other than opening her eyes to name and withdrawing to noxious stimuli. EEG was performed for concern of subclinical seizures, and just showed slow and disorganized background and bursts of generalized slowing, consistent with encephalopathy. She was treated with keppra 1000mg IV q12hrs empirically. 2. ID: She remained persistently febrile through her hospitalization. Differential diagnosis included central fever from the hemorrhage, inflammatory disease, drug fever, and infectious etiology. Given the history of endocarditis, she was treated with vancomycin (both intravenously and, for 10 days, intrathecally) and meropenem IV. Multiple blood, urine, and sputum cultures only grew out "yeast", not speciated. Given that no other source was identified, she was treated with a seven day course of caspofungin. After this was completed, she grew out yeast in her CSF (thought by the ID service to be a contaminant) and so she was briefly treated again with caspofungin. This was discontinued [**4-13**]. Of note, TTEs showed aortic valve disease, significant enough that the TEE fellow felt valve vegetations would not be able to be ruled out even with a TEE. CT torso showed a splenic infarct, thought to be secondary to septic emboli. The ID service did not feel that a bone scan would be beneficial. Notably, rheumatology was consulted for other reasons for fever and question of vasculitis. They felt an infectious etiology was more likely. She had a very weakly positive [**Doctor First Name **] and negative ANCA. On [**4-13**], antibiotic coverage was narrowed to just vancomycin. On [**4-20**] the patient became hyypothermic/hypoglycaemic/hypotensive-suspected sepsis>Cultures resent, she was transferred to SICU for closer observation. Her PICC line was removed and sent for culture which showed no growth.A CVL placed. She was fluid resuscitated and restarted meropenem. On [**4-21**] txf to step-down slight elev LFTs, [**Month (only) **] Albumin; Na146; Her meropenum was stopped on [**4-26**] as the final cultures were negative. She will have weekly CBC/ ESR and vanco trough drawn and fax'd to ID office. She had a new PICC placed on [**4-26**]. MRI brain should be repeated in 3 weeks. 3. CV: Mrs. [**Known lastname 9381**] initially needed to be on pressors to maintain SBP>160 for HHH therapy. She was started on levophed, but this caused runs of ventricular tachycardia, so she was changed to neosynephrine and vasopressin. The nimodipine brought down her BP significantly. The HHH therapy caused pulmonary edema due to hypervolemia. Cardiology was consulted due to her difficult situation. They recommended diuresis: she was treated with lasix prn and eventually lasix gtt. On [**4-9**], she went into atrial fibrillation with rapid ventricular rhythm and was started on an amiodarone gtt. This caused conversion to NSR. 4. Hematology: She was initially maintained with Hct<30 for the HHH therapy, eventually requiring a blood transfusion to maintain intravascular volume. 5. Renal: She arrived in renal failure, but after HHH therapy and acetylcysteine, her creatinine improved to 1.1. 6. Nutrition: Tube feeds until placement of PEG on [**2130-4-17**]. Tolerating feeds at goal. 7. PPX: H2B, insulin sliding scale, heparin SQ 8. Commun: Husband [**Telephone/Fax (1) 72091**] Medications on Admission: Keppra thiamine, folate Ceftriaxone 2 Gram q 12 hours to stop on [**2130-4-11**] vanco 750mg q 12 to stop on [**2130-3-30**] flagyl 500 TID to stop on [**2130-4-13**] zocor heparin sq (gentamycin held per son for renal failure) Discharge Medications: 1. Outpatient Lab Work every monday - please draw CBC+diff/ESR/ CRP/LFTs/lytes/ Vanco trough and fax results to ID office Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) **] 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain or fever. 5. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. Vancomycin 500 mg Recon Soln Sig: 1.5 Recon Solns Intravenous Q 24H (Every 24 Hours): Titrate to vanco level<20 should continue until [**2130-5-15**]. 11. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 12. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 13. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours): This can be d/c'd once final bc are negative . Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 38**] Discharge Diagnosis: Brain abcess PICA aneurysm rupture Hypoglycemia CHF / hypervolemia anemia aortic and mitral valve regurgiation CVA enocarditis afib Discharge Condition: neurologically stable and improved Discharge Instructions: ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5866**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2130-5-12**] 11:00 Have weekly cbc w/ diff, cr, vanco trough, esr, crp fax results to 2-0779 attention [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) **] You will need an MRI on [**2130-5-12**] with and without gadolidium / this is ordered Follow up with Dr. [**Last Name (STitle) **] in 4 weeks at [**Telephone/Fax (1) **] Completed by:[**2130-4-26**]

[ "396.8", "430", "438.11", "401.9", "421.9", "518.81", "584.9", "E932.3", "331.4", "251.1", "322.9", "427.31", "398.91", "444.89", "324.0" ]

icd9cm

[ [ [] ] ]

[ "43.11", "31.1", "03.90", "39.72", "02.31", "99.04", "38.93", "96.71", "96.6", "02.2", "88.41", "54.95", "96.04" ]

icd9pcs

[ [ [] ] ]

18392, 18473

12139, 16715

377, 608

18649, 18686

4121, 4139

19714, 20220

2555, 2659

16994, 18369

18494, 18628

16741, 16971

18710, 19691

2674, 4102

280, 339

636, 2244

4153, 12116

2266, 2385

2401, 2539

30,883

112,744

27219+57531

Discharge summary

report+addendum

Admission Date: [**2200-8-25**] Discharge Date: [**2200-8-28**] Service: NEUROSURGERY Allergies: Codeine / Sulfa (Sulfonamides) / Penicillins Attending:[**First Name3 (LF) 1271**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] F who lives in an independent living facility has been taking OTC meds for a chest cold of which the robitussin makes her lightheaded. She stood up to get out of bed this morning and fell down. Does not rememebr hitting her head or LOC but admits it took quite a while to get back up. She was taken to an OSH where a head CT showed a 0.9cm R SDH with a 0.45cm midline shift. A CXR was c/w pneumonia. Pt has a h/o CAD with 2 stents, currently anticoagulated with Plavix and ASA. Past Medical History: type 2 diabetes, previous myocardial infarctions, deafness, thyroid surgery, hysterectomy, cholecystectomy, hip surgery, shingles. Social History: Independent living facility Family History: non-contributory Physical Exam: Exam upon admission: T: 101.8 BP: 144/54 HR: 81 R 20 O2Sats 91/2l NC Gen: Well appearing, comfortable, NAD. HEENT: PERRL 3mm to 1mm b/l EOMI Neck: Supple. Lungs: rhonchi throughout b/l. Cardiac: RRR. S1/S2. Abd: Soft, NT Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-3**] throughout. No pronator drift Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Pertinent Results: CT head [**2200-8-25**]: FINDINGS: There is a mixed attenuation subdural collection layering along the right cerebral hemisphere, compatible with acute on chronic subdural hematoma, which measures up to 1 cm. There is mild right- to- left midline shift measuring approximately 4 mm. There is sulcal effacement along the right cerebral hemisphere. No intra- axial hemorrhage or edema is seen. There is focal calcification in the left basal ganglia. Subcutaneous tissues and orbits are grossly unremarkable. The mastoids are clear. There is nasal septal deviation to the right. Mucosal thickening is noted in the ethmoid and sphenoid sinuses as well as air- fluid level in the bilateral maxillary sinuses. The lamina papyracea appear intact. There is calcification of the carotid siphons. IMPRESSION: 1. Acute on chronic subdural hematoma along the right cerebral hemishpere causing sulcal effacement and mild shift of midline. 2. Small air-fluid levels in the maxillary sinuses and paranasal sinus mucosal thickening. CT facial bones may be obtained if there is concern for facial bone fracture. CT head [**2200-8-26**]: Comparison is made with [**2200-8-25**]. Right hemispheric acute subdural hematoma is unchanged in size. There is minimal midline shift, which is also unchanged. A small amount of hemorrhage along the left tentorial reflection is also seen. There has been no extension of the hematoma or new hemorrhage seen. There is mild small vessel ischemic sequela in the subcortical and periventricular white matter. Ventricles are stable. IMPRESSION: Essentially no change. CT head [**2200-8-27**]: Comparison with [**2200-8-26**], 12:03 p.m. The subdural hematoma outlining the right cerebral convexity is unchanged, as is the amount of blood along the tentorial reflections. No significant midline shift, hydrocephalus, or acute major vascular territorial infarct is identified. No fractures are seen. Imaged sinuses are notable for scattered opacification of scattered ethmoid air cells and sphenoid sinuses. Mastoid air cells and frontal sinuses are clear. IMPRESSION: Similar appearance of subdural hematoma. CHEST (PORTABLE AP) [**2200-8-25**]: FINDINGS: AP portable chest radiograph was obtained in a semi-upright position. The lungs appear clear bilaterally. There is no evidence of pneumonia or CHF. No pleural effusion or pneumothorax is present. The heart size is top normal. Mediastinal contour is unremarkable. Aortic arch calcification is noted. Degenerative changes are seen at the AC joints bilaterally. Surgical clips in the right upper quadrant likely from prior cholecystectomy. There may be slight compression of a lower thoracic vertebra, though this is suboptimally assessed. Degenerative changes are noted in the spine. IMPRESSION: 1. No evidence of acute intrathoracic process. 2. Borderline cardiomegaly. 3. Possible compression deformity in the mid thoracic spine. Correlation with lateral view may be helpful to further evaluate. CHEST (PA & LAT) [**2200-8-27**] 5:23 PM Reason: pneumonia [**Hospital 93**] MEDICAL CONDITION: [**Age over 90 **] year old woman with pneumonia REASON FOR THIS EXAMINATION: pneumonia CHEST, PA AND LATERAL VIEWS IN COMPARISON WITH [**2200-8-25**]. PA and lateral views of the chest reveals the heart to be enlarged. There is calcium in the aorta with uncoiling. There is slight blunting of the left costophrenic angle and haziness at the left base. The vascular markings are prominent. There is pleural fluid in both fissures as well as both costophrenic angles posteriorly. The pattern is that of congestive failure. Small patch of pneumonitis cannot be excluded, however. A focal area cannot be identified. CONCLUSION: Changes consistent with cardiac failure, however, a small area of pneumonitis cannot be excluded. Brief Hospital Course: Pt was admitted to neurosurgery service on [**8-25**] after a fall with a CT showing a 0.9cm R Subdural hematoma. A chest-x-ray from her referring hospital was consistent with pneumonia and the pt was c/o cough with productive sputum. A 5 day course of levofloxacin was initiated. Plavix and ASA were held, the pt recieved a unit of platelets, was loaded on dilantin for seizure prophylaxis and Pt was admitted to the ICU for strict neurological monitoring. On the night of HD#1 the pt's blood pressure dropped to a systolic in the 80s with a corresponding HR in the 30s and required dopamine to maintain her SBP>100. Her antihypertensive medications were held. A reduced dose of metoprolol was restarted the next day when she was tranfered out of the ICU to the neurosurgical floor. Follow-up CTs on [**8-26**] and [**8-27**] showed no progression of her subdural hematoma. Her hospital course was uncomplicated. Neurological exam showed no defecits on admission and remained normal throughout her hospital course. Her pneumonia continued to resolve during her hospital stay, treated with levofloxacin and robitussin for cough. Follow-up CXR was consistent with resolving pneumonia. Her aspirin was restarted during her hospital course and her plavix is to be restarted on [**9-1**]. Medications on Admission: Plavix 75 mg daily Nexium 40 mg daily Lipitor 20 mg nightly Diovan 150 mg nightly Levothyroxine 0.075 mg nightly Amiodarone 200 mg nightly Metoprolol 100 mg [**12-31**] in the morning and [**12-31**] at dinnertime. Aspirin 325 mg nightly. Trazodone 2.5 mg nightly. Aerobid inhaler two puffs twice a day. Metformin 500 mg daily Lisinopril 5 mg daily. Calcium carbonate 600 mg twice a day Centrum one daily. Discharge Medications: 1. Plavix Please restart Plavix 75mg Daily on [**9-1**]. 2. Outpatient Lab Work Dilantin level: Please send results to your primary care physician. 3. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 4 weeks: Continue until follow-up appointment with neurosurgery. Disp:*84 Capsule(s)* Refills:*0* 4. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Trazodone 50 mg Tablet Sig: [**12-31**] Tablet PO HS (at bedtime) as needed for sleep. 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 11. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H (every 24 hours) for 2 days: Dose 4 of 5 on [**8-28**], final dose on [**8-29**]. 12. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q4H (every 4 hours) as needed. 13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 15. Diovan 160 mg Tablet Sig: One (1) Tablet PO at bedtime. 16. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. 17. Calcium Antacid 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. 18. Multivitamin Centrum One Daily Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) **] Discharge Diagnosis: Stable Right Subdural hematoma, Pneumonia Discharge Condition: Good Discharge Instructions: Please call your surgeon if you develop chest pain, shortness of breath, fever greater than 101.5, persistent nausea or vomiting, inability to eat or drink, or any other symptoms which are concerning to you. Followup Instructions: Please call the office of Dr.[**Last Name (STitle) 739**] at ([**Telephone/Fax (1) 88**] to schedule a follow-up appointment for 4 weeks from discharge. You will need to have a Head CT scan at this time. Please follow up with your primary care physician [**Last Name (NamePattern4) **].[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 66752**] regarding your recent pneumonia as well as your blood pressure medication. Your metoprolol dose was reduced during your hospital stay because of a decrease in your heart rate and blood pressure. You should also have your primary care physician check your dilantin level. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Name: [**Known lastname **],[**Known firstname 11599**] M. Unit No: [**Numeric Identifier 11600**] Admission Date: [**2200-8-25**] Discharge Date: [**2200-8-28**] Date of Birth: [**2108-10-22**] Sex: F Service: NEUROSURGERY Allergies: Codeine / Sulfa (Sulfonamides) / Penicillins Attending:[**First Name3 (LF) 1698**] Addendum: The patient slipped out of bed this afternoon ([**2200-8-28**]) while trying to get up without assistance. She reports that she hit the back of her head but did not lose consciousness. The patient was examined and was neurologically intact. Her exam was completely unchanged from this morning. The patient had a stat CT which showed that her known SDH was unchanged. She was deemed safe for discharge. Discharge Disposition: Extended Care Facility: [**Hospital6 2876**] - [**Location (un) 4415**] [**Name6 (MD) **] [**Name8 (MD) 1041**] MD [**MD Number(2) 1709**] Completed by:[**2200-8-28**]

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Discharge summary

report+report

Admission Date: [**2103-5-17**] Discharge Date: [**2103-5-18**] Date of Birth: [**2039-3-10**] Sex: M Service: MEDICINE Allergies: Levofloxacin Attending:[**First Name3 (LF) 613**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 64 year old gentleman who a history of severe COPD who presents with acute shortness of breath. Patient has FEV1/FVC of 35%, fev1=20% and is on 4L of home oxygen at baseline. He has a history of frequent admissions and has been intubated twice in the past. He denies recent increase in cough or sputum but does report rhinorrhea. He has been compliant with his inhalers. Today he had sudden onset of sob which rapidly worsened, prompting him to come to ED. Denies fevers, chills, cough, chest pain, nausea, vomiting, abdominal pain, lightheadedness. In the ED the patient appeared in distress. He was tachypnic to 30 with O2 sat of 90% on bipap and with accessory muscle use. He appeared in distress. He received solumedrol and and nebulizers and improved rapidly. He was weaned to 6L 02. Past Medical History: 1. COPD on 4 L O2 at home and s/p multiple admissions and intubations for flares-FEV1/FVC 35% 2. Hypertension 3. Hyperlipidemia 4. Elevated TnT with normal catherization in setting of copd flare 5. Chronic low back pain L1-2 laminectomy from accident at work 6. Steroid induced hyperglycemia 7. Left shoulder pain for several months 8. Cataract 9. GERD MEDICATIONS: Aspirin E.C. 325 mg PO 1x/day Ipatropium Brodmide 18 mcg/puff [**Hospital1 **] Lisinopril 5 mg PO 1x/day Sertraline Hcl 50 mg PO 1x/day Atorvastatin 10 mg PO 1x/day Pantoprazole sodium 40 mg PO 1x/[**Last Name (un) **] Percocet 325 mg PO 2 pills TID Flovent 110 mcg IH 2 puffs [**Hospital1 **] Lactulose 10g/15 ml PO 30 cc at bedtime Ensure PO BID Verapamil Hcl 120 mg PO q8hrs Predisone 10 mg PO 1.5/day Albuterol 90 mcg IH 2 puffs TID PRN: Ibuprofen 400 mg PO TID Nitroglycerin 400 mcg sublingual Lorazepam 500 mcg PO qHS Albuterol 0.83 mg/ml IH QID Salmeterol 50 one [**Hospital1 **] Social History: Married with six children. Lives at home in [**Location (un) 16174**] with wife. Retired [**Company 19015**] mechanic. Exposed to a lot of spray paint. Former smoker. Quit 25 years ago. 20 pack year history. Occassional EtOH Quit marijuana 3 years ago. Denies IV drug use. Activity limited due to prior spine and current shoulder problems. Family History: Mother with asthma and [**Name (NI) 2481**] Father with [**Name2 (NI) 499**] cancer Physical Exam: VS: T 98.5 HR 120 BP 168/71 RR 25 O2 sat 94% on bipap after nebs and steroids: HR 100 BP 106/60 RR 20 O2 sat 97% 6L Gen - Comfortable. Sleeping. Unable to speak in full sentances, but breathing slowly at rest. No accessory muscle use. HEENT - Anicteric sclera. PERRL Neck - no JVD. No bruit. Trachea midline. No thyromegaly CV- RRR Faint but audible S1, S2. No MRG Pulm - Faint breath sounds, good air movement. No wheezes. Prolonged expiratory phase. No ronchi, rales. Abd - Soft, non distended, non tender NABS Ext - No cyanosis, edema. Warm and dry. Nails - No clubbing. No pitting/color changes/indentations Neuro - AOx3. CN intact, no focal motor/sensory deficits Pertinent Results: PORTABLE AP CHEST RADIOGRAPH: The lung fields are clear. Again, seen is slight hyperinflation of the lung fields bilaterally, consistent with COPD. The heart size is normal. The mediastinal and hilar contours are stable in appearance. No pleural effusions, pneumothorax. The soft tissue and osseous structures are stable in appearance. IMPRESSION: No evidence of pneumonia or CHF. Brief Hospital Course: 64 y/o male with severe COPD and CAD admitted with COPD exacerbation. 1)COPD: Given his history, the symptoms of shortness of breath seem most consistent with a COPD exacerbation, probably incited by a viral URI. He was started on methylprednisolone at 125mg in the ED and continued on his home dose of fluticasone and salmeterol. He received frequent bronchodilator nebulizers. He was also started on tiotroprium and a steroid taper, and he quickly improved back to his baseline. On the day of discharge, he felt "dandy" & ready to go home. 2) Cardiovascular: Cardiac catherization last admission showed no significant disease. In the past the patient has had CK and troponin elevations in the setting of severe COPD exacerbation which, given his normal cath, were thought to be due to COPD flare and not due to atherosclerotic coronary disease. 3) HTN: stable; continued outpatient meds. 4) Dispo: [**Month (only) 116**] need to consider chronic oral steroids due to frequent exacerbations. Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed for shortness of breath or wheezing. 4. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours) for 4 days. [**Month (only) **]:*4 Capsule(s)* Refills:*0* 5. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 9. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 10. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation Q12H (every 12 hours). 11. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO QHS (once a day (at bedtime)). 12. Verapamil HCl 120 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 14. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 16. Prednisolone Acetate 0.12 % Drops, Suspension Sig: One (1) Drop Ophthalmic QID (4 times a day). 17. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4 times a day). 18. Prednisone 10 mg Tablet Sig: taper; [**1-11**] Tablet(s) as directed PO once a day: take six tabs once a day for three days; decrease dose by 1 tab every three days thereafter . [**Month/Day (3) **]:*63 tabs* Refills:*0* 19. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). [**Month/Day (3) **]:*30 Cap(s)* Refills:*2* 20. Albuterol (Refill) 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing. [**Month/Day (3) **]:*1 mdi* Refills:*3* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: COPD flare Secondary: hypertension Discharge Condition: Stable, afebrile. Discharge Instructions: Please seek medical attention for worsened shortness of breath unrelieved with your home nebs or for fevers>101.4. Please take your medications as directed. Your prescriptions were called into the Procare pharmacy at [**Location (un) **]. Followup Instructions: Please see your PCP [**Last Name (NamePattern4) **] [**1-7**] weeks for follow-up. You also have the following appointments: 1) Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Where: [**Hospital6 29**] PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2103-5-24**] 9:15 2) Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Where: [**Hospital6 29**] MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2103-5-24**] 9:30 3) Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Where: [**Hospital6 29**] [**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2103-6-5**] 9:15 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Admission Date: [**2103-5-19**] Discharge Date: [**2103-5-24**] Date of Birth: [**2039-3-10**] Sex: M Service: MEDICINE Allergies: Levofloxacin Attending:[**First Name3 (LF) 613**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: mechanical ventilation History of Present Illness: 64 yo man with COPD called EMS early this am when he developed acute-onset [**10-15**] SOB while failed to improve with combivent nebs. In the field he requested intubation. Therefore I was not able to obtain further history (following is from recent D/C Summary). In the ED he was started on propofol and BP dropped to 80s systolic. Was given solumedrol 125 mg IV, Levoquin 500 mg IV. Past Medical History: 1. COPD on 4 L O2 at home and s/p multiple admissions and intubations for flares-FEV1/FVC 35% 2. Hypertension 3. Hyperlipidemia 4. CAD s/p NSTEMI ([**2101**]) 5. Chronic low back pain L1-2 laminectomy from accident at work 6. Steroid induced hyperglycemia 7. Left shoulder pain for several months 8. Cataract 9. GERD Social History: Married with six children. Lives at home in [**Location (un) 16174**] with wife. Retired [**Company 19015**] mechanic. Exposed to a lot of spray paint. Former smoker. Quit 25 years ago. 20 pack year history. Occassional EtOH Quit marijuana 3 years ago. Denies IV drug use. Activity limited due to prior spine and current shoulder problems. Family History: Mother with asthma and [**Name (NI) 2481**] Father with [**Name2 (NI) 499**] cancer Physical Exam: PE: Afeb, 94/56, 84, 18, 96% on AC 480 x22, 1.0, 5 GEN - intubated, sedated, NAD NECK - no JVD HEART - could not hear heart sounds LUNGS - poor air movement on R, loud wheezes on L ABD - soft, NT/ND, NABS EXT - no edema Pertinent Results: [**5-23**] CTA w/ contrast: 1) No evidence of pulmonary embolism. 2) Emphysema. 3) Stable bronchiectasis and linear opacities in the right and left lower lobes, which may represent atelectasis or scarring. CXR [**5-19**]: 1) No evidence of pneumonia. 2) Emphysema. ECG [**5-19**]: Sinus tachycardia with ventricular premature beat. Low voltage. Right atrial abnormality. Early transition. Compared to the previous tracing sinus tachycardia is new. ADMISSION LABS: [**2103-5-18**] 06:30AM BLOOD WBC-17.3* RBC-4.14* Hgb-10.9* Hct-33.7* MCV-82 MCH-26.4* MCHC-32.4 RDW-14.4 Plt Ct-302 [**2103-5-18**] 06:30AM BLOOD Glucose-99 UreaN-16 Creat-0.6 Na-137 K-4.1 Cl-98 HCO3-30* AnGap-13 [**2103-5-19**] 06:22AM BLOOD Type-[**Last Name (un) **] pO2-205* pCO2-67* pH-7.25* calHCO3-31* Base XS-0 DISCHARGE LABS: [**2103-5-24**] 06:45AM BLOOD WBC-14.9* RBC-4.60 Hgb-12.0* Hct-38.3* MCV-83 MCH-26.2* MCHC-31.4 RDW-14.6 Plt Ct-324 [**2103-5-24**] 06:45AM BLOOD Glucose-77 UreaN-16 Creat-0.8 Na-137 K-4.1 Cl-98 HCO3-29 AnGap-14 [**2103-5-21**] 03:25AM BLOOD Type-ART pO2-74* pCO2-67* pH-7.31* calHCO3-35* Base XS-4 Brief Hospital Course: 64 yo man with severe COPD on home prednisone and O2 presents with acute-onset COPD exacerbation, requiring intubation. 1) COPD exacerbation/respiratory distress - Patient just D/Ced home [**5-18**] after 1 day stay for COPD flare. Given sudden decline, etiologies considered include pulmonary embolism or mucus plugging. CTA was negative. He was initially started on solumedrol 125 mg IV q8h, then pred taper. He was also treated empirically for pneumonia with azithromycin for 5 days, nebs, and tiotropium. Twice during his stay in the MICU, he had episodes of flash pulmonary edema that were excerbated by the patient's anxiety causing an increased RR and breath stacking. These episodes responded to Lasix with diuresis. 2) EKG changes - inferolateral ST depressions, likely rate related ischemia in setting of respiratory distress. He ruled out for an MI and has had a clean cath in the recent past. 3) HTN - Initially, antihypertensives were held since the patient was intubated. However, once extubated, he continue to have SBPs in the 80 - 90s secondary to likely dehydration. This is thought to be due to overdiuresis and the this resolved with encouaged increased PO intake of fluids. 4) Abdominal Pain - Transient pain that the patient described as soreness in left lower quadrant, not associated with constipation. Pain resolved spontaneously. Medications on Admission: 1. Sertraline 50 mg po qd 2. Flovent 2 puffs IH [**Hospital1 **] 3. Serevent discus 1 inhalation [**Hospital1 **] 4. Aspirin 325 mg po qd 5. Lactulose 30 ml po q8h prn 6. Vitamin D 800 IU po qd 7. Calcium 500 mg po tidwm 8. Verapamil 120 mg po q8h 9. Albuterol IH 2 puffs q6h prn 10. Lisinopril 5 mg po qd 11. Pantoprazole 40 mg po q12h 12. Senna 8.6 mg po bid 13. Docusate Sodium 100 mg po bid 14. Lipitor 10 mg po qd 15. Tylenol prn 16.Ibuprofen 400 mg po q8h prn 17.Lorazepam 0.5 mg po qhs 16.Prednisolone Acetate 0.12 % Drops, Suspension Sig: One (1) Drop Ophthalmic QID 18.Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID 19.Prednisone 10 mg Tablet Sig: taper (starting [**2103-5-18**]; [**1-11**] Tablet(s) as directed PO once a day: take six tabs once a day for three days; decrease dose by 1 tab every three days thereafter . 20 .Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Discharge Medications: 1. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Albuterol 90 mcg/Actuation Aerosol Sig: 4-8 Puffs Inhalation Q1H (every hour) as needed. 3. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 4. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation Q12H (every 12 hours). 5. Prednisolone Acetate 0.12 % Drops, Suspension Sig: One (1) Drop Ophthalmic QID (4 times a day). 6. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 7. Zolpidem Tartrate 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Calcium Carbonate 1,250 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Albuterol Sulfate 0.083 % Solution Sig: Four (4) Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 12. Erythromycin 5 mg/g Ointment Sig: One (1) application Ophthalmic QID (4 times a day): as previously directed by opthalmology. 13. Verapamil HCl 120 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 14. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 15. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 16. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 19. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO at bedtime as needed. 20. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. Prednisone 50 mg Tablet Sig: 1-5 Tablets PO DAILY (Daily): as directed (reduce dose by [**1-7**] tablet every three days). [**Month/Day (2) **]:*26 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Chronic obstructive pulmonary disease exacerbation Respiratory failure Possible pneumonia type II diabetes, steroid-induced Discharge Condition: Stable, afebrile, at his baseline respiratory status. Discharge Instructions: Please seek medical attention for fevers>101.4, for severe shortness of breath unrelieved by your nebulizers or inhalers or for anything else medically concerning. Please take your medications as directed. Your prednisone prescription was called into the Procare pharmacy. Prednisone Taper 10mg tablets date dose [**Last Name (LF) 2974**], [**2103-5-25**] 50 mg 5 tablets Saturday, [**2103-5-26**] 50 mg 5 tablets [**Last Name (LF) 1017**], [**2103-5-27**] 50 mg 5 tablets [**Last Name (LF) 766**], [**2103-5-28**] 45 mg 4.5 tablets Tuesday, [**2103-5-29**] 45 mg 4.5 tablets Wednesday, [**2103-5-30**] 45 mg 4.5 tablets Thursday, [**2103-5-31**] 40 mg 4 tablets [**Last Name (LF) 2974**], [**2103-6-1**] 40 mg 4 tablets Saturday, [**2103-6-2**] 40 mg 4 tablets [**Last Name (LF) 1017**], [**2103-6-3**] 35 mg 3.5 tablets [**Last Name (LF) 766**], [**2103-6-4**] 35 mg 3.5 tablets Tuesday, [**2103-6-5**] 35 mg 3.5 tablets Wednesday, [**2103-6-6**] 30 mg 3 tablets Thursday, [**2103-6-7**] 30 mg 3 tablets [**Last Name (LF) 2974**], [**2103-6-8**] 30 mg 3 tablets Saturday, [**2103-6-9**] 25 mg 2.5 tablets [**Last Name (LF) 1017**], [**2103-6-10**] 25 mg 2.5 tablets [**Last Name (LF) 766**], [**2103-6-11**] 25 mg 2.5 tablets Tuesday, [**2103-6-12**] 20 mg 2 tablets Wednesday, [**2103-6-13**] 20 mg 2 tablets Thursday, [**2103-6-14**] 20 mg 2 tablets [**Last Name (LF) 2974**], [**2103-6-15**] 15 mg 1.5 tablets Saturday, [**2103-6-16**] 15 mg 1.5 tablets [**Last Name (LF) 1017**], [**2103-6-17**] 15 mg 1.5 tablets [**Last Name (LF) 766**], [**2103-6-18**] 10 mg 1 tablets Tuesday, [**2103-6-19**] 10 mg 1 tablets Wednesday, [**2103-6-20**] 10 mg 1 tablets Thursday, [**2103-6-21**] 5 mg 0.5 tablets [**Last Name (LF) 2974**], [**2103-6-22**] 5 mg 0.5 tablets Saturday, [**2103-6-23**] 5 mg 0.5 tablets Followup Instructions: 1) Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Where: [**Hospital6 29**] PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2103-5-24**] 9:15 2) Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Where: [**Hospital6 29**] MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2103-5-24**] 9:30 3) Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Where: [**Hospital6 29**] [**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2103-6-5**] 9:15 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "789.06", "514", "518.81", "401.9", "491.21", "414.01", "285.9" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

15590, 15648

11124, 12490

8492, 8517

15815, 15870

9995, 10446

17753, 18493

9653, 9739

13486, 15567

15669, 15794

12516, 13463

15894, 17730

10799, 11101

9754, 9976

8433, 8454

8545, 8932

10462, 10783

8954, 9274

9290, 9637

78,879

136,071

39505

Discharge summary

report

Admission Date: [**2150-8-14**] Discharge Date: [**2150-9-7**] Date of Birth: [**2086-5-6**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2836**] Chief Complaint: 1. Small bowel obstruction 2. Duodenal mass, metastatic breast cancer Major Surgical or Invasive Procedure: [**2150-8-28**]: Biopsy of metastatic nodules and gastrojejunostomy. History of Present Illness: Patient is a 64-years-old woman with a history of breast cancer (metastatic to bone) who presented to an outside hospital on [**7-31**] with nausea, vomiting and 24 lb weight loss over the preceding 2 weeks (constant since prior admission for same). She was found to have hypokalemia and acute on chronic renal failure. She then developed a 7 second episode of Torsades shortly after admission on [**2150-8-1**] with spontaneous conversion, thought to be due to electrolyte abnormalities (Cr 3.1, K 2.5). QT was prolonged. Cardiology was consulted and she was transferred to the ICU. Lytes aggressively repleted. She then had a grand mal seizure [**8-2**], treated with ativan. Neurology consulted. MR head done (see report in chart and briefly in results below, no major findings). Neuro notes report that they think the seizure was due to acute metabolic encephalopathy due to acute illness. She was stabilized and called out to the medical floor, but her persistent vomiting, inability to tolerate PO and abdominal discomfort continued. Transfused 1 unit PRBCs [**8-8**] with Hct bump from 26.9 to 30.1. A noncontrast abd CT scan was done. It was a poor study and showed contrast remaining in stomach and duodenum c/w SBO. NGT placed; TPN started. SBFT showed the same. EGD could not be passed beyond D3 due to a possible extrinsic mass, even with pedi scope. At that point, reportedly, review of her CT suggested possible uncinate mass (per our GI team discussion with OSH GI team - I do not see this documented in OSH records however). She is transferred to [**Hospital1 18**] for evaluation by our advanced endoscopy team and consideration for EUS with biopsy if appropriate. On arrival: She is tired, has dull aching epigastric abdominal pain, non radiating. She has nausea. She has discomfort from her NG tube. All other review of systems asked in detail is negative. Past Medical History: CAD (3 vessel disease per cath [**2145**]) dCHF with preserved EF Diabetes type two complicated by neuropathy, retinopathy, gastroparesis, started on insulin 1 month ago hypertension Metastatic breast CA - treated with surgery, chemo, radiation htn hyperlipidemia ?stage 3 ckd Social History: Has 5 children; son is HCP, daughter is RN. Nonsmoker, no alcohol. Family History: no history of GI malignancy Physical Exam: Gen: obese, fatigued, ill appearing woman in bed, nad VS: 99.2, 154/72, 82, 18 97% RA HEENT: MM dry, EOMI, CV: RRR. + S1S2. [**1-24**] blowing systolic murmur Pulm: clear but diminished at bases. no crackles. ABD: obese, soft. + epigastric tenderness. quiet, hypoactive bowel sounds. no palpable mass though exam limited by obesity EXT: warm. [**11-22**]+ pitting edema b/l LE. GU: no foley Neuro: strenght and sensation grossly intact. oriented x3. skin: warm, clammy. no rash. Psych: sad, appropriate. Pertinent Results: [**2150-9-6**]: CBC WBC-8.3 Hgb-8.9 Hct-27.1 Plt Ct-209 [**2150-9-7**] Chem: Glucose-39 UreaN-33 Creat-1.9 Na-140 K-3.9 Cl-109 HCO3-21 AnGap-14 [**2150-9-4**] LFTs: ALT-33 AST-48 AlkPhos-1019 TotBili-1.6 MRI Abdomen [**2150-8-16**]: Inadequately characterized 2 x 4 cm ill-defined mass involving the junction of second and third part of duodenum with mass effect on the pancreatic head and compression of the duodenal lumen resulting in mild upstream gastric distention. This lesion may represent an intrinsic duodenal intramural mass, or extramural lesion. While this lesion may possibly arise from the pancreatic head, this is considered less likely given the morphology of the lesion and apparent mass effect on the pancreatic head. CT HEAD [**2150-8-28**]: No evidence of acute intracranial abnormalities. Brief Hospital Course: 64 yo woman with history of breast cancer - metastatic to bone, who presented to [**Hospital6 **] [**7-31**] with ARF and hypokalemia, course complicated by brief self limited episode of Torsades as well as seizure, now stabilized but with likely new pancreatic mass leading to duodenal obstruction and inability to take PO. Oncw stable, patient was transferred to [**Hospital1 18**] for treatment of duodenal obstruction. Patient was admitted on [**2150-8-14**] for treatment of duodenal obstruction. NG tube was placed with relief of abdominal pain and nausea. Port was accessed and TPN was started. Communications with patient's oncologist revealed poor prognosis from breast cancer. Prognosis was discussed with family who agreed that goal would be for return of po intake. Patient was given nutritional support with IVF and TPN and optimized medically through pulmonary toilet (nebs, oxygen, chest PT) and balanced with lasix diuresis for CHF and IV hydration for acute renal failure, in preparation for surgical intervention. Patient underwent biopsy of metastatic nodules and gastrojejunostomy on [**2150-8-28**] without complications. In PACU, patient found to be unresponsive and was reintubated for altered mental status. CT head was negative for intracranial pathology and patient slowly regained neurological function spontaneously. She was admitted overnight for observationa and successfully extubated on [**2150-8-29**] (POD1) without difficulty. She had no residual neurological deficits and episode was attributed to anesthetic reaction. Patient was kept in the ICU until POD#3 for management of tachycardia. Patient was then transferred to the floor in good condition, remainder of her course is described below by system. GI: Patient was kept NPO with NG tube in place until POD#3. Patient had episodes of emesis on POD#4 and POD#5 and was started on reglan with good effect. LFTs increased mildly postop and TPN was held until they trended down, then restarted on POD#5. Patient tolerated clear liquid diet on POD#6 and was advanced to regular diet by POD#9. Po intake improved daily and patient was passing flatus and having bowel movements. Pathology revealed metastatic breast cancer in duodenum. Results were discussed with the patient and her family with plans to f/u with current oncologist for treatment. She was discharged to rehab on a regular diet with ensure shakes for supplemental nutrition. ID: Patient developed a wound infection of superior [**11-23**] of abdominal incision on POD#8. Wound was opened and packed with gauze. Patient was afebrile throughout this period with normal WBC count. Wound vac will be applied in rehab and TID dressing changes will continue until then. CV: Patient's CHF was managed throughout preop and postop period with lasix diuresis and IV metoprolol. Lasix was held several times due to increase in Cr (Max 2.4) but was resumed when ARF resolved. Cardiology was consulted preop for perioperative recommendations. Echo was done on [**8-25**] and demonstarted mild left ventricular systolic dysfunction (LVEF= 45 %) consistent with coronary artery disease. Post surgery, patient was continued to be monitored via telemetryn with no events. Renal: Patient's CRF was complicated with several instances of increased Cr with max 2.4. Renal failure was pre-renal according to FNA and was treated with IV hydration balanced with lasix diuresis. Cr on discharge was stable at 1.9-2. Neuro: No events during postop period outside of episode described above. She was alert and oriented throughout hospital stay. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. Endocrine: Patient's diabetes was managed with RISS throughout stay. Once tolerating clears, she was restarted on home diabetic meds. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. At the time of discharge on POD#10 to rehab, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Medications on Admission: Meds on transfer: Mucomyst (for ARF) Fragmin (as DVT prophylaxis) Lopressor 5 mg IV every 6 hours Protonix 40 mg IV daily Sliding scale insulin TPN Procrit every other week zofran prn ativan prn tylenol prn Meds at home (per OSH records -- pt could not recall) -- needs additional med rec prior to discharge: amlodipine 5 mg daily Lisinopril 40 mg daily Lasix 40 glimepiride 4 mg daily Crestor 10 mg daily Zoledronic acid 5 mg monthly Novolin Aspirin 81 mg daily arimidex 1 mg daily lopressor 150 mg [**Hospital1 **] reglan 10 mg QID Diovan 80 mg daily procrit calcium, vitamin D Discharge Medications: 1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*1* 4. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*120 Tablet(s)* Refills:*2* 5. glimepiride 4 mg Tablet Sig: One (1) Tablet PO daily (). 6. metoprolol succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. 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* Discharge Disposition: Extended Care Facility: [**Location (un) **] Nursing & Rehabilitation Center - [**Location (un) **] Discharge Diagnosis: 1. Duodenal obstruction secondary to metastatic breast cancer. 2. Congestive heart failure, systolic 3. Chronic renal insufficiency 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: Please resume all regular home medications. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**3-30**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. Followup Instructions: Please follow up with Dr. [**First Name (STitle) **] in two weeks. Please call her office at ([**Telephone/Fax (1) 6347**] for your appointment. Completed by:[**2150-9-7**]

[ "197.6", "428.0", "537.3", "357.2", "261", "362.01", "198.5", "250.60", "V10.3", "428.20", "250.50", "401.9", "530.10", "780.39", "584.9", "272.4", "998.59" ]

icd9cm

[ [ [] ] ]

[ "45.13", "99.15", "44.39", "54.23" ]

icd9pcs

[ [ [] ] ]

10063, 10165

4180, 8436

382, 453

10341, 10341

3342, 4157

11317, 11492

2771, 2800

9067, 10040

10186, 10320

8462, 8462

10524, 11040

11055, 11294

2815, 3323

273, 344

481, 2369

10356, 10500

2391, 2670

2686, 2755

8480, 9044

2,589

178,411

316

Discharge summary

report

Admission Date: [**2186-6-23**] Discharge Date: [**2186-7-6**] Date of Birth: [**2120-1-2**] Sex: M Service: MEDICINE Allergies: Pneumovax 23 Attending:[**First Name3 (LF) 905**] Chief Complaint: pneumonia, hypoxia, hypotension Major Surgical or Invasive Procedure: None History of Present Illness: The pt is a 66-yo man with paroxysmal atrial fibrillation, hepatitis C, h/o C.diff colitis, and a recent pneumonia, discharged [**2186-6-21**] on Vanc / Zosyn, who was found by his family to be more hypoxic and tired than usual so they brought him into the ED. His wife found him to be more sick than usual at about 4pm today, needing more supplemental O2 than prior (2L --> 3-4L), feeling warm and looking [**Doctor Last Name 352**]. She called EMS, who brought him in to the ED today. . On arrival in the ED, VS - Temp 101.4F, 148/78, HR 98, R 28, SaO2 99% NRB. He received Tylenol 650mg PR x2. Blood Cx sent x2, UA negative. He was initially weaned down to 4L NC, but desaturated to the 80s so was re-started on the NRB with improvement to the mid-90s. Lactate was 2.6 and CXR showed a possible right basilar pneumonia and a coiled PICC line. He subsequently became hypotensive to the high-70s but was fluid responsive. His PICC line was pulled and sent for Cx and a RIJ CVL was placed, and he got 4L NS IVF with SBPs 95-100. ID was curbsided regarding Abx coverage, and he received Vancomycin, Meropenem, and Tobramycin for broad coverage. He is admitted to the MICU for sepsis. He did not require any vasopressor support. . On arrival to the ICU, he feels well and has no complaints. He acknowledges fever but denies SOB, chest pain, abdominal pain, nausea, diarrhea, or swelling. Past Medical History: - Paroxysmal Atrial Fibrillation - History of C diff colitis - Bipolar Affective Disorder - History of resolved hepatitis B - History of rheumatic heart disease - History of right MCA aneurysm clipped in [**2167**] at [**Hospital1 112**] - History of pernicious anemia - Gastroesophageal reflux disease Social History: He lives with his wife. Questionable history of alcohol abuse (did abuse alcohol >20 years ago). He has not smoked for one month but previously has a 40 pack year history. Previously on 2L O2 at home but not prior to this hospitalization. Family History: His father had lung cancer and his mother had congestive heart failure. Physical Exam: VS: Temp 96.9F, BP 112/87, HR 85, R 17, SaO2 96%NRB; CVP 4 GENERAL: NAD HEENT: PERRL, dry MM NECK: supple LUNGS: +crackles @ left base, decreased BS on right HEART: irreg irreg, nl S1-S2, [**3-24**] SM ABDOMEN: +BS, soft/NT/ND, no rebound/guarding EXTREM: 2+ BLE pitting edema SKIN: no rash NEURO: A&Ox3, strength 5/5 throughout, sensation grossly intact throughout . Pertinent Results: Pertinent labs: [**2186-6-23**] 06:15PM BLOOD WBC-8.3 RBC-3.52* Hgb-11.4* Hct-35.0* MCV-99* MCH-32.4* MCHC-32.6 RDW-16.6* Plt Ct-162 [**2186-6-23**] 06:15PM BLOOD Neuts-68.9 Lymphs-22.5 Monos-7.1 Eos-1.1 Baso-0.4 [**2186-6-23**] 06:15PM BLOOD PT-16.1* PTT-39.9* INR(PT)-1.4* [**2186-6-23**] 06:15PM BLOOD Glucose-125* UreaN-8 Creat-0.8 Na-139 K-3.6 Cl-103 HCO3-25 AnGap-15 [**2186-6-23**] 06:15PM BLOOD ALT-9 AST-47* CK(CPK)-48 AlkPhos-253* TotBili-1.0 [**2186-6-23**] 06:15PM BLOOD Lipase-63* [**2186-6-23**] 06:15PM BLOOD CK-MB-NotDone cTropnT-<0.01 proBNP-1333* [**2186-6-23**] 06:15PM BLOOD Albumin-3.0* Calcium-8.4 Phos-2.5* Mg-2.2 [**2186-6-26**] 03:46AM BLOOD IgG-815 IgA-198 IgM-93 [**2186-6-28**] 03:15AM BLOOD HIV Ab-NEGATIVE [**2186-6-28**] 03:15AM BLOOD Vanco-20.6* [**2186-6-23**] 06:15PM BLOOD Vanco-15.5 [**2186-6-23**] 06:15PM BLOOD Digoxin-0.5* [**2186-6-27**] 04:14AM BLOOD Valproa-23* [**2186-6-23**] 06:27PM BLOOD Lactate-2.6* [**2186-6-28**] 03:42PM BLOOD B-GLUCAN-Test >500 pg/mL * . Labs on discharge: Na139 Cl103 BUN9 Na4.7 Bicarb30 Creatinine0.7 WBC4.22 H/H 10/30.5 plts 138 . Blood cx: [**2186-7-2**] 1:43 am BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. OF TWO COLONIAL MORPHOLOGIES. ISOLATED FROM ONE SET ONLY. SENSITIVITIES PERFORMED ON REQUEST.. . PICC line and central line tips negative on [**6-23**] & [**6-28**] Bloox cx pending [**7-3**] & [**7-4**], blood cx neg from [**6-23**], [**6-24**], [**6-28**] C diff negative x3 Ucx [**7-2**] grew yeast . [**2186-7-3**] CXR: FINDINGS: In comparison with the study of [**7-1**], there is some increasing opacification at the right base medially with silhouetting of the hemidiaphragm, consistent with right middle lobe consolidation. Mild atelectatic changes at the left base with blunting of the costophrenic angle persist. Upper lung zones remain clear. . [**6-23**] CXR: IMPRESSION: Limited study due to patient motion. 1. Possible right basilar pneumonia. Recommend repeat radiograph of the chest to confirm with more optimized technique. 2. Interval slight retraction of the right PICC which is looped in the right subclavian vein. . [**2186-6-26**] ECHO: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened/deformed. No discrete vegetation is seen, but cannot be excluded due to suboptimal image quality and diffuse aortic valve thickening. There is a minimally increased gradient consistent with minimal aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2186-6-14**], the findings are similar. CLINICAL IMPLICATIONS: Based on [**2184**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. . [**6-27**] Video swallow IMPRESSION: Moderate-to-severe oral and mild pharyngeal dysphagia resulting in penetration and aspiration due to premature spillover, delayed swallow initiation, and mildly reduced laryngeal valve closure. . [**6-27**] CT head NONCONTRAST CT HEAD: There is no intra- or extra-axial hemorrhage, shift of normally midline structures, edema, mass effect, or evidence of acute infarct. Evidence of previous right pterional craniotomy and vascular clip in the right ICA are unchanged since [**2186-6-16**]. Periventricular and subcortical white matter hypodensity represent chronic microvascular infarction, unchanged since [**2186-6-16**]. The paranasal sinuses and mastoid air cells are unremarkable. IMPRESSION: No acute intracranial process. . [**6-27**] LE U/S IMPRESSION: No evidence of bilateral lower extremity DVT, although there is limited visualization of the calf veins bilaterally. . [**6-28**] CT Chest IMPRESSION: 1. Stable right middle lobe consolidation with interval increase in right middle lobe volume loss without evidence of endobronchial lesion. Several enlarged and numerous prominent mediastinal lymph nodes not significantly changed from the prior study and likely reactive in nature. 2. Interval increase in bilateral pleural effusions right greater than left. 3. Multiple bilateral 3-6 mm nodules, unchanged compared to the prior study. A followup CT is recommended in one year to ensure two-year stability. 4. Findings consistent with cirrhosis and portal hypertension. Brief Hospital Course: Assessment and Plan: 66M with a history of pAF, c.diff colitis, recent pneumonia, admitted to the ICU with recurrent PNA/sepsis and found to have RML/RLL PNA & and being empirically tx for c diff colitis. . # Pneumonia: The patient was admitted with high fever, hypoxia, and hypotension. His CXR showed evidence of a RML/RLL pneumonia thought to be due to aspiration given dysphagia on swallow study. He was treated with a 14 day course of meropenem which was completed today. He does have pleural effusions but no thoracentesis was done given that it was difficult to position the patient and there was not enough fluid to safely tap. He was gently diuresed during his admission. His CT scan showed pulmonary nodules that need to be followed up as an outpatint. Given his repeated pneumonias checked HIV Ab and IgG both unremarkable. His b-glucan came back at >500 pg/mL. Given his clinical improvement and no known reason for immunocompromise he was not treated for a fungal infection. This lab should be redrawn in [**4-19**] weeks after discharge to ensure that it improves. A galactomannan was drawn while he was in the ICU and should be followed up as an outpatint. He was placed on a dysphagia diet given concern for repeat aspiration PNA and failure of swallow study. He required 3L of oxygen at the time of discharge (he had 2L oxygen requirement prior to admisison). . # Fever/ Sepsis: Pt has septic physiology in the ED and MICU. She grew gram + cocci in clusters in 1 bottle anaerobic from [**2186-7-2**] and was started on vancomycin IV which she received for one day until it came back coag negative staph. His last fever was [**2186-7-3**]. All other blood cx have been negative. His urine cx was negative (except for [**Female First Name (un) **]). His fever/sepsis was treated with a 14 day course of meropenem as detailed above under the PNA section. . # Diarrhea: The patient had diarrhea while in the ICU. He was empirically treatment for c.diff although he was c diff negative x3 during this hospitalizatoin. He had 5 BM the day prior to discharge some of which were loose stools. Given his completion of meropenem on [**2186-7-6**] the patient will be given an additional 7 day course of flagyl with the last dose the eveing of [**2186-7-13**]. His diarrhea may not be c diff in origin and could just be due to his meropenem. . # Anisicoria: Anisicoria was noticed on exam with R eye dilated more than left. This is an old finding for the patient as he has a PCOM aneurysm compressing CN III. . # Paroxysmal atrial fibrillation: The patient is being continued on his home dose of Flecainide and Digoxin. His metoprolol was decreased to [**Hospital1 **] on [**7-1**] given occassional low HR and at times his metoprolol still needs to be held for decreased BP. He is being continued on aspirin. Per a discussion the ICU team had with his PCP and cardiology he is not being anticoagulation given his history of falls. On the medicine floor he did not have a fib with RVR, however, he is at higher risk for RVR given that he was started on ritalin. However, given his decreased affect and the positive effect of ritalin on his energy level we have continued the ritalin. . #Anemia: His HCT has been stable at approximately 30. The anemia is macrocytic and likely from liver disease. His recent B12/Folate were within normal limits. His ferrous sulfate supplement should be continued. . # Psych: The patient has bipolar disorder and has been stable on Depakote for several years with no recent changes. In the ICU there was concern for somnolence and his flat affect and his Zyprexa was discontinued. Given his decreased energy level he was started on ritalin ([**2186-6-30**]) which he has responded to. His outpatient psychiatrist Dr. [**Last Name (STitle) 1968**] is aware of these changes. I spoke with Dr. [**Last Name (STitle) 1968**] about our concern for his depression and he was started on citalopram 20mg daily ([**2186-7-3**]) which should be increased to 30mg daily (on [**2186-7-10**]) if he does well on it. Given his history of bipolar disorder he needs to be closely monitored for symptoms of mania since his zyprexa was stopped and citalopram was started. He varied from A & O x2 to 3. He does not always participate when asked date. His mental status can wax and wanes sometimes with the patient not always answering questions in an appropriate time frame especially in evening. His affect is flat and his thinking is very slow. . Severe dry eyes and keratitis: also saw the patient and found severe dry eyes and keratitis of the right eye. Continue aritifical tears. . # ? Liver disease: There is concern for liver disease given AP 408, AST 89, INR 1.4, and mild thrombocytopenia. He was Hep C Ab neg. His Hep B serologies were consistent with prior infection (surface and core Ab+). He hoes have a remote history of heavy alcohol use. He needs outpatient liver follow up after he leaves rehab. . # Bradycardia/Hypotension: he had a few short episodes of bradycardia and hypotension on arrival to ED which resolved. He has some low BPs in the ICU. He also had some SBP in the high 80s/low 90s while on the medicine floor and he was assymptomatic. . # Nutrition: He is on a dysphagia diet: PO diet nectar thick liquids, soft solids, and pills whole with puree or nectar thick liquid. He aspirated liquids when he takes large sips. At rehab he can take small sips of regular liquids between meals if he is undersupervison. He still has severe LE edema which is likely influenced by poor nutrition. . # Prophylaxis: -DVT: heparin sc. No anticoagulation for A fib (see above) -Stress ulcer: H2 blocker . # Code status: Full code . # Emergency contact: wife makes health care decisions [**Name (NI) **] [**Known lastname 2933**] [**Telephone/Fax (1) 2938**] (home), [**Telephone/Fax (1) 2945**] (cell) . FOLLOW UP NEEDED by PCP AFTER DISCHARGE: -galactomannan -repeat b-glucan in [**4-19**] weeks -liver follow up -psychiatry follow up Medications on Admission: MEDICATIONS (per d/c summary [**2186-6-21**]) - Aspirin 325mg PO daily - Cholyestyramine-Sucrose 4grams PO BID - Divalproex 500mg PO QAM - Divalproex 1000mg PO QPM - Digoxin 125mcg PO daily - Ferrous sulfate 325mg PO daily - Olanzapine 5mg PO daily - Ranitidine 75mg PO daily - MVI daily - Flecainide 50mg PO Q12hrs - Vancomycin 1gram IV Q12hrs (5 more days) - Piperacillin-Tazobactam 4.5gram IV Q8hrs (5 more days) - Tylenol 325-650mg PO Q6hrs PRN fever, pain - Metoprolol 25 mg TID (had been held at home) Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ranitidine HCl 75 mg Tablet Sig: One (1) Tablet PO once a day. 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Flecainide 50 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing. 9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. 10. Divalproex 125 mg Capsule, Sprinkle Sig: Four (4) Capsule, Sprinkle PO QAM (once a day (in the morning)). 11. Divalproex 125 mg Capsule, Sprinkle Sig: Eight (8) Capsule, Sprinkle PO QPM (once a day (in the evening)). 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 13. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for empiric tx for cdiff for 7 days. 14. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-17**] Drops Ophthalmic QID (4 times a day). 15. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): at 8 am and 3 pm. 16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 17. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): hold BP<100 or HR<55. 18. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 days: continue until [**2186-7-10**] and then discuss with Dr. [**Last Name (STitle) 1968**] (psychiatrist) about increasing dose to 30mg daily. . Discharge Disposition: Extended Care Facility: [**Location (un) 582**] Of [**Location (un) 620**] Discharge Diagnosis: Primary diagnosis: -RML and RLL pneumonia -Diarrhea presumptive c diff (negative x3) -Abnormal liver enzymes -Severe dry eyes and keratitis -Depression -Dysphagia . Secondary Diagnosis: - Paroxysmal Atrial Fibrillation - History of C diff colitis - Bipolar Affective Disorder - History of hepatitis C - History of rheumatic heart disease - History of right MCA aneurysm clipped in [**2167**] at [**Hospital1 112**] - History of pernicious anemia - Gastroesophageal reflux disease Discharge Condition: Stable. A & O x2 to 3 (does not always participate when asked date). Mental status can wax and wanes sometime with the patient not always answering questions in an appropriate time frame- especially in evening. Flat affect. Very slow thinking. Discharge Instructions: You were admitted with increased oxygen requirement and decreased blood pressure and found to have a new pneumonia. You went to the ICU and you were treated with a 14 day course of meropenem which has been completed. Your pneumonia is likely a result of aspiration and a swallow study showed that your are aspirating thin liquids. You are being discharged on the following diet: nectar thick liquids, soft solids, pills whole with puree or nectar thick liquids. You can have regular liquids between meals but ONLY IF YOU TAKE SMALL SIPS AND SOMEONE SUPERVISES YOU. If you take large sips you will likely aspirate again. You also developed diarrhea and you were treated with flagyl although your stool never tested positive for c diff. You need to take 7 more days of flagyl to continue to treat your diarrhea. Followup Instructions: Please make a follow up appointment to see your PCP [**Name9 (PRE) **],[**First Name3 (LF) 2946**] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 2205**] after you leave rehab . Please call your psychiatrist Dr. [**Last Name (STitle) 1968**] and make a follow up appointment for after you leave rehab. . Please discuss with your PCP seeing [**Name Initial (PRE) **] liver specialist after you leave rehab. . The patient needs a b-glucan drawn in Mid/End of [**Month (only) **] to trend it. [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**] Completed by:[**2186-7-6**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

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302, 308

16753, 17001

2801, 2801

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2325, 2398

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2817, 3812

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52,188

175,803

31079

Discharge summary

report

Admission Date: [**2195-5-21**] Discharge Date: [**2195-5-29**] Date of Birth: [**2119-1-11**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: dyspnea on exertion/fatigue Major Surgical or Invasive Procedure: Coronary artery bypass graft x4: [**2195-5-22**] 1. Left internal mammary artery to left anterior descending artery. 2. Saphenous vein graft to posterior left ventricular. 3. Saphenous vein graft to first obtuse marginal branch of the circumflex. 4. Saphenous vein graft to the first diagonal branch of the left anterior descending. 5. Endoscopic harvesting of the long saphenous vein. History of Present Illness: 76 year old man with complaint of severe fatigue and dyspnea on exertion which has been worsening over the past 3 years. He had a positive dobutamine stress echocardiogram. Admitted to [**Hospital1 18**] for prehydration prior to cardiac catheterization. Past Medical History: Diabetes mellitus 2 Hypertension Hyperlipidemia Chronic kidney disease(baseline creat 1.8) Chronic obstructive pulmonary disease Obstructive sleep apnea Severe depression Vertigo Fatigue h/o ETOH abuse Obesity Celiac trunk atherosclerotic disease Past Surgical History: Tonsillectomy Cervical disc surgery Transurethral resection prostate nose surgery for fractured bones Social History: Lives with wife and mother-in-law retired IRS auditor +tobacco <1 pack per day(h/o [**1-3**] ppd x40 years) +ETOH-2 martinis/day at times supplemented with beer Family History: Father s/p MI @52yo Physical Exam: HR 60 BP rt 157/65 lft 170/69 RR 14 O2 sat 100%-RA Ht 5'9" Wt 212 lbs Gen NAD Skin warm and dry HEENT PERRL-EOMI Neck supple, full ROM Chest CTA bilat Cor RRR, no murmur Abdm soft, NT/ND/+BS Ext warm well perfused, no varicosities Neuro A&O x3, grossly intact. Caotid- no bruits Pulses fem 2+ bilat, Rad 2+ bilat, DP/PT 2+ bilat Pertinent Results: [**2195-5-21**] 07:50AM HGB-12.4* calcHCT-37 [**2195-5-21**] 07:50AM GLUCOSE-99 LACTATE-1.2 NA+-139 K+-4.1 CL--108 [**2195-5-21**] 12:17PM PT-15.8* PTT-36.7* INR(PT)-1.4* [**2195-5-21**] 12:17PM PLT COUNT-179 [**2195-5-21**] 12:17PM WBC-8.5# RBC-2.78* HGB-9.4* HCT-28.6* MCV-103* MCH-33.8* MCHC-32.9 RDW-15.2 [**2195-5-21**] 12:18PM GLUCOSE-105 LACTATE-2.8* NA+-139 K+-4.7 CL--112 [**2195-5-21**] 01:33PM UREA N-23* CREAT-1.2 CHLORIDE-116* TOTAL CO2-21* ============================================= [**Known lastname **],[**Known firstname **] [**Medical Record Number 73392**] M 76 [**2119-1-11**] Radiology Report CT HEAD W/O CONTRAST Study Date of [**2195-5-26**] 6:26 PM [**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2195-5-26**] 6:26 PM CT HEAD W/O CONTRAST [**Hospital 93**] MEDICAL CONDITION: 76 year old man with altered mental status/delerium REASON FOR THIS EXAMINATION: ischemic event CONTRAINDICATIONS FOR IV CONTRAST: None. Final Report HISTORY: 76-year-old male with altered mental status and delirium concerning for ischemic event. COMPARISON: MR head from [**2193-7-16**]. TECHNIQUE: MDCT-axial imaging was performed through the brain without administration of IV contrast. NON-CONTRAST HEAD CT: Slight tilting of the patient's head during imaging limits evaluation for symmetry somewhat. Allowing for this, no evidence of acute intracranial hemorrhage, edema, mass effect, hydrocephalus, or large vascular territory infarction is seen. Study is also limited due to patient motion, particularly the imaging through the skull base. Again prominence of the sulci and ventricles is consistent with age-related involutional change. Periventricular white matter hypodensities are likely due to chronic small vessel ischemic disease. Note is also made of likely chronic small lacunar infarcts in bilateral basal ganglia. The soft tissues, orbits, and skull appear intact. The visualized paranasal sinuses and mastoid air cells are normally aerated. Vascular calcifications are noted along the cavernous carotid arteries. IMPRESSION: No acute intracranial process seen. There is evidence of chronic microvascular as well as old lacunar infarction, as on the previous MR. If there is persistent concern for acute infarction, MRI with diffusion-weighted imaging would be recommended for more sensitive evaluation. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 95**] [**Last Name (NamePattern1) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7593**] ================================================= [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 73393**] (Complete) Done [**2195-5-21**] at 10:11:20 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2119-1-11**] Age (years): 76 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Coronary artery disease. Left ventricular function. Mitral valve disease. Preoperative assessment. ICD-9 Codes: 440.0, 424.0 Test Information Date/Time: [**2195-5-21**] at 10:11 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 168**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2009AW1-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: >= 55% >= 55% Aorta - Annulus: 2.4 cm <= 3.0 cm Aorta - Sinus Level: 3.4 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.9 cm <= 3.0 cm Aorta - Ascending: *3.5 cm <= 3.4 cm Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: PFO is present. Left-to-right shunt across the interatrial septum at rest. LEFT VENTRICLE: Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. 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. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions Prebypass A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen at a systolic blood pressure of 110 mm Hg.. At a systolic blood pressure of 180 mm Hg and Trendelenburg position the mitral regurgitation increased to mild to moderate (2+). Postbypass. There is preserved biventricular systolic function. MR is now trace/mild. The remaining study is unchanged from the prebypass period. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2195-5-21**] 12:12 ===================================== Brief Hospital Course: Mr [**Known lastname 16905**] was admitted to [**Hospital1 18**] for cardiac catheterization which revealed 3 vessel disease and preserved ejection fraction. Cardiac surgery was consulted and on [**5-21**] the patient was brought to the operating room where he had coronary artery bypass grafting. Please see operative report for details. In summary he had coronary artery bypass grafts including left internal mammary to left anterior descending artery, reverse saphenous vein graft to Diagonal artery, reverse saphenous vein graft to obtuse marginal and reverse saphenous vein graft to posterior left ventricular artery. His bypass time was 105 minutes with a crossclamp time of 90 minutes. He tolerated the operation well and was transferred from the operating room to the cardiac surgery ICU in stable condition. Once in the ICU he remained hemodynamically stable his anesthesia was reversed and he was extubated. On POD1 he was transferred from the cardiac surgery ICU to the stepdown floor for continued care and recovery. Over the next several days his tubes, lines, and drains were uneventfully removed according to protocol. His activity level was advanced with the assistance of nursing and physical therapy. He was noted to have intermittent episodes of atrial fibrillation that were treated with beta blockers and amiodarone following which he returned to [**Location 213**] sinus rhythm. He also had some confusion, he was seen by psychiatry and had a negative head CT. the confusion cleared after stopping his narcotics. Additionally he had a chest CT that revealed a 5 mm right lower lobe density that will require a follow up CT in [**4-6**] weeks. On POD seven he was discharged to rehabilitation at [**Location (un) 8641**] on [**Location (un) **] Care Rehabilitation Center. Medications on Admission: Effexor 75" Glipizide 5" Avodart 0.5' Januvia 50' Metoprolol 50' Simvastatin 10' Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO daily (). Disp:*30 Capsule(s)* Refills:*2* 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Venlafaxine 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 10 days. Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 9. 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* 10. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 11. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Januvia 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Location (un) 8641**] on [**Location (un) **] Care Rehab Center Discharge Diagnosis: Coronary artery disease NIDDM Chronic renal insufficiency Hyperlipidemia Depression ETOH abuse COPD Obstructive sleep apnea Celiac atherosclerotic disease BPH-status post TURP status post cervical disc surgery Discharge Condition: Good. Discharge Instructions: Take medications as directed in discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 pounds for 10 weeks. Shower daily, let water flow over wounds, pat dry with a towel. Do not use creams, lotions, or powders on wounds. Call our office for temperature >101.5, sternal drainage or redness. Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 68527**] for 1-2 weeks. Make an appointment with Dr. [**Last Name (STitle) 911**] for 3 weeks. Make an appointment with Dr. [**First Name (STitle) **] for 4 weeks. Will need a chest CT in [**4-6**] weeks to evaluate lung nodules seen on chest CT during your admission. Your primary care physician can arrange this study. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2195-5-29**]

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icd9cm

[ [ [] ] ]

[ "39.61", "99.04", "36.15", "36.13" ]

icd9pcs

[ [ [] ] ]

11571, 11664

8159, 9955

348, 748

11918, 11926

2013, 2807

12285, 12780

1622, 1643

10087, 11548

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1658, 1994

281, 310

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7,241

143,273

24248

Discharge summary

report

Admission Date: [**2176-9-20**] Discharge Date: [**2176-9-22**] Date of Birth: [**2139-9-13**] Sex: M Service: MEDICINE Allergies: Betadine / Lisinopril / Valsartan Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Hypertensive urgency Major Surgical or Invasive Procedure: None History of Present Illness: 37 y/oM with chronic type B dissection, uncontrolled HTN with chronic kidney disease, and congestive heart failure admitted to MICU with hypertensive urgency in the setting of medication noncompliance. The patient complained of worsening fatigue and symptoms of an upper respiratory tract infection x 1 week with increasing dyspnea x 36hrs. His first episode of shortness of breath woke him in the middle of the night. He subsequently complained of dyspnea on mild exertion. + Intermittent nonproductive cough with post-tussive emesis x 1. + Increasing peripheral edema, orthopnea and PND. He denied any chest discomfort, palpitations, fever, increased sputum production or other complaints. He does have a remote history of asthma but has not needed an inhaler since childhood. Of note, the patient has not taken his home doses of amlodipine or HCTZ x 2 weeks because "his prescription ran out and he was unable to go to the pharmacy while it was open." He initially presented to OSH with a BP [**Location (un) 1131**] of 207/127. CXR showed atelectasis vs infiltrate on L side and CT chest w/o contrast without significant abnormality. His dyspnea resolved with oxygen therapy and he became asymptomatic. He received his home BP medications of labetolol 600mg, spironolactone 50mg, amlodipine 10mg and ceftriaxone/ levaquin for a possible PNA. Due to concern for expanding aortic dissection, he was transferred to [**Hospital1 **] for further evaluation. On presentation to [**Hospital1 **], initial VS: 96.8 85 188/110 18 99%. Vascular surgery consult recommended CTA to r/o increased dissection but patient refused IV contrast. After talking with radiology, decided to pursue MRI which showed stability of type B dissection with slight increase in size of thoracic aorta. For hazy left lower lobe opacity, given levaquin 750mg. For management of HTN, patient received another dose of home blood pressure medications including amlodipine 10mg, HCTZ 50mg ([**12-2**] of home doses) and labetolol 600mg without significant effect. He was subsequently started on a labetolol drip with BP decreasing slightly. As there was no acute surgical issue, patient admitted to the medical ICU for further management. Past Medical History: - chronic type B aortic dissection - poorly controlled HTN - chronic renal insufficiency, baseline Cr 2.5 -3 - Acute disseminated encephalomyelitis - group B streptococcal bactremia - eczema - childhood asthma - allergic rhinitis - rotator cuff injury - G6PD deficiency Social History: currently employed as a bartender - tobacco: smokes [**12-2**] ppd - ETOH: [**1-3**] drinks/ week Denies illicit drugs Family History: Mother w/ CAD in her forties as well as DM and HTN. Maternal grandfather with DM and maternal grandmother w/ HTN. Aunt w/ breast cancer in her late 40's. Physical Exam: VS: Temp: afebrile BP: 163/107 HR: 83 RR: 25 O2sat: 100% RA GEN: moderately obese, comfortable, NAD HEENT: PERRL, injected sclera, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy NECK: JVP @ 13cm, no carotid bruits, no thyromegaly or thyroid nodules RESP: crackles at bases b/l CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: warm well perfused; +2 radial/ +2 dorsal pedal pulse SKIN: thickened hyperkeratotic skin with plaques on extensors NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. No pass-pointing on finger to nose. Pertinent Results: =================== LABORATORY RESULTS =================== At Presentation: WBC-10.6 RBC-3.76* Hgb-11.7* Hct-36.0* MCV-96 RDW-14.8 Plt Ct-205 -----Neuts-83.1* Lymphs-8.1* Monos-3.4 Eos-5.0* Baso-0.4 Glucose-88 UreaN-40* Creat-2.7* Na-142 K-4.9 Cl-110* HCO3-24 proBNP-2333* On Discharge: WBC-8.0 RBC-3.59* Hgb-11.3* Hct-33.9* MCV-95 RDW-14.9 Plt Ct-196 Glucose-104* UreaN-41* Creat-3.3* Na-137 K-4.7 Cl-104 HCO3-26 AnGap-12 =============== OTHER RESULTS =============== ECG [**2176-9-20**]: Sinus rhythm. Left atrial abnormality. A-V conduction delay. Left ventricular hypertrophy. Non-specific lateral ST-T wave changes. Compared to the previous tracing of [**2176-7-1**] atrial ectopy is absent. Otherwise, no diagnostic interim change. CHEST RADIOGRAPH [**2176-9-20**]: IMPRESSION: 1. Small bilateral pleural effusions. 2. Prominent, tortuous aorta again seen. Please note that the patient is to have an MRI to further evaluate his aorta. MRI CHEST/ MEDIASTINUM W/O CONTRAST [**2176-9-20**]: IMPRESSION: Little overall change in the appearance of the known type A dissection with continued slight interval increase in size of the descending thoracic aorta. RENAL DOPPLER U/S [**2176-9-21**]: IMPRESSION: Main renal arteries are patent bilaterally with appropriate waveforms. Brief Hospital Course: This is a 37 y.o. male with chronic type B dissection, uncontrolled HTN with CKD, and CHF admitted to MICU with hypertensive urgency in the setting of medication noncompliance. 1. Hypertensive urgency: The patient presented with hypertensive urgency presumed due to medication noncompliance. He initially required a labetalol drip to maintain SBP's under 180 but was weaned off of it in the context of restarting his home anti-hypertensive regimen. Prior to discharge given persistent mild hypertension to the 160's his labetalol was increased to TID. 2. Aortic dissection: Initial concern on transfer was that the patient's aneurysm could be expanding in the setting of hypertensive urgency. MRI imaging was not suggestive of this and aneurysm remained stable. He will resume his regular surveillance regimen for this. 3. CKD: At presentation the patient's Cr was 2.7 but increased to 3.3 prior to discharge. Given benign ultrasound and fact that baseline Cr has vacillated to above 3 in the past as well as the fact the patient had close outpatient follow up this was not considered a contraindication to discharge. 4. Dyspnea: The patient presented with subjective dyspnea without any hypoxia. Despite concern for infiltrate in the ED given no leukocytosis and no other signs suggestive of pneumonia antibiotics were stopped. No EKG changes suggesting unlikely to be due to coronary ischemia. The patient's dyspnea was ultimately thought most likely due to mild volume overload in the context of hypertension and an increased afterload. This resolved by the day after admission and never recurred. 5. Eczema: The patient has severe eczema particularly on extensor surfaces of his toes. He was continued on his home regimen of clobetasol and triamcinolone creams. The patient tolerated a full diet. He was full code. Medications on Admission: - amlodipine 10mg daily - labetalol 800mg [**Hospital1 **] - pletal (patient d/c'd) - HCTZ 50mg daily - celexa 40mg daily - claritin 10mg daily - calcitriol 0.25mg TID - clonazepam 0.5mg [**Hospital1 **] - spironolactone 50 mg Tablet daily - cholecalciferol 800mg daily - triamcinolone cream - clobetasol cream Discharge Medications: 1. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day as needed for allergy symptoms. 3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO three times a day. 4. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day. 5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. clobetasol 0.05 % Cream Sig: One (1) Application Topical twice a day. 7. triamcinolone acetonide 0.1 % Ointment Sig: One (1) Application Topical twice a day: No more than 2 weeks per month to avoid skin thinning. Not to be used on face. 8. hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 9. spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 10. labetalol 200 mg Tablet Sig: Four (4) Tablet PO three times a day. Disp:*360 Tablet(s)* Refills:*2* 11. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: Primary: Hypertensive urgency Secondary: Chronic type B aortic dissection Chronic renal insufficiency Eczema Allergic rhinitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname **], You were admitted to the intensive care unit at [**Hospital1 18**] for severely elevated blood pressures. You were given a continuous infusion of a medication to lower your blood pressure, which gradually improved. You were restarted on your home blood pressure medications, which you had not been taking for some time. You had an MRI and an ultrasound, which did not show any worsening of your aortic dissection. As your blood pressures remained a bit high we increased your labetalol to 800 mg three time a day (from two times a day). Your other medications have not been changed. It is crucial that you take your daily medications as directed, to avoid further medical emergencies and hospitalizations. Please let your regular doctors know if [**Name5 (PTitle) **] need assistance obtaining these medications. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2176-9-24**] 2:35 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 721**] Date/Time:[**2176-9-25**] 9:30 Provider: [**Name10 (NameIs) 247**] SHU, MD Phone:[**Telephone/Fax (1) 1387**] Date/Time:[**2176-9-26**] 2:00 [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "305.1", "V15.81", "493.90", "428.0", "404.91", "692.9", "441.03", "585.9", "428.43", "459.81", "311" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8435, 8441

