ChanBeDu/relevant_section_length · Datasets at Hugging Face

32,736

185,249

46845

Discharge summary

report

Admission Date: [**2135-8-2**] Discharge Date: [**2135-8-5**] Date of Birth: [**2077-4-6**] Sex: F Service: MEDICINE Allergies: Barbiturates / Penicillins / Sulfonamides / Lisinopril / Latex Attending:[**First Name3 (LF) 348**] Chief Complaint: lip swelling Major Surgical or Invasive Procedure: Intubation/Mechanical Ventilation History of Present Illness: 58 F with HTN, DM, on lisinopril, admit from ED with lip swelling concerning for angioedema. Patient has been on ACEI for several months, had recent switch from one ACEI to a different "pril" medication 3 weeks ago. Patient had eaten grapes, water, and Jarlsberg cheese 20 minutes prior to this occurring. Basically noted lip tingling with ?central swollen area, then gradually felt more tight and looked more swollen, so came to ED. Has never had swelling like this before, though does report whole lower facial swelling in past after teeth removed. Swelling affecting upper lip only, no tongue swelling, no hoarseness, no stridor/evidence of airway compromise, no wheezing, no rash/hives. Initially reported no history of similar symptoms but did note episode of facial swelling after teeth pulled years ago, resolved with unknown medication as an outpatient. No other unusual food exposures, no shellfish. ROS significant only for intermittent lower abdominal pain x years at past surgical site. . In the ED, vitals . Received benadryl 25 IV x 2, IV famotidine 20 x2, methylprednisolone 125 x1. Ordered for FFP 1 unit for refractory angioedema, has not yet received. With the above treatments, her swelling did not improve (actually worsened), and so admitted to MICU for continued monitoring. Past Medical History: HTN DM type II History of endometriosis abd mult abdominal surgeries in past ?Hyperlipidemia Social History: Lives alone, works as bus monitor for [**Location (un) **] schools, now on summer break. Smokes 1ppd x 40 years, drinks daily 1-2 per night, no history of withdrawal symptoms (cannot recall last time she did not drink for 1 week). Family History: No family history of angioedema. Extensive FH of DM. Physical Exam: Vitals: T 97.1, P78, 149/80, R16, 100% RA General: Very pleasant female, prominent upper lip swelling. No hoarseness. No stridor. HEENT: PERRL, sclera anicteric. Upper lip markedly swollen, no erythema, warmth, tenderness. MMM, tongue not swollen, no OP lesions. Neck: supple, no LAD, JVD flat, full neck ROM. Chest: CTA bilat good air entry, no wheezes. Heart: RRR S1 S2 no m/r/g Abdomen: soft, diffuse lower abd TTP, no rebound/guarding, old healed lower abdominal incision. Extrem: Warm, no edema. Neuro: A/O x 3, MAE. Pertinent Results: [**2135-8-1**] 10:00PM WBC-7.5 Hgb-12.7# Hct-38.2# MCV-80* RDW-14.3 Plt Ct-353 Glucose-110* UreaN-21* Creat-1.1 Na-142 K-5.4* Cl-105 HCO3-25 AnGap-17 . [**2135-8-2**] 04:10AM WBC-9.5 Hgb-12.5 Hct-37.1 MCV-80* -14.2 Plt Ct-345 Neuts-77.0* Lymphs-20.3 Monos-0.4* Eos-1.6 Baso-0.8 Glucose-155* UreaN-18 Creat-1.0 Na-141 K-4.3 Cl-105 HCO3-25 AnGap-15 ALT-16 AST-28 LD(LDH)-141 AlkPhos-93 TotBili-0.3 TotProt-7.6 Albumin-4.8 Globuln-2.8 Calcium-9.7 Phos-4.2 Mg-2.0 C3-146 C4-22 . CXR [**2135-8-2**]: 1. ET tube approximately 3 cm from the carina. Of note the tube appears to impinge upon the right tracheal border, and the balloon appears slightly hyperexpanded. 2. Mild pulmonary edema, could be cardiogenic or noncardiogenic in origin. Brief Hospital Course: ASSESSMENT AND PLAN: 58 F with history of HTN on lisinopril, admitted with lip swelling in setting of eating grapes today. Continued to have increase in swelling following steroids, histamine blockers, thus prompting ICU admission. . # Lip swelling. Most likely etiology was angioedema due to ACEI use. First episode. No rash. No tongue swelling, evidence of laryngeal edema/airway compromise. Received IV steroids, H2 blockers, diphenhydramine in ED with continued worsening of symptoms. Received 1 unit FFP as trial for nonresponsive angioedema (has been effective in case reports of ACEI angioedema but more classically effective - though still only case reports - in hereditary or acquired C1 inhibitor disorders). She was admitted to the ICU for monitoring. Her swelling continued to expand and soon involved bilateral cheeks. At this time she was intubated for airway protection; advanced intubation techniques were available but not required, as patient was intubated easily. Her swelling continued to worsen and involved lower lip and face. H2 blockers, diphenhydramine, steroids were continued. Allergy was consulted and recommended multiple complement/C1 and functional studies to rule out acquired C1 inhibitor defiency (still pending at discharge). ACE inhibitors were added to her allergy list. . She was successfully extubated on [**2135-8-3**] (~24 hrs after being intubated). She tolerated the extubation well and was mentating well afterwards. She was kept on trach mask, then transitioned to nasal canula followed by room air and was satting well. Her diet was advanced as tolerated, and she did not complain of any airway swelling or dysphagia. . Patient was eventually discharged home and had marked improvement of her facial swelling. Dr. [**Last Name (STitle) **] from the [**Hospital 9039**] clinic was consulted regarding the patient's steroid taper and the feasability of restarting aspirin for cardiac prevention. Dr. [**Last Name (STitle) **] stated that medications for which the patient was taking for a period of at least one year were safe to resume, including HCTZ and aspirin, as these drugs caused angioedema through a mechanism that was unrelated to ACEI-related angioedema, the patient's likely diagnosis. He will follow the patient as an outpatient. . # HTN. Hypertensive at times to 170s-180s systolic. ACE inhibitor not continued as above. Pt also reports being on hydrochlorothiazide at home (after extubation). This was held as patient has report of a sulfa allergy. HTN mostly in the setting of discomfort from intubation and responded to sedating medications. Her home anti-HTN meds were held in the setting of her recent anaphylactic reaction and can be re-started at later date after medication review per her PCP. [**Name10 (NameIs) **] was initiated on a calcium channel blocker before discharge. # DM. On metformin at home. On ASA 81 mg at home (per pt after extubation). No contrast agents uses, so restarted w/ PO medications once patient could tolerate food PO. ISS also used. ASA held during admission as ASA/NSAIDS have been associated w/ urticaria and angioedema. . #Hypercholesterolemia: PCP reports that patient is on Gemfibrozil, which can also cause angioedema in < 1% of patients. Pt reports that it is a recent new medication that she started about 1 month ago ([**6-28**]). Held during hospital stay. Medications on Admission: Per Patient: . Metformin 500 mg po BID ACEI - Lisinopril 40 mg po daily <--- can cause angioedema Gemfibrozil 600 mg PO BID <--- can cause angioedema in < 1% of patients ASA 81 mg daily HCTZ 40 mg PO daily <--- should not be used in patients w/ sulfa allergies . ALLERGIES: barbituates, PCN, sulfa. Patient reports that one of these meds (probably either barbs or PCN) caused significant unilateral neck swelling, the other caused perioribital facial rash/blisters. Unknown what sulfa allergy is. Discharge Medications: 1. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 4. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H () as needed for pain. Disp:*24 Tablet(s)* Refills:*0* 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 9. Prednisone 5 mg Tablet Sig: As directed Tablet PO As directed: Day 1 ([**8-6**]) - 30mg twice per day;Day 2 - 25 mg twice per day;Day 3 - 20 mg twice per day;Day 4 - 15 mg twice per day;Day 5 - 10 mg twice per day;Day 6 - 15 mg ONCE per day;Day 7 - 10 mg ONCE per day;Day 8 - 7.5 mg ONCE per day;Day 9 - 5 mg ONCE per day. Disp:*240 Tablet(s)* Refills:*0* 10. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) as directed Intramuscular as needed as needed for shortness of breath or face/throat edema. Disp:*2 pens* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Angioedema Discharge Condition: Good Discharge Instructions: You were admitted to the [**Hospital1 18**] with a diagnosis of angioedema (lip and facial swelling) due to your Lisinopril use. You were intubated briefly in the ICU to protect your airway, and were successfully extubated. You were discharged in good health. . Please do NOT use Lisinopril anymore. It is now listed in your allergy record here at the [**Hospital1 18**] and should also be listed on your allergy record with your primary care physician at [**Hospital1 2292**]. We restarted your metformin after the tube was removed from your throat and we confirmed it was safe for you to eat and swallow medications. . Do not eat grapes or dairy products until you see Dr. [**Last Name (STitle) **] from the [**Hospital 9039**] clinic. . We also held your other medications (aspirin/ hydrochlorothiazide/gemfibrozil) during your hospital stay, as all of these medications have been known to cause either angioedema or urticaria (hives). However, because you have taken aspirin for over a year, it is safe to continue using this drug. It is also safe to use hydrochlorothiazide because you have also been taking it for over a year. We were unable to confirm your dose, however, and you should therefore not take this again until you see your primary doctor and have your blood pressure checked, as we started you on a new blood pressure medication (amlodipine). . Please follow the directions for your steroid taper, as listed in your discharge medications. . Please return to the nearest ED or call your primary care physician if you experience any of the following symptoms: Any increased facial swelling or swelling of other parts of your body, extreme difficulty breathing, fever greater than 102, loss of consciousness, difficulty swallowing, light-headedness or dizziness, decreased urine output, new confusion or changes in your thinking or speaking, or any new rapidly spreading rashes. Also please return if you experience worsening chest pain, abdominal pain, back pain, extremity pain, or any other symptoms that are concerning to you. Followup Instructions: You have a follow up appointment at [**Hospital1 **] next week: Dr. [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) **] 10:20 AM Thursday, [**2135-8-11**] Please call [**Telephone/Fax (1) 2115**] with any questions. At this appointment you will need to get a referral to your follow up appointment with Dr. [**Last Name (STitle) **] in the allergy clinic. You have a follow up appointment at the [**Hospital 9039**] Clinic ([**Location (un) **]) Dr. [**Last Name (STitle) **] 1:00 PM Thursday, [**2135-8-18**] Please call [**Telephone/Fax (1) 9316**] with any questions. Please follow up with your primary care physician at [**Hospital1 2292**] and discuss your medication list in detail. Many of the medications you were on put you at risk for repeated episodes of angioedema. . You were noted to have red blood cells in your urine while here. This was likely due to having a foley catheter in place to drain your urine. However, you should have a followup urine check at your next PCP appointment to make sure that this is not continuing. Completed by:[**2135-8-5**]

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Discharge summary

report

Admission Date: [**2169-12-31**] Discharge Date: [**2170-1-5**] Date of Birth: [**2094-11-9**] Sex: M Service: [**Year (4 digits) 662**] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 800**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: Femoral line placed History of Present Illness: 75 y/o M [**First Name3 (LF) **] speaking only PMH ESRD on HD, CAD, PAF, COPD, HTN who presensts with altered mental status of 2 days duration. Initially felt to be secondary to percocet use at rehab, but HD facility was concerned and sent patient to be evaluated. Per family patient is AOx3 at baseline but has been more confused recently. Notes slow decline over several days since being at the rehab. States he was also given a "sleeping pill" the day before admission. Family did not notice any increased cough, SOB, or fever. . Patient was recently admitted [**Date range (3) 5527**] for left humeral fracture, hypoxia and inability to care for himself at home. For left humeral fracture patient was evaluated by ortho who recommended sling. Hypoxia was felt to be secondary to mild COPD exacerbation and was treated with aggressive neb therapy and oral steroids. At time of discharge his O2 sats were 90% on RA with occasional desats to the high 80s and discharged on 1L NC to be weaned as tolerated. Patient was discharged to rehab. . In the ED, initial VS were: 96.9 86 107/84 22 91. Patient spiked a temp to 100.2. rectally. CT head demonstrated no abnormalities. CXR demonstrated right lower lobe infiltrate. Patient was given levofloxacin and zosyn and 1L NS. A groin CVL was placed. His LUE was noted to be swollen and echymotic but an u/s revealed no DVT. Ortho evaluated it in the ED and recommended continued sling and NWB. He was agitated and confused, so received 5mg Zyprexa. Vitals on transfer were 98.8 rectal, HR 63, BP 149/52, RR 13, 100% facemask. He would reportedly desat to upper 80s on 6L NC so he was admitted to the MICU for further care. . On the floor, still mildly agitated and confused. Unable to obtain further ROS. Past Medical History: -ESRD on HD via left AVF from polycystic kidney disease. HD-M,W,F on [**State **] St in [**Location (un) **] -Asymptommatic Bradycardia/WCT: [**Company 1543**] single-lead pacemaker placed -CAD - cath here in [**2155**] with moderate ramus intermedius disease (discrete 50% stenosis) and mild diastolic ventricular dysfunction -PAF with [**Year (4 digits) 5509**] documented once in the ED in [**3-/2167**] -ETT [**2153**]: Atypical symptoms in the absence of ischemic ECG changes or reversible defects by thallium to the acheived low level of exercise -Asthma/COPD -Hypertension -Prostate CA [**2160**] -recent left humeral fracture Social History: Patient currently lives at rehab but lived alone before (wife has passed away recently). [**Year (4 digits) 595**] speaking only. Currently smokes <10 cigs/day for 60yrs, [**1-13**]/wk EtOH, no ilicit drug use. Family History: Denies significant family history. Physical Exam: Gen: Well appearing elderly man in NAD Eye: extra-occular movements intact, pupils equal round, reactive to light, sclera anicteric, not injected, no exudates ENT: mucus membranes moist, no ulcerations or exudates Neck: no thyromegally, JVD: flat Cardiovascular: regular rate and rhythm, normal s1, s2, no murmurs, rubs or gallops Respiratory: Clear to auscultation bilaterally, no wheezes, rales or rhonchi Abd: Soft, non distended, no heptosplenomegaly, bowel sounds present. Mildly tender to palpation in RUQ and LLQ. Extremities: Left arm in sling, painful with movement, warm, 2+ radial pulse, sensation intact, ecchymotic, no cyanosis, clubbing, joint swelling Neurological: Alert and oriented x2, CN II-XII intact, normal attention, sensation normal Pertinent Results: Labs during event leading to death: [**2170-1-5**] INR(PT)-7.8* [**2170-1-5**] Hct-25.2* [**2170-1-5**] 06:28PM BLOOD Type-ART pO2-74* pCO2-53* pH-7.21* calTCO2-22 Base XS--7 [**2170-1-5**] 06:12PM BLOOD Glucose-161* UreaN-66* Creat-5.1*# Na-144 K-6.8* Cl-97 HCO3-20* AnGap-34* Lactate 11.4 . Labs on admission: [**2169-12-31**] 06:50PM BLOOD WBC-10.3 RBC-3.26* Hgb-9.8* Hct-30.5* MCV-94 MCH-30.1 MCHC-32.1 RDW-17.5* Plt Ct-177 [**2169-12-31**] 06:50PM BLOOD Neuts-95.1* Lymphs-3.5* Monos-1.0* Eos-0.1 Baso-0.2 [**2169-12-31**] 06:50PM BLOOD PT-19.4* PTT-47.3* INR(PT)-1.8* [**2169-12-31**] 06:50PM BLOOD Glucose-98 UreaN-33* Creat-3.2*# Na-145 K-3.7 Cl-100 HCO3-32 AnGap-17 [**2169-12-31**] 06:50PM BLOOD ALT-36 AST-43* LD(LDH)-380* AlkPhos-90 TotBili-0.5 . Other pertinent labs: [**2170-1-2**] 06:00AM BLOOD Vanco-13.4 [**2170-1-3**] 09:28AM BLOOD Vanco-22.4* [**2170-1-4**] 05:55AM BLOOD Vanco-21.5* [**2169-12-31**] 07:01PM BLOOD Lactate-2.2* K-3.7 [**2170-1-1**] 12:06AM BLOOD Lactate-2.0 [**2170-1-5**] 06:28PM BLOOD Lactate-11.4* [**2170-1-1**] 05:59AM BLOOD ALT-12 AST-42* LD(LDH)-339* CK(CPK)-220* AlkPhos-49 TotBili-0.5 . [**2169-12-31**] 06:50PM URINE RBC-21-50* WBC-0-2 Bacteri-OCC Yeast-NONE Epi-0 [**2169-12-31**] 06:50PM URINE Blood-LG Nitrite-NEG Protein-500 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG . [**2169-12-31**] INR(PT)-1.8*, INR(PT)-2.1*, [**2170-1-1**] INR(PT)-1.8*, [**2170-1-2**] INR(PT)-2.0*, [**2170-1-3**] INR(PT)-2.9*, [**2170-1-4**] INR(PT)-5.2*, [**2170-1-4**] INR(PT)-4.5*, [**2170-1-5**] INR(PT)-5.1*, [**2170-1-5**] INR(PT)-7.8* [**2170-1-3**] Hct-26.4, Hct-27.2* [**2170-1-4**] Hct-28.0*, [**2170-1-4**] Hct-26.9*, [**2170-1-5**] Hct-25.4*, [**2170-1-5**] Hct-26.1*, . [**2169-12-31**] 6:50 pm BLOOD CULTURE **FINAL REPORT [**2170-1-6**]** KLEBSIELLA OXYTOCA. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA OXYTOCA | AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- 8 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Anaerobic Bottle Gram Stain (Final [**2170-1-1**]): GRAM NEGATIVE ROD(S). REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5528**] AT 14:08PM ON [**2170-1-1**]. Aerobic Bottle Gram Stain (Final [**2170-1-1**]): GRAM NEGATIVE ROD(S). . [**Date range (3) 5529**] blood cx negative . [**2169-12-31**] 6:50 pm URINE Site: CLEAN CATCH URINE CULTURE (Final [**2170-1-1**]): NO GROWTH. . [**2170-1-5**] 3:51 pm STOOL **FINAL REPORT [**2170-1-6**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2170-1-6**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). . [**2169-12-31**] CT head: IMPRESSION: No acute intracranial abnormality. No significant change in cerebral volume loss and chronic microvascular ischemic changes. Bilateral maxillary sinus disease. . [**2169-12-31**] Humerus AP/Lat: LEFT HUMERUS, THREE VIEWS: Evaluation is limited by patient positioning. Within this limitation, there is no significant change in the comminuted left humeral neck fracture with approximately 2 cm of foreshortening. There is nodislocation. There is no new fracture. There is subtle soft tissue calcification noted on the second and third images at the level of the fracture which may represent early callous formation. No radiopaque foreign body is identified. . [**2169-12-31**] RUE Ultrasound: IMPRESSION: No evidence of DVT. Exam is limited due to patient-related factors. . [**2170-1-1**] Abdomen upright: IMPRESSION: No evidence of obstruction; incomplete assessment for free air -upright or left lateral decubitus views are recommended to better assess for perforation. . [**2170-1-2**] RUQ ultrasound: IMPRESSION: 1. Innumerable cysts seen within the liver and right kidney. 2. Focally distended gallbladder at the fundus without signs of cholecystitis. If clinically indicated, a HIDA scan could be performed to further assess for cholecystitis. No gallstone is identified. 3. No biliary dilatation and no ascites in the right upper quadrant. . [**2169-12-31**]: SINGLE AP VIEW OF THE CHEST: Evaluation is limited by patient position. Compared to the prior study, there is increased opacity at the right lung base concerning for infection. An opacity in the right upper lung is stable compared to prior and may represent a calcified granuloma. The heart is enlarged and there is a small residual right pleural effusion. The left costophrenic angle is excluded from view. A single lead follows a normal course from a right-sided battery pack terminating in the expected position over the right ventricle. There is a left tunneled internal jugular catheter terminating at the cavoatrial junction. There is no pneumothorax. Left humeral fracture better evaluated on dedicated humeral radiographs. . [**2170-1-3**] Video Swallow: FINDINGS: Barium passed freely through the oropharynx and esophagus without evidence of obstruction. There was aspiration with thin consistency. . [**2170-1-5**] CXR: FINDINGS: As compared to the previous radiograph, the patient has taken a better inspiration. There is unchanged extent of the bilateral basal areas of opacity. However, no opacity has newly occurred in the interval. Moreover, no evidence of pulmonary edema is seen. The size of the cardiac silhouette is unchanged. Unchanged moderate tortuosity of the thoracic aorta, unchanged position of central venous access line and the right-sided pacemaker. Brief Hospital Course: Assessment and Plan: 75 year old [**Month/Day/Year 595**] speaking male with hx of COPD, CAD, and recent humerus fracture presents with altered mental status and found to have pneumonia and GNR bacteremia on [**2169-12-31**]. . #. His hospital course is detailed below. On the evening of [**2170-1-5**] I was called to evaluated him for "being less responsive and looking more blue." He was DNR/DNI at the time. His initial BP was normal and then we were unable to obtain a blood pressure. O2 sats were being obtained on his forehead as he was satting higher on his forehead than on his digits earlier in the day. His initial o2 sat was 90 and then was unobtainable. He was noted to be in agonal breathing and had fixed non responsive pupils (minimally responsive pupils per neuro). A code stroke was immediately called. Fluids were opened wide. Labs were obtained and notable for pH 7.21 pCO2 53 pO2 74 on non rebreather, lactate of 11.4, WBC 22.4, HCT stable at 25.2, INR of 7.8, and potassium of 6.8 (this K+ was obtained within 1 min of his death and thus no medication had been administered). FFP was ordered and brought down to the CT scanner but arrived within minutes of his death. The patient was rushed to the CT scanner for a head CT without contrast. While at the CT scanner he had an episode of bloody emesis. He died within seconds of his CT scan being completed and the scan showed no evidence of bleed or stroke. His family members and his primary care physician were [**Name (NI) 653**] about his death and declined autopsy. Dr. [**Last Name (STitle) **] was being updated throughout the code stroke. He likely did from a GI bleed in the setting of a high INR. . #. Klebsiella Bacteremia: His blood cx on [**2169-12-31**] were positive for pansensitive Klebsiella bacteremia and he was on cefepime. Subsequent blood cultures were found to be negative from [**Date range (1) 5530**]. . # Pneumonia: His CXR showed RUL and RLL PNA. He was being treated with vancomycin and cefepime given need to cover for HAP and he was on flagyl for possible HAP. He had a new oxygen requirement throughout his hospitalization and he was continued on nebulizers. He was never able to produce a sputum for us. His blood cx grew Klebsiella as detailed above. . #. Elevated WBC: His elevated WBC was thought to be secondary to PNA and klebsiella bacteremia. He was afebrile for several days prior to his death. His white count trended up to 23 and then remained stable between 17-18 until the time of his death when his WBC was 22.4. His stool was negative for c diff. His abdominal exam was followed and was benign and he denied abdominal pain. . # Altered Mental Status: His CT scan of his head was negative. His AMS was likely due to bactermia and PNA. His mental status improved after he started treatment for his PNA & bacteremia and then again after narcotic medications & clonazepam were discontinued. The days prior to his death he was oriented to himself and his location. The only exception to this was the evening of [**2170-1-4**] when he received a dose of pain medication for his broken humerus and he delirius. His family member (who speaks [**Name (NI) 595**]) noted to me early in the day on [**2170-1-5**] that he was much clear compared to the evening before and knew where he was and who he was. . # Anemia: His HCT was 30.5 on arrival on [**2169-12-31**]. His HCT remained stable in the 25-28 range for the several days prior to his death and his transfusion threshold was<25. Please see humerus fracture below. On [**2170-1-4**] ortho came to evaluate the patient as his left arm (where he had humeus fracture) looked larger and there was concern that he could be bleeding into it in the setting of his elevated INR. His HCT was followed closely and was stable. He had no evidence of compartment syndrome on exam. He was found to be guaiac positive on exam but was having rare bowel movements. The late morning of his death he had question of coffee ground emesis. This was discussed with the attending and it was decided not to place an NG tube in the setting of a high INR. The patient was started on an IV PPI. . # Elevated INR: He was given reduced dosing of coumadin given that he was on antibiotics. His INR became supratherapeutic on [**1-4**] to 5.9. On the morning of [**1-5**] his INR was 5.1. His coumadin was held. In the setting of ? coffee ground emesis (detailed below under anemia section) on [**1-5**] in AM he was given vitamin K. . # COPD: He was on standing nebs and advair with a clear lung exam. . # ESRD: He received dialysis throughout his hospitalization. He had one episode of hypotension post dialysis but otherwise tolerated it well. . # Humerus fracture: On [**2170-1-4**] ortho came to evaluate the patient as his left arm (where he had humerus fracture) looked larger and there was concern that he could be bleeding into it in the setting of his elevated INR. His HCT was followed closely and was stable. He had no evidence of compartment syndrome on exam. Pain was controlled with tylenol and lidocaine and no narcotics were given since they were thought to contribute to his AMS. . # Paroxysmal atrial fibrillation: He was continued on home dronedarone and diltiazem. His coumadin was held in the setting of his high INR. . # Hypertension, benign: He was continue on his home diltiazem, lisinopril, and valsartan. . # Coronary artery disease: He was continued on his home ACE, [**Last Name (un) **], and aspirin . # Dementia: He was continued on his home Aricept. . # Depression: He was continued on his home citalopram. . # FEN: He was on a puree diet and nectar thick liquids given concern for aspiration and was followed by speech and swallow. Medications on Admission: 1. Clonazepam 1 mg PO QHS as needed for insomnia. 2. Citalopram 20 mg PO DAILY 3. Warfarin 5 mg t PO QHS 4. Simvastatin 10 mg PO QHS 5. Donepezil 5 mg PO HS 6. Amylase-Lipase-Protease 60,000-12,000- 38,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. Montelukast 10 mg PO DAILY 8. Fexofenadine 180 mg PO DAILY 9. Lisinopril 20 mg PO BID 10. Hyoscyamine Sulfate 0.375 mg Capsule, Sust. Release 12 hr Sig: One (1) Capsule, Sust. Release 12 hr PO BID 11. Valsartan 80 mg PO DAILY 12. Aspirin 81 mg PO DAILY 13. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Capsule PO once a day. 14. Fluticasone-Salmeterol 250-50 mcg [**Hospital1 **] 15. Tiotropium Bromide 18 mcg DAILY 16. Diltiazem HCl 60 mg PO BID 17. Dronedarone 400 mg PO BID 18. Sevelamer Carbonate 800 mg PO TID W/MEALS 19. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Q6H 20. Ipratropium Bromide 0.02 % Q6H 21. Lidocaine 5 %(700 mg/patch) Q24H (every 24 hours) as needed for shoulder pain. 22. Oxycodone-Acetaminophen 5-325 mg 1-2 Tablets PO every 4-6 hours as needed for pain 23. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 24. Lactulose (30) ML PO Q8H as needed for constipation. 25. Docusate Sodium 100 mg PO BID 27. Prednisone taper: Now on 20mg qdaily x 2d, then take 10mg x2d, then stop. Discharge Medications: Deceased Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: Deceased [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**] Completed by:[**2170-1-17**]

[ "585.6", "294.8", "486", "305.1", "V45.01", "427.31", "790.7", "578.0", "414.01", "311", "403.91", "753.12", "V45.11", "041.3", "493.20", "285.21" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.93" ]

icd9pcs

[ [ [] ] ]

16889, 16898

9736, 12407

353, 374

16950, 16960

3882, 4180

17017, 17183

3054, 3090

16856, 16866

16919, 16929

15487, 16833

16984, 16994

3105, 3863

292, 315

402, 2153

6953, 9713

4663, 6944

4194, 4641

12422, 15461

2175, 2810

2826, 3038

23,324

116,596

23362

Discharge summary

report

Admission Date: [**2135-1-11**] Discharge Date: [**2135-1-18**] Date of Birth: [**2081-3-23**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5018**] Chief Complaint: Slurred speech and right sided facial weakness Major Surgical or Invasive Procedure: None. History of Present Illness: Patient is a 53 yo RH man with poorly controlled HTN who was found by his daughter at 5:30Pm today confused with slurred speech and right sided weakness. He was taken to an OSH where a head CT revealed a moderate sized left basal ganglia bleed. He was transferred to [**Hospital1 18**] for further evaluation. He denies headache, dizziness, blurry vision or diplopia, numbness or tingling. ROS negative for fever, URI sxs, N/V/D, dysuria. Denies cp, sob. Past Medical History: HTN, NIDDM, GERD, PVD s/p right BKA, left great toe amputation Social History: Lives at home with his sister, Smokes 1 ppd, denies ETOH or other drugs Family History: Noncontributory Physical Exam: Vitals: 98 209/123 on entry to ED now 175/109 20 RA Gen: NAD Neuro: awake, oriented to "End of [**2134-12-13**] and [**Hospital3 **]"; fluent; severe dysarthria, naming intact to pen and thumb with more difficulty with low frequency objects; repetition intact to 7 word sentence but dysarthric, good attention with months year forward and backward to [**Month (only) **]; memory [**4-14**] at 30 seconds and [**2-13**] at 5minutes pupils equal and reactive b/l; EOMI with no nystagmus b/l; no field cut face with right facial droop at rest and with activation; facial sensation intact; tongue midline and moves in all directions with good coordination; palate elevates symmetrically Power [**6-16**] in LE b/l and right pronator drift. Has more weakness distally at interossei on right reflexes 2+ in UE b/l and 1+ in LE b/l at knees (difficult to examine right knee); no ankle jerks b/l; toes moot b/l; sensory exam: intact to LT, temperature, and joint position in UE and LE b/l No ataxia or dysmetria on FNF in UE b/l Gait: deferred Pertinent Results: Head CT (OSH): left basal ganglia bleed with surrounding edema in 4 sections with minimal mass effect on left frontal [**Doctor Last Name 534**] of lateral ventricle Head CT [**1-11**] and [**1-12**] are stable ESR 73 Lipid panel pending HgBA1C pending ECHO pending Carotid ultrasound pending Brief Hospital Course: Patient admitted to the ICU for blood pressure managment and monitoring. NEURO: Remained stable in ICU with exam notable for R facial droop, mild RUE distal weakness and dysarthria. Repeat head CT's were stable. He is due for an MRI/MRA to evaluate for any underlying etiology (vascular malformation, tumor) for his hemorrhage. Most likely pt's hemorrhage is secondary to hypertension. CV: Pt's blood pressure difficult initially to control. He required nicardipine and nipride drips initially, then was transitioned to IV lopressor and hydralazine. On ICU day 3 he was transferred to PO antihypertensives after he passed his swallowing evaluation. RENAL: Pt had creatinine of 2, unclear if this is new or chronic in the setting of long standing diabetes. Pt was transferred to the floor on HD 3 in stable condition. On the floor his blood pressure medications were titrated in order to achieve optimal blood pressure control. The patient continued to do well and is now discharged in stable condition to [**Hospital1 **] Rehabilitation Center. Medications on Admission: glipizide, norvasc, lasix, lopressor, lipitor, protonix Discharge Medications: 1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 5. Hydralazine HCl 10 mg Tablet Sig: Two (2) Tablet PO Q6 HOURS PRN SBP>160 (). 6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 7. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: 1. Intracerebral Hemorrhage 2. hypertension Discharge Condition: good Discharge Instructions: Please take medications as prescribed. Return to ER if symptoms worsen. Keep all follow-up appointments. Followup Instructions: Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in 3 months, call [**Telephone/Fax (1) 56548**] to schedule a convenient time. [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**] Completed by:[**2135-1-18**]

[ "250.70", "438.83", "431", "342.02", "401.9", "V49.75", "443.81", "530.81" ]

icd9cm

[ [ [] ] ]

[ "38.91" ]

icd9pcs

[ [ [] ] ]

4299, 4371

2468, 3519

363, 371

4459, 4465

2148, 2445

4620, 4926

1050, 1067

3625, 4276

4392, 4438

3545, 3602

4489, 4597

1082, 2129

277, 325

399, 858

880, 945

961, 1034

28,794

183,588

33410

Discharge summary

report

Admission Date: [**2112-1-29**] Discharge Date: [**2112-2-10**] Date of Birth: [**2062-3-31**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 458**] Chief Complaint: Patient was found down. Major Surgical or Invasive Procedure: . History of Present Illness: 49 yo M with a history of EtOH abuse and DT's, significant tobacco history and prescription drug abuse with odd behavior and ?respiratory suppression found unresponsive at home with cardiac arrest. . The patient's mother and sister report that the patient has a long history of substance abuse. He has a history of significant EtOH abuse with DT's and more recently prescription drug abuse including benzodiazepines. The patient has been acting odd by family report since [**2111-7-22**]. There is high concern for substance abuse. The patient was not known to be suicidal. On the morning of admission, the patient was seen by his mother at his home and was noted to be "in a haze" acting as if "in a stupor." Later in the day the patient's mother found him asleep in bed and over many minutes was noted to have poor breathing. EMS was called and the he was thought to be in asystole vs. VF and received epinephrine and atropine x3 followed by cardioversion with return to sinus rhythm. The patient was intubated and sedated in the field and brought to [**Hospital **] Hospital prior to transfer to [**Hospital1 18**] [**Location (un) 86**]. There was concern for intentional overdose as a cause of his arrest however tox screen was notable only for EtOH level in the 200's at the OSH. In the ED the patient was initiated on a cooling protocol. CXR revealed left-sided retrocardiac opacity concerning for aspiration and in light of leukocytosis, the patient was started on levofloxacin and metronidazole for antibiotic coverage. . Review of Systems: Negative in detail including no CP, SOB, DOE, edema, orthopnea, N/V or diaphoresis. Past Medical History: Alcoholic with history of DT's 2ppd smoking history x decades Prescription drug abuse Paranoia with history of elopement from hospitals Social History: Engaged, lived alone. Unemployed orderly in hospitals. Significant EtOH and tobacco use. No illicit drug use but thought to abuse prescription drugs. Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS 98.4-99.9 65-89 125-138/88-107 AC Vt 550 RR 16 PEEP 5 100% Gen: Intubated and sedated. HEENT: PERRL. CV: RRR. Normal S1 and S2. No M/R/G. Pulm: Roncorous upper airway sounds. Abd: Soft, nontender. Ext: No edema. Neuro: Sedated. Integumentary: No rashes or lesions. Pertinent Results: ADMISSION LABS: [**2112-1-29**] 09:38PM BLOOD WBC-17.5* RBC-4.15* Hgb-13.6* Hct-38.3* MCV-92 MCH-32.7* MCHC-35.5* RDW-13.8 Plt Ct-189 [**2112-1-29**] 09:38PM BLOOD Neuts-86.4* Lymphs-9.1* Monos-4.0 Eos-0.2 Baso-0.2 [**2112-1-29**] 09:38PM BLOOD Plt Ct-189 [**2112-1-29**] 09:38PM BLOOD Glucose-94 UreaN-10 Creat-0.8 Na-143 K-3.6 Cl-106 HCO3-25 AnGap-16 [**2112-1-29**] 09:38PM BLOOD CK(CPK)-449* [**2112-1-29**] 09:38PM BLOOD Cholest-104 [**2112-1-30**] 04:06AM BLOOD TSH-0.31 [**2112-1-31**] 05:56PM BLOOD Ammonia-17 [**2112-1-29**] 09:38PM BLOOD HDL-22 CHOL/HD-4.7 LDLmeas-57 [**2112-1-29**] 09:52PM BLOOD Type-[**Last Name (un) **] pO2-54* pCO2-52* pH-7.29* calTCO2-26 Base XS--1 [**2112-1-29**] 09:52PM BLOOD Glucose-90 Lactate-2.8* Na-144 K-3.7 Cl-103 [**2112-1-29**] 09:52PM BLOOD freeCa-1.05* [**2112-1-30**] 06:39AM BLOOD O2 Sat-99 CARDIAC ENZYMES: [**2112-1-29**] 09:38PM BLOOD CK-MB-21* MB Indx-4.7 [**2112-1-29**] 09:38PM BLOOD cTropnT-1.02* [**2112-1-30**] 04:06AM BLOOD CK-MB-27* MB Indx-5.2 cTropnT-0.49* EKG ([**2112-1-29**]): Sinus rhythm at a rate of 68. Normal axis. Normal intervals. Downgoing T's in III and aVF. No acute ST or T wave changes. No prior for comparison. Rhythm strip from [**Hospital **] Hospital ([**2112-1-29**] 16:24): Atrial tachycardia at 150. CT head/C-spine ([**2112-1-29**]): No intracranial process, no C-spine fracture. Fluid within the nasal cavity and some layering within the sinuses. CXR ([**2112-1-29**]): Retrocardiac opacities on the left representing either aspiration, atelectasis, or pneumonia. [**2112-11-30**] EEG: Abnormal portable EEG due to the widespread monotonous alpha background. This suggests medication effect as the most common cause of such records. There were no areas of prominent focal slowing, and there were no epileptiform features. [**2112-12-5**] EEG This is an abnormal portable EEG due to the low voltage, disorganized and poorly modulated background, consisting mainly of a faster beta frequency rhythm, likely reflecting medication effects from benzodiazepine or barbiturate administration. Findings are consistent with a moderate encephalopathy, suggestive of dysfunction of bilateral subcortical or deep midline structures. Medications, metabolic disturbances, infection, and anoxia are among the common causes of encephalopathy. There were no areas of prominent focal slowing. Several episodes of lower extremity tremulousness were noted by the EEG technician; no associated epileptiform features were noted. No electrographic seizure activity was noted. [**2112-2-6**] MRI Brain: 1. Low ADC is identified in the white matter of parietooccipital lobes and temporal lobes, suspicious for a hypoxic injury. 2. The exact nature of the increased signal identified in the basal ganglia on ADC map and FLAIR is unclear but could be also due to hypoxic injury. 3. Enhancement along the sulci and also in the basal ganglia region could be secondary to meningitis or meningeal inflammation from other causes. Clinical correlation is recommended. 4. Extensive paranasal sinus changes as described above. [**2112-2-6**] LUMBAR PUNCTURE: [**2112-2-6**] 05:47PM CEREBROSPINAL FLUID (CSF) WBC-4 RBC-2* Polys-2 Lymphs-83 Monos-15 [**2112-2-6**] 05:47PM CEREBROSPINAL FLUID (CSF) TotProt-34 Glucose-71 LD(LDH)-271 Opening pressure 40 Cryptococcal antigen: negative Culture: [**2112-2-8**] CTA Chest: [**2112-2-8**] CXR: IMPRESSION: Persistent bilateral basal atelectasis with almost complete collapse of the left lower lobe. ============== MICROBIOLOGY: ============== [**2112-2-5**] 9:09pm SPUTUM Site: ENDOTRACHEAL GRAM STAIN (Final [**2112-2-6**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS. 1+ (<1 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. RESPIRATORY CULTURE (Preliminary): RARE GROWTH OROPHARYNGEAL FLORA, YEAST. SPARSE GROWTH. STAPH AUREUS COAG +. SPARSE GROWTH. Brief Hospital Course: CARDIAC ARREST: Mr. [**Known lastname 14887**] is a 49 yo M with a history of EtOH and prescription drug abuse, who was found unresponsive at home by his mother. EMS was called and thought Mr. [**Known lastname 14887**] was in VF asystole vs. VF and received epinephrine and atropine x3 followed by cardioversion with return to sinus rhythm. The patient was intubated and sedated in the field and brought to [**Hospital **] Hospital prior to transfer to [**Hospital1 18**]. There was concern for intentional overdose as a cause of his arrest; however, tox screen was notable only for EtOH level in the 200's at the OSH. TSH was normal. CXR revealed left-sided retrocardiac opacity concerning for aspiration and in light of leukocytosis, the patient was started on levofloxacin and metronidazole for antibiotic coverage. It is likely that hypoxia, possibly from the aspiration, led to a cardiac arrest. He was also found to be hypokalemic on admission, which may have also contributed to cardiac arrest. ANOXIC BRAIN INJURY: In the ED the patient was initiated on a cooling protocol. Neurology was consulted to advise on prognosis, but his acute febrile illness made it difficult to prognosticate long-term function from the cardiac arrest. He remained intubated and sedated on propofol from admission to [**2112-12-7**], at which point his sedation was changed to fentanyl/versed. EEG on [**2112-1-31**] revealed widespread monotomous slowing with no areas of prominent focal slowing; there were also no epileptiform features. Repeat EEG was later performed on [**2112-2-5**] because of concern that the patient may have been in status epilepticus after he was noted to have rhythmic shaking movements from his toes to his face. It did not show epileptic activity and was unchanged from the prior EEG. Ultimately, it was felt that his movements were tremors, possibly the result of his brain stem injury. Mr. [**Known lastname 14887**] made no progress neurologically and remained ventillator dependent. In light of this, and his peristent fevers and leikocytosis (see below) he was made CMO on [**2112-2-9**] and extubated on [**2112-2-10**]. He expired on [**2112-2-11**]. PNEUMONIA and RESPIRATORY FAILURE Sputum cultures from early in the admission grew out MSSA, and he was treated with several rounds of broad spectrum antibiotics. Patient continued to require ventilator support, so he was made CMO on [**2112-2-9**] and extubated on [**2112-2-10**] PERSISTENT FEVERS AND LEUKOCYTOSIS: Mr. [**Known lastname 14887**] had positive sputum cultures from his MSSA pneumonia. He also had blood cultures showing GPCs in pairs and clusters. His high fevers and elevated WBC persisted despite several rounds of antibiotics. He had an LP on [**2112-2-6**], with an opening pressure of 40 but otherwise normal. His abdomen was also noted to be tense, and he developed diarrhea, but tested negative for C.diff twice and had a C.diff toxin B pending. He likely had a central component to his persistent fevers. He had no evidence of a drug reaction, and never developed any rash or eosinophilia. ETOH WITHDRAWAL The patient was monitored for EtOH withdrawal when intubated, but he had no signs of withdrawal and required no benzodiazepines for treatment. He was given thiamine, folate and a banana bag. Medications on Admission: Xanax Percocet Lomotil Discharge Medications: Expired. Discharge Disposition: Expired Discharge Diagnosis: Expired. Discharge Condition: Expired. Discharge Instructions: Expired. Followup Instructions: Expired.

[ "305.90", "473.8", "427.41", "291.81", "518.81", "303.91", "482.41", "348.1", "535.50", "507.0", "276.8" ]

icd9cm

[ [ [] ] ]

[ "96.6", "99.81", "03.31", "96.72" ]

icd9pcs

[ [ [] ] ]

10181, 10190

6760, 10075

338, 341

10242, 10252

2702, 2702

10309, 10320

2349, 2367

10148, 10158

10211, 10221

10101, 10125

10276, 10286

2382, 2392

6638, 6737

2414, 2683

1919, 2005

3560, 6597

275, 300

369, 1900

2718, 3543

2027, 2165

2181, 2333

58,377

178,345

50526

Discharge summary

report

Admission Date: [**2138-8-26**] Discharge Date: [**2138-9-9**] Date of Birth: [**2056-2-17**] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5084**] Chief Complaint: loss of consiousness Major Surgical or Invasive Procedure: [**2138-8-26**] Right Frontal EVD History of Present Illness: This is a 82 year old female who developed a headache yesterday and was found down at home and unresponsive on the day of admission. The patient was transferred to [**Hospital1 18**] for further care where CT head showed a hemorrhage within the right lateral ventricle with mild hydrocephalus but no midline shift. Past Medical History: Basal cell carcinoma in forehead (s/p) resection and another lesion on her upper lip. Trigeminal neuralgia Cholecystectomy Ascending Aortic Aneurysm s/p replacement Atrial fibrillation s/p MAZE and LAA ligation [**2137-05-25**] Aortic, mitral, and tricuspid valve regurgitation Dyslipidemia Hypertension Diverticulosis Cataract Surgery Bladder Suspension cholecystitis Social History: Lives with: Son, independent of ADLs Tobacco: Never ETOH: Rare Family History: Extensive family history of cardiovascular disease and cancer -Father died at 49 with unknown cancer ?prostate -Mum died at 91 after multiple strokes -5 brothers and 1 sister died of cancer (1 sister with bladder cancer, brother with unknown cancer with brain mets, other cancers unknown) -6 sisters with heart disease all except 1 deceased. Physical Exam: On Admission: BP: 177/99 HR: 88 R 17 O2Sats 96% HEENT: Pupils: 2-1mm Neuro: Mental status: EO to voice, following commands in all extremities, cooperative with exam but somewhat sleepy Orientation: Oriented to person, place, and year but not month. 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,2 to 1 mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-31**] throughout. No pronator drift Sensation: Intact to light touch Reflexes: B T Br Pa Ac Right 2----------- Left 2----------- On the day of Discharge: A&O to self, month, year,not to place ("arena") . PEERL, motor intact, has 2 stables at EVD site. Pertinent Results: [**8-26**] Chest Xray: Cardiomediastinal silhouette is enlarged in this patient who is status post median sternotomy. Opacities at the left base are improved from the prior radiograph. Parenchymal opacities are better appreciated on the CT from the same day and given change since prior radiograph are consistent with mild interstitial edema. No bony irregularities are appreciated. Abdominal clips seen in right upper quadrant. [**8-26**] CT head 11:55am : Large intraventricular hemorrhage. No definitive intraparenchymal component is seen. Enlargement of the temporal horns bilaterally raising concern for hydrocephalus. [**8-26**] CT C-spine: There is no critical spinal canal stenosis or prevertebral soft tissue swelling. Degenerative changes are seen in the cervical spine; however, no evidence of acute fracture. No major alignment abnormalities are noted. Imaged portions of the lung apices show left upper lobe ground glass opacities. There are bilateral extensive carotid bulb calcifications. [**8-26**] CT with and without contrast C/A/P: 1. No evidence of acute intrathoracic or intra-abdominal injury. 2. Mild pulmonary edema. [**8-26**] Chest Xray: Interval placement of endotracheal tube with tip approximately 6 cm from the carina. No other change. [**8-26**] Chest Xray: The tip of the endotracheal tube projects 5.5 cm above the carina. Tip of the orogastric tube is in the stomach. No complications. Otherwise, unchanged appearance of the radiograph. [**8-26**] CTA head: CTA HEAD: There is no aneurysm greater than 3 mm. No vascular malformation is noted. Major intracranial vessels remain patent. There are scattered foci of atherosclerotic plaques in the cavernous segments of the internal carotid arteries, without flow-limiting stenosis. There is moderate decreased caliber of the distal basilar artery, with bilateral fetal origins of PCAs, likely represent atherosclerotic disease superimposed on normal variants. There is no distal occlusion. The visualized paranasal sinuses and mastoid air cells are clear. There is no acute skull base fracture. NON-CONTRAST HEAD CT: There is slightly improved appearance of the lateral ventriculomegaly. A new ventriculostomy tube is seen via a right transfrontal approach, with the catheter crossing midline and terminating in the left frontal [**Doctor Last Name 534**]. There is large amount of intraventricular hemorrhage in the right lateral hemorrhage, possibly decreased from prior. There is also a small amount of blood layering in the occipital [**Doctor Last Name 534**] of the left lateral ventricle. There is no gross midline shift. Small pockets of air and minimal subarachnoid hemorrhage track along the catheter to the entry site, in keeping with the recent procedure. The basal cisterns remain patent. Significant periventricular white matter hypodensity, right worse than left, likely represents transependymal CSF migration superimposed with underlying chronic microvascular ischemic disease. [**8-26**] CT head 10:30pm: 1. Re-positioned right frontal approach ventriculostomy catheter, now terminating at the proximal third ventricle. 2. Unchanged appearance of intraventricular hemorrhage, lateral ventriculomegaly, and extensive neighboring edema. No superimposed acute hemorrhage or new mass effect seen since the 8:30 p.m. study. [**2138-8-29**] NCHCT: In comparison to [**2138-8-26**] exam, there is interval improvement of intraventricular hemorrhage involving predominantly right lateral ventricle. Small amount of blood products are seen in the occipital [**Doctor Last Name 534**] of the left ventricle. No definite hemorrhage is seen in the third and fourth ventricles on today's exam. Ventriculomegaly has improved since prior, as demonstrated by decrease in size of the temporal horns. No new intracranial hemorrhage. CHEST (PORTABLE AP) Study Date of [**2138-9-1**] 8:45 AM FINDINGS: As compared to the previous radiograph, all monitoring and support devices, particularly the endotracheal tube, have been removed. Sternal wires in correct alignment. Surgical clips in unchanged position. The lung volumes are normal. There is moderate cardiomegaly and tortuosity of the thoracic aorta, but without evidence of pulmonary edema. No pneumonia, no pleural effusions. No pneumothorax. CT HEAD W/O CONTRAST [**2138-9-2**] IMPRESSION: 1. Interval decrease in intraventricular hemorrhage. Decreased size of the temporal and occipital horns of the right lateral ventricle. Mildly increased size of the frontal [**Doctor Last Name 534**] of the right lateral ventricle and of third ventricle; they are not abnormally large for age. 2. New small isodense right frontal subdural collection with no significant associated mass effect. Recommend continued follow-up. CT Head [**2138-9-3**] IMPRESSION: Status post ventriculostomy catheter removal with stable intraventricular hemorrhage and stable blood products along the catheter tract. [**2138-9-4**] BLE Lenis No deep vein thrombosis in the bilateral lower extremities Brief Hospital Course: Ms. [**Known lastname 11193**] was evaluated in the ED and recieved FFP, and Vitamin K for INR reversal. After she was examined she was intubated for airway protection and transferred to the ICU. Right frontal EVD was placed at the bedside for progressionof hydrocephalus. CT head demonstrated malpositioned catheter tip and so the catheter was withdrawn and replaced. Postprocedure CT demonstrasted the catheter tip to be in good position. EVD hung at 5cm above the tragus. CSF was blood tinged initially and over time the drain became clotted and TPA was administered. After the TPA CSF flowed freely. CTA was performed that was negative for aneursysm or vascular malformation. The following morning on [**8-27**] the patient was extubated. She was AOx1, oriented to self only, following commands. EVD remained at 5cm above the tragus. Overnight the drain clotted again and another dose of TPA was administered with good effect. On [**8-28**] the patient remained AOx1 however mental status improved and she followed commands more briskly.Her EVD functioned without problem. On [**8-29**] the patient was noted to have increasing ICP's. Upon inspection and removal of the dressing, the catheter was noted to be kinked. Once this was resolved the ICP's returned to [**Location 213**]. A head CT was also performed and noted to be stable but there was a collapsed right ventricle. Due to this the EVD was raised to 10cm H20. On [**8-30**] the patient and EVD remained stable. On [**9-1**] the patient's EVD height was increased to 15cm. ICPs remained stable overnight between [**2-2**] and the patient was better oriented. On [**9-2**], The patient's external ventricular drain was clamped at 0900 am. The intercranial pressure measured at 2-13 throughtout the day. A non contrast Head CT was perormed which showed "interval decrease in intraventricular hemorrhage, Decreased size of the temporal and occipital horns of the right lateral ventricle. Mildly increased size of the frontal [**Doctor Last Name 534**] of the right lateral ventricle and of third ventricle as well as a new small isodense right frontal subdural collection with no significant associated mass effect. The patient's neurologic exam remained stable. on [**9-3**] the patient's ICP had remained stable overnight (less than 10mmH2O) and she remained intact neurologically so the decision was made to remove the EVD. This was done without complication. A post removal CT was performed which revealed a small hemorrhage along the previous catheter tract. Due to this she was kept in the ICU overnight. On [**9-4**] she was neurologically intact and hemodynamically stable. She was cleared for transfer to the floor. PT and OT consults were requested. Physical therapy found the patient demonstrated good functional improvement over the weekend but Occupational therapy found that she was limited by poor memory and insight and would not be able to return home without 24 hour supervision. On [**9-8**] her coumadin was retarted at her home dose and patient agreed to go to rehab for further evaluation and treatment. On [**9-9**], patient remained stable and was discharged to rehab. She was started on levoquin for a complicated UTI prior to her discharge. Medications on Admission: 1. gabapentin 100 mg Capsule Sig: One (1) Capsule PO QID (4 times a day). 2. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. warfarin 1 mg Tablet Sig: Two (2) Tablet PO once a day. 4. 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* Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H 2. Bisacodyl 10 mg PO/PR DAILY constipation 3. CloniDINE 0.2 mg PO BID hold for SBP < 90, HR <60 RX *clonidine 0.2 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 4. Docusate Sodium 100 mg PO BID 5. Metoprolol Tartrate 50 mg PO BID 6. Senna 1 TAB PO BID 7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain RX *oxycodone 5 mg 1 tablet(s) by mouth Q4hr Disp #*30 Tablet Refills:*0 8. Levofloxacin 750 mg PO Q24H Duration: 5 Days 9. Warfarin 2 mg PO DAILY16 1.5mg alternating with 2mg daily Discharge Disposition: Extended Care Facility: [**Hospital1 **] Nursing & Therapy Center - [**Location 1268**] ([**Location (un) 86**] Center for Rehabilitation and Sub-Acute Care) Discharge Diagnosis: Intraventricular Hemorrhage hydrocephalus Discharge Condition: Mental Status: clear, coherent but intermettently not oriented to place or date. Level of Consciousness: Alert and interactive. Activity Status: physically independent but limited due to poor memory and insight. Discharge Instructions: Nonsurgical Brain Hemorrhage ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. ??????We recommend you see Dr [**First Name (STitle) **] in the Traumatic Brain Injury (TBI) clinic the phone number is [**Telephone/Fax (1) 6335**]. If you have any problems booking this appointment please ask for [**First Name8 (NamePattern2) 16367**] [**Last Name (NamePattern1) 16368**]. ---Please return to the office by [**9-13**] for removal of your final staples. This appointment can be made with the Nurse Practitioner [**First Name (Titles) **] [**Last Name (Titles) **] [**Name Initial (PRE) 19158**]. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. Completed by:[**2138-9-9**]

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Discharge summary

report

Admission Date: [**2180-11-29**] Discharge Date: [**2180-12-2**] Date of Birth: [**2115-3-19**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1711**] Chief Complaint: elective admission for tracheal stent Major Surgical or Invasive Procedure: Pericardiocentesis Pulmonary Stenting History of Present Illness: Mr. [**Known lastname 88214**] is a 65 yom with h/o hyperlipidemia, s/p pacemaker, Hep C ([**1-11**] to IVDU 30 yrs prior and untreated), h/o PTX, alcohol abuse, and smoking p/w SCLCA s/p 6 cycles etop/cisplatin, large mediastinal masses with critical obstruction to the LUL who was admitted for elective stent placement and is being transferred to the CCU for pericardial effusion with early tamponade physiology. Per the outside report, he had progressive cough and voice changes over the past few months and reports trouble with both solids and liquids. He has had weight loss of approximately 15-20 lbs during this time as well. Biopsy of his left upper lung mass was consistent with small cell lung cancer in [**11-16**]. CT brain with contrast was negative for mets. PET scan showed b/l subcarinal nodes but no more distant disease. He was recently noted to have very bulky [**Location (un) 21851**] with LUL collapse and partial occlusion of the left pulmonary artery. Patient presented for direct admit for stent placement but CT scan showed pericardial effusion and pulsus was reportedly measured on the floor to be 15-20. Cardiology fellow was called for evaluation. Bedside echo showed RV collapse with signs of tamponade. Transfer to CCU for monitoring with plan for pericardiocentesis in AM. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: -SCLC: [**11-16**] - SCLCA diagnosed, had etoposide/carboplatin with 6th cycle given [**4-17**] (good tolerance). [**2-16**] and [**3-18**]: RT done [**2-16**]: showed regression in most areas. [**5-18**]: reduction in mass, persistent subtotal central occlusion of LUL bronchus, reduction in constriction of pulmonary artery to the LUL and reduction in central adenopathy, reexpansion of LUL. [**4-17**]: last chemo [**2180-6-1**]: PET showed reduction in all areas, no new areas. [**2180-6-14**]: hemoptysis of teaspoon 5cc BRB. CT scan noted for new infiltrate showing encasement of artery to LUL and subtotal occlusion of the bronchus to the LUL. Smoking was continued at this point 2ppd. Bronchoscopy by Dr [**First Name (STitle) **] was suspiciuous for tumor. [**8-18**]: continued worsening of hoarseness, paroxysmal cough, left anterior chest dsicomfort, increased dyspnea, no other pain or headache, no addtional bleed. CT: increasing central adenopathy, narrowing of left mainstem bronchus to [**12-11**] of the right bronchus, complete obliteration of the LUL bronchus with collapse of LUL with compromise of left pulmonary artery. Bronchus to LLL, lingular were compromised. Started on: Etoposide and carboplatin - 2 cycles, progressive disease noted, has a pericardial effusion. - continued to be symptomatic dyspnea, no dysphagia, continued anorexia. presented for paliative treatment. Hyperlipidemia Pacemaker [**2169**] H/O Hep C untreated [**1-11**] IVDU 30 yrs ago spontaneous PTX cigarette addiction significant alcohol intake tendon repair 4th finger on the right hand Social History: 2 Drinks daily, smoke [**12-11**] ppd or more till [**2-/2180**], started a nicotine patch. married to [**Doctor First Name **]. working 12-14 hr days. Family History: Father: died in 50's, emphysema Mother: dies in 100's, Natural causes Sister 1: 68 yrs Sister 2: 66 yrs Has two grown children Physical Exam: VS: T=99 BP=128/80 HR=102 RR=20 O2 sat=93% RA Pulsus=6 GENERAL: NAD. Oriented x3. Depressed mood. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 10cm. CHEST: Device in place in L upper chest CARDIAC: Muffled heart sounds. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Diffuse expiratory rhonchi with decreased BS at L apex ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: Trace pitting edema b/l. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: Admission Labs: [**2180-11-29**] 07:45PM BLOOD WBC-13.5* RBC-2.99* Hgb-10.3* Hct-29.4* MCV-99* MCH-34.4* MCHC-35.0 RDW-16.0* Plt Ct-229 [**2180-11-29**] 07:45PM BLOOD Neuts-83* Bands-2 Lymphs-5* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-1* [**2180-11-29**] 07:45PM BLOOD PT-15.0* PTT-29.1 INR(PT)-1.3* [**2180-11-29**] 07:45PM BLOOD Glucose-128* UreaN-13 Creat-0.7 Na-134 K-3.9 Cl-95* HCO3-30 AnGap-13 [**2180-11-29**] 07:45PM BLOOD ALT-80* AST-94* LD(LDH)-271* AlkPhos-69 TotBili-0.5 [**2180-11-29**] 07:45PM BLOOD Albumin-2.7* Calcium-8.4 Phos-3.4 Mg-1.4* Discharge labs: [**2180-12-2**] 06:27AM BLOOD WBC-13.9* RBC-2.65* Hgb-8.8* Hct-26.1* MCV-99* MCH-33.1* MCHC-33.6 RDW-16.0* Plt Ct-209 [**2180-12-2**] 06:27AM BLOOD Glucose-119* UreaN-14 Creat-0.5 Na-135 K-3.5 Cl-101 HCO3-29 AnGap-9 [**2180-12-2**] 06:27AM BLOOD ALT-70* AST-105* AlkPhos-55 TotBili-0.4 [**2180-12-2**] 06:27AM BLOOD Calcium-7.7* Phos-2.5* Mg-1.9 Studies: Portable TTE (Focused views) Done [**2180-11-29**] at 9:10:48 PM Conclusions Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is unusually small. with normal free wall contractility. The mitral valve leaflets are mildly thickened. There is a moderate to large sized pericardial effusion. No right ventricular diastolic collapse is seen. There is brief right atrial diastolic collapse. IMPRESSION: Moderate to large pericardial effusion located mostly at the LV apex and LV inferolateral wall. There is relatively little fluid overlying the right ventricular free wall. Apical approach to pericardiocentesis likely better. No frank echo evidence of tamponade although both ventricles are small and patient is tachycardic. Cardiac Cath Study Date of [**2180-11-30**] FINAL DIAGNOSIS: 1. Successful pericardiocentesis with 240 cc of serosanguinous fluid removed with access obtained under echocardiographic guidance and pericardial drainage bag secured and sutured into position. (refer to comments section) 2. Monitor drainage with plan for removal of drain in 24-36 hours CHEST (PORTABLE AP) Study Date of [**2180-11-30**] 5:22 PM FINDINGS: The patient is intubated, the tip of the endotracheal tube projects 4.5 cm above the carina. Massive volume loss in the left lung due to fibrosis and consolidations. Subsequent elevation of the left hemidiaphragm. A central airway stent is visible. No pathological changes in the right lung. Portable TTE (Focused views) Done [**2180-11-30**] at 12:00:00 PM Conclusions Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is no pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Prior to tap, moderate to large circumferential pericardial effusion is seen. Post-tap, there is minimal fluid with normal biventricular function. Brief Hospital Course: 65yo M with metastatic SCLC admitted for tracheal stent placement, found to have pericardial effusion with concern for early tamponade physiology on TTE, hemodynamically stable now. # Pericardial effusion: He presented with reported shortness of breath. He had a pulsus paradoxus of 15-20. He had questionable tamponade physiology on echo. He was hemodynamically stable, however, needed to drain the effusion prior to bronchial stenting. In the CCU his pulsus was less than ten. He was taken to the cath lab on [**2180-11-30**] and had 260cc's. A drain was kept overnight, with drainage overnight. After multiple hours of no output, the drain was pulled. A post procedure echo showed minimal effusion, and echo the following day ([**12-1**]) showed minimal increase from post procedure, after minimal output from the drain. His pulsus remained less than ten after the procedure. # Small Cell Lung CA: He is undergoing palliative measures as an outpatient. He was admitted for elective tracheal stenting. After pericardiocentesis, he was taken for bronchial stenting. They did not observe there to be any purulence posterior to the obstruction, however there was extensive invasion and necrosis from tumor, including into the [**Female First Name (un) 5309**]. He was very sedated after the procedure, and required intubation overnight, for airway protection post procedurally. There were minimal secretions suctioned the morning after the procedure. He was extubated successfully. He was well oxygenated (sats in the high 90s) throughout his stay. # Transaminitis: [**Month (only) 116**] be [**1-11**] chronic untreated HCV infection given concomitant elevated INR and low albumin. Also possibly a component of alcoholic cirrhosis/hepatitis, though AST not significantly more elevated than ALT. Metastatic disease also on the differential. Unclear etiology while an inpatient, and could be worked up as an outpatient. # Leukocytosis: WBC elevated with left shift. His WBCs increased post procedurally to 22.6. Treatment was started with Levaquin for postobstructive pneumonia. His WBCs trended down to 13 at discharge. # Follow-up: Mr. [**Known lastname 88214**] has a few pending labs that will need to be followed-up by his primary care physician or [**Name9 (PRE) 269**] service and faxed to his PCP [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 64198**]: Blood cultures - no growth to date Respiratory culture - no growth to date Broncoalveolar lavage fluid cultures - no growth to date Medications on Admission: Megace ES 625mg prn Atenolol 25mg QD aspirin 325 prn mucinex 600mg prn guaiatussin AC 20-200 prn Discharge Disposition: Home With Service Facility: angels visiting nurse Discharge Diagnosis: Primary: Left main bronchus obstruction Small cell lung cancer Pericardial effusion Secondary: HLD Alcoholism Hepatitis C Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 88214**], it was a pleasure taking part in your care. You were admitted to have a procedure called a pulmonary stenting. This was to open the airway to your left lung. On admission you were found to have fluid surrounding your heart, which was causing mild shortness of breath. You had a procedure called a pericardiocentesis. The cardiologists drained the fluid from around your heart and the pulmonologists took you for the stenting. You tolerated the procedure well. You required intubation (a breathing tube) overnight to help you rest and breath. You were extubated the following day and did very well. On discharge you were doing well, and your breathing was improved. However, you may need oxygen at home to help you breathe better. A visiting nursing service will evaluate you for this at home. You should continue to take antibiotics for a total 10-day course, for what we believe may be a pneumonia. We have made the following changes to your medications: 1) START Levofloxacin 750mg daily until [**2180-12-10**] 2) STOP atenolol and aspirin, until advised to restart by your physicians 3) START Percocet at night as needed for pain. IT IS IMPORTANT THAT YOU DO NOT DRIVE WHILE TAKING A SEDATING MEDICATION LIKE THIS. PLEASE USE A DIFFERENT OVER-THE-COUNTER PAIN RELIEVER IF [**Street Address(1) 88215**]. Followup Instructions: Please call [**Telephone/Fax (1) 32949**] to schedule follow-up with your primary care doctor. You will be contact[**Name (NI) **] by Interventional Pulmonology for outpatient follow-up in the next 2 weeks. Please call your oncologist for follow-up. Completed by:[**2180-12-3**]

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icd9cm

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Discharge summary

report+addendum

Admission Date: [**2199-1-4**] Discharge Date: [**2199-1-28**] Date of Birth: [**2121-8-10**] Sex: M Service: Medicine HISTORY OF PRESENT ILLNESS: The patient is a 77 year old man with a history of atrial fibrillation and aortic valve replacement, who presented to his primary care physician's office on the day of admission with one to two weeks of progressive dyspnea. It has evolved to the point where the patient is only able to walk two to three steps before he must sit down. Over the last week, the patient has also been taking sublingual nitroglycerin with these episodes three to four times per day. This has not given him any relief. The patient denies chest pain, nausea, vomiting or diaphoresis with these events. He sleeps on three pillows. He describes difficulty sleeping over the last several weeks, but denies paroxysmal nocturnal dyspnea. He does not note increased swelling of his lower extremities. He describes an occasional productive cough with yellow sputum but denies fevers. He has had a decrease in his appetite recently. The patient has a history of gastrointestinal bleed. He notes a small amount of blood on the toilet paper over the past weeks. He denies bright red blood per rectum as well as hematemesis. PAST MEDICAL HISTORY: 1. Status post aortic valve replacement secondary to rheumatic heart disease in [**2184**]. 2. Atrial fibrillation. 3. Type 2 diabetes mellitus. 4. Status post gunshot wound to left leg. 5. History of left lower extremity cellulitis. 6. History of gastrointestinal bleeding attributed to gastritis, requiring over 20 units of blood transfusions earlier this year. 7. Chronic renal failure. 8. History of colonic adenoma. 9. History of diverticulosis. MEDICATIONS ON ADMISSION: Protonix 40 mg p.o.q.d., Coumadin 10 mg p.o.q.d., Glucotrol XL 5 mg p.o.b.i.d., digoxin 0.125 mg p.o.q.d., Lasix 40 mg p.o.q.d., Prozac 20 mg p.o.q.d., Zestril 20 mg p.o.q.d., Zocor 20 mg p.o.q.d., iron 325 mg p.o.b.i.d. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient lives with his wife of 50 years. He has a remote history of tobacco and alcohol use. PHYSICAL EXAMINATION: On physical examination on admission, the patient had a temperature of 98.9, blood pressure 126/59, heart rate 81, respiratory rate 25 and oxygen saturation 96% on two liters. General: Patient in no acute distress, alert and oriented times three, speaking in complete sentences. Head, eyes, ears, nose and throat: Pupils equal, round, and reactive to light and accommodation, positive left cataract, extraocular movements intact, anicteric sclerae, oropharynx clear. Neck: No lymphadenopathy, jugular venous pressure at 9 cm, supple. Lungs: Bilateral crackles two-thirds of the way on the left, one-half of the way on the right, moving air in all segments. Cardiovascular: Mechanical click, irregularly irregular rhythm, II/VI systolic ejection murmur at right upper sternal border. Abdomen: Soft, nontender, nondistended, positive bowel sounds. Rectal: Normal tone, no masses, heme positive brown stool, no hemorrhoids, no fissures. Genitourinary: Scrotal edema, reportedly unchanged per patient. Extremities: No cyanosis, clubbing or edema in upper extremities, hyperemia of venous stasis in lower extremities with some edema of right lower extremity, 2+ pitting edema mid-calf and below in left lower extremity, no ulcers. Neurologic examination: Alert and oriented times three, cranial nerves II through XII intact, motor and sensation grossly intact. LABORATORY DATA: Admission white blood cell count was 7.9, hematocrit 28.6, platelet count 208,000, INR 1.8, partial thromboplastin time 32.4, sodium 139, potassium 5.1, chloride 106, bicarbonate 22, BUN 66, creatinine 2.2, glucose 110, ALT 12, AST 25, alkaline phosphatase 214, amylase 100, lipase 71, total bilirubin 0.5, CK/MB 3 and troponin-I less than 0.3. Chest x-ray: No evidence of congestive heart failure, no infiltrate. Electrocardiogram: Atrial fibrillation, unchanged from prior tracing except for inverted T waves in V4 and V5. Right lower extremity Doppler: Preliminary read negative. HOSPITAL COURSE: 1. Gastrointestinal: Of note, the patient has a history of presenting with shortness of breath when he has had anemia secondary to gastrointestinal bleeding. His stool was guaiac positive on admission. The patient was transfused one unit of blood, with an appropriate increase in his hematocrit to 32.1 and his heparin was continued for aortic valve replacement related anticoagulation. The patient was transfused another unit of blood on [**2199-1-5**] for a hematocrit of 28.9, again with an appropriate increase to 32.8. At this time, he continued to have guaiac negative stools and no melena. When the patient had another drop in his hematocrit to 29.1 on [**2199-1-8**], the gastroenterology service was contact[**Name (NI) **] regarding possible endoscopy. At this time, they declined endoscopy because the patient has had multiple upper endoscopies and an colonoscopy earlier this year, which revealed gastritis. On [**2199-1-8**], the patient's Protonix was increased to 40 mg every 12 hours. On the afternoon of [**2199-1-9**], the patient noted melena. On [**2199-1-10**], his hematocrit decreased to 27.5. On [**2199-1-12**], the gastroenterology service was consulted for occult gastrointestinal bleed evaluation. The gastroenterology service opted to do an endoscopy to evaluate the status of his gastritis and possible arteriovenous malformation. On [**2199-1-14**], the patient's hematocrit decreased to a level of 24.7. The patient was transferred to the Medical Intensive Care Unit for more intensive monitoring in the setting of his gastrointestinal bleed. The patient received an upper endoscopy on [**2199-1-14**], which revealed a single nonbleeding arteriovenous malformation in the pylorus of the stomach, which was electrocauterized, as well as a single small arteriovenous malformation with stigmata of recent bleeding in the jejunum, which was also electrocauterized. The patient continued to have a low hematocrit, with blood transfusion requirements and a tagged red blood cell scan was performed, which was negative for evidence of active bleeding. The patient also underwent a colonoscopy on [**2198-1-17**], which revealed two nonbleeding polyps in the ascending and descending colon as well as multiple nonbleeding, not diverticula, in all portions of the colon. After this, the patient maintained his hematocrit in response to the red blood cell transfusions and he was called out of the Medical Intensive Care Unit on [**2199-1-22**]. From this time until the time of dictation ([**2199-1-27**]), the patient had a stable hematocrit in the range of 32 to 34. He has had guaiac negative stools and no evidence of gastrointestinal bleeding. He has continued on a twice a day proton pump inhibitor. 2. Cardiovascular: Both heart failure and cardiac ischemia were felt to be in the differential diagnosis for the patient's shortness of breath on presentation. On [**2199-1-7**], the patient underwent a pharmacological stress test, which was negative for evidence of ischemia. He received an echocardiogram on [**2199-1-8**], which revealed a left ventricular ejection fraction of about 40%, depressed right ventricular function with evidence of right greater than left heart failure. The patient was continued on his Captopril, Isordil, Zocor, digoxin and Lasix. While in the Medical Intensive Care Unit, the patient became hypotensive, requiring fluid boluses and, briefly, a dobutamine drip. In response to the fluids he received, the patient developed evidence of heart failure on physical examination and on chest x-ray. He was successfully diuresed and, at the time of dictation, had much improved oxygen saturation and ease of breathing. After the patient's stay in the MICU, the patient was noted to have a substantial amount of ventricular ectopy. He had one 18 beat run of nonsustained ventricular tachycardia. The electrophysiology service was consulted and they recommended that he be continued on rate control for atrial fibrillation (metoprolol) without a recommendation for an ICD or amiodarone. The patient was anticoagulated for his prosthetic aortic valve except when he had evidence of active gastrointestinal bleeding. After his endoscopy and electrocauterization procedure, the patient was placed on heparin again and eventually on Coumadin until his INR became therapeutic at a left between 2.5 and 3.5. 3. Pulmonary: At the time of the patient's admission to the Intensive Care Unit, the patient was in respiratory distress and was intubated without complications. On [**2199-1-18**], the patient was placed on pressure support ventilation. He continued to improve with diuresis. He was extubated on [**2199-1-21**] and has not had significant respiratory difficulties on minimal oxygen from nasal cannula since then. 4. Infectious disease: While in the Intensive Care Unit, the patient had a chest x-ray which was suggestive of possible ventilator associated pneumonia. He was also noted to have substantial erythema of the left lower extremity, possibly consistent with cellulitis. The patient was placed on Unasyn to complete a 14 day course. On [**2199-1-25**], the patient was noted to have a large quantity of loose stool. His stool test for Clostridium difficile toxin was positive and the patient was started on a 14 day course of Flagyl. The patient did not grow any organisms from his blood or urine cultures throughout admission. 5. Renal: The patient has chronic renal failure with a baseline creatinine in the vicinity of 2. His creatinine increased to a level of around 3 at the time of his admission to the MICU. At the time of discharge, the patient had improvement back to his baseline level. 6. Musculoskeletal: On the evening of [**2199-1-10**], the patient was noted to have severe pain in the left popliteal region. A lower extremity Doppler ultrasound was performed, which was negative for deep vein thrombosis but positive for a ruptured [**Hospital Ward Name 4675**] cyst. The patient was treated with analgesic medications for the pain from this cyst. An orthopedic consult did not recommend any intervention and did not feel that the patient had any evidence of compartment syndrome. 7. Neurologic: The patient was noted to have delirium after his stay in the Medical Intensive Care Unit. Sedating medications were avoided and the patient's mental status gradually improved to the point where he is currently oriented to his location, the month and year, and his reason for admission to the hospital. The above is a dictation of the [**Hospital 228**] hospital course through [**2199-1-27**]. Please refer to a discharge addendum for discharge medications and additional discharge information. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**] Dictated By:[**Last Name (NamePattern1) 5596**] MEDQUIST36 D: [**2199-1-27**] 04:44 T: [**2199-1-27**] 18:26 JOB#: [**Job Number **] Name: [**Known lastname 18261**], [**Known firstname **] J. Unit No: [**Numeric Identifier 18262**] Admission Date: [**2199-1-4**] Discharge Date: [**2199-1-29**] Date of Birth: [**2121-8-10**] Sex: M Service: ADDENDUM: Hospital course addendum; 1. INFECTIOUS DISEASE: The patient received a full 2-week course of Unasyn at 1.5 g intravenously b.i.d. for left lower lobe ventilation associated pneumonia. 2. CARDIOVASCULAR SYSTEM: Although the patient was well diuresed, he still had lower leg edema due to congestive heart failure, so his Lasix was increased from 40 mg to 80 mg p.o. b.i.d. on [**2199-1-29**]. His creatinine should be monitored while on the Lasix. His atrial fibrillation was well rate controlled. 3. PSYCHIATRY: The patient's delirium resolved once Haldol was discontinued and Risperidol started at 1 mg p.o. q.h.s. For his depression, he was restarted on Prozac 20 mg p.o. q.d. DISCHARGE DIAGNOSES: 1. Gastrointestinal bleed secondary to arteriovenous malformation; status post electrocauterization. 2. Atrial fibrillation. 3. Aortic valve replacement. 4. Congestive heart failure. 5. Type 2 diabetes mellitus. 6. Chronic renal failure with a baseline creatinine of 2. 7. Status post pneumonia. 8. Clostridium difficile infection. 9. Delirium secondary to Haldol. 10. Depression. MEDICATIONS ON DISCHARGE: 1. Metoprolol 12.5 mg p.o. b.i.d. 2. Digoxin 0.25 mg p.o. q.d. 3. Lisinopril 20 mg p.o. q.d. 4. Lasix 80 mg p.o. b.i.d. 5. Glipizide-XL 5 mg p.o. q.d. 6. Flagyl 500 mg p.o. t.i.d. (end on [**2199-2-8**]). 7. Coumadin 5 mg p.o. q.h.s. 8. Protonix 40 mg p.o. b.i.d. 9. Atrovent 2 puffs inhaled q.i.d. 10. Albuterol 1 to 2 puffs inhaled q.4-6h. as needed. 11. Risperidol 1 mg p.o. q.h.s. 12. Zyprexa 5 mg p.o. q.h.s. as needed. 13. Prozac 20 mg p.o. q.d. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 224**], M.D. [**MD Number(1) 225**] Dictated By:[**Last Name (NamePattern1) 4387**] MEDQUIST36 D: [**2199-1-29**] 15:09 T: [**2199-1-29**] 15:24 JOB#: [**Job Number **]

[ "518.82", "427.31", "292.81", "585", "428.0", "537.83", "276.0", "486", "008.45" ]

icd9cm

[ [ [] ] ]

[ "83.94", "96.72", "44.43", "38.91", "45.23", "96.04" ]

icd9pcs

[ [ [] ] ]

12189, 12589

12616, 13364

1782, 2058

4197, 12167

2196, 3440

169, 1272

3465, 4179

1294, 1755

2075, 2173

48,417

173,453

54832

Discharge summary

report

Admission Date: [**2139-4-29**] Discharge Date: [**2139-5-13**] Date of Birth: [**2076-12-8**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 348**] Chief Complaint: "I'm taking too many medicines and I fell" Major Surgical or Invasive Procedure: None History of Present Illness: 62 y/o woman with history of CVA (right sided deficit), ETOH dependence, sCHF LVEF 40% who presented with somnolence and multiple falls from her wheelchair. Per family she has been drinking alcohol and taking baclofen. She falls asleep then subsequently falls from her wheelchair or the cough. She hit her right upper extremity but not her head by her report. On the morning of admission she fell out of her wheelchair and was found on the floor. Last drink was 1 day PTA. No tremor, headache or neck pain. In the ED, initial vitals: 99.2 117 147/63 16 100% RA Exam notable for baseline right-sided spasticity. No cervical spine tenderness to palpation. Right upper extremity skin tears. Right lower extremity pressure ulcer. Labs notable for Na 129 (at her baseline). Tox screen negative. CT head: showed prior MCA infarct, no acute process, CT C spine showed large posterior osteophyte at C5-6 with moderate spinal canal narrowing. CXR showed increased interstitial marking consistent with chronic lung disease. EKG showed sinus tachycardia at 103 with TWI in V1-V4. She received 1L NS without change in sinus tachycardia. Upon arrival to the floor ECG showed sinus tachycardia with TWI V1-V4. SBP persistently 180s with HR 120s. She reportedly did not take her regular BP meds today. Nurse checked on patient because an alarmed bed and found her to be somnolent and hypoxic 82% on RA. She was diaphoretic and tachypneic with RR 30-40, sats improved to 92% on 30% ventimask. D-dimer was checked which was positive ~[**2126**]. ECG then showed LBBB. CE negative. Cardiology called who completed a bed side echocardiogram. She received 325mg aspirin. CXR showed increased RLL opacity suggestive of either aspiration versus atelectasis and increase in pulmonary edema. ABG 7.44/34/61/24, lactate 2.1. Received hydralazine and lasix. On arrival to the MICU, she was diaphoretic and Ox sats stable on a venti-mask. Denies chest pain. Knows she is at [**Hospital1 18**]. Recalls events and falls prior to admission. Breathing feels "short". Review of systems: (+) Chronic RUE and RUE spasticity (-) Denies chest pain. No cough. No abdominal pain. No headache. No lower extremity edema. No melena, hematochezia, dysuria or hematuria. Past Medical History: LBBB (left bundle branch block) Hyponatremia : Has improved in past with water restriction. Baseline is 128-133. Tobacco dependence ANEMIA ALCOHOL DEPENDENCE HYPERTENSION STROKE : s/p [**2121**]. s/p r endartedectomy. expressive aphasia. unable to raise right arm or open hand; hospitalized [**1-5**] with recurrent symptoms; MRA showed bilaterally occluded carotids ;r vertebral artery narrowing; saw interventional radiologist ; feels no intervention on vertebral artery unless she has recurrent symptoms HYPERLIPIDEMIA LDL GOAL < 100 Arterial insufficiency Muscle spasticity Venous stasis ulcer Peripheral edema Systolic CHF with EF 40% in [**2138-3-30**] on echo at [**Hospital 1263**] Hospital Pressure ulcer of heel Osteoporosis Social History: She is sedentary, uses a wheelchair for mobility. Essentially homebound except for medical appointments. Smoking 1 pack cigarettes every 2 days. Etoh: 2 cans of beer nightly. Denies illicit drug use. Son assists with laundry and groceries Family History: Sister with cancer (unknown type) Physical Exam: Admission Exam: General: Alert, oriented to place and name, no acute distress, using neck accessory muscles, facial skin greyish in appearance HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Sinus tachycardia, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation anteriorly, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley Ext: RLE patchy ecchymosis with mottling RLE with pressure ulcer, palpable pulse, warm. Neuro: CNII-XII intact, RUE and RLE spastic and contracted, [**4-4**] strength LUE and LLE, grossly normal sensation Discharge: Deceased Pertinent Results: Admission Labs: [**2139-4-29**] 07:10PM BLOOD WBC-10.0 RBC-3.93* Hgb-11.7* Hct-35.9* MCV-91 MCH-29.9 MCHC-32.7 RDW-13.1 Plt Ct-334 [**2139-4-29**] 07:10PM BLOOD Neuts-80.3* Lymphs-13.2* Monos-5.6 Eos-0.4 Baso-0.4 [**2139-4-29**] 07:10PM BLOOD PT-12.3 PTT-26.4 INR(PT)-1.1 [**2139-4-29**] 07:10PM BLOOD Glucose-117* UreaN-14 Creat-0.7 Na-129* K-4.1 Cl-93* HCO3-29 AnGap-11 [**2139-4-29**] 07:10PM BLOOD ALT-14 AST-32 CK(CPK)-708* AlkPhos-55 TotBili-0.7 [**2139-4-29**] 07:10PM BLOOD Albumin-3.8 [**2139-4-29**] 07:10PM BLOOD D-Dimer-1898* [**2139-4-29**] 07:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Cardiac Enzyme Trend: [**2139-4-29**] 07:10PM BLOOD ALT-14 AST-32 CK(CPK)-708* AlkPhos-55 TotBili-0.7 [**2139-4-30**] 06:12AM BLOOD ALT-17 AST-41* LD(LDH)-289* CK(CPK)-1238* AlkPhos-58 TotBili-0.9 [**2139-4-29**] 07:10PM BLOOD CK-MB-6 [**2139-4-29**] 07:10PM BLOOD cTropnT-<0.01 [**2139-4-30**] 06:12AM BLOOD CK-MB-9 cTropnT-<0.01 Imaging: R Hand Xray: IMPRESSION: Limited exam, without evidence of fractures. R Arm Xray: IMPRESSION: Limited exam, without evidence of fractures. CXR: IMPRESSION: No definite acute cardiopulmonary process. Increased interstitial markings suggestive of underlying chronic lung disease. Head CT: IMPRESSION: No acute intracranial process. There is a large region of left frontal encephalomalacia consistent with history of prior infarction, with associated ex vacuo dilatation of the ventricles. C-Spine CT: IMPRESSION: No fracture or malalignment of the cervical spine. There is a large posterior osteophyte, at C5-6, which results in moderate canal narrowing. If there is concern for cord injury, please note that MRI is more sensitive for this. TTE: IMPRESSION: Suboptimal image quality. Moderate concentric LVH with a small LV cavity size and moderately depressed global LV function. The inferolateral wall appears more hypokinetic than other segments. Chest CT with Contrast - Prelim Read: COPD with severe emphysema and diffuse bronchial wall thickening, worst in RLL with probable aspiration. Mild pulm edema + small effusions R>L. Severe atherosclerosis. No PE. Brief Hospital Course: ID: 62F with history of CVA with right-sided deficit, presenting today somnolence and frequent falls, now with acute respiratory failure. # Acute respiratory failure: Occurred suddenly a few hours after admission and promted MICU transfer. Most likely combination of flash pulmonary edema +/- aspiration event. EKG and cardiac enzymes not suggestive of ischemia. CTA with no PE, questions of trace aspiration in RLL. BP was very high and was tachycardic in setting of not taking home BP meds (including high home dose of atenolol) that day. Home ACE had also been stopped for unclear reasons. Improved with 20mg IV lasix and IV labetalol. Bedside ECHO with no focal wall motion abnormalities and baseline EF. Not given Abx as breathing quickly improved and CTA with very minimal aspiration and no obvious pneumonia. Breathing comfortably on RA at time of callout to floor. Pt was readmitted to the ICU on [**5-3**]-12am after a code blue for pulselessness found to be PEA arrest. At approx 0830 [**5-3**], pt was found to be very pale/yellow, with eyes open and fixed, blue lips w/ mouth open with yellowish froth coming out of mouth onto chin. She had no pulse and code blue was called and chest compressions commenced. Unknown how long she had been pulseless for. Pt was initially in PEA arrest and then s/p two pushes of epi was in V-tach and received shock; reentered PEA arrest then rec'd two more pushes of epi; then had wide-complex tachycardia and received 2nd shock; reentered PEA and rec'd one more amp of epi with ROSC and return of pulse. Pt was intubated; NGT placed to remove gas and improve ventilation; IO placed for access and fluids given wide open. Was treated for hyperkalemia with calcium and insulin; D50 given for hypoglycemia; amio 300 push given then started on gtt; 1 amp bicarb given for acidosis; portable echo showed beating heart but possible e/o WMA in inferior septum and wall. BP after ROSC had SBP's in 80s so started on norepinephrine gtt. Pt was transferred to the MICU, where she was intubated and pressors were continued. Pressors were eventually weaned. However, patient did not have any improvement in her mental status. She was empirically started on vancomycin and zosyn out of concern for possible infectious etiology contributing to her arrest. She was initially cooled with the Arctic Sun protocol. During this time she was sedated and paralyzed. Following rewarming she had no further sedative medications. She was monitored with continuous EEG. Her brain activity continued to worsen throughout the stay. She was transferred to the floor and on comfort measures only care per the family's request after extensive discussion in the ICU and ultimately passed peacefully on [**2139-5-13**] on a morphine drip. # Somnolence/Delerium: Unclear etiology but likely due to coupled ETOH and baclofen use. CT head in ED unrevealing for hemorrhage. No acute fractures on skeletal imaging. No significant findings to suggest infectious etiology although blood and urine cultures sent. Started on thiamine, MTV, folate and monitored for signs of withdrawal. . # Hypertension: Home regimen is 100mg daily of atenolol and supposedly had recently stopped an ACE. Was hypertensive at time that triggered for respiratory issues and suspect that flashed. Given a few doses of labetalol overnight and next morning restarted on ACE-I and BB switched from atenolol to equivalent dose of metoprolol. Her ACEi was stopped out of concern for rhabdomyolysis possibly affecting her kidney function. # Rhabdo: Had elevated CK in 700s that went up to 7000 on recheck. Had fallen at home and down for unknown time, could have been up to 6 hours per discussion with son. As her RLE became more concerning for ischemia, it became clear that rhabdomyolysis may be secondary to the ischemic leg. # Chronic hyponatremia: Thought to be due SIADH, and per history improves with free water restriction. Kept on 1L daily fluid restriction during hospitalization. # ETOH dependence: Drinks 2-3 beers daily. Was not tremulous initially so was just monitored for signs of withdrawal. Given thiamine, folate and multivitamin orally and SW consulted. # Communication: [**Telephone/Fax (1) 112055**] [**Name (NI) **] (HCP) # Code: Patient was a full code on admission, but was DNR after admitted to the MICU and transitioned to CMO. Medications on Admission: Medications Unable to confirm-- patient does not know her meds. Per recent outpatient medication lists: Baclofen 10 mg Oral [**Hospital1 **] AS NEEDED for muscle spasms Naproxen 500 mg [**Hospital1 **] Alendronate 70 mg Qweekly Atenolol 100 mg Oral Tablet take 1 tablet daily Simvastatin (ZOCOR) 40mg daily ASPIRIN TABLET DR 81MG PO daily Discharge Medications: Deceased Discharge Disposition: Expired Discharge Diagnosis: s/p PEA arrest Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: Deceased Completed by:[**2139-5-13**]

[ "707.23", "251.2", "305.1", "438.89", "728.87", "285.9", "718.48", "V66.7", "427.1", "427.5", "440.24", "276.7", "459.81", "780.97", "728.88", "707.09", "V49.86", "272.4", "348.1", "780.09", "303.91", "707.25", "707.19", "515", "707.07", "785.50", "401.9", "518.81", "E884.3", "428.23", "728.85", "438.50", "253.6", "733.00", "428.0", "V15.81" ]

icd9cm

[ [ [] ] ]

[ "38.93", "38.91", "96.04", "89.19", "99.60", "96.72" ]

icd9pcs

[ [ [] ] ]

