ChanBeDu/relevant_section_length · Datasets at Hugging Face

21,660

150,817

51196

Discharge summary

report

Admission Date: [**2195-10-29**] Discharge Date: [**2195-10-30**] Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2698**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: none History of Present Illness: 85 yo M c h/o of ischemic CMP, s/p 5VD CABG [**2179**], MI [**3-5**] c cath showing severe CAD (see below) s/p PTCA + stent of Saph Vein Graft to second diagonal + second obtuse marginal, ESRD on HD presents to OSH c hypotension (as low as 50 SBP). Had seizure in ED (rhythmic jerking of feet, temporily unresponsive), Neg Head CT. Put on pressors (NE + Neo) to r/o sepsis and given gent+vanc X 1. Enzymes at OSH: CK 75->251, MB 24, EKG showing afib 70s LBBB. Past Medical History: ischemic CMP, severe CAD, CHF, ESRD on HD (2 to HTN), ?seizure d/o, s/p CABG, s/p PTCA, Anemia of Chronic Disease, Prostate CA (radidation tx [**2186**]), GERD Social History: Married with a daughter. Quit [**Name2 (NI) 106241**] 15 years ago Family History: NC Physical Exam: Vitals: T= 98, HR = 81, BP = 90/45, RR =12, SaO2 = unable to get perph o2 sat. General: mild distress, cachetic. HEENT: Normocephalic and atraumatic head, no nuchal rigidity,anicteric sclera Neck: No thyromegaly, no lymphadenopathy, no carotid bruits. + JVD Chest: chest rose and fell with equal size, shape and symmetry, lungs were clear to auscultation bilaterally. CV: PMI appreciated in the fifth ICS in the midclavicular line with a LV heave, RRR, normal S1 and S1 no murmurs rubs or gallops. Abd: Normoactive BS, NT and ND. No masses or organomegaly Back: No spinal or CVA tenderness. Ext: + cyanosis, no clubbing or edema with 1=dorsalis pedis with doppler pulses bilaterally Integument: no rash Neuro: CN II-XII symmetrically intact, PERRLA. Pertinent Results: [**2195-10-29**] 11:25PM TYPE-MIX PO2-35* PCO2-32* PH-7.30* TOTAL CO2-16* BASE XS--10 [**2195-10-29**] 11:25PM O2 SAT-55 [**2195-10-29**] 10:17PM LACTATE-10.1* [**2195-10-29**] 10:13PM TYPE-ART PO2-322* PCO2-23* PH-7.39 TOTAL CO2-14* BASE XS--8 [**2195-10-29**] 10:13PM HGB-14.2 calcHCT-43 O2 SAT-99 [**2195-10-29**] 09:47PM GLUCOSE-77 UREA N-28* CREAT-4.9* SODIUM-142 POTASSIUM-4.6 CHLORIDE-99 TOTAL CO2-14* ANION GAP-34* [**2195-10-29**] 09:47PM ALT(SGPT)-608* AST(SGOT)-926* LD(LDH)-1276* CK(CPK)-393* ALK PHOS-87 AMYLASE-61 TOT BILI-3.5* [**2195-10-29**] 09:47PM LIPASE-12 [**2195-10-29**] 09:47PM CK-MB-52* MB INDX-13.2* cTropnT-2.46* [**2195-10-29**] 09:47PM ALBUMIN-3.6 CALCIUM-9.7 PHOSPHATE-7.3*# MAGNESIUM-2.1 IRON-61 [**2195-10-29**] 09:47PM calTIBC-195* FERRITIN-GREATER TH TRF-150* [**2195-10-29**] 09:47PM TSH-5.0* [**2195-10-29**] 09:47PM WBC-8.5 RBC-3.96* HGB-13.8*# HCT-42.1# MCV-106*# MCH-34.8*# MCHC-32.8 RDW-15.4 [**2195-10-29**] 09:47PM PLT COUNT-148* [**2195-10-29**] 09:47PM PT-18.4* PTT-38.1* INR(PT)-2.1 EKG: NSR LBBB 85 nl axis, No ST changes Brief Hospital Course: The patient was admitted to the CCU as a transfer from an OSH very late in the evening on [**10-29**]. He was in cardiogenic shock likely from a NSTEMI. He was on Levophed for his low BP which was attempetd to be weaned off. The A Swan-[**Last Name (un) 26645**] catherter was placed to monitor his fluid status. However, the patient stopped breathing early in the morning of [**10-30**] and a code bloe was called. Anesthesia intubated the patient. The patient then had a VF arrest and after 30 minutes of resusitation, he was pronounced dead. The attending Dr. [**Last Name (STitle) **] was present for the code. His family and PCP were notified. Discharge Disposition: Expired Discharge Diagnosis: cardiac arrest end stage renal disease Discharge Condition: expired

[ "427.31", "403.91", "410.71", "785.51", "414.8", "276.5", "414.00", "285.9", "V45.81" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

3596, 3605

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233, 239

3687, 3697

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1011, 1015

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34734

Discharge summary

report

Admission Date: [**2151-7-8**] Discharge Date: [**2151-8-2**] Date of Birth: [**2109-6-7**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 473**] Chief Complaint: Pancreatic Head Mass Major Surgical or Invasive Procedure: Whipple Dissection of hepatic artery and GDA with excision of tumor off hepatic artery and repair of hepatic artery at GDA takeoff. Re-exploration and evacuation of clot Gastrotomy for hemorrhage control - gastrojejunostomy. Feeding jejunostomy tube placement. History of Present Illness: This is a 42 M s/p ERCP for abdominal pain and icterus/jaundice - ERCP showed a 2 cm stricture in the middle third of the common bile duct. 10 FR stent placed and sphincterotomy done. Common bile duct brushing: POSITIVE FOR MALIGNANT CELLS - adenocarcinoma. CTA showing mass at head of pancreas. Past Medical History: none Social History: [**11-25**] PPD x 25 yrs, former 6=pack/day drinker, no drugs, works for [**Company 31653**], lives with wife and daughter in [**Name (NI) 1474**] Physical Exam: 97.8 69 118/70 16 97% RA Icteric, difficult to assess jaundice due to dark complexion AAOx3 NAD no LAD, no neck masses RRR CTAB Soft NT/ND, no masses Rectal - tight tone, no masses, heme negative no edema, extrem warm Pertinent Results: SPECIMEN SUBMITTED: common hepatic artery lymph node, gall bladder, peri pancreatic soft tissue, proximal jejunum, Whipple, Pancreatic Neck. DIAGNOSIS: I) Common hepatic artery lymph node (A): - One lymph node, no carcinoma seen. II) Gallbladder (A2-C): - Chronic cholecystitis. - One lymph node, no carcinoma seen. III) Peri-pancreatic soft tissue (D-F): Fibrous and adipose tissue with acute inflammation and fibrin deposition. IV) Jejunum (G-H): Segment of jejunum, no evidence of malignancy. V) Whipple specimen (I-AG): Adenocarcinoma, pancreas, 3 cm, see synoptic report. VI) Pancreatic neck (AH): Pancreatic tissue with extensive cautery artifact, no carcinoma seen. Pancreas (Exocrine): Resection Synopsis MACROSCOPIC Specimen Type: Pancreaticoduodenectomy, partial pancreatectomy. Tumor Site: Pancreatic head. Tumor Size Greatest dimension: 3.0 cm. Other organs/Tissues Received: Gallbladder, jejunum. MICROSCOPIC Histologic Type: Ductal adenocarcinoma. Histologic Grade: G3: Poorly differentiated. EXTENT OF INVASION Primary Tumor: pT3: Tumor extends beyond the pancreas but without involvement of the celiac axis or the superior mesenteric artery. Regional Lymph Nodes: pN1b: Metastasis in multiple regional lymph nodes. Lymph Nodes Number examined: 26. Number involved: 4. Distant metastasis: pMX: Cannot be assessed. Margins: Margins uninvolved by invasive carcinoma: Distance from closest margin: 33 mm. Specified margin: Proximal duodenal. Venous/Lymphatic vessel invasion: Present. Perineural invasion: Present. . Radiology Report LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Study Date of [**2151-7-8**] 9:59 PM IMPRESSION: 1. Increased diastolic flow in the main, right and left hepatic arteries is a nonspecific findings. Hepatic arteries are patent. 2. Patent portal and hepatic veins. 3. No evidence of fluid collection or intra- or extra-hepatic biliary dilatation. . Radiology Report CHEST (PORTABLE AP) Study Date of [**2151-7-13**] 5:01 PM IMPRESSION: Intubated, unchanged position of NG tube and CVL. No pneumothorax. Left lower lobe retrocardiac density consistent with atelectasis-infiltrate, progressing since preceding study [**7-9**] and compatible with clinical diagnosis of aspiration pneumonia. . Radiology Report CHEST (PORTABLE AP) Study Date of [**2151-7-14**] 5:05 AM Final Report REASON FOR EXAMINATION: Evaluation of ET tube position. Portable AP chest radiograph was compared to [**2151-7-13**]. The ET tube tip is 4.5 cm above the carina. The right internal jugular line tip is in distal SVC. The NG tube tip is in the stomach. The cardiomediastinal silhouette is stable and unremarkable. There is no appreciable change in the left lower lobe opacity involving both retrocardiac and the lateral aspect of the chest accompanied by pleural effusion. The right lower lobe minimal atelectasis is present. There is no appreciable pneumothorax. . [**Known lastname 79609**],[**Known firstname 79610**] [**Age over 90 79611**] M 42 [**2109-6-7**] Radiology Report CHEST (PA & LAT) Study Date of [**2151-7-21**] 2:02 PM IMPRESSION: Left lower lobe consolidation and moderate effusion, not significantly changed in appearance, concerning for pneumonia with parapneumonic effusion. . Radiology Report CT PELVIS W/CONTRAST Study Date of [**2151-7-25**] 3:44 PM IMPRESSION: 1. No evidence of intra-abdominal abscess, free air, or small bowel obstruction. 2. Subcutaneous collection immediately subjacent to right abdominal wall incision staple line. Open wound on the left. 3. Left-sided pleural effusion, with left greater than right atelectasis. . Brief Hospital Course: This is a 42 year old female with a pancreatic mass who went to the OR on [**2151-7-8**] for: 1. Whipple procedure (pancreaticoduodenectomy). 2. Open cholecystectomy. 3. Direct repair of abdominal arterial vessel (proper and common hepatic). 4. Staging laparoscopy. He followed the "Whipple" pathway. His post-op course was complicated by Uncontrolled postoperative gastrointestinal hemorrhage on POD 5. POD 0-1 He remained in the PACU overnight for observation. He was noted to have elevated LFT's. He had low urine output and received several LR boluses and albumin for post-op hypovolemia. He received 2 units PRBCs for post-op blood loss anemia in the PACU. Pain: He had an epidural for pain control and was followed by APS. The epidural, per the pathway, was removed on POD 4. He was transitioned to a PCA and then oral pain medications once tolerating a diet. GI/ABD: He was NPO, with a NGT and IVF. The NGT, per the pathway, was removed on POD 3. Post-op GI Bleed: POD 5, he had a post-op GI bleed. He had hematemesis, and melena and was hypotensive with a SBP in the 70's. He received a NGT for lavage and was transferred to the ICU. GI was called and did an emergent endoscopy. A Pantoprazole IV bolus (80mg) and infusion (8mg/h) was started. His Hct was 20.3. Between the ICU and OR he received 6 units of PRBCs, 2 units FFP, and 4.5L LR. He then went to the OR for re-exploration on POD 5. He went for: 1. Reopening of recent laparotomy. 2. Gastrotomy for hemorrhage control - gastrojejunostomy. 3. Feeding jejunostomy tube placement He remained in the ICU and was intubated and sedated. He was weaned and extubated and transferred to the floor. GI: He remained NPO with NGT. He continued to have high outputs from the NGT. The NGT stayed in place for 6 days. Wound erythema: The wound was opened due to fat necrosis and clear yellow drainage. A VAC was placed. This continued for several days. The VAC was discontinued on POD [**8-29**]. The wound dehiscenced with no evisceration on the left side and had purulent, smelly drainage. Swab from the wound showed: POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS SINGLY. He continued with dressing changes tid for purulent drainage from the left side. Post-op Fevers: He contiued to spike fevers and was pan-cultured. He was on broad antibiotics. A PICC was placed. He was then switched to PO ABX and the PICC was D/C'd on [**2151-7-29**]. FEN: tubefeeding were started and ramped up to goal. These were eventually cycled at night. His PO diet was slowly advanced to regular diet. He was discharged with TF and PO diet. He reported +flatus and +BM prior to discharge. Medications on Admission: none Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 weeks. Disp:*42 Tablet(s)* Refills:*0* 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. Disp:*45 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Pancreatic Cancer Post-op Bleed Wound Dehiscence Malnutrition Discharge Condition: Good Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. . * Take all new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to increase activity daily * No heavy lifting (>[**9-8**] lbs) for 6 weeks. * You may shower and wash. No tub baths or swimming. * Monitor your incision for signs of infections * continue with wound care. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 468**] in 2 weeks. Call [**Telephone/Fax (1) 2835**] to schedule an appointment. Completed by:[**2151-8-3**]

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icd9cm

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icd9pcs

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1634

Discharge summary

report

Admission Date: [**2140-11-3**] Discharge Date: [**2140-11-8**] Date of Birth: [**2060-5-11**] Sex: F Service: MEDICINE Allergies: Losartan / Lisinopril / Penicillins / Flagyl Attending:[**First Name3 (LF) 689**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: Intubation with Brochoscopy with BAL x 2 History of Present Illness: 80F with COPD, CHF, and hypertension presenting with acute hypoxia. She was recently discharged on [**2140-10-28**] from [**Hospital1 18**] after a complicated hospital stay that was notable for c. dif colitis, hospital acquired MSSA pneumonia, acute on chronic diastolic congestive heart failure, urinary tract infection, and new onset atrial fibrillation. She completed a course of therapeutic po vanc but as she was to have a course of levofloxacin until [**2140-11-6**] the po vanc was continued as well. The decision to anti-coagulate her for atrial fibrillation was deferred to her outpatient provider. [**Name10 (NameIs) **] was discharged to [**Hospital1 9494**]-[**Location (un) 701**] on [**2140-10-28**] for pulmonary rehab. On [**11-1**] a CT chest showed LLL bronchus intra-lumen mucous impaction and LLL actelectasis and infiltrate. There was a right sided pleural effusion with associated atectasis. There was no PE or pneumothorax. On admission she was noted to be ~80% on room air and acutely short of breath while during a bath with the nurse. Prior to transfer she was given solumedrol, levofloxacin (started on [**2140-11-2**]), and vancomycin IV. Of note a vancomycin level was >40 prior to transfer. Upon arrival to the ED, her initial vital signs were 97.9 80 113/73 and 88% on NRB. She was placed on NIPPV. She received nebs and steroids (solumedrol 80mg IV) as well as cefepime/levofloxacin. Past Medical History: -C. diff colitis during last admission -MSSA PNA during last admission -Atrial fibrillation for breif episode during last hospitalization -Atrial tachycardia intermittent, no symptoms -COPD -CHF- diastolic (EF 40-45% by TTE [**2139-7-21**]) -Osteoarthritis -H/o myocarditis in [**2137**] with EF 20-25% at that time, cath negative -Hyperlipidemia -Peripheral artery disease -HTN -Migraine HA -Chronic eosinophilic lung disease (chronic eosinophilic pneumonia or Churg-[**Doctor Last Name 3532**] syndrome) -Hypoalbuminemia Social History: Lives with daughter and husband. Stopped smoking 30 years ago. Smoked 1-2PPD x40 years. Denies alcohol and illicit drug use. Family History: Mother's family had "heart disease". Father died of cancer or spleen. No hx of stroke or DM. Physical Exam: After transfer from MICU VS: T-97, BP-134/74, P-80, R-20, 94%2L then 98%2L after neb GEN: NAD, sitting in chair, talking HEENT: NC/AT, MMM, some mucus in OP Neck: no JVD, supple, no LAD Cor: RRR, no m/r/g Resp: No accessory muscle use or retractions. Few expriatory wheezes and few small rhonchi, no crackles appreciated Abd: +BS, soft/NT/ND, no rebound or guarding Ext: WWP. diffuse non-pitting edema noted in b/l LE and UEs, distal pulses 2+ Skin: thin skin with scattered ecchymoses Pertinent Results: labs- [**2140-11-3**] 01:50PM BLOOD WBC-13.1*# RBC-3.79* Hgb-11.6* Hct-35.6* MCV-94 MCH-30.7 MCHC-32.7 RDW-15.3 Plt Ct-390 [**2140-11-8**] 07:37AM BLOOD WBC-12.6* RBC-3.83* Hgb-11.9* Hct-36.3 MCV-95 MCH-31.1 MCHC-32.8 RDW-15.3 Plt Ct-245 [**2140-11-3**] 01:50PM BLOOD Neuts-94.9* Lymphs-2.6* Monos-2.3 Eos-0.1 Baso-0 [**2140-11-3**] 01:50PM BLOOD Glucose-270* UreaN-24* Creat-0.9 Na-138 K-3.8 Cl-98 HCO3-28 AnGap-16 [**2140-11-8**] 07:37AM BLOOD Glucose-114* UreaN-14 Creat-0.8 Na-139 K-4.5 Cl-99 HCO3-32 AnGap-13 [**2140-11-3**] 01:50PM BLOOD CK(CPK)-76 [**2140-11-4**] 01:08AM BLOOD CK(CPK)-59 [**2140-11-4**] 04:06AM BLOOD CK(CPK)-53 [**2140-11-6**] 06:05AM BLOOD LD(LDH)-312* [**2140-11-3**] 01:50PM BLOOD CK-MB-4 cTropnT-0.02* proBNP-3466* [**2140-11-4**] 01:08AM BLOOD CK-MB-NotDone cTropnT-0.07* [**2140-11-4**] 04:06AM BLOOD CK-MB-NotDone cTropnT-0.06* [**2140-11-4**] 04:06AM BLOOD Calcium-7.6* Phos-3.7 Mg-2.6 [**2140-11-5**] 06:48AM BLOOD Calcium-7.6* Phos-3.3 Mg-2.9* [**2140-11-8**] 07:37AM BLOOD Calcium-8.5 Phos-2.7 Mg-2.4 [**2140-11-3**] 01:50PM BLOOD Vanco-36.6* [**2140-11-5**] 08:51PM BLOOD Vanco-17.2 [**2140-11-3**] 02:39PM BLOOD Type-ART pO2-83* pCO2-35 pH-7.54* calTCO2-31* Base XS-6 [**2140-11-3**] 09:08PM BLOOD Type-ART pO2-220* pCO2-39 pH-7.51* calTCO2-32* Base XS-7 [**2140-11-4**] 11:51AM BLOOD Type-ART PEEP-5 FiO2-60 pO2-53* pCO2-54* pH-7.39 calTCO2-34* Base XS-5 -ASSIST/CON Intubat-INTUBATED [**2140-11-3**] 01:53PM BLOOD Lactate-4.4* [**2140-11-4**] 01:26AM BLOOD Lactate-3.1* [**2140-11-4**] 11:51AM BLOOD Lactate-2.1* K-4.1 [**2140-11-3**] 7:06 pm BRONCHIAL WASHINGS **FINAL REPORT [**2140-11-6**]** GRAM STAIN (Final [**2140-11-3**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. RESPIRATORY CULTURE (Final [**2140-11-6**]): 10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA. ACINETOBACTER BAUMANNII COMPLEX. >100,000 ORGANISMS/ML.. MORPHOLOGY #1. "Note, for Amp/sulbactam, higher-than-standard dosing needs to be used, since therapeutic efficacy relies on intrinsic activity of the sulbactam component". ACINETOBACTER BAUMANNII COMPLEX. >100,000 ORGANISMS/ML.. MORPHOLOGY #2. "Note, for Amp/sulbactam, higher-than-standard dosing needs to be used, since therapeutic efficacy relies on intrinsic activity of the sulbactam component". SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ACINETOBACTER BAUMANNII COMPLEX | ACINETOBACTER BAUMANNII COMPLEX | | AMPICILLIN/SULBACTAM-- 4 S 4 S CEFEPIME-------------- 32 R 32 R CEFTAZIDIME----------- =>64 R =>64 R CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ 4 S 4 S IMIPENEM-------------- 8 I 8 I TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S Cardiology Report ECG Study Date of [**2140-11-3**] 1:39:16 PM Sinus rhythm. Baseline artifact. Non-specific intraventricular conduction delay. Compared to the previous tracing of [**2140-10-22**] the QRS change in lead V3 could be positional. Baseline artifact is new. Read by: [**Last Name (LF) 2889**],[**First Name3 (LF) 2890**] K. Intervals Axes Rate PR QRS QT/QTc P QRS T 80 150 122 370/405 107 70 28 [**2140-11-3**] CXR pre bronch IMPRESSION: Interval development of complete left hemithorax opacification. Given the leftward shift of mediastinal structures, left lung collapse is favored; however, superimposed infection and/or effusion cannot be excluded. [**2140-11-3**] post bronch IMPRESSION: AP chest compared to [**11-3**], 1:51 p.m.: Atelectasis in the left lung is dramatically improved, with some residual at the base and perihilar left mid lung, which should be followed to exclude coexistent infection. A new small opacity in the right lower lung projecting over the anterior aspect of the fourth rib could be another adenitis or infection. Heart is mildly enlarged, remains left-shifted. Large cardiac calcification is probably mitral annulus. ET tube is in standard placement. No pneumothorax. Pleural effusion, if any, is small, on the left. The study and the report were reviewed by the staff radiologist. Echo [**2140-11-4**] The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. 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 normal (LVEF>55%). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with normal free wall contractility. 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. An eccentric, anteriorly directed jet of at least moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2140-10-25**], no change (degree of MR underestimated on prior study). [**2140-11-4**] CXR IMPRESSION: AP chest compared to [**11-3**]: Left perihilar consolidation has improved minimally, small region of consolidation in the right lower lung is unchanged. Findings suggest pneumonia developing after clearance of previous left lung collapse. Heart size normal. Heavy cardiac calcification is probably mitral annular. No pulmonary [**Month (only) 1106**] engorgement or edema. Pleural effusion, if any, is minimal and incidental. ET tube in standard placement. Nasogastric tube ends in the stomach. [**2140-11-5**] CXR IMPRESSION: AP chest compared to [**11-2**] through 19: Left lower lobe is still largely atelectatic, and a small accompanying pleural effusion secondary of that. There is a smaller volume of atelectasis and effusion at the base of the right lung. Upper lungs are clear. Heart size normal. Findings discussed by telephone with the patient's clinical care team at the time of this dictation. [**2140-11-6**] PA and L CXR Two views. Comparison with the previous study done [**2140-11-5**]. There is interval improvement in left lower lobe atelectasis. Blunting of the left costophrenic sulcus consistent with pleural fluid persists. The heart is within normal limits in size. The aorta is tortuous and calcified. There is calcification in the mitral annulus. The bony thorax is grossly intact. IMPRESSION: Interval improvement in left lower lobe atelectasis. Persistent small left effusion. Brief Hospital Course: 80 year old woman with history of COPD, diastolic CHF, atrial fibrillation and tachycardia, with recent MSSA pneumonia, and C Diff colitis who presented with acute onset of hypoxia and left lung collapse secondary to mucus occlusion on [**2140-11-3**]. Initially treated in the ICU and then later transferred to a medicine floor. Her hypoxia was multi-factorial in woman with impaired lungs at baseline with recent pneumonia and diastolic CHF exacerbation who now presents with complete white-out of left hemi-thorax and markedly elevated pro-BNP that was initially concerning for either left lung collapse vs massive pleural effusion and/or severe CHF exacerbation. Her respiratory status dramatically improved after her BAL and mucus plug removal. She had a second BAL the next day to further evaluate the LLL. She was extubated and set to the floor. She remained afebrile. She was initially on vancomycin and cefepime, these were stopped upon transfer to the floor. Then her BAL showed GNR with Acinetobacter, resistant to cefepime. It was unclear if this was a colonization vs an infection since she had improving WBC and symptoms. However, due the concern for a possible infection with a multidrug resistant bacteria she was started on Bactrim for a 10 day course. She was also treated with chest PT and mucolytics. Her CXR appeared dramatically improved after the mucus removal and continued to improve throughout her hospitalization. Her history of recent acute diastolic CHF exacerbation was a concerning cause of her dyspnea. Therefore she had a TTE, which did not show significant changes from her last echo a month ago, EF 55%. She had three sets or biomarkers that did were not consistent with a ACS, no ST changes on EKG. Her COPD and chronic pneumonitis was treated with continuation of albuterol and ipratropium. Also continued treatment with Spiriva and Montelukast. She required 2 Liters of oxygen at discharge at rest. She was also improved her breathing with her inspiratory spirometer. Her hypoxia was likely the cause of her elevated lactate. Once her mucus plug was removed her lactic acid trended down, it had peaked at 4.4. She had been treated for C. Diff during her last hospitalization. She remained on PO vancomycin, but due to a elevated blood level, her dose was reduced to 125mg from 250mg. She will need to remain on this medication for 10 days after her last day of Bactrim. She developed some watery stools the day before discharge. These may have been recurrent C. Diff vs antibiotic associated diarrhea. She may need probiotics. She was initially on high dose steroids (IV methylpred 40 mg q 12) and this resulted in hyperglycemia. he has temporarily required insulin. After her transfer from the ICU, she was changed back to her home dose of steroids and her sugars improved before discharge. She did not have any afib or atrial tachycardia or problems with hypertension during her stay. Her dose of metoprolol was decreased to 12.5 [**Hospital1 **] and her diltiazem was stopped. She may need to restart these medications if her heart rate increases. She would like to post [**Last Name (un) 9495**] starting anticoagulation until discussion with her PCP. [**Name10 (NameIs) **] was continued on ASA. She continued to have peripheral edema, likely partially from her low albumin and then also from her chronic diastolic heart failure. Her Lasix was initially stopped in the ICU, then 40 mg [**Hospital1 **] was restarted with some improvement in her edema. She requires daily weights for her heart failure. She will need to continue to have ensure between meals to increase her protein. She was on ASA and Metoprolol for her heart failure. Of note, on day of discharge, patient had small amount ~half a tsp of fresh blood in sputum. Lungs were clear and she was afebrile, sating in 90's on 2L, comfortable. Likely caused by combination of irritation of airway from intubation and BAL combined with COPD and increased cough strength today. Also was on non-humidified oxygen. If continues to have hemoptysis would consider CXR and if unstable transfer back to hospital for further work up. Patient will be transferred to pulmonary rehab and will have follow up care with her PCP. [**Name10 (NameIs) **] will need continued PT including chest PT to improve her respiratory status and strength. Medications on Admission: Aspirin 325 mg Tablet daily Ipratropium neb q6 Albuterol neb q6:prn Furosemide 80 mg daily Fosamax 70 mg Cyanocobalamin 50 mcg daily Prednisone 10 mg PO MWFSA Prednisone 5 mg PO TUTHSU Diclofenac Sodium 50mg Tablet, daily Vancomycin 250 mg Q6H last day [**11-6**] Levofloxacin 500 mg [**2140-11-6**] Nitrofurantoin 100 mg [**Hospital1 **] (completed [**11-1**]) Trazodone 50 mg HS Ferrous Sulfate 325 mg daily Toprol XL 50 mg daily Fluticasone 50 mcg Spray nasal daily Montelukast 10 mg daily Atorvastatin 40 mg daily Tiotropium Bromide 18 mcg daily Dextromethorphan-Guaifenesin q6h:prn Pantoprazole 40 mg PO Q24H Fluticasone 220 mcg puffs [**Hospital1 **] Docusate Sodium 100 mg [**Hospital1 **] Tylenol 325-650 mg q6h:prn Diltiazem HCl SR 120 mg DAILY Discharge Medications: 1. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 2. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation every six (6) hours: nebulizer treatment. 3. Cyanocobalamin 100 mcg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day) as needed for constipation: hold for loose stool. 5. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day for 8 days: for 8 days. 6. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 7. Fluticasone 50 mcg/Actuation Spray, Suspension [**Hospital1 **]: One (1) Spray Nasal DAILY (Daily). 8. Prednisone 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO 4X/WEEK ([**Doctor First Name **],MO,WE,FR). 9. Prednisone 5 mg Tablet [**Doctor First Name **]: One (1) Tablet PO QTUTHSA (TU,TH,SA). 10. Atorvastatin 40 mg Tablet [**Doctor First Name **]: One (1) Tablet PO DAILY (Daily). 11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Doctor First Name **]: One (1) Cap Inhalation DAILY (Daily). 12. Montelukast 10 mg Tablet [**Doctor First Name **]: One (1) Tablet PO DAILY (Daily). 13. Furosemide 40 mg Tablet [**Doctor First Name **]: One (1) Tablet PO BID (2 times a day). 14. Metoprolol Tartrate 25 mg Tablet [**Doctor First Name **]: 0.5 Tablet PO BID (2 times a day): hold for SBP<100 or HR <60. 15. Acetaminophen 325 mg Tablet [**Doctor First Name **]: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 16. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Liquid [**Doctor First Name **]: Ten (10) ML PO TID (3 times a day) as needed for cough. 17. Lorazepam 0.5 mg Tablet [**Doctor First Name **]: One (1) Tablet PO Q8H (every 8 hours) as needed for Anxiety. 18. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Doctor First Name **]: One (1) Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 19. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Doctor First Name **]: One (1) Inhalation Q4H (every 4 hours). 20. Vancomycin 125 mg Capsule [**Doctor First Name **]: One (1) Capsule PO Q6H (every 6 hours) for 18 days: give for 18 days (until 10 days after Bactrim is done and no diarrhea). 21. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 22. Acetylcysteine 20 % (200 mg/mL) Solution [**Last Name (STitle) **]: One (1) ML Miscellaneous Q6H (every 6 hours) as needed for dyspnea. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary: Hypoxia secondary to mucus plug Acinetobacter in bronchial washing Lactic acidosis Hyperglycemia Secondary: COPD chronic diastolic heart failure C. Diff Colitis Hypertension Discharge Condition: Hemodynamically stable, afebrile, needs assistance with ambulation. Discharge Instructions: You were admitted to [**Hospital1 18**] due to difficulty breathing. You had a mucus plug in your lungs, this was removed with a bronchoscopy in the ICU. You were started on antibiotics to prevent a possible lung infection. You were continued on your antibiotics to prevent C. Diff infection. You will be going to rehab to regain your stregth. Please keep your follow up appointments. Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Fluid Restriction: of 2 liters. Please take your medications as persribed you will need 8 more days of Bactrim and 18 more days of vancomycin. You Metoprolol dose was decreased and your diltiazem was stopped, these medications may be changed by your PCP in the future. If you have chest pain, shortness of breath, fever, worsening diarrhea or other concerning symptoms please seek medical attention or go to the ER. Followup Instructions: Primary Care Doctor: PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 9489**] Please call for an appointment. Pulmonary: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 575**] Please call to make an follow up appointment once you leave the rehab. Provider: [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2140-12-29**] 9:20 Completed by:[**2140-11-8**]

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icd9cm

[ [ [] ] ]

[ "96.05", "96.71", "96.04", "33.23" ]

icd9pcs

[ [ [] ] ]

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10177, 14518

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14544, 15300

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50321

Discharge summary

report

Admission Date: [**2150-8-11**] Discharge Date: [**2150-8-20**] Date of Birth: [**2096-10-22**] Sex: F Service: MEDICINE Allergies: Ativan Attending:[**First Name3 (LF) 613**] Chief Complaint: Hypercarbic Respiratory Failure Major Surgical or Invasive Procedure: Endotracheal intubation Arterial line History of Present Illness: Ms. [**Known lastname **] is a 53 y.o. woman with PMH of T1-T2 paraplegia, frequent admissions for PNA and UTI, and COPD (on 1.5-2L NC at home), who presented with acute mental status changes and changes in her breathing status. She had dinner with her friend and one of her primary caregivers, [**Name (NI) **]. She was having some trouble eating - her friend notes chronic trouble eating/food sticking in her throat. 45 minutes after eating, the friend went back to her room where she found her vomiting and not feeling well. She put her friend in bed and gave her 1.5 mg of clonazepam. 30 minutes later she found her to be lethargic with O2sat 83-84% on 2L NC (usually 90-92%). Given this, her friend drove her to the [**Hospital1 18**] [**Name (NI) **] from [**Location (un) 1475**] while keeping her on 8L NC. Her friend noted that she got poorer Chest PT over the weekend and resumed smoking over the last two weeks. She denied noticing any increase in cough, SOB, dysuria, incontinence, or cloudy urine over the past few days. She recently was given a narcotic agreement w/ her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 665**] who noted that he would not be prescribing her narcotics anymore since he felt her burning lower extremity pain was neuropathic in nature, not c/w her pain from her vehicle accident, and would be better treated w/ gabapentin rather than narcotics. Upon arrival in the ED, initial VS were: T 34.6, HR 110, BP 128/102 or 156/108, RR 8, O2sat to 80s. She had blue lips and was breathing at RR 8. She was given Narcan and became arousable. However, 40 minutes later she became somnolent, de-satted to the 80s, and was unresponsive to a 2nd dose of Narcan. She was intubated, which was reportedly difficult. Aspirate was suctioned out. She was given a dose of levaquin. A U/A was significant for negative nitrites, large leuks, negative blood, negative glucose, negative ketones, 2 RBCs, 152 WBCs, few bacteria, and 1 epi. Utox was positive for benzos and methadone, but she did get benzos with intubation. On an ABG following her intubation, pH 7.28/pCO2 60/pO2 370/HCO3 29. On arrival to the MICU, VS: T 96.8, HR 89, BP 141/106, RR 13, 100% on ventilator. She was started on vanc/[**Last Name (un) 2830**] and given a 1L NS bolus given that her BP fell to SBP 80s. Past Medical History: # T1 to T2 paraplegia status post a motor vehicle accident. # Recurrent pneumonia (followed by pulm - Last [**2149-4-9**]) - Per pulm, recurrent pneumonia likely from pulmonary toilet issues secondary to neuromuscular disease with improvement with consistent and aggressive bronchopulmonary therapy. - Prior sputum cultures + for MRSA, pan-sensitive Klebsiella, and Pseudomonas. # Recurrent UTIs in the setting of urinary retention requiring straight catheterization # COPD # hepatitis C # anxiety # DVT in [**2142**] -IVC filter placed in [**2142**] # Pulmonary nodules # Hypothyroidism # Chronic pain # Chronic gastritis # Anemia of chronic disease # S/p PEA arrest during hospitalization in [**2147-10-3**] Social History: Lives at home with husband and 2 adolescent children. - Tobacco: 35-pack-years, has tried to quit but smokes intermittently - started again 2 weeks ago. - Alcohol: Denies. - Illicits: Denies. Family History: Mom - lung cancer Dad - healthy Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T 96.8, HR 89, BP 141/106, RR 13, 100% on ventilator General: somnolent but arousable HEENT: Sclera anicteric, oropharynx clear, EOMI, PERRL, MMM Neck: JVP not appreciated CV: RRR, soft S1/S2, no murmurs, rubs, gallops Lungs: diffuse rhonchi and adventitial sounds Abdomen: soft, non-tender, obese, BS+ GU: Foley in place Ext: cool but perfused, trace/1+ pulses in LE b/l, trace/1+ LE edema to ankles Neuro: arousable and oriented to self; detailed exam deferred DISCHARGE PHYSICAL EXAM: Vitals: T 98.7F, BP 137/77, HR 83, RR 20, 96%3L NC General: A&OX3, NAD HEENT: Sclera anicteric, oropharynx clear, EOMI, PERRL, MMM Neck: JVP not appreciated CV: RRR, soft S1/S2, no murmurs, rubs, gallops Lungs: diffuse rhonchi over R lung fields Abdomen: soft, non-tender, obese, BS+ Ext: cool but well perfused, trace/1+ pulses in BLE with trace edema to ankles in BLE Neuro: A&Ox3, CNII-XII grossly intact, 5/5 strength in BUE, 0/5 strength in BLE Pertinent Results: ADMISSION LABS: [**2150-8-11**] 12:01AM BLOOD WBC-7.9 RBC-3.98* Hgb-10.8* Hct-34.5* MCV-87 MCH-27.0 MCHC-31.2 RDW-16.1* Plt Ct-145* [**2150-8-11**] 12:01AM BLOOD PT-11.7 PTT-37.5* INR(PT)-1.1 [**2150-8-11**] 12:01AM BLOOD Fibrino-401* [**2150-8-12**] 05:51AM BLOOD Glucose-94 UreaN-8 Creat-0.3* Na-142 K-3.0* Cl-112* HCO3-21* AnGap-12 [**2150-8-11**] 12:01AM BLOOD Lipase-23 [**2150-8-12**] 05:51AM BLOOD Calcium-7.9* Phos-1.6* Mg-1.6 [**2150-8-11**] 12:01AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2150-8-11**] 01:53AM BLOOD Type-ART Temp-34.6 Rates-14/ Tidal V-450 PEEP-5 FiO2-100 pO2-370* pCO2-60* pH-7.28* calTCO2-29 Base XS-0 AADO2-284 REQ O2-54 -ASSIST/CON Intubat-INTUBATED [**2150-8-11**] 12:02AM BLOOD Glucose-126* Lactate-0.6 Na-142 K-4.1 Cl-99 calHCO3-35* DISCHARGE LABS: [**2150-8-20**] 05:25AM BLOOD WBC-6.2 RBC-3.35* Hgb-8.8* Hct-28.8* MCV-86 MCH-26.4* MCHC-30.7* RDW-16.3* Plt Ct-282 [**2150-8-20**] 05:25AM BLOOD Glucose-83 UreaN-7 Creat-0.4 Na-148* K-4.0 Cl-106 HCO3-33* AnGap-13 [**2150-8-20**] 05:25AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.2 PERTINENT MICRO: [**2150-8-18**] BLOOD CULTURE Blood Culture, Routine-PENDING, no growth at discharge [**2150-8-15**] BLOOD CULTURE Blood Culture, Routine-PENDING, no growth at discharge [**2150-8-11**] BLOOD CULTURE Blood Culture, Routine-FINAL NEG [**2150-8-11**] BLOOD CULTURE Blood Culture, Routine-FINAL NEG [**2150-8-15**] URINE URINE CULTURE-FINAL {YEAST} [**2150-8-14**] URINE Legionella Urinary Antigen -FINAL NEG [**2150-8-13**] URINE Legionella Urinary Antigen -FINAL NEG [**2150-8-11**] URINE URINE CULTURE-FINAL {PROTEUS MIRABILIS} [**2150-8-13**] 10:45 am SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2150-8-13**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [**2150-8-16**]): Commensal Respiratory Flora Absent. YEAST. SPARSE GROWTH. STAPH AUREUS COAG +. SPARSE GROWTH OF TWO COLONIAL MORPHOLOGIES. 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----------- =>8 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------------ 1 S LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. FUNGAL CULTURE (Preliminary): YEAST. OF TWO COLONIAL MORPHOLOGIES. ACID FAST SMEAR (Final [**2150-8-14**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. PERTINENT IMAGING: pCXR [**2150-8-11**] FRONTAL CHEST RADIOGRAPH: The patient is slightly rotated. A right-sided central line terminates at the low SVC. The heart is mildly enlarged. The central pulmonary vessels are engorged, and mild pulmonary edema is present. This is not significantly changed since the [**2150-6-18**] examination. There is a new right base opacity concerning for consolidation. There is no pneumothorax or large pleural effusion. Old right-sided rib fractures are present. IMPRESSION: 1. New right basilar opacity may represent a consolidation. 2. Unchanged mild cariomegaly, pulmonary vascular congestion, and interstitial edema. Brief Hospital Course: 53 y.o. woman with history of T1/T2 paraplegia s/p MVA, frequent PNA/UTIs who presented with unresponsiveness and apnea requiring mechanical ventilation and was found to have a RLL pneumonia and proteus UTI, complicated by altered mental status associated with sedating medications as well as septic shock requiring pressors in the MICU. #) RLL pneumonia: Per witness, patient reportedly vomited and then became lethargic/unresponsive after being administered 1.5 mg clonazepam, with desaturation to 80s on baseline 2L NC. CXR on admission with RLL opacity highly suspicious for aspiration pneumonia or pre-existing pneumonia. Patient requiried intubation and mechanical ventilation in the MICU this admission due to persistent unresponiveness and hypoxia on admission after transient response to narcan. If pneumonia were pre-existing, most likely culprit would be strep pneumo, but if aspiration pneumonia then respiratory distress likely [**3-5**] pneumonitis, with polymicrobial infection possibly prevented with 8 day course of Vancomycin/Meropenem, recieved four days of ciprofloxacin. Respiratory status improved and patient was extubated after seven days. Sputum cultures grew staph aureus, possibly reflective of infection vs. colonization. -Blood cultures from [**8-15**] and [**2150-8-18**] pending at time of discharge #) Proteus mirabilis UTI: On [**2150-7-30**] she had cloudy urine and increased incontinence for which she was given a 7-day course of Bactrim for what was found to be a Klebsiella UTI. She reportedly completed her Bactrim on Friday [**2150-8-7**]. Patient self-catheterizes at home and has had recurrent multidrug-resistant UTIs. UA on admission showed large leuks, neg nitrites and she was started on meropenem for empric [**Year (4 digits) 40097**] coverage, though [**Year (4 digits) **] eventually grew >100k CFU of meropenem-sensitive proteus mirabilis #) Hypotension: She was normotensive in the ED but became hypotensive to SBPs in the 80s while in the MICU soon after admission. This was thought to be from sedation. However, given that she dropped to the 70s systolic and did not respond to fluids, she required pressors the first day of admission to maintain SBPs in the 90s. Notably, she lives in the SBPs 90s-100s per outpatient BP reads over the past few years. She developed a fever to 102.1F and also was found to have a Proteus UTI (>100K) on [**Last Name (LF) 21574**], [**First Name3 (LF) **] she had a possible urosepsis picture. Her hypotension resolved as she clinically improved from her UTI and was able to be extubated. She was occasionally hyPERtensive on the regular medical floor to SBP 160s-170s but asymptomatic, likely due to anxiety, as improved with decreased anxiety. #) AMS: Per witness, patient became lethargic/unresponsive after dinner after an episode of vomiting following administration of PO clonazepam. AMS likely due to over-sedation with medications given timing of medication administration, Utox positive for methadone, as well as bradypnea and transient response to narcan on presentation. Urosepsis and hypotension may have also played a role in AMS. -Careful monitoring of polypharamcy with multiple sedating medications -Adherence to narcotics agreement and appointment at pain clinic CHRONIC ISSUES: # COPD/ Chronic Hypercarbia: On 2L O2 at home. Was on 3L NC at time of discharge likely secondary to recent pneumonia. Home albuterol and ipratroprium were continued. -Continue to week to baseline O2 requirment -Encourage smoking cessation (restarted 2wk prior to admission) #)Chronic Pain: Foot and shoulder pain related to prior MVA and likely neuropathy. Narcotics contract terminated as documented in OMR because of negative Utox while be prescribed narcotics. Currently on lidocaine patches, baclofen, gabapentin, pregabalin. -Rescheduled pain clinic appointment (missed during admission) #)Urinary Retention: Patient usually self-catheterizes at home but foley catheter used during admission extending past period needed for UOP monitoring because of patient request. # Anemia of chronic disease: Her baseline Hct~28. Hct 34.5 on admission, 28.8 at time of discharge. # Constipation: Continued on home polyethylene glycol # Anxiety/Depression: Continued on citalopram, clonazepam and trazodone restarted when mental status improved. # Hypothyroidism: Continued levothyroxine # Hypercholesterolemia: Continued simvastatin # Hep C: Stable, no current treatment, no LFT abnormalities this admission. # GERD: Continued omeprazole Transitional issues for this patient: -Pain management -Sterile straight cath teaching for patient given recurrent UTIs -Consider outpatient speech and swallow evaluation given suspicion for recurrent aspiration pneumonias Medications on Admission: 1. albuterol NEB Q6hr PRN dyspnea 2. baclofen 20 mg Qam, 10 mg 4PM, 20 mg Qpm 3. citalopram 40 mg PO DAILY 4. ipratropium Q6hr PRN dyspnea 5. levothyroxine 112 mcg PO DAILY 6. clonazepam 1 mg PO TID PRN (takes 2 mg QHS) 7. lidocaine patch - feet and shoulder blade 8. omeprazole 20 mg [**Hospital1 **] 9. oxybutynin chloride 10 mg Qam, 5 mg 4pm, 10mg QHS 10.Polyethylene Glycol 17g QD 11.gabapentin 600 mg TID 12.simvastatin 10 mg PO DAILY 13.sucralfate 1 gram TID 14.trazodone 100 mg QHS PRN anxiety. Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea 2. Baclofen 20 mg PO QAM, QPM 3. Baclofen 10 mg PO 4PM 4. Citalopram 40 mg PO DAILY 5. Clonazepam 1 mg PO TID:PRN anxiety 6. Lidocaine 5% Patch 1 PTCH TD DAILY feet and shoulder blade 7. Omeprazole 20 mg PO DAILY 8. Polyethylene Glycol 17 g PO DAILY 9. Simvastatin 10 mg PO DAILY 10. traZODONE 100 mg PO HS:PRN anxiety 11. Clonazepam 2 mg PO QHS 12. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN dyspnea 13. Oxybutynin 10 mg PO QAM, QHS 14. Oxybutynin 5 mg PO 4PM 15. Sucralfate 1 gm PO TID 16. Levothyroxine Sodium 112 mcg PO DAILY 17. Gabapentin 600 mg PO TID Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Primary: -RLL aspiration pneumonia with hypoxic respiratory failure Secondary: -proteus urinary tract infection -chronic obstructive pulmonary disease -chronic pain syndrome 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: Dear Mrs. [**Known lastname **], It was a pleasure participating in your care during your hospitalization at [**Hospital1 18**]. You were admitted for increased oxygen requirement and decreased responsiveness, and a breathing tube was placed for a machine to help you breathe. A chest xray showed a pneumonia in your right lung and a urine study showed a urinary tract infection. You received antibiotics (vancomycin and meropenem) for eight days during your stay in the intensive care unit and your breathing improved and the breathing tube was removed. You were stable for the regular medical floor and were able to be discharged from there. Followup Instructions: Department: [**Hospital3 249**] When: TUESDAY [**2150-9-1**] at 12:00 PM With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PAIN MANAGEMENT CENTER When: WEDNESDAY [**2150-9-2**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], [**First Name3 (LF) **] [**Telephone/Fax (1) 1652**] Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Parking on Site *** Unfortunately there were no later appointments available. The next reported opening was not until [**9-29**]. If you are unable to make this appointment, we recommend that you speak with the office directly. *** Department: [**Hospital3 249**] When: TUESDAY [**2150-9-22**] at 10:40 AM With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2150-8-20**]

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icd9cm

[ [ [] ] ]

[ "96.04", "96.6", "96.72" ]

icd9pcs

[ [ [] ] ]

14486, 14541

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299, 339

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47,271

196,301

35702

Discharge summary

report

Admission Date: [**2122-8-16**] Discharge Date: [**2122-8-27**] Date of Birth: [**2057-1-21**] Sex: F Service: MEDICINE Allergies: Erythromycin Base Attending:[**First Name3 (LF) 1257**] Chief Complaint: Weakness Major Surgical or Invasive Procedure: Plasmapheresis cathether placement Plasmapheresis History of Present Illness: 65 year old female with past medical history of abdominal aortic aneurysm status post endovascular repair, hypertension, cerebrovascular accident, atrial fibrillation, small cell lung cancer and myasthenia [**Last Name (un) 2902**] who presented to the ER today with weakness and hypoxia. Of note, she presented to her neurologist complaining of weakness on [**8-6**] and he was concerned for steroid myopathy. He decreased her dose of prednisone to 40mg daily, started Imuran and stopped cellcept. Patient has felt weak for the past few weeks with generalized exhaustion without any known causative events. Patient has fallen a few times this week with one fall sustaining head impact last night. No loss of consciousness. Over the past couple of days, patient has also had some dysuria as well as vomiting without nausea, fever, or chills. . In the ED, initial vs were: T 98.2 P 92 BP 150/97 R 22 O2 sats of 88% on RA. CXR and CT head were negative for acute processes. Patient was given Ceftriaxone 1gram for a positive urinalysis and Mestinon 60mg for her myasthenia. Neurology was consulted and felt this was unlikely consistent a myasthenia crisis but recommended following NIFs. Patient was found to have elevated lactate at 4 and transferred to the ICU for respiratory monitoring after gentle hydration. . On arrival to the ICU, patient was denying chest pain, shortness of breath, abdominal pain, nausea, joint pain. She complains of generalized exhaustion. No sick contacts. . Review of systems: (+) Per HPI, reports good appetite with 20 pound weight gain, chronic cough occasionally productive of yellow sputum (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. Denied arthralgias or myalgias. Past Medical History: 1. Myasthenia [**Last Name (un) 2902**] Dx in [**2121**]: primary neurologist in [**Location (un) 38**], mild crisis in past marked by visual changes (diplopia) nd generalized weakness, treated with mestinon 60mg TID, prednisone and cellcept. At baseline, uses wheelchair for any extended travel and walks around the home with a walker, ADLs with support by her husband- primary caretaker 2. Stroke, [**2121**]- residual weakness in BLLE 3. History of lung CA in [**2116**], s/p chemoradiation, treated by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 4223**] in [**Hospital1 392**], ? small cell lung cancer. 4. Atrial fibrillation on dig/coumadin 5. Hypertension 6. Hypercholesterolemia 7. OSA 8. GERD 9. Chronic low back pain 10. Spine surgery, [**2120**] 11. Bilateral knee arthroscopy 12. Degenerative arthritis 13. Cholescystecomy Social History: Lives with husband. She is a former heavy smoker up to a pack and a half of cigarettes per day and stopped smoking in [**Month (only) 958**]. Denies alcohol or drug use. Family History: Denies any known neurological familial history. Physical Exam: On admission: Vitals: T: 98.8 BP: 184/94 P: 81 R: 19 O2: 97% on 4L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Irregularly irregular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, [**5-12**] muscle strength in all extremities, sensation intact all four extremities, mild dysarthria and bilateral lid lag. Pertinent Results: On admission: WBC-13.9* RBC-4.37 Hgb-14.3 Hct-43.1# MCV-99* MCH-32.8* MCHC-33.2 RDW-15.5 Plt Ct-162 Neuts-83.2* Lymphs-10.1* Monos-6.0 Eos-0.3 Baso-0.4 PT-23.3* PTT-21.0* INR(PT)-2.2* Glucose-142* UreaN-27* Creat-1.5* Na-131* K-4.0 Cl-84* HCO3-34* AnGap-17 Albumin-4.3 Calcium-15.9* Phos-5.8*# Mg-1.7 UricAcd-9.6* PTH-16 freeCa-1.65* Calcium trends: ([**8-16**]) 15.9 -> ([**8-17**]) 13.5 -> 12.4 -> 11.8 -> ([**8-18**]) 9.9 -> 9.3 -> ([**8-19**]) 9.3 URINE CULTURE (Final [**2122-8-18**]): PROTEUS MIRABILIS. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS | AMIKACIN-------------- 4 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 2 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S PIPERACILLIN---------- =>128 R PIPERACILLIN/TAZO----- 16 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R [**8-16**] EKG: Atrial fibrillation. Incomplete right bundle-branch block. Extensive ST-T wave changes may b e due to myocardial infarction. Also, consider digitalis effect. [**8-16**] CXR: No acute intrathoracic process. Stable appearance of enlargement of the main pulmonary arteries compatible with pulmonary hypertension. [**8-16**] CT Head: 1. No evidence of acute intracranial abnormalities. 2. Moderate chronic small vessel ischemic changes. [**8-16**] Abdominal films: 1. Gastric distention. No evidence of small bowel dilatation or free air. 2. Stool and air are seen throughout the colon. [**8-19**] CT chest: 1. Left upper lobe nodular density with adjacent bronchial dilatation is most likely infectious or inflammatory in etiology. 2. Persistent right infrahilar nodular density with adjacent infrahilar lymphadenopathy for which FDG PET is recommended to exclude neoplasm. Because PET may be false positive in the setting of infection, consider postponing the PET until after antibiotic treatment for the potentially infectious lesion in the left apex to avoid a false positive finding in this location. 3. New Scleotic lesion of the T8. Although compression fracture is most likely, pathological fracture can not be excluded. This may also be assessed at the time of PET. [**2122-8-25**] ECHO: Dilated right ventricle with normal systolic function. Mild symmetric left ventricular hypertrophy with preserved systolic function. Moderate tricuspid regurgitation. Moderate pulmonary hypertension with signs of RV volume overload. Brief Hospital Course: Weakness: Likely due to myasthenia crisis or hypercalcemia. Patient's home dose of pyridostigmine and prednisone 40mg were continued and azathioprine started. Patient received five plasmapheresis sessions. At discharge, patient was saturating in the high 90s on room air and denied shortness of breath at rest. Negative Intrathoracic Force ranged from 30-50 and vital capactities were between 0.8-1.3L. . Hypercalcemia: Calcium on admission was 15.9 but was down around 8 after receiving calcitonin and bisphophonate. Parathyroid hormone, parathyroid related hormone, and vitamin D levels were normal. Given history of small cell cancer, there is a concern for an osteolytic process secondary to metastasis. Chest CT showed lesion in T8. Would recommend PET imaging for further evaluation. . Hypertension: Patient's anti-hypertensive regimen was altered during admission. Hydrochlorothiazide was discontinued due to hypercalcemia and hydralazine discontinued due to peripheral edema. Patient was switched from 25mg metoprolol three times daily to atenolol 100mg daily and lisinopril 40mg po twice daily. . Atrial fibrillation: Coumadin was held during plasmapheresis. Heparin drip was started. Coumadin was restarted on [**2122-8-26**] after completion of plasmapharesis. INR at discharge was 1.1. Digoxin was held because of EKG findings of digoxin toxicity on admission. Rate control was achieved with beta blockers. . Urinary tract infection: Patient's urine culture was positive for Proteus sensitive to ceftriaxone. Patient completed a three day course of ceftriaxone. Medications on Admission: Advair Diskus 250 mcg-50 INH 1 puff [**Hospital1 **] Ambien 5mg po qhs Ascorbic Acid 500mg po qday ASA 81mg po qday Atrovent Bisacodyl 10mg po qday Citalopram 20mg po qday Colace 100mg po BID Digoxin 250mcg po qday Ferrous sulfate 325mg po qday Folic acid 1mg po qday Hydralazine 25mg po q6 hours HCTZ 50mg [**Hospital1 **] Hydrocodone-APAP 5-500mg po qday Hyoscyamine Sulfate 0.375mg po qday Ibuprofen 400mg po q4 PRN Isopto tears 0.5% 1 drops ou [**Hospital1 **] Lisinopril 40 mg [**Hospital1 **] Mestinon 60mg po TID Metoprolol tartrate 12.5mg [**Hospital1 **] MVI Omega 3 1g TID Omeprazole 20mg po qday Oyster Shell calcium 1g TID Prednisone 40 mg qday (just changed from 60mg qd) Provigil 200mg po qday Senna 8.6mg po qhs Vitamin D 800 units qday Warfarin 3mg po qday Discharge Disposition: Extended Care Facility: [**Hospital 671**] [**Hospital 4094**] Hospital Discharge Diagnosis: Primary diagnosis: Myasthenia [**Last Name (un) 2902**] flare, hypercalcemia Secondary diagnosis: Hypertension, atrial fibrillation, small cell lung cancer, Discharge Condition: Stable Discharge Instructions: You presented with generalized weakness. You were admitted to the ICU due to concern about your respiratory status. You did not require intubation in the ICU. Work up showed that your weakness was likely due to your diagnosis of myasthenia [**Last Name (un) 2902**] or high calcium level. You were started on azathioprine and your home dose of pyridistigmine was increased. You also received five sessions of plasmapheresis. You also received bisphophonate and calcitonin to reduce your calcium level. During plasmapheresis, coumadin was held and heparin drip started. The heparin drip was discontinued and coumadin restarted after completion of plamapharesis. . Please seek medical care immediately if you experience worsening weakness, difficulty breathing, changes in mental status, fevers, chills or any other concerning symptoms. Followup Instructions: Please follow up with Dr. [**First Name (STitle) **] (endocrinologist) in clinic on [**2122-9-7**] at 1pm. His clinic is on the [**Location (un) 436**] of the [**Last Name (un) 469**] building. . Please follow up with Dr. [**Last Name (STitle) 1206**] (neurologist) on [**2122-9-18**] at 4pm. His clinic is on the [**Location (un) **] of the [**Last Name (un) 469**] building. . Please give warfarin 7.5 mg on [**2122-8-27**], then 5mg po daily for two days and then 3mg po daily. Please monitor INR with goal of [**2-10**]. . Please check calcium, magnesium, albumin and phosphate level on [**2122-8-31**] and fax results to Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 81220**]. . Please follow up on anti-hypertensive regimen which was altered during admission.

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icd9cm

[ [ [] ] ]

[ "38.93", "99.71" ]

icd9pcs

[ [ [] ] ]

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104,124

5917

Discharge summary

report

Admission Date: [**2131-6-7**] Discharge Date: [**2131-6-15**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5827**] Chief Complaint: Bright red blood in bowel movement Major Surgical or Invasive Procedure: none History of Present Illness: This is an 83yo female with a past medical history of CAD/CVA, DM2, hypertension, hypercholesterolemia, chronic pain on hospice for pain control, with abd pain x 2 days, BRBPR x 1. Initially constipated for 1 day, then took dulcolax and now with brbpr in stool on the day of admission. She apparently fainted while having bm, no fall, and then vomited x 1. Denied f/c/sob. . In ED, + BRBPR in vault, + TTP LLQ/RLQ. CT abd performed with results suggestive of proctocolitis, differential including ischemic bowel vs. less likely, infectious etiology. Surgery was consulted for possible bowel ischemia, who recommended IVF, Hct trending and possible OR if abdominal exams worsen. . Past Medical History: - CAD: s/p CABG '[**15**] (reportedly had 2 vein grafts, but unclear anatomy) and cath at [**Name (NI) 336**] in [**3-22**] revealed severe triple vessel disease, patent SVG to RCA, SVG to OM, SVG to D1, SVG to D2, SVG to OM1. - h/o multiple CVA's: residual L sided weakness. Severely limited activity at home, with daughter providing help with all [**Name (NI) 5669**]. - h/o seizures (last sz reportedly 1 yr ago, on keppra at home) - DM2 x 20 yrs - HTN - hyperlipidemia - hypothyroidism (on synthroid) - arthritis - spinal stenosis w/ chronic leg and hand pain Social History: Lives at home with elderly partner. Daughter helps with most ADL. No tobacco, EtOH or illicit drugs. Retired professional singer Family History: Mother died of stomach CA. Brother and sister with "heart problems." Physical Exam: PHYSICAL EXAM: Vitals: Tm 99.0 P 64 BP 154/72 R [**12-7**] 100%ra I/O- 1.6/1.5 General: Anxious appearing, but NAD HEENT: AT/NC, PERRL, EOMI, anicteric. OP clear, MM dry. Neck: no LAD. JVP at 5cm. Neck supple. EJ in place, c/d/i Lungs: CTAB no w/r/r Heart: RRR no m/r/g +S3 Abd: soft, ND, mild ttp LLQ, no rebound/guarding Ext: no e/c/c. warm and well perfused. 2+ DP pulses. Neuro: CN II-XII in tact bilaterally. Mild [**3-22**] LUE weakness, hip flexors LLE [**3-22**], plantarflexion on L [**4-21**]. Right [**4-21**]. Pertinent Results: Pt. had a spike in WBC to 17.9 with a left shift on [**6-7**] which subsequently decreased to 12.0 on discharge with resolution of L shift. . Upon admission ([**6-6**]), BUN/Creat were elevated to 31/1.5 which subsequently decreased with treatment to normal limits (9/0.7). Potassium on [**6-6**] was 8.5 and decreased to normal limits by discharge. . Troponin-T ranged from 0.17 to 0.10. . Stool studies showed WBCs, but was negative for all of the following: C.dif, O+P, Salmonella and Shigella. . Urine cx showed no growth, blood cx: ****** . EKG ([**6-13**])Atrial fibrillation, average ventricular response 116. Since [**2131-6-11**] atrial fibrillation is now seen. The inferior T wave inversions are less prominent. The Q-T interval is shortened. Increased ST-T wave abnormalities are noted . CXR: ([**6-6**])IMPRESSION: No acute cardiopulmonary process. . CTA Head ([**6-12**]): IMPRESSION: 1) Occlusion of the entire visualized superior left internal carotid artery and left middle cerebral artery. The left anterior cerebral artery is supplied from the right via the ACOM. Obscuration of the left putamen consistent with evolving left MCA infarction. No evidence of acute intracranial hemorrhage or hemorrhagic transformation. Findings discussed immediately with the neurology team, and an MRA with Gadolinium of the neck was suggested to evaluate the more proximal carotid system. 2) Short segment stenosis of the left posterior cerebral artery. 3) Scattered chronic small vessel ischemic disease in the white matter and chronic right thalamic lacune. . MRA/MRI Head/Neck ([**6-12**]): IMPRESSION: 1) Evolving infarction involving the left putamen, caudate body, corona radiata, and medial aspect of the left temporal lobe. 2) Occlusion of the distal left cervical ICA, with two probable areas of high-grade stenosis in the proximal left cervical ICA, though the latter would be far better assessed with a gadolinium enhanced study, and if the patient is able to tolerate such, a repeat study with gadolinium is recommended. . Echocardiogram ([**6-14**]):Conclusions: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with basal inferior and inferolateral hypokinesis. There is normal systolic function of the remaining segments. [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 (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . IMPRESSION: Mild regional left ventricular systolic dysfunction. Moderate-to-severe mitral regurgitation. Moderate pulmonary hypertension. . Compared with the prior study (images reviewed) of [**2130-12-12**], mitral regurgitation severity has increased and pulmonary pressures are higher. The other findings are similar. . CT Abdomen/Pelvis: IMPRESSION: 1. Uniform, circumferential bowel wall thickening involving the descending colon, sigmoid and rectum, concerning for an inflammatory or infectious etiology. Rectal involvement make ischemic etiology less likely. 2. Multiple hypodensities within the kidneys, too small to characterize. Brief Hospital Course: The patient was initially admitted to the MICU for monitoring of BRBPR. Her HCT fell from 42.8-- 34-- 29 over 20 hours (baseline 28-32). The patient was evaluated by GI and felt to have an ischemic vs. infectious proctocolitis. She was given levo/flagyl, IV ppi, 2L LR. Kayexelate was held as the patient was having diarrhea and no peaked t's. She remained stable throughout her MICU course, she was given 1 unit of blood, she remained afebrile with stable vitals and was transferred out to the floor the following day. . On the floor her GI sx shortly resolved with levo/flagyl, and her pain was adequately controlled. She had a run of atrial fibrillation with RVR that responded to IV Diltizem and returned to sinus. This recurred once again during her stay and again converted to sinus after IV Dilt. and was maintained on po metoprolol. . On the morning of [**6-12**] she was found to have a new right sided facial droop and R sided hemiparesis as well as aphasia. A stroke alert was called, the patient was given aspirin and underwent urgent CT/CTA of the head which showed a L sided carotid occlusion and evolving area of infarction in the L internal capsule. There was no bleed. MRI/MRA confirmed these findings. Due to the unclear time of onset of symptoms, thrombolysis was not performed. In addition, due to the patient's history of bleeding and risk of hemorrhagic transformation of the infarction, heparin was not given. Coumadin was started on [**6-14**] due to discovery of paroxysmal Afib to prevent future embolic events. . The patient remained stable throughout the remainder of the hospital course. Speech/swallow eval determined that she was in fact globally aphasic, and recommended pureed foods and nectars. On the days of discharge she was afebrile, displaying normal vital signs (sinus rhythm) and tolerating po with assistance. Medications on Admission: Colace sodium 100 mg 1 cap(s) [**Hospital1 **] Synthroid 75 mcg (0.075 mg) 1 tab(s) once a day atenolol 25 mg 1 tab(s) once a day aspirin 325 mg 1 tab(s) qd roxanol 20 mg/mL .25 ml Q4H benadryl 25 mg 1 tab(s) TID Sarna 0.5%-0.5% as directed TID Claritin 10 mg 1 tab(s) once a day lactulose 10 g/15 mL 15 mL [**Hospital1 **] Protonix 40 mg 1 tab(s) once a day metformin 500 mg 1 tab(s) [**Hospital1 **] Zetia 10 mg 1 tab(s) once a day Aspirin Low Strength 81 mg 1 tab(s) once a day Keppra 250 mg 2 tab(s) [**Hospital1 **] simvastatin 40 mg 1 tab(s) once a day (at bedtime) lisinopril 10 mg 1 tab(s) once a day Morphine IR 15 mg 1 tab(s) q 12 hrs morphine 5 mg sl q2hrs . Medications on transfer: 1. DiphenhydrAMINE 25 mg PO Q6H:PRN 2. Insulin SC (per Insulin Flowsheet) 3. Levofloxacin 750 mg IV Q48H 4. Levothyroxine Sodium 75 mcg PO DAILY 5. Levetiracetam 500 mg PO BID 6. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H 7. Morphine Sulfate 2-4 mg IV Q6H:PRN pain in abd, legs 8. Pantoprazole 40 mg IV Q24H 9. Simvastatin 40 mg PO DAILY 10. Vancomycin 1000 mg IV Q24H Discharge Medications: 1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for prn pain. 4. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 5. Insulin Regular Human 100 unit/mL Solution Sig: Sliding Scale Injection ASDIR (AS DIRECTED). 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: One (1) infusion Intravenous Q8H (every 8 hours) for 7 days. 13. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Levofloxacin in D5W 750 mg/150 mL Piggyback Sig: One (1) infusion Intravenous once a day for 7 days. 15. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg Injection Q8H (every 8 hours) as needed for nausea. 16. Morphine 2 mg/mL Syringe Sig: Two (2) mg Injection Q4H (every 4 hours) as needed for pain legs/abd/chest. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: 1. Infectious colitis 2. L-sided CVA (Stroke) 2. DMII 3. Chronic pain Discharge Condition: fair Discharge Instructions: You were admitted with an infection of your intestines and placed on antibiotics. While you were in the hospital you suffered a stroke that resulted in weakness of the right side of your face and body. Continue full course of antibiotics and take all other medications as prescribed. If your condition worsens, such as severe abdominal pain, vomiting, bloody diarrhea contact your physician. [**Name10 (NameIs) **] if you have any new weakness, chest pain, difficulty breathing or palpitations seek medical care. Continue to keep all health care appointments. Followup Instructions: Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1789**] in one week of discharge from your rehab facility. Follow-up with your physician for blood work to check INR and adjust Coumadin dose as necessary

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icd9cm

[ [ [] ] ]

[ "99.04", "38.93" ]

icd9pcs

[ [ [] ] ]

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296, 302

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17,582

159,570

27827

Discharge summary

report

Admission Date: [**2141-4-22**] Discharge Date: [**2141-5-13**] Date of Birth: [**2082-3-19**] Sex: F Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 783**] Chief Complaint: OSH MICU transfer Major Surgical or Invasive Procedure: Intubation Bronchoscopy PICC line placement Enteroscopy with biopsy History of Present Illness: 59 F transfer from [**Hospital3 3583**] with partial SBO and hypotension. . On [**4-21**], she presented to [**First Name4 (NamePattern1) 46**] [**Last Name (NamePattern1) **] with nausea, vomiting, and diarrhea x 2 days. That evening, she acutely became hypoxic. While undergoing a CT-PA to r/o PE, went into respiratory distress necessitating intubation and mechanical ventilation. She was fluid rescusitated and started on vasopressin and dopamine. Transferred to [**Hospital1 18**] for further management. . Laboratory data at [**Hospital1 46**] were significant for hyponatremia with Na 120, renal insufficiency with cr 2.2, Trop-I 0.28[nl 0-0.04, pos > 0.40], and CK 339. Of note, she did not have leukocytosis (WBC 6.9 with 81% polys). A CT scan (details below) was consistent with a partial SBO. . Of note, the patient had previously been hospitalized at [**Hospital1 3325**] in [**2140-12-9**] with cholecystitis. She had an NSTEMI during that admission and was transferred to [**Hospital 15629**] for catheterization which showed 3 vessel disease. She was initially planned to undergo CABG, but intubation was complicated by airway perforation, left pneumothorax, and cardiopulmonary arrest (hypoxia and bradycardia). CABG was cancelled. She subsequently came to [**Hospital1 18**] in [**2141-1-9**] for flexible bronchoscopy with debridement of necrotic tissue. A TTE at that time showed an overall normal EF with no wall motion abnormalities. Decision was made to pursue CABG as elective procedure at a later date. Past Medical History: 1. CAD with 3 vessel disease (70% LAD, 80% RCA, 80% Circ) 2. HTN 3. CHF 4. Obstructive sleep apnea 5. Morbid obesity 6. DM 7. Rheumatoid arthritis 8. Psoriasis 9. Hyperlipidemia 10. Cholelithiasis 11. Spinal stenosis 12. s/p airway perforation, left pneumothorax, and cardiopulmonary arrest ([**12-14**]) during intubation attempt (OSH) Social History: The patient lives alone, but her daughter ([**Name (NI) **]) lives nearby with her 3 children; they have a very close relationship. The patient has homemaker services. Fiance- Mark. 15 pack year smoking history, she quit 2 years ago. Denies alcohol use. Family History: The patient is adopted; FH unknown. Physical Exam: ADMISSION EXAM Vitals - T 100.2, BP 136/65, HR 100, wt 119 kg SaO2 100% on AC 600x14, FiO2 0.6, PEEP 5 General - intubated & sedated, but easily arousable and responds simple questions by nodding HEENT - sclera anicteric, PERRL, EOMI, R IJ TLC C/D/I, JVP difficult to appreciate given body habitus CV - tachy, but regular, no mur appreciated Chest - ventilated breath sounds without crackles or wheezes Abdomen - obese, soft, diffusely tender throughout; no organomegaly; scab to R of umbilicus Neuro - responds to simple questions by nodding; moves extremities x 4 Pertinent Results: [**2141-4-22**] 06:09PM PT-14.3* PTT-37.2* INR(PT)-1.3* [**2141-4-22**] 06:09PM PLT COUNT-188 [**2141-4-22**] 06:09PM WBC-9.2 RBC-4.72# HGB-12.8# HCT-36.2# MCV-77*# MCH-27.2 MCHC-35.5* RDW-14.9 [**2141-4-22**] 06:09PM CALCIUM-7.5* PHOSPHATE-4.1 MAGNESIUM-2.4 [**2141-4-22**] 06:09PM estGFR-Using this [**2141-4-22**] 06:09PM GLUCOSE-264* UREA N-39* CREAT-1.2* SODIUM-118* POTASSIUM-4.1 CHLORIDE-88* TOTAL CO2-18* ANION GAP-16 [**2141-4-22**] 08:42PM LACTATE-1.7 [**2141-4-22**] 08:42PM TYPE-ART TEMP-37.9 PEEP-5 PO2-217* PCO2-26* PH-7.41 TOTAL CO2-17* BASE XS--5 INTUBATED-INTUBATED VENT-CONTROLLED [**2141-4-22**] 09:38PM URINE MUCOUS-MOD [**2141-4-22**] 09:38PM URINE RBC-2 WBC-2 BACTERIA-RARE YEAST-NONE EPI-1 [**2141-4-22**] 09:38PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-100 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2141-4-22**] 09:38PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.020 [**2141-4-22**] 09:39PM CORTISOL-25.3* [**2141-4-22**] 10:58PM O2 SAT-70 [**2141-4-22**] 11:13PM TYPE-ART TEMP-38.2 PO2-126* PCO2-29* PH-7.37 TOTAL CO2-17* BASE XS--6 INTUBATED-INTUBATED [**2141-4-22**] 11:21PM PLT COUNT-213 . Radiographic Studies: CXR ([**Hospital1 46**] [**2141-4-22**] 08:31): Tip of the endotracheal tube is at the level of the sternal notch. Central catheter tip is at the junction of the superior vena cava and right atrium. No active cardiopulmonary disease. Slightly elevated right diaphragm. No change has occurred since [**2141-4-21**] at 2113 hours. . Head CT w/o contrast ([**Hospital1 46**] [**2140-4-21**] 18:06): No intracranial abnormality. Left scalp hematoma. . CT Abd/Pelvis w/o contrast ([**Hospital1 46**] [**2141-4-21**]): 1) Small bowel dilatation consistent with partial small bowel obstruction. Limited study secondary to patient obesity. 2) Cholelithiasis. 3) Coronary artery calcification. 4) Subcarinal adenopathy or mass appreciated in the lower thoracic images. 5) Vague patchy density seen at both lung bases of questionable significance and this may be acute or chronic. . ECG ([**2141-4-22**] 20:33): Sinus tach @ 109, nl axis & intervals; no voltage; flat Ts in limb leads, overall unchanged from OSH ECG @07:43 . [**4-23**] CT ABD: 1. Dilated loops of small bowel within the mid abdomen, with associated multifocal bowel wall thickening and mesenteric fluid. These findings are most consistent with mesenteric ischemia. Although small bowel obstruction is a possible consideration, it is less likely given the presence of normal appearing colon. 2. Mildly dilated gallbladder with dependent hyperdense material likely representing sludge. There is no secondary evidence to suggest cholecystitis. 3. Small amount of perihepatic fluid. . Abd US [**4-24**]: The gallbladder was not visualized due to patient's body habitus and inability to cooperate with the study. Appropriate hepatopedal flow is demonstrated in the main portal vein. There is no hydronephrosis in the right kidney. . [**4-25**] HIDA SCAN- Imaging findings most suggestive of chronic cholecystitis, and hepatocellular dysfunction . [**5-3**] MRI/A Abdomen FINDINGS: The abdominal aorta is normal in caliber. The origins of the celiac artery and SMA appear widely patent. There are two right renal arteries, and at least one left renal artery, which are also widely patent. There may be an accessory artery supplying the lower pole of the left kidney. The [**Female First Name (un) 899**] is patent. There may be an equivocal area of narrowing just distal to the origin of the inferior mesenteric artery with potential post-stenotic dilatation. No filling defects are seen within main vessels and proximal branches. Assessment of extremely distal vessels is limited due to small size. There are innumerable gallstones within the gallbladder. There is no free fluid in the abdomen. There is no overt bowel obstruction, hydronephrosis or abnormality in either adrenal gland. The liver and spleen are incompletely imaged. Multiplanar 2D and 3D reformatted images were essential in evaluating the mesenteric vasculature. IMPRESSION: 1. Patent celiac artery, SMA, and [**Female First Name (un) 899**]. Equivocal mild narrowing of the proximal inferior mesenteric artery. 2. Cholelithiasis without evidence of acute cholecystitis. . [**5-2**]: Small Bowel Follow Through SMALL BOWEL FOLLOW-THROUGH: Barium passes freely through the small bowel, entering the colon within one hour. The mid small bowel demonstrates multisegment areas of submucosal and mucosal thickening with one segment of slight luminal narrowing and fold effacement. No ulceration or nodularity.The terminal ileum is unremarkable. No fixed strictures, obstruction or fistulae. FINDINGS: Multisegment areas of submucosal and mucosal thickening with a segment of apparent fold effacement. Appearances are not typical for Crohns disease. Ischemia/vasculitis would be included in the differential diagnosis. Correlate clinically. . [**5-2**] Transthoracic Echocardiogram The left atrium is normal in size. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2141-1-18**], estimated pulmonary artery pressures are lower. No intracardiac shunt is evident. . Enteroscopy: Granularity, erythema and petechiae in the whole stomach compatible with NG trauma versus gastritis. An area of at least 4 cm of circumferential ulceration and erythema was seen in the mid-jejunum (biopsy). . BIOPSY RESULTS: Small intestine, jejunum, mucosal biopsy: 1. Focal ulceration with acute fibrino-purulent exudate. 2. No tumor seen. Note: Possible causes include drug injury, vascular lesion and Crohn's disease. . CT ABDOMEN W/CONTRAST [**2141-5-10**] 2:14 PM 1. No bowel obstruction. 2. Previously seen small ascites with fluid in the pelvis is resolved. 3. Interval development of left flank subcutaneous edema, for which correlation with patient's history, i.e. trauma, is requested. 4. Small mesenteric lymph nodes are unchanged. Brief Hospital Course: ICU Course: The patient was transferred to [**Hospital1 18**] ICU for further care on [**2141-4-22**] on an Insulin gtt, Dopamine gtt, Vasopressin gtt, and Propofol gtt. Her pressors were weaned off on [**4-23**]. Bronchoscopy was performed [**4-24**]; found patent airways without stenosis, she was extubated under direct visualization w/o complication. An abdominal CTA on [**4-23**] was concerning for mesenteric ischemia. GI and surgery consults were obtained. Transfused one unit PRBC's [**4-24**]. An abdominal US was obtained for concern re: cholecystitis, however, it was not helpful due to pt's body habitus. Therefore a HIDA scan was obtained on [**4-25**] which showed inflammed liver and chronic cholecystitis. . The patient was transferred to the medical floor on [**2141-4-25**]. The following issues were addressed: . #Abdominal pain: The patient continued to have constant crampy diffuse abdominal pain, with intermittant diarrhea (occasionally heme positive, but not bloody). Stool studies were negative x 3 for infectious etiologies. The patient was found to have thickened skip segments of small bowel seen on CT abd and small bowel follow through, with a differential including ischemia, IBD, and vasculitis. MRA and CTA showed patent vessels. TTE was without source for emboli. An enteroscopy and colonoscopy were performed on [**5-5**], and showed granularity, erythema and petechiae in the whole stomach compatible with NG trauma versus gastritis, an area of at least 4 cm of circumferential ulceration and erythema was seen in the mid-jejunum; the biopsy was negative for malignancy and chron's was unlikely per the GI specialists. She was treated empirically with antibiotics given her septic physiology on presentation- Zosyn/Vanco in the ICU, narrowed to Cipro/Flagyl on the floor; completed a 10 day course. She was also treated with her home regimen of both PPI amd ranitidine. Patient continued to have persistent loose stools so c diff was re-checked and it was negative post complettion antibiotic treatments. It is likely she is experiencing abdominal symptoms due to bilary colic from chronic cholecystitis. A repeat CT abdomen showed resolution of bowel wall inflammation and no evidence of obstruction. She was started on imodium to symptomatically treat the diarrhea. Gall bladder percutaneous drainage was considered though it was ultimately decided that she should instead have a cholecystectomy after management of her heart disease in the near future. She will follow up with Dr [**First Name (STitle) 679**] at [**Hospital1 18**] GI service, as an outpatient for possible colonoscopy as she refused to have one while inpatient. . # Hypotension: The patient's hypotension at OSH and in the MICU was resolved with IVF resuscitation and was most likely due to hypovolemia [**2-10**] n/v/d, though sepsis cannot be ruled out. All blood cultures were negative. She was treated with IVF resuscitation as well as empiric abx as above. A random cortisol was WNL. . # Anemia: Likely secondary to GI bleed. Remains hemodynamically stable. EGD on [**5-5**] showed gastritis and ulceration in jejunum. Now with OB+ stool. Pt refused colon prep given adverse effects post previous colon prep. As Hct remains stable post 2u pRBC transfusion, will monitor for now and can have colonoscopy outpatient. GI to do outpatient colonoscopy once pt decides to have the procedure. Continued on PPI, ranitidine. . # Hyponatremia: Likely [**2-10**] hypovolemia on admission. Resolved with IVF hydration. . # Respiratory failure: Etiology unclear, but quickly resolved in the MICU. Bronch w/o evidence of airway obstruction. Per OSH, ?of aspiration; pt also likely has OSA, with body habitus may have risk of positional obstruction (though she was able to lay flat on the floor). . # CAD: Known 3vd on prior cath. Mild troponin leak in setting of hypotension. The patient was continued on aspirin, plavix and statin. Her beta blocker was added back as her BP allowed. She will follow up with Cardiac Surgery in anticipation of CABG. . # DM Type 2: On Lantus 100 U and Humalog at home. Lantus was restarted on the floor and she was covered with and insulin sliding scale. . # Elevated transaminases on admission: This was most likely due to hypotension on admission. Resolved with out intervention. . # Ppx: The patient was treated with a PPI, ranitidine, SQ heparin prophylactically. . # Dispo: To followup with gastroenterology and cardiac surgery. Medications on Admission: Home Medications: Labetalol 200 mg [**Hospital1 **] Lisinopril 40 mg qday Aspirin 325 mg Imdur 30 mg qday Atorvastatin 80 mg Albuterol Sulfate 0.083 % Solution q4 PRN Tiotropium Bromide 18 mcg Capsule DAILY Pantoprazole 40 mg q24 Ranitidine 150 [**Hospital1 **] Senna 8.6 mg Tablet Docusate Sodium 100 mg [**Hospital1 **] Zolpidem 5 mg HS PRN Duloxetine 40 mg EC qday Neurontin 300 mg [**Hospital1 **] Methocarbamol 750 tid Ibuprofen 800 tid Ativan 0.25 prn Mag Ox 200 mg [**Hospital1 **] Spiriva qd Triamcinalone 0.1% paste Niferex 150 qd HISS, Lantus 100 U qHS Enbrel 2x/week . Meds on Transfer from OSH: Insulin gtt Dopamine gtt Vasopressin gtt Propofol gtt Discharge Medications: 1. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 5. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 12. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 13. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 14. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Methocarbamol 500 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day) as needed. 16. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea/loose stools. 17. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 18. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 19. Triamcinolone Acetonide 0.1 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 20. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: SLIDING SCALE Subcutaneous AS DIRECTED. 21. Lantus 100 unit/mL Cartridge Sig: 30 units Subcutaneous at bedtime. 22. Ondansetron 4 mg IV Q8H:PRN 23. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 24. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 25. 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. 26. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 27. Prochlorperazine 10 mg IV Q6H:PRN Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**] Discharge Diagnosis: Primary: Enteritis Sepsis Gastroenteritis Chronic cholecystitis Secondary: CAD HTN Diabetes Discharge Condition: Hemodynamically stable, tolerating PO diet, minimal diarrhea/abdominal pain. Discharge Instructions: During this admission you have been treated for gastroenteritis, abdominal pain, diarrhea, and sepsis. . Please continue to take all medications as prescribed. . Please seek immediate medical attention if you develop fevers >101, recurrent vomiting or diarrhea, worsening abdominal pain, or any other concerning symptoms. Followup Instructions: You have an appointment with Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] at [**Hospital1 18**] Gastroenterology on [**2141-5-24**] at 10:45am. Phone: ([**Telephone/Fax (1) 16940**] Follow up with Dr [**Last Name (STitle) **] ([**Hospital1 18**] Cardiac Surgery) on [**2141-6-6**] at 1:30pm Phone: ([**Telephone/Fax (1) 6876**] . Follow up with your PCP [**Last Name (NamePattern4) **] [**1-10**] weeks, call [**Last Name (LF) 67830**],[**First Name3 (LF) **] F [**Telephone/Fax (1) 23520**] for an appointment. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

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Discharge summary

report

Admission Date: [**2129-2-2**] Discharge Date: [**2129-2-9**] Service: NEUROLOGY Allergies: Sulfur / Loperamide Attending:[**First Name3 (LF) 618**] Chief Complaint: right sided weakness, difficulty speaking Major Surgical or Invasive Procedure: Intravenous TPA History of Present Illness: [**Age over 90 **]yo RH F who was apparently well until 10am this morning when she had the acute onset of difficulty speaking and right face/arm weakness. By her arrival here, her right arm had returned to [**Location 213**] - she denies weakness - but she still cannot speak. Denies headache, numbness. At baseline, she is demented and lives in a home. Recent OMR notes comment on a self-increase on lasix to 80mg daily due to increasing peripheral edema and shortness of breath. This was decreased back to 60mg daily when she was found to be orthostatic and complaining of light-headedness. ROS: On review of systems, the pt denied recent fever or chills. No night sweats or recent weight loss or gain. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Denied rash. Past Medical History: CRI s/p recent NSTEMI COPD hemorrhoids s/p appy s/p bilateal carotid endarterectomy severe sigmoid diverticulosis (seen on [**8-30**] colonoscopy) Hyperlipidemia HTN Hypothyroid Social History: denies tob/etoh, though 40py history. Family History: unable to offer due to aphasia Physical Exam: VS 94.0 80 130/70 12 100% 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. Fully oriented. Attentive to examiner. Speech non-fluent, with impaired repetition as well. Comprehension is intact; she can follow simple commands and point to some body parts (likely anomia as well - can point to nose but not her ear). No apraxia. No apparent neglect. Unable to assess for slurred speech. CN CN I: not tested CN II: Visual fields were full to confrontation, no extinction. Pupils 3->2 b/l. Fundi clear CN III, IV, VI: EOMI no nystagmus or diplopia 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 [**3-28**] and symmetric CN XII: tongue midline and agile Motor Normal bulk and tone. No pronator drift. Does not cooperate with formal power testing; can hold both arms antigravity for 10s and both legs for 5s. Sensory intact to light touch, pinprick throughout. No extinction to double simultaneous stimulation. Reflexes Br [**Hospital1 **] Tri Pat Ach Toes L 2 2 2 2 2 down R 2 2 2 2 2 down Coordination Fine finger movements, rapid alternating movements, finger-to-nose, and heel-to-shin were all normal Gait deferred to get CT/CTA CODE STROKE SCALE: Neurologic (NIHSS): 9 1a. LOC: alert, responsive (0) 1b. LOC questions: knew age and name of month (2) 1c. LOC commands: closed eyes and gripped with **(nonparetic) hand (0) 2. Best gaze: No gaze palsy (0) 3. Visual: No visual loss (0) 4. Facial Palsy: R facial droop lower face (1) 5a. Left arm: No drift (0) 5b. Right arm: now plegic (after CT/CTA) 4 6a. Left leg: No drift (0) 6b. Right leg: no drift (0) 7. Limb ataxia: absent (0) 8. Sensory: no sensory loss bilaterally (0) 9. Language: mod aphasia (2) 10. Dysarthria: None (0) 11. Extinction/inattention: None (0) --- On discharge: Pt has normal cranial nerves other than a mild right facial asymmetry. She has full strength, but a right PD. Coordination normal. Sensation normal. Speech is just barely fluent, and comprehension is normal. She is alert and oriented and has good insight. Pertinent Results: [**2129-2-2**] 11:00AM BLOOD WBC-12.6* RBC-3.41* Hgb-10.8* Hct-31.8* MCV-93 MCH-31.8 MCHC-34.1 RDW-17.0* Plt Ct-188# [**2129-2-3**] 03:16AM BLOOD PT-11.6 PTT-24.7 INR(PT)-1.0 [**2129-2-2**] 11:00AM BLOOD Glucose-93 UreaN-35* Creat-1.6* Na-140 K-4.2 Cl-98 HCO3-28 AnGap-18 [**2129-2-3**] 03:16AM BLOOD ALT-19 AST-26 LD(LDH)-381* CK(CPK)-55 AlkPhos-55 TotBili-0.5 [**2129-2-2**] 10:00PM BLOOD CK-MB-NotDone cTropnT-0.11* [**2129-2-3**] 03:16AM BLOOD %HbA1c-6.6* [**2129-2-3**] 03:16AM BLOOD Triglyc-113 HDL-94 CHOL/HD-2.1 LDLcalc-80 CT BRAIN PERFUSION [**2129-2-2**] 11:56 AM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS NON-CONTRAST HEAD CT: There is no evidence of hemorrhage, edema, mass, mass effect, or acute infarction. Periventricular hypodensities correspond to chronic small vessel ischemic disease. CTA HEAD: The carotid and vertebral arteries and their major branches are patent with no evidence of stenoses. The distal cervical internal carotid arteries measure 5 mm in diameter on the left and 5 mm in diameter on the right. There is no evidence of aneurysm formation or other vascular abnormality. PERFUSION STUDY: In the distribution of the inferior division of the left MCA, there is increased mean transit time and decreased cerebral blood flow in a pattern that demonstrates no perfusion/diffusion mismatch when compared to concurrently performed MRI. Incidental note is made of a diminutive B4 branch of the right vertebral artery. There is also beam hardening artifact causing apparent filling defect in the left proximal ICA, which is seen to be secondary to artifact. IMPRESSION: 1) Irreversible ischemia in the distribution of the inferior division of the left MCA. 2) No vascular stenosis or occlusion. 3) Chronic small vessel ischemic disease. MRI/MRA BRAIN W/O CONTRAST [**2129-2-2**] 2:53 PM FINDINGS: There is a small focus in a portion of the territory of the inferior division of the left middle cerebral artery, which demonstrates abnormal high signal on the ADC map. Corresponding hyperintensities on T2 and FLAIR demonstrate this to be an evolving subacute infarct. There is no abnormal vessel cut-off, no evidence of vascular stenosis or occlusion, and no evidence of hemorrhage. Periventricular hyperintensity on T2 imaging is likely indicative of chronic small vessel ischemic disease. IMPRESSION: Evolving subacute infarct of a portion of the inferior division of the left MCA territory. Echocardiogram- The left atrium is normal in size. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Overall left ventricular systolic function is normal (LVEF 70%). 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 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. There is severe mitral annular calcification. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a small posterior pericardial effusion. FOREARM (AP & LAT) SOFT TISSUE RIGHT [**2129-2-3**] 10:05 AM Two portable radiographs of the right forearm were obtained and there are no prior studies for comparison. The bones are diffusely demineralized. No displaced fractures are noted. There are severe degenerative changes of the first CMC joint and triscaphe joint. No soft tissue calcification is seen. IMPRESSION: No displaced fracture. Severe first CMC and triscaphe joint degenerative change. Severe osteopenia. CT head [**2-4**]: IMPRESSION: No hemorrhage or mass effect. Subtle hypodensity in the posterior inferior portion of the left frontal lobe consistent with site of known ischemic stroke. Brief Hospital Course: Ms. [**Known lastname **] is a [**Age over 90 **] year old woman with vascular risk factors and prior cardiac disease who presented with acute onset of global aphasia and right face/arm weakness. Her right arm difficulties resolved intially, but then returned, inculding concerning for left MCA territory dysfunction. 1) Left inferior division MCA infarction- CT perfusion scan revealed a deficit in the posterior right frontal lobe and her exam is worsened after the scan, with the right arm now plegic. She presented within the window for IV tPA (wt yesterday 107lbs). Her recent hospital course for GI bleed was noted and the risks and benefits were discussed with the patient's daughter. She was found to be guaiac negative and given IV TPA. She was admitted to the neurology ICU for close monitoring. MRI/A revealed left posterior frontal infarction with patent cerebral vessels. Her examination dramatically improved within short interval of TPA infusion with persistent non-fluent aphasia, but only minimal right pronator drift. Guaiac continued to be negative, serial hematocrits were stable and pt was started on aspirin for secondary stroke prevention (held during previous several weeks given recent admission for GI bleeding. Echocardiogram revealed preserved EF and severe mitral annular calcification. A1c 6.6%. Fasting lipid profile Total chol=197, LDL=80. Her blood pressure was allowed to autoregulate and was on the low side in the 105-120 range for the last few days of her admission. She had no symptoms of hypotension, but her metoprolol was not restarted due to the desire to allow her brain to perfuse better in the setting of her acute stroke. She can have her metoprolol added back as needed at rehab if she requires it for BP or HR control (did not need either here). On the floor, she initially fluctuated, with decreased speech and increased right arm weakness at times. These episodes were unclear, but seizure was considered. She was started on Keppra briefly. EEG was then performed and returned with only mild left temporal slowing. The Keppra was stopped as we have no hard evidence for seizure. If she begins to fluctuate again, consider seizure and the possibility of restarting Keppra 500 mg [**Hospital1 **]. 2) Troponin Leak- Likely demand ischemia without EKG changes. Highest trop was 0.19. CKs were not elevated. Telemetry without arrhythmia. Lasix dose initially reduced to 40mg daily and she was discharged on 60 mg daily dose. She may need additional, but has had no respiratory issues during her stay. 3) History of GI bleeding- Thought secondary to severe divertulosis. Stools were guaiac negative. Serial hct were stable. The risk vs. benefit weighs in favor of continuing aspirin therapy given risk of severe disability from stroke in the future. 4) Speech and Swallowing evaluation- She passed a video swallow exam with modified diet as in page 1. She also received speech evaluation and should continue speech therapy at rehab and beyong likely. Her speech has been gradually recovering and is much improved from admission. Code Status- DNR/DNI, discussed with pt's daughter. Medications on Admission: Lipitor 80 NTG prn Metoprolol 25mg TID Entocort SR 9mg daily Levothyroxine 88mcg daily Citalopram 10 Lasix 60 Protonix Ipratropium MVI Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day. 6. Entocort EC 3 mg Capsule, Sust. Release 24 hr Sig: Three (3) Capsule, Sust. Release 24 hr PO once a day. 7. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO once a day. 8. Celexa 10 mg Tablet Sig: One (1) Tablet PO once a day. 9. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 10. Lasix 40 mg Tablet Sig: 1.5 Tablets PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] of [**Location (un) 55**] Discharge Diagnosis: Stroke, left posterior frontal lobe Discharge Condition: Stable. Strength is essentially full, with right drift. She has a Broca's type aphasia with near fluency at this time. Swallowing is with modified diet only. Discharge Instructions: Please call your PCP or return to the ED if you have any new weakness, numbness, vision problems, new speaking problems, or walking problems. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2129-3-15**] 11:00 -- Please see your PCP [**Last Name (NamePattern4) **] [**12-26**] weeks for follow-up [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

[ "244.9", "434.11", "403.90", "496", "585.9", "562.10", "272.4", "787.22" ]

icd9cm

[ [ [] ] ]

[ "99.10" ]

icd9pcs

[ [ [] ] ]

12385, 12457

8262, 11410

267, 284

12537, 12698

4086, 4727

12888, 13209

1551, 1583

11596, 12362

12478, 12516

11436, 11573

12722, 12865

1598, 3793

3807, 4067

186, 229

312, 1277

4736, 8239

1299, 1479

1495, 1535

50,094

165,870

40232

Discharge summary

report

Admission Date: [**2147-12-30**] Discharge Date: [**2148-1-26**] Date of Birth: [**2106-11-5**] Sex: F Service: PLASTIC Allergies: Aspirin Attending:[**First Name3 (LF) 5667**] Chief Complaint: Severe soft tissue injury b/l UE after dog bite requiring Rt UE revascularization Major Surgical or Invasive Procedure: [**12-30**]-OR for debridement of wounds [**1-2**]- OR for further debridement [**1-4**]-OR for washout/dressing change [**1-10**]-OR for simple amputation of right arm, skin graft to L arm History of Present Illness: 41F who was attacked by a dog (per report, American Bulldog on the street, possibly intentionally), suffering extensive soft tissue damage to b/l UE, centered around volar/dorsal proximal forearms but with > 50 individual soft tissue punctures. + Severe blood loss at the scene. Pt called her fiance, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**] (ph [**Telephone/Fax (1) 88316**]) who found her lying in a mud on the side of the street and transported her to the local hospital in [**State 1727**]. There she was noted to have a BP of 62/48 and was taken emergently for exploration/washout/revascularization of her Rt UE (brachial artery to distal radial artery reconstruction with Rt saphenous vein graft). Pt has Rt TLC central line and femoral Arterial line. She arrives as a transfer for to [**Hospital1 18**] SICU intubated and sedated for further evaluation/management of extensive soft tissue defects. Past Medical History: unknown Social History: Lives on couch at home and does not have bed. Family History: unknown Physical Exam: Gen:NAD CVS: RRR Pulm: CTAB Abd: soft, NT ND Ext: s/p R above elbow amputation, stump healing well. L arm s/p split- thickness skin graft on forearm, well healed. Splint in place. Pertinent Results: [**2148-1-26**] 06:31AM BLOOD WBC-7.5 RBC-3.15* Hgb-9.2* Hct-29.7* MCV-94 MCH-29.4 MCHC-31.1 RDW-16.2* Plt Ct-429 [**2148-1-26**] 06:31AM BLOOD Plt Ct-429 [**2148-1-26**] 06:31AM BLOOD Glucose-105* UreaN-10 Creat-0.6 Na-143 K-3.8 Cl-104 HCO3-30 AnGap-13 [**2148-1-26**] 06:31AM BLOOD Calcium-10.4* Phos-4.4 Mg-2.3 [**2148-1-26**] 06:31AM BLOOD PT-21.3* INR(PT)-2.0* Brief Hospital Course: Patient transfered from OSH in [**State **] [**12-30**] and taken to the OR for debridment of right and left upper extremity injuries. She was given 3 u PRBCs. The following day [**12-31**] an extubation trial was started. [**1-1**] an odor was noted from her right arm wound and right leg incision which was the donor site of right saphenous vein was erythematous. She developed fevers, WBC 13.2, was pancultured x2 and then started on zosyn. On [**1-2**] she was taken back to OR for further debridement and I&D was performed of abscess that was productive of prurulent material near right median nerve. Her abx were changed to cipro/vanc/zosyn [**1-8**] patient stated she was now ready to see pictures of her injury and conversation was had about the need for amputation of her right arm. [**1-9**] Dr. [**Last Name (STitle) 5385**] had further conversation with patient and [**1-10**] patient taken to OR for simple proximal humerus right arm amputation with skin graft to LUE from ATL thigh. She was moved to the floor from the ICU [**1-11**] and. [**1-12**] her diet was advanced and foley d/ced. [**1-15**] patient spiked fever with urine and blood culture showing budding yeast and Micafungin 100mg IV daily was added. [**1-17**] ultrasound of old right IJ site showed clot and patient started on heparin gtt. [**1-18**] speciation showed [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 88317**] and pt switched to fluconazole PO x4 wks, TTE echo showed no vegetation and pt taken to OR for final closure/skin grafting to right stump site and VAC removal to left graft site. [**1-19**] central line removed, heparin gtt stopped, started on coumadin daily, enoxaparin q12 and pt switchted to PO cipro, flagyl and linezolid. [**1-20**] pt had an event that may have been a siezure and neuro recommended no medication at this time, f/u with neurology as outpatient and no driving x6 months. Pt continues to have elevated wbc count and ID recommned continueing abx/fluconazole regime. [**1-22**] IR guided central line placed. [**1-25**] final recs from heme regarding clot are continue enoxaparin until INR 2.5 then d/c, check INR 2-3x week until stable at 2.5 then x2 month, close pcp f/u and discontinue coumadin in three months. Final ID recs are to maintain fluconazole x4 wks until [**2-16**] then have blood culture done with PCP. [**Name10 (NameIs) **] neuro recs are no meds, no driving x 6 months, no dangerous activity such as working at height and f/u with neuro as out patient that pcp will arrange. At the time of discharge the patient was doing well, she was afebrile and vital signs were stable. She was tolerating a regular diet, ambulating and voiding without assistance. The patient is being discharged home with PT and VNA. Her PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 45417**] has been contact[**Name (NI) **] and informed of her hospital course and discharge plan. All documentation has also been faxed to his office. The patient will follow up with him on Monday. Her INR was 2 at the time of discharge. Medications on Admission: unknown Discharge Medications: 1. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 5 days. [**Name (NI) **]:*15 Tablet(s)* Refills:*0* 2. linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. [**Name (NI) **]:*10 Tablet(s)* Refills:*0* 3. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. [**Name (NI) **]:*10 Tablet(s)* Refills:*0* 4. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for to left forearm skin graft sites. [**Hospital1 **]:*1 bottle* Refills:*3* 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: Hold for loose stool. [**Hospital1 **]:*30 Capsule(s)* Refills:*2* 6. nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day) as needed for rash: Apply to affected area as needed. [**Hospital1 **]:*1 tube* Refills:*0* 7. warfarin 5 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 30 days: Take as directed by PCP. [**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*2* 8. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for neuropathic pain for 30 days. [**Name Initial (NameIs) **]:*90 Capsule(s)* Refills:*2* 9. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: Max 12/day. [**Name Initial (NameIs) **]:*100 Tablet(s)* Refills:*3* 10. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 21 days: Take until finished. [**Name Initial (NameIs) **]:*42 Tablet(s)* Refills:*0* 11. bacitracin-polymyxin B Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for to Left forearm open areas: apply to any reddened or open areas of arm wounds, twice/day. [**Hospital1 **]:*1 tube* Refills:*0* 12. morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours) as needed for pain for 7 days. [**Hospital1 **]:*14 Tablet Sustained Release(s)* Refills:*0* 13. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [**5-23**] hours as needed for pain for 7 days. [**Month/Day (3) **]:*70 Tablet(s)* Refills:*0* 14. enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) syringe Subcutaneous once a day for 3 days. [**Month/Day (3) **]:*3 syringes* Refills:*2* 15. SATURDAY [**2148-1-27**] and SUNDAY [**2148-1-28**] Please give lovenox injection 120 mg subcutaneous QD. Patient has own lovenox. Please page Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 45417**] [**Telephone/Fax (1) 88318**] with questions. 16. SATURDAY [**2148-1-27**] AND SUNDAY [**2148-1-28**] Please give lovenox injection 120 mg subcutaneous QD. Patient has own lovenox. Please page Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 45417**] [**Telephone/Fax (1) 88318**] with questions. Discharge Disposition: Home Discharge Diagnosis: Severe soft tissue injury to bilateral upper extremities after dog bites. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Followup Instructions: -You should continue taking your antibiotics as prescribed and until they are finished. -Elevate your left arm while you are sitting in a chair and while in bed and maintain it in your splint. -you may apply Eucerin cream to your left arm skin graft site twice a day and put bacitracin ointment to any areas of redness or areas that are open. You may wrap the surgical site lightly with kerlix gauze to protect it from rubbing from the splint. -Your right stump should be dressed with xeroform to the graft site, covered with gauze fluffs and wrapped with kerlix gauze for 2 weeks after you leave hospital. After two weeks, you may treat your right stump graft site the same as your left by applying Eucerin lotion twice a day and bacitracin ointment to any areas of concern. -Leave your the skin graft donor sites on your thighs open to air and continue to let them dry out. The dried xeroform dressing will fall off on it's own or your doctor may help to gently remove it if it's ready. -If you want to shower, you should wrap your thigh wounds/skin graft donor sites with plastic wrap to protect them from the water and then uncover when done showering. You should do the same for your right stump. - If your surgical areas begin to worsen after discharge home with an acute increase in swelling or pain, please call the Hand Clinic at the number given and ask them to page 'Plastic surgery on call' to speak with you. -You had questionnable seizure activity so should follow these recommendations: 1) no driving x 6 months 2) no dangerous activity such as working at height, standing near fires, etc. 3) f/u with neuro in [**State 1727**] as outpatient . Medications: * Resume your regular medications unless instructed otherwise. * You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so do not take these meds with additional Tylenol. * Take prescription pain medications for pain not relieved by tylenol. * Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication to prevent constipation. You may use a different over-the-counter stool softerner if you wish. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. . Go to your local Emergency Room/Hospital if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. Followup Instructions: SATURDAY ([**2148-1-27**]) AND SUNDAY ([**2148-1-28**]) You need to go to Emergency Room at you nearest hospital so they can give you your daily Lovenox injections. Bring your prescription for the injection with you to the ER. . You have a follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 45417**] on Monday, [**2148-1-29**] at 10:30am. . Hand Clinic: ([**Telephone/Fax (1) 32269**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building, [**Location (un) **] Please follow up in the Hand Clinic on Tuesday, [**2148-2-6**]. You must call ([**Telephone/Fax (1) 32269**] to make an appointment. The clinic is open from 8-12pm most Tuesdays. The clinic is located on the [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building, [**Location (un) **]. Please make sure that you obtain a referral from your insurance company prior to your clinic appointment. . If you are having any problems with communication or transportation with/to [**Hospital1 69**], please contact [**Name (NI) 501**] [**Last Name (NamePattern1) 1637**], Social Worker, for help/assistance: ([**Telephone/Fax (1) 88319**] Completed by:[**2148-1-26**]

[ "880.29", "507.0", "112.89", "881.11", "300.00", "285.1", "881.10", "353.6", "518.5", "V15.41", "780.39", "E906.0", "041.7", "112.2", "E849.0", "117.9", "041.6", "305.1", "453.81", "041.85", "958.4", "E001.0", "293.0", "V14.6", "525.10", "525.40", "996.62" ]

icd9cm

[ [ [] ] ]

[ "38.03", "38.97", "86.28", "86.69", "04.79", "83.32", "84.07", "96.6", "33.24", "96.72" ]

icd9pcs

[ [ [] ] ]

8235, 8241

2231, 5343

350, 542

8359, 8359

1841, 2208

11508, 12701

1616, 1625

5401, 8212

8262, 8338

5369, 5378

8510, 8510

1640, 1822

229, 312

570, 1506

8374, 8486

1528, 1537

1553, 1600

25,131

189,230

47674+59022

Discharge summary

report+addendum

Admission Date: [**2204-5-18**] Discharge Date: [**2204-5-26**] Date of Birth: [**2132-3-13**] Sex: F Service: MEDICINE Allergies: Levaquin / Gabapentin Attending:[**First Name3 (LF) 106**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac catheterization s/p DES to mid-LAD (for in-stent restenosis) CVVH History of Present Illness: Ms [**Known lastname 1728**] is a 72 year-old female with history of ESRD on HD, sCHF, history of CAD, diabetes, and a.fib on coumadin who was transferred to [**Hospital1 18**] ED this morning from [**Location (un) 620**] due to need for cardiac catheterization. The patient has had angina for the past month and was recommened to undergo cardiac catheterization, however her son just died and she was overwhelmed and had put off the procedure. Yesterday she developed right-sided, nonradiating, dull chest pain while watching TV. She had associated nausea and dyspnea. The pain ranges between a [**2202-2-25**]. She went to [**Hospital1 18**] [**Location (un) 620**] and was given nitroglycerin with short-term resolution of the pain, but she states the pain would return about 30 minutes after the nitro was given. She had one epsidoe of vomiting last night. She was transferred to the [**Hospital1 18**] ED where EKG shows TWI and STD in V4-V6. . She was taken to the cath lab where she was found to have instent restenosis of the mid-LAD BMS that was placed in 9/[**2203**]. Also was found to have tight dig that was felt to be consistent with prior dimensions. A RHC showed elevated right sided pressures with PAD pressure 27. A DES was deployed across the instent restenosis. The right sided pressures dropped to the 15's by report. . She was dyspneic throughout the procedure and maintained on BiPAP. She is transferred to the CCU for urgent HD for fluid overload following procedure. . On arrival to the CCU she was initially hypertensive with MAPs in the 80's and SBP of 150 on BIPAP with SaO2 100%. She was comfortable. HD was initiated for fluid optimization. Shortly after initiation of HD she developed worsening CP with acute drop in BP to MAP of 50. HD was discontinued. BiPAP was also discontinued to avoid interfereing wiht pre-load. She received 500c of fluid as HD was being discontinued. . EKG at that time showed evoulution of ST depressions in V3-V4 from pre-procedure EKGs. There is no post cath EKG in the chart to compare with. CXR at the time of her decompensation was fairly unremarkable on bedside interpretation. . BiPap was discontinued. Her BP's have retunred to normal and she is satting 95% on 4L NC. She is still endorsing chest pain [**5-1**]. . Past Medical History: 1. CARDIAC RISK FACTORS: + Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -PCI: - [**2196**]: Cypher x 2 to left circumflex - [**2198**]: Cypher to LAD after NSTEMI - [**9-/2203**]: catheterization w/ known occluded RCA, 90% mid LAD intervened on w/ BMS, minimal LCX - [**12/2204**]: Found to have LAD and LCx disease with placement of DES to ostial LCX, DES to LAD 3. OTHER PAST MEDICAL HISTORY: -Heart failure with preserved ejection fraction ([**2201**] EF >55%) -Paroxysmal atrial fibrillion on coumadin -Mild to moderate mitral regurgitation (TTE [**2201**]) -carotid artery disease (s/p left carotid stenting, [**2202**]; right carotid with 80-99% stenosis) -h/o recurrent pulmonary edema -ESRD on HD TUES THURS SAT at [**Location (un) **] in [**University/College **] -COPD -Lung CA, status post resection [**2182**] -h/o uterine cancer -Neuropathy secondary to DM -Gout -Sleep apnea (not on CPAP) -Obesity -DVT after a fistula was placed on coumadin -GERD: status post endoscopy in [**2198-11-21**] which revealed nonerosive gastritis, reflux disease -Depression -S/p ligation of LUE AV fistula due to steel syndrome, with DVT -legally blind Social History: -Lives at home w/ husband who is main caregiver -3 children, 1 lives w/ her and is learning disabled -Tobacco history: 1 ppd most of her life, continues to smoke -ETOH: None -Illicit drugs: none Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM: General Appearance: Well nourished, Overweight / Obese Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Rhonchorous: ) Abdominal: Soft, Obese Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent Skin: Not assessed Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented (to): person, place, time, Movement: Not assessed, Sedated, Paralyzed, Tone: Not assessed DISCHARGE PHYSICAL EXAM: GENERAL: sitting at edge of bed, oriented, in no acute distress HEENT: mucous membranes dry, no lymphadenopathy, JVP non elevated CHEST: LS with crackles at left base CV: S1 S2 Normal in quality and intensity RRR, [**3-27**] holosystolic murmur at LUSB ABD: soft, non-tender, non-distended, BS normoactive. EXT: wwp, no edema. DPs, PTs 2+. NEURO: 3/5 strength in U/L extremities. Appears oriented, speech clear. SKIN: no rash, right big toe with small healing ulceration PSYCH: discouraged, wants to go home. Pertinent Results: ADMISSION LABS: [**2204-5-18**] 03:26PM BLOOD WBC-11.4* RBC-3.13* Hgb-9.2* Hct-31.0* MCV-99* MCH-29.4 MCHC-29.7*# RDW-14.9 Plt Ct-157 [**2204-5-18**] 10:45AM BLOOD PT-19.8* PTT-39.1* INR(PT)-1.9* [**2204-5-18**] 03:26PM BLOOD Glucose-116* UreaN-47* Creat-5.8*# Na-140 K-4.9 Cl-99 HCO3-25 AnGap-21* [**2204-5-18**] 03:26PM BLOOD Calcium-9.6 Phos-6.4*# Mg-2.4 . CARDIAC ENZYMES: [**2204-5-18**] 03:26PM BLOOD CK-MB-3 cTropnT-0.06* [**2204-5-18**] 10:06PM BLOOD CK-MB-4 cTropnT-0.09* [**2204-5-19**] 04:57AM BLOOD CK-MB-6 cTropnT-0.18* [**2204-5-19**] 10:02AM BLOOD CK-MB-8 cTropnT-0.24* [**2204-5-23**] 09:52AM BLOOD CK-MB-6 cTropnT-11.54* [**2204-5-25**] 09:15AM BLOOD CK-MB-4 cTropnT-11.09* . DISCHARGE LABS: [**2204-5-26**] 07:15AM BLOOD WBC-7.3 RBC-2.79* Hgb-8.2* Hct-27.2* MCV-98 MCH-29.6 MCHC-30.3* RDW-15.3 Plt Ct-191 [**2204-5-26**] 07:15AM BLOOD PT-62.2* INR(PT)-6.2* [**2204-5-26**] 07:15AM BLOOD Glucose-74 UreaN-73* Creat-2.4*# Na-138 K-4.5 Cl-98 HCO3-27 AnGap-18 [**2204-5-26**] 07:15AM BLOOD Calcium-8.9 Phos-6.2* Mg-2.2 . EKG [**2204-5-18**]: Sinus rhythm. Possible septal myocardial infarction, age undetermined. Anterolateral ST-T wave changes may be due to ischemia. Clinical correlation is suggested. Compared to tracing #2 ST-T wave changes are seen in leads V3-V4 and more prominently in leads V5-V6 raising concern for ischemia. Clinical correlation is suggested. . CARDIAC CATHETERIZATION [**2204-5-18**]: 1. Two vessel coronary artery disease. 2. Congestive heart failure NYHA class 4, on BiPAP during the procedure. 3. Unstable angina CCS class 4 4. Mid-LAD 90% in-stent restenosis (likely culprit lesion for unstable angina) was successfully treated with a 2.75 x 15 mm promus drug-eluting stent. Unchanged stenosis at the ostium of the diagonal following PCI to LAD. 5. Successful deployment of Angioseal to right femoral artery with excellent hemostasis. . TTE [**2204-5-21**]: The left atrium is moderately dilated. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with severe hypokinesis of the inferolateral, anterolateral, distal septal and distal anterior walls. The remaining segments contract normally (LVEF = 30-35 %). No intraventricular thrombus is seen.Right ventricular cavity size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is mild to moderate aortic valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The estimated pulmonary artery systolic pressure is high normal. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Normal left ventricular cavity size with regional systolic dysfunction c/w multivessel CAD or other diffuse process. Mild to moderate aortic valve stenosis. At least moderate mitral regurgitation. Compared with the prior study (images reviewed) of [**2204-1-13**], left ventricular systolic function is slightly less vigorous with more extensive regional and depressed global systolic function. The severity of aortic stenosis has slightly progressed. Brief Hospital Course: 72F complex PMHx notable for CAD s/p multiple PCIs, most recently in [**12/2203**], ESRD on [**Hospital 58910**] transferred from [**Hospital1 18**] [**Location (un) 620**] for cardiac cath in the setting of rest angina found to have in stent restenosis of mid LAD BMS and elevated right sided filling pressures s/p DES to mid LAD admitted to CCU for diuresis in setting of ongoing chest pain. Hospitalization complicated by persistent chest pain secondary to demand ischemia in setting of significant CAD, making hemodialysis difficult to tolerate. She declied repeat cardiac catheterization, and is discharged home with plans for HD as tolerated while readdressing long-term goals of care as an outpatient. ACTIVE ISSUES: # Acute on Chronic Systolic Heart Failure: euvolemic on discharge. Patient presented with pulmonary edema of multifactorial etiology, secondary to 1.) subacute progression of CAD and 2.) dietary indiscretions, also worsened by receiving extra IVFs in cath lab and with initiation of HD on arrival to CCU post-PCI. Fluid overload was likely contributing to demand ischemia. She was unable to initially tolerate hemodialysis in setting of dropping BPs, so she was underwent CVVH to remove large amount of fluid, which was tolerated well. She is at risk for frequent admissions for fluid overload and hypoxia, as she has significant dietary indiscretion and difficulty tolerating fluid removal at hemodialysis. # Coronary Artery Disease: s/p DES to mid-LAD. Patient s/p DES to mid LAD after in-stent restensosis which was likely subacute in progression, contributing to worsening heart failure. Significant fluid overload first 1.5 days of admission likely was causing demand ischemia with inferior and lateral T wave depressions. Chest pain improved after fluid removal, though she did continue to have chest pain episodes with initiation of hemodialysis, which was attributed to further demand ischemia in setting of significant underlying coronary artery disease (cardiac enzymes were elevated in the setting of these episodes). She was offered another cardiac catheterization to search for another lesion which may be intervenable, as she does have chronic severe disease of a diagonal branch which has never been intervened upon, but she declined the procedure multiple times. She was continued on aspirin, plavix, metoprolol, and statin. Was started on low-dose Lisinopril this admission, which she tolerated and is being discharged on. # End Stage Renal Disease: on HD. Patient with end-stage renal disease requiring hemodialysis (M/W/F); she was briefly on CVVH, and then transitioned to HD, which she did not tolerate with regularity. She frequently had chest pain, nausea, or shortness of breath with initiation of hemodialysis, causing dialysis to terminate early with no fluid removal. Held multiple family meetings with patient discussing whether or not she would like to continue Hemodialysis; she stated on multiple occasions that she would be ready to quit, except that her son recently died, and she does not want her family to have to grieve for her so soon after the death of her son. Discussed various other options including nighttime dialysis sessions potentially at another center where the sessions could be spread out over more hours and be more gentle. She tolerated HD on the day of discharge (though required 300cc fluid for blood pressure) and will follow-up at her regular HD center. # Supratherapeutic INR: 6.2 upon discharge. Patient presented with rising INR over the last two days of admission, no signs of bleeding. She has had decreased appetite, likely the etiology. INR on 6.2 on discharge. Patient instructed to hold Warfarin and VNA will recheck INR the day after discharge. [**Hospital1 **] [**Hospital 620**] [**Hospital3 **] manages her anticoagulation. # COPD: on home O2. Patient on 4L home O2 at baseline. She was continued salmeterol-fluticasone, and continued O2 supplementation with goal SaO2 93-94% along with duonebs. # Goals of care: ongoing discussion. Per discussion with daughter, family requesting palliative care to discuss goals of care. Palliative care and social work met with the pt and family, and the pt designated her husband as the HCP and daughter as alternate. As above, she discussed the possibility of discontinuing hemodialysis in the future, but she is not ready to do so at this time because she recently lost her son and does not want her family to suffer further. Code Status still Full Code, had difficulty readdressing after this family meeting. CHRONIC ISSUES: # Anemia: Chronic, likely secondary to ESRD. ***Of note, patient declines blood products.*** # PAROXYSMAL ATRIAL FIBRILLATION: She presented in sinus rhythm and remained thus for most of the admission. She did have one very brief limited episode of reported Afib to 160s on the floor. CHADS 3. Not a candidate for pradaxa given renal failure. We continued her metoprolol except during HD sessions. Her warfarin was held during admission when INR rose >3.0 in setting of poor po intake. # HYPERTENSION: Held PO anti-HTN meds given labile blood pressures initially, then slowly restarted meds. Lisinopril 2.5mg was initiated at bedtime and should be held night before dialysis. Imdur was restarted at 30mg daily and should be uptitrated as tolerated to 60mg daily. Eplerenone was held and may be restarted by cardiologist if tolerated. # INSULIN RESISTANCE: Noted to have elevated blood sugars on admission, but fasting sugars normalized. Insulin sliding scale while in house, decreased requirement in last couple days of hospitalization. Consider Hemoglobin A1c as outpatient. # HYPERLIPIDEMIA: Continued statin. # DEPRESSION: Continued paroxetine TRANSITIONS OF CARE: - INR repeat on Sunday by VNA (managed by [**Hospital1 **] [**Hospital 620**] [**Hospital3 **]) - [**Month (only) 116**] uptitrate Imdur and restart Eplerenone as tolerated - F/u BP and HR (Lisinopril was started this admission, Metoprolol dose changed) - Ongoing conversation between patient and outpatient dialysis unit - Ongoing palliative care vs hospice conversation as needed Medications on Admission: HOME MEDICATIONS: (per OMR) cinacalcet 30 mg by mouth day clopidogrel 75 mg by mouth once a day colchicine 0.6 mg by mouth QD prn GOUT eplerenone 25 mg by mouth DAILY fluticasone 50 mcg Spray, Suspension 2 puffs(s) to nose q.d. fluticasone-salmeterol 250 mcg-50 mcg/Dose inhaled [**Hospital1 **] isosorbide mononitrate 60 mg Extended Release by mouth daily lactulose 10 gram/15 mL Solution 15-30 mL by mouth [**Hospital1 **] prn lidocaine 5 % (700 mg/patch) Adhesive Patch [**1-23**] patches to area of pain QD for 12 hours (12 hours off inbetween) metoprolol tartrate 50 mg by mouth three times a day nitroglycerin 0.4 mg Tablet, Sublingual 1 Tablet(s) sublingually q 10 min as needed for prn chest pain oxygen o2 nasal canula 2-4 L titrate to sat >92% DX:COPD,SleepApnea paroxetine HCl 10 mg by mouth once a day pentoxifylline 400 mg Tablet Extended Release by mouth daily ranitidine HCl 150 mg by mouth twice a day rosuvastatin 40 mg by mouth daily sevelamer HCl 800 mg Tablet by mouth t.i.d. with meals warfarin adjusted to INR aspirin 325 mg by mouth once a day docusate sodium 100 mg by mouth twice a day prn sennosides prn Discharge Medications: 1. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 2. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day as needed for gout pain. 3. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 4. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tab Sublingual as directed as needed for chest pain. 8. paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. pentoxifylline 400 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO DAILY (Daily). 10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day. 11. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 12. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 13. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 14. warfarin 1 mg Tablet Sig: as directed Tablet PO as directed: Your INR was 6.2 at the time of discharge, so hold your Warfarin, have your INR checked on Monday [**5-28**], and restart as directed by your [**Hospital3 **]. 15. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime: hold on the nights before dialysis. Disp:*30 Tablet(s)* Refills:*2* 16. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day. 17. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO once a day. 18. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tab Sublingual every 10 minutes as needed for chest pain: (resume your previous dose). 19. lactulose 10 gram/15 mL (15 mL) Solution Sig: 15-30 mL PO twice a day as needed for constipation. 20. sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO three times a day: with meals. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Acute on Chronic Systolic congestive heart failure End Stage Renal Disease Unstable angina with demand ischemia Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mrs. [**Known lastname 1728**], It was a pleasure caring for you at [**Hospital1 18**]. You had continuing chest pain at home and received a bare metal stent in your left anterior descending coronary artery to open a blockage. You will need to take Aspirin indefinitely and Plavix every day for at least one year. Do not stop taking Plavix or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) **] says it is OK. Unfortunately, you continued to have chest pain after the procedure. Another cardiac catheterization was discussed but you decided against having this now. Your medicines have been titrated to hopefully prevent chest pain as much as possible in the future. You needed to have an intravenous type of dialysis in the CCU because your blood pressure was too low for regular dialysis treatments. You now are back on your dialysis schedule and will continue that next week in [**University/College **]. . We made the following changes in your medicines: -STOP Epleronone -START Lisinopril to help your heart pump better (hold on the nights before dialysis) -DECREASE Imdur to 30 mg daily, this may help your blood pressure in dialysis -CHANGE Metoprolol tartrate to metoprolol succinate, a long acting version (and a different dose) -HOLD Warfarin (Coumadin) until your INR levels are below 3.0. The VNA will check your INR tomorrow, Sunday [**2204-5-27**] Followup Instructions: PRIMARY CARE Department: [**Hospital **] HEALTHCARE OF [**Location (un) **] When: TUESDAY [**2204-5-29**] at 11:50 AM With: [**First Name8 (NamePattern2) 3679**] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 3070**] Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground Campus: OFF CAMPUS Best Parking: Parking on Site CARDIOLOGY Department: [**Location (un) 620**] Cardiology When: Tuesday [**2204-6-5**] at 9:00 AM With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4135**], MD [**Telephone/Fax (1) 4105**] Building: [**Street Address(2) 3001**] ([**Location (un) 620**], MA) Name: [**Known lastname **],[**Known firstname 16178**] O Unit No: [**Numeric Identifier 16179**] Admission Date: [**2204-5-18**] Discharge Date: [**2204-5-26**] Date of Birth: [**2132-3-13**] Sex: F Service: MEDICINE Allergies: Levaquin / Gabapentin Attending:[**First Name3 (LF) 4473**] Addendum: To clarify, patient received DES to LAD for in-stent restenosis. This was specified in d/c paperwork. Also was correctly specified under "procedures" section of the d/c paperwork she was given. But in one sentence on the d/c paperwork it was [**Last Name (un) 16180**] as being a bare metal stent which is incorrect. This was relayed/reinforced to the patient and her daughter [**Name (NI) 1782**] after discharge. Discharge Disposition: Home With Service Facility: [**Hospital 136**] Homecare [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4474**] MD [**MD Number(1) 4475**] Completed by:[**2204-5-26**]

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icd9cm

[ [ [] ] ]

[ "00.45", "88.56", "00.66", "39.95", "36.07", "37.23", "00.40" ]

icd9pcs

[ [ [] ] ]

21711, 21926

8869, 9581

292, 368

18617, 18617

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68,882

173,760

43943

Discharge summary

report

Admission Date: [**2120-12-6**] Discharge Date: [**2120-12-19**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6565**] Chief Complaint: Right hip pain, unable to walk Major Surgical or Invasive Procedure: Partial Hip Replacement History of Present Illness: 85 yo M with superficial bladder ca (dx [**2103**]) - stage IV, mets to bone - R femur and s/p excision of R sided lung cancer [**2118**] who presents with acute on chronic worsening of R hip pain felt to be secondary to R femur metastatic lesion. He has actually been unable to walk for the last 3 days and has been mostly sitting in a chair at home. He had been evaluated for hospice services, though recently doses not qualify as he is using Aranesp (successfully) for anemia. He has tried Advil 600mg prn leg pain as well as Tylenol #3 (taken infrequently) at home. He is also using a Lidocaine patch. His pain in minimal while lying in bed, though he likens standing and walking to "giving birth" because the pain is so bad. He otherwise feels well. Nephrostomy tubes are functioning well without bleeding. No SOB or chest pain. No fevers. Past Medical History: ONCOLOGIC HISTORY: Mr. [**Known lastname 94340**] is an 84-year-old male with a history of superficial bladder cancer originally diagnosed in [**2103**] and treated with local resection and intravesicular BCG/IFN in [**2114**] and [**2115**]. In [**2-/2118**], TURBT revealed papillary urothelial carcinoma, largely low grade with focal high grade features and lamina propria invasion in his prostatic urethra. He received intravesicular BCG and IFN, completed in 3/[**2118**]. Restaging TURBT on [**2118-6-17**] revealed two small recurrences of papillary urothelial carcinoma, low-grade, with a focus of invasion into the lamina propria but muscularis was free of tumor. Retrograde pyelograms demonstrated severe bilateral hydronephrosis and he was in acute renal failure with Cr of 2.2, up from 1.3. Ureteral obstruction was thought to be due to locally advanced bladder cancer. Bilateral percutaneous nephrostomy tubes were placed and he underwent 6660cGy of radiation to the pelvis in [**10-14**]. The left nephrostomy tube was removed on [**2119-1-3**]. The right nephrostomy tube was removed on [**2119-2-16**] but on [**2119-4-4**], he developed bilateral hydronephrosis again and a left nephrostomy tube was placed. He has had multiple complications, including ureteral obstruction, hydronephrosis, renal failure (Cr of 2.8 in [**6-14**]) and hematuria felt to be due to radiation cystitis. Cystoscopy in [**1-14**] showed one tumor on the right bladder wall which was fulgurated. Follow-up cystoscopy in [**3-/2120**] was normal, but in [**2120-6-7**] he had several areas of infiltrative papillary urothelial carcinoma. In [**2120-9-7**] pelvic imaging disclosed stage IV bladder cancer and a destructive bone lesion of the right lesser trochanter, for which he received radiation, completed on [**2120-10-9**]. . PAST MEDICAL HISTORY: # Superficial bladder cancer (see OMR for details) # Squamous cell cancer RLL s/p excision [**11-13**] # Adenocarcinoma in RML s/p excision [**11-13**] # Lingular nodule, ? bronchoalveolar carcinoma # CAD # s/p pacemaker # hypercholesterolemia # s/p bilateral inguinal hernia repairs # Chronic renal insufficiency, baseline Cr ~2.0 (stage III CKD) Social History: Lives with his wife. Difficult caring for him at home even prior to this leg pain given severity of illnesses. Considering hospice care. Family History: NC Physical Exam: Vitals: T 98.2 BP 168/64 HR 96 RR 18 O2 99% RA GENERAL: WDWN older male in bed, awake and alert HEENT: Sclerae anicteric. PERRL, EOMI. Conjunctiva injected and pale, lower lids are lax OP: MMM. Oropharynx is clear. No thrush. Neck supple. LYMPH: No cervical, supraclavicular, infraclavicular or axillary LAD. HEART: Distant heart sounds, regular, with normal S1 and S2, no murmurs. LUNGS: Clear to auscultation and percussion bilaterally. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. + Quiet BS. No hepatosplenomegaly., pressure ulcers b/l ischial tub. EXTREMITIES: 2+ pitting edema to his mid calves bilaterally. Skin is flaky, warm NEURO: Pain with abduction of R leg, no tenderness to palpation. Unable to lift leg off bed due to pain. Pertinent Results: [**2120-12-6**] 02:50PM URINE BLOOD-LG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2120-12-6**] 02:50PM URINE RBC->50 WBC->50 BACTERIA-MOD YEAST-NONE EPI-0 [**2120-12-6**] 12:00PM WBC-11.7* RBC-3.73* HGB-10.1* HCT-33.4* MCV-90 MCH-27.1 MCHC-30.2* RDW-16.0* . XRay: There is no evidence of a new fracture. Patient has known osteolytic lesion in the proximal shaft of the femur and large osteolytic lesion in the lesser trochanter; this is unchanged from prior as does degenerative changes in the right hip joint. . CT Pelvis 1. Destructive mass involving the right lesser trochanter and lateral subtrochanteric femur has progressed. There is high risk for pathologic fracture if this has not already occurred. Dedicated femur radiographs are recommended as this lesion is only partially visualized. 2. New lesions within the left pubic symphysis and right sacrum. The right sacral lesion abuts the S3 nerve root. 3. Slight progression of disease within the pelvis. . CT spine: 1. New right sacral lesion with soft tissue component, most likely lytic metastasis of rapid progression. These findings were not appreciated on prior exam of [**2120-10-22**]. 2. L3 left pedicle blastic lesion , overall unchanged since [**2118**]. 3. Extensive degenerative disease of the lumbar spine. Brief Hospital Course: Mr. [**Known lastname 94340**] is an 85-year-old male with invasive bladder cancer and lung cancer, who is not pursuing aggressive treatment who presents with severe, worsening leg pain secondary to lytic lesion in prox femur. . #. Hip Fracture: A hip X-ray was done that showed lytic lesion of femur and subsequent CT demonstrated extensive cortical destruction of right femur and of left pubic symphysis. Patient evaluated by ortho and XRT. Patient expressed he wanted to have surgery. Ortho recommended partial hip replacement given the significant destruction seen on CT. Preoperative risk assessment was done by anesthesiology and nephrology, as well as by obtaining an echocardiogram. Echo showed mild symmetric left ventricular hypertrophy with hyperdynamic systolic function without LVOT gradient as well as mild pulmonary artery systolic hypertension. Patient was transfused with 3 units pRBC prior to surgery. . The patient underwent R total hip hemiarthroplasy on [**2120-12-13**]. During the procedure he was hypotensive and had EBL of about 1000cc. He received 2 units of PRBCs and was briefly on norepinephrine. Postoperatively he was admitted to the [**Hospital Unit Name 153**] for monitoring. On presentation to [**Name (NI) 153**], pt. was A+O x 0. There was concern that the patient may have focal neurological deficits on right side, but those resolved quickly as the patient became more oriented. Post-operatively, the patient was noted to have poor UOP with hematuria that resolved. The patient also had leukocytosis to WBC of 30, likely post-procedural stress and trended downward. He was again trasnfused 1 additional unit of pRBC with appropriate Hct response. The patient remained alert, oriented, and hemodynamically stable and was transferred back to the floor. He was seen by orthopedic surgery who recommended Lovenox for 4 weeks, outpatient follow-up with Dr. [**Last Name (STitle) 5322**] and touch down weight bearing for activity. - Touch down weight bearing on Right leg - Continue lovenox - F/u with Dr. [**Last Name (STitle) 5322**] . # UTI - Urine cultures significant for MRSA infection sensitive to vanc and bactrim. Patient initially started on bactrim but was switched to vanc as renal function deteriorated (see below). Patient completed a course of vanc for his UTI. . # Acute on Chronic RF - Patient had an elevated Cr and low UO through nephrostomy tube. Patient's was evaluated by IR who saw that the nephrostomy was displaced and had to be changed. Nephrology was consulted who felt that his ARF was likely post-obstructive, but could not rule out an element of AIN given pos eos seen on smear. Patient was switched from bactrim to vanc and lasix was held. Cr trended downward and patient maintained good urine output through replaced nephrostomy. Post-operatively, patient was found to have hematuria (as stated above), that resolved. His Cr elevated again, thought to be secondary to blood loss from surgery and ATN. Patient maintained good urine output and Cr trended downward. Cr on discharge was 1.9. Lasix was restarted prior to discharge. . #. Anemia: Managed with blood transfusion as stated above. Patient was not restarted on his home aranesp. - Check weekly hematocrit; Transfuse 1u pRBC if hct <25 Medications on Admission: lipitor 40 aranesp q2 weeks proscar 5 lasix 20 daily metoprolol 25 [**Hospital1 **] MVI lidocaine patch advil 600mg [**Hospital1 **] prn tylenol #3 prn Discharge Disposition: Extended Care Facility: [**Hospital1 10283**] Center - [**Location (un) **] Discharge Diagnosis: Primary: Metastatic Bladder Cancer to the bone Discharge Condition: Stable Discharge Instructions: You were seen in the hospital because of your leg pain. We saw that you had bone destruction to your femur which was causing your leg pain. You agreed to have surgery for this problem. We made the following changes to your medications: 1. We are treating your pain with tylenol, lidocaine patch, and morphine. You do not need to take tylenol #3. 2. We started you on senna, colace, biscodyl, mylanta 3. We started you on omeprazole 4. We did not continue your aranesp, please talk to your physician before restarting this. If you experience fevers >101, worsening pain, nausea, vomiting, or any concerning symptoms please contact your PCP. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 5322**] on [**2121-1-9**] at 1:40pm. She is on the [**Location (un) 1773**] of the [**Hospital Ward Name 23**] Building [**Hospital Ward Name 516**]. Her number is ([**Telephone/Fax (1) 2007**]. [**First Name4 (NamePattern1) 2946**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 3218**] Completed by:[**2120-12-24**]

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icd9cm

[ [ [] ] ]

[ "81.52", "55.93" ]

icd9pcs

[ [ [] ] ]