5188, 7026

323, 330

8613, 8613

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262, 285

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151,288

39988

Discharge summary

report

Admission Date: [**2179-8-18**] Discharge Date: [**2179-9-1**] Date of Birth: [**2121-12-28**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 7651**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Tunneled subclavian HD line placement PRBC transfusion x2 Cardiac Catheterization X2 with DES to Ramus and DES to LCx/OM2 History of Present Illness: 57M with a complex medical hx including HTN, CHF, DM on insulin, ESRD (s/p AVF placement and now revision 2 weeks ago), s/p severe Fournier's gangrene requiring an extended MICU stay and a diverting end-sigmoid colostomy on [**2177-12-11**]. He presented to [**Hospital6 19155**] on [**8-18**] with CP, SOB, found to have trop of 6.8, BNP 627 and EKG c/w NSTEMI, started on heparin gtt, given nitro which relieved his pain, transferred to [**Hospital1 18**]. Past Medical History: MEDICAL & SURGICAL HISTORY: 1. Fournier's gangrene (requiring diverting sigmoid colostomy and multiple washouts/testicular debridements) 2. hypoxic respiratory failure 3. CHF (LVEF 50%, on [**12/2177**]) 4. MRSA tracheobronchitis 5. type 2 diabetes mellitus 6. gastroparesis 7. kidney stones 8. hypertension 9. hyperlipidemia Social History: Currently lives by himself at home. Patient is a former policeman. Quit tobacco in [**2154**], 10 pack year history. Occasional alcohol use; denies illicit substance use. Family History: Family history of diabetes. Mother died of cancer 'in her lung and liver' Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: 98.3 153/82 97# 84 GENERAL: Well appearing in NAD HEENT: PERRL, EOMI NECK: no carotid bruits, mildly elevated JVD LUNGS: Crackles in bibasilar distribution, otherwise good air entry HEART: RRR, normal S1 S2, no MRG ABDOMEN: Soft, NT, NABS, no organomegaly. Ostomy without surrounding erythema or tenderness EXTREMITIES: 1+ edema b/l NEUROLOGIC: A+OX3 DISCHARGE PHYSICAL EXAM V: Afebrile 98.6, 129/73, P-65 18 95RAL out made 250cc urine all day yesterday GENERAL: Middle aged male in NAD, lying in bed. 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 7 cm. CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3, S4. LUNGS: Resp were unlabored, no accessory muscle use. Mild bibasilar crackles, no wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Colostomy bag in place and draining brown stool EXTREMITIES: 2+ pitting edema to knees bilaterally. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: ADMISSION LABS [**2179-8-18**] 06:00PM BLOOD WBC-9.4 RBC-2.74* Hgb-8.7* Hct-27.0* MCV-99* MCH-31.7 MCHC-32.1 RDW-14.8 Plt Ct-195 [**2179-8-18**] 06:00PM BLOOD PT-10.9 PTT-96.4* INR(PT)-1.0 [**2179-8-18**] 06:00PM BLOOD Glucose-94 UreaN-67* Creat-5.5* Na-146* K-4.5 Cl-113* HCO3-18* AnGap-20 [**2179-8-18**] 06:00PM BLOOD CK-MB-25* MB Indx-3.4 [**2179-8-19**] 08:20AM BLOOD Calcium-8.3* Phos-5.6* Mg-2.0 ON DISCHARGE [**2179-8-31**] 05:45AM BLOOD WBC-11.5* RBC-2.79* Hgb-8.7* Hct-26.2* MCV-94 MCH-31.1 MCHC-33.2 RDW-15.5 Plt Ct-204 [**2179-8-31**] 05:45AM BLOOD UreaN-30* Creat-3.8*# Na-141 K-3.9 Cl-102 HCO3-31 AnGap-12 [**2179-8-31**] 05:45AM BLOOD CK-MB-5 [**2179-8-31**] 05:45AM BLOOD Calcium-8.0* Phos-3.6 Mg-2.1 EKG [**2179-8-18**]: Sinus rhythm. Minor non-specific lateral ST-T wave abnormalities. Compared to the previous tracing of [**2179-1-15**] no significant change. CXR [**2179-8-18**]: FINDINGS: Cardiomegaly is noted with pulmonary edema and trace pleural effusions, right greater than left. No pneumothorax. Bony structures intact. Degenerative AC joint arthropathy. IMPRESSION: Findings compatible with congestive heart failure. CXR [**2179-8-26**] FINDINGS: As compared to the previous radiograph, there is no relevant change. Moderate fluid overload, combined to cardiomegaly and a small right pleural effusion. Hemodialysis catheter in situ. The retrocardiac atelectasis that pre-existed is less severe than on the previous exam. No newly appeared focal parenchymal opacities suggesting pneumonia. ECHO [**2179-8-19**]: The left atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**1-25**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the findings of the prior study (images reviewed) of [**2178-1-19**], the findings are similar, but the technically suboptimal nature of both studies precludes definitve comparison. CARDIAC CATHETERIZATION [**2179-8-20**] FINAL DIAGNOSIS: 1. Severe 3 vessel CAD. CAGG not a good option given no LAD or RCA targets. 2. Moderate elevated right sided and moderate to severely elevated left sided filling pressures. 3. Preserved cardiac output. CARDIAC CATHETERIZATION [**2179-8-30**] COMMENTS: 1. Successful PCI of Ramus with Resolute 2.75 X 22mm stent 2. Successful PCI of LCX/OM1 with Resolute 2.75 X 26mm stent FINAL DIAGNOSIS: 1. Severe 3 vessel CAD 2. Success PCI with DESs of Ramus (Resolute 2.75 X 22mm) and LCX/OM2 (Resolute 2.75 X 26mm). 3. ASA 81mg indefinitely. Prefer Prasugrel 60mg load and 10mg daily for 1 year. [**Month (only) 116**] change to Plavix 75mg daily after 6 month uninterrupted use of Prasugrel. 4. Risk factor reduction 5. A terumo pressure band was applied to right radial artery at the conclusion of procedure. Brief Hospital Course: 57 M with complex medical hx incl ESRD, DM2, CHF, p/w NSTEMI. Hospital course complicated by acute renal failure requiring initiation of dialysis and staged cardiac catheterization. # NSTEMI. Pt admitted from OSH for unstable angina, found to have trop of 1.26 and elevated MB. ECG showed lateral ST-changes. Continued on heparin and plavix loaded. On the floor pt denied CP, SOB. Pt initially refused catheterization fearing it might lead to accelerated need for hemodialysis. After several conversations w/ attending physician, [**Name10 (NameIs) **] weighed risks and benefits of procedure and agreed to proceed. Pt appeared overloaded prior to procedure, and received 60 IV lasix X 2 with good urine output. He was still mildly volume positive before catheterization, judged to be acceptable in the setting of ESRD. He received left heart catheterization [**8-20**], revealing signficant disease with complicated lesions in his LAD and LCx. However, he received a large amount of dye and his case was aborted given the desire to avoid the need for hemodialysis given his ESRD. The patient remained chest pain free between his diagnostic cath [**8-20**] and therapeutic cath [**8-30**] on maximal medical regimen including heparin gtt (48 hrs) ASA 325mg, plavix, metoprolol and statin. On [**8-30**], the patient had a DES to Ramus and DES to LCx/OM2. He [**Month/Day (4) 8337**] the procedure well. He has follow-up with his outpatient cardiologist Dr. [**Last Name (STitle) 41007**] in the coming weeks. ESRD. Pt had AVF placed six months prior to this admission, and revision two weeks prior. Pt desires transplant and expressed strong wish to postpone dialysis as long as possible. Renal consulted for management of catheterization in setting of ESRD; recommended simultaneous hydration and diuresis. Unfortunately after cath [**8-20**], patient creatinine began to rise from 3.5 to 8.8, necessitating urgent dialysis. Unfortunately, the patient's AV fistula was still too immature for use and a tunnel catheter was placed [**8-25**]. Mr [**Known lastname **] [**Last Name (Titles) 8337**] dialysis well and went for subsequent treatments after his second cardiac cath [**8-31**]. He has been discharged with outpatient dialysis MWF, which he will likely require long term. He also has outpatient follow up with the transplant service. Dirty UA with positive Urine culture The patient had a dirty UA and a positive urine culture that grew Klebsiella. The patient was asymptomatic. He completed a 7 day course of ciprofloxacin while in house. Depression While in house, the patient had passive suicidal ideations and a depressed mood. He was seen by psychiatry, who recommended long term therapy and medication. The patient refused both. The psychiatry team spoke with the [**Hospital 228**] health care proxy and sister in law, who felt the patient was not safe at home with a firearm. Psych had the local police department (for whom the patient used to work) confiscate Mr [**Known lastname **] firearm from his home. The patient denies any homicidal or suicidal ideations at discharge. Anemia The patient appeared to have anemia from iron deficiency and chronic kidney disease. Guaiac of stools was negative. He was kept on PO iron and also received EPO treatments at dialysis. Past Hx of Fournier's Gangrene c/b bowel resection. The patient had no active issues with his ostomy site. Diabetes The patient had 2 episodes of AM hypoglycemia. His basal insulin dose was decreased and his bolus doses were increased to limit post-prandial hyperglycemia. Transitional Issues The patient is confirmed DNR/DNI He will continue to follow up with Nephrology at dialysis. He also has an appointment with the transplant team. The patient's fistula should continue to be monitored to determine when it will be mature enough for use. Hopefully, he will not need the tunnel catheter for a prolonged period of time. Cardiologist Dr [**Last Name (STitle) 41007**] will monitor for symptoms of angina post-cath. Echo in house revealed normal ejection fraction with restrictive physiology. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **] 2. Calcium Carbonate 500 mg PO TID:PRN Meals 3. Rosuvastatin Calcium 10 mg PO DAILY 4. Aspirin 325 mg PO DAILY 5. Bisacodyl 10 mg PO HS 6. Calcitriol 0.25 mcg PO 5 DAYS A WEEK 7. Vitamin D 1000 UNIT PO DAILY 8. Ferrous Sulfate 325 mg PO BID 9. Furosemide 80 mg PO BID 10. Gabapentin 300 mg PO DAILY 11. Metoprolol Tartrate 50 mg PO BID 12. Omeprazole 40 mg PO DAILY 13. Prochlorperazine 5 mg PO Q8H:PRN N/V 14. Acetaminophen 1000 mg PO Q6H:PRN Pain Not to exceed 4 grams daily 15. Albuterol Inhaler 1 PUFF IH Q4H:PRN Wheezing 16. Glargine 60 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 17. Nephrocaps 1 CAP PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain Not to exceed 4 grams daily 2. Bisacodyl 10 mg PO HS 3. Calcitriol 0.25 mcg PO 5 DAYS A WEEK 4. Calcium Carbonate 500 mg PO TID:PRN Meals 5. Ferrous Sulfate 325 mg PO BID 6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **] 7. Glargine 50 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 8. Rosuvastatin Calcium 20 mg PO DAILY RX *Crestor 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 9. Vitamin D 1000 UNIT PO DAILY 10. Prasugrel 10 mg PO DAILY RX *Effient 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 11. sevelamer CARBONATE 800 mg PO TID W/MEALS RX *Renvela 0.8 gram 1 Powder(s) by mouth three times daily with meals Disp #*90 Pack Refills:*0 12. Albuterol Inhaler 1 PUFF IH Q4H:PRN Wheezing 13. Omeprazole 40 mg PO DAILY 14. Prochlorperazine 5 mg PO Q8H:PRN N/V 15. Nephrocaps 1 CAP PO DAILY RX *Nephrocaps 1 mg 1 capsule(s) by mouth daily Disp #*30 Tablet Refills:*0 16. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 17. Metoprolol Succinate XL 150 mg PO DAILY RX *metoprolol succinate 50 mg 3 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 18. Gabapentin 300 mg PO QHD Discharge Disposition: Home Discharge Diagnosis: Primary: NSTEMI, ESRD on HD, DMII Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You came to the hospital with chest pain and shortness of breath. An electrocardiogram and blood tests showed you were having a heart attack. A cardiac catheterization revealed extensive coronary artery disease. Due to your renal disease, no stents were placed initially to limit the amount of contrast injected into your body. Unfortunately, this contrast still caused severe kidney damage that caused you to need dialysis. Your AV fistula was not mature enough to be used and a tunneled catheter was placed in your R chest. You [**Hospital1 8337**] dialysis very well and you will continue to need Dialysis as an outpatient. This will be done every Monday, Wednesday, and Friday @3PM at [**Location (un) **] [**Location (un) 32944**] Renal Center. It will start @230PM on [**9-3**]. When your renal function stabilized, a second cardiac catheterization was performed and 2 stents were placed in 2 different diseased arteries. With these stents, you must continue to take Aspirin. You have been switched from Plavix to Prasugrel, which is a very similar medication. Please see all of your medication changes below Please follow up with your PCP, [**Name10 (NameIs) **], Nephrologist, and Kidney Transplant physicians at the appointment times listed below. It was a true pleasure taking care of you, Mr [**Known lastname **] Followup Instructions: Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP Specialty: Primary Care When: Tuesday [**9-7**] at 10:30am Location: [**Hospital 46644**] MEDICAL ASSOCIATES Address: [**Location (un) 32946**], [**Location (un) **],[**Numeric Identifier 32948**] Phone: [**Telephone/Fax (1) 32949**] *We rescheduled your appt with Dr.[**Last Name (STitle) 87947**] from this Friday to Tuesday to fit around your dialysis days, you will see [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP Name: [**Last Name (LF) **],[**First Name3 (LF) **] MD Specialty:Cardiology When: Thursday [**9-16**] at 9:45am Location: [**Hospital 46644**] MEDICAL ASSOCIATES Address: [**Street Address(1) **] WAY, [**Location (un) **],[**Numeric Identifier 75553**] Phone: [**Telephone/Fax (1) 86181**] [**Location (un) **] [**Location (un) 32944**] Renal Center [**Doctor Last Name 56282**] [**Location (un) 32944**], [**Numeric Identifier 87948**] Phone: [**Telephone/Fax (1) 60552**] Nephrologist: Your outpatient dialysis schedule will be every Mon, Wed & Fri at 3:00pm, you will see a Nephrologist at these visits. Department: TRANSPLANT CENTER When: TUESDAY [**2180-1-4**] at 10:40 AM With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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icd9cm

[ [ [] ] ]

[ "88.56", "88.55", "00.44", "00.46", "00.66", "00.41", "38.95", "36.07", "39.95", "37.23" ]

icd9pcs

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315, 439

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12,771

135,943

49187

Discharge summary

report

Admission Date: [**2175-12-25**] Discharge Date: [**2176-1-2**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Known firstname 2387**] Chief Complaint: right arm/leg weakness Major Surgical or Invasive Procedure: [**Country **] stent History of Present Illness: This patient is a 84 yo caucasian male w/ PMX of CAD s/p NSTEMI + PCI in [**2170**], HTN, hyperlipidemia, COPD, CRI admitted to the CCU following [**Country **] stent. Pt states that on [**12-24**] he was in his usual state of health when he was at the store paying a cashier and his right arm went dead. It feel to his side and the patient had no control over it what so ever. He did not notice any impairment in any other extremity. He then drove home using just his left hand to steer the car. He eventually regained use of his right hand. At home, the patient then lost use of his right hand and right leg for a 20 minute period. He does not report any change of vison, dysarthria, facial droop or numbness during this episode. Ar OSH, head CT was negative for acute infarct but carotid US showed 70% [**Country **] occlusion and 100% [**Doctor First Name 3098**] occlusion. PT was treated at OSH w/ plavix/heparin gtt and then transferred to [**Hospital1 18**]. Past Medical History: COPD BPH CRI s/p cholecystectomy CAD MI '[**70**] HTN Social History: Quit tobacco but has 80 pack year history + ETOH socially Family History: non-contributory Physical Exam: Temp 97.3 BP 164/72 HR 81 RR 15 O2 sat 99% 2L Weight 99% 2L Gen: obese appearing male, lying flat in bed nad HEENT: no scleral incterus, PERRL, EOMI, mmm, no JVD CV: RRR no m/r/g Resp: CTA anteriorly Abd: obese soft NT ND + BS - HSM Ext: no c/c/e - r groin site bandaged, no drainage Neuro: CN II-XII intact, pinprick intact all 4 extremities, [**5-31**] strength in UE b/l Skin: no rash Pertinent Results: [**2175-12-25**] 10:45PM GLUCOSE-171* UREA N-33* CREAT-1.6* SODIUM-135 POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-29 ANION GAP-10 [**2175-12-25**] 10:45PM CK(CPK)-23* [**2175-12-25**] 10:45PM CK-MB-NotDone cTropnT-<0.01 [**2175-12-25**] 10:45PM CALCIUM-8.6 PHOSPHATE-2.7 MAGNESIUM-2.0 [**2175-12-25**] 10:45PM WBC-7.5 RBC-4.30* HGB-11.4* HCT-35.1* MCV-82 MCH-26.6* MCHC-32.5 RDW-15.0 [**2175-12-25**] 10:45PM PLT COUNT-215 [**2175-12-25**] 10:45PM PT-15.4* PTT-128.8* INR(PT)-1.5 Brief Hospital Course: 84 yo male w/ PMHx significant for CAD s/p NSTEMI, HTN, hyperlipidemia, CRI p/w acute onset right sided weakness likely from TIA admitted for right internal carotid artery stent. . TIA - Patient had a [**Country **] stent placed without difficulty and was transferred to the CCU with a goal SBP of 140-160 post procedure. Neosynephrine was on hold in case patient needed help to maintain goal pressures but was not required. The patient's home blood pressure medications were held post stenting. He was given mucomyst for renal protection from contrast. He was completely stable in the CCU and was transferred to the floor after 1 day. CV: CAD - patient was continued on his aspirin and zetia. He has a history of myalgias on statins. . [**Name (NI) **] - Pt had a documented EF 40-50% throughout hospitalization he showed no overt signs of failure. His lasix was temporarily held for renal protection from the load. . Rhythm - no issues . Neuro - s/p [**Country **] stent, stable upon d/c. Neuro exam was consistent without changes. . CRI - The patient was given IVFand mucomyst pre and post catheterization for renal protection. . [**Name (NI) 103170**] - pt has some trace hematuruia in the setting of foley placement with BPH and heparin gtt. Once the floey was d/c no gross hematuria was note. His HCT remained stable. . UTI - Ciprofloxacin started on [**12-25**]. Pt was given a presciption to finish a 14 day course. . PPX - patient was given influenza vaccine prior to d/c. Discharge Medications: 1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H for 8 days Disp:*4 Tablet(s)* Refills:*0* 3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-27**] Puffs Inhalation Q6H (every 6 hours). 7. Fenofibrate Micronized 160 mg Tablet Sig: One (1) Tablet PO qday (). 8. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day. Tablet(s) Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: TIA s/p R ICA stent Acute Tubular Necrosis Discharge Condition: Stable Discharge Instructions: Patient was instructed to take all of the medications as intstructed including Plavix for the stent. Pt was instructed to seek medical attention if he were to develop another neurological symptoms including weakness, numbness, confusion, trouble with swallowing/speech, or any other concerning symptoms Followup Instructions: Follow with Dr. [**Last Name (STitle) **] in 1 month. [**Telephone/Fax (1) 2394**] Please follow up with your PCP in one week to check your serum creatinine. Please call the [**Hospital1 18**] sleep unit to have a sleep study performed for obstructive sleep apnea ([**Telephone/Fax (1) 9525**].

[ "433.30", "401.9", "600.00", "427.89", "584.5", "593.9", "599.0", "496", "412" ]

icd9cm

[ [ [] ] ]

[ "00.63", "00.61", "88.41", "99.04" ]

icd9pcs

[ [ [] ] ]

4741, 4798

2441, 3937

284, 307

4884, 4892

1929, 2418

5244, 5545

1481, 1499

3960, 4718

4819, 4863

4916, 5221

1514, 1910

222, 246

335, 1312

1334, 1390

1406, 1465

82,463

100,698

13451

Discharge summary

report

Admission Date: [**2131-10-14**] Discharge Date: [**2131-10-15**] Date of Birth: [**2104-5-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: found down. Major Surgical or Invasive Procedure: None History of Present Illness: patient is a 27-year-old man with history of obsessive-compulsive disorder and depression who presents from home after being found down by his friend's girlfriend. According to Friend, [**Name (NI) **] (see below) they were "partying hard" at a friend's house and then woke up the next morning to find [**Doctor Last Name **] as well as another friend unable to wake up. [**Doctor First Name **] believes that [**Doctor Last Name **] took too many "opiates", because "this is what opiate overdose looks to me." Everyone was worried about [**Doctor Last Name **] so they called Police and the ambulance which took [**Doctor Last Name **] to the Emergency Room. . In the ED, initial vs were: T afebrile, P 114, BP 113/86, R 14, O2 sat 94%RA. An EKG showed sinus tachycardia with normal intervals and no ischemic changes. Patient was given 2mg IN Narcan in the field, 2mg IM narcan in ED and then got 2nd mg IV Narcan - as he appeared to be protecting his airway adequately, he was not intubated. He was however started on Narcan drip prior to admission for concern of persistent somnolence. He also received 1L of intravenous fluids. . On the floor, he feels sleepy and tired. He does not recall what happened. He would prefer to have his brother [**Name (NI) 653**] and when asked, he agrees for us to contact his outpatient psychiatrist. He endorses a friend named [**Name (NI) **] ([**Telephone/Fax (1) 40783**]. . As per his outpatient psychiatrists (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] - former pediatric psychiatrist, and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] - current psychiatrist with whom patient has only met for a couple of sessions), patient has a history of "disabling" obsessive-compulsive disorder, complicated by mild depression. Patient has no history of suicide attempts or intentional drug overdose. . Review of systems: patient states that he feels sleepy, denies coughing, fevers, chills, recent illness . 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: --obsessive-compulsive disorder (diagnosed years ago) --depression with history of psychiatric hospital admissions (per psychiatric note from [**2130-3-29**]) Social History: Social History: Lives by himself. ?On Disability due to psych ilness. Started smoking about 6 months ago and smokes a pack every 2 days. Drinks socially but in large amounts. Family History: (As per OMR) Extensive OCD FH - eldest brother (controlled on multiple meds), another brother (present at interview) had a "brief stint" with OCD that resolved, father (undiagnosed, except by children). Physical Exam: Vitals: T: 98.4 BP: 92/67 P: 103 R: 12 O2: 96%RA General: Patient is alert to name, address, president, and hospital. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: large scar on right shin (old burn), and scar on forehead, well healed. Pertinent Results: [**2131-10-15**] 01:00PM BLOOD WBC-6.4 RBC-3.95* Hgb-11.7* Hct-33.7* MCV-85 MCH-29.5 MCHC-34.6 RDW-12.7 Plt Ct-174 [**2131-10-14**] 02:00PM BLOOD WBC-16.9* RBC-4.85 Hgb-14.3 Hct-41.2 MCV-85 MCH-29.4 MCHC-34.6 RDW-12.7 Plt Ct-265 [**2131-10-14**] 05:38PM BLOOD PT-13.3 PTT-31.7 INR(PT)-1.1 [**2131-10-15**] 03:25AM BLOOD Glucose-72 UreaN-19 Creat-0.8 Na-141 K-4.5 Cl-108 HCO3-27 AnGap-11 [**2131-10-14**] 02:00PM BLOOD Glucose-95 UreaN-19 Creat-1.3* Na-143 K-5.9* Cl-104 HCO3-29 AnGap-16 [**2131-10-14**] 05:38PM BLOOD ALT-21 AST-28 AlkPhos-45 Amylase-28 TotBili-0.4 [**2131-10-14**] 05:38PM BLOOD Lipase-16 [**2131-10-15**] 03:25AM BLOOD Calcium-8.8 Phos-4.2 Mg-1.8 [**2131-10-14**] 02:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2131-10-14**] 02:10PM BLOOD Glucose-94 Lactate-3.5* K-5.7* [**2131-10-15**] 03:55AM BLOOD Lactate-1.1 Benzodiazepine Screen, Urine NEG Barbiturate Screen, Urine NEG Opiate Screen, Urine NEG Cocaine, Urine POS Amphetamine Screen, Urine POS Methadone, Urine POS Brief Hospital Course: # Overdose/Somnolence - No evidence of trauma on exam. Urine toxicology was positive for methadone, cocaine, and amphetamines. Amphetamine likely positive in setting of prescribed Adderall. He does not have medication patches on his body or needle track marks. Patient responded to Narcan and was on Narcan Drip in ED. His alertness waxed and waned the morning of admission. His respiratory rate remained normal and he did not require Narcan after admission. He received 4L IVF. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] scale was maintained. Psychiatry was consulted in the morning; they did not believe there was any element of suicidality in the presentation. Outpatient psychiatrists [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 40784**], and [**First Name8 (NamePattern2) 40785**] [**Last Name (NamePattern1) **] (former Psychiatrist) have been [**Last Name (NamePattern1) 653**] and are aware of admission; both agree with involving the inpatient psychiatric consult team. Throughout the day, the patient's mental status returned to an appropriate baseline; he continued to deny opiod ingestion, but he does state that he was unaware of what he was consuming at the shindig. # Hypotension - likely related to opiate overdose. Differential in a person who overdosed in his age group would include GI bleed; his HCT did trend down from 41-33 but his other cell lines decreased and he was not noted to have diarrhea. He received 4L IVF. . #Leukocytosis - Initial leukocytosis quickly resolved after admission. Unclear etiology. Medications on Admission: Medications: --Adderall 15 mg [**Hospital1 **] --Abilify 10 mg QD --citalopram 60 mg QAM --clonazepam 0.5 mg [**Hospital1 **] PRN Discharge Disposition: Home Discharge Diagnosis: Overdose Discharge Condition: Good, stable Discharge Instructions: You were evaluated in the ED and the ICU for increased sedation after "a night of partying." Although you do not know what specifically you ingested, your lab results demonstrate that you ingested opiods. This would explain your increased sedation, decreased drive to breath, and decreased blood pressure; these symptoms reversed when we used an [**Doctor Last Name 360**] that targets opiods. You were observed throughout the day and improved to a normal mental status. Stop using drugs. Continue to see your psychiatrist. See below instructions for danger signs that would suggest that you return to the ED. Followup Instructions: Followup with your outpatient psychiatrist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], within 3 days. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "970.81", "780.09", "709.2", "E850.2", "296.31", "E854.3", "288.60", "965.09", "427.89", "305.92", "305.1", "300.3", "458.8", "V17.0" ]

icd9cm

[ [ [] ] ]

[ "94.65" ]

icd9pcs

[ [ [] ] ]

6807, 6813

5017, 6627

336, 342

6865, 6879

3965, 4994

7542, 7811

3120, 3324

6834, 6844

6653, 6784

6903, 7519

3339, 3946

2275, 2730

285, 298

370, 2256

2752, 2912

2944, 3104

1,808

184,172

6370+55749

Discharge summary

report+addendum

Admission Date: [**2132-6-4**] Discharge Date: [**2132-6-18**] Date of Birth: [**2089-1-9**] Sex: F Service: SURGERY Allergies: Iodine Attending:[**First Name3 (LF) 5880**] Chief Complaint: Colovaginal Fistula Major Surgical or Invasive Procedure: Colovaginal fistula takedown/stoma revison Removal of Portacath History of Present Illness: This is a 43 year old woman who has a history of Colon CA that presented with a rectovaginal fistula, s/p resection with pouch. She then recieved xrt and developed a colovagianl fistula. She presents today for takedown of the fistula and revision of her stoma. She is otherwise at her baseline level of health Past Medical History: COPD Pelvic fluid collections - s/p pigtail catheter drainage, levo/flagyl Colon CA-presented w/rectovaginal fistula s/p descending colon resection w/loop ileostomy [**12-12**], colostomy and [**Doctor Last Name 3379**] pouch [**1-15**], s/p xrt with 5FU Social History: + tobacco [**1-13**] ppd for 30yrs. No etoh, drugs. Divorced, lives with boyfriend of 18yrs Family History: No family history of colon cancer, polyps or rectal bleeding. No family history of eye problems or CNS problems. Physical Exam: 98.9 96 20 98/48 96% NAD RRR CTA Abd: soft, non-tender, no masses, stoma intact, multiple scars. Ext: well perfused, warm Pertinent Results: [**2132-6-4**] 09:21PM GLUCOSE-102 UREA N-30* CREAT-0.9 SODIUM-135 POTASSIUM-3.0* CHLORIDE-100 TOTAL CO2-22 ANION GAP-16 [**2132-6-4**] 09:21PM CALCIUM-9.2 PHOSPHATE-3.2 MAGNESIUM-1.8 [**2132-6-4**] 09:21PM WBC-10.7 RBC-3.29* HGB-8.6* HCT-26.9* MCV-82 MCH-26.2* MCHC-32.1 RDW-17.9* [**2132-6-4**] 09:21PM PLT COUNT-438 [**2132-6-4**] 09:21PM PT-13.4* PTT-26.1 INR(PT)-1.2 Brief Hospital Course: The patient was taken to the operating room for takedown of her colovaginal fistula, this was uneventful. Post-op, she has some difficulty controling pain, but this was managed with a PCA. She was put back on her fentanyl patch, which was part of her home pain regimen, and APS was consulted. On POD 2 she was started on tube feeds, first at a trophic level. She had an episode of desaturation into the 80's%. She was transfered to the SICU for closer monitioring. Her pulmonary toilet was increased. Bronchoscopy was performed, which showed colapsed LLL. It was suctioned and she improved a great deal. She was transferred out of the unit on POD 6, and did well since then. It was noticed that her portacath site was exudiding some pus, so she was taken to the operating room for removal of the port, this was done without problem. [**Name (NI) **], her TF were advanced to goal and were started to be cycled without difficulty. She was started on PO food, which was slowly advanced, She tolerated this well. On POD 12 (from her initial surgery) she was discharged home with tube feeds and home services Medications on Admission: Percocet TPN Albuterol Fluticasone inhaler Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. Sodium Hypochlorite 0.5 % Liquid Sig: One (1) Appl Miscell. ASDIR (AS DIRECTED). Disp:*QS ML(s)* Refills:*0* 7. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*QS IH* Refills:*2* 8. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). Disp:*10 Patch 72HR(s)* Refills:*0* 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q3H (every 3 hours). 10. Acetylcysteine 20 % (200 mg/mL) Solution Sig: 3-5 MLs Miscell. Q4-6H (every 4 to 6 hours). Disp:*QS ML(s)* Refills:*2* 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO q6:prn as needed for Anxiety. Disp:*30 Tablet(s)* Refills:*0* 13. Probalance Liquid Sig: One (1) PO once a day: 2/3rds strength Rate 90cc/hour from 8PM to 8AM (1080cc total. Disp:*QS ML(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: left lower lobe collapse enterovaginal fistula with adenocarcinoma COPD post-operative atrial fibrillation infected portacath Discharge Condition: Stable Discharge Instructions: If you have severe belly pain, nausea/vomiting, fevers/chills, dislodgement of your feeding tube, redness/oozing from your incision site, seek medical attention. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] on [**2132-6-24**], call for a time: [**Telephone/Fax (1) 6439**] Follow up with Dr. [**Last Name (STitle) 5361**] as needed: call [**Telephone/Fax (1) 19564**] for an appointment. Completed by:[**2132-6-16**] Name: [**Known lastname 3992**],[**Known firstname **] Unit No: [**Numeric Identifier 4182**] Admission Date: [**2132-6-4**] Discharge Date: [**2132-6-18**] Date of Birth: [**2089-1-9**] Sex: F Service: SURGERY Allergies: Iodine Attending:[**First Name3 (LF) 813**] Addendum: See below Brief Hospital Course: On the initial day of discharge, Ms. [**Known lastname **] had a bout of bilious, non-bloody emesis. It was also noted that she did not have any output or flatus from her ostomy throughout the day. It was decided to keep her overnight for observation and check some labwork. Her CBC and Chem 7 were unremarkable. On POD 13/5, she had some emesis overnight but later in the day tolerated a clears diet; in addition, her ostomy put out approximately 200cc of stool. She felt well. She was discharged home on POD #14/6 in stable condition, with no changes to prior discharge planning. Discharge Disposition: Home With Service Facility: [**Hospital3 413**] VNA [**First Name11 (Name Pattern1) 801**] [**Last Name (NamePattern4) 815**] MD [**MD Number(2) 816**] Completed by:[**2132-6-18**]

[ "996.62", "427.31", "V10.09", "305.1", "619.1", "614.4", "V15.3", "496", "197.4", "E879.2", "558.1", "909.2", "518.0", "614.6", "281.9" ]

icd9cm

[ [ [] ] ]

[ "46.01", "70.74", "45.62", "86.05", "46.39", "54.59", "33.24", "46.51", "96.6" ]

icd9pcs

[ [ [] ] ]

6193, 6405

5582, 6170

284, 349

4730, 4738

1373, 1756

4948, 5559

1098, 1212

2989, 4486

4581, 4709

2922, 2966

4762, 4925

1227, 1354

225, 246

377, 691

713, 970

986, 1082

10,515

166,761

48334

Discharge summary

report

Admission Date: [**2163-1-26**] Discharge Date: [**2163-2-5**] Date of Birth: [**2110-9-29**] Sex: F Service: MEDICINE Allergies: Heparin (Porcine) / Erythromycin Base Attending:[**First Name3 (LF) 1990**] Chief Complaint: anemia, fatigue Major Surgical or Invasive Procedure: None History of Present Illness: 52 y.o. F with lupus s/p cadaveric renal transplant [**2151**] on immunosuppressive therapy, C4 tetraplegia, CAD, CHF, PVD, HCV, recently here for prolonged hospitalization [**Date range (1) 101813**]/07 for multiple medical problems, now returns with complaint of anemia and fatigue, worsening x 1 day. Hematocrit 23, baseline 28-29. No improvement with epo injections. Patient also more lethargic over past day. Therefore requesting blood transfusion. Denies associated chest pain, fever, chills, nausea, vomiting. In ER, hct 23. Also found to have Na 125 (baseline 126-128). Head CT negative. Admitted to the medicine service for anemia. ROS: as above. also with chronic debilitation, sacral decubitus ulcers. bed bound. osteomy draining. foley catheter in place, producing concentrated urine. otherwise negative. Past Medical History: -s/p Cadaveric Renal Translpltn [**2151**] (s/p Post-Strep GN? vs lupus-like syndrome [though NOT SLE or lupus nephritis])-> chronic allograft nephropathy -s/p parathyroidectomy for hyperparathyroidism -AVN of hips -Dilated Cardiomyopathy -Peripheral vascular disease -h/o hypothyroidism -Osteoarthritis -s/p colectomy w/ end ileostomy [**2-19**] perforated ischemic colon -CAD - s/p perioperative MI -HCV -hemochromatosis 2/2 blood transfusions -ACD -Zenker's diverticulum -right first toe amputation -chronic allograft nephropathy. -status post bilateral femoral popliteal bypass. -left total hip replacement. -Status post multiple AV fistula revisions. -Anemia of Chronic Disease - Atrial fibrillation and NSVT on amiodarone - C spine cord compression with upper extremity weakness Social History: Bed-bound given progressive weakness and debilitation. No tobacco or etoh. Husband is very involved in care; he is a [**Company 2267**] employee, and is knowledgeable about her medical condition and course; he is the HCP. Family History: No CAD or cancers. Father with lung CA. Many family members with SLE. Physical Exam: VS T 97.6, BP 102/62, HR 66, RR 16, 94% RA Gen: Chronically ill-apperanig female lying in bed in mild discomfot from decubitus ulcers HEENT: MM dry, PERRL, EOMI Neck: no appreciable jvp. CV: RR, nl s1 and S2, 3/6 SEM at RUSB Pulm: decreased bs throughout, no focal ronchi or wheezes, dry basilar rales. Abd: ostomy pink, non-purulent or friable, +BS, non-tender, non-distended Ext: upper extremity with multipodus splints. [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] wrapped with gauze. skin: sacrum/coccyx with multiple deep decubitus ulcers, malodorous, covered with gauze Rectal: guaiac negative in ER Pertinent Results: Admission Labs: -------------- [**2163-1-26**] 06:58PM WBC-6.5# RBC-2.75* HGB-7.9* HCT-23.1* MCV-84 MCH-28.6 [**2163-1-26**] 06:58PM NEUTS-88.0* LYMPHS-8.6* MONOS-2.9 EOS-0.4 BASOS-0.2 [**2163-1-26**] 06:58PM CALCIUM-11.1* PHOSPHATE-3.4 MAGNESIUM-1.6 [**2163-1-26**] 06:58PM PT-14.1* PTT-30.7 INR(PT)-1.2* [**2163-1-26**] 06:58PM GLUCOSE-69* UREA N-48* CREAT-1.2* SODIUM-125* POTASSIUM-4.4 CHLORIDE-94* TOTAL CO2-22 ANION GAP-13 [**2163-1-26**] 09:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-NEG [**2163-1-26**] 09:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 Reports: [**2163-1-26**]- head CT: FINDINGS: No edema, masses, mass effect, hemorrhage or major vascular territorial infarction is noted. Dystrophic calcification of the basal ganglia is visualized. The patient shows severe calcification of both vertebral arteries and the cavernous portion of both carotid arteries. The patient shows signs of hyperostosis frontalis. The paranasal sinuses and mastoid air cells are clear. IMPRESSION: No acute intracranial pathology including no intracranial hemorrhage. Brief Hospital Course: A/P: 52 y.o. F with lupus s/p cadaveric renal transplant [**2151**] on immunosuppressive therapy, C4 tetraplegia, CAD, CHF, PVD, HCV, recently here for prolonged hospitalization [**Date range (1) 101813**]/07 for multiple medical problems, now returns with complaint of anemia and fatigue, worsening x 1 day. She was transferred to the ICU for fever and hypotension concerning for possibility of sepsis. Her course was unremarkable with stable blood pressure and respiratory status. She did have persistent oliguric renal failure throughout her ICU stay unresponsive to IVF. . # Goals of care: Though her multiple medical problems are described below, in many ways the primary issue during much of her ICU stay was that of goals of care. She seemed hesitant to undergo more invasive interventions (e.g., central lines, NG tubes, and other means of giving nutritional support) but was initially also reluctant to embrace the idea of a comfort-care plan. Her husband also was torn about how aggressively to pursue attempts at prolonging life vs increasing comfort. Two family discussions in the MICU moved the patient's code status from full code (on arrival) to DNR and probably DNI (but with a request to contact husband in the event of the possibility of intubation, which was not a sustainable code status); and to DNR/DNI with the caveat that the patient and husband would be willing to reverse this code status for procedures. Palliative care service was consulted and followed. . # Fever, hypotension: Concerning for possibility of sepsis [**2-19**] bacteremia from recent debridement of sacral decubitus ulcers. Pneumonia also considered although no evidence of infiltrate on CXR. She was treated with vancomycin and piperacillin-tazobactam for broad coverage. Given oliguric renal failure vancomycin was dosed based on daily trough levels. She was bolused initially to maintain SBP >60 and then remained stable hemodynamically for the remainder of her ICU stay. . # Oliguric renal failure s/p renal transplant: likely from intravascular volume depletion given fever, hypotension, possible sepsis. She continues with oliguria despite IVF boluses and MAP > 60. She was followed by renal throughout her ICU stay; a 24 hour urine collection suggested that she has profound renal failure, masked by standard chem 7 because her creatinine production is so low because of low muscle mass. She was continued on her transplant medications including MMF, prednisone and cyclosporine, though as she was less able to take PO medications, this was being reconsidered as she was transferred back from the ICU. Her furosemide and ACE inhibitor were held given oliguria. Bactrim DS for PCP prophylaxis was continued. . # Sacral decubitus and ischial ulcers - She has stage III/IV ulcers, twice debrided by plastics. Based on their second debridement they do think that osteomyelitis is a strong possibility and she will therefore need 4-6 weeks of antibiotics for suppression of presumed osteo. She was continued on vanc and zosyn. Her extremely poor nutritional status would have to be corrected for these to even begin to heal (plastics recommended albumin at least >3.0); and given her immobility and the fact that these ulcers are located at each pressure point of any supine position, how she might heal even under better circumstances is not clear. . # Hyponatremia: Her sodium was often near her recent baseline around 126-128. On last admission this had gone down to 116. This was likely secondary to heart failure and poor perfusion, leading to ADH response to defend volume. We attempted to give normal saline to the extent tolerated to try to increase her sodium, with slight success. . # Acute on chronic anemia: Her hematocrit was 23 as she came in, baseline 28-29. We transfused several times during the admission. She was guiaic negative suggesting against GI blood loss. She does receive epoeitin as an outpatient and her anemia is most likely secondary to her kidney failure. . # s/p Cadaveric Renal Transplant: We continued cyclosporine, prednisone, and CellCept. As above, as she has increasing trouble with POs, these may need to be revisited. . # Severe Deconditioning: She remained highly deconditioned. Palliative care was consulted for overall goals of care and help with pain and comfort control. See above regarding goals of care. One primary obstacle was her extreme weakness, at least partly due to poor nutritional status. As of the time of discharge from the [**Hospital Unit Name 153**] an enduring strategy for her nutrition had not been agreed on. . # Systolic CHF, chronic: EF 30%. Hypovolemic clinically. We held standing lasix. We continued her beta-blocker and ACE-inhibitor but discontinued these later in admission with hypotension and renal failure. . # CAD, native vessel: Chest pain free. She did have some episodes of chest tightness, but EKG was negative and her presentation was of a constant mild chest tightness, not consistent with ACS. . # h/o arrhythmia: We continued amiodarone. She remained in NSR. . # FEN: repleted lytes prn, cardiac/renal diet with crushed medications. . # PPx: Initially started on no heparin (possible HIT), however, HIT Ab came back negative so she was restarted; PPI; pneumoboots; fall precautions; and air mattress. . # Code: Full Code discussed with Dr. [**Last Name (STitle) **] (renal attending) - he has stated that pt. is dying, that renal transplant is failing (Cr. does not adequately reflect degree of renal impairment in her as she has extensive muscle wasting), and that treatment with HD (if she would want the invasive procedure of HD access, which she does not) would extend her life but would not provide any improvement in graft function or lead to any other treatment options; treatment options essentially exhausted under these circumstances. . Had extensive meeting with family today (75 minutes) in which we discussed the course of illness, state of renal failure, lack of treatment options - Mr. [**Name (NI) 101760**] (husband and HCP) expressed his wishes that only comfort measures be pursued from this point forward (he states that his wife has long expressed her wishes for no futher invasive measures, including no invasive IV or HD access). CMO status established. Palliative care RN and SW present for discussion and will continue to follow. Pt. expired peacefully night of [**12-5**]. Medications on Admission: 1. Gabapentin 300 mg PO HS 2. Aspirin 325 mg PO DAILY 3. Prednisone 7.5 Tablets PO DAILY 4. Oxycodone 10 mg PO Q12H 5. Amiodarone 200 mg PO DAILY 6. Epoetin Alfa 4,000 QMOWEFR 7. Escitalopram 10 mg PO DAILY 8. Lorazepam 0.5 mg PO Q4H 9. Nystatin(5) ML PO QID as needed. 10. Cyclosporine Modified 25 mg PO Q12H 11. Fentanyl 75 mcg/hr Patch 72 hr 12. Sodium Bicarbonate 650 mg PO TID 13. Carvedilol 3.125 mg PO BID 14. Isosorbide Mononitrate 60 mg PO DAILY 15. Mycophenolate Mofetil 500 mg PO BID 16. Allopurinol 100 mg PO DAILY 17. Pantoprazole 40 mg PO Q24H 18. Calcitriol 0.25 mcg PO DAILY 19. Folic Acid 1 mg PO DAILY 20. Acetaminophen 325 mg PO Q6H as needed. 21. Docusate Sodium 100 mg PO BID 22. Miconazole Nitrate 2 % Powder [**Hospital1 **] prn. 23. Psyllium PO DAILY 24. Trimethoprim-Sulfamethoxazole 80-400 mgPO QMOWEFR 25. Oxycodone-Acetaminophen 5-325 PO q6prn 26. Lisinopril 2.5mg daily 27. Docusate Sodium 100 mg [**Hospital1 **] prn 29. Lasix 40 mg PO daily prn Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: pt. expired Followup Instructions: pt. expired

[ "728.2", "799.3", "458.9", "428.0", "730.28", "707.09", "996.81", "038.9", "070.70", "995.92", "276.1", "V66.7", "584.9", "730.25", "786.59", "276.50", "285.21", "428.20", "414.01", "263.9", "707.03" ]

icd9cm

[ [ [] ] ]

[ "86.22", "99.04" ]

icd9pcs

[ [ [] ] ]

11601, 11610

4141, 10541

313, 319

11661, 11670

2963, 2963

11730, 11744

2233, 2304

11569, 11578

11631, 11640

10567, 11546

11694, 11707

2319, 2944

258, 275

347, 1169

3646, 4118

2979, 3637

1191, 1978

1994, 2217

41,343

154,703

30006

Discharge summary

report

Admission Date: [**2139-3-1**] Discharge Date: [**2139-3-3**] Date of Birth: [**2091-4-10**] Sex: M Service: SURGERY Allergies: Cisatracurium Attending:[**First Name3 (LF) 668**] Chief Complaint: HTN, ESRD Major Surgical or Invasive Procedure: none History of Present Illness: 47 M ESRD, on HD since [**2136**] presents for kidney transplant. He presents for transplant. He has no complaints, and his ROS is completely WNL as documented below. He was last dialyzed [**2139-3-1**]. ROS: (+) per HPI (-) Denies pain, fevers, chills, night sweats, unexplained weight loss, fatigue/malaise/lethargy, changes in appetite, trouble with sleep, pruritis, jaundice, rashes, bleeding, easy bruising, headache, dizziness, vertigo, syncope, weakness, paresthesias, nausea, vomiting, hematemesis, bloating, cramping, melena, BRBPR, dysphagia, chest pain, shortness of breath, cough, edema. Past Medical History: DM, HTN, HLD, CAD, PVD, DVT, GERD PSH: CABG x 3 [**12/2137**], amputation of the toe [**1-/2138**], right knee replacement over 20 years ago Social History: single, lives alone, former smoker, no current EtOH Family History: NC Physical Exam: On discharge: vitals 96.6, 74, 157/81, 17, 100% RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R, normal S1/S2 PULM: Clear to auscultation b/l, no crackles, or wheezes ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses Ext: No LE edema, LE warm and well perfused Pertinent Results: [**2139-3-3**] 01:59AM BLOOD WBC-9.7 RBC-4.14* Hgb-12.7* Hct-36.5* MCV-88 MCH-30.8 MCHC-34.9 RDW-15.8* Plt Ct-221 [**2139-3-2**] 12:21PM BLOOD WBC-12.9* RBC-4.73 Hgb-14.2 Hct-41.8 MCV-88 MCH-30.1 MCHC-34.0 RDW-15.6* Plt Ct-245 [**2139-3-1**] 07:10PM BLOOD WBC-10.1 RBC-4.45* Hgb-13.3* Hct-39.4* MCV-89# MCH-29.9# MCHC-33.8 RDW-15.9* Plt Ct-237 [**2139-3-3**] 01:59AM BLOOD Plt Ct-221 [**2139-3-2**] 12:21PM BLOOD Plt Ct-245 [**2139-3-1**] 07:10PM BLOOD Plt Ct-237 [**2139-3-1**] 07:10PM BLOOD PT-9.8 PTT-29.7 INR(PT)-0.9 [**2139-3-1**] 07:10PM BLOOD Plt Ct-237 [**2139-3-1**] 07:10PM BLOOD PT-9.8 PTT-29.7 INR(PT)-0.9 [**2139-3-3**] 01:59AM BLOOD Glucose-129* UreaN-74* Creat-9.6*# Na-134 K-4.3 Cl-100 HCO3-22 AnGap-16 [**2139-3-2**] 12:21PM BLOOD Glucose-155* UreaN-66* Creat-8.4* Na-140 K-4.4 Cl-104 HCO3-23 AnGap-17 [**2139-3-1**] 07:10PM BLOOD UreaN-47* Creat-7.7*# Na-139 K-4.5 Cl-95* HCO3-29 AnGap-20 [**2139-3-3**] 06:49AM BLOOD CK(CPK)-64 [**2139-3-2**] 11:34PM BLOOD CK(CPK)-68 [**2139-3-2**] 01:35PM BLOOD CK(CPK)-103 [**2139-3-1**] 07:10PM BLOOD ALT-36 AST-35 [**2139-3-3**] 06:49AM BLOOD CK-MB-4 cTropnT-0.09* [**2139-3-3**] 01:59AM BLOOD cTropnT-0.09* [**2139-3-2**] 11:34PM BLOOD CK-MB-4 cTropnT-0.09* [**2139-3-2**] 01:35PM BLOOD CK-MB-3 cTropnT-0.09* [**2139-3-3**] 01:59AM BLOOD Calcium-8.9 Phos-5.3* Mg-2.9* [**2139-3-2**] 12:21PM BLOOD Calcium-9.4 Phos-4.2 Mg-3.0* [**2139-3-1**] 07:10PM BLOOD Albumin-5.4* Calcium-10.2 Phos-4.2# Mg-3.1* [**2139-3-2**] 11:32AM BLOOD Type-ART pO2-368* pCO2-41 pH-7.35 calTCO2-24 Base XS--2 Intubat-INTUBATED [**2139-3-2**] 11:32AM BLOOD Glucose-125* Lactate-1.6 Na-139 K-4.2 Cl-103 [**2139-3-2**] 11:32AM BLOOD Hgb-14.3 calcHCT-43 [**2139-3-2**] 11:32AM BLOOD freeCa-1.22 Brief Hospital Course: Mr. [**Known lastname 2174**] was admitted to the hospital on [**2139-3-1**] for a kidney transplant. The patient was consented, prepped and prepped for the procedure according to kidney transplant protocol. His systolic blood pressures in the morning prior to the surgery were in the range of 120-160s with metoprolol 10IV x 2 doses at ~6am and 7:45am. He was brought into the operating room and approximately 10-15 min following anesthesia induction the patient had drop in BP to 50s and sinus tachy with HR 120s. He was started on phenylephrine and epinephrine drip with improvement in pressures. There was no evidence of rash. Since he was pressor dependant, he was brought to the surgical ICU for further evaluation and management. A cardiology consult was obtained and after a normal ECG and echo they determined that this event was likely not cardiac in origin. They also noted that the "patient will likely have some elevation in troponins in the next 24 hrs given hypotension, tachycardia, LVH and ESRD". He did have some elevations in troponins to 0.09. The next day he was weaned off pressors sucessfully. He was asymptomatic thereafter with stable vital signs throughout, tolerating regular diet and ambulating. Since he was due for HD on [**3-3**] (day of discharge) anyway, he underwent bedside HD while in house prior to discharge. There were no events and pt tolerated the procedure well. He was discharged on HD 3, asymptomatic and with stable vital signs. The patient's PCP was notified and spoken with by telephone and agreed to follow up on this event. Medications on Admission: Renal Caps 1', calcium acetate 1230''', epogen 10,000 w/ HD, Lasix 40', lantus 15' hs, humalog SSI, lisinopril 5', metoprolol 25''', omeprazole 20', sevelamer 80''', ASA 81' Discharge Medications: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Renal Caps 1 mg Capsule Sig: One (1) Capsule PO once a day. 4. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO three times a day. 5. Epogen 10,000 unit/mL Solution Sig: One (1) Injection with HD: with HD. 6. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. Lantus 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous at bedtime. 8. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO three times a day. 10. sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO three times a day. 11. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous four times a day: per sliding scale four times a day . Discharge Disposition: Home Discharge Diagnosis: Induction hypotension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for a potential kidney transplant. Unfortunately the procedure was aborted because your blood pressure became unstable after anesthesia was introduced. You were taken to the ICU for 1 1/2 days for further work up and because you needed a constant infusion of medications to keep your blood pressure up. A cardiac work up revealed that this was likely not a cardiac event and probably a reaction to one of the anesthesia medications. Your symptoms and blood pressure problems have now resolved and it is safe for you to go home with the following instructions: Please call your doctor or go to the emergency department if: *You experience new chest pain, pressure, squeezing or tightness. *You develop new or worsening cough, shortness of breath, or wheeze. *You are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience an unusual discharge. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *You develop any concerning symptoms. General Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please also follow-up with your primary care physician. Followup Instructions: Please follow up with your primary care physician at your scheduled appointment next week. He is aware of the situation. Please follow up with the transplant surgery team in [**2-16**] weeks. Provider: [**Name10 (NameIs) **],DIALYSIS SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2139-3-4**] 7:30 Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2139-5-1**] 10:40 Completed by:[**2139-3-3**]

[ "403.91", "V49.72", "V43.65", "458.29", "530.81", "V45.11", "585.6", "414.00", "V45.81", "272.4", "E938.4", "250.40", "V64.1" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

6065, 6071

3313, 4890

280, 287

6137, 6137

1565, 3290

7918, 8374

1171, 1175

5115, 6042

6092, 6116

4916, 5092

6288, 7647

1190, 1190

1205, 1546

7679, 7895

231, 242

315, 918

6152, 6264

941, 1085

1101, 1155

59,380

158,904

39692

Discharge summary

report

Admission Date: [**2111-10-14**] Discharge Date: [**2111-10-21**] Date of Birth: [**2038-5-19**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Fatigue/Dizziness Major Surgical or Invasive Procedure: [**2111-10-14**] Coronary Artery Bypass Graft Surgery x 2 LIMA-->LAD, RSVG-->OM, Aortic Valve Replacement ([**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Porcine) History of Present Illness: 73 year old male with known history of aortic stenosis followed with serial echocardiograms. Recently he had become symptomatic with fatigue and occasional postural dizziness. Recent Echo revealed severe aortic stenosis. Cath also confirmed severe aortic stenosis along with mutlivessel coronary artery disease. He presented for surgical evaluation. Past Medical History: Hypertension Hyperlipidemia Diabetes Mellitus Past Surgical History: s/p Tonsillectomy Social History: Last Dental Exam: 6 months ago Lives with: wife Occupation: retired Tobacco: quit 5 yrs ago; 90 PYHx ETOH: social Family History: Family History: + CAD Physical Exam: Pulse: 65 Resp:16 O2 sat: 98% B/P Right: 135/69 Left: 137/71 Height: 67" Weight: 208 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x]; benign nevi Heart: RRR [x] Irregular [] Murmur- 3/6 SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema -none Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit- transmitted murmur to carotids Pertinent Results: [**2111-10-14**] ECHO Pre CPB: The cardiac output is 4.6L/min. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the descending thoracic aorta. There is critical aortic valve stenosis (valve area <0.8cm2). Mild aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is no mitral valve prolapse. There is severe mitral annular calcification. There is mild valvular mitral stenosis (area 1.5-2.0cm2). Mild (1+) mitral regurgitation is seen. The posterior leaflet has reduced mobility due to MAC. The mean gradient across the mitral valve was 2mmHg. Dr. [**Last Name (STitle) **] was notified in person of the results. Post CPB: The cardiac output is 5.9L/min with the patient on a phenylephrine infusion. There is trivial tricuspid regurgitation. There is trivial mitral regurgitation. The biventricular systolic function is preserved. There is a well seated bioprosthetic valve in the aortic position, with an EOA of 1.5cm2, and a mean gradient of 21mmHg. The visible contours of the thoracic aorta are intact. Admission labs [**2111-10-14**] 12:35PM HGB-11.9* calcHCT-36 [**2111-10-14**] 12:35PM GLUCOSE-148* LACTATE-1.8 NA+-139 K+-4.0 CL--107 [**2111-10-14**] 04:15PM PT-15.5* PTT-29.6 INR(PT)-1.4* [**2111-10-14**] 04:15PM FIBRINOGE-186 [**2111-10-14**] 04:15PM PLT COUNT-117* [**2111-10-14**] 04:15PM WBC-12.5*# RBC-2.72*# HGB-8.7*# HCT-24.1*# MCV-89 MCH-31.8 MCHC-35.9* RDW-13.4 [**2111-10-14**] 05:33PM UREA N-25* CREAT-1.0 SODIUM-139 POTASSIUM-4.2 CHLORIDE-110* TOTAL CO2-25 ANION GAP-8 Discharge labs [**2111-10-21**] 06:40AM BLOOD WBC-8.7 RBC-3.11* Hgb-9.3* Hct-27.4* MCV-88 MCH-29.8 MCHC-33.9 RDW-13.2 Plt Ct-259 [**2111-10-21**] 06:40AM BLOOD Plt Ct-259 [**2111-10-21**] 06:40AM BLOOD PT-15.5* INR(PT)-1.4* [**2111-10-21**] 06:40AM BLOOD UreaN-27* Creat-1.3* Na-137 K-4.4 Cl-101 [**2111-10-21**] 06:40AM BLOOD Mg-1.9 Radiology Report CHEST (PORTABLE AP) Study Date of [**2111-10-18**] 3:06 PM [**Hospital 93**] MEDICAL CONDITION: 73 year old man with CABG/AVR REASON FOR THIS EXAMINATION: eval for interval change in effsuions Final Report Compared with [**2111-10-14**], multiple lines and tubes and Swan-Ganz catheter have been removed. The patient is status post sternotomy with mediastinal clips. There is continued prominence of cardiomediastinal silhouette consistent with recent surgery. There is patchy opacity at the left lung base consistent with left lower lobe collapse and/or consolidation. This may be slightly worse compared with [**2111-10-14**] but is likely accentuated by low lung volumes. Minimal atelectasis at the right base is noted. No definite CHF, though the low inspiratory volumes make this assessment difficult. Brief Hospital Course: Admitted [**10-14**] and underwent surgery with Dr. [**Last Name (STitle) **]. Transferred to the CVICU in stable condition on titrated phenylephrine and propofol drips. Extubated later that day and transferred to the floor on POD 31 to begin increaasing his activity level. gently diuresed toward his preop weight. Beta blockade titrated. Chest tubes and pacing wires removed per protocol. Somewhat lethargic initially, but this continued to improve significantly. Went into intermittent A Fib on POD #4 and treated with amiodarone and coumadin. Stage II pressure ulcer noted on coccyx. Keflex started for inferior aspect sternal drainage. Continued to make good progress and was ck\leared for discharge to home on POD #7. Target INR 2.0-2.5 for A Fib. First blood draw [**10-22**] with results to Dr [**Last Name (STitle) 40075**]. All followup appts were advised. Medications on Admission: Lisinopril 40mg daily Metoprolol 12.5mg daily Nifedipine 30mg daily Glyburide 3mg [**Hospital1 **] Metformin 850mg [**Hospital1 **] Simvastatin 10mg daily Folic Acid 1mg daily Aspirin 81mg daily Discharge Medications: 1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 5. glyburide micronized 3 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 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:*1* 7. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*1* 8. miconazole nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*2 tubes* Refills:*0* 9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 5 days: 400 mg daily through [**10-25**], then 200 mg daily ongoing. Disp:*60 Tablet(s)* Refills:*1* 10. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 6 days. Disp:*12 Capsule(s)* Refills:*0* 11. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 12. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 13. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 14. warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY (Daily): target INR 2-2.5. 15. warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day: 4mg on [**10-21**] then as diredted by Dr [**Last Name (STitle) 40075**] . Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: Aortic Stenosis Coronary Artery Disease postop A Fib hypertension dyslipidemia non-insulin dependent diabetes mellitus Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with tylenol Incisions: Sternal - healing well, no erythema or drainage Leg Left - Healing well, no erythema or drainage. Edema ........... Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month 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) **] at 11/4 @ 1:00 pm Cardiologist: [**Doctor Last Name 40149**] [**11-13**] @ 10:15am Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 40075**] in [**4-6**] weeks [**Telephone/Fax (1) 40076**] **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:[**2111-10-21**]

[ "285.9", "707.03", "V17.3", "293.0", "278.00", "424.1", "707.22", "250.00", "272.4", "V15.82", "427.31", "788.5", "414.01", "401.9" ]

icd9cm

[ [ [] ] ]

[ "35.21", "36.15", "39.61", "36.11" ]

icd9pcs

[ [ [] ] ]

8131, 8194

4985, 5853

342, 525

8357, 8582

1874, 2907

9506, 10016

1180, 1188

6099, 8108

4246, 4276

8215, 8336

5879, 6076

8606, 9483

996, 1016

1203, 1855

284, 304

4308, 4962

553, 905

927, 973

1032, 1148

2917, 4209

21,156

146,554

654

Discharge summary

report

Admission Date: [**2169-6-22**] Discharge Date: [**2169-6-29**] Date of Birth: [**2090-2-1**] Sex: F Service: [**Doctor First Name 147**] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4995**] Chief Complaint: right colon mass Major Surgical or Invasive Procedure: right colectomy History of Present Illness: Patient is a 79 year old Russian speaking female with history of cardiopulmonary disease diagnosed with adenocarcinoma of the right colon in [**2169-5-18**]. Past Medical History: 1. hypertension 2. diabetes type II 3. hypercholesterolemia 4. coronary artery disease 5. chronic renal failure 6.pulmonary hypertension- 7.left ventricle outflow tract obstruction,diastolic heart failure-ejection fraction of 70% 8. gastro-esophageal reflux disease pancreatic resection [**2155**], [**2166**]- required intubation with history of delirium resection of neuroendocrine tumor septal ablation [**2164**] Social History: positive for tobacco, negative for alcohol and recreation drug use. Family History: non-pertinant Physical Exam: On discharge, patient is afebrile with stable vitals. Abodomen is soft and non tender on exam. Abdominal incision has no evidence of infection, and staples are in place. Pertinent Results: [**2169-6-22**] 06:59PM TYPE-MIX PO2-42* PCO2-50* PH-7.27* TOTAL CO2-24 BASE XS--4 [**2169-6-22**] 06:59PM O2 SAT-70 [**2169-6-22**] 06:58PM TYPE-ART TEMP-37.5 RATES-[**10-23**] TIDAL VOL-500 PEEP-8 O2-40 PO2-117* PCO2-43 PH-7.33* TOTAL CO2-24 BASE XS--3 INTUBATED-INTUBATED [**2169-6-22**] 06:45PM WBC-9.7 RBC-3.73* HGB-11.8* HCT-35.0* MCV-94 MCH-31.5 MCHC-33.6 RDW-13.4 [**2169-6-22**] 02:55PM TYPE-ART PO2-82* PCO2-43 PH-7.29* TOTAL CO2-22 BASE XS--5 [**2169-6-22**] 02:55PM HGB-11.3* calcHCT-34 [**2169-6-22**] 01:49PM HCT-29.6* [**2169-6-22**] 12:43PM TYPE-ART PO2-96 PCO2-45 PH-7.25* TOTAL CO2-21 BASE XS--7 [**2169-6-22**] 11:47AM TYPE-ART PO2-97 PCO2-53* PH-7.22* TOTAL CO2-23 BASE XS--6 INTUBATED-INTUBATED [**2169-6-22**] 11:22AM WBC-13.9*# RBC-3.92* HGB-12.4 HCT-36.1 MCV-92 MCH-31.6 MCHC-34.4 RDW-13.2 Brief Hospital Course: Patient was taken to the operating room on [**2169-6-22**] for the above stated procedure. The patient was hemodynamically stable throughout the operation, requiring a small amout of pressors. She was then admitted to the intensive care unit post-operatively intubated and monitored with a swan cathater that was placed intraoperatively. Rising pulmonary artery pressures were noted- 60/30's. Patient [**Last Name (un) 4996**] a course of kefzol/flagyl which was continued for 2 days. On post operative day 1, the patient was extubated, and remained nothing by mouth. On post operative day 2, patient experienced shortness of breath, satting 89% on 2 liters. Intra-venous fluids were decreased from 100 cc per hour to 80 than 50cc and remained on [**1-19**] liters oxygen. Patient was noted to have good urinary output of 90-100cc per hour. On post operative day 2, intra-venous fluids were dereased to 30 cc per hour, oxygen saturation remained good on 3 liters, and urinary output was also adequate and she was transferred to the floor and advanced to clears. On post-operative day 4, patient tolerated clears. On post-operative day 5, patient was noted to be slightly distended and was made nothing by mouth. On post-operative day 6, patient reported to pass flatus, clears were advance and she was evalutated by physical therapy. Home physical therapy was reccommended. Also on post-operative day 5, family noted some acute mental status changes, she was seen by neurology. On post-operative day 6, mental status was noted to have greatly improved per family futher neuro workup was deferred to outpatient. Patient was discharged on post-operative day 7 with home services. Medications on Admission: lasix cardura toprol aricept lisinopril lipitor Discharge Medications: not requiring narcotics Discharge Disposition: Home With Service Facility: [**Hospital1 **] Family & [**Hospital1 1926**] Services Discharge Diagnosis: adenocarcinoma of the right colon Discharge Condition: good Discharge Instructions: Do not soak incisions in [**Last Name (LF) 4997**], [**First Name3 (LF) **] shower and then pat incision line dry. Resume prehospital medications. [**Month (only) 116**] take tylenol for pain. Followup Instructions: Patient is to call and make appointment to be by Dr. [**Last Name (STitle) 1888**] in [**11-18**] weeks. Please follow up with neurologist.

[ "403.91", "414.01", "E935.2", "250.00", "530.81", "425.4", "780.93", "780.09", "153.6" ]

icd9cm

[ [ [] ] ]

[ "99.77", "40.3", "47.19", "45.73", "88.72" ]

icd9pcs

[ [ [] ] ]

4003, 4089

2174, 3856

350, 367

4167, 4173

1316, 2151

4414, 4557

1096, 1111

3955, 3980

4110, 4146

3882, 3932

4197, 4391

1126, 1297

294, 312

395, 554

576, 995

1011, 1080

9,505

155,492

53462

Discharge summary

report

Admission Date: [**2190-7-10**] Discharge Date: [**2190-7-14**] Service: MEDICINE Allergies: Zosyn Attending:[**First Name3 (LF) 1257**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: [**Age over 90 **] y/o F with PMHx of mult-infarct dementia and diverticulosis who had a witnessed aspiration event at home and was brought into the ED with cough and shortness of breath. On arrival to the [**Name (NI) **], pt was tachypneic to 40s with audible secretions. Per HCP, pt was in her usual state of health prior to the witnessed aspiration event. She has not have any fevers, sick contacts, upper respiratory congestion, sore throat, shortness of breath or DOE, though she is bedridden at baseline. . In the ED, initial vs were: T 97.1 P 83 BP 147/110 R 35 Sats 100% on NRB. Pt was notably rhoncherous and having difficulty clearing secretions. Attempts were made at NG suction which pt was unable to tolerate. Pt was placed on BiPAP with some improvement in resp status. Blood Cx were obtained, she was given 1LNS, Clindamycin and Ceftriaxone for presumed aspiration pneumonia though portable CXR did not show any acute infiltrate. Pt was noted to have intermittent respiratory distress with audible rhonchi during attempts to wean from non-invasive ventilation. . On arrival to the ICU, pt was mildly tachypneic though sating well on NRB and in no acute respiratory distress. She was coughing spontaneously but did not respond to questions due to underlying dementia and husband provided additional ROS. Past Medical History: - Diverticulosis - Multi-infarct dementia - Hearing loss - Retinal detachment - B12 deficiency - Chronic abdominal pain - Irritable bowel syndrome - Spinal Stenosis Social History: She was an English professor for many years. She now lives with her husband, [**Name (NI) **], who is her primary caregiver. She has two sons, one in [**Name (NI) 531**] and the other one in [**Location (un) 86**]. She has profound vascular dementia, is dependant with all ADLs and is non verbal at baseline. Family History: Not contributory Physical Exam: General: NAD HEENT: Sclera anicteric, MMM Neck: supple Lungs: Diffuse wheezes and rhonchi, audible airway secretions CV: RRR, normal S1/S2, no apprec m/r/g Abdomen: soft, NT/ND, bowel sounds present, no rebound or guarding Ext: Cool, no edema, + pulses Pertinent Results: [**2190-7-10**] 09:52PM BLOOD WBC-14.3*# RBC-4.83# Hgb-14.6# Hct-42.3# MCV-88 MCH-30.2 MCHC-34.5 RDW-14.6 Plt Ct-356 [**2190-7-10**] 09:52PM BLOOD Neuts-85.2* Lymphs-10.0* Monos-3.9 Eos-0.6 Baso-0.4 [**2190-7-10**] 09:52PM BLOOD PT-12.2 PTT-27.4 INR(PT)-1.0 [**2190-7-10**] 11:19PM BLOOD Glucose-220* UreaN-31* Creat-1.4* Na-137 K-4.3 Cl-102 HCO3-22 AnGap-17 [**2190-7-11**] 02:02AM BLOOD Type-ART Temp-36.7 pO2-70* pCO2-36 pH-7.34* calTCO2-20* Base XS--5 [**2190-7-11**] 02:02AM BLOOD Lactate-2.8* [**2190-7-10**] 11:28PM BLOOD Lactate-2.8* [**2190-7-10**] 11:35PM URINE Blood-SM Nitrite-NEG Protein-500 Glucose-100 Ketone-50 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2190-7-10**] 11:35PM URINE RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE Epi-<1 Brief Hospital Course: This is a [**Age over 90 **] year old woman who was admitted for acute shortness of breath related to aspiration pneumonitis. Initially, there was no clear infiltrate on the CXR but on repeat it showed a new left infiltrate. A third subsequent CXR showed improvement in the left lung infiltrate. She was weaned off oxygen quickly and was on RA on the day of discharge. She had no fever, or leukocytosis to suggest aspiration pneumonia. The acute event and the rapid resolution suggested pneumonitis. However, she was treated with antibiotics by the ED AND THE ICU TEAMS. She had severe dementia and difficulty clearing secretions. She was on special aspiration precaution diet and this was reinforced during this admission. She had audible rhonchi with wheezes and mild tachypnea initially but this has resolved. She remained afebrile and responded well to nebs and humidified O2. Although the patient should be DNR/DNI (on papers by her request and wish), the HCP is her elderly husband who exhibited poor cognitive function. The son agreed to DNR and DNI status. The husband requested to be informed in case of cardiopulmonary arrest as he will make descision then (case by case). I recommended to the son to override the HCP and make a clear DNR/DNI status to avoid confusion. The [**Last Name (LF) 109934**], [**First Name3 (LF) **], and case manager agreed to hospice services at home. She was discharged on hospice care. She remained in the hospital for an extra day as the husband refused to take her home because of some construction work on the roof. Total discharge time 35 minutes. Medications on Admission: Aspirin 81mg daily Aricept 10mg daily Vitamin B-12 1000mcg daily Vitamin 800units daily Simvastatin 10mg daily 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. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB, wheeze. 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for wheeze. 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 4 days. Disp:*12 Tablet(s)* Refills:*0* 7. Donepezil 10 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO HS (at bedtime). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Cyanocobalamin 1,000 mcg Lozenge Sig: One (1) PO DAILY (Daily). 11. Vitamin D-3 400 unit Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 days. Disp:*4 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Season's Hospice Discharge Diagnosis: aspiration pneumonitis Discharge Condition: Hospice. Discharge Instructions: Your wife had aspiration pneumonitis. Please make sure she is fed slowly with the special aspiration precaution diet. Please call your PCP if she develops fever or shortness of breath. You agreed to hospice care. Followup Instructions: [**Last Name (LF) **],[**First Name3 (LF) **] E. [**Telephone/Fax (1) 719**]

[ "585.3", "266.2", "562.10", "518.81", "290.40", "437.0", "507.0" ]

icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

6163, 6210

3196, 4792

233, 239

6276, 6286

2428, 3173

6547, 6626

2121, 2139

4954, 6140

6231, 6255

4818, 4931

6310, 6524

2154, 2409

174, 195

267, 1588

1610, 1777

1793, 2105

7,821

192,169

18866

Discharge summary

report

Admission Date: [**2131-8-5**] Discharge Date: [**2131-8-7**] Date of Birth: [**2107-8-2**] Sex: F Service: TRAUMA [**Last Name (un) **] CHIEF COMPLAINT: Fall from horseback riding accident. PRESENT ILLNESSES INCLUDE: 1. C1 fracture of the cervical spine involving a lateral mass. HISTORY OF PRESENT ILLNESS: The patient is a 24 year old female who was in a horseback riding accident on [**8-4**]. She had amnesia of the event and did not complain of any abdominal or chest pain, but had a chief complaint of muscle spasm of her lower back and headache. The patient reported no previous injuries to her head or spinal canal and at an outside hospital she was worked up and this revealed a fracture of the first cervical vertebral body involving the lateral mass and therefore the patient was transported to [**Hospital1 69**] Emergency Department. PAST MEDICAL HISTORY: The patient has no significant past medical history. PAST SURGICAL HISTORY: She has a past surgical history including a right ankle fracture and a right index finger fracture. MEDICATIONS: She takes only oral contraceptive pills and Paxil as a prescription medicine. ALLERGIES: She has no known drug allergies. She is allergic to bee stings. PHYSICAL EXAMINATION: Initial vital signs upon presentation to [**Hospital1 69**] included: Heart rate of 77; blood pressure 122/palpable; respiratory rate of 16; 100% on room air. Upon arrival to the Emergency Department included the following. The patient was awake and alert, [**Location (un) 2611**] Coma Scale of 15. HEENT examination noted a right eye ecchymosis with edema of the upper lid without hemorrhage. Cervical collar was in place. Chest was clear to auscultation bilaterally. Cardiovascular examination showed a regular rhythm. Abdomen was soft, nontender, nondistended, with no contusions of ecchymoses. Extremities were warm without deformities. Back: No stepoff signs. No bony tenderness. No contusions. Rectal examination showed normal tone and was guaiac negative. Sensation is equal bilaterally. Motor examination shows five out of five strength and tone, equal bilaterally. LABORATORY: Pertinent x-ray findings in the Emergency Department included a trauma series, lateral cervical spine, A/P which showed no evidence of traumatic injury to the chest or pelvis. Also, x-rays obtained included a lumbar spine and a thoracic spine, which showed slight anterior wedging of a mid-thoracic vertebral body of unknown significance. She had a right ankle x-ray which was negative for any fracture. A CT scan of the head was also obtained without contrast, which showed no evidence of hemorrhage or mass effect. A CT scan examination was then performed of the cervical spine without contrast and with reconstruction. It was noted on this CT scan that the patient had a non-displaced fracture of the right lateral mass of C1. Also, during her initial hospital course, the same evening, the patient was sent for an MR of her cervical spine which showed fluid within the right C1 to 2 joint which could be secondary to trauma with no evidence of ligamentous disruption or vertebral malalignment. No evidence of epidural hematoma or spinal cord compression was seen. Initial laboratory data drawn upon arrival included a white blood cell count of 16.0, hemoglobin of 14, hematocrit of 40.7, platelets of 212. PT of 13, PTT of 25 and an INR of 1.1. The blood urea nitrogen of 15, creatinine of 0.7 and amylase of 83. Toxicology screen was positive for only opiates, but the patient had been given pain medicine prior to this study. Chemistry values upon Emergency Department presentation included a sodium of 141, a potassium of 4.9, a chloride of 102, bicarbonate of 27, glucose of 93 and a lactate of 0.9. Free calcium of 1.10. HOSPITAL COURSE: The patient was admitted to the Trauma Intensive Care Unit Service for close observation and q. one hour neurological checks. Orthopedic surgery / Spine Surgery was consulted. The patient had no events in the Trauma Intensive Care Unit and was transferred to the Trauma Floor. Her hard collar will remain in place for two to three months per Spine Surgery. The patient and her family chose non-operative management of her C1 fracture. Her neurologic examination has remained completely intact with a five out of five strength in the C5 to T1 distribution as well as sensation intact from the C5 to T1 distribution, five out of five strength from the L1 to S1 distribution as well as sensation intact from the L1 to S1 distribution. All extremities were warm and supple throughout her hospital course. She developed no neurologic deficits throughout her course. The patient was kept in a hard collar throughout her hospital stay; she was hemodynamically stable throughout her hospital stay. She was removed from thoracic and lumbar spine precautions by Orthopedics. Ophthalmology was consulted due to the ecchymoses and contusions around her right eye and determined that there was a low probability for a globe rupture or orbital fracture; however, a CT scan of the right orbit was recommended and completed, showing no signs of any orbital fracture. CONDITION ON DISCHARGE: Good. DISPOSITION: The patient is discharged home in the care of her family. DISCHARGE INSTRUCTIONS: 1. Her cervical collar is to be worn at all times. 2. There is no treatment needed for her thoracic spine injury. 3. The patient is to follow-up with Orthopedic surgeon, Dr. [**Last Name (STitle) 363**], at phone number [**Telephone/Fax (1) 3573**]. This follow-up appointment should be within two to three weeks of her discharge date. DISCHARGE DIAGNOSES: 1. C1 fracture of the lateral mass. 2. T7 to T8 mild compression injury. DISCHARGE MEDICATIONS: 1. Acetaminophen 325 mg tablet p.r.n. for pain. 2. Paroxetine, 20 mg tablet, one orally q. day. 3. Percocet 5/325, one to two tablets orally q. four to six hours p.r.n. pain. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**] Dictated By:[**Name8 (MD) 5541**] MEDQUIST36 D: [**2131-8-7**] 18:37 T: [**2131-8-12**] 12:19 JOB#: [**Job Number 51641**]

[ "780.09", "E828.2", "952.15", "806.00", "921.1" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5693, 5769

5792, 6232

3840, 5200

5331, 5672

977, 1250

1273, 3821

173, 303

333, 874

898, 952

5226, 5307

17,201

163,111

43025

Discharge summary

report

Admission Date: [**2197-5-23**] Discharge Date: [**2197-5-31**] Date of Birth: [**2124-1-15**] Sex: F Service: [**Doctor Last Name **] Medicine CHIEF COMPLAINT: MICU follow up for chronic obstructive pulmonary disease flare HISTORY OF PRESENT ILLNESS: This is a 73-year-old woman with chronic obstructive pulmonary disease (on home O2 and home nebulizers, PFTs [**12/2195**] revealed FEV1 0.43, FEV1/FVC equals 43%) who arrived at the [**Hospital6 256**] Emergency Room complaining of some tendencies of shortness of breath and cough (productive of green white sputum, but no hemoptysis). She also had a fever to 101?????? two days prior to admission. At home, she had been using home nebulizers without improvement. The patient has also been noted to have substernal chest pain in the past, variably responsive to sublingual nitroglycerin. At the time of admission, she was noted to be diaphoretic and nauseous, but denied vomiting, orthopnea, lower extremity edema, chills, lightheadedness, abdominal pain, bright red blood per rectum, melena or dysuria. EMERGENCY DEPARTMENT COURSE: The patient was given frequent nebulizers secondary to tachypnea and low saturations on 2 liters of nasal cannula. She did not improve until the nebulizers remained continuous, at which point her O2 saturation came up to 99%. She was able to speak in full sentences. By the time she was discharged from the Emergency Department, her arterial blood gas on 100% nonrebreather was 7.39, 57, 234. She was then admitted to the MICU. MICU COURSE: The patient was kept on continuous nebulizers for two to three hours and then tapered to nebulizers q 4 to 6 hours. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease on home O2, 2 liters nasal cannula, has had four to five hospitalizations in the past year. Her PFTs of 12/99 revealed FEV1 of 0.43, FEV1/FVC 43%. 2. Ejection fraction of 45%, mild aortic regurgitation. Prior echocardiogram showed cardiomyopathy and pulmonary hypertension. 3. Bronchiectasis 4. Irritable bowel syndrome 5. Anxiety 6. Hypothyroidism SOCIAL HISTORY: The patient lives alone, has home VNA, has a daughter. She smoked one to two cigarettes per day and quit in [**2191**]. She denies alcohol. She has a 50 pack year history of smoking. ALLERGIES: NSAIDS MEDICATIONS: 1. Levaquin 500 po q day 2. Digoxin 0.125 alternating with 0.250 3. Captopril 25 po tid 4. Methimazole 10 po tid 5. Albuterol nebulizers prn 6. Multivitamin 1 po q day 7. Prednisone taper 8. Librium tid prn 10 mg 9. Imdur 60 po q day 10. Bentyl 10 mg po tid 11. Prilosec 40 po q day 12. Colace 100 po bid 13. Vitamin D 400 units po q day 14. Atrovent nebulizers prn 15. Flovent 2 puffs [**Hospital1 **] 16. Serevent 2 puffs [**Hospital1 **] 17. Atrovent 3 puffs qid 18. Albuterol metered dose inhaler prn 19. Sublingual nitroglycerin prn PHYSICAL EXAM: VITAL SIGNS: Temperature max 100.2??????, heart rate 113 to 127 regular, blood pressure 104 to 116/41 to 57, respiratory rate 16 to 28, saturating 100% on 2 liters nasal cannula. GENERAL: She is in no apparent distress on nasal oxygen, has a nebulizer on at the time of admission. She is able to speak in full sentences. HEAD, EARS, EYES, NOSE AND THROAT: Normocephalic, atraumatic. Nebulizer mask in place as is the nasal cannula. NECK: No jugular venous distention. LUNGS: Poor air movement, occasional wheezing, no consolidations were appreciated. HEART: Tachycardia 2 to [**3-14**], left upper sternal border murmur, ? diastolic murmur. ABDOMEN: Soft, nontender. EXTREMITIES: No cyanosis, clubbing or edema. NEUROLOGIC: She was alert and oriented x3 and grossly nonfocal. LABS: White count 5.2, hematocrit 32.2, 7 eosinophils. BUN and creatinine 15/0.7. TSH on [**5-17**] was 0.35. Free T4 was 1.4. IMAGING: Chest x-ray revealed no pneumonia or congestive heart failure, but did reveal a calcified left hilar lymph node. Her chest x-ray on [**5-23**] revealed chronic obstructive pulmonary disease/emphysema, no pneumonia or congestive heart failure. Stress test in [**2197-3-9**] was negative. Echocardiogram on [**2197-1-24**] showed ejection fraction of 45%, moderate aortic regurgitation, trace mitral regurgitation. Blood cultures negative. Urine cultures negative. ASSESSMENT: A 73-year-old woman with severe chronic obstructive pulmonary disease, mild cardiomyopathy ? admitted with chest pain (ruled out), shortness of breath (refractory to home nebulizers, but responsive to the Emergency Department/MICU continuous nebulizers), 7 to 10 days of cough and fever likely representing community acquired pneumonia. She was admitted for chronic obstructive pulmonary disease flare. She was originally admitted to the Medical Intensive Care Unit, but called out to the floor. Her chronic obstructive pulmonary disease flare was thought to be a result of increased dyspnea secondary to acute bronchitis with some component of anxiety leading to a decreased respiratory rate which causes hyperinflation and then dyspnea. The patient also uses albuterol frequently which has left her with a tremor. It has been suggested that Atrovent, Serevent as standing medications with albuterol prn would be better for her. It has also been suggested that her steroid might benefit her, ALTHOUGH SHE DOES HAVE A HISTORY OF ALLERGIC REACTIONS TO INHALED STEROIDS. HOSPITAL COURSE BY SYSTEMS: 1. CHRONIC OBSTRUCTIVE PULMONARY DISEASE FLARE: On [**2197-5-24**], the patient was continued on Solu-Medrol with plans to switch to po prednisone when she was more stable. Nebulizers and metered dose inhalers were continued. No inhaled steroids were ordered. Levaquin was continued for bronchitic component. Protime pump inhibitor was given to her because of her steroid use. On [**2197-5-26**], overnight, she was noted to have shortness of breath and chest pain with pursed lip breathing noted. The chest pain revealed sinus tachycardia without changes from her prior electrocardiogram and her chest pain was relieved with two sublingual nitroglycerin and 2 mg of subcutaneous morphine. On [**2197-5-27**], she was switched to 60 mg of prednisone q day with the thought being that she would be tapered in a slow fashion from 60 down to 10 over the course of one week before each change of the taper. After the time of discharge, she was placed back on her outpatient regimen of inhalers and nebulizers. The only difference was that she was on a higher dose of prednisone and she was on Levaquin. The decision as to whether or not she should go to pulmonary rehabilitation or go home with services remained a challenging one. 2. INFECTIOUS DISEASE: The patient had a fever and cough on admission. Although she did not have evidence of pneumonia on chest x-ray, it was felt she might have had bacterial bronchitis as of [**2197-5-24**]. She was started on Levaquin which is to be continued for a 10 to 14 day course. 3. CARDIOVASCULAR: She has a history of chest pain, but ruled out on this admission. She has been tachycardic, which is most likely an albuterol effect, possibly a hyperthyroid effect, possibly due to her infection. She was maintained on Imdur, sublingual nitroglycerin, ACE inhibitors and Digoxin, as well as her hypothyroid medication. 4. HEME: She had a low white blood cells as an aberrant lab value which was repeated. There was a concern that this might be a Tapazole effect, although, as mentioned, the repeat values were normal and she was restarted on Tapazole. 5. ENDOCRINE: The patient's hypothyroidism, she was maintained on Tapazole during the hospital course except for one day. ALLERGIES: SHE IS INTOLERANT TO ASPIRIN, IT CAUSES GASTROINTESTINAL UPSET AND SHE IS INTOLERANT TO BETA BLOCKERS BECAUSE OF HER CHRONIC OBSTRUCTIVE PULMONARY DISEASE. DISCHARGE MEDICATIONS: 1. Levaquin 500 mg po q day, started [**2197-5-23**] to continue until [**2197-6-2**]. 2. Atrovent 0.2 mg per ml inhaler, using nebulizer 4x a day. 3. Serevent 31 mcg 2 puffs every day at bed time. 4. Combivent 103 to 180 mcg inhaler 2 puffs every four hours as needed. 5. Albuterol 0.083% solution 4x a day up to q2h prn. 6. Prednisone 1 by mouth every day 60 mg x1 week, 40 mg x-ray 1 weeks, 20 mg x-ray 1 week and then 10 mg po q day ongoing. 7. Imdur 60 mg po q day. 8. Vitamin D 400 units po q day. 9. Tapazole 10 mg po tid. 10. Digoxin 25 mcg po q od. 11. Digoxin 250 mcg po alternating with the 125 mcg. 12. Librium 10 mg po tid. 13. Phenergan 25 mg po bid prn. 14. Captopril 25 po tid. 15. Prevacid 30 mg po q day 16. Bentyl 10 mg po tid prn nausea. 17. Colace 100 mg po bid 18. Nebulizer compressor to use with her medications qid. 19. Nebulizer accessories. DISCHARGE CONDITION: Improved FOLLOW UP: The patient will follow up with Dr. [**Last Name (STitle) **] as an outpatient. DISCHARGE DIAGNOSES: 1. Chronic obstructive pulmonary disease flare 2. Bacterial bronchitis 3. Chest pain 4. Hypothyroidism [**Name6 (MD) **] [**Name8 (MD) 21809**], M.D. [**MD Number(1) 21812**] Dictated By:[**Last Name (NamePattern1) 9336**] MEDQUIST36 D: [**2197-5-29**] 11:10 T: [**2197-5-29**] 13:42 JOB#: [**Job Number 92840**]