11334, 11343

6566, 10911

346, 352

11401, 11411

4390, 4390

11468, 11507

3646, 3681

11301, 11311

11364, 11380

10937, 11278

11435, 11445

3696, 4371

2439, 2614

264, 308

380, 1171

1180, 2420

5661, 6543

4406, 5652

2636, 3374

3390, 3630

55,973

152,234

4029

Discharge summary

report

Admission Date: [**2181-11-18**] Discharge Date: [**2181-12-4**] Date of Birth: [**2120-10-31**] Sex: F Service: MEDICINE Allergies: Penicillins / Imuran / Cephalosporins / Sulfa (Sulfonamide Antibiotics) / Reglan / Latex / Ampicillin / Lactose / Soy, Lentils, Beans / Neomycin Attending:[**First Name3 (LF) 11552**] Chief Complaint: RLE edema, erythema Major Surgical or Invasive Procedure: Tunnelled Dialysis Catheter Placement History of Present Illness: 61 yo F child psychiatrist w/ PMH significant for type 1 IDDM (s/p revision renal and pancreas transplants, [**2160**] and [**2174**]), diastolic CHF (Echo 35-40%, [**7-/2181**]), recurrent MDR E coli UTIs, chronic anemia, currently on dialysis for repeated hyperkalemia, and h/o recurrent fevers and infections presents with right lower extremity swelling and redness x 3 days, associated with temp to 99.4 w/ chills last night. These symptoms were present at a hospital admission on [**11-5**] and resolved spontaneously while the patient was on antibiotics (meropenem). She was switched to ceftazidime with dialysis as an outpatient for gram negative bacteremia. The patient states that she was doing well at rehab until the end of last week, when she experienced increasing edema and erythema of her RLE. Symptoms worsened until 1 day PTA, when the patient experienced subjective fever and chills. In the ED, VSS. The patient was found to have right LE w/ 1+ pitting edema, erythema, and warmth, no open wounds or lesions. Lower extremity duplex showed non-occlusive thrombus in the R. popliteal vein. She was started on a heparin drip 1000u/hr, without bolus. The patient also received 1 dose of IV vancomycin for presumed cellulitis. On the floor, the patient currently feels well. She believes that erythema is improved from 2 days PTA. No fevers/chills, SOB, pleuritic chest pain, cough. Patient does endorse several weeks of diarrhea since starting ceftazidime. She began a course of loperimide in rehab that resulted in improvement in the frequency of her diarrhea, although stools are still loose. Past Medical History: #hypercarbic respiratory failure - complicated by intubation, pressor dependence ([**10-2**]) #[**Last Name (un) **] now on HD #afib with RVR with brief stint on amiodarone drip ([**10-2**]) #coag negative staph aureus bacteremia ([**10-2**]) #diastolic CHF (preserved EF 35-40%, moderate regional systolic dysfunction, [**7-/2181**]) #s/p renal transplant ([**2157**], complicated by chronic rejection, second transplant [**2160**]) #s/p pancreas transplant (with allograft pancreatectomy [**5-/2174**], redo transplant [**6-/2175**], acute rejection [**7-/2180**] which resolved with increased immunosuppresion) #diabetes mellitus type I (complicated by neuropathy, retinopathy, dysautonomia, no longer requires regular insulin after pancreas transplant) #autonomic neuropathy #sleep-disordered breathing (on 2L NC nighttime, unable to tolerate CPAP) #osteoporosis #hypothyroidism #pernicious anemia #cataracts #glaucoma #anemia from chronic kidney disease (on Aranesp previously) #Right foot fracture, complicated by RLE DVT #chronic LLE edema #Reucrrent MDR E.coli pyelonephritis #s/p anal polypectomy ([**5-/2176**]) #s/p bilateral trigger finger surgery ([**8-/2178**]) #s/p left [**Year (4 digits) 6024**] ([**8-/2179**]) Social History: Child psychiatrist, on disability. Lives alone in [**Hospital1 8**], MA. Has a PCA 8 hours/day. Ambulatory with a prosthesis for left leg. Was at rehab prior to this admission. Denies tobacco use or alcohol use; no recreational substance use. Family History: Father with MI at 57 year old; denies family history of arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: On Admission: VS: 98.5 127/56 87 20 100%RA GENERAL: Thin, woman in NAD, comfortable, appropriate. HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear. NECK: Supple, no thyromegaly, no JVD, no carotid bruits. HEART: RRR, normal S1-S2, [**2-25**] blowing holosystolic murmur best heard at apex LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored. ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES: WWP; left [**Month/Day (4) 6024**]. RLE with 4 cm band of erythema on anterior aspect of lower calf, mildly warm, non-tender to palpation (marked with marker); 1+ edema of right LE to mid-calf; DP 1+ in right foot LYMPH: No cervical LAD. NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**4-26**] throughout. Discharge Exam: VS: Afebrile SBPs 90s-100s HR 80s-100s 18 100%RA GENERAL: Thin, woman in NAD, comfortable, appropriate. HEENT: NC/AT, PERRL, EOMI, MMM NECK: Supple, no thyromegaly, no JVD, no carotid bruits. HEART: RRR, S1-S2 clear and of good quality, [**2-25**] blowing holosystolic murmur best heard at apex LUNGS: CTA, though with reduced breath sounds at bases bilaterally, no r/rh/wh, good air movement, resp unlabored. ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES: WWP; left [**Month/Day (4) 6024**]. RLE without edema, erythema or tenderness LYMPH: No cervical LAD. NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**4-26**] throughout. Pertinent Results: Admission: [**2181-11-17**] 07:59AM BLOOD WBC-2.4* RBC-3.38* Hgb-9.8* Hct-32.1* MCV-95 MCH-29.0 MCHC-30.5* RDW-16.4* Plt Ct-170 [**2181-11-18**] 03:29PM BLOOD PT-12.2 PTT-38.0* INR(PT)-1.0 [**2181-11-18**] 11:10AM BLOOD Glucose-90 UreaN-42* Creat-2.5* Na-144 K-4.2 Cl-107 HCO3-30 AnGap-11 [**2181-11-18**] 11:10AM BLOOD ALT-4 AST-13 AlkPhos-72 TotBili-0.2 [**2181-11-18**] 11:10AM BLOOD Albumin-2.9* [**2181-11-19**] 06:00AM BLOOD Calcium-8.6 Phos-3.3# Mg-2.0 [**2181-11-18**] 11:20AM BLOOD Lactate-1.2 Anticoagulation: [**2181-11-21**] 07:29AM BLOOD PT-11.2 PTT-74.0* INR(PT)-1.0 [**2181-11-22**] 06:45AM BLOOD PT-13.7* PTT-112.5* INR(PT)-1.3* [**2181-11-23**] 07:19AM BLOOD PT-19.9* PTT-78.2* INR(PT)-1.9* [**2181-11-24**] 07:00AM BLOOD PT-25.5* PTT-82.5* INR(PT)-2.4* [**2181-11-25**] 06:15AM BLOOD PT-25.8* PTT-37.1* INR(PT)-2.5* [**2181-11-27**] 05:54AM BLOOD PT-39.1* INR(PT)-3.8* [**2181-11-29**] 06:05AM BLOOD PT-52.8* PTT-51.4* INR(PT)-5.2* [**2181-11-30**] 06:45AM BLOOD PT-33.6* INR(PT)-3.3* Discharge Labs: [**2181-12-4**] 05:58AM BLOOD WBC-3.1* RBC-3.08* Hgb-8.6* Hct-27.7* MCV-90 MCH-27.8 MCHC-30.9* RDW-17.3* Plt Ct-284 [**2181-12-4**] 05:58AM BLOOD PT-25.2* INR(PT)-2.4* [**2181-12-4**] 05:58AM BLOOD Glucose-72 UreaN-50* Creat-3.5* Na-137 K-4.5 Cl-98 HCO3-31 AnGap-13 [**2181-12-4**] 05:58AM BLOOD Calcium-8.3* Phos-3.9 Mg-2.1 Micro: BCx negative x6 BCx NGTD x1 UCx Negative x1 UCx x2 Yeast >100k FECAL CULTURE (Final [**2181-11-21**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2181-11-21**]): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [**2181-11-20**]): NO OVA AND PARASITES SEEN. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2181-11-20**]): Feces negative for C.difficile toxin A & B by EIA. ASPERGILLUS ANTIGEN 0.1 Fungitell (tm) Assay for (1,3)-B-D-Glucans Results Reference Ranges ------- ---------------- 34 pg/mL Negative Less than 60 pg/mL Indeterminate 60 - 79 pg/mL Positive Greater than or equal to 80 pg/mL Reports: CXR [**2181-11-24**] 1. Interval placement of a right internal jugular dialysis catheter, which has its tip in the right atrium and is in similar position to that on prior study dated [**2181-11-6**]. 2. The previously seen left effusion has decreased in size. There is a diffuse bilateral interstitial process, which likely reflects a component of mild pulmonary edema. The heart remains borderline enlarged. Mediastinal contours are unchanged. No pneumothorax. No focal airspace consolidation to suggest pneumonia. CXR [**2181-11-25**] 1. Right internal jugular dialysis catheter again having its tip within the right atrium in similar position as compared to multiple prior studies. There is increasing bibasilar and perihilar airspace opacities, which likely reflect worsening moderate pulmonary edema. There are likely layering effusions, left greater than right. Diffuse pneumonia would be less likely given the rapidity of interval change. No pneumothorax is seen. Overall, cardiac and mediastinal contours are unchanged, with the heart being stably enlarged. . CXR [**2181-11-25**] afternoon Moderately severe pulmonary edema has not worsened since earlier in the day, though moderate right and small left pleural effusions have increased. Moderate cardiomegaly has remained stable over the past several days, but has progressed substantially since [**Month (only) 359**] and could be due to cardiomegaly and/or pericardial effusion. Dual-channel catheter, presumably for hemodialysis ends in the right atrium. No pneumothorax. CXR [**2181-11-28**] FINDINGS: In comparison with the study of [**11-27**], there is continued diffuse bilateral pulmonary opacifications consistent with worsening effusions, volume loss, and increased pulmonary vascular congestion. Possibility of supervening pneumonia must be seriously considered in the appropriate clinical setting, though this is difficult to evaluate in view of the substrate of extensive pulmonary changes. CXR [**2181-11-30**]: Previous severe pulmonary edema has cleared with residual moderate right and small left pleural effusion. Heart size is normal. Could be substantial right lower lobe atelectasis. Followup advised. No pneumothorax.Dual-channel right supraclavicular dialysis catheter ends low in the right atrium Video Swallow [**2181-11-30**]: IMPRESSION: No gross aspiration or penetration seen. Delayed passage of 13-mm tablet at the lower esophageal sphincter. For full details, please refer to the speech and swallow note in OMR. Brief Hospital Course: Patient is a 61 yo F with PMH type 1 IDDM (s/p revision renal and pancreas transplants, [**2160**] and [**2174**]), chronic diastolic and systolic CHF (Echo 35-40%, [**7-/2181**]), recurrent MDR E coli UTIs, on dialysis for refractory hyperkalemia, initially presented with right lower extremity cellulitis s/p completed course of Vancomycin, sent to MICU for tachycardia, fevers, and respiratory distress requiring biPAP. She responded well to broad spectrum antibiotics and HD/ultrafiltration for fluid overload and transfered afebrile on room air. . ACTIVE ISSUES: # Low grade fevers: After being on the floor for treatment of right lower extremity DVT versus cellulitis (see below), she developed low grade fevers and tachycardia. She was transferred to the ICU for further management of suspected pneumonia and evolving sepsis. Due to her chronic immunosuppression and suspicious chest xray, her antibiotics were broadened to daptomycin, meropenem, and atovaquone. She was fluid resuscitated judiciously to avoid volume overload given her heart failure and renal failure. Beta glucan and galactomannans were sent and are still pending. Infectious disease consulted and felt this was not likely infectious process and antibiotics were narrowed to Meropenem for 7 day course, completed on [**2181-12-2**] . # Respiratory distress: On floor patient developed progressive worsening respiratory status with increased work of breathing and developed hypoxia with exertion. Respiratory status initially improved with ultrafiltration but then she deteriorated exhibiting posturing, accessory muscle use and began tiring out and so she was transferred to MICU. Prior to transfer she was given 60mg IV Lasix x2 and started on braod spectrum antibiotics for HCAP coverage without improvement in her symptoms. While in the ICU, the patient was continued on antibiotics for possible pneumonia, but CXRs were more consistent with volume overload. The patient's oxygen requirement increased in the unit, and she was using BIPAP. She then underwent HD, which she tolerated very well. Post HD, the patient's oxygen requirment dropped, and she was initially stable on 2-4L NC, and on transfer out of the unit, she was stable on RA. The patient was also being followed by ID in the unit and her antibiotic coverage was reduced to vanc/[**Last Name (un) 2830**], as atovaquone and dapto were discontinued. As per ID recs, the Vanc was discontinued on D10 of treatment, and her [**Last Name (un) **] was continued. Of note, the patient has a history sleep disordered breathing and has been tried on CPAP at home. She was called out to the floor with CPAP settings for overnight. . # Tachycardia: The patient became tachycardic, with rhythm in atrial fibrillation vs. atrial flutter. The patient's pressure dropped into the 80s systolic during this episode of tachycardia, likely because of inadequate time for diastolic filling. Amiodarone drip was started (1.0 mg/[**Last Name (un) **] for 6 hours, 0.5 mg/[**Last Name (un) **] for 18 hours), and then she was maintained on 200 mg PO daily. After starting the amiodarone, the patient's heart rates were better controlled and she remained hemodynamically stable. Coumadin was started and continued for atrial fibrillation anticoagulation. # Right lower extremity suspected deep veinous thrombosis: Patient admitted with right non-occlusive popliteal DVT and was started on warfarin. However, the final read of her LENIs found that there was no DVT, and her warfarin was stopped after she had some episodes of hemoptysis in the ICU. She remained hemodynamically stable, with minimal pain, and no evidence of pulmonary embolism. Hemoptysis resolved. . # Lower extremity erythema: Erythema marked on admission, thought to be due to DVT initially but then as above more likely isolated cellulitis. Cellulitis improved on Vancomycin however she continued to have fevers so was changed to daptomycin when she was transferred to the ICU. Erythema and swelling resolved with completion of antibiotics and hemodialysis to remove volume overload. . # Recent Hx E. Coli bacteremia: Patient discharged in [**10-2**] for E. Coli bacteremia, s/p inpatient course of IV meropenem. She was discharged on ceftazidime with HD, and completed a course. Due to ongoing fevers and concern for pneumonia, was restarted on meropenem. Meropenem completed as above. . # End-stage renal disease (ESRD) on hemodialysis (HD): Patient is s/p renal transplant x2, complicated by acute kidney injury on recent admission. She has since been on HD on monday, wednesday, friday schedule. She remains on tacrolimus, sirolimus and prednisone for immunosuppression. The patient last received inhaled pentamidine on [**10-4**] for PCP [**Name Initial (PRE) 1102**]. Continued her HD schedule MWF. Sevalamer increased to 2400 PO TID with meals. Immunosuppression was titrated to sirolimus 2mg Daily, prednisone 5 mg Daily and Tacro 3mg [**Hospital1 **]. . CHRONIC ISSUES: # Diarrhea - Patient has had diarrhea while taking ceftazidime. Stool cultures on last admission negative. Started on loperimide at rehab and diarrhea improved to 2 loose stools daily. C.Diff negative, fecal cultures negative during this admission. Diarrhea resolved after completion of ceftazidime . # Peripheral neuropathy of amputation: Chronic. Intermittently symptomatic. Continued gabapentin 300mg po q48hrs PRN (renally dosed). . # Coronary artery disease and chronic systolic/diastolic heart failure (CAD/CHF): Echo [**2181-11-7**] with moderately dilated left ventricular cavity with moderate global hypokinesis, especially the anterior wall and septum, severe mitral regurgitation, and small ASD/stretched PFO present with left to right shunting at rest. Continued atorvastatin 80mg daily, aspirin 325 mg daily, Clopidogrel 75mg daily. ACE/[**Last Name (un) **] not started given her worsening end stage renal disease. . # Type 1 diabetes mellitus: Resolved status post pancreatic transplant and did not require insulin while inpatient. . # Glaucoma - Chronic, Stable, continued eyedrops . # Hypothyroid - Chronic, Stable, continued levothyroxine. TRANSITIONAL ISSUES: - Reevaluate anticoagulation for Atrial Fibrillation - Monitor INR - Check Tacro levels and titrate accordingly - CPAP at night, patient may require formal sleep study - BCx no growth to date x1 but not final on discharge - Monitor Tacro and [**Last Name (un) 1380**] levels - Outpatient HD schedule should be established Medications on Admission: 1. acyclovir 200 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 3. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic three times a day. 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette Ophthalmic daily (). 6. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic twice a day. 7. famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. hydrocortisone-pramoxine 2.5-1 % Cream Sig: One (1) Topical once a day as needed for itching. 11. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 12. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day): MWF Sat. 13. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day): Tu, Th, Sun. 14. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule, Delayed Release(E.C.) Sig: [**1-25**] Caps PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 15. methazolamide 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 16. prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day. 17. sirolimus 1 mg Tablet Sig: 1.5 Tablets PO q am. 18. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO twice a day. 19. travoprost 0.004 % Drops Sig: One (1) drop Ophthalmic once a day. 20. trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as needed for insomnia. 21. triamcinolone acetonide 0.1 % Cream Sig: One (1) Topical once a day: apply to itchy skin, no longer than 2 wks at a time. 22. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every 48 hours) as needed for peripheral neuropathy. 23. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 24. Citracal + D 315-200 mg-unit Tablet Sig: One (1) Tablet PO twice a day. 25. senna 8.6 mg Capsule Sig: Two (2) Capsule PO at bedtime: hold for loose stool. 26. ceftazidime 1 gram Recon Soln Sig: [**1-25**] g Intravenous with dialysis for 9 days: Pt is to receive 2/2/3g w/ HD until [**11-20**]. Disp:*qs g* Refills:*0* 27. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 28. insulin regular human 100 unit/mL Solution Sig: as directed Injection four times a day. Discharge Medications: 1. acyclovir 200 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 4. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 5. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 8. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO Q TUES, [**Last Name (LF) **], [**First Name3 (LF) **] (). 9. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. methazolamide 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 13. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every 48 hours). 14. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO Q MON, WED, FRI, SAT (). 16. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 18. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**12-24**] Drops Ophthalmic HS (at bedtime) as needed for dry eyes. 19. cyclosporine 0.05 % Dropperette Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 20. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 21. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Neb Inhalation Q6H (every 6 hours) as needed for SOB/Wheezes. 22. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 23. hydrocortisone-pramoxine 2.5-1 % Cream Sig: One (1) topical Rectal once a day as needed for itching. 24. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Neb Inhalation Q6H (every 6 hours) as needed for SOB/Wheezes. 25. ipratropium bromide 0.02 % Solution Sig: One (1) IH Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 26. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 27. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 28. sirolimus 0.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 29. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: Roscommon on the Parkway - [**Location 1268**] Discharge Diagnosis: Active: - DVT - RLE Cellulitis - Pulmonary Edema - ARF now on HD Chronic: - ESRD s/p renal transplant in [**2157**] and [**2160**] - DM I s/p Pancreas transplant - Hypothyroidism - AOCD - Osteoporosis - Multiple prior infections - Retinopathy, glaucoma, cataracts 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 17759**], It was a pleasure treating you during this hospitalization. You were admitted to [**Hospital1 69**] with Right Lower Extremity Edema and Reddness. You were though to have a DVT in your right leg and also cellulitis of your right leg. You were treated with Heparin and bridged to Coumadin for anticoagulation, you had no evidence of developing pulmonary embolus. On further evaluation the final read of the ultrasound did not show a DVT. The cellulitis was treated with IV Vancomycin and the erythema resolved. During your admission you became progressively ill with the concern for a hospital acquired infection. You were treated with IV Daptomycin and Meropenem for broad spectrum antibiotic coverage. In addition, you were treated with Pentamidine to prophylax against PCP [**Name Initial (PRE) 1064**]. You were in the intensive care unit for some time where a CPAP mask was used to help your breathing. The breathing difficulty was thought to be related to too much fluid in your lung rather than an infection. After the fluid was removed your breathing improved and antibiotics completed. You are being discharged in improved condition from admission with instructions to continue wearing a CPAP mask at night. The following changes to your medications were made: - START Coumadin 3mg Daily for atrial fibrillation - Increase Sevelamer to 2400 mg three times a day W/MEALS - START Amiodarone 200 mg PO DAILY - CHANGE Tacrolimus to 2 mg twice daily - CHANGE Sirolimus to 1.5 mg DAILY Other Instructions: - Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. - Continue CPAP mask at night: Autoset [**5-11**] - Test for consideration post-discharge: Homocysteine Followup Instructions: Department: MEDICAL SPECIALTIES When: FRIDAY [**2181-12-7**] at 10:40 AM With: BONE DENSITY TESTING [**Telephone/Fax (1) 4586**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: FRIDAY [**2181-12-7**] at 11:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10545**], M.D. [**Telephone/Fax (1) 4586**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: TRANSPLANT CENTER When: FRIDAY [**2181-12-28**] at 10:50 AM With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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Discharge summary

report

Admission Date: [**2146-6-17**] Discharge Date: [**2146-7-28**] Date of Birth: [**2080-10-11**] Sex: M Service: MEDICINE Allergies: Ativan / Plavix / Premarin Attending:[**First Name3 (LF) 783**] Chief Complaint: Bleeding from ostomy Major Surgical or Invasive Procedure: Intubation TIPS ([**6-28**]) History of Present Illness: The pt is a 65 year-old male with alcoholic cirrhosis and h/o bladder cancer s/p ileal loop who transferred from OSH with bleeding from his ostomy site. He initially presented [**6-17**] with bleeding from ileal loop since the evening of [**6-16**]. He reported ??????spirting?????? of blood from his ostomy. His initial Hct was 18.6 at 0230. He was given a total of 5UPRBC per nursing signout and most recent Hct at 2100 was 22.4 ( down from 25 at 1823). At 2pm he underwent scope by GI that showed peri ??????stomal varices and evidence of recent bleeding. Upper EGD showed non-bleeding varices. At 3pm he had a large bleed with clots from the stoma. EBL 2400cc Pressure dressing applied and he was started on octreotide at 50mcg/hour and systolic blood pressure dropped to 83-78 so he was started on neosynephrine peripherally. His INR was 1.6 and it is unclear how many units of [**Name (NI) 9087**] he received, but it was between 2 and 5 units. Prior to transfer he became hypotensive with SBPs in the low 80s and was transiently started on a neosyneprhine gtt peripherally. His Neopsynephrine was dc??????d during [**Location (un) **] because he was normotensive. He was transferred to [**Hospital1 18**] for evaluation for possible TIPS. Of note, the patient had a similar bleed 3 weeks ago which resolved spontaneously amd for which the patient did not seek medical evaluation. Past Medical History: 1. Alcoholic Cirrhosis c/b esophageal varices 2. Squamous Cell Carcinoma of the bladder s/p Radical cystoprostatectomy with ileal loop diversion [**8-17**] c/b osteomyelitis to pubis 3. CAD s/p cath [**4-15**] with stents to RCA and OM1. Echo [**7-17**] showed EF >75%. 4. IDDM 5. HTN 6. Hyperchoesterolemia 7. Alcohol Abuse with h/o Delirium Tremens 8. Appendectomy [**11-15**] at [**Hospital 1474**] Hospital Social History: Lives with wife and son in [**Name (NI) 2624**]. Retired. Drinks beer daily. Non-smoker. Family History: Noncontributory. Physical Exam: VITAL SIGNS: Temperature was 99.6, heart rate 75, blood pressure 116/54, respiratory rate 17, and he was oxygenating 100% 2L NC GENERAL: This was a 63-year-old obese white male in NAD but diaphoretic. HEENT: Pupils were equal, round, and reactive to light. His oropharynx was clear. His mucous membranes were dry. Sclerae were anicteric. NECK: Soft and supple with a normal thyroid exam, and no palpable lymphadenopathy. CHEST: Crackles at right base greater than left base. CARDIOVASCULAR: Regular rate and rhythm without murmurs, gallops, or rubs. ABDOMEN: obese, soft, min tender to palpation in epigastrium, ostomy site pink without active bleeding- with serosangoiunous drainage. No fluid wave or shifting dullness. SKIN: Warm and dry without rashes. NEURO: A+O x 3, minimal fine resting tremor, no asterixis. Pertinent Results: DATA: [**6-17**] OSH GI Procedure: Ileoscopy to the proximal end of the ileal loop: Both ureteral orifices were identified and appear intact, There was no bleeding or bleeding site noted, but he did have some peri stomal varices noted, some with stigmata of bleeding. EGD showed distal erosive esophagitis. 2 esophageal variceal chains; 1+ portal gastropathy and mild fundal variceal, and small duodenal varices. EKG: at OSH 2033: NSR at 88, nl axis, nl intervals, q waves in 3,f no sttw changes [**2146-6-17**] 08:14PM GLUCOSE-238* UREA N-21* CREAT-1.2 SODIUM-139 POTASSIUM-5.1 CHLORIDE-112* TOTAL CO2-18* ANION GAP-14 [**2146-6-17**] 08:14PM LIPASE-31 [**2146-6-17**] 08:14PM CK-MB-NotDone cTropnT-<0.01 [**2146-6-17**] 08:14PM ALBUMIN-2.9* CALCIUM-7.9* PHOSPHATE-2.2* MAGNESIUM-2.2 [**2146-6-17**] 08:14PM WBC-9.7 RBC-3.16* HGB-8.7* HCT-27.2* MCV-86 MCH-27.7 MCHC-32.1 RDW-15.8* [**2146-6-17**] 08:14PM NEUTS-90.3* BANDS-0 LYMPHS-5.8* MONOS-3.1 EOS-0.4 BASOS-0.3 [**2146-6-17**] 08:14PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL [**2146-6-17**] 08:14PM PLT SMR-LOW PLT COUNT-126*# LPLT-1+ [**2146-6-17**] 08:14PM PT-14.4* PTT-25.0 INR(PT)-1.4 [**2146-6-17**] 08:14PM FIBRINOGE-311 Brief Hospital Course: This 65 year old gentleman with a history of alcoholic cirrhosis, metastatic bladder cancer s/p radical resection, CAD, HTN, IDDM presented on [**2146-6-17**] with upper gastrointestinal bleed from ostomy varices. Bleeding was successfully treated with embolization and TIPS procedure, however ensuing hepatic encephalopathy led to a waxing and [**Doctor Last Name 688**] delirium that could not be successfully treated despite lactulose enemas. His course was further complicated by Klebsiella sepsis which resolved early in the hospital course with ceftriaxone treatment, hypernatremia, and hyperglycemia which was never successfully controlled. On [**7-24**] the family decided to place the patient on hospice care, largely because of the lack of improvement in the patients mental status. All non-comfort medications were subsequently discontinued. In the ensuing days, attempts were made to find a suitable hospice care facility and an appropriate facility was found for the patient to transfer for [**7-28**]. On the morning of the 14th pt. began becoming unresponsive and went into agonal breathing. The family was notified that the patient would probably pass away soon. With the family present, the patient went into respiratory arrest and expired. He was pronounced dead at 1:20 pm, [**2146-7-28**]. Autopsy declined by family. The hospital course of this patient is summarized by problem below: 1. GI Bleed: Known cirrhotic with bleeding from ostomy varices. Hepatology was consulted. Further investigation via endoscopy revealed bleeding from varices around the stoma site. He was placed on octretide, and a TIPS procedure was attempted and was unsuccessful. The area was the embolized by IR. Patient remained stable and a repeat TIPS was successful (done on [**6-28**]). The gradient was reduced from 30 to 8. In addition, repeat TIPS showed a portal vein clot and he was placed on heparin for 24 hours. However repeat TIPS showed no evidence of portal vein clot - therefore heparin was dc'ed. Patient was given vitamin K and [**Month/Year (2) 9087**] as needed to correct coagulapathy. -After the TIPS and embolization, GI bleeding resolved. 2. Sepsis: Patient grew 4/4 bottles positive for Klebsiella. He was started in meropenem initially, but switched to ceftriaxone once sensitivities were back. In the setting of being infected he was also hypotensive, requiring pressors that were slowly weaned off. His CVP was closely monitered to keep his cvp >12. On transfer to floor, all surveillance cultures are negative and he has been afebrile while maintaining his blood pressure. -Pt remained afebrile on the floor thereafter. 3. Respiratory failure: Initially he was intubated electively for his first TIPS. Patient remained reintubated in his septci state post TIPS. As his clinical status improved, he was weaned from ventilator and extubated. - Pt remained with o2 sats above 92% on room air. 4. Encephalopathy: Waxing and [**Doctor Last Name 688**] MS. difficult to assess what pt's baseline MS is. Likely toxic-metabolic encephalopathy contributing factors have included hypernatremia, and liver disease s/p TIPS. Hyperantremia corrected for now, will follow Na. - aspiration precautions with aggressive suctioning - Pt was placed on lactulose and rifaximin for the encephalopathy and received it while NG tube was in place. However pt self d/c'ed the NG tube and thereafter it was difficult to place NG again, he is receiving lactulose by enema at present. Family aware and they have decided against NG tube placement. Per nurses the pt had difficulty retaining lactulose enemas. Lower volume/higher concentration solutions were therefore given with only slight improvement in rectal output. Lactulose enema treatment proved unsatisfactory in this patient. -Pt mental status improved slightly but this improvement was generally unsatisfactory. He did not show signs of being able to protect his airway and continually failed to exhibit gag reflex . 5. Hypernatremia: Pt's Na was elevated upto 153 during the hospitilazation. Likely secondary to intravascular depletion. Pt was losing free water from several sources, GI tract on lactulose, osmotic diuresis (sugars in 300s) and low po intake. It was corrected over time with D5w and free water flushes in TF. . 6. Alcohol Withdrawal: Patient is a heavy drinker and given history of DTs, he was originally placed on a CIWA scale with ativan, and then this was switched to valium. He was given several hundred mg of valium before his agitation resolved. - After the initial Rx there were no further issues with EtOH withrdrawl 6. CAD/HTN: h/o MI- Aspirin was held given bleeding. Consider statin once other issues are stabilized. EKG was not changed. . 7. DM: RISS. patient was transiently on insulin gtt for sugar control in the MICU. He was placed on 50U glargine with RISS. The initial glargine dose was increased upto 100 units daily yet pt required more than a 100 units of regular insulin to cover daily. [**Last Name (un) **] was consulted and pt received 68 units AM and a strict sliding scale. Once pt was NPO (ng d/c'ed) it was changed to 28 units in AM and sliding scale with nothing for sugar < 150. On TPN glargine adjusted to 36 units in AM with 90 units of RI in TPN. Despite these measures, FS glucose remained in 200-300 range. When family elected for hospice care, pt was made NPO and RISS was adjusted for goal of avoiding hyperglycemia. On morning prior to expiration, FS was noted to be greater than 400, 7 units of insulin were given. . 8. Non AG MA: likely from bicarb loss from ostomy, patient placed on bicitra and then calcium carbonate. Non AG MA resolved 9. Acute renal failure: Developed renal failure in setting of sepsis, now resolved 10) cirrhosis- on nadolol, dc'ed octretide drip, ppi, and cont lactulose. pt receving lactulose by enema at present. 11) Otitis exterma- on ctx, add cipro drops and erythromycin, f/u with ENT in [**2-17**] weeks. Patient needs hearing aid evaluation. will need to be treated for 3 wks and then can d/c ear drops. 12) FEN - dobhoff placed on [**7-6**]. Self d/c'ed by pt. He has failed speech and swallow evaluation twice, but family decided against replacement of NG tube. Pt has been on for most of remainder of hospital course. TPN is now d'c'd. 13) Code - Family has decided to make this patient DNR/DNI. -[**2146-7-22**], family meeting with Dr. [**First Name (STitle) **], Dr. [**Last Name (STitle) 19868**], [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 34577**] MS [**Name13 (STitle) 1105**] to discuss long term disposition. -[**2146-7-24**], family elected to place this patient in palliative care. palliative care measures: 1. General -transfer to palliative care facility, code is DNR/DNI. -all non-comfort medications discontinued. 2. Glucose Control -NPO, still hyperglycemic, RISS modified with primary goal of avoiding hypoglycemic episode. 3. Agitation -controlled with haldol, olanzapine. 4. Pain -controlled with morphine,acetaminophen. 5. Ear infection -neomycin otic drops. 6. any respiratory distress may be treated with O2, inhalers. -[**2146-7-28**], pt expired. Medications on Admission: Meds on Transfer: Insulin Sliding Scale Propanolol 20mg po BID Neosynephrine gtt Protonix 40iv [**Hospital1 **] Octeotide 50mcg/hr Discharge Medications: Medications prior to death: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Neomycin-Polymyxin-HC 3.5-10,000-1 mg-unit/mL-% Drops, Suspension Sig: Four (4) Drop Otic QID (4 times a day). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. 5. Ciprofloxacin 0.3 % Drops Sig: Three (3) Drop Ophthalmic [**Hospital1 **] (2 times a day) as needed for Ear Infection. 6. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 7. Haloperidol Lactate 2 mg/mL Concentrate Sig: Two (2) mL PO BID (2 times a day) as needed for agitation. 8. Insulin Glargine 100 unit/mL Solution Subcutaneous 9. Morphine 10 mg/5 mL Solution Sig: 2.5-5 mL PO Q4-6H (every 4 to 6 hours) as needed for pain. 10. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO BID (2 times a day). 11. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift Scopolamine patch. Discharge Disposition: Extended Care Discharge Diagnosis: Hepatic Encephlopathy HTN Hypernatremia EtOH abuse Portal hypertension Bleeding esophageal varices/ bleeding ostomy Klebsiella sepsis Respiratory distress Alcohol withdrawal syndrome. Discharge Condition: Expired [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

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icd9cm

[ [ [] ] ]

[ "96.04", "39.79", "99.04", "96.6", "96.72", "38.93", "39.1", "99.15" ]

icd9pcs

[ [ [] ] ]

13089, 13104

4523, 11707

308, 338

13332, 13472

3190, 4500

2319, 2338

11889, 13066

13125, 13311

11733, 11733

2353, 3171

248, 270

366, 1761

1783, 2196

2212, 2303

11751, 11866

24,095

184,475

2481

Discharge summary

report

Admission Date: [**2116-7-24**] Discharge Date: [**2116-7-31**] Date of Birth: [**2041-9-27**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: back pain Major Surgical or Invasive Procedure: PICC placement History of Present Illness: 74 yo F with a history of hypertension, coronary artery disease, carotid stenosis, hypercholesterolemia, afib, lacunar stroke, who presented to the ED complaining of weakness. She was found to have severe bradycardia, hypotension and acute on chronic renal failure. She was initially treated with kayexalate and atropine intially. However, upon arrival to the MICU goals of care were further discussed. After multiple family meetings, the decision was not to proceed with further workup and have the goals directed at comfort measures only. She was changed to morphine prn and zofran. Additionally she was given NTG prn for back pain with relief. Past Medical History: Hypertension Coronary artery disease non-intervenable 3 vessel disease (severe disease of her left cx, mid and distal LAD) medically managed Hypercholesterolemia Paroxysmal afib Mini strokes Right ICA 80-99%, left ICA 60-90% stenosis. Renal insufficiency baseline Cr 1.2-1.4 Social History: A 35-40 pack year history, she quit in [**2103**]. No alcohol use. Family History: Her brother and mother have CAD. Physical Exam: GENERAL: tired-appearing, NAD, speaks in very short phrases (baseline) NECK: JVP elevated CV: regular, nl S1S2, nl M/R/G PULM: crackles bilaterally, no wheezing ABD: + BS, soft NT, ND, obese Ext: no edema NEURO: approprite; exam non-focal Pertinent Results: Admission labs: [**2116-7-23**] 08:15PM BLOOD WBC-11.6* RBC-4.04* Hgb-12.5 Hct-37.4 MCV-93# MCH-30.9 MCHC-33.4 RDW-14.7 Plt Ct-253 [**2116-7-23**] 08:15PM BLOOD PT-11.5 PTT-23.9 INR(PT)-1.0 [**2116-7-23**] 08:15PM BLOOD Glucose-185* UreaN-35* Creat-2.4*# Na-134 K-7.4* Cl-109* HCO3-16* AnGap-16 [**2116-7-24**] 03:42AM BLOOD Calcium-8.7 Phos-4.7* Mg-2.1 [**2116-7-24**] 03:42AM BLOOD Hapto-202* Brief Hospital Course: 74 yo with CAD, afib, hypertension, bilateral carotid stenosis, hypercholesterolemia, lacunar stroke, who presented to the ED with hyperkalemia, acute on chronic renal failure and with bradycardia. Bradycardia. Found in the ED to be severely bradycardic and was given atropine. On review of the ECG it appears to be slow atrial fib or junctional escape rhythm. Currently she is in normal sinus rhythm with a rate of 54 (only slightly bradycardic). It is difficult to tell if the bradycardia preceeded/caused renal failure. She was evaluated by PE and thought not to be a candidate for a pacer currently. If she again goes into atrial fib or has persistent bradycardia, may need to consider pacer at that time. Acute on chronic renal failure: initally had rapidly worsening renal function. Potassium continued to increase and patient refused dialysis. She was treated with kayexelate but continued to have poor renal function. Was briefly CMO but had improvement in renal function. Cause thought to be secondary to prerenal causes. Renal function continued to improve without any clear cause. CHF. EF 55% with 3+ MR [**First Name (Titles) **] [**Last Name (Titles) 1192**] TR. WAs volume overloaded and had oxygen requirement. Held on diuresis until renal function improved and then was given 1 dose of 20 mg lasix to which she had large volume diuresis and at time of discharge did not have an oxygen requirement. CAD. Per history has non-intervenable 3 vessel disease that is managed medically. Per previous records has refused catherization. Will follow for now. [**Month (only) 116**] need stress test per cardiology as outpatient. - Continued on ASA, Plavix - Held beta-blockers, lisinopril, imdur for now and will restart with symptoms and increased BP. Hypothyroidism. Continued Synthroid. TSH normal. Anemia. Baseline Hct low 30's and stable but without signs of iron deficiency (chronic disease). . PAF. No nodal agents. No amiodarone. Code: DNR/I Medications on Admission: amiodarone 200 mg p.o. daily, Zetia 10 mg po daily, Inderal LA 160 mg p.o. daily, lisinopril 20 mg twice a day, Plavix 75 mg p.o. daily, Nitro prn Levoxyl 75 mcg p.o. daily, Norvasc 10 mg p.o. daily, aspirin 81 mg p.o. daily, Triamterene/HCTZ 25 mg p.o. daily. Imdur [**Hospital1 **] Discharge Medications: 1. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 3. Simethicone 80 mg Tablet, Chewable Sig: [**2-11**] Tablet, Chewables PO QID (4 times a day) as needed for indigestion. 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q 24H (Every 24 Hours) as needed for back pain: 12 hours on, 12 hours off. 6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY OTHER DAY (Every Other Day). 14. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 3 days. 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: Roscommon Discharge Diagnosis: Renal failure Bradycardia Congestive heart failure Secondary: Hypertension, coronary artery disease, hypercholesterolemia, history of atrial fibrillation, history of strokes, carotid stenosis, renal insufficiency Discharge Condition: improved renal function Discharge Instructions: You were admitted with renal failure and low heart rate. You were treated with IV fluids and holding your heart rate medications Please return to the ED or call your doctor if you have any shortness of breath, pain, passing out or any other concerning sytmptoms. Patient recently had renal failure leading to hyperkalemia. Will need close monitoring of her renal function and electrolytes. Also patient with volume overload. Will need monitoring of fluid status. Responds well to lasix. She has been taken off all of her cardiac medicines including imdur, norvasc, lisinopril, zetia, inderal, and amiodarone due to bradycardia. She has a history of atrial fibrillation and hypertension. If patient becomes tachycardic or hypertensive will need to restart. Followup Instructions: Please follow up with your PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Telephone/Fax (1) 250**] in [**2-11**] weeks Please follow up with cardiology.

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

5954, 5990

2146, 4115

324, 341

6248, 6274

1727, 1727

7088, 7243

1418, 1452

4450, 5931

6011, 6227

4141, 4427

6298, 7065

1467, 1708

275, 286

369, 1018

1743, 2123

1040, 1317

1333, 1402

76,698

154,857

28615

Discharge summary

report

Admission Date: [**2165-8-8**] Discharge Date: [**2165-8-16**] Date of Birth: [**2096-8-6**] Sex: F Service: MEDICINE Allergies: morphine Attending:[**Last Name (NamePattern1) 13159**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is a 69 yo woman with a history of seizure disorder, recurrent UTI's and indwelling foley who was last discharged from [**Hospital1 18**] on [**2165-7-30**] for seizures, was brought in from [**Location 69248**] for altered mental status. The patient states that she remembers suddenly "falling quiet" at the nursing home and waking up at [**Hospital1 18**], not knowing how she arrived. In talking to [**Hospital1 **] Village, who based the story on a written report, the patient started becoming confused, had bilateraly upper extremity weekness and slurred speech. No loss of consciousness. This is a typical pattern for her in the past when she had an UTI. This was corroborated by the pt's sister/HCP, [**Name (NI) **], who visited her today, and noticed that she was more confused than usual. She reports that when she visited Ms. [**Known lastname **] yesterday, she noticed that she had developed an attitude and was cranky and that her arms were shaky, which is her typical behavior before her prior [**Hospital **] hospital admissions. The pt does not recall being confused. She reports having no new symptoms and wants to return back to the nursing home, stating that she is very tired of her frequent admissions. She indicated [**6-28**] pain in her back, left arm and along her kneecaps bilaterally, which are chronic. No new symptoms of dysuria, suprapubic tenderness, fevers, chills, dyspnea, abdominal pain, diarrhea, nausea or vomiting. She indicated that her last bowel movement was yesterday, and believes it is normal. 12 point ROS otherwise negative. Past Medical History: - Neurogenic bladder with chronic foley and recurrent urinary tract infections - Hypertension - Anemia - Hyperlipidemia - Paroxysmal atrial fibrillation - Gastroesophageal reflux disease - Severe osteoarthritis of her left hip - Small bowel obstruction s/p laparotomy in [**4-/2164**] - Lumbar discectomy in [**2123**]. T6-9 laminectomy done in [**Month (only) 956**] [**2158**] done due to residual fluid left in spinal canal. Non ambulatory since - seizure disorder - UGIB [**12-20**] duodenal ulcer [**2-/2165**] Social History: -Home: She has been at Wyngate of [**Location (un) 583**] since discharge from [**Hospital1 18**] on [**2165-5-13**]. Widowed. Has one child (son, slightly estranged per sister as he is on parole). Very close with her sister/HCP [**Name (NI) **]. -Occupation: No longer working. -Tobacco: Previously smoked two packs per day for 40 years, but quit eight years ago. -EtOH: No alcohol use. -Illicits: None. Family History: Per OMR: Father deceased at age 57 from a heart virus. Her brother is alive but had leukemia as well as complications of a brain bleed and he also had coronary artery disease status post MI. Physical Exam: Admission: VS - Temp 98.8F, BP124/64 , HR77 , R18 , O2-sat 97% RA GENERAL - appeared very uncomfortable. In cyclic bouts of pain that made her tense up entire body. HEENT - NC/AT, EOMI, sclerae anicteric, OP clear but dry. NECK - supple, no thyromegaly, no JVD HEART - PMI non-displaced, regular rate and rhythm (not in afib), nl S1-S2, no MRG. LUNGS - No respiratory distress or use of abdominal muscles. Occasional expiratory rales on upper left. Clear on right. No crackles. No areas of decrease breath sounds. ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, 1+ edema in lower extremities bilaterally. Pt's legs were bent, but not contracted. SKIN - no rashes or lesions NEURO - awake, A&Ox3,mostly lucid. CNII-XII grossly intact. Muscle strength: LLE: [**12-23**], RLE: [**11-22**], LUE: [**1-21**], RUE: [**2-21**]. Patient has not walked since [**2158**]. PSYCH - Labile affect. Very labile ranging from teary to angry to dismissive. Hyper-reactive to movement and sounds. Very unhappy about being back in the hospital. Discharge: Pt's exam was mostly unchanged. Vitals stable, pt continues to be afebrile. Reporting [**2-26**] pain in her back and knees. No focal neuro [**Month/Year (2) 4493**], stable compared to admission exam. Pt A%O x 3 but continues to have an odd and very labile affect. Pertinent Results: Admission Labs: [**2165-8-8**] 11:00AM BLOOD WBC-6.4 RBC-3.09* Hgb-10.0* Hct-30.6* MCV-99* MCH-32.3* MCHC-32.6 RDW-16.0* Plt Ct-194 [**2165-8-8**] 11:00AM BLOOD Glucose-92 UreaN-15 Creat-0.7 Na-144 K-4.2 Cl-111* HCO3-29 AnGap-8 [**2165-8-9**] 07:20AM BLOOD WBC-4.7 RBC-3.09* Hgb-10.0* Hct-31.1* MCV-101* MCH-32.4* MCHC-32.2 RDW-15.6* Plt Ct-180 [**2165-8-9**] 07:20AM BLOOD Glucose-83 UreaN-16 Creat-0.6 Na-145 K-4.2 Cl-114* HCO3-24 AnGap-11 [**2165-8-9**] 07:20AM BLOOD ALT-15 AST-31 LD(LDH)-214 AlkPhos-174* TotBili-0.3 [**2165-8-9**] 07:20AM BLOOD Calcium-8.2* Phos-3.6# Mg-1.5* [**2165-8-15**] 07:00AM BLOOD ALT-13 AST-24 AlkPhos-158* TotBili-0.4 [**Month/Day/Year 706**] CXR ([**2165-8-8**]): [**Month/Day/Year **]: As compared to the previous radiograph, there is unchanged evidence of a parenchymal opacity at the right lung base. Severity of the opacity has not changed. The opacities are accompanied by a small pleural effusion. The pre-existing left parenchymal opacity has almost completely resolved. The size of the cardiac silhouette is unchanged. There is unchanged evidence of volume loss in the right lung, with shift of the mediastinum towards the right. Unchanged vertebral fixation devices. Right-sided PICC line. The tip projects over the subclavian vein and the catheter is located too proximally. Reposition of the catheter appears indicated. CXR [**2165-8-13**]: IMPRESSION: Technically successful exchange of a single-lumen Power PICC with the tip in the distal SVC. The PICC is flushed and ready for use. Renal Ultrasound [**2165-8-16**]: IMPRESSION: Limited exam due to patient non-cooperation. No evidence of hydronephrosis in the right kidney. Incidentally noted splenomegally. UA ([**2165-8-9**]): [**2165-8-9**] 11:14AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.016 [**2165-8-9**] 11:14AM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG [**2165-8-9**] 11:14AM URINE RBC-58* WBC->182* Bacteri-MOD Yeast-NONE Epi-0 [**2165-8-9**] 11:14AM URINE WBC Clm-FEW Mucous-FEW MICROBIOLOGY: Urine Culture: URINE CULTURE (Final [**2165-8-9**]): YEAST. 10,000-100,000 ORGANISMS/ML. URINE CULTURE (Final [**2165-8-11**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION [**2165-8-11**] 8:15 pm BLOOD CULTURE Blood Culture, Routine (Pending): [**2165-8-11**] 8:16 pm BLOOD CULTURE Source: Line-midline. Blood Culture, Routine (Preliminary): ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES. HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of gentamicin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details. HIGH LEVEL STREPTOMYCIN SCREEN: Resistant to 1000mcg/ml of streptomycin. Screen predicts NO synergy with penicillins or vancomycin. Consult ID for treatment options. . Daptomycin = 3 MCG/ML Sensitivity testing performed by Etest. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECIUM | AMPICILLIN------------ =>32 R DAPTOMYCIN------------ S LINEZOLID------------- 2 S PENICILLIN G---------- =>64 R VANCOMYCIN------------ =>32 R Aerobic Bottle Gram Stain (Final [**2165-8-12**]): URINE CULTURE (Final [**2165-8-15**]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. YEAST. ~7000/ML. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 128 R TETRACYCLINE---------- =>16 R VANCOMYCIN------------ =>32 R MRSA SCREEN (Final [**2165-8-15**]): No MRSA isolated. BLOOD CULTURES [**2165-8-15**]: PENDING BLOOD CULTURES [**2165-8-16**]: PENDING EEG [**2165-8-10**]: IMPRESSION: This is an abnormal continuous ICU monitoring study. There are two pushbutton events with no EEG correlate. The background rhythm consists of predominant theta activity. This is consistent with moderate encephalopathy. There are also infrequent triphasic waves and brief runs of periodic generalized frontally predominant sharp waves. Compared to the EEG recording the day before, the triphasic waves and the periodic sharp waves are much less frequent. There are no electrographic seizures recorded. ECG [**2165-8-13**]:Sinus rhythm. Low voltage. T wave abnormalities. Since the previous tracing of [**2165-6-7**] probably no significant change. Discharge Labs: [**2165-8-16**] 06:30AM BLOOD WBC-7.6 RBC-2.60* Hgb-8.3* Hct-26.0* MCV-100* MCH-32.0 MCHC-31.9 RDW-15.5 Plt Ct-126* [**2165-8-16**] 06:30AM BLOOD Plt Ct-126* [**2165-8-16**] 06:30AM BLOOD PT-13.9* PTT-30.6 INR(PT)-1.3* [**2165-8-16**] 06:30AM BLOOD Glucose-59* UreaN-18 Creat-0.7 Na-137 K-4.8 Cl-110* HCO3-18* AnGap-14 [**2165-8-16**] 06:30AM BLOOD AlkPhos-166* Brief Hospital Course: Ms. [**Known lastname **] is a 69 year old female with seizure disorder, recurrent UTIs, and indwelling foley who was brought in from [**Location 69249**] for altered mental status. She was transferred to the ICU for hypotension and worsening confusion, and was found to have VRE bacteremia from urinary source and is now stable, and being treated with lineozolid. Active Issues: #) Altered Mental Status - Patient confused and dysarthric on admission. Electrolytes wnl. CXR w/ no signs of infiltrate. Differential was UTI vs seizure. Cultures were initially negative, and antibiotics were held, with her AMS thought to be from seizure activity. Neurology was consulted and EEG did not reveal siezures to be the cause. Blood cultures drawn from [**2165-8-11**] illustrated gram-positive cocci speciated to VRE and Lineozolid was initated on the floor. She subsequently dropped her SBP to the 80s and remained hypotensive in the 90s despite fluid resusitation. Mental staus revealed orientation to self only.. Urine cultures from [**2165-8-11**] also grew VRE. Catheter was changed, and sedating medications (oxycontin,oxycodone, and gabapentin) were held. Marked improvement was noted and the patient was noted, and patient was stabilized on Linezolid. # VRE Bacteremia / UTI: Previous cultures were postive for gram positive cocci in pairs and chains. She has a significant history of urosepsis with resistant organisms. Multiple WBCs seen in urine. Blood cultures drawn from [**2165-8-11**] illustrated gram-positive cocci speciated to VRE and Lineozolid was initated on the floor. Her mental status improved throughout her stay, her WBC trended down and she remained afebrile. She had a mild temperature of 100.7 on [**2165-8-14**], but otherwise remained stable. Surveillance culture were no growth at time of discharge but not yet finalized. She was started on linezolid with plan for 14 day course from time of negative blood culture. Infectious disease was consulted. Weekly CBC should be obtained on linezolid. . #Recurrent UTI: Patient with neurogenic bladder and history of recurrent UTI. She was counseled on the importance of adequate hydration and should be encouraged to maintain adequate PO intake. Wound recommend against indwelling foley catheter. She can use diapers and should be straight catheterized regularly (TID PRN) for urine retention in order to limit urinary stasis. Renal ultrasound was performed and was preliminarily negative for hydronephrosis or pyelonephritis or stone. Patient was ordered for intravaginal estrogen to help prevent further urinary tract infections. Frequent voiding is recommended to also help prevent urinary tract infections. Scheduled for outpatient urology f/u for further urodynamic testing. #) Seizure disorder - was last discharged on [**2165-7-30**] for possible nonconvlusive status. On Keppra 2000mg [**Hospital1 **]. Overnight EEG showed no seizure activity. Per Neuro recommendations, antiepileptics were continued at current dose. While linezolid could potentially lower seizure threshold she remained stable without evidence of clinical seizure. #)#Hypotension which required ICU admission - likely requires volume rescucitation. Could be related to an infectious process. Blood culture postive GRAM POSITIVE COCCUS(COCCI), IN PAIRS AND CHAINS. PT was volume rescucitate with fluids to MAP of 55. repeat blood cultures and urine cultures were drawn which showed ENTEROCOCCUS SP in urine and ENTEROCOCCUS FAECIUM in blood. Pt was placed on Linezolid. Pt BP stablized quickly in the MICU and was [**Doctor Last Name **] out to the floor. # Sacral decubitus ulcer: noted on clinical exam. Wound care was consulted and recommendations appreciated. Pressure relief per pressure ulcer guidelines. Support surface. Atmospheric air. Turn and reposition every 1-2 hours and prn. Limit time sitting up in bed Heels off bed surface at all times, Suspend over a pillow. If OOB, limit sit time to one hour at a time and sit on a pressure relief cushion, will need a ROHO cushion.Elevate LE's while sitting. Moisturize B/L LE's and feet daily. Topical:Commercial foam cleanser to clean. Apply Criticaid clear after every 3rd incontinence episode. Stable Issues: #) Neurogenic bladder. We kept her off foley. Post-void bladder scan showed 0cc. Should not have foley in future if patient is able to void. If having retention, would intermittently straight cath rather than place indwelling foley given history of repeated UTI and suspected colonization. #) Hypertension - stable. No medications - Continue to monitor #) Anemia, stable. Likely anemia of chronic disease. #) Hyperlipidemia - Continued home atorvastatin #) Paroxysmal afib - was not in afib during hospitalization #) GERD - continued home omeprazole #) Left hip osteoarthritis - continued home pain meds: oxycodone, oxycontin, acetaminophen, dilaudid Transitional Issues: [ ] Please maintain good urine hygeine with increased oral fluid intake per day, frequent voiding, and bladder scans to check for PVR. Straight catheter if urine retention. [ ] Please avoid using foley in nursing home. [ ] Please f/u in Neurology with [**Doctor Last Name 1220**]. [**Name5 (PTitle) **] & [**Last Name (un) 22698**] during scheduled appointment on [**2165-8-13**] at 9:45am. [ ] Please f/u with [**Year (4 digits) **] surgery on [**2165-8-15**] at 9:30am. [ ] Please f/u with Urology on [**2165-9-13**] at 1:30 PM for urodynamic testing [ ] Will need weekly CBC to trend for pancytopenia as side effect of lineozolid. [ ] Continue Linezolid 600 mg PO Q12 hrs for a total of 14 days after 1st negative blood culture [ ] F/U surviellance cultures [ ] Please apply vaginal estrogen daily [ ] Please maintain adequate care of sacral wound. Pressure relief per pressure ulcer guidelines. Support surface. Atmospheric air. Turn and reposition every 1-2 hours and prn. Limit time sitting up in bed Heels off bed surface at all times, Suspend over a pillow. If OOB, limit sit time to one hour at a time and sit on a pressure relief cushion, will need a ROHO cushion.Elevate LE's while sitting. Moisturize B/L LE's and feet daily. Topical:Commercial foam cleanser to clean. Apply Criticaid clear after every 3rd incontinence episode. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from [**Year (4 digits) 581**]. 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze/sob 2. Artificial Tears Preserv. Free 1-2 DROP BOTH EYES TID 3. Ascorbic Acid 500 mg PO BID 4. Atorvastatin 40 mg PO DAILY 5. Baclofen 5 mg PO TID:PRN muscle spsms 6. Docusate Sodium 100 mg PO BID 7. Ferrous Sulfate 325 mg PO DAILY 8. Fleet Enema 1 Enema PR DAILY:PRN constipation 9. FoLIC Acid 1 mg PO DAILY 10. Fondaparinux Sodium 2.5 mg SC DAILY 11. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB / wheeze 12. Multivitamins 1 TAB PO DAILY 13. OxycoDONE (Immediate Release) 5 mg PO Q3H:PRN pain 14. Oxycodone SR (OxyconTIN) 20 mg PO Q12H 15. Polyethylene Glycol 17 g PO DAILY 16. Prochlorperazine 25 mg PR Q12H:PRN nausea 17. Simethicone 80 mg PO QID:PRN gas 18. Zinc Sulfate 220 mg PO DAILY 19. Senna 1 TAB PO BID:PRN constipation 20. Bisacodyl 5 mg PO DAILY:PRN constipation 21. Milk of Magnesia 30 mL PO DAILY:PRN constipation 22. Omeprazole 20 mg PO DAILY 23. Mirtazapine 15 mg PO HS 24. Gabapentin 900 mg PO TID 25. Fluconazole 200 mg PO Q24H 26. CeftriaXONE 1 gm IV Q24H 27. Acetaminophen 650 mg PO Q6H:PRN fever/pain 28. Heparin Flush (10 units/ml) 2 mL IV PRN before heparin 29. HYDROmorphone (Dilaudid) 0.125 mg IV Q4H:PRN pain 30. LeVETiracetam [**2152**] mg PO BID Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN fever/pain 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze/sob 3. Artificial Tears Preserv. Free 1-2 DROP BOTH EYES TID 4. Ascorbic Acid 500 mg PO BID 5. Atorvastatin 40 mg PO DAILY 6. Baclofen 5 mg PO TID:PRN muscle spsms 7. Bisacodyl 5 mg PO DAILY:PRN constipation 8. Docusate Sodium 100 mg PO BID 9. Ferrous Sulfate 325 mg PO DAILY 10. Fleet Enema 1 Enema PR DAILY:PRN constipation 11. FoLIC Acid 1 mg PO DAILY 12. Fondaparinux Sodium 2.5 mg SC DAILY 13. Gabapentin 900 mg PO TID 14. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB / wheeze 15. LeVETiracetam [**2152**] mg PO BID 16. Milk of Magnesia 30 mL PO DAILY:PRN constipation 17. Mirtazapine 15 mg PO HS 18. Multivitamins 1 TAB PO DAILY 19. Omeprazole 20 mg PO DAILY 20. OxycoDONE (Immediate Release) 5 mg PO Q3H:PRN pain 21. Oxycodone SR (OxyconTIN) 20 mg PO Q12H 22. Polyethylene Glycol 17 g PO DAILY 23. Prochlorperazine 25 mg PR Q12H:PRN nausea 24. Senna 1 TAB PO BID:PRN constipation 25. Simethicone 80 mg PO QID:PRN gas 26. Zinc Sulfate 220 mg PO DAILY 27. Estrogens Conjugated 1 gm VG DAILY restoration of vaginal and urethral flora 28. Linezolid 600 mg PO Q12H VRE bacteremia Duration: 12 Days Discharge Disposition: Extended Care Facility: [**Hospital1 **] Village - [**Location 4288**] Discharge Diagnosis: Primary: Altered mental status, Bacteremia (VRE) Secondary: UTI (VRE), seizures Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Mental Status: Confused - sometimes. Discharge Instructions: Dear Ms. [**Known lastname **], It was a pleasure taking care of you during your hospitalization at [**Hospital1 18**]. You were admitted with altered mental status. This was either due to a seizure or infection. You had bacteria in your urine, but no evidence of inflammation so we did not think this was an infection. Your confusion improved without antibiotics. We want to avoid antibiotics in order to decrease the chance that you will become resistant to these medications. We also stopped a couple of your medications called ceftriaxone and fluconazole since you completed treatment with these. To further investigate your seizures, we did a study called an EEG, which looks at your brain activity. It showed that ther was no seizure activity. Neurology did not change your siezure medications at this time. It is important that you do not use a foley while you are at the nursing home, since this will increase your risk of getting Urine infections. It is also very important that you continue to drink lots of fluids and attempt void your urine as frequently as possible. We made the following changes to your medication list: Please START taking linezolid 600 mg by mouth twice daily for 14 days, and vaginal estrogen 1g vaginally once a day. Please STOP ceftriaxone and fluconazole. Please CONTINUE taking taking your home medications as prescribed. Followup Instructions: Department: NEUROLOGY When: TUESDAY [**2165-8-13**] at 9:45 AM With: [**Year (4 digits) 1220**]. [**Name5 (PTitle) **] & [**Last Name (un) 22698**] [**Telephone/Fax (1) 857**] Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital Ward Name **] SURGERY When: THURSDAY [**2165-8-15**] at 9:30 AM [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: [**Hospital Ward Name **] SURGERY When: THURSDAY [**2165-8-15**] at 10:00 AM With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1490**], MD [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: SURGICAL SPECIALTIES- Urology When: FRIDAY [**2165-9-13**] at 1:30 PM With: PELVIC FLOOR UNIT [**Telephone/Fax (1) 274**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**Last Name (LF) **],[**First Name3 (LF) **] Location: [**Hospital3 249**] [**Hospital1 **] Address: [**Location (un) **], [**Hospital Ward Name **] 1, [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 2010**] Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge.

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icd9cm

[ [ [] ] ]

[ "00.14", "38.97" ]

icd9pcs

[ [ [] ] ]

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298, 305

18733, 18848

4480, 4480

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2912, 3104

17311, 18513

18630, 18712

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237, 260

10035, 14550

333, 1934

4497, 6868

18863, 18887

1956, 2473

2489, 2896

7,275

103,990

43651

Discharge summary

report

Admission Date: [**2134-10-20**] Discharge Date: [**2134-10-23**] Date of Birth: [**2078-11-11**] Sex: M Service: [**Doctor First Name 147**] Allergies: Penicillins / Iodine; Iodine Containing / Carbamazepine Attending:[**First Name3 (LF) 668**] Chief Complaint: Bleeding R brachiocephalic AV fistula Major Surgical or Invasive Procedure: repair bleeding AV fistula aneurysm History of Present Illness: 55yo male who presents wth bleeding from R brachiocephalic fistula. Pt is s/p repair of AV fistula aneurysm on [**10-8**]. Pt with acute blood loss and Hct drop secondary to bleeding Past Medical History: ESRD secondary to glomerulonephritis HTN Hep C PVD Hypoparathyroidism CHF Restless Leg Syndrome Social History: N/C Family History: N/C Physical Exam: AAO times 3 RRR S1+S2 CTA Bilat Soft NT/ND BS+ R AV Fistula pulsating, tender R Ulnar/Radial pulses 2+ Pertinent Results: [**2134-10-19**] 11:55PM BLOOD WBC-4.5 RBC-2.49*# Hgb-7.1*# Hct-21.8*# MCV-88 MCH-28.6 MCHC-32.5 RDW-18.6* Plt Ct-253 [**2134-10-20**] 04:09AM BLOOD WBC-5.9 RBC-3.18*# Hgb-9.2*# Hct-26.8* MCV-84 MCH-28.8 MCHC-34.2 RDW-16.5* Plt Ct-189 [**2134-10-20**] 02:57PM BLOOD Hct-32.7* [**2134-10-21**] 05:00AM BLOOD WBC-11.4*# RBC-2.54* Hgb-7.7* Hct-21.5*# MCV-85 MCH-30.4 MCHC-36.0* RDW-18.4* Plt Ct-229 [**2134-10-21**] 08:08AM BLOOD Hct-21.1* [**2134-10-21**] 07:30PM BLOOD Hct-24.7* [**2134-10-22**] 05:55AM BLOOD WBC-6.4 RBC-3.13* Hgb-9.1* Hct-26.4* MCV-85 MCH-29.2 MCHC-34.5 RDW-17.8* Plt Ct-189 [**2134-10-23**] 05:10AM BLOOD WBC-4.4 RBC-3.54* Hgb-10.7* Hct-30.4* MCV-86 MCH-30.2 MCHC-35.2* RDW-17.0* Plt Ct-190 [**2134-10-20**] 2:10 am SWAB Site: FISTULA R A-V. GRAM STAIN (Final [**2134-10-20**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2134-10-22**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. Brief Hospital Course: Pt admitted on [**2134-10-20**] with bleeding AV fistula, taken to the OR. Aneursym of fistula ligated and resected. Pt given 3U PRBC during the operation. Pt on GET secondary to SOB at the onset of MAC. Pt unable to be extubated after the case, transferred to the MICU intubated. Pt then extubated overnight, tolerated well. Pt transferred to the floor. Pt with tunneled dialysis cath placed on [**10-22**]. Pt continued to improve. Pt tolerated diet well, pain controlled. Pt D/C'd with VNA for dressing changes on [**10-23**]. Discharge Medications: 1. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO QD (once a day). 2. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QD (once a day). 3. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Prednisone 5 mg Tablet Sig: 0.5 Tablet PO QD (once a day). 6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO QD (once a day). 7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every 4-6 hours. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: ESRD with repaired AV fistula, tunneled dialysis catheter Discharge Condition: stable Discharge Instructions: Please keep all follow-up appointments Take all medications as prescribed Reuturn for dialysis as scheduled Return to the ER if any increased pain, fevers, redness or swelling, drainage from wound, significant weight gain or weight loss, shortness of breath, chest pain, or nausea and vomitting Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] (TRANSPLANT) TRANSPLANT CENTER (NHB) Where: LM [**Hospital 5628**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2134-10-25**] 1:10 Provider: [**Name Initial (NameIs) **]/ [**Doctor Last Name 1201**] Where: [**Hospital6 29**] NEUROLOGY Phone:[**Telephone/Fax (1) 8302**] Date/Time:[**2135-1-5**] 4:00 Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 902**] Date/Time:[**2135-3-24**] 1:00 Completed by:[**2134-10-23**]

[ "E878.2", "442.0", "443.9", "285.1", "070.54", "403.91", "428.0", "252.1", "996.73" ]

icd9cm

[ [ [] ] ]

[ "39.95", "39.42", "99.04", "38.95" ]

icd9pcs

[ [ [] ] ]

3248, 3306

1920, 2451

375, 413

3408, 3416

924, 1848

3759, 4328

781, 786

2474, 3225

3327, 3387

3440, 3736

801, 905

298, 337

441, 625

1884, 1897

647, 744

760, 765

27,121

133,635

34635

Discharge summary

report

Admission Date: [**2126-7-22**] Discharge Date: [**2126-8-13**] Date of Birth: [**2065-12-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3913**] Chief Complaint: Right Ventricular Mass Major Surgical or Invasive Procedure: CT guided biopsy of right renal mass ([**2126-7-23**]) Placement of Pericardial window and drain ([**2126-7-25**]) Bone Marrow Biopsy ([**2126-7-25**]) Transesophageal echocardiogram ([**2126-7-25**]) Diagnostic lumbar punctures* 2 ([**2126-7-30**] and [**2126-8-2**]) Intrathecal injection of methotrexate Placement of right sided PICC line Placement of Left-sided PICC line History of Present Illness: 60 y/o old male with newly diagnosed NHL with disease in lung, heart (RA, RV, AoA), adrenals, and kidneys, p/w fever and 30 lb weight loss. Ventricular masses were found on TTE as well as pericardial effusion which has since been drained and a pericardial window with drain has been placed. Patient is being transferred from surgical ICU to [**Hospital Unit Name 153**] to receive chemotherapy, to monitor pericardial drain placed yesterday [**7-25**] and in hypercalcemic crisis [**1-19**] metastasis with Ca of ~15 on transfer s/p [**2126-7-25**] administration of 30mg IV pamidronate, decadron, and IVFs at OSM. Labs on admission were concerning for TLS given elevated uric acid in the range of [**7-27**]. Past Medical History: -Nephrolithiasis Status post cystoscopy 7-8 years ago. -NHL high grade, likely stage 3 or 4 with involvement of kidneys bilaterally, adrenals bilaterally, RA, and RV -Anemia -CKD with baseline cr on [**2126-7-18**] of 1.2 -Status post amputation of the right second digit following an electrical accident 45 years ago. -Tobacco abuse. Social History: Former engineer. Part-time custodian currently. 45 pack year history. Lives with wife. 3 alcohol drinks per week. Family History: Older brother with arrhythmia. His mother died in her 70s from diabetes and heart disease. Physical Exam: Physical Exam At transfer to medicine service VS: Patient afebrile, all vital signs stable and within normal limits GEN: cachetic male, agitated in bed, pulling at pericardial drain and foley HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, dry MM, OP Clear NECK: No JVD, flat JVP, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: tachycardic, periardial rub, radial pulses +2, pericardial drain in place draining serosanguinous fluid with dressing in place PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: Not oriented to place or time, just person. no asterixis. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength [**4-22**] in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. No cerebellar dysfunction. SKIN: pallid. No jaundice, cyanosis, or petechiae. . At discharge all vital signs continued to be stable and within normal limits. Exam notably changed in patient was alert and oriented times three and asking appropriate questions about his medical condtions and treatment plan. Pericardial drain also removed at discharge with healing incision in left chest with dressing C/D/I. Pertinent Results: LABORATORY RESULTS ====================== Admission Labs: ----------------- WBC-11.0 RBC-3.14* Hgb-10.3* Hct-30.6* MCV-97 Plt Ct-247 PT-16.2* PTT-28.0 INR(PT)-1.5* Glucose-137* UreaN-32* Creat-1.4* Na-139 K-4.2 Cl-101 HCO3-27 AnGap-15 ALT-24 AST-31 LD(LDH)-228 AlkPhos-60 Amylase-20 TotBili-0.9 Albumin-2.8* Calcium-12.8* Phos-3.8 Mg-2.1 . Discharge Labs: ---------------- WBC-0.8* RBC-3.01* Hgb-9.8* Hct-26.9* MCV-90 MCH-32.5* MCHC-36.4* RDW-15.7* Plt Ct-126* Gran Ct-490* PT-13.3 PTT-31.6 INR(PT)-1.1 ALT-38 AST-29 AlkPhos-79 TotBili-0.6 Glucose-118* UreaN-14 Creat-0.8 Na-136 K-3.5 Cl-103 HCO3-28 AnGap-9 Albumin-2.5* Calcium-8.1* Phos-2.2* Mg-1.7 UricAcd-2.5* . Delirium Labs: -------------- VitB12-1309* Folate-12.8 TSH-1.3 Ammonia-13 . Coagulopathy Labs ------------------ Fibrino-250-446*-610*#-519*-490*-438*-389-326-305-[**Telephone/Fax (3) 79451**] ([**2126-8-1**]) . CSF: ---- [**2126-7-30**] (CSF) WBC-0 RBC-8* Polys-6 Lymphs-38 Monos-55 Macroph-1 [**2126-7-30**] (CSF) TotProt-39 Glucose-65 LD(LDH)-18 [**2126-8-2**] (CSF) WBC-2 RBC-3* Polys-1 Lymphs-62 Monos-37 [**2126-8-2**] (CSF) WBC-2 RBC-3* Polys-0 Lymphs-68 Monos-32 . . RADIOLOGY DATA Cardiac MRI of [**2126-7-22**] Impression: 1. The myocardium appeared to have heterogenous signal intensity with tumor infiltration involving the majority of the right ventricular cavity, interventricular septum, left ventricular apex, interatrial septum, right atrial free wall , region surrounding the tricuspid annulus, and left atrium near the mitral annulus. Resting myocardial perfusion images of the mass reveal similar perfusion characteristics to normal myocardium, . This suggests that the mass is vascular, and less likely to represent chronic thrombus 2. Numerous pulmonary nodules are identified in both lungs. The left adrenal gland is grossly enlarged and appears to be infiltrated by a mass. 3. There is a small to moderate circumferential pericardial effusion.. 4. Normal left ventricular cavity size with normal regional left ventricular systolic function. The LVEF was normal at 60%. Normal right ventricular cavity size and systolic function. The RVEF was normal at 65%. 5. The indexed diameters of the ascending and descending thoracic aorta were normal. The main pulmonary artery diameter index was normal. . TTE on [**2126-7-25**]: IMPRESSION: Large tumor mass in the right ventricle with extensive mass infiltration into the right atrium, interatrial septum, and possibly the left ventricular apex. There is large circumferential pericardial effusion most anterior to the right atrium and right ventricle with signs of early tamponade. . TTE on [**2126-8-5**]: : left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-10mmHg. 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 aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . Compared with the prior study (images reviewed) of [**2126-8-5**], the current study better defines the valves with no discrete vegetation identified (does not exclude endocarditis if clinically suggested) CT Head w/o Contrast on [**2126-7-28**] IMPRESSION: No evidence of hemorrhage or recent infarction. Left maxillary air- fluid level. . CT Chest and Abdomen W/IV contrast on [**2126-8-3**]: IMPRESSION: 1. No focal liver abnormality, or other CT finding to explain sudden increase in liver function tests. 2. Interval improvement in intracardiac nodules, multiple pulmonary nodules, and bilateral renal and adrenal masses. 3. Cholelithiasis, without evidence of cholecystitis. 4. Worsening ascites. 5. Small bilateral pleural effusions, and associated bibasilar atelectasis. 6. 2.4 cm right common iliac artery aneurysm. . . PATHOLOGY Kidney, needle core biopsy [**2126-7-23**]: Gross: Involvement by high grade non Hodgkin B-cell lymphoma best classified as diffuse large B-cell type Cytology: Three color gating is performed (light scatter vs. CD45) to optimize lymphocyte yield. Abnormal / lymphoma cells comprise 2% of total events. B cells demonstrate a monoclonal lambda light chain restricted population. They co-express pan-B cell markers CD19, 20, long with FMC-7. They do not express any other characteristic antigens including CD5, CD23 or CD10. INTERPRETATION Immunophenotypic findings consistent with involvement by a lambda-restricted B-cell lymphoproliferative disorder. . Bone Marrow Biopsy on [**2126-7-25**]: DIAGNOSIS: 1. Multiple paratrabecular and non-paratrabecular lymphoid aggregates, in keeping with involvement by patient's known B-cell Non-Hodgkin lymphoma (see note). Note 1: Although a majority of the cells in the lymphoid infiltrate are large in size, and are thus in keeping with involvement by the patient's recently diagnosed high-grade lymphoma, some paratrabecular aggregates including with admixed smaller lymphocytes are also noted. The possibility of an antecedent lower-grade lymphoma cannot be excluded. Findings discussed with Dr. [**Last Name (STitle) **]. [**Doctor Last Name 410**] via telephone. Please correlate with cytogenetic findings. 2. Mildly hypercellular bone marrow with mild dyserythropoiesis and dysmegakaryopoiesis noted. . Heart Biopsies [**2126-7-25**]: DIAGNOSIS: 1. Tumor, surface of the heart, incisional biopsy (A-B): --Markedly crushed atypical lymphoid infiltrate in keeping with involvement by patient's recently diagnosed B-cell, non-Hodgkin lymphoma, high grade (see note). --Note: Sections A and B show a dense mononuclear infiltrate with extensive crush artifact. In focal, better preserved areas, the cells appear to have scant cytoplasm, irregular nuclear outlines, hyperchromatic nuclei with inconspicuous nucleoli. By immunohistochemistry, the infiltrate is diffusely immunoreactive for pan B-cell marker CD20 with scant CD3 positive T-cells. By MIB-1 staining the proliferation fraction is greater than 90%. TdT stain is negative. 2. Pericardium biopsies (C-E): -- Fibroadipose tissue with patchy involvement by patient's known B-cell non-Hodgkin lymphoma, high grade. See note. Note: In sections C through D, there is a patchy atypical lymphoid infiltrate, comprised of cells similar to those described above. There is prominent mitotic activity and single cell apoptosis. By immunohistochemistry, the infiltrate is diffusely immunoreactive for pan B-cell marker CD20 with scant CD3 positive T-cells. By MIB-1 staining the proliferation fraction is greater than 90%. TdT stain is negative. ADDENDUM: Reason for addendum: additional stains received. In situ hybridization studies for [**Doctor Last Name 3271**] [**Doctor Last Name **] Virus encoded RNA ([**Last Name (un) **]) is negative. . CSF cytogenetics [**2126-7-30**]: RESULTS: Three color gating is performed (light scatter vs. CD45) to optimize lymphocyte yield. Due to paucicellular nature of the specimen, a limited panel is performed to determine B-cell clonality/look for residual disease. B cells are scant in number precluding evaluation of clonality. INTERPRETATION Non-diagnostic study. Cell marker analysis was attempted, but was non-diagnostic in this case due to insufficient numbers of cells/insufficient amount of tissue for analysis. If clinically indicated, we recommend a repeat specimen be submitted for further studies. Brief Hospital Course: 60 year male with new diagnosis NHL involving lung, pericardium, heart, adrenals, and kidneys admitted with this new diagnosis and in hypercalcemic crisis with persistent encephalopathy status post placement of pericardial window. . 1) High grade NHL likely stage 3 or 4: This was diagnosed with a CT guided renal biopsy on [**2126-7-23**]. Separate biopsies of the patient's bone marrow, pericardium and a mass on the surface of his heart also all revealed B-cell lymphoma. Imaging also revealed pulmonary nodules that could potentially be further malignant involvement. After placement of a PICC line the patient was started on CHOP on [**2126-7-26**] for a 4 day course. Pretreatment prophylaxis for tumor lysis syndrome was initiated with allopurinol and discontinued after several days of normal uric acid levels. There was never any signs of [**Last Name (un) **] following the chemotherapy and uric acid peaked at 3.1. A CT chest performed on [**2126-8-4**] showed interval improvement in the cardiac, pulmonary, and renal masses. Given the patient's persistent mental status changes, an LP was performed and showed cytology indeterminate for malignancy. Still, given lack of other sources of mental status changes he was considered high risk for CNS lymphoma and received intrathecal methotrexate and then high dose methotrexate on [**2126-8-9**]. After this last treatment he received leucovorin rescue. Overall, the patient tolerated chemotherapy very well with minimal nausea and no appreciated mucositis or other toxicities. After his MTX levels were within safe limits following this final treatment and his neutropenic nadir begun to recover he was discharged to home with plans to return for further cycles of outpatient CHOP. . 2.) Encephalopathy: The patient presented with encephalopathy that persisted despite correction of hypercalcemia (corrected with IVFs and pamidronate 30mg IV X1 [**7-25**], decadron 20mg IV bid and lasix 20mg X1 and IVFs) and hyponatremia. Head CT without contrast was negative for bleeding or other acute intracranial pathology. Thiamine and folate were given initially, but B12, folate, TSH, LFT's, and ammonia were all checked early in his course and were within normal limits. An LP was performed to evaluate for CNS involvement or infection but cytology was inconclusive and there were no signs of infection. An infectious work up was initiated on [**2126-7-31**] given persistent encephalopathy despite correction of his electrolyte abnormalities and discontinuation of CNS inhibiting drugs but no signs of UTI or pneumonia. 1/2 blood cultures from a PICC site was positive for gram + cocci in pairs and chains (see management below). During the height of this confusion the patient was quite agitated and required feeding by NG tube as well as olanzapine and soft restraints in order to be administered his medical care. Eventually, the patient began to clear on his own and as of [**2126-8-5**] was responding in a meaningful way to most questions, though he continued to not be oriented to time and would become extremely disoriented about time and situation at night. This confusion continued to gradually improve and by time of discharge he was at his baseline mental status and alert and oriented times three. . 3.) Strep viridans bacteremia: The patient never had a fever but on ICU day 8 an infectious work-up was initiated due to his continued encephalopathy. At that time, one out of two cultures drawn from his PICC site were positive for gram positive cocci in pairs and chains that were eventually speciated as viridans streptococcus. At the time gram positive cocci were reported empiric vancomycin was initiated and the PICC was discontinued. Cultures of the PICC catheter tip did not grown any bacteria. When speciation revealed strep viridans he was switched from vancomycin to ceftriaxone. This was briefly switched to Penicillin G during the period of leucovorin rescue given a concern that the calcium in the leucovorin could precipitated with ceftriaxone. Though there was never fever, embolic phenomena, or other high risk features for endocarditis, multiple echocardiograms were performed and none showed vegetations. At discharge he was switched back to ceftriaxone for an easier dosing interval with plans to continue a four week course for uncomplicated bacteremia. Source was never determined. . 4.) Pericardial effusion: On [**2126-7-25**] an echocardiogram revealed a large pericardial effusion that caused some diastolic collapse of the ventricle. This was considered a risk for hemodynamic compromise so a pericardial window was placed. Pericardial window was chosen over pericardial drain given this was now thought most likely to be a malignant infusion and the risk of recurrence was high. Drain output gradually decreased and the drain was discontinued when there was only a minimal amount of drainage. At the time of discharge he was left with only a small healing incision on his chest. . 5.) Acute Renal insufficiency: He presented with [**Last Name (un) **] with Cr elevated to 1.8 over his baseline of 1.2. Given his hypercalcemia at the time this was considered most likely to be prerenal and secondary to dehdration. This resolved with vigorous IV hydration and never recurred. . 6.) Right-sided catheter associated DVT: On ICU day five his right upper extremity was noted to be swollen. Ultrasound was obtained and revealed a DVT at the PICC site. The PICC was discontinued. Heparin gtt was held given concern for triggering pericardial hemorrhage in light of recent pericardial window. The swelling in the right resolved by the time of discharge. . 7.) Tachycardia: The patient had a history of tachycardia that was treated with metoprolol during his hospitalization. He never had hemodynamically significant tachycardia during his hospitalization. . 8.) Anemia, Thrombocytopenia: At presentation he was noted to be thrombocytopenic and anemic that was presumed to be secondary to his lymphoma and myelopthisis. This worsened in an expected manner with chemotherapy and was recovering at the time of discharge. . 9.) At the time of presentation the patient was hypercalcemic, presumably secondary to his malignancy. He received IVF, pamindronate, and furosemide and his calcium resolved to a normal value by [**2126-7-28**]. His hypercalcemia never recurred. . The patient intially required tube feeds in the ICU due to his mental clouding. After this resolved he was placed on a neutropenic diet. He received DVT prophylaxis with pneumoboots and then was encouraged to ambulate. SC heparin was held due to his history of hemopericardium. While he was in the ICU he was kept on H2 blocker for ulcer prophylaxis, but this was discontinued after he was transferred to the floor and his condition improved. He was full code. Medications on Admission: Medications on transfer: 2 amps NaHCO3 D5W at 100/hr lasix 20mg iv q4h Metoclopramide 5 mg IV Q6H:PRN nausea/vomiting CefazoLIN 2 g IV Q8H Duration: 4 Doses Oxycodone-Acetaminophen [**12-19**] TAB PO Q4H:PRN pain Acetaminophen 650 mg PO/PR Q4H:PRN temperature >38.0 Docusate Sodium 100 mg PO BID Allopurinol 150 mg PO DAILY Metoprolol Tartrate 12.5 mg PO BID Nystatin 500,000 UNIT PO Q8H Ranitidine 150 mg PO DAILY Sevelamer 800 mg PO TID W/MEALS Heparin 5000 UNIT SC TID IV 1000 mL D5 1/2NS continuous at 100 ml/hr Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 2. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous daily and PRN as needed for line flush. Disp:*2 ML(s)* Refills:*0* 3. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig: One (1) gm Intravenous Q24H (every 24 hours) for 16 days. Disp:*18 doses* Refills:*0* 4. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea for 2 weeks. Disp:*20 Tablet, Rapid Dissolve(s)* Refills:*0* 5. PICC dressing Please change PICC dressing weekly/PRN per critical care systems protocol 6. Saline Flushes Please flush PICC with 10 ml NS daily/PRN prior to heparin flush. Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Primary Diagnoses: ------------------- Non-Hodgkin's Lymphoma Pericardial effusion Strep Viridans Bacteremia Discharge Condition: Good, afebrile, tolerating a full diet Discharge Instructions: You were admitted to the hospital because you had a tumor in your heart as well as in your lungs, adrenal glands, and kidneys. Initially, the tumor in your heart was causing fluid to collect around the heart so the cardiac surgeons drained this fluid and left a drain in place. This drain was eventually removed. After the fluid around your heart was drained the mass in your adrenal gland was biopsied and was found to be lymphoma. You have received intravenous chemotherapy and chemotherapy into the space around your spine for your lymphoma in the hospital. You will need more chemotherapy but this will be given as an oupatient. . You had one blood culture that grew a bacteria from your blood. You will need a total of four weeks of IV antibiotic therapy for this bacterium. This treatment will continue until [**8-29**], [**2125**]. . Your medications have been changed. You have been started on METOPROLOL, a medication to help slow your heart rate. You have also been started on CEFTRIAXONE, an antibiotic to treat your bloodstream infection. Finally, you have been given a prescription for ONDANSETRON (ZOFRAN), a medication to treat nausea. You can take this medication up to three times a day if you are nauseous but do not need to take it otherwise. Please take all these medications as prescribed. . Please keep all scheduled follow-up appointments as these are important to maintain your health. . Please take your temperature daily. Please call your doctor or come to the emergency room if you have a temperature >100.5. Please call your doctor or report to the emergency room if you have fevers or chills, chest pain, shortness of breath, increased bleeding, inability to tolerate eating or drinking due to mouth pain or nausea, or any other concerning changes to your health. Followup Instructions: You will follow up with Dr. [**Last Name (STitle) **] in the outpatient hematology clinic on [**Hospital Ward Name 23**] 7 at 10:00 am. His office can be reached at [**Telephone/Fax (1) 3241**].

[ "275.42", "423.9", "285.21", "453.8", "276.0", "584.9", "276.52", "995.91", "038.0", "E879.8", "202.80", "423.3", "782.3", "511.8", "287.5", "996.74", "275.3", "427.89", "999.31", "348.39" ]

icd9cm

[ [ [] ] ]

[ "37.12", "55.23", "88.72", "03.31", "99.25", "38.91", "99.26", "38.93", "07.11", "41.31", "99.04" ]

icd9pcs

[ [ [] ] ]

19417, 19469

11214, 18069

339, 717

19622, 19663

3330, 3378

21517, 21716

1964, 2056

18636, 19394

19490, 19601

18095, 18095

19687, 21494

3693, 11191

2071, 3311

277, 301

745, 1458

3394, 3677

18120, 18613

1480, 1816

1832, 1948

28,223

121,068

12930

Discharge summary

report

Admission Date: [**2190-8-30**] Discharge Date: [**2190-9-12**] Service: MEDICINE Allergies: Percocet Attending:[**First Name3 (LF) 1936**] Chief Complaint: Severe anemia & with Coffee-grounds per OG tube Major Surgical or Invasive Procedure: NGT placement on [**8-30**] (ER) Arterial line (right radial) on [**8-30**] Intubation, admission to ICU EGD History of Present Illness: This is a 89 yoM w/ a h/o of atrial fibrillation on coumadin, peripheral vascular disease, CAD, CHF EF 45% and diastolic dysfunction, presenting with altered mental status (agitation) and found to have a hct of 14. . History was obtained via his wife: she states that at baseline he is alert and oriented x 1, he is able to feed himself only occasionally and not able to bathe himself. He was in his usual state of health until Saturday when he experienced insomnia and then this a.m. (monday) when he became tachypneic. His wife states that she did hear audible wheezing and he looked to be in distress. She states over the past few days he was complaining of pain "all over." Other than this he had not complained of anything but is a poor historian at baseline. . In the ED: initally presented with altered mental status / agitation. Intubated given agitation. Unable to obtain O2 sat prior to intubation but per EMS he was hypoxic. . SBP 134 initially in ER. Coffee grounds in OG tube. CXR multilobar pneumonia given levo, vanc, and ceftriaxone. . HCT 14.5 and INR 3.0 (on coumadin for Atrial fibrillation). He was given 10 IV vitamin K, Protonix 40mg IV x 1, he has not rec'd FFP or PRBC. He has been type and crossed x 4 units. 1 amp of D50 for glucose of 67. Admitted to ICU [**8-30**] Past Medical History: #. Advanced dementia, small vessel disease and lacunar ischemic changes per CT, has been on Seroquel and Depakote #. s/p CVA, right frontal subcortical area, with L hemiparesis #. CAD, s/p MI ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD - Cardiologist) #. Chronic Diastolic CHF, EF 45% per Cardiac Echo @ NEBH ([**2186-4-29**]) #. Atrial fibriallation on coumadin #. Tachy-brady syndrome, s/p pacemaker #. Mod MR & mod tricuspid valve insufficiency, per Cardiac Echo @ NEBH ([**2186-4-29**]) #. Severe PVD: - s/p PTA and stenting of his R SFA and PTA of his R PA ([**2-/2190**]) - s/p Right tarsometatarsal amputation ([**2-/2190**]) - s/p angiography, PTA of the L PA, Stenting of the LSFA ([**2190-5-27**]) - s/p Amputation of left first and third toes ([**6-/2190**]) #. DM #. GERD #. h/o Minimal esophagitis in the stomach, per EGD @ NEBH ([**5-15**]) #. Diverticulosis #. Cholelithiasis with no signs of cholecystitis, per U.S ([**5-/2190**]) #. h/o Internal Hemorrhoids #. Bilateral atrophic kidneys, per U.S. #. Renal cyst, Right upper pole simple cyst #. CRI (baseline Cr 1.5-2.0) #. h/o Locally advanced prostate cancer #. h/o Anemia, colonoscopy and EGD unremarkable ([**5-/2189**]) - Chronic disease - Chronic kidney disease - Fe deficiency #. h/o Lung nodules, likely silicosis vs malignancy #. Chronic obstructive pulmonary disease, silicosis ? [**1-9**] miner's lung #. h/o Hypercarbic respiratory failure, requiring intubation ([**5-/2188**]), [**1-9**] narcotic induced hypoventilation #. Pulmonary artery hypertension, per Cardiac Cath @ NEBH ([**2185-6-14**]) #. Gout #. h/o UTIs #. h/o Urinary retention and incontinence #. Skin - pressure ulcer on his occiput - h/o neurotic excoriations on neck - non-healing right foot TMA site - non-healed site @ the site of the left 3rd toe amputation - eschar lateral to left 5th toes - bilat heels w/ ? deep tissue injury PSHx: [**2190-7-1**] - s/p Amputation of left first and third toes [**2190-5-27**] - s/p angiography, PTA of the L PA, Stenting of the LSFA [**2190-2-25**] - s/p Right transmetatarsal amputation toes [**12-12**] [**2190-2-13**] - s/p arteriography with catheter placement, angioplasty of peroneal artery wiyh a single-vessel runoff on the right lower extremity and to the dorsalis pedis. s/p TURP ([**2188**]) s/p Upper GI and lower GI complete endoscopies @ NEBH ([**2189-5-8**]) [**2188-7-24**] - s/p pace maker generator replacement [Pacemaker generator was a St. [**First Name4 (NamePattern1) 923**] [**Last Name (NamePattern1) 39716**] ADX XL SR, model #5159, serial #[**Serial Number 39717**]. [**2185-6-14**] - s/p Cardiac cath @ NEBH [**2184-1-14**] - s/p Pacer @ NEBH [Ventricular lead Pace Setter, Tendril SDX, Model # 1488T, Serial # [**Serial Number 39718**]] s/p cataract surgery Social History: Married for 19 years to his current wife (his second) - 12 living children between them - his eldest son died unexpectedly in 6/[**2189**]. Was a resident of [**Location (un) 37452**], worked as a coal miner and emigrated to [**Location (un) 4480**] ~[**2175**]. Had also been a minister of his own store-front church. . Has 24/7 care at home (family & friends). Not ambulating since his [**2190-5-9**] amputation on of toes on right foot ([**2190-5-9**]). Dependent for all ADLs/IADLs. Has had services with [**Location (un) 86**] VNA. . The patient has never smoked, drank alcohol, or used any illicit drugs. Family History: Mother with "cancer" died at age 42. Brother and sister with "heart problems." Physical Exam: ON last day before passing away: Vitals: 96.4 80/43 60 18 93%3Lnc Gen:peacefully asleep CV: RRR, [**1-13**] SM Resp: clear anteriorly Abd; no grimacing Ext; no edema, s/p b/l toe amputations Skin: b/l gangrenous/necrotic ulcers are dressed Pertinent Results: NONE pertinent Brief Hospital Course: 89 yo male with multiple medical problems including advanced dementia (baseline A&OX1), with rapid decline x 6 months, admitted [**8-30**] with MS changes, tachpnea/resp distress: Found to have PNA, agitated, UGIB and hgb drop to 4.3, EGD unrevealing. treated with broad spectrum Abx X10days for possible aspiration PNA. Transfered to Gen med, MS did not improved, remained minimally responsive except for clear pain with position changes, dressing changes of necrotic LE wounds. Nutrition was an issue as he was not able to take anything PO. After many attempts DHT finally placed for nutrition, but pt eventually pulled it out. Poor candidate for many reasons for PEG tube and wife [**Company 191**] agreed to forgoe PEG placement and other heroic measures which are unlikely to benefit the patient. Finally made DNR/I 9/30 per discussion with wife, who is HCP, despite resistance from other family members whose expectations have overall been unrealistic. Goals of care were redirected to comfort measures/hospice with main focus pain control. he was managed on fentanyl patch with prn roxanol and levsin for oral secretions. Given that death was expected over next few days, he was kept in the hospital over the weekend. On saturday, pt's breathing became irregular with apenic episodes. Family was notified and questions answered, support given (seem my OMR note the time declared the patient and filled out paperwork. Family interested in autopsy and request is submitted. Medications on Admission: Allopurinol 100 mg po daily Montelukast 10 mg po daily Atorvastatin 10 mg Tablet po daily Valproate Sodium 250 mg/5 mL po q12 hours Multivitamins po daily Iron 27 mg two tablets daily Aspirin 81 mg Tablet po daily Warfarin 2.5 mg po daily Colace [**Hospital1 **] Megace daily Toprol 50mg daily Amlodipine 5 mg po daily Plavix 75mg daily Lasix 40-80mg po daily Colchicine 0.6 mg Tablet po daily Tolterodine 4 mg po daily Discharge Medications: NONE Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnosis: ================= Anemia UGI Bleed Acute on Chronic Renal Failure Aspiration Pneumonia Advanced Dementia . Secondary Diagnosis: =================== Peripheral Arterial Disease Non-healing surgical wounds s/p CVA with left-sided deficits CHF CAD Atrial Fib, s/p pacer placement COPD, silicosis Prostate Cancer Discharge Condition: EXPIRED Discharge Instructions: NONE Followup Instructions: NONE

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icd9cm

[ [ [] ] ]

[ "99.04", "99.07", "96.71", "96.04", "45.13", "89.61" ]

icd9pcs

[ [ [] ] ]

7599, 7608

5615, 7099

264, 374

7980, 7989

5576, 5592

8042, 8049

5215, 5296

7570, 7576

7629, 7629

7125, 7547

8013, 8019

5311, 5557

177, 226

402, 1706

7776, 7959

7648, 7755

1728, 4571

4587, 5199

67,265

189,882

44693

Discharge summary

report

Admission Date: [**2130-1-20**] Discharge Date: [**2130-1-24**] Date of Birth: [**2077-8-20**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 301**] Chief Complaint: Increasing fatigue, melena, and epigastric pain Major Surgical or Invasive Procedure: EGD [**2130-1-20**] Colonoscopy [**2130-1-22**] History of Present Illness: Ms [**Known lastname **] is a 52F s/p gastric bypass in [**2126**], presenting with her 3rd episode of UGI bleeding from an anastomotic ulcer. She had an EGD on her last admission [**2130-1-10**], which demonstrated an area of bright red clot overlying what appeared to be an ulcerated area at the anastomosis just proximal to the patent [**Month/Day/Year 3099**]. This was friable and oozing slowly, but there was not obvious vessel. She was managed conservatively with high-dose PPI and carafate, as there was no active bleeding at that time. She returned to the ED today with increasing fatigue, as well as melena and epigastric pain that have not resolved since her discharge on [**2130-1-11**]. The epigastric pain was moderately improved with oral carafate. She denies nausea, vomiting, diarrhea, BRBPR, dizziness, or LOC. Upon presentation to the ED, her hematocrit was 23.9, down from 31.9 at the time of discharge on [**2130-1-11**]. Bariatric surgery is consulted for possible surgical management. Of note, she is a Jehovah's Witness and is refusing blood transfusion, though she states she would accept albumin, FFP, or platelets. Past Medical History: PMH: - Peptic ulcer disease with hx of 4 ulcers in stomach and small bowel, requiring emergent endoscopy in the past (presented with syncope and blood per rectum) - s/p treatment for H. pylori - s/p gastric bypass in [**2126**] - Fatty liver disease - Obstructive sleep apnea - Hyperparathyroidism - Depression PSH: roux-en-y gastric bypass by Dr. [**Last Name (STitle) **] at [**Hospital 882**] Hospital [**5-/2127**]; "exploratory surgery" (laparoscopy) for persistent abdominal pain [**8-/2127**] Social History: Works for [**Location (un) 86**] Public Schools. Jehovah's Witness. No EtOH or tobacco use. Family History: Non-contributary Physical Exam: Vital signs: T 97.9, HR 60, BP 104/62, RR 18, O2 98% RA Constitutional: No acute distress; flat affect Neuro: Alert and oriented to person, place and time Cardiac: Regular rhythm and rate, no murmurs/rubs/gallops Lungs: CTA B Abdomen: Soft, nontender, nondistended, no rebound tenderness or guarding Extremities: No clubbing, cyanosis or edema Pertinent Results: [**2130-1-24**] 07:00AM BLOOD Hct-22.6* [**2130-1-23**] 06:40AM BLOOD Hct-22.5* [**2130-1-22**] 08:55PM BLOOD Hct-21.8* [**2130-1-22**] 02:11PM BLOOD Hct-21.6* [**2130-1-22**] 05:49AM BLOOD WBC-5.3 RBC-2.58* Hgb-7.3* Hct-22.6* MCV-88 MCH-28.2 MCHC-32.1 RDW-14.4 Plt Ct-287 [**2130-1-21**] 11:59PM BLOOD Hct-21.2* [**2130-1-21**] 06:00PM BLOOD Hct-21.7* [**2130-1-21**] 06:15AM BLOOD Hct-21.5* [**2130-1-21**] 01:15AM BLOOD Hct-23.6* [**2130-1-21**] 12:35AM BLOOD WBC-5.5 RBC-2.51* Hgb-7.1* Hct-21.9* MCV-88 MCH-28.4 MCHC-32.5 RDW-14.5 Plt Ct-260 [**2130-1-20**] 05:05PM BLOOD Neuts-51.4 Lymphs-42.6* Monos-4.7 Eos-0.9 Baso-0.4 [**2130-1-22**] 05:49AM BLOOD Plt Ct-287 [**2130-1-21**] 12:35AM BLOOD Plt Ct-260 [**2130-1-20**] 05:05PM BLOOD Plt Ct-317 [**2130-1-20**] 05:05PM BLOOD PT-12.7 PTT-25.0 INR(PT)-1.1 [**2130-1-23**] 06:40AM BLOOD Glucose-88 UreaN-5* Creat-0.8 Na-139 K-3.6 Cl-107 HCO3-23 AnGap-13 [**2130-1-22**] 05:49AM BLOOD Glucose-99 UreaN-5* Creat-0.7 Na-139 K-3.7 Cl-108 HCO3-21* AnGap-14 [**2130-1-21**] 06:15AM BLOOD Glucose-96 UreaN-8 Creat-0.7 Na-141 K-3.9 Cl-108 HCO3-25 AnGap-12 [**2130-1-20**] 05:05PM BLOOD Glucose-90 UreaN-14 Creat-0.9 Na-141 K-4.0 Cl-107 HCO3-25 AnGap-13 [**2130-1-23**] 06:40AM BLOOD Calcium-8.9 Phos-3.7 Mg-1.8 [**2130-1-22**] 05:49AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.8 [**2130-1-21**] 06:15AM BLOOD Calcium-8.6 Phos-3.7 Mg-1.9 [**2130-1-20**] 05:12PM BLOOD Hgb-7.7* calcHCT-23 EGD [**2130-1-20**]: Previous Roux-en-Y gastric bypass; Small polypoid lesion at G-J anastamosis with a small amount of red blood but no evidence of active bleeding (endoclip); Jejunal ulcer distal to the G-J anastamosis; No lesion or bleeding at the J-J anastamosis, and no blood from the pancreatico-biliary [**Year/Month/Day 3099**] of the Roux-en-Y gastric bypass; Otherwise normal EGD to jejunum Colonoscopy [**2130-1-22**]: Melanosis coli in the rectum and sigmoid colon No blood seen throughout, and no blood visualized from the terminal ileum. Otherwise normal colonoscopy to cecum Brief Hospital Course: Ms. [**Known lastname **] presented to the Emergency Department on [**2130-1-20**] at the direction of her primary care provider due to symptomatic, recurrent blood loss anemia related to known gastric ulcers. The patient is a Jehovah's Witness and adamantly declined blood transfusion despite a critically low hematocrit level and a thorough explain of its potential consequences, including death. At this point her hematocrit decreased to 21.6 and an emergent EGD was performed. This revealed a small polypoid lesion at the G-J anastamosis with a small amount of red blood but no evidence of active bleeding. An endoclip was placed. A jejunal ulcer distal to the G-J anastomosis was noted; No lesion or bleeding at the J-J anastomosis, and no blood from the pancreatico-biliary [**Year (4 digits) 3099**] of the Roux-en-Y gastric bypass was noted. The study was otherwise normal to the jejunum. Following the procedure, she was transferred to the Surgical Intensive Care Unit (SICU) for further management. In the SICU, Epogen therapy was initiated and the patient was placed on a Protonix drip. Hematocrit levels were monitored serially and remained stable. On hospital day 3, the patient underwent a colonoscopy to rule out additional sources of bleeding. Diffuse melanosis coli was noted predominantly in the rectum and sigmoid colon; no blood was seen throughout, and no blood visualized from the terminal ileum. Gastroenterology initially recommended a capsule endoscopy following the colonoscopy, but did not proceed as they felt confident that the source of bleeding could be attributed to the known anastomotic ulceration and the risk of the procedure was great. As the hospital course progressed, the patient remained stable. Her hematocrit remained between 21.2 and 22.6 and the Protonix drip was transitioned to intravenous Protonix [**Hospital1 **]. She was without pain and remained stable from both a cardiovascular and pulmonary standpoint; vital signs were routinely monitored. She was able to tolerate a Bariatric Stage 5 diet without incident. Additionally, there was no recurrence of melena. The patient was seen by physical therapy prior to discharge given signs of deconditioning. Physical therapy felt that the patient was approaching her baseline level of functioning and demonstrated safe mobility without need for further need for rehabilitation. Also, Social Work was asked to see the patient given her complicated social situation. The patient found this meeting helpful and planned to reflect further upon the discussion. At the time of discharge, the patient was stable. She was afebrile with stable vital signs and deemed safe for discharge home without rehabilitation services. The patient was tolerating a stage 5 diet. The patient received discharge teaching and follow-up instructions including the need for subcutaneous injections of Epogen three times weekly to stimulate red blood cell production. She agreed to have a hematocrit drawn within a few days of discharge and to see her primary care provider the following week for further management; an appointment was made for her. Also, she will follow-up with her a bariatric surgeon and the gastroenterologist; per in-patient gastroenterology these appointments were non-urgent as the patient will be seeing her primary care provider for close [**Name9 (PRE) 702**]. Ms. [**Known lastname **] [**Last Name (Titles) 87406**] understanding and agreement with this discharge plan. Medications on Admission: 1. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 2. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Discharge Medications: 1. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 2. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 9. epoetin alfa 20,000 unit/2 mL Solution Sig: 1.5 ml Injection [**Doctor First Name **]/TU/TH (). Disp:*45 ml* Refills:*2* 10. syringe with needle, safety 3 mL 25 x [**4-23**] Syringe Sig: Thirty (30) units Miscellaneous once a day. Disp:*30 ml* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Acute blood loss anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. ********You are getting dehydrated or experiencing signs and symptoms of acute bleeding including dry mouth, rapid heartbeat, or feeling dizzy or faint when standing; Please go to the Emergency Department or call 911 if these symptoms should occur; Please ensure that you are taking your Omeprazole, Carafate, Iron, Multivitamin and B12 supplementation as prescribed. Also, do not smoke, drink alcohol or take NSAIDS (i.e. Ibuprofen, Advil, Motrin, Naproxen, Aspirin, Aleve, etc.)*************. ********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 [**4-25**] lbs until you follow-up with your surgeon. *******Avoid driving or operating heavy machinery until deemed appropriate by your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].************ A visiting nurse will be coming to your home three times weekly to administer subcutaneous Epogen. Followup Instructions: A follow-up appointment has been made for you with Dr. [**Last Name (STitle) **] on Tuesday, [**2130-1-31**] at 1:30pm. Also, Dr.[**Name (NI) 66663**] office will be contacting you to arrange for your hematocrit to be checked before the end of the week and she will follow-up with you regarding the result. Dr. [**Last Name (STitle) **] has been notified of your hospitalization. Please contact your gastroenterologist to make a follow-up appointment within 1 week or at the direction of your primary care provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 305**] to make a follow-up appointment within 2-3 weeks. Completed by:[**2130-2-1**]

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icd9cm

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icd9pcs

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350, 400

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263, 312

428, 1579

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43,431

111,058

12796

Discharge summary

report

Admission Date: [**2146-10-20**] Discharge Date: [**2146-10-25**] Date of Birth: [**2082-12-26**] Sex: M Service: MEDICINE Allergies: Penicillins / Cefepime / Bactrim Attending:[**First Name3 (LF) 8810**] Chief Complaint: shortness of breath, fever Major Surgical or Invasive Procedure: Chest tube placement History of Present Illness: Mr. [**Known lastname 24735**] is a 63 y/o M with a history of AML s/p allo SCT [**10/2144**], chronic GVHD (liver, skin, ?lung) on prednisone and cyclosporine who presents from home with fever and worsening shortness of breath after bronchoscopy/biopsy on the day prior to admission. He reports that there were no immediate complications following the procedure. The next morning, the patient reports worsening dyspnea and the onset of fever. Per ED report, the patient's wife also reports that he has had altered mental status on the day of admission. . Of note, the patient was recently seen by pulmonary in consultation for daily productive cough over at least five months. He was prescribed moxifloxacin for ten days after a CT chest ([**2146-8-30**]) demonstrated mosaic ground-glass attenuation with bronchiectasis throughout and in left lower lobe a tree-in-[**Male First Name (un) 239**] pattern also notable for a lingular consolidation (pulmonary read). There was also diffuse mosaic attenuation affecting small airway obstruction and the thought that this could be a transplant-related bronchiolitis obliterans. The patient completed the moxifloxacin without change in his respiratory symptoms. He subsequently underwent bronchoscopy with transbronchial biopsy on the day prior to admission. . In the ED inital vitals were, 120 25 97% on NRB 156/86. Exam significant for diffuse rhonchi throughout, alert and oriented to person place and month but easily distractible and answers questions slowly. Labs were significant for Na 125, WBC 13.4, lactate 2.6. Chest x-ray revealed large left pneumothorax without mediastinal shift. A 28 French chest tube was placed in the ED, and repeat chest x-ray showed lung re-expansion, with the chest tube curving inferiorly. Patient was given vancomycin, zosyn, azithromycin (BAL from [**10-19**] showing Moraxella Catarrhalis, G+ cocci in pairs and chains, and G- diplococci). He recived fentanyl 250 mg IV X 1 during the chest tube insertion. He was also given stress dose Solu-Medrol 125 mg IV X 1. . On arrival to the ICU, the patient reports improvement in his breathing, he is A+OX3. Denies any SOB, cough, sputum. Past Medical History: 1. AML s/p allo SCT D+105: - [**3-/2144**]: presented to [**Hospital **] hospital with fatigue and weakness. His Hgb was 4.9, WBC 14.8 (16% neutrophils, 2% bands,26% lymphocytes, and 55% monocytes). BMBx was notable for a population of monoblasts and promonocytes which appeared to approach 20%. He was diagnosed with AML-M5. Cytogenetics were notable for +8. - initially treated with 7 and 3 (idarubicin and ARA-C, however, day 14 marrow showed persistent blasts. He was enrolled in the randomized trial of HiDAC with or without clofarabine and began treatment on [**2144-4-27**]. This course was c/b fevers to 105, rashes, LFTs 300s. - [**2144-6-23**]: Bone marrow showed a mildly hypercellular erythroid dominant bone marrow with no morphologic evidence of leukemia. - [**2144-8-17**]: received single cycle Dacogen due to donor issues - [**2144-11-5**]: started reduced intensity conditioning with Fludarabine-Busulfan and ATG. Day 0 was [**2144-11-12**]. He received one bag CD34/kg x 10e6= 8.40. His post-transplant course was uncomplicated with the exception of a mild transaminitis. He was discharged to the apartments on Day +14. Donor Info: recipient is CMV(+), ABO:Opos donor NMDP#5188-3407-2 male CMV(-), ABO:Apos. 2. EBV-related lymphoproliferative disease 3. ABO mismatch 4. Testicular Cancer: s/p orchiectomy and chemotherapy 20 years ago at [**Hospital3 328**] 5. Hypertension 6. Renal insufficiency Social History: Married with 2 children and 3 grandchildren. Formerly in sales, now on disability. He has no history of tobacco use, one drink every other day. Family History: Father died from liver cancer. Mother with [**Name (NI) 2481**]. All siblings have HTN. Physical Exam: Admission Physical Exam: Vitals: T: 96.7 BP: 139/78 P: 105 R: 20 O2: 94% NRB General: Alert, oriented, no acute distress, slow to respond HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: BS b/l, course rhochi b/l, no wheezes or rales CV: Regular rate and rhythm, normal S1 + S2, no m/r/g Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge Physical Exam: Pertinent Results: MICROBIOLOGY: Sputum culture ([**2146-10-21**])- GRAM STAIN (Final [**2146-10-21**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Preliminary): SPARSE GROWTH Commensal Respiratory Flora. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. Blood culture ([**2146-10-20**])- pending, no growth to date Blood culture ([**2146-10-20**])- STREPTOCOCCUS PNEUMONIAE.PRELIMINARY SENSITIVITY. These preliminary susceptibility results are offered to help guide treatment; interpret with caution as final susceptibilities may change. Check for final susceptibility results in 24 hours. SENSITIVITIES: MIC expressed in MCG/ML ________________________________________________________ STREPTOCOCCUS PNEUMONIAE | VANCOMYCIN------------ S Aerobic Bottle Gram Stain (Final [**2146-10-21**]): GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Reported to and read back by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 39446**] [**2146-10-21**] @1900. Anaerobic Bottle Gram Stain (Final [**2146-10-21**]): GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Bronchoalveolar lavage (left lower lobe, [**2146-10-19**])- GRAM STAIN (Final [**2146-10-19**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI. RESPIRATORY CULTURE (Preliminary): 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. MORAXELLA CATARRHALIS. >100,000 ORGANISMS/ML.. STREPTOCOCCUS PNEUMONIAE. 10,000-100,000 ORGANISMS/ML.. Tissue biopsy (left lower lobe, [**2146-10-19**])- GRAM STAIN (Final [**2146-10-19**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Preliminary): Reported to and read back by DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] @ 12:50PM ON [**2146-10-20**]. Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. RARE GROWTH Commensal Respiratory Flora. STREPTOCOCCUS PNEUMONIAE. SPARSE GROWTH. MORAXELLA CATARRHALIS. SPARSE GROWTH. ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. ACID FAST SMEAR (Final [**2146-10-20**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. Tissue culture (Left upper lobe transbronchial biopsy, [**2146-10-19**])- GRAM STAIN (Final [**2146-10-19**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [**2146-10-22**]): Reported to and read back by DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] @ 12:50 PM ON [**2146-10-20**]. STREPTOCOCCUS PNEUMONIAE. SPARSE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 335-7795G [**2146-10-19**]. MORAXELLA CATARRHALIS. SPARSE GROWTH. IDENTIFICATION PERFORMED ON CULTURE # 335-7795G [**2146-10-19**]. ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. ACID FAST SMEAR (Final [**2146-10-20**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. IMAGING: CXR ([**2146-10-22**])- Slight interval improvement in aeration. Persistent patchy opacity of the left base and unchanged subcutaneous emphysema. However, there is no evidence of pneumothorax. Stable cardiac and mediastinal contours. No evidence of pulmonary edema. CXR ([**2146-10-20**])- AP upright portable view of the chest was obtained. In the interval since the prior study, there has been development of a very large left pneumothorax with collapse of the left lung. There may be slight tension component. The right lung is clear. No pleural effusion. The left cardiac border appears somewhat flattened, which may be due to tension. IMPRESSION: Interval development of large left pneumothorax CT Chest ([**8-30**]): 1. Since [**2146-4-20**], left lower lobe and lingular consoldation has resolved leaving behind brochiolitis and bronchiectasis, and previous multifocal bronchiolitis has minimally decreased. Overall improvement in lung consolidation is probably resolving infection , but focal consolidation in inferior lingular segment is new and could be infectious or non-infectious organzing pneumonia. Similarly, the multifocal bronchiolitis picture can be infectious or non-infectious, transplant-related, bronchiolitis obliterans. 2. Diffuse mosaic attenuation reflects small airway obstruction, a finding often seen with transplant-related, bronchiolitis obliterans Brief Hospital Course: Mr. [**Known lastname 24735**] is a 63 y/o male with a history of AML s/p allo SCT [**10/2144**] (D+703), chronic GVHD (liver, skin, ?lung) on prednisone and cyclosporine who presented from home with fever to 102 and increasing shortness of breath after bronchoscopy/biopsy on the day prior to admission, found to have left pneumothorax and persistent LLL consolidation. . #.PNEUMOTHORAX: Patient had a bronchoscopy with biopsy on the day prior to admission which likely caused pneumothorax to develop. Chest tube was placed in the ER with re-expansion of the lung. Patient was followed by interventional pulmonology Patient self-discontinued chest tube on the evening of admission, and serial chest x-rays showed that the lung remained expanded without need for replacement of chest tube. Patient was weaned off of oxygen successfully and repeat chest x-rays continued to show no reaccumulation of pneumothorax. . #.LLL CONSOLIDATION: patient had fever and leukocytosis on admission, likely secondary to infectious vs. non-infectious organizing pneumonia. Other possible cause was strep pneumo bacteremia, although less likely (see below). Patient has h/o 3 episodes of pneumonia in early [**2145**]. Also has chronic cough since [**2146-3-20**], thought to be [**12-22**] GVHD versus organizing pneumonia. Bronchoalveolar lavage on [**10-19**] showed moraxella catarrhalis and strep pneumoniae, strep sensitive to levoquin/PCN G/tetracycline/bactrim/vancomycin. On [**10-23**], vancomycin was discontinued and pt started on Levoquin. As patient reported history of achilles tendon swelling on Levoquin, as well as h/o diarrhea with penicillins and macrolides (augmentin and azithromycin are best agents for moraxella), he was switched to moxifloxacin 400mg PO BID to complete 2 week course. He has tolerated moxifloxacin in the past without complications. White count and fever curve rapidly trended back to normal during hospitalization. . #.STREP PNEUMO BACTEREMIA: pt with 2/4 bottles growing strep pneumo on [**10-20**], sensitive to levofloxacin, tetracycline, bactrim, vancomycin. [**Month (only) 116**] have been secondary to disruption of pulmonary parenchyma during transbronchial biopsy, given pt's chronic immunosuppression putting him at greater risk for this issue. Per above, patient treated with moxifloxacin rather than levoquin due to h/o achilles tendon swelling on levoquin. Surveillance blood cultures all without growth to date. . #.AML s/p ALLOGENEIC STEM CELL TRANSPLANT: pt is s/p 7+3 with idarubacin and ARA-C, followed by HiDAC consolidation. He received allogeneic SCT from an unrelated on [**2144-11-12**] after conditioning with fludarabine, busulfan, and ATG. His course has been complicated by liver, skin and ?lung GVHD. Also developed EBV, which caused lymphoproliferative disease. Has also been found CMV positive. . # GVHD OF LIVER, SKIN AND ?LUNG: complication of patient's allogeneic stem cell transplant in [**2143**]. Patient followed by Dr. [**Last Name (STitle) **]; purpose of preceding transbronchial biopsy was to determined whether lung GVHD was present. Patient continued on home Prednisone 10mg PO daily and Cyclosporin 25mg PO daily. . #.HYPONATREMIA: hypovolemic hyponatremia. Resolved with IV fluids. . #.HYPOTHYROIDISM: continued home levothyroxine. . #.HYPERTENSION: continued home moexipril 15mg PO daily. . ========================= TRANSITION OF CARE: -galactomannan/bglucan pending Medications on Admission: ACYCLOVIR - 400 mg Tablet by mouth three times a day ATOVAQUONE - 10 mL by mouth daily (1500 mg) BENZONATATE - 100 mg by mouth three times a day as needed for cough CLOBETASOL - 0.05 % Cream - twice a day CYCLOSPORINE MODIFIED - 25 mg by mouth once a day ERGOCALCIFEROL - 50,000 unit by mouth every other week FOLIC ACID 1 mg by mouth once a day LEVOTHYROXINE - 88 mcg by mouth once a day MOEXIPRIL - 15 mg by mouth daily PREDNISONE - 10 mg by mouth daily Discharge Medications: 1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 2. atovaquone 750 mg/5 mL Suspension Sig: Two (2) PO DAILY (Daily). 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. moexipril 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. cyclosporine modified 25 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO QDAY () for 14 days: First day = [**2146-10-23**] Last day = [**2146-11-5**]. Disp:*11 Tablet(s)* Refills:*0* 9. benzonatate 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day) as needed for cough. 10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. Disp:*1 inhaler* Refills:*2* 11. nebulizer machine Please dispense one nebulizer machine. Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: 1. Pneumothorax 2. Pneumonia SECONDARY DIAGNOSES: 1. Graft Versus Host Disease (GVHD) 2. Acute Myelogenous Leukemia, in remission Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 24735**], It was a pleasure participating in your care at [**Hospital1 771**]. You were admitted to the hospital with a punctured lung (pneumothorax) after having a bronchoscopy. This was treated with a chest tube. You were also found to have a pneumonia, which was treated with antibiotics. Please attend the follow-up appointments listed below with your oncologist Dr. [**Last Name (STitle) **] and your pulmonologists Dr. [**Last Name (STitle) 4011**] and Dr. [**Last Name (STitle) **] to follow up on your pneumonia and your chronic lung problems. We made the following changes to your medications: 1. ADDED moxifloxacin 400mg by mouth daily for 14 days (first day = [**2146-10-23**], last day = [**2146-11-5**]) 2. ADDED albuterol nebulizer once every 6 hours as needed for wheezing or shortness of breath Please see your doctor if you develop increased swelling or pain in your Achilles tendons while you are on Moxifloxacin, as this could be a side effect of the medication. Followup Instructions: Department: PULMONOLOGY When: Monday, [**2146-11-7**] at 3:10 PM With: Dr. [**Last Name (STitle) 4011**] and Dr. [**Last Name (STitle) **] Building: [**Hospital6 **] [**Location (un) **], [**Apartment Address(1) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/BMT When: THURSDAY [**2146-11-3**] at 9:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD [**Telephone/Fax (1) 3241**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/BMT When: THURSDAY [**2146-11-3**] at 9:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], NP [**Telephone/Fax (1) 3241**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2146-11-3**] at 10:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6543**], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "34.04" ]

icd9pcs

[ [ [] ] ]