9217, 9295

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294, 320

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4378, 5713

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3586, 3590

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9419, 9629

3605, 4359

9658, 10065

224, 256

348, 1195

3065, 3415

3431, 3570

22,442

116,608

27084

Discharge summary

report

Admission Date: [**2149-1-3**] Discharge Date: [**2149-1-8**] Date of Birth: [**2095-9-22**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1711**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: intubation History of Present Illness: 53 yo male with history of CHF EF 40%, HTN, HLD, PAF, tobacco abuse, COPD, PE, severe PVD with SFA and B/L iliac stents and medication noncomplicance. He also underwent DCCV on [**2148-1-3**] orning and started on amiodarone (despite prior LFT elevations with amiodarone). He presented with chest pain [**2147-4-5**] of sudden onset while at the store doing some shopping; he also developed shortness of breath at that time. The patient states that the pain is pleuritic in nature. Otherwise the patient does not have any leg swelling. Pain not worse with exertion. Otherwise no abdominal pain, fevers, chills, cough, sputum. Pain not worse with exertion. Otherwise no abdominal pain, fevers, chills, cough, sputum. . He was recently admitted [**Date range (1) 66521**] for Afib with RVR and chest pain. He ruled in for NSTEMI felt to be demand from hypertensive urgency (SBP 200/100's) and RVR. Consideration was given to AVJ ablation and pacemaker placement as well but he remained in sinus rhythm after DCCV and amiodarone initiation. Also treated with a course of levofloxacin for pneumonia, and treated for a CHF exacerbation. He was also started on dabigatran. There was also some question if he was having intermittent short runs of VT vs Afib with aberrancy.Furthermore, this morning he had undergone Successful electrical cardioversion of atrial fibrillation to sinus rhythm. . ED Course (labs, imaging, interventions, consults): - Initial Vitals/Trigger: Pain-7 98.5 73 182/103 20 93% RA - EKG: sr 69, lad/no ST/TW changes. [x] cxr - unremarkable. [x] asa [x] [**Hospital Unit Name **] attending: give lasix 120 mg iv, admit Admission Vitals: Pulse: 63, RR: 21, BP: 166/87, O2Sat: 94 2L PIV: 18 g x1. CTA not done due to elevated creatinine. . On arrival to the floor, patient complained of mild chest pain, which was unchanged from his initial presentation, and was relieved with morphine. He had no other active complaints. His blood pressures continued to go up to about 200/100, therefore he was started on a nitro drip. . At about 7 am, he desatted to 70s, was given atrovent nebs, and became unresponsive. A code blue was called. BP 220s/110s. ABG 7.02/109/113. Lactate 5.5. IV lasix/NTG started, and pt emergently intubated. During the code, he was also noted to have some bleeding out of his left ear, and his pupils were noted to be unequal He was intubated and transferred to the ICU. In the CCU, initial vitals were 174/93, 113, 22, 99% on [**10-8**] 70% FiO2. He became responsive, and was orientated x3. Pupils were equal. Continues to complain of left-sided mild chest pain, no worse than prior. He was started on fenatyl/ midazolam. His blood pressures started dropping, nitroglycerin drip was stopped. However, BP plateaued at 85 systolic, and are currently stable at around 110 systolic. . REVIEW OF SYSTEMS: + -fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: Atrial fibrillation with RVR s/p multiple DCCV, most recently on [**12-11**] now on dabigatran and amio; has hx of poor rate control partly due to noncompliance with meds -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: None -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: PE ([**2138**]); unknown cause CHF PVD s/p Aortoiliac bifurcation stents SFA [**2147-7-28**] and CIA [**2147-2-10**] Small Infarenal AAA Scoliosis Tobacco abuse (1 1/2 packs daily)- Interested in quitting smoking Heroin abuse Social History: -Tobacco history: 1.5 ppd for >30 years -ETOH: Used to drink 10 beers per day. Now does not take any. -Illicit drugs: Snorts every other day. Otherwise, no illicits. He is married, working as a night crew clerk. Family History: Father: Leukemia Mother: emphysema, CHF Mother died from CHF. Physical Exam: On admission: Gen: Intubated, calm, NAD HEENT: No conjunctival pallor. No icterus. MMM. OP clear. Otoscopic examination: tympanic membranes both clear. NECK: Supple, No LAD. Normal carotid upstroke without bruits CV: Irreg/Irreg. Normal S1,S2. No murmurs. LUNGS: CTAB. No wheezes, rales, or rhonchi. Reduced air entry bilaterally. ABD: NABS. Soft, NT, ND. EXT: WWP, NO CCE. Full distal pulses bilaterally. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Grossly non-focal. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . At discharge: Vitals: 97.9/97.9 HR:57-60 BP:160-168/88-101 RR:18 02 sat:97% RA 53 yo M in no acute distress, sitting in chair HEENT: mucous membs moist, no lymphadenopathy, JVP non elevated CHEST: CTABL no wheezes, no rales, no rhonchi CV: S1 S2 Normal in quality and intensity RRR, 2/6 systolic murmur at right upper sternal border. ABD: soft, non-tender, non-distended, BS normoactive. EXT: wwp, no edema. DPs, PTs 2+. NEURO: 5/5 strength in U/L extremities. gait WNL. SKIN: no rash PSYCH: a/o, pleasant, conversant Pertinent Results: [**2149-1-3**] 09:03PM BLOOD WBC-12.4* RBC-4.29* Hgb-12.1* Hct-36.5* MCV-85 MCH-28.2 MCHC-33.2 RDW-15.3 Plt Ct-263 [**2149-1-4**] 10:59AM BLOOD WBC-19.8*# RBC-4.09* Hgb-11.4* Hct-34.8* MCV-85 MCH-27.9 MCHC-32.8 RDW-15.4 Plt Ct-256 [**2149-1-5**] 05:03AM BLOOD WBC-8.5# RBC-4.02* Hgb-11.3* Hct-33.6* MCV-84 MCH-28.1 MCHC-33.6 RDW-15.2 Plt Ct-181 [**2149-1-6**] 06:34AM BLOOD WBC-8.4 RBC-4.10* Hgb-11.6* Hct-35.0* MCV-86 MCH-28.4 MCHC-33.2 RDW-15.4 Plt Ct-194 [**2149-1-7**] 06:20AM BLOOD WBC-8.0 RBC-4.19* Hgb-11.8* Hct-35.3* MCV-84 MCH-28.1 MCHC-33.3 RDW-15.4 Plt Ct-208 [**2149-1-3**] 09:03PM BLOOD Neuts-68.5 Lymphs-23.5 Monos-3.3 Eos-3.8 Baso-1.0 [**2149-1-7**] 06:20AM BLOOD Neuts-62.5 Lymphs-25.4 Monos-4.9 Eos-5.9* Baso-1.3 [**2149-1-3**] 09:03PM BLOOD PT-15.8* PTT-87.1* INR(PT)-1.5* [**2149-1-3**] 09:03PM BLOOD Plt Ct-263 [**2149-1-3**] 10:30PM BLOOD PT-15.9* PTT-90.5 INR(PT)-1.5* [**2149-1-4**] 10:59AM BLOOD PT-13.6* PTT-65.5* INR(PT)-1.3* [**2149-1-4**] 10:59AM BLOOD Plt Ct-256 [**2149-1-5**] 05:03AM BLOOD Plt Ct-181 [**2149-1-6**] 06:34AM BLOOD PT-14.6* PTT-77.3* INR(PT)-1.4* [**2149-1-6**] 06:34AM BLOOD Plt Ct-194 [**2149-1-7**] 06:20AM BLOOD Plt Ct-208 [**2149-1-3**] 09:03PM BLOOD Glucose-114* UreaN-26* Creat-1.3* Na-141 K-4.3 Cl-106 HCO3-24 AnGap-15 [**2149-1-4**] 10:59AM BLOOD Glucose-124* UreaN-26* Creat-1.9* Na-143 K-3.8 Cl-105 HCO3-26 AnGap-16 [**2149-1-4**] 07:51PM BLOOD UreaN-27* Creat-1.8* Na-145 K-3.2* Cl-103 [**2149-1-5**] 05:03AM BLOOD Glucose-98 UreaN-23* Creat-1.5* Na-145 K-3.1* Cl-104 HCO3-28 AnGap-16 [**2149-1-5**] 04:49PM BLOOD Glucose-101* UreaN-26* Creat-1.4* Na-144 K-3.7 Cl-104 HCO3-28 AnGap-16 [**2149-1-6**] 06:34AM BLOOD Glucose-116* UreaN-24* Creat-1.3* Na-145 K-3.5 Cl-106 HCO3-28 AnGap-15 [**2149-1-6**] 02:45PM BLOOD UreaN-26* Creat-1.5* Na-146* K-3.5 Cl-104 HCO3-28 AnGap-18 [**2149-1-7**] 06:20AM BLOOD Glucose-110* UreaN-25* Creat-1.2 Na-140 K-3.3 Cl-101 HCO3-27 AnGap-15 [**2149-1-4**] 03:40AM BLOOD CK(CPK)-51 [**2149-1-4**] 10:59AM BLOOD CK(CPK)-57 [**2149-1-3**] 09:03PM BLOOD proBNP-1870* [**2149-1-3**] 09:03PM BLOOD cTropnT-<0.01 [**2149-1-4**] 03:40AM BLOOD CK-MB-2 cTropnT-<0.01 [**2149-1-4**] 10:59AM BLOOD CK-MB-3 cTropnT-0.02* [**2149-1-4**] 10:59AM BLOOD Calcium-8.8 Phos-5.7*# Mg-2.2 [**2149-1-4**] 07:51PM BLOOD Mg-2.0 [**2149-1-5**] 05:03AM BLOOD Calcium-8.8 Phos-3.3# Mg-2.1 [**2149-1-6**] 06:34AM BLOOD Mg-2.2 [**2149-1-6**] 02:45PM BLOOD Mg-2.3 [**2149-1-7**] 06:20AM BLOOD Calcium-9.5 Phos-4.2 Mg-2.1 [**2149-1-4**] 07:35AM BLOOD Type-ART pO2-113* pCO2-109* pH-7.02* calTCO2-30 Base XS--6 Intubat-NOT INTUBA [**2149-1-4**] 11:51AM BLOOD Type-ART pO2-149* pCO2-44 pH-7.40 calTCO2-28 Base XS-2 [**2149-1-3**] 09:06PM BLOOD K-4.4 [**2149-1-4**] 07:35AM BLOOD Glucose-268* Lactate-5.5* Na-146* K-4.0 Cl-101 [**2149-1-4**] 11:51AM BLOOD Lactate-1.0 [**2149-1-4**] 07:35AM BLOOD Hgb-13.8* calcHCT-41 O2 Sat-94 COHgb-2 MetHgb-0 [**2149-1-4**] 07:35AM BLOOD freeCa-1.36* . Discharge labs: [**2149-1-8**] 06:20a 140 104 21 102 AGap=14 3.6 26 1.1 Comments: Glucose: If Fasting, 70-100 Normal, >125 Provisional Diabetes Mg: 2.3 6.9>12.1/35.8<212 [**2149-1-3**] CXR Slight vascular prominence with peribronchial cuffing, but otherwise unremarkable. . [**2149-1-4**] Echocardiogram The left atrium is moderately dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is mild to moderate regional left ventricular systolic dysfunction with basal to mid inferior and inferolateral hypokinesis. The other segments are very mildly hypokinetic. Right ventricular chamber size is normal. with borderline normal free wall function. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2148-12-2**], the right ventricle is probably mildly hypokinetic on the current study. Overall LV systolic dysfunction has worsened. . [**2149-1-4**] Echocardiogram AP radiograph of the chest was reviewed in comparison to [**1-3**], [**2148**]. The ET tube tip is 5 cm above the carina. The NG tube tip is in the stomach. There is interval development of moderate interstitial pulmonary edema. Note is made that the left costophrenic angle was excluded from the field of view but small bilateral pleural effusions cannot be excluded. Findings discussed with Dr. [**First Name (STitle) 17385**] over the phone by Dr. [**Last Name (STitle) **] at 10:20 a.m. on [**2149-1-4**]. Brief Hospital Course: 53 yo male with history of CHF EF 40%, HTN, HLD, PAF, tobacco abuse, COPD, PE, severe PVD with SFA and B/L iliac stents and medication noncomplicance, and cardioversion this morning, who presented with chest pain [**2147-4-5**] of sudden onset while at the store doing some shopping, s/p code blue in hosptial for hypoxia and unresponsiveness. . # Hypoxia/flash pulmonary edema: S/p pulmonary edema and respiratory arrest [**2149-1-4**] with hypoxemia and unresponsiveness, intubated and then extubated 7 hours later. We diuresed him with furosemide, then transitioned him to his home lasix dose. He rapidly became euvolemic, had good oxygen saturation and respiration, and was stable prior to dishcarge. . # HTN: Workup for secondary causes negative. Pt has strong family history. Medication compliance an issue in the past, pt states he has no cost issues now and takes his medicines regularly. Has BP cuff at home. Goal BP 120-140. High this am before meds. We continued carvedilol, lisinopril and amlodipine. . #Atrial fibrillation - He was in sinus rhythm during this hospitalization. then started on amiodarone. At the time of discharge he had cardioverted, in sinus with some bradycardia to the high 40s. Planned amiodarone schedule: 200mg [**Hospital1 **] ([**2148-1-3**]), then 200mg daily maintenance starting [**1-9**]. He will also continue carvedilol and pradaxa. . #Acute on Chronic Systolic CHF ?????? EF was mildly depressed from previous TTE, however recently s/p cardioversion for afib. We continued carvedilol, lisinopril and lasix. He was euvolemic at the time of discharge. . #[**Last Name (un) **] ?????? baseline 1-1.2. Elevation to 1.9 likely in the setting of flash pulmonary edema/respiratory arrest with poor forward flow. We continued gentle diuresis until he was euvolemic. His [**Last Name (un) **] had resolved and his creatinine was trending down at the time of discharge. Medications on Admission: 1. clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 2 days: [**2066-12-25**]. Disp:*6 Capsule(s)* Refills:*0* 2. carvedilol 12.5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 3. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 4. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 6. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. diazepam 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 9. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day. 10. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). Disp:*30 Capsule, Extended Release(s)* Refills:*2* 11. amiodarone 100 mg Tablet Sig: Four (4) Tablet PO twice a day: Take 400mg twice daily [**12-26**], 300mg twice daily [**Date range (1) 66523**], 200mg twice daily [**Date range (1) 33500**], then 200mg daily starting [**1-9**]. Disp:*120 Tablet(s)* Refills:*0* Discharge Medications: 1. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. 4. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 8. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day. 9. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Imdur 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 11. diazepam 5 mg Tablet Sig: One (1) Tablet PO PRN as needed for anxiety. Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Acute on Chronic systolic congestive heart failure with respiratory arrest Atrial fibrillation s/p cardioversion Hypertension, poorly controlled Leukocytosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had high blood pressure after your cardioversion and developed flash pulmonary edema or congestive heart failure. You had to have a breathing tube inserted to help your breathe and you were given diuretics to get rid of the extra fluid. You will continue to take your lasix 80 mg daily at home. Your weight at discharge is 191 lbs. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 2 lbs in 1 day or 5 pounds in 3 days. You will have a home tele monitoring system set up at home that will check your weight, blood pressure, heart rate and oxygen level at home once a day. If you feel like your blood pressure is high at other times of the day, you can check it and if the blood pressure is higher than 150 (the top number) call the heartline or call your PCP (Dr. [**Last Name (STitle) 66517**]. When you are working nights, you should continue to take your medicines every 12 hours if possible and make sure that you take your twice a day medicines within a 24 hour period. We made the following changes to your medicines: -DECREASE the Amiodarone to 200mg daily -DECREASE your Carvedilol to 25 mg every 12 hours (was 37.5 mg) -ADD Imdur 30mg daily (long acting nitrate to help contol your blood pressure) Followup Instructions: Department: CARDIAC SERVICES When: TUESDAY [**2149-1-21**] at 2:40 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: FRIDAY [**2149-1-31**] at 12:30 PM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: FRIDAY [**2149-1-31**] at 2:00 PM With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2149-1-8**]

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icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

14454, 14537

10317, 12230

313, 325

14739, 14739

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3819, 4046

3456, 3524

4062, 4278

31,775

117,510

4459

Discharge summary

report

Admission Date: [**2161-6-8**] Discharge Date: [**2161-6-18**] Date of Birth: [**2108-10-2**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: [**2161-6-18**] ORIF left radius fracture History of Present Illness: 52 y/o female s/p fall approx [**6-27**] steps today with multiple injuries. No reported LOC. These injuries include a right orbital wall fracture, multiple rib fractures, and a possible left wrist fracture. She was taken to an area hospital and then transferred to [**Hospital1 18**] for further care. Past Medical History: Mental retardation HTN Hypothyroidism Right hip dislocation s/p fall 4 years ago Patellar dislocation and ORIF s/p fall Social History: Previously lived with her mother Family History: Noncontributory Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2161-6-18**] 07:20AM 9.7 2.97* 9.7* 28.9* 97 32.6* 33.5 14.8 262# BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**2161-6-18**] 07:20AM 262# Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2161-6-18**] 07:20AM 78 26* 1.6* 138 5.2* 103 28 12 ESTIMATED GFR (MDRD CALCULATION) estGFR [**2161-6-18**] 07:20AM CT HEAD W/O CONTRAST [**2161-6-8**] 2:47 PM IMPRESSION: 1. Right maxillary sinus, orbital floor, and zygomatic fractures, with hemorrhage, and displacement of fracture fragments into right maxillary antrum. These fractures, particularly those of the orbital floor and ZMC, are incompletely characterized, and might be further evaluated with dedicated maxillofacial CT, with coronal and sagittal reformations. 2. Laceration overlying left parietal bone, and soft tissue contusion with subcutaneous gas overlying right maxillary fracture. 3. No intracranial hemorrhage or other evidence of acute brain parenchymal injury. 4. Chronic small vessel infarction. RENAL U.S. [**2161-6-9**] 3:17 PM RENAL U.S. FINDINGS: The right kidney measures 9.6 cm. There is no hydronephrosis and no stones or solid masses are identified in the right kidney. Note is made that the patient was unable to turn and therefore the left kidney was unable to be visualized on this exam. IMPRESSION: Unremarkable right kidney. Nonvisualization of the left kidney as described above. MR L SPINE W/O CONTRAST [**2161-6-12**] 4:43 PM IMPRESSION: Limited study secondary to motion. Old appearing compression injuries of T11 and T12 with minimal retropulsion and indentation on the thecal sac. Mild multilevel degenerative changes. Brief Hospital Course: She was admitted to the Trauma Service. Neurosurgery, Orthopaedics, and Plastics were consulted because of her injuries. Her spine injuries were managed non operatively; she was placed on a pain regimen and will follow up in 8 weeks with Dr. [**Last Name (STitle) **] for repeat spine imaging. Physical therapy was consulted early on to facilitate mobility. She was taken to the operating room on [**6-11**] by Orthopedics for open reduction internal fixation of left distal radius three-part fracture. A short cast was applied which patient removed during an episode of agitation; it was later decided that a long arm cast be applied. She will follow up in [**Hospital 5498**] clinic in 2 weeks. In the meantime she is to remain non weight bearing on her left arm. He orbital wall fracture was nonoperative; she was started on Clindamycin and has completed a 7 day course. She will follow up in [**Hospital 3595**] clinic in 2 weeks. Her home medications were restarted; including her Olanzapine at hs; standing doses of this were also initiated because of several episodes of agitation. She was placed on 1:1 sitter for safety reasons. She will need to follow up with her primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]e from rehab regarding an incidental finding on renal ultrasound. She is being recommended for short term rehab following acute hospitalization. Medications on Admission: Zyprexa 15 hs, Atenolol 50', Clonazepam 0.5', Imipramine 150hs, Benztropine 1', Depakote 1000', Synthroid 100', Colace 100' Discharge Medications: 1. Olanzapine 5 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 2. Imipramine HCl 25 mg Tablet Sig: Six (6) Tablet PO HS (at bedtime). 3. Benztropine 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**4-26**] hours as needed for pain. 7. Divalproex 500 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day). 9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 10. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) NEB Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 12. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for increased sedation. 13. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's PO twice a day as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: s/p Fall INJURIES: 1) Left distal radius fracture - ORIF [**6-11**] 2) C7-T1 transverse process fx, T12/L1 compression fx 3) Right 5th rib fracture 4) Right orbital floor fracture 5) Scalp laceration Discharge Condition: Good Followup Instructions: Follow up in [**Hospital 5498**] Clinic with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in 2 weeks, call [**Telephone/Fax (1) 1228**] for an appointment. Follow up in 2 weeks with Dr. [**Last Name (STitle) **] [**Last Name (STitle) 159**], for the left renal mass; call [**Telephone/Fax (1) 921**] for an appointment. Follow up in 8 weeks with Dr. [**Last Name (STitle) **], Neurosurgery for your spine fractures. Call [**Telephone/Fax (1) 1669**] for an appointment. Inform the office that you will need flex/ext films for this appointment. Completed by:[**2161-6-18**]

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icd9cm

[ [ [] ] ]

[ "79.32" ]

icd9pcs

[ [ [] ] ]

5541, 5620

2717, 4115

322, 366

5865, 5872

946, 2694

5895, 6497

908, 925

4291, 5518

5641, 5844

4141, 4268

274, 284

394, 698

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9,384

187,655

45752

Discharge summary

report

Admission Date: [**2106-11-7**] Discharge Date: [**2106-11-15**] Date of Birth: [**2046-11-22**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 59-year-old man with known CAD, status post stent in [**2098**] to the LAD. He reports a several month history of dyspnea on exertion and exertional angina. Stress test done on [**10-26**] was stopped after the patient experienced angina and it showed a moderately reversible perfusion defect of the anterior wall. He was then referred for cardiac catheterization, which showed two-vessel coronary disease, 90 percent left main and 80 percent left circumflex. An intra-aortic balloon pump was placed at that time. PAST MEDICAL HISTORY: The patient's past medical history is significant for diabetes mellitus, neuropathy, hypertension, CAD, chronic renal insufficiency, GERD, Barrett's esophagus, appendectomy, left arm fistula and status post a renal transplant done in [**2101**]. ALLERGIES: He states an allergy to cyclosporin, which causes hematuria. SOCIAL HISTORY: He lives in [**Location **] with his wife. [**Name (NI) **] is retired. Remote tobacco use, quit 12 years ago. No alcohol use. MEDICATIONS PRIOR TO ADMISSION: 1. Actos 45 daily. 2. Lipitor 40 daily. 3. Imdur 120 daily. 4. Toprol 100 b.i.d. 5. Tricor 160 daily. 6. Prilosec 40 daily. 7. Prednisone 5 daily. 8. CellCept [**Pager number **] b.i.d. 9. Lasix 80 t.i.d. 10. Allopurinol 100 daily. 11. Neupogen 4,000 every Monday, Wednesday and Friday. 12. Humulin 60 units in the morning and 70 units at bedtime. 13. Humalog 50 units in the morning, 60 with dinner and a sliding scale as needed. 14. Aspirin 81 daily. 15. Fish oil 1 b.i.d. 16. Folic acid 1 b.i.d. 17. Co-enzyme 200 daily. 18. Coral calcium 1500 two times per week. 19. Fosamax 70 once a week. 20. Metamucil t.i.d. 21. Aldactone 25 daily. 22. Melatonin 3 daily. 23. Valium 5 p.r.n. 24. Trazodone 50 at bedtime. PHYSICAL EXAMINATION: Height 6 feet, 1 inch. Weight 265 pounds. VITAL SIGNS: Heart rate 69 sinus rhythm, blood pressure 136/73, respiratory rate 18, O2 sat 98 percent on room air. GENERAL: Flat in bed in no acute distress. NEURO: Alert and oriented times three, moves all extremities, follows commands. NECK: supple with no carotid bruits. RESPIRATORY: Clear to auscultation. CARDIOVASCULAR: Regular rate and rhythm, S1, S2 with no murmur. Intra-aortic balloon pump at 1:1. GI: Soft, nontender, nondistended with normoactive bowel sounds. EXTREMITIES: Warm and well-perfused with no edema and no varicosities. LABORATORY DATA: White count 8.5, hematocrit 27.3, platelets 317, PT 13.5, PTT 24.1, INR 1.2, sodium 137, potassium 3.0, chloride 96, CO2 28, BUN 65, creatinine 3.4, glucose 114, ALT 14, AST 13, alk phos 66, amylase 96, total bilirubin 0.4, albumin 4.1. The patient was accepted for coronary artery bypass grafting and on [**11-9**], he was brought to the Operating Room. Please see the OR report for full details. In summary, the patient had a CABG times two with a LIMA to the LAD and a saphenous vein graft to the OM as well as an ASD repair. His bypass time was 80 minutes with a cross clamp time of 54 minutes. He tolerated the operation well and was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit. At the time of transfer the patient was AV paced at 80 beats per minute with a mean arterial pressure of 96 and a CVP of 17. He had propofol at 20 mcg/kg/minute. The patient did well in the immediate postoperative period. His anesthesia was reversed. He was weaned from the ventilator and successfully extubated. He remained stable throughout the operative day. On postoperative day one, the patient continued to be hemodynamically stable. His intra-aortic balloon pump was weaned and ultimately discontinued. Throughout that period, the patient remained hemodynamically stable, requiring only nitroglycerin to control his blood pressure. Following balloon pump removal, the patient was started on Lasix. He was mobilized to out of bed and his chest tubes were then removed. The patient was noted to have periods of atrial fibrillation and was begun on amiodarone. On postoperative day two, the patient remained hemodynamically stable. He was weaned from all cardioactive IV medications, transitioned to oral medicines and transferred to the floor for continuing postoperative care and cardiac rehabilitation. Over the next several days, the patient had an uneventful postoperative course. His activity level was increased with the assistance of the nursing staff as well as the physical therapy staff. His medications were adjusted to maintain adequate blood pressure control and to optimize diuresis. On postoperative day six, it was decided that the patient was stable and ready to be discharged to home. At the time of this dictation the patient's physical exam is as follows: Temperature 98.7, heart rate 66 sinus rhythm, blood pressure 152/63, respiratory rate 20, O2 sat 96 percent on room air. Weight preoperatively 120 kg, at discharge 127 kg. LABORATORY DATA: hematocrit 27.1, sodium 138, potassium 3.3, chloride 99, CO2 25, BUN 61, creatinine 3.3, glucose 119. NEUROLOGICALLY: Alert and oriented times three, moves all extremities, follows commands, nonfocal exam. PULMONARY: Clear to auscultation bilaterally. CARDIAC: Regular rate and rhythm, S1, S2, no murmur. Sternum is stable, incision with Steri-Strips, no erythema or drainage. ABDOMEN: soft, nontender, nondistended with normoactive bowel sounds. EXTREMITIES: Warm with 1 plus edema. Left saphenous vein graft harvest site with Steri-Strips open to air. CONDITION ON DISCHARGE: The patient's condition at time of discharge is good. Discharged to home with visiting nurses for follow up. FOLLOWUP: The patient is to see the [**Hospital 409**] Clinic in 2 weeks, Dr. [**Last Name (STitle) 7047**] or Dr. [**Last Name (STitle) **] in [**2-11**] weeks and Dr. [**Last Name (STitle) 70**] in 6 weeks. DISCHARGED DIAGNOSES: 1. Coronary artery disease, status post coronary artery bypass grafting times two with a LIMA to the LAD and saphenous vein graft to the OM as well as an ASD repair. 2. Diabetes mellitus. 3. Renal transplant. 4. Chronic renal insufficiency. 5. Hypertension. 6. Gastroesophageal reflux disease. 7. Barrett's esophagus. 8. Osteopenia. 9. Left AV fistula. 10. Appendectomy. 11. Rotator cuff surgery. MEDICATIONS AT TIME OF DISCHARGE: 1. Potassium chloride 20 mEq daily. 2. Colace 100 mg b.i.d. 3. Aspirin 81 mg daily. 4. Prednisone 5 mg daily. 5. CellCept [**Pager number **] mg b.i.d. 6. Epo 4000 units every Monday, Wednesday and Friday. 7. Niferex 150 mg daily. 8. Ascorbic acid 500 mg b.i.d. 9. Folate 1 mg daily. 10. Amiodarone 400 mg daily times 1 week, then 200 mg daily. 11. Tricor 160 mg daily. 12. Dilaudid 2 to 4 mg Q4-6 hours p.r.n. 13. Lasix 80 mg t.i.d. 14. Toprol 50 mg b.i.d. 15. Lipitor 40 mg daily. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**] Dictated By:[**Last Name (NamePattern4) 1718**] MEDQUIST36 D: [**2106-11-15**] 17:17:28 T: [**2106-11-15**] 22:08:21 Job#: [**Job Number 97484**]

[ "530.81", "V42.0", "272.4", "250.60", "784.2", "V58.65", "401.9", "285.9", "414.01", "530.85", "745.5", "733.90", "357.2", "V45.82", "411.1", "593.9" ]

icd9cm

[ [ [] ] ]

[ "37.61", "88.72", "88.56", "38.93", "97.44", "36.15", "39.61", "36.11", "37.22" ]

icd9pcs

[ [ [] ] ]

1240, 2035

2058, 5758

167, 716

739, 1060

1077, 1208

5783, 7367

32,715

108,075

3097

Discharge summary

report

Admission Date: [**2102-3-27**] Discharge Date: [**2102-4-8**] Date of Birth: [**2036-3-22**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: exertional angina Major Surgical or Invasive Procedure: [**4-3**] CABGx5 (LIMA>LAD,SVG>Diag,SVG>Ramus,SVG>OM,SVG>dRCA) History of Present Illness: 66 yo M with history of untreated prostate cancer x 11 years who presented to ED with chest pain. Past Medical History: prostate ca x 11 years, hyperlipidemia Social History: works as film director denies tobacco 5 glasses of wine/week Family History: father with MI at ages 48, 53 and 58 Physical Exam: HR 61 BP 120/72 NAD, flat after cath Lungs CTAB Heart RRR, no murmur Abdomen benign Extrem warm, no edema No varicose veins Pertinent Results: [**2102-4-8**] 06:50AM BLOOD WBC-6.6 RBC-3.30*# Hgb-10.1*# Hct-28.8*# MCV-87 MCH-30.5 MCHC-34.9 RDW-14.0 Plt Ct-243 [**2102-4-3**] 12:40PM BLOOD PT-14.6* PTT-38.8* INR(PT)-1.3* [**2102-4-8**] 06:50AM BLOOD Glucose-104 UreaN-21* Creat-1.2 Na-140 K-4.6 Cl-102 HCO3-31 AnGap-12 Neurophysiology Report EEG Study Date of [**2102-4-7**] OBJECT: STATUS POST CABG, NOW WITH VISUAL DISTURBANCES, RULE OUT SEIZURES. REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 14691**] FINDINGS: BACKGROUND: A well-formed 8 Hz posterior dominant rhythm was noted in wakefulness which attenuated appropriately with eye opening. The anterior to posterior voltage gradient was preserved. HYPERVENTILATION: Could not be performed. INTERMITTENT PHOTIC STIMULATION: Could not be performed. SLEEP: The patient progressed from the waking to drowsy state but did not attain stage II sleep during the recording. CARDIAC MONITOR: Showed a generally regular rhythm with an average rate of 84 beats per minute. IMPRESSION: This is a normal routine EEG in the waking and drowsy state. There were no areas of prominent focal slowing. There were no epileptic features. RADIOLOGY Final Report CHEST (PORTABLE AP) [**2102-4-6**] 8:02 AM CHEST (PORTABLE AP) Reason: eval for pleural effusions [**Hospital 93**] MEDICAL CONDITION: 66 year old man s/p CABG REASON FOR THIS EXAMINATION: eval for pleural effusions CHEST RADIOGRAPH INDICATION: Followup. COMPARISON: [**2102-4-4**]. As compared to the previous radiograph, the left-sided pleural effusion has minimally increased. On the right, there is no evidence of effusion. Unchanged retrocardiac atelectasis. No newly occurred parenchymal opacities suggestive of pneumonia. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**] Approved: [**Doctor First Name **] [**2102-4-6**] 10:53 AM INTERPRETED BY: [**Last Name (LF) **],[**First Name3 (LF) 7495**] B. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 14692**], [**Known firstname 5445**] [**Hospital1 18**] [**Numeric Identifier 14693**] (Complete) Done [**2102-4-3**] at 9:10:54 AM PRELIMINARY Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. Division of Cardiothoracic [**Doctor First Name **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2036-3-22**] Age (years): 66 M Hgt (in): 66 BP (mm Hg): 120/70 Wgt (lb): 150 HR (bpm): 70 BSA (m2): 1.77 m2 Indication: Intraoperative TEE for CABG ICD-9 Codes: 410.91, 786.05, 786.51, 440.0, 424.1 Test Information Date/Time: [**2102-4-3**] at 09:10 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], 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 #: 2008AW3-: Machine: [**Pager number 14694**] Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.6 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 55% >= 55% Aorta - Annulus: *3.1 cm <= 3.0 cm Aorta - Sinus Level: 3.4 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.9 cm <= 3.0 cm Aorta - Ascending: 3.4 cm <= 3.4 cm Aorta - Descending Thoracic: 2.1 cm <= 2.5 cm Findings LEFT ATRIUM: Normal LA size. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). Mildly thickened aortic valve leaflets. Mildly thickened aortic valve leaflets (3). Significant AR, but cannot be quantified. Eccentric AR jet directed toward the anterior mitral leaflet. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Pulmonic valve not well seen. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. See Conclusions for post-bypass data The post-bypass study was performed while the patient was receiving vasoactive infusions (see Conclusions for listing of medications). Conclusions PRE-BYPASS: 1. The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 5. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. The aortic valve leaflets are mildly thickened. The aortic valve leaflets (3) are mildly thickened. Significant aortic regurgitation is present, but cannot be quantified. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. 6. The mitral valve appears structurally normal with trivial mitral regurgitation. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine and was in normal sinus rhythm. 1. Regional and global left ventricular systolic function are normal. 2. Right ventricular systolic function is normal. 3. Valves are the same as noted pre-bypass. 4. Aortic contours are intact post-decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting physician Brief Hospital Course: He was admitted to cardiology. He ruled in for an NSTEMI. He refused cardiac catheterization and was started on heparin, [**Last Name (LF) 4532**], [**First Name3 (LF) **], metoprolol, and ACE-I and a statin. He underwent [**First Name3 (LF) **] test on [**3-29**] where he had ST changed with minimal exercise. He agreed to cardiac cath which showed moderate left main and severe 3 vessel disease. He was referred for cardiac surgery. His [**Month/Day (4) 4532**] was dc'd and he was started on heparin. He awaited [**Month/Day (4) 4532**] washout prior to being taken to the operating room on [**4-3**] where he underwent a CABG x5. He was transferred to the ICU in stable conditon. He was extubated post op. His chest tubes were dc'd and he was transferred to the floor on POD #1. Bladder scan post void showed 1 liter residual and foley was reinserted. He had a fever for which he was pancultured. He was evaluated by neurology for visual changes. Pacing wires removed on POD #3. Oncology also consulted. Beta blockade titrated and he was gently diuresed toward his preop weight. On POD#3 he complained of visual changes, seeing frames in front of his eyes, and neurology was consulted. He had an EEG which was negative and then underwent CTA of the head and neck as he did not want to have an MRI/MRA. The CTA was negative for CVA and he was instructed to follow up with Dr. [**First Name (STitle) **] from neurology as an outpatient. The visual changes improved and he was dischared to home on POD#5 in stable condition. Medications on Admission: ambien 5', [**First Name (STitle) **] 81', celebrex 200', diazepam 2.5', uroxatral 10', viagra prn Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 5. Uroxatral 10 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 6. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 8. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 5 days. Disp:*10 Packet(s)* Refills:*0* 9. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:*10 Tablet(s)* Refills:*0* 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital3 3765**] Hospice Program Discharge Diagnosis: CAD s/p CABG PMH: prostate ca x 11 years, hyperlipidemia Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower daily, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds for 10 weeks or driving until follow up with surgeon. Followup Instructions: Dr. [**Last Name (STitle) **] in 2 weeks Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9834**] [**Telephone/Fax (1) 14695**] 2 weeks Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] Provider: [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. Phone:[**Telephone/Fax (1) 127**] Date/Time:[**2102-5-10**] 10:30 Provider: [**Name Initial (NameIs) 10081**]/EXERCISE LAB Phone:[**Telephone/Fax (1) 1566**] Date/Time:[**2102-4-26**] 10:30 Completed by:[**2102-4-8**]

[ "788.20", "185", "596.8", "414.01", "410.71", "272.4", "401.9", "368.8", "780.6", "285.9" ]

icd9cm

[ [ [] ] ]

[ "99.04", "39.61", "36.15", "36.14", "88.56", "88.72", "39.64", "88.53", "37.22" ]

icd9pcs

[ [ [] ] ]

10465, 10532

7570, 9101

338, 403

10633, 10641

885, 2219

10959, 11493

688, 726

9250, 10442

2256, 2281

10553, 10612

9127, 9227

10665, 10936

741, 866

281, 300

2310, 7547

431, 530

553, 593

609, 672

28,238

122,378

50347

Discharge summary

report

Admission Date: [**2102-7-15**] Discharge Date: [**2102-7-18**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3556**] Chief Complaint: generalized weakness Major Surgical or Invasive Procedure: bilateral nephrostomy tube placement History of Present Illness: Pt is an 84 yo F w/ a hx of remote colon CA s/p resection and radiation, CAD s/p MI, recently diagnosed w/ metastatic ca of unknown primary. She presents feeling lethargic w/ poor PO intake for the past few days. She had been feeling unwell chronically, and had fallen last thursday, which worsened her overall state of health. She was initially taken to [**Location (un) 620**] ED and transferred to [**Hospital1 18**] after being found have a K of 6.3 and dilated small bowel on [**Last Name (un) **]. At [**Location (un) 620**], she was given Vanc/Cipro and Flatyl IV, as well as calcium gluconate IV, 1 amp of sodium bicarbonate, and 10 U IV regular insulin + D50. . On transfer to the [**Hospital1 18**] ED, her vitals were initially T 96.7 HR 100, BP 126/33, 94% on 3L. She remained afebrile and hemodynamically stable. He K was 7.2 with no EKG changes. Sh was given insulin and D50 x3. She was also given kayexalate 30 mL x1 initially, but had no bowel movements. She got a total 4.5 L IV NS. . On arrival to the floor, she was stable, afebrile, and not c/o pain. She was tired and not answering many questions. Her daughter accompanied her and confirmed the brief above hx. Immediately after arriving to the floor, she had a large, loose, green bowel movement. Past Medical History: PAST MEDICAL HISTORY: 1. Colorectal cancer - [**2073**] Status post treatment with resection and adjuvant radiation. 2. CAD status post MI 3. Squamous cell carcinoma of the bilateral lower extremities - The patient underwent excision of a squamous cell cancer on the right in 4/[**2102**]. She underwent excision of a squamous cell cancer with skin grafting on the left in 1/[**2102**]. 4. Osteoarthritis 5. Natural fusing of the neck resulting in chronic pain PAST SURGICAL HISTORY: 1. Status post resection of colorectal cancer - [**2073**] 2. Status post bilateral total hip replacement - [**2077**] and [**2084**] 3. Status post resection of squamous cell cancers 4. Status post hysterectomy for fibroids - [**2054**] A small portion of one ovary was left. Social History: SOCIAL HISTORY: The patient is married and lives with her husband. They divide their time between a single family home in [**State 108**] during the winter and an apartment in [**Location (un) 620**] during the summer. Although there are living space is on one floor, she has three stairs outside to reach her apartment. The patient has three children who live in [**Location (un) 511**] and are involved in her care. She reports smoking cigarettes for three months in her early 30, but no tobacco use since that time. No alcohol. She has been utilizing a cane since her recent illness. She reports that she feels safe at home. Family History: FAMILY HISTORY: The patient reports her father died of lung cancer. Her mother had dementia. She is an only child. Physical Exam: Vitals: T: 96.6 BP: 93/58 P: 90 RR 18 O2 sat: 97% on 2L . Gen: pt moaning, looking uncomfortable HEENT: clear OP, MMM, dry skin around mouth Neck: supple, no LAd, no JVD CV: RR, nl rate, NL S1/s2, no m/r/g Pulm: crackles at bases, BSBL, no wheezes or rhonchi abd: distended, + fluid wave, mildly tender throughout, no rebound +BS ext: 2+ edema, 2+ DP bulses BL skin: stage II pressure ulcer on buttock neuro: [**1-11**]+ reflexes, equal BL. gait assessment deferred. difficulty w/ concentration (not answering questions appropriately) Pertinent Results: cbc [**2102-7-15**] 03:30PM BLOOD WBC-23.0*# RBC-3.65* Hgb-10.1* Hct-30.4* MCV-83 MCH-27.7 MCHC-33.3 RDW-15.1 Plt Ct-123*# [**2102-7-16**] 03:04AM BLOOD WBC-20.9* RBC-3.92* Hgb-10.7* Hct-33.3* MCV-85 MCH-27.4 MCHC-32.3 RDW-14.9 Plt Ct-114* [**2102-7-17**] 01:47AM BLOOD WBC-23.7* RBC-3.25* Hgb-9.2* Hct-26.6* MCV-82 MCH-28.3 MCHC-34.5 RDW-15.2 Plt Ct-124* [**2102-7-15**] 03:30PM BLOOD Neuts-85* Bands-2 Lymphs-5* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-3* . coags [**2102-7-15**] 03:30PM BLOOD PT-14.1* PTT-27.4 INR(PT)-1.2* . chem-10: [**2102-7-15**] 03:30PM BLOOD Glucose-92 UreaN-166* Creat-7.6*# Na-131* K-6.3* Cl-88* HCO3-17* AnGap-32* [**2102-7-17**] 01:47AM BLOOD Glucose-137* UreaN-152* Creat-6.4* Na-137 K-4.3 Cl-89* HCO3-26 AnGap-26* [**2102-7-15**] 03:30PM BLOOD Calcium-9.6 Phos-7.4*# Mg-3.0* [**2102-7-17**] 01:47AM BLOOD Calcium-8.0* Phos-7.1* Mg-2.4 . LFTs [**2102-7-15**] 10:10PM BLOOD ALT-19 AST-20 LD(LDH)-214 AlkPhos-137* TotBili-0.8 . Cardiac enzymes [**2102-7-15**] 03:30PM BLOOD cTropnT-0.01 [**2102-7-15**] 03:30PM BLOOD CK(CPK)-29 . Miscellaneous Tests [**2102-7-16**] 09:38AM BLOOD Hapto-379* [**2102-7-15**] 10:10PM BLOOD TSH-0.76 [**2102-7-15**] 03:49PM BLOOD Lactate-1.6 K-6.2* [**2102-7-16**] 09:54AM BLOOD Lactate-2.3* . ABGs [**2102-7-16**] 05:16AM BLOOD Type-ART pO2-104 pCO2-39 pH-7.35 calTCO2-22 Base XS--3 [**2102-7-16**] 09:54AM BLOOD Type-[**Last Name (un) **] pO2-84* pCO2-47* pH-7.32* calTCO2-25 Base XS--2 . Microbiology: . Blood cx's:(Final [**2102-7-18**]): Blood Culture, Routine KLEBSIELLA PNEUMONIAE. . Urine cx: [**2102-7-16**] 5:55 pm URINE NEPHROSTOMY TUBE. ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. . Radiology Imaging: CT Abd/Pelvis ([**2102-7-15**]): INDICATION: 84 year old with history of carcinomatosis, abdominal pain and renal failure. . COMPARISON: CT dated [**2102-5-18**] from outside hospital, [**Hospital 104955**] Medical Imaging. PET CT dated [**2102-7-6**] which demonstrated abnormal uptake in the anterior abdomen and pelvis concerning for peritoneal carcinomatosis and the proximity of the uptake in the pelvis to the prior colon resection site was concerning for recurrence of colon carcinoma. . TECHNIQUE: MDCT acquired images were obtained through the abdomen and pelvis without administration of intravenous contrast. Oral contrast was administered. . CT ABDOMEN: Heart size is within the upper limits of normal. The lung bases demonstrate mild bibasilar atelectasis and trace pleural effusions. . An enteric catheter is present with its tip coursing through the esophagus into the mid stomach. The liver is grossly unremarkable. Abdominal ascites has decreased. The gallbladder is somewhat distended without evidence of pericholecystic fluid or gallstones to suggest acute cholecystitis. The pancreas and spleen are grossly unremarkable. The adrenals are unremarkable. Both kidneys have increased in size since prior exam. There is marked right hydroureteronephrosis that is increased since the prior study. There is no evidence of stone or mass on the right. The left kidney has also increased in size without evidence of hydronephrosis, stone or mass. The increase in renal size is thought to be secondary to obstruction caused by the pelvic mass and or pelvic carcinomatosis. . There is a small amount of mesenteric fluid, decreased somewhat since prior exam. The small bowel is somewhat dilated but does contain contrast proximal to the pelvic resection site. Small bowel does not fill with contrast distal to the resection site and the small bowel segments seem somewhat tethered at the resection site, which may be secondary to adhesions. These findings could represent an evolving small bowel obstruciton. . There is an ill-defined mass in the pelvis adjacent to multiple clips, which is markedly obscured by streak artifact from bilateral hip prostheses, and is concerning for tumor recurrence. Colon does not appear dilated. Cecum and ascending colon appears mildly thickened, and there appears to be soft tissue thickening in the right lower quadrant adjacent to the region of prior resection, concerning for carcinomatosis and or tumor recurrence. . CT PELVIS: Evaluation is markedly limited by bilateral hip prostheses. There is increased amorphous soft tissue density in the pelvis adjacent to surgical clips with adjacent small bowel wall thickening and colonic wall thickening suggestive of increased carcinomatosis. . BONE WINDOWS: Degenerative changes throughout the thoracolumbar spine without evidence of acute fracture or malalignment. Grade 1 anterolisthesis of L4 on L5 is noted. . IMPRESSION: 1. Findings concerning for evolving small-bowel obstruction. 2. Progressive peritoneal carcinomatosis; concerning soft tissue mass/thickening adjacent to surgical clips in pelvis, partially obscured by streak artifact from hip prostheses. 3. Right hydroureteronephrosis and increased size of kidneys bilaterally. There may be developing obstruction of both kidneys related to pelvic mass/ carcinomatosis. . CXR: ([**2102-7-17**]) IMPRESSION: Bibasal opacities/aspiration atelectasis. Infectious process cannot be excluded. Dilated upper mediastinum most likely related to volume overload and asymmetric position of the patient. Evaluation with symmetric radiograph is recommended. Brief Hospital Course: Pt is an 84 you F w/ a history of remote colon CA and recent dx of metastatic cancer in the abdomen (unknown primary) who presents w/ a partial large bowel obstruction and hyperkalemia 2' to acute post obstructive renal failure. Given her multiple medical co-morbidities and poor cancer prognosis, the family chose to change the patient's code status from FULL to DNR/DNI/CMO and she expired on [**2102-7-18**] due to cardiopulmonary arrest. . Hyperkalemia. The maximum K was 7.2. She was given Calc gluconate at OSH and insulin and D50 x4, and Kayexelate 30 ml x1. She had an EKG on admission with peaked T waves. Sh did have bowel movements on the floor. EKG and Ks were checked frequently (q4-8H.). Renal was consulted for dialysis, but they did not recommend any, given at the time of consult the family was interested in comfort measures only. She was given insulin, IVFs, and kayexelate as needed. All these meds were discontinued when the code status was changed to DNR/DNI/CMO. . ARF: Her baseline Cre was 1.0, was 7.2 on admission. The etiology was likely post-renal given the obstructing pelvic masses and the fact that her U/O was less than 200 ccs on the first few hours of admission. Urology was consulted, and their recommendation was not to place a stent, which would most likely fail. IR placed bilateral nephrostomy tubes which resulted in less than desired u/o, but allowed resolution of hyperkalemia to ~4.3. Paracentesis was considered to aid in decompressing ureter, but was not performed because the nephrostomy tubes were placed w/ good effect. . Partial large bowel obstruction. She was suspected to have a partial LBO 2' to her hx of bowel surgery for Colon CA and her new pelvic masses. Pt was reported to have a BO on OSH KUB, and had not have bowel movements x2-3 days at home. No vomiting. CT on admission was c/f evolving SBO (areas of adhesion near the resection site), and also noted the new pelvic mass and some abdominal thickening in the RLQ adjacent to the resection site c/f new cancer formation/carcinomatosis. She began having bowel movements on the floor. She was kept NPO w/ IVFs. Surgery was consulted and did not recommend any invasive surgical procedures beyond the IR nephrostomy tube placement. She was given an aggressive bowel regimen of standing colace and senna w/ kayexelate, lactulose, and enemas PRN. All these meds were discontinued when the code status was changed to DNR/DNI/CMO. . Leukocytosis. Pt had UTI (final read E. coli) and urosepsis (Klebsiella). WBC never resolved during hospital admission despite broad spectrum abx (Flagyl, Vancomycin, Levoquin => Cipro after speciation of UTI pathogen). All these meds were discontinued when the code status was changed to DNR/DNI/CMO. . Metastatic Carcinoma of Unknonw primary: s/p first round of Carboplatin/Paclitaxel on [**7-4**]. Had planned to have chemotherapy every 3 weeks. Given her multiple medical morbidities, oncology assessment was that prognosis was poor and no chemotherapy was administered while inpatient. . Anemia: Hct of 26.6 dropped from 33.3 on admission. No transfusion given as dnr/dni/cmo. . Back pain: chronic back pain, worsening. Given percocet elixer as needed. Once dnr/dni/cmo, pt was given IV morphine 2-10 mg q2H:PRN for comfort. . FEN: NPO, electrolytes repleted, IFVs. All labs and IVFs were stopped w/ dnr/dni/cmo change in code status. . PPX: heparin sc, pneumoboots. All stopped w/ change in code status. . access: pivs. Kept in place for administration of morphine. . Code: initially full, changed to dnr/dni/cmo on [**2102-7-17**]. Pt expired on [**2102-7-18**] at 10:03 AM 2' to cardiopulmonary arrest. . Medications on Admission: ACETAMINOPHEN-CODEINE [TYLENOL-CODEINE #3] - 300 mg-30 mg Tablet - [**1-11**] Tablet(s) by mouth every four (4) hours as needed for pain DEXAMETHASONE - 4 mg Tablet - 5 Tablet(s) by mouth take the night before and the morning of chemotherapy LORAZEPAM [ATIVAN] - 0.5 mg Tablet - 1 Tablet(s) by mouth every six (6) hours as needed for nausea ONDANSETRON HCL [ZOFRAN] - 8 mg Tablet - 1 Tablet(s) by mouth every eight (8) hours as needed for nausea POLYETHYLENE GLYCOL 3350 [MIRALAX] - 100 % Powder - 1 Powder(s) by mouth daily as needed for constipation PROCHLORPERAZINE EDISYLATE [COMPAZINE] - 10 mg Tablet - 1 Tablet(s) by mouth every six (6) hours as needed for nausea Medications - OTC ACETAMINOPHEN [TYLENOL] - (OTC) - Dosage uncertain DOCUSATE SODIUM [COLACE] - 100 mg Capsule - 1 Capsule(s) by mouth twice a day PRN POLYCARBOPHIL CALCIUM [FIBERCON] - 625 mg Tablet - 2 Tablet(s) by mouth morning PROPOXYPHENE N-ACETAMINOPHEN [DARVOCET A500] - (Prescribed by Other Provider; OTC) - Dosage uncertain SENNA - 8.6 mg Tablet - 1 Tablet(s) by mouth [**Hospital1 **] PRN Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Partial Bowel Obstruction Acute Renal Failure Urinary Tract Infection . Secondary Diagnosis Colon CA s/p resection Metastatic abdominal/pelvic CA (unknown origin) Chronic Back Pain Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**] Completed by:[**2102-8-4**]

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icd9cm

[ [ [] ] ]

[ "96.07", "55.03" ]

icd9pcs

[ [ [] ] ]

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9102, 12755

283, 321

14140, 14149

3775, 9079

14202, 14365

3103, 3205

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3220, 3756

223, 245

349, 1619

1663, 2109

2449, 3070

14,385

175,841

1647

Discharge summary

report

Admission Date: [**2140-2-15**] Discharge Date: [**2140-2-22**] Date of Birth: [**2057-6-29**] Sex: M Service: MEDICINE Allergies: Morphine / Percocet Attending:[**First Name3 (LF) 2972**] Chief Complaint: shortness of breath, chest pain Major Surgical or Invasive Procedure: none History of Present Illness: 82 yo M w/ CAD s/p CABG, multi PCIs, with chronically occluded SVG-RCA., NSTEMI in [**2-3**], mod. AS, HTN, CRI, hyperchol, Prostate CA, PVD, dementia, p/w SOB since 6am and CP (c/w chronic angina) not relieved by NTG SL. The CP was described as worse w/ coughing. Per daughter, pt. has had poor PO intake and a dry cough over the past week and has not felt well. EMS was called [**1-30**] to his SOB. He was given ASA by EMS and transported to [**Hospital1 18**]. In the ED: initial vitals were 100.4, 189/93, 92, 20, 95%2L NC. A CXR showed a RLL consolidation and pt. was given 750 IV levaquin. 1mg IV morphine for CP and was made CP free, 1L of NS/K+, 40 po K+, 5mg IV lopressor. Pt then desat. to 90% on 5L and was placed on an NRB with impr. of sats to 98%. He was started on a nitro gtt and given lasix 40mg IV. ECG changes were noted (STD in I, avL, v4, v5) and trop was elevated to 0.71 (in setting of ARF on CRI) pt was started on a heparin GTT, cardiology was notified and rec. continued medical management. A foley was placed w/ 1600ml of clear urine emptied. Now bloody, therefore hep GTT was stopped. Admitted to icu for resp. distress. Past Medical History: # CAD - CAD s/p CABG [**2125**]: LIMA to LAD, SVG to Diagonal, SVG to OM1, and SVG to rPDA and rPL. - PCI [**2136-3-26**]: Cath showed 3VD, LM 99%, LAD occluded (filling via LIMA, patent), LCX occluded (filling via SVG, patent). RCA occluded (filling via collaterals from distal LAD and OMs). SVG to diag and OM's patents. SVG to RCA occluded. Successful rotatonal atherectomy, PTCA, and stenting of the distal LMCA into the proximal LCX with Taxus DES. withs 2.75 x 20 mm Taxus DES. - PCI [**10-2**]: 3VD, SVG to D, significant new disease in SVG to OM with successfull POBA performed (failed attempt at stent), known occluded SVG to RCA. - PCI [**12-2**]: 3VD, patent SVG-D1, patent SVG-OM with 80% stenosis in the distal graft with successful PTCA performed, SVG-RCA known to be occluded, LIMA-LAD not engaged. - PCI [**2138-2-5**]: 3VD, SVG to OM1 90% lesion at anastomosis site of prior POBA, successfull angioplasty performed. - NSTEMI [**5-3**] - medically managed Social History: Social history is significant for the absence of current tobacco use (quit 15 yrs ago, had smoked 1ppd for 50 yrs. There is no history of alcohol abuse, although the patient drank in the past, quit 15 hrs ago. Father died of MI at 48, brother died in 70's of MI, other 2 brothers with CAD. Family History: Social history is significant for the absence of current tobacco use (quit 15 yrs ago, had smoked 1ppd for 50 yrs. There is no history of alcohol abuse, although the patient drank in the past, quit 15 hrs ago. Father died of MI at 48, brother died in 70's of MI, other 2 brothers with CAD. Physical Exam: VS: Temp:97.8 BP:138 /77 HR:98 RR: O2sat 99 on 5L NC GEN: AA0x1, comfortable, sitting in chair HEENT: dry MM, no JVD at 90 degrees RESP: CTA b/l with good air movement throughout CV: RRR, III/VI harsh systolic murmur throughout precordium ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e, warm, good pulses SKIN: no rashes/no jaundice Pertinent Results: ADMIT LABS: [**2140-2-15**] 08:15AM BLOOD WBC-14.7*# RBC-3.21* Hgb-9.2*# Hct-27.6* MCV-86 MCH-28.7 MCHC-33.3 RDW-13.2 Plt Ct-295 [**2140-2-15**] 08:15AM BLOOD Neuts-88.3* Bands-0 Lymphs-7.9* Monos-3.1 Eos-0.5 Baso-0.2 [**2140-2-15**] 08:15AM BLOOD Plt Ct-295 [**2140-2-15**] 08:15AM BLOOD Glucose-161* UreaN-31* Creat-2.1* Na-140 K-2.6* Cl-99 HCO3-26 AnGap-18 [**2140-2-15**] 07:45PM BLOOD Calcium-10.5* Phos-3.7 Mg-1.8 [**2140-2-15**] 08:35AM BLOOD Lactate-1.5 . Cardiac labs: [**2140-2-15**] 08:15AM BLOOD CK-MB-8 [**2140-2-15**] 08:15AM BLOOD cTropnT-0.71* [**2140-2-15**] 02:00PM BLOOD cTropnT-1.02* [**2140-2-15**] 07:45PM BLOOD CK-MB-33* MB Indx-8.3* cTropnT-2.06* proBNP-GREATER TH [**2140-2-16**] 03:40AM BLOOD CK-MB-18* MB Indx-6.6* cTropnT-3.00* [**2140-2-16**] 03:00PM BLOOD CK-MB-12* MB Indx-5.4 cTropnT-3.14* [**2140-2-17**] 02:11AM BLOOD CK-MB-7 cTropnT-2.08* [**2140-2-15**] portable CXR: Comparison is made with prior study performed four hours earlier. Moderate cardiomegaly is stable. There has been slight interval worsening in asymmetric moderate pulmonary edema, worse in the right side. There is no pneumothorax or pleural effusion. Patient is post-median sternotomy and CABG. [**2140-2-15**]: Mild cardiomegaly has increased. There is mild-to-moderate pulmonary edema asymmetric on the right, with more dense consolidation in the right lower lobe. There is no pneumothorax. If any, there is small right pleural effusion. There are low lung volumes. The patient is post-median sternotomy and CABG. [**2140-2-15**] ECG 7 am: Sinus tachycardia. Left atrial abnormality. Frequent atrial ectopy. Left ventricular hypertrophy. Compared to the previous tracing of [**2139-5-27**] the rate has increased, atrial ectopy has appeared and there is ST segment depression in leads I, II, aVL and V3-V6 consistent with inferolateral ischemic process. Followup and clinical correlation are suggested. TRACING #1 Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**] Intervals Axes Rate PR QRS QT/QTc P QRS T 99 200 114 390/458 79 -26 134 [**2140-2-15**] 9 am ECG: Sinus rhythm with slowing of the rate as compared with prior tracing of [**2140-2-15**]. Atrial ectopy has abated. The ST segment depression persists. No diagnostic interim change. TRACING #2 Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**] Intervals Axes Rate PR QRS QT/QTc P QRS T 88 [**Telephone/Fax (3) 9544**]/383 101 -25 133 [**2140-2-15**] 12pm ECG: Sinus tachycardia with recurrence of tachycardia as compared with prior tracing of [**2140-2-15**]. Otherwise, no diagnostic interim change. TRACING #3 Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**] Intervals Axes Rate PR QRS QT/QTc P QRS T 104 188 114 386/463 73 -26 107 [**2140-2-16**] ECHO: The left atrium is mildly dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild to moderate regional left ventricular systolic dysfunction with inferior/inferolateral hypokinesis. Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (area 1.0-1.2cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-30**]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [**2138-5-6**], left ventricular systolic function is now depressed. [**2140-2-16**] ECG 1:30 pm: Sinus rhythm with marked slowing of the rate as compared with prior tracing of [**2140-2-15**]. There is Q-T interval prolongation. Atrial ectopy has reappeared and the ischemic appearing ST segment changes persist. Clinical correlation is suggested. TRACING #4 Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**] Intervals Axes Rate PR QRS QT/QTc P QRS T 61 184 108 454/455 26 -7 135 [**2140-2-17**] CXR portable: AP UPRIGHT CHEST: Moderate cardiomegaly is stable. The patient is status post median sternotomy and CABG. Pulmonary edema has substantially cleared. No sizable pleural effusion is identified. There is no pneumothorax. Visualized osseous structures are unremarkable. IMPRESSION: Clearing pulmonary edema. Discharge labs [**2140-2-22**]: Na 137, K 3.8, Cl 106, CO2 22, BUN 15, Creat 1.1, glucose 107, ca 7.9, mg 2.1, P 2.1. WBC 10.4, Hct 27.1, Plt 352. Brief Hospital Course: 82 yo M w/ CAD s/p CABG, mult PCI, mod AS, angina, prostate CA, admitted with NSTEMI, CHF, PNA, and acute on chronic renal failure. # CHF: Pt was found to have NSTEMI with pulmonary edema. Pt's hypoxia required NRB and was admitted to MICU for observation and iv lasix. He received nitroglycerin and iv lasix with good diuresis and at the time of transfer to the floor, he no longer required supplement O2. Repeat echo on [**2-17**] revealed a new decreased EF of 40% as well as a mild to moderate regional left ventricular systolic dysfunction with inferior/inferolateral hypokinesis likely [**1-30**] NSTEMI. Pt autodiuresed well and did not require any lasix while on the floor. His I/O were initially negative and then were even on the floor. # NSTEMI: Pt has had periodic anginal pain which is chronic per his daughter, and he has a known occluded [**Name (NI) 9545**]. Pt ruled in for NSTEMI and was seen cardiology who recommended medical management and daughter and pt. did not want intervention. He was continued on BB, nitro patch, ASA, and plavix. ACEI was held due to ARF. Pt received heparin gtt briefly but was stopped due to hematuria liekly [**1-30**] to traumatic foley insertion. Statin was added on the floor. Once ARF resolved, he was restarted on his home ACEI. Pt remained chest pain free on the floor. # RLL PNA: Likely contributed to hypoxia in addition to pulmonary edema. Levofloxacin was started at the time of admission for community acquired pneumonia and finished a 7 day course. # Acute on chronic renal failure: His baseline creatinine is around 1.3-1.5. At admission, creatinine was 2.1. Pt. had significant urinary retention/prostate cA which probably caused ARF as well as poor flow due to CHF. His creatinine eventually returned to baseline and ACEI was restarted and his creatinine and 'lytes remained stable thereafter. # Hematuria: likely [**1-30**] to traumatic foley insertion. Pt has known bph and prostate ca, with urinary retention in the past. Hematuria eventually resolved after d/cing heparin and hct remained stable. He did nto require any blood transfusion. He has an appointment with Dr. [**Last Name (STitle) 770**] (urology) on [**2140-2-25**] to decide on further treatment (i.e TURP) or continuing foley. # Anemia: He had hematuria but hct remained stable. His iron studies were consistent with anemia of chronic inflammation. # HTN: continued BB and then later re-started ace-I when creatinine normalized. His BP was well-controlled on the regimen. Medications on Admission: flomax 0.8mg qhs lisinopril 20mg [**Hospital1 **] lopressor 100 [**Hospital1 **] nitr-dur 0.4 patch qdaily plavix 75mg qdaily proscar 5mg qdaily seroquel 100mg qhs ASA 325 qdaily Discharge Medications: 1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO HS (at bedtime). 2. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Nitroglycerin 0.4 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal Q24H (every 24 hours): 12-14 hours/day and off. 6. Quetiapine 25 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime). 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 10. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). Discharge Disposition: Extended Care Facility: [**Hospital3 9475**] Care Center - [**Location (un) 3146**] Discharge Diagnosis: Primary diagnoses: NSTEMI Congestive heart failure Community acquired pneumonia Acute renal failure- resolved Secondary diagnoses: Hypertension Dementia Prostate cancer Hyperlipidemia Discharge Condition: Stable, satting 97-99% on RA Discharge Instructions: Please call your doctor or report to emergency room if you develop chest pain not relieved with nitroglycerin, shortness of breath, nausea, vomiting, diarrhea, abdominal pain, fevers, chills or any other worrisome symptoms. Please take medications as instructed. Keep all your appointments. We added levofloxacin for pneumonia and started simvastatin for your cholesterol and heart disease. It is very important that you keep your appointment so that you can discuss with Dr. [**Last Name (STitle) 770**] about your prostate and foley catheter and possible surgery. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9546**], MD Phone:[**Telephone/Fax (1) 1047**] Date/Time:[**2140-2-23**] 10:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2140-2-24**] Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2140-2-25**] 9:00 Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1147**], MD (Cardiology) on [**2140-3-1**] at 3:00PM

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icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

12211, 12297

8563, 11085

312, 318

12526, 12557

3500, 8540

13175, 13748

2817, 3108

11314, 12188

12318, 12429

11111, 11291

12581, 13152

3123, 3481

12450, 12505

241, 274

346, 1498

1520, 2494

2510, 2801

60,737

131,393

51808

Discharge summary

report

Admission Date: [**2171-6-23**] Discharge Date: [**2171-6-27**] Date of Birth: [**2104-10-2**] Sex: M Service: MEDICINE Allergies: fish / Spiriva with HandiHaler / Lithium Attending:[**Last Name (un) 7835**] Chief Complaint: SOB Major Surgical or Invasive Procedure: none History of Present Illness: 65M h/o esophageal dysmotility, aspiration PNA, G-tube, ?Churg [**Doctor Last Name 3532**], COPD and MS presented to the ED with CP and SOB x 1 day. Of note, has had 4 admissions in the last 2 months, most recently [**Date range (1) 107262**] for CP and SOB. His prednisone was increased and he was discharged to [**Hospital3 2558**]. . On arrival to the ED, vital signs were T 101.9, HR 104, BP 134/59, RR 24, 86% on 10L. Sat remained < 90% on NRB. Pt endorsed that his Sx were similar to prior flares but worse. He c/o left-sided CP, but no radiation, nausea, vomiting, or diaphoresis. No Hx of cardiac interventions, but pt does states that he has nitro at home to use PRN chest pain. He was put on BiPAP in the ED. No subjective improvement, but pt's sat did improve. Prior to transfer, he was put back on NRB and was satting 93%. he got 5mg IV morphine x 1 for CP which didn't help. He then got SL NTg x 1, which relieved his CP. Of note, first trop <0.01, no ECG changes. Given concern for new infiltrates on CXR, he was given cefepime/levo/vanc. Labs showed WBC 10 but 88% PMNs. Hct at baseline, lactate 1.0. ABG on BiPAP 7.59/29/82/29. CXR was conferning for increased infiltrate in the right base compared to prior. Pt ws given vancomycin, cefepime, and levoflox for HCAP coverage. Also given solumedrol, 1L NS, and morphine for pain. . In the [**Name (NI) 153**], pt arrived on NRB mask but was sating close to 100% and mentating well. He was switched to nasal cannula. His vitals were 119/65, 72, 20, 92% 3L NC Past Medical History: Suspected Churg [**Doctor Last Name 3532**] Recurrent aspiration pneumonia h/o PE s/p IVC filter MS (diagnosed in [**2158**], presenting with optic neuritis and lower extremity weakness) chronic back pain s/p spinal fusion depression bipolar disorder hypothyroidism henia repair multiple spinal compression fractures (thought to be secondary to prednisone use) COPD with 2L NC at home OSA with CPAP at home Social History: 75 pack year h/o smoking; quit several years ago. H/o heavy alcohol use, also quit several years ago. Family History: Not discussed this admission Physical Exam: Vitals: 119/65, 72, 20, 92% 3L NC General: frail appearing male, kyphotic. AOx3 HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: good air movement bilaterally, crackles in RLL CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. distant heart sounds Abdomen: NTND, normoactive bowel sounds, Gtube site without drainage or erythema. GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Pertinent Results: [**2171-6-23**] 11:21PM VoidSpec-SPECIMEN Q [**2171-6-23**] 11:08PM GLUCOSE-175* UREA N-15 CREAT-0.5 SODIUM-139 POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-28 ANION GAP-14 [**2171-6-23**] 11:08PM CK(CPK)-35* [**2171-6-23**] 11:08PM CK-MB-1 [**2171-6-23**] 11:08PM CALCIUM-9.0 PHOSPHATE-3.6 MAGNESIUM-2.0 [**2171-6-23**] 11:08PM WBC-14.9* RBC-3.35* HGB-10.2* HCT-31.0* MCV-92 MCH-30.5 MCHC-33.1 RDW-15.3 [**2171-6-23**] 11:08PM NEUTS-96.7* LYMPHS-2.1* MONOS-1.1* EOS-0.1 BASOS-0 [**2171-6-23**] 11:08PM PLT COUNT-194 [**2171-6-23**] 11:08PM PT-14.0* PTT-30.9 INR(PT)-1.3* [**2171-6-23**] 09:10PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.028 [**2171-6-23**] 09:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-7.0 LEUK-NEG [**2171-6-23**] 09:10PM URINE RBC-4* WBC-2 BACTERIA-NONE YEAST-NONE EPI-0 [**2171-6-23**] 09:10PM URINE MUCOUS-RARE [**2171-6-23**] 08:04PM TYPE-ART PO2-82* PCO2-29* PH-7.59* TOTAL CO2-29 BASE XS-6 [**2171-6-23**] 07:07PM TYPE-[**Last Name (un) **] COMMENTS-GREEN TOP [**2171-6-23**] 07:07PM LACTATE-1.8 [**2171-6-23**] 06:55PM GLUCOSE-111* UREA N-17 CREAT-0.5 SODIUM-136 POTASSIUM-3.4 CHLORIDE-98 TOTAL CO2-29 ANION GAP-12 [**2171-6-23**] 06:55PM estGFR-Using this [**2171-6-23**] 06:55PM cTropnT-<0.01 [**2171-6-23**] 06:55PM WBC-10.0 RBC-3.38* HGB-10.2* HCT-31.3* MCV-93 MCH-30.3 MCHC-32.7 RDW-15.9* [**2171-6-23**] 06:55PM NEUTS-87.7* LYMPHS-8.4* MONOS-1.8* EOS-2.0 BASOS-0.1 [**2171-6-23**] 06:55PM PLT COUNT-183 [**2171-6-23**] 06:55PM PT-13.8* PTT-28.6 INR(PT)-1.3* [**2171-6-23**] CXR FINDINGS: The lung volumes are low. The heart size is difficult to assess. Multifocal opacities in the lower lungs appear more confluent than on the prior study, particularly at the right lung base. The significance is uncertain since there has been opacification in the area suggesting chronic scarring. However, along the lateral right lung base, a new lateral component was not clearly present on recent prior radiographs and may represent superimposed pneumonia in the appropriate clinical setting. IMPRESSION: Patchy lateral right lower lung opacity for which the possibility of pneumonia superimposed upon existing atelectasis could be considered in the appropriate setting. Brief Hospital Course: 66 y/o M with h/o MS, G-tube for recurrent h/o aspiration PNA, severe COPD, possible churg-[**Last Name (un) **]/eosinophilic pneumonia and multiple recent admissions for SOB who presents from [**Hospital 7137**] with SOB and CP requiring BiPAP in the ED. . # Hypoxia/Aspiration Pneumonia - Pt was initially admitted to the ICU due to BIPAP requirement, yet he did not need that by the time he arrived. He was placed on nasal cannula initially at 4L and titrated down. His symptoms and findings are most consistent with aspiration pneumonia. He was started on broad spectrum antibiotics and will continue HCAP coverage to complete 7 days. Pt has remained afebrile and improving clinically with decreased oxygen requirement. - PICC was placed to complete 7 days of IV antibiotics with Zosyn for aspiration/hospital acquired pneumonia -cont incentive spirometer, oxygen by nasal cannula as needed and titrate as possible, at baseline uses 2L occasionally -cont standing nebs, and prednisone for COPD/Churg [**Last Name (LF) 3532**], [**First Name3 (LF) **] complete 5 days of prednisone 60mg then back to 10mg - Bcx remain negative at time of discharge - aspiration precautions as possible - Recommend PT for pulmonary toilet . # Hypotension: resolved, was asymptomatic, and given 1L NS on [**2171-6-25**]. He runs at low BPs at baseline. . # Back pain: stable on home morphine and fentanyl patch . # Hypothyroidism: Continue levothyroxine 25 mcg qday . # OSA: will have repeat sleep study in [**Month (only) 205**] to reassess . # Esophageal dysmotility: Continue Reglan 5 mg QID # HLD: on pravastatin . # Depression: continue celexa 30 mg qday . # Bipolar d/o: continue quetiapine 12.5 mg hs prn, trazodone 50 mg hs prn . # Osteopenia: continue home Ca + Vit D # Communication: Patient, [**Name (NI) **] [**Last Name (NamePattern1) 107263**] (partner, [**Telephone/Fax (1) 107261**]) # Code: Pt wants intubation per discussions in ED. However, pt is known to palliative care and their notes document DNR but OK to intubate. He was seen by them here and they will continue to follow whenever he gets admitted Transitional: - will need repeat sleep study in future to determine if his OSA has really resolved -Recommend PT for pulmonary toilet Medications on Admission: ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) (Not Taking as Prescribed: pt on pravacol at [**Hospital3 **]) - 10 mg Tablet - 1 Tablet(s) by G-tube at bedtime AZATHIOPRINE [IMURAN] - (Prescribed by Other Provider) - 50 mg Tablet - 3 Tablet(s) by G-tube once a day CITALOPRAM [CELEXA] - (Prescribed by Other Provider) - 10 mg Tablet - 3 Tablet(s) by G-tube once a day FENTANYL [DURAGESIC] - (Prescribed by Other Provider) - 50 mcg/hour Patch 72 hr - apply one patch to skin every 72 hours GABAPENTIN [NEURONTIN] - (Prescribed by Other Provider) - 250 mg/5 mL Solution - 800 mg by G-tube three times a day IPRATROPIUM-ALBUTEROL [COMBIVENT] - 18 mcg-103 mcg (90 mcg)/actuation Aerosol - 2-3 puffs inhaled up to four times daily when out of the house IPRATROPIUM-ALBUTEROL [DUONEB] - (Prescribed by Other Provider) - 0.5 mg-3 mg (2.5 mg base)/3 mL Solution for Nebulization - 1 nebulization treatment every six (6) hours LACTULOSE - (Prescribed by Other Provider) - 10 gram/15 mL Solution - 30 cc by G-tube once a day LANSOPRAZOLE - (Prescribed by Other Provider) - 30 mg Capsule, Delayed Release(E.C.) - 30 mg Capsule(s) by mouth via feeding tube once daily LEVOTHYROXINE - (Prescribed by Other Provider) - 25 mcg Tablet - 1 Tablet(s) by G-tube once a day LORAZEPAM [ATIVAN] - (Prescribed by Other Provider) - 0.5 mg Tablet - 0.5 mg Tablet(s) by mouth via feeding tube every 6 hours prn anxiety METOCLOPRAMIDE [REGLAN] - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by G-tube four times a day MORPHINE - (Prescribed by Other Provider) - 10 mg/5 mL Solution - 15 mg by G-tube 5 times per day as needed for pain MUCOMYST NEB - (Prescribed by Other Provider) - - 100mg/ml 3ml every 6 hours prn POTASSIUM CHLORIDE - (Prescribed by Other Provider) - 20 mEq Packet - 2 Packet(s) by G-tube once a day PREDNISONE - (Prescribed by Other Provider) - 1 mg Tablet - 3 (Three) Tablet(s) by mouth once a day PROTEIN POWDER - (Prescribed by Other Provider) - - 1 scoop 2 times daily QUETIAPINE [SEROQUEL] - (Prescribed by Other Provider) (Not Taking as Prescribed: pt now on 100 mg once daily at [**Hospital3 **]) - 25 mg Tablet - 0.5 (One half) Tablet(s) by G-tube at bedtime QUETIAPINE [SEROQUEL] - (Prescribed by Other Provider) - 100 mg Tablet - 100 mg Tablet(s) by mouth once daily via feeding tube RISPERIDONE - (Prescribed by Other Provider) - 1 mg Tablet - 1 mg Tablet(s) by mouth every 6 hours prn agitation SULFAMETHOXAZOLE-TRIMETHOPRIM [BACTRIM] - (Prescribed by Other Provider) - 400 mg-80 mg Tablet - 200-40 mg Tablet(s) by mouth via feeding tube every other day TRAZODONE - (Prescribed by Other Provider) (Not Taking as Prescribed: pt on 25 mg at [**Hospital3 **]) - 50 mg Tablet - 1 Tablet(s) by G-tube at bedtime ZEGRID OTC POWDER - (Prescribed by Other Provider) - - 40 mg by G-tube twice a day ACETAMINOPHEN [TYLENOL] - (Prescribed by Other Provider) - 325 mg Tablet - 3 Tablet(s) by G-tube three times a day ASPIRIN - (Prescribed by Other Provider) (Not Taking as Prescribed: pt not taking at [**Hospital3 **]) - 81 mg Tablet, Chewable - Tablet(s) by G-tube once a day BISACODYL [DULCOLAX] - (Prescribed by Other Provider) - 10 mg Suppository - 1 Suppository(s) rectally once a day CALCIUM CARBONATE - (Prescribed by Other Provider) (Not Taking as Prescribed: pt on 500 mg 3 times daily at [**Hospital3 **]) - 500 mg calcium (1,250 mg) Tablet - 1250 mg by G-tube once a day CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - (Prescribed by Other Provider) (Not Taking as Prescribed: pt on 400 units onde daily at the [**Hospital3 **]) - 1,000 unit Tablet, Chewable - 1 Tablet(s) by G-tube once a day DOCUSATE SODIUM [COLACE] - (Prescribed by Other Provider) - 60 mg/15 mL Syrup - 100 mg(s) by mouth twice a day SENNOSIDES [SENNA] - (Prescribed by Other Provider) - 8.6 mg Tablet - 1 Tablet(s) by G-tube twice a day Discharge Medications: 1. docusate sodium 50 mg/5 mL Liquid [**Hospital3 **]: Ten (10) ml PO BID (2 times a day). 2. Senna Concentrate 8.6 mg Tablet [**Hospital3 **]: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. prednisone 20 mg Tablet [**Hospital3 **]: Three (3) Tablet PO DAILY (Daily) for 2 days: then go back to 10mg daily. 4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital3 **]: One (1) inhaler Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 5. ipratropium bromide 0.02 % Solution [**Hospital3 **]: One (1) inhaler Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 6. acetylcysteine 10 % (100 mg/mL) Solution [**Hospital3 **]: One (1) ML Miscellaneous q6hr (). 7. levothyroxine 25 mcg Tablet [**Hospital3 **]: One (1) Tablet PO DAILY (Daily). 8. pravastatin 20 mg Tablet [**Hospital3 **]: Two (2) Tablet PO DAILY (Daily). 9. gabapentin 250 mg/5 mL Solution [**Hospital3 **]: Fifteen (15) ml PO Q8H (every 8 hours). 10. calcium carbonate 500 mg calcium (1,250 mg) Capsule [**Hospital3 **]: One (1) Capsule PO TID (3 times a day). 11. metoclopramide 5 mg Tablet [**Hospital3 **]: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 12. quetiapine 100 mg Tablet [**Hospital3 **]: One (1) Tablet PO HS (at bedtime). 13. trazodone 50 mg Tablet [**Hospital3 **]: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 14. bisacodyl 10 mg Suppository [**Hospital3 **]: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 15. risperidone 1 mg Tablet [**Hospital3 **]: One (1) Tablet PO Q6HR () as needed for agitation. 16. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution [**Hospital3 **]: 0.5 ml PO Q4H (every 4 hours) as needed for pain. 17. aspirin 81 mg Tablet, Chewable [**Hospital3 **]: One (1) Tablet, Chewable PO DAILY (Daily). 18. citalopram 10 mg Tablet [**Hospital3 **]: Three (3) Tablet PO DAILY (Daily). 19. sulfamethoxazole-trimethoprim 200-40 mg/5 mL Suspension [**Hospital3 **]: Twenty (20) ML PO QOD (). 20. azathioprine 50 mg Tablet [**Hospital3 **]: Three (3) Tablet PO DAILY (Daily). 21. fentanyl 50 mcg/hr Patch 72 hr [**Hospital3 **]: One (1) Transdermal Q72H (every 72 hours). 22. fentanyl 12 mcg/hr Patch 72 hr [**Hospital3 **]: One (1) patch Transdermal every seventy-two (72) hours. 23. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 24. clobetasol 0.05 % Solution [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **] (2 times a day). 25. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback [**Hospital1 **]: 4.5 grams Intravenous Q8H (every 8 hours) for 3 days: through [**2171-6-30**]. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: [**Hospital **] Hospital acquired pneumonia COPD Churg [**Doctor Last Name 3532**] Esophageal dysmotility Recurrent aspiration requiring G tube placement in [**2170**] Orthostatic Hypotension 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, initially to the ICU, with hypoxemia and were found to have pneumonia, which is thought to be from aspiration. You were treated empirically with antibiotics and have been receiving additional steroids as well as nebulizer treatments. Due to the pneumonia you are requiring oxygen by nasal cannula and should cont to monitor your oxygen and place it of <92% saturation. Your oxygen will be monitored in [**Hospital3 2558**] and once it improves, you will be taken off oxygen. You will complete a 7 day course of antibiotics for pneumonia with IV antibiotics at [**Hospital3 2558**]. Followup Instructions: Department: RADIOLOGY CARE UNIT When: WEDNESDAY [**2171-7-31**] at 9:30 AM [**Telephone/Fax (1) 446**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage . ***The Pulmonary Dept is working on a follow up appt for you and will call you at home with the appt. IF you dont hear from them by Monday, please call the office at [**Telephone/Fax (1) 612**] to book.

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icd9cm

[ [ [] ] ]

[ "38.93", "96.6" ]

icd9pcs

[ [ [] ] ]

14267, 14337

5307, 7558

303, 309

14572, 14572

2977, 5284

15399, 15876

2433, 2463

11478, 14244

14358, 14551

7584, 11455

14754, 15376

2478, 2958

260, 265

337, 1867

14587, 14730

1889, 2297

2313, 2417

11,416

161,142

53638

Discharge summary

report

Admission Date: [**2184-7-20**] Discharge Date: [**2184-7-25**] Date of Birth: [**2112-9-14**] Sex: F Service: MEDICINE Allergies: Iodine / Pravastatin Attending:[**First Name3 (LF) 425**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: CARDIAC CATHETERIZATION: CLEAN CORONARIES; EF 30%; APICAL AND ANTERIOR DYSKINESIS History of Present Illness: 71 yo F with h/o HTN, hyperlipidemia, and s/p LAD [**Last Name (un) 2435**] at [**Hospital1 2025**] 4 yrs ago, came in with subacute onset of DOE and fatigue progressing to rest sxs of chest pain this am. Was sx-free in ED. Pt had a normal ETT-MIBI 4 day prior to presentation. ECG revealed slight ST elevations in V2-4; portable echo showqed EF 25%--> pt was taken urgently to cardiac cath lab where she was found to have no flow limiting CAD with oatent previous LAD stent. LV gram revelaed EF 33% with basal sparing and akinetic apex. She was [**Hospital 110165**] transferred to medical floor, but developed an episode of hypotension to 50/p and tachycardia--> retroperitoneal bleed was suspected and pt [**Hospital **] [**Hospital 110166**] transferred to CCU for rescusitation Past Medical History: Basal cell ca Remote MVA Social History: married; lives with husband; no etoh or smoling Family History: premature CAD: father Physical Exam: 98 88/50 130 20 pale female dry mm no jvd cta b tachy;RR; s1/2; no m/r/g benigh abdomen no c/c/e; small hematoma R groin; no fem bruit; intact periph pulses by dippler Pertinent Results: [**2184-7-20**] 12:45PM PLT COUNT-224 [**2184-7-20**] 12:45PM POIKILOCY-1+ [**2184-7-20**] 12:45PM NEUTS-71.4* LYMPHS-21.9 MONOS-4.5 EOS-1.8 BASOS-0.3 [**2184-7-20**] 12:45PM WBC-9.3 RBC-4.27 HGB-12.7 HCT-37.0 MCV-87 MCH-29.8 MCHC-34.4 RDW-14.3 [**2184-7-20**] 12:45PM CK-MB-14* MB INDX-8.1* [**2184-7-20**] 12:45PM CK(CPK)-173* [**2184-7-20**] 12:45PM GLUCOSE-113* UREA N-35* CREAT-1.4* SODIUM-138 POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-28 ANION GAP-15 [**2184-7-20**] 02:07PM PT-13.7* PTT-27.8 INR(PT)-1.2 [**2184-7-20**] 04:38PM HGB-10.9* calcHCT-33 O2 SAT-93 [**2184-7-20**] 04:38PM TYPE-ART PO2-74* PCO2-42 PH-7.35 TOTAL CO2-24 BASE XS--2 Brief Hospital Course: 1. Retroperitoneal bleed post cath: hypoT post cath; retroperitoneal bleed was clinically suspected. Central IV access was established by placement of R IJ. Dopamine was started. 4 U PRBCs were raoidly infused. Bedside R groin U/S did not reveal femoral pseudoaneurism but showed AV fistula. Dopamine was weaned off. CT abd/pelvis confirmed retroperitoneal bleed. Vascular [**Doctor First Name **] was consulted and no surgical interventions were required. 2. Myopericarditis vs [**Last Name (un) **]-Tsubo cardiomyopathy: transient apical ballooning syndrome ([**Last Name (un) **]-Tsubo cardiomyophathy) was suspected based on appearance of LV on LV gram in the absence of coronary disease. Low dose beta blocker and ace were started. Fe studies and TSH were normal. Plannned for repeat outpt Echocardiogram in 4 weeks to evaluate for resolution of wall motion abnormalities 3. AV fistula: by U/S. no need for intervention. Pt was seen by vascular surgery, and it 6 mos outpt vascular follow up was recommended. Medications on Admission: maxide; aspirin; SSRI Discharge Medications: 1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 2. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. 4. Fluoxetine HCl 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Rofecoxib 12.5 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*20 Tablet(s)* Refills:*0* 6. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 7. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: 1. MYOPERICARDITIS, LIKELY VIRAL 2. RETROPERITONEAL BLEED Discharge Condition: STABLE; NEEDS TITRATION OF HER OUTPATIENT MEDICATIONS Discharge Instructions: 1. pLEASE TAKE ALL MEDIACTIONS AS DIRECTED 2. PLEASE CALL YOUR PCP IF YOU DEVELOP CHEST PAIN, SHORTNESS OF BREATH OR LIGHTHEADEDNESS Followup Instructions: 1. PLEASE FOLLOW UP WITH DR. [**Last Name (STitle) 7726**] WITHIN NEXT FEW DAYS AFTER DISCHARGE. Please phone to schedule your appointment. Completed by:[**2184-12-10**]

[ "272.0", "414.01", "285.1", "420.91", "V45.82", "998.11", "E879.0", "401.9", "424.0" ]

icd9cm

[ [ [] ] ]

[ "99.04", "37.23", "88.53", "88.56" ]

icd9pcs

[ [ [] ] ]

3965, 3971

2231, 3248

291, 375

4073, 4128

1546, 2208

4309, 4482

1316, 1339

3320, 3942

3992, 4052

3274, 3297

4152, 4286

1354, 1527

241, 253

403, 1187

1209, 1235

1251, 1300

30,747

108,971

1940

Discharge summary

report

Admission Date: [**2156-9-2**] Discharge Date: [**2156-9-9**] Date of Birth: [**2083-12-27**] Sex: M Service: SURGERY Allergies: Levofloxacin / Penicillins / Morphine Sulfate Attending:[**First Name3 (LF) 1481**] Chief Complaint: RUQ pain, hypotension, and recurrent cholecystitis Major Surgical or Invasive Procedure: ultrasound-guided percutaneous cholecystostomy tube placement History of Present Illness: Mr. [**Known lastname 10733**] is a 72 yo male with a complicated cardiac history, and EF of 20%. He presents now with RUQ pain and hypotension. He is well known to Dr. [**Last Name (STitle) **] who has managed his recurrent cholecystitis that have required percutaneous cholecystotomy drainage. His was discharged home with a drain in place during last admission. The drain fell out about 2 months ago. On day of admission, her reported Past Medical History: S/P MI - NSTEMI [**2144**], S/P CABGX4 with a LIMA to the LAD and vein graphs to his PDA, and sequential graphs to the first diagonal and obtuse marginal CHF LVEF 10-20% - ischemic cardiomyopathy s/p Biventricular ICD implantation DM diagnosed in [**2130**] - has been insulin for approx. 25 years. GB stone h/o cholangitis, s/p choledochostomy tube Peripheral Viscular Disease - Right foot transmetatarsal amputation, [**2153**], a right femoral popliteal bypass - [**2151**] H/O stroke, [**2145**] - MRI here demonstrated a left pontine stroke with a history of a right hemiparesis and dysphasia Social History: Lives with wife; no tob/illicits. Previous 35 pk-year smoker (quit 20 years ago). Family History: NC Physical Exam: Vitals in ICU: T-96.2, HR-66, BP-117/67, MAP-78, RR-23, O2 sat-99% on 3Liters NC Gen: NAD, A/Ox3, comfortable Neck: supple, no LAD, no bruits heard Cardiac: RRR Resp: CTAB, no rales noted ABD: Distended, hypoactive bowel sounds, soft, nontender throughout, no rebound or guarding, no scars or hernias, neg [**Doctor Last Name **] Elim: Foley in place. Rectal guaiac negative, normal tone, no masses Pertinent Results: [**2156-9-6**] 05:45AM BLOOD WBC-8.1 RBC-3.06* Hgb-9.0* Hct-27.2* MCV-89 MCH-29.5 MCHC-33.1 RDW-16.6* Plt Ct-271 [**2156-9-2**] 06:58PM BLOOD WBC-10.8 RBC-3.30* Hgb-9.7* Hct-28.0* MCV-85 MCH-29.3 MCHC-34.4 RDW-16.5* Plt Ct-221 [**2156-9-6**] 05:45AM BLOOD Plt Ct-271 [**2156-9-3**] 04:35PM BLOOD PT-14.7* PTT-29.3 INR(PT)-1.3* [**2156-9-2**] 06:58PM BLOOD PT-13.5* PTT-27.8 INR(PT)-1.2* [**2156-9-6**] 05:45AM BLOOD Glucose-244* UreaN-63* Creat-1.6* Na-136 K-4.9 Cl-107 HCO3-22 AnGap-12 [**2156-9-2**] 06:58PM BLOOD Glucose-93 UreaN-107* Creat-1.9* Na-127* K-4.5 Cl-97 HCO3-19* AnGap-16 [**2156-9-6**] 05:45AM BLOOD ALT-32 AST-9 AlkPhos-232* Amylase-17 TotBili-0.2 [**2156-9-2**] 06:58PM BLOOD ALT-119* AST-87* CK(CPK)-33* AlkPhos-361* Amylase-29 TotBili-0.3 [**2156-9-6**] 05:45AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.3 [**2156-9-2**] 06:58PM BLOOD Albumin-3.0* Calcium-8.2* Phos-5.3* Mg-2.3. . [**2156-9-2**] 10:20 pm BILE **FINAL REPORT [**2156-9-5**]** GRAM STAIN (Final [**2156-9-3**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). REPORTED BY PHONE TO [**First Name8 (NamePattern2) 10734**] [**Last Name (NamePattern1) **] @ 2:30A [**2156-9-3**]. FLUID CULTURE (Final [**2156-9-5**]): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for Pseudomonas aeruginosa, Staphylococcus aureus and beta streptococcus). KLEBSIELLA PNEUMONIAE. MODERATE GROWTH. Trimethoprim/Sulfa sensitivity testing available on request. STAPH AUREUS COAG +. MODERATE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. PENICILLIN SENSITIVITY AVAILABLE ON REQUEST. ENTEROCOCCUS SP.. MODERATE GROWTH. . Urine and blood cultures-negative . RADIOLOGY Final Report GUIDANCE PERC TRANS BIL DRAINAGE US [**2156-9-2**] 10:57 PM GB DRAINAGE,INTRO PERC TRANHEP; GUIDANCE PERC TRANS BIL DRAINA Reason: GB SLUDE, DRAINAGE IMPRESSION: Technically successful ultrasound-guided percutaneous cholecystostomy tube placement (8 French). . RADIOLOGY Final Report LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**2156-9-2**] 7:37 PM Reason: assess for possible perc drainage, discussed with radiology IMPRESSION: Distended gallbladder containing sludge and debris with thickened wall, findings that are consistent with acute cholecystitis. . RADIOLOGY Final Report CHEST (PORTABLE AP) [**2156-9-2**] 7:11 PM CHEST (PORTABLE AP) Reason: pre-op IMPRESSION: AP chest compared to [**7-6**] through [**7-16**]: Mild cardiomegaly has improved, but borderline interstitial edema and pulmonary [**Month (only) 1106**] congestion remain. There is no pleural effusion. Transvenous right atrial and left ventricular pacer leads and right ventricular pacer defibrillator lead are in standard placements, unchanged, continuous from the left axillary pacemaker. No pneumothorax or appreciable pleural effusion is seen. . RADIOLOGY Preliminary Report ART EXT (REST ONLY) [**2156-9-8**] 2:00 PM Reason: Eval. for signs of [**Month/Day/Year 1106**] insufficiency HISTORY: Necrotic left foot ulcer. IMPRESSION: Significant right-sided tibial disease, left-sided SFA and tibial disease. Findings are little changed compared to the exam of 6/[**2153**]. Brief Hospital Course: Mr. [**Known lastname 10733**] presented to [**Hospital1 18**] ED for work-up of RUQ pain and hypotension. He was transferred to the SICU for blood pressure management with vasopressors, correction of electrolyte imabalances, IV hydration, and IV antibiotics. . CARDIAC:His blood pressure stabilized in the ICU, and he was weaned from the vasopressors. His hemodynamic status normalized, and he was transferred to [**Hospital Ward Name **] for further management of the acute cholecystitis.He was transitioned back to his oral medication regimen once he was able to tolerate PO fluids. His blood sugars were elevated ranging 150-300's. Adjustments were made to the regular sliding scale for tighter control with positive affect, and he was restarted on his NPH and Humalog. . NUT:He remained NPO for a few days to aid in resolution of the cholecystitis. His labwork returned to baseline, and his diet was advanced to regular, cardiac/diabetic healthy diet. He was tolerating regular food without complaints of nausea/vomiting. . ID:He underwent a RUQ Ultrasound at an outside hospital revealed sludge, thickening, fluid around gallbladder. A repeat ultrasound was obtained at [**Hospital1 18**] on [**2156-9-2**] which confirmed the ultrasoud findings from the outside hospital, and the presence of acute cholecystitis. He underwent a CT guided drainage of the gallbladder which was sent for cultures & sensitivitied. His IV antibiotic regimen was adjusted according to culture sensitivities. He remained afebrile, and was transitioned to oral Ampi and Cipro on [**2156-9-5**]. He will finish the 2 week regimen at home. . GI/ABD:His abdomen is round and nontender, skin intact. He has bowel sounds in all four quadrants. He reports passing gas. He was started on a bowel regimen to promote a bowel movement. He has a Right lower flank percutaneous pigtail drainage device. The site is intact, and draining small amounts of bilious fluid. He and his family were instructed on drain care and flushing at discharge. He will follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. . PAIN:He reports 0/10 pain presently. His RUQ pain has subsided. He had been intially managed with IV Dilaudid with adequate relief. He was transitioned to oral Dilaudid, and will be discharged home with a 2 week supply to be used as needed. . EXTREM:He has a left non-infected necrotic foot ulcer that has been managed per Dr. [**Last Name (STitle) 3407**] ([**Last Name (STitle) 1106**]) from some time. He was seen by the [**Last Name (STitle) **] service during this admission. He underwent ultrasounds of the lower extremeties which was unchanged from the last report. He will follow-up with Dr. [**Last Name (STitle) 3407**] in 1 week to set up an out-patient angiogram/venous studies. Medications on Admission: Insulin NPH 45(AM), humolog 5(PM); ASA 325; Lasix 80"; plavix 75'; isosorbide dinitrate 60'; coreg 25'; lipitor 20'; lisinopril 20'; colchicine 0.6"'; potassium Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. 3. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: One (1) 45 UNITS Subcutaneous QAM. 4. Humalog 100 unit/mL Solution Sig: One (1) 5 Units Subcutaneous at bedtime. 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 2 weeks. Disp:*30 Tablet(s)* Refills:*0* 6. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. 7. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 9. Imdur 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 10. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day as needed for pain. 11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Metolazone 5 mg Tablet Sig: 0.5 Tablet PO MWF (Monday-Wednesday-Friday). 13. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. 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* 15. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 16. Ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 10 days. Disp:*80 Capsule(s)* Refills:*0* 17. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary: recurrent cholecystitis Left non-infected necrotic foot ulcers . Secondary: Ischemic cardiomyopathy w/LVEF 10-15% Coronary artery disease s/p Myocardial infarction s/p CABG Hypertension Diabetes Mellitus Type II Peripheral [**Company **] Disease chronic renal insufficiency (baseline 1.4) Discharge Condition: Stable Tolerating a regular, cardiac, diabetic diet Adequate pain control with oral medication Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Restrict Fluid to 2 liters per day. . Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomitting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. *Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to amubulate several times per day. Followup Instructions: 1. Please call Dr.[**Name (NI) 1482**] office at [**Telephone/Fax (1) **] for a follow-up appointment in 2 weeks. 2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2156-9-14**] 11:15 3. Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2156-10-4**] 11:00 4. Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2156-10-19**] 11:00 5. Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 665**] [**Telephone/Fax (1) **] in 1 week to review your cardiac medication regimen. Completed by:[**2156-9-9**]

[ "428.22", "707.14", "428.0", "414.8", "V45.81", "585.9", "276.1", "412", "250.80", "V58.67", "575.0", "V45.02" ]

icd9cm

[ [ [] ] ]

[ "51.02" ]

icd9pcs

[ [ [] ] ]

10424, 10473

5834, 8607

355, 418

10815, 10912

2063, 5811

12141, 12885

1625, 1629

8818, 10401

10494, 10794

8633, 8795

10936, 12118

1644, 2044

265, 317

446, 885

907, 1508

1524, 1609

9,526

125,656

51744

Discharge summary

report

Admission Date: [**2113-11-16**] Discharge Date: [**2113-11-26**] Service: BLUE SURGERY DATE AND TIME OF DEATH: [**2113-11-26**], 02:00. CAUSE OF DEATH: Cardiac arrest secondary to cardiogenic shock. PROCEDURES DURING ADMISSION: 1. Exploratory laparotomy. 2. Sigmoid colectomy with [**Doctor Last Name 3379**] pouch and end colostomy on [**2113-11-7**]. 3. The patient also had mechanical ventilation. 4. Swan-Ganz catheterization and arterial line monitoring during this hospital stay. REASON FOR ADMISSION: The patient is an 87 year-old female who was transferred from [**Hospital6 **] per the family's request. The patient was unresponsive at that institution starting on the 10th. She had a pacemaker placed for atrial fibrillation on the [**11-10**] and on the 7th the patient was noted to have abdominal distention on KUB, which showed large bowel dilatation. The patient was then treated with nasogastric tube, rectal tube decompression. She is being anticoagulated for atrial fibrillation with Coumadin and receiving Lovenox as well. PAST MEDICAL HISTORY: Significant for atrial fibrillation, coronary artery disease status post non Q wave myocardial infarction in [**2109**], hypercholesterolemia, congestive heart failure, mitral regurgitation, tricuspid regurgitation, hypothyroidism, gout and blindness. MEDICATIONS ON TRANSFER: The patient was on Prevacid 30 q day, Timolol drops OU, Tolamide drops OU, topical Hydrocortisone, Ensure plus, Colchicine .6 q day, Levothyroxine .05 mg q day, Oxybutynin 2.5 b.i.d., Prednisone eye drops, Dulcolax prn, Digoxin .5 q day, Lopressor 50 t.i.d., Lovenox 30 subq b.i.d., magnesium oxide 400 b.i.d., Tequin 400 intravenous q day and Albuterol and Atrovent nebulizers. After transfer to [**Hospital1 69**] the patient was placed on aspirin 325 mg q day, Lopressor 5 intravenous q 6, Levaquin 250 q day, Vancomycin 500, morphine prn, Digoxin .125 intravenous q day, Flagyl 500 intravenous t.i.d., Albuterol and Atrovent nebulizers, subq heparin, Diltiazem 10 mg intravenous times one, Protonix 40 q day intravenous, Levothyroxine 25 intravenous q day, Brimonidine eye drops and Latanoprost eye drops. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: Temperature 101.8. 97.0. Pulse 107 and irregular. Blood pressure 110/59. Respirations 20. Saturations 92%. She is on normal saline at 75 cc an hour. On examination in general the patient was unresponsive. Heart was irregular and tachy. Lungs showed decreased breath sounds bilaterally. Abdomen soft, distended. The patient winces to deep palpation in the left lower quadrant. Extremities without edema and perfused. Lines include a left PICC line, left femoral triple lumen catheter, nasogastric tube, Foley and rectal tube. LABORATORY: White blood cell count 11.9, hematocrit 28.7, platelets 313, PT 17, PTT 29.7, INR 2.0, sodium 146, potassium 5.3, chloride 116, CO2 22, BUN 38, creatinine 1.3, glucose 127, calcium 7.9, magnesium 1.5, phos 2.6, lipase 7, albumin 2.5, ALT 363, AST 593, alkaline phosphatase 193 and total bilirubin is 0.8, amylase is 91, lactate 3.0, troponin was 13.9, CPK 65.33 and MB was not done. Urinalysis showed moderate leukocyte esterase, moderate blood, few bacteria, 3 to 5 red cells and 6 to 10 white blood cells. Arterial blood gas was 7.34, 45, 188, 25, and negative 1. CT of her head was unchanged showing a left parietal lobe infarct, unchanged right thalamic lacunar infarct. CT of her abdomen showed bilateral pleural effusions. No small bowel thickening, descending and sigmoid bowel thickening with fat stranding and minimal free fluid. No pneumatosis, questionable colonic polyp in the descending colon and mild dilatation of the small bowel. KUB showed the cecum not very dilated, no free air, no evidence of obstruction and air throughout the colon. ASSESSMENT: The patient is an 87 year-old female with likely ischemic colitis of the descending and sigmoid colon. The plan was to take the patient emergently to the Operating Room for exploratory laparotomy. In preparation for surgery the patient was given fresh frozen platelets and a left subclavian port was placed along with the Swan-Ganz catheter. The patient's son was available for discussion about the patient's prognosis and they were made aware that the patient's chances of survival were slim even with surgery and they chose to proceed with surgery and informed consent was obtained from the family. She was taken to the Operating Room and underwent exploratory laparotomy where a ischemic left colon was encountered. She underwent a left hemicolectomy, [**Doctor Last Name 3379**] pouch and colostomy, J tube placement and the splenic flexure was taken down. She required 2 units of packed red blood cells and 2 units of fresh frozen platelets during the surgery. She also had [**2111**] cc of crystalloid and she was transferred to the [**Hospital Unit Name 153**] in critical condition. Postoperatively the patient remained intubated. Refer to operative dictation for more details. Initially out of the Operating Room the patient was on an epinephrine drip, which was weaned off. Additionally she was taken off her Amiodarone and a nitro drip was added initially for after load reduction. She is also put on Dobutamine to increase her bowel function and remained antibiotic coverage of Flagyl, Levaquin and Vancomycin initially. For prophylaxis she was placed on Protonix. She is also on a beta blocker, Metoprolol 5 mg intravenous q 6 hours. For deep venous thrombosis prophylaxis as well as coagulation given her atrial fibrillation she was placed on Lovenox 40 mg subQ q day. She remained on her Levothyroxine, digoxin and aspirin. She did require fluid boluses aggressively throughout postoperative day one to support her urine output. Postoperative day two the patient remained on a Dobutamine drip of 5 micrograms per kilogram per minute and nitro .5 micrograms per kilogram per minute. She had received a total of 10 liters over the previous 24 hours and had no fevers or desaturations. Initially the inferior portion of the patient's colostomy was dusky, however, this improved by postoperative day three. The plan for the day was to slow down the patient's hydration and to continue broad antibiotic coverage. She was kept on the Lovenox initially, however, she was showing a downward trend in her platelets. By postoperative day three the patient's Dobutamine had been weaned to 2 micrograms per kilogram per minute and she remained on nitro and trophic tube feeds were started. The plan was attempt to wean Dobutamine to off and to restart the patient's beta blocker. For antibiotic coverage the plan was to initially continue for five days postoperatively. By postoperative day five the patient's Dobutamine drip was off and her nitro drip was off. Due to hypoglycemia following the institution of total parenteral nutrition an insulin drip was started. Enalapril was attempted, however, blood pressure dropped so this was discontinued. She was restarted on Lopresor 5 mg intravenous q 6 once the Dobutamine was weaned off and began on gentle diuresis with prn loop diuretics. Due to her thrombocytopenia her Lovenox was dropped and all heparin was eliminated on her carrier fluids. The HIP panel was sent, which ultimately returned negative. On postoperative day five the patient developed what appeared to be an embolic phenomenon to her fingers and toes. The concern was that the patient could possibly be embolizing from atrial clot given her atrial fibrillation and stopping of her anticoagulation. Cardiology consult was obtained the recommendations of which were to anticoagulate the patient with guidance from hematology. Hematology recommended a Lepirudin drip, which was started on the [**11-22**]. On postoperative day six the patient had been restarted on Dobutamine due to low cardiac index and also begun on a Lasix drip for diuresis. Her Lepirudin was on at 3 mg per hour. She had begun to show an upper trend in her fever curve to 100.8 for a temperature max. She was on Vancomycin at this time. This was due to a positive sputum culture three days prior, which was positive for MRSA. The patient had cardiac enzymes sent, which were initially negative for an myocardial infarction. She began showing output from her ostomy with stool mixed with liquid. Her cardiac index continued to be very marginal alone with marginal urine output. An echocardiogram was obtained on postoperative day six. This ultimately showed adequate pump function. A left femoral line, which was initially in place from transfer from the outside hospital and then discontinued after the patient was transferred from the Operating Room and cultures of this showed E-Coli. By postoperative day seven the patient was febrile to 101.8 so she was begun on Zosyn prophylactically. Additionally she grew out yeast from her urine culture and was started on Fluconazole. Due to low cardiac indexes refractory to Dobutamine as well as tachycardia the patient was changed to a Milrinone with initial improvement in her cardiac index. Additionally, she was started on a neo drip to support her blood pressure, which had been trending down. Dopamine was attempted, which was accompanied by marked tachycardia, so this was discontinued. Throughout the [**Hospital 228**] hospital stay her ostomy continued to be pink, viable and functioning. On postoperative day seven the patient continued to deteriorate. A CAT scan was obtained to rule out further bowel ischemia and/or intraabdominal source of sepsis. This was negative. The CAT scan did show some ascites for which a diagnostic tap was obtained the results of which are pending at the time of this dictation. The patient showed an upward trend in her white count as well. As of postoperative day seven it was 24,000. The patient was also started on oral Flagyl for empiric treatment of possible C-diff colitis, however, these were not confirmed on her laboratory tests. On postoperative day eight the patient is on Levophed, Milrinone, Vasopressor had been started at .8 units per minute and she was still given a Lepirudin drip for anticoagulation. Her index continued to be marginal and her urine output had slowly decreased throughout the night. Her white count was 27.5. Throughout the day the patient became oliguric and her blood pressure and cardiac index continued to decline despite the pressors previously mentioned. Due to the patient's grave status the family was gathered and after discussion it was elected to make the patient DNR. The patient continued to worsen her acidosis throughout the day and night and she was found to be asystolic at 2:00 a.m. this morning on the [**11-26**]. On examination with the mechanical ventilator turned off the patient had no heart sounds and no breath sounds. The patient was declared at 0200 on the [**11-26**]. The attending was notified. The intern notified the family of the patient's death. The family had previously been asked regarding post mortem and declined. The family member [**Name (NI) 653**] was [**Name (NI) **] [**Name (NI) 107187**] the patient's son. The admitting office was notified and the death certificate was completed. ADMISSION DIAGNOSIS: Ischemic colitis. DIAGNOSIS AT THE TIME OF EXPIRATION: Immediate cause of death is cardiac arrest and secondary to cardiogenic shock, status post exploratory laparotomy, left hemicolectomy and end colostomy. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 19318**] Dictated By:[**Last Name (STitle) 45848**] MEDQUIST36 D: [**2113-11-26**] 02:48 T: [**2113-11-29**] 06:52 JOB#: [**Job Number **]

[ "557.0", "348.1", "444.22", "789.5", "287.4", "482.41", "785.51", "427.31", "276.5" ]

icd9cm

[ [ [] ] ]

[ "45.95", "99.15", "96.6", "46.11", "54.59", "89.64", "46.39", "54.91", "45.75" ]

icd9pcs

[ [ [] ] ]

2241, 11277

11298, 11772

1368, 2218

1089, 1342

16,805

101,763

25624

Discharge summary

report

Admission Date: [**2179-7-16**] Discharge Date: [**2179-7-19**] Date of Birth: [**2102-1-20**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1561**] Chief Complaint: SOB Major Surgical or Invasive Procedure: s/p Bronch and stent removal History of Present Illness: 77M with tracheal malasia Past Medical History: COPD, home O2, TBM, OA, diverticulosis, nephrolithiasis, MRSA, asbestosis, GERD Social History: sormer insulation (asbestos) worker minimal smoking history Family History: none Physical Exam: AVSS Course with wheezes Pertinent Results: [**2179-7-16**] 08:11PM TYPE-ART PO2-180* PCO2-57* PH-7.36 TOTAL CO2-34* BASE XS-5 [**2179-7-16**] 08:11PM O2 SAT-97 [**2179-7-16**] 08:03PM GLUCOSE-110* UREA N-14 CREAT-0.9 SODIUM-140 POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-32 ANION GAP-12 [**2179-7-16**] 08:03PM CALCIUM-9.0 PHOSPHATE-4.5 MAGNESIUM-2.0 [**2179-7-16**] 08:03PM WBC-13.0*# RBC-3.79* HGB-11.6* HCT-34.5* MCV-91 MCH-30.5 MCHC-33.5 RDW-14.4 [**2179-7-16**] 08:03PM PLT COUNT-190 Brief Hospital Course: Pt taken to OR for stent removal and clean out. Post op admitted to CSRU on vent. Kept on vent overnight and wean and extubated in AM. Diet advanced. CXR showed patent airways with minimal consolidation. Medications on Admission: Capsaicin Dilt Colace Nexium [**Doctor First Name **] Advair Xopenex Levofloxacin Lopressor Prednisone Spiriva Tylenol Codeine Guaifenesin Discharge Medications: 1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* As above Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: TBM Discharge Condition: stable Discharge Instructions: Continue IS, coughing, and deep breathing. Followup Instructions: F/U with Dr. [**Last Name (STitle) **] in [**12-13**] wks F/U with Dr. [**Last Name (STitle) 952**] in 2 wks Completed by:[**0-0-0**]

[ "501", "519.1", "V10.21", "530.81", "496" ]

icd9cm

[ [ [] ] ]

[ "33.22", "98.15" ]

icd9pcs

[ [ [] ] ]

1695, 1767

1158, 1363

333, 364

1815, 1823

682, 1135

1915, 2051

616, 622

1553, 1672

1788, 1794

1389, 1530

1847, 1892

637, 663

290, 295

392, 419

441, 522

538, 600

41,562

124,066

47794

Discharge summary

report

Admission Date: [**2162-10-14**] Discharge Date: [**2162-10-29**] Date of Birth: [**2079-10-10**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5606**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: ERCP with biliary stent placement [**2162-10-14**] PEG placement on [**2162-10-27**] History of Present Illness: Ms. [**Known lastname 100910**] is an 83 year-old woman with a history of severe dementia (baseline oriented to name, minimally verbal, has to be fed, non-ambulatory), depression, hypertension and hypothyroidism who was sent in from her nursing home due to worsening mental status. According to the nursing home, she has had decreased PO intake over the past 3 days as well as fevers. She has had increased somnolence as well with her spending a lot of time sleeping. She was noted to have a positive U/A and was started on Levaquin. She also had labs on [**10-13**] which showed BUN 81, Cr. 2.6, Sodium 150. Due to her decline she was sent to the ED for further evaluation. In the ED inital vitals were, T102.6 HR 92 113/62 RR30s 99% on NRM. She was started on Vancomycin, Ceftriaxone and given a dose of tylenol for her fever. Her sodium was noted to be 157, creatinine of 2.9 and ALT of 164/AST of 147. She was given 1.5L of normal saline. She had a RUQ ultrasound which showed biliary stone but no evidence of cholangitis. She was admitted to the ICU for management of sepsis. She was unresponsive and was unable to answer questions. She was tachypneic. According to her nursing home, she did not have any cough, chest pain, vomiting, rashes or skin changes. Past Medical History: - Advanced dementia - Hypertension - Hypothyroidism - Depression Social History: Lived in [**Hospital3 537**] until recently. Currently lives in [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]. She does not have close family. Her healthcare proxy is [**Name (NI) **] [**Name (NI) **], a friend of hers for the last 40+ years. She enjoys going to church services. Family History: pt unable to give history. Physical Exam: EXAM at time of arrival to medicine floor (from ICU) on [**2162-10-17**]: VS: T 96.8, BP 94/52, HR 68, RR 18, O2 94% on 2LNC PAIN: Unable to assess. GEN: No acute distress, comfortable breathing HEENT: EOMI, MMM, no oral lesions, but poor dentition NECK: Supple CHEST: CTAB CV: RRR ABD: Soft, nontender, nondistended, bowel sounds present SKIN: Ecchymoses on arms. EXT: 3+ BLE pitting edema NEURO: Awake, eyes open, surgical pupils, hypertonicity in all extremities, mostly non-verbal, does not follow commands. PSYCH: Calm Pertinent Results: [**2162-10-14**] 09:00AM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG [**2162-10-14**] 09:00AM URINE RBC-43* WBC->182* Bacteri-MANY Yeast-NONE Epi-0 [**2162-10-14**] 08:37AM BLOOD WBC-8.4 RBC-3.51* Hgb-10.6* Hct-31.1* MCV-89 MCH-30.2 MCHC-34.1 RDW-14.3 Plt Ct-132* [**2162-10-14**] 08:37AM BLOOD Plt Ct-132* [**2162-10-14**] 08:37AM BLOOD Glucose-142* UreaN-94* Creat-2.9* Na-157* K-4.3 Cl-117* HCO3-27 AnGap-17 [**2162-10-14**] 08:37AM BLOOD ALT-164* AST-147* AlkPhos-233* TotBili-0.3 [**2162-10-14**] 08:37AM BLOOD Calcium-8.7 Phos-4.0 Mg-3.0* [**2162-10-14**] 08:37AM BLOOD TSH-2.7 [**2162-10-14**] 08:37AM BLOOD T3-39* Microbiology: Urine culture [**2162-10-14**]: E.COLI >100,000 AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Blood Culture [**2162-10-14**]: Coagulase negative Staphylococcus in 1 set. All other blood cultures no growth (5 other sets). MRSA Screen: Negative ECG [**2162-10-14**]: Sinus rhythm, rate 71, normal axis, nonspecific T-wave changes in anterior precordial leads. CXR [**2162-10-14**]: BEDSIDE FRONTAL RADIOGRAPH OF THE CHEST: Cardiac, mediastinal and hilar contours are normal. Subsegmental atelectasis is bilateral. There is no pneumothorax, pleural effusion or focal consolidation. There is no pulmonary edema. CT ABDOMEN [**2162-10-14**]: 1. Retroperitoneal, pelvic and inguinal lymphadenopathy. Possible right axillary lymphadenopathy as well. Given these findings, considerations include lymphoma. 2. Numerous spinal compression deformities, with the most severe, at L3 new from [**0-0-0**] 3. Cholelithiasis 4. Fibroids. 5. Diverticulosis. 6. Diffuse thickening of the left adrenal gland without definite nodularity, possible hyperplasia. 7. Bibasilar pulmonary opacities, greater on the left than right, possibly atelectatic or infectious depending on the appropriate clinical context. CT HEAD [**2162-10-14**]: No acute intracranial abnormality. RUQ ULTRASOUND [**2162-10-14**]: Cholelithiasis and choledocholithiasis, without specific signs to confirm cholecystitis. LOWER EXTREMITY ULTRASOUND [**2162-10-15**]: 1. Extensive DVT in the left lower extremity as above. 2. DVT in the right proximal superficial femoral vein. 3. Incidental probable [**Hospital Ward Name 4675**] cyst on the right. ERCP [**2162-10-14**]: Impression: Multiple large stones in the entire biliary tree. Given hypotension and over all clinical condition no attempt at stone extraction was made. A double pig-tail stent was placed. Otherwise normal ercp to third part of the duodenum. CXR [**2162-10-26**] CHEST RADIOGRAPH INDICATION: evaluation for fluid overload. COMPARISON: [**2162-10-19**]. FINDINGS: Compared to the previous radiograph, there is a newly appeared opacity at the lung base. In addition, the left lung base also shows a newly appeared parenchymal opacity in the retrocardiac lung areas. The opacities are more likely to represent pneumonia rather than pulmonary edema, given the distribution and the lack of other signs indicative of overhydration. The size of the cardiac silhouette is unchanged. The position of the PICC line is also constant. [**2162-10-26**] CXR:Impression The right PICC line tip is at the level of mid low SVC. Cardiomediastinal silhouette is unchanged, but there is interval progression of pulmonary edema. Right hilar prominence is noted, more pronounced than on [**2162-7-13**] radiograph and may reflect engorged vasculature as well as hilar lesion. Evaluation of the patient preferably with PA and lateral radiographs is recommended or if not possible, chest CT might be an option for evaluating of this area. Brief Hospital Course: 83 year-old woman with advanced dementia presented to the hospital with acute metabolic encephalopathy from urinary tract infection with sepsis complicated by hypovolemic hypernatremia and acute kidney injury. Further investigation found cholelithiasis and choledocholithiasis without cholecystitis. She underwent ERCP with biliary stent placed. Muliple gallstones were observed but none were removed at this time given her clinical condition. She was also found to have DVTs in both legs and was started on a heparin gtt. Many "family meetings" took place with the patient's HCP. The patient was not able to take PO and the decision was made to pursue a temporary feeding tube to give the patient one more chance to recover to a standard of living that she would find acceptable. If no significant improvement is seen or the patient's condition worsens despite these interventions, then transition to comfort oriented care and discontinuation of feeding tube. The patient's PCP agrees with this approach. Geriatrics and Palliative Care services were closely involved. After some delay due to scheduling issues, a PEG was placed on [**2162-10-27**]. . PROBLEM LIST: # Cholelithiasis, Choledocholithiasis, and Cholangitis: She had an elevated alkaline phosphatase and transaminitis on admission with imaging showing cholelithiasis and choledocholithiasis. ERCP showed multiple stones that were causing partial obstruction seen at the biliary tree. Given hypotension and over all clinical condition no attempt at stone extraction was made and a stent was placed. If patient's condition is acceptable for undergoing an ERCP, repeat ERCP in 8 weeks for stent removal and stone extraction/lithotripsy occurs. She was treated for 14-days with Unasyn for Cholangitis. . # UTI with E. Coli: This was treated with Unasyn as it is being used for Cholangitis (see above). . # BLE DVT: The patient was started on a heparin gtt and transitioned to coumadin after PEG placement by IR. She will be discharged with a lovenox bridge. INR goal is [**3-11**]. The day prior to discharge she had a large bowel movement that was guiac positive; there was a question of melena. Her Hct was followed which remained stable and the patient had no further episodes. Please monitor closely. . # Hypernatremia [**3-10**] hypovolemia: Admission Na 159. Hypernatremia resolved with volume resuscitation. . # Acute kidney injury (baseline Cr 1.1): Admission Cr 2.9. [**Last Name (un) **] was [**3-10**] hypovolemia and sepsis. [**Last Name (un) **] improved gradually with treatment of sepsis and hypovolemia. Discharge Cr is 0.9. . # Hypothyroidism: TSH was normal at admission. She was treated with IV levothyroxine until her PEG was placed at which time she was restarted on her oral dose. . # Advanced dementia with overlying delirium [**3-10**] critical illness and metabolic abnormalities including hypernatremia, hypovolemia, [**Last Name (un) **], UTI, Cholangitis, and DVT. Her baseline function is oriented to name, minimally verbal, has to be fed, and non-ambulatory. Given the severity of the illness that led her to this hospitalization, she will be unlikely to return to her prior level of (low) function. Risperdone was restarted at discharge as a liquid form can be given through the PEG. . # Tachypnea: During the patient's hospitalization, she was noted to be intermittently tachypnic. Her O2 sats were normal on RA but she was placed on a 35% FM for comfort. On [**10-26**] she had a transient episode of tachypnea vs agitation and a repeat CXR was obtained. There was some concern for pneumonia vs asymmetric pulmonary edema. The patient's symptoms resolved completely with a nebulizer treatment and given that she remained afebrile without a leukocytosis, antibiotics were not initiated. After her PEG was placed, the patient was again more tachypneic but after suctioning, returned to her baseline. CXR at that time showed some worsening of pulmonary edema. She did receive a dose of lasix at at the time of discharge, O2 sats were 96% on RA. Pt should have repeat CXR to evaluate for resolution. Right hilar prominence was noted and if unresolved, Chest CT may be pursued in the future. . # Nutrition: The patient had a prolonged period of being NPO as there were scheduling challenges with the PEG. It was placed on [**2162-10-27**] and she was started on Fibersource HN at 45cc/hr. The patient did receive vit K x 1 when INR rose to 2. It down trended to 1.2. . #Goals of care: I was in close contact with [**Name (NI) **] [**Last Name (NamePattern1) **], the HCP; She felt the patient would not want any heroic measures to resuscitate her if she should experience cardiac arrest. She would also not like to be on any long-term life supportive treatments such as mechanical ventilation or long-term tube feeding. Intubation for clearly reversible respiratory failure is acceptable. Short-term tube feeding is also okay. Primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **], assisted Ms. [**Name13 (STitle) **] in determining the goals of care for the patient. . # CODE STATUS: DNR, but OK to intubate for reversible causes of respiratory failure. Ms. [**Name13 (STitle) **] is aware that there is a difference between DNI and ok to intubate for procedure and is in the process of considering this as well as other goals of care. For now, she wishes for the patient to return to [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] with the hopes that with additional nutrition she can build her strength and return to her prior baseline. . Medications on Admission: 1. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO twice a day as needed for fever or pain. 2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. nystatin 100,000 unit/g Powder Sig: One (1) app Topical twice a day. 5. Oyster Shell Calcium-Vit D3 500 mg(1,250mg) -400 unit Tablet 6. PreserVision AREDS 14,[**Telephone/Fax (3) 24725**] unit-mg-unit Capsule 7. risperidone 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Discharge Medications: 1. acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q 8H (Every 8 Hours) as needed for pain. 2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. levothyroxine 200 mcg Recon Soln Sig: One (1) Recon Soln Injection DAILY (Daily). 4. Vitamin D-3 400 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 5. therapeutic multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 6. Lovenox 100 mg/mL Syringe Sig: One (1) 90 units Subcutaneous twice a day for until INR is [**3-11**] for 2 days days. 7. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 8. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 10. risperdone Sig: 0.25 mg 0.25 mg PO once a day: liquid form via PEG. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**] Discharge Diagnosis: - Sepsis - Cholangitis - Urinary tract infection - Acute kidney injury - Hypernatremia - Deep venous thrombosis, bilateral lower extremities - Choledocholithiasis - Cholelithiasis - Advanced dementia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted to the ICU with sepsis from urinary tract infection and cholangitis. Complications of your sepsis included hypernatremia and acute kidney injury. You were also found to have blood clots in both legs. An ERCP procedure was performed and stent placed in your bile duct. Stones were found in your bile ducts that were not removed because your condition was too poor to tolerate stone removal. You also had a PEG placed for tube feeds. MEDICATION CHANGES: 1. HELD: PreserVision AREDs 12, [**Telephone/Fax (3) 24725**] unit-mg-unit capsule 2. HELD: Amlodipine 5mg tablet daily - may be restarted a BP tolerates 5. STOPPED: Aspirin 81mg tablet daily Followup Instructions: Department: DIGESTIVE DISEASE CENTER When: THURSDAY [**2162-12-9**] at 10:00 AM With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], MD [**Telephone/Fax (1) 463**] Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**] Campus: EAST Best Parking: Main Garage *This appointment is for an ERCP

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icd9cm

[ [ [] ] ]

[ "43.11", "51.87", "38.93", "96.6" ]

icd9pcs

[ [ [] ] ]

14042, 14164

6726, 7883

329, 416

14408, 14408

2728, 6703

15236, 15669

2141, 2169

13099, 14019

14185, 14387

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15020, 15213

268, 291

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14423, 14520

1734, 1800

1816, 2125

40,103

117,233

23572

Discharge summary

report

Admission Date: [**2107-4-14**] Discharge Date: [**2107-4-19**] Date of Birth: [**2030-7-21**] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 165**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: 1. Aortic valve replacement with a size 19 [**First Name9 (NamePattern2) 12640**] [**Last Name (un) 3843**]- [**Doctor Last Name **] tissue valve. 2. Coronary artery bypass graft x3, left internal mammary artery to left anterior descending artery and saphenous vein grafts to obtuse marginal and posterior descending arteries History of Present Illness: 76F w h/o aortic stenosis and CAD, s/p LAD stent in [**2104**]. Echo in [**2106-7-14**] revealed [**Location (un) 109**] 0.8-1cm2 with EF 75%. Further workup was delayed at this time, as there was some question of GI bleed. Endoscopy and colonoscopy have been performed in the meantime, and were both negative. She has developed shortness of breath with moderate exertion recently. Cardiac cath today reveals moderate CAD. The patient is referred for cardiac surgery evaluation. Past Medical History: Aortic Stenosis Coronary artery disease s/p stent to LAD [**2104**] Hypertension Hypercholesterolemia Osteopenia/Osteoarthritis Anemia Gastroesophageal reflux disease s/p hernia repair s/p tonsillectomy s/p right shoulder surgery Social History: Race: caucasian Last Dental Exam: 2 weeks ago Lives with: husband Occupation: retired, office work Tobacco: none ETOH: approx 3/week Family History: non-contributory Physical Exam: Pulse: 73SR Resp: 18 O2 sat: 100%RA B/P Right: 177/63 Left: Height: 5'6" Weight: 61.7kg General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur 3/6 SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [] no edema or varicosities Neuro: Grossly intact x Pulses: Femoral Right: cath site Left: 2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: Left: no bruits appreciated Pertinent Results: [**2107-4-14**] Echo: PRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is 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. There are focal calcifications in the aortic arch. The aortic valve leaflets are severely hickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). The peak and mean gradients are 60 and 35 m of Hg. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is no pericardial effusion. Dr. [**First Name (STitle) **] was notified in person of the results on Mrs [**Known lastname **] [**Name (STitle) 60351**]: Preserved biventricular systolic function. LVEF 55%. Normal RV systolic function. Aortic prosthesis is stable and functioning well with residual peak and means of 30 and 12 mm of Hg. Mild to Moderate TR. Intact thoracic aorta. Trivial MR. Brief Hospital Course: Mrs. [**Known lastname **] was a same day admit and on [**4-14**] she was brought to the operating room and underwent an aortic valve replacement and coronary artery bypass graft. Please see operative report for surgical details. Following surgery she was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours she was weaned from sedation, awoke neurologically intact and extubated. Amiodarone was started for premature atrial contractions and eventually discontinued. Chest tubes were removed on post-op day two and she was transferred to the telemetry floor for further care. She started on having episodes of atrial fibrillation and amiodarone was re-started. Epicardial pacing wires were removed and she worked with physical therapy for strength and mobility. By the time of discharge on POD 5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to rehab in good condition with appropriate follow up instructions. Medications on Admission: fosamax 70 q wednesday atenolol 25' lisinopril 20' omeprazole 20' simvastatin 80' aspirin 162' calcium vitamin D MVI ibuprofen prn Discharge Medications: 1. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg [**Hospital1 **] x5days then decrease to 400mg daily x7days then 200 daily ongoing. 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] Of [**Location (un) 620**] Discharge Diagnosis: Aortic Stenosis/Coronary artery disease s/p Aortic valve replacement and coronary artery bypass graft x 3 Past medical history: Hypertension Hypercholesterolemia s/p stent to LAD [**2104**] Osteopenia/Osteoarthritis Anemia Gastroesophageal reflux disease s/p hernia repair s/p tonsillectomy s/p right shoulder surgery post operative afib Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Please call to schedule appointments Surgeon Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] Primary Care Dr. [**Last Name (STitle) **] in [**1-15**] weeks Cardiologist Dr. [**Last Name (STitle) **] in [**1-15**] weeks [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2107-4-19**]

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icd9cm

[ [ [] ] ]

[ "39.61", "36.12", "35.21", "36.15" ]

icd9pcs

[ [ [] ] ]

5845, 5922

3573, 4604

306, 633

6304, 6399

2301, 3550

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4630, 4762

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247, 268

661, 1146

6071, 6283

1415, 1549

6,023

144,115

16743

Discharge summary

report

Admission Date: [**2136-10-29**] Discharge Date: [**2136-11-2**] Date of Birth: [**2066-9-30**] Sex: M Service: [**Hospital1 212**] HISTORY OF PRESENT ILLNESS: The patient is a 70 year old man who was transferred to [**Hospital1 69**] medical intensive care unit on [**2136-10-29**], with the diagnoses of pancreatic pseudocyst and pancreatitis. He was transferred from [**Hospital3 417**] Hospital for further evaluation and treatment at [**Hospital1 188**]. His current illness course dates back to [**2136-9-27**], when he was admitted to [**Hospital3 417**] Hospital for acute on chronic pancreatitis. His hospital course was complicated by changes in mental status thought to be toxic metabolic. He also had aspiration pneumonia diagnosed on chest x-ray and chest CT. On [**2136-10-13**], he was discharged from [**Hospital3 417**] to [**Hospital1 **] for rehab. He was placed on Levaquin at the time of discharge from [**Hospital3 417**]. At rehab at [**Hospital1 **] he spiked a temperature. Urinalysis and culture revealed gram positive cocci, methicillin resistant staph aureus and he was started on vancomycin and his fever improved. However, on [**10-28**] he developed fever again and was transferred back to [**Hospital3 418**] and started on imipenem, Flagyl and vancomycin. Reviewing his imaging history (all of the CT scans and readings were performed at [**Hospital3 417**] Hospital), on [**2136-9-28**] he had an abdominal and pelvic CAT scan with contrast. This revealed acute pancreatitis with modest ascites, decreased enhancement of body of the pancreas worrisome for pancreatic necrosis. Also noted was a small right pleural effusion. On [**2136-10-1**] CT abdomen and pelvis revealed acute pancreatitis, bilateral pleural effusions, bilateral lung base consolidations. On [**2136-10-5**] chest CT with contrast showed bilateral effusions with pulmonary consolidation likely aspiration of oral contrast. On [**2136-10-6**] CTA of the chest no evidence of pulmonary embolus. Diffuse thickening of the distal esophagus, question of esophagitis. On [**2136-10-23**] chest CT decreased effusions in the pleural space. Scattered small nodular densities. Also on [**2136-10-23**] he had an abdominal CT which showed enlargement of the pancreatic head with cystic transformation. CT scan on [**2136-10-28**] was an abdominal CT showing extensive pseudocyst in the head measuring 6 x 7 cm and uncinate process which measured 3 x 4 cm of the pancreas. There was no free fluid observed. Given this history of possible pseudocyst, he was transferred to [**Hospital1 69**] for further evaluation of his fever and potential surgical drainage of a pseudocyst. PAST MEDICAL HISTORY: Recurrent pancreatitis. History of alcohol abuse. Urinary tract infection with MRSA. COPD. Tremors times seven months with preliminary diagnosis of Parkinson disease. Type 2 diabetes mellitus. Hypertension. Hiatal hernia. Esophagitis. Esophageal dysmotility. Gastroesophageal reflux disease. Ulcer at the GE junction. MEDICATIONS ON TRANSFER: Imipenem, Protonix, heparin subcutaneously, trazodone, Atrovent, sliding scale insulin. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He is a former smoker, former drinker. He currently lives with his wife. REVIEW OF SYSTEMS: No fever, chills, headache, chest pain, shortness of breath, cough, dysuria, frequency of urination, blood in bowel movements, nausea, vomiting or diarrhea, numbness, weakness or tingling, abdominal pain. PHYSICAL EXAMINATION: Temperature 98.2, blood pressure 120/82, heart rate 88, respirations 20, saturation 93% in room air. In general, in no acute distress, alert and oriented times two, not oriented to date, but oriented to person and place. HEENT: pupils equal, round and reactive to light. Extraocular motions intact. Oropharynx clear. Neck supple, no nuchal rigidity, no lymphadenopathy. Lungs clear to auscultation bilaterally except for scattered bibasilar rales. Cardiovascular regular rate and rhythm, no murmurs, gallops or rubs. Abdomen soft, mildly distended, nontender, active bowel sounds. Extremities no cyanosis, clubbing or edema. Neurologically he had motor strength which was 4/5 times four extremities in both proximal and distal muscles. Sensation to light touch was intact. Cranial nerves II-XII were intact. LABORATORY DATA: On transfer from the MICU to the medicine floor white blood cell count 6.9, hematocrit 28.0, platelets 548. Sodium 136, potassium 3.8, chloride 104, bicarb 22, BUN 11, creatinine 0.6, glucose 87. Calcium 7.6, mag 2.4, albumin 2.3, total bili 0.3, amylase 54, lipase 33, LDH 149, AST 14, ALT 2, alka phos 52. INR 1.2, PTT 26.1. Urinalysis revealed negative leukocyte esterase, negative nitrite, 6 red blood cells, 12 white blood cells, 2 bacteria. EKG normal sinus rhythm, no acute ST-T wave changes. Mild left axis deviation with left atrial enlargement. Initial portable chest x-ray showed a left retrocardiac density. Subsequent Patient and lateral chest x-ray revealed continued retrocardiac infiltrate and a possible small left sided pleural effusion which likely represented either atelectasis, pneumonia or resolution of previous aspiration pneumonia. MRI of the brain showed no intracranial mass effect, no evidence of infarction. MRI of the thoracic, lumbar and cervical spine revealed multilevel degenerative changes of the lumbosacral spine with mild spinal canal stenosis at L2-L3 and moderate spinal canal stenosis at L3-L4. HOSPITAL COURSE: 1. Pancreatitis. Upon arrival at the medical intensive care unit from [**Hospital3 417**] Hospital, the patient has not complained of any abdominal pain. He has not shown any ill effects from his current bout of pancreatitis. His pancreatic enzymes have all been within normal limits during the course of his hospital stay. These pancreatic enzymes have been checked serially. There is clearly evidence of chronic pancreatitis on his previous CT scans, but there appears to be no acute pancreatitis at present. Patient's pancreatitis was initially treated when he was made NPO and given IV fluids for hydration. Upon arrival to the medicine floor on [**10-31**], he was started slowly on a clear liquid diet. He tolerated this very well, did not complain of abdominal pain. Pancreatic enzymes did not become elevated after starting this diet and he has done very well since starting his diet and has slowly advanced to a full diet. 2. Pancreatic pseudocyst. Regarding the pseudocyst, the hepatobiliary service was consulted to evaluate patient for his pseudocyst. Their initial evaluation and evaluation throughout his hospital course do not indicate any need for surgical intervention or drainage at this point. The pseudocyst has been stable since arrival at [**Hospital1 346**]. 3. Neuro. The patient carried a preliminary diagnosis of Parkinson disease and had apparently been started on both Sinemet and Requip at some point prior to his admission. His wife also informed us that he had seen multiple neurologists and had been evaluated. We asked the neurology consult service to see patient regarding the diagnosis of Parkinson disease and evaluate for any over-medication. After their evaluation, they suggested an MRI of the brain and spine to evaluate for any compression that could possibly be explaining his weakness. The MR of his brain was normal. The MR of his spine did show some spinal canal stenosis which could be consistent with his weakness in an upper motor neuron pattern in the lower extremities. We also checked a CK as a possible explanation for his weakness. This came back at 11. 4. Infectious disease. The patient came to the hospital on imipenem. He was continued on imipenem for a five day course. His white count has remained stable and low throughout his hospital stay. He has been afebrile since arriving at this facility and there is no indication that there is active infection. He will be discharged on no antibiotics. 5. Endocrine. The patient has a history of diabetes mellitus. He has been maintained on sliding scale insulin and has required very little insulin. 6. Pulmonary. The patient has been continued on Atrovent for his COPD. He has been given an incentive spirometer. 7. Rehab. Both the physical therapy and occupational therapy teams were consulted to help patient with his rehabilitation goals. Physical therapy has been working with him on his strength, ambulation and getting from bed. They have continued this throughout his hospital course and recommend working with patient on an intense basis three to five times per week in the rehab facility where he will be discharged to. Patient also had a speech and swallow evaluation given his history of aspiration pneumonia. Upon evaluation there was no evidence that patient was aspirating. He will continue to advance his diet. Recommendation from the speech and swallow team was a soft diet with full liquids. 8. Fluids, electrolytes and nutrition. The patient's electrolytes have been stable throughout the course of his admission. Magnesium has been repleted two times. Patient's urine output dropped somewhat on [**11-1**] when his p.o. intake was not adequate. He responded well to an IV fluid bolus and subsequently has had adequate urine output and has been taking adequate p.o. Again, his diet will be a soft food diet with full liquids. 9. Prophylaxis. The patient has been maintained on heparin subcutaneously, Protonix and pneumo-boots. 10. Cardiovascular. He has been stable throughout his hospital course. 11. Communication. We have communicated with patient's wife throughout hospital stay, updating her on his condition. She is very involved in his care and interested in improving his functional status. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: [**Hospital1 700**] for acute rehab. DISCHARGE MEDICATIONS: 1. Ipratropium bromide two puffs i.h. q.i.d. 2. Trazodone HCl 25 mg p.o. q.h.s. p.r.n. 3. Protonix 40 mg p.o. q.day. 4. Thiamine HCl 100 mg p.o. q.day. 5. Bisacodyl 10 mg p.o. q.day p.r.n. 6. Ropinirole HCl 0.25 mg p.o. t.i.d. 7. Heparin 5000 units subcu q.12 hours. 8. Acetaminophen 325 to 650 mg p.o. q.four to six hours p.r.n. 9. Insulin sliding scale. Regular insulin less than 50 drink [**Location (un) 2452**] juice, 51 to 150 nothing, 151 to 200 2 units subcutaneously, 201 to 250 4 units subcutaneously, 251 to 300 6 units subcutaneously, 301 to 350 8 units subcutaneously, 351 to 400 10 units subcutaneously and please [**Name8 (MD) 138**] M.D. DISCHARGE DIET: Thin liquids with soft solids, diabetic diet. DISCHARGE INSTRUCTIONS: Physical therapy three to five times per week for transfer training, ambulation and HEP. Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10029**] in neurology clinic in four weeks for reevaluation, call [**Telephone/Fax (1) 29128**] for that appointment. Follow up with primary care doctor in the next one to two weeks, please call for an appointment. DISCHARGE DIAGNOSES: 1. Recurrent pancreatitis. 2. Pancreatic pseudocyst. 3. Parkinson disease. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 15868**] Dictated By:[**Last Name (NamePattern1) 47340**] MEDQUIST36 D: [**2136-11-2**] 13:14 T: [**2136-11-2**] 13:12 JOB#: [**Job Number **]