[ "416.0", "V15.82", "425.4", "492.8", "244.9", "494.1", "424.1", "300.00", "466.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8747, 8757

8871, 9228

7847, 8725

5415, 7824

2900, 5386

8769, 8850

183, 247

276, 1680

1702, 2100

2117, 2885

11,849

177,381

22017

Discharge summary

report

Admission Date: [**2110-12-16**] Discharge Date: [**2110-12-21**] Date of Birth: [**2038-3-31**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This is a 72 year old male with known aortic stenosis. He is a patient of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 57621**] who reports a one month history of increasing dyspnea and dizziness with testing showing severe aortic stenosis with an aortic valve area of 0.63 cm2 and a mean gradient of 40 mmHg. He was then referred for an aortic valve replacement. PAST MEDICAL HISTORY: Past medical history includes aortic stenosis, severe emphysema, arthritis, osteoporosis, peptic ulcer disease with a GI bleed four years ago. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Atenolol 25 mg daily, Accupril 40 mg daily, Protonix 40 mg daily, Lipitor 10 mg daily, prednisone 5 mg daily, Fosamax 70 mg q week and aspirin 81 mg daily. PHYSICAL EXAMINATION: Neurologic - alert and oriented times three. Neck - no carotid bruits. Chest - clear to auscultation bilaterally with right pectoral muscle absence since birth. Cardiac - regular rate and rhythm, 1/6 systolic ejection murmur. Abdomen is soft, nontender and nondistended. Extremities - significant for right arm varicosity known to patient. CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted on [**2110-12-16**] and proceeded to the Operating Room for an aortic valve replacement with a 25 mm CE pericardial valve by Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **]. His total cardiopulmonary bypass time was 116 minutes and a cross-clamp time of 146 minutes. He proceeded to the Cardiac Surgery Recovery Room with mean arterial pressure of 67, CVP of 4 and a normal sinus rhythm at a rate of 71. He was on nitroglycerin and propofol drip for support. On postoperative day 1, the patient was woken up, weaned from his ventilator and extubated. He continued to receive intravenous nitroglycerin for support and also received 1 unit of packed red blood cells. Over the first three postoperative days, the patient had some trouble with his mean arterial pressure with nitroglycerin and labetalol drips titrated along with po Lopressor started to keep his mean arterial pressure greater than 55. On postoperative day 3, his chest tubes were discontinued and he was transferred to the Inpatient Floor for continued recovery. On postoperative day 3, he also experienced some intermittent atrial fibrillation treated with IV push Lopressor. He continued to have bursts of intermittent atrial fibrillation through postoperative day 5 and was treated with Lopressor as well as an increase in his po Lopressor and po Captopril. Anticoagulation was considered and decided against. At the time of discharge, he had been without any atrial fibrillation for over 24 hours. The patient was also followed by Physical Therapy throughout his hospital course, the last visit on [**12-21**] when the patient was found to be safe for discharge home when medically stable. On [**2110-12-21**], the patient was discharged home with [**Hospital1 1474**] Visiting Nurses to follow up with patient. CONDITION ON DISCHARGE: Vital signs - temperature 98.8, blood pressure 154/74, heart rate 77 and sinus rhythm, respiratory rate 20, O2 sat 93 percent on room air. Cardiovascular - regular rate and rhythm. Respiratory - crackles in the left base and clear on the right. Abdomen is soft, nontender and nondistended. Sternal incision is clean and dry with Steri-Strips intact and sternum stable. DISCHARGE DIAGNOSES: Aortic stenosis, osteoarthritis and postoperative atrial fibrillation. DISCHARGE MEDICATIONS: Lasix 20 mg po bid for seven days, potassium chloride 20 mEq po bid for seven days, Colace 100 mg po bid, aspirin 81 mg po bid, Tylenol 325-650 mg po q4h prn, Percocet 5/325 one to two tablets po q4h, prn - do not take in addition to Tylenol, folic acid 1 mg po daily, thiamine 100 mg po daily, Protonix 40 mg po daily, Lipitor 10 mg po daily, Captopril 37.5 mg po tid and Lopressor 100 mg [**Hospital1 **] and prednisone 10 mg po daily. FO[**Last Name (STitle) 996**]P PLANS: The patient is to see Dr. [**Last Name (Prefixes) **] in one month and to see cardiologist in one to two weeks. He will also be followed by the visiting nurses at home and will be seen in the Outpatient [**Hospital 409**] Clinic in approximately two weeks. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern1) 5898**] MEDQUIST36 D: [**2110-12-22**] 13:34:38 T: [**2110-12-22**] 14:23:49 Job#: [**Job Number 57622**]

[ "305.00", "715.90", "V58.65", "427.31", "424.1", "733.00", "401.9", "458.29", "286.7", "492.8", "997.1", "530.81" ]

icd9cm

[ [ [] ] ]

[ "99.07", "99.04", "39.61", "35.21" ]

icd9pcs

[ [ [] ] ]

3577, 3649

3673, 4668

785, 942

1343, 3160

965, 1314

167, 553

576, 758

3185, 3555

30,695

147,876

6312

Discharge summary

report

Admission Date: [**2186-3-24**] Discharge Date: [**2186-4-2**] Date of Birth: [**2119-1-7**] Sex: F Service: MEDICINE Allergies: Compazine Attending:[**First Name3 (LF) 2160**] Chief Complaint: Melena Major Surgical or Invasive Procedure: EGD x 2 PICC line placement History of Present Illness: Ms. [**Known lastname 24446**] [**Last Name (Titles) **] s 67 year old woman with iron deficiency anemia, anorexia nervosa, and idiopathic chronic pancreatitis who presented approximately 1 month of melanotic stool. She describes this as intermittent "diarrhea"; per her report, the stool has been dark black, tarry, and loose. She wasn't having these stools with every bowel movement, but intermittently over the past several weeks. Over the past few days, she has felt lightheaded, but without any vertiginous symptoms. She hasn't had chest pain, heartburn, vomitting, hematochezia. She has had her baseline epigastric pain. She does not drink alcohol, and she has not been using NSAIDs aside from a daily 81 mg aspirin. . This morning, she woke up and felt that she was having this "diarrhea" again, as well as nausea. As she was walking to the bathroom, she felt extremely lightheaded, and her legs gave out from underneath her. She did not hit her head or lose consciousness. She did have a large melanotic stool at the time which did also have visible red blood. Her daughter called EMS who brought her to [**Hospital6 3105**]. She was afebrile, BP 82/45, HR 85, and O2 sat 100% on room air. There, she was found to have a hematocrit of 13.9% with normal platelets and coagulation studies. She was given pantoprazole 80 mg IV bolus followed by a continuous infusion at 8 mg/hr; she was also given octreotide 100 mcg/hr bolus followed by 50 mcg/hr. She was given 1500cc of crystalloid and received 2 units pRBCs. A third unit of pRBCs was hung prior to transfer to [**Hospital1 18**]. . Review of Systems: Denies chest pain, dyspnea, pedal edema, rashes. Otherwise, per HPI. Past Medical History: 1. Chronic pancreatitis s/p Puestow procedure [**2182-9-25**] 2. Status post cholecystectomy. 3. Known renal infarction. 5. Anorexia and bulimia x 25 years. 6. Gastritis. 7. COPD 8. Pulmonary nodules LUL, LLL believed inflammatory etiology. 8. Bronchiectasis. 9. s/p ORIF in [**2172**] complicated by aspiration pneumonia and ARDS requiring mechanical ventilation times six weeks. 10. Depression. 12. Spinal stenosis s/p two back surgeries 13. Hemorrhoids 14. Chronic headaches; MR in [**1-20**] microvascular ischemic changes. 15. Anemia, baseline HCT 33-34. 16. s/p tubal ligation. 17. s/p appendectomy. 18. s/p bilateral varicose vein removal 19. Renal mass 20. Depression Social History: Patient has 4 children, lives with one of her daughters. ETOH: quit many years ago, previously 2 drinks per night TOB: started at age 12, 1 PPD, about 50 pack years Denies any recreational drug use Family History: Pt was adopted, does not know her family history Physical Exam: T 98.6 BP 75/51 on noninvasive cuff HR 73 RR 18 Sat 100% on 2 L/min nasal cannula Weight: 103 lbs Gen: thin, pale middle-aged woman lying comfortably in bed, conversing easily HEENT: moist mucosae, oropharynx clear, no scleral icterus. Neck: supple, JVP 6cm CV: rrr, II/VI early-peaking systolic murmur loudest at RUSB Chest: CTA b/l, no w/r/r Abd: soft, moderate epigastric tenderness to deep palpation, no rebound/guarding, no HSM Extr: warm, 2+ PT pulses, no edema Neuro: alert, appropriate, CN 2-12 intact,5/5 strength in all four extremities Pertinent Results: labs from [**Hospital3 **] [**2186-3-24**]: WBC 6.7, Hct 13.9%, Plts 220 Na 137, K 4.5, Cl 104, HCO3 27, BUN 54, Cr 1.11, Gluc 176, Ca 8.7, Mg 1.4 AST 16, ALT 19, TBili 0.3, alk phos 57, albumin 1.9, Tot Prot 3.9, amylase 97, lipase 34 PTT 23.5 sec, INR 1.0 [**2186-4-1**] 06:55AM BLOOD Hct-29.1* [**2186-3-28**] 04:27AM BLOOD WBC-5.3# RBC-2.95* Hgb-9.4* Hct-27.2* MCV-92 MCH-32.0 MCHC-34.8 RDW-16.2* Plt Ct-218 [**2186-3-24**] 08:31AM BLOOD WBC-7.0 RBC-2.51*# Hgb-7.9*# Hct-23.0*# MCV-92# MCH-31.5 MCHC-34.4 RDW-16.3* Plt Ct-209 [**2186-3-24**] 08:31AM BLOOD Neuts-83.2* Bands-0 Lymphs-11.6* Monos-4.6 Eos-0.4 Baso-0.2 [**2186-3-29**] 07:05AM BLOOD PT-12.1 PTT-26.7 INR(PT)-1.0 [**2186-4-1**] 06:55AM BLOOD UreaN-14 Creat-0.8 [**2186-3-31**] 06:30AM BLOOD Glucose-93 UreaN-12 Creat-0.8 Na-140 K-4.2 Cl-104 HCO3-34* AnGap-6* [**2186-3-24**] 08:31AM BLOOD Glucose-111* UreaN-47* Creat-0.9 Na-137 K-4.9 Cl-109* HCO3-26 AnGap-7* [**2186-3-24**] 08:31AM BLOOD ALT-18 AST-14 LD(LDH)-123 CK(CPK)-63 AlkPhos-56 Amylase-72 TotBili-0.5 [**2186-3-30**] 07:00AM BLOOD proBNP-758* [**2186-3-24**] 08:31AM BLOOD Lipase-30 [**2186-3-29**] 07:05AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.9 [**2186-3-31**] 06:30AM BLOOD RheuFac-<3 CRP-23.7* [**2186-4-2**] 06:12AM BLOOD Vanco-26.2* [**2186-3-27**] 03:38PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.009 [**2186-3-27**] 03:38PM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG [**2186-3-27**] 03:38PM URINE RBC-76* WBC-96* Bacteri-FEW Yeast-NONE Epi-0 [**2186-3-24**] 3:36 pm SEROLOGY/BLOOD Source: Line-A line. **FINAL REPORT [**2186-3-27**]** HELICOBACTER PYLORI ANTIBODY TEST (Final [**2186-3-27**]): NEGATIVE BY EIA. (Reference Range-Negative). [**2186-3-24**] - 2 sets of blood cultures: negative. [**2186-3-27**] 4:43 am URINE Site: CATHETER **FINAL REPORT [**2186-3-29**]** URINE CULTURE (Final [**2186-3-29**]): ENTEROBACTER CLOACAE. >100,000 ORGANISMS/ML.. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER CLOACAE | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN---------- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [**2186-3-27**] 6:35 am BLOOD CULTURE Source: Line-a-line. **FINAL REPORT [**2186-4-2**]** Blood Culture, Routine (Final [**2186-4-2**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET ONLY. SENSITIVITY REQUESTED BY DR. [**Last Name (STitle) **] #[**Numeric Identifier 24447**] [**2186-3-30**]. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. 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 ([**7-/2484**]) immediately if sensitivity to clindamycin is required on this patient's isolate. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- =>4 R PENICILLIN------------ 0.25 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 2 S Anaerobic Bottle Gram Stain (Final [**2186-3-28**]): REPORTED BY PHONE TO [**First Name5 (NamePattern1) 24448**] [**Last Name (NamePattern1) 24449**] @ 5PM [**2186-3-28**]. GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Blood cultures on [**2186-3-28**] and [**2186-3-29**] negative at time of discharge. CHEST (PORTABLE AP) [**2186-3-24**] 8:57 AM CHEST (PORTABLE AP) Reason: Pls eval lung parenchyma [**Hospital 93**] MEDICAL CONDITION: 67 year old woman with abdominal pain, UGIB REASON FOR THIS EXAMINATION: Pls eval lung parenchyma HISTORY: Abdominal pain and upper GI bleed, to evaluate lung parenchyma. FINDINGS: In comparison with the study of [**9-10**], there again is evidence of old healed apical granulomatous disease as well as chronic obstructive pulmonary disease. No acute pneumonia appreciated at this time. Cardiology Report ECG Study Date of [**2186-3-24**] 1:21:04 PM Sinus rhythm Low QRS voltages in limb leads Since previous tracing of the same date, no significant change Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A. Intervals Axes Rate PR QRS QT/QTc P QRS T 69 186 76 390/405 80 71 73 CT PELVIS W/CONTRAST [**2186-3-25**] 11:54 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Reason: GI BLEED, HX. PANCREATITIS, NPO, FEBRILE, ? PERFORATION, ORDERED WITH NO ORAL CONTRAST Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 67 year old woman with GI bleed and h/o pancreatitis, NPO, febrile REASON FOR THIS EXAMINATION: r/o perforation of ulcer, no oral contrast CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 67-year-old woman with GI bleeding and history of pancreatitis and fever. Please evaluate for perforation of ulcer. Comparison is made to the prior study of [**2185-7-28**]. TECHNIQUE: Axial MDCT images were obtained from lung bases to the symphysis pubis after administration of Optiray intravenously. No oral contrast was used. Sagittal and coronal reformatted images were then obtained. CT OF THE ABDOMEN WITH IV CONTRAST: The visualized portion of the lung bases does not demonstrate any pulmonary nodule. Dependent atelectatic changes are noted at both lung bases. Moderate left and small right pleural effusions are visualized. The heart and great vessels appear normal. Small axial hiatal hernia is visualized. The liver, spleen, and adrenal glands appear normal. There is mild scarring in the upper pole of both kidneys which is unchanged compared to the prior study. Both kidneys demonstrate multiple small hypodense lesions which are too small to characterize. The pancreas contains multiple areas of coarse calcification with parenchymal atrophy and irregular pancreatic duct dilatation, all consistent with a diagnosis of chronic pancreatitis. There is mild intrahepatic and moderate extrahepatic bile duct dilatation with the common bile duct measuring up to 15 mm.This appearnce is stable since mR of abdomen performed in [**2182-1-17**]. The patient is status post cholecystectomy with moderate dilatation of the cystic duct remnant. The stomach, duodenum, and loops of small bowel and large bowel appear normal. No free air is noted within the abdomen and pelvis. Surgical sutures of the prior bowel surgery are noted within the left lower quadrant area. No pathologically enlarged retroperitoneal or mesenteric nodes are visualized. CT OF THE PELVIS WITH IV CONTRAST: The urinary bladder, distal ureters, uterus and adnexa, rectum and sigmoid colon appear normal. Moderate amount of ascites is noted within the pelvis. No free air is visualized. BONE WINDOWS: No concerning lytic or sclerotic lesion is identified. The patient is status post dynamic hip screw placement on the left side. No concerning lytic or sclerotic lesions are identified. Multilevel degenerative changes of the lumbar spine are noted with grade 2 retrolisthesis of L5 over L4. Disc bulge is also noted at the level of L4-L5. IMPRESSION: 1. No pneumoperitoneum or other signs of bowel perforation is noted. 2. Unchanged chronic pancreatitis with moderate pancreatic duct dilatation. 3. Unchanged multiple hypodense kidney lesions and bilateral kidny scarring. 4. Moderate ascites. The etiology is unclear. 5. Unchanged moderate right and small left pleural effusion. 6. Unchanged moderate extrahepatic and mild intrahepatic bile duct dilatation since MR of abdomen performed in [**2182-1-17**]. 7. Grade 2 retrolisthesis of L4 over L5 with a small disc bulge at the same level. [**2186-3-29**]: PA and lateral upright chest radiograph compared to [**3-27**] and [**2186-3-24**]. The heart size is normal. Mediastinal position, contour, and width are unremarkable. The apical fibronodular bilateral opacities are stable. Interval development of bilateral small pleural effusion is demonstrated, especially between [**3-24**] and [**3-27**], with minimal progression between [**3-27**] and [**3-29**]. There are no focal consolidations worrisome for pneumonia. There is no pneumothorax. The patient is not in failure. UNILAT UP EXT VEINS US LEFT [**2186-3-29**] 5:35 PM UNILAT UP EXT VEINS US LEFT Reason: assess for thrombus associated with phlebitis [**Hospital 93**] MEDICAL CONDITION: 67 year old woman with left UE phlebitis and GPc in blood REASON FOR THIS EXAMINATION: assess for thrombus associated with phlebitis INDICATION: Please evaluate for thrombus or phlebitis in a 67-year-old female with left upper extremity swelling. No comparison is available. Grayscale, color flow and Doppler images of the left upper extremity were obtained. The left internal jugular vein, subclavian vein, axillary vein, and brachial veins and cephalic vein demonstrate normal compressibility, respiratory variation in venous flow and venous augmentation. The basilic vein contains an occluding thrombus which starts in the antecubital fossa but does not extend into the deep venous system. This vein is non- compressible. IMPRESSION: 1. Thrombosis of the distal portion of the left basilic vein with no extension into the deep venous system. This is consistent with a superficial thrombophlebitis. [**12-25**] Pathology Tissue: GI BIOPSIES (2 JARS). [**2186-3-29**] [**Last Name (LF) **],[**First Name3 (LF) **] - pending. ECHO: Conclusions The left atrium is normal in size. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2185-7-26**], no change. IMPRESSIOn: No valvular vegetations seen. PORTABLE CHEST [**2186-4-1**]. CLINICAL INFORMATION: PICC placement. COMPARISON STUDY: [**2186-3-29**]. FINDINGS: Right PICC terminates in superior vena cava. The lungs are clear with the exception of mild blunting of the costophrenic angles, stable. Again noted is mild fibronodular scarring or stranding at the lung apices. The lungs are grossly clear. EGD: [**2186-3-24**] Findings: Esophagus: Normal esophagus. Stomach: Mucosa: Erosions of the mucosa were noted in the antrum and stomach body. Duodenum: Excavated Lesions A single cratered 2cm ulcer was found in the proximal bulb. The ulcer bed appeared necrotic with pigmented material suggestive of recent bleeding. There was thick dark material adherent to the ulcer (food vs. old blood) which could not be fully cleared. Because it was difficult to get a clear view of the ulcer base and vessel, we decided against intervening at present. Other findings: Pictures could not be obtained due to technical difficulties with the computer. Impression: Erosion in the antrum and stomach body Ulcer in the proximal bulb Pictures could not be obtained due to technical difficulties with the computer. Recommendations: - IV PPI 80mg bolus then 8mg/hr x 72 hours. - Can then switch to IV PPI [**Hospital1 **]. - NPO x 24 hours. - Please check H.pylori serology and treat if positive. - Clear liquid diet over weekend is ok if pt remains stable. Will plan for re-scope on Monday in endoscopy unit after futher stabilization. [**2186-3-29**] Findings: Esophagus: Mucosa: Normal mucosa was noted in the whole esophagus. Stomach: Mucosa: Erythema and congestion of the mucosa were noted in the antrum. These findings are compatible with mild gastritis. Cold forceps biopsies were performed for histology at the stomach antrum. Duodenum: Excavated Lesions Two ulcers were seen in the first part of the duodenum. The first ulcer measures 3cm in diameter with clean base and surrounding edema. The second ulcer measures 2cm with clean base and surrounding erythema.There was no active bleeding noted. Cold forceps biopsies were performed for histology at the duodenal bulb- ulcer edge. Other A 1 X 2cm soft submucosal lesion suggestive of lipoma was seen in the second part of the duodenum. This was not biopsied due to recent bleed. Impression: Normal mucosa in the whole esophagus Erythema and congestion in the antrum compatible with mild gastritis (biopsy) Ulcer in the first part of the duodenum (biopsy) A 1 X 2cm soft submucosal lesion suggestive of lipoma was seen in the second part of the duodenum. This was not biopsied due to recent bleed. Otherwise normal EGD to secondpart of the duodenum Recommendations: 1. Follow biopsy results and treat if positive for H. pylori. 2. Need lifelong PPI po BID due to her co-morbid conditions 3. Out-pt follow up with Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] in 4weeks. Brief Hospital Course: 67 year old F with PMHx of chronic pancreatitis p/w 3 wks of melena, severe hct drop & necrotic duodenal ulcer seen on EGD. #GI bleed: EGD reports as above. Patient treated with PPI and transfusion. Per GI - will need lifelong [**Hospital1 **] PPI, avoid NSAIDs. ASA stopped. H pylori serology negative. Biopsy of ulcers taken at EGD and pending. Pt to follow up with Dr [**First Name (STitle) 679**] for follow up of biopsy read and to see if H pylori positive. Hypotension resolved with PRBC. Superficial thrombophlebitis: Septicemia, coagulase negative staphylococcus: The patient developed Superficial thrombophlebitis at the left brachial IV cath site. Cath was removed and patient was treated with IV vancomycin for total 7 days. Last day in [**2186-4-4**]. PICC placed after negative culture and after pt was afebrile to continuation of IV antibiotics. On the day of discharge, vancomycin trough level was 26 and so dose was decreased to 1 gram q24 hours as per discussion with ID fellow - Dr [**Last Name (STitle) 7443**]. The patient should have vanco trogh level checked on [**2186-4-3**] to targert of [**11-6**]. further management per physicians at rehab. Also, BUN, creat and CBC should be done to ensure stability. The patient should follow up with PCP for repeat blood cultures in [**1-18**] weeks after the antibiotics completed for follow up labs. The patient has COPD and CXR showed some changes as above. Folow up CXR at discretion of PCP. Urinary tract infection, catheter related, bacterial - foley cath removed. Culture grew enterobacter sensitive to ciprofloxacin. last day of 7 day scourse is [**2186-4-2**] (i.e. day of discharge). History of chronic pancreatitis - pt has chronic pain and was treated with oxycontin with prn oxycodone. Pancreatic enzymes with meals were continued. For depression - thioridazine, fluoxetine and trazodone were continued. Patient had a stable mood and not suicidal or homicidal. Medications on Admission: fluoxetine 20 mg daily [**Month/Day/Year 24445**] 1 cap TIDAC trazodone 150 mg qhs prn vitamin D 800 units daily chlorpromazine 25 mg daily ferrous sulfate 325 mg daily aspirin 81 mg daily acetaminophen prn Thioridazine 25 mg Tablet at 4pm daily Discharge Medications: 1. Heparin Flush PICC (100 units/ml) 2 mL IV DAILY:PRN 10 ml NS followed by 2 mL of 100 Units/mL heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 3. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime) as needed. 4. Vitamin D 400 unit Tablet Sig: Two (2) Tablet PO once a day. 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 1 doses: Evening dose on [**2186-4-2**]. 8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for adbominal pain: hold for sedation, RR < 12. 9. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours): hold for sedation, RR < 12. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 11. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 12. Thioridazine 25 mg Tablet Sig: One (1) Tablet PO Q4PM (). 13. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO QAC. 14. Vancomycin Vancomycin 1000 mg IV Q 24H (for 2 days); last day [**2186-4-4**]. Discharge Disposition: Extended Care Facility: Academy Manor of [**Location (un) 7658**] - [**Location (un) 7658**] Discharge Diagnosis: Acute blood loss anemia Gastrointestinal bleeding Hypotension - resolved Superficial thrombophlebitis Septicemia, coagulase negative staphylococcus urinary tract infection, catheter related, bacterial History of chronic pancreatitis History of COPD Discharge Condition: Stable. Discharge Instructions: You were treated for bleeding from ulcer in your stomach and also for a IV catheter related infection and a urine infection. It is recommended that you complete the course of antibiotics (vancomycin) that will be administered thru PICC catheter. Last day of antibiotic is [**2186-4-4**]. The rehab will monitor the levels of the antibiotic as well as your other blood work. Follow up with Dr [**Last Name (STitle) 16258**] - your primary care doctor to get blood work withing 10 days of your discharge from the rehab facility. Also discuss with your primary care doctor about getting another lung xray. Make an appointment with Dr [**First Name (STitle) 679**] for results of biopsy (stomach) in the next 2-4 weeks. Followup Instructions: PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 11595**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 19196**]. Call and schedule an appointment within 10 days of rehab discharge. The physicians at rehab will be caring for your further medical needs while you are there. Dr [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] [**Telephone/Fax (1) 682**]. Please call to make an appointment with Dr [**First Name (STitle) 679**] in [**2-20**] weeks for the results of the biopsy.

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icd9cm

[ [ [] ] ]

[ "45.16", "38.93" ]

icd9pcs

[ [ [] ] ]

21957, 22052

18250, 20198

275, 305

22345, 22355

3598, 8680

23122, 23632

2961, 3011

20495, 21934

13449, 13507

22073, 22324

20224, 20472

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3026, 3579

1958, 2029

229, 237

13536, 18227

333, 1939

2051, 2729

2745, 2945

19,911

180,900

21433

Discharge summary

report

Admission Date: [**2130-10-26**] Discharge Date: [**2130-12-7**] Date of Birth: [**2066-3-22**] Sex: F Service: MED Allergies: Keflex / Erythromycin Base Attending:[**First Name3 (LF) 281**] Chief Complaint: Respiratory Distress Major Surgical or Invasive Procedure: Endotracheal Intubation History of Present Illness: 64 y/o F, with a PMHx significant for oxygen dependent COPD, diastolic CHF, [**First Name3 (LF) 1291**] (St. [**Male First Name (un) 923**]) on coumadin, s/p MRSA sternotomy wound infxn, DM2, and a fib, who presented to [**Hospital 1474**] Hospital on [**2130-10-24**] with hypoxia, dyspnea and symtpoms c/w with similar episodes of CHF. She was initially treated with BiPap, but failed and therefore required ET-intubation. She also had fevers with Tmax of 103, hypotension with SBP in 80's treated with agressive fluid resucitation. On [**10-25**] blood cultures, [**4-23**] were positive for GPC. Urine Culture + for staph. The bacteria was further identified as MRSA. She was started on Vanc/Gatiflox/Flayl and stress dose steroids (solumedrol 125mg IV TID). It was suspected the patient may have been developing possible DIC. At this time she was transferred to [**Hospital1 18**] for further care beginning on [**2130-10-26**]. She did not require any pressors during her transfer. Past Medical History: decompensated diastolic heart failure Acute on chronic renal failure aortic valve replacement paroxysmal a fib Thrombocytopenia Coagulopathy COPD (Prior ET intubation 5 years ago) MRSA + sternotomy wound infxn ~2year ago. Treated with ~1years of IV Vanc at [**Hospital1 2177**] (per daughter) Social History: lives with husband, has multiple children who are very involved in her care Family History: non-contributory Physical Exam: At the time of discharge: vitals: Temp 99, HR 88 in a fib, BP 105/55, sats 100% on AC FiO2 0.4, RR 12, Tv 650, PEEP 5 GEN: obese female, NAD, tracheostomy in place, mouths words, right sided hemiparesis, interactive HEENT: PERRL, EOMI, oral pharynx clear, thick neck PULM: course breath sounds bilaterally, no wheeze CHEST: Left HD catheter in place CV: irregularly irregular rhythm, mechanical S2 heart sound ABD: soft +BS, non-tender, nondistended, PEG tube in place with no signs of skin infection GU: inguinal areas erythematous with minimal skin breakdown RECTAL: multiple stage II ulcerations, granulating, no necrosis, no discharge EXT: right picc line, no edema of LE, edema of UE NEURO: interactive, right sided paralysis, able to squeeze with left hand, now mouthing words. Pertinent Results: [**2130-12-7**] 03:43AM BLOOD WBC-9.1 RBC-2.50* Hgb-7.1* Hct-23.3* MCV-93 MCH-28.2 MCHC-30.3* RDW-23.2* Plt Ct-337 [**2130-12-7**] 03:43AM BLOOD Plt Ct-337 [**2130-12-7**] 03:43AM BLOOD Glucose-153* UreaN-30* Creat-2.0*# Na-143 K-3.4 Cl-107 HCO3-26 AnGap-13 [**2130-11-29**] 02:00AM BLOOD ALT-12 AST-21 LD(LDH)-380* AlkPhos-205* TotBili-0.5 [**2130-12-7**] 03:43AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.0 [**2130-10-26**] 03:01AM BLOOD TSH-0.41 [**2130-12-3**] 05:31AM BLOOD Type-ART Rates-/2 Tidal V-700 PEEP-5 O2-40 pO2-97 pCO2-40 pH-7.45 calHCO3-29 Base XS-3 -ASSIST/CON Intubat-INTUBATED [**2130-11-27**] 3:53 pm BRONCHOALVEOLAR LAVAGE LEFT. **FINAL REPORT [**2130-11-30**]** GRAM STAIN (Final [**2130-11-27**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI. RESPIRATORY CULTURE (Final [**2130-11-30**]): MODERATE GROWTH OROPHARYNGEAL FLORA. ESCHERICHIA COLI. SPARSE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 178-9614A [**2130-11-27**]. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # 178-9614A [**2130-11-27**]. Brief Hospital Course: Mrs [**Known lastname **] presented to an outside hospital with SOB and hypoxia presumed secondary to CHF. After developing Staph aureus bacteremia, she was transferred to [**Hospital1 18**] for evaluation of a possible prosthetic valve endocarditis. Despite a negative work-up for a source of bacteremia (possibly related to skin breakdown) including TEE, the patient improved on antibiotics. Early in her course, she developed left parietal hemorrhage in the setting of heparin anticoagulation for [**Hospital1 1291**] stroke prophylaxis. She was left with a right-sided hemiparesis. She was successfully extubated but then sufferred a PEA arrest on [**2130-11-11**], the etiology of which is unclear possibly secondary to a mucous plug vs. hypovolemia. During the arrest the patient was reintubated. Because of difficulty weaning from the vent, a tracheostomy was performed on [**2130-11-20**]. On chest x-ray [**11-22**], a left pleural effusion was noted and tapped for fluid analysis. The fluid was found to be transudative in nature, with no infectious organisms. The effusion appears to be as a result of volume overload, decreasing in size after hemodialysis. The patient's respiratory status has not been compromised by the effusion. The patient also developed acute renal failure and is currently anuric. She is hemodialysis dependent and receives dialysis MWF. Her left subclavian tunnel catheter was placed on [**11-24**]. The patient had remained afebrile for multiple days until [**12-3**] when a temp of 102 was noted. Sputum cultures were positive for pseudomonas. She is currently being treated with IV abx including levofloxacin and azetreonam and will complete a 3 week course. At the time of discharge the patient was afebrile. 1) Resp Failure: The pt was intubated and stable upon admission to [**Hospital1 18**]. Her resp failure was presumed secondary to an acute CHF exacerbation along with underlying severe obesity, deconditioning, and COPD. Given her bacteremia, a concern for sepsis was also put forth with resultant resp failure, but her hemodynamic state was not concordant with sepsis. Over her course, her resp status was complicated after a PEA arrest and reintubation, subsequent tracheostomy, left pleural effusion (stable) and pseudomonas pneumonia as well as underlying obesity and deconditioning. At the time of discharge the patient was doing well on AC with an FiO2 of 0.4, RR of 12, Tv of 650, and PEEP of 5. Over her course, she was treated with albuterol/atrovent MDI along with inhaled steroids to target COPD. To address her CHF, diuresis (with lasix and nesiritide) was only marginally successful and she was commenced on hemodialysis which she remains on three times weekly. 2) Staph Aureus Bacteremia: The patient had four of four positive blood cultures at the OSH for MRSA. Her initial set of blood cultures (along with her urine culture) at [**Hospital1 18**] were also positive for MRSA. Vancomycin was commenced for a four week course (for empiric endocarditis coverage) and subsequent blood cultures were unremarkable. However, early in her course she had intermittent fevers. Her previous intravenous lines were discontinued. After a negative TEE, TTE, culture data (including previous lines), and panimaging, a source of her MRSA was unknown. The patient has sacral and subpannus skin break down diffusely, which was treated with antifungals and topical powders as outlined in the nursing notes. She was seen by the ID service who provided recommendations. Wound cultures were negative for HSV, VZV, syphillis. 3) CHF: Again, the patient was fluid overloaded by central hemodynamic evaluation along with her exam. However, echocardiography showed a preserved LVEF. Given her history of diastolic CHF, she was initially started on Lasix, a Lasix drip, and then Nesiritide. With little success, she was tried on HD and then CVVHD for fluid removal. At the time of discharge the patient is HD dependent. 5) ARF: Upon admission, her Cr was 4.0 from a baseline of 1.5-1.7. The etiology was presumed secondary to CHF and/or mild sepsis with poor renovascular flow. She had intermittent oliguria and intermittent adequate urine ouput over her course. Initially, there was ATN based on urine sediment (with likely poor perfusion to precipitate this based on low FENa/Urea and an elevated lactate). Of note, there was initially a concern for septic/nonseptic emboli, but given obesity, a renal U/S was not pursued. The patient's CR at discharge was 2.0, but she remains anuric and dialysis dependent. 6) Cerebral Infarction/Bleed: On admission, a CT scan of her head was purusued because of right-sided hemiparalysis in the setting of likely endocarditis. Left parietal and right occipital hypodensities were noted. The Stroke service was consulted. Given a concern for septic embolic stroke, further imaging (CT) was pursued. A repeat head CT showed a left parietal bleed in the setting of heparin for [**Hospital1 1291**] anticoagulation. MRI was not pursued because of constraints secondary to body habitus. The patient had a stable right-sided paresis with plegia of the right upper extremity. She was followed by OT/PT. 7) C.Diff: The patient developed loose stools early in her course along with fevers. She was positive for the C.Diff toxin A and was started on Flagyl. Oral Vancomycin was then added because of a poor response. She completed a full abx course and was c diff toxin neg on [**12-3**]. 8) AF: She had atrial fibrillation with a rapid ventricular response through most of her course. She was rate controled with Metoprolol. However, with increasing doses of beta-blocker, she had intermittent pauses of up to 2.0 seconds. After holding anticoagulation for an intracranial bleed, she was continued on ASA. After allowing 10 days for recovery, she was restarted on anticoagulation and will be continued on coumadin with a goal INR of 2.5. She was started on diltiazem and will be discharged on a dose of 90 mg QID. 9) [**Month/Year (2) 1291**]: The patient had a St. [**Initials (NamePattern4) 1525**] [**Last Name (NamePattern4) 1291**] in [**2128**]. Coumadin was initially held because of a supratherapeutic INR on admission and concern for DIC. Once this concern was put to rest, with the aid of Hematology, she was restarted on heparin as above. After her hemorrhagic stroke, anticoagulation was held and the patient was put on ASA. As above, anti-coagulation was recommenced with heparin and then warfarin, she will be maintained on warfarin (coumadin) at discharge. 10) ANEMIA: HCT should be maintained >21. Likely secondary to chronic disease. Medications on Admission: Meds on Transfer: Dig, pepcid, prop, asa, vanc, gatiflox, flagyl, solumedrol. Discharge Medications: 1. Acetaminophen 160 mg/5 mL Elixir Sig: [**1-20**] tsps PO Q4-6H (every 4 to 6 hours) as needed. Disp:*60 tsps* Refills:*2* 2. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). Disp:*1 month supply* Refills:*2* 3. Lansoprazole 30 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* 4. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:*1 MDI* Refills:*2* 5. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl Topical PRN (as needed). Disp:*1 month supply* Refills:*2* 6. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical Q8H (every 8 hours) as needed. Disp:*1 month supply* Refills:*2* 7. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 8. Ascorbic Acid 100 mg/mL Drops Sig: Five (5) drops PO DAILY (Daily). Disp:*1 month supply* Refills:*2* 9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 10. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 MDI* Refills:*2* 11. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*1 month supply* Refills:*2* 12. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO four times a day. Disp:*120 Tablet(s)* Refills:*2* 13. Insulin Glargine 100 unit/mL Solution Sig: One (1) dose Subcutaneous ONCE (once): at night. Disp:*1 month supply* Refills:*2* 14. Aztreonam in Dextrose(IsoOsm) 1 g/50 mL Piggyback Sig: Five Hundred (500) mg Intravenous every twelve (12) hours: please stop on [**2130-12-20**]. Disp:*2 week supply* Refills:*0* 15. Levofloxacin 25 mg/mL Solution Sig: Two [**Age over 90 1230**]y (250) mg Intravenous q48: please stop on [**2130-12-18**]. Disp:*2 week supply* Refills:*0* 16. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: decompensated diastolic heart failure Acute on chronic renal failure aortic valve replacement paroxysmal a fib Thrombocytopenia Coagulopathy COPD (Prior ET intubation 5 years ago) MRSA + sternotomy wound infxn ~2year ago. Treated with ~1years of IV Vanc at [**Hospital1 2177**] (per daughter) Pseudomonas pneumonia respiratory failure Discharge Condition: stable Discharge Instructions: The patient should be weaned on the vent as tolerated, currently on AC settings. She has a PEG tube and is tolerating her tube feeds at goal continue Nepro w/ promote at 40 cc/hr. She should receive hemodialysis three times weekly. Her wound care should be strictly maintained as related in the nursing records. Patient is anti-coagulated on coumadin, she will need INR monitoring and potential dosing adjustments. Followup Instructions: Follow up with your PCP and the physicians at the rehab facility. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]

[ "997.02", "263.9", "008.45", "431", "995.92", "427.31", "427.5", "707.03", "428.0", "V43.3", "428.33", "482.1", "698.3", "518.82", "038.11", "V58.61", "286.9", "342.90", "584.5", "284.8", "403.91", "278.01", "496" ]

icd9cm

[ [ [] ] ]

[ "38.93", "88.72", "33.23", "89.64", "99.04", "99.07", "96.72", "34.91", "31.1", "43.11", "00.13", "33.24", "96.6", "86.11", "38.95", "39.95" ]

icd9pcs

[ [ [] ] ]

12771, 12850

3930, 10559

303, 328

13229, 13237

2608, 3907

13700, 13860

1770, 1788

10687, 12748

12871, 13208

10585, 10585

13261, 13677

1803, 2589

243, 265

356, 1345

1367, 1661

1677, 1754

10603, 10664

42,430

100,969

37502

Discharge summary

report

Admission Date: [**2142-11-26**] Discharge Date: [**2142-11-30**] Date of Birth: [**2061-12-10**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6075**] Chief Complaint: code stroke - L sided weakness Major Surgical or Invasive Procedure: Intubated - [**2142-11-28**] History of Present Illness: CC: Code stroke - L sided weakness Code activated 6:12pm Patient examined 6:20pm NIHSS: Best gaze - forced to R 2 Visual - Complete L hemianopia 2 Facial palsy - partial on L 2 Motor - L arm 4 L leg 4 Sensory - Severe/total loss on L 2 Dysarthria - mild dysarthria 1 Extinction - profound inattention to L side 2 Total 19 HPI: Patient is a 80yo RHM with Afib but not on Coumadin, HTN, DM and hx of stroke over 10 years ago with some residual L sided weakness who was found down per VNA at 3pm with L slurred speech and L sided weakness. Per report, he was taken by ambulance to [**Location 84234**]where his initial BP was extremely elevated with SBP into 280s for which he was given labetalol x2~3. Head CT was negative for hemorrhage then patient was transferred to [**Hospital1 18**] for further care. Per patient, he woke up around 10am and ate breakfast which was delivered per meals on wheels. He did not speak to anybody - he lives alone and ambulates with a walker and reports to have VNA once or twice weekly. He then fell around 10:30 am - he is unable to recall why he fell but he thinks he may have tripped but he could not get up hence was on the floor until VNA found him at 3pm. He denies any recent illness, fever, cough, N/V/D or HA. He reports to be smoking as much as possible (>1 PPD) which he has been doing over 50 years and not taking any of his meds. He reports to have not taken any meds for over 2 months at least, however, per [**Hospital1 802**] who is also his HCP, she reports that his meds are overseen per VNA hence he may be more compliant than he reports. Also, she recalls that when she accompanied him to his PCP appt about 6 months ago, his PCP may have told him that he can take ASA instead of Coumadin for his Afib. Of note, patient was in nursing home about 6~8 weeks ago for PT and rehab after vascular surgery for RLE artery occlusion. Past Medical History: 1. Stroke - over 10 yrs ago, initially could not move L side, talk or walk per patient. 2. Afib 3. HTN 4. DM - oral [**Doctor Last Name 360**] only 5. s/p abdominal surgery to remove tumor 6. PVD - s/p bypass surgery in RLE 7. s/p cataract repair bilaterally Social History: Lives alone with weekly VNA for assistance and has meals delivered per Meals on Wheels. Walks with walker at baseline and does not leave the house much. Reports to smoke as much as possible, >1 PPD for the past 50 years. Divorced and has 3 grown children out in West Coast, nearest [**Doctor First Name **] and HCP is [**Last Name (LF) 802**], [**Name (NI) **] [**Telephone/Fax (1) 84235**] in [**Location (un) 3844**]. Full code - confirmed per HCP. Family History: NC Physical Exam: Exam: T 98.0 BP 193/86 HR 64 RR 19 O2Sat 100% 2L NC Gen: Lying in bed, disheveled appearing 80yo man. HEENT: No teeth - does not wear dentures per patient Neck: No carotid or vertebral bruit CV: Irregularly irregular but difficult to auscultate due to very faint heart sounds. Lung: Clear anteriorly. Abd: Well healed abdominal scar with ventral hernia - reducible. +BS, soft and nontender. Ext: No edema, scar over R interior thigh. Neurologic examination: Mental status: Awake and alert, cooperative with exam, normal affect. Oriented to person, place, and month. Fluent speech with mild dysarthria, no dysnomia with high frequency words and intact repetition. Cranial Nerves: II: R pupil slightly larger than L and more asymmetric. S/p bilateral cataract - both are reactive but L more brisk than R. No blinking to visual threat on L. III, IV & VI: Forced deviation to R. V: Decreased sensation on L to LT and PP. VII: L facial droop. VIII: Hearing intact to finger rub bilaterally. X: Palate elevation symmetrical. XII: Tongue midline. Motor: Normal bulk - slightly higher tone on L than R and more on LUE than LLE. No adventitious movements. Unable to move L side but appears full strength on R. Withdraws to noxious stim on L but not anti-gravity. Sensation: Intact to light touch, pinprick and cold on R but decreased/near total absence on L body although intact to noxious stim. Reflexes: +2 for LUE and 2 for RUE. None for patellar or Achilles in either lower legs. Toes upgoing bilaterally Pertinent Results: [**2142-11-28**] 02:06AM BLOOD WBC-12.8* RBC-3.12*# Hgb-9.8*# Hct-30.0*# MCV-96 MCH-31.3 MCHC-32.6 RDW-14.4 Plt Ct-127* [**2142-11-27**] 08:58AM BLOOD WBC-15.9*# RBC-4.32* Hgb-13.5* Hct-40.6 MCV-94 MCH-31.2 MCHC-33.2 RDW-13.7 Plt Ct-183 [**2142-11-28**] 02:59AM BLOOD PT-14.4* PTT-30.0 INR(PT)-1.2* [**2142-11-28**] 02:06AM BLOOD Glucose-121* UreaN-25* Creat-0.9 Na-145 K-3.0* Cl-114* HCO3-21* AnGap-13 [**2142-11-27**] 12:38AM BLOOD CK-MB-NotDone cTropnT-0.02* [**2142-11-28**] 02:06AM BLOOD Calcium-7.0* Phos-2.1* Mg-1.6 [**2142-11-27**] 08:58AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.9 [**2142-11-27**] 12:38AM BLOOD Triglyc-45 HDL-50 CHOL/HD-3.0 LDLcalc-92 [**2142-11-27**] 12:38AM BLOOD TSH-0.82 Echo [**2142-11-27**]: The left atrium is dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed (LVEF= 30-40 %) secondary to hypokinesis of the inferior septum and akinesis of the inferior free wall and posterior wall. The basal inferior and posterior walls are thin and fibrotic. There is no ventricular septal defect. Right ventricular chamber size is normal. with depressed free wall contractility. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. Moderate [2+] tricuspid regurgitation is seen. The tricuspid regurgitation jet is eccentric and may be underestimated. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. CTA head and neck and perfusion ([**2142-11-26**]) IMPRESSION: 1. Likely embolic occlusion of the M1 segment of the right middle cerebral artery with perfusion findings of infarct involving virtually the entire right MCA distribution. 2. Just over 60% stenosis of the proximal left common carotid artery. 3. Moderate atherosclerotic disease at the carotid bifurcations bilaterally, with likely an ulcerated plaque involving the proximal right external carotid artery and extensive soft plaque within the carotid bulb on the right. 4. 8 mm nodular soft tissue density within the left paraglottic fat may be a lymph node but is of unclear etiology and should be correlated with clinical findings and/or direct visualization. Associated mild thickening of the lingual tonsils, glossoepiglottic fold and anterior surface of the epiglottis. 5. Extensive degenerative changes of the cervical spine. 6. Severe atrophy and evidence of old cortical embolic infarcts. Extensive chronic microvascular ischemic change. CT head [**11-28**] IMPRESSION: 1. Evolving acute and virtual-complete right middle cerebral artery territory infarction with hemorrhagic transformation and extension of the hemorrhage into the right lateral and third ventricles, layering in bilateral occipital horns. 2. Significant leftward shift of midline structures, with marked subfalcine herniation and less marked uncal herniation. COMMENT: A wet read was also provided on [**2142-11-28**] at 14:07, and Dr. [**Last Name (STitle) 656**] was notified of the results at 14:05 on [**2142-11-28**]. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: The patient is a 80yo RHM with Afib not on Coumadin but possibly ASA, HTN, DM and hx of stroke with some residual L sided weakness who smokes >1PPD found per VNA at home down on the floor with slurred speech and L sided weakness around 3pm. Patient initially presented to [**Location (un) **] ED then transferred here for further care. Patient seen and examined 6:20pm - ~ 8hrs after presumed onset of symptoms. His initial NIHSS score was 19 for R gaze deviation, L sided weakness and sensory deficit. His CT of head shows dense R MCA with likely M2 level occlusion and loss of [**Doctor Last Name 352**]/white matter differentiation over the distribution. His INR was 1.2 but patient reports not to have taken meds including Coumadin for possibly over 2 months. The patient was admitted to the neurology ICU for further care. He was initially started on a heparin drip but follow up CT scan showed a large size of infarct and it was determined that the risk of bleeding outweighed the benefits of heparin. In addition the patient had an episode of emesis, and possible aspiration. On [**11-27**] the patient was less esponsive to commands and was tachypneic, a CXR showed a worsening infiltrate in the right lower lobe. His respiratory status worsened and he required intubation. Later in the afternoon the patient was found to have an fixed and dilated right pupil. A head CT was obtained showing a large hemorrhagic coversion. The bleed was catastrophic, and the patient had negative brainstem reflexes by the time he returned from the scan. The patient was terminally extubated on [**11-27**]. The prognosis was discussed in detail and he was extubated. He expired on [**2142-11-30**]. Medications on Admission: has not taken any meds over 2 months per patient 1. Metoprolol 2. Coumadin (?ASA) 3. Metformin Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Right middle cerebral artery stroke Discharge Condition: expired Discharge Instructions: You were admitted with left sided weakness and slurring of your speech. You were found to have a large stroke on the right side of your brain. This was likley a blood clot from your heart as a result of your irregular heart beat and not taking a blood thinning [**Doctor Last Name 360**]. You also had an episode were you vomitted and likely aspirated requiring you to be started on antibiotics and intubated Followup Instructions: none

[ "443.9", "507.0", "401.9", "496", "427.31", "518.81", "305.1", "434.11", "250.00", "348.4" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

10012, 10021

8131, 9836

350, 380

10101, 10111

4633, 8108

10571, 10579

3080, 3084

9983, 9989

10042, 10080

9862, 9960

10135, 10548

3099, 3535

280, 312

408, 2309

3783, 4614

3574, 3767

3559, 3559

2331, 2592

2608, 3064

61,605

145,905

43531

Discharge summary

report

Admission Date: [**2120-5-29**] Discharge Date: [**2120-6-1**] Date of Birth: [**2043-10-16**] Sex: F Service: MEDICINE Allergies: Demerol / Vicodin / amiodarone Attending:[**First Name3 (LF) 1711**] Chief Complaint: Afib with RVR and hypotension. Major Surgical or Invasive Procedure: cardioversion History of Present Illness: 76F with Afib on warfarin s/p DCCV in [**2116**], h/o rheumatic fever s/p AVR and MVR, h/o strep endocarditis, systolic CHF (EF=30% in [**2117**]) and interstitial lung disease who presents to the ED after she was noted to have a heart rate in the 130s at her PCP's office. The patient reports feeling generally unwell for the past [**4-14**] days. She has had symptoms of worsening DOE with walking from room to room in her home. She has had these symptoms several times. Often associated with atrial fibrillation. She has noted that her appetite has decreased lately and she has been experiencing diarrhea for the last three days. She decribes the stool as loose to liquid, no blood, no melana, or mucous. She had seen her PCP [**Name Initial (PRE) **] 1 week prior, who noted 'fluid in her lungs' and her lasix dose was increased. She has chronic 1+ orthopnea, no PND, no fluttering in her chest, no chest pain/pressure, or dietary indiscretion. She admits to decreased PO intake and appetite, she also states she has a small amount of peripheral edema which is chronic. She was at her PCPs this morning who noted a rapid heart rate. EKG at the time reportedly, revealed atrial fibrillation with rapid ventricular response without evidence of ischemic changes and she was referred to the ED. Upon arrival to the ED, her initial vitals were 96.0, 128 99/59 20 96%. Her labs and imaging significant for therapeutic INR of 2.8, Cr elevated to 4.2. She was given diltiazem 10mg IV followed by diltiazem 30mg PO with an SBP drop to the 70s. She has receieved a total of 1.5 liters of fluids and her SBPs have slightly improved to the the 80-90s. Her HR has remained in the 130s after dilt. Given her borderline blood pressures, she was admitted to the CCU for further management. Her vitals on transfer were 97.4, 91/62, 130, 99% 3 L NP. Of note she has had several admissions to NEBH with hypovolemic ARF and heart failure exacerbations. Most recently she had an admission in [**2119-10-12**] for ARF with hyperkalemia. Her Creatinine was 5.5 on admission, was treated with hydration and her creatinine improved to 2.1 On arrival to the floor, patient reports feeling well. No CP/pressure, no abdominal pain, no HA, no N/V. She is breathing comfortably and able to speak easily in full sentances. Her LBM this am. Past Medical History: 1. CARDIAC RISK FACTORS: (+)DM, (+)HTN, (+)HLD 2. CARDIAC HISTORY: Afib s/p cardioversion in [**2116**], mechanical MVR and AVR in [**2098**] -h/o strep endocarditis in [**2115**] s/p 6 weeks of vanc/PCN -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: -psoriasis -interstitial lung pathology per PFTs in [**3-21**]; felt to possibly be [**3-14**] amiodarone toxicity. -gallbladder removal -hernia repair -s/p TIA in [**2115**] -DMII -Gout -Hypothyroidism Social History: Pt lives in [**Location 29789**] with her daughter and son. She has 5 children, 10 grandchildren, and 1 greatgrandchild. -Tobacco history: Former, quit 23 yr prior, smoked 1 ppd for 'many years' -ETOH: Denies -Illicit drugs: Denies Family History: Father - died of MI at age 42 Mother - 2 MI, died of PE. Physical Exam: VITALS: 98.1 113/53 71 18 97% on 3L GENERAL: 76 yo F in no acute distress, sitting in bed HEENT: mucous membs moist, no lymphadenopathy, JVP non elevated CHEST: CTABL no wheezes, faint crackles at bases. CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or gallops ABD: soft, non-tender, opbese, BS hypoactive. no rebound/guarding. EXT: wwp, no edema. DPs, PTs 2+. NEURO: 4/5 strength in U/L extremities. Gait WNL. SKIN: no rash PSYCH: alert, oriented, cooperative Pertinent Results: [**2120-6-1**] 06:50AM BLOOD WBC-5.6 RBC-3.21* Hgb-10.5* Hct-34.4* MCV-107* MCH-32.7* MCHC-30.5* RDW-16.0* Plt Ct-116* [**2120-6-1**] 06:50AM BLOOD Glucose-157* UreaN-78* Creat-2.3* Na-149* K-5.0 Cl-113* HCO3-27 AnGap-14 [**2120-5-31**] 06:50AM BLOOD Calcium-8.5 Phos-4.4 Mg-2.6 [**2120-6-1**] 06:50AM BLOOD PT-27.7* INR(PT)-2.7* [**2120-5-31**] 06:50AM BLOOD PT-28.9* PTT-34.5 INR(PT)-2.8* [**2120-5-30**] 05:24AM BLOOD PT-25.7* PTT-29.8 INR(PT)-2.5* [**2120-5-29**] 02:38PM BLOOD PT-29.1* PTT-33.7 INR(PT)-2.8* [**2120-5-30**] ECHO The left atrium is mildly dilated. The estimated right atrial pressure is 5-10 mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is severely depressed (LVEF= 20-25 %) with akinesis of the inferior segments and at least hypokinesis of the remaining segments. Due to suboptimal technical quality, additional focal wall motion abnormalities cannot be fully excluded. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size is normal. with mild global free wall hypokinesis. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. A mechanical aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. Mild (1+) aortic regurgitation is seen. [Due to acoustic shadowing, the severity of aortic regurgitation may be significantly UNDERestimated.] A mechanical mitral valve prosthesis is present. The mitral prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is a trivial/physiologic pericardial effusion. IMPRESSION: Biatrial enlargment. Mildly dilated left ventricle with severely depressed global left ventricular systolic function with regional wall motion abnormalities as described above. Mildly dilated ascending aorta and aortic arch. Well-seated, normally functioning aortic and mitral mechanical valve prostheses. Mild aortic regurgitation. Mild mitral regurgitation. Moderate tricuspid regurgitation. Significant pulmonic regurgitation. Moderate pulmonary artery systolic hypertension. Compared to the previous study of [**2117-11-24**], the global left ventricular sytolic function is slightly worse; LVEF previously 30%, now 20-25%. The left ventricle has minimally decreased in size; previously 6.2 centimeters, now 5.9 centimeters. Brief Hospital Course: 76F with Afib on warfarin, h/o rheumatic fever s/p mechanical AVR and MVR in [**2098**], systolic CHF (EF=30%), interstitial lung disease (question of amio toxicity), and h/o strep endocarditis who presents with SOB and diarrhea x3 days, noted to be in afib with RVR. . # AFib/RVR: Patient presented in Afib with RVR in the setting of recently increased Lasix dose, and as such volume depletion may have precipitated her worsening RVR and tachycardia. She is s/p multiple DCCV in the past for her afib and has presumed amiodarone toxicity. She became hypotensive after receiving dilt in the ED for rate control. She was mildly hypotensive on admission to the CCU, and given her vital signs, it was decided that she should be cardioverted to normal sinus. This was performed successfully and she remained in sinus with good rate control. Warfarin was continued and her INR was maintained at goal 2.5-3.5. Carvedilol was increased to 12.5mg [**Hospital1 **]. # Chronic systolic CHF TTE showed EF 20-25% with TR and mod PHTN. Appeared somewhat dry on exam on admission. Received some IV fluids with improvement of blood pressures and heart rate. Lasix was held, then restarted at a lower dose of 40mg daily PO. Lisinopril was also held indefinitely given her low blood pressures. Carvedilol was increased to 12.5mg [**Hospital1 **]. # Acute on chronic kidney disease: Cr 4.2 at admission, prior baseline appears to be around 2.1 in [**2119-10-12**]. Improved when returned to [**Location 213**] sinus. 2.3 on discharge. #UTI: Started on Cipro at PCP's office, UA in the ED c/w > 180 WBCs and few bacteria. She was started on ceftriaxone in the ED. This was changed to cefpodoxime and she was discharged to complete a 7 day course. # H/o rheumatic fever s/p mechanical AVR and MVR: Valves well seated on last TTE. INR therapeutic at admission. Continued warfarin with goal INR 2.5-3.5. # Interstitial lung disease: Crackles at bases. Stable on home O2 level. PFT's show restrictive pattern thought [**3-14**] amiodarone rx. Continued Supplemental oxygen as needed. . # Diabetes: Hold home oral diabetic medications. Used sliding scale in house. Restarted metformin and glipizide on discharge. Medications on Admission: -allopurinol 300 mg po qday -carvedilol 6.25 mg po BID -citalopram 20 mg po qday (? no prescription) -fluticasone 50 mcg nasal spray [**Hospital1 **] -folic acid 1 mg po qday -furosemide 80 mg po qday -glipizide XL 2.5 mg po qday -levothyroxine 25 mcg po qday -lisinopril 5 mg po qday -prednisone 15 mg Tablet po qday -warfarin 5 mg po on FRI and SUN, 2.5mg all other days -ferrous sulfate 324 mg (65 mg Elemental Iron) po BID -multivitamin-minerals-lutein [Centrum Silver] qday Discharge Medications: 1. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 3 days. Disp:*6 Tablet(s)* Refills:*0* 2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1) spray Nasal twice a day. 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 7. warfarin 5 mg Tablet Sig: One (1) Tablet PO 2X/WEEK ([**Doctor First Name **],FR). 8. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO 5X/WEEK (MO,TU,WE,TH,SA). 9. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 12. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Atrial fibrillation with rapid ventricular response Acute on Chronic kidney injury Chronic systolic congestive heart failure Urinary tract infection Diabetes Mellitus Intersticial lung disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You had a rapid heart rate and was cardioverted into a normal rhythm. Your kidney function worsened but is now improving. A urinary tract infection was treated with antibiotics for a total of 7 days. You will need to have your labs checked at Dr. [**Name (NI) 93671**] office on Wendesday [**6-5**]. Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. . WE made the following changes to your medicines: 1. Decrease furosemide to 40 mg daily instead of 80 mg daily 2. Stop lisinopril Followup Instructions: Name: [**Last Name (LF) 68054**],[**First Name3 (LF) **] Location: HEALTHWORKS Address: [**Street Address(2) 93672**], [**Location (un) **],[**Numeric Identifier 9310**] Phone: [**Telephone/Fax (1) 68055**] Appointment: Wednesday [**2120-6-5**] 4:00pm Name: [**Last Name (LF) **], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD Address: [**Hospital1 **], [**Location (un) **],[**Numeric Identifier 6425**] Phone: [**Telephone/Fax (1) 6937**] *Please call your cardiologist to book a follow up appointment for your hospitalization. You need to be seen within 1 month of discharge.

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icd9cm

[ [ [] ] ]

[ "99.61" ]

icd9pcs

[ [ [] ] ]

10588, 10647

6842, 9042

322, 337

10883, 10883

4068, 6819

11652, 12258

3497, 3555

9571, 10565

10668, 10862

9068, 9548

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2784, 2996

252, 284

365, 2694

10898, 11041

3027, 3231

2716, 2763

3247, 3481

27,245

116,028

32081

Discharge summary

report

Admission Date: [**2199-9-20**] Discharge Date: [**2199-9-22**] Date of Birth: [**2117-3-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2736**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: The patient is an 82-year-old male with history of CAD, s/p MI in [**2187**], CHF w/ EF 10-15% who had a recent admission to [**Hospital 16843**] hospital for CHF exacerbation. He was discharged 1 week prior to this admission on [**2199-9-22**]. The patient has been complaining of shortness of breath since his last hospitalization. He reports new exertional dyspnea after walking just "10 feet" and he has [**1-13**] pillow orthopnea and needs to sleep upright on occasion. No new lower extremity swelling and he reports weight loss of 15lbs over the last 2-3 months. Has has a "constant cough" with white/green phlegm but no blood. No sick contacts. [**Name (NI) **] recent travel. By report from family patient's lasix dose was recently decreased by his home visiting nurses/CNAs due to low blood pressures. Previously had been taking 60mg [**Hospital1 **] and now was taking 40-60mg daily (unclear, patient limited historian and daughter uncertain). Patient was admitted to [**Hospital3 7571**]Hospital a week ago where he was treated for a CHF exacerbation. 2D Echo done at [**Hospital **]demonstrated an EF of 10% w/ severe global LV hypokinesis, pulmonary HTN, and severe aortic stenosis. BNP was elevated to 5,000, Troponin I of 0.05. Mr. [**Name14 (STitle) 75012**] was diuresed 1.5L but fluid removal was limited by hypotension. The [**Hospital 228**] hospital course was further complicated by acute on chronic renal failure with Cr 1.7, and by recurrent NSVT. He was started on amiodarone infusion at OSH. Impression from cardiology was for re-stenosis of stents placed in [**2199-2-9**] and he was transferred to [**Hospital1 18**] for cardiac catheterization and EP consult for discussion of possible upgrade of ICD to BivPM. . In the cath lab, RHC demonstrated CI 1.78, PCWP 28, RA pressure of 5, PAP of 34. LHC demonstrated LM w/ obstruction, LCX with proximal TO, RCA and LAD with minimal disease. Were unable to cross the LCx w/ wire. Felt to be a CTO. Post-procedure patient was hypotensive to upper 70's low 80's. Baseline BP 80-90's. Also with brief episode of chest pain post procedure (no EKG changes). Transferred to CCU for further management. . On arrival in CCU, patient was chest pain free and otherwise had complaints of mild dyspnea. No complaints of dizziness, back pain, groin pain, or leg pain. . Past Medical History: CAD with MI in [**2187**], underwent angiogram at [**Hospital1 498**] (no stent placed) ICD placement in [**2193**] at [**Hospital6 15083**] Prostate Cancer, no intervention, "slow growing" per patient HTN Nephrolithiasis Gout h/o pancreatic duct obstruction Borderline Diabetes, diet controlled Acute on Chronic Kidney Disease Social History: Social history is significant for the absence of current tobacco use. Past tobacco use over 50years ago. There is no history of alcohol abuse or drug abuse per patient. Patient is a retired firefighter and is currently still very active working with lumber. He ambulates 2 flights of stairs easily. Family History: There is no family history of premature coronary artery disease or sudden death. Father lived to be [**Age over 90 **] years old. Physical Exam: T 98.3 F, HR 103, NBP 82/62, ABP 95/61, RR 15-20, O2 sat 98 % 2L NC. Gen: Well appearing elderly man resting supine in bed, NAD, very pleasant affect HEENT: NCAT, pupils constricted, reactive b/l symmetric, Neck: supple, fully recumbent and unable to appreciate JVD. Lungs: rales at bases bilaterally L>R Heart: RRR, systolic murmur at apex, S3 noted, weak carotid upstrokes bilaterally Abd: soft, nontender and nondistended, no abdominal bruits, Ext: cold LE bilaterally, dopplerable DP/PT pulses, no LE edema, 1+ left femoral pulse, 1+ radial pulses b/l Neuro: AOx3, CN II-XII grossly intact, full strength upper and lower extremities and no focal moror or sensory deficits on exam. Skin: Warm but pale comlexion Pertinent Results: [**2199-9-20**] 08:04PM TYPE-ART PO2-132* PCO2-32* PH-7.51* TOTAL CO2-26 BASE XS-3 INTUBATED-NOT INTUBA [**2199-9-20**] 08:04PM LACTATE-2.3* [**2199-9-20**] 07:32PM GLUCOSE-158* UREA N-40* CREAT-1.4* SODIUM-140 POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-26 ANION GAP-18 [**2199-9-20**] 07:32PM estGFR-Using this [**2199-9-20**] 07:32PM ALT(SGPT)-30 AST(SGOT)-24 LD(LDH)-251* CK(CPK)-91 ALK PHOS-113 TOT BILI-0.9 [**2199-9-20**] 07:32PM CK-MB-NotDone cTropnT-0.04* proBNP-[**Numeric Identifier **]* [**2199-9-20**] 07:32PM CALCIUM-9.4 PHOSPHATE-4.8*# MAGNESIUM-2.2 [**2199-9-20**] 07:32PM WBC-8.1 RBC-4.30* HGB-13.5* HCT-39.7* MCV-92 MCH-31.4 MCHC-34.1 RDW-16.8* [**2199-9-20**] 07:32PM PLT COUNT-251# [**2199-9-20**] 07:32PM PT-22.3* PTT-62.4* INR(PT)-2.1* [**2199-9-20**] 04:36PM TYPE-ART RATES-/34 O2 FLOW-2 PO2-124* PCO2-46* PH-7.44 TOTAL CO2-32* BASE XS-6 INTUBATED-NOT INTUBA COMMENTS-NASAL [**Last Name (un) 154**] [**2199-9-20**] Admission EKGs: Several for review, baseline rhythm is Sinus with LBBB, occasional PVC's, 1st degree AV conduction delay, no ST T changes. One EKG with no discernable p-waves and atrial fibrillation . . TELEMETRY: Several runs of polymorphic NSVT on arrival to floor on [**2199-9-20**] and on [**2199-9-21**]. . [**2199-9-21**] 2D-ECHOCARDIOGRAM: The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is severely depressed (LVEF= 15-20 %) with global hypokinesis. The inferior and infero-lateral walls are thinned and akinetic. There is no ventricular septal defect. Right ventricular chamber size is normal. There is mild global right ventricular free wall hypokinesis. The aortic valve leaflets are moderately thickened. Significant aortic stenosis is present (not quantified). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-12**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . CARDIAC CATH [**2199-9-21**]: RHC demonstrated CI 1.78, PCWP 28, RA pressure of 5, PAP of 34. LHC demonstrated LM w/ obstruction, LCX with proximal TO, RCA and LAD with minimal disease. Were unable to cross the LCX w/ wire. Felt to be a CTO. [**2199-9-21**] 04:06AM BLOOD WBC-9.2 RBC-4.36* Hgb-13.6* Hct-40.6 MCV-93 MCH-31.3 MCHC-33.6 RDW-16.0* Plt Ct-256 [**2199-9-21**] 04:06AM BLOOD Glucose-194* UreaN-45* Creat-1.9* Na-141 K-4.8 Cl-99 HCO3-29 AnGap-18 [**2199-9-21**] 04:06AM BLOOD CK-MB-162* MB Indx-22.3* cTropnT-1.47* Brief Hospital Course: In summary, the patient is an 82yo male with longstanding history of CHF with poor EF of [**9-25**]%, severe aortic stenosis and CAD who was transferred from OSH for evaluation of progression of CHF and question of in-stent re-stenosis. He underwent cardiac catheterization which showed CTO of LCX and no other acute lesions. He had complication post-procedure for hypotension and he was transferred to the CCU. . CORONARY ARTERY DISEASE /NSTEMI: The patient had a prior CABG, an MI in [**2187**] and a PCI 6 months ago at OSH. He also has advanced COPD and he has had several CHF episodes in the recent past. The patient had CTO of LCX but otherwise no obstructive disease was noted on his cardiac catheterization. He initially had no elevation in his CK level and a mild increase in his troponin which was attributed to his worsening renal function. Unfortunately, however, his CK trended up from 469 to 726 post-catheterization and MB-I went up to 22.3 from 19.8 and troponins increased from .75 to 1.47 on [**2199-9-21**]. He had some T-wave changes suggesting ischemia and a possible NSTEMI on EKG. Follow-up EKG later in the evening after admission showed left axis deviation, evidence of old inferior wall myocardial infarction with q-waves and old anteroseptal myocardial infarction. He also had marked intraventricular conduction delay and continuing ST-T wave changes which were non-specific and difficult to interpret amongst his LBBB. For NSTEMI management, hHe was continued on his ASA 325 mg daily, Plavix 75 mg, Atorvastatin 80mg daily and a heparin drip was started. He continued to have intermittent mild to moderate chest pains during his hospital stay which were relieved with low doses of IV Morphine. Beta blockers were held given the concern for cardiogenic shock and his extremely low EF. . CHF: The patient had decompensated heart failure with elevated PCWP and low CI. He had an EF of [**9-25**]% on most recent ECHO and his blood pressures began to worsen throughout his CCU stay. He entered the CCU with systolic BPs in the 80-90 range which worsened to SBP in the 70s and diastolic pressures in the mid-40s. An arterial line was placed for better monitoring of his hemodynamics and his non-invasive BP was noted to be approximately 10mmHg less then arterial measurement. He was given some gentle diuresis as tolerated by SBP and his Spironolactone was held due to his low BPs. Unfortunately, the patient continued to required increasing amounts of supplemental oxygen to maintain oxygen saturations above 90%. ECHO done (TTE) on [**2199-9-21**] showed a dilated LA and LV and severely depressed LV function (LVEF= 15 %) with global hypokinesis. The inferior and infero-lateral walls were notably thinned and akinetic and there was global right ventricular free wall hypokinesis as well. . HYPOTENSION: The patient's SBPs of 80-90s declined to the low 70s and his MAP by arterial line measure dropped into the mid-40s to low 50s range so the patient was started on a Dopamine drip. . AORTIC STENOSIS: On physical exam the patient had a prominent mid-systolic ejection murmur best heard at the right second intercostal space, with radiation into the right neck. TTE also noted severe aortic stenosis. The patient's valvular disease further contributed to Mr. [**Last Name (Titles) 75103**] poor cardiac output and worsening heart failure. . RHYTHM: The patient was in normal sinus rhythm initially but began to have multiple episodes of short NSVT, PACs and progressive tachycardia into the 160s. He had started on Amiodarone at an OSH just prior to admission but this was held in the setting of his severe hypotension. He was monitored via continuous telemetry. . RENAL FAILURE : The patient's renal dysfunction and climbing creatinine were felt to be secondary to his poor forward flow and faltering cardiac index in the setting of his advanced heart failure and overnight NSTEMI. . PULMONARY EDEMA/ RESPIRATORY DISTRESS: Mr. [**Name14 (STitle) 75012**] was hypoxic from accumulating pulmonary edema from his worsening CHF. He remained difficult to wean off of oxygen and diuresis was limited because of extreme renal failure and inability to dose large amounts of lasix in the setting of his extreme hypotension with SBPs in the 70s. Moreover, the patient had underlying risk factors for interstitial lung disease and COPD history per records which also negatively impacted his pulmonary reserve. . PRE-DIABETES: The patient was placed on sliding scale insulin for glycemic control in the setting of ACS. He had a poor appetite during his stay and was unable to take in oral food over the last day of his CCU stay prior to his death as he was in fulminant CHF with respiratory distress. . ADDITIONAL CARE / PROPHYLAXIS: -In terms of wound care, the patient was given a Duoderm for additional care of his buttock ulcer during his hospital course. A bowel regimen was given with Colace and Senna tablets and Heparin drip per ACS protocol covered the DVT prophylaxis concerns. . As the patient's clinical status rapidly declined Mr. [**Name14 (STitle) 75012**] and his family were counseled and a family meeting was held to discuss the patient's goals of care and end of life wishes. The patient expressed his desire to be DNR/DNI status and he expressed his desire to be made as comfortable as possible in the closing hours of his rapidly failing heart. The EP team was called to deactivate the patient's pacemaker and he was given IV Morphine for comfort and IV Lasix drip for additional relief of his gross fluid overloaded state and pulmonary edema. He became hypotensive and bradycardic and went into respiratory arrest. Unfortunately, the patient passed away after respiratory arrest and was pronounced on [**2199-9-22**]. Medications on Admission: - lasix 40mg daily (?60mg [**Hospital1 **]) - Potassium 10 meq [**Hospital1 **] - Metoprolol 12.5 daily - Allopurinol 300mg daily - ASA 325mg daily - Plavix 75mg daily - Fish Oil 1000mg daily - Vitamin D 1000 units daily - Spironolactone [**12-12**] pill daily - MVI daily Discharge Medications: patient deceased, pronounced on [**2199-9-22**] Discharge Disposition: Expired Discharge Diagnosis: patient deceased, pronounced on [**2199-9-22**] Discharge Condition: patient deceased, pronounced on [**2199-9-22**] Discharge Instructions: patient deceased, pronounced on [**2199-9-22**] Followup Instructions: patient deceased, pronounced on [**2199-9-22**] Completed by:[**2199-9-26**]

[ "585.9", "496", "428.0", "707.21", "584.9", "414.01", "785.51", "707.03", "274.9", "428.33", "403.90", "414.8", "V45.02" ]

icd9cm

[ [ [] ] ]

[ "88.53", "88.56", "37.22" ]

icd9pcs

[ [ [] ] ]