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323, 345

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16394, 17639

4173, 4262

14012, 14983

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257, 285

373, 2547

8432, 8552

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2569, 3995

4011, 4157

4820, 4820

29,426

168,380

34371

Discharge summary

report

Admission Date: [**2126-3-27**] Discharge Date: [**2126-3-30**] Date of Birth: [**2064-1-11**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2009**] Chief Complaint: Whole body pain Major Surgical or Invasive Procedure: Central line placement; percutaneous nephrostomy History of Present Illness: 62 year-old male with a history of CVA and neurogenic bladder now with suprapubic tube, also s/p colostomy and transverse myeltitis. Had fever at NH this AM, sent to normal [**First Name3 (LF) 159**] appointment and was found to be moaning and in pain. With diffuse pain. Sent to ED, found to hypotensive and tachycardic. Spanish speaking only. In ED c/o L buttock pain and does have a sacral decubitus. In the ED, VS 54/40, 105-111, 99.5, 16, 100/3-4L (not necessarily needing O2). Got Vanc/Zosyn and LIJ sepsis line. He recd 2L of IVF and the SBP came up. Total IVF in ED was 4L NS. He also was noted to have [**First Name3 (LF) **] in stoma, so CT was obtained and surgery saw him. CT abdomen shows no bowel pathology, no e/o ischemic colitis but did have a suprapubic tube at his left ureter, with increased hydronephrosis on that side. [**First Name3 (LF) 159**] was consulted and replaced the tube. Will likely need percutaneous tube per [**First Name3 (LF) 159**] so IR should be contact[**Name (NI) **]. Upon arrival to the MICU, patient follows commands and is oriented. Interview was via a telephonic Spanish interpreter. Denies pain, headache, CP/SOB, abd pain/N/V. States that the morning of admission he felt 'weak in his whole body' and had some lightheadedness so he was sent to the ED from [**Name (NI) 159**]. Denies any pain, fevers, chills, changes in his colostomy or urostomy output, poor appetite or decreased oral intake. Discussed findings on CT and concern that he may need a percutaneous nephrostomy. He states understanding and that he has had similar things in the past. Past Medical History: s/p CVA x 2; residual LE weakness R > L Neurogenic bladder s/p suprapubic cath Recurrent UTIs with Klebsiella/Pseudomonas & Entercoccus Non-hodgkins Marginal Zone Lymphoma of the left orbit Dx in 03 (s/p R-CHOP x 6 cycles) Bells Palsy BPH (patient denies) Hypertension Partial Bowel obstruction s/p colostomy Hepatitis C Cryoglobulinemia SLE with transverse myelitis, anti-dsDNA Ab+ Insulin Dependant Diabetic Fungal Esophagitis Vasculitis Polyneuropathy Social History: Lives in a nursing home since [**3-9**]. Denies smoking, ETOH, drug use. Has sister close by ([**Name (NI) 79061**]) who he is close to. Is a Jehova's Witness and in the past did not agree to [**Name (NI) **] transfusions. Minimial ambulation, and requires both a walker and assistance. Family History: Non-Contributory Physical Exam: ADMISSION EXAM VS 96.9, 87, 180/89, 14 and 97/2L GENERAL: Mildly diaphoretic, sleepy but easily awakens to loud voice HEENT: Diaphoretic, R facial droop, PERRL, EOMI CARDIAC: RRR without M/G/R LUNG: CTAB without W/W/R ABDOMEN: Active bowel sounds, large midline scar, ostomy with brown output, red/pink ostomy; suprapubic catheter draining pink tinged urine; no abdominal pain EXT: WWP, dopplerable pulses, no edema NEURO: CN II-XII intact except R facial droop; decreased SCM strength; strength UE 4/5 L and [**5-7**] R DERM: buttocks decubitus ulcer Pertinent Results: ADMISSION LABS [**2126-3-27**] 12:00PM WBC-15.1* RBC-4.22* HGB-11.3* HCT-34.1* MCV-81* MCH-26.9* MCHC-33.3 RDW-15.8* NEUTS-82.6* LYMPHS-9.4* MONOS-5.8 EOS-1.9 BASOS-0.3 [**2126-3-27**] 12:00PM GLUCOSE-181* UREA N-11 CREAT-1.4* SODIUM-134 POTASSIUM-3.1* CHLORIDE-101 TOTAL CO2-26 ANION GAP-10 [**2126-3-27**] 12:00PM LIPASE-102* [**2126-3-27**] 12:00PM ALT(SGPT)-26 AST(SGOT)-22 ALK PHOS-90 TOT BILI-1.1 [**2126-3-27**] 12:00PM CALCIUM-7.4* PHOSPHATE-2.6* MAGNESIUM-1.5* [**2126-3-27**] 12:00PM CORTISOL-8.9 [**2126-3-27**] 12:00PM CRP-68.7* [**2126-3-27**] 12:00PM PT-14.9* PTT-33.9 INR(PT)-1.3* [**2126-3-27**] 11:30AM LACTATE-2.7* [**2126-3-27**] 03:47PM URINE [**Month/Day/Year 3143**]-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-MOD [**2126-3-27**] 03:47PM URINE RBC->50 WBC->50 BACTERIA-MOD YEAST-NONE EPI-0-2 urine culture: gram negative rods; speciation pending. CT abdomen 1. Left hydronephrosis and hydroureter, with associated perinephric stranding and apparent delayed contrast excretion from the left kidney. The suprapubic catheter tip terminates in the distal left ureter, which may be related to the the hydroureteronephrosis. 2. Cholelithiasis, without evidence for cholecystitis. 3. Unchanged appearance of right upper quadrant diverting colostomy, with post-surgical changes in the pelvis. The visualized loops of small and large bowel appear normal. There is no evidence of bowel ischemia or inflammation. CXR: PICC line slightly too deep RA/prox RV. Per Radiology attending, pulled back 5cm. Per radiology attending and PICC line nurse, no repeat Xray warranted. Brief Hospital Course: This is a 62 yo male with neurogenic bladder and suprapubic cath, multiple past UTIs and urosepsis presenting urosepsis and L kidney obstruction. # Urosepsis: Patient was initially hypotense to the 50's, treated with aggressive hydration, CVL placement, vancomycin, zosyn. He was briefly admitted to the MICU. Interventional radiology found that his suprapubic catheter had migrated to obstruct his L ureter. They placed a L nephrostomy tube with drainage of a large amt of urine, and replaced his suprapubic tube. He rapidly improved with complete resolution of his hypotension, renal failure, and symptoms. He should finish a 14-day course of zosyn for gram negative UTI. He will be seen in [**Month/Day/Year **] for removal of his nephrostomy tube. If he has [**Month/Day/Year **] clots, the suprapubic tube should be hand irrigated. # Elevated [**Month/Day/Year **] Pressure: After resuscitation, the patient was found to have elevated [**Month/Day/Year **] pressures in the 150s-160s sytolic. On discharge his BP was noted to be 185/100, asymptomatic. We recommend that his BP be re-checked at the nursing home as he will likely need to start an anti-hypertensive. However, given his past h/o of diagnosis and that he is asymptomatic with these high [**Month/Day/Year **] pressures, he likely has chronic hypertension, which will need periodic monitoring. # Acute renal failure: obstructive; improved with IVF and with nephrostomy tube. # Leg pain: continued on home regimen. # DM: lantus + SSI. # Decubitus Ulcer: stage II, not infected.. - Wound care consult - Continue Zinc / Vitamin C # SLE / Vasculitis: Patient admitted with chronic steroids, presumedly for his autoimmune illness. Continued on Prednisone 10mg. he needs f/u in Rheumatology. Please arrange for this at [**Hospital1 1501**]. # H/o CVA: Continued Statin # Access: had a L IJ placed; removed. PICC line placed on [**3-29**] Medications on Admission: Omeprazole 20mg daily Senna 2 TAB PO HS Insulin SC Sliding Scale & Fixed Dose Acetaminophen 325-650 mg PO Q4H:PRN pain or fever > 101 Simvastatin 10 mg PO DAILY Gabapentin 1200mg TID Docusate Sodium 100 mg PO BID Calcium 600mg +D3 [**Hospital1 **] PredniSONE 10 mg PO DAILY Citalopram Hydrobromide 20 mg PO DAILY Nortriptyline 25 mg PO HS Zinc Sulfate 220 mg PO DAILY Ascorbic Acid 500 mg PO BID Ferrous Sulfate 325 mg PO DAILY Doxycycline 100mg [**Hospital1 **] (started [**3-26**]) MS [**First Name (Titles) **] [**Last Name (Titles) **] 30mg Q8H Percocet 1-2 tabs q4 hours prn breakthrough pain Discharge Medications: 1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Calcium Carbonate 500 mg/5 mL (1,250 mg/5 mL) Suspension Sig: Two (2) PO BID (2 times a day). 14. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q8H (every 8 hours). 15. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO TID (3 times a day). 16. Zosyn 4.5 gram Recon Soln Sig: One (1) Intravenous every eight (8) hours for 12 days. 17. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18) Units Subcutaneous at bedtime. 18. Insulin Aspart 100 unit/mL Solution Sig: One (1) Subcutaneous QIDACHS: per sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare-[**Location (un) 86**] Discharge Diagnosis: urosepsis Discharge Condition: good. Discharge Instructions: You were admitted to the hospital with a malfunction of your suprapubic catheter and with infection. You had a revision of your suprapubic catheter and had a nephrostomy tube placed with good effect. You will need to complete a 14-day course of antibiotics. If you have fevers, chills, decreased output from your urostomy tube, or any other worrisome symptoms, then please seek medical attention. Followup Instructions: with your PCP at the nursing home. With your rheumatologist in the next month Provider: [**Name10 (NameIs) **] UNIT Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2126-5-8**] 10:00

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icd9cm

[ [ [] ] ]

[ "55.03", "38.93" ]

icd9pcs

[ [ [] ] ]

9214, 9290

5114, 7034

331, 381

9344, 9352

3430, 5091

9800, 9986

2822, 2840

7682, 9191

9311, 9323

7060, 7659

9376, 9777

2855, 3411

276, 293

409, 2023

2045, 2501

2517, 2806

5,680

164,173

46266+58890

Discharge summary

report+addendum

Admission Date: [**2142-5-6**] Discharge Date: Service: MED This is a partial discharge summary of the Intensive Care Unit hospital course. CHIEF COMPLAINT: GI bleed. HISTORY OF PRESENT ILLNESS: This is an 81-year-old female with history of diastolic congestive heart failure, hypertension, temporal arteritis, chronic renal insufficiency, and peripheral vascular disease, who presented with painless bright red blood per rectum. The patient stated that she woke up at 2 a.m. on the day of admission to go to the bathroom. After urinating she noted that the toilet bowl was filled with bright red blood with some blood clots. The patient's niece brought her to the Emergency Department. She denied any abdominal pain, nausea, vomiting, fevers, chills, chest pain, dizziness, palpitations, or lightheadedness. She has never had bright red blood per rectum before. She has had a colonoscopy previously, which showed diverticulosis. She has no history of GI bleed. She has not had any weight loss, melena, change in bowel habits. PAST MEDICAL HISTORY: CHF with diastolic dysfunction with an ejection fraction of 70 percent in [**2139**]. Hypertension. Peripheral vascular disease, status post aortofemoral bypass. Temporal arteritis. Chronic renal insufficiency with baseline creatinine of 1.5 to 2.5. Hypothyroidism. Paroxysmal atrial fibrillation. Hypercholesterolemia. Diabetes mellitus type 2. Gastroesophageal reflux disease complicated by Barrett's esophagus. Gout. Macular degeneration. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg daily. 2. Protonix 40 mg daily. 3. Prednisone 5 mg daily. 4. Levoxyl 50 mcg daily. 5. Tramadol 50 mg p.o. q.4-6h. prn. 6. Dulcolax 10 mg daily. 7. Calcium acetate 667 mg t.i.d. 8. Epogen 10,000 units q week. 9. Tylenol number 3 1-2 tablets p.o. q.6h. prn. 10. Hydralazine 25 mg p.o. q6. 11. Calcitriol 0.25 q.d. 12. Toprol XL 150 mg daily. 13. Gabapentin 300 mg p.o. q.h.s. 14. Insulin 70/30 26 units q.a.m. 15. NPH insulin 4 units q.p.m. 16. Zestril 10 mg daily. 17. Lasix 40 mg p.o. q.a.m. SOCIAL HISTORY: She quit smoking tobacco 10 years ago. She has a 40 pack year history of smoking. She rarely drinks alcohol. No history of IV drug use. She lives at home alone. INITIAL EXAM IN THE EMERGENCY DEPARTMENT: Temperature 97.9, heart rate 72, blood pressure 180/54, respiratory rate 16, and oxygen saturation 96 percent on room air. General: Elderly female lying in bed in no acute distress. HEENT: Extraocular muscles are intact. Pupils are equal, round, and reactive to light. No JVD, moist mucosal membranes. Cardiovascular examination: Regular, rate, and rhythm, normal S1, S2, 3/6 systolic ejection murmur radiating to the carotids. Lungs: Bibasilar crackles. Abdomen is soft, nontender, nondistended, positive bowel sounds. No external hemorrhoids. Extremities: Warm, 1plus lower extremity pitting edema, chronic venous stasis changes with mild erythema over both anterior shins. Neurologic examination: Alert and oriented times three. Cranial nerves II through XII are intact bilaterally. INITIAL LABORATORY DATA: White blood cell count 11.1, hematocrit 39.4, platelets 390. Sodium 141, potassium 4.6, BUN 60, creatinine 1.7, INR 1.0. PTT 24.5. Chest x-ray showed no pneumonia, congestive heart failure, mild cardiomegaly with a left ventricular configuration. HOSPITAL COURSE: Atrial fibrillation with rapid ventricular response. In the Emergency Department the patient developed atrial fibrillation with rapid ventricular response resulting in hypotension with systolic blood pressures in the 80s and 90s. The patient was symptomatic with lightheadedness and dizziness. Attempts were made to slow her rate with IV Lopressor, so when her rate did not respond, electrical cardioversion was attempted with 200, 300, and then 360 joules without success. Her rate was eventually slowed to the 110-120 range with IV Lopressor. Upon transfer to the Intensive Care Unit, the patient again developed rapid atrial fibrillation with heart rate in the 130s to 140s. She was given 15 mg of IV diltiazem, which showed her rate into the 60s and 70s, and converted her into normal sinus rhythm. The patient was continued on her outpatient dose of Lopressor dosed 3x a day with 50 mg/dose, and she remained well rate controlled throughout the remainder of her ICU stay. As at the time of transfer to the medical floor, she had been in normal sinus rhythm for approximately 24 hours. The patient was not anticoagulated given her recent GI bleed. In addition, the patient has reportedly refused anticoagulation in the past as an outpatient for her paroxysmal atrial fibrillation. As in the time of discharge to the medical floor, the patient was restarted on 81 mg of aspirin daily to decrease her risk of stroke. Bright red blood per rectum. During her Emergency Department stay, the patient had another witnessed episode of bright red blood per rectum that was again painless. The patient's hematocrit dropped from 39 to 31, and she had no further episodes of bright red blood per rectum throughout the remainder of her Intensive Care Unit stay. Given the presentation of the patient's bleeding, the etiology of her bright red blood per rectum was felt to be due to diverticulosis, versus AVM, versus malignancy. The patient was seen by Gastroenterology, and underwent a colonoscopy, which revealed diverticular disease and one nonbleeding arteriovenous malformation, which was cauterized. There was no obvious site to explain the patient's bright red blood per rectum, however, it is felt that her bleeding episode was most consistent with a diverticular bleed. Anemia. The patient has a baseline anemia with a hematocrit that had been around 30 for the past several months. This is presumably secondary to her renal disease as she is on Epogen as an outpatient. Her colonoscopy was negative for any malignancy, however, given her history of Barrett's esophagus, she should have an outpatient EGD as surveillance for esophageal malignancy. She was continued on her PPI during this admission. Diastolic dysfunction. The patient has a history of congestive heart failure with an ejection fraction of 70 percent and mild pulmonary artery systolic hypertension. The patient's Lasix was initially held during her fluid resuscitation, however, on the day of transfer from the ICU to the medical floor, the patient was clinically fluid overloaded, and was given a dose of 40 mg of IV Lasix. She was also restarted on her outpatient cardiac medications and diuretic. Temporal arteritis. The patient was asymptomatic and was continued on her suppressive dose of prednisone 5 mg daily. Hypertension. The patient was mildly hypertensive during her ICU stay with blood pressures in the 140s-170s as her antihypertensives were held during fluid resuscitation. At the time of her transfer out of the Intensive Care Unit, she was restarted on her lisinopril and hydralazine. Hypothyroidism. The patient has a history of hypothyroidism and was admitted on 50 mcg of Levoxyl daily. The patient's TSH was slightly elevated at 8, however, given her atrial fibrillation with rapid ventricular response, this dose was not increased. It is also felt that this elevation may have been due to stress given her GI bleeding and rapid Afib. The patient's TSH should be checked as an outpatient 4-6 weeks after discharge as her dose of Levoxyl may need to be increased. Code status. The patient's code status is do not resuscitate/do not intubate. The remainder of this discharge summary will be dictated by the intern on the medicine floor. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 18138**] Dictated By:[**Last Name (NamePattern1) 18139**] MEDQUIST36 D: [**2142-5-10**] 13:56:21 T: [**2142-5-10**] 14:25:10 Job#: [**Job Number **] Name: [**Known lastname 15687**],[**Known firstname 2219**] Unit No: [**Numeric Identifier 15688**] Admission Date: [**2142-5-7**] Discharge Date: [**2142-5-11**] Date of Birth: [**2061-1-31**] Sex: F Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4656**] Chief Complaint: GIB Major Surgical or Invasive Procedure: electrical cardioversion for afib with fast ventricular response colonoscopy with arteriovenous malformation cauterized History of Present Illness: please refer to previous d/c summary Past Medical History: please refer to previous d/c summary Social History: please refer to previous d/c summary Family History: please refer to previous d/c summary Physical Exam: please refer to previous d/c summary Pertinent Results: please refer to previous d/c summary Brief Hospital Course: please refer to previous d/c summary, pt remain stable, walked with PT, ambulating well, no further bleeding episodes, HCT stable at discharge. Pt d/cd on [**5-11**]. Medications on Admission: please refer to previous d/c summary Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 2. Calcium Acetate (Phos Binder) 667 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Tablet(s)* Refills:*2* 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:*30 Capsule(s)* Refills:*2* 4. 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* 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (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). Disp:*60 Capsule(s)* Refills:*2* 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Hydralazine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:*120 Tablet(s)* Refills:*2* 9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 10. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 11. Furosemide 80 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 12. Insulin NPH-Regular Human Rec 70-30 unit/mL Syringe Sig: Twenty Six (26) U Subcutaneous qam. Disp:*30 prefilled syringe* Refills:*2* 13. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO once a day. Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2* 14. Insulin NPH/Reg 70-30 InnoLet 70-30 unit/mL Syringe Sig: Four (4) U Subcutaneous qpm. Disp:*30 prefilled syringe* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 42**] VNA Discharge Diagnosis: 1. CHF: Diastolic dysfunction, 2. Diabetes mellitus type 2 on insulin. 3. Hypertension 4. PAD, status post A-fem bypass in [**2134**]. 5. Bilateral double renal arteries with left renal artery stenosis. 6. Hypothyroidism. 7. Paroxysmal atrial fibrillation. 8. Status post cholecystectomy in [**2140-10-30**]. 9. Temporal arteritis. 10.Hypercholesterolemia. 11.GERD. 12.Barrett's esophagus. 13.Chronic renal insufficiency with a baseline creatinine of 1.5-2.5. 14.Macular degeneration. 15.Gout. 16. GIB due to AVM Discharge Condition: stable Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 233**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Please call your doctor or go to ED if has more episodes of bleeding per rectum, or any other concerning symptoms. Please take all your medication as directed. We have increased your thyroid dosage from 50 to 75mcg. Followup Instructions: Please call Dr. [**Last Name (STitle) **] for appt in 1wk. Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 282**] SURGERY Where: [**Last Name (NamePattern4) 282**] SURGERY Date/Time:[**2142-5-15**] 1:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4877**], MD Where: [**Hospital6 189**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 1849**] Date/Time:[**2142-7-9**] 2:20 [**First Name11 (Name Pattern1) 46**] [**Last Name (NamePattern4) 4657**] MD [**MD Number(1) 4346**] Completed by:[**2142-5-11**]

[ "446.5", "428.33", "562.12", "272.0", "427.31", "274.9", "428.0", "593.9", "569.84" ]

icd9cm

[ [ [] ] ]

[ "99.61", "45.23", "45.43" ]

icd9pcs

[ [ [] ] ]

10957, 11014

8918, 9086

8429, 8551

11570, 11578

8857, 8895

11942, 12578

8747, 8785

9173, 10934

11035, 11549

9112, 9150

3467, 8369

11602, 11919

8800, 8838

8386, 8391

8579, 8617

3084, 3449

8639, 8677

8693, 8731

18,225

133,745

29666

Discharge summary

report

Admission Date: [**2167-1-22**] Discharge Date: [**2167-2-10**] Date of Birth: [**2085-11-30**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Codeine / Ativan Attending:[**First Name3 (LF) 398**] Chief Complaint: Cardiopulmonary arrest Major Surgical or Invasive Procedure: Tracheostomy and G-tube on [**2167-2-5**] L PICC on [**2167-1-27**] History of Present Illness: This is an 81 y/o female with history of obesity, HTN, IDDM, who presented to the ED with cardiac arrest after having a witnessed collapse earlier today. Per daughter, patient was doing well at her baseline until yesterday night, when patient was in the bathroom to take her insulin. Her daughter went into the bathroom to administer the insulin when all of a sudden the patient fell backwards and collapsed (she was sitting on the toilet). EMS was activated, who upon arrival found the patient to be asystolic. CPR was initiated and recheck of the rhythm revealed bradycardia and hypotension. She was intubated in the field and brought to the ED at [**Hospital1 18**]. . On arrival to the ED here, SBP's were in the 60's and pulses were thready. Initial vent settings were AC 400x16, FiO2 100%, PEEP 5 with ABG of 7.17/99/85/38. She received 3 L NS in the ED. Dopamine gtt was started with response to SBP's in the 110's, dopamine was attempted to be weaned off, however pt's BP fell off dopamine so it was restarted. A right femoral CVL was placed. Pt was given 2 gm of CTX and 500 mg of Azithromycin for consolidation seen in LUL. CXR also demonstrated a low ETT, which was pulled back appropriately. CTA negative for PE. CT torso significant for LUL consolidation only. CT spine clear. . Per family, the pt had GI symptoms of primarily diarrhea last week, without any fevers, abd pain, n/v. This had resolved, but for the last two days, the pt had been complaining of SOB, primarily difficulty breathing when laying down (+orthopnea, +PND). No chest pain, LH/dizziness, diaphoresis. No prior h/o lung disease or cardiac history. Has not had these symptoms previously. Past Medical History: 1. HTN 2. DM - on insulin 3. Lymphoma, s/p chemotherapy several years ago and s/p XRT [**11-12**] (unclear where radiation was targeted to) - followed at [**Hospital1 2025**]\ 4. Glaucoma 5. Cataracts, baseline anisocoria (R pupil<L pupil) Social History: Lives at home with her daughter, at baseline very active. No tobacoo/EtOH/illicits. Receives medical care primarily from B&W and [**Hospital1 2025**]. Family History: non-contributory Physical Exam: Admission VS: Tc 99.7, BP 101/57, HR 76, RR 28, SaO2 100% on AC 400 x 28, FiO2 50%, PEEP 10 General: Intubated, withdraws to painful stimuli, ETT in place HEENT: NC/AT, right pupil pinpoint, left pupil 3 mm, both non-reactive to light. Dried blood in mouth and on tongue. ETT in place. Neck: supple, unable to determine JVD given thickness of neck Chest: decreased BS over bases b/l, coarse rhonchi b/l CV: RRR, s1 s2 normal, no m/g/r Abd: obese, NT, NABS Ext: trace edema b/l, warm extremities Neuro: Sedated, withdraws to pain but not arousable to voice. Does not follow commands. Anisocoria of pupils (?new) with no reactivity. +extensor responses b/l. Moving all four extremities. Pertinent Results: Admission Laboratories: [**2167-1-21**] 08:05PM BLOOD WBC-12.0* RBC-4.78 Hgb-14.0 Hct-43.9 MCV-92 MCH-29.3 MCHC-32.0 RDW-14.4 Plt Ct-282 [**2167-1-22**] 02:17AM BLOOD Neuts-91.0* Lymphs-4.8* Monos-3.9 Eos-0.1 Baso-0.2 . [**2167-1-22**] 02:17AM BLOOD Glucose-284* UreaN-39* Creat-1.1 Na-140 K-4.2 Cl-96 HCO3-34* AnGap-14 [**2167-1-22**] 02:17AM BLOOD Albumin-3.9 Calcium-8.2* Phos-3.0 Mg-2.3 [**2167-1-22**] 02:17AM BLOOD ALT-68* AST-47* LD(LDH)-344* CK(CPK)-358* AlkPhos-124* Amylase-59 TotBili-0.4 . [**2167-1-21**] 08:05PM BLOOD PT-12.9 PTT-24.7 INR(PT)-1.1 . Discharge Laboratories: [**2167-2-6**] 01:50AM BLOOD WBC-10.7 RBC-3.46* Hgb-9.7* Hct-30.1* MCV-87 MCH-28.0 MCHC-32.2 RDW-14.7 Plt Ct-253 . [**2167-2-6**] 01:50AM BLOOD Glucose-99 UreaN-15 Creat-0.6 Na-141 K-4.2 Cl-105 HCO3-30 AnGap-10 [**2167-2-6**] 01:50AM BLOOD Calcium-8.4 Phos-3.6 Mg-2.1 . [**2167-2-6**] 01:50AM BLOOD PT-14.1* PTT-26.1 INR(PT)-1.3* . [**2167-2-5**] 09:05PM BLOOD Type-ART Temp-37.7 Rates-12/ Tidal V-400 PEEP-8 FiO2-50 pO2-112* pCO2-46* pH-7.45 calTCO2-33* Base XS-6 -ASSIST/CON Intubat-INTUBATED . CT Torso ([**2167-1-21**]) 1. Traumatic stranding anterior to thyroid. No fractures. 2. Extremely limited examination due to habitus and patient positioning. No central pulmonary embolism or definite aortic dissection. 3. Left lobe consolidations suggestive of aspiration. Right large pleural effusion and associated atelectasis. 4. Small amount of free fluid around the gallbladder, liver, and in the pancreas, likely from fluid overload. 5. 4.7 cm exophytic round lesion adjacent to the left aspect of the lower uterine segment ? cervical fibroid. Followup imaging/ultrasound recommended when the patient is more stable. 6. Gallstones. 7. Left adrenal indeterminate lesion, 2 cm. This can be further evaluated with dedicated adrenal CT scan with washout study 8. Left kidney indeterminate lesion, 2.2 cm, which can also be evaluated at time of adrenal CT. . TTE ([**2167-1-22**]) The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF 70%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Tricuspid regurgitation is present but cannot be quantified. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . Chest ([**2167-2-6**]) Comparison with [**2-5**] at 14:12 hours. The tracheostomy tube terminates 6 cm above the carina. Again there is a suggestion of lucency within the right paratracheal region, which may represent a small amount of air within the mediastinum. The mediastinum remains widened. There is no pneumothorax. The left PICC line projects over the junction of the brachiocephalic veins. There is a stable small right pleural effusion, and mild pulmonary edema. The cardiac contour is stable. Clinical correlation regarding the widened mediastinum is recommended, and a CT could be performed if clinically indicated. Brief Hospital Course: # Cardiopulmonary arrest - EMS notes indicated that the patient was found with agonal breathing, but initially in sinus bradycardia at a rate of @ 34 with a palpable pulse. An oral airway was placed and she was ventilated. However, she subsequently lost her pulse, and CPR was initiated. The etiology of her cardiopulmonary arrest was unclear. [**Name2 (NI) 227**] her infiltrate by chest X-ray, as well as the reports by EMS, a primary respiratory event is likely. A primary cardiac event was felt unlikely. There was no evidence of ischemia by cardiac biomarkers. There was no evidence of pulmonary embolus by CT angiography. Blood glucose was 211 in field. There was no evidence of adrenal insufficiency by cosyntropin stimulation testing. The patient had no further episodes of arrest during the admission. . # Respiratory failure - Patient was intubated during her cardiopulmonary arrest. She received a of 7 day course of vancomycin, cefepime, and flagyl for a left upper lobe infiltrate on chest X-ray. After a prolonged intubation, she remained difficult to wean from mechanical ventilation. Her rapid shallow breathing indexes remained between 250-300. Although she was not previously known to have lung disease, she had evidence of chronic CO2 retention. She had previously received radiation to the chest for lympthoma. A bronchoscopoy during this admission demonstrated tracheomalacia. Decision was made to pursue tracheostomy. This was initially planned by the interventional pulmonary service, but was ultimately performed by surgery on [**2167-2-6**] due to her body habitus. She was discharged to an acute care facility for weaning from mechanical ventilation. . # Atrial tachycardia - Patient was noted to have paroxysms of atrial tachycardia during this hospitalization. Her rate averaged in the 130s during these episodes. She tolerated the tachycardia with stable blood pressures. She was initially started on metoprolol 75 TID. Given her respiratory status, diltiazem was started with the goal of weaning down her metoprolol. She was discharged with plans to complete this transition at her acute care facility. . # Alkalosis - She was noted to have a transient alkalosis in the setting of lasix diuresis. This improved after cessation of diuresis. . # Elevated transaminases - She had a mild elevation in her transaminases on admission, felt likely to reflect hepatic ischemia in setting of hypotension during her cardiopulmonary arrest. . # Glaucoma - she was continued on her home regimen of eye drops. . # Diabetes - she was initially on subcutaneous insulin. However, she was placed on an insulin drip for tighter glucose control during her tracheostomy and gastric tube placement. She was transitioned back to subcutaneous insulin prior to discharge, with instructions to follow her blood glucose closely, and titrate her insulin regimen as needed. . # F/E/N - She received tubefeeds as Promote, 60cc/hr. This was initially provided via an OG tube, but transitioned to her G-tube prior to discharge. . # Prophylaxis - She received subcutaneous heparin for DVT prophylaxis and an H2 antagonist for GI prophylaxis. She was also maintained on aspiration precautions. . # Access - A left-sided PICC was placed by interventional radiology on [**2167-1-27**]. . # Code - FULL (confirmed with daughter, HCP) . # Communication - with daughter [**Name (NI) **] Medications on Admission: 1. Lisinopril 40 2. Glyburide 10 [**Hospital1 **] 3. Lasix 40 4. Nifedipine XL 90 5. Atenolol 50 6. Humulin 60 units qAM, 40 units qPM (uncertain of doses) 7. Lipitor 10 8. Multiple eye gtt 9. Ambien 5 hs 10. Remeron 15 daily Discharge Medications: 1. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical QID (4 times a day) as needed. 2. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: 4-6 Puffs Inhalation Q6H (every 6 hours). 3. Brimonidine 0.15 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 4. Nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO QID (4 times a day) as needed. 5. Olanzapine 2.5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times a day) as needed for agitation. 6. Trazodone 50 mg Tablet [**Hospital1 **]: 0.5 Tablet PO HS (at bedtime) as needed. 7. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: 5000 (5000) U Injection TID (3 times a day). 8. Dorzolamide-Timolol 2-0.5 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 9. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One Hundred (100) mg PO BID (2 times a day). 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 12. Diltiazem HCl 90 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4 times a day). 13. Insulin NPH Human Recomb 100 unit/mL Cartridge [**Last Name (STitle) **]: Twenty Two (22) units Subcutaneous twice a day: please give qAM and qhs. 14. Insulin Lispro (Human) 100 unit/mL Cartridge [**Last Name (STitle) **]: AS DIRECTED Subcutaneous QACHS: Sliding scale, fingersticks: 0-60 1 amp D50 61-150 0 units 151-200 2 untis 201-250 4 units 251-300 6 units 301-350 8 units 351-400 10 units > 400 contact MD. Discharge Disposition: Extended Care Facility: [**Hospital1 **]- [**Location (un) 86**] Discharge Diagnosis: s/p asystolic cardiac arrest Respiratory failure s/p tracheostomy and G-tube placement Pneumonia Atrial tachycardia Discharge Condition: good, stable on ventilator Discharge Instructions: Please take all of your medications as prescribed. Please attend all of your follow up appointments. . If you experience shortness of breath, chest pain, fever >101, or other concerning symptoms, please call your doctor or go to the ER. Followup Instructions: You will be transferred to a facility which will manage your ventilator. You should follow-up with your primary care physician: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2167-2-26**] at 11:15 AM. His phone number is [**Telephone/Fax (1) 18745**]. Completed by:[**2167-2-9**]

[ "428.0", "V10.79", "518.84", "V15.3", "785.51", "486", "211.1", "427.0", "519.19", "250.00", "276.3", "V58.67", "401.9", "348.1", "278.00", "365.9" ]

icd9cm

[ [ [] ] ]

[ "43.41", "43.11", "33.22", "31.1", "96.72", "96.6", "38.93" ]

icd9pcs

[ [ [] ] ]

11963, 12030

6532, 9912

323, 392

12190, 12219

3278, 6509

12505, 12817

2540, 2558

10188, 11940

12051, 12169

9938, 10165

12243, 12482

2573, 3259

261, 285

420, 2093

2115, 2356

2372, 2524

65,021

141,340

13228

Discharge summary

report

Admission Date: [**2178-5-13**] Discharge Date: [**2178-5-18**] Date of Birth: [**2110-7-7**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: Redo sternotomy, Coronary Artery Bypass Graft x 5 (LIMA>LAD, SVG>OM1>diag, SVG>OM2, SVG>PDA) [**5-14**] History of Present Illness: Mr. [**Name13 (STitle) **] is a 67 year old male with progressive dyspnea on exertion since [**Month (only) 404**] with intermittent chest pain. Transferred from outside hospital after undergoing cardiac cath which revealed severe 3 vessel coronary disease. Past Medical History: Hypertension Perpheral vascular disease Benign Prostatic Hypertrophy Arthritis s/p hernia repair s/p multi trauma (man v trolley) 26 yrs ago with median sternotomy s/p multiple shoulder surgeries s/p subclavian artery clot removal s/p bilateral knee pain chronic back pain Social History: Retired from [**Company 2318**] since trauma. Stopped smoking 21 yrs ago after 2-3ppd x 30yrs. Admits to rare alcohol use. Family History: Mother with MI at age 43 but died at age 79. Physical Exam: Vitals: 58 20 160/89 5'9" 220lbs General: No acute distress Skin: Healed sternotomy incision with multiple areas on calves that appeared to be well-healed HEENT: Unremarkable Neck: Supple, thick neck with full range of motion Chest: Clear to auscultation bilaterally but distant Heart: Regular rate and rhythm without murmurs Abd: Soft, non-tender, non-distended, +bowel sounds Ext: Warm, well-perfused, -edema, multiple large varicosities on legs Neuro: Grossly [**Company 5235**], alert and oriented x 3 Pertinent Results: [**2178-5-14**] Echo: Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is mildly depressed (LVEF= 45 - 50 %). with normal free wall contractility. There are simple atheroma in the descending thoracic [**Month/Day/Year 5236**]. The aortic valve leaflets are mildly thickened . No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Torn mitral chordae are present, and seem to be on both the anterior and posterior leaflets. No mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: Patient is AV-paced, on no infusions. Preserved biventricular systolic fxn. No AI, no MR. [**First Name (Titles) **] [**Last Name (Titles) 5235**]. [**2178-5-13**] 08:10PM BLOOD WBC-9.8 RBC-4.15* Hgb-12.4* Hct-35.8* MCV-86 MCH-29.8 MCHC-34.6 RDW-14.1 Plt Ct-283 [**2178-5-18**] 05:15AM BLOOD WBC-9.6 RBC-2.81* Hgb-8.4* Hct-24.8* MCV-88 MCH-30.0 MCHC-34.0 RDW-14.0 Plt Ct-317 [**2178-5-13**] 08:10PM BLOOD PT-13.9* PTT-26.1 INR(PT)-1.2* [**2178-5-18**] 05:15AM BLOOD PT-14.6* INR(PT)-1.3* [**2178-5-13**] 08:10PM BLOOD Glucose-138* UreaN-13 Creat-0.8 Na-138 K-4.2 Cl-106 HCO3-23 AnGap-13 [**2178-5-18**] 05:15AM BLOOD Glucose-97 UreaN-15 Creat-0.8 Na-138 K-4.2 Cl-103 HCO3-29 AnGap-10 [**2178-5-18**] 05:15AM BLOOD ALT-27 AST-31 LD(LDH)-301* AlkPhos-72 TotBili-0.7 [**2178-5-18**] 05:15AM BLOOD Albumin-3.2* Mg-2.5 Brief Hospital Course: As mentioned in the HPI, Mr. [**Known lastname **] was transferred from an outside hospital after cardiac cath revealed three vessel and left main disease. Upon admission he was medically managed and underwent pre-operative work-up. He was brought to the operating room on [**5-14**] where he received a coronary artery bypass graft x 5. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically [**Month/Day (2) 5235**] and extubated. On post-op day one he was transferred to the telemetry floor for further care. Chest tubes and epicardial pacing wires were removed per protocol. On post-op day two he had an episode of rapid atrial fibrillation and responded well to beta blockers. He remained in sinus rhythm for the rest of his hospital course and recovered well while working with physical therapy. He was discharged home on post-op day six with the appropriate medications and follow-up appointments. Medications on Admission: Meds at home: Propanolol 160mg daily, Lipitor 10mg daily, Tramadol 1-2 tabs every 6hrs, HCTZ 25mg daily, Gabapentin 400mg daily, Ketoprofen 50mg q6hrs, Tizandine 8mg daily, Cyclobenzaprine 10mg [**Hospital1 **] PRN, Pantoprazole 40mg daily Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: Coronary Artery Disease status post redo sternotomy, Coronary Artery Bypass Graft x 5 Hypertension Perpheral vascular disease Benign Prostatic Hypertrophy Arthritis s/p hernia repair s/p multi trauma (man v trolley) 26 yrs ago with median sternotomy s/p multiple shoulder surgeries s/p subclavian artery clot removal chronic back pain 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 No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse ([**Telephone/Fax (1) 3071**]) Sternal Precautions No lifting greater than 10 pounds for 10 weeks No driving for 1 month and off narcotics Cardipulmonary Assessment Wound Care Medication Compliance Follow up appointment compliance Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) Dr. [**Last Name (STitle) 8579**] (cardiologist)in 1 week Dr. [**Last Name (STitle) 40075**] (primary care)in [**3-17**] weeks Please call for appointments Completed by:[**2178-5-18**]

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icd9cm

[ [ [] ] ]

[ "39.61", "36.15", "36.14" ]

icd9pcs

[ [ [] ] ]

4563, 4626

3211, 4273

340, 445

5004, 5010

1771, 3188

5860, 6119

1184, 1230

4647, 4983

4299, 4540

5034, 5837

1245, 1752

281, 302

473, 732

754, 1028

1044, 1168

9,266

173,215

8680+8681

Discharge summary

report+report

Admission Date: [**2182-2-11**] Discharge Date: [**2182-2-21**] Date of Birth: [**2113-2-28**] Sex: M Service: [**Location (un) **] HISTORY OF PRESENT ILLNESS: The patient is a 68 year old male with a history of coronary artery disease, peripheral vascular disease, diabetes mellitus, end-stage renal disease and chronic atrial fibrillation who presented with a fall, contusion and fever. His history per [**Hospital 228**] health care proxy, [**Name (NI) 7019**] [**Name (NI) 30420**]. The patient had an unwitnessed fall heard by Mrs. [**Last Name (STitle) 30420**] on [**2-9**], and was found on the floor alert, but mildly confused. The patient states that his confusion did not last very long. He is generally without complaints of pain but was noted to have poor p.o. intake. Today, he had a second unwitnessed but overheard fall, was alert but confused and complained of pain in his right hand. The patient remained confused for hours and was thus brought to the Emergency Department. In the Emergency Department, the patient was noted to be febrile to 100.7 F.; he complains of increasing right hand pain. The patient has a small amount of pus at the bottom of his graft that was sent for a culture. PAST MEDICAL HISTORY: 1. Diabetes mellitus. 2. End-stage renal disease on hemodialysis. 3. Coronary artery disease status post coronary artery bypass graft in [**2164**]; status post myocardial infarction in [**2173**] and [**2180**]. 4. Congestive heart failure with a ejection fraction of 20%. 5. Atrial fibrillation. 6. Anemia. 7. Peripheral vascular disease. 8. Status post cerebrovascular accident. 9. Questionable protein S deficiency. ALLERGIES: Doxycycline. MEDICATIONS: 1. Enteric coated aspirin 325 q. day. 2. Lisinopril 5 q. day. 3. Imdur ER, 30 q. day. 4. Lopressor 100 twice a day. 5. Amiodarone 200 q. day. 6. Protonix 40 q. day. 7. Oxycodone SR 20 twice a day. 8. Digoxin 0.125 q. day. 9. Insulin subcutaneously NPH p.r.n. glucose greater than 200. SOCIAL HISTORY: All that could be obtained was that alcohol p.r.n. and [**First Name8 (NamePattern2) 7019**] [**Last Name (NamePattern1) 30420**] is the [**Hospital 228**] health care proxy. PHYSICAL EXAMINATION: On admission, temperature was 100.7 F.; heart rate 85, ranging 82 to 95; blood pressure was 106/37; respiratory rate 18; 96 to 99% on two liters. In general, the patient was oriented to [**Hospital1 **] and was in moderate distress. Could not follow commands regularly. HEENT was dry mucous membranes. Pupils equal, round and reactive to light. Neck supple. Chest: Coarse breath sounds bilaterally. Cardiovascular is regular rate with no murmurs. Abdomen soft, nontender, nondistended. Extremities with left graft with no bruits, no pulse in graft. Left hand is red, tender, with sensation intact. Right radial pulse is palpable. LABORATORY: Pertinent labs on admission were lactate of 2.1. CBC with white blood cell count 16.4 with 87% neutrophils, zero percent bands. Left hand x-ray showed no osteo, no fractures. Chest x-ray was positive for congestive heart failure and a retrocardiac opacity. Graft ultrasound showed no fluid pockets, no flow, noncompressible. SUMMARY OF HOSPITALIZATION COURSE: 1. INFECTIOUS DISEASE: The patient had sepsis secondary to an infected AV graft. The patient's AV graft was removed on [**2182-2-11**], and the patient was found to have both a clot and an infection at the AV graft site. This infection later turned out to be Methicillin sensitive Staphylococcus aureus. The patient was sent to the Medical Intensive Care Unit after graft removal because of rising oxygen requirements. Additionally, the patient's left hand film on [**2-11**] was negative for a fracture or osteomyelitis. The patient had an MRI of his hand which was also negative for osteomyelitis but positive for cellulitis and a nonspecific fluid collection over the first and second digits. The patient's OR graft tissue and blood cultures last on [**2-10**], were both showing Methicillin sensitive Staphylococcus aureus. The patient was originally treated with Vancomycin, however, when sensitivities came back, the patient was switched to Oxicillin 2 grams intravenously q. six. On the 16th, the decision was made to push Cefazolin one gram q. Hemodialysis, because there were no sites left for a PICC line and if a PICC line were placed, it would destroy the only AV graft site available. The patient had a transesophageal echocardiogram which was negative for any vegetations during this hospitalization. The patient also had an MRI of his left shoulder which was negative for any osteomyelitis, however, imaging showed two peripheral lung nodules which led to a chest CT scan which showed multiple peripheral ill defined cavitary lesions concerning for septic emboli. The appropriate Infectious Disease regimen will be Cefazolin one gram intravenous q. Hemodialysis for a total of four weeks until [**2-/2108**]. Infectious Disease signed off and stated that no Infectious Disease follow-up is needed at this point in time. 2. END-STAGE RENAL DISEASE ON HEMODIALYSIS: The patient had his AV graft removed in the Operating Room on [**2-11**] secondary to infection and clot. Part of the AV graft remains in the patient's arm. A temporary femoral Quinton catheter was placed in the medical Intensive Care Unit and was later removed once a tunnel catheter was placed on [**2-18**]. The patient was to continue hemodialysis three times a week and continue calcium acetate. The Nephrology Service was following throughout this hospitalization. 3. GENERALIZED TONIC/CLONIC SEIZURES: The patient had one episode of a generalized tonic/clonic seizure in the setting of sepsis. Neurologic and Infectious Disease both stated that his lumbar puncture was not suspicious for a meningitis. A head CT scan was done with no acute lesion. EEG was non-specific. The patient was loaded with intravenous Dilantin in the Emergency Department and remained on Dilantin throughout the majority of his hospitalization; however, at the end of the hospitalization, the Dilantin was removed as Neurology recommended no need to continue Dilantin for seizures in the setting of sepsis. The patient should not be given any Ativan, Haldol and morphine given his renal failure and increasing sedation when any of these medications are given for his agitation. 4. CARDIOVASCULAR / CORONARY: The patient had coronary artery disease status post coronary artery bypass graft. He had a non-ST elevation myocardial infarction in the Medical Intensive Care Unit with peak CKs of 184 and troponin T 0.21. The patient was started on aspirin and once arriving to the floor was started on a beta blocker and ACE inhibitor. His blood pressure remained less than 130/80 on the floor. PUMP: The patient has an ejection fraction of 20%. An ACE inhibitor was started once the patient arrived on the floor. The patient was getting dialysis for weight control. The patient is to remain on two gram sodium diet. RHYTHM: The patient has a history of atrial fibrillation on Amiodarone. Per the patient's primary care physician the patient is not to be anti-coagulated due to the increased risk of bleeding and high risk of fall in this patient. VALVES: The patient's transesophageal echocardiogram was negative for any endocarditis. 5. INSULIN DEPENDENT DIABETES MELLITUS: The patient was continued on a regular insulin sliding scale with fingersticks consistently below 180. 6. PERIPHERAL VASCULAR DISEASE AND FOOT INFECTIONS: The patient had a necrotic appearing fourth toe during this hospitalization. Podiatry was following for this and stated that there was no need for surgery at this point in time. A foot x-ray was done which was questionable for osteomyelitis, however, the Podiatry staff felt that this was not osteomyelitis. Non-invasive imaging was performed to assess lower extremity vasculature which were normal. The patient is to have outpatient Podiatry follow-up in two weeks. 7. HEMATOLOGY: The patient, at one point in time, had increased INR to 4.0 of unclear etiology. The patient's DIC panel was negative. The patient was given 10 mg of vitamin K subcutaneously and the patient's INR decreased to 1.3. 8. DERMATOLOGY: The patient had multiple papule like lesions on his lower extremities. Dermatology was consulted and biopsied these lower extremity lesions which were eventually consistent with Kyrle's Disease. This disease is associated with end-stage renal disease. 9. FLUIDS, ELECTROLYTES AND NUTRITION: The patient had a video swallowoing study during this hospitalization, which showed minimal aspiration. Diet was recommended to be soft solids with pills given in applesauce. 10. CONTACT: The [**Hospital 228**] health care proxy was [**Name (NI) 7019**] [**Name (NI) 30420**]. 11. ELEVATED LIVER FUNCTION TESTS: The patient had a right upper quadrant tenderness on one day of his hospitalization with an elevated GGT of 179. A right upper quadrant ultrasound was done which was consistent with cholelithiasis but no cholecystitis. The patient's liver function tests trended down during this hospitalization and no further imaging was needed. CONDITION AT DISCHARGE: The patient's condition on discharge was stable on room air to an acute care facility. DISCHARGE STATUS: The patient will be discharged to an acute care facility. DISCHARGE DIAGNOSES: 1. Infected arteriovenous graft status post removal. 2. End-stage renal disease on hemodialysis. 3. Generalized tonic/clonic seizure in the setting of sepsis. 4. Congestive heart failure with an ejection fraction of 20%. 5. Coronary artery disease status post coronary artery bypass graft. 6. Chronic atrial fibrillation. 7. Kyrle's Disease. 8. Insulin dependent diabetes mellitus. 9. Atrial fibrillation. 10. Delirium. 11. Cellulitis. DISCHARGE MEDICATIONS: 1. Calcium acetate, three tablets p.o. three times a day with meals. 2. Docusate 100 mg p.o. twice a day. 3. Senna one tablet p.o. twice a day p.r.n. 4. Aspirin 325 mg p.o. q. day. 5. Amiodarone 200 mg p.o. q. day. 6. Digoxin 125 micrograms p.o. q. day. 7. Ipratropium one nebulizer q. six hours. 8. Albuterol one nebulizer q. six hours. 9. Metoprolol 25 mg p.o. twice a day. 10. Heparin 5000 units subcutaneously q. eight hours. 11. Captopril 12.5 mg p.o. three times a day. 12. Tylenol 325 mg one to two tablets p.o. q. four to six hours p.r.n. 13. Pantoprazole 40 mg p.o. q. day. 14. Sulfasolin 1 gram intravenously q. Hemodialysis to be continued until 02/30/[**2182**]. 15. Lidocaine patch to be applied to the left arm over 12 hours per day. DISCHARGE INSTRUCTIONS: 1. The patient is to follow-up with Dr. [**Last Name (STitle) 10869**] on [**2182-3-4**], who is his primary care physician. 2. The patient is to follow-up with Dr. [**Last Name (STitle) **] of Podiatry, [**2182-3-5**], at 09:00 a.m. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**] Dictated By: [**Name6 (MD) **] [**Name8 (MD) **], M.D. MEDQUIST36 D: [**2182-2-20**] 16:34 T: [**2182-2-20**] 17:39 JOB#: [**Job Number 30421**] Admission Date: [**2182-2-11**] Discharge Date: [**2182-2-21**] Date of Birth: [**2113-2-28**] Sex: M Service: [**Location (un) **] HISTORY OF PRESENT ILLNESS: The patient is a 68 year old male with a history of coronary artery disease, peripheral vascular disease, diabetes mellitus, end-stage renal disease and chronic atrial fibrillation who presented with a fall, contusion and fever. His history per [**Hospital 228**] health care proxy, [**Name (NI) 7019**] [**Name (NI) 30420**]. The patient had an unwitnessed fall heard by Mrs. [**Last Name (STitle) 30420**] on [**2-9**], and was found on the floor alert, but mildly confused. The patient states that his confusion did not last very long. He is generally without complaints of pain but was noted to have poor p.o. intake. Today, he had a second unwitnessed but overheard fall, was alert but confused and complained of pain in his right hand. The patient remained confused for hours and was thus brought to the Emergency Department. In the Emergency Department, the patient was noted to be febrile to 100.7 F.; he complains of increasing right hand pain. The patient has a small amount of pus at the bottom of his graft that was sent for a culture. PAST MEDICAL HISTORY: 1. Diabetes mellitus. 2. End-stage renal disease on hemodialysis. 3. Coronary artery disease status post coronary artery bypass graft in [**2164**]; status post myocardial infarction in [**2173**] and [**2180**]. 4. Congestive heart failure with a ejection fraction of 20%. 5. Atrial fibrillation. 6. Anemia. 7. Peripheral vascular disease. 8. Status post cerebrovascular accident. 9. Questionable protein S deficiency. ALLERGIES: Doxycycline. MEDICATIONS: 1. Enteric coated aspirin 325 q. day. 2. Lisinopril 5 q. day. 3. Imdur ER, 30 q. day. 4. Lopressor 100 twice a day. 5. Amiodarone 200 q. day. 6. Protonix 40 q. day. 7. Oxycodone SR 20 twice a day. 8. Digoxin 0.125 q. day. 9. Insulin subcutaneously NPH p.r.n. glucose greater than 200. SOCIAL HISTORY: All that could be obtained was that alcohol p.r.n. and [**First Name8 (NamePattern2) 7019**] [**Last Name (NamePattern1) 30420**] is the [**Hospital 228**] health care proxy. PHYSICAL EXAMINATION: On admission, temperature was 100.7 F.; heart rate 85, ranging 82 to 95; blood pressure was 106/37; respiratory rate 18; 96 to 99% on two liters. In general, the patient was oriented to [**Hospital1 **] and was in moderate distress. Could not follow commands regularly. HEENT was dry mucous membranes. Pupils equal, round and reactive to light. Neck supple. Chest: Coarse breath sounds bilaterally. Cardiovascular is regular rate with no murmurs. Abdomen soft, nontender, nondistended. Extremities with left graft with no bruits, no pulse in graft. Left hand is red, tender, with sensation intact. Right radial pulse is palpable. LABORATORY: Pertinent labs on admission were lactate of 2.1. CBC with white blood cell count 16.4 with 87% neutrophils, zero percent bands. Left hand x-ray showed no osteo, no fractures. Chest x-ray was positive for congestive heart failure and a retrocardiac opacity. Graft ultrasound showed no fluid pockets, no flow, noncompressible. SUMMARY OF HOSPITALIZATION COURSE: 1. INFECTIOUS DISEASE: The patient had sepsis secondary to an infected AV graft. The patient's AV graft was removed on [**2182-2-11**], and the patient was found to have both a clot and an infection at the AV graft site. This infection later turned out to be Methicillin sensitive Staphylococcus aureus. The patient was sent to the Medical Intensive Care Unit after graft removal because of rising oxygen requirements. Additionally, the patient's left hand film on [**2-11**] was negative for a fracture or osteomyelitis. The patient had an MRI of his hand which was also negative for osteomyelitis but positive for cellulitis and a nonspecific fluid collection over the first and second digits. The patient's OR graft tissue and blood cultures last on [**2-10**], were both showing Methicillin sensitive Staphylococcus aureus. The patient was originally treated with Vancomycin, however, when sensitivities came back, the patient was switched to Oxicillin 2 grams intravenously q. six. On the 16th, the decision was made to push Cefazolin one gram q. Hemodialysis, because there were no sites left for a PICC line and if a PICC line were placed, it would destroy the only AV graft site available. The patient had a transesophageal echocardiogram which was negative for any vegetations during this hospitalization. The patient also had an MRI of his left shoulder which was negative for any osteomyelitis, however, imaging showed two peripheral lung nodules which led to a chest CT scan which showed multiple peripheral ill defined cavitary lesions concerning for septic emboli. The appropriate Infectious Disease regimen will be Cefazolin one gram intravenous q. Hemodialysis for a total of four weeks until [**2-/2108**]. Infectious Disease signed off and stated that no Infectious Disease follow-up is needed at this point in time. 2. END-STAGE RENAL DISEASE ON HEMODIALYSIS: The patient had his AV graft removed in the Operating Room on [**2-11**] secondary to infection and clot. Part of the AV graft remains in the patient's arm. A temporary femoral Quinton catheter was placed in the medical Intensive Care Unit and was later removed once a tunnel catheter was placed on [**2-18**]. The patient was to continue hemodialysis three times a week and continue calcium acetate. The Nephrology Service was following throughout this hospitalization. 3. GENERALIZED TONIC/CLONIC SEIZURES: The patient had one episode of a generalized tonic/clonic seizure in the setting of sepsis. Neurologic and Infectious Disease both stated that his lumbar puncture was not suspicious for a meningitis. A head CT scan was done with no acute lesion. EEG was non-specific. The patient was loaded with intravenous Dilantin in the Emergency Department and remained on Dilantin throughout the majority of his hospitalization; however, at the end of the hospitalization, the Dilantin was removed as Neurology recommended no need to continue Dilantin for seizures in the setting of sepsis. The patient should not be given any Ativan, Haldol and morphine given his renal failure and increasing sedation when any of these medications are given for his agitation. 4. CARDIOVASCULAR / CORONARY: The patient had coronary artery disease status post coronary artery bypass graft. He had a non-ST elevation myocardial infarction in the Medical Intensive Care Unit with peak CKs of 184 and troponin T 0.21. The patient was started on aspirin and once arriving to the floor was started on a beta blocker and ACE inhibitor. His blood pressure remained less than 130/80 on the floor. PUMP: The patient has an ejection fraction of 20%. An ACE inhibitor was started once the patient arrived on the floor. The patient was getting dialysis for weight control. The patient is to remain on two gram sodium diet. RHYTHM: The patient has a history of atrial fibrillation on Amiodarone. Per the patient's primary care physician the patient is not to be anti-coagulated due to the increased risk of bleeding and high risk of fall in this patient. VALVES: The patient's transesophageal echocardiogram was negative for any endocarditis. 5. INSULIN DEPENDENT DIABETES MELLITUS: The patient was continued on a regular insulin sliding scale with fingersticks consistently below 180. 6. PERIPHERAL VASCULAR DISEASE AND FOOT INFECTIONS: The patient had a necrotic appearing fourth toe during this hospitalization. Podiatry was following for this and stated that there was no need for surgery at this point in time. A foot x-ray was done which was questionable for osteomyelitis, however, the Podiatry staff felt that this was not osteomyelitis. Non-invasive imaging was performed to assess lower extremity vasculature which were normal. The patient is to have outpatient Podiatry follow-up in two weeks. 7. HEMATOLOGY: The patient, at one point in time, had increased INR to 4.0 of unclear etiology. The patient's DIC panel was negative. The patient was given 10 mg of vitamin K subcutaneously and the patient's INR decreased to 1.3. 8. DERMATOLOGY: The patient had multiple papule like lesions on his lower extremities. Dermatology was consulted and biopsied these lower extremity lesions which were eventually consistent with Kyrle's Disease. This disease is associated with end-stage renal disease. 9. FLUIDS, ELECTROLYTES AND NUTRITION: The patient had a video swallowoing study during this hospitalization, which showed minimal aspiration. Diet was recommended to be soft solids with pills given in applesauce. 10. CONTACT: The [**Hospital 228**] health care proxy was [**Name (NI) 7019**] [**Name (NI) 30420**]. 11. ELEVATED LIVER FUNCTION TESTS: The patient had a right upper quadrant tenderness on one day of his hospitalization with an elevated GGT of 179. A right upper quadrant ultrasound was done which was consistent with cholelithiasis but no cholecystitis. The patient's liver function tests trended down during this hospitalization and no further imaging was needed. CONDITION AT DISCHARGE: The patient's condition on discharge was stable on room air to an acute care facility. DISCHARGE STATUS: The patient will be discharged to an acute care facility. DISCHARGE DIAGNOSES: 1. Infected arteriovenous graft status post removal. 2. End-stage renal disease on hemodialysis. 3. Generalized tonic/clonic seizure in the setting of sepsis. 4. Congestive heart failure with an ejection fraction of 20%. 5. Coronary artery disease status post coronary artery bypass graft. 6. Chronic atrial fibrillation. 7. Kyrle's Disease. 8. Insulin dependent diabetes mellitus. 9. Atrial fibrillation. 10. Delirium. 11. Cellulitis. DISCHARGE MEDICATIONS: 1. Calcium acetate, three tablets p.o. three times a day with meals. 2. Docusate 100 mg p.o. twice a day. 3. Senna one tablet p.o. twice a day p.r.n. 4. Aspirin 325 mg p.o. q. day. 5. Amiodarone 200 mg p.o. q. day. 6. Digoxin 125 micrograms p.o. q. day. 7. Ipratropium one nebulizer q. six hours. 8. Albuterol one nebulizer q. six hours. 9. Metoprolol 25 mg p.o. twice a day. 10. Heparin 5000 units subcutaneously q. eight hours. 11. Captopril 12.5 mg p.o. three times a day. 12. Tylenol 325 mg one to two tablets p.o. q. four to six hours p.r.n. 13. Pantoprazole 40 mg p.o. q. day. 14. Sulfasolin 1 gram intravenously q. Hemodialysis to be continued until 02/30/[**2182**]. 15. Lidocaine patch to be applied to the left arm over 12 hours per day. DISCHARGE INSTRUCTIONS: 1. The patient is to follow-up with Dr. [**Last Name (STitle) 10869**] on [**2182-3-4**], who is his primary care physician. 2. The patient is to follow-up with Dr. [**Last Name (STitle) **] of Podiatry, [**2182-3-5**], at 09:00 a.m. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**] Dictated By: [**Name6 (MD) **] [**Name8 (MD) **], M.D. MEDQUIST36 D: [**2182-2-20**] 16:34 T: [**2182-2-20**] 17:39 JOB#: [**Job Number 30422**]

[ "585", "250.41", "996.62", "410.71", "428.0", "996.73", "780.39", "038.11", "427.31" ]

icd9cm

[ [ [] ] ]

[ "39.43", "38.95", "86.11", "39.95", "88.72" ]

icd9pcs

[ [ [] ] ]

20720, 21166

21189, 21947

21971, 22493

13487, 20517

20533, 20699

11429, 12484

12506, 13271

13288, 13464

7,368

108,968

24496

Discharge summary

report

Admission Date: [**2154-7-10**] Discharge Date: [**2154-7-16**] Date of Birth: [**2078-11-11**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 17683**] Chief Complaint: Right colon mass Major Surgical or Invasive Procedure: Right colectomy with primary hand-sewn anastomosis side-to-side of distal ileum to transverse colon History of Present Illness: 75 had an episode of appendicitis possibly perforated in [**2153-1-11**] treated at [**Hospital 4415**]. She then went back to [**Country 651**] and at that time continued to have weight loss and blood in her stools. Eventually she got a colonoscopy in [**Country 651**] in [**2154-5-12**] and that showed a malignant appearing neoplasm in the right colon. She was advised to have surgery but wanted to come back to the United States and have her surgery here. So she came back to the United States where she was found on second attempt colonoscopy again to have a right colonic malignant neoplasm and on a CT scan it appeared like quite a large circumferential cecal mass with a mucocele of the appendix. Past Medical History: HTN increased cholesterol history of "racing heart" Social History: She currently is not working. She does not smoke or drink any alcohol. She takes some herbal products the name of which is unknown. She also has fish oil and multivitamins. Family History: noncontrib Physical Exam: On discharge Afebrile NAD, A&Ox3 RRR CTAB soft nontender, nondistended well healing midline scar no lower extremity edema Pertinent Results: [**2154-7-15**] 06:20AM BLOOD WBC-7.1 RBC-3.60* Hgb-9.8* Hct-29.7* MCV-83 MCH-27.2 MCHC-32.9 RDW-16.3* Plt Ct-416 [**2154-7-15**] 06:20AM BLOOD Plt Ct-416 [**2154-7-14**] 06:05AM BLOOD Glucose-136* UreaN-7 Creat-0.6 Na-141 K-4.2 Cl-107 HCO3-26 AnGap-12 [**2154-7-12**] 06:00AM BLOOD CK(CPK)-344* [**2154-7-12**] 02:40PM BLOOD CK(CPK)-290* [**2154-7-13**] 04:21AM BLOOD CK(CPK)-212* [**2154-7-12**] 06:00AM BLOOD CK-MB-3 cTropnT-<0.01 [**2154-7-12**] 02:40PM BLOOD CK-MB-3 cTropnT-<0.01 [**2154-7-13**] 04:21AM BLOOD CK-MB-2 cTropnT-<0.01 . pCXR [**2154-7-12**]: Left mid lung atelectasis. No evidence of pneumonia or CHF. . Pathology pending at the time of d/c Brief Hospital Course: Pt tolerated the procedure well and was transferred to the surgical floor the night of operation. In the early morning of POD 2 the pt went into Afib w/ RVR (HR 110-170 and SBP 120) and experienced some chest tightness. Pt has a history of similar episodes (assumed to be pAF) and was seen by Cardiology. They started her on Atenolol and did not want to start antiarrhythmic drugs. Lopressor and Dilt push slowed the rate to 100's. CXR, EKG, and cardiac enzymes were sent and no evidence of PNA or MI were noted. She was transferred to the SICU for a dilt drip. She converted to sinus within hours and was transitioned to PO dilt. On POD 3 she was transferred back to the surgical floor. She remained stable in NSR for the remainder of her stay. She did well and past flatus on POD 4. A clear diet was started and was tolerated. Her diet was advanced. She had a bowel movement on POD 5. Pt ambulated without difficulty. She was d/c'd home on POD 6 in good condition. The atenolol and diltiazem were continued. Her PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] ([**Telephone/Fax (1) 8236**]), was contact[**Name (NI) **] and they will arrange a follow up appointment. Medications on Admission: Atenolol 100 mg Po QDay Iron Discharge Medications: 1. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*0* 2. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 3. Tylenol-Codeine #3 300-30 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: 1. Malignant neoplasm of right colon, mucinous with mucin in abdomen 2. post-op Afib 3. HTN Discharge Condition: Good Discharge Instructions: Please call your surgeon if you develop chest pain, shortness of breath, fever greater than 101.5, foul smelling or colorful drainage from your incisions, redness or swelling, severe abdominal pain or distention, persistent nausea or vomiting, inability to eat or drink, or any other symptoms which are concerning to you. No tub baths or swimming. You may shower. If there is clear drainage from your incisions, cover with a dry dressing. Leave white strips above your incisions in place, allow them to fall off on their own. Activity: No heavy lifting of items [**11-25**] pounds until the follow up appointment with your doctor. Medications: Resume your home medications. You should take a stool softener, Colace 100 mg twice daily as needed for constipation. You will be given pain medication which may make you drowsy. No driving while taking pain medicine. Followup Instructions: [**Name6 (MD) 843**] [**Name8 (MD) 844**], MD Phone:[**Telephone/Fax (1) 10533**] Date/Time:[**2154-7-22**] 9:30 Please follow up with your PCP within one week. [**Name6 (MD) 843**] [**Name8 (MD) 844**] MD [**MD Number(1) 845**]

[ "427.31", "153.6", "997.1", "272.0", "E878.2", "196.2", "401.9" ]

icd9cm

[ [ [] ] ]

[ "45.73", "45.93" ]

icd9pcs

[ [ [] ] ]

4040, 4046

2310, 3512

333, 435

4182, 4189

1624, 2287

5103, 5365

1454, 1466

3591, 4017

4067, 4161

3538, 3568

4213, 5080

1481, 1605

277, 295

463, 1170

1192, 1245

1261, 1438

52,586

102,293

40046+58346

Discharge summary

report+addendum

Admission Date: [**2132-7-22**] Discharge Date: [**2132-7-24**] Date of Birth: [**2094-8-31**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 3290**] Chief Complaint: GI Bleed Major Surgical or Invasive Procedure: Upper endoscopy with epinephrine injection and cauterization History of Present Illness: 37M with history of back pain on ibuprofen presenting with two days of black stools, severe nausea and vomiting, inability to tolerate POs. Patient states that vomiting and diarrhea episodes were occuring every two hours until last night, now less frequent. Emesis was initially [**Location (un) 2452**], then coffee ground since Sunday (last two days). Early this morning, he noticed bright red blood streaks in emesis, small amount. He presented to PCP today where stool was found hemoccult positive. Reports epigastric cramping, no other abdominal pain. No hx of GERD, gastric ulcers, liver disease. No prior abdominal surgeries. No sick contacts. [**Name (NI) **] recent eating out or travel. . In the ED, initial vitals were as follows: 99.0 65 126/88 16 99% RA. Patient was having no abdominal pain or tenderness. NG lavage was done in the ED which showed 200CC of coffee ground emesis with some bright red blood. Hemoccult positive. No BRBPR. Typed and crossed x2 units. . On the floor, patient feels well overall. Denies lightheadness. Endorses abdominal cramping. Past Medical History: see admit H&P Social History: see admit H&P Family History: see admit H&P Physical Exam: Vitals: T: 99.2 BP: 145/78 P: 66 R: 14 O2: 99% 2LNC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: tatoos on left upper extremity Pertinent Results: On Admission: [**2132-7-22**] 11:43AM BLOOD WBC-9.9 RBC-4.50* Hgb-14.7 Hct-40.5 MCV-90 MCH-32.6* MCHC-36.3* RDW-13.0 Plt Ct-257 [**2132-7-22**] 12:32PM BLOOD PT-14.3* PTT-20.0* INR(PT)-1.2* [**2132-7-22**] 11:43AM BLOOD Glucose-133* UreaN-21* Creat-1.3* Na-144 K-3.4 Cl-103 HCO3-32 AnGap-12 On Discharge: [**2132-7-23**] 06:40AM BLOOD WBC-6.5 RBC-3.95* Hgb-13.1* Hct-37.0* MCV-94 MCH-33.2* MCHC-35.5* RDW-12.8 Plt Ct-223 [**2132-7-23**] 06:40AM BLOOD Glucose-91 UreaN-16 Creat-1.2 Na-142 K-3.2* Cl-106 HCO3-29 AnGap-10 Studies: EGD [**2132-7-22**]-A single cratered ulcer was found in the pylorus. A visible vessel suggested recent bleeding. 4cc epinephrine 1/[**Numeric Identifier 961**] injection was applied. A bipolar cautery probe was applied for hemostasis successfully. Erythema and congestion in the antrum compatible with gastritis No blood was seen in the stomach or duodenal lumen. The esophageal mucosa had a slightly 'furrowed' appearance, which is a nonspecific finding. In the proper clinical setting it can be indicative of eosinophilic esophagitis. Brief Hospital Course: Mr. [**Known lastname 10528**] is a 37 year-old man with history of high dose ibuprofen use who presented with coffee ground emesis. # Upper GI Bleed-The patient presented with N/V, coffe ground emesis and dark stools for 2 days. In the [**Last Name (LF) **], [**First Name3 (LF) **] NG lavage showed 200ml of coffee ground emesis with some bright red blood. He was hemoccult positive. The patient was brought to the MICU due to GI bleeding. In the MICU he underwent EGD where a cratered ulcer with a visible vessel was found in the pylorus. The vessel was cauterized and he was continued on a PPI gtt x1 day. H. Pylori testing was done and found to be negative. The patient remained stable during his MICU stay and was ready fir discharge on [**7-24**]. He will have a repeat upper endoscopy in [**8-8**] weeks with Dr. [**First Name (STitle) 908**] and Dr. [**First Name (STitle) **] to confirm ulcer healing. Also counseled to reduce NSAID use as this was likely etiology of ulceration. # Depression-No active issues. He was continued on home citalopram after endoscopy. Medications on Admission: citalopram ibuprofen 800mg - takes 4 times/day for last couple years Discharge Medications: 1. clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 14 days. Disp:*28 Tablet(s)* Refills:*0* 2. amoxicillin 500 mg Capsule Sig: Two (2) Capsule PO twice a day for 14 days. Disp:*56 Capsule(s)* Refills:*0* 3. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 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:*1* 5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:*14 Adhesive Patch, Medicated(s)* Refills:*0* 6. acetaminophen 500 mg Capsule Sig: [**12-30**] Capsules PO three times a day. Disp:*42 Capsule(s)* Refills:*0* 7. diazepam 2 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*7 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Pyloric ulcer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 10528**], you were admitted to the hospital with a bleeding ulcer in your stomach. There are two potential causes of this. First, ibuprofen can causes ulcers. Please stop taking ibuprofen and discuss alternatives therapies for back pain with your primary care physician. [**Name10 (NameIs) **], you were found to have a bacteria called H.pylori that can cause ulcers. You will need to take antibiotics for the next two weeks. It is important that you complete the full course of antibiotics. The gastroenterologists did an endoscopy to find the ulcer, and they cauterized it. You will need to follow-up with your gastroenterologist, and also have a repeat endoscopy in about 8 weeks. You will need to continue a medication to reduce the amount of acid in your stomach to prevent ulcers in the future. Continue you current medications with the following changes: STOP ibuprofen START pantoprazole 40mg twice a day (for the ulcer) START amoxicillin 1g twice a day for 14 days (for the H pylori) START clarithromycin 500mg twice a day for 14 days (for the H pylori) START acetaminophen [**12-30**] pills up to three times a day for back pain START lidocaine patch once a day as needed for back pain START donazepam one pill at bedtime as needed for back pain Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] A. Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 2261**] Appointment: Friday [**2132-8-1**] 10:30am Name: [**Last Name (LF) 26390**], [**First Name7 (NamePattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2296**] Appointment: Thursday [**2132-8-21**] 4:20pm Completed by:[**2132-7-24**] Name: [**Known lastname 13956**],[**Known firstname 394**] Unit No: [**Numeric Identifier 13957**] Admission Date: [**2132-7-22**] Discharge Date: [**2132-7-24**] Date of Birth: [**2094-8-31**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 376**] Addendum: Correction to hospital course: H. Pylori testing on serology was found to be POSITIVE. Discharge Disposition: Home [**Name6 (MD) **] [**Last Name (NamePattern4) 377**] MD [**MD Number(2) 378**] Completed by:[**2132-7-24**]

[ "041.86", "535.51", "E935.9", "724.2", "531.40", "311" ]

icd9cm

[ [ [] ] ]

[ "44.43" ]

icd9pcs

[ [ [] ] ]

7959, 8102

3276, 4362

314, 377

5413, 5413

2183, 2183

6868, 7862

1576, 1591

4482, 5326

5376, 5392

4388, 4459

7879, 7936

5564, 6845

1606, 2164

2489, 3253

266, 276

405, 1491

2197, 2475

5428, 5540

1513, 1528

1544, 1560

9,965

194,053

43885

Discharge summary

report

Admission Date: [**2169-1-1**] Discharge Date: [**2169-1-7**] Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 598**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [**2169-1-1**]: exploratory laparotomy, extended left colectomy with Hartmann's pouch and end transverse colostomy. History of Present Illness: [**Age over 90 **] y/o F with h/o stroke in past year, minimally interactive and nonverbal since then, who presents from nursing home with worsening abdominal distension. The patient was febrile to 103 in ED. Because the patient is nonverbal, she had not been having any complaints prior to presentation. She also had not been experiencing emesis or diarrhea. Past Medical History: CAD s/p stent, pacemaker, type 2 DM, HTN, hyperlipidemia, CVA ([**2153**]), chronic renal insufficiency, chronic lower extremity lymphedema, depression, iron deficiency anemia, MSSA bacteremia, persistent eosinophilia PSH: C-section, PEG tube placement, cholecystectomy. Stent placement (LAD,RCA [**2-/2162**]) and dual chamber pacemaker Social History: Currently residing at [**Hospital3 2558**]. Family History: non-contributory Physical Exam: Upon discharge: Tm 98.2 Tc 98.2 HR 70 BP 136/60 RR 20 O2sat 98%RA General: in no acute distress, opens eyes to voice, name HEENT: mucus membranes moist, nares clear CV: regular rate, rhythm Pulm: slightly decreased breath sounds at bases. Significantly decreased upper airway noises. Abd: soft, nontender, nondistended. Obese. Staples in place; clean, dry, with minimal erythema. No drainage or induration. Ostomy in place; pink, patent with thickened effluent in ostomy bag with + gas. GU: foley in place MSK: pneumatic compression boots bilaterally, [**12-5**]+ pitting edema bilaterally, symmetric in extremities. Warm, well perfused. Neuro: nonverbal at baseline. Awakens to voice, name. Pertinent Results: On admission:[**2169-1-1**]: Na 150 Cl 107 BUN 69 Glu 193 AGap=16 K 4.1 CO2 31 Cr 1.9 ∆ ALT: 104 AP: 111 Tbili: 0.4 Alb: AST: 88 LDH: Dbili: TProt: [**Doctor First Name **]: Lip: 65 WBC 27.9 ∆ Hgb 15.4 ∆ Plt 419 ∆ Hct 45.3 ∆ N:85 Band:2 L:6 M:3 E:0 Bas:0 Atyps: 4 [**2169-1-2**] 01:38AM BLOOD WBC-21.9* RBC-3.29* Hgb-10.9* Hct-31.4* MCV-95 MCH-33.3* MCHC-34.9 RDW-14.0 Plt Ct-277 [**2169-1-4**] 01:42AM BLOOD WBC-11.9* RBC-2.97* Hgb-9.3* Hct-28.3* MCV-95 MCH-31.4 MCHC-33.0 RDW-15.3 Plt Ct-150 [**2169-1-7**] 06:14AM BLOOD WBC-7.2 RBC-3.01* Hgb-9.7* Hct-29.7* MCV-98 MCH-32.4* MCHC-32.9 RDW-15.4 Plt Ct-173 [**2169-1-2**] 01:38AM BLOOD Glucose-156* UreaN-65* Creat-1.5* Na-147* K-3.9 Cl-115* HCO3-22 AnGap-14 [**2169-1-5**] 11:15AM BLOOD Glucose-110* UreaN-37* Creat-1.3* Na-152* K-4.0 Cl-122* HCO3-22 AnGap-12 [**2169-1-7**] 06:14AM BLOOD Glucose-158* UreaN-31* Creat-1.0 Na-151* K-3.3 Cl-121* HCO3-22 AnGap-11 [**2169-1-2**] 01:38AM BLOOD Calcium-7.7* Phos-4.0 Mg-3.4* [**2169-1-7**] 06:14AM BLOOD Calcium-8.0* Phos-2.6* Mg-2.2 Imaging: CT abdomen/pelvis: [**2169-1-1**]: 1. Diffuse dilation of the entire colon, without evidence of volvulus or obstruction, suggesting most likely pseudo-obstruction. 2. Small areas of pneumatosis in the ascending colon, with tiny locule of air in the right lower quadrant superior mesenteric venous tributary, concerning for bowel ischemia. CXR: Endotracheal tube ends approximately 6 cm above the carina. Orogastric tube courses into the upper stomach; however, its sideport is just below the GE junction. Consider advancing the orogastric tube by approximately 5 cm for better seating. Dual-lead left pectoral pacemaker device is present with each lead terminating into the right atrium and right ventricle respectively. Moderate-to-severe atherosclerotic calcifications are present in the aortic knob and there is a coronary stent. Mildly enlarged heart size, mediastinal and hilar contours are stable at least since the most recent radiograph. Left lower lung atelectasis and presumed small left pleural effusions are stable. The right lung and left upper lungs are clear. ECHO: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. There is an apical left ventricular aneurysm. Overall left ventricular systolic function is low normal (LVEF 50-55%). No masses or thrombi are seen in the left ventricle, this was rule out with definity. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened (?#). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Brief Hospital Course: Ms. [**Known lastname 94216**] was taken to the OR emergently for exploratory laparotomy after extensive discussion with her family on [**2169-9-2**]. She was transferred to the ICU postoperatively intubated and on pressors. Her course is below by system: Neuro: Patient is non-verbal and minimally interactive at baseline. Once extubated, she was back at her baseline, though with rare agitation requiring small doses of prn haldol; this was no longer needed throughout the rest of her hospitalization. Her pain was well controlled with morphine. Her pain medications were transitioned to oral, which appeared to control her pain. Her vital signs remained stable. CV: Patient was aggressively resuscitated with crystalloid and blood on POD#1. Her pressors were weaned off and she remained hemodynamically stable therafter. Her metoprolol was started on POD#3, and her home doses resumed soon thereafter with no evidence of hemodynamic stability. Her heart rate and rhythm were in sinus, and within normal limits respectively. Resp: Patient was extubated on POD#2. She maintained excellent O2 saturations throughout her stay on the floor between 96-98% RA but was noted to have some secretions with upper airway noises. These required minimal suctioning on two occasions with resolution. She otherwise was started on nebulizer and ipratroptium treatments for comfort. GI: Patient's colostomy began to have output on POD#2. NGT was removed on POD#3 and patient was not nauseated or vomiting. Her ostomy functioned well with thickened effluent afterwards with no signs of obstruction. She initially underwent a G tube clamp trial, which she tolerated, and was started on tube feeds at 10cc/hr and increased to her goal of 60cc/hr, which she tolerated. GU: Urine output and Cr were at baseline postoperatively. A foley catheter was placed for urine output monitoring, and was kept upon discharge. She was found to be hypernatremic upon admission, with the initiation of free water flushes through her gastric tube with some decrease in her serum sodium. These were also continued through discharge. She did not exhibit any typical sequelae of hypernatremia. Heme: Patient was transferred 1U PRBC which assisted in weaning off her pressors. Her hematocrit was stable at 29 prior to discharge, and did not require any additional units while on the floor. She was maintained on subcutaneous heparin tid for DVT prophylaxis and her relative immobility. ID: Patient was given 24 hours of periop cipro/flagyl, with no requirements afterwards. Her wound appeared cleaned, with no signs of infection or drainage prior to discharge. She remained afebrile throughout her stay on the floor and was afebrile upon discharge. Endo: Patient was maintained on an insulin sliding scale. Her lantus was started after tube feeds were reinitiated at her usual pre-admission dose. Prophylaxis: the patient received subcutaneous heparin for DVT prophylaxis, and wore pneumatic compression boots bilaterally. Medications on Admission: scopalamine patch 1.5 mg patch q3days, metoprolol 37.5 mg qAM 25 mg qPM, lantus 12 units sc qhs, novolin R sliding scale, dulcolax 10 mg pr qday prn, fleet enema qday prn, mom 30 mL qday prn, colace 100 mg [**Hospital1 **], senna 8.6 mg [**Hospital1 **], miralax 17 g daily, famotidine 20 mg daily, cephalexin 250 mg q12hr, lovenox 40 mg SC daily Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 10 days. Disp:*25 Tablet(s)* Refills:*0* 3. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO QAM (once a day (in the morning)). 4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 5. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. insulin NPH & regular human 100 unit/mL (70-30) Insulin Pen Sig: One (1) Subcutaneous once a day: Novolin sliding scale. 9. Lantus 100 unit/mL Solution Sig: One (1) 12 Subcutaneous at bedtime: 12 units of lantus qhs. 10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for sob/wheeze. 11. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 12. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Sigmoid volvulus with subsequent megacolon and bowel ischemia Discharge Condition: Mental status: alert and oriented to person; opens eyes to voice, name(baseline). Ambulatory status: bed, wheel-chair bound Discharge Instructions: You were admitted to the hospital for a known sigmoid volvulus with abdominal pain and underwent an exploratory laparotomy, extended left hemicolectomy with end colostomy; you have recovered well from this operation and are now ready to continue the rest of your recovery at home. Your ostomy is functioning with good output and your tube feeds were started and were increased to goal feeds at 60cc/hr, which you have tolerated. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Please follow-up in [**Hospital 2536**] clinic in [**1-6**] weeks; you may call ([**Telephone/Fax (1) 37488**] to schedule an appointment. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2169-1-7**]

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Discharge summary

report

Admission Date: [**2124-10-13**] Discharge Date: [**2124-11-3**] Date of Birth: [**2042-4-3**] Sex: F Service: MEDICINE Allergies: morphine / Iodine Attending:[**First Name3 (LF) 38616**] Chief Complaint: fever Major Surgical or Invasive Procedure: Blood transfusion Bone marrow biopsy Intubation and ventilation Palate Biopsy PICC line placement and removal History of Present Illness: 82F with recently diagnosed MDS, presenting with fever, malaise, and pain over L SCM and right lateral neck. Recent admission to [**Hospital1 18**] [**Date range (3) 56873**] with fevers (after OSH admission starting [**2124-9-1**]); found to have MDS (RAEB-2) by bone marrow biopsy (at OSH, and then again at [**Hospital1 18**]). Significant hypoxemia at time of transfer to [**Hospital1 18**], initially in [**Hospital Unit Name 153**]. Abnormal chest CT, had intubated bronch, micro unremarkable but significant blood seen. Had L IJ placement at OSH, removed on [**2124-9-13**] at [**Hospital1 18**]. Of note her bone marrow biopsy also showed granulomatous inflammation; Quantiferon was indeterminate, urine histo antigen was weakly positive. Received steroids briefly at OSH; here vanco/cefepime then zosyn/azithro/ambisome then vori; discharged on vori plus few more days levofloxacin. Has had ID and hemeonc followup as an outpatient. . At home fevers the day before admission, also noted L SCM area neck pain around that time. The right lateral neck pain has been going on [**1-6**] days. No sweats or rigors (though having here). No pains elsewhere. No dyspnea, chest pain, cough, hemoptysis, sputum, abdominal pain, weight changes, edema, rash. Overall reports eating and ambulating normally until yesterday. . In the ED fever as high 101.7. Exam of neck concerning for abscess. WBCs 1.7 with 37N and 21B. Remainder of CBC at baseline. CT neck done - small anterior abscess (9mm), likely at prior CVL site. Lung apices also with bilateral infiltrate. I&D done and culture sent. Given vanco/cefepime. Feels significantly improved since incision done. . On the morning of the transfer to ICU, she was noted to be mildly wheezy on morning rounds and afebrile. The patient states she got up to go to the bathroom, she reports she was straining, and became acutely tachypneic, tachycardic to the 130s, and reportedly hypoxic to 66% on RA with sats progressively reaching 100%. The patient was immediately evaluated by the BMT attending and fellow, who felt she was "very wheezy," she was given nebulizers. She was noted to be febrile to 101.3. By the time of ICU transfer heart rate had decreased to the low 100's. Oxygen saturation was 100% on NRB and she was not tachypneic. Her JVP at 90 degrees was noted to be at the angle of the mandible. She was never hypotensive. On arrival to the [**Hospital Unit Name 153**] the patient continued to look well, and was rapidly transitioned to nasal canula, and room air on which she was noted to be 100% and non-tachypneic. . Her [**Hospital Unit Name 153**] stay was largely uncomplicated. She experienced tachypnea with moderate hypertension and tachycardia but was never hypoxic and never required more than supplemental oxygen. These episodes occured when she had fevers and resolved with Tylenol, Motrin, Ativan 0.5, and coaching to take deep breaths. She was given intravenous lasix (20mg on more than one occasion) since she was 1.6 liters positive on admission to the [**Hospital Unit Name 153**]; on transfer out she was net negative. She was transferred to the floor on [**10-18**] and at that time stated that she feels well without any difficulty breathing. REVIEW OF SYSTEMS: (+) Per HPI (-) Denies night sweats, recent weight loss or gain. Denies headache, sinus tenderness, cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, change in diarrhea, constipation or abdominal pain. No dysuria. Denied arthralgias or myalgias or rash. . Past Medical History: PAST ONCOLOGIC HISTORY: - MDS. Presented to OSH with flu like illness and rash in late [**2124-8-3**]. Found to be pancytopenic. BMBx at OSH with RAEB-II, confirmed here on [**2124-9-17**]. Granulomatous changes also present in BMBx with micro stains, culture and PCR negative. Unclear if past toxic exposure and/or infection as trigger. . OTHER MEDICAL HISTORY: - ulcerative colitis s/p colectomy [**2105**] w/ ilioanal anastamosis (loose stools at baseline) - multiple SBOs - GERD - Hyperlipidemia - Osteoporosis - s/p CCY Social History: Originally from [**Country 13622**] Republic; has been living in US for 27y ears. Has 3 daughters. Lives with oldest daughter [**Name (NI) **]. - [**Name2 (NI) 1139**]: Hx of social smoking. Quit in the [**2092**] - Alcohol: Social EtOH, glass of wine occasionally. - Illicits: None Family History: Mother: MI (60s) Brother: CV disease Brother: emphysema Physical Exam: ADMISSION EXAM VS: 97.7 114/72 HR 110 RR 24 SaO2 100RA Gen: no respiratory distress. rigors. HEENT: NCAT. Sclera anicteric. EOMI. MMM, OP benign. Neck: full ROM. no current drainage or bleeding or tenderness CV: regular tachycardia, no m/r/g appreciated. Chest: Respiration unlabored, no accessory muscle use. CTAB without crackles, wheezes or rhonchi. Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly or masses. Ext: warm, no edema, no clubbing Skin: No rashes, ulcers Neuro: no focal deficits Psych: logical, coherent . DISCHARGE EXAM VS afebrile, HR/BP wnl, O2 sat >95%/RA GEN well-appearing elderly female sitting up in NAD HEENT NCAT EOMI PERRL OP clear nasal packing removed, hard palate vesicles resolved NECK supple no LAD no JVD PULM CTAB no r/r/w CV RRR nl S2 S2 no murmur, no dependent edema ABD soft nontender nondistended normoactive BS no HSM EXT no edema SKIN resolving erythematous scaly patches on intertriginous regions of fingers NEURO AOX3 CN intact motor [**4-6**] reflexes 2+ cerebellar wnl gait stable Pertinent Results: ADMISSION LABS [**2124-10-12**] 09:51PM LACTATE-1.8 [**2124-10-12**] 09:45PM GLUCOSE-103* UREA N-11 CREAT-0.9 SODIUM-133 POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-19* ANION GAP-17 [**2124-10-12**] 09:45PM estGFR-Using this [**2124-10-12**] 09:45PM ALT(SGPT)-11 AST(SGOT)-21 LD(LDH)-159 ALK PHOS-159* TOT BILI-0.3 [**2124-10-12**] 09:45PM proBNP-87 [**2124-10-12**] 09:45PM ALBUMIN-3.8 [**2124-10-12**] 09:45PM WBC-1.7* RBC-3.34* HGB-8.9* HCT-27.6* MCV-83 MCH-26.6* MCHC-32.1 RDW-18.4* [**2124-10-12**] 09:45PM NEUTS-37* BANDS-21* LYMPHS-27 MONOS-5 EOS-6* BASOS-0 ATYPS-2* METAS-0 MYELOS-0 BLASTS-2* [**2124-10-12**] 09:45PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL [**2124-10-12**] 09:45PM PLT SMR-LOW PLT COUNT-91* [**2124-10-12**] 09:45PM PT-12.4 PTT-27.2 INR(PT)-1.0 . PERTINENT LABS [**2124-10-19**] 06:30AM BLOOD GGT-585* [**2124-10-21**] 08:10AM BLOOD AMA-NEGATIVE Smooth-POSITIVE * [**2124-10-21**] 08:10AM BLOOD RheuFac-4 [**2124-10-20**] 07:23PM BLOOD IgG-1658* IgA-637* IgM-243* FLT3 NEGATIVE NPM1 NEGATIVE . DISCHARGE LABS [**2124-11-3**] 12:00AM BLOOD WBC-2.5* RBC-3.00* Hgb-8.6* Hct-26.6* MCV-89 MCH-28.5 MCHC-32.2 RDW-18.3* Plt Ct-102* [**2124-11-3**] 12:00AM BLOOD Neuts-86* Bands-1 Lymphs-8* Monos-1* Eos-0 Baso-1 Atyps-0 Metas-2* Myelos-1* NRBC-2* [**2124-11-3**] 12:00AM BLOOD PT-10.4 PTT-20.4* INR(PT)-1.0 [**2124-11-3**] 12:00AM BLOOD Glucose-162* UreaN-20 Creat-0.6 Na-137 K-4.7 Cl-104 HCO3-25 AnGap-13 [**2124-11-3**] 12:00AM BLOOD ALT-95* AST-114* LD(LDH)-359* AlkPhos-596* TotBili-0.5 [**2124-11-3**] 12:00AM BLOOD Albumin-3.0* Calcium-8.3* Phos-2.1* Mg-1.9 . MICRO NUMEROUS BLOOD CULTURES - ALL NEGATIVE URINE CULTURE - VRE POSITIVE, SUBSEQUENTLY NEGATIVE RPR NON-REACTIVE VIRAL SWAB NEGATIVE STOOL CDIFF NEGATIVE X4 BONE MARROW FLUID CULTURE (Final [**2124-10-23**]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED [**2124-11-1**] 04:10PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-NEGATIVE (X3) [**2124-11-1**] 04:10PM BLOOD B-GLUCAN-NEGATIVE (X3) [**2124-10-21**] 08:10AM BLOOD HTLV I AND II, NONREACTIVE [**2124-10-21**] 08:10AM BLOOD CYCLIC CITRULLINATED PEPTIDE (CCP) ANTIBODY, IGG-NEGATIVE [**2124-10-20**] 07:23PM BLOOD HERPES 6 DNA PCR, QUANTITATIVE-NEGATIVE [**2124-10-20**] 07:23PM BLOOD Q-FEVER (COXIELLA BURNETTI) ANTIBODY-NEGATIVE [**2124-10-20**] 07:23PM BLOOD PARVOVIRUS B19 ANTIBODIES -IGG POS IGM NEG . PATH [**10-15**] SKIN BIOPSY Skin, left digit, biopsy (A): Interstitial granulomatous inflammation, see note and comment. Note: Sections reveal histiocytes and giant cells within the interstitium of the superficial dermis. Well formed granulomas are not observed. There is associated mild lymphocytic inflammation. There is marked elastophagocytosis within the giant cells. Special stains (PAS, GMS, AFB, [**Last Name (un) 18566**], and gram) are negative for organisms. The findings are similar to the "B" biopsy, however, there are prominent neutrophils in that biopsy. See comment. Skin, left 2nd finger, biopsy (B): Interstitial neutrophilic and granulomatous inflammation, see note and comment. Note: Sections reveal histiocytes and giant cells with associated clusters of neutrophils within the interstitium of the superficial dermis. Well formed granulomas are not observed. There is marked elastophagocytosis within the giant cells. Special stains (PAS, GMS, AFB, [**Last Name (un) 18566**], and gram) are negative for organisms. The differential diagnosis includes a palisaded neutrophilic and granulomatous dermatitis which may be observed with a number of underlying systemic disorders including as a paraneoplastic process which may be associated with leukemias and lymphomas and as a reaction pattern associated with various autoimmune disorders, in particular rheumatoid arthritis, and less likely sarcoidosis. There is a case report describing elastophagocytosis in association with Sweet's syndrome, therefore, due to the neutrophilic component and mild papillary dermal edema, Sweet's syndrome (or due to the acral site - neutrophilic dermatosis of the hands variant of Sweet's) is possible. Granuloma annulare is considered, however, the number of neutrophils would be unusual. An interstitial granulomatous drug reaction is considered less likely. The pattern is not a typical pattern observed with infections, however, due to the finding of mixed granulomatous and neutrophilic inflammation infection cannot be excluded. Special stains were negative, however, if the process persists, a re-biopsy for culture may be helpful as culture is a more sensitive method to detect organisms than histologic special stains. . [**10-20**]: BONE MARROW ASPIRATE AND CORE BIOPSY DIAGNOSIS: Erythroid dominant myelodysplastic marrow with excess blasts. Multiple non-necrotizing granulomata seen. [**11-1**] SINUS BIOPSY DIAGNOSIS: 1.Left inferior turbinate, nose, intranasal biopsy (A): 1. Respiratory-type mucosa and fibrovascular tissue with mild chronic inflammation and surface epithelial degenerative changes. 2. No organisms identified by PAS or GMS stains. 2.Left middle turbinate, nose, intranasal biopsy (B): 1. Respiratory-type mucosa, bone, and vascular tissue with mild chronic inflammation. 2. No organisms identified by PAS or GMS stains. . NOTABLE IMAGING . [**10-12**] CT NECK IMPRESSION: 1. Tiny 9 mm fluid collection with possible rim enhancement anterior to the left sternocleidomastoid muscle may be at the site of prior central line insertion and could represent a superficial abscess. 2. No thrombus within the left internal jugular vein to suggest Lemierre's disease. 3. Bilateral ground-glass opacities within the upper lungs are incompletely evaluated, but are concerning for an infectious process, less likely pulmonary edema. Recommend clinical correlation. . [**10-25**] MRCP IMPRESSION: 1. Hepatomegaly with a nodular contour to the liver and prominent porta hepatis lymph nodes. The morphology suggests chronic liver disease, although no diagnostic features of PSC are seen. 2. Dilated common bile duct measuring up to 1.2 cm without a definite cause seen. This appearance could be due to a choledochal cyst versus ampullary stenosis, the latter is considered less likely given the normal caliber of the pancreatic duct. 3. Distended endometrial canal as seen on the prior CT. This could be further evaluated by pelvic ultrasound if clinically appropriate. 4. Cluster of cysts in the left adnexal region, also seen on the recent CT. Again, this could be clarified with dedicated ultrasound if deemed appropriate. . [**10-31**] LUE LENI CONCLUSION: There is thrombus in the left axillary vein as well as in the basilic vein, although intervening brachial vein appears to be patent. PICC line noted within these vessels. Overall, the thrombus has increased from the previous study of [**2124-9-15**]. Results discussed with Dr. [**Last Name (STitle) 56874**] at 10 AM. Brief Hospital Course: Ms [**Known lastname 56872**] is an 82 year old woman with a history of ulcerative colitis recently hospitalized with hypoxemic respiratory failure, at which time she was diagnosed with pulmonary histioplasmosis and myelodysplastic syndrome (RAEB-2), who presented on [**2124-10-13**] with fevers and left sided neck pain, found to have idiopathic granulomatous disease, hospital course complicated by 1 episode severe epistaxis. . She was originally admitted to the floor, transferred to the ICU for respiratory decompensation, out to the floor on the BMT service once stabilized, back to the ICU for epistaxis requiring 4U PRBC transfusion and nasal balloon placement, then to the BMT service for further workup. Her primary problem was determined to be fever [**1-5**] idiopathic granulomatous disease, diagnosed during this admission. . PROBLEMS: . # FEVER Fevers started two days prior to admission. Multiple potential sources of fever were identified and treatment without improvement in fevers, as follows: . #NECK ABSCESS Patient c/o left sided neck pain on admission, was found to have 9mm fluid collection concerning for superficial abscess at the site of a previous central venous line. She was also febrile with significant bandemia. She was started empirically on Vancomycin and Cefepime. She underwent successful incision and drainage. Fluid G/S was positive for leukocytes and Gram positive cocci in pairs but culture was ultimately negative. . #UTI Infectious work-up revealed Vancomycin resistant/Daptomycin senstive UTI. Despite Daptomycin treatment, fevers persisted. #IDIOPATHIC GRANULOMATOUS DISEASE Given the patient??????s h/o ulcerative colitis, rash, previous biopsies showing granulomatous disease in the skin and bone marrow, and persistence of fever despite appropriate antibiotic treatment of multiple infections, as above. Lack of definitive infectious source or clinical improvement despite broad antimicrobial coverage, there was increasing concern for a rheumatologic source of fevers. Sarcoidosis was suggested as a plausible diagnosis given granulomatous disease, EN, and mediastinal adenopathy; ultimately, rheumatology consult determined that the patient's cluster of symptoms and pathology findings of granulomas in multiple anatomic sites could be explained by a unifying diagnosis of Idiopathic Granulomatous Disease. She was started on steroids with good improvement in overall well-being, diarrhea, and fevers. Discharge with plan to follow-up with rheumatology for further medical management. . #NEUTROPHILIC DERMATOSIS The patient developed a rash on her legs and hands during her previous admission with biopsy revealing erythema nodosum, consistent with h/o UC. During this admission, she again developed erythematous papules on bilateral hands and thighs. Repeat biopsy revealed neutrophilic dermatosis suggestive of Sweet??????s syndrome, deep fungal infection or atypical mycobacterial infection; these were treated with 2 weeks of topical steroids with good effect. . #ICU stay #1/PNA Patient was in the ICU for parts of the workup, as above. In addition to what is described, she had hypoxia requiring intubation. PNA identified on CXR was treated with antibiotics with good resolution of symptoms and successful extubation. She was also lasix-diuresed. Additional episodes of tachypnea & tachycardia thereafter resolved rapidly; the ICU team felt mucous plug and/or panic disorder might explain these transient symptoms given rapid resolution without significant intervention. . #ICU stay #2/EPISTAXIS Patient was sent to the [**Hospital Unit Name 153**] for hemodynamic monitoring after she was noted to have spontaneous epistaxis that began [**10-27**] AM. Suffered multiple episodes of L sided bleeding that lasted 1 hour and stopped spontaneously. In the afternoon she experienced a 5th episode unresponsive to afrin, ice and pressure. ENT packed the L nares lesion at 1 AM w cautery and advised avoidance of NC O2 administration. She had an estimated blood loss of [**Telephone/Fax (1) 56875**] cc. Resuscitation was limited by peripheral access. She was noted be tachycardic to 110s and hypertensive to SBP 160s. IV team placed additional peripheral for total of 2 x 22g, 1 x 20g PIV. Labs notable for WBC 2.1, Plt 193, INR 1.1 and K 5.7. She received 1L NS at 200cc/hr and 2u pRBC total. Bleeding subsided with packing in place and she remained hemodynamically stable, with stable HCT. She was transferred back to the BMT service on [**2124-10-29**]. CT of the sinuses was done to rule out fungal infection which showed no obvious source. She underwent maxillary sinus biopsy by ENT when her nasal packing was removed; this showed only non-specific inflammation of normal mucosa. No recurrent epistaxis. Discharged home with nasal sprays recommended by ENT & with ENT follow-up appointment. She was also discharged with a few doses augmentin, to complete a 5-day course of antibiotics started when nasal balloons were removed and dissolvable packing was placed. . #LEFT ARM PICC-ASSOCIATED DVT PICC placed [**10-31**]; patient developed pain and swelling in her left arm overnight that night - doppler ultrasound showed DVT, which was seen to have been present (but smaller) on imaging earlier during this admission. PICC was replaced in the right arm for frequent blood draws and antibiotic administration; it was tolerated without problems during admission and removed prior to discharge. No anticoagulation was given for this line-associated clot given concominant severe epistaxis. #DIARRHEA Having loose stools throughout admission, although this was difficult to differentiate from her baseline. Infectious diarrhea vs autoimmune (given UC history s/p colectomy) vs osmotic diarrhea. Stool studies were negative for C. Diff, bacterial, parasitic or viral infection. Started empirically metronidazole without improvement. Diarrhea did improve when she was started on steroids for systemic granulomatous disease, suggesting inflammatory diarrhea. Per GI consult recommendations, she was also started on antidiarrheals (Modil, Loperamide, fiber flakes) with good effect. . *Hx HISTOPLASMOSIS INTERMEDIATE-POSITIVE URINE ANTIGEN Pt carried a diagnosis of histoplasmosis from previous admission for which she was being treated with voriconazole. Her beta glucan and galactomanan levels were WNL and voriconazole level was therapeutic. CT of the chest revealed overall improvement in previously seen opacities, although it was notable for some slightly increased adenopathy. Blood cultures continued to be negative. She also developed a rash in her extremities. Biopsy was obtained out of concern for disseminated fungal infection, but culture revealed no growth of bacterial or fungal organisms. . # ELEVATED Alk Phos/POSITIVE GGT: Noted during this admission, with biliary ductal dilatation on ultrasound. Primary Sclerosing Cholangitis was high on the differential given h/o Ulcerative Colitis (s/p colon resection many years ago). Seen by both GI and liver consult services. MRCP [**10-24**] showed no biliary dilatation, no obstruction, and was most c/w chronic liver disease plus porta hepatis lymphadenopathy. Despite MRSC negative for PSC rheumatology felt symptoms and labs could be consistent with biliary inflammation below the level of detection of imaging. [**Month (only) 116**] need follow-up liver biopsy which was deferred to outpatient follow-up given lack of RUQ symptoms. . #MDS Recent diagnosis during prior admission. There was concern that her fevers might be due to transformation of underlying MDS, but BM biopsy showed no leukemia. She required multiple blood transfusions to maintain Hct >21. She was continued on prophylactic acyclovir and started on prophylactic bactrim given steroid aministration. Will continue to be followed by hematology-oncology as an outpatient. . #HARD PALATE VESICLES Patient noted to have asymptomatic clustered vesicles on her hard palate on [**10-29**]. DFA was inconclusive. She was on acyclovir 400 mg q8h prior to their appearance and was continue on this antiviral treatment throughout admission. Self-resolved. . TRANSITIONAL ISSUES 1. Steroid taper to be managed by Rheumatology 2. Needs follow-up labs to trend LFTs, possible liver biopsy 3. Exam for recurrent/worsening skin lesions after stopping topical steroids at time of discharge (2 week course completed). Expect possible recurrence given inflammatory etiology; will need intermittent treatment. 4. [**Month (only) 116**] need reimaging to document resolution of line-associated DVT. Medications on Admission: ischarge Medications: 1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. loperamide 2 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day) as needed for diarrhea. 3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO once a day. 5. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 6. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain or fever. 7. Combivent 18-103 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*0* 8. Other Home oxygen 9. alendronate 35 mg Tablet Sig: One (1) Tablet PO once a week. 10. voriconazole 200 mg Tablet Sig: One (1) Tablet PO twice a day: Continue to take until directed to stop by your physician. 11. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Discharge Medications: 1. loperamide 2 mg Capsule Sig: One (1) Capsule PO three times a day as needed for after each loose stool. 2. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO once a day. 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Combivent 18-103 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 6. alendronate 35 mg Tablet Sig: One (1) Tablet PO once a week. 7. Tylenol Extra Strength 500 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain: do not take more than 4 pills (2 mg) per day. 8. voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 9. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:*90 Tablet(s)* Refills:*0* 10. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 8 doses: please finish all antibiotics. . Disp:*8 Tablet(s)* Refills:*0* 11. prednisone 50 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. Disp:*14 Tablet(s)* Refills:*0* 12. prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day for 2 weeks: Please take prednisone 50 mg/day for 1 week (one 50 mg tab - other prescription), then start taking 40 mg/day for 2 weeks (two 20-mg tabs). Disp:*28 Tablet(s)* Refills:*0* 13. diphenoxylate-atropine 2.5-0.025 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for diarrhea. Disp:*60 Tablet(s)* Refills:*0* 14. psyllium Packet Sig: One (1) Packet PO TID (3 times a day): take with meals to prevent diarrhea. Disp:*90 Packet(s)* Refills:*0* 15. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for pain, itching of rash. Disp:*1 bottle* Refills:*0* 16. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-5**] Sprays Nasal TID (3 times a day) as needed for nasal congestion. for 1 weeks. Disp:*1 bottle* Refills:*0* 17. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Multicultural VNA Discharge Diagnosis: Primary Diagnosis: Idiopathic Granulomatous Disease . Secondary Diagnoses: Myelodysplastic Syndrome Epistaxis 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 fevers. . You underwent an extensive investigation for a source for your fevers. We found: 1. You had an abscess in your neck which resolved with antibiotics after drainage. 2. You had pneumonia which was also treated with antibiotics. 3. You were evaluated by rheumatologists who felt that your persistent fever and many of your other symptoms could be explained by a diagnosis of Idiopathic Granulomatous Disease (IDP), which is likely related to your ulcerative colitis. This was causing changes in your bone marrow and your skin, and fever. These symptoms improved with steroids. 4. We started you on antibiotics to prevent viral and fungal infections. All other studies including labs and imaging were negative. . You were recently diagnosed with Myelodysplastic Syndrome. You had a bone marrow biopsy because we were concerned that your symptoms might be related to your Myelodysplastic Syndrome. Myelodysplastic Syndrome can sometimes develop into leukemia, but the bone marrow showed that you do not have leukemia. . You also had an episode of nosebleeding which required 4 blood transfusions and nasal packing. We are not sure why this happened, but we were reassured that your nosebleed did not recur after the packing was removed. You were seen by the ear-nose-throat doctors who would also like to see you for a follow-up appointment (details below). They would also like you to take antibiotics for two more days. . You also had a biopsy of your palate (the roof of your mouth) which did not show infection. The sores resolved. . We made the following changes to your medications: 1. STARTED AUGMENTIN, TAKE 500 mg every 8 hours THROUGH SUNDAY, [**11-5**]. 2. STARTED STEROIDS: TAKE 50 MG PREDNISONE ONCE PER DAY FOR 1 WEEK, THEN 40 MG ONCE PER DAY FOR TWO WEEKS. PREDNISONE DOSE WILL BE TAPERED BY YOUR RHEUMATOLOGIST AT A FOLLOW-UP APPOINTMENT. 3. STARTED ACYCLOVIR, TAKE 400 MG EVERY 8 HOURS 4. STARTED BACTRIM, TAKE ONE SINGLE-STRENGTH TAB DAILY 5. STARTED MODIL (DIPHENOXYLATE-ATROPINE): TAKE 1 TAB EVERY 6 HOURS AS NEEDED FOR DIARRHEA. 6. STARTED PSYLLIUM FLAKES 1 packet three times per day (with meals; fiber source for diarrhea) 7. STARTED SALINE NASAL SPRAY, [**12-5**] SPRAYS PER NOSTROL AS NEEDED FOR SINUS CONGESTION FOR 1 WEEK. 8. STOPPED SIMVASTATIN (because of liver labs) 9. STOPPED LEVOFLOXACIN (LEVAQUIN). 10. STARTED Sarna Lotion, APPLY UP TO THREE TIMES PER DAYS FOR pain, itching of rash on hands . Since there are so many medication changes, we recommend that you review the medication list (attached) with your primary doctor and your oncologist at your next appointments. . Note that we stopped the other hand lotion because you had already used it for two weeks, which dermatology recommended. If the sores on your hands re-appear, you should discuss this with your rheumatologist who may restart this medication. . You may also need a liver biopsy in the future. You should have your liver labs checked soon by your primary physician or rheumatologist, and they can help you set up an appointment with a liver specialist if needed. Followup Instructions: Department: OTOLARYNGOLOGY-AUDIOLOGY When: THURSDAY [**2124-11-9**] at 11:30 AM With: [**Name6 (MD) 15040**] [**Last Name (NamePattern4) 15041**], MD [**Telephone/Fax (1) 41**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 895**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: HEMATOLOGY/BMT When: THURSDAY [**2124-11-9**] at 1:30 PM With: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3885**], NP [**Telephone/Fax (1) 3886**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2124-11-9**] at 1:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3884**], MD [**Telephone/Fax (1) 3237**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . RHEUMATOLOGY, DR [**First Name8 (NamePattern2) 674**] [**Last Name (NamePattern1) **] [**2123-11-16**] AM [**Hospital Unit Name **], [**Hospital Ward Name **] [**Hospital Unit Name **] ([**Telephone/Fax (1) 1668**] . PRIMARY CARE DR. [**Last Name (STitle) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 412**] [**2124-11-14**] 1:00 PM [**Location (un) **] PRIMARY CARE [**Apartment Address(1) 56876**], [**Location (un) **],[**Numeric Identifier 41397**] Phone: [**Telephone/Fax (1) 9146**] [**Name6 (MD) 11021**] [**Name8 (MD) 11022**] MD [**MD Number(2) 38620**]