[ "507.0", "294.0", "332.0", "250.00", "577.2", "303.90", "496", "401.9", "577.1" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11126, 11477

9956, 10685

5559, 9844

10710, 11105

3557, 5542

3328, 3534

182, 2713

3089, 3216

2736, 3063

3233, 3308

9869, 9933

13,480

167,966

15951+15952

Discharge summary

report+report

Admission Date: [**2160-5-24**] Discharge Date: [**2160-6-6**] Date of Birth: [**2102-10-23**] Sex: M Service: HISTORY OF PRESENT ILLNESS: This 57 year old white male has a history of coronary artery disease and had dyspnea on exertion while working to work. He had a cast on [**5-22**] which revealed an in-stent restenos. DICTATION ENDED. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Name8 (MD) 964**] MEDQUIST36 D: [**2160-6-6**] 16:37 T: [**2160-6-6**] 18:35 JOB#: [**Job Number 45713**] Admission Date: [**2160-5-24**] Discharge Date: [**2160-6-6**] Date of Birth: [**2102-10-23**] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 57-year-old white male with a known history of coronary artery disease. He is status post multiple PCIs, and most recently had a stent to the LAD on [**2160-5-22**]. On [**2160-5-24**], he became syncopal and his wife was unable to palpate a pulse and initiated CPR. He woke up and complained of chest pain and was taken to [**Hospital **] Hospital Emergency Room where he was found to be in rapid atrial fibrillation. He was treated with IV Lopressor and heparinized and transferred to [**Hospital1 188**]. A cardiac catheterization revealed an EF of 53%, 50% left main, an LAD stent which was patent and he subsequently had a positive stress test which showed ischemic changes and was referred for a CABG. PAST MEDICAL HISTORY: 1. History of coronary artery disease, status post MI with arrest in [**11-1**]. Status post LAD stent in [**11-1**], RCA stent in [**6-2**]. 2. Hypercholesterolemia. 3. Chronic low back pain. SOCIAL HISTORY: He lives with his wife. [**Name (NI) **] works at [**Hospital6 14475**]. He does not smoke cigarettes. He drinks alcohol occasionally. ADMISSION MEDICATIONS: 1. Lipitor 20 mg p.o. q.d. 2. Plavix 75 mg p.o. q.d. 3. Lopressor 25 mg p.o. b.i.d. 4. Nitroglycerin p.r.n. 5. Lisinopril 5 mg p.o. q.d. 6. Aspirin 325 mg p.o. q.d. 7. Niacin. 8. Fish oil. 9. B12. 10. B6. 11. Folic acid. ALLERGIES: The patient has no known drug allergies. REVIEW OF SYSTEMS: Unremarkable. PHYSICAL EXAMINATION: The patient is a thin white male in no apparent distress. Vital signs: Stable, afebrile. HEENT: normocephalic and atraumatic. The extraocular movements were intact. The oropharynx was benign. Neck: Supple. Full range of motion. No lymphadenopathy or thyromegaly. Carotids were 2+ and equal bilaterally without bruits. Lungs: Clear to auscultation and percussion. Cardiovascular: Regular rate and rhythm. Normal S1, S2. No rubs, murmurs, or gallops. Abdomen: Soft, nontender, with positive bowel sounds. No masses or hepatosplenomegaly. Extremities: Without cyanosis, clubbing or edema. Neurologic: Nonfocal. HOSPITAL COURSE: Dr. [**Last Name (STitle) 70**] was consulted and on [**2160-5-30**], the patient underwent a CABG times three and he had a cardiac arrest on induction. He was put on bypass and cannulated from the groin. He had saphenous vein graft to the LAD with a Y graft to the ramus and a saphenous vein graft to the OM. The cross clamp time was 33 minutes, total bypass time 118 minutes. He was transferred to the CSRU on milrinone, Levophed, epinephrine, Amiodarone, and an insulin drip. He also had a repair of his right femoral artery after the cannulas were taken out. He was extubated on his postoperative night. On postoperative day number one, he was weaned off milrinone and Levophed, started on Lasix. On postoperative day number two, he had his chest tubes discontinued. On postoperative day number three, he was transferred to the floor in stable condition. He had his epicardial pacing wires discontinued on postoperative day number four. He continued to have a stable postoperative course. On postoperative day number seven, he was discharged to home in stable condition. His laboratories on discharge revealed a white count of 10,400, hematocrit 28.8, platelets 245,000. Sodium 140, potassium 4.4, chloride 103, C02 30, BUN 17, creatinine 0.9, blood sugar 99. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q.d. 2. Colace 100 mg p.o. b.i.d. 3. Plavix 75 mg p.o. q.d. 4. Lipitor 10 mg p.o. q.d. 5. Atenolol 25 mg p.o. q.d. 6. Levofloxacin 500 mg p.o. q.d. for 14 days. 7. Vicodin one to two p.o. q. four to six hours p.r.n. pain. DISCHARGE DIAGNOSIS: 1. Coronary artery disease. 2. Hyperlipidemia. 3. Status post myocardial infarction. FOLLOW-UP: The patient will be followed-up by Dr. [**Last Name (STitle) **] in one to two weeks, Dr. [**Last Name (STitle) **] in one to two weeks, and Dr. [**Last Name (STitle) 70**] in six weeks. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (NamePattern1) 6516**] MEDQUIST36 D: [**2160-6-6**] 04:45 T: [**2160-6-6**] 18:35 JOB#: [**Job Number 45714**]

[ "414.01", "401.9", "780.2", "272.0", "997.2", "997.1", "427.5", "413.9", "412" ]

icd9cm

[ [ [] ] ]

[ "37.23", "38.87", "88.53", "36.13", "39.61", "88.56", "39.31", "88.72" ]

icd9pcs

[ [ [] ] ]

4222, 4475

4496, 5087

2921, 4199

1934, 2218

2276, 2903

2238, 2253

811, 1535

1557, 1755

1772, 1911

78,251

144,353

41891

Discharge summary

report

Admission Date: [**2104-2-21**] Discharge Date: [**2104-4-10**] Date of Birth: [**2064-1-26**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 6346**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Incarcerated ventral hernia repair with mesh, diastasis plication, and panniculectomy History of Present Illness: 40 year old female with complex PMH significant for severe morbid obesity. Presented to OSH 2 months prior with concern for incarcerated ventral hernia. Imaging revealed no incarceration, however patient continues to experience significant pain and disability related to hernia. Presents for herniorrhaphy ventral w/ mesh. Consulted by surgical team for epidural placement for post-operative pain management. The patient is a very pleasant young woman with a history of super morbid obesity with a BMI of 73. She has multiple medical problems. Had had multiple cesarean sections and developed a very painful anterior abdominal bulge which was not reducible. It was causing her severe discomfort. It was making it difficult for her to ambulate. Outpatient CT demonstrated that there was incarcerated fat and colon within the hernia sac, but there was no evidence of ischemia or obstruction. She was offered repair of that hernia understanding the significant risk given her multiple medical problems. Consent was reviewed and signed on the date of surgery, understanding that severe complications outside of wound morbidity were possible. Past Medical History: PMHx: Hypothyroidism GERD cellulitis - bilateral LEs/abdomen severe morbid obesity venous stasis disease diverticulitis Pickwickian syndrome dyslipidemia asthma dyspnea (with rest and exertion) O2 dependent (2LNC) mild concentric LVH - ECHO [**6-26**] HTN h/o renal stones chronic low back and leg pain anxiety PSHx: c-section x 2 left foot cyst excision bilateral lower extremity surgery as child ? hip dysplasia; "full body cast" Social History: h/o tobacco abuse - quit [**2104-2-13**]; prior [**4-6**] cigs/day x 20 yrs denies ETOH or illicits wheelchair bound with home VNA services Family History: Non-contributory Physical Exam: Admission Exam: GENERAL: morbidly obese female; intubated; sedated in ICU HEENT: PERRL; ETT in situ; trachea midline HEART: RRR LUNGS: diminished bilaterally with scattered coarse rhonchi ABD: morbidly obese; soft; transverse abdominal incision intact with surgical dressing MSK/EXT: warm/perfused; chronic venous stasis changes to bilateral LEs; unable to assess motor function [**12-20**] sedation Discharge Exam: Pertinent Results: [**2104-2-21**] 10:36PM TYPE-ART TEMP-36.9 PO2-62* PCO2-48* PH-7.35 TOTAL CO2-28 BASE XS-0 [**2104-2-21**] 10:36PM TYPE-ART TEMP-36.9 PO2-62* PCO2-48* PH-7.35 TOTAL CO2-28 BASE XS-0 [**2104-2-21**] 09:29PM LACTATE-1.4 [**2104-2-21**] 09:29PM freeCa-1.14 [**2104-2-21**] 09:20PM GLUCOSE-168* UREA N-11 CREAT-0.9 SODIUM-138 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13 [**2104-2-21**] 09:20PM estGFR-Using this [**2104-2-21**] 09:20PM PLT COUNT-265 [**2104-2-21**] 03:41PM TYPE-[**Last Name (un) **] PO2-72* PCO2-41 PH-7.42 TOTAL CO2-28 BASE XS-1 INTUBATED-INTUBATED [**2104-2-21**] 03:41PM HGB-13.6 calcHCT-41 [**2104-2-21**] 03:41PM HGB-13.6 calcHCT-41 [**2104-2-21**] 03:41PM freeCa-1.15 [**2104-2-21**] 03:41PM freeCa-1.15 Brief Hospital Course: 40 y/o F with known pulmonary hypertension secondary to obesity hypoventilation syndrome with low oxygen saturation at baseline, severe morbid obesity and decreased functional capacity presented for repair of a large incarcerated bowel-containing ventral hernia. The surgery itself went without complication, however, post-operatively she remained intubated and was transfered to ICU for low oxygen saturation/suboptimal ventilation requiring mechanical ventilation. In brief, her hospital course was characterized by two codes during attempted extubation in the perioperative period due to severe pulmomnary hypertension with frequent desaturation, excessive PEEP requirements (up to 36), a resistant pseudomonas ventilator acquired pneumonia resulting in a prolonged endotracheal intubation with slow wean with eventual tracheostomy on POD 39. Neuro: She was initially sedated with midazolam drips, fentanyl drips and intermittently paralyzed with cisatracurium as needed for ventilation (when dysynchronous with the ventilator). She was monitored with BIS to try and help ensure sedation. The sedation was gradually weaned to off as of POD 24 with intermittent fentanyl being used for pain control as needed thereafter. She grimaced to pain and was intermittently opening her eyes initially but by the latter end of her hospital course (POD 44) was awake and oriented and appropriately responsive. Of note, she was noted to have what appeared to be a generalized seizure on POD 38. The seizure was attributed to withdrawal from benzodiazepines due to discontinuation of a rather heavy initial benzodiazepine sedation requirement. The neurology team consulted and recommended low dose ativan around the clock with a slow wean. She did not have further seizures during this hospitalization. Cardiac: She was initally on a number of different pressors including norepinephrine, epinephrine, vasopressin and milrinone which did help keep her blood pressures adequate. Several echocardiograms were done which consistently showed right heart strain. A swan was also inserted on POD 7. Her BP was monitored with radial arterial lines. She coded 3 times while in the unit. The first two described above (and in the pulmonary section) and the third time on POD 8 following an incident in she was being turned for nursing care. The patient became acutely hypoxic with saturations down to the low 40's for about a 10 minute period of time. She also became very tachycardic with V tach noted on the monitor. While the pads were being charged to shock she spontaneously converted back to sinus rythym, though tachycardic. She was briefly started on an epinephrine drip and slowly weaned without incident. She was only briefly hypotensive during this time. She did not have any additional code or abnormal rythyms following the incidents as mentioned above, but did remain low-grade tachycardic throughout her hospitalization. Please see the "Pulmonary" section for further details. Pulmonary: Ms. [**Known lastname 24642**] had severe pulmonary insuffiency requiring ventilation with very high FiO2 and PEEP settings. She was unable to wean off the ventilator post-operatively and while in the SICU (2 failed attempts at extubation in the first few post-operative days that involved desats, bradycardia, hypotension ultimately leading to codes being called and epinephrine and atropine given with stabilization). She required very high PEEP levels -- which was at one point as high as 36. She had known pulmonary hypertension (thought to be Pickwikian syndrome, obesity hypoventilation syndrome) and was found to have significant pulmonary artery pressures (PA pressures higher than arterial pressures at times by swan but generally in the 90's systolic) and treated with sildenafil 40 TID. The Pulmonology team was consulted to assist with her pulmonary hypertension and her ventilatory status. Lasix was used in both bolus and drip dosing at various points during her hospitalization to help with diuresis and to improve PA pressures. Her hospital course was characterized by her oxygen saturation fluctuating between the high 90s and low 80s, with fluctuations onset with small changes in positioning or other slight changes. Due to her tenuous respiratory status and excessive PEEP requirement cardiac surgery was consulted early for consideration of ECMO however she was deemed a poor candidate given the high risk of complication given her body habitus. When the PEEP was weaned to below 16, she was taken for tracheostomy with the thoracic surgery team on POD 39. Because of her persistently high PEEP requirement and rather tenuous respiratory status, interventional cardiology and cardiac surgery coordinated to provide standby ECMO in the event that she coded during the tracheostomy procedure. Fortunately, while she was cannulated for ECMO through her neck vasculature, she did not require actual ECMO bypass and the tracheostomy was completed without acute complication. Post tracheotomy her PEEP was gradually lowered, to 14 at the time of discharge. She was transitioned to CPAP and tolerated this well as she awoke from the sedation. Of note, she did have a ventilator associated pneumonia -- with resistant pseudamonas and serratia. Please see the ID section for additional details. Additionally, she was maintained on a heparin drip empirically due to her severe respiratory compromise and then continued prophylactically to avoid developing a pulmonary embolism which would have been catastrophic (due to her tenous condition on high ventilator settings initially as well as body habitus it was not possible to obtain a CT scan to definitively rule out a pulmonary embolism. Nonetheless, there was no secondary evidence of one either by LENIS or by echo though given the severity of the pulmonary hypertension it could not be ruled out. She was transitioned to coumadin at the end of her stay. GI: When deemed safe, she started on tube feeds via an OGT (later converted to an NGT then dobhoff) for nutrition which she tolerated well. Her tube feeds were Peptamen Bariatric Full Strength with additives: Banana flakes, 3 packets per day at a goal rate of 65 ml/hr with 100 cc flushes every 8 hours. On POD 42, a PEG tube was attempted at bedside however the procedure was aborted as it was difficult to obtain a safe window through which to percutaneously enter the stomach (inability to transilluminate through abdominal wall, inability to insufflate). A dobhoff was placed at this time which was deemed the safest way to pursue enteral nutrition and this continued to serve as the conduit for her tube feeding. GU: Foley was in place during this admission both for urine output monitoring as well due to incontinence while intubated and sedated and the inherent difficulties in cleaning her while she was fragile from a respiratory perspective. Urine cultures grew Pseudomonas, Serattia and Yeast and she was covered with antibiotics's as outlined below in the ID section. She was on a lasix drip intermittently and then switched to intermittent lasix boluses as needed as noted in the CV/Pulmonary section. Heme: She was maintained on a heparin drip initially empirically and then prophylactically to avoid complications of a potential pulmonary embolism which was believed would be fatal given her severe respiratory compromise. The PTT was titrated to a level between 60-90 and during the latter portion of her stay she was started on coumadin while the heparin drip was continued. Her discharge INR was 1.8 and the heparin drip was discontinued on discharge with plans to continue warfarin 5 mg daily with INR checks at rehab. ID: Ms. [**Known lastname 24642**] received therapy with multiple antibiotics, including vancomycin, cipro, zosyn, meropenem, flagyl, tobramycin, ceftazidime and fluconazole. She was found to have pseudomonas and serratia marcasens in the urine on [**2-27**]. She was treated with ciprofloxacin and then vancomycin and zosyn when it was also found in the sputum on [**3-5**]. Repeat urine cultures were then initially negative until multiple repeat urine cultures with yeast, as recently as [**2104-4-4**]. This was thought to be colonization and she was seemingly asymptomatic (no erythema or obvious infection in the genital region) and since it was a single source it was not treated with antifungals. The foley catheter was replaced several times after positive cultures. Her respiratory culture initially was positive for pseudamonas and serratia on [**3-5**] and since repeated positive for pseudamonas on sputum, mini-BAL and BAL samples, as recently as [**4-3**]. She completed the aforementioned course of vanc/zosyn and then was placed on [**Last Name (un) 2830**]/ceftazidime before finally finishing with a 10 day course of ceftazidime/tobramycin that completed on [**3-30**] per recommendations of the infectious disease service. She was febrile again on [**4-6**], which was thought to be potentially related to a line infection. The LIJ CVL was removed as well as the arterial line and she was started on vancomycin. She completed a three day course of vancomycin which was dc'd on [**4-9**]. She remained afebrile after the initial temperatures on [**4-6**], her WBC count trended back up (peak 14)but stabilized and was trending down at time of discharge. Her pan cultures as well as line tip cultures were no growth to date as of time of her discharge. She did test positive for Cdiff on PCR testing on [**2104-2-29**] and was started on PO and IV vancomycin with flagyl IV. This was discontinued on [**2104-3-21**] after repeated negative cdiff tests and clinical improvement of loose stool and her WBC count. Tubes lines and drains: Foley, dobhoff, flexiseal, right PICC ([**4-4**]-). She also had the following with dates of insertion/removal as listed: R IJ CVL ([**Date range (1) 90944**]), R radial aline ([**Date range (1) 90945**] ), L radial aline ([**Date range (1) 70307**]), L axillary a-line ([**Date range (1) 90946**]) right midline ([**Date range (1) 90947**]), left PICC ([**Date range (1) 90948**]), A-line (dc'd [**4-4**]), L IJ CVL ([**Date range (1) 43828**]) Endo: FSG Goals were BG < 150 which was generally achieved using SSI. She was continued on home levothyroxine. Due to concern for adrenal insufficiency she was placed on hydrocortisone succinate 100 mg Q8 which was eventually weaned to off. Goals of Care: Patient did not have a health care proxy so one was appointed by the state. Medications on Admission: Colace 100mg daily Flexeril 10 mg TID Ibuprofen prn Klonopin 1 mg [**Hospital1 **] Lasix 40 mg daily MVI Potassium ER 20 Meq daily Niacin 500 mg daily Percocet 5/325mg 1 tab prn Omeprazole 20 mg daily Synthroid 50 mcg daily Zoloft 150 mg daily Discharge Medications: 1. levothyroxine 50 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler [**Hospital1 **]: 6-8 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. 3. miconazole nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID (3 times a day). 4. docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2 times a day): hold if loose stools. 5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 6. white petrolatum-mineral oil 56.8-42.5 % Ointment [**Hospital1 **]: One (1) Appl Ophthalmic PRN (as needed) as needed for dry eyes. 7. nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO QID (4 times a day) as needed for thrush. 8. sildenafil 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3 times a day). 9. oxycodone 5 mg/5 mL Solution [**Hospital1 **]: One (1) PO Q4H (every 4 hours) as needed for Pain. Disp:*30 * Refills:*0* 10. sertraline 50 mg Tablet [**Hospital1 **]: Three (3) Tablet PO DAILY (Daily). 11. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 12. zolpidem 5 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO HS (at bedtime). 13. lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 14. furosemide 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 15. metoprolol tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2 times a day). 16. warfarin 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QHS (once a day (at bedtime)). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Ventral Hernia Acute Respiratory Failure Pulmonary Hypertension Congestive Heart Failure Morbid Obesity 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: Dear Ms. [**Known lastname 24642**], You were admitted to the West 3 general surgery service for you ventral hernia repair. Post operatively you were admitted to the ICU for continued respiratory support. While in the ICU you were treated with antibiotics for a number of different infections. Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drive or operate heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. Incision Care: *Please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until cleared by your surgeon. *You may shower and wash incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Thank you for letting us participate in your care. We wish you a speedy recovery. Followup Instructions: Department: SURGICAL SPECIALTIES When: MONDAY [**2104-3-17**] at 1:45 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8318**], MD [**Telephone/Fax (1) 2998**] Building: [**Street Address(2) 3001**] ([**Location (un) 620**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Parking on Site Completed by:[**2104-4-10**]

[ "041.85", "V46.3", "278.1", "008.45", "V85.45", "493.90", "401.9", "E879.8", "552.21", "790.7", "244.9", "300.00", "728.84", "459.81", "278.03", "292.0", "997.31", "530.81", "682.8", "428.0", "707.8", "276.2", "996.64", "518.51", "272.4", "304.10", "416.8", "278.01", "780.39", "276.4", "V46.2", "041.7", "E879.6" ]

icd9cm

[ [ [] ] ]

[ "96.72", "88.72", "33.22", "33.24", "83.65", "96.6", "53.61", "03.90", "31.1", "86.83" ]

icd9pcs

[ [ [] ] ]

16089, 16155

3472, 14014

318, 405

16302, 16302

2691, 3449

18141, 18498

2209, 2228

14308, 16066

16176, 16281

14040, 14285

16477, 17531

17546, 18118

2243, 2655

2672, 2672

264, 280

433, 1580

16317, 16453

1602, 2036

2052, 2193

12,754

169,279

24338

Discharge summary

report

Admission Date: [**2111-4-1**] Discharge Date: [**2111-4-7**] Date of Birth: [**2073-6-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 18369**] Chief Complaint: cough, fever Major Surgical or Invasive Procedure: R CVL History of Present Illness: 37M h/o recently diagnosed widely metastatic melanoma s/p 1 dose dacarbazine on [**2111-3-26**]. Reports feeling unwell the night prior to admission and had fever of 101.5 at home. Also reports 1 day of cough productive of green sputum. +nausea related to chemo. +diarrhea. +le edema and abdominal distention which have been present from >1 week. +night sweats. reports decreased appetite but states he has been drinking plenty of fluids. . denies ha, neck stiffness, emesis, cp, constipation, dysuria, urinary frequency or discharge, rashes. no sick contacts. no h/o or risk factors for TB exposure. . In ED, found to have T 97.9, HR 86, BP 94/60, Lactate =6.5; Started on MUST protocol. received 5L of NS, cefepime 2gm iv, CVL placement. BP increased to 130/76. Admitted to ICU for sepsis monitoring Past Medical History: 1. Widely metastatic melanoma diagnosed [**3-26**] after seeking medical attention for a large L posterolateral neck mass. CT as OSH has shown extensive liver, lung, mesenteric mets and pleural effusion. Pt was started on dacarbazine q 3wks on [**2111-3-26**], if responds then plans to initiate interleukin therapy. . 2. HTN Social History: Brother [**Name (NI) **] [**Name (NI) 61660**] is proxy. Sister is [**Name (NI) **] [**Name (NI) **]. Pt is single unemployed computer programmer. Denies tob, EtOH, drugs. Lives in [**Location 7658**] MA. Family History: Father died of colon CA at 63, Mother EtOH cirrhosis Physical Exam: On admission to ICU: -------------------- 97.3, hr 99 (80-100), 117/69 (90-130/70s); rr 24 99% on 3l, 88-90% on ra; urine output 200cc. Gen: slightly diaphoretic, unwell appearing HEENT: anicteric; pupils/OP clear Neck: large black fungating mass on left neck, no evidence of superimposed infection or necrosis; neck supple CV: rrr PULM: basilar crackles b/l; decreased bs on rt comparted to left; no egophony or tactile fremitus ABD: +bs, soft, distented but nontender; no cva tenderness EXT: 2+ LE edema b/l SKIN: no rashes NEUR: AAOx3, cn 2-12 intact Pertinent Results: Admission Labs: --------------- * CBC:WBC-21.9* RBC-4.92 HGB-13.8* HCT-41.9 MCV-85 MCH-28.0 PLT 282 * DIFF:NEUTS-80* BANDS-6* LYMPHS-6* MONOS-8 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1* * CHEM: GLUCOSE-98 UREA N-47* CREAT-1.2 SODIUM-126* POTASSIUM-6.1* CHLORIDE-86* TOTAL CO2-25 ANION GAP-21* * LFTs: AST/ALT- 563/263 (baseline 172/173); Tbili 4.8 (b/l 3.6); A/P 233 (b/l 248) * Lactate Trend: [**2111-4-1**] 02:05PM LACTATE-6.5* [**2111-4-1**] 06:04PM BLOOD Lactate-3.9* [**2111-4-1**] 08:40PM BLOOD Lactate-3.5* [**2111-4-1**] 09:36PM BLOOD Lactate-3.7* [**2111-4-1**] 10:56PM BLOOD Lactate-4.4* [**2111-4-2**] 04:24AM BLOOD Lactate-4.0* [**2111-4-2**] 08:49AM BLOOD Lactate-4.2* * Micro: ------- [**4-1**] Blood Cx: NGTD [**4-1**] Urine Cx: NGTD [**4-1**] Stool Cx: NGTD [**4-1**] Sputum CX: 4+ oropharyngeal flora * Radiologic Studies: ------------------ [**4-1**] CXR: No focal pneumonic consolidation. Subtle interstitial and nodular pattern may represent atypical or miliary type infection given the history of recent chemotherapy and probable immunosuppression [**4-2**] RADIOLOGY Final Report Slight increase in opacity in the right lower lobe represents increasing atelectasis/consolidation. Persistent subtle reticulonodular pattern throughout both lung fields. If further characterization is desired, a CT scan is recommended [**4-2**] Echo Conclusions: 1. The left atrium is normal in size. 2.Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3.Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic root is mildly dilated. The ascending aorta is mildly dilated. 5.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. 6.The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. 7.The estimated pulmonary artery systolic pressure is normal. 8.There is no pericardial effusion. [**4-3**] Abdominal MRI REPORT: The patient has diffuse metastatic disease, with pulmonary, soft tissue, hepatic, renal and bone marrow metastases being seen. The liver is diffusely replaced by hepatic metastases. The liver is also enlarged. The metastases are causing marked compression of the intrahepatic IVC. The intrahepatic IVC, however, does appear to be patent. Note is made of attenuation of the posterior branch of the right portal vein ,but this remains patent. The left hepatic vein, however, is occluded throughout its proximal extent. In the lateral segment of the left lobe, it may be partially patent. No other vascular occlusion is noted. CONCLUSION: Extensive metastatic disease. Markedly compressed, but patent IVC. Markedly compressed, but patent intrahepatic portal vein, particularly the posterior branch of the right portal vein. Partial thrombosis of left hepatic vein. Brief Hospital Course: Brief Hospital Course: Admitted to ICU for sepsis monitoring on MUST protocol for lactate >4. He was aggressively IVF repleted to maintain CVP >8, and mixed venous O2 was maintained >70%. He never required pressor support or intubation. His random cortisol was normal at 36. Given his localizing symptoms of cough and positive CXR for atypical pneumonia he was treated with ceftriaxone and azithromycin empirically. In addition blood, urine, sputum and stool cultures were sent for infectious work-up. His lactate improved overnight to 4.0 and he remained afebrile and hemodynamically stable. Therefore he was transfered to the general medicine service on hospital day 2. after being transferred to medicine main issue were as follows: . 1. PNA: imaging seemed consistent with atypical pna with ceftriaxone (which would also cover urinary source as well) and azithromycin. Urinary legionella ag was negative. However, on repeat imaging a consolidation became apparent and patient sputum cultures grew staph aureus. He was started on vancomycin and then switched to oxacillin when his cultures grew MSSA. Urine cultures and blood cultures showed no growth at the time of this dc summary. White count continued to increase into the 30's- likley from bm involvement of tumor (was seen on mri). . 2.SOB: Patient continued to complain of some sob and dyspnea, though to be likely from pna and mets, patient was continued on oxygen with close monitoring . 3. metastatic melanoma: very poor prognosis. Dacarbazine response rate is 10-20% of pt's with this severity of dz and subsequent interleukin-2 (which pt is already too ill for) only has 10% response rate as well. Dacarbazine could be source of fever as well (flu-like symptoms seen in [**12-1**]% of cases) and source of elevated LFTs. We expected counts to nadir in [**5-31**] days from chemo ([**3-26**]). Given his poor prognosis and tenous clinical status, code status was readdressed, and patient was made dnr/dni. Patient clinical status continued to decline (see below) and he was made cmo (see below) . 4. Abdominal distention/LE edema/ liver failure- Patient continued to complain of abdominal distenstion and he had a transaminitis, with elevated ldh, alk phos, and t bili. It was suspected that this was due to his liver mets and perhaps compression/obstruction of biliary ducts and vascular system. Given his abdominal distension there was a question of ascites. (originally the possibility of sbp was addressed but patient abdomen was nontender and in the [**Hospital Unit Name **] the team felt it was unlikely to be the cause of his symptoms). He also had extensive lower extremity edema and there was concern of ivc comprssion. An ultrasound was obtained to eval portal/ivc flow and see if there was enough fluid to be tapped. The ultrasound showed no fluid. We felt that his elevated lactate may be secondary to his liver mets It was also felt that part of his transaminitis was from dacrabazine. An MRI was obtained that showed markedly compressed, but patent IVC; markedly compressed, but patent intrahepatic portal vein, particularly the posterior branch of the right portal vein; and probable partial thrombosis of left hepatic vein. We spoke with attending and decided to hold off on anticoagulation for now as patient was. not a good candidate for anticoagulation. It was felt that compression of vessels and partial thrombus combined with a low albumin was likely causing patients extensive lower extremity edema. 5. coagulapthy: His inr was 2.4, likely due to poor synthetic function and nutritional deficiency. He was gievn vitamin K. 6. Diarrhea: stool was sent for c. diff, cultures, O and P- all no growth to date. 7. Acute renal failure - cr began trending up with decreased urine output, urine lytes and FENA support that he was intravascularly dry and likely third spacing fluid. In addition, MRI showed renal mets which were likley contributing to her failure. We had curbsided renal who felt that that patient would not be a dialysis candidate. At that point his clinical and mental status began to deteriorate, and the patient seemed at a terminal stage. It seemed futile to further work up his renal failure, and a family meeting was held with the hospice team. Patient was then transitioned to comfort care only. . 8. FEN -hyponatremia: likely hypervolemic hyponatremia, urine lytes did not support SIADH . 9. Neuro: Patient developed diplopia, but refused imaging/ work up as he did not want to know if he had brain mets, csf or brainstem involvement. Patient passed away [**4-7**] at 10:30 AM- attdg, family and admitting aware Medications on Admission: MS contin 30 [**Hospital1 **] stool softeners atenolol 50 daily ativan 1mg qhs prn compazine Discharge Medications: Patient passed away [**4-7**] at 10:30 AM- attdg, family and admitting aware Discharge Disposition: Expired Discharge Diagnosis: Patient passed away [**4-7**] at 10:30 AM- attdg, family and admitting aware Discharge Condition: Patient passed away [**4-7**] at 10:30 AM- attdg, family and admitting aware Discharge Instructions: Patient passed away [**4-7**] at 10:30 AM- attdg, family and admitting aware Followup Instructions: Patient passed away [**4-7**] at 10:30 AM- attdg, family and admitting aware Completed by:[**2111-4-7**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

10305, 10314

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327, 334

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24,824

108,861

7754

Discharge summary

report

Admission Date: [**2115-3-13**] Discharge Date: [**2115-3-20**] Service: Cardiothoracic HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old woman with left circumflex stent in [**2113-7-30**] after a non Q-wave myocardial infarction with recent return of angina at rest x2 weeks, referred to [**Hospital6 2018**] for a diagnostic catheterization from [**Hospital3 28116**]. On catheterization prior to her stenting in [**2113-7-30**], the patient had an LAD with a total occlusion, a proximal circumflex of 90% at the OM1 and an RCA of 50%. Her ejection fraction at that time was 45%. She has done well since then with no recurrence of symptoms. Two weeks ago, she had an acute onset of nocturnal angina, took two sublingual nitroglycerin with relief. She saw her primary care provider and was started on nitroglycerin paste and is now referred back for catheterization. PAST MEDICAL HISTORY: 1. Severe low back pain which is chronic. 2. Hypothyroid. 3. Status post appendectomy. 4. Status post bladder suspension. 5. Status post hemorrhoidectomy. 6. Status post ovarian cyst removal. 7. Abdominal aortic aneurysm, which has been stable for the past three to four years followed by CT scan q 3 to 4 months. 8. Hypertension. Cardiac risk factors include positive for hypertension, positive for high cholesterol, negative for diabetes mellitus, negative for smoking, positive for family history. SOCIAL HISTORY: Significant for tobacco use. She has stopped x1 year. Prior to that she smoked one pack per day for 60 years. TRANSFER MEDICATIONS: 1. Captopril 37.5 mg tid. 2. Synthroid 0.15 mg qd. 3. Lopressor 25 mg [**Hospital1 **]. 4. Hydrochlorothiazide 25 mg qd. 5. Lipitor 10 mg qd. 6. Potassium chloride 20 milliequivalents qd. 7. .............. 20 mg qd. 8. Miacalcin nasal spray 2200 international units qd. 9. Aspirin 325 mg qd. 10. Nitroglycerin 0.4 sl prn. SOCIAL HISTORY: The patient lives in [**Location 28117**] with [**Last Name (LF) 15560**], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 28118**]. LABORATORY DATA: INR is 1.0. White blood cell count is 8.5, hematocrit 37.7, platelets 442. Sodium is 140, potassium 4.6, chloride 101, CO2 31, BUN 18, creatinine 0.8, glucose 87. ADMISSION PHYSICAL EXAM: GENERAL: The patient feels well with no complaints of shortness of breath or chest pain. LUNGS: Clear to auscultation. HEART: Heart sounds are regular rate and rhythm, S1, S2 with no murmurs, rubs or gallops. EXTREMITIES: She has bilateral femoral pulses with a soft bruit, trace dorsalis pedis and posterior tibial pulses. ABDOMEN: Soft, nontender with no bruits. She has been NPO for cardiac catheterization. The patient underwent cardiac catheterization. Please see catheterization report for full details. In summary, the catheterization showed apical dyskinesis, inferior hypokinesis with an ejection fraction of 35%, LAD 100% lesion, circumflex 60% mid lesion, RCA 75% mid lesion with diffuse disease throughout. The cardiothoracic surgical team was consulted. The patient was seen by cardiothoracic surgery and the option of surgical intervention was discussed with the patient. She was accepted by cardiothoracic surgery for coronary artery bypass grafting and on [**3-15**] she was brought to the Operating Room where she underwent coronary artery bypass grafting x3. Please see the Operating Room report for full details. In summary, the patient had a coronary artery bypass graft x3 with a left internal mammary artery to the LAD, a saphenous vein graft to the PDA and a saphenous vein graft to OM1. The patient tolerated the procedure well and was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit. She did well immediately postoperatively and was extubated on the day of her surgery. She remained hemodynamically stable overnight on a small dose of Neo-Synephrine which was weaned off on the morning of postoperative day #1. She remained hemodynamically stable off the Neo-Synephrine and was transferred to the floor for continuing postoperative care and cardiac rehabilitation. Her chest tubes were discontinued on postoperative day #1. Over the next several days, the patient did well. Her activity level was increased. Her only complaint throughout the next several days was nausea felt to be related to the Percocet which she was receiving for pain. Percocet was discontinued and nausea resolved. On postoperative day #3, the patient's Foley catheter was removed and on postoperative day #5, the patient's temporary pacemaker wire was removed. At that time, it was felt that the patient was hemodynamically stable and her activity level was adequate that she could be discharged to home and arrangements were made for the patient to be discharged to home with a [**Month (only) **] nurse [**First Name (Titles) **] [**Last Name (Titles) **] physical therapy follow up at her home. At the time of discharge, the patient's condition is stable. DISCHARGE PHYSICAL EXAM: VITAL SIGNS: Temperature 98.7??????, heart rate 67 sinus rhythm, blood pressure 119/65, respiratory rate 20, O2 saturation 94% on room air. Her preoperative weight is 70.8 kg. Her discharge weight is 72.6 kg. GENERAL: Alert and oriented x3, moves all extremities, follows commands. RESPIRATORY: Breath sounds decreased at the left base, otherwise clear to auscultation. Heart sounds regular rate and rhythm, S1, S2, no murmurs, rubs or gallops. Sternum is stable. Incision with Steri-Strips open to air, clean and dry. ABDOMEN: Soft, nontender, nondistended with normoactive bowel sounds. EXTREMITIES: Warm and well perfused with 1+ edema of the left lower extremity. Left lower extremity incisions are with Steri-Strips, open to air, clean and dry. DISCHARGE LAB DATA: Hematocrit 24.9, sodium 138, potassium 4.3, chloride 102, CO2 28, BUN 30, creatinine 0.9, glucose 108. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg qd. 2. Colace 100 mg [**Hospital1 **]. 3. Lasix 20 mg qd x7 days. 4. Potassium chloride 20 milliequivalents qd x7 days. 5. Metoprolol 25 mg [**Hospital1 **]. 6. Captopril 37.5 mg q8h. 7. Synthroid 0.15 mg qd. 8. Lipitor 10 mg qd. 9. Miacalcin nasal spray 2200 international units qd. 10. Tylenol 650 mg q4h prn. The patient is to be discharged home with VNA. She is to have follow up with Dr. [**Last Name (STitle) 1537**] in one month, follow up wound check in two weeks, also to have follow up with Dr. [**Last Name (STitle) 28119**] within a month and with her primary care provider also within [**Name Initial (PRE) **] month. DISCHARGE DIAGNOSES: 1. Coronary artery disease, status post coronary artery bypass graft x3 with left internal mammary artery to LAD and saphenous vein graft to PDA and saphenous vein graft to OM. 2. Hypothyroid. 3. Status post appendectomy. 4. Status post bladder suspension. 5. Ovarian cyst removal. 6. Abdominal aortic aneurysm. 7. Hypertension. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Name8 (MD) 415**] MEDQUIST36 D: [**2115-3-20**] 12:14 T: [**2115-3-20**] 12:25 JOB#: [**Job Number 28120**]

[ "411.1", "429.9", "244.9", "412", "441.4", "272.0", "V17.3", "414.01", "401.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6615, 7219

5934, 6594

2287, 4999

1581, 1913

129, 896

918, 1429

1930, 2272

5024, 5911

53,787

126,817

2629

Discharge summary

report

Admission Date: [**2163-3-24**] Discharge Date: [**2163-3-30**] Date of Birth: [**2089-9-14**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 602**] Chief Complaint: Anemia/ Hyperkalemia Major Surgical or Invasive Procedure: Upper endoscopy Colonoscopy History of Present Illness: 73 yo F DM2, COPD, CKD, called in by outpatient provider due to hyperkalemia and anemia. Initially complained of dyspnea at PCPs office. Patient reported a few weeks of progressive dyspnea, severe over past 3 days limiting her to only a few steps. Patient reports no recent sputum production, f/c but does endorse a runny nose. No med non-compliance, no orthopnea/ PND, no chest pain. Patient also does not report changes in her bowel habits (no melanotic stools). PCP diagnosed with COPD exacerbation, had labs drawn, gave prednisone taper and sent home. PCP then called patient into the ED from home when labs came back with Hct 19.7 and K of 6.9. Upon arrivival to the ED, initial vitals [**Company 13206**] 98.7, BP 162/53, HR 96, RR 22 97% on 2L NC. Exam was remarkable for coarse breath sounds. CXR negative. EKG shows TWI in V3-V6, STD in I, II, AVF, V3-V6. Guaiac negative rectal exam. Patient got 10 units regular insulin, 25gm IV dextrose, 2g IV calcium gluconate and kayexalate. On arrival to the ICU, initial vitals T 100.2, HR 93, BP 129/30, RR 20 sat 90% on RA, up to 100% on nebulizer. Patient had bowel movement upon arrivival which was guiac positive. She was speaking in full sentences and not using accessory muscles to breath. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight changes. Denies headache, sinus tenderness 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 COPD - last PFTs [**3-9**] FVC/FEV1 68, FVC 82% pred, FEV1 81% pred. stage I, mild COPD. She reports being on Home O2 for a period of [**4-3**] months in the past. Her last COPD flare requiring steroids and admission was 1.5 years ago. #2 current tobacco use although cutting back #3 DM II - hgb A1c 7.9, on insulin #4 Obesity #5 Hyperlipidemia #6 Diverticulosis #7 h/o adrenal adenoma #8 herpes simplex #9 hx PE in setting of OCPs 30+ years ago #10 Chronic kidney diease - baseline Cr 2.0-3.0 Social History: Retired spot welder, lives alone in [**Location (un) **] with dog. She reports smoking 2PPD x 60 years. She has quit in the past for 6 months at a time and she has been smoking 8 cigarettes daily recently. She denies EtOH or drugs. Family History: father died in 60's - EtOH mother died @ 36 - MI. obese, smoked sister - DM, renal failure brother - mentally retarded, recently passed away. had 4 children, 1 son died @ 42 - EtOH, hemochromatosis, seizure Physical Exam: Admission: Vitals: T 100.2, HR 93, BP 129/30, RR 20 sat 90% on RA, up to 100% on nebulizer General: Alert, oriented, no acute distress, no accessory muscle use. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Diffuse inspiratory and expiratory wheezes overlaid with rhonci. CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic flow murmur. No rubs or gallops Abdomen: obese, soft, non-tender, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge: VS: Tm Afebrile Tc HR 70s-80s BP 130-140s/50s-70s RR 20-21 SaO2 91% RA -> 96% 1L NC I/O GENERAL: [x] NAD [] Uncomfortable Eyes: [x] anicteric [] PERRL ENT: [x] MMM [] Oropharynx clear [] Hard of hearing NECK: [] No LAD [] JVP: CVS: [x] RRR [x] nl s1 s2 [x] no MRG [x] no edema LUNGS: [x] No rales [x] No wheeze [x] comfortable ABDOMEN: [x] Soft [x]nontender []bowel sounds present []No hepatosplenomegaly SKIN: []No rashes []warm []dry [] decubitus ulcers: LYMPH: [] No cervical LAD []No axillary LAD [] No inguinal LAD NEURO: [] Oriented x3 [x] Fluent speech Psych: [x] Alert [x] Calm [] Mood/Affect: Pertinent Results: Admission Labs: [**2163-3-24**] 07:20PM BLOOD Neuts-94* Bands-0 Lymphs-5* Monos-0 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* [**2163-3-24**] 08:36AM BLOOD WBC-8.3 RBC-2.38*# Hgb-6.0*# Hct-19.7*# MCV-83# MCH-25.4*# MCHC-30.7* RDW-15.9* Plt Ct-291 [**2163-3-24**] 07:20PM BLOOD WBC-6.7 RBC-2.27* Hgb-5.9* Hct-19.1* MCV-84 MCH-26.1* MCHC-31.1 RDW-15.5 Plt Ct-331 [**2163-3-24**] 07:20PM BLOOD Hypochr-3+ Anisocy-NORMAL Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-OCCASIONAL Target-OCCASIONAL [**2163-3-24**] 07:20PM BLOOD PT-12.5 PTT-25.4 INR(PT)-1.2* [**2163-3-24**] 08:36AM BLOOD UreaN-65* Creat-2.9* Na-143 K-6.9* Cl-112* HCO3-21* AnGap-17 [**2163-3-24**] 07:20PM BLOOD Glucose-299* UreaN-63* Creat-2.7* Na-136 K-6.7* Cl-106 HCO3-18* AnGap-19 [**2163-3-24**] 08:36AM BLOOD ALT-15 AST-16 [**2163-3-24**] 07:20PM BLOOD cTropnT-0.04* [**2163-3-24**] 07:20PM BLOOD Calcium-8.6 Phos-4.1 Mg-2.0 [**2163-3-24**] 08:36AM BLOOD %HbA1c-7.9* eAG-180* [**2163-3-24**] 08:36AM BLOOD Triglyc-61 HDL-47 CHOL/HD-2.4 LDLcalc-56 [**2163-3-24**] 09:00PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008 [**2163-3-24**] 09:00PM URINE Blood-SM Nitrite-NEG Protein-100 Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2163-3-24**] 09:00PM URINE RBC-4* WBC-<1 Bacteri-NONE Yeast-NONE Epi-0 Imaging: CHEST (PA & LAT) Study Date of [**2163-3-24**] 10:33 AM FINDINGS: Chest PA and lateral radiograph demonstrates unremarkable mediastinal, hilar and cardiac contours. Lungs are clear. No pleural effusion or pneumothorax evident. Stable mild kyphosis of the thoracic spine with anterior osteophyte formation. IMPRESSION: No acute cardiopulmonary process [**2163-3-27**] CXR: IMPRESSION: Small effusions and left-sided atelectasis/scarring, unchanged compared with [**2163-3-24**]. UZRD without other evidence of CHF. COPD and suspected pulmonary hypertension. Pathology: sophageal and intestinal mucosal biopsies, four: 1. Distal esophagus (A): Mild neutrophilic esophagitis. 2. Duodenum (B): Small intestinal mucosa, no diagnostic abnormalities recognized. 3. Cecum, polyp, polypectomy (C): Fragments of adenoma. 4. Ascending colon, polyp, polypectomy (D): Adenoma. Discharge/Notable Labs: [**2163-3-29**] 06:55AM BLOOD WBC-7.2 RBC-3.36* Hgb-9.3* Hct-28.2* MCV-84 MCH-27.7 MCHC-33.0 RDW-15.4 Plt Ct-234 [**2163-3-30**] 06:45AM BLOOD Glucose-118* UreaN-71* Creat-2.4* Na-141 K-4.1 Cl-107 HCO3-25 AnGap-13 [**2163-3-24**] 07:20PM BLOOD cTropnT-0.04* [**2163-3-24**] 11:33PM BLOOD CK-MB-5 cTropnT-0.04* [**2163-3-25**] 04:53AM BLOOD CK-MB-5 cTropnT-0.04* [**2163-3-26**] 05:25AM BLOOD CK-MB-6 cTropnT-0.04* [**2163-3-30**] 06:45AM BLOOD Phos-4.1 [**2163-3-25**] 04:53AM BLOOD calTIBC-345 VitB12-279 Folate-12.8 Ferritn-8.1* TRF-265 [**2163-3-24**] 11:33PM BLOOD Hapto-361* [**2163-3-24**] 08:36AM BLOOD %HbA1c-7.9* eAG-180* [**2163-3-24**] 08:36AM BLOOD Triglyc-61 HDL-47 CHOL/HD-2.4 LDLcalc-56 [**2163-3-25**] 04:53AM BLOOD PEP-NO SPECIFI Studies pending at discharge: None Brief Hospital Course: 73 yo F with type 2 Diabetes mellitus, chronic obstructive pulmonary disease, hypertension, and hyperlipidemia admitted with iron deficiency anemia, hyperkalemia, and COPD exacerbation #Chronic obstructive pulmonary disease exacerbation: Patient was found to have a COPD exacerbation at PCP [**Name Initial (PRE) **]. She was started on prednisone and bronchodilators and continued on these inpatient. She improved and was able to ambulate without desaturation prior to discharge. She was discharged on a prednisone taper along with prior home medications. #Iron deficiency anemia due most probably to chronic gastrointestinal bleeding: Patient was found to have a hematocrit of 17 and was noted to have ST depression on EKG that resolved with transfusion of 3 units of packed red blood cells. Labs were notable for iron deficiency. Patient remained hemodynamically stable and anemia remained stable after red cell transfusions. The patient was seen by GI and had an upper endoscopy and colonscopy which could not identify a source of bleeding, but colonoscopy had poor prep. Therefore, the patient was discharged to follow up for a repeat scope in 3 weeks. #Hyperkalemia/Stage IV, Chronic kidney disease: Patient was admitted with K of 6.7 which improved over admission. She has had trouble with hyperkalemia in the past and lisinopril has been reduced in the past. Her lisinopril was held and her lasix was continued. She was discharged off lisinopril pending follow up with her PCP and Renal. #Probable CAD: Patient had ST depressions with hematocrit of 17 that resolved with transfusion of red cells to hematocrit of 27. She was on aspirin and statin at home per report, but aspirin was held in the setting of chronic blood loss anemia. This was not restarted on discharge, but could be restarted in the outpatient setting if hematocrit remains stable. Additionally, stress testing was deferred, but this could be considered in the outpatient setting as a positive test may reduce threshold for addition of a betablocker to the patient's hypertension regimen. #Atrial fibrillation: Patient was noted to have asymptomatic atrial fibrillation, paroxysmal, up to rate of 150s-160s without hemodynamic effect. These episodes usually occured after ambulation or after bronchodilators. Therefore, patient was started on low dose Diltiazem in place of nifedipine. This can be followed and adjusted at PCP and Renal outpatient visits. #Type 2 diabetes mellitus complicated by hypoglycemia: Patient recently had NPH reduced for hypoglycemia. However, on regimen of NPH 20 units [**Hospital1 **] the patient had consistent morning hypoglycemia. Therefore, NPH was reduced to 14 units in the AM and 10 in the PM. Given the patient's most likely underlying dementia, the patient was discharged on 10 units NPH [**Hospital1 **] for ease of administration. #Congitive impairment/Social: Patient was noted to have significant cognitive impairment and the patient's daughter noted that there was often discrepancy between the patient's glucometer readings and her log. Therefore, the patient was discharged with home services. However, if her cognition continues to decline she may require more intensive services or 24 hour care in the near future. #CODE: Full #Disposition: Patient was discharged on prednisone taper to follow up with PCP and outpatient GI for repeat colonscopy. Patient did not have a follow up with Renal on discharge, but patient was encouraged to make this appointment given her CKD and medication changes. She may also benefit from outpatient cardiac ischemia workup. Medications on Admission: -albuterol sulfate 90 mcg HFA Aerosol Inhaler 2 puffs(s) inhalation q4-6 hours as needed for cough/wheeze -atorvastatin 40 mg qd -calcitriol 0.25 mcg qod -fluticasone-salmeterol [Advair Diskus] 500 mcg-50 mcg/Dose Disk with Device 1 puffs(s) inhaled twice a day \ -furosemide 20 mg [**Hospital1 **] -lisinopril 5 mg qd -nifedipine [Nifedical XL] 30 mg Tablet Extended Rel 24 hr qd -aspirin 81 mg qd -carbamide peroxide [Debrox] 6.5 % Drops 4 gtt R ear at bedtime -NPH insulin human recomb [Humulin N Pen] 24 units via pen twice a day (Dose adjustment - [**2163-3-24**]: up from 20 units daily while on steroids) Just started today [**3-24**]: -prednisone 10 mg Tablet 6 Tablet(s) by mouth once a day Taper as directed [**2163-3-24**] Discharge Medications: 1. diltiazem HCl 120 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day. Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2* 2. 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* 3. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. carbamide peroxide 6.5 % Drops Sig: Four (4) Drop Otic HS (at bedtime). 5. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY OTHER DAY (Every Other Day). 7. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 8. NPH insulin human recomb 100 unit/mL (3 mL) Insulin Pen Sig: Ten (10) units Subcutaneous twice a day. 9. Medication Changes The following medications have been ADDED: -Prednisone taper -Diltiazem 120mg po daily -Pantoprazole 40mg po BID The following medications have been STOPPED: Please stop taking the above medications until you have had your follow up appointment with Dr. [**Last Name (STitle) 410**]. -Lisinopril -Nifedipine -Aspirin The following medications have been CHANGED: NPH insulin has been reduced from 20 units twice a day to NPH insulin 10 units twice a day. Please start taking your NPH insulin at 10 units before breakfast and before dinner. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Anemia, Iron deficiency, chronic blood loss Coronary Artery Disease COPD exacerbation Diabetes Mellitus, type 2 Chronic Kidney Disease, stage IV Hyperkalemia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were referred to the hospital for evaluation of anemia and hyperkalemia in addition to treatment of your COPD. You were initially admitted to the ICU and were transfused 3 units of red blood cells. Your lisinopril was held. You were seen by the Gastroenterology team and had an upper endoscopy and a colonoscopy to evaluate for cause of GI bleeding. Your upper endoscopy did not show evidence of bleeding but did show abnormalities. These were biopsied and the GI team will inform you of these results when they return. Additionally, your colonoscopy did not show evidence of bleeding but you had a poor prep. Therefore, you are scheduled to have another colonoscopy as listed below. It is very important that you keep this appointment so that any cause of bleeding can be identified. Additionally, when your blood counts were low you had EKG changes which suggest possible underlying coronary artery disease. You were continued on a statin medication and may benefit from increasing your dose depending on a recheck of your lipid levels. Additionally, you were not continued on an aspirin since you may have GI bleeding. However, your PCP will follow you and decide if an aspirin should be started at a later date. She will also likely order you for a stress test once your bleeding is worked up completely. With regards to your COPD, you were treated with inhalers and steroids and should continue to take prednisone taper as prescribed. Lastly, your blood sugars were noted to be low during this admission. Therefore, your insulin has been reduced. Please remember to take the NEW amount of NPH rather than your previous prescription until you have had time to follow up with your PCP. Followup Instructions: Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED When: FRIDAY [**2163-4-1**] at 12:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6887**], MD [**Telephone/Fax (1) 1144**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: RADIOLOGY When: TUESDAY [**2163-4-12**] at 2:30 PM With: RADIOLOGY [**Telephone/Fax (1) 9045**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: WEST PROCEDURAL CENTER When: TUESDAY [**2163-4-26**] at 1 PM With: WPC ROOM THREE [**Telephone/Fax (1) 5072**] Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage

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icd9cm

[ [ [] ] ]

[ "45.42", "45.16" ]

icd9pcs

[ [ [] ] ]

13228, 13286

7382, 10973

324, 354

13488, 13488

4327, 4327

15363, 16277

2875, 3083

11760, 13205

13307, 13467

10999, 11737

13641, 15340

3098, 4308

7353, 7359

1659, 2089

264, 286

382, 1640

4343, 7339

13503, 13617

2111, 2610

2626, 2859

54,625

176,749

37212

Discharge summary

report

Admission Date: [**2112-2-24**] Discharge Date: [**2112-3-9**] Date of Birth: [**2035-12-1**] Sex: M Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) / Niacin / Lisinopril / Lorazepam Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Aortic valve replacement with a 25-mm [**Doctor Last Name **] Magna bioprosthesis, Coronary artery bypass grafting x1, with left internal mammary artery to left anterior descending coronary artery, subtotal pericardiectomy from phrenic to phrenic due to constrictive pericarditis. [**2112-3-2**] permanent pacemaker History of Present Illness: Mr. [**Known lastname 4660**] is a 76 year old gentleman with a history of DM, ESRD on HD, AS who called EMS for substernal chest pain refractory to treatment with aspirin. Ruled in for MI. At [**Hospital 5279**] Hospital he underwent a cath revealing single vessel CAD (90% LM) and aortic stenosis. He presented for surgical evaluation. Cardiac Catheterization: Date: [**2112-2-24**] Place: [**Hospital 5279**] Hospital 90% Left Main, nml LV, mild AS. Cardiac Echocardiogram:[**4-19**] at [**Doctor First Name 5279**]: LVEF 55, trivial MR, AS with [**Location (un) 109**] 1.4, peak gradient of 26 Past Medical History: Past Medical History: CAD, AS, PVD, DM, DM neuropathy, DM retinopathy, DM nephropathy, hyperlipidemia, HT, glaucoma, hx of pericardial effusion w tamponade, CHF, chronic iron dificiency anemia, agranulcytosis, recurrent pleural effusion s/p thoracentesis '[**07**], '[**08**], '[**09**] now w chronic left pleural effusion, ESRD on HD, hx of GI bleed, chronic constipation, hx of CVA, s/p left forefoot amputation, cataract surgery, pericardiocentesis, umbilical hernia, tonsillectomy, right carotid endartarectomy Past Surgical History: s/p left forefoot amputation, cataract surgery, pericardiocentesis, umbilical hernia, tonsillectomy, right carotid endartarectomy Social History: Race:caucasian Last Dental Exam:edentulous Lives with:wife Occupation:retired Tobacco:quit at age 43, smoked 25 years and 2 ppd ETOH:seldomly drinks beer Family History: Non contributory Physical Exam: Pulse: 71 Resp: 14 O2 sat: 97% RA B/P Right: Left: 118/64 Height: 5'7" Weight:158 General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Left forefoot amputation Neuro: Grossly intact: gait disturbance, but strength 5/5 throughout Pulses: Femoral Right:1+ Left:1+ DP Right:1+ Left:1+ PT [**Name (NI) 167**]:1+ Left:1+ Radial Right:2+ Left:2+ Left upper arm fistula with thrill Pertinent Results: [**2112-2-24**] 08:00PM PT-12.1 PTT-28.1 INR(PT)-1.0 [**2112-2-24**] 08:00PM PLT COUNT-212 [**2112-2-24**] 08:00PM WBC-7.8 RBC-3.77* HGB-11.1* HCT-32.9* MCV-87 MCH-29.4 MCHC-33.7 RDW-15.0 [**2112-2-24**] 08:00PM %HbA1c-5.6 [**2112-2-24**] 08:00PM ALBUMIN-3.7 CALCIUM-8.1* PHOSPHATE-3.7 MAGNESIUM-2.3 [**2112-2-24**] 08:00PM LIPASE-54 [**2112-2-24**] 08:00PM ALT(SGPT)-8 AST(SGOT)-12 LD(LDH)-164 ALK PHOS-96 AMYLASE-115* TOT BILI-0.2 [**2112-2-24**] 08:00PM GLUCOSE-126* UREA N-51* CREAT-7.5* SODIUM-134 POTASSIUM-4.5 CHLORIDE-94* TOTAL CO2-26 ANION GAP-19 [**2112-3-7**] 09:26AM BLOOD WBC-9.2 RBC-3.86* Hgb-11.2* Hct-34.5* MCV-89 MCH-29.0 MCHC-32.4 RDW-14.9 Plt Ct-215 [**2112-3-7**] 09:26AM BLOOD Plt Ct-215 [**2112-3-1**] 03:19AM BLOOD PT-14.6* PTT-39.1* INR(PT)-1.3* [**2112-3-5**] 06:55AM BLOOD Glucose-169* UreaN-32* Creat-5.1*# Na-140 K-3.6 Cl-98 HCO3-29 AnGap-17 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT LEFT VENTRICLE: Mild symmetric LVH. Normal regional LV systolic function. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Simple atheroma in ascending aorta. Simple atheroma in aortic arch. Simple atheroma in descending aorta. AORTIC VALVE: Moderately thickened aortic valve leaflets. Severe AS (area 0.8-1.0cm2). No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PERICARDIUM: No pericardial effusion. Pericardium appears thickened. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the results on [**2112-2-25**] at 1430 . POST CPB: 1. Preserved [**Hospital1 **]-ventricular systolic function. 2. Bioprosthesis in aortic position. Well seated and stable with good leaflet excursion. 3. Trace AI. PG = 18 mm MG = 8 mm Hg. 4. Intact aorta. 5. Dynamic mitral regurgitation, transiently [**2-13**] + with fluid administration without any hemodynmaic instability, wmas'S or change in SVO2 CHEST (PA & LAT) Study Date of [**2112-3-3**] 2:45 PM [**Hospital 93**] MEDICAL CONDITION: 76 yo man with heart block. Asess atrial and ventricular lead s/p PPM Final Report REASON FOR EXAMINATION: Evaluation of the pacemaker placement. PA and lateral upright chest radiographs were reviewed in comparison to [**2112-2-28**]. The pacemaker leads terminate in the expected location of right atrium and right ventricle allowing the technical quality of the study. The patient is after replaced aortic valve. Cardiomegaly, large left and small right pleural effusion are unchanged as well as there is no change in mild-to-moderate pulmonary edema. No pneumothorax is currently present. DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**] Brief Hospital Course: The patient is a 76-year-old gentleman with a history of acute myocardial infarction admitted to [**Hospital 5279**] Hospital. Echo revealed moderate aortic stenosis. The patient had a cardiac catherization and found to have severe left main disease and was, therefore, transferred down from [**Hospital 5279**] Hospital in [**Location (un) 3844**] to [**Hospital1 771**] for coronary artery bypass grafting and possible aortic valve replacement. He was taken to the operating room on [**2112-2-26**] and had an aortic valve replacement with a 25-mm [**Doctor Last Name **] Magna bioprosthesis, coronary artery bypass grafting x1, with left internal mammary artery to left anterior descending coronary artery and subtotal pericardiectomy from phrenic to phrenic due to constrictive pericarditis. See operative note for full details. He was transferred to the intensive care unit in stable condition. He was extubated on post operative day 1 and continued on Neosynephrine for hypotension. Postoperatively he was transiently in sinus rhythm, then went into a complete heart block and was pacer dependent. Attempts to decrease pacing rate results in unreliable underlying ventricular escape rhythm (up to 30 bpm, occasional not present at all). EP was consulted for need for PPM placement. He lost 100% sensing and capture with the epicardial pacing wires and a temporary ventricular wire was placed with good capture. He was taken on [**2112-3-2**] for a permanent pacemaker placement. See procedure note for full details. He was being 100% paced with good capture and weaned off Neosynephrine after placement. Of note, the patient has a history of chronic left pleural effusion. Thoracic surgery was consulted and recommended a formal decortication. He needs to follow up with Dr. [**Last Name (STitle) 11482**] [**Name (STitle) **] in [**3-16**] weeks to determine the timing for the decortication. He continued to be followed by the renal team and dialyzed 3 times per week via left upper extremity fistula. Transplant surgery was consulted for a concern in the exam of his LUE fistula. Reportedly prior to surgery the graft had a strong thrill and postoperatively found to have only a weak pulse. Access was found to be patent. Last hemodialysis treatment was [**2112-3-7**]. Chest tubes and pacing wires were removed per cardiac surgery protocol. He was transferred to the step down unit on post operative day 8 in stable condition. Physical therapy continued to work with him for increased strength and endurance. A bedside swallowing was performed due to coughing while taking thin liquids. It was suggested a diet of thin liquids and soft consistency solids with 1:1 supervision during meals secondary to mental status. Of note, patient did have episodes of sundowning, for which he received Haldol with good results. Once on the step down unit, Mr. [**Known lastname 4660**] [**Last Name (Titles) 27836**] well. He was working with physical therapy, tolerating a full po diet and his incisions were healing well. It was felt that he was safe for transfer to rehab at this time. He was discharged to rehab following hemodialysis on POD 13. Medications on Admission: ASA 81mg daily, insulin sliding scale, imdur 60mg daily, lopressor 25mg daily, prilosec 20mg daily, renvela 8--mg TID, Travatan opthalmic solution, Vitamin B complex/vitamin C/folic acid 1 capsule daily, crestor 20mg daily, repaglinide 2mg daily, fligrastim 300 mcg SC Saturdays Allergies:Sulfa, niacin, lisinopril, lorazepam (disorientation) Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 7. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Travoprost 0.004 % Drops Sig: One (1) gtt Ophthalmic QHS. 9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Repaglinide 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Nephrocaps 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 12. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. 13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 15. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED): dose according to sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital3 17921**] Center - [**Location (un) 5450**], NH Discharge Diagnosis: Coronary Artery Disease, Aortic Stenosis-s/p AVR/CABG/pericardiotomy PMH::CAD, AS,PVD,DM europathy/retinopathy/nephropathy,hyperlipidemia, HT, glaucoma, hx of pericardial effusion w tamponade, CHF,anemia, granulcytosis, recurrent pleural effusion s/p thoracentesis w chronic left pleural effusion,ESRD on HD, hx of GI bleed, chronic constipation, hx of CVA, s/p left forefoot amputation, cataract surgery,umbilical hernia, tonsillectomy, RT CEA Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal wound healing well-CDI Sternal pain managed with percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Surgeon Dr [**Last Name (STitle) 914**] in 2 weeks [**Telephone/Fax (1) 170**] [**4-5**] at 1:30 PM Please call to schedule appointments Primary Care Dr. [**First Name8 (NamePattern2) 38748**] [**Name (STitle) **] in [**2-13**] weeks [**Telephone/Fax (1) 74598**] Cardiologist Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39975**] in 4 weeks Thoracic Surgeon [**Last Name (un) 11482**] [**Doctor Last Name **] in [**3-16**] weeks to follow up pleural effusion [**Hospital **] clinic for PM follow up in 2 weeks Completed by:[**2112-3-9**]

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icd9cm

[ [ [] ] ]

[ "37.31", "37.83", "39.61", "39.95", "38.93", "36.15", "37.72", "35.21" ]

icd9pcs

[ [ [] ] ]

11265, 11351

6304, 9483

342, 661

11840, 11967

2901, 5157

12592, 13153

2172, 2190

9877, 11242

5609, 6281

11372, 11819

9509, 9854

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1853, 1984

2205, 2882

291, 304

689, 1293

1337, 1830

2000, 2156

5167, 5572

27,249

100,203

31803

Discharge summary

report

Admission Date: [**2174-10-13**] Discharge Date: [**2174-11-2**] Date of Birth: [**2121-11-5**] Sex: F Service: SURGERY Allergies: Lisinopril/Hydrochlorothiazide Attending:[**First Name3 (LF) 6346**] Chief Complaint: bright red blood per rectum transfer from outside hospital Major Surgical or Invasive Procedure: Exploratory laparotomy, lysis of adhesions and right colectomy with ileocolostomy History of Present Illness: 52 F Jehovah's witness w/ pmhx of HTN who presents with 1 day hx of BRBPR rectum, occured last night 4 episodes of dark red blood mixed with loose stools, no clots at that time, denies maroon stools, or dark tarry stools, 1st episode. with associated lightheadness, weakness later in the evening w/ no LOC, or falls, also with some nausea, but no vomitting, no abdominal pain. . Presented to OSH where HCT was noted to be 30 stable VS 164/85 104 16 98RA, and then tx'd to [**Hospital1 18**] ED as pt jehovah's witness. . In ED VS 98 88 142/70 16 99RA, received 1L NS, BRB in rectal vault, GI was consulted and recommended bowel prep and colonoscopy. Here, denies weakness, no cp/sob/palpitations, dysuria Past Medical History: Diverticulosis - cscope 2 yrs ago Lap CCY [**9-2**] Csection x3 HTN Social History: No smoking, scoial drinker adminstrative assistant Family History: No colon ca/ibd, NC Physical Exam: 98.8 99 118/88 16 100RA GEN: NAD, pleasant, speaking in full sentences HEENT: PERRL, EOMI, OP Clear, MMM, JVD nondistended, anicteric CV: tachycardic no mrg CHEST: CTA b/l no mrg ABD: Soft, +BS, NT/ND, midline cscetion scar EXT: No c/c/ce Neuro: AAOx3, no focal deficits Pertinent Results: OSH HCT 31.9 . EKG-NSR 90bpm, NA, NI, q wave in III, No STT changes [**2174-10-14**] 06:31AM BLOOD WBC-2.9* RBC-1.52*# Hgb-4.8*# Hct-13.7*# MCV-90 MCH-31.3 MCHC-34.7 RDW-14.0 Plt Ct-168 [**2174-10-19**] 10:20AM BLOOD WBC-4.9 RBC-0.94* Hgb-2.8* Hct-8.8* MCV-94 MCH-29.4 MCHC-31.3 RDW-15.3 Plt Ct-293 [**2174-11-2**] 12:10PM BLOOD WBC-5.7 RBC-2.58*# Hgb-6.5* Hct-23.9*# MCV-92 MCH-25.1* MCHC-27.2* RDW-21.7* Plt Ct-708* [**10-14**] Tagged RBC Scan - Moderately brisk intermittent bleeding originating from the ascending colon. [**10-28**] CT - ?cortical infarct or pyelonephritis, small simple left pleural effusion with adjacent atelectasis Brief Hospital Course: Patient was admitted on [**10-13**] from OSH with lower GI bleed since patient was a Jehovah's witness and continued to have bloody bowel movements. Patient was admitted to the medical ICU and underwent a tagged RBC scan which suggested that the bleeding eminated from the ascending colon. Angiography was then performed which did not visualize the source of bleeding. The patient continued to have BRBPR and the general surgery service was consulted. Upon consultation the patient was found to have a hematocrit of 13.7 and an emergent colectomy was offered to resolve the active bleeding. The patient refused blood products citing her religious perference and all the patient was aware of all risks of the procedure and consented. The patient went to the OR on [**10-14**] and underwent a right hemicolectomy with ileocolostomy. The procedure was without complications and the patient was transfered to the TSICU in critical condition. Patient remained on the ventilator for several days, and was started on erythropoetin and IV Iron to maximize her RBC production capability. She was started on parenteral nutritional prior to return of bowel function. She was successfully extubated on pod# 10 and transfered to the floor once her hematocrit stabilized. Once the patient was transferred to the floor her hematocrit slowly increased each day and upon discharge was 23. GI Bleed - The patient continued to have guiac positive stool while in the ICU however these were felt to be the result of retained blood in the colon. After the patient was transferred to the floor patient had no episodes of BRBPR and no evidence of GI bleeding. Heme - Upon discharge the patients hematocrit was 23.9 which was significantly higher than her post op Hct of 8. The patient was started on 20K Units of EPO and will continue therapy for 1 week as well as Iron supplementation for 1 month. Pulm - Post operatively the patient developed a left lower lobe pneumonia which was treated with a one week course of cipro. Upon discharge the patient was afrebrile with a normal WBC. GI - The patient was started on parenteral nutrition while in the unit however was advanced to a regular diet after admission to the floor. Patient was discharged able to tolerate a regular diet. CV - Patient continued to be tachycardic throughout her hospital course as a result of her anemia. She was also hypertensive on several occassions which was treated with IV then PO Lopressor. Upon discharge the patient remained tachycardic and continued to have episodic hypertension which we will have her PCP follow up on. GU - While in the ICU the patient developed an enterococcal urinary tract infection which was treated appropriately with antibiotics Dispo - Patient will be discharged to short term rehab and will follow up with Dr. [**First Name (STitle) 2819**] in approximately 1-2 weeks Medications on Admission: Diovan 160mg Daily HCTZ 25mg Daily ASA 81mg daily MVI Discharge Medications: 1. Epoetin Alfa 20,000 unit/mL Solution Sig: One (1) injection Injection QMOWEFR (Monday -Wednesday-Friday) for 1 weeks. Disp:*3 injection* Refills:*0* 2. NuvaRing Vaginal 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:*60 Tablet(s)* Refills:*0* 6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical 12 HOURS A DAY (). Disp:*20 Adhesive Patch, Medicated(s)* Refills:*1* 7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for breakthrough pain only. Disp:*20 Tablet(s)* Refills:*0* 10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Lower GI bleeding Hemorrhagic Shock Acute Blood loss anemia Urinary tract infection Left Lower Lobe pneumonia Post op fluid overload Discharge Condition: Good, patient is afebrile with stable vital signs, tolerating regular diet, ambulating and is without bloody bowel movements. Discharge Instructions: Please [**Name8 (MD) 138**] MD or go to ER if you experience Temp>101.5, severe chest pain, shortness of breath, bloody stools, severe abdominal pain, severe nausea/vomiting or inability to tolerate food. The steri strips covering your incision will fall off on their own. You may shower, however keep your incision clean and dry. Followup Instructions: Please call Dr.[**Name (NI) 11471**] office to schedule a follow up appointment in approximately 1-2 weeks.

[ "285.1", "997.3", "562.12", "486", "401.9", "599.0", "785.59", "627.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "45.73", "88.47", "45.93", "88.77", "99.15", "96.6" ]

icd9pcs

[ [ [] ] ]

6338, 6408

2346, 5211

350, 434

6585, 6713

1678, 2323

7093, 7204

1349, 1370

5315, 6315

6429, 6564

5237, 5292

6737, 7070

1385, 1659

252, 312

462, 1174

1196, 1265

1281, 1333

16,999

184,222

26535

Discharge summary

report

Admission Date: [**2113-1-13**] Discharge Date: [**2113-1-25**] Date of Birth: [**2054-2-27**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Burping/LUQ Pain w/ Positive stress test Major Surgical or Invasive Procedure: [**2113-1-19**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to [**Last Name (LF) **], [**First Name3 (LF) **], PDA) [**2113-1-13**] Cardiac Catheterization History of Present Illness: The pt is a 58 yo M with a h/o HTN, hypercholesterolemia who presented to this hospital as a transfer from [**Hospital3 19345**] for cardiac cath. Pt had visited his PCP last week, [**Name Initial (PRE) **]/o frequent eructation and nausea x 2 weeks along with LUQ pressure. He also previously had a postitve ETT and was referred for a cardiac cath. Cath done on [**2113-1-13**] revealed 3 vessel disease. He was then referred for CABG. Past Medical History: Hypertension Hypercholesterolemia Diabetes Mellitus Hearing loss h/o Benign Prostatic Hypertrophy s/p T&A s/p Kidney Contusion Social History: Occ EtOH (approx 4 drinks/wk) Remote tobacco (smoked pipe for approx 6 years, quit >25 yrs ago) Works as delivery man Lives with wife Family History: Father deceased MI @ 49 Mother ?cardiac Physical Exam: Gen: Pleasant man in NAD, lying supine on stretcher in cath recovery VS: Afebrile 63 18 161/83 100 2L nc HEENT: PERRL, EOMI, nl sclera Cor: s1s2 RRR no m/r/g Lungs: CTAB anteriorly, laterally Abd: NABS, soft, NT/ND GU: Foley to gravity Ext: Minimal eccymosis at R groin, no hematoma, no thrill; DP palpable, PT by doppler (baseline) Skin: Pink, warm, dry Neuro: A&O x 3, CN grossly intact Pertinent Results: Cath [**1-13**]: Selective coronary angiography of this right dominant system revealed three vessel coronary artery disease. The LMCA had no angiographically apparent disease. The LAD had 70% proximal, 80% mid, and 90% proximal D1 stenoses. The LCX had 80% diffuse proximal stenosis with total occlusion of OM2. The RCA had ostial occlusion with extensive left coronary collaterals to distal vessel. Limited hemodynamics demonstrated elevated LVEDP (23mmHg) and systemic pressures. Calculated ejection fraction was 63%. TTE [**1-13**]: The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). No regional wall motion abnormality is seen. GB U/S /13: The gallbladder again contains extensive sludge. There is some gallbladder wall thickening to approximately 4 mm. No pericholecystic fluid is identified, but there is some mild edema seen There is no intra-or extra-hepatic biliary dilatation. The findings are nonspecific. While not definitive for acute cholecystitis, the findings are at least somewhat suspicious. Given the patient's upcoming bypass surgery, consideration towards cholecystectomy should be made. Again, HIDA scan may be useful to aid diagnostic certainty HIDA [**1-18**]: Normal study. No evidence of cholecystitis. [**2113-1-13**] 11:30AM BLOOD WBC-5.9 RBC-4.39* Hgb-13.5* Hct-37.2* MCV-85 MCH-30.7 MCHC-36.3* RDW-12.1 Plt Ct-272 [**2113-1-20**] 02:09AM BLOOD WBC-14.6* RBC-3.22* Hgb-10.2* Hct-27.7* MCV-86 MCH-31.7 MCHC-36.8* RDW-12.3 Plt Ct-310 [**2113-1-23**] 06:10AM BLOOD WBC-8.4 RBC-3.63* Hgb-10.9* Hct-30.9* MCV-85 MCH-30.1 MCHC-35.3* RDW-13.7 Plt Ct-268 [**2113-1-22**] 02:16AM BLOOD PT-13.3* PTT-30.2 INR(PT)-1.2* [**2113-1-13**] 11:30AM BLOOD Glucose-153* UreaN-23* Creat-1.2 Na-135 K-3.8 Cl-104 HCO3-22 AnGap-13 [**2113-1-23**] 06:10AM BLOOD Glucose-89 UreaN-18 Creat-1.1 Na-138 K-3.9 Cl-99 HCO3-29 AnGap-14 [**2113-1-23**] 06:10AM BLOOD Calcium-8.2* Phos-3.5 Mg-2.0 [**2113-1-13**] 11:30AM BLOOD %HbA1c-5.7 [Hgb]-DONE [A1c]-DONE [**2113-1-13**] 11:45AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG Brief Hospital Course: The patient was admitted s/p positive cath, consulted by CT [**Doctor First Name **] and scheduled for CABG. He underwent the usual pre-operative work-up for CABG, but continued to complain of intermittent eructation/discomfort in abd. GI was consulted and pt had a RUQ U/S which showed sludge but this study was post-prandial and repeated after being NPO. LFTs WNL. The repeat U/S was again concerning for possible cholecystitis. GI was consulted and an EGD was performed which revealed gastritis. A HIDA scan was performed which revealed no evidence for cholecystitis. Following entire GI work-up, Mr. [**Known lastname 4281**] seemed suitable/stable for bypass surgery and on hosptital day seven, [**2113-1-19**], he was brought to the operating room where he underwent coronary artery bypass surgery x 4. He tolerated the procedure well with no complications. Please see operative note for surgical details. Afterward he was transferred to the Cardiac surgery recovery unit in stable condition and awakened neurologically intake. He was weaned from ventilator support, extubated, and pressors were weaned. On POD 2 he was then transferred to the Stepdown unit for further recovery. His chest tubes were removed without complication. He was gently diuresed to his preoperative weight, beta blockade and aspirin therapy were resumed, and physical therapy service was consulted to assist with his postoperative strength and mobility. Electrolytes were repleted as needed. On POD 3 his epicardial pacing wires were removed without complication, he continued to improve his ability to ambulate including climbing stairs without respiratory distress or chest pain. On POD 4 there was some evidence of sternal drainage that was nonpurulent. IV vancomycin was empirically started. Mr. [**Known lastname 4281**] was slow to progress in his ability to ambulate and was complaining of musculoskeletal chest pain frequently. Serial ecg's and telemetry did not reveal any ST changes. His pain was relieved with narcotics. On POD 5 Mr. [**Name13 (STitle) **] was 5kg his preop weight with good exercise tolerance, no SOB, or Chest pain. His blood pressure was stable. His sternotomy and leg incision were clean, minimal serosanguinous drainage present at his sternotomy, and intact without evidence of infection. He was discharged home on POD 6 with services in good condition, cardiac diet, sternal precautions, and instructed to follow up with his PCP/cardiologist in [**12-5**] weeks. He will come to [**Hospital Ward Name 121**] 2 for a wound check in three days. He will follow up with Dr. [**Last Name (STitle) **] in four weeks. Medications on Admission: 1. MVI 2. Lisinopril 10mg qd 3. Zantac Started after ETT: 4. ASA 81mg qd 5. Lipitor 20mg qd 6. Toprol XL 50mg qd 7. Plavix 75mg qd 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. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. 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* 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*0* 6. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 10 days. Disp:*40 Capsule, Sustained Release(s)* Refills:*0* 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*20 Tablet(s)* Refills:*0* 9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 10. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) **] vna Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 Hypercholesterolemia Hypertension Diabetes Mellitus Gastritis Discharge Condition: Good Discharge Instructions: [**Month (only) 116**] take shower. Wash incisions with water and gentle soap. Gently pat dry. Do not take bath. Do not apply lotions, creams, ointments or powders to incisions. Do not drive for 1 month. Do not lift more than 10 pounds for 2 months. Please contact office immediately with any chest/sternal drainage or if you experience a fever more than 101.5. Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks. Dr. [**Last Name (STitle) **](PCP) in [**12-5**] weeks. Dr. [**Last Name (STitle) **](Cardiologist) in [**1-6**] weeks. Completed by:[**2113-1-25**]

[ "389.9", "535.00", "414.01", "413.9", "401.9", "272.4", "794.39", "793.3", "250.00" ]

icd9cm

[ [ [] ] ]

[ "36.13", "88.56", "88.72", "36.15", "37.22", "45.13", "39.61", "88.53", "99.04" ]

icd9pcs

[ [ [] ] ]

8075, 8130

3940, 6581

362, 526

8296, 8302

1775, 3917

8712, 8904

1310, 1351

6763, 8052

8151, 8275

6607, 6740

8326, 8689

1366, 1756

282, 324

554, 992

1014, 1142

1158, 1294

1,787

138,205

49641+49642

Discharge summary

report+report

Admission Date: [**2116-11-14**] Discharge Date: [**2116-11-21**] Service: HISTORY OF PRESENT ILLNESS: The patient is an 84-year-old gentleman with a past medical history significant for coronary artery disease, type 2 diabetes, and paroxysmal atrial fibrillation who presents with a left lower extremity redness and swelling as well as pain to touch. This swelling is chronic; however, he has noticed intermittent left lower extremity pain for the past month, but the erythema is now new. He first noted an erythematous/brown spot on his left medial calf on the evening prior to admission which progressed to diffuse and very tender erythema with petechiae on the entire left leg. The patient was able to walk, but the rash is very tender to touch. It is nontender at rest. The patient denies any trauma, fevers, chills, night sweats, paroxysmal nocturnal dyspnea, or orthopnea. This rash is new. He has never had this before. The patient denies any cough or sputum production. PAST MEDICAL HISTORY: (Past medical history is significant for) 1. Coronary artery disease. 2. History of gastrointestinal bleed. 3. Prostate cancer. 4. Paroxysmal atrial fibrillation. 5. Fatty liver by liver biopsy. 6. Type 2 diabetes. ALLERGIES: 1. PENICILLIN (causes a rash). 2. ERYTHROMYCIN. 3. BIAXIN. 4. SULFA. MEDICATIONS ON ADMISSION: (His medications on admission included) 1. Digoxin 0.25 mg by mouth every day. 2. Lasix 40 mg by mouth once per day. 3. Aldactone 25 mg by mouth once per day. 4. Glyburide 2.5 mg by mouth once per day. 5. Lipitor 5 mg by mouth once per day. 6. Zantac 75 mg by mouth at hour of sleep. 7. Tylenol. 8. Sublingual nitroglycerin. 9. Toprol-XL 100 mg by mouth once per day. SOCIAL HISTORY: The patient is married and lives with his wife. [**Name (NI) **] quit tobacco 35 years. He denies any ethanol use. FAMILY HISTORY: His mother had coronary artery disease at the age of 74. Father has coronary artery disease. EMERGENCY DEPARTMENT COURSE: In the Emergency Department, he was given clindamycin and ciprofloxacin before blood cultures were drawn. In the Emergency Department, he was also bolused with 2 liters for a systolic blood pressure of 95 to 105. He was also noted to have heart rates in the 50s to 60s but beta blocked. The patient was also noted to qualify for the sepsis protocol four hours into his Emergency Department stay. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed the patient's temperature was 94 degrees Fahrenheit orally, his heart rate was 69, his blood pressure was 105/33, his respiratory rate was 23, and his oxygen saturation was 96%. In general, the patient was in no acute distress. Pertinent findings on examination revealed the patient's neck was supple. No jugular venous distention. No adenopathy. Chest examination revealed his lungs had bibasilar crackles two thirds of the way up. Cardiovascular examination revealed a regular rate and rhythm. He had a grade [**1-9**] holosystolic murmur. The abdomen was soft. Extremity examination revealed his right lower extremity had 1+ edema. On his left lower extremity there was erythema and petechiae to the knee. There was an original spot on the left medial calf which was circular. There was no fluctuance. There were no lesions between the toes. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratory data was remarkable for a white blood cell count of 16.2 (with a differential of 79% neutrophils and 17% polymorphonuclear leukocytes). His lactate was 4.1. Arterial blood gas revealed 7.43/29/109/19 and a lactate of 2.5. Blood cultures times two were sent. PERTINENT RADIOLOGY/IMAGING: A lower extremity noninvasive study revealed no deep venous thrombosis. An electrocardiogram showed paced at 50 with an incomplete right bundle-branch block. There was diffuse T wave flattening. He had upright T waves in V2, V3, and I. He had T wave inversions in leads III and aVF. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The patient was admitted to the Medical Intensive Care Unit for likely severe cellulitis. It was not felt that the patient had necrotizing fasciitis. He was evaluated by Surgery and was felt not to need emergent surgical debridement. He was given broad coverage with clindamycin and ciprofloxacin. On [**2116-11-15**], the patient remained afebrile. The area of infection appeared to be improving, and his white blood cell count came down to 13.2. The patient was changed to Ancef for better streptococcus A coverage of his cellulitis. His blood pressure remained stable. The patient was also noted to be tachypneic. On [**2116-11-16**] the patient continued to remain afebrile. He was noted to have bibasilar crackles and scrotal swelling. On his leg examination, there was a decrease in intensity of the erythema on his leg. His leg computed tomography was negative for subcutaneous gas or fluid collection. A chest x-ray had widening of the right paratracheal and anterior/posterior window, and an increased opacity at the right apex, as well as congestive heart failure. He was also noted to have a small troponin leak and an increased creatinine. His troponin was noted to be 0.04, with a creatine kinase of 123, and a MB of 5. He was continued on ciprofloxacin and cefazolin for treatment of his cellulitis. Cardiovascular wise, he had a small troponin leak (as mentioned). He was continued on statin and beta blocker. Given the elevated enzymes, he was not put on aspirin. An echocardiogram and echocardiogram were checked. He had a peak creatine kinase of 369 and a troponin of 0.06; which were felt most likely most likely due to demand ischemia. His Medical Intensive Care Unit course was also complicated by congestive heart failure without hypoxia, as well as profuse diarrhea, and an increase in his creatinine from 1.4 to 1.7, as well as evidence of clinical hypovolemia. An echocardiogram showed an ejection fraction of 20% to 25%, mildly dilated atrium, 1 to 2+ mitral regurgitation, 3+ tricuspid regurgitation, and moderate pulmonary artery hypertension. Blood cultures and urine cultures on that day had no growth to date. He was then transferred out of the Medical Intensive Care Unit on [**2116-11-17**]. His acute renal failure was felt to be due to a prerenal state secondary to diarrhea and congestive heart failure. He was given diuretics to increase the flow to his kidneys and decrease his creatinine. The diarrhea was felt likely secondary to his antibiotics. Studies were sent for Clostridium difficile. On [**2116-11-18**] the patient was continued on ciprofloxacin and cefazolin. Congestive heart failure wise, he was continued on Aldactone, and Lasix 40 mg by mouth was changed to twice per day. Again, his acute renal failure was felt most likely to be due to congestive heart failure. The diarrhea started to improve. On [**2116-11-19**] the patient was again continued on his antibiotics. Congestive heart failure wise, he was on Aldactone and Lasix. His Aldactone was increased to 50 mg once per day. At this time, the Clostridium difficile was pending. On [**2116-11-20**] the patient was noted to have worsening of congestive heart failure with an oxygen requirement and was given Lasix for stabilization. On this day, he was continued on antibiotics for his cellulitis. For his systolic congestive heart failure, he was continued on Aldactone and as-needed Lasix and continued with his beta blocker, angiotensin receptor blocker, and statin. He was continued on digoxin for his atrial fibrillation. The patient refused to be on Coumadin secondary to a history of gastrointestinal bleed. On [**2116-11-21**] Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1147**] saw the patient and felt that the patient appeared to be breathing better. His edema persisted in both legs. His left lower extremity looked good. His lungs still had rales one third of the way up. He was noted to be accepted at [**Hospital1 **] for congestive heart failure treatment and rehabilitation. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1147**] would follow up from there. DISCHARGE DIAGNOSES: 1. Left lower extremity cellulitis. 2. Congestive heart failure exacerbation. 3. Coronary artery disease. 4. Atrial fibrillation. 5. Diarrhea with negative Clostridium difficile. MEDICATIONS ON DISCHARGE: (Discharge medications were to include) 1. Lipitor 10 mg by mouth once per day. 2. Protonix 40 mg by mouth once per day. 3. Heparin 5000 units subcutaneously q.8h. 4. Percocet one to two tablets by mouth q.4-6h. as needed. 5. Digoxin 0.25 mg by mouth once per day. 6. Glyburide 2.5 mg by mouth once per day. 7. Spironolactone 25 mg by mouth once per day. 8. Albuterol and Atrovent nebulizers as needed. 9. Toprol-XL 50 mg by mouth once per day. 10. Losartan 25 mg by mouth once per day. 11. Ciprofloxacin 400 mg intravenously q.12h. (scheduled to be stopped on [**11-28**]). 12. Cefazolin 1 gram intravenously q.12h. (scheduled to be stopped on [**11-29**]). CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE DISPOSITION: The patient was to be discharged to [**Hospital1 **]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12175**], M.D. [**MD Number(1) 37596**] Dictated By:[**Name8 (MD) 8288**] MEDQUIST36 D: [**2116-11-21**] 10:29 T: [**2116-11-21**] 10:45 JOB#: [**Job Number 103804**] Admission Date: [**2116-11-14**] Discharge Date: [**2116-11-21**] Service: [**Doctor Last Name **] Medicine CHIEF COMPLAINT: Left lower extremity cellulitis. HISTORY OF PRESENT ILLNESS: This is an 84-year-old male with history of coronary artery disease and diabetes, paroxysmal atrial fibrillation, who presented with left lower extremity redness and swelling with pain. He has had a chronic swelling and intermittent left lower extremity pain for months, but the erythema is new. He started with a spot on his medial calf last evening and progressed to diffuse very tender erythema with petechiae in the entire left leg. He is able to walk with severe pain. He denies any trauma. He has no fevers, chills, night sweats, chest pain, anginal equivalent, PND, or orthopnea. He may have accidentally kicked the furniture with his leg. He has no respiratory or GI complaints. PAST MEDICAL HISTORY: 1. Coronary artery disease status post three vessel CABG in [**2105**]. Exercise treadmill test in '[**10**] showed severe apical inferior reversible defects, an EF of 46%. 2. History of GI bleed secondary to peptic ulcer disease. 3. Prostate cancer status post XRT complicated by rectal bleeding. 4. Paroxysmal atrial fibrillation without anticoagulation due to GI bleed. 5. Fatty liver by ultrasound with normal LFTs in [**2116-11-2**]. ALLERGIES: 1. Aspirin - GI bleed. 2. Penicillin - rash. 3. Erythromycin, Biaxin, and sulfa - unknown reactions. MEDICATIONS: 1. Digoxin 0.25 q.d. 2. Toprol XL 100 q.d. 3. Lasix 40 q.d. 4. Aldactone 25 q.d. 5. Glyburide 2.5 q.d. 6. Lipitor 5 q.d. 7. Zantac 75 h.s. 8. Tylenol. 9. Sublingual nitroglycerin prn. SOCIAL HISTORY: He is married and lives with his wife. [**Name (NI) **] quit tobacco 35 years ago. He does not drink. FAMILY HISTORY: Shows that the mother had coronary artery disease at 74 and father had coronary artery disease. PHYSICAL EXAMINATION: Patient's physical exam showed temperature of 94 in ED triage rising to 96 on admission to the ED, pulse of 79, blood pressure 105/33, respiratory rate of 23, and sat of 96% on room air. Blood sugar was 196. In general, he was in no distress. He was anicteric. HEENT examination was otherwise negative. He had no JVD, no lymphadenopathy. His lungs had crackles [**1-6**] of the way up. He had a normal S1, S2 and a [**1-9**] holosystolic murmur. Abdomen was soft, nontender, tympanitic. Right lower extremity showed increased edema. Left lower extremity showed marked erythema with petechiae, pain, no lesions were seen as a portal for cellulitis. LABORATORIES ON ADMISSION: White count of 16.2 with 79 neutrophils and 17 bands, a hematocrit of 43.7, 225 platelets. Chem-7 was notable for creatinine of 1.4, up from 1.3 at baseline, lactate was 4.1, glucose was 222. ABG showed pH of 7.43, CO2 of 27, and oxygen of 109. Because of the patient's vital signs, and his bandemia, and elevated lactate, he was admitted to the ICU for sepsis protocol. He was initially treated with Cipro and clindamycin before blood cultures were performed, and he was given several liters of fluid in the ED for blood pressure that dropped to 95 with a heart rate of 50s-60s while he was beta blocked. The initial concern was for necrotizing fasciitis. He was evaluated by Surgery, who felt that he would not need emergent debridement, but he was monitored for decompensation, which did not occur. He had a CT of his leg which showed no free air. Vancomycin was initially added for concern for MRSA. This was later discontinued and he was kept on clindamycin and Cipro alone. Patient was oxygenating well despite his CHF on examination, and he was given only gentle fluids initially. He was followed by Surgery in the ICU. His cellulitis improved on antibiotics of cefazolin and Cipro. He was continued on his routine heart failure medications. He was felt to be hypovolemic despite his crackles and was given more IV fluid repletion due to his picture of sepsis. He remained hemodynamically stable, and was transferred to the floor on the 16th. The only notable events in the ICU were a new T-wave inversion in V2 and V3 and a peak CK of 369 with a troponin of 0.6 felt to be consistent with demand ischemia. On the floor, he continued his antibiotics, and his cellulitis continued to be improving. He was seen by Physical Therapy, who cleared him for discharge home. However, he had worsening diarrhea. Clostridium difficile was sent and was negative. He, however, had difficulty with worsening CHF on the evening of the 17th and 18th. His diuresis was increased requiring 40 b.i.d. IV Lasix. He had repeat EKG and troponins, which were negative for new ischemia at that time. The cause of his CHF exacerbation was felt to be the fluids he received for diarrhea and for sepsis originally. He was given a slightly lower dose of his beta blocker, and continued on his statin, and digoxin, and aldactone. Patient was seen by Occupational Therapy, who felt that he had a borderline requirement for rehab stay, however, given his relatively tenuous CHF status and medication balancing, he was felt to be someone who would benefit from a short rehab stay, which was arranged for [**2116-11-21**]. DISCHARGE DIAGNOSES: 1. Left lower extremity cellulitis complicated by sepsis and mild hypotension. 2. Congestive heart failure due to volume overload. 3. History of GI bleed preventing aspirin and anticoagulation use. DISCHARGE CONDITION: Will be updated on the time of his departure on the 20th. DISCHARGE MEDICATIONS: 1. Ipratropium nebulizers or MDIs q.4h. prn. 2. Albuterol nebulizer or MDI q.4h. prn. 3. Metoprolol XL 50 q.d. 4. Losartan 25 q.d. 5. Guaifenesin [**4-11**] mL p.o. q.6h. prn. 6. Spironolactone 25 q.d. 7. Glyburide 2.5 mg p.o. q.d. 8. Cefazolin 1 gram IV q.12h. to be converted to a 14 day total duration of antibiotics with Keflex on departure from acute rehab. 9. Digoxin 0.25 mg p.o. q.d. 10. Ciprofloxacin 500 mg p.o. b.i.d. 11. Protonix 40 mg q.d. 12. Lipitor 5 mg p.o. q.h.s. 13. Lasix dose to be determined but likely 80 mg b.i.d. FOLLOW-UP INSTRUCTIONS: Followup should be with Dr. [**Last Name (STitle) 1147**] and the patient's cardiologist. Patient's daily weight must be monitored and his Lasix may need to be increased if his weight increases. Saturations must also be closely followed with his respiratory rate and physical exam. He should consume a 2-gram sodium cardiac diet. DISCHARGE STATUS: Full code, but this spares clarification with the patient. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12175**], M.D. [**MD Number(1) 37596**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2116-11-20**] 14:50 T: [**2116-11-25**] 07:44 JOB#: [**Job Number 103805**]

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icd9cm

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Discharge summary

report

Admission Date: [**2125-10-31**] Discharge Date: [**2125-11-15**] Date of Birth: [**2047-4-24**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1835**] Chief Complaint: residual suprasellar mass Major Surgical or Invasive Procedure: Right Craniotomy History of Present Illness: 78 y/o M s/p partial transhpenoidal pituitary resection in [**2125-7-5**] for a macroadenoma presents for follow up. The patient reports persistent intermittent headaches and some visual deficits that have not worsened since his last visit. He has been seen by ophthalmology and is also being followed by endocrine who have been following his lab results regularly. He denies any dizziness, n/v, or dysarthria. Since the transphenoidal resection in [**7-5**] was a subtotal approach (the chiasmatic portion of the adenoma did not fall into the sella once the lower portion of the tumor had been evacuated), the patient is in need of a second stage surgery to ermove the tumor part that sits above the dumbbell waistline. MRI head shows that residual pituitary lesion. Past Medical History: - HTN - Per chart, history of atrial fibrillation. - Pituitary adenoma s/p resection Social History: He is married and lives with his wife, daughter, and granddaughter. [**Name (NI) **] previously served in the armed forces. He continues to smoke [**11-26**] ppd X 40+ years. He denies any alcohol or illicit drug use. He works as a parking attendant at [**Hospital3 1810**] [**Street Address(1) 9069**]. Family History: no stroke, no heart disease, has 3 siblings with HTN Physical Exam: On Admission: Gen: WD/WN, comfortable, NAD. HEENT: atraumatic, normocephalic Pupils:3-2mm bilaterally EOMs; intact Neck: Supple. Lungs: no audible wheezing or rhonchi. Cardiac: RRR. Abd: Soft, NT, Extrem: Warm and well-perfused. No C/C/E. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**1-25**] 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, 3 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to 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 [**3-29**] throughout. No pronator drift Sensation: Intact to light touch On Discharge: EO, oriented to self and hospital. PERRL. MAE spon very STRONG/equal. simple commands. Inc c/d/i Pertinent Results: [**2125-10-31**] CT head demonstrates expected postop changes, no hemorrhage, moderate hydrocephalus Pathology Report Tissue: Right sellar tumor. Study Date of [**2125-10-31**] ****Report not finalized. Assigned Pathologist [**Doctor Last Name **],HASINI Please contact the pathology department, [**Name (NI) **] [**Numeric Identifier 1434**] PATHOLOGY # [**-9/5170**] Right sellar tumor. MR HEAD W/ CONTRAST Study Date of [**2125-10-31**] 6:07 AM IMPRESSION: Stable residual neoplasm in the right side of the sella extending into the right cavernous sinus, and encasing the cavernous segment of right internal carotid artery. MR PITUITARY W&W/O CONTRAST Study Date of [**2125-11-1**] 7:53 PM IMPRESSION PER RADIOLOGY: The study is limited due to motion artefact. 1. Postoperative changes in the form of right frontal and temporal craniotomy. Pneumocephalus in bifrontal regions. Extra-axial collection in right frontal region. 2. Residual neoplasm in the right side of the sella extending into the right cavernous sinus and encasing the right internal carotid artery. This is unchanged since the prior study. 3. Interval resection of the suprasellar component of the mass. Mild enhancement in the pituitary stalk which may represent postoperative change or residual neoplasm. 4. Changes of chronic small vessel ischemic disease. The study and the report were reviewed by the staff radiologist. CHEST (PORTABLE AP) Study Date of [**2125-11-2**] 4:34 AM IMPRESSION: PA and lateral chest compared to [**2124-12-13**]: Moderately severe opacification in the left mid and lower lung zones is probably edema, also affecting the right lower lung and accompanied by a moderate right pleural effusion. Emphysema is severe. Thickening of the right apical pleural surface is chronic. A large reticulated opacity projecting over the right mid lung could be unusual atelectasis or bronchiectasis or even a pleural calcification present in [**2122**]. Inferior to it is scarring in the right mid lung. CT HEAD W/O CONTRAST Study Date of [**2125-11-2**] 8:11 PM IMPRESSION: 1. No evidence of cerebral edema or acute intracranial process. 2. Expected postoperative changes related to right craniotomy CHEST (PORTABLE AP) Study Date of [**2125-11-2**] 7:02 PM IMPRESSION: AP chest compared to [**11-2**] at 4:33 a.m. and 1:08 p.m.: New endotracheal tube in standard placement. Edema in the left lung appears less radiodense but this may be a function of better inflation following tracheal intubation. Severe right lung scarring and concurrent emphysema make it difficult to determine if a concurrent pneumonia is present. Heart size is normal. Right pleural thickening is more pronounced now than it was in [**Month (only) 404**] suggesting either a component of pleural effusion or pathologic pleural involvement. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 9070**], [**Known firstname 1112**] [**Hospital1 18**] [**Numeric Identifier 9071**]Portable TTE (Complete) Done [**2125-11-3**] at 11:07:24 AM FINAL The left atrium and right atrium are normal in cavity sizes. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). The estimated cardiac index is normal (>=2.5L/min/m2). 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 (1+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved regional and hyperdynamic global biventricular systolic function. Mild mitral regurgitation. Compared with the prior study (images reviewed) of [**2123-4-15**], biventricular systolic function is more dynamic (and the heart rate is higher). CLINICAL IMPLICATIONS: Based on [**2120**] 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. CHEST (PORTABLE AP) Study Date of [**2125-11-3**] 10:07 AM IMPRESSION: AP chest submitted for review at 4:53 p.m.: Moderate pulmonary edema unchanged since [**11-3**]. Emphysema, right pleural thickening and pleural calcification have been discussed on prior and subsequent radiographic reports. Heart size is normal. ET tube in standard placement. CHEST (PORTABLE AP) Study Date of [**2125-11-3**] 1:03 PM IMPRESSION: Dobbhoff tube with a wire stylet in place ends at the gastroesophageal junction and should be advanced at least 5 cm to move the entire weighted tip into the body of the stomach. Mild pulmonary edema is clearing. Inferiorly severe scarring in the right lung is a persistent region of opacification, could be atelectasis or pneumonia. Heart size normal. ET tube in standard placement. Extensive thickening of the right pleural margin has increased since [**2124-11-25**] and could be either more infiltration of pleural surface or additional component of right pleural effusion. No pneumothorax. Radiology Report CHEST (PORTABLE AP) Study Date of [**2125-11-3**] 1:03 PM IMPRESSION: Dobbhoff tube with a wire stylet in place ends at the gastroesophageal junction and should be advanced at least 5 cm to move the entire weighted tip into the body of the stomach. Mild pulmonary edema is clearing. Inferiorly severe scarring in the right lung is a persistent region of opacification, could be atelectasis or pneumonia. Heart size normal. ET tube in standard placement. Extensive thickening of the right pleural margin has increased since [**2124-11-25**] and could be either more infiltration of pleural surface or additional component of right pleural effusion. No pneumothorax. CHEST (PORTABLE AP) Study Date of [**2125-11-4**] 10:06 AM IMPRESSION: AP chest compared to [**11-2**] through 10: Minimal edema persists in the left lung. Large region of consolidation inferior to the central lungs and pleural scarring has not cleared. Heart size is normal. ET tube is in standard placement. Feeding tube ends in the upper stomach. Denser right pleural thickening is chronic, but more pronounced today than in [**2124-11-25**]. No pneumothorax. CHEST (PORTABLE AP) Study Date of [**2125-11-5**] FINDINGS: The endotracheal tube sits 4 cm above the carina. The endogastric tube tip sits within the stomach, although a portion of the weighted tip sits above the GE junction. The heart size is within normal limits. The mediastinal and hilar contours appear unremarkable. The lungs continue to demonstrate heterogeneous opacity in the right mid and lower portion, which may represent an area of scarring. Additionally, more scattered punctate densities throughout the right and left lung are compatible with calcified pleural plaques as confirmed by the visualized chest portion of the abdominal and pelvic CT from [**2125-2-9**]. Trace bilateral pleural effusions. There is no pneumothorax. IMPRESSION: 1. Lines and tubes as described above. 2. Right mid and lower lung scarring and trace bilateral pleural effusions. Radiology Report BILAT LOWER [**Year (4 digits) **] VEINS Study Date of [**2125-11-5**] IMPRESSION: No DVT in both lower extremities. CHEST (PORTABLE AP) Study Date of [**2125-11-6**] FINDINGS: As compared to the previous radiograph, there is no relevant change. Right apical parenchymal opacity is unchanged in extent. The right basal parenchymal scarring is also unchanged. Minimal left parenchymal scarring. Normal size of the cardiac silhouette. No evidence of pulmonary edema, a linear lucency at the left lung apex, mimicking a pneumothorax, is in fact outside of the patient. Unchanged course and position of the monitoring and support devices. MRI BRAIN WITH & WITHOUT CONTRAST [**2125-11-7**] FINDINGS: The patient is status post right frontotemporal craniotomy for resection of pituitary mass. There is interval resolution of previous pneumocephalus with unchanged right frontal and temporal tip extra-axial fluid collection (measuring 10 or 5 mm in maximal thickness). Previously reported bilateral, predominantly frontal hygroma is likewise stable (measuring approximately 9 mm in thickness). While postsurgical subgaleal soft tissue swelling is largely unchanged, there is an increasing fluid collection noted along the right temporal muscle. In the absence of peripheral enhancement and restricted diffusion, there is no evidence of abcess. There is restricted diffusion and FLAIR signal abnormality involving the tip of the right temporal ventricle, in keeping with a small area of infarct. A small focus of hyperintensity on diffusion weighted imaging involving the medial left high frontal lobe is too small to characterize by ADC map and may represent artifact versus a small area of infarct. No interval change is seen with regard to the homogeneously enhancing mass at the right side of the sella, extending into the right cavernous sinus. There is persistent encasement of the cavernous segment of the right internal carotid artery. Unchanged periventricular and deep white matter FLAIR/T2 signal abnormalities are again noted and likely represent sequelae of chronic small vessel ischemic disease. Previously noted opacification of the bilateral mastoid air cells has progressed since the prior. The paranasal sinuses are clear. IMPRESSION: 1. Interval resolution of pneumocephalus with stable [**Hospital1 **]-hemisperic hygroma as well as right frontal and temporal tip subdural collections. 2. Acute ischemia involving the tip of right temporal lobe. A small focus of hyperintensity on diffusion weighted imaging involving the medial left high frontal lobe is too small to characterize by ADC map and may represent artifact versus a small area of infarct. 3. More prominent fluid collection along the medial aspect of the right temporal muscle that does not demonstrate ring enhancement or restricted diffusion, likely consistent with seroma. 4. Status post partial resection of suprasellar mass with stable appearance of residual tumor. EEG [**2125-11-7**] IMPRESSION: This continuous recording shows what appears to be an evolving diffuse encephalopathy. There were no clear epileptic features. While there were some asymmetries with either voltage increase on the right or decrease on the left, depending on underlying pathophysiology, no clear epileptic or sustained abnormalities were identified. CHEST (PORTABLE AP) Study Date of [**2125-11-7**] Right mid and lower lung and left lower lung opacities concerning for multifocal pneumonia have worsened since [**2125-11-6**]. An coexisting component pulmonary edema is possible. No other interval changes. Scarring in the right lower lungs and right apical dense pleural thickening are unchanged. Small bilateral pleural effusions are similar. No pneumothorax. CHEST (PORTABLE AP) Study Date of [**2125-11-8**] FINDINGS: As compared to the previous radiograph, the entire upper part of the chest missing on the current image. The basal parts of the right and left hemithorax are unchanged. There is bullous disease at the lung bases. The tip of the Dobbhoff catheter projects over the middle parts of the stomach. The size of the cardiac silhouette is within the upper range of normal. No evidence of pleural effusions. CHEST (PORTABLE AP) Study Date of [**2125-11-9**] Extensive infiltrative pulmonary abnormality in the right lower lobe, and overlying pleural calcification are longstanding, but previous pulmonary edema in this location has improved if not resolved, leaving behind a small residual right pleural effusion. The left lung base was relatively clear on [**11-5**] and also developed some edema, which has decreased since [**11-8**]. Given the severe scarring in these lungs, some pneumonia could be present and not appreciated, for example, just projecting over the right hilus, but in the left lung, there is no evidence of pneumonia. ET tube is in standard placement. Feeding tube ends in the upper stomach. The heart is not enlarged. Right pleural thickening is most extensive at the apex and unchanged. No pneumothorax. EEG [**11-8**]- [**11-9**]: This is an abnormal continuous ICU video EEG due to diffuse attenuation and slowing of background consistent with a moderate encephalopathy. EEG [**11-10**]: [**2125-11-10**]: CXR portable: New right PICC line tip terminates at the level of mid SVC. The Dobbhoff tube tip passes below the diaphragm with its tip not included in the field of view. No substantial change in the extensive parenchymal opacities as well as no changes in the cardiomediastinal silhouette demonstrated. [**2125-11-11**] CT head: 1. Prominent hypodense bifrontal hygromas, unchanged over multiple prior examinations, including the most recent MR examination from [**2125-11-6**]. No new fluid collection or hematoma detected. No new mass effect. Post-right frontal approach pituitary mass resection, with no evidence of hemorrhage or new mass effect [**2125-11-13**] Lower extremty doppler ultrasounds: IMPRESSION: No evidence of deep vein thrombosis in either leg. Brief Hospital Course: Mr. [**Known lastname **] was admitted for a stage 2 resection of pituitary adenoma. On [**10-31**] he underwent right subfrontal craniotomy for resection of the tumor under general anesthesia. Intraoperatively he was found to be hypothermic and thus postoperatively he remained intubated on transfer to the ICU where he was rewarmed and then extubated. Postoperative head CT demonstrated expected postoperative changes with minimal pneumocephalus. Postoperatively the patient was monitored with frequent Serum Na and Osm checks and frequent Urine specific gravities, Na and Osms and close Urine output monitering for signs of Diabetes Insipitus. Endocrinology was consulted. On POD 1, 24 hours after surgery, the patient's Serum Na started trending up and urine specific gravity trended down. Urine output consistently was between 150 and 300cc/hour. Overnight on [**11-1**] into [**11-2**] Serum Na trended up to 156 and the patient became agitated. Urine Specific gravity was 1.005. He was given DDAVP and IVF boluses to match urine output. He underwent postoperative MRI overnight that demonstrated expected postoperative changes without evidence of stroke. On [**11-2**], the patient was reintubated after extreme agitation and acute hypoxic event.The patient was given a total of 40 mg IV lasix for pulmonary edema and crackles heard over the lung bases. The patient was hypernatremic NA 156. A repeat head CT was perfomed and found to be stable. DDAVP was given twice over for treatment of Diabetes Inspipidus. On [**11-3**] The patient continued to be hypernatremic. The serum sodium was NA 153. The urine specific gravity was 1.021. The patient was no longer thought to be in Diabetes Insipidua but was intrvascuarly dry. The urine output was decreased and there were crackles at bilateral bases. The patient was given Lasix 20 mg and D5W at 75 cc/hr was initiated to correct hypernatremia. On [**11-4**], The patient was not thought to be in Diabetes Insipitus (the urine specific gravity was 1.018) per endocrine consultation. The patient continued to to be hypernatremic and free water per dop hoff was administered. The serum sodium has improved to 148. An attempt was made to wean the patient from sedation medication in hopes to extubate the patient. Propofol was discontinued and precedex was initiated. At maximum doses of Precedex, the patient was extremly aggitated, attempting to pull at tubes and wires and the patient was resedated with propofol. There were copious secretions and a mini BAL was sent which was positive for hemophilus and Gram Positive Cocci. On [**11-5**], Tube feedings were at goal at a rate of 60 cc/hr, the patient had had no bowel movement and was given a fleets enema with results. LENIS were performed due to prolonged bedrest and there was No Deep Vein Thrombosis present in both lower extremities. The patient remained intubated due to secretions and aggitation. The BAL from [**11-5**] was found to be consistent with Ventilator Assisted Pneumonia. The patient was patient was started on VANComycin, zosyn, cipro for treatment of VAP. started. The patient underwent a bronchcoscopy today and there were copious secretion and mucous plugs and a BAL was sent for culture. Tube feedings remained at goal a goal of 60 cc hr via the dophoff and free water per endo 250 every four hours continued. The urine sodium, specific gravity and osmolaity /serum osmoality and sodium were changed to every 8 hours from every 4 hours. On [**11-6**] an MRI was performed and was negative for stroke or significant edema. His neurological exam was stable. On [**11-7**] his secretions remained copius despite 48hrs of antibiotics. He was on CPAP and ABG was within normal limits but BAL from [**11-4**] revealed multiple organisms therefore an ID Consult was requested. Na was 145 and urine was WNL therefore free water was decreased to 200ml Q4hrs. Also per endocrines recommendation, the hydrocortisone was decreased to 20mg [**Hospital1 **]. ID recommended discontinuign his cipro and vancomycin and keeping Zosyn for H. flu and anerobe coverage. He also had another bronchoscopy and washigns were sent for culture and evaluation. The ICU also initiated a 24 hour EEG to monitor for any seizure activity. On [**11-8**] he was planned to recieve a PICC line and his fre water boluses were discussed with endocrinology who recommended keeping them at 200ml every 4 hours. The patient underwent a lumbar puncture which was negative for infection. He remained intubated overnight. On [**11-9**] the patient was extubated in the AM. EEG monitoring continued to be negative for seizure activity. His NA level increase from 150 to 152 and he recieved 1mcg of DDAVP which led to a decrease in his urine output. On [**11-11**], patient was much improved on examination. He was OOB to chair and MAE with good strength. A repeat head CT was done to evaluate bilateral hygromas seen on MRI. Head CT showed stable hygromas and patient was then transferred to the step down unit. Endocrine asked to decrease his PM dose of hydrocortisone to 10mg, send t4, thrb, and free t4, and add levothyroxine 50mcg QD. On [**11-12**] he had a swallow evaluation and his diet was advanced. PT/OT evaluated him and recommended acute rehab. All medications were changed to PO. ID final recs are to continue Zosyn for a full 8 day course, last dose given [**11-13**]. On [**11-14**] Pt's serum Na bumped to 151 and he was started on Intranasal ddAVP 10mcg [**Hospital1 **] per endocrinology as they felt he was in mild DI and was unable to match his intake with his output. Labs continued to be followed Q12hrs. On [**11-15**] he was deemed fit for trasnfer to rehab at [**Hospital1 **] [**Location (un) 86**]. At the time of discharge he is tolerating a regular ground solid and thin liquid diet, ambulating with assistance, afebrile with stable vital signs. He will need Routine labs checked to evaluate for hypo- and hypernatremia. Medications on Admission: lisinopril, tylenol prn Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Pituitary Adenoma Acute delirium due to metabolic encephalopathy Diabetes Insipidus Hypernatremia Pulmonary edema Pneumonia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: ?????? 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. ?????? 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) & Senna while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: increasing redness, increased swelling, increased tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in 6 weeks. No further imaging will be needed before this appointment. - Follow up with Endocrinology in 4 weeks with Dr. [**Last Name (STitle) **] call ([**Telephone/Fax (1) 9072**] to schedule an appointment. - Please call [**Hospital1 18**] Endocrinology at [**Telephone/Fax (1) 1803**] on [**11-16**] to find out results of thyroid function testing that was done just prior to your discharge. You may need to have your medication altered depending on these results. Completed by:[**2125-11-15**]

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icd9cm

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107,405

21616

Discharge summary

report

Admission Date: [**2177-11-29**] Discharge Date: [**2177-12-16**] Date of Birth: [**2098-2-21**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2078**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: This is a 79yo M with history of hypertension, hyperlipidemia, PVD who presented with 5/10 nonradiating burning chest pain in midchest that started at 3 AM on the morning of admision. HE denies nausea/vomitting/ diaphoresis / dizziness/palpitation. THe pain did not wake him up from sleep and he noticed it while he was waking up to get to the bathroom. The pain was not relieved by mylanta/tums. At baseline, he could only walk a few hundred feet because of claudication. This has not changed recently. He did not notice any leg swelling/weight change. Patient went to [**Hospital 487**] Hospital where he had ST depression in V4-V6 and noted to have crackles on exam. Chest pain was relieved by 2SLNTG. patient geiven lasix. trop noted to be 9.37 at OSH(0-0.5) with MB 65.1. IV heparin was started. He was then transferred to [**Hospital1 18**]. Patient is chest pain free on IV heparin and integrillin Past Medical History: 1. CAD??silent MI in the past 2. COPD 3. paroxysmal Afib 4. hypercholesterolemia 5. bilateral CEA about 20y ago 6. PVD s/p angioplasty LLE about 10y ago 7. neck CA s/p XRT 7y ago Social History: denies tobacco/ETOH Family History: MI in father at 65yo Physical Exam: T97.5 BP 90-110/50-60 P68 94% on RA Gen-very pleasant elderly gentleman, comfortable in no pain/distress HEENT-anicteric, oral mucosa moist, neck supple CVS-regular HS, no murmur, faint heart sound, no pedal edema, no JVD, carotid bruit on right ext-femoral pulse 2+ bilaterally, no bruit, DP 1+ bilaterally(diffuicult to find) resp-mild bibasilar crackles [**Last Name (un) 103**]-nl BS, NT/ND neuro-A+Ox3, move all 4 limbs symmetrically, no facial asymmetry Pertinent Results: ECG-irregular rate, wandering atrial pacemaker, normal axis and interval, ST depression in V2-V6 I, II CXR [**2177-11-28**]-bilateral hazy opacities c/w CHF [**2177-11-29**] 09:55AM PTT-113.3* [**2177-12-16**] 07:05AM BLOOD WBC-8.7 RBC-3.75* Hgb-11.1* Hct-32.1* MCV-86 MCH-29.5 MCHC-34.5 RDW-16.3* Plt Ct-321 [**2177-12-16**] 07:05AM BLOOD Plt Ct-321 [**2177-12-16**] 07:05AM BLOOD Glucose-97 UreaN-87* Creat-3.8* Na-130* K-3.0* Cl-87* HCO3-36* AnGap-10 [**2177-12-11**] 07:25AM BLOOD LD(LDH)-273* [**2177-12-5**] 05:36AM BLOOD ALT-18 AST-23 LD(LDH)-322* AlkPhos-68 TotBili-0.5 [**2177-12-3**] 03:59PM BLOOD CK-MB-23* MB Indx-12.9* cTropnT-4.82* [**2177-12-3**] 05:27AM BLOOD CK-MB-36* MB Indx-13.7* cTropnT-5.10* [**2177-12-2**] 01:36PM BLOOD CK-MB-98* MB Indx-18.5* cTropnT-3.84* [**2177-12-16**] 07:05AM BLOOD Calcium-8.5 Phos-4.4 Mg-2.2 [**2177-11-30**] 01:56PM BLOOD calTIBC-270 VitB12-229* Folate-19.2 Ferritn-71 TRF-208 [**2177-11-29**] 06:30AM BLOOD Triglyc-68 HDL-46 CHOL/HD-2.6 LDLcalc-59 [**2177-11-30**] 01:56PM BLOOD TSH-1.4 Brief Hospital Course: Patient had a NSTEMI on admission. Over the weekend, the decision had been to watch him since he was chest pain free and his Cr was rising. However, he eventually developed chest pain, his troponin peaked at 5.10 with very ischemic looking ECG. He was initially put on integrillin and heparin. However, his renal function continues to worsen and the integrillin was then switched to reapro. He subsequently passed large liquid black stool. The reapro and heparin was thus discontinued. The renal function continues to worsen and he also developed flash pulmonary edema with acute respiratory distress. He was then transferred to the CCU and aggressively diuresed with natrecor and achieved a net loss of 3.2L. The flash pulmoary edema was thought to be caused by his evolving MI. His EF was known to be 35%. He was then transferred to the floor. His oxygen saturation did not improve despite aggressive diuresis with natrecor and lasix drip. His CXR showed moderate to large bilateral pleural effusion. Bilateral thoracentesis was performed and he had a therapeutic tap about 2L on the right and 1.4 L on the left. Pleural fluid was consistent with transudative effusion. His respiratory status improved dramatically since then. His diuretic regimen was gradually switched to IV and then to oral medication. He will be discharged on oral lasix 20 [**Hospital1 **]. There is no plan for cardiac catheterization at this moment. [**Name2 (NI) **] will be managed medically with aspirin, metoprolol XL, simvastatin and nitroglycerin. Patient also has a history of paroxysmal atrial fibrillation. He was on digoxin, diltiazem and coumadin as outpatient. However,coumadin was discontinued because of his GI bleed. Diltiazem and digoxin were discontinued because of the frequent 4s pauses seen on telemetry. On discharge,he was in sinus rhythm on metoprolol and amiodarone 400 [**Hospital1 **]. Digoxin was not restarted due to his renal failure. He will have to have a GI workup before coumadin could be restarted. GI workup will have to be arranged as outpatient. Meanwhile, he would continue on PPI. He had recieved a total of 3 units of pack red cells while he was actively bleeding and since then his hematocrit had been stable. He was also started on iron pills. Once his EGD/colonoscopy has been done, he should be restarted on coumadin for stroke prevention (Afib) with a goal INR of [**2-25**]. His creatinine peaked at 4.1, likely due to decreased perfusion from worsening CHF in the setting of MI. Renal U/S showed no hydronephrosis or stone. There was also no cast in urine to suggest ATN. The creatinine gradually drifted down with resolution of his CHF status He will be discharged to rehabilitation with close follow up. Medications on Admission: zocor 20 qhs terazosin 2mg oi qhs allopurinol 100 [**Hospital1 **] albuterol 2 puffs qid digoxin 0.125 po qd diltiazem 240 qd HCTZ 12.5 qam coumadin 5 qd NKDA Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). 4. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-24**] Sprays Nasal QID (4 times a day) as needed. 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 8. Ipratropium Bromide 0.02 % Solution Sig: 1-2 puffs Inhalation Q6H (every 6 hours) as needed for SOB. 9. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO twice a day: Please give 200 mg [**Hospital1 **] for two weeks and then change to 200 mg once daily as his maintenance dose. 10. Trazodone HCl 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 11. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: 0.5 Tablet Sustained Release 24HR PO DAILY (Daily). 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Tablet(s) 14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: NSTEMI acute on chronic renal failure GI bleed congestive heart failure pneumonia Discharge Condition: good Discharge Instructions: Please follow-up with your primary care doctor in [**2-25**] weeks. Dr. [**Last Name (STitle) 50167**], [**First Name3 (LF) **] [**Telephone/Fax (1) 50168**]. Fax [**Telephone/Fax (1) 56897**] Once you have had your colonoscopy and upper endoscopy, you should be restarted on coumadin if it is safe to do so. Please check with your primary care doctor prior to restarting this medication. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**], [**Hospital1 18**] Gastroenterology ([**Telephone/Fax (1) 19233**], will call your Rehab and your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 10542**] the follow-up endoscopy and colonoscopy. Please follow-up with your nephrologist and cardiologist as scheduled. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D., PH.D.[**MD Number(3) **]: [**Hospital6 29**] MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2178-1-26**] 2:30 Please follow-up with your primary care doctor in [**2-25**] weeks. Provider: [**Name10 (NameIs) 475**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 474**], M.D. Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2178-2-13**] 1:00 Outpatient EGD/Colonoscopy to be scheduled. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**], [**Hospital1 18**] Gastroenterology ([**Telephone/Fax (1) 8892**], will call your Rehab and your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] the follow-up endoscopy and colonoscopy.

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4213

Discharge summary

report

Admission Date: [**2101-12-2**] Discharge Date: [**2101-12-21**] Date of Birth: [**2042-7-17**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 4377**] Chief Complaint: Chest Pressure and shortness of breath Major Surgical or Invasive Procedure: cardiac cath with placement of a 3.0 x 18 Cypher in the LAD placement of pericardial drain left thoracentesis History of Present Illness: 59 yo f without signif cardiac hx p/w 2 weeks of DOE and 1 day of chest pressure. Tx from OSH for possible STEMI, given STE in inferior leads, STD in lat leads. CXR with cardiomegaly. Bedside echo here with large pericardial effusion with tamponade physiology. Emergent drainage of 1200cc of sero-sanguinous fluid. Angio revealed CAD, 80% lad lesion stented with drug-eluding stent. repeat echo with small effusion. Now with pericarditis. . ROS: +fever, night sweats, unintentional weight loss Past Medical History: depression hysterectomy for fibroids hx of disc surgery s/p hip replacement alcholism s/p rehab, AA Social History: Substance use history: Pt has hx of cocaine, marijuana, alcohol, valium, and vicodin abuse; she has been abstinent x5 months and has been attending AA. She denies any hx withdrawal sx, seizures, or DTs. She has smoked cigarettes 1 pack/day x40 yrs. Personal and Social History: Pt reports that prior to her intervention, her addiction led to her losing her very rewarding job at a shoe company and losing her home. She reports relying on the goodwill of AA members for housing since becoming sober, and she currently lives in a sparsely-furnished apt owned by a fellow AA member in [**Location (un) 620**]. She has found work in a medical office. She has relatively few social contacts, but she speaks w/her son, who is her health care proxy, daily. [**Name2 (NI) **] son has a master's degree, went to [**Location (un) 18316**], and works as a Weapons Officer in the Navy. He, his wife, and their 7y/o and 1y/o children live in [**Location (un) 18317**]; as a result of her hospitalization, pt just had to cancel her plane ticket to visit them for [**Holiday **]. Pt has some friends from work and from AA. Family History: no history of malignancy. Physical Exam: Vitals: t 98.1 bp 99/68 hr 73 rr 16 sat 96-97% 4 L NC Gen: nad, mood is depressed HEENT: EOMI, op clear Neck: palpable submandibular lad Axillae: palpable L ax lad Lung: clear bilat. Heart: reg, no murmurs, pericardial rub. pericardial drain in place Abd: + bs, non-tender, no HSM Ext: no edema Neuro: CN 2-12 grossly intact, strength and sensation intact in upper and lower ext bilat Pertinent Results: Admission labs: 134 107 21 -------------< 110 4.1 19 0.9 Ca: 8.1 Mg: 2.1 P: 4.4 ALT: 16 AP: 66 Tbili: 0.2 Alb: 3.0 AST: 19 LDH: 313 TProt: 6.8 [**Doctor First Name **]: 235 Lip: 760 TSH:4.0 Free-T4:1.1 . 10.6 11.5 >------< 352 31.7 N:68.3 L:19.5 M:6.9 E:4.6 Bas:0.7 . PT: 12.8 PTT: 31.6 INR: 1.1 pH 7.24, pCO2 40, pO2 75 . PERICARDIAL FLUID Other Body Fluid Chemistry: TotProt: 5.3 Glucose: 83 LD(LDH): 511 Amylase: 35 Albumin: 2.5 . PERICARDIAL FLUID Other Body Fluid Hematology: WBC: [**Numeric Identifier **] RBC: [**Numeric Identifier 18318**] Polys: 68 Lymphs: 19 Monos: 6 Eos: 1 Mesothe: 1 Macro: 5 . Trends: WBC: 11.5 to 10.4 Hct: 31.7 to 27.3 [**12-9**]: ANC 8220 Sodium: 134 - 130 - 129 - 125 - 122 - 125 - 121 - 124 - 130 - 134 LDH 313 to 369 [**Doctor First Name **]-NEGATIVE BLOOD PEP-ABNORMAL B IgG-2334* IgA-53* IgM-19* IFE-MONOCLONAL [**12-2**]: Trop 0.77 to 0.71 and CKMB not done [**Date range (1) 18319**]: Trop 0.73 - 0.68 - 0.67 - 0.43 - 0.45 - 0.50, CKMB neg . Micro: HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HAV-NEGATIVE HIV Ab-NEGATIVE HCV Ab-NEGATIVE . [**12-2**]: pericardial fluid: AEROBIC BOTTLE (Final [**2101-12-6**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL SENSITIVITIES . Blood and urine cultures negative [**12-11**]: Sputum culture: MORAXELLA CATARRHALIS. . Imaging: [**12-2**]: CT chest/abd/pelvis: 1. No evidence of aortic dissection or aneurysm. 2. Large pericardial effusion. 3. Multiple bilateral large mediastinal, axillary, retroperitoneal, and mesenteric lymph nodes of unclear etiology. This is concerning for lymphoma and correlation with hematologic profile or biopsy is recommended. 4. Bibasilar atelectasis with a small right pleural effusion. 5. Multiple diverticuli throughout the colon without evidence for diverticulitis. . [**12-2**]: CXR: 1. Large pericardial effusion. 2. Small right pleural effusion. No evidence for infiltrate. . [**12-2**]: ECHO: Inferior infarct with RV dysfunction. Moderate to large circumfirential pericardial effusion with early tamponade. . [**12-2**]: ECHO (post procedure): The left atrium is elongated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with inferior and infero-lateral hypokinesis. No masses or thrombi are seen in the left ventricle. There is mild global right ventricular free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. The main pulmonary artery is dilated. There is a small pericardial effusion. No right atrial or right ventricular diastolic collapse is seen. There is significant (30%) respiratory variation of mitral inflow. Compared with the prior study (images reviewed) of [**2101-12-2**], the pericardial effusion is smaller and RA collapse is no longer seenh. Regional LV and RV systolic dysfunction persist. . [**12-3**]: CXR: 1. Decrease in size of the cardiac silhouette since the previous study. 2. Moderate left-sided pleural effusion. . [**12-5**]: ECHO: There is symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2101-12-2**], the pericardial effusion appears slightly smaller than immediately post-tap. . [**12-9**]: CXR: Increased bilateral pleural effusions with bibasilar atelectasis . [**12-9**]: CXR post-thoracentesis: Previous moderate-sized left pleural effusion is now much smaller. There is no pneumothorax. Moderate right pleural effusion, enlargement of the cardiomediastinal silhouette, and bibasilar atelectasis are unchanged. Tip of the left PIC catheter can be traced as far as the right atrium but the tip is indistinct. . [**12-9**]: ECHO: Overall left ventricular systolic function is mildly depressed with inferior hypokinesis. Right ventricular chamber size and free wall motion are normal. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. . [**12-10**]: CT Chest with contrast: 1. Increasing, large right and small left pleural effusions. 2. Increasing lingular and left lower lobe atelectasis or consolidation. 3. Enlarging mediastinal and left hilar lymphadenopathy, consistent with patient's history of lymphoma. Stable, less pronounced lymphadenopathy in both axillae and imaged portions of the abdomen. 4. Subcentimeter lung nodules, two stable, one new, presumably infectious. 5. Indeterminate lesion in liver, too small to characterize. . [**12-15**]: ECHO: Mild regional left ventricular systolic dysfunction. Moderate-to-severe mitral regurgitation. Mild aortic regurgitation. Moderate tricuspid regurgitation. Moderate pulmonary hypertension. Small pericardial effusion. Compared with the prior study (images reviewed) of [**2101-12-12**], the findings are similar. . Pathology: Pericardial fluid: Immunophenotypic findings consistent with involvement by a small population (2% of total events) of monotypic kappa light chain restricted B-cells. These findings are consistent with involvement of pericardial space by the concurrently diagnosed nodal lymphoplasmacytic lymphoma . Subclavian lymph node: LOW GRADE NON-HODGKIN B-CELL LYMPHOMA, MOST CONSISTENT WITH A LYMPHOPLASMACYTOID IMMUNOCYTOMA (SEE NOTE). . [**12-21**] Echo: Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with mid septal hypokinesis. Overall left ventricular systolic function is mildly depressed. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is a small pericardial effusion (seen mainly around the right atrium). There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2101-12-15**], the pericardial effusion is now probably slightly larger. Brief Hospital Course: 59 yo female admitted with chest pressure, found to have large pericardial effusion s/p drainage and also CAD with PCI in LAD s/p cath with 80% stenosis of LAD. Also, found to have lymphoplasmacytic lymphoma with transformation. Hospital course by problem: . # Pericardial effusion: The patient was found to have a large pericardial effusion with evidence of tamponade. She was taken to the cath lab for urgent drainage. Equalization of her diastolic pressures and pericardial pressures were found. Initially ~800 cc of serosanginous fluid was drained and a pigtail catheter was placed. The catheter continued to drain fluid without evidence of recurrent tamponade. Culture of the fluid revealed coag negative staph for which she completed 7 days of antibiotics. Serial echocardiograms were done revealing resolution of the effusion. Cardiac surgery was consulted regarding the need for a pericardial window. Given that the pericardial effusion had largely resolved, it was determined that we would hold off on the pericardial window. A pulsus was measured daily and was [**6-2**]. A repeat echocardiogram the day prior to d/c revealed a stable small pericardial effusion. Appointments were made for her to follow-up with a repeat echo in 2 wks from discharge as well as with Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **]. . # Lymphoma: The patient presented with the large pericardial effusion, diffuse lymphadenopathy, fevers, night sweats and weight loss. Subclavian lymph node biopsy revealed lymphoma and the flow was consistent with lymphoplasmocytic lymphoma with transformation. Please see full report on OMR. Heme/onc was involved and she was transferred to the BMT service on [**12-8**]. She was started on CHOP on [**2101-12-9**] which she tolerated well. She received rituxan on [**12-16**] and tolerated this well. . # Shortness of breath: This was thought to be multifactorial [**1-27**] her cardiac disease, diffuse lymphadenopathy, anxiety, and bilateral pleural effusions. She had drainage of her left pleural effusion on [**12-9**] with removal of 1200cc. She tolerated this well. Flow demonstrated diffuse large B cells in the fluid. Her effusion rapidly reaccumulated and she was on an oxygen requirement. Her exam was consistent with fluid overload (elevated JVP and periph edema) so we aggressively treated with lasix. She was net negative for several days and had improvement in her symptoms. At discharge, her ambulating sat was 100% RA and she was discharged on 40 mg PO Lasix QD. . # Cards Vasc: The patient's initial chest pain and ST elevations in inferior leads were concerning for acute infart. She was loaded with aspirin, plavix, and heparin. She underwent cardiac cath which revealed significant stenosis in the LAD which was stented with a drug eluting stent. She will continue on aspirin and plavix for a year. She will follow-up with Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **] in [**Location (un) 620**]. . # Cards Pump: A post-cath echo showed good cardiac function. However, followup echocardiograms demonstrated an EF of 50% in the setting of mod/severe MR. [**Name13 (STitle) **] SOB, as above, was thought to be partially related to her poor cardiac function. We treated with lasix and started lisinopril. Per CT surgery, she will need repeat echocardiogram in 2 weeks from discharge. . # Cards rhythm: The patient did develop atrial fibrillation while in the CCU. As there was concern for anticoagulating her with the potential chemotherapy and pericardial window, attempt was made for cardioversion. She was given two doses of ibutilide without success. She underwent DC cardioversion and had successful return of sinus rhythm with one attempt. She remained in sinus rhythm for the remainder of her stay. . # Anxiety: The patient has a long history of anxiety and has been receiving effexor xr and risperidone which she continued as in inpatient with prn ativan as well. Psychiatry followed and made recommendations for her management (please see OMR notes for details). Per psychiatry, she should not be discharged on ambien or ativan given her past psych history. . # Hyponatremia: The patient developed hyponatremia while in the hospital. The serum and urine studies were consistent with a component of SIADH and a component of pre-renal physiology. Renal was consulted prior to starting chemo. She was placed on a fluid restricted diet. She also briefly was treated with hypertonic saline with slow and steady improvement in her sodium. It then remained in the normal range. . # Pain: On admission, pt c/o had left shoulder and breast pain. CE were negative and no changes on EKG. CT Chest showed worsening lymphadenopathy. In addition, on [**12-19**], she started c/o RUE numbness and achiness, which she states has been bothering her since prior to admission. Pain not in any dermatomal distribution. CT surgery felt there was concern for DVT, RUE U/S negative for DVT. It was felt that there was a component of muscle spams and tense shoulders contributing to her pain. Her pain improved by [**12-12**] and switched to PO pain meds. . # Full code. ISSUES PENDING at DISCHARGE: 1) Pt will have repeat Echo 2 weeks after d/c. If that is normal, then she can be followed more infrequently as per her cardiologist. 2) Pt was instructed to have outpatient follow-up with Dr. [**Last Name (STitle) **] (cards) and Dr. [**First Name (STitle) **] (onc) 3) Pt concerned re missing days at work for chemo. A letter was written to her employer. . NEW MEDS STARTED: 1) ASA 2) Plavix 75 QD X 1 year 3) Lasix 40 PO QD 4) Toprol XL 50 QD 5) Lisinopril 5 QD 6) Lipitor 20 QD Medications on Admission: effexor risperidone trazodone Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). [**First Name (STitle) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**First Name (STitle) **]:*30 Tablet(s)* Refills:*2* 3. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: Three (3) Capsule, Sust. Release 24HR PO DAILY (Daily). [**First Name (STitle) **]:*90 Capsule, Sust. Release 24HR(s)* Refills:*2* 4. Risperidone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**First Name (STitle) **]:*30 Tablet(s)* Refills:*2* 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**First Name (STitle) **]:*30 Tablet(s)* Refills:*2* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**First Name (STitle) **]:*60 Capsule(s)* Refills:*2* 7. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO Q8H (every 8 hours) as needed. [**First Name (STitle) **]:*qs ML(s)* Refills:*0* 8. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). [**First Name (STitle) **]:*30 Patch 24HR(s)* Refills:*2* 9. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain: take 1, if pain persists after 5 min, take another for up to 15 min. If pain persists, call 911 or doctor. [**Last Name (Titles) **]:*20 Tablet, Sublingual(s)* Refills:*2* 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Last Name (Titles) **]:*30 Tablet(s)* Refills:*2* 11. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. [**Last Name (Titles) **]:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 12. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. [**Last Name (Titles) **]:*30 Tablet(s)* Refills:*2* 13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for pain for 3 days. [**Last Name (Titles) **]:*15 Tablet(s)* Refills:*0* 14. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. [**Last Name (Titles) **]:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: - lymphoplasmocytic lymphoma with transformation - cardiac tamponade - CHF - atrial fibrillation (s/p DC cardioversion) - anxiety/depression - bilateral pleural effusions - pneumonia - hyponatremia Secondary: - hx of substance abuse Discharge Condition: fair Discharge Instructions: You were admitted to the hospital with shortness of breath and chest pain. You had fluid around your heart which was relieved with a drain. You also had evidence of a heart blockage so you had a stent placed. You were diagnosed with lymphoma so received treatment with chemotherapy. . Please contact your oncologist if you experience a fever or chills. Please go to the emergency department urgently if you experience shortness of breath, chest pain, or syncope. . Please take your medications as instructed. Please followup with your oncologist and cardiologist. Followup Instructions: Please follow-up at the [**Hospital Ward Name 1826**] [**Location (un) 436**] outpatient clinic on Friday [**2101-12-23**] at 9:30 AM . Please follow-up with your oncologist, Dr. [**First Name (STitle) **]. Your appointment is on [**2101-12-28**] (Wed) at 2PM. Please call ([**Telephone/Fax (1) 12625**] if you need to reschedule. . You should followup with a cardiologist, Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **]. Your appointment is his earliest available on [**2102-1-16**] 11:30 AM. The phone number for his [**Location (un) 620**] office is ([**Street Address(2) 18320**], [**Location (un) 620**], MA. . You will have a repeat echocardiogram of your heart 2 weeks from discharge from the hospital. Your repeat echocardiogram is scheduled for [**2102-1-6**] at 8AM. Please go to the [**Hospital1 18**] [**Hospital Ward Name 5074**], [**Hospital Ward Name 23**] [**Location (un) 436**]. please call [**Telephone/Fax (1) 128**] if your need to reschedule.