13198, 13207

7041, 12803

328, 353

13298, 13347

4281, 7018

13443, 13521

3400, 3531

13126, 13175

13228, 13277

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13371, 13420

3546, 4262

276, 290

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2737, 3067

3083, 3384

17,457

199,636

15370+15371

Discharge summary

report+report

Admission Date: [**2196-10-31**] Discharge Date: [**2196-11-3**] Date of Birth: [**2122-1-13**] Sex: M SERVICE: HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname 44633**] is a 74-year-old male with a past medical history significant for hypertension, aortic stenosis, prostate cancer, gout, lower extremity DVT. He had a known murmur for several years. He had an echocardiogram performed by the cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**], approximately two years prior to this admission revealing aortic stenosis. However, the report is unavailable at this time. He has had progressive shortness of breath, warranting a recent echocardiogram and cardiac catheterization for his cardiologist in [**Location (un) 47**] showing severe aortic stenosis with left ventricular hypertrophy and mild right coronary artery disease at the level of the posterior descending artery. Additionally, echocardiogram had revealed mitral stenosis in conjunction with the aortic lesion. In consultation with the cardiologist, Dr. [**First Name (STitle) 1075**] and the patient's primary care provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], the patient was recommended to undergo evaluation for possible valvular repair with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **]. FAMILY HISTORY: 1. Hypertension. 2. Aortic stenosis. 3. Prostate cancer. 4. Possible gout. 5. Obesity., 6. Possible sleep apnea. 7. Bilateral cataracts. 8. Left left fracture in [**2196-5-25**], complicated by left lower extremity DVT in [**2196-7-24**]. 9. Old rib fracture remote on the right side. PAST SURGICAL HISTORY: 1. Prostatectomy in [**2193**]. 2. Nasal polypectomy. MEDICATIONS ON ADMISSION: 1. Enteric coated aspirin 325 mg q.d. 2. Atenolol 25 mg q.d. 3. Calcium carbonate 1000 mg q.d. 4. Iron 325 mg b.i.d. 5. Niaspan 500 mg q.d. 6. Probenecid and Colchicine as needed. 7. Vitamin E 400 IU q.d. 8. Lasix 40 mg q.d. 9. Lupron injections given to the patient every three months. ALLERGIES: The patient has no known drug allergies. The last dental examination was performed prior to this admission. Report from that office visit is unavailable, but as per patient history and during the hospital course, dentition was never an issue. No extraction needs to be performed. FAMILY HISTORY: The patient's father died of coronary artery disease/MI in his 80s, as well as a mother who died in her 80s of a similar ailment. The patient is a retired engineer. He lives with his wife. The patient does have approximately one alcoholic drink per day. The patient smokes one pipe per month. There is no other significant illegal drug history. PHYSICAL EXAMINATION: GENERAL: Heart rate 78, blood pressure on the right arm 126/65, left 154/70, weight 210 pounds and height 5 feet 3 inches. The patient is an obese, pleasant gentleman. SKIN: Skin had no obvious lesions. HEENT: Normal buccal mucosa. Pupils equal, round, and reactive to light. Extraocular muscles are intact. NECK: No evidence of JVD. There was no bruit. The patient did have a murmur that radiated to the bilateral neck. CHEST: Examination was notable for being clear, no crackle, rhonchi, or wheeze. HEART: Normal S1 and S2, regular rate and rhythm with 3/6 systolic ejection murmur radiating to the neck and throughout the chest. ABDOMEN: Abdomen revealed a well healed suprapubic incision noted from a prior prostatectomy. It was soft, nontender, nondistended. He had positive bowel sounds in all four quadrants. There was no hepatosplenomegaly. Obese pannus was noted. No bruit, no pulsatile mass. EXTREMITIES: 2+ pedal edema bilaterally. There was no clubbing, cyanosis or edema. The extremities were warm and well perfused with palpable pulses distally. Varicosities: Spider veins in the bilateral lower extremities, but no gross saphenous vein insufficiency. The patient did have a questionable tenderness and erythema at the right toe, which was thought to be consistent with no history of gout. NEUROLOGICAL: Cranial nerves II through XII grossly intact. There was, otherwise, a nonfocal examination. He had 5/5 strength throughout all extremities. PULSE: The patient was palpable throughout the femoral, DP, PT, and radial arteries bilaterally. EKG was notable for some questionable inferior and lateral ST and T segment changes, left ventricular hypertrophy by cardiographic criteria was seen. He was in sinus rhythm at 73. Given this assessment, the patient has probable coronary artery disease, known severe aortic stenosis, possible mitral valve lesion. The patient was, therefore, scheduled to undergo aortic and mitral valve replacement as well as coronary artery disease. After informed consent had been obtained on [**2196-10-31**], the patient came to the operating room and under the assistance of Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21815**], as well as [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 44634**], NP, the patient underwent aortic valve replacement with a 21 mm pericardial [**Last Name (un) 3843**]-[**Doctor Last Name **] valve, as well as mitral valve regurgitation with a 25 mm Carbomedics mechanical valve. CABG times one was performed using saphenous vein graft from the left lower extremity to the posterior descending artery and the right dominant circulation, as well as he underwent extensive debridement of the mitral annulus prior to the valve replacement, also requiring extensive reconstruction of the previous annulus architecture. This procedure was performed under general endotracheal anesthesia. He left the operating room with the pericardium open. He had a right radial A-line, right IJ Swan-Ganz catheter. He had two ventricular pacing wires, two atrial pacing wires, and two mediastinal chest tubes. Due to the fact that the patient has had a poorly functioning right ventricle noted after the reconstruction and repair of the mitral annulus after its debridement, the patient had to have a right ventricular assist device placed intraoperatively, as well as having an intra-aortic balloon pump placed into the left femoral artery for support. He did come out of the operating room on propofol, Levophed, epinephrine and milrinone with an intra-aortic balloon pump at 1:1 setting and the right ventricular assist device noted to have flows of 3.2 to 3.4. He required multiple fluid boluses, thereafter, with three units of packed cells and two units of FFP during the night postoperatively. On postoperative day #0 the RVAD flow numbers were somewhat poor despite being given multiple fluid boluses, the CVP was approximately 30. Dr. [**Last Name (STitle) 72**] was at the bedside throughout much of the patient's postoperative recovery in the first twenty-four hour adjusting the RVAD and the patient positioned to optimize flow. The saturations ranged 54 to 64 with cardiac index of 2.5. By postoperative day #1, the patient had experienced episodes of atrial fibrillation with rates into the 130s as well as some episodes of supraventricular tachycardia that responded to amiodarone boluses. He was afebrile. He was being A-V paced. Blood pressure was 119/64. The CVPs were approximately 26 to 30 with PA pressures of 51/39. Cardiac output was 5.2 with thermodilution measured at 3.30 with an index of 1.50. Systemic vascular resistance was 1358, RVAD flow in liters per minute was 3.30. He was still on intra-aortic balloon pump at 1:1 setting. He was still on epinephrine infusion at 0.02 mcg per kilogram per minute, as well as having had Levophed weaned off. He was still on milrinone at 0.500 mcg per kilogram per minute, as well as being supported with pitressin at 0.04 mcg per kilogram per minute. Propofol drip at 20 mcg per minute was being utilized for sedation. He was on an insulin drip at 12 units per hour to control the postoperative hyperglycemia. He was being maintained on a PEEP of 15, 60% FIO2 and the blood gases measured 7.40 for PACO2 of 34, PAO2 of 135, base deficit -2, but he was saturating at 100%. Postoperative hematocrit was 30.0. He had been transfused at least a total of three units of packed cells. BUN and creatinine were 19 and 1.0. Given this, the plan was to continue full support. He was not acidotic at this time. The patient was being heparinized at this point to maintain ACT values in the range of 180 to 200. Due to the poor flow in the RVAD it was ultimately decided that the patient would require to go back to the operating room for repositioning of the RVAD cannula lead. He had a bedside echocardiogram on the morning of postoperative day #1 to reconfirm that there was a need for this readjustment basically showing that the right ventricle was overloaded and as a consequence we were not successfully unloading this ventricle. We reconfirmed the idea that the cannulas were in poor position. He went back to the operating room and received repositioning of the cannulas. He came out again on maximum ventilatory support and pressors. By the evening of postoperative day #2, it became more and more difficult for this patient to be oxygenated. As a consequence, he was ultimately transitioned, being paralyzed, postoperative day #2 and put on pressure-control ventilation. Over the evening of postoperative day #1 to #2, he had additional chest tubes placed for chest tube drainage, after chest x-ray had shown large bilateral pleural effusions although we were able to drain some serosanguinous fluid and bloody exudate around the wound. This did no improve the oxygenation. As this still continued to be marginal, he did, however, have improved flow to the RVAD system had values ranging from 4.4 to 4.7 liters per minute. Given this, the patient was started on an aggressive diuresis and Lasix dripped in attempt to pull off the volume as it was likely that the patient was between 17 and 25 liters positive. He was continued on Vancomycin and Levofloxacin for the questionable bilateral infiltrates that were seen in conjunction with the large effusions. He was having low-grade temperatures. Ultimately, the vasopressin was titrated back. Epinephrine was maintained at the effusion rate of 0.02. He was being paralyzed with ....................and sedated with Fentanyl. By[**Last Name (STitle) 44635**] of postoperative day #2, the patient began to clinically deteriorate. Oxygenation became increasing more difficult to maintain for the patient after having had multiple attempts at pressure control and assist-control ventilation with the assistance of the respiratory staff, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21815**] in conjunction with Dr. [**Last Name (Prefixes) **], opened the patient's chest at the bedside at approximately 10:30 PM on [**2196-11-2**]. This immediately improved the patient's oxygenation, however, over the ensuing hours, ventilation became a problem. [**Name (NI) **] became acidotic and hemodynamically unstable requiring multiple epinephrine boluses and fluid boluses. Ultimately, the Levophed, epinephrine, and pitressin were titrated to a maximum dosing. Given the maximal support that the patient was receiving, he continued to spiral. Ultimately, he became anuric and endometrial hyperplasia was started on CVVH over the ensuring hours. The patient clinically deteriorated and became labile and hypotensive. On 3:20 am on [**2196-11-3**] the patient expired despite maximal efforts in therapy. The family was notified by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21815**], thereafter. All of the decisions involving this patient's care were ultimately cleared through Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] in conjunction with the senior fellow, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21815**]. The family was informed of the patient risk of this operation prior to the patient going to the operating room on [**2196-10-31**], given the comorbidity and severe valvular disease and overall risk profile. DISCHARGE DIAGNOSES: 1. Significant aortic stenosis with mitral valve stenosis and mitral regurgitation, coronary artery disease status post aortic valve replacement and mitral valve replacement as well as coronary artery bypass times one in conjunction with a mitral annular calcification, debridement, reconstruction resulting in postoperative heart failure and ultimately death. The patient's primary care physician is [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Cardiologist is Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**]. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern4) 3204**] MEDQUIST36 D: [**2196-11-3**] 11:39 T: [**2196-11-3**] 12:15 JOB#: [**Job Number 44636**] cc:[**Last Name (Prefixes) 44637**] Admission Date: [**2196-10-31**] Discharge Date: [**2196-11-3**] Date of Birth: [**2122-1-13**] Sex: M Service: ADMITTING DIAGNOSES: 1. Aortic stenosis. 2. Mitral regurgitation. 3. Hypertension. 4. Prostate cancer. 5. Gout. 6. Cataracts. 7. History of deep venous thrombosis. DISCHARGE DIAGNOSES: 1. Aortic stenosis. 2. Mitral regurgitation. 3. Hypertension. 4. Prostate cancer. 5. Gout. 6. Cataracts. 7. History of deep venous thrombosis. PROCEDURE PERFORMED: Aortic valve replacement, mitral valve replacement, and coronary artery bypass grafting x1 on [**2196-10-31**]. Re-operation with repositioning of right ventricular assist device on [**2196-11-1**]. INDICATIONS FOR ADMISSION: Mr. [**Known lastname 44633**] was a 74-year-old gentleman who had increasing shortness of breath over the past two years with a known murmur. This was followed by serial echocardiograms. He had significant aortic stenosis and was symptomatic, and therefore, referred for surgery. PHYSICAL EXAMINATION ON ADMISSION: In general, no weight changes. Skin showed some mild keratoses. HEENT showed cataracts, otherwise unremarkable. Heart revealed a regular, rate, and rhythm with a 3/6 systolic ejection murmur radiating to his neck and throughout the chest. Lungs were clear to auscultation bilaterally. Abdomen is soft, nontender, and nondistended with active bowel sounds, no hepatosplenomegaly. Extremities revealed 2+ pedal edema with some mild varicosities. Neurologically he was grossly intact. His medications preoperatively were aspirin, atenolol, calcium, iron, Niaspan, probenecid, colchicine, vitamin E, Lasix, and Lupron. HO[**Last Name (STitle) **] COURSE: The patient underwent the above procedure on [**2196-10-31**] by Dr. [**Last Name (STitle) **] [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]. He had a prolonged operative procedure owing to the difficulty to the case. He required large amounts of fluid during his long cardiopulmonary bypass run. At the end of the case, attempts to initially wean the patient from bypass were successful, and the patient manifested right heart failure despite multiple maneuvers and medications, a right ventricular assist device needed to be placed emergently to facilitate weaning from extracorporal bypass. This was performed and the patient was brought back to the Intensive Care Unit in critical condition. The patient required massive fluid resuscitation and pressor support as well as ventilatory support during this time period. On the first postoperative day, the patient's condition was stable, but critical, and there was some difficulty with venous return. The patient was therefore taken back to the operating room for repositioning of his venous cannula. Subsequent to that, venous return was quite excellent and flows were able to be achieved in the [**4-29**] leader range on the right ventricular assist device. Over the intervening 12 hours, the patient was requiring full hemodynamic and respiratory support that was reasonably stable. At this point on postoperative day two, a valid attempt at massive diuresis was attempted in order to wean from right heart assist. Lasix was started as an infusion as well as a bolus form with excellent response, with urine output in the 3-500 range. Despite making the patient negative, there were increasing difficulties with ventilation and oxygenation. Maneuvers including chemical paralysis and optimizing the ventilator in regards to oxygenation proved progressively insufficient. Therefore, his chest was reopened on the night of postoperative day two, and retractors were placed. His oxygenation improved dramatically for a short period of time. There is no evidence of significant bleeding or tamponade. Retractor was left in place and the area was covered with a sterile dressing. Over the intervening 4-6 hours, the patient's clinical status deteriorated. Although his hypoxia was reasonable, his hemodynamic status was progressively worse despite drips of Levophed, Epinephrine, milrinone, and vasopressin in addition to replacing his clotting factors as well as blood. Patient's hemodynamic status was unrecoverable, and heroic efforts could not maintain hemodynamic stability. After every viable option was entertained and tried, the patient was given comfort measures and expired within a few minutes. Ti[**Last Name (STitle) 44638**]death was approximately 3:20 am on [**2196-11-3**]. The family was notified as was Dr. [**Last Name (Prefixes) **]. DISCHARGE CONDITION: Dead. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 44639**] MEDQUIST36 D: [**2196-11-3**] 03:34 T: [**2196-11-8**] 05:43 JOB#: [**Job Number 44640**]

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icd9cm

[ [ [] ] ]

[ "35.24", "34.09", "37.62", "96.71", "37.61", "39.61", "88.72", "35.22", "36.11", "37.63", "34.03" ]

icd9pcs

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120,357

29826

Discharge summary

report

Admission Date: [**2199-11-29**] Discharge Date: [**2199-12-3**] Date of Birth: [**2127-12-1**] Sex: M Service: MEDICINE Allergies: Penicillins / Lisinopril / [**Last Name (un) **]-Angiotensin Receptor Antagonist Attending:[**First Name3 (LF) 4327**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a 71 male with a history of coronary artery disease s/p CABG ([**2186**] at [**Hospital1 112**] SVG to OM, SVG to RCA-RPL), PCI [**2192**], [**2197**], [**2199-11-6**] (NSTEMI with DES of SVG to OM) as well as hypertension, hyperlipidemia, and diabetes who presents from cardiology clinic with worsening dyspnea. At baseline, he ambulates slowly outside for about twenty minutes several times per week. Several days ago, he was outside walking when he developed dyspnea with limited ambulation. He returned home but continued to feel short of breath with minimal exertion. He also feels that his lower extremities were more swollen. He denies chest pain, cough, fever, chills, syncope, diaphoresis. He reports stable 2 pillow orthopnea. He endorses taking his medications as prescribed. He monitors his blood pressure at home with values typically 130s this past week. Today, he presented to his cardiologist where he was found to have an oxygen saturation of 91%. He was referred to the ED for further evaluation of his dyspnea. . He was recently hospitalized ([**Date range (1) 25545**]) in the CCU for NSTEMI (trop 2.45) with decompensated heart failure with a preserved ejection fraction. Cath showed 90% distal stenosis with visible thrombus of SVG-OM graft and he underwent successful PCI with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**]. TTE showed ejection revealed that regional/global systolic function were normal (>55%) with mild to moderate mitral regurgitation. He was diuresed and was felt to be euvolemic on discharge with O2 sats in mid to high 90s on room air. His decompensation was felt to be due to IV fluids received in the and acute ischemia. He was not discharged on a diuretic. . In the ED, initial vitals were 97.7 54 132/65 18 94% 2L (78%RA). On exam, patient appeared quite comfortable and minimally symptomatic despite low oxygen saturation, crackles in lower lung fields. Labs notable for creatinine 1.0 (baseline 1.2), BNP of 2446 (was 985 in [**2196**]), troponin <0.01, d-dimer 910. ABG: 7.49/34/53 on 4L NC. EKG per report showed sinus bradycardia, lateral Q waves, unchanged compared to prior. CT chest was negative for pulmonary embolism but noted severe emphysema w/ right heart strain, interstitial pulmonary edema and small bilateral pleural effusions. He was given albulterol and ipratropium nebulizers. He was given lasix 40IV with 2.1L of urine output in ED. Currenlty on 50% face tent satting mid-90s and comfortable. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: - CABG: [**2186**] - PERCUTANEOUS CORONARY INTERVENTIONS: PTCA [**2192**], Stent [**2197**], [**2198**] - PACING/ICD: none - h/o multifocal atrial tachycardia 3. OTHER PAST MEDICAL HISTORY: - BPH - COPD - Diabetes Social History: - retired chemist - married with one daughter - [**Name (NI) 1139**] history: smokes 1PPD x 55 years - ETOH: infrequent ETOH - Illicit drugs: denies Family History: -Father died in his 70s of heart disease. -Brother died in his 70s of presumed heart disease. Physical Exam: ADMISSION EXAM VS: 100.1 127/62 HR:70 RR:20 92% 50%FM GENERAL: NAD. Oriented x3. speaking in full sentences HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 8cm. CARDIAC: healed sternotomy incision, PMI located in 5th intercostal space, midclavicular line. regular rhythm, normal rate, S1, S2 LUNGS: mildly labored respirations, crackles 1/3 up from bases bilaterally R>L, no wheezes 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: ADMISSION LABS . [**2199-11-29**] 02:50PM BLOOD WBC-5.9 RBC-3.89* Hgb-11.8* Hct-34.6* MCV-89 MCH-30.3 MCHC-34.1 RDW-16.3* Plt Ct-273 [**2199-11-29**] 02:50PM BLOOD Neuts-69.6 Lymphs-20.7 Monos-4.5 Eos-4.9* Baso-0.2 [**2199-11-29**] 02:50PM BLOOD PT-12.3 PTT-29.7 INR(PT)-1.1 [**2199-11-29**] 02:50PM BLOOD Glucose-195* UreaN-17 Creat-1.0 Na-140 K-4.7 Cl-108 HCO3-23 AnGap-14 [**2199-11-29**] 02:50PM BLOOD ALT-16 AST-15 LD(LDH)-183 CK(CPK)-61 AlkPhos-130 TotBili-0.3 [**2199-11-29**] 02:50PM BLOOD Albumin-3.7 Calcium-8.7 Phos-3.3 Mg-1.8 . PERTINENT LABS AND STUDIES [**2199-11-29**] 09:31PM BLOOD Type-ART pO2-53* pCO2-34* pH-7.49* calTCO2-27 Base XS-2 [**2199-11-30**] 01:07AM BLOOD TSH-0.82 [**2199-11-29**] 04:40PM BLOOD D-Dimer-910* [**2199-11-29**] 02:50PM BLOOD CK-MB-2 proBNP-2446* [**2199-11-29**] 02:50PM BLOOD cTropnT-<0.01 [**2199-11-30**] 01:07AM BLOOD CK-MB-2 cTropnT-<0.01 . CXR [**2199-11-29**] Mild-to-moderate interstitial pulmonary edema with small bilateral pleural effusions and bibasilar airspace opacities, likely atelectasis. . CT CHEST WITH AND WITHOUT CONTRAST [**2199-11-29**] 1. No pulmonary embolus or acute intrathoracic process. 2. Mild pulmonary edema and bilateral pleural effusions. 3. Severe emphysema with early fibrosis. 4. Pulmonary nodules up to 1.0 cm, for which PET-CT or three-month follow-up chest CT recommended. 5. Prominent mediastinal lymph nodes, non-specific . ECHO [**2199-11-30**] The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with mild hypokinesis of the inferior wall. The remaining segments contract normally (LVEF = 50 %). There is no ventricular septal defect (limited views). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with mild regional systolic dysfunction c/w CAD. No significant mitral regurgitation or definite VSD identified. Compared with the prior study (images reviewed) of [**2199-11-3**], inferior left ventricular hypokinesis is more clearly defined. Brief Hospital Course: The patient is a 71 male with a history of coronary artery disease s/p CABG ([**2186**] at [**Hospital1 112**] SVG to OM, SVG to RCA-RPL), PCI [**2192**], [**2197**], [**2199-11-6**] (NSTEMI with DES of SVG to OM) as well as hypertension, hyperlipidemia, and diabetes who presents from home with worsening dyspnea found to be in hypoxic respiratory distress . ACUTE CARE: # HYPOXIA: He likely has a low pulmonary reserve from obstructive airway disease, as although he does not carry a diagnosis of COPD his chest imaging findings in the setting of significant smoking history are highly suggestive. His acute decompensation with hypoxic respiratory distress with a significant A-a gradient is likely due to worsening V/Q mismatch from pulmonary edema and pleural effusion from decompensated heart failure. There is no evidence of pulmonary embolism on chest CT. Pneumonia considered but lower suspicion given that he is afebrile, without leukocytosis and absence of focal consolidation on chest CT. COPD exacerbation considered but does not meet GOLD criteria as no change in sputum frequency or amount so will defer steroids and antibiotics at this time. The patient was diuresed aggressively and required 6L initially, but was weaned progressively to room air without issue. . # CORONARY ARTERY DISEASE: Patient with a history of coronary artery disease s/p CABG, multiple PCI and recent hospitalization for NSTEMI with non-occlusive thrombus in SVG supplying LCX territory. Patient without chest pain, unchanged EKG, and negative biomarkers. Continue clopidogrel 75 mg daily, aspirin 325 mg dialy, carvedilol twice daily, atorvastatin 80 mg daily. . # ACUTE ON CHRONIC HEART FAILURE WITH PRESERVED EJECTION FRACTION: Patient with most clinical (crackles bilaterally), lab (elevated BNP) and imaging (pulmonary edema) evidence suggestive of decompensated heart failure. The etiology of the decompensation is not clear but is likely diet noncompliance. Mechanical complications following myocardial infarction are considered, in particular worsening valvular function, but there is no evidence of acute mitral regurgitation or VSD on trans-thoracic echocardiogram. Arrhythmia considered but remains in sinus rhythm on telemetry. Calcium channel blockers can worsen heart failure and he was recently restarted on nifedipine. Uncontrolled hypertension considered but patient reports reasonable control at home. He was diuresed with lasix. . CHRONIC CARE # HYPERTENSION: nifedipine, carvedilol . # HYPERLIDEMIA: Continue atorvastatin . # DIABETES: Held metformin and glyburide, treated with sliding scale insulin . # TOBACCO ABUSE: Pre-contemplative at this time regarding quitting. The pt was counseled about the benefits of quitting smoking and he declined a nicotine patch. . # PULMONARY NODULE: Patient with significant smoking history found to have enlarged lymph node and pulmonary nodules. He will need repeat CT or PET in 3 months to follow nodules. . ? COPD: Patient will likely require outpatient tiotropium and PFTs. . # BPH: Continue doxazosin . ISSUES OF TRANSITIONS IN CARE: 1. We started Furosemide daily to promote diuresis. 2. We started Spiriva to help with his emphysema. 3. Repeat CT chest or PET in 3-months to follow nodules seen on CT chest done [**2199-11-29**]. 4. Patient needs outpatient PFTs for lung disease assessment in the future. Medications on Admission: 1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS 2. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day. 3. glyburide-metformin 2.5-500 mg Tablet [**Hospital1 **] 4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID 6. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY 8. doxazosin 4 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 9. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 10. nifedipine CR 90mg daily Discharge Medications: 1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. glyburide-metformin 2.5-500 mg Tablet Sig: One (1) Tablet PO twice a day. 4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual as directed as needed for chest pain. 7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. doxazosin 4 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 9. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 10. nifedipine 90 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO DAILY (Daily). 11. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*30 capsules* Refills:*2* 12. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. Outpatient Lab Work Please check Chem-7 on Thursday [**2199-12-5**] with results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP[**MD Number(3) **]: [**Telephone/Fax (1) 62**] or fax [**Telephone/Fax (1) 19842**] Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Acute on Chronic Diastolic congestive Heart failure Acute Kidney Injury Coronary artery disease Hypertension Hyperlipidemia Chronic Obstructive Pulmonary Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted because of extra fluid that had accumulated in your lungs and legs, making it hard for you to breathe. You received intravenous lasix to remove the fluid and you are now on lasix pills. You will need to watch yourself very closely to make sure the fluid does not return. Weigh yourself every morning, call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. Please also call [**Doctor First Name **] if your legs swell or if you have trouble breathing. It is very important that you avoid salt in your diet. . There were some nodules seen on your CT scan that are concerning, you will need to have another CT scan checked in 3 months. . We made the following changes to your medicines: 1. START taking furosemide daily to prevent fluid from accumulating in your legs and lungs 2. START taking Spiriva to help with your emphysema. It is extremely important that you quit smoking to prevent lung cancer and the need for oxygen permanantly. Followup Instructions: . Department: CARDIAC SERVICES When: MONDAY [**2200-2-10**] at 9:40 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: CARDIAC SERVICES When: TUESDAY [**2199-12-10**] at 1 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], NP [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4094**]: PRIMARY CARE Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **] Address: [**State 4607**], [**Location (un) **],[**Numeric Identifier 588**] Phone: [**Telephone/Fax (1) 4606**] Appointment: [**12-26**] at 12:45 PM

[ "496", "250.00", "696.1", "305.1", "793.11", "428.33", "272.4", "584.9", "401.9", "V17.3", "V65.49", "V45.81", "412", "428.0", "414.00", "600.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12723, 12780

7326, 10691

350, 356

12986, 12986

4842, 7303

14200, 15164

3905, 4000

11385, 12700

12801, 12965

10717, 11362

13137, 14177

4015, 4823

3505, 3664

303, 312

384, 3397

13001, 13113

3695, 3720

3419, 3485

3736, 3889

28,432

178,420

32452

Discharge summary

report

Admission Date: [**2159-12-16**] Discharge Date: [**2159-12-28**] Date of Birth: [**2086-10-31**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 618**] Chief Complaint: Speaking difficulty and last time seen well was 8.30am and was then brought as code stroke at 1.53pm from [**Location (un) 75749**], MA via [**Location (un) **]. Major Surgical or Invasive Procedure: None History of Present Illness: 73yo M h/o CAD s/p CABG, HTN, hyperlipidemia and DM2 who was last known well at 8:30am today, according to the history given by the patient's wife when he presented at [**Hospital3 **] Hospital. She returned home at 10:30am to find him unable to speak with slurred speech as well and a right facial droop. He was taken to [**Location (un) 21541**] Hospital and was already outside the three-hour window for IV tPA and airlifted here for consideration of further therapies. Past Medical History: CAD s/p CABG, HTN, hyperlipidemia and DM2 Social History: Denies EtOH, tobacco or drugs Family History: NA Physical Exam: VS 198/109 94 19 100% Gen Awake, cooperative, NAD HEENT NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck Supple, no carotid bruits appreciated. No nuchal rigidity Lungs CTA bilaterally CV 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 NEURO MS Awake, alert. Attentive to our exam. Speech is non-fluent, with impaired naming, [**Location (un) 1131**] and comprehension but relatively intact repetition. Normal prosody. There were multiple paraphasic errors in the form of neologisms when the patient tried to read or name. Cannot follow simple commands. Responds to both sides of space equally. Moderate dysarthria. CN CN I: not tested CN II: blinks to threat bilaterally, no extinction. Pupils 3->2 b/l. CN III, IV, VI: EOMI no nystagmus CN V: intact to LT throughout CN VII: R facial droop CN VIII: hearing intact to FR b/l CN IX, X: palate rises symmetrically CN [**Doctor First Name 81**]: shrug asymmetric CN XII: unable to assess Motor Decreased tone in the right arm. Mild R pronator drift (fingers curl on the right hand). Holds both arms up for 10 seconds and both legs for 5. Sensory intact to LT, PP throughout. No extinction. Reflexes deferred Coordination unable to assess Gait deferred, due to need to get the patient to the scanner and interventional suite CODE STROKE SCALE: Neurologic (NIHSS): 7 1a. LOC: alert, responsive (0) 1b. LOC questions: knew age and name of month (0) 1c. LOC commands: closed eyes and gripped with **(nonparetic) hand (2) 2. Best gaze: No gaze palsy (0) 3. Visual: No visual loss (0) 4. Facial Palsy: normal, symmetrical movements (1) 5a. Left arm: No drift (0) 5b. Right arm: no drift (0) 6a. Left leg: No drift (0) 6b. Right leg: no drift (0) 7. Limb ataxia: not assessed due to lack of comprehension 8. Sensory: no sensory loss bilaterally (0) 9. Language: severe aphasia (2) 10. Dysarthria: moderate (1) 11. Extinction/inattention: None (0) Pertinent Results: [**2159-12-16**] 07:31PM BLOOD WBC-12.4* RBC-4.76 Hgb-13.9* Hct-40.0 MCV-84 MCH-29.2 MCHC-34.7 RDW-17.0* Plt Ct-270 [**2159-12-17**] 01:52AM BLOOD WBC-16.6* RBC-4.83 Hgb-13.8* Hct-40.3 MCV-83 MCH-28.6 MCHC-34.3 RDW-17.2* Plt Ct-272 [**2159-12-19**] 04:14AM BLOOD WBC-15.1* RBC-4.00* Hgb-11.7* Hct-33.2* MCV-83 MCH-29.1 MCHC-35.1* RDW-17.0* Plt Ct-217 [**2159-12-21**] 05:06AM BLOOD WBC-10.3 RBC-4.19* Hgb-11.8* Hct-34.6* MCV-83 MCH-28.2 MCHC-34.1 RDW-16.7* Plt Ct-237 [**2159-12-23**] 02:52AM BLOOD WBC-14.0* RBC-4.81 Hgb-13.3* Hct-40.1 MCV-83 MCH-27.8 MCHC-33.3 RDW-16.7* Plt Ct-266 [**2159-12-24**] 06:30AM BLOOD WBC-13.6* RBC-4.94 Hgb-14.0 Hct-41.4 MCV-84 MCH-28.3 MCHC-33.8 RDW-17.1* Plt Ct-364 [**2159-12-24**] 06:30AM BLOOD PT-13.9* PTT-26.7 INR(PT)-1.2* [**2159-12-20**] 04:07AM BLOOD PT-13.5* PTT-30.3 INR(PT)-1.2* [**2159-12-16**] 07:31PM BLOOD PT-13.3 PTT-35.6* INR(PT)-1.1 [**2159-12-19**] 02:11PM BLOOD Ret Aut-1.7 [**2159-12-16**] 07:31PM BLOOD Glucose-153* UreaN-16 Creat-0.7 Na-140 K-5.4* Cl-111* HCO3-20* AnGap-14 [**2159-12-19**] 04:14AM BLOOD Glucose-173* UreaN-15 Creat-0.9 Na-142 K-3.6 Cl-108 HCO3-25 AnGap-13 [**2159-12-22**] 03:49AM BLOOD Glucose-133* UreaN-16 Creat-1.0 Na-139 K-3.7 Cl-102 HCO3-28 AnGap-13 [**2159-12-24**] 06:30AM BLOOD Glucose-145* UreaN-15 Creat-1.1 Na-138 K-4.1 Cl-100 HCO3-29 AnGap-13 [**2159-12-16**] 07:31PM BLOOD ALT-18 AST-35 LD(LDH)-494* CK(CPK)-191* AlkPhos-60 Amylase-43 TotBili-0.4 [**2159-12-16**] 07:31PM BLOOD CK-MB-4 cTropnT-<0.01 [**2159-12-17**] 04:03AM BLOOD CK-MB-3 cTropnT-<0.01 [**2159-12-17**] 11:08AM BLOOD CK-MB-3 cTropnT-<0.01 [**2159-12-16**] 07:31PM BLOOD Albumin-3.0* Calcium-7.5* Phos-3.3 Mg-1.9 [**2159-12-19**] 04:14AM BLOOD calTIBC-208* Ferritn-194 TRF-160* [**2159-12-17**] 01:52AM BLOOD %HbA1c-6.0* [**2159-12-17**] 01:52AM BLOOD Triglyc-186* HDL-30 CHOL/HD-4.6 LDLcalc-72 [**2159-12-16**] 07:31PM BLOOD TSH-1.6 [**2159-12-16**] 07:31PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG CTA: 1. Ischemia in the distribution of the entire left ACA and MCA by mean transit time criteria, and a smaller area of presumed irreversible injury by blood volume criteria. 2. Total occlusion of the left internal carotid artery from its origin with partial reconstitution at the cavernous portion with attenuation of the M1 segment of the left MCA and occlusion of the superior division. 3. Emphysema. TTE: The left atrium is mildly dilated. 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 with normal cavity size and regional/global systolic function (LVEF>55%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Brief Hospital Course: Mr. [**Known lastname **] was admitted to the ICU for closer monitoring. He was taken to the Neuro-interventional suite were he received IA tPA and MERCI. After the procedure his blood pressure goals were <185 systolic and <105 diastolic. PRN labetalol was initially used to maintain his pressure. In the first 24 hours after the procedure, he was not instrumented to avoid bleeding and antiplatelet/anticoagulation was avoided. The following day he had an MRI/MRA which showed a L MCA infarct. His stroke work-up included being monitored on tele. During his hospital course, he developed afib and was treated with metoprolol, aspirin and Plavix. No Coumadin was used given concern for the increased risk of bleeding. A TTE was negative for PFO or thrombus. His LDL was 72 and he was treated with simvastatin. He was continued on Plavix for his CAD and stent history and aspirin for stroke prevention. He was also maintained euglycemic and normothermia with Tylenol and SSI. His afib was rate controlled with metoprolol TID and low dose lisinopril for his CAD. During his hospitalization he was also found to have a staph UTI. He was treated initially with Nafcillin and then switched to Bactrim DS for a 10 day course. An NG was placed after his infarct and he was started on TF. After several days, it was evident that his dysarthria and dysphagia would not improved quickly enough to ensure his ability to safely take PO, therefore a PEG was placed by IR. In regards to his afib, he was started on Coumadin 10 days out from his infarct with no bridging with heparin. He will need his INR checked regularly with a goal INR of [**2-17**]. The aspirin should be stopped when the INR is greater than 1.9. On discharge he remained significantly dysarthric and expressively aphasic. He also had weakness but antigravity movement of his R arm and fingers. The R leg was clearly antigravity. He will follow-up with Dr. [**Last Name (STitle) **] as an outpatient. Medications on Admission: Metoprolol Lisinopril HCTZ Vytorin Nexium Discharge Medications: 1. Clopidogrel 75 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO DAILY (Daily). 3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 4. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 5. Simvastatin 40 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 6. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) for 4 days. 7. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). 8. Lisinopril 5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY (Daily). 9. Coumadin 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**] Discharge Diagnosis: Stroke Afib Dysphagia Aphagia Dysarthria R arm weakness Discharge Condition: Stable, no focal neurological deficts Discharge Instructions: 1. Please take all medications as prescribed 2. Please call your doctor or come to the closest ED if you have new symptoms 3. Please continue coumadin with a goal INR of [**2-17**]. Stop the aspirin when the INR is > 1.9 Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2160-2-25**] 1:30 [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

[ "433.10", "784.5", "250.00", "599.0", "272.4", "401.9", "427.31", "V45.81", "041.11", "784.3", "434.11" ]

icd9cm

[ [ [] ] ]

[ "88.41", "00.61", "44.32", "00.45", "99.10", "00.40", "96.6", "00.63", "39.74" ]

icd9pcs

[ [ [] ] ]

9690, 9802

6682, 8645

481, 488

9902, 9942

3186, 6659

10211, 10430

1120, 1124

8738, 9667

9823, 9881

8671, 8715

9966, 10188

1139, 3167

279, 443

517, 992

1014, 1057

1073, 1104

54,105

123,102

10965

Discharge summary

report

Admission Date: [**2119-2-6**] Discharge Date: [**2119-2-11**] Date of Birth: [**2045-12-9**] Sex: F Service: SURGERY Allergies: Augmentin / Sulfa (Sulfonamide Antibiotics) / Tetanus Attending:[**First Name3 (LF) 3376**] Chief Complaint: GI Bleed Major Surgical or Invasive Procedure: Colonoscopy Laparoscopic ileocecectomy History of Present Illness: This is a 73 yo female who was admitted with GI bleed after polypectomy. She was found to have a 6-7 cm x 5-6 cm benign looking polyp ([**First Name8 (NamePattern2) **] [**Last Name (un) **] report) that encompassed 2 or the proximal folds of the cecum and ascending colon. A piece meal polypectomy was performed and APC was applied to edges of resection for tissue destruction and hemostasis. She was discharged home, but early this afternoon had BRBPR and passed large clots as well. She didn't return to the hospital immediately, but had 4 subsequent episodes of BRBPR. She returned to [**Hospital1 18**] and went for repeat colonoscopy this afternoon. There was visible clot over a bleeding arterial vessel. APC was attempted initially and when vessel was visualized, this was clipped x 2 with hemostasis achieved. Currently, she complains of dizziness that worsens with standing, although she does have a history of vertigo. She has no chest pain, shortness of breath, abdominal pain, headache, visual changes, recent fevers, chills or night sweats. No recent weight loss. Past Medical History: * Hypothyroidism * Myasthenia [**Last Name (un) 2902**] - s/p thymectomy at age 16 * GERD * H/o angina - on diltiazem. Had recent stress test - negative * H/o rheumatic fever as a child x 2 - takes prophylactic antibiotics * Hyperlipidemia * h/o cataract surgery Social History: Lives in [**Location 32775**] with her husband, [**Name (NI) **]. [**Name2 (NI) **] history of tobacco, occasional EtOH, IVDU.` Family History: No family history GI cancers. Has had colonoscopy 3 years ago with 2 polyps that were resected. Physical Exam: Vitals: 96.1, Orthostatics: lying - 151/79, 87; sitting 149/83, 93; standing 141/78, 103; 18, 98%RA Gen: lying in bed, appears comfortable, NAD HEENT: EOMI, sclera anicteric, OP clear, no cervical LAD CV: +s1s2, rrr, 2/6 systolic murmur heard best at LLSB and apex Lungs: ctab Abd: obese, soft, ttp in RLQ, no rebound or guarding, +bs Ext: no c/c/e Neuro: CN 2-12 intact, motor strength 5/5 throughout, reflexes at patella and brachial 2+, sensation intact, gait intact, cerebellar testing not performed . At Discharge: Vitals:AVSS GEN: NAD, A/Ox3 CV: RRR, no m/r/g RESP: CTAB, no w/r/r ABD: soft, ND, appropriately TTP, +BS, +flatus Incision: small midline upper abdomen OTA with steri strips, CDI Extrem: no c/c/e Pertinent Results: ADMISSION LABS: WBC-9.4# RBC-3.78* HGB-11.1* HCT-34.1* MCV-90 MCH-29.3 MCHC-32.4 RDW-12.2 PLT COUNT-199 . GLUCOSE-106* UREA N-9 CREAT-0.5 SODIUM-139 POTASSIUM-7.6* CHLORIDE-108 TOTAL CO2-25 ANION GAP-14 . PT-12.3 PTT-23.3 INR(PT)-1.0 . CALCIUM-9.2 PHOSPHATE-2.6* MAGNESIUM-2.2 . [**2119-2-7**] 07:20AM BLOOD Hct-32.1* [**2119-2-7**] 10:51AM BLOOD Hct-30.8* [**2119-2-7**] 02:07PM BLOOD Hct-30.2* [**2119-2-7**] 08:27PM BLOOD Hct-29.9* . ABG [**2119-2-7**] 06:15PM BLOOD Type-ART Temp-37 pO2-230* pCO2-42 pH-7.34* calTCO2-24 Base XS--2 [**2119-2-7**] 06:15PM BLOOD Glucose-120* Lactate-1.4 Na-139 K-3.2* Cl-113* calHCO3-22 . Brief Hospital Course: This is a 73 yo female admitted with post-polypectomy bleeding. She went for repeat colonoscopy today and which revealed bleeding arterial vessel that was clipped. . ##. Hematochezia: Suspect source of bleed is site of polypectomy given prior colonoscopy finding several hours ago. Contact[**Name (NI) **] GI who recommended transfusing for Hct >30. Prior to her polypectomy it was decided that should GI not be able to remove polyp she would undergo hemicolectomy with Dr.[**Name (NI) 3377**] service. Patient had BRBPR upon arriving to floor, and Hct dropped. Hct remained the same after 2 U PRBCs. However, patient continued to have BRBPR and dropping Hct. She was orthostatic and received IVF. She was taken for attempting IR angiography but they were unable to locate lesion for embolization. Pt was taken to OR for partial colectomy. . ##. H/O Angina/HTN: Held pt's Diltiazem dose given active GI bld will tolerate higher pressures for now. EKG wnl. . ##. Hypothyroidism: Continued on home regimen IV equivalent of levothyroxine. . ##. GERD: Continued on home regimen IV equivalent of PPI. . ##. HL: Continue on home regimen of Simvastatin once pt is able to tolerate PO intake. . ##. Vertigo: Pt usually is on Clonazepam TID for her vertigo, will hold medication for now. . Admitted to general surgery. Operative course uncomplicated. Admitted to Stone 5 for post-op care. Pain controlled with PCA. Abdominal incision intact with dermabond, CDI. Diet advanced gradually from sips to regular food as bowel function and abdominal distention improved. Reported flatus, and eventual loose stools. IV fluid discontinued. Foley removed. Voided without issue. Medications switched to oral. Pain well controlled with oral Percocet. Activity returned to baseline. Ambulated in halls independently. . Medications on Admission: Clonazepam 0.5mg TID Diltiazem 180mg SR daily Synthroid 75mcg daily Prilosec 20mg daily Pyridostigmine 60mg 3-4 times a year Simvastatin 40mg daily Discharge Disposition: Home Discharge Diagnosis: Bleeding from cecum, status post endoscopic polypectomy. Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Completed by:[**2119-2-14**]

[ "998.11", "211.3", "458.0", "272.4", "790.01", "530.81", "780.4", "398.90", "E878.8", "358.00", "244.9" ]

icd9cm

[ [ [] ] ]

[ "88.47", "17.33", "45.93", "45.42", "45.43" ]

icd9pcs

[ [ [] ] ]

5426, 5432

3428, 5228

321, 362

5533, 5533

2779, 2779

1930, 2028

5453, 5512

5254, 5403

2043, 2549

2563, 2760

273, 283

390, 1481

2795, 3405

5547, 5683

1503, 1768

1784, 1914

19,833

120,759

11104

Discharge summary

report

Admission Date: [**2198-4-17**] Discharge Date: [**2198-5-26**] Date of Birth: [**2125-8-6**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3276**] Chief Complaint: DOE, cough Major Surgical or Invasive Procedure: Bronchoscopy Chest Tube Mechanical Ventilation Port-a-cath placement History of Present Illness: 72yoM with pmh tobacco use, COPD, CHF, presents c/o approx 6 weeks of gradually worsening DOS and nonproductive cough, and stating that CT scan done recently at [**Hospital 4199**] Hospital outpt radiology showed "a large lymph node." He states that when DOE became noticable 6 weeks ago he increased his lasix to triple dose for 3 days, lost 4 pounds, and felt his breathing was much improved. However, within the next week the DOE returned and he increased his lasix dose again but this time without effect. He denies night sweats, weight loss, fevers, rash. He denies CP, productive cough, recent palpitations. He denies LE edema, though states that even when "in CHF" he never has LE edema. Baseline weight at home 190 lbs, on admission 202 lbs. ROS: No headache, paraesthesias, weakness; No N/V/diarrhea, ROS otherwise negative except as per HPI and moonlighter note. Past Medical History: CHF, systolic COPD NSVT Hyperlipidemia HTN Gout Arthritis ICD placed for sustained VT Focal penetrating aortic arch ulcer Focal infra-renal aortic dissection Social History: Lives with wife, history positive for tobacco use but quit approx 20 years ago, no alcohol use, no drug use. Family History: NC Physical Exam: T 98 HR 70 BP 121/80 RR 14 94%RA Weight 201 lbs NAD, breathing easily HEENT: [**Month (only) **] vision, EOMI Neck supple No LAD RRR nl s1s2 no mrg Lungs with mild decreased bs at r base and crackles, no labored breathing Abd soft, NT/ND, nabs LE with 1+ edema, UE with 2+ edema in right arm, scattered healing papules Pertinent Results: CBC [**2198-4-17**] 07:30PM BLOOD WBC-11.8*# RBC-4.12* Hgb-12.1* Hct-35.9* MCV-87 MCH-29.5 MCHC-33.8 RDW-15.5 Plt Ct-198 [**2198-4-18**] 05:30AM BLOOD WBC-9.8 RBC-3.91* Hgb-12.1* Hct-34.9* MCV-89 MCH-30.9 MCHC-34.6 RDW-15.3 Plt Ct-204 [**2198-4-20**] 02:19AM BLOOD WBC-56.5*# RBC-3.06* Hgb-9.3* Hct-28.0* MCV-92 MCH-30.5 MCHC-33.3 RDW-15.7* Plt Ct-204 [**2198-4-20**] 11:04AM BLOOD WBC-49.6* RBC-2.88* Hgb-8.8* Hct-26.0* MCV-90 MCH-30.6 MCHC-33.9 RDW-15.4 Plt Ct-209 [**2198-4-20**] 04:31PM BLOOD WBC-31.3* RBC-2.83* Hgb-8.6* Hct-25.2* MCV-89 MCH-30.3 MCHC-34.0 RDW-15.6* Plt Ct-166 [**2198-4-21**] 03:00AM BLOOD WBC-16.2* RBC-2.71* Hgb-8.2* Hct-24.3* MCV-90 MCH-30.3 MCHC-33.7 RDW-15.6* Plt Ct-134* [**2198-4-21**] 02:44PM BLOOD WBC-9.8 RBC-2.52* Hgb-7.6* Hct-23.0* MCV-91 MCH-30.2 MCHC-33.1 RDW-15.7* Plt Ct-119* [**2198-4-24**] 02:49AM BLOOD WBC-8.2 RBC-2.51* Hgb-7.4* Hct-22.8* MCV-91 MCH-29.7 MCHC-32.7 RDW-15.5 Plt Ct-125* [**2198-4-24**] 08:18AM BLOOD WBC-10.4 RBC-2.48* Hgb-7.4* Hct-22.7* MCV-92 MCH-29.9 MCHC-32.7 RDW-15.4 Plt Ct-137* [**2198-4-27**] 04:20AM BLOOD WBC-27.2* RBC-3.14* Hgb-9.5* Hct-28.7* MCV-92 MCH-30.4 MCHC-33.2 RDW-15.3 Plt Ct-155 [**2198-4-28**] 04:58AM BLOOD WBC-31.7* RBC-3.26* Hgb-9.7* Hct-29.9* MCV-92 MCH-29.8 MCHC-32.5 RDW-15.5 Plt Ct-144* [**2198-5-5**] 02:32AM BLOOD WBC-37.9* RBC-3.40* Hgb-10.2* Hct-29.1* MCV-86 MCH-29.9 MCHC-34.9 RDW-16.8* Plt Ct-115* [**2198-5-5**] 04:21PM BLOOD WBC-50.6* RBC-3.45* Hgb-10.3* Hct-29.7* MCV-86 MCH-29.8 MCHC-34.5 RDW-16.6* Plt Ct-120* [**2198-5-6**] 12:00AM BLOOD WBC-54.9* RBC-3.07* Hgb-9.2* Hct-27.0* MCV-88 MCH-29.9 MCHC-34.1 RDW-16.5* Plt Ct-113* [**2198-5-7**] 12:00AM BLOOD WBC-57.0* RBC-3.68* Hgb-10.7* Hct-31.6* MCV-86 MCH-29.1 MCHC-33.8 RDW-16.0* Plt Ct-115* [**2198-5-10**] 12:00AM BLOOD WBC-0.9*# RBC-2.98* Hgb-8.7* Hct-25.8* MCV-87 MCH-29.0 MCHC-33.5 RDW-15.0 Plt Ct-60* [**2198-5-13**] 12:00AM BLOOD WBC-1.5*# RBC-3.44* Hgb-9.8* Hct-29.3* MCV-85 MCH-28.4 MCHC-33.3 RDW-14.7 Plt Ct-12* [**2198-5-14**] 12:00AM BLOOD WBC-4.1# RBC-3.40* Hgb-9.8* Hct-28.0* MCV-82 MCH-28.7 MCHC-34.8 RDW-14.8 Plt Ct-26* [**2198-5-18**] 12:01AM BLOOD WBC-2.6* RBC-3.13* Hgb-9.0* Hct-26.7* MCV-85 MCH-28.8 MCHC-33.8 RDW-15.1 Plt Ct-55* [**2198-5-19**] 12:00AM BLOOD WBC-2.4* RBC-3.66* Hgb-10.5* Hct-30.6* MCV-84 MCH-28.7 MCHC-34.3 RDW-15.2 Plt Ct-60* [**2198-5-20**] 12:00AM BLOOD WBC-2.2* RBC-3.63* Hgb-10.3* Hct-30.3* MCV-84 MCH-28.5 MCHC-34.1 RDW-15.1 Plt Ct-66* [**2198-4-17**] 07:30PM BLOOD Neuts-78.9* Lymphs-14.1* Monos-5.5 Eos-1.4 Baso-0.2 [**2198-4-20**] 05:39AM BLOOD Neuts-99* Bands-0 Lymphs-0 Monos-0 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* [**2198-4-25**] 02:50AM BLOOD Neuts-94.6* Lymphs-3.3* Monos-2.0 Eos-0 Baso-0.1 [**2198-5-3**] 12:00AM BLOOD Neuts-85.0* Bands-0 Lymphs-6.8* Monos-7.8 Eos-0.4 Baso-0.1 [**2198-5-17**] 12:01AM BLOOD Neuts-64 Bands-15* Lymphs-20 Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2198-5-26**] 12:00AM WBC 2.5* HB10.5* HCT 31.6* PLT 196 [**2198-5-10**] 12:00AM BLOOD Gran Ct-760* [**2198-5-11**] 12:01AM BLOOD Gran Ct-140* [**2198-5-12**] 12:00AM BLOOD Gran Ct-140* [**2198-5-13**] 12:00AM BLOOD Gran Ct-890* [**2198-5-14**] 12:00AM BLOOD Gran Ct-3360 [**2198-5-19**] 12:00AM BLOOD Gran Ct-1780* [**2198-5-20**] 12:00AM BLOOD Gran Ct-1500* [**2198-5-26**] 12:00AM BLOOD Gran Ct-2670* . Chem 7 [**2198-4-18**] 05:30AM BLOOD Glucose-92 UreaN-23* Creat-1.6* Na-142 K-4.2 Cl-102 HCO3-31 AnGap-13 [**2198-4-20**] 02:19AM BLOOD Glucose-128* UreaN-33* Creat-2.3* Na-141 K-5.0 Cl-109* HCO3-20* AnGap-17 [**2198-4-20**] 04:31PM BLOOD Glucose-171* UreaN-42* Creat-2.7* Na-140 K-5.0 Cl-111* HCO3-18* AnGap-16 [**2198-4-21**] 03:00AM BLOOD Glucose-180* UreaN-45* Creat-2.5* Na-142 K-4.6 Cl-114* HCO3-20* AnGap-13 [**2198-4-22**] 03:09AM BLOOD Glucose-138* UreaN-50* Creat-1.9* Na-146* K-4.5 Cl-117* HCO3-22 AnGap-12 [**2198-4-23**] 01:50AM BLOOD Glucose-122* UreaN-58* Creat-1.7* Na-148* K-4.2 Cl-117* HCO3-24 AnGap-11 [**2198-4-24**] 02:49AM BLOOD Glucose-135* UreaN-56* Creat-1.5* Na-148* K-4.4 Cl-114* HCO3-28 AnGap-10 [**2198-4-24**] 05:14PM BLOOD Glucose-124* UreaN-55* Creat-1.5* Na-150* K-4.5 Cl-114* HCO3-30 AnGap-11 [**2198-4-25**] 02:50AM BLOOD Glucose-135* UreaN-57* Creat-1.4* Na-151* K-4.0 Cl-112* HCO3-31 AnGap-12 [**2198-4-26**] 04:35AM BLOOD Glucose-140* UreaN-53* Creat-1.2 Na-151* K-3.9 Cl-109* HCO3-32 AnGap-14 [**2198-4-27**] 04:20AM BLOOD Glucose-127* UreaN-52* Creat-1.2 Na-149* K-3.8 Cl-110* HCO3-33* AnGap-10 [**2198-4-29**] 03:58AM BLOOD Glucose-131* UreaN-60* Creat-1.3* Na-144 K-4.1 Cl-104 HCO3-29 AnGap-15 [**2198-5-3**] 12:00AM BLOOD Glucose-98 UreaN-49* Creat-1.2 Na-144 K-4.1 Cl-109* HCO3-28 AnGap-11 [**2198-5-5**] 12:22AM BLOOD Glucose-82 UreaN-37* Creat-1.0 Na-142 K-3.9 Cl-107 HCO3-28 AnGap-11 [**2198-5-6**] 12:00AM BLOOD Glucose-41* UreaN-34* Creat-0.9 Na-141 K-3.8 Cl-106 HCO3-28 AnGap-11 [**2198-5-8**] 12:11PM BLOOD Creat-0.7 [**2198-5-10**] 12:00AM BLOOD Glucose-150* UreaN-24* Creat-0.7 Na-138 K-4.2 Cl-107 HCO3-27 AnGap-8 [**2198-5-11**] 10:19PM BLOOD Glucose-83 UreaN-27* Creat-1.0 Na-138 K-4.0 Cl-105 HCO3-30 AnGap-7* [**2198-5-13**] 12:00AM BLOOD Glucose-99 UreaN-26* Creat-0.8 Na-137 K-4.1 Cl-105 HCO3-27 AnGap-9 [**2198-5-19**] 12:00AM BLOOD Glucose-99 UreaN-27* Creat-1.1 Na-139 K-3.9 Cl-100 HCO3-34* AnGap-9 [**2198-5-19**] 04:30PM BLOOD UreaN-24* Creat-1.0 Na-137 K-4.3 Cl-99 [**2198-5-20**] 01:00PM BLOOD Glucose-118* UreaN-23* Creat-1.0 Na-138 K-4.1 Cl-100 HCO3-31 AnGap-11 [**2198-5-26**] 01:00PM BLOOD Glucose-196* UreaN-48* Creat-1.2 Na-138 K-4.6 Cl-101 HCO3-31 AnGap-11 [**2198-4-17**] 07:30PM BLOOD Calcium-9.5 Phos-3.3 Mg-2.4 [**2198-4-19**] 05:30AM BLOOD Calcium-9.4 Phos-3.9 Mg-2.4 UricAcd-8.9* [**2198-4-23**] 01:50AM BLOOD Calcium-9.4 Phos-3.4 Mg-3.0* [**2198-4-25**] 02:50AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.6 [**2198-4-26**] 05:11PM BLOOD Calcium-9.2 Phos-3.3 Mg-2.8* [**2198-4-29**] 03:58AM BLOOD Calcium-8.4 Phos-4.5 Mg-2.7* [**2198-5-17**] 01:37PM BLOOD Calcium-7.7* Phos-2.4* Mg-1.7 [**2198-5-18**] 12:23PM BLOOD Calcium-7.6* Phos-3.0 Mg-2.1 [**2198-5-19**] 12:00AM BLOOD Calcium-7.5* Phos-2.7 Mg-2.0 [**2198-5-20**] 12:00AM BLOOD Albumin-2.6* Calcium-7.9* Phos-2.7 Mg-2.0 [**2198-5-20**] 01:00PM BLOOD Calcium-7.9* Phos-2.6* Mg-2.0 . MISC [**2198-5-16**] 12:00AM BLOOD TotProt-4.6* Albumin-2.7* Globuln-1.9* Calcium-7.7* Phos-2.6* Mg-1.9 . CXR [**4-17**]: 1. Right superior mediastinal mass, likely anterior. Recommend chest CT for better evaluation. 2. Probable right lower lobe pneumonia. 3. New small right pleural effusion. . CXR [**4-20**]: Again, there has been apparent resolution of the right pneumothorax. However, an opacity projecting over the right mid lung remains, and is consistent with either aspiration or hemorrhage in the post-biopsy setting. This is approximately unchanged since the prior study. There is suggestion of developing right lower lobe atelectasis. There is unchanged position of a right pleural catheter, right subclavian line, and left chest dual-lead pacer. The endotracheal tube is unchanged in appearance. IMPRESSION: Continued right mid lung opacity consistent with aspiration or hemorrhage. Right lower lobe opacity likely representative of developing atelectasis. CT Chest; 1. Right-sided central tumor with associated large conglomerate lymph node masses in the right superior mediastinum and right hilar/subcarinal regions, as described. There is compression of the airways as described, with associated post-obstructive atelectasis in the right middle lobe. Findings most likely represent either a primary lung cancer with associated lymphadenopathy or lymphoma. Findings very unlikely represent atypical appearance of sarcoid, given the unilaterality of the finding as well as associated effusion. Lesion would be amenable to tissue sampling via bronchoscopy. 2. New moderate right-sided pleural effusion. 3. New 2- to 3-mm pulmonary nodule in the right middle lobe, concerning for possible metastatic disease. 4. New moderate pericardial effusion. 5. Unchanged nodule in the left lower lobe. . CT head: Normal contrast-enhanced head CT with no evidence of metastasis. . CT OF THE CHEST: There is a right-sided AICD with its lead in the right ventricle. When compared with the prior study, there have been interval placements of endotracheal tube, nasogastric tube, and a right internal jugular central line that are seen in satisfactory position. There is also a new right-sided chest tube, which is seen in the right posteromedial right hemithorax. There is a rounded, heterogeneous 6.6 x 7.7 x 12 cm collection in the right posterior medial hemithorax adjacent to the chest tube, which is consistent with a hematoma. Additionally, there has been interval development of a moderate- sized pneumothorax, which is predominantly seen anteriorly. There is also a new diffuse infiltrate involving the posterior aspect of the right upper lobe, right middle lobe and portion of the right lower lobe, which likely reflects pneumonia, possibly aspiration related. The previously seen right pleural effusion has nearly resolved. There is; however, a small new left pleural effusion demonstrating simple fluid density with associated airspace disease. The previously noted 1.6-cm rounded nodule in the left lower lobe is now obscured by pleural fluid and atelectasis. The previously seen 2-3 mm nodule in the right middle lobe, is also not seen, likely due to a new infiltrate in this region. The lungs demonstrate diffuse severe emphysematous changes. The aorta and pulmonary arteries are normal in caliber. As before, note is made of extensive, bulky mediastinal and hilar confluent masses/lymphadenopathy, exact dimensions of which are difficult to measure due to poorly-defined margins and confluent nature of the process. The right hilar mass/lymphadenopathy measures 5 x 7 x 8 cm and as before, causes obstruction of the right middle lobe bronchus and some of the right lower lobe bronchi. There is also mild mass effect on the anterior aspect of the right upper lobe bronchus. There are also large, bulky and anterior mediastinal/right paratracheal masses/adenopathy that measures 9.6 x 9 x 6.2 cm. This surrounds and narrows the brachiocephalic veins and superior vena cava which remain patent; however. The hilar mass also causes mild narrowing of the distal portion of the right pulmonary artery and right pulmonary veins. There is a large subcarinal mass/lymphadenopathy appears to be contiguous with the right hilar mass and measures at least 4 x 4 cm. The previously seen pericardial effusion has decreased in size and now a small residual pericardial effusion is seen. Coronary artery calcifications are noted. Heart is borderline in size. No axillary lymphadenopathy is identified. The largest axillary lymph node is seen on the left and measures approximately 0.7 x 0.9 cm. There is a small lymph node in the AP window region that measures 0.7 cm in short axis and 1.3 cm in long axis. No left hilar adenopathy is seen. There are diffuse severe emphysematous changes in both lungs. Heavy atherosclerotic calcifications with areas of eccentric plaque are seen in the thoracic aorta. Coronary artery calcifications are present. CT OF THE ABDOMEN: The liver is normal in size and contour. There is no intrahepatic or extrahepatic biliary dilatation. No suspicious focal liver lesions are seen. A 3-mm calcified gallstone is seen within the gallbladder. The pancreas and spleen are within normal limits. The right adrenal gland is unremarkable. The left adrenal gland is thickened. However, this appearance is unchanged since the prior CT from [**2195**]. The kidneys enhance symmetrically. There is no hydronephrosis. Multiple small para-aortic lymph nodes are seen, which measure less than 1 cm in short axis and do not meet CT criteria for malignancy. There are heavy atherosclerotic calcifications within the abdominal aorta. There is no abdominal aortic aneurysm and the abdominal aorta measures approximately 2.1 cm in maximum diameter. There are also prominent porta hepatis lymph nodes abutting the inferior vena cava. There is no ascites. Small and large bowel are normal in caliber. CT OF THE PELVIS: The urinary bladder contains a Foley catheter and is grossly unremarkable. There is trace amount of free pelvic fluid. Prostate gland is not enlarged and measures 3.1 x 3.9 cm. No pelvic masses or adenopathy is identified. There is a right femoral arterial line in place, with its tip in the right external iliac artery. There is a dissection flap in the infrarenal abdominal aorta that originates to 30-cm distal to the left renal artery origin and extends to the level of the iliac bifurcation. The common iliac, external iliac and internal iliac arteries are grossly patent. BONE WINDOWS: No focal suspicious lytic or sclerotic lesions are identified. However, the osseous structures in the pelvis have a somewhat mottled, heterogeneous appearance. A bone scan may be more sensitive in detection of subtle metastatic lesions. There are multilevel degenerative changes in the thoracolumbar spine. IMPRESSION: 1. Right hilar mass with bulky confluent mediastinal adenopathy, resulting in compression of the bronchi and vascular structures on the right. No axillary or left hilar lymphadenopathy. 2. Interval placement of a right-sided chest tube, which is seen with its tip in the posterior right hemithorax medially. New hematoma in the right posterior hemithorax, adjacent to the chest tube. 3. Extensive new right-sided airspace disease involving upper and lower lobes, probably reflects pneumonia. 4. Interval improvement in pericardial effusion. 5. Previously identified right middle and left lower lobe nodules are not seen on the current study due to interval development of a small left pleural effusion and the right-sided airspace disease. 6. Borderline enlarged porta hepatis lymph nodes measuring 1.0 x 2.5 cm. No other pathologically enlarged lymph nodes or metastatic lesions are identified. 7. Nodular appearance of the left adrenal gland, stable since [**2195**]. 8. Heterogenous appearance of the osseous structures in the pelvis. Further evaluation with a bone scan may be helpful with subtle underlying metastatic lesions. 9. Moderate-sized right pneumothorax, predominantly anterior. . CT orbits:In the orbits, the eye globes demonstrate possible surgical changes, the density and configuration as well as the size of the optic nerves appear within normal limits. There is no evidence of intra- or extra- conal lesions. The orbital fat is preserved. The extraocular orbital muscles appear within normal limits. Normal enhancement is identified in the major vascular structures. Atherosclerotic changes are noted in the carotid siphons. The intracranial structures demonstrates no evidence of intra- or extra-axial hemorrhage, mass, mass effect or shift of normally midline structures. The images of the temporal bones are unremarkable with normal pneumatization on the mastoid air cells. The ossicles and middle ear appear within normal limits. Small amount of cerumen is identified on the left external auditory canal. The paranasal sinuses demonstrate normal pneumatization with nasal septum deviation and S-shaped configuration. Mild bilateral degenerative changes are identified on the temporomandibular joint consistent with osteopenia, however, the glenoid cavities appear within normal limits. IMPRESSION: There is no evidence of abnormal enhancement, the optic nerves as well as the orbital structures appear within normal limits. Bilateral atherosclerotic calcifications are visualized in the carotid siphons as described above. Possible post-surgical changes are visualized in the eye globes, please correlate clinically. . CT Chest [**5-15**]: Marked enlarged right pleural effusion with associated new right middle lobe and right lower lobe collapse. There has been interval decrease in size in large right perihilar mass and mediastinal lymphadenopathy. Complete obstruction of the right middle lobe bronchus, partial obstruction of the right lower lobe superior segment bronchus is stable. Left lower lobe lung nodule is slightly decreased in size. New mild cardiomegaly with interval mild decrease in size in pericardial effusion. Resolved left pleural effusion. Stable right lower lobe hematoma. . Pleural fluid: WBC, Pleural 1000* #/uL 0 - 0 RBC, Pleural [**Numeric Identifier 35822**]* #/uL 0 - 0 Polys 83* % 0 - 0 Lymphocytes 12* % 0 - 0 Monos 1* % 0 - 0 Macrophages 4* % 0 - 0 Total protein 2.2 glucose 103 LDH 845 amylase 76 albumin 1.4 PH 5.5 Brief Hospital Course: 72-year-old man with COPD, CHF, presented with 6 weeks of DOE, cough. . # Lung cancer: Admission CT scan showed a mediastinal mass and right pleural effusion. A thoracentesis was performed and the cytology was negative for malignancy. The patient underwent a bronchoscopy that revealed a necrotic mass with biopsy revealing small-cell carcinoma. His post-bronchoscopy course was complicated by PTX and respiratory failure as described below. The patient had chemotherapy with carboplatin and etoposide (cycle 1) and underwent XRT. He developed neutropenia and required neupogen. His WBC did not recover and remained low at 2.0, but not neutropenic. He received a second cycle of carboplatin and etoposide with reduced dose. He should receive neupogen for 10 days, 1st dose [**2198-5-26**]. He will need daily CBC and absolute neutrophil count check. His WBC is 2.4, ANCis 2190 on [**2198-5-26**]. He will need daily XRT. He should follow up with his oncologist Dr. [**Last Name (STitle) 3274**]. . # Respiratory failure: During the bronchoscopy there was some oozing of blood. After the procedure the patient felt dyspneic and dropped his O2 saturation despite being on a NRB. He was intubated. CXR showed a right-sided pneumothorax. Chest tube was placed, and he was transferred to the ICU. His antibiotic coverage, which had been levofloxacin initially, was changed to vanc/unasyn. He was also found to be bronchospastic and treated for COPD exacerbation with steroid taper. He was then switched to fluticasone, albuterol and ipratropium nebs. Fluticasone was discontinued when he became less bronchospastic. Albuterol was discontinued when he had SVT to 150's. Ipratropium was continued. He was also diuresed as he was 10L positive with EF of 20%. He was successfully extubated on [**2198-4-24**] and transferred to OMED. The patient required supplemental O2 via nasal cannulae to maintain adequate saturation. His oxygenation improved with diuresis. However, he developed an increasing, large right pleural effusion. With the increase in effusion, he became more SOB with worsening hypoxia. He received a thoracenteisis with improvement, exudative effusion on labs. He was then further diuresed wit lasix 60 mg IV BID and was able to come off of 02. His extremety edema also markedly improved. His creatinine bumped and he was changed to lasix 80mg PO BID on [**2198-5-26**]. He will need his creatinine followed every other day. He should be switched back to his home dose of lasix 80mg daily when his edema has resolved. As he has underlying COPD, his goal SaO2 is 90-93%. He was sat'ing 94% RA on discharge. . # Hypotension: Pt had transient hypotension following propofol, which improved with dc of propofol and boluses of fluid. He then became hypotensive to 60/40 evening of [**4-19**] with three pressors, levophed, neo, and vasopressin. A sig. component was felt to be due to autPEEP and pt improved after being disconnected from the ventilator. There was also concern for pericardial tamponade as he has known pericardial effusion from ECHO on [**4-20**]. Cardiology was consulted and repeat ECHO on [**4-21**] showed no sig effusion but noted that echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. There was also a concern of sepsis and pt was continued on vanc/unasyn for pna/aspiration. He was also started on stress dose steroids and fludracort for possible adrenal insufficiency from possible mets. Pt was weaned off of pressors within 72 hours and then became hypertensive. Stress dose steroids were tapered and fludrocort was discontinued. As his BP improved, his home heart failure regimen was restarted. Nifedipine was discontinued to all room for medications for diuresis and heart rate control. . # Visual loss: After extubation, the patient noted that his vision was impaired. Head CT negative for stroke. CT of orbits negative. Opthalmology was consulted. He had visual field tested in [**Hospital 464**] clinic which showed severely impaired vision. He was diagnosed with retrobulbar ischemia that likely occured during hypotension and hypoxia. He is to follow up in [**Hospital 35823**] clinic. He received OT. . # Acute on chronic renal failure: Pt has a basline Cr of 1.0. His creatinine peaked at 2.7, likely [**1-13**] hypotension/ATN. This improved to baseline with IVF resuscitation during his hypotensive episodes. His creatinine crept up to 1.2 with diureses and his lasix was cut back. . # Acute on chronic systolic CHF: Prior to admission, pt was noted to have 10 lb weight gain. In the ICU, he was positive 10 L for stay. he had significant peripheral edema. Digoxin was held with his renal failure. Once his blood pressure recovered, he was restarted on his home digoxin, metoprolol, which was titrated up, and diuresed. His peripheral edema improved. Asa was initially held for biopsy and then for bloody secretions after bronchoscopy. . # HTN: Pt was well controlled on home regimen. This regimen was held when he become hypotensive. As his BP recovered, he was restarted on metoprolol, ca blocker added for HR control, see below. His BP remained low around SBP 100. . # h/o SVT/VT: Pt has an ICD placed in 07. On the Omed service, he developed multiple forms of SVT wit HR to 130-150 - sinus tachycardia and occ afib. He was hemodynamically stable. He was restarted on metoprolol and titrated up to 100mg TID. Diltiazem was added for rate control. Digoxin was also started; dig level 0.4, digoxin dose increased. His HR improved to 80-90. He also has occ NSVT, approx 2 episodes a day, usually assymptomatic, HD stable. ONce his pleural effusion was tapped and he was diuresed, his heart rate improved. He was maintained on metoprolol 100 TID and digoxin 250mcg with HR in 90's at discharge. EKG showing NSR with occ PVC's. Medications on Admission: aspirin 81 mg qd, carvedilol 3.125 mg b.i.d., Procardia XL 60 mg qd, Zocor 40 mg qd, allopurinol 100 mg qd, digoxin 0.125 mg qd, lasix 80 mg a day, and Combivent two puffs up to four times daily Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 3. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 4. Docusate Sodium 50 mg/5 mL Liquid Sig: Five (5) ml PO BID (2 times a day) as needed for constipation. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q4-6H () as needed for nausea. 7. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed for anxiety. 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 11. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q3H (every 3 hours) as needed for pain. 15. Filgrastim 480 mcg/1.6 mL Solution Sig: One (1) tablet Injection Q24H (every 24 hours) for 10 days. 16. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary: Small Cell Lung Cancer Secondary: Pneumothorax Vision Impairment Acute Renal Failure Congestive Heart Failure Supraventricular Tachycardia Non-Sustained Ventricular Tachycardia Discharge Condition: improved Discharge Instructions: You were admitted for a bronchoscopy. You subsequently had a pneumothorax and respiratory failure, which have now resolved. You also suffered from vision loss that is thought to be due to injury to the eye nerves secaondary to decreased oxygen. You were also diagnosed with small cell lung cancer and received two rounds of chemotherapy and radiation. You will need to continue with chemotherapy and radiation. . If you have worsening shortness of breath or fever, you should go to the emergency room Followup Instructions: You will need to have CBC and absolute neutrophil count checked daily for one week [**Date range (3) 35824**]. You will need Chem 7 checked every other day to monitor your renal function. . Radiation oncology appointments Mon-Fri 2:45pm on [**Hospital Ward Name 332**] 4 until [**6-13**]. . Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 15108**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2198-6-1**] 9:00 . Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] (neuro-opthalmology) [**2198-6-6**] 1:30 in clinic and 2:00 for visual field testing . Provider: [**Name Initial (NameIs) **] (pulmonology) [**2198-7-2**] 7:30 PFT's; 8:OO am with Dr. [**Last Name (STitle) **] . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2198-9-13**] 3:00 Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2198-9-6**] 9:00 . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2198-7-4**] 2:00 [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]

[ "272.4", "162.8", "427.1", "377.39", "428.23", "585.9", "998.12", "512.1", "785.50", "423.8", "496", "458.29", "511.9", "584.9", "427.89", "403.90", "428.0", "284.1", "507.0" ]

icd9cm

[ [ [] ] ]

[ "99.25", "34.04", "38.93", "38.91", "92.24", "96.6", "99.05", "99.04", "96.04", "33.27", "86.07", "34.91", "96.72" ]

icd9pcs

[ [ [] ] ]