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48025

Discharge summary

report

Admission Date: [**2115-11-28**] Discharge Date: [**2115-12-5**] Date of Birth: [**2046-6-27**] Sex: F Service: MEDICINE Allergies: Motrin / Lipitor Attending:[**First Name3 (LF) 562**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Endotracheal intubation. Chest CT Hemodialyis with additional ultrafiltration sessions. History of Present Illness: HPI: 69-yo-woman w/ HIV, COPD, ESRD on HD presents w/ shortness of breath x 2 hours. She reportedly was feeling well until 7pm, when she developed dyspnea at rest. The dyspnea became progressively worse over the next 2 hours, prompting presentation to the ED. The pt did not complain of any fever, chills, increased cough, chest pain, abd pain, melena, or hematochezia. On arrival in the ED, her temp 103, HR 162, BP 230/104, RR 38. She was in acute resp distress and was intubated immediately and placed on CMV ventilation. Propofol gtt was started for sedation, resulting in decreased BP to 70/42. Propofol was then d/c, and levophed was added, resulting in increased BP to 118/55. Initial CXR was concerning for PNA w/ diffuse interstitial infiltrates, and the pt was treated w/ levo/vanco/ flagyl/bactrim/hydrocortisone. The MICU team was then called for further evaluation. Past Medical History: Past Medical History: 1. CAD s/p NSTEMI [**5-19**], s/p PTCA/stent LCX [**2113**]. Latest catheterization in [**10-21**] with 2-vessel disease. Persantine MIBI [**4-22**] without symptoms or EKG changes. MIBI images significant for severe fixed inferior defect, EF 58%. 2. DM type 2, on NPH. 3. HIV, last CD4 count 940 in [**7-/2115**] 4. ESRD on HD since '[**10**] (M, W, F) 5. CHF, with mixed systolic (EF 45-50%) and diastolic dysfunction. 6. Severe mitral regurgitation [**2115-6-20**] 7. History of RUL segmental PE in [**11/2114**], on coumadin ([**2114-12-5**]) D/C'd in 06/[**2115**]. 8. Recently diagnosed right popliteal DVT [**7-/2115**], restarted on Coumadin 9. H/o multiple AVF clots, s/p thrombectomies, last in [**2115-1-8**] 9. H/o GIB in the setting of coagulopathy and NSAIDs 10. Eosinophilic pneumonia diagnosed [**4-22**], on chronic prednisone therapy. 11. Anemia [**2-20**] CRF 12. Vulvar intraepithelial neoplasia diagnosed in [**2113-4-18**]. 13. COPD with PFTs with FVC 0.69 (27%), FEV1 0.46 (24%), FEV1/FVC 92%. 14. History of positive Galactomannan antigen 15. RUL nodules on CT, not FDG avid on PET on [**8-20**]. Etiology unclear. 16. Vulvar squamous cell carcinoma in situ. Social History: Recently was at the [**Hospital **] rehab. Lives in [**Location 686**] with her daughter. [**Name (NI) **] EtOH. Ex-smoker (60 pack-year smoking history) Family History: Non-contributory Physical Exam: On admission to MICU: PE: T 103, HR 112, BP 118/55, O2 sat 100% CMV 500 x 12/40%/5 Gen: chronically ill appearing woman lying flat in bed, intubated, moving all 4 extremities in NAD. HEENT: anicteric, EOMI, PERRL, OP clear w/ MMM, no JVD CV: reg s1/s2, no s3/s4/m/r Pulm: coarse BS throughout, no wheezes or crackles Abd: obese, +BS, soft, NT, ND Ext: warm, 2+ DP B, no edema Neuro: pt too lethargic to cooperate; moving all extremities spontaneously and follows basic commands Pertinent Results: Initial chest x-ray. 1. Endotracheal tube properly positioned with tip at the thoracic inlet. 2. Findings consistent with severe pulmonary edema with possibly etiologies including congestive failure or, less likely, ARDS. [**2115-12-4**] chest x-ray. Resolution pulmonary edema Initial chest CT. There is an endotracheal tube in place. The airways are patent. There is no pericardial effusion. There are no filling defects in the pulmonary arterial vasculature. No pulmonary embolism is identified. Some calcifications are seen in the coronary arteries, the aortic arch and descending aorta. Otherwise, the heart and great vessels are unremarkable. There is mild bilateral pleural effusion. There is no axillary lymphadenopathy. There is a precarinal 16 x 17-mm lymph node. Interval increase in size in the spiculated mass located in the right upper lobe measuring now 34 x 24 mm concerning for lung cancer. New extensive patchy areas of ground-glass opacities are seen throughout the lungs, mostly compromising the upper lobes . Limited images of the upper abdomen did not demonstrate significant abnormalities. BONE WINDOWS: There are no concerning bone lesions. CT RECONSTRUCTIONS: Confirmed the findings in the axial images. IMPRESSION: 1. No evidence of pulmonary embolism. 2. Diffuse ground-glass opacities through the lung parenchyma, concerning for PCP or pulmonary interstitial lymphoma with underlying probable lung cancer in the right upper lobe. 3. Bilateral pleural effusion. Brief Hospital Course: This is a 69 year old woman with HIV on HAART (last CD4 940), CHF (EF 50%) COPD, eosinophilic pneumonia, prior DVT and PE on coumadin, and ESRD on HD who presented to this hospital on [**11-28**] for 2 dyspnea and was found on arrival to be in acute respiratory distress. She was intubated immediately and placed on CMV ventilation. Of note the patient also became hypotensive soon after a propofol drip was started for sedation. Propofol was then discontinued, and levophed was added, resulting in increased BP to 118/55. The initial chest x-ray was concerning for PNA as diffuse interstitial infiltrates were visualized. The pt was admittted to the MICU and was treated empirically with broad spectrum antibiotics along with hydrocortisone for possible COPD exacerbation. In the MICU the pt was weaned off pressors fairly quickly, extubated by hospital day 2, and was subsequently transferred to the floor. It was believed that her respiratory distresss had a large component secondary to fluid overload which was treated by hemodialysis. She underwent several rounds of ultrafiltration in addition to her regular hemodialysis which resulted in improvement of her volume status as evidenced by her improvement in respiratory status, her physical exam, and by resolution of pulmonary edema on chest x-ray. Her course on the medical [**Hospital1 **] was complicated only by one episode of chest pain that was not associated with EKG changes and for which she ruled out for MI by cardiac enzymes. As her admission INR was subtherapeutic, she was maintained on a heparin drip along with coumadin for her history of DVT and PE until therapeutic INR was reachieved. Her hospital course on the [**Hospital1 **] was otherwise unremarkable. She was discharged breathing normally on room air and with instructions to finish her empiric course of antibiotics. Of note, review of her chest CT scan with the pulmonary service revealed that a previously noted mass in the right upper lobe had increased in size in comparison to a chest CT performed 3 months ago. This raised concern that this mass may be malignant. She was to follow up with the pulmonary service regarding this finding. In summary, this is a 69 year old HIV positive woman on HAART with CHF, COPD, ESRD on HD, and history of DVT and PE on coumadin who was admitted in respiratory failure, intubated briefly and treated empirically for pneumonia with broad spectrum antibiotics, for COPD exacerbation with steroids, and with hemodialysis for evidence of CHF exacerbation. Her respiratory status satisfactorily improved with these treatments and it was felt that her presentation was largely secondary to volume overload from CHF exacerbation. Issues and plan arising from this hospitalization. 1. Pneumonia/Resp failure: Hypoxic respiratory failure now seems to have been from pulmonary edema from CHF exacerbation. Contriubtion from pneumonia/reactive airway disease and eosinophilic PNA also possible. Status post extubation [**11-29**], doing well. - breathing improved well with serial ultrafiltration sessions along with dialysis. Pt to continue regular dialysis sessions as outpatient. - question PNA; although no source was identified, pan cultures were unrevealing, Pt received empiric 10 day course of levofloxacin, flagyl, and vancomycin (start [**11-28**]) - AFB smear negative, PCP negative [**Name Initial (PRE) **] serum CMV IgG positive, IgM negative suggesting no recent exposure. . 3. COPD: Has required intubation in past for COPD. Initially received high dose steroids which were tapered down to her home dose - continue atrovent/albuterol nebulizers. - on prednisone taper to 10 tomorrow. . 4. Hypotension: Had brief pressor requirement, prior hypotensive episode likely secondary to propofal along with sepsis. Now blood pressure nl without pressor requirement. -Initially held metoprolol, lisinopril 2.5 q day and Isordil 10 [**Hospital1 **]. Restarted these by discharge. . 5. CAD/ Episode. Pt with known CAD s/p p NSTEMI [**5-19**], s/p PTCA/stent LCX [**2113**]. Latest catheterization in [**10-21**] with 2-vessel disease. CP now resolved, no EKG changes or new elevation in CE, pt was ruled out for MI. -continue ASA 325 -restarted metoprolol and titrated up until rate control was optimized -continue imdur and lisinopril as outpatient. . 6. ESRD on HD (M,W,F), her CHF exacerbation and fluid status were largely managed by hemodialysis and additional ultrafiltration sessions. -Pt to continue regular HD schedule as outpatient. . 6. HIV: CDR count 253; previous CD4 count 900s 3 months ago on HAART. Unclear compliance with meds but pt says she has been taking them. - HIV viral load undetectable - cont zidovudine, nevirapine, lamivudine . 7. Eosinophilic PNA: CT findings suggestive of infection but different from previous studies. - continued home dose ofsteroids prednisone to taper. . 8. H/O DVT, possible oncompliance given INR was 1 on admission. No PE on CTA. - pt was successfully bridged with heparin and discharged on coumadin with therapeutic INR . 9. DM2: controlled with sliding scale with NPH while in hospital. . 10. FEN: - [**Doctor First Name **], heart healthy, renal diet - lytes repleted cautiously given renal status. 11. Prophylaxis included heparin/coumadin, protonix . 12. Access: R subclavian IJ placed [**11-28**], discontinued by discharge. . 13. Contact: [**Name (NI) **] [**Last Name (NamePattern1) 42692**] (daughter) is HCP [**Telephone/Fax (1) 101301**] (H), [**Telephone/Fax (1) 101302**] (W) . Code status remains full. Medications on Admission: Bactrim 80-400 mg q M/W/Fri Prednisone 20 mg qd (to be tapered slowly) B Complex-Vitamin C-Folic Acid 1 mg qd Zidovudine 200 [**Hospital1 **] Nevirapine 200 [**Hospital1 **] Lamivudine 100 qd Docusate Sodium 100 mg [**Hospital1 **] Pantoprazole 40 q 24 Albuterol q 4 prn Albuterol-Ipratropium q6 Hydromorphone 4 mg Q3-4H prn Calcium Carbonate 500 tid Oxycontin 10 mg q12 hr Senna 8.6 [**Hospital1 **] prn Epogen inj Coumadin 2.5 qhs Paricalcitol 5 mcg/mL Solution [**Hospital1 **]: As decided at dialysis Intravenous 3X/WEEK (MO,WE,FR). NPH 20 units qam, with regular sliding scale twice a day ASA 325 q day Metoprolol 25 [**Hospital1 **] Lisinopril 2.5 q day Isordil 10 [**Hospital1 **] Discharge Medications: 1. Prednisone 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Zidovudine 100 mg Capsule [**Hospital1 **]: Two (2) Capsule PO BID (2 times a day). Disp:*120 Capsule(s)* Refills:*2* 3. Nevirapine 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2* 6. Lamivudine 100 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Vancomycin in Dextrose 1 g/200 mL Piggyback [**Last Name (STitle) **]: One (1) gram Intravenous X1 (ONE TIME) for 1 doses: Please give one more vancomycin treatment during next dialysis session. Disp:*1 gram* Refills:*0* 8. Nitroglycerin 0.3 mg Tablet, Sublingual [**Last Name (STitle) **]: One (1) Tablet, Sublingual Sublingual Q5MIN X 3 () as needed for prn pain: Take 1 pill for chest pain, if no relief after 5 min take another, if still no relief after 5 min take one more; seek medical attention. Disp:*30 Tablet, Sublingual(s)* Refills:*0* 9. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Last Name (STitle) **]: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 10. Warfarin 2.5 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 11. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [**Last Name (STitle) **]: [**1-20**] Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*1 solution* Refills:*1* 12. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR [**Month/Day (2) **]: 1.5 Tablet Sustained Release 24HRs PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 13. Loperamide 2 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. Disp:*120 Capsule(s)* Refills:*1* 14. Ipratropium Bromide 0.02 % Solution [**Month/Day (2) **]: One (1) inhalattion Inhalation Q4H (every 4 hours) as needed. Disp:*30 inhalattion* Refills:*0* 15. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO QHD (each hemodialysis). Disp:*30 Tablet(s)* Refills:*2* 16. Metronidazole 500 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO twice a day for 3 days: Total course is 10 days, day 1 is [**2115-11-28**]. Disp:*6 Tablet(s)* Refills:*0* 17. Levofloxacin 250 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO every other day for 3 days: A total course of 10 days, day 1 is [**2115-11-28**]. Disp:*2 Tablet(s)* Refills:*0* 18. Calcium Acetate 667 mg Tablet [**Month/Day/Year **]: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*60 Tablet(s)* Refills:*2* 19. Calcium Carbonate 500 mg Tablet, Chewable [**Month/Day/Year **]: Two (2) Tablet, Chewable PO QID (4 times a day) as needed. 20. Acetaminophen 325 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 21. Albuterol Sulfate 0.083 % Solution [**Month/Day/Year **]: One (1) inhalation Inhalation Q6H (every 6 hours) as needed. Disp:*1 solution* Refills:*1* Discharge Disposition: Home With Service Facility: Uphams Corner Home Care Discharge Diagnosis: Hypoxic respiratory failure. Congestive heart failure exacerbation. Possible pneumonia Non cardiac chest pain. Fluid overload R middle lobe mass in lung of unknown etiology Discharge Condition: Good, breathing normally on room air. Chest pain free. Able to tolerate solid food. Appropriately anticoagulated. Discharge Instructions: Please return to hospital if you start to experience chest pain or if you feel you it is gettting difficult to breathe. Please continue to attend all of your hemodialysis regimen. Please continue all medications prescribed in hospital, please note you are taking 7.5 mg of coumadin at night. Please note you are now taking 10 mg of prednisone every day. Please note you will be taking levoquine and flagyl until [**2115-12-7**]. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] at the [**Hospital 778**] Clinic on [**2115-12-10**] at 11:15 AM. (Phone number is [**Telephone/Fax (1) 2393**]). Please follow up with Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) **] on [**12-23**], [**2115**] at 4:30 pm their number is [**Telephone/Fax (1) 55570**]. You will receive Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) 4174**], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2115-12-18**] 1:15 Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **] & DR [**First Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2115-12-23**] 4:30 Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2116-9-17**] 1:15

[ "496", "276.2", "V08", "V58.67", "250.00", "518.81", "285.21", "428.0", "V58.61", "584.9", "414.01", "585.6", "162.3", "518.3", "V45.82", "397.0", "412", "424.0" ]

icd9cm

[ [ [] ] ]

[ "96.04", "99.04", "96.71", "39.95", "33.24" ]

icd9pcs

[ [ [] ] ]

14392, 14446

4765, 10326

285, 374

14662, 14780

3241, 4742

15381, 16178

2709, 2727

11066, 14369

14467, 14641

10352, 11043

14804, 15358

2742, 3222

238, 247

402, 1293

1337, 2521

2537, 2693

13,622

149,614

7236

Discharge summary

report

Admission Date: [**2113-6-20**] Discharge Date: [**2113-6-24**] Date of Birth: [**2032-10-5**] Sex: F Service: MEDICINE Allergies: Sulfonamides / Nortriptyline / Ultram / Diltiazem / Ace Inhibitors / Norvasc / Percocet / Zetia / Cymbalta Attending:[**First Name3 (LF) 2186**] Chief Complaint: Dypsnea. Major Surgical or Invasive Procedure: None. History of Present Illness: 80 y.o. F h/o COPD, diastolic CHF, HTN, s/p PPM for Mobitz II, AAA s/p repair, RAS s/p stent, MRSA bacteremia, presenting with 4 days increasing dyspnea. Began with URI symptoms of rhinorrhea and cough increasingly productive of gree/yellow sputum. Denies fevers or night sweats, admits chills once or twice. Daughter with whom she lives had cold several days before patient's onset of symptoms. Ms. [**Known lastname 12056**] states she had worsening SOB. Saw PCP yesterday, who added Flovent to her COPD regimen and started treatment for UTI with Levaquin 250mg PO daily. He also checked a CXR which had no infiltrate. This morning, dyspnea worsened, daughter describes patient as "gasping for air", brought to the ED. In the ED, initial VS T: 98.2F, BP 177/96, HR: 90, RR: 30, SaO2: 89% RA. Noted to have bilateral expiratory wheezing with increased respiratory effort. She was given SoluMedrol 125mg IV, combivent nebs, and covered for possible COPD flare with vancomycin 1gm IV, CTX 1gm IV, and Azithromycin 500mg PO. She received ASA 325mg. Wbc 9.1 with 84% PMN, lactate 3.1. BNP >70,000 (baseline 30,000). Repeat CXR done which showed no infiltrate, no evidence of pulmonary edema. Ddimer was positive, and she had a CTA, which demonstrated no evidence of PE or dissection, but showed peribronchial opacities potentially concerning for early multifocal PNA. Past Medical History: 1) Vasculopathy--has history of AAA, s/p endovascular AAA repair (AAA was 4.7 cm) in [**2109-1-3**]. In [**2112-7-12**] under aortogram, celiac balloon angioplasty and stent, superior mesenteric artery stent. She was noted to have endovascular leak in [**10-10**] and underwent open AAA repair and RAS stent placed. -# s/p Rt. SFA-TPT vein graft [**10-5**] -Carotid disease. Asymptomatic. Rt. 60-69% Lt. 40-59% 2) Cardiac conduction disease --s/p post operative AF [**8-6**] --s/p SVT s/p ablation [**4-7**] -- h/o Mobitz II block s/p pacemaker -- diastolic CHF 3) COPD, [**8-/2112**] PFTs with FEV 1.16 FVC 1.86 0.53 FEV/FVC ratio 63 (92% predicted) 4) Hypertension on multiple agents 5) hypercholestremia 6) Hiatal hernia with reflux/Gastritis/GERD 7) CRI baseline creatinine 1.3-1.5 8) anemia 9) MRSA urine/blood [**11-8**] subsequent to RAS - was on vanc, but recently changed to doxycycline chronically Other Surgical history: 10) s/p ovarian cyst ecxision with appendectomy [**4-/2059**] 11) s/p CCY [**2-/2080**] 12) s/p spinal surgery [**6-/2085**] 13) s/p spinal fusion [**8-6**] Social History: The patient lives at home with a daughter in [**Name (NI) 4628**], previously a homemaker. Tobacco: 60 years x 2PPD: 120 pk-yr, quit [**2096**]. ETOH: None. Illicits: None Family History: Noncontributory Physical Exam: T: 98.3 BP: 177/89 HR: 89 RR: 22 SaO2: 98% 2L NC Gen: Elderly Caucasian female, lying comfortably in bed, using accessory muscles to breathe, speaking in partial sentences. Oriented, answers questions appropriately HEENT: PERRL, EOMI, oropharynx clear Neck: Supple, no LAD or thyromegaly, JVP not elevated CV: RRR, no m/r/g Chest: Distant breath sounds, no wheezing auscultated, decent air movement and chest expansion, mild bibasilar rales Abd: Soft, NT/ND, pain (old) over left flank, +BS Extr: Trace LE edema, R>L, trace DPs bilaterally, no calf tenderness Neuro: A&Ox3, 5/5 strength throughout, sensation intact to LT Pertinent Results: ADMISSION LABS: ================ 12.4 9.1 >-------< 357 39.5 MCV 97 Neuts 84.2 Lymphs 13.4 Monos 1.9 Eos 0.1 Baso 0.4 PT 23.5 PTT 34.3 INR 2.3 145 106 36 -----|-----|-----< 154 4.4 23 1.2 CK 184 MB 9 Trop 0.04 BNP >70,000 D-dimer 1390 Lactate 3.2 UA: BLOOD-MOD NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM, RBC-[**3-8**]* WBC-[**3-8**] BACTERIA-FEW YEAST-NONE EPI-[**3-8**] PERTINENT LABS DURING HOSPITALIZATION: ====================================== WBC trend: 9.1 - 8.5 - 6.9 - 5.4 - 7.3 Cr trend: 1.2 - 1.3 - 1.3 - 1.1 - 1.1 Lactate trend: 3.2 - 2.5 - 2.2 INR trend: 2.3 - 2.3 - 5.3 - 7.2 - 3.5 CK 184 - 177 MB 9 - 10 Trop 0.04 - 0.05 MICROBIOLOGY: ============= [**6-20**] BCx: NGTD [**6-20**] URINE CULTURE (Final [**2113-6-22**]): KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 16 I CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 128 R PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- 2 S [**6-21**] Legionella Urinary Ag: negative STUDIES: ======== [**6-19**] CXR (PA & LATERAL) IMPRESSION: No evidence of acute cardiopulmonary process. [**6-20**] EKG Atrial fibrillation or possible flutter Left ventricular hypertrophy Q-Tc interval appears prolonged but is difficult to measure Diffuse ST-T wave abnormalities These findings are nonspecific but clinical correlation is suggested Since previous tracing of the same date, ventricular rate faster [**6-20**] EKG Atrial fibrillation or possible flutter Left ventricular hypertrophy Q-Tc interval appears prolonged but is difficult to measure Diffuse ST-T wave abnormalities These findings are nonspecific but clinical correlation is suggested Since previous tracing of [**2113-5-10**], ventricular paced rhythm absent [**6-20**] CXR (PORTABLE) FINDINGS: There is minimal interval change. The left-sided dual pacemaker with leads terminating in the right atrium and right ventricle remains unchanged. Cardiomegaly is moderate and stable. The tortuous aorta is unchanged. The lungs are slightly hyperinflated but there is no infiltrate. There is some linear atelectasis at the bases. There is no pleural effusion or pneumothorax. IMPRESSION: No evidence of acute cardiopulmonary process. [**6-20**] CTA CHEST W&W/O C&RECONS, NON-CORONARY IMPRESSION: 1. No evidence of PE or acute aortic syndrome. 2. Multiple patchy opacities in a bronchovascular pattern seen as in bilateral lungs, which are concerning for an early multifocal pneumonia with adjacent adenopathy, likely reactive. [**6-21**] EKG Atrial fibrillation Diffuse ST-T wave abnormalities with prolonged Q-Tc interval - cannot exclude in part ischemia - clinical correlation is suggested Since previous tracing of [**2113-6-20**], QRS voltages less prominent and further ST-T wave changes present Brief Hospital Course: MICU SUMMARY: ============== Ms. [**Known lastname 12056**] is an 80 y.o. F with COPD, diastolic CHF, HTN, s/p PPM for Mobitz II, AAA s/p repair, RAS s/p stent, MRSA bacteremia, presenting with 4 days of increasing dyspnea that was preceded with rhinorrhea and productive cough of green/yellow sputum. She denied fevers/night sweats, but admits to chills 1-2x. Her daughter who lives with her also had a cold several days prior to the patient's onset of symptoms. She had increasing SOB and saw her PCP the day PTA, who gave her Flovent and started her on Levaquin for a UTI. A CXR was negative at PCP's office. The morning of ICU admission, the patient was "gasping for air" and brought to the ED by her daughter. In the ED, VS notable for BP 177/96, RR 30 and O2 sat 89% RA. Noted to have bilateral expiratory wheezing with increased respiratory effort. Given SoluMedrol 125 mg IV, Combivent nebs, and covered for COPD flare with vancomycin 1 gm IV, CTX 1 gm IV, and Azithromycin 500 mg po. Of note, BNP >70,000 (baseline 30,000). CXR showed no infiltrate, no pulmonary edema. D-dimer was positive, CTA did not show PE or dissection, but showed peribronchial opacities, concerning for early multifocal PNA. In the MICU, she was continued on broad spectrum antibiotics(Vancomycin/Zosyn/Azithromycin). She also received Lasix on admission. She was switched to po prednisone for COPD exacerbation. EP was consulted for changing EKG with new TWI in II, III, AVF, which was thought to be T wave memory from pacer placement. EP recommended keeping her I=O and correctly lytes, no plan for DCCV until pt medically stable. She was transferred to the medicine floor for further management. MEDICINE FLOOR COURSE: ======================= # ? Multifocal Pneumonia: Concerning for pneumonia on CT. Urine legionella was negative. She never produced a sputum culture. She remained afebrile without leukocytosis. On transfer from MICU, her broad spectrum antibiotics were changed to azithromycin and ceftriaxone and then she was switched to Levofloxacin for CAP and completed her course while in the hospital. Blood cultures remained negative. # COPD: She continued to have wheezing throughout lung fields and was intermittently tachypneic. She was switched to po prednisone and a taper was started and will be completed after discharge. Atrovent and albuterol nebs were given standing. She was also continued on azithromycin. Her supplemental oxygen was weaned. PT evaluated the patient, and with ambulation, her O2 sats remained in the mid 90's. # Supratherapeutic INR: Likely secondary to antibiotics. Her Coumadin was held. She will follow up with her PCP and have an INR check. # Diastolic CHF: Exam with bibasilar crackles c/w some mild pulmonary edema in setting of known diastolic dysfunction. Her home dose of Lasix was continued. # Hypertension: Her home regimen was continued with good control of her BPs. # AFib: Rate well controlled with metoprolol. Scheduled for outpatient elective cardioversion, but was cancelled due to her hospitalization. Coumadin was held while INR was supratherapeutic. # New TWI: Noted on EKGs. As discussed above, EP believed the TWI were due to pacer maker and did not recommend any intervention during this hospitalization. # UTI: Urine grew out Klebsiella susceptible to ceftriaxone. She completed her 3 day course of ceftriaxone while in the hospital. # h/o MRSA bacteremia: She was on vancomycin upon transfer to the Medicine floor. After vancomycin was stopped, she was restarted on her doxycycline suppressive therapy. # Hyperlipidemia: Continued Statin. # Code: Full Code, confirmed with patient . # Contact: Daughter - [**Name (NI) 2048**] [**Telephone/Fax (1) 26798**] # Dispo: Home with services and close follow up with PCP. Medications on Admission: MEDICATIONS ON ADMISSION: From OMR ALBUTEROL SULFATE - Nebulization 1 neb q6h as needed ATORVASTATIN - 80mg by mouth once a day CLONIDINE - 0.2mg by mouth twice a day CLOPIDOGREL - 75mg by mouth once a day DOXYCYCLINE - 100mg every twelve (12) hours ESOMEPRAZOLE 40mg by mouth once a day FLUTICASONE - 110 mcg/Actuation Aerosol - 2 puffs twice a day FUROSEMIDE 20mg by mouth once a day for edema HYDRALAZINE - 50mg by mouth three times a day VICODIN - 5 mg-500 mg - [**1-4**] Tablet(s) by mouth q6 hours as needed ISOSORBIDE DINITRATE - 30mg by mouth three times a day LEVOFLOXACIN 250mg by mouth once a day x 7 days (started [**6-19**]) METOPROLOL - 50mg by mouth three times a day WARFARIN - 2mg qHS S/W/Fr, 4mg qHS M/T/Th/Sa MEDICATIONS ON TRANSFER: Acetaminophen 325-650 mg po q6 hours prn Albuterol 0.083% 1 nebulizer IH q6 hours Albuterol 0.083% 1 nebulizer IH q2 hours prn Atorvastatin 80 mg po daily Azithromycin 250 mg po q24 hours (day 1 = [**2113-6-20**]) Clonidine 0.2 mg po BID Clopdiogrel 75 mg po daily Hydralazine 50 mg po q8 hours Ipratropium Bromide 1 neb IH q6 hours Isosorbide Mononitrate 30 mg po daily Metoprolol Tartrate 50 mg po TID Pantoprazole 40 mg po q24 hours Zosyn 2.25 g IV q6 hours (day 1 = [**2113-6-20**]) Prednisone 30 mg po daily Vancomycin 1 gm IV q48 hours (day 1 = [**2113-6-20**]) Coumadin 2 mg po 3 x week Coumadin 4 mg po 4 x week Discharge Medications: 1. Atorvastatin 40 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO DAILY (Daily). 2. Clonidine 0.1 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO BID (2 times a day). 3. Clopidogrel 75 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily). 4. Doxycycline Hyclate 100 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO Q12H (every 12 hours). 5. Esomeprazole Magnesium 40 mg Capsule, Delayed Release(E.C.) [**Month/Day/Year **]: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Month/Day/Year **]: One (1) treatment Inhalation every 4-6 hours as needed for wheezing. 7. Furosemide 20 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily). 8. Hydralazine 50 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q8H (every 8 hours). 9. Fluticasone 110 mcg/Actuation Aerosol [**Month/Day/Year **]: Two (2) puffs Inhalation twice a day. 10. Metoprolol Tartrate 50 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO TID (3 times a day). 11. Ipratropium Bromide 0.02 % Solution [**Month/Day/Year **]: One (1) treatment Inhalation Q6H (every 6 hours). 12. Docusate Sodium 100 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO BID (2 times a day) as needed for constipation. 13. Prednisone 10 mg Tablet [**Month/Day/Year **]: As directed Tablet PO DAILY (Daily) for 9 days: Please take two tablets (20 mg) once daily X 3 days ([**6-25**], [**6-26**], [**6-27**]) then one tablet (10 mg) once daily X 3 days ([**6-28**], [**6-29**], [**6-30**]). Then, take [**1-4**] tablet (5 mg) once daily X 3 days ([**7-1**], [**7-2**], [**7-3**]) then stop. Disp:*11 Tablet(s)* Refills:*0* 14. Isosorbide Dinitrate 30 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO three times a day. 15. Acetaminophen 325 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: total acetaminophen dose 4 g daily. 16. Senna 8.6 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnosis: Acute on chronic diastolic heart failure exacerbation Chronic obstructive pulmonary disease flare Secondary Diagnosis: Hypertension Peripheral vascular disease Hypercholesterolemia Stage 3 chronic kidney disease Discharge Condition: Afebrile, normotensive, comfortable on room air, room air oxygen saturation 100% Discharge Instructions: You have been evaluated for your shortness of breath. You were treated for heart failure, COPD, and pneumonia. Your breathing improved. You were evaluated by physical therapy who feel that you can return home with home physical therapy. Please continue your home medications as prescribed. Your new medication is prednisone. Please take this as directed. We have held your coumadin as your lab level was too high. You need to have this checked at your doctor's office on [**Hospital 766**], [**6-26**]. Please keep all your medical appointments. Please call your physician or return to the emergency if you experience any of the following symptoms: fever > 101, chills, nausea or vomiting with inability to keep down liquids or by mouth medications, shortness of breath, chest pain, or any other concerns. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Followup Instructions: Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], on [**Last Name (LF) 766**], [**6-26**] at 12:45 pm. Call [**Telephone/Fax (1) 1144**] if there is a problem with this appointment. Please have your INR checked at this appointment. Please keep these other already-scheduled appointments: Provider: [**First Name11 (Name Pattern1) 4952**] [**Last Name (NamePattern4) 10591**], MD Phone:[**Telephone/Fax (1) 10590**] Date/Time:[**2113-7-3**] 1:00 Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2113-9-11**] 9:15 Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 1142**] Date/Time:[**2113-9-25**] 10:15 Completed by:[**2113-6-25**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

14400, 14458

7125, 10915

376, 384

14734, 14817

3775, 3775

15778, 16619

3100, 3117

12340, 14377

14479, 14479

10967, 11670

14841, 15755

3132, 3756

328, 338

412, 1780

14618, 14713

3791, 7102

14498, 14597

11695, 12317

1802, 2895

2911, 3084

20,913

102,847

4472

Discharge summary

report

Admission Date: [**2137-12-10**] Discharge Date: [**2138-1-2**] Date of Birth: [**2087-10-22**] Sex: M Service: MEDICINE Allergies: Penicillins / Codeine Attending:[**First Name3 (LF) 19157**] Chief Complaint: SOB, dizziness Major Surgical or Invasive Procedure: Dialysis catheter placement peg placement tunnled line placement peritoneal dialysis catheter trachestomy History of Present Illness: Pt is 50 yo M with ESRD-PD(daily at night), HTN, DM, CAD s/p NSTEMI and CHF with EF20% who presents to OSH with SOB, fatigue and with c/o feeling dizzy X 2days. He was found to be hypotensive to 80/20 and transferred to [**Hospital1 18**]. Overall has not been feeling well for about 3 days. Has developed progressive SOB, orthopnea. Unable to lay flat at this point. States edema unchanged. Had episode of chest pain last week and earlier yesterday that radiated down his left arm, now resolved. Denies anynausea, vomiting, diaphoresis. Denies any fevers, chills, dysuria. Minimal urine output which is his baseline. Denies any recent episodes of confusion. . In the ED found to have trop of 3.04 so he was started on heparin which was then d/c per cardiology recommendation. He also have further hypotensive to 60s, given gental ivf initially with BP going up to 80s, then started on dopamine infusion with BP's going to 110's. Also given Levofloxacin and flagyl in ED. Also got 2 units of PRBC's Past Medical History: -Hypertension. -CHF with an EF equal to 20% in [**2133-2-5**]. -Mild pulmonary hypertension. -Diabetes mellitus for greater than 20 years. -ESRD on PD -History of upper GI bleed secondary to gastritis. -Asthma. -Right below the knee amputation in [**2127**]. -Left eye blindness. -Coronary artery disease, status post non ST wave MI ([**2132**]),status post catheterization showing 50% D1 stenosis,pulmonary hypertension, increased right and left filling pressures, pulmonary artery pressure 70/35/51, wedge equal to29. -h/o pneumonia -Anemia. -Left elbow septic joint. -Peripheral neuropathy. -Hand/elbow arthritis. Social History: No alcohol, tobacco, or drugs. Lives in [**Location 3146**] with wife and kids. . Family History: Noncontributory. Physical Exam: T 97.9 BP 103/43 HR 78 RR 16 O2sats 94% 2L NC Gen- Obese, A&O times 3, mild respiratory distress HEENT- Blind in left eye, Rt eye reactive pupil, Rt eye EOMI, anicteric, dry mmm Neck- Unable to assess JVD given obesity Chest- Decreased breath sounds at bases CV- Distant heart sounds, regular, unable to appreciate any murmur Abd- Distended, obese, + BS, NT, + PD catheter, pannus pitting edema Ext- Rt BKA, Lt leg with edema, chronic venous stasis changes, + erythema Neuro- Grossly intact Pertinent Results: [**2137-12-9**] 08:45PM WBC-13.5* RBC-2.58*# HGB-7.6* HCT-23.3*# MCV-90# MCH-29.6# MCHC-32.8 RDW-16.1* [**2137-12-9**] 08:45PM NEUTS-85.0* LYMPHS-10.5* MONOS-3.4 EOS-1.0 BASOS-0.1 [**2137-12-9**] 08:45PM PLT COUNT-275 [**2137-12-9**] 08:45PM PT-15.6* PTT-29.1 INR(PT)-1.7 [**2137-12-9**] 08:45PM CK-MB-16* MB INDX-13.0* [**2137-12-9**] 08:45PM cTropnT-3.07* [**2137-12-9**] 08:45PM CK(CPK)-123 [**2137-12-9**] 09:03PM GLUCOSE-179* K+-5.2 [**2137-12-10**] 01:45AM ASCITES WBC-415* RBC-783* POLYS-52* LYMPHS-8* MONOS-31* MESOTHELI-3* MACROPHAG-6* . Imaging: DATA: Echo [**2-5**] - Mildly dilated LA, Mild LVH, moderately dilated LV, LVEF <20%, moderate pulm artery systolic hypertension. . Cath [**9-7**]- no flow limiting disease, RA 27 PCWP 29, LVEDP 32. . Stress MIBI [**12-10**] - no perfusion defect however only 50% target HR achieved. Brief Hospital Course: A/P: 50yo man with ESRD on PD, DM, CAD s/p NSTEMI, CHF with EF 20%, and HT, admitted with hypotension and acute on chronic renal failure, worsening acidosis. . Patient was admitted with hypotension and acute renal failure. Given high WBC count in peritoneal fluid concern for peritoneal infection was high and pt was started on ceftaz. He remained hypotensive and on and off dopamine for most of the hospitilaztion. Renal sevice followed pt and dialyzed pt with CCVH while he was hypotensive. Pt was intubated for respiratory distress and attempts to wean the went were unsuccessful. He underwent Tracheostomy, PEG placement, removal of peritoneal dialysis catheter and tunnled line for dialysis placement with surgery. He was weaned off all pressors. His respirattory status was stable and he was finally able to sit up in a chair. He was noted to be in a wide complex tachycardia on tele. He was unresponsive with no pulse and CPR was initiated. A code was run and after ~45-50 minutes of unsuccessful efforts to maintain a pulse of a viable rhythm after discussion with family code was stopped and pt expired. Medications on Admission: Medications: Calcium Acetate 667 mg, Two (2) Tablet PO TID W/MEALS Polysaccharide Iron Complex 150 mg PO DAILY B-Complex with Vitamin C. (1) Tablet PO DAILY. Folic Acid 1 mg Tablet (1) Tablet PO DAILY. Pravastatin Sodium 40 mg PO daily. Percocet 1 tablet q12 hours PRN. Lasix 80 mg po bid. Metolazone 2.5 mg po daily Losartan 50 mg po daily Metoprolol 100mg po daily Imdur 120 mg po daily Coumadin 2.5 mg po qhs Protonix 40 E.C. daily NPH 84 qam, 70 qpm RISS 10 u qAM Fosrenal 250 mg po qAC. Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired Completed by:[**2138-1-6**]

[ "250.41", "785.51", "585.6", "786.3", "278.00", "427.31", "V49.75", "V64.41", "420.0", "403.91", "008.45", "412", "996.68", "416.8", "584.9", "427.5", "038.9", "V58.67", "518.81", "567.29", "428.0", "369.60" ]

icd9cm

[ [ [] ] ]

[ "00.17", "96.72", "99.04", "38.95", "96.04", "54.98", "54.95", "43.19", "38.93", "31.1", "33.22", "39.95", "99.60", "97.82", "96.6" ]

icd9pcs

[ [ [] ] ]

5323, 5332

3629, 4752

299, 406

5383, 5392

2748, 3606

5448, 5485

2202, 2220

5294, 5300

5353, 5362

4778, 5271

5416, 5425

2235, 2729

245, 261

434, 1447

1469, 2087

2103, 2186

5,685

193,803

44876

Discharge summary

report

Admission Date: [**2146-5-19**] Discharge Date: [**2146-5-25**] Date of Birth: [**2062-6-1**] Sex: M Service: CARDIOTHORACIC Allergies: Statins-Hmg-Coa Reductase Inhibitors / Ezetimibe / lisinopril / Niacin Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion and Fatigue Major Surgical or Invasive Procedure: [**2146-5-20**] Mitral valve repair with a triangular resection of the middle scallop of the posterior leaflet and a mitral valve annuloplasty with a 28-mm St. [**Hospital 923**] Medical Saddle Ring. History of Present Illness: 83 year old gentleman has been followed for mitral regurgitation for several years. Recently, he has been experiencing dyspnea on exertion with minimal activity; such as walking within his home. He has still been able to walk one mile on a regular basis, but states he is totally wiped out at the end. He is also reporting a sharp band like chest discomfort which occurs at rest, about once per month. It lasts for 1-2 hours and then subsides on its own. Over the last 2 months he has had 2 admissions at [**Hospital6 4620**] for extreme fatigue and then with pneumonia. He has been caring for his wife who has jaw cancer with lymph node involvement. She is due to start radiation therapy in [**Month (only) 547**]. He was seen by Dr. [**Last Name (STitle) **] on [**2146-4-28**] and an echo was done which revealed severe mitral regurgitation as noted below. He has now been referred for TEE, outpatient cardiac catheterization and surgical consultation for a mitral valve replacment. Past Medical History: Prior silent IMI in approx [**2136**] Peripheral neuropathy-reports calf/feet pain when in bed Renal insufficiency Mitral regurgitation Diabetes type II-dietary management Pulmonary embolus approximately 7 yrs ago Prostate cancer 18 yrs ago s/p radical prostatectomy, radiation Hypertension Cardiac catheterization [**7-/2145**]: one vessel CAD with a 60% OM1 lesion Pneumonia Past Surgical History: Hernia surgery c/b perforated bowel Appendectomy Social History: Lives with:Wife Occupation:Retired travel [**Doctor Last Name 360**] Tobacco:denies ETOH:occasional glass of wine Family History: non contributory Physical Exam: Pulse:64 Resp:16 O2 sat: 98/RA B/P Right:133/83 Left:131/77 Height:6'2" Weight:180 lbs 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 [] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: No edema/(L)superficial varicosity [] Neuro: Grossly intact Pulses: Femoral Right: Left: DP Right: 2+ Left:2+ PT [**Name (NI) 167**]: Left: Radial Right:2+ Left:2+ Carotid Bruit-none carotid pulses Right: 2+ Left:2+ Pertinent Results: [**2146-5-24**] Ultrasound 1. No etiology for acute right upper quadrant pain localized. Gallbladder lumen containing sludge and rounded complex cystic structures within it, which could either represent a polypoid lesion, forming hematoma, or less likely a forming stone. Recommend MRI for further evaluation. 2. Echogenic liver, most compatible with fatty infiltration. Other forms of liver disease including more significant disease such as significant hepatic fibrosis/cirrhosis cannot be excluded on this study. 3. Small right pleural effusion. [**2146-5-24**] 04:50AM BLOOD WBC-8.4 RBC-3.17* Hgb-9.2* Hct-27.6* MCV-87 MCH-29.0 MCHC-33.4 RDW-14.0 Plt Ct-169 [**2146-5-19**] 05:25PM BLOOD WBC-6.4 RBC-3.50* Hgb-9.8* Hct-30.4* MCV-87 MCH-28.1 MCHC-32.4 RDW-13.9 Plt Ct-255 [**2146-5-25**] 04:55AM BLOOD PT-12.6 INR(PT)-1.1 [**2146-5-19**] 05:25PM BLOOD PT-18.6* PTT-27.6 INR(PT)-1.7* [**2146-5-24**] 04:50AM BLOOD Glucose-93 UreaN-24* Creat-1.1 Na-135 K-3.9 Cl-102 HCO3-24 AnGap-13 [**2146-5-19**] 05:25PM BLOOD Glucose-93 UreaN-29* Creat-1.4* Na-141 K-4.4 Cl-105 HCO3-27 AnGap-13 [**2146-5-24**] 04:50AM BLOOD ALT-9 AST-19 LD(LDH)-254* AlkPhos-56 Amylase-101* TotBili-0.5 Brief Hospital Course: The patient was brought to the operating room on [**2146-5-20**] where the patient underwent Mitral Valve Repair with Dr. [**Last Name (STitle) **]. 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. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. He was on coumadin preoperatively for history of pulmonary embolism. He developed brief post-op a-fib and coumadin was resumed on [**5-24**]. ACE inhibitor was not restarted for heart failure as his BP would not tolerate it.He will continue lasix until wound check appt [**6-1**] and will evaluate further therapy at that time. By the time of discharge on POD #5 the patient was ambulating freely, the wound was healing and pain was controlled with tylenol. The patient was discharged to home with VNA in good condition with appropriate follow up instructions. First blood draw Friday [**5-27**]. Target INR 2.0-3.0 for PE. Medications on Admission: DILTIAZEM HCL [CARTIA XT] - (Prescribed by Other Provider) - 120 mg Capsule, Ext Release 24 hr - 1 Capsule(s) by mouth once a day DULOXETINE [CYMBALTA] - 60 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day ENOXAPARIN - (Prescribed by Other Provider) - 60 mg/0.6 mL Syringe - 1 injection [**Hospital1 **] SAT and SUN while Coumadin is on hold prior to cath. As per Dr. [**Last Name (STitle) **]. OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day ROSUVASTATIN [CRESTOR] - 5 mg Tablet - 1 (One) Tablet(s) by mouth Monday, Wed and Friday at bedtime TIMOLOL - (Prescribed by Other Provider) - 0.25 % Drops - 1 drop both eyes once a day TRAVOPROST [TRAVATAN Z] - (Prescribed by Other Provider) - 0.004 % Drops - 1 gtt OU daily WARFARIN - (Prescribed by Other Provider) - 2 mg Tablet - 1.5-2.0 Tablet(s) by mouth takes 3mg 4x week, 4mg 3 times per week. Last dose pre cath [**4-27**]. Bridged w/Lovenox Medications - OTC ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (OTC) - 2,000 unit Capsule - 1 Capsule(s) by mouth once a day FISH OIL-DHA-EPA - (Prescribed by Other Provider) - 1,200 mg-144 mg Capsule - 1 Capsule(s) by mouth once a day MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1 Tablet(s) by mouth once a day OTC 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. 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. duloxetine 60 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:*1* 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 5. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY (Daily): 1000 mg daily. Disp:*30 Capsule(s)* Refills:*1* 6. cholecalciferol (vitamin D3) 2,000 unit Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*1* 7. timolol maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily): one drop both eyes. Disp:*1 bottles* Refills:*1* 8. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime): one drop both eyes. Disp:*1 bottle* Refills:*1* 9. 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:*1* 10. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks: daily until wound check appt [**6-1**]; will eval further dosing then. Disp:*14 Tablet(s)* Refills:*0* 11. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). Disp:*30 Tablet(s)* Refills:*1* 12. potassium chloride 10 mEq Capsule, Extended Release Sig: One (1) Tablet Extended Release PO DAILY (Daily) for 1 weeks: for one week until wound check [**6-1**]; will evaluate further therapy then. Disp:*14 Tablet Extended Release(s)* Refills:*0* 13. warfarin 2 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for 2 days: 4 mg [**5-25**] today; 4mg [**5-26**] tomorrow; then all further dosing per [**Hospital 2274**] [**Hospital **] clinic;target INR for PE 2.0-3.0. Disp:*50 Tablet(s)* Refills:*1* 14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). Disp:*60 Tablet(s)* Refills:*1* 15. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*60 Tablet Extended Release 24 hr(s)* Refills:*1* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Hypercholesterolemia/hypertriglyceridemia Prior silent IMI in approx [**2136**] Peripheral neuropathy-reports calf/feet pain when in bed Renal insufficiency Mitral regurgitation Diabetes type II-dietary management Pulmonary embolus approximately 7 yrs ago Prostate cancer 18 yrs ago s/p radical prostatectomy, radiation Hypertension Cardiac catheterization [**7-/2145**]: one vessel CAD with a 60% OM1 lesion Pneumonia Past Surgical History: Hernia surgery c/b perforated bowel Appendectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema- trace 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: Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] Wed [**6-1**] @ 10:00AM Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] [**6-16**] @ 1:45 pm Dr. [**Last Name (STitle) **] [**6-17**] @ 3:00 pm Cardiologist: [**First Name8 (NamePattern2) 2890**] [**Last Name (NamePattern1) 2889**], M.D. Phone:[**Telephone/Fax (1) 62**] date/Time:[**2146-6-24**] 12:00 ( lipid clinic) Please call to schedule the following: Primary Care Dr. [**Last Name (STitle) 90835**],[**First Name3 (LF) **] P. [**Telephone/Fax (1) 17794**] in [**5-17**] weeks Gen. Surgeon Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] as an outpt. **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR Coumadin for h/o pulmonary embolism Goal INR [**3-17**] First draw Fri [**5-27**] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by [**Hospital1 **] [**University/College **] coumadin clinic ( as pre-op) Results to phone fax : [**Name6 (MD) 3548**] [**Name8 (MD) 6358**] RN [**Telephone/Fax (1) 87875**] Completed by:[**2146-5-25**]

[ "412", "789.31", "357.2", "401.9", "414.01", "250.60", "593.9", "427.31", "424.0", "V10.46", "789.01", "356.9", "V12.51", "V15.3", "E878.1", "428.0", "272.4", "E849.7", "272.0", "997.1" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

9254, 9313

4121, 5592

369, 571

9849, 10018

2921, 4098

10806, 12082

2210, 2229

6932, 9231

9334, 9754

5618, 6909

10042, 10783

9777, 9828

2244, 2902

297, 331

599, 1588

1610, 1988

2078, 2194

62,478

112,654

44803

Discharge summary

report

Admission Date: [**2113-9-14**] Discharge Date: [**2113-9-17**] Service: MEDICINE Allergies: Statins-Hmg-Coa Reductase Inhibitors Attending:[**First Name3 (LF) 443**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Heart Catheterization History of Present Illness: [**Age over 90 **] year old man with CAD s/p CABG [**2086**] h/o PCI to SVG and PDA ([**2108**]) and to ostial, proximal Lcx and distal Lcx ([**2110**]), systolic CHF (LVEF 50%), HTN and HLD, who presented initially to OSH with chest pain beginning around 8PM on night of admission. He was in his usual state of health until 2 days ago when he was wading in the pool at his senior center and had brief transient chest pain that spontaneously resolved. On the afternoon of admission, he felt fatigued and "off" in general. He walked to a function at the senior center and then sat down where he developed gradual onset dull chest pressure in the lower chest radiating in a band and downward to his abdomen. He had associated SOB, diaphoresis, and nausea. Denied lightheadedness, back/jaw/arm pain. He became more and more uncomfortable and thus EMS was called. At the OSH, ECG showed inferior ST elevations and anterior ST depressions. There he received atorvastatin, aspirin full dose, metoprolol 5mg IV, and nitro SL x2 with resolution of chest pain. He was not started on anticoagulation due to a reported history of hemoptysis (described by patient as specks of blood with cough). In the [**Hospital1 18**] ED, initial vitals were 98.2 76 161/83 18 97% 2L NC. Labs and imaging significant for trop <0.01, creatinine 1.2, WBC 10, HCT 45, INR 1.0. ECG showed ST elevation [**Hospital1 1105**] and ST depression anteriorly. Received SL nitro 0.4mg once and then was started on a nitro drip for hypertension (no further chest pain). He was also started on a heparin drip but not [**Hospital1 4532**] loaded (guaiac was negative). Vitals on transfer were afebrile, 94 157/83 17 100% RA. On arrival to the floor, he is chest pain free. Denies SOB, lighteadedness or abdominal pain. REVIEW OF SYSTEMS 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. He denies recent fevers, chills or rigors. Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: CAD s/p CABG [**2086**], s/p PCI [**2108**] with Taxus stent x 2 to SVG to PDA and PCI [**2110**] of the ostial, proximal LCx and distal LCx. 3. OTHER PAST MEDICAL HISTORY: GERD Glaucoma OSA on CPAP Cataracts Glaucoma Prostate CA s/p radiation Social History: Lives w/ son in [**Name2 (NI) 13089**] housing in [**Name (NI) **] ([**Hospital1 **] Village), not [**Hospital3 **]. Occupation: None. Drugs: None. Tobacco: None. Quit 60 years ago. Alcohol: 1 drink daily Family History: Son w/ 2 previous MIs, otherwise no arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: Admission: GENERAL: NAD. Oriented x3. Hard of hearing. HEENT: PERRL, EOMI. No OP lesions. No xanthalesma. NECK: Supple, unable to localize JVP. CARDIAC: RR, normal S1, S2. No m/r/g. LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . Discharge: GENERAL: NAD. Oriented x3. Hard of hearing at baseline. No complaints overnight. HEENT: EOMI. No OP lesions. No xanthalesma. Hearing aids in place. NECK: Supple, unable to localize JVP given large neck. CARDIAC: RR, normal S1, S2. No m/r/g. LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: EKG [**2113-9-14**]: sinus rhythm at 97 bpm with prolonged AV conduction (1st degree heart block), normal axis, ST elevation [**Last Name (LF) 1105**], [**First Name3 (LF) **] depression I, avL, V4-V6, q wave [**First Name3 (LF) 1105**] . 2D-ECHOCARDIOGRAM: [**2110**]: IMPRESSION: Suboptimal image quality. Moderate concentric LVH with mild regional systolic dysfunction LVEF 50%. Mild pulmonary hypertension. Mild aortic and mitral regurgitation. . ECHOCARDIOGRAM [**2113-9-15**]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild to moderate regional left ventricular systolic dysfunction with hypo-to akinesis of the basal and mid-inferior segments, and near-akinesis of the mid- and distal septum, distal anterior wall and the apex (multivessel CAD). The remaining segments contract normally (LVEF = 35-40%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild to moderate regional left ventricular systolic dysfunction, c/w multivessel CAD. Mild mitral regurgitation. Mild pulmonary hypertension. Compared with the prior study (images reviewed) of [**2110-9-2**], distal LAD-territory regional LV dysfunction is new. The other findings are similar. . CARDIAC CATH: [**2110**]: FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Patent SVG -> PDA and LIMA -> LAD. 3. Systemic arterial hypertension. 4. Successful PTCA and stenting of the ostial and proximal LCx. 5. Successful direct stenting of the distal LCx. . [**2113-9-14**] 10:00PM PT-10.5 PTT-30.6 INR(PT)-1.0 [**2113-9-14**] 10:00PM PLT COUNT-169 [**2113-9-14**] 10:00PM NEUTS-86.2* LYMPHS-7.9* MONOS-4.2 EOS-1.4 BASOS-0.2 [**2113-9-14**] 10:00PM WBC-10.0# RBC-4.81 HGB-15.7 HCT-45.1 MCV-94 MCH-32.6* MCHC-34.8 RDW-13.5 [**2113-9-14**] 10:00PM CALCIUM-8.7 PHOSPHATE-1.7* MAGNESIUM-2.1 [**2113-9-14**] 10:00PM cTropnT-<0.01 [**2113-9-14**] 10:00PM estGFR-Using this [**2113-9-14**] 10:00PM GLUCOSE-122* UREA N-18 CREAT-1.2 SODIUM-140 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-26 ANION GAP-14 . DISCHARGE: [**2113-9-17**] 07:30AM BLOOD WBC-7.9 RBC-4.52* Hgb-14.8 Hct-42.2 MCV-94 MCH-32.8* MCHC-35.0 RDW-13.5 Plt Ct-173 [**2113-9-17**] 07:30AM BLOOD Plt Ct-173 [**2113-9-17**] 07:30AM BLOOD Glucose-93 UreaN-31* Creat-1.5* Na-134 K-3.6 Cl-98 HCO3-27 AnGap-13 [**2113-9-16**] 05:56AM BLOOD CK-MB-9 cTropnT-0.60* [**2113-9-17**] 07:30AM BLOOD Calcium-8.7 Phos-4.0 Mg-2.1 Brief Hospital Course: [**Age over 90 **] year old man with CAD s/p CABG (LIMA-->LAD and SVG-->PDA), systolic CHF (LVEF 50%), HTN and HLD, who presented initially to OSH with chest pain found to have ST elevations inferiorly and ST depressions antero-laterally that improved with sublingual nitroglycerin. . # STEMI: The patient presented with chest pain that was suspected to be secondary to acute coronary syndrome given ST depressions anteriorly and initial ST elevations in the inferior leads. His chest pain resolved with sublingual nitroglycerin and ECG findings improved. Likely vessels affected are LAD territory potentially involving the LIMA. The patient received heparin drip and nitroglycerin drip. He also received aspirin 325mg daily, and his rosuvastatin was increased from 20 to 40mg daily. His clopidogrel was continued, as was his home lisinopril. He had previously been taken off of a beta blocker for episodes of bradycardia, but we started him on a low dose of metoprolol. He did become bradycradic to the 30s while sleeping, so his evening dose of metoprolol was held. The decision was made not to go to the cardiac cath lab for PCI initially. CK-MB peaked at 25 and troponin at 0.96 on [**9-15**] and then trended down. He was taken for exercise stress test on [**9-17**], (submaximal) exercise stress test, where he exercised for 3 METs (about as much as he does at home), had no further EKG changes beyond baseline and no angina. He was d/c with [**Month/Day (4) **] 75mg QD, Imdur 60mg qd, Metoprolol XL 12.5mg PO QD, Lisinopril 40mg daily and amlodipine 10mg. His home lasix was held because Cr uptrended with diuresis and he was euvolemic on discharge. He was discharged home and will follow-up with Dr. [**Last Name (STitle) 4469**] as an outpatient to f/u on his Cr and reassess for restarting lasix. . # Chronic Systolic CHF: Most recent LVEF prior to admission was 50% in [**2110**]. Repeat echo during this admission showed an EF of 35-40%, likely due to the STEMI. In addition to the medications listed above, Lasix was used for diuresis. . # HTN: Poorly controlled on admission. The patient was initially started on a nitro drip. He was transitioned to Imdur. His home amlodipine and lisinopril were continued. Metoprolol was started as above. . # GERD: Home ranitidine was continued. . # OSA: The patient is on CPAP at home and used CPAP during this hospitalization. When he fell asleep during the day without CPAP, he woke up disoriented, likely due to obstruction and CO2 retention. In addition, he was more confused at night which also occurs in his [**Last Name (un) **] setting per his family. . Transitional Issues: # Elevated Cr - pt Cr 1.5 on discharge, we held his Lasix and will need CMP two days after discharge. Please follow results # CODE: Confirmed FULL # EMERGENCY CONTACT: [**Name (NI) **] (daughter?) [**Telephone/Fax (1) 95855**], [**Telephone/Fax (1) 95856**], [**Telephone/Fax (1) 95854**] # HCP: [**Name (NI) 2411**] [**Name (NI) **] (daughter) [**Telephone/Fax (1) 95857**] Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Isosorbide Dinitrate 60 mg PO BID 2. Amlodipine 10 mg PO DAILY 3. Clopidogrel 75 mg PO DAILY 4. Furosemide 40 mg PO DAILY 5. Ranitidine 150 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Acetaminophen 500 mg PO BID:PRN pain 8. Psyllium 1 PKT PO DAILY:PRN constipation 9. Lisinopril 40 mg PO DAILY 10. Rosuvastatin Calcium 20 mg PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. travoprost *NF* 0.004 % OU daily 13. Nitroglycerin SL 0.4 mg SL PRN chest pain 14. Sertraline 25 mg PO DAILY Discharge Medications: 1. Acetaminophen 500 mg PO BID:PRN pain 2. Amlodipine 10 mg PO DAILY 3. Aspirin 325 mg PO DAILY RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Clopidogrel 75 mg PO DAILY 5. Lisinopril 40 mg PO DAILY 6. Ranitidine 150 mg PO DAILY 7. Rosuvastatin Calcium 40 mg PO DAILY RX *rosuvastatin [Crestor] 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY hold for SBP<90 RX *isosorbide mononitrate 60 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 10. Metoprolol Succinate XL 12.5 mg PO DAILY hold for HR <50 RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 11. Multivitamins 1 TAB PO DAILY 12. Nitroglycerin SL 0.4 mg SL PRN chest pain RX *nitroglycerin 0.4 mg 1 tab sublingually as needed for chest pain, can repeat after five minutes if chest pain persists, please call Dr. [**Last Name (STitle) 4469**] immediately or go to the emergency room if you develop chest pain Disp #*30 Tablet Refills:*0 13. Psyllium 1 PKT PO DAILY:PRN constipation 14. Sertraline 25 mg PO DAILY 15. travoprost *NF* 0.004 % OU daily 16. Outpatient Lab Work Please have creatinine, BUN, Na, K, HCO3 drawn on [**2113-9-19**] or [**2113-9-20**] and have results faxed to Dr. [**Last Name (STitle) 4469**] (see below for contact information). Dr. [**Last Name (STitle) 4469**]: Phone: [**Telephone/Fax (1) 4475**] Fax: [**Telephone/Fax (1) 29683**] Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Primary Diagnoses: ST elevation myocardial infarction Secondary Diagnoses: Coronary artery disease Hypertension Chronic systolic congestive heart failure Hyperlipidemia Heart block: Type 2, Mobitz I Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname **], You came into the hospital because of chest pain. You were found to have had a heart attack. You were treated with medications and improved. You had a stress test that showed that you did not have chest pain with your normal activity. Please continue to take your medications as perscribed in order to prevent a further heart attack. In particular, please take aspirin and clopidogrel ([**Known lastname **]) everyday and do not stop these medications unless instructed to do so by your cardiologist, Dr. [**Last Name (STitle) 4469**]. Stopping aspirin or clopidogrel could cause another heart attack. It was a pleasure caring for you. We wish you a speedy recovery. Followup Instructions: Tomorrow morning, please make an appointment to see Dr. [**Last Name (STitle) 4469**]. You will need to have blood work drawn in 2 days to check your kidney function and the results should be faxed to Dr. [**Last Name (STitle) 4469**]. You should see Dr. [**Last Name (STitle) 4469**] for a follow up visit this week.

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12444, 12515

7226, 9860

254, 277

12759, 12759

4226, 6035

13675, 13996

3056, 3148

10886, 12421

12536, 12591

10284, 10863

6052, 7203

12944, 13652

3163, 4207

12612, 12738

2573, 2715

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204, 216

305, 2479

12774, 12920

2746, 2818

2501, 2553

2834, 3040

2,842

124,867

6400+55751

Discharge summary

report+addendum

Admission Date: [**2189-11-25**] Discharge Date: Date of Birth: [**2116-1-5**] Sex: M Service: VSU HISTORY OF PRESENT ILLNESS: This is a 73-year-old male with a recent right ankle fracture who underwent an open reduction and internal fixation on [**2189-9-4**], with a history of peripheral vascular disease and a right popliteal to DP bypass in [**2182**] by Dr. [**Last Name (STitle) 1391**]. The patient presents from an outside hospital with severe right lower extremity deformity at the ankle with necrosis at the ankle and cool foot. Per [**Hospital6 **], the patient fell and twisted the ankle 4 days prior to admission. He then went to his orthopedist today for his foot which had become purple. It was noted to be pulseless and cool, and the patient had closed reduced ankle fracture about 50%. The patient is without pain. The patient was transferred here for further evaluation by the orthopedic and vascular services. ALLERGIES: Sulfa causes confusion and delirium. MEDICATIONS ON TRANSFER: Coumadin 2.5 mg daily, sublingual Nitroglycerin p.r.n., Vicodin p.r.n. for pain, Trazodone 200 mg at h.s., Protonix 40 mg daily, Ativan 0.5 mg t.i.d. p.r.n., lisinopril 5 mg b.i.d., Zoloft 100 mg daily, Coreg 3.125 mg daily, Imdur 30 mg daily, Renaphro 1 g daily, gemfibrozil 600 mg b.i.d., clonazepam 1 mg t.i.d. p.r.n., Pravachol 20 mg at h.s., Plavix 75 mg daily, folate 2 mg daily, Lasix 80 mg daily, Senokot p.r.n., NPH insulin 15 units q.a.m. with a sliding scale. PAST ILLNESSES: End-stage renal disease on dialysis Monday, Wednesday and Friday; coronary artery disease status post coronary artery angioplasty with a history of congestive heart failure; peripheral vascular disease, status post bilateral lower extremity bypasses; diabetes mellitus type 2 with neuropathy, retinopathy and end-stage renal disease; hypercholesteremia on a statin; anemia, chronic; hyperparathyroidism, treated; depression on medication; a right ankle fracture with open reduction and internal fixation; atrial fibrillation, anticoagulated. PHYSICAL EXAMINATION: Vital signs: 98.2, 82, 26, O2 saturation 100% on 3 L, blood pressure 144/68. General: No acute distress. Carotids 2+ without bruits. Heart: Regular, irregular rhythm. Lungs: Clear to auscultation. Abdomen: Soft, nontender, nondistended. Pulse exam: Palpable distal grafts bilaterally. The right lower extremity is with a gross deformity at the ankle with a necrotic region over the medial malleolus. There is no signal. The foot is mottled. The graft is palpable in the anterior tibial area but absent below the injured area. HOSPITAL COURSE: The patient was initially evaluated in the emergency room. He was seen by ortho-trauma. The ex-fix was removed. The patient was begun on vancomycin, Cipro and Flagyl. Subcu heparin was begun for DVT prophylaxis and the patient was continued on Plavix. The patient did well after his external ex-fix. He did require 1 unit of FFP for an INR of 2.3. renal was consulted for hemodialysis needs who determined that the patient will require a right BKA. Serial CKs were monitored. The patient was evaluated preoperatively by the cardiology service. It was thought that he would be at moderately high risk but given that the amputation is emergent we should proceed with surgery as most recent echocardiogram result were done at outside and they were not available. The patient had a diagnostic arteriogram of the right lower extremity via the left common femoral approach. It was determined that the patient was nonreconstructible and would require BKA. The patient underwent a right BKA on [**2189-12-2**]. The patient's intraoperative course was complicated by ventricular fibrillation, PE arrest. The patient was resuscitated and transferred to the SICU for continued. care. Intraoperative TEE showed a clot in the RV which was TPA bolused and infused. The patient remained intubated and neurologically he was below baseline. A head CT was obtained which was unremarkable for acute event. Chest x-ray showed a moderate right-sided pleural effusion with atelectasis. Repeat transthoracic echocardiogram showed an ejection fraction of 55%. There was no clot noted. The patient remained in the ICU. He required multiple transfusions for postoperative anemia. On postoperative day 3, hematocrit was 29.0, white count 8.7, BUN 31, creatinine 4.1, potassium 3.9. The patient was extubated on [**12-6**] without incident. He continued to do well and was transferred to the VICU later that day. The patient was tolerating diet. His confusion had improved. Antibiotics were discontinued. His IV heparin, Coumadin conversion was instituted. The patient was transferred to the floor on [**2189-12-7**]. Physical therapy was requested to see the patient for assessment for discharge planning. Rehab screening was instituted. He continues to be mildly disoriented but at baseline. Hematocrit is stable at 27.4, BUN 22, creatinine 3.4. Geriatric nurse consult was done on [**2189-12-8**], regarding skin changes. The patient has stage 1 sacral decubitus changes. An air bed was ordered. DuoDerm was placed on the infected area and should be changed every 3 days. Because of his delirium the nurse practitioner [**First Name (Titles) 3675**] [**Last Name (Titles) 24676**] techniques and continue encouraging ambulation to chair. The amputation site is clean, dry and intact. There is some mild ecchymosis on the medial aspect of the superior flap but no skin degradation. The patient will be discharged to rehab when a bed is available and when he is medically stable. DISCHARGE MEDICATIONS: Artificial tears with lanolin ophthalmic ointment p.r.n., pravastatin 20 mg daily, folic acid 2 mg daily, senna tablets 8.6 mg b.i.d. as needed, Nitroglycerin sublingual 0.3 mg tablets p.r.n., lorazepam 0.5 mg tablets at bed time p.r.n., Trazodone 100 mg at bed time, Zoloft 100 mg daily, warfarin 2.5 mg daily, metoprolol tartrate 12.5 mg t.i.d., aspirin 81 mg daily, simvastatin 10 mg daily, oxycodone/acetaminophen elixir 5-10 cc q.4-6 hours p.r.n., Protonix 40 mg daily. The patient's right IJ will remain in place until discharge since he has poor peripheral access. DISCHARGE DIAGNOSES: 1. Ischemic right foot, status post open reduction and internal fixation of right ankle for fracture with recurrent falls and injury, ischemic right foot. 2. Coronary artery disease, status post myocardial infarction. 3. History of congestive heart failure. 4. History of type 2 diabetes, insulin dependent. 5. History of end-stage renal disease on hemodialysis Monday, Wednesday and Friday. 6. History of hyperlipidemia on statin. 7. History of chronic anemia on Epogen at dialysis. 8. History of atrial fibrillation, anticoagulated. 9. History of depression. 10. History of hyperparathyroidism, treated. 11. Right ventricular thrombus by TEE on [**12-3**]. 12. Postoperative blood loss anemia, transfused. 13. Intraoperative ventricular fibrillation arrest, resuscitated. 14. PEA arrest, resuscitated. 15. Pulmonary embolus postoperatively. 16. Stage 1 sacral decubitus ulceration. DISCHARGE INSTRUCTIONS: The patient should followup with Dr. [**Last Name (STitle) 1391**] in 3 weeks post discharge, call for an appointment at [**Telephone/Fax (1) 1393**]. The patient should not have any stump shrinkers applied to the amputation wound. Please notify his office for fever greater than 101.5 or the wound shows changes consistent with infection. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**] Dictated By:[**Last Name (NamePattern1) 2382**] MEDQUIST36 D: [**2189-12-8**] 13:21:24 T: [**2189-12-8**] 14:06:43 Job#: [**Job Number 24677**] Name: [**Known lastname 4191**],[**Known firstname **] Unit No: [**Numeric Identifier 4192**] Admission Date: [**2189-11-25**] Discharge Date: [**2189-12-10**] Date of Birth: [**2116-1-5**] Sex: M Service: SURGERY Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 231**] Addendum: left gfroin wound with intermttent serous sangueous oozing where IV line was placed.Wil treat conservitavely. Moniter wound dry sterile drsssing daily with occlusive dressing change daily. Moniter WBC. will sendout on augmentin 500mgm qd.x 1 week stump sutures/skin clips remain in place until seen by Dr. [**Last Name (STitle) **]. No stump shrinkers. samm ecchmotic area of BKA stump- stable. Last HD [**2189-12-9**] INR @ d/c 2.7 om 2.5mgm daily.Transfered to rehab stable. Discharge Disposition: Extended Care Facility: [**Hospital6 41**] - [**Location (un) 42**] [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**] Completed by:[**2189-12-10**]

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icd9cm

[ [ [] ] ]

[ "99.04", "39.95", "79.26", "84.72", "88.72", "78.67", "78.17", "00.17", "79.66", "99.07", "99.10", "84.15", "88.48", "99.62" ]

icd9pcs

[ [ [] ] ]

8612, 8840

6210, 7124

5615, 6189

2629, 5591

7149, 8589

2084, 2611

149, 1003

1029, 2061

47,974

163,366

39236

Discharge summary

report

Admission Date: [**2169-2-22**] Discharge Date: [**2169-3-3**] Date of Birth: [**2095-12-17**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1115**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: ICU admission with intubation (<48 hours) Cardioversion - 4 trials History of Present Illness: The patient is a 73 yoM w/ a h/o Crohn's disease s/p colectomy who presented with a complaint of intermittent chest pain x 1 day, pleuritic and a pressure in nature. He has had chills and rigors. He has been feeling tired and unwell x 1 week but otherwise has no other symptoms. Some urinary retention at home, but no dysuria or frequency, no change in colostomy output, no SOB or orthopnea, no PND, no DOE or angina. No pedal edema. No bleeding. No other symptoms, rest of ROS is negative. . The patient was sent to [**Hospital3 4107**] ER where he was found to have STE in a LAD territory and sent to the cath lab for PCI, he was cathed here at the [**Hospital1 18**] and found to have no obstructive coronary disease and a LV Gram with Takotsubo's cardiomyopathy. Past Medical History: COPD, Mild Crohn's disease s/p colectomy in [**2144**]- colosctomy bag borderline HTN Social History: Married without children, smokes 5 cigars per day, occasional ETOH, no drug use. He is an english teacher. Family History: Father died of "heart disease" at the age of 25, mother of liver CA at 51. One brother who died from emphysema. Physical Exam: PHYSICAL EXAM ON ADMISSION: Vitals - 98, 72, 127/70, 19, 100/2L (no home oxygen). GENERAL: AO x 3, NAD HEENT: JVP elevated CARDIAC: Regular, distant heart sounds but no appreciable M/G/R LUNG: CTAB anteriorly ABDOMEN: soft, NT, ND, no masses or organomegaly, colostomy EXT: WWP with distal DP pulses; 2+ edema in calves NEURO: AO x 3, moving all 4 extremities . PHYSICAL EXAM: Vitals - 99.1, 118/58, 76, 20, 96% 6L GENERAL: AAOx3, appears anxious HEENT: PERRLA, EOMI, no LAD, JVP slightly elevated CARDIAC: S1S2, RRR, heart sounds slightly distant, difficult to appreciate m/r/g LUNG: CTA b/l, no w/r/r ABDOMEN: soft, NT, ND, no masses or organomegaly, colostomy EXT: WWP with distal DP pulses; R hand and forearm edematous and bruised, nontender to touch. 1+ edema to calves bilaterally NEURO: CN II-XII grossly intact Pertinent Results: Cardiac Cath Study Date of [**2169-2-22**] FINAL DIAGNOSIS: 1. Diffuse non-obstructive coronary artery disease. 2. Takotsubo pattern cardiomyopathy with preserved EF. 3. Hyperkalemia with acute renal failure. ABDOMEN U.S. (COMPLETE STUDY) PORT Study Date of [**2169-2-23**] 10:03 AM IMPRESSION: 1. No ultrasonographic evidence for acute cholecystitis. No evidence of hydronephrosis. 2. Thin renal cortices bilaterally consistent with chronic renal parenchymal disease. 3. Limited Doppler evaluation of the kidneys but no obvious evidence for renal artery stenosis. Portable TTE (Complete) Done [**2169-2-23**] at 12:10:35 PM The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the distal septum and apex. The remaining segments contract normally (LVEF = 50%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. IMPRESSION: Mild regional left ventricular systolic dysfunction. CT CHEST/ABDOMEN/PELVIS W/O CONTRAST Study Date of [**2169-2-23**] 4:01 PM IMPRESSION: 1. Right upper and patchy right lower lobe consolidations, may represent pneumonia. Ground-glass opacity in the left upper lobe in the setting of emphysema raises concern for infection as well. 2. No source of infection in the abdomen and pelvis. 3. Severe emphysema. 4. Pleural effusions, total body wall edema, small amount of abdominal ascites, consistent with third spacing. Cytology Report SPUTUM Procedure Date of [**2169-2-24**] ATYPICAL. Atypical epithelial cells in a background of pulmonary macrophages and inflammatory cells. Cytology Report SPUTUM Procedure Date of [**2169-2-27**] NEGATIVE FOR MALIGNANT CELLS. Pulmonary macrophages, squamous cells, and numerous neutrophils. CHEST (PORTABLE AP) Study Date of [**2169-3-1**] 7:24 AM FINDINGS: As compared to the previous examination, the course of the right PICC line is unchanged, the line appears to have been retracted by approximately 2 cm. Unchanged appearance at the right lung base. On the left, however, the image is improving, with increased transparency of the left lower lung. Unchanged size of the cardiac silhouette. Unchanged hilar and mediastinal contours. AFB smear - negative x3 CBC [**2169-3-2**] 04:20PM BLOOD Hct-25.6* [**2169-3-2**] 06:04AM BLOOD WBC-8.1 RBC-2.27* Hgb-7.5* Hct-22.3* MCV-98 MCH-32.9* MCHC-33.6 RDW-12.6 Plt Ct-157 [**2169-3-1**] 06:00AM BLOOD WBC-11.6* RBC-2.74* Hgb-8.8* Hct-26.1* MCV-95 MCH-32.1* MCHC-33.7 RDW-12.9 Plt Ct-153 [**2169-2-28**] 09:00AM BLOOD WBC-10.5 RBC-3.03* Hgb-9.7* Hct-29.2* MCV-96 MCH-32.0 MCHC-33.3 RDW-12.8 Plt Ct-147* [**2169-2-27**] 04:00PM BLOOD WBC-10.3 RBC-2.93* Hgb-9.5* Hct-28.2* MCV-96 MCH-32.4* MCHC-33.6 RDW-12.7 Plt Ct-144* [**2169-2-27**] 06:30AM BLOOD WBC-11.3* RBC-2.96* Hgb-9.7* Hct-28.7* MCV-97 MCH-32.6* MCHC-33.7 RDW-12.9 Plt Ct-162 [**2169-2-26**] 04:14AM BLOOD WBC-13.6* RBC-2.48* Hgb-8.1* Hct-24.1* MCV-97 MCH-32.6* MCHC-33.6 RDW-12.8 Plt Ct-120* [**2169-2-25**] 03:54AM BLOOD WBC-18.5* RBC-2.80* Hgb-9.1* Hct-26.9* MCV-96 MCH-32.4* MCHC-33.7 RDW-12.9 Plt Ct-139* [**2169-2-24**] 02:43PM BLOOD WBC-14.6* RBC-2.94* Hgb-9.7* Hct-28.9* MCV-98 MCH-32.8* MCHC-33.4 RDW-12.7 Plt Ct-151 [**2169-2-24**] 03:43AM BLOOD WBC-10.6 RBC-2.77* Hgb-9.3* Hct-26.4* MCV-95 MCH-33.5* MCHC-35.2* RDW-12.9 Plt Ct-113* [**2169-2-23**] 02:34AM BLOOD WBC-13.3* RBC-3.19* Hgb-10.4* Hct-30.8* MCV-97 MCH-32.6* MCHC-33.7 RDW-13.0 Plt Ct-169 [**2169-2-22**] 10:37PM BLOOD WBC-15.0* RBC-3.02* Hgb-10.2* Hct-30.5* MCV-101* MCH-33.9* MCHC-33.6 RDW-12.8 Plt Ct-200 [**2169-2-22**] 07:00PM BLOOD WBC-13.8* RBC-3.29* Hgb-10.5* Hct-32.3* MCV-98 MCH-31.8 MCHC-32.4 RDW-12.8 Plt Ct-145* [**2169-2-22**] 04:00PM BLOOD WBC-16.9* RBC-3.64* Hgb-12.3* Hct-36.7* MCV-101* MCH-33.8* MCHC-33.5 RDW-12.7 Plt Ct-192 Chemistry [**2169-3-2**] 06:04AM BLOOD Glucose-72 UreaN-25* Creat-2.9* Na-144 K-4.7 Cl-112* HCO3-25 AnGap-12 [**2169-3-1**] 05:00AM BLOOD Glucose-87 UreaN-26* Creat-3.0* Na-144 K-4.0 Cl-111* HCO3-26 AnGap-11 [**2169-2-28**] 09:00AM BLOOD Glucose-111* UreaN-29* Creat-3.3* Na-146* K-4.0 Cl-113* HCO3-24 AnGap-13 [**2169-2-27**] 04:00PM BLOOD Glucose-145* UreaN-33* Creat-3.8* Na-144 K-3.5 Cl-112* HCO3-27 AnGap-9 [**2169-2-27**] 06:30AM BLOOD Glucose-75 UreaN-33* Creat-3.8* Na-146* K-3.2* Cl-112* HCO3-25 AnGap-12 [**2169-2-26**] 04:14AM BLOOD Glucose-93 UreaN-37* Creat-3.9* Na-142 K-3.6 Cl-110* HCO3-24 AnGap-12 [**2169-2-25**] 04:24PM BLOOD Glucose-138* UreaN-36* Creat-3.7* Na-138 K-4.0 Cl-106 HCO3-19* AnGap-17 [**2169-2-25**] 03:54AM BLOOD Glucose-163* UreaN-35* Creat-3.5* Na-136 K-3.6 Cl-105 HCO3-19* AnGap-16 [**2169-2-24**] 02:43PM BLOOD Glucose-141* UreaN-33* Creat-3.5* Na-136 K-4.0 Cl-105 HCO3-22 AnGap-13 [**2169-2-24**] 03:43AM BLOOD Glucose-156* UreaN-31* Creat-3.2* Na-136 K-3.8 Cl-107 HCO3-20* AnGap-13 [**2169-2-23**] 10:18PM BLOOD Glucose-97 UreaN-30* Creat-3.2* Na-138 K-3.5 Cl-108 HCO3-23 AnGap-11 [**2169-2-23**] 05:07PM BLOOD Glucose-106* UreaN-37* Creat-3.6* Na-138 K-3.5 Cl-108 HCO3-22 AnGap-12 [**2169-2-23**] 12:55PM BLOOD Glucose-116* Na-141 K-3.4 Cl-114* HCO3-21* AnGap-9 [**2169-2-23**] 10:01AM BLOOD Glucose-120* UreaN-50* Creat-4.5*# Na-140 K-3.5 Cl-111* HCO3-21* AnGap-12 [**2169-2-23**] 02:34AM BLOOD Glucose-121* UreaN-73* Creat-6.5*# Na-141 K-4.3 Cl-111* HCO3-18* AnGap-16 [**2169-2-22**] 07:00PM BLOOD Glucose-169* UreaN-124* Creat-11.7* Na-138 K-5.0 Cl-107 HCO3-15* AnGap-21* [**2169-2-22**] 04:00PM BLOOD Glucose-121* UreaN-134* Creat-12.4* Na-132* K-8.1* Cl-104 HCO3-10* AnGap-26* [**2169-3-1**] 05:00AM BLOOD Calcium-7.3* Phos-2.2* Mg-1.6 [**2169-2-28**] 09:00AM BLOOD Calcium-7.9* Phos-1.2* Mg-2.1 [**2169-2-27**] 04:00PM BLOOD Calcium-7.7* Phos-1.6* Mg-1.5* [**2169-2-27**] 06:30AM BLOOD Calcium-7.8* Phos-2.3* Mg-1.8 [**2169-2-25**] 04:24PM BLOOD Calcium-7.6* Phos-3.6 Mg-1.9 [**2169-2-25**] 03:54AM BLOOD Calcium-7.7* Phos-3.9 Mg-2.1 [**2169-2-24**] 02:43PM BLOOD Calcium-8.0* Phos-4.8* Mg-1.7 [**2169-2-24**] 03:43AM BLOOD Calcium-7.3* Phos-4.0 Mg-1.7 [**2169-2-23**] 10:18PM BLOOD Calcium-7.0* Phos-2.8 Mg-1.9 [**2169-2-23**] 05:07PM BLOOD Calcium-8.2* Phos-2.1* Mg-2.2 [**2169-2-23**] 12:55PM BLOOD Calcium-5.7* Phos-2.0* Mg-1.7 [**2169-2-23**] 10:01AM BLOOD Calcium-7.2* Phos-2.5*# Mg-2.3 [**2169-2-22**] 07:00PM BLOOD Calcium-7.8* Phos-7.1*# Mg-1.6 [**2169-2-22**] 04:00PM BLOOD Albumin-3.6 Calcium-8.2* Phos-8.8* Mg-1.8 LFT [**2169-3-2**] 06:04AM BLOOD ALT-20 AST-24 AlkPhos-61 TotBili-0.4 [**2169-2-27**] 06:30AM BLOOD ALT-28 AST-34 AlkPhos-61 TotBili-0.4 [**2169-2-22**] 04:00PM BLOOD ALT-11 AST-31 CK(CPK)-432* AlkPhos-45 Amylase-110* TotBili-0.2 CEs [**2169-2-24**] 02:43PM BLOOD CK(CPK)-422* [**2169-2-23**] 02:34AM BLOOD CK(CPK)-722* [**2169-2-22**] 07:00PM BLOOD CK(CPK)-494* [**2169-2-24**] 02:43PM BLOOD CK-MB-17* MB Indx-4.0 cTropnT-1.83* [**2169-2-23**] 02:34AM BLOOD CK-MB-66* MB Indx-9.1* cTropnT-2.09* [**2169-2-22**] 07:00PM BLOOD CK-MB-39* MB Indx-7.9* cTropnT-0.98* Iron Studies [**2169-3-2**] 06:04AM BLOOD calTIBC-153* VitB12-799 Folate-16.2 Ferritn-290 TRF-118* TFT [**2169-3-2**] 06:04AM BLOOD TSH-2.6 Brief Hospital Course: 73 M with h/o COPD presents with chest pain, found to ST elevations due to Takotsubo's, pneumonia, septic shock, and ARF requiring urgent dialysis. He was admitted initially to the MICU where he had a complex course however, he recovered well. # Septic shock / Pneumonia: The patient was found to have a multifocal pneumonia and was treated with vancomycin / zosyn for an 9 day course and improved. He was initially intubated mainly for mental status depression / hypotension. He was weaned off the ventilator without difficulty. He will need to complete a 10 day course of antibiotics. He remains stable on 5L of supplemental O2 at discharge. He does have a history of "mild COPD"; however, his CT scan showed severe disease. Pulm follow up was arranged; he should have outpatient PFTs once his infection has resolved. # Atrial tachycardia: The patient developed atrial tachycardia while septic in the ICU. The Electrophysiology team was consulted; 4 trials of cardioversion and adenosine were undertaken. He was then started on amiodarone with resolution of atrial tachycardia. Outpatient cardiology follow up was arranged; the patient will need repeat TSH and LFTs in 6 months as an outpatient. When respiratory status improves he should have outpatient PFTs. # Acute on Chronic renal failure: His baseline Cr is 2.2, however, it was >12 on admission in the setting of septic shock. In addition the patient had an element of cardiogenic shock given his takatsubo's cardiomyopathy. Emergent dialysis was performed for hyperkalemia, and the patient underwent CVVH while in the ICU. His renal function slowly recovered and dialysis was discontinued. His Cr improved to 3.0 upon discharge. Patient will follow up with nephrology as an outpatient. # Takotsubo - The patient was found to have anterior ST segment elevations on admission and therefore was taken for urgent cath; however cath showed diffuse but non obstructive CAD as well as Takotsubo's. This may be due to physiologic stress of sepsis. Cardiac cath showed EF improved the day after presentation. The patient will require a f/u ECHO in 6 weeks from discharge and follow up with cardiology. # Pulmonary lesion: CT scan revealed a RUL lesion initially concerning for TB. Patient was ruled out with three negative AFB smears. Lung cancer is of concern, and sputum was positive for atypical epitheliod cells; however, it may all be due to inflammatory reaction from pneumonia. Interventional pulm was consulted on this admission, who reviewed his films and commented that it is difficult to tell if he has any malignancy now because his overlying pneumonia obscures the scans; additionally he has very extensive blebs which make a biopsy risky; especially as this may simply all represent infection. He is recommended to have a repeat chest CT in [**12-11**] months once infection has resolved. Pulmonary follow up was arranged. #Dysphagia - patient was cleared by Speech and Swallow for soft solids and thin liquids. However, nurses were still concerned as still coughed. A video swallow could not be obtained prior to discharge. He should undergo video swallow testing at rehab to further assess for aspiration risk. #Anemia - Patient's hematocrit has been stable in the low 20s. Iron studies [**Location (un) 381**] iron, low TIBC, normal ferritin. TSH, vitamin B12, and folate were normal. This requires close outpatient monitoring and further workup should it not gradually improve as the patient recovers from his critical illness. Medications on Admission: Lisinopril 20mg daily Spriva daily Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-10**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 3. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 7. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-10**] Sprays Nasal QID (4 times a day) as needed for nasal congestion. 8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for wheezing, sob. 10. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) nebulizer Inhalation Q6HPRN () as needed for sob, wheezing. 11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. 12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Piperacillin-Tazobactam 2.25 g IV Q8H 14. Zosyn 2.25 gram Recon Soln Sig: 2.25 gram Intravenous every eight (8) hours for 1 days. 15. Vancomycin 750 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750) mg Intravenous once a day for 1 days: please hold if AM vanc level >20. 16. Outpatient Lab Work please draw vancomycin trough on [**3-4**] Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 701**] Discharge Diagnosis: Primary Diagnosis: Takotsubo's cardiomyopathy Acute renal failure requiring CVVH Atrial tachycardia s/p 4 trials of cardioversion, adenosine, and amiodarone Secondary Diagnosis: COPD, Mild Crohn's disease s/p colectomy in [**2144**]- colosctomy bag borderline HTN Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - requires assistance or aid (walker or cane) Saturating in high 90s, breathing comfortably, on 5L of O2. Gets short of breath with ambulation. Discharge Instructions: You were admitted to [**Hospital1 69**] for chest pain. You were found to have a condition called Takotsubo's cardiomyopathy. Over the course of your admission, you were intubated because of respiratory distress and were found to have a pneumonia for which we are treating you with antibiotics. You were temporarily on dialysis for poor kidney functions, but they have been gradually improving. You were also found to have an irregular rhythm of your heart which you were cardioverted and started on medication. You are being transferred to rehab where they will help you get reconditioned. Your medications have changed. Please only take the medications listed below: tylenol 650 mg every 6 hours as needed for pain or fever amdiodarone 200 mg daily artificial tears 1-2 drops as needed for dry eyes fluticasone-salmeterol 1 inhalation twice a day heparin 5000 units injected under your skin three times a day ipratropium 1 nebulizer every 6 hours as needed for shortness of breath lorazepam 0.5mg every 4 hours as needed for anxiety nicotine patch 14 mg daily oxycodone 5 mg every 6 hours as needed for pain zosyn 2.25 mg IV every 8 hours for 1 more day tiotropium 1 cap daily vancomycin 750 mg IV daily for 1 more day xopenex 1 nebulizer every 6 hours as needed for shortness of breath Followup Instructions: MD: Dr. [**Known firstname 122**] [**Last Name (NamePattern1) **] Specialty: Pulmonary Date/ Time: [**2169-5-3**] 12:30pm Location: [**Location (un) 830**] [**Hospital Ward Name 23**] Building [**Location (un) **], [**Location (un) 86**] MA Phone number: [**Telephone/Fax (1) 612**] MD: Dr. [**First Name8 (NamePattern2) 5045**] [**Last Name (NamePattern1) **] Specialty: Nephrology Date/ Time: [**2169-4-4**] 2:30pm Location: [**Location (un) 830**] [**Hospital Ward Name 23**] Building [**Location (un) **], [**Location (un) 86**] MA Phone number: [**Telephone/Fax (1) 721**] MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Specialty: Cardiology Date/ Time: [**2169-4-10**] 3:20pm Location: [**Location (un) 830**] [**Hospital Ward Name 23**] Building [**Location (un) **], [**Location (un) 86**] MA Phone number: [**Telephone/Fax (1) 62**]

[ "276.2", "584.9", "V44.3", "785.52", "429.83", "486", "305.1", "518.81", "427.89", "995.92", "496", "785.51", "038.9", "518.89", "555.9", "585.9", "276.7", "414.01" ]

icd9cm

[ [ [] ] ]

[ "96.04", "37.22", "96.71", "38.93", "88.53", "39.95", "88.55" ]

icd9pcs

[ [ [] ] ]

15023, 15105

9763, 13292

326, 394

15413, 15413

2410, 2453

17012, 17886

1440, 1553

13377, 15000

15126, 15126

13318, 13354

2470, 9740

15691, 16989

1946, 2391

276, 288

422, 1191

15304, 15392

15145, 15283

1596, 1931

15428, 15667

1213, 1300

1316, 1424

5,388

175,180

25265

Discharge summary

report

Admission Date: [**2114-10-3**] Discharge Date: [**2114-10-13**] Date of Birth: [**2077-7-5**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2186**] Chief Complaint: fever, nausea, abdominal pain Major Surgical or Invasive Procedure: Lumbar puncture History of Present Illness: 37 yo F w/o significant [**Hospital 63245**] transferred from OSH for management of pyelonephritis, bilateral pleural effusions, ascites. . Pt originally admitted to OSH on [**2114-9-30**] after presenting w/CC of vomiting, malaise, fever and back pain X4d, and Hx of recent UTI (treated in [**Month (only) 216**] w/unknown Abx as outpt). At the time, T 102, had upper abd tenderness, bilateral CVA tenderness, WBC [**Numeric Identifier **], (+) Ua, CT abd confirmed severe Rt pyelonephritis with no other abnormalities. Pt started on Levoflox 500 IV q24h and Rocephin 2 gr IV q24h. Pt became afebrile within 36 h. Ux (+) for E.coli sensitive to ceftiaxone, resistant to levoflox. Levoflox D/Ced on [**10-2**] and replaced with gentamycin. On [**10-3**], pt afebrile w/WBC down to 8100, however c/o HA/ abd and flank pain and SOB. O2 sat 92-97% on RA. Vomited and became bradycardic (42, then up to the 50s). ECG sinus brady. On Lovenox 60 mg sc. Repeat CT of the abdomen showed new bilateral pleural effusions R>L, ascites and "generalized inflammation of the liver". Rt kidney looks improved compared to [**9-30**]. Sent to [**Hospital1 18**] for further management. Past Medical History: Hospitalized only for vaginal delivery X2. Recent UTI in [**Month (only) 216**]. No surgeries. LMP: [**2114-9-27**]. Social History: moved from [**Country 4194**] in [**4-10**], works in housecleaning, not married, 2 children in [**Country 4194**]; currently sexually active with 1 male partner ("rare" unprotected sex); No STDs Family History: NC Physical Exam: Tc 101.1 HR 48 BP 110/70 RR 16 O2sat 95% RA general- sitting up in bed, ill-appearing, no respiratory distress HEENT- sclerae anicteric, dry MM Neck- HOB 45deg: JVD to mandible Pulm- poor inspiratory effort, poor air movement, no audible wheezes Heart- bradycardic, regular, no m/r/g Abd- distended but soft, hypoactive bowel sounds, + tenderness to mild palpation of RUQ/epigastrium, + peritoneal signs, + guarding Ext- no peripheral edema, +2 PT pulses b/l Neuro- CN III-XII intact, strength exam limited by poor effort Pertinent Results: [**2114-10-3**] 08:35PM PT-13.7* PTT-34.8 INR(PT)-1.3 [**2114-10-3**] 08:35PM WBC-7.4 RBC-3.12* HGB-9.8* HCT-29.3* MCV-94 MCH-31.5 MCHC-33.5 RDW-13.1 [**2114-10-3**] 08:35PM ALT(SGPT)-17 AST(SGOT)-21 LD(LDH)-165 ALK PHOS-130* AMYLASE-27 TOT BILI-0.3 [**2114-10-3**] 08:35PM GLUCOSE-89 UREA N-8 CREAT-0.8 SODIUM-140 POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-20* ANION GAP-16 [**2114-10-3**] 08:35PM CALCIUM-7.9* PHOSPHATE-3.0 MAGNESIUM-1.8 . Hepatitis B Surface Antigen NEGATIVE Hepatitis B Core Antibody, IgM NEGATIVE Hepatitis A Virus IgM Antibody NEGATIVE Hepatitis C Virus Antibody NEGATIVE [**Doctor First Name **] negative . ESR 64* Parst S NEGATIVE . CT abd/pelv (OSH, [**9-30**]): R sided pyelonephritis, "generalized inflammation of the liver" . RUQ US: normal gallbladder, no gallstones, CBD 5mm, small calcification in R lobe of the liver likely representing granuloma, normal portal vein, no intrahepatic biliary ductal dilatation, small pleural effusion . [**2114-10-5**], CT HEAD WITHOUT CONTRAST: No intracranial mass effect, hydrocephalus, shift of normally midline structures, minor or major vascular territorial infarct is apparent. The density values of the brain parenchyma are normal. The surrounding soft tissue and osseous structures are unremarkable. . [**2114-10-5**], CT ABDOMEN WITH IV CONTRAST: There are bilateral pleural effusions with atelectatic changes. There are no nodules visualized. The liver is enlarged and heterogeneous, which could be consistent with hepatitis. The gallbladder contains high attenuation material within the lumen consistent with sludge, but is not distended and there is no evidence of stones. There is a moderate amount of abdominal ascites. The pancreas, adrenal glands, spleen, left kidney, stomach, and abdominal loops of small and large bowel are within normal limits. The right kidney is enlarged and there are mottled wedge shaped areas of hypodensity. This appearance is suggestive of infarct versus pyelonephritis. The appendix is visualized and there are no signs of acute appendicitis. There is no free air and no pathologic mesenteric or retroperitoneal lymphadenopathy. . CT PELVIS WITH CONTRAST: The bladder, uterus, rectum, and sigmoid colon are within normal limits. There is a moderate amount of fluid surrounding the uterus, but no evidence for tubo-ovarian abscess. There is no pathologic mesenteric or inguinal lymph adenopathy. . BONE WINDOWS: No lytic or sclerotic foci are visualized. . TTE [**10-8**]: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is top normal. There is a very small likely loculated pericardial effusion around the right atrium (?small pericardial cyst).. . MICRO: [**2114-10-6**] 9:41 am urine/serology **FINAL REPORT [**2114-10-7**]** Legionella Urinary Antigen (Final [**2114-10-7**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2114-10-8**]): POSITIVE BY EIA. [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2114-10-8**]): POSITIVE BY EIA. [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2114-10-8**]): NEGATIVE <1:10 BY IFA. INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION. TOXOPLASMA IgG ANTIBODY (Final [**2114-10-9**]): NEGATIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA. 0.0 IU/ML. Reference Range: Negative < 4 IU/ml, Positive >= 8 IU/ml. TOXOPLASMA IgM ANTIBODY (Final [**2114-10-9**]): NEGATIVE FOR TOXOPLASMA IgM ANTIBODY BY EIA. INTERPRETATION: NO ANTIBODY DETECTED. CMV IgG ANTIBODY (Final [**2114-10-9**]): POSITIVE FOR CMV IgG ANTIBODY BY EIA. 60 AU/ML. Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml. CMV IgM ANTIBODY (Final [**2114-10-9**]): NEGATIVE FOR CMV IgM ANTIBODY BY EIA. INTERPRETATION: INFECTION AT UNDETERMINED TIME. Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final [**2114-10-5**]): Negative for Chlamydia trachomatis by PCR. NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final [**2114-10-5**]): Negative for Neisseria Gonorrhoeae by PCR. LYME SEROLOGY (Final [**2114-10-8**]): NO ANTIBODY TO B. BURGDORFERI DETECTED BY EIA. Reference Range: No antibody detected. RAPID PLASMA REAGIN TEST (Final [**2114-10-8**]): NONREACTIVE. Reference Range: Non-Reactive. Brief Hospital Course: A/P: 37yo F with pyelonephritis, ascites, and pleural effusions. . 1) Pyelonephritis: > 100K colonies of E. coli grew on urine culture from OSH ([**Hospital6 18346**]), which was sensitive to ceftriaxone, resistant to levoflox and cipro. Patient was initially treated with ceftriaxone here but due to development of serositis (pleural eff, ascites), without rash or arthralgias, which was thought to be possibly secondary to ceftriaxone. Because of this possibilty, she was changed to aztreonam per infectious disease recommendations. Another more plausible etiology of her serositis may have been due to inlfammatory response to overwhelming infectious process. The patient's symptoms of abdominal pain and dyspnea improved dramatically after 2 days of being on Aztreonam. A repeat abdominal and pelvis CT revealed wedge-shaped densities in R kidney: radiologically consistent with infarct vs. pyelonephritis, and not indicative of abscess or necrosis. Blood cultures have had no growth to date here or at OSH. Repeat urine cultures here showed no growth of organisms. WBC count improved throughout her stay and back to normal range prior to discharge. She completed a complete 14d course of IV antibiotics prior to discharge. It was felt, with assistance of an allergist, that this patient should not receive ceftriaxone in the future but can take other cephalosporins and other beta-lactam antibiotics. . 2) RUQ pain: Unclear what the cause was but felt to be most likely all secondary to her severe pyelonephritis. CT showed a heterogeneously enlarged liver with some small amt of ascites but LFTs were in normal range. Gallbladder with sludge but no stones. Hepatitis panel for Hep A, B and C were negative. Given Fitz-[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] syndrome was on differential diagnosis a pelvic exam was performed which was negative for cervical motion tenderness, a normal bimanual exam, and cultures for Chlamydia/gonorrhea were negative. No tubo-ovarian abscess was seen on CT scan. . Additional serologies were sent for more rare causes of hepatitis. Given her living environment ([**Hospital1 6687**] and [**Country 4194**]), she was at risk for tick-borne illnesses as well as tropical diseases. Serologies for Lyme, Ehrlichia, babesiosis were negative. Her smear (thick and thin) showed no parasites basically ruling out malaria. In addition, her EBV IgM, CMV IgM, and Toxo. serologies were negative. . 3) Neck pain: Patient complained of severe neck pain and stiffness. An LP was performed on Hospital Day 2 to eval for meningitis. CT Head showed no gross abnormality. Her CSF had 1 WBC, 7 RBCs, glucose and protein wnl, bacterial culture with no growth, viral culture no growth to date. Her neck pain improved throughout her stay especially with use of NSAIDs. . 4) Sinus bradycardia: Patient had profound sinus bradycardia initially during her first 5-6 days of hospitalization with heart rates in 20-40s. She maintained adequate blood pressures despite this heart rate. Her EKG consistently revealed a sinus rhythm with normal intervals. Given her bradycardia, abdominal pain and infectious condition, typhoid fever or other enteric fever were entertained as possible diagnoses. In addition, her bradycardia and relative normotensive state was concerning for possible increase intracranial pressure. Her CT head was unremarkable and blood cx never grew an organism likely ruling out these possible etiologies. In addition, an echocardiogram was obtained to evaluate for myocarditis, cardiomyopathy, or evidence of valvular vegetations. Her echo was basically normal with normal valves, normal EF, etc. Thus, her bradycardia remains a mystery and her heart rate improved to rates in 60s-70s prior to discharge. ? If bradycardia was due to increased vagal response from nausea and pain (? with normal BP). . 5) Dyspnea: Patient complained of inability to take deep breaths and shortness of breath during her first several days in the hospital. Her dyspnea was attributed to her bilateral pleural effusions and likely resulting pleurisy. Her symptoms improved and her oxygenation was never a significant issue. She was ambulating well without evidence of effusions or hypoxia prior to discharge home. . Medications on Admission: None at home (ceftriaxone 2g q24h, gent 80 mg [**Hospital1 **], promethazine, ambien, ibuprofen, vicodin on transfer) Discharge Medications: None Discharge Disposition: Home Discharge Diagnosis: 1. Pyelonephritis 2. Serositis 3. Reaction to ceftriaxone Discharge Condition: Stable, afebrile, no pain Discharge Instructions: If you experience any fevers, chills, shortness of breath, back pain, abdominal pain; please call your doctor or go to ER. You should not take the antibiotic ceftriaxone again. Followup Instructions: Please make an appt with your primary doctor in 2 weeks. Completed by:[**2114-10-13**]