[ "486", "300.00", "303.93", "327.23", "202.80", "786.05", "780.52", "584.9", "428.0", "276.1", "410.71", "496", "414.01", "427.31", "420.90" ]

icd9cm

[ [ [] ] ]

[ "00.45", "36.07", "40.11", "99.28", "99.62", "37.0", "00.66", "37.23", "38.93", "00.40", "34.91", "99.25", "88.56" ]

icd9pcs

[ [ [] ] ]

17199, 17205

9256, 14460

363, 474

17491, 17498

2712, 2712

18115, 19109

2264, 2291

15038, 17176

17226, 17470

14984, 15015

17522, 18092

2306, 2693

14474, 14958

285, 325

502, 997

2728, 9233

1019, 1121

1416, 2248

41,704

179,896

22970

Discharge summary

report

Admission Date: [**2195-12-7**] Discharge Date: [**2195-12-11**] Date of Birth: [**2113-8-11**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Otosporin Attending:[**First Name3 (LF) 1406**] Chief Complaint: aortic stenosis Major Surgical or Invasive Procedure: [**2195-12-7**] aortic valve replacement(19mm CE pericardial) History of Present Illness: This 82 year old female with known severe aortic stenosis with complaints of significant dyspnea on minimal exertion, which is limiting her daily activities. The most recent echocardiogram from [**2195-8-25**] revealed critical AS with [**First Name8 (NamePattern2) **] [**Location (un) 109**] 0.5cm2 with a peak gradient of 130mmHg and mean gradient of 64mmHg. Catheterization in [**2195-9-24**] showed normal coronary arteries. She was admitted for aortic valve replacement. Past Medical History: Hypertension Hyperlipidemia Diabetes Type II degenerative joint disease h/o Breast Cancer Macular degeneration h/o Cholecystitis Social History: lives with husband [**Name (NI) 1139**]: quit [**2160**], <1ppd x 10 yrs ETOH: denies Family History: non contributory Physical Exam: Admission: Pulse: 71 Resp: 16 O2 sat: 96% BP: 157/67 Height: 5'3" Weight:200 lbs General: NAD, uses walker 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 3/6 SEM Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema: 1+ Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right: [**12-26**]+ Left: [**12-26**]+ DP Right/Left: 1+ PT [**Name (NI) 167**]/Left: 1+ Radial Right/Left: 2+ Carotid Bruit Right/Left: Trans. murmur Pertinent Results: PRE Bypass No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild to moderate ([**12-26**]+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is severe mitral annular calcification. There is moderate functional mitral stenosis (mean gradient 6.4 mmHg, MVA 1.5 cm2) due to mitral annular calcification. Moderate to severe (3+) mitral regurgitation is seen. (MR decreased to 2+ prior to bypass) Findings discussed with Dr [**Last Name (STitle) **]. POST Bypass Te LV is hyperdynamic. There is a well seated, well functioning bioprosthesis in the aortic position. There is trace valvular AI. The MR is now moderate (2+). The MVA now calculates to 1.7 cm with a mean MV gradient of 5.5. The remaining study is unchanged from prebypass. 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) **] [**2195-12-7**] 10:52 [**2195-12-10**] 04:56AM BLOOD WBC-13.7* RBC-3.68* Hgb-10.8* Hct-33.7* MCV-92 MCH-29.3 MCHC-31.9 RDW-15.2 Plt Ct-130* [**2195-12-10**] 04:56AM BLOOD Glucose-85 UreaN-41* Creat-1.2* Na-142 K-4.3 Cl-104 HCO3-30 AnGap-12 [**2195-12-9**] 02:11AM BLOOD Glucose-143* UreaN-33* Creat-1.3* Na-137 K-4.9 Cl-104 HCO3-24 AnGap-14 Brief Hospital Course: She was admitted on [**12-7**] and underwent surgery with Dr. [**Last Name (STitle) **]. See operative note for details. She weaned from bypass on Propofol and Neo Synephrine infusions. She remained stable condition. There was some transient oliguria which resolved with diuretics. Pressors weaned easily and she was extubated without problem. She transferred to the floor on POD 2 and mediastinal CTs were removed uneventfully. Physical Therapy was consulted for strength and mobility. Diuresis towards her preoperative weight was begun and beta blockers begun. Renal function was followed closely. Temporary pacing wires were removed on POD 3 and antihypertensives were adjusted for optimal control. Metformin was resumed and glucoses were fairly well controlled. A stay at rehabilitation was recommended for further recovery prior to returning home. Diuretics were continued at transfer as she was still above her preoperative weight. On [**12-11**] she was feeling well, her edema was markedly improved and diuretics were changed to oral for another week. She was transferred to Five [**Hospital **] rehabilitation for furthe recovery. Medications were as written along with folow up and restrictions. Medications on Admission: HCTZ 25mg by mouth daily Metformin 500mg by mouth twice a day Metoprolol Tartrate 50mg by mouth twice a day Simvastatin 20mg by mouth daily Diovan 80mg by mouth daily Aspirin 81mg by mouth daily Fish oil one capsule by mouth daily MVI one tablet by mouth daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 4 weeks. 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain for 4 weeks. 11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 12. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 13. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. 14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Discharge Disposition: Extended Care Facility: tba Discharge Diagnosis: aortic stenosis s/p aortic valve replacement Hypertension Hyperlipidemia Diabetes Type II degenerative joint disease h/o Breast Cancer s/p right mastectomy Macular degeneration Cholecystitis Discharge Condition: alert, oriented and intact. Pain controlled well with oral analgesics. Ambulatory with support. Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Surgeon Dr.[**Last Name (STitle) **] Wednesday [**2196-1-6**] @ 1:00 PM [**Telephone/Fax (1) 170**] Primary Care Dr.[**First Name (STitle) **] [**Telephone/Fax (1) 24398**] in [**12-26**] weeks Cardiologist Dr.[**First Name (STitle) 437**] in [**1-27**] weeks Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse will schedule Completed by:[**2195-12-11**]

[ "997.5", "V10.3", "278.00", "V43.64", "788.5", "292.81", "E935.9", "362.50", "E878.2", "396.0", "416.8", "272.4", "250.00", "401.9", "715.96", "433.10" ]

icd9cm

[ [ [] ] ]

[ "88.72", "38.93", "35.21", "39.61", "39.63" ]

icd9pcs

[ [ [] ] ]

6522, 6552

3693, 4910

307, 371

6787, 6885

1862, 3670

7510, 7917

1152, 1170

5222, 6499

6573, 6766

4936, 5199

6909, 7487

1185, 1843

252, 269

399, 879

901, 1032

1048, 1136

30,579

142,555

34677

Discharge summary

report

Admission Date: [**2142-4-14**] Discharge Date: [**2142-5-16**] Date of Birth: [**2078-1-27**] Sex: M Service: MEDICINE Allergies: Penicillins / Vancomycin / Levofloxacin / Unasyn / Tigecycline Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Pancreatitis Major Surgical or Invasive Procedure: Endotrachial Intubation and Tracheostomy Multiple central lines placements, Right IJ and Left Subclavian PICC line History of Present Illness: 64 year-old M with PMHx of DMII, HTN, HLD, CHF, CAD s/p CABG in [**2139**], presented to OSH with RUQ/epigastric pain radiating to the back, + n/v/distension and found to have pancreatitis and cholecystitis. Lower abdomenal pain started while patient was sleeping on the night before presentation. Continued to worsen over the course of the night, not positional, started to have back pain in the same band like fashion, then right upper quadrant pain. Patient last had BM on the day prior, small, non-bloody x2. Does not carry dx of diverticulitis or divertivulosis. Never had these symptoms prior. Denies sick contacts, recent trauma, travel or alcohol use. Never had surgery to the bowel, no h/o hernia. Reported positive n/v/chills, but no fevers. Patient is obese with BMI of 44.6. At the OSH, he was found to have WBC to 17.1 (94% P), lipase of 946, transaminitis (AST 156, ALT 121), creatinine of 1.7, glucose of 336, d-dimer of 3050, troponin was flat. RUQ U/S and CT abdomen were done. Findings were consistent with pancreatitis and acalculus cholecystitis. Pt was evaluated by surgeons. Vital signs were 150/80; afebrile. He recieved flagyl/cetaz and 1L bolus and maintenance. On the floor, initial vs were: T: 98.9 BP: 132/72 P: 107 R: 34 O2: 97%. Patient was given pain medication and fluid resus. Review of sytems: (+) Per HPI (-) Denies fever, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: DM II with neuropath CHF (EF 35-40% [**8-5**] TTE) HTN hyperlipidemia PNA - [**5-5**] treated at [**Hospital6 19155**] MSSA epidural abscess s/p laminectomy - [**2133**] Acute on chronic systolic heart failure Social History: Divorced, lives alone in [**Location (un) **], MA. Retired high school english teacher. Former cigar smoker, [**12-30**] cigars/day, quit 8 years ago. Rare ETOH use, no illicits. Family History: Dad passed away from complications of CAD (MI in 60s) and CHF. Mother had an MI in her 50s. Sister with obesity, DM. Physical Exam: Exam on Admission - Vitals: T: 98.9 BP: 132/72 P: 107 R: 34 O2: 97% General: Alert, oriented, no acute distress, morbidly obese HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, mildly tender, non-distended, bowel sounds present, no rebound tenderness or guarding, positive RUQ tenderness. GU: no foley Exam on Discharge - VS Tcurrent 99, Tmax 99.3 BP: 137/62 (range 114/54- 149/81) HR: 113 (range 109-123) RR: 19 (15-32) SaO2: 96% on trach mask GEN: alert, oriented pleasant obese M in NAD HEENT: EOMI, PERRLA, anicteric sclerae, MMM, o/p clear Neck: supple, no JVD, no LAD CV: tachycardic rate, regular rhythm, nl S1, S2 no murmurs appreciated LUNGS: CTAB/L no wheeze/rales/rhonchi ABD: obese, soft +BS, nontender to palpation, nondistended EXT: B/L LE edema 2+, distal pulses palpable SKIN: multiple excoriated skin lesions B/L UE, LE, hands, healed and crusted over exfoliative desquamating lesions NEURO: A&Ox3, appropriate, able to follow commands, speaking full sentences in hoarse voice Pertinent Results: Initial Labs: [**2142-4-14**] 08:56PM BLOOD WBC-23.1*# RBC-6.14# Hgb-17.9# Hct-56.5*# MCV-92# MCH-29.1 MCHC-31.6 RDW-13.2 Plt Ct-219 [**2142-4-14**] 08:56PM BLOOD Neuts-90.8* Lymphs-4.0* Monos-4.9 Eos-0 Baso-0.3 [**2142-4-14**] 08:56PM BLOOD PT-13.0 PTT-21.7* INR(PT)-1.1 [**2142-4-14**] 08:56PM BLOOD Glucose-277* UreaN-33* Creat-1.7* Na-137 K-5.2* Cl-102 HCO3-18* AnGap-22* [**2142-4-14**] 08:56PM BLOOD ALT-85* AST-55* LD(LDH)-388* AlkPhos-70 TotBili-1.1 [**2142-4-14**] 08:56PM BLOOD Lipase-1164* [**2142-4-14**] 08:56PM BLOOD Albumin-3.9 Calcium-8.3* Phos-3.6 Mg-1.8 Cholest-125 [**2142-4-14**] 08:56PM BLOOD %HbA1c-6.2* eAG-131* [**2142-4-14**] 08:56PM BLOOD Triglyc-86 HDL-47 CHOL/HD-2.7 LDLcalc-61 [**2142-4-15**] 10:45AM BLOOD Type-ART pO2-81* pCO2-33* pH-7.36 calTCO2-19* Base XS--5 [**2142-4-15**] 10:45AM BLOOD Lactate-1.8 LFT Trend: [**2142-4-14**] 08:56PM BLOOD ALT-85* AST-55* LD(LDH)-388* AlkPhos-70 TotBili-1.1 [**2142-4-17**] 04:22AM BLOOD ALT-16 AST-19 LD(LDH)-385* AlkPhos-39* TotBili-1.1 [**2142-4-18**] 04:02PM BLOOD Amylase-24 [**2142-4-24**] 04:08AM BLOOD ALT-15 AST-35 LD(LDH)-399* AlkPhos-63 TotBili-0.4 [**2142-4-26**] 04:56AM BLOOD ALT-13 AST-32 LD(LDH)-326* AlkPhos-71 TotBili-0.5 [**2142-4-28**] 02:43AM BLOOD ALT-15 AST-38 LD(LDH)-301* CK(CPK)-55 AlkPhos-81 TotBili-0.5 [**2142-5-1**] 03:31AM BLOOD ALT-18 AST-29 AlkPhos-89 Amylase-27 TotBili-0.3 [**2142-5-11**] 04:19AM BLOOD ALT-7 AST-18 AlkPhos-65 TotBili-0.5 [**2142-4-14**] 08:56PM BLOOD Lipase-1164* [**2142-4-15**] 04:30AM BLOOD Lipase-977* [**2142-4-17**] 04:22AM BLOOD Lipase-50 [**2142-4-18**] 04:02PM BLOOD Lipase-18 [**2142-5-1**] 03:31AM BLOOD Lipase-35 [**2142-5-5**] 01:30AM BLOOD Lipase-25 [**2142-5-6**] 03:48AM BLOOD Lipase-23 Urine Studies: [**2142-4-15**] 12:17AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.018 [**2142-4-15**] 12:17AM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-300 Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2142-4-15**] 12:17AM URINE RBC-2 WBC-3 Bacteri-NONE Yeast-NONE Epi-<1 [**2142-4-15**] 12:17AM URINE CastGr-3* CastHy-20* [**2142-5-10**] 04:07PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020 [**2142-5-10**] 04:07PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.0 Leuks-NEG [**2142-5-10**] 04:07PM URINE RBC-3* WBC-1 Bacteri-FEW Yeast-NONE Epi-0 [**2142-5-8**] 03:20PM URINE CastGr-4* CastHy-4* [**2142-4-24**] 09:59AM URINE Hours-RANDOM UreaN-934 Creat-74 Na-23 K-41 Cl-36 Microbiology: [**2142-5-11**] RESPIRATORY CULTURE-PRELIMINARY {GRAM NEGATIVE ROD(S) [**2142-5-6**] SPUTUM GRAM STAIN - GRAM NEGATIVE ROD #1, ACINETOBACTER BAUMANNII COMPLEX [**2142-5-3**] BLOOD CULTURE - ACINETOBACTER BAUMANNII; STAPHYLOCOCCUS, COAGULASE NEGATIVE} [**2142-4-28**] BLOOD CULTURE - ENTEROCOCCUS FAECALIS [**2142-4-28**] BLOOD CULTURE - ENTEROCOCCUS FAECALIS [**2142-4-27**] BLOOD CULTURE - ENTEROCOCCUS FAECALIS; STAPHYLOCOCCUS, COAGULASE NEGATIVE [**2142-4-26**] BLOOD CULTURE - ENTEROCOCCUS FAECALIS; STAPHYLOCOCCUS, COAGULASE NEGATIVE [**2142-4-25**] BLOOD CULTURE - STAPHYLOCOCCUS; COAGULASE NEGATIVE [**2142-4-24**] BLOOD CULTURE - STAPHYLOCOCCUS; COAGULASE NEGATIVE [**2142-4-23**] CATHETER TIP-IV WOUND CULTURE-FINAL STAPHYLOCOCCUS, COAGULASE NEGATIVE} [**2142-4-23**] SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL STAPHYLOCOCCUS, COAGULASE NEGATIVE [**2142-4-23**] SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL STAPHYLOCOCCUS, COAGULASE NEGATIVE Imaging: CXR ([**2142-4-14**]) - Opacification in the infrahilar left lung suggests that it is still once again collapsed. Small left pleural effusion is minimal, if any. New right infrahilar atelectasis is moderate to severe. Upper lungs clear. The heart is not enlarged. No pneumothorax. Nasogastric tube can be traced as far as the lower esophagus but the tip is not distinct. On a subsequent radiograph, 9:13 a.m. on [**4-15**], it ends in the stomach. CT A/P ([**2142-4-15**]) - IMPRESSION: 1. Edema and peripancreatic stranding consistent with pancreatitis. Focal area of hypoenhancement involving the pancreatic neck and portions of the body and head, which are most consistent with early pancreatic necrosis. 2. Edema within the duodenal wall and gallbladder likely reactive in nature. 3. Indeterminant 3-cm cystic appearing lesion exophytic off the upper pole of the left kidney in addition to multiple bilateral simple renal cysts. A renal ultrasound or MRI may be obtained for further characterization the the 3cm indeterminate lesion as the patient's clinical condition warrants. 4. Small bilateral pleural effusions and adjacent airspace disease likely representing predominantly atelectasis. Echo ([**2142-4-20**]): 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 root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved global biventricular systolic function. Grossly normal valve morphology without pathologic flow identified. CTA Torso ([**2142-4-20**]): 1. No definite pulmonary embolism identified. Limited evaluation of the subsegmental branches on the left and the segmental and subsegmental branches of the right pulmonary arteries secondary to bolus timing. 2. Progression of marked edema and peripancreatic stranding, consistent with patient's history of pancreatitis. Focal area of hypoenhancement involving the pancreatic neck and portions of the body and head, most suggestive of pancreatic necrosis. No organized fluid collections identified. 3. Indeterminate 3 cm cystic lesion exophytic off the upper pole of the left kidney in addition to multiple bilateral renal cysts, which are redemonstrated. A renal ultrasound or MRI may be obtained for further characterization as previously recommended on an outpatient basis. 5. Small left pleural effusion and adjacent airspace disease, most likely representing atelectasis. 6. An 8 mm filling defect within the splenic vein which may represent a tiny nonocclusive splenic vein thrombosis. KUB ([**2142-4-23**]): FINDINGS: As compared to the previous radiograph, there is no relevant change. The monitoring and support devices are in unchanged position. Unchanged slight right hilar enlargement, retrocardiac atelectasis and suspicion of a small left-sided pleural effusion. No newly occurred focal parenchymal opacities. Moderate overhydration. CT Abd ([**2142-4-27**]) - IMPRESSION: 1. Unchanged appearance of pancreas compatible with pancreatitis and areas of pancreatic necrosis at the pancreatic head, body and, to a lesser extent, tail. 2. Unchanged appearance to bilateral renal cystic lesions which may be further evaluated with ultrasound or MRI on a non-emergent basis. 3. Bibasilar atelectasis with small bilateral pleural effusions, more marked on the left. Echo ([**2142-4-30**]): The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. 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 appears normal (LVEF 50-60%). There is no ventricular septal defect. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. No mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Tricuspid regurgitation is present but cannot be quantified. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2142-4-20**], no definite [**Doctor Last Name **]. If indicated, a TEE would be better to exclude a small valvular vegetation. TEE ([**2142-5-2**]): No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are 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) appear structurally normal with good leaflet excursion and no aortic stenosis. 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. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. No vegetation/mass is seen on the pulmonic valve. IMPRESSION: No echocardiographic evidence of endocarditis or paravalvar abcess. CT Abd ([**2142-5-4**]) Markedly limited IV bolus timing secondary to hand injection, particularly limiting evaluation of potential vascular complication. 1. Extensive pancreatic necrosis. Although the quantity of fluid associated with necrotic tissue appears slightly increased, residual enhancing areas of the pancreas are similar in extent. Although gas formation is not noted in the pancreatic fluid collection, infection of necrosis cannot be excluded. 2. New mild diffuse bowel dilatation suggestive of a very mild ileus. Upper Ext U/S ([**2142-5-9**]) - IMPRESSION: No evidence of thrombosis seen in right or left internal jugular or subclavian veins. KUB ([**2142-5-6**]) - Two portable views of the abdomen were obtained, both supine. One includes the diaphragms and the other includes the obturator foramina. There are multiple loops of dilated small bowel. Gas is seen throughout much of the colon -- the colon is distended, but not frankly dilated. The appearance is in keeping with the appearance on the CT scout film from [**2142-5-4**]. The most likely etiology is ileus, though a partial small- bowel obstruction cannot be excluded. CXR ([**2142-5-10**]) - Lung volumes are very low, crowding all of the normal structures and abnormalities. Since [**5-9**] although heart size may have increased only mildly, there is more mediastinal vascular engorgement and dilatation of upper lobe pulmonary vessels due to worsening cardiac decompensation or volume overload. Confluent opacification at the lung bases could be explained by combination of atelectasis and confluent edema though radiographically one cannot exclude aspiration or even pneumonia. Pleural effusions if any are small. Tracheostomy tube in standard placement. Tip of the left subclavian line projects over the junction of the brachiocephalic veins. No pneumothorax. Nasogastric tube passes into the stomach and out of view. CXR ([**2142-5-11**])- 1. The right PICC line tip is now in the right atrium. 2. Enlargement of the cardiopericardial silhouette with pulmonary vascular congestion and bilateral pleural effusions, unchanged, and likely related to volume overload/congestive heart failure. The study and the report were reviewed by the staff radiologist. CT ABD/PELVIS (pancreas protocol- [**2142-5-14**])- 1. Stable extent of necrotizing pancreatitis with the largest area of hypoenhancement centered along the proximal body. No venous thrombosis or arterial pseudoaneurysm. No pseudoaneurysm. Slight increase in small ascites. 2. Persistent mild ileus. 3. Interval improvement of mild anasarca. KUB- nasointestinal tube placement [**2142-5-14**]- Post-pyloric feeding tube placement complete without complications. Incidental note of intestinal distension CXR ([**2142-5-14**])- No acute cardiopulmonary process. Stable lung volumes and interval improvement in left basilar opacification. Brief Hospital Course: Mr. [**Known lastname **] is a 64 year old male with history of with HTN, DMII, HLD, morbid obesity who presented with severe acute necrotizing pancreatitis. 1. NECROTIZING PANCREATITIS: Etiology of the patient's pancreatitis was not clear. CT imaging revealed a partially-necrosed pancreas with a fluid collection. There was no history of significant EtOH use, triglycerides were WNL, he had not had a recent ERCP or steroid use, and there was no evidence of gallstones on imaging. His [**Last Name (un) 5063**] score was calculated to be >7. He received aggressive fluid resuscitation and was started on IV meropenem. Given his very significant resuscitation requirements, the patient was intubated to maintain oxygenation and ventilation in the setting of worsening anasarca and third-spacing of fluid. Surgery did not feel that his presentation warranted operative management. The patient initially began to show interval improvement after the first 48 hours as measured by lab abnormalities and fluid resuscitaton requirements, but then again decompensated with fevers > 103, a precipitous rise in WBC, a diffuse rash, and hypotension requiring more aggressive fluid resuscitation and eventual initiation of vasopressors. Repeat imaging showed no evidence of progression of necrotic pancreas or other any intra-abdominal process. The patient was empirically switched to aztreonam/flagyl given concern for a drug-induced reaction (see below). The patient was followed with serial CT scans of his pancreas, which ultimately showed extensive pancreatic necrosis. He was maintained on TPN until he was able to tolerate enteric feeding. His clinical course was complicated by development of an ileus. His ileus was followed with serial KUB's and eventually improved. Due to significant difficulty placing a post-pyloric feeding tube, he had an NG tube placed and was started on tube feeds, which he tolerated. He had a post-pyloric feeding tube placed on [**5-14**] and tube feeds were continued. At the time of discharge, he was tolerating tube feeds well and did not require TPN. 2. RESPIRATORY DISTRESS: His respiratory failure was secondary to LLL collapse and pulmonary edema and increased abdominal distension from ileus and anascarca. Requiring PEEP initially as high as 18 likely secondary to increased intrabdominal pressure. When blood pressue was stable and he was able to be diuresed, he began to require less positive pressure. Dead space measurement did not reveal a significant amount of dead space present, and he was able to increasingly tolerate pressure support. Ultimately, he underwent trach placement. He was transitioned to trach mask ventilation and had a Passy-Muir Valve placed. Of note, on the afternoon after having the sutures removed from his tracheostomy site, the patient's trach tube was noted to be out of proper position. Anesthesia and CT surgery urgently evaluated the patient. He was transiently intubated, and his trach was replaced at the bedside. The patient did not have any further problems with his tracheostomy. As he approached discharge, the patient remained grossly fluid overloaded. Diuresis with IV lasix should be continued with a goal of [**12-30**] L negative a day. At the time of discharge he is slighly positive for length of stay. He will require further weaning from the trach mask. 3. BACTEREMIA/ FEVERS: As above, he was initially started on meropenem on admission for severe pancreatitis. The meropenum was transitioned to aztreonam after he developed skin changes concerning for an allergic reaction. He continued to spike daily fevers, which were felt to possibly be related to his pancreatitis but also possibly related to an underlying infection. Eventually, he grew coag neg staph sensitive to linezolid in consecutive blood cultures from [**Date range (1) 71614**] and then coag neg staph that was resistant to linezolid in a blood culture on [**5-3**]. Additionally, he grew pan-sensitive enterococcus faecalis in consecutive blood cultures from [**Date range (1) 40693**]. His central venous lines were the suspected source. However, his diffuse skin breakdown in the setting of his allergic reaction was also thought to be a possible source of his staph. He underwent multiple CVL changes, given these positive cultures. TEE negative for vegetations or abscesses. Also, he grew acinetobacter from a right IJ blood cx on [**5-3**] and from multiple sputum cultures. Given his various positive cultures, he was followed by the infectious disease service, who recommended various adjustments to his antibiotic regimen. He was unable to be started on vancomycin because of a questionable history allergy reported from another facility. Allergy was consulted and felt that he is unlikely to be allergic to vancomycin; however, to be safe he should undergo a desensitization if vancomycin was necessary. He was placed on aztreonam, amikacin, and linezolid. However, aztreonam was ultimately stopped as it appeared that the acinetobacter was not susceptible. He was tried on tigecycline but developed a questionable allergic reaction. At the time of discharge, the infectious disease team recommended a total 14 day course of amikacin to end on [**5-21**]. 3. SKIN RASH: As above, the patient was initially started on meropenem on admission. However, he thereafter developed a clinical decompensation, including a diffuse rash. This rash consisted of significant erythema and desquamation and ultimately covered a significant portion of the patient's upper and lower extremities as well as his trunk. When he developed this rash, he was empirically switched to aztreonam/flagyl given concern for a drug-induced reaction (i.e. DRESS syndrome). Dermatology was consulted and agreed that the rash likely represented a drug reaction but felt that the likely inciting [**Doctor Last Name 360**] was unasyn approximately two weeks prior to rash development. Biopsies were performed and were also consistent with a hypersensitivity reaction. Later in his hospital course, the patient was started on tigecycline, after which he was noted to develop a new papular rash, concerning for an allergy. The tigecycline was promptly discontinued. Allergy and Immunology was consulted to comment on patient's multiple skin reactions to various antibiotics, and it was thought the culprit was tigecycline since it correlated to his time course. However, if tigecycline would be needed in the future, the patient could undergo desensitization. Pt's skin rash improved throughout hospital course and he was seen multiple times by the wound care team who left excellent recommendations for care, which was transcribed into his discharge paperwork for continuation at rehab. 4. ABDOMINAL DISTENTION/ ILEUS : The [**Hospital 228**] hospital course was complicated by a prolonged ileus. There was some initial concern for c.diff, and he was kept on flagyl for an extended period of time, given the impossibility of collecting stool samples. However, stool samples were eventually negative for C. diff. His ileus was followed by serial KUB's. After several unsuccessful attempts at placement of a post-pyloric feeding tube, he was started on gastric tube feedings. He subsequently developed marked abdominal distention and tube feeds were held. His ileus improved after weaning narcotics and a few doses of methylnaltrexone. After the patient's ileus improved, he was restarted on tube feeds and tolerated them well. 5. AGITATION/ DELERIUM: Given his intubation, the patient was initially on large amounts of IV sedation. After tracheostomy placement, the patient's sedation was weaned. In the setting of weaning his sedation, he began to experience some agitation and delirium, for which he was started on standing methadone and haldol. As these medications were tapered, he was started on standing seroquel. At time of discharge, pt was A&Ox3, at his baseline and had good insight into his condition. 6. DISTRIBUTIVE SHOCK: His pancreatitis was complicated by hypotension, ultimately requiring pressors. The etiology was likely multifactoiral, including his pancreatitis, his bacteremia, and his sedation while he was intubated. As his clinical status improved and his sedation was weaned, his hypotension improved and his pressors were weaned and stopped. 7. ACUTE KIDNEY INJURY: The patient presented with acute renal failure, which initially improved with IV hydration. His hospital course was complicated by some additional elevations in his creatining, generally in the setting of CT scans. At the time of discharge, his creatinine was stable and within normal limits. 8. ANEMIA Patient's hematocrit slowely trended down during his hospitalization. NG tube contents and stool were both guaiac negative, and felt to be secondary to repeated phelbotomy. His hematocrit was trended and he was transfused PRN to maintain a HCT above 21. His blood counts had been stable for several days prior to discharge. 9. TYPE II DIABETES, c/b neuropathy: The patient was continued on sliding scale insulin and was given insulin in his TPN. Following transfer from TPN to tube feeds he required lantus and an insulin sliding scale with meals. Due to high blood sugars, lantus 10u daily was added to his regimen, and he will continue on hospital humalog sliding scale, which may need to be adjusted as appropriate. Medications on Admission: TRANSFER MEDS: Tylenol 650 Q6H Heparin 5000u SQ Q12H Dilaudid PCA not started Lisinopril 20 mg daily Metoprolol 100 mg daily Metoprolol 50 mg QHS Zofran 4mg Q6H PRN Zocor 20 mg PO HOME MEDS: Aspirin 81mg Daily Metformin 500mg [**Hospital1 **] Metoprolol 200mg AM 100mg PM Glyburide 5mg [**Hospital1 **] Lisinopril 20mg Daily Amlodipine 5mg daily Neuremedy 150mg [**Hospital1 **] Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Quetiapine 50 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 3. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 4. Amikacin 880 mg IV Q24H Duration: 5 Days 5. Furosemide 40 mg IV BID Start: In am 6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day). 7. Famotidine 20 mg IV Q12H 8. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 9. DiphenhydrAMINE 50 mg IV Q6H:PRN rash 10. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 11. Ondansetron 4 mg IV Q8H:PRN nausea 12. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 13. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 14. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 15. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 18. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 19. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 20. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 21. Mineral Oil Oil Sig: 15-30 MLs PO DAILY (Daily). 22. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Four (4) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. 23. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN (as needed) as needed for NJ tube placement. 24. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 25. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 26. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever/pain. 27. Insulin Glargine 100 unit/mL Cartridge Sig: Ten (10) units Subcutaneous qAM. 28. Insulin Lispro 100 unit/mL Cartridge Sig: ASDIR Subcutaneous ASDIR: AS DIRECTED BY INPATIENT HUMALOG (LISPRO) SLIDING SCALE. Discharge Disposition: Extended Care Facility: [**Hospital1 **] Pavilion - [**Location (un) **] Discharge Diagnosis: Primary: Necrotizing Pancreatitis and distributive shock Respiratory failure requiring tracheostomy Bactermia with Coagulase Negative Staphylcoccus, Enterococcus and Acinetobacter at various points during his hospitalization. Desquamating hypersensitivity skin rash Secondary: Diabetes Mellitus, Type II. Congestive Heart failure Hypertension Delerium Acute kidney injury Anemia Ileus Discharge Condition: Level of Consciousness: Alert and interactive. Mental Status: Confused - sometimes. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure caring for you during this hospitalization. You were admitted for severe pancreatitis, complicated by respiratory failure, shock, and multiple blood stream infections. The cause of your pancreatitis is unknown, but you should NOT drink alcohol anymore as you are at high risk of losing complete function in your pancreas. In addition, you were noted to have a severe allergic skin reaction most likely related to Unasyn, but possibly due to Meropenum. You also developed a worsening skin rash after being started on Tigecycline. Please do not take any of these medications in the future. There have been multiple changes to your medications during this hospitalization. Please stop all of your previous medications, and follow the medication list provided to you and to your rehabilitation facility. You will need to take amikacin for 14 day course, to end on [**5-21**] We also added lantus 10 units in the morning, because your sugars were high. Please take only the medications listed in your medication list provided after this hospitalization. Followup Instructions: Called insurance PCP, [**Name10 (NameIs) **],[**Name11 (NameIs) 275**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 79522**], and was informed that patient has never been seen in that clinic before. Patient will need new PCP prior to leaving rehab facility. Will need to have TSH, T4 re-checked w/ new PCP [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

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Discharge summary

report

Admission Date: [**2145-4-7**] Discharge Date: [**2145-4-14**] Date of Birth: [**2069-3-6**] Sex: M Service: SURGERY Allergies: Nitroglycerin Attending:[**First Name3 (LF) 2777**] Chief Complaint: iscemic leg Major Surgical or Invasive Procedure: 1. Abdominopelvic arteriogram. 2. PROCEDURE: a. Bilateral groin explorations. b. Left superficial femoral artery and profunda thrombectomy. c. Thrombectomy of femoral-femoral graft. d. Patch angioplasty of left common femoral artery. History of Present Illness: The patient is a 76 year-old male with past medical history of peripheral [**First Name3 (LF) 1106**] disease as well as multiple strokes, hypercholesterolemia, status post carotid endarterectomy who presented with acute left lower extremity ischemia. Past Medical History: 1. DMII, last HgA1c 5.9% 2. CAD s/p CABG x3+x2 last [**2136**] 3. h/o embolic CVA, source not identified 4. mild [**Last Name (LF) 19874**], [**First Name3 (LF) **] 50-55% in [**4-/2144**] 5. HTN 6. COPD 7. Hypercholesteroemia 8. GOUT 9. Amarousis Fugax. 10. PVD s/p L CEA in [**2143**], now with R carotid stenosis 80% 11. 3 prior CVA thought d/t L carotid stenosis 12. h/o GIB Social History: Cab driver Lives alone Occassional ETOH (drinks [**11-30**] scotch every few months) Hx of 50 pack year smoking, quit several years ago Family History: No strokes or seizures. Multiple family members with MI. Physical Exam: PE: AFVSS NEURO: PERRL / EOMI MAE equally Answers simple commands Neg pronator drift Sensation intact to ST 2 plus DTR Neg Babinski HEENT: NCAT Neg lesions nares, oral pharnyx, auditory Supple / FAROM neg lyphandopathy, supra clavicular nodes LUNGS: CTA b/l CARDIAC: RRR without murmers ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness EXT: Pulses: L palp PT, dop DP. R dop PT/DP. Groin C/D/I Pertinent Results: [**2145-4-13**] WBC-8.0 RBC-3.47* Hgb-10.1* Hct-30.7* MCV-88 MCH-29.0 MCHC-32.7 RDW-16.6* Plt Ct-316 [**2145-4-13**] Plt Ct-316 [**2145-4-10**] Glucose-130* UreaN-24* Creat-1.0 Na-137 K-4.2 Cl-107 HCO3-22 AnGap-12 [**2145-4-10**] CK(CPK)-53 [**2145-4-10**] Calcium-7.7* Phos-3.4 Mg-1.6 [**2145-4-8**] Glucose-122* Lactate-1.4 Na-138 K-4.6 Cl-110 [**2145-4-8**] Hgb-9.3* calcHCT-28 [**2145-4-8**] Cardiology Report ECG Sinus bradycardia with first degree A-V block. Left atrial abnormality. Intraventricular conduction defect. Inferior myocardial infarction, age undetermined. Lateral ST-T wave changes may be due to myocardial ischemia. Low QRS voltages in the precordial leads. Since the previous tracing the rate is slower. Intervals Axes Rate PR QRS QT/QTc P QRS T 55 [**Telephone/Fax (2) 19875**] 6 101 Cardiology Report ECHO Study Date of [**2145-4-8**] MEASUREMENTS: Left Atrium - Long Axis Dimension: *4.3 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *6.1 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *5.4 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: *1.3 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 5.5 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 35% to 40% (nl >=55%) Aorta - Valve Level: 3.4 cm (nl <= 3.6 cm) Aortic Valve - Peak Velocity: 1.5 m/sec (nl <= 2.0 m/sec) Aortic Valve - Pressure Half Time: 704 ms Mitral Valve - E Wave: 1.3 m/sec Mitral Valve - A Wave: 1.0 m/sec Mitral Valve - E/A Ratio: 1.30 Mitral Valve - E Wave Deceleration Time: 189 msec TR Gradient (+ RA = PASP): *35 mm Hg (nl <= 25 mm Hg) LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Normal LV cavity size. Moderately depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic root diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate thickening of mitral valve chordae. Calcified tips of papillary muscles. Moderate to severe (3+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA systolic hypertension. PERICARDIUM: No pericardial effusion. Conclusions: 1. The left atrium is mildly dilated. 2. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed. Posterior and apical akinesis with lateral hypokinesis is present. 3. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. 4. The mitral valve leaflets are mildly thickened. There is moderate thickening of the mitral valve chordae. Moderate to severe (3+) mitral regurgitation is seen. 5. There is mild pulmonary artery systolic hypertension. 6. Compared with the report of the prior study (images unavailable for review) of [**2144-4-22**], LV function has deteriorated. [**2145-4-7**] 8:31 PM CHEST (PRE-OP PA & LAT) COMPARISON: [**2144-11-7**]. PA AND LATERAL CHEST RADIOGRAPHS: Cardiomediastinal and hilar contours appear unchanged. Again noted is calcification within the aorta. Again seen are median sternotomy wires. Pulmonary vascularity appears within normal limits. No focal consolidations are seen within the lungs. There is no evidence of pleural effusions. IMPRESSION: No evidence of acute cardiopulmonary disease. Brief Hospital Course: The patient as placed on heparin drip and underwent angiogram which showed occlusion of his common femoral artery on the left. A proposed fem-fem bypass was recommended. The patient, however, has had previous [**Year (4 digits) 1106**] surgery with bilateral groin explorations and it was unclear whether he has had a previous fem-fem bypass or peripheral distal bypass. Therefore, groin exploration and possible fem- fem bypass is recommended. The patient agreed to proceed to surgery. Risks and benefits were explained and he consented. The patient agreed to the below procedure: PROCEDURE: 1. Bilateral groin explorations. 2. Left superficial femoral artery and profunda thrombectomy. 3. Thrombectomy of femoral-femoral graft. 4. Patch angioplasty of left common femoral artery. Pt tolerated the procedure well, there were no complications. Pt extubated in the OR. Transfered to the PACU in stable condition. Once recovered from anesthesia. Pt transfered to the VICU in stable condition. Pt had normal post operative recovery. On DC, pt is stable. taking PO / ambulating / urinating / pos BM Medications on Admission: protonix, metformin 850", 70/30 28 U qAM, 20 U qPM, lasix 40', lisinopril 10', feSO4, lipitor 20', ASA 81', allopurinol 300', atenolol 50' . Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Insulin Fingerstick QACHS Insulin SC Fixed Dose Orders Breakfast Dinner 70 / 30 14 Units 70 / 30 10 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Glucose Insulin Dose 0-75 4 oz OJ 76-110 mg/dL 0 Units 0 Units 0 Units 0 Units 111-160 mg/dL 2 Units 2 Units 2 Units 2 Units 161-200 mg/dL 4 Units 4 Units 4 Units 4 Units 201-240 mg/dL 6 Units 6 Units 6 Units 6 Units 241-280 mg/dL 8 Units 8 Units 8 Units 8 Units > 280 mg/dL Notify M.D. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: Left leg ischemia. Discharge Condition: Stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOLLOWING LEG BYPASS SURGERY This information is designed as a guideline to assist you in a speedy recovery from your surgery. Please follow these guidelines unless your physician has specifically instructed you otherwise. Please call our office nurse if you have any questions. Dial 911 if you have any medical emergency. ACTIVITY: There are no specific restrictions on activity. You should be as active as is comfortable. Some fatigue is expected for the first several weeks. Leg swelling is typical following this type of surgery and can be controlled by elevating your leg above the level of your heart when you are not walking. PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness in or drainage from your leg wound(s). New pain, numbness or discoloration of your foot or toes. Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. Exercise: Limit strenuous activity for 4 weeks. No heavy lifting greater than 20 pounds for the next 7 days. No Driving. BATHING/SHOWERING: You shower immediately upon coming home. No bathing. A clear dressing may cover your leg incision and this should be left in place for three (3) days. Remove it after this time and wash your incision(s) gently with soap and water. Dissolving sutures, which do not have to be removed, were probably used. If you have staples these will be removed on your follow-up appointment. WOUND CARE: Sutures / Staples may be removed before discharge. If they are not, an appointment will be made for you to return for removal. When the sutures / staples are removed the doctor may or may not place pieces of tape called steri-strips over the incision. These will stay on about a week and you may shower with them on. If these do not fall off after 10 days, you may peel them off with warm water and soap in the shower. Avoid taking a tub bath, swimming, or soaking in a hot tub for two weeks after surgery. MEDICATIONS: Unless told otherwise you should resume taking all of the medications you were taking before surgery. You will be given a new prescription for pain medication, which can be taken every three (3) to four (4) hours only if necessary. Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. CAUTIONS: NO SMOKING! We know you've heard this before, but it really is an important step to your recovery. Smoking causes narrowing of your blood vessels which in turn decreases circulation. If you smoke you will need to stop as soon as possible. Ask your nurse or doctor for information on smoking cessation. Avoid bending for 4-6 weeks. No strenuous activity for 4-6 weeks after surgery. DIET : There are no special restrictions on your diet postoperatively. Poor appetite is expected for several weeks and small, frequent meals may be preferred. For people with [**Location (un) 1106**] problems we would recommend a cholesterol lowering diet: Follow a diet low in total fat and low in saturated fat and in cholesterol to improve lipid profile in your blood. Additionally, some people see a reduction in serum cholesterol by reducing dietary cholesterol. Since a reduction in dietary cholesterol is not harmful, we suggest that most people reduce dietary fat, saturated fat and cholesterol to decrease total cholesterol and LDL (Low Density Lipoprotein-the bad cholesterol). Exercise will increase your HDL (High Density Lipoprotein-the good cholesterol) and with your doctor's permission, is typically recommended. You may be self-referred or get a referral from your doctor. If you are overweight, you need to think about starting a weight management program. Your health and its improvement depend on it. We know that making changes in your lifestyle will not be easy, and it will require a whole new set of habits and a new attitude. If interested you can may be self-referred or can get a referral from your doctor. If you have diabetes and would like additional guidance, you may request a referral from your doctor. FOLLOW-UP APPOINTMENT: Be sure to keep your medical appointments. The key to your improving health will be to keep a tight reign on any of the chronic medical conditions that you have. Things like high blood pressure, diabetes, and high cholesterol are major villains to the blood vessels. Don't let them go untreated! Please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are 8:30-5:00 Monday through Friday. PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE. Followup Instructions: Call dr[**Initials (NamePattern4) 1720**] [**Last Name (NamePattern4) 19876**] at [**Telephone/Fax (1) 1241**]. Schedule an appointment for 2 weeks. Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3627**] [**Name12 (NameIs) 3628**] [**Name12 (NameIs) **] [**Name12 (NameIs) 3628**] (NHB) Date/Time:[**2145-8-26**] 1:30 Provider: [**Name10 (NameIs) 1111**],[**First Name7 (NamePattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB) Date/Time:[**2145-8-26**] 2:00 Completed by:[**2145-4-14**]

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icd9cm

[ [ [] ] ]

[ "88.47", "88.48", "39.49", "88.45", "38.48", "38.08" ]

icd9pcs

[ [ [] ] ]

8120, 8179

5348, 6461

283, 522

8242, 8251

1885, 5325

13482, 14020

1376, 1434

6653, 8097

8200, 8221

6487, 6630

8275, 9867

1449, 1866

232, 245

9880, 12784

12808, 13459

550, 803

825, 1206

1222, 1360

44,061

107,667

32187

Discharge summary

report

Admission Date: [**2136-7-18**] Discharge Date: [**2136-7-23**] Date of Birth: [**2073-9-29**] Sex: M Service: MEDICINE Allergies: Bee Pollens Attending:[**First Name3 (LF) 10293**] Chief Complaint: post-operative pain HCT monitoring Major Surgical or Invasive Procedure: liver biopsy radiofrequency ablation History of Present Illness: 62yo M with history of alcoholic cirrhosis complicated by encephalopathy and ascites with three HCC liver lesions who is admitted for monitoring after scheduled RFA. He underwent RFA by IR to the three lesions this afternoon and had liver biopsy. After ablation of the third lesion, active mild extravasation was noted but the tract was ablated. He was hemodynamically stable throughout. His Hct after procedure 33 from baseline of 39 two days prior. . On the floor, he complains of some RUQ pain over biopsy area that is starting to come back after pain meds he received in PACU. Otherwise, he has been in his normal state of health and feels fine. Past Medical History: -ETOH cirrhosis (MELD 12 in [**11-16**]) with history of decompensations with hepatic encephalopathy, ascites, and varices. Currently listed for transplant at [**Hospital1 18**]. -Osteoarthritis -S/p multiple back/neck surgeries for "disc disease" -S/p bowel resection & anastamosis ~15 yrs ago for perforation Social History: Married. Retired. Former smoker. No EtOH currently. Hobbies include fly fishing and golf. Family History: Father and brother with prostate CA. Two brothers with DM type 2 Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 97.8 BP: 103/64 P: 54 R: 18 O2: 100% RA 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, 3/6 systolic murmur loudest over L upper sternal border Abdomen: soft, RUQ tenderness with mild guarding, non-distended, bowel sounds present, no rebound tenderness, hepatomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: No asterixis . DISCHARGE PHYSICAL EXAM: O: Tc 98.8/99.8, 120/70, 67, 18, 96% RA, I/O: 960/820+ (32h), BM x 3 x 24h General: appears sad, NAD HEENT: Sclera icteric, MMM Lungs: pleural rub over RLL but no crackles, wheezes, or rhonchi throughout rest of lung CV: Regular rate and rhythm, normal S1 + S2, 3/6 systolic ejection murmur heard best over RUSB Abdomen: soft, NT, distended, normoactive bowel sounds Ext: trace edema in LE bilat at ankles Neuro: AAOx3, can say DOW backward, no asterixis Pertinent Results: Admission Labs: [**2136-7-18**] 10:11PM BLOOD WBC-9.2# RBC-2.36* Hgb-8.7* Hct-25.0* MCV-106* MCH-37.1* MCHC-35.0 RDW-14.1 Plt Ct-79* [**2136-7-18**] 10:11PM BLOOD PT-18.7* PTT-39.3* INR(PT)-1.7* [**2136-7-18**] 10:11PM BLOOD Glucose-137* UreaN-16 Creat-1.0 Na-133 K-6.8* Cl-105 HCO3-24 AnGap-11 [**2136-7-18**] 09:20PM BLOOD ALT-53* AST-174* AlkPhos-73 TotBili-4.6* [**2136-7-18**] 10:11PM BLOOD Calcium-7.5* Phos-4.0# Mg-1.6 CTA AP [**2136-7-19**] 1. Moderate right hemothorax along with progression of previously visualized perihepatic hemorrhage. There is no evidence of active arterial extravasation. These findings are likely related to venous bleeding, either from post-procedure or from variceal rupture. 2. Evidence of cirrhosis with varices and a recanalized periumbilical vein. 3. The patient is status post RFA of three hepatic sites. CXR [**2136-7-19**]: Right side chest tube is seen with its tip approximately at posterior 6th rib but the side hole is located at the level of the intercostal space. Minimal air is seen in the right subcutaneous region, likely following the recent chest tube placement. Right hemothrax better demonstrated on prior chest CT dated [**2136-7-18**] is mild-to-moderate in quantity. There is no pneumothorax. Left lung is clear. Heart size, mediastinum and hilar contours are normal. ABD U/S [**2136-7-20**]: 1. Shrunken nodular liver consistent with cirrhosis. Limited evaluation of known hepatic lesions. 2. Patent main portal vein with hepatopetal flow. Evaluation of the portal branches is limited. 3. Evidence of portal hypertension including splenomegaly and moderate intra-abdominal ascites. 4. Gallbladder sludge. CXR [**2136-7-22**]: As compared to the previous radiograph, there is an improvement. The linear opacities along the right minor fissure have almost completely resolved. A small gas bubble in the right soft tissues, at the site of the previous chest tube insertion, is also resolved. There is no evidence of pneumothorax or of pleural effusion. The appearance of the left hemithorax is unchanged. Unchanged left axillary clips. DISCHARGE LABS: [**2136-7-23**] 05:50AM BLOOD WBC-6.7 RBC-3.23* Hgb-11.2* Hct-31.0* MCV-96 MCH-34.5* MCHC-36.0* RDW-17.3* Plt Ct-70* [**2136-7-23**] 05:50AM BLOOD PT-18.7* PTT-35.4* INR(PT)-1.7* [**2136-7-23**] 05:50AM BLOOD Glucose-104* UreaN-10 Creat-0.6 Na-136 K-4.1 Cl-101 HCO3-28 AnGap-11 [**2136-7-23**] 05:50AM BLOOD ALT-61* AST-75* AlkPhos-69 TotBili-7.0* [**2136-7-23**] 05:50AM BLOOD Calcium-8.2* Phos-1.6* Mg-1.7 Brief Hospital Course: 62yo M with history of alcoholic cirrhosis complicated by encephalopathy and ascites who was initially admitted to the medical floor for observation after schedule radiofrequency ablation of three HCC liver lesions and liver biopsy, complicated by right hemothorax. # hemothorax: Post procedure Hct was 33 down from 39 prior to the RFA. On the floor the evening of admission, he became hypotensive to the 70s. He was noted to have low UOP with concentrated urine, dry-appearing, and cool to the touch. He recieved 3L NS with improvement in pressures to 100s and better UOP. Hct was 25 upon recheck. After discussion with IR, pt was sent emergently to CT given concern for intra-abdominal bleeding and was found to have a right-sided hemothorax. He got one unit of PRBC's at this time and labs also showed K 6.8. He was given insulin/D50 and calcium; no significant ECG changes were seen. In the MICU, a chest tube was placed by thoracics on [**2136-7-19**]. He got a total 6 units pRBCs, 3 units FFP, and 1 unit plts while in the MICU. Pt was on an octreotide gtt in the MICU at the request of liver. His Hct stabilized near 31 and he was transferred to the general medicine service to be followed by the liver attending. On the floor, he was continued on octreotide subcutaneously for another 2d. On the evening of [**2136-7-21**] the chest tube had minimal output and Hct was stable and the tube was removed by thoracics. His Hct remained stable and a repeat CXR showed near resolution of hemothorax. He was discharged on oxycodone 5mg po q6h prn for pain in addition to his home dose of tramadol 50mg po BID. He was instructed not to drive while on narcotics. # cirrhosis: diuretics were held after patient developed hemothorax, but pt was continued on rifaximin, lactulose, and pantoprazole during admission. Nadolol was held initially but was restarted upon transfer to the general medicine floor on [**2136-7-20**]. he began to develop trace edema in his LE on [**2136-7-23**]; his volume status and Hct were stable at this time so his diuretics were restarted. His LFT's remained stable throughout admission. He was also placed on levofloxacin for 5d for infection prophylaxis. His home medication regimen included both omeprazole and pantoproazole, which was thought to be redundant, so pantoprazole was discontinued on discharge and pt was instructed to take only omeprazole 20mg po BID with plans to further discuss this with Dr. [**Last Name (STitle) 497**]. # tachycardia: on [**2136-7-22**] pt developed tachycardia to the 160s. He did not have symptoms. He had not yet received his AM nadolol and was given this medication, after which his tachycardia resolved, but nadolol has little systemic effect so it is more likely that the tachycardia resolved spontaneously. He said he had a similar episode in the past 7-8 years ago. He denied a history of afib or being treated for a heart condition, and an EKG taken at the time revealed multifocal atrial tachycardia, so no further work up or treatment was pursued. TRANSITIONAL ISSUES: # follow up with liver specialist in one week # discuss PPI regimen with Dr. [**Last Name (STitle) 497**] (pantoprazole was DC'ed and omeprazole was continued) # repeat CT scan in 1 month Medications on Admission: Alprazolam 0.25 mg PO PRN nightly Calcipotriene ointment Clobetasol ointment EpiPen PRN Furosemide 40 mg PO QD Lactulose 10gm/15ml solution 30 ml TID PO Nadolol 20 mg PO QD Omeprazole 20 mg PO BID Pantoprazole 40 mg PO QD Rifaximin 550 mg PO BID Spironolactone 100 mg PO BID Tramadol 50 mg PO BID MVI Discharge Medications: 1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 6. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day): titrate to [**2-10**] bowel movements per day. 7. spironolactone 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 9. calcipotriene 0.005 % Ointment Sig: One (1) application Topical twice a day: Apply to hands and feet twice daily Monday through Friday. . 10. clobetasol 0.05 % Ointment Sig: One (1) application Topical twice a day: Apply to hands and feet twice daily. Use 2 wks/month. Do not apply to face, skin folds, armpits, groin. . 11. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) injection Intramuscular once as needed for anaphylaxis. 12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 13. tramadol 50 mg Tablet Sig: One (1) Tablet PO twice a day. 14. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days: Last Dose [**2136-7-26**]. Disp:*3 Tablet(s)* Refills:*0* 15. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 16. spironolactone 100 mg Tablet Sig: One (1) Tablet PO twice a day. 17. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*28 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: acute post-procedure bleeding/hemothorax radiofrequency ablation Secondary Diagnoses: hepatocellular carcinoma alcoholic cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: Dear Mr. [**Known lastname 976**], It was a pleasure taking care of you in the hospital. You had radiofrequency ablation of parts of your liver. After the procedure, you were admitted for close observation to control post-operative pain and ensure that you were not actively bleeding. You developed a bleed into your chest cavity and you received 6 units of blood cells, 3 units of fresh frozen plasma, and 1 unit of platelets to control your bleeding. You also had a chest tube placed to drain the blood that had collected there. Your blood counts stabilized and the chest tube was removed. Change the dressing daily over the chest tube site and keep the area dry. Avoid baths until scab has completely formed over the area. You may shower starting on [**2136-7-24**]. We reviewed your medications and noticed that you were on both Pantoprazole and Omeprazole which have a similar mechanism of action. It is unnecessary to take both of these; we recommend that you take omeprazole only and discuss this with Dr. [**Last Name (STitle) 497**] at your next visit. The following changes were made to your medications: STOP Pantoprazole and discuss at your next appointment with Dr. [**Last Name (STitle) 497**] START levofloxacin 750mg by mouth daily for three days (last dose [**2136-7-26**]) START oxycodone 5mg by mouth every 6 hours as needed for pain Followup Instructions: 1. TRANSPLANT [**Hospital 1389**] CLINIC Phone: [**Telephone/Fax (1) 673**] Date/Time: [**2136-8-1**] @ 8:00 2. CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time: [**2136-8-20**] @ 11:30

[ "511.89", "155.0", "998.11", "303.90", "799.02", "572.2", "275.3", "458.29", "276.7", "E879.8", "571.2", "285.1" ]

icd9cm

[ [ [] ] ]

[ "50.11", "50.24", "34.04" ]

icd9pcs

[ [ [] ] ]

10531, 10537

5207, 8251

308, 347

10732, 10732

2660, 2660

12228, 12422

1490, 1556

8814, 10508

10558, 10643

8488, 8791

10840, 12205

4775, 5184

1596, 2159

10664, 10711

8273, 8462

234, 270

375, 1028

2676, 4759

10747, 10816

1050, 1364

1380, 1474

2184, 2641

27,082

112,940

3071

Discharge summary

report

Admission Date: [**2111-4-5**] Discharge Date: [**2111-4-22**] Date of Birth: [**2064-1-18**] Sex: M Service: SURGERY Allergies: Nsaids Attending:[**First Name3 (LF) 473**] Chief Complaint: GI Bleed Pancreatic Pseudocyst Hypotension Major Surgical or Invasive Procedure: EGD and stent removal Embolization - Left gastric artery Subtotal pancreatectomy with splenectomy, Primary takedown of gastro-cystic fistula with gastrohorrhaphy repair. History of Present Illness: This is a 47 year old male with a pancreatic pseudocyst and he had endoscopic drainage of the pseudocyst on [**2111-3-26**] by Dr. [**Last Name (STitle) **]. He was recently readmitted and discharge on [**2111-4-2**] with fever and pseudocyst infection, in which he was discharge home on Fluconazole and Augmentin. He now returns with abdominal pain, and weakness. Past Medical History: pancreatitis thought to be due to NSAID use in mid [**2092**]'s, hernia repair EGD and pseudocyst-gastrostomy [**2111-3-26**] Social History: He is a mental health worker. Smokes, drinks alcohol one to two times a month. No prior history of heavy alcohol ingestion. Denies drug use. Family History: Family History: Positive for colon cancer in the patient's maternal aunt. She was diagnosed with cancer in her 70's, otherwise negative for colon cancer, rectal cancer or other HNPCC related cancers in first or second degree relatives. Physical Exam: 98.8, 94, 110/70, 22, 100% RA Gen: NAD CV; RRR Pulm: Clear to ausc. bilat. Abd: soft, distented, mild discomfort to deep palpation difusely Pertinent Results: [**2111-4-5**] 02:25AM BLOOD WBC-24.9*# RBC-3.92* Hgb-11.7* Hct-33.5* MCV-85 MCH-29.8 MCHC-35.0 RDW-13.0 Plt Ct-635*# [**2111-4-5**] 08:50AM BLOOD WBC-11.1*# RBC-2.82*# Hgb-8.5*# Hct-24.3*# MCV-86 MCH-30.1 MCHC-34.9 RDW-13.1 Plt Ct-369 [**2111-4-5**] 02:09PM BLOOD WBC-10.7 RBC-3.30* Hgb-9.9* Hct-28.0* MCV-85 MCH-29.9 MCHC-35.3* RDW-14.0 Plt Ct-335 [**2111-4-7**] 06:15AM BLOOD WBC-9.2 RBC-3.34* Hgb-10.0* Hct-27.9* MCV-84 MCH-30.1 MCHC-36.0* RDW-13.9 Plt Ct-370 [**2111-4-5**] 02:25AM BLOOD Glucose-224* UreaN-22* Creat-1.4* Na-142 K-4.3 Cl-103 HCO3-25 AnGap-18 [**2111-4-7**] 06:15AM BLOOD Glucose-96 UreaN-9 Creat-0.7 Na-143 K-4.0 Cl-107 HCO3-27 AnGap-13 [**2111-4-5**] 02:25AM BLOOD ALT-137* AST-106* CK(CPK)-41 AlkPhos-80 Amylase-44 TotBili-0.1 [**2111-4-5**] 02:25AM BLOOD Lipase-49 [**2111-4-7**] 06:15AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.6 [**2111-4-5**] 02:36AM BLOOD Lactate-3.3* [**2111-4-5**] 08:59AM BLOOD Lactate-1.2 . EGD Impression: 1. Large adherent clot in the fundus of the stomach at the site of the cyst gastrostomy site. 2. Distal aspect of the two pigtail stents were seen in the gastric antrum. 3. Fresh blood was seen emanating at the cyst gastrotomy site. 4. These pigtail stents were removed with a snare. Otherwise normal EGD to third part of the duodenum Recommendations: 1. Continue management in ICU 2. Consult IR for angio embolization of the bleeding source. . ABDOMINAL AORTA [**2111-4-5**] 4:57 PM INDICATION: Upper GI bleeding with the source at the gastric fundus by upper endoscopy. Based on the findings on endoscopy with the bleeding site at the gastric fundus, it was decided to proceed with embolization of the left gastric artery. A microcatheter was then advanced into the left gastric artery with the help of a guidewire. Another arteriogram was performed, demonstrating no evidence of active extravasation, pseudoaneurysm or neovascularity. Four cc's of Gelfoam slurry were then slowly injected through the microcatheter into the left gastric artery until stagnation of flow. The microcatheter was then pulled back and another arteriogram was performed demonstrating no opacification of the peripheral branches of the left gastric artery at the gastric fundus. The microcatheter was then removed and another arteriogram was performed from the main catheter engaged into the celiac trunk. Once again no active extravasation was documented and there was no opacification of the peripheral branches at the gastric fundus. The catheter was removed. A guidewire was advanced through the sheath and the sheath was then removed from the common femoral artery. An Angio-Seal closure device was then deployed at the femoral artery puncture site and hemostasis achieved. The patient tolerated the procedure well. There were no immediate complications. IMPRESSION: No evidence of active extravasation or detectable pseudoaneurysm in the celiac trunk territory. Prophylactic embolization of the left gastric artery with Gelfoam based on the endoscopic findings of the bleeding site at the gastric fundus. . CT ABDOMEN W/CONTRAST [**2111-4-5**] 3:35 AM IMPRESSION: 1. Unchanged size of pseudocyst with slightly decreased surrounding stranding. Double pigtail drainage catheter is in unchanged position. 2. No other new pathology in the abdomen is identified as a possible source of infection. 3. Large filling defect in the stomach is most likely representing food. However, if the patient did not recently eat the possibility of hemorrhage into the stomach should be considered. . CHEST (PORTABLE AP) [**2111-4-6**] 4:15 AM INDICATION: Question of atelectasis. As compared to the previous radiograph, the endotracheal tube has been removed. There is moderate motion artifacts that inhibit a closer morphologic analysis of the lung parenchyma. The subtle area of hypoventilation in the right lung apex could be unchanged. No evidence of newly occurred areas of atelectasis. . CT ABDOMEN W/CONTRAST [**2111-4-9**] 11:19 AM IMPRESSION: 1. No significant interval change in the hyper dense pseudocyst noted in the pancreatic tail. There has been interval removal of double pigtail drainage catheter. The air noted in the pseudocyst is most likely related prior connection with stomach. 2. Stable absence of pancreatic neck and stable distal pancreatic atrophy with distal ductal dilatation. 3. Multiple hypodense liver lesions are consistent with cysts/hemangiomas. . SPECIMEN SUBMITTED: distal pancreas and spleen. Procedure date Tissue received Report Date Diagnosed by [**2111-4-10**] [**2111-4-11**] [**2111-4-17**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 7001**]/cma?????? DIAGNOSIS: Pancreas and spleen, distal pancreatectomy and splenectomy: 1. Pancreas with hemorrhagic pseudocyst and marked acute-on-chronic pancreatitis with necrosis and peripancreatic abscess formation; no residual in-tact pancreatic acinar tissue identified. 2. Spleen with incidental littoral cell angioma and simple epithelial cyst (see note). 3. Small fragment of unremarkable adrenal tissue. 4. No malignancy is identified. . CT PELVIS W/CONTRAST [**2111-4-17**] 11:07 AM IMPRESSION: 1. Interval decrease in size of a now low-density fluid collection adjacent to the greater curvature of the stomach. 2. Status post subtotal pancreatectomy and splenectomy. . Brief Hospital Course: This is a 47 year old male who had EGD and pancreatic pseudocyst gastrostomy and 2 stents placed on [**2111-3-26**]. He returned with hypotension and a GI Bleed. He went for CT ABD showing The pseudocyst unchanged measuring approximately 6.6 x 6 cm in the axial plane. There is mild surrounding stranding, slightly decreased since the prior study. There are again mixed attenuation material within the pseudocyst, with increased air components. A large filling defect in the stomach most likely represents food, although hemorrhage into the stomach cannot be excluded. He was admitted to the ICU and had hematemesis and NG aspirate revealed frank blood. He received 4 units of PRBC for blood loss anemia and aggressive IVF. He was electively intubated for urgent EGD and therapy. He went for EGD and and stent removal, with bleeding at the site of the tube (fundus). He had a suspected He then went to IR and no bleeding source found, left gastric embolized prophylactically. He was extubated the next day and moved to the floor. His diet was advanced to clears on HD 3. He continued on antibiotics for pseudocyst infection. He was doing well on the floor and able to advance his diet. On [**2111-4-9**], the patient became diaphoretic and briefly unresponsive on the floor. He maintained a pulse and blood pressure. He was transferred to the ICU. He had a HCT drop from 30.7 to 22.9. NGT lavage revealed BRB. He received 2 Units of RBC and his HCT was stable at 28.1. He went to the OR on [**2111-4-10**] for: Subtotal pancreatectomy with splenectomy, Primary takedown of gastro-cystic fistula with gastrohorrhaphy repair. He did well post-operatively. Pain: He had an epidural for pain control and was followed by APS. The epidurla was removed on POD 5. He was started on a PCA and once taking adequate orals, was switched to PO meds. GI/ABD: He was NPO, with IVF and TPN, and a NGT. The NGT was removed on POD 4 after clamp trials revealed low residuals. He was started on clears on POD 5. His diet was slowly advanced and he was tolerating a regular diet at time of discharge. His abdomen was soft, nondistened and appropriately tender. His incision was opened on the left side for a post-op wound infection and packed with wet to dry gauze. The staples were removed and steri strips applied Medications on Admission: cipro, percocet prn Discharge Medications: 1. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 3. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. Disp:*40 Tablet(s)* Refills:*0* 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNA Southeastern Mass Discharge Diagnosis: 1. Chronic pancreatitis. 2. Pancreatic pseudocyst. 3. Gastro-cystic fistula causing recurrent life-threatening hemorrhage from pancreatic pseudocyst into the stomach. . abd pain, fevers, and hypotensive Hypotension Post-op Wound infection Discharge Condition: Good Discharge Instructions: You were admitted pain, fevers, and hypotensive Please return to the ED or call the doctor if: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. . * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to increase activity daily * No heavy lifting (>[**9-23**] lbs) for 6 weeks. * Continue with wound dressing changes. Followup Instructions: Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 476**] Date/Time:[**2111-5-8**] 9:45 Completed by:[**2111-4-22**]

[ "577.1", "537.4", "578.9", "401.9", "458.9", "998.59", "577.8", "285.1", "577.2" ]

icd9cm

[ [ [] ] ]

[ "44.44", "99.04", "99.15", "45.13", "44.63", "52.52", "41.5", "97.56" ]

icd9pcs

[ [ [] ] ]

9991, 10043

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896, 1023

1039, 1182

46,872

163,396

24931+57425

Discharge summary

report+addendum

Admission Date: [**2158-1-22**] Discharge Date: [**2158-1-25**] Date of Birth: [**2079-1-25**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5018**] Chief Complaint: transfer to [**Hospital1 18**] from OSH for stroke Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a 78-year-old right-handed male with a PMH of AFib, DM, prostate ca s/p radiation, hemorrhoids s/p recent surgery, chronic venous insufficiency, OA L knee, HLD (unable to tolerate statins), HTN, thoracic aortic aneurysm '[**39**], Fe-deficiency anemia, GERD, colonic polyps, who in the middle of the night on [**2158-1-20**] (~1 am), awakened spontaneously, and reports that he "felt fine" used the restroom and then went back to sleep. He returned to bed but around 430 AM, he woke up again and at this time was unable to move his left arm or leg. He called his brother, who then also noted some dysarthria. At this point, he called '9-1-1' and was brought to the emergency room. There, he was found to have a mild left facial droop and dysarthria, and dense left hemiparesis, arm and leg, slightly decreased sensation to light touch on the left side, without hemineglect. He complained of some numbness on the left side as well. Blood pressure in the field was reported as 190/100, and blood sugar 152, per EMS. His intial CT scan revealed no acute process. He was given 4 baby [**Name (NI) 17408**], and a neurology "telemedicine consultation" was called. The neurology telemedicine consultation found no movement proximally at the left arm, but some fine finger movement . He was able to flex somewhat at the hip on the left leg. Sensation was normal to light touch. A cardiac echo was ordered which found no clot or source of embolus. The consulting physician advised no IV heparin and the patient was outside of the time-window for tPA administration, as the 1 AM episode was considered to be the beginning of the symptomatic period. 3 hours later in the ED, his left sided weakness worsened in the arm, now with little movement below the elbow, as well as possible worsening of left leg weakness. At this point, he was transferred to the ICU and started on a heparin gtt. He received IV fluids, and his exam improved overnight and throughout the day on [**2158-1-21**] with his speech returning to baseline per his brother's report. He received an MRI/MRA on [**1-21**], which revealed a new acute infarct in the corona radiata and basal ganglia, deep white matteras well as was occlusion in the distal right MCA branches versus motion artifact, M1 segment, with superimposed preexisting, diffuse, distal MCA branch narrowing. Nonetheless, due to his improving exam, his heparin was d/c'd on [**1-21**]. However, on the morning of [**2158-1-22**], it was found that his left sided weakness had worsened once again around 10:30 am. His Blood pressures had reportedly been running between 140 and 160, however it is unclear what his BP was at that time. His weakness was worse in his arms and he complained of "heaviness" in his legs. He had a CTA done at the [**Location (un) 620**], whose final read is still pending. These symptoms improved somewhat upon administration of fluids, but nonetheless a decision was made to transfer him [**Hospital1 18**] for concern over this worsening exam and the possible need for intervention. He has a history of a TIA in [**2157-3-14**], associated with left sided weakness (involving the arms and legs, but not face), that resolved within one hour. A subsequent MRI imaging study revealed a right temporal lobe infarct. Patient has also been on coumadin off and on for about 3 years. It was recently discontinued in [**Month (only) **] and [**Month (only) 359**] due to bleeding hemorrhoids. His rectal bleeding persisted off coumadin despite suture ligation and banding rpocedure was done [**12-8**]. His rectal bleeding stopped approximately a week ago. He has been on aspirin 325 mg a day all along. His Coumadin was also on hold in [**Month (only) 547**]/[**Month (only) 116**] due to hematuria due to radiation cystitis. (h/o prostate carcinoma. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: 1. Longstanding atrial fibrillation. 2. Type 2 diabetes mellitus. 3. Prostate carcinoma, status post radiation. 4. Hemorrhoids, with recent surgery. 5. Chronic venous insufficiency. 6. Osteoarthritis - left knee. 7. Hyperlipidemia, unable to tolerate statins in the past. 8. Hypertension. 9. Thoracic aneurysm diagnosed [**2139**]. 10. Iron deficiency anemia. 11. Gastroesophageal reflux. 12. Colonic polyps. Social History: Retired contractor, nonsmoker, social alcohol use. He lives with his brother. Family History: Sister with hypertension, both parents have hypertension. Physical Exam: Physical Exam: Vitals: T:98.1 P:86 R: 16 BP:196/98 SaO2:95% General: Awake, cooperative, NAD. HEENT: NC/AT, Neck: no carotid bruits appreciated Pulmonary: Lungs CTA bilaterally Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities:warm and well perfused. Fungal rash on BL feet. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt. was able to register 3 objects and recall [**4-13**] at 5 minutes. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: mild left facial droop VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. pseudoathetosis on the left.No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB L 4- 5 5- 4 5 4 5 4+ 5 4+ 3 5 5- 4 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory:decreased vibration sense in the left lower extremity, preserved cold sensation BL, No extinction to DSS. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 1 1 1 0 0 R 1 1 1 0 0 Plantar response was extensor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF on the right (not tested on left secondary to weakness) or HKS bilaterally. Pertinent Results: [**2158-1-22**] 07:18PM GLUCOSE-119* UREA N-15 CREAT-1.3* SODIUM-139 POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-23 ANION GAP-14 [**2158-1-22**] 07:18PM estGFR-Using this [**2158-1-22**] 07:18PM CALCIUM-9.2 PHOSPHATE-3.0 MAGNESIUM-2.0 [**2158-1-22**] 07:18PM WBC-9.9 RBC-3.82* HGB-11.1* HCT-34.3* MCV-90 MCH-29.2 MCHC-32.4 RDW-15.7* [**2158-1-22**] 07:18PM PLT COUNT-207 [**2158-1-22**] 07:18PM PT-13.4 PTT-41.8* INR(PT)-1.1 [**2158-1-25**] 06:10AM BLOOD WBC-6.6 RBC-3.67* Hgb-10.7* Hct-32.7* MCV-89 MCH-29.1 MCHC-32.7 RDW-15.8* Plt Ct-211 [**2158-1-25**] 08:45AM BLOOD PT-17.5* INR(PT)-1.6* [**2158-1-25**] 06:10AM BLOOD Glucose-100 UreaN-25* Creat-1.6* Na-138 K-3.8 Cl-107 HCO3-24 AnGap-11 [**2158-1-23**] 01:51AM BLOOD ALT-15 AST-18 LD(LDH)-253* CK(CPK)-43* AlkPhos-107 TotBili-0.7 [**2158-1-23**] 08:22AM BLOOD CK(CPK)-33* [**2158-1-23**] 08:22AM BLOOD CK-MB-2 cTropnT-<0.01 [**2158-1-23**] 01:51AM BLOOD CK-MB-3 cTropnT-<0.01 [**2158-1-25**] 06:10AM BLOOD Calcium-8.5 Phos-3.9 Mg-2.0 ** [**2158-1-24**] 06:00AM BLOOD Triglyc-92 HDL-42 CHOL/HD-3.5 LDLcalc-86 [**2158-1-24**] 06:00AM BLOOD %HbA1c-6.2* eAG-131* ** [**1-20**] Echo: Mild LV systolic dysfunction, no cardiac source of embolism identified. MRI/A -NEW ACUTE INFARCTION IN THE RIGHT DEEP WHITE MATTER. -EXPECTED EVOLUTION OF TWO SMALL RIGHT TEMPORAL CORTICAL INFARCTION WHICH WERE ACUTE ON [**2157-3-31**]. -MILD, LESS THAN 40% STENOSIS AT THE ORIGIN OF THE LEFT INTERNAL CAROTID ARTERY. -APPARENT OCCLUSION OF THE DISTAL M1 SEGMENT OF THE RIGHT MIDDLE CEREBRAL ARTERY. HOWEVER, GIVEN EXTENSIVE MOTION ARTIFACT ON THE HEAD MRA, THIS FINDING COULD BE ARTIFACTUAL IN THE SETTING OF PRE-EXISTING NARROWING OF THE M2 AND M3 SEGMENTS OF THE RIGHT MIDDLE CEREBRAL ARTERY. CTA OF THE HEAD IS SUGGESTED FOR FURTHER EVALUATION. CXR on arrival to [**Hospital1 18**] ICU: FINDINGS: No previous images. The heart is moderately enlarged and there is tortuosity of the aorta. No convincing evidence of pulmonary edema or acute focal pneumonia. Renal/bladder U/S ordered on day of discharge due to rising creatinine: PENDING Brief Hospital Course: <<See above for hospital course at OSH / prior to admission to our ICU then transfer to Neurology floor service>> Mr. [**Known lastname 23203**] was stable on arrival and transferred rapidly out of the ICU to our SDU on the floor. He was hemodynamically stable throughout his hospital course. His symptoms remained stable -- he has Full EOMs, mild Left NLF flattening, mild weakness of several left-sided muscle groups (Left pronator drift, delt [**5-16**], tri 4+/5, [**Hospital1 **] full, WE 4+/5, FE [**5-16**], FF full, IP 4-/5, Quad 5-/5, Ham [**5-16**], [**Last Name (un) 938**] 5-/5). Pinprick exam was grossly normal and symmetric on the day of discharge. He will continue on ASA 325mg for now, then d/c it when warfarin is therapeutic, goal [**3-16**] INR. (INR 1.6 on DOD). To continue statin, although FLP looked OK (LDL 86, and stroke is most likely cardioembolic). To continue BP medications: quinapril, nifedipine, MTP. Consider up-titrating versus adding to these BP meds; his BP range was 145/75 - 166/94 24h prior to discharge. A1c was good at 6.2%. **One issue that arose with Mr. [**Known lastname 23203**] is that despite good PO food/fluid intake and despite IVF at 70/h during his 2.5d stay on our service, his BUN and Cr have been rising. An U/S of the kidneys/ureters/bladder was performed, as he has a uro/prostate history with h/o XRT and occasional blood clots in his Foley catheter. He says the last time this happened was in [**5-/2157**], but he does not know whether his renal function was impaired as a consequence. We held his ACE inhibitor on discharge, although this can be re-started if the GFR turns around and does not continue to fall. The U/S study results should be f/u (report not yet available). We will leave in the Foley catheter, which is draining a normal-appearing urine currently (with occasional clots recently). If cystic bleeding becomes more than an intermittent problem, the warfarin should be held until urgent Urologic evaluation can be conducted. Medications on Admission: Aspirin 325 mg a day, Lopressor 25mg am, 50 mg noon, 25 mg pm, Glipizide, Lasix 40 mg twice daily, potassium 20 mg a day, Accupril 20 mg twice daily, valsartan 160 mg 2 a day, nifedipine 30 mg a day, sodium usually 2 mg, not taking currently, Colace 100 mg twice daily, Darvocet as needed for pain. Discharge Medications: 1. famotidine 20 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. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 6. insulin regular human 100 unit/mL Solution Sig: One (1) per sliding scale Injection ASDIR (AS DIRECTED). 7. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): for DVT ppx. 10. warfarin 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily): with DAILY INR monitoring (goal [**3-16**]). 11. nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 12. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as needed for Stroke. (holding quinapril [**3-15**] elevated creatinine) Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at [**Hospital6 1109**] - [**Location (un) 1110**] Discharge Diagnosis: Primary diagnosis: -Right-hemispheric Stroke, thought to be cardioembolic (patient has afib, prior TIA, was not on A/C) Secondary diagnoses: -Acute Renal failure -HTN -h/o bladder hematoma / prostate Ca / radiation -h/o bleeding hemorrhoids s/p banding Also, 1. Longstanding atrial fibrillation. 2. Type 2 diabetes mellitus. 3. Prostate carcinoma, status post radiation. 4. Hemorrhoids, with recent surgery. 5. Chronic venous insufficiency. 6. Osteoarthritis - left knee. 7. Hyperlipidemia, unable to tolerate statins in the past. 8. Hypertension. 9. Thoracic aneurysm diagnosed [**2139**]. 10. Iron deficiency anemia. 11. Gastroesophageal reflux. 12. Colonic polyps. 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 stroke on the Right side of your brain, which caused your Left-sided symptoms (moderate weakness). Your atrial fibrillation (heart rhythm) put you at risk for a blood clot going from your heart to your brain and causing a stroke, and you were not taking medicine (warfarin/Coumadin) to prevent it becuase you had experienced a problem/procedure that put you at risk for bleeding on warfarin. We think you have more to benefit than risk on this medicine, in order to reduce your risk for more strokes in the future. You will take aspirin 325 until the warfarin is therapeutic (INR between 2 and 3, most recent was 1.6). Followup Instructions: (1) With Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] and [**First Name8 (NamePattern2) 25368**] [**Last Name (NamePattern1) 7741**] [**5-3**] at 1:00pm at the [**Hospital 23**] clinic building [**Location (un) **] ([**Hospital1 18**] at [**Hospital1 1426**] & [**Location (un) **].) (2) With your previous PCP and Urologist regarding your bladder (blood clot) and kidney function (renal function) -- please call to arrange these appointments ASAP. [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**] Completed by:[**2158-1-25**] Name: [**Known lastname 2180**],[**Known firstname 77**] Unit No: [**Numeric Identifier 11237**] Admission Date: [**2158-1-22**] Discharge Date: [**2158-1-25**] Date of Birth: [**2079-1-25**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1886**] Addendum: I spoke with Radiology regarding the U/S study of Mr. [**Known lastname 11238**] bladder on Day of Discharge. They said that, preliminarily, there is no hydro, his urinary outflow system is not obstructed, and that his bladder is decompressed by the Foley catheter which remains in place. Please consider pre-renal or intrinsic renal etiology of his renal failure (rising creatinine). Stopped ACE (quinapril) beginning on DOD ([**2158-1-25**]). Blood pressures have been good, but of note, the patient's h/o thoracic aortic pathology (see above) could be causing a renal perfusion deficit this was not apparent on BP cuff monitoring. Consider this in any further evaluation. Recommend AM-BMP to trend Cr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11239**], MD, PhD N1 Resident in Neurology [**Pager number 11240**] Discharge Disposition: Extended Care Facility: [**Hospital3 1174**] [**Hospital **] [**Hospital 2270**] Rehab Unit at [**Hospital6 2271**] - [**Location (un) 437**] [**Name6 (MD) **] [**Last Name (NamePattern4) 1887**] MD, [**MD Number(3) 1888**] Completed by:[**2158-1-25**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

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16876, 17160

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169,303

44476

Discharge summary

report

Admission Date: [**2194-10-3**] Discharge Date: [**2194-10-7**] Service: NEUROLOGY Allergies: Aspirin / Penicillins Attending:[**First Name3 (LF) 2569**] Chief Complaint: speech difficulties Major Surgical or Invasive Procedure: tPA administration History of Present Illness: 89F RH woman with a PMH of AF off copumadin, prior strokes, short-term memory loss (MCI) presenting with acute onset aphasia and RIGHT-sided weakness. She was participating in a social exercise in her assissted living facility when she was found to be mute, not following commands (though alert and awake). Her RIGHT side was limp. It started at 16:30 as per Assisted facility nurse ([**Doctor First Name 391**] Place: [**Telephone/Fax (1) 95317**]). Taken to [**Hospital1 18**] ED. At [**Hospital1 18**] ED: FSBS 109, SBP 158/86. She had an episode of emesis and received zofran. Discussed case with her son [**Name (NI) **] [**Name (NI) 95318**]( HCP) who confirmed that she is DNR and DNI. However, he did agree with tpa once we explained the risk-benefit in this clinical situation. Past Medical History: Intermittent atrial fibrillation CHF Bilateral knee replacement s/p cholecystectomy h/o CVA, not on anticoagulation [**1-6**] h/o falls and elevated INR Social History: Lives at [**Hospital3 **], independent in ADLs. Unable to respond regarding habits. CONTACT: [**First Name4 (NamePattern1) **] [**Known lastname 95318**]( HCP) [**Telephone/Fax (1) 95319**], son. CODE: DNR/DNI Family History: NC Physical Exam: Exam on admission: BP: 158/86; HR: 88; RR:18 SaO2: 97% RA Gen: Alert. Sclerae anicteric. MMM. No meningismus. No carotid bruits auscultated. Lungs clear bilaterally. Heart regular in rate. Abd soft, nontender, nondistended. Bowel sounds heard throughout. Neuro: MS??????Alert. Conpletely aphasic. CN??????Fundi not visualized. PERRL . LEFT gaze deviation. No ptosis. Mild RIGHT facial droop. Motor?????? Sensory??????Ligwithdraws to noxious stimuli (LEFT side appropietly, right less briskly). Localizes pain. DTRs?????? Toe upgoing on her RIGHT. Patellas 1+. Coord/Gait??????unable to assess. 1a LOC =2 1b Orientation =1 1c Commands =1 2 Gaze =2 3 Visual Fields =0 4 Facial Paresis = 2 5a Motor Function R UE = 3 5b Motor Function L UE= 0 6a Motor Function R LE= 3 6b Motor Function L LE= 0 7 Limb Ataxia = 0 8 Sensory perception = 0 9 Language = 3 10 Dysarthria = 2 11 Extinction/Inattention = 0 TOTAL = 17 Examination at time of discharge: 98.4F BPs 150-160/80-96 HR 70-80s 98% RA, RR 18-20. Neurological examination: MS: Oriented to self. Follows 2 step commands. Comprehension intact. Unable to repeat, name or read. Expressive aphasia full of neologisms with occasional accurate word. CN: Right facial droop UMN, EOMI, 1.5mm b/l and minimally reactive, speech is dysarthric. Motor: Diffuse R > L weakness in UMN pattern of distribution (4+ to 4 in delts, tri, FEs); LEs with R > L IP and hamstrings weakness, otherwise full. Incraesed tone in LEs on right vs. left. Right pronator drift. Right toe extensor. Pertinent Results: labs on admission and discharge: [**2194-10-3**] 05:00PM BLOOD WBC-10.2 RBC-4.72 Hgb-13.2 Hct-39.3 MCV-83 MCH-28.0 MCHC-33.7 RDW-14.7 Plt Ct-310 [**2194-10-6**] 05:50AM BLOOD WBC-10.0 RBC-5.05 Hgb-14.0 Hct-41.8 MCV-83 MCH-27.6 MCHC-33.4 RDW-14.2 Plt Ct-274 [**2194-10-3**] 05:00PM BLOOD PT-13.2 PTT-22.4 INR(PT)-1.1 [**2194-10-6**] 05:50AM BLOOD PT-14.6* PTT-97.3* INR(PT)-1.3* [**2194-10-6**] 04:10PM BLOOD PTT-51.5* [**2194-10-7**] 12:55AM BLOOD PTT-67.1* [**2194-10-4**] 03:00AM BLOOD Glucose-116* UreaN-16 Creat-1.0 Na-141 K-5.2* Cl-111* HCO3-25 AnGap-10 [**2194-10-6**] 05:50AM BLOOD Glucose-86 UreaN-14 Creat-1.0 Na-141 K-4.3 Cl-104 HCO3-28 AnGap-13 [**2194-10-4**] 03:00AM BLOOD ALT-5 AST-19 LD(LDH)-219 CK(CPK)-50 AlkPhos-59 TotBili-0.5 [**2194-10-3**] 05:00PM BLOOD cTropnT-<0.01 [**2194-10-4**] 03:00AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2194-10-4**] 03:00AM BLOOD Albumin-3.5 Calcium-7.9* Phos-3.7 Mg-1.9 Iron-36 Cholest-159 [**2194-10-6**] 05:50AM BLOOD Calcium-8.7 Phos-2.7 Mg-2.0 [**2194-10-4**] 03:00AM BLOOD calTIBC-285 TRF-219 [**2194-10-4**] 03:00AM BLOOD %HbA1c-6.0* [**2194-10-4**] 03:00AM BLOOD Triglyc-75 HDL-50 CHOL/HD-3.2 LDLcalc-94 [**2194-10-4**] 03:00AM BLOOD TSH-0.71 [**2194-10-5**] 03:43PM URINE RBC-143* WBC-7* Bacteri-FEW Yeast-NONE Epi-14 TransE-<1 [**2194-10-5**] 03:43PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [**2194-10-5**] 03:43PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008 Imaging: CTA perfusion: [**10-3**] IMPRESSION: 1. Findings indicative of dense left middle cerebral artery. Extensive small vessel disease identified with brain atrophy and chronic right periatrial watershed infarct. 2. CT perfusion demonstrates a large area of increased mean transit time in the left MCA distribution with patchy small areas of low blood volume indicative of ischemia with areas of infarction. 3. No occlusion or hemodynamically significant stenosis in the arteries of the neck. 4. Findings indicative of occlusion at the bifurcation of left middle cerebral artery with diminished number of sylvian branches distally. CT head [**10-4**]: IMPRESSION: 1. Interval development of hypodensity in the left frontoparietal region compatible with evolution of known large region of ischemia and infarction in the left MCA territory (as demonstrated on yesterday's CT- perfusion study). 2. No significant associated mass effect or herniation, and no hemorrhage. 3. Encephalomalacia involving the right parietal lobe compatible with chronic infarction in a watershed distribution. Brief Hospital Course: Ms. [**Known lastname 95318**] is a [**Age over 90 **]-year-old woman who has atrial fibrillation but was not anticoagulated due to concerns about prior falls, hx of prior strokes and MCI who was admitted to the [**Hospital1 18**] Neurology service with a left MCA territory stroke. On initial presentation, she had a global aphasia with dense right hemiplegia. CTA showed a dense left middle cerebral artery stroke with extensive small vessel disease and a chronic right periatrial watershed infarct. No occlusion was noted in the neck arteries. This event was felt to be cardioembolic in origin. Given no contraindications therfore IV-thrombolytics were administered at 1820 on [**10-3**]. There was delay in obtaining initial imaging as patient became ill in CT scanner with vomiting. She was admitted to ICU for post tpa management. Her blood pressure was allowed to autoregulate, IVF were adminstered to maintain CPP. Modifiable risk factors were A1C of 6.0 and LDL of 97. Statin was incrased to 40mg daily. Her heart rate remained in 60-80s [**Hospital 95320**] hospital stay and should this increase, a metoprolol formulation may be used to control the heart rate, goal 60-70s. She remained neurologically stable and her CT head follow up showed expected evolution of her stroke. She was started on heparin gtt (goal 60-80) and bridged with coumadin. Her INR goal is [**1-7**]. She will require HCT monitoring and guiac of her stools. Due to intermittent agitation, she was given haldol IV 1mg, which lead to significant somnolence, resolved by HD3. Seroquel may be used cautiously in its place. At time of discharge, her examination improved to the point of able to follow 2 step commands and improved comprehension. She was unable to repeat, name or read. Expressive aphasia full of neologisms with occasional accurate word. Please see discharge exam for details. She will require physical and occupational therapy. She did not have a swallowing deficit, however PO intake has been poor over past 24 hours. She was able to take PO medications in pudding. Follow up with neurology was arranged. She will also require arrangement of follow up with PCP. Code status: DNR/I. Medications on Admission: Statin, unknown dose Discharge Medications: 1. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours) as needed for fever or pain. 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for agitation. 4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 5. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 6. Famotidine 20 mg IV Q24H 7. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 8. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral Solution Sig: 850 units Intravenous ASDIR (AS DIRECTED): Goal PTT 60-80. Please check PTT Q6 hours. Page house officer with results. Please d/c after INR > 2 for > 24 hours. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: Embolic stroke Secondary: Hyperlipidemia, prior strokes Discharge Condition: Improved neurologically. Exam at discharge: 98.4F BPs 150-160/80-96 HR 70-80s 98% RA, RR 18-20. Neurological examination: MS: Oriented to self. Follows 2 step commands. Comprehension intact. Unable to repeat, name or read. Expressive aphasia full of neologisms with occasional accurate word. CN: Right facial droop UMN, EOMI, 1.5mm b/l and minimally reactive, speech is dysarthric. Motor: Diffuse R > L weakness in UMN pattern of distribution (4+ to 4 in delts, tri, FEs); LEs with R > L IP and hamstrings weakness, otherwise full. Incraesed tone in LEs on right vs. left. Right pronator drift. Right toe extensor Discharge Instructions: You were admitted to [**Hospital1 18**] with loss of speech and right sided weakness. You were found to have a stroke affecting your ability to speak and strenght in theright side of your body. For this you were treated with thrombolytics and anticoagulation. With this treatment your symptoms improved (comprehension and RUE strength). The following changes were made to your medications: - Started on heparing infusion, to be continued until your coumadin is therapeutic INR goal of [**1-7**] - Increased dose of simvastatin to 40mg daily - You were intermittently treated with other medications, please refer to list below for complete description. Please follow up with your appointments. Should you develop any further difficulty with speech, changes in vision, weakness, difficulty with balance, dizziness, lightheadedness, black or bloody stools or any other symptom concerning to you, please call your doctor or go to the emergency room. Followup Instructions: Please follow up with your primary care doctor [**Last Name (LF) **],[**First Name3 (LF) 8207**] M. [**Telephone/Fax (1) 3581**] within one month of your discharge from the hospital for blood pressure control, lipid control and heart rate control. Neurology: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2194-11-10**] 2:30 [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**] Completed by:[**2194-10-7**]

[ "V15.88", "342.90", "428.0", "307.9", "V43.65", "E939.2", "434.11", "427.31", "784.3", "438.0", "780.09" ]

icd9cm

[ [ [] ] ]

[ "99.10" ]

icd9pcs

[ [ [] ] ]

8884, 8950

5719, 7924

250, 270

9059, 9090

3091, 5696

10686, 11227

1511, 1515

7995, 8861

8971, 9038

7950, 7972

9710, 10663

1530, 1535

9105, 9686

191, 212

298, 1091

1550, 3072

1113, 1267

1283, 1495

76,186

136,273

35179+57982

Discharge summary

report+addendum

Admission Date: [**2121-1-13**] Discharge Date: [**2121-1-26**] Date of Birth: [**2054-12-25**] Sex: M Service: CARDIOTHORACIC Allergies: Hurricaine Attending:[**First Name3 (LF) 922**] Chief Complaint: Palpitations Major Surgical or Invasive Procedure: [**2121-1-20**] 1. Placement of two epicardial left ventricular pacing leads via a left anterior thoracotomy. 2. Evacuation of hematoma from previously- placed pacemaker generator in the upper left pectoralis region. History of Present Illness: Pt is a 65yo M with a PMH significant for DM, HTN, HL, COPD, left atrial tumor resection in [**2118**], s/p mechanical AVR [**2106**], s/p pacemaker most recently revised in [**2120-11-20**], transferred for a-flutter ablation/ BIV ICD placement/pacemaker removal and initiation of Dofetilide. The patient states that he has had occasional palpitations without any specific pattern or inciting events. The patient states that he has had rare episodes of SOB. He states that he can walk several blocks without SOB/ CP. These symptoms have improved with lasix. The patient denied orthopnea/PND. The patient does have c/o lower ext edema that has also improved since initiation of his lasix. . The patient reports that he has had drainage from a pin-point lesion from his pacer site that began a few weeks after the revision on [**2121-11-20**]. He states it was a rusty color and no visble pus. He denied fevers, chills, or other systemic signs of infection. He was starte on Keflex and the wound healed. The lesion opened up again and began to drain again about 2 weeks ago. He was again started on Keflex and is still currently taking it. . Patient underwent an isthmus ablation on [**2120-1-14**] for his a-flutter. Started on dofetilide. On [**2120-1-15**] BiV ICD placement was attempted, but the LV lead could not be placed; therefore, he only received a dual chamber pacer on the left. His old right-sided generator was removed, with the old leads left in. After the procedure, he experienced dyspnea, desating to the 80s on 4L NC. ABG 7.36/43/83. He received furosemide 20 mg IV x 1 and ondansetron for nausea. CXR revealed no PTX. Got a dose of gentamicin--already on vancomycin for old pacer site infection. Transferred to CCU for close monitoring. Cardiac surgery was consulted on epicardial lead placement. . Upon arrival to the CCU, patient looked comfortable, no longer dyspneic. Oxygen was weaned down to 2L NC. Past Medical History: PAST MEDICAL HISTORY: -DMII -HTN -Hyperlipidemia -Asthma-Exercise Induced -COPD -Ascites of uncertain cause ?secondary to right heart failure -GERD -Right eye hollenhorst plaque -Atrial tachycardia (previously on sotalol) [**2117**] -Mild carotid stenosis bilaterally [**10-9**] -Vegetation on Tricuspid valve noted on multiple TEEs in 02, 03, 05. -complex cyst on right kidney . PAST Cardiothoracic Surgeries -s/p mechanical AVR ([**Company 1543**] [**Doctor Last Name **])/aortic root prosthesis (placed for AI, c/b complete heart block in [**2106**]) -Left atrial tumor s/p resection (papillary elastofibroma) [**2118**] -PFO, moderate atrial septal aneurysm s/p closure -s/p dual chamber pacemaker (Elite Dual) for complete heart block s/p device explant and reimplantation on the right ([**Company 1543**]) in [**2114**] for device infection after trauma. (performed at [**Hospital1 112**] by Dr. [**Last Name (STitle) 3271**]. . PAST SURGICAL HISTORY: -left rotator cuff repair -tonsillectomy -back surgery (disk herniation Social History: Married. Previously drank 12 beers per week and has had no alcohol for 3 months. Smoked 35 years/2ppd, quit in early [**2102**]. Retired. Family History: Brother with diabetes died of heart failure at age 29 Physical Exam: VS - 97.3 92/51 62 18 98%RA Gen: male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 5 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2, mechanical click. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Dressing C/I/D. minimal streak of erythema and small 0.5cm collection in the subq, no drainage, bleeding or puss. Abd: obese, soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: 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: [**2121-1-13**] 06:49PM BLOOD WBC-6.7 RBC-3.51* Hgb-10.7* Hct-30.4* MCV-87 MCH-30.6 MCHC-35.3* RDW-15.0 Plt Ct-151 [**2121-1-14**] 06:25AM BLOOD Neuts-58.6 Lymphs-29.2 Monos-9.0 Eos-2.9 Baso-0.4 [**2121-1-13**] 06:49PM BLOOD PT-17.7* PTT-43.6* INR(PT)-1.6* [**2121-1-13**] 06:49PM BLOOD Glucose-197* UreaN-41* Creat-1.4* Na-139 K-4.5 Cl-106 HCO3-23 AnGap-15 [**2121-1-17**] 05:02AM BLOOD %HbA1c-7.3* [**2121-1-16**] TTE: The left atrium is moderately dilated. The estimated right atrial pressure is 10-20mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild global left ventricular hypokinesis with septal dyskinesis (LVEF = 40-45 %). The right ventricular cavity is moderately dilated with normal free wall contractility. A bileaflet aortic valve prosthesis is present. The transaortic gradient is normal for this prosthesis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The left ventricular inflow pattern suggests impaired relaxation. Moderate [2+] tricuspid regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. [**2121-1-20**] Intraop TEE: No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is mildly depressed (LVEF= 40 %). with mild global RV free wall hypokinesis. There are simple atheroma in the descending thoracic aorta. A mechanical aortic valve prosthesis is present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. [**2121-1-25**] 08:25AM BLOOD WBC-7.9 RBC-3.22* Hgb-9.5* Hct-28.4* MCV-88 MCH-29.6 MCHC-33.5 RDW-14.9 Plt Ct-346# [**2121-1-26**] 09:35AM BLOOD Glucose-73 UreaN-39* Creat-1.6* Na-134 K-4.3 Cl-101 HCO3-27 AnGap-10 Brief Hospital Course: Patient is a 65yo M with a PMH significant for DM, HTN, HL, COPD, left atrial tumor resection in [**2118**], s/p mechanical AVR [**2106**], s/p pacemaker most recently revised in [**2120-11-20**], transferred for a-flutter ablation/ BIV ICD placement/pacemaker removal and initiation of dofetilide, transferred to CCU after having respiratory distress after attempted BiV ICD placement. Patient underwent an isthmus ablation on [**2120-1-14**] for his a-flutter. Started on dofetilide. On [**2120-1-15**] BiV ICD placement was attempted, but the LV lead could not be placed; therefore, he only received a dual chamber pacer on the left. His old right-sided generator was removed, with the old leads left in. After the procedure, he experienced dyspnea, desatting to the 80s on 4L NC. ABG 7.36/43/83. He received furosemide 20 mg IV x 1 and ondansetron for nausea. CXR revealed no PTX. He received of gentamicin and was already on vancomycin for old pacer site infection. He was transferred to CCU for closer monitoring. In the CCU, the patient had an expanding hematoma on chest wall over the site of hte new pacer. A pressure dressing was applied. Patient received 2 units packed RBC (along with several liters of fluid). Hct was stable. CT surgery was consulted and agreed to place an epicardial lead on [**2121-1-20**]. Postoperatively, his heart failure therapy was resumed and EP service continued to titrate his anti-arrhythmia regimen. The ID service was consulted and recommended to continue intravenous Vancomycin until [**2121-1-28**]. Operative cultures eventually showed no growth. Due to some incisional discomfort, he was started on Dilaudid and Neurontin with good results. He was maintained on intravenous Heparin until INR became therapeutic. Warfarin was dosed for a goal INR between 2.0 - 3.0. Given a persistently elevated creatinine, he remained off Metformin. Lantus and Glyburide were titrated accordingly with improved glucose control. He initially required aggressive diuresis with intravenous Lasix. By discharge he had transitioned to oral Lasix with adequate urine output. He was discharged home in good condition on POD 6 with instructions to follow up with his local infusion clinic for completion of his antibiotic course. Medications on Admission: Coumadin 5mg Tues/Thurs/Sat/Sun, 7.5mg MWF, last dose Tues [**11-12**] Lovenox [**Hospital1 **] started [**2120-11-13**], last dose Mon PM Spironolactone 25mg daily Januvia 100mg daily in the am Glyburide 10mg [**Hospital1 **] Metformin 500mg tablets [**Hospital1 **] Simvastatin 80mg daily in the PM Ranitidine 150mg [**Hospital1 **] Furosemide 20mg daily in the am Metoprolol 50mg [**Hospital1 **] Cozaar 25mg daily Cinnamon 1000mg [**Hospital1 **] MVI daliy Atrovent inhaler [**Hospital1 **] Discharge Medications: 1. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gm Intravenous Q 24H (Every 24 Hours) for 2 days: last dose [**2121-1-28**] will need flushes x 48hrs post abx until line d/c. Disp:*2 gm* Refills:*0* 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 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. Dofetilide 250 mcg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:*60 Capsule(s)* Refills:*0* 5. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:*60 Capsule(s)* Refills:*0* 7. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 11. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 12. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 13. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 14. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 15. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Community Health and hospice Discharge Diagnosis: Atrial Flutter s/p transvenous implantation of pacer/defibrillator & removal old pacemaker s/p thoracotomy and epicardial pacing lead noninsulin dependent diabetes mellitus hyperlipidemia hypertension Hyperlipidemia chronic obstructive pulmonary disease gastric reflux Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month, and while taking narcotics Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: *** call [**Location (un) 11248**] Infusion Service [**Telephone/Fax (1) 80286**]** ([**Female First Name (un) 24743**]) for schedule of antibiotic infusion through [**2121-1-28**] Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]), call for appt Dr. [**First Name4 (NamePattern1) 11249**] [**Last Name (NamePattern1) 11250**] in [**1-3**] weeks ([**Telephone/Fax (1) 11254**]), call for appt Dr. [**Last Name (STitle) 11250**] will continue to follow coumadin/INR as previously Completed by:[**2121-1-26**] Name: [**Known lastname 12902**],[**Known firstname **] Unit No: [**Numeric Identifier 12903**] Admission Date: [**2121-1-13**] Discharge Date: [**2121-1-26**] Date of Birth: [**2054-12-25**] Sex: M Service: CARDIOTHORACIC Allergies: Hurricaine Attending:[**First Name3 (LF) 1543**] Addendum: The patient was discharged on coumadin 5mg (MWF), 7.5mg (T,R,S,S) as per his home regimen. Dr. [**Last Name (STitle) 12904**] will continue to follow INR and manage coumadin dosing. Discharge Disposition: Home With Service Facility: Community Health and hospice [**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**] Completed by:[**2121-1-27**]

[ "584.9", "585.9", "428.22", "V58.61", "564.00", "276.52", "530.81", "272.4", "E878.1", "276.51", "403.90", "V43.3", "593.2", "426.0", "379.8", "V45.89", "433.10", "998.12", "250.00", "787.02", "427.89", "493.22", "427.32", "428.0", "425.4", "285.1" ]

icd9cm

[ [ [] ] ]

[ "37.72", "37.27", "37.34", "37.89", "86.04", "37.83", "37.74", "37.26" ]

icd9pcs

[ [ [] ] ]

13374, 13592

6751, 9021

290, 509

11781, 11788

4712, 6728

12283, 13351

3691, 3746

9568, 11384

11487, 11760

9047, 9545

11812, 12260

3445, 3519

3761, 4693

238, 252

537, 2464

2508, 3422

3535, 3675

16,684

116,587

7809

Discharge summary

report

Admission Date: [**2188-1-24**] Discharge Date: [**2188-2-12**] Date of Birth: [**2156-12-9**] Sex: M Service: CARDIOTHORACIC Allergies: Bactrim Attending:[**First Name3 (LF) 165**] Chief Complaint: malaise, decreased PO intake Major Surgical or Invasive Procedure: [**2-6**] MVR ([**First Name8 (NamePattern2) 7163**] [**Male First Name (un) 923**] Tissue), AVR ([**Street Address(2) 11688**]. [**Male First Name (un) 923**] Tissue) History of Present Illness: Mr. [**Known lastname **] is a 31yo male with HIV, not on HAART, with last CD4 27, HIV nephropathy on HD, HBV, HCV who presented with several weeks of malaise and diarrhea, found to have MSSE endocarditis. He initially presented to the hospital on [**1-24**] with chief complaints of 3 weeks of GI upset, watery diarrhea [**2-20**] times/day, nausea, vomiting X1 followed by shaking chills and mild non-productive cough for several days. Vitals in the ED were T 95, HR 64, BP 117/55, RR 18, 99%RA. CXR was concerning for RLL pneumonia and he was started on Vancomycin IV 1gm X1 and Levaquin 250 PO X1. Past Medical History: PAST MEDICAL HISTORY: - HIV dx [**2172**], reports from sexual contact but hx of IVDU; [**Year (4 digits) **] HAART [**2186-10-18**] with renally adjusted 3TC and ZDV, and ritonavir boosted atazanavir; Currently not on HAART due to intolerance. [**8-/2187**] CD4 34 - HCV+ but has no detectable circulating virus - HBV+ but HBc equivocal [**10/2186**] - ESRD [**1-19**] HIV Nephropathy on HD (was on PD until a few weeks ago) - Genital and anal wart s/p surgical removal - History of R thigh abscess - Chronic LBP; seen in pain clinic;told secondary to osteoarthritis/ nerve impingement - Asthma - Migraine - s/p L knee arthroscopy for lateral meniscus tear ('[**75**]) - s/p tonsillectomy (as child) Social History: - Patient is originally from the Bronx, [**State 531**]. He is single and lives with his mother. - He currently works as an HIV case manager although has been noted to have history of poor HAART compliance himself. Currently not on HARRT - Tobacco: 1/2-2/3ppd x 20yrs, denies EtoH; IVDU as teenager, denies recent use. - Not currently sexually active Family History: - Father: Hypertension/Diabetes [**State **] - No family hx of liver problems Physical Exam: PE: 95.7 102/50 101 16 100%RA O2 Sats Gen: thin, emaciated, fatigued HEENT: Clear OP, MM dry, no thrush, oral lesions NECK: Supple, No LAD, No JVD CHEST: RIJ tunneled HD line, site slightly erythematous and tender with large area of skin discoloration CV: RR, NL rate. No murmurs, rubs or [**Last Name (un) 549**] LUNGS: end expiratory wheezes heard throughout, no crackles ABD: Soft, mildly tender to palpation throughout especially at site of old PD catheter EXT: No edema. 2+ DP pulses BL, hypersensitive to light tough in calves Bilterally and over tibial bone SKIN: No lesions, rashes, sores NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 4+/5 strength throughout. [**12-19**]+ reflexes, equal BL. Pertinent Results: CHEST (PA & LAT) [**2188-2-12**] 10:09 AM CHEST (PA & LAT) Reason: f/o pneumomediastinum [**Hospital 93**] MEDICAL CONDITION: 31 year old man with s/p avr mvr REASON FOR THIS EXAMINATION: f/o pneumomediastinum PROCEDURE: Chest PA and lateral on [**2188-2-12**]. COMPARISON: [**2188-2-10**]. HISTORY: Followup pneumomediastinum. FINDINGS: The air-fluid level seen in the right upper quadrant has decreased on today's examination. There is persistent pneumoperitoneum persistent in both right and left upper quadrants of the abdomen. Pulmonary and mediastinal vascular engorgement has improved, although the heart remains enlarged. There is small bilateral right more than left pleural effusion. Pneumopericardium and pneumomediastinum are no longer visualized on today's examination. The moderately severe bibasilar atelectasis are unchanged. No pneumothorax. IMPRESSION: 1. Pneumopericardium and pneumomediastinum are no longer visualized. 2. Persistent pneumoperitoneum with a decrease in the air-fluid level seen in the right upper quadrant of the abdomen underneath the right hemidiaphragm. 3. Small bilateral right more than left pleural effusion. 4. Small pulmonary and mediastinal vascular engorgement. 5. Persistent severe bibasilar atelectasis. Cardiology Report ECG Study Date of [**2188-2-7**] 7:00:04 PM Sinus rhythm. Borderline left ventricular hypertrophy. Prolonged Q-T interval. Intraventricular conduction delay. Compared to the previous tracing diffuse ST-T wave changes are slightly more prominent. Read by: [**Last Name (LF) **],[**First Name3 (LF) **] Intervals Axes Rate PR QRS QT/QTc P QRS T 77 154 100 456/485 55 53 15 [**2188-2-12**] 06:55AM BLOOD WBC-8.7 RBC-2.31* Hgb-6.9* Hct-23.2* MCV-101* MCH-30.0 MCHC-29.8* RDW-24.9* Plt Ct-203 [**2188-1-24**] 12:02AM BLOOD WBC-4.2 RBC-2.68*# Hgb-7.7*# Hct-24.2*# MCV-91# MCH-28.9 MCHC-31.9 RDW-17.4* Plt Ct-72* [**2188-2-12**] 06:55AM BLOOD Neuts-80.4* Lymphs-13.5* Monos-4.7 Eos-1.1 Baso-0.3 [**2188-2-12**] 06:55AM BLOOD Plt Ct-203 [**2188-2-11**] 03:15PM BLOOD PT-15.7* PTT-28.8 INR(PT)-1.4* [**2188-1-24**] 12:02AM BLOOD Plt Ct-72* [**2188-2-7**] 05:02PM BLOOD Fibrino-208 [**2188-1-26**] 05:45AM BLOOD ESR-68* [**2188-1-24**] 10:05PM BLOOD WBC-5.3 Lymph-17* Abs [**Last Name (un) **]-901 CD3%-56 Abs CD3-501* CD4%-3 Abs CD4-27* CD8%-47 Abs CD8-427 CD4/CD8-0.06* [**2188-1-24**] 10:05PM BLOOD Ret Aut-1.6 [**2188-2-12**] 06:55AM BLOOD Glucose-87 UreaN-47* Creat-7.6* Na-133 K-4.6 Cl-96 HCO3-25 AnGap-17 [**2188-2-10**] 10:30AM BLOOD ALT-9 AST-31 LD(LDH)-351* AlkPhos-452* Amylase-44 TotBili-0.6 [**2188-2-10**] 10:30AM BLOOD Lipase-22 [**2188-1-24**] 01:45AM BLOOD GGT-293* [**2188-2-11**] 06:20AM BLOOD Calcium-7.9* Phos-5.9*# Mg-2.8* [**2188-1-24**] 01:45AM BLOOD calTIBC-176 Hapto-351* Ferritn-[**2104**]* TRF-135* [**2188-1-24**] 10:05PM BLOOD PTH-168* [**2188-1-26**] 05:45AM BLOOD CRP-107.0* [**2188-2-12**] 06:55AM BLOOD Vanco-16.4 Brief Hospital Course: Once admitted to the medical floor he underwent an echocardiogram which showed mitral and aortic valve vegetations, suggestive of endocarditis. He was started Vancomycin with plan for TEE and cardiac surgery evaluation. found to have MSSE bacteremia (cxs on [**1-24**]), believed source is HD cath. TEE which again showed MV involvement w/ severe MR, and AV involvement w/ severe AI. HD line was resited. He also underwent a CT scan of abdomen, which showed splenic infarction vs. septic emboli, also pulmonary nodules suggesting possible septic emboli. He became hypoxic as well as had episode of hemoptysis and tachycardia and was transferred to the MICU. EKG showed sinus tach with inverted t waves in lateral leads. CXR at the time demonstrated primarily R sided consolidation vs volume overload. Emergent repeat TTE at time of event showed no change in MR. The likely explanation for the hemmoptysis was felt to be acute pulmonary HTN combined with pulmonary edema and bacteremia leading alveolar hemorrhage. Pt was stabilized on NRB face mask, nitorprusside drip, hydralazine, and metoprolol following transfer to the MICU. Pt had no subsequent respiratory distress and was transferred to the medical floor while awaiting MVR/AVR, hydralazine and metoprolol were continued on the medical floor. Pt received HD while in-house with continued EPO as dosed by the HD protocol for chronic anemia in the setting of ESRD/HIV. Pt's HD frequency was adjusted/increased given acute volume overload in the setting of valvular insufficiency-related heart failure. He continued on methadone. He continued with preoperative workup including dental clearance, CT head and TEE. He was electively intubated and then extubated after TEE. His blood cultures remained negative and he was taken to the operating room on [**2-7**] where he underwent an AVR/MVR. He was transferred to the ICU in critical but stable condition. He was extubated the morning of POD #1. He was transferred to the floor later on POD #1. He did well postoperatively. His AV fistula failed, and he was taken for a fistulogram which showed Severe stenosis of the draining vein of the brachiocephalic AV fistula within 2 cm of the arterial anastomosis. It was angioplastied and he underwent dialysis on [**2-12**] with PRBC transfusion. He was ready for discharge to rehab that same day. He will require 4 total weeks of vanco from the day of surgery (until [**3-7**]). Medications on Admission: MEDs per last d/c summary; however, Pt unable to confirm . Methadone 40 mg TID Lisinopril 40 mg daily Cinacalcet 60 mg daily Calcium Acetate 667 mg [**Hospital1 **] Albuterol Clonidine 0.1 mg [**Hospital1 **] Nifedipine 90 mg Tablet Sustained Release daily Trimethoprim-Sulfamethoxazole 160-800 mg 3X/WEEK (TU,TH,SA) after HD Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) g Intravenous HD PROTOCOL (HD Protochol) for 4 weeks: with HD; 4 weeks from surgery ([**3-7**]). Dose for level < 20. 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Methadone 10 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 11. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Epogen with HD Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital Discharge Diagnosis: MV and AV endocarditis now s/p AVR/MVR HIV, HCV+, HBV+, ESRD [**1-19**] HIV Nephropathy on HD, Genital and anal wart s/p surgical removal, R thigh abscess, Chronic LBP, Asthma, Migraine Discharge Condition: good Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week, Shower, no baths, no lotions,creams or powders to incisions. No lifting more than 10 pounds or driving until follow up with surgeon. Followup Instructions: Dr. [**Last Name (STitle) **] 1-2 weeks. Dr. [**First Name (STitle) **] 4 weeks [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2188-2-12**]

[ "042", "421.0", "416.0", "729.5", "424.1", "786.3", "041.11", "285.21", "428.21", "996.62", "287.4", "790.5", "787.91", "444.89", "403.91", "428.0", "486", "996.73", "585.6", "424.0" ]

icd9cm

[ [ [] ] ]

[ "39.61", "00.40", "38.93", "39.95", "39.50", "35.23", "35.21", "89.60", "88.72" ]

icd9pcs

[ [ [] ] ]

10090, 10145

6044, 8475

302, 472

10375, 10382

3090, 3183

10680, 10882

2227, 2306

8851, 10067

3220, 3253

10166, 10354

8501, 8828

10406, 10657

2321, 3071

234, 264

3282, 6021

500, 1104

1148, 1834

1850, 2211

42,672

179,658

40490

Discharge summary

report

Admission Date: [**2103-6-23**] Discharge Date: [**2103-6-29**] Date of Birth: [**2077-1-15**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2195**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname **] is a 26M with h/o IVDA (heroin and crushed oxycodone) who presents with dyspnea. He reports DOE, fever, chills, pleuritic CP x 2 days, but denies SOB at rest or cough. He reports that his 3 year old son and roommate have had URI symptoms recently. He was unable to sleep last night [**1-17**] dyspnea. He presented to an OSH where he was febrile to 103. A CXR showed patchy b/l infiltrate c/f multifocal PNA vs septic emboli. He was given Vanc, Ceftriaxone, 2L IVF, Tylenol at the OSH and transferred here. Of note, he was seen at [**Hospital 5028**] Hospital 3 weeks ago after having 2 seizures, and reports being discharged from their ED without plan for follow up. He denies weight changes or focal neuro deficits. His last use of heroin was at 3am on day of admission ([**2103-6-23**]). . In the ED, his initial VS were 97.9, 94, 90/56, 22, 95%. Levofloxacin was given here along with 2L IVF with improvement in BP to the low 100s systolic. CXR again showed mostly right sided infiltrates. His VS at time of transfer were: 98.0 103 98/58 30 99% 3L NC. . In the ICU, he reports continued SOB slightly improved from presentation, chills, and [**6-24**] pleuritic CP. . Review of systems: (+) Per HPI (-) Denies night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough or wheezing. Denies 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: None Social History: - Tobacco: quit 5 days ago, 1/2ppd x 10yrs prior - Alcohol: denies - Illicits: current IVDA (heroin and crushed oxycodone), ?cocaine in OSH records though denies Family History: Non-contributory Physical Exam: ON ADMISSION: Vitals: T: 98.0 BP: 98/58 P: 103 R: 30 O2: 99% 3L NC General: Alert, oriented, appears uncomfortable HEENT: Sclera anicteric, Pupils 5->4 b/l and symmetric, MMM, oropharynx clear Neck: supple, JVP not elevated Lungs: Crackles at bases B/L, R>L, also in R mid-axillary line CV: Fast rate and regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, no [**Doctor Last Name **] spots or splinter hemorrhages, track marks b/l Neuro: CN III-XII intact, motor [**4-19**], patellar 3+ b/l and symmetric PRIOR TO TRANSFER: Vitals: T: 98.3-100.4 BP: 105-122/62-84 P: 88-118 R: 26-32 O2: 95% on RA. General: Alert+OX3. Mood and affect appropriate. Excited to be improving. HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear Neck: supple, JVP not elevated Lungs: Decreased breath sounds at bases B/L, R>L CV: Fast rate and regular rhythm, normal S1 + S2, 2/6 systolic murmur heard best at LSB. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, no [**Doctor Last Name **] spots or splinter hemorrhages, track marks b/l Neuro: CN III-XII intact, motor [**4-19**], patellar 3+ b/l and symmetric Pertinent Results: Labs: [**2103-6-23**] 05:30PM BLOOD WBC-5.9 RBC-3.78* Hgb-11.3* Hct-32.2* MCV-85 MCH-29.8 MCHC-35.0 RDW-13.5 Plt Ct-65* [**2103-6-24**] 04:24AM BLOOD WBC-9.9# RBC-4.49* Hgb-13.3* Hct-39.3* MCV-88 MCH-29.6 MCHC-33.8 RDW-14.0 Plt Ct-96* [**2103-6-25**] 06:40AM BLOOD WBC-12.5* RBC-3.90* Hgb-11.4* Hct-34.1* MCV-87 MCH-29.2 MCHC-33.4 RDW-13.8 Plt Ct-179# [**2103-6-26**] 06:10AM BLOOD WBC-10.8 RBC-4.19* Hgb-12.3* Hct-37.1* MCV-89 MCH-29.4 MCHC-33.1 RDW-13.9 Plt Ct-261 [**2103-6-27**] 06:45AM BLOOD WBC-12.1* RBC-3.96* Hgb-11.7* Hct-34.7* MCV-88 MCH-29.7 MCHC-33.8 RDW-14.1 Plt Ct-333 [**2103-6-28**] 06:35AM BLOOD WBC-12.9* RBC-4.02* Hgb-11.5* Hct-34.5* MCV-86 MCH-28.7 MCHC-33.5 RDW-14.2 Plt Ct-374 [**2103-6-29**] 06:05AM BLOOD WBC-12.2* RBC-3.88* Hgb-11.4* Hct-34.9* MCV-90 MCH-29.3 MCHC-32.7 RDW-14.4 Plt Ct-475* Diff: [**2103-6-23**] 05:30PM BLOOD Neuts-78.2* Lymphs-14.4* Monos-6.2 Eos-0.4 Baso-0.8 [**2103-6-24**] 04:24AM BLOOD Neuts-70 Bands-4 Lymphs-14* Monos-12* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2103-6-25**] 06:40AM BLOOD Neuts-77* Bands-8* Lymphs-4* Monos-8 Eos-0 Baso-0 Atyps-3* Metas-0 Myelos-0 [**2103-6-26**] 06:10AM BLOOD Neuts-77.0* Lymphs-15.1* Monos-6.2 Eos-0.4 Baso-1.4 [**2103-6-27**] 06:45AM BLOOD Neuts-66 Bands-1 Lymphs-18 Monos-13* Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 [**2103-6-28**] 06:35AM BLOOD Neuts-77* Bands-0 Lymphs-17* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [**2103-6-29**] 06:05AM BLOOD Neuts-75* Bands-0 Lymphs-19 Monos-6 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Coags: [**2103-6-23**] 08:42PM BLOOD PT-14.6* PTT-34.7 INR(PT)-1.3* [**2103-6-25**] 06:40AM BLOOD PT-14.9* PTT-31.2 INR(PT)-1.3* Electrolytes: [**2103-6-23**] 05:30PM BLOOD Glucose-104* UreaN-11 Creat-0.6 Na-134 K-3.9 Cl-100 HCO3-26 AnGap-12 [**2103-6-24**] 04:24AM BLOOD Glucose-99 UreaN-7 Creat-0.5 Na-131* K-4.1 Cl-95* HCO3-26 AnGap-14 [**2103-6-25**] 06:40AM BLOOD Glucose-109* UreaN-7 Creat-0.5 Na-133 K-3.2* Cl-99 HCO3-24 AnGap-13 [**2103-6-26**] 06:10AM BLOOD Glucose-114* UreaN-11 Creat-0.6 Na-135 K-4.0 Cl-100 HCO3-26 AnGap-13 [**2103-6-27**] 06:45AM BLOOD Glucose-89 UreaN-13 Creat-0.7 Na-136 K-4.3 Cl-103 HCO3-24 AnGap-13 [**2103-6-28**] 06:35AM BLOOD Glucose-111* UreaN-19 Creat-1.1 Na-138 K-4.5 Cl-102 HCO3-23 AnGap-18 [**2103-6-29**] 06:05AM BLOOD Glucose-99 UreaN-13 Creat-1.1 Na-136 K-4.7 Cl-104 HCO3-23 AnGap-14 LFTs: [**2103-6-23**] 05:30PM BLOOD ALT-38 AST-56* AlkPhos-45 TotBili-0.7 [**2103-6-26**] 06:10AM BLOOD ALT-37 AST-45* AlkPhos-74 TotBili-0.7 Elements: [**2103-6-24**] 04:24AM BLOOD Calcium-7.6* Phos-2.9 Mg-2.1 [**2103-6-25**] 06:40AM BLOOD Calcium-7.8* Phos-2.0* Mg-2.1 [**2103-6-26**] 06:10AM BLOOD Calcium-7.9* Phos-4.2# Mg-2.4 [**2103-6-27**] 06:45AM BLOOD Albumin-2.3* Calcium-7.6* Phos-4.2 Mg-2.2 [**2103-6-28**] 06:35AM BLOOD Calcium-7.7* Phos-4.8* Mg-2.5 Folate/B12: [**2103-6-24**] 04:24AM BLOOD VitB12-834 Folate-6.7 Hep B: [**2103-6-28**] 06:35AM BLOOD HBcAb-PND [**2103-6-24**] 04:24AM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE Tox ScreeN: [**2103-6-23**] 05:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG HCV Ab: [**2103-6-24**] 04:24AM BLOOD HCV Ab-POSITIVE* HCV VIRAL LOAD (Final [**2103-6-26**]): 1,270,000 IU/mL. Urine: [**2103-6-23**] 04:15PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.003 [**2103-6-23**] 04:15PM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2103-6-23**] 04:15PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1 [**2103-6-23**] 04:15PM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG mthdone-NEG Microbiology: [**2103-6-23**] 5:30 pm BLOOD CULTURE **FINAL REPORT [**2103-6-26**]** Blood Culture, Routine (Final [**2103-6-26**]): STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus and [**Female First Name (un) 564**] species. FINAL SENSITIVITIES. 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 _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S Anaerobic Bottle Gram Stain (Final [**2103-6-24**]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Reported to and read back by DR. [**Last Name (STitle) **] [**2103-6-24**] 14:07. Aerobic Bottle Gram Stain (Final [**2103-6-24**]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. [**2103-6-24**] 1:45 pm BLOOD CULTURE Source: Venipuncture #1. Blood Culture, Routine (Preliminary): STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus and [**Female First Name (un) 564**] species. SENSITIVITIES PERFORMED ON CULTURE # 326-0286M [**2103-6-23**]. Anaerobic Bottle Gram Stain (Final [**2103-6-25**]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. [**2103-6-25**] 6:40 am BLOOD CULTURE **FINAL REPORT [**2103-6-28**]** Blood Culture, Routine (Final [**2103-6-28**]): STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus and [**Female First Name (un) 564**] species. SENSITIVITIES PERFORMED ON CULTURE # 326-0286M [**2103-6-23**]. Aerobic Bottle Gram Stain (Final [**2103-6-26**]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Anaerobic Bottle Gram Stain (Final [**2103-6-26**]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. [**2103-6-23**] 4:15 pm URINE Site: CLEAN CATCH **FINAL REPORT [**2103-6-24**]** URINE CULTURE (Final [**2103-6-24**]): NO GROWTH. CT Chest with IV contrast [**2103-6-25**]: Multiple bilateral cavitary and non-cavitary areas of consolidation are noted to vary in size and number. The largest cavitary lesion is in the right middle lobe measuring 3 x 3.5 cm. A right upper lobe cavitary lesion measures 1.3 x 1.5 cm. In addition, there are wedge-shaped areas of parenchymal opacifications in both lower lobes (4:149 on the right and 4:160 in the inferior segment of the left upper lobe). In addition, dense opacification is noted in the basilar segments of both lower lobes which is likely atelectasis associated with the small simple pleural effusions. The pulmonary arteries are patent to the segmental level. The airways are patent down to the subsegmental level. The thyroid gland is unremarkable. There is no axillary lymphadenopathy by CT size criteria. There is a 1.5-cm enlarged subcarinal lymph node. The heart is unremarkable. There is a small simple pericardial effusion. Although this examination was not intended for subdiaphragmatic evaluation, the partially imaged abdomen shows wedge-shaped hypoattenuation of the spleen, consistent with a splenic infarction. OSSEOUS STRUCTURES: The visible osseous structures show no suspicious lytic or blastic lesions or fractures. IMPRESSION: 1. Multiple cavitary and non-cavitary nodules nodules and consolidation in both lungs consistent with septic emboli. Splenic infarct in upper abdomen is likely due to same process. 2. Small bilateral pleural effusions. TTE [**2103-6-26**]: The left atrium is elongated. Late saline contrast is seen in left heart suggesting intrapulmonary shunting. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) 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 a moderate vegetation on the anterior tricuspid leaflet. Moderate [2+] tricuspid regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a very small pericardial effusion. IMPRESSION: Moderate-sized tricuspid valve vegetation with moderate regurgitation. Normal global and regional biventricular systolic function. Late right-to-left transition of agitated saline contrast, most consistent with intrapulmonary shunting. CT Abdomen without IV contrast [**2103-6-28**]: Bilateral pleural effusions are moderate in the visualized lung bases, with passive bibasilar atelectasis. A rounded focal consolidation in the lateral left lower lobe measures 2.1 cm in diameter (image 2:2), compatible with an evolving focus of infection. Small cavitary lesions in the right base are similar in appearance. There is small amount of pericardial effusion. The absence of IV contrast significantly limits evaluation of the intra-abdominal parenchymal organs. In addition, the patient has minimal intraperitoneal fat to separate the visceral organs, limiting assessment of bowel and lymph nodes. Allowing for the limitations, the liver is grossly unremarkable. The spleen is enlarged, measuring 15.4 cm craniocaudally. Persistent hypodensity in the posterior aspect of the spleen, which wedge-shaped morphology most likely represent ongoing evolution of splenic infarct that was previously noted in the chest CT three days ago. The gallbladder, spleen, adrenal glands, and kidneys are grossly unremarkable. The stomach, loops of small bowel and duodenum are patent with oral contrast. There is no evidence of intra-abdominal fluid collection. No free air is noted. Evaluation of intra-abdominal lymphadenopathy is limited, but there are several small celiac lymph nodes. CT PELVIS WITHOUT IV CONTRAST: The urinary bladder is normally distended without focal abnormality. There is a moderate amount of liquid stool in the rectal vault. The colon is otherwise grossly unremarkable, without colonic wall thickening. Limited evaluation of the appendix reviews no gross abnormality (image 2:66). There is no fluid collection or free air in the pelvis. Small amount free pelvic fluid pools in the deep pelvis. Evaluation of lymphadenopathy is limited without IV contrast. BONE WINDOW: There are no suspicious osteolytic or osteosclerotic lesions. Mild L4/L5 posterior disc bulging is noted. IMPRESSION: 1. Persistent wedge-shaped hypodensity in the posterior aspect of the enlarged spleen, representing splenic infarction; differential considerations including sequelae of splenic enlargement or an embolic process. 2. No evidence of intra-abdominal fluid collection to suggest abscess. 3. Moderate bilateral pleural effusions, with moderate bibasilar atelectasis. Persistent evidence of multifocal pneumonia, with similar small cavitary lesions. 4. Fluid within the colon, which is non-specific. LABS PENDING AT THE TIME OF TRANSFER: HepBcAb, Daily Blood Cultures from [**6-24**] - [**6-29**]. Please call [**Telephone/Fax (1) 4645**] for the microbiology lab to obtain final results. Brief Hospital Course: Primary Reason for Hospitalization: Mr. [**Known lastname **] is a 26 y/o male with active IVDA with heroin and oxycodone who presented with dyspnea and fever and was found to have Tricuspid Valve Endocarditis caused by Methicillin Sensitive Staph Aureus (MSSA) with multiple septic emboli to the lungs. . ACTIVE ISSUES: . # Tricuspid Valve Endocarditis: Endocarditis was initially suspected after chest x-ray suggested multifocal pneumonia and blood cultures grew staph aureus. TTE confirmed a vegetation on the tricuspid valve with mild-moderate tricuspid regurgitation. The patient initially received empiric therapy with vancomycin, ceftriaxone, and azithromycin, and after antibiotic sensitivites were known he was switched to IV nafcillin 2g Q4h. Daily EKG's during hospitalization did not reveal any conduction abnormalities. There was no evidence of heart failure. Of note, CT of the chest and abdomen showed a splenic infarct that may have been caused by a septic embolus. No other systemic emboli were detected. It was not clear what the source of this embolus was as TTE did not show any left sided vegetation. TEE was not performed because it would not have changed management, however it is possible that the patient has a vegetation in the left heart that was too small to be seen by TTE but was large enough to cause a septic embolus. Bubble echo did not show a PFO to suggest paradoxical embolism. The patient also reported new seizures 3 weeks prior to this hospitalization. No imaging was performed as he did not have any seizures during the hospitalization and no neurologic abnormalities were detected. Because the patient had intermitten spikes of fever after several days of IV antibiotics, there was a concern that he could have a abscess or fluid collection that required drainage. CT abdomen without contrast on [**6-28**] did not show any evidence of fluid collections. At the time of transfer from [**Hospital1 18**] the patient was afebrile although on tylenol and ibubrofen. He was persistently tachycardic from the 80's to low 100's although this was improved from prior when he was consistently from 110 to 150. His respirations were still rapid, ranging from 26-32. He has pleuritic pain in his right side in the mid axillary line below the nipple. This pain appears to correlate with a focus of infection on Chest CT. The pain causes the patient to tend towards rapid shallow breathing to reduce pleuritic pain. This pain has been well controlled with oxycodone 10mg Q4h, acetaminophen 1000mg q6h, and ibuprofen 400mg Q8h. The patient will likely require 4-6 weeks of IV antibiotics although discretion [**Name6 (MD) **] accepting MD. . Hepatitis C: When the patient presented he had a platelet count of 65, and given his history of IV drug use he was tested for Hepatitis C. Viral load was 1,270,000. Given his acute illness, he was not started on any antiviral therapy. However he should follow-up with an infectious disease physician after he finishes his course of IV antibiotics. The patient was counseled about the mechanisms of transmission of HCV and advised to avoid sharing toothbrushes, razors, needles, and any other blood exposed objects. After acute illness has resolved he will likely require vaccination for hepatitis A, and possibly B as his surface antibody was borderline. . # Thrombocytopenia: He had an admission PLT of 65, however this quickly normalized and his platelets were prior to discharge. It is unclear whether this was related to hepatitis C, sepsis or another etiology. . # Thursh: Felt likely secondary to abx, although cannot rule out possiblity that HIV is invovled, patient is refusing testing. Patient will need oral swish and swallow until symptoms resolve . # Substance abuse: Prior to admission he was actively injecting heroin and oxycodone. Urine drug screen at the OSH showed cocaine however the patient denies using cocaine. Social work and addiction consults were ordered. Non-narcotic pain medications were used initially, however the patient had severe pleuritic pain that caused rapid shallow breathing and therefore oxycodone was added to his pain regimen. The patient was strongly urged to go to drug rehab after his acute illness is managed. . # Tachycardia: This was most likely multifactorial with contributions from opiate withdrawal, fever/infection and pain. . TRANSITIONAL ISSUES: . # Labs pending at the time of transfer: HepBcAb, Daily Blood Cultures from [**6-24**] - [**6-29**]. Please call [**Telephone/Fax (1) 4645**] for the microbiology lab to obtain final results. . # Need for HIV testing: Given the patient's IV drug use and hepatitis C infection he is at high risk for HIV infection. He was counseled about this on several occassions throughout the hospitalization and repeatedly refused. Prior to transfer he decided that he would consent to testing prior to his final discharge to rehab. He should be urged to have testing as soon as possible. . # As outlined above, patient will need follow-up for new diagnosis of Hepatitis C. After acute illness has resolved he will likely require vaccination for hepatitis A, and possibly B as his surface antibody was borderline. . Medications on Admission: None Discharge Medications: 1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 4. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 5. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 6. nafcillin 2 gram Recon Soln Sig: Two (2) grams Intravenous every four (4) hours: Start day [**2103-6-25**] - to end in [**3-21**] weeks per your ID specialists. Discharge Disposition: Extended Care Discharge Diagnosis: Primary -Tricuspid Valve Endocarditis -Staph Aureus Bacteremia Secondary -Hepatitis C infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname **], You initially went to the hospital because you were short of breath. At the outside hospital they found that you had fever as well as signs of infection in your lungs. You were then transferred here to [**Hospital1 18**] for care. We found a bad staph infection in your blood. The staph infection had spread to one of your heart valves and then to your lungs. We started you on strong IV antibiotics and also had the infectious disease specialists help with your care. You will at least 4 weeks of IV antibiotics to be sure that the infection clears from your heart valve. During the hospitalization we also found that you have a viral infection that affects your liver called Hepatitis C. This infection is treatable, but there is no cure. You were not started on treatment for Hepatitis C during your hospitalization. Once you have finished your antibiotics you will need to see an infectious disease specialist. Right now it looks like you are not having any symptoms from the hepatitis C, but it is important that you see the infectious disease doctor because they may be able to prevent future damage to your liver. Hepatitis C is spread through blood and occasionally through sexual contact. For this reason, it is very important you avoid sharing toothbrushes, razors, needles or anything else that is exposed to your blood. As we discussed while you were here, it is very important you get tested for HIV. Hepatitis C and HIV often travel together because they are spread in similar ways. Please consider getting tested. HIV is a treatable disease, but the sooner that treatment is started, the better the results. Finally, it is very important that once you have finished your IV antibiotics that you start drug rehab. The risks of continuing drug use include another infection, overdose, or even death. I cannot overemphasize how important this is. It is the most important thing that you can do for your health. When you leave the hospital: - START Acetaminophen 1000 mg every six hours - START OxycoDONE (Immediate Release) 10 mg PO/NG every four hours as needed for pain - START Heparin 5000 UNIT SC three times a day while you are immobile - START Ibuprofen 400 mg every 8 hours - START Nafcillin 2 g IV every four hours (start date was [**2103-6-25**], to end in [**3-21**] per your hospital's ID specialists) - START Nystatin Oral Suspension 5 mL PO four times a day until your symptoms resolve We did not make any other changes to your medications, so please continue to take them as you normally have been. Followup Instructions: You will need to see an Infectious Disease Specialist and establish a primary care doctor. We did not schedule you with any of the physicians at [**Hospital1 18**] because you requested to have doctors [**Name5 (PTitle) **] to [**Name5 (PTitle) **]. Please make sure that you have appointments scheduled before you leave the hospital in New [**Location (un) **].