26024, 26103

18531, 24372

325, 396

26333, 26344

1984, 9997

26893, 28123

1626, 1630

24617, 26001

26124, 26312

24398, 24594

26368, 26870

1645, 1965

275, 287

424, 1303

10006, 18508

1325, 1484

1500, 1610

17,901

138,432

53390+53391

Discharge summary

report+report

Admission Date: [**2173-7-13**] Discharge Date: [**2173-7-19**] Date of Birth: [**2125-5-20**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Codeine / Nitroglycerin Attending:[**First Name3 (LF) 1505**] Chief Complaint: Substernal chest pain Major Surgical or Invasive Procedure: [**2173-7-13**] Septal Myomectomy History of Present Illness: Mr. [**Known lastname 109820**] is a 48 year old male with known history of hypertrophic obstructive cardiomyopathy(HOCM). Despite several ETOH septal ablations in [**2171**] and [**2172**], he continues to experience worsening substernal chest pain of increasing duration. In preperation for upcoming surgery, he underwent cardiac catheterization which confirmed subaortic gradient consistent with HOCM. Angiography showed no evidence of coronary artery disease. Preoperative ECHO showed only trivial mitral regurgitation. Past Medical History: - Hypertrophic Obstructive Cardiomyopathy: echo [**3-/2173**] resting LVOT Gradient 100 - S/P EtOH septal ablation [**8-/2171**], [**5-/2172**] - h/o NSVT; S/P ICD Placement (Guidant Vitality) for primary prevention - Hyperlipidemia - Secumdum ASD - Chronic chest pain: no CAD by cath in [**5-/2172**] - Chronic Low Back Pain with RLE Radiculopathy: MRI [**10-15**] L5-S1 Right paracentral disc herniation, displacing S1 nerve root. - GERD - Spontaneous Pneumothorax S/P Right lobectomy - Left testicular seminoma S/P bilateral orchiectomy - Hemorrhoids s/p hemorrhoidectomy - s/p Appendectomy - s/p Tonsillectomy Social History: Married, lives in Savin [**Doctor Last Name **] with his wife. [**Name (NI) **] smokes [**3-16**] cigarettes/day for 20 years. Denies illicit drug use, including cocaine. Alcohol use of [**3-17**] beers/day. Family History: Notable for a number of family members with MI and sudden cardiac death. Uncle sudden death. Brother and sister with HOCM. Physical Exam: PREOP EXAM Vitals: 118/80, 72, 14 General: WDWN male in no acute distress HEENT: Oropharynx benign, EOMI Neck: Supple, no JVD, carotids 2+ without bruits Lungs: CTA bilaterally Heart: Regular rate and rhythm, normal s1s2, no murmur or rub Abdomen: Soft, nontender with normoactive bowel sounds Ext: Warm, no edema Pulses: 2+ distally Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal deficits noted Pertinent Results: [**2173-7-19**] 05:22AM BLOOD WBC-4.6 RBC-3.23* Hgb-10.2* Hct-30.2* MCV-94 MCH-31.6 MCHC-33.7 RDW-14.6 Plt Ct-300 [**2173-7-17**] 10:25AM BLOOD WBC-5.3 RBC-3.46*# Hgb-10.9*# Hct-32.3*# MCV-94 MCH-31.6 MCHC-33.8 RDW-15.3 Plt Ct-242 [**2173-7-13**] 10:50AM BLOOD PT-13.7* PTT-39.4* INR(PT)-1.2* [**2173-7-19**] 05:22AM BLOOD Glucose-92 UreaN-12 Creat-0.8 Na-141 K-4.2 Cl-107 HCO3-27 AnGap-11 [**2173-7-13**] Intraop TEE: PREBYPASS A mass/thrombus associated with a pacing wire is seen in the right atrium and is most likely on the RV pacing wire. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. There is asymmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is a moderate resting left ventricular outflow tract obstruction of 27mm Hg.. The gradient increased with the Valsalva manuever to 40mm Hg. There is systolic anterior motion of the mitral valve leaflets. There is a prominent septal know of 1.8-2.0 cm at the anterosepal base. There is thinning of the septum below this area consistent with previous septal ablations. The findings are consistent with hypertrophic obstructive cardiomyopathy (HOCM). Right ventricular chamber size and free wall motion are normal. The descending thoracic aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. An eccentric, posteriorly directed jet of Mild (1+) mitral regurgitation is seen. POSTBYAPASS Preserved biventricular systolic function. The anteroseptal know appears less prominent ~1.2cm. [**Male First Name (un) **] of the MV is still present but appears less obstructive than compared to prebypass. Resting gradient across LVOT is ~ 13mm HG. Images were not able to be obtained with Valsalva maneuver. MR is still present and is mild in quantity. Radiology Report CHEST (PA & LAT) Study Date of [**2173-7-18**] 2:52 PM [**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2173-7-18**] SCHED CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 109821**] Reason: evaluate apical ptx [**Hospital 93**] MEDICAL CONDITION: 48 year old man with s/p septal myectomy REASON FOR THIS EXAMINATION: evaluate apical ptx Final Report CHEST RADIOGRAPH INDICATION: Followup. COMPARISON: [**2173-7-17**]. FINDINGS: As compared to the previous examination, the pre-existing left apical pneumothorax is no longer visible. There are no signs of tension. Otherwise, the radiograph is also unchanged. Brief Hospital Course: Mr. [**Known lastname 109820**] was admitted and underwent septal myomectomy by Dr. [**Last Name (STitle) **]. Given he was a same day admit, Cefazolin was used for perioperative antibiotic coverage. For surgical details, please see seperate dictated operative note. Following the operation, he was brought to the CVICU for invasive monitoring. The initial postoperative chest x-ray showed a left sided pneumothorax. A chest tube was placed without complication. Within 24 hours, he awoke neurologically intact and was extubated without incident. Followup chest x-rays showed total re-expansion of his left lung. His CVICU course was otherwise uneventful. On postoperative day one, he transferred to the SDU for further care and recovery. ICD was interrogated and found to be functioning normally. He did well postoperatively and he was ready for discharge home on POD #6. Medications on Admission: Aspirin 325 qd, Pantoprazole 40 [**Hospital1 **], Toprol XL 150 tid, Verapamil 240 [**Hospital1 **], Folate, MV, Percocet prn Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 8. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*0* 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 weeks. Disp:*14 Tablet(s)* Refills:*0* 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day) for 1 weeks. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 11. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Hypertrophic Obstructive Cardiomyopathy - s/p Septal Myomectomy Prior Septal Ablations in [**2171**], [**2172**] AICD Placement [**2168**] Prior Right Lobectomy [**2145**] Discharge Condition: Good Discharge Instructions: 1)Please shower daily. No baths. Pat dry incisions, do not rub. 2)Avoid creams and lotions to surgical incisions. 3)Call cardiac surgeon if there is concern for wound infection. 4)No lifting more than 10 lbs for at least 10 weeks from surgical date. 5)No driving for at least one month. Followup Instructions: Dr. [**Last Name (STitle) **] in [**4-17**] weeks, call for appt Dr. [**Last Name (STitle) 911**] in [**2-14**] weeks, call for appt Dr. [**First Name (STitle) 1022**] in [**2-14**] weeks, call for appt Completed by:[**2173-7-19**] Admission Date: [**2173-7-25**] Discharge Date: [**2173-7-28**] Date of Birth: [**2125-5-20**] Sex: M Service: MEDICINE Allergies: Penicillins / Codeine / Nitroglycerin Attending:[**First Name3 (LF) 45**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 109820**] is a 48M with a PMH s/f HOCM s/p septal myomectomy on [**7-13**], chronic atypical chest pain with a negative cath in [**6-/2173**] who is presenting with chest pain. The pain started at 5PM as a "dull feeling with each heart beat." Non-radiating. Associated with "nausea, sweatiness, and palpiations". He is requesting IV morphine for his chest pain. . 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 dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . In the ED, initial vitals were 99.2, 102/98, 98, 16, 98%RA. He was given a total of 16mg IV morphine inthe ED. EKG unchanged, and first set of cardiac enzymes CK 42, Trop 0.04, thought to be related to post-operative leak. A CXR was wnl. The patient was seen by cardiac surgery, and they did not feel that this was a [**Last Name **] problem. . Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: Clean C's in [**6-/2173**] -PACING/ICD: S/p ICD placement for SVT 3. OTHER PAST MEDICAL HISTORY: Hypertrophic Obstructive Cardiomyopathy: -echo [**3-/2173**] resting LVOT Gradient 100 -s/p septal myomectomy on [**2173-7-13**] HTN Hyperlipidemia NSVT -s/p ICD placement Secundum ASD Chronic chest pain -cath negative in [**5-/2172**] Chronic back pain History of narcotic dependence Spontaneous pneumothorax Left testicular seminoma Hemorrhoids -s/p hemorrhoidectomy Appendectomy Social History: -Tobacco history: [**3-16**] cigarettes/day -ETOH: formerly 2-3 beers/day, has quit for his surgery since [**Month (only) 116**] -Illicit drugs: Denies Family History: Notable for a number of family members with MI and sudden cardiac death. Uncle sudden death. Brother and sister with HOCM. Physical Exam: VS: T=96...BP=99/70...HR=84...RR=18...O2 sat=992L GENERAL: WDWN male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. CARDIAC: 3/6 systolic murmur best heard at the axilla 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/STUDIES EKG: Unchanged from prior . 2D-ECHOCARDIOGRAM [**7-/2173**]: PREBYPASS A mass/thrombus associated with a pacing wire is seen in the right atrium and is most likely on the RV pacing wire. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. There is asymmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is a moderate resting left ventricular outflow tract obstruction of 27mm Hg.. The gradient increased with the Valsalva manuever to 40mm Hg. There is systolic anterior motion of the mitral valve leaflets. There is a prominent septal know of 1.8-2.0 cm at the anterosepal base. There is thinning of the septum below this area consistent with previous septal ablations. The findings are consistent with hypertrophic obstructive cardiomyopathy (HOCM). Right ventricular chamber size and free wall motion are normal. The descending thoracic aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. An eccentric, posteriorly directed jet of Mild (1+) mitral regurgitation is seen. POSTBYAPASS Preserved biventricular systolic function. The anteroseptal know appears less prominent ~1.2cm. [**Male First Name (un) **] of the MV is still present but appears less obstructive than compared to prebypass. Resting gradient across LVOT is ~ 13mm HG. Images were not able to be obtained with Valsalva maneuver. MR is still present and is mild in quantity. . CARDIAC CATH [**6-/2173**]: Normal . TTE [**7-27**]: EF of 60% The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with focal anteroseptal hypokinesis at the junction of the basal and mid septum (myomectomy site). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. . LABORATORY DATA: [**2173-7-25**] 09:15PM GLUCOSE-103 UREA N-10 CREAT-0.8 SODIUM-136 POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-21* ANION GAP-17 [**2173-7-25**] 09:15PM WBC-7.2# RBC-4.15*# HGB-12.7* HCT-37.4* MCV-90 MCH-30.7 MCHC-34.1 RDW-13.8 [**2173-7-25**] 09:15PM NEUTS-67.4 LYMPHS-23.6 MONOS-5.5 EOS-3.1 BASOS-0.5 [**2173-7-25**] 09:15PM PLT COUNT-700*# CK 42 --> 35 Tn-T 0.05 --> <0.01 Brief Hospital Course: Mr. [**Known lastname 109820**] is a 48M with a PMH s/f HOCM s/p myomectomy, HTN, hyperlipidemia, chronic atypical chest pain, who is presenting with atypical chest pain. . # Chest pain: The patient has multiple reasons for chest pain: post-op pain from his recent septal myomectomy, pericarditis secondary to recent heart surgery or mid-LAD vessel myocardial bridge. Unlikely to be ACS as the patient had a clean cath in [**Month (only) **]. While admitted we treated his chest pain with ultram and tylenol. Due to concern for pericarditis, he underwent a TTE which showed no pericardial effusion. During his stay, his pain improved and he was discharged home with ultram for continued pain control and follow up with his primary doctor and cardiologist. . # CORONARIES: Unlikely ACS as above, clean coronary artieries seen in [**Month (only) **]. The patient was continued on ASA. . # PUMP: EF preserved, no signs of volume overload on exam. . # Episode of bloody bowel movement: The patient had one epsisode of a formed bowel movement with bright red blood around the stool. No other signs of active bleeding. His VS and Hct remained stable. The patient states he had a colonoscopy > 10 years ago. Will have the patient follow up with his primary doctor. Have avoided NSAIDs due to concern for GI bleeding. He will need another colonoscopy in the near future. . # RHYTHM: HX of SVT s/p ICD. The patient was monitored on telemetry and remained in sinus rhythm with occasional episodes of tachycardia during his admission. Metoprolol was continued. . # Tobacco use: The patient was counseled about smoking cessation and has a plan to continue to decrease the number of cigarettes he smokes per day each month. Medications on Admission: MEDICATIONS: Docusate Sodium 100 mg [**Hospital1 **] Aspirin 81 mg daily Pantoprazole 40 mg [**Hospital1 **] Thiamine HCl 100 mg daily Folic Acid 1 mg daily Hydromorphone 2 -4mg every 4hrs prn Metoprolol Tartrate 50 mg [**Hospital1 **] Multivitamin Furosemide 20 mg [**Hospital1 **] for two weeks Potassium Chloride 20 mEq [**Hospital1 **] for one week Ibuprofen 600 mg q8H prn Discharge Medications: 1. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule 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. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*24 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary - Atypical chest pain Secondary - Hypertension Hypertrophic obstructive cardiomyopathy status post myomectomy Discharge Condition: Stable with continued chest discomfort. Discharge Instructions: You were admitted to the hospital with chest pain. You had an echo which showed no pericardial effusion (build up of fluid around your heart). While here you had an episode of blood in your stool. You should follow up with your primary doctor and consider getting a colonoscopy. You were started on ultram every 4 hours as needed to control your chest pain. Otherwise continue your outpatient medications as prescribed. Please stop smoking. Information was given to you on admission regarding smoking cessation. Go to the emergency room if you experience chest pain or shortness of breath. Followup Instructions: We made a follow up appointment for you with your primary doctor, Dr. [**First Name (STitle) 3441**]. The appointment is located at the [**Hospital Ward Name 23**] building on the 6th Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2173-8-30**] 2:30. Please keep your previously scheduled appointments: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2173-9-9**] 4:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2173-11-11**] 4:00 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**] Completed by:[**2173-7-28**]

[ "425.1", "427.1", "401.9", "512.1", "745.5", "V45.02", "E878.8", "530.81", "272.4" ]

icd9cm

[ [ [] ] ]

[ "39.61", "37.33", "34.04" ]

icd9pcs

[ [ [] ] ]

17377, 17435

14429, 16154

8655, 8661

17598, 17640

11667, 14406

18284, 19128

10751, 10875

16582, 17354

4614, 4655

17456, 17577

16180, 16559

17664, 18261

10890, 11648

10034, 10150

8605, 8617

4687, 4986

8689, 9940

10181, 10565

9962, 10014

10581, 10735

31,569

164,510

51607

Discharge summary

report

Admission Date: [**2123-9-29**] Discharge Date: [**2123-10-22**] Date of Birth: [**2071-2-5**] Sex: M Service: MEDICINE Allergies: Dilantin Attending:[**First Name3 (LF) 2167**] Chief Complaint: alcohol Withdrawal Major Surgical or Invasive Procedure: Femoral triple lumen catheter placement History of Present Illness: Patient is a 52 yo male who left the ICU earlier this evening AMA. He was being treated for etoh withdrawal prior to his departure. . He was found in the halls of his apartment building covered in feces and urine; he told police he felt lousy. In the ED a femoral line was placed for access. He was given Valium 10 mg IV, potassium 20 mg and mag 2 gm. Head CT and CXR were unremarkable. he was admitted to hte MICU due to persistant tachycardia and concern for EtOH withdrawal. Past Medical History: Alcohol abuse H/o MI 7 years ago Hypertension Hepatitis C Virus History of a positive PPD in [**5-19**] Asymptomatic bradycardia Depression Anxiety COPD GERD Hiatal Hernia Social History: Patient has a 40 pack year history of smoking. Drinks mutiple bottles of alcohol daily. Denies any drug use or history of IVDA. He lives in pine street shelter. Family History: Denies any significant family history. Physical Exam: VS: RR 16, HR 107, BP 148/112, O2Sat 94% RA Gen: moaning, cursing, 4 point restraints HEENT: pupils 4 mm, equal and reactive to light CV: Tachycardic, no m/r/g Pulm: Clear anteriorly Abd: soft, NT, ND, bowel sounds present Ext: no peripheral edema, 4 point restraints Neuro: moving all extremities, following commands, AxOx3 Pertinent Results: [**2123-9-29**] 01:15AM PLT COUNT-213 [**2123-9-29**] 01:15AM NEUTS-71.7* LYMPHS-23.2 MONOS-4.4 EOS-0.3 BASOS-0.4 [**2123-9-29**] 01:15AM WBC-9.1# RBC-4.92 HGB-14.7 HCT-42.5 MCV-86 MCH-30.0 MCHC-34.7 RDW-13.7 [**2123-9-29**] 01:15AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG [**2123-9-29**] 01:15AM CK-MB-3 [**2123-9-29**] 01:15AM LIPASE-32 [**2123-9-29**] 01:15AM ALT(SGPT)-92* AST(SGOT)-62* CK(CPK)-239* ALK PHOS-100 TOT BILI-0.3 [**2123-9-29**] 01:15AM GLUCOSE-116* UREA N-20 CREAT-0.9 SODIUM-144 POTASSIUM-2.9* CHLORIDE-102 TOTAL CO2-33* ANION GAP-12 [**2123-9-29**] 01:29AM cTropnT-<0.01 CT HEAD TECHNIQUE: Contiguous axial images of the head were obtained without IV contrast; several sections were degraded by patient motion artifact, and were repeated. FINDINGS: There is no intra- or extra-axial hemorrhage, edema, mass effect, shift of normally midline structures, or acute major vascular territorial infarction. The ventricles and sulci are mildly prominent, likely reflecting atrophy. Visualized paranasal sinuses revealed mucosal thickening of the right maxillary sinus. Noted are burr holes in the left parietal and frontal bones, as before. IMPRESSION: No acute intracranial process. CXR PORTABLE SUPINE CHEST, ONE VIEW: The heart is normal in size. Atherosclerotic calcifications of the aorta are present. Otherwise, cardiomediastinal and hilar contours are unremarkable. Lung volumes are low. Lungs are clear without consolidation or pulmonary edema. There is no pleural effusion. Osseous structures are unremarkable. IMPRESSION: No acute cardiopulmonary process. Brief Hospital Course: Mr. [**Known lastname 7168**] is a 52 yo male with alcohol abuse, here for alcohol.benzo withdrawal within three hours of being discharged AMA from MICU. He was found in his apartment building running in the halls naked, intoxicated, and covered in feces. He was brought in by the police. . 1. Alcohol withdrawal. The patient presented in alcohol/benzo withdrawal. He was started on folate, thiamine and a multivitamin. He was given diazepam per hourly CIWA. He required a 1:1 sitter and restraints for safety. However, following large amounts of benzos (>200 mg of Valium) the patient remained agitated, tachycardic, and delerious. At that point, we became concerned that the patient may have developed benzo intoxication. Psychiartry was consulted. He was started on PRN haldol for agitation and benzos were discontinued on [**10-1**]. The patient remained acutely agitated and assaulted staff on numerous occasions. He required a security sitter and was placed in seclusion. Psychiatry suggested that his acute agitation could possibly be secondary to keppra, for which there are case reports citing aggressive behavior in the setting of keppra for seizure prophylaxis. However, his delerium and acute agitation could have also resulted secondary to benzo withdrawal, of note his urine was positive for benzodiazapine several days after stopping these medications. With neurology consultation, his keppra was tapered off and he was started on neurontin. His delerium slowly resolved over the course of his stay. The haldol was tapered off while in house. . 2. CAD: through history, the patient was intially thought to have a history of an MI, however, medical records obtained showed normal LV and RV function on echo. A previous excercise test in [**2120**] showed no evidence of flow limiting CAD. Noted were frequent PVCs. He was continued on his BB, HCTZ and an aspirin. . 3. hypertension: continued on home dose of hctz and metoprolol was added. . 4. Agitation/Psych. The patient was initially continued on his home psychiatric medication regimen- buspar, trazodone, remeron. However, with psychiatric consultation his regimen was simplified. He required haldol and zyprexa for agitation; psychiatry followed and assisted with his medication adjustments. The haldol was tapered off while in the hospital. . 5. chronic back pain: Mr. [**Known lastname 7168**] required prn doses of oxycodone for his radicular back pain. He has a history of SDH and was told not to take aspirin. . 6. Insomnia: trazadone prn Medications on Admission: Advair 500/50 [**Hospital1 **] prilosec 20 [**Hospital1 **] keppra 500 [**Hospital1 **] buspar 15 [**Hospital1 **] chantix 1 [**Hospital1 **] trazodone 300 hs hctz 25 daily lactaid with meals remeron 15 hs Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 2. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Trazodone 100 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime) as needed. Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] house Discharge Diagnosis: delerium alcohol abuse hypertension hepatitis c history of positive ppd depression anxiety reflux hiatal hernia Discharge Condition: baseline mental status. ambulating at baseline. Discharge Instructions: you were admitted for alcohol withdrawal. During your hospital stay became acutely confused and delerious. Overtime your symptoms improved. . we stopped your keppra, remeron, buspar. Do not restart these medications without consulting with your doctors. . Currently your seizure disorder is being treated with neurontin. . Followup Instructions: you have an appointment to see [**First Name8 (NamePattern2) 19267**] [**Last Name (NamePattern1) 84796**], NP on [**12-17**] at 8:30am at [**Location (un) **]. [**Location (un) 86**], MA. Alternatively, you can go in for a walk in appointment M-F 8am to 4:30pm. Completed by:[**2123-10-22**]

[ "292.81", "518.0", "300.00", "518.89", "530.81", "291.81", "338.29", "348.30", "345.90", "303.00", "E936.3", "296.32", "414.01", "305.1", "070.54", "292.0", "496", "E939.4", "780.52", "553.3", "704.8", "729.2" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

6935, 7033

3289, 5814

288, 329

7189, 7239

1628, 3266

7612, 7907

1227, 1267

6071, 6912

7054, 7168

5840, 6048

7263, 7589

1282, 1609

230, 250

357, 837

859, 1033

1049, 1211

13,133

132,302

14610

Discharge summary

report

Admission Date: [**2101-8-5**] Discharge Date: [**2101-8-8**] Date of Birth: [**2047-10-15**] Sex: M Service: CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 53-year-old gentleman status post myocardial infarction in [**2099**] with stent and angioplasty in [**2099**], angioplasty in [**2100**] and angioplasty [**2101**] who presents with chest pain. Cardiac catheterization was performed which revealed 70% left anterior descending disease and an occluded right coronary artery. Ejection fraction 25% Mr. [**Known lastname **] was subsequently evaluated for cardiac surgery. PAST MEDICAL HISTORY: As above. Also meniscectomy on the left in [**2069**]. FAMILY HISTORY: Remarkable for father who passed away from coronary artery disease. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Coumadin 2.5 mg q day. 2. Lopressor 25 mg b.i.d. 3. Lipitor 10 mg q day. 4. Aspirin 81 mg q day. PHYSICAL EXAMINATION: The patient is afebrile, vital signs stable. He is well appearing male in no distress. Head is normocephalic, atraumatic. Neck is supple with no jugular venous distention. His lungs were clear to auscultation bilaterally. His heart is regular rate and rhythm without murmur. Abdomen is soft and nontender with normal active bowel sounds. Extremities are without clubbing, cyanosis or edema. HOSPITAL COURSE: Mr. [**Known lastname **] was taken to the operating room on [**2101-7-6**] for coronary artery bypass graft times two. Graphs included left internal mammary artery to left anterior descending, and SVG to PL. The procedure was performed without complication and Mr. [**Known lastname **] was subsequently transferred to the CSRU. In the Unit he was extubated, weaned off drips and fluid resuscitated. He was transferred to the floor on the evening of postop day one. His status continued to improve. He was tolerating oral diet and his pain was controlled with oral medications. He was ambulating well without assistance. On [**2101-8-8**] Mr. [**Known lastname **] was felt stable for discharge home. PHYSICAL EXAMINATION: At discharge vital signs temperature 99.1, pulse 77, Blood pressure 108/60, respirations 18, O2 sat 92% on room air. His heart is regular rate and rhythm. Lungs are clear to auscultation bilaterally. His incision is clean, dry and intact. His abdomen is soft, nontender and nondistended. Normal active bowel sounds. Extremities were without clubbing, cyanosis or edema. DISCHARGE MEDICATIONS: 1. Lisinopril 5 mg q day. 2. Metoprolol 25 mg b.i.d. 3. Aspirin entericoated 325 mg q day. 4. Vicodin 1 to 2 tabs q 4 to 6 hours p.r.n. 5. Colace 100 mg b.i.d. 6. Lipitor 10 mg q day. 7. Coumadin 2.5 mg q day six days a week. FOLLOW-UP: Mr. [**Known lastname **] is to follow-up with Dr. [**Last Name (STitle) **] in four weeks and Dr. [**Last Name (STitle) **] in 3 to 4 weeks. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: Mr. [**Known lastname **] is to be discharged home. DIAGNOSIS: 1. Status post coronary artery bypass graft times two. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2101-8-8**] 15:23 T: [**2101-8-8**] 12:58 JOB#: [**Job Number **]

[ "V45.82", "414.00", "411.1", "412" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

2948, 3356

742, 966

2537, 2926

1405, 2115

2138, 2514

148, 161

190, 645

668, 725

31,134

158,222

47419

Discharge summary

report

Admission Date: [**2145-4-22**] Discharge Date: [**2145-4-25**] Service: MEDICINE Allergies: Zocor Attending:[**First Name3 (LF) 2745**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: Intubation History of Present Illness: [**Age over 90 **] yo female with PMH below who presented from NH with worsening mental status and hypoxia to 70s. In [**Name (NI) **], pt was intubated for airway protection. Head CT negative for bleed. Ct revelaed RLL collapse and possible PNA. Of note, the patient was DNR/DNI, but her documentation was not reportedly sent with her from her NH. Past Medical History: Stage IV chronic kidney disease due to both arteriolar nephrosclerosis and renal artery stenosis Hypertension Chronic compression fractures Lumbar stenosis Hypercholesterolemia Macular edema Left intertrochanteric fracture and left proximal humerus fracture in 06/96. Peptic ulcer disease. Status post appendectomy. Status post ovarian cyst. Social History: No current tobacco use history; however, the patient smoked for approximately 50 years, [**11-3**] cigarettes a day. No history of alcohol abuse. Retired, office worker at [**Last Name (un) **]. She is divorced and has two adopted children. Family History: Coronary heart disease in both parents, diabetes mellitus in one brother, CVA in one sister, and cancer in one sister. Physical Exam: Vitals: BP 128/58 HR 107 RR 23 100% AC 400 20 40% PEEP Intubated, sedated. HEENT: MMM Neck: Supple, no JVD CV Tachy, RR. no m,r,g Abd: Soft, NT, ND Ext: no edema Pertinent Results: [**2145-4-22**] 03:49PM TYPE-ART O2-40 PO2-62* PCO2-41 PH-7.26* TOTAL CO2-19* BASE XS--8 INTUBATED-INTUBATED VENT-SPONTANEOU [**2145-4-22**] 06:27AM WBC-24.1* RBC-3.39* HGB-9.6* HCT-32.3* MCV-95 MCH-28.2 MCHC-29.6* RDW-17.2* [**2145-4-21**] 08:55PM WBC-37.7*# RBC-3.98* HGB-10.7* HCT-36.9 MCV-93 MCH-27.0 MCHC-29.1* RDW-17.2* Brief Hospital Course: Hypoxemia) Likely secondary to RLL collapse and pneumonia. Patient's family wanted patient made CMO and patient was transferred to the medical floor where she expired secondary to respiratory failure at 7:05 am on [**2145-4-25**]. Leukocytosis) Per above. ARF on CKD) Patient ahd CR of 4 on baseline 2.3-3. Demand ischemia) made CMO HTN, benign) Systolic CHF, chronic) CMO, expired in hospital per above. Medications on Admission: Per [**4-12**] D/C summary Discharge Medications: Patient expired Discharge Disposition: Expired Discharge Diagnosis: Hypoxemia Pneumonia ARF Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None

[ "V66.7", "403.90", "V17.3", "V15.82", "518.81", "410.71", "507.0", "272.0", "584.9", "585.4", "995.90", "294.8", "V18.0", "428.0", "786.6", "428.42" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.56", "33.23", "96.71" ]

icd9pcs

[ [ [] ] ]

2460, 2469

1930, 2343

221, 233

2536, 2545

1574, 1907

2598, 2605

1256, 1377

2420, 2437

2490, 2515

2369, 2397

2569, 2575

1392, 1555

174, 183

261, 614

636, 980

996, 1240

72,819

109,463

42894

Discharge summary

report

Admission Date: [**2150-11-11**] Discharge Date: [**2150-11-16**] Date of Birth: [**2104-10-1**] Sex: M Service: CARDIOTHORACIC Allergies: General Anesthesia / phenobarbital / Pentobarbital Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea and Chest pain Major Surgical or Invasive Procedure: [**2150-11-12**]: Coronary artery bypass grafting x3: Left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the first marginal branch and diagonal branch. History of Present Illness: 46 year old male with type 1 diabetes on an insulin pump, hypertension, and hypercholesterolemia, with admission to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**11-2**] with chest pain and mild dyspnea. The chest pain initially started on Sunday radiating across chest and under axilla. This persisted all night and by Monday it was radiating to his left collar bone and down left arm with left 5th digit numbness. Ruled out for MI. Gated study revealed LVEF of 41% with global hypokinesis with no areas of ischemia or infarct. It was initially thought that his CP was non-cardiac and he was sent home on percocet, but when he tried to return to work, he became very short of breath and diaphoretic. He then contact[**Name (NI) **] her primary MD who sent him to see Dr. [**Last Name (STitle) 77919**]. He was sent to the [**Hospital1 **] where he had a cardiac cath that showed multivessel disease and was referred for surgical evaluation However, he and his wife have been anxious at home and over the past day, he notes slightly more dyspnea at rest. He also has had continuous CP since his d/c. He contact[**Name (NI) **] cardiac surgery who asked that he come to the ED. In the ED, his HR and bp were well controlled, and his pain improved from [**5-15**] to [**3-15**] with SL nitro. He was still slightly dyspneic at rest. Denies PND, edema, leg swelling, h/o DVTs or PEs. ROS otw neg in detail. Past Medical History: Type I DM diagnosed on [**2140-8-16**], on insulin pump HTN Hypercholesterolemia Seizure as a child in the setting of fevers only Past Surgical History S/p Lap Cholecystectomy [**2148**] Social History: He is married and lives with his wife in [**Name (NI) 20935**] MA. He has four children ages [**9-25**]. He works full time as an operator at sewage treatment center. Denied any tobacco and alcohol Family History: Father with CABG at age 58. Paternal grandfather died of MI at age 52. Maternal grandfather died of HF at age 79. Maternal uncle died of Ventricular Fibrillation at age 49. Another maternal uncle died during valve replacement surgery in his mid 50's. Physical Exam: Physical Exam Pulse: 67 Resp:18 O2 sat:100 B/P Right:107/60 Left: Height:5 feet 9.5 inches Weight: 201 pounds General: Skin: Dry and intact HEENT: PERRLA, EOMI. Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally Heart: JVP < 5 cm. PMI focal. Nl S1, S2. No S4. No m. Abdomen: Soft, non-distended and non-tender. Extremities:No edema. Warm and well perfused. Neuro: Grossly intact Psych: Anxious but otherwise appropriate Pulses: Femoral Right:2+ Left:2+ DP Right:1+ Left:1+ PT [**Name (NI) 167**]:1+ Left:1+ Radial Right:2+ Left:2+ Pertinent Results: [**2150-11-10**]; CTA CHEST: The aorta is normal in caliber without acute pathology. The pulmonary arterial tree is well opacified to the subsegmental level, demonstrating no filling defects to suggest pulmonary embolism. The heart is normal in size without pericardial effusion. Multivessel coronary arterial calcifications are present. There is no mediastinal, hilar, or axillary adenopathy by size criteria. The lungs are clear with the exception of bibasilar dependent atelectasis. Central airways are patent. BONE WINDOW: No focal concerning lesion. Limited subdiaphragmatic evaluation demonstrates a 12-mm interpolar exophytic left renal cyst. The spleen is mildly enlarged to 14 cm. IMPRESSION: 1. No acute aortic pathology or pulmonary embolism. 2. Borderline splenomegaly to 13-14 cm, clinical significance unclear. [**2150-11-15**] 05:49AM BLOOD WBC-6.6 RBC-3.32* Hgb-9.8* Hct-28.1* MCV-85 MCH-29.5 MCHC-34.8 RDW-12.4 Plt Ct-132* [**2150-11-14**] 05:06AM BLOOD WBC-6.7 RBC-3.40* Hgb-10.0* Hct-27.8* MCV-82 MCH-29.3 MCHC-35.8* RDW-12.2 Plt Ct-125* [**2150-11-15**] 05:49AM BLOOD Glucose-173* UreaN-14 Creat-1.1 Na-136 K-4.0 Cl-101 HCO3-31 AnGap-8 [**2150-11-14**] 03:00PM BLOOD Glucose-237* UreaN-19 Creat-1.2 Na-135 K-4.0 Cl-100 HCO3-30 AnGap-9 [**2150-11-14**] 05:06AM BLOOD Glucose-123* UreaN-20 Creat-1.3* Na-133 K-4.4 Cl-101 HCO3-28 AnGap-8 Brief Hospital Course: Mr. [**Known lastname **] is a 46 year-old male with type I DM with left main equivalent CAD was admitted with acute chest pain and and marked dyspnea at rest. His chest pain was somewhat atypical given his essentially normal EKG and prev neg troponins however given his coronary anatomy and improvement of his chest pain and dyspnea on Nitro he was admitted to the MICU for presumed subendocardial ischemia. He was followed by [**Hospital **] Clinic for his type I Diabetes and insulin pump. On [**2150-11-12**] he was taken to the operating room with cardiac surgery for Coronary Artery Bypass Graft surgery. See operative report for further details. Overall the he tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. He was extubated on post operative night, alert, oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support on POD 1. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. His insulin pump was restarted which he managed himself. He transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD four he was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The he was discharged home with services in good condition with appropriate follow up instructions Medications on Admission: INSULIN ASPART [NOVOLOG] - (Prescribed by Other Provider) - 100 unit/mL Solution - insulin pump 12 0.925 units per hour, 3am 1.4 unit hr, 5am 0.65 units, 7a 0.6 units her hour, 12pm 0.4 units per hour, 6pm 0.65 units per, 8pm 0.8 units her hour. LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - 1 (One) Tablet(s) by mouth once a day OXYCODONE-ACETAMINOPHEN - (Prescribed by Other Provider) - 5 mg-325 mg Tablet - 1 Tablet(s) by mouth every four hours as needed for chest pain SIMVASTATIN - (Prescribed by Other Provider) - 80 mg Tablet - 1 (One) Tablet(s) by mouth once a day Medications - OTC ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Chewable - 1 (One) Tablet(s) by mouth once a day Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 3. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*1* 4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 5. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 7 days. Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*0* 6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*1* 8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 9. insulin pump Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Coronary Artery Disease s/p CABG Diabetes Mellitus Type I on insulin pump Hypertension Hypercholesterolemia Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with Percocet Sternal Incision - healing well, no erythema or drainage Left leg EVH no erythema or drainage Edema +1 bilateral lower extremities Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please follow up with outpatient endocrinology for blood glucose management goal 100-130 **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] Tuesday [**11-24**] at 10:30 am Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2150-12-16**] 1:00 Location: [**Hospital Unit Name **] [**Last Name (NamePattern1) **] [**Hospital Unit Name **] Cardiologist Dr. [**Last Name (STitle) 92599**] [**Telephone/Fax (1) 65733**] - Wednesday [**12-23**] at 2pm Please call to schedule the following: Primary Care Dr. [**First Name (STitle) 1661**] [**Telephone/Fax (1) 79522**] in [**3-10**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2150-11-16**]

[ "285.9", "250.01", "V58.67", "458.29", "411.1", "272.4", "414.01", "V45.01" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8160, 8243

4713, 6343

344, 543

8395, 8618

3331, 4690

9424, 10209

2450, 2703

7111, 8137

8264, 8374

6369, 7088

8642, 9401

2718, 3312

281, 306

571, 2007

2029, 2218

2234, 2434

30,071

199,383

16062

Discharge summary

report

Admission Date: [**2203-7-26**] Discharge Date: [**2203-8-1**] Date of Birth: [**2136-7-10**] Sex: M Service: MEDICINE Allergies: Bacitracin / Aminoglycosides / Neomycin / opthalmic ointments Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: HD line History of Present Illness: 67 M h/o CHF, CABG, DM, CVA, kidney transplant at [**Hospital1 18**] p/w progressive SOB x 2 months, acutely worse x4-5 days. SOB occurs at rest, worse with exertion. Endorses chronic cough, no fevers, chills. Denies CP. Seen at BIDN where he was found to have troponin elevation to 0.5 which was felt to be demand. He was transferred to [**Hospital1 18**] for further cardiac & nephrology evaluation. Felt to have CHF exacerbation at BIDN, given 80 mg lasix & ASA 162 mg. CXR at BIDN showed pulmonary edema, no consolidative process. Renal saw patient in ED, Dr. [**Last Name (STitle) **] will follow as consulting attending. In terms of his renal disease, the patient had a biopsy several months ago for worsening creatinine which was negative for rejection. In the ED, the patient initially wanted to leave AMA but his wife would not come pick him up. They are frustrated that he was not directly admitted. Of note, the patient's wife was just recently diagnosed with breast cancer and is having staging done. Cardiology was consulted and they believed likely NSTEMI, b/c trop out of proportion to [**Last Name (un) **]. Started IV heparin in ED. Pt refused rectal exam, explained risks. Atorvastatin 80 mg received in ED. Patient received 164 mg ASA at [**Hospital1 **]. NPO after MN for possible cath. Vitals at time of admission 99.1 92 132/56 25 96% On my interview, the patient reports that he is feeling better and that his breathing is improved but he cannot make it though a sentence without being short of breath or snorting to open up his airways. He minimizes his symptoms but says that his wife reports he's been making much more noise breathing, especially at night. He says this morning was the worst day in terms of his over breathing. He also has painful legs, but says they have been that way since a stroke several years ago. He denies any chest pain. He again denies any dyspnea when lying down, though he does have dyspnea with exertion. He denies palpitations. Past Medical History: Hypertension Diabetes Mellitus w/ Retinopathy (legally blind) Carotid Artery Disease End Stage Renal Disease s/p Renal Transplant [**2196**] c/b delayed graft function and wound healing Obesity Osteoporosis CVA - with residual right sided deficits (per patient, difficulty moving/controlling right hand, intermittent feeling of "coldness" on right side) s/p Bilat. Victrectomies s/p Cataract surgery s/p AV Fistula placement GERD Social History: Married, lives with wife. [**Name (NI) **] tobacco, rare alcohol, no IVDU Family History: Colon CA, sibling with lymphoma. Sister with DM Physical Exam: ADMIT VS: T=99.6 BP=141/78 HR=102 RR=24 O2 sat=96% 3L GENERAL: Obese in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric and without injection. PERRL, EOMI. Conjunctiva were pink; no pallor or cyanosis of the oral mucosa. Oropharynx clear and without erythema or exudate. NECK: Supple, JVP unable to be determined due to habitus CARDIAC: Heart sound sdifficult to hear, distant. RR, normal S1, S2. No m/r/g. LUNGS: No chest wall deformities, scoliosis or kyphosis. Labored breathing with upper respiratory sounds, CTAB, faint crackles at bases. ABDOMEN: Soft, NTND, bowel sounds positive. EXTREMITIES: Lower extremities with mild edema, right lower leg tender to touch, flaky, dry skin in patches on lower extremities. Scars from saphenous vein harvesting. SKIN: No stasis dermatitis. PULSES: Right: Carotid 2+ Radial 2+ DP 2+ Left: Carotid 2+ Radial 2+ DP 2+ DISCHARGE: Expired Pertinent Results: ADMIT: [**2203-7-26**] 07:20PM URINE HOURS-RANDOM CREAT-42 TOT PROT-67 PROT/CREA-1.6* albumin-44.6 alb/CREA-1061.9* [**2203-7-26**] 06:15PM GLUCOSE-114* UREA N-53* CREAT-2.6* SODIUM-140 POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-16* ANION GAP-21* [**2203-7-26**] 06:15PM estGFR-Using this [**2203-7-26**] 06:15PM CK(CPK)-283 [**2203-7-26**] 06:15PM cTropnT-0.70* [**2203-7-26**] 06:15PM CK-MB-20* MB INDX-7.1* [**2203-7-26**] 06:15PM WBC-8.1# RBC-3.43* HGB-9.3* HCT-29.1* MCV-85 MCH-27.1 MCHC-32.0 RDW-14.8 [**2203-7-26**] 06:15PM NEUTS-80.3* LYMPHS-10.1* MONOS-6.9 EOS-2.0 BASOS-0.6 [**2203-7-26**] 06:15PM PLT COUNT-234 [**2203-7-26**] 06:15PM PT-12.7* PTT-30.8 INR(PT)-1.2* DischargE: EXPIRED Brief Hospital Course: 67-year-old man with a complicated medical history that includes renal transplant and CABG who presented with worsening dyspnea and likely has an NSTEMI. . ## The patient was initially admitted to the cardiology floor service due to history of CAD (s/p CABGX4 in [**2197**]) and based on patient's elevated troponins and EKG changes, he likely had NSTEMI. Troponins 0.70 here up from reported 0.59 at outside hospital, CKMB downtrended. He was medically managed with ASA, Statin, Plavix, Beta blocker. ACEI/[**Last Name (un) **] was held given worsening renal function. An echo was done that showed worsening systolic function EF 25-30%. Pt was in sinus rhythm on the floor. The patient's systolic pressures were 90s/60s on the floor and given his worsening renal function (Cr up to 4.6 on the floor), decision was made to transfer patient to CCU for pressors with Dobutamine to increase inotropy and renal perfusion. In the CCU the patient's MAP continued to worsen with Dobutamine so pt was switched to Norepinephrine to maintain MAP > 60. The patient's renal function did not improve in the CCU and the patient was scheduled for dialysis. Unfortunately overnight the patient expired, please see note below about the details of that event. .. ## CCU DEATH NOTE - On [**2203-8-1**] at 2:30 AM CCU intern was notified by the nurse about patient??????s nausea. I saw the patient at the bedside. He complained of some nausea that resolved after one dose of Zofran. Furthermore, he denied any pain, including lack of chest pain, no shortness of breath and no diaphoresis. The patient was oriented x 3, patient??????s mental status was at his baseline and he was interacting appropriately. At that time his heart exam was unchanged from earlier in the day, and his lungs sounded clear, warm and well perfused and non toxic appearing. I spoke with the patient for about 15 minutes and confirmed that he was comfortable at that time. At 3:30am I was again notified by the nurse about the patient??????s labored breathing. I evaluated the patient. He now looked significantly worse than at 2:30 am. His breathing was labored with respiration rate in the 30s. He was diaphoretic and visibly uncomfortable. The patient denied chest pain but did confirm difficulty breathing. I notified my senior resident and the cardiology fellow at this time. An EKG was done and the patient received one nebulizer treatment, followed by check of Chem 7, VBG, lactate. The patient??????s respiratory rate continued to increase, blood pressures were variable with some 160s/100s and others 90s/60s by cuff. A non rebreather was started, and Anesthesia was stat notified. EKG returned that showed a new left bundle branch block that was not on his prior EKGs. The patient was intubated at this point as he was in significant respiratory distress. The patient??????s telemetry strip showed new onset Ventricular ectopy followed by Vfib arrest. Chest compressions and a full code were initiated at this time. The patient??????s wife was made aware of the life threatening status and that he was pulseless with active CPR. The code was called at 4:25 and patient was pronounced dead at 4:56 am after multiple shocks, and multiple rounds of anti-arrhythmics. There was no ROSC during the full code. Please see the code med list for details of medications received and at what time. The patient??????s wife was notified of her husband??????s death and she decided not to come in today, she did want an autopsy. Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from webOMR. 1. Sulfameth/Trimethoprim SS 1 TAB PO DAILY Start: In am 2. Valsartan 80 mg PO DAILY Start: In am Hold for SBP < 100. 3. Furosemide 40 mg PO DAILY Start: In am Hold for SBP < 100. 4. Escitalopram Oxalate 20 mg PO DAILY Start: In am 5. Clopidogrel 75 mg PO DAILY Start: In am 6. Sirolimus 1.5 mg PO DAILY Start: In am Daily dose to be administered at 6am 7. Ezetimibe 10 mg PO DAILY Start: In am 8. Mycophenolate Mofetil 1000 mg PO BID Start: In am 9. Simvastatin 10 mg PO DAILY Start: In am 10. Metoprolol Tartrate 25 mg PO BID Start: In am 11. Glargine 50 Units Bedtime Discharge Medications: pt expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired Completed by:[**2203-8-1**]

[ "785.51", "584.9", "996.81", "427.41", "276.4", "401.9", "E878.0", "428.23", "362.01", "427.1", "410.71", "733.00", "438.89", "250.50", "428.0", "728.89", "272.0", "285.21", "V45.81", "327.23", "426.3" ]

icd9cm

[ [ [] ] ]

[ "39.95", "96.04", "99.60", "38.95" ]

icd9pcs

[ [ [] ] ]

8912, 8921

4649, 8134

337, 346

8972, 8981

3914, 4626

9037, 9074

2924, 2974

8877, 8889

8942, 8951

8160, 8854

9005, 9014

2989, 3895

290, 299

374, 2362

2384, 2816

2832, 2908

18,954

192,559

13930

Discharge summary

report

Admission Date: [**2158-5-22**] Discharge Date: [**2158-6-9**] Date of Birth: [**2089-3-28**] Sex: F Service: SURGERY Allergies: Maxitrol Attending:[**First Name3 (LF) 17683**] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: CT guided placement of pigtail catheter [**2158-5-29**] Cardiac catheterization without stent placement [**2158-6-8**] History of Present Illness: 69yo F who presented to her OB/GYN physician with [**Name Initial (PRE) **] 3 day h/o abdominal pain with nausea/vomiting, fever but no chills, diarrhea. Had last BM 3 days prior to presentation with no changes, no blood/melena/BRBPR. Past Medical History: Afib, Asthma, Glaucoma, sleep apnea, RA, fibromyalgia, h/o R ovarian cyst, CHTN, sigmoid diverticulae PSurgHx- LCEA, appy, hysterectomy, NSVDx3 Social History: NC Family History: NC Physical Exam: On Admission: T-101.3, HR-110 in Afib, BP 88/60 Head intact Abd soft, tender out of proportion to PE Rectal exam shows stool in vault but no gross blood Pertinent Results: [**2158-5-22**] 12:09PM URINE RBC-2 WBC-8* BACTERIA-NONE YEAST-NONE EPI-<1 [**2158-5-22**] 12:09PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-50 BILIRUBIN-SM UROBILNGN-NEG PH-6.0 LEUK-TR [**2158-5-22**] 12:09PM URINE COLOR-LtAmb APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2158-5-22**] 12:09PM PT-13.1 PTT-26.0 INR(PT)-1.1 [**2158-5-22**] 12:09PM PLT COUNT-220 [**2158-5-22**] 12:09PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL [**2158-5-22**] 12:09PM NEUTS-88* BANDS-5 LYMPHS-6* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2158-5-22**] 12:09PM WBC-10.8 RBC-3.63* HGB-11.9* HCT-35.6* MCV-98 MCH-32.7* MCHC-33.4 RDW-16.4* [**2158-5-22**] 12:09PM CALCIUM-9.0 PHOSPHATE-2.5* MAGNESIUM-1.8 [**2158-5-22**] 12:09PM CK-MB-14* MB INDX-11.7* cTropnT-0.08* [**2158-5-22**] 12:09PM LIPASE-41 [**2158-5-22**] 12:09PM ALT(SGPT)-16 AST(SGOT)-30 CK(CPK)-120 AMYLASE-62 [**2158-5-22**] 12:09PM GLUCOSE-73 UREA N-23* CREAT-1.1 SODIUM-130* POTASSIUM-3.6 CHLORIDE-95* TOTAL CO2-24 ANION GAP-15 [**2158-5-22**] 01:56PM LACTATE-1.58 [**2158-5-22**] 03:52PM FIBRINOGE-631* [**2158-5-22**] 03:52PM PT-14.7* PTT-31.2 INR(PT)-1.3* [**2158-5-22**] 03:52PM PLT COUNT-153 [**2158-5-22**] 09:36PM CK(CPK)-332* [**2158-5-22**] 09:36PM CK-MB-45* MB INDX-13.6* cTropnT-0.72* [**5-22**] CT A/P: Moderate amount of free air in the abdomen likely due to perforated acute sigmoid diverticulitis. No CT evidence of duodenal perforation. Gallstones and a distended gallbladder. Small amount of fluid in the right colic gutter. Severe atherosclerotic disease of the aorta and its main branches with a small left kidney secondary to renal artery stenosis. There is also severe atherosclerotic disease at the origin of the SMA and celiac. However, these vessels are still patent. Large cystic mass within the right ovary. Further evaluation is necessary with pelvic ultrasound to exclude an ovarian malignancy [**5-22**] KUB: Pneumoperitoneum [**5-23**] ECHO: Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. [**5-26**] UGI: No evidence of extravasation of contrast on this study which visualizes through to the second portion of the duodenum [**5-26**] KUB: Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. [**5-28**] CT Abd/Pelvis: Large pelvic abscess adjacent to the distal sigmoid colon. Sigmoid diverticulosis is also present. This likely represents a complication of sigmoid diverticulitis. 2. Small exophytic cyst in the interpolar region of the right kidney which measures 27 Hounsfield units. This should be further evaluated with ultrasound or MR since it does not show typical characteristics of a simple cyst. 3. Distended gallbladder with a small calcified stone in the neck. 4. Atrophic left kidney likely secondary to renal artery stenosis. 5. Severe atherosclerotic disease of the aorta and its main abdominal branches [**5-29**] CT Guided Drainage-Approximately 20 cc of bloody pus-like fluid was aspirated and sent to the lab for Gram stain and culture. The remainder of the fluid was left in the drainage bag.Successful placement of 8-French pigtail catheter drain within the right pelvic fluid collection. [**5-31**] CT A/P: Catheter within the pelvic abscess, which is smaller than on the prior study. Persistent stranding in the region of this abscess. No evidence of free intraperitoneal air at this time. 2. Bilateral small pleural effusions with associated atelectasis. Opacity in the left base not seen on the prior studies is likely inflammatory in nature. 3. Hypodensity in the dome of the liver is too small to characterize. 4. Hypodensity in the right kidney is not clearly a simple fluid attenuation and could be followed up with ultrasound. 5. Extensive atherosclerosis of the abdominal aorta and its branches [**6-5**] CT A/P:Relatively unchanged size of complex right pelvic collection intimately associated with small bowel, the right ovary, and the rectum. Drainage catheter is slightly pulled posteriorly, but still appears to be within the collection. Contrast material and gas tracking from the sigmoid colon to the inferior aspect of this collection suggests continued connection with the sigmoid colon to some portions of this collection. Correlation with catheter output is recommended to decide management of this drainage catheter. 2. Decrease size of pleural effusions with only minimal lung base atelectasis [**6-8**]: Coronary Angiography: was performed in multiple projections using a 6 French JL4 and a 6 French JR4 catheter, with manual contrast injections. Percutaneous coronary revascularization was performed using balloon angioplasty. Peripheral Catheter placement was performed: Pigtail catheter was used to perform abdominal and iliac angiography. Peripheral Imaging was performed of the abdominal aorta and the iliac vessels. Brief Hospital Course: Patient admitted to surgical service on [**2158-5-22**] following PE findings of distended mildly tender abdomen that demonstrated rebound but no guarding and radiological studies showing findings of free air. She was initially transferred to the SICU for serial abdominal exams and conservative management based on her multiple comorbidities. GEN: Patient originally febrile to 101.3 in [**Hospital1 18**] ED but defervesced at time of SICU acceptance. Remained afebrile until low grade fever of 101 on HD4, and fever of 101.7 on HD5 for which she was pan-cultured. Patient transferred to regular surgical floor on HD4 following ICU stabilization and resolution of tachypnea on [**5-24**]. NEURO: Patient had dilaudid pain control on admission, but had at home fentanyl patch resumed while hospitalized. Patient required little additional pain control CV: Patient aggressively resuscitated with 6L of crystalloid on presentation to hospital [**1-26**] hypotension (SBP in 70-80's and tachy into 110-120), and had A-line and CVL placed. Patient monitored for new-onset afib, which converted to SR following volume resuscitation. Patient ruled in on cardiac enzymes for MI. Cardiology was consulted and recommended continued ASA therapy, initiation of lopressor, and careful volume management (cardiac cath at some future time). Patient maintained stable blood pressure throughout remainder of ICU and surgical floor stay. Patient noted to enter into Afib on morning of HD7 that could not be rate-controlled after 4x 5mg IV lopressor and 10mg of IV diltiazem. The patient was transferred to the VICU on HD7 and placed on dilt gtt converting 4-5 hours after initiation. The patient was transitioned to IV lopressor on HD8 and monitored overnight to insure sinus rhythm maintenance. The patient relapsed into afib on HD8 and was moved back to the VICU for dilt gtt, converting to sinus rhythm after IV lopressor/IV dilt and dilt gtt. The patient was converted to PO lopressor on HD9 and remained in sinus rhythm but with cardiology recommendations was started on amiodarone; patient did not desaturate or drop pressure during these episodes, and did not rule in for another MI. Because of initial NSTEMI, patient underwent cardiac catheterization on [**6-8**] after having been started on plavix. Patient did not have catheter stent placed but was notable for severe bilateral iliac artery stenosis. RESP: Patient maintained stable oxygen saturations throughout hospitalization, and had albuterol nebs/inhalers available on PRN basis. Patient noted to be tachypneic into RR of 30's on [**5-24**] and was maintained in ICU for overnight observation, but was stable after this isolated episode for the remainder of her hospitalization GI: Patient placed NPO with IVF hydration, NGT placement to wall sxn. Patient had serial abdominal exams performed throughout HD1-HD2. Patient abdominal tenderness improved gradually with each hospital day and was noted to be nontender on PE on HD5. Patient had UGI performed on HD5 which showed no duodenal ulcer and normal gastric filling/emptying without extravasation through second part of duodenum. With negative UGI series, patient had NGT d/c'd but had resumption of abdominal pain later in the day of HD5 with development of nausea. NGT was replaced with immediate return of 100cc of bilious fluid. Patient had repeat CT abdomen on HD7 which demonstrated a possible abscess that had previously been read as a right ovarian cyst. Patient had collection tapped on HD8 by CT guidance with removal of frank pus that grew vanc sensitive/amp resistant enterococcus. Patient was started on TPN on HD8 with gradual transition to lipid containing TPN on HD10. Patient had TPN discontinued on HD13 and was transitioned to regular diet the same day, with good tolerance. Because of questionable second fluid collection in pelvis, we contact[**Name (NI) **] Dr. [**Last Name (STitle) 41683**] from radiology with regards to the size of the second intrabdominal fluid collection. He did not feel any interval increase in size had taken place, therefore no additional instrumentation was pursued and th patient's original pigtail catheter was removed on HD16 GU: Patient had foley placed on admission for accurate UOP msmts, but had it removed on HD5 with good UOP following d/c. Foley was later replaced on HD6 as patient's UOP was not felt to be accurately recorded. Patient had foley d/c'd again on HD11 ENDO: Patient started on triple coverage IV abx (amp/levo/flagyl) on admission and continued through her hospitalization, SSRI, protonix, hydrocortisone stress steroids started at 25q8, with subsequent taper to 15q8 on [**5-24**] and 10q8 on [**5-26**], and patient's at home prednisone 5' on PPD7 (HD14) PROPH: SQH, Protonix started on admission; Patient received plavix in anticipation of catheterization, and started on lovenox upon discharge as bridge for coumadin anticoagulation DISPO: Patient originally admitted to surgical ICU, tx'd to regular surgical floor, had 2x visits to VICU for afib and then to regular surgical floor. Patient was discharged to ECF on HD19 with good ambulation, appropriate PO intake, and good pain control. Medications on Admission: prednisone 5', methrotexate 30 Qweek, Diovan 40', Lasix 20', Lipitor 60', asa81', aldactone 25', diltiazem XR 180', prilosec 40', folate 1', singular 10', Advair 1puff", trazodone 100', provigil 100', lorazepam 1", mirapex 0.250, glycolax PRN, cymbalta 60', albuterol 2puffs PRN, fentanyl patch 50mcg Q3d, vicodin PRN, xalatan 0.005%, betimol 0.5% [**Hospital1 **] Discharge Medications: 1. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 4. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 6. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 7. Atorvastatin 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day) as needed for thrush. 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 14. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours) for 9 doses. Disp:*9 piggybacks* Refills:*0* 15. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 17. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 18. Lovenox 100 mg/mL Solution Sig: 0.7 milliliters Subcutaneous twice a day. Disp:*10 bottles/syringes* Refills:*2* Discharge Disposition: Extended Care Facility: Cape [**Hospital **] Rehabilitation & Nursing Center - [**Location (un) **] Discharge Diagnosis: Abdominal pain with free air and question of hollow organ injury; New onset atrial fibrillation Discharge Condition: Stable Discharge Instructions: You may resume all of your home medications. Take your new medications as prescibed. Do not drive while taking narcotics. You may shower, maintain a regular diet avoiding nuts and seeds. Please call the "purple" surgery resident on call, or come to the [**Hospital1 18**] emergency room for fevers greater than 101.4, worsening abdominal pain or shortness of breath, development of nausea/vomiting. Also return to [**Hospital1 18**] ER for any other worrisome isses that may arise You will need to follow up with your primary care provider on monday [**2158-6-12**] to have blood drawn and your INR monitored. Please follow up with your appointments Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in [**12-26**] weeks, call [**Telephone/Fax (1) 10533**] to schedule an appointment Please follow up with your primary care provider on [**2158-6-12**] to have your blood drawn and your INR monitored Please follow up with Dr. [**Last Name (STitle) **] of the [**Hospital1 18**] vascular surgery department to discuss your bilateral iliac artery stenosis as seen on your cardiac cath from [**2158-6-8**] Please follow up with an exercise stress test with the cardiology division on [**2158-6-15**] at 230pm. Do not eat within three hours of the test, and do not have caffeine within 12 hours of the test. On the day of the appointment go to the [**Hospital Ward Name 23**] building [**Location (un) 436**] on the [**Hospital1 18**] [**Hospital Ward Name **]. When your test is performed, schedule an appointment to see Dr. [**Last Name (STitle) 10543**] to discuss the results. If you need to reschedule your stress echo, call [**Telephone/Fax (1) 1566**]. [**Name6 (MD) 843**] [**Name8 (MD) 844**] MD [**MD Number(1) 845**] Completed by:[**2158-6-9**]

[ "440.1", "427.31", "414.01", "780.57", "410.71", "557.1", "447.1", "365.9", "714.0", "593.2", "401.9", "493.90", "041.04", "562.11", "511.9", "569.5", "568.89", "574.20", "518.0" ]

icd9cm

[ [ [] ] ]

[ "00.40", "38.93", "54.91", "00.66", "88.56", "99.15", "38.91", "34.04", "88.47" ]

icd9pcs

[ [ [] ] ]

13802, 13904

6487, 11685

283, 403

14044, 14053

1064, 6464

14756, 15895

872, 876

12101, 13779

13925, 14023

11711, 12078

14077, 14733

891, 891

229, 245

431, 668

905, 1045

690, 836

852, 856

54,077

100,454

40809

Discharge summary

report

Admission Date: [**2192-3-20**] Discharge Date: [**2192-3-23**] Date of Birth: [**2119-5-21**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5606**] Chief Complaint: sore throat Major Surgical or Invasive Procedure: none History of Present Illness: 72 M on C10D23 of FU/leucovorin for rectal CA presents with throat pain and fever, found to have parapharyngeal phlegmon commpressing the airway. Pt reports 4 days of right sided chest wall pain, fever that began today to 102 at home. Denies SOB/cough/abdpain/dysuria. Was seen earlier on day of admission for chest pain which was noted to be reproducible on palpation and onset while pt doing yardwork. c/o sore throat, sensation of something stuck in his throat. He has been able to drink, but it hurts. Pt thought he could palpate a lump on the left side of his neck beneath the mandible, but this area was not paniful to him on external palpation. Currently says throat when swallowing is [**8-13**] pain. No back pain. He denies trauma, previous head and neck surgery or recent dental work. He notes that he needs some dental work performed, but can not because of the chemo. He denies voice change or difficulty breathing. His last dose of chemo was on [**2192-3-12**]. No XRT currently. Of note, his prior imaging has documented diffuse spinal bone metastasis. . ED COURSE: vs on arrival: pain10 T102.2 HR114 104/53 RR20 98% exam in ED showed tenderness to palpation of left anterior cervical area, clear oropharynx without exudate or uvula deviation. Labs significant for WBC 8.3 with 78%pmns and 14%lymphs. HCT 36.9 from b.l 39, plt 158 Na 130, K 4.2, 98/21, bun/cr 21/1.0 lactate 1.3 CT neck wetread showed hypodensity left of oropharynx involving L aryepiglottic fold and compressive effect on airway. ENT was consulted. pt given steroids and zosyn in ED with plan to give vanc as well. transferred to [**Hospital Unit Name 153**] after 2L IVF. . In the [**Name (NI) 153**], pt appears comfortable, not requiring oxygen. Is able to control his own secretions. Endorses pain on swallowing and right lower ribcage/sternal sharp pains with movement. Past Medical History: peripheral neuropathy - possibly chemo induced, takes gabapentin ONCOLOGIC HISTORY: 1. [**2191-6-17**]: screening colonoscopy: rectal mass distally and multiple polyps identified. 2. Admitted with lower GI bleeding following the colonoscopy and imaging revealed multiple bone metastasis and extensive retroperitoneal and pelvic lymphadenopathy. Bone lesions were confirmed with bone scan and MRI. 3. [**2191-7-5**]: Started on FOLFOX for palliation. 4. [**2191-11-7**]: Start on 5FU/leucovorin. Stop oxaliplatin due to allergic reaction. 5. [**2-/2192**]: Torso CT: no disease progression Social History: Lives at home with his wife. His children live nearby. Smokes [**12-5**] pack cigarettes for 45 years, continues to smoke. denies alcohol, denies IVDA. Family History: One sister died of breast cancer, another of lung cancer (smoker), one brother died of MI. Physical Exam: ON ADMISSION: Tcurrent: 36.9 ??????C (98.5 ??????F) HR: 98 (97 - 98) bpm BP: 132/65(79) {132/65(79) - 132/65(79)} mmHg RR: 17 (17 - 20) insp/min SpO2: 92% RA Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric,dry mucous membranes, oropharynx not well visualized, no sores inside the mouth Neck: supple, JVP not elevated, no LAD. Unable to palpate mass in the left cervical SCM area and pt is nontender to palpation of this area Lungs: crackles at the bases bilaterally, no wheezes. 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: EKG [**2192-3-21**]: NSR @90s, unchanged from prior no signs of ischemia [**2192-3-20**] 11:52PM URINE HOURS-RANDOM UREA N-422 CREAT-63 SODIUM-45 POTASSIUM-64 CHLORIDE-61 [**2192-3-20**] 11:52PM URINE OSMOLAL-388 [**2192-3-20**] 11:10PM URINE HOURS-RANDOM [**2192-3-20**] 11:10PM URINE GR HOLD-HOLD [**2192-3-20**] 11:10PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014 [**2192-3-20**] 11:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2192-3-20**] 08:08PM LACTATE-1.3 [**2192-3-20**] 08:00PM GLUCOSE-113* UREA N-21* CREAT-1.0 SODIUM-130* POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-21* ANION GAP-15 [**2192-3-20**] 08:00PM estGFR-Using this [**2192-3-20**] 08:00PM WBC-8.3 RBC-3.65* HGB-12.2* HCT-36.9* MCV-101* MCH-33.5* MCHC-33.1 RDW-15.8* [**2192-3-20**] 08:00PM NEUTS-78.4* LYMPHS-14.2* MONOS-6.8 EOS-0.4 BASOS-0.3 [**2192-3-20**] 08:00PM PLT COUNT-158 . [**2192-3-20**] CXR: IMPRESSION: Streaky left base opacity, developing/early pneumonia not excluded. Bibasilar atelectasis. . [**2192-3-22**] CXR: IMPRESSION: Small bilateral pleural effusions. No evidence of focal consolidation. . [**2192-3-22**] right rib film: IMPRESSION: No evidence for rib fracture. No pneumothorax. . [**2192-3-20**] CT NECK:IMPRESSION: 1. Ill defined area of hypodensity along the left of the oropharnx extending to involve the left aryepiglottic fold with medialization of the left aryepiglottic fold and with compressive effect on the air way, appears consistent with edema/phlegmonous change. No definite rim of enhancement. No retropharyngeal edema seen. 2. Atherosclerotic calcification and thrombus involving the cervical portion the right internal carotid artery (series 2, 45) which appears asymmetrically narrowed when compared to the left. Brief Hospital Course: 72 y/o M undergoing chemo for rectal CA (not currently neutropenic) p/w throat pain and fever found with parapharyngeal phlegmon compressing airway. . #Sepsis - Patient presented with tachycardia and fever with known source (paratracheal phlegmon). Was treated with 2L IVF in ED, and started on vanc/zosyn. On arrival to [**Hospital Unit Name 153**] his tachycardia/fever had resolved. He was not hypotensive. Given desire to also provide coverage for possible ESBL, antibiotics were changed to vanc/[**Last Name (un) 2830**]. The patient remained hemodynamically stable overnight, and did not require pressors. His infection was treated as below. . #Paratracheal phlegmon- CT revealed L parapharyngeal phlegmon without a drainable collection. His airway was patent, but left AE fold edematous. Was c/f airway protection requiring ICU admission, as well as concern that at some point the inflammation could liquify. He was seen by ENT, and started on IV steroids with decadron 10mg IV Q8H x3 doses. He was covered with broad spectrum antibiotics (vanc/meropenem for ESBL coverage). He was monitored closely for evidence of stridor, and also on continuous O2 monitoring. The following morning, steroids were stopped. Plan was for 14 day course of antibiotics, with IV abx for first 48-72 hours. Can likely be transitioned to augmentin to complete antibiotics course. He was initially kept NPO, then started on regular diet on hospital day 2. Monospot was negative. Blood cultures are negative at the time of discharge. ENT did not feel patient needed repeat imaging, unless clinical course changed. He should follow-up with Dr. [**Last Name (STitle) **] in [**1-6**] weeks after abx course completed. (The patient was called and given a phone number to call as this was not done prior to discharge.) Pain was controlled with acetaminophen and oxycodone as needed initially but at discharge he did not require any pain medications. . #Hyponatremia - Na initially 130, likely secondary to hypovolemia. Hyponatremia resolved after 2L of fluid. Hypovolemia was likely secondary to decreased PO intake in setting of sore throat, and also from insensible losses in setting of sepsis. Of note, his FeNA (checked in context of initial decreased urine output) was 0.55%, c/w prerenal etiology. . #Nutrition - Patient was initially kept NPO. His diet was advanced the following morning without incident. . #Chest pain - Patient c/o 4 days of chest pain after working in the yard. Pain was reproducible with palpation, and worse with movement. It was most consistent with a musculoskeletal etiology. A cardiac etiology was unlikely; EKG was without signs of ischemia and unchanged from prior. Portable CXR showed bibasilar atelectasis and no pneumonia. Formal PA/lateral CXR showed no infiltrate. Rib films showed no signs of fracture. His pain improved with warm compresses. . #Metastatic rectal cancer - On admission, patient not neutropenic although he is immunosuppressed. Noted to have bony metastases on previous MRI to lumbar, sacral, and cervical spine. Day of admission was C10D23 of FULFOX. His oncologist was contact[**Name (NI) **] during this hospitalization. He will follow up with his oncologist as previously scheduled. Medications on Admission: pt states he is only taking neurontin 900mg [**Hospital1 **] Discharge Medications: 1. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). 2. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 12 days. Disp:*24 Tablet(s)* Refills:*0* 3. Tylenol 325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Discharge Disposition: Home Discharge Diagnosis: parapharyngeal phlegmon Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for further evaluation of sore throat and fevers. You were found to have a parapharyngeal phlegmon and were started on antibiotics. You were evaluated by ENT. There was no need for drainage. You also had some chest pain which was thought to be musculoskeletal pain and improved with warm packs. Your rib x-rays did not show any signs of fracture. Your chest x-rays showed small pleural effusions and an opacity that is likely just atelectasis. There was no evidence of pneumonia. You will have re-staging scans soon and should discuss the results with your oncologist. START: Augmentin 875 mg po BID. CONTINUE: Gabapentin Followup Instructions: Follow up with your oncologist as scheduled below. Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2192-3-26**] at 9:00 AM With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 14688**], RN [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2192-4-9**] at 9:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2192-4-9**] at 11:00 AM With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 14688**], RN [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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Discharge summary

report

Admission Date: [**2147-1-16**] Discharge Date: [**2147-1-28**] Date of Birth: [**2078-1-10**] Sex: M Service: MEDICINE Allergies: Seroquel / Fentanyl / Flagyl Attending:[**First Name3 (LF) 1945**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: EGD x 2 arterial line placement History of Present Illness: This is a 69-year-old man with COPD, HTN, a. fib on enoxaparin and coumadin, PE, and recent admission for sternal wound infection s/p multiple debridements presents from OSH with unstable upper GI hemorrhage. Per report, patient developed episodes of hematemesis and melena yesterday at [**Hospital **] rehab. He was transferred to [**Hospital3 7362**] where he underwent emergent EGD overnight. He was found to have a distal esophageal ulcer that was clipped x5. Patient was also started on a PPI and octreotide drip, given 9 units of PRBCs, 7 units of FFP, 20mg of IV vitamin K, and protamine. He was also started on a levophed gtt for persistent hypotension. After EGD, hct was still ~20, and patient continued to have copious amounts of melena. Patient was apparently seen by IR at [**Hospital1 3597**], who did not feel comfortable intervening with this sort of bleed, and surgery who did not feel that patient would survive a distal esophagectomy. As such, Mr. [**Known lastname 63108**] was transferred to [**Hospital1 18**] for further treatment. Patient was recently admitted to the cardiothoracic surgery service for reucrrent sternal wound infections in setting of CABG. Mr. [**Known lastname 63108**] was maintained on vancomycin and ceftaz at rehab. He also has a history of C.diff for which he is on po vancomycin. Upon arrival to ICU, vitals were: HR 107, BP 96/61 on 16mcg of levophed, SP02 100% on CMV fi02 60%, PEEP 5, tidal volume 500. Patient has a non-functioning PICC and a left IJ placed at outside facility. Gastroenterology, thoracic surgery, and interventional radiology were called. Past Medical History: - h/o atrial Fibrillation - s/p Pacer ([**Company 1543**] DDD) - COPD - Hypertension - PVD s/p Aortobifemoral bypass - Hyperlipidemia - Chronic liver disease [**2-22**] EtOH (sober now) - Anemia: h/o maroon stools; colonoscopy in [**2146**] with hemorrhoids, colon polyps, adenoma - h/o epistaxis - history of AAA that was repaired in 07 - h/o PE ~2-3 months ago per pt. Notes from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] mention PE and imaging from today mentions stable PE. However, no records at [**Hospital1 18**] mention PE. - Wedge fractures - Noted in lumbar region on CT scan - prolonged hospitalization at [**Hospital1 18**] in [**8-30**] for epiglottitis requiring cric/trach, with hospital course complicated by GI bleeding and pseudonomas bacteremia Social History: Unemployed. Used to work in the stockroom at the [**Location (un) **] Corportation. Lives alone. Has a scooter at home. Health care proxy is his friend [**Name (NI) 892**] [**Name (NI) 16471**], (c) [**Telephone/Fax (1) 106834**], (h) [**Telephone/Fax (1) 106835**]. Tobacco: used to smoke 1.5 ppd x ~50 years. Quit 6 months ago. Alcohol: per records, hx of heavy EtOH use. Quit 9 months ago. Illicits: none Family History: Father and mother both died of CAD, dad died after age >50 Physical Exam: Physical Exam on Discharge: O: Tc 98, Tm 98.6, BP 100/59 (94-127/59-78), HR 90 (83-101), RR 20 (18-22), O2Sat 96% 3L I/O: 1790/975 over last 24 hours, 100/460 over last 8 hours HEENT: NC AT Chest: Healing sternotomy. Improved airway sounds, coarse rhonchi in the bases but cleared with coughing, no wheeze or crackles CV: Heart sound distant, difficult to hear with also coarse rhonchi. Does have a [**3-26**] holosystolic murmur present when patient holds breath for a second (this valvular disease is known, evident by based on available echo) Abd: soft, NT, mildly distended, BS present Ext: no edema, 2+ DP bilaterally, no asterixis Neuro: AAOx3 Pertinent Results: [**2147-1-16**] 12:05PM PT-17.5* PTT-34.8 INR(PT)-1.6* [**2147-1-16**] 12:05PM PLT SMR-NORMAL PLT COUNT-310 [**2147-1-16**] 12:05PM HYPOCHROM-OCCASIONAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+ SCHISTOCY-OCCASIONAL ENVELOP-OCCASIONAL ACANTHOCY-1+ [**2147-1-16**] 12:05PM NEUTS-88* BANDS-2 LYMPHS-6* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-2* MYELOS-0 [**2147-1-16**] 12:05PM WBC-24.7*# RBC-2.52* HGB-8.1* HCT-21.6* MCV-86 MCH-32.1*# MCHC-37.3*# RDW-16.5* [**2147-1-16**] 12:05PM DIGOXIN-0.4* [**2147-1-16**] 12:05PM ALBUMIN-2.9* CALCIUM-7.7* PHOSPHATE-3.4 MAGNESIUM-1.6 [**2147-1-16**] 12:05PM CK-MB-6 cTropnT-0.02* [**2147-1-16**] 12:05PM ALT(SGPT)-29 AST(SGOT)-105* CK(CPK)-68 ALK PHOS-68 TOT BILI-3.4* DIR BILI-0.8* INDIR BIL-2.6 [**2147-1-16**] 12:05PM estGFR-Using this [**2147-1-16**] 12:05PM GLUCOSE-150* UREA N-44* CREAT-1.1 SODIUM-140 POTASSIUM-4.2 CHLORIDE-110* TOTAL CO2-21* ANION GAP-13 [**2147-1-16**] 12:33PM LACTATE-1.7 [**2147-1-16**] 12:33PM TYPE-MIX PO2-39* PCO2-44 PH-7.32* TOTAL CO2-24 BASE XS--3 [**2147-1-16**] 03:25PM URINE AMORPH-FEW [**2147-1-16**] 03:25PM URINE RBC-[**3-25**]* WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 [**2147-1-16**] 03:25PM URINE [**Month/Day/Year 3143**]-LG NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2147-1-16**] 03:25PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019 [**2147-1-16**] 03:26PM FIBRINOGE-221 [**2147-1-16**] 03:26PM PT-17.3* PTT-33.0 INR(PT)-1.5* [**2147-1-16**] 03:26PM PLT COUNT-325 [**2147-1-16**] 03:26PM WBC-24.0* RBC-3.31*# HGB-9.9* HCT-28.1*# MCV-85 MCH-29.9 MCHC-35.2* RDW-17.0* [**2147-1-16**] 03:26PM CALCIUM-8.0* PHOSPHATE-3.1 MAGNESIUM-1.6 [**2147-1-16**] 03:26PM GLUCOSE-140* UREA N-42* CREAT-0.9 SODIUM-141 POTASSIUM-4.2 CHLORIDE-110* TOTAL CO2-21* ANION GAP-14 [**2147-1-16**] 07:54PM LACTATE-1.4 [**2147-1-16**] 07:54PM TYPE-ART PO2-128* PCO2-37 PH-7.36 TOTAL CO2-22 BASE XS--3 [**2147-1-16**] 09:08PM CK-MB-8 cTropnT-0.02* [**2147-1-16**] 09:08PM CK(CPK)-98 [**2147-1-16**] 09:09PM HCT-29.4* [**2147-1-16**] 09:22PM freeCa-1.08* [**2147-1-16**] 09:22PM TYPE-[**Last Name (un) **] PH-7.35 [**2147-1-17**] 12:00AM HCT-27.4* . EGD [**1-16**] [**Month/Year (2) **] in the whole Esophagus 5 previously placed endoclips visualized in linear fashion in distal esophagus terminating at the GE junction. Appearance of potential ulceration beneath. [**Month/Year (2) **] in the whole stomach Red [**Month/Year (2) **], less than seen in stomach and esophagus visualized in duodenum. No active bleeding source identified. Otherwise normal EGD to second part of the duodenum . EGD [**1-17**] Five endoclips in a linear pattern from 41 to 45 cm from the incisors were noted in the esophagus. It is unclear what the clips were overlying but one clip was positioned over a protuberance that was suspicious for a varix. There was also [**Month/Year (2) **] throughout the esophagus without obvious source but likely emanating from the stomach. [**Month/Year (2) **] throughout the stomach with a large clot in the cardia and fundus overlying active oozing of unclear source [**Name (NI) **] in the visualized portions of the duodenum Otherwise normal EGD to second part of the duodenum . [**1-18**] CT abdomen/pelvis 1. No evidence of active extravasation. High-attenuation material in the stomach could be consistent with hemorrhagic products. 2. Multiple enlarged intra-abdominal lymph nodes, with 3.6-cm heterogeneous and centrally necrotic mass near pancreatic head. Following resolution of patient's acute GI bleed, this could be further investigated by FDG-PET or endoscopic ultrasound-guided aspiration. 3. Aorto-biiliac stent graft, with no evidence of endoleak or aortoenteric fistula. 4. Increased bilateral pleural effusions and trace ascites. 5. New loculated pericardial fluid collection, compressing right atrium and ventricle. [**1-27**] EUS: Salmon colored mucosa in a localized pattern suggestive of Barrett's Esophagus, 3 hemostatic clips found in distal esophagus. Biopsies done in the stomach. Diffuse continuous nodularity of the mucosa without bleeding in the stomach. A large peri-pancreatic LN was noted near the head of the pancreas about 3 cm in max diameter s/p FNA. Fluid collection (? necrotic) adjacent to the lower third of the CBD near the pancreatic head. Apparent infiltrative process in the stomach manifest by thickened gastric walls (particularly in the body) suggestive of intestinal metaplasia or less likely lymphoma or linitis plastica. Brief Hospital Course: This is a 69-year-old gentleman with a pmhx. significant for afib, PE (on coumadin and now lovenox), CAD s/p recent CABG, c.diff infection, who is transferred here from [**Hospital3 7362**] with continued GI bleed despite placement of 5 clips in lower esophageal ulcer. . # UGI BLEED/Mass near pancreas: Patient underwent endoscopy at OSH and s/p clips to esophageal ulcers. He was transferred to [**Hospital1 18**] ICU [**1-16**]. He underwent EGD [**1-16**] that showed: [**Month/Year (2) **] in the esophagus and stomach, 5 previously placed endoclips, potential ulceration beneath and no active bleeding source identified. The following day [**1-17**], he underwent repeat EGD that showed: suspicion for varix underlying esophageal clip, [**Month/Year (2) **] throughout the esophagus without obvious source but likely emanating from the stomach and [**Month/Year (2) **] throughout the stomach with a large clot in the cardia and fundus overlying active oozing of unclear source. CT abdomen showed: enlarged abdominal lymphnodes and necrotic mass near pancreatic head. This mass was biopsied and pathology pending from EGD/EUS on [**1-27**]. While in the ICU, patient required pRBC, but on transfer to medicine floor remained stable w/ hcts in the low 30s. He was transitioned from iv ppi to po ppi. Palliative care was consulted while on the floor as patient expressed that he was uncertain if he wanted further work up. He expressed that he wanted to be DNR/DNI. Goals of care discussion held with him and HCP. [**Name (NI) **] decided to undergo further work up, and as stated had a biopsy of the mass. He will follow up with gastroenterology for biopsies and will need oncology referral if malignancy. He was started on morphine for pain. Of note given his CHADS score, discussion with GI, he was restarted on low dose of ASA 81 mg daily with PPI and follow-up with gastroenterology. - Check Hct on [**2147-1-31**]. Transfuse for hct <25. . # HYPOTENSION: Secondary to hypovolemia, with high CVP and low lactate. Responded to ivf's and pRBC in the ICU. BP on the floor remained in 90s. He was restarted on lasix for diuresis (see below) and tolerated this. . # PLEURAL EFFUSION: Bilateral effusions noted on CT imaging. Patient diuresed w/ iv lasix while on the floor and then switched to po. On discharge patient sating in mid 90s on RA. - If patient develops worsening dyspnea or edema, can increase lasix from 40mg daily to [**Hospital1 **]. . # PERICARDIAL EFFUSION: Secondary to h/o surgeries. [**Hospital1 **] done that showed no tamponade physiology, but was notable for severe TR and depressed RV function. . # CIRHOSIS: Found to have cirrhosis on imaging, likely related to ETOH. Possible varix on EGD. Patient will follow up with GI as an outpatient, will need referal to Liver. . # STERNAL WOUND INFECTION: Patient with recent CABG and subsequent sternal wound infection that grew out pseudomonas. Has been on vanc and ceftaz at rehab and this was continued on this hospitalization. Patient will follow up with [**Hospital **] clinic on discharge. -Continue ceftaz -Continue dry dressings . # CDIFF: Continued po vanc while on ceftaz. . # CAD s/p CABG: PAtient was continued on his statin and lasix restarted. Aspirin was held in the setting of GI bleed. -Do not restart aspirin until patient follows up with GI as an outpatient. . # AFIB: Continued digoxin for atrial fibrillation. Coumadin was held in the setting of bleed and should not be restarted until patient follows up as outpatient with GI and cardiology. . # COPD: Continued inhalers/nebs. . # BPH: Restarted tamsulosin when stable. Okay to continue. Medications on Admission: digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID tamsulosin 0.4 mg Capsule daily simvastatin 40 mg Tablet daily citalopram 20 mg Tablet daily vancomycin 125 mg Capsule PO Q6H for 14 days treatment clonazepam 0.5 mg Tablet [**Hospital1 **] PRN ceftazidime 2 gram Q8H (every 8 hours): plan for 6-8 weeks total Percocet 5-325 mg Q4H PRN pain aspirin 81 mg Tablet daily warfarin 1 mg Tablet Sig: 0.5mg daily for 2 weeks, INR goal [**2-23**] for afib/PE (patient very sensitive to coumadin). Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days, then taper to 40 mg daily alum-mag hydroxide-simeth 200-200-20 mg/5 mL QID (4 times a day) as needed for gas pain. fluticasone-salmeterol 250-50 mcg/dose [**1-22**] puff Inhalation [**Hospital1 **] potassium chloride 20 mEq Tab Sust.Rel daily Wellbutrin SR 150 mg Tablet Sustained Release Sig: One Tablet Sustained Release PO once a day: 150mg daily for 3 days, then increase to [**Hospital1 **] for smoking cessation ipratropium bromide 0.02 % Solution Sig: Two (2) Q6H PRN wheezing albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **] PRN Coumadin 0.5mg QD Discharge Medications: 1. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 3. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). 4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for gas. 8. ceftazidime 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q8H (every 8 hours). 9. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. 10. Wellbutrin SR 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. 11. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Inhalation every four (4) hours as needed for shortness of breath or wheezing. 13. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1) Inhalation twice a day. 14. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. 15. morphine 10 mg/5 mL Solution Sig: One (1) PO Q4H (every 4 hours) as needed for pain. Discharge Disposition: Extended Care Facility: Maplewood Care & Rehabilitation Center - [**Location (un) 32944**] Discharge Diagnosis: Necrotic mass near the pancrease Upper GI bleed Pleural effusion Discharge Condition: A&Ox3 Ambulate with assistance. Discharge Instructions: Dear Mr. [**Known lastname 63108**], You were admitted to the hospital because you were vomiting [**Known lastname **]. At [**Hospital3 7362**] you had an upper endoscopy and had clips placed to prevent further bleeding. You were transferred to [**Hospital1 18**] for further work up. While you were here you had repeat endoscopies, that showed [**Hospital1 **] in the esophagus and the stomach. You required [**Hospital1 **] transfusions while you were here, but your repeat hematocrits have been stable. On imaging it appeared that you had a mass close to the pancreas, and so you had a biopsy to evaluate the mass. We continued you on your antibiotics for your sternal wound and c diff. For your follow up you will need to see the gastroenterology team to find the final results of your biopsy. You should also continue to see the infectious disease doctor regarding your sternal wound and cardiac surgery. We have made the following changes to your medications: 1. Stop aspirin. This is a [**Hospital1 **] thinner and you have had a recent upper gastrointestinal bleed. Do not restart this until you have seen the gastroenterologist in follow up. Please discuss restarting this medication with your gastroenterologist and cardiologist. 2. Stop coumadin. This is also a [**Hospital1 **] thinner. Do not restart this until you have seen the gastroenterologist in follow up. Please discuss restarting this medication with your gastroenterologist and cardiologist. 3. Start morphine for pain. This is a sedating medication, please take only as directed. DO NOT TAKE WITH ALCOHOL OR WHILE OPERATING A MOTOR VEHICLE. 4. Stop citalopram, you are on wellbutrin. 5. Stop potassium chloride, you have not required supplementation while you have been here. 6. Stop midodrine. 7. Stop percocet, you were started on morphine instead. Followup Instructions: Department: DIV. OF GASTROENTEROLOGY When: TUESDAY [**2147-2-7**] at 2:30 PM With: [**Name6 (MD) 11170**] [**Last Name (NamePattern4) 11171**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Department: INFECTIOUS DISEASE When: WEDNESDAY [**2147-2-8**] at 11:30 AM With: [**Known firstname **] [**Last Name (NamePattern4) 13896**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: CARDIAC SURGERY When: MONDAY [**2147-2-13**] at 2:30 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 170**] Building: LM [**Hospital Unit Name **] [**Location (un) 551**] Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE

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41479

Discharge summary

report

Admission Date: [**2172-3-14**] Discharge Date: [**2172-3-30**] Date of Birth: [**2088-8-10**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 905**] Chief Complaint: Melena, low platelets Major Surgical or Invasive Procedure: Blood product transfusions PICC line placement History of Present Illness: Ms. [**Known lastname 90237**] is an 83 y/o F with a h/o critical AS (valve area of 0.67cm2), AF on coumadin, h/o prior GIB not worked up due to patient refusal, CRI who was initially transferred from [**Hospital3 12748**] for a CORE valve with Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 914**], who shortly after arrival was found to have platelets of 6, an INR of 4.3 and an HCT that was initially 27.3 down to 24.2 with active melena. She initially presented to [**Hospital3 **] on [**2172-3-9**] with complaints of tightness and heaviness in her epigastric region, that lasts for hours and has been present intermittently for years. During that hospital stay she was diuresed with an increase in her lasix dose to 80mg from her home dose of 40mg, and she underwent a work up of her abdominal pain. She had elevated LFT's, so she underwent a CT and HIDA scan which showed cholilithiasis, no cholecystitis and splenomegaly. She was started on a PPI, and transfused 2 units of PRBC's for her anemia. After her doctors at the OSH felt that her abdominal pain had resolved she was referred to [**Hospital1 18**] for a percutaneous aortic valve replacement given her repeated admissions for heart failure related her critical AS. . During her stay at the OSH her platelets were initially 131 on [**3-9**], then 96 and 86 on [**3-10**], her HCT was 25.5 and increased to 31.6 after 2 units of PRBC's on [**3-10**], after that time she did not have any further CBC's checked. Her creatinine there was 2.24, which appears to be her baseline and her INR was initally therapeutic and then increased to 4.0 and remained elevated despite holding her coumadin. . On arrival to [**Hospital1 18**] her initial VS were: 97.8, 156/55, 57, 18, 98% on 2LNC. Initially she had no complaints except that she felt her abdomen was "tight", but denied any chest pain, palpitations, shortness of breath, cough, congestion, or fever/chills. Shortly after her arrival to the floor her admission labs returned and were notable for platelets of 5, HCT of 27.3, that on recheck had dropped to 24.2. She was also noted to be having melanotic stools. A few hours later she triggered on the floor for bradycardia transiently to the 30's and relative hypotension to 104/51 from an initial baseline of 156/55. At that time she was started on a PPI gtt, given 500cc's of IVF and 1 unit of PRBC's. At that time given her multiple medical concerns transfer was initiated to the MICU. On arrival to the MICU her initial VS were: 97.1, 53, 148/43, 27, 98% on 1.5LNC. . On review of systems, she denies any prior history of stroke, deep venous thrombosis, pulmonary embolism, myalgias, joint pains, cough, hemoptysis. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: - Mild CAD - Mitral valve stenosis s/p balloon valvuloplasty [**2165**] now with moderate MS and mild MR - Severe TR - Atrial fibrillation on Coumadin, currently held - Vtach with torsades - ?TIA in the past year - h/o "arrhythmias" - CRI - Gout - Mild pulmonary HTN - GIB [**10/2171**], not worked up due to refusal by patient - Sigmoid diverticulosis - Pancreatic cyst - Thalassemia - Familial Mediterranean ?anemia vs ?macrothrombocytopenia - h/o anemia - Hemorrhoids s/p hemorrhoidectomy Social History: SOCIAL HISTORY: originally from [**Country 5881**], mainly greek speaking -Tobacco history: denies -ETOH: social -Illicit drugs: denies Family History: noncontributory Physical Exam: ADMISSION PHYSICAL EXAM: VS: T=97.1 BP=148/43 HR=53 RR=27 O2 sat=98% on 1.5LNC GENERAL: thin, frail appearing female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL NECK: Supple with JVP to her earlobes. 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, TTP in the RUQ and epigastric area, +BS EXTREMITIES: +edema. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. . DISCHARGE PHYSICAL EXAM: O: Tc: 97 BP: 132-155/73-84 HR: 69-82 RR: 18 O2: 97%RA I: 1120 O: 1750 Blood Sugar: 109 <-- 469 <-- 308<-- 176 <-- 139 GEN: NAD, pleasant, frail appearing HEENT: PERRL, EOMI, MMM NECK: Visible carotid pulsations, JVD up to earlobe (but has severe TR) PULM: bibasilar crackles without wheezes CARD: RR, 2/6 sem heard at upper sternal borders with radiation to carotids, III/VI SEM heard loudest at sternal border 5/6th intercostal space, delayed carotid upstroke, ABD: Soft, BS+, NT, ND EXT: 3+ BLE edema, trace edema of upper extremities with resolving hematomas SKIN: No rashes NEURO: Patient oriented x 3, 4/5 strength upper/lower extremities, CN II-XII intact Pertinent Results: ADMISSION LABS: [**2172-3-14**] 11:45PM BLOOD WBC-7.8 RBC-3.92* Hgb-8.4* Hct-27.3* MCV-70* MCH-21.4* MCHC-30.7* RDW-21.9* Plt Ct-6* [**2172-3-15**] 01:16AM BLOOD WBC-6.8 RBC-3.56* Hgb-7.9* Hct-24.2* MCV-68* MCH-22.1* MCHC-32.6 RDW-22.1* Plt Ct-5* [**2172-3-15**] 06:19AM BLOOD WBC-7.8 RBC-3.79* Hgb-8.6* Hct-26.4* MCV-70* MCH-22.8* MCHC-32.7 RDW-22.1* Plt Ct-5* [**2172-3-14**] 11:45PM BLOOD PT-40.5* PTT-36.8* INR(PT)-4.3* [**2172-3-15**] 06:19AM BLOOD PT-41.5* PTT-36.4* INR(PT)-4.4* [**2172-3-15**] 01:03PM BLOOD PT-21.4* PTT-30.7 INR(PT)-2.0* [**2172-3-14**] 11:45PM BLOOD Glucose-263* UreaN-81* Creat-2.2* Na-135 K-4.5 Cl-100 HCO3-25 AnGap-15 [**2172-3-15**] 06:19AM BLOOD Glucose-60* UreaN-85* Creat-2.2* Na-137 K-4.6 Cl-103 HCO3-27 AnGap-12 [**2172-3-14**] 11:45PM BLOOD LD(LDH)-260* CK(CPK)-10* [**2172-3-14**] 11:45PM BLOOD CK-MB-3 cTropnT-0.03* proBNP-8183* [**2172-3-15**] 06:19AM BLOOD CK-MB-3 cTropnT-0.03* [**2172-3-14**] 11:45PM BLOOD Calcium-8.5 Phos-2.8 Mg-2.0 [**2172-3-15**] 06:19AM BLOOD Albumin-3.1* Calcium-8.1* Phos-3.4 Mg-1.9 . . STUDIES: RUQ U/S [**2172-3-16**]: IMPRESSION: 1. Shadowing gallstone seen within the gallbladder which does not appear to be tense or distended. A minimal amount of gallbladder wall edema is a nonspecific finding as this may be related to the patient's low albumin state; however, cholecystitis cannot be ruled out. If there is concern for cholecystitis, a HIDA scan could be performed for further evaluation. 2. Mild splenomegaly. 3. Right pleural effusion CXR [**2172-3-15**]: FINDINGS: No previous studies for comparison. The cardiac silhouette is enlarged. There is also prominence of the paratracheal stripe superiorly. This may be due to a prominent thyroid or vascular structures, lymphadenopathy or mass is felt less likely. If there is high clinical concern, this could be further evaluated with CT. There is coarsening of the bronchovascular markings without focal consolidation, pleural effusions or pulmonary edema. Bony structures are grossly intact. CXR [**2172-3-18**]: FINDINGS: In comparison with the study of [**3-17**], there is further improvement in pulmonary vascular status. Huge enlargement of the cardiac silhouette persists. Soft tissue prominence in the right paratracheal region is again seen, consistent with the known goiter. No evidence of acute focal pneumonia. Echo [**2172-3-28**]: The left atrial volume is severely increased. The right atrium is moderately dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Diastolic function could not be assessed. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with normal free wall contractility. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is critical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are severely thickened/deformed. The mitral valve shows characteristic rheumatic deformity. There is moderate valvular mitral stenosis (area 1.0-1.5cm2). Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are moderately thickened. There is a rhematic deformity of the tricuspid valve. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is a small pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Rheumatic heart disease with moderate mitral stenosis, critical aortic stenosis, mild to aortic regurgitation, moderate to severe tricuspid regurgitation and moderate to severe pulmonary hypertension. Pressure/volume overload of the right ventricle. Small pericardial effusion without evidence of volulme overload. EKG [**2172-3-25**]: Sinus rhythm with marked first degree atrio-ventricular conduction delay. P-R interval at approximately 400 milliseconds. Diffuse non-diagnostic repolarization abnormalities. Compared to the previous tracing of [**2172-3-16**] cardiac rhythm now appears to be sinus mechanism with marked P-R interval prolongation. Upper Endoscopy [**2172-3-25**]: Findings: Esophagus: Lumen: A small size hiatal hernia was seen, displacing the Z-line to 35 cm from the incisors, with hiatal narrowing at 39 cm from the incisors. Additional findings include erythema and granularity, consistent with esophagitis. Stomach: Mucosa: Diffuse continuous erythema, granularity, friability and mosaic appearance of the mucosa with contact bleeding were noted in the whole stomach. These findings are compatible with gastritis. Duodenum: Normal duodenum. Other findings: No discrete lesion identified on careful inspection. Impression: Small hiatal hernia Diffuse gastritis No discrete lesion Otherwise normal EGD to third part of the duodenum Recommendations: The findings account for the symptoms Change PPI gtt to PPI 40mg [**Hospital1 **] Treat for H.pylori given positive serology Continue supportive care with transfusions as needed . MICRO: URINE CULTURE (Final [**2172-3-18**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S HELICOBACTER PYLORI ANTIBODY TEST (Final [**2172-3-18**]): POSITIVE BY EIA. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2172-3-23**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). DISCHARGE LABS: [**2172-3-30**] 05:01AM BLOOD WBC-15.1* RBC-2.93* Hgb-8.4* Hct-25.6* MCV-88 MCH-28.7 MCHC-32.8 RDW-17.0* Plt Ct-94* [**2172-3-30**] 05:01AM BLOOD PT-12.7 PTT-24.6 INR(PT)-1.1 [**2172-3-30**] 05:01AM BLOOD Glucose-135* UreaN-114* Creat-1.5* Na-144 K-4.3 Cl-108 HCO3-26 AnGap-14 [**2172-3-29**] 05:07AM BLOOD Glucose-169* UreaN-115* Creat-1.6* Na-142 K-4.5 Cl-109* HCO3-27 AnGap-11 [**2172-3-22**] 04:35AM BLOOD LD(LDH)-241 [**2172-3-21**] 06:22AM BLOOD ALT-21 AST-12 LD(LDH)-258* AlkPhos-105 TotBili-1.3 [**2172-3-29**] 05:07AM BLOOD Calcium-8.0* Phos-4.2 Mg-2.3 [**2172-3-26**] 05:50AM BLOOD Albumin-3.0* Calcium-8.0* Phos-4.0 Mg-2.3 Brief Hospital Course: HOSPITAL COURSE: Ms. [**Known lastname 90237**] is an 83 y/o primarily Greek speaking female with critical aortic stenosis, h/o mitral stenosis s/p balloon valvuloplasty 2 years ago, afib, CRI, DM, HTN, MR who initially presented to an OSH with dyspnea on exertion. She was diuresed and worked up for chronic abdominal pain, then transferred to [**Hospital1 18**] for percutaneous aortic valve replacement. She then developed melena, anemia, thrombocytopenia thought to be secondary to Idiopathic thrombocytopenia (treated with IVIG, dexa, now on prednisone), gastritis (H pylori positive treated with PPI, amox, clarithro). Patient no longer a candidate for percutaneous valve replacement nor surgical replacement at this time, peripherally overloaded from blood products and likely right heart failure - gentle diuresis given preload dependent state of aortic stenosis. . ACTIVE ISSUES: #) Idiopathic Thrombocytopenic Purpura: Per OSH records her platelets were 131 on admission, then decreased to 86 the next day, however no further CBC's were checked, so the trend over the next five days is unclear. [**Name2 (NI) **] her report she started having dark stools the day prior to transfer, her HCT went to 24.2 from 31.6 on [**3-10**]. DIC labs demonstrated normal fibrinogen & d-dimer, though her coags were elevated. Her coagulopathy was reversed with IV Vitamin K, and FFP. Her Platelets continued to be low, and Heme/onc was consulted. Smear showed rare schistocytes and findings c/w thalassemia. She was transfused multiple units of platetelets, though her platelets continued to be low. Heme speculated post-transfusion purpura versus idiopathic thrombocytopenic purpura (ITP). Laboratory results were most consistent with ITP with a positive anti-platelet antibody. She continued to be intermittently refractory to platelet transfusions. She was treated with 5 days of IVIG and a dexamethasone taper which was switched to oral prednisone 60mg daily with good response of her platelets --> 94 on discharge. The patient was started on atovaquone 1500mg daily for PCP prophylaxis given prolonged steroid course. . Her hematocrit was also closely followed and she was transfused PRBCs for Hct less than 24. She did not require any blood transfusions on the floor. On the day of discharge, she was hemodynamically stable and Hct was stable. She required total 16 units of PRBC's, 14 bags of platelets, 6 units of FFP, and 2 units of cryoprecipitate over her length of stay. . #) Melena: Patient new melena on history and exam, per her history she had a recent GI bleed in [**10/2171**] with a work-up deferred by the patient. She was started on a protonix gtt. GI was consulted. She underwent upper endoscopy when platelets were above 50 which showed diffuse gastritis. She was also H. pylori positive. Treated with amoxicillin, clarithromycin, and pantoprazole. She had no more N/V and tolerated a regular diet. She was transitioned to lansoprazole 30mg PO as she had difficulty swallowing pantoprazole pills. No more melena and stable hematocrit on the floor. . #) Critical aortic stenosis: The patient has critical aortic stenosis with a valve area of 0.7cm2 on echo done on [**3-28**]. Her volume status was closely monitored and treated with lasix IV based on her respiratory status. On discharge, she had bibasilar crackles and JVP to her earlobe, although she has severe tricuspid regurgitation complicating this factor. She was saturating well on room air, 94-97%. She will need follow-up with cardiology (Friday [**4-3**]) to further discuss her aortic stenosis. She is currently not a candidate for percutaneous aortic valve replacement given her frail status, recent GI bleed, and ITP. She is a very high risk for surgical valve replacement. On the floor, she was diuresed with lasix 10-20mg IV to achieve 250-500cc negative fluid balance. ** Her diuresis will have to be gentle, 250-500cc per day given her critical aortic stenosis and Preload dependence** . #) Atrial fibrillation: CHADS of 4. Patient with history of afib currently in sinus rhythm on telemetry. Her coumadin was initially held. Amiodarone was held in setting of GIB and concern for low BP. The patient remained in sinus rhythm while on floor. Her digoxin was restarted at half her home dosing to help with rate control. The patient was rate controlled without medication while on the floor, but her digoxin was restarted on the day of discharge to give her better inotropy as well. After discussion with GI and Hematology, her coumadin was restarted once her platelets were consistently above 70. As she is also on clarithromycin and digoxin, she was started at coumadin 0.5mg daily. She is at high risk of rebleeding given her ITP and previous gastritis so this needs to be closely monitored. . # Diabetes Mellitus: Her home glipizide was held. Her blood sugars rose dramatically in reponse to the dexamethasone and prednisone. She was started on lantus 20units qHS and a sliding scale. She showed a pattern of running low blood sugars in the morning (although always asymptomatic) and high blood sugars (~400) in the evenings. Her lantus was adjusted to 15units at bedtime then switched to AM dosing to provide better nighttime control. Her dinner sliding scale was increased as well to help provide better nighttime coverage. Goal blood sugars were between 150 to 200 to prevent hypoglycemia. . # CRI: Had elevated creatinine that was thought to be secondary to poor forward flow given her critical aortic stenosis. Her fluid status was carefully monitored and her renal function stablized at a creatinine of 1.5. Based on outpatient records, her baseline creatinine seems to be 1.4-1.6. . # Urinary retention - Prior to discharge, the patient was noted to have 600cc of urine in her bladder. She was straight cathed with good drainage. Anticholinergic medications should be avoided in this patient. Bladder scans should be done daily on this patient to evaluate for urinary retention and if she continues to retain, may need intermittent straight catheterization or foley placement. . # Hypernatremia: She was noted to be hypernatremic to a peak 157 in the setting of poor free water intake. Her free water defecit calculated to be 6 liters and this was supplied gently with careful monitoring. She was encouraged with free water PO intake and had stable sodium levels, 144 on the day of discharge. . # UTI: Had a pan-sensitive urinary tract infection while in the ICU, treated with 3 day course of ceftriaxone. . # Gout: Patient uses Allopurinol prn. No need for current use . TRANSITIONAL CARE: 1. CODE: FULL 2. MEDICAL MANAGEMENT: Prednisone 60mg daily for ITP until Hematology follow up Blood glucose control on dexamethasone - adjust lantus and humalog sliding scale as needed - CARDIOLOGY follow up - Friday, [**4-3**] with Dr. [**Last Name (STitle) **] to further discuss aortic stenosis and atrial fibrillation management - GI follow-up - In [**Month (only) 547**] to discuss severe gastritis - needs to finish triple therapy, 7 days of therapy (started on [**2172-3-25**]) - GENTLE diuresis to help remove lower extremity edema - lasix 10-20mg IV daily, goal 250-500cc negative daily Medications on Admission: - Digoxin 125mg qod - Amiodarone 400mg daily - Lasix 40mg daily - Potassium Cl ER 20mg daily - Pepcid 20mg daily - Coumadin 1mg qhs - Nitro 2% ointment 1 inch strip (30mg) [**Hospital1 **] - Glipizide 2.5mg daily - Allopurinol 300mg daily as needed for gout flare Discharge Medications: 1. captopril 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day). Tablet(s) 2. amoxicillin 250 mg/5 mL Suspension for Reconstitution [**Hospital1 **]: Ten (10) mL PO Q12H (every 12 hours) for 2 days. 3. clarithromycin 250 mg/5 mL Suspension for Reconstitution [**Hospital1 **]: Five (5) mL PO BID (2 times a day) for 2 days. 4. atovaquone 750 mg/5 mL Suspension [**Hospital1 **]: Ten (10) mL PO DAILY (Daily): Take with food. 5. camphor-menthol 0.5-0.5 % Lotion [**Hospital1 **]: One (1) Appl Topical QID (4 times a day) as needed for itching. 6. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 7. insulin glargine 100 unit/mL Solution [**Last Name (STitle) **]: Fifteen (15) units Subcutaneous qAM. 8. Humalog 100 unit/mL Solution [**Last Name (STitle) **]: Per attached sliding scale Subcutaneous four times a day. 9. prednisone 20 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO once a day: Will be adjusted by Hematologist - Appointment on [**4-1**]. 10. digoxin 125 mcg Tablet [**Month/Year (2) **]: 0.5 Tablet PO every other day. 11. Coumadin 1 mg Tablet [**Month/Year (2) **]: 0.5 Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital1 **] Pavilion - [**Location (un) **] Discharge Diagnosis: Primary: Idiopathic thrombocytopenic purpura, GI bleed secondary to gastritis, diabetes mellitus, critical aortic stenosis, atrial fibrillation Secondary: Gout Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**] Completed by:[**2172-3-30**]

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icd9cm

[ [ [] ] ]

[ "38.91", "99.14", "45.13", "38.97" ]

icd9pcs

[ [ [] ] ]

21463, 21538

12685, 12685

313, 362

21743, 21743

5659, 5659

4253, 4270

20220, 21440

21559, 21722

19931, 20197

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4310, 4949

3497, 3560

252, 275

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390, 3389

5675, 12010

21758, 22018

3591, 4084

3411, 3477

4116, 4237

4974, 5640

21,362

150,386

24183

Discharge summary

report

Admission Date: [**2165-3-9**] Discharge Date: [**2165-3-14**] Date of Birth: [**2107-2-12**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 99**] Chief Complaint: rectal bleeding, hypotension Major Surgical or Invasive Procedure: R femoral arterial sheath L femoral central venous line History of Present Illness: 58F w/ metastatic non-small lung cancer recent d/c'd from [**Hospital1 18**] on [**3-7**] following cervical/thoracic decompression (for presumed mets) complicated by LGIB now returning for bleeding per rectum and hypotension. . To OR on [**2-26**] for spinal decompression and post op course complicated by LGIB requiring 6 units prbc and SICU transfer. Did have a bleeding scan that was unrevealing on [**3-3**] and underwent colonscopy on [**3-6**] which demonstrated small internal hemorrhoids and multiple diverticuli w/ mixed openings in sigmoid and descending colon. Pt ultimately transferred to Medicine but review of OMR indicates that crit stabilized at 28-30 after [**3-4**] w/ last transfusion on [**3-2**]. Also worked up for hyponatremia and found to have SIADH. Discharged to rehab on [**3-7**]. . Now returns to ED w/ bleeding per rectum. Apparently, had crit checked at 3/24 am w/ crit of 31. On evening of admission, noted at rehab to pass large amounts of bright red blood per rectum. Reported no abdominal pain. Initially noted to be tachy to 120's but w/ systolic blood pressures in 110's. Arrangements made for transfer to [**Hospital1 18**] and upon ED arrival, noted to hypotensive to sytolic blood pressure of 60's and labs notable for crit of 22 (28.3 on [**3-7**]) and sodium of 123. Had 3 large peripheral IV's placed and has received total of 6L IVF and 4 units PRBC. NG lavage reported negative. Systolic blood pressures running in 90's-100's. Urine output noted to be 40cc over last hour. Surgery consulted, suggested potential colectomy if bleeding persisted and pt hemodynmically unstable. Patient then transported to IR and plans made for urgent angio. . Angio failed to demonstrate evidence of active bleeding within the SMA and [**Female First Name (un) 899**] system. Apparently, clinical bleeding had also stopped. Recommendations were made for nuclear tagged scan. Past Medical History: -metastatic non-small lung cancer w/ known spinal mets (based upon pathology from surgery) s/p cervical/thoracic decompression [**2-26**] -s/p RUL lobectomy of Pancoast tumor w/ xrt, chemo in '[**51**] c/b bronchopleural fistula -s/p recurrent/?new non-small LUL cancer in '[**62**] for which received chemo and xrt (etoposide/cisplatin in '[**63**] via Dr. [**Last Name (STitle) 3274**] -s/p scapular osteomylitis -hyponatremia thought secondary to siadh -lower gi bleed as above (thought diverticular) Social History: former tobacco history (40 pack years), no etoh, ivda Family History: Mother died from ovarian cancer. Father alive with HTN. Has 6 children. Physical Exam: 152/72 92 16 96%ra gen: chronically ill appearing female lying in bed flat, somewhat anxious heent: dry mm, mild scleral icterus cv: s1, s2 regular w/ no mrg appreciated pulm: ctab abd: positive bs, soft, mild diffuse tender, worse on the ruq, pool of bright red blood in rectum extr: no edema, right groin w/ femoral arterial sheath, palpable dp pulses in both le Pertinent Results: EKG SR at 92, nl axis/interval, borderline low limb voltage, no definite ischemic changes . [**3-9**] Tagged RBC scan- Blood flow images show increased tracer activity beginning at approximately 40 minutes in the pelvis just right of midline projecting superior to the bladder. There is an indentation of the superior bladder contour that may be secondary to the adjacent uterus. . IMPRESSION: Findings suggestive of slow bleeding of the sigmoid colon. . [**3-9**] Arteriogram- Selective arteriograms of the superior mesenteric and inferior mesenteric arteries and superselective arteriograms of the superior hemorrhoidal and sigmoidal arteries did not demonstrate any active contrast extravasation, focal vascular lesion or other potential source of bleeding. As such, embolization was not performed. . Brief Hospital Course: 58F w/ recurrent metastatic non-small lung cancer and recent lower gi bleed who was admitted to MICU for recurrent large volume GI bleed. It initially appeared by nuclear scan that bleeding was localized to the sigmoid colon. However clinically bleeding had subsided, therefore no intervention was undertaken. Unfortunately, clinical course was also complicated by the development of high-grade MSSA bacteremia. Suspected source was infection at her spinal surgery site. She underwent washout of her R shoulder and cervical spine with post-op course requiring monitoring in the ICU for hypotension and persistent hypoxia (secondary to volume overload) requiring venitlatory support. She was weaned off the ventilator but continued to require BiPap to maintain oxygenation despite diuresis. She did not tolerate the BiPap and expressed wishes to her family to be made comfortable. She did not wish to be intubated or kept on bipap, and she did not want to continue with any further aggressive measures. Discussion with patient, family (husband, [**Name (NI) 61443**]), [**Name (NI) 2270**] [**Name (NI) 11835**] with palliative care, and social work on [**3-14**] with plan made to transition care to DNR/DNI with goals geared towards comfort. She was taken off bipap and given dilaudid and ativan for pain control and respiratory distress. She passed away shortly after this time. . . A brief review of her hospital course by problem is outlined below: . # Respiratory Distress: Required intubation initially in setting of volume overload and then again post-operatively. She was weaned off ventilator but still required BiPap. She did not tolerate the BiPap and made wishes clear that she wished to be taken completely off respiratory support. After discussion with the patient, family, and palliative care services, her goals of care were changed to comfort measures only and she was taken off bipap support. She was kept comfortable with pain control and sedation and passed away shortly after this time. . 1. Hematochezia: Second ICU admission in nearly one week for large lower GIB. NGT lavage neg in the ED. Transported to angiography from ED where pt had stopped bleeding and engagement of [**Female First Name (un) 899**] and SMA territory failed to reveal site of bleeding. Nuclear bleeding scan on [**3-9**] suggestive of potential localized bleed in region of sigmoid colon. Upon arrival to MICU, pt had been aggressively resusicated with 6L IVF and 5 units pRBC. Her crit improved from 22 to 30. Surgery was consulted and given 2 recent life-threatening bleeds, had low threshold for OR for ?partial or total colectomy. Pt's hematocrit did eventually drop further on second ICU stay from 30 back to 22 for which she required 4 units of prbc. She was not taken for surgery however since she had no clinical evidence of bleeding per rectum. . 2. Hypotension: Pt initially presented to ED hypotensive to systolic 60's in the setting of massive lower gi bleed. She was aggressively resusicated with IVF and multiple units of PRBC and her pulse improved to high 90's and low 100's. However, during her first ICU stay, she remained hemodymically tenous. High suspicion was for recurrent bleed but crit did remain fairly stable. Recheck of CBC demonstrated a new leukocytosis to 35K and pt was hypothermic later during HD1. Empiric abx initiated including vanc, unasyn, and flagyl. 2 sets of blood cultures subsequently positive for MSSA (4 out of bottles) and uc w/ ecoli. Pt did undergo [**Last Name (un) 104**] stim which was unrevealing. Her lactate never rose substantially but she did have systolics in 70's and 80's on HD1 that did require pressors and further IVF. . 3. MSSA Bacteremia: Blood cultures from [**3-9**] have grown Methicillin Sensitive Staph Aureus in 4 out of 4 bottles. She did present with elevated wbc to 35K as mentioned above. Subsequent blood cultures from [**3-10**] and [**3-11**] are no growth to date. Given sensitivities she was transitioned from Vancomycin to Oxacillin. In order to evaluates source, TTE was performed, which was negative for vegetations. CT of T&C spine was negative for epidural abscess. However, there was evidence of local infection at spinal surgery site. Therefore she went for surgical washout on [**2165-3-12**]. Culture data from this washout demonstrated MSSA. . 4. E.Coli UTI: Culture reveals EColi that was pan-sensitive, however her initial UA was not suggestive of infection. Initially treated with Zosyn and this was changed to Levofloxacing once sensitivity data returned for a complete course . 5. Metastatic lung cancer: She has long history of non-small lung cancer dating to early 90's at which point she underwent RUL resection followed by XRT, chemo for Pancoast's tumor. Apparently, she had recurrence vs. ?new cancer in left lung. She has received etoposide and cisplatin in '[**63**]. Dr. [**Last Name (STitle) 3274**] has been notified about her second hospitalization and to speak about overall prognosis. She does have metastatic dz (for which recent spinal surgery performed) but felt that would be reasonable to proceed with aggressive therapy for GIB and sepsis since condition not believed to be immenintly terminal. However, the patient subsequently requested withdrawl of aggressive care and wished for goals of care to be directed towards comfort measures only. Medications on Admission: megace 40 qd, oxycontin 30 [**Hospital1 **], vicodin prn, protonix 40 qd, ferrous sulfate. Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: metastatic lung cancer massive lower gi bleed staph aureus bacteremia respiratory failure Discharge Condition: dead Discharge Instructions: n/a Followup Instructions: none

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icd9cm

[ [ [] ] ]

[ "38.91", "99.04", "88.47", "96.04", "77.89", "77.81", "96.71", "38.93" ]

icd9pcs

[ [ [] ] ]

9775, 9784

4249, 9606

341, 398

9918, 9925

3420, 4226

9977, 9985

2946, 3019

9747, 9752

9805, 9897

9632, 9724

9949, 9954

3034, 3401

273, 303

426, 2332

2354, 2859

2875, 2930

57,049

122,203

49634

Discharge summary

report

Admission Date: [**2107-10-10**] Discharge Date: [**2107-10-10**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5893**] Chief Complaint: hypotension, coffee ground emesis Major Surgical or Invasive Procedure: Right internal jugular line placement History of Present Illness: Mr. [**Known lastname 5419**] is an 84 yo Russian speaking male resident of [**Location **] with h/o vascular dementia, DM2, CAD, CHF, HTN and recent overnight admission [**2107-8-19**] for chest pain now admitted with coffee ground emesis and hypotension. According to report from HRC he became hypotensive overnight and was started on IVF with NS at 75ml/hour due to concern for dehydration. His VS overnight were 88/60 HR 66 RR 18 T97.8. He reportedly became confused and had three episodes of dark brown emesis concerning for UGIB so he was transferred to the ED for further eval. . On arrival to the ED T96.4 BP 104/55 HR 84 RR 24 100% on 3L NC. He was noted to have guaiac positive brown stool on exam. NG lavage with 250ml x 2 with coffee grounds and red blood that did not completely clear with lavage. They were unable to obtain good peripheral access in the ED so a RIJ was placed. GI was consulted and he was started on protonix gtt with plan for endoscopy in the ICU. Surgery was consulted and agreed with non-surgical management at this point. He was given 3 L IVF with improvement in BP to 139/76, prior to transfer. He was also given vanc 1g IV x1, ciprofloxacin 400mg IV and flagyl 500mg IV given leukocystosis and hypotension concerning for sepsis. . Of note, during his recent admission he was noted to have possible LLL opacity. He was given one dose of levofloxacin in the ED for suspected LLL pneumonia, however this was not continued on admission because of lack of symptoms and low level of suspicion for pneumonia. In addition, it is noted that a urine culture from [**9-26**] showed a proteus mirabalis UTI that was not sensitive to fluoroquinolones. Past Medical History: Type II DM PVD s/p L AKA CHF HTN SDH s/p fall in [**2106**] Hypothyroidism Depression CAD (? history s/p MI) delirium Vascular dementia -BPH (s/p Turp) -s/P cataract surgery x 2 -S/P bladder surgery -s/p hip fracture s/p surgical repair Social History: He is a resident of [**Hospital1 100**] Reabilitation facility. His wife died 2 years ago and he had a fall in 08 which caused him to have subdural hematoma. He has a stepson, Vladmimir, who lives in [**Country 2784**] and has not been able to visit since his wife has cancer. His son's friend [**Name (NI) **] [**Name (NI) 656**] is his health care proxy (cell #[**Telephone/Fax (1) 103793**]. He has a remote history of tobacco and ETOH use. Family History: n/c Physical Exam: Vitals: T:96.8 SBP:70 (left) 115 (right) CVP:12 P:66 R:18 O2: 99% RA General: waking up to voice but soon falling back to sleep, oriented x1, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, adentuous 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, guarding to palpation. non-tender, non-distended, bowel sounds present, no rebound tenderness, no organomegaly GU:foley catheter in place with gross hematuria Ext: warm, left AKA stump site intact. well perfused, no clubbing, cyanosis or edema Skin: clean stage II sacral decub ulcer with surrounding hyperpigmented skin, no exudate or evidence of infection Pertinent Results: Labs: WBC 25.8 (N88 L9.3) HCT 38.1 PLT 557 Venous lactate 1.1 Na 138 K 5.6 CL99 HCO 20 BUN 103 Creat 2.5 Gluc 201 CK 92 MB - Trop 0.12 . UA: moderate Leukocytes, large blood, nitrate negative, 21-50 RBC, 50 WBC, moderate bacteria, 0-2 epi. . Micro: [**2107-10-10**] Blood culture: pending (drawn 45mins after abx started in ED) [**2107-10-10**] Urine Culture: pending . Images: [**2107-10-10**] CXR: (my read) RIJ CVL appears to terminate in the right atrium, NG tube looped in the stomach with tip in the fundus, significant rightward rotation, likely small LLL infiltrate. . EKG: [**2107-10-10**] 7:14 NSR at 76 bpm, leftward axis, normal intervals, old q wave in AVF, compared with prior EKG from [**2107-8-18**] no acute changes. . OSH Labs/MICRO: [**2107-9-26**] Urine Culture: >100,000 proteus mirabilis (sensistive to Bactrim, Augmentin, unasyn, ceftriaxone; resistant to ciprofloxacin/levo Brief Hospital Course: Mr. [**Known lastname 5419**] is an 84yo Russian speaking man with a history of vascular dementia, DM Type II, PVD s/p AKA, CAD, h/o CHF (EF unkown) admitted with likely urosepsis. On arrival to the ICU his vital signs were stable and he did not appear to be in any acute distress. Within two hours of his arrival in the ICU he acutely became apnic and then was noted to become bradycardic on telemetry. He was in a pulseless cardiac arrest. Given his code status of DNR/DNI, which was confirmed with his health care proxy, he was not resuscitated. He was pronounced dead at 12:10 pm on [**2107-10-10**]. His health care proxy [**Name (NI) **] [**Name (NI) 656**] was notified. Of note he was initially admitted with concern for upper gastrointestinal bleeding however this was not felt to be a significant contributing factor to his death. Medications on Admission: Humulin N 4 units qam Humulin R [**Hospital1 **] metoprolol xl 50mg daily citalopram 40mg daily lisinopril 20mg daily tylenol 1000mg TID thiamine 100mg daily miralax 17grams daily Depakote sprinkles 250mg po BID lorazepan 0.5mg po q4 hours prn glucagon 1mg IM prn Eucerin cream Lac Hydrin 12% daily Iodosorb gel Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

5764, 5773

4519, 5369

298, 338

5825, 5835

3596, 4496

5891, 5902

2785, 2790

5732, 5741

5794, 5804

5395, 5709

5859, 5868

2805, 3577

225, 260

366, 2046

2068, 2306

2322, 2769

42,411

170,816

53783

Discharge summary

report

Admission Date: [**2101-2-14**] Discharge Date: [**2101-2-22**] Date of Birth: [**2034-4-29**] Sex: M Service: CARDIOTHORACIC Allergies: Percocet / Vicodin Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain/Dyspnea on exertion Major Surgical or Invasive Procedure: [**2101-2-14**] Mitral Valve Repair(28mm Annuloplasty Band) and Three Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary artery to left anterior descending with saphenous vein grafts to diagonal and obtuse marginal. History of Present Illness: 66 year old gentleman with known coronary artery disease who has undergone stenting in the past who in Novemeber was admitted to a hospital in [**State 108**] and treated for heart failure, severe pulmonary hypertension and bilateral pneumonia. A cardiac catheterization was performed which revealed severe left main and two vessel disease. Given the severity of his disease, he has been referred for surgical rvascularization. He has felt significantly better with diuresis however continues to have some chest pain and dypnea on exertion. Past Medical History: -CAD s/p PTCA and stenting in past (PTCA [**2077**], PTCA/Stent [**2085**], Cypher stent [**2094**] Prox Lcx) -Dyslipidemia -Hypertension -COPD -CHF (Episode [**12-13**]) BNP up to 1369 -Recent Pneumonia -Nephrolithiasis -Pulmonary hyertension -Barrett's esophagus -s/p Cholescystectomy Social History: Lives with: Fiancee. Divorced with 4 children. Half the year is spent living in [**State 108**] and the other half in [**State 350**]. Occupation: Retired Tobacco: Former 35 pack year. Quit [**2092**]. ETOH: Occassional Family History: Brother with CABG at age 66 Physical Exam: Pulse: 74 Resp: 20 O2 sat: 98% B/P Right: 109/61 Left: 117/79 Height: 5' 10.5" Weight: 182lbs General: Well-developed, well-nourished male in no acute distress Skin: Dry [X] intact [x] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [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/Left: 2+ DP Right/Left: 2+ PT [**Name (NI) 167**]/Left: 2+ Radial Right/Left: 2+ Carotid Bruit Right/Left: none Pertinent Results: [**2101-2-22**] 05:50AM BLOOD WBC-6.4 RBC-3.19* Hgb-9.7* Hct-28.8* MCV-90 MCH-30.4 MCHC-33.7 RDW-15.2 Plt Ct-246 [**2101-2-14**] 12:18PM BLOOD WBC-14.5*# RBC-3.09*# Hgb-9.2*# Hct-27.2*# MCV-88 MCH-29.6 MCHC-33.6 RDW-15.4 Plt Ct-155 [**2101-2-14**] 12:18PM BLOOD Neuts-77.5* Lymphs-18.9 Monos-2.5 Eos-0.7 Baso-0.5 [**2101-2-22**] 05:50AM BLOOD Plt Ct-246 [**2101-2-22**] 05:50AM BLOOD PT-13.6* INR(PT)-1.2* [**2101-2-14**] 12:18PM BLOOD PT-16.1* PTT-42.4* INR(PT)-1.4* [**2101-2-22**] 05:50AM BLOOD Glucose-95 UreaN-24* Creat-0.9 Na-142 K-4.3 Cl-104 HCO3-31 AnGap-11 [**2101-2-14**] 01:26PM BLOOD UreaN-11 Creat-0.8 Cl-120* HCO3-22 [**2101-2-22**] 05:50AM BLOOD Mg-2.4 [**2101-2-15**] 03:09AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.6 [**Known lastname **],[**Known firstname **] [**Medical Record Number 110386**] M 66 [**2034-4-29**] Radiology Report CHEST (PA & LAT) Study Date of [**2101-2-22**] 9:27 AM [**Last Name (LF) **],[**First Name3 (LF) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 147**] FA6A [**2101-2-22**] 9:27 AM CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 110387**] Reason: evaluate left effusion [**Hospital 93**] MEDICAL CONDITION: 66 year old man with s/p cabg REASON FOR THIS EXAMINATION: evaluate left effusion Final Report PA AND LATERAL CHEST ON [**2-22**] HISTORY: Status post CABG. Evaluate left pleural effusion. IMPRESSION: PA and lateral chest compared to [**2101-2-20**]: Small left pleural effusion is stable, and there is no pneumothorax. Mild-to-moderate enlargement of the cardiac silhouette is stable but there has been a decrease in vascular plethora consistent with improving cardiac function. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] Approved: [**First Name8 (NamePattern2) **] [**2101-2-22**] 1:36 PM [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 110388**] (Complete) Done [**2101-2-14**] at 9:10:33 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2034-4-29**] Age (years): 66 M Hgt (in): 70 BP (mm Hg): 123/67 Wgt (lb): 185 HR (bpm): 78 BSA (m2): 2.02 m2 Indication: Intraoperative TEE for CABG and mitral valve repair. Chest pain. Left ventricular function. Mitral valve disease. Preoperative assessment. Pulmonary hypertension. Right ventricular function. ICD-9 Codes: 786.51, 424.0, 424.2 Test Information Date/Time: [**2101-2-14**] at 09:10 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1510**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2010AW2-: Machine: [**Doctor Last Name **] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Peak Pulm Vein S: 0.2 m/s Left Atrium - Peak Pulm Vein D: 0.4 m/s Left Ventricle - Ejection Fraction: 35% >= 55% Aorta - Ascending: 3.1 cm <= 3.4 cm Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Moderate regional LV systolic dysfunction. Moderately depressed LVEF. No resting LVOT gradient. RIGHT VENTRICLE: Mild global RV free wall hypokinesis. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. No MS. Moderate (2+) MR. TRICUSPID VALVE: Mild [1+] TR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions Prebypass No atrial septal defect is seen by 2D or color Doppler. There is moderate regional left ventricular systolic dysfunction with hypokinesia of the apical and mid portions of the inferior, inferolateral and inferoseptal walls.. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %). with mild global RV free wall hypokinesis. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2101-2-14**] at 900am Post bypass Patient is AV paced and receiving an infusion of phenylephrine and epinephrine. Biventricular systolic function is unchanged. Annuloplasty ring seen in the mitral position. Appears well seated. Mild mitral regurgitation persists. Mean gradient across the mitral valve is 4 mm Hg. Dr [**Last Name (STitle) **] aware. Aorta is intact post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2101-2-16**] 14:19 Brief Hospital Course: Was admitted same day surgery and underwent coronary artery bypass grafting and a mitral valve repair. For surgical details, please see operative note. Following the operation, he was brought to the CVICU for invasive monitoring. He took several days to wean from inotropic support. On postoperative day three, he transferred to the stepdown unit for ongoing post-operative care. He was started on betablockers, statins and diuresed toward his pre-operative weight. He was slow to wean from supplemental oxygen due to persistent left effusion requiring more aggressive diuresis. He responded well to additional IV Lasix and Zaroxolyn with oxygen saturation 93% on room air at the time of discharge. He was evaluated and treated by physical therapy for strength and conditioning. He was discharged to home on POD#8 in stable condition. Medications on Admission: Lasix 40mg QD Atenolol 25mg QD Aspirin 325mg QD Zocor 20mg QD Omeprazole 20mg QD Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours). Disp:*qs qs* Refills:*0* 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks: please follow up with cardiologist prior to completion . Disp:*14 Tablet(s)* Refills:*0* 9. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day for 2 weeks. Disp:*14 Capsule, Sustained Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: Coronary Artery Disease, Mitral Valve Regurgitation Chronic Systolic Congestive Heart Failure Hypertension Dyslipidemia COPD Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with dilaudid prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Please call to schedule appointments Surgeon Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] [**3-17**] at 1:30 PM Primary Care Dr. [**First Name (STitle) **] in [**2-5**] weeks Cardiologist Dr. [**Last Name (STitle) 13175**] in [**2-5**] weeks Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse will schedule Completed by:[**2101-2-22**]

[ "V58.66", "428.23", "424.0", "496", "V45.82", "414.01", "428.0", "401.9", "272.4" ]

icd9cm

[ [ [] ] ]

[ "36.15", "35.12", "39.61", "36.12" ]

icd9pcs

[ [ [] ] ]

10617, 10676

8282, 9122

317, 559

10845, 10941

2418, 3562

11482, 11894

1694, 1724

9253, 10594

3602, 3632

10697, 10824

9148, 9230

10965, 11459

6816, 8259

1739, 2399

246, 279

3664, 6767

587, 1129

1151, 1440

1456, 1678

25,117

165,600

44883

Discharge summary

report

Admission Date: [**2200-11-26**] Discharge Date: [**2200-12-3**] Date of Birth: [**2117-3-5**] Sex: F Service: MEDICINE Allergies: Gentamicin Attending:[**Doctor Last Name 10493**] Chief Complaint: Mechanical fall, leg pain Major Surgical or Invasive Procedure: Open Reduction/Internal Fixation Left Femur Intubation/Extubation History of Present Illness: History of Present Illness: 83 year-old female with history of systolic and diastolic CHF with EF 50%, hypertension presenting status post a mechical fall at home. She initially presented to the ED with left hip and thigh pain. In [**Hospital1 18**] ED, developed hypertension to the 220s/100s, rales, became hypoxemic, and was subsequently intubated. She was placed on nitroglycerin gtt. . Imaging included CT head read as negative for acute process, CT C-spine, hip/pelvis/femur films showing left femoral shaft fracture (closed, spiral, middle third). She received aspirin 600 mg PR x 1. It does not appear as if she received lasix. She received ciprofloxacin 400 mg IV x 1 for a urinalysis indicative of urinary tract infection. Past Medical History: 1. Chronic systolic and diastolic congestive heart failure, EF 50% per TTE [**4-/2198**] 2. Pulmonary embolus [**3-/2198**] 3. Hypertension 4. Gastroesophageal reflux disease 5. Meniere's disease 6. Distal radius fracture managed conservatively Past Surgical History 1. Status post L3, L4, L5 decompressive lumbar laminectomy for lumbar spinal stenosis [**4-/2195**] 2. Status post jaw surgery for cyst removals - unknown date 3. Status post abdominal wall lipoma excision [**12/2194**], [**2-/2195**] 4. Status post breast lumpectomy for benign lesion - unknown date 5. Status post right ear surgery [**2169**] Social History: SOCHX: Patient lives alone with her cat. She has a 60pack year smoking history widowed. Family History: no fam h/o heart dz, although father died suddenly at age 37 due to "heart problems" possibly associated with service in WWI, no h/o abnl clotting Physical Exam: ADMISSION EXAM: General Appearance: Intubated, sedated Eyes/Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: S1 normal, S2 normal Peripheral Vascular: Right radial pulse present, left radial pulse present, right DP pulse present, left DP pulse present Respiratory/Chest: Expansion symmetric, crackles at bases bilaterally Abdominal: Soft, non-tender, bowel sounds present Extremities: left leg splinted Skin: not assessed Neurologic: Sedated, intubated *** DISCHARGE EXAM: Vitals: Tc 98.6F, BP 142/50, HR 76, RR 20, Sat 95%4L; BP range (142-192/50-82); blood sugars 162-163 HEENT: OP clear, EOMI, PERRL Neck: No JVD Heart: RRR, normal S1/S2, 1-2/6 systolic murmur loudest at RUSB Lungs: Bibasilar crackles anteriorly; patient did not lean forward secondary to pain Abd: Soft, non-tender, non-distended + bowel sounds Ext: Warm, well-perfused; trace pitting edema on the left; staples in left thigh intact, wound clean and dry Neuro: A&O x 2 Pertinent Results: [**2200-11-25**] 10:30PM BLOOD WBC-15.4* RBC-4.25 Hgb-13.3 Hct-37.7 MCV-89 MCH-31.4 MCHC-35.4* RDW-14.8 Plt Ct-336 [**2200-11-26**] 08:42AM BLOOD WBC-18.5* RBC-3.39* Hgb-10.6* Hct-30.4* MCV-90 MCH-31.2 MCHC-34.8 RDW-14.8 Plt Ct-254 [**2200-11-26**] 07:43PM BLOOD Hct-31.7* [**2200-11-27**] 03:33AM BLOOD WBC-16.8* RBC-3.48* Hgb-11.2* Hct-31.1* MCV-90 MCH-32.0 MCHC-35.8* RDW-14.8 Plt Ct-231 [**2200-11-27**] 04:03PM BLOOD WBC-17.9* RBC-3.08* Hgb-9.6* Hct-27.6* MCV-90 MCH-31.3 MCHC-34.9 RDW-14.7 Plt Ct-235 [**2200-11-28**] 03:02AM BLOOD WBC-20.7* RBC-2.81* Hgb-8.8* Hct-24.8* MCV-88 MCH-31.4 MCHC-35.5* RDW-14.9 Plt Ct-243 [**2200-11-29**] 02:23AM BLOOD WBC-14.7* RBC-2.55* Hgb-7.9* Hct-22.7* MCV-89 MCH-31.2 MCHC-34.9 RDW-14.6 Plt Ct-179 [**2200-11-29**] 03:04PM BLOOD WBC-13.8* RBC-2.38* Hgb-7.5* Hct-21.5* MCV-91 MCH-31.5 MCHC-34.8 RDW-14.8 Plt Ct-199 [**2200-11-30**] 03:06AM BLOOD WBC-11.7* RBC-2.33* Hgb-7.2* Hct-21.3* MCV-91 MCH-31.1 MCHC-34.0 RDW-14.7 Plt Ct-222 [**2200-12-1**] 05:10AM BLOOD WBC-10.9 RBC-2.64* Hgb-8.0* Hct-23.6* MCV-89 MCH-30.4 MCHC-34.0 RDW-14.6 Plt Ct-288 [**2200-12-2**] 04:55AM BLOOD WBC-13.0* RBC-2.86* Hgb-8.8* Hct-25.7* MCV-90 MCH-30.9 MCHC-34.3 RDW-14.8 Plt Ct-307 [**2200-12-3**] 04:45AM BLOOD WBC-12.6* RBC-2.90* Hgb-8.9* Hct-26.2* MCV-90 MCH-30.6 MCHC-33.8 RDW-14.9 Plt Ct-326 [**2200-11-25**] 11:06PM BLOOD PT-12.2 PTT-23.8 INR(PT)-1.0 [**2200-11-26**] 03:37PM BLOOD PT-13.4 PTT-25.9 INR(PT)-1.1 [**2200-11-27**] 03:33AM BLOOD PT-17.1* PTT-38.4* INR(PT)-1.5* [**2200-12-3**] 04:45AM BLOOD PT-13.7* PTT-24.5 INR(PT)-1.2* [**2200-11-25**] 10:30PM BLOOD Glucose-124* UreaN-11 Creat-0.9 Na-143 K-3.2* Cl-105 HCO3-28 AnGap-13 [**2200-11-26**] 08:42AM BLOOD Glucose-146* UreaN-13 Creat-0.9 Na-144 K-3.3 Cl-107 HCO3-30 AnGap-10 [**2200-11-27**] 03:33AM BLOOD Glucose-117* UreaN-18 Creat-1.2* Na-144 K-3.7 Cl-106 HCO3-29 AnGap-13 [**2200-11-27**] 04:03PM BLOOD Glucose-124* UreaN-26* Creat-1.7* Na-140 K-3.8 Cl-105 HCO3-29 AnGap-10 [**2200-11-28**] 03:02AM BLOOD Glucose-116* UreaN-30* Creat-1.7* Na-142 K-3.5 Cl-107 HCO3-27 AnGap-12 [**2200-11-28**] 03:21PM BLOOD Glucose-131* UreaN-31* Creat-1.4* Na-144 K-3.8 Cl-108 HCO3-29 AnGap-11 [**2200-11-29**] 02:23AM BLOOD Glucose-111* UreaN-34* Creat-1.3* Na-144 K-3.8 Cl-108 HCO3-28 AnGap-12 [**2200-11-30**] 03:06AM BLOOD Glucose-111* UreaN-36* Creat-1.1 Na-146* K-3.9 Cl-110* HCO3-28 AnGap-12 [**2200-12-1**] 05:10AM BLOOD Glucose-122* UreaN-35* Creat-1.0 Na-148* K-3.5 Cl-110* HCO3-31 AnGap-11 [**2200-12-2**] 04:55AM BLOOD Glucose-131* UreaN-41* Creat-1.1 Na-152* K-3.5 Cl-111* HCO3-31 AnGap-14 [**2200-12-2**] 04:50PM BLOOD UreaN-46* Creat-1.1 Na-150* K-3.3 Cl-110* HCO3-30 AnGap-13 [**2200-12-3**] 04:45AM BLOOD Glucose-124* UreaN-46* Creat-0.9 Na-148* K-3.3 Cl-108 HCO3-31 AnGap-12 [**2200-11-25**] 10:30PM BLOOD CK(CPK)-61 [**2200-11-26**] 08:42AM BLOOD ALT-9 AST-24 LD(LDH)-230 CK(CPK)-224* AlkPhos-91 TotBili-0.7 [**2200-11-26**] 07:43PM BLOOD CK(CPK)-372* [**2200-11-27**] 03:33AM BLOOD CK(CPK)-462* [**2200-11-27**] 04:03PM BLOOD CK(CPK)-774* [**2200-11-28**] 03:02AM BLOOD CK(CPK)-567* [**2200-11-25**] 10:30PM BLOOD CK-MB-2 [**2200-11-25**] 10:30PM BLOOD cTropnT-LESS THAN [**2200-11-26**] 08:42AM BLOOD CK-MB-3 cTropnT-<0.01 [**2200-11-26**] 07:43PM BLOOD CK-MB-4 cTropnT-<0.01 [**2200-11-27**] 03:33AM BLOOD CK-MB-4 cTropnT-<0.01 [**2200-11-27**] 04:03PM BLOOD CK-MB-7 cTropnT-<0.01 [**2200-11-28**] 03:02AM BLOOD CK-MB-3 cTropnT-<0.01 [**2200-11-26**] 08:42AM BLOOD Calcium-7.9* Phos-3.9 Mg-1.9 [**2200-11-27**] 03:33AM BLOOD Calcium-8.7 Phos-3.9 Mg-1.8 [**2200-11-27**] 04:03PM BLOOD Calcium-8.4 Phos-4.4 Mg-1.7 [**2200-11-28**] 03:02AM BLOOD Calcium-8.3* Phos-3.5 Mg-1.7 [**2200-11-28**] 03:21PM BLOOD Calcium-8.3* Phos-3.9 Mg-1.9 [**2200-11-29**] 02:23AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.7* [**2200-11-30**] 03:06AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.6 [**2200-12-1**] 05:10AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.4 [**2200-12-2**] 04:55AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.1 [**2200-12-3**] 04:45AM BLOOD Calcium-8.6 Phos-4.2 Mg-2.2 ECG [**11-25**]: Sinus tachycardia Left atrial abnormality Left bundle branch block Since previous tracing of [**2200-2-19**], no significant change . CXR [**11-25**]: 1. Endotracheal tube ends at the thoracic inlet. 2. Pulmonary edema. . ECG [**11-26**]: Sinus rhythm Left atrial abnormality Left bundle branch block Since previous tracing of [**2200-11-25**], sinus tachycardia absent . CXR [**11-26**]: 1. ET tube is in appropriate position. 2. Pulmonary edema. . CT Head [**11-26**]: 1. No acute intracranial process, including no edema, hemorrhage or mass. 2. Findings consistent with chronic small vessel and lacunar infarction. 3. Age-related atrophy. . CT C-spine [**11-26**]: 1. No evidence of acute fracture or subluxation. 2. Multilevel degenerative changes with moderate ventral spinal canal narrowing and flattening of the thecal sac at the C6-7 level, which, in the setting of trauma, may predispose to cord injury. If there are myelopathic symptoms, or the patient cannot be assessed reliably, consider MR (with STIR sequence) for further evaluation. 3. Enlarged, heterogeneous thyroid gland, with bilateral nodules. 4. Biapical pulmonary interstitial septal thickening with pleural effusions; while these findings likely reflect volume overload/CHF, the dependent consolidation in the right upper lobe may represent aspiration pneumonitis, particularly, given the large amount of retained fluid in the esophagus and pharynx. Pneumonic consolidation is also a consideration; correlate with chest radiography. . Hip/femur film [**11-26**]: Displaced angulated mid left femoral diaphyseal fracture. . CXR [**11-26**]: In comparison with the earlier study of this date, there has been dramatic decrease in the diffuse pulmonary opacifications. The findings are consistent with substantial clearing of pulmonary edema. Opacification persists at the left base in the area behind the heart, consistent with atelectasis. Endotracheal and nasogastric tubes remain in place. . Echo [**11-27**]: The left atrium is moderately dilated. The right atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal for the patient's body size. There is mild global left ventricular hypokinesis (LVEF = 45-50 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. There is an anterior space which most likely represents a fat pad. Compared with the report of the prior study (images unavailable for review) of [**2198-5-4**], the left ventricle is more hypertrophied. Elevated estimated left ventricular filling pressure is now detected. . Carotid studies [**11-28**]: 1. 40-59% stenosis of the right internal carotid artery. 2. 70-79% stenosis of the left internal carotid artery. . CXR [**11-29**]: There is a Dobbhoff tube with tip in the proximal stomach. Again seen is volume loss and bibasilar airspace opacities and small effusions. Brief Hospital Course: Ms. [**Known lastname 96022**] is an 83 year old woman with history of systolic/diastolic heart failure, presenting after mechanical fall and pulmonary edema in the setting of hypertension. #) Hypertension. Known diastolic dyfunction and stiff arteries contributing. On lisinopril, metoprolol, clonidine, and hydralazine, which should continue to be titrated as tolerated for blood pressure control 120's-130's systolic. #) Respiratory distress. Secondary to flash pulmonary edema in the setting of hypertension; currently on 4L nasal cannula. Improved with Lasix and blood pressure control. Should continue to wean oxygen as tolerated and control blood pressure. Should receive Lasix with any fluid boluses (i.e. transfusions). Discharged on 40mg PO Lasix [**Hospital1 **], should continue on this dosage until oxygen saturations improve. #) Anemia. Baseline likely in the mid-30's, currently 25. Received one unit pRBC's on [**12-1**]. Currently asymptomatic, suspect down in the post-op setting. A repeat CBC should be performed on [**12-5**] to ensure hematocrit is stable; if she requires a blood transfusion, she should receive IV Lasix halfway through. #) s/p ORIF for left femoral shaft fracture. [**Month/Year (2) 1957**] following. Continue prophylaxis with Lovenox. She has two follow up appointments on [**12-17**] and [**12-29**]. Staples should be removed on [**12-10**]. #) Hypernatremia. Free water boluses at 250cc Q3H, with resolving hypernatremia. Should have a repeat sodium drawn on [**12-5**], with free water boluses adjusted accordingly. #) Chronic systolic and diastolic heart failure. Continued beta blocker, lisinopril, Lasix. #) Renal insufficiency. Renal function up to 1.7 during the admission, attributed to third spacing of fluid post-op and diuresis; improved now back to baseline. #) Leukocytosis. Elevated on arrival, has been very elevated in post-op setting, now stable around 12. Should have repeat CBC to ensure resolution. No signs/symptoms of infection. #) F/E/N. Tube feeds with free water boluses. Did not clear speech and swallow on [**12-3**]; should have repeat evaluation in [**1-13**] days to ensure no aspiration. #) Prophylaxis. Lovenox, bowel regimen. #) Code Status. DNR/DNI. No transfer to ICU. Confirmed with healthcare proxy. Medications on Admission: 1. Omeprazole 20 mg PO DAILY 2. Metoprolol Succinate 75 mg PO DAILY 3. Lisinopril 20 mg PO DAILY 4. Fluoxetine 40 mg PO DAILY 5. Calcium 600 mg-Vitamin D 400 unit PO DAILY 6. Aspirin 81 mg PO DAILY 7. Lasix 40 mg PO DAILY 8. Lipitor 10 mg PO DAILY 9. Multivitamin One Capsule PO DAILY 10. Ferrous Gluconate 325 mg PO DAILY Discharge Medications: 1. Lisinopril 10 mg Tablet [**Date Range **]: Three (3) Tablet PO DAILY (Daily). 2. Clonidine 0.1 mg Tablet [**Date Range **]: Two (2) Tablet PO TID (3 times a day). 3. Metoprolol Tartrate 50 mg Tablet [**Date Range **]: One (1) Tablet PO TID (3 times a day). 4. Hydralazine 10 mg Tablet [**Date Range **]: One (1) Tablet PO Q6H (every 6 hours): Hold for SBP < 160. 5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Date Range **]: One (1) Neb Inhalation Q6H (every 6 hours) as needed. 6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Date Range **]: [**12-11**] Puffs Inhalation Q4H (every 4 hours). 7. Enoxaparin 30 mg/0.3 mL Syringe [**Month/Day (2) **]: One (1) syringe Subcutaneous DAILY (Daily). 8. Furosemide 40 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO twice a day. 9. Aspirin 81 mg Tablet, Chewable [**Month/Day (2) **]: One (1) Tablet, Chewable PO DAILY (Daily). 10. Atorvastatin 10 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 11. Calcium Carbonate 500 mg Tablet, Chewable [**Month/Day (2) **]: One (1) Tablet, Chewable PO TID (3 times a day). 12. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 13. Multivitamin Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 14. Fluoxetine 20 mg Capsule [**Month/Day (2) **]: Two (2) Capsule PO DAILY (Daily). 15. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 16. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 17. Acetaminophen 500 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) mL PO every eight (8) hours. 18. Oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: Five (5) mL PO Q6H (every 6 hours) as needed for pain. 19. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 20. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) as needed. 21. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: Left femur fracture Respiratory failure secondary to flash pulmonary edema Secondary: Diastolic heart failure Hypertension Hypertension Anemia Discharge Condition: Stable, O2 sats 96-98% on 4L Discharge Instructions: It was a pleasure taking care of you during your hospitalization. You were admitted after a fall, during which you broke your left femur. It was repaired in the operating room on [**11-28**]. However, while in the ER, you developed respiratory distress, and you were subsequently intubated. . You are being discharged to the MACU at [**Hospital3 **] Center, where your medications may be changed slightly. They will continue to work to get your BP under control and your respiratory status stable, as well as give you the physical therapy that you need to heal from your fracture. Please take all of your medications as prescribed, and keep your follow up appointments as scheduled. . If you develop shortness of breath, chest pain, abdominal pain, nausea, vomiting, or diarrhea, please seek medical attention as soon as possible. Followup Instructions: Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2200-12-18**] 8:40 Provider: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1228**] Date/Time:[**2200-12-18**] 9:00 Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2200-12-30**] 9:25 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2200-12-30**] 9:45 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]

[ "780.62", "428.42", "285.1", "288.60", "386.00", "514", "403.00", "518.81", "428.0", "585.9", "530.81", "E885.9", "276.0", "821.01", "V12.51" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.72", "79.35", "99.04", "96.04" ]

icd9pcs

[ [ [] ] ]

15366, 15432

10457, 12752

298, 365

15627, 15657

3043, 10434

16536, 17221

1889, 2039

13126, 15343

15453, 15606

12778, 13103

15681, 16513

2054, 2537

2553, 3024

233, 260

422, 1129

1151, 1765

1781, 1873

65,636

144,994

2641

Discharge summary

report

Admission Date: [**2197-11-3**] Discharge Date: [**2197-11-11**] Service: NEUROLOGY Allergies: Sulfa (Sulfonamide Antibiotics) / Penicillins Attending:[**First Name3 (LF) 13252**] Chief Complaint: seizures Major Surgical or Invasive Procedure: Endotracheal intubation Lumbar puncture History of Present Illness: The pt is a [**Age over 90 **] y/o woman with a history of AD. lives in a nursing home. Had a witnessed GTC x3 min. EMS called, came back to baseline. EMS noted another GTC x3 min. Ativan 2mg given. At OSH GTC x2, 2mg Ativan and dilantin load given 1g. Intubated for airway protection. Was given two different paralytic. Here seen initially off propofol. Not following commands and intubated. At baseline, pt is able to feed herself and walk with a walker. Is unable to carry on a conversation "she just repeats herself and talks about how much she loves her kids". 4 days prior to admission, she was diagnosed with a URI because of cough and fever for one day to 99.0 (initially thought to be PNA, but had a CXR that did not show an opacification) and put on ABx (? which one). She was sleepy and eating less until the day prior to admission when she was able to walk with a walker to the dining room. Per her daughter she was "back to baseline" the day prior to admission but then when her daughter was leaving, pt had an episode of "slurred speech and speaking nonsense". Pt's daughter became concerned, and told the nurses she thought that her mother may have had a stroke. She then got a phone call that 5 mins after that episode, pt had had a seizure. EMS called, pt came back to baseline. However, EMS noted another GTC x3 min. Ativan 2mg given. Pt was brought to an OSH where she had two more GTCs. She was given 2mg Ativan and 1gram of dilantin load given. Patient was intubated for airway protection and sent to [**Hospital1 18**]. When here, pt was found to have an alcohol level of 129. When asked about alcohol level, pt's family was shocked, reported that pt has no access to alcohol and has "never liked alcohol, she doesn't drink". . Past Medical History: AD OA spinal stenosis GERD monoclonal paraproteinemia. Social History: lives at [**Location **], family denies EtOH Family History: unknown Physical Exam: ADMISSION PHYSICAL EXAM: Physical Exam: Vitals: 97.1 p71 bp172/53 RR 20 O2 100% General: Intubated and sedated HEENT: NC/AT, Neck: No nuchal rigidity Pulmonary: Lungs CTA bilaterally Cardiac: RRR, nl. S1S2 Abdomen: soft, NT/ND. Extremities: No edema. Skin: no rashes or lesions noted. Neurologic: Intubated off propofol x 10 min. Not opening eyes to pain or voice. Pupils 2 to 1 reactive, symmetric. No BTT. No corneal b/l. no VOR noted. + gag. B/L localizing to sternal rub. At the LE's would withdraw to pain. Tone appreciated as normal. toes upgoing. Reflexes brisk at the biceps 2; 1 at the patella and 0 at the ankles. Pertinent Results: [**2197-11-2**] 11:29PM BLOOD WBC-18.2* RBC-3.32* Hgb-10.1* Hct-28.8* MCV-87 MCH-30.4 MCHC-35.1* RDW-16.1* Plt Ct-325 [**2197-11-2**] 11:29PM BLOOD Neuts-48* Bands-0 Lymphs-49* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2197-11-2**] 11:29PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-NORMAL Microcy-1+ Polychr-NORMAL [**2197-11-2**] 11:29PM BLOOD PT-16.3* PTT-30.6 INR(PT)-1.5* [**2197-11-2**] 11:29PM BLOOD Glucose-220* UreaN-5* Creat-1.4* Na-140 K-6.8* Cl-104 HCO3-23 AnGap-20 [**2197-11-3**] 03:58AM BLOOD ALT-UNABLE TO AST-100* CK(CPK)-257* AlkPhos-54 TotBili-0.2 [**2197-11-2**] 11:29PM BLOOD Calcium-10.0 Phos-4.5 Mg-2.5 [**2197-11-4**] 12:35PM BLOOD VitB12-855 Folate-GREATER TH [**2197-11-3**] 03:58AM BLOOD Ferritn-72 [**2197-11-3**] 03:58AM BLOOD TSH-3.7 [**2197-11-2**] 11:29PM BLOOD Phenyto-17.8 [**2197-11-3**] 03:58AM BLOOD ASA-NEG Ethanol-129* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2197-11-2**] 11:59PM BLOOD Type-ART Rates-/14 Tidal V-400 PEEP-5 FiO2-100 pO2-413* pCO2-44 pH-7.39 calTCO2-28 Base XS-1 AADO2-265 REQ O2-51 -ASSIST/CON Intubat-INTUBATED [**2197-11-2**] 11:29PM URINE Blood-SM Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2197-11-2**] 11:29PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.025 [**2197-11-2**] 11:29PM URINE RBC-1 WBC-5 Bacteri-NONE Yeast-NONE Epi-1 Discharge Labs: [**2197-11-11**] 04:29AM BLOOD WBC-10.1 RBC-3.31* Hgb-9.4* Hct-29.9* MCV-90 MCH-28.3 MCHC-31.4 RDW-15.4 Plt Ct-352 [**2197-11-11**] 04:29AM BLOOD Plt Ct-352 [**2197-11-6**] 12:41AM BLOOD PT-16.3* PTT-39.3* INR(PT)-1.4* [**2197-11-11**] 04:29AM BLOOD Glucose-107* UreaN-14 Creat-0.8 Na-140 K-4.5 Cl-104 HCO3-25 AnGap-16 [**2197-11-10**] 04:25AM BLOOD Calcium-8.6 Phos-2.6* Mg-2.1 Lipids: [**2197-11-3**] 03:58AM BLOOD Triglyc-1823* HDL-33 CHOL/HD-15.0 LDLmeas-LESS THAN [**2197-11-4**] 12:35PM BLOOD Triglyc-879* HDL-30 CHOL/HD-14.9 LDLmeas-188* [**2197-11-5**] 02:32AM BLOOD Triglyc-602* HDL-33 CHOL/HD-12.0 LDLmeas-247* [**2197-11-6**] 06:23AM BLOOD Triglyc-520* [**2197-11-8**] 02:01AM BLOOD Triglyc-929* [**2197-11-10**] 04:25AM BLOOD Triglyc-735* CSF Studies: [**2197-11-4**] 04:44PM CEREBROSPINAL FLUID (CSF) EBV, VZV, HSV: negative [**2197-11-4**] 04:44PM CEREBROSPINAL FLUID (CSF) TotProt-30 Glucose-68 [**2197-11-4**] 04:44PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-0 Lymphs-93 Monos-8 Microbiologic Data: [**2197-11-4**] 4:44 pm CSF;SPINAL FLUID Source: LP. **FINAL REPORT [**2197-11-5**]** CRYPTOCOCCAL ANTIGEN (Final [**2197-11-5**]): CRYPTOCOCCAL ANTIGEN NOT DETECTED. [**2197-11-4**] 4:44 pm CSF;SPINAL FLUID Source: LP TUBE # 3. GRAM STAIN (Final [**2197-11-4**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2197-11-7**]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED. [**2197-11-5**] 7:47 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2197-11-7**]** GRAM STAIN (Final [**2197-11-5**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [**2197-11-7**]): Commensal Respiratory Flora Absent. STAPH AUREUS COAG +. MODERATE GROWTH. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . 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. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=0.5 S [**2197-11-5**] 12:00 pm Mini-BAL **FINAL REPORT [**2197-11-7**]** GRAM STAIN (Final [**2197-11-5**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [**2197-11-7**]): Commensal Respiratory Flora Absent. STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES PERFORMED ON CULTURE # 332-7479K [**2197-11-5**]. Neuroimaging: MRI: No evidence of acute infarcts seen. No definite signs of chronic cortical infarcts identified. Moderate to severe changes of small vessel disease seen with moderate cortical atrophy. Evidence of a medial temporal atrophy particularly on the right side is noted with dilatation of the temporal horns. Other findings as above. EEG ([**2197-11-5**]): This is an abnormal continuous ICU monitoring study because of moderate diffuse background slowing and disorganization, with continuous focal attenuation and occasional epileptiform discharges in the left temporal region. These findings are indicative of potentially epileptogenic focal cortical dysfunction in the left temporal region, possibly structural in origin. Alternatively, the focal attenuation could represent a postictal pattern. This is superimposed on moderate diffuse cerebral dysfunction, which is etiologically nonspecific. Compared to the prior day's recording, background frequencies have improved slightly, indicating improvement in diffuse cerebral dysfunction, but the left hemisphere remains attenuated, and epileptiform discharges have increased slightly in frequency. No electrographic seizures are present. EEG ([**2197-11-4**]): This is an abnormal continuous ICU monitoring study because of moderate diffuse background slowing and disorganization, with continuous focal attenuation and occasional epileptiform discharges in the left temporal region. These findings are indicative of potentially epileptogenic focal cortical dysfunction in the left temporal region, possibly structural in origin. Alternatively, the focal attenuation could represent a postictal pattern. This is superimposed on moderate diffuse cerebral dysfunction, which is etiologically nonspecific. Compared to the prior day's recording, background frequencies have improved slightly, indicating improvement in diffuse cerebral dysfunction, but the left hemisphere remains attenuated, and epileptiform discharges have increased slightly in frequency. No electrographic seizures are present. NCHCT ([**2197-11-3**]): No acute intracranial process with marked sinus opacification, perhaps related to intubation. EKG: Sinus rhythm. Minor non-specific ST segment abnormality. No previous tracing available for comparison. Rate PR QRS QT/QTc P QRS T 74 98 86 382/406 75 33 59 Brief Hospital Course: [**Known firstname **] is a [**Age over 90 **] y/o woman with history of Alzheimer's dementia who presented as an OSH transfer in apparent status epilepticus. She was loaded with AEDs, intubated and sent to [**Hospital1 18**], where she was worked up for a cause of her seizure. # NEURO: When she arrived she was intubated and sedated. However, even after propofol was weaned off her exam was limited and she did not follow commands or open her eyes to stimulation. She was continued on phenytoin IV 100mg Q8H, and her EEG did not show any seizure activity. Her MRI that did not show any acute process. Her alcohol level on arrival was 129, which her family reported was impossible because she did not drink alcohol ever. Then, 12 hours later her alcohol level was 149 when she clearly had not had any access to alcohol. The cause of this was not determined. She was switched to keppra to prevent any med-med reactions and to avoid any possible cognitive slowing [**2-22**] dilantin. She had an LP done which was unremarkable. Her EEGs continued to show no seizure activity but she remained very somnolent. Ultimately, following extubation, she was transferred to the floor. Prior to discharge, her neurological examination was reportedly at baseline per her family. She is a little bit more lethargic than usual, but awake, makes reasonably good eye contact, may follow commands intermittently. During the transition from ICU to the floor, as her mental status was returning to baseline, she was noted to be a little agitated at times, occasionally pulling at her lines and EEG leads. She did require restraints briefly, but has not required mits/wrist restraints in the 24 hours prior to her transfer back to the NH. # CARDS: We restarted patient's home baby aspirin. We monitored her on telemetry while she was here and there were no events noted. As a part of a routine work up for a possible stroke, we checked a lipid panel which showed an extremely elevated triglyceride level. This was checked in the setting of propofol sedation, and so may have been spuriously elevated. Her TG level continued to downtrend as propofol was weaned off. She received a few days of statin therapy, but deferred any long term treatment until the outpatient setting until her lipid panel can be checked again. # PULM: She arrived intubated, but was able to be successfully extubated on [**11-8**]. However, her hospital course was complicated by a VAP (see below) for which she was treated with antibiotics. She was given PRN doses of lasix to prevent her 6L positive volume overload from effecting her lungs. Her oxygenation remained in the mid-90's on NC once extubated, and remained stable from a respiratory standpoint following extubation and tolerated being without a nasal cannula. # ID: pt arrived with leukocytosis, which increased from 18->19 within the first 24 hours then began to drop. She remained afebrile throughout much of her stay, but spiked a fever on the night of [**11-4**] and was pan-cultured. She was started on vancomycin, cefepime and tobramycin. Her BAL and sputum Cx grew out MRSA and she was continued on vancomycin and other ABx were D/C'd. Day 1 of vancomycin was [**11-5**], she is to finish a presumed 14 day course for VAP, to end on [**2197-11-19**]. To receive long term antibiotics, a PICC line was placed. # HEMATOLOGY: HCT dropped on arrival from 28->23, of unclear cause. We guiac'd all pt's stools and they were negative. Her HCT continued to drop to 21, and she ws given 1u pRBC with improvement. However, it was felt that her HCT drop was likely dilutional because she was 6L positive for her LOS and when given some lasix her HCT improved. # RENAL: unclear Cr baseline, she arrived at a mildly elevated creatinine of 1.2. This improved with fluid hydration as above. # CODE: DNR but okay to remain intubated, confirmed with family. Patient lives at Nursing Life Care of [**Location (un) 3320**] if futher questions needed. TRANSITIONAL CARE ISSUES: - Continue vancomycin until [**11-19**]. Please make sure that patient does not pull at her PICC line. Consider wrapping it up in dressing when not in use. - Continue keppra 500mg [**Hospital1 **] indefintely, patient to follow up with her own neurologist. - Please monitor levels of vancomycin especially if other medications will be changed - Have patient follow up with PCP and neurologist - Please check a repeat lipid panel in [**1-22**] weeks - Obtain a repeat CXR following resolution of vancomycin therapy to check for clearance of VAP Medications on Admission: Alendronate ASA 81 Sertraline 12.5 daily omeprazole folate, Vit D, Calcium albuterol prn Discharge Medications: 1. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. vancomycin 500 mg Recon Soln Sig: 750mg Recon Solns Intravenous Q 24H (Every 24 Hours): Stop on [**2197-11-19**]. Recon Soln(s) 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. sertraline 25 mg Tablet Sig: Half Tablet PO once a day. 5. Multi-Vitamins W/Iron Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. Discharge Disposition: Extended Care Facility: Life Care Center of [**Location (un) 3320**] Discharge Diagnosis: Alzheimer's disease Seizure Disorder Osteoarthritis GERD Monoclonal paraproteinemia Discharge Condition: Mental Status: Confused, poorly oriented but interactive. Level of Consciousness: Variable, lethargic at times, interactive at other times Activity Status: Bedbound. Discharge Instructions: Dear Ms. [**Known lastname 13253**], You were seen in the hospital because of multiple seizures. You were admitted to the intensive care unit where you received an intensive level of care, particularly with your breathing tube. We obtained an MRI of your brain, as well as obtained a lumbar puncture which allowed us to rule out very serious causes of new seizures such as bleeding, stroke, infections, or other such causes. It is most likely that your seizures are a consequence of longstanding Alzheimer's disease, and this was exacerbated in the setting of an upper respiratory tract infection. - We started you on a medication called Keppra for preventing further seizures. Please be sure to take all your medications as instructed below. - We also initiated you on a medication called vancomycin, which we would like for you to take by IV (intravenously) until [**2197-11-19**]. This is to treat a pneumonia that you developed during your stay here. - It was a pleasure taking care of you during this hospitalization. Do not hesitate to contact us should further questions arise. If you experience any of the below listed Danger Signs, please contact your doctor or go to the nearest Emergency Room. It was a pleasure taking care of you on this hospitalization. Followup Instructions: Please call your primary care physician (PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 13254**]) as well as your outside neurologist to set up a follow up appointment. [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 13255**] Completed by:[**2197-11-11**]