[ "E930.5", "041.4", "427.89", "511.9", "590.10", "789.5" ]

icd9cm

[ [ [] ] ]

[ "03.31" ]

icd9pcs

[ [ [] ] ]

11969, 11975

7491, 11772

345, 363

12077, 12105

2497, 7468

12331, 12420

1932, 1936

11940, 11946

11996, 12056

11798, 11917

12129, 12308

1951, 2478

276, 307

391, 1562

1584, 1703

1719, 1916

22,026

141,081

10054

Discharge summary

report

Admission Date: [**2160-8-8**] Discharge Date: [**2160-8-19**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 783**] Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: 87 y/o woman, with PMH significant for afib, dementia, who fell down unknown number of stairs. Found down. Scan at outside hospital showed C1/C2 fracture, c/w old fracture. Initially admitted to trauma service for observation. Past Medical History: 1) Left frontal infarct ten years ago. 2) Totally occluded left internal carotid artery. 3) Hypertension. 4) High cholesterol. 5) Chronic right arm lymphedema after a lymph node biopsy on the right for evaluation of breast cancer. Social History: : Denies alcohol or tobacco use. She lives alone. Her son is supportive and lives nearby. She is widowed. He reports having someone who comes by to help with cleaning and being very involved in her care. He contacts her several times a day and takes her shopping. He does her books for her. Although the son does not feel she has significant cognitive difficulties at baseline it is unclear if he has a realistic assessment of her abilities. Family History: unable to obtain Physical Exam: VS: T98.6 BP 142-177/50-65 P 46-72 RR 24 Sat 98% NRBI: 680 O: 1500 Gen: NAD, grabbing at examiner during exam frequently HEENT: PERRL, R eyelid droop, NCAT, sclerae anicteric/noninjected, MMM Neck: JVP at mandible with +HJR CV: irregular rhythm, Grade 2/6 SEM LUSB with radiation to both carotids Lungs: diffuse crackles R>L and greater at the bases Ab: soft, NTND, further exam difficult due to pt being uncooperative Extrem: MAFE except RUE Neuro: Difficult to assess as pt was not cooperative and would not answer questions, she was moving all extrem except RUE, reflexes 1+ throughout Skin: diffuse eccymoses Pertinent Results: [**2160-8-7**] 10:05PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 [**2160-8-7**] 10:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2160-8-7**] 10:05PM FIBRINOGE-514* [**2160-8-7**] 10:05PM WBC-19.6* RBC-3.73* HGB-10.2* HCT-30.4* MCV-81* MCH-27.4 MCHC-33.6 RDW-14.7 [**2160-8-7**] 10:05PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2160-8-7**] 10:15PM HGB-10.5* calcHCT-32 O2 SAT-54 CARBOXYHB-1.9 MET HGB-0.5 [**2160-8-7**] 10:15PM GLUCOSE-145* LACTATE-2.1* NA+-131* K+-4.4 CL--99* TCO2-26 [**2160-8-8**] 06:30PM WBC-11.5* RBC-3.01* HGB-8.5* HCT-24.6* MCV-82 MCH-28.3 MCHC-34.7 RDW-14.9 [**2160-8-8**] 06:30PM CK-MB-22* MB INDX-2.6 cTropnT-0.28* [**2160-8-8**] 06:30PM GLUCOSE-142* UREA N-8 CREAT-0.5 SODIUM-129* POTASSIUM-3.5 CHLORIDE-99 TOTAL CO2-21* ANION GAP-13 [**2160-8-8**] 09:00PM HCT-24.1* . Radiology- [**8-9**] Echo: hyperdynamic w/LVEF 75%, 3+ TR [**8-8**] CT Head: No acute intracranial hemorrhage or mass effect. [**8-8**] CT head ([**Location (un) 620**]): no acute injury, old L frontal infarct [**8-8**] CT c-spine ([**Location (un) 620**]): rotary subluxation of C1 on C2, no definitive acute fx. [**8-8**]: Shoulder films: Left eighth and ninth rib fractures. [**8-7**] TL-spine: mild compression deformities of L1 and L3.Disc space narrowing and associated discogenic endplate changes are noted at L4/5 and L5/S1 . TRAUMA #2 (AP CXR & PELVIS PORT) [**2160-8-7**] 9:47 PM -CHEST, AP: The study is carried out on a trauma board. No prior studies are available for comparison. The heart is enlarged. There is significant rotation due to scoliosis. Aorta is calcified. There is a small right effusion. No pneumothorax. -PELVIS, AP VIEW: No prior studies available. There is no evidence of fracture, dislocation, bony destruction. There are marked degenerative changes of the lower lumbar spine, particularly at L5-S1. . EKG [**8-7**]-Sinus rhythm and frequent atrial ectopy. Compared to the previous tracing of [**2158-5-18**] the Q waves in leads III and aVF are obscured by baseline artifact. However, the tracing of [**2158-5-18**] records evidence for prior inferior wall myocardial infarction. . CT HEAD W/O CONTRAST [**2160-8-8**] 6:29 PM 1) No acute intracranial hemorrhage or mass effect. 2) Large encephalomalacia from chronic left frontal infarct. 3) No CT evidence of acute major vascular territorial infarction, though if clinical suspicion remains high, MRI is far more sensitive to assess. . CTA CHEST W&W/O C &RECONS [**2160-8-12**] 2:39 PM CT CHEST WITH CONTRAST: A left-sided central venous catheter terminates in the mid portion of the superior vena cava (SVC). The heart is enlarged. There is atherosclerotic disease of the aorta and major branches. There is coronary artery calcification. There is no evidence for acute aortic injury. The pulmonary arteries opacify, but there are multiple large filling defects bilaterally consistent with pulmonary emboli. Clot burden is moderate. Clot density is greatest on the right. Note is made of a large hiatal hernia. Small mediastinal nodes are present, but there is no pathologic axillary, mediastinal, or hilar adenopathy. Evaluation of the lung windows is limited secondary to respiratory motion, but there is right apical scarring and calcified plaque formation. There are small bilateral pleural effusions with associated atelectasis (left greater than right). The osseous structures are remarkable for degenerative disease. Multiple left-sided posterior rib fractures are present. No pneumothoraces are identified. There is a compression deformity of the lower thoracic spine. There is anterior fusion of the thoracic vertebrae. IMPRESSION: 1. Bilateral pulmonary emboli with moderate/significant clot burden. 2. Left-sided posterior rib fractures. 3. Bilateral pleural effusions and associated atelectasis. 4. Cardiomegaly, coronary artery calcification and atherosclerotic aortic calcification, large hiatal hernia, and degenerative disease. 5. Age indeterminate compression deformity of the lower thoracic spine. Brief Hospital Course: 87 yo woman with dementia, HTN, LVH, occluded left ICA, old left frontal infarct who was initially admitted to the TSICU after a fall. Her course was complicated by BRBPR, anemia, HTN, demand ischemia. Her hematocrit is stable and she has had no more episodes of BRBPR. Shortly before discharge, she was found to be C. diff positive, explaining her elevated WBC. The following issues were investigated during her hospitalization: . # Dyspnea/CHF: Thought to be due to submassive PE in addition to CHF component. IVC in place as patient is unable to be anticoagulated given history of GI bleed and guiaic positive stool. Additionally pt. was diuresed with good effect and discharged on PO Lasix for continued diuresis in the setting of CHF. . # CAD/Ischemia: The pt. initially had elevated Troponin (.28) thought to be secondary to demand ischemia in the setting of anemia and tachycardia. Pt. was thought to be a high risk for cath and is DNR/DNI. For this reason, medical management was elected. Pt. was maintained on Metoprolol, Moexipril ASA, Atorvastatin and pain control. . # CHF: Echo showed hyperdynamic LV with EF at 75%, symmetric LVH likely [**12-27**] hypertension and minimal AS. She was diuresed with Lasix and Metolazone. She was maintained on Moexipril, Imdur, Amlodipine and Hydralazine for afterload reduction and Metoprolol for rate control. . # Dementia: She is alert to person and can speak minimally with an expressive aphasia and according to her son is close to her baseline. Sedating medications were avoided during this hospitalization. UA +, consider UTI as cause of mental status change in this elderly patient. On Ciprofloxacin 500 mg x 7 days, today is [**2-29**]. . #UTI: Patient was found to have a + UA with purulence near foley site. She was started on Cirpofloxacin 500 mg for a 7 day course. . #C. diff Colitis: Likely cause of leukocytosis (18.0 on discharge). Pt. was started on Flagyl 500 mg TID and placed on contact precautions. . # S/P Fall: her C1/C2 fracture appears old. US on [**8-14**] showed hematoma. The hematoma remained stable. She will need a repeat CT of the C-spine in 8wks and will need rehab as an outpatient. . # HTN: Labile SBP, at times elevated to 200. Patient was adequately controlled on Moexipril, Metoprolol, Imdur, Hyrdalazine and Amlodipine. . # Cerebral Ischemia: Chronic disease with known cerebral pathology. Patient was continued on Aspirin and Atorvastatin. . # Hyponatremia: Steadily improved and thought to be hypervolemic hyponatremia in the setting of CHF. . # GI Bleed: BRBPR. HCT remained stable during hospitalization and patient never required a transfusion. . # Hyperlipidemia: Patient was maintained on Atorvastatin . # Endo: DM, Hypothyroidism. Patient was maintained on ISS, Levothyroxine and Calcium. Medications on Admission: ASA 81mg qd lipitor 20mg qd toprol XL 200mg qd moexipril 7.5mg qd fosomax 20mg qweek calcium 600mg TID aggrenox 1mg [**Hospital1 **] . Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). Disp:*90 Tablet, Chewable(s)* Refills:*2* 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). Disp:*qs * Refills:*2* 7. Moexipril 15 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 days. Disp:*4 Tablet(s)* Refills:*0* 9. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:*120 Tablet(s)* Refills:*2* 10. 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* 11. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 12. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 13. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 weeks. Disp:*63 Tablet(s)* Refills:*0* 14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: 1. Pulmonary Embolism 2. Gastrointestinal Bleed Discharge Condition: Stable, afebrile, chest pain free Discharge Instructions: 1. Please take all of your medications as directed 2. Please keep all of your follow-up appointments 3. Call your doctor or go to the ER for any of the following: chest pain, shortness of breath, fevers/chills, bleeding from your rectum or vomiting blood or any other concerning symptoms [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

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icd9cm

[ [ [] ] ]

[ "38.93", "99.04", "38.7" ]

icd9pcs

[ [ [] ] ]

10778, 10844

6098, 8887

265, 271

10936, 10972

1937, 2937

1270, 1288

9073, 10755

10865, 10915

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47,816

147,646

46032

Discharge summary

report

Admission Date: [**2150-8-10**] Discharge Date: [**2150-8-17**] Date of Birth: [**2067-1-13**] Sex: M Service: SURGERY Allergies: Neurontin Attending:[**First Name3 (LF) 4748**] Chief Complaint: LLE extremity cellulitis,hypotension. Major Surgical or Invasive Procedure: None. History of Present Illness: The patient is 83 year male well known to Vascular Service with extensive history of vascular disease. Most recently, patient is s/p L CFA to AK-popliteal artery bypass with 8 mm PTFE in [**2150-3-9**] and L 1st/4th toe amp. In [**2150-5-9**], pt was admitted for LLE cellulitis and was treated with a course of Cipro. Patient has been doing well until yesterday when he began having low grade fever and his LLE appeared to be warm and painful. He also reported have some nausea but no emesis. Patient denied any diarrhea, abd pain, constipation. Patient said that he has been ambulating without much difficulty. Patient became hypotensive in the ED in the interim. He continued to complained of back pain and intermittent LLE pain. Past Medical History: PMH: End stage renal disease on HD every second day; Hypertension; coronary artery disease; hyperlipidemia; arthritis; h/o TIA; s/p PEG tube placement for dysphagia PSH: 4x CABG in [**2138**]; s/p partial colectomy for colon ca; s/p fall with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] and PTX (chest tube placement) Social History: retired police officer, married, no EtOH, former history of smoking Family History: non contributory Physical Exam: Vitals- 97.4 68 155/54 16 97RA Gen-AxOx3, NAD CV-RRR, No MRG Pulm- CTA BL Abd-soft, NT,ND Ext- LLE mildy edematous, minimally erythematous(significantly improved) Pulses- R p/p/d/d L p/p/d/d Brief Hospital Course: Pt was admitted [**2150-8-10**] with fevers and LLE redness/cellulitis. Pt became hypotensive to the 80's in the ED and was transferred to the CVICU in stable condition after responding to fluid bolus. Initially there was concern for septic shock with lactate>3 and WBC's>20 however pt remained HD stable with no pressors initially required. Pt was was put on broad spectrum antibiotics for presumed LE cellulitis. On HD 2 lactate was down to 1.1. The Renal team was consulted and pt was dialysed as tolerated while hospitalized. On HD 3 pt went into Afib during HD session and pt was started on Amiodarone PO. Afib relolved and pt remained HD stable. A cortisol stim test showed lack of appropriate response and pt was started on Hydrocortisone taper and his BP continued to remain stable. Pt leg was wrapped with an ACE and elevated daily and erythema improved significantly. On HD 5 pt was tranferred to the VICU in stable condition. Pt remained afebrile, stable and leg continued to improve. Pt was dc'd home on HD 8 with a course fo oral antibiotics and to follow up with his usual regimen of dialysis. Medications on Admission: Glipizide 5', Diovan 80', lasix 40' (not on dialysis days); omeprazole 40'; IC [**Location (un) **] caps T', Plavix 75', Renagel 800', Zocor 80', ambien 10 QHS, Oxycontin 10' PRN, Oxycodone 5mg Q4hrs PRN pain; Spiriva 18mcg T' Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for 1 days. Disp:*1 Tablet(s)* Refills:*0* 5. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Left lower extremity cellulitis. Discharge Condition: Stable. Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the vascular surgery service for treatment of left lower extremity cellulitis and decreased blood pressure. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 1391**] in [**2-11**] weeks as necessary. Also, please follow-up with [**Hospital1 882**] for your usual dialysis appointments starting tomorrow.

[ "V45.81", "274.9", "V45.11", "414.00", "427.31", "403.91", "V10.05", "682.6", "250.00", "285.9", "585.6", "440.20" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

3668, 3674

1799, 2908

307, 315

3751, 3759

4064, 4262

1544, 1562

3186, 3645

3695, 3730

2934, 3163

3910, 4041

1577, 1776

230, 269

343, 1077

3774, 3886

1099, 1442

1458, 1528

23,002

173,459

28727

Discharge summary

report

Admission Date: [**2195-8-30**] Discharge Date: [**2195-9-25**] Date of Birth: [**2131-11-25**] Sex: M Service: MEDICINE Allergies: Zyvox / Vancomycin Hcl Attending:[**First Name3 (LF) 1148**] Chief Complaint: Hip infection Major Surgical or Invasive Procedure: Right IJ left PICC line placement by interventional radiology NG tube placement History of Present Illness: Mr. [**Known lastname 12843**] is a 63 yo m w/ h/o CAD s/p THR [**2195-7-15**] for OA. He had persistent drainage post-op. He was taken back to OR 7 days post op for irrigation and wound cxs then were negative. He was given about 4 days of IV kefzol and he was d/c??????ed on diclox for 10 days. He developed fever and purulent wound discharge at home and represented to OSH. He had the hardware removed around [**8-3**] and Dr. [**First Name (STitle) 2572**] put in a tobramycin/gentamicin/vanco spacer. ID was consulted and he was given IV vanco when wound cx??????s grew MRSA. ESR at that time about 100 and CRP of 9.6. Post op, he had a vac dressing for about 6 days and then he went back to the OR for wound closure. He was d??????ced tp home with picc line for outpt iv vanco. Six days ago, VNA called and said pt was febrile at home to 102 with n/v sweats, chills. He was brought back to the hospital where he had a nl wbc but had 10% eosinophils. His wound apparently looked okay. He was taken off IV vanco and placed on iv linezolid. He had been on the vanco for ~2wks. His ESR was up to 110 but his CRP was 2.4. Patient states that ~6 hours after beginning linezolid, he developed a whole body rash. It began on his legs and back and spread to his face, trunk, and arms. It was accompanied by face and neck swelling and was pruritic. It was then thought that he was reacting to the linezolid and he was switched back to vancomycin. He contined spiking temps so he was taken back to OR this past [**Last Name (un) **] and the abx spacer was removed. There was small amt of purulent drainage in wound. He did some additional debridement. Pt got some blood before going to OR cause he was anemic. Wound was left open with vac dressing on. Prior to transfer, he was said to be in delirium. He??????d been on coumadin since his operation and his last INR on [**8-30**] was 5.8 at which time he was taken off all anticoagulation. It is unclear whether blood cultures were drawn at outside hospital. On admission to the floor, Mr. [**Known lastname 12843**] is alert and oriented x 3, hemodynamically stable. He is complaining of some pain at his R hip surgical site but is otherwise w/o complaint. ROS: He denies any chest pain, SOB, HA, vision changes, lightheadedness, change in his BMs. No diarrhea. No constipation. No brbpr, hematochezia, melena. No dysuria. No changes in urination. No abdominal pain. No numbness, tingling, or weakness. Past Medical History: CAD- stents x 2- [**2190**], [**2192**]. Cath [**2195**]- mild inf. hypokinesis; EF~66% Osteoarthritis hypertension hypercholesterolemia MRSA wound infection h/o skin cancer s/p TKR x 2 (most recently in [**2194**]) s/p cervical spine spur removal (No hardware) s/p appendectomy s/p cholecystectomy s/p lower lumbar surgery x 2 w/ hardware (plates and wires) Social History: Lives w/ wife. [**Name (NI) **] [**Name2 (NI) 69446**] Frisee. Has electric chair lift. Walks w/ walker. Distant smoking hx. 2-4 beers/night prior to surgery. No IVDU. Family History: father- throat cancer mother- vaginal cancer brothers and sisters- alive and well. Physical Exam: PE: T:95.2 BP: 134/70 HR: 72 RR: 18 O2 99% RA Gen: Pleasant, well appearing male in NAD HEENT: No conjunctival pallor. No icterus. PERRL. MMM. Mucosal ulcers on upper lip. NECK: Supple, No LAD, No JVD. No thyromegaly. CV: RRR. Distant heart sounds. No murmurs, rubs or [**Last Name (un) 549**] LUNGS: CTAB, good BS BL ABD: Obese. Soft, NT, ND. NL BS. No HSM EXT: WWP, NO CCE. 2+ DP pulses BL. PICC C/D/I in R UE. R hip wound C/D/I w/ wound vac in place. SKIN: Diffuse maculo-papular rash, non blanching over legs, trunk, arms, face. NEURO: A&Ox3. Appropriate. Listens and responds to questions appropriately, pleasant Pertinent Results: Admission Labs: . [**2195-8-30**] 08:25PM BLOOD WBC-16.8* RBC-3.43* Hgb-10.1* Hct-29.4* MCV-86 MCH-29.6 MCHC-34.5 RDW-14.8 Plt Ct-178 [**2195-8-30**] 08:25PM BLOOD PT-35.3* PTT-42.4* INR(PT)-3.9* [**2195-8-30**] 08:25PM BLOOD Glucose-75 UreaN-22* Creat-1.1 Na-139 K-3.4 Cl-103 HCO3-26 AnGap-13 [**2195-8-30**] 08:25PM BLOOD ALT-607* AST-356* CK(CPK)-598* AlkPhos-663* TotBili-1.3 [**2195-8-30**] 08:25PM BLOOD Calcium-7.8* Phos-3.0 Mg-1.6 [**2195-8-30**] 06:53PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2195-8-30**] 06:53PM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-5.0 Leuks-NEG [**2195-8-30**] 06:53PM URINE RBC-7* WBC-0 Bacteri-MANY Yeast-NONE Epi-0 . Other Labs: . [**2195-9-7**] 04:45AM BLOOD calTIBC-160* Hapto-97 Ferritn-1417* TRF-123* [**2195-8-31**] 11:00AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2195-9-7**] 03:13PM BLOOD Smooth-POSITIVE [**2195-9-7**] 03:13PM BLOOD [**Doctor First Name **]-NEGATIVE [**2195-9-7**] 04:45AM BLOOD AFP-1.6 [**2195-9-1**] 08:57AM BLOOD CRP-79.4* [**2195-9-7**] 04:45AM BLOOD PEP-NO SPECIFI IgG-1288 IgA-31* [**2195-8-31**] 11:00AM BLOOD HCV Ab-NEGATIVE . Microbiology: Blood cx (1/4 bottles) [**2195-9-11**]: grew pan-sensitive E.coli SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN----------<=0.25 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Would cx [**2195-9-9**] grew pan-sensitive E. coli All other blood cxs were no growth to date URINE CULTURE sent on [**2195-9-22**] and Urine analysis negative on [**2195-9-22**] ACINETOBACTER BAUMANNII. 10,000-100,000 ORGANISMS/ML.. "Note, for Amp/sulbactam, higher-than-standard dosing needs to be used, since therapeutic efficacy relies on intrinsic activity of the sulbactam component". 2ND ISOLATE. <10,000 organisms/ml. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ACINETOBACTER BAUMANNII | AMPICILLIN/SULBACTAM-- 4 S CEFEPIME-------------- 32 R CEFTAZIDIME----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R IMIPENEM-------------- 8 I LEVOFLOXACIN---------- =>8 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R . RUQ U/S ([**2195-8-31**]): No biliary ductal dilatation. Status post cholecystectomy. Atrophic left lobe of the liver. . PELVIS AND RIGHT HIP, THREE VIEWS([**2195-8-31**]): Explanted right hip prosthesis. Irregular lucencies and new bone formation in the residual aspect of the proximal right femur could nonspecific but could reflect residual osteomyelitis. . CT abdomen and pelvis ([**2195-9-7**]): 1. No intra-abdominal fluid collections identified. 2. Patent hepatic vasculature. 3. Small nonobstructing left renal calculus. 4. Air within the bladder. This is presumably secondary to recent Foley catheterization. If not, this could be secondary to an infectious etiology. 5. Fluid and calcific densities at the right femoral prosthesis removal site. Foci of air along the right femoral diaphysis may be secondary to packing material. If there was no packing material placed at this location, this could represent an infectious process. Evaluation for osteomyelitis is difficult given the extensive postoperative changes. . Echo ([**2195-9-10**]): 1. The left atrium is mildly dilated. 2. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 3. The aortic valve leaflets (3) are mildly thickened. 4. The mitral valve leaflets are mildly thickened. . CT head non-contrast ([**2195-9-14**]) and [**2195-9-16**]: Low attenuation involving the right frontal subcortical white matter, which probably represents microvascular ischemic disease. The presence of a small subacute infarct cannot be totally excluded. If the patient has any neurologic deficit, correlation with diffusion-weighted MRI would be helpful. . EEG ([**2195-9-15**]): This is a mildly abnormal EEG in the primarly drowsy state due to the presence of generalized bursts of polymorphic delta. This abnormality suggests subcortical deep midline irritability, which, given the patient's age, would most likely be related to vascular disease. . MRI/MRA of brain ([**2195-9-17**]): IMPRESSION: No evidence of acute infarction. Probable chronic microvascular angiopathy. Faint flow signal demonstrated within the distal right vertebral artery, which appears to have increased in caliber at the vertebrobasilar junction. These findings may be secondary to stenosis of the distal right vertebral artery versus a developmentally hypoplastic vertebral artery. If clinically indicated, further evaluation of the vertebral artery can be performed with a CT angiogram or MR angiogram of the neck. Otherwise, normal MRA of the circle of [**Location (un) 431**]. . Disharge Labs: [**2195-9-25**] 06:03AM BLOOD WBC-11 RBC-2.82* Hgb-8.3* Hct-24.9* MCV-88 MCH-29.4 MCHC-33.3 RDW-15.9 Plt Ct-332 [**2195-9-25**] 06:03AM BLOOD PT-13.6* PTT-29.2 INR(PT)-1.2* [**2195-9-25**] 06:03AM BLOOD Glucose-91 UreaN-8 Creat-0.7 Na-131* K-4.4 Cl-101 HCO3-27* AnGap 7* [**2195-9-25**] 06:03AM BLOOD ALT-43* AST-38 LDH 206 AlkPhos-163* TotBili-0.5 [**2195-9-25**] 06:03AM BLOOD Calcium-7.8* Phos-3.6 Mg-1.9 [**2195-9-25**] 12:28PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2195-9-25**] 12:28PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011 Brief Hospital Course: This is a 63 y.o. man with a history of CAD s/p PCI/stentx2 s/p elective R THR in [**6-23**] complicated by wound infection s/p hardware removal in [**7-23**] admitted with persistent wound infection with subsequent allergic drug rash, recent GNR bacteremia and with lab data concerning for DIC. . 1 Infected hip. S/p hardware removal and multiple debridements, most recently on [**8-23**]. Patient with persistent pain. Past cultures grew MRSA. On this admission with swab cultures growing pan-sensitive E. Coli. Transient GNR bacteremia (1/4 bottles on [**2195-9-11**] grew E.coli) possibly from this source. Surviellance cxs [**Doctor Last Name **] after [**2195-9-11**] showed no growth to date. We continued Vac dressing in place and changed every 3 days by orthopedics, pain control with oxycodone, Hydromorphone PRN, Abx coverage for infected hip with Daptomycin 600mg IV Q24h for past MRSA, which was discontinued after a total of 6 weeks course, and Ciprofloxacin 400mg IV Q12h switched to cipro 500mg PO q12 hr on [**2195-9-15**] per ID rec for E.Coli bacterimia, and will be continued for a total of 6 weeks. We went back to the OR on [**2195-9-24**] for I&D of the right hip and primary closure by orthopedics, and continued to be hemodynamically stable and afebrile after the procedure. . 2 Coagulopathy/DIC. Low fibrinogen (dropped to 70s on [**2195-9-12**]), low haptoglobin (<20), elevated D-Dimer (elevated to 3800s on [**2195-9-11**]), elevated T Bili (peaked to 3.0 on [**2195-9-13**]), elevated INR (peaked to 2.3 on [**2195-9-12**] while not on any anticoagulation) all consistent with DIC. Although pt's platelets remained >100,000s, Some schistocytes seen on peripheral smear. Hem/Onc was consulted and recommended checking heiz body (negative) and G6PD level 6.5 (WNL), Cryoprecipitate PRN (he received a two units total) to keep fibrinogen>100, FFP prn for bleeding (pt didn't require any), Vitamin K for elevated INR, and continued to monitor coags and DIC labs which improved. . 3 E. Coli bacteremia. initially presented with fever, but negative cxs; however blood cx 1/4 bottles on [**2195-9-11**] grew E. Coli pan-sensitive, like from hip wound source (same organism). Patient was started on Ciprofloxacin 400mg IV Q12h switched to cipro 500mg PO q12 hr on [**2195-9-15**] per ID rec for a total of 6 weeks (day1 [**2195-9-11**]). Surveillance cultures since then showed no grwoth to date. . 4 Delirium - initially thought to be related to recent fevers, eosinophilic drug rash, but pt reported having some increased confusion and hallucination which was getting worse on [**9-14**] and [**9-15**]. head CT w/o contrast [**9-14**] showed Low attenuation involving the right frontal subcortical white matter, which probably represents microvascular ischemic disease, EEG which r/o seizures. neuro was consulted and recommended checking folate, vit B12, ammonia which are WNL; RPR NR; started thiamine 100mg/day prophylaxis given ho of ETOH use, but [**Last Name (un) **] unlikely, MRI/MRA brain with gadolinium showed no acute changes. His delirium improved since [**9-20**] with improved PO intake and correction of his hyponatremia (see below). . 5 LFT abnormalities. Pt's LFT's were elevated without clear eitiology earlier on this admission. They were improving initially, and subsequently trending up again on [**2195-9-11**] in the setting of decreasing Fibronogen, haptoglobin, increasing D-dimers and INR. Liver disease may also explain low fibrinogen, low haptoglobin and elevated T. Bili. Unlikely concern for infarct. Hep serologies negative, Anti-smooth muscle Ab positive (1:40). ?Autoimmune hepatitis? [**Doctor First Name **] negative, U/S ([**2195-9-11**]) without signs of obstruction. We continued to monitor LFTs, which continued to trend down with resolution of DIC/coagulapathy . 6 Rash with eosinophilia. Rash developed with eosinophilia elevated as high as 40% around [**2195-8-31**], most likely drug rash. Dermatology was consulted who agreed with diagnosis of likely drug rash. He was treated symptomatically with benadryl, Triamcinolone cream, and Sarna lotion. Avoided Beta lactams and vanc and linezolid, all possible sources of prior eosinophilic reaction. His rash continued to improve and resolved during his hospital stay. . 7 ? UTI (likely contamination from Foley). Urine cx on the [**9-22**] grew actinobacter <100,000 organisms, resistent to cipro, and cefepime, sensitive to unasyn and augmentin, however UA on the same day was negative and patient had a foley in at the time; A repeat UA done on [**2195-9-25**] was obtained after Foley was d/c'ed was negative; this is most likley contanmination from the foley; After discussion with ID team, abx treatment was not necessary. Patient will have a follow up UA and Urine cx in a week at the rehab as a follow up; . 8 Anemia. Potentially related to DIC or hemolysis. Direct coombs negative x2, inconsistent with autoimmune hemolysis; G6PD WNL and [**Doctor Last Name 17012**] body negative We ontinued to monitor his Hct, which remained stable. . 9 IgA deficiency. This was initially a concern for blood product reaction/hemolysis. Significance unclear. Pt is deficient, though IgA is present. . 10 CAD. Stable. No acute issues. Continued Metoprolol 50mg PO BID, which was increased to 75mg PO BID on [**9-20**], increaed to 100mg Po bid on [**2195-9-23**], Isosorbide Mononitrate 60mg PO QD with holding parameters; continued Ramipril 5 mg PO qday, which was increased to 10mg PO qday for better BP control; we held Aspirin 81mg PO QD initially, after likely DIC/coagulapathy, which was restarted on [**2195-9-18**] after resolution of his coagulapathy/DIC; held home furosemide 20mg PO QD given apparent volume depletion and poor po intake, and monitored his I/O very closely. . 11 Hyponatremia - started on [**2195-9-13**] with Na nadired to 128; Urine lytes: Creat:60; Na:73; Osmolal:539; Urine Na 73; differential diagnosis included appropriate vs inappropriate increase in ADH vs hypothyroidism vs adrenal insufficiency; given patient has poor PO intakes in the past three weeks, most likely increased ADH (appropriately response to hypovolemia); we started him on some IV fluids, and his hyponatremia resolved. . 12 Nutrition/FEN - nutrition was consulted; patient reported having decreasing PO intake despite encouragement from staff and family memebers, was initially started with PPN on [**2195-9-12**] x 3 days, after discussion with family, tube feeding was started on [**2195-9-15**], but patient self-extubated the NG tube x 2. After discussion with family and nutritionist, carolie count was started on [**2195-9-19**] for three days, and showed improved PO intake and nutrition intake. With patient's delirium resolving around [**9-20**], he was more willing to take PO and boost supplements with much encouragement by staff and family. . 13 Prophylaxis - Enoxaparin 40mg SC Q24h. - Dolasetron 12.5mg IV Q8h: PRN - Docusate 100mg PO BID, Senna 1 tab PO BID - Bisacodyl 10mg PO/PR PRN . 14 Code status - DNR/DNI, confirmed with patient and wife; Medications on Admission: Diphenhydramine HCl 25-50 mg PO Q6H:PRN celebrex 200 mg daily granisetron 1 mg IV Q8-12hrs prn metoclopramide 10 mg IV Q4-6 hrs prn nausea promethazine 12.5-25 mg po Q6-8hrs prn nausea propoxyphene 100-200 mg po Q4-6hrs prn morphine pca 2-4 mg Q 6 min. 30 mg/4hr limit Ramipril 5 mg PO DAILY Pantoprazole 40 mg PO Q24H Metoprolol 50 mg PO BID Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY Furosemide 20 mg PO DAILY Atorvastatin 40 mg PO DAILY Discharge Medications: 1. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR 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. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) injection Subcutaneous once a day: Continue until instructed to stop by your orthopedist. Disp:*30 syringes* Refills:*0* 5. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*80 Tablet(s)* Refills:*0* 6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 weeks. Disp:*56 Tablet(s)* Refills:*0* 7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Ramipril 5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) 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 for constipation. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: Three (3) Tablet Sustained Release 12HR PO Q12H (every 12 hours). 13. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. Discharge Disposition: Extended Care Facility: [**Hospital6 19504**] of [**Location (un) 1514**] - [**Location (un) 1514**], NH Discharge Diagnosis: Primary: 1. MRSA wound infection 2. Type 4 hypersensitivity to vancomycin 3. E. coli bacteremia 4. Delirium 5. Right hip infection 6. questionable DIC (with transaminitis, decreased fibronogen, and decreased haptoglobin, although platelets remained >50,000) 7. Eosionophilia and drug rash . Secondary: 1. CAD 2. hypertension 3. hypercholesterolemia 4. osteoarthritis Discharge Condition: hemodynamically stable, afebrile, tolerating POs Discharge Instructions: Please call your doctor or return to the hospital with increased pain, swelling, wound drainage, chest pain, shortness of breath, lightheadedness, fevers, chills, nausea, vomiting, abdominal pain, changes in your stools or urination, or any other concerns. . You were admitted for hip wound infection and subsequent E. coli bacteremia, you completed a 6 week course of IV daptomycin for your MRSA wound infection, you need to continue Ciproflaxin 500mg by mouth twice a day for a total of 6 weeks (you were started on [**2195-9-11**]). . You right hip infection was treated and healed nicely with vac dressing changes, you had an incision and drainage and primary closure of your right hip on [**2195-9-24**]. Surgical staples can be removed on post op day 10 by the rehab doctors, and if you experience any fever, erythema, drainage, signs of infection around the right hip, dihiscience of the closure, please go the nearest ER or call orthopedic clinic at [**Hospital1 18**] [**Telephone/Fax (1) 1228**]. In addition, please follow up with Dr. [**Last Name (STitle) 1005**] in the orthopedic clinic in 2 weeks for follow up your hip closure done on [**2195-9-24**], and Dr. [**Last Name (STitle) **] in [**2-20**] months after for discusion of future hip replacement at [**Telephone/Fax (1) 1228**]. . Please take your medications as prescribed. . Please follow up with your appointments see below. Followup Instructions: Please Follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 69447**], [**First Name3 (LF) 1158**] on [**10-12**], [**2195**] at 9:30am . Please follow up with Dr. [**Last Name (STitle) 1005**] in the orthopedic clinic in 2 weeks by calling [**Telephone/Fax (1) 1228**] for primary hip closure follow up. . Please follow up with Dr. [**Last Name (STitle) **] in [**2-20**] months after for discusion of future hip replacement at [**Telephone/Fax (1) 1228**] . Please follow up Dr [**First Name8 (NamePattern2) 7618**] [**Name (STitle) **], MD in the [**Hospital **] clinic Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2195-10-27**] 9:00 Completed by:[**2195-9-25**]

[ "286.6", "279.01", "276.1", "E930.8", "693.0", "V43.64", "285.9", "414.01", "576.8", "293.0", "288.3", "790.7", "998.59" ]

icd9cm

[ [ [] ] ]

[ "86.22", "77.65", "38.93", "99.04" ]

icd9pcs

[ [ [] ] ]

19523, 19630

10450, 17541

298, 379

20041, 20092

4188, 4188

21544, 22239

3448, 3532

18047, 19500

19651, 20020

17567, 18024

20116, 21521

3547, 4169

245, 260

407, 2862

4204, 4914

2884, 3245

3261, 3432

4926, 10427

6,133

111,487

46038

Discharge summary

report

Admission Date: [**2131-10-19**] Discharge Date: [**2131-11-5**] Date of Birth: [**2084-7-31**] Sex: F Service: [**Hospital Unit Name 153**] This discharge summary covers the period from [**2131-10-19**] until [**2130-12-5**]. HISTORY OF THE PRESENT ILLNESS: The patient is a 47-year-old female with a new diagnosis of large B cell lymphoma who was transferred to the [**Hospital Unit Name 153**] from Bone Marrow Transplant Service for respiratory distress, urgent need for central venous access and initiation of CHOP chemotherapy in anticipation of tumor lysis syndrome. The patient was initially admitted to [**Hospital6 649**] on [**2131-10-19**] to the Medical Service with the chief complaint of worsening shortness of breath and fatigue. She was found to have prominent mediastinal lymphadenopathy and bilateral pleural effusions. Of note, the patient was suspected to have lymphoma prior to admission to the hospital. She was suppose to be evaluated by the Oncologist as an outpatient. In the hospital, she was treated with broad spectrum antibiotics for presumed pneumonia. Her pleural effusions were tapped. Pathology from pleural fluid returned positive for B cell lymphoma. The pathology of supraclavicular node biopsy which was done as an outpatient prior to admission also was consistent with B cell lymphoma. One day prior to transport, the patient had worsening shortness of breath and was ruled out for a pulmonary embolism for CT angio. She also had a transthoracic echocardiogram which showed normal cardiac function. She was transferred to Bone Marrow Transplant for initiation of chemotherapy on [**2130-11-23**]. Within a few hours after transfer, she developed worsening tachypnea, shortness of breath. Because of the lack for venous access and high likelihood of deterioration after the initiation of chemotherapy he was transferred to the [**Hospital Unit Name 153**]. Upon transfer, she was short of breath, denied any chest pain, any nausea or vomiting. She was complaining of right axillary and left knee pain. She had no other complaints. PAST MEDICAL HISTORY: 1. SLE diagnosed in [**2112**] complicated by end-stage renal disease requiring cadaveric renal transplant in [**2120**]. She was receiving azathioprine, cyclosporin, and prednisone for immunosuppression. Her kidney transplant was very close match and she had no episodes of rejection. 2. Left hip avascular necrosis, status post replacement times two in [**2126**] and [**2130**]. 3. Hypertension. 4. Cataracts, status post surgery. 5. Status post cholecystectomy done by Dr. [**Last Name (STitle) **] at the [**Hospital6 256**]. 6. Hypothyroid. 7. Gout. ALLERGIES: Plaquenil, Fosamax, Lipitor. SOCIAL HISTORY: The patient is married. She has two sisters, one daughter 16 years of age. She does not smoke. She drinks alcohol occasionally. OUTPATIENT MEDICATIONS: 1. Percocet. 2. Levothyroxine 50 once a day. 3. Verapamil SR 240 mg in the morning, 180 mg at night. 4. Colace. 5. Colchicine 0.6 mg once a day. 6. Senna. 7. Bisacodyl. 8. Zofran. 9. Ceftriaxone. 10. Levofloxacin. 11. Flagyl. 12. Protonix. 13. Ativan. 14. Prednisone taper. 15. Heparin subcutaneous. 16. Cyclosporin. 17. Atrovent. 18. Albuterol. 19. Allopurinol. 20. Morphine. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 96.9, heart rate 92, blood pressure 108/63, respirations 28, oxygen saturation 98% on 4 liters nasal cannula. General: The patient was in moderate respiratory distress, alert and oriented times three. HEENT: The oropharynx had a wide plaque on the hard palate, also a covered tongue and buccal mucosal. The pupils were equal, round, and reactive to light and accommodation bilaterally. The extraocular movements were intact. Neck: No JVD. Cardiovascular: Regular, no murmurs, rubs, or gallops. Pulmonary: Crackles two-thirds down bilaterally with no wheezes. Abdomen: Obese, nontender, nondistended, positive bowel sounds. Extremities: No edema, 2+ dorsalis pedis pulses bilaterally, 2+ radial pulses bilaterally. Neurologic: Cranial nerves II through XII were intact. LABORATORY/RADIOLOGIC DATA: White cell count 13.3, hematocrit 35.7, platelets 273,000. PT 15, INR 1.5. Sodium 133, potassium 4.5, chloride 95, bicarbonate 23, BUN 43, creatinine 1.4. ALT 40, AST 28, LDH 75, alkaline phosphatase 64, amylase 26, lipase 14, total bilirubin 1.2, CK 25, albumin 2.8, troponin less than 0.01. Uric acid 15. Cyclosporin level 270. White cell count 1,215, 40 red blood cells, no polys, 4 lymphs, total protein 2.0, glucose 107, LD 341. ABG drawn on 4 liters of nasal cannula returned at 7.38, 42, and 37. Lactate 2.3. Echocardiogram done in [**2129-10-22**] was normal. A CT of the chest was done on [**2131-10-20**] which showed massive axillary, mediastinal, and hilar lymphadenopathy, with bilateral pleural effusions and collapse of posterior left lower lobe. CTA was done on [**2131-10-21**] and showed no pulmonary embolism. HOSPITAL COURSE: Upon transfer to the [**Hospital Unit Name 153**], the patient was intubated for hypercarbic respiratory distress and CHOP chemotherapy was started the same night. 1. LYMPHOMA: Diagnosed by chest CT confirmed by supraclavicular node biopsy and malignant cells and pleural effusion tap, large B cell lymphoma was positive for EBV virus, Burkitt's type with 100% cells dividing. The patient's large tumor burden in the chest and neck was initially treated with the cycle of CHOP chemotherapy followed by five days of Cytoxan and high-dose prednisone. Tumor lysis laboratories were followed every six hours. She received aggressive IV fluid hydration with sodium bicarbonate to alkalinize the urine. The urine output was maintained at 80-100 cc per hour. LDH initially was elevated at 4,000. It subsequently decreased and reached a level of 500 at nadir. On day number four post chemotherapy, [**2131-10-28**], a CT of the chest was obtained to evaluate for the interval change. All lymph nodes have decreased in size in general. The patient indeed has severe mediastinal lymphadenopathy with large lymph nodes compressing on the major airways and great vessels of the chest. She developed chemotherapy-induced pancytopenia on day number three postchemotherapy, granulocyte colony stimulator factor was started at 400 mg IV q.d. On [**2131-11-2**], the patient was started on another chemotherapy regimen with an AZT and hydroxyurea. Because of the risk of AZT induced lactic acidosis per ABGs, the lactate levels were followed closely. RESPIRATORY FAILURE: Multifactorial, caused by airway and great vessel compression and obstruction by tumor mass as well as large and growing malignant pleural effusions, hypoalbuminemia leading to third spacing and severe volume overload as well as atelectasis. The patient was initially thought to have pneumonia and was treated with antibiotics without significant success. She was later ruled out for pulmonary embolism with CTA. Her pleural effusion was tapped on [**2131-10-20**] prior to transfer to the [**Hospital Unit Name 153**]; 600 cc were drained with almost immediate reaccumulation of fluids. During the course of her ICU stay on [**2131-10-26**], another attempt was made at therapeutic thoracentesis; however despite large pleural effusions bilaterally on the chest x-ray only 10-15 cc of fluid were obtained. Follow-up CT done on [**2131-10-29**] showed growing large pleural effusions as well as persisting multiple lymph nodes, described above. The patient remained on assist-control ventilation, sedated. The plan was to readdress therapeutic pleural tap versus chest tube placement when she is more stable otherwise. INFECTIOUS DISEASE: Soon after initial intubation, the patient began complaining of abdominal pain. On [**2131-10-28**], the abdominal pain worsened. She developed diarrhea positive for C. difficile colitis and was started on Flagyl p.o. However, because of the ileus which developed soon after, Flagyl had to be changed to IV vancomycin 125 mg p.o. q. six hours was added for the treatment of C. difficile. She developed a fever and was started on cefepime with vancomycin IV. The patient remained afebrile on antibiotics for three days. Therefore, AmBisome was added to her antibiotic regimen. Her other positive cultures included urine and sputum yeast speciated as [**Female First Name (un) 564**] on [**2131-11-4**]. At the time of this dictation, the patient was on cefepime, Flagyl IV day number nine, vancomycin IV day number eight, vancomycin p.o. day six, AmBisome day number four, AZT and hydroxyurea day number three. GASTROINTESTINAL/FLUIDS ELECTROLYTES AND NUTRITION: As above, the patient developed abdominal pain with KUB consistent with ileus on [**2131-10-28**]. This was followed by abdominal CT scan which showed dilated sigmoid colon and significant thickening of the jejunum. Surgery was consulted due to the concern for typhlitis, infiltration of the small bowel by lymphoma and/or ischemic bowel. The consult felt that the presentation was consistent. Their recommendations included conservative medical management and holding tube feeds. Tube feeds were started two days after; however, due to severe gastroparesis and ileus, the patient could not tolerate even a minimal amount of tube feedings. On [**2131-11-1**], the patient was taken to Interventional Radiology and postpyloric Dobbhoff feeding tube was placed. Of note, during this procedure, significant small bowel wall thickening was also noted. It was also noted that the dye in the small bowel did not move through into ours for the length of the procedure. On [**2131-11-2**], tube feeds were restarted at half strength at 10 cc an hour. The patient was also maintained on TPN. CARDIOVASCULAR: Shortly after intubation, the patient developed paroxysmal atrial fibrillation as well as atrial ectopy. She was initially started on Diltiazem drip. Subsequently, she required an Amiodarone drip times two and one attempt at cardioversion. She was then started on Lopressor IV every four hours, Amiodarone drip as well as Diltiazem drip were discontinued. With regards to her pump, the patient had three echocardiograms done during this admission. The last echocardiogram was done on [**2131-10-31**] and showed hyperdynamic left ventricular function with mild outflow obstruction and mild pulmonary artery hypertension, both new compared with a previous study. She had two episodes of hypotension requiring pressors. She was successfully weaned off pressors during both episodes within 24 hours. RENAL: Status post kidney-renal transplant in [**2119**]. Because of the concern for post transplant proliferative disorder, she was withdrawn of immunosuppression except for a low-dose of Solu-Medrol. The patient's creatinine remained stable for the first seven days; however, subsequently, it started rising in the setting of some tumor lysis, multiorgan failure, multiple nephrotoxic medications, and likely renal hyperperfusion. She was maintained on Allopurinol. She received blood transfusions to maintain hematocrit above 28. The patient was followed by the Renal Transplant Team. HEME: Secondary to pancytopenia induced by chemotherapy, the patient required daily platelet transfusions and packed red blood cells every other day. Her INR remained elevated despite vitamin K administration. Laboratory data was consistent with chronic diffuse intravascular coagulation. ACCESS: Because of the severe lymphadenopathy, obtaining access was a difficult task. Initially, a left femoral line was placed. This was changed to a left internal jugular central line under the ultrasound guidance. However, secondary to thrombosis, the line needed to be discontinued. A right subclavian line was placed on [**2131-10-31**] and remained functional at the time of this dictation. Communication was maintained with the patient's husband as well as her sister. At the time of this dictation, a family meeting was planned for [**2131-11-5**] with the patient's oncologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], as well as the Intensive Care Unit attending to discuss the patient's prognosis and further treatment plans. The remainder of the patient's course will be dictated at a later date by another physician. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 3795**] Dictated By:[**Last Name (NamePattern4) 26613**] MEDQUIST36 D: [**2131-11-4**] 01:32 T: [**2131-11-4**] 14:39 JOB#: [**Job Number 97991**]

[ "286.6", "427.31", "008.45", "284.8", "200.28", "996.81", "710.0", "518.84", "427.5" ]

icd9cm

[ [ [] ] ]

[ "99.07", "34.91", "99.25", "96.04", "99.28", "38.93", "96.72", "99.04", "38.91", "96.6", "99.15" ]

icd9pcs

[ [ [] ] ]

5033, 12664

2910, 3318

3333, 5015

2130, 2738

2755, 2886

9,250

184,904

52329

Discharge summary

report

Admission Date: [**2106-6-15**] Discharge Date: [**2106-6-22**] Date of Birth: [**2053-10-9**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Morphine Attending:[**First Name3 (LF) 6743**] Chief Complaint: Abdominal/pelvic mass; abdominal pain Major Surgical or Invasive Procedure: Ex lap, drainage of ascites, LSO History of Present Illness: 52yo G1P0010 postmenopausal female initially presented to [**Hospital 1474**] Hospital (1 day PTA at [**Hospital1 18**]) complaining of diffuse abdominal pain x 1 day and increasing abdominal girth x several months. Denied nausea, vomiting, constipation, diarrhea, vaginal bleeding, or urinary symptoms. At [**Name (NI) 1474**] pt was found to have a WBC count of 22 with 80% PMNs. Electrolytes and hct were normal, CEA not elevated (0.5). CT of abdomen/pelvis performed at [**Hospital1 1474**] showed an approximately 20cm pelvic/abdominal mass extending to the xyphoid with ascites, concerning for ovarian cancer. Pt was transferred to [**Hospital1 18**] for further management. Past Medical History: Medical: none Surgical: Ex-Lap for ectopic pregnancy in her 20's OB/Gyn: Menopausal at age 46. Has not had any vaginal bleeding since then. No gynecologic care or pelvic exams since around age 40. Denies history of STD's. Pap smear performed at [**Hospital1 1474**]; result pending. Social History: Smokes [**7-24**] cigarettes/day x many years. Denies EtOH or IVDU. Works during the year as a cleaner at [**Location 108195**]but was recently laid off for the summer. Family History: No known family history of gyn or colon cancer. Physical Exam: T 100.9 BP 120/70 P 112 RR 20 O2sat 93%on 2L Gen: slightly uncomfortable and diaphoretic but NAD Lungs: expiratory wheezes throughout. No crackles or rhonchi. Breast: no masses bilaterally, no nipple discharge or irritation, no enlarged axillary lymph nodes. CV: tachycardic, no murmurs. Normal S1/S2. Abd: large, firm, tender abdominal mass extending to xyphoid. Mass is fixed, non mobile. No rebound tenderness. Hypoactive bowel sounds. Pelvic: large pelvic, fixed mass filling abdomen. Ext: pulses 2+ bl, no edema Rectal: normal tone, no cul-de-sac nodularity. Heme negative at [**Hospital1 1474**]. Pertinent Results: [**2106-6-17**] 09:45AM BLOOD WBC-14.7* RBC-3.90* Hgb-10.8* Hct-32.0* MCV-82 MCH-27.6 MCHC-33.6 RDW-14.2 Plt Ct-279 [**2106-6-17**] 09:45AM BLOOD Glucose-94 UreaN-8 Creat-0.8 Na-135 K-3.6 Cl-101 HCO3-23 AnGap-15 [**2106-6-17**] 09:45AM BLOOD Calcium-7.9* Phos-2.5* Mg-2.1 [**2106-6-15**] 10:39PM BLOOD WBC-20.1* RBC-4.00* Hgb-11.3* Hct-32.7* MCV-82 MCH-28.3 MCHC-34.6 RDW-14.0 Plt Ct-230 [**2106-6-15**] 10:39PM BLOOD Neuts-85.4* Lymphs-7.2* Monos-6.6 Eos-0.6 Baso-0.1 [**2106-6-15**] 10:39PM BLOOD CA125-618* [**2106-6-18**] 07:10PM BLOOD WBC-17.9* RBC-3.87* Hgb-10.8* Hct-31.0* MCV-80* MCH-28.0 MCHC-34.9 RDW-13.8 Plt Ct-313 [**2106-6-18**] 11:25PM BLOOD WBC-17.5* RBC-4.01* Hgb-10.7* Hct-32.0* MCV-80* MCH-26.7* MCHC-33.4 RDW-13.8 Plt Ct-334 [**2106-6-19**] 04:57AM BLOOD WBC-17.7* RBC-3.77* Hgb-10.5* Hct-31.1* MCV-83 MCH-27.7 MCHC-33.6 RDW-14.1 Plt Ct-296 [**2106-6-20**] 05:30AM BLOOD WBC-13.2* RBC-3.26* Hgb-9.0* Hct-26.9* MCV-83 MCH-27.6 MCHC-33.3 RDW-14.3 Plt Ct-317 [**2106-6-21**] 01:40AM BLOOD Neuts-72.1* Lymphs-17.9* Monos-4.6 Eos-5.1* Baso-0.3 [**2106-6-15**] 10:39PM BLOOD CA125-618* Brief Hospital Course: OR/Post-op course: Pt was taken to OR on HD#4 for exploratory laparotomy. L oophorectomy with resection of 25cm L ovarian mass was performed. Prelim path report: spindle cell neoplasm, benign. EBL 100cc, 1L ascites drained. Pt was kept intubated during transfer to SICU but was extubated the evening of POD#0. Pt reported marked symptomatic improvement post-operatively w/ respect to abdominal pain and respiratory status. She was transferred out of SICU back to floor POD#1. CV: [**Name (NI) 4452**], pt was persistently tachycardic with HR's in 100-110's. EKG x 2 was performed, both showing sinus tachycardia with no ST/T wave changes. Pt was clinically euvolemic with good UOP, and so tachycardia likely due to fever and pain. BP remained stable throughout course. Post-op, tachycardia resolved with HR's in the 90's. Pulm: Because of ?pulm infiltrate seen on CXR at [**Hospital1 1474**] and pt febrile, was started on IV levofloxacin for possible pneumonia. Chest CT performed HD#2 showed bibasilar opacities likely secondary to atelectasis but could not exclude pneumonia. Pt required supplemental O2 (2-3L) while in house likely secondary to a combination of pna/atelectasis/ascites. Atrovent nebulizer treatments were given as needed for wheezing. Post-op, respiratory status improved significantly and she had no oxygen requirement. Heme: Hct remained stable throughout course (32.7-->32) and pt did not require any blood products. ID: --[**Name (NI) 4452**], pt was intermittently febrile with Tmax of 102.4. Though fever was thought to be due primarily to large pelvic tumor/torsion/pulm infection, other sources of infection were investigated. Urinalysis was negative x 2, urine cultures still pending. KUB showed no evidence of obstruction or perforation. 2 sets of blood cultures x 4 showed no growth. Spiked to high of 101.5 on [**6-20**]; CXR ordered at that time showed no evidence PNA, urine Cx and blood cultures negative --IV levofloxacin was administered throughout course for possible pulm infection as described above; pt was discharged on oral abx Pt was found to be stable for discharge on [**2106-6-22**]. Medications on Admission: None Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*45 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Left ovarian fibroma Discharge Condition: stable Discharge Instructions: Pelvic rest for 6 weeks No heavy lifting for 6 weeks No driving while taking narcotics Call for fever>101 Followup Instructions: Call Dr. [**Last Name (STitle) 2028**] for an appointment for next week [**Telephone/Fax (1) 108196**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6753**]

[ "620.5", "486", "518.0", "789.5", "220" ]

icd9cm

[ [ [] ] ]

[ "65.39" ]

icd9pcs

[ [ [] ] ]

5875, 5881

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320, 354

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2274, 3375

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21,374

145,839

21466

Discharge summary

report

Admission Date: [**2114-11-13**] Discharge Date: [**2114-11-18**] Date of Birth: [**2048-4-14**] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 3556**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 66 year old male with multiple medical problems including diabetes, COPD on oxygen at baseline, hypertension and hyperlipidemia who presented to the [**Last Name (un) **] diabetes clinic this afternoon complaining of increased fatigue, shortness of breath and cough for the past three weeks. He also has been experiencing lightheadedness and blurry vision intermittently. The patient also experienced an episode of hypoglycemia this morning (finger stick of 25) which he treated with [**Location (un) 2452**] juice and glucose with rapid resolution. Given his symptoms this AM in diabetes clinic, he was advised to present to the ED. . He denies chest pain and worsening cough. He does report increased shortness of breath but has not needed to increase his home oxygen use. He denies fevers, chills. He has a cough at baseline which is non-productive and non-purulent and may be slightly more productive over the past few weeks. He has lost 15 lbs over three months when his lasix dose was increased. He denies any recent medication changes, or dietary changes. He denies hemoptysis. He denies any recent periods of immobility, long distance travel. No recent sick contacts. . In the ED the patient was found to be afebrile, hypoxic with an O2 sat of 84% on 100% O2, and hypotensive with a BP of 83/60 and HR 92. His hypotension resolved with IV fluids. An EKG was performed which revealed a right bundle branch block and there was concern for anterioseptal ST-depression. Cardiology was consulted who did not feel that he was experience an acute coronary event. He did recieve aspirin 325, and was started on a heparin and nitroglycerine gtt. First set of troponins came back negative. Initial chem7 revelaed a serum potassium of 6.4 on an non-hemolyzed specimen and he received insulin, sodium bicarbonate, calcium gluconate, dextrose and kaexylate. Past Medical History: 1. DM2 (complicated by nephropathy, neuropathy) 2. CKD (proteinuria) 3. HTN 4. Hyperlipid 5. COPD, home O2 3-4L NC 6. depression 7. anxiety 8. morbid obesity 9. Obstructive sleep apnea Social History: Single, lives in [**Location 3786**]. Currently not working. Used to smoke 5 packs per day, currently smokes [**3-24**] cigarettes daily. No alcohol use, no ilicits Family History: Sons had [**Name2 (NI) **] in 30s and 40s, mother and father had [**Name2 (NI) **] in older age. History of cancer but unknown type. Physical Exam: Vitals: T: 98.2 HR: 87 BP: 119/62 RR: 22 02: 98% on non-rebreather mask Gen: Alert and oriented, mild-respiratory distress HEENT: PERRL, EOMI, pharynx clear and without exudates Neck: JVP ~ 12 cm CV: Distant heart sounds, RRR, no murmurs or gallops appreciated Resp: Decreased breath sounds throughout, no wheezes or ronchi appreciated GI: Obese, soft, non-tender, non-distended, + BS GU: Foley in place draining clear yellow urine Ext: WWP, 1+ pulses bilaterally, 1+ pitting edemas to shins, no clubbing or cyanosis Neuro: Grossly intact Rectal: Guaiac negative per ED Pertinent Results: Admit Labs [**2114-11-13**] 04:38PM BLOOD WBC-10.5 RBC-4.99 Hgb-13.8* Hct-44.2 MCV-89 MCH-27.7 MCHC-31.2 RDW-17.4* Plt Ct-148* [**2114-11-13**] 04:38PM BLOOD Neuts-75.4* Lymphs-17.2* Monos-5.8 Eos-0.9 Baso-0.7 [**2114-11-13**] 04:38PM BLOOD Hypochr-3+ Anisocy-1+ Microcy-1+ [**2114-11-13**] 04:38PM BLOOD PT-39.8* PTT-37.7* INR(PT)-4.5* [**2114-11-13**] 05:30PM BLOOD Glucose-190* UreaN-29* Creat-1.3* Na-134 K-6.4* Cl-95* HCO3-36* AnGap-9 [**2114-11-13**] 05:30PM BLOOD CK(CPK)-153 [**2114-11-13**] 05:30PM BLOOD CK-MB-6 cTropnT-<0.01 proBNP-5032* [**2114-11-14**] 04:30AM BLOOD CK-MB-6 cTropnT-<0.01 [**2114-11-13**] 04:38PM BLOOD Lactate-5.8* K-8.7* [**2114-11-13**] 05:14PM BLOOD Lactate-4.2* K-6.4* [**2114-11-14**] 12:32PM BLOOD O2 Sat-87 . Discharge Labs [**2114-11-18**] 04:16AM BLOOD WBC-8.9 RBC-4.89 Hgb-13.5* Hct-41.0 MCV-84 MCH-27.7 MCHC-33.1 RDW-16.9* Plt Ct-132* [**2114-11-18**] 04:16AM BLOOD PT-14.7* PTT-23.5 INR(PT)-1.3* [**2114-11-18**] 04:16AM BLOOD Glucose-80 UreaN-22* Creat-0.8 Na-141 K-4.0 Cl-99 HCO3-39* AnGap-7* [**2114-11-18**] 04:16AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.2 . Imaging . [**11-13**] CXR: Suspected bilateral hilar enlargement and bilateral consolidations, suggesting infectious process as a more likely diagnosis. . [**11-13**] CT-PA: 1. Bibasilar posterior patchy consolidations representing multifocal pneumonia versus aspiration versus aspiration pneumonia. Mild atelectasis. Associated prominence of lymph nodes is probably reactive, however, follow-up scan after appropriate clinical interval recommended to ensure resolution. 2. Evidence of mild fluid overload. No pleural effusions. 3. No pulmonary embolism or aortic dissection. 4. Radiopaque gallstone with calcification in gallbladder wall which may reflect porcelain gallbladder. Please correlate. 5. Left kidney scarring with calcification. 6. Left adrenal adenoma. . [**11-14**] TTE 1.The left atrium is mildly dilated. 2.There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3.The right ventricular cavity is markedly dilated. Right ventricular systolic function appears depressed. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. 4.The aortic valve is not well seen. No aortic regurgitation is seen. 5.The mitral valve is not well seen. No mitral regurgitation seen. 6.The estimated pulmonary artery systolic pressure is normal. 7.There is no pericardial effusion. 8. Bubble study for shunt was performed Bubble study with cough was recorded but not at rest or with valsalva. Reported to be negative by Fellow and echo technician present. Brief Hospital Course: The patient is a 66 year old male with multiple medical problems including diabetes, COPD on oxygen at baseline, hypertension and hyperlipidemia who presented to the [**Last Name (un) **] diabetes clinic complaining of increased fatigue, shortness of breath and cough for the past three weeks. Pt was admitted to the MICU for management of respiratory distress with hypercarbic hypoxia. The following issues were addressed during this admission: . # Hypoxemia: We originally considered cardiac versus primary respiratory etiologies for his hypoxia. There was no evidence of ischemia per routine cycling of cardiac markers. Additionally, clinical exam, TTE, and CXR failed to reveal significant evidence of CHF, and CT-PA was negative for PE. Physical exam and CXR findings appeared most consistent with an exacerbation of COPD, possibly compounded by underlying cardiac disease. Accordingly, pt began a one week course of azithromycin, started high dose IV steroids, combivent nebs, home-dose flovent/advair/spiriva, and was placed on BiPAP for improved ventilation/oxygenation. Pt showed rapid improvement in his respiratory status. As pt continued to improve, his steroids were transitioned from IV to po with subsequent taper, and mask ventilation was transitioned to nasal cannula w/o issue. At discharge, pt had returned to his clinical baseline, with mildly increased O2 requirement vs. baseline (currently SpO2 >88% on 6 L NC). Pt was discharged on prednisone taper, azithromycin, home resp meds, with recommendation for close PCP/pulmonology f/u. Pt noted that he understood and agreed with this plan. . # Diabetes: [**Last Name (un) **] continued to follow during admission, adjusting insulin dosing as needed in the face of inflammation and steroid use. Pt will continue to f/u with [**Last Name (un) **] as an outpatient as he tapers off of the prednisone. . # Hypertension: BP was well-controlled on home meds (Toprol XL 50 mg, Norvasc 5 mg, Lisinopril 20 mg); lasix, diovan, and spironolactone were held during this admission due to thickened resp secretions suggesting the need for hydration. Pt will f/u with his PCP for further management. . # Hyperkalemia - Resolved with withdrawal of agents with a tendency to induce hyperkalemia (spironolactone). . # A-Fib - chronic coumadin for anticoagulation, toprol for rate control; INR 1.3 at discharge, so returned to home-dose coumadin schedule (initially altered due to INR 4.5 on admission). Pt instructed to f/u with PCP for INR check this week. . # Chronic Kidney Disease: Stable at baseline, admission Cr 1.3 improved rapidly with fluid resuscitation. . # Hyperlipidemia - continued lipitor 80 mg daily and niaspan 500 mg daily. . # Depression, Anxiety - continued home Xanax PRN, zoloft 50 mg [**Hospital1 **]. . # FEN: Renal, diabetic, heart healthy diet. Continued to replete electrolytes as needed. . # Prophylaxis: DVT (on coumadin, daily ambulation), GI (PPI). Medications on Admission: Gabapentin 300 mg TID NPH 30 units in AM, 10 units in PM Toprol 50 mg [**Hospital1 **] Diovan 160 mg daily Niaspan 500 mg QHS Potassium Chloride 10 mg QID Lipitor 80 mg daily Glyburide 5 mg (2 in AM, 2 in PM) Coumadin 8 mg daily Lisinopril 20 mg daily Lasix 40 mg daily Norvasc 5 mg daily Zoloft 50 mg [**Hospital1 **] Centrum Silver MVI daily Xanax 0.5 mg [**3-24**] x daily PRN Spironolactone 25 mg daily Spiriva daily Advair 500/50 1 PUFF [**Hospital1 **] Albuterol 2 PUFFs QID Oxygen 4-5 L at baseline Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Sertraline 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed. 7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q2H (every 2 hours) as needed. 10. Niacin 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 11. Azithromycin 250 mg Capsule Sig: Two (2) Capsule PO Q24H (every 24 hours) for 1 days: Last dose 10/30. 12. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 13. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 16. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 4 days: Last dose 11/1. 17. Warfarin 4 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 18. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: start [**11-22**]. Disp:*2 Tablet(s)* Refills:*0* 19. Prednisone 20 mg Tablet Sig: .5 Tablet PO once a day for 2 days: start [**11-24**]. Disp:*1 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary 1. COPD Exacerbation 2. Pneumonia 3. A-Fib Secondary 1. DM2 (complicated by nephropathy, neuropathy) 2. Chronic Proteinuria 3. HTN 4. Hyperlipidemia 5. Obstructive sleep apnea Discharge Condition: Improved Discharge Instructions: You were diagnosed with a COPD exacerbation, likely due to infection. Please complete your antibiotic regimen as instructed, finish your prednisone taper as prescribed, take all medications as instructed, and follow up with your primary physician(s) within the next week to reevaluate your condition and adjust medications as needed. Of note, your coumadin level (INR) was lower than therapeutic and will need to be addressed by your primary care provider (the physician that manages your coumadin dosing). Also, please continue to follow up with [**Last Name (un) **] for management of your diabetes. Finally, we highly recommend that you quit smoking ASAP given your lung disease, hypertension and diabetes. Followup Instructions: Please call to schedule an appointment with your primary care doctor within the next week for a reevaluation and manaagement of your coumadin level. Please call to schedule an appointment with your primary pulmonologist for reevaluation of your COPD. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**] Completed by:[**2114-11-18**]

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icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

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Discharge summary

report

Admission Date: [**2132-3-6**] Discharge Date: [**2132-3-9**] Date of Birth: [**2085-8-31**] Sex: F Service: MEDICINE Allergies: Haldol / Flagyl Attending:[**First Name3 (LF) 905**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: none History of Present Illness: 46 yo F with known osteomyelitis of heel and pelvis and culture positive for pseudomonas, recent discharge from [**Hospital1 18**] ICU on [**2132-2-27**], presents from rehab with altered mental status and hypotension. Patient has been on vancomycin, imipenem since discharge from [**Hospital1 18**]. Her sister reports that patient was not feeling well yesterday, though does not have any additional history. Run sheet from EMS suggests that patient was extremely somnolent and hypotensive though denied dyspnea, pain, N/V, prior to transfer to ED. . Upon arrival to the ED vitals were: T 96, HR 100, BP 68/32, RR 34, O2Sat 100%. Was given LR bolus and started on norepinephrine after no improvement in hypotension. Received a head CT that was read as no acute process. Urine specimen with moderate leuks, though unable to perform cell count due to [**Doctor Last Name **] unsufficient. Orthopaedic team saw patient in the ED and felt that bilateral foot wounds were not acutely changed. Vitals prior to transfer to the MICU were: T 97, HR 98, BP 98/60, RR 20, O2Sat 100% 2L NC. . REVIEW OF SYSTEMS: *limited due to patient's altered mental state* (+)ve: breast pain (-)ve: chest pain, dyspnea, nausea, vomiting, diarrhea, constipation Past Medical History: PAST MEDICAL HISTORY: 1) Chronic right ischial and bilateral foot ulcers 2) Sacral osteomyelitis s/p 6wks of meropenem and vancomycin [**7-25**] 3) Ankle osteomyelitis s/p 6wks meropenem and vancomycin [**Date range (1) 108746**] 4) Paraplegia due to transverse myelitis at T7 5) Neurogenic bladder 6) Multiple complications from pressure ulcers 7) Schizophrenia and delusional paranoia, has intermittently needed a guardian in past 8) Depression with suicidal ideation, treated at [**Hospital1 **] 9) Osteomyelitis of left foot and pelvis diagnosed during [**2-/2132**] hospitalization with 6 week course of Vanc/[**Last Name (un) **] planned starting on [**2132-2-20**] Social History: Lives with 24 hour personal care assistant when not in rehab. Has a sister and two brothers who live in the area. Is a Jehovah's Witness and does not want to be transfused with any blood products. Previously with guardian, but has been deemed competant by court in mid [**2131**] and so now makes her own decisions. Sister was former guardian. TOBACCO: Smoked up to 1 pack every few days for 10 years ETOH: occasionally at social occasions ILLLICTS: Has tested positive for cocaine in the past Family History: NC Physical Exam: VS: HR 87, BP 84/65, RR 16, O2Sat 96% 2L GEN: Confused, laying on back HEENT: PERRL with pupils reactive 5 -> 4 mm bilaterally, EOMI, oral mucosa dry NECK: Supple, no [**Doctor First Name **] PULM: CTAB anteriorly CARD: RR, nl S1, nl S2, no M/R/G ABD: Obese, BS+, soft, non-tender, non-tympanic EXT: bilateral heel ulcers healing with granulation tissue, deep (8-10 cm) tracking perirectal ulcer with large caivty volume SKIN: Multiple abrasions with skin breakdown along inguinal regions and under breasts bilaterally GU: foley catheter in place NEURO: Patient only oriented to self with garbled and nonsensical speech, making purposeful bilateral upper extremity movements -------- On discharge, the patient was deceased. Pertinent Results: [**2132-3-6**] 01:00PM BLOOD WBC-13.2*# RBC-3.69*# Hgb-8.1*# Hct-28.2* MCV-76* MCH-21.9* MCHC-28.7* RDW-18.4* Plt Ct-281 [**2132-3-8**] 01:09AM BLOOD WBC-20.1* RBC-3.75* Hgb-8.0* Hct-28.8* MCV-77* MCH-21.4* MCHC-27.9* RDW-18.4* Plt Ct-211 [**2132-3-6**] 01:00PM BLOOD PT-17.4* PTT-47.3* INR(PT)-1.6* [**2132-3-6**] 01:00PM BLOOD Glucose-136* UreaN-7 Creat-0.4 Na-145 K-3.6 Cl-120* HCO3-14* AnGap-15 [**2132-3-6**] 10:30PM BLOOD Glucose-127* UreaN-6 Creat-0.3* Na-144 K-3.2* Cl-123* HCO3-14* AnGap-10 [**2132-3-8**] 01:09AM BLOOD Glucose-139* UreaN-6 Creat-0.3* Na-142 K-3.8 Cl-117* HCO3-14* AnGap-15 [**2132-3-6**] 01:00PM BLOOD ALT-13 AST-20 AlkPhos-155* TotBili-0.2 [**2132-3-6**] 01:00PM BLOOD Albumin-1.1* [**2132-3-6**] 01:18PM BLOOD Glucose-130* Lactate-3.3* Na-140 K-3.4* Cl-123* [**2132-3-6**] 10:46PM BLOOD Lactate-2.7* imaging: cxr: IMPRESSION: Ill-defined retrocardiac opacity which may represent atelectasis but infection is not excluded. Small left pleural effusion. . head CT: FINDINGS: There is no intracranial hemorrhage. There is no edema or mass effect. Differentiation of the grey and white matter is preserved. The ventricles are normal in configuration and size. The sulci are prominent and the extra-axial spaces are widened compatible with diffuse cerebral atrophy. Paranasal sinuses and mastoid air cells are clear. IMPRESSION: No acute intracranial process. Diffuse atrophy. Brief Hospital Course: 46 yo F with known osteomyelitis of heel and pelvis and culture positive for pseudomonas, recent discharge from [**Hospital1 18**] ICU on [**2132-2-27**], presents from rehab with altered mental status and hypotension consistent with sepsis. Family meeting was had to address goals of care and the decision was made to make the patient comfort measures only. She subsequently was started on a morphine drip and passed on [**3-9**]. . # Goals of Care: In discussion with the family, the decision was made to make the patient comfort measures only. Life prolonging medications were withdrawn and she was started on a morphine gtt. She remained comfortable, without air hunger or agitation, and passed on [**3-9**] around 11:10am. . #. Altered mental status: Most likely delerium from sepsis given multiple potential ports of entry with known osteo, extensive pressure ulcers, and indwelling foley catheter. Head CT reassuring normal without mass effect or hemorrhage. Urine toxicology only positive for known opiate use. Is on multiple potential deleriogenic meds that may be complicating picture. Did not clear throughout stay despite improvement in hemodynamics. Had discussion with her HCP and decided to pursue comfort measures only. . #. Hypotension: Most consistent with sepsis given history of repeat osteomyelitis and known current heel and pelvic osteo. Is at high risk for ongoing or recurrent infection and sepsis. In light of repeated use of vancomycin and carbapenems as well as repeated visits to healthcare, must consider pathogens that are missed by current Abx regimen such as VRE, VISA, cdiff, and stenotrophomonas. Must also consider line sepsis given PICC placed during last admission. CXR with possible retrocardiac opacity, thought patient without history of pulmonary complaints leading up to admission. Of note, patient's baseline blood pressure appears to be in range of 80s to 90s systolic. ID knows patient well and preliminarily recommended continuing patient on her Vanc and carbapenem while awaiting culture results. She continued to have worsening blood pressures and amikacin and linezolid were added for broader coverage. In order to treat the sepsis, we asked the surgical consultants for their advice. Urology was consulted as her sacral wound likely eroded through her urethra as the wound was draining urine. They suggested possible B NU tubes. Gen [**Doctor First Name **] thought she would need a colostomy, skin flaps and urethral reconstruction. [**Doctor First Name 1957**] recommended a BKA for her heel osteo. These options were presented to the family but they aggreed to comfort measures. . #. Schizophrenia, paranoid features: Patient on olanzapine and lorazepam as outpatient, unknown if currently having active delusions. Held her PO meds while here. . #. Sacral decubitus ulcer: Deep stage IV ulcer and known pelvic osetomyelitis. Wound care consulted, see above, was made comfort measures. . #. Heel ulcers: Known underlying osetomyelitis. Again wound care consulted, [**Doctor First Name **] following, she would have need amputation for treatment. Medications on Admission: MEDICATIONS: *from [**Hospital 671**] rehab records* 1) Imipenem / Cilastatin 500 mg IV TID 2) Vancomycin 750 mg Q24H 3) Lorazepam 0.5 mg [**Hospital1 **]:PRN 4) Oxycodone 5 mg Q6H:PRN pain 5) Santyl applied daily to wound 6) Calcium Carb 500 mg QID:PRN 7) Solifenacin 5 mg DAILY 8) Fondaparinux 2.5 mg SQ DAILY 9) Acetaminophen 650 mg Q6H:PRN 10) Oxybutynin 5 mg [**Hospital1 **] 11) Olanzapine 5 mg QHS 12) Docusate 100 mg [**Hospital1 **] 13) Multivitamin DAILY 14) Vitamin E 400 IU DAILY 15) Vitamin C 500 mg DAILY 16) Senna [**Hospital1 **] 17) Ferrous Sulfate 325 mg DAILY 18) Zinc 220 mg DAILY 19) Clotrimazole topical DAILY 20) Lorazepam 0.5 mg [**Hospital1 **] Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: septic shock Discharge Condition: deaceased Discharge Instructions: the patient was deceased Followup Instructions: the patient was deceased [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

[ "041.7", "293.0", "707.03", "V12.04", "041.6", "707.07", "E879.8", "730.17", "995.92", "311", "730.15", "276.2", "295.30", "596.54", "038.9", "707.15", "707.24", "867.0", "305.1", "326", "344.1" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8836, 8845

4974, 5715

285, 291

8901, 8912

3547, 4530

8985, 9106

2783, 2787

8807, 8813

8866, 8880

8112, 8784

8936, 8962

2802, 3528

1420, 1558

234, 247

319, 1401

4539, 4951

5730, 8086

1603, 2255

2271, 2767

7,742

179,378

18160

Discharge summary

report

Admission Date: [**2180-2-29**] Discharge Date: [**2180-3-19**] Date of Birth: [**2131-3-20**] Sex: M Service: GENERAL SURGERY PURPLE CHIEF COMPLAINT: Esophgeal cancer. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 50214**] is a 48 year-old man who is generally healthy who presented as an outpatient with approximately a two month history of epigastric pain. He was started on a proton pump inhibitor and hospitalized. At this time he was ruled out for an myocardial infarction and upper endoscopy actually revealed a tumor in the cardia of the stomach, which extended into the distal esophagus. A biopsy of the tumor revealed a well differentiated adenocarcinoma. He was referred to Dr. [**Last Name (STitle) **] for an esophagogastrectomy. The patient has not described any dysphagia. He is able to eat soft foods and liquids without any trouble, but does report a small amount of solid dysphagia. He does report that he ahs had approximately a 20 pound weight loss unintentionally over the past several months. He denies fevers, nausea, vomiting or any recent respiratory illnesses. PAST MEDICAL HISTORY: 1. Hypertension. 2. History of cerebrovascular accident with mild residual left hemiparesis. 3. Asthma. 4. History of basal cell carcinoma. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Hydrochlorothiazide 12.5 q.d. 2. Paxil 40 mg po q.d. 3. Protonix 40 mg po q.d. 4. Norvasc 10 mg po q.d. 5. Diovan 320 mg po q.d. 6. Coumadin 1 mg po q.d. for his cerebrovascular accident. 7. Oxycodone as needed for pain. FAMILY HISTORY: Notable for multiple family members with carcinoma. His mother died of breast cancer. His father died of lung carcinoma. Maternal grandfather died of esophageal cancer and his maternal uncle died of breast cancer. PHYSICAL EXAMINATION: This is a well developed man with obvious recent weight loss. His head and neck examination is all within normal limits. His neck is supple without any nodes or masses. His lungs are clear to auscultation bilaterally. Heart sounds are regular rate and rhythm. Abdomen is soft without any distention, tenderness, masses or organomegaly. His extremities are without any clubbing, cyanosis or edema. Neurologically he is basically intact, although there is a slight right facial droop. HOSPITAL COURSE: After reviewing the endoscopic photos and discussing his options with Dr. [**Last Name (STitle) **] the patient opted for an elective Ivor-[**Doctor Last Name **] esophagogastrectomy. He presents on [**2-29**] for that procedure. Please refer to the previously dictated operative note by Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **] from [**2180-2-29**] for the specifics of this surgery. In brief, an Ivor-[**Doctor Last Name **] esophagogastrectomy was performed with resection of the tumor at the junction of the stomach and distal esophagus. The specimen was sent for pathology. Eventually the pathology returned to show a well differentiated adenocarcinoma, T1 with no involvement in 13 adjacent lymph nodes. There is no lymphatic or venous invasion. Margins were all clear. In addition, during this procedure a feeding jejunostomy was placed as well as bilateral chest tubes. The patient tolerated the procedure well and was transferred to the floor on subcutaneous heparin twice a day and an epidural for his pain control. The patient was doing well postoperatively until postoperative day two. The patient was noted to have respiratory distress with markedly decreasing oxygen saturation, tachypnea, tachycardia and significant confusion. In fact he pulled out his nasogastric tube at this point. He was transferred to the Intensive Care Unit. A arterial blood gas at this time showed a pH of 7.52, PCO2 of 32, PO2 of 60, bicarb of 27 and a base deficit of 3. Because of his significant AA gradient the patient was intubated at this time. Workup for the respiratory distress included a CTA of the chest, which revealed bilateral pulmonary emboli in the right upper lobe and left lower lobe. The patient was started on a heparin drip and was soon having therapeutic anticoagulation. On postoperative day three the patient's nasogastric tube was replaced under fluoroscopy. His deep veins in his lower and upper extremities were examined for thrombotic sources of pulmonary emboli, however, none were noted on these studies. His respiratory status improved and he was extubated. On the morning of postoperative day four the patient had again another bout of significant hypoxia with a large AA gradient. It was determined that he had a recurrent pulmonary emboli despite being on therapeutic heparin. At this point it was decided that he should have an inferior vena cava filter placement. This was placed by the Vascular Service on postoperative day five and the patient tolerated the procedure without any complications. The patient remained well for the next few days and on postoperative day nine was reextubated. At this time he was noted to be at his goal tube feedings. On [**3-10**] a swallow study revealed no leak at the patient's esophagogastric anastomosis. The patient's nasogastric tube was discontinued and he was transferred to the floor from the Intensive Care Unit. The next day the patient was started on clears. In addition he had his chest tubes removed without complications. The other remaining issues while the patient was on the floor revolved around preparing the patient for home. Basically his nutritional status was buffed. By the time he was being discharged the patient was on a regular post esophagogastrectomy diet with six small meals a day. In addition for nutritional supplementation he received cycle tube feeds at night. He was also put on oral anticoagulation with Coumadin and once his INR was greater then 2 it was determined that he was able to go home on oral Coumadin. His primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 50215**] was consulted and agreed to follow his INR as an outpatient. While on the unit he had been placed on antibiotics for several positive sputum cultures. These antibiotics were discontinued prior to discharge and finally a physical therapy evaluation determined that he was ready to go home and that he did not need outpatient rehab treatment. Therefore on [**2180-3-19**], which was postoperative day 19 the patient was tolerating a regular diet. He was afebrile for the last several days and he was properly anticoagulated for his pneumothorax. He was discharged home in good condition. DISCHARGE MEDICATIONS: 1. Protonix 40 mg once a day. 2. Paxil 40 mg once a day. 3. Hydrochlorothiazide 12.5 mg once a day. 4. Norvasc 10 mg once a day. 5. Diovan 325 mg once a day. 6. Coumadin 10 mg once a day. 7. Atrovent and Albuterol inhalers as needed. 8. Ambien 10 mg po q.h.s. prn as needed for sleep. 9. Roxicet one to two teaspoons as needed for pain every four to six hours. 10. Replete with fiber tube feeds at 80 cc an hour for 12 hours at night. He is recommended to have twice weekly laboratory work to assess his INR with the results forwarded to Dr. [**Last Name (STitle) 50215**]. DISCHARGE DIAGNOSES: 1. Esophageal carcinoma status post Ivor-[**Doctor Last Name **] esophagogastrectomy. 2. Status post feeding jejunostomy tube placement. 3. Hypertension. 4. Asthma. 5. History of cerebrovascular accident. 6. Pulmonary emboli status post inferior vena cava filter placement. 7. Pneumonia. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**] Dictated By:[**Last Name (NamePattern1) 1179**] MEDQUIST36 D: [**2180-3-17**] 12:03 T: [**2180-3-18**] 09:13 JOB#: [**Job Number 50216**]

[ "151.0", "415.11", "518.5", "997.3", "276.6", "482.83" ]

icd9cm

[ [ [] ] ]

[ "46.39", "96.04", "38.91", "38.7", "34.09", "96.72", "43.99", "96.6" ]

icd9pcs

[ [ [] ] ]

1585, 1803

7227, 7802

6620, 7206

2334, 6597

1826, 2316

169, 188

217, 1118

1140, 1568

14,559

195,217

5303

Discharge summary

report

Admission Date: [**2113-7-13**] Discharge Date: [**2113-7-16**] Date of Birth: [**2071-12-4**] Sex: F Service: UROLOGY OPERATIONS OR PROCEDURES: Cystoscopy, right ureteral stent, retrograde pyelogram, right extracorporeal shock wave lithotripsy. MEDICAL SUMMARY: A 35 year-old female who presents with right renal stones for shock wave lithotripsy. The risks, benefits, potential complications of the procedure were reviewed with the patient. Informed consent was obtained. The patient was known to have several stones in the right kidney and had progressive and persistent discomfort in that area. Patient was brought to the cystoscopy [****]. She underwent cystoscopy and right retrograde which showed an extrarenal pelvis with a tight ureteropelvic junction. The catheter was left indwelling and she was brought to the extracorporeal shock wave lithotripsy suite. She underwent shock wave lithotripsy uneventfully. The stent was removed and she was then brought to the recovery room. Over the course of the next several hours she had progressive discomfort in the right kidney which required a large amount of analgesics. For this reason the decision was made to bring her back to the cystoscopy suite and put in an internal stent. This was performed uneventfully. Thereafter the patient had some respiratory compromise thought to be secondary to the large amount of analgesics that she had received. For this reason she was brought to the Intensive Care Unit for careful monitoring. Over the ensuing days she was diuresed. Her CT scan was performed which did show some hilar adenopathy for which the patient was told to seek follow up with her internist. Her internist, Dr. [**Last Name (STitle) 9006**], was informed of these findings and follow up was arranged for the patient. The patient was discharged on [**2113-7-16**]. Follow up was to be performed in the very near future to determine the overall efficacy of the disintegration and removal of stent. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 5728**] Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2113-8-9**] 09:35 T: [**2113-8-14**] 20:35 JOB#: [**Job Number 21625**]

[ "486", "E878.8", "997.3", "592.0" ]

icd9cm

[ [ [] ] ]

[ "98.51", "59.8" ]

icd9pcs

[ [ [] ] ]

11,147

112,523

20715

Discharge summary

report

Admission Date: [**2172-4-30**] Discharge Date: [**2172-5-12**] Date of Birth: [**2117-1-11**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 443**] Chief Complaint: abdominal pain, dyspnea Major Surgical or Invasive Procedure: intra-aortic balloon bump central line PA catheter arterial line intubation History of Present Illness: This is a 55 YOM with PMHX significant for CAD, HTN, smoking, hyperlipidemia who presents in shock. He was well until 5 days PTA. Per his family he had onset of abdominal pain/indigestion (similar to 1st ACS presentation). They are unaware of the nature of the pain or if he had any other symptoms including fevers, chest pain, dyspnea, nausea, vomiting, or dysuria. He was taken by his girldriend to [**Hospital1 **] [**Location (un) 620**] ED for evaluation [**2172-4-29**]. At their ED his intial vitals were, T 98.7 HR 110 BP 116/83 RR 18 and 99% on RA. PEr their ED records he complained of orthopnea, denied N/V, chest pain, palps, fevers. The abdominal pain was characterized as gradual onset, constent, [**4-30**], and diffuse in location. Their exam noted mild tenderness in LLQ and normal cardipulmonary exam aside from tachycardia.He was found to have an elevated WBC count and treated with levo/flagyl empirically for presumed diverticulitis. EKG revealed afib with rate of 171. nl axis. TWI in V5 V6. He was given a total of 25 mg IV diltiazem, 30 mg po, atenolol 50 mg po. His pulse then dropped to 70 and SBP to 40. He was then intubated and started on dopamine. Dopamine titrated up to 20 mcg with SBP still in the 50s. He then also started on levophed and given a total of 8L of NS. Pressures then to 113 systolic. . Upon arrival to the [**Hospital1 18**] ED, his vitals were HR 116, BP 113/96. He was not making urine. A right IJ triple lumen was placed. He was given 1g of vancomycin. Dopamine switched to dobutamine with out significant improvement in urine output. He was also given 1 amp of bicarb for pH of 7.11. . REVIEW OF SYSTEMS: Unobtainable Past Medical History: hypertension coronary artery disease hyperlipidemia ethanol abuse smoking Social History: significant for current tobacco use. There is history of daily alcohol use. Family History: Brother and father with CAD in 50s Physical Exam: VS: T 97.8 BP111/78 HR103 RR 23 O2 100% VENT" AC Vt 600 RR 20 FiO2 60% Peep 10 Gen: Intubated/sedated HEENT: NCAT. Sclera anicteric. PERRL, . Conjunctiva were pink with periorbital edema.No pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: R IJ cordis in place CV: irregular, normal S1, S2. Distant heart sounds 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 (anterior, no crackles, wheezes or rhonchi. Abd: Soft, NT, distended. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: Percutaneous coronary intervention, in [**2-23**] anatomy as follows: 1. Selective coronary angiography revealed a right-dominant system with single-vessel coronary disease. The LMCA had no angiographically apparent disease. The LAD had no angiographically apparent disease. The LCx had a proximal 30% ulcerated plaque and the large first OM was occluded proximally. The RCA had minor diffuse plaquing and the posterolateral branch had a distal 60% stenosis. 2. Limited resting hemodynamics revealed a moderately elevated left-sided filling pressure of 28 mmHg. There was no gradient across the aortic valve on pullback of the catheter from the left ventricle. 3. Left ventriculography revealed no significant mitral regurgitation, normal wall motion, and a calculated ejection fraction of 60%. 4. Successful PTCA and stenting of the totally occluded OM1 with a 2.5x 8 mm Cypher DES. Final angiography revealed no residual stenosis, no apparent dissection, and normal flow in the vessel . . EKG demonstrated afib,rate 79 bpm. nl axis. narrow qrs. ST depressions in v5 v6 . TELEMETRY demonstrated: afib . 2D-ECHOCARDIOGRAM performed in ED demonstrated: Global hypokinesis . HEMODYNAMICS: CVP 20 RV 47-53/17 PA 50/38 PCWP 23 CO 3.6 SVR 1467 . CXR: There is a new right central venous catheter terminating in the superior vena cava. The nasogastric tube projects only immediately beyond the hemidiaphragms and a side hole is within the distal esophagus. Advancing the tube is recommended into the stomach. Patient remains intubated. There is distention of the azygos vein and vascular pedicle, as well as marked cardiomegaly and a small effusion. . CT OF THE ABDOMEN WITHOUT IV CONTRAST: There are bibasilar atelectases and effusions. There is fatty infiltration of the liver. There is dense material throughout the gallbladder, which is nondistended, which may represent sludge, and less intravenous contrast was administered recently, which could suggest vicarious excretion. The spleen is normal in size. The pancreas is somewhat atrophic. The kidneys show a small 2-mm calcification on the right, which may be vascular or tiny nonobstructing stone. The adrenal glands are within normal limits. The bowel is not dilated, and there is a full thickening of the small bowel, as well as stranding in the retroperitoneum and ascites, all of this could be explained by fluid overload. There is fatty infiltration of the wall of the ascending colon, which is suggestive of chronic inflammation. There is stranding focussed in the central mesentery. Although nondistended jejunal folds appear thickened, and more distally the bowel is collapsed. There is marked diverticulosis, but no evidence of diverticulitis. . CT OF THE PELVIS WITHOUT IV CONTRAST: There is a Foley catheter in the bladder. Rectum appears normal. Severe diverticulosis is noted. There is fairly extensive fatty hypertrophy of the perirectal fat. . RUQ U/S WET READ No gallstones or gallbladder distension. Wall edema may be due to anasarca. Fatty liver. . [**2172-4-30**] Echo: Conclusions: 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. The left atrial appendage emptying velocity is depressed (<0.2m/s). No spontaneous echo contrast is seen in the body of the right atrium or right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is severe global left ventricular hypokinesis. Overall left ventricular systolic function is severely depressed. Right ventricular systolic function appears depressed. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild to moderate ([**12-24**]+) mitral regurgitation is seen. There is no pericardial effusion. Impression: No [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA thrombus. Severely depressed LV function. Mild to moderate mitral regurgitation. [**2172-5-7**] CT head: No acute intracranial hemorrhage, shift of normally midline structures, or major vascular territorial infarct. [**Doctor Last Name **]-white matter differentiation is preserved. There is no hydrocephalus. Osseous structures and soft tissues are unremarkable. IMPRESSION: no hemorrhage or major vascular territorial infarct. . TTE [**2172-5-7**]: EF 30%. The left atrium is mildly dilated. The right atrium is moderately dilated. The estimated right atrial pressure is 11-15mmHg. Left ventricular wall thicknesses and cavity size are normal. There is moderate to severe global left ventricular hypokinesis (ejection fraction 30 percent). Right ventricular chamber size is normal. Right ventricular systolic function appears depressed. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. Mild to moderate ([**12-24**]+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . [**2172-4-30**] 12:28AM WBC-12.5* RBC-3.80* HGB-13.2* HCT-40.1 MCV-106* MCH-34.8* MCHC-33.0 RDW-14.4 [**2172-4-30**] 12:28AM cTropnT-0.09* [**2172-4-30**] 12:28AM CK-MB-8 [**2172-4-30**] 12:28AM ALT(SGPT)-491* AST(SGOT)-705* LD(LDH)-692* CK(CPK)-118 ALK PHOS-56 AMYLASE-45 TOT BILI-2.9* DIR BILI-2.1* INDIR BIL-0.8 [**2172-4-30**] 12:28AM GLUCOSE-183* UREA N-38* CREAT-1.8* SODIUM-136 POTASSIUM-4.9 CHLORIDE-105 TOTAL CO2-13* ANION GAP-23* Brief Hospital Course: Hospital course: This is a 55 year old male who presented from an OSH intubated in atrial fibrillation with RVR and cardiogenic shock. He initially required multiple pressors to support his blood pressure. His hemodynamics were monitored with a PA catheter and he required an intra-aortic balloon pump to be placed. Soon after the IABP was placed his cardiac indices improved and he was weaned off of pressor support and the IABP was removed. He was aggressively diuresed and extubated. . 1) Shock: The differential of the etiology of shock in this patient was cardiogenic vs septic. He had initially presented with complaints of abdominal pain to the OSH. Per the OSH ED record, the patient had a leukocytosis and some LLQ tenderness to palpation concerning for a possible abdominal infection. However, there were no conclusive findings on abd. CT or U/S. Seen on CT was some stranding and thickening of the small bowel (could be explained by fluid overload). On admission, he was started empirically on vanc/levo/flagyl for presumed sepsis. More likely was cardiogenic shock in the setting of atrial fibrillation with RVR and many nodal blocking agents given at OSH. Given his significant alcohol history it was felt that he may have had an underlying cardiomyopathy that in setting of his arrhythmia and drugs tipped him over into cardiogenic shock requiring intubation. TTE here showed global hypokinesis consistent with this. A right-heart catheter was placed. Hemodynamics were also consistent with cardiogenic shock (elevated filling pressures, elevated SVR, low CO and CI). He required pressors to maintain MAPs >65. He was placed on levophed and dobutamine drips transiently. Elevated lactate was consistent with decreased tissue perfusion. An IABP was placed due to worsening cardiac status. He eventually improved on the IABP which allowed weaning off the pressors. His IABP was removed again and the patient remained hemodynamically stable off pressors and mechanical support and could be extubated. His Afib was managed as described below. His CHF and BP were also medically managed and optimized towards the end of his hospital stay. He was discharged on ASA 81, BB, Lasix, Spironolactone and Dig (also for Afib, see below). He has an outpatient appointment with his PCP, [**Name10 (NameIs) 2085**] and electrophysiologist. He was off oxygen requirement, hemodynamically stable and with minimal LE edema upon discharge. He should weigh himself daily and follow a sodium restricted diet. . 2) ID: As above, there was concern for initial sepsis with possible abdominal source. He was started on vanco/levo/flagyl empirically. Cultures were negative. He completed a 7 day course of antibiotics. His leukocytosis trended down and he remained afebrile. . 3) Respiratory failure: Hypoxic secondry to pulmonary edema in the setting of afib and RVR. In addition, the patient had been given 8 liters of fluid at the OSH. Patient was intubated at OSH and remained intubated in the CCU. Once his hemodynamics improved and he was maintaining his BP without pharmacologic support he was given boluses of IV lasix for diuresis. His respiratory status improved with diuresis and he was successfully extubated. He was off any oxygen requirement upon discharge. . 4) CAD: Stent to OM in [**2168**]. No CP. No significant cardiac enzyme elevations. . 5) Rhythm: AFib with RVR. DC cardiovesion was attempted several times without success in addition to medical management including frequent IV metoprolol doses. Medical conversion was also attempted with Amiodarone. However, the patient remained in Afib although he was rate controlled later during his hospital stay. He was eventually stabilized on a regimen of Amiodarone, metoprolol, and Digoxin. Anticoagulation was initiated transiently with a heparin drip and with coumadin 5mg qHS towards his discharge. His INR prior to discharge was 1.8. An appointment with his PCP was scheduled two days after discharge in order to check another INR with a goal of [**1-25**]. . 6) Pump: Global hypokinesis. Unclear cause. Myocarditis vs depression in setting of sepsis vs other. Likely underlying alcohol-induced cardiomyopathy given his history of ethanol abuse until recently. See above with regards to his CHF/cardiogenic shock management. . 7) Acidosis: metabolic with inadequate respiratory response initially. High lactate. No osmolar gap. Gap eventually closed after having stabilized his cardiogenic shock. Lactate trended down. Acidosis resolved. . 8) Renal failure: In setting of likely poor PO intake. Pre-renal vs ATN from cardiogenic shock. No hydro seen. Renal function improved slowly throughout the course of his hospital stay. His renal function returned to [**Location 213**] prior to discharge. . 9) Acute Liver failure: History of daily alcohol use. Fatty liver on U/S. No stones or ductal dilation. Transaminases elevated and direct hyperbilirubinemia. Likely shock liver due to cardiogenic shock. Hepatitis serologies were negative LFTs were slowly trending down throughout his hospital stay. . 10) Coagulopathy: [**1-24**] liver failure. Improved with improving liver function. Towards the end of his hospital stay, coumadin was started for anticoagulation for Afib. . 11) Alcohol use: H/o [**12-24**] bottle of whiskey until recently. No history of DTs. MCV was high. Patient received B12/thiamine/folate. . 12) Hyperlipidemia: Normal cholesterol and TGs. Chol/HDL was 2.0. . 13) DM: No history. Sugars transiently elevated. Covered with SSI. HbA1c was 5.7. . 14) FEN: cardiac, heart healthy diet after extubation. . 15) PPX: Pneumoboots, PPI, later coumadin. . 16) Access: A-line, R IJ, initially femoral line . 17) Code: Full . Medications on Admission: Atenolol Lipitor Lisinopril Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 7. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO every twelve (12) hours for 3 days: twice daily for 3days, then daily after that until you see your cardiologist. Disp:*12 Tablet(s)* Refills:*0* 11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: Start daily doses after 3 days of twice daily doses after discharge. . Disp:*60 Tablet(s)* Refills:*2* 12. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day: Start on [**2172-5-13**]. Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2* 13. Outpatient Lab Work INR check on [**2172-5-14**] Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. Cardiomyopathy with cardiogenic shock and CHF (EF initially 15%, then up to 30%), status post intubation and inotropic pressure support and intraaortic balloon pump 2. Systolic and diastolic CHF, EF 15% (now 30%) 3. Hypertension 4. Hyperlipidemia 5. Atrial fibrillation with rapid ventricular response requiring DC cardioversion, on coumadin 6. Questionable sepsis, completed 7 day course of vanc/levo/flagyl empirically 7. CAD s/p stent in [**2168**] 8. Acute renal failure secondary to poor forward flow from CHF 9. Acute liver failure in setting of cardiogenic shock 10. Fatty liver, h/o Etoh abuse . Secondary Diagnosis: 1. H/o Ethanol abuse 2. Obesity Discharge Condition: Stable. Afebrile. Tolerating PO. Ambulating without difficulty. Discharge Instructions: You have been treated for a heart condition called cardiomyopathy with congestive heart failure. You have been intubated and sedated and received intravenous medications to keep your blood pressure and circulation stable. You have partially recovered from this condition. You have been started on several new oral medications: Amiodarone, Digoxin and Coumadin (a blood thinner) for anticoagulation and rate control for a heart rhythm condition called atrial fibrillation; blood pressure and heart failure medications (lisinopril, spironolactone, toprol XL, lasix). Please take all medications as prescribed and discontinue your previous oral medications. . You should weigh yourself daily and call your PCP if you gain more weight than 3 pounds. You should follow a low sodium diet and restrict your fluid intake to 1.5 liters per day. . Please call your primary doctor or return to the ED with fever, chills, chest pain, shortness of breath, leg swelling, nausea/vomiting, spontaneous bleeding or any other concerning symptoms. . Please take all your medications as directed. . Please keep you follow up appointments as below. Followup Instructions: You should have a lung function test (called PFTs) as an outpatient because you have been started on a drug called amiodarone to control your heart rate and rhythm. This medication can sometimes compromise lung function and therefore you should have a baseline test to be scheduled by your PCP. . You should follow up with an electrophysiologist regarding your atrial fibrillation and arrythmias. You have an appointment scheduled with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for [**5-25**] at 9:20am in the [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 436**]. Call ([**Telephone/Fax (1) 5862**] with any questions. . Please also follow up with your cardiologist at [**Hospital1 18**] [**Location (un) 620**] (Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **], phone: ([**Telephone/Fax (1) 8937**]. An appointment has been scheduled for [**6-29**], Monday, at 3pm. The office will contact you if an earlier appointment is going to be available as you should follow up earlier than that with him, if possible. . You have an appointment with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 1022**], on [**2172-5-20**] at 3:30pm. [**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 15818**] . You should go to your Dr.[**Name (NI) 2989**] office on [**2172-5-14**] for lab work. The so called INR should be checked which is a lab test to determine if your anticoagulation (blood thinning) on coumadin is accurate. Your last INR on discharge was 1.8.