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Discharge summary

report

Admission Date: [**2112-12-15**] Discharge Date: [**2112-12-23**] Date of Birth: [**2042-7-28**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3556**] Chief Complaint: Transfer from OSH for multiple medical problems Major Surgical or Invasive Procedure: -Percutaneous tracheostomy tube placement -- Drs. [**Last Name (STitle) 13670**] and [**Name5 (PTitle) **] [**2112-12-19**] -Percutaneous gastrostomy tube under direct endoscopic guidance - Drs. [**Last Name (STitle) 13670**] and [**Name5 (PTitle) **] [**2112-12-19**] History of Present Illness: Mr. [**Known lastname 90989**] is a 70yoM recently hospitalized at [**Hospital1 18**] from [**2112-11-11**] to [**2112-11-23**] for bilateral subdural hematoma s/p cranio who now presents from OSH after a complicated course for CVA, acute renal failure, and respiratory failure. He was previously very healthy until his presentation to [**Hospital1 18**] in [**Month (only) 359**] when he was found to have bilateral SDH after a mechanical fall. He had bilateral craniotomy on [**11-13**] and initially did well post-operatively, but then became hypoxic, tachycardic, febrile, tachypneic, and hypertensive with b/l pulmonary infiltrates on CXR. He was transferred to MICU and was treated with labetolol gtt and IV lasix. His BP and oxygenation improved and he was weaned to nasal cannula. Of note, a CXR prior to discharge to evaluate interval changes was formally read as possible infiltrate vs septic emboli. Given he was afebrile and had no supplemental O2 requirement by time of discharge, this finding was felt to be inconsistent with his clinical picture and he was discharged with plans to repeat CXR as outpatient for f/u. . Two days after discharge, he developed SOB and fatigue. He presented to OSH ED where he was febrile and had CXR with bilateral interstitial infiltrates. CT PE was negative for PE. He was admitted for treatment of pneumonia and treated with Vanc/Zosyn/Azithromycin. Sputum cultures had no growth. He was transferred to the ICU for increasing O2 requirement. He was also noted to have new dysphagia and he was made NPO and started on TPN. CXR showed b/l intersitial vs intra-alveolar infiltrates. He was diuresed but had no improvement in his O2 requirement. On [**12-5**] Zosyn was changed to Cefepime. He also had periods of significant hypertension with SBP > 200. He became progressively SOB and was started on BiPap but then developed respiratory arrest. He was intubated, received CPR and had ROSC within 2-3 minutes. Bronch washings grew [**Female First Name (un) 564**]. . He was sedated with propofol from [**12-5**] to [**12-9**]. By [**12-11**] he continued to be unresponsive and spike fevers. He had a CT head/chest/abdomen/pelvis, and head CT showed left cerebellar nonhemomrrhagic stroke, with ?brainstem involvement. . He also developed acute renal failure with creat increasing from 1.6 to 4.1 on [**2112-12-8**]. His Na level also increased with dilute urine, suggesting diabetes insipidus. He was treated with hypotonic fluid and SC desmopressin. He was also noted to have mildly elevated serum ammonia of unknown etiology and was treated with lactulose. . Given his complicated course, his family requested that he be transferred to [**Hospital1 18**] for further evaluation and management. . On arrival to the MICU, pt is intubated but alert, although does not appear to respond to voice. Initial vitals were T 100.9, HR 77, BP 128/51, RR 20 and O2 sat 93% on CMV with FIO2 0.4. . 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: - Bilateral subdural hematomas with midline shift, admitted to NSurg for bilateral mini-craniotomies and burr holes in [**11/2112**]; course complicated by hypoxia (thought to be aspiration + flash edema), difficult to control supraventricular tachycardia (started on Amiodarone, Labetalol, and Metoprolol), severe hypertension, and thrombocytosis - Essential thrombocytosis on Anagrelide for past 20 yrs and Aspirin, per family he failed Hydroxyurea. Has a Hematologist in the VA system, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 90983**] [**Telephone/Fax (1) 90984**] or [**Telephone/Fax (1) 90985**]. Denies episodes of hemorrhage in the past - HTN - HLD - Bilateral cataract ops - Fractured left 3 ribs c/b pneumthroax following fall 3 years ago Social History: Prior to the events described in HPI, pt lived with wife, worked for restaurant (>60 hours/week per family). Former 1.5 ppd smoker, quit 3 yrs ago. 2 glasses of wine per night, no illicits. Has daughter [**Name (NI) **] home [**Telephone/Fax (1) 90986**], cell [**Telephone/Fax (1) 90990**] Family History: Mother - bladder ca Father - died of PE Sibs - 3 brothers with ca - pancreatic, lung ca and brain ca Physical Exam: T 100.9, HR 77, BP 128/51, RR 20 and O2 sat 93% on CMV with FIO2 0.4. Gen: Intubated, awake but not interactive HEENT: PERRL, MMM, no oropharyngeal lesions Cardiac: Irregular, no m/r/g Lungs: Rhonchi in upper lobes bilat, lower lungs with decreased breath sounds Abdomen: soft, NTND NABS no hepatomegaly Extremities: WWP, no c/c/e Neuro: Awake but not interactive, does not track or follow commands. Does not withdraw to noxious stimuli. Spontaneous movement of right extremities. Pertinent Results: CBC: [**2112-12-15**] 09:55PM BLOOD WBC-22.3*# RBC-2.56* Hgb-7.6* Hct-24.5* MCV-96 MCH-29.7 MCHC-31.0 RDW-15.4 Plt Ct-489*# [**2112-12-18**] 02:08AM BLOOD WBC-19.7* RBC-2.56* Hgb-7.7* Hct-24.1* MCV-94 MCH-30.1 MCHC-32.0 RDW-15.7* Plt Ct-764* [**2112-12-21**] 03:52AM BLOOD WBC-17.8* RBC-2.57* Hgb-7.8* Hct-23.7* MCV-92 MCH-30.5 MCHC-33.1 RDW-15.9* Plt Ct-1040* . BMP: [**2112-12-15**] 09:55PM BLOOD Glucose-133* UreaN-92* Creat-3.0*# Na-154* K-3.7 Cl-124* HCO3-20* AnGap-14 [**2112-12-16**] 05:10PM BLOOD Glucose-185* UreaN-94* Creat-2.8* Na-153* K-3.9 Cl-121* HCO3-23 AnGap-13 [**2112-12-17**] 08:30AM BLOOD Glucose-159* UreaN-88* Creat-2.6* Na-150* K-3.5 Cl-120* HCO3-22 AnGap-12 [**2112-12-18**] 11:56AM BLOOD Glucose-109* UreaN-73* Creat-2.1* Na-146* K-4.1 Cl-117* HCO3-23 AnGap-10 [**2112-12-19**] 12:02PM BLOOD Glucose-96 UreaN-65* Creat-2.1* Na-145 K-3.8 Cl-111* HCO3-27 AnGap-11 [**2112-12-21**] 03:52AM BLOOD Glucose-112* UreaN-49* Creat-1.8* Na-139 K-3.6 Cl-104 HCO3-28 AnGap-11 . LFTs: [**2112-12-16**] 08:24PM BLOOD ALT-34 AST-25 CK(CPK)-120 AlkPhos-92 TotBili-0.2 . Cardiac Enzymes: [**2112-12-16**] 12:00PM BLOOD CK-MB-2 cTropnT-0.05* [**2112-12-16**] 08:24PM BLOOD CK-MB-2 cTropnT-0.04* . Serum Ammonia: [**2112-12-16**] 04:51PM BLOOD Ammonia-96* [**2112-12-19**] 11:41AM BLOOD Ammonia-23 . Urine Studies: [**2112-12-15**] 09:56PM URINE Hours-RANDOM Creat-69 Na-13 K-16 Cl-14 [**2112-12-18**] 04:31PM URINE Hours-RANDOM UreaN-483 Creat-26 Na-87 K-17 Cl-104 TotProt-20 Prot/Cr-0.8* [**2112-12-15**] 09:56PM URINE Osmolal-526 [**2112-12-18**] 04:31PM URINE Osmolal-422 [**2112-12-21**] 02:41PM URINE Osmolal-407 . MICROBIOLOGY: [**2112-12-15**] 9:56 pm URINE Source: Catheter. **FINAL REPORT [**2112-12-17**]** . URINE CULTURE (Final [**2112-12-17**]): NO GROWTH. [**2112-12-15**] 9:56 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [**2112-12-16**]** . CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2112-12-16**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). . [**2112-12-16**] 12:19 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2112-12-18**]** GRAM STAIN (Final [**2112-12-16**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final [**2112-12-18**]): RARE GROWTH Commensal Respiratory Flora. YEAST. SPARSE GROWTH. GRAM NEGATIVE ROD(S). RARE GROWTH. . IMAGING: CXR [**2112-12-15**]: IMPRESSION: AP chest compared to [**11-23**]: New endotracheal tube is in standard placement, nasogastric tube passes below the diaphragm and out of view, left PIC line is traceable to the upper SVC. No pneumothorax. Pleural effusion is small on the right if any. Lung volumes are quite low and lungs are generally opacified and in a heterogeneous fashion, more so inferiorly. Process is either diffuse pneumonia or pulmonary edema, even though heart is normal in size. . TTE [**2112-12-17**]: The left atrium is mildly dilated. No thrombus/mass is seen in the body of the left atrium. No atrial septal defect is seen by 2D or color Doppler. 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. A mid-cavitary gradient is identified. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with normal free wall contractility. The diameters of aorta at the sinus, ascending and arch levels are normal. 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. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2112-11-16**], no change. . MRI BRAIN [**2112-12-17**]: TECHNIQUE: T1 sagittal and FLAIR, T2 susceptibility and diffusion axial images of the brain were acquired. Correlation was made with CT of [**2112-11-27**]. FINDINGS: An infarct is visualized in the left cerebellum with a small hyperintensity in the right cerebellum indicative of bilateral cerebellar infarcts. There infarcts are slightly hyperintense on diffusion images and ADC map indicative of subacute to early chronic infarcts. A small area of diffusion abnormality in the anterior right pons also does not have corresponding ADC abnormality and could be due to a subacute infarct. Subacute infarct is also seen in the left posterior corpus callosum. There is a small area of restricted diffusion seen in the frontal lobe which appears to have corresponding low signal intensity on ADC map indicative of an acute infarct. This is best visualized on series 7 and 8 image 17. A small left-sided subdural hematoma is identified which measures approximately 3 mm without mass effect. Left-sided postoperative changes in craniotomy are noted. A craniectomy defect in the right frontal region is also identified. IMPRESSION: Subacute infarcts in the cerebellum and pons. A small subcortical infarct in the right frontal lobe. Tiny left subdural. Brief Hospital Course: 70 y/o previously healthy male until recent complicated medical course with SDH s/p cranio, transferred from OSH for new cerebellar CVA, [**Last Name (un) **], respiratory failure and altered mental status/encephalopathy. . # AMS: Pt's mental status waxed/waned but overall improved gradually during hospitalization. He became more alert, was able to follow commands, and answered yes/no questions. He was evaluated by the neurology service, who felt that his mental status was unlikely to be due to his recent CVAs, and more likely encephalopathy due to multiple medical problems. . # CVA: OSH records noted cerebellar infarcts detected on non-contrast head CT. MRI of the brain showed subacute small infarcts in the cerebellum and pons. Per the neurology team, these infarcts were likely cardioembolic given their size and location and pt's known atrial fibrillation. They recommended treatment with anticoagulation, and he was started on ASA and coumadin. . # Respiratory failure: On transfer from OSH pt was intubated on CMV. On HD#2 he was transitioned to PSV and passed SBT. He was extubated, however over several hours he had difficulty clearing airway secretions and developed a respiratory alkalosis and his mental status worsened, requiring re-intubation. He had tracheostomy placed on HD#5, although the neurology team felt that this respiratory failure was more related to his mental status and pneumonia than to his CVAs and was hopeful that as his toxic/metabolic encephalopathy improves he may ultimately be able to have the trach removed. . # Fevers/leukocytosis: Per OSH records pt had been febrile for 2 weeks, and on admission was febrile to 102 with WBC 22. Blood and urine cx showed no growth. CXR showed diffuse pneumonia vs pulmonary edema. Given he had been intubated for several days prior to transfer, he was treated empirically for ventilator associated pneumonia with IV vancomycin/cefepime/ciprofloxacin. Sputum cx grew fungus and rare GNRs, and his antiobiotics were narrowed to IV cefepime. His fevers resolved and his gradually trended down from 22.3 to 17.8 on day of discharge. Cefepime will continue until [**12-25**]. # [**Last Name (un) **]: Per OSH records, pt's creatinine had increased from 1.0 to 4.0 following episode of respiratory arrest. He was evaluated by the renal service who felt his renal failure was likely due to ATN given his bland urine sediment. His creatinine gradually improved throughout hospitalization and on day of discharge was 1.8. . # Afib: Patient was in atrial fibrillation on admission, and had occasional episodes of bradycardia (HR to 30s) as well as episodes of atrial tachycardia with HR 150s. He remained hemodynamically stable during episodes. His metoprolol was increased to 50mg PO QID and his HR and BP remained stable. Rate currently controlled on metoprolol 50mg QID with diltiazem 30 mg QID. Restarted coumadin prior to discharge, with goal INR [**3-10**]. Discharge INR 2.0 # Hypernatremia: Na now wnl. Initially presented with high serum Na with low urine osm suggest diabetes inspidius, likely central DI given SDH, CVA and improved with DDAVP. Had trial off DDAVP, Na remains normal. # Anemia ?????? Pt received 1 pRBC transfusion. Hemodynamically stable. Etiology unclear at this time. Hemolysis labs reassuring. Retic count 1.2%, suggesting insufficient production. # Essential thrombocytosis: Plt count rising on home anegrilide, dose increased yesterday. Pt's heamtologist suggested to perform CBC at discharge facility and outpt followup for ET and anegrilide dosing. # Nutrition: PEG placed. Speech and Swallow held off on swallow eval and passey muir valve placement until MS improves and secretions decreased. This will be pursued at rehab facility. He will continue on TF as prescribed. # Sacral decubitus ulcer: Developed at OSH. Was followed by wound care. Will need continued surveillence. # Rehabilitation: Will likely require PT/OT at discharge facility. Medications on Admission: Medications: 1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. multivitamin Tablet Sig: One (1) Tablet PO once a day. 4. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO once a day: Continue taking this if you were taking before admission, otherwise don't. 5. vitamin A Oral 6. Vitamin C Oral 7. Vitamin B Complex Oral 8. anagrelide 1 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 9. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 10. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO four times a day. Disp:*120 Tablet(s)* Refills:*2* 12. phenytoin sodium extended 100 mg Capsule Sig: 1.5 Capsules PO TID (3 times a day). Disp:*135 Capsule(s)* Refills:*2* 13. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 16. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 17. amiodarone 400 mg Tablet Sig: One (1) Tablet PO three times a day for 3 days: Take 3 times a day on [**10-19**], [**11-25**], and [**11-26**]. Then, on [**11-27**] only take 400 mg daily until your Cardiology follow up. . Disp:*9 Tablet(s)* Refills:*0* 18. amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day: Take 3 times a day on [**10-19**], [**11-25**], and [**11-26**]. Then, on [**11-27**] only take 400 mg daily until your Cardiology follow up. . Disp:*30 Tablet(s)* Refills:*2* . Medications on Transfer: -Anagrelide 0.5mg PO BID -ASA 81mg OGT daily -chlorhexidine 15mL PO BID -desmopressin 1mcg SC q12hours -enalapril 5mg PO BID -Fluconazole 200mg IV q48 hours (received [**12-14**]) -Heparin 5000U SC TID -Lactulose 20gm OGT q12 hours -Levofloxacin 750mg IV q48 hours (received [**12-15**]) -Methylprednisolone 20mg IV BID -Metoprolol tartrate 75mg OGT q8 hours -Nystatin [**Numeric Identifier 78144**] units Swish QID -Pantoprazole 40mg IV q12 hours -Acetaminophen 650mg OGT q6hours prn pain/fever -Mucomyst 5mL ETT q6hours prn 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: Please give via PEG tube. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation: Please give via PEG tube. 3. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day): Please give via PEG tube. 4. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever: Please give via PEG tube. 6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please give via PEG tube. 7. anagrelide 1 mg Capsule Sig: One (1) Capsule PO twice a day: Please give via PEG tube. 8. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day: Please give via PEG tube. 9. furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day: Please give via PEG tube. Hold for SBP<100. 10. cefepime 2 gram Recon Soln Sig: Two (2) gram Injection Q12H (every 12 hours) for 5 days: Take until [**12-25**] to complete 8 day course. 11. multivitamin Tablet Sig: One (1) Tablet PO once a day: Please give via PEG tube. 12. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day: Please give via PEG tube. 13. warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day. 14. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 15. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO four times a day: Please hold for HR<60 or SBP<100. 16. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**] Discharge Diagnosis: Stroke Respiratory failure Acute kidney injury Hypernatremia Essential thrombocytosis Atrial fibrillation Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You were transferred to [**Hospital1 18**] from [**Doctor Last Name 38554**] Hospital because you had a stroke, and for management of several medical problems including kidney failure, fevers, and high sodium levels. While you were here, you had an MRI of the brain and the neurology service evaluated you. Based on your MRI, you had several small strokes, likely due to your atrial fibrillation. We started aspirin and coumadin, which you should continue indefinitely to prevent future strokes. We had to place a tracheostomy tube to help you breathe and a feeding tube to help you eat. We hope that through physical and occupational therapy at a rehab facility, you will continue to recover. . You also had a pneumonia, which was likely the cause of your fevers. We changed your antibiotic from levofloxacin to a stronger antibiotic (cefepime), which you should continue until [**12-25**] to complete an 8 day course. . Your kidney failure was likely due to the episode of respiratory arrrest you experienced at Addison-[**Doctor Last Name **]. Your kidney function improved while you were here, and we expect it will return to normal. Your sodium levels also improved. . Your platelet count increased while you were here. We spoke with your outpatient hematologist, Dr. [**Last Name (STitle) 45462**], who recommended that you have your platelet count checked at your rehab facility and faxed to her office. She will then adjust your medications as needed. . It was a pleasure taking care of you at [**Hospital1 18**], and we wish you a speedy recovery. . Please note the following changes to your medications: -START coumadin 5mg daily, and have your coumadin levels monitored by your rehab facility -START diltiazem 30 mg four times a day for improved heart rate control. -START metoprolol 50 mg four times a day for improved heart rate control. Stagger with diltiazem doses. -STOP labetolol. This medication was stopped at Addison-[**Doctor Last Name **], and your blood pressure has been well controlled here without it. -STOP lisinopril. You may need to restart this medication once your kidney function improves. Please follow up with the physicians at your rehab facility about when to restart this medication. -STOP phenytoin. This medication was stopped at Addison-[**Doctor Last Name **]. -STOP amiodarone. This medication was stopped at Addison-[**Doctor Last Name **] and your heart rate has been well controlled without it. Please follow up with your cardiologist about whether to resume taking this medication. . We made no other changes to your medications. Please see the attached page for your complete list of current medications. Followup Instructions: Department: RADIOLOGY When: TUESDAY [**2112-12-27**] at 1 PM 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: TUESDAY [**2112-12-27**] at 1:45 PM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 9151**], MD [**Telephone/Fax (1) 1669**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . Department: CARDIAC SERVICES When: FRIDAY [**2113-1-6**] at 1 PM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**] Completed by:[**2112-12-23**]

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icd9cm

[ [ [] ] ]

[ "31.1", "43.11", "33.23", "96.72", "96.6" ]

icd9pcs

[ [ [] ] ]

19650, 19750

11453, 15432

354, 625

19900, 19900

5822, 6901

22723, 23671

5200, 5303

17974, 19627

19771, 19879

15458, 17398

20036, 21629

5318, 5803

21658, 22700

3627, 4074

6918, 11430

267, 316

653, 3608

19915, 20012

17423, 17951

4096, 4874

4890, 5184

30,575

186,455

7396

Discharge summary

report

Admission Date: [**2205-5-28**] Discharge Date: [**2205-6-1**] Date of Birth: [**2154-5-25**] Sex: M Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 16851**] Chief Complaint: hypercarbic respiratory failure Major Surgical or Invasive Procedure: Intubation History of Present Illness: The pt is a 51 yo with PMH notable for COPD on intermittent home O2, OSA on CPAP, obesity hypoventilation syndrome, and chronic pain on narcotics who presented with increasing somnelence and developed hypercarbic respiratory failure. Mr. [**Known lastname 14323**] was in his USOH until approximately 3 days ago when he developed progressive somnelence. His family noted that he was very somlenent today, so they called 911. When he arrived in the ED, initial VS were: T98.8 HR110 BP142/67 RR14 O270% on RA. Initial ABG was notable for 7.30/80/61/41 (unclear if on O2). He was put on a non-rebreather with sats responding to the 90s. Pt was arousable to voice, answering simple yes/no questions. He denied fever, chills, cough. His lungs were felt to be clear. Because there was a question of him taking 80mg [**Hospital1 **] oxycontin plus PRN oxycodone (home dose only 40mg [**Hospital1 **] plus PRN), he received a dose of narcan with some response, so pt was placed on a narcan drip. He was also started on BiPAP. However, due to continued somnolence, worsening hypercarbia on ABG (7.30/61/80/41 to 7.26/295/95/45), and transient hypotension to 90s, pt was intubated. Pt was not given any abx, steroids or nebulizers in the ED. CXR showed some haziness of the costophrenic angles bilaterally, but no clear effusions or consolidations. VS prior to transfer were P88, RR18, BP112/64, O2Sat: 100%. On arrival to the MICU, patient's VS were T99.4, P96, BP159/85, satting 95% on Assist Control (Tv500 R20 Peep10 60%FiO2). Past Medical History: - Type 2 DM has been followed at [**Last Name (un) **] (last A1c 8.0 [**2204-10-8**]) - OSA on CPAP at home - Hepatits C - s/p aborted course of interferon - Major depressive disorder, ? of schizophrenia and bipolar disorder - Hypertension - Bilateral avascular necrosis of femoral heads s/p hip replacements in '[**79**] and '[**85**] - s/p L1/L2 kyphoplasty after fall [**6-25**] - s/p left distal radius fracture after fall [**6-25**] - Bilateral lower extremity edema, thought to be secondary to venous stasis - DJD of his back - Osteoporosis - Morbid Obesity - Schatski's ring Social History: On disability, lives with his mother, attends a day program. - Tobacco: Smokes [**12-21**] ppd for > 10yrs - Alcohol: no EtoH for 15 years - Illicits: Stopped IVDA in [**2186**] after 3 years of use, did take cocaine with heroine. Has not used since then. Family History: father with DM and CAD Physical Exam: Admission Exam: General: awake, alert, distressed at intubation, agitated HEENT: Sclera anicteric, MMM Neck: supple, JVP unable to be assessed due to body habitus CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops - Heart sounds distant due to body habitus Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi - challenging to assess due to body habitus and positioning Abdomen: soft, non-distended, non-tender, bowel sounds present GU: foley in place Ext: Warm, well perfused, 2+ pulses, [**11-19**]+ bilateral LE edema Neuro: opens eyes to voice, turns head on command, responds to yes/no questions, squeezes fingers bilaterally, wiggles toes bilaterally Discharge Exam: VS: 97.9 165/92 115 21 96% on Bipap GEN: nad, sitting up in chair eating breakfast HEENT: abrasion on bridge of nose NECK: supplse CHEST: ctab CV: tachy no m/r/g ABD: soft, nt/nd EXT: +2 pitting edema to knees (chronic, stable) Pertinent Results: Admission Labs: [**2205-5-28**] 12:30PM BLOOD WBC-11.2*# RBC-3.91* Hgb-11.8* Hct-36.4* MCV-93 MCH-30.1 MCHC-32.3 RDW-15.7* Plt Ct-160 [**2205-5-28**] 12:30PM BLOOD Neuts-90.6* Lymphs-6.0* Monos-2.7 Eos-0.4 Baso-0.3 [**2205-5-29**] 04:30AM BLOOD PT-12.0 PTT-24.1* INR(PT)-1.1 [**2205-5-28**] 12:45PM BLOOD Glucose-106* UreaN-41* Creat-1.2 Na-137 K-4.2 Cl-94* HCO3-35* AnGap-12 [**2205-5-28**] 12:45PM BLOOD proBNP-1420* [**2205-5-29**] 04:30AM BLOOD Calcium-9.4 Phos-2.6* Mg-1.4* [**2205-5-28**] 12:36PM BLOOD Lactate-1.6 Tox: [**2205-5-28**] 12:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2205-5-28**] 01:30PM URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG Initial blood gasses: [**2205-5-28**] 12:37PM BLOOD Type-ART pO2-61* pCO2-80* pH-7.30* calTCO2-41* Base XS-8 [**2205-5-28**] 02:05PM BLOOD Rates-/12 FiO2-100 pO2-295* pCO2-95* pH-7.26* calTCO2-45* Base XS-11 AADO2-324 REQ O2-59 Intubat-NOT INTUBA Vent-SPONTANEOU [**2205-5-28**] 03:59PM BLOOD Type-ART Rates-20/ PEEP-10 FiO2-100 pO2-193* pCO2-70* pH-7.36 calTCO2-41* Base XS-11 AADO2-451 REQ O2-77 -ASSIST/CON Intubat-INTUBATED [**2205-5-29**] 10:41AM BLOOD Type-ART Temp-37.4 Rates-/12 Tidal V-500 FiO2-40 pO2-94 pCO2-76* pH-7.38 calTCO2-47* Base XS-15 -ASSIST/CON Intubat-INTUBATED Urine: [**2205-5-28**] 01:30PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006 [**2205-5-28**] 01:30PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR [**2205-5-28**] 01:30PM URINE RBC-<1 WBC-3 Bacteri-FEW Yeast-NONE Epi-0 Micro: Blood cultures and MRSA screen are negative [**5-28**] EKG: Artifact is present. Sinus tachycardia. Low voltage in the precordial leads. Compared to the previous tracing of [**2204-11-24**] the rate is faster. [**5-28**] CXR: IMPRESSION: Bilateral parenchymal opacities, worse at the bases, left greater than right, suggestive of underlying edema or bilateral infection superimposed on atelectasis. PA and lateral with better inspiratory effort may help further characterize. [**5-28**] CXR: FINDINGS: Single portable view of the chest is compared to previous exam from earlier the same day at 12:35 p.m. Interval placement of nasogastric tube is seen, noting that the tube can only be identified to the mid portion of the mediastinum and should be advanced. Endotracheal tube tip is approximately 5 cm from the carina. Otherwise, there has been no change. Brief Hospital Course: 51 yo M with h/o OSA, COPD, obesity hypoventilation, and chronic pain on narcotics, who presented with increasing somnelence and developed hypercarbic respiratory failure. Active issues: # Hypercarbic respiratory failure: Likely multifactorial with concurrent narcotic/benzo use and obestity hypoventialtion on top of poor substrate with COPD/OSA. Reportedly responded to narcan in ED, but became hypercarbic with high FiO2. [**Month (only) 116**] be due to decreased respiratory drive from high oxygen. Possible PNA as pt with cough and CXR wet and so levofloxacin x 5 days was completed during admission. Pt was brought up to ICU after intubation in ED. His respiratory status improved and pt was extubated approximately 16 hrs after admission. He was transitioned from NC to room air without complication. He was given albuterol/ipratropium nebs PRN. On general medicine floor patient's respiratory status remained at his baseline with no further episodes of hypoxia. # Somnelence: Almost certainly from hypercarbia. See above. With improvement in respiratory status, pt became increasingly awake and alert and returned to baseline normal function. Chronic issues: # Chronic pain: Significant chronic hip pain from bilateral necrosis/replacement. Also with chronic knee pain. On extensive narcotic regimen including oxycontin 40 po tid with oxycodone 10q6 prn breakthrough. Narcotics were held for entirety of ICU stay due to concern for sedation and pain was well-controlled with tylenol. On arrival to general medicine pt was restarted on prn oxy only. This did not adequately control his pain and so he was restarted on 40mg [**Hospital1 **] oxycontin with improved pain control and without change in respiratory status. # Psych: Signficant psych history including concern for schizophrenia. Outpatient med list includes seroquel and risperdal. Also on buspar and xanax for anxiety. Per mother, is in process of transitioning from seroquel to risperdal. Buspar, Xanax and seroquel were held during ICU stay due to concern for sedation. Risperdal was continued per home regimen. Xanx was resumed on arrival to gen med at a lower dose and frequency. Patient will need to address these changes with his psychiatrist. # Diabetes: Home meds (metformin, glipizide, novolog 70/30) were held. Pt was placed on humalog insulin sliding scale. He will resume home meds on discharge. # HTN: Contiued home regimen (amlodipine, metoprolol, losartan, and HCTZ). Patient still hypertensive throughout admission. Possibly opioid withdrawl? He should follow up with his PCP for possible medication adjustment. # HCV: Failed interferon course. Outpatient FU as directed. Medications on Admission: ALPRAZOLAM 2 mg PO QID (takes 1 tab [**Hospital1 **]) AMLODIPINE 5 mg PO daily ATORVASTATIN 40 mg PO daily BIPAP - Pressure 20/16 qhs, Use with heated humidification For treatment of OSA. Patient is using regularly and has significant clinical benefit with treatment. BUSPIRONE 15 mg PO qAM and 30mg PO qHS GLIPIZIDE 10 mg PO daily (takes [**Hospital1 **]) INSULIN ASPART [NOVOLOG MIX 70-30] 40 units [**Hospital1 **] LOSARTAN-HYDROCHLOROTHIAZIDE - 100 mg-12.5 mg PO daily METOPROLOL SUCCINATE [TOPROL XL] - 100 mg Tablet Extended Release daily OXYCODONE - 10 mg PO every 6 hours prn OXYCODONE [OXYCONTIN] 40 mg Tablet Extended Release 12 hr PO TID QUETIAPINE [SEROQUEL] - 600 mg PO qhs RISPERIDONE - 1mg PO qAM and 2mg qPM (hasn't started yet, but is transitioning to) ALBUTEROL MDI prn ATROVENT MDI prn METFORMIN 850 tid with meals Discharge Medications: 1. atorvastatin 40 mg tablet Sig: One (1) tablet PO DAILY (Daily). 2. risperidone 1 mg tablet Sig: One (1) tablet PO QAM (once a day (in the morning)). 3. risperidone 2 mg tablet Sig: One (1) tablet PO QHS (once a day (at bedtime)). 4. amlodipine 5 mg tablet Sig: One (1) tablet PO DAILY (Daily). 5. bisacodyl 5 mg tablet,delayed release (DR/EC) Sig: Two (2) tablet,delayed release (DR/EC) PO DAILY (Daily) as needed for constipation. 6. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. 7. docusate sodium 100 mg capsule Sig: One (1) capsule PO BID (2 times a day) as needed for constipation. 8. senna 8.6 mg tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. oxycodone 5 mg tablet Sig: 1-2 tablets PO Q6H (every 6 hours) as needed for pain. 10. alprazolam 1 mg tablet Sig: One (1) tablet PO BID (2 times a day) as needed for ANXIETY. 11. oxycodone 40 mg tablet extended release 12 hr Sig: One (1) tablet extended release 12 hr PO Q12H (every 12 hours). 12. metoprolol succinate 100 mg tablet extended release 24 hr Sig: One (1) tablet extended release 24 hr PO once a day. 13. losartan-hydrochlorothiazide 100-12.5 mg tablet Sig: One (1) tablet PO once a day. 14. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every six (6) hours as needed for wheeze. 15. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig: One (1) puff Inhalation every six (6) hours as needed for wheezing. 16. levofloxacin 750 mg tablet Sig: One (1) tablet PO Q 24H (Every 24 Hours) for 5 days. Disp:*1 tablet(s)* Refills:*0* 17. glipizide 10 mg tablet Sig: One (1) tablet PO twice a day. 18. insulin aspart 100 unit/mL Solution Sig: Forty (40) units Subcutaneous twice a day. 19. metformin 850 mg tablet Sig: One (1) tablet PO three times a day. Discharge Disposition: Home Discharge Diagnosis: Hypoxic respiratory failure 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 do not increase your pain medication regimen without discussing it with Dr. [**Last Name (STitle) 2204**]. Followup Instructions: Department: [**State **]When: MONDAY [**2205-6-10**] at 10:00 AM With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 6564**], MD [**Telephone/Fax (1) 2205**] Building: [**State **] ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: On Street Parking Department: MEDICAL SPECIALTIES When: FRIDAY [**2205-8-16**] at 3:40 PM With: DR. [**Last Name (STitle) 27184**]/DR. [**First Name (STitle) **] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

11715, 11721

6266, 6439

301, 313

11793, 11793

3763, 3763

12114, 12737

2765, 2790

9820, 11692

11742, 11772

8960, 9797

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229, 263

6454, 7422

341, 1869

3779, 6243

11808, 11952

7438, 8934

1891, 2474

2490, 2749

23,390

177,693

23311

Discharge summary

report

Admission Date: [**2148-1-20**] Discharge Date: [**2148-1-26**] Date of Birth: [**2076-7-5**] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamides) / Acetaminophen / Percocet Attending:[**First Name3 (LF) 13541**] Chief Complaint: Altered mental status, melena Major Surgical or Invasive Procedure: LP unsuccessful attempt x 2 RIJ central venous line Intubation for procedure for airway protection EGD VP shunt tap Colonoscopy History of Present Illness: History obtained from patient's family, outside ED/Hospital records, our ED records, & OMR as the patient is minimally responsive and not communicative on interview. The patient has been admitted from and OSH ED from her nursing home for nausea/vomiting, abdominal pain and leukocytosis for the past 24 hours. She has become increasingly altered over that time. Since [**2147-7-14**] she has been in declining health. At that time she was living at home and was admitted to an OSH for chest pain found to be coronary artery disease medically managed presumedly with anti-platelet therapy. She developed black tarry stools and was found to have a bleeding ulcer at that time. In [**2147-10-14**] she had a dyspnea admission ruled anxiety. In [**2147-12-14**] she was admitted again for vomiting and found to have a VRE UTI, L sided pneumonia with LLE cellulitis. Per her daughter, during this admission the patient had an "upper GI obstruction," likely volvulus warranting surgery. However no surgery was performed. She was transferred to Country [**Hospital 731**] Rehab for several hours and returned with an acute MI. She was transferred to [**Hospital 12017**] Hospital for cath and had bare metal stent placed in the "front artery." Upon return to rehab she was again readmitted for Pulmonary edema. This most recent stay ended [**2148-1-17**] with discharge to [**Hospital 32944**] Rehab. Per the patient's daughter, the patient was vomiting and complaining of abdominal pain the night prior to presentation. The patient is alert and oriented at [**Hospital 5348**] but does become combative when irritated. At the OSH ED she was somnolent but arousable and oriented. There she received Dilaudid & a benzodiazepine with IV Fluids. She was monitored on telemetry. Concern for Small Bowel Obstruction warranted Abdominal CT with PO contrast only (no sufficient IV access). That scan was reviewed by our radiologists and showed only a ventral hernia and poor penetration of contrast into her colon, not suggestive of obstruction or acute abdominal process. She was noted to have a WBC of 21 with 91% neutrophils, HCT 34.3, Cr 1.1. CK 29 with CKMB 8.6 which is elevated and tropinin I of 0.12 which is within the normal range. They treated her with 1g vancomycin for concern of shunt infection and sent her to [**Hospital1 18**] for further evaluation. Of note, she has recently been on doxycycline, vanomycin and levafloxacin for M. Catarrhalis from her sputum, resistant E coli from urine and also with linezolid for VRE in the urine (per records from [**Hospital 12017**] Hospital). In our ED, VS: 96.5 BP 125/79 P 118 RR 14 98% on room air. The patient received Flagyl/Zosyn for putative abdominal infection. Surgery was consulted and based on exam and review of the films, did not feel she had an acute problem nor did she warrant surgical intervention. Stable ventral hernia, easily reducible with bowel in hernia. She was admitted to medicine for elevated WBC count and evaluation of her mental status. On arrival to the floor the patient is tachycardia and minimally responsive. She awakes to vigorous stimulation and multiple sternal rubs. She is unable to give any history or status. Past Medical History: Obtained from family and OSH records and OMR: - CAD s/p recent MI and cardiac stenting on [**2148-1-9**] (likely BMS to LAD given family history, but waiting for OSH records) - Bilateral fem-[**Doctor Last Name **] bypass - Right AKA - Pseudoaneurysm repair to left fem artery - [**2142**] massive hydrocephalus with brain stem compression s/p craniectomy complicated by cerebellar hemorrhage and non communicating hydroceph and need for VP shunt - COPD - Gout - HTN - Recent pneumonia - Recent VRE UTI - MRSA history - s/p CCy and appy - AAA (reported per OSH records) Social History: Lives in nursing home technically, however in and out of hospitals as above for the past 6-8 months per daughter. Smoking history of strong tobacco use until very recently (1ppd for 55 years), denies EtOH. Family History: Non-contributory Physical Exam: Vitals: 98.8 110/52 86 20 98% RA General: Awake and pleasant HEENT: No JVD, MM dry, oropharynx clear CV: S1&S2 regular without murmur Lungs: Scant crackles at bases, otherwise clear Abdomen: Prominent reducible ventral hernia, BS present, no tenderness elicited. Ext: R AKA, Left palpable DP pulse Neuro: AAOx3, Cranial nerves grossly intact to confrontation Pertinent Results: [**2148-1-20**] 04:07AM BLOOD WBC-34.2*# RBC-4.60 Hgb-10.6* Hct-34.1* MCV-74* MCH-23.0*# MCHC-31.0 RDW-17.0* Plt Ct-428# [**2148-1-20**] 07:51PM BLOOD Hct-26.0* [**2148-1-21**] 09:54AM BLOOD Hct-32.6* [**2148-1-22**] 04:24AM BLOOD WBC-10.3 RBC-3.56* Hgb-9.1* Hct-28.4* MCV-80* MCH-25.5* MCHC-31.9 RDW-17.2* Plt Ct-200 [**2148-1-22**] 01:35PM BLOOD Hct-30.4* [**2148-1-20**] 04:07AM BLOOD Glucose-95 UreaN-45* Creat-0.9 Na-138 K-3.9 Cl-101 HCO3-24 AnGap-17 [**2148-1-22**] 04:24AM BLOOD Glucose-73 UreaN-10 Creat-0.5 Na-140 K-4.6 Cl-111* HCO3-21* AnGap-13 [**2148-1-20**] 04:17AM BLOOD Lactate-1.6 [**2148-1-20**] 09:52AM BLOOD Lactate-1.1 Discharge Labs: 140 105 7 --------------<97 3.5 29 0.5 Ca: 7.8 Mg: 1.5 P: 3.8 D Wbc 8.6 Hgb 8.6 Hct 26.4 Plt 319 PT: 14.6 PTT: 27.1 INR: 1.3 CT head [**1-20**] AM: IMPRESSION: Stable position of ventricular shunt with slightly increased ventricular size and transependymal edema. No evidence of acute hemorrhage. CT head [**1-20**] PM: IMPRESSION: No short interval change in ventricular caliber. No new intracranial hemorrhage or shift of normally midline structures. Endoscopy [**2148-1-20**]: Normal EGD to third part of the duodenum Recommendations: Monitor HCT q6hrs Continue PPI Additional notes: There was absolutely no blood seen in the upper GI tract as far as the scope could be passed. Source of melena likely right sided colonic versus small bowel lesion. Colonoscopy [**2148-1-24**] Multiple diverticula were seen in the whole colon. Melena was seen in the ascending colon, transverse colon, descending colon and sigmoid colon. No active bleeding seen from the diverticula. No large polyps or masses identified; however the presence of small polyps or lesions cannot be completely excluded due to the presence of melena. Consider capsule endoscopy to r/o small bowel source of bleeding [**2148-1-23**]: UE U/S Small partial filling defect in the right subclavian vein suggesting chronic nonocclusive thrombus. Microbiology: HELICOBACTER PYLORI ANTIBODY TEST (Final [**2148-1-22**]): EQUIVOCAL BY EIA. GRAM STAIN (Final [**2148-1-21**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2148-1-24**]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST CULTURE (Preliminary): The sensitivity of an AFB smear on CSF is very low.. If present, AFB may take 3-8 weeks to grow.. VIRAL CULTURE (Preliminary): No Virus isolated so far. CRYPTOCOCCAL ANTIGEN (Final [**2148-1-21**]): CRYPTOCOCCAL ANTIGEN NOT DETECTED. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2148-1-22**]): Feces negative for C.difficile toxin A & B by EIA. Blood Culture, Routine (Final [**2148-1-26**]): NO GROWTH. URINE CULTURE (Final [**2148-1-21**]): GRAM NEGATIVE ROD(S). ~[**2138**]/ML. Brief Hospital Course: 71 year old lady with recent stented NSTEMI, multiple medical problems admitted to the hospital for leukocytosis and altered mental status found to have a GI bleed. 1) GI Bleed: The patient developed melena during a lumbar puncture attempt to evaluate her altered mental status. Her hematocrit dropped signficantly over the next 6 hours and she was transported to the ICU with central venous line and 1 unit of packed reb blood cells already in place. During her bleed she was maintained on Aspirin & Plavix & carvedilol for her coronary disease despite the risks given her recent stent. She remained in the ICU for 2 days where she was intubated for airway protection during an endoscopy. Endoscopy did not find any bleeding and the patient was successfully extubated, transfused a second unit of blood and returned to the medical floor. She continued to experience melena and was prepared for a MAC anesthesia colonoscopy which showed melena but no source of bleeding. After the colonoscopy the patient's melena slowed and stopped. She was transfused a third (final) unit of blood for a hct < 28 prior to discharge. To further investigate the source of bleeding, she has a capsule endoscopy [**Year (4 digits) 1988**] on [**2148-2-7**]. She has no melena on discharge. 2) Coronary artery diseas/CHF: Record review indicated the patient had a Bare Metal Stent placed late [**2147-12-14**]. She was continued on aspirin, clopidogrel, carvedilol (increased to 12.5 once bleeding subsided) and a statin despite the inherent risks of these medications. She will be discharged on these medicines and on her home lasix/potassium regimen. We have stopped her HCTZ. 3) Leukocytosis: The patient had a significant leukocytosis not clearly explained during this admission. She was started on Flagyl for possible C. diff colitis and stopped after several days when her assay and colonoscopy returned negative. Her white count resolved. Her VP shunt was tapped and found to be functioning and not infected. 4) Altered mental status: The patient was admitted altered, likely from narcotic and sedative medication administered prior to transfer/admission. Her status cleared and returned to a pleasant [**Year (4 digits) 5348**]. During her admission she occasionally became agitated and 0.5mg of Haldol PO was used successfully. 5) COPD: The patient was continued on home inhaled medications. 6) GERD: The patient was continued on protonix for Gi bleed, switched back to omeprazole on discharge. Full code Medications on Admission: Lasix 20 mg PO qday Carvedilol 6.25 mg PO BID Hydrochlorothiazide 12.5 mg PO qday ASA 325 mg PO qday Clopidogrel 75 mg PO qday Omeprazole 40 mg PO daily Isosorbide 60mg PO daily Lisinopril 10 mg PO QAM K+ 20 mEq PO QAM Simvastatin 40 mg PO QAM Advair diskus 1 puff [**Hospital1 **] Spiriva 18 mg QAM Albuterol inhaler 2.5% 2 puffs q4hr PRN Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 9. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. 10. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 11. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 12. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital1 **] Health of [**Hospital3 **] - [**Location (un) 32944**] Discharge Diagnosis: Lower gastrointestinal bleeding Acute blood loss anemia Altered mental status Coronary artery disease Discharge Condition: Vital signs stable, tolerating regular diet, no melena observed Discharge Instructions: You were admitted to the hospital because of abdominal pain and because of bleeding from below. You have been given 3 units of blood and your bleeding has stopped. You had a colonoscopy and upper endoscopy and no source of your bleeding was found. You are still [**Location (un) 1988**] for a "Capsule Endoscopy" to evaluate the part of your bowels that could not be seen from either endoscopy or colonoscopy to keep looking for a cause of bleeding. Despite your bleeding, we have continued your Aspirin and Plavix to protect your heart. This puts you at high risk of bleeding, but you must continue these medications uninterrupted given your recent stent. Do not stop these medications without discussing this with your cardiologist. Your blood pressure medications have been changed. 1. Coreg (carvedilol) was increased to 12.5mg by mouth twice daily. 2. Stop taking HCTZ (no need for it after increasing your other medication. 3. Continue lisinopril 10mg, lasix 20mg daily Your VP shunt was investigated by neurosurgery and found to be functioning well and was without infection. Should you experience chest pain, shortness of breath, notice bright red blood from below, please call your doctor or 911. You may notice small amounts of very dark stools, but if it increases, please call your doctor or 911. Followup Instructions: 1. Capsule Endoscopy: You have been [**Location (un) 1988**] for a Capsule Endoscopy on [**2148-2-7**] at 8am. This requires some preparation, so please review the attached paperwork. Please call [**First Name8 (NamePattern2) 13544**] [**Last Name (NamePattern1) 39685**] at [**Telephone/Fax (1) 13545**] should you need to reschedule. To Prepare: You must eat a low residue diet three days prior to study. Please have only a clear liquid diet for the day before the study and take the prescribed prep; and do not eat anything from midnight before your study. For the capsule study: Go to [**Hospital1 18**] [**Hospital Ward Name 516**] [**Hospital Ward Name 1950**] building [**Location (un) **]: ERCP 2 (ST-4) GI ROOMS Date/Time:[**2148-2-7**] 8:00 (please arrive at 7:45am). The study will be done by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2148-2-7**] 8:00 Please call to make an appointment with Dr. [**First Name (STitle) **] within 2 weeks of discharge. He can be reached at [**Telephone/Fax (1) 59868**]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 13546**]

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icd9cm

[ [ [] ] ]

[ "45.23", "01.02", "45.13", "38.93" ]

icd9pcs

[ [ [] ] ]

12005, 12103

7984, 10012

352, 482

12249, 12315

4959, 5599

13677, 14903

4546, 4564

10897, 11982

12124, 12228

10532, 10874

12339, 13654

5615, 7337

4579, 4940

7433, 7961

7370, 7394

283, 314

510, 3713

10028, 10506

3735, 4307

4323, 4530

32,419

153,925

22430

Discharge summary

report

Admission Date: [**2203-2-15**] Discharge Date: [**2203-2-22**] Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 598**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [**2203-2-15**] Exploratory Laparotomy; right colectomy; cholecystectomy; End ileostomy and mucous fistula. History of Present Illness: 89 yoM with multiple medical problems, including severe CAD s/p CABG [**06**] years ago and multiple stents, as well as B/L carotid stents. Patient describes 4 days of worsening abdominal pain, with radiation to the R flank. He describes no nausea, vomiting or diarrhea. He states that his bowel habits and urinary habits have not changed signifcantly from baseline. He reports no dyspnea, no SOB no chest pain and no changes in vision, mental status or speech. Patient has a history of CVA and multiple TIA's, as well as vocal cord paralysis in the past after carotid endarterectomy. Patient has been told he has 'blockage' on the Right carotid but no surgery pursued due to risks. Past Medical History: Past Medical: 1. Type 2 diabetes mellitus, complicated by peripheral neuropathy. 2. Coronary artery disease. 3. Complete heart block. 4. Bilateral carotid stenosis. 5. History of TIA. 6. Frontoparietal stroke [**2184**]. 7. Low back pain. 8. Glaucoma, followed at MEEI. 9. Anemia. 10. Hyperlipidemia. 11. Gastroesophageal reflux disease. 12. History of right-sided Bell's palsy. 13. History of hematuria. 14. Chronic disease. 15. Orthostatic hypotension. Past Surgical: 1. Coronary artery bypass graft [**2163**]. 2. Dual chamber pacemaker. 3. Left carotid stent [**2198**]. 4. Cataract surgery. 5. Right hip ORIF [**2191**]. Social History: Lives independantly in senior housing but has caregivers, quit smoking ~40 years ago, but intermittently smoked for ~20 years sometimes heavily (3ppd). He denies drinking alcohol. Family History: Both parents lived to be in their 90s. Physical Exam: Temp:98.2 HR:93 BP:114/78 Resp:20 O(2)Sat:100 Normal Constitutional: Comfortable HEENT: Extraocular muscles intact Mucous membranes moist Chest: Clear to auscultation Cardiovascular: Normal first and second heart sounds without murmur Abdominal: Soft with distinct tenderness in the right lower quadrant as well as referred rebound to the right lower quadrant Rectal: Heme Positive but brown stool GU/Flank: No costovertebral angle tenderness Extr/Back: No edema calf tenderness Neuro: Speech fluent Psych: Normal mood Pertinent Results: [**2203-2-15**] 01:47PM GLUCOSE-220* UREA N-28* CREAT-1.2 SODIUM-138 POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-23 ANION GAP-9 [**2203-2-15**] 01:47PM WBC-8.2 RBC-3.28* HGB-8.9* HCT-27.8* MCV-85 MCH-27.3 MCHC-32.2 RDW-17.2* [**2203-2-15**] 01:47PM PLT COUNT-302 [**2203-2-15**] 01:47PM PT-13.9* PTT-32.9 INR(PT)-1.2* IMAGING: CT SCAN Abd/Pelvis IMPRESSION: 1. Focal stricturing at the hepatic flexure with suggestion of intusseception, with upstream distention of the ascending colon and multiple loops of small bowel, findings are also concerning for obstructing neoplasm. 2. Stranding and abnormal thickening of the appendix, measuring 10 mm in diameter, with communicating free fluid tracking along the right paracolic gutter, concerning for ruptured appendicitis. 3. Markedly enlarged gallbladder with stones/sludge, unchanged in size since [**2199**]. Brief Hospital Course: He was admitted to the Acute Care Surgery Service. He underwent CT imaging of his abdomen revealing focal stricturing at the hepatic flexure with suggestion of intussusception, with upstream distention of the ascending colon and multiple loops of small bowel with findings concerning for obstructing neoplasm; stranding and abnormal thickening of the appendix, measuring 10 mm in diameter, with communicating free fluid tracking along the right paracolic gutter, concerning for ruptured appendicitis and a markedly enlarged gallbladder with stones/sludge, unchanged in size since [**2199**]. Discussions took place between patient and his family and the decision was made to proceed with operative management. he was taken to the operating room on [**2203-2-15**] for an exploratory laparotomy; right colectomy; cholecystectomy; end ileostomy and mucous fistula. There were no operative complications. Postoperatively he was transferred to the surgical ICU where he remained for a several days. He remained hemodynamically stable and was transferred to the regular nursing unit where he progressed slowly. He developed a fever and elevated WBC on [**2203-2-18**]. His chest xray showed some bibasilar atelectasis small pleural effusions. He was started on Vancomycin and Zosyn for a possible hospital acquired pneumonia. He has remained afebrile for 48 hours and his WBC is down to 12K. His antibiotics will end after the last dose on [**2203-2-23**]. His blood sugars have been in the 140 range on a diabetic diet. His Metformin has not been renewed as his creatinine is slightly elevated at 1.6, same as on admission. This can be reassessed at rehab. He was evaluated by Wound Ostomy nursing and by Physical therapy. There have been no issues with ostomy functioning since his surgery; his output has been adequate. Patient teaching surrounding care of this was initiated. His diet was advanced to regular for which he has been able to tolerate. He is being recommended by Physical therapy for rehab stay after his acute hospitalization. His pathology results were consistent with stage IIA colon adenocarcinoma. Hematology/Oncology were consulted and it was felt that adjuvant fluorouracil- based adjuvant chemotherapy was only recommended for patients with stage III colon adenocarcinoma. A follow up appointment has been scheduled for him to be seen on their outpatient clinic with Dr. [**Last Name (STitle) **]. After a long hospital stay he was discharged on [**2203-2-22**] to [**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **] for short term rehab prior to returning home. Medications on Admission: plavix 75', lipitor 10', lumigan 0.03& each eye, alphagan 0.15% both eyes, cosopt 0.5% BIS, lexapro 5', folic acid 1 tba qd, neurontin 300 qhs, lisinopril 5', metformin 500", omeprazole 40', miralax, tylenol, vitamin c, asa 81, vit b12 250', Caltrate-600', FeSO4 325' Discharge Medications: 1. insulin lispro 100 unit/mL Solution Sig: One (1) dose Subcutaneous ASDIR (AS DIRECTED) as needed for per sliding scale: see attached sliding scale. 2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day). 3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 8. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for SBP <110. 9. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. 10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) GM Intravenous Q 24H (Every 24 Hours) for 1 days. 12. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback Sig: 4.5 GM Intravenous Q8H (every 8 hours) for 1 days. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **] Discharge Diagnosis: 1. Colonic obstruction 2. Acute appendicitis 3. Cholelithiasis with massively distended gallbladder 4. Stage IIa colon cancer 5. Pneumonia 6. Acute Kidney Injury Discharge Condition: Level of Consciousness: Alert and interactive; HOH; short term memory loss. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital with an obstructing mass in your intestines requiring an operation. During this operation your gallbladder was removed due to gallstones being present. You also required that an ostomy be performed because of the obstruction. You were found to have colon cancer and were seen by the Oncology team during your hospital stay. You will be seen in follow up as an outpatient in the next several weeks. Due to the extensive surgery and long hospital stay you will spend some time in rehab prior to returning home to help increase your stamina and mobility. You will also get more instruction in caring for your ostomy. 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 [**4-19**] 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. *Your staples will be removed at rehab. Followup Instructions: Follow up in Acute Care Surgery clinic in [**12-12**] weeks; call [**Telephone/Fax (1) 600**] for an appointment. You have an appointment with Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD (Hematology/Oncology) Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2203-3-16**] at 10:00 a.m. The following appointments were made for you prior to this hopsital stay: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2203-2-23**] 1:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2203-2-23**] 2:00 [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2203-2-22**]

[ "564.00", "584.9", "530.81", "486", "541", "585.9", "789.59", "250.60", "574.10", "153.0", "357.2", "724.5", "560.89", "V45.81", "V45.01", "414.00", "V12.54", "365.9", "403.90", "433.10" ]

icd9cm

[ [ [] ] ]

[ "51.22", "45.73", "46.20", "47.09" ]

icd9pcs

[ [ [] ] ]

7536, 7632

3440, 6051

264, 373

7838, 7983

2553, 3417

10494, 11291

1957, 1997

6371, 7513

7653, 7817

6077, 6348

8007, 10117

10133, 10471

2012, 2534

210, 226

401, 1092

1114, 1743

1759, 1941

81,464

176,514

33708

Discharge summary

report

Admission Date: [**2194-10-3**] Discharge Date: [**2194-10-8**] Date of Birth: [**2170-11-12**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3227**] Chief Complaint: Progressive Headache, and intermittant gagging Major Surgical or Invasive Procedure: PROCEDURE [**10-3**]: 1. Bilateral posterior fossa craniectomy for tumor resection. 2. Stereotactic guidance. 3. Microscopic dissection. 4. Pericranial graft harvest for secondary dural repair History of Present Illness: INDICATIONS: This is a 23-year-old right-handed woman who was referred to my office for a left-sided cervicomedullary junction tumor with significant mass effect. Of note, the patient had complained of progressive headache as well as intermittent gagging. Given her symptoms and the significant mass effect of the tumor, she elected to undergo an elective resection of the tumor. Past Medical History: s/p Child Birth Social History: Resides at home in [**Location 34697**] with fiance, and young daughter. Family History: Family history of schwannomatosis Physical Exam: On Discharge: AOx3, full strength and motor function throughout upper and lower extremities. Sensation also intact. PERRL. Visual fields grossly intact. Wound is clean, dry and intact. Pertinent Results: Labs on Admission: [**2194-10-3**] 06:34PM BLOOD WBC-28.7*# RBC-3.84* Hgb-11.2* Hct-33.7* MCV-88 MCH-29.1 MCHC-33.1 RDW-13.4 Plt Ct-395 [**2194-10-3**] 06:34PM BLOOD PT-14.5* PTT-24.2 INR(PT)-1.3* [**2194-10-3**] 06:34PM BLOOD Glucose-207* UreaN-11 Creat-0.6 Na-143 K-4.7 Cl-114* HCO3-20* AnGap-14 [**2194-10-3**] 06:34PM BLOOD Calcium-7.6* Phos-5.1* Mg-1.9 Labs on Discharge: [**2194-10-7**] 07:05AM BLOOD WBC-11.0 RBC-4.04* Hgb-12.0 Hct-34.1* MCV-84 MCH-29.6 MCHC-35.0 RDW-13.5 Plt Ct-356 [**2194-10-7**] 07:05AM BLOOD Glucose-94 UreaN-15 Creat-0.5 Na-137 K-3.8 Cl-101 HCO3-26 AnGap-14 [**2194-10-7**] 07:05AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.0 Imaging: MRI Head [**10-4**]: IMPRESSION: Status post resection of left cerebellopontine angle mass. There is no evidence of unexpected post-operative findings. No hydrocephalus. The mass appears to have considerably resected with suggestion of a small area of residual enhancement at the expected upper margin of the mass. Further followup can help in determination residual enhancement. Pathology: DIAGNOSIS: 1. "Left sided skull-based tumor" (A-B):Schwannoma. 2. "Left sided skull-based tumor" (C-D):Schwannoma. 3. "Left sided skull-based tumor" (E-F):Schwannoma. Note: The tumor is composed of spindle cells arranged in short fascicles with nuclear palisading. Immunohistochemical stains are diffusely positive for S100 and negative for EMA. Brief Hospital Course: Patient was electively admitted to the neurosurgery service on [**2194-10-3**] for resection of a presumed posterior fossa schwanoma. She tolerated the procedure well, and was monitored with ICU level care for POD#0-2. On POD#3 she was transferred to the neurosurgery step down unit. A speech and swallow evaluation was done. She was determined to require a mechanical soft diet with thin liquids, and all pills to be crushed. On [**2194-10-7**], she was seen by physical therapy and determined to be appropriate to be discharged to home with the need for services. She was also seen by social work to assist with her coping of the surgery in the setting of a young child, at home. Pathology confirmed schwanoma. The patient was discharged on [**2194-10-8**]. Medications on Admission: None Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: No driving while on narcotics. Disp:*50 Tablet(s)* Refills:*0* 4. Methocarbamol 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for muscle spasm. Disp:*30 Tablet(s)* Refills:*0* 5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) mL PO Q8H (every 8 hours) as needed for oral thrush for 2 days. Disp:*30 mL* Refills:*0* 6. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Left cerebellopontine junction tumor; schwanoma. Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair after 10 days. Before that time, you may have a friend or family member help you wash around the area. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. 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 ??????Please return to the office in [**9-9**] days for a wound check. ??????Follow-up with Dr. [**First Name (STitle) **] in 1 month. Call [**Telephone/Fax (1) 1669**] for an appointment. Please have a non-contrast head CT prior to the appointment. Completed by:[**2194-10-8**]

[ "787.23", "225.0", "338.18" ]

icd9cm

[ [ [] ] ]

[ "01.59" ]

icd9pcs

[ [ [] ] ]

4441, 4447

2805, 3570

368, 567

4540, 4564

1380, 1385

5990, 6308

1125, 1160

3625, 4418

4468, 4519

3596, 3602

4588, 5967

1175, 1175

1189, 1361

281, 330

1758, 2782

595, 980

1399, 1739

1002, 1019

1035, 1109

352

121,050

4722

Discharge summary

report

Admission Date: [**2144-5-17**] Discharge Date: [**2144-5-21**] Date of Birth: [**2069-3-6**] Sex: M Service: NEUROLOGY Allergies: Nitroglycerin Attending:[**First Name3 (LF) 5868**] Chief Complaint: Right arm and leg weakness Major Surgical or Invasive Procedure: MRI brain, MRA head and neck CT head CT C-spine Carotid US History of Present Illness: Patient was admitted [**Date range (1) 19867**] to Neurology after presenting with acute onset of R arm and leg weakness with significant resolution of deficits. According to patient, he had full strength at discharge. During that admission, MRI revealed a small acute stroke in the L anterior centrum semiovale and a large old L frontal stroke. Carotid US showed 70-79% stenosis. Echo showed no thrombus. He was taking aspirin at time of stroke and Plavix was added. However, abnormal signal of the clivus on MRI prompted a a bone scan which revealed multiple foci of abnormal uptake in long bones. This led to a torso CT which showed B/L infiltrating renal masses. His antiplatelets were stopped in anticipation of a biopsy which was performed [**5-11**], results of which are pending. He has remained off any aspirin or Plavix since. He went to sleep at 1AM this morning with normal strength. He woke at 730AM and fell when trying to get out of bed, with R arm and leg weakness. After about 30 minutes, he was able to get up, eat breakfast, and then drive his cab. His details are somewhat unclear based on his account, but he called 911 at some point when his weakness was not improving. He arrived at [**Hospital1 18**] at 11AM code stroke page went out at 1116AM. I arrived at 1120AM and he was in CT scanner. When CT scan completed, he complained of R arm and leg weakness and numbness but denied visual changes, facial weakness, dysarthria, dysphagia, L sided symptoms, fever, SOB, CP, palpitations, headache or neck pain. Past Medical History: 1) L centrum semiovale stroke [**4-2**] 2) L frontal stroke on MRI 3) HTN 4) Hypercholesterolemia 5) S/p CABG 6) Gout 7) DM 8) B/L 70-79% ICA stenosis 9) B/L renal masses Social History: Cab driver Lives alone Occassional ETOH (drinks [**12-1**] scotch every few months) Hx of 50 pack year smoking, quit several years ago Physical Exam: Vitals 97.8 BP 119/56 P 67 R 19 O2 sat 99% General: Well nourished, in no acute distress HEENT: NCAT Neck: supple, no carotid bruits Lungs: Clear to auscultation CV: Regular rate and rhythm. No m/g/r BACK: Pinpoint scab at L renal biopsy site. No hematoma. Neurologic Examination: Mental Status: Awake and alert, cooperative with exam, normal affect. Oriented to person, place, month, day, and date Attention: Can say days of week backward with 1 self corrected omission. Language: Fluent, no dysarthria, no paraphasic errors, reptition and comprehension intact, names [**3-4**] items on stroke card (not hammock or feather). [**Location (un) **] intact. Unable to write due to weakness. Cranial Nerves: Visual fields are full to confrontation. Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Extraocular movements intact, no nystagmus. Facial sensation and facial movement normal bilaterally. Hearing decreased to finger rub bilaterally. [**Location (un) **] midline, no fasciculations. Sternocleidomastoid and trapezius normal bilaterally. Motor: Increased tone in legs bilaterally. No tremor. D T B WF WE FiF [**Last Name (un) **] HF HE KF KE AF AE TF TE Right 5- 5- 5 4 3 4 0 5- 5 5 5 5 5 5 5 Left 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Right pronator drift Sensation was intact to Light touch. Stocking glove loss to pin prick and temperature. Absent vibration in toes. Reflexes: B T Br Pa Pl Right 2 2 2 1 tr Left 1 1 1 1 tr Toes were downgoing L, mute R Coordination is normal on finger-nose-finger on L Gait was not assessed Pertinent Results: [**2144-5-18**] 04:00AM BLOOD WBC-10.3 RBC-3.64* Hgb-8.8* Hct-28.7* MCV-79* MCH-24.3* MCHC-30.7* RDW-22.0* Plt Ct-292 [**2144-5-18**] 04:00AM BLOOD Plt Ct-292 [**2144-5-18**] 04:00AM BLOOD PT-12.9 PTT-26.6 INR(PT)-1.1 [**2144-5-18**] 04:00AM BLOOD Glucose-90 UreaN-50* Creat-1.2 Na-141 K-5.3* Cl-114* HCO3-19* AnGap-13 [**2144-5-17**] 06:46PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2144-5-18**] 04:00AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2144-5-18**] 04:00AM BLOOD Calcium-8.7 Phos-3.6 Mg-1.6 Cholest-88 [**2144-5-18**] 04:00AM BLOOD %HbA1c-5.9 [Hgb]-DONE [A1c]-DONE [**2144-5-17**] 11:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2144-5-18**] 04:00AM BLOOD Triglyc-190* HDL-18 CHOL/HD-4.9 LDLcalc-32 CT: Small areas of low attenuation visualized in the left centrum semiovale. There is white matter area just anterior to the left lateral ventricle and a small area in the left caudate nucleus. These areas were not clearly visualized on the prior study. However, they do not appear to be of acute nature. An old infarct is also visualized in the left frontal cortex, unchanged in appearance since the prior study. There is no evidence of hydrocephalus, shift of normally midline structures or new acute major territorial infarction. The surrounding soft tissue and osseous structures appear unremarkable. MRI increased diffusion-weighted imaging sequence signal located in the left parietal lobe, head of the putamen on the left side and basal ganglia on the right side. These are consistent with acute infarction. An area of increased FLAIR/T2 signal is visualized in the left parietal lobe consistent with an old infarction, unchanged in appearance since the prior study. An area of increased DWI signal is also visualized in the left centrum semiovale, unchanged since the prior study. MRA Severe stenosis at the origin of the right internal carotid artery and a moderate stenosis at the left ICA origin. This appearance has not changed since the previous study. There is a stenosis of the A1 segment of the right anterior cerebral artery. There are no other hemodynamically significant stenoses of the visualized vasculature. Carotid US: Rt: 70-79% Lt: 60-69% TEE: Small secundum atrial septal defect. Simple atheroma in the descending aorta and aortic arch. Basal inferior left ventricular aneurysm/dyskinesis. Brief Hospital Course: 75yo man recently admitted to stroke for acute R arm and leg weakness found to have small L CSO stroke and made a full recovery. Workup at that time showed B/L 70-90% carotid stenoses, B/L renal masses of unclear etiology. ASA, Plavix held for renal biopsy, done [**5-11**]. Presented with R arm and leg weakness and fall. Had fluctuating deficits ranging from RUE weakness (4+/5) to plegia. MRI showed several small strokes bilaterally (left>right). MRA showed carotid stenoses but adequate distal flow. There was intitial concern for hypoperfusion in setting of carotid stenosis, although symptoms not clearly BP dependent. He was admitted to ICU for q1hr checks. Unable to achieve goal SBP of 130-150 with IVF. He was started on neosynephrine briefly for waxing and [**Doctor Last Name 688**] deficits. No significant change. He was started on anticoagulation with IV heparin as the most likely etiology of his strokes was felt to be cardioembolic +/- hypercoagulable state from unknown malignancy. He was transferred to the neurology step down unit for close neuro observation. Throught the remainder of his admission, his exam was stable. He had a repeat carotid US which showed: Rt ICA 60-79% Lt ICA 60-69% (no change from previous). He had a TEE which showed an ASD with ASA and mild right to left shunt with valsalva. He was transitioned to Lovenox and Coumadin. He should have his INR checked in several days and dose should be adjusted for goal INR 2.0-3.0. He ruled out for MI with negative cardiac enzymes x3. TEE was done (results noted above). Cholesterol level was normal, HDL was low. Antihypertensives were held in setting of acute stroke. He was continued on Lipitor. He had a renal biopsy prior to admission ([**5-11**]) to evaluate for possible lymphoma given multiple renal masses found on previous admission. Prelim path results suggest a reactive process/ inflammation (cells were polyclonal) His blood sugars have been fairly well controlled on insulin sliding scale; his HbA1C was 5.9. He was restarted on outpaient dose of metformin prior to discharge Medications on Admission: 1) Iron 150mg QD 2) Allopurinol 150mg QD 3) Simvastatin 40mg QD 4) Atenolol 25mg QD 5) Lisinopril 10mg QD 6) Lasix 20mg QD 7) Metformin 850mg [**Hospital1 **] 8) Insulin (70/30) 28 units AM and 20 units PM Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 3. Enoxaparin Sodium 80 mg/0.8 mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours). Disp:*20 syringe* Refills:*2* 4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 5. Protonix 40 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* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Metformin 850 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital **] Rehabilitation & Nursing Center - [**Location (un) **] Discharge Diagnosis: left-sided cerebral infarction Discharge Condition: strength in right arm improved Discharge Instructions: discharge to acute rehab Followup Instructions: 1. Primary Care: Patient is to call insurance and change PCP [**5-27**] at 2pm (Dr. [**Last Name (STitle) 19868**], preceptor [**First Name8 (NamePattern2) 3403**] [**Last Name (NamePattern1) **]...this is new PCP)[**Telephone/Fax (1) 250**] [**Hospital Ward Name 23**] building south suite. 2. Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**] NEUROLOGY Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2144-7-14**] 1:30

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Discharge summary

report

Admission Date: [**2148-1-11**] Discharge Date: [**2148-1-17**] Date of Birth: [**2071-11-7**] Sex: M Service: [**Hospital1 **] HISTORY OF PRESENT ILLNESS: The patient is a 76 year-old male with a history of pancreatic cancer status post duodenal and biliary stent placement who presents with multiple episodes of coffee ground emesis, dark stools, and bright red blood per rectum. The patient had five episodes of vomiting with coffee grounds two days prior to admission. One day prior to admission the patient had dark stools one of which was covered by bright red blood. He denies any abdominal pain, nausea, vomiting, fevers, chills, cough, chest pain, or shortness of breath. He did have some lightheadedness, which resolved on its own. The patient came to the Emergency Department for evaluation. He had single blood pressure measurement of 80/50, which improved after a fluid bolus. His hematocrit decreased from 37 to 17 in the course of four hours for which he was treated with five units of packed red blood cells. An nasogastric lavage was performed and was clear of blood. The patient was evaluated by gastroenterology and was admitted to the MICU. PAST MEDICAL HISTORY: 1. Pancreatic cancer, status post common bile duct stent, status post duodenal stent. 2. Cerebrovascular accident. 3. Peripheral vascular disease status post bypass surgery. 4. Hypercholesterolemia. 5. Hernia. 6. Hypertension. 7. Abdominal aortic aneurysm, infrarenal. 8. Status post cholecystectomy. 9. Status post appendectomy. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Pentoxifylline 400 mg po t.i.d. 2. Aspirin 325 mg po q day. 3. Prilosec 20 mg po q day. 4. Norvasc 5 mg po q day. 5. Atenolol 50 mg po q day. 6. Hydrochlorothiazide 12.5 mg po q day. 7. Lipitor 10 mg po q day. SOCIAL HISTORY: The patient has a remote history of alcohol and tobacco usage. He lives at home with his daughter. PHYSICAL EXAMINATION: The patient was afebrile with a temperature of 96.3, heart rate 63, blood pressure 113/64, respiratory rate 11, and oxygen saturation 99% on 2 liters by nasal cannula. In general, the patient was an elderly cachectic male in no acute distress. Head and neck examination were significant for mild scleral icterus, flat neck veins and no carotid bruits. Lungs were clear to auscultation bilaterally. Cardiac examination revealed a regular rate and rhythm with a 2 out of 6 systolic murmur. Abdomen was soft, nontender, nondistended with positive bowel sounds and no rebound tenderness. Extremities had no clubbing or edema. Rectal examination was heme positive in the Emergency Department. LABORATORY STUDIES: CBC was significant for a white blood cell count of 4.5 and a hematocrit of 16.0. Panel 7 is significant for a BUN of 55 and creatinine of 1.6. Liver function tests were elevated with an AST of 507, and alkaline phosphatase of 387. LDH was 507. Amylase was elevated at 164, and total bilirubin was 0.9. Lipase was elevate at 281. Coagulation studies were within normal limits. Electrocardiogram showed normal sinus rhythm at 75 beats per minute, Q waves in leads 3 and AVF, and flat T waves throughout. HOSPITAL COURSE: 1. Gastrointestinal bleed: The patient was transfused with 5 units of packed red blood cells and his hematocrit increased to 40.0. He had no further episodes of hematemesis, and his hematocrit remained stable throughout the rest of his hospitalization. He was continued on proton pump inhibitor, and esophageal gastroduodenoscopy was performed on [**2148-1-12**]. Results showed obstruction of the pylorus due to the duodenal stent with an associated nonbleeding ulcer. Also present was Barrett's esophagus and gastritis. Repositioning of the duodenal stent was performed by esophagogastroduodenoscopy with fluoroscopy on [**2148-1-16**]. No complications of this procedure were encountered and the patient tolerated full oral diet afterwards. No further follow up is recommended at this time. 2. Hypertension: The patient was maintained on low dose beta blocker during his hospitalization and his calcium channel blocker and diuretic were held. His blood pressures remained 110 to 140, and he should be followed and his hypertensive regimen adjusted by his primary care physician. 3. Peripheral vascular disease: The patient was restarted on his Pentoxifylline and Atorvastatin during his hospitalization. DISCHARGE CONDITION: The patient was discharged in stable condition to home. DISCHARGE DIAGNOSES: 1. Pyloric obstruction due to duodenal stent. 2. Upper gastrointestinal bleed. 3. Barrett's esophagus. 4. Gastritis. 5. All prior diagnoses. DISCHARGE MEDICATIONS: 1. Pentoxifylline 400 mg po b.i.d. 2. Prilosec 20 mg po q day. 3. Lipitor 10 mg po q day. 4. Atenolol 50 mg po q day. DISCHARGE PLAN: 1. The patient should follow up with his primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in one week. At this time the patient can be evaluated for resumption of his aspirin, Norvasc or Hydrochlorothiazide. 2. If the patient has further episodes of hematemesis or bleeding, he should contact gastroenterology. The esophagogastroduodenoscopy was performed by Dr. [**Last Name (STitle) **]. [**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**] Dictated By:[**Last Name (NamePattern1) 6916**] MEDQUIST36 D: [**2148-1-17**] 11:09 T: [**2148-1-17**] 12:29 JOB#: [**Job Number 32818**]

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Discharge summary

report

Unit No: [**Numeric Identifier 71281**] Admission Date: [**2115-3-14**] Discharge Date: [**2115-6-28**] Date of Birth: [**2115-3-14**] Sex: F Service: NBB IDENTIFICATION: Baby Girl [**Known lastname 71199**], [**Name2 (NI) 37336**] #2, "[**Known lastname **]", is a 106 day old former 25 [**3-20**] wk infant who is being discharged from the [**Hospital1 18**] Neonatal Intensive Care Unit. HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 71199**] is the second born of triplets born at 25-2/7 weeks gestation to a 27-year-old, G1, P0 woman. Prenatal screens: Blood type O positive, antibody negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, Group beta strep status negative. The pregnancy was notable for a conception by in [**Last Name (un) 5153**] fertilization with 2 embryos resulting in 3 fetuses, dichorionic/triamniotic gestation. EDC was [**2115-6-25**]. Pregnancy was complicated by diagnosis of twin-to-twin transfusion at 18 weeks gestation. This infant #2 was the recipient and [**Year (4 digits) 37336**] #1 was the donor. This twin required 1 amnio reduction of 800 mL of fluid on [**2115-2-12**]. A karyotype was sent from that sample and showed chromosomal analysis of 46 XX. The mother was noted to have vaginal bleeding on [**2115-2-14**] and was admitted to the [**Hospital1 188**]. She was treated with bed rest. She was again admitted with cervical changes at 23-3/7 weeks on [**2115-3-1**]. She became beta complete on [**2115-3-3**]. On the day of delivery she was noted to have significant vaginal bleeding and the decision was made to deliver in the setting of advanced cervical changes and concern regarding placental abruption. The mother's medical history was otherwise noncontributory. There was no maternal fever. Rupture of membranes occurred at delivery. Mother received intraoperative antibiotics. This [**Year (4 digits) 37336**] #2 emerged at C- section with Apgars of 7 at one minute and 8 at five minutes. She required intubation in the delivery room and was transferred to the neonatal intensive care unit for further care. Anthropometric measures at birth: Weight 835 gm, 50th percentile; head circumference 24 cm, 50th percentile; length 32 cm, 50th percentile. PHYSICAL EXAMINATION AT DISCHARGE: General: Alert, nondysmorphic infant in room air. Weight 3.46 kg, 75th percentile; length 49.5 cm, 50th percentile, head circumference 35.25 cm, 75th-90th percentile. Skin: Warm and dry, color pink, well perfused. HEENT: Anterior fontanel open and flat, sutures approximated. Eyes clear. Palate intact. Neck: Supple, without masses. Chest: Breath sounds equal, well aerated, mild intercostal retractions. Cardiovascular: Soft systolic murmur at the left sternal border. Normal S1, S2. Pulses +2, equal femorals and brachial's. Abdomen: Soft, nontender, nondistended. Large umbilical hernia, soft and easily reduced. No organomegaly. GU: Normal female genitalia, mild labial edema. Extremities: Moves all well. Hips stable. Neurological: Alert, positive grasp, positive suck, symmetric tone. Post menstrual age at discharge 40-3/7 weeks gestation. HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: 1. Respiratory: [**Known lastname **] was treated with Surfactant upon admission to the neonatal intensive care unit. She eventually received 3 doses. She was placed on high frequency oscillator ventilator at admission due to severity of respiratory distress. She remained on HFOV for 3 weeks and then transitioned to continuous positive airway pressure following self-extubation. She remained on continuous positive airway pressure from [**4-5**] through [**2115-5-17**]. At that time, she was placed on a high flow nasal cannula O2. She gradually weaned to room air by [**2115-6-6**]. She was treated for apnea of prematurity with caffeine citrate from [**4-4**] to [**2115-5-26**]. Due to her evolving chronic lung disease she was started on Lasix 2 mg/kg every Monday, Wednesday, Friday. Her last episode of spontaneous bradycardia occurred on [**2115-6-23**]. She will be followed in pulmonary clinic at [**Hospital3 1810**] with Dr. [**First Name4 (NamePattern1) 4468**] [**Last Name (NamePattern1) 37305**]. At the time of discharge, she is breathing comfortably in room air with a respiratory rate of 30-70 breaths per minute. Oxygen saturations in room air are greater than 95%. She is being continued on lasix, although the dose is no longer being adjusted for weight; she is discharged on 6 mg three times a week, approximately 1.7 mg/kg dose. Lasix may be able to be discontinued in [**4-14**] weeks if infant remains stable. 2. Cardiovascular: [**Known lastname **] initially had hypotension shortly after birth and was treated with dopamine. The dopamine was discontinued by day of life #5. An echocardiogram performed on day of life #2 showed a 3 mm patent ductus arteriosus with right ventricular dilatation. She received one course of Indomethacin. Repeat echocardiogram on [**2115-3-18**] showed the patent ductus arteriosus resolved. A murmur persisted and the second post Indomethacin echocardiogram was obtained on [**2115-3-20**] that showed right ventricular hypertrophy with pulmonary hypertension. An echocardiogram on [**2115-3-26**] showed persistence of the right ventricular hypertension and a patent foramen ovale, with no PDA. Echocardiogram on [**2115-6-15**] showed persistence of the patent foramen ovale and right ventricular pressures greater than [**2-12**] systemic with mild tricuspid regurgitation. A final echocardiogram was performed on [**2115-6-26**] which showed mild pulmonary hypertension, with right ventricular pressures approximately one-half of systemic. Anatomy was normal, and there was normal left ventricular size and systolic function. [**Known lastname **] will be followed for her pulmonary hypertension in the pulmonary clinic also with Dr. [**Last Name (STitle) 37305**]. Her baseline heart rate is 120-150 beats per minute with a recent blood pressure of 83/31 mmHg and a mean arterial pressure of 51 mm Hg. 3. Fluids/Electrolytes/Nutrition: [**Known lastname **] was initially NPO and maintained on intravenous fluids. She had initially umbilical arterial and venous catheters. She had a percutaneously inserted central catheter for parenteral nutrition. Enteral feedings were started on day of life #8 and gradually advanced to full volume. Her maximum caloric intake was Similac Special Care formula 30 calories/ounce. At the time of discharge she is taking Similar 20 calorie/ounce by mouth ad lib. She takes 130- 150 mL/kg/day. Serum electrolytes have remained within normal limits, even with the administration of the x weekly Lasix. Her most recent electrolytes on [**2115-6-18**] had a sodium of 137, a potassium of 4.8, a chloride of 105, and a total carbon dioxide of 25. 4. Infectious disease: [**Known lastname **] was evaluated for sepsis upon admission to the neonatal intensive care unit. A complete blood count with white blood cell differential was within normal limits. She received an initial course of 10 days of ampicillin and gentamicin due to severity of illness, and then had ceftazidime added on day of life #9 due to severity of illness. She received a total 14-day course of antibiotics. Her blood culture was no growth. She did not have any other infectious disease concerns during the remainder of her neonatal intensive care unit admission. 5. Hematologic: [**Known lastname **] is blood type O positive and was direct antibody test negative. She has received 6 transfusions of packed red cells during her admission, the last occurring on [**2115-5-6**]. Her most recent hematocrit was 30.8% with a reticulocyte count of 4.7% on [**6-26**]. She is being discharged home on supplemental iron. 6. Gastrointestinal: [**Known lastname **] required treatment for unconjugated hyperbilirubinemia with phototherapy. She received approximately 1 week of phototherapy in the first week of life. Her peak serum bilirubin was 4.4 mg/dl. Her final rebound bilirubin on day of life #25 was a total of 2 mg/dl. A large umbilical hernia has been present, without clinical consequence. 7. Neurology: Infant was treated with fentanyl for sedation for approximately first three weeks of life. Initial head ultrasound on day of life #1 was within normal limits. A head ultrasound of day of life #6 showed a grade 2 intraventricular hemorrhage on the right. Subsequent head ultrasounds on [**3-29**] and [**2115-4-17**] showed resolving grade 2 intraventricular hemorrhage on the right. On [**2115-5-23**], a head ultrasound was notable for ventriculomegaly with normal resistive indices. Repeat scans on [**6-4**] and [**2115-6-11**] were unchanged. The clinical significance of the ventriculomegaly is unknown at this time, but likely is minimal. [**Known lastname **] will be followed in the neonatal neurology program at [**Hospital1 71282**] with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], with appointment 6 months after discharge. 8. Audiology: Hearing screening was performed with automatic auditory brainstem responses. [**Known lastname **] passed in both ears on [**2115-6-27**]. 9. Ophthalmology: [**Known lastname **] had multiple eye exams, screening for retinopathy of prematurity. Her most severe exam showed stage 2, zone II both eyes. Her most recent exam on [**6-17**], [**2115**] showed mature retinas. Pediatric ophthalmology follow-up is recommended at 9-moths of age. 10. Psychosocial: [**Known lastname 49445**] sister, [**Name (NI) 71283**] [**Name (NI) **], passed away at approximately 1-week of life. Her sister, [**Name (NI) 23829**], remains hospitalized in the neonatal intensive care unit with a continued oxygen requirement and feeding issues. Parents have been very involved in [**Known lastname **] and her sister's care and participated in discharge teaching. The [**Hospital1 **] social service department has been involved with this family. The contact social worker is [**Name (NI) **] [**Initials (NamePattern5) **] [**Last Name (NamePattern5) 36527**], and she can be reached at ([**Telephone/Fax (1) 64591**]. CONDITION AT DISCHARGE: Good. DISCHARGE DISPOSITION: Home with the parents. PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 71284**], [**First Name3 (LF) 5700**] Clinic, [**Street Address(2) 71285**], [**Hospital1 1559**], [**Numeric Identifier 46362**], phone number ([**Telephone/Fax (1) 71286**]. CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: 1. By mouth feeding ad lib, Similac 20 calorie/ounce formula. 2. Medications: Furosemide 6 mg by mouth once daily three times a week, Monday. Wednesday, Friday, ferrous sulfate 25 mg/mL 0.3 mL by mouth once daily. 3. Iron and vitamin D supplementation: Iron supplementation is recommended for preterm and low birth weight infants until 12 months corrected age. All infants fed predominantly breast milk should receive vitamin D supplementation at 200 international units (may be provided as a multivitamin preparation) daily until 12 months corrected age. 4. Car seat position screening was performed. [**Known lastname **] was observed in her car seat for 90 minutes without any episodes of bradycardia or oxygen desaturation. 5. State newborn screens were sent multiple times. The initial screens on [**3-18**], [**3-21**] and [**3-28**], [**2115**] showed some amnio acid abnormalities that were likely related to the total parenteral nutrition [**Known lastname **] was receiving at that time. Scans on [**4-6**] and [**3-28**] had borderline low T4 levels. Specimens on [**4-26**] and [**2115-4-23**] had all results within normal limits. 6. Immunizations: Pediarix, Hemophilus influenza B, and Pneumococcal 7-Valent conjugate vaccines were administered on [**2115-5-15**]. 7. Immunizations recommended: Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following 4 criteria: 1) born at less than 32 weeks; 2) born between 32 and 35 weeks with 2 of the following: Daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school age siblings; 3) chronic lung disease; or, 4) hemodynamically significant congenital heart disease. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age, and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers. This infant has not receive rotavirus vaccine. The American Academy of Pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable and at least 6 weeks but fewer than 12 weeks of age. 8. Follow-up appointment scheduled are recommended: 1) appointment with Dr. [**Last Name (STitle) 71284**], primary pediatrician, within 3 days of discharge, 2) pulmonary clinic with Dr. [**First Name4 (NamePattern1) 4468**] [**Last Name (NamePattern1) 37305**], phone number ([**Telephone/Fax (1) 71287**] two weeks after the discharge of [**Known lastname **], 3) neonatal neurology, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 46082**], at [**Hospital3 1810**], phone number ([**Telephone/Fax (1) 71288**], appointment in 6 months for [**2115-12-12**], and 4) pediatric ophthalmology at 9 months of age. DISCHARGE DIAGNOSES: 1. Prematurity at 25-2/7 weeks gestation. 2. Number 2 of [**Year (4 digits) 37336**] gestation. 3. Respiratory distress syndrome. 4. Suspicion for sepsis, ruled out. 5. Patent ductus arteriosus, status post Indomethacin. 6. Pulmonary hypertension. 7. Right intraventricular hemorrhage. 8. Apnea of prematurity. 9. Anemia of prematurity. 10. Retinopathy of prematurity. 11. Chronic lung disease. 12. Unconjugated hyperbilirubinemia. 13. Umbilical hernia. 14. Patent foramen ovale with cardiac murmur. 15. Ventriculomegaly. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**] Dictated By:[**Last Name (Titles) 64588**] MEDQUIST36 D: [**2115-6-28**] 04:37:25 T: [**2115-6-28**] 10:06:46 Job#: [**Job Number 71289**]

[ "770.81", "772.12", "362.21", "746.89", "769", "553.1", "770.2", "779.3", "V34.01", "776.6", "765.03", "774.2", "776.4", "779.81", "745.5", "747.0", "765.23", "429.3", "416.0", "779.89" ]

icd9cm

[ [ [] ] ]

[ "99.55", "99.04", "96.04", "96.6", "96.72", "38.92", "99.83", "38.93", "99.15" ]

icd9pcs

[ [ [] ] ]

10667, 11236

14123, 14905

10636, 10643

12392, 14102

427, 2287

11272, 12365

6,750

128,931

24949

Discharge summary

report

Admission Date: [**2165-8-29**] Discharge Date: [**2165-9-14**] Date of Birth: [**2103-2-13**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Exertional chest pain Major Surgical or Invasive Procedure: [**2165-9-2**] Three vessel coronary artery bypass grafting utilizing left internal mammary artery to left anterior descending, saphenous vein graft to obtuse marginal, saphenous vein graft to posterior descending artery [**2165-8-29**] Cardiac catheterization History of Present Illness: Mr. [**Known lastname 9241**] is a 62 year old male with multiple cardiac risk factors. He recently complained of some exertional chest discomfort while performing yard work. He was subsequently referred to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5293**] and underwent stress testing which was positive for ischemia. He experienced chest tightness at five minutes with ST depressions in V3-V6. The EKG changes resolved after 8 minutes of rest. Imaging revealed reversible inferior and lateral wall defects. His LVEF was estimated at 45-50%. Based on the above, he was admitted for cardiac catheterization. Of note, Mr. [**Known lastname 9241**] prior to admission was undergoing neurologic evaluation at the [**Hospital1 **] for complaints of severe numbness and paresthesias of the legs and feet. He also had significant balance issues and has fallen several times. He currently walks with a cane. Past Medical History: Coronary artery disease, Hypertension, Hypercholesterolemia, Chronic Renal Insufficiency, Borderline Diabetes Mellitus, Hypothyroidism - s/p Thyroidectomy, Peripheral Neuropathy, Depression, Diverticular Disease - s/p Partial Bowel resection, s/p Right total knee replacement, Possible Sleep Apnea, s/p Right shoulder surgery, s/p Left foot surgery, s/p Tarsal Tunnel release bilaterally Social History: Married with children. Retired firefighter. Former smoker. Former ETOH abuse. Smoked 2 ppd for 30 yrs. Quit 16 yrs ago. Was a heavy drinker until 25 yrs ago. Lives with his wife in [**Name (NI) 620**]. Unknown past drug use, but not currently using. Has tattoos covering most of his body. Family History: Denies premature coronary disease Physical Exam: Vitals: BP 130/70, HR 50's General: Well developed male in no acute distress HEENT: Oropharynx benign Neck: Supple, no JVD Chest: Lungs CTA bilaterally Heart: REgular rate, normal s1s2, no murmur or rub Abdomen: Benign Ext: Warm, no edema Pulses: 2+ distally, no carotid or femoral bruits Neuro: Nonfocal Pertinent Results: [**2165-9-5**] 06:20AM BLOOD WBC-14.5* RBC-3.03* Hgb-9.5* Hct-27.5* MCV-91 MCH-31.3 MCHC-34.6 RDW-14.3 Plt Ct-195 [**2165-9-5**] 06:20AM BLOOD Glucose-117* UreaN-34* Creat-1.7* Na-140 K-4.2 Cl-101 HCO3-28 AnGap-15 [**2165-9-3**] 02:13AM BLOOD Mg-2.8* Brief Hospital Course: Mr. [**Known lastname 9241**] was admitted and underwent cardiac catheterization. Coronary angiography showed a right dominant system with 50% stensosis in distal left main; 50% ostial and 70% mid lesions in the left anterior descending; 90% stenosis of first obtuse marginal and total occlusion of the proximal right coronary artery. Based on the above results, cardiac surgery was consulted and further evaluation was performed. A carotid ultraound was unremarkable. His baseline creatinine was around 1.5 - 1.7. Given his ongoing gait disorder, the neurology service was consulted and found no contraindication to proceed with surgery. They attributed his gait disturbance to multiple neurologic issues - prior ETOH abuse, possible diabetes, tarsal tunnel syndrome, h/o lumbar radiculopathy, and prior foot surgery. On exam, he had decreased sensation to all modalities in his RLE and LLE to a lesser extent, including proprioception. This is also likely contributing to his gait dysfunction. He is also being worked up for possible demyelination/MS although in his age group this is very unlikely. Further outpatient evaluation was recommended. On [**2165-9-2**], Dr. [**Last Name (STitle) **] performed three vessel coronary artery bypass grafting. The operation was uneventful and he transferred to the CSRU in stable condition. There he awoke neurologically intact and was extubated without incident. He maintained stable hemodynamics and transferred to the SDU on postoperative day one. On postoperative day two, he went on to experience paroxsymal atrial fibrillation. Amiodarone therapy was initiated while beta blockade was resumed. Due to persistent paroxysmal atrial fibrillation, he was eventually started on Heparin with transition to Warfarin. Beta blockade was slowly advanced as tolerated while Amiodarone was continued. Warfarin was dosed for a goal INR around 2.0 - 2.5. Over the remainder of his hospital stay, medical therapy was optimized. He continued to experience intermittent episodes of atrial fibrillation but otherwise maintained stable hemodynamics and continued to make clinical improvements. K and Mg levels were monitored closely and repleted per protocol. After several doses of Warfarin, his prothrombin time became supratherapeutic with INR peaking at 5.6. Warfarin was therefore held over the remainder of his hospital stay. At time of discharge, his INR was at 3.9. At discharge, he will not resume Warfarin until follow up with Dr. [**Last Name (STitle) **]. His postoperative course was otherwise uneventful and he was discharged to home on postoperative day 12. At time of discharge, his wounds wre clean, his BP was 110-120/70's, HR 60-70's(sinus) and room air saturations of 96%. Medications on Admission: Ecotrin 325mg daily Crestor 10mg every evening Zetia 10mg every morning Toprol XL 100mg every morning Levoxyl 225mcg daily Lisinopril 20mg every morning Omeprazole 20mg every morning Celebrex 200mg every morning Darvocet 100mg, two-three tablets every day Folic acid 400mcg daily Vitamin E 400 IU daily Vitamin C 1000mg daily MVI Lysine Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 6. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 7. Celecoxib 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 5 days: Then decrease dose to 400 mg PO daily for 7 days, then decrease to 200 mg PO daily. Disp:*60 Tablet(s)* Refills:*0* 9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed. Disp:*50 Tablet(s)* Refills:*0* 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 11. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 12. Coumadin 1 mg Tablet Sig: Zero (0) Tablet PO once a day: No Coumadin until blood drawn (on Tuesday, [**9-17**]), and checked by Dr[**Doctor Last Name **] office. They will dose for target INR 2.0-2.5 . Disp:*120 Tablet(s)* Refills:*2* 13. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 14. Lopressor 50 mg Tablet Sig: 1 [**12-9**] Tablet PO twice a day. Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Coronary artery disease - s/p CABG, Hypertension, Hypercholesterolemia, Diabetes mellitus, Chronic Renal Insufficiency, Hypothyroidism - s/p Thyroidectomy, Peripheral Neuropathy, Depression, Diverticular Disease - s/p Partial Bowel resection, s/p Right total knee replacement, Possible Sleep Apnea, Abnormal Gait, Postoperative Atrial Fibrillation, Elevated INR Discharge Condition: Good Discharge Instructions: 1)Patient may shower. No baths. No creams or lotions to incisions. 2)No driving for at least one month. 3)No lifting more than 10 lbs for at least 10 weeks. Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 2 weeks - will manage Warfarin as outpatient Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5293**] in 2 weeks Completed by:[**2165-10-15**]

[ "427.31", "244.9", "414.01", "356.9", "272.0", "401.9", "250.00", "585.9", "411.1", "V43.65" ]

icd9cm

[ [ [] ] ]

[ "39.61", "37.22", "88.53", "36.12", "36.15", "88.55" ]

icd9pcs

[ [ [] ] ]

8002, 8051

2946, 5674

343, 606

8457, 8464

2671, 2923

8669, 8945

2296, 2331

6062, 7979

8072, 8436

5700, 6039

8488, 8646

2346, 2652

282, 305

634, 1561

1583, 1972

1988, 2280

82,073

121,324

39538

Discharge summary

report

Admission Date: [**2160-11-15**] Discharge Date: [**2160-12-11**] Date of Birth: [**2088-9-1**] Sex: F Service: SURGERY Allergies: Spiriva with HandiHaler / Seroquel Attending:[**First Name3 (LF) 3376**] Chief Complaint: Abdominal Abcsess Major Surgical or Invasive Procedure: 1. Exploratory laparotomy. 2. Drainage of abdominal abscess. History of Present Illness: This is a 72 year-old woman with a complicated past medical history, including SLE on chronic steroids, diabetes, COPD, and multiple strokes. Briefly, she initially presented with perforated diverticultis requiring left hemi-colectomy with diverting loop ileostomy ([**2160-7-16**]). Her post-operative course was complicated by prolonged mechanical ventilation, watershed CVA with residual weakness. She was discharged to rehab on broad spectrum antibiotics, and was subsequently re-admitted for altered mental status and was found to have recurrent strokes and non-convulsive status epilepticus. She had developed on subdiaphragmatic abscess which has been treated by an IR placed drain. She has had prolonged delirium, felt to be related to loss of normal sleep-wake cycles. She was admitted on [**11-6**] with a dislodged drain which was subsequently replaced by IR on [**11-8**] with 120 cc of purulent drainage removed. She had been afebrile with a leukocytosis on that admission. Antibiotics had been forgone at that time and cultures were obtained. The patient is intermittently agitated and unable to comply with history or physical exam. She returns to the [**Hospital1 18**] ED with fever to 101.3 per her rehab facility, a leukocytosis to 20.1 (N 85.5). Since discharge, her LUQ abdominal abscess has cultured two-strands of MRSA. In the ED she received Ativan IV for anxiety and Vancomycin, Levaquin, and Flagyl. Past Medical History: SLE HTN Chronic steroids DM2 Spinal stenosis COPD CVA - 10 yrs ago secondary to carotid disease, and again this year believed to be embolic. Hyperipidemia, Neurogenic bladder Hypercholesterolemia Diverticulosis Spinal stenosis Right rotator cuff injury/tear Past Surgical History: s/p laminectomy ([**2160-5-30**]) s/p splenectomy, s/p LLL lung resection for nodule s/p appendectomy s/p L CEA s/p D&C s/p open L hemicolectomy w/diverting ileostomy s/P PEG [**2160-9-11**] Social History: Married. Previously lived in [**Location 53428**], NH; now at rehab facility. Does not currently drink or smoke. Family History: Father: esophageal cancer Mother: CVA Brother: CAD Physical Exam: VS: 98.2 98.1 92 126/70 20 99%RA Gen - Pt confused, agitated at baseline Pulm - CTAB CV - rrr no m/g/r Abd - +BS, soft, ND, mildly TTP, left subcostal incision CDI with drain in place, currently draining serosanguinous fluid. Extrem - no c/c/e Pertinent Results: Dilantin levels [**2160-12-10**] 06:00 12.2 [**2160-12-9**] 05:50 13.4 [**2160-12-7**] 09:25 13.9 [**2160-12-6**] 07:20 14.4 [**2160-12-5**] 05:50 16.8 [**2160-12-4**] 05:50 18.7 [**2160-12-3**] 05:30 18.1 [**2160-12-2**] 06:00 19.6 INR trend 3.6 -> 2.5 -> 1.9 ->1.7 Serum sodium trend 127 -> 130 -> 129 -> 128 Glucose UreaN Creat Na K Cl HCO3 AnGap [**2160-12-11**] 06:00 150*1 14 0.3* 128* 3.9 96 25 11 [**2160-12-10**] 17:45 110*1 12 0.4 129* 5.0 96 25 13 [**2160-12-10**] 06:00 158*1 13 0.4 130* 4.5 95* 25 15 [**2160-12-9**] 15:30 961 10 0.3* 127* 5.2* 95* 25 12 [**2160-12-9**] 05:50 142*1 11 0.3* 130* 4.8 99 25 11 [**2160-12-8**] 15:35 901 10 0.3* 130* 4.9 98 24 13 [**2160-12-8**] 05:50 981 10 0.3* 131* 4.6 100 26 10 [**2160-12-7**] 13:25 145*1 9 0.3* 130* 5.0 97 23 15 [**2160-12-7**] 09:25 166*1 11 0.3* 129* 4.8 98 22 14 [**2160-12-6**] 15:00 114*1 9 0.3* 132* 5.2* 99 24 14 [**2160-12-6**] 12:50 147*1 9 0.3* 129* 6.3*2 98 21* 16 GROSSLY HEMOLYZED SPECIMEN [**2160-12-6**] 07:20 125*1 11 0.3* 131* 4.5 99 24 13 [**2160-12-5**] 13:15 111*1 13 0.4 130* 5.1 97 26 12 [**2160-12-5**] 05:50 160*1 14 0.4 131* 4.8 98 26 12 [**2160-12-4**] 16:20 128* 5.2* 96 [**2160-12-4**] 05:50 127*1 11 0.4 129* 5.1 94* 27 13 [**2160-12-3**] 05:30 147*1 15 0.4 131* 4.9 99 25 12 [**2160-11-15**] WBC-20.1* Hct-29.8* [**2160-11-16**] WBC-16.9* Hct-29.2* [**2160-11-19**] WBC-11.7* Hct-25.6* [**2160-11-15**] URINE CULTURE (Preliminary): ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. OF TWO COLONIAL MORPHOLOGIES. Piperacillin/tazobactam sensitivity testing available on request. GRAM NEGATIVE ROD #2. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ 4 S 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-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [**2160-11-15**] ABSCESS GRAM STAIN (Final [**2160-11-15**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. WOUND CULTURE (Final [**2160-11-18**]): STAPH AUREUS COAG +. MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES. 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. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>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------------ 1 S ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. [**2160-11-16**] 1:19 am ABSCESS Source: LUQ Abscess/abdomen. GRAM STAIN (Final [**2160-11-16**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. FLUID CULTURE (Final [**2160-11-19**]): STAPH AUREUS COAG +. HEAVY GROWTH OF TWO COLONIAL MORPHOLOGIES. SENSITIVITIES PERFORMED ON CULTURE # 312-8304C [**2160-11-15**]. ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. [**2160-11-15**] - CT Abd/Pelvis IMPRESSION: 1. Retraction of peritoneal drain to abdominal wall, and interval reaccumulation of multiloculated fluid collection, with features concerning for superinfection. Persistent inflammatory changes and additional small fluid collections in the remainder of the abdomen. 2. Changes of loop ileostomy and left hemicolectomy. 3. Cholelithiasis, without acute cholecystitis. 4. Extensive atherosclerosis. Brief Hospital Course: The patient was admitted to the Colorectal service on [**2160-11-15**] for an elevated WBC and drain replacement and on HD 3 had an exploratory laparotomy with washout. The patient tolerated the procedure well. Due to her history of CVA the patient was admitted to the ICU postoperatively. Propofol was weaned and she was extubated on POD 1. [**2079-11-18**] [**Hospital Unit Name 153**] course: -aline d/c'd -lovenox started for DVT/PE -given hypoactive delirium post extubation, geriatrics weaned down valium, prn haldol for agitation, standing tylenol and prn morphine for pain -phenytoin levels subtherapeutic, additional doses given, and levels monitored -restarted on insulin sliding scale and home lantus -changed cipro to meropenem given resistent klebsiella in urine, total 10 day course needed -hyponatremia resolved with pain control and initiation of tube feeds Neuro: Post-operatively, the patient received Dilaudid IV with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. Neurology was consulted and followed closely with regular monitoring of neuroleptic and antipsychotic regimen and appropriate titration. They deemed her as non-epileptic and her confusional state acute on chronic encephalopathy. They recomended continuing phenytoin 125 q12h and oxcarbazepine 450mg [**Hospital1 **] which she was on at time of discharge with weekly phenytoin and albumin levels. Of note, her confusional state led to waxing and [**Doctor Last Name 688**] agitation and intermittently required restraints for safety. ALBUMIN AND DILANTIN LEVELS WILL BE DRAWN EVERY WEDNESDAY, PLEASE CALL DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 84410**] FOR ADJUSTMENT OF HER DILANTIN DOSING. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: Hospitalization was unremarkable from a pulmonary standpoint except for the initial brief intubation post-operatively. After extubation, there were no pulmonary issues during this hospitalization. F/E/N: Pt was supported on IV fluids until tolerating tube feeds and a dysphagia diet. Pt was persistently hyponatremic during this admission requiring intermittent normal saline fluid boluses with lasix until the time of discharge. Her antipsychotic and neuroleptic medications were regularly monitored and titrated in an attempt to minimize iatrogenic causes. HER SERUM SODIUM LEVELS WILL BE DRAWN EVERY MONDAY. PLEASE CALL DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 84410**] FOR ADJUSTMENT OF HER SODIUM TABLET DOSING. GI: Post-operatively, the patient was made NPO and supported on IV fluids until able to tolerate a diet. Her diet was advanced to a clears on POD 3 and then to a dysphasia diet on POD 6 with supplements which was tolerated well. Due to hyponatremia, pt was free water restricted at this time to 1.5 L. Tube Feeds, started in the pre-operative period due to poor PO intake was continued post-operatively initially as Fibersource HN reaching goal POD 3 and cycled [**2160-11-27**] then switched to Nutren 2.0 Full strength on [**2160-12-5**] for hyponatremia which continued until discharge. Ostomy output was regularly recorded and stoma site was monitored for signs of infection. GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. Foley was discontinued on POD 1 and patient was started on intermittent catheterization. Intake and output were closely monitored and patient was free water restricted for persistent hyponatremia. She was started on salt tablets to help stabilize her sodium level. ID: Pre-operatively, the patient was started on IV Ciprro, and Flagyl for a UTI and to cover enteric organisms. She started on Vancomycin on POD 1 to cover gram positive organisms once her abscess cultures grew gram positive cocci. Coag + staph ultimately grew out of that culture. Her regimen of Vancomycin, Ciprofloxacin, and Flagyl were changed to Vancomycin, Meropenem, and Flagyl [**2161-11-19**] to tailor antibiosis for culture sensitivities and concern for ESBL Klebsiella from a preoperative urine culture. Patient was started on Bactrim and Fluconazole [**2160-11-25**] for E.Coli/ Klebsiela in her urine cultures and Fluconazole sensitive [**Female First Name (un) 564**] from the drain cultures. The patient was ultimately discharged on an oral regimen of Fluconazole and Bactrim x 8 days. The patient's temperature was closely watched for signs of infection and remained afebrile throughout the course of this admission. Heme/Prophylaxis: The patient received lovenox SC during this stay and was bridged to coumadin prior to discharge with regular INR monitoring. At time of discharge, INR was 1.7. In addition, pt remained on sequential compression boots while in bed. INR WILL BE DRAWN EVERY MONDAY, WEDNESDAY, AND FRIDAY. PLEASE CALL DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 84410**] FOR ADJUSTMENT OF HER WARFARIN DOSING. Dispo: Given the patient's baseline mental status and impairment and recurrent intraabdominal disease, multiple family meetings with case management, social work, geriatric psychiatry, palliative care, and the surgical service were held during this admission. Pt was made DNR/DNI [**2160-12-1**] following a final family meeting with Attending Physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1120**] present. Despite the recommendations against taking the patient home, the family requested the patient be discharged into their care. CONDITION OF DISCHARGE IS THAT FAMILY SCREEN 2 HOSPICE CARE FACILITIES and choose one in the event that the patients medical status deteriorates and that she requires an increased level of care. If the patient is no longer able to provide the level of care required of the patient they are to contact their [**Name (NI) 269**] who will arrange transfer to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] HOSPICE HOME. [**Doctor First Name 87317**] [**Hospital1 1559**], [**Numeric Identifier 87318**]. Consulting Services: Neurology, Geriatric Psychiatry, Infectious Disease, Palliative Care She was discharged home under the care of her daughter with baseline mental status (chronic confusion), afebrile with stable vital signs, tolerating a dysphagia diet, supplements, and tube feeds and pain was well controlled. Medications on Admission: Prednisone 10 mg PO daily, Warfarin 5 mg PO daily, Humalog SSI TID, Lantus 7 units SC daily, B complex vitamins, Clotrimazole 1% cream applied vaginally QHS, Diazepam 5 mg PO BID, Erythromycin 5mg/gram (0.5%) ophthalamic TID, Loperamide 2 mg PO BID, Melatonin 0.5 mg PO QHS, Metoprolol 25 mg PO BID, Miconazole 2% applied topical [**Hospital1 **], Omeprazole 20 mg EC PO daily, Oxcarbazepine 300 mg/5mL Susp PO BID, Phenytoin ER 100 mg PO daily @ 14:30, Phenytoin ER 300 mg PO BID, Vitamin D3 400 units 5 tbs PO daily, Tylenol 325 mg PO Q4H PRN pain Discharge Medications: 1. loperamide 1 mg/5 mL Liquid [**Hospital1 **]: Two (2) PO BID (2 times a day). Disp:*60 5mL* Refills:*2* 2. B complex-vitamin C-folic acid 1 mg Capsule [**Hospital1 **]: One (1) Cap PO DAILY (Daily). Disp:*30 capsule* Refills:*2* 3. prednisone 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. sulfamethoxazole-trimethoprim 800-160 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) for 8 doses. Disp:*8 Tablet(s)* Refills:*0* 5. fluconazole 200 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q24H (every 24 hours) for 8 days. Disp:*16 Tablet(s)* Refills:*0* 6. sodium chloride 1 gram Tablet [**Hospital1 **]: One (1) Tablet PO 5x/day. Disp:*300 Tablet(s)* Refills:*2* 7. nystatin 100,000 unit/g Ointment [**Hospital1 **]: One (1) Appl Topical QID (4 times a day) as needed for around drain site for erythema. 8. melatonin 3 mg Tablet [**Hospital1 **]: One (1) Tablet PO QHS (once a day (at bedtime)). 9. oxcarbazepine 300 mg/5 mL Suspension [**Hospital1 **]: Four [**Age over 90 1230**]y (450) mg PO BID (2 times a day): OK to give PO or NG. Disp:*30 suspension* Refills:*2* 10. acetaminophen 650 mg/20.3 mL Solution [**Age over 90 **]: One (1) PO QID (4 times a day). 11. B complex-vitamin C-folic acid 1 mg Capsule [**Age over 90 **]: One (1) Cap PO DAILY (Daily). 12. cholecalciferol (vitamin D3) 400 unit Tablet [**Age over 90 **]: One (1) Tablet PO DAILY (Daily). 13. metoprolol tartrate 25 mg Tablet [**Age over 90 **]: One (1) Tablet PO BID (2 times a day): PO/NG. Disp:*30 Tablet(s)* Refills:*2* 14. phenytoin 125 mg/5 mL Suspension [**Age over 90 **]: One (1) PO Q12H (every 12 hours). Disp:*60 5mL* Refills:*2* 15. warfarin 1 mg Tablet [**Age over 90 **]: Two (2) Tablet PO once a day for 1 doses: *****Will have INR levels checked MWF to adjust dosing*****. Disp:*60 Tablet(s)* Refills:*4* 16. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day. Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2* 17. furosemide 10 mg/mL Solution [**Last Name (STitle) **]: One (1) PO once a day. Disp:*30 10mL* Refills:*2* Discharge Disposition: Home with Service Facility: [**Hospital 54752**] Rehab & Skilled Nursing Center - [**Hospital1 1559**] Discharge Diagnosis: Abdominal abscess. Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: You were admitted because the abdominal drain placed to treat your abdominal fluid collections came out in your rehabilitation facility. You were found to have fluid collections not amenable to drainage and were taken to the OR for an exploratory laparotomy and washout of your abdomen. A new drain has been left in place and subsequently removed after minimal output was noted, and you have recovered enough to return to a rehabilitation facility to continue your recovery. Please call your [**Hospital1 269**] if you experience 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. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. General Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: *Please call your [**Hospital1 269**] 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. Followup Instructions: Please call Dr [**Last Name (STitle) 1120**] for follow up in 2 weeks. Her office number is [**Telephone/Fax (1) 15106**]. Condition of discharge is that patient's family interview 2 hospice locations and choose one in the week following discharge, in the case that patient's condition worsens. If patient needs an increased level of care, please contact your [**Name (NI) 269**] who has contacts with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 87319**] House.

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icd9cm

[ [ [] ] ]

[ "54.19", "54.91", "54.3" ]

icd9pcs

[ [ [] ] ]

16884, 16989

7566, 14078

313, 376

17052, 17052

2810, 4315

19160, 19643

2478, 2531

14679, 16861

17010, 17031

14104, 14656

17186, 18377

18777, 19137

2137, 2330

2546, 2791

7079, 7543

18409, 18762

256, 275

4350, 6438

404, 1833

7019, 7046

17067, 17162

1855, 2114

2346, 2462

62,745

133,623

249

Discharge summary

report

Admission Date: [**2145-11-30**] Discharge Date: [**2145-12-1**] Date of Birth: [**2091-4-13**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2485**] Chief Complaint: Afib with RVR Major Surgical or Invasive Procedure: None History of Present Illness: 54M with hx of ETOH abuse, HCV, presented to the ED this evening intoxicated. Upon arrival the pt was noted to have slurred speech and decreased responsiveness. The patient states that today he invited a friend over to his house where he shared 1L of vodka. The pt reports that while drinking he experienced left sided chest pain that led his friend to call EMS for him. The pt states he drinks heavily [**2-3**]/month. He denies history of seizure, loss of urine or stool. No loss of consciousness, no known trauma. The pt describes his chest pain as left sided [**8-12**], with radiation to the left arm. No known CAD. +Reproducibility with palpation. . In the emergency department initial vitals 98.2 100 116/71 20 100%RA Exam was notable for an intoxicated male with clear lungs and without signs of aspiration on CXR. Upon assessment the pt reportedly became combative with a HR revealing AF with RVR with rates in 160-170s. Pt has received a total of 100mg of Valium during his ED course, Diltiazem 30mg IV of dilt x3, Dilt 30mg PO and subsequently placed on a Diltiazem drip at 15mg/hr. Lactate of 3.2->2.6->1.8 following 4L of NS. . The pt subsequently re-developed chest pain while in the ED. Received ASA 325mg and Nitro 0.4mg x3. Repeat ECG unchanged. Cardiology evaluated pt and felt his pain was unlikely cardiac. Recommended Metoprolol. Chest Pain improved with a total of Morphine 12mg IV and Dilaudid 1mg IV. . Upon arrival to the unit the patient states his chest pain remains a [**8-12**] with radiation to left arm. Denies headache, visual changes, sweats, hallucination, fevers, chills, cough, BRBPR, melena, emesis, abdominal pain. Past Medical History: 1. ETOH abuse as above 2. Hepatitis C: He has never been treated and is followed by his PCP. 3. s/p cholecystectomy in [**2121**] 4. s/p bariatric surgery in [**2110**] 5. h/o PUD in [**2121**] 6. h/o C. diff in [**2132**] Social History: Pt lives alone. His only child is the son who died in the war. He is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] at [**Company 2486**]. . Tobacco: quit 4 years ago, 10 year pack history ETOH: as above Recreational drugs: denied use, inc. IVDA Family History: Colorectal cancer in uncle (45yo), uncle (37yo), grandmother (92) Physical Exam: VITAL SIGNS: T=97.5 BP=154/76 HR 90 RR=16 94RA PHYSICAL EXAM GENERAL: Pleasant, mildly discheveled male in NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Irregularly irregular, tachycardic. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. JVP flat LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: No nystagmus. No asterxis. A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [**12-4**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: CXR [**11-30**]: UPRIGHT AP VIEW OF THE CHEST: The cardiac silhouette is top normal in size. The mediastinal and hilar contours are stable. Pulmonary vascularity is normal. The lungs are clear. No pleural effusion or pneumothorax is visualized. Left acromioclavicular joint separation is redemonstrated, unchanged. IMPRESSION: No acute cardiopulmonary abnormality. . [**2145-11-30**] 01:30PM WBC-5.5# RBC-3.97* HGB-9.0* HCT-30.3* MCV-76*# MCH-22.7*# MCHC-29.8* RDW-18.9* [**2145-11-30**] 01:30PM NEUTS-59.4 LYMPHS-34.1 MONOS-4.1 EOS-1.5 BASOS-0.8 [**2145-11-30**] 01:30PM PLT COUNT-309 [**2145-11-30**] 01:30PM GLUCOSE-111* UREA N-15 CREAT-0.8 SODIUM-144 POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-25 ANION GAP-15 [**2145-11-30**] 09:30PM CK-MB-7 cTropnT-<0.01 [**2145-11-30**] 09:30PM CK(CPK)-547* [**2145-11-30**] 09:35PM LACTATE-2.6* [**2145-11-30**] 01:30PM BLOOD ASA-NEG Ethanol-412* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2145-12-1**] 01:54AM BLOOD Lactate-1.8 Brief Hospital Course: ASSESSMENT AND PLAN: 54M with hx of ETOH abuse, HCV, presenting with AF with RVR, Chest Pain in the setting of ETOH intoxication. . #: AF with RVR: Pt was in AF with RVR at presentation, which was a new finding from prior EKGs. EKG showed no evidence of ischemia. Pt was started on dilt gtt in ED and was transitioned to PO metoprolol after arriving the ICU. HR was stable in 90s at rest. Patient left AMA without waiting to receive his prescriptions or cardiology follow-up. He was instructed to return to the ED for palpitations, chest pain, SOB or any other symptoms. He was instructed to follow up with his PCP. . # ETOH Intoxication: Pt presented with ETOH level of 412 and was intoxicated. Lactate elevated but quickly trended down. He received banana bag, and PO folate and thiamine. Electrolytes were normal. Patient was monitored on CIWA scale in the ICU and received Valium prn. SW was consulted. However, patient left AMA. He stated he planned to take his home dose Campral and continue attending AA meetings. He lives in a recovery home and was instructed to have EMS notified if he experiences shaking, confusion or any other symptoms. . #. Chest pain: Pt presented with atypical chest pain in the setting of intoxication that was reproducible on palpation. He denies trauma but had been lifting heavy boxes recently. Pt evaluated by Cards while in ED who felt that pain was non-cardiac. ASA 325mg and Nitroglycerin x1. One set of CE was significant for elevated CK but normal troponin. DDx includes muscluoskeletal, no evidence of PNA or ACS. PE unlikely given reproducibility. . # Anemia: Hct 30 on arrival. Near prior baseline. No evidence of GI Bleed, no known prior hx of varies. . # HCV: Currently not receiving treatment. [**Hospital6 1597**], records confirmed that Hep C antibody was confirmed to be positive [**2143-6-2**]. HCV genotype was type IB, and RNA viral load was 996,000 copies at that time. Medications on Admission: None Discharge Medications: Patient left against medical advice. Discharge Disposition: Home Discharge Diagnosis: Patient left against medical advice. Discharge Condition: Patient left against medical advice. Discharge Instructions: Patient left against medical advice. Followup Instructions: Patient left against medical advice.