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Discharge summary

report

Admission Date: [**2111-12-6**] Discharge Date: [**2111-12-26**] Date of Birth: [**2056-11-5**] Sex: F Service: MEDICINE Allergies: Wellbutrin Attending:[**First Name3 (LF) 2186**] Chief Complaint: L3 osteo and question abscess Major Surgical or Invasive Procedure: 1. Multiple thoracic laminectomies, extending from T4-T12 and total laminectomies from L1-L5 with evacuation of epidural abscess as well as intradural abscess. 2. Excision and debridement. 3. Repair of dural degradation. History of Present Illness: 55 y/o female with PMH significant for lung cancer in [**2109**], HTN, and [**Hospital **] transferred from [**Hospital 1474**] Hospital for further treatment of L3 osteo and question of an abcess at that level. Pt was in her normal state of health until early [**11/2111**] when she developed low back pain while bending over. She was evaluated by her PCP for this on [**11-26**] and prescribed percocet and flexeril. Her pain did not resolve and she presented to the [**Hospital1 1474**] ED for further evaluation on [**11-30**]. She described the pain as a constant stabbing pain associated weakness. The pain was increased with ambulation. At that time, the pt denied loss of bowel or bladder control. Spinal films were significant for anterolisthesis of L3-4 and L4-5. No fracture or destructive lesion was noted. Pt's SBP was decreased in the 70s but responded to a fluid bolus. Per notes from [**Hospital 1474**] Hospital, she was going to be admitted and receive a MRI but decided to go home. Pt then called EMS from home on [**12-2**] to be trasported to [**Hospital1 1474**] secondary to her ongoing low back pain. Her husband reports that she was unable to ambulate at that time due to bilateral LE weakness. Per EMS notes, her VS were HR 138, BP 86/P, and a RR of 20. Per notes, pt had noted recent fevers at home up to 101. Her family reports that these had started occuring when she developed the back pain. In the [**Hospital1 1474**] ED, she received toradol and dilaudid with a decrease in her SBP into the 70s. She also received Tequin and Flayl. A CT of the abdomen and pelvis was obtained that showed marked distention of the gallbladder. . Pt was initially admitted to the MICU at [**Hospital 1474**] Hospital. There, she received IV fluids and was started on a dilaudid PCA for pain control. Pt was then transferred to the floor on the day of admission. On the floor, she developed respiratory distress and became obtunded. She was noted to have crackles on exam and was given lasix 60 mg IV x1 with some improvement of her respiratory status. However, approximately five hours later, she once again developed increased respiratory effort. CXR was consistent with pulmonary edema. Pt was given another 60 mg of IV lasix and put out 300 cc of urine in the next 1.5 hours. Her BP was 100/60 and she remained obtunded. Pt was given another 80 mg of IV lasix and transferred back to the MICU for further care. In the MICU, the pt was placed on BiPAP 10/5. Her oxygen sats were 94 to 100%. She was noted to be in new atrial tachycardia with a HR ranging from 140 to 170 so was gien Dilaudid 2 gm IV x1. Pt's SBP then decreased to the 70s. A right femoral A line and central line were placed. The pt was cardioverted with return to sinus rhythem. An echo was done which was significant for a LVEF of 65 to 70%, diminished RV function, and mild TR. There was a concern at that time that the pt had sufferred a PE. It was felt that she was not stable enought to receive a VQ scan or CTA so she was emperically started on a heparin drip. . During her time in the [**Hospital1 1474**] MICU, the pt's blood cultures returned growing gram positive cocci. These were obtained prior to placement of her central line. The pt was started on vamcomycin and zosyn. Her creatinine increased to a high of 2.4 and has now trended down to 1.8. A CT scan of the lumbosacral spine was obtained that was concerning for osteomyelitis of L3. There was also concern for an abcess in this area. She could not receive a MRI at [**Hospital1 1474**] as she was intubated. Therefore, the pt was transferred to [**Hospital1 18**] for further care. Past Medical History: 1. Small cell lung carcinoma on the right- Pt was diagnosed in [**2109**]. She was treated with chemotherapy and radiation. She did not have any surgery. Per her family, it was not known to be metastatic and she has been in remission for over on year. Oncologist is Dr [**Last Name (STitle) 21628**] at [**Telephone/Fax (1) **] 2. [**Name (NI) **] Pt had a non ST MI in [**2110**] in the setting of a COPD exacerbation. Pt had a stress test in [**2110**] which was signifcant for a LVEF of 38% and a moderate sized fixed inferior lateral defect. 3. Hypertension 4. GERD 5. S/P excision of lipoma 6. S/P eye surgery 7. S/P knee surgery 8. S/P tonsillectomy 9. COPD 10. Anxiety 11. MRSA bactaremia during her chemotherapy. Social History: Pt lives at home with her husband. She works as a receptionist. She currently smokes. No ETOH or drugs. Family History: non-contrib Physical Exam: 98.3 126/74 103 31 100% AC 550/16/.40/PEEP 5 Gen- Heavily sedated. Not responding at all. HEENT- NC AT. PERRL. Anicteric sclera. MMM. Mild bleeding from tongue following oral care. Cardiac- RRR. S1 S2. No m,r,g. Pulm- CTA anteriorly and laterally. Abdomen- Obese. Soft. NT. ND. Positive bowel sounds. Extremities- 1+ edema to mid calf bilaterally. 2+ DP pulses bilaterally. Erythema between the thighs. Hematoma of the anterior left arm with break in the skin. Neuro- Heavily sedated. Not responsive. Downgoing toes bilaterally. No clonus. Weak, symmetric DTRs. Pertinent Results: Culture date from [**Hospital1 1474**]: micro lab [**Telephone/Fax (1) 65800**] Urine culture ([**12-5**])- FINAL- No growth Sputum culture ([**12-5**])- Many staph aureus. Blood culture- [**2-25**] MRSA - [**2-25**] GPC. . CT abdomen and pelvis ([**12-3**]-[**Hospital1 1474**])- Moderate to marked gallbladder distention without surrounding inflammatory change. No definite ureteral catheters or obstructive hydroureteronephrosis. Aortic calcification without evidence of aneurysm or leak. No definite intra abdominal or pelvic inflammatory process. Patchy left lower lung interstitial opacity. Slight nodular thickening of the left adrenal gland. Small retroperitoneal lymph nodes. . CT lumbar spine ([**12-5**]-[**Hospital1 1474**])- Moderate erosion of the face joints bilaterally at L3-4 and L4-5. Vacuum phenomenon is noted in the right L4-5 facet joint raising the question of septic arthritis. Mild nonspecific edema of the subcutaneous tissues posteriorly in the midline extending from L1 to at least L5 most pronounced at L4. There is a suggestion of a 2 x 1.5 cm fluid collection in the midline posterior to the L3 and L4 spinous processes. The thecal sac and the epidural space cannot be evaluated at these levels. In the thecal sac at the level of L5 and S1 there are whate appear to be vertically oriented linear calcifications that is suspicious for arachnoiditis ossificans. At L1-2, L2-3, and L5-S1 there is no disc herniation, central stenosis, or foraminal stenosis. . MR L spine ([**12-8**]) - Large multilobulated fluid collection centered at L3-4, extending bilaterally into the perivertebral soft tissues and posteriorly into the midline subcutaneous tissues. In addition, there is a large epidural collection, presumably abscess, which extends at least as far superiorly as T11. The superior extent of this collection is unknown. In addition, a right psoas/iliopsoas abscess is present. The full extent of this abscess is also not determined. . MR C/T spine ([**12-8**]) - Severe arachnoid and ependymal enhancement most compatible with an intradural inflammatory or infectious process. No discrete epidural fluid collection is definitely seen in the thoracic or cervical spine in this somewhat technically limited examination. . TTE ([**12-7**]) - Preserved global and regional biventricular systolic function. No valvular pathology or pathologic flow identified. Mild pulmonary artery systolic hypertension. . TEE ([**12-25**]): 1. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 2. The PICC line tip is seen entering the right atrium, and is free of mass or vegetation. 3. No echocardiographic evidence of endocarditis. . CT chest ([**12-7**]): No evidence of focal consolidation or mass within the lungs. Scarring is seen within the right upper lobe anteriorly. Minor bibasilar atelectasis. . CT pulm angio ([**12-17**]): No evidence for central or segmental pulmonary embolus. No evidence of focal airspace consolidation or mass within the lungs. New small right pleural effusion with mild associated subsegmental compressive atelectasis. Stable right upper lobe scarring. . Intraoperative swab culture of spine abscess ([**2111-12-9**]): STAPH AUREUS COAG +. HEAVY GROWTH. _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 4 I OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=1 S Brief Hospital Course: 1) Abscess: At [**Hospital1 18**], pt received an MRI of C/T/L spine demonstrating a large epi/intra-dural abscess, involving the perivertebral soft tissues and extending into the psoas and ileopsoas. She was taken to the OR for evacuation of this abscess, with T4-L5 laminectomies. Intraoperative cultures grew MRSA, and pt was continued on vancomycin for this MRSA abscess as well as the MRSA bacteremia at OSH. Pt was followed by ID consult service during hospitalization. They recommended an 8-week course of vancomycin. Her last day of IV Vancomycin is [**2112-2-7**]. Pt had good symptomatic control of her post-operative pain on a 75 mcg fentanyl patch, with IV and PO morphine for breakthrough pain. Her lower extremity strength remained weak. However, pt was able to tolerate several hours of sitting in a chair with physical therapy by the end of hospitalization. . 2) Skin lesions: pt was noted to develop indurated, erythematous rashes on her right and left upper extremities, as well as her right lower extremity. These initially appeared cellulitic and pt was already on vancomycin therapy for gram positive coverage. However, these lesions failed to improve. Levofloxacin was added to her antibiotic regimen for gram negative coverage. She is to complete 10 more days of levofloxacin 500mg po qd after discharge per Infectious Disease consult recs. There was also concern that these lesions could represent embolic seeding from endocarditis, given her high-grade MRSA bacteremic. However, a TTE was negative and a subsequent TEE was negative as well. Dermatology was consulted and they biopsied the left upper extremity lesion. Preliminary results of the biopsy were nonspecific, consistent with an acute on chronic inflammatory process. . 3) Respiratory distress: Pt sufferred respiratory distress at the OSH necessitating intubation. The etiology was thought likely multifactorial, including decreased respiratory drive with sedation from pain medications in addition to pulmonary edema from the large volume of IV fluid complicated by her tachyarrthmia. There was initially also concern for a PE. However, she had a standard chest CT with contrast, as well as a CT pulmonary angiogram that was only significant for post-XRT scarring. After extubation, pt's pulmonary status remained stable, though with a persistent O2 requirement of 2L by nasal canula. This improved with activity, and the pt maintained an oxygen saturation > 95% on room at the time of discharge. . 4) Nutrition: Pt had an NG placed for tubefeeds, as she remained intubated early during hospitalization. After extubation, a swallow study was performed on [**12-16**]. However, the pt failed and was felt to be at risk for aspiration. She was therefore kept NPO with TF. Subsequent attempts for repeat swallow studies were delayed secondary to altered mental status. On [**12-21**], after pt's mental status cleared, she self D/C'ed her NG tube. A swallow study at that time cleared her to advance to nectar-thick liquids. She was periodically reevaluated throughout hospitalization and her diet advanced as tolerated. At the time of discharge, she was tolerating a ground solid diet with her dentures. However, she continued to require supplemental IV fluid hydration secondary to poor PO intake. . 5) Tachycardia: pt was tachycardic, with a heart rate between 100 and 140 the first several days after extubation. The pt had been aggressively diuresed in the days prior for pulmonary edema, and the etiology of her tachycardia was presumed secondary to a combination of dehydration and persistent fevers. Her tachycardia improved with gentle fluid resuscitation and control of her infection and fever. . 6) Hyponatremia: pt was noted to have a serum sodium in the low 130s, presumed secondary to volume depletion. She responded to fluid hydration. . 7) ARF: Pt was found to be in acute renal failure at OSH with her creatinine peaking at 2.4, thought likely from hypotension precipitating ATN. Her creatinine quickly normalized after transfer to [**Hospital1 18**], stabilizing at 0.7-0.8. . 8) Small cell lung cancer: Pt was treated for small cell lung cancer in [**2109**]. Per her family, she never had any known mets and has been in remission for over one year. She was scheduled for a follow-up scan the week she was admitted to OSH. Multiple CT scans while hospitalized at [**Hospital1 18**] did not show evidence of local recurrence or mets. . 9) CAD/HTN: Pt has a h/o troponin leak assoc with chest pain, thought to represent demand ischemia in setting of COPD exacerb with mild anemia (OSH records reviewed). She had a cardiac stress on that admission, which showed a fixed inf-lat defect with an EF 38%. She has not had a cardiac catheterization. Echocardiogram here on [**12-7**] (and subsequent TEE on [**12-25**]) showed nl EF>65%. Her metoprolol was continued at a dose of 100mg PO TID, with good control of her BP. . 10) GERD: Pt received a PPI during hospitalization for GI prophylaxis. . 11) Access - She had a right PICC line placed under radiographic guidance on [**12-18**]. . 12) Code: Pt was made DNR/I during hospitalization, accordance with pt and family wishes. Medications on Admission: 1. ASA 81 mg daily 2. Verapamil 120 mg daily 3. Lisinopril 10 mg daily 4. Protonix 40 mg daily 5. Ativan 1 mg [**Hospital1 **] 6. Plavix 75 mg daily 7. Toprol 100 mg daily Discharge Medications: 1. Acetaminophen 160 mg/5 mL Solution Sig: Thirty (30) mL PO Q4-6H (every 4 to 6 hours) as needed. 2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation [**Hospital1 **] (2 times a day). 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. Papain-Urea [**Telephone/Fax (3) 3335**] unit-mg/g Ointment Sig: One (1) Appl Topical DAILY (Daily). 7. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 8. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 10. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed: Each port daily and as needed. 11. Pantoprazole 40 mg IV Q24H chronic therapy 12. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) g Intravenous Q 12H (Every 12 Hours) for 42 days. Disp:*qs * Refills:*0* 13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: as dir ML Intravenous DAILY (Daily) as needed: 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. . 14. Morphine 4 mg/mL Syringe Sig: 4-8 mg Injection Q4H (every 4 hours) as needed. 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 16. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Primary: Intradural/Epidural MRSA Abcess Secondary: HTN Coronary Artery Disease Delerium Hyponatremia Respiratory Distress Acute Tubular Necrosis - Acute Renal Failure Discharge Condition: Hemodynamically Stable Afebrile, able to swallow, working with PT Discharge Instructions: Please take all medications and make all appointments as listed in the discharge paperwork. If you have fevers, chills, chest pain, shortness of breath, abdominal pain, or other concerning . Patient will need agressive PT. She will also need to complete her course of IV vancomycin. She will take this until [**2-7**], [**2112**]. Followup Instructions: Primary Care Provider [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 34561**] [**Telephone/Fax (1) 33330**] --- [**2111-1-29**] 2pm . Neurosurgery - Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] - [**Telephone/Fax (1) 3573**] --- [**2112-1-1**] 10:15 am . Dermatology: Dr [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2112-1-14**] 11:15 . Infectious Disease - appt is scheduled with Provider: [**Name10 (NameIs) 1037**] [**Name8 (MD) 65801**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2112-1-20**] 10:00 Completed by:[**2111-12-26**]

[ "567.31", "995.92", "324.1", "276.1", "V09.0", "293.0", "276.51", "491.21", "038.11", "V10.11", "707.10", "518.81", "428.0", "V15.3", "584.5", "682.3", "730.08", "682.6" ]

icd9cm

[ [ [] ] ]

[ "88.72", "83.45", "86.28", "86.04", "03.09", "96.6", "03.59", "86.11", "99.04", "38.93", "96.72" ]

icd9pcs

[ [ [] ] ]

16577, 16674

9444, 14621

302, 535

16887, 16955

5698, 9421

17338, 18012

5083, 5096

14843, 16554

16695, 16866

14647, 14820

16979, 17315

5111, 5679

233, 264

563, 4201

4223, 4946

4962, 5067

79,584

158,216

36095

Discharge summary

report

Admission Date: [**2113-6-21**] Discharge Date: [**2113-7-4**] Date of Birth: [**2028-9-8**] Sex: M Service: CARDIOTHORACIC Allergies: Percocet / Vicodin / cefazolin / Penicillins Attending:[**First Name3 (LF) 1505**] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: CABG x3 (LIMA-LAD, SVG-OM, SVG -PDA) [**2113-6-30**] History of Present Illness: 84M s/p revision of R TKA on [**6-13**] who originally presented to [**Hospital3 **] from rehab with h/o MS changes. At the time of admission, he was unable to clearly answer questions, and was febrile to 101. A CXR revealed a LLL infiltrate and the patient was started on levaquin and vancomycin. The patient had a troponin on his admission of 0.04 and subsequent labs demonstrated a trop of 1.38, with an eventual peak of 1.65 (CK247, CK/MB 3.1). His mentas status improved and he underwent nuclear imaging with a fixed inferior-posterior hypokineesis. Cardiac cath was performed showing three vessel disease and the patient was transferred to [**Hospital1 18**] for further evaluation. Past Medical History: HTN, HL, AAA, AF on coumadin Social History: Last Dental Exam: unkown Lives with: wife Cigarettes: Smoked no [] yes [X] last cigarette __5yrs ago___ Hx: Other Tobacco use: ETOH: < 1 drink/week [X] [**1-9**] drinks/week [] >8 drinks/week [] Illicit drug use Family History: Premature coronary artery disease Physical Exam: Pulse:83 Resp: 18 O2 sat: 97 2L B/P 137/78 General: Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [] Neck: Supple [X] Full ROM [] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur [] grade ______ Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [] Edema [] _____ Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right: Palp Left: Palp DP Right:Palp Left: Palp PT [**Name (NI) 167**]:Palp Left:Palp Radial Right:Palp Left:Palp Carotid Bruit Right:None Left:None Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 81873**]Portable TTE (Complete) Done [**2113-6-22**] at 2:02:38 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2028-9-8**] Age (years): 84 M Hgt (in): 69 BP (mm Hg): 127/79 Wgt (lb): 197 HR (bpm): 75 BSA (m2): 2.05 m2 Indication: Coronary artery disease. Preoperative assessment. Valvular heart disease. ICD-9 Codes: 414.8, 424.1, 424.0, 424.3, 424.2 Test Information Date/Time: [**2113-6-22**] at 14:02 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **], RDCS Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6 Contrast: None Tech Quality: Adequate Tape #: 2011W000-0:00 Machine: Vivid q-2 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 3.8 cm <= 4.0 cm Left Atrium - Four Chamber Length: *6.9 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.7 m/s Left Atrium - Peak Pulm Vein D: 0.3 m/s Right Atrium - Four Chamber Length: *5.3 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.0 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 2.3 cm Left Ventricle - Fractional Shortening: 0.43 >= 0.29 Left Ventricle - Ejection Fraction: 70% >= 55% Left Ventricle - Lateral Peak E': 0.12 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.09 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 12 < 15 Aorta - Sinus Level: *4.1 cm <= 3.6 cm Aorta - Ascending: *3.7 cm <= 3.4 cm Aortic Valve - Peak Velocity: 2.0 m/sec <= 2.0 m/sec Aortic Valve - Valve Area: *1.8 cm2 >= 3.0 cm2 Mitral Valve - E Wave: 1.3 m/sec Mitral Valve - A Wave: 0.3 m/sec Mitral Valve - E/A ratio: 4.33 Mitral Valve - E Wave deceleration time: 242 ms 140-250 ms TR Gradient (+ RA = PASP): *26 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global systolic function (LVEF>55%). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildy dilated aortic root. Mildly dilated ascending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Borderline PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: No pericardial effusion. Conclusions The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with normal global and regional biventricular systolic function. Aortic valve sclerosis without stenosis. Mildly dilated thoracic aorta. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2113-6-22**] 15:27 Brief Hospital Course: On [**2113-6-21**] Mr. [**Known lastname 37806**] was transferred to [**Hospital1 18**] for evaluation of coronary revascularization. At the OSH he had been started on Vancomycin and Levoquin for a Left lower lobe pneumonia. Once at the [**Hospital1 18**] preoperative workup included TTE/Carotid US and Chest ct scan as well as standard PATS. Dr.[**Last Name (STitle) 7111**], the orthopeadic surgeon from [**Hospital3 **] that performed Mr.[**Known lastname 81874**] total right hip revision on [**6-13**] was contact[**Name (NI) **] for recommendations regarding postoperative care precautions to protect hip dislocation. In house orthopedics was consulted as well. His original OR date was post poned due to elevated creat which peaked at 1.9 and decraesed to 1.6 on [**2113-6-30**]. On [**2113-6-30**] he was taken to the operating room and underwent Coronary artery bypass grafting x3 left internal mammary artery graft to left anterior descending and reversed saphenous vein graft to the posterior descending artery and the first marginal branch (see operative note for details). Immediately post-operatively he was admitted to the ICU intubated and sedated. He was weaned from sedation and extubated without difficulty. His chestubes and pacing wires wwere removed per protocol. He was started on baetablocker, statin and diuretic and transferred to the stepdown unit on POD #2. His coumadin was resumed for afib. His voice quality was hoarse and he was scoped at the bedise by ENT and found to have normal vocal cord quality and movement. Hoarse speech felt to be related to inability to take a deep breath due to discomfort- pain medication adjusted. He was evaluated by physical therapy for strength and conditioning and rehab was recommended. He was cleared for discharge to [**Hospital 582**] rehab [**Location (un) **] on POD#4 and all appointments and instructions were advised. Medications on Admission: Tylenol 650prn, Amlodipine 10', Omeprazole 20', Rosuvastatin 10', Toprol XL 25', Dilaudid prn, Coumadin 2.5 SaMF 5 SuTWTh (On Transfer) Tylenol 650'''prn, Amlodipine 10', ASA 325', Colace 100''prn, FeSO4 325', Levofloxacin 325', Toprol XL 50', Morphine 2'prn, NG 0.4 SL orn, Zofran 4 prn, Protonix 40', Rosuvastatin 20', Senna PRN, Vano 750 IV'' Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-4**] Sprays Nasal QID (4 times a day) as needed for dryness. 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 8. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 9. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas pain. 11. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*65 Tablet(s)* Refills:*0* 12. warfarin 5 mg Tablet Sig: 1/2-1 Tablet PO once a day: 2.5mg x 5days week and 5mg x2 days week Dose based on INR goal 2.0-2.5. 13. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. 14. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours) for 7 days. 15. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 16. Ultram 50 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. Disp:*65 Tablet(s)* Refills:*0* 17. Ambien 5 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed for insomnia. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Location (un) 582**] at [**Location (un) **] Discharge Diagnosis: HTN, HL, AAA, AF on coumadin. reported LLL/PNA on transfer(Levaquin), THA([**Month (only) **]), Revision THA ([**6-13**]), Colectomy (unsure of locatioN) for diverticulitis, Colostomy takedown, RIH, multiple other abd surgeries (unknown) Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema 1+ 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**] Weight bearing as tolerating s/p Right total hip revision [**2113-6-13**] **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) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2113-7-26**] 1:15 in the [**Hospital **] medical office building [**Hospital Unit Name **] Cardiologist: Dr. [**Last Name (STitle) 81875**] [**2113-8-11**] at 11:30am Dr. [**Last Name (STitle) 5730**] at [**Hospital1 2025**] [**Location (un) 4047**] Please call to schedule appointments with your Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14879**] in [**2-3**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication afib Goal INR 2.0-2.5 First draw [**2113-7-5**] Results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5730**] [**Hospital1 2025**] [**Location (un) 4047**] Completed by:[**2113-7-4**]

[ "272.4", "V12.54", "414.01", "584.5", "285.9", "E849.7", "427.31", "530.81", "443.9", "784.42", "E947.8", "V58.61", "V15.82", "486", "585.9", "403.90" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

10325, 10399

6234, 8131

332, 387

10681, 10910

2093, 6211

11826, 12784

1406, 1442

8529, 10302

10420, 10660

8157, 8506

10934, 11803

1457, 2073

270, 294

415, 1106

1128, 1159

1175, 1390

31,043

147,334

1669

Discharge summary

report

Admission Date: [**2188-3-9**] Discharge Date: [**2188-3-19**] Date of Birth: [**2108-7-24**] Sex: M Service: SURGERY Allergies: Latex Attending:[**First Name3 (LF) 668**] Chief Complaint: Reversal of Colostomy Major Surgical or Invasive Procedure: [**2188-3-10**]: Exploratory laparotomy and takedown of Hartmann's procedure. History of Present Illness: This is a 79-year-old male who underwent an abdominal aortic aneurysm repair ([**4-18**]) which was complicated by ischemic colon requiring colostomy/hartmanns procedure ([**2187-4-26**]) complicated by stomal prolapse 4-5 cm wide presents for reversal of colostomy. Pt was scheduled for barium enema [**2-20**]. Results show normal pouchogram. No evidence of leak. However pt is severely bothered by stomal prolapse. Pt has been stable with no new medical issues since discharge. Pt does have intermittent asymptomatic atrial fibrillation for which he normally takes Coumadin. Pt has had a few episodes of syncope in the last year associated with low blood pressures. Last syncopal episode was [**2187-12-13**]. Pt stopped Coumadin([**3-2**]), Plavix ([**3-2**]) and apsrin ([**3-1**]) 4-5 days prior to surgery. Pt was cleared for surgery by cardiology (Dr. [**Last Name (STitle) **]. Recent ECHO ([**2-21**]) shows EF 50-55% with moderate mitral regurgitation and only mild LA enlargement. Review of symptoms is negative Patient was admitted on [**2188-3-7**], however wanted to delay the surgery till [**2188-3-10**]. He was discharged on Lovenox and returns today for preop eval. Patient reports no new changes in medical condition over last two days. Past Medical History: AAA, repair bilat renal stents [**2187-4-24**] L hemicolectomy with Hartmanns/colostomy [**2187-4-26**] debridement of peripancreatic necrosis [**2187-5-25**] HTN Hypercholesterolemia DM Afib (off coumadin) claudication vericose veins GERD anxiety Social History: pt denies ETOH cigarettes or illicit drug use. lives with wife. Family History: N/C Physical Exam: GEN: NAD, AOX3 Cards: RRR, faint holosystolic murmur [**2-15**], distant heart sounds Lungs: CTAB Abd: soft, NT, non distended. colostomy bag brown stool Skin: around colostomy no calor/rubor/tumor/dolor or other signs of infection. Ext: no edema Pertinent Results: On Admission: [**2188-3-9**] WBC-7.5 RBC-3.72* Hgb-12.1* Hct-34.2* MCV-92 MCH-32.6* MCHC-35.5* RDW-13.7 Plt Ct-152 PT-13.3 PTT-27.6 INR(PT)-1.1 Glucose-91 UreaN-24* Creat-1.3* Na-138 K-4.6 Cl-102 HCO3-29 AnGap-12 Calcium-9.1 Phos-3.2 Mg-2.0 At Discharge: [**2188-3-18**] WBC-10.2 RBC-3.12* Hgb-9.9* Hct-27.9* MCV-90 MCH-31.8 MCHC-35.5* RDW-14.3 Plt Ct-256 PT-23.2* PTT-32.7 INR(PT)-2.2* Glucose-111* UreaN-24* Creat-1.3* Na-135 K-3.9 Cl-102 HCO3-28 AnGap-9 Calcium-8.2* Phos-2.5* Mg-2.0 Brief Hospital Course: 79 y/o male who was admitted for pre-op heparinization and was taken to the OR for ex lap with reversal of his Hartmans by Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Per operative note, the abdomen was free of adhesions. The ostomy was successfully taken down and the abdomen was primarily repaired without mesh. He was extubated in the OR and transferred to the PACU in stable condition. ASA and plavix were restarted on POD 1. A heparin drip was started on POD 2. Coumadin was restarted on pod 2 once PTT was in range. INR was monitored daily. On POD 3, he developed a rapid heartbeat. 12 lead EKG showed Atrial fibrillation with rapid ventricular response. The patient was asymptomatic, however, the Afib did not respond to 5 mg IV Lopressor x 3 doses therefore he was transferred to the SICU for a diltiazem drip. Cardiac enzymes were unremarkable. Cardiology was consulted, and recommended uptitrating the metoprolol as BP allowed and titrating off the IV diltiazem. This was done with conversion to PO meds over 2 days with the diltiazem drip stopped. He transferred back to the medical/surgical floor. He was only off the diltiazem one day when he was noted to again have atrial fibrillation. The diltiazem PO was restarted controlling his rate. A cardiology follow up with Dr. [**Last Name (STitle) **] was arranged for [**3-26**] to followup the change in regimen as well as restarting the INR monitoring once he is discharged to home. He developed diarrhea on POD 6 and was found to be C. Diff positive. Six weeks of PO Vanco was recommended by ID. Patient does have a prior history of C diff infection. He was started on vancomycin 250mg q 6 hours x 10 days. This was started on [**3-17**]. Vanco then would decrease to 150mg q 6 hours for 1 week then 150mg twice daily for 1 week then 150mg qd x 1 week then 150mg every other day for 1 week then every 3 days x 1 week. He was screened for MRSA (nasal and rectal)while in the SICU and found to be positive. The wound incision was clean/dry/intact. The open area at the site of the ostomy takedown required a small saline wet to dry packing dressing [**Hospital1 **]. This area appeared clean. Coumadin was started at 5mg qd on [**3-12**]. He received this thru [**3-16**]. INR increased to 4.1 on [**3-17**]. Coumadin was held on [**3-17**]. On [**3-18**], 3mg of coumadin was given for INR of 2.2. On [**3-19**], INR was 1.5. Coumadin 5mg daily was ordered. This was his home dose. He should have daily INRs until stabilized on home dose. Patient was evaluated by PT. He initially had some orthostatic hyppotension, but this resolved and he was ambulating using a walker. Rehab was recommended to increase endurance, progress distance ambulated and maximize function. A rehab bed was available at [**Hospital **] Rehab Hospital. He was transferred there in stable condition. Medications on Admission: Asprin 81 mg (stopped Sat [**3-1**]) Plavix 75 mg QD (stopped sun [**3-2**]) Coumadin 5mg QD (stopped Sat [**3-1**]) gabapentin 300mg QD lisinopril 5mg QD metoprolol 50mg QD simvastatin 20mg QD Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 4. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: inr daily until stable. 8. Reglan 5 mg Tablet Sig: One (1) Tablet PO four times a day. 9. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 7 days: then 150 QID x1 week then 150mg BIDx1 wk, then 150mg Qday x1 wk then 150 QOD x1 wk then 1 week of Q3days. . 10. Insulin Regular Human 100 unit/mL Solution Sig: follow sliding scale Injection ASDIR (AS DIRECTED): qid see printed scale. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: s/p Hartmanns reversal Atrial fibrillation C.difficile Discharge Condition: Stable/Fair Discharge Instructions: Please call Dr[**Name (NI) 670**] office at [**Telephone/Fax (1) 673**] for fever > 101, chills, nausea, vomiting, increased abdminal pain, wound drainage or erythema, increase in diarrhea (currently c diff positive on PO Vanco), or constipation. Follow up appointment with Dr [**Last Name (STitle) **] scheduled for [**3-26**] due to changes in cardiac meds during admission. Once patient is discharged to home; [**Doctor First Name 6480**] in Dr [**Last Name (STitle) **] office is the contact person for managing PT/INR. Fax # is [**Telephone/Fax (1) 9672**] Followup Instructions: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 8645**] Date/Time:[**2188-3-26**] 3:40 [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 8645**] Date/Time:[**2188-5-27**] 2:40 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2188-3-28**] 2:00 Completed by:[**2188-3-19**]

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icd9cm

[ [ [] ] ]

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Discharge summary

report

Admission Date: [**2139-7-9**] Discharge Date: [**2139-7-29**] Date of Birth: [**2057-3-18**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1253**] Chief Complaint: FEVERS, WEAKNESS Major Surgical or Invasive Procedure: NONE History of Present Illness: 82M with history of HTN, HL, BPH and prior stroke, who initially presented to an OSH on [**2139-7-3**] with 2-3 day history of fevers to 101, chills, and malaise. Patient reports that over the several days preceding his admission, he felt increasingly fatigued and weak. Had poor appetite and became so weak he had difficulty walking. Presented to [**Hospital 1562**] Hospital for evaluation. At OSH, he was admitted with presumed sepsis of unclear etiology, pan-cultured and empirically started on ceftriaxone. Was noted to have a mild transaminitis and underwent RUQ ultrasound, which showed fatty infiltration of the liver. CXR in ED did not show PNA, and there was no evidence of a UTI. He continued to have fevers to 101.9, and antibiotics were broadened to vanc/zosyn. Given L knee pain and swelling, Ortho consulted and patient underwent MRI of L knee and arthrocentesis on [**7-7**]. Synovial fluid w/4182 WBCs, 6000 RBCs, no crystals. Felt unlikely to be septic joint. ID was consulted, and given concern for tick-borne illness, patient started on azithro/atovaquone and doxycycline. Zosyn d/c'd, vanco continued. On [**7-9**], azithro/atovaquone/doxy/vanc d/c'd and patient started on ertapenem. Testing for Lyme, Babesia, and anaplasma had all returned negative, and blood cultures remained negative. The patient had no focal symptoms, including no CP, SOB, cough, abdominal pain, vomiting, diarrhea, or dysuria. He remained hemodynamically stable. However, he did develop hypoxia, which was attributed to acute on chronic dCHF in setting of iatrogenic volume overload. Noted to have bilateral pleural effusions. He was started on lasix 20 mg IV BID, with decrease in O2 requirement. He underwent a CT torso on [**7-8**], to evaluate for possible abscess or malignancy given unclear source of fever. No abscess or pathologic lymphadenopathy noted. Given question of possible cholecystitis on imaging, General Surgery was consulted. Urology was consulted given findings of non-obstructing nephrolithiasis and ureterolithiasis. Also of note, patient's WBC rose throughout his hospital course, from 13 on admission to as high as 40.5 on [**7-8**]. Heme/Onc consulted, but as patient's family was requesting transfer to a tertiary care center, the consultation was put on hold. Plan was to stop antibiotics and pursue further work-up for non-infectious causes of fever at [**Hospital1 18**]. Of note, [**Doctor First Name **] came back positive at 1:80. On arrival to [**Hospital1 18**], he reports ongoing fatigue but is otherwise without complaints. He recently returned to the area from [**State 108**], but has otherwise not traveled recently. No sick contacts. [**Name (NI) **] insect or tick bites. Had had mild nausea which has since resolved, and he did not have any vomiting. Also reports several episodes of loose stools, non-bloody. REVIEW OF SYSTEMS: Denies night sweats, weight loss, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, vomiting, constipation, BRBPR, melena, hematochezia, dysuria, hematuria, or myalgias. No arthralgias other than left knee pain as above. No rash. Past Medical History: HTN HL BPH Prior stroke, minimal right sided weakness Osteoarthritis s/p cataract surgery s/p hernia repair s/p kidney surgery for nephrolithiasis Social History: Married, lives with wife. Non-[**Name2 (NI) 1818**]. No alcohol or illicit drug use. Retired, previously worked in public relations. Family History: No CAD, DM, or cancer. No family history of autoimmune disease or rheumatologic diseases. Physical Exam: Admission physical exam: VS: 98.2 113/60 82 20 95% 3L GENERAL: elderly male, fatigued appearing but alert, oriented x3, NAD HEENT: NC/AT, right pupil slightly larger than left, both reactive to light, EOMI, sclerae anicteric, dry mucous membranes, OP clear NECK: supple, JVD to earlobe LYMPH: no cervical LAD, subcentimenter non-tender lymph node in left supraclavicular area, no axillary adenopathy, no inguinal adenopathy LUNGS: faint bibasilar rales, no wheezing or rhonchi, good air movement, respirations unlabored, no accessory muscle use HEART: RRR, normal S1-S2, II/VI systolic murmur heard throughout precordium, loudest at LLSB, radiating to carotids ABDOMEN: normoactive bowel sounds, soft, slightly distended, non-tender, no organomegaly, no guarding or rebound tenderness EXTREMITIES: warm, well-perfused, L ankle more edematous compared to R, [**11-17**]+ edema of lower legs bilaterally, 2+ peripheral pulses MSK: left knee with mild soft tissue edema compared to right, no appreciable joint effusion, no overlying warmth or erythema, mild tenderness to palpation over medial joint line SKIN: venous stasis changes, no jaundice, no petechiae NEURO: CNs II-XII grossly intact, muscle strength 4+/5 upper extremities, 3+/5 lower extremities, slight tremor of hands bilaterally Discharge Physical Exam: GENERAL: elderly male, fatigued appearing, AAOx3, NAD HEENT: NC/AT, right pupil slightly larger than left, both reactive to light, EOMI, sclerae anicteric, dryMM, OP clear NECK: supple, JVD elevated to angle of the jaw LYMPH: no cervical LAD LUNGS: faint bibasilar crackles, decreased breath sounds at the bases, no wheezing or rhonchi, good air movement, respirations unlabored HEART: RRR, normal S1-S2, II/IV diastolic murmur, loudest at LLSB, nonradiating ABDOMEN: normoactive bowel sounds, soft, slightly distended, non-tender, no organomegaly, no guarding or rebound tenderness, flex-seal in place draining melanotic stool EXTREMITIES: warm, well-perfused, bilateral LE edema to the thigh, bilateral UE edema in the hands, 2+ peripheral pulses SKIN: venous stasis changes, no jaundice, no petechiae, hemorrhagic appearing pressure ulcer on right heel intact skin overlying NEURO: CNs II-XII grossly intact, muscle strength 4+/5 upper extremities, 4+/5 lower extremities Pertinent Results: ADMISSION: [**2139-7-10**] 12:27AM BLOOD WBC-37.9* RBC-3.13* Hgb-8.9* Hct-27.5* MCV-88 MCH-28.5 MCHC-32.4 RDW-14.2 Plt Ct-219 [**2139-7-10**] 12:27AM BLOOD Neuts-93.5* Lymphs-5.2* Monos-1.2* Eos-0 Baso-0.1 [**2139-7-10**] 12:27AM BLOOD PT-14.0* PTT-32.8 INR(PT)-1.3* [**2139-7-10**] 06:30AM BLOOD ESR-135* [**2139-7-10**] 12:27AM BLOOD Glucose-112* UreaN-38* Creat-1.2 Na-150* K-3.9 Cl-116* HCO3-21* AnGap-17 [**2139-7-10**] 12:27AM BLOOD ALT-30 AST-19 LD(LDH)-277* AlkPhos-170* TotBili-1.1 [**2139-7-10**] 12:27AM BLOOD Calcium-8.6 Phos-2.5* Mg-2.3 [**2139-7-10**] 06:30AM BLOOD Albumin-3.0* Iron-22* [**2139-7-10**] 06:30AM BLOOD calTIBC-185* VitB12-909* Ferritn-561* TRF-142* [**2139-7-10**] 06:30AM BLOOD CRP-219.7* [**2139-7-10**] 07:58AM BLOOD Lactate-2.4* [**2139-7-10**] 02:43PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.013 [**2139-7-10**] 02:43PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2139-7-10**] 02:43PM URINE RBC-39* WBC-1 Bacteri-FEW Yeast-NONE Epi-0 [**2139-7-10**] 02:43PM URINE Mucous-OCC Discharge labs: [**2139-7-29**] 05:50AM BLOOD WBC-9.7 RBC-3.13* Hgb-9.5* Hct-28.7* MCV-91 MCH-30.4 MCHC-33.3 RDW-19.3* Plt Ct-239 [**2139-7-29**] 05:50AM BLOOD PT-12.4 PTT-34.0 INR(PT)-1.1 [**2139-7-29**] 05:50AM BLOOD Glucose-118* UreaN-13 Creat-0.7 Na-134 K-3.6 Cl-98 HCO3-29 AnGap-11 [**2139-7-29**] 05:50AM BLOOD Calcium-7.2* Phos-2.4* Mg-1.9 Other relavent labs: [**2139-7-10**] 07:58AM BLOOD Lactate-2.4* [**2139-7-10**] 06:30AM BLOOD b2micro-4.1* [**2139-7-10**] 06:30AM BLOOD CRP-219.7* [**2139-7-10**] 06:30AM BLOOD calTIBC-185* VitB12-909* Ferritn-561* TRF-142* [**2139-7-10**] 06:30AM BLOOD ESR-135* [**2139-7-14**] 04:15PM BLOOD CK-MB-1 cTropnT-<0.01 [**2139-7-16**] 06:30AM BLOOD Hapto-311* [**2139-7-16**] 06:30AM BLOOD Ret Aut-3.1 [**2139-7-16**] 06:30AM BLOOD PEP-NO SPECIFI b2micro-4.0* IgG-759 IgA-345 IgM-62 [**2139-7-17**] 06:15AM BLOOD PSA-6.9* [**2139-7-18**] 06:45AM BLOOD Ret Aut-2.9 [**2139-7-18**] 06:45AM BLOOD HIV Ab-NEGATIVE [**2139-7-19**] 07:05AM BLOOD ESR-105* [**2139-7-21**] 04:40AM BLOOD freeCa-1.00* Studies: [**2139-7-27**] LUE U/S: IMPRESSION: No left upper extremity DVT. [**2139-7-20**] EGD: Ulcer in the stomach body on greater curve (endoclip) Blood in the fundus. There was a copious amount of old blood in the stomach so other bleeding sites could of been hidden under the blood which could not be completely cleaned. Otherwise normal EGD to third part of the duodenum. [**7-17**]: B/l LENI: no DVT [**7-17**]: b/l upper extremity US: 1. No evidence of deep vein thrombosis either right or left upper extremity. 2. Clot in the medial right cephalic vein, a superficial vein, consistent with a superficial thrombophlebitis. [**7-16**] CXR: As compared to the previous radiograph, there is a minimal improvement of the atelectatic changes at the left lung base. Moreover, the plate-like atelectasis at the left lung base is slightly improved. No newly occurred parenchymal opacities or mediastinal or hilar abnormalities. The size of the heart continues to be at the upper range of normal. No pulmonary edema is seen. [**7-15**] CXR post thoracentesis: (wet read) no pneumothorax. left basilar linear atelectasis, unchanged. [**7-14**] CXR: Stable chest findings, moderate cardiac enlargement, bilateral small amount of pleural effusions, stable appearance of previously described parenchymal infiltrates. Stable appearance during the four days' examination interval raises the possibility of chronic scar formations. [**7-14**] KUB: Unremarkable bowel gas pattern with no evidence of obstruction or Preliminary Reporttoxic megacolon. [**7-14**] CT torso: 1. Since [**2139-7-8**], small bilateral pleural effusions are larger with adjacent enhancing atelectasis. Supervening infection cannot be entirely excluded. The aerated lungs are clear. 2. Small ascites, diffuse body wall edema and small pericardial effusion and pleural effusions are all increased and may be related to volume overload. 3. No evidence of infection in the abdomen or pelvis. 4. Coronary artery and aortic valve calcifications of unknown hemodynamic significance. 5. Pulmonary artery enlargement suggests underlying pulmonary arterial hypertension. [**2139-7-10**] TTE: IMPRESSION: Suboptimal image quality. No vegetations seen. [**2139-7-10**] CXR: Multifocal pneumonia with foci in the left lung base and the right mid and lower zones. [**2139-7-9**] ECG: Sinus rhythm. Short P-R interval. Borderline low precordial lead voltage. No previous tracing available for comparison. Pathology: Thoracentesis path: [**2139-7-15**] Pleural fluid: - Gram stain: 3+ PMNs (concentrated smear), transudative - PLEURAL ANALYSIS: 101 WBC; 153 RBC; 64 Polys; 22 Lymphs; 2 Monos; 12 Meso - PLEURAL CHEMISTRY: 1.2 TotProt; 161 Glucose; 0.9 Creat; 68 LD(LDH); LESS THAN asssay Albumin; 11 Cholest; 6 Triglyc; - Cytology: DIAGNOSIS: NEGATIVE FOR MALIGNANT CELLS. Reactive mesothelial cells and histiocytes. Brief Hospital Course: 82M with history of HTN, HL, BPH and prior stroke, transferred from OSH with ongoing fevers and malaise with rising leukocytosis found to be C. diff positive. Hospital course was complicated by acute anemia from a bleeding gastric ulcer which was clipped by GI with hemostasis. # C. diff infection: Patient presented from outside hospital with persistent fever and leukocytosis despite an extensive and appropriate infectious workup in consultation with ID at OSH. CXR, U/A were reportedly negative. Ortho was consulted and did left knee arthrocentesis on [**7-7**]-> WBC 4182, RBC 6000, no crystals. Infectious Diseases started empiric Azithromycin, Atovaquone, and Doxycycline. Due to persistent fevers, his antibiotics were broadened from Ceftriaxone to Vancomycin and Pip-Tazo. On [**2139-7-9**], his above abx were stopped, and he was started on Ertapenem when serologies for Lyme, Babesia, and Anaplasma reported negative. He has has no positive blood cultures. CT torso on [**2139-7-8**] was unremarkable, except for non-obstructing kidney stones. While as OSH, he had no new symptoms and WBC increased to 40.5. [**Doctor First Name **] was found to be positive at 1:80. Course at OSH was otherwise uncomplicated. Transferred to [**Hospital1 18**] for further management on [**2139-7-10**]. He was found to be C. diff positive on transfer to [**Hospital1 18**] and was started on PO vancomycin on [**7-10**]. He had a CXR on [**2139-7-10**] that suggested multifocal PNA, so he was started empirically on Levofloxacin, which was discontinued after 3 days when subsequent imaging revealed no pneumonia. A transthoracic ECHO was done on [**2139-7-10**], which was negative for vegetations (suboptimal study). A CT chest/abd/pelvis on [**2139-7-14**] showed bilateral pleural effusions and small ascites, but no evidence of abscess, GB wall thickening, colitis, toxic megacolon, consolidations, or significant lymphadenopathy. Despite reassuring imaging, he continued to spike fevers up to 102.8 with stable leukocytosis in 30s, so he was ultimately broadened to vancomycin, cefepime, and IV metronidazole on [**2139-7-14**] without improvement. A thoracentesis of the pleural effusions on [**2139-7-15**] revealed an unremarkable transudate with no malignant cells identified. Given his knee pain and swelling, persistent fevers, and [**Doctor First Name **] of 1:80, rheumatology was called and a repeat knee arthrocentesis was performed which was unremarkable. After several days on broad antibiotics, his fevers resolved and leukocytosis began trending down. His antibiotics were scaled back to PO vanco and IV flagyl. IV flagyl was discontinued after 14 days and he remained on PO vanco to complete a 21 day total course to end on [**2139-8-1**]. # Bleeding gastric ulcer: Patient presented The patient developed a low hematocrit that was not responsive to pRBC transfusion. He then developed tachycardia to the 120s and subsequent drop in his systolic BPs to 90. NG tube was suctioned and showed 200cc of blood, prompting admission to the ICU for urgent EGD intervention. He was started on a pantoprazole drip and aspirin was held. His INR of 1.5 was reversed with vitamin K IV. EGD showed a 20mm ulcer with a visible vessel that was clipped x3. Follow-up hematocrits were stable. Prior to sending back to the medicine floor, H. pylori antibody was sent to elucidate etiology of the peptic ulcer and returned negative. PPI drip was continued for 72 hours, then transitioned to pantoprazole 40 mg PO BID and should continue until resolution of ulcer is seen on endoscopy. He will follow up as an outpatient with Dr. [**Last Name (STitle) **] [**Name (STitle) 12332**] of GI and will need a repeat endoscopy in sevral weeks, which will be scheduled. Aspirin 81 mg daily was restarted several days prior to discharge and should be continued at rehab. # Hypoxia: Patient presented with hypoxia to 95% on 3 L NC. This was initially thought to be due to pneumonia given his fever, leukocytosis, and possible infiltrates on CXR and was treated emperically with levofloxacin for 3 days until subsequent imaging ruled out a pneumonia. CHF was also a consideration given long-standing history of HTN, bilateral pleural effusions, iatrogenic volume overload, but TTE was normal, making this unlikely. It is possible that he has diastolic dysfunction as his hypoxia improved with lasix. Atalectasis is also possible. He remained asymptomatic without complaints of cough or dyspnea and was not in any respiratory distress. # Pleural effusions: Patient with pleural effusions on CXR. Thoracentesis by IP on [**7-15**] revealed 360cc straw colored transudative fluid. Etiology is unclear, but the cytology was negative for malignant cells. EF was 75% on [**7-10**]. It is possible that he has diastolic dysfunction, as as his hypoxia was improved with IV lasix and was clinically fluid overloaded with upper and lower extremity edema. Hypoalbuminemia is likely contributing to low oncotic pressure intravascularly (albumin 2.2 during hospitalization). He was initially provided with supplemental oxygen as needed, but this requirement was weaned and was started on tube feeds (below) for malnutritioin and poor PO intake (below). # Tachycardia: Patient presented with tachycardia to 110s-120s in the setting of volume depletion from diarrhea and acute blood loss (above). This resolved somewhat as his hematocrit stabilized and his diarrhea decreased. He remains tachycardic in the 90s-110s range on discharge. This is possibly related to his persistent, albeit stable anemia or possible intravascular volume depletion from a combination of decreased PO intake and hypoalbuminemia. As his nutrition status continues to improve and his anemia resolves with time, we would expect his tachycardia to resolve as well. # Hypernatremia: Na 150 on admission. Likely secondary to poor PO intake/free water intake. His free water deficit was corrected and his hyponatremia resolved. He later became mildly hyponatremic in his hospital course. # HTN: Initially hypotensive in the setting of severe diarrhea from C. diff and bleeding from gastric ulcer so his blood pressure medications were held on admission. Following hemostasis of bleeding gastric ulcer (above) and resolution of diarrhea, his BP normalized and became hypertensive as is his baseline. His BP meds were titrated back individually and eventually all restarted. He was discharged on his home regimen of lisinopril, hydrochlorothiazide and amlodipine with BPs ranging from 120s-160s/70s-80s. # HL: Stable. Continued on home pravastatin. # BPH: Stable. Continued on home finasteride. # History of stroke: Patient is on aspirin for stroke prevention. This was held when bleeding ulcer was discovered (above) and was restarted several days prior to discharge after hemostasis was achieved. He should continue taking aspirin 81 mg daily upon discharge. # Osteoarthritis: Stable. Acetaminophen was geven prn for pain. # FEN: Patient had reduced appetite on admission and labs concerning for chronic malnutrition including albumin of 3.0 on admission (trended down to 2.2 prior to discharge) and elevated INR of 1.5. He continued to have a minimal appetite throughout his hospitalization. Nutrition was consulted and provided recommendations for ensure supplementation, but patient continued to have decreased appetite. He was ultimately started on tube feeds through Dobhoff with Fibersource HN at 55cc/hr which he tolerated well and should be continued as he is discharged to rehab. He should also be encouraged to eat in addition to getting tube feeds. # Pressure ulcer: Patient with pressure ulcer on right heel that is hemorrhagic appearing with intact overlying skin. This will require regular wound care on discharge to rehab. # PPX: Pantoprazole 40 mg PO BID, pneumoboots # CODE: Full (confirmed) # CONTACT: [**Name (NI) **], wife [**Name (NI) **] [**Telephone/Fax (1) 83103**]; [**Name2 (NI) **]er [**Name (NI) **]: [**Telephone/Fax (1) 83104**] or work [**Telephone/Fax (1) 83105**] # Transitional issues: - Will need outpatient colonoscopy when acute illness has resolved - Will need continued agressive nutrition supplementation with tube feeds if he is not taking enough PO - Dr. [**Last Name (STitle) **] [**Name (STitle) 12332**] of GI at [**Hospital1 18**] will schedule follow up - He will need a repeat EGD to monitor for resolution of gastric ulcer - He should continue on pantoprazole 40 mg PO until resolution of ulcer seen on endoscopy - He was restarted on aspirin 81 mg daily and should continue this going forward - Patient should continue tube feeds through Dobhoff with Fibersource HN at 55cc/hr - His PSA was found to be mildly elevated at 6.9, and this should be followed up as an outpatient - He will need his HCT followed. Please check HCT on [**2139-7-31**] to monitor for stable HCT. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Lisinopril 10 mg PO DAILY 2. Hydrochlorothiazide 12.5 mg PO DAILY 3. Pravastatin 20 mg PO HS 4. Amlodipine 5 mg PO DAILY 5. Finasteride 5 mg PO DAILY 6. Aspirin 81 mg PO DAILY Discharge Medications: 1. Amlodipine 5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Finasteride 5 mg PO DAILY 4. Hydrochlorothiazide 12.5 mg PO DAILY 5. Lisinopril 10 mg PO DAILY 6. Pravastatin 20 mg PO HS 7. Pantoprazole 40 mg PO Q12H 8. Vancomycin Oral Liquid 125 mg PO Q6H Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital for Continuing Medical Care - [**Hospital1 8**] Discharge Diagnosis: Primary diagnosis: - C. difficile infection - Bleeding gastric ulcer s/p endoclip placement - L knee swelling s/p arthrocentesis Secondary diagnosis: - Hypertension - Hyperlipidemia - Prior stroke Discharge Condition: Mental Status: Confused - sometimes. Alert and oriented x 3 at discharge. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname **], You were admitted to the hospital for lethargy, fevers, diarrhea and an elevated white blood cell count at the outside hospital. On admission, you were found to have an infection of your GI tract called C. difficile. We treated you with antibiotics and your infection eventually resolved. You should continue taking antibiotics (oral vancomycin) for the C. difficile infection through [**2139-8-1**]. During your hospitalization, you were also found to have low red blood cell counts (anemia) and had bleeding from your GI tract. We consulted our GI colleagues who put a scope in your stomach (EGD) and found a bleeding ulcer, which was clipped. Your blood counts stabilized and the bloody stools resolved. You should follow up with GI as an outpatient to have a colonoscopy and another endoscopy when you are discharged from rehab. Followup Instructions: Please schedule an appointment with your PCP when you are discharged from rehab. Please call Dr. [**First Name8 (NamePattern2) 2092**] [**Last Name (NamePattern1) 12332**] of [**Hospital1 18**] Gastroenterology to schedule follow up for repeat endoscopy in several weeks to evaluate for resolution of ulcer and for colonoscopy when your current illness resolves: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 463**] Completed by:[**2139-7-29**]

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icd9cm

[ [ [] ] ]

[ "96.6", "45.13", "34.91", "81.91", "44.43" ]

icd9pcs

[ [ [] ] ]

20818, 20917

11321, 19391

320, 326

21159, 21159

6281, 7372

22269, 22762

3862, 3954

20544, 20795

20938, 20938

20243, 20521

21376, 22246

7388, 11298

3994, 5260

3225, 3526

264, 282

354, 3206

21089, 21138

20957, 21068

21174, 21352

19414, 20217

3548, 3696

3712, 3846

5285, 6262

16,159

154,548

26935

Discharge summary

report

Admission Date: [**2182-1-16**] Discharge Date: [**2182-1-27**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: transfer for worsening BL alveolar and interstitial infiltrates and possible lung biopsy Major Surgical or Invasive Procedure: VATS procedure Tracheostomy PEG placement Chest tube placement History of Present Illness: 89 yo with h/o afib, HTN, pulm HTN, and RV dysfunction, transferred from [**Hospital 1562**] Hospital at request of the pt for management of worsening BL alveolar and intersitial infiltrates. The pt was admitted at the OSH from [**Date range (1) 66239**] with an initial presentation of 5 days of SOB, weakness, and ?URI. Per OSH records, the pt had a h/o interstitial lung dx on CXR from [**8-29**]. After admission to OSH, the pt was transferred to the ICU on HD 2 for respiratory distress and was intubated. He was started on abx (CTX and azithro initially) and was diuresed, but he continued to fail therapy. R heart cath was performed to assess RV function and revealed PA pressure 52/22, wedge 10, RA pressure 16-18. BAL was performed on [**12-29**] and revealed several AFB staining bacilli. During the BAL, the pt was unable to tolerate spontaneous breathing. The pt was shortly treated for TB, however culture revealed atypical mycobacteria and TB tx was discontinued. CXRs continued to demonstrate this BL infiltrate and the pt remained hypoxic. The pts endotracheal tube became plugged with thick brown-black secretions and was changed. Repeat BAL on [**1-8**] was concerning for HSV cytopathic changes. The pt was treated with 7 days of acyclovir 750 mg IV qd prior to transfer. He was also started on solumedrol on [**1-12**]. Chest CT on [**1-11**] revealed BL interstitial lung involvment and 10 mm mediastinal and aorticopulmonary window nodes. The pts oxygenation improved and he was extubated on [**1-15**]. However, [**1-26**] hrs later he failed and was reintubated. The pt was transferred to [**Hospital1 **] for further management. . Pt was transferred to the [**Hospital Unit Name 153**] and monitored overnite on [**1-16**] and was transferred to MICU [**Location (un) 2452**] on [**1-17**] as pt was scheduled for VATS by thoracic. Pt's heparin gtt (for a fib was held) prior to OR. Pt went to the OR and have RUL and RML wedge bx. Pt came out w/ 2 chest tube to wall suction. Past Medical History: HTN chronic afib anxiety osteoarthritis old lacunar infarcts TTE [**8-29**]: EF 65%, enlarged RV, mildly decreased RV systolic function, mild-mod MR R heart cath [**12-31**]: RA pressure 16-18, RV 50/16, PA 52/22, Wedge 10 Social History: Married, lives with wife; no h/o ETOH, smoking,illicit drugs Family History: NC Physical Exam: Vitals: T 97.5 BP 145/81 P 90 R 18 Sat 100% on CMV TV 500, R 16, PEEP 5, 60%FiO2, CVP 5 Gen: elderly man, arousable but drowsy, not talking, NAD HEENT: NCAT, MMM, PERRL, BL injected conjunctivae but anicteric, OP clear Neck: No JVP but +HJR, no LAD Lungs: Bibasilar rales L>R CV: irreg irreg, Grade 2/6 SEM at LUSB Ab: NABS, NTND, soft Extrem: 2+ pitting in BL LE with 1+pitting in L thigh, 1+pitting in BL hands and forearms Neuro: drowsy, awake, not talking Pertinent Results: EKG: at OSH--RBBB, afib, nl asix, TWI anterior leads and lead III CXR: . Labs at OSH: Na 134, K 4.1, Cl 97, Bicarb 36, BUN 18, Cr 0.5, WBC 7.6, Hct 33, Plt 145, AST 16, ALT 24, Alk phos 76, TP 5.6, Alb 2.2, Bili 0.8, iron 31, ferritin 748, haptoglobin 137, iron binding capacity 144, alb 2.8 . [**2182-1-16**] 07:07PM TYPE-ART TEMP-36.9 RATES-16/2 TIDAL VOL-535 PEEP-5 O2-60 PO2-86 PCO2-57* PH-7.40 TOTAL CO2-37* BASE XS-7 -ASSIST/CON [**2182-1-16**] 07:07PM LACTATE-1.4 [**2182-1-16**] 05:46PM GLUCOSE-115* UREA N-21* CREAT-0.6 SODIUM-136 POTASSIUM-4.0 CHLORIDE-96 TOTAL CO2-34* ANION GAP-10 [**2182-1-16**] 05:46PM ALT(SGPT)-27 AST(SGOT)-20 LD(LDH)-264* CK(CPK)-26* ALK PHOS-81 AMYLASE-13 TOT BILI-0.8 [**2182-1-16**] 05:46PM LIPASE-10 [**2182-1-16**] 05:46PM CK-MB-3 [**2182-1-16**] 05:46PM cTropnT-<0.01 [**2182-1-16**] 05:46PM WBC-4.7 RBC-3.85* HGB-12.5* HCT-35.8* MCV-93 MCH-32.4* MCHC-34.8 RDW-15.5 [**2182-1-16**] 05:46PM TSH-1.2 . CXR [**1-16**]- IMPRESSION: Bilateral lower lobe opacities. Tubes and lines in appropriate position. Tissue/Pathology - 1. Lung, right middle lobe, wedge resection (A-E): A. Organizing pneumonitis with features of bronchiolitis obliterans organizing pneumonia. See note. B. Interstitial fibrosis with areas of honey comb change. C. No granulomas or [**Month/Year (2) 18617**] inclusions seen. 2. Lung, right upper lobe, wedge resection (F-I) A. Organizing pneumonitis with features of bronchiolitis obliterans organizing pneumonia. See note. B. Interstitial fibrosis with areas of honey comb change. C. No granulomas or [**Month/Year (2) 18617**] inclusions seen. *** The biopsies show a background of interstitial lung disease, suggestive of UIP (usual interstitial pneumonia) with superimposed organizing pneumonia with features of BOOP (cryptogenic organizing pneumonia -COP). A [**Month/Year (2) 18617**] or bacterial etiology should be considered. *** A GMS stain performed on a representative section of lung is negative for fungal organisms. . [**1-17**] Pleural fluid cytology- NEGATIVE FOR MALIGNANT CELLS. [**1-18**] Echo. Conclusions: The left atrium is normal in size. The right atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is dilated. Right ventricular systolic function is borderline normal. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. . [**2182-1-24**] - CXR - Tracheostomy tube is 7 cm above the carina. No pneumothorax or pneumomediastinum. Diffuse bilateral interstitial disease as previously demonstrated. Brief Hospital Course: A/P: 89 yo with h/o afib, HTN, pulm HTN, and RV dysfunction, transferred from [**Hospital 1562**] Hospital at request of the pt for management of worsening BL alveolar and intersitial infiltrates. . #Respiratory failure(hypercarbia)/BL alveolar/interstitial infiltrates: Unclear etiology after extensive w/u at OSH (s/p 2 BALs with atypical mycobacteria from 1st BAL and changes concerning for HSV on 2nd BAL; neg Legionella and influenza). Pt was initially treated with Azithro/CTX, tx for short time for ?TB, and was discharged on levoflox and prednisone. Per reports, pt has an acute on chronic process (h/o interstitial process in [**8-29**]). . Here he underwent a VATS procedure with RUL and RML wedge bx, sample sent for fungal cx, gram stain, PCP, [**Name10 (NameIs) 18617**] studies. Two chest tubes were placed during the surgery. He underwent an echocardiogram which was notable for pulm HTN, dilated RV, borderline Right ventricular function. Antibiotics were stopped and after the biopsy results returned he was started on Solumedrol 60 mg IV bid for UIP vs COP. Chest tubes were manged by thoracis and were discontinue [**Male First Name (un) **] [**2182-1-24**]. Solumedrol was changed over to prednisone 60 mg daily on [**2182-1-23**]. He also had a low grade fever and was treated for a 7 day course of zosyn. He required mechanical ventilation. Trials of changing over to pressure support were attempted however pt became tachypneic and volume controlled ventilation was continued. Pt underwent tracheostomy on [**2182-1-24**] and PEG on [**2182-1-23**]. Plan on discharge is to wean mechanical ventilation as tolerated. He should be continued on Prednisone 60mg daily for 3 months (~[**2182-4-25**]), after which prednisone should be tapered slowly over 1 year as tolerated. . #HTN: Pt was on norvasc 10 as outpt, however on transfer pt was on no BP meds. He was started on metoprolol for HTN and a. fib see below. . #Afib: Pt has h/o chronic afib on digoxin. Digoxin was continued. He had 2 episodes of afib with RVR to 120s. He responded well to IV lopressor and was started on 25 mg PO lopressor. He tolerated this well. He was anticoagulated with Heparin in the ICU. After the trach he was restarted on coumadin 5mg qhs on [**2182-1-24**]. Heparin should be continued with goal ptt 50-70, until the INR is therapeutic (goal INR [**12-28**]). . #Anasarca: Likely related to pts albumin of 2 and poor nutrition. No evidence of protein on UA from OSH. He was started on Resplor TFs. He will need continued nutrition and physical thearpy support. . #Anemia: BL hct 27-33. Labs c/w ACD (iron low, ferritin wn, iron binding capacity low). Hematocrit remained stable. . #FEN: on tube feeds. PEG placed [**2182-1-23**]. . #Communication: HCP--daughter [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 66240**] (cell), [**Telephone/Fax (1) 66241**] (work); wife--Ms [**First Name8 (NamePattern2) **] [**Name (NI) **] [**Telephone/Fax (1) 66242**] . #Access: A-line [**1-17**] R midline placed by IR [**1-18**] ***** Addendum: Prior to transfer to rehab, the pt deteriorated clinically with new worsening hypoxia requiring an increased FiO2 to 100% and PEEP to 12 to improve oxygenation. Empirically, the patient was restarted on Zosyn for presumptive aspiration PNA and solumedrol for UIP. CTA of chest was obtained, and the patient was ruled out PE but showed small R pneumothorax. Thoracics were reconsulted and a chest tube was placed. However, given the patient's poor prognosis, his goals of care was discussed with the family, including the health care proxy, and the decision was made to make the patient CMO; he was disconnected from the ventilator on [**2182-1-27**] and expired soon thereafter. Medications on Admission: Meds PTA to OSH: dig 0.125 mg poqd, norvasc 10 mg qd, terazosin 2 mg qhs, coumadin 5 mg po qd, zestril/HCTZ 20/25 mg qd . Meds on transfer from OSH: Acyclovir 750 mg IV qd x 7d Solumedrol 60 mg IV bid (start [**1-12**]) Levoflox 500 mg IV qd (start [**1-13**]) Diflucan 100 mg IV qd (start [**1-15**]) Digoxin 0.25 mg IV qd Lovenox 80 mg SC BID Seroquel 25 mg qhs Protonix 40 mg IV qd Peridex Artificial tears Versed Morphine Discharge Medications: 1. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-26**] Drops Ophthalmic QD (). 3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Albuterol 90 mcg/Actuation Aerosol Sig: 4-10 Puffs Inhalation Q6H (every 6 hours). 7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 4-10 Puffs Inhalation QID (4 times a day). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 3 months: Slow taper over a year afterwards as tolerated. 10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. Acetaminophen 160 mg/5 mL Solution Sig: [**11-26**] PO Q4-6H (every 4 to 6 hours) as needed for pain/fever. 13. Digoxin 0.25 mg IV DAILY 14. Pantoprazole 40 mg IV Q24H 15. Prochlorperazine 10 mg IV Q6H:PRN 16. Dolasetron Mesylate 12.5 mg IV Q8H:PRN 17. Fentanyl Citrate 25-100 mcg IV Q4H:PRN hold for excessive sedation Discharge Disposition: Extended Care Facility: [**Hospital3 20639**] Rehab - [**Location (un) 38**] Discharge Diagnosis: Bilateral pulmonary infiltrates, BOOP vs. UIP Atrial fibrillation Hypertension Discharge Condition: Mechanical ventilation via tracheostomy Discharge Instructions: Please continue to administer all medications as directed. If patient complaints of shortness of breath, has fevers or has difficulty with ventilation please seek medical attention. Followup Instructions: Please follow up with your PCP once you are discharged from Rehab hospital. Please follow up with Pulmonary, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2182-2-25**] 2:10

[ "518.84", "516.8", "427.31", "428.0", "512.1", "V58.61", "427.5", "280.9", "V58.65", "515", "273.8", "416.8", "507.0" ]

icd9cm

[ [ [] ] ]

[ "34.04", "38.93", "43.11", "96.6", "33.28", "31.1" ]

icd9pcs

[ [ [] ] ]

12020, 12099

6458, 10214

351, 416

12222, 12264

3302, 6435

12495, 12746

2802, 2806

10691, 11997

12120, 12201

10240, 10668

12288, 12472

2821, 3283

223, 313

444, 2462

2484, 2708

2724, 2786

29,581

198,737

1756

Discharge summary

report

Admission Date: [**2127-4-26**] Discharge Date: [**2127-5-2**] Date of Birth: [**2048-11-29**] Sex: F Service: MEDICINE Allergies: Penicillins / Streptomycin / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 3561**] Chief Complaint: femur fracture, supratherapeutic INR Major Surgical or Invasive Procedure: CVL placement A-line placement Left hemiarthroplasty History of Present Illness: History obtained from patient with Russian interpreter (via phone) . HPI: Ms. [**Known lastname 9950**] is a 78 y/o woman with PMH of CAD s/p CABG, hypertension, and atrial fibrillation on coumadin wh presents after a mechanical fall at rehab. Patient has been at Tower [**Doctor Last Name **] Rehab center following a presumed embolic stroke in [**2127-1-7**] (see d/c summary for details). Yesterday morning, the patient sustained a fall onto her left side per her report. The patient denies any symptoms of chest pain, lightheadedness, dizziness, or palpitations prior to the fall. She remembers leaning against the wall and the walker that she was using not being in front of her. She fell onto her left side but did not strike her head. She did not lose consciousness. She reports that she was not confused following the fall and recalls being put back into bed. She experienced pain after the fall and could not ambulate. X-ray done at the facility showed ? femoral neck fracture so she was then taken to the hospital for further evaluation. . Initial vitals on arrival to our emergency room were T 98.4, HR 72, BP 118/66, 97% (O2 unknown). X-ray of the left hip demonstrated a femoral fracture; the patient was evaluated by orthopedics but due to supratherapeutic INR and acute on chronic renal failure, she is admitted to medicine. For pain, she was treated with morphine 4 mg IV X 1 at 2230. She received 1 L NS. CT head demonstrated no acute hemorrhage. Of note, oxygen saturations noted to be 97-98% on RA while patient was in ED. . On arrival to the floor, the patient is complaining of pain with any movement of her leg. She denies chest pain, difficulty breathing, dizziness/lightheadness, or palpitations. Past Medical History: PMH: * CAD s/p CABG X 2 * hypertension * type 2 DM * atrial fibrillation on coumadin (goal INR 3-3.5 per recent d/c summary) * h/o stroke ([**2125**], [**2127**]) * h/o bioprosthetic MVR * s/p pacemaker Social History: Nonsmoker. No alcohol. Recently living at Tower [**Doctor Last Name **] Rehab follow her stroke in [**Month (only) 404**]. Daughter lives in [**State 4565**]. Family History: noncontributory Physical Exam: T: 99.8 BP: 118/60 HR: 60 RR: 20 O2 84% RA, 93% on 4.5L NC FSBS 133 Gen: Pleasant, elderly female in minimal distress, lying in bed, touching left hip HEENT: no conjunctival pallor, no scleral icterus, MMM, wearing dentures NECK: supple, no lymphadenopathy CV: RRR, normal S1, S2, 3/6 systolic murmur at LUSB LUNGS: clear anteriorly, no apparent crackles or rhonchi ABD: soft, normoactive bowel sounds, nontender to palpation EXT: warm, DP pulses 2+ bilaterally, able to wiggle toes on left leg, slight ecchymosis developing over left hip, tender to palpation of left hip, left leg slightly shortened & SKIN: No rashes/lesions, ecchymoses. NEURO: A&O X 3, speech clear, face symmetric, moving bilateral arms without difficulty Pertinent Results: [**2127-4-26**] 09:00PM WBC-12.1*# RBC-4.36 HGB-11.7* HCT-35.8* MCV-82 MCH-26.8* MCHC-32.6 RDW-17.1* [**2127-4-26**] 09:00PM PLT COUNT-245 [**2127-4-26**] 09:00PM NEUTS-78.7* LYMPHS-15.0* MONOS-5.8 EOS-0.2 BASOS-0.3 [**2127-4-26**] 09:00PM GLUCOSE-127* UREA N-21* CREAT-1.8* SODIUM-138 POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-23 ANION GAP-18 . EKG: A-V paced at 60, LBBB with left axis, compared to prior, pacing is new, QTc 512 (old 450 but at higher rate) . CXR: Right upper lobe opacity which is relatively stable in comparison to studies from [**2127-1-7**]. At that time, this was presumed pneumonia; however, no intervening radiographs are available to document a complete resolution. This may represent recurrent pneumonia or possibly the progression of an indolent growing bronchoalveolar cell carcinoma. Chest CT is recommended for further evaluation as clinically indicated. There may be an element of superimposed mild edema. . Left hip x-ray: Fracture of the base of the left femoral neck with no definite trochanteric involvement. . Head CT: 1. No acute intracranial process. Specifically, no evidence of hemorrhage. 2. Interval evolution of right middle cerebral artery territory infarct. Brief Hospital Course: A/P: 78yo Russian speaking woman with h/o CAD s/p CABG, chronic diastolic CHF with EF 55%, afib on coumadin, s/p CVA x 2, DM who presented s/p fall with L femoral fracture now s/p hemiarthroplasty who was transferred to he MICU with hypoxia and hypotension in pACU immediately following surgery. . 1. MICU Admission for hypotension/hypoxia- Post-operatively patient became hypoxic after receiving 1 litre of fluid and 2 units of FFP on the day of the procedure. She received furosemide bolus 20mg IV and then developed hypotension with systolic in the 70s, with urine output below 20cc/hr. She was transiently on neosynephrine which was stopped on morning of [**2127-3-2**]. While in the MICU, she required 3 250 cc boluses for SBP below 90 or urine output less than 20. Workup for infectious sources revealed Gram negative rods in urine culture and patient was started on ciprofloxacin for this. Her oxygen requirement improved with the initial diuretics and remained stable prior to floor transfer. She did receive 1 unit of PRBC for fall in hematocrit. Her UCx came back with pan-sensitive E coli to be treated with Cipro for five more days. Her BB and home lasix were held and should be restarted as tolerated after discharge. . 2. UTI: pt with positive UA. Pt febrile to 102 on arrival to PACU, however resolved to 100 without intervention. WBC jumped to 16 however on recheck returned to 8.5. Replaced foley catheter on arrival to MICU. Started empiric ciprofloxacin. Her UCx came back with pan-sensitive E coli to be treated with Cipro for five more days. . 3. Afib: Pt on amio and BB as outpt. Held BB given hypotension but pt was continued on amio and was monitored on telemetry. Pt on coumadin with INR goal of [**3-10**].5 given 2 CVAs while anticoagulated. She was on a heparin drip and restarted on her coumadin on day of discharge. INR should be checked daily given multiple medical interactions (amio, cipro) and coumadin dose to be adjusted as needed. Heparin drip can be discontinued once stable INR in therapeutic range for two days. . 4. L hip fracture s/p hemiarthroplasty: Pt was followed by ortho. VAC was placed post-op and needs to be discontinued on Sunday [**6-3**]. Pt received morphine IV prn pain and vancomycin x 2 doses peripoeratively per ortho recs. Pt needs to follow up with ortho 14 days after the operation for staples removal. Weight bearing as tolerated with anterior hip precautions. . 5. Chronic diastolic CHF with EF 55%: Held home BB and lasix dose (20po qday) during hypotensive episode. Should be retarted as tolerated after discharge. . 6. CAD s/p CABG: stable at present. Pt was ruled out for MI. Not on ASA at baseline for unclear reasons, to be clarified as outpatient with her PCP. [**Name10 (NameIs) **] was continued on her statin. Held BB as above. . 7. DM II: Pt is diet controlled as outpt. Followed qid FS and kept on ISS. . 8. ARF: On admission pt with Cr 1.8 from baseline 1.2. This has improved during her stay, likely prerenal in origin. Cr was back at baseline of 1.2 on discharge. . 9. Chronic RUL infiltrate: present since 1/[**2126**]. Needs to be followed up as outpatient as concerning for possible carcinoma. Pt likely needs outpatient CT for further workup. . 10. FEN: Repleted lytes prn. Kept transiently NPO. Cleared by speech/swallow to received pills crushed in purree and nectar thick liquids. . 11. PPX: heparin drip, PPI, bowel regimen . 12. Access: R IJ placed under sterile conditions in PACU by anesthesiology on [**4-30**]. R radial A-line. . 13. Code: full code . 14. Comm: daughter [**Name (NI) **] [**Last Name (NamePattern1) 9951**] is HCP (lives in [**Name (NI) 4565**]) [**Telephone/Fax (1) 9952**]. Medications on Admission: * amiodarone 200 mg daily * colace 100 mg [**Hospital1 **] * metoprolol 12.5 mg [**Hospital1 **] * modafinil 200 mg QAM * omeprazole 20 mg daily * senna 2 tabs QHS * simvastatin 40 mg daily * dulcolax suppository 10 mg PR daily prn * coumadin 2 mg daily * tylenol 650 mg PO q6h prn pain * lasix 20 mg PO daily Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Modafinil 100 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Insulin Lispro 100 unit/mL Solution Sig: as directed Subcutaneous ASDIR (AS DIRECTED): per ISS. 7. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet Sig: One (1) Powder in Packet PO daily (). 8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once Daily at 16): Adjust per daily INR checks. 9. Cipro 250 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days: until [**5-6**]. 10. Morphine 10 mg/mL Solution Sig: One (1) ml Intravenous every four (4) hours as needed for pain. 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 12. Heparin (Porcine) in D5W 10,000 unit/100 mL Parenteral Solution Sig: per sliding scale Intravenous per SS: until INR 3-3.5 on coumadin. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary diagnosis: 1. L femur fracture, s/p hemiarthroplasty 2. Hypoxia post-OP, requiring non-rebreather, likely from fluid overload 3. Hypotension post-OP, transiently on pressors 4. Acute blood loss anemia post-OP, requiring 1U PRBC 5. E.coli UTI, pansensitive . Secondary diagnosis: 1. Chronic, diastolic CHF 2. Afib, on coumadin 3. Diabetes mellitus Discharge Condition: Hemodynamically stable, afebrile Discharge Instructions: You have been admitted after a fall. Orthopedics has operated on you and placed a left hemiarthroplasty. You were briefly hypotensive after the operation requiring transiently pressors. You were found to have a UTI and are being treated with ciprofloxacin. . VAC needs to be discontinued on Sunday, [**6-3**]. Followup Instructions: Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from orthopedics 14 days after your surgery, i.e. 10 days from day of discharge. Please call [**Telephone/Fax (1) 1228**] to schedule this important appointment. On that day, your staples will be taken out. . Please also follow up with your PCP ([**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 5522**]) within the next 1-2 weeks.