[ "995.91", "V17.3", "425.4", "293.0", "401.9", "272.4", "038.9", "412", "414.01", "427.31", "V45.82", "276.2", "428.40", "428.0", "584.9", "276.1", "305.1", "518.81", "286.9", "303.90", "570", "785.51" ]

icd9cm

[ [ [] ] ]

[ "37.22", "96.6", "99.07", "37.61", "97.44", "99.61", "96.72", "88.72", "88.56" ]

icd9pcs

[ [ [] ] ]

16094, 16100

8790, 8790

295, 372

16824, 16890

3072, 7182

18071, 19646

2280, 2317

14587, 16071

16121, 16121

14534, 14564

8807, 14508

16914, 18048

2332, 3053

2057, 2071

232, 257

400, 2038

7191, 8767

16769, 16803

16140, 16748

2093, 2169

2185, 2264

19,913

147,652

29448

Discharge summary

report

Admission Date: [**2183-10-21**] Discharge Date: [**2183-11-19**] Date of Birth: [**2136-12-18**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3223**] Chief Complaint: Status post-crush injury. Major Surgical or Invasive Procedure: 1. Exploratory laparotomy. 2. Oversewing of multiple mesenteric vessels. 3. Oversewing of liver laceration. 4. Small intestinal resection. 5. Exploratory laparotomy and peritoneal irrigation. 6. Small intestinal resection x3. 7. Near enterectomy with right colectomy. History of Present Illness: Mr.[**Known lastname **] is a 46 M s/p crush injury at construction site. He was unfortunately pinned between two trucks and was brought in by EMS, initially hemodynamically stable, complaining of inability to feel below his umbilicus. In the emergency department he was alert, oriented, and responsive. An initial FAST exam was negative, however, Mr.[**Known lastname **] shortly began complaining of difficulty breathing and was noted to have an increasingly distended abdomen. Repeat FAST exam was equivocal and a subsequent DPL was grossly positive. He was taken emergently to the OR for exploratory laparotomy. Past Medical History: CAD, DM2, s/p CABG Social History: Supportive and involved family network. Worked as a foreman in construction Family History: Noncontributory. Physical Exam: VS: GEN: awake, alert, oriented x3. Complaining of decreased sensation below the umbilicus intermittently HEENT: Loss of L eye vision in all fields CV:RRR PULM: Breath sounds equal bilaterally. Good chest wall excursion. ABD: Soft NT/ND. Nl rectal tone without induration. Incision with good granulation tissue PELVIS:Stable. EXT: No injuruy. Min edema NEURO: Moves all extremities Pertinent Results: TRAUMA #2 (AP CXR & PELVIS POR Clip # [**Clip Number (Radiology) 70702**] IMPRESSION: 1. No definite evidence of osseous injury. Unusual appearance of the right proximal femur is most likely related to prominent osteophytes, although CT scan could be performed if there is clinical concern for a femoral neck fracture. Chest radiograph is severely limited due to exclusion of the upper thorax. 2. Severe degenerative changes of the hips bilaterally, slightly worse on the --------- CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 70703**] CONCLUSION: Endotracheal tube in position as described above. Bilateral patchy pulmonary opacities consistent with pulmonary contusion and/or edema. --------- CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 70704**] IMPRESSION: Probable mild cerebral edema without evidence of herniation. This may be secondary to generalized fluid overload status of the patient. Close followup and clinical correlation is recommended. No evidence of hemorrhage or traumatic injury. --------- CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # [**Clip Number (Radiology) 70705**] IMPRESSION: 1. Distraction injury of the lumbar spine at the level of L1/L2 with mild 3-4 mm retrolisthesis of L1 over L2. No definite osseous spinal canal narrowing is appreciated. However, CT does not provide good detail of the epidural or intradural spacea. MRI could be considered to evaluate spine injury if indicated. 2. Thickened remaining small bowel could represent bowel wall edema related to surgery and fluid overload, but residual bowel ischemia cannot be excluded. 3. Left transverse process fractures of L1, L2 and L4 as described above. 4. Bilateral large pleural effusions with associated atelectasis. 5. Packing material within the abdominal cavity. --------- CT C-SPINE W/O CONTRAST Clip # [**Clip Number (Radiology) 70706**] IMPRESSION: 1. Preserved cervical spine alignment. Tiny osseous focus visualized superior to the C7 spinous process, which may represent a chip fracture versus a dystrophic calcification. 2. Lung effusions and consolidation, right greater than left. --------- CT T-SPINE W/O CONTRAST Clip # [**Clip Number (Radiology) 70707**] IMPRESSION: 1. No evidence of traumatic injury to the thoracic spine. 2. Large bilateral effusions with consolidations, right greater than left. L1 fracture. Please refer to the lumbar spine report for further details. --------- CT L-SPINE W/O CONTRAST Clip # [**Clip Number (Radiology) 70708**] IMPRESSION: Avulsion fracture of the anterior portion of the inferior endplate of the L1 vertebra, with widened disc space consistent with a hyperextension injury. Left L4 transverse process fracture with an equivocal left L2 transverse process fracture. --------- LIVER OR GALLBLADDER US (SINGL Clip # [**Clip Number (Radiology) 70709**] IMPRESSION: Findings equivocal for cholecystitis. HIDA scan is recommended for further evalutaion. --------- MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # [**Clip Number (Radiology) 70710**] MRI BRAIN FINDINGS: No intracranial mass lesion, hydrocephalus, shift of normally midline structures, minor or major vascular territorial infarct IMPRESSION: No findings to suggest brain swelling. Subgaleal scalp fluid collection. Opacification of the maxillary sinuses, right mastoid air cells, and ethmoid sinus. ---------- MR CERVICAL SPINE W/O CONTRAST; MR THORACIC SPINE W/O CONTRAST Clip # IMPRESSION: Small amount of prevertebral fluid may indicate ligamentous injury, even in the absence of direct evidence of such. Please note that the quality of study is compromised by motion artifact. ---------- MR CERVICAL SPINE W/O CONTRAST; MR THORACIC SPINE W/O CONTRAST Clip # IMPRESSION: Small amount of prevertebral fluid may indicate ligamentous injury, even in the absence of direct evidence of such. Please note that the quality of study is compromised by motion artifact. ---------- MR L SPINE W/O CONTRAST Clip # [**Clip Number (Radiology) 70711**] IMPRESSION: Three column ligamentous disruption, including torn anterior wedged in ligament, posterior longitudinal ligament and ligamentum flavum, as well as left facet capsule disruption. This constitutes an unstable injury. No hemorrhage or spinal cord compromise. ----------- Brief Hospital Course: He was admitted to the trauma surgery service under the care of Dr. [**Last Name (STitle) 519**]. He was taken to the OR on [**2183-10-21**] after positive DPL where he was found to have extensive damage to the SMA, liver laceration, small bowel perforation and retroperitoneal bleed. Artery, laceration and retroperitoneal bleed were repaired and a section of jejunum was resected, abodmen was packed and he was sent back to the TSICU. On [**10-22**] he was taken back to the OR where bowel was resected from the jejunum through [**1-10**] of transverse colon. Abdomen was packed and he was sent back to TSICU. He remained in the TSICU with steady improvement in his clinical status. A tracheostomy was performed, and a Passy-Muir Valve was placed. TPN was administered via PICC line for long-term nutrition. Ophthalmology was consulted as pt complained of loss of vision in left eye; they feel this represents a traumatic optic neuropathy and that it is likely irreversible at this stage. He is pending an attending level evaluation Medications on Admission: none Discharge Medications: 1. Lo-Peramide 2 mg Tablet Sig: One (1) Tablet PO four times a day: please administer as a scheduled medication. 2. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 3. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 7. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTUES (every Tuesday). 8. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 9. Ibuprofen 100 mg/5 mL Suspension Sig: One (1) PO Q8H (every 8 hours) as needed. 10. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 11. Glutamine 10 g Packet Sig: One (1) Packet PO TID (3 times a day). 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 14. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2 hours). 15. Meropenem 1 g Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 3 days: to complete a 14 day course. 16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Ten (10) ML Intravenous DAILY (Daily) as needed. 17. Dolasetron 12.5 mg/0.625 mL Solution Sig: 12.5 mg Intravenous Q8H (every 8 hours) as needed for nausea. 18. Citrucel 2 g/19g Powder Sig: One (1) PO three times a day. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Status post-crush injury. Small Bowel Mesenteric Injury with small bowel resection Traumatic Right optic neuropathy Discharge Condition: Good Discharge Instructions: 1. Continue Meropenem 1 gram IV q 8 until [**11-22**] 2. Continue TPN at goal 2150 cal 110g protein 3. Please contact Dr. [**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) 519**] for all questions regarding this patient ([**Telephone/Fax (1) 5323**] Followup Instructions: With Dr. [**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) 519**] in 2 weeks: call ([**Telephone/Fax (1) 5323**] to schedule appointment. With Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**] in 2 weeks: call ([**Telephone/Fax (1) 2007**] to schedule appointment. With opthalmology, please call ([**Telephone/Fax (1) 5120**] to schedule appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]

[ "865.00", "377.39", "996.62", "780.6", "863.29", "864.03", "518.5", "958.4", "557.0", "482.82", "805.4", "369.60", "E821.7", "926.19", "790.7", "902.26", "958.93" ]

icd9cm

[ [ [] ] ]

[ "50.61", "77.79", "45.93", "45.73", "99.15", "54.25", "54.91", "38.7", "99.04", "54.72", "45.61", "99.07", "31.1", "03.53", "81.62", "45.62", "99.00", "34.04", "39.31", "81.08", "96.6", "96.72", "99.05", "38.93" ]

icd9pcs

[ [ [] ] ]

9025, 9095

6228, 7268

343, 620

9255, 9262

1855, 6205

9577, 10098

1417, 1435

7323, 9002

9116, 9234

7294, 7300

9286, 9554

1450, 1836

278, 305

648, 1265

1287, 1308

1324, 1401

18,010

101,269

22122

Discharge summary

report

Admission Date: [**2106-7-11**] Discharge Date: [**2106-7-14**] Service: NMED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5868**] Chief Complaint: Left arm weakness Major Surgical or Invasive Procedure: None History of Present Illness: The patient is an 87 year old RH woman with a history of PAF not on anti-coagulation now presenting with new onset left arm weakness. The history as per the patient and her husband is that they were eating dinner this morning at around 9:30 am when the patient felt the sudden onset of "terrible lightheadedness". The husband put down the newspaper and looked over at his wife to see her left arm hanging off the chair. He went over to her, lifted the arm into the air and asked her to keep it raised. It fell to the ground. He became concerned and called for the [**Hospital3 **] facility nurse who examined the patient and activated EMS after discovering similar findings. In the ambulance, she began moving her left arm a little more but it still was significantly weak. She denied any headache, visual problems, loss of consciousness, extremity shaking, or numbness/tingling. Past Medical History: Paroxysmal atrial fibrillation Anxiety Depression GERD Past history of Sciatica At least one ER visit within past 2 years for "syncope" Social History: She lives with husband at [**Hospital3 **] facility. She requires assistance with ADL's such as bathing, cooking. At baseline, walks with walker in the home. No recent alcohol or tobacco use. Family History: No family history of seizures or strokes. Physical Exam: Vitals T:97.8 BP:110/70 P:70 RR:16 Sat:99% on 2L General: Elderly woman in no acute distress. Head, neck, lungs, cardaic, abdominal and extremity exam were normal except for 1+ pre-tibial edema. Neurologic Examination: Mental Status: Awake and alert, cooperative with exam, normal affect; she is oriented to person, place, month and president. Attention: able to say months of year backward and forward. Language: Fluent, no dysarthria, no paraphasic errors, naming intact; fund of knowledge normal. Registration: [**1-20**] items, and recalls [**12-22**] with prompting at 5 minutes; she has no apraxia and no neglect 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 intact; facial movement decreased on left with decreased left NLF; Hearing decreased to finger rub bilaterally. Tongue midline, no fasciculations. Sternocleidomastoid and trapezius normal bilaterally. Motor: Normal bulk and tone bilaterally; no tremor. D T B WF WE FiF [**Last Name (un) **] IP Gl Q H AF AE TF TE Right 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Left 3 3 4 4 3 4 4 3 3 4 3 3 4 4 3 Sensation: intact to light touch, pin prick, temperature (cold), vibration, and proprioception; extinction to DSS on left. Reflexes: B T Br Pa Pl Right 2 2 2 2 1 Left 2 2 2 2+ 1 Some crossed adductor activity at left patellar; grasp reflex absent; toes were equivocal on both sides Coodination: mild ataxia on right FNF and unable to perform on left secondary to weakness. Pertinent Results: Laboratory results: CBC, CHEM-7, U/A all within normal limits. HEAD CT/CTA ([**7-11**]): No evidence of acute intracranial hemorrhage. Questionably asymmetrical left ventricular dilatation. Left vertebral artery is occluded just below the skull base. The nature and duration of this finding is unknown. Flow is present in the other major branches of the circle of [**Location (un) 431**]. No evidence of large territorial infarct or enhancing lesion. Brief Hospital Course: In the emergency department, her systolic blood pressure was in 100s. A CT of head was consistent with chronic microvascular disease without hemorrhage; CT with angiography demonstrated calcifications of the ICAs and L vertebral artery occlusion. Clinically, she had an ischemic stroke in right cerebral hemisphere. Therefore, pt was admitted to the Neuro ICU for pressors to elevate her blood pressure. However, she refused central line, arterial line and Neo-Synephrine for BP maintenance. She did agree to aspirin, and she was started on heparin as well for her paroxysmal atrial fibrillation, which was the likely etiology of her stroke. She initially refused warfarin. As her blood pressure increased, her symptoms gradually improved and she was transferred to the floor. TTE demonstrated no significant sources of thrombus and carotid duplex u/s demonstrated <40% flows bilaterally (as per tech at bedside; pending final read). On [**7-13**], following discussion with pt and PCP, [**Name10 (NameIs) **] accepted anticoagulation with warfarin and aspirin was discontinued. Her exam demonstrated mild improvement to her weakness. However, she continues to have some left-sided weakness, and PT/OT evaluation recommended a short stay at an acute rehabilitation facility. Medications on Admission: Seroquel Prilosec Ambien Discharge Medications: 1. Quetiapine Fumarate 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 2. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Sotalol HCl 80 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: Five Hundred (500) Units Intravenous ASDIR (AS DIRECTED): Adjust dosage for goal PTT 40-60. Discharge Disposition: Extended Care Facility: [**Location (un) 4480**] [**Hospital 4094**] Hospital - [**Location (un) 1110**] Discharge Diagnosis: Right Cerebral Infarct Paroxysmal Atrial Fibrillation Gastroesophageal Reflux Disease Sciatica Anxiety Depression Discharge Condition: Good, with persistent left arm and leg weakness. Discharge Instructions: Please follow-up with your Primary Care Physician: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 2808**] [**Last Name (NamePattern1) **] in [**11-20**] weeks. Call [**Telephone/Fax (1) 8506**] to schedule an appointment. Please schedule an appointment to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] or Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the Stroke Service at [**Telephone/Fax (1) 1694**] in [**2-23**] weeks. If you notice any worsening weakness, difficulty swallowing, changes in your vision, sudden headache, tingling, numbness or any other concerning symptom, please call your PCP immediately or come to the Emergency Department for evaluation. Take all medicines as prescribed. We have started you on a new medicine called coumadin to help thin your blood and try to prevent another stroke. Followup Instructions: Please schedule an appointment with your Primary Care Physician: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 2808**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 8506**]. She will follow your INR after you get out of rehabilitation. Please schedule an appointment to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] / Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the Stroke Service at [**Telephone/Fax (1) 1694**].

[ "724.3", "530.81", "300.4", "434.91", "458.9", "427.31" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5775, 5882

3804, 5080

276, 283

6040, 6090

3328, 3781

7021, 7523

1581, 1624

5155, 5752

5903, 6019

5106, 5132

6114, 6998

1639, 1842

219, 238

311, 1197

2284, 3309

1882, 2268

1867, 1867

1219, 1356

1372, 1565

21,793

187,247

27087

Discharge summary

report

Admission Date: [**2102-2-8**] Discharge Date: [**2102-3-13**] Date of Birth: [**2036-4-27**] Sex: F Service: PLASTIC Allergies: Imipenem Attending:[**First Name3 (LF) 7733**] Chief Complaint: Bilateral Hand and Feet necrosis Major Surgical or Invasive Procedure: Free flaps + Skin Graft History of Present Illness: Mrs. [**Known lastname 66532**] is the mother of a physician in internal medicine who works at the [**Hospital3 3765**]. Several months ago, she had contracted a pneumococcal sepsis and was hospitalized for a prolonged period of time in severe condition with a very low-flow state. Fortunately, she was resuscitated, but as a result of the prolonged low-flow developed gangrene of both hands and both feet. She has demarcated fairly well and is brought to the operating room for removal of the just grossly nonviable tissue which was dry and black, but not putrefied. She was admitted to the [**Hospital1 **] where she was treated for ongoing medical problems. The recommendation there was to do bilateral, both below-knee amputations emergently. The family decided to wait. She is now admitted to the [**Hospital1 69**] for conservative debridements and salvage of as much viable tissue as possible. Past Medical History: Pneumonia, DIC, asthma, COPD, DIC ARDS, L pleural effusion s/p tap, non-hogkins lymphoma, s/p splenectomy, Social History: Non contributory Physical Exam: On admision. Patient awake, alert and oriented x3. Subtotal dry gangrene, both feet and both hands secondary to prolonged low-flow state associated with pneumococcal sepsis. Pertinent Results: [**2102-2-8**] 11:47PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009 [**2102-2-8**] 11:47PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2102-2-8**] 10:00PM GLUCOSE-150* UREA N-13 CREAT-0.4 SODIUM-139 POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-30 ANION GAP-11 [**2102-2-8**] 10:00PM CALCIUM-10.4* PHOSPHATE-3.6 MAGNESIUM-2.0 [**2102-2-8**] 10:00PM WBC-12.0* RBC-3.59* HGB-10.7* HCT-33.4* MCV-93 MCH-29.9 MCHC-32.1 RDW-16.4* [**2102-2-8**] 10:00PM PLT COUNT-488* [**2102-2-8**] 10:00PM PT-11.8 PTT-28.2 INR(PT)-1.0 [**2102-2-9**] Surgeon: [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 5385**], [**MD Number(1) 24266**] ASSISTANT: Dr. [**Last Name (STitle) 23606**] Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] DIAGNOSIS: Subtotal dry gangrene, both feet and both hands secondary to prolonged low-flow state associated with pneumococcal sepsis. POSTOPERATIVE DIAGNOSIS: Subtotal dry gangrene, both feet and both hands secondary to prolonged low-flow state associated with pneumococcal sepsis. OPERATION: 1. Debridement feet bilateral with amputation at tarsal metatarsal level. 2. Application of VAC dressings bilateral. ANESTHESIA: General with LMA tube. [**2102-2-11**] Surgeon: [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 5385**], [**MD Number(1) 24266**] ASSISTANT: Dr. [**Last Name (STitle) 23606**]. [**First Name8 (NamePattern2) 66533**] [**Name8 (MD) **], MD. [**First Name (Titles) **] [**Last Name (Titles) 38918**]: Gangrene, both hands and feet secondary to pneumococcal sepsis and low-flow state. POSTOPERATIVE DIAGNOSIS: Gangrene, both hands and feet secondary to pneumococcal sepsis and low-flow state. Status post initial debridement of both feet. OPERATION PERFORMED: 1. Debridement of both feet. 2. VAC change of both feet. ANESTHESIA: General with LMA tube. [**2102-2-13**] Surgeon: [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 5385**], [**MD Number(1) 24266**] ASSISTANT: [**First Name8 (NamePattern2) 66533**] [**Name8 (MD) **], MD [**First Name (Titles) **] [**Last Name (Titles) 38918**]: 1. Status post subtotal amputation, both feet. 2. Status post gangrene both hands and feet associated with sepsis secondary to pneumococcal pneumonia. POSTOPERATIVE [**Last Name (Titles) 38918**]: 1. Status post subtotal amputation, both feet. 2. Status post gangrene both hands and feet associated with sepsis secondary to pneumococcal pneumonia. OPERATION PERFORMED: 1. Debridement, soft tissue and bone, both feet. 2. Irrigation and change of VAC dressing, both feet. ANESTHESIA: General inhalation by mask (Dr. [**Last Name (STitle) 66534**] and team). [**2102-2-16**] Surgeon: [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 5385**], [**MD Number(1) 24266**] CO-SURGEON: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD ASSISTANT: Dr. [**Last Name (STitle) **]. Dr. [**Last Name (STitle) 4427**] Dr. [**Last Name (STitle) **]. [**Last Name (STitle) **] DIAGNOSIS: 1. Gangrene both feet associated with low-flow sepsis. 2. Status post a total amputation of both feet including all toes and soles of the feet. 3. Dry gangrene of both hands. POSTOPERATIVE DIAGNOSIS: 1. Gangrene both feet associated with low-flow sepsis. 2. Status post a total amputation of both feet including all toes and soles of the feet. 3. Dry gangrene of both hands. OPERATION PERFORMED: 1. Debridement of both feet. 2. Free latissimus dorsi muscle flap to the left foot and sole. 3. Split-thickness skin graft to vascularized flap, left foot and sole. 4. Free rectus abdominis muscle to right foot and sole. 5. Split thickness skin graft to right foot and sole. 6. Application foot-leg splints bilateral. [**2102-2-20**] Surgeon: [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 5385**], [**MD Number(1) 24266**] ASSISTANT: [**First Name8 (NamePattern2) 11705**] [**Last Name (NamePattern1) **], RES [**First Name8 (NamePattern2) 66533**] [**Name8 (MD) **], MD. [**First Name (Titles) **] [**Last Name (Titles) 38918**]: Dry gangrene, both hands, secondary to low-flow state during prolonged pneumococcal sepsis. POSTOPERATIVE DIAGNOSIS: Dry gangrene, both hands, secondary to low-flow state during prolonged pneumococcal sepsis. OPERATION: 1. Amputation, right hand metacarpal level. 2. Amputation, left hand at metacarpal joint level with preservation of first, second, third and fourth metacarpals. 3. Application of VAC dressings bilaterally. 4. Dressing changes, bilateral feet. [**2102-2-23**] Surgeon: [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 5385**], [**MD Number(1) 24266**] ASSISTANTS: [**First Name8 (NamePattern2) 66533**] [**Name8 (MD) **], MD and Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**Last Name (STitle) 38918**]: 1. Gangrene hands and feet associated with pneumococcal sepsis and low-flow. 2. Status post subtotal amputation of both hands, metacarpal level. POSTOPERATIVE [**Last Name (STitle) 38918**]: 1. Gangrene hands and feet associated with pneumococcal sepsis and low-flow. 2. Status post subtotal amputation of both hands, metacarpal level. OPERATION PERFORMED: 1. Dressing change, left hand. 2. Dressing change, debridement, soft tissue and bone, right hand. 3. Application of vacuum-assisted closure dressings. ANESTHESIA: General inhalation in patient's bed. [**2102-2-26**] Surgeon: [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 5385**], [**MD Number(1) 24266**] ASSISTANT: Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) 66535**], and Dr. [**Last Name (STitle) 66536**]. ANESTHESIA: General endotracheal. [**Last Name (STitle) **] DIAGNOSIS: Gangrene both hands, status post multiple previous debridement's and vac changes. POSTOPERATIVE DIAGNOSIS: Gangrene both hands, status post multiple previous debridement's and vac changes. OPERATION PERFORMED: 1. Debridement of soft tissue and bone on both hands. 2. Creation of first web space left hand with phalangealization. 3. Pin fixation of left thumb and index metacarpals. 4. Vac dressing right forearm and hand. 5. Right radial forearm fascia cutaneous flap to the left hand (microvascular). 6. Dressing changes both feet. ANESTHESIA: General endotracheal. [**2102-3-6**] Surgeon: [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 5385**], [**MD Number(1) 24266**] ASSISTANT: [**First Name8 (NamePattern2) 66533**] [**Name8 (MD) **], MD. [**First Name (Titles) **] [**Last Name (Titles) 38918**]: 1. Status post subtotal amputation, both hands. 2. Status post free tissue transfer from right forearm to left hand. 3. Status post pneumococcal sepsis and low-flow state. POSTOPERATIVE DIAGNOSIS: 1. Status post subtotal amputation, both hands. 2. Status post free tissue transfer from right forearm to left hand. 3. Status post pneumococcal sepsis and low-flow state. OPERATION PERFORMED: 1. Debridement soft tissue and bone right hand. 2. Debridement soft tissue left hand. 3. Split-thickness skin graft to right forearm. 4. Split-thickness skin graft to right hand. 5. Split-thickness skin graft to left hand. 6. Application of VAC dressing right forearm and hand. ANESTHESIA: General endotracheal. Microbiology info: [**2102-3-11**] URINE URINE CULTURE-FINAL {YEAST}; ANAEROBIC CULTURE-FINAL INPATIENT [**2102-2-28**] SWAB VIRAL CULTURE-FINAL INPATIENT [**2102-2-27**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL INPATIENT [**2102-2-27**] URINE URINE CULTURE-FINAL INPATIENT [**2102-2-27**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL INPATIENT [**2102-2-17**] URINE URINE CULTURE-FINAL {PSEUDOMONAS AERUGINOSA} INPATIENT [**2102-2-26**] Radiology CHEST PORT. LINE PLACEMENT [**2102-3-11**] 11:04a Na 139, Cl 100, BUN 7, Glu 113, AGap=9, K 4.7, Bic 35, Cr 0.3 Ca: 10.6 Mg: 1.9 P: 3.6 WBC 13.4, Hb 7.6, Pl 558, Hct 24.3 Brief Hospital Course: The patient was admited and a resume postoperative course is described below. [**2-11**] & [**2-13**]: status post surgical debridement and vac change. Will increase methadone 5 qid. dilaudid IV for postop pain will transition to oral later [**2-17**] Cefepime was started for a Pseudomona UTI. [**3-6**] OR for split thickness skin graft, Nutrition consult placed, social service consult placed, PT consult for Tilt boarding [**3-7**] Q of HyptoTA, f/u Labs, Chronic Pain serv eval (PCA changes made, added Percocet, plan to DC PCA in a couple of days) [**3-8**] Stable, PT, [**Name (NI) 1194**] service f/u, [**3-9**] DC the PCA [**3-10**] Rehab screen today, Drain 50 ml (stays) [**3-11**] Foley with some bloody output. WBC 13, Hct 24.3 (same on [**2-7**]). Urine Cultures negative (Foley exchanged). Dressing changed by RN/MD today. [**3-13**] ABX stopped. [**3-14**] DC drain. Discharge to Rehab Discharge Medications: 1. Mineral Oil Oil Sig: 15-30 MLs PO BID (2 times a day) as needed. 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q2-4H (every 2 to 4 hours) as needed. 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 4. Alendronate 70 mg Tablet Sig: One (1) Tablet PO 1X/WEEK (WE). 5. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical PRN (as needed). 7. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 8. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 9. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID (3 times a day). 14. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 15. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO QHS (once a day (at bedtime)) as needed. 16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 17. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Montelukast 10 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 20. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 21. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 22. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 23. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 24. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 25. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed). 26. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 27. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 28. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 29. Methadone 5 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 30. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 31. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: Bbilateral hand-foot necrosis status post Pneumonia, Sepsis, DIC. Discharge Condition: Good Discharge Instructions: -For the physician [**Name9 (PRE) 66537**] this patient, please contact Dr [**Last Name (STitle) 5385**] or his Fellow Dr [**Name (NI) 12434**] ([**Hospital1 18**] Pager [**Numeric Identifier 66538**])for an update postoperative course. -Please call Dr[**Name (NI) 23346**] office for a follow up appointmnet [**0-0-**] -If any wound complication, please call Dr [**Last Name (STitle) 12434**] ([**Hospital1 18**] Pager [**Numeric Identifier 66538**]) -The leg dressing can be changed Q 3 days with Xeroform -The hand dressings needs to be changed Q1 with Xeroform and sponges for two weeks, after that it can be change Q 3 days. Followup Instructions: With Dr [**Last Name (STitle) 5385**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 7738**] Completed by:[**2102-3-13**]

[ "286.6", "V10.79", "785.4", "496" ]

icd9cm

[ [ [] ] ]

[ "82.89", "86.73", "88.49", "86.22", "77.69", "82.81", "81.72", "86.69", "83.82", "84.03", "88.48", "84.12" ]

icd9pcs

[ [ [] ] ]

13291, 13365

9591, 10495

300, 326

13475, 13482

1631, 9568

14160, 14351

10518, 13268

13386, 13454

13506, 14137

1436, 1612

228, 262

354, 1256

1278, 1387

1403, 1421

21,548

186,041

7752

Discharge summary

report

Admission Date: [**2184-8-24**] Discharge Date: [**2184-9-7**] Service: CSU CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **] year old man with peripheral vascular disease, hypertension, and coronary artery disease, positive stress test and preserved ejection fraction who was admitted in [**Month (only) **] of this year for a cardiac workup, refused surgical intervention at that time, and has had recurrent episode of chest pain. He underwent cardiac catheterization at [**Hospital3 **] Hospital and transferred to [**Hospital1 1444**] for possible surgical option. PAST MEDICAL HISTORY: Peripheral vascular disease. Hypertension. B12 deficiency anemia. Coronary artery disease. PAST SURGICAL HISTORY: Appendectomy. SOCIAL HISTORY: He lives with his wife. [**Name (NI) **] tobacco and no ethanol use. Echocardiogram done in [**2184-7-6**], showed an ejection fraction of 60 percent with one plus aortic regurgitation and one plus mitral regurgitation. He had a positive stress test in [**Month (only) **] of this year. Also, cardiac catheterization done at [**Hospital3 **] Hospital showed 90 percent ostial left anterior descending coronary artery, 50 percent mid lesion, 80 percent obtuse marginal one, tubular 80 percent diagonal lesion, right coronary artery with a 70 percent proximal lesion and ramus with a 20 percent lesion. LABORATORY DATA: White blood cell count was 7.8, hematocrit 40.3, platelet count 159,000. Sodium 140, potassium 3.9, chloride 102, CO2 27, blood urea nitrogen 23, creatinine 1.3, glucose 132. Prothrombin time 12.8, partial thromboplastin time 27.1, INR 1.1. MEDICATIONS ON ADMISSION: 1. Hydrochlorothiazide 25 mg once daily. 2. Aspirin 325 mg once daily. 3. IMDUR 30 mg once daily. 4. Nitroglycerin p.r.n. 5. Norvasc 7.5 mg once daily. 6. Ambien q.h.s. 7. Pentoxifylline 400 mg twice a day. PHYSICAL EXAMINATION: Temperature 97, heart rate 60, blood pressure 113/67, respiratory rate 18, oxygen saturation 100 percent in room air. An elderly man in no acute distress. Speaks Russian. He is younger than age. Respiratory is clear to auscultation bilaterally. Cardiovascular is regular rate and rhythm. The abdomen was soft, nontender, nondistended. Right groin catheterization site no hematoma. Extremities are warm with no edema. Electrocardiogram showed sinus bradycardia, heart rate 50, T wave inversion in lead [**Last Name (LF) 1105**], [**First Name3 (LF) **] changes in aVF. HOSPITAL COURSE: The patient was admitted to the medical service and CT surgery was consulted and the patient was seen and accepted for coronary artery bypass grafting. On [**2184-8-26**], he went to the operating room at which he underwent coronary artery bypass grafting times three. Please see the operating room report for full details. In summary, he had a coronary artery bypass graft times three with left internal mammary artery to the left anterior descending coronary artery, saphenous vein graft to the obtuse marginal, saphenous vein graft to left posterior descending coronary artery. His bypass time was 69 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. The patient did well in the immediate postoperative period. His anesthesia was reversed. He was weaned from the ventilator and successfully extubated on postoperative day number one. He remained hemodynamically stable requiring Nitroglycerin to maintain an adequate blood pressure. He was begun on Lasix as well as Lopressor and his chest tubes were discontinued. He remained in the Cardiothoracic Intensive Care Unit for close hemodynamic monitoring. On postoperative day number two, the patient remained hemodynamically stable in sinus rhythm. His preoperative Norvasc was resumed. The patient remained in the Cardiothoracic Intensive Care Unit as he was slightly confused and lethargic. Additionally, the patient's Foley catheter was removed on postoperative day number three. The patient continued to be hemodynamically stable. His beta blocker and diuretic doses were increased. He failed to void and his Foley was reinserted. He was additionally started on Flomax and the patient was kept in the Cardiothoracic Intensive Care Unit yet again for monitoring of his pulmonary and neurological status. On postoperative day number four, the patient continued to do well hemodynamically. His minor confusion had cleared by this point and he was less lethargic and he was transferred to the floor for continuing postoperative care and cardiac rehabilitation. Following transfer to the floor, the patient was found in the bathroom somewhat unresponsive and he was placed in the bed. At that point, he was fully responsive, cooperative and following commands. He had a heart rate in the 90s and a blood pressure of 150/90. He had no memory of the event. Following this event, neurology was consulted as well as cardiology. Both the neurology service and the cardiology service felt that this event was due to cough syncope. The patient continued on telemetry for close hemodynamic and cardiac event monitoring. Over the next several days, the patient's activity level was advanced with the help of the nursing staff and the physical therapist. He remained hemodynamically stable with no further syncopal events. He had a head CT that showed no hemorrhage and only old chronic infarcts. On postoperative day number eleven, it was decided that the patient would be stable and ready for discharge within the next day or two. At that time, the patient's physical examination was as follows: Vital signs revealed temperature 97.6, heart rate 85, sinus rhythm, blood pressure 120/40, respiratory rate 20, oxygen saturation 93 percent in room air. Laboratories showed sodium 136, potassium 4.2, chloride 106, CO2 22, blood urea nitrogen 24, creatinine 1.2, glucose 115. White blood cell count 14.0, hematocrit 32.0, platelet count 435,000. Physical examination revealed he is alert and responsive, respiratory rate clear to auscultation bilaterally. Cardiovascular shows regular rate and rhythm, S1 and S2, no murmur. The sternum is stable. The incision is open to air, clean and dry. The abdomen is soft, nontender, nondistended, with positive bowel sounds. Extremities are warm and well perfused with no edema. MEDICATIONS ON DISCHARGE: 1. Metoprolol 25 mg twice a day. 2. Amlodipine 10 mg once daily. 3. Aspirin 325 mg once daily. 4. Simvastatin 20 mg once daily. 5. Tamsulosin 0.4 q.h.s. 6. Zantac 150 mg twice a day. 7. Atrovent two puffs four times a day. 8. Albuterol two puffs four times a day. 9. Pentoxifylline 400 mg twice a day. 10. Colace 100 mg twice a day. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSES: Coronary artery disease, status post coronary artery bypass grafting times three with left internal mammary artery to the left anterior descending coronary artery, saphenous vein graft to obtuse marginal and saphenous vein graft to left posterior descending coronary artery. Hypertension. Peripheral vascular disease. Anemia. Status post appendectomy. FOLLOW UP: The patient is to be discharged to rehabilitation. He is to follow-up with Dr. [**Last Name (STitle) **] in two to three weeks following his discharge from rehabilitation and follow-up with Dr. [**Last Name (STitle) **] in four weeks from the date of discharge from [**Hospital1 69**]. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**] Dictated By:[**Last Name (NamePattern4) 1718**] MEDQUIST36 D: [**2184-9-6**] 17:50:27 T: [**2184-9-6**] 19:38:27 Job#: [**Job Number 28108**]

[ "401.9", "281.1", "414.01", "427.31", "780.2", "396.3", "443.9", "411.1", "373.00" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6847, 7204

6453, 6793

1690, 1899

2516, 6427

764, 779

7216, 7742

1922, 2498

106, 119

148, 622

645, 740

796, 1664

6818, 6825

6,630

155,256

23660

Discharge summary

report

Admission Date: [**2130-10-14**] Discharge Date: [**2130-10-17**] Date of Birth: [**2086-7-21**] Sex: F Service: MEDICINE Allergies: Keppra Attending:[**First Name3 (LF) 1253**] Chief Complaint: Seizure Major Surgical or Invasive Procedure: Intubated prior to arrival to [**Hospital1 18**] Extubation on [**10-15**] History of Present Illness: Ms. [**First Name4 (NamePattern1) 14163**] [**Known lastname 1007**] is a 44 year old woman with uncertain medical history who was brought to [**Hospital3 **] Emergency Department by police after being found intoxicated and having a seizure in the police care. At [**Hospital3 **] she was found to have an alcohol level of 277 with negative serum tox screen. While there she had a witnessed seizure lasting less than five minutes. She was given Ativan IM 4 mg. Immediately after her seizure she was found to be hypoxic and hypotensive. Intubation was attempted but reportedly very difficult requiring multiple attempts and anasthesia consult. Patient reportedly had emesis and hemoptysis during attempted intubation. After intubation a central line was placed and patient was started on levophed and given a cetriaxone 2 mg IV. Patient was transferred to [**Hospital1 18**] for higher acuity of care. . On arrival to the [**Hospital1 18**] ED, vital signs were T BP 107/61 HR 72 RR 35 SpO2 76%. Labs were notable for Hct 31, etoh 128, lactate 1.0, creatinine 0.7. She underwent CT head which was negative for an acute process. She underwent CXR to confirm ET tube and CVL placement which revealed bilateral infiltrates. In the ED he received ceftriaxone 1 g IV, Flagyl 500 mg IV x 1, levophed and 2 L IV NS. . Of note patient was known to local EMS who reported a known alcohol and seizure history. She is currently under police custody for domestic assault (reportly tried to stab her boyfriend). At the OSH a nurse was able to get ahold of her health care proxy who reported she was recently admitted to [**Hospital 1263**] Hospital for double pneumonia. . Review of systems: Unable to obtain as patient is sedated. Past Medical History: Seizure disorder ADHD Hypertension Alcohol dependence Neuropathy, alcoholic Anxiety COPD/Asthma Tobacco abuse Hx pancreatitis Lower back pain Gastric ulcers GERD Recent admission for pneumonia Depression, likely Bipolar PTSD Social History: Patient has a remote history of living in a shelter. Prior to her admission she was living with boyfriend. She reports a remote history of spending 9 months in prison for OUI. She reports her alcoholism began at the age of 37 after sexual assault. She denies abuse of any illicit drugs. She reports she began smoking three months ago and is trying to quit. Family History: Family History: Unable to obtain as patient was sedated. Otherwise, not relevant to this admission. Physical Exam: Physical Exam on Arrival to ICU: Vitals: T: 99.8 BP: 121/88 P: 76 R: 24 O2: 99% on FiO2 100% on vent General: Awake, uncomfortable, significant facial edema HEENT: Sclera anicteric, MMM, intubated, injected conjunctiva Neck: supple, JVP not elevated, no LAD CV: Distant heart sounds, Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, appears distended, bowel sounds present, no rebound tenderness or guarding GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Discharge: Vitals: T: Afeb 132/97 88 22 93 RA GEN: AAOx3. Appears comfortable, non-toxic. HEENT: eomi, perrl, MMM. Neck: No LAD. JVP WNL. RESP: Minor scattered wheezes throughout, with good AE. Otherwise CTA. Coarse rhonchi clear with cough. CV: RRR. No mrg. ABD: +BS. Soft, NT/ND. Ext: No CEE. Neuro: CN 2-12 grossly intact. No tremor or asterixis. Psych: Pleasant, conversant. Pertinent Results: ADMISSION LABS: . [**2130-10-14**] 11:35PM GLUCOSE-82 UREA N-10 CREAT-0.5 SODIUM-140 POTASSIUM-3.5 CHLORIDE-108 TOTAL CO2-27 ANION GAP-9 [**2130-10-14**] 11:35PM CALCIUM-7.3* PHOSPHATE-2.5* MAGNESIUM-2.4 [**2130-10-14**] 05:10PM TYPE-ART TEMP-37.2 PO2-110* PCO2-52* PH-7.35 TOTAL CO2-30 BASE XS-2 INTUBATED-INTUBATED [**2130-10-14**] 10:43AM LACTATE-0.9 [**2130-10-14**] 12:06AM ALT(SGPT)-21 AST(SGOT)-34 ALK PHOS-46 TOT BILI-0.1 [**2130-10-14**] 12:06AM LIPASE-34 [**2130-10-14**] 12:06AM ALBUMIN-3.4* IRON-15* [**2130-10-14**] 12:06AM calTIBC-393 VIT B12-199* FOLATE-11.2 FERRITIN-12* TRF-302 [**2130-10-14**] 12:06AM PHENOBARB-LESS THAN PHENYTOIN-<0.6 VALPROATE-LESS THAN [**2130-10-14**] 12:06AM ASA-NEG ETHANOL-128* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2130-10-14**] 12:06AM FIBRINOGE-162 . URINE STUDIES: [**2130-10-14**] 12:06AM URINE UCG-NEGATIVE [**2130-10-14**] 12:06AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2130-10-14**] 12:06AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2130-10-14**] 12:06AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008 . MICRO: [**2130-10-14**] Blood cx: pending . [**2130-10-14**] Sputum cx: no growth . [**2130-10-15**] Sputum cx: pending . [**2130-10-14**] MRSA screen: negative . IMAGING: . [**2130-10-16**] ECHO: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. Doppler parameters are most consistent with normal left ventricular diastolic function. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . IMPRESSION: Normal global and regional biventricular systolic function. No diastolic dysfunction or pathologic valvular disease seen. . [**2130-10-14**] CXR: 1. Lines and tubes in satisfactory position. 2. Mild pulmonary vascular congestion. 3. Right upper lobe and left lower lobe atelectasis versus aspiration. . [**2130-10-16**] CXR: The patient was extubated in the meantime interval with removal of the vent tube. The right internal jugular line has been removed as well. There is no change in the cardiomediastinal silhouette. Prominence of the pulmonary arteries is redemonstrated and might be consistent with pulmonary hypertension. The lungs are essentially clear with no new consolidations worrisome for interval development of infectious process. Right pleural effusion is most likely present, small. Minimal atelectasis at the right lung base is unchanged. . [**2130-10-14**] CT head: 1. No evidence of acute intracranial process. 2. Paranasal sinus disease Brief Hospital Course: . 46 year old woman transferred from OSH ED after presenting with intoxication and experiencing witnessed seizure. . # Hypoxic respiratory failure: Initial hypoxia was likely due to apnea during her seizure. Patient with known history of alcohol intoxication, witnessed seizure, emesis during attempted intubation, and CXR findings were all suggestive of an aspiration event. Patient's respiratory status, however, improved dramatically with lasix alone. She was able to be extubated the following day and remained afebrile, with normal WBC making aspiration pneumonia unlikely. . # Seizure: Initially unclear whether patient had a primary seizure disorder or if patient's seizure history is in the setting of alcohol withdrawal. Patient's active intoxication during her seizure suggests that she has an underlying seizure disorder and her alcohol use lowered her seizure threshold. This was later confirmed with the patient and her boyfriend. [**Name (NI) **] was restarted on her home Zonisamide 500 mg daily and monitored on a CIWA scale. She had no further episodes of seizure activity during her admission. . # Alcohol intoxication: Patient brought into OSH ED while intoxicated. Per EMS patient is known to them to have alcohol dependence. Her last drink was reportedly around 7 pm on [**2130-10-13**]. Toxicology screen positive for benzos (after ativan and versed given at OSH). Patient admits to a history of delirium tremens during prior attempts to get sober. She was monitored for > 72 after her last drink on a CIWA scale without evidence of DTs. She declined discharge to an alcohol rehabilitation program. She was discharged home with plans to attend daily AA meetings and follow up with her therapist on regular basis. Recommend patient continue home naltrexone, clonazepam, thiamine, folate, multivitamin. . # Intermittent hypotension: Patient intermittently required levophed after intubation at OSH. This appeared directly related to sedation for mechanical ventilation and resolved with weaning sedation and extubation. . # Anemia: Patient with hematocrit of 31 on presentation. Unclear baseline. No evidence of active bleeding on presentation. She has known B12 deficiency and was continued on B12 and folate supplements. . # Asthma: Patient reports diagnosis of asthma. Currently breathing comfortably, but with some wheezing on exam. Pt was returned to her home regimen at the time of discharge. . # ? Gastric ulcer vs. gastritis: This history is provided per report of HCP and not confirmed. Counsel against continued alcohol abuse. Recommend patient continue her home omeprazole 20 mg po bid and have her hematocrit monitored by her primary care provider. . # Question of abnormal chest imaging: Needs to have CT chest to evaluate for hilar adenopathy on CXR, ? sarcoid. The ICU team discussed with the PCP, [**Name10 (NameIs) 1023**] reported pt had a recent CT chest to further evaluate. Will defer further workup to pt's PCP. . # Hypertension, benign - Lisinopril 10 mg PO/NG DAILY . # Neuropathy, d/t alcohol - Gabapentin 300 mg PO/NG HS - Pregabalin 100 mg PO/NG TID . # B12 deficiency [**Month (only) 116**] also contribute to neuropathy and anemia. - Cyanocobalamin 1000 mcg PO/NG DAILY . # Anemia: No evidence of active bleeding, but pt with hx of gastric ulcers and recent alcohol abuse. . # Asthma/COPD: . # Psychiatric: Bipolar, Depression, ADHD, PTSD Will continue home medications. - Risperidone 1 mg PO BID - Mirtazapine 15 mg PO/NG HS - Clonazepam 1 mg PO/NG TID - Citalopram 40 mg PO/NG DAILY . # Polypharmacy/Patient medication confusion: Per discussion with the ICU team, pt seems to have some confusion about her extensive medication list. Her medications were reconciled with her PCP and her pharmacy, however, would encourage patient to bring all of the medications that she currently uses to her next PCP appointment for further reconciliation, to ensure they are being used appropriately. . # Emergency Contact: [**Name (NI) **] [**Name (NI) 1661**] (boyfriend/HCP) [**Telephone/Fax (1) 60503**] # Code: FULL # Disposition: Home with referral to alcohol rehabilation resources Medications on Admission: Med list confirmed with patient and [**Location (un) 535**]: Claritin 10 mg po daily Flovent 44 mcg 2 puffs [**Hospital1 **] Naltrexone 50 mg daily Albuterol nebulizer Gabapentin 300 mg qhs Pregabalin 200 mg tid Symbicort 80-4.5 2 puffs [**Hospital1 **] Cyanocobalamin 1000 mcg po daily---NOT ON PHARMACY'S LIST Remeron 15 mg qhs Risperidone 1 mg po bid Multivitamin daily Zonisamide 500 mg qhs Prednisone 40 mg daily x 3 days [**Date range (1) 60504**] Citalopram 40 mg daily Klonopin 1 mg tid Methylphenidate 20 mg daily Lisinopril 10 mg daily Omeprazole 20 mg [**Hospital1 **] Colace 100 mg [**Hospital1 **] Thiamine 100 mg daily Folic Acid 1mg daily OTHER ACTIVE PRESCIPTIONS PER PHARMACY (patient does not report taking these medications) Creon [**Numeric Identifier 890**] units po with meals Prazosin 1 mg qhs Lorazepam was to be replaced by clonazepam but both Rx were filled on [**10-11**] Flovent 220 mcg inh [**Hospital1 **] Nicotine patches Lamotrigine (now listed as an allergy but patient has refills available) Propanolol Discharge Medications: 1. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. Flovent HFA 44 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. 3. naltrexone 50 mg Tablet Sig: One (1) Tablet PO once a day. 4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for sob/wheeze. Disp:*30 neb* Refills:*0* 5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 6. pregabalin 200 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 7. Symbicort 80-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation twice a day. 8. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): (Remeron). 10. risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. zonisamide 100 mg Capsule Sig: Five (5) Capsule PO at bedtime. 13. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 14. clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 15. methylphenidate 20 mg Tablet Sig: One (1) Tablet PO once a day. 16. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 18. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily) for 10 days. Disp:*10 Patch 24 hr(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: # Hypoxic respiratory failure # Seizures # Alcohol abuse/withdrawl # B12 deficiency Secondary: Hypertension Neuropathy Anemia Asthma/COPD Hx gastric ulcers Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted after a seizure while you were intoxicated. You required intubation and management in the ICU. You were also treated for alcohol withdrawl. You are strongly encouraged to quit alcohol, and to use the resources in your community to help you quit, such as AA.

[ "493.20", "401.1", "357.5", "281.1", "309.81", "458.29", "345.90", "291.81", "303.01", "296.50", "518.81" ]

icd9cm

[ [ [] ] ]

[ "96.71", "38.97" ]

icd9pcs

[ [ [] ] ]

13733, 13739

6845, 10981

277, 353

13940, 13940

3803, 3803

2770, 2855

12070, 13710

13760, 13919

11007, 12047

14091, 14371

2870, 3784

2070, 2111

230, 239

381, 2050

6747, 6822

3819, 6738

13955, 14067

2133, 2360

2376, 2737

12,720

175,987

49951

Discharge summary

report

Admission Date: [**2173-12-23**] Discharge Date: [**2173-12-25**] Date of Birth: [**2127-3-1**] Sex: M Service: MEDICINE Allergies: Penicillins / Sulfonamides / Tetracyclines Attending:[**First Name3 (LF) 562**] Chief Complaint: LOC Major Surgical or Invasive Procedure: Intubation History of Present Illness: 45 yo male drug abuser on methadone with AIDS ([**5-2**] cd4 292, vl>100k, h/o pcp pneumonia and [**Month/Year (2) 11395**] on HAART) and HCV+ found unconscious at his group home. He was on the couch and unresponsive for 3-4 minutes. EMS administered 1mg of narcan with good response, GCS 3-->14. His pupils were constricted but reactive. On arrival to the ED, he was minimally responsive, he received 1mg of narcan and became a+0x3. He was able to tell the team that he used iv heroine (which he later recounted), chewed two fentanyl patches, and ingested 2mg of klonopin. He became unresponsive to noxious stimuli, received 4.8mg of narcan and was started on a narcan gtt, intubated and given 50g of charcoal with sorbitol. Toxicology was consulted and felt not opioid overdose, instead likely benzo intoxication with possible narcotic withdrawal. He also received 5liters of NS. Past Medical History: # HIV- Question of compliance with HAART # hcv+- genotype 1 grade 1 hepatic fibrosis on bx [**2169**] # polysubstance abuse # past apap overdose # etoh related pancreatitis # DTs # CAD- s/p lcx stent [**11-29**], normal ef on echo # neurogenic bladder # hiv nephropathy- cr as low as 0.8-1.0 and as high as 7 in [**2172**] # herpes # zoster- [**11-1**] treated with acyclovir # peripheral neuropathy- likely [**12-30**] HIV # depression or anxiety given on zoloft in past and maybe currently Social History: Lives in group home. h/o EtOH and heroin use, though denies any use currently. No longer on methadone maintenance. Family History: NC Physical Exam: t96.1, p53, 96/57 (map 72), 100% on [**4-1**], fio2 40% Opens eyes to voice and squeezes hand. Pupils dilated but reactive. Neck Supple. Intubated. Brady s1/s2 CTA anteriorly Soft, +bs, no hepatomegaly, vertical scar to right side of umbilicus, and small surgica appearing scar in rlq No peripheral edema, no interdigitary injection sites, abreasions on shins, +dp and pt pulses bilaterally Pertinent Results: Labs on admission: WBC 8.0, Hgb 14.7, Hct 41.9, MCV 86, Plt 151 (DIFF: Neuts-52.6 Lymphs-37.7 Monos-6.2 Eos-3.0 Baso-0.5) Na 135, K 5.1, Cl 100, HCO3 19, BUN 20, Cr 3.1, Glu 79 Albumin 2.9*, Ca 7.9*, Phos 3.9, Mg 1.3* ALT 16, AST 32, AP 128, TBili 0.4, Amylase 92, Lipase 37 CK(CPK) 236*, CK-MB 5, cTropnT <0.01 Serum Osm 276 serum tox screen: TCA+ urine tox screen: benzo +, negative opioids but did not check for fentanyl U/A: 1.010, 5.0, 30 prot, rare bacteria . Labs on discharge: WBC 4.5, Hgb 12.6*, Hct 36.5*, MCV 90, Plt 121* PT 11.2, PTT 27.8, INR(PT) 0.9 Na 137, K 4.1, Cl 108, HCO3 22, BUN 14, Cr 1.3, Glu 80 Ca 8.1*, Phos 2.9, Mg 2.0 . Imaging: EKG [**2173-12-23**]: NSR @65bpm, nl axis, normal intervals, Qtc-420 unchanged except for Qtc 400 [**7-2**]. . CXR [**2173-12-23**]: AP single view of the chest has been obtained with the patient in supine position and is analyzed in direct comparison with a similar study obtained 1-1/2 hours earlier during the same day. The patient is now intubated. The ETT is terminating in the trachea, some 6 cm above the level of the carina. An NG tube has been passed, reaching well the fundus of the stomach. There is no pneumothorax or any other placement related complication. In comparison with the next preceding study, diffuse lateral pulmonary densities have developed and progressed significantly since the previous study obtained 1-1/2 hours earlier. The most likely explanation is CHF or perhaps fluid overload as the heart shadow does not identify marked cardiomegaly. . CT head [**2173-12-23**] :There is significant limitation of the study secondary to patient motion, but there is no evidence for intracranial hemorrhage. The [**Doctor Last Name 352**]-white matter junction is distinct. The ventricles, sulci, and cisterns demonstrate no effacement. There is no mass effect or shift of normally midline structures. The osseous structures are unremarkable. The visualized paranasal sinuses are clear. The mastoid air cells are well pneumatized. . CXR [**2173-12-24**]: AP chest radiograph shows endotracheal tube and nasogastric tube in stable position. The cardiac and mediastinal contours appear unchanged. Again seen are increased bilateral pulmonary densities consistent with CHF or fluid overload, unchanged from prior study. . Brief Hospital Course: 46 yo male with likely fentanyl overdose and benzo withdrawal vs. intoxication, s/p intubation for airway protection. . # Altered mental status: His mental status began to clear in the ICU after administration of narcan and activated charcoal. Intoxication with methylene or ethylene glycol were ruled out, as was hepatic encephalopathy. Toxicology was consulted to help in his management. Once his sedation (propofol) was weaned, he was able to be extubated and his mental status appeared to be back to his baseline. He was restarted on his outpatient medications which include klonopin, zoloft, elavil, neurontin and fentanyl. He was also given thiamine/folate/MVI for h/o EtOH abuse. Social work was consulted to address the patient's substance abuse issues and he noted that he has strong support system in place, through the [**Hospital1 778**] Health Clinic and AA. . # Anion gap metabolic acidosis: On admission, Mr. [**Known lastname 429**] had an AG metabolic acidosis, most likely from ARF. Ingestion of another toxin or alcohol was ruled out, EtOH was negative, salicylates were negative, and his lactate was normal (1.1 - 1.2). The AG acidosis resolved w/ the administration of IVF and his AG was down to 11 on discharge. . # ARF: Urine lytes were checked and were c/w prerenal etiology (FeNa 0.41%). He demonstrated a quick improvement in Cr w/ IVF which also supported that diagnosis. Urine eos were negative, so AIN was ruled out. IVF were discontinued once he was tolerating adequate POs. His Cr was down to 1.3 prior to discharge. . # AIDS: His HAART was held until [**12-25**] when his PCP could confirm his regimen. He is currently not on any PCP [**Name9 (PRE) **] as he is allergic to Bactrim, but he and his PCP will discuss starting dapsone as an outpatient. . # FEN: Once extubated, he was given a regular diet. He was continued on IVF until his Cr came back to baseline. His electrolytes were checked daily and were repleted prn. . # PAIN: Pt has chronic pain, likely from HIV-related peripheral neuropathy. He was restarted on his outpatient regimen of gabapentin, amitryptyline, and fentanyl once he was transferred to the floor. On discharge, it was advised that he follow-up with the acupuncture clinic again to attempt to address his chronic pain needs. . # PPX: Heparin SC, bowel regimen, thiamine/folate/MVI. . # ACCESS: Peripheral IV. . # CODE: Presumed full code. . # DISPO: To home. Medications on Admission: listed by ED- but unsure if these are his real meds elavil zoloft epivir viread sustiva crixivan lipitor atenolol lisinopril neurontin fentanyl patches methadone novair Discharge Medications: 1. Efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Epzicom 600-300 mg Tablet Sig: One (1) Tablet PO once a day. 3. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 11. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 12. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Gabapentin 800 mg Tablet Sig: Three (3) Tablet PO twice a day. 14. Amitriptyline 150 mg Tablet Sig: One (1) Tablet PO at bedtime. 15. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Benzodiazepine and fentanyl overdose Acute renal failure Urinary retention . Secondary diagnosis: HIV Hepatitis C h/o polysubstance abuse CAD Discharge Condition: Good. Able to urinate on his own. Afebrile, BP 128/90, HR 76. Discharge Instructions: 1. Please follow up with your PCP or go to the nearest ER if you develop any of the following: fever, chills, chest pain, shortness of breath, difficulty breathing, worsening pain, rash, nausea, vomiting, or any other worrisome symptoms. 2. Please take all your medications as prescribed. 3. Please follow-up with your PCP in the next two weeks. Followup Instructions: 1. Please follow up with Dr. [**Last Name (STitle) **] as previously scheduled. It is important that you follow-up with her to continue on your HAART regimen and to follow up on your renal failure. 2. Please follow up with [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 13146**], PA on [**2173-12-29**] at 1:00pm. Phone:[**Telephone/Fax (1) 2422**] 3. Please follow up with AA and the acupuncture group at [**Hospital1 778**].

[ "E853.2", "365.9", "E850.2", "V45.82", "965.09", "042", "305.40", "414.01", "969.4", "584.9", "276.2", "070.54" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

8457, 8463

4650, 4780

307, 320

8668, 8732

2331, 2336

9126, 9607

1901, 1905

7289, 8434

8484, 8484

7096, 7266

8756, 9103

1920, 2312

264, 269

2816, 4627

348, 1238

8601, 8647

8503, 8580

2350, 2797

4795, 7070

1260, 1753

1769, 1885

62,751

116,864

42335

Discharge summary

report

Admission Date: [**2110-8-8**] Discharge Date: [**2110-8-8**] Date of Birth: [**2067-6-17**] Sex: F Service: MEDICINE Allergies: lisinopril / hydrochlorothiazide Attending:[**First Name3 (LF) 2712**] Chief Complaint: hoarseness Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 91708**] is a 43 yo female h/o discoid lupus and hypertension who presented to the ED with hoarseness, sensation of throat closing, and nausea and vomiting that started this evening. Patient had been on lisinopril, although perhaps not taking this consistantly. She was switched to lisinopril-HCTZ combination pill at her NP[**MD Number(3) **] [**2110-8-6**]. She took 1 dose of the new medication [**2110-8-7**]. She awoke at 2 am this morning with sensation of shortness of breath and nausea, and had emesis x 7 times. She drove herself to the ED. She reports no chest pain, rash, abdominal pain, or diarrhea. Physical exam in the ED shows no stridor or adventitious sounds in the lung fields, but presence of uvular hydrops and some respiratory distress, although the pt remained on roomn air with good O2 sats. Patient symptomatically improved after Epipen, solumedrol 125mg, Benadryl 50mg IV, and famotidine 60mg IV. She is being admitted to the MICU for observation x 24 hours . On the floor, pt is quite tired. She c/o sore throat. No emesis since 3 or 4am. No nausea currently. Past Medical History: DEPRESSIVE DISORDER TUBERCULOSIS ([**2086**]; tx meds x 2 yrs-neg cxray x 2 THROAT PAIN feels like something in throat-gags freq URINARY, INCONTINENCE, STRESS FEMALE ALOPECIA (dx by derm biopsy cutaneous lupus) PYELONEPHRITIS, ACUTE ([**2083**]) DYSMENORRHEA, MENORRHAGIA HTN Social History: Mother dies from stomach CA. Uncle died from tongue CA (smoker). Family History: - Tobacco: Current smoker, 1ppd x 15 years - Alcohol: Drinks 2 drinks 3xs per week, no Hx of withdrawl Sx Physical Exam: On Admission: General: Alert, oriented, appears fatigued but otherwise comfortable HEENT: Sclera anicteric, MMM, no lip swelling Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, no clubbing, cyanosis or edema On discharge: Angioedema of the uvula much improved. Pertinent Results: [**2110-8-8**] 05:47AM BLOOD WBC-6.6 RBC-4.77 Hgb-10.7* Hct-33.3* MCV-70* MCH-22.5* MCHC-32.2 RDW-17.7* Plt Ct-240 [**2110-8-8**] 05:47AM BLOOD Neuts-49.5* Lymphs-44.4* Monos-3.8 Eos-2.0 Baso-0.3 [**2110-8-8**] 05:47AM BLOOD Glucose-100 UreaN-13 Creat-0.8 Na-137 K-3.5 Cl-102 HCO3-25 AnGap-14 Brief Hospital Course: 43yo F with HTN whose antihypertensive was swuitched from lisinopril to lisinopril-HCTZ who presents with feeling as if her throat was closing. # Angioedema: Likely ACEi-related angioedma given the absence of any other systemic symptoms and the fact that angioedema can occur any time while on the drug. She was treated with IV solumedrol in the ED, converted to PO prednisone on the floor, benadryl, famotidine, and an epipen. Her edema was greatly improved at time of discharge and she was tolerating a diet. She was discharged on amlodipine 10mg, epipen and prednisone 40mg x 5 days. She was told to follow-up with her PCP [**Last Name (NamePattern4) **] [**2-15**] days and to be referred to allergy. She was told to avoid both HCTZ and ACEi. Both drugs were added to her allergy list. # HTN: Discharged on amlodipine 10mg daily and told to follow-up with her PCP. Medications on Admission: Lisinopril-Hydrochlorothiazide 20-25 mg Oral Tablet TAKE ONE TABLET DAILY Ibuprofen 800 mg Oral Tablet TAKE 1 TABLET THREE TIMES A DAY AS NEEDED take WITH FOOD Hydroquinone 4 % Topical Cream apply to face TWICE DAILY Clobetasol 0.05 % Topical Solution Apply sparingly twice daily Ammonium Lactate (LAC-HYDRIN) 12 % Topical Lotion APPLY TO BOTH FEET QD NUQUIN HP 4 % TOPICAL CREAM (DIOXYBENZONE/PDO/HYDROQUINONE) apply TWICE DAILY to TO AFFECTED AREA Discharge Medications: 1. prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day for 5 days. Disp:*10 Tablet(s)* Refills:*0* 2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 3. hydroquinone 4 % Cream Sig: One (1) application Topical twice a day: apply to the face twice a day. 4. clobetasol 0.05 % Cream Sig: One (1) apply Topical once a day: apply to affected area. Do not apply to the face. 5. ammonium lactate 12 % Lotion Sig: One (1) application Topical twice a day: apply to feet. 6. epinephrine 0.15 mg/0.15 mL Combo Pack Sig: One (1) Intramuscular Once as needed for allergic reaction, trouble breathing for 1 doses: Use in extreme case of difficulty breathing/ throat closing. Disp:*1 pen* Refills:*3* Discharge Disposition: Home Discharge Diagnosis: Primary: Angioedema Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**Last Name (Titles) 91709**], It was a pleasure taking part in your care. You were admitted to [**Hospital1 18**] for difficulty breathing and throat swelling. This was likely a reaction to one of your blood pressure medications. You were treated with medications including epinephrine, steroids, and benadryl, and your breathing and swelling improved. You were monitored in the ICU prior to discharge home. The following changes to your medications were made: - STOP lisinopril - STOP hydrochlorothiazide - START Prednisone 40mg daily for 5 days - START amlodipine 10mg by mouth daily - Please fill, and carry, an epinephrine pen with you at all times so that you may use it in the event that you have this reaction again Please take all other medications as prescribed. Followup Instructions: Please follow-up with your PCP [**Last Name (NamePattern4) **] [**2-15**] days. Please have your primary care doctor refer you to an allergy specialist. Completed by:[**2110-8-8**]

[ "E849.9", "427.89", "305.1", "E944.3", "695.4", "995.1", "787.01" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4950, 4956

2815, 3688

303, 310

5033, 5033

2498, 2792

5989, 6173

1847, 1956

4188, 4927

4977, 5012

3714, 4165

5184, 5966

1971, 1971

2439, 2479

252, 265

338, 1447

1985, 2425

5048, 5160

1469, 1747

1763, 1831

58,351

191,162

33084

Discharge summary

report

Admission Date: [**2121-9-1**] Discharge Date: [**2121-9-4**] Date of Birth: [**2048-1-3**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4057**] Chief Complaint: dyspnea, methemoglobinemia Major Surgical or Invasive Procedure: intubation History of Present Illness: Mr. [**Known lastname **] is a 73 year old gentleman well known to the OMED service, recently discharged for dysphagia, recently s/p tracheal dilitation and stent placement; presented to the ED with 2 days of dyspnea, chills and an inability to clear sputum, leading to difficult sleeping. . In the ED, initial vs were: 98.6 110 149/74 20 100. Pulmonary was consulted and a bronch was performed. The patient was found to have a paralyzed R vocal cord. Around the time of the bronch, he became hypoxic with sats in the 80s refractory to oxygenation. A blood gas was obtained and he was found to have methemeglobinemia of 64%. Toxicology was consulted and the patient was given 90mg of Methylene blue, with subsequent blood gases demonstrating a reduction in methemeglobin. The patient also received Racemic epi & heliox prior to intubation for stridor. Transfer VS 135 148/95 CMV Peep 10 Fi02100 on Propofol. . On arrival to the floor, the patient is intubated and sedated, unable to provide further history. His partner confirms the limited story prior to the ED above. Past Medical History: Poorly-differentiated anaplastic carcinoma of the thyroid Well-differentiated squamous cell carcinoma of the esophagus tracheal compression related to the large thyroid cancer s/p a sequential dilation tracheal stenosis and the placement of a covered metal stent hypercalcemia of malignancy HTN Chronic kidney disease stage III-IV probably related to untreated hypertension Asthma or COPD H/o tobacco and alcohol dependence Social History: He is retired, formerly worked as a safecracker for a safe company. He lives with his wife. [**Name (NI) **] is a half to one pack per day smoker for at least 50 years, but quit recently. Family History: His parents lived to advanced age. His father died at age [**Age over 90 **]. His mother died in her late 80s. He had four siblings, two of whom are now deceased. One of his brothers died at age 66 from complications of diabetes and one of his sisters died in her 50s from breast cancer. He has a 67-year-old brother who remains alive and is well other than a past stroke and he has a 72-year-old sister who is alive and well. He has four children aged 45, 43, 42, and 40. His 42-year-old son has metastatic colon cancer. Physical Exam: Gen: Well appearing adult male, no acute distress HEENT: PERRL, EOMi, Dry MM, OPC, conjunctivae well pigmented Neck: Supple, no LAD or JVD Chest: CTAB CV: RRR Ab: Soft NTND Ext: No edema Neuro: AO3 Pertinent Results: Labs on admission: [**2121-9-1**] 11:52PM TYPE-ART TEMP-36.3 RATES-/15 TIDAL VOL-550 PEEP-10 O2-70 PO2-346* PCO2-30* PH-7.50* TOTAL CO2-24 BASE XS-1 INTUBATED-INTUBATED VENT-CONTROLLED [**2121-9-1**] 11:52PM HGB-9.4* calcHCT-28 O2 SAT-90 MET HGB-8* [**2121-9-1**] 10:59PM TYPE-ART TEMP-36.7 RATES-/16 TIDAL VOL-500 PEEP-10 O2-99 PO2-375* PCO2-30* PH-7.50* TOTAL CO2-24 BASE XS-1 AADO2-315 REQ O2-57 INTUBATED-INTUBATED VENT-CONTROLLED [**2121-9-1**] 10:59PM O2 SAT-69 MET HGB-31* [**2121-9-1**] 10:14PM TYPE-ART RATES-/18 TIDAL VOL-550 PEEP-8 O2 FLOW-100 PO2-495* PCO2-34* PH-7.47* TOTAL CO2-25 BASE XS-2 INTUBATED-INTUBATED [**2121-9-1**] 10:14PM HGB-9.7* calcHCT-29 O2 SAT-34 MET HGB-64* [**2121-9-1**] 06:35PM GLUCOSE-103* UREA N-18 CREAT-1.2 SODIUM-132* POTASSIUM-4.0 CHLORIDE-97 TOTAL CO2-29 ANION GAP-10 [**2121-9-1**] 06:35PM estGFR-Using this [**2121-9-1**] 06:35PM CK(CPK)-40* [**2121-9-1**] 06:35PM CK-MB-2 cTropnT-0.03* [**2121-9-1**] 06:35PM CALCIUM-9.3 PHOSPHATE-2.4* MAGNESIUM-1.4* [**2121-9-1**] 06:35PM OSMOLAL-279 [**2121-9-1**] 06:35PM WBC-2.0* RBC-3.21* HGB-9.3* HCT-27.9* MCV-87 MCH-28.9 MCHC-33.3 RDW-15.9* [**2121-9-1**] 06:35PM NEUTS-69.1 LYMPHS-24.9 MONOS-5.1 EOS-0.8 BASOS-0.2 [**2121-9-1**] 06:35PM PLT COUNT-220 . Labs on Discharge: [**2121-9-4**] 05:30AM BLOOD WBC-1.9* RBC-2.56* Hgb-7.4* Hct-22.6* MCV-88 MCH-28.9 MCHC-32.8 RDW-15.6* Plt Ct-198 [**2121-9-4**] 05:30AM BLOOD Neuts-62 Bands-0 Lymphs-19 Monos-15* Eos-1 Baso-2 Atyps-1* Metas-0 Myelos-0 [**2121-9-4**] 05:30AM BLOOD Plt Smr-NORMAL Plt Ct-198 [**2121-9-4**] 05:30AM BLOOD PT-13.2 PTT-38.8* INR(PT)-1.1 [**2121-9-4**] 05:30AM BLOOD Gran Ct-1180* [**2121-9-4**] 05:30AM BLOOD Glucose-79 UreaN-9 Creat-1.1 Na-139 K-3.0* Cl-101 HCO3-30 AnGap-11 [**2121-9-4**] 05:30AM BLOOD Calcium-8.5 Phos-2.0* Mg-1.5* . Imaging: CT-Neck [**9-3**]: IMPRESSION: 1. Soft tissue attenuation noted within the soft tissues of the right neck extending from the level of the hyoid bone inferiorly to the superior mediastinum as described above. Nonvisualization of the inferior right internal jugular vein, which reconstitutes at the level just superior to the hyoid bone. Adjacent focal area of hypoattenuation may represent thrombosed jugular vein vs cystic lymph nodes. Color doppler US is may be obtained for further characterization. 2. Tracheal stent noted originating in the subglottic airway, extending to the superior mediastinum with secretions noted inferior to the stent. 3. Right vocal cord paralysis, with or without tumor involvement. Correlation with direct visualization is recommended. 4. Linear air-filled structure extending to the right of midline, originating from the esophagus, possibly representing an esophageal diverticulum. 5. Lytic lesions in vertebral bodies C2 and C3, present on prior PET without abnormal FDG uptake. While these findings may be attributed to degenerative change, a bone scan may be obtained for further characterization. . Neck US [**9-3**]: IMPRESSION: 1. Large mass in the right neck consistent with tumor spread. 2. Occlusion of the right internal jugular vein but apparently related to mass effect or invasion rather than thrombosis. Brief Hospital Course: # Respiratory failure/Methemeglobinemia: The patient was intubated with sats in the high 90s after methylene blue. ABGs showed improving trend. Methemeglobinemia likely over at point of transfer to MICU. Weaned off vent to CPAP and was extubated in the afternoon on [**9-2**] by the pulmonary team. Cardiac enzymes were trended and were stable. Reglan was held. Toxicology followed during stay in MICU and methylene blue was redosed. . # Thyroid & Esphageal Carcinoma: Intent of care remained palliative during this admission. Chemoradiation was deemed to not have made a significant impact on the patient's symptoms, which continue to be cough, difficulty breathing / talking, and dysphagia. The decision was made to stop further chemotherapy and pursue potential surgical avenues for further palliation. A number of medication changes were also made, including starting Mirtazapine for appetite stimulation per palliative care, and Acetylcysteine and Codeine/Guiafenesin to promote productive coughing. . # Transient hypotension: The patient developed transient hypotension in the setting of propofol boluses, diarrhea. Hypovolemia also possible given sinus tach. Blood pressure normalized with fluid boluses and in the absence of fever or leukocytosis, sepsis was deemed unlikely and empiric Vanc/Zosyn was discontinued. . # ARF: Recent elevation this month in the setting of new chemo, possibly prerenal from chemo associated diarrhea. Cr remained stable at 1.2; the patient was discharge with Cr 1.1. # Hyponatremia: Hypovolemic hyponatremia normalized from 132 to 139 upon discharge with volume resuscitation. Medications on Admission: Fibersource HN Liquid Sig: 1560 (1560) cc PO once a day: goal rate of 65 cc/hr. Ipratropium Bromide 0.02 % Q6 PRN Fentanyl 25 mcg/hr Patch 72 hr Docusate Sodium 50 mg/5 mL PO BID Albuterol Sulfate 2.5 mg /3 mL Q4 PRN Acetylcysteine 20 % (200 mg/mL) Solution Sig: 6-10 MLs Q6h Enoxaparin 60 mg SC BID Ferrous Sulfate 300 mg PO Daily Metoclopramide 10 mg PO Q6H Metoprolol Tartrate 12.5 PO BID Morphine 10 mg/5 mL Solution Sig: [**6-16**] mL PO Q2H (every 2 hours) as needed for pain. Ipratropium-Albuterol Q6H PRN Senna 8.8 mg/5 mL PRN Guaifenesin 50 mg/5 mL PO Q6PRN Lidocaine-Diphenhyd-[**Doctor Last Name **]-Mag-[**Doctor Last Name **] 200-25-400-40 mg/30 mL Q6 PRN Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation Inhalation every six (6) hours. 3. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal every seventy-two (72) hours. 4. Albuterol Sulfate 2.5 mg/0.5 mL Solution for Nebulization Sig: [**2-8**] pulvules Inhalation every four (4) hours as needed for shortness of breath or wheezing. 5. Acetylcysteine 20 % (200 mg/mL) Solution Sig: [**7-17**] mL Miscellaneous [**Hospital1 **] (2 times a day). 6. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours). 7. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day. 10. Morphine 10 mg/5 mL Solution Sig: [**6-16**] mL PO Q2hrs as needed for pain. 11. Senna 8.8 mg/5 mL Syrup Sig: [**6-16**] mL PO twice a day as needed for constipation. 12. Lidocaine-Diphenhyd-[**Doctor Last Name **]-Mag-[**Doctor Last Name **] 200-25-400-40 mg/30 mL Mouthwash Sig: 15-30 mL Mucous membrane every six (6) hours as needed for Throat pain. 13. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO BID (2 times a day). Disp:*600 1* Refills:*2* 14. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 15. Sodium Chloride 3 % Solution for Nebulization Sig: One (1) neb Inhalation every eight (8) hours. Disp:*90 nebs* Refills:*2* 16. Tube Feeds Fibersource HN Liquid 1560 cc once a day at rate of 65 ml/hr Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Metastatic anaplastic thyroid cancer Right vocal cord paralysis Squamous cell cancer of the esophagus Methemaglobinemia 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 for issues with your breathing. A bronchoscopy was attempted to see if your stent needed adjustment but it was appropriately positioned. Due to a rare side effect of a medication your oxygen level went low and you had to go to the intensive care unit. You were then extubated and brought to the floor. On the floor we adjusted your medications to try and help you deal with your coughing and secretions. This slightly improved. Dr. [**First Name (STitle) **] discussed mechanical or procedural fixes to your swallowing and breathing issues with interventional pulmonolgy and surgery and they have one possible solution that requires further work up. Dr. [**First Name (STitle) **] will help arrange this next week. Your medications have been changed. Please take your medications as prescribed. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2121-9-15**] 3:00

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Discharge summary

report

Admission Date: [**2174-8-1**] Discharge Date: [**2174-8-7**] Date of Birth: [**2100-1-17**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2901**] Chief Complaint: dysphagia/odynophagia, with development of chest pain while hospitalized Major Surgical or Invasive Procedure: Cardiac Catherization History of Present Illness: Mr. [**Known lastname 2379**] is a 74 year old man with history of metastatic renal cell carcinoma to lung and sinuses, who was receiving therapy with AMG 386 and Sunitinib on [**6-27**] according to the protocol 09-014. He received a total of three administrations of AMG 386, last [**7-11**], and sutent until [**7-18**]. On [**7-18**] the therapy was held due to multiple symptoms, including nausea, vomiting, diarrhea, extreme fatigue, and h hallucinations. . Today he is admitted with complaints of of difficulty swallowing. Patient admits that he can't swallow water or food. He also complaints of tenderness over front of neck, stating that it is exquisitely tender, especially on the right side, where he feels there is a node. He states that this began three days ago and he stopped eating due to pain. Feeling as if can't swallow for three days. complaining of pain in abdomen. Claims food gets stuck and choking on fluids. He was found to have a fever of 101, but did not feel febrile himself. He endorsed nausea/vomiting for 2 days twice each day but currently not nauseated. . He also complains of L-sided abdominal pain that radiates to his L groin and L leg, [**5-9**] pain. Been present for 6-7 months, but has worsened recently, but gotten better since last admission. Has not noticed any masses in his groin, but pain seems to worsen with bearing weight. . He denies any sick contacts or any other constitutional symptoms. . On the floor, patient denies any nausea and started drinking fluids. Past Medical History: ONCOLOGIC HISTORY: Diagnosis of Stage IV clear cell renal cell carcinoma - [**2163**]: Left-sided nephrectomy about ten years ago at [**Location (un) 86773**]Hospital (we do not have the original pathology or details surrounding this operation). - [**2173-12-31**]: Presented for evaluation of pain in his left groin and testicle. An abdominal CT scan showed multiple pulmonary nodules at the lung bases, up to 1 cm in size. - [**2174-2-7**]: CT-guided biopsy confirmed metastatic clear cell carcinoma thought to be consistent with a renal cell carcinoma primary. - [**2174-2-11**]: PET CT confirmed multiple pulmonary nodules (though they were not found to be FDG avid) and showed "complete opacification of the right maxillary sinus by soft tissue attenuation which demonstrates mild hypermetabolic uptake. There is associated destruction of the anterior,posterior, and medial walls of the right maxillary sinus, the floor of the maxillary sinus as well as destruction of the inferior wall of the orbit." - [**2174-3-4**]: Biopsy of the right and left maxillary sinuses: the right maxillary sinus mass biopsy confirmed the presence of metastatic clear cell renal cell carcinoma; the left-sided sinus biopsy was benign. - [**2174-6-27**] Started therapy with Sunitinib + AMG 386 on protocol 09-014 (CT Torso [**7-12**] showed decrease size of some of the pulmonary lesions, the other being stable)- sunitinib d/c [**7-18**], AMG 386 third and last dose 7/12, held due to worsening of symptoms including nausea, vomiting, hallucinations. . PMH: Hypertension Gout Social History: retired; former garage supervisor; married; quit smoking 30 years ago (20 ppy history); no EtOH currently; denies IVDU Wife has liver cancer. 19yo son just found out he is having twins. Family History: sister with stomach cancer Physical Exam: VS: 99.7- 130/74-80-20-96RA GA: well appearing male, AOx3, NAD HEENT: PERRLA. MMM. peri-orbital edema noted bilaterally containg serous fluid. one palpapble node on right supraclavicular region. no JVD. neck supple. no thyromegaly palpated; a small pad of palpable tissue noted overlying the substernal notch noted Cards: PMI palpable at 5/6th IC space. No RVH. bradycardic, S1/S2 heard. no murmurs/gallops/rubs. Pulm: CTAB no crackles or wheezes Abd: soft, TTP in the LLQ, +BS. no g/rt. neg HSM. Extremities: wwp, no lower extremity edema or pretibial myxedema. FROM. Ambulates well. Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.. On discharge: no palpable node noted. Pertinent Results: [**2174-8-1**] 02:47PM BLOOD WBC-7.9 RBC-4.12* Hgb-12.8* Hct-37.1* MCV-90 MCH-31.0 MCHC-34.4 RDW-17.2* Plt Ct-180# [**2174-8-1**] 08:45PM BLOOD WBC-6.8 RBC-3.88* Hgb-11.8* Hct-35.2* MCV-91 MCH-30.5 MCHC-33.6 RDW-17.3* Plt Ct-175 [**2174-8-2**] 06:00AM BLOOD WBC-5.9 RBC-3.79* Hgb-11.8* Hct-34.3* MCV-90 MCH-31.2 MCHC-34.5 RDW-17.5* Plt Ct-154 [**2174-8-3**] 06:10AM BLOOD WBC-6.9 RBC-3.76* Hgb-11.4* Hct-34.8* MCV-93 MCH-30.4 MCHC-32.8 RDW-16.8* Plt Ct-214 [**2174-8-4**] 08:20AM BLOOD WBC-5.9 RBC-3.54* Hgb-11.2* Hct-32.6* MCV-92 MCH-31.5 MCHC-34.2 RDW-17.6* Plt Ct-220 [**2174-8-5**] 07:40AM BLOOD WBC-6.3 RBC-3.52* Hgb-11.1* Hct-33.0* MCV-94 MCH-31.6 MCHC-33.7 RDW-17.9* Plt Ct-260 [**2174-8-5**] 05:07PM BLOOD WBC-5.5 RBC-3.38* Hgb-10.5* Hct-30.5* MCV-90 MCH-31.1 MCHC-34.6 RDW-18.6* Plt Ct-284 [**2174-8-6**] 06:10AM BLOOD WBC-5.8 RBC-3.19* Hgb-9.8* Hct-29.5* MCV-93 MCH-30.6 MCHC-33.1 RDW-18.6* Plt Ct-321 . [**2174-8-5**] 05:07PM BLOOD Neuts-75.4* Lymphs-20.9 Monos-2.8 Eos-0.7 Baso-0.2 . [**2174-8-2**] 06:00AM BLOOD PT-15.6* PTT-29.9 INR(PT)-1.4* [**2174-8-5**] 05:07PM BLOOD PT-16.3* PTT-35.2* INR(PT)-1.4* [**2174-8-6**] 06:10AM BLOOD PT-17.5* PTT-28.9 INR(PT)-1.6* . [**2174-8-1**] 02:47PM BLOOD UreaN-14 Creat-1.1 Na-139 K-3.3 Cl-100 HCO3-30 AnGap-12 [**2174-8-1**] 08:45PM BLOOD Glucose-156* UreaN-14 Creat-1.1 Na-140 K-3.3 Cl-102 HCO3-27 AnGap-14 [**2174-8-2**] 06:00AM BLOOD Glucose-136* UreaN-16 Creat-1.1 Na-140 K-3.2* Cl-102 HCO3-30 AnGap-11 [**2174-8-3**] 06:10AM BLOOD Glucose-154* UreaN-14 Creat-1.1 Na-140 K-3.1* Cl-102 HCO3-30 AnGap-11 [**2174-8-4**] 08:20AM BLOOD Glucose-170* UreaN-13 Creat-1.0 Na-142 K-3.3 Cl-104 HCO3-29 AnGap-12 [**2174-8-5**] 07:40AM BLOOD Glucose-164* UreaN-13 Creat-1.1 Na-140 K-3.6 Cl-101 HCO3-28 AnGap-15 [**2174-8-5**] 05:07PM BLOOD Glucose-130* UreaN-14 Creat-1.1 Na-139 K-3.9 Cl-104 HCO3-24 AnGap-15 [**2174-8-6**] 06:10AM BLOOD Glucose-137* UreaN-18 Creat-1.3* Na-140 K-4.5 Cl-104 HCO3-27 AnGap-14 . [**2174-8-1**] 02:47PM BLOOD ALT-18 AST-23 LD(LDH)-321* CK(CPK)-118 AlkPhos-86 TotBili-0.9 DirBili-0.3 IndBili-0.6 [**2174-8-2**] 06:00AM BLOOD ALT-16 AST-23 LD(LDH)-269* CK(CPK)-79 AlkPhos-79 TotBili-0.7 . [**2174-8-2**] 02:20PM BLOOD CK(CPK)-87 [**2174-8-3**] 04:07PM BLOOD CK(CPK)-141 [**2174-8-4**] 12:02AM BLOOD CK(CPK)-158 [**2174-8-4**] 08:20AM BLOOD CK(CPK)-247 [**2174-8-4**] 12:50PM BLOOD CK(CPK)-259 [**2174-8-4**] 08:40PM BLOOD CK(CPK)-232 [**2174-8-5**] 07:40AM BLOOD CK(CPK)-168 [**2174-8-6**] 06:10AM BLOOD CK(CPK)-125 . [**2174-8-1**] 02:47PM BLOOD Lipase-31 GGT-42 [**2174-8-2**] 06:00AM BLOOD CK-MB-3 cTropnT-0.04* [**2174-8-2**] 02:20PM BLOOD CK-MB-4 cTropnT-0.05* [**2174-8-3**] 06:10AM BLOOD cTropnT-0.06* [**2174-8-3**] 04:07PM BLOOD CK-MB-8 cTropnT-0.07* [**2174-8-4**] 12:02AM BLOOD CK-MB-10 MB Indx-6.3* cTropnT-0.11* [**2174-8-4**] 08:20AM BLOOD CK-MB-23* MB Indx-9.3* cTropnT-0.20* [**2174-8-4**] 12:50PM BLOOD CK-MB-23* MB Indx-8.9* cTropnT-0.25* [**2174-8-4**] 08:40PM BLOOD CK-MB-17* MB Indx-7.3* cTropnT-0.35* [**2174-8-5**] 07:40AM BLOOD CK-MB-10 MB Indx-6.0 cTropnT-0.30* [**2174-8-6**] 06:10AM BLOOD CK-MB-9 cTropnT-0.74* . [**2174-8-1**] 02:47PM BLOOD TotProt-5.9* Albumin-3.1* Globuln-2.8 Calcium-8.6 Phos-2.4* Mg-1.9 UricAcd-4.5 Cholest-129 [**2174-8-1**] 08:45PM BLOOD Calcium-8.6 Phos-2.4* Mg-2.0 [**2174-8-2**] 06:00AM BLOOD Albumin-3.0* Calcium-8.4 Phos-2.7 Mg-2.0 [**2174-8-3**] 06:10AM BLOOD Calcium-8.8 Phos-2.5* [**2174-8-5**] 07:40AM BLOOD Calcium-9.0 Mg-2.0 [**2174-8-5**] 05:07PM BLOOD Calcium-9.0 Phos-3.9 Mg-2.0 [**2174-8-6**] 06:10AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.0 . [**2174-8-1**] 02:47PM BLOOD TSH-0.32 [**2174-8-1**] 02:47PM BLOOD T4-19.3* Free T4-3.8* . [**2174-8-5**] 02:11PM BLOOD Type-ART pO2-68* pCO2-32* pH-7.46* calTCO2-23 Base XS-0 Intubat-NOT INTUBA [**2174-8-5**] 05:14PM BLOOD Type-ART pO2-63* pCO2-34* pH-7.50* calTCO2-27 Base XS-3 . MICROBIOLOGY [**2174-8-3**] 1:39 pm STOOL CONSISTENCY: LOOSE Source: Stool. **FINAL REPORT [**2174-8-5**]** FECAL CULTURE (Final [**2174-8-5**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2174-8-5**]): NO CAMPYLOBACTER FOUND. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2174-8-4**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). . IMAGING CT neck [**8-2**]: 1. No evidence of pathologic lymphadenopathy. 2. The right maxillary sinus mass is stable compared to the [**7-26**] MRI, though smaller compared to earlier studies. 3. Right vallecular soft tissue density. Please correlate with direct visualization to exclude malignancy. 4. Right periorbital subcutaneous soft tissue density, enlarged in the short interim since the [**7-26**] MRI. Please correlate with any trauma history and physical exam. The rapid enlargement is unusual for malignancy. 5. Increased size and density of a nodular opacity in the apical left lung. Tumor progression cannot be excluded. . TTE [**8-5**]: LV systolic function appears depressed. Right ventricular chamber size and free wall motion are normal. There is a trivial/physiologic pericardial effusion. . PROCEDURES Cardiac Cath [**2174-8-5**]: 1. Three vessel coronary artery disease. 2. Successful bare metal stenting of OM/LCX coronary artery. 3. Successful bare metal stenting of LMCA for guide induced dissection. 4. Plavix (clopidogrel)75 mg daily for 1 month uninterrupted, preferably for 12 months. 5. Secondary prevention of CAD 6. Intergrillin for 18 hours. Brief Hospital Course: Mr. [**Known lastname 2379**] was admitted with complains of nausea, dysphagia/odynophagia to both solids and liquids. This issue has been slowly resolving. He was also febrile on admission, but this resolved immediately post admission. CT scan of the neck was performed to look for underlying pathology showed no evidence of pathologic lymphadenopathy. This issue was slowly resolving. His hospitalization was complicated by an episode of significant chest pain, NTEMI was confirmed on EKG, pos CEs, and on cardiac cath. # Chest Pain - Pt developed chest pain during his hospitalization described as [**8-9**] substernal, nonradiating, reproducible with pressure applied to sternum. EKG showed ST-T depressions in leads V3-V6. Cardiac enzymes were mildly elevated and notable for upward trend [**Date range (1) 20341**]. He was started on imdur and HCTZ. Pt was transferred to [**Hospital Ward Name 517**] for cardiac cath, during which he was found to have diffuse disease, particularly in the mid circumflex and OM1. Bare metal stents were placed in both. Guide wire dissection of the LMCA occured, with stent placement of LCA into LMCA. When the dissection occurred, patient became hypotensive, hypoxic, and complained of chest pain. Patient was admitted to CCU [**8-5**] for monitoring. He cont'd to be hypoxic in the CCU, initially requiring 6 liters O2 NC, with occasional desats to the high 80s. Overnight pt's O2 sat improved and was comfortable on RA at time of discharge. PE unlikely given intermittent nature and resolution of hypoxia. Pulmo edema unlikely given lack of physical findings and normal chest xray. PNA unlikely given lack of leukocytosis, fever or clinical presentation. Patient's vitals otherwise stable and patient had no episodes of chest pain or shortness of breath. Patient is to follow up with Dr. [**Last Name (STitle) 171**] as outpt and will cont metoprolol, plavix and asa therapy. . #Hypertension: Patient had one episode of hypotension during his catheterization, but stabilized throughout his stay in the CCU. Hypotensive episode likely [**2-1**] to dissection in cardiac cath. Resolved after reaching floor. Patient was continued on all of his antihypertensives, and his atenolol was replaced with metoprolol given his s/p NSTEMI. . # Hypothyroidism: On last admission diagnosed w hypothyroidism: elevated TSH and markedly suppressed free T4 was noted. Patient with normal TFTs in the past. Patient with multiple symptoms including peri-orbital swelling, cold intolerance, and possible dysphagia. Patient without evidence of myxedema coma clinically on admission(no hypotension or altered mental status). Hypothyroidism may also explain hallucinations as is a reversible cause of altered mental status in the past. Etiology of hypothyroidism is unclear, as patient has not had any URI symptoms recently. He was continued with levothyroxine 125mcg daily. He will need to follow up on thyroid function to make sure that dosage of levothyroxine is adequate to treat his hypothyroidism. . # Renal cell carcinoma: s/p Left nephrectomy in [**2163**]. Metastases to lung and maxillary sinus, last dose of Sunitinib and AMG 386 stopped at end of [**Month (only) 205**] secondary to nausea and vomiting. Plan is to restart treatment with resolution of current episode. Follow with onc as outpatient. . #Gout - continue allopurinol. . # Depression/Anxiety - cont paroxetine, lorazepam prn Medications on Admission: 1. Allopurinol 300 mg Tablet PO once a day. 2. Amlodipine 10 mg Tablet PO once a day. 3. Advair Diskus 100-50 mcg twice a day. 4. Atenolol 50 mg Tablet Sig: PO DAILY (Daily): AM. 5. Atenolol 25 mg Tablet Sig: QHS PM. 6. Vytorin 10-40 10-40 mg Tablet .5 Tablet Mon, Wed, Fri, Sat. 7. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO four times a day. 8. Vicodin 5-500 mg Tablet PO four times a day as needed for pain. 9. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 10. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q8H 11. Paroxetine HCl 20 mg Tablet 12. Tylenol Extra Strength 500 mg PRN for pain 13. Aspirin 81 mg PO once a day. 14. Vitamin D 400 unit Capsule PO once a day. 15. Folic Acid 400 mcg PO once a day. 16. Imodium A-D 2 mg PO prn as needed for diarrhea. 17. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Medications: 1. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 10. Vytorin 10-40 10-40 mg Tablet Sig: 0.5 Tablet PO Mon, Wed, Fri, Sat. 11. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO four times a day as needed for pain. Tablet(s) 12. Imodium A-D 2 mg Tablet Sig: One (1) Tablet PO twice a day as needed for diarrhea. 13. Outpatient Lab Work Chem 7 Please fax to Dr. [**Last Name (STitle) 171**] at [**Telephone/Fax (1) 19842**] 14. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 15. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 16. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 17. Folic Acid 400 mcg Tablet Sig: One (1) Tablet PO once a day. 18. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: NSTEMI Dysphagia Coronary Artery Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 2379**], You have been admitted to our hospital for the treatment of your inability to drink and swallow. We have done a CT scan that did not reveal any new pathology and your trouble swallowing has improved. You were complaining of chest pain and you were taken to the [**Hospital Ward Name **] to evaluate the blood vessels of your heart. You continued to have chest pain and the blood tests that show your heart is damaged, continued to increase and you were taken for cardiac catheterization procedure. Stents were placed in your heart vessels. After the procedure, you were taken to the Cardiac Care Unit to be monitored. While there, you did not have any chest pain or shortness of breath. You were then moved to the cardiology floor for further monitoring before being discharged home. . The following changes were made to your medications: STARTED Metoprolol XL 100 every day STARTED Ranitidine 150 mg two times a day STARTED Clopidogrel 75 mg once a day STARTED Hydrocholorothiazide 25 mg once a day INCREASED Aspirin to 325 mg once a day STOPPED Atenolol . Please follow up with your doctors at the [**Name5 (PTitle) 32723**] specified below. Followup Instructions: Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office (cardiologist) at [**Telephone/Fax (1) 1989**] on Monday for an appointment within 1 week. . Provider: [**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2174-8-8**] 1:00 . Provider: [**Name10 (NameIs) 17246**] [**Name11 (NameIs) **], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2174-8-8**] 2:00 . Provider: [**Name10 (NameIs) 17246**] [**Name11 (NameIs) **], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2174-8-8**] 2:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

[ "300.4", "787.20", "E879.0", "458.29", "V10.52", "274.9", "414.12", "799.02", "414.01", "998.2", "197.3", "276.51", "780.60", "401.9", "197.0", "410.71", "244.3" ]

icd9cm

[ [ [] ] ]

[ "88.56", "00.42", "00.66", "99.20", "36.06", "37.23", "00.47" ]

icd9pcs

[ [ [] ] ]

16090, 16096

10046, 13473

386, 411

16181, 16181

4523, 10023

17536, 18257

3766, 3794

14412, 16067

16117, 16160

13499, 14389

16332, 17513

3809, 4465

4479, 4504

274, 348

439, 1956

16196, 16308

1978, 3546

3562, 3750

29,371

138,717

50859+59294

Discharge summary

report+addendum

Admission Date: [**2141-5-30**] Discharge Date: [**2141-6-4**] Date of Birth: [**2065-3-25**] Sex: M Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 3223**] Chief Complaint: Abdominal pain from perforated diverticulitis Major Surgical or Invasive Procedure: Low anterior resection for perforated sigmoid diverticulitis with drainage of pelvic/pericolonic abscess and takedown of splenic flexure Echocardiogram History of Present Illness: This was a 76-year-old man who had initially entered the hospital on [**4-29**] with severe sigmoid diverticulitis. On his initial CT scan he appeared to have a small amounts of free air within the peritoneal cavity suggesting a transient free perforation. However, after a somewhat delay, he did eventually respond to intravenous antibiotics and was able to be discharged 5 days later on oral antibiotics with resolved abdominal tenderness and a normalized white blood cell count. Unfortunately, 3 days after his discharge from the hospital, his left-sided abdominal pain returned requiring readmission on [**5-6**]. He now on CT scanning had a contained pericolonic abscess, which was treated with a percutaneous CT-guided drain. Apparently after an initial amount of purulent material, the drain became nonfunctional. On [**5-15**] the patient had returned for his outpatient follow up appointment, at which time his catheter was removed. A CT scan now demonstrated an even larger pericolonic collection with an air-fluid level. However, the patient was asymptomatic and it was elected to observe him. 1 week later on [**5-22**], the patient was finishing his second course of outpatient antibiotics. At that time he had no complaint of pain and no focal tenderness. Definitive resection was deemed to be the best course of action for his complicated diverticulitis, which had required multiple hospital admissions and had failed to resolve on antibiotics. Past Medical History: PMH: chronic back pain, diverticulitits PSH: appendectomy, cholecytectomy, R TKA Social History: Married, supportive wife. Denies use of ETOH, illicit drugs, and tobacco products. Family History: noncontributory Physical Exam: Tmax 98.7, Tcurrent 96.9, HR 89 atrial fibrillation (range 74-111), BP 116/70, RR 18, O2 sat 96% room air, finger stick 119-146. 24 I/O: 1240 PO in, 500 IVF in, 8250 UOP, BM x1 General: No apparent distress, Alert and oriented x 3 CV: Irregularly irregular Resp: Clear to auscultation bilaterally Abd: Soft, non-distended, appropriate incisional tenderness. Wound with staples, no erythema or induration Extremities: Warm and well-perfused. No cyanosis, clubbing, or edema Pertinent Results: [**2141-5-30**] 04:00PM GLUCOSE-218* UREA N-22* CREAT-1.5* SODIUM-136 POTASSIUM-5.1 CHLORIDE-103 TOTAL CO2-23 ANION GAP-15 [**2141-5-30**] 04:00PM CALCIUM-8.2* PHOSPHATE-5.8*# MAGNESIUM-1.7 [**2141-5-30**] 04:00PM WBC-14.9* RBC-3.79* HGB-11.6* HCT-34.7* MCV-91 MCH-30.7 MCHC-33.6 RDW-12.9 [**2141-5-30**] 04:00PM WBC-14.9* RBC-3.79* HGB-11.6* HCT-34.7* MCV-91 MCH-30.7 MCHC-33.6 RDW-12.9 [**2141-5-30**] 04:00PM PLT COUNT-345 [**2141-5-30**] 11:19AM TYPE-[**Last Name (un) **] TEMP-36 RATES-7/ TIDAL VOL-1000 O2 FLOW-2 INTUBATED-INTUBATED VENT-CONTROLLED [**2141-5-30**] 11:19AM HGB-13.8* calcHCT-41 Brief Hospital Course: [**5-30**]: Patient underwent low anterior resection for perforated sigmoid diverticulitis, splenic flexure takedown, and drainage of pelvic/pericolonic abscesses. He was admitted to the surgical floor from the PACU in stable condition. His creatinine had bumped postoperatively to 1.5, so his urine output was closely followed overnight. He was started on a course of ciprofloxacin and metronidazole for a planned 3 day course. An EKG obtained preoperatively showed him to be in normal sinus rhythm. [**5-31**]: POD 1: Antibiotics were continued. Urine output increased to 40-60cc/hour. PCA was used for pain control. At patient's request, PCA was discontinued in favor of IV Dilaudid. Foley was kept in. [**6-1**]: POD 2: The antibiotics were continued and the Foley was kept in. Pt requested to go back on PCA instead of IV Dilaudid. Ongoing telemetric monitoring showed him to continue to be in normal sinus rhythm until noon, at which time he was first noted to have converted to atrial fibrillation. Pt denies any past diltiazem IV for rate control in an effort to promote spontaneous conversion back to normal sinus rhythm. Pt also received Lasix IV for diuresis and IV Lopressor for rate control. Cardiology was consulted and recommended a rate control strategy. After receiving a total of 30 mg of IV diltiazem on the floor with transient response and heart rates quickly rebounding back to the 150's, pt continued to trigger and the decision was made to transfer him to the [**Hospital Ward Name 332**] ICU for a diltiazem drip. [**6-2**]: Pt continued to be in atrial fibrillation but was transferred back to the floor with a heart rate in the 90's, rate controlled on diltiazem. He complained of dysuria overnight while still having the Foley in place; a urinalysis was sent and was negative. He still had not passed flatus. [**6-3**]: Diet was advanced to regular. Foley was discontinued and pt was able to void on own. Propranolol was increased to 100 mg TID at the recommendation of cardiology. Pt remained in atrial fibrillation. Aspirin 325 mg was also started per cardiology, who recommended discharging pt home on this regimen and outpatient follow up with them in 3 weeks. [**6-4**]: Pt was discharged home on home medications with changes as noted above and PO Dilaudid for pain control. His atrial fibrillation had not yet converted back to normal sinus rhythm. Medications on Admission: Folate 1'', inderal 80'', celebrex 200', hytrin 5', celexa 40', Lotrel5 10' Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 3. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*30 Capsule(s)* Refills:*2* 5. Propranolol 40 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day). Disp:*200 Tablet(s)* Refills:*2* 6. Lotrel 5-10 mg Capsule Sig: [**11-16**] Capsules PO daily (). 7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*45 Tablet(s)* Refills:*0* 8. Senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day as needed for constipation. Disp:*30 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Perforated diverticulitis status post low anterior resection Atrial fibrillation Discharge Condition: Stable, afebrile with current temp of 97.8, HR 109, still in atrial fibrillation but rate controlled on medications, BP 122/73, RR 18, O2 sat 100% on room air Tolerating a regular Adequate pain control with oral medication Discharge Instructions: General d/c instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * 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 becoming progressively worse, or inadequately controlled with the prescribed pain medication. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. Incision Care: *You may shower. Pat incision dry. *Avoid swimming and baths until further instruction at your followup appointment. *Leave the staples in. They will be removed when you follow up with your surgeon. *Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: -Call the hospital operator at ([**Telephone/Fax (1) 2529**] tomorrow morning and tell them that Dr. [**Last Name (STitle) 519**] has instructed you to page him to your home phone number to update him on how you are doing. -Call Dr.[**Name (NI) 1745**] office at ([**Telephone/Fax (1) 5323**] to make a follow up appointment in 1 week. -Call Dr.[**Name (NI) 35583**] office (cardiology) at ([**Telephone/Fax (1) 2037**] to schedule a follow up appointment in 3 weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**] Name: [**Known lastname 17222**],[**Known firstname 15856**] E Unit No: [**Numeric Identifier 17223**] Admission Date: [**2141-5-30**] Discharge Date: [**2141-6-4**] Date of Birth: [**2065-3-25**] Sex: M Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 5964**] Addendum: Secondary diagnosis for Mr. [**Known lastname **] During admission, his creatinine had bumped postoperatively to 1.5, so his urine output was closely followed overnight, which was consistent with a diagnosis of acute renal failure. He was treated with IVF for hydration and his urine output was closely monitored. The patient's creatinine trended down to baseline of 1.0 on [**2141-6-1**]. Discharge Disposition: Home [**First Name11 (Name Pattern1) 1080**] [**Last Name (NamePattern4) 3711**] MD, [**MD Number(3) 5966**] Completed by:[**2141-7-18**]

[ "285.1", "997.1", "427.31", "562.11", "569.5", "E878.6", "401.9", "276.50" ]

icd9cm

[ [ [] ] ]

[ "48.63" ]

icd9pcs

[ [ [] ] ]