[ "305.02", "070.70", "786.59", "293.0", "285.9", "427.31" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6528, 6534

4485, 6412

287, 293

6614, 6652

3473, 4462

6737, 6776

2528, 2595

6467, 6505

6555, 6593

6438, 6444

6676, 6714

2610, 3454

234, 249

321, 1975

1997, 2228

2244, 2512

16,241

101,623

5439

Discharge summary

report

Admission Date: [**2157-5-29**] Discharge Date: [**2157-6-16**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: SSCP x 3 days Major Surgical or Invasive Procedure: Catheterization cabg x3 on [**2157-6-3**] (LIMA to LAD, SVG to OM, SVG to RCA) History of Present Illness: Pt is as [**Age over 90 **] y/o male who was seen in the ER for non-radiating SSCP of three days duration and now admitted to the floor for Acute Coronary Syndrome. Pt explains CP as a "tooth ache", that will last 10-20 minutes at most. He denies CP currently, SOB, diaphoresis, dizziness, nausea or vomitting during his prior CP. Pt explains that he had a dry non-productive cough without fever and chills. He states that his son had pneumonia last week. No previous cardiac hx. Past Medical History: HTN Left shoulder hemiarthroplasty Legally blind CRI (baseline 2.1) Social History: lives at home with children, denies smoking/alcohol/drugs Family History: non-contrib Physical Exam: PEx: Vitals: 97.2 143/67 59 18 95% on 2L Gen: AAOx3, NAD, [**Last Name (un) 1425**] HEENT: normocephalic, PERRLA, MMM, no LAD, no JVD PULM: CTA b/l CV: RRR, nl S1 S2, no m/r/g Abd: soft, NT/ND, obese, no r/g LE: + palpable pedal pulses, minimal non-pitting edema b/l 73" 275# Pertinent Results: [**2157-6-16**] 10:40AM BLOOD WBC-5.2 RBC-3.76* Hgb-10.8* Hct-32.6* MCV-87 MCH-28.6 MCHC-33.0 RDW-15.2 Plt Ct-281 [**2157-6-12**] 05:10AM BLOOD PT-13.9* PTT-26.7 INR(PT)-1.2* [**2157-6-16**] 10:40AM BLOOD Glucose-125* UreaN-38* Creat-2.7* Na-143 K-3.9 Cl-110* HCO3-23 AnGap-14 RADIOLOGY Final Report CHEST (PA & LAT) [**2157-6-14**] 10:46 AM CHEST (PA & LAT) Reason: eval effusions [**Hospital 93**] MEDICAL CONDITION: [**Age over 90 **] year old man with HTN, and ACS s/p CABGx3 REASON FOR THIS EXAMINATION: eval effusions PA AND LATERAL VIEWS OF THE CHEST REASON FOR EXAM: [**Age over 90 **]-year-old man with hypertension, ACS, S/P CABG. Please follow up pleural effusions. Comparison is made with prior study dated [**2157-6-10**]. FINDINGS: Allowing the difference of technique and positioning of the patient, moderate bilateral pleural effusions are again seen, likely the right decreased and increase in the left side. There is no evidence of CHF. There are bibasilar atelectasis. Patient is S/P median sternotomy and CABG. Stable cardiomegaly. Widened superior mediastinum and deviation of the trachea to the right, unchanged from prior studies. IMPRESSION: Bilateral pleural effusions, likely increase in the left and decrease in the right side. Bibasilar atelectasis. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 3901**] [**Name (STitle) 3902**] DR. [**First Name (STitle) 5432**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Approved: WED [**2157-6-15**] 4:36 PM Cardiology Report ECHO Study Date of [**2157-6-3**] PATIENT/TEST INFORMATION: Indication: Aortic valve disease. Coronary artery disease. Left ventricular function. Mitral valve disease. Valvular heart disease. Status: Inpatient Date/Time: [**2157-6-3**] at 09:59 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006AW04-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) 1112**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] MEASUREMENTS: Left Ventricle - Septal Wall Thickness: *1.3 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.7 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 3.6 cm Left Ventricle - Fractional Shortening: *0.23 (nl >= 0.29) Left Ventricle - Ejection Fraction: >= 55% (nl >=55%) Aorta - Valve Level: 2.1 cm (nl <= 3.6 cm) Aorta - Ascending: 3.3 cm (nl <= 3.4 cm) Mitral Valve - E Wave: 0.6 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A Ratio: 0.86 Mitral Valve - E Wave Deceleration Time: 299 msec INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. All four pulmonary veins identified and enter the left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No spontaneous echo contrast or thrombus in the body of the RA or RAA. No ASD by 2D or color Doppler. The IVC is normal in diameter with appropriate phasic respirator variation. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Mild symmetric LVH. Normal LV cavity size. Normal regional LV systolic function. Overall normal LVEF (>55%). LV WALL MOTION: basal anterior - normal; mid anterior - normal; basal anteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal; mid inferoseptal - normal; basal inferior - normal; mid inferior - normal; basal inferolateral - normal; mid inferolateral - normal; basal anterolateral - normal; mid anterolateral - normal; anterior apex - normal; septal apex - normal; inferior apex - normal; lateral apex - normal; apex - normal; 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: Three aortic valve leaflets. Mildly thickened aortic valve leaflets. No AS. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild thickening of mitral valve chordae. Mild to moderate ([**11-22**]+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. Conclusions: PRE-BYPASS: The left atrium is moderately dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No spontaneous echo contrast or thrombus is seen in the body of the right atrium or the right 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. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**11-22**]+) mitral regurgitation is seen. There is no pericardial effusion. POST CPB: Preserved biventricular systolic function. Mild MR [**First Name (Titles) **] [**Last Name (Titles) **]. No other change. Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD on [**2157-6-3**] 12:43. [**Location (un) **] PHYSICIAN: ([**Numeric Identifier 22048**]) Brief Hospital Course: Pt received ASA, Lopressor and Heparin in the ED. Labs of note were troponin at .11, and a chest x-ray that stated possible pneumonia in his left lower lobe. Pt underwent catheterization on [**5-30**] which revealed severe 3 vessel disease, and did not receive stenting. It was then determined that his best next option would be CABG, CT surgery was consulted. Pt was monitored on the floor, received SL nitro for CP and repeat EKGs. Of concern was his renal function, however his creatinine remained stable around 2.0 pre- and post- catheterization. He had an echo, carotid US, UA and LFTs completed before his CABG procedure on [**6-3**] with results above. Underwent cabg x3 with Dr. [**Last Name (STitle) **] on [**6-3**] and transferred to the CSRu in stable condition on neosynephrine and propofol drips. Epinephrine and insulin drips added overnight, slightly acidotic and transfused on POD #1 as vent wean started. Platelet count decreased to 88K and HIT panel sent. Extubated on POD #2 and Swan removed. Went into AFib on POD #3 and amiodarone started as well as beta blockade and gentle diuresis. Pacing wires removed without incident on POD #4.HIT negative on [**6-7**] and converted to SR on amiodarone.Foley removed on POD #5 and transferred to the floor to begin increasing his activity level. Lethargy improved and alert and oriented on POD #6. Had some confusion overnight and treated with haldol. He eventually improved and had a creat of 3.0. Renal was consulted and felt that he was pre renal, and he was encouraged to increase PO intake. His creat decreased to 2.7 and he was discharged to home on POD#13 in stable condition. Medications on Admission: ASA 325mg daily lipitor 10 mg daily plavix 75 mg daily (LD [**5-31**]) Protonix 40 mg daily lopressor 25 mg [**Hospital1 **] SL NTG ? Multivitamin mucomyst bicarbonate heparin drip colace 100 mg daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for 1 months. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:*1 month supply* Refills:*2* 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 5 days. Disp:*15 Tablet(s)* Refills:*0* 8. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: s/p cabg x3 HTN CRI renal calculi legally blind left shoulder surgery Discharge Condition: stable Discharge Instructions: may shower over incisions and pat dry may not drive for one month no lifting greater than 10 pounds for 10 weeks call for fever greater than 100, redness, or drainage no lotions, creams or powders on any incision Followup Instructions: follow up with Dr. [**Last Name (STitle) **] in [**11-22**] weeks follow up with Dr. [**Last Name (STitle) 171**] in [**12-24**] weeks follow up with Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] Completed by:[**2157-6-16**]

[ "403.91", "584.9", "410.71", "414.01", "369.4", "787.91", "276.2", "276.50", "427.31", "273.8", "518.0", "272.4" ]

icd9cm

[ [ [] ] ]

[ "88.72", "36.12", "88.56", "39.61", "36.15", "37.22" ]

icd9pcs

[ [ [] ] ]

10436, 10494

7366, 9019

282, 363

10608, 10617

1387, 1775

10878, 11128

1060, 1073

9270, 10413

1812, 1873

10515, 10587

9045, 9247

10641, 10855

3026, 7018

1088, 1368

229, 244

1902, 3000

391, 878

7301, 7343

900, 969

985, 1044

7029, 7267

57,604

163,003

52036

Discharge summary

report

Admission Date: [**2127-12-23**] Discharge Date: [**2127-12-28**] Date of Birth: [**2055-9-5**] Sex: M Service: MEDICINE Allergies: Vioxx / Protonix Attending:[**First Name3 (LF) 5608**] Chief Complaint: LGI Bleeding Major Surgical or Invasive Procedure: TRACHEOSTOMY PERCUTANEOUS GASTRIC TUBE PLACEMENT History of Present Illness: 72 year old male with CAD who was admitted to [**Hospital 4199**] Hospital [**2127-12-1**] after MVA causing R. tibial fracture. He subsequently underwent ORIF; post op he had increasing pain that was difficult to control; as sa result of increased pain meds he became sedated which was felt to have led to an aspiration event; he was given narcan. Subsequently on [**12-5**] he had a hypoxic event and a diagnosis of PE was made; which required intubation. Since that time he has required AC ventilation with requirements of FIO2 80%/PEEP 5. Of note, this hypoxic event was felt to be extensive and patients neurologic status has not improved since. He was transferred to [**Hospital1 **] for rehab on the ventilation while on heparin & today was transferred back to [**Last Name (un) 4199**] for evaluation for Trach/PEG. He was noted to have BRBPR, a hct was 22 (down from 27). PTT>150. He was given 1U prbcs and per report an EGD was done with no source of bleeding. The GI service felt pt would benefit from arteriogram with vasopressin adminstration; he was given peripheral vasopressin he was subsequently transferred to [**Hospital1 18**] for evaluation of GIB plus evaluation for trach/peg. Past Medical History: CAD s/p MI [**2111**] and [**2114**]; most recent MI accompanied by cardiac arrest; tx medically with Sotalol Lumbar stenosis s/p lumbar surgery Polymyalgia Rheumatica s/p CCY Hyperlipidemia DJD COPD- 3 ppd history Social History: 60 pack-year smoking history. He is now down to 6 cigarettes per day. He denies any alcohol consumption. He is married and lives with his wife. [**Name (NI) **] has 3 children. He used to work as a parking garage manager. Family History: No history of malignancy in first degree relatives. History of coronary artery disease. Physical Exam: Vitals - T:99.3 BP:113/68 HR:77 RR:29 02 sat:100% GENERAL: sedated, intubated HEENT:Intubated, ET tube in place CARDIAC: Regular rate and rhythm LUNG: scattered rhonchi anteriorly ABDOMEN: Soft, non-distended, BS present EXT: edema R>L NEURO:not responsive to verbal stimuli Cool extremities Pertinent Results: ================== ADMISSION LABS ================== [**2127-12-23**] 04:33AM BLOOD WBC-17.4*# RBC-2.68*# Hgb-8.2*# Hct-24.7*# MCV-92 MCH-30.5 MCHC-33.2 RDW-17.7* Plt Ct-233 [**2127-12-23**] 04:33AM BLOOD Neuts-89.7* Lymphs-7.6* Monos-2.1 Eos-0.4 Baso-0.2 [**2127-12-23**] 04:33AM BLOOD PT-13.7* PTT-27.4 INR(PT)-1.2* [**2127-12-23**] 04:33AM BLOOD Glucose-186* UreaN-32* Creat-0.6 Na-139 K-4.0 Cl-102 HCO3-32 AnGap-9 [**2127-12-23**] 04:33AM BLOOD Calcium-7.4* Phos-3.1 Mg-2.1 [**2127-12-23**] 04:33AM BLOOD Cortsol-22.2* Brief Hospital Course: 54 year old woman with past medical history of morbid obesity (s/p gastric lap banding), hypertension, hyperlipidemia, presenting with acute respiratory distress and malignant hypertension. . # RESPIRATORY FAILURE: The patient was initially intubated at an OSH following respiratory failure in the setting of increased sedation and PE. He was intubated and remained intubated upon transfer to rehab. He was referred for trach/PEG, but while undergoing the procedure he was found to have a GI bleed and transferred to [**Hospital1 18**]. On arrive the patient with respiratory failure likely multifactorial including PE, HAP/aspiration and volume overload. His prior sputum cultures had grown Enterobacter aerogenes and initially treated with Cefepime. However, his abx were changed to vancomycin/zosyn after repeat CXR [**12-11**] showed new left sided infiltrate. He completed a 14 day course of Vancomycin/Zosyn on [**2127-12-26**]. Additionally, given his pulmonary edema he was diuresed with IV lasix. He was also restarted on his heparin gtt for his prior PE, LENI were negative for DVT. The patient underwent trach and PEG on [**2127-12-26**] and weaned to PS support. The trach should not be changed for 10 days after placement and if he needed to be re-intubated it should be from above. The patient was on MMV ventilation on discharge TV 500, RR 6, FiO2 50%, PEEP 8 PSV 12 #. Mental Status: The patient with limited mental status after his accident and respiratory arrest. He was AAOx3 and fully functional prior to his accident. He was evaluated by neurology and underwent an EEG that showed some questional delta activity concerning for seizure. He was started on phenytoin per neuro. He also underwent an MRI that did not show evidence of anoxic brain injury. The etiology of his mental status is likely metabolic encephalopathy, but his prognosis is unclear. The plan is to lighten sedation and assess neurologic status. Per the wife [**Name (NI) 382**] if he does not have meaningful recovery and ventilator dependent then will likely be transitioned to comfort care. He will continue Dilantin 100mg TID and levels should be checked. #Hypotension- Patient initially hypotensive on arrival and on vasopressin. He was changed over the levophed and it was sucessfully weaned off on [**12-26**]. The patient's hypotension was likely multifactorial including infectious (pneumonia), GIB and sedation. #LGIB- The patient was noted to have bright red blood per rectum at rehab while on heparin gtt. His heparin gtt was held and after evaluation at the OSH he was noted to have 7pt Hct drop and received 1U prbcs. Per report, he had EGD and did not find a source of bleeding. On arrive the the [**Hospital1 18**] MICU he was noted to have brown stool that was guaiac positive, but no further episodes of BRBPR. The patient was transfused a total of 3U pRBC during his admssion, the most recent on [**12-24**]. Given that the patient did not have any further episodes of bleeding he was restarted on his heparin gtt without further evidence of bleeding. He was also evaluated by GI and recommended outpatient colonoscopy and follow-up given no evidence of acute bleeding. #LV Thrombus/PE: Pt with history of LV thrombus previously on coumadin. A repeat TTE did not show evidence of LV thrombus. He was transitioned to lovenox on discharge and will need to be started on coumadin. #H/o CAD s/p cardiac arrest [**2114**]: The pateint was continued on his home sotolol. His aspirin was held given his history of GI bleed. #DM: The patient was covered with an insulin sliding scale Medications on Admission: acetaminophen 650mg q6prn aspirin 81mg atropine 0.5mg IV push q1hr prn calcium carbonate/vit D daily Colace 100mg [**Hospital1 **] Zetia 10mg daily Fentanyl 50mcg/hr topical patch q72hr heparin gtt (off since [**12-22**] at 8am) Glargine 40u SCqhs Inulin Regular Flovent 4puffs WID Jevity 1.2 cal; full strength at 60mg/hr; shut off 730am ([**12-22**]) Lactobacillus 2U per NGT TID Lactulose 30mg per NGT q12prn Lansoprazole 30mg disintegrating daily Ativan 2mg IV q1hr prn Morphine Sulfate 2mg IV q2prn Zosyn 3.375g q6; start date [**12-13**] propofol gtt sotalol 80mg PO q12 Discharge Medications: 1. Calcium Carbonate 500 mg Tablet, Chewable [**Month/Year (2) **]: One (1) Tablet, Chewable PO DAILY (Daily). 2. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Month/Year (2) **]: Four (4) Puff Inhalation Q6H (every 6 hours). 3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 4. Sotalol 80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 5. Chlorhexidine Gluconate 0.12 % Mouthwash [**Last Name (STitle) **]: 1-2 MLs Mucous membrane [**Hospital1 **] (2 times a day). 6. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment [**Hospital1 **]: One (1) Appl Ophthalmic PRN (as needed) as needed for dry eyes. 7. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: [**11-22**] PO BID (2 times a day). 8. Fentanyl Citrate 25-50 mcg IV Q1:PRN pain For trach / peg pain 9. Fentanyl 25 mcg/hr Patch 72 hr [**Month/Day (2) **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 10. Lovenox 80 mg/0.8 mL Syringe [**Month/Day (2) **]: One (1) Subcutaneous twice a day. 11. Phenytoin 50 mg Tablet, Chewable [**Month/Day (2) **]: Two (2) Tablet, Chewable PO Q8H (every 8 hours). 12. Insulin Regular Human 100 unit/mL Cartridge [**Month/Day (2) **]: One (1) unit Injection four times a day: Per sliding scale; see attached. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Respiratory Failure Pulmonary Embolism Lower GI Bleed VAP Metabolic Encephalopathy Seizures Discharge Condition: Mental Status:Confused - always Level of Consciousness:Lethargic and not arousable Activity Status:Bedbound Discharge Instructions: You were admitted to the hospital for GI bleed and management of your respiratory status. You did not have any further bleeding. You did undergo a tracheostomy and PEG. You were evaluated by neurology and there was concern for seizures thus you were started on phenytoin, an anti-seizure medication. Followup Instructions: Please follow-up with GI as an outpatient You will be followed by the doctors [**First Name (Titles) **] [**Hospital3 105**] who will make recommendations regarding follow up when discharged.

[ "349.82", "518.4", "E812.0", "V45.86", "250.00", "518.5", "272.4", "V46.11", "997.31", "725", "345.90", "401.0", "415.19", "578.9", "496" ]

icd9cm

[ [ [] ] ]

[ "96.72", "43.11", "45.13", "31.1", "38.93", "33.22" ]

icd9pcs

[ [ [] ] ]

8653, 8724

3033, 4429

291, 341

8860, 8860

2483, 3010

9320, 9515

2066, 2155

7279, 8630

8745, 8839

6677, 7256

8994, 9297

2170, 2464

239, 253

369, 1571

8874, 8970

1593, 1810

1826, 2050

56,582

103,892

27888+57570

Discharge summary

report+addendum

Admission Date: [**2123-11-1**] Discharge Date: [**2123-11-5**] Date of Birth: [**2060-8-13**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain/Dyspnea Major Surgical or Invasive Procedure: Coronary Artery Bypass x 3 (LIMA-LAD, SVG-PDA, SVG-OM) [**2123-11-1**] History of Present Illness: 63 year old gentleman who developed exertional dyspnea over this past summer. A stress test was obtained in [**Month (only) 359**] which reveal inferior hypokinesis as well as scar in the infra-apical region with peri-infarct ischemia. Given the findings, he was referred on for a cardiac catheterization which revealed a 70% stenosed left main coronary artery and three vessel disease. Given the severity of his disease, he has been referred for surgical revascularization. Past Medical History: Myocardial infarction Hypertension peripheral vascular disease Hyperlipidemia Obesity COPD scrotal raphe abscess Right subclavian stenosis Active tobacco use Past Surgical History: [**2110**] Right inguinal hernia repair Nasal Septum Repair x2 [**2118**] Left inguinal hernia repair c/b epididymal hematoma Social History: Lives with: Wife in [**Name2 (NI) 47**]. 3 kids. Occupation: Farmer Tobacco: Active smoker 1 pack per day for 50 years. ETOH: Denies Family History: Mother died at 88/Father alive at 91 Physical Exam: Pulse:63 Resp: O2 sat: 98% B/P Right: Left: 168/86 Height:5'9" Weight: 215 # General:obese, using cane today for support as right groin is still sore from cath Skin: Warm[x] Dry [x] intact [x] HEENT: NCAT[x] PERRLA [x] EOMI [x]anicteric sclera,edentulous with the exception of one tiny partial tooth stump Neck: Supple [x] Full ROM []no JVD Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur-none Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] no HSM, obese Extremities: Warm [x], well-perfused [x] Edema -trace BLE right groin ecchymosis s/p cath Varicosities: bil. superficial spider veins Neuro: Grossly intact, MAE [**4-7**] strengths, nonfocal exam Pulses: Femoral Right: 1+ Left:1+ DP Right: NP Left: NP PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: 1+ Left: 2+ Carotid Bruit Right:none Left:none Pertinent Results: [**2123-11-4**] 04:55AM BLOOD WBC-12.4* RBC-3.48* Hgb-10.8* Hct-30.5* MCV-88 MCH-30.9 MCHC-35.4* RDW-13.9 Plt Ct-180 [**2123-11-3**] 04:55AM BLOOD WBC-14.4* RBC-3.66* Hgb-11.1* Hct-32.2* MCV-88 MCH-30.3 MCHC-34.4 RDW-14.0 Plt Ct-168 [**2123-11-4**] 04:55AM BLOOD Glucose-105* UreaN-18 Creat-0.6 Na-134 K-3.9 Cl-95* HCO3-32 AnGap-11 Intra-op TEE [**2123-11-1**] Conclusions Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is low normal (LVEF 50-55%). with mild global free wall hypokinesis. There are simple 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. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: The patient is AV-Paced, on no inotropes. Preserved biventricular systolic fxn. Mild MR, no AI. Aorta intact. Brief Hospital Course: The patient was brought to the operating room on [**2123-11-1**] where the patient underwent CABG x 3. See operative note for details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Wellbutrin SR was initiated for smoking cessation. 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 4, the patient was ambulatory, yet deconditioned, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to [**Location (un) 44563**] in [**Hospital1 10478**] in good condition with appropriate follow up instructions. Medications on Admission: Aspirin 81mg daily metoprolol SR 25 mg daily HCTZ 25mg daily Norvasc 5mg daily nicotine 21 mg /24 hr patch daily Zocor 40mg daily Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. 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* 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 9. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 10. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 13. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-5**] Puffs Inhalation Q6H (every 6 hours) as needed for dyspnea. 14. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Discharge Disposition: Extended Care Facility: [**Location (un) 44563**] Nursing and Rehabilitation Center - [**Hospital1 10478**] Discharge Diagnosis: Coronary Artery Disease PMH Myocardial infarction Hypertension peripheral vascular disease Hyperlipidemia Obesity COPD scrotal raphe abscess Right subclavian stenosis Active tobacco use Past Surgical History: [**2110**] Right inguinal hernia repair Nasal Septum Repair x2 [**2118**] Left inguinal hernia repair c/b epididymal hematoma Discharge Condition: Alert and oriented x3 nonfocal Deconditioned Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema [**1-6**]+ bilateral LEs Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Surgeon Dr. [**Last Name (STitle) **] at MWMC Thursday, [**2123-11-25**] 9am Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4610**] Tues, [**2123-11-30**], 1pm Please call to schedule the following: Primary Care Dr. [**First Name (STitle) **],[**First Name3 (LF) 8758**] [**Telephone/Fax (1) 67950**] in [**3-8**] weeks Completed by:[**2123-11-5**] Name: [**Known lastname 11725**],[**Known firstname **] Unit No: [**Numeric Identifier 11726**] Admission Date: [**2123-11-1**] Discharge Date: [**2123-11-5**] Date of Birth: [**2060-8-13**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 741**] Addendum: the patient was discharged with Keflex 500mg QID x2 weeks. He is to follow up in the [**Wardname 11727**] wound clinic on [**11-9**] @11AM Discharge Disposition: Extended Care Facility: [**Location (un) 11728**] Nursing and Rehabilitation Center - [**Hospital1 11729**] [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2123-11-5**]

[ "443.9", "305.1", "496", "458.29", "413.9", "272.4", "278.00", "348.39", "E878.2", "401.9", "414.01", "412" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8666, 8899

3395, 4569

330, 403

6721, 6898

2391, 3372

7686, 8643

1406, 1444

4750, 6208

6362, 6549

4595, 4727

6922, 7663

6572, 6700

1459, 2372

271, 292

431, 908

930, 1088

1255, 1390

30,041

170,860

26259

Discharge summary

report

Admission Date: [**2124-1-25**] Discharge Date: [**2124-2-2**] Date of Birth: [**2081-3-17**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3376**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: Laparotomy and small-bowel resection and mesenteric biopsies. History of Present Illness: The patient is a 42-year-old male who is transferred from [**Hospital 1562**] Hospital with a 2 day history of a GI bleed. His history of present illness is as follows: has had iron deficiency anemia treated with intravenous iron (8 doses); has had no rectal/guaiac exam with PCP. [**Name10 (NameIs) **] care MD [**First Name (Titles) 1988**] [**Last Name (Titles) 2792**] for [**2124-2-4**]. * one week ago at night, had nausea, dizziness, diaphoresis and syncope. No bloody stool at that time. * one day prior to admission, had a small [**Last Name (un) 30212**] colored stool. Three hours later, had dizziness, dyspnea, diaphoresis, syncope and one episode of clear non-bloody, non-bilious emesis. Called EMS and was taken to [**Hospital 1562**] Hospital * 6 units of blood over 20 hours (Hct 20->29) * while there, underwent EGD -> hiatal hernia, [**Doctor Last Name 15532**] esophagus but no active bleed. Past Medical History: Diabetes mellitus type I, uncontrolled - diagnosed at age 5 HTN membranous glomerulonephritis OSA on BiPAP Social History: works in real estate, quit smoking 10 yrs ago. one glass wine nightly. Family History: Mother committed [**Name2 (NI) 65034**] at age 37. Very strong family history of type I diabetes in 1st and 2nd degree relatives. Father died of MI at age 61 (also a type I diabetic) Physical Exam: PE: v/s 98.2 88 128/72 18 99% RA Gen: well-appearing overweight male in NAD HEENT: NC/AT, EOMI, PERRLA bilat., MMM, soft neck without LAD Cor: RRR with 2/6 blowing systolic murmur at L SB Lungs: CTA bilat. [**Last Name (un) **]: + BS, soft, NT, ND, no tympany, protuberant [**Last Name (un) 103**].; no masses, no hernias PVasc: palpable pulses, no edema. Musc/Skel: full ROM' Neuro: grossly intact, non-focal Pertinent Results: [**2124-1-25**] 05:27PM RET AUT-2.7 [**2124-1-25**] 05:27PM FIBRINOGE-228 [**2124-1-25**] 05:27PM PT-11.8 PTT-35.8* INR(PT)-1.0 [**2124-1-25**] 05:27PM PLT COUNT-302 [**2124-1-25**] 05:27PM NEUTS-77.1* LYMPHS-15.5* MONOS-6.2 EOS-0.8 BASOS-0.3 [**2124-1-25**] 05:27PM WBC-9.6 RBC-3.34* HGB-10.2* HCT-29.5* MCV-88# MCH-30.6 MCHC-34.6 RDW-15.5 Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 65035**],[**Known firstname **] [**2081-3-17**] 42 Male [**-8/5022**] [**Numeric Identifier 65036**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/cofc SPECIMEN SUBMITTED: PERITONEAL IMPLANTS, SMALL BOWEL TUMOR. Procedure date Tissue received Report Date Diagnosed by [**2124-1-26**] [**2124-1-26**] [**2124-1-28**] DR. [**Last Name (STitle) **]. BROWN/tcc Previous biopsies: [**Numeric Identifier 65037**] native renal biopsy DIAGNOSIS: A. Small bowel resection: Malignant gastrointestinal stromal tumor, with: 1. 9.3 cm tumor diameter. 2. Focal necrosis. 3. Invasion into lamina propria and ulceration. 4. Mesenteric implants. Dissection of the mesentery reveals fourteen (14) small nodules. Eleven (11) of the nodules are implants of gastrointestinal stromal tumor. Three of the nodules are lymph nodes with no evidence of malignancy. 5. The tumor is cellular with up to 5 mitoses/10 HPF. 6. Sections of proximal and distal small bowel resection margins are free of tumor. B. Peritoneal implants: Gastrointestinal stromal tumor. Brief Hospital Course: The patient was admitted to the SICU from the ER for close hemodynamic monitoring and serial hematocrits. On HD 2 he had large bloody bowel movement, was hypotensive to the 60's and was therefore taken to interventional radiology where no bleeding source was identified. He was therefore taken for urgent laparotomy where a bleeding mass was identified in the small bowel. Post operatively he was taken back to the SICU for continued resuscitation. On POD#0 he was started on an insulin drip for high blood sugars. On POD#1 he was started on sips and his NGT was removed. On POD#2 he was transferred to the floor and continued on sips. His abdomen was still distended ADN he was therefore kept NPO. His insulin drip was stopped on POD#2 when his insulin pump was placed. His ileus persisted and on POD#5 the patient had emesis, a KUB was obtained which was consistent with post-operative ileus. On the evening of POD#5 he had flatus and a bowel movement and his diet was advanced. An oncology consult was obtained on POD #6 and they set up outpatient follow up for the patient. On POD#7 he was tolerating a regular diet, having bowel movements, voiding normally and his pain was under control with oral medications. The patient also has a history of chronic renal disease. His renal doctor saw the patient and recommended tapering the CellCept. He was sent home on 1000mg [**Hospital1 **] and his renal attending will call him and tell him to reduce his dose to 500 mg [**Hospital1 **]. He was discharged home with follow up with Dr. [**Last Name (STitle) 1120**], his renal doctor [**First Name (Titles) **] [**Last Name (Titles) **]y. Medications on Admission: lisinopril 80mg qd MMF 1500mg [**Hospital1 **] valsartan 320mg qd folic acid 1mg qd ASA 325mg qd diltiazem CR 120mg qd insulin via pump Discharge Medications: 1. Mycophenolate Mofetil 200 mg/mL Suspension for Reconstitution Sig: Five (5) PO BID (2 times a day). Disp:*30 * Refills:*0* 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 3. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Gastrointestinal stromal tumor Discharge Condition: Stable Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomitting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomitting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to amubulate several times per day. Incision Care: -Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 1120**] in [**2-2**] weeks. Please call([**Telephone/Fax (1) 6316**] to schedule an appointment. Please follow up with your renal doctor in [**2-2**] weeks. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6970**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2124-2-4**] 11:30

[ "585.9", "285.1", "560.1", "159.8", "997.4", "403.90", "250.01", "780.57" ]

icd9cm

[ [ [] ] ]

[ "45.62", "99.04", "88.47", "54.23" ]

icd9pcs

[ [ [] ] ]

6243, 6249

3851, 5499

322, 386

6324, 6333

2196, 3828

7760, 8119

1565, 1750

5716, 6220

6270, 6303

5525, 5693

6357, 7399

7414, 7737

1765, 2177

274, 284

414, 1328

1350, 1459

1475, 1549

17,848

140,462

27323

Discharge summary

report

Admission Date: [**2116-5-11**] Discharge Date: [**2116-6-3**] Date of Birth: [**2046-7-15**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2485**] Chief Complaint: CC: Transferred from OSH for management of respiratory failure Major Surgical or Invasive Procedure: Bronchoscopy History of Present Illness: Pt is a 69 yo M with h/o myelofibrosis, hepatosplenomegaly, COPD who is transferred here from [**Location (un) **] [**Location (un) 1459**] for further management of his hemoptysis, CHF, leukocytosis, and thrombocytopenia. He initially presented to [**Hospital1 **] [**2116-5-1**] with complaints of weakness, inability to walk and shortness of breath x 1 week. In the ED, he was found to have a WBC of >100,000 and platelet count of 28,000. He was followed by heme/onc and pulmonary. He was started on hydrea and allopurinol and WBC responded decreasing to the 30's. He was also noted to have a RLL opacity on CXR thus was started ceftriaxone on [**5-3**]. Sputum culutre grew out Klebsiella pneumonia and he was switched from Ceftriaxone to avelox on [**5-5**]. He then developed hemoptysis in the setting of thrombocytopenia, however per family he has had small amounts of hemoptysis for the past 6 months. From a respiratory standpoint he was still saturating well at this point, however CT chest on [**5-7**] showed extensive ground glass infiltrates in the right lung field and scattered on the left. Given the worsening hemoptysis concern was for DAH vs CHF vs PNA. He was started on IV solumedrol, diuresed and initially improved. He had persistent hemoptysis and required blood and platelet transfusions. . Then on [**5-10**] he had acute onset of respiratory distress. CXR showed patchy infiltrates with no obvious CHF. Because of his respiratory status he required intubation. He underwent bronchoscopy which showed BAL with blood from RML, and BAL sent for multiple studies including cultures, fungal, AFB, PCP, [**Name10 (NameIs) 13607**], cytology, cell count. PA catheter was placed which demonstrated PCWP of 14, PA 44/20. Started on PS for vent settings. CXR showed pulm edema vs ARDS. Past Medical History: Myeloproliferative Disorder/Myelofibrosis with anemia and thrombocytopenia, leukocytosis followed by Dr. [**Last Name (STitle) 66973**] ([**Telephone/Fax (1) 66974**]). BM biopsy in [**2115**] c/w myeloproliferative, myelofibrosis and myelodysplasia. Anemia - B12 deficiency, on epogen COPD Hepatosplenomegaly Hypertension Colon polyps Bladder carcinoma s/p resection Hemoptysis Congestive Heart Failure Leg edema Thrombocytopenia Leukocytosis Lung fibrosis Social History: Past smoking history x 50 years, no EtOH or smoking currently. Lives with wife. 2 daughters live in area. Family History: NC Physical Exam: T 97.8 BP 122/55 HR 96 RR 14 O2sats 97% Vent: AC/14/500/70%/PEEP 10 PIP 27 Gen: Sedated no response to noxious stimuli HEENT: PERRL, dry mm Neck: + Right IJ, unable to assess JVD Lungs: Rhoncherous throughout right greater then left Heart: RRR + S1/S2 no m/r/g Abd: Soft, + BS, + HSM Ext: [**2-21**]+ pitting edema in his LE and UE and sacrum, + petechea Neuro: Sedated, moving all 4 extremities Pertinent Results: CXR- Diffuse fluffy infiltrate on the right side in upper and lower fields, left lower lobe infiltrate. PA catheter in zone 2 . ECG- NSR- 93, nl axis, nl intervals, TWF in III, II, avF (old), no ST, TW changes from old ECG . CXR: diffuse interstitial infiltrates bilaterally and fluffy alveolar infiltrates in the right lung, small left pleural effusion. . ECHO [**2116-5-4**] EF 65% nl LV, AV sclerotic, trace MR, RV nl . RIGHT UPPER QUADRANT ULTRASOUND: The gallbladder is not distended and there is no evidence of stones or sludge. There is a mild amount of pericholecystic fluid. There is mild gallbladder wall thickening. The common bile duct measures 7 mm, which is age appropriate. The liver demonstrates no focal textural abnormalities. The portal vein is patent with appropriate hepatopetal flow. Visualized portions of the right kidney and pancreas are unremarkable. IMPRESSION: 1. Gallbladder wall thickening. While this can be seen in cholecystitis, there are no other findings to support this (such as gallstones or gallbladder distention) the differential diagnosis includes hypoalbuminemia, CHF, cirrhosis, pancreatitis and hepatitis. Further evaluation could be performed with HIDA scan if warranted. Brief Hospital Course: 69 year-old man with history of myelofibrosis, COPD and hepatosplenomegaly who was initially transferred to [**Hospital1 18**] from [**Location (un) **] [**Location (un) 1459**] for management of hemoptysis, CHF, respiratory failure, leukocytosis, and thrombocytopenia and who is now being transferred to the [**Hospital Ward Name 517**] for tracheostomy and PEG placement. . The patient initially presented to [**Hospital1 **] on [**2116-5-1**] with complaints of weakness, inability to walk and shortness of breath for one week. In the ED, he was found to have a WBC of >100,000 and platelet count of 28,000. He was followed by Heme-Onc and Pulmonary consult services. He was started on hydrea and allopurinol, with his WBC decreasing to the 30's. He was also noted to have a RLL opacity on CXR and on [**2116-5-3**] was started on ceftriaxone. A sputum culutre grew out Klebsiella pneumonia and he was switched from Ceftriaxone to moxifloxacin on [**5-5**]. He then developed hemoptysis in the setting of thrombocytopenia, although according to family members he has had small amounts of hemoptysis for the past 6 months. A CT chest on [**5-7**] showed extensive ground glass infiltrates in the right lung field and scattered on the left. Given the worsening hemoptysis, there was a concern for DAH vs CHF vs PNA. He was started on IV solumedrol, diuresed and initially improved. He had persistent hemoptysis and required blood and platelet transfusions. . On [**5-10**] he had the acute onset of respiratory distress with new hypoxia. CXR showed patchy infiltrates with no obvious CHF. He required intubation and subsequently underwent a bronchoscopy which revealed blood from RML. A BAL was sent for multiple studies including cultures, fungal, AFB, PCP, [**Name10 (NameIs) 13607**], cytology, and cell count. A PA catheter was placed which demonstrated PCWP of 14, PA 44/20. Started on PS for vent settings. CXR showed pulm edema vs ARDS. . In the [**Hospital Unit Name 153**], the patient was continued on the ventilator and eventually weaned and extubated on [**2116-5-19**]. Sputum cultures from [**5-12**] grew MRSA and he was started on vancomycin and zosyn on [**2116-5-11**]. A bronchoscopy was performed on [**2116-5-15**] which revealed diffuse alveolar hemorrhage. PCWP remained elevated in 14-15 range, suggesting coexisting congestive heart failure and the patient was diuresed. After extubation he had stable oxygen saturations on 4L and he was called out to the floor, but at that time had another episode of respiratory distress and stayed in the [**Hospital Unit Name 153**]. He did well until [**5-26**] when had tachypnea and hypoxia and was reintubated. He was continued on Zosyn and vancomycin and is currently on day 20, though continues to spike fevers. He was recently placed on a lasix drip on [**5-29**] for volume overload, with reasonable urine output but this was stopped today due to hypernatremia and hypokalemia. He didn't tolerate lasix drip previously related to hypotension. He was transferred to the MICU [**Hospital Ward Name **] for trach and PEG by the surgical service. However, Oncology noted the extrememly poor prognosis from his underlying disease, as well as the lack of realistic treatments other than bone marrow transplant for which he is not a candidate. A family meeting was held and the decision was made to withdraw care the next day on [**2116-6-3**]. He was extubated and died within an hour with his family at bedside. Medications on Admission: Moxifloxacin 400mg qday(started [**5-5**]), vancomycin 1gm q12hrs (started [**5-10**]), RISS, NPH 5units q12hrs, Epogen [**Numeric Identifier **] qsat, lasix 40mg IV bid, metoprolol 5mg IV q6hrs, Propofol gtt, protonix 40mg iv qday, solumedrol 1gm qday, lorazepam 2mg prn, morphine 2mg prn Discharge Disposition: Expired Discharge Diagnosis: Primary: respiratory failure Myeloproliferative Disorder/Myelofibrosis with anemia and thrombocytopenia, leukocytosis Secondary: Anemia - B12 deficiency, on epogen COPD Hepatosplenomegaly Hypertension Colon polyps Bladder carcinoma s/p resection Hemoptysis Congestive Heart Failure Leg edema Thrombocytopenia Leukocytosis Lung fibrosis Discharge Condition: dead Discharge Instructions: n/a Followup Instructions: n/a

[ "584.9", "276.0", "482.0", "518.84", "786.3", "276.8", "238.7", "255.4", "496", "482.41", "428.0", "284.8", "V09.0" ]

icd9cm

[ [ [] ] ]

[ "33.24", "99.05", "99.07", "00.17", "96.72", "96.6", "96.04", "99.04", "38.93" ]

icd9pcs

[ [ [] ] ]

8361, 8370

4540, 8021

377, 391

8750, 8756

3296, 4517

8808, 8814

2861, 2865

8391, 8729

8047, 8338

8780, 8785

2880, 3277

275, 339

419, 2239

2261, 2721

2737, 2845

5,614

162,211

23753

Discharge summary

report

Admission Date: [**2189-3-27**] Discharge Date: [**2189-4-6**] Date of Birth: [**2122-2-21**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: Chest pressure Major Surgical or Invasive Procedure: 1. Coronary aretery bypass graft x3 (LIMA-LAD, SVG-OM1, SVG-PDA) History of Present Illness: 67M PMH GERD, admitted for cath this AM, found to have 70% LM occlusion, currently admitted over the weekend for CABG on Monday. The patient reports having chest discomfort for the past 2-4 months with exertion. It occurs after activity such as climbing about 50 stairs, with an associated pressure in his throat and upper arm pain bilaterally. He was originally scheduled for elective cath today, but was admitted to [**Hospital1 3793**] Thurs [**3-26**] after reporting that he has been having throat/arm pain since having his stress test last week. Enzymes were negative there. Cardiac cath on [**2189-3-27**] showed left main disease. Pt was deemed good candidate for CABG. Past Medical History: DM HTN Hyperchol CAD GERD Bronchitis Lap cholecystectomy Appendectomy Skin graft * [**2189-3-18**] ETT: The pt exercised for 7'[**15**]" [**First Name8 (NamePattern2) **] [**Doctor First Name **] protocol to 86% of his APHR. Negative for chest pain. EKG: Diffuse 1mm ST segment depression. Nuclear imaging: small in size, moderate in severity, inferoapical ischemia. EF 66% Social History: Pt is a teacher and hairdresser. Lives with his wife. [**Name (NI) **] smoking history. No alcohol use. Family History: Mother had coronary history, [**6-22**] siblings have CAD, 4 have had CABG. Physical Exam: Vitals: T: 97.3 HR: 56 BP: 106/56 R: 20 Sat: 100% * PE: G: Obese male, NAD HEENT: MMM, anicteric sclerae Neck: Unable to assess JVP due to thick neck. No carotid bruit appreciated Lungs: CTA BL BS, No W/R/C CV: Distant S1S2, No M/R/G appreciated Abd: Soft, NT, ND BS+ Ext: No E/C/C, DP pulses palpable Nails: Lunulae present, no splinters Pertinent Results: Cath ([**2189-3-27**]): 70% Distal LM, 80% OM1, 80% prox RCA, 70% RPL, and 50% RPDA. EF 53%. Brief Hospital Course: A/P: 67M PMH DM, CAD, HTN, s/p cath with 70% LM disease. CABG x3 (LIMA-LAD, SVG-OM1, SVG-PDA) [**2189-3-30**]. [**Name (NI) **], pt transferred to the CSRU where he was extubated on POD 0 and pressors were weaned to off. On POD 1, he had his PA catheter and chest tubes removed and he was transferred to the floor. On the floor, he did well with no complications. [**Last Name (un) **] was consulted to manage his diabetes. Pacing wires were taken out on POD 4. Pt was below his pre-op weight on discharge. Medications on Admission: Avandia Prilosec Vytorin Lisinopril 10mg daily Glipizide Metoprolol 25mg [**Hospital1 **] ASA 81mg Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 4. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Glipizide 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. 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* 10. Rosiglitazone Maleate 4 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: 1. Coronary artery disease (left main, 2-vessel) 2. Diabetes mellitus, type 2 3. Hypertension 4. Hypercholesterolemia 5. GERD Discharge Condition: Good Discharge Instructions: 1. Resume medications as directed. 2. F/U cardiologist in 2 weeks. 3. Call office or go to ER if fever/chills, drainage from sternal incision, chest pain, shortness of breath. Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 1112**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Call to schedule appointment Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 2295**] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 60669**] Call to schedule appointment Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 11554**] Call to schedule appointment

[ "V70.7", "278.00", "250.00", "414.01", "V17.3", "V45.79", "272.0", "401.9", "429.9", "530.81", "411.1" ]

icd9cm

[ [ [] ] ]

[ "37.22", "36.15", "39.61", "89.64", "36.12", "89.68", "88.53", "39.64", "88.56", "34.04" ]

icd9pcs

[ [ [] ] ]

4264, 4322

2315, 2830

335, 402

4492, 4498

2197, 2292

4722, 5171

1686, 1763

3016, 4241

4343, 4471

2856, 2993

4522, 4699

1778, 2178

281, 297

430, 1111

1133, 1549

1565, 1670

20,688

108,316

18840

Discharge summary

report

Admission Date: [**2159-4-9**] Discharge Date: [**2159-4-15**] Date of Birth: [**2102-2-23**] Sex: F Service: [**Last Name (un) **] HISTORY OF PRESENT ILLNESS: Right breast cancer. PHYSICAL EXAMINATION: Unremarkable. SUMMARY OF THE HOSPITALIZATION COURSE: The patient is a 57- year-old female who has a history of right breast cancer. She underwent a right mastectomy with axillary dissection and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5884**] flap reconstruction, this occurred on [**2159-4-9**]. The patient tolerated the procedure well. She was kept in the recovery room for 24 hours. The details of the operation can be found in the operative note. She was kept in the recovery room for 24 hours for flap monitoring. There was return of good blood flow to the flap. She was transferred to the floor. She was in the hospital for 4 days. She was discharged on [**2159-4-15**] without any difficulties. Her Foley was removed over the interim, 2 of her JP drains were removed, and she was ambulating and tolerating a regular diet. She is to follow up with Dr. [**First Name (STitle) **] in 1 week. Her discharge medications include Keflex and Percocet for pain, and for drain removal in 1 week. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 39103**] Dictated By:[**Last Name (NamePattern4) 51569**] MEDQUIST36 D: [**2159-8-6**] 12:53:14 T: [**2159-8-6**] 13:40:47 Job#: [**Job Number 51570**]

[ "401.9", "244.9", "530.81", "174.9" ]

icd9cm

[ [ [] ] ]

[ "85.43", "85.89" ]

icd9pcs

[ [ [] ] ]

227, 1523

182, 204

82,828

143,859

3306+55456

Discharge summary

report+addendum

Admission Date: [**2125-4-25**] Discharge Date: [**2125-5-1**] Date of Birth: [**2064-9-29**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Known firstname 2724**] Chief Complaint: Progressive leg weakness Major Surgical or Invasive Procedure: THORACIC LAMINECTOMY T3-T5 History of Present Illness: 60M with h/o prostate CA since [**2111**], several weeks of right shoulder pain treated with PT, no better. Saw Dr [**Last Name (STitle) **] last week who ordered MRI - was scheduled for tonight, but patient has had progressive tingling and weakness of lower extremities since Sunday - worse this am, went to OSH, had MRI and transferred here for T4 lesion. Past Medical History: Prostate ca,inc chol, asthma, NIDDM, polio Social History: Social Hx:lives with wife, nonsmoker Family History: Non contributory Physical Exam: PHYSICAL EXAM: O: T:97.6 BP: 194/98 HR: 74 R16 O2Sats98 Gen: WD/WN, comfortable, NAD. Neck: Supple. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T WE WF IP Q H AT [**Last Name (un) 938**] G R 5 5 5 5 5 2 3 3 5- 5- 5- L 5 5 5 5 5 4- 5 5 5 5 5 Sensation: Light touch decreased throughout right leg.Intact to propioception bilaterally. Toes downgoing bilaterally Spine: non tender MRI:T4 lesion with compression on cord L>R, areas of diffuse mets throughout spinE EXAM UPON DISCHARGE:Intact with the exception of weakness right leg muscle groups IP/Q/H 4+ and decrease sensation throughout entire right leg. Pertinent Results: [**2125-4-25**] 03:00PM GLUCOSE-132* UREA N-14 CREAT-0.8 SODIUM-142 POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-26 ANION GAP-16 [**2125-4-25**] 03:00PM WBC-7.8 RBC-4.07* HGB-12.1* HCT-35.9* MCV-88 MCH-29.7 MCHC-33.6 RDW-14.1 [**2125-4-25**] 03:00PM PLT COUNT-187 [**2125-4-25**] 03:00PM PT-13.0 PTT-24.3 INR(PT)-1.1 [**2125-4-25**] 02:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019 [**2125-4-25**] 02:40PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-9.0* LEUK-SM [**2125-4-25**] 02:40PM URINE RBC-0-2 WBC->50 BACTERIA-MANY YEAST-NONE EPI-0-2 MRI:T4 lesion with compression on cord L>R, areas of diffuse mets throughout spine Brief Hospital Course: Mr [**Known lastname 15379**] was taken to the OR for an emergent T3-T5 laminectomies without complications. Post operatively he was extubated then monitored in the PACU and then transferred to the floor. He had a JP drain in place which was removed on POD#2. He had immediate improvement in motor strength in his right leg. He worked with PT who recommended rehab. His diet and activity were advanced. Incision was clean and dry. He was able to manage pain with PO meds. He will follow up with Dr [**Last Name (STitle) **] on [**5-15**] and see radiation oncology at that time. Medications on Admission: FINASTERIDE - 5 mg Tablet - 1 Tablet(s) by mouth once a day HYDROCORTISONE - 10 mg Tablet - 10 mg Tablet(s) by mouth take two pills in the am and one in the afternoon , after eating KETOCONAZOLE - 200 mg Tablet - (200 mg tabs) Tablet(s) by mouth take two twice a day on an empty stomach LUPRON - (Prescribed by Other Provider) - Dosage uncertain METFORMIN - (Prescribed by Other Provider) - Dosage uncertain MONTELUKAST [SINGULAIR] - (Prescribed by Other Provider) - Dosage uncertain OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - 1 or 2 Tablet(s) by mouth as needed every 4 hours for pain Discharge Medications: 1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever,pain. 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 9. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 99 doses. 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at [**Hospital6 1109**] - [**Location (un) 1110**] Discharge Diagnosis: Metastatic Prostate Cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Weak right leg Discharge Instructions: DISCHARGE INSTRUCTIONS FOR SPINE CASES ?????? Do not smoke ?????? Keep wound clean / No tub baths or pools until seen in follow up/ remove dressing [**2125-4-29**] / begin daily showers [**2125-4-30**] - OK to shower with staples ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting for two weeks. ?????? Limit your use of stairs to 2-3 times per day ?????? Have a family member check your incision daily for signs of infection ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake if you experience muscle stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. for 1 week. ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine ?????? Any weakness, numbness, tingling in your extremities ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F ?????? Any change in your bowel or bladder habits Followup Instructions: PLEASE RETURN TO THE OFFICE IN [**8-4**] DAYS FOR REMOVAL OF YOUR STAPLES OR HAVE THESE REMOVED AT REHAB BY [**2125-5-5**] PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR. [**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS. YOU WILL NOT NEED XRAYS PRIOR TO YOUR APPOINTMENT Dr[**Name (NI) 15380**] office would like you to be seen on [**5-15**] they will call you with a specific time. You will also see radiation oncology at that time. Completed by:[**2125-4-30**] Name: [**Known lastname 2425**],[**Known firstname **] Unit No: [**Numeric Identifier 2426**] Admission Date: [**2125-4-25**] Discharge Date: [**2125-5-1**] Date of Birth: [**2064-9-29**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Known firstname 2427**] Addendum: Mr [**Known lastname **] was kept overnight on [**4-30**] becuase his insurance did not approve his rehab bed placement. He was rescreened on Tuesday [**5-1**] and was successfully placed at [**Hospital **] rehab center. He was stable overnight in house and did not have any further problems or complaints. He will pursue aggressive PT at rehab over the next several days to weeks, we will see him in follow up clinic in 6 weeks. Discharge Disposition: Extended Care Facility: [**Hospital3 1174**] [**Hospital **] [**Hospital 2270**] Rehab Unit at [**Hospital6 2271**] - [**Location (un) 437**] [**Known firstname **] [**Last Name (NamePattern4) 2428**] MD [**MD Number(2) 2429**] Completed by:[**2125-5-1**]

[ "493.90", "272.0", "250.00", "336.3", "V12.02", "198.4", "V10.46", "198.5" ]

icd9cm

[ [ [] ] ]

[ "03.4" ]

icd9pcs

[ [ [] ] ]

7783, 8070

2550, 3133

342, 371

4910, 4910

1823, 2527

6453, 7760

895, 913

3774, 4671

4860, 4889

3159, 3751

5108, 6430

943, 1099

278, 304

399, 759

4925, 5084

781, 825

841, 879

1679, 1804

4,950

109,626

45335+58806

Discharge summary

report+addendum

Admission Date: [**2194-4-14**] Discharge Date: [**2194-5-15**] Date of Birth: [**2117-10-8**] Sex: M Service: TRAUMA HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 96823**] is an unfortunate 76 year old gentleman unrestrained driver of an SUV who was rear-ended at a moderate to high speed. The patient's car jumped out of a curve and hit a brick wall with significant front end damage. Air bags were deployed. The patient had positive loss of consciousness with no recall of the events. he was found by the paramedics and transferred here to the [**Hospital1 69**] for further evaluation. Upon arrival, he was complaining of face pain, neck pain and shoulder pain. He denied any headache, chest pain or shortness of breath. He had facial lacerations that were not actively bleeding. He also had epistaxis of bilateral nares with a right eyelid significant swelling. His initial trauma evaluation revealed that he sustained fractures of the nasal bones as well as the spleen, of C4 and 5 cervical spine with anterior widening of the fracture of the right facet joint. He was stabilized in the Trauma Bay and Neurosurgery Spine Service was called for consultation as well as Ophthalmology and ENT. At that time, he was denying blurry vision, numbness, weakness, tingling or any other neurological symptoms. He was transferred to the Intensive Care Unit for close monitoring and he was started on a protocol. He was electively intubated on [**4-15**] due to oropharyngeal bleeding and high risk of aspiration with initiation of a Propofol drip for sedation at that time. The patient was transiently hypotensive to the low 60's over 30's with a map of 40. This improved with fluids and adjustment of his Propofol. He was noticed to have a rise in his creatinine and while awaiting cardiac clearance and a renal consultation, the patient remained in the Intensive Care Unit. PAST MEDICAL HISTORY: 1. Hypertension. 2. Prostate cancer. 3. Status post brachy therapy. 4. History of breast cancer status post left mastectomy. 5. History of supraventricular tachycardia; he underwent a pre-procedure catheterization which demonstrated 60 to 70% mid left anterior descending with 50 to 60% proximal diagonal to a 60% proximal right coronary artery. No percutaneous transluminal coronary angioplasty was performed. He underwent ablation for supraventricular tachycardia on [**2194-3-19**], for an atypical nodal re-entry. 6. The patient had a history of distant appendectomy. 7. Status post left hip replacement. 8. Status post bilateral inguinal hernia repair. 9. Status post left rotator cuff repair. OUTPATIENT MEDICATIONS: 1. Tamoxifen. 2. Metoprolol. 3. Lisinopril. 4. Aspirin. 5. Magnesium oxide. 6. Verapasol. 7. Hydrochlorothiazide. 8. Colace. 9. Folate. 10. Colchicine. 11. Allopurinol. 12. Vitamin B12. ALLERGIES: The patient had no known drug allergies. SOCIAL HISTORY: He was a former smoker, quit in [**2161**]; drinks one to two martinis every day. PHYSICAL EXAMINATION: His examination upon admission, he had a blood pressure of 196/90; heart rate of 80; respiratory rate of 18; 99% on two liters nasal cannula; his temperature was 98.6 F. In the Trauma Bay, he was awake, alert, oriented times three, [**Location (un) 2611**] Coma Score of 15. Neck was in a collar. He was noted to have a laceration on the left side of the nose, hematoma in the right upper and lower eyelids, bleeding from the nose more on the right than the left side, bruise on the left eye, with no bleeding. His mouth and face were stable. Trachea in the midline. No crepitus. Good respiratory effort and clear to auscultation bilaterally. Regular rate and rhythm. Abdomen was soft, nontender, no scars. Pelvis was stable. Back showed no step-offs, no tenderness to palpation. Rectal examination showed normal tone, guaiac negative. Extremities with superficial abrasions; all peripheral pulses were present. LABORATORY: His hematocrit upon arrival was 38.4, white blood cell count of 11.6 with a platelet count of 214. His coagulation studies were within normal limits with a lactate of 2.2. His gas showed a pH of 7.49, CO2 of 31, O2 of 82, bicarbonate of 24 with a base excess of 1. His chest x-ray was unremarkable. The cervical spine, as stated above, showed a C4-5 sprain injury. Pelvis showed no fractures. A head CT scan showed a left temporal lobe subarachnoid hemorrhage with a question of a small subdural hematoma in the right temporal region. There was a right nasal bone fracture. The chest CT scan and the abdomen shows some degenerative joint disease of the thoracic spine and pleural thickening, otherwise the rest of the scans were unremarkable. HOSPITAL PROGRESS AND COURSE: Mr. [**Known lastname 96823**], on [**4-18**], was taken to the Operating Room by the Neurosurgical team after cardiac clearance and underwent a C4-5 anterior fusion with diskectomy and fixation. This included an open reduction of a hyperextension injury followed by a C4-5 ALDF with a fibula allograft and ventral screw plate fixation. This patient tolerated well the complicated procedure and he was transferred in stable condition to the Surgical Intensive Care Unit. His postoperative course was complicated by a peri-operative myocardial infarction with a high troponin and supraventricular tachycardia that required cardioversion. Cardiology was again consulted and they recommended to start him on Amiodarone as well as beta blockers. Over the course of the next couple of days, he remained waxing and [**Doctor Last Name 688**] hemodynamically speaking. He was not spiking fevers and we tried to wean him off the ventilatory support. On this effort, he was aggressively diuresed since he was very positive after the surgery. He continued to require suctioning multiple times on the different shifts and he was producing fairly large amounts of bronchial secretions. The patient failed T-piece trials, especially due to the increased bronchial secretions and it was decided clinically at that time to place a tracheostomy. Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **] put a #8 Portex tracheostomy on [**2194-4-25**]. The patient tolerated the procedure well. Once the patient had a tracheostomy, he was able to wean much easier and faster and by postoperative day number eight, he was on 100% trache collar, tolerating it well with good O2 saturations. Around this time, he was much more awake than prior days; he was following commands. He remained afebrile with moderately elevated white count in the 15,000. He continued to have massive amount of secretions requiring suctioning from the nursing staff fairly frequently. Multiple sputum samples were sent for culturing to the Microbiology Laboratory but nothing grew out initially. He started to spike temperatures and because of the increasing amount of secretions he was started on Levofloxacin empirically. Over the course of the next couple of days, he was bronchoscoped multiple times and on the 10th, a bronchial alveolar lavage sample was sent to Microbiology and finally came positive for Methicillin resistant Staphylococcus aureus. He was started on Vancomycin and the Levofloxacin was discontinued. Around this time, when the patient continued having increased bronchial secretions, he had sporadic events of cardiac arrhythmias presenting as supraventricular tachycardia to the 130s, always maintaining good blood pressure. Once again, Cardiology recommended to continue the Amiodarone and the beta blockers. On the night of [**5-5**], the patient bradied down to the 40s, requiring Atropine to increase his heart rate and the Amiodarone as well as the Lopressor was held. The patient was started on Dopamine and Levophed to keep his blood pressure, and a new Cardiology evaluation was obtained. Their recommendation was to hold the Amiodarone and the beta blockers and wean the pressors as tolerated. By the next day he converted to normal sinus rhythm and he was restarted on a lower dose of beta blockers, Lopressor 12.5 mg p.o. twice a day or three times a day if blood pressure allowed. A GJ tube was placed by Interventional Radiology and the patient was started on tube feeds. He continued to do well and defervesced from his spiking temperatures. His tube feeds were advanced to Impact with fiber at 90 cc with good tolerance and he was continued on the antibiotic therapy. His mental status continued to improve and by postoperative day 23, tolerating tube feeds, being awake, appropriate, following commands and less rhonchorous and not having as much secretions as he was having in the previous days. He was found to be stable enough to be transferred to the Regular Floor to await rehabilitation placement. The rest of his hospital course, once on the Floor, was relatively uneventful, and finally today he was offered a bed on the Rehabilitation Facility and he is being transferred to this institution to continue his recovery. At the time of discharge, the patient's list of medications included: DISCHARGE MEDICATIONS: 1. Insulin sliding scale q. six hours. 2. Heparin 5000 units subcutaneously q. 12 hours. 3. Prevacid oral solution, 30 mg per GJ tube once a day. 4. Allopurinol 100 mg p.o. q. day. 5. Multivitamin 5 ml p.o. per GJ-tube q. day. 6. TUMS 500 mg per G-tube four times a day. 7. Aspirin 325 mg per G-tube q. day. 8. Lopressor 50 mg per G-tube twice a day. 9. Calcium, magnesium and potassium p.r.n. 10. Lasix 20 mg per G-tube twice a day. 11. Zoloft 50 mg per G-tube q. day. 12. Lorazepam 1 mg intravenous q. six hours p.r.n. 13. Intravenous Vancomycin 750 mg intravenously once a day, was started on [**5-5**]. The recommendation is to continue the Vancomycin for at least two weeks. DISCHARGE INSTRUCTIONS: 1. The patient's diet consists at this time of tube feeds that are Impact with fiber at 90 cc an hour continuously. 2. He is Methicillin resistant Staphylococcus aureus positive. 3. Recommendation from Neurosurgery was to keep the patient on the cervical hard collar until he follows up with [**Hospital 4695**] Clinic and Dr. [**Last Name (STitle) 1327**] on [**2194-6-1**]. Up until that time, the patient should not remove the cervical collar by any means. 4. The patient will follow-up in the Trauma Clinic only as needed. CONDITION AT DISCHARGE: As stated above, the condition at the time of discharge is stable. DISCHARGE STATUS: Once again, as stated above, he should make a follow-up appointment for Dr. [**Last Name (STitle) 1327**] in the Neurosurgerical Clinic on [**2194-6-1**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**] Dictated By:[**Last Name (NamePattern4) 26544**] MEDQUIST36 D: [**2194-5-14**] 17:00 T: [**2194-5-14**] 17:51 JOB#: [**Job Number 96824**] Name: [**Known lastname 15391**], [**Known firstname **] Unit No: [**Numeric Identifier 15392**] Admission Date: [**2194-5-15**] Discharge Date: [**2194-5-19**] Date of Birth: Sex: M Service: Trauma Surgery ADDENDUM: This is an addendum for the previously dictated Discharge Summary for this patient who was admitted to the Trauma Service from [**2194-4-14**] to [**2194-5-19**]. The previous complete Discharge Summary was dated [**2194-5-15**]. The patient remained in the hospital for an additional four days (from [**5-15**] to [**5-19**]) because of the inability to place him in a rehabilitation facility. His medical status remained completely unchanged from the previously dictated Discharge Summary. On [**5-19**], he was transferred to a [**Hospital 2754**] rehabilitation facility in stable condition. [**First Name11 (Name Pattern1) 1080**] [**Last Name (NamePattern4) 3711**], M.D. [**MD Number(1) 3712**] Dictated By:[**Last Name (NamePattern4) 7757**] MEDQUIST36 D: [**2194-9-30**] 13:43 T: [**2194-9-30**] 16:12 JOB#: [**Job Number 15393**]

[ "805.05", "427.89", "802.0", "518.5", "482.41", "E812.0", "410.91", "852.00", "805.04" ]

icd9cm

[ [ [] ] ]

[ "44.32", "96.6", "81.02", "33.23", "96.72", "80.51", "31.1", "38.93", "96.04" ]

icd9pcs

[ [ [] ] ]

9132, 9823

9847, 10390

2670, 2921

3044, 9109

10406, 12075

168, 1913

1935, 2646

2938, 3021

52,934

118,805

43611

Discharge summary

report

Admission Date: [**2162-3-2**] Discharge Date: [**2162-3-8**] Date of Birth: [**2107-11-15**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: Known dilated aortic root/coronary artery disease Major Surgical or Invasive Procedure: s/p Bentall AVR (#23mmSt.[**Male First Name (un) 923**] Mechanical)/CABG x2 (Lima->LAD/SVG->Diag) History of Present Illness: 54year old male with known dilated aortic root and coronary disease who recently underwent bare metal stent x2 to the RCA [**1-18**]. He was scheduled for Bentall/CABG [**2162-3-2**] with Dr. [**Name (NI) **]. Past Medical History: HTN Dislipidemia Obesity Hyperhomocysteinemia Multiple skin nevi followed by derm Erectile dysfunction Hearing loss in left ear No history of cellulitis or buttock abscess. Social History: The patient was born in [**State 4260**] and moved to [**Location (un) 86**] for graduate school. He continues to work in business. He has fairly long hours and does a lot of traveling. He quit smoking at age 25. He drinks alcohol rarely. He is married and lives with his wife. Family History: Father had MI in 60's. Physical Exam: GENERAL:A&OX3, NAD VSS HEENT:AT/NC, CAROTIDS 2+(B) CVS:RRR LUNGS:CTA(B) ABD:BENIGN EXTR:NO CYANOSIS/CLUBBING/EDEMA discharge: VS: 98.3, 118/77, 72SR, 18, 97%RA Gen: NAD HEENT: unremarkable CV: RRR, no murmur Chest: LCTAB Abd: +BS, soft, non-tender, non-distended Ext: no edema Incision: sternal- c/d/i without erythema or drainage, sternum stable Pertinent Results: [**2162-3-8**] 06:30AM BLOOD WBC-8.1 RBC-3.39* Hgb-10.3* Hct-28.1* MCV-83 MCH-30.4 MCHC-36.6* RDW-14.9 Plt Ct-281# [**2162-3-8**] 06:30AM BLOOD Glucose-105 UreaN-23* Creat-0.9 Na-136 K-4.4 Cl-101 HCO3-27 AnGap-12 [**2162-3-2**] 12:45PM BLOOD WBC-14.9*# RBC-3.02*# Hgb-9.4*# Hct-25.1*# MCV-83 MCH-31.0 MCHC-37.3* RDW-14.1 Plt Ct-127* [**2162-3-5**] 06:58AM BLOOD Hct-25.3* Plt Ct-88* [**2162-3-2**] 12:45PM BLOOD PT-16.1* PTT-38.6* INR(PT)-1.4* [**2162-3-5**] 06:58AM BLOOD PT-13.6* PTT-30.5 INR(PT)-1.2* [**2162-3-4**] 06:45AM BLOOD Glucose-125* UreaN-19 Creat-0.7 Na-137 K-3.9 Cl-101 HCO3-31 AnGap-9 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 93781**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 93782**] (Complete) Done [**2162-3-2**] at 12:43:29 PM 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: [**2107-11-15**] Age (years): 54 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Aortic valve disease. Left ventricular function. Preoperative assessment. ICD-9 Codes: 441.2, 424.1 Test Information Date/Time: [**2162-3-2**] at 12:43 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 #: 2009AW5-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.5 cm <= 5.6 cm Left Ventricle - Ejection Fraction: >= 55% >= 55% Aorta - Annulus: 2.3 cm <= 3.0 cm Aorta - Sinus Level: *4.5 cm <= 3.6 cm Aorta - Sinotubular Ridge: *4.5 cm <= 3.0 cm Aorta - Ascending: *5.9 cm <= 3.4 cm Aorta - Descending Thoracic: 2.2 cm <= 2.5 cm Aortic Valve - Pressure Half Time: 620 ms Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Top normal/borderline dilated LV cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Markedly dilated ascending aorta. Normal descending aorta diameter. AORTIC VALVE: Three aortic valve leaflets. Moderate to severe (3+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Physiologic MR (within normal limits). TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. Results were 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. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta and aortic root are markedly dilated. There is effacement of the sinotubular junction. There are three aortic valve leaflets. Moderate to severe (3+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). POSTBYPASS Biventricular systolic function is preserved. There is a well functioning, well seated bileaflet mechanical valve in the aortic position AI is present which is normal in quantity and location for this type of prosthesis (Size 23 valve/aorta conduit). There is a tube graft positioned in the ascending aorta. The study is otherwise unchanged from the prebypass exam. 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) **] [**2162-3-3**] 09:52 ?????? [**2156**] CareGroup IS. All rights reserved. Brief Hospital Course: [**2162-3-2**] Mr.[**Known lastname **] went to the operating room and underwent Bentall procedure with #23mm St.[**Male First Name (un) 923**] Valsalva mechanical Aortic Valve graft/coronary artery bypass grafting x2 (LIMA->LAD/SVG->Diag) with Dr.[**Last Name (STitle) **]. Please refer to Dr[**Doctor Last Name 14333**] operative report for further details. He was intubated and sedated and transferred to the CVICU. Drips were weaned and he awoke neurologically intact and was extubated in a timely fashion.All lines and tubes were discontinued when appropriate criteria was met. POD#1 beta-blocker, statin,aspirin was initiated and he was transferred to the step down unit for further telemetry monitoring. POD#2 2units Packed Red Blood cells were transfused for acute anemia , hematocrit=21.9. Appropriate response to transfusion. Anticoagulation with Coumadin was started on POD#2 for INR goal 2.0-3.0 for mechanical AVR. As discussed with Dr[**Doctor Last Name **] office, [**Hospital 6308**] [**Hospital3 **] ([**Telephone/Fax (1) 93783**] follow Mr. [**Known lastname 93784**] INR/Coumadin dosing upon discharge. Heparin drip to bridge anticoagulation was started on POD#3. The patient did have 2 episodes of atrial fibrillation. He converted to sinus after IV lopressor and amiodarone. The remainder of his postoperative course was essentially uneventful. He was ready for discharge to home on POD#6. INR was therapeutic at 2.0. All follow up appointments were advised. Medications on Admission: Plavix 75(1) ASA 325(1) Lisinopril 10(1) Lipitor 80(1) Toprol XL 50(1) Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg 2x/day for 1 week, then 200mg 2x/day for 1 week, then 200mg/day. Disp:*120 Tablet(s)* Refills:*0* 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 6. 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:*2* 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 8. Warfarin 2 mg Tablet Sig: Zero (0) Tablet PO once a day: INR to be managed by [**Company 191**] anticoagulation mgmt services for goal INR [**3-16**], dose of coumadin will change daily. Disp:*30 Tablet(s)* Refills:*2* 9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: INR to be managed by [**Company 191**] anticoagulation mgmt services for goal INR [**3-16**], dose of coumadin will change daily. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: s/p Bentall AVR (#23mmSt.[**Male First Name (un) 923**] Mechanical)/CABG x2 (Lima->LAD/SVG->Diag) Discharge Condition: good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr [**Name (NI) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment Dr [**Last Name (STitle) 171**] in 1 week please call for appointment **[**Hospital6 733**] [**Hospital3 **] # [**Telephone/Fax (1) **] for INR/Coumadin dosing. VNA will draw INR on [**2162-3-9**] with results to the clinic** Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse ([**Telephone/Fax (1) 3071**]) [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2162-3-8**]

[ "427.31", "270.4", "441.2", "V15.82", "285.1", "E878.2", "327.23", "V45.82", "401.9", "424.1", "276.2", "278.00", "414.01", "272.4" ]

icd9cm

[ [ [] ] ]

[ "38.45", "36.15", "99.04", "36.11", "35.22", "39.61" ]

icd9pcs

[ [ [] ] ]

9215, 9264

6182, 7667

369, 469

9406, 9413

1623, 4719

9925, 10474

1216, 1240

7788, 9192

9285, 9385

7693, 7765

9437, 9902

4768, 6159

1255, 1604

280, 331

497, 708

730, 904

920, 1200

22,079

190,263

44658

Discharge summary

report

Admission Date: [**2144-5-7**] Discharge Date: [**2144-5-11**] Service: CHIEF COMPLAINT: Worsening anginal symptoms, recent catheterization showing three vessel coronary disease. HISTORY OF PRESENT ILLNESS: This is an 80 year old with coronary artery disease status post CABG in [**2134**], who presented on [**2144-4-27**] with worsening anginal symptoms. Cardiac catheterization showed an ejection fraction of 50%, 100% proximal RCA, 70% proximal LAD, 100% mid LAD, a mid 90% ramus intermedius, an 80% proximal circumflex, a patent saphenous vein graft to the diagonal with a 40% lesion at the anastomosis, and a patent LIMA. He was deemed stable on [**2144-4-29**] for discharge home and returned on [**2144-5-5**] for percutaneous intervention. At admission, he denied prolonged angina or shortness of breath since catheterization. PAST MEDICAL HISTORY: The past medical history revealed coronary artery disease with (A) angina--onset in [**2132**]; (B) [**2132-3-5**] catheterization at [**Hospital6 1708**] with a 70% LAD lesion; (C) [**2134-5-28**] presenting to [**Hospital **] Hospital with chest pain and transferred to [**Hospital6 1760**] for catheterization, which showed heavily calcified LAD with proximal 80% lesion, nondominant RCA with a 90% stenosis, and ejection fraction of 66%; (D) [**2134-6-11**], CABG with LIMA to the LAD, SVG to the diagonal, complicated by supraventricular tachycardia and atrial fibrillation; (E) [**2141-10-3**] chest pain, with echocardiogram revealing aortic stenosis, ETT was negative; (F) [**2141-10-16**], cardiac angiography: Diffusely diseased LAD with 90% proximal lesion and 80% mid LAD lesion, 60% proximal circumflex, bifurcating ramus with up to 60% lesion in the inferior branch, total occlusion of the RCA, patent SVG to the diagonal and LIMA to the LAD, peak aortic gradient 24, ejection fraction 75%, and 1+ mitral regurgitation; (G) [**2144-3-17**] echocardiogram revealed left atrium moderately enlarged, mild to moderate concentric left ventricular hypertrophy, moderate to severe aortic stenosis with a peak gradient of 66 mmHg, mean of 43 mmHg, estimated aortic valve area 0.6 cm2, mild aortic insufficiency, mild mitral regurgitation, ejection fraction 60%. The patient is status post right carotid endarterectomy in [**2134-6-2**]. There is a history of hiatal hernia; peptic ulcer disease status post upper GI bleed; transient ischemic attack; sleep apnea; aortic stenosis; diabetes mellitus, insulin dependent, with complications; spinal stenosis; and narcolepsy. ALLERGIES: Possibly to shellfish. MEDICATIONS ON ADMISSION: Aspirin 325 mg q.d., Quinidine 324 mg b.i.d., Prevacid 30 mg q.d., Norvasc 2.5 mg q.d., Avandia 10 mg q.d., Lipitor, Lasix 40 mg q.d., Zestril 20 mg q.d., Ritalin 20 mg b.i.d., NPH Insulin 20 units b.i.d. subq., Nitro-patch 0.2 mg per hour during the day, and Plavix 75 mg q.d. SOCIAL HISTORY: There is a remote tobacco history 20 years ago. The patient lives alone in [**Location (un) 1475**]. There is occasional alcohol. FAMILY HISTORY: Positive for coronary artery disease; his mother had myocardial infarction at age 57. PHYSICAL EXAMINATION: Blood pressure was 112/60, heart rate 50, respirations 16. Carotids were 2+ without bruits, no jugular venous distention. The heart was regular with normal S1 and S2. There was a 3/6 systolic ejection murmur at the right upper sternal border. The lungs were clear. The abdomen was benign and obese. Femoral pulses were 1+ without bruits. There were trace, faint dorsalis pedis pulses and trace lower extremity edema. LABORATORY DATA ON ADMISSION: Potassium was 4.4, BUN 26, creatinine 1.1, hematocrit 29.6, platelets 197,000. EKG on admission revealed normal sinus rhythm at 61, mild left axis deviation, normal intervals with QTC 429 milliseconds, less than [**Street Address(2) 4793**] elevation in V2 and V3, T wave inversion in V5, V6, I, and aVL, unchanged from [**2144-4-28**]. SUMMARY OF HOSPITAL COURSE: This is an 80-year-old gentleman with history of aortic stenosis, peripheral vascular disease, coronary artery disease, status post CABG in [**2134**] (LIMA to the LAD, SVG to D-1) with recent echocardiogram demonstrating normal left ventricular systolic function and valve area of 0.6 cm2, recent cardiac catheterization showing severe three vessel CAD and a left dominant system with patent grafts but severe ramus disease and moderate to severe proximal left circumflex lesion, referred for elective revascularization of the ramus and consideration of PCI to the proximal left circumflex. Cardiac: Percutaneous intervention was performed on [**2144-5-5**]. Rotational atherectomy was performed on the ramus intermedius and PTCA with balloon resulting in 20% residual stenosis, no dissection, and normal flow. Fractional flow reserve across the proximal left circumflex was determined to be 0.81 with Adenosine infusion, thus had no intervention. Post procedure, the patient was continued on Integrelin and aspirin, and had no further ischemic symptoms. However his course was complicated by gastrointestinal bleed. Gastrointestinal: Mr. [**Known lastname 95577**] had a history of gastrointestinal bleed in the past. After cardiac catheterization on [**2144-5-5**], the patient was continued on aspirin and Integrelin and had been on Plavix until admission on [**2144-5-5**]. He developed abdominal cramping and melena the next morning. A GI consult was promptly obtained. He was transfused to maintain hematocrit of 26 but after a second large melanotic stool, nasogastric lavage demonstrated bright red blood that did not clear. The patient was transferred to the MICU Service. EGD was performed on [**2144-5-7**] with red blood seen in the second portion of the duodenum, but no active bleeding was found nor any lesion which would cause it. On [**2144-5-8**], hematocrit had continued to drop and a second EGD was performed showing a single acute superficial oozing 3 mm ulcer in the second portion of the duodenum. The ulcer was injected with epinephrine, with BICAP electrocautery applied for hemostasis. Mr. [**Known lastname 95577**] received a total of 8 units of packed red blood cells with a nadir hematocrit of 23.9. Hematocrit was followed on the floor and remained stable until the time of discharge in the high 20s and low 30s. All anticoagulation and antiplatelet agents were discontinued and after conversation with the cardiology and GI services, it was determined that aspirin could be safely restarted within two weeks after discharge. Prilosec was continued at 40 mg b.i.d. Diabetes mellitus: Regular insulin sliding scale was used during his stay with NPH and Avandia restarted at the time of discharge. CONDITION ON DISCHARGE: Stable with no further ischemic symptoms after percutaneous intervention, no evidence of further gastrointestinal bleed, and patient able to ambulate and cleared by physical therapy to return home. DISCHARGE MEDICATIONS: Prilosec 40 mg b.i.d., Lasix 40 mg q.d., Zestril 20 mg q.d., Avandia 10 mg q.d., Quinidine 324 mg b.i.d., NPH 20 units b.i.d., Lipitor 10 mg q.d., Ritalin 20 mg b.i.d., aspirin 81 mg q.d. to start [**2144-5-16**] and not before. Nitro-patch, Plavix, and Norvasc were held. DISCHARGE DIAGNOSES: Coronary artery disease; status post rotational atherectomy of ramus intermedius; bleeding duodenal ulcer; blood loss anemia; diabetes mellitus, insulin dependent, with complications; aortic stenosis. DISCHARGE FOLLOWUP: Followup will be with Dr. [**Last Name (STitle) 83788**] his home cardiologist, results were communicated to him. [**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**] Dictated By:[**Last Name (NamePattern1) 95578**] MEDQUIST36 D: [**2144-6-16**] 13:31 T: [**2144-6-17**] 18:18 JOB#: [**Job Number 39212**] cc:[**Location (un) 95579**]

[ "553.3", "411.1", "414.01", "532.00", "250.00", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "99.20", "36.05", "88.53", "37.22", "88.56", "99.69", "45.13", "44.43" ]

icd9pcs

[ [ [] ] ]

3064, 3151

7293, 7495

6996, 7271

2618, 2897

3998, 6748

3174, 3615

99, 190

7516, 7929

219, 851

3630, 3969

874, 2591

2914, 3047

6773, 6972

6,518

138,062

8957

Discharge summary

report

Admission Date: [**2195-12-18**] Discharge Date: [**2195-12-19**] Date of Birth: Sex: F Service: HISTORY OF PRESENT ILLNESS: Patient is a 54-year-old right-handed woman with probable CNS lymphoma, whose first biopsy was nondiagnostic and her second one shows inflammatory cells, chronic encephalitis with CMV cells. Since early [**Month (only) **], she has become more sleepy and somnolent with headaches in the frontal region and nausea, but no vomiting. She also developed horizontal double vision. She was started on Decadron 4 mg q day without improvement. Her most recent story begins on the day of admission when she saw her neuro-oncologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] and fainted in the parking lot going in to see him. She recovered shortly thereafter. She saw Dr. [**Last Name (STitle) 724**], and at that time she was alert, awake, oriented. She was sent home on an increased decadron regimen 4 mg qid. She received one dose of decadron prior to leaving [**Location (un) 86**] to go back to [**Hospital3 **]. On her way home, she fainted again, and did not regain consciousness. Her husband took her home and called [**Hospital1 **]. He was told to come back to the [**Hospital1 **] [**First Name (Titles) 2142**] [**Last Name (Titles) **]. During the examination, she was intubated on a SIMV with pressure support and nonresponsive. PAST MEDICAL HISTORY: 1. Hypertension. 2. Gastroesophageal reflux disorder. 3. Likely CNS lymphoma. MEDICATIONS: 1. Decadron 4 mg po q day. 2. Lisinopril 2.5 mg po q day. 3. Zantac 150 mg po q day. ALLERGIES: 1. Morphine. 2. Dilantin. 3. Erythromycin. SOCIAL HISTORY: She lives in [**Hospital3 **] with her family. FAMILY HISTORY: None known. PHYSICAL EXAMINATION: Vital signs: Temperature 98.0, blood pressure 180/100, heart rate 101, O2 saturation 99% on room air. In general, she is a woman, who is intubated and sedated. Head and neck: Normocephalic, atraumatic, supple. Mucous membranes are moist, no bruits. Cardiovascular: Regular rhythm, normal rate. Pulmonary: Clear to auscultation bilaterally. Abdomen is soft, nontender, positive bowel sounds, nondistended. Neurologic: Mental status: She is not responsive to sternal rub. Cranial nerves: Right pupil is widely dilated to 5 mm and normally responsive to light. The left was 2 mm and unresponsive. Fundoscopic examination was pale retina and blurred disk margin on the right. Left retinal could not be evaluated. Motor system: Bulk and tone are normal. She does not move any extremities. Reflexes are present and symmetric. Corneal and gag reflex are present. No doll's eye. Plantar reflexes are extensor. Sensory examination to pain, she has a decerebrate posture bilaterally. STUDIES: Head CT scan with significant edema and mass effect. The right appears more effected. There is no space in the cisterns, and there is evidence of early herniation on the right. HOSPITAL COURSE: The patient was admitted to the Neurology Service. She was started on mannitol 50 grams and Decadron 10 mg IV. Admitted to the Neuro SICU. After the decadron 10 mg IV, she was given 6 mg every six hours. The patient's family was contact[**Name (NI) **] and the next morning, they came in and found the patient to be intubated and unresponsive. Her sedatives had been withdrawn. They decided to make the patient comfort measures only and she expired on [**2195-12-19**]. DISCHARGE DIAGNOSIS: Central nervous system lymphoma. DISCHARGE CONDITION: Expired. [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], M.D. [**MD Number(1) 4269**] Dictated By:[**Last Name (NamePattern1) 5476**] MEDQUIST36 D: [**2196-7-17**] 11:04 T: [**2196-7-22**] 11:38 JOB#: [**Job Number 31099**]

[ "780.01", "348.4", "401.9", "518.81", "530.81", "276.0", "202.80", "348.5" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

3561, 3834

1766, 1779

3505, 3539

3006, 3483

1802, 2988

153, 1429

1451, 1684

1701, 1749

71,467

199,409

37889

Discharge summary

report

Admission Date: [**2185-4-7**] Discharge Date: [**2185-4-22**] Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) / Morphine Attending:[**First Name3 (LF) 165**] Chief Complaint: Pre-syncope Major Surgical or Invasive Procedure: [**2185-4-18**] 1. Re-do sternotomy. 2. Aortic valve replacement with a size 23-mm St. [**Male First Name (un) 923**] Epic tissue valve. History of Present Illness: 87M with AS s/p valvuloplasty x3 most recet of which was in [**1-/2185**], MVP, CABG x 6 vessel (remote), bradycardia s/p dual ICD/pacer, ischemic cardiomyopathy with EF 45%, now presenting with 3 day history worsening shortness of breath. The patient reports he developed dyspnea on exertion last week which progressively became worse. He reports he was getting out of bed and developed a hot flash and became short of breath as he was getting up, then felt dyspneic as he was walking to the bathroom. This was almost identical to the syncopal episode he had that led to his valvulopsty in 12/[**2184**]. He denies chest pain, shortness of breath at rest, lightheadedness, dizziness, nausea/vomiting. The patient reported to [**Hospital 6930**] [**Hospital 12018**] Hospital in NH for the dyspnea on exertion and was found there to have guiac posistive stool (he's on iron supplements), anemia (at his baseline), and increased weakness. He remained chest-pain free and did not report changes in dyspnea. The patient denies abdominal pain, hematemesis, changes in his bowel movements, but does report black stool due to iron supplements he takes every morning. On arrival to the [**Hospital1 18**] ED, initial vital signs were: 97.6 62 122/68 18 98% 2L NC. The patient had a CXR which was clear, and had a stool guiac which was brown and faintly positive. Cr was 1.4 from baseline 1.1, BNP 6985, CE's neg x1. The patient has had a remote h/o DVT, so underwent a CTA to r/o PE which was negative. Past Medical History: 1. CARDIAC RISK FACTORS: +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -Aortic Stenosis s/p valvuloplasty [**2184-10-15**] -CAD, prior CABG x 6 ([**Hospital3 17921**] Center, [**2174**]) Anatomical detail: LIMA to LAD, aortosaphenous Y-graft to the diagonal and intermediate arteries, aortosequential saphenous vein to right acute marginal - to RPDA, OM3, OM2. -h/o bradycardia s/p ICD placement in [**2181**] for VT ([**Hospital 3278**] Medical Center) -Ischemic cardiomyopathy 3. OTHER PAST MEDICAL HISTORY: -BPH -s/p cataract surgeries -s/p cholecystectomy Social History: Lives in [**Location 84728**] NH with his wife. [**Name (NI) **] is a retired construction worker/contractor. He smoked unknown amount for 40 years quit smoking 30 years ago and drinks beer rarely. No illicit drugs. Family History: NC Physical Exam: VS: 98.8 95-125/60-73 65 18 95RA GENERAL: Alert, interactive, appropriate, NAD. HEENT: Sclera anicteric, pupils round and equal, MMM. NECK: Supple, JVP 8cm CARDIAC: RRR, 2/6 systolic murmer at RUSB, [**2-17**] holosystolic murmer at apex with faint diastolic component. LUNGS: CTAB, fair air movement, no crackles, wheezes, rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: 2+ DP 2+ PT 2+ Pertinent Results: ECHO: The left atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 40-45 %). [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 severely thickened/deformed. There is probably severe aortic valve stenosis (valve area 0.8-1.0cm2) but Doppler recordings are technically suboptimal. The mitral valve leaflets are mildly thickened. Moderate to severe ([**4-15**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2185-1-27**], the prior study was of better technical quality. Mitral regurgitation is now more prominent. . CTA: 1. No evidence of pulmonary embolism or acute aortic syndrome. 2. Small right greater than left pleural effusions. 3. Moderate to severe emphysema. . ECHO [**2185-4-13**] The left atrium is markedly dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with septal hypokinesis. Diastolic function could not be assessed. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2185-4-8**], Doppler velocities across the aortic valve can be more clearly seen on the current study. The valve is severely stenotic. The degree of mitral regurgitation appears moderate on the current study (although may be UNDERestimated due to acoustic shadowing). It was probably moderate on the prior study also. Pulmonary artery pressures can be estimated on the current study and are moderately elevated. [**2185-4-21**] 03:31AM BLOOD WBC-9.3 RBC-2.99* Hgb-8.9* Hct-26.3* MCV-88 MCH-29.6 MCHC-33.7 RDW-16.8* Plt Ct-124* [**2185-4-7**] 08:45PM BLOOD WBC-5.7 RBC-3.27* Hgb-9.4* Hct-29.1* MCV-89 MCH-28.7 MCHC-32.3 RDW-16.7* Plt Ct-174 [**2185-4-21**] 03:31AM BLOOD PT-17.5* PTT-62.5* INR(PT)-1.6* [**2185-4-7**] 08:45PM BLOOD PT-31.4* PTT-34.5 INR(PT)-3.1* [**2185-4-21**] 03:31AM BLOOD Glucose-149* UreaN-21* Creat-1.1 Na-139 K-3.4 Cl-105 HCO3-26 AnGap-11 [**2185-4-7**] 08:45PM BLOOD Glucose-135* UreaN-23* Creat-1.4* Na-144 K-3.6 Cl-109* HCO3-27 AnGap-12 Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2185-4-7**] for further work-up of his dyspnea. A CT scan was negative for a pulmonary embolism. An echocardiogram showed severe aortic valve stenosis. Given the severity fo his disease, the cardiac surgery service was consulted for surgical evaluation. Mr. [**Known lastname **] was worked-up in the usual preoperative manner. Carotid ultrasound showed a less then 40% bilateral internal carotid artery stenosis. Vein mapping showed small but usuable vein in his right leg. Cardiac catheterization revealed patent grafts from his previous surgery with native three vessel disease and severe aortic valve stenosis. He had visual changes following his catheterization and a CTA was performed which was negative for any acute abnormality. As he was previously on coumadin for a pulmonary embolism many years ago, in discussion with his primary care physician, [**Name10 (NameIs) **] was discontinued. On [**2185-4-18**], Mr. [**Known lastname **] was taken to the operating room where he underwent a redo sternotomy with and aortic valve replacement. Please see operative note for surgical details. Postoperatively he was taken to the intensive care unit for monitoring. Over the next 24 hours, he awoke neurologically intact and was extubated. The electrophysiology service interogated his AICD/Pacemaker. No adjustments were made and it was functioning well with good battery life. Beta blockade, aspirin and a statin were resumed. On postoperative day two, he was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. He was experiencing loose stool due to milk products and fruit juices (which was a problem at home as well and he took imodium). His stool for cdiff was neg x4 and he was started on imodium w/ resolution of loose stool. On POD# 4 he was cleared for discharge to [**Hospital3 13268**] Hospitals of [**Location (un) 4368**]. All follow up appointments were advised. Medications on Admission: 1. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY 2. doxazosin 2 mg Tablet Sig: One (1) Tablet PO at bedtime. 3. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO twice a day. 4. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 6. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous every twelve (12) hours: Please take until instructed otherwise by your outpatient physician. [**Name Initial (NameIs) **]:*2 syringes* Refills:*0* 8. amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day: to be started after completion of 12 days of 400mg twice a day. [**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0* 9. warfarin 1 mg Tablet Sig: Two (2) Tablet PO every Mon/Wed/Fri. 10. warfarin 1 mg Tablet Sig: Four (4) Tablet PO every Sun/Tues/Thurs/Sat. 11. amiodarone 400 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 12 days. [**Name Initial (NameIs) **]:*24 Tablet(s)* Refills:*0* Discharge Medications: 1. insulin lispro 100 unit/mL Solution Sig: per finger stick sliding scale Subcutaneous AC and HS: dose per sliding scale protocol. 2. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. potassium chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours). 10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 11. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 12. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for sleep. 13. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 14. warfarin 1 mg Tablet Sig: dose per daily INR Tablet PO Once Daily at 4 PM: Indication afib Goal INR 2.0-2.5 2mg alter w/ 4mg was home dose. . 15. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. sodium chloride 0.65 % Aerosol, Spray Sig: [**2-13**] Sprays Nasal QID (4 times a day) as needed for congestion. 17. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for loose stool. 18. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours). 19. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: until lower extermity edema resolved. 20. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: Two (2) Tablet, ER Particles/Crystals PO once a day: with lasix. 21. Outpatient Lab Work electrolyes [**Hospital1 **] INR daily until INR stable and therapeutic- goal 2.0-2.5 Discharge Disposition: Extended Care Facility: [**Hospital6 19504**] of [**Location (un) 1514**] - [**Location (un) 1514**], NH Discharge Diagnosis: Aortic Stenosis s/p Redo-Sternotomy, Aortic Valve Replacment(tissue #23 St. [**Male First Name (un) **]) Past medical history: Home O2 at night Dyslipidemia Hypertension s/p valvuloplasty [**2184-10-15**], [**2185-1-26**] Coronary artery disease s/p CABG Bradycardia s/p ICD placement in [**2181**] for VT ([**Hospital 3278**] Medical Center) Ischemic cardiomyopathy Benign prostatic hypertrophy Gout Past Surgical History: s/p CABG x 6 in [**2174**]([**Hospital3 17921**] Center)- LIMA to LAD, aorto saphenous Y-graft to the diagonal and intermediate arteries, aorto sequential saphenous vein to right acute marginal - to RPDA, OM3, OM2. s/p cataract surgeries s/p cholecystectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait with assist Incisional pain managed with tramadol Incisions: Sternal - healing well, no erythema or drainage 1+ Edema of lower extremities OF note: Has loose stool when he drinks fruit juices or milk products- C-diff negative x 4- started on immodium and rec'd flagyl x1 Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication Afib Goal INR 2.0-2.5 First draw [**2185-4-23**] Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**First Name (STitle) **] on [**Telephone/Fax (1) 170**] Date/Time:[**2185-5-16**] 2:15 Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 11250**] on [**2185-5-24**] at 2:30pm Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 3647**] in [**5-17**] 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 [**2185-4-23**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2185-4-22**]

[ "280.9", "274.9", "428.0", "E939.4", "787.91", "401.9", "E935.2", "V45.02", "424.1", "368.15", "414.8", "600.00", "V45.81", "414.01", "428.31", "492.8", "272.4", "584.9" ]

icd9cm

[ [ [] ] ]

[ "39.61", "88.56", "35.21", "37.23", "38.93" ]

icd9pcs

[ [ [] ] ]

11820, 11927

6515, 8635

266, 405

12654, 12986

3311, 6492

13920, 14715

2768, 2772

9722, 11797

11948, 12054

8661, 9699

13010, 13897

12373, 12633

2787, 3292

2027, 2435

215, 228

433, 1931

2466, 2518

12076, 12350

2534, 2752

42,510

161,943

35041

Discharge summary

report

Admission Date: [**2134-1-15**] Discharge Date: [**2134-1-21**] Date of Birth: [**2061-9-18**] Sex: M Service: SURGERY Allergies: Oxycodone / Nifedipine Attending:[**First Name3 (LF) 371**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [**2134-1-15**] Ileocecectomy History of Present Illness: 72M presented to ED with abdominal pain since Monday (3 days prior). Says pain started just below his umbilicus, and is centered in the center and right of his abdomen. He has also noted increasing abdominal distention since Monday, and doesn't think he has been passing gas. He has noted increased bowel movements, but no diarrhea, melena, or blood in his bowel movements. He has not had any nausea or vomiting. He last ate Monday, and has not had an appetite since that time. He denies fever, chills, SOB. He denies similar pain previously. He has a history of renal artery stenosis and CKD, which has improved since renal artery stenting in late [**2133-3-10**]. Past Medical History: dCHF Gout BPH Spinal stenosis s/p surgery HTN HL Atrial fibrillation (not on coumadin) Pacemaker Renal insufficiency bladder/bowel incontinence s/p spinal surgery Social History: Lives alone. Worked as a photographer. No tobacco, 1 beer/day, no drugs. Has one son. Family History: Mother had stroke. Physical Exam: Temp: 96.3 HR: 60 BP: 203/42 Resp: 18 O(2)Sat: 100 Normal Constitutional: NAD, looks uncomfortable HEENT: Normocephalic, atraumatic, Extraocular muscles intact, Pupils equal, round and reactive to light Oropharynx within normal limits Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Tender to palpation in mid-epigastic and right upper quadrant and mid righ abdomen GU/Flank: No costovertebral angle tenderness Extr/Back: No cyanosis, clubbing or edema Skin: No rash, Warm and dry Neuro: Awake alert and oriented x3. Cranial nerves II through XII intact. Nonfocal motor sensory exam. No nystagmus. No dysmetria. No pronator drift. Gait normal. No tremors. Speech fluent. Psych: Normal mentation, Normal mood Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae Pertinent Results: [**2134-1-15**] 06:46PM GLUCOSE-115* UREA N-44* CREAT-2.0* SODIUM-136 POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-22 ANION GAP-15 [**2134-1-15**] 06:46PM CK(CPK)-152 [**2134-1-15**] 06:46PM CK-MB-4 cTropnT-<0.01 [**2134-1-15**] 06:46PM WBC-6.6# RBC-3.75* HGB-11.4* HCT-33.8* MCV-90 MCH-30.5 MCHC-33.8 RDW-13.2 [**2134-1-15**] 06:46PM PLT COUNT-198 [**2134-1-15**] 05:48AM WBC-3.2*# RBC-3.80* HGB-11.7* HCT-34.3* MCV-90 MCH-30.7 MCHC-34.0 RDW-13.4 [**2134-1-15**] 05:48AM PLT SMR-NORMAL PLT COUNT-199 CT Abdomen/Pelvis: IMPRESSION: Extensive small bowel and cecal pneumatosis and dilatation, with portal venous air and possible rectal hemorrhage and small intra-abdominal ascites, consistent with bowel infarct. Extensive atherosclerotic disease with likely near-complete occlusion of the SMA at baseline and possible supervening embolic disease which could not be confirmed on current non-contrast exam. Brief Hospital Course: He was admitted to the Acute Care Surgery team and underwent abdominal CT imaging showing extensive small bowel and cecal pneumatosis and dilatation, with portal venous air and possible rectal hemorrhage and small intra-abdominal ascites, consistent with bowel infarct. He was taken to the operating room for an ileo cecectomy. There were no complications. Postoperatively while in the PACU he was noted to be in atrial fibrillation with RVR. Of note he has a history of Afib. He was given Diltiazem and started on a drip and was then transferred to the surgical ICU for ongoing monitoring. His rate was eventually controlled and the Diltiazem drip was stopped. His home cardiac medications were restarted; the Labetalol did require an increased adjustment. he was seen by his [**Hospital1 **] cardiologist and will follow up as an outpatient after discharge. His heart rate at time of discharge ranged within the low to mid 70's. His bowel function was slow to return and therefore his diet advanced slowly. He was given a one time dose of Methylnaltrexone on POD# 4 with large bowel movement resulting. He is tolerating a regular diet at this time and his home medications were restarted. It should also be mentioned that at time of admission he was noted with a sacral wound that is 3 x 0.5 x 1 cm with approx 0.25 cm of undermining around periphery; the peri wound tissue is badly macerated and there are skin tags adjacent to the wound. There is a mild mal odor. The wound bed is dark red, not healthy or granulating. Per patient this has been present for several months and visiting nurses at home are packing it with aquacel daily. He is being discharged to home with nurses services. Medications on Admission: vicodin prn, ASA 81', pravastatin 80', diltiazem 120'', labetalol 200'', hctz 12.5', mvi Discharge Medications: 1. diltiazem HCl 120 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO twice a day. 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days. Disp:*6 Tablet(s)* Refills:*0* 6. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 3 days. Disp:*9 Tablet(s)* Refills:*0* 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 8. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 9. labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 12. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 13. arginine-glutamine-calcium Hmb 7-7-1.5 gram Powder in Packet Sig: One (1) packet PO twice a day: 1 PACKET IN 8-10OZ ICE WATER [**Hospital1 **]. Discharge Disposition: Home With Service Facility: Care Tenders Discharge Diagnosis: Ischemic bowel 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 decreased blood flow to your intestines requiring an operation to remove the affected area. You are being discharged on medications to treat the pain from your operation. These medications will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely. You MUST refrain from such activities while taking these medications. Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Activity: No heavy lifting of items [**11-21**] pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: TUESDAY [**2134-2-9**] at 3:00 PM With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Name:[**First Name8 (NamePattern2) **] [**Name8 (MD) **],MD Specialty: Cardiology Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 6425**] Phone: [**Telephone/Fax (1) 2258**] When: We are working on a follow up within a week. You will be called at home tomorrow with an appointment. If you do not hear by Friday, please call above number and ask for [**Doctor Last Name 2563**]. Completed by:[**2134-1-21**]

[ "585.9", "428.32", "428.0", "274.9", "707.23", "427.31", "272.4", "557.0", "600.00", "707.03", "789.59", "V45.01", "403.90" ]

icd9cm

[ [ [] ] ]

[ "45.73" ]

icd9pcs

[ [ [] ] ]

6379, 6422

3179, 4876

296, 328

6481, 6481

2242, 3156

8339, 9120

1338, 1358

5015, 6356

6443, 6460

4902, 4992

6632, 7969

1373, 2223

242, 258

7981, 8316

356, 1032

6496, 6608

1054, 1218

1234, 1322

5,689

121,702

5738+55696

Discharge summary

report+addendum

Admission Date: [**2124-9-4**] Discharge Date: [**2124-9-8**] Date of Birth: [**2048-7-14**] Sex: F Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 905**] Chief Complaint: Anemia, GIB Major Surgical or Invasive Procedure: Endoscopy, transfusion of PRBC History of Present Illness: 76 yo woman with ESRD on HD, CAD, CHF, atrial fibrilation on coumadin, recent pelvic fractures with 2 episodes of coffee ground emesis last night at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (rehab). She has never had this before and denies nausea, abdominal pain, melena or BRBPR. [**Last Name (un) **] was seen at [**Hospital1 **] [**Location (un) 620**], VS: T 99.3, HR 102, BP 130/51, RR 16, Sat 95% RA. She was found to have hct 16 from recent baseline of 30, with INR of 6.6 from recent 2.0 ([**2124-8-15**]). She was given 1u PRBC's there and sent here. On arrival hct 20. She was guaiac + and had NGL showing coffee grounds-cleared after 500cc NS lavage. She was given 10mg vitamin K SC, pantoprazole 40mg iv, and ceftriaxone 1gm iv (for aspiration pneumonitis). GI was consulted. In ED VS: T 98.7, HR 101, BP 96/20, RR 22, Sat 99% on 2L NC. . ROS: She notes dry mouth, dizziness today, chest pressure radiating to back (unable to rate on 0-10 scale), and chronic right leg/hip pain. She denies weight change, vision change, hearing change, nasal congestion, cough, shortness of breath, chest pain, abdominal pain, nausea, constipation, diarrhea, melena, BRBPR, dysuria (makes minimal urine), hematuria, or rash. Past Medical History: -CAD s/p MI treated at [**Hospital1 112**] [**12-11**] -CHF: per cards note Echo [**4-9**]: s/p MVR, Mod-Severe TR, Atrial dilatation, LVEF 45%, followed mostly at [**Hospital1 112**] (last TTE here [**2120**]); report of eval at [**Hospital **] hospital [**2123-5-11**]: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) **] 55-60% with LVH and new wall motion abnormalities, severe pHTN (>65mmHg). -pulmonary hypertension as above -Cirrhosis -Ascities -Inguinal Hernia -Lower Extrem Edema -NIDDM -ESRD on HD T/T/S, s/p failed transplant, makes minimal urine -Valvular Disease -atrial fibrilation, s/p pacer placement -s/p multiple pelvic fractures ? adynamic [**First Name3 (LF) 500**] (not secondary hyperparathyroid) -stage II/III sacral decubitis ulcer Social History: Prior to recent admit with multiple pelvic fractures had been living at home, independent of ADL's. Recently has been in rehab. No tobacco, alcohol, illicit drug use. Supportive son. Family History: nc Physical Exam: VS: T: 98.8 HR: 103 BP: 156/33 RR: 19 Sat: 99% on 2L NC Gen: Fatigued but comfortable, speaking in full sentences HEENT: NCAT, PERRL, sclera anicteric, pale conjunctiva, OP clear, mm dry Neck: Supple, no LAD, JVD difficult to assess (lying on left side) CV: II/VI HSM heard best at LUSB, no rubs/gallops Resp: Bibasilar rales, no w/r Abdomen: Soft, NT, ND, +BS, no HSM Ext: 3+ PE bilateral LE to mid-thigh, left arm fistula with excellent bruit/thrill Neuro: A&Ox3, motor [**4-8**], sensation grossly intact Skin: Pale but warm, no rashes, breakdown/erythema over sacral area--stage II-III ulcer appears to be healing, approx 0.5cm by 0.5cm Pertinent Results: [**2124-9-4**] 03:46PM BLOOD WBC-9.3# RBC-2.12*# Hgb-6.4*# Hct-20.3*# MCV-96 MCH-30.3 MCHC-31.6 RDW-23.6* Plt Ct-440# [**2124-9-4**] 07:46PM BLOOD Hct-19.5* [**2124-9-4**] 11:40PM BLOOD Hct-16.0* [**2124-9-5**] 02:59AM BLOOD WBC-7.3 RBC-2.87*# Hgb-8.8*# Hct-25.7*# MCV-90 MCH-30.6 MCHC-34.2 RDW-19.8* Plt Ct-244 [**2124-9-5**] 05:36PM BLOOD Hct-31.0* [**2124-9-5**] 09:32PM BLOOD Hct-34.5* [**2124-9-6**] 04:05AM BLOOD WBC-8.0 RBC-3.50* Hgb-11.0* Hct-32.7* MCV-94 MCH-31.5 MCHC-33.7 RDW-20.3* Plt Ct-263 [**2124-9-6**] 03:15PM BLOOD WBC-7.2 RBC-3.66* Hgb-11.4* Hct-33.5* MCV-92 MCH-31.2 MCHC-34.1 RDW-20.2* Plt Ct-266 [**2124-9-7**] 01:30PM BLOOD WBC-6.2 RBC-3.54* Hgb-10.9* Hct-33.6* MCV-95 MCH-30.9 MCHC-32.5 RDW-19.6* Plt Ct-293 [**2124-9-7**] 09:00PM BLOOD Hct-36.1 [**2124-9-8**] 05:20AM BLOOD WBC-6.2 RBC-3.90* Hgb-11.8* Hct-38.0 MCV-97 MCH-30.3 MCHC-31.2 RDW-19.8* Plt Ct-305 . [**9-5**] EGD - Esophagus: Normal esophagus. Stomach: Excavated Lesions Two 10mm ulcers were found in the antrum, above pylorus, at 12 o'clock and 2 o'clock. 2nd ulcer had visible vessel, nonbleeding.. [**Hospital1 **]-CAP Electrocautery was applied to the 2nd ulcer for hemostasis successfully. Duodenum: Normal duodenum. Impression: Ulcers in the antrum, above pylorus, at 12 o'clock and 2 o'clock. 2nd ulcer had visible vessel, nonbleeding. (thermal therapy) Brief Hospital Course: This is a 76 year old woman with ESRD on HD, DM, CAD, CHF, atrial fibrilation on coumadin who presented with coffee-ground emesis and positive NG lavage suggestive of an upper GI bleed. She also presented with a Hct of 16 and a supratherapeutic INR of 6.1. She was admitted to the MICU and received a total of 3 u FFP, vitamin K and 3 U PRBCs. Coumadin and aspirin were stopped. She underwent an upper endoscopy on [**9-5**] which showed 2 non-bleeding gastric ulcers. One ulcer was noted to have an exposed blood vessel that was cauterized. Biopsies came back positive for H.pylori, so she was started on triple therapy of clarithromycin, flagyl, and protonix - she has 11 days left of the antibiotics to complete and needs to remain on the PPI [**Hospital1 **] until follow-up with GI. Her Hct has been stable after the EGD, ranging from 31-37, and she was transferred to the medical floor. No further signs of active bleeding were noted. She was restarted on low-dose Aspirin on [**9-7**]; however, her coumadin will need to be held for at least one month until she follows up with GI. . Secondary issues: . # CAD - while in the MICU, patient was noted to have lateral and inferior ST changes concerning for ischemia in ED and elevated biomarkers (trop 0.18 on admission, negative CK). This was thought to be related to demand ischemia secondary to her acute anemia. Her repeat EKGs have since improved and she was restarted on her aspirin on [**2124-9-7**]. She was continued on her metoprolol and simvastatin. # Afib - continued on metoprolol, anticoagulation has been stopped (coumadin) until patient follows up with GI in [**10-11**]. # ESRD - on HD Tu/Th/Sa. Continue nephrocaps, calcium, and phos-lo. # Pelvic fractures - This was thought to be secondary to adynamic [**Date Range 500**] disease and less likely secondary hyperparathyroidism in the setting of ESRD. Both [**12-30**] hydroxy vitamin D and 25-hydroxy vitamin D levels were sent and pending at the time of discharge. The patient is scheduled for a BMD on [**2124-9-13**] and has follow-up with endocrinology on [**2124-9-20**]. Her calcium acetate needs to be held on the day of the BMD. # DM - continued on fixed dose NPH (16 units q AM, 3 units qPM) and sliding scale coverage. # Pressure ulcer - patient noted to have a pressure ulcer on her sacrum and was seen by wound care. Recommended following pressure ulcer guidelines for treatment, including dry gauze dressing changes daily. Medications on Admission: aspirin 81mg daily NPH insulin 16u q daily, 6u QHS, SSHI Procrit at HD omeprazole 20mg daily metoprolol 25mg QHS daily, qam M/W/F/Sun [**Hospital1 **] zocor 40mg po qhs phoslo 667mg tid coumadin 1.5mg qhs tylenol 1gm [**Hospital1 **] benadryl 12.5mg iv q8 heparin 5000u sc tid oxycodone 5mg q 4hr colace senna Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] - [**Location (un) **] Discharge Diagnosis: Primary - Upper GI bleed Secondary - ESRD on HD Atrial fibrillation CAD Pelvic fractures Discharge Condition: Stable, no further bleeding and stable Hct Discharge Instructions: You were admitted for an upper GI bleed and received blood products as well as an endoscopy. Your aspirin and coumadin were stopped initially and the aspirin was restarted on [**2124-9-7**]. Please do not take coumadin for at least one month and until you follow-up with your PCP. [**Name10 (NameIs) **] are scheduled to follow-up with GI in one month. Please continue the protonix twice daily. In regards to the pelvic fractures, you are scheduled for a [**Name10 (NameIs) 500**] mineral density scan on [**2124-9-13**] - please do not take your calcium the day prior to the scan. Please keep all appointments as scheduled below. Continue hemodialysis on Tuesdays/Thursdays/Saturdays. If you any symptoms of bleeding, dark stools, dizziness, lightheadedness or any other concerning symptoms, please seek medical attention. Followup Instructions: Provider: [**Name10 (NameIs) **] DENSITY TESTING Phone:[**Telephone/Fax (1) 4586**] Date/Time:[**2124-9-13**] 5:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2124-9-20**] 1:30 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name12 (NameIs) **] INTERNAL MEDICINE (NHB) Date/Time:[**2124-9-22**] 12:30 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5085**], MD Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2124-10-30**] 11:00 [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**] Name: [**Known lastname 3874**],[**Known firstname **] M Unit No: [**Numeric Identifier 3875**] Admission Date: [**2124-9-4**] Discharge Date: [**2124-9-8**] Date of Birth: [**2048-7-14**] Sex: F Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 391**] Addendum: Discharge Medications accidentally left out of Discharge summary. They are as follows: . -Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. -Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. -Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. -Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). -Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) as needed for pain. -B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). -Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q2H (every 2 hours) as needed for wheezing. -Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. -Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)): On Tu/Th/Sa, hold for sbp<100 and hr<60. -Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): [**Hospital1 **] on M/W/F/Sunday Hold for SBP<100 or HR<60 . -Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). -Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 11 days. -Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 11 days. -Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). -Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). -Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). -NPH 16/3 and HISS Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] - [**Location (un) 3876**] [**Name6 (MD) 116**] [**Name8 (MD) 117**] MD [**MD Number(1) 392**] Completed by:[**2124-9-8**]

[ "V45.1", "428.0", "414.01", "531.40", "397.0", "403.91", "V54.23", "285.9", "041.86", "414.8", "E934.2", "412", "585.6", "427.31", "790.92", "428.32", "250.00", "V43.3", "707.03" ]

icd9cm

[ [ [] ] ]

[ "44.43", "39.95", "99.04", "99.07" ]

icd9pcs

[ [ [] ] ]

11382, 11626

4676, 7143

277, 309

7751, 7796

3303, 4653

8668, 11359

2623, 2627

7639, 7730

7169, 7480

7820, 8645

2642, 3284

226, 239

337, 1584

1606, 2407

2423, 2607

47,983

156,024

39919

Discharge summary

report

Admission Date: [**2117-11-6**] Discharge Date: [**2117-12-31**] Date of Birth: [**2061-3-20**] Sex: F Service: SURGERY Allergies: Zosyn Attending:[**First Name3 (LF) 4691**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [**2117-11-8**] ERCP with stent replaced History of Present Illness: This 56 year old woman with a history of hypertension, hyperlipidemia, and depression who was recently admitted to an OSH for choledocholithiasis and underwent ERCP w/ bile duct stent placement c/b pancreatitis and ARDS/pneumonia. She was discharged to rehab 6 days ago and presented to an OSH w/ worsening RUQ pain. Roughly one month ago this unilingual spanish speaking patient was admitted to [**Hospital6 3105**] w/ choledocholithiasis and bile duct dilatation on U/S. ERCP on [**10-20**] showed a 1cm stone that could not be removed. A bile duct stent was therefore placed. After ERCP, she developed pancreatitis c/b ARDS requiring ICU admission and mechanical ventilation. Because the patient continued to saturate at 87% on RA, she was discharged to rehabilitation on [**2117-11-2**] w/ 2L supplemental O2 by NC and a steroid taper to end on [**2117-11-10**]. She presented to [**Hospital6 3105**] w/ RUQ pain 3 days after discharge w/ worsening right upper quadrant pain. After a diagnosis of acute cholecystitis and receiving a dose of unasyn, she was transferred to [**Hospital1 18**] for further evaluation and management. Past Medical History: Hypertension Hyperlipidemia Depression Choledocholithiasis Pancreatitis ARDS Elbow surgery Tubal ligation Social History: - Tobacco: 2-3 per day for many years - Alcohol: occasional - Illicits: denies Family History: sister s/p cholecystectomy Physical Exam: On Admission General: Alert, oriented, in pain w/ respiratory distress HEENT: Jaundiced, MMM, oropharynx clear Neck: supple, no LAD Lungs: Irregular breathing with expiratory flaring of nostrils and accessory muscle use. Coarse lung sounds bilaterally w/ a few faint crackles at the bases. CV: Loud S1, normal S2, no murmurs, rubs, gallops Abdomen: soft, tender especially RUQ, slightly distended, bowel sounds present, voluntary guarding, but no rebound, no organomegaly GU: foley in place Ext: warm, well perfused hands, 2+ radial pulses, slightly cool feet w/ 1+ DP pulses bilat. no clubbing or cyanosis. Trace pedal edema. Pertinent Results: [**2117-11-6**] 09:05AM GLUCOSE-155* UREA N-14 CREAT-0.3* SODIUM-138 POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-30 ANION GAP-10 [**2117-11-6**] 09:05AM ALT(SGPT)-43* AST(SGOT)-35 ALK PHOS-202* AMYLASE-224* TOT BILI-1.4 DIR BILI-0.9* INDIR BIL-0.5 [**2117-11-6**] 09:05AM LIPASE-51 [**2117-11-6**] 09:05AM CALCIUM-8.7 PHOSPHATE-3.1 MAGNESIUM-2.2 [**2117-11-6**] 09:05AM WBC-17.6* RBC-3.96* HGB-11.5* HCT-34.6* MCV-88 MCH-29.1 MCHC-33.2 RDW-14.3 [**2117-11-6**] 09:05AM PLT COUNT-441* [**2117-11-5**] 11:39PM COMMENTS-GREEN TOP [**2117-11-5**] 11:39PM LACTATE-1.1 [**2117-11-5**] 11:30PM GLUCOSE-148* UREA N-14 CREAT-0.3* SODIUM-135 POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-29 ANION GAP-9 [**2117-11-5**] 11:30PM estGFR-Using this [**2117-11-5**] 11:30PM ALT(SGPT)-45* AST(SGOT)-36 ALK PHOS-183* [**2117-11-5**] 11:30PM LIPASE-48 [**2117-11-5**] 11:30PM ALBUMIN-2.9* [**2117-11-5**] 11:30PM WBC-16.9* RBC-3.95* HGB-11.7* HCT-34.5* MCV-87 MCH-29.5 MCHC-33.8 RDW-14.2 [**2117-11-5**] 11:30PM NEUTS-90* BANDS-1 LYMPHS-2* MONOS-6 EOS-0 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 [**2117-11-5**] 11:30PM PLT COUNT-446* [**2117-11-5**] 11:30PM PT-13.0 PTT-23.9 INR(PT)-1.1 Brief Hospital Course: On arrival at [**Hospital1 18**], her vitals were 97 108 107/73 16 100% on NC. She received 750cc LR for tachycardia and hypotension to 90s/60s. Her pain, which was associated w/ nausea and vomiting improved w/ morphine. She was started on unasyn. Liver U/S showed the presence of gallstones and gallbladder wall thickening suggestive of cholecystitis. CT [**Last Name (un) 103**] showed a large multilobulated pancreatic pseudocyst possibly compressing the CBD. The pt was admitted to ACS and then sent for ERCP. Antibiotics were changed from unasyn to vancomycin, ciprofloxacin, and flagyl after blood cultures grew GPCs. ERCP revealed an obstructed stent in the major papilla. This stent was successfully replaced and a 5mm stone removed. The patient became tachycardic with SBP in the 80s and poor O2 sats and was bolused, started on phenylephrine and NRB in the ERCP suite. Her BP and O2 sats improved the patient was transferred to [**Hospital Unit Name 153**] after the procedure for management of hemodynamic instability in the context of a likely biliary sepsis. On transfer, her BP was 90s/60s. . ICU course: On arrival in the ICU, vitals 98.2 109 106/85 26 95% on 6L NC. Phenylephrine was discontinued and she was given 1L of LR after which her BP was 80s/60s w/ good O2 saturation on 6L NC. She was placed on a non-rebreather for comfort and a right IJ CVL was placed for SBPs that dropped to 70s. The patient was initially resuscitated w/ 10L or more of crystalloid. She was intubated soon after arrival for hypoxic respiratory failure and started on levophed for hypotension refractory to IVF. The patient was started on broad coverage of gram positive cocci, gram negatives, & anaerobes w/ Vancomycin & Zosyn. A cortisol stimulation test carried out because of the patient's history of steroid use showed normal adrenal function. A brachial arterial line was inserted for close BP monitoring and frequent blood gases. The patient's distributive shock was initially thought to be secondary to biliary sepsis, possibly w/ an impending pancreatitis or alternatively, an infected pancreatic pseudocyst. Numerous blood cultures were taken during her ICU course. 1/2 bottles from [**11-7**] grew Strep Anginosus, but all other cultures were negative or pending when the patient left the ICU. She also developed pulmonary edema and a echocardiogram showed normal biventricular function suggesting that the edema was secondary to the large fluid load she received in the context of underlying lung injury from her previous ARDS. Over the first days after admission to [**Hospital Unit Name 153**], the patient's liver enzymes and bilirubin trended down indicating that the restenting of the biliary system had succesfully decompressed the obstruction. Her pulmonary edema also improved when her IVF were decreased in the context of adequate CVP. The patient continued however, to be hemodynamically unstable and vasopressin was added to levophed to maintain a map near 60. Because of the patient's lack of improvement and the fact that strep anginosus is associated with abscess formation, the patient underwent repeat abdominal CT that showed the pancreatic pseudocyst had shrunk, but there was an increased amount of intra-peritoneal fluid, particularly in the left gutter. A drain was inserted into the paracolic gutter and milky fluid was drained and sent for culture. The fluid had an amylase level of [**Numeric Identifier 61575**] suggesting that the patient's pseudocyst had ruptured, either before the patient's ERCP or at some point in her hospital course. After draining the fluid collection, the patient's hemodynamic status improved. Her levophed was reduced to 0.02 and her map stayed around 70. With a new diagnosis of ruptured pseudocyst, she was transferred to SICU on [**Hospital Ward Name **] in case she requires OR emergently. On transfer, she remained intubated on antibiotics, levophed 0.02 and vasopressin 2.4. SICU course: [**2117-11-7**] transferred from ACS, Zosyn started, bolused 1750 cc [**2117-11-8**] ERCP with stent replaced, septic tx to [**Hospital Unit Name 153**] [**2117-11-9**] intubated on pressors [**2117-11-10**] U/S guided drain placement, pressors increased, FIO2 decreased, T101.7 [**2117-11-11**] transferred to SICU, getting bolused, increased PEEP to 12, tightened insulin sliding scale, increased IVFs. [**11-12**]: Changed to CPAP, weaning settings. Nutrition labs sent. Dobhoff placed (not post-pyloric), reglan given. [**11-13**]: Reglan repeated, still did not pass. Albumin started 25g Q6H. Started albuterol Ipratropium. Dobhoff placed, feeds held due to still on levophed. Large autodiuresis - urine lytes w/ osm 113, but UOP decreasing - will follow. Na at 150 - changed fluids to 1/2NS from LR. Repeat Na 153 with continued high UOP. Changed 1/2NS to D5W @ 100cc/hr, following close Na. This AM, Hct 18 --> xfuse 2 units. Repeat Na 156, Osm 310. Was ~4L negative yesterday w/ UOP of 8L. [**11-14**]: Wet read of abd CT showed no large bleed, ?small bleed into pseudocyst. Head CT neg. Albumin started q6h. Esophageal balloon showed transthoracic pressure 18 (on inspiration; -2 expiration) on PEEP on 15. DDAVP given in am and reduced UOP from 210 cc/hr (for 9 previous hours) to 80cc/hr for 9 hours after DDAVP. Dose repeated in evening. Crit dropped in evening from 26-->23, so 2units given. Post transfusion crit of 30. Started tube feeds @ 1/2 strength. [**11-15**]: D/c'd vanco per ID recs. Stopped RTC albumin. Consulted endocrine: DI is attributable to vasopressin withdrawal, hold further workup. KVO. Plan to continue Zosyn to [**11-22**] (14 days from last negative blood cx [**11-8**]). [**11-16**]: Free water deficit calculated to 1.5L. 250cc free water Q4H. Off levophed. Peritoneal fluid cx + ([**11-11**]) for 2 morphologies of CoNS. [**11-17**]: Advanced feeds to goal w/ full strength. D/C'd vigileo. weaned PEEP to 10. Placed left radial a-line, placed left SC CVL. Becoming more alert. Started diamox RTC & changed tube feeds/free water. [**11-18**]: decreased TF goal (nutrition recs) to 50cc/hr. Diuresed target -3 L. Free water at 1 L/day. Weaning to extubate. [**11-19**]: Extubated, tolerated well, D/C'd diamox. [**11-20**]: 20mg IV lasix x2. Small doses ativan for tolerating CPAP. Still w/ increased WOB on CPAP - gave 20 more lasix. Patient not improving so was reintubated. Fentanyl to be synchronous w/ vent. [**2117-11-21**]: pan cx for temp101.6; goal neg 2.5L (gave 40iv lasix). Re-assess for extubation Monday/Tues & if not: trach & peg. [**11-22**]: failed CPAP ->tachypnec. bronch unremarkable. currently on CPAP [**10-29**]. diamox x 24hrs. PM bicarb 33-> 29, abg: 7.43/191/46/32/5. [**11-23**]: Failed CPAP, has been on [**10-26**] or CMV throughout the day. ALine resited, LSC switch to RIJ after bacteremia. Started vanc empirically for GPCs. Discussing trach w/ primary team. [**11-24**]:did well with RSBI, NIF in afternoon. overnight became tachypneic on [**5-26**], switched to CMV for short time [**11-26**]: Trach'd w/o complication. ALine resited. Pigtail accidentally dc'd during patient positioning, planning for CT in AM. Pt febrile, tachycardic. Started empiric zosyn for abdominal coverage. [**11-27**]: CT C/A/P for concern of intra-abd process, however read showed improvement. Spiked to 101.6, recultured. [**11-28**]: Primary team thought the intra-abd collections were getting better, elected not to have drainage. TF restarted. No progress on ventilator. [**11-29**]: rehab screening. Afebrile [**11-30**]: Hypotensive and tachy at times, responsive to fluid bolus. Afebrile. Had IR-guided L abdominal fluid collection drain placed. Stable overnight. [**12-1**]: Afebrile. Failed bedside PICC placement. Weaned vent. [**12-2**]: PICC placed. Tolerated trach mask without ventilator requirement. [**12-3**]: Transferred to floor. [**12-8**]: Transferred to SICU. Started on cipro/flagyl. Seen by ID, started Tigecycline, Dapto, Cipro and Mica. PICC dc'd, tip sent. New CVL placed. [**12-9**]: Continues to require increasing amts of pressors to maintain CVP>8. Skin bx confirmed drug rash (likely zosyn). HIDA scan concerning for acute cholecystitis, however IR did not want to do perc chole overnight. Had desaturation to high 80s, tachypneic- concern for flash pulm edema. CXR with slightly more perihylar edema; 20mg IV lasix x1 with improvement. Again became tachypneic in 30s, hypoxemic on ABG. Decision made to put on CPAP/PS. [**12-10**]: Pulmonary edema. Decreased IVF. Stopped micafungin. Transfused 2u FFP. Percutaneous cholecystostomy tube placed at bedside. Bile cultured. [**12-11**]: Bile growing GPCs. CXRs w/ worsening infiltrate. Initially PCV ventilation, changed to APRV w/ improved oxygenation. Given 2 uprbc. Hypotensive/tachycardic in the evening, required neo to support. ALine placed on R w/ poor waveform. [**12-12**]: Worsening ABGs despite being placed on APRV last night. Placed axillary A-line and moved to prone bed with significant improvement in oxygenation/ventilation and blood pressures. Persistently febrile overnight and tachycardic to 130s. Met with family to discuss current issues;confirmed full code status. [**12-13**]: Pronation bed x 48h. Blood from NGT, pulled back to good position. Started protonix gtt. Held heparin gtt. Heme: WBC most likely from infection. Started tobra. [**12-14**]: DC'd rotoprone bed, tried dc paralysis, but reparalyzed after hypercapnia. Gently titrated vent throughout the day. DC cipro. Formal echo --> dilated RV. [**12-15**]: Required several vent changes but relatively stable on CMV. Dropped pressures twice when turned to the left, responsive to increased pressors. Per ID ok to d/c linezolid since coverage is adequate for MRSA (although none has grown from cultures). GI wont scope at this time given hct stable, blood resolved w/flushes; rec to put OG to intermittent suction instead. [**12-17**]: No acute events. Did not tolerate PS. Given 2 u prbcs for hct 22.7 w/ appropriate response. [**12-19**]: Gave free water per dobhoff for hypernatremia. Started ativan PRN anxiety. D/c'd perc chole tube. Bloody drainage from NGT with hct 23.5 -> 2u PRBC -> 29.5 -> 28.5. Underwent upper endoscopy, saw no active bleed. Diffuse gastritis and duodenitis. Negative 1.5 L without diuretics. [**12-20**]: cont bloody drainage from NGT. PM Hct 27 -> 25. Pantoprazole 8 mg/hr. GI: no c-scope. CTA. [**Doctor First Name **]: no CTA. dobhoff curled in back of mouth but still post-pyloric per CXR. TF restarted. C-diff PCR and U/A sent. ID recs: restart tobramycin, micafungin and tigecycline until w/u of leukocytosis complete. 1 episode of hematemesis. 1 unit PRBC per primary. HCt 27 -> 24 -> 27. PS 40% 10/10 TVs 300-400 RRs 30s. [**12-21**]: Transfused 1u PRBC. Rescoped by GI - multiple duodenal ulcers with oozing but no definitive site. TF restarted. [**12-24**]: PICC placed and central line dc'ed, cultured. tolerating trach mask since noon. [**12-25**]: PICC repositioned. serial hcts stable. tolerating trach mask [**12-26**]: continued on trach mask, tolerating tube feeds, hematocrit stable [**12-27**]: transferred to floor, pulled off the NG tube [**12-28**]: passy-muir valve, speech and swallow eval, ? replace dubhoff, ? PEG [**12-29**]: speech and swallow re-eval, approved for soft solids, tolerated well [**12-30**]: calorie counts (not recorded at discharge), occupational therapy eval [**12-31**]: patient discharged to rehab Medications on Admission: Lovastatin 20 mg daily, Prednisone taper(40-30-20-10 mg daily until [**11-10**]), Nystatin until [**11-10**], Home O2@2L, acetominophen 325 mg daily, citalopram 20 mg daily, lisinopril 10 mg daily Discharge Medications: 1. insulin regular human 100 unit/mL Solution Sig: sliding scale Injection ASDIR (AS DIRECTED). 2. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain or fever. 4. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze. 6. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation QID (4 times a day). 7. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for skin rash. 8. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for pain. 9. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 10. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 11. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 12. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 13. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 14. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Tablet(s) 16. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 8957**] Discharge Diagnosis: Ruptured pancreatic pseudocyst. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Please call your doctor or nurse practitioner if you experience 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 is 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. . General Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**5-31**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. JP Drain Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *Maintain suction of the bulb. *Note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or VNA nurse if the amount increases significantly or changes in character. *Be sure to empty the drain frequently. Record the output, if instructed to do so. *You may shower; wash the area gently with warm, soapy water. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Followup Instructions: Please call [**Telephone/Fax (1) 2998**] to schedule a follow up with Dr. [**First Name (STitle) **] in 2 weeks. Patient will need interpreter services at the [**Hospital1 18**] for this visit.

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icd9cm

[ [ [] ] ]

[ "51.01", "96.6", "45.13", "86.11", "51.87", "31.1", "38.97", "51.88", "54.91", "96.72" ]

icd9pcs

[ [ [] ] ]

16983, 17057

3627, 15081

282, 324

17132, 17132

2423, 3604

20235, 20433

1733, 1761

15330, 16960

17078, 17111

15107, 15305

17383, 18364

18990, 20212

1776, 2404

18396, 18975

227, 244

352, 1489

17147, 17359

1511, 1618

1634, 1717

77,951

180,024

13946

Discharge summary

report

Admission Date: [**2194-11-28**] Discharge Date: [**2194-12-12**] Date of Birth: [**2118-2-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor First Name 1402**] Chief Complaint: Cardiac arrest Major Surgical or Invasive Procedure: Cardioversion Intubation History of Present Illness: The patient is a 76 year old male with a history of CAD s/p CABG, HTN, AF, syncope s/p PPM who presents following out-of-hospital cardiac arrest. The patient has been noted to be slightly dysnpic over the last two days. He has not experienceid any chest pain, palpitations, light-headnedness, or any other symtpoms. On the day of presenation, the patient went out to do errands. He had spoken to his wife pulling into a wall-mart parking lot, and did not make any notable complaints. He was found down in the parking lot unresponsive. The event was unwitnessed. Security was called, who placed an AED on the patient, and fired twice for a shockable rhythm. EMS was activated. From being found down to confirmation of a purfusing rhythm, the estimated time down is roughly ten minutes. He was intubated in the field and transfered to [**Hospital3 6592**]. . While there, the patient was noted to be hemodynapically stable. A CT scan of the head and neck were performed, and reportadly normal. The patients wife says that at [**Name (NI) **] the patient was squeezing hands on command and was intially grabing at lines with purposeful movement of all for extremities. He was emergently transfered to [**Hospital1 18**] for futher evaluation and care. . In the ED, the patient's HR was 72, BP 137/74, satting 100% on the ventillator. He was give IV versed for sedation. He was noted to have BRB in the anal vault. The patient was transfered to the CCU for further care. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, or presyncope Past Medical History: 1. CARDIAC RISK FACTORS:: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: in [**2182**] by Dr. [**Last Name (STitle) 4026**] [**Name (STitle) 41709**] CORONARY INTERVENTIONS: -PACING/ICD: PPM placed in [**2189**] following syncopal event 3. OTHER PAST MEDICAL HISTORY: . Atrial Fibrillation Social History: Married, former Physical Exam: VS: T=96 BP= 123/71 HR= 60 RR= 16 O2 sat= 100% AC TV 600/5/40% GENERAL: Elderly male, intubated, sedated, unresponsive. In C-colllar. HEENT: NCAT. PERRL (3mm to 2mm), in C-collar. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. Scar on left leg and arm. 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+ . Neuro: Absenct corneal reflex, down going babinski, no clonus, opens eyes to name calling Pertinent Results: Labs on admission: . [**2194-11-28**] 09:00PM BLOOD WBC-17.6* RBC-3.38* Hgb-12.4* Hct-34.7* MCV-103* MCH-36.8* MCHC-35.7* RDW-16.3* Plt Ct-152 [**2194-11-29**] 01:54AM BLOOD WBC-13.4* RBC-3.44* Hgb-12.2* Hct-34.5* MCV-100* MCH-35.4* MCHC-35.3* RDW-16.9* Plt Ct-148* [**2194-11-28**] 09:00PM BLOOD Neuts-83.5* Lymphs-12.1* Monos-3.5 Eos-0.3 Baso-0.5 . [**2194-11-28**] 09:00PM BLOOD PT-28.2* PTT-33.0 INR(PT)-2.8* . [**2194-11-28**] 09:00PM BLOOD Glucose-161* UreaN-28* Creat-1.3* Na-139 K-4.7 Cl-105 HCO3-20* AnGap-19 [**2194-11-29**] 01:54AM BLOOD Glucose-187* UreaN-28* Creat-1.1 Na-135 K-5.2* Cl-105 HCO3-19* AnGap-16 . [**2194-11-28**] 09:00PM BLOOD ALT-20 AST-27 CK(CPK)-83 AlkPhos-60 TotBili-0.8 . [**2194-11-29**] 01:54AM BLOOD CK(CPK)-124 [**2194-11-29**] 11:38AM BLOOD CK(CPK)-269* [**2194-11-28**] 09:00PM BLOOD CK-MB-NotDone cTropnT-0.27* [**2194-11-29**] 01:54AM BLOOD CK-MB-11* MB Indx-8.9* cTropnT-0.34* [**2194-11-29**] 11:38AM BLOOD CK-MB-14* MB Indx-5.2 cTropnT-0.17* . [**2194-11-28**] 09:00PM BLOOD Calcium-9.1 Phos-3.0 Mg-2.3 [**2194-11-29**] 01:54AM BLOOD Triglyc-113 HDL-30 CHOL/HD-3.4 LDLcalc-49 . [**2194-11-28**] 09:16PM BLOOD Type-[**Last Name (un) **] Temp-37.3 pH-7.26* [**2194-11-28**] 11:11PM BLOOD Type-ART Rates-/16 Tidal V-600 PEEP-5 FiO2-100 pO2-408* pCO2-34* pH-7.39 calTCO2-21 Base XS--3 AADO2-278 REQ O2-53 -ASSIST/CON Intubat-INTUBATED [**2194-11-28**] 09:16PM BLOOD Glucose-152* Lactate-4.2* Na-141 K-4.8 Cl-102 calHCO3-21 . Urine studies: . [**2194-11-28**] 09:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017 [**2194-11-28**] 09:00PM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2194-11-28**] 09:00PM URINE RBC-[**11-6**]* WBC-0-2 Bacteri-MOD Yeast-NONE Epi-0-2 [**2194-11-28**] 09:00PM URINE CastGr-0-2 CastHy-[**2-19**]* . Studies/Imaging: . CXR [**11-28**] - FINDINGS: Single AP chest radiograph without comparison shows ET tube terminating 3.6 cm above the carina. The lungs are clear. The heart is moderately enlarged. The patient is status post median sternotomy and CABG. There is no pleural effusion or pneumothorax. NG-tube is in satisfactory position with tip in the stomach. Leads of a right-sided pacemaker terminate in the right atrium and ventricle. Surgical staple overlies the left upper abdomen. IMPRESSION: Moderate cardiomegaly without evidence of pneumonia or overt CHF. . CTA [**11-28**] - IMPRESSION: 1. No pulmonary embolism or thoracic aortic dissection. 2. Small-to-moderate bibasilar consolidation with aspiration favored over pneumonia. 3. Small amount of secretions surrounding the proximally visualized endotracheal tube. 4. Dilated ascending thoracic aorta . ECHO [**11-28**]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. There is severe regional left ventricular systolic dysfunction with inferior, inferolateral and basal inferoseptal akinesis (likely RCA territory). There is moerate to severe hypokinesis of the remaining segments (LVEF = 15-20%). The right ventricular cavity is mildly dilated with borderline normal free wall function. The aortic root is moderately dilated at the sinus level. The ascending aorta is moderately dilated. The descending thoracic aorta is mildly dilated. There are three moderately thickened aortic leaflets, with poor excursion. Two-dimensional imaging suggests significant aortic stenosis, but its severity cannot be reliably quantified given low LV stroke volume. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Severe regional and global left ventricular systolic dysfunction, suggestive of a global process (toxic, metabolic, etc.) on a background of prior inferior myocardial infarction. Mild right ventricular systolic dysfunction. Significant aortic stenosis. Moderate tricuspid regurgitation. Mild pulmonary hypertension. Dilated thoracic aorta. . ECHO [**12-8**]: . The left atrium is dilated. There is an inferobasal left ventricular aneurysm. There is severe regional left ventricular systolic dysfunction with akinesis of the inferior, inferolateral segments. The other segments are moderately hypokinetic. There is no left ventricular outflow obstruction at rest or with Valsalva. The right ventricular cavity is mildly dilated with borderline normal free wall function. The aortic root is moderately dilated at the sinus level. The ascending aorta is moderately dilated. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. Significant aortic stenosis is present (not quantified as LV systolic function is significantly impaired). The mitral valve leaflets are mildly thickened. Mild mitral regurgitation is seen. Moderate tricuspid regurgitation is seen. The tricuspid regurgitation jet is eccentric and may be underestimated. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2194-11-29**], the inferior and inferolateral akinesis persists. The other segments have slightly better function. The other findings - aortic stenosis, mild mitral and at least moderate tricuspid regurgitation - are similar. Brief Hospital Course: 76 y/o male w/ a hx of CAD s/p CABG, syncope s/p PPM, AF who presented with cardiac arrest, intubated and transferred to [**Hospital1 18**] for further care. . # SEPSIS. Sources included VAP and line related infection. On [**11-30**], pt was found to be febrile with SBPs below 90mmHg, and RR 20-30s. BCx from R femoral line placed on [**12-1**] (no neck access due to neck collar) grew Pseudomonas A. He remained hypotensive and required pressor support with Dopamine and Levophed. Patient also had also developed bilateral opacities on CXR, thick and bloody secretions. His sputum [**12-1**] and [**12-2**] grew MSSA and Enterobactericae. UA and UCx were negative, there was no diarrhea. R femoral line was removed on [**12-3**]. He was started on Zosyn and Vancomycin on [**12-1**] and pt intially defervesced on this regimen, however next day became febrile again. Tobramycin was added for initially unknown GNR coverage in sputum. Once Cx from sputum and perphery were finalized, ABx regimen was changed to nafcicillin IV and ciprofloxacin for a total treatment length of 14 days. His dopamine was weaned on [**12-2**], while levophed was weaned on [**12-6**]. Pt. was successfully extubated on [**12-6**]. He remained afebrile until discharge. Since patient developed worsening renal failure on [**12-8**], which was felt to be consistent w/ AIN, his nafcillin was changed to cefazolin IV. He has completed that course. He is still due to complete the 14 day course of cipro, and is currently on day 10 of 14. . # RESPIRATORY FAILURE. Pt. was intubated on transfer. Most likely felt to be [**1-18**] possible volume overload and VAP (see above). He was initially afebrile and euvolemi on exam, but required volume resuscitation due to hypotension developed on HD#2. Initial CXRs did not show vascular congestion or consolidation, however pt became febrile on [**11-30**] and was found to have b/l lower lobe opacities. He was started on treatment for VAP. ABGs were consistent w/ mixed respiratory alkalosis and metabolic alkalosis, likely [**1-18**] sepsis and possible CNS injury. PaO2/FiO2 min was 214. By [**12-6**] pH and CO2 normlaized, CNS status improved significantly and patient was successfully extubated. Pt. continued to have mild wheezing on exam, treated w/ albuterol nebs prn. He has since been oxygenating well on room air, and has not required additional nebulizer treatments. . # CORONARIES: Patient with history of CAD, s/p CABG. No ischemic changes on EKG, although limited to interpret with V pacing. CKs peaked at 269, MB at 15 w/ index 8.9 and normalized by HD#1. It was felt that CK elevations were due to fall and possible VF that lead to cardiac arrest. This event was not believed to be ischemic in nature. Patient was continued on ASA, beta-blocker and ACE were held due to septic shock. LDL was 49 and HbA1C was 6.2. Patient was continued on simvastatin. Low dose metoprolol was restarted on [**12-7**] once BP tolerated. Lisinopril was held due to worsening RF, but has since been restarted. . # PUMP. Patient w/ known history of CHF, systolic likely [**1-18**] CAD. Last EF of 30-35% on ECHO as outpatient in [**2194-6-17**]. Patient was noted to have EF of 15-20%, severe regional and global left ventricular systolic dysfunction on a background of prior inferior myocardial infarction (akinesis). Mild right ventricular systolic dysfunction was also noted. Pt had significant AS, moderate TR and mild PAH. As patient was volume resuscitated for septick shock, he became volume overloaded evident w/ peripheral edema and vascular congestion on CXR. As sepsis was controlled and patient was extubated, he was started on low dose lasix with moderate effect. On [**12-7**] patient was started on Spironolactone 25mg QD which was subsequently d/ced due to worsening renal failure. A repeat ECHO on [**12-8**] showed mild improvement in EF 20-25%, new L inferobasal aneurysm, and inferior and infrelolateral akinesis persisting w/ prior findings. Given akinesis of inferior wall and atrial fibrillation, patient was started on heparin gtt and transitioned to coumadin. Patient will require follow up ECHO and cardiology appt in one month to assess for ICD placment. He will have his repeat TTE in [**1-19**] weeks, and see Dr. [**Last Name (STitle) **] in clinic for evaluation of possible CRT/d. . # RHYTHM: Hx of chronic Afib. PPM interrogations showed episodes of VT, followed VF prior to cardiac arrest. Patient received 2 shocks from AED. Throughout hospitalization patient was in atrial fibrillation w/ v-pacing 40 - 60% of the time. He was restarted on coumadin as well as started on amiodarone 400mg [**Hospital1 **] for cardioversion on [**12-8**] to augment CO w/ atrial kick. Cardioversion with biphasic 200J and 300J was attempted with patient remaining in atrial fibrillation. The patient is being continued at amioderone 400mg daily, and will have a second attempt at cardioversion in [**1-19**] weeks. He will also see Dr. [**Last Name (STitle) **] in clinic in [**2-18**] weeks for ICD placement versus CRT/d. . # CARDIAC ARREST. Based on records, it appears he was in VF for up to 6 minutes and it is unclear how long patient remained w/o rhythm. During this time, he received two DCCV but it is not entirely clear if he was receiving chest compressions as well. He was intubated in the field. Pt was unresponsive on admission. No initial neurological exam off sedation was performed at OSH. In [**Name (NI) **] pt had "absent corneal reflexes but opened eyes to name." CT head at OSH was wnl. Patient underwent 24 hours of cooling to 34C per Artic sun cooling protocol. Repeat at [**Hospital1 18**] did not show ICH or infarction. Exam at 72h off sedation showed eyes opening to command, intact corneal and pupillary reflexes, spontaneous extermities movements and flexor withdrawal to pain, all consistent w/ ~ 50% meaningful neurological recovery. Neurology team was consulted and followed patient throughout the stay. On [**12-6**] patient was following simple commands, responding to yes/no questions with improving strength in all extremities. He was extubated on [**12-6**]. His neurological status improved, orientation (A&Ox3). Patient with generalized weakness, but no focal deficit. Given previous cardiac arrest and EF ~ 20-25% patient is to undergo a 1mo follow up ECHO with further evaluation for ICD placement with Dr. [**Last Name (STitle) **]. . # HTN. Patient was hypotensive in shock during early stages of hospitalization. Once shock resolved, patient was restarted on low dose BBk, ACE, and spironolactone. . # BG management. Pt initially w/ FS consistently > 200. No known history of diabetes, w/ HbA1C of 6.2. He was maintained on TF while intubated. His BG was consistently elevated and he was on Lantus and ISS. His lantus had to be uptitrated to 18units daily. This regimen will be continued while in rehab, but should be switched to metformin in coordination with his PCP, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 41710**]. . # ANEMIA. Normocytic, hypoproliferative. HCT on admission of 35, dropping to 22. HCT on discharge was 25. This was felt to be due to combination of ACD and dilutional effects from fluid administaration (at HCT nadir, pt was 7.8L positive). Fe studies were consistent w/ ACD. Haptoglobin was nl, as were TSH, B12 and Folate. The patient was started on iron, folate, and pyridoxime supplementation. . # RENAL FAILURE. Baseline unknown. Cr. on admission was 1.3 and fluctuated between 1.4 and 0.8 during cooling and sepsis. On [**12-7**] Cr increased to 1.6 with diuresis and aldactone and rose to maximum of 2.1. This was felt to be most likely [**1-18**] pre-renal etiology and AIN given FEUrea of 37% and WBC cast/eosinophilia on UA. Patient's nafcillin was switched to cefazolin on [**12-8**]. At time of discharge, Cr was improved to 1.5. Medications on Admission: Warfarin 2mg daily Lisinorpil 20mg daily Zocor 10mg daily HCTZ 25mg daily Fishoil 1000mg TID Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 10. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 4 days. 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18) Subcutaneous at bedtime. 14. Insulin Lispro 100 unit/mL Solution Sig: Sliding Scale Subcutaneous qACHS: see attached sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Primary: Cardiac arrest, sepsis, pneumonia, acute renal failure Secondary: coronary artery disease, heart failure, hypertension, hyperlipidemia, chronic atrial fibrillation Discharge Condition: Hemodynamically stable, afebrile. Discharge Instructions: You were admitted to [**Hospital1 18**] with cardiac arrest. To help treat this event, you required intubation and a cooling procedure to maintain your brain function. Your course was complicated by sepsis (severe infection in your blood and other orgains). You required treatment with multiple intravenous antibiotics and medications to maintain your blood pressure. With these treatments your condition improved significantly. You were extubated and your mental functioning improved significantly. Your course was also complicated by worsening heart failurek, kidney failure and atrial fibrillation (irregular heart rate in your atrium). You underwent a cardioversion procedure for atrial fibrillation which was unsuccessful. Your heart failure and your kidney failure are much improved at time of discharge. You will need to complete a 14 day course of ciprofloxacin to treat your blood infection. You are being discharged to rehab. We will plan a second attempt at cardioversion in [**1-19**] weeks, and you will see Dr. [**Last Name (STitle) **] in clinic for evaluation of an ICD in [**2-18**] weeks. Your medication regimen was also changed significantly from the medications you were taking at home. Please review the list provided below and take the medications as prescribed. It was felt that your cardiac arrest was likely due to a dangerous arrhythmia, vetricular fibrillation (irregular heart beat of your ventricle). For this reason, you will require a close follow up with your cardiologist and an additional evaluation for a defibrillator, once your heart failure is stable. Should you experience worsening shortness of breath, chest pain, sweats, palpitations, cough, fevers, chills, nausea, or any other symptom concerning to you, please call the rehabilitation facility doctor or go to the nearest emergency room. Please follow up with your appointments as listed below. Followup Instructions: Please follow up with your PCP, [**Name10 (NameIs) **] and Neurologist. You have a follow up with Dr. [**Last Name (STitle) **] on [**2193-12-28**] at 1:20pm in the [**Location (un) 8661**] Building of the [**Hospital Ward Name 516**] of [**Hospital1 18**] on the [**Location (un) 3971**]. You will be contact[**Name (NI) **] to set up a second attempt at cardioversion and follow up echocardiogram planned for [**1-19**] weeks. If you do not hear in week, please call [**Telephone/Fax (1) 62**] and ask for Jassen [**Doctor Last Name 7086**]. You had requested a referral for a cardiologist. You could see [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 41711**], [**Last Name (NamePattern5) 41712**] [**Location (un) 3320**], [**Numeric Identifier 34852**] Phone: ([**Telephone/Fax (1) 5319**] Ext.3822 We would recommend follow up in the next 4 weeks. You should also follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 41710**], in [**1-20**] weeks.