[ "599.0", "285.1", "790.92", "E888.9", "403.90", "427.31", "428.33", "250.00", "995.91", "038.9", "V45.81", "820.8", "585.3", "041.4", "E934.2", "428.0", "V58.61", "998.59", "V43.3" ]

icd9cm

[ [ [] ] ]

[ "38.91", "81.52", "99.04", "38.93" ]

icd9pcs

[ [ [] ] ]

9767, 9833

4581, 8275

347, 402

10232, 10267

3349, 4400

10626, 11112

2570, 2587

8635, 9744

9854, 9854

8301, 8612

10291, 10603

2602, 3330

271, 309

430, 2152

10141, 10211

4409, 4558

9873, 10120

2174, 2378

2394, 2554

26,115

152,351

13624

Discharge summary

report

Admission Date: [**2122-11-10**] Discharge Date: [**2122-11-18**] Date of Birth: [**2060-10-7**] Sex: F Service:ORTHO HISTORY OF PRESENT ILLNESS: This patient is a very pleasant 62-year-old female with a history of a previous laminectomy at the T12-L1 level resulting in a scoliotic deformity. The patient was admitted to the [**Hospital6 256**] on kyphoscoliosis by Dr. [**Last Name (STitle) 363**]. This procedure consisted of an anterior T10-L4 fusion. The estimated blood loss from the surgery was approximately 300 cc, and the procedure was without complications. HOSPITAL COURSE: In the Postanesthesia Care Unit, the patient complained of moderate pain, and postoperative labs packed red blood cells. On postoperative day #1, the patient's pan control was much improved on a Morphine PCA. She was afebrile with stable vitals signs. On the evening of postoperative day #1, the house officer was asked to see the patient who complained of some mild left-sided chest pain. The patient at the time denied radiation to the left upper extremity or to the neck, and she had no shortness of breath or palpitations. Electrocardiogram obtained at that time showed no ischemic changes and no interval changes from previous electrocardiogram taken on [**2122-10-28**]. This chest pain was attributed to postoperative pain, and the patient was monitored carefully. On postoperative day #2, the patient remained afebrile with stable vital signs. Neurologic exam showed full motor and sensory function in her lower extremities bilaterally. The patient had no peritoneal signs. The patient still had not had flatus however, and her diet was maintained at ice chips while awaiting improvement in bowel function. On [**2122-11-13**], the second part of the fusion procedure was performed by Dr. [**Last Name (STitle) 363**] with assistance of Dr. [**First Name (STitle) 11674**]. This consisted of a T5-L5 fusion. Estimated blood loss for this procedure was significant at 4000 cc. Intraoperatively the patient received 8 U of packed red blood cells, 20 [**Location 31319**], 1 U of cryoprecipitate, and 3000 cc of lactated Ringer's. Although the patient was transferred to the Postanesthesia Care Unit in stable condition, her significant blood loss during the surgery was thought to warrant a short stay in the Surgical Intensive Care Unit. The patient was transferred to the Surgical Intensive Care Unit in stable condition and remained intubated. In the Surgical Intensive Care Unit, the patient was sedated and kept on Propofol overnight for comfort. The patient was notably slightly bradycardiac and hypertensive, a condition that was treated with intravenous Nitroglycerin. Cardiac enzymes were cycled and were not suggestive of myocardial ischemia or infarction. On [**2122-11-14**], the patient was awake and alert with stable vital signs. She was placed on a PCA for pain management and fitted for a TLSO brace. The patient was also evaluated by Physical Therapy on [**2122-11-14**], who recommended that the patient be allowed to be out of bed with the TLSO brace but that the patient should use the brace for ambulation. Throughout the remainder of the patient's postoperative course, she remained afebrile with stable vital signs. Her hematocrit was checked on a regular basis to ensure that it was stable; however, the patient did not require additional blood transfusions after postoperative day #2. With the assistance of Physical Therapy, the patient's ambulatory status improve significantly over her postoperative days #3 and #4, and she was considered in good condition for discharge to rehabilitation on [**2122-11-18**]. CONDITION ON DISCHARGE: Good and improved. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 3863**] Dictated By:[**Last Name (NamePattern1) 13717**] MEDQUIST36 D: [**2122-11-18**] 07:52 T: [**2122-11-18**] 08:01 JOB#: [**Job Number 41111**]

[ "401.9", "244.9", "737.30", "710.0" ]

icd9cm

[ [ [] ] ]

[ "77.79", "77.89", "80.51", "81.04", "81.05" ]

icd9pcs

[ [ [] ] ]

611, 3679

166, 593

3704, 4004

66,054

154,173

31773

Discharge summary

report

Admission Date: [**2159-12-17**] Discharge Date: [**2159-12-21**] Date of Birth: [**2080-7-14**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Mild Dyspnea on exertion, pre-op finding for AAA repair Major Surgical or Invasive Procedure: [**2159-12-17**] - Coronary Artery Bypass Graft x 3 History of Present Illness: This is 79 year old female with a history of a prior myocardial infarction, Hypertension, Hyperlipidemia and + Tobacco abuse who was undergoing pre-operative work-up for a AAA repair. She underwent a stress test that revealed a large anteroseptal and anteroapical abnormality which is non-reversible. Subsequently underwent cardiac cath which revealed three vessel coronary artery disease and she was referred for surgical revascularization prior to her AAA repair. Past Medical History: Myocardial Infarction at the age 46 Chronic obstructive pulmonary disease Abdominal Aortic Aneurysm 5.1cm Hypertension Hyperlipidemia Hypothyroidism TIA's (right brain hemispheric)patient denies any TIA's since endarterectomy Right arm cellulitis in [**6-9**] from cat bite Past Surgical History s/p Right Carotid endarterectomy and angioplasty [**2157-10-28**] s/p Tonsillectomy s/p Appendectomy age 9 Social History: Occupation: Retired Last Dental Exam: Full dentures Lives with husband [**Name (NI) **]: Caucasian Tobacco: [**6-6**] cigarettes a day x 50 years ETOH: [**2-2**] glasses of wine daily Family History: Father had CAD, PVD Physical Exam: Pulse: Resp: O2 sat: B/P Right: Left: Height: 5'7" Weight: 120lbs General: Elderly female in no acute distress Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [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 Pulses: Femoral Right: 1+ Left: 1+ DP Right: NP Left: NP PT [**Name (NI) 167**]: NP Left: NP Radial Right: 1+ Left: 1+ Carotid Bruit Right: ? Left: - Pertinent Results: [**12-17**] Echo: Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is moderately dilated. There are complex (>4mm) atheroma in the ascending aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Post bypass: The patient is on a Neosynephrine drip. LV function is preserved. The ascending aorta is normal with no dissection flaps. [**2159-12-17**] 12:09PM HGB-11.6* calcHCT-35 [**2159-12-17**] 12:09PM GLUCOSE-97 LACTATE-1.4 NA+-137 K+-3.9 CL--95* [**2159-12-17**] 04:02PM GLUCOSE-83 LACTATE-3.3* NA+-132* K+-3.6 CL--102 TCO2-27 [**2159-12-17**] 05:10PM PT-14.7* PTT-40.1* INR(PT)-1.3* [**2159-12-17**] 05:10PM PLT COUNT-194# [**2159-12-17**] 05:10PM WBC-17.8*# RBC-3.76* HGB-11.8* HCT-35.1* MCV-93 MCH-31.5 MCHC-33.7 RDW-15.6* [**2159-12-17**] 05:10PM UREA N-11 CREAT-0.5 CHLORIDE-109* TOTAL CO2-26 [**2159-12-17**] 05:16PM GLUCOSE-106* NA+-136 K+-3.5 [**2159-12-17**] 09:37PM PT-14.5* PTT-34.5 INR(PT)-1.3* [**2159-12-21**] 06:50AM BLOOD WBC-8.7 RBC-3.22* Hgb-9.5* Hct-29.1* MCV-90 MCH-29.4 MCHC-32.5 RDW-16.2* Plt Ct-185 [**2159-12-21**] 06:50AM BLOOD Plt Ct-185 [**2159-12-20**] 06:05AM BLOOD Glucose-93 UreaN-15 Creat-0.6 Na-139 K-4.0 Cl-102 HCO3-32 AnGap-9 Radiology Report CHEST (PA & LAT) Study Date of [**2159-12-20**] 6:17 PM CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 74599**] Bilateral small pleural effusions, with adjacent atelectasis at the lung bases. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Doctor First Name **] [**2159-12-20**] 10:48 PM Brief Hospital Course: Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2159-12-17**] for elective surgical management of her coronary artery disease. She was taken to the Operating Room where she underwent coronary artery bypass grafting to three vessels. Please see operative note for details. In summary she had: Coronary artery bypass surgery x3 left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the marginal branch of the posterior descending artery. Her bypass time was 78 minutes with a crossclamp time of 61 minutes. She tolerated the operation well and postoperatively she was taken to the intensive care unit for monitoring. She was hemodynamically stable in the immediate post operative period, she awoke neurologically intact and was extubated. On POD# 1 she was weaned from all vasoactive infusions and on POD# 2 she was transferred from the ICU to the step down unit for continued recovery. The chest tubes and temporary pacing wires were removed per cardiac surgery guidelines. She was started on betablockers and diuretics and gently diuresed toward her pre-op weight. She was evaluated by physical therapy and rehab was recommended. The remainder of her post operative course was uneventful. She was discharged to rehab at Lifecare of [**Location 15289**] on POD# 4. Medications on Admission: Atenolol 50mg(2),Folic Acid 1mg (1)Levothyroxine 112mcg (1)Lisinopril 10mg (1)Simvastatin 40mg(1)Acetaminophen 325mg prn,Aspirin 81mg (1)Hydrochlorothiazide 25mg (1) Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): 20mg [**Hospital1 **] x7 days then 20mg QD. 2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours): 20mEq [**Hospital1 **] x 7days then 20mEq QD. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day: hold for SBP<100 HR<60. 11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day: hold for SBP<100. 14. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: Life Care Center of [**Location 15289**] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 Myocardial Infarction at the age 46 Chronic obstructive pulmonary disease Abdominal Aortic Aneurysm 5.1cm Hypertension Hyperlipidemia Hypothyroidism TIA's (right brain hemispheric)patient denies any TIA's since endarterectomy Right arm cellulitis in [**6-9**] from cat bite Past Surgical History s/p Right Carotid endarterectomy and angioplasty [**2157-10-28**] s/p Tonsillectomy s/p Appendectomy age 9 Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. Please contact your [**Name2 (NI) 5059**] with all wound issues at ([**Telephone/Fax (1) 1504**]. 2) Report any temperature greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) Please shower daily. Wash incisions with soap and water. No lotions, creams or powders to incisions for 6 weeks. No swimming for 6 weeks. 5) No driving for 1 month. 6) No lifting greater then 10 pounds for 10 weeks from date of surgery. 7) Please call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 10740**] in [**3-6**] weeks. [**Telephone/Fax (1) 40144**] Please follow-up with your cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] [**Telephone/Fax (1) 3183**] Please follow-up with your vascular [**Telephone/Fax (1) 5059**] Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 3121**] Completed by:[**2159-12-21**]

[ "496", "412", "244.9", "305.1", "443.9", "426.52", "441.4", "401.9", "272.4", "433.10", "414.01" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7042, 7109

4080, 5411

379, 432

7616, 7622

2255, 4057

8267, 8805

1570, 1591

5627, 7019

7130, 7595

5437, 5604

7646, 8244

1606, 2236

284, 341

460, 927

949, 1353

1369, 1554

19,074

159,407

23945

Discharge summary

report

Admission Date: [**2200-3-15**] Discharge Date: [**2200-3-31**] Date of Birth: [**2151-12-2**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: pancreatitis Major Surgical or Invasive Procedure: none History of Present Illness: 48 yo primarily Portuguese-speaking woman with a several year history of intermittent RUQ/epigastric pain precipitated by certain foods (salmon, red meat, beans, chocolate) who noted an acute exacerbation of this pain after eating some chocolate on [**2200-3-8**]. This was associated with significant nausea and bilious emesis but no diarrhea, constipation, fevers, chills, or sweats. She went to an OSH where she was diagnosed with acute pancreatitis based upon lab data (amylase 8289, lipase 36,687) and imaging studies (abdominal CT scan done [**3-9**] showed extensive pancreatitis with a large amount of ascites and poor enhancement in the body and tail raising a question of necrosis). The etiology was presumed to be due to gallstones; her initial CT scan reportedly showed 7 cm CBD dilatation without evidence of cholelithiasis. She was treated supportively with IV fluids, analgesics, and IV antibiotics (initially Unasyn, then Zosyn, and finally imipenem) and initially did well with decreasing pain and improving lab parameters. Despite her initial improvement, she subsequently developed a recrudescence of fever to 101 with an associated leukocytosis to 26,000 on [**3-14**]. A repeat CT scan reportedly showed progression of pancreatitis with increasing ascites. On [**3-15**] her leukocytosis rose to 29,000 and she was therefore transferred here for further management and possible surgical debridement. Past Medical History: 1. cesarean section 2. breast implants Social History: Quit drinking alcohol 15 years ago, previously drank 1-2 beers per week. Denies tobacco or illicit drug use. Unemployed. Lives with her husband. Family History: Mother and brother had gallbladder disease (presumably cholelithiasis vs. cholecystitis). No known history of pancreatic or hepatic disease. Physical Exam: Temp-100.5 HR-115 BP-162/65 RR-30 SpO2-95% room air Gen: Pleasant, Portuguese speaking, tachypneic but able to speak in full sentences, non-toxic HEENT: NCAT, no sinus tenderness, PERRL, conjunctivae clear without icterus, OP slightly dry, no sublingual jaundice Neck: 2+ carotid pulses, no bruits, soft, supple CV: Hyperdynamic, flow murmur, normal S1 and S2 Pulm: Decreased bibasilar breath sounds without crackles, egophony at both bases, decreased resonance to percussion at both bases Abd: Soft, mildly tender over the RUQ, moderately distended, active bowel sounds, no periumbilical ecchymosis Back: No CVA or spinal tenderness Ext: No edema, 2+ DP and femoral pulses Skin: No rashes, ecchymoses, or lesions Neuro: Grossly non-focal Pertinent Results: ABG on admission: 7.51/29/60 on room air, lactate 1.2, ionized Ca 1.17 WBC-29.3 (diff pending) Hct-30.4 MCV-88 Plt-393 PT-13.7 PTT-22.0 PT-1.2 Na-143 K-3.2 Cl-109 Bicarb-25 BUN-9 Cr-0.6 Glu-136 Ca-8.3 Mg-2.1 Phos-1.1 Alb-2.7 ALT-54 AST-44 Alk Phos-181 TBili-1.2 [**Doctor First Name **]-113 Lip-pending OSH Data ([**2200-3-15**]): WBC-29.0 Hct-30.6 MCV-89.1 Plt-351 WBC trend: [**3-8**]: 27.7 (N-75 band-15 L-6 M-2) (Hct-46.6) [**3-9**]: 19.4 [**3-10**]: 21.0 [**3-11**]: 17.2 (N-67 band-18 L-12 M-3) [**3-12**]: 20.7 [**3-14**]: 26.9 [**3-15**]: 29.0 Na-138 K-2.8 Cl-104 Bicarb-25 BUN-7 Cr-0.5 Gluc-242 Ca-7.5 Mg-1.9 Phos-1.4 Trig-213 (up from 101 [**3-11**]) [**3-13**]: ALT-70 AST-45 Alk Phos-106 TBili-0.6 TP-5.0 Alb-2.1 [**Doctor First Name **]-204 (all stable/trending down) Guaiac negative [**3-14**] Blood Cultures 4/1: NGTD CT Abd [**3-14**]: Extensive pancreatitis with increasing peri-pancreatic fluid, small right pleural effusion, larger left pleural effusion, compressive bibasilar atelectasis, ascites, diffuse ileus CXR [**3-14**]: Well-placed R subclavian TLC, L pleural effusion vs. infiltrate Brief Hospital Course: 48 yo woman with severe pancreatitis and leukocytosis. 1. Pancreatitis: Appears most likely to be due to gallstones or biliary sludge despite lack of evidence of cholelithiasis on OSH CT scans. There is no history of recent EtOH use, and the patient was not hypercalcemic or hyperlipidemic on admission to the OSH. She was not taking any medications known to cause pancreatitis, and there was no antecedent viral prodrome or trauma. By all lab parameters, her pancreatitis is improving, but the severity of her pancreatitis is worsening by CT scanning. Her pancreatic inflammation also appears to have resulted in significant pleural effusions that now appear to be causing signficant tachypnea and hypoxemia (see below). - NPO - Maintenance IV fluids - Pain control with hydromorphone as needed - RUQ U/S now to evaluate for cholelithiasis or cholecystitis 2. Fever and Leukocytosis: [**Month (only) 116**] be attributable to worsening pancreatitis given increasing severity on CT scan. There is clear concern for a secondary bacterial infection, however. Possible sources include infected pleural or ascitis fluid, pneumonia, bacteremia from bacterial gut translocation, or UTI. Absent evidence of pancreatic necrosis on CT scanning, there is no apparent indication for empiric antibiotics. - D/C imipenem - CXR now to evaluate pleural effusions, r/o infiltrate - Abd U/S now to evaluate extent of ascites - Consider thoracentesis vs. paracentesis to r/o secondary infection - Blood cultures x2 now - U/A and urine culture now - Stool for C. diff (patient developed diarrhea at OSH); consider metronidazole - Low threshold to repeat CT scan to r/o necrosis or abscess 3. Respiratory Alkalemia: Likely due to mechanical compression of the pulmonary parenchyma caused by atelectasis, pleural effusions, and ascites. The primary process is respiratory; her serum bicarb is 25. - CXR now as above - Consider therapeutic paracentesis, although fluid will likely reaccumulate - Supplemental oxygen - [**Month (only) 116**] require intubation for adequate oxygenation - Consider arterial line 4. Anemia: Patient has no chronic diseases, so anemia of chronic inflammation appears unlikely. There is concern for hemorrhagic pancreatitis given the severity of her inflammation, but there is no physical exam evidence of this. - Send iron studies, folate, B12, retic count - TFTs likely to be unhelpful in acute setting - Send type and screen - Transfuse for Hct less than 21 5. Proph: IV famotidine, heparin sq 6. Access: R subclavian TLC placed [**3-13**] at OSH 7. F/E/N: Maintenance IV fluids, follow lytes closely, NPO 8. Code: Full (presumed) 9. Communication: Patient, family 10. Dispo: MICU for now HD7: patient was transfered to the floor. She remained on Imipenem. Her tube feeds were advanced. Vivonex 1/2 strength starting at 20cc/hr and advancing. Her central venous catheter was taken out and sent for culture. None of her cxs. for the hospital course grew any organisms. HD8: Continued Abx and advanced tube feeds. She continued to spike fevers to 101.2 and slightly tachy at 102. She was on Metoprolol 5mg IV Q6. Tube feeds where changed to Peptamen 3/4strength. HD 9: she was advanced to sips and medications were made PO. Continued to monitor her LFTs which stayed stable. HD 11: Pt's pain continued to decrease. Her diet was changed to Low fat. over the subsequent week the patient was able to tolerate more of her Low fat diet and required less tube feeding. Her tube feeding was stopped on HD 13. Her pain also decreased slowly over the week. [**Last Name (un) **] was consulted and helped manager her insulin requirements. While in house she was kept on imipenem, but will not require it as an outpatient. Over the course of her hospitalization her platelets went from 393 to 1108 at which time she was started on ASA 81 qd. Medications on Admission: Home: 1. MVI 2. vitamin C 3. vitamin E 4. ginseng Discharge Medications: 1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. 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* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 4. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection as directed: see sliding scale. Disp:*qs large bottle* Refills:*2* 5. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: as directed Subcutaneous twice a day: 8units breakfast 8units Bedtime . Disp:*qs large bottle* Refills:*2* 6. Insulin Syringe .5cc/28G Syringe Sig: as directed Miscell. as directed: 29G preferable. Disp:*qs large box* Refills:*2* 7. Lancets Misc Sig: as directed Miscell. as directed: compatable with One touch Ultra. Disp:*qs large box* Refills:*2* 8. test strips Sig: as directed as directed: compatable with One touch Ultra. Disp:*qs large box* Refills:*2* Discharge Disposition: Home with Service Discharge Diagnosis: necrotizing pancreatitis DM insulin requiring polycythemia [**Doctor First Name **] Discharge Condition: stable Discharge Instructions: Please monitor for the following: fever, chills, nausea, vomiting, inability to tolerate food/drink. If any of these occur, please call your physician [**Name Initial (PRE) 2227**]. Followup Instructions: Please call Dr.[**Name (NI) **] office for a follow up appointment in 3-4weeks. ([**Telephone/Fax (1) 2047**] Please call Dr. [**First Name (STitle) **] [**Name (STitle) 61010**] office for an appointment regarding your gallbladder. [**Telephone/Fax (1) 2799**] Please call [**Last Name (un) **] Diabetes Center for an appointment. You need to be followed by someone for your Diabetes care. Completed by:[**2200-3-31**]

[ "250.00", "276.3", "577.0", "238.4", "574.51", "789.5", "V58.67", "995.93", "511.8" ]

icd9cm

[ [ [] ] ]

[ "96.6", "99.15", "38.93" ]

icd9pcs

[ [ [] ] ]

9242, 9261

4096, 8013

327, 334

9389, 9397

2949, 2953

9628, 10052

2032, 2175

8115, 9219

9282, 9368

8039, 8092

9421, 9605

2190, 2930

275, 289

362, 1791

2967, 4073

1813, 1853

1869, 2016

67,598

145,807

36446

Discharge summary

report

Admission Date: [**2128-4-9**] Discharge Date: [**2128-4-14**] Date of Birth: [**2044-1-10**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 106**] Chief Complaint: dyspnea, STEMI Major Surgical or Invasive Procedure: Cardiac catheterization and placement of three bare metal stents History of Present Illness: Ms. [**Known lastname 9241**] is a 84 YOF with prior history of 3 vessel coronary artery disease, prior NSTEMI presenting as shortness of breath, CHF (EF 25%), and COPD who was in her usual state of health with almost daily dyspnea on exertion who developed shortness of breath associated with diaphoresis, nausea, and diarrhea this morning. She notes that her symptoms were similar to her usual symptoms, however, they did not go away throughout the day so she called her grandson. [**Name (NI) **] called EMS who found ST elevations in II, III, and avF as well as depressions in V3 and brought her to [**Hospital1 18**]. She took 325 mg aspirin at home. Past Medical History: 1. Coronary artery disease - prior NSTEMI in [**4-25**] - recent hospitalization at [**Location (un) 620**] for NSTEMI 2. CHF - last EF 20% ([**2127-11-3**]) 3. COPD 4. Recent GI bleed [**11-25**] at [**Location (un) 620**] (transfused 3 units RBCs, no endoscopy) 5. Upper back pain, s/p spinal fusion 6. s/p left femoral neck fracture and left hip hemiarthroplasty with chronic hip pain Social History: The patient lives alone in her home. Her grandson and granddaughter are her primary caregivers. She denies alcohol use, and quit smoking 20 years ago. uses walker at baseline with back pain. Husband of many years died in [**Month (only) 1096**] and pt admits to loneliness and sadness since although this is not new for her per family. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: en: pale elderly female, emotionally distressed by hospitalization and chest/abdominal pain Pale skin HEENT: EOMI. MMM. OP clear. tongue midline Neck: Supple, without adenopathy or JVD. Chest: Lungs clear to auscultation with normal respiratory effort. Cor: Normal S1, S2. RRR. No murmurs appreciated. Abdomen: + BS, tender to palpation in lower abdomen. Soft, non-distended. + Extremity: Large hematoma at right groin access cath site. Otherwise warm, without edema. 2+ DP pulses bilaterally. Neuro: Alert and oriented. CN 2-12 intact. Motor strength intact in all extremities. . Pertinent Results: Labs on admission: CBC [**2128-4-9**] 07:13PM BLOOD WBC-7.7 RBC-2.70*# Hgb-7.3* Hct-22.6* MCV-84 MCH-27.2 MCHC-32.5 RDW-14.6 Plt Ct-199 [**2128-4-9**] 07:13PM BLOOD Plt Ct-199 Chem 7 [**2128-4-9**] 07:13PM BLOOD Glucose-117* UreaN-48* Creat-0.8 Na-138 K-4.7 Cl-105 HCO3-26 AnGap-12 LFTs [**2128-4-9**] 07:13PM BLOOD ALT-8 AST-28 CK(CPK)-160 AlkPhos-44 TotBili-0.3 Cardiac biomarkers [**2128-4-9**] 07:13PM BLOOD CK-MB-16* MB Indx-10.0* cTropnT-0.55* [**2128-4-10**] 05:07AM BLOOD CK-MB-54* MB Indx-11.6* cTropnT-1.46* Other chemistry [**2128-4-9**] 07:13PM BLOOD Albumin-3.4* Calcium-8.1* Phos-3.7 Mg-2.0 Cholest-108 [**2128-4-9**] 07:13PM BLOOD Triglyc-51 HDL-37 CHOL/HD-2.9 LDLcalc-61 [**2128-4-9**] 11:10PM BLOOD Lactate-3.0* [**2128-4-10**] 05:24AM BLOOD Lactate-1.2 [**2128-4-9**] 11:10PM BLOOD freeCa-1.09* [**2128-4-9**] 11:10PM BLOOD Type-[**Last Name (un) **] pH-7.27* Comment-PERIPHERAL Cardiac catheterization [**2128-4-9**]: COMMENTS: 1. Coronary angiography in this right dominant system demonstrated three vessel disease. The LMCA had mild luminal irregularities but no flow limiting stenosis. The LAD had a mid subtotal occlusion after the 1st diagonal branch with collateral filling of the distal vessel. The LCx had an 80% proximal stenosis of OM1. The RCA had sequential 90% mid stenoses followed by a subtotal occlusion before the distal bifurcation of the PDA and PL. There was minimal flow into the PL branch. 2. Limited resting hemodynamics revealed mild systemic arterial hypertension with SBP 141mmHg and DBP 85mmHg. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Acute subtotal occlusion of the distal RCA. Echo [**2128-4-10**] IMPRESSION: Mild symmetric left ventricular hypertrophy with normal cavity size and extensive systolic dysfunction c/w multivessel CAD or other diffuse process. Mild aortic regurgitation.Minimal aortic valve stenosis. Mild mitral regurgitation. Compared with the prior study (images reviewed) of [**2127-5-6**], the left ventricular cavity is smaller with improved inferolateral systolic function. The other findings are similar. CLINICAL IMPLICATIONS: The left ventricular ejection fraction is <40%, a threshold for which the patient may benefit from a beta blocker and an ACE inhibotor or [**Last Name (un) **]. Based on [**2124**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Brief Hospital Course: # STEMI: In the ED, initial vitals were: HR 100 BP 126/72 RR 24 Sat 98%. The patient was given plavix 600 mg, integrillin, and heparin. She was taken to the cath lab where she was found to have TIMI 1 flow in a large rPL branch and serial lesion in the RCA. She was given three overlapping bare metal stents. She developed a moderate hematoma during case which was compressed and remained stable, but for this reason she was not continued on integrellin. She was chest pain free at the end of case but with residual ST elevations. She then developed mild chest discomfort and was tachycardic. She was given IV lopresser 2.5 mg and the chest discomfort resolved. Her echo showed EF 30% and extensive systolic dysfunction consistent with multivessel CAD or other diffuse process but with improved inferrolateral systolic function compared with prior. She will need to continue the aspirin 81 mg (lower dose given GI bleed below), plavix 75 mg for at least one month, atorvastatin 80 mg, metoprolol, and lisinopril. She will need to follow up with her cardiologist and Primary Care, Dr. [**Last Name (STitle) 11302**] on Friday [**4-16**]. . # GI bleed: After her catheterization the patient had 300 cc of melenotic stool. NG lavage was performed and revealed evidence of old coffee ground blood. GI was consulted who decided that she should be supported medically given her recent procedure/STEMI. (Of note, the patient was recently admitted to [**Location (un) 620**] in [**2127-11-18**] where she had a GI bleed and refused endoscopy at that time) RBCs were requested, but due to antibodies, the pt had to request blood products from the Red cross. The patient was found to be hypotensive to the low 80s/high 70s and was bolused with LR until she received 3 units of RBCs. She was started on a protonix drip and had no evidence of further bloody stools. Her Hct remained stable and her lactate was not elevated. It was thought that her bleed was likely from an upper source in the setting of receiving heparin, integrillin, plavix, and aspirin. She was initially made NPO, but her diet was advanced slowly and she tolerated this well. Her beta blocker, ACEi, and lasix were initially held and restarted before discharge. H pylori is currently pending. She has an appt with outpt gastroenterologist at [**Location (un) 620**] and was encouraged to keep the appt. . # Groin Hematoma: The patient developed a large right hematoma as a complication from her catheterization. No bruits were auscultated. She was not continued on integrellin post cath for this reason. The hematoma remained stable and should improve over time. . # Back pain: The patient has chronic back pain at baseline. To treat her pain she was given morphine 1 - 2 mg Q 4 hr while she was NPO. She was also given tylenol 1 gm Q 6 hours and Lidoderm patch which she said did not improve the pain. therefore, she was sent home with no change to her pain regimen. . # Depression: noted by pt appearance and history. Gerontology consult called and recommended 15 mg Remeron qhs to treat depression, help her sleep and possibly improve her appetite. This medicine should be uptitrated to effect by PCP. [**Name10 (NameIs) **] agree with plan and pt encouraged to make her wishes clear about further medical therapy. A social work consult was asked for on page 1 to help her with end of life decision making. . # Urinary urgency: pt stated she felt like she had UTI on day of discharge, long history of these after foley catheterization. U/A mostly bland and cx pending. Given symptoms, pt was sent home on 3 day course of ciprofloxacin. Medications on Admission: Aspirin 325 mg Q day Atorvastatin 80 mg Tablet Q day Carvedilol 3.125 mg [**Hospital1 **] Furosemide 40 mg Q day Lisinopril 2.5 mg Tablet Q day 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). 3. Calcium 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1) Tablet PO twice a day. 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. 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* 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. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 10. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO twice a day. 11. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual every 5 minutes x3 as needed for chest pain. 12. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) patch Topical once a day. Disp:*30 patches* Refills:*2* 13. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days. Disp:*6 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Caregroup Discharge Diagnosis: Primary diagnosis: ST Elevation Myocardial Infarction GI bleed (source unknown) Right groin hematoma Depression Secondary diagnosis: low back pain systolic CHF Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent Discharge Instructions: You came to the hospital because you were having shortness of breath and were found to be having a heart attack. You were emergently taken to the cath lab where you received three bare metal stents to your blocked artery. You had some leaking of blood from your blood vessel in your groin after the procedure. You also developed bleeding from your rectum and this was thought to be from bleeding up near your stomach. You were given red blood cells and IV fluids and the bleeding stopped. Please note the following changes to your medications: 1. Continue Plavix every day to prevent the stent from clotting off. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking Plavix for one month unless Dr. [**Last Name (STitle) **] tells you to. 2. Decrease your aspirin to 81 mg daily 3. Start taking Calcium with Vitamin D to prevent bone loss 4. Start Pantoprazole twice daily to prevent further stomach bleeding 5. Start Lidocaine patch to painful back area once daily 6. Start Mirtazipine 15 mg at night to help your mood and your appetite. This will probably need to be increased by Dr. [**Last Name (STitle) 11302**]. 8. Take senna up to twice daily to prevent constipation 9. Take Ciprofloxacin for 3 days to treat your urinary tract infection . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. Followup Instructions: Please follow up with the following providers: Cardiology and Primary Care: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] Phone: [**Telephone/Fax (1) 29110**] Date/time: Friday [**4-16**] at 11:30am. . Gastroenterology: [**Name (NI) 23804**], [**Name (NI) **], MD [**Street Address(2) 25332**] [**Location (un) 620**], [**Numeric Identifier 3002**] Phone: [**Telephone/Fax (1) 3259**] Fax: [**Telephone/Fax (1) 82574**] Date: [**5-11**] at 10:15pm. Completed by:[**2128-4-15**]

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icd9cm

[ [ [] ] ]

[ "00.40", "88.56", "00.66", "36.06", "00.47", "37.22", "00.44", "88.53", "99.20" ]

icd9pcs

[ [ [] ] ]

10364, 10404

5141, 8755

328, 394

10609, 10609

2590, 2595

12187, 12677

1859, 1974

8949, 10341

10425, 10425

8781, 8926

4156, 4698

10759, 11278

1989, 2571

4721, 5118

11307, 12164

274, 290

422, 1079

10559, 10588

10444, 10538

2610, 4139

10624, 10735

1101, 1490

1506, 1843

25,522

119,854

5871+55705

Discharge summary

report+addendum

Admission Date: [**2144-9-23**] Discharge Date: Date of Birth: [**2095-7-17**] Sex: F Service: OMED HISTORY OF THE PRESENT ILLNESS: This is a 44-year-old woman with metastatic breast cancer diagnosed on [**1-/2139**] status post left mastectomy, 19/21 positive lymph nodes, status post four cycles of CAF and subsequent autologous BMT in [**2138**] which was unsuccessful. Since that time, the patient has had slowly progressive disease with pathological fractures in the ribs, the pelvic rami, and concurrently being treated with monthly treatments of Zometa. The patient was admitted for dizziness, lightheadedness. On admission, the patient was found to be incidentally pancytopenic and also had a subacute left parietal subdural hematoma without a midline shift. No enhancing lesions were noted. The patient did not have neurologic symptoms at the time of presentation and was evaluated by Neurosurgery in the Emergency Department. She was transferred to the ICU for frequent neurologic checks and blood pressure and heart rate monitoring. The patient did not have any recent history of trauma; however, had been taking large amounts of NSAIDS for her bone pain. The patient was found to be neurologically stable without increasing subdural hematoma based on MRI on [**2144-9-26**]. Subsequently, the patient was transferred to the Oncology Service. The patient's chief complaint of dizziness had resolved after adequate hydration in the ICU. During the hospital stay in the ICU, the patient received a Porta-Cath for permanent intravascular access with the right internal jugular for temporary access. PAST MEDICAL HISTORY: 1. Left breast cancer in 03/98, status post mastectomy in 04/98, positive lymph nodes, status post CAF, Taxol, TAH, Faslodex, .................... The patient has metastatic disease to bone. 2. Liver nodules diagnosed in [**9-20**]. 3. Osteoblastic metastatic lesions in the pelvis and acetabula bilaterally. 4. Status post high-dose chemotherapy with stem cell rescue in [**2138**]. ALLERGIES: Sulfa, Benadryl. ADMISSION MEDICATIONS: 1. Zometa 4 mg IV q. month. 2. Vioxx 25 mg once a day. 3. Xeloda three tablets twice a day one time a week. 4. Ativan 1 mg at bedtime. 5. Tylenol p.r.n. 6. Tramadol 100 mg q.i.d. 7. Celebrex 20 mg q.d. SOCIAL HISTORY: The patient is married, lives with her husband. She has two children, 8 and 11 years old. She drinks alcohol socially. Positive smoking history. FAMILY HISTORY: Grandmother died of gastric cancer. Father had liver cancer. PHYSICAL EXAMINATION ON ADMISSION TO OMED SERVICE: Vital signs: Temperature 98.0, pulse 92, respiratory rate 20, blood pressure 120/60, oxygen saturation 96% on room air. HEENT: The oropharynx was clear. There was no visible thrush, lesions, mucous membranes were moist. Cardiac: Regular rate and rhythm. No murmurs, rubs, or gallops appreciated. Lungs: Clear to auscultation bilaterally. There was visible left mastectomy with scars. Abdomen: No splenomegaly. No hepatomegaly, nontender, nondistended, no masses appreciated, positive bowel sounds. Extremities: There was no edema, +2 pulses dorsalis pedis bilaterally. LABORATORY/RADIOLOGIC DATA: White count 2.8, hematocrit 26.5, platelets 106,000, AST 102, ALT 45, LDH 50,270, alkaline phosphatase 270, total bilirubin 2.7, albumin 3.7, haptoglobin 508, fibrinogen 819. HOSPITAL COURSE: The patient was admitted to the Oncology Service to monitor her pancytopenia and neurologic examination for her subdural hematoma. During the hospital course, the patient progressively became anemic. The hematocrit ranged between 18 and 26. The patient required frequent blood transfusions. The patient received 8 units of packed red blood cells at the time of dictation. In addition, the patient's platelet count also continued to fall, ranging between 50 and 115. Because of the subdural hematoma, the patient's platelet level was kept around 100. She required 8 units of platelet transfusion. The cause of the pancytopenia was unclear. It was unlikely due to bleeding as there is no obvious source of bleeding, unlikely to be hemolysis. The haptoglobin was elevated. The bilirubin levels were not elevated. Coombs' tests were negative. Bone marrow biopsy was performed on the patient to determine if cancer had invaded the bone marrow causing the pancytopenia. Biopsies showed extensive breast tissue within the marrow confirming infiltration. After bone marrow biopsy showed extensive infiltration of the breast cancer, the patient was treated with Navelbine and Faslodex. The patient was monitored regularly on neurologic examination for her subdural hematoma. She had no focal neurologic deficits. CT examinations showed no increase in interval changes. The patient was followed by Neurosurgery for the subdural hematoma. The patient was taken off NSAIDs and platelets were kept above 100,000. On [**2144-10-2**], the patient complained of some mild blurry vision in the right eye. Ophthalmology was consulted and examination was performed which showed bilateral papilledema and small hemorrhage in the left optic disk. There was concern that the patient had increased intracranial pressure. MRI with gadolinium scan was performed to evaluate for possible increasing subdural hematoma versus emergence of a new intracranial metastasis. The results of the MRI were unchanged from previous showing no parenchymal metastasis but involvement of the bone of the skull. There was no evidence of herniation or increased intracranial pressure. The patient was started on Decadron. On hospital day number six, the patient began to develop fevers of 100.8 which progressed to lows of 100.2. The source of fever was unclear. The patient's right internal jugular central line was taken out prior to the emergence of fever. The patient's newly placed Porta-Cath did not appear infected. The patient had no complaints or localizing source of infection. The patient was monitored and treated with Tylenol on an p.r.n. basis. Antibiotics were not given as the patient looked clinically stable and no obvious source of infection could be elucidated. A CT scan of the torso and sinuses were performed which did not show abscesses or signs of infection. Abdominal CT did show increased size of the liver and spleen with increasing size of metastasis. To the time of this dictation, cultures have been negative or show contamination. The patient's pain initially prior to admission was managed with NSAIDs; however, given her subdural hematoma and thrombocytopenia, all NSAIDs were discontinued upon her admission. Her pain was controlled with opiates. The pain was managed unsuccessfully with Percocet; however, the pain was well controlled after administration of Fentanyl at 50 micrograms per hour. The patient had a transaminitis. AST 127, ALT 55, LDH 3,000. It was thought that this was likely related to the liver metastases. The elevated LDH possibly was secondary to hemolysis. A right upper quadrant ultrasound was performed which showed no evidence of ductal dilatation. CT scan of the torso also did not show evidence of ductal dilatation. However, GTT levels were elevated. To see the rest of the hospital course, please see the discharge summary addendum. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], M.D. [**MD Number(1) 10999**] Dictated By:[**Name8 (MD) 10402**] MEDQUIST36 D: [**2144-10-3**] 07:05 T: [**2144-10-3**] 19:21 JOB#: [**Job Number 23221**] Name: [**Known lastname 3939**], [**Known firstname **] Unit No: [**Numeric Identifier 3940**] Admission Date: [**2144-9-23**] Discharge Date: [**2144-10-14**] Date of Birth: [**2095-7-17**] Sex: F Service: OMED ADDENDUM: The final read of the MRI done to evaluate for possible increasing subdural hematoma versus emergence of new intracranial metastasis was consistent with meningeal enhancement suggesting metastatic disease of leptomeningeal involvement. A more focal MRI was repeated to rule out optic nerve infiltration of metastatic cancer cells as a cause of the patient's papilledema. This was negative. Thus, the decision was made to go ahead with attempts to carry out a lumbar puncture in order to determine whether or not malignant cells existed in the CSF requiring Ommaya shunt for intrathecal chemotherapy. The patient was transferred to the ICU for bur hole evacuation of her subdural hematoma and placement of a subdural drain to permit lumbar puncture by Neuro-Oncology. Lumbar puncture was done and cytology was negative for malignant cells so there was no need for an Ommaya shunt. The patient was transferred out of the unit and back to the floor and received her regularly scheduled Taxol on [**2144-10-11**]. She will follow-up with Dr. [**First Name (STitle) **] for continued chemotherapy treatments. In the interim, she has developed no new neurological complaints other than the persistent blurry vision. In regards to her fever, Radiology notified the team of significant evidence of sinusitis by CT. The patient was thus started on Levaquin but subsequently developed itching and rash on her hands bilaterally. She managed to continue the course of Levaquin despite her symptoms. DISCHARGE STATUS: The patient is to be discharged to home. DISCHARGE CONDITION: Good. The patient is taking good p.o., no nausea or vomiting. The neurological examination is stable. DISCHARGE MEDICATIONS: 1. Fentanyl patch 75 micrograms per hour transdermal q. 72 hours. 2. Oxycodone 15 mg p.o. q. three hours p.r.n. breakthrough pain. 3. Zyprexa 5 mg p.o. q.h.s. 4. Dexamethasone 2 mg p.o. b.i.d. 5. Colace 100 mg p.o. b.i.d. 6. Senokot two tablets p.o. q.h.s. 7. Lactulose 20 gram packet, one packet p.o. q. four hours p.r.n. constipation. 8. Ativan 1 mg p.o. q. four to six hours p.r.n. anxiety. 9. Protonix 40 mg p.o. q.d. 10. MiraLax 17 grams p.o. q.d. 11. Folate 1 mg p.o. q.d. FOLLOW-UP: The patient is to follow-up with Dr. [**First Name (STitle) **] to have her blood drawn on Friday to check her blood count and to return on Monday for a follow-up visit to be scheduled by Dr. [**First Name (STitle) **]. The patient also has follow-up with Dr. [**Last Name (STitle) 1342**] on [**2144-10-16**] at 9:30 a.m. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3113**], M.D. [**MD Number(1) 2212**] Dictated By:[**Name8 (MD) 3941**] MEDQUIST36 D: [**2144-10-25**] 08:29 T: [**2144-10-27**] 10:43 JOB#: [**Job Number 3942**]

[ "276.5", "432.1", "V10.3", "198.3", "198.5", "197.7", "198.4", "V42.82" ]

icd9cm

[ [ [] ] ]

[ "03.31", "02.2", "01.09", "86.07", "41.31" ]

icd9pcs

[ [ [] ] ]

9432, 9537

2498, 3399

9560, 10651

3417, 9410

2105, 2315

1662, 2082

2332, 2481

19,619

149,061

24790

Discharge summary

report

Admission Date: [**2179-9-14**] Discharge Date: [**2179-9-23**] Date of Birth: [**2111-11-3**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 25876**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: OMED - Last Updated by [**Last Name (LF) **],[**First Name3 (LF) **] A on [**2179-9-16**] @ [**2103**] Patient Location: 11R-1174-01 ID: 67 YOF . CC:[**CC Contact Info 62452**]. HPI: 67 yo with metastatic melanoma (last chemo 2.5 wks ago) with one day of emesis and headaches on [**9-12**], developed an expressive aphasia and increased lethargy on [**9-13**]. CT scan reveals a >20cc LEFT occipital bleed per neuroICY team. It is unclear if this represents an acute spontaneous bleed in the setting of thrombocytopenia and repeated Valsalva maneuvering or an underlying metastasis. Spent 2 days in ICU with slow resolution of her mental status. As she is improving she has been transferred to the OMED service for further care. . ROS (+) nausea, L leg pain, L leg swelling, last BM >5 days ago (-) headache Past Medical History: PMHx: -Melanoma X 20yrs 1st lesion or left arm ([**Doctor Last Name **] IV)followed 10 years later by lesion on left leg (also [**Doctor Last Name **] IV). More recently inguinal mass found -ITP s/p splenectomy -s/p partial colectomy (for uncontroled LGIB during ITP) . . She is a current Social History: SOCIAL HISTORY: (Per Dr.[**Last Name (STitle) 18619**], confirmed with pt) The patient lives in [**Location 4288**], [**State 350**]. She has 6 children and 14 grandchildren. She is a current smoker and she has smoked one pack per day x50 years. At the present time, she says she smokes about five cigarettes per day. She used to drink two alcoholic beverages each night, but she has not had any alcohol since [**Month (only) 205**]. She is currently retired, and she formerly worked for UPS. Family History: FAMILY HISTORY: (Per Dr.[**Last Name (STitle) 18619**], confirmed with pt)The patient reports that her father had "heart problems." She states that her mother had [**Name (NI) 5895**] disease. In terms of history of malignancy, she notes that her maternal aunt had ovarian cancer. Physical Exam: 98.4 143/93 85 12 96% RA wt 126 lbs Gen: [**Last Name (un) 1425**] woman lying in bed, daughters at bedside [**Name (NI) 4459**]: PERRL [**Name (NI) 3899**] sclera white mmm OP clear NECK: Supple no lad or jvd CV:RRR nl s1-s2 no m/r/g Lungs CTAB Abd: soft NT/ND BS+ large (10X8) hard mass felt in the LLQ EXT: L leg markedly larger than R. healed skin graft sites on thighs b/l. L inguinal crease-hard collection of masses belowed healed skin graft site. ppp Skin: warm, dry, tan, multiple sebhoaric keratosis Neuro: AOX3, follows commands, CNII-XII intact, sensation intact in EXT, decreased strength in LLE Pertinent Results: [**2179-9-14**] 08:09PM GLUCOSE-127* UREA N-6 CREAT-0.5 SODIUM-135 POTASSIUM-3.2* CHLORIDE-95* TOTAL CO2-23 ANION GAP-20 [**2179-9-14**] 08:09PM CALCIUM-8.2* PHOSPHATE-2.4* MAGNESIUM-1.4* [**2179-9-14**] 08:09PM WBC-4.5 RBC-2.73* HGB-8.3* HCT-24.6* MCV-90 MCH-30.5 MCHC-33.8 RDW-17.9* [**2179-9-14**] 08:09PM PLT COUNT-72* [**2179-9-14**] 08:09PM PT-14.3* PTT-28.6 INR(PT)-1.4 [**2179-9-14**] 11:25AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021 [**2179-9-14**] 11:25AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-SM [**2179-9-14**] 11:25AM URINE RBC-0-2 WBC-[**10-10**]* BACTERIA-FEW YEAST-NONE EPI-0-2 TRANS EPI-0-2 [**2179-9-14**] 11:21AM LACTATE-2.0 [**2179-9-14**] 11:15AM GLUCOSE-112* UREA N-8 CREAT-0.7 SODIUM-135 POTASSIUM-4.1 CHLORIDE-95* TOTAL CO2-22 ANION GAP-22* [**2179-9-14**] 11:15AM ALT(SGPT)-10 AST(SGOT)-21 ALK PHOS-176* AMYLASE-51 TOT BILI-0.7 [**2179-9-14**] 11:15AM LIPASE-38 [**2179-9-14**] 11:15AM CALCIUM-8.6 PHOSPHATE-2.9 MAGNESIUM-1.7 [**2179-9-14**] 11:15AM WBC-6.2 RBC-3.40* HGB-10.6* HCT-31.2* MCV-92 MCH-31.2 MCHC-34.0 RDW-17.8* [**2179-9-14**] 11:15AM NEUTS-88.7* LYMPHS-10.3* MONOS-0.7* EOS-0.3 BASOS-0 [**2179-9-14**] 11:15AM ANISOCYT-1+ MACROCYT-1+ [**2179-9-14**] 11:15AM PLT COUNT-76* [**2179-9-14**] 11:15AM PT-14.8* PTT-28.3 INR(PT)-1.5 [**2179-9-13**] 01:22PM ALT(SGPT)-9 AST(SGOT)-18 LD(LDH)-296* ALK PHOS-178* TOT BILI-0.8 [**2179-9-13**] 01:22PM PHOSPHATE-3.0 MAGNESIUM-1.7 [**2179-9-13**] 01:22PM WBC-7.0 RBC-3.11* HGB-9.3* HCT-28.9* MCV-93 MCH-29.9 MCHC-32.3 RDW-17.4* [**2179-9-13**] 01:22PM NEUTS-88.0* LYMPHS-10.4* MONOS-0.9* EOS-0.3 BASOS-0.5 [**2179-9-13**] 01:22PM ANISOCYT-1+ MACROCYT-1+ [**2179-9-13**] 01:22PM PLT COUNT-85*# RADIOLOGY Final Report CT ABD W&W/O C [**2179-9-13**] 10:36 AM CT CHEST W/CONTRAST; CT ABD W&W/O C Reason: Follow-up oncology CT scan. Please mark and measure all lesi Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 67 year old woman with metastatic melanoma. REASON FOR THIS EXAMINATION: Follow-up oncology CT scan. Please mark and measure all lesions [**Hospital1 **]-dimensionally and include in an oncology table. INDICATION: 67-year-old woman with metastatic melanoma. Please followup with oncology table. COMPARISONS: [**2179-7-27**]. TECHNIQUE: MDCT-acquired axial images of the abdomen were obtained without IV contrast. Subsequently, MDCT-acquired axial images of the chest, abdomen and pelvis obtained with IV contrast. Delayed phase images of the abdomen and pelvis were also obtained. ONCOLOGY TABLE: Oncology table is available on the CareWeb under "X-ray", "Imaging Lab". Three target lesions were selected on the previous scans. On today's scan, Lesion 1 measures 19 x 17 mm (left lower lobe lung nodule), Lesion 2 measures 26 x 20 mm (left liver lobe dome metastasis), and Lesion 3 measures 121 x 75 mm (left pelvis soft tissue mass). There has been interval increase in size of these target lesions. CT OF THE CHEST WITH IV CONTRAST: Again seen are innumerable bilateral metastatic lesions scattered throughout the lungs. These metastases appear to have increased in both size and number. Lesion 1 as identified on the oncology table, which previously measured 15 x 13 mm, now measures 19 x 17 mm on today's study, and is best seen on series 3, image 49. No pleural effusions or consolidations are identified within the lungs. The heart and great vessels appear unremarkable. No pathologic axillary, mediastinal, or hilar lymphadenopathy is identified. Incidentally seen are multiple hypodense areas in the thyroid consistent with nodules. CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: Again seen are innumerable metastatic hypodense lesions throughout the liver. These lesions appear to have increased in both size and number. The lesion identified in the left lateral segment of the liver and designated as Lesion 2 on the oncology table, which previously measured 20 x 19 mm, now measures 26 x 20 mm on today's study. The previously seen biliary dilatation appears to have increased. The bile duct dilatation extends to the head of the pancreas, and metastasis to the distal bile duct cannot be excluded. There appears to have been interval increase in the size and number of aortic and caval nodes. Again seen is a lesion in the left side overlying the peritoneum that has increased in size from approximately 0.5 cm on prior study to 1.2 cm on today's study, and is concerning for metastatic disease. Again seen is a very large soft tissue mass arising at the level of the kidneys and extending all the way down into the pelvis. On prior study the greatest cross-sectional diameter of this mass was 10 x 6.9 cm. On today's study, greatest cross-sectional diameter measures 12.1 x 7.5 cm. Again seen are multiple bilateral hypodense renal lesions that possibly represent simple renal cysts although metastatic disease cannot be ruled out. Large and small bowel appear unremarkable. CT OF THE PELVIS WITH CONTRAST: The distal ureters appear within normal limits. The uterus appears normal. The large soft tissue mass which extends into the pelvis as described above is seen with cross-sectional dimensions measured on series 4, image 71. Again seen is a soft tissue mass in the left inguinal area measuring 3.4 x 2.3 cm on today's study. BONE WINDOWS: Several lucent areas are seen within the vertebrae, possibly consistent with degenerative disease of the spine, however, lytic metastases cannot be excluded. IMPRESSION: Interval progression of widely metastatic disease. Increase in intrathoracic, abdominal, and pelvic disease. Oncology table was updated for this patient. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**] Approved: WED [**2179-9-15**] 8:35 AM RADIOLOGY Final Report CT CHEST W/CONTRAST [**2179-9-13**] 10:36 AM CT CHEST W/CONTRAST; CT ABD W&W/O C Reason: Follow-up oncology CT scan. Please mark and measure all lesi Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 67 year old woman with metastatic melanoma. REASON FOR THIS EXAMINATION: Follow-up oncology CT scan. Please mark and measure all lesions [**Hospital1 **]-dimensionally and include in an oncology table. INDICATION: 67-year-old woman with metastatic melanoma. Please followup with oncology table. COMPARISONS: [**2179-7-27**]. TECHNIQUE: MDCT-acquired axial images of the abdomen were obtained without IV contrast. Subsequently, MDCT-acquired axial images of the chest, abdomen and pelvis obtained with IV contrast. Delayed phase images of the abdomen and pelvis were also obtained. ONCOLOGY TABLE: Oncology table is available on the CareWeb under "X-ray", "Imaging Lab". Three target lesions were selected on the previous scans. On today's scan, Lesion 1 measures 19 x 17 mm (left lower lobe lung nodule), Lesion 2 measures 26 x 20 mm (left liver lobe dome metastasis), and Lesion 3 measures 121 x 75 mm (left pelvis soft tissue mass). There has been interval increase in size of these target lesions. CT OF THE CHEST WITH IV CONTRAST: Again seen are innumerable bilateral metastatic lesions scattered throughout the lungs. These metastases appear to have increased in both size and number. Lesion 1 as identified on the oncology table, which previously measured 15 x 13 mm, now measures 19 x 17 mm on today's study, and is best seen on series 3, image 49. No pleural effusions or consolidations are identified within the lungs. The heart and great vessels appear unremarkable. No pathologic axillary, mediastinal, or hilar lymphadenopathy is identified. Incidentally seen are multiple hypodense areas in the thyroid consistent with nodules. CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: Again seen are innumerable metastatic hypodense lesions throughout the liver. These lesions appear to have increased in both size and number. The lesion identified in the left lateral segment of the liver and designated as Lesion 2 on the oncology table, which previously measured 20 x 19 mm, now measures 26 x 20 mm on today's study. The previously seen biliary dilatation appears to have increased. The bile duct dilatation extends to the head of the pancreas, and metastasis to the distal bile duct cannot be excluded. There appears to have been interval increase in the size and number of aortic and caval nodes. Again seen is a lesion in the left side overlying the peritoneum that has increased in size from approximately 0.5 cm on prior study to 1.2 cm on today's study, and is concerning for metastatic disease. Again seen is a very large soft tissue mass arising at the level of the kidneys and extending all the way down into the pelvis. On prior study the greatest cross-sectional diameter of this mass was 10 x 6.9 cm. On today's study, greatest cross-sectional diameter measures 12.1 x 7.5 cm. Again seen are multiple bilateral hypodense renal lesions that possibly represent simple renal cysts although metastatic disease cannot be ruled out. Large and small bowel appear unremarkable. CT OF THE PELVIS WITH CONTRAST: The distal ureters appear within normal limits. The uterus appears normal. The large soft tissue mass which extends into the pelvis as described above is seen with cross-sectional dimensions measured on series 4, image 71. Again seen is a soft tissue mass in the left inguinal area measuring 3.4 x 2.3 cm on today's study. BONE WINDOWS: Several lucent areas are seen within the vertebrae, possibly consistent with degenerative disease of the spine, however, lytic metastases cannot be excluded. IMPRESSION: Interval progression of widely metastatic disease. Increase in intrathoracic, abdominal, and pelvic disease. Oncology table was updated for this patient. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**] Approved: WED [**2179-9-15**] 8:35 AM RADIOLOGY Final Report CT HEAD W/O CONTRAST [**2179-9-14**] 11:37 AM CT HEAD W/O CONTRAST Reason: eval for bleed [**Hospital 93**] MEDICAL CONDITION: 67 year old woman with met melanoma now with AMS REASON FOR THIS EXAMINATION: eval for bleed CONTRAINDICATIONS for IV CONTRAST: None. Please note that in regard to the category of stroke, the etiologies could include amyloid angiopathy (primary hemorrhage), hemorrhagic transformation of either an arterial or venous infarct. NON-CONTRAST HEAD CT SCAN: HISTORY: Melanoma. Altered mental status. TECHNIQUE: Non-contrast head CT scan. COMPARISON: Gadolinium enhanced MR study of [**2179-7-29**]. FINDINGS: There is a faintly demonstrable 2mm area of hyperdensity within the superior aspect of the left cerebellar hemisphere. While not the same modality, this lesion was not likely present on the prior MR study. A nearly 3 cm area of hemorrhage is noted within the left occipital lobe, with intraventricular extension as well. There are no other areas of abnormal density within the brain. The left cerebral sulci are effaced, likely reflecting mass effect from the hemorrhage, as well as edema surrounding this abnormality. There is no shift of normally midline structures or hydrocephalus. The surrounding osseous and soft tissue structures are unremarkable. CONCLUSION: Large left occipital lobe hemorrhage with surrounding edema and intraventricular extension of blood. Given the history of melanoma, hemorrhage into a new metastasis could be considered as opposed to a hemorrhagic infarct. A second punctate area of hyperdensity likely indicates a hemorrhagic metastasis within the left cerebellum. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9987**] Approved: TUE [**2179-9-14**] 1:19 PM RADIOLOGY Final Report CT HEAD W/O CONTRAST [**2179-9-15**] 7:52 AM CT HEAD W/O CONTRAST Reason: 7:50A [**Hospital 93**] MEDICAL CONDITION: 67 year old woman with left occipital bleed, met melanoma REASON FOR THIS EXAMINATION: eval interval change CONTRAINDICATIONS for IV CONTRAST: None. CT SCAN OF THE BRAIN, [**2179-9-15**]: INDICATION: Left occipital hemorrhage from metastatic melanoma, evaluate for interval change. TECHNIQUE: Axial noncontrast CT scans of the brain were obtained. Comparison is made to previous examinations, the most recent of which was performed on [**2179-9-14**] at 17:19. FINDINGS: There is no appreciable change in the left occipital lobe hemorrhage or surrounding edema. Better defined on today's examination are two foci of hemorrhage within the cerebellar hemispheres, right slightly larger than left. These were previously present. No new areas of hemorrhage are identified. There is no ventricular dilatation. There is no shift of normally midline structures or narrowing of the basal cisternal spaces. IMPRESSION: Stable intracranial hemorrhages, likely associated with the patient's underlying diagnosis of melanoma. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 21104**] Approved: WED [**2179-9-15**] 11:39 AM MR CONTRAST GADOLIN [**2179-9-16**] 2:02 PM MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Reason: STAT for decision making: OR late today?, eval for met (with Contrast: MAGNEVIST [**Hospital 93**] MEDICAL CONDITION: 67 year old woman with met melanoma with head bleed REASON FOR THIS EXAMINATION: STAT for decision making: OR late today?, eval for met (with and without contrast) CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: History of melanoma with intracranial hemorrhage. Assess for metastatic disease. TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the brain without and with gadolinium. COMPARISON: Head CT from [**2179-9-15**]. MRI OF THE BRAIN WITHOUT AND WITH GADOLINIUM: Three abnormally enhancing foci are seen within the cerebellum, which are most likely metastases. Located within the right cerebellar hemisphere just posterior and lateral to one metastasis is a focal rounded area of low signal intensity, which is of unknown etiology. The area of hemorrhage in the left occipital lobe is unchanged allowing for differences in modality. A small rounded nodular area of presumed enhancement is seen in the lateral anterior aspect of the lesion. Direct comparison with the non-contrast sagittal T1 image is limited, but this finding appears to represent enhancement, and a hemorrhagic metastasis as an etiology for the patient's hemorrhage in this area is of concern, given the history of melanoma and metastases seen in the cerebellum. Additionally, a questionable enhancing focus in the midline at the anterior corpus callosum, and a smaller rounded focus of enhancement just lateral to the right temporal ventricular tip are present, which are also suspicious for metastatic disease. There is no hydrocephalus or shift of normally midline structures. Diffusion- weighted imaging shows no areas of acute ischemia. IMPRESSION: 1. Multiple abnormally enhancing foci within the cerebellum, and likely within both cerebral hemispheres, most likely representing metastases. 2. Questionable area of enhancement seen in the left occipital lobe lateral to area of hemorrhage. This cannot be directly confirmed as there are no pre- contrast axial T1-weighted sequences, but the proximity of this probable area of enhancement raises suspicion for a hemorrhagic metastasis as the etiology for the patient's occipital hematoma. 3. Left occipital parenchymal hemorrhage unchanged allowing for differences in modality, since the head CT from [**9-15**]. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) 640**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9987**] Approved: [**Doctor First Name **] [**2179-9-16**] 8:43 PM Brief Hospital Course: #Altered mental status - due to hemorrhage from brain mets. Spent 3 days in neuro ICU. Seen by neurosurgery who did not think surger would help. Started on decadron and phenytoin. Mental status slowly cleared. Pt now doing well and thinking clearly. . #hemmorrhage - Around area of bran mets. Follow up imaging showed hemmorrhage to be stable. HCT remained stable. DVT prophylaxis held. . #Melanoma - Disease progression into brain. Neuro-onc and rad-onc consult [**9-17**]. Planing for XRT done on [**9-20**]. Pt comppleted 3 out of 12 radiation sessions. Cont Phenytoin and decadron. SBP 130-150 per neuro. -On decadron - with PPI and RISS -?nausea related to XRT. watch for now. Consider cerebral edema if worsens. . #Thrombocytosis - Likely reactive in response to gCSF in setting of splenectomy. Holding asa and plavix for now given Hx of head bleed. Also holding sc heparin. Needs to be followed. . #Oxygen requirement - developed overnight on [**2179-9-22**]. Desat to 91% on RA, back up to 95% on 1L by nasal canula. CXR showed no new air space opacities but slight increase in size in known metastatic nodules. discussed with fellow [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], should just be followed clinically for now. . #Neutropenia - Chemo related. ANC dropped below 1000 for 2 days. Never febrile. No antibiotics given. Now resolved with WBC >7000. #Pain control - oxycontin 80 mg po bid with dilaudid prn for breakthrough with good control. [**Month (only) 116**] need to go up on dose but want to watch mental status. . #Constipation - On [**Last Name **] problem. On bowel regimen. Pt has large mass in L pelvis which makes feeling of constipation worse. Medications on Admission: oxycontin 80 mg oxycodone 20 for breakthrough bowel regimen zofran prn Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) as directed Injection ASDIR (AS DIRECTED). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) for 10 days. 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 6. Oxycodone 40 mg Tablet Sustained Release 12HR Sig: Two (2) Tablet Sustained Release 12HR PO Q12H (every 12 hours). 7. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO twice a day. 8. Heparin Lock Flush (Porcine) 10 unit/mL Solution Sig: Five (5) ML Intravenous DAILY (Daily) as needed. 9. Phenytoin Sodium 50 mg/mL Solution Sig: One Hundred (100) mg Intravenous Q8H (every 8 hours). 10. Dexamethasone Sodium Phosphate 4 mg/mL Solution Sig: Six (6) mg Injection Q6H (every 6 hours). 11. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 12. Dolasetron 12.5 mg/0.625 mL Solution Sig: 12.5 mg Intravenous Q8H (every 8 hours) as needed for nausea. 13. Prochlorperazine Edisylate 5 mg/mL Solution Sig: Ten (10) mg Injection Q6H (every 6 hours) as needed for nausea. 14. Hydromorphone 2 mg/mL Syringe Sig: 1-4 mg Injection Q6H (every 6 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: metastatic melanoma Discharge Condition: good Discharge Instructions: Please call Dr.[**Last Name (STitle) 1729**] or return to emargency department if you become confused, have headaches, changes in your vision, increased nausea or vomitting, or weakness in your arms or legs Followup Instructions: With Dr. [**Last Name (STitle) 1729**] in [**11-22**] weeks With radiation onncology for 9 more radiation sessions. Completed by:[**2179-9-23**]

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Discharge summary

report

Admission Date: [**2118-12-11**] Discharge Date: [**2118-12-20**] Date of Birth: [**2053-11-10**] Sex: F Service: MEDICINE Allergies: Zosyn / ceftriaxone Attending:[**First Name3 (LF) 2782**] Chief Complaint: Unresponsiveness, altered, intubated for airway protection found to have urosepsis Major Surgical or Invasive Procedure: intubated, mechanical ventilation History of Present Illness: 65 yo female with MS [**First Name (Titles) **] [**Last Name (Titles) 84078**] for questionable hx TMJ who was sent in from her NSH after being found covered in vomit with agonal breathing. NSH notes reports "symptoms of seizure activity" with patient subsequently unresponsive and found to be hypoxic with sats <83% on 2L. Per EMS, she was unresponsive en route, still breathing but not withdrawing to pain. . In the ED, initial vitals were: no temp recorded, 118 135/71 34 100% on NRB. She was easily intubated for airway protection with a grade 1 view. Head CT was unremarkable for bleed. Neuro was consulted and felt this was likely toxic metabolic if seizure activity, but will continue to follow. She has had multiple episodes of UTI in the past. Blood and urine cultures were sent and she was given vanco/zosyn. Foley was changed. Per the ED resident, they were not aware of her potential allergy but she did not have a rash prior to transfer to the MICU. When the patient was signed out she was currently doing well on vent with most recent vitals prior to transfer being afeb, 92, 103/60 with sats 100% on 400x18, 5x50%. She dropped her pressures prior to transfer to 67/41 with HR 94. She was given 2L of IVF and started on levophed. Sedation was held. . Of note, per Dr.[**Name (NI) 84079**] note to her PCP, [**Name10 (NameIs) **] last admission was for urinary tract infection, E. coli bacteremia, and sepsis, and initially required admission to the ICU for vasopressor support. She was also found to have an obstructing left renal stone and had a percutaneous nephrostomy tube placed with improvement in her infection. She was able to be taken of vasopressor agents and was discharged to complete a 14 day total course of antibiotics. At that time, urology recommended to leave the nephrostomy tube in the left renal system indefinitely with tube changes every 3 months as she was high risk for both nephrolithotomy and extracorporeal shock wave lithotripsy. Her hospital course was also notable for hypoxia with a 4L oxygen requirement which was felt to be due to a combination of mild volume overload, respiratory muscle weakness in the setting of multiple sclerosis and infection, and intermittent aspiration. Her oxygen requirement was stable and she was discharged to rehab to have gentle diuresis as tolerated and tocontinue her usual dysphagia diet. She has been on 2L at her NSH with unclear continued workup. . Past Medical History: Multiple Sclerosis - about 14yrs, followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Location (un) 2274**] - wheelchair at baseline, lives in nursing home - has no use of her lower extremities, sometimes spastic movements - bladder chronically contracted UTI with ESBL E.coli--sensitive to zosyn, [**Last Name (un) 2830**], gent in past [**Last Name (un) 8304**] Depression Anxiety PVD s/p lower extremity bypass COPD Osteoporosis Hx of +PPD bilateral femur supracondylar fractures [**2113**] hx of Urosepsis - hospitalized about once/yr, per husband Neurogenic bladder - indwelling foley x [**4-27**] [**Last Name (LF) 1686**], [**First Name3 (LF) **] husband Recurrent C. Diff Hx of Sacral Decub LE spasticity Hx of jaw pain -- ?TMJ, improved on [**First Name3 (LF) **] Social History: Lives in nursing home for last 4 [**First Name3 (LF) 1686**]. Husband is HCP, lives with one of their daughters. [**Name (NI) **] daughter married and lives in the area. Nonambulatory and in wheelchair at baseline, dependent for transfers and some of ADLs. Has no use of lower extremities at baseline. On pureed thickened liquids at rehab. -Tobacco: started at age 20, quit about 15yrs ago -ETOH: social, occasional, per husband -[**Name (NI) 3264**]: none Family History: No family members with Multiple Sclerosis. Physical Exam: Admission exam Vitals: 101.9 100 117/64 17 100% on 400x18, 5x50% General: Intubated, sedated, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, blood around mouth, no lesions identified Neck: supple, JVP not elevated, no LAD CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: CTAB, no wheezes, rales, ronchi Abdomen: +BS, soft, non-tender, non-distended, no organomegaly Back: stage 2 sacral decub on right buttocks, stage 1 decub on left hip, left perc neph tube in place and c/d/i GU: +foley Ext: cool, well perfused, 2+ pulses distally, no clubbing, cyanosis or edema, moving her toes, PICC line in right upper arm is c/d/i Neuro: sedated Discharge Exam: Afebrile Gen: Alert, awake, responding appropriately to questions, soft spoken with some slurring of speech HEENT: dry MM CV: RRR, no MRG Lungs: poor inspiratory effort, no wheezes, crackles, consolidations Abd: +BS, soft, NT, surgical scars Back: Decub GU: Foley and left perc nephrostomy CDI Neuro: baseline Pertinent Results: ADMISSION LABS: [**2118-12-11**] 01:49PM GLUCOSE-103* UREA N-16 CREAT-0.7 SODIUM-142 POTASSIUM-4.2 CHLORIDE-110* TOTAL CO2-25 ANION GAP-11 [**2118-12-11**] 01:49PM CALCIUM-8.0* PHOSPHATE-2.7 MAGNESIUM-1.8 [**2118-12-11**] 06:23AM CK-MB-7 cTropnT-0.50* [**2118-12-11**] 06:23AM ALT(SGPT)-30 AST(SGOT)-72* CK(CPK)-90 ALK PHOS-183* TOT BILI-0.4 [**2118-12-11**] 06:23AM WBC-14.7*# RBC-3.40* HGB-9.9* HCT-31.1* MCV-91 MCH-29.0 MCHC-31.7 RDW-15.5 DISCHARGE LABS: [**2118-12-20**] 06:07AM BLOOD WBC-6.0 RBC-3.09* Hgb-8.6* Hct-27.4* MCV-89 MCH-27.7 MCHC-31.2 RDW-15.5 Plt Ct-407 [**2118-12-19**] 10:46AM BLOOD Neuts-67.6 Lymphs-22.0 Monos-4.6 Eos-5.1* Baso-0.6 [**2118-12-20**] 06:07AM BLOOD Glucose-75 UreaN-7 Creat-0.4 Na-141 K-3.9 Cl-106 HCO3-31 AnGap-8 [**2118-12-13**] 05:54AM BLOOD ALT-16 AST-20 LD(LDH)-180 AlkPhos-130* TotBili-0.2 [**2118-12-20**] 06:07AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.0 TTE: The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with hypokinesis of the distal half of the septum and apical anterior and inferior walls. The remaining segments contract well (LVEF 40%). The apex is not aneurysm and no apical thrombus is seen. The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal left ventricular cavity size with regional systolic dysfunction c/w CAD (mid-LAD distribution). Pulmonary artery hypertension. CTAbd/pelvis: IMPRESSION: 1. Foley catheter is now positioned with its distal tip seen in the right ureter. Repositioning is recommended. These findings were discussed with Dr. [**Last Name (STitle) **] Dr. [**Last Name (STitle) **] by telephone at 12:10 a.m. on [**2118-12-12**]. 2. Left nephrostomy tube with small left subcapsular hematoma and unchanged left ureteropelvic junction stone. 3. No evidence of small-bowel obstruction despite large amount of stool seen within the rectum and sigmoid. 4. Unchanged right renal staghorn calculus. Renal US: IMPRESSION: 1. Right renal stones without hydronephrosis. 2. Unchanged mild left collecting system fullness. Brief Hospital Course: 65 yo female with history of MS [**First Name (Titles) 151**] [**Last Name (Titles) **] indwelling foley and left percutaneous nephrostomy tube found to be unresponsive admitted to the MICU with septic shock secondary to Pseudomonas urosepsis. The patient was started on Meropenem and did well on the floor. . 1. Sepsis: Urosepsis due to pseudomonas in setting of obstructing stone. Pt with known obstructing staghorn in R, & L percutaneous nephrostomy for ureteral stone. The patient had been on suppressive ertapenem, but this was switched to Meropenem 500mg IV Q6hr given ID recs and better urinary penetration. ID evaluated the patient and felt she should continue on this antibiotic until obstruction relieved. The patient was started on methemazine and ascorbic acid for symptomatic relief. Pt will follow up with outpatient urology to undergo intraoperative lithotripsy/stone extraction. . 2. Elevated troponin/Possible NSTEMI: Pt's troponin found to be elevated on admission. This was likely secondary to demand ischemia in the setting of hypotension. An echo was formed that showed wall motion abnormalities, the chronicity of which could not be determined. The patient's troponin trended down and she was monitored on telemetry for several days with no events. . 3. Multiple sclerosis: The patient had relapsing and remitting MS treated with Glatimer. Our neuro colleagues were initially consulted to determine whether her altered mental status was neurological in origin. They determined that it was not and did not change her treatment regimen. She remains on Baclofen, Glatimer, and cyclobenzaprine. . 4. Hyperlipidemia: Continue simvastatin . 5. Depression: Continue citalopram . 6. CODP: Respiratory status stable. Continue nebulizers/inhalers . 7. Follow Up: The patient will follow up with urology for elective stone removal. She will continue on meropenem until urinary obstruction is remedied. . Transitional Issues: The patient had yeast grow in 2 of 2 urine cultures. With her h/o urosepsis and indwelling catheters, we called her rehab facility and recommended starting Fluconazole. As an outpatient, the patient should be started on a low dose B-blocker given her NSTEMI. She should have outpatient cardiology follow-up at some point as well. Medications on Admission: 1. methenamine hippurate 1 gram Tablet Sig: One (1) Tablet PO bid 2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY 3. carbamazepine 100 mg Tablet, Chewable Sig: one daily 4. Carbamazepine 100 mg Tablet, Chewable Sig: Three (3) Tablet [**Hospital1 **] 5. baclofen 10 mg Tablet Sig: One (1) Tablet PO twice a day. 6. glatiramer 20 mg Kit Sig: Twenty (20) mg Subcutaneous Daily 7. Os-Cal 500 + D 500 mg(1,250mg) -200 unit Tablet daily 8. alendronate 70 mg Tablet PO once a week. 9. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. donepezil 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 11. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS prn insomnia. 12. cranberry 250 mg Tablet Sig: One (1) Tablet PO once a day. 13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet daily 14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for nebs q4h 15. ipratropium bromide 0.02 % Solution Sig: One (1) neg q6h 16. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 17. vitamin E 1,000 unit Capsule Sig: One (1) Capsule PO daily 18. senna 8.6 mg Tablet Sig: One (1) Tablet PO prn constipation 19. potassium chloride 20 mEq Packet Sig: One (1)daily 20. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) Rectal q M/W/F. 21. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID 22. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff [**Hospital1 **] 23. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush q8h prn 24. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC 25. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID 26. meropenem 500 mg Recon Soln Sig: One (1)IV q8 hours for 5 days. Discharge Medications: 1. methenamine hippurate 1 gram Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. baclofen 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Other glatiramer 20 mg Kit Sig: Twenty (20) mg Subcutaneous Daily 5. Os-Cal 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1) Tablet PO once a day. 6. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 7. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. Other Trazodone 25 mg QHS PRN insomnia 10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Nebulizer Inhalation every 4-6 hours as needed for SOB, wheeze. 12. ipratropium bromide 0.02 % Solution Sig: One (1) Nebulizer Inhalation every 6-8 hours as needed for shortness of breath or wheezing. 13. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 14. vitamin E 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 15. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for Constipation. 16. potassium chloride 20 mEq Packet Sig: One (1) Packet PO once a day. 17. Other Fleet enema Q M/W/F 18. docusate sodium 50 mg/5 mL Liquid Sig: Two (2) Tablespoons PO BID (2 times a day). 19. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puffs Inhalation twice a day. 20. 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. 21. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 22. Meropenem 500 mg IV Q6H Day 1 = [**12-11**] 23. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 24. carbamazepine 100 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day: Daily at noon. 25. carbamazepine 300 mg Cap, ER Multiphase 12 hr Sig: One (1) Cap, ER Multiphase 12 hr PO twice a day. Discharge Disposition: Extended Care Facility: [**Location (un) 583**] House Rehab & Nursing Center Discharge Diagnosis: PRIMARY DIAGNOSIS: - Sepsis from a urinary source related to [**Location (un) **] partial obstruction and [**Location (un) **] nephrolithiasis - [**Location (un) 8304**] indwelling Foley and Perc nephrostomy tube on Left - Demand cardiac ischemia SECONDARY DIAGNOSES: - Multiple Sclerosis Discharge Condition: Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Mental Status: Confused - sometimes. Discharge Instructions: Ms. [**Known lastname **], it was a pleasure to participate in your care while you were at [**Hospital1 18**]. You came to the hospital after you were found unresponsive. You were admitted to the MICU where you were ultimately found to have septic shock due to a urinary tract infection and a large infected kidney stone. You were evaluated by several specialists including the infectious disease team and the urology team. You antibiotics were changed while you were here. You will need to follow up with your urologist for kidney stone removal in the near future. Followup Instructions: It is recommended that you have a lithotripsy within the next 1-3 days. Please discuss with your urologist the best time to have this done.

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