9542, 9710

3345, 5733

316, 470

6731, 6955

2706, 3322

8182, 9519

2181, 2198

5859, 6577

6627, 6710

5759, 5836

6979, 7835

7850, 8159

2213, 2687

231, 278

498, 1959

1981, 2064

2080, 2165

18,976

178,053

11735+11689+11690+11691+11692+56280

Discharge summary

report+report+report+report+report+addendum

Admission Date: [**2120-11-26**] Discharge Date: Service: ADDENDUM: Since the previous dictation, the patient has had a video swallowing study which showed accumulation of bullous in the vallecula. The study was not continued for fear of further accumulation in the vallecula, which could lead to frank aspiration. It was recommended that the patient be kept on nothing by mouth and continue on tube feeds. Speech and swallow evaluation recommends that the patient have a repeat video swallowing study in approximately one month. The patient also had bilateral lower extremity venous Dopplers. There was concern at [**Hospital1 **] that the patient had persistent hypoxia which may have been thought to persistent pulmonary emboli. There was no evidence of deep vein thrombosis on bilateral lower extremity Doppler studies. The patient had her Foley catheter changed and a repeat urine showed 140 white blood cells and many yeast. The patient was started on Diflucan 200 mg orally/per G-tube times the first day and then 100 mg daily times four days. If there are any other changes to the [**Hospital 228**] hospital course, another addendum will be added. [**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**] Dictated By:[**Last Name (NamePattern1) 218**] MEDQUIST36 D: [**2120-11-29**] 10:19 T: [**2120-11-29**] 10:32 JOB#: [**Job Number 37136**] Admission Date: [**2120-11-26**] Discharge Date: [**2120-11-28**] Service: CHIEF COMPLAINT: Difficulty breathing, tracheal stenosis. HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old female with complicated medical history within the past year, transferred from [**Hospital3 33538**] to have treatment for tracheal stenosis. The patient has had difficulty breathing since Friday due to increased secretions and weakness. Patient had bronchoscopy on day of admission by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3100**] which showed mild tracheal stenosis. The patient is transferred to [**Hospital1 346**] for bronch, possible stent, possible balloon dilation of the tracheal stenosis. The patient has had a prolonged hospital course since [**2120-7-17**] when she was admitted to [**Hospital1 3487**] Hospital for a 9 cm thoracic aneurysm repair and coronary artery bypass graft of left anterior descending artery (50% lesion), complicated by bleeding requiring reop. Postop course complicated by afib managed with Lopressor and amio. The patient was slow to wean off vent and on [**2120-8-8**] had a trache and PEG placed. Hospital course was also complicated by congestive heart failure and a cerebrovascular accident which presented with right sided weakness with negative CT scan. Tracheostomy complicated by necrosis at site with positive Methicillin-resistant Staphylococcus aureus swab culture. Sputum and Gram stain at [**Hospital1 3487**] Hospital was positive for Gram-negative rods and Gram-positive cocci. The patient was transferred to [**Hospital1 **] for slow vent wean. No DC sent from [**Hospital1 **] was available, however, patient's family states that she was taken off the vent around [**Holiday 1451**] time. Her hospital course was complicated by multiple pneumonias and increased secretions. The patient complained of difficulty breathing in [**Hospital1 **] and had a bronch on the morning of admission which showed mild tracheal stenosis. The patient states the breathing has improved since Friday before admission after aggressive suctioning. PAST MEDICAL HISTORY: 1. Thoracic aneurysm repair in [**2120-7-18**] with coronary artery bypass graft times one to left anterior descending artery complicated by bleeding requiring repeat surgery. 2. Cerebrovascular accident. 3. Atrial fibrillation with RVR treated with amiodarone. The patient is currently in sinus. 4. Methicillin-resistant Staphylococcus aureus positive. 5. Status post trach. 6. Status post PEG. 7. Status post left fem endarterectomy with patch graft and left posterolateral thoracoplasty with Hemashield graft. 8. Echocardiogram shows ejection fraction of greater than 55%, mild-to-moderate mitral regurgitation, mild tricuspid regurgitation with left ventricular hypertrophy at [**Hospital1 37009**] Hospital at 08/01. 9. Hypertension. 10. Arthritis. 11. Hyperthyroidism treated with PTU. 12. Claustrophobia. ALLERGIES: Penicillin. MEDICATIONS ON TRANSFER FROM [**Hospital1 **]: Captopril 87.5 mg q eight hours, Atrovent q four hours prn, enoxaparin 60 mg subQ q 12 hours, Coumadin 2 mg q hs, free water boluses via G-tube 250 cc q six hours, Glyburide 2.5 mg q day, bacitracin ointment topical q 12 hours, Vancomycin 1 gram IV q 12 hours, Bactrim 20 ml q shift, propanolol 40 mg q 12 hours, venlafaxine 50 mg [**Hospital1 **], amiodarone 200 mg q day, bisacodyl 10 mg pr, lactulose 30 mg q day prn, multivitamins, lactobacillus two tablets q eight hours, Flagyl 500 mg q eight hours, levofloxacin 500 mg q day, digoxin 0.125 mg qod, droperidol 0.6 q 5 mg q eight hours prn, Peratize 60 ml an hour, PTU 50 mg q eight hours, oxymetazoline two sprays q day prn, docusate sodium 100 mg q eight hours, aspirin 81 mg q day, Atrovent/Albuterol inhalers four puffs q eight hours prn, Motrin 400 mg q four hours prn, Tylenol 650 mg q four hours prn. SOCIAL HISTORY: The patient is transferred from [**Hospital3 105**]. Has eight children and has a living will. No history of tobacco use. PHYSICAL EXAMINATION: On physical exam, vital signs: Temperature 96.0, blood pressure 110/80, heart rate 60, respiratory rate 20, O2 saturation is 96% on 5 liters nasal cannula. In general, the patient is an elderly woman, weak appearing in no apparent distress. HEENT: Extraocular movements are intact. Neck is supple. No jugular venous distention. Heart: Systolic murmur 2-3/6 at left sternal border, hyperdynamic heart, PMI shifted 1 cm to the left. Lungs: Poor air movement, positive rhonchi bilaterally. Abdomen is soft, nontender, positive bowel sounds. G tube still slightly erythematous, no induration, no discharge. End site is nontender. Extremities: Hyperpigmentation to mid shin bilaterally. No edema noted. Neurologic: Right sided upper and lower extremity 3-4/5 strength, left upper and lower extremity 4/5 strength. Right nasolabial fold decreased excursion with smile, tongue midline. 2+ patellar reflexes. Babinski right upgoing and left downgoing. LABORATORY DATA ON ADMISSION: White blood cell count 8.9, hematocrit 28.9, platelets 219,000. PT 14.4, PTT 29.7, INR 1.5. Urinalysis: Specific gravity 1.015, red blood cells 38, white blood cells [**Pager number **], occasional bacteria, many yeast, no epithelial cells. Sodium 146, potassium 4.4, chloride 112, bicarb 27, BUN 54, creatinine 0.7, glucose 55. Calcium 8.2, magnesium 2.4, phosphorus 4.6, albumin 2.6. TSH 6.7. Free T4 0.8. Urine culture currently pending. HOSPITAL COURSE: In sum this is an 81-year-old female with complicated medical history admitted for treatment of tracheal stenosis. 1. Pulmonary: Tracheal stenosis, PNA diagnosed at outside hospital, increased secretions. Anticoagulation was held in anticipation of surgery. The patient was taken to the operating room on [**2120-11-27**]. Patient had general anesthesia. Patient had rigid/flexible bronchoscopy rigid dilation and balloon dilation of the tracheal stenosis found at the level of passed trach. The mild tracheal stenosis was dilated. Patient did not have any complications and returned to the floor afterwards. The patient was also continued on her albuterol/Atrovent prn metered-dose inhalers and nebulizers which she did not require during this admission. 2. Cardiac: History of afib, congestive heart failure secondary to diastolic dysfunction. Anticoagulation was started after the surgery with Lovenox 60 mg subQ [**Hospital1 **] and Coumadin 2 mg po q hs which she had started at the outside hospital. The patient is currently in sinus rhythm. Will continue amiodarone 200 mg po bid and propanolol 40 mg po bid. Patient was also continued on captopril 87.5 mg per G tube q eight hours and digoxin 0.125 mg per G tube qod. 3. ID: Pneumonia diagnosed at outside hospital and methicillin-resistant Staphylococcus aureus positive. A chest x-ray was done during this admission which showed a probable right upper lobe pneumonia and left apical pleural thickening versus loculated pleural effusion. [**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4518**] Dictated By:[**Last Name (NamePattern1) 218**] MEDQUIST36 D: [**2120-11-28**] 07:53 T: [**2120-11-28**] 08:26 JOB#: [**Job Number 37010**] Admission Date: [**2120-11-26**] Discharge Date: [**2120-11-28**] Service: Pneumonia diagnosed at outside hospital. During this hospitalization we did a chest x-ray which showed probable right upper lobe pneumonia, apical pleural thickening versus loculated pleural effusion. Patient was continued on Levaquin 500 mg via G tube q day and Flagyl 500 mg q eight hours and Vancomycin 1 gram IV q day. We did not continue the Bactrim during this hospitalization. It is unclear whether the patient is colonized with methicillin-resistant Staphylococcus aureus or whether she has sputum positive for methicillin-resistant Staphylococcus aureus causing a pneumonia. Sputum cultures were ordered, but were not able to be sent because the patient was in the operating room all day. 4. GI: G tube, possible aspiration pneumonia. We continued the tube feeds and lactobacillus, Colace, and Protonix during this hospitalization. The patient will also have a video swallowing study to be done this am to rule out aspiration pneumonia. An addendum will be added to this dictation with the results of the video swallowing test. 5. Genitourinary: The patient had an indwelling Foley catheter. A urinalysis was positive for 288 white blood cells and many yeasts. The Foley was changed during this admission and we will recheck a repeat urinalysis. Patient has not been started on treatment for yeast cystitis as of yet. 6. Endocrine: The patient has a history of hyperthyroidism and was on PTU which was continued during this admission. A TSH was checked which was 6.7 and T4 was checked which was 0.8. It is unclear to us at this time whether the patient needs to be continued on PTU. 7. Neurologic: The patient is status post cerebrovascular accident and had remained stable neurologically during this admission. The patient had a left PICC line placed at outside hospital which is maintained during this admission. In terms of nutrition, the patient was continued on her tube feeds and required more free water boluses at 500 cc q eight hours. It appears that her sodium is 146, which most likely indicates free water losses. The patient's electrolytes were repleted. We will continue to observe. DISCHARGE DIAGNOSIS: Mild tracheal stenosis. CONDITION ON DISCHARGE: Stable. DISCHARGE INSTRUCTIONS: The patient will return to [**Hospital3 105**] today. DISCHARGE MEDICATIONS: Captopril 87.5 mg via G tube q eight hours, Atrovent metered-dose inhaler, albuterol metered-dose inhaler, free water boluses, 250 cc per G tube q six hours, Vancomycin 1 gram IV q day, Tylenol 650 mg po q 4-6 hours prn, albuterol/Atrovent nebulizers q four hours prn, Protonix 40 mg via G tube q day, amiodarone 200 mg per G tube q day, Dulcolax 10 mg per G tube q day, multivitamin per G tube q day, Levaquin 500 mg via G tube q day, digoxin 0.125 mg via G tube qod, droperidol 0.625 mg q eight hours IV prn. PTU 50 mg/G tube q eight hours, Colace 100 mg per G tube [**Hospital1 **]. Bacitracin ointment applied to infected area prn. Propanolol 40 mg/G tube [**Hospital1 **], Flagyl 500 mg per G tube q eight hours, Lovenox 60 mg subQ [**Hospital1 **], venlafaxine 50 mg/G tube [**Hospital1 **], lactobacillus two tablets/G tube q eight hours, Coumadin 2 mg po q hs, aspirin 81 mg/G tube q day. Of note, the patient was not continued on her Glyburide as she has no history of diabetes and her blood sugars during this admission have been low. [**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4518**] Dictated By:[**Last Name (NamePattern1) 218**] MEDQUIST36 D: [**2120-11-28**] 07:59 T: [**2120-11-29**] 10:21 JOB#: [**Job Number 37011**] Admission Date: [**2120-11-26**] Discharge Date: [**2120-12-16**] Service: MICU-[**Location (un) **] This note picks up with her transfer from the [**Hospital1 **] Internal Medicine Service to the Medical Intensive Care Unit [**Location (un) **] Service following her asystolic cardiac arrest. The following note will summarize her hospital course until that point. A subsequent summary will describe the rest of her hospital course. HISTORY OF PRESENT ILLNESS: The patient was transferred to the Medical Intensive Care Unit following asystolic cardiac arrest. Mrs. [**Known lastname 1356**] is an 81-year-old woman with a complicated medical history including thoracic aortic aneurysm repair with a coronary artery bypass graft times one in [**2120-7-17**]. She also has had CVAs, history of tracheostomy complicated by tracheal stenosis, and she was transferred from [**Hospital3 105**] on [**11-26**] for treatment of tracheal stenosis at [**Hospital6 649**]. The patient has a complicated recent medical course dating back to [**2120-7-17**] when she was admitted to the [**Hospital6 4193**] for repair of a 9 cm thoracic aneurysm and coronary artery bypass graft times one of the left anterior descending. Postoperative course was complicated by bleeding requiring reoperation, atrial fibrillation, started on Lopressor and amiodarone. Congestive heart failure felt secondary to diastolic dysfunction. CVA with residual right-sided weakness. She was slow to wean from the ventilator and on [**2120-8-8**], had a tracheostomy placed and percutaneous endoscopic gastrostomy placed. Tracheostomy was further complicated by necrosis at the placement site, question of timing, and nosocomial pneumonia. She was transferred to [**Hospital1 **] in [**2120-7-17**] for a slow wean. According to the family, she was on the ventilator for 12 weeks and was taken off around [**Holiday 1451**] time. Her hospital course was complicated by recurrent episodes of pneumonia with copious secretions and intermittent atrial fibrillation. Bronchoscopy was done on [**11-26**], when she was noted to have mild tracheal stenosis and she was transferred to [**Hospital6 256**]. She was placed on vancomycin, Levaquin and Flagyl for a presumed nosocomial aspiration pneumonia. Bactrim was discontinued. Initially saturating at 96% on five liters. She had no evidence of cardiac ischemia and was in sinus rhythm on admission. SUMMARY OF HER HOSPITAL EVENTS: On [**11-27**], the patient was hypotensive to 80/palp after receiving captopril, responded to fluid bolus, underwent rigid flexible bronchoscopy with mild tracheal stenosis and dilation up to 18 mm. Aspiration by swallow study was on the 13th. Started on fluconazole for oral candidiasis, fungal urinary tract infection. From [**11-29**] through the 16th, she had mild shortness of breath, afebrile, good oxygen saturation in the high 90s on one to three liters of oxygen, systolic blood pressure 90-100 with scant sputum. On [**12-2**] she had right upper extremity swelling ultrasound showed right IJ and subclavian vein thrombosis. She had a right PICC. Vancomycin, Levaquin and Flagyl were discontinued following completion of a 14 day course on [**12-2**]. She had a right upper lobe consolidation improving, new bibasilar opacities, left greater than right. On the 19th, acute shortness of breath and had been suctioned for a large amount of secretion, desaturated to 91% on room air. Electrocardiogram showed worsening T wave inversions in the anterior leads, in I, aVL and V4 through V6. Chest x-ray showed increased perihilar haziness consistent with congestive heart failure and small bilateral effusions. She received Lasix again. On [**12-5**], she was noted to have acute hypoxia, question of mucus plug, suctioned with improvement. She had MRV to evaluate the extent of her right upper extremity deep vein thrombosis whether or not it was originating from the PICC. At MRV, following the examination, the patient was noted to be diaphoretic, clammy, initially breathing and arousable. Once on the floor, breathing became agonal and she became pulseless and asystolic. Question patient pulseless for 15-30 minutes. Code was called. CPR was initiated and the patient was intubated. There was some difficulty secondary to stenosis. Initially thought to be in ventricular fibrillation. She was shocked with 200 joules and then assessed systolic point. She was given epinephrine and atropine, paced, and converted to narrow complex rhythm, initially at 80-90. Systolic blood pressure 190 and then increased to rapid atrial fibrillation supraventricular tachycardia with systolic blood pressure of 90 and dropped to 60. She was then cardioverted. She was treated with intravenous insulin, glucose, calcium gluconate and bicarbonate for a potassium of 7.5 on ABG. A left subclavian line was placed. Pressors were started on arrival to the Coronary Care Unit. Although she was on the Medical Intensive Care Unit Service she was actually boarding in the Coronary Care Unit. PAST MEDICAL HISTORY: Significant for thoracic aortic aneurysm, coronary artery bypass graft times one, left CVA with residual right-sided weakness, atrial fibrillation with history of RVR and rate control with propranolol. She was in sinus at the beginning of the admission. She also has a history of Methicillin resistant Staphylococcus aureus pneumonia, tracheal stenosis, tracheostomy as above, status post percutaneous endoscopic gastrostomy, status post left femoral endarterectomy with patch graft and left posterolateral thoracoplasty with Hemashield graft. She has history of congestive heart failure with mild diastolic dysfunction. Last CVA was [**2120-7-17**] at [**Hospital6 8866**]. Ejection fraction of 55%, mild to moderate mitral regurgitation, mild tricuspid regurgitation, left ventricular hypertrophy, hypertension and hypothyroidism. She was made NPO. Treated with PTU. MEDICATIONS ON TRANSFER TO THE MEDICAL INTENSIVE CARE UNIT: Atrovent MDI 2-3 puffs q.i.d., Lactobacillus 2 tablets per percutaneous endoscopic gastrostomy q. 8, PTU 50 mg per percutaneous endoscopic gastrostomy q. 8, Colace 100 mg per percutaneous endoscopic gastrostomy b.i.d., digoxin 0.125 mg per percutaneous endoscopic gastrostomy q.o.d., venlafaxine 50 mg po b.i.d., ............ 300 mg po q.d., Dulcolax 10 mg po q.d., multivitamin 1 tablet po q.d., ........... propranolol 40 mg po b.i.d., Prevacid solution 30 mg po q.d., Lovenox 50 mg subcutaneous b.i.d., Captopril 75 mg po t.i.d., Coumadin 5 mg po q.h.s. and water boluses to add to the percutaneous endoscopic gastrostomy at 500 cc and tube feed for fiber. ALLERGIES: Possibly to penicillin, but not well documented as to responses. PHYSICAL EXAMINATION: She was intubated and responsive to voice or painful stimuli. Her temperature is 98.5. Heart rate 88. Blood pressure 108/46. Respiratory 22. Oxygen saturation 95%, .......... of 10. Her vent was assist controlled, 550 times, 100% FIO2, and a PEEP of 5. Arterial blood gases was 745,54 and 256. Pupils were 3-4 mm and minimally reactive to light with an endotracheal tube in the throat. Neck was supple, no jugular venous distention or scar at the tracheostomy site. She has occasional coarse rhonchi bilateral, no wheezing, decreased breath sounds at bases. Heart: Regular rate and rhythm S1, S2, 2/6 systolic ejection murmur heard at the left sternal border, nonradiating. Abdomen soft, mildly distended, nontender, no bowel sounds. Extremities: Left upper extremity edema, greater than right upper extremity, 1+ pitting edema at the ankles, warm, non-clammy extremities. Left femoral pulses. Neurological: Unresponsive to voice or pain. Pupils are minimally reactive, bilateral extensor plantar reflex. LABORATORY VALUES: White blood cell count 9.0, hematocrit 27.1, platelets 175,000. Coags 21.9, 44.7, INR 3.3. SMA-7: 142, 4.5, 102, 131, 24, 0.9, 346. CK number one 19. CK number two 23. Troponin 0.5. Calcium 8.6, magnesium 2.2, albumin 2.6, iron 42, total iron binding capacity 288 which is above normal. Ferritin 92. TSH 6.7, 54, 8.8%. Digoxin 1.2. [**Hospital6 256**] urine culture was negative. Urine yeast showed yeast. Blood cultures times two were no growth to date. Only sputum showed anything with 25 PMNs and less than 10 epithelial cells, 4+ gram negative rods, found to be Klebsiella pneumonia and beta lactamase resistant constructing which was treated with imipenem ultimately. HOSPITAL COURSE IN THE MEDICAL INTENSIVE CARE UNIT: From a systems approach. From a neurological prospective, the patient's exam was consulted by the Neurological Team. We also found as did they that the patient had a positive corneal response. She also had a positive pupillary response to light. She on the third day may have opened eyes to verbal command and was calling out her name, but she hasn't repeated that ever since the third day and moreover it is not clear that that was really a result of random activity on the part of the patient. By day seven and eight, she began to develop tremors in her right lower extremity. She was maintained on Ativan prn. Cardiovascularly: She had atrial fibrillation with first low then high blood pressures. Patient was ultimately controlled on captopril 50 t.i.d. and Lopressor 50 t.i.d. and a diltiazem drip which was originally effective was stopped, which will be discussed later. Hypertension was also controlled. Pulmonary: She was maintained on assist control for all the time that she was on the ventilator and kept stable. Infectious Disease: She had imipenem designed for a 14 day course to treat her Klebsiella pneumonia found in her sputum. Endocrine: She was taking propylthiouracil but that was discontinued prior to becoming extubated. Gastrointestinal: To reach .................... checking. Renal: There were no issues. Drains: She had a right A line femoral placed on the 20th. Left subclavian line placed on the 20th. Also left PICC line of an undetermined duration. Patient was made "Do Not Resuscitate," and it was decided with the family that she would be extubated around noon time on Sunday, [**2120-12-15**]. Please see addendum as to her short and/or long course after this particular note. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3851**] Dictated By:[**Last Name (NamePattern1) 3033**] MEDQUIST36 D: [**2120-12-20**] 14:21 T: [**2120-12-20**] 14:21 JOB#: [**Job Number 23612**] Admission Date: [**2120-11-26**] Discharge Date: [**2120-12-16**] Service: MICU-ORANG HISTORY OF PRESENT ILLNESS: Patient is an 81-year-old woman with a complicated medical history including thoracic aneurysm repair and single vessel coronary artery bypass graft in [**2120-7-17**], CVA, history of tracheostomy complicated by tracheal stenosis, who is transferred from [**Hospital3 105**] on [**11-26**] for treatment of tracheal stenosis at [**Hospital6 256**]. The patient has a complicated recent medical course dating back to [**Month (only) 216**] of this year when she was admitted to the [**Hospital6 4193**] for repair of a 9 cm thoracic aneurysm and single vessel coronary artery bypass graft of her left anterior descending. Her postoperative course was complicated by bleeding requiring reoperation, atrial fibrillation for which she was started on Lopressor and amiodarone. Congestive heart failure felt secondary to diastolic dysfunction and CVA with a residual right-sided weakness. She was slow to wean from the ventilator at that time and on [**8-8**] of [**2119**] had a tracheostomy and percutaneous endoscopic gastrostomy placed. Tracheostomy was further complicated by necrosis at the placement site and a nosocomial pneumonia. She was transferred to the [**Hospital3 33538**] in [**Month (only) **] of this year secondary to a slow wean. According to the family, she was on the ventilator for approximately 12 weeks and taken off around [**Holiday 1451**] time. Her hospital course was complicated by recurrent episodes of pneumonia with copious secretions and intermittent atrial fibrillation. Bronchoscopy was performed on [**11-26**] when she was noted to have mild tracheal stenosis and she was transferred to the [**Hospital6 649**]. She was placed on vancomycin, Levaquin and Flagyl for a presumed nosocomial aspiration pneumonia. Initially, her oxygen saturation was 96% on five liters. She had no evidence of cardiac ischemia and was in sinus rhythm on admission. When admitted to [**Hospital6 2018**], she was found on [**11-27**] to be hypertensive to pressure 80/palp after receiving captopril. This responded well to a fluid bolus. She underwent a rigid and flexible bronchoscopy and was found to have mild tracheal stenosis. She was dilated to 18 mm. On the 13th, she was noted to have aspiration by swallow study. She was also started on fluconazole for oral candidiasis and a fungal urinary tract infection. On the 14th to the 16th, she was noted to have mild shortness of breath, was afebrile, and was maintaining oxygen saturations in the high 90s on one to three liters of oxygen with good blood pressure control. Her sputum was scant. On the 17th, she was noted to have right upper extremity swelling. An ultrasound showed a right internal jugular and subclavian vein thrombosis. She had a right-sided PICC line. Her vancomycin, Levaquin and Flagyl were stopped following completion of a 14 day course. Chest x-ray on the 17th showed resolution of her right upper lobe consolidation, but with new bibasilar opacities, more so on the left than on the right. On the 19th, she was noted to have acute shortness of breath and was suctioned for a large amount of secretions. Her oxygen saturation dropped to 91% on room air and an electrocardiogram done at the time showed worsening of T wave inversions in the anterior and lateral leads (I, aVL and V4 through V6). Chest x-ray done at the time also showed increased perihilar haziness consistent with congestive heart failure and small bilateral effusions. Patient was treated with Lasix. On the 20th, she was noted to have acute hypoxia and had a questionable mucus plus that was suctioned with improvement. A magnetic resonance venogram was performed to evaluate the extent of her right upper extremity deep vein thrombosis that was seen by ultrasound earlier. Following the MRV, the patient was noted to be diaphoretic and clammy with depressed mental status. On her way back up to the floor from the MRI scanner, her breathing became more agonal in nature and she was noted to be pulseless/asystolic. It is unclear exactly how long the patient was pulseless, but it seems that she was pulseless for at least ten minutes and perhaps for as long as half an hour. A cardiac arrest code was called. CPR was initiated and the patient was intubated. She was initially thought to be in ventricular fibrillation and shocked with 200 joules, but then was thought to be asystolic. For this, she was given epinephrine, atropine, as well as being paced, which successfully converted her to a narrow complex rhythm, initially, in the 80 to 90 range with a systolic blood pressure of 190. This, then increased to rapid atrial fibrillation or supraventricular tachycardia rhythm with a systolic blood pressure in the range of 90 which subsequently continued to drop to 60. She was cardioverted at this time. She was also treated with intravenous insulin, glucose, calcium gluconate and bicarbonate for a potassium of 7.5. Left subclavian line was placed and pressors were started on arrival to the Intensive Care Unit. PAST MEDICAL HISTORY: 1. Notable for a thoracic aneurysm repair and coronary artery bypass graft times one to the left anterior descending in [**2120-7-17**], which was complicated by re-bleeding requiring repeat surgery. 2. Left CVA with residual right-sided weakness. 3. Atrial fibrillation with a history of rapid ventricular response. This is being treated with amiodarone and Coumadin with her rate well-controlled propranolol. She is noted to be in sinus rhythm at the beginning of this admission. 4. History of Methicillin resistant Staphylococcus aureus pneumonia. 5. Tracheal stenosis following tracheostomy as above. 6. Status post percutaneous endoscopic gastrostomy. 7. Status post left femoral endarterectomy with patch graft and left posterolateral thoracoplasty with Hemashield graft. 8. History of congestive heart failure with diastolic dysfunction. Last transthoracic echocardiogram in [**2120-7-17**] at the [**Hospital6 1708**] showed an ejection fraction of 55% with mild to moderate mitral regurgitation, mild tricuspid regurgitation and left ventricular hypertrophy. 9. Hypertension. 10. Arthritis. 11. Hypothyroidism treated with PTU. MEDICATIONS ON TRANSFER TO THE MEDICAL INTENSIVE CARE UNIT: [**Unit Number **]. Atrovent MDI [**1-20**] three puffs q.i.d. 2. Lactobacillus 2 tablets per percutaneous endoscopic gastrostomy q. 8 hours. 3. PTU 50 mg per percutaneous endoscopic gastrostomy q. 8 hours. 4. Colace 100 per percutaneous endoscopic gastrostomy b.i.d. 5. Digoxin .125 mg per percutaneous endoscopic gastrostomy q.o.d. 6. Venlafaxine 50 mg per percutaneous endoscopic gastrostomy b.i.d. 7. Amiodarone 200 mg per percutaneous endoscopic gastrostomy q.d. 8. Dulcolax 10 mg per percutaneous endoscopic gastrostomy q.d. 9. Multivitamin 1 tablet per percutaneous endoscopic gastrostomy q.d. 10. Bacitracin. 11. Propranolol 40 mg per percutaneous endoscopic gastrostomy b.i.d. 12. Prevacid suspension 30 mg q.d. 13. Lovenox 60 mg subcutaneous b.i.d. 14. Captopril 75 mg per percutaneous endoscopic gastrostomy t.i.d. 15. Coumadin 5 mg per percutaneous endoscopic gastrostomy q.h.s. 16. Free water boluses per percutaneous endoscopic gastrostomy 500 cc q.i.d. 17. Tube feeds or ProMod with fiber. ALLERGIES: She has an allergy to penicillin though the specific nature of the allergy is not known. SOCIAL HISTORY: She lives at the [**Hospital **] Nursing Home. She formerly lived with her son. She has eight children. Health care proxy is her daughter, [**Name (NI) **]. ON PHYSICAL EXAMINATION TO THE MEDICAL INTENSIVE CARE UNIT: In general, she was intubated and unresponsive to voice or painful stimuli. Her vital signs showed a temperature of 98.5. Heart rate of 88. Blood pressure 108/46 with a MAP of 67. Respiratory rate 22. O2 saturation 95%. Her vitals were taken on a dopamine drip of 10. Head, eyes, ears, nose and throat: Her pupils were 3-4 mm and minimally reactive. Her neck was supple without jugular venous distention. Chest showed occasional coarse rhonchi bilaterally, no wheezing and decreased breath sounds at the bases. Heart is regular S1, S2 with a 2/6 systolic ejection murmur at the left sternal border without radiation. Abdomen is soft, mildly distended, nontender with normal bowel sounds. Extremities: Her left upper extremity edema more so than right upper extremity edema, 1+ pitting edema at the ankles. Extremities were warm and nonclammy. Neurologically, she is unresponsive to voice or pain. Pupils are minimally reactive and toes were upgoing bilaterally. LABORATORIES: Significant laboratories showed a white count of 9.0, hematocrit 27.1, platelets of 175,000. INR was 3.3. Sodium 142, potassium 4.5, chloride 102, bicarbonate 31, BUN 24, creatinine 0.9. Her first cardiac enzymes showed on [**12-5**] a CK of 19 and a second enzyme of 23. Her troponin was intermediate 0.5. Calcium was 8.6 and magnesium was 2.2. HOSPITAL COURSE: The Neurology Service was consulted on the first full day in the Medical Intensive Care Unit to offer their input on her prognosis following an apparently prolonged anoxic event with her cardiac arrest. Their initial impression is that her prognosis was quite guarded and they wished to re-evaluate her again in a couple of days. Over the next day or two, the patient's neurological examination improved slightly. However, she was responsive only to vigorous sternal rub and at that only opened her bilateral eyes minimally. Pupils were reactive and she was noted to have a corneal reflex and doll's eye reflex; however, she did not have any spontaneous movement. Withdrawal to nailbed compression was noted in the right upper and lower extremities. For further evaluation, the Neurology Service recommended performing an electroencephalogram and MRI to assist with offering a more accurate prognostic information. INCOMPLETE DICTATION [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3851**] Dictated By:[**Name8 (MD) 11847**] MEDQUIST36 D: [**2120-12-22**] 16:27 T: [**2120-12-22**] 16:27 JOB#: [**Job Number **] Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 6657**] Admission Date: [**2120-11-26**] Discharge Date: [**2120-12-16**] Date of Birth: [**2039-1-2**] Sex: F Service: ADDENDUM: The Neurology service continued to follow the patient and following the electroencephalogram and MRI examinations, offered the following advice. Given this is an 81 -year-old female who is status post cardiac arrest and comatose with no significant change in her examination, and an MRI showing bilateral occipital infarcts, an electroencephalogram consistent with encephalopathy and no seizure activity, she was considered to have a dismal prognosis. Specifically she is estimated to have an approximately 60% chance of remaining in a vegetative state and approximately 40% chance of remaining severely disabled at best. However, it was somewhat difficult for these numbers to be entirely accurate given her complex medical comorbidities. Nevertheless it was felt that her prognosis overall was dismal. Several family meetings were held to discuss further plans and what the patient's ultimate wishes would be under these circumstances. It was ultimately decided to withdraw care and offer comfort measures only. This was done on [**2120-12-15**], and the patient expired approximately eighteen hours later from cardiopulmonary arrest. A postmortem examination was offered to the family following the pronouncement; however, they were not interested in such an examination, feeling that it would not yield any information that would help settle any questions for them or provide any closure. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 6658**] Dictated By:[**Name8 (MD) 1681**] MEDQUIST36 D: [**2120-12-16**] 02:12 T: [**2120-12-16**] 13:48 JOB#: [**Job Number 6659**]

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Discharge summary

report

Admission Date: [**2178-2-23**] Discharge Date: [**2178-3-5**] Date of Birth: [**2108-10-16**] Sex: M Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6736**] Chief Complaint: Renal subcapsular hematoma Major Surgical or Invasive Procedure: Embolization of renal artery branch (inferior branch of a duplicated renal artery) [**2178-2-26**] History of Present Illness: 69M w/ severe vasculopathy, on Coumadin for mechanical aortic valve being followed by Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] a stable 2.8 cm RLP enhancing renal mass suspicious for carcinoma who presented to OSH with new onset right flank pain. A CT scan was performed, which per report demonstrated a subcapsular hematoma with associated stranding in the perinephric space and within the retroperitoneum. The patient was noted to have minor abdominal tenderness and positive psoas sign. He is on Coumadin for a mechanical aortic valve. He has had nausea and vomiting associated with this episode. Prior to this episode, the patient had a syncopal episode with a fall of a ladder approximately one month ago. At that time, the patient's Hct was 38. He does not recall if he hit his right flank during that fall. Past Medical History: PMH: TIA ([**2158**], [**2163**], [**2165**]), CVA ([**2164**], [**2166**]) now on coumadin (goal 2.5-3.5), asc. aortic aneurysm (6.2cm), severe HTN, anti-Fy(a) antibodies, hypercholesterolemia, arthritis PSH: AVR ([**2146**]--mechanical), redo AVR with R subclavian to carotid bypass with asc. aortic replacement, s/p aoritc arch endovascular stent on [**2175-8-8**], LCFA to L axillary bypass graft [**2175-11-21**]; RIHR; PVP with TURP [**2174**]; lipoma excision ([**2170**]) Meds: coumadin 6-7.5mg [**Last Name (LF) **], [**First Name3 (LF) **] 81mg, diovan 80mg [**Hospital1 **], norvasc 5mg [**Hospital1 **], IC bisoprolol fumarate 2.5mg [**Hospital1 **], meloxicam 15mg, citalopram 20mg, zytrec [**Hospital1 **], vytorin [**9-14**] [**Month/Year (2) **], APAP prn All: NKDA Social History: Lives with wife. [**Name (NI) 4084**] smoked. Occasional alcoholic beverage. Family History: Mother died in her 60's of heart disease Physical Exam: General: comfortable Abd: non tender, softly distended, flank ecchymosis Void: clear yellow urine Pertinent Results: [**2178-3-5**] 06:30AM BLOOD Hct-26.9* [**2178-3-5**] 06:30AM BLOOD PT-28.9* PTT-38.6* INR(PT)-2.9* [**2178-3-5**] 06:30AM BLOOD Glucose-124* UreaN-33* Creat-1.5* Na-135 K-4.2 Cl-94* HCO3-29 AnGap-16 Brief Hospital Course: Mr. [**Known lastname 63903**] renal bleed was initially managed conservatively with bedrest and transfusion for hematocrit goal 30. He was anticoagulated throughout his stay for INR 2.5-3.5 goal, given his mechanical aortic valve. On [**2178-2-25**], he had acute back and chest pain, emergent CT scan identified no dissecting aneuysm and cardiac enzymes and serial EKG identified no myocardial infarction. He required daily transfusions for 5 days and had increased right flank pain and shortness of [**Last Name (LF) 1440**], [**First Name3 (LF) **] underwent embolization of a branch of one of his right renal arteries supplying the inferior pole [**2178-2-26**]. Patient tolerated procedure without complications, no infections of hematoma, monitored in ICU before transfer to the floor. He has been hemodynamically stable since embolization. At discharge patient's pain well controlled with no narcotics, tolerating regular diet, ambulating without assistance, and voiding; Hct 27, INR 2.9. Discharge Medications: 1. Warfarin 5 mg Tablet Sig: One (1) Tablet PO 8PM (): Titrate for INR 2.5-3.5. Disp:*0 Tablet(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*0 Tablet, Chewable(s)* Refills:*0* 3. Valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*0 Tablet(s)* Refills:*0* 4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*0 Tablet(s)* Refills:*0* 5. Bisoprolol Fumarate 5 mg Tablet Sig: 0.5 Tablet PO at bedtime. Disp:*0 Tablet(s)* Refills:*0* 6. Meloxicam 15 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*0 Tablet(s)* Refills:*0* 7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*0 Tablet(s)* Refills:*0* 8. Zyrtec Oral 9. Vytorin [**9-14**] 10-20 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*0 Tablet(s)* Refills:*0* 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation for 1 weeks. Disp:*20 Capsule(s)* Refills:*0* 11. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain for 1 weeks. Disp:*60 Tablet(s)* Refills:*0* 12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 4 days. Disp:*4 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Renal subcapsular bleed Discharge Condition: Stable Discharge Instructions: Resume all of your home medications, NO CHANGES in your home medications including doses. Continue your coumadin, check with your coumadin team for INR check within 3 days of discharge. Call Dr.[**Name (NI) 10529**] office to schedule a follow-up appointment AND if you have any questions. If you have fevers > 101.5 F, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest emergency room. Followup Instructions: 1. Call Dr.[**Name (NI) 10529**] office to schedule a follow-up appointment. 2. Continue your coumadin, check with your coumadin team for INR check within 3 days of discharge.

[ "583.89", "790.92", "584.9", "786.59", "441.2", "519.9", "599.7", "V43.3", "285.1", "401.9", "276.6", "272.4", "V58.61", "189.0", "V12.54", "593.81", "E934.2" ]

icd9cm

[ [ [] ] ]

[ "88.45", "99.07", "99.04", "39.79" ]

icd9pcs

[ [ [] ] ]

4888, 4894

2626, 3624

341, 442

4962, 4971

2402, 2603

5469, 5648

2227, 2269

3647, 4865

4915, 4941

4995, 5446

2284, 2383

275, 303

470, 1307

1329, 2116

2132, 2211

28,849

183,719

32089

Discharge summary

report

Admission Date: [**2198-8-20**] Discharge Date: [**2198-8-24**] Service: NEUROSURGERY Allergies: Novocain / Zantac Attending:[**First Name3 (LF) 2724**] Chief Complaint: S/p fall Major Surgical or Invasive Procedure: None History of Present Illness: 89F lives in [**Hospital3 **] facility, s/p fall this morning, pt does not remember falling but remembers waking up on the floor of her apartment and was able to go to the bathroom and pull the cord for help. Pt was taken to OSH where a CT showed an intraparenchymal hemorrhage. Pt was transfered to [**Hospital1 18**] where a head CT shows a 1.5cm bleed into the posteriomedial left temporal lobe. Nonfocal neurological exam, pt is A&Ox2, is at baseline per daughter. Pt reports having a headache since [**Month (only) 547**], no change. Past Medical History: PMHx: HTN, Hypothythyroidism, RA, Osteoperosis Social History: Lives in [**Hospital3 **] apartment. Ambulatory without assistance at baseline Family History: non contributory Physical Exam: PHYSICAL EXAM: O: T: BP: 172/42 HR:67 R 16, 97% RA Gen: Well, comfortable, NAD. HEENT: Normocephallic, atraumatic, PERRL, EOMI Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Alert and oriented x2. Oriented to person, knows she is in a hospital but did not know where, oriented to year and season. 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, 2 down to 1.5 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Proximal leg weakness 4+/5 IP and Quads bilaterally, Triceps/Biceps 5-/5 bilaterally, otherwise full strength throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: Patellar and achilles reflexes intact b/l Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements Pertinent Results: [**2198-8-20**] 04:36PM PT-12.1 PTT-23.6 INR(PT)-1.0 [**2198-8-20**] 04:21PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013 [**2198-8-20**] 04:21PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2198-8-20**] 04:21PM URINE RBC-[**2-12**]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-<1 [**2198-8-20**] 04:21PM URINE AMORPH-MOD [**2198-8-20**] 02:55PM GLUCOSE-85 UREA N-24* CREAT-1.2* SODIUM-137 POTASSIUM-3.3 CHLORIDE-98 TOTAL CO2-30 ANION GAP-12 [**2198-8-20**] 02:55PM estGFR-Using this [**2198-8-20**] 02:55PM CK(CPK)-124 [**2198-8-20**] 02:55PM CK-MB-6 cTropnT-0.01 [**2198-8-20**] 02:55PM WBC-9.5 RBC-4.08* HGB-13.7 HCT-38.0 MCV-93 MCH-33.5* MCHC-35.9* RDW-12.9 [**2198-8-20**] 02:55PM NEUTS-73.1* LYMPHS-19.4 MONOS-4.5 EOS-2.7 BASOS-0.3 [**2198-8-20**] 02:55PM PLT COUNT-215 CT HEAD W/O CONTRAST [**2198-8-20**] 2:21 PM IMPRESSION: 1.5-cm parenchymal hemorrhage in the medial posterior left temporal lobe with leptomeningeal extension. Given the pattern and location of the hemorrhage, and patient age, amyloid angiopathy is suspected for the etiology of the bleed. Please correlate clinically. CT HEAD W/O CONTRAST [**2198-8-21**] 6:04 PM FINDINGS: Again demonstrated within the medial posterior left temporal lobe is an area of hyperdensity that appears grossly similar in extent compared to prior study. This comparison is limited given the extreme motion on prior CT. No new areas of hemorrhage are identified. There is no evidence of mass effect. The ventricles are symmetric. There is atrophy of the frontal lobes bilaterally. There is no evidence of acute major vascular territorial infarction. The paranasal sinuses and mastoid air cells are stable. IMPRESSION: Grossly stable left medial posterior temporal lower lobe intraparenchymal hemorrhage. Brief Hospital Course: Ms [**Known lastname 75116**] was admitted to neurosurgery service on [**2198-8-20**] for intraparenchymal hemorrhage (left temporal lobe) s/p fall. Patient was taking daily ASA 325MG prior to the fall. Upon admission, she was oriented to person/hospital/year and season, which was her baseline. Her motor exam was non focal. Her ASA was on hold since admission and restarted on [**2198-8-24**]. Neurologically she remains stable, and her intracranial hemorrhage also remains stable with repeat CT scan of head. Geriatric service was consulted regarding intermittent confusion, she was recommended starting celexa/haldol and increasing activity. PT was also consulted and recommended pt to be discharged to rehabilitation. A MRI of brain was performed and reviewed by neurologist Dr [**First Name (STitle) **]. MRI showed possible amyloid angiopathy, she is recommended follow up with her PCP and keep her BP < 140/90. She is also recommended to repeat MRI brain with and without contrast to rule out underline mass. Upon discharge, pt is neurologically stable, and tolerating regular diet. Medications on Admission: Boniva 150mg Q month Calcium 500mg TID ASA 325 QDay Centrum Silver MV Dicyclomide 10mg QHS HCTZ 50mg QD Levothyroxine 75mcg QD Meclizine 25mg TID Fluoxetine 10mg QD Citalopram 10mg QHS Discharge Medications: 1. Hydrochlorothiazide 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for delirium. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule 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. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Intra parenchymal hemorrhage (left temporal lobe), possible amyloid angiopathy. Discharge Condition: Neurologically stable. Discharge Instructions: ?????? Take your medicine, including your pre-admission medication as prescribed. * Please keep your blood pressure less than 140/90. ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication Followup Instructions: PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR. [**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS. YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST PRIOR TO YOUR VISIT. Completed by:[**2198-8-24**]

[ "733.00", "724.02", "E888.9", "311", "459.9", "272.0", "V45.61", "851.81", "293.0", "401.9", "E849.0", "244.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6757, 6804

4443, 5536

238, 245

6928, 6953

2555, 4420

7807, 8036

998, 1016

5772, 6734

6825, 6907

5562, 5749

6977, 7784

1046, 1281

190, 200

273, 814

1619, 2536

1296, 1603

836, 885

901, 982

18,841

139,381

22239

Discharge summary

report

Admission Date: [**2120-6-29**] Discharge Date: [**2120-6-30**] Date of Birth: [**2046-6-28**] Sex: Male Service: TRAUMA PRESENT ILLNESS: The patient is a 74 year old white male who is status post fall and suffered a large subdural hematoma. He had a history of coronary artery disease status post CABG times two, known 4 cm AAA, diabetes mellitus, and a history of hydrocephalus status post AP shunt, who had a witnessed fall the day prior to admission with transient loss of consciousness. He hit his posterior aspect of his head on a carpeted floor and was initially taken to [**Hospital **] Hospital, where he was reportedly alert and oriented with a nonfocal exam. However, while he was being evaluated there he became more confused and was sent to [**Hospital6 2910**] for CT scan of the head. In route he developed some nausea, vomiting, headache, slurred speech and left-sided weakness. He was also noted to become hypertensive and lethargic. He had a dilated right pupil prior to his CT scan and the CT scan showed a large left-sided subdural hematoma. He was intubated at the [**Hospital6 2910**] for mental status deterioration and was started on Dilantin for seizure prophylaxis and Labetalol for hypertension. He was transported to [**Hospital1 18**] for further evaluation. HOSPITAL COURSE: A Neurosurgery consult was obtained, as well as Neurology consultation. The initial decision was made by the family to not pursue any operative intervention and he was taken to the Intensive Care Unit for monitoring and further care. Neurology consultation revealed that the patient's head injury was the devastating one, and his neurologic exam in addition to apnea testing confirmed the patient's diagnosis of brain death. The patient's family was notified of this and it was decided along with the family that the patient be taken off his ventilator and given comfort measures only. DISCHARGE DIAGNOSES: Large left subdural hematoma with mass affect. DISCHARGE MEDICATIONS: None. FOLLOW UP: Follow up plans per family and organ bank personnel. [**First Name11 (Name Pattern1) 518**] [**Last Name (NamePattern4) **], [**MD Number(1) 17554**] Dictated By:[**Doctor Last Name 58003**] MEDQUIST36 D: [**2120-11-4**] 14:08:53 T: [**2120-11-4**] 14:52:50 Job#: [**Job Number 58004**]

[ "852.26", "250.00", "414.00", "E888.9", "348.8", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

1947, 1995

2019, 2026

1335, 1925

2038, 2356

59,463

192,615

40342

Discharge summary

report

Admission Date: [**2124-11-1**] Discharge Date: [**2124-11-5**] Date of Birth: [**2087-2-12**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2724**] Chief Complaint: Neck and right arm pain after MVA Major Surgical or Invasive Procedure: Anterior C7 corpectomy with allograft and plate History of Present Illness: Pt is a 37f who was involved in a MVA where she thinks she fell asleep leading to her car being involved in a rollover. She was removed from the car at the scene, placed in a cervical collar and was taken to [**Hospital1 18**] for further evaluation. She currently complains of neck and right arm pain, numbness in her RUE that involves her thumb and index finger and R shoulder pain. She has no complaints of lower extremity weakness, B/B incontinence or sensory changes in her legs. CT C spine shows R C5-6 jumped facet and C6-7 perched facet with C7 anterior wedge fracture. Past Medical History: IVDA Depresseion anxiety Social History: Vet Tech IVDA Family History: NC Physical Exam: Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRLA EOMs Full Neck: pain with palpation to C7/T1, C collar in place 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 4 4 5 5 5 5 5 5 5 5 5 Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 3 3 3 3 Left 3 3 3 3 Propioception intact Toes downgoing bilaterally CT C spine: R C5-6 jumped facet, perched facet C6-7 EXAM ON DISCHARGE: 4+ R tricep, OTHERWISE INTACT Pertinent Results: [**2124-11-1**] 10:40AM WBC-6.0 RBC-3.77* HGB-12.2 HCT-35.2* MCV-94 MCH-32.4* MCHC-34.6 RDW-12.8 [**2124-11-1**] 10:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2124-11-1**] 10:40AM UREA N-14 CREAT-0.8 [**2124-11-1**] 10:44AM GLUCOSE-163* LACTATE-2.0 NA+-139 K+-3.6 CL--99* TCO2-28 [**2124-11-1**] 02:10PM URINE BLOOD-TR NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2124-11-1**] 02:10PM URINE UCG-NEGATIVE [**2124-11-1**] CT C SPINE compression fx of anterior C7 vert body, ~ 50% loss of ht. anterior subluxation of C6 over C7. jumped facets on the right at C5/C6. perched facets on the left at C6/C7. suggest MRI for further evaluation for ligamentous/cord injury. spine consult pending. [**2124-11-1**] MRI C SPINE IMPRESSION: 1. Fracture/compression deformity of C4 with retropulsion causing severe spinal stenosis at C6-7 level. No abnormal signal detected within the cord. Rupture of the posterior longitudinal and interspinous ligaments at C6-7 interspinous space with surrounding edema. 2. Perched facet on left and dislocated/locked facet on right at at C6-7 level. Multilevel degenerative changes with disc bulge and neural foraminal narrowing as described above CT C-Spine [**11-3**]: No significant change, status post anterior spinal fusion of C6 through T1 with partial corpectomy of C7 and bone graft placement. CXR [**11-4**]: Patchy opacity left lower lobe, consistent with collapse and/or consolidation, new c/w [**2124-11-1**]. Small effusions. Brief Hospital Course: Pt seen in emergency room after MVA and CT C spine with findings of C5-6 jumped facet and C6-7 perched facet. On admission she was slightly weak in her RUE with strength 4/5. In discussion with attending Dr. [**Last Name (STitle) 548**] it was decided that she would benefit from urgent decompression with C7 corpectomy with allograft and plate from an anterior approach. She tolerated this procedure very well with no complications. Post operatively she was transfered to the ICU for further care including q1 neurochecks and pain control with dilaudid PCA. On post op exam she was doing well. Her complaints of R arm pain had improved as did the strength in her R arm. Though she was somewhat limited by pain her strength was 4+/5. She had no difficulties overnight and on the morning of POD#1 she was transferred to the floor in stable condition. The pain management team was consulted for recommendations to change to PO pain medications given her history of IV drug abuse. Pain medications were altered in attempt of achieving adequate control. On [**11-3**] her foley was removed and PT/OT consults were requested. They determined that she met criteria for discharge to home with PT services. On [**11-4**] she developed a fever and slight cough. A CXR was obtained, which demonstrated LLL consolodation, consistent with CAP. She was started on Levaquin PO for 7 days. Her central line was removed, and the tip of the catheter was sent for cultures. On [**11-5**] she was afebrile, and ambulatory with PT. Cantral line cx were still pending, but the decision was made to discharge the patient and follow up on the line cultures as an outpatient. She was discharged to home on [**11-5**]. Medications on Admission: Neurontin 600mg q4 Clonopine 0.5mg q12 Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 2. docusate sodium 50 mg/5 mL Liquid Sig: [**1-8**] PO BID (2 times a day). Disp:*60 * Refills:*0* 3. gabapentin 600 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*0* 4. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:*60 Adhesive Patch, Medicated(s)* Refills:*0* 5. carisoprodol 350 mg Tablet Sig: One (1) Tablet PO TID; PRN () as needed for muscle spasm. Disp:*30 Tablet(s)* Refills:*0* 6. hydromorphone 2 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 7. phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous membrane Q4H (every 4 hours) as needed for sore throat. 8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours). 9. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. methocarbamol 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*0* 11. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 12. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: R C5-6 jumped facet R C6-7 perched facet Community Aquired pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ?????? Do not smoke. ?????? Keep your wound(s) clean and dry / No tub baths or pool swimming for two weeks from your date of surgery. ?????? If you have steri-strips in place, you must keep them dry for 72 hours. Do not pull them off. They will fall off on their own or be taken off in the office. You may trim the edges if they begin to curl. ?????? No pulling up, lifting more than 10 lbs., or excessive bending or twisting. ?????? Limit your use of stairs to 2-3 times per day. ?????? Have a friend or family member check your incision daily for signs of infection. ?????? your collar is for comfort only. . ?????? Take your pain medication as instructed; you may find it best if taken in the morning when you wake-up for morning stiffness, and before bed for sleeping discomfort. ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc. unless directed by your doctor. ?????? Increase your intake of fluids and fiber, as pain medicine (narcotics) can cause constipation. We recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. Followup Instructions: Follow Up Instructions/Appointments ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) 548**] to be seen in 4 weeks. ??????You will need cervical spine x-rays prior to your appointment. You will also need an Ap/Lat Chest X-ray to follow up on your pneumonia. Completed by:[**2124-11-5**]

[ "355.9", "486", "E816.0", "806.05", "300.4" ]

icd9cm

[ [ [] ] ]

[ "81.62", "80.99", "03.53", "81.02" ]

icd9pcs

[ [ [] ] ]

6593, 6599

3471, 5173

353, 402

6712, 6712

1882, 3448

8133, 8477

1106, 1110

5263, 6570

6620, 6691

5199, 5240

6863, 8110

1125, 1282

280, 315

430, 1011

1832, 1863

6727, 6839

1033, 1059

1075, 1090

27,658

199,156

31307

Discharge summary

report

Admission Date: [**2106-6-16**] Discharge Date: [**2106-6-19**] Date of Birth: [**2026-11-27**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1271**] Chief Complaint: intraventricular hemorrhage s/p fall Major Surgical or Invasive Procedure: none History of Present Illness: 70 F fell at doctor's office for follow up visit for tooth extraction(taking hydrocodone for pain). fell with associated LOC. Past Medical History: CHF, DM, Arthritis,, ? AF on coumadin Social History: Pt lives w/husb & son lives w/them in same house in own apt. Other son lives nearby and dtr lives down the street. Very close, supportive family. Family History: noncontributory Physical Exam: O: T:98.6 BP:135 / 85 HR:75 R 15 98 RAO2Sats Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PEARLA 3-2 mm EOMs full Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, Orientation: Oriented x2 (did not know year but knew her name and where she was) Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**4-10**] throughout(weakness noted in right shoulder due to recent rotator cuff surgery) . No pronator drift Sensation: Intact to light touch Toes downgoing-could only asses left due to bunion surgery Coordination: normal on finger-nose-finger, Pertinent Results: CT C-SPINE W/O CONTRAST [**2106-6-15**] 7:12 PM Reason: Eval for c-spine injury Multilevel degenerative changes of the cervical spine are identified, including extensive atlantodental joint space narrowing and osteophytes, facet joint degeneration at associated neural foraminal stenosis at nearly every cervical interspace, and large lower cervical anterior bridging osteophytes. There does not appear to be overt bony central canal stenosis. Moderate atherosclerotic calcification of the common carotid bifurcations is seen. IMPRESSION: No fracture or subluxation is noted within the cervical spine. Degenerative changes, as noted above. CT HEAD W/O CONTRAST [**2106-6-15**] 7:12 PM 1. Bilateral intraventricular hemorrhage, most evident in the right lateral ventricle; minimal left frontal and parietal subarachnoid hemorrhage. 2. Blood is noted within the maxillary and sphenoid sinuses. No overt fracture seen. 3. Large right frontal subgaleal hematoma. CT HEAD W/O CONTRAST [**2106-6-16**] 2:09 PM IMPRESSION: Unchanged appearance of bilateral intraventricular hemorrhage, right greater than left, and right frontal subgaleal hematoma. Brief Hospital Course: Patient is admitted to trauma intensive unit on [**2106-6-15**] for traumatic intraventricular hemorrhage and subarachnoid hemorrhage seen on CT. She was on coumadin for Afib prior to fall. Her anticoagulation was reversed and a course of dilantin was begun. On [**6-17**] she was transferred from the ICU to the floor and PT/OT was consulted who recommended discharge to a rehab facility. She did have a potassium level of 2.8 on [**6-19**]. An EKG was obtained which showed no new changes and no Q-waves were present. Her potassium level was repleted. She was neurologically stable prior to discharge. Medications on Admission: Potassium supp Metolozone 2.5 mg Pioglitazone 20 mg Dialtiazem 240 mg Furosemide 80 mg Digoxin .25 mg Esomeprazole 40 mg Lisinopril 20 mg Atorvastatin 20 mg Fluoxetine 10 mg Coumadin 5 mg Hydrocodone 500 mg q4-6 Discharge Medications: 1. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO daily (). 5. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Metolazone 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 8. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital 18979**] Healthcare [**Location 39857**] Discharge Diagnosis: intraventicular hemorrhage Discharge Condition: neurologically stable Discharge Instructions: ?????? Have a 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, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? 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, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.[**Last Name (STitle) 548**] TO BE SEEN IN 4 WEEKS. YOU WILL A CAT SCAN OF THE BRAIN WITHOUT CONTRAST YOU WILL NOT NEED AN MRI COUMADIN [**Month (only) **] BE RESTARTED 1 MONTH AFTER DISCHARGE FROM THE HOSPITAL [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2106-6-19**]

[ "276.8", "V58.61", "873.42", "428.0", "E849.6", "293.0", "715.90", "851.80", "E880.9", "427.31", "250.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4686, 4765

3195, 3800

357, 364

4836, 4860

2013, 3172

6195, 6604

761, 778

4063, 4663

4786, 4815

3826, 4040

4884, 6172

793, 1045

281, 319

392, 520

1198, 1994

1060, 1182

542, 581

597, 745

64,037

189,337

37544

Discharge summary

report

Admission Date: [**2117-2-16**] Discharge Date: [**2117-2-20**] Date of Birth: [**2038-12-28**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 281**] Chief Complaint: End stage tracheobronchomalacia Major Surgical or Invasive Procedure: [**2117-2-17**] Rigid bronchoscopy and Y stent removal History of Present Illness: 78 year old male with COPD on supplemental oxygen who was found to have tracheobronchomalacia on bronchoscopy done at outside hospital. One year ago patient began having shortness of breath and productive cough. He was treated for bronchitis. When this did not resolve, he was referred to pulmonologist and was diagnosed with COPD. He was initially started on nocturnal oxygen, however, now uses oxygen most of the day. He reports DOE. He is barely able to shower. He is short of breath walking 20 feet to the bathroom. He has a cough that is productive of greenish sputum. Occasionally, he has coughing "fits", barking in nature, and is unable to expectorate sputum. He uses two pillows to sleep and does not experience positional dyspnea. He has lost 40 lbs over the past year. Denies any decrease in appetite. Denies fever, chills. No night sweats. No nausea, vomiting. He presents today for TBM evaluation. Past Medical History: PMHx: COPD on supplemental oxygen, Hypercholesterolemia, s/p TURP ([**12-30**]), S/P StentY placed for tracheobronchomalacia [**1-31**], GERD, Inguinal hernia repair Social History: Married. Retired 10 years ago. Was a truck driver. Quit smoking 40 years ago, had been a 35ppy smoker. Rare ETOH use. Denies any recent or international travel. Family History: Mother had asthma, father may have had COPD. Physical Exam: At time of admission: VS: Afebrile, HR 89, BP 132/74, RR 20, Oxygen saturation 97% on 2 L. N/C General Appearance: AA&Ox3, in NAD. HEENT: MMM, O/P clear, sclera anicteric Neck: trachea midline, no stridor, supple Lymphatics: no cervical or supraclavicular lymphadenopathy Chest: Diminished with occasional wheezes in the bases. Cardiovascular: Tachycardia, sinus, nl S1/S2 Abdomen: soft, NT/ND, NABS Extremities: no CCE Neurological: A&O x3 Psychiatric: normal mood, no depression/anxiety Pertinent Results: [**2117-2-18**] 03:15AM BLOOD WBC-7.9 RBC-4.33* Hgb-13.3* Hct-38.9* MCV-90 MCH-30.6 MCHC-34.1 RDW-12.5 Plt Ct-185 [**2117-2-18**] 03:15AM BLOOD Glucose-114* UreaN-12 Creat-0.9 Na-140 K-4.3 Cl-101 HCO3-31 AnGap-12 [**2117-2-18**] 03:15AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.0 CTA: 1. No evidence of aortic dissection or pulmonary embolism. 2. Stable cylindrical bronchiectasis and distal bronchiolectasis with some bronchial wall thickening and inspissated secretions. The degree of tree-in-[**Male First Name (un) 239**] opacities diffusely throughout the lung has slightly increased in the interval, which may suggest superimposed infection/inflammation. Additional new ground-glass opacities noted within the left lower lobe, whichis nonspecific, may also reflect infection or sequelae from recent bronchoscopies/lavage. Echo: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity is unusually small. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. Brief Hospital Course: Mr. [**Known lastname 84305**] [**Last Name (Titles) 1834**] his rigid bronchoscopy and Y stent removal on [**2117-2-17**] and was transferred to the PACU, where he had some respiratory distress and failed to maintain his O2 saturations on supplemental 02. He was started on CPAP which resulted in good 02 saturations. He was then transferred to the SICU for close observation due to his CPAP/BiPAP requirement. On post procedure day 1, he did well and was on supplemental O2 during the day and CPAP overnight. He was eating a regular diet and making good volumes of urine. On PPD 2, he maintained his saturations in the high 90's on 3L nasal cannula, which back to his baseline. He [**Date Range 1834**] a physical therapy evaluation and was deemed a good candidate for pulmonary rehab. He was discharged in similar condition to his baseline and will require supplemental 02 and CPAP/BiPAP on an ongoing basis. He was transferred to [**Hospital **] Medical Center for CPAP/BiPAP work-up. Medications on Admission: Albuterol, Xanax, Lipitor, Symbicort, Omeprazole, Sulfamethoxzole, Flomax, Spiriva, Effexor, Aspirin, Fish Oil Discharge Medications: 1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for dyspnea. 2. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety/insomnia. 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: [**1-23**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain / fever. 8. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for productive cough. 9. Venlafaxine 37.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 12. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Codeine Phosphate 15 mg/mL Syringe Sig: One (1) Injection ONCE (Once) as needed for COUGH. 14. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Discharge Diagnosis: Tracheobronchomalacia status post Y stent placement without symptomatic improvement, now status post rigid bronchoscopy and Y stent removal 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: Follow-up with your pulmonologist if develop increased shortness of breath, fevers greater than 101.5, or cough productive of purulent sputum. Followup Instructions: Please call the office at your discretion for a follow-up appointment with Dr. [**Last Name (STitle) **] - ([**Telephone/Fax (1) 17398**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**] Completed by:[**2117-2-20**]

[ "530.81", "519.19", "496", "272.0", "V58.66", "V46.2", "996.59", "518.5" ]

icd9cm

[ [ [] ] ]

[ "33.24", "33.78" ]

icd9pcs

[ [ [] ] ]

6535, 6550

3959, 4951

353, 410

6734, 6734

2328, 3936

7071, 7331

1755, 1802

5113, 6512

6571, 6713

4977, 5090

6904, 7048

1817, 2309

282, 315

438, 1367

6748, 6880

1389, 1557

1573, 1739

80,592

159,996

46507

Discharge summary

report

Admission Date: [**2183-7-4**] Discharge Date: [**2183-7-8**] Date of Birth: [**2098-10-3**] Sex: M Service: MEDICINE Allergies: Nsaids Attending:[**First Name3 (LF) 1990**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None. History of Present Illness: Per night float admission, 84 yo male with hypertension, hyperlipidemia, history of MI, and recent intraparenchymal hemorrhage suspected secondary to amyloid angiopathy. On [**6-22**] patient fell in bathroom, was taken to [**Hospital 3278**] Medical center and found to have a right temporal parietal bleed. He remained stable and was d/c'd to rehab on [**6-27**] with residual left-sided weakness and was initially doing well. He then complained of weakness and poor PO, was noted to be hypotensive 82/38 and so he was brought to [**Hospital3 417**] where his SBPs were apparently in the 60s and came up with 3L IV fluids. They did a CT of the head which showed an acute right parietal hemorrhage around the site of an old bleed and he was thus transferred to [**Hospital1 18**] for further management. . At [**Hospital1 18**], he was thought initially to have suffered stroke as his [**Hospital 3278**] hospital course was not known. However, when radiology reviewed the CT head with the CT from [**Hospital1 3278**], findings actually improved. He was admitted to the neuro ICU for concern for head bleed. . In the neuro ICU, he was found to be dehydrated with acute renal failure and a urinary tract infection. He received IV ceftriaxone and vancomycin which was then switched to Cipro. He remained afebrile without decreasing leukocytosis (15 down to 12). With IVF, his renal function improved from 2.9 to 2.4 (baseline is 1.4) and his SBP remained in the 90s. ECHO showed EF of 55%. . Neurologically, he had left sided weakness, mostly of distal limb muscles which the patient felt was stable to improved since his initial hemorrhage. He had increased tone in the legs, upgoing toes but absent knee and ankle jerks. He continued to have an old tremor of the right arm/leg which is worse with movement. He is alert, oriented x3 with good attention. MRI done today showed unchanged right temportal parietal bleed, no new hemmorhage or shift. . Also of note, he has a right groin hematoma secondary to the attempted placement of a femoral line at the outside hospital. Past Medical History: MEDICAL HISTORY: - Hypertension - Hyperlipidemia - CAD s/p MI [**2179**] - Macular degeneration - Hard of hearing, has hearing aides but doesn't wear them - Right sided tremor x 30 years - Hx hip fracture (left) and chronic pain. - PUD, s/p gastrectomy - Appendectomy as a child Social History: Divorced. Retired Retail VP. Veteran of the Navy, served in the Pacific. Prior to going to rehab, lived with his son. Quit smoking in [**2165**]. "Was never a one beer man", also quit in [**2165**]. Family History: Non-contributory Physical Exam: T 96.6 121/60 90 16 96% on RA General: Awake, alert, responding appropriately, AxOx3. HEENT: PERRL. EOMI. Poor dentition. No lesions noted. in oropharynx, neck Supple, no carotid bruits CV: Distant heart sounds, rrr, no murmur. Pulmonary: Lungs clear to auscultation bilaterally Abdomen: soft, non-tender, normoactive bowel sounds, palpable liver edge 2cm below RCM. Extremities: 1+ radial, DP pulses bilaterally. Skin: PVD changes of the lower extremities bilaterally. Neurologic: Alert, oriented x 3. Speech was not dysarthric. The pt. had good knowledge of current events. CN2-12 grossly intact. diminished bulk and increased tone throughout upper and lower extremities. Tremor of the right arm and right leg at rest and worse with motion. Decreased sensation in LUE compared to the right. Decreased strength in the LLE compared to the right. Pain in left hip limited exam. Gait deferred. Pertinent Results: ADMISSION LABS: [**2183-7-3**] 10:37PM URINE RBC-[**3-14**]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-[**3-14**] [**2183-7-3**] 10:37PM URINE BLOOD-LG NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-MOD [**2183-7-3**] 10:37PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.015 [**2183-7-3**] 10:37PM WBC-15.2* RBC-3.36* HGB-10.4* HCT-32.1* MCV-96 MCH-30.9 MCHC-32.3 RDW-13.1 [**2183-7-3**] 10:37PM NEUTS-91.2* LYMPHS-4.6* MONOS-3.4 EOS-0.6 BASOS-0.2 [**2183-7-3**] 10:37PM PT-11.4 PTT-27.8 INR(PT)-0.9 [**2183-7-3**] 10:37PM GLUCOSE-120* UREA N-65* CREAT-2.9* SODIUM-135 POTASSIUM-5.9* CHLORIDE-106 TOTAL CO2-17* ANION GAP-18 [**2183-7-3**] 10:46PM LACTATE-1.4 FINAL LABS: [**2183-7-7**] 06:33AM BLOOD WBC-8.8 RBC-3.09* Hgb-9.6* Hct-28.9* MCV-94 MCH-31.0 MCHC-33.2 RDW-13.3 Plt Ct-464* [**2183-7-7**] 06:33AM BLOOD Glucose-91 UreaN-18 Creat-1.1 Na-139 K-4.5 Cl-107 HCO3-23 AnGap-14 [**2183-7-7**] 06:33AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.0 [**2183-7-8**] 05:50AM BLOOD WBC-9.7 RBC-3.23* Hgb-10.3* Hct-30.4* MCV-94 MCH-31.9 MCHC-33.9 RDW-13.5 Plt Ct-449* [**2183-7-8**] 05:50AM BLOOD Glucose-86 UreaN-15 Creat-1.0 Na-137 K-4.6 Cl-103 HCO3-26 AnGap-13 IMAGING: CT HEAD: IMPRESSION: Allowing for differences in patient positioning, no change in the mixed density right frontoparietal acute-to-subacute intraparenchymal hemorrhage with mass effect on the right ventricle and subjacent sulci. No evidence of herniation or new hemorrhage. ECHO: The left atrium is normal in 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. with normal free wall contractility. The diameters of aorta at the sinus, ascending and arch levels are normal. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal global biventricular systolic function. Mild pulmonary hypertension. Limited study. MR HEAD: IMPRESSION: Right temporoparietal mixed intensity hematoma with surrounding mass effect and edema, unchanged since the recent study of [**2183-7-3**]. No new hemorrhage or shift of midline structures is detected. Administration of Gadolinium contrast may help identify the etiology of hemorrhage such as underlying neoplasms or AV malformations. Brief Hospital Course: Mr. [**Known lastname 98783**] was admitted to neurology ICU for evaluation and care of head bleed as well as for presumptive sepsis secondary to urinary tract infection. The neurology ICU did the following: Neuro He was frequently monitered Q2 H for neuro checks. He underwent CT scan of head. We called the [**Hospital1 3278**] neuroradiology room and discussed with them about the CT scan findings from the previous admission and it appeared that there was no area concerning for acute bleed. It appeared that the size of bleed had decreased as compared to the CT scan 2 weeks ago. The worsened weakness on the left side was attributed to the urinary tract infection. ID He was found to have a urinary tract infection. He had hypotension, and so fluids were given for treatment of hypotension. Care was taken not to give him too agressive fluids as that may lead to increase in the intracerebral edema. He was started on ciprofloxacin. Renal He was noted to have acute renal failure. The baseline creatinine as discussed with the PCP office was found to be 1.4. The reason was thought to be due to dehydration and UTI. Medicine Due to complex medical issues, it was felt that he may be better served on medicine floor as opposed to neuromed floor. Medicine was consulted and addressed the following problems: # Altered mental status: Patient was AAOx3 during wntire stay on medicine floor. Possible causes of his episode of AMS included (a) Seizure: Per neuro recommendation, seizure prophylaxis was Keppra 750 mg [**Hospital1 **]. (b) Hypotension, see below. (c) IPH, see below. (d) UTI, see below (e) Uremia, see below. # Recent intraparenchymal hemorrhage: Per neuro, MRI and CT scans appear to be stable/improving since initial insult on [**6-22**]. Per patient, he was initially getting stronger at rehab but feels like this has set him back to where he was prior to starting rehab with his left sided weakness. This worsening appears to be due to weakness from hypotension and poor PO intake, which have now resolved. Hold anticoagulants (except SC heparin and ASA). Control BP (SBP < 160). . # UTI: Urine culture showed E coli, resistant to ciprofloxacin. Foley catheter removed. Ciprofloxacin therapy had to be changed to cefpodoxime therapy, which will be continued for 7 days. . # Anemia: Followed CBC with tranfusion parameter set at hematocrit < 25. Hematocrit was stable during hospital stay. . # Groin hematoma, secondary to attempted femoral line placement: Remained stable in appearance during stay on medicine floor. CBC was followed. . # Hypotension, resolved following IVF: Upon first transfer, SBP was 90-120s in early morning of [**7-5**], but had recovered to 120s-130s in late morning. Blood pressure recovered to above baseline, so hypertension therapy was initiated. See below. . # Acute Renal Failure, resolved: Likely secondary to hypotension, improved with fluids. Good UOP. The patient was below his baseline creatinine by his first morning on the medicine floor, and his BUN/Cr improved every day thereafter. . # Atypical chest pain: On the second to last day of his hospital admission, the patient complained of localized chest pain on the left, mid-clavicular, approximately 8th rib. Presentation was suggestive of musculoskeletal pain and was reproducible. EKG showed no changes in comparison to EKG from [**7-3**]. Cardiac enzymes negative. Patient reported some relief after Percocet. Presumed musculoskeletal. # CAD s/p MI [**2179**]: ECHO 55% here, no previous records. Patient does not believe he has any stents. Home simvastatin therapy was continued. Aspirin therapy was initiated. . # Hyperlipidemia: Continued simvastatin therapy. . # Hypertension: Amlodipine therapy instituted to keep SBP < 160, due to intraparenchymal hemorrhage. Metoprolol was slowly restarted until we returned to his original home dose. . # Depression: Continued Celexa therapy from home regimen. . # Chronic hip pain: Continued Neurontin (currently renally dosed) and Percocet, both from home regiman, as needed. . # GERD and history of PUD: - Continued home Protonix therapy from home regimen. . # Chronic Nausea: - Continued patient's home regimen as necessary. . # B12 deficiency: - Continue outpatient B12. Medications on Admission: Neurontin 100mg TID (new) Celexa 10mg (new) Percocet 5/325 q6 PRN Zocor 80mg qday Compazine 10mg Q6 PRN nausea Calcium 600mg + Vit D [**Hospital1 **] Vitamin B12 1000mg daily Isosorbide Mononitrate 0mg daily Lisinopril 5mg daily Magnesium oxide 400mg daily Colace 200mg PO BID Metoprolol XL 100mg daily Multivitamin daily Protonix 40mg Daily Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 3. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Multivitamin 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. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO three times a day. 8. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. Prochlorperazine Maleate 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for nausea. 10. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 6 days. Disp:*11 Tablet(s)* Refills:*0* 12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Levetiracetam 750 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 14. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 16. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital 2971**] Rehabilitation and Nursing Center - [**Hospital1 1474**] Discharge Diagnosis: PRIMARY Likely sepsis due to urinary tract infection History of recent intraparenchymal brain hemorrhage with cerebral edema SECONDARY Anemia Groin hematoma Acute renal failure Hypertension Hyperlipidemia Coronary artery disease Peptic ulcer disease Gastroesophageal reflux disease Depression Chronic hip pain Chronic nausea B-12 deficiency Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Mr. [**Known lastname 98783**], It was a pleasure meeting you and treating you at [**Hospital1 **] hospital. You were brought to the hospital because you were feeling weak and confused and because your blood pressure was low. We think that your weakness, confusion, and low blood pressure were caused by an infection. We have started you on antibiotics that you can take in pill form with your other medications. You will need to continue to take these antibiotics for five more days at the rehabilitation facility. We also took some pictures of your brain with our imaging machines. Those pictures showed us that you did not have another stroke. Your first stroke looks better on the pictures so far. We hope that you continue to get stronger on your left side as you work at the rehabilitation center. START levetiracetam as directed. START aspirin as directed. START cefpodoxime as directed. Take for 6 days. Again, we enjoyed caring for you at [**Hospital1 **] hospital. Followup Instructions: The patient should return to his rehabilitation facility.

[ "438.89", "599.0", "401.9", "041.4", "414.01", "412", "277.30", "584.9", "728.89", "786.59", "038.9", "995.92", "996.74", "348.5", "272.4", "285.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12554, 12657

6461, 7788

287, 294

13042, 13042

3876, 3876

14182, 14243

2931, 2949

11093, 12531

12678, 13021

10727, 11070

13177, 14159

2964, 3857

226, 249

322, 2396

5109, 6438

3893, 5100

13057, 13153

2418, 2699

2715, 2915

7,356

193,145

2975

Discharge summary

report

Admission Date: [**2183-11-5**] Discharge Date: [**2183-11-13**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2605**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: This is an 86 yo man w/ end-stage NHL with known malignant pleural effusions, lymphangitic spread to RML lung, presenting with increased shortness of breath. On admission, the patient reported coughing, feeling lethargic, dizzy and nauseous for several weeks. He developed fever and was sent to the ED from [**Hospital3 **]. + productive cough with colorless sputum. + increased shortness of breath. No chest pain/abdominal pain/dysuria/increased urinary frequency. Decreased appetite. Of note, patient was recently admitted [**10-6**] with cough and unsteady gait. He was treated for pneumonia with levofloxacin and his weakness/unsteady gait recovered with rest. In ED, vital signs were T 99.7 P 116 BP 118/56 RR 25 Sat 93% on 2L. He received 3 L of fluid and remained tachycardic. His oxygen requirement increased to 3.5 L with sats in low 90s. He was given Vanco/CTX and Azithromycin. Past Medical History: Large cell lymphoma, s/p CHOP + R, R, and CVP + R History of prostate cancer ACD Mild chronic renal insufficiency with baseline creat 1.1-1.3 Hypothyroidism Social History: Lives in [**Location (un) 5481**] [**Hospital3 **] facility. Uses a scooter at home for mobilization. Family History: Non-contributory Physical Exam: Physical exam per admission note: T 96.8, HR112, BP 98/60, R32, O2 sat 95% on 4L Gen: Patient unable to speak in full sentences Heart: Tachy, S1S2, no g/m/r Lungs: Decreased breath sounds Abdomen: Benign Extremities: No c/c/e Pertinent Results: Labs on Admission [**2183-11-6**] 07:34AM BLOOD Lactate-2.2* [**2183-11-6**] 12:33PM BLOOD Lactate-1.5 [**2183-11-6**] 12:10PM BLOOD Calcium-7.7* Phos-3.2 Mg-1.7 [**2183-11-9**] 06:15AM BLOOD LD(LDH)-282* [**2183-11-5**] 08:08PM BLOOD Glucose-101 UreaN-18 Creat-1.0 Na-141 K-4.5 Cl-102 HCO3-29 AnGap-15 [**2183-11-5**] 08:08PM BLOOD Plt Ct-283 [**2183-11-5**] 08:08PM BLOOD Neuts-85.0* Lymphs-9.3* Monos-4.8 Eos-0.8 Baso-0.2 Labs on Discharge [**2183-11-12**] 04:49AM BLOOD Calcium-8.3* Phos-2.5* Mg-1.8 [**2183-11-12**] 04:49AM BLOOD Glucose-99 UreaN-22* Creat-0.9 Na-143 K-3.9 Cl-106 HCO3-28 AnGap-13 [**2183-11-12**] 04:49AM BLOOD Plt Ct-254 [**2183-11-12**] 04:49AM BLOOD WBC-9.4 RBC-3.87* Hgb-10.1* Hct-33.5* MCV-87 MCH-26.2* MCHC-30.2* RDW-17.0* Plt Ct-254 [**11-7**] Chest CT IMPRESSION: 1. No evidence of pulmonary embolism. 2. Interval development of a large left lower lobe consolidation likely representing pneumonia. 3. Interval reduction in the left axillary and mediastinal lymphadenopathy. 4. Increase in the size of patchy opacities in the right upper lobe which could represent pneumonia or aspiration. 5. Interval increase in the size of the loculated right pleural effusion causing tracheal narrowing due to mass effect Brief Hospital Course: Mr. [**Known lastname 2405**] is an 86 yo male with end-stage NHL with known lymphangitic spread to right middle lobe, admitted with shortness of breath. His hospital course will be reviewed by problems. 1. Shortness of breath: The patient was initially admitted to the MICU for close observation given his tenuous respiratory status. He was initially given Vancomycin, Ceftriaxone and azithromyciin prior in the ED. A CTPA on [**11-7**] was negative for PE, but was remarkable for a LLL consolidation consistent with pneumonia. He was contionued on CTX, Levo and Flagyl intravenously for coverage of CAP and possible aspiration pneumonia. He received supportive care, and was subsequently transferred to the floor for further management. He was continued on the above abx, changed to Levofloxacin and Flagyl PO on [**11-13**] (Ceftriaxone D/C'd on [**11-13**]), with plan to complete a 14-day course of antibiotics (day 9 on the day of discharge). He also received supportive care with nebulizers, supplemental oxygen. He continues to require 1-3L to maintain O2 sats ranging from 90%-93%. He remains tachypenic. Plan to complete a 14-day course total of antibiotics, last doses on [**2183-11-18**]. Please continue supportive care. Consider administration of Morphine sublingual for respiratory distress. 2. Tachycardia: In the setting of the above pulmonary processes. No specific therapy. 3. Large cell lymphoma: No plan for further therapy per primary oncologist Dr. [**Last Name (STitle) 410**]. On acyclovir prophylaxis. 4. Hypothyroidism: He was continued on his out-patient regimen with Levoxyl. 5. Dispo: After speaking with case managment, the social worker and the primary medicine team, the patient expressed his desire to seek hospice care because he is tired of suffering. Patient returned to [**Location 14230**] Cove, where hospice care can be administered. Medications on Admission: Levothyroxine 25 mcg QD Allopurinol 300 mg QD Fluticasone/salmeterol 250-50 [**Hospital1 **] Metoprolol 25 mg [**Hospital1 **] Acyclovir 400 mg TID Tamsulosin 0.4 mg QHS Atrovent Oscal with vitamin D 500 [**Hospital1 **] MVI Omeprazole 20 mg QD Discharge Medications: 1. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 9. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO Q8H (every 8 hours) as needed. 15. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a day. 16. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 5 days: Last doses on [**11-18**]. 17. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 5 days: Last doses on [**11-18**]. 18. Saline neb as needed for comfort 19. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO q2 hours: Morphine 5-20 mg PO/SL q 2 hours prn for respiratory distress. 20. Ativan liquid 0.5-1 mg PO q 4 hours prn Discharge Disposition: Extended Care Facility: [**Location (un) 5481**] TCU Discharge Diagnosis: End stage non-hodgkin's lymphoma Left lower lobe pneumonia Discharge Condition: Patient discharged to [**Location (un) 5481**] for hospice care. His condition at the time of discharge is fair, still requiring oxygen to maintain stable saturation. Discharge Instructions: Patient seeking hospice care. Followup Instructions: Patient seeking hospice care [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2608**] MD, [**MD Number(3) 2609**] Completed by:[**2183-11-13**]

[ "244.9", "V10.46", "507.0", "585.9", "285.29", "200.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7039, 7094

3073, 4955

283, 289

7197, 7366

1808, 3050

7444, 7634

1528, 1546

5250, 7016

7115, 7176

4981, 5227

7390, 7421

1561, 1789

224, 245

317, 1210

1232, 1392

1408, 1512

12,351

182,236

20100

Discharge summary

report

Admission Date: [**2187-2-1**] Discharge Date: [**2187-2-5**] Date of Birth: [**2111-4-21**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2160**] Chief Complaint: fatigue Major Surgical or Invasive Procedure: EGD History of Present Illness: 75 yo male with h/o CAD s/p MI x3, MDS, CHF (EF 40%), HTN, chronic AFib (off coumadin), chronic GI bleed x 1 year who presented with fatigue, admitted for GI bleed. Guaiac positive for one year; requiring chronic blood transfusions in the setting of MDS. Received 5 units of blood [**2187-1-17**]. Just had endoscopy on Monday at OSH (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7493**] [**Telephone/Fax (1) 54080**]); per report, EGD was negative. He was found to have a hct 17.8 on [**1-30**] at Hematologist's office. He reports that his hematologist advised him to go home with the hopes that the Hct could be checked again later to see if he would retic on his own. Has had continued dark stools and felt fatigue and DOE, so he presented today to [**Hospital1 18**]. No dizziness or lightheadedness. No chest pain. Has chronic bandlike pain around abdomen (X 6 months). No ASA, coumadin, plavix, NSAIDs. In the ED, vitals revealed T 97.1 BP 87/39 HR 75 RR 18 SpO2 100% on 2L NC. Hct in the ED was 17.5. His pressure transiently dipped to 80s systolic but responded to IVF. He received 1L NS and 1u pRBCs. NG lavage was not performed. GI was consulted and recommended ICU admission for monitoring. ROS: No fevers/chills/URI sx/cough. No lightheadedness/dizziness, no changes in vision, no focal numbness/tingling/weakness, no CP/palpitations, no dysuria/hematuria/trouble starting/stopping stream. Denies increase in his home O2 use. Transfusion history: [**2186-12-21**]: 2 units [**2186-12-28**]: 5 units (admission) [**2187-1-12**]: 2 units [**2187-1-17**]: 5 units (admission) Past Medical History: 1. CAD status post MI [**2167**], s/p PTCA [**2167**], s/p 2-vessel CABG in [**12/2182**], with LIMA to LAD, SVG to OM1; s/p BMS to LCx in [**2185**] 2. CHF, [**12-8**] echo EF 40%, No AR, 2+ MR, 4+ TR. 3. Aortic stenosis s/p porcine AVR [**12/2182**] - normal AV gradient 4. Hypertension 5. Hypercholesterolemia 6. Chronic atrial fibrillation, Coumadin D/C'd [**2185-9-17**] secondary to GI bleed. 7. Bilateral fibrothoraces and history of recurrent pleural effusions. Status post right total decortication; pleural biopsies and fluid cytology benign. Status post left-sided decortication in [**11/2185**] complicated by hemothorax. 8. MDS. Baseline platelets 75-100K, baseline Hct 27-29. Primary hematologist-oncologist, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 4223**]. Never had a BM Bx. Transfused average of 2 units every 2 weeks 9. s/p admissions for UGI bleed [**9-/2185**], [**1-8**]. Seen by Dr. [**Last Name (STitle) **]. 10. Pulmonary HTN 11. Home oxygen--on 2L with activity, sometimes at night; started in [**2185**]; never told he had emphysema 12. h/o shingles PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**] [**Telephone/Fax (1) 4475**] GI: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7493**] [**Telephone/Fax (1) 54080**] Hematologist: [**First Name8 (NamePattern2) **] [**Location (un) 4223**] [**Telephone/Fax (1) 10728**] Social History: Lives in [**Location 17927**] with his wife and daughter (a nurse). Quit smoking in [**2167**], approx. 40 pack yr smoking hx. No EtOH use x 5 years. Retired telephone technician. +asbestos exposure at age 18 x 2 years when working in shipyard. Family History: F d. 72 MI. M d. in 80s, uncertain cause, but did have h/o CAD. Physical Exam: Vitals: 97.8 101/26 68 19 100% RA Gen: NAD, pleasant, joking, interactive, sitting up on edge of bed. HEENT: MMM, OP clear. Neck: JVP 7cm, supple, no LAD CV: S1, S2, RRR, 3/6 systolic murmur. No radiation to the neck. Resp: Moving air well; clear b/l, no crackles or wheeze Abd: Somewhat distended but soft, non-tender with +BS. Back: Brown macules in dermatomal distribution on R lower thoracic back. Ext: No edema b/l Neuro: A & Ox3, CN 2-12 intact grossly. Pertinent Results: [**1-/2186**] EGD: Granularity, erythema and congestion in the antrum and stomach body compatible with gastritis Erosions in the antrum Otherwise normal EGD to second part of the duodenum CXR [**2187-2-1**]: PORTABLE UPRIGHT VIEW OF THE CHEST AT 13:35 HOURS: Again seen is chronic left-sided pleural thickening with left lower lobe atelectasis. The remainder of the lungs is clear with no consolidation or pleural effusion. The pulmonary vasculature is not engorged. The cardiomediastinal silhouette is unchanged. Median sternotomy wires, aortic valve replacement and surgical clips are unchanged. Aortic calcifications are again noted. There is no pneumothorax. IMPRESSION: No acute cardiopulmonary abnormalities. Chronic left-sided pleural thickening with associated atelectasis. EGD: Normal esophagus. Stomach: Excavated Lesions A single 10mm ulcer was found in the proximal antrum. A red spot suggested recent bleeding. No fresh blood/clots was seen in the stomach Duodenum: Normal duodenum. Normal bile flow from the major papilla Other procedures: Two [**Company 2267**] Resolution clips were applied to the gastric ulcer Impression: 1. Ulcer in the proximal antrum 2. Two [**Company 2267**] Resolution clips were applied to the gastric ulcer 3. Otherwise normal EGD to third part of the duodenum Recommendations: 1.PPI twice daily. 2.Serial hematocrit and PRC as appropriate. 3. Follow up with ICU/floor team. [**2187-2-5**] 05:50AM BLOOD WBC-3.3* RBC-2.30* Hgb-7.4* Hct-23.2* MCV-101* MCH-32.0 MCHC-31.6 RDW-19.4* Plt Ct-81* [**2187-2-4**] 06:20AM BLOOD WBC-3.6* RBC-2.23* Hgb-7.2* Hct-22.4* MCV-100* MCH-32.4* MCHC-32.3 RDW-19.7* Plt Ct-93* [**2187-2-1**] 12:30PM BLOOD WBC-3.7* RBC-1.75*# Hgb-5.7*# Hct-17.5*# MCV-100*# MCH-32.3* MCHC-32.3 RDW-20.3* Plt Ct-111* [**2187-2-4**] 06:20AM BLOOD Neuts-82* Bands-0 Lymphs-8* Monos-4 Eos-4 Baso-1 Atyps-0 Metas-1* Myelos-0 [**2187-2-4**] 06:20AM BLOOD Hypochr-NORMAL Anisocy-3+ Poiklo-1+ Macrocy-2+ Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+ Burr-OCCASIONAL [**2187-2-5**] 05:50AM BLOOD Glucose-80 UreaN-26* Creat-1.0 Na-135 K-4.3 Cl-104 HCO3-23 AnGap-12 [**2187-2-1**] 12:30PM BLOOD Glucose-87 UreaN-62* Creat-1.6* Na-135 K-4.8 Cl-102 HCO3-24 AnGap-14 [**2187-2-4**] 06:20AM BLOOD CK(CPK)-31* [**2187-2-4**] 06:20AM BLOOD CK-MB-4 cTropnT-0.03* [**2187-2-2**] 05:15AM BLOOD CK-MB-5 cTropnT-0.06* [**2187-2-1**] 10:49PM BLOOD CK-MB-5 cTropnT-0.05* [**2187-2-1**] 12:30PM BLOOD cTropnT-0.04* [**2187-2-5**] 05:50AM BLOOD Calcium-8.1* Phos-2.8 Mg-2.0 [**2187-2-1**] 01:11PM BLOOD Hgb-5.5* calcHCT-17 Cardiology Report ECG Study Date of [**2187-2-2**] 10:27:40 AM Atrial fibrillation with controlled ventricular response. Compared to the previous tracing of [**2187-2-1**] the previously mentioned multiple abnormalities persist without 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 64 0 156 438/445 0 160 0 Brief Hospital Course: 75yo gentleman with h/o CAD and myelodysplastic syndrome admitted with chronic guaiac positive stools and Hct of 17. 1. GI bleed: Patient has chronic GI bleed and requires chronic transfusions due to inability to sufficiently produce in the setting of myelodysplastic syndrome. The patient had an EGD performed with 2 clips placed to an atral gastric ulcer (full report above). He was transfused 2 units of PRBCs prior to the procedure and his hct was monitored serially for further signs of blood loss. He was placed on [**Hospital1 **] ppi, initially IV and then transitioned to po. The patient's goal hct was >28 given his extensive CAD history however this was felt to be unattainable due to his pre-existing MDS. Follow up hematocri is recommended with PCP/hematologist. Discussed with primary outpt GI physician [**Name Initial (PRE) **] [**Name10 (NameIs) **] [**Last Name (STitle) **] - who stated he follows pt closely and last colonoscopy was a few month back and did not show significant source of bleed. 2. Acute Renal Failure: Baseline Cr 0.7 ([**1-/2186**]), Cr 1.6 at admisson. This was felt to be likely secondary to poor perfusion from a low hct. He was given IVF and blood products with subsequent normalization of his cr over the course of the hospitalization. Lasix (furosemide), aldactone (spironolactone) and metoprolol (lopressor) were held due to normal BP without these meds and it is recommended that he follow up with PCP prior to restarting these meds. 3. Myelodysplastic syndrome: - chronic thrombocytopenia and macrocytic anemia - continue f/u with outpatient hematologist; may need BM Bx as outpatient . # CAD: No acute event noted. # CHF: EF of 40% in [**12/2185**], but with 2+ MR and 4+ TR. # Oxygen requirement: He uses home O2, though does have smoking history, asbestos exposure, and b/l fibrothoraces. No PFTs available in our system. Follow up with PCP [**Name Initial (PRE) 3675**]. # AFib: currently in NSR. Patient was rate controlled on digoxin. Beta blocker held due to normal BP. # HTN: as above. Medications on Admission: 1. Nexium 40mg daily 2. Zoloft 50 mg QDay 3. Colace 100mg [**Hospital1 **] 4. MVI 5. Folic acid 1 mg once a Day 6. Zinc sulfate 220 mg once a Day 7. Digoxin 125mcg once a Day 8. spironolactone 25 mg once a Day 9. lisinopril 5 mg once a Day 10. Lopressor 12.5mg [**Hospital1 **] 11. Lasix 20mg once a Day 12. simvastatin 40 mg once a Day 13. colchicine 0.6 mg prn gout 14. trazodone 50 mg QHS prn 15. darvocet prn pain 16. sarna lotion 17. Carafate TID 18. Ambien prn Discharge Medications: 1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 8. Carafate continue to take at dose you were taking at home 9. Zinc Continue to take at dose you were taking at home 10. Colchicine Continue to take at dose you were taking at home 11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 12. Ambien 5 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed for insomnia. 13. Trazodone Continue to take at dose you were taking at home as needed 14. darvocet Continue to take at dose you were taking at home 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Anemia, acute blood loss Gastric ulcer bleeding Hypotension Discharge Condition: stable Discharge Instructions: You were admitted with anemia and acute blood loss and found to have an ulcer in your stomach. You required several blood transfusions while hospitalized. You should call your PCP or come to the ER if you develop shortness of breath, chest pain, worsening fatigue, or dark stools or bleeding. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2 Liters. Keep your appointments with the hematologist, gastroenterologist and primary care doctor for a follow up blood work to see if you need further tranfusions. The following medications were held while you were here due to low blood pressure: lasix (furosemide), aldactone (spironolactone) and metoprolol (lopressor). Discuss with your primary care doctor before you restart these medications. Physical therapy has been arranged for you at home. Followup Instructions: You will need to see your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4469**] at [**Telephone/Fax (1) 4475**] this week for a repeat blood work and BP check. Appointment is on Friday [**2187-2-9**] at 2-30pm GI - ([**Telephone/Fax (1) 54080**]) - Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. make an appointment with his for follow up. Also follow up with your hematologist Dr [**First Name (STitle) **] for blood work in 1 week.