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icd9cm

[ [ [] ] ]

[ "38.93", "89.45", "96.72", "96.6", "99.07", "99.61" ]

icd9pcs

[ [ [] ] ]

18486, 18558

9186, 17135

333, 360

18775, 18811

3652, 3657

20763, 21773

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129,562

29487

Discharge summary

report

Admission Date: [**2197-12-25**] Discharge Date: [**2197-12-30**] Date of Birth: [**2144-9-29**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3326**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: liver biopsy History of Present Illness: Ms. [**Known lastname **] is a 53 woman with no past medical history who was in her usual state of good health until the weekend before [**Holiday **] when she developed nausea and bilious vomitting x 6. There was no hematemesis. Although she had not seen a doctor in 20 years, she asked her husband to make an appointment with a PCP. [**Name10 (NameIs) **] she was seen, she was sent to the [**Location (un) **] emergency room for dehydration and further workup. She was admitted to their ICU for control of her hypertension and was diagnosed with a troponin leak and an e.coli urinary tract infection. At that time, a CT abdomen showed a liver with a hyperechoic foci. She was then sent out to the floor with a plan for a liver biopsy but she developed acute change in mental status. An MRI was performed that showed multiple acute and subacute embolic lesions. At that time, she was started on decadron, enalapril, and metoprolol and transferred to this facility for diagnosis of her presumed metastatic process. Of note, the patient has never had colonoscopy, her last pap was at least 15 years ago, as was her last mammogram until one was done at [**Location (un) **]. . Upon admit to [**Hospital Unit Name 153**], she was found to completely disoriented and unresponsive. Her history is per her husband. . ROS: + sweats/fevers/epigastric pain. 10 lb weight loss over last 4 weeks but prior to that 10 lb weight gain in association with stressful job. No rashes or chest pain. Past Medical History: obesity gallstones Social History: patient is married x 29 years. No smoking, illicits. Drinks 2 gin and tonics per year. Recently quit stressful job as attorney. Family History: father died of stroke in [**2193**]. Mother died of CHF 12 days later. No h/o CA. Mom with history of HTN. Physical Exam: T 98.8 BP 163/88 HR 87 O2 sat 96% on shovel mask wt 117.7 Gen: NAD obese woman in bed, appears alert HEENT: cannot assess MM, NCAT, diaphoretic, PERRLA, no scleral icteris or conjunctival injection Neck: no LAD, supple Cor: RRR no M/R/G Pulm: CTAB anteriorly Breast: fibronodular tissue noted, no axilllary LAD, peau d'orange, nipple discharge, or discrete masses Abd: obese, soft NT ND decreased BS Ext: WWP, left great toenail with ecchymosis, feet with multiple hyperpigmented irregular macules. No edema, DP 2+ bilaterally, no osler's nodes/splinter hemorrhages Neuro: opens eyes to name, does not respond to commands, PERRLA, withdraws to painful stimuli in all 4 extremities, does not blink to threat consistently Pertinent Results: [**2197-12-25**] 05:14PM GLUCOSE-139* UREA N-25* CREAT-0.8 SODIUM-137 POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-21* ANION GAP-19 [**2197-12-25**] 05:14PM ALT(SGPT)-82* AST(SGOT)-70* LD(LDH)-907* CK(CPK)-60 ALK PHOS-551* TOT BILI-0.7 [**2197-12-25**] 05:14PM CK-MB-8 cTropnT-0.52 [**2197-12-25**] 05:14PM ALBUMIN-3.4 CALCIUM-9.2 PHOSPHATE-4.2 MAGNESIUM-2.3 CHOLEST-237* [**2197-12-25**] 05:14PM VIT B12-1451* FOLATE-12.5 [**2197-12-25**] 05:14PM TRIGLYCER-250* HDL CHOL-25 CHOL/HDL-9.5 LDL(CALC)-162* [**2197-12-25**] 05:14PM TSH-2.7 [**2197-12-25**] 05:14PM CEA-42* CA125-2433* [**2197-12-25**] 05:14PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2197-12-25**] 05:14PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2197-12-25**] 05:14PM WBC-27.1* RBC-4.62 HGB-12.7 HCT-36.7 MCV-80* MCH-27.5 MCHC-34.6 RDW-14.5 [**2197-12-25**] 05:14PM NEUTS-90* BANDS-3 LYMPHS-6* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2197-12-25**] 05:14PM PLT COUNT-261 [**2197-12-25**] 05:14PM PT-11.8 PTT-25.7 INR(PT)-1.0 [**2197-12-25**] 05:14PM RET AUT-2.2 . EKG NSR rate 87, normal axis, left bundle, no T wave inversions, Q III, F and STE in V1 V2. . OSH chest CT: multiple bilateral pulmonary nodules OSH abdominal U/S: multiple gallstones up to 1 cm, borderline thickening of gallbladder wall 3mm, multiple round hypoechoic foci in both lobes of liver, omental nodularity suspicious of intraperitoneal metastasis, 14 cm fundal fibroid Transthoracic Echo: EF 70% no focal wall motion abnormalities . CT [**12-25**]: 1. No intracranial hemorrhage or mass effect. 2. Multiple chronic infarctions in diffuse vascular territories. This appearance is most consistent with an embolic phenomenon versus venous infarct. MRI with diffusion-weighted imaging would be more sensitive for the detection of an acute infarction. . MRI/MRA Brain [**12-26**]: There are multiple small-to-moderate sized infarcts throughout the cerebral and cerebellar hemispheres as well as the punctate left midbrain infarct. The distribution is consistent with a history of embolic disease. The study is limited by patient motion. No major arterial total occlusion is seen. A venous 2D time-of-flight study was derived from an angled sagittal slab. Flow is identified in the superior sagittal sinus, the deep venous system and straight sinus, as well as the visualized segments of the transverse and sigmoid sinuses. No major venous occlusion is seen. . Carotid duplex [**12-26**]: Normal study. . Bilateral Lower Extremity Ultrasound [**12-26**]: No evidence of DVT bilaterally. . EEG [**12-26**]: This is an abnormal EEG due to the disorganized and slow background with bursts of generalized delta slowing. This EEG suggests an encephalopathic pattern, which may occur with infections, ischemia, toxic metabolic abnormalities or medications. . Echo [**12-26**]: Asymmetric left ventricular hypertrophy with regional left ventricular systolic dysfunction c/w CAD. Moderate pulmonary artery systolic hypertension. Dilated ascending aorta. Mild aortic regurgitation. Mild mitral regurgitation. . Liver cytology [**12-28**]: POSITIVE FOR MALIGNANT CELLS. Consistent with adenocarcinoma. . CSF [**12-28**]: NEGATIVE FOR MALIGNANT CELLS. Lymphocytes. Brief Hospital Course: Ms. [**Known lastname **] is a 53 woman who presented to [**Hospital1 18**] from an outside hospital with acute changes in mental status in association with emesis and NSTEMI. Her brief hospital course, by problem: . # Altered Mental Status: Differential diagnosis includes posterior reversible encephalopathy syndrome (PRES) vs. ischemic vs. metastatic vs. embolic. Tox screen, TSH, B12, folate, calcium, BUN/Cr negative. LFTs elevated but not likely enough to cause this level of alteration. CA 125 very high and consistent with metastatic process. LP done on [**12-26**] w/o evidence of infection. No evidence of active seizure on continuous EEG. Over the course of the admission, her mental status continued to deteriorate; she became less responsive and her neurologic examination deteriorated. Supportive care was continued. # Metastatic disease: Liver, omental, and lung nodules in setting of elevated Ca [**10**]-9 and CEA are consistent with probable cancer of unknown etiology. A liver biopsy was consistent with signet ring adenocarcinoma. Oncologic process could have been associated with possible non-infectious endocarditis leading to cerebral embolic infarcts. Oncology was consulted, but noted that chemotherapy was not indicated at this time given extensive neurologic insult. Palliative care was consulted. . # Fever, tachypnea: The patient developed a fever on [**12-27**], which continued throughout the rest of the admission. Possible etiologies considered were infection/sepsis (especially given one episode of hypotension), vasculitis (but no elevated vasculitis markers), known metastatic adenocarcinoma, PRES (see above) and dysregulation from neurologic insult. Sedimentation rate < 30 x 2. No antibiotics were initiated given negative cultures and low suspicion for infection. . # Troponin leak: Troponin was elevated throughout the admission. Her cholesterol panel high. STEMI vs NSTEMI, evidence of old IMI on EKG. ECHO on [**12-26**] demonstrated wall motion abnormality in LAD territory, new compared to ECHO at OSH. Cardiology was consulted, and they indicated that she was not a candidate for cath, thus was medically managed without heparin given neurologic condition and risk of bleed. She was given metoprolol during her admission orally, and her blood pressure was managed with a labetalol drip. Her hypertension was particularly labile, which was thought to be secondary to autonomic dysfunction. . # Rash: She developed a rash on her back, arms, and belly, thought to be consistent with contact dermatitis but other etiologies include vasculitis vs. PRES vs. drug rash were considered. She was given hypoallergenic sheets for the remainder of her hospital stay. . # Hyperglycemia: Blood sugar was high on admission, but was controlled with a regular insulin sliding scale. . # FEN/GI: She was admitted with an anion gap acidosis, which resolved with fluids. She was given free water to correct 2.6L free water deficit. Her electrolytes were monitored and repleted as needed. . # Dispo: She required ICU-level care throughout the admission. Given her extremely poor prognosis from stage IV metastatic adenocarcinoma, unrelenting fevers, and unresolving altered mental status, the husband wished to pursue hospice. She was discharged home with hospice care on [**2197-12-30**]. Medications on Admission: tums PRN Discharge Medications: 1. Acetaminophen 650 mg Suppository Sig: [**1-30**] Suppositorys Rectal Q4-6H (every 4 to 6 hours) as needed. Disp:*80 Suppository(s)* Refills:*2* 2. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO every two hours. 3. Levsin/SL 0.125 mg Tablet, Sublingual Sig: One (1) tablet Sublingual every six (6) hours. 4. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every two hours. 5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. Disp:*60 Suppository(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company **] Discharge Diagnosis: Metastatic adenocarcinoma Discharge Condition: Stable for transport Discharge Instructions: You have been provided with multiple medications that will help keep you comfortable. Please call your hospice nurse with any questions. [**Company 1519**] 1-[**Telephone/Fax (1) 12065**], fax 1-[**Telephone/Fax (1) 24704**] VNAC Home Hospice, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7518**] RN Followup Instructions: As needed with hospice

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icd9cm

[ [ [] ] ]

[ "03.31", "50.11" ]

icd9pcs

[ [ [] ] ]

10156, 10201

6252, 6479

339, 353

10271, 10294

2930, 6229

10660, 10686

2067, 2175

9628, 10133

10222, 10250

9595, 9605

10318, 10637

2190, 2911

278, 301

381, 1864

6494, 9569

1886, 1906

1922, 2051

20,117

107,563

26572

Discharge summary

report

Admission Date: [**2168-4-19**] Discharge Date: [**2168-5-10**] Date of Birth: [**2098-7-7**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Congestive heart failure Major Surgical or Invasive Procedure: [**2168-4-21**] Redo sternotomy, Tricuspid Valve Replacement utilizing a 29 millimeter pericardial valve [**2168-4-22**] Laparoscopy [**2168-5-3**] Left Side Thoracentesis History of Present Illness: This is a 70 year old female who underwent a mechanical aortic valve replacement, replacement of ascending aorta and myomectomy in [**2156-5-19**]. She recently was hospitalized for congestive heart failure. Workup was notable for severe tricuspid regurgitation, mild aortic insufficiency, mild mitral regurgitation, and normal LVEF. Cardiac catheterization in [**2168-1-20**] showed normal coronary arteries. Based upon the above results, she was referred for cardiac surgical intervention. Since her hospitalization, she has been placed on Lasix with improvement in symptoms. At the time of this admission, she denied chest pain, shortness of breath, orthopnea, PND and pedal edema. She was also recently treated with Amoxicillin for community acquired pneumonia. A follow up chest x-ray from [**2168-3-19**] confirmed improving right lower lobe pneumonia. She currently denies fevers, chills and rigors. She admits to improving cough of only white sputum. Past Medical History: AS, HOCM, Ascending aortic aneurysm - s/p AVR(21 millimeter [**Company **] [**Doctor Last Name **]), Replacment of Ascending Aorta, and Myomectomy; Atrial Fibrillation, Hypertension, Diabetes Mellitus Type II, Pulmonary Hypertension, Peripheral Vascular Disease, Reactive Airway Disease, Ascites - s/p paracentesis, s/p tubal ligation, s/p uterine prolapse repair Social History: Denies tobacco/EtoH/drugs. Spanish speaking only. Has recieved most of her medical care in [**Country 13622**] Republic and at [**Hospital 794**] Hospital in [**Hospital1 789**] RI. She lives alone. Family History: Daughter died of aortic aneurysm in her 30's Physical Exam: Vitals: BP 130/90, HR 74, RR 16, SAT 96% on room air General: elderly obese female in no acute distress HEENT: oropharynx benign, PERRL, EOMI Neck: supple, mild JVD noted Heart: irregular rate, normal s1s2, loud holosystolic murmur Lungs: clear bilaterally Abdomen: obese, soft, nontender, normoactive bowel sounds Ext: warm, [**12-21**]+ edema, rubor changes noted bilaterally Pulses: 2+ distally Neuro: CN 2-12 intact, MAE, no focal deficits noted Skin: Sternotomy and right groin incision well healed Pertinent Results: [**2168-5-9**] 06:05AM BLOOD WBC-12.6* RBC-3.50* Hgb-10.5* Hct-32.1* MCV-92 MCH-30.0 MCHC-32.7 RDW-21.0* Plt Ct-317 [**2168-4-19**] 08:30PM BLOOD WBC-12.3* RBC-3.90* Hgb-10.7* Hct-33.7* MCV-86 MCH-27.3 MCHC-31.6 RDW-16.8* Plt Ct-370 [**2168-5-10**] 06:05AM BLOOD PT-18.3* PTT-65.6* INR(PT)-1.7* [**2168-4-19**] 08:30PM BLOOD PT-18.3* PTT-23.8 INR(PT)-1.7* [**2168-5-10**] 06:05AM BLOOD Glucose-96 UreaN-11 Creat-0.9 Na-140 K-4.2 Cl-102 HCO3-27 AnGap-15 [**2168-4-19**] 08:30PM BLOOD Glucose-186* UreaN-6 Creat-0.8 Na-137 K-4.3 Cl-97 HCO3-30 AnGap-14 [**2168-5-3**] 05:25AM BLOOD TotBili-5.3* [**2168-4-19**] 08:30PM BLOOD Digoxin-1.5 Brief Hospital Course: Mrs. [**Known lastname 65582**] was admitted several days prior to surgery for routine preoperative evaluation and heparinization. Workup was unremarkable and she was cleared for surgery. On [**4-21**], Dr. [**Last Name (STitle) 914**] performed a redo sternotomy and a tricuspid valve replacement utilizing a 29mm pericardial valve. The operation was uneventful and she transferred to the CSRU in stable condition. On postoperative day one, she was noted to have a leukocytosis with significant elevation in lactate and bilirubin levels. Some RUQ abdominal tenderness was concomitantly noted. A RUQ ultrasound found no focal liver lesions or biliary dilatation. Subsequent CT scan revealed findings consistent with colitis involving the right colon and proximal transverse colon. She was empirically started on broad spectrum antibiotics and transplant surgery was consulted for exploratory laparoscopy. Diagnostic laparoscopy was performed on [**4-22**]. The mesentery, gall bladder, bowel and appendix all appeared normal. The liver appeared cirrhotic, micronodular. She returned to the CSRU in stable condition. Over several days, she made clinical improvements. Her white count, lactate and LFTs improved. She was eventually extubated and weaned from inotropic support. Broad spectrum antibiotics were continued. C. Diff cultures were checked and remained negative. She otherwise maintained stable hemodynamics and transferred to the SDU on postoperative day four. She intermittently required Haldol for confusion. By discharge, her mental status completely returned to baseline. Warfarin was resumed for her prior mechanical AVR and dosed for a goal INR between 2.0 - 3.0. Heparin was transiently required for some time for a sub therapeutic prothrombin time. She continued to have elevated bilirubin levels for which the hepatology service was consulted. Lactate and total bilirubin levels peaked to 687 and 10.6 respectively. She progressively became jaundiced and started on Ursodiol for cholestasis, the most likely etiology for elevated bilirubin levels. The micronodular liver was attributed to right sided congestive heart failure. Over her hospital stay, her total bilirubin eventually improved to 5.3. The remainder of her LFTs were stable and essentially remained normal except for her LDH. The ID service was also consulted for a persistent leukocytosis. Her white count remained mostly remained in the 20K range. During her hospital stay, she remained afebrile. Broad spectrum antibiotics were empirically continued for a total of 10 day course. The leukocytosis was attributed to postop pleural effusions with bilateral upper lobe pneumonia which was confirmed by chest CT scan. On [**5-3**], left sided thoracentesis was performed without complication. Approximately one liter of bloody fluid was drained. Her white count gradually improved. Serial chest x-rays showed improvement in pleural effusions. Chest x-rays were also notable for a persistent finding of a retrosternal opacity corresponding to fluid collection on recent CT which remained stable in appearance - most likely mediastinal hematoma. The remainder of her hospital course was uneventful. She remained mostly in a normal sinus rhythm with only intermittent atrial arrhythmias and continued to maintain stable hemodynamics. She was stabilized on medical therapy and continued to make clinical improvements with diuresis. She worked daily with physical therapy and continued to make steady progress. She was eventually cleared for discharge to home on postoperative day 18. Medications on Admission: Lasix 20 qd, Digoxin 0.25 qd, Glipizide 10 qd, Protonix 40 qd, Aspirin 81 qd, Warfarin 5 qd, Albuterol MDI, Amoxicillin 875 [**Hospital1 **] Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 5. 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* 6. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Disp:*60 Tablet(s)* Refills:*2* 10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day. Disp:*60 Capsule, Sustained Release(s)* Refills:*2* 11. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 MDI* Refills:*2* 12. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 13. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). Disp:*1 MDI* Refills:*2* Discharge Disposition: Home With Service Facility: VNA of [**Doctor Last Name **] Discharge Diagnosis: Tricuspid Regurgitation - s/p TVR; Postop leukocytosis, Postop cholestasis with elevation of total bilirubin; Postop pleural effusions with pneumonia, History of Congestive Heart Failure; AS, HOCM, Ascending aortic aneurysm - s/p AVR(21 millimeter [**Company **] [**Doctor Last Name **]), Replacment of Ascending Aorta, and Myomectomy in [**2155**]; Atrial Fibrillation, Hypertension, Diabetes Mellitus Type II, Pulmonary Hypertension, Peripheral Vascular Disease, Reactive Airway Disease, Ascites - s/p paracentesis, s/p tubal ligation, s/p uterine prolapse repair Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Followup Instructions: Dr. [**Last Name (STitle) 914**] in 4 weeks, call office for appt. Dr. [**Last Name (STitle) 65583**](PCP) in 2 weeks, call office for appt. Dr. [**Last Name (STitle) 7594**](cardiologist) in 2 weeks, call office for appt. Completed by:[**2168-5-11**]

[ "397.0", "427.31", "428.0", "V43.3", "250.00", "458.29", "998.2", "401.9", "486", "571.5", "511.9", "576.8" ]

icd9cm

[ [ [] ] ]

[ "34.91", "39.32", "99.04", "35.27", "39.61", "54.21", "96.6", "88.72" ]

icd9pcs

[ [ [] ] ]

8773, 8834

3373, 6935

344, 518

9444, 9451

2714, 3350

9770, 10024

2128, 2174

7126, 8750

8855, 9423

6961, 7103

9475, 9747

2189, 2695

280, 306

546, 1507

1529, 1894

1910, 2112

82,208

188,268

69

Discharge summary

report

Admission Date: [**2200-10-21**] Discharge Date: [**2200-10-27**] Date of Birth: [**2139-8-15**] Sex: F Service: MEDICINE Allergies: Iron Dextran Complex Attending:[**First Name3 (LF) 832**] Chief Complaint: respiratory failure Major Surgical or Invasive Procedure: Bronchoscopy Intubation Hemodialysis after HD line placement History of Present Illness: 61 year-old female with ESRD on HD, Stage IV NSLC lung cancer (EGFR wild type), DM2, HTN who presents with respiratory distress. Patient was with cough and not feeling well this AM. She went to dialysis where she was coughing intensely to the point that the needles came out of her AV graft. She appeared short of breath. Unclear what EMS course was. Upon presentation to the ED, her eyes were open but she was none verbal. Some history obtained by cousin in [**Name (NI) **]. Of note, her lung cancer involves the right upper lobe mass and adjacent hilar/mediastinal/supraclavicular nodes. Patient met with Dr. [**Last Name (STitle) **] in [**Month (only) **], who started vinorelbin for palliative chemotherapy about 2 weeks ago. In addition, patient's admit weight was 62 kg with an estimated dry weight of 58 kg. ED Course: Initial VS at 11:40 on [**10-21**] were T 97.7 HR 100 BP 181/69 RR 32 Sat 84 %. She triggered for respiratory distress. Eyes were open but non-verbal. There was a question about intubation/code status. ED physician spoke to next of [**Doctor First Name **] (Mr.[**Last Name (Titles) 732**]). He stated that she would want to be intubated. Intubated with 7.5 ETT with ricironium 60 mg and etomidate 20 mg. Sedation with versed and propofol. After intubation, VS were 95, 125/59, 25, 99% on vent CXR revealed RUL opacity. She was given ceftriaxone 1 gm IV x 1 and levofloxacin 750 mg IV x 1 initially followed by addition of vancomycin 1 gm IV x 1 to cover HCAP. EKG showing Sinus Tach, TWI V4-6, ? peaked T's. . On the floor, patient was sedation and tolerating ventilator well. Renal was consulted for HD but noticed left graft not functioning. Placed RIJ line for dialysis access. Dialysis was going to be performed but hypotensive to MAPs ~ high 50s. CVP 4. Propofol was switched to versed/fentanyl. Dialysis was not performed. Patient subsequently underwent bronchoscopy with BAL showing RL apical segmental occlusion (? tumor), 90 % anterior segment occlusion, and patent posterior segment. Pressure subsequently in 180s. . Review of systems: Patient unable to answer Past Medical History: -NSCLC, poorly differentiated w believed lymphangitic spread -Clear cell renal carcinoma s/p R nephrectomy [**4-/2200**] -DM type 2 c/b retinopathy, neuropathy -Reactive airway disease, likely COPD. -Hypertension, poorly controlled. H/o hypertensive urgency. -CRI, most recent Cr values in the 4's. -Chronic anemia thought [**12-24**] CKD -MGUS -CHF - TTE ([**2200-1-2**]) LVEF 30%, moderate MR, and moderate pulmonary artery hypertension -Depression -Menorrhagia -Hypercholesterolemia -Chronic lower back pain -Thyroid mass never followed up with biopsy -Osteoporosis Social History: Lives with roomate in [**Last Name (un) 813**] in apt. She grew up with her family as a carnival worker and traveled with them. Illiterate. smokes 1ppd, has 50 pack yr history. no etoh/illicits. on SSI currently. only family support seems to be her [**Last Name (un) 802**] in NY. Family History: Multiple family members with DM, MI, CVA. Uncle and two cousins had kidney disease requiring dialysis. Mother with breast cancer. Physical Exam: Vitals: T 100.9 HR 94 BP 126/88 RR 25 SaO2 99 on CMV, FiO2 50 PEEP 8 PIP 28 Vt 500 with vent settings of Tv 400 RR 20 PEEP 8 FiO2 50 General: intubated and sedation 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 Port on right-side of test. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley Ext: warm, well perfused UE, LE cool, 2+ pulses, no clubbing, cyanosis or edema. Left arm graft without bruit or thrill. RIJ in place. Pertinent Results: ADMISSION LABS [**2200-10-21**] 11:50AM BLOOD WBC-3.7* RBC-3.65* Hgb-11.2* Hct-33.2* MCV-91 MCH-30.7 MCHC-33.7 RDW-16.8* Plt Ct-310 [**2200-10-21**] 04:52PM BLOOD Neuts-18* Bands-30* Lymphs-43* Monos-7 Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0 [**2200-10-21**] 04:52PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Stipple-1+ Tear Dr[**Last Name (STitle) 833**] [**2200-10-21**] 12:30PM BLOOD PT-12.8 PTT-40.6* INR(PT)-1.1 [**2200-10-21**] 11:50AM BLOOD Glucose-381* UreaN-49* Creat-6.7* Na-132* K-4.7 Cl-94* HCO3-23 AnGap-20 [**2200-10-21**] 11:50AM BLOOD CK(CPK)-63 [**2200-10-21**] 11:50AM BLOOD Calcium-8.1* Phos-6.6* Mg-1.3* [**2200-10-21**] 04:52PM BLOOD TSH-0.70 [**2200-10-21**] 11:58AM BLOOD Type-[**Last Name (un) **] pH-7.09* [**2200-10-21**] 12:27PM BLOOD Type-ART Rates-/16 Tidal V-400 PEEP-5 FiO2-100 pO2-91 pCO2-69* pH-7.16* calTCO2-26 Base XS--5 AADO2-584 REQ O2-92 -ASSIST/CON Intubat-INTUBATED [**2200-10-21**] 11:58AM BLOOD Glucose-376* Lactate-2.7* Na-134* K-4.7 Cl-94* calHCO3-24 [**2200-10-21**] 11:58AM BLOOD Hgb-11.4* calcHCT-34 O2 Sat-55 COHgb-4 MetHgb-0 [**2200-10-21**] 11:58AM BLOOD freeCa-1.05* CARDIAC ENZYMES [**2200-10-21**] 11:50AM BLOOD cTropnT-0.01 [**2200-10-21**] 04:52PM BLOOD CK-MB-4 cTropnT-0.05* [**2200-10-22**] 12:05AM BLOOD CK-MB-5 cTropnT-0.07* [**2200-10-22**] 03:59AM BLOOD CK-MB-5 cTropnT-0.05* BRONCHIAL WASHING [**2200-10-21**] NEGATIVE FOR MALIGNANT CELLS. ADMISSION EKG [**2200-10-21**] Sinus tachycardia. Intraventricular conduction delay. Left ventricular hypertrophy. ST-T wave abnormalities may be due to intraventricular conduction delay, left ventricular hypertrophy and possible ischemia. Clinical correlation is suggested. Since the previous tracing of [**2200-7-29**] sinus tachycardia is now present and ST-T wave abnormalities are more prominent. CHEST X RAY [**2200-10-21**] IMPRESSION: Multiple limitations as above. There is diffuse and severe pulmonary edema. A dense consolidation on the right may indicate confluent edema, although pneumonia or underlying mass lesion cannot be excluded. ECHO [**2200-10-22**] The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is moderately depressed (LVEF= XX %). 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. There is no mitral valve prolapse. Physiologic mitral regurgitation is seen (within normal limits). The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. IMPRESSION: Mild symmetric LVH with moderate to severe global hypokinesis. Lateral wall function is relatively better. No significant mitral regurgitation seen. CHEST X RAY [**2200-10-24**] There is now complete opacification of the right upper lung with increase of the right mediastinal shift. The findings are consistent with interval development of atelectasis but there is potentially some additional cause that precludes significant volume loss such as hemorrhage. Correlation with bronchoscopy is highly recommended. Position of tubes and lines and the left perihilar region opacities are unchanged. Brief Hospital Course: Assessment and Plan: 61 year-old female with ESRD on HD, Stage IV NSCLC involving RUL, DM2, HTN who presents with acute hypercarbic/hypoxic respiratory distress and RUL opacification secondary to possible post-obstructive pneumonia in addition to initial neutropenia. . # Hypercarbic/hypoxic respiratory distress Ms. [**Known lastname 784**] was originally intubated and ventilated in the ICU setting upon admission. After initially failing pressure support trial, she was ultimately able to be extubated on [**2200-10-23**] after a discussion with the family concluded that if Patient extubated initially failing trial of pressure support. Cause of the respiratory distress thought to be likely multifactorial with RUL opacification representing post-obstructive pneumonia given bronchscopy and ? pulmonary edema contribution although not clinically evident (?lymphangitic spread of cancer). Per goals of care conversation with the family and HCP, the decision was made to not reintubate, and ultimately, she was made CMO. She was kept comfortable with morphine concentrated oral solution and scopolamine patch was used for secretion control. She was started on a morphine gtt with bolus morphine for breakthrough [**12-24**] tachypnea on [**2200-10-27**]. The patient passed away on [**2200-10-27**]. . # Sepsis secondary to post-obstructive pneumonia with subsequent pan-sensitive E. Coli bacteremia. Patient with leukocytosis and fever (100.7) during MICU stay. She was originally treated with vanc/levofloxacin however this was changed to Zosyn after cx data returned. Upon admission, she was neutropenic [**Last Name (un) 834**] vinrelbin chemo 2 weeks PTA. This resolved over time. The source of her bacteremia was thought most likely [**12-24**] pulmonary system. After the decision was made to become CMO, antibiotics were discontinued and she was kept comfortable with tylenol liquid prn for fever. . # Non-gap mixed respiratory acidosis and metabolic alkalosis. Metabolic acidosis resolved s/p dialysis. Continued to have respiratory acidosis likely secondary to hypoventilation post-extubation. ABGs and blood draws to monitor lytes and K were discontinued after the patient was made CMO. . # Hypotension: Patient had issues with pre-load dependent hypotension during her MICU course. Patient appeared adequately resuscitated and a recent ECHO showed moderate to severe hypokinesis, which may represent myocardial depression [**12-24**] to sepsis and acute illness vs. baseline heart disease. After the patient was made CMO, dialysis was discontinued and vital signs were no longer taken. # EKG changes: TWI different from prior on admission. In state of acute illness, demand ischemia possible. EKG changes resolved by morning. Troponins bland. Acute plaque rupture very unlikely. Many of her cardiac medications were stopped during her MICU stay, and were not restarted given her CMO status (ASA, plavix, lipitor, heparin gtt, ACE/BB). . # Chronic kidney disease requiring HD. HD was performed by renal during her MICU stay. Medications were renally dosed, and nephrotoxins and IV contrast were avoided in the setting of CKD. HD was discontinued when the patient was made CMO. . # Stage IV NSCLC - discussed with primary oncologist (Dr. [**Last Name (STitle) **], who thinks chemotherapy unlikely to provide patient any benefit. . # Anemia Baseline Hgb ~ 11. Current stable around ~ 8. No evidence of acute blood loss. This was trended, but after the patient was made CMO, no more labs were checked. . # Chronic heart failure, systolic, EF 30 % with MR. [**Name13 (STitle) **] does not have active signs of heart failure although transient diastolic function can cause pulmonary edema. ECHO showed resolving MR. . # History of reactive airway disease: continued on ipratropium nebs, until CMO status, at which point they were d/c'ed as family felt pt did not derive help with them. . # Diabetes - pt did not receive oral hypoglycemics, but rather was placed on a SSI until this was stopped when she was made CMO. . # Goals of care Multiple family meetings held (see ICU attending note for more details). Per HCP, DNR/[**Name2 (NI) 835**] with no pressors. Given that her health deteriorated during her MICU stay, the patient was made CMO by the family including her HCP in light of the post-obstructive pneumonia difficult to treat in the setting of Stage IV NSCLC. She was transferred to the medicine floor after lines were d/c'ed. All vital sign checks and lab draws were discontinued, and the family remained at the bedside. The patient was prescribed only medications for comfort, which included tylenol liquid, morphine sulfate concentrated oral solution, ativan, and haldol. . Of note, SW saw the pt and provided counseling to the family throughout her stay on [**Wardname 836**]. Medications on Admission: ALBUTEROL SULFATE - (Prescribed by Other Provider) - 90 mcg HFA Aerosol Inhaler - [**11-23**] HFA(s) inhaled every four (4) hours as needed for shortness of breath or wheezing B COMPLEX-VITAMIN C-FOLIC ACID [NEPHROCAPS] - (Prescribed by Other Provider) - 1 mg Capsule - 1 Capsule(s) by mouth once daily CALCIUM ACETATE - (Prescribed by Other Provider) - 667 mg Capsule - 2 caps Capsule(s) by mouth 3 x daily w/meals FUROSEMIDE [LASIX] - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth once a day GABAPENTIN - (Prescribed by Other Provider) - 100 mg Capsule - 2 Capsule(s) by mouth once a day HAIR PROSTHESIS - - use on scalp as needed For chemotherapy-induced alopecia. ICD 9. 162.9 LACTULOSE - 10 gram/15 mL Solution - 15 mL by mouth once or twice a day if constipation METOPROLOL SUCCINATE - 50 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth once a day OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day OXYCODONE - 20 mg Tablet Sustained Release 12 hr - 1 Tablet(s) by mouth twice a day for ICD 9. 162.9 OXYCODONE - 5 mg Tablet - 1 Tablet(s) by mouth every 8 hours as needed for pain for breakthrough pain for ICD 9. 162.9 PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth 8 hours as needed for nausea if nausea during chemotherapy SIMVASTATIN - 80 mg Tablet - 1 Tablet(s) by mouth once a day TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule, w/Inhalation Device - 1 ih ih daily Medications - OTC ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet - 1 Tablet(s) by mouth once a day DOCUSATE SODIUM [DOC-Q-LACE] - (Prescribed by Other Provider) - 100 mg Capsule - 12 Capsule(s) by mouth 2 x daily as needed for asneeded Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Post obstructive PNA in setting of Stage IV NSCLC Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None Completed by:[**2200-10-28**]

[ "285.21", "338.29", "428.22", "995.92", "428.0", "518.81", "276.4", "305.1", "362.01", "V45.11", "V66.7", "V10.52", "403.91", "486", "272.0", "311", "416.8", "724.2", "799.02", "496", "038.42", "585.6", "250.60", "V49.86", "288.00", "733.00", "250.50", "357.2" ]

icd9cm

[ [ [] ] ]

[ "96.04", "39.95", "96.71", "38.95", "33.24", "38.91" ]

icd9pcs

[ [ [] ] ]

14374, 14383

7715, 12535

302, 364

14477, 14487

4254, 7692

14540, 14577

3409, 3540

14345, 14351

14404, 14456

12561, 14322

14511, 14517

3555, 4235

2473, 2500

243, 264

392, 2454

2522, 3093

3109, 3393

40,689

111,103

40864

Discharge summary

report

Admission Date: [**2182-5-15**] Discharge Date: [**2182-6-11**] Date of Birth: [**2134-4-7**] Sex: F Service: CARDIOTHORACIC Allergies: Heparin Agents Attending:[**First Name3 (LF) 1406**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: [**2182-5-15**] 1. Replacement of ascending aorta with a 28-mm Gelweave Dacron graft. 2. Bentall procedure with a composite St. [**Male First Name (un) 923**] mechanical graft, size 21 mm, reference number [**Serial Number 89248**]. [**2182-5-29**] Tunneled hemodialysis catheter placement- History of Present Illness: This patient is a 48 year old female who complains of abdominal pain. Patient presents with abdominal pain to an outside hospital. Patient reports having intermittent abdominal pain became more constant over last day. Patient underwent a CT scan which showed a descending aortic aneurysm. Patient transferred to [**Hospital1 18**]. CT reviewed and found to show type A dissection starting at the root and extending to the iliac bifurcation. She was brought emergently to the operating room for repair. Past Medical History: Mild mental retardation, hypertension Social History: Lives independently with husband works at Stop and Shop Cigarettes: no ETOH: no Family History: Family History: heart disease; HTN Physical Exam: General: awake, somewhat anxious Skin: Dry [x] intact [] HEENT: PERRLA [x] EOMI [] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [] Extremities: Warm [x], well-perfused [x] no Edema Neuro: Grossly intact [] Pulses: Femoral Right: 2 Left: 2 DP Right: 2 Left:2 PT [**Name (NI) 167**]: 2 Left:2 Radial Right: 2 Left:2 Carotid Bruit Right: no Left: no Pertinent Results: [**2182-6-10**] 07:10AM BLOOD WBC-7.2 RBC-3.49* Hgb-10.5* Hct-30.5* MCV-88 MCH-30.2 MCHC-34.5 RDW-15.4 Plt Ct-434 [**2182-6-9**] 05:50AM BLOOD WBC-7.3 RBC-3.54* Hgb-10.6* Hct-30.5* MCV-86 MCH-30.1 MCHC-35.0 RDW-15.4 Plt Ct-381 [**2182-6-7**] 06:10AM BLOOD WBC-8.2 RBC-3.26* Hgb-9.9* Hct-28.1* MCV-86 MCH-30.4 MCHC-35.3* RDW-15.5 Plt Ct-326 [**2182-6-11**] 06:54AM BLOOD PT-44.6* INR(PT)-4.6* [**2182-6-10**] 07:10AM BLOOD PT-42.5* INR(PT)-4.4* [**2182-6-9**] 05:50AM BLOOD PT-39.6* PTT-32.3 INR(PT)-4.0* [**2182-6-8**] 05:10AM BLOOD PT-44.1* INR(PT)-4.6* [**2182-6-7**] 06:10AM BLOOD PT-46.0* PTT-33.0 INR(PT)-4.8* [**2182-6-6**] 03:15PM BLOOD PT-44.2* INR(PT)-4.6* [**2182-6-11**] 06:54AM BLOOD Glucose-104* UreaN-22* Creat-2.6*# Na-126* K-3.4 Cl-86* HCO3-30 AnGap-13 [**2182-6-10**] 07:10AM BLOOD Glucose-91 UreaN-73* Creat-4.7* Na-134 K-4.7 Cl-93* HCO3-23 AnGap-23* [**2182-6-9**] 05:50AM BLOOD Glucose-84 UreaN-54* Creat-4.2*# Na-135 K-4.2 Cl-94* HCO3-23 AnGap-22* [**2182-6-8**] 05:10AM BLOOD Glucose-98 UreaN-28* Creat-2.7*# Na-136 K-4.5 Cl-95* HCO3-25 AnGap-21* [**2182-6-9**] 05:50AM BLOOD ALT-13 AST-19 LD(LDH)-303* AlkPhos-109* Amylase-66 TotBili-0.7 [**2182-6-10**] 07:10AM BLOOD Mg-2.3 [**2182-6-9**] 05:50AM BLOOD Albumin-3.2* Calcium-8.7 Phos-8.2*# Mg-2.3 Admission labs: [**2182-5-15**] 09:30AM PT-13.9* PTT-25.1 INR(PT)-1.2* [**2182-5-15**] 09:30AM PLT SMR-NORMAL PLT COUNT-208 [**2182-5-15**] 09:30AM WBC-22.7* RBC-5.34 HGB-14.6 HCT-45.0 MCV-84 MCH-27.3 MCHC-32.4 RDW-14.6 [**2182-5-15**] 09:30AM CALCIUM-7.5* PHOSPHATE-5.9* MAGNESIUM-2.1 [**2182-5-15**] 09:30AM cTropnT-0.04* [**2182-5-15**] 09:30AM ALT(SGPT)-50* AST(SGOT)-56* ALK PHOS-53 TOT BILI-1.2 [**2182-5-15**] 09:30AM GLUCOSE-366* UREA N-20 CREAT-1.3* SODIUM-137 POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-14* ANION GAP-27* [**2182-5-15**] 10:30AM FIBRINOGE-209 Discharge labs: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 4.0 cm <= 4.0 cm Left Atrium - Four Chamber Length: 5.0 cm <= 5.2 cm Left Ventricle - Septal Wall Thickness: 0.8 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 3.9 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 55% to 65% >= 55% Aorta - Annulus: 2.1 cm <= 3.0 cm Aorta - Sinus Level: *3.7 cm <= 3.6 cm Aorta - Ascending: *4.0 cm <= 3.4 cm Aorta - Descending Thoracic: 2.1 cm <= 2.5 cm Pericardium - Effusion Size: 1.0 cm Findings LEFT ATRIUM: Mild LA enlargement. No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. Bidirectional shunt across the interatrial septum at rest. Secundum ASD. LEFT VENTRICLE: Normal LV wall thickness. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildy dilated aortic root. Mildly dilated ascending aorta. Normal descending aorta diameter. Ascending aortic intimal flap/dissection.. Aortic arch intimal flap/dissection. Descending aorta intimal flap/aortic dissection. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Moderate to severe (3+) AR. Eccentric AR jet. MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) PR. PERICARDIUM: Moderate 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. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Results were personally reviewed with the MD caring for the patient. Conclusions PRE-CPB: The left atrium is mildly dilated. No thrombus is seen in the left atrial appendage. An ASD is present. There is a bidirectional shunt across the interatrial septum at rest. Left ventricular wall thicknesses are normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. A mobile density is seen in the ascending aorta consistent with an intimal flap/aortic dissection. A mobile density is seen in the aortic arch, extending through the descending aorta, consistent with an intimal flap/aortic dissection. There are multiple fenestrations in the dissection flap with flow across. There are three aortic valve leaflets which fail to completely coapt. Moderate to severe (3+) eccentric aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is a moderate sized pericardial effusion. POST-CPB: There is a mechanical valve in the aortic position. The valve appears well seated with normal leaflet mobility. There are the normal washing jets. Otherwise no AI is seen. The peak gradient across the aortic valve is 7mmHg, the mean gradient is 4mmHg with CO of 3L/min. There is a tube graft in the ascending aorta. A dissection flap is seen in the distal arch extending through the descending thoracic aorta. The LV systolic function appears normal, estimated EF is 65%. The RV appears moderately hypokinetic. This improved mildly with initiation of epinephrine infusion. The TR appears to be mild-to-moderate. Dr. [**Last Name (STitle) **] was notified in person of the results at time of study. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) 17792**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2182-5-15**] 19:42 Radiology Report RENAL U.S. [**2182-5-18**] 4:52 PM Clip # [**Clip Number (Radiology) 89249**] Final Report: Right kidney measures 11.5 cm, demonstrating no hydronephrosis, or focal lesion. The Doppler images demonstrate flow within the right kidney with limited spectral waveforms obtained due to venous contamination. Main right renal vein appears patent. The left kidney measures 11.5 cm without focal lesion or hydronephrosis. As on the right, there is blood flow to the left kidney though the spectral waveform is limited due to venous contamination. Main left renal vein appears patent. IMPRESSION: No hydronephrosis. Renal vascularity is confirmed though spectral waveforms are suboptimal to evaluate for renal artery stenosis or subtle changes. Consider CTA to further assess given h/o aortic dissection. DR. [**First Name8 (NamePattern2) 814**] [**Name (STitle) 815**] Radiology Report CT HEAD W/O CONTRAST [**2182-5-19**] 2:12 PM Final Report: There is no acute intracranial hemorrhage, edema, mass effect or major vascular territorial infarct. Ventricles and sulci are normal in size and symmetric in configuration. There is no shift from normally midline structures. [**Doctor Last Name **]-white matter differentiation is well preserved. Fluid in the bilateral paranasal sinuses and mastoid air cells is likely related to intubation. No osseous abnormality is identified. Subcutaneous lesions at the right parietal and left temporal regions may be lipomas. IMPRESSION: No acute intracranial process. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**] [**2182-5-24**] CT Head 1. No evidence of acute intracranial process. If clinical suspicion for stroke or an embolic event is high, MR is the recommended study of choice. 2. Increased interval opacification of the mastoid air cells and paranasal sinuses. [**2182-5-24**] Renal Ultrasound IMPRESSION: 1. No hydronephrosis. 2. Mildly elevated intrarenal resistive indices are nonspecific and may be seen with medical renal disease. 3. Limited evaluation for subtle changes associated with renal artery stenosis. Brief Hospital Course: Ms [**Known lastname 5395**] was amitted through the emergency room with a presumed Type B aortic dissection. Once in the ER a review of the CT scan revealed a type A aortic dissection, once discovered the patient was brought emergently to the operating room for dissection repair. Please see operative report for details, in summary she had: 1. Replacement of ascending aorta with a 28-mm Gelweave Dacron graft. 2. Bentall procedure with a composite St. [**Male First Name (un) 923**] mechanical graft, size 21 mm, reference number [**Serial Number 89248**]. Her cardiopulmonary bypass time was 267 minutes, with a cross clamp time of 81 + 43 + 85 = 209 minutes and a circulatory arrest time of 22 minutes. She tolerated the operation and post-operatively was transferred to the cardiac surgery ICU on Epinephrine, Levophed and Propofol infusions. She was hypotensive and coagulopathic upon arrival to the ICU and was therefore kept sedated to allow for volume resuscitation and correction of coagulopathy. She was also quite hypoxic, a chest xray revealed a left effusion for which a chest tube was placed. Her cardiac indices remained poor and additional inotropic support with Milrinone was begun (weaned off by POD4). She continued to be hypoxic, diuresis was begun with Lasix infusion and an esophogeal ballon was placed to optimize PEEP levels. She was kept sedated and ultimately chemically paralyzed for several days while attempts were made to diurese the patient and to optimize her pulmonary status. During this period she developed acute renal failure and did required dialysis to take volume off. When sedation was minimized the patient became hypertensive requiring multiple antihypertensives to control her BP. She also was encephalopathic and slow to wake from sedation. A head CT was done that showed no acute process. Sedation was held and the patient's neuro status slowly improved. She developed thrombocytopenia and was found to have heparin dependent antibodies so she was placed on argatroban. By POD 7 she was noted to have Serratia in her urine and sputum and was treated with appropriate antibiotics. She developed diarrhea which was positive for c-diff and she was placed on Vanco and Flagyl. On post-operative day fifteen she was extubated successfully. Her epicardial wires were removed and coumadin was started for her heparin dependent antibodies and mechanical aortic valve. She developed atrial fibrillation and was started on Amiodarone. She did convert to Sinus Rhythm. Speech Pathology was consulted for swallowing evaluation and diet modification recommendations. The patient received Physical Therapy for assistance with range of motion exercises, strength and mobility. Occupational Therapy evaluated for ADL recommendations. [**2182-5-29**] a tunnel line was placed for hemodialysis. [**2182-6-5**] she was transferred to the step down unit for further monitoring. POD#22 there was concern that the patient had a seizure. Neurology was consulted. An MRI and 24 hour EEG was performed. Per Radiology the MRI showed three discrete small foci of susceptibility artifact at the [**Doctor Last Name 352**]-white matter junction supratentorially and in the right cerebellar hemisphere, with a separate small focus of slow diffusion demonstrated within the left occipital lobe. EEG was non-specific and did not reveal evidence of seizure. INR became supratherapeutic at 4.5 on [**6-5**], coumadin has been held since. INR will be checked daily upon discharge to rehab, and results will be called to cardiac surgery office for coumadin management until stable. The patient is discharged to [**Hospital1 **] of [**Location (un) 1110**] with appropriate follow-up instructions. Medications on Admission: lisinopril or labetolol hydrochlorthiazide Discharge Medications: 1. Outpatient Lab Work Labs: PT/INR for mechanical Aortic Valve Goal INR 2.5-3.0 First draw [**2182-6-12**]- please draw DAILY and call results to [**Telephone/Fax (1) 170**], on-call PA/NP 2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for fever or pain. 3. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**11-18**] Drops Ophthalmic PRN (as needed) as needed for dry eyes . 4. ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO DAILY (Daily). 5. sodium citrate 4 % (3 mL) Syringe Sig: One (1) ML Miscellaneous ASDIR (AS DIRECTED) as needed for catheter not in use: Do not inject intravenously. For catheter dwell only. 6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 7. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for fungal rash. 8. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezes. 10. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 12. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 14. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 16. calcium acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 17. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2 times a day). 18. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 8 days: through [**2182-6-19**], OK to substitute oral liquid. Discharge Disposition: Extended Care Facility: TBA Discharge Diagnosis: Type A Aortic dissection with tamponade- s/p Bentall(21 StJude mech)Hemiarch(28 Gelweave) Hypertension, Mild mental retardation Discharge Condition: Alert and oriented x 3 Max assist Incisions: Sternal - healing well, no erythema or drainage Edema - trace 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 one month or while taking narcotics. Driving will be discussed at follow up appointment with surgeon. No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: Labs: PT/INR for mechanical Aortic Valve Goal INR 2.5-3.0 First draw [**2182-6-12**]- please draw DAILY and call results to [**Telephone/Fax (1) 170**], on-call PA/NP You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] on [**2182-7-3**] at 1:00pm #[**Telephone/Fax (1) 170**] [**Hospital **] Medical Building [**Hospital Unit Name **] Cardiologist: Dr. [**Last Name (STitle) 4610**] in [**Location (un) 1110**] office ([**Hospital1 89250**] Medical office next to [**First Name4 (NamePattern1) 3075**] [**Last Name (NamePattern1) 3549**] Hospital) on [**2182-7-5**] at 2:00pm Please call to schedule an appointment with your: PCP: [**Name10 (NameIs) **] [**Last Name (STitle) **],[**First Name3 (LF) **] C. [**Telephone/Fax (1) 25493**] in 4 weeks Completed by:[**2182-6-11**]

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icd9cm

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icd9pcs

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53820

Discharge summary

report

Admission Date: [**2196-4-13**] Discharge Date: [**2196-4-16**] Date of Birth: [**2124-6-25**] Sex: F Service: MEDICINE Allergies: Penicillins / clindamycin / Nickel / Sulfa(Sulfonamide Antibiotics) / mycins Attending:[**First Name3 (LF) 3326**] Chief Complaint: "s/p esophageal stent placement with HTN urgency." Major Surgical or Invasive Procedure: EGD with esophageal stent placement History of Present Illness: 71 yo female with history of multiple malignancies (Breast, Ovarian, Colon) and recent diagnosis of esophageal mass([**3-30**]) who presented to [**Hospital1 18**] for esophageal stent placement. Patient notes approx one week of dysphagia/odynophagia prior to evaluation at [**Hospital3 **] where EGD was performed on [**2-24**] and esophageal stricture was dilated. Symptoms recurred and patient eventually presented to [**First Name5 (NamePattern1) 46**] [**Last Name (NamePattern1) **] again on [**3-30**] where EGD revealed poorly diff malignancy involving the stomach/esophagus. CT chest was performed and revealed likely metastases. PET scan performed approx one week aggo revealed lung, liver, brain mets. MRI of brain with left temporal lobe (1.2cm) brain met. Started on decadron and met with radiation onc. Got one dose of XRT to brain. She has not started chemotherapy though port is placed in anticipation. She was transferred to [**Hospital1 18**] for esophageal stent placement on [**4-13**]. After stent placement she has continued to have upper abdominal pain which is acute on chronic but worse since stent placement. PO intake makes pain worse. She has lost approx 40 lbs since the start of these symptoms. Patient has been noted to be chronically aspirating and CXR was performed during admission which identified changes consistent with chronic aspiration. Patient had low grade temperature on [**4-14**] and started on levofloxacin. No bowel movement in the last 3 days. Passing gas. KUB with evidence of mild small bowel distention. Patient has intermittently been hypertensive requiring IV hydralazine. Morning of transfer to ICU patient was noted to be tachycardic. EKG showed atrial fibrillation with lateral ST depressions at rate of 158. Patient was given metoprolol IV 5mg x4 and metoprolol 25mg daily with improvement in rates to 120s. Patient was given full strength aspirin. Troponin was checked and negative. Blood pressure transiently decreased to systolic of 100s. During this time patient was asymptomatic. Patient was transfered to the ICU given potential need for diltiazem gtt as patient unable to tolerate PO currently. On arrival to the MICU, patient's VS 129/61, 140, 20, 96 2L (93RA). Tmax 99.9 last 24 hours. Patient notes no chest pain or shortness of breath, no dizziness. She continues to not some abdominal discomfort in the center of the belly which has been present for the last month. Past Medical History: -h/o CVA at age 38 yo-[**1-21**] to HTN per patient-no residual deficits -HTN -HLD -h/o tachycardia -asthma -COPD, no on home oxygen -h/o aspiration pna [**2196-3-13**] -GERD -history of congenital kidney dysfunction (congenital solitary kidney) and renal biopsy -colon adenocarcinoma s/p resection-[**2145**] -uterine cancer s/p oopherectomy and fallopian tube removal-[**2146**] -right breast cancer s/p mastectomy-[**2168**] -esophageal carcinoma-diagnosed 1 week ago, also s/p port placement [**2196-4-1**] for anticipated chemotherapy -h/o anemia -DJD -constipation Social History: etoh-none tobacco-quit in [**2186**], 50 PY history ADL's-independent Living situation-had lived with sister in [**Name (NI) 3320**] prior to her admission, was at [**Hospital1 1501**] for 5 days prior to her admission here Family History: father-h/o suicide mother-CHF, DM [**Name (NI) 110452**] Physical Exam: Admission PE VS 162/76 68 20 100 RA General: AAOX3, in nad but does retch multiple times during exam, appears older then stated age HEENT: OP clear, MM somewhat dry Endocrine/Lymph: no lad, no obvious thyroid masses CV: distant HS, RRR, no RMG Lungs: CTAB, no WRR Abdomen: TTP in epigastrum and suprapubic area, active BS, no HSM, no rebound Extremities: BUE are cool to touch (patient reports this is chronic), pulses 1+ and equal, no edema Neuro: CN and MS, strength and sensation wnl Derm: no obvious rashes Psyc: mood and affect wnl Discharge PE: 156/71, 93, 20, 96% on 3Liters General: AAOX3, NAD HEENT: OP clear, MM dry Endocrine/Lymph: no lad, no obvious thyroid masses CV: RRR, no MRG Lungs: Rhonchi at bilateral bases Abdomen: TTP in epigastrum and suprapubic area, active BS, no HSM, no rebound Extremities: BUE are cool to touch (patient reports this is chronic), pulses 1+ and equal, no edema Neuro: CN and MS, strength and sensation wnl Derm: no obvious rashes Psyc: mood and affect wnl Pertinent Results: Labs: CBC: [**2196-4-13**] 08:45PM BLOOD WBC-11.6* RBC-4.59 Hgb-12.5 Hct-39.7 MCV-86 MCH-27.3 MCHC-31.6 RDW-15.3 Plt Ct-220 [**2196-4-14**] 06:25AM BLOOD WBC-11.2* RBC-4.60 Hgb-12.4 Hct-39.2 MCV-85 MCH-27.1 MCHC-31.7 RDW-14.3 Plt Ct-227 [**2196-4-15**] 06:33AM BLOOD WBC-15.6* RBC-4.30 Hgb-12.0 Hct-36.1 MCV-84 MCH-28.0 MCHC-33.3 RDW-15.3 Plt Ct-259 [**2196-4-16**] 04:21AM BLOOD WBC-11.4* RBC-3.78* Hgb-10.4* Hct-32.0* MCV-85 MCH-27.4 MCHC-32.4 RDW-15.0 Plt Ct-227 Coags: [**2196-4-14**] 06:25AM BLOOD PT-12.0 PTT-19.5* INR(PT)-1.1 [**2196-4-15**] 06:33AM BLOOD PT-15.9* PTT-28.6 INR(PT)-1.5* [**2196-4-13**] 08:45PM BLOOD Glucose-107* UreaN-12 Creat-0.6 Na-136 K-3.0* Cl-102 HCO3-22 AnGap-15 Electrolytes: [**2196-4-14**] 06:25AM BLOOD Glucose-96 UreaN-10 Creat-0.6 Na-136 K-3.1* Cl-99 HCO3-22 AnGap-18 [**2196-4-14**] 07:30PM BLOOD Glucose-95 UreaN-12 Creat-0.6 Na-138 K-3.8 Cl-102 HCO3-24 AnGap-16 [**2196-4-15**] 06:33AM BLOOD Glucose-93 UreaN-13 Creat-0.6 Na-138 K-3.1* Cl-100 HCO3-21* AnGap-20 [**2196-4-15**] 02:44PM BLOOD Glucose-238* UreaN-16 Creat-0.6 Na-134 K-3.5 Cl-101 HCO3-19* AnGap-18 [**2196-4-16**] 04:21AM BLOOD Glucose-122* UreaN-20 Creat-0.6 Na-140 K-3.2* Cl-108 HCO3-20* AnGap-15 [**2196-4-13**] 08:45PM BLOOD Calcium-8.9 Phos-3.0 Mg-1.6 [**2196-4-14**] 06:25AM BLOOD Calcium-8.4 Phos-3.0 Mg-1.6 [**2196-4-14**] 07:30PM BLOOD Calcium-8.3* Phos-2.7 Mg-1.8 [**2196-4-15**] 06:33AM BLOOD Calcium-8.4 Phos-1.9* Mg-2.1 [**2196-4-15**] 02:44PM BLOOD Albumin-2.8* Calcium-7.6* Phos-1.8* Mg-2.0 [**2196-4-16**] 04:21AM BLOOD Calcium-7.8* Phos-1.6* Mg-1.9 [**2196-4-15**] 03:20PM BLOOD Lactate-1.2 . CXR ([**4-14**]):The patient obviously has received an esophageal stent. The proximal part of the stent projects over the middle third of the esophagus, the distal part of the stent is at the gastroesophageal junction. There is no evidence of pneumomediastinum. Left pectoral Port-A-Cath in situ. Relatively widespread bilateral parenchymal opacities, left more than right, presumably being the result of chronic aspiration. No pulmonary edema. Mild cardiomegaly. No pleural effusions. KUB ([**4-14**]): IMPRESSION: Mild small bowel dilatation, suggestive of ileus. No evidence of pneumoperitoneum. EGD: --A very narrow malignant appearing stricture was noted in the distal esophagus about 30 cm. The scope could not traverse the lesion. --A 450 JAG wire was passed under fluoroscopic vision through the stricture into the stomach. --A 125mm by 23mm WallFlex TM Esophageal fully covered metal stent (REF: 1674, LOT: [**Numeric Identifier 110453**]) was placed successfully under fluoroscopic vision. --Otherwise normal EGD to esophagus EKG: [**4-13**]: Sinus 93, NA, borderline PR prolongation, Q wave III, withou concerning ST-T wave changes [**4-15**]: Atrial fibrillation 158, St depressions v4-v6 [**4-15**] -6:48: Atrial fibrillation 124, interval resolution of ST depressions [**2196-4-15**] 02:44PM BLOOD TSH-2.0 Brief Hospital Course: 71 yo female with history of multiple malignancies (Breast, Ovarian, Colon) and recent diagnosis of esophageal mass([**3-30**]) who presented to [**Hospital1 18**] for esophageal stent placement. Found to have aspiration pneumonia and small bowel illeus. Started on Levofloxacin/Metronidazole. Transferred to ICU on [**2-15**] for atrial fibrillation with RVR. Patient is now rate controlled and will be transferred to [**Hospital3 3583**] (Dr. [**Last Name (STitle) 69038**] for continued oncology care. #. Atrial Fibrillation with RVR: Patient developed atrial fibrillation with RVR on [**7-15**]. Despite IV and PO metoprolol patient was unable to be rate controlled. Patient was briefly placed on a diltiazem gtt before returning to sinus rhythm. She was continued on oral diltiazem. She remained in sinus rhythm for the remaining time in the intensive care unit. Anticoagulation was not started given brain mets and likelihood for further procedures in the near future. TSH was within normal range. Cardiac enzymes were cycled and negative. #. Metastatic CA, unknown primary: Mass identified in esophagus creating a stricture. Patient transferred to [**Hospital1 18**] for esophageal stent which was placed. PET scan with known lung, liver, brain mets. Patient was continued on decadron during hospitalization given brain met and associated edema. Patient will be transferred back to Dr. [**Last Name (STitle) 69038**] at [**Hospital3 3583**] for ongoing treatment. #. Aspiration Pneumonia: Patient appears to be chronically aspirating which is likely secondary to esophageal obstruction. Recent low grade fever and rise in white blood cell count concerning for pneumonia. Patient started on levofloxacin/metronidazole. At [**Hospital3 3583**] patient should have a speech and swallow evaluation. #. Small Bowel dilation suggestive of illeus: Currently passing gas however has not moved bowels in several days. Patient was continued on clears/sips as tolerated and abdomen was serially examined. Bowel regimen was continued however at the time of discharge patient had not yet moved her bowels. Management of this should be continued at the time of discharge. #. COPD: Continued advair, albuterol, tiotroprium #. HLD: Continued simvastatin once tolerating POs #. HO CVA: Continued Aspirin 81mg Code Status: DNR/DNI Transitional Issues: 1. Continued Oncology Care: [**Hospital1 46**] oncologist Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 69038**] 2. Telemetry Monitoring for recurrent atrial fibrillation 3. Complete 10 day course of Levofloxacin/Metronidazole for aspiration pneumonia 4. Monitoring/Treatment of mild small bowel illeus and constipation 5. Nutrition assessment and discussion of feeding tube 6. Speech and Swallow evaluation given concern for chronic aspiration Dispo: Plan for transfer to [**Hospital3 **] in am for continued treatment for ileus, start of brain radiation. Medications on Admission: List acquired from [**Company **] Pharmacy [**Telephone/Fax (1) 110454**] advair 250/50 amlodipine 5 QD carafate 1 g [**Hospital1 **] simvastatin 80 QHS meloxicam 15 QD lisinopril 10 QD proair prn spiriva QD 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. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 3. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 4. dexamethasone sodium phosphate 4 mg/mL Solution Sig: Two (2) Injection twice a day: 2 mg iv bid. 5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. meloxicam 7.5 mg/5 mL Suspension Sig: Fifteen (15) mg PO QD (). 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 9. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Levofloxacin 750 mg IV Q24H 13. Morphine Sulfate 1-8 mg IV Q4H:PRN pain hold for sedation 14. Ondansetron 8 mg IV Q8H:PRN nausea 15. Promethazine 6.25 mg IV Q6H:PRN nausea may repeat times one, hold for sedation 16. Pantoprazole 40 mg IV Q24H 17. Heparin Flush (10 units/ml) 5 mL IV PRN line flush Indwelling Port (e.g. Portacath), heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN per lumen. 18. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port Indwelling Port (e.g. Portacath), heparin dependent: When de-accessing port, flush with 10 mL Normal Saline followed by Heparin as above per lumen. 19. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Discharge Disposition: Extended Care Discharge Diagnosis: Primary: Esophageal Mass with stricture, s/p stent placement Atrial Fibrillation Hypertension Ileus COPD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms. [**Known lastname 13712**], You were admitted to [**Hospital3 **] Hospital for placement of a stent in your esophagus to open up the blockage caused by your cancer. While here, we found that you had an ileus, or that your gut was not moving and propelling food and contents forward. This somtimes happens when people take pain medications. You found to have a aspiration pneumonia and were started on IV antibiotics. Finally, you were found to have atrial fibrillation (a fast irregular heart rate) which was controlled with a new medication called diltiazem. You are being transferred to [**Hospital3 3583**] for further oncology care. When you are discharged from [**Hospital3 3583**] you will be provided with a updated list of medications you should take at home. It was a pleasure caring for you. Followup Instructions: Follow up will be arranged at the time of discharge from [**Hospital1 3325**].

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icd9cm

[ [ [] ] ]

[ "42.81" ]

icd9pcs

[ [ [] ] ]

12776, 12791

7803, 10133

388, 425

12940, 12940

4841, 7780

13958, 14040

3746, 3804

10991, 12753

12812, 12919

10759, 10968

13123, 13935

3819, 4357

10154, 10733

4371, 4822

298, 350

453, 2895

12955, 13099

2917, 3489

3505, 3730

74,966

112,109

35349

Discharge summary

report

Admission Date: [**2173-2-11**] Discharge Date: [**2173-2-18**] Service: SURGERY Allergies: Iodine; Iodine Containing Attending:[**First Name3 (LF) 5547**] Chief Complaint: PERFORATED DUODENUM Major Surgical or Invasive Procedure: None. History of Present Illness: Pt is a 88yoF with c/o abd pain and n/v/d x 3 days. Pt reports being unwell x 3 days - initially generalized malaise, followed by n/v and diarrhea (worsened than usual diarrhea). After vomiting, she had sudden onset of periumbilical pain. Pain sharp, constant, worsens w/ movement. She denies fever/chills. Denies NSAIDS. She was initially admitted to [**Hospital3 3765**] [**2173-2-10**] w/ diagnosis of pancreatitis ([**Doctor First Name **] 196, Lipase 140). CT abdomen performed [**2173-2-11**] (after prep for ? IV contrast allergy) showed retroperitoneal air concerning for posterior perforated duodenal ulcer. Pt transferred to [**Hospital1 18**]. On arrival, pt reports mild generalized abd pain, despite IV morphine. Of note, pt has had chronic diarrhea which has been worked up w/o final diagnosis. Initially, celiac disease was suspected and trial on gluten-free diet seemed to improve diarrhea. However, she was told by her physician she did not have celiac disease. Past Medical History: htxn, hypothyroidism, chronic diarrhea (? celiac disease), diverticulosis, s/p hysterectomy & appy '[**56**], lower back pain Social History: daily brandy 2oz HS, widow, lives at [**Location **] Commons [**Hospital3 12272**] Family History: mother had chronic diarrhea as well Physical Exam: At discharge: V.S: 98.2, 63, 121/65, 18, 94% RA Gen: A and O x 3, NAD Resp: LSCTA bilat, denies SOB CV: RRR, no m/r/g Abd: soft, nt, nd, + bs Ext: no c/c/e Pertinent Results: [**2173-2-13**] 07:35AM BLOOD WBC-7.2# RBC-3.50* Hgb-11.3* Hct-34.6* MCV-99* MCH-32.4* MCHC-32.7 RDW-13.4 Plt Ct-247 [**2173-2-11**] 03:36PM BLOOD Neuts-32* Bands-37* Lymphs-20 Monos-3 Eos-0 Baso-0 Atyps-3* Metas-5* Myelos-0 Other-0 [**2173-2-11**] 03:36PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-OCCASIONAL [**2173-2-13**] 07:35AM BLOOD PT-12.3 PTT-26.2 INR(PT)-1.0 [**2173-2-17**] 07:00AM BLOOD Glucose-66* UreaN-17 Creat-0.6 Na-137 K-3.4 Cl-103 HCO3-26 AnGap-11 [**2173-2-15**] 09:10PM BLOOD CK(CPK)-31 [**2173-2-11**] 03:36PM BLOOD Lipase-74* [**2173-2-16**] 07:25AM BLOOD CK-MB-2 cTropnT-0.03* [**2173-2-17**] 07:00AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.7 . CLOSTRIDIUM DIFFICILE TOXIN A & B TEST: negative x 2 . HELICOBACTER PYLORI ANTIBODY TEST: NEGATIVE BY EIA. . MRSA SCREEN: No MRSA isolated . Blood Culture, Routine [**2173-2-17**]: NO GROWTH X2 . UGI SGL CONTRAST W/ KUB [**2173-2-15**] No gross extravasation of contrast on this technically limited examination. Known retroperitoneal free air on CT examination, compatible with duodenal ulcer perforation. . CHEST (PORTABLE AP) [**2173-2-13**] Features of worsened CHF along with new opacities at the lung bases. The latter could be due to atelectasis or pneumonia. . ABDOMEN (SUPINE ONLY) [**2173-2-12**] Significant free intraperitoneal air largely unchanged from prior study. Retroperitoneal air is likley present; however its evaluation is limited. No bowel obstruction or dilatation. . Brief Hospital Course: Pt was admitted to the TICU from OSH, she was evaluated by surgery, abx and a protonix drip were started, NGT was placed, CXR done without evidence of free air and she was closely assessed overnight and schedule for upper GI in the am. . She was transferrd to [**Hospital Ward Name 1950**] 5 with IV hydration secondary to dehydration/NGT, a foley and telemetry secondary to new IV beta blocker. Her protonix drip was changed to IV q 12 hrs. The patient had an upper GI study which indicated no gross extravasation of contrast on this technically limited examination, because patient could not shift positions as requested. Known retroperitoneal free air on CT examination, compatible with duodenal ulcer perforation. Her NGT was removed and she was continued on po protonix and her medications were changed to oral. . Patient was fluid overloaded and several doses of IV lasix were administered with good effect and electrolytes were repleated as necessary. [**2173-2-15**] the patient had an episode of new onset tachycardia/A-Fib. She was administered IV lopressor with good effect and her electrolytes were rechecked and repleated as needed. . The patient's foley was d/c'd and she voided with out any issues. C-dif x2 was sent secondary to loose stool-both negative. She was started on her home dose of immodium. . Physical therapy recommended home physical therapy or rehab. The patient and family discussed this issue and decided on home physical therapy, the patient is already set up with the VNA and will continue this. . Discharge paperwork was reviewed with paitent and family. She was started on protonix, handout was provided and the purpose of the medication was reviewed. Her PCP was [**Name (NI) 653**] regarding her situation, change in medications and an appointment was made for 1 week. She will also follow up with Dr. [**Last Name (STitle) 1924**] on [**2173-3-2**] Medications on Admission: quinapril 10mg daily, aldactone 25mg daily, HCTZ 25mg daily, levoxyl 75mcg daily, ativan 0.5mg HS prn, glucosamine, chondroitin, Ca, vitamin D, ibuprofen? Discharge Medications: 1. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Quinapril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Pain: For neck pain. Please do not exceed more than 4000 mg in 24 hours. . 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. Loperamide 2 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). Discharge Disposition: Home With Service Facility: deaconness abundant life homecare Discharge Diagnosis: Primary: Perforated Duodenum Pancreatitis Dehydration Fluid over load New on set A-fib . Secondary: htxn, hypothyroidism, chronic diarrhea (? celiac disease), diverticulosis, s/p hysterectomy & appy '[**56**], lower back pain Discharge Condition: Stable. Tolerating regular diet. Pain well controlled with oral medications. Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Medications: 1. Protonix: -You were started on this medication because of your duodenal ulcer. -This medication will help prevent future ulcerations, by decreasing stomach acid swallowing. -You should take this every 12 hrs. Followup Instructions: 1. Please follow up with Dr. [**Last Name (STitle) 1924**] on [**2173-3-2**]. Please call his office for the time [**Telephone/Fax (1) 7508**]. 2. An appointment has been made for you to see [**Name8 (MD) 80591**] [**First Name5 (NamePattern1) 80592**] [**Last Name (NamePattern1) 80593**] on [**2173-3-1**]. If you can not make this appointment please call to reschedule [**Telephone/Fax (1) 21640**]. Completed by:[**2173-2-18**]

[ "532.50", "401.9", "562.10", "787.91", "276.51", "276.6", "579.0", "577.0", "244.9", "427.31" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6186, 6250

3297, 5188

252, 260

6520, 6599

1766, 3274

7860, 8294

1538, 1575

5394, 6163

6271, 6499

5214, 5371

6623, 7837

1590, 1590

1604, 1747

193, 214

288, 1271

1293, 1421

1437, 1522

4,671

124,063

50209

Discharge summary

report

Admission Date: [**2178-9-19**] Discharge Date: [**2178-9-29**] Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 2186**] Chief Complaint: SOB Major Surgical or Invasive Procedure: None History of Present Illness: HPI: 85 yo lady w/ dementia, living at hospice brought in by EMS when daugther reversed code status this evening to full from CMO. Patient has been reportedly febrile, hypoxic at hospice. Daughter called PCP and reversed code status. Patient was given ceftriazone 1 g IV x 1, labs sent, then called 911, wanted all measures done. Upon arrival to ED, sats in 80's, patient not arousable with frothy, secretions. Intubation x2 was attempted in the field but successful intubation happened on arrival in ED. BP noted to be 80/P, P 100, sats 80%, rectal temp 104. ED placed femoral line, started levophed for low bp's, gave levoflox and clindamycin for pna coverage. Admitted to the [**Hospital Unit Name 153**]. Past Medical History: Severe dementia on hospice care Multiple UTIs with episode urosepsis Embolism/thrombosis GERD Hypothyroidism Sacral decubitus ulcuer Heart failure Iron def anemia Osteoporosis CHronic airway obstruction FTT Pneumonia Social History: SOCIAL: lives at [**Hospital 2188**]; DNR/DNI/hospice care until tonight On her face sheet, patient listed as NO hospitalization, NO IV or IM antibiotics; NO IV fluids for hydration; Enteral feedings ok; advance care planning sheet in chart states that no laboratory testing or hospitalization should be done-- on hospice/comfort care only; DTR reversed all of this tonight. Family History: not elicited Physical Exam: PE: T 100 BP 72.42 --> 96/25 P 100 VENT: AC 450 x 16 fio2 0.5 PEEP 5 VBG on 100% 7.37/50/41 Gen: not arousable, ill-appearing elderly woman, contracted arms HEENT: mm very dry, ETT in place, eyes tracking but not to command neck: large and unable to assess JVP, soft CV: distant heart sounds, regular, tachy ABD: PEG in place, soft, nabs Chest: anteriorly coarse EXTRM: no clonus, minimal edema, warm; right groin line c/d/i minimal ooze NEURO: minimally arousable, tracks w/ eyes, not moving extrm spontaneously; minimally arousable to pain, sternal rub; completely contracted upper extremities. Pertinent Results: [**2178-9-19**] 09:33PM URINE AMORPH-MOD [**2178-9-19**] 09:33PM URINE RBC-[**2-28**]* WBC-[**6-5**]* BACTERIA-FEW YEAST-NONE EPI-0-2 [**2178-9-19**] 09:33PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-MOD [**2178-9-19**] 09:33PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.020 [**2178-9-19**] 09:33PM PT-14.8* PTT-26.9 INR(PT)-1.5 [**2178-9-19**] 09:33PM PLT SMR-UNABLE TO PLT COUNT-233 [**2178-9-19**] 09:33PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL ENVELOP-1+ [**2178-9-19**] 09:33PM NEUTS-69 BANDS-23* LYMPHS-3* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-3* MYELOS-0 [**2178-9-19**] 09:33PM WBC-23.3* RBC-2.92* HGB-7.8* HCT-25.8* MCV-88 MCH-26.5* MCHC-30.1* RDW-16.6* [**2178-9-19**] 09:33PM GLUCOSE-140* UREA N-120* CREAT-3.8* SODIUM-163* POTASSIUM-3.9 CHLORIDE-115* TOTAL CO2-31 ANION GAP-21* [**2178-9-19**] 09:34PM LACTATE-5.2* Brief Hospital Course: 85 yo lady presents from hospice with hypoxia, dyspnea, sepsis. . 1. Hypotension/sepsis. The source of her septic episode was likely pulmonary, with a small right hilar opacity seen on CXR. She also had a UTI her urinalysis at her hospice. She was placed on levofloxacin and clindamycin in the ED. She was intuibated in the ED for respiratory distress. It was difficult to assess her respiratory status originally because an ABG could not be drawn, [**1-28**] her flexure contracture of her upper extremities. VBG obtained 7.37/50/41, and patient was pan-cultured. Her sputum cultures grew out 2+MRSA and proteus, and she was placed on vancomycin, ceftriaxone, and azithromycin, later switched to vancomycin and ceftriaxone of which she completed 10 of a 14 day course. Her ventilator settings were weaned, gradually down to FiO2 0.40 and PEEP 5. She was placed on norepinephrine for pressure support, and was gradually weaned down, with intermittent fluid boluses. At the time that the decision was made to make patient CMO, she was not completely off her norepinephrine drip because she was unable to keep her MAPs above 60. Her cortisol stimulation test was normal, and her blood sugars were well-controlled with ISS. 2. Hypernatremia. Patient originally had a free water deficit of approximately 6.5 liters. She received IVF and free water boluses with her tube feeds. Her hypernatremia resolved through her hospital stay. 3. Comfort/sedation: She was placed on a fentanyl/versed drip, and remained comfortable. She was transitioned to morphine and ativan when CMO. 4. Access: Patient originally had a femoral line placed in the ER. This was then replaced by a right subclavian. 5. Diarrhea. Patient was found to be C. difficile positive, and was started on flagyl tid. She was on day 7 of abx when made CMO. 6. Anemia. Patient had known iron deficiency anemia. She was transfused prn to goal Hct>25. 7. FEN. Patient received tube feeds with free water flushes to correct her hypernatremia. Her electrolytes were supplemented as needed. 8. Code status: Multiple sites of documented hospice, dnr, dni, do not hospitalize, all reversed by daughter night prior to admission. Day prior to pt's death, ethics and palliative care consultants, in meeting with daughter, arranged for pt. to be CMO (again). She was then extubated and started on a morphine/ativan drip, and transferred out of the [**Hospital Unit Name 153**] to the floor. 9. Dispo: Patient expired on the floor. 10. PPx: Patient was placed on heparin sc 1000 tid, given protonix 40 qd, and pneumoboots. Medications on Admission: prevacid 30 mg po qd colace 100 mg [**Hospital1 **] lasix 40 mg [**Hospital1 **] remeron 15 qhs synthroid 100 mcg qd MOM 30 cc tiw Iron sulfate albuterol mdi prn SL morphine prn scolopomine prn duragesic patch jevity tube feeds Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Sepsis Lobar pneumonia, MRSA Diarrhea, Clostridium difficile Iron deficiency anemia Hypothyroidism Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None

[ "294.8", "482.83", "482.41", "276.0", "008.45", "038.9", "584.9", "707.03", "599.0", "428.0", "280.9", "995.92", "507.0", "244.9", "496", "518.84" ]

icd9cm

[ [ [] ] ]

[ "96.72", "38.93", "00.17", "96.6", "99.04", "96.04" ]

icd9pcs

[ [ [] ] ]

6151, 6160

3266, 5843

232, 238

6302, 6311

2280, 3243

6364, 6371

1628, 1642

6122, 6128

6181, 6281

5869, 6099

6335, 6341

1657, 2261

189, 194

266, 979

1001, 1220

1236, 1612

74,835

133,120

4521+55586

Discharge summary

report+addendum

Admission Date: [**2201-9-5**] Discharge Date: [**2201-10-5**] Date of Birth: [**2164-5-10**] Sex: M Service: SURGERY Allergies: Shellfish / Topamax / Augmentin Attending:[**First Name3 (LF) 2836**] Chief Complaint: abdominal pain Major [**First Name3 (LF) 2947**] or Invasive Procedure: Tracheostomy History of Present Illness: This is a 37 y/o M with PMHx of alcoholic pancreatitis s/p splenectomy and distal pancreatectomy ('[**92**]) who presents after 4 wk ETOH binge with abdominal pain, nausea, vomiting and pancreatitis. Pt denied any hematemesis or dark stools. In the [**Name (NI) **], pt received approx 5L IVF, Levofloxacin/Flagyl and was transferred to floor with a diagnosis of alcoholic pancreatitis. On the floor, the pt has received another 2.5L boluses and has been notably tachycardic, hypertensive, requiring valium q2hrs on CIWA and developed a new oxygen requirement. The patient was transferred to the ICU for further care. Past Medical History: 1. Alcoholic pancreatitis; history of ARDS requiring intubation in the setting of severe pancreatitis in [**2194**] 2. splenic hematoma s/p splenectomy. Tail of pancreas was densely adherent to spleen hilum, had distal pancreatectomy 3. GERD 4. HTN 5. Sleep apnea tried on CPAP, biPAP but hasn't tolerated 6. Hypercholesterolemia. 7. Chronic pain in left side of abdomen and left shoulder, followed in pain clinic. Pt has declined trigger point injections due to fear of needles 8. Alcohol withdrawal; long history of alcohol abuse; several admissions for DTs and intubations 9. Right upper quadrant abscess, status post percutaneous catheter drainage in [**2192-5-5**]. 10. hx elevated LFTs, fatty liver and hepatomegaly on US [**2191**] 11. hypertriglyceridemia, has been on Gemfibrozil off and on (self-d/c'd due to abdominal bloating, loose stools) 12. migraine HA/cluster HAs - since age 15, has been on multiple abortive and prophylactic meds, none have been successful, currently on Fioricet prn. Pain back of neck, behind eyes, sometimes has several HA in a day, HAs can last several days. Worse in rainy weather. 13. asthma 14. depression - slit wrists age 17, has been in counselling off and on, first time was at age 11 when his parents went through a divorce. 15. Psychiatric hospitalization for 24 hrs at [**Location (un) **] [**Location (un) 1459**] for detox (age 19) 16. false positive RPR Social History: Tobacco: quit smoking over a year ago, used to smoke 1 ppd EtOH: started drinking 7th grade, drank 30 beers a night plus few shots of alcohol in his 20's, abstinent since [**2194**], attended AA but found it boring. Started drinking vodka daily 2 weeks ago. Drugs: remote hx MJ, cocaine. Denies IVDA. Denies recent drug use. Living: lives with mother who takes care of his medications. On disability for chronic pain. Family History: father CAD (1st MI in 40's), EtOH mother type 2 DM, 3 sisters: 1 with seizure d/o, 1 with migraines, + family hx alcoholism (father, 2 sisters) Physical Exam: On admission: Appearance: uncomfortable Eyes: EOMI, PERRL, conjunctiva clear, noninjected, anicteric, no exudate ENT: MM dry Neck: No JVD Cardiovascular: RRR, nl S1/S2, no m/r/g Respiratory: CTA bilaterally, comfortable, no wheezing, no ronchi, no rales Gastrointestinal: soft, diffusely tender to palpation, obese, non-distended, normal bowel sounds Musculoskeletal/Extremities: no clubbing, no cyanosis, no joint swelling, no edema in the bilateral extremities Neurological: Alert and oriented x3, fluent speech, no asterixis, sensation WNL, CNII-XII intact Integument: warm, no rash, no ulcer Pertinent Results: [**2201-10-5**] WBC 11.8 RBC 2.52 Hgb 7.3 Hct 22.8 MCV 91 MCH 28.8 MCHC 31.8 RDW 13.6 Plt 900 Electrolytes [**2201-10-5**] Glucose 137* BUN 10 Creat 0.6 Na 135 4.4 Cl 96 HCO3 31 URINE CULTURE (Final [**2201-10-4**]): NO GROWTH. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2201-9-29**]): Feces negative for C.difficile toxin A & B by EIA. [**2201-9-24**] 11:01 am BRONCHOALVEOLAR LAVAGE **FINAL REPORT [**2201-9-26**]** GRAM STAIN (Final [**2201-9-24**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2201-9-26**]): 10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA. STAPH AUREUS COAG +. >100,000 ORGANISMS/ML.. SULFA X TRIMETH sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ =>16 R LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN G---------- =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- =>16 R TRIMETHOPRIM/SULFA---- =>16 R VANCOMYCIN------------ <=1 S [**2201-9-24**] 6:49 am BLOOD CULTURE Source: Venipuncture. **FINAL REPORT [**2201-9-26**]** Blood Culture, Routine (Final [**2201-9-26**]): ESCHERICHIA COLI. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Aerobic Bottle Gram Stain (Final [**2201-9-24**]): REPORTED BY PHONE TO [**First Name5 (NamePattern1) 19282**] [**Last Name (NamePattern1) 19283**] @ 1827 ON [**9-24**] - CC6C. GRAM NEGATIVE ROD(S). Anaerobic Bottle Gram Stain (Final [**2201-9-24**]): GRAM NEGATIVE ROD(S). Speech and Swallow evaluation [**2201-9-30**] Mr. [**Known lastname 19280**] [**Last Name (Titles) 19284**] PMV well. He was able to participate in swallow evaluation, however he was very lethargic after being washed up by RN this am. He continues to present with signs of aspiration on thin liquids as evidenced by throat clearing, wet volitional cough and sensation of a tickle in his throat. He did appear to tolerate alternating bites and sips of nectar thick liquids and puree. However, based on patient's increased fatigue, suggest he begin pleasure feeds of nectar thick liquids and puree in small amounts when he is awake and alert during the day. Continue use of dobhoff as primary nutrition, hydration and medications at this time. If patient noted with any s/sx of aspiration (i.e. coughing, po noted in or around trach site), please refrain from giving po. PMV must be in place for ALL POs. This swallowing pattern correlates to a Dysphagia Outcome Severity Scale (DOSS) rating of level 3, moderate dysphagia. RECOMMENDATIONS: 1. PMV in place for ALL POs. 2. Initiate small amounts of nectar thick liquids and puree consistencies as pleasure feeds when patient is awake and alert and requesting throughout the day. 3. Continue use of tube feeds as primary means of nutrition, hydration and medications. 4. Strict 1:1 supervision if patient takes pos. 5. If patient noted with coughing, desaturation, or po in or around trach please refrain from giving pos. 6. We will continue to follow to see how he is [**Last Name (Titles) 19284**] and if his diet may safely be advanced at a later time. CT abd with IV and PO contrast [**2201-10-3**] Minimal periportal edema is unchanged. Otherwise the liver, gallbladder, adrenal glands, right kidney, and both ureters appear normal. Posterior cortical defects in the left kidney are unchanged, consistent with old insult. Atherosclerotic calcifications are again noted in the aorta and the iliac arteries. The prior NG tube has been replaced with a Dobbhoff tube, which terminates in the proximal stomach. Oral contrast opacifies part of the stomach and the distal small bowel, without opacifying much of the duodenum. Otherwise the stomach and small bowel appear normal. Moderate-to-large amount of stool is noted throughout the colon. The patient is again noted to be status post distal pancreatectomy and splenectomy. A large rim-enhancing fluid collection measuring approximately 9.4 (TRV) x 7.8 (AP) x 12.1 (CC) cm is little changed from the prior study of [**2201-9-28**]. A small fluid collection seen anterior to the gastric body and also a small amount of fluid tracking along the transverse mesocolon are also unchanged. Lymph nodes measuring up to 12 mm in short axis are again noted, particularly at the gastrohepatic and cardiophrenic regions. Again small amount of pancreatic tissue is noted remaining proximal to the [**Date Range **] clips from distal pancreatectomy. The current single phase study is suboptimal for evaluating the vascular structures, however the portal vein appears attenuated as it crosses over the pseudocyst, and the SMV and the confluence of the portal veins are not well opacified. Collateral veins are noted along the left margin of the pseudocyst. The SMA remains patent. No free air is seen within the abdomen. CT PELVIS WITH IV CONTRAST: The urinary bladder is mildly distended. The balloon of the Foley catheter is noted to be inflated possibly within the upper portion of the prostate. The seminal vesicles appear normal. Again a moderate-to-large amount of stool is noted throughout the rectosigmoid colon. No free air or free fluid is noted in the pelvis. Small inguinal lymph nodes do not meet CT size criteria for adenopathy. OSSEOUS STRUCTURES: No region of bony destruction is seen concerning for malignancy. IMPRESSION: 1. Large pseudocyst is unchanged from [**2201-9-28**], with fluid extending anterior to the stomach and in the transverse mesocolon. SMV and confluence of the portal vein are not well opacified on this single phase study but are likely involved. 2. Moderate-to-large amount of stool. Brief Hospital Course: The patient was admitted to the hospitalist service on [**2201-9-5**] for acute-on-chronic pancreatitis. Due to tachypnea and tachycardia, the patient was admitted the [**Hospital Unit Name 153**] and subsequently to the [**Hospital Unit Name **] ICU. Neuro: The patient takes methadone 40mg daily (he self-divides into smaller doses) and oxycodone 5mg q6h prn, which was confirmed with his pharmacy; also takes zanaflex. At the time of discharge, pain was well controlled with methadone 85 mg PO Q4H and Tizanidine. At the time of discharge, the patient was also maintained on clonazapam and lorazapam. Cardiac: During the hospital course, the patient had elevated blood pressures, likely related to the systemic inflammatory response and also to pain. Also, the patient takes propranolol as outpatient and likely has underlying hypertension. At the time of discharge, the patient was normotensive and stabilized on blood pressure medications. Pulmonary: The patient was intubated on [**9-5**] for an increased CO2. Bronchoscopy was performed on [**9-13**]. The patient was thought to be in ARDS. The patient was treated for an MRSA pneumonia during his hospital stay. Treatment course with vancomycin was completed on [**2201-9-30**]. A stat tracheotomy was performed at bedside for a endotracheaal cuff herniation that became supraglottic on [**9-14**]. The patient was weaned from ventilation and was transferred to trach mask on [**9-22**]. The tracheostomy tube was changed from a Portex 8.0 to 6.0 for improved patient tolerance on [**9-28**]. The patient was unable to tolerate a Passameur valve on 3 separate occassions. EtOH withdrawl: On admission, the patient was treated with a CIWA scale. At time of discharge, no CIWA scale dosing was required but the patient was maintained on standing benzodiazapines. ID: The patient was emperically started on vancomycin and zosyn. Vancomycin was continued for MRSA pneumonia. Gram negative rods were identified in the blood and which was treated by both meropenum and Cipro. Meropenum should should discontinued on [**10-8**]. Vancomycin was discontinued on [**2201-10-1**] (21 day course) per ID. FEN: Tube feedings were used to maintain nutrition. Dobhoff tube was placed on [**9-7**]. Due to resuscitation, the patient was slowly diuresed with lasix during his ICU stay. At discharge, he was thought to be still somewhat volume overloaded. Speech and swallow saw the patient on [**9-30**]. Recommendations are as follows: 1. PMV in place for ALL POs. 2. Initiate small amounts of nectar thick liquids and puree consistencies as pleasure feeds when patient is awake and alert and requesting throughout the day. 3. Continue use of tube feeds as primary means of nutrition, hydration and medications. 4. Strict 1:1 supervision if patient takes pos.5. If patient noted with coughing, desaturation, or po in or around trach please refrain from giving pos. At the time of discharge, diet was as follows: Regular; Consistency: Pureed; Nectar prethickened liquids 1:1 supervision with all meals. Tubefeeding: Replete w/fiber Full strength; Goal rate: 75 ml/hr Residual Check: q4h Hold feeding for residual >= : 250 Flush w/ 30 ml water q4h. At the time of discharge, the patient was afebrile, vital signs were stable, and the patient was [**Month/Year (2) 19284**] his diet. Medications on Admission: (per [**Location (un) 535**] [**Telephone/Fax (1) 19285**]) acamprosate 666mg tid bupropion 100mg [**Hospital1 **] fioricet 1 tab [**Hospital1 **] prn klonopin 2mg tid plus 4mg qhs gemfibrozil 600mg [**Hospital1 **] methadone 10mg q6h prn oxycodone 5-10mg q6h prn protonix 40mg qd propranolol 40mg [**Hospital1 **] seroquel 100mg qhs zanaflex 8mg [**Hospital1 **], 12mg qhs Patient also on a variety of inhalers in the past, but none filled at CVS recently: albuterol 2 puffs q4-6h prn flovent 2 puffs [**Hospital1 **] advair 250-50 1 puff [**Hospital1 **] serevent 1 puff [**Hospital1 **] azmacort 2 puffs [**Hospital1 **] Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Artificial Tear with Lanolin Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 3. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML Miscellaneous Q6H (every 6 hours) as needed for tk secr/ consolidation. 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 5. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 6. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO QID (4 times a day). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO Q 24H (Every 24 Hours). 9. Tizanidine 2 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day). 10. Tizanidine 2 mg Tablet Sig: Six (6) Tablet PO QHS (once a day (at bedtime)). 11. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 12. Bupropion 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 13. Clonidine 0.3 mg/24 hr Patch Weekly Sig: Two (2) Patch Weekly Transdermal Q WEEK (). 14. medication Papain 2.5 % Solution 30 ml NGT PRN 15. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 16. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) for 5 days. 17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 18. Metoclopramide 10 mg Tablet Sig: Two (2) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 20. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed. 21. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 22. Methadone 10 mg Tablet Sig: Six (6) Tablet PO Q4H (every 4 hours). 23. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed. 24. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: One (1) 15 Subcutaneous twice a day. 25. Insulin Regular Human 100 unit/mL Cartridge Sig: One (1) Injection four times a day: Sliding scale. 26. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 27. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 28. Meropenem 500 mg Recon Soln Sig: One (1) Intravenous every six (6) hours: END DATE [**2201-10-8**]. Discharge Disposition: Extended Care Facility: [**Hospital1 19286**] Discharge Diagnosis: Acute on chronic pancreatitis Respiratory distress Acute respiratory obstruction due to endotracheal tube displacement with inability to re-intubate Discharge Condition: Stable Followup Instructions: Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SPECIALTIES CC-3 (NHB) Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2201-10-14**] 12:45. [**Hospital3 **] [**Hospital Ward Name 23**] [**Location (un) **]. You will have a CT scan in the AM prior to your appointment. Your CT will be at 10 AM. Please arrive at 9AM. [**Hospital Unit Name **], [**Location (un) **]. You will need to be NPO for 3 hours prior to the exam. You will get you PO contrast when you arrive at 9AM. You may take your medications by motuh prior to the exam. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6887**], MD Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2201-10-16**] 11:30 Completed by:[**2201-10-5**] Name: [**Known lastname 3147**],[**Known firstname 651**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 875**] Unit No: [**Numeric Identifier 3148**] Admission Date: [**2201-9-5**] Discharge Date: [**2201-10-5**] Date of Birth: [**2164-5-10**] Sex: M Service: SURGERY Allergies: Shellfish / Topamax / Augmentin Attending:[**First Name3 (LF) 3149**] Addendum: At the time of discharge, the patient was taking NPH insulin 20 units Q12 in addition to his Regular insulin sliding scale. This order was changed from 15 units NPH on [**2201-10-5**]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2306**], MD Discharge Disposition: Extended Care Facility: [**Hospital1 3150**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2000**] MD [**MD Number(2) 3151**] Completed by:[**2201-10-5**]

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Discharge summary

report

Admission Date: [**2180-2-23**] Discharge Date: [**2180-3-29**] Date of Birth: [**2110-3-6**] Sex: M Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 4679**] Chief Complaint: Further treatment of alveolopleural fistula Major Surgical or Invasive Procedure: [**2180-3-12**]: Right thoracotomy. Excision of 6th rib. Repair of alveolar pleural fistula with glue and pleural tent. Bronchoscopy. [**2180-3-8**]: Right Pleurodesis with Doxycycline via chest tube [**2180-3-6**]: Bronchoscopy with IBV valves deployed to anterior and posterior segment of the RUL. History of Present Illness: Mr. [**Known lastname 89451**] is a 69 year old male with COPD (on 3L home O2 and 5L with exertion) and RUL mass which was PET avid, thought to be cryptogenic organizing PNA by pathology. Admitted [**1-9**] and underwent VATS/wedge resection [**1-12**] with placement of chest tube in [**State 1727**]. Procedure complicated by persistent alveolopleural fistula, still requiring chest tube on constant suction. He is being admitted for elective endobronchial intervention to see if the fistula can be sealed, possibly with an endobronchial valve or plug. Past Medical History: Alveolopleural fistula following VATS resection on [**2180-1-12**] Organizing PNA in LUL [**2173**] HTN sarcoidosis in [**2138**] h/o alcoholism GERD iron deficiency h/o tobacco abuse ADHD Bone graft in the wrist Social History: 100 pack yr hx of smoking, quit 25 yrs ago. Former ETOH, denies now. no illicits. Lives in [**State 1727**] with wife, two sons live in [**State 38104**] and [**Name (NI) 108**]. Prior to [**2179-9-24**], was able to play golf, perform ADLs. Family History: Father had MI Mother died of CHF Physical Exam: Admission: Vitals: T: 98.1 BP: 133/76 P: 118 (90 on my exam) R: 20 O2: 98% NRB General: Alert, oriented, appears slightly uncomfortable but improving at end of exam, speaking in full sentences HEENT: Sclera anicteric, MMM, oropharynx clear, facemask in place Neck: supple, JVP not elevated, no LAD Lungs: Moderate symmetric air entry, bibasilar insp crackles, continuous gurgling sound above chest tube site under R scapula 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, mild clubbing, no cyanosis or edema Neuro: CNs2-12 intact, motor function grossly normal Discharge Vital signs: T 96, BP 105/53, HR 108 after walking, O2 sats 92% 8L NC, walking on 100% NRB 88-95%. Discharge Physical Exam: Gen: Pleasant, dyspneic at baseline, Alert and oriented x 3, without deficit, PERRLA Lungs: diminished b/l. Right thoracotomy site healing. Right chest tube to water seal via pneumostat. CV: RRR S1, S2, No MRG Abd: Soft, NT, ND Ext: warm without edema Pertinent Results: Admission Labs: [**2180-2-23**] 08:30PM BLOOD WBC-10.3 RBC-3.83* Hgb-11.3* Hct-33.1* MCV-87 MCH-29.6 MCHC-34.2 RDW-15.8* Plt Ct-411 [**2180-2-24**] 05:30AM BLOOD Neuts-66.9 Lymphs-20.6 Monos-5.2 Eos-6.8* Baso-0.5 [**2180-2-23**] 08:30PM BLOOD PT-13.3 INR(PT)-1.1 [**2180-2-24**] 05:30AM BLOOD Glucose-94 UreaN-9 Creat-0.7 Na-142 K-4.2 Cl-106 HCO3-29 AnGap-11 [**2180-2-24**] 05:30AM BLOOD Calcium-8.9 Phos-4.0 Mg-2.2 Discharge Labs: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2180-3-29**] 05:11 9.6 3.76* 11.0* 31.9* 85 29.2 34.4 15.8* 494* RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2180-3-29**] 05:11 112*1 15 0.8 137 4.0 98 33* 10 [**2180-3-29**] 05:11 Calcium 9.3 Phos 4.2 Mg 2.2 [**2180-3-16**]: ANCA neg, HIV Neg, [**Doctor First Name **] neg [**2180-3-22**]: Prealbumin 16 [**2180-3-16**]: ASPERGILLUS GALACTOMANNAN ANTIGEN Test Result Reference Range/Units ASPERGILLUS ANTIGEN 0.1 <0.5 [**2180-3-16**] HISTOPLASMA ANTIBODY (BY CF AND ID) Test Result Reference Range/Units YEAST PHASE ANTIBODY <1:8 <1:8 MYCELIAL PHASE ANTIBODY <1:8 <1:8 Interpretive Criteria: <1:8 - Antibody Not Detected > or = 1:8 - Antibody Detected [**2180-3-16**] COCCIDIOIDES ANTIBODY, IMMUNODIFFUSION Test Result Reference Range/Units COCCIDIOIDES ANTIBODY, ID Negative Negative Interpretive Criteria: Negative: Antibody Not Detected Positive: Antibody Detected [**2180-3-16**] ANGIOTENSIN 1 - CONVERTING [**Last Name (un) **] Test Result Reference Range/Units ACE, SERUM 27 [**8-/2136**] U/L [**2180-3-16**] BLASTOMYCOSIS ANTIBODY (BY CF AND ID) Test Name In Range Out of Range Reference Range --------- -------- ------------ --------------- Blastomyces Antibody Panel, CF and ID Blastomyces Antibody, CF <1:8 <1:8 INTERPRETIVE CRITERIA: <1:8 = Antibody Not Detected > or = 1:8 = Antibody Detected [**2180-3-16**] B-GLUCAN Test ---- Fungitell (tm) Assay for (1,3)-B-D-Glucans Results Reference Ranges ------- ---------------- <31 pg/mL Negative Less than 60 pg/mL Indeterminate 60 - 79 pg/mL Positive Greater than or equal to 80 pg/mL [**2180-3-15**] 20:50 Report Comment: PLEURAL FLUID CHEMISTRY Total Protein, Pleural 2.9 g/dL Glucose, Pleural 103 mg/dL Lactate Dehydrogenase, Pleural 733 IU/L PLEURAL ANALYSIS WBC RBC Polys Lymphs Monos Eos [**2180-3-15**] 20:50 [**Numeric Identifier 16351**]* [**Numeric Identifier 89452**]* 98* 0 1* 1* PLEURAL FLUID pH 7.21 [**2180-3-16**] 2:41 pm SEROLOGY/BLOOD Source: Line-L-PICC. **FINAL REPORT [**2180-3-17**]** CRYPTOCOCCAL ANTIGEN (Final [**2180-3-17**]): CRYPTOCOCCAL ANTIGEN NOT DETECTED. [**2180-3-15**] 8:50 pm PLEURAL FLUID PLEURAL FLUID. GRAM STAIN (Final [**2180-3-15**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2180-3-18**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2180-3-21**]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2180-3-16**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. [**2180-3-15**] 7:20 pm SPUTUM Source: Expectorated. GRAM STAIN (Final [**2180-3-15**]): <10 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final [**2180-3-15**]): TEST CANCELLED, PATIENT CREDITED. FUNGAL CULTURE (Preliminary): GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS. Specimen is only screened for Cryptococcus species. New specimen is recommended. ACID FAST SMEAR (Final [**2180-3-16**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. Imaging: [**2-23**] PCXR: FINDINGS: No previous images. Evidence of prior surgical procedure on the right with a small amount of subcutaneous gas along the chest wall. No evidence of pneumothorax. Diffuse prominence of interstitial markings consistent with the clinical observation of pulmonary fibrosis. Left central catheter extends to the lower portion of the SVC. . [**3-7**] PCXR: There is interval worsening of now moderate right pneumothorax. A right-sided chest tube remains in the right lateral pleural space, unchanged. Clips in the right superior hilum and suture lines in the right upper lung are compatible with the reported wedge resection. There is no left-sided pneumothorax. There is also interval increase of right lateral chest wall subcutaneous gas. Unchanged moderate bibasilar honeycombing is grossly similar in severity. The cardiomediastinal silhouette is normal. IMPRESSION: Interval increase of right pneumothorax with increase of right lateral chest wall subcutaneous gas. . [**3-11**] PCXR: One view. Comparison with the previous study done [**2180-3-8**]. There is interval increase in a small right pneumothorax. A right chest tube has been withdrawn. Bilateral pulmonary opacities persist. Left apical capping is unchanged. A left PICC line remains in place. Mediastinal structures are stable. Subcutaneous emphysema is again demonstrated on the right. IMPRESSION: Interval increase in right pneumothorax post chest tube withdrawal. . TTE [**2180-3-20**]: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-10mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2180-3-6**], no change. [**2180-3-21**] CT chest: IMPRESSION: 1. Small right apical and anterior pneumothorax which is slightly increased in size since the prior study. 2. New irregularly shaped pulmonary nodule in the right upper lobe measuring up to 1.5 cm, most consistent with COP given its appearance and relatively rapid appearance since the prior study. 3. Severe emphysema and severe pulmonary fibrosis, stable. 4. Prominent mediastinal lymph nodes are stable and likely reactive to the underlying pulmonary process. [**2180-3-29**]: CXR IMPRESSION: AP chest compared to 8 p.m. on [**3-28**]: Moderate to large right pneumothorax is unchanged. Small fluid component has decreased. Pulmonary fibrosis and left apical pleural thickening are unchanged. Heart size is normal. Apical pleural tube unchanged in position. Brief Hospital Course: Mr. [**Known lastname 89451**] was admitted to [**Hospital1 18**] from [**State 1727**] for management of alveolarpleural fistula with ongoing airleak via chest tube. He was admitted initially to the medicine service with a chest tube to suction on [**2180-2-23**]. Inteventional pulmonology was consulted and performed IBV valve placement after IRB approval on [**2180-3-6**]. Doxycycline pleurodesis was done on [**2180-3-8**] however despite this, the alveolar pleural fistula continued. Thoracic surgery was initally consulted and followed along. On [**2180-3-12**] Dr. [**First Name (STitle) **] took the patient to the operating room for a Right thoracotomy, Excision of 6th rib, Repair of alveolar pleural fistula with glue and pleural tent, and Bronchoscopy. From the operating room he transfered to the SICU intubated, sedated, 2 chest tubes, an Bupivicaine Epidural and foley. On [**2180-3-13**] he was successfully extubated however required high amounts of oxygen for several days. Pulmonary medicine was consulted to assist in augmenting medical management. See their note for full recommendations. Labs all drawn and negative (see results section). An echo was done showing moderate pulmonary hypertention. The patient was actively diuresed, and over time his oxygen requirement went down from facemask to 8L NC. He remained in the SICU for close respiratory monitoring. Given his poor lung function, ongoing chest tube leak despite multiple interventions, we discussed lung transplantation with [**Hospital1 112**], who recommended six minute walk which was done twice, first on [**2180-3-24**] which he performed 500 feet walk in 6.5 minutes. He repeated this on [**2180-3-29**] which he passed. Below is systems review of his hospital course: Neuro: The patient was mentally intact throughout his stay. He required ativan for anxiety control and pain was controlled with percocet. As mentioned above he had bupivicaine epidural and dilaudid PCA which was stopped [**2180-3-17**]. Pulmonary: Pulmonary toilet has continued throughout his stay. As noted above his oxygen requirements on admit were 5L now 8L NC. He was intubated for a day during surgery [**2180-3-12**]. He has one remaining chest tube from surgery to water seal x 1 day with stable pneumothorax and obligate space following pleural tent. A CXR was done on pneumostat with persistent PTX. Secretions are not an issue. If the patient developed worsening dyspnea or desaturation, we would recommend stat portable chest xray and if worse PTX convert pneumostat to pneumovac to wall suction. CV: The patient remained hemodynamically stable in SR throughout his stay. Nutrition: The patient was able to eat throughout his stay. Nutrition consulted and recommended ongoing supplementation with "Magic cup" TID and ongoing monitoring as his prealbumin is low. GI: Constipation became an issue on [**2180-3-29**], therefore a bisacodyl suppository was added to his regimine of stool softeners with a large BM prior to discharge. Renal: He was gently diuresed 20-40mg IV daily to maintain euvolemia and assist/ improve oxygenation. His lasix was changed to 40mg po daily starting [**2180-3-27**]. His renal function within normal limits with good urine output. His electrolytes were replete as needed. Please assess this daily along with electrolytes. Lines: Double lumen Left PICC maintained from [**State 1727**], in good condition. ID: No issues throughout his stay nor antibiotic requirements. Endo: The patient's blood sugars were watched and covered with insulin sliding scale. Disposition: PT/OT consultation was made. Pt ambulated and got out of bed. It was recommended the patient go to acute rehab. [**Hospital1 **] [**Location (un) 86**] accepted the patient and he was deemed stable by Dr. [**First Name (STitle) **] for discharge on [**2180-3-29**]. [**State 1727**] did not have the acute care rehab therefore it was decided he would best be served staying in the city. The wife was called and plan communicated that patient was transferring. Report called to Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 26091**]. Pt was in agreement to transfer. He was stable at time of transfer. Medications on Admission: Aspirin 81mg QOD Calcium 500/Vit D 2 tabs [**Hospital1 **] Advair 250/50 1 puff [**Hospital1 **] Spiriva 18mcg IH daily MVI daily Protonix 40mg PO daily Fish oil Iron 1 tab daily 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. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) mL Inhalation Q4H (every 4 hours) as needed for wheezing. 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) SQ Injection TID (3 times a day). 6. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed for anxiety. 7. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas cramps. 13. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 16. Regular insulin sliding scale 71-119 mg/dL 0 Units 0 Units 0 Units 0 120-159 mg/dL 2 Units 2 Units 2 Units 2 160-199 mg/dL 4 Units 4 Units 4 Units 4 200-239 mg/dL 6 Units 6 Units 6 Units 6 240-279 mg/dL 8 Units 8 Units 8 Units 8 280-319 mg/dL 10 Units 10 Units 10 Units 10 320-359 mg/dL 12 Units 12 Units 12 Units 12 360-399 mg/dL 14 Units 14 Units 14 Units 14 17. 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. 18. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Persistent air leak following wedge resection of right upper lobe. Pulmonary fibrosis/BOOP Organizing Pneumonia in LUL [**2173**] COPD Chronic mediastinal lymph node, Sarcoidosis GERD ETOH abuse: iron deficiency ADHD Osteopenia L inguinal hernia 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: Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience: -Fevers > 101.5 or chills -Increased shortness of breath, cough or chest pain -Right thoracotomy incision develops drainage -Chest tube to water seal via Pneumostat. Assess every shift, drain if drainage and record. If acute shortness of breath get a stat CXR and if worse PTX change to pneumovac with wall suction. -Change dressing daily Activity: -Shower daily. Wash incision with mild soap and water, rinse, pat dry -No tub bathing, swimming or hot tubs until incision healed. -PT [**Name (NI) **] and treat. PICC line per protocol. Daily weight with adjustment of lasix. Monitor daily lytes and replace as needed. Check blood sugars q AC and q HS and use insulin sliding scale. Followup Instructions: Follow-up with Dr. [**First Name (STitle) **] [**0-0-**] [**2180-4-27**] 9:30am on the [**Hospital Ward Name 5074**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**] Chest X-Ray [**Location (un) 861**] Radiology 30 minutes before your appointment Completed by:[**2180-3-29**]

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icd9cm

[ [ [] ] ]

[ "34.92", "33.23", "34.73", "03.90", "33.71" ]

icd9pcs

[ [ [] ] ]

17336, 17407

10758, 12504

341, 643

17697, 17697

2946, 2946

18675, 18972

1739, 1773

15176, 17313

17428, 17676

14973, 15153

12522, 14947

17880, 18652

3381, 6495

1788, 2648

7503, 10735

7157, 7467

258, 303

671, 1228

2962, 3363

17712, 17856

1250, 1464

1480, 1723

2673, 2927

20,826

133,513

46063

Discharge summary

report

Admission Date: [**2177-2-4**] Discharge Date: [**2177-2-7**] Date of Birth: [**2110-4-26**] Sex: F Service: UROLOGY Allergies: Penicillins / Sulfonamides / Percocet Attending:[**First Name3 (LF) 5272**] Chief Complaint: nephrolithiasis. Major Surgical or Invasive Procedure: 1. Percutaneous nephrolithotomy. 2. Antegrade ureteral stent placement. History of Present Illness: This is a 66 year old female who was found to have high volume left sided nephrolithiasis. Past Medical History: Arthritis Anxiety hyperlipidemia Ovarian cyst melanoma s/p excision s/p appy Social History: 40 pack/year smoking daily EtOH Family History: non-contributory Physical Exam: On Discharge 98.6 100 106/66 18 98% RA NAD, Anxious RRR slightly decreased BS in LLL otherwise clear soft, NT/ND no LE C/C/E nephrostomy site- c/d/i Pertinent Results: [**2177-2-5**] 03:03AM BLOOD WBC-11.4*# RBC-3.96* Hgb-12.2 Hct-35.9* MCV-91 MCH-30.8 MCHC-33.9 RDW-12.5 Plt Ct-229 [**2177-2-5**] 03:03AM BLOOD Glucose-167* UreaN-17 Creat-0.7 Na-139 K-4.1 Cl-105 HCO3-23 AnGap-15 [**2177-2-5**] 03:03AM BLOOD CK-MB-4 cTropnT-<0.01 [**2177-2-4**] 05:32PM BLOOD Type-ART FiO2-100 pO2-110* pCO2-55* pH-7.26* calHCO3-26 Base XS--2 AADO2-547 REQ O2-91 Intubat-NOT INTUBA [**2177-2-4**] 05:32PM BLOOD freeCa-1.19 . . . CXR ([**2-4**]) Low inspiratory volumes. Left retrocardiac opacity, which may represent atelectasis, aspiration, or developing pneumonia. . CXR ([**2-5**]) Lung volumes are low, but improved since [**2-4**], with only mild atelectasis at the base of the right lung. There is no pneumothorax or appreciable pleural effusion. Heart size is normal. Upper lungs show vascular engorgement, but are otherwise clear. Brief Hospital Course: Pt tolerated procedure well and 22 of her 25 stones were removed. Left in place: a 6 x 26 double J ureteral stent with the curl confirmed to be in the bladder and in the renal pelvis fluoroscopically and a #24 French Foley as a left nephrostomy tube. Stones were sent for pathological exam. Pt was started on clidamycin, which was continued until d/c. . In the PACU the pt experienced respiratory distress and desaturated to 58%, became cyanotic and unresponsive. Anesthesia was called and pt was ventilated. Narcan was administered, ABG and EKG sent. O2 sat returned quickly to 95% and spontaneous breathing and responsiveness returned. HR and BP remained stable and appropriate throughout. At post-op check, pt was comfortable, A&O and saturating in the high 90's on nasal canula. It was thought the patient may have been volume overloaded and diuresis with lasix was started. Pt received lasix 20 IV x2. She was transferred to [**Hospital Unit Name 153**] for monitoring overnight. . POD1 pt did well was weaned off supp. O2 and was comfortable. Nephrostomy tube was clamped and Foley was removed. The pt was transferred to the floor. . POD2 pt comfortable on room air with good sats. Nephrostomy tube was removed. Pt had leakage from site overnight . POD3 one 3-0 ethilon suture was placed to close the drain site. Pt was comfortable, tolerating PO and ambulating. She was afebrile and saturating well. Pt was d/c'd home in good condition. She will follow up for stent removal, suture removal and plan for removing remaining stones. Medications on Admission: Lipitor 20 QD Ativan 1 prn vitamins Discharge Medications: Lipitor 20 QD Ativan 1 prn vitamins 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: nephrolithiasis Discharge Condition: Good Discharge Instructions: Resume your regular medications. Take all new medications as directed. Do not drive while taking narcotics. You may shower, allow water to run over the wound. Don't scrub the wound. Pat dry. Do not take a bath or swim untill after follow-up. Please call your doctor or return to the ER if you experience: -Fever (> 101.4) -Inability to eat/drink or persistant vomiting -Increased pain -Inability to urinate -Bleeding -Other symptoms concerning to you Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in one week. Call his office, ([**Telephone/Fax (1) 7707**], to arrange the appointment.

[ "300.00", "518.5", "592.0", "V10.82", "493.90", "272.4" ]

icd9cm

[ [ [] ] ]

[ "55.01", "00.33", "56.0", "97.61", "59.8" ]

icd9pcs

[ [ [] ] ]

3638, 3695

1766, 3320

312, 388

3754, 3761

885, 1743

4267, 4412

675, 693

3406, 3615

3716, 3733

3346, 3383

3785, 4244

708, 866

256, 274

416, 508

530, 609

625, 659

83,520

136,892

8820

Discharge summary

report

Admission Date: [**2181-7-28**] Discharge Date: [**2181-8-4**] Date of Birth: [**2141-6-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: heat stroke Major Surgical or Invasive Procedure: -central venous line -intubated from [**Date range (1) 30784**] History of Present Illness: Mr. [**Known lastname 30785**] is a 40 year old man with no significant [**Hospital **] transferred from an outside hospital with hyperthermia to 108 and question of a seizure while running in a road race. During the race, he reportedly collapsed and was found to have temperature 107.6. He was taken to [**Hospital3 10310**] where he was paralyzed with vecuronium, intubated for airway protection with 8.0 ETT and cooled with ice packs, 4L cooled NS and NG lavage as well as bladder irrigation. He had tachycardia to 170 and received adenosine x 2 with no response. Cardiology was consulted but felt rhythm was c/w sinus tach. R SC CVL placed and he had neg head CT. Temp decreased to 102.7 and he was med-flighted here for further management. En route, he was shaking and was given 9mg IV ativan for concern for seizure which was later felt to be secondary to chills and improved with removal of cool blanket. . In the ED, initial vs were: T38.6 P105 BP 111/65 R18 SpO2100%. He remained cool at 102 and continued to have shaking but was not felt to be seizing. ECG revealed sinus tach at 105. He was given fentanyl and versed for sedation and he was given 4L NS for hypotension to 90s. Labs were remarkable for Cr 1.6, UA with lg blood and 0-2 RBC, INR 1.2, lactate 3.1->2.8, CK 590, WBC 13 with 14% bands. ABG 7.33/47/228 on AC 550x18 100% PEEP 5. VS prior to transfer:38.8 99 99/63 20 100%. Past Medical History: Nasal fx s/p closed reduction [**2171**] Back injury s/p MVC, receives cortisone injections s/p umbilical hernia repair Social History: Lives with wife and 2 children (2.5, 3.5 years old, both with sensory processing disorders). Software engineer. No tobacco or drug use. Drinks 1-2 beers a couple times per week. Increased stress at home. Family History: Mother died of multiple myeloma. Father with HTN, arthritis. No other medical illness in family. Physical Exam: On discharge: O: Tc 99.4 Tm 100.4 BP 132/86 HR 82 RR 97 %RA (130-144/80-90), 82-85, 20, 97-100%RA 8H I/O: 1000/950 24H I/O: [780 + 200cc/hr]/1550 GENERAL: pt lying on back sleeping, NAD HEENT: NCAT, EOMI, PERRL, neck supple, oropharynx clear CARDIAC: RRR, no M/R/G, normal S1, S2 LUNG: CTAB, scattered bibasilar crackles, no wheezes or rhonchi appreciated ABDOMEN: Soft, nontender, nondistended BS+, no HSM EXT: W/W/P, no C/C, 2+ pulses in DP's bilaterally, b/l feet 1+ non-pitting edema (stable) R>L NEURO: Alert and orientedx3, responds appropriately, strength, tone and senstation equal bilaterally DERM: warm, sweaty (esp back), intact except for scrape on L knee and R shin Pertinent Results: On discharge: [**2181-8-4**] 05:33AM BLOOD WBC-7.3 RBC-4.05* Hgb-11.9* Hct-33.9* MCV-84 MCH-29.3 MCHC-35.0 RDW-14.4 Plt Ct-303 [**2181-8-4**] 05:33AM BLOOD Fibrino-530* [**2181-8-4**] 05:33AM BLOOD Glucose-95 UreaN-12 Creat-0.7 Na-141 K-3.4 Cl-108 HCO3-26 AnGap-10 [**2181-8-4**] 05:33AM BLOOD ALT-442* AST-265* LD(LDH)-322* CK(CPK)-5321* AlkPhos-94 TotBili-0.9 DirBili-0.5* IndBili-0.4 [**2181-8-4**] 05:33AM BLOOD Albumin-2.8* Calcium-7.8* Phos-3.6 Mg-1.9 Brief Hospital Course: #. Rhabdo/ [**Last Name (un) **]: Cr back down to within normal limits. Cr elevation was likely secondary to mild rhabdo and hypovolemia vs ATN. Patient received IV NS @ 200cc/hr. CK reached a peak of 15000s, but trended down to 5000s on discharge. . #. Hyperthermia/Heat stroke: Most likely patient had exertional heat stroke related to running on hot day in context of nortriptyline which can predispose toward heat stroke and may interfere w/ perspiration due to anticholinergic effects. No clear endocrinologic or toxic insults. No longer being actively cooled and temps have been low-grade off antibiotics. Had multisystem organ dysfunction in the context of this resolving syndrome. We held nortriptyline and gave the patient acetaminophen at less than the maximum dose . #. Hypoxia: Patient states that his breathing has improved and denies any shortness of breath. We monitored him for symptoms of fluid overload and there was no need for diuresis. Patient used incentive spirometry as instructed. . #. Transaminitis/acute hepatitis: Resolving. Likely due to heat injury and syndrome like shock liver. Although it is documented that the patient was hypotensive to SBP of 90, it is likely that pt was more hypotensive at some point and it was not recorded. No reason to suspect acute viral hepatitis or toxic or medication mediated injury. Transaminases, coags and total bilirubin continue to trend down. . #. Coagulopathy: Resolved. INR and PTT were elevated with low PLT, low fibrinogen and elevated FDP consistent with early DIC. Smear did not show schistocytes, however, and parameteres now steadily improving. Fibrinogen still > 500 and INR improving. There was no need for blood transfusion. . #. Thrombocytopenia: Resolved. Was likely secondary to acute illness and mild DIC; possibly with an element of sequestration given likely acute hepatitis. Smear neg for schistocytes. . #. Hypotension: Resolved. Likely secondary to multisystem dysfunction due to heat injury at presentation as well as vascular leak and likely hypovolemia. Pt's lowest recorded SBP in the 90s although it is likely that he dropped lower at some point given the extent of the systematic dysfunction. . #. Altered mental status: Resolved. Pt was intially quite altered though improves as distance from sedation increases. Now fully oriented and appropriate. Patient is concerned about residual cognitive impairment from hitting his head when he lost consciousness. He had an inpatient occupational therapy consult and will follow up as needed as an outpatient. . #. Leukocytosis: Leukocytosis and bandemia resolved. Waxing and [**Doctor Last Name 688**] bandemia early in course with other premature forms likely due to leukemoid reaction. No signs of acute infection. Final urine and blood cultures were negative. Medications on Admission: -Nortryptiline 25 mg qam and 50 mg qpm -MVI pack including fish oil, vitamin C, D, calcium -Gabapentin (prescribed but not taken) Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever. 2. Outpatient Lab Work Blood, To be collected on [**2181-8-10**]: CBC; Sodium; ALT; CK; Potassium; AST; Chloride; Alk Phos; Bicarbonate; Total Bili; Glucose; LD; BUN; Albumin; PT (includes INR); Creatinine; PTT; Calcium; Phosphate; Fibrinogen; Magnesium; Bilirubin, Direct Discharge Disposition: Home Discharge Diagnosis: hyperthermia rhabdomyolysis acute kidney injury hypoxia hypotension acute hepatitis disseminated intravascular coagulation altered mental status leukocytosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure treating you at [**Hospital1 1170**]. You were admitted for management of your episode of hyperthermia with subsequent muscle injury, kidney injury, shortness of breath, liver injury, blood count abnormalities, low blood pressure and altered mental status. You were treated with IV fluids and your laboratory abnormalities gradually resolved. No changes were made in your medications. Please have labs drawn when you see your primary doctor [**First Name (Titles) 2593**] [**Last Name (Titles) 30786**]. Followup Instructions: PCP [**Name Initial (PRE) **]: Friday, [**8-10**] at 11:45am Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 30787**]* Location: FAMILY MEDICINE ASSOCIATES Address: [**Location (un) 29112**], [**Location (un) 29113**],[**Numeric Identifier 29114**] Phone: [**Telephone/Fax (1) 29115**] *Your physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], is on vacation. Dr. [**Last Name (STitle) 30787**] will see you for this visit. Completed by:[**2181-8-5**]

[ "286.6", "992.0", "584.9", "E900.0", "V16.8", "728.88", "E001.1", "276.52", "287.5", "799.02", "570" ]

icd9cm

[ [ [] ] ]

[ "96.71", "38.91", "38.93" ]

icd9pcs

[ [ [] ] ]

6867, 6873

3490, 5691

324, 390

7075, 7075

3007, 3007

7775, 8274

2195, 2293

6474, 6844

6894, 7054

6319, 6451

7226, 7752

2308, 2308

3022, 3467

273, 286

418, 1814

7090, 7202

1836, 1958

1974, 2179

17,617

128,901

28339

Discharge summary

report

Admission Date: [**2194-11-14**] Discharge Date: [**2194-12-18**] Date of Birth: [**2116-1-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 9240**] Chief Complaint: melena Major Surgical or Invasive Procedure: Upper Endoscopy History of Present Illness: 78 yo arabic speaking M with CHF EF 25%, mechanical AVR, afib on coumadin, cirrhosis with ascites, CKD, and recent UGIB secondary to AVM s/p thermal therapy presents with melena. History obtained via arabic speaking RN. Pt reports lightheadedness yesterday but is otherwise asymptomatic. He reports black stools x7 days. He [**First Name3 (LF) **] CP, SOB, nausea, hematemesis, BRBPR, fever, chills, cough, orthopnea, or PND. He is able to walk 50-100 meters or climb 20 steps before getting short of breath. He reports increased abdominal girth over the last 3 days. During his last admission 4.5 liters of fluid was removed from his abdomen. HBV or HCV serologies were negative on last admission. . In the ED he was hemodynamically stable (BP 94/58, HR 70). His HCT was 21 down from 32 on [**10-30**]. INR elevated at 3.9. GI fellow felt melena was likely secondary to recent AVM in setting of elevated INR. NG lavage felt unecessary. He received 2 bags of FFP, 1 unit of PRBC, and 500 cc's of NS prior to transfer to the [**Hospital Unit Name 153**]. Past Medical History: - AF on coumadin - mechanical AVR (bileaflet aortic valve prosthesis) [**2182**] - h/o GIB secondary to AVM s/p thermal therapy [**2194-10-24**] (first GIB in [**Hospital1 46**] 6 months ago) - ascites (first noted 4 months ago) - CKD (baseline Cr unknown) - CHF EF 25% - ?clean cath prior to AVR Social History: -From [**Last Name (un) 26580**], Arabic speaking only. Occupation: Former farmer in [**Hospital1 46**]. Quit 30years ago, smoked 1ppd x24 years. [**Hospital1 4273**] any ETOH or other drug use hx. Family History: -M: Stomach CA -F:? -No known liver disease in the family Physical Exam: Tc 98.1 BP 95/66 HR 81 RR 20 Sat 99% RA Gen: well appearing male, NAD HENNT: dry MM, anicteric, EOMI, conjunctival palor Neck: no LAD, JVD elevated past ear CV: irregulary irregular, harsh systolic murmur heard best at apex radiating to axilla, loud S2 Lungs: crackles left base o/w clear Abd: distended, +fluid wave, nontender, +BS, liver span ~12 cm Ext: 3+ pitting edema, strong DP/PT pulses bilaterally Neuro: A&Ox3, moving all extremities Skin: no stigmata of chronic liver disease Pertinent Results: GI Bleeding Study: INTERPRETATION: Following intravenous injection of autologous red blood cells labeled with Tc-[**Age over 90 **]m, blood flow and dynamic images of the abdomen for 120 minutes were obtained. A left lateral view of the pelvis was also obtained. Blood flow images and dynamic blood pool images show no evidence of GI bleeding. IMPRESSION: No evidence of bleeding . ECG [**2194-11-14**]: Irregular, rate 81, slight left axis, low voltage, unchanged from prior . CXR [**2194-11-14**]: Cardiomegaly with mild CHF. . EGD [**2194-10-24**]: Normal mucosa in the esophagus, Normal mucosa in the duodenum, Angioectasia in the stomach body (thermal therapy), Erosions in the antrum and stomach body . Echo [**2194-10-24**]: 1. The left atrium is markedly dilated. The right atrium is markedly dilated. 2. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis. Overall left ventricular systolic function is severely depressed. 3. The right ventricular cavity is markedly dilated. There is severe global right ventricular free wall hypokinesis. 4. The ascending aorta is moderately dilated. 5. A bileaflet aortic valve prosthesis is present. The aortic prosthesis appears well seated, with normal leaflet motion and transvalvular gradients. 5. The mitral valve leaflets are mildly thickened. Severe (4+) mitral regurgitation is seen. 6. Severe [4+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. . ABD U/S [**2194-10-24**]: 1. Nodular echotexture of liver with irregular contour suggestive of cirrhosis. Moderate ascites. 2. Splenomegaly. 3. Patent portal, hepatic vein and hepatic arterial vessels with normal flow and waveform analysis. 4. Bilateral simple renal cysts. . MRI L spine [**2194-12-5**]: 1. No evidence of discitis, osteomyelitis, or epidural abscess. 2. Moderate spinal stenosis due to disc and facet degenerative changes at L3-4 level. 3. Mild spinal stenosis at L4-5 level with right foraminal disc herniation with cystic degeneration resulting in severe narrowing of the foramen, which could result in irritation of the right L4 nerve root. 4. Multilevel degenerative changes at other levels as described above. . TEE: The left atrium is moderately dilated. No mass/thrombus is seen in the left atrium or left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is dilated. LV systolic function appears depressed. Right ventricular chamber size is normal. Right ventricular systolic function appears depressed. There are simple atheroma in the aortic arch and the descending thoracic aorta. A bileaflet aortic valve prosthesis is present. The aortic prosthesis leaflets appear thickened but move normally without impaired excursion. No masses or vegetations are seen on the aortic, mitral or tricuspid valves. No aortic valve abscess is seen. Trace aortic regurgitation is seen. [The amount of regurgitation present is normal for this prosthetic aortic valve.] The mitral valve leaflets are mildly thickened. Mild to moderate ([**1-27**]+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: No endocarditis or aortic root abscess identified. . pMIBI: 1. Moderate, fixed inferior and inferolateral wall perfusion defects. 2. Left ventricular enlargement with global hypokinesis and depressed ejection fraction of 34%. . CT Chest: 1. Innumerable bilateral ground-glass nodules within the lungs. These opacities are visible on recent chest radiographs in [**Month (only) **], but were not appreciated on the prior chest radiograph of [**2194-11-14**]. These opacities may be related to pulmonary edema or infection,, less likely cryptogenic organizing pneumonia, in keeping with the patient's clinical history. Followup after treatment is recommended to ensure resolution. 2. Cardiomegaly. 3. Small right pleural effusion. 4. Ascending aorta measures 4.6 cm in diameter. 5. Evidence of cirrhosis, with ascites and a probably enlarged spleen. There is a hypodense liver lesion which is not characterized on this non-contrast exam. 6. Hypodense lesions of the upper poles of the kidneys, some of which represent cysts. Some of these lesions are not fully characterized. . RUQ U/S: 1) No evidence of biliary ductal dilatation. 2) Perhaps minimally echogenic liver with a small to moderate amount of ascites, consistent with the given history of cirrhosis. 3) Right simple renal cysts. . Brief Hospital Course: # GIB: In setting of elevated INR likely secondary to known AVM treated 2 wks ago with thermal therapy. EGD on [**2194-11-15**] showed nonbleeding ulcer and AVM. Negative tagged RBC scan on [**2194-11-17**]. Patient is s/p capsule study which showed active bleeding in duodenum but no source identified. Repeat enteroscopy performed with 2 AVMS cauterized in small bowel. From GI perspective, pt with multiple AVMs who will likely be transfusion dependent as these AVMs will rebleed as patient is on anticoag. All of this was discussed with patient and his son. [**Name (NI) 6196**] daily. As rebled, started on estrogen (though data on this is limited). Hct remained stable on discharge, he will have his CBC rechecked on Monday. . # CHF: Patient with very poor EF 25% and mild failure on chest xrays secondary to blood transfusions and volume resuscitation. Initially, on lasix and spironolactone. CHF service consulted and recommended started digoxin, stopping spironolactone. Pt was diuresed with IV lasix 40mg [**Hospital1 **] with effect. His creat increased on [**11-20**] from 2.2 to 2.6 so lasix held. Restarted on lower dose on [**12-14**]. Cr remained stable on discharge. Will have Cr rechecked on Monday. . # Non-sustainted VT: Patient with long runs (6-38 beats) of asymptomatic VT. - Per EP recs, no ICD indicated as inpatient, will call for follow up appointment with Dr. [**Last Name (STitle) **] - Beta blockade - Aggressive lytes repletions . # MRSA bacteremia: felt to be due to source from hand wound. No other clear sources. TEE was negative for endocarditis, was seen by ID and recommended treatment empirically for 4 weeks and f/u in [**Hospital **] clinic. . # Nonischemic dilated cardiomyopathy (EF 25%). - Metoprolol, Lasix, dig - strict I/O's - No ICD indicated at this point, per recent EP consult . # Mechanical AVR: - Anticoagulation with heparin and coumadin. . # lip hematoma: Pt. developed rapidly enlarging hematoma on his lower lip with overlying necrotic tissue. He was seen by both surgery and dermatology who felt there was no need for intervention. Recommended vaseline and warm compresses and this will eventually slough off. Lesion remained stable on discharge. . # Ascites: Patient is s/p 4.5L paracentesis early in admission. Got albumin after procedure, no complications. Diuresis as above. . # CKD. Cr baseline 2.0. Cr up to 2.6 but stable on d/c, follow up Cr Monday. - On admission, creatinine has varied based on diuresis. . # Afib. Rate well controlled. - Continued Metoprolol - anticoagulation. . # Communication: Son [**Name (NI) 66224**] - [**Telephone/Fax (1) 68792**] . # Code: Full code Medications on Admission: 1. Furosemide 40 mg PO DAILY 2. Warfarin 5 mg PO at bedtime 3. Lisinopril 5 mg PO DAILY 4. Pantoprazole 40 mg PO Q24H 5. Metoprolol 25 mg Sustained Release PO DAILY Discharge Medications: 1. Conjugated Estrogens 0.625 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. 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* 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime: Please have your INR checked on [**12-19**] to have your coumadin dose adjusted. Disp:*30 Tablet(s)* Refills:*2* 5. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 6. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed. Disp:*qs 1 month* Refills:*2* 7. Vancomycin 500 mg Recon Soln Sig: Five Hundred (500) mg Intravenous Q 24H (Every 24 Hours): day 1 = [**2194-12-2**], please continue until at least [**2195-1-2**]. Disp:*qs 3 weeks* Refills:*0* 8. Outpatient Lab Work Please check INR [**2194-12-19**] to have coumadin dose adjusted for AVR goal [**2-28**]. 9. Outpatient Lab Work Please have CBC with diff, Cr, vanco level checked on [**12-22**] and faxed to Dr. [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 1419**]. 10. Chest CT without contrast Please call [**Telephone/Fax (1) 327**] on [**2194-12-19**] to schedule your Chest CT preferrably on [**12-31**] just before your follow up appointment with Dr. [**Last Name (STitle) **]. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: MRSA Bacteremia Systolic CHF Acute Renal Failure Gastrointestinal Bleeding Atrial Fibrillation Lip Hematoma Non Sustained Ventricular Tachycardia Discharge Condition: stable Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2L Please take your medications as listed below. Please make your follow up visits as listed below. Call your doctor if you develop fever, shortness of breath, chest pain, lightheadedness, or other concerning symptoms. Followup Instructions: 1. Please follow up with your PCP in the next 1-2 weeks. You will need to discuss when to restart your lasix and lisinopril as these were held due to poor kidney function. 2. Please have your coumadin level (INR) checked on Friday so that your coumadin dose can be adjusted. 3. Please have your lab work checked on Monday and faxed to Dr. [**Last Name (STitle) **] (of infectious diseases) at [**Telephone/Fax (1) 68793**]. 4. Please call [**Telephone/Fax (1) 327**] to schedule your follow up chest CT on [**12-31**] (or preferrably before the 8th when you will see Dr. [**Last Name (STitle) **] 5. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5866**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2195-1-2**] 10:30 6. Please also follow up with Dr. [**Last Name (STitle) 2357**] (regarding your arrythmia) to see if you need an ICD implanted. Call [**Telephone/Fax (1) 285**] for an appointment.