[ "285.1", "412", "584.9", "238.75", "V58.61", "V42.2", "424.0", "416.8", "531.40", "397.0", "428.22", "272.0", "401.9", "428.0", "427.31", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "44.43", "99.04" ]

icd9pcs

[ [ [] ] ]

11027, 11078

7300, 9357

321, 327

11182, 11191

4264, 7277

12107, 12583

3703, 3768

9875, 11004

11099, 11161

9383, 9852

11215, 12084

3783, 4245

274, 283

355, 1992

2014, 3421

3437, 3687

61,500

164,843

52287

Discharge summary

report

Admission Date: [**2148-8-17**] Discharge Date: [**2148-8-24**] Date of Birth: [**2066-10-17**] Sex: F Service: MEDICINE Allergies: Bactrim Ds Attending:[**First Name3 (LF) 106**] Chief Complaint: Flash Pulmonary Edema, Hypotension, NSTEMI Major Surgical or Invasive Procedure: Arterial line History of Present Illness: 81F hx of anterior STEMI in [**9-3**] s/p thrombectomy and BMS x 2 to proximal LAD, EF 55% to 60% ([**1-5**]), also with distant hx of Non-Hodkins Lymphoma and is currently undergoing her third cycle of Gemzar/Cisplatin for Bladder CA (most recent treatment [**8-15**]) that presented to the ED this evening with SOB and later hypotension. . Of note the pt was admitted on [**2147-9-19**] for palpitations where she was noted to have SVT (likely AVNRT) on telemetry. During the admission the pt had nausea, without any CP or SOB. ECG at that time revealed new ST elevations anteriorly and the pt was subsequently taken emegently to the cath lab. . Last night the pt awoke in with nausea. The pt took Compazine and later Zofran without effect. The pt was given Decadron 10mg iv, given NS 300 cc, and 2 units of PRBCs. The pt also took Benadryl 25mg PO as well as Excedrin 500mg x2. The pt went to sleep from 6pm to 9pm this evening when she awoke acutely SOB and thus was brought to the ED. . Upon arrival to the ED, initial vitals BP 100/58, HR 101, afebrile, 98% on 100% nrb, RR 22. Pt noted to have elevated JVP and diffuse rales on exam. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . Past Medical History: PAST ONCOLOGIC HISTORY: (summary per note of Dr. [**Last Name (STitle) **] Her oncologic history begins in approximately [**2147-8-28**], at which time she presented with hematuria. She had a prior workup for hematuria in [**2143**], which was reportedly negative. She underwent cystoscopy with Dr. [**Last Name (STitle) **], which revealed diffuse disease of the bladder. Biopsy performed on [**2147-9-4**] revealed high-grade urothelial carcinoma infiltrating the lamina propria present in the left lateral and right lateral walls. There was low grade papillary urothelial carcinoma without lamina propria invasion seen in the trigone. Her course was then complicated by a STEMI approximately 2 weeks following the diagnosis of bladder cancer. She received bare metal stents to the LAD. She then underwent TURBT on [**2147-11-17**]. This was followed by BCG x6 between [**2147-11-27**] and [**2148-1-11**]. Staging CT torso performed on [**2148-1-11**] revealed no evidence of visceral disease. She then went for repeat cystoscopy with TURBT on [**2148-2-20**], with biopsy showing a focus suspicious for muscularis propria invasion identified in the deep biopsy of the tumor bed. There was also a rare focus suspicious for lymphovascular invasion. Tumor at present on the left lateral wall did show high-grade urothelial carcinoma invasive into the muscularis propria. She met with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] this time for consideration of a bladder resection, however, given the complications of her recent heart attack, she was felt to be a nonoperative candidate. She was then considered for a trial through RTOG using combined radiation with concurrent chemotherapy with taxane and possibly with Herceptin, pending HER2/neu staining. However, she has had progressive right greater than left knee pain over the last 3 to 6 months, which prompted a visit to the rheumatologist, Dr. [**Last Name (STitle) 1667**], on [**2148-4-9**]. Plain films of the knees were obtained on [**2148-4-16**] revealing multiple sclerotic foci involving bilateral femur and proximal tibia, highly concerning for metastasis. She then underwent MR of the right knee on [**2148-4-17**], which revealed markedly abnormal marrow signal in the distal femur and tibia, with areas of pathologic fracture along the medial epicondyle and medial condyle associated with soft tissue extension given this appearance is highly concerning for extensive metastases with pathologic fractures. She then met with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4223**] of orthopedics, who proceeded with a [**Last Name (NamePattern1) 500**] biopsy on [**2146-5-2**], pathology consistent with metastatic carcinoma, consistent with urothelial origin. The pt succesfully underwent XRT which provided pain relief and began her first dose of gemzar/cisplatin on [**6-18**]. . PAST MEDICAL HISTORY: ==================== Coronary artery disease, status post STEMI in [**2147-8-28**] (BMSx2 to proximal LAD) hypertension hypothyroidism lymphoma in [**2115**] with a large axillary mass, status post MOP chemotherapy and mantle radiation osteoporosis hypercholesterolemia diverticulitis s/p cholecystectomy stomach ulcers: status post surgery in [**2135**] incisional hernia repair at the gallbladder sight partial thyroidectomy due to injury after mantle radiation vein stripping on the left lower extremity Social History: -Tobacco history: never -ETOH: rare -Illicit drugs: denies -lives with husband and has two daughters that live near by who have been very helpful and present for the patient Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Her father died age [**Age over 90 **], her mother died in her 90s with a PPM (unknown reason why she got it) - son died in 20's of NH lymphoma - mother had a pacemaker in place, died at 92. Physical Exam: VS - BP 100/58, HR 101, afebrile, 98% on 100% nrb, rr 22 Gen'l - Mild respiratory distress, able to complete short sentences HEENT - JVP 14 cm Lungs - Diffuse rales both anteriorly and posteriorly obscuring heart sounds CV - difficult to assess, but tachycardic with regular rhythm Abd - soft, non tender, non distended Ext - 1+ edema, warm Pulses - 2+ distal pulses bilaterally Pertinent Results: [**2148-8-22**] 04:20AM Glucose- 96 BUN- 19 Cr- 0.8 Na- 137 K- 3.6 Cl- 104 Bicarb- 25 AG- 12 [**2148-8-23**] 06:25AM 3.4* 3.62* 10.4* 31.6* 88 28.7 32.8 19.7* 213 [**2148-8-22**] 04:20AM BLOOD WBC-3.8*# RBC-3.51* Hgb-10.1* Hct-30.7* MCV-87 MCH-28.9 MCHC-33.1 RDW-20.0* Plt Ct-362 [**2148-8-21**] 05:47AM BLOOD WBC-2.0* RBC-3.67* Hgb-10.6* Hct-31.6* MCV-86 MCH-28.8 MCHC-33.5 RDW-20.0* Plt Ct-377 [**2148-8-20**] 05:04AM BLOOD WBC-2.1*# RBC-3.89* Hgb-10.8* Hct-32.9* MCV-85 MCH-27.9 MCHC-32.9 RDW-19.1* Plt Ct-412 [**2148-8-19**] 05:58AM BLOOD WBC-4.8 RBC-3.93* Hgb-11.7* Hct-33.5* MCV-85 MCH-29.7 MCHC-34.8 RDW-19.6* Plt Ct-596* [**2148-8-18**] 10:52AM BLOOD Hct-34.3* [**2148-8-18**] 06:08AM BLOOD WBC-6.1 RBC-4.28 Hgb-12.9 Hct-35.5* MCV-83 MCH-30.3 MCHC-36.5*# RDW-19.6* Plt Ct-612* [**2148-8-17**] 05:56AM BLOOD WBC-8.4 RBC-5.02 Hgb-14.2 Hct-44.1 MCV-88 MCH-28.2 MCHC-32.1 RDW-19.7* Plt Ct-864* [**2148-8-17**] 12:10AM BLOOD WBC-8.2 RBC-4.58 Hgb-13.2 Hct-39.0 MCV-85 MCH-28.7 MCHC-33.8 RDW-20.6* Plt Ct-685* [**2148-8-17**] 12:10AM BLOOD Neuts-91.3* Lymphs-5.4* Monos-2.2 Eos-0.6 Baso-0.6 [**2148-8-22**] 04:20AM BLOOD Plt Ct-362 [**2148-8-22**] 04:20AM BLOOD PT-11.4 PTT-37.0* INR(PT)-0.9 [**2148-8-21**] 05:47AM BLOOD Plt Ct-377 [**2148-8-20**] 05:04AM BLOOD Plt Ct-412 [**2148-8-19**] 05:58AM BLOOD Plt Ct-596* [**2148-8-18**] 06:08AM BLOOD PT-11.9 PTT-50.7* INR(PT)-1.0 [**2148-8-17**] 05:56AM BLOOD Plt Ct-864* [**2148-8-17**] 05:56AM BLOOD PTT-104.1* [**2148-8-17**] 12:10AM BLOOD PT-11.6 PTT-25.2 INR(PT)-1.0 [**2148-8-17**] 12:10AM BLOOD Plt Ct-685* [**2148-8-22**] 04:20AM BLOOD Glucose-96 UreaN-19 Creat-0.8 Na-137 K-3.6 Cl-104 HCO3-25 AnGap-12 [**2148-8-21**] 05:47AM BLOOD Glucose-112* UreaN-23* Creat-0.9 Na-139 K-3.9 Cl-106 HCO3-22 AnGap-15 [**2148-8-20**] 05:04AM BLOOD Glucose-128* UreaN-30* Creat-1.0 Na-137 K-3.0* Cl-103 HCO3-23 AnGap-14 [**2148-8-19**] 05:58AM BLOOD Glucose-103 UreaN-36* Creat-1.3* Na-134 K-3.5 Cl-97 HCO3-23 AnGap-18 [**2148-8-18**] 04:32PM BLOOD Glucose-107* UreaN-39* Creat-1.5* Na-131* K-3.7 Cl-98 HCO3-19* AnGap-18 [**2148-8-18**] 06:08AM BLOOD Glucose-99 UreaN-40* Creat-1.5* Na-134 K-4.1 Cl-97 HCO3-19* AnGap-22* [**2148-8-18**] 01:32AM BLOOD Glucose-168* UreaN-40* Creat-1.5* Na-132* K-3.3 Cl-96 HCO3-16* AnGap-23* [**2148-8-17**] 02:29PM BLOOD Glucose-184* UreaN-40* Creat-1.7* Na-134 K-4.1 Cl-99 HCO3-15* AnGap-24* [**2148-8-17**] 12:10AM BLOOD Glucose-230* UreaN-32* Creat-1.4* Na-130* K-4.7 Cl-98 HCO3-17* AnGap-20 [**2148-8-16**] 09:20AM BLOOD UreaN-23* Creat-1.1 Na-131* K-4.0 Cl-99 HCO3-19* AnGap-17 [**2148-8-18**] 06:08AM BLOOD CK(CPK)-165* [**2148-8-17**] 10:00PM BLOOD CK(CPK)-230* [**2148-8-17**] 02:29PM BLOOD CK(CPK)-278* [**2148-8-17**] 05:56AM BLOOD CK(CPK)-289* [**2148-8-17**] 12:10AM BLOOD CK(CPK)-191* Amylase-49 [**2148-8-18**] 06:08AM BLOOD CK-MB-15* MB Indx-9.1* cTropnT-1.07* [**2148-8-17**] 10:00PM BLOOD CK-MB-21* MB Indx-9.1* cTropnT-1.56* [**2148-8-17**] 02:29PM BLOOD CK-MB-31* MB Indx-11.2* cTropnT-1.85* [**2148-8-17**] 05:56AM BLOOD CK-MB-32* MB Indx-11.1* cTropnT-2.29* [**2148-8-17**] 12:10AM BLOOD CK-MB-19* MB Indx-9.9* [**2148-8-17**] 12:10AM BLOOD cTropnT-1.51* [**2148-8-22**] 04:20AM BLOOD Calcium-7.9* Phos-2.5* Mg-1.6 [**2148-8-21**] 05:47AM BLOOD Calcium-7.5* Phos-2.1* Mg-2.0 [**2148-8-20**] 05:04AM BLOOD Calcium-7.7* Phos-2.3* Mg-1.8 [**2148-8-19**] 05:58AM BLOOD Calcium-8.2* Phos-3.4 Mg-2.4 [**2148-8-18**] 04:32PM BLOOD Calcium-7.9* Phos-4.3 Mg-1.8 [**2148-8-18**] 06:08AM BLOOD Calcium-8.2* Phos-5.5* Mg-2.0 [**2148-8-18**] 01:32AM BLOOD Calcium-7.6* Phos-6.0* Mg-2.2 [**2148-8-17**] 10:00PM BLOOD Calcium-7.4* Phos-6.9* Mg-2.3 [**2148-8-17**] 02:29PM BLOOD Calcium-7.3* Phos-7.6*# Mg-1.5* [**2148-8-18**] 06:08AM BLOOD TSH-4.0 [**2148-8-18**] 06:08AM BLOOD Cortsol-39.9* [**2148-8-17**] 05:34PM BLOOD Type-ART pO2-124* pCO2-24* pH-7.40 calTCO2-15* Base XS--7 [**2148-8-19**] 02:10PM BLOOD Type-ART Temp-37.2 Rates-/19 pO2-120* pCO2-28* pH-7.46* calTCO2-21 Base XS--1 Intubat-NOT INTUBA Vent-SPONTANEOU Comment-NC [**2148-8-18**] 08:05AM BLOOD Lactate-1.5 [**2148-8-18**] 02:08AM BLOOD Lactate-3.3* [**2148-8-17**] 10:20PM BLOOD Lactate-2.2* [**2148-8-17**] 05:34PM BLOOD Lactate-3.9* [**2148-8-17**] 06:12AM BLOOD Lactate-3.6* [**2148-8-17**] 12:17AM BLOOD Glucose-215* Lactate-2.8* Na-129* K-4.1 Cl-99* calHCO3-17* [**2148-8-19**] 02:10PM BLOOD freeCa-0.90* [**2148-8-18**] 04:54PM BLOOD freeCa-1.00* [**2148-8-18**] 08:05AM BLOOD freeCa-0.87* [**2148-8-18**] 02:08AM BLOOD freeCa-0.95* [**2148-8-17**] 10:20PM BLOOD freeCa-0.89* [**2148-8-17**] 05:34PM BLOOD freeCa-0.82* ECHO [**8-17**]- There is severe regional left ventricular systolic dysfunction with severe hypokinesis/akinesis of almost all myocardial segments. The basal inferolateral and lateral apical segments have relatively preserved function. Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. The mitral valve leaflets are mildly thickened. Compared with the prior study (images reviewed) of [**2148-1-22**], wall motion abnormalities are new. The current study has limited views so comparison of valvular function cannot be done. CXR [**8-17**]- IMPRESSION: Mixed response with improved aeration of the left mid lung field and increased opacity in the right lower lung field, for which positioning differences might be contributing. ECHO [**8-19**]- The left atrium is normal in size. There is mild regional left ventricular systolic dysfunction with moderate basal antero-septal hypokinesis and mild hypokinesis of the distal 2/3rds of the LV. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [**2148-8-17**], the function of the distal 2/3rds of the ventricle has improved. This change is consistent with resolving stress cardiomyopathy. Stress test [**8-22**]- IMPRESSION: No anginal symptoms or significant ST segment changes. MIBI [**8-22**]- No evidence of perfusion defects. LVEF:51% representing an interval decrease in function from 71% in [**2146**]. Decreased wall motion when compared to the previous study. Brief Hospital Course: # Shortness of breath- Patient admitted to CCU with shortness of breath and hypotension. Found to be in flash pulmonary edema. She was started on a lasix drip and diuresed well. Arterial line was place. Shortness of breath and hypoxia improved. Patient 2300cc negative on [**8-16**] while on lasix 5mg/hr IV drip and evophed. CXR improved. However, she then required increased levophed to maintain BP. Due to this, lasix drip was decreased to 3mg/hr for target diuresis of 75-100cc/hr so that levo could also be titrated down. CXR reviewed with radiology and it was felt that she may have a RLL PNA. Empiric coverage with vanco and levaquin was started. Diuresis was stopped as patient is potentially septic. ECHO showed LVEF of 15-20%. Repeat ECHO performed on [**8-19**] showed markedly improved LVEF (40-45%). It is thought the patient had takotsubo cardiomyopathy. By [**8-20**], lungs were clear to auscultation bilaterally with no complaints of shortness of breath. Patient no longer requiring oxygen. Patient transferred to floor on [**8-22**]. Upon discharge, patient was stable and comfortable. # Rhythm- Patient in sinus tachycardia on admission. She then experienced some chest tightness with elevated cardiac enzymes. Question of isolated ST elevation in lead V2. Did not experience any more chest pain/palpitations that night. At 1AM on [**8-18**], patient had a 2 minute run of SVT and her pressures dropped to 50s-60s systolic. It broke spontaneously and then recurred for about a minute with a similar BP drop. EKG obtained. Patient was asymptomatic. This happened as levophed was being titrated down because lasix drop was shut off. BP after event 70s-80s despite increased levophed. Patient bolused 250cc NS. She continued to periodically go into and out of SVT with BP going as low as 40s systolic. At 2:30AM she was taken off levophed and switched to neosynephrine. Did not have any more episodes of SVT that evening/morning. On [**8-18**], patient again had 26 beat run of SVT at 3pm, which resolved spontaneously. BP remained in the 90s-100s. Patient was asymptomatic. At 7:00pm she had another, longer run of SVT with rate into 170s. Again self-resolved. BP up to 130s. Gave 12.5 PO metoprolol- HR dropped to 90s. Patient very anxious. Given .5mg PO ativan. On [**8-19**], she had another self-resolved run of SVT to HR 150s while she was asleep. It resolved before ekg could be taken. Patient again said she did not notice/feel palpitations. [**Name8 (MD) **] RN, there was one other shorter SVT run overnight. Patient experienced no other runs of SVT while in-house. Upon discharge, vital signs were stable and patient was doing well. # Pump: EF in [**12/2147**] was 55%. ECHO on admission showed EF of 15-20%. Given patient's pneumonia and UTI, it is thought the patient had Takotsubo's cardiomyopathy. Again, patient initially diuresed but was then stopped due to concern of sepsis. Once treated with antibiotics, patient's heart function improved, symptoms resolved and EF upon discharge was approaching baseline (40-45%). On dischage, patients home metoprolol succinate was increased to 150mg daily and she was started on lisinopril 5mg daily. # Coronaries: Pt with known 1 vessel CAD and is s/p thrombectomy and placement of two bare metals stents after STEMI in 9/[**2146**]. On admission, cardiac enzymes were positive, and EKG showed questionable ST elevation in leads V1-V3. DDx at time included strain vs. acute plaque rupture. Enzymes peaked at CK: 289 MB: 32 MBI: 11.1 Trop-T: 2.29. Trended down afterwards with no more chest pain. Patient was continued on home aspirin 325mg, metoprolol 50mg daily, simvastatin 80mg daily. She was initally started on heparin gtt and loaded with [**Year (4 digits) 4532**] due to concern of ACS. EKG's followed closely. Stress MIBI showed no evidence of perfusion defects. LVEF:51% representing an interval decrease in function from 71% in [**2146**]. Decreased wall motion when compared to the previous study. There was no need to send patient cath lab on this admission. No episodes of chest pain while in hospital. Aspirin dose increased to 162mg daily. # Pneumonia/UTI: Patient presented with questionable RLL pneumonia on CXR. She was started on vancomycin and levaquin. Blood and urine cultures from ED grew pseudomonas. There was concern of sepsis so lasix drip was stopped. Patient improved. Remained afebrile. She had another positive culture on [**8-20**] which was most likely contaminated (grew back coag negative staph- one set only). Vancomycin was discontinued on [**8-19**]. Patient continued on levofloxacin and improved. All other cultures were negative. Upon discharge, patient given remainder of her 10 day levofloxacin dose. # Hematuria- Patient had gross hematuria on every urination after foley d/c'd around 2 pm on [**8-22**]. Denied lightheadedness, dizziness. She maintained BPs, checked stat Hct and T&C'd 1 unit, Hct 32.8, stable. Urology consulted regarding hematuria they recommended follow-up as an outpatient if hematuria has not resolved in a week. Should she need to have a procedure she is able to stop [**Month/Year (2) **] but resume once procedure is done. # Hyponatremia - Presented with sodium of 131. Thought to be related to hypervolemic hyponatremia in setting of CHF exacerbation. Urine lytes were checked. Sodium followed and continued to trend up. Upon discharge sodium was 137. # Metabolic acidosis - Bicarb 17 and lactate 3 on admission. Lactate trended down to 1.5 on [**8-18**]. Bicarb 23 on discharge. Acidosis was most likely related to poor forward flow in setting of volume overload and CHF exacerbation. Now resolved. # Acute renal failure - Baseline Cr 0.8 but up to 1.4 on admission. Suspected to be pre-renal etiology given BUN/Cr ratio and physical exam. Resolved over course of admission (Cr down to .8 on discharge). # Hypertension- Hypotensive on admission. Home BP meds held initially. Restarted on 6.25mg [**Hospital1 **] once pressures began to rise. Slowly increased dose of metoprolol (12.5 [**Hospital1 **] --> 12.5 TID --> 25mg TID). Discharged on metoprolol 75mg PO TID # Hypothyroidism - continued home dose synthroid. # Metastatic bladder cancer - received third cycle of Gemzar/Cisplatin (most recent treatment [**8-15**]). Previously received BCG therapy. Monitored CBC. # Distant hx of Non-Hodkins Lymphoma - lymphoma in [**2115**] with a large axillary mass, status post MOP chemotherapy and mantle radiation. # Osteoporosis - Continued fosamax, as per home regimen. FEN: regular heart healthy diet. Repleted lytes as needed. PROPHYLAXIS: -DVT ppx with heparin gtt -Boel regimen with senna/colace CODE: full, confirmed with patient and daughter Medications on Admission: -metoprolol succinate 50 mg tab SR -simvastatin 80 mg -alprazolam -aprepitant -dexamethasone 4 mg tablet (2 tabs po daily prn nausea) -synthroid 137 mcg -zofran 8 mg tab -prochlorperazine maleate -excedrin migraine Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2* 6. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 2 doses. Disp:*2 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Community acquired pneumonia, UTI, Takotsubo's cardiomyopathy Secondary diagnoses: - Bladder CA with [**Year (4 digits) 500**] metastases - hypertension - hypothyroidism - lymphoma in [**2115**] with a large axillary mass, status post MOP chemotherapy and mantle radiation - osteoporosis - hypercholesterolemia - diverticulitis - s/p cholecystectomy - stomach ulcers: status post surgery in [**2135**] - incisional hernia repair at the gallbladder sight - partial thyroidectomy due to injury after mantle radiation - vein stripping on the left lower extremity Discharge Condition: stable, afebrile, ambulatory Discharge Instructions: You were admitted to [**Hospital1 69**] with shortness of breath and decreased blood pressure. You were found to have a pneumonia and urinary tract infection which were causing stress on your heart leading to decreased heart function. This phenomenon is called Takotsubo's cardiomyopathy. Your heart function completely recovered after your infections were treated appropriately with antibiotics. You developed blood in your urine prior to discharge and will follow-up closely with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] urology clinic if it does not resolve in one week. The following changes have been made to your home medication regimen: 1. You will complete a 10 day course of Levaquin with 2 more doses at home. 2. You will increase your home metoprolol succinate to 150mg daily. 3. You will start lisinopril 5mg daily. 4. Your home aspirin dose will be changed to 162mg daily (two 81mg tablets). Please follow-up with all of your outpatient medical appointments listed below. Please seek medical care if you experience any concerning symptoms such as fevers, chills, dizziness, lightheadedness, shortness of breath, chest pain, abdominal pain, or continued blood in your urine. Followup Instructions: Please follow-up with all of your outpatient medical appointments listed below. 1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5465**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2148-9-5**] 10:30 2. Provider: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 3217**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2148-9-5**] 10:30 3. Provider: [**Known firstname 26**] [**Name8 (MD) 28**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2148-9-5**] 12:00 Please follow-up in one week with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] the blood in your urine does not stop. Please follow-up with your cardiologist, Dr. [**Last Name (STitle) **], at your earliest convenience. Completed by:[**2148-8-24**]

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Discharge summary

report+addendum+addendum

Admission Date: [**2163-1-5**] Discharge Date: [**2163-1-11**] Date of Birth: [**2087-9-22**] Sex: F Service: CARDIOTHORACIC Allergies: Codeine / Trazamine / Percocet / Vicodin Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [**2163-1-6**] Coronary Artery Bypass Graft x 5 (Left internal mammary artery to Left anterior descending, Saphenous vein graft to Diagonal, Saphenous vein graft to Ramus, Saphenous vein graft to Obtuse Marginal, Saphenous vein graft to Right coronary artery) History of Present Illness: 75 y/o female with extensive past medical history who developed acute onset chest pain and dyspnea at the end of [**Month (only) 321**]. The symptoms progressively worsened and EMS brought patient to outside hospital. Underwent cardiac cath which revealed severe three vessel coronary artery disease and was transferred to [**Hospital1 18**] for surgical revascularization. Past Medical History: Diabetes Mellitus, Hypertension, Hypercholesterolemia, Congestive Heart Failure, Diabetic Retinopathy, Hypothyroidism, Carpal tunnel syndrome s/p bilateral surgery, s/p Hysterectomy, Obesity, Recurrent Urinary Tract Infections, s/p Appendectomy, s/p Tonsillectomy, s/p bilateral cataract surgery, s/p Thyroidectomy Social History: Patient lives with her son, smoked 1ppd for 20 years before quitting 30 years ago, drinks socially, no illicit/IVDU. Family History: Positive for [**Name (NI) 2320**], mother died of CAD Physical Exam: At discharge: VS: 99.2 97BPM 96/51 20 96% 4L NC Gen: Pleasant, answers questions appropriately HEENT: PERRLA Neck: supple, tender to palpation along sternocleidomastoid, worse when coughing Chest: Decreased lung sounds at left base. Serous drainage from distal pole of sternal incision. Sternum stable with cough. Heart: Bradycardic rate, distant heart sounds with normal S1S2 Abd: obese, normoactive bowel sounds. Soft and nontender without rebound/guarding Ext: warm with 1+ edema to mid shins Neuro: intact Pertinent Results: [**1-5**] ChestCT: 1. Mild calcifications of the aortic annulus and anterior ascending aorta extending to the level of the right pulmonary artery. 2. Pulmonary arterial hypertension. 3. Mediastinal lymph nodes likely reactive. [**1-6**] Echo: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 60-70%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened and display slightly reduced systolic excusion. However, frank aortic stenosis is NOT present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2162-4-29**], no major change is evident. [**2163-1-6**] Carotid U/S: 1. 40-59% stenosis of the right internal carotid artery. 2. Less than 40% stenosis of the left internal carotid artery. [**2163-1-9**] 06:45AM BLOOD WBC-8.7 RBC-3.10* Hgb-9.2* Hct-25.5* MCV-82 MCH-29.6 MCHC-36.1* RDW-15.4 Plt Ct-120* [**2163-1-5**] 07:24PM BLOOD WBC-8.0 RBC-4.26 Hgb-12.0 Hct-34.4* MCV-81* MCH-28.1 MCHC-34.8 RDW-15.0 Plt Ct-219 [**2163-1-6**] 06:57PM BLOOD PT-14.9* PTT-34.8 INR(PT)-1.3* [**2163-1-5**] 07:24PM BLOOD PT-13.6* PTT-24.6 INR(PT)-1.2* [**2163-1-10**] 05:19AM BLOOD Glucose-130* UreaN-37* Creat-1.6* Na-135 K-5.1 Cl-101 HCO3-26 AnGap-13 [**2163-1-9**] 06:45AM BLOOD Glucose-118* UreaN-33* Creat-1.3* Na-136 K-4.3 Cl-102 HCO3-21* AnGap-17 [**2163-1-8**] 06:03AM BLOOD Glucose-111* UreaN-26* Creat-1.2* Na-136 K-4.5 Cl-103 HCO3-24 AnGap-14 [**2163-1-5**] 07:24PM BLOOD Glucose-255* UreaN-20 Creat-0.9 Na-138 K-3.9 Cl-102 HCO3-28 AnGap-12 [**2163-1-9**] 06:45AM BLOOD Mg-2.5 [**2163-1-7**] 02:00AM BLOOD Mg-2.3 [**2163-1-5**] 07:24PM BLOOD %HbA1c-7.4* Brief Hospital Course: As mentioned in the HPI, Mrs. [**Known lastname 4886**] was transferred from OSH for cardiac surgery. She was appropriately worked-up and brought to the operating room on [**1-6**] where she underwent a coronary artery bypass graft x 5. 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. She was gently diuresed with IV lasix towards her pre-operative weight. On POD 4 she had a slight increase in her BUN/CR and her lasix was changed to [**Hospital1 **]. Physical therapy was consulted to work on strength and balance and felt that she would be best served by a short stay at a rehab facility. There was serous drainage from the distal pole of her sternal incision and she was started on a 5 day course of Keflex. On POD 4 she was screened and received a bed and was discharged to rehab. Medications on Admission: Carvedilol 12.5mg [**Hospital1 **], Lasix 40mg qd, KCL, Aspirin 325mg qd, Lisinopril 2.5mg qd, Amlodipine 10mg qd, Levothyroxine 125mg qd, Simvastatin 80mg qd, Insulin Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): Hold for SBP < 90, HR < 50. Disp:*30 Tablet(s)* Refills:*0* 2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days. Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 5. 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* 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp:*qs Tablet(s)* Refills:*0* 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. Disp:*qs ML(s)* Refills:*0* 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. Disp:*5 Suppository(s)* Refills:*0* 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): until patient is ambulatory and out of bed on a consistent basis. Disp:*qs qs* Refills:*2* 10. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 11. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 12. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:*30 Tablet(s)* Refills:*0* 13. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 14. Insulin Lispro Protam & Lispro 100 unit/mL (75-25) Insulin Pen Sig: One (1) Subcutaneous three times a day: Patient to receive 20 units at breakfast, 10 units at lunch, and 25 units at dinner. Disp:*qs qs* Refills:*2* 15. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. Disp:*qs ML(s)* Refills:*0* 16. Cephalexin 250 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours) for 5 days. Disp:*30 Capsule(s)* Refills:*0* 17. Furosemide 40 mg IV BID 18. Ondansetron 4 mg IV Q8H:PRN Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 5 PMH: Diabetes Mellitus, Hypertension, Hypercholesterolemia, Congestive Heart Failure, Diabetic Retinopathy, Hypothyroidism, Carpal tunnel syndrome s/p bilateral surgery, s/p Hysterectomy, Obesity, Recurrent Urinary Tract Infections, s/p Appendectomy, s/p Tonsillectomy, s/p bilateral cataract surgery, s/p Thyroidectomy Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**Last Name (STitle) 914**] in 4 weeks Dr. [**Last Name (STitle) 5717**] in [**2-3**] weeks Dr. [**First Name (STitle) **] in [**3-7**] weeks Completed by:[**2163-1-10**] Name: [**Known lastname 2601**],[**Known firstname 6310**] M Unit No: [**Numeric Identifier 15824**] Admission Date: [**2163-1-5**] Discharge Date: [**2163-1-11**] Date of Birth: [**2087-9-22**] Sex: F Service: CARDIOTHORACIC Allergies: Codeine / Trazamine / Percocet / Vicodin Attending:[**First Name3 (LF) 1543**] Addendum: Patient will be on Metoclopramide 10MG IV q6 hours for 24 hours. Discharge Disposition: Extended Care Facility: [**Hospital1 49**] - [**Location (un) 50**] [**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**] Completed by:[**2163-1-10**] Name: [**Known lastname 2601**],[**Known firstname 6310**] M Unit No: [**Numeric Identifier 15824**] Admission Date: [**2163-1-5**] Discharge Date: [**2163-1-11**] Date of Birth: [**2087-9-22**] Sex: F Service: CARDIOTHORACIC Allergies: Codeine / Trazamine / Percocet / Vicodin Attending:[**First Name3 (LF) 1543**] Addendum: [**2163-1-11**] Addendum: Minimal Serous drainage noted from the sternal inferior pole. Sternum stable. No [**Doctor Last Name **]/click. Afebrile, WBC ct 9.7 As discussed with Dr.[**Last Name (STitle) **]: Betadine swabs/DSD b.id/prn. Keflex x 7day course. Wound check scheduled at clinic in 1 week: [**1-19**] coming from rehab. Discharge Disposition: Extended Care Facility: [**Hospital1 49**] - [**Location (un) 50**] [**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**] Completed by:[**2163-1-11**]

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icd9cm

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icd9pcs

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119,219

3698

Discharge summary

report

Admission Date: [**2192-3-21**] Discharge Date: [**2192-4-4**] Date of Birth: [**2136-12-24**] Sex: F Service: MEDICINE Allergies: Vancomycin / Iodine; Iodine Containing / Tape / Ibuprofen / Levofloxacin / Bactrim Attending:[**Doctor First Name 2080**] Chief Complaint: dyspnea, cough Major Surgical or Invasive Procedure: Tracheotomy change to cuffed 6 french cuff History of Present Illness: HPI: Ms. [**Known lastname **] is a 55 YOF with type I diabetes, morbid obesity (wheelcheer bound), CAD s/p CABG, diastolic CHF, sarcoidosis, asthma complicated by airway obstruction with chronic uncuffed tracheostomy, and neurogenic bladder with chronic indwelling urinary catheter who presented from home after experiencing worsening dyspnea on [**2192-3-21**]. The pateint states while watching TV she became more short of breath than usual, took albuterol which, helped but not as much as should so she came in. She noted she had been having a productive cough with brown sputum but no fevers. . In the ED her vitals were 98.3 85 131/67 20 95 (on home 02 of 2.5L). Her CXR showed mild pulmonary edema, stable severe cardiomegaly and a small left pleural effusion. Her creatinine was 1.6 (up from baseline 1.1) so she was not given lasix. EKG showed some changes-diffuse ST flattening, now more depressed inferior and laterally. The patient was given aspirin. BNP was 5861 and the pt was admitted to medicine for CHF exacerbation. ROS: (+) As per HPI. Pt denied HA, CP, cough, change in diet prior to hospitalization ,medication noncompliance, fever, chills, nausea, vomiting, or change in MBs. She has urinary incontinence at baseline and has a chronic catheter. ROS: (+) As per HPI. Pt denied HA, CP, cough, change in diet prior to hospitalization ,medication noncompliance, fever, chills, nausea, vomiting, or change in MBs. She has urinary incontinence at baseline and has a chronic catheter. . Past Medical History: PAST MEDICAL HISTORY: Morbid obesity Asthma Diastolic heart failure Diabetes mellitus Type 1 (since age 16): neuropathy, gastroparesis, nephropathy, & retinopathy Sarcodosis ([**2175**]) Tracheostomy - [**3-13**] upper airway obstruction, sarcoid. [**2191-5-19**] trach changed from #6 cuffed portex to a #6 uncuffed, nonfenestrated portex Arthritis - wheel chair bound Neurogenic bladder with chronic foley Asthma Hypertension Pulmonary hypertension Hyperlipidemia CAD s/p CABG [**2179**] (SVG to OM1 and OM2, and LIMA to LAD) last c. cath [**2187-2-28**]: widely patent vein grafts to the OM1 and OM2, widely patent LIMA to LAD (distal 40% anastomosis lesion). Chronic low back pain-disc disease s/p cholecystectomy s/p appendectomy History of sternotomy, status post osteomyelitis in [**2179**]. Leukocytoclastic vasculitis [**3-13**] vancomycin in [**2179**]. History of pneumothorax in [**2179**]. Colon resection, status post perforation. J-tube placement in [**2173**]. Social History: The patient formerly lived alone and has a female partner for 25 years that visits frequently and is her HCP. She had been living in rehab recently, but most recently discharged home w/o services. The patient is mobile with scooter or wheelchair and can walk short distances. Remote smoking history <1 pack per day >30 years ago, denies EtOH or drug use. Family History: Father: [**Name (NI) **], Diabetes & MI in 60s Mother's side: Family history of various cancers & heart disease Physical Exam: Physical Exam: Vitals: T: 98.7 P: 72 BP: 140/62 R: 20 SaO2: 100% on 10 L (fiO2 40%) General: Awake, alert, NAD, eating dinner HEENT: NC/AT, EOMI without nystagmus, no scleral icterus noted, MMM, no lesions noted in OP NECK: no lymphadenopathy, no elevated JVD Pulmonary: Lungs CTA bilaterally, poor air movement Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses b/l. Skin: no rashes or lesions noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact Pertinent Results: Labs on admission: [**2192-3-21**] 02:41AM BLOOD WBC-9.1 RBC-4.15* Hgb-12.4 Hct-38.3 MCV-92 MCH-29.9 MCHC-32.4 RDW-14.3 Plt Ct-135* [**2192-3-21**] 02:41AM BLOOD Neuts-92* Bands-0 Lymphs-6* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2192-3-21**] 02:41AM BLOOD PT-12.2 PTT-23.8 INR(PT)-1.0 [**2192-3-21**] 02:41AM BLOOD Glucose-359* UreaN-65* Creat-1.6* Na-127* K-8.3* Cl-91* HCO3-30 AnGap-14 [**2192-3-21**] 02:41AM BLOOD CK(CPK)-124 [**2192-3-21**] 02:41AM BLOOD CK-MB-3 proBNP-5861* [**2192-3-21**] 02:41AM BLOOD cTropnT-<0.01 [**2192-3-21**] 11:07AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2192-3-21**] 02:34PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2192-3-21**] 02:34PM BLOOD Calcium-9.0 Phos-4.5 Mg-2.3 ABG prior to MICU transfer [**2192-3-21**] 08:12AM BLOOD Type-ART pO2-55* pCO2-66* pH-7.30* calTCO2-34* Base XS-3 Labs on discharge [**2192-4-4**] 06:02AM BLOOD WBC-8.5 RBC-3.94* Hgb-11.4* Hct-35.1* MCV-89 MCH-29.0 MCHC-32.6 RDW-13.7 Plt Ct-216 [**2192-4-1**] 05:38AM BLOOD Neuts-79.7* Lymphs-14.5* Monos-4.0 Eos-1.5 Baso-0.3 [**2192-4-4**] 06:02AM BLOOD Glucose-131* UreaN-34* Creat-1.1 Na-137 K-4.0 Cl-93* HCO3-36* AnGap-12 [**2192-4-4**] 06:02AM BLOOD ALT-82* AST-31 AlkPhos-202* TotBili-0.9 [**2192-4-4**] 06:02AM BLOOD Calcium-8.8 Phos-3.7 Mg-1.5* [**2192-4-1**] 05:38AM BLOOD calTIBC-299 Ferritn-326* TRF-230 [**2192-3-31**] 04:21AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE MICRO: [**2192-3-23**] 3:20 am URINE Source: Catheter. URINE CULTURE (Preliminary): KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML.. GRAM NEGATIVE ROD(S). ~[**2182**]/ML. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- =>64 R CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- =>128 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Images: EKG [**2192-3-23**]: Sinus tachycardia with increase in rate as compared with previous tracing of [**2192-3-21**]. Atrial ectopy persists. There is baseline artifact. The ST-T wave changes are less prominent but this may represent pseudonormalization. Clinical correlation is suggested. . EKG [**2192-3-22**]: Sinus rhythm. Premature atrial contractions. Borderline left axis deviation with possible left anterior fascicular block. Diffuse ST-T wave changes. Cannot rule out myocardial ischemia. Compared to the previous tracing of [**2191-7-22**] inferior and anterolateral ST-T wave changes are more prominent. Clinical correlation is suggested. . Echo [**2192-3-21**]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50-55%). There is no ventricular septal defect. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . [**2192-3-22**] CXR: FINDINGS: As compared to the previous radiograph, there is unchanged mild-to-moderate pulmonary edema. Blunting of the left costophrenic sinus, so that a small left pleural effusion cannot be excluded. Unchanged low lung volumes, unchanged moderate cardiomegaly. No focal parenchymal opacities suggesting pneumonia. . [**2192-3-23**] CXR: 1. Moderate cardiomegaly with increased moderate pulmonary edema compared to [**2192-3-22**]. 2. Retrocardiac opacity most likely represents left basilar atelectasis. However, the differential diagnoses include layering left-sided pleural effusion, increased pulmonary edema, aspiration or pneumonia in the correct clinical setting. . [**2192-3-24**] CXR: There is again a tracheostomy tube in place, in good position. There is overall interval decrease in left lung base opacity compared to the prior examination. The left costophrenic angle is not seen. Right hemithorax is unremarkable. No evidence of pneumothorax. No new parenchymal opacity is visualized. Remainder of the examination is unchanged. Kidney Ultrasound [**2192-3-30**]: FINDINGS: No hydronephrosis of the right kidney or left kidney. The bipolar diameter of the right kidney is 9.8 cm and left kidney 8.8 cm. A 0.3 cm x 0.2 cm x 0.3 cm non-obstructing calculus is identified at the mid to lower pole of the right kidney. No other calculi are seen in the right kidney. A tiny hyperechoic focus at the mid pole of the left kidney most likely represents crystals and a caliceal diverticulum. No other focal abnormalities are seen in the left kidney. The urinary bladder is empty with a Foley catheter in situ. Liver Ultrasound [**2192-3-30**]: FINDINGS: Overall, evaluation is very limited by difficult son[**Name (NI) 493**] penetration. No definite focal hepatic lesion is seen. The patient is status post cholecystectomy. Dilation of the extrahepatic common duct to 1.2 cm is noted in the setting of mild left intra-hepatic biliary ductal dilatation, findings which are unchanged since a CTA CHEST from 11/[**2189**]. The main portal vein demonstrates normal hepatopetal flow. No free fluid is seen in the right upper quadrant. IMPRESSION: Unchanged biliary ductal dilatation may be related to prior cholecystectomy, however the etiology is not completely certain. MRCP may be utilized for further evaluation, if clinically indicated. Chest X ray [**2192-4-3**]: The patient has chronic low lung volumes which limit intrathoracic evaluation. The left pleural scarring/pleural effusion is unchanged . Cardiac silhouette is moderately enlarged, also unchanged. Tracheostomy tube is grossly normal. Right PICC terminates with its tip in the mid to distal SVC. IMPRESSION: No pulmonary edema or infectious process. Brief Hospital Course: # Dyspnea/respiratory distress: When pt arrived on the floor she was tachypnic and somnolent. She was sating 88-90% on 100% trach mask. Normally she is on 2.5 liters trach mask at home. There was concern for CHF exacerbation so lasix was given and pt had thick yellow urine. ABG was 7.30/66/55. Resp therapy was called to beside. Pt has a size 6 cuffless trach. Suctioning removed thick yellow secretions and sats improved to 97% on 50% trach mask. There was also some concern of Twave changes on her EKG. She was transferred to the MICU [**2192-3-24**] for respiratory distress. In the Unit the patient had her trach changed to a cuffed trach in case she needed to be vented. However, she did not require this. She received nebs, suctioning, and IV lasix (80 mg with good result). Cultures were obtained and the patient was empirically treated for pneumonia with cefepime and flagyl. The patient remained afebrile and her flagyl was stopped. The cefepime was kept as she had evidence of UTI on UA. At time of transfer out from the ICU to the medicine floor the patient had been diuresed 12 L over the length of stay. The patient continued to be diuresed on the medicine floor. However, she lost her IV access and received 80 mg lasix PO BID instead of by IV. She continued to receive her albuterol, ipratropium, acetyl cysteine nebs. Her O2 sats improved and she was able to tolerate FiO2 of 35% which roughly corresponded to her 2.5 L O2 at home. She remained afebrile and her shortness of breath returned to baseline. The source of her exacerbation is unclear as she states she was compliant with medications and diet. She should continue her salt restricted diet, diuretics, and daily weight monitoring. #) assymptomatic bacteriuria: From chronic foley catheter (which was placed for neurogenic bladder). The patient was found to have a dirty UA and was initially started on cefepime in the ICU. Urine cultures grew Klebsiella senisitive to cipro but the patient was allergic to floroquinolones so she was started on bactrim. However, this caused acute interstitial nephritis so it was stopped on day 5. Her foley was changed and a repeat Urinalysis and culture showed 6 WBCs, and 10,000 to 100,000 bacteria that eventually grew E coli (ESBL). She was not started on antibiotics given that she was assymptomatic, has a chronic indwelling catheter and is likely colonized, there were less than 100,000 bacteria in the sample, and she has had multiple adverse reactions to antibiotics including her recent AIN. She should get a repeat UA and culture when she goes to her follow up appointment with her PCP. [**Name10 (NameIs) **] patient was counseled to call her doctor or return to the ED if she felt like she was developing a UTI. #) Acute renal failure/acute interstitial nephritis: The pateint presented to the hospital with Cr 1.6 up from 1.1. Her creatinine improved to 0.8 with diuresis supporting poor forward flow as the cause of her ARF. She developed acute renal failure again after starting the bactrim for her UTI. Her creatinine bumped up to 2.1 on day # 5 of antibiotics. Renal was consulted and recommended stopping bactrim. After this was stopped her creatinine slowly improved. It was 1.1 the day of discharge. She should list Bactrim as an allergy due to AIN and not take this in the future. #) dyspepsia/nausea/transaminitis/hepatitis: On hospital day 8 the patient developed nausea that was first thought to be due to worsening gastroparesis as it was noticed she was not receiving her home reglan. This medication was restarted but the patient continued to have nausea without abdominal pain or diarrhea. Her LFTs were noted to be elevated with a cholestatic picture. A liver ultrasound was performed which showed unchanged biliary ductal dilatation. Hepatology was consulted and they recommended a full work up given she has had elevated enzymes in the past but never had a work up to identify the source. Initial hepatology labs were unrevealing including hepatitis serologies, IgG, TtG, and fe levels (although she had an elevated ferretin). Autoimmune antibodies, ceruloplasmin, and alpha 1 antitrypsin were pending at the time of discharge. Hepatology also considered an MRCP and liver biopsy but these were not performed because her labs trended back down. It was thought that they may have transiently been elevated because of her CHF exacerbation. Nevertheless, she was set up with an appointment with the liver doctors to follow up on the rest of her labs and discuss the utility of a liver biopsy in the future as she may still have an underlying liver problem contributing to her acute elevation in enzymes given her history of elevated enzymes in the past. #) Depression: the patient was continued on her home regimen of citalopram #) Diabetes, type 2 uncontrolled: the patient was continued on Glargine 54 U Q HS with humalog sliding scale. Her blood glucose was noted to be elevated despite her not taking in much PO due to nausea. [**Last Name (un) **] was consulted and they recommended increasing her sliding scale. Blood cultures were obtained to rule out infection but were negative. #) CAD, native: the patient was continued on her metoprolol, aspirin, simvastatin, and valsartan #) dCHF: echo performed showed EF 50-55%. BNP was elevated. The patient was aggresively diuresed. She was maintained on her valsartan and metoprolol. She was euvolemic at the time of discharge. #) pain control: the patient was continued on her home regimen of vicodin and gabapentin #) dispo: The patient lives at home and has VNA once a month (per pt). Although the patient enjoys her indiependence, it was thought that she would benefit from more assistance with monitoring, medication compliance, foley, and trach care. She was discharged with home services with VNA who may determine if she required more care. . #) FEN: The patient was placed on a p.o. diabetic, cardiac healthy diet . #) Code Status: Full Medications on Admission: ACETYLCYSTEINE 1 nebulizer treatment twice a day ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) 1-2 puffs po twice a day BENZTROPINE MESYLATE - 1MG Tablet THREE TIMES A DAY BUTALBITAL-ACETAMINOPHEN-CAFF [FIORICET] - 50 mg-325 mg-40 mg Tablet - 1 Tablet(s) by mouth q4hr CITALOPRAM - 40 mg Tablet once a day CLOPIDOGREL [PLAVIX] 75 mg Tablet once a day FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose Disk with Device - 1 puff po twice a day FUROSEMIDE - 60 mg Tablet once a day GABAPENTIN [NEURONTIN] - 300 mg Capsule PO three times a day INSULIN GLARGINE [LANTUS] 54u at bedtime INSULIN LISPRO [HUMALOG] Dosage uncertain IPRATROPIUM BROMIDE - 0.2 mg/mL (0.02 %) 2 puffs po q6hr LORAZEPAM - 2 mg Tablet -PO at bedtime as needed for insomnia may take additional one tab qAM for anxiety METOCLOPRAMIDE - 60 mg Tablet qd as directed--2 pills-1 pill-2 pills and 1 pill METOPROLOL TARTRATE - 50 mg Tablet [**Hospital1 **] NORMAL SALINE - - to clean tracheotomy [**Hospital1 **] and prn OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - [**Hospital1 **] ONDANSETRON - 8 mg Tablet, Rapid Dissolve [**Hospital1 **] PRN for nausea PNV W/O CALCIUM-IRON FUM-FA [M-VIT] 27 mg-1 mg TabletBID SIMVASTATIN - 20 mg Tablet PO Qday VALSARTAN [DIOVAN] - 40 mg Tablet PO Qday VICODIN - 5-500MG Tablet - 1-2 TABS PO TID, PRN FOR BACK AND KNEE PAINS ASPIRIN - 325 mg Tablet PO Qday CALCIUM CARBONATE [TUMS ULTRA] - 1,000 mg Tablet, DOCUSATE CALCIUM - 100MG Capsule - PO BID Discharge Medications: 1. Acetylcysteine 20 % (200 mg/mL) Solution [**Hospital1 **]: One (1) ML Miscellaneous [**Hospital1 **] (2 times a day). 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: 1-2 puffs Inhalation twice a day. 3. Benztropine 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO three times a day. 4. Fioricet 50-325-40 mg Tablet [**Hospital1 **]: One (1) Tablet PO every four (4) hours. 5. Citalopram 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 6. Clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 7. Advair Diskus 250-50 mcg/Dose Disk with Device [**Hospital1 **]: One (1) puff Inhalation twice a day. 8. Furosemide 20 mg Tablet [**Hospital1 **]: Three (3) Tablet PO once a day. 9. Neurontin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO three times a day. 10. Insulin Glargine 100 unit/mL Solution [**Hospital1 **]: Fifty Four (54) units Subcutaneous at bedtime. 11. Insulin Lispro Subcutaneous 12. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: Two (2) puffs Inhalation QID (4 times a day). 13. Lorazepam 1 mg Tablet [**Hospital1 **]: Two (2) Tablet PO at bedtime as needed for insomnia: may take additional tab Qam for anxiety. 14. Metoclopramide Oral 15. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 16. Normal Saline Flush 0.9 % Syringe [**Hospital1 **]: One (1) trach flush Injection twice a day: PRN to clean tracheotomy. 17. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 18. Ondansetron 8 mg Tablet, Rapid Dissolve [**Hospital1 **]: One (1) Tablet, Rapid Dissolve PO twice a day as needed for nausea. 19. PNV w/o Calcium-Iron Fum-FA 27-1 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day. 20. Simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 21. Valsartan 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 22. Hydrocodone-Acetaminophen 5-500 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q8H (every 8 hours) as needed for pain: PRN for back and knee pain. 23. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 24. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2 times a day). 25. Calcium Carbonate 1,000 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO once a day. 26. Psyllium Packet [**Hospital1 **]: One (1) Packet PO TID (3 times a day). 27. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) for 11 days: Last day = [**2192-4-4**]. Disp:*22 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary diagnosis: diastolic CHF exacerbation Klebsiella urinary tract infection acute renal failure Secondary diagnosis: Diabetes Coronary artery disease pulmonary hypertension Depression Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Out of Bed with assistance to chair or wheelchair Discharge Instructions: You came to the hospital because you were having trouble breathing. You were admitted but then had worsening shortness of breath so you were transferred to the intensive care unit. It was thought that you had an exacerbation of your CHF which was the cause for the shortness of breath. You were given lasix and your breathing improved. You were also found to have a urinary tract infection and so you were started on Bactrim antibiotics. Unfortunately, this medication caused you to have damage to your kidney so it was stopped. You should not take this antibiotic in the future. Repeat urine cultures showed a small amount of bacteria but we thought that it was contamination and with the risks of antibiotic use on your kidneys we decided not to treat this. If you develop any symptoms of a urinary tract infection you should call Dr. [**Name (NI) 16684**] office right away. You also were noted to have nausea and abnormalities in your liver [**Name (NI) **] tests. It was thought that your nausea was from your gastroparesis. You were evaluated by the liver specialists who thought the abnormal liver labs were caused by your CHF. They improved over time. Because this is not the first time your liver labs have been abnormal the liver specialists think you should follow up with them as an outpatient to see if you need further testing. No changes have been made to your medications. However, you should note that Bactrim should be added to your list of medications that cause allergy and you should not take this drug in the future. Please go to your follow up appointments (see below). Please continue to take all of your medications as prescribed and adhere to a low salt diet. You should weigh yourself every morning, and call your primary care doctor if your weight goes up more than 3 lbs. It was a pleasure taking part in your care. Followup Instructions: Please have your visiting nurse draw your blood next Monday or Tuesday to check your liver enzymes and white blood cell count. Please have these results sent to your primary care doctor, Dr. [**Last Name (STitle) **]. Her phone number is [**Telephone/Fax (1) 250**]. Please go to your follow up appointment at your primary care clinic for post-hospitalization check up. We have made this appointment for you. You will be seeing a nurse [**Last Name (Titles) 16685**], [**Last Name (LF) **],[**First Name3 (LF) **] G., on [**4-23**] at noon. You also have an appointment with Dr. [**Last Name (STitle) **] on [**6-4**] at 4:10 pm. The phone number for Dr. [**Last Name (STitle) **] is [**Telephone/Fax (1) 250**] if you need to change these appointments. It is very important that you go to your follow up appointment on [**4-23**] because we want to check your urine to make sure that you do not develop another urinary tract infection. Please call the office if you develop symptoms before this appointment. You also have a follow up appointment with the liver doctors. You will be seeing Dr. [**First Name (STitle) **]. at 3:40 pm on [**4-12**], located in the [**Hospital Unit Name **] on the [**Location (un) **], suite E. This has been scheduled as an 'urgent' visit and they are squeezing you in so you can be seen at this time. The phone number is ([**Telephone/Fax (1) 16686**] if you need to reschedule this appointment or call for directions.

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icd9cm

[ [ [] ] ]

[ "97.23", "38.93" ]

icd9pcs

[ [ [] ] ]

20582, 20639

10396, 16383

359, 404

20873, 20873

4156, 4161

22933, 24399

3350, 3464

17900, 20559

20660, 20660

16409, 17877

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432, 1946

20783, 20852

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4175, 5638

20888, 21022

1997, 2958

2974, 3334

29,388

109,498

4886

Discharge summary

report

Admission Date: [**2200-6-9**] Discharge Date: [**2200-6-18**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 443**] Chief Complaint: CHIEF COMPLAINT: Chest pain/NSTEMI Major Surgical or Invasive Procedure: Cardiac catheterization with [**Last Name (un) 2435**] placement Swan ganz catheter placement History of Present Illness: Patient is an 85 yo M with h/o CAD s/p MI and 3 vessel CABG in [**3-10**] (LIMA ->LAD, SVG -> LAD; D1, SVG -> RCA 40% stenosis per cath in [**2198**]), CKD, bladder cancer with recent transurethral resection of tumor on [**6-9**], complicated by SOB, chest pain, now found to have NSTEMI who presents to the CCU for further management of his ACS. For full details of prior hospital course please refer to [**Hospital Unit Name 153**] notes. In brief, pt underwent successful transurethral resection of his bladder tumor on [**6-9**]. However, due to persistent bleeding he was put on CBI. The patient subsequently suffered a vasovagal episode with SOB, increased 02 requirement, nausea/vomitting, and hypotension. Pt was treated with nebs, steroids, vanco/zosyn for asthma/aspiration. His BP improved with fluid boluses but was transferred to the [**Hospital Unit Name 153**] for further observation. . In the [**Hospital Unit Name 153**], the patient's BP and and respiratory status improved with the above interventions. He was also transfused 2 units PRBCs given his urinary clotting. However, prior to being transferred to the floor the patient developed SSCP, SOB, and bilateral arm pain. EKG demonstrated RBBB, inferior STT changes. CK, MB, and troponin trended upwards. The patient was given ASA/Plavix, heparin gtt, nitro gtt, metoprolol, and morphine. Cardoiology was consulted who felt the patient was undergoing an NSTEMI. Therefore, the patient was transferred to the CCU for further care. . On arrival to the CCU, the patient feels well and was chest pain free. He denied HA, dizziness/lightheadedness, diplopia, CP, SOB, orthopnea, paroxysmal nocturnal dyspnea, nausea, diaphoresis, leg pain. . On further review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. In the past he had episode of CP on exertion with dyspnea. He can climb one flight of stairs. . Past Medical History: 1. CAD s/p MI w Vfib arrest/syncope and CABGx3 [**3-10**], no warning symptoms, syncopized; EF [**10-12**] 45-50% on dobutamine stress echo, followed by outside cardiologist. Cath in [**2198**] with 40% stenosis of SVG -> RCA, otherwise patent grafts 2. Asthma: exacerbated by cats, coal, furnaces 3. Bladder cancer found [**5-15**] on cystoscopy, s/p transuretheral resection on [**6-9**] 4. Gout 5. cataract surgery '[**97**], '[**99**] 6. cholecystectomy '[**89**] 7. TURP [**4-13**] 8. Depression Social History: Retired [**University/College **] Professor Lives with wife Quit smoking in [**2182**] Former drinker . Family History: Non-contributory, no history of early CAD . Physical Exam: VS: T 96.5, BP 122/60, HR 85, RR 18, O2 95% on 2L NC Gen: Pleasant talkative elderly male in NAD HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of 8 cm. No bruits appreciated CV: RRR, no m/r/g, nl S1 S2 Chest: Bibasilar crackles noted, no wheezing. symmetric Abd: Soft, NT/ND + BS, no HSM. Ext: No c/c/e. No femoral bruits. Ext warm and well perfused Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP . Pertinent Results: [**2200-6-9**] Bladder, biopsy: A. Papillary urothelial carcinoma, high grade, with lamina propria invasion. Muscularis propria is present and is free of tumor. B. Urothelial carcinoma in situ. C. Squamous metaplasia, keratinized. [**2200-6-12**]. Cardiac cath. 1. Selective coronary angiography of this right dominant system demonstrated a three vessel native CAD. The LMCA had mild disease with moderate calcification. The LAD was occluded proximally. The LCx was a non-dominant vessel with a moderate diffuse disease. The RCA was a dominant vessle with a proximal 90% stenosis at the bifurcation with the AM. 2. Vein graft angiography revealed a patent SVG to the RCA. There was mild disease just distal to the touch down site. SVG to the D1 was patent as well. Arterial conduit angiography initially could not be performed due to a tight left subclavian occlusion that was likley thrombotic in nature. 3. Resting hemodynamics revealed elevated right and left sided filling pressures with an RVEDP of 21 mmHg and a PAD pressure of 26 mm Hg. The cardiac index was depressed at 1.86 l/min/m2. There was a moderate systemic arterila hypertension with an SBP of 150 mmHg. 4. Left ventriculography was deferred given elevated creatinine. 5. Successful PCI/stent to proximal left subclavian thrombosis with a 7.0x39mm Genesis stent deployed at 18atms and postdilated with a 9.0mm balloon. Normal flow down vessel with no gradient across stent at end of procedure. There was a hazy 70% distal LAD lesion at the end of the case. Echo. [**2200-6-12**] Conclusions: The left atrium is mildly dilated. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with mid to distal anteroseptal akinesis, apical akinesis/dyskinesis and mid to distal anterior hypokinesis. No definite LV thrombus seen (but cannot definitively exclude). Overall left ventricular systolic function is moderately depressed. Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is no pericardial effusion. Renal u/s [**2200-6-16**]. IMPRESSION: Thick-walled bladder with vascular flow. This most likely represents residual bladder tumor. No hydronephrosis. [**6-17**]. Echo. The left atrium is mildly dilated. There is mild to moderate regional left ventricular systolic dysfunction with focal dyskinesis of the apex and hypokinesis of the distal left ventricle. The other segments contract well. No masses or thrombi are seen in the left ventricle. Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. There are mobile filamentous strands on the aortic leaflets consistent with possible Lambl's excresences (normal variant) although an aortic valve vegetation/mass cannot be definitively excluded. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2200-6-12**], the left ventricular function has slightly improved. No apical thrombus is visualized. A small filamentous mobile lesion on the aortic valve is present (seen on prior study but not mentioned) which is consistent with probable Lambl's excrescence. Brief Hospital Course: In summary, this is an 85 yo M with CAD, s/p MI and 3 vessel CABG in [**2194**], CKD, bladder tumor s/p recent transurethral resection c/b [**Hospital 7792**] transferred to the CCU for further care. NSTEMI/CAD. Patient with known CAD and previous history of MI now with concerning EKG changes and positive cardiac enzymes. Patient experienced vasovagal symptoms, n/v and chest pain/arm pain all indicative of ACS. On the morning after he was transferred to the CCU, the patient complained of [**9-17**] substernal chest pain and chest pressure, with radiation of the pain to his arms bilaterally, in the setting of pain/dysuria at the distal penile urethra. Also complained of dyspnea, confusion, no lightheadedness or dizziness. He was treated with morphine, nitro drip, increased O2, and a nebulizer treatment and the pain subsided. EKG showed new TWI in V2-V5. Hemodynamically stable. He went urgently to the cath lab where he was found to have a large, L subclavian thrombosis resulting in decreased perfusion to the LIMA-LAD graft as well as distal stenosis/haziness of the LAD. Bare metal stent was placed in the L subclavian. During the remainder of the admission the patient showed no further signs or symptoms of ischemia. The patient was maintained on ASA 325mg daily, Plavix 75mg daily, integrilin x 18hours post cath, heparin IV, Metoprolol, and Lipitor 80mg (lipid panel adequate). Heparin and coumadin for prevention or LV thrombus was held due to hematuria. Repeat ECHO prior to discharge showed no sign of ventricular thrombus despite wall motion abnormalities, and given risk of rebleeding from bladder, anticoagulation was held on discharge. Aspiration Pneumonia. Patient originally admitted to the [**Hospital Unit Name 153**] with SOB thought to be related to vasovagal episode and possible aspiration event versus asthma exacerabation. On [**6-10**] the patient was started on broad spectrum levo/flagyl/vanc plan for a total of 14 days due to concern of aspiration pneumonia given setting of fever and leukocytosis. Patient was discharged home off vanco, but to finish a total 14 day course of flagyl and levofloxacin. Anemia: Hct has trended down during admission in the setting of urethral clotting from mid 30s to high 20s from a baseline of 35-40. Has required 3 units pRBCs with moderate response. On [**6-14**], a CT of the abdomen and pelvis ruled out a retroperitoneal bleed. However, CT showed the site of bleeding to be in the bladder - on [**6-14**] 500cc of clot was irrigated by urology. They continued to follow along and irrigate the bladder prn. Heparin and coumadin were held during this episode of active bleeding. A bladder ultrasound later showed residual tumor in the bladder but no further blood clots. Bleeding resolved and CBI was able to be discontinued prior to discharge. Change in mental status. Patient exhibited some confusion and waxing/[**Doctor Last Name 688**] mental status during his ICU stay. He was given a 1:1 sitter and ditropan was held. He was given prn Zydis. Delerium resolved once patient stabilized. Volume depletion. On [**6-14**] a swan ganz catheter was placed to more closely assess the patient's volume status. He was found to have volume depletion, which resolved with administration of IVF. The SGC was pulled on [**6-15**] without complication. Bladder resection: Pt is s/p bladder resection. He underwent CBI with good effect. Repeat Bladder US showed residual tumor in bladder. Foley catheter was initially removed but was replaced on the day of discharge due to retention of ~ 400 cc in the bladder; the patient's foley catheter is to remain in place until evaluated at Dr.[**Name (NI) 6444**] office for voiding trial on Monday, [**6-23**]. Coumadin and heparin were held in setting of hematuria. Gout: Currently asymptomatic. Given CKD, he was given allopurinol every other day. Hyperglycemia: Resolved, No h/o DM, cover with RISS in acute setting. Patient was discharged to rehabilitation facility with planned cardiac follow-up with his cardiologist at the [**Hospital3 **] and with urology for his bladder resection. Medications on Admission: Medications (outpatient): ASA 81mg daily Lipitor 10mg daily Prilosec 20mg daily Allopurinol 100mg daily Centrum silver MVI daily Buproprion 100mg daily Discharge Medications: 1. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 8. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed for SOB. 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 11. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 8 days. 12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 13. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: bladder cancer s/p bladder resection coronary artery disease acute coronary syndrome hospital acquired pneumonia acute on chronic renal insufficiency anemia Discharge Condition: stable, breathing comfortably Discharge Instructions: Please call your physician if you experience fevers, chest pain, abdominal pain, blood in the urine, dizzines, lightheadedness or other concerning symptoms. Followup Instructions: Please return to Dr.[**Name (NI) 6444**] office at 319 [**Hospital1 1426**] on Monday, [**2200-6-23**] at 1:15 pm for a voiding trial. Until that time, you should keep your foley catheter in place. We have also scheduled you a follow-up appointment with a nurse practitioner in Dr.[**Name (NI) 6444**] Urology office on [**Last Name (LF) 2974**], [**2200-7-11**] at 10:00a.m. for BCG therapy. Please call ([**Telephone/Fax (1) 6441**] if there is a problem with this appointment. You have a follow-up appointment with your cardiologist, Dr. [**Last Name (STitle) 20391**], [**Telephone/Fax (1) 20392**] on [**2200-7-22**] at 10:00a.m. Please call to reschedule if you are unable to keep this appointment. Please schedule follow-up with your primary care physician within the next 2 weeks.

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icd9cm

[ [ [] ] ]

[ "57.49", "88.56", "89.64", "37.23", "39.50", "00.40", "89.68", "39.90", "99.04", "00.45" ]

icd9pcs

[ [ [] ] ]

13210, 13282

7694, 11820

295, 390

13483, 13515

3861, 7671

13721, 14517

3150, 3195

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11846, 12000

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134,156

42590

Discharge summary

report

Admission Date: [**2125-2-20**] Discharge Date: [**2125-3-10**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1974**] Chief Complaint: CC: LBP, buttock pain Major Surgical or Invasive Procedure: Placement of left internal jugular triple lumen central catheter Placement of right radial arterial catheter Intubation and mechanical ventilation History of Present Illness: . HPI: 85 y/o female with a PMH significant for dementia, CHF, HTN, AF on coumadin, bilateral AKA, presenting with hip and back pain. The pt is unable to give any history and following history is obtained over the telephone from her daughter. According to the daughter, the pt has had decreased po intake for about six months. Since Friday she did not take anything. The pt is seen by a visiting nurse 3/wk at home. Over the last weeks she noted a draining lesion on her left buttock which continued to worsen. Over the last couple of days the pt was complaining of excrutiating pain in her buttocks, especially when turned. . In the ED the patient received Unasyn after blood cultures were obtained for presumed osteomyelitis. The patient had been spiking low grade temps throughout her course. She was being medically managed for all of her chronic medical issues. . On the morning [**2125-3-3**], the patient was noted to be unresponsive by the care aide. A code blue was called. The patient was found to be in PEA arrest. She received a total of 2mg of epi and 2mg of atropine. She reverted back to afib with AVR. The patient was tranferred to the MICU. Within minutes of arriving to the MICU the patient was noted again to be in afib. She received a total of 2mg of epi. She was later in stable V-tach. She received 150mg amio and was started on amio drip. She returned to afib. Past Medical History: Past Medical History: # Dementia # CHF, ECHO [**2-17**]: 1. The left atrium is mildly dilated. 2. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 3. The aortic valve leaflets (3) are mildly thickened. 4. The mitral valve leaflets are mildly thickened. 5. There is mild pulmonary artery systolic hypertension. # HTN # Hypothyroidism # DM 2 # anxiety # s/p CVA # h/o of PVD s/p bilaterally AKA # AF on coumadin # Blindness Social History: . Social History: lives with daughter at home, visiting nurse 3/wk, no tobacco/alcohol . Family History: Noncontributory Physical Exam: . Physical exam: VS T 97.6 BP 116/56 HR 63 RR 14 O2Sat 98RA, wt 63kg Gen: NAD, screaming "[**Doctor Last Name **]", occ answering questions with no/yes HEENT: NC/AT, pupil reactive to light on the L, not reactive and cranially displaced on the R, mmm NECK: no LAD, no JVD COR: S1S2, irregular rhythm, no m/r/g PULM: CTA b/l, decreased breath sounds at bases ABD: + bowel sounds, soft, nd, nt Skin: warm extremities, no rash, EXT: palpable inguinal pulses, ? L leg slightly warmer than right, AKA, 4cm deep decubitus, stage iV, tracking to the [**Doctor Last Name 500**], with residual deressing inside, foul smelling. Fragile erythematous skin covering the buttocks Neuro: not following commands . Pertinent Results: . CXR [**2125-2-26**]: Marked increase in the right-sided pleural effusion since the prior day. Lesser degree of increase in the left pleural effusion. . Repeat CXR [**2125-2-25**] (s/p aspiration event): Bilateral pleural effusions, right greater than left with volume loss in the right lower lobe and alveolar infiltrates on the right. The overall appearance is unchanged compared to the film from earlier the same day. . CXR [**2125-2-25**]: The left lateral lung is off the film. There is a right effusion layering posteriorly that is moderate in size and increased compared to prior. Given the large size of this effusion it is difficult to assess for underlying alveolar infiltrate although this is also likely present. There is probably also left pleural effusion. There is bilateral lower lobe volume loss. IMPRESSION: Increased right greater than left effusions. Infiltrates superimposed so difficult to assess. . CXR [**3-9**]: Stable moderate bilateral pleural effusions and bibasilar consolidations, likely representing atelectasis. Slight interval worsening of mild pulmonary edema. . Pelvic MRI [**2125-2-22**]: The study is slightly limited due to difficulty in positioning patient and absence of contrast enhanced images. There is a slight mottled appearance of the [**Month/Day/Year 500**] marrow, likely due to red marrow replacement. The T1 signal of the bones appears to be preserved without evidence of suspicious focal hypointense areas. There is also no significant areas of edema within the visualized bones. Two focal areas of decreased T1 signal in the left ilium are likely areas of accented red marrow replacement especially if the patient has no history of malignancy. There is severe atrophy of all visualized muscles and diffuse muscle edema on the STIR images, likely due to patient's immobility. A Foley catheter is seen in the urinary bladder. There are surgical clips within the right groin from prior vascular procedure. A small soft tissue and skin defect is seen inferiorly below the tip of the coccyx. It does not appear to contact the [**Name2 (NI) 500**]. IMPRESSION: Limited study, but no evidence of osteomyelitis. . EKG [**2125-2-21**]: atrial fibrillation with slow ventricular response, IVCD with left axis deviation, prior anteroseptal MI, ? inferior MI (old) . CXR [**2125-2-20**]: rotated, no infiltrate, no cardiopulmonary process (my read) . Pelvic XR [**2125-2-20**]: Bowel gas pattern appears unremarkable. Surgical clips noted over the right femoral head, unchanged in appearance from prior study. Bones again appear demineralized. Degenerative changes noted within the hips bilaterally. No definite osseous destruction is identified, however, plain radiography is not sensitive for evaluation of osteomyelitis. . ECHO [**2-17**]: 1. The left atrium is mildly dilated. 2. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 3. The aortic valve leaflets (3) are mildly thickened. 4. The mitral valve leaflets are mildly thickened. 5. There is mild pulmonary artery systolic hypertension . [**2125-2-22**] 04:35AM BLOOD ESR-41* [**2125-2-22**] 04:50PM BLOOD Ret Aut-1.8 [**2125-2-23**] 04:30AM BLOOD calTIBC-116* Ferritn-123 TRF-89* [**2125-2-22**] 04:50PM BLOOD Hapto-208* [**2125-2-22**] 04:35AM BLOOD TSH-1.1 [**2125-2-22**] 04:35AM BLOOD CRP-28.3* . Brief Hospital Course: . 86 yo F with dementia, h/o CHF, HTN, hypothyroidism, DM II, s/p CVA, h/o PVD s/p bilateral AKA presenting with decubitus ulcers, FTT and UTI, developed pulseless electrical activity arrest and so transferred to the ICU . # shock, s/p PEA arrests: The etiology of the PEA is not entirely clear. It is most likely that the patient became hypoxic. There was no evidence of trauma, hypothermia, hyperthermia, hyperkalemia, tension pneumo, tamponade etc. Cosyntropin stim test showed adequate cortisol response. Treated with broad spectrum antibiotics for infectious sources including sacral decubitus, poss pneumonia, and UTI, without chance in pressor requirement. . # ? anoxic brain injury s/p PEA arrests: pt's baseline dementia, blindess, and HOH makes mental status difficult to eval, but suspect that PEA arrests on day of MICU transfer caused some element of anoxic injury. . # Respiratory: Patient with history of CHF and volume overload. CXR also supports this. Patient intubated during code, not clear if respiratory arrest preceeded PEA or PEA preceeded respiratory failure. - Continued with mechanical vent support while on pressors . #. ID: Patient was being treated for sacral decub with antibiotics. In the setting of her clinical picture it is unclear if she became septic. Also consider possible pneumonia as etiology of hypoxia. - Continued vanc/zosyn since Staph aureus in sputum as well as sacral wound and Pseudomonas in sacral wound. - iv fluconazole for yeast in urine . # Decubitus Ulcers: StageIV decub, cont abx, dressing changes per wound care recs and plastics has been following . # Afib: Patient had been on Amiodarone, stopped b/c of bradycardia. INR down to 1.4. Given low daily risk of CVA [**3-16**] afib, allowed INR to drift while in ICU. . # CHF: Pt has h/o CHF, TTE EF >55%. Effusions on CXR. Difficult to obtain afterload reduction in the setting of being on pressors and try to maintain blood pressure. . # NIDDM - ISS. . # Hypothyroidism - Continued IV synthroid . # Anemia- Baseline Hct is 28-31 with chronic iron deficiency; transfused one unit PRBCs on [**3-5**] for Hct 24.5. Will continue monitor; restart iron supplements once tolerating tube feeds. . # Dementia- according to records, pt not aware of surroundings at time of hospital admission. Had been on risperdal at home, currently held since not taking po meds. . # F/E/N - Post pyloric tube placed [**3-2**]; holding tube feeds and po meds for now [**3-16**] ileus; started low-dose, ie 10cc/hr, tube feeds . # Prophylaxis: PPI and subq heparin . # Code: DNR. After several meetings with family, medical/ICU team, and ethics team, family agreed that further resuscitation was futile given her significant co-morbid illnesses as well as lack of response to aggressive ICU treatment aimed at her cardiovascular system, pulmonary system, and infections, and agreed that goals of care should be comfort, rather than life-sustaining. She was extubated to comfort measures only with her family at the bedside on [**3-10**]. Medications on Admission: . Medications on admission: Lasix 40 mg [**Hospital1 **] Levothyroxine Sodium 75 mcg PO DAILY Isosorbide Dinitrate 10 mg PO BID,at 8am and 6pm Risperidone 0.5 mg PO am, 1mg in pm Potassium Chloride 40 mEq PO DAILY Potassium Chloride 40 mEq Zinc Sulfate 220 mg PO DAILY Multivitamins 1 CAP PO DAILY Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY Ascorbic Acid 500 mg PO BID Ferrous Sulfate 325 mg PO DAILY TraMADOL (Ultram) 25mg PO BID Zinc Coumadin 6mg M/W/Fr, 5mg T/T/S . Discharge Medications: None (expired) Discharge Disposition: Expired Discharge Diagnosis: Primary: PEA arrest Sacral decubitus ulcers Failure to thrive Aspiration Alzheimer's dementia CHF Atrial fibrillation on Coumadin . Secondary: PVD s/p bilateral AKA HTN Hypothyroidism DM 2 h/o CVA Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A

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icd9cm

[ [ [] ] ]

[ "96.6", "96.72", "99.15", "38.93", "96.04" ]

icd9pcs

[ [ [] ] ]

10273, 10282

6685, 9706

284, 432

10523, 10532

3257, 6662

10584, 10590

2506, 2523

10234, 10250

10303, 10502

9760, 10211

10556, 10561

2555, 3238

223, 246

460, 1846

1890, 2383

2417, 2490

50,738

161,919

20058

Discharge summary

report

Admission Date: [**2138-5-11**] Discharge Date: [**2138-5-16**] Service: NEUROSURGERY Allergies: Vancomycin / Cipro / Penicillins / Naproxen / Tetracycline Attending:[**First Name3 (LF) 1835**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: None History of Present Illness: Patient is an 88 yo woman with history of NPH s/p shunt,HTN who fell at her [**Hospital3 **]. She was in her USOH walking with a walker when she fell. There was no LOC. She would not eat and went to bed. Was later noted to be "groggy". Became progressively more sleepy. Was taken to [**Location (un) 620**] where large,diffuse SAH and left SDH were found. Past Medical History: NPH s/p shunt, HTN, Anxiety Social History: Lives in [**Hospital3 **]. DTR [**First Name8 (NamePattern2) **] [**Known lastname 28181**] [**Telephone/Fax (1) 54000**] and [**Telephone/Fax (1) 54001**]. Family History: non contributory Physical Exam: PE: Vs: BP 129/71 P 105 R 20 Sat 100% Neuro: MS: Sleepy, arrouses to voice but cannot maintain eye opening and attention for more than seconds. Oriented to self but does not know place, year. Says [**2099**]. Follows simple commands. Inattentive with exam. Comprehension intact. Speech clear, fluent to [**12-25**] words. CN: Difficult to assess VF. Perrl [**2-21**] bilaterally. Bilateral 6th nerve palsy left > right. Face symmetric. Tongue midline. MOTOR: no adventitious movements. Full strength in triceps and IPs and AT bilaterally, but could not do full assessment. Tone normal. Coord: No gross ataxia. Gait: Could not be assessed. Exam on Discharge: Comfortable, occasional eye opening to loud voice. intermittent reflexic grasping of left hand. Spontaneous movement of all extremities (L>R). PERRL. No commands Pertinent Results: Labs on Admission: [**2138-5-11**] 07:50PM DIGOXIN-0.6* [**2138-5-11**] 07:50PM WBC-11.4* RBC-4.28 HGB-13.0 HCT-37.9 MCV-89 MCH-30.4 MCHC-34.4 RDW-14.3 [**2138-5-11**] 07:50PM PLT COUNT-193 [**2138-5-11**] 07:50PM PT-14.2* PTT-19.9* INR(PT)-1.2* [**2138-5-11**] 07:50PM GLUCOSE-149* UREA N-14 CREAT-0.6 SODIUM-142 POTASSIUM-2.7* CHLORIDE-99 TOTAL CO2-32 ANION GAP-14 Labs on Discharge: [**2138-5-16**] 11:20AM BLOOD WBC-12.8* RBC-3.96* Hgb-11.8* Hct-35.4* MCV-90 MCH-29.9 MCHC-33.5 RDW-15.1 Plt Ct-352 [**2138-5-16**] 11:20AM BLOOD PT-15.9* PTT-20.9* INR(PT)-1.4* [**2138-5-16**] 11:20AM BLOOD Glucose-152* UreaN-18 Creat-0.6 Na-152* K-2.3* Cl-110* HCO3-27 AnGap-17 [**2138-5-16**] 11:20AM BLOOD Calcium-8.8 Phos-1.6* Mg-2.3 [**2138-5-16**] 11:20AM BLOOD Phenyto-22.7* IMAGING: HEAD CT [**5-12**]: FINDINGS: There is acute on chronic subdural hematoma layering along both cerebral convexities and the falx cerebri, surrounding the entire cerebral hemispheres. The hemorrhage is greater on the left than the right. There is effacement of the left cerebral sulci, with a 5-mm rightward shift of midline structures. The hematoma is seen layering along the tentorium cerebelli bilaterally, greater on the left side. There is extension of the bleed into the pre-pontine cistern and also extends along the lateral edge of the left cerebellar hemisphere. In comparison to the prior study there has been no Significant change in the size of the hemorrhage. The infratentorial hemorrhage is better assessed in the current study . An extraventricular drainage catheter is seen through a right parietal approach, with the tip terminating in the left caudate nucleus. The ventricles are nondilated and unchanged since the prior study. The suprasellar cisterns and the quadrigeminal cisterns are widely patent. The visualized paranasal sinuses are well aerated. No acute fractures are identified. IMPRESSION: 1. Bilateral acute on chronic subdural hematomas, layering along the cerebral convexities, the falx and the tentorium, greater on the left side have not significantly changed since the prior study. 2. Mass effect and rightward shift of midline structures also unchanged since prior study. HEAD CT [**5-13**] IMPRESSION: 1. No significant interval change in bilateral subdural hematomas, left greater than right, and the associated mass effect. 2. Stable ventricular size. EEG [**5-14**]: IMPRESSION: This is an abnormal routine EEG due to a persistently slow and disorganized background consisting of mixed theta frequencies. There were no focal, lateralized, or epileptiform abnormalities noted. Overall, this background is suggestive of a moderate encephalopathy. Amongst the most common causes of encephalopathy are metabolic derangements, medications, hypoxia, and infection. Brief Hospital Course: She was admitted to ICU for close observation after discussion with family that the likelihood of a functional outcome for this size hemorrhage in her age demographic was very poor. Family decided on DNR but intubatable for resp distress should a respiratory decline occur. She was also given dilantin in loading dose. Overnight the patient had several episodes of seizure like activity which was treated successfully with ativan. She had an EEG to further evaluate this, and was determined to be absent of epileptiform characteristics. On [**5-13**] a repeated head ct was performed with was unrevealing for new findings. A family meeting was conducted on [**5-13**] and [**5-15**] at which time the prognosis of <1% likelihood of functional outcome was conveyed. The family has requested a bit of time to think over this information before making definitive decisions toward CMO versus pursuing PEG feeding. On [**5-16**], Ms. [**Known lastname 28181**] was identified to have electrolyte abnormalities that would favor enteric route for treatment. Given the family's recent thoughts about possible withholding of enteric supplementation, the HCP was asked about treating these abnormalities. Given these changes, the HCP([**Name (NI) **] [**Name (NI) **]) elected to pursue comfort measures only. All supportive care was withdrawn, and morphine, scopalamine and tylenol were added. Case management was then involved with the assistance of palliative care in arranging for discharge to [**Location (un) 6159**] Palliative care facility. She was discharged as such on [**5-16**]. Medications on Admission: Temazepam, Atenolol 50 daily, Sertraline 100, HCTZ 25daily, Digoxin 0.125 daily, Vit D, ASA 81, Mrialax, melatonin,Norvasc, Lisinopril, Tylenol, Ca. Discharge Medications: 1. Morphine Concentrate 20 mg/mL Solution Sig: 5-10 drops drops PO Q2H (every 2 hours) as needed for RR>15. 2. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr Transdermal ONCE (Once) for 1 doses. 3. Lorazepam 2 mg/mL Syringe Sig: .5-1mg Injection Q1-2HRS () as needed for SEIZURE ACTIVITY. 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). Discharge Disposition: Extended Care Facility: Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**] Discharge Diagnosis: Left convexity, tentorial, parafalcine Subdural hematoma Discharge Condition: Neurologically Stable Discharge Instructions: -You have been diagnosed with a significantly sized intracranial bleed. Your care goals at this point are directed to comfort an pallation. ?????? Take your pain medicine(MORPHINE/TYLENOL) as prescribed for signs of discomfort(rapid breathing, or fever). * Ativan can be used for the treatment of seizure like activity. * Scopalamine patch can be used to treat oral secretions. * Oral diet can be given for comfort, please provide frequent mouth care. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. Completed by:[**2138-5-16**]

[ "348.31", "V45.01", "852.21", "V45.2", "V64.2", "852.01", "300.00", "E888.9", "E849.7", "331.5", "V10.3" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6820, 6914

4633, 6216

279, 286

7015, 7039

1818, 1823

7554, 7915

919, 937

6416, 6797

6935, 6994

6242, 6393

7063, 7531

952, 1617

231, 241

2215, 4610

314, 677

1636, 1799

1837, 2196

699, 728

744, 903

11,657

103,198

12755

Discharge summary

report

Admission Date: [**2131-5-16**] Discharge Date: [**2131-5-22**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 465**] Chief Complaint: Bradycardia, hypotension Major Surgical or Invasive Procedure: Intubation Thoracentesis History of Present Illness: Pt is an 88 yo male with h/o CHF (EF 45%), CAD, CKD, TIIDM admitted to the MICU from rehab with hypotension, junctional bradycardia, and mental status change [**2131-5-16**]. The patient was admitted to [**Hospital3 1196**] [**Date range (1) 39358**] after a mechanical fall and treated for UTI and CHF exacerbation. He was discharged to [**Hospital 18979**] rehab on [**2131-5-5**]. For the past few days he complained of worsening weakness and fatigue. He was noted to be bradycardic and metoprolol was held as of [**2131-5-15**]. On the day of admission he was found to be hypotensive (SBP 90s), bradycardic (HR 30s), and with mental status changes; he was sent to [**Hospital1 18**] ED. . In the ER the pt was in a junctional rhythm with a rate in the 30s and was treated with atropine. He was treated for hyperkalemia and also given glucagon due to beta-blockade. He reverted to NSR with rate in the 60s. The patient was intubated in the ER for mental status changes and airway production in setting of uremia and patient vomiting. He was seen by cardiology who thought the bradycardia was secondary to hyperkalemia, which was secondary to renal failure, and recommended dialysis. Renal was consulted and did not believe dialysis was indicated at this time. Past Medical History: Type II diabetes mellitus CKD with baseline creat 2.0 in [**1-/2131**], thought secondary to diabetic nephropathy CAD s/p CABG 13yrs ago, s/p NSTEMI with PCI x3 ~2 months prior CHF (EF 45% echo [**2131-4-25**] with inferior hypokinesis, left atrial enlargement) Chronic 02 requirement of 2.5 L NC for CHF Hypothyroidism h/o Proteus UTI Vertigo Left eye blindness s/p childhood accident HOH R ear s/p recent mechanical fall Social History: Lives with wife. [**Name (NI) **] three daughters, two that live in the area and visit twice a week. Family History: Mother died of MI at 67. Physical Exam: Wt 82.2kg T 96.6 HR 59 BP 119/67 RR 14 99% A/C Tv 550 RR 14 FiO2 40% PEEP 5 Gen: intubated, sedated male in NAD HEENT: right pupil reactive, left opacified, anicteric, MMM Neck: supple, JVP nondistended Cardio: bradycardic with reg rhythm, nl S1 S2, no m/r/g Pulm: occasional bilateral wheeze, o/w CTA Abd: soft, NT, distended with fluid wave, + BS, no masses, no HSM Ext: 2+ peripheral edema (R>L); decreased DP and PT pulses B Pertinent Results: [**5-21**] chest ct: 1. No evidence of that moderate to large right pleural effusion is anything other than a transudate. Relaxation atelectasis probably responsible for collapsed right middle and lower lobe. 2. Mild mediastinal adenopathy could be due to congestive heart failure. 3. Severe atherosclerosis, predominantly in coronaries, also in the aorta, innominate artery, and upper abdomen. 4. Probable pulmonary arterial hypertension. Mild cardiomegaly. Aortic valvular calcification, hemodynamic significance uncertain. 5. Ascites. 6. No evidence of sternotomy complications. ecg: Normal sinus rhythm with left anterior fascicular block. Cannot exclude prior inferior myocardial infarction. Compared to the previous tracing of [**2131-5-18**] no diagnostic interval change. Brief Hospital Course: A/P: 88yo male with h/o TIIDM, CAD, CHF, CKD p/w hyperkalemia, bradycardia, hypotension, and acute on chronic renal failure. Admitting diagnoses improved on discharge. Pt discharged to rehab for PT/OT. . 1) Bradycardia/hypotension/hyperkalemia: Likely multifactorial due to hyperkalemia in the setting of beta-blocker and amiodarone in addition to the recent diagnosis of hypothyroidism. Initial rhythm was junctional bradycardia in 40s which improved to sinus rhythm/sinus brady with atropine, treatment of hyperkalemia, and increase of levothyroxine. Blood pressure also improved with treatment of bradycardia. The pt had no further episodes of bradycardia after his initial stabilization. Amiodarone and metoprolol were restarted in the intensive care unit prior to transfer to the floor. . 2) Renal Failure: Current presentation likely acute on chronic renal failure due to overdiuresis (and subsequent CHF precipitated by volume load to treat hypovolemia). Etiology of CKD most likely diabetic nephropathy. Nephrology believes he will need dialysis within the year. [**Last Name (un) **] discontinued during hospitalization and was not restarted on discharge. Recent creat 2.0-2.6 at OSH; 2.2 on discharge. Pt was followed in house by nephrology, who by discharge recommended: discontinuing renagel, decreasing calcium to 500mg tid, decreasing lasix to 40mg po qd to decrease risk of hypovolemia, and continuing epogen 10,000u qmwf. Pt discharged with caudet catheter and is scheduled for follow-up with urology. Pt will follow-up with nephrology locally as he will need close observation. . 3) CHF: Diastolic dysfunction with EF 60% and home O2 requirement of 2.5L. Pt diuresed with lasix IV and po. Outpatient regimen of ASA, metoprolol, statin continued; [**Last Name (un) **] discontinued because of ARF. At dry weight and baseline O2 requirement on discharge. Lasix 40mg po qd on discharge with care not to overdiurese. Pt will follow-up with his cardiology at [**Hospital1 **]. . 4) Right pleural effusion: The pt received a therapeutic/diagnostic thoracentesis for non-resolving right pleural effusion the day prior to discharge. 2L fluid removed, with subjective improvement in dyspnea. The effusion was found to be transudative and is most likely secondary to heart failure. The effusion is less likely secondary to infection in this pt who remained afebrile and appear nontoxic. Gram stain negative, although cultures pending. Also of concern is malignant effusion in setting of ascites. Pleural fluid culture and cytology will need follow-up. . 5) Ascites/liver function: Likely secondary to right heart failure; RUQ showed no liver pathology. Repeat US showed mild ascites. Improved with diuresis. Repeat LFTs showed resolved transaminases with alk phos 192, GGT 147, total bili 0.3. Pt without symptoms of biliary disease. Recommend follow-up LFTs for resolution within one month of discharge. . 6) CAD: Pt denied CP during admission. Outpatient regimen of ASA, lipitor, and metoprolol continued; as above, [**Last Name (un) **] held for ARF. . 7) TIIDM: QID FS's, RISS. Glyburide held in house with adequate blood sugar control; consider restarting as outpatient as needed. . 8) Communication: Wife . 9) Code status: Full Medications on Admission: RISS Tylenol 650 PO q 3 hrs milk of magnesia PRN dulcolax PRN lasix 80 mg qd prilosec 20 mg PO BID glyburide 2.5 mg colace 100 mg PO BID folic acid 1 mg qd vitamin B12 500 mg qd Vitamin B6 50 mg PO qd Ambien 5 mg qhs PRN Lopressor 50 mg PO BID ( d/c'd [**5-15**]) ASA 325 mg PO qd Plavix 75 mg qd Amiodarone 200 mg PO qd Lipitor 40 mg qd Metolazone 2.5 PO qd Losartan 50 mg PO Levothyroxine 25 mcg qd Flomax 0.4 PO BID Remeron 15 mg PO qhs Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Albuterol 90 mcg/Actuation Aerosol Sig: 6-8 Puffs Inhalation Q6H (every 6 hours) as needed. 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) 10,000 Injection QMOWEFR (Monday -Wednesday-Friday). 13. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Haloperidol Lactate 5 mg/mL Solution Sig: 2.5 mg Injection Q4H (every 4 hours) as needed for agitation. 17. Insulin Regular Human 100 unit/mL Solution Sig: as directed units Injection ASDIR (AS DIRECTED): sliding scale is attached. 18. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Vitamin B-6 50 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 25759**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: Bradycardia Congestive heart failure Acute on chronic renal failure Right pleural effusion Discharge Condition: On 2.5L O2 as per outpatient, afebrile, vital signs stable Discharge Instructions: Please contact a physician if you have shortness of breath that does not improve. . Please contact a physician if you have chest pain that does not resolve. . Please take your medications as prescribed. Followup Instructions: Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4027**] Please follow-up with you cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 39359**] Please follow-up with a renal physician in your area or you may call the renal clinic at [**Hospital1 18**] ([**Telephone/Fax (1) 773**] for an appointment- you should see them within 1 month of discharge Please f/u with urology on [**2131-6-1**] at 10:15 am on [**Hospital Ward Name **] 3 ([**Hospital1 18**]) [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]

[ "412", "276.7", "414.01", "599.7", "414.8", "293.0", "584.9", "285.21", "789.5", "428.0", "585.9", "458.8", "511.9", "428.30", "250.40", "276.52", "427.89" ]

icd9cm

[ [ [] ] ]

[ "96.71", "34.91", "99.04", "96.04" ]

icd9pcs

[ [ [] ] ]

8878, 8964

3495, 6737

286, 313

9099, 9160

2684, 3472

9411, 10094

2187, 2213

7228, 8855

8985, 9078

6763, 7205

9184, 9388

2228, 2665

222, 248

341, 1605

1627, 2052

2068, 2171

17,282

134,677

42928

Discharge summary

report

Admission Date: [**2130-1-25**] Discharge Date: [**2130-3-15**] Date of Birth: [**2080-6-9**] Sex: F Service: MEDICINE Allergies: Tegretol Attending:[**First Name3 (LF) 613**] Chief Complaint: "fluid leaking from legs" Major Surgical or Invasive Procedure: None History of Present Illness: On the morning of [**2130-1-23**] (2 days PTA), Ms.[**Name (NI) 21862**] mother discovered that [**Known firstname 47168**] sheets were drenched with fluid from her legs and feet. She noted that her socks were so sodden that "you could wring them out" and that there was some skin breakdown along her calves. She emergently scheduled an appt with the PCP (Dr.[**First Name4 (NamePattern1) 717**] [**Last Name (NamePattern1) **]) and the vascular doctor (Dr. [**Last Name (STitle) 92652**]for the following day. Upon presentation to the doctor, she was sent to the ED. Her mother had noted increasing LE and full-body edema for the past 2-3 months, so much so that she had to buy her new pants in a larger size. She has a history of LE brawny edema(L>R)and blanching erythema over the past 10 yrs, but never as severe or with leakage of fluid. She presented to [**Company 191**] on [**2129-12-28**] for this increasing edema, and her regular dose of furosemide was increased from 150 mg [**Hospital1 **] to 240 mg [**Hospital1 **]. However, the swelling worsened. Her mother also noted that she began to develop a "pimply rash" along her left calf and that it seemed to be itchy. She has been treating it with a topical antiseptic. Per her mother, she has not had any SOB, CP, or increased DOE. Pt denies PND or orthopnea, but wears a Bipap machine at night for past 20 yrs. Other symptoms include a dry cough that occasionally leads to post-tussive emesis, and some loose stools. Her blood pressure is usually 120/80, but over the wknd it was 140/84. She has been afebrile. . She has had UTIs in the past, but only every [**4-13**] yrs. . In the ED, urinalysis showed 21-25 WBCs, 21-25 RBCs. Dipstick showed prot 500. CXR showed possible atelectasis vs infiltrate. She was given cipro 500 mg and ceftriaxone 1 gm. . ROS: No nausea, diarrhea, headaches, dizziness, positive for pain in R knee when walking. Past Medical History: 1. Osteoarthritis. 2. Rheumatoid arthritis. 3. Osteoporosis with vertebral compression fractures - normal BMD at the femoral neck, osteopenia at the trochanter, and osteoporosis at the total hip ([**2129**]) 4. Developmental delay. 6. Sleep apnea; since [**2116**] on nocturnal ventilation with BiPAP at 18/12 cm H20 plus 4 liters of nasal cannular oxygen titrated in, else will desaturate to 45% 7. Obesity. 8. History of leg ulcers. 9. Leg swelling - since [**2116**], followed by podiatry and vascular surgery (Dr. [**Last Name (STitle) **] 10. Pilonidal cyst removal - [**2117**], complicated by wound dehiscence 11. R knee replacement - [**2126**] 12. SLE - dx [**2120**], diagnosis not documented well Social History: Developmentally delayed, lives with mother and sister Family History: NA Physical Exam: T:96.8 BP: 126/68 P: 80 RR: 16 O2 sats: Gen: Pleasant woman, NAD HEENT: Malar rash EOMI, PERL, MMM, no tonsilar exudates CV: RRR, nl S1, S2, no M/R/G Resp: slight crackles bilaterally Abd: soft, slightly tense, tender to deep palpation in R and L UQ Ext: 4+ edema in both LE, red, erthymatous, non-indurated area covering L calf, some skin breakdown, oozing fluid. Scaly in areas, with scattered pustules. 3+ edema in L arm (normal R). Swanneck deformity in fingers, nodule on L forefinger Neuro: CN II-XII intact, no focal deficits Pertinent Results: [**2130-1-25**] 03:30PM WBC-5.3 RBC-3.89* HGB-11.4* HCT-34.7* MCV-89 MCH-29.2 MCHC-32.8 RDW-16.8* [**2130-1-25**] 03:30PM CALCIUM-7.7* PHOSPHATE-4.6*# MAGNESIUM-2.5 [**2130-1-25**] 03:30PM ALT(SGPT)-24 AST(SGOT)-43* ALK PHOS-81 AMYLASE-42 TOT BILI-0.1 [**2130-1-25**] 03:30PM LIPASE-32 [**2130-1-25**] 03:30PM GLUCOSE-86 UREA N-30* CREAT-0.6 SODIUM-139 POTASSIUM-6.7* CHLORIDE-109* TOTAL CO2-25 ANION GAP-12 [**2130-1-25**] 04:00PM URINE RBC-21-50* WBC-21-50* BACTERIA-MOD YEAST-NONE EPI-0-2 [**2130-1-25**] 04:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-SM [**2130-2-3**] 02:31PM BLOOD WBC-5.4 RBC-2.70* Hgb-7.9* Hct-24.3* MCV-90 MCH-29.2 MCHC-32.5 RDW-17.4* Plt Ct-226 [**2130-1-29**] 04:00PM URINE 24Creat-651 24Prot-[**Numeric Identifier **] [**2130-1-27**] 05:54PM URINE 24Creat-510 24Prot-6780 [**2130-1-27**] 05:54PM URINE U-PEP-MULTIPLE P Osmolal-317 [**2130-1-25**] 11:08PM URINE Hours-RANDOM UreaN-394 Creat-59 Na-22 TotProt-1850 Prot/Cr-31.4* [**2130-1-31**] 02:21PM URINE Blood-LG Nitrite-NEG Protein-500 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM . CT Chest [**1-26**]: IMPRESSION: 1. Limited study. Poorly defined nodules are likely secondary to bronchopneumonia. However, along with several more well-defined nodules, the differential diagnosis includes fungal and Nocardia infection as well as metastatic disease. Short-term followup CT after treatment for infection is recommended. 2. Peripheral and basilar honeycombing is consistent with interstitial fibrosis. It demonstrates mild progression since the prior examinations six years earlier. Such slow progression favors a fibrotic subtype of NSIP over UIP. 3. Mild hydrostatic pulmonary edema. . [**1-26**]: Films of hand: 3 VIEWS RIGHT HAND: There is moderate to severe degenerative disease of the right hand. Juxta-articular osteopenia and moderate to severe joint space narrowing are seen within the proximal and distal interphalangeal joints. Mild erosive changes are most prominent at the second proximal phalangeal joint. There is narrowing of the first CMC joint. Narrowing and partial ankylosis is seen within the carpal bones. There is mild subluxation at the second and fifth MCP joint. Hyperextension of the third and fifth proximal phalangeal joints with associated flexion of the distal phalangeal joints is consistent with "swan neck deformity." There is mild erosion of the ulnar styloid process. 3 VIEWS LEFT HAND: There is moderate to severe degenerative disease of the left hand. Juxta-articular osteopenia and moderate to severe joint space narrowing is seen within the proximal and distal interphalangeal joints. Mild erosive changes are most prominent at the second, third, and fourth proximal interphalangeal joints. There is narrowing of the first CMC joint. Narrowing and partial ankylosis is seen within the carpal bones. There is mild subluxation at the fifth MCP joint. Hyperextension of the proximal phalangeal joints with associated flexion of the distal phalangeal joints is consistent with "swan neck deformity." There is mild erosion of the ulnar styloid process. IMPRESSION: 1. FIndings consistent with rheumatoid arthritis. . RUQ U/S 1. Normal hepatic echotexture without focal lesion. 2. Cholelithiasis without cholecystitis. . Renal U/S RENAL ULTRASOUND: Study is limited due to patient's body habitus and difficulty complying with instructions. The right kidney measures 12.4 cm, and the left kidney measures 11.4 cm. Both kidneys are echogenic. At least three nonobstructing calculi measuring up to 8 mm are present within the lower pole of the left kidney. There is no hydronephrosis or solid renal masses. A foley catheter is seen within a collapsed bladder. IMPRESSION: 1. Limited examination. Three nonobstructing calculi within the lower pole of the left kidney. 2. Echogenic kidneys, suggestive of underlying renal parenchymal disease. . [**1-26**] Echo: Conclusions: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF 70%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflet(3)appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. Compared with the findings of the prior report (images unavailable for review)of [**2127-2-28**], a small pericardial effusion is now present. . Bilateral lower ext u/s: IMPRESSION: No evidence of deep venous thrombosis in either lower extremity . EKG [**1-31**]: Sinus rhythm. Non-specific lateral ST-T wave abnormalities. Low precordial lead voltage. Compared to the previous tracing of [**2130-1-25**] the rate is increased. Otherwise, no diagnostic interim change . [**2130-3-2**] CT C/A/P: 1. Bilateral small pleural effusions and diffuse pulmonary interstitial prominence likely indicating cardiac failure. 2. Left pericolic gutter fluid collection, likely due to recent extensive spinal surgery, however, superinfection of this collection cannot be excluded. 3. Slightly enlarged right abdominal rectus sheath hematoma. 4. Small right perinephric fluid collection in association with a right renal low density lesion; most likely common this represents a ruptured cyst, however, correlation with ultrasound is recommended for further evaluation. Solid mass, such as neoplasm, not excluded. 5. Small left-sided abdominal wall high density fluid collection likely representing hemorrhage within a seroma. 6. Radiopaque gallstones without CT evidence of cholecystitis. 7. Right adrenal lesion concerning for metastatic deposit. 8. Interval spinal fusion from T10 to L4. . [**2130-3-3**] renal U/S: Extremely limited study demonstrating a nonobstructed right kidney. Small right perinephric fluid collection is noted as seen on the CT study of one day prior. . [**2130-3-10**] MRI T-,L-spine: (pt. unable to tolerate contrast phase [**2-10**] to back pain) 1. Fluid in the laminectomy bed at L1/2, which is expected at three weeks following surgery. Superimposed infection cannot be excluded by imaging. 2. While there is persistent angulation at L1/2 with focal obliteration of the cerebrospinal fluid around the conus, the fluid collection in the laminectomy site may not necessarily exert pressure on the conus. Abnormal signal within the conus may be related either to persistent compression, or to myelopathy resulting from presurgical compression. 3. Left retroperitoneal fluid collection, better defined on the [**2130-3-2**] torso CT. 4. Contrast-enhanced images may be performed for assessment for intradural infection, if clinically indicated. . [**2130-3-10**] TEE: No echo evidence of endocarditis. o/w study unchaned when compared with above TTE. Brief Hospital Course: 49 yo F with h/o developmental delay and rheumatoid arthritis admitted for anasarca, found to have nephrotic syndrome and has had a prolonged hospital course complicated by new LE weakness/numbness. Now s/p T8-L3 fusion and prolonged intubation transferred out of the SICU on [**2130-2-25**] to the general medical service. . # Nephrotic syndrome: Secondary to biopsy proven Focal segmental glomerulosclerosis. The biopsy showed significant nephron hypertrophy, a finding associated with obesity. However, per pathology, such glomerular findings, when secondary to obesity, typically do not produce the profound edema and proteinuria seen in this patient. Electron microscopy showed global foot process effacement which further supports a primary process. She was diuresed with lasix. Her urine Pr:Cr improved to 1.1 on [**2130-3-12**] from 2.8 on [**2-28**] and 1.8 on [**3-6**]. ACEI has been held given Pr:Cr <3. Cyclosporin was not restarted given her infections. Her cholesterol was found to be elevated while her triglycerides were normal and she was started on a statin. Weekly urine Pr:Cr levels and serum albumin should be checked (next [**2130-3-20**]) and results faxed to nephrology. She will be discharged on 20mg PO lasix once daily (currently in conjunction with diamox, but please see below re: discontinuation of this). She should follow up with nephrology as scheduled and results of her weekly urine protein:creatinine and serum albumin should be faxed to Dr.[**Name (NI) 433**] office. . # Leukocytosis: Total WBC normalized, but did have a bandemia that maxed at 13% prior to her 2nd surgery and then resolved following debridement of her surgical wound. Etiology of her early leukocytosis was explored in the setting of abdominal discomfort. Although positive for cholelithiasis, RUQ U/S was negative for cholecystitis. There was also some concern for abscess given recent surgery with abdominal approach and CT abdomen/pelvis showed no definitive abscess or evidence of such. Despite no clear intraabdominal process causing leukocytosis, blood and urine cultures were positive for VRE on [**3-3**] as discussed below. Her white blood cell count and differential should be monitored at rehab given her multiple sources of infection and treatment with linezolid. . # VRE bacteremia: Blood and urine cultures from [**2130-3-3**] were positive for VRE. Her PICC line was pulled and her foley changed and subsequent cultures have been negative. Although her total WBC count normalized, she developed a bandemia of 13% which resolved after being taken to the OR for surgical wound debridement; surgical wound also grew VRE and MRSA. She has remained afebrile on linezolid. Given her recent orthospine surgery and hardware, infectious disease was consulted. CRP and ESR were both found to be grossly elevated. TTE and TEE both negative for vegetation. Given there was no involvement of hardware on 2nd trip to the OR, ID has reccommended a 2 week course of linezolid to be completed on [**2130-3-24**]. Daily CBCs must be monitored while she is on linezolid and it should be discontinued on [**3-24**] with close monitoring following its discontinuation. . # Lower extremity Weakness/Numbness: Most likely secondary to L1-L2 vertebral compression fracture. Orthospine was consulted and she is now s/p T8-L3 fusion. Although she states that sensation is improved, she remains unable to move her lower extremities actively. Ortho spine feels that these deficits may not improve significantly given similar pre-and post-op function. Physical therapy was consulted and they worked with her with passive range of motion. She will need to follow up with Dr. [**Last Name (STitle) 363**] of orthospine within 2-3 weeks of discharge. . # Surgical wound infection: Following her surgery, her back wound was noted to have increased drainage and was malodorous. Ortho spine took her back to the OR for surgical wound debridement. Although infected wound, there was apparently no involvement of hardware. Cultures were sent which revealed VRE and MRSA. She is already on linezolid for duration as outlined above. . # Coccygeal ulcer: Plastics was consulted and ulcer was thought [**2-10**] to coccygeal bone spur. They have reccommended [**Hospital1 **] wet to dry dressing changes which should be continued at rehab. When other medical issues improved, an oupatient f/u appointment can be scheduled with plastic surgery at ([**Telephone/Fax (1) 2868**] to remove the bone spur which likely precipitated ulcer formation. This appointment has not yet been scheduled and can be done as an outpatient. . # Hypoalbunemia: Albumin ranged from 1.4-2.0 secondary to proteinuria in the setting of nephrotic syndrome and poor nutritional intake. She was getting tube feeds while intubated in the MICU following her first surgery, but it was removed on transfer to the floor. Although her PO intake did improve slightly, it did not increase significantly. She was started on reglan for motility and megace for appetite stimulation. Additionally, her meals were supplemented with ensure. . # Elevated INR: INR became elevated to 1.4. This was thought most likely [**2-10**] to poor nutrition and vitamin K deficiency given its normalization with PO vitamin K. . # Hypoxia: Directly following her first surgery, she remained intubated. This was thought secondary to volume overload and CT chest demonstrated diffuse interstitial disease that could be [**2-10**] heart failure, but TTE revealed normal function. . # Elevated bicarb: Elevation occurred in the setting of diuresis with IV lasix so thought to represent a contraction alkalosis. Diamox was added to the lasix with improvement in the bicarb level. Per renal, diamox should be discontinued at rehab when bicarb is 26-27. On day of discharge, HCO3 was 29. Daily chem 10 should, thus, be monitored daily while at rehab. . # OSA: Uses Bi-PAP and 4L O2 by NC at home. Settings 18/12. Has not required it while in-house. Home CPAP should be reinitiated while at rehab. . # MRSA Cellulitis: She had a recent history of MRSA cellulitis and given her known VRE as above, was continued on linezolid. Left lower extremity swelling and erythema persists, but is improved. Course of linezolid as above (to finish [**3-24**]). . # Osteoporosis: Most likely related to vitamin D deficiency with low vitamin 25 hydroxy D. She has a history of several vertebral compression fractures, present since [**2116**]. Endocrine was consulted and she was started on vitamin D supplementation, calcium and calcitonin. Per pt's sister, [**Name (NI) 92653**] was started approximately 2 years ago in the outpatient setting, prescribed by Dr. [**Last Name (STitle) **]. It has been held, however, given concern for possible contribution to FSGS/nephrotic syndrome. She will need to follow up with endocrine as an outpatient at her convenience for continued management of her osteoporosis and multiple medications for this problem. . # Rheumatoid arthritis: Per prior discussion with Dr. [**Last Name (STitle) **], the patient has long standing interstitial lung disease and her joint disease is likely JRA. [**Name2 (NI) **] films were consistent with dx of RA. Additionally, spinal arthritis was seen on KUB during this hospital stay. Her pain remained well controlled with tylenol and dilaudid (used post operatively). . # Anemia: Previous baseline Hct appears to be in the low to mid 30s, more recently 24s-25s. She did develop a hematoma s/p renal biopsy that subsequently remained stable. Throughout this hospitalization, with surgery x2, and hematoma, she received a total of 23 units of prbcs. B12 was found to be slightly low and she will need to be continued on qmonthly B12 injections upon discharge (first dose given [**2130-3-3**]). Additionally, erythropoeitin was initiated per renal which should be delivered qMWF. . # F/E/N: Speech & swallow evaluated her and cleared her for thin liquids and soft solids. Meals were supplemented with ensure pudding. . # Prophylaxis: SQ heparin was discontinued given the risk of worsening osteoporosis and she was continued on fondaparinux for prophylaxis. Medications on Admission: ALENDRONATE SODIUM 70MG--one tablet once a week-drink with at least 8 ounces of water and remain upright for 30 minutes afterwards not eating or drinking anything COLASE 100MG-- 3 tablets qday FUROSEMIDE 80 MG--3 tab [**Hospital1 **] KLARON 10%--Apply twice a day to cheeks and nose KLOR-CON 10 10MEQ--3 by mouth TID NIZORAL 2 %--apply to affected area twice a day NIZORAL SHAMPOO --As directed every other day NYSTATIN [**Numeric Identifier 4856**] U/G--Apply beneath each breast up to twice a day for rash TYLENOL EXTRA STRENGTH 500MG--1 pill by mouth TID PRN. Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for fever, pain. 4. Epoetin Alfa 3,000 unit/mL Solution Sig: 6000 (6000) units Injection MWF ([**Numeric Identifier 766**]-Wednesday-Friday). 5. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 1X/WEEK (ONCE PER WEEK) for Please see below for duration weeks: To be delivered every Sunday and complete [**5-21**], [**2130**]. 6. Megestrol 40 mg/mL Suspension Sig: Four Hundred (400) mg PO DAILY (Daily). 7. Fondaparinux 2.5 mg/0.5 mL Syringe Sig: 2.5 mg Subcutaneous DAILY (Daily). 8. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day. ***SEE ADDENDUM FOR CORRECT DOSE 9. Diamox Sequels 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day: To be given only until bicarb (HCO3) is 26-27. It should be stopped at that time. 10. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 9 days: TO BE COMPLETED ON [**2130-3-24**]. 11. Dilaudid 2 mg Tablet Sig: 1-3 Tablets PO every four (4) hours as needed for pain. 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 13. Reglan 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours: To aid in GI motility. 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): To be used while patient requiring narcotics for pain control. 15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: To be used while patient is requiring narcotics for pain control. 16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed: To be used while patient is requiring narcotics for pain control. 17. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. 18. Calcitonin (Salmon) 200 unit/mL Solution Sig: One (1) spray intranasal Injection DAILY (Daily): Please alternate nostrils. 19. Nizoral 2 % Cream Sig: One (1) Topical once a day: Apply to affected areas on face. 20. Nizoral A-D 1 % Shampoo Sig: One (1) Topical once a day. 21. Cyanocobalamin 1,000 mcg/mL Solution Sig: 1000 (1000) mcg Injection once a month. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary: Nephrotic syndrome Osteoporosis Compression fracture now s/p T8-L3 posterior fusion Lower extremity weakness secondary to compression fracture Vancomycin resistent enterococcal UTI, bacteremia MRSA cellulitis Rheumatoid arthritis Anemia Discharge Condition: Stable, afebrile. Discharge Instructions: Please call your doctor or return to the emergency room if you develop fevers/chills, drainage from your back wound, worsening back pain, worsening lower extremity sensory deficits, open wounds on your legs, nausea/vomiting/diarrhea or any other symptoms that concern you. . Please follow up with your appointments as below. . Please take your medications as prescribed. In particular, please complete the course of linezolid (to finish on [**2130-3-24**]). Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] at [**Company 191**] on Tuesday, [**3-21**] at 2:20pm. . Please follow up with Dr. [**Last Name (STitle) 118**] [**Telephone/Fax (1) 60**] at renal clinic in the [**Hospital Ward Name 23**] building on [**Hospital Ward Name **], [**Location (un) 436**] on Tuesday, [**3-28**] at 11:30am. Labs will be drawn while at rehab that should be faxed to Dr.[**Name (NI) 433**] office at [**Telephone/Fax (1) 434**]. . Please follow up with Dr. [**Last Name (STitle) 363**] in the [**Hospital **