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icd9cm

[ [ [] ] ]

[ "38.93", "45.43", "54.91", "45.13", "88.72", "99.04" ]

icd9pcs

[ [ [] ] ]

11621, 11679

7175, 9827

324, 342

11869, 11878

2561, 7152

12264, 13204

1979, 2038

10043, 11598

11700, 11848

9853, 10020

11902, 12241

2053, 2542

278, 286

370, 1427

1449, 1747

1763, 1963

18,538

156,042

17089

Discharge summary

report

Admission Date: [**2157-5-19**] Discharge Date:[**2157-6-8**] Date of Birth: [**2094-4-19**] Sex: F Service: SICU HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 48035**] is a transfer from [**Hospital1 1474**] with respiratory distress. Ms. [**Known lastname 48035**] is a 63-year-old woman with history of heavy tobacco and chronic obstructive pulmonary disease, question of asthma diagnosed one year ago who was in her usual state of health until late [**2157-2-12**] when she presented with back pain and nasal congestion. Her initial chest x-ray showed a right lower lobe infiltrate. She was treated with pneumonia with an antibiotic course. She subsequently had continued respiratory and back symptoms and was treated with several other antibiotic courses without any improvement. Follow-up chest x-rays revealed increased infiltrates in the right upper lobe and posterior right hilum. She went on to have a chest CT which showed a 2 cm pleural-based mass and hilar and mediastinal lymphadenopathy and diagnosis of bronchogenic carcinoma was entertained. She then underwent a bronchoscopy which revealed no endobronchial lesions and a nondiagnostic biopsy. She then underwent CT guided needle biopsy of the right middle lobe which again was nondiagnostic. Over the next several months she continued to have decline in her respiratory symptoms, was again given several antibiotic courses without effect and then presented to an outside hospital on [**2157-5-13**], with increasing temperatures to 102.5 degrees, elevated white count and severe shortness of breath. Her initial chest x-ray revealed a large right-sided density with effusion. At the outside hospital she was treated with ceftriaxone and azithromycin, was admitted. She continued to have worsening respiratory distress and was transferred to the ICU there. Repeat CT scan revealed extensive right-sided infiltrates and a new left upper lobe infiltrate. At that time she had a blood gas of 97/19/86/98 and was intubated for both hypercarbic and hypoxic respiratory failure. Later in that course she was bronch'd and repeat bronchoscopy revealed thick secretions but no lesions. Biopsy again was done which was negative. She continued to have temperature spikes and it was decided for her to go to VATS. At VATS, however, she had thick adhesive pleuritis and, therefore, the procedure was converted to open lung biopsy. It was a right mini thoracotomy with wedge biopsy which initial frozen section revealed organizing pneumonia. Due to patient's worsening oxygenation and higher oxygen requirements, the patient was transferred to [**Hospital1 1444**] for further management. Of note, the patient had a right chest tube that was placed at the time of mini thoracotomy and had a subclavian and radial A-line placed as well at the time of her procedure. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease and has been on home oxygen for the last several weeks. 2. Hypertension. 3. Anemia. 4. Heavy ex-tobacco, quit ten years ago. MEDICATIONS AT HOME: 1. Neurontin 300 t.i.d. 2. Lipitor 20. 3. Celexa 20. 4. Advair 250/50. 5. Albuterol MDI. 6. Motrin p.r.n. 7. Vicodin p.r.n. 8. Ativan p.r.n. MEDICATIONS ON TRANSFER: 1. Ceftriaxone 1 g IV q. day. 2. Erythromycin 500 IV q. day. 3. Vancomycin 1 g IV q. day. 4. Pepcid 20 IV b.i.d. 5. Neurontin 300 t.i.d. 6. Lipitor 40. 7. Advair. 8. Atrovent. 9. Albuterol. 10. Ultracal tube feeds. SOCIAL HISTORY: She lives alone in [**Hospital1 1474**]. Has three daughters and one son who have close contact with her. She is a former telephone operator. No asbestos exposure. She smoked 30 years times two packs a day. Quit ten years ago. PHYSICAL EXAMINATION ON ADMISSION: Her temperature was 101.9 degrees, heart rate 100-120, blood pressure 80-100/40-50. Settings: She was on AC at 800 x 14, FiO2 80%, PEEP of 10, PIP 33, __ of 30 and her blood gas was 7.38/49/67. In general, she was intubated, sedated but opened her eyes to voice. Pupils were reactive. She had an endotracheal tube in place. She had diffuse coarse rales bilaterally, right greater than left. Right subclavian line intact. Cardiac regular. Abdomen benign. Extremities: She had [**12-16**]+ pedal edema. Left radial A-line intact. Neuro: She was sedated. Skin: She had a bullous [**Last Name (un) **]-sized lesion on the dorsum of her right foot with surrounding erythema. LABORATORY: Initial white count was 17.5 which was showing 81 polys, 4 bands and 12% eosinophils. H&H: 9.3/28. Platelet count 465,000. Seven within normal limits. ALT, AST normal. Alk phos 430. Total bilirubin 1.4. LDH 191, INR 1.5, PT 15.2, PTT 30.0. RADIOLOGY: Initial chest x-ray here revealed a right lower and middle lobe infiltrate and a left lower lobe opacity. She had a right chest tube in place. No evidence of pneumothorax. ELECTROCARDIOGRAM: Initial EKG was sinus tachycardia at 118. No acute changes. HOSPITAL COURSE: 1. Hypoxic respiratory failure: Patient initially admitted with bilateral pulmonary processes unresponsive to antibiotics and eventually undergone VATS at an outside hospital with a diagnosis consistent with organizing pneumonia. A question of BOOP was entertained given that patient had a process that was not responsive to traditional antibiotics. The diagnosis of atypical infection, vasculitis, sarcoid, tuberculosis and ARDS was entertained. Patient had a workup including a sed rate, [**Doctor First Name **], ANCA and rheumatoid factor. In addition, multiple serologies were sent including AFB. Patient's sed rate came back at 11. Decision was made to empirically start the patient on high dose steroids. The patient was started on Solu-Medrol 125 times one and then 80 IV t.i.d. The patient was also continued on antibiotics for several days. All culture data came back negative initially. Patient's sed rate came back at 130. Patient had a positive [**Doctor First Name **] initially at 1:40. Patient's rheumatoid factor also had a low positive factor. Patient continued to improve on intravenous steroids and several days into her course, patient's C-ANCA came back positive which is consistent with a vasculitis. Then Cytoxan 150 mg p.o. q. day was added to her regimen of high dose steroids. Again, over the course of several days the patient's FiO2 requirement was able to be weaned to 40%, after several days, approximately hospital day ten. On [**5-28**], hospital day 10, patient was successfully extubated after a prolonged course on the vent and patient maintained off the vent. Again, Rheumatology was asked to follow the patient given the ANCA even as the initial peripheral eosinophilia history of asthma and now bilateral infiltrates, the question of [**Last Name (un) 48036**]-[**Doctor Last Name 3532**] syndrome versus Wegener's granulomatosis was entertained. On further history, patient gave a history of right lower extremity neuropathy and further studies were done including nerve conduction and EMG which revealed a mononeuritis multiplex. The patient then went on to a sterile nerve biopsy which again revealed a small vessel vasculitis confirming a diagnosis of either [**Last Name (un) 48036**]-[**Doctor Last Name 3532**] or Wegener's. The patient's steroids were eventually tapered after several days from 80 IV t.i.d. down to prednisone 80 q. day and finally down to 60 q. day and patient will be discharged on a prolonged course of Cytoxan 150 q. day and prednisone 60 q. day. After patient was extubated for several days she was eventually transferred to the floor off all antibiotics, however, several days into her stay on the floor patient had transient desaturations. Upon discharge from the ICU patient's saturations were 93-96% on five liters, however, on the floor patient had desaturations to the mid 80's requiring temporary nonrebreather with suctioning and chest PT. Patient was able to cough up several blood tinged mucus plugs. Patient also had an elevation in her white count up to 13-20 during these episodes and, due to subsequent desaturations, she was transferred back to the ICU where she was pan cultured and apparently started on vancomycin, Zosyn and Levaquin for nosocomial pneumonia. After several days of antibiotics her saturations improved back to her baseline around 93-96% on four to five liters. Sputum cultures eventually grew back positive MRSA, methicillin-resistant Staphylococcus aureus and rare Pseudomonas as well as heavy alpha Strep and patient will continue a prolonged course of intravenous vancomycin and p.o. Levaquin for empiric pneumonia, however, Pseudomonas sensitivities need to be followed. As she is ______________ resistant, she may need further adjustments in her antibiotic medications. 2. Patient with history of chronic obstructive pulmonary disease probably in the setting of underlying lung dysfunction. Her pulmonary vasculitis caused a more aggressive course. Patient was treated with high dose steroids initially as well as Atrovent and albuterol nebs. Oxygen was attempted to be weaned, however, despite a prolonged course, patient continues on four to five liters. Patient may need continued supplemental oxygen upon discharge. Tobacco cessation was encouraged. 3. Patient with history of right chest tube. The chest tube was placed initially to suction, however, with CT Surgery input, chest tube was changed to water seal for several days and when no increase in pneumothorax chest tube was pulled. No further evidence of pneumothorax. 4. Hypotension. Patient initially admitted with systolics in the 80's. She was transiently on a dopamine drip, however, was weaned off rather quickly. She was given fluid boluses as need and all culture data initially came back negative. As sedation was weaned, her blood pressure improved and she maintained ____ greater than 70. 5. Hypertension. Following this initial hypotensive episode, patient became quite hypertensive on her steroid regimen. She has this baseline history of hypertensive. She was initially started on hydralazine for temporary relief of her blood pressure. As her creatinine remained normal she was transitioned to an ACE inhibitor, titrated up on captopril and eventually changed to a standing dose of Zestril 40 mg p.o. q. day and hydrochlorothiazide 25 was added for additional blood pressure support. Patient with good blood pressures upon discharge. 6. Anemia. Patient initially presented with an hematocrit between 26 and 28. Anemia workup revealed a severe iron deficiency. She had temporary episodes of occult blood positive stools as well as minor vaginal bleeding, however, both of these have normalized with the addition of proton pump inhibitor and patient is not on any anticoagulation. She was started on supplemental iron pills, however, given her history of OB positive stools and vaginal bleeding in a postmenopausal woman, the patient will need follow up both with Gastroenterology and with Gynecology for further workup of her iron deficiency. 7. Prophylaxis. The patient was started on a high dose of steroids and Cytoxan. Given this high dose of steroids she was initially also started on an H2 blocker as well as calcium and vitamin B. She was initially on subcu heparin. She also was started on Bactrim Double Strength three times a week for PCP [**Name Initial (PRE) 1102**]. Prior to discharge Fosamax was also added 5 mg p.o. q. day for additional osteoporosis protection. The patient will be discharged on this regimen of prophylactic medicines. She was tolerating a full diet upon discharge. 8. History of right ankle fracture. She sustained a right ankle fracture several months prior to her admission. In the setting of a new neuropathy her right ankle fracture was imaged here which revealed a well-healed lateral fibular fracture. Orthopedics was consulted who deemed that the fracture was well-healed and no further bracing was necessary. She would be able to maintain full weightbearing on her lower extremity as tolerated. 9. Neuropathy. Given this patient with this history of accelerated neuropathy, again, Neurology was consulted. EMG and nerve conduction studies revealed a mononeuritis multiplex, more severe on the right lower extremity. Further sural nerve and muscle biopsies confirmed a small artery vasculitis. After receiving several days of Cytoxan and steroids, she did gain some strength in her lower extremity function, more on the left, but towards the end of her hospitalization was able to move toes on her right side. She still is severely debilitated and will need aggressive physical therapy prior to returning to her previous level of function. DISCHARGE DIAGNOSES: 1. C-ANCA vasculitis, ? [**Last Name (un) 48036**]-[**Doctor Last Name 3532**] syndrome, ? Wegener's granulomatosis. 2. Mononeuritis multiplex. 3. Methicillin-resistant Staphylococcus aureus/Pseudomonas nosocomial pneumonia. 4. Chronic obstructive pulmonary disease. 5. Hypertension. 6. Iron deficiency anemia. 7. Depression. 8. Vaginal bleeding. 9. Occult blood positive stools. 10. Elevated sugars on steroids. DISCHARGE MEDICATIONS: Will include: 1. Cytoxan 150 mg p.o. q. day. 2. Prednisone 60 mg p.o. q. day. 3. Lisinopril 40 mg p.o. q. day. 4. Hydrochlorothiazide 25 mg p.o. q. day. 5. _________ 20 mg p.o. q. day. 6. Iron 325 t.i.d. 7. Celexa 20 q. day. 8. Regular insulin sliding scale. 9. Bactrim Double Strength t.i.w. 10. Calcium 500 t.i.d. 11. Vitamin D 400 q. day. 12. Albuterol and Atrovent nebs. 13. Subcu heparin. 14. Colace. 15. Senna. DISCHARGE INSTRUCTIONS: The patient will be discharged to rehabilitation for further aggressive physical therapy. The patient will need follow up with her primary care physician as well as with a new rheumatologist at [**Hospital1 1474**]. The patient will need supplemental oxygen prior to discharge and she will need a prolonged course of Cytoxan and prednisone as dictated by her private rheumatologist. DR [**First Name (STitle) **] LI 12.735 Dictated By:[**Name8 (MD) 2439**] MEDQUIST36 D: [**2157-6-7**] 15:41 T: [**2157-6-7**] 16:16 JOB#: [**Job Number 48037**]

[ "401.9", "493.20", "280.9", "446.4", "516.8", "482.41", "577.0", "354.5", "518.81" ]

icd9cm

[ [ [] ] ]

[ "04.12", "96.72", "83.21", "96.04" ]

icd9pcs

[ [ [] ] ]

12755, 13178

13202, 13629

4995, 12734

13654, 14228

3079, 3229

163, 2865

3765, 4978

3254, 3479

2887, 3058

3496, 3750

18,379

127,728

14124

Discharge summary

report

Admission Date: [**2102-12-26**] Discharge Date: [**2103-1-20**] Date of Birth: [**2030-9-8**] Sex: F Service: ADMISSION DIAGNOSIS: Coronary artery disease. DISCHARGE DIAGNOSIS: 1. Coronary artery disease. 2. Status post coronary artery bypass graft times four. 3. Rapid atrial fibrillation. 4. Wound breakdown, status post left pectoral flap advancement. 5. Tachy-brady syndrome. HISTORY OF THE PRESENT ILLNESS: The patient is a 72-year-old woman status post cardiac catheterization with multiple small MIs and PTCA performed at [**Hospital3 2358**] in the early 90s. She now presents with chest pressure on exertion. She had a positive ETT on [**2102-11-8**]. The patient had been seen in clinic and now returns as a preoperative admission for coronary artery bypass grafting. PAST MEDICAL HISTORY: 1. Hypertension. 2. Diabetes mellitus. 3. Bilateral hip osteoarthritis. 4. Peripheral neuropathy. 5. Status post right CEA in [**2094**]. 6. Urinary incontinence. 7. Hypercholesterolemia. 8. Status post TAH. 9. Status post cataract surgery. MEDICATIONS ON ADMISSION: 1. Aspirin q.d. 2. Verapamil 120 mg q.d. 3. Coumadin 5 mg q.d., stopped [**2102-11-28**]. 4. Isosorbide 20 mg b.i.d. 5. Lipitor 10 mg q.d. 6. Lisinopril 10 mg q.d. 7. Niacin 250 mg q.d. 8. Ibuprofen 600 mg q.i.d. 9. Tramadol 50-100 mg q. six hours p.r.n. 10. Plavix 75 mg q.d. 11. NPH insulin 20 q.a.m./8 q.p.m. 12. Regular insulin 10 q.a.m./4 q.p.m. ALLERGIES: The patient is allergic to Detrol, Procardia. PHYSICAL EXAMINATION ON ADMISSION: General: The patient was in no acute distress. Vital signs: The patient's vital signs were stable, afebrile. HEENT: Normocephalic, atraumatic. EOMI, PERRL, anicteric. The throat was clear. The neck was supple, midline. Chest: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm without murmur, rub, or gallop. Notable for left carotid bruit. Abdomen: Soft, nontender, nondistended. Extremities: Warm, noncyanotic, nonedematous times four. Neurological: Grossly intact. HOSPITAL COURSE: The patient was admitted for coronary artery bypass grafting times four. The procedure was performed on [**2102-12-26**] and complicated in the immediate postoperative period by bleeding. The patient was taken back to the Operating Room for reexploration. A mammary artery bleeder was identified and controlled. Subsequent to this, the patient was taken to the ICU for close monitoring. The patient was transfused 8 units of packed red blood cells, 2 in the OR, 9 units of fresh frozen plasma, 3 units of platelets, 1 unit of cryo. In the ICU, the patient was extubated without difficulty on [**2102-12-28**]. An episode of rapid atrial fibrillation with conversion back to normal sinus rhythm with 5 mg of IV Lopressor and 150 mg IV Amiodarone. On postoperative day number four, the patient was transferred to the floor. On postoperative day number five, the patient went into sustained rapid atrial fibrillation but was hemodynamically stable, converted to normal sinus after 10 mg of IV Lopressor and 400 mg of p.o. Amiodarone. Anticoagulation was then begun for recurrent atrial fibrillation episodes. The sternal wound was seen to be draining serosanguinous for a number of days and Plastic Surgery was consulted on postoperative day number 13. The patient was deemed a good candidate for flap procedure for wound breakdown and transfused 4 units of fresh frozen platelets preoperative. A pectoral advancement flap was performed on postoperative day number 14. Wound cultures sent at that time ultimately grew coagulase-negative Staphylococcus and probable Enterococcus from the superficial swab. The deep swab remained without growth. The patient was maintained on Levaquin, vancomycin and Flagyl subsequent to the flap procedure. The patient was monitored in the ICU and had an uneventful course. Subsequently, the patient was again transferred to the floor on postoperative day number 19 with the left IJ central venous line noted to be nonfunctioning. This line was changed over a wire with an x-ray showing coiling of the new CVL, probably secondary to pectoral flap. The CVL was then discontinued and re-sighted to the right subclavian. The patient then had an episode of sinus bradycardia which was evaluated by Cardiology. They thought this to be part of a "tachy/brady syndrome". They recommended no changes in management except to avoid negative dromotropic and negative chronotropic drugs. Lopressor was stopped. The patient, after this, had an uneventful course and was maintained with wound dressing changes per Plastics and JP drains for drainage. The JP drains were discontinued and prior to discharge, a right PICC line was placed and the CVL was discontinued. The patient had some difficulty with constipation but did move his bowels the evening prior to discharge. The patient was tolerating a regular diet and adequate pain control on p.o. pain medications. DISCHARGE CONDITION: Good. DISPOSITION: Rehabilitation facility. DIET: Cardiac and diabetic. DISCHARGE MEDICATIONS: 1. Percocet 5/325 one to two q. four hours p.r.n. 2. Colace 100 mg b.i.d. 3. Aspirin 325 mg q.d. 4. Regular insulin sliding scale. 5. Tylenol p.r.n. 6. Amiodarone 400 mg b.i.d. 7. Lipitor 10 mg q.d. 8. Lasix 20 mg q.d. times seven days. 9. Potassium chloride 20 mEq q.d. times seven days. 10. Lactulose 30 ml q. eight hours p.r.n. 11. Dulcolax 10 mg b.i.d. p.r.n. 12. Vancomycin 1 gram IV q. 18 hours. DISCHARGE INSTRUCTIONS: The patient is to continue dry sterile dressing changes to wound b.i.d. PICC line care per protocol. The patient should have an aggressive bowel regimen, and may require Fleets enemas due to long-standing constipation. Vancomycin levels should be checked around the third dose and every week after documented therapeutic levels. The patient should continue physical therapy with strengthening and respiratory therapy including incentive spirometry. FOLLOW-UP: The patient should follow-up with Dr. [**Last Name (STitle) 13797**] of Plastic Surgery in one week. The patient should follow-up with the cardiologist in one to two weeks for assessment for the need of diuretics as well as adjustment of other cardiac medications. The patient should follow-up with Dr. [**Last Name (STitle) 70**] in four weeks time. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (NamePattern1) 5745**] MEDQUIST36 D: [**2103-1-20**] 06:14 T: [**2103-1-20**] 18:29 JOB#: [**Job Number 42084**]

[ "807.2", "427.31", "998.59", "998.11", "414.01", "E878.8", "998.31", "427.81", "401.9" ]

icd9cm

[ [ [] ] ]

[ "36.15", "39.61", "36.13", "34.03", "83.82", "86.72", "39.31", "78.51" ]

icd9pcs

[ [ [] ] ]

5026, 5103

5126, 5538

200, 812

1111, 1552

2094, 5004

5563, 6687

153, 179

1567, 2076

834, 1085

4,637

138,467

6592

Discharge summary

report

Admission Date: [**2192-9-12**] Discharge Date: [**2192-9-16**] Date of Birth: [**2128-11-15**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: left BKA sore, malaise, n/v Major Surgical or Invasive Procedure: None. History of Present Illness: Briefly, this is a 63 yo M w/DM2, s/p left BKA, h/o multiple episodes of cellulitis now with a non-healing LBKA sore x 3 weeks. He was started on Keflex with intial improvement, but he became more lethargic and developed malaise, body aches, n/v, and intractable hiccups. On a f/u visit to his PCP, [**Name10 (NameIs) 25194**] was noted and he was sent to the ED. . Patient has been non-compliant with his Diabetes medications FS x 1 month. No h/o previous admissions for DKA. He has had recurrent episodes of cellulitis of his LBKA in the past which have always responded to Keflex. . At presentation to the ED, his vitals were 100.2, 102, 157/72, 94%/RA. He then spiked to 101.2. Labs were significant for DKA with BS ~580, AG ~20. He was given 1 L of NS and started on Insulin gtt. He was also found to have elevated Creatinine to 4.8 (baseline unknown). His CE's were elevated with CK of 580 and Trop-T of 0.1 but did not experience chest pain. His EKG showed LVH with ST dep in lateral I, aVL, V4-6. He was started on Heparin gtt, given lopressor, ASA. His CXray showed right upper lobe opacity and was given Levoflox. He was given one dose of Vanc for his cellulitis. . In the MICU, the Pt was started on an Insulin gtt overnight for DKA which was thought to be due to DKA with component of starvation ketosis and ARF on CRF. Hydration was given and potassium was repleted. Pt was subsequently transitioned to NPH in am. He was continued on Cephalexin (day 6) for cellulitis and on Levo/Flagyl for PNA. Subsequently Flagyl was discontinued and only Levo and Cephalexin were continued. Blood Cx were obtained. Pt was also found to have mild troponin lead and ST depressions in lateral leads which were stable overnight. Heparin gtt was started initially but was subsequently discontinued. On ROS the pt denied dizziness, SOB, chest pain abdominal pain, burning micturition. Bowel movements are normal. He has had a cough for several days PTA. Past Medical History: DM2 (diagnosed 10 yrs back) LBKA (10 yrs back) recurrent Cellulitis HTN Chronic renal failure Hyperlipidemia Social History: Never smoked or consumed alcohol. Retired. Used to be a automobile dealer. Lives in [**Location 11252**], NH during summer and [**Location (un) 22361**], MA during the year. Family History: Mother died from pulmonary embolism Physical Exam: Vitals: 97.5 142/79 70 18 99% RA Gen: comfortable, obese, alert, oriented x3 HEENT: mucous membranes moist, thick neck , JVD not appreciable Heart: S1 S2, RRR, no murmurs appreciable Lungs: mild right sided crackles Abd: obese, soft/NT, BS+ Ext: Left BKA, ulcer with healing granulation tissue at base and decreased induration from marked site, no edema Neuro: AOx3, no focal deficits Pertinent Results: [**2192-9-12**] 01:30PM GLUCOSE-580* UREA N-80* CREAT-4.8* SODIUM-126* POTASSIUM-4.2 CHLORIDE-90* TOTAL CO2-17* ANION GAP-23 [**2192-9-12**] 01:45PM GLUCOSE-479* LACTATE-1.7 K+-4.0 [**2192-9-12**] 07:00PM TRIGLYCER-976* HDL CHOL-20 CHOL/HDL-15.0 LDL([**Last Name (un) **])-73 [**2192-9-12**] 09:52PM TYPE-ART PO2-100 PCO2-29* PH-7.41 TOTAL CO2-19* BASE XS--4 [**2192-9-12**] 07:00PM CK-MB-10 MB INDX-1.7 [**2192-9-12**] 07:00PM cTropnT-0.12* [**2192-9-12**] 01:30PM CK-MB-11* MB INDX-1.9 cTropnT-0.10* [**2192-9-12**] 01:30PM CK(CPK)-581* [**2192-9-12**] 03:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-1000 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2192-9-12**] 03:00PM URINE RBC-[**3-4**]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 Brief Hospital Course: PCP: [**Name10 (NameIs) **] [**Name11 (NameIs) 25195**] ([**Hospital1 2436**]) . CC:[**CC Contact Info 25196**]. HPI: Briefly, this is a 63 yo M w/DM2, s/p left BKA, h/o multiple episodes of cellulitis now with a non-healing LBKA sore x 3 weeks. He was started on Keflex with intial improvement, but he became more lethargic and developed malaise, body aches, n/v, and intractable hiccups. On a f/u visit to his PCP, [**Name10 (NameIs) 25194**] was noted and he was sent to the ED. . Patient has been non-compliant with his Diabetes medications FS x 1 month. No h/o previous admissions for DKA. He has had recurrent episodes of cellulitis of his LBKA in the past which have always responded to Keflex. . At presentation to the ED, his vitals were 100.2, 102, 157/72, 94%/RA. He then spiked to 101.2. Labs were significant for DKA with BS ~580, AG ~20. He was given 1 L of NS and started on Insulin gtt. He was also found to have elevated Creatinine to 4.8 (baseline unknown). His CE's were elevated with CK of 580 and Trop-T of 0.1 but did not experience chest pain. His EKG showed LVH with ST dep in lateral I, aVL, V4-6. He was started on Heparin gtt, given lopressor, ASA. His CXray showed right upper lobe opacity and was given Levoflox. He was given one dose of Vanc for his cellulitis. . In the MICU, the Pt was started on an Insulin gtt overnight for DKA which was thought to be due to DKA with component of starvation ketosis and ARF on CRF. Hydration was given and potassium was repleted. Pt was subsequently transitioned to NPH in am. He was continued on Cephalexin (day 6) for cellulitis and on Levo/Flagyl for PNA. Subsequently Flagyl was discontinued and only Levo and Cephalexin were continued. Blood Cx were obtained. Pt was also found to have mild troponin lead and ST depressions in lateral leads which were stable overnight. Heparin gtt was started initially but was subsequently discontinued. On ROS the pt denied dizziness, SOB, chest pain abdominal pain, burning micturition. Bowel movements are normal. He has had a cough for several days PTA. . PMHx: DM2 (diagnosed 10 yrs back) LBKA (10 yrs back) recurrent Cellulitis HTN Chronic renal failure Hyperlipidemia . Allergies: NKDA . Medications on admission: glipizide Lipitor ASA 81 QD Keflex (6 days) . Family Hx: Mother died from pulmonary embolism . Social Hx: Never smoked or consumed alcohol. Retired. Used to be a automobile dealer. Lives in [**Location 11252**], NH during summer and [**Location (un) 22361**], MA during the year. . EXAM: Vitals: 97.5 142/79 70 18 99% RA Gen: comfortable, obese, alert, oriented x3 HEENT: mucous membranes moist, thick neck , JVD not appreciable Heart: S1 S2, RRR, no murmurs appreciable Lungs: mild right sided crackles Abd: obese, soft/NT, BS+ Ext: Left BKA, ulcer with healing granulation tissue at base and decreased induration from marked site, no edema Neuro: AOx3, no focal deficits . Labs: See below . EKG: Initial: Sinus @ ~95, LAD, ST dep in I, aVL, V4-6, 1mm elevation in aVR, III . CXRAY [**2192-9-12**] Right upper lobe opacity, possibly aspiration, although bronchopneumonia is also a diagnostic consideration Echo: 1. The left atrium is mildly dilated. 2. 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 normal (LVEF>55%). 3. The aortic valve leaflets are moderately thickened. Trace aortic regurgitation is seen. 4. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Renal U/S [**2192-9-15**] No comparison. Right kidney measures 11.9 cm, and is without evidence of masses or hydronephrosis. Normal flow is seen. The left kidney measures 12.7 cm, and is also normal in son[**Name (NI) 493**] appearance, without mass or hydronephrosis. Normal flow is seen. IMPRESSION: Normal renal ultrasound. . A/P: 63 M with DM2, noncompliant on meds, p/w DKA (now resolved), cellulitis, NSTEMI, PNA, and ARF (on CRF). . # DKA: Likely precipitated by med noncompliance, infection (cellulitis and PNA), and starvation. Acidosis possibly contributed to by ARF. Pt has been febrile to 101F during the admission. - continue maintainance fluids (100 cc/hr NS) - RISS and NPH increased from 10 ->14 [**Hospital1 **] - q4h FSG - daily lytes with repletion as needed - [**Last Name (un) **] consult for med optimization . # NSTEMI: given elevated CEs, EKG changes. Has risk factors for CAD (DM, hyperlipidemia, age). No baseline EKG, initially heparin drip started - now D/C'd. obtain stress test consider as inpatient. Lipid panel: chol 300, Tri 976, HDL 20, LDL 73. Echo showed no WMAs and EF>55% however Echo was suboptimal. - continue trending CEs, until troponin and CKs stabilize - Increased ASA, initiated BB and high dose statin - consider cards consult - hold ACE until Cr improves . # Cellulitis: h/o recurrent cellulitis from LBKa ulcer. Always improves after Keflex. Was given one dose of Vanc in the ED but then switched to Keflex as pt has responded to this in past multple times - f/u Bl cx . # Renal Failure: elevated Creatinine to 4.8 in admission. baseline unknown - will get records from PCP. [**Name10 (NameIs) 3081**] pt recalls that his PCP had told him about his bad renal function but does not remember his creatinine level. This could be chronic vs acute on chronic RF from dehydration since has had a small improvement w/fluid hydration. - obtain records from PCP ([**Name10 (NameIs) **] [**Doctor Last Name 25195**]) - check urine lytes - renally dose meds - ordered iron studies, microab/cr, pro/cr, PTH, SPEP - [**9-15**] renal U/S f/u . # RUL infiltrate on Cxray: no cough/sputum. Had intermittent fevers in the last few days. Mildly elevated white count - currently at normal level. CXray shows aspiration vs bronchoPNA in the upper R lobe. Currently sat fine on RA. - Levo, flagyl started emperically ->swithed to Levo - sputum cx - CXray in AM . # Access: piv . # FEN: Diabetic diet (was NPO), IV fluids . # PPX: PPI, heparin sq . # Code: full . # Contact: [**Name (NI) **] [**Name (NI) 25197**] (Son/HCP); Cell: [**Telephone/Fax (1) 25198**], Home: [**Telephone/Fax (1) 25199**], Work: [**Telephone/Fax (1) 25200**] Medications on Admission: Glipizide Lipitor ASA 81 QD Keflex (6 days) Discharge Disposition: Home Discharge Diagnosis: Principal: 1. Diabetic Ketoacidosis. 2. Right Upper Lobe Pneumonia. 3. Acute Renal Failure. 4. LLE Stump Cellulitis. 5. Anemia of Chronic Inflammation. 6. Metabolic Acidosis. 7. Hypercholesterolemia. 8. Hypertryglyceridemia. Secondary: 1. Diabetes Type II Uncontrolled. 2. CKD Stage V - Unknown Chronicity. 3. S/P LLE BKA. 4. Hypertension. Discharge Condition: Stable. Discharge Instructions: Please take all medications as prescribed, please keep all follow-up visits. . Please call your primary care doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 25195**], or return to the ED if you have chest pain, shortness of breath, nausea, vomitting, diarrhea, fever, chills, or any other symptoms that concern you. Followup Instructions: Please follow-up with your primary care doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 25195**], ([**Telephone/Fax (1) 25201**], in the next 1-2 weeks. He will refer you to a nephrologist for care of your kidneys. You will also need an endocrinologist and may call ([**Telephone/Fax (1) 4847**] to follow up at [**Last Name (un) **] Diabetes center here or you may follow-up with someone closer to home if your doctor has a recommendation that you would prefer. Please call ([**Telephone/Fax (1) 773**] to make a follow-up appointment with Nephrology (kidney doctors). Completed by:[**2192-10-17**]

[ "250.42", "584.9", "276.51", "403.91", "486", "272.4", "997.62", "272.1", "799.02", "997.69", "V15.81", "585.5", "250.12", "794.31", "285.21" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10256, 10262

3922, 6128

342, 350

10647, 10657

3128, 3899

11047, 11675

2670, 2707

10283, 10626

10188, 10233

10681, 11024

2722, 3109

275, 304

378, 2330

2352, 2462

2478, 2654

14,412

190,126

8656+55964

Discharge summary

report+addendum

Admission Date: [**2155-4-28**] Discharge Date: [**2155-5-3**] Date of Birth: [**2085-6-21**] Sex: M Service: VSU CHIEF COMPLAINT: Failed graft. HISTORY OF PRESENT ILLNESS: This is a 69-year-old gentleman who underwent a left fem posterior tibial bypass graft with nonreversed saphenous vein in [**2154-12-20**], who underwent a graft surveillance on [**2155-4-16**], which demonstrated significant graft stenosis in the distal segment in the region of the distal anastomosis. The patient underwent an arteriogram today with hopes of interventional procedure. They were not able to intervene. The patient now is admitted for preoperative hydration and postoperative angio hydration for revision of his left fem PT bypass. ALLERGIES: No known drug allergies. MEDICATIONS: On admission include Toprol XL 25 mg daily, Lasix 40 mg in the a.m. and 20 mg in the p.m., Trental 400 mg 4 times daily, Lantus 36 units at bedtime, Humalog insulin sliding scale, folate 1 mg daily. PAST MEDICAL HISTORY: Peripheral vascular disease, status post left fem PT in [**2154-12-20**], history of carotid artery stenosis status post right CEA in [**2153-3-20**], history of coronary artery disease and non Q wave MI in [**2149-10-20**], status post CABG x5 in [**2149-10-20**], history of systolic congestive heart failure with ejection fraction of 35% [**2153-1-20**], history of diabetes type 2 insulin-dependent with neuropathy and retinopathy, history of vitreous hemorrhage with vitrectomy. SOCIAL HISTORY: The patient is married, lives with his wife. [**Name (NI) **] has 35 tobacco years of smoking, has not smoked for greater than 20 years. Occasional alcohol intake. PHYSICAL EXAMINATION: Vital signs 97.4, 64, 138/76, respirations 18, O2 saturation 99% in room air. General appearance: Alert, white male in no acute distress. Lungs are clear to auscultation. Heart: Regular rate and rhythm. Abdominal examination is unremarkable. Right groin is clean, dry and intact without hematoma. Pulse exam shows palpable femoral bilaterally. The popliteal is palpable. The DP and PT are dopplerable signals. On the left, the DP is dopplerable. There are 3 lateral plantar ulcerations without erythema or exudate. HOSPITAL COURSE: The patient underwent diagnostic arteriogram. He was without any event and was admitted for elective surgery. Labs: White count was 8.5, hematocrit 36.6. INR 1.1. BUN 20, creatinine 1.0. Urinalysis was negative. EKG was normal sinus rhythm without significant changes from previous EKG of [**2151-1-20**]. Chest x-ray was unremarkable. The patient's post-angio labs were without any changes. The patient underwent on [**4-29**], a patch angioplasty of the left common femoral DP graft with lesser saphenous vein jump graft from the left graft to DP distally. The patient tolerated the procedure well and was transferred to the PACU in stable condition. Postoperatively, he remained hemodynamically stable. Postoperative hematocrit was 32.5. The patient was placed on a heparin drip for goal PTT of 50 to 60. Heparin dosing was adjusted according to goal PTT from 50 to 60. The patient was transferred to the VICU for continued monitoring and care from the PACU. Postoperative day 1, he did require nitroglycerin for systolic hypertension which was weaned the following day. His hematocrit dropped to 28.7. BUN and creatinine remained stable at 14 and 0.8. PTT was 56.3 with an adjustment in his heparin with PTT 6 hours later of 75.4 and repeat PTT was continued and heparin was adjusted accordingly. The patient had palpable graft pulse at the calf and a palpable left radial pulse. The patient remained on bedrest. His fluids were HEP-locked. His nitroglycerin was weaned and he was continued on his home medications. He auto-diuresed and did not require Lasix. His diet was advanced. His Humalog sliding scale was adjusted secondary to hyperglycemia with improvement in his glycemic control. Postoperative day 2, blood pressure was under excellent control with systolic blood pressure 133, diastolic 65. He was afebrile. His heparin was discontinued. His Foley was discontinued. A line was discontinued. The patient was allowed up out of bed to the chair. He was to be nonweightbearing on the left foot secondary to site of incision. Ace wrap should be worn when ambulating from foot to knee on the left. Postoperative day 3, it was noted the patient had a troponin spike from 0.04 to 0.17. The patient denied any symptoms, was hemodynamically stable. An EKG was obtained and enzymes were continued to be cycled. The patient was allowed to ambulate. Decision regarding discharge will be made after evaluation of the elevated enzymes at that time. DISCHARGE INSTRUCTIONS: The patient may ambulate essential distances. He should wear an ace wrap from foot to knee on the left when ambulating. He should keep the left leg elevated when sitting in a chair. He may shower but no tub baths. He should call Dr.[**Name (NI) 1392**] office if he develops a fever greater than 101.5. if the leg wounds become red, swollen or drain. He should not drive until seen in follow- up. He should continue taking his stool softener while taking pain medications to prevent constipation. DISCHARGE MEDICATIONS: 1. Folic acid 1 mg daily. 2. Trental 400 mg 3 times daily. 3. Protonix 40 mg daily. 4. Colace 100 mg twice a day. 5. Acetaminophen 500 mg tablets, 2 q.4-6 hours p.r.n. for pain. 6. Hydromorphone 2 mg tablet, 1 q-2 hours p.r.n. for pain. 7. Aspirin 325 mg daily. 8. Plavix 75 mg daily. 9. Metoprolol 75 mg 3 times daily. 10. Lasix 20 mg q.p.m. and 40 mg q.a.m. 11. Amoxicillin/Clavulanate 500/125 mg tablets q.8 hours for a total of 7 days. 12. Insulin Glargine U-100 at 36 units at bedtime with a Humalog sliding scale. 13. Simvastatin 10 mg daily. The patient should also follow up with [**Last Name (un) **] for management of his diabetes. He can call for an appointment to the [**Hospital **] Clinic. DISCHARGE DIAGNOSES: 1. Left femoral posterior tibial graft stenosis. 2. History of peripheral vascular disease. 3. History of carotid stenoses, status post right carotid endarterectomy. 4. History of coronary artery disease, status post non Q wave myocardial infarction in [**2149-10-20**], status post coronary artery bypass graft x5 in [**2149-10-20**]. 5. History of congestive heart failure, systolic ejection fraction 35%. 6. History of type 2 diabetes mellitus, insulin dependent, with neuropathy and retinopathy. 7. History of vitreous hemorrhage, status post vitrectomy. MAJOR SURGICAL PROCEDURES: 1. Diagnostic arteriogram with left leg runoff via the right femoral access on [**2155-4-28**]. 2. Patch angioplasty of the left common femoral artery posterior tibial bypass with a jump graft from bypass to distal dorsalis pedis with saphenous vein on [**2155-4-29**]. FOLLOW UP: The patient should follow up with Dr. [**Last Name (STitle) 1391**] in 2 weeks time. He should also follow up with the [**Hospital **] Clinic. An addendum will be dictated regarding the patient's elevated troponin level. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**] Dictated By:[**Last Name (NamePattern1) 2382**] MEDQUIST36 D: [**2155-5-2**] 11:21:48 T: [**2155-5-2**] 12:24:16 Job#: [**Job Number 30308**] Name: [**Known lastname 5309**],[**Known firstname 651**] F Unit No: [**Numeric Identifier 5310**] Admission Date: [**2155-4-28**] Discharge Date: [**2155-5-8**] Date of Birth: [**2085-6-21**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 231**] Addendum: [**2155-5-2**] patient's troponin level increased from 0.04-0.17. patient asymptomatic EKG with st changes in lateral leads. cardology consulted.enzymes cycled x3 more draws and ECHO to assess LVF and wall motion were pending. [**2155-5-3**] patient seen by cardilogy . IV heparin began. [**2155-5-7**] underwent Pmibi . new changes with ef 23%.Patient asymptomatic. d/c home [**5-8**] to followup with his cardology. Discharge Disposition: Home With Service Facility: [**Hospital 197**] [**Name (NI) 198**] [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**] Completed by:[**2155-7-31**]

[ "443.9", "250.50", "250.60", "428.30", "414.01", "E878.2", "362.01", "357.2", "996.74" ]

icd9cm

[ [ [] ] ]

[ "39.29", "88.48", "39.49" ]

icd9pcs

[ [ [] ] ]

8223, 8449

5991, 6890

5243, 5970

2246, 4697

4722, 5220

6902, 8200

1712, 2228

153, 168

197, 999

1022, 1507

1524, 1689

80,332

156,456

34894

Discharge summary

report

Admission Date: [**2125-11-30**] Discharge Date: [**2125-12-8**] Date of Birth: [**2065-9-30**] Sex: M Service: CARDIOTHORACIC Allergies: Codeine Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2125-12-3**] Four Vessel Coronary Artery Bypass Grafting(LIMA to LAD, SVG to Diagonal, SVG to OM2, SVG to RCA) History of Present Illness: Mr. [**Known lastname 32416**] is a 60 year old male with known coronary artery disease. Recent stress test was positive for ischemia. Cardiac catheterization on [**2125-11-30**] at [**Hospital 5279**] Hospital revealed severe three vessel coronary artery disease, including 60% left main lesion. LVEF was estimated at 60%. Given his critical coronary anatomy, he was transferred to the [**Hospital1 18**] for cardia surgical intervention. On admission, patient denied history of chest pain. There was no prior history of MI or CHF. Past Medical History: Coronary Artery Disease, prior PCI/stenting in [**2115**] Iron Deficiency Anemia Hypertension Dyslipidemia Hypothyroidism History of Polyps, s/p Polypectomy History of Hemorrhoids, Bright Red Blood Per Rectum Prior Hemorrhoid Banding Tonsillectomy Ankle Surgery Social History: Retired FBI [**Doctor Last Name **], currently special education teacher. Denies tobacco history. Admits to social alcohol, no history of alcohol abuse. Married. Family History: Uncle died at age 55 of MI. Mother had CABG in her 50's. Physical Exam: Discharge exam: Vitals -99.4, 125/77, 84SR, 20, 93%RA HEENT -NCAT, EOMI Lungs -diminished at bases Heart - RRR, no murmur or rub Abdomen -NABS, soft, non-tender, non-distended Ext - 2+edema b/l Neuro - non-focal Wounds - sternotomy- c/d/i, no erythema or drainage, sternum stable EVH- c/d/i, no erythema or drainage Pertinent Results: [**2125-11-30**] BLOOD WBC-8.3 RBC-4.52* Hgb-10.6* Hct-34.6* MCV-77* MCH-23.4* MCHC-30.6* RDW-15.5 Plt Ct-228 [**2125-11-30**] BLOOD PT-13.1 PTT-29.2 INR(PT)-1.1 [**2125-11-30**] BLOOD Glucose-89 UreaN-18 Creat-1.2 Na-140 K-4.1 Cl-103 HCO3-27 AnGap-14 [**2125-11-30**] BLOOD ALT-32 AST-31 CK(CPK)-359* AlkPhos-78 Amylase-57 TotBili-1.0 [**2125-11-30**] BLOOD CK-MB-5 cTropnT-<0.01 [**2125-11-30**] BLOOD Albumin-4.4 Mg-2.2 [**2125-11-30**] BLOOD %HbA1c-7.1* [**2125-12-1**] ECHO: 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 with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. [**2125-12-7**] 06:00AM BLOOD WBC-10.6 RBC-3.40* Hgb-8.2* Hct-25.7* MCV-76* MCH-24.1* MCHC-31.9 RDW-17.1* Plt Ct-195 [**2125-12-7**] 06:00AM BLOOD Glucose-59* UreaN-17 Creat-1.2 Na-138 K-3.7 Cl-102 HCO3-25 AnGap-15 TEE [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 79865**] (Complete) Done [**2125-12-3**] at 1:03:38 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 177**] C. [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2065-9-30**] Age (years): 60 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Intraoperative TEE for CABG ICD-9 Codes: 440.0 Test Information Date/Time: [**2125-12-3**] at 13:03 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Suboptimal Tape #: 2008AW3-: Machine: AW3 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *5.5 cm <= 4.0 cm Left Atrium - Four Chamber Length: *7.3 cm <= 5.2 cm Left Ventricle - Ejection Fraction: 60% >= 55% Aorta - Arch: 2.6 cm <= 3.0 cm Aorta - Descending Thoracic: 2.2 cm <= 2.5 cm Aortic Valve - LVOT diam: 2.4 cm Findings LEFT ATRIUM: Moderate LA enlargement. Elongated LA. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. All four pulmonary veins identified and enter the left atrium. 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: Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Focal calcifications in aortic root. Normal ascending aorta diameter. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Physiologic MR (within normal limits). TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) 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. Suboptimal image quality. The patient appears to be in sinus rhythm. Results were Conclusions PRE BYPASS The left atrium is moderately dilated. The left atrium is elongated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. 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 aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). Dr. [**Last Name (STitle) 914**] was notified in person of the results in the operating room at the time of the study. POST BYPASS Normal biventricular systolic function. No significant changes from pre bypass study. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2125-12-3**] 13:16 ?????? [**2120**] CareGroup IS. All rights reserved. Brief Hospital Course: Mr. [**Known lastname 32416**] was admitted to the cardiac surgical service and underwent routine preoperative evaluation. This included preoperative echocardiogram(see result section) and GI consult for history of intermittent BRBPR over the last 4-5 months. There was no evidence of active GI bleeding and colonoscopy was deferred secondary to critical left main lesion and severe three vessel coronary artery disease. Preoperative course was otherwise uneventful and he was cleared for surgery. On [**12-3**], Dr. [**Last Name (STitle) 914**] performed coronary artery bypass grafting surgery. For surgical details, please see separate dictated operative note. Following surgery, he was brought to the CVICU for invasive monitoring. He received Vancomycin 1gram IV every 12 hours for four doses due to being in the hospital greater than 24 hours prior to surgery. Within 24 hours, he awoke neurologically intact and was extubated without incident. On post-op day one he was transferred to the telemetry floor for further care. On post operative day 2 his chest tubes were discontinued. He was gently diuresed towards his pre-op weight and beta blockers were titrated for maximum hemodynamics. Epicardial pacing wires were removed on post-op day three. He worked with physical therapy during his post-op course for strength and mobility. Pre-op blood work revealed a hemoglobin A1C of 7.1. He was started on sliding scale insulin and glyburide with good control of his blood sugars. He did not tolerate the glyburide as he became symptomatic with blood sugars in the 70's. On post-op day 5 he appeared to be doing well and was discharged home with VNA services and the appropriate follow-up appointments. Medications on Admission: Transfer Meds: Aspirin 81 qd, Diazepam 5 qd, Diltiazem 180 qd, Synthroid 125 qd, Lipitor 20 qd, MVI, Niacin Cr [**2117**] qd, Bendaryl 25 qd, Nitro prn 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. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Niacin 500 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO BID (2 times a day). Disp:*120 Capsule, Sustained Release(s)* Refills:*2* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). Disp:*qs * Refills:*0* 10. Multivitamin Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*0* 11. Vitamin C 1,000 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 12. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 2 weeks. Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 15. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 6011**] Care Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 Elevated Hemoglobin A1C PMH: s/p Coronary Stent [**2115**], Hypertension, Dyslipidemia, Hypothyroidism, Iron Deficiency Anemia, History of Hemorrhoids and Colon Polyps, s/p Tonsillectomy, s/p Left ankle surgery Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: Dr. [**Last Name (STitle) 914**] in [**3-4**] weeks, call for appt Dr. [**Last Name (STitle) 39975**] in [**5-5**] weeks, call for appt Dr. [**Last Name (STitle) 74449**] in [**1-31**] weeks, call for appt Dr [**Last Name (STitle) 4539**] (gastroenterology, [**Telephone/Fax (1) 463**]) Tuesday [**2126-1-1**] @1pm. Completed by:[**2125-12-8**]

[ "455.2", "280.9", "244.9", "414.01", "V45.82", "790.21", "251.1", "569.89", "E932.3", "569.3", "272.4", "401.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

11030, 11086

7274, 8989

285, 400

11401, 11407

1851, 7251

12184, 12531

1442, 1500

9191, 11007

11107, 11380

9015, 9168

11431, 12161

1515, 1515

1531, 1832

235, 247

428, 962

984, 1247

1263, 1426

9,957

116,602

6963

Discharge summary

report

Admission Date: [**2160-11-27**] Discharge Date: [**2160-12-3**] Date of Birth: [**2082-3-31**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2186**] Chief Complaint: tachypnea at nursing home Major Surgical or Invasive Procedure: None History of Present Illness: HPI: (pt non-verbal non-responsive at baseline) 78 yo m NH resident w/ h/o DM, HTN, CVA, who had an attack of hypoglycemia on [**2160-11-26**] which resolved with [**Location (un) 2452**] juice administration. Next morning he was tachypneic and required NRB. hence transferred to [**Hospital1 **] ED. In the ED was hypotensive to 80s, which resolved with 2L NS. thought to be sepsis and started on vanc, levo and flagyl. per family, h/o cough w/ yellowish sputum production without fever, chills. was admitted to MICU. . In MICU, abx changed to vanc and zosyn. also received 4 L NS for hypotension. Patient had afib with RVR and heart rate was stabilized with IV diltiazem and lopressor. Pt was stabilized and transferred to floor . On floor, he triggered for HR in 150s. also was found to have vomit in mouth and chest with satts in low 90s on 8L. was transferred to MICU for presumed aspiration. . Continued on vanc and zosyn. lopressor ineffective in controlling HR. hence continued on dilt 30 qid. pt stable and hence transferred back to floor. Past Medical History: DM2 (HgbA1c 6.0% [**6-/2160**]) HTN Tobacco abuse CRI (followed by Dr. [**Last Name (STitle) **], b/l Cre 1.5) gout cataracts glaucoma s/p left inguinal hernia repair h/o TB (while in [**Country 651**] in his 30's, denies ever being treated) Social History: Retired machinist, moved to the United States 13 years ago from [**Country 651**]. He lives in a nursing home. His daughter lives nearby. Long-time smoker. He denies any alcohol or illicit drug use. Family History: noncontributory Physical Exam: VS: T 97.1 HR 94(91-104) BP 152/73 (151-173/61-84) RR 24 O2 sat 98% Face mask 35% O2. Gen: elderly male, lying in bed, non-verbal, non responsive to deep stimuli, tachphyneic HEENT: PERRL, no JVD, no LAD, MMM Neck: supple Heart: irregularly irregular, no M/R/G Pulm: CTABL ant Abd: soft, NT, ND, + BS, Gtube in place Ext: no peripheral edema, distal pulses 2+ Neuro: awake, unable to assess motor or sensory function Pertinent Results: Urine [**11-27**]: STAPHYLOCOCCUS, COAGULASE NEGATIVE | GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R NITROFURANTOIN-------- <=16 S OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 2 S . bcx [**11-27**]: coag negative staph in [**11-27**] bottles sputum cx [**11-27**]: moderate growth of MRSA . Diagnostics: ECG: atrial fibrillation with a rate of 143 TWF in III, V6, AVF . CXR [**11-27**]:Bilateral consolidations due to pneumonia or aspiration . CXR [**11-28**]: Worsening left perihilar and right lower lobe opacities highly suspect for aspiration versus multifocal pneumonia. . CXR [**11-30**]:: No interval change. Diffuse airspace opacities consistent with known multifocal pneumonia. . Sputum [**2160-11-30**]: GRAM STAIN (Final [**2160-11-30**]): <10 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S). QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [**2160-12-2**]): MODERATE GROWTH OROPHARYNGEAL FLORA. GRAM NEGATIVE ROD(S). SPARSE GROWTH. . MRSA screen [**2160-12-1**]: MRSA SCREEN (Final [**2160-12-1**]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS . Blood culture [**2160-11-27**]: AEROBIC BOTTLE (Final [**2160-11-30**]): REPORTED BY PHONE TO [**Doctor First Name **] [**Doctor Last Name 10280**] @ 2035 ON [**11-28**] - CC6D. STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET ONLY. SENSITIVITIES PERFORMED ON REQUEST.. ANAEROBIC BOTTLE (Final [**2160-12-3**]): NO GROWTH. Brief Hospital Course: A/P: 78 yo male with h/o HTN, DM, CVA, afib w/ RVR p/w hypoglycemia, hypotension. was treated for aspiration pneumonia and suspected sepsis. was in MICU twice and was finally transferred to floor for further care. . #Tachypnea/hypoxia: Patient had a known multifocal PNA, with MRSA in his sputum. had witnessed aspration of his vomit. CXR showed bilat consolidation. pt was afebrile and wbc count was wnl. was hypotensive on presentation and hence considered to be in sepsis. was started on vanc, zosyn and flagyl initially. on transfer to the MICU, the flagyl was discontinued. on discharge the antibiotics were converted to PO abx. hence vanc and zosyn were d/c'd and linezolid and ciproflox were started. the patient will be treated for total 14 days. hence will be on linezolid and ciproflox for 7 more days from discharge. the O2 satts improved after starting the abx. as mentioned above, pt was afebrile with nl wbc count.aspiration precautions were followed . #Afib with RVR: identified during this admission. HR ranged from 90 to 170. pt used to convert to sinus rhythm by himself sometimes and then would [**Last Name (un) 7162**] go back into afib. was started on dilt 30 qid and was uptitrated to 60 qid. the HR was well controlled at this dose with patient in sinus rhythm. will require anticoagulation with coumadin. coumadin was held during this admission as INR was supratherapeutic. will need to restart once INR becomes therapeutic. . #Hypertension: Admitted with hypotension, which was thought to be from sepsis. received 2 L NS in ED and BP returned to [**Location 213**]. was hypertensive later in the course. was treated with dilt 60 qid. . #s/p CVA: Patient was anticoagulated. was supratherapeutic on coumadin. hence it was held. will need to restart once INR becomes therapeutic. . #FEN: Continue tube feeds. NPO as aspiration risk. will need to check electrolytes daily and replete accordingly as his potassium, magnesium and phosphate were low during this admission. . #Prophylaxis: no need of heparin SQ as INR was supratherapeutic, bowel regimen, famotidine . #Code: DNR/DNI. . #Communication: With patient and family. daughter [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 26144**]) . Medications on Admission: Hydrochlorothiazide 50 mg PO DAILY Insulin sliding scale Docusate Sodium (Liquid) 100 mg PO BID Famotidine 20 mg PO BID Piperacillin-Tazobactam Na 4.5 gm IV Q8H Vancomycin HCl 1000 mg IV Q 12H Diltiazem 30 mg PO QID Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Tablet(s) 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 4. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day): hld for HR <60, SBP <90. 5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. 6. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital1 2670**] - [**Location (un) **] Discharge Diagnosis: Aspiration pneumonia Atrial fibrillation . DM2 HTN Tobacco abuse CRI gout cataracts glaucoma s/p left inguinal hernia repair h/o TB (while in [**Country 651**] in his 30's, denies ever being treated) Discharge Condition: Stable Discharge Instructions: You were diagnosed with pneumonia and hence will be treated with antibiotics for total 14 days. . If you have chest pain, shortness of breath, palpitations, dizziness, fever, chills, cough, pain in stomach, nausea or vomitting please call your doctor or go to the emergency room Followup Instructions: Please make a follow up appointment with your Primary care provider Dr [**Last Name (STitle) **] ([**Telephone/Fax (1) 26145**]) within 2 weeks of discharge . Please check Serum potassium, magnesium and phosphate regularly as these have been low during this hospitalization. Please replete these electrolytes accordingly. . We have held the coumadin as patient's INR was supratherapeutic. Please restart it when the INR becomes therapeutic. . Please follow aspiration precautions. Completed by:[**2160-12-3**]

[ "428.0", "403.90", "507.0", "585.9", "038.9", "250.80", "305.1", "427.31", "995.91" ]

icd9cm

[ [ [] ] ]

[ "96.6" ]

icd9pcs

[ [ [] ] ]

7127, 7197

4079, 6339

342, 349

7441, 7450

2397, 4056

7777, 8289

1927, 1944

6605, 7104

7218, 7420

6365, 6582

7474, 7754

1959, 2378

277, 304

377, 1428

1450, 1693

1709, 1911

22,380

167,728

19981

Discharge summary

report

Admission Date: [**2193-1-12**] Discharge Date: [**2193-1-20**] Date of Birth: [**2116-2-21**] Sex: M Service: Cardiac Surgery CHIEF COMPLAINT: Chest pain HISTORY OF PRESENT ILLNESS: This is a 76 year old man with Type 2 diabetes, hypertension who had a melanoma excised from his back on the day of admission, and was driving back to [**Location (un) 86**] when he had an acute onset of 5 out of 10 substernal chest pain with radiation to the neck which was associated with some mild shortness of breath. He went to the Emergency Department at [**Location (un) 620**] where an electrocardiogram showed normal sinus rhythm with significant ST elevation in 2, 3, AVF and ST depression in V1 and V2 which was consistent with an acute inferior posterior myocardial infarction. He was given Aspirin, heparin, beta blockade, intravenous nitroglycerin and had resolution of both of his chest pain and ST changes. A couple of weeks prior to admission the patient does report that he had an abnormal exercise tolerance test. MEDICATIONS AT HOME: Zestril, Toprol XL, Aspirin and multivitamins. PAST MEDICAL HISTORY: Hypertension, diabetes mellitus Type 2, melanoma and recent back surgery. He also has hypercholesterolemia and hypertension. SOCIAL HISTORY: He does not smoke, he does not drink, he does not use drugs, he is single. He is an active man and likes to ice skate. PHYSICAL EXAMINATION: The patient has a pulse of 60, blood pressure of 130/76, respiratory rate of 14. In general appearance, he appears in no apparent distress. He has no jugulovenous distension. Respiratory rate is clear to auscultation bilaterally. His heart is regular rate and rhythm, S1 and S2, no murmurs were noted. He has 2+ and equal pulses bilaterally with no pedal edema. His abdomen is soft, nontender, nondistended. HOSPITAL COURSE: Mr. [**Known lastname 1968**] was admitted to the Telemetry Unit and he [**Known lastname 1834**] a cardiac catheterization on [**1-12**]. Catheterization showed severe multivessel disease with a 50% stenosis of the left main coronary artery, 80% stenosis of the left anterior descending coronary artery and 50% stenosis of the left circumflex artery and up to 80% stenosis of right coronary artery. His heart function was good with a left ventricular ejection fraction of 75%. Because of this multivessel disease and the patient's diabetes mellitus, Cardiothoracic Surgery was consulted and Mr. [**Known lastname 1968**] was eventually taken to the Operating Room on [**1-14**], hospital day #3. Please refer to the previously dictated operative note by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from [**2193-1-14**]. In brief, four grafts were performed, the left internal mammary artery was connected to the left anterior descending artery and saphenous vein grafts were connected to the diagonal branch, the obtuse marginal branch and the posterior descending artery. Mr. [**Known lastname 1968**] [**Last Name (Titles) 1834**] cardiopulmonary bypass for 90 minutes and the aorta was crossclamped for 76 minutes during the procedure. He tolerated the procedure well and he was transferred to the Cardiac Surgery Recovery Unit, intubated with Propofol, insulin, Neo-Synephrine drips. The patient did well postoperative and on postoperative day #1 he was extubated and his drips were all weaned, and later on in the day he was transferred to the floor. Despite his significant disease, his postoperative course was relatively unremarkable. He was diuresed and beta blocked, and he was cleared by physical therapy on postoperative day #6. Of note, Mr. [**Known lastname 10881**] postoperative course was remarkable for an oxygen requirement until postoperative day #5, [**1-19**] which was successfully weaned prior to discharge as well as hyperglycemia which would be expected for his prior diabetes mellitus. [**Last Name (un) **] was consulted and they followed him and prior to discharge his sugars were much better controlled than immediately postoperative. He has a follow up appointment with his [**Last Name (un) **] doctor [**First Name (Titles) **] [**1-26**]. On postoperative day #6, [**2193-1-20**], Mr. [**Known lastname 1968**] was afebrile, stable vital signs. He was 101.5 kg. His blood sugars were ranging 76 to 166. His wound was clean, dry and intact. His lungs were clear to auscultation bilaterally. His heart was regular rate and rhythm. His abdomen was soft, nontender, nondistended. Legs showed mild edema. A chest x-ray showed resolution of many congestive heart failure symptoms and there were no infiltrates. He was discharged home with [**Hospital6 407**] care. DISCHARGE MEDICATIONS: His discharge medications included Aspirin 325 mg once a day, Metoprolol 75 mg twice a day, Lipitor 40 mg once a day, Lasix 20 mg twice a day and [**Doctor First Name 233**]-Ciel 20 mEq twice a day. Lasix and [**Doctor First Name 233**]-Ciel were for ten days. He was also given a home dose of insulin, NPH 32 units twice a day, Humalog sliding scale as directed. He was also given Percocet and Colace as needed for pain and constipation respectively. FOLLOW UP: He has a follow up appointment with Dr. [**Last Name (STitle) 53858**], his primary care physician in one to two weeks and Dr. [**Last Name (STitle) 27658**] his cardiologist in two to three weeks, with [**Last Name (un) **] doctors [**First Name (Titles) **] [**2193-2-16**] and with Dr. [**Last Name (STitle) **] in one month. DISCHARGE DIAGNOSIS: 1. Unstable angina 2. Type 2 diabetes mellitus 3. Hypertension 4. Hypercholesterolemia 5. History of back surgery 6. History of melanoma 7. Coronary artery disease 8. Acute inferior myocardial infarction status post coronary artery bypass graft [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern1) 1179**] MEDQUIST36 D: [**2193-1-20**] 19:02 T: [**2193-1-20**] 19:16 JOB#: [**Job Number 53859**]

[ "172.5", "250.00", "428.0", "410.31", "414.01", "998.11", "E878.2", "401.9" ]

icd9cm

[ [ [] ] ]

[ "36.13", "37.23", "39.61", "88.53", "88.56", "36.15", "99.20" ]

icd9pcs

[ [ [] ] ]

4724, 5180

5543, 6075

1858, 4700

1066, 1114

5192, 5522

1425, 1840

166, 178

207, 1044

1137, 1264

1281, 1402

82,846

165,373

37009

Discharge summary

report

Admission Date: [**2195-10-13**] Discharge Date: [**2195-10-16**] Date of Birth: [**2112-8-3**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5167**] Chief Complaint: Seizure Major Surgical or Invasive Procedure: Intubation History of Present Illness: Patient is a 83 yo RHW with hx of traumatic SDH back in [**9-10**] but did not undergo any surgical intervention transferred from [**Hospital3 **] after ~45 minutes of generalized convulsion. Patient fell back in [**9-10**] while carrying laundry basket - thought to have tripped over something and found to have L SDH. She was admitted here from [**9-11**] ~ [**9-13**] under NSURG service but did not have surgical intervention. She was discharged to home with Dilantin then she was found to have some word-finding difficulty on [**9-25**] hence was admitted to [**Last Name (un) 1724**] from 8/14~[**9-30**]. She was initially sent to rehab and she has been home afterwards and per sister, she has been getting stronger day by day. She was actually able to take a lengthy walk with sister who held her hand yesterday and was in her USOH this morning. Then around 1pm, patient was found in the bathroom calling for her sister. [**Name (NI) **] sister, patient was shaking her head and arms with L hand clenched but was able to talk to her sister. [**Name (NI) **] was also quite diaphoretic per sister. EMS was called and patient was able to answer their questions but upon arrival to [**Hospital3 **], she was reportedly having generalized convulsion. The ambulance that took her was not equipped to give her any meds. At [**Hospital3 **], she was given 30mg IV Valium then 4mg of IV Ativan and intubated after a bolus of Propofol. Her convulsion supposedly lasted ~45 minutes. She then was transferred here for further evaluation. Also, she was febrile up to 101 at [**Hospital1 3494**] per records. There is no hx of seizures per sister but it appears that her Dilantin dose was increased from 100/100/100 to 100/100/200 at [**Last Name (un) 1724**]. ROS completely negative per sister including fever/chills, change in appetite, N/V/D, or sick contact. Given the fever of 101 and status, patient was empirically started on broad ABX with plan for LP but repeat head CT shows acute but small SDH (R frontal and occipital) hence LP deferred per ED. NSURG was also consulted who did not feel that intervention was warranted at this point. Past Medical History: 1. hx of traumatic SDH back in [**9-10**] 2. Hypothyroidism 3. Osteoporosis 4. s/p mastectomy Social History: Lives with sister, [**Name (NI) **] [**Name (NI) 83449**] who is also HCP (full code). Retired in her 70's - no cigarette or EtOH hx. Family History: No FH of seizures Physical Exam: Patient sedated on propofol and had received 20mg of IV Valium and 4mg of IV Ativan prior to transfer. T 99.8 (rectal) BP 158/68 HR 60 RR 14 O2Sat 100% on CMV Gen: Lying in bed, intubated and sedated. CV: RRR, 2/6 systolic murmur auscultable on LUSB. Lung: Clear anteriorly. Abd: +BS, soft, nondistended. Ext: No edema Neurologic examination: Mental status: Intubated and sedated. CN: Pupils small but symm and reactive (2.5 -> 2mm). No OCR but bilateral corneal's present. No gag. Face appears symmetric. Motor: Purposeful withdrawal to noxious stim in both LEs but nothing on UEs. No spontaneous movement. [**Last Name (un) **]: Appears intact to noxious stim in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 83074**]: 2+ and symm throughout and toes appear upgoing bilaterally. Neurological examination at time of discharge: MS: Alert, oriented to place, time and person. She was attentive: MOYB, was awake. There was no aphasia, no paraphasic errors. No dysarthria. She repeated, registered [**4-14**] but recall was [**2-14**]. She was able to follow simple commands, but perserveration was noted with multiple step commands and she required multiple redirection. No right left confusion. Naming of low and high frequency objects was intact. CN: PERRL 2.5->2mm, VFF to threat, EOMI, lateral gaze nystagmus x2bts b/l, facial sensation and symmetry were present, hearing impaired to finger rub (presbycusis hx), papate midline, tongue midline, shoulder shrug intact. Motor: Normal tone, trace asterixis. She was full strength in UEs with exception of L delt/tri/FE which were 4+. She was 3+ at biceps and triceps b/l. Position sense was intact. No tremor. In LEs, IPs were 4+ on R and 4 on L, H 4+ on L, otherwise strength was full. No clonus, DTRs were 3+ b/l and 1+ at achilles. Toe was down on R, equivocal on L. Sensory: intact to PP and LT throughout. Proprioception impaired at great toes, vibration impaired by 5 seconds b/l in LEs. Gait: able to stand up from chair on own w/ use of hands. Gait was wide-based, patient nearly fell to the R when walking w/ examiner. Pertinent Results: Admission Labs [**2195-10-13**] 05:10PM URINE MUCOUS-MOD HYALINE-0-2 RBC-[**7-22**]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-[**4-16**] TRANS EPI-3-5 BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017 [**2195-10-13**] 05:10PM PLT COUNT-257 PT-12.5 PTT-26.4 INR(PT)-1.1 NEUTS-76.2* LYMPHS-15.7* MONOS-5.8 EOS-1.8 BASOS-0.5 WBC-7.4 RBC-3.47* HGB-10.5* HCT-32.8* MCV-95 MCH-30.3 MCHC-32.0 RDW-14.6 GLUCOSE-139* UREA N-15 CREAT-0.7 SODIUM-133 POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-24 ANION GAP-13 LACTATE-1.5 Cardiac Biomarkers [**2195-10-13**] 05:10PM cTropnT-0.12* CK-MB-6 CK(CPK)-313* [**2195-10-13**] 10:35PM cTropnT-0.05* CK-MB-6 CK(CPK)-459* CT HEAD W/O CONTRAST Study Date of [**2195-10-13**] 6:07 PM MPRESSION: 1. New right cerebral convexity subdural hematoma, without midline shift. 2. Resolution of left frontotemporal subdural hematoma. CT C-SPINE W/O CONTRAST Study Date of [**2195-10-13**] 8:49 PM IMPRESSION: 1. No cervical spine fracture, subluxation, or interval change. 2. Multilevel degenerative disease causes moderate to severe central canal stenosis and thecal effacement predisposing the patient to spinal cord injury with minor trauma. In the appropriate clinical situation (for example myelopathy), consider MR for further characterization. 3. Rotation of C1 on C2 for which rotary subluxation cannot be excluded and clinical correlation is necessary. Thyroid function tests: [**2195-10-15**] 05:00AM BLOOD TSH-23* [**2195-10-15**] 05:00AM BLOOD Free T4-0.64* Brief Hospital Course: Ms. [**Known lastname 83449**] is an 83 year old right handed woman with a history of a traumatic left subdural hematoma on [**9-10**] who presented with suspected status epilepticus while on Dilantin. # Neuro/Seizures/Subdural Hematoma: The patient was admitted intubated and sedated in the setting of a possible seizure and transferred to [**Hospital1 18**]. On arrival to ICU, CT of the head demonstrated resolution of her prior SHD but a new, small right sided SDH. Since her apparent seizure events occurred while on dilantin, the patient was loaded with 500mg fosphenytoin and her daily dose of dilantin was increased to 100/200/200. With this treatment, her seizures resolved and she was successfully extubated. Her dilantin level returned as 13.8. She markedly improved and was transferred to a neuromedicine floor on HD2. Her MS examination was remarkable for being alert, oriented to place, time and person. She was attentive, had no neglect. Her naming was intact. Her registration was intact, recall [**2-14**]. She was continued on dilantin at above dosing. Dilantin level at time of discharge was 17.7. Although she remained seizure free, she had signficant difficulties with balance and gait (likely due to peripheral neuropathy and cerebellar dysfunction). Because of this, her age and prior falls and gait instability, the plan is to wean her off dilantin and crostitrate with Keppra. She was started on 250mg [**Hospital1 **] of Keppra which is to be increased by 250mg in each dose every five days to maximum dose of 1g [**Hospital1 **]. At dose of 750mg [**Hospital1 **], her dilantin is to be tapered at by 100mg TID and then discontinued once dosing of Keppra reaches 1g [**Hospital1 **]. She will require neurology follow up for this. Given significant clinical improvement, she was discharged home with Neurosurtery and Neurology follow up. # Cervical Spine Evlauation: Because of her history of traumatic SDH, a CT of the C-spine was conducted. No fracture was seen and the patient was cleared by neurosurgery. # Cardiovascular/? NSTEMI: The patient had no documented history of coronary artery disease but was noted to have an elevated troponin on admission. Admission EKG demonstrated NSR w/ Left atrial abnormality, PAC and telemetry monitoring in the ICU was unremarkable. Repeat EKG was notable for no change. She did have troponin elevations but her CKMB was wnl. # Hypothyroidism. TSH was elevated and her T4 was low. She had sx of paresthesias and numbness in her extremities. There were no other signs of hypothyroidism. It is known that phenytoin can decrese circulating levels of T4, however, given her symptoms, levothyroxine was increased to 100mcg daily. Her PCP office was [**Name (NI) 653**] regarding this and requirement for further work up of peripheral neuropathy (we will send B12, Folate, RPR, UPEP/SPEP, LFTs, A1C, Lyme antibody). # Hyperkalemia. K was noted to be 5.1 on day of discharge. Pt. was asymptomatic. Medications on Admission: 1. Levothyroxine 75mcg daily 2. Dilantin 100/100/200 3. Oscal 4. Fosamax 5. Glucosamine 6. Fish oil 7. ASA Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for T>100.4 or pain. 2. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO BREAKFAST (Breakfast). 3. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO DINNER (Dinner). 4. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO NOON (At Noon). 5. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): x 4 days, then increased by 250mg each dose every five days until final dose of 1g [**Hospital1 **]. 6. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: Life care center of [**Location (un) **] Discharge Diagnosis: Primary: Right subdural hematoma, Status epilepticus Secondary: Peripheral neuropathy, Subdural hematoma Discharge Condition: Seizure free Discharge Instructions: You were admitted to [**Hospital1 18**] from another hospital for treatment of a prolonged seizure. It was found that your seizure was due to a new subdural hematoma (bleed) on your right side. This was felt to due to a possible fall you experienced. Fortunately, the hematoma on your left side has actually improved. Because of unresponsiveness to dilantin initially, and ongoing seizures, you required sedation and temporary intubation. With this her seizures were controlled. Dilantin dosing was increased and you were started on Keppra. Because of you balance difficulties, you will require rehabilitation and will require outpatient evaluation for peripheral neuropathy. The following changes were made to you medications: - Dilantin doses changed to 100mg/200mg/200mg with breakfast, lunch and dinner - Started on Keppra 250mg twice daily to be increased every five days. - Increased levothyroxine to 100micrograms daily Should your symptoms worsen, you develop confusion, headache, vision changes, difficulty with movements, worsening numbness in the legs or arms, chest pain or shortness of breath or any other symptom concerning to you, please call your primary care doctor or go to the emergency room. Followup Instructions: Please call your primary care doctor, [**Doctor Last Name **],[**Doctor Last Name 1037**] J. at [**Telephone/Fax (1) 34048**] to set up a follow up appointment within 2 weeks of discharge from the hospital. Please call the office of Dr. [**First Name (STitle) 3322**] [**Name (STitle) **] at ([**Telephone/Fax (1) 83450**] to set up a follow up appointment within 2 weeks of discharge from the hospital. Please call the office of Dr. [**Last Name (STitle) **] at [**Hospital6 1597**] at TELEPHONE # ([**Telephone/Fax (1) 83451**] to confirm your follow up neurosurgery appointment. Completed by:[**2195-10-16**]

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icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

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49015

Discharge summary

report

Admission Date: [**2181-10-5**] Discharge Date: [**2181-10-12**] Date of Birth: [**2130-4-3**] Sex: F Service: SURGERY Allergies: Penicillins / Codeine / Optiray 350 Attending:[**First Name3 (LF) 695**] Chief Complaint: HCV/HCC here for liver transplant Major Surgical or Invasive Procedure: [**2181-10-5**]: orthotopic liver transplant History of Present Illness: Ms. [**Known lastname 102887**] is a 50 yo F with h/o ETOH/HCV cirrhosis, focal liver lesion likely HCC by imaging (path [**9-/2180**]: small cell dysplasia),and TIPS x2 with h/o encephalopathy, MELD 29, listed for a liver transplant on [**2176-12-5**], now presents for liver transplant. Pt is morbidly obese, and her most recent BMI was calculated at 41.6. She is 5 feet 3 inches and weighs 106.8 kilos. Pt feels well. No recent illness except for possible R leg cellulitis treated with clinamycin in mid [**Month (only) **], which has since resolved. Denies fever, CP, SOB, nausea, vomiting. Denies dysuria. Past Medical History: - COPD - Cirrhosis c/b variceal bleed, hepatic encephalopathy, and ascites s/p TIPS procedure and embolization of duodenal varix - History of Heavy ETOH abuse - HCV (antibody postive, RNA negative) - Celiac: diagnosed with bx, noncompliant to gluten free diet - Chronic LE neuropathy - ?Diastolic CHF - Depression - Osteopenia - Hypothyroidism - s/p CCY - s/p TAH for endometrial hyperplasia Social History: Lives with husband. [**Name (NI) **] 1 son. Previously worked as an accountant but is not currently working. Former smoker, quit in [**2175**], has 30 pack year smoking history. Was drinking alcohol [**12-10**] gallon of vodka until [**2175**] when she quit. Denies IVDU. Family History: Father died of MI in 80s. Many alcoholics in family. One cousin with celiac sprue. Physical Exam: NAD HEENT NC, AT, trachea midline, JVD can't be appreciated, CN II-XII intact no murmurs appreciated, but distant breath sounds ctab abd soft, nt, nd but protuberant, no rebound or guarding 1+ LE edema. No erythema of RLE. Pertinent Results: On Admission: [**2181-10-5**] WBC-5.1 RBC-4.91 Hgb-15.4 Hct-44.2 MCV-90 MCH-31.3 MCHC-34.8 RDW-14.2 Plt Ct-159 PT-15.4* PTT-26.1 INR(PT)-1.3* Glucose-108* UreaN-19 Creat-1.0 Na-140 K-4.0 Cl-102 HCO3-27 AnGap-15 ALT-63* AST-75* AlkPhos-67 TotBili-1.2 Albumin-4.2 Calcium-9.4 Phos-3.2 Mg-1.8 At Discharge: [**2181-10-12**] WBC-11.8* RBC-3.36* Hgb-10.1* Hct-29.7* MCV-88 MCH-30.0 MCHC-34.0 RDW-15.0 Plt Ct-121* Glucose-107* UreaN-66* Creat-1.9* Na-130* K-4.8 Cl-93* HCO3-25 AnGap-17 ALT-100* AST-45* AlkPhos-123* TotBili-0.6 Calcium-8.2* Phos-3.0 Mg-3.0* FK: Brief Hospital Course: 51 y/o female with history of HCV and possible HCC and ETOH abuse in the past who now presents for orthotopic liver transplant. She was taken to the OR with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and underwent Orthotopic deceased donor liver transplant (piggyback) portal vein to portal vein anastomosis, common bile duct to common bile duct without a T tube, splenic artery of the recipient to the common hepatic artery of the donor. The patient received 4 units FFP and 4 units RBCs in the OR. She had persistent air in the right chest. Despite earlier aspiration, the air persisted so a [**Doctor Last Name 406**] drain was placed as a chest tube into the right chest and placed to Pleur-Evac suction. She had two JP drains placed. She tolerated the surgery and was transferred to the SICU intubated, in stable condition. She received routine induction immunsuppression, to include solumedrol 500 mg (with subsequent protocol taper) MMF and prograf was started on the evening of POD 0. Routine ultrasound on POD 1 showed patent hepatic arteries and veins and portal veins post-transplant. The chest tube was removed on POD 1, the patient extubated and she was able to transfer to the regular surgical floor on POD 2. She continued the solumedrol to prednisone taper, tolerated the mycophenylate and had daily trough prograf levels drawn with adjustments. It was held a few days due to levels as high as 17. The patient received several days of IV lasix to help with volume management. Lower extremity edema was greatly improved. Creatinine peaked at 2.8 and was trending back to normal by day of discharge. Urine output was adequate, and responded well to the lasix. Home Venlaxafine and pregabalin were restarted. The patient was evaluated by physical and occupational therapy and they recommended rehab Medications on Admission: ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) q6 prn FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg [**Hospital1 **] FUROSEMIDE [LASIX] 80qAM, 40 qPM IBANDRONATE [BONIVA] - 3 mg/3 mL Syringe - 1 injection q3mo LACTULOSE - 10 gram/15 mL Solution - 30cc Solution 3-4x/day prn LEVOTHYROXINE - 50 mcg Tablet qday OMEPRAZOLE EC 20 mg qdaily PREGABALIN [LYRICA] - 50 mg [**Hospital1 **] RIFAXIMIN [XIFAXAN] - 550 mg Tablet [**Hospital1 **] SPIRONOLACTONE - 100 mg Tablet [**Hospital1 **] TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule qdaily VENLAFAXINE - 75 mg Tablet qdaily ZOLPIDEM [AMBIEN] - 10 mg Tablet qHS Discharge Medications: 1. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 2. prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily): Follow transplant clinic taper. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 7. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Four (4) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. 9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed for wheezing. 10. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO once a day. 11. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical PRN (as needed) as needed for dry skin. 12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 13. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 14. venlafaxine 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. pregabalin 50 mg Capsule Sig: One (1) Capsule PO twice a day. 16. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 17. NPH insulin human recomb 100 unit/mL Suspension Sig: Fourteen (14) units Subcutaneous once a day: Breakfast. 18. insulin lispro 100 unit/mL Solution Sig: per sliding scale Subcutaneous four times a day. 19. tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: HCV/HCC cirrhosis now s/p liver transplant Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Please see PT/OT evaluation Discharge Instructions: Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever > 101, chills, nausea, vomiting, diarrhea, constipation, increased abdominal pain, redness, drainage or bleeding from the incision or old drain sites, increased edema, weight gain of greater than 3 pounds in a day or 5 pounds in a week, worsening respiratory status, inability to tolerate food, fluids or medications, yellowing of skin or eyes or any other concerning symptoms. Please obtain labwork on Mondays and Thursday and fax labs to the transplant clinic at [**Telephone/Fax (1) 697**]. CBC, Chem 10, AST, ALT, ALk Phos, T Bili, trough prograf level. Please do not change medications without consultation with the transplant clinic. No heavy lifting. Patient may shower, no tub baths or swimming Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2181-10-18**] 9:00, [**Hospital **] Medical Building, [**Location (un) **], [**Last Name (NamePattern1) 10357**], [**Location (un) 86**], MA Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2181-10-24**] 10:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14254**], [**Name12 (NameIs) 1046**] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2181-10-24**] 11:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2181-10-12**]

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icd9cm

[ [ [] ] ]

[ "50.59", "34.04", "00.93" ]

icd9pcs

[ [ [] ] ]

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255, 290

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125,364

50883

Discharge summary

report

Admission Date: [**2105-5-24**] Discharge Date: [**2105-6-3**] Date of Birth: [**2024-8-16**] Sex: M Service: MEDICINE Allergies: Vicodin Attending:[**First Name3 (LF) 896**] Chief Complaint: back and leg pain Major Surgical or Invasive Procedure: [**2105-6-3**] - Posterior lumbar laminectomy and fusion of L3-5 History of Present Illness: This is an 80M w/ history of A-fib on coumadin at home, admitted on [**5-27**] for heparin bridge prior to L3-5 lumbar lami/fusion. Intraoperatively, 1L EBL, post-operatively 1L through hemovac, and pt required phenylephrine gtt post-op, however this was weaned after receiving 3 u PRBC. On day of admission to SICU (POD#2), pt presented w/ delerium, tachycardia, fever to 100.9. . The patient underwent the procedure on [**2105-5-27**] without complications with 1L EBL intraop, and 1L EBL postop. However, post-operatively, his course has been complicated by delirium, agitation, and low-grade fevers post-op on [**2105-5-29**]. He was transferred to the SICU, briefly on Vanc/Cefepime, and was followed by the medicine consult service, who started him on Seroquel for delirium. In setting of increased agitation, the patient went into AFib with RVR in 120s and was restarted on his home sotalol. He was given IV Metoprolol 5 mg followed by IV Diltiazem 20mg x2. Per report, patient was hemodynamically stable throughout this period. He did miss doses of sotalol in past 48 hours due to inability to take PO medications for a time period. Cardiology was consulted on [**6-2**] per request of the medicine consult service and SICU team to for the afib. He was found to have heart rates in the 70-100s with SBP 110-120s. Cardiology c/s spoke with the patient's outpatient cardiologist who preferred the patient to be back on the home Sotolol and given the longstanding history of afib, did not wish to cardiovert the patient. Currently, the patient is A&Ox3 but does speak tangentially and also is unable to provide a completely coherent history. He does report he feels well without chest pain, dyspnea, lightheadedness, palpitations, or back pain. He notes that he has mild right lateral neck strain that occurs with turning his head to the left, and believes he slept in a position that may have strained his neck several days ago. Per report, the patient's wife confirms that his mental status has improved dramatically over the past 24-hour. Past Medical History: 1. CAD s/p IMI in [**12/2104**], s/p BMSx2 to RCA, IMI c/b VT arrest 2. [**Company 1543**] ICD for 2ndary prevention of VT arrest 3. PAF (on coumadin/sotalol since [**1-/2105**]) 4. HTN 5. L3-5 spinal fusion 6. PMR Social History: Patient lives with his wife, per wife's report, independent in ADLs. Unknown smoking history. Denies smoking, alcohol use currently and he denies recreational susbtance use. Family History: non-contributory Physical Exam: ADMISSION EXAM: . 98.2 130/80 85 24 98%RA GEN: Alert, interactive, pleasant, oriented x3, no acute distress HEENT: EOMI, sclera anicteric, MMM Neck: JVD <9cm, neck supple CV: Irreg irreg, no m/r/g PULM: Minimal inspiratory crackles at bases b/l, no wheezes or rhonchi, respirations unlabored ABD: Soft, NT/ND, +BS EXT: Warm, 2+ DP pulses, no pedal edema . DISCHARGE EXAM: . VITALS: 98.3 97.6 122/84 83 20 95% RA FS: 118-150 mg/dL I/Os: 780 (120) / - | 1220 (800) GENERAL: Appears in no acute distress. Alert and interactive; appropriate. Oriented to self, knew this was a hospital, knew year and president. HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear. Mucous membranes dry. NECK: supple without lymphadenopathy. JVD 2-cm above clavicle at 30-degrees. CVS: Irregularly irregular rate and rhythm, wit II/VI early systolic murmur at LUSB, without rubs or gallops. S1 and S2 normal. RESP: Decreased breath sounds to auscultation bilaterally at bases, without adventitious sounds. No wheezing, rhonchi or crackles. Stable inspiratory effort. ABD: soft, non-tender, non-distended, with normoactive bowel sounds. No palpable masses or peritoneal signs. BACK: Lumbar spinal incision clean, dry and intact. EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses NEURO: CN II-XII intact throughout. Alert and oriented x 3. Strength 4/5 bilaterally only limited by pain with excessive movement; sensation grossly intact. Gait deferred. Pertinent Results: ADMISSION & PERTINENT LABS: . [**2105-5-24**] 06:00PM BLOOD WBC-5.9 RBC-4.30* Hgb-12.4* Hct-39.6* MCV-92 MCH-28.7 MCHC-31.2 RDW-12.7 Plt Ct-154 [**2105-5-29**] 08:25AM BLOOD Neuts-81.5* Bands-0 Lymphs-9.8* Monos-7.8 Eos-0.4 Baso-0.5 [**2105-5-29**] 08:25AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2105-5-24**] 06:00PM BLOOD PT-13.3* PTT-63.3* INR(PT)-1.2* [**2105-5-24**] 06:00PM BLOOD Glucose-115* UreaN-36* Creat-1.2 Na-146* K-4.6 Cl-108 HCO3-28 AnGap-15 [**2105-5-29**] 08:25AM BLOOD ALT-45* AST-91* CK(CPK)-1247* AlkPhos-49 TotBili-0.5 [**2105-5-29**] 08:25AM BLOOD CK-MB-7 cTropnT-0.03* [**2105-5-29**] 05:36PM BLOOD CK-MB-4 cTropnT-0.03* [**2105-5-24**] 06:00PM BLOOD Calcium-9.7 Phos-3.1 Mg-2.2 [**2105-5-29**] 08:25AM BLOOD TSH-1.8 [**2105-5-30**] 04:45PM BLOOD Vanco-3.2* [**2105-5-29**] 11:41AM BLOOD Type-ART pO2-30* pCO2-45 pH-7.42 calTCO2-30 Base XS-2 [**2105-5-29**] 11:41AM BLOOD Lactate-1.2 [**2105-5-30**] 08:12PM BLOOD Lactate-0.8 . DISCHARGE LABS: . [**2105-6-3**] 04:00AM BLOOD WBC-5.9 RBC-3.01* Hgb-8.6* Hct-27.1* MCV-90 MCH-28.4 MCHC-31.7 RDW-12.5 Plt Ct-234 [**2105-6-3**] 04:00AM BLOOD PT-16.4* PTT-33.3 INR(PT)-1.5* [**2105-6-3**] 04:00AM BLOOD Glucose-105* UreaN-23* Creat-1.0 Na-142 K-4.3 Cl-106 HCO3-28 AnGap-12 [**2105-6-3**] 09:00AM BLOOD CK(CPK)-141 [**2105-6-3**] 09:00AM BLOOD CK-MB-3 cTropnT-0.05* [**2105-6-3**] 04:00AM BLOOD CK-MB-2 cTropnT-0.05* [**2105-6-3**] 04:00AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.0 . MICROBIOLOGY DATA: [**2105-5-29**] Urine culture - negative [**2105-5-29**] Blood culture (x 2) - pending [**2105-5-29**] MRSA screen - negative [**2105-6-3**] Blood culture - pending . IMAGING: [**2105-6-2**] CHEST (PORTABLE AP) - As compared to the previous radiograph, there is no relevant change. The Dobbhoff catheter has been advanced and is now in correct position, projecting over the middle parts of the stomach. Normal size of the cardiac silhouette. No pulmonary edema. No parenchymal opacities. Unchanged course of the cardiac pacemaker lead. . [**2105-6-3**] CHEST (PORTABLE AP) - Comparison is made to the prior study, [**2105-6-2**]. Cardiac size is top normal. Transvenous pacemaker lead terminate in the right ventricle. Faint opacity in the right upper lobe and increasing opacification in the lower lobes bilaterally are worrisome for multifocal pneumonia. There is no pneumothorax. If any, there is a small left pleural effusion. Brief Hospital Course: IMPRESSION: 80M with a PMH significant for atrial fibrillation, chronic back pain, coronary artery disease (s/p inferior myocardial infarction and ventricular fibrillation arrest requiring ICD placment for secondary prevention) who presented on [**2105-5-24**] for lumbar spine fusion surgery with a post-op course complicated by acute delirium and hemodynamically stable atrial fibrillation with rapid ventricular response that has all improved. # ATRIAL FIBRILLATION - The patient has a history of paroxysmal atrial fibrillation, and has been on Coumadin and Sotalol since 1/[**2105**]. Cardiology was consulted in the SICU and spoke to the outpatient Cardiologist who did not wish to cardiovert the patient given his long-standing history of atrial fibrillation. The patient responded to IV dosing of Diltiazem and required only intermittent dosing of IV phenylephrine for pressor support. He was quickly weaned following transfusion of 3 units of packed red cells. His rapid ventricular response was likely precipitated by holding his home anti-arrhythmic and volume depletion post-operatively. His home dosing of Sotalol was continued following his stabilization. We also initiated rate control with Metoprolol twice daily. He remained in atrial fibrillation with a ventricular rate in the low 100s prior to discharge, while on telemetry monitoring. He had only ocassional PVCs and his ICD interrogation was reassuring this admission. He was continued on Coumadin 2.5 mg PO daily for anticoagulation and had no bleeding concerns. He will continue on this dose at discharge. His INR was 1.5 at discharge. He should schedule follow-up with his outpatient Cardiologist. # LUMBAR SPINAL FUSION - The patient is status-post L3-5 spinal fusion ([**2105-5-24**]) and will utilize a back brace and can advance activity as tolerated. His post-op pain was controlled with Dilaudid. Given his narcotic needs, his mental status should be monitored and his bowel regimen should be aggressive. He will also continue working with physical therapy. He will need follow-up with Orthopedic Spine Surgery in [**10-25**] days following discharge. # ACUTE DELIRIUM - Patient developed post-op acute delirium in the setting of sedation and narcotic administration. His Venlafaxine and Trazodone was discontinued. His infectious work-up was overall reassuring and his blood and urine cultures remained reassuring at the time of discharge. One should note, at the time of discharge, he had a CXR concerning for multifocal opacifications that could be an early infectious process, but he remained afebrile and had no leukocytosis. One could consider healthcare-associated pneumonia coverage if this generates symptoms. His mental status improved overall at the time of discharge. He remained alert and oriented to time, place and person. # HYPERTENSION - The patient had lower blood pressures with the atrial fibrillation with RVR, but this improved with blood products post-operatively and rate control. We did decreased his ACEI dose to 10 mg PO daily and titrated his beta-blocker. # CORONARY ARTERY DISEASE - Patient is s/p inferior myocardial infarction in [**12/2104**], s/p BMS x 2 to RCA and his inferior MI was complicated by a VT arrest and a [**Company 1543**] ICD was placed for secondary prevention. No evidence of active ischemia this admission. EKG and cardiac biomarkers remained reassuring. Cardiology and EP evaluated him this admission and felt his cardiac medications were optimized and interrogated his pacer; there were no concerning events and his ICD was operating well. He was maintained on telemetry with minimal concern and his electrolytes were optimized. # POLYMYLAGIA RHEUMATICA - The patient is currently on Prednisone 1 mg for his reported history of PMR, per his wife. We resumed his Prednisone dose of 1 mg daily following stabilization. His blood glucose remained below 200 mg/dL and he required minimal insulin sliding scale. TRANSITION OF CARE ISSUES: 1. Assistance with medication administration while at facility. 2. Coumadin 2.5 mg PO daily with INR goal [**2-13**]. Indication: atrial fibrillation. Does NOT need telemetry monitoring. ICD device recently interrogated and functioning well. 3. The back brace is to be worn for comfort when you are walking. You may take it off when sitting in a chair or while lying in bed. 4. Wound care: incision is completely dry; (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. 5. Consider insulin sliding scale if fingerstick glucose is consistently elevated above 200 mg/dL given Prednisone needs. 6. Patient was discharged with no cough or respiratory symptoms, no oxygen needs, afebrile and without a white count. However, a CXR showed some small areas that may be concerning for multifocal consolidation. IF SYMPTOMS ARISE, consider treatment health-care associated pneumonia. 7. Patient needs follow-up schedued with primary care physician, [**Name10 (NameIs) **] and Orthopedic Surgery spine clinic. 8. At the time of discharge, the patient had blood cultures pending from admission, but these were no growth to-date. Medications on Admission: ASA 81mg Lisinopril Prednisone Simvastatin Trazodone Venlafaxine Sotalol 40mg [**Hospital1 **] Coumadin Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. sotalol 80 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: goal INR [**2-13**]. 6. prednisone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three times a day as needed for pain. 10. multivitamin Tablet Sig: One (1) Tablet PO once a day. 11. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: Monitor for sedation or RR < 8. Disp:*45 Tablet(s)* Refills:*0* 12. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital **] Rehabilitation and Skilled Nursing - [**Location (un) 22361**] Discharge Diagnosis: Primary Diagnoses: 1. Lumbar spinal stenosis 2. Atrial fibrillation with rapid ventricular response 3. Acute delirium or encephalopathy . Secondary Diagnoses: 1. Hypertension 2. Coronary artery disease 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: Patient Discharge Instructions: . You were admitted to the Internal Medicine service at [**Hospital1 1535**] on CC6 regarding management of your lumbar spine and your need for recent surgery. Following the surgery, you developed atrial fibrillation with an increased heart rate and had some issues with altered mental status and delirium, which improved. You are being discharged to a rehabilitation facility to improve your strength and work with physical therapy. . Please call your doctor or go to the emergency department if: * You experience new chest pain, pressure, squeezing or tightness. * You develop new or worsening cough, shortness of breath, or wheezing. * You are vomiting and cannot keep down fluids, or your medications. * If you are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include: dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit, or have a bowel movement. * You experience burning when you urinate, have blood in your urine, or experience an unusual discharge. * You have pain that is not improving within 12 hours or is not under control within 24 hours. * Your pain worsens or changes location. * You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. * You develop any other concerning symptoms. . ACTIVITY RESTRICTIONS: You should NOT lift anything greater than 10 lbs for 2-weeks. You will be more comfortable if you do not sit or stand more than 45 minutes without getting up and walking around. . BRACING: You have been given a brace. This brace is to be worn for comfort when you are walking. You may take it off when sitting in a chair or while lying in bed. . WOUND CARE INSTRUCTIONS: Remove the dressing in 2-days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. . CHANGES IN YOUR MEDICATION RECONCILIATION: . * Upon admission, we ADDED: START: Metoprolol 50 mg by mouth twice daily START: Senna 8.6 mg tablet by mouth twice daily for constipation START: Colace 100 mg tablet by mouth twice daily for constipation START: Multivitamin 1 tablet by mouth daily START: Dilaudid 2 mg (1-2 tablets) by mouth every 4-6 hours for pain control (AVOID taking this medication if anticipate driving or while consuming alcohol) START: Acetaminophen 1000 mg by mouth three times daily for pain control . * This admission, we CHANGED: DECREASED: Lisinopril from 20 to 10 mg by mouth daily. . * The following medications were DISCONTINUED on admission and you should NOT resume: DISCONTINUE: Venlafaxine DISCONTINUE: Trazodone . * You should continue all of your other home medications as prescribed, unless otherwise directed above. Followup Instructions: You should schedule follow-up with your primary care physician [**Last Name (NamePattern4) **] [**1-12**] weeks. Your rehabilitation facility with assist with scheduling this. . Please call the Orthopedic Surgery-Spine surgery team at [**Telephone/Fax (1) 3573**] to schedule follow-up with Dr. [**Last Name (STitle) 363**] or his nurse practitioner in 2-weeks. . You should also call and schedule follow-up with your outpatient Cardiologist in [**2-13**] weeks, following discharge.

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icd9cm

[ [ [] ] ]

[ "81.63", "96.6", "81.07" ]

icd9pcs

[ [ [] ] ]

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284, 351

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50273

Discharge summary

report

Admission Date: [**2193-12-14**] Discharge Date: [**2193-12-16**] Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2297**] Chief Complaint: AMS, resp distress Major Surgical or Invasive Procedure: None History of Present Illness: This is a 86 yo h/o F with h/o DMII, Afib on Coumadin, HTN, HL, CAD, obesity, colon ca s/p resection in [**2173**], a recent CVA in [**10-25**] resulting in dysphagia, aphasia and R sided weakness and a recent admission with worsened mental status thought to be [**12-18**] VRE UTI (completed Linezolid [**2193-12-12**]) now presents from rehab with persistent altered mental status and respiratory distress. At rehab, was noted to have O2 sat of 74% on RA and lethargic. ABG there was pH 7.31 pCO2 73 pO2 73 O2 sat 93% on 2L NC. Pt was started there on BiPAP 10/4. Pt noted to have improved MS at that time. Arrived to [**Hospital1 18**] ED on a NRB. Pt is not on home oxygen or CPAP. . In the ED, initial VS 95.8 58 151/48 24 100% 12L NRB. Pt was then weaned off the NRB, but then was 87-88% on [**Last Name (LF) **], [**First Name3 (LF) **] was put on NC. Then was noted to be breathing with accessory muscle use, so was placed back on NRB. ABG showed hypercapnea pH 7.36 pCO2 61 pO2 186. ED physicians talked to family regarding pt's code status which is currently full code, however would like to rethink if intubation was iminent. Pt has a dobhoff in place since the stroke. CXR showed bibasilar infiltrates concerning for pna so pt was given Levofloxacin 750mg and Vancomycin 1g. Lactate was wnl. VS on transfer were HR 65 BP 162/46 RR 18 O2 sat 100% on BiPAP 10/8 with FiO2 of 50%. . Upon arrival to the ICU, pt is lying in bed, with BiPAP mask on. Appears comfortable. Non responsive to voice or touch, though family at bedside seems to think she is minimally responding. Pt's family states her current mental status is similar to what it has been for the last few weeks since the stroke. But, have noticed that she has become progressively more lethargic, sleepy. No fevers at rehab. Pt recieved 1U pRBCs for Hct 21. Past Medical History: Afib on coumadin CHF (EF 40-45%) DMII HTN Obesity CAD Hypercholesterolemia Urinary urgency Gait disorder h/o colon cancer Social History: used to live at home with her granddaughter, but recently at [**Hospital 100**] rehab. Denies tobacco, EtOH, and illicits. Family History: significant for HTN, CAD, and asthma Physical Exam: VS: Temp: 97.6 BP: 170/54 HR: 60 RR: 18 O2sat: 100% on BiPAP [**8-23**] FiO2 50% GEN: NAD, not responsive to voice but responsive to sternal rub, does not follow simple commands HEENT: PERRL, anicteric, dry MM, BiPAP mask on Neck: unable to assess JVP given body habitus, no LAD or masses RESP: CTAB anteriorly, no wheezes CV: RRR, S1 and S2 wnl, 3/6 systolic murmur best heard at RUSB ABD: obese, well-healed midline scar, nd, soft, nt, no masses or hepatosplenomegaly EXT: 3+ edema in all ext SKIN: left heel ulcer with dressing c/d/i NEURO: unable to assess due to pt not able to cooperate O2 sats improved to mid 90s on 1L NC at discharge. BP 160/50 HR 60s Afebrile Pertinent Results: [**2193-12-14**] WBC-5.3 RBC-3.10* Hgb-8.4* Hct-25.5* MCV-82 MCH-27.0 MCHC-32.8 RDW-17.3* Plt Ct-106*# [**Month/Day/Year 3143**] PT-31.2* PTT-21.6* INR(PT)-3.1* 04:20PM [**2193-12-16**] 03:38AM [**Month/Day/Year 3143**] PT-60.9* PTT-31.4 INR(PT)-6.9* Glucose-168* UreaN-46* Creat-0.8 Na-146* K-4.1 Cl-108 HCO3-31 AnGap-11 [**2193-12-14**] 04:20PM [**Month/Day/Year 3143**] [**2193-12-16**] 03:38AM [**Month/Day/Year 3143**] Glucose-122* UreaN-40* Creat-0.7 Na-146* K-3.9 Cl-107 HCO3-33* AnGap-10 04:45PM [**Month/Day/Year 3143**] proBNP-6462* [**2193-12-14**] 04:45PM [**Month/Day/Year 3143**] Type-ART pO2-179* pCO2-64* pH-7.34* calTCO2-36* Base XS-6 Comment-NASAL [**Last Name (un) 154**] [**2193-12-15**] 01:27AM [**Month/Day/Year 3143**] Type-ART pO2-78* pCO2-59* pH-7.39 calTCO2-37* Base XS-7 [**2193-12-16**] WBC-5.6 RBC-3.26* Hgb-8.8* Hct-26.2* MCV-80* MCH-27.0 MCHC-33.5 RDW-17.6* Plt Ct-252 WBC-5.6 RBC-3.26* Hgb-8.8* Hct-26.2* MCV-80* MCH-27.0 MCHC-33.5 RDW-17.6* Plt Ct-252 [**2193-12-16**] 04:11PM [**Month/Day/Year 3143**] Hct-24.5* Imaging CT head [**12-14**]:IMPRESSION: No acute intracranial process. Known infarction of the posterior limb of the left internal capsule. CXR [**12-14**]: IMPRESSION: Mild-to-moderate pulmonary edema with mild increase in bilateral pleural effusions. Brief Hospital Course: 86 yo h/o F with h/o DMII, Afib on Coumadin, systolic CHF, obesity, recent CVA and a recent admission for VRE UTI now here for worsening mental status and respiratory distress. . 1. Respiratory distress: Most likely secondary to acute on chronic systolic CHF given CXR with pulm edema and increased effusions as well as elevated BNP and overall improvement with diuresis. Pneumonia unlikely given lack of fever or leukocytosis. PE unlikely given therapeutic INR. Hypercapnea may be multifactorial [**12-18**] obesity or central hypoventilation 2/2 stroke. Patient's respiratory status improved with diuresis and she was weaned off bipap and down to 1-2L NC. . 2. AMS: Per family, pt has been nimimally responsive, occasionally opening her eyes to voice and saying some words but only to certain family members. Overall, she has not been consistently following commands or opening eyes to voice or communicating. Family states pt's mental status has been progressively worsening since the CVA. CT head without acute process and [**Month/Day (2) **] and urine cx NGTD. Overall, minimal responsiveness likely secondary to CVA and possibly udnerlying delirium of unclear etiology. . 3. CAD/HTN/HL: Continued home medications. . 4. Acute on chronic systolic CHF: EF 40-45%, pulm edema on CXR. Shre received Lasix 40mg IVx1 and was 1L negative, overall 3L negative for length of stay. She was weaned down to 1L NC O2 and home diuretic regimen was restarted. She should be weighed daily and regimen should be increased to 60mg PO BID if weight increases. . 5. DMII: Continued home insulin regimen with fingersticks QID . 5. Anemia: rec'd 1U pRBCs at rehab for Hct 21 and was transfused 1 unit PRBCs on [**12-15**] with subsequent stable HCTs in mid 20s. Guaiac negative. HCT should be repeated on [**2193-12-17**] to ensure stability. . 6. Afib: held warfarin in setting of supratherapeutic INR which was attributed to heart failure. INR should be monitored daily and coumadin restarted at lower dose (was on 6mg Po daily) when INR<3. FEN: TFs Access: PIVs Comm: son [**Name (NI) **] [**Name (NI) 13662**] (HCP) [**Name (NI) 7092**]: full confirmed with HCP . Medications on Admission: 1. lisinopril 20 mg DAILY 2. labetalol 200 mg 3 times a day 3. aspirin 81 mg Daily 4. simvastatin 20 mg once a day 5. ferrous sulfate 300 mg Daily 6. diltiazem HCl 120 mg Sust. Release twice a day 7. warfarin 6 mg Daily 8. clonidine 0.1 mg 2 times a day 9. Colace 100 mg twice a day 10. senna 8.6 mg twice a day as needed for constipation 11. furosemide 40 mg [**Hospital1 **] 12. pantoprazole 40 mg twice a day 13. insulin glargine 100 unit/mL Solution Sig: 18 units Subcutaneous once a day. 14. insulin lispro 100 unit/mL Solution Sig: as per sliding scale units Subcutaneous QACHS. Discharge Medications: 1. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Aspirin [**Hospital1 1926**] 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 4. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 6. diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO twice a day. 7. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 9. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day. 10. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day. 11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 12. glargine Sig: Eighteen (18) units at bedtime. 13. lispro Sig: per sliding scale four times a day: Sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital 671**] [**Hospital 4094**] Hospital - [**Location (un) 86**] Discharge Diagnosis: Primary Diagnosis: Acute on chronic systolic heart failure Secondary Diagnosis: s/p CVA, altered mental status Discharge Condition: Patient is somnolent, opens eyes to painful stimuli and occasionally family's voices. Aphasic. R hemiparesis. O2 sats mid 90s on 1L NC Discharge Instructions: You were admitted to the ICU with low oxygen levels. You were given a medicien called lasix to remove fluid from your lungs and your oxygen levels improved. According to your family, you have also been less awake and interactive since your stroke. This did not improve during yoru ICU stay but we checked your [**Location (un) **] and urine for infection and did not find any evidence of infection. We made the following changes to your medications 1. We held your coumadin because you INR was high. Your INR should be rechecked on [**12-17**] and daily until it is less than 3. When it is less than 3, it should be restarted Followup Instructions: Please follow up at your facility with the physician [**Name Initial (PRE) **].

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8296, 8395

4495, 6659

240, 247

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275, 2118

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44,624

153,961

42319

Discharge summary

report

Admission Date: [**2181-9-21**] Discharge Date: [**2181-9-25**] Date of Birth: [**2102-10-20**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: hypotension, syncope, L1 burst fracture Major Surgical or Invasive Procedure: None History of Present Illness: 78 y/o w/cirrhosis (unclear if decompensated) presents with nausea, vomitting and syncope. . Is at baseline an active person. Per family, she has complained of feeling tired and increased urination but was otherwise well until 2 days prior to admission. 2 days ago, she began to feel lethargic She complained of feeling nauseated and lightheaded for one to 2 days with 2-3 episodes of nonbloody emesis, but no fever, headache, chest pain, dyspnea, abdominal pain, diarrhea, dysuria, cough. She got up to vomit, and then felt lightheaded and syncopized, falling on her back on a carpetted hallway. She initially presented to OSH, where CT torso and C-spine was completed which was notable for L1 burst fracture, but no evidence for pulmonary or abdominal infection or hemorrhage. At the OSH, she was afebrile, but hypotensive with SBP 70s unresponsive to fluid rescusitation (2L given at OSH (at 0919 and 1018) and was started on dopamine at 1258. She was started on vancomycin and cefepime at 1pm on [**2181-9-21**](uncertain whether cultures were drawn). . In the ED, initial vitals were 98.8 80 130/62 16 95% 2L. Labs were notable for leukocytosis 17, HCT 30.5, HCO3 20, normal liver enzymes and synthetic function, and cortisol (pending). UA not suggestive of infection. Guaiac exam was negative. She was neurologically intact. She received a FAST ultrasound which was negative and bedside echocardiogram did not reveal a pericardial effusion. She received a right IJ and was started initially on dopamine and then transitioned to levophed for blood pressure support. Also received morphine and zofran. Total 3L NS given (2L at OSH and 1L in ED). Most recent vitals prior to transfer 97.6 65 112/48 (on levophed) 16 98%2L. Access CVL and 2 peripherals. . On arrival to the MICU, she is oriented, pleasant and complaining of pain on movement. . Ms. [**Known lastname 10881**] last hospitalization was in [**2178**] from [**6-28**] to [**7-2**]. She was admitted [**Last Name (un) 26512**] of gait disturbance, weakness and a progressive inability to care for self. At this time she was drinking etoh and taking HCTZ, Lisinopril, Amlodipine and Propranolol as well as Ca, and Vit D. She was admitted with low K, Mg and asterixis. A CT scan apparently revealed cirrhosis and varices that were also (apparently) seen on ultrasound. A murmur was investigated by TTE with 60%EF and no valvular abnormalities detected. She was dischrged on Folic/B12/B1, Norvasc 5, Lisinopril 20, Corgard 20, Protonix 40, K 20, lisinopril 20. Propranolol and HCTZ were dc'd. Past Medical History: ETOH cirrhosis - possibly decompensated with encephalopathy during possibly etoh hepatitis. - EGD [**2179-7-23**] - chronic active gastritis, - AFP elevated and then "normal" Colonoscopy - [**2177**] - polyps, diverticulosis Macrocytic Anemia HTN Dyslipidemia IBS Colon adenoma [**11/2178**] Appendectomy Social History: Lives with huband for whom she is the primary caretaker (he is blind and diabetic). Has 3 children, [**Doctor First Name **] is the HCP. A son is presently in [**Country **] - Tobacco: none - Alcohol: "1-2 drinks per night" quit 1-2 years ago - Illicits: none Family History: NC Physical Exam: ADMISSION EXAM General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD, RIJ in place (c/d/i) 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, no ascites GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema DISCHARGE EXAM VS: 68, 104/62, 99% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD, RIJ in place (c/d/i) CV: Regular rate and rhythm, normal S1 + S2, 2+ systolic murmur at RUSB, no rubs or gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, no ascites GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS [**2181-9-21**] 03:25PM BLOOD WBC-17.6* RBC-3.14* Hgb-10.8* Hct-30.5* MCV-97 MCH-34.3* MCHC-35.3* RDW-13.3 Plt Ct-103* [**2181-9-21**] 03:25PM BLOOD Neuts-75* Bands-13* Lymphs-2* Monos-9 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [**2181-9-21**] 03:25PM BLOOD PT-14.1* PTT-30.4 INR(PT)-1.2* [**2181-9-21**] 03:25PM BLOOD Glucose-161* UreaN-23* Creat-1.0 Na-136 K-4.3 Cl-109* HCO3-20* AnGap-11 [**2181-9-21**] 03:25PM BLOOD ALT-12 AST-33 AlkPhos-65 TotBili-1.1 [**2181-9-21**] 03:25PM BLOOD Calcium-8.5 Phos-2.8 Mg-2.0 [**2181-9-21**] 09:23PM BLOOD Lactate-2.4* DISCHARGE LABS [**2181-9-25**] 02:54AM BLOOD WBC-4.7 RBC-2.58* Hgb-9.0* Hct-24.9* MCV-97 MCH-34.9* MCHC-36.0* RDW-13.4 Plt Ct-124* [**2181-9-25**] 02:54AM BLOOD PT-12.9 PTT-39.5* INR(PT)-1.1 [**2181-9-25**] 02:54AM BLOOD Glucose-85 UreaN-6 Creat-0.6 Na-137 K-4.0 Cl-108 HCO3-27 AnGap-6* [**2181-9-25**] 02:54AM BLOOD Calcium-7.8* Phos-2.0* Mg-1.9 PERTINENT LABS [**2181-9-23**] 04:10AM BLOOD ALT-12 AST-32 AlkPhos-50 TotBili-0.8 [**2181-9-22**] 05:37AM BLOOD CK-MB-5 cTropnT-0.01 [**2181-9-21**] 03:25PM BLOOD Lipase-21 [**2181-9-22**] 05:37AM BLOOD TSH-2.3 [**2181-9-21**] 03:25PM BLOOD Cortsol-33.6* PERTINENT IMAGING [**9-24**] ECHO Conclusions The left atrium is elongated. The right atrium is moderately dilated. 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 ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. An eccentric, jet of mild to moderate ([**12-31**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Mild aortic valve stenosis. Mild-moderate mitral regurgitation. Normal biventricular cavity sizes with preserved global biventricular systolic function. Mild pulmonary artery hypertension. Brief Hospital Course: 78 y/o w/cirrhosis, presents with nausea, vomitting and syncope, and persistent bradycardia and hypotension . ACTIVE ISSUES #) Hypotension and bradycardia: While the patient had no signs of end organ failure, hypotension and bradycardia were concerning. The etiology for hypotension and bradycardia is thought primarily medication induced, especially nadolol. Her Lisinopril, Nadolol, lasix and aldactone were held. The patient also had signs and laboratory findings suggesting of sepsis, notably the bandemia. However the patient remained afebrile while here, and was generally fluid responsive. Patient was covered prophylactically with antibiotics. Pt had an TTE, which did not show evidence of left ventricular hypertrophy, or ongoing ischemia, nor were her laboratory results. Her BP and bradycardia resolved after a short period of pressor support. OUTPATIENT ISSUES: - Held patient's lasix, lisinopril, aldactone, please gradually restart as needed. - Held patient's nadolol. We think this is the major culprit of her hypotension and bradycardia. Please discuss with patient's PCP or hepatologist before restarting this medication. . # L1 burst fracture - no neurological compromise, evaluated by orthopedics, patient to be braced. Patient's pain was controlled with a combination of long acting and short acting oxycodone. Serial neurological exams did not show change. OUTPATIENT ISSUES: - STARTED MSContin 10 mg [**Hospital1 **], and oxycodone 5 mg prn - STARTED to use spine brace - patient needs Ortho-Spine follow-up in 6 weeks, should wear brace until then . # Cirrhosis: Cirrhosis was a relatively recent diagnosis. Likely decompensated in [**2178**] with encephalopathy during a mild etoh hepatitis in the setting of profound hypokalemia related either to hypomagnesemia of etoh or HCTZ. There is a mention of varices on CT/US, was on lactulose though briefly, on aldactone/furosemide though no mention of ascites. Family is suspicious that the patient is actively drinking for which their is some ancillary confirmatory signs (low plts, macrocytosis). We held her nadolol, aldactone, fursomide. We started her thiamine and folate. . # HTN - holding meds as above . Anemia - around her baseline - trend per routine . CHRONIC ISSUES # Thrombocytpoenia: At baseline, multifactorial, including alcohol abuse, cirrhosis and poHTN. . # Gastritis - started on PPI . # Depression - continued celexa 10 mg. . TRANSITIONAL ISSUES Pt declared a full code during this hospitalization. Medications on Admission: Lisinopril 20 qd Folate 1mg Nadolol 20 mg daily Thiamine 100 mg daily; Magox 40 Citalopram 10 Protonix 40 Lasix 20 d Aldactone 25 qd Hx of Lactulose Discharge Medications: 1. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q12H (every 12 hours). Disp:*30 Tablet Extended Release 12 hr(s)* Refills:*0* 2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) as needed for pain: please hold for SBP < 100. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain: Please hold for SBP < 100. Disp:*30 Tablet(s)* Refills:*0* 4. citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day. 5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Location (un) **] House Nursing Home - [**Location 9583**] Discharge Diagnosis: L1 burst fracture Hypotension Bradycardia 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: Dear Ms. [**Known lastname 1968**], You came to our hospital for weakness and a recent fall. You were found to have a low blood pressure and low heart rate, the likely cause of most of your symptoms. You were treated with supportive treatment in the intensive care unit. We initially started you on antibiotics, but later stopped these as we did not feel you had an infection. Your low blood pressure and heart rate may have been due the medication Nadolol that you were taking, which we have stopped. Imaging studies also showed that you had a fracture in your spine. You were seen by the Orthopedic-Spine surgeons, who did not feel you needed surgery. They recommended you wear a brace, and follow-up with them in 6 weeks. We started you on medication for pain control. Please note that the following medication has been changed: - We held your medication that may lower your blood pressure, inculding lisinopril, lasix, Aldactone and Nadolol. Your doctor can slowly add back lisinopril, lasix and aldactone. Please talk to your PCP or hepatologist before restarting nadolol. - We started oxycodone extended release and oxycodone immediate releasse for pain control Followup Instructions: You will need an orthopedics follow up in 6 weeks. Please call ([**Telephone/Fax (1) 2007**] to schedule your appointment. You can schedule an earlier appointment if you have trouble with the brace. Please also call your PCP to schedule an appointment in two weeks. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

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icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

[ [ [] ] ]

10322, 10410

6860, 9357

353, 359

10496, 10496

4633, 6837

11876, 12284

3581, 3585

9557, 10299

10431, 10475

9383, 9534

10672, 11853

3600, 4614

273, 315

387, 2954

10511, 10648

2976, 3284

3300, 3565

11,233

164,411

30061

Discharge summary

report

Admission Date: [**2179-3-18**] Discharge Date: [**2179-3-25**] Date of Birth: [**2119-9-13**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8747**] Chief Complaint: found down Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 59yo handed woman with ESRD, HTN, bladder ca, Afibb (off coumadin for procedure), hyperlipidemia, psychiatric disease who is transferred from OSH for L-thalamic bleed. The pt was found down this am by her son. Pt is not able to tell when she fell or what precipitated the fall. She was conscious but "confused" and was not able to move her R-side well. She was brought to OSH where a R-fibula fracture was noted as well as a L-thalamic bleed. She was transferred here. BP 229/105. In the ED she is able to talk and follow commands but unable to provide any details or come up with the phone number of her son. She denies headache, or pain in her extremities when she is laying (when moving her R leg is hurts though). She does not understand why her R-arm is not moving and reaches out for it with her L-arm. She denies nausea or vomiting; no chills or recent fevers. She says she has been taking her meds. No tingling. When talking to son later, he found blood in her bathroom, on floors and walls. He called her at 7am and she did not answer, then at 8am she was able to answer and told her son that she had fallen. ROS: denies any fever, chills, weight loss, visual changes, hearing changes, headache, neckpain, nausea, vomiting, dysphagia, tingling, numbness, bowel-bladder dysfunction, chest pain, shortness of breath, abdominal pain. Past Medical History: -ESRD, on HD; fibrotis and sclerosis -bladder ca [**2178-10-28**] -HTN -Afibb with RVR -anxiety disorder, psychosis and non-compliance with anti-psych meds -hyperlipidemia Social History: lives alone; 2 adult sons; smokes one ppd; no ethoh; no drugs Family History: pt denies Physical Exam: VITALS: T99.5 HR81 BP229/105 RR18 sO2 98 on sL GEN: lethargic, bruised HEENT: mmm, neck supple NECK: no LAD; no carotid bruits LUNGS: Clear to auscultation bilaterally HEART: Regular rate and rhythm, normal S1 and S2, no murmurs, gallops and rubs. ABDOMEN: normal bowel sounds, soft, nontender, nondistended EXTREMITIES: extensive bruises and some laceration on the extr on the R. fracture R fibula MENTAL STATUS: Awake somewhat lethargic, cooperative with exam. Oriented to place, month, [**2175-3-22**] Attention: DOWbw fine Memory: Registration: [**3-20**] items; Recall [**1-20**] at 5 min. Language: fluent; repetition: intact; Naming intact; Comprehension intact, but difficulties with complex tasks; mild dysarthria, no paraphasic errors. [**Location (un) **]: intact; No Apraxia. No Neglect.Cannot remember her sons phone number. CRANIAL NERVES: II: Visual fields are full to confrontation, pupils equally round and reactive to light both directly and consensually, 2-->1 mm bilaterally. Disc margins sharp, no pappilledema. III, IV, VI: Extraocular movements intact without nystagmus. Fixation and saccades are normal. No ptosis. V: Facial sensation intact to light touch and pinprick. VII: R-facial droop, UMN pattern VIII: Hearing intact to finger rub bilaterally. IX: Palate elevates in midline. XII: Tongue protrudes in midline, no fasciculations. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. MOTOR SYSTEM: Decreased bulk throughout. Mild postural tremor LUE Full strength LUE and LLE. R-arm not able to move antigravity proximally, trace movement in her fingers. RLE hard to test given fracture, but unable to lift off the bed for >2 secs. REFLEXES: B T Br Pa Pl Right 2+ 2+ 2+ 3 ? Left 2 2 2 3 2 Toes: down on L; unable to test on the R due to fracture SENSORY SYSTEM: Sensation intact to light touch, pin prick, temperature (cold), vibration, and proprioception in all extremities. Unclear whether there was extinction. COORDINATION: Normal [**Last Name (LF) 11140**], [**First Name3 (LF) **] on the L. Unable to perform HTS on the L and unable to test the R. GAIT: deferred On discharge: still with complete right hemiparesis, improving R facial droop, improving speech. Pertinent Results: OSH labs: trop 00.7 PT 12.4 INR 1.1 PTT 28 WBC 9.3 N89.6 Hct 39 PLT 202 139 103 73 -------------- 101 5.5 21 6.2 Ca 9.6 CK 423 Mg 2.0 CT spine: fine, but not able to assess C2 due to motion artifact CT head: "An 18mm hemorrhagic focus is demonstrated in the region of the left thalamus and adjacent posterior limb of the internal capsule. No significant midline shift identified. An old lacunar infarct is shown in the basal ganglia on the right. There is some prominence of the CSF spaces inidicating volume loss. There patchy hypodensities in the periventricular white matter consistent with small vessel ischemia more likely chronic. The skull vault appears intact. Impression: 18mm hemorrhage within or adjacent to the left thalamus and likley involving the posterior limb of the left internal capsule." - repeat head CT @2:10pm "17mm hemorrhage with a rim of edema but no significant resultant mass effect or intraventricular extension, essentially stable." On admission: [**2179-3-18**] 01:15PM BLOOD WBC-7.8 RBC-4.43 Hgb-11.9* Hct-37.5 MCV-85 MCH-26.8* MCHC-31.6 RDW-20.6* Plt Ct-247 [**2179-3-18**] 01:15PM BLOOD Neuts-89.0* Lymphs-5.2* Monos-5.6 Eos-0.2 Baso-0.1 [**2179-3-18**] 01:15PM BLOOD PT-12.9 PTT-23.8 INR(PT)-1.1 [**2179-3-18**] 01:15PM BLOOD Glucose-93 UreaN-73* Creat-6.1* Na-139 K-5.7* Cl-106 HCO3-20* AnGap-19 [**2179-3-18**] 01:15PM BLOOD ALT-19 AST-28 AlkPhos-69 TotBili-0.2 Other: Cholest-181 Triglyc-121 HDL-65 CHOL/HD-2.8 LDLcalc-92 %HbA1c-5.9 TSH-0.69 Imaging: x-rays: No bony injury to the shoulder, elbow, or wrist. There is a cast over the lower leg and ankle obscuring fine bony detail. The study was acquired portably and positioning was limited. The knee joint grossly is appropriately aligned. No proximal fibular or other knee fracture is identified. There is no joint effusion. There is suggestion of chondrocalcinosis, likely from underlying calcium pyrophosphate deposition disease. The casting material again obscures the fine bony detail. There is clearly an oblique minimally displaced fracture of the lateral malleolus extending to the level of the tibial plafond. There is also suggestion of a transverse fracture of the medial malleolus. These findings suggest an eversion injury. The talar dome is not appropriately evaluated. The ankle mortise is grossly preserved. No further fracture is definitively identified. IMPRESSION: Bimalleolar fracture externally reduced as above. No definite mortise disruption. Knee joint grossly unremarkable. Repeat: Distal fibular fracture on the current examination appears in adequate alignment. Ankle mortise not optimally visualized. Medial malleolar fracture obscured by overlying casting material. HCT: FINDINGS: The extracalvarial soft tissues are unremarkable. The skull base and calvarium are intact. Scattered calcific plaque is noted in the cavernous and supraclinoid portions of the internal carotid artery. The globes are intact with lenses in place. Intracranially, consistent with the given history, there is a 17 mm diameter focal high attenuation consistent with hemorrhage centered over the posterior limb of the left internal capsule with a thin rim of surrounding low attenuation representing edema. No significant mass effect results. There is baseline mild age-appropriate global atrophy which accommodates the small hemorrhage. No intraventricular extension is noted. Mild scattered foci of low attenuation are noted throughout the periventricular white matter likely due to chronic small vessel ischemic disease. There is an ovoid low- attenuation focus in the region of the right choroidal fissure which likely represents a small neuroepithelial or arachnoid cyst. IMPRESSION: Consistent with the given history, there is a small left hemorrhage involving the basal ganglia with a rim of edema but no significant resultant mass effect or intraventricular extension. RUE u/s: Noncompressible vein in the right neck medial to carotid artery and internal jugular vein which connects into internal jugular vein, representing thrombosis probably in the superficial vein. Otherwise no clot seen. EKG: Atrial fibrillation with a rapid ventricular response. Left ventricular hypertrophy. Leftward axis. Compared to the previous tracing of [**2179-3-18**] atrial fibrillation has appeared and the rate is increased. Clinical correlation is suggested. Brief Hospital Course: 59yo handed woman with ESRD, HTN, bladder ca, Afib (thought to be off coumadin for procedure - but reports still taking it), hyperlipidemia, psychiatric disease who is transferred from OSH for L-thalamic bleed. Also has R-fibular fracture. It is not clear what happened as the patient is not able to provide detailed info. On exam she has a low grade fever, is lethargic, and at times a bit inattentive. She is not aphasic. She has a R-hemi (arm> face>leg). Sensation appears intact, but is unreliable. She most likely had a hypertensive hemorrhage. Hospital course is reviewed below by problem: 1. L thalamic bleed: She was admitted to the neurology ICU. Her neurology exam remained stable. She was treated with blood pressure control, see below. Vascular risk factors were evaluated; she was started on lipitor 10mg daily for elevated cholesterol and HbA1C was normal. 2. HTN: eventually requiring metoprolol, isordil, norvasc, and dialysis. She also intermittently needed prn hydralazine. Her cardura was held. She had a drop in her blood pressure after hemodialysis and antihypertensives on [**3-24**], which resolved with lying down. Her lisinopril was given a little later in the day. These will need to be titrated/tapered for goal SBP<140. 3. Atrial fibrillation: well controlled on metoprolol. 4. Psych: She was treated with her home dose of perphenazine (initially held to monitor her mental status). 5. Right bimalleolar fracture: She was seen by orthopedics and placed in a short cast. They reviewed her repeat x-rays and were satisfied with the treatment. Will follow up in 2 weeks with Dr. [**Last Name (STitle) **]. 6. ESRD: Treated with hemodialsyis, MWF. The renal service followed her, and she was treated with nephrocaps and renagel. Her outpatient dialysis was performed @ [**Location (un) **] in [**Location (un) 1468**]. Communication: PCP [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. ([**Telephone/Fax (1) 58598**], updated [**2-23**] Nephrologist Dr. [**Last Name (STitle) **] [**Name (STitle) **] [**Telephone/Fax (1) 71700**] (son) [**Name (NI) **] [**Telephone/Fax (1) 71701**] (son) Medications on Admission: (per pharmacist): -coumadin, on hold for procudure -lopressor 100mg [**Hospital1 **] PO -cardura 4mg in pm -lisinopril 40mg PO daily -imdur 30mg daily -perphenazine 4mg in am 8mg in pm -renagel 800 1 [**3-27**] daily -renocaps 1 daily Discharge Medications: 1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): hold for SBP<130. Tablet(s) 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 6. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO QID (4 times a day). 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 12. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 13. Perphenazine 2 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 14. Perphenazine 2 mg Tablet Sig: Four (4) Tablet PO QHS (once a day (at bedtime)). 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Location (un) 246**] Nursing Center - [**Location (un) 246**] Discharge Diagnosis: Left caudate hemorrhage Right bimalleolar fracture Hypertension End stage renal disease Atrial fibrillation Discharge Condition: Stable; still with right hemiparesis, some improving speech and improving movement of her right face. Discharge Instructions: Take medications as prescribed. Please follow up with Dr. [**First Name (STitle) 6359**] when you have finished rehabilitation; follow up in neurology clinic and orthopedics clinic as scheduled. Call your doctor or go to the emergency room if you have any chest pain, palpitations, difficulty breathing, new weakness, difficulty speaking, change in level of consciousness, fever, chills, or any other concerning symptoms. Followup Instructions: Please follow up with Dr. [**First Name (STitle) 6359**] when you have finished rehabilitation - [**Telephone/Fax (1) 23281**]. Follow up with orthopedics: Dr. [**Last Name (STitle) **] in the [**Hospital Ward Name 23**] building, [**Location (un) **]. Your son will be making the appointment for you for 2 weeks from now (the following needs to be confirmed). Provider: [**Name10 (NameIs) 5865**] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2179-4-1**] 1:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2179-4-1**] 1:20 Follow up with neurology: Provider: [**First Name11 (Name Pattern1) 3688**] [**Last Name (NamePattern4) 33346**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2179-4-20**] 9:00

[ "V58.61", "E888.9", "585.6", "438.20", "305.1", "427.31", "431", "188.9", "272.4", "824.4", "403.91" ]

icd9cm

[ [ [] ] ]

[ "79.06", "39.95" ]

icd9pcs

[ [ [] ] ]

12450, 12541

8695, 10844

328, 335

12693, 12797

4301, 4517

13269, 14082

2015, 2026

11130, 12427

12562, 12672

10870, 11107

12821, 13246

2041, 2442

4198, 4282

277, 290

363, 1725

2898, 4184

4526, 5282

5296, 8672

2457, 2882

1747, 1920

1936, 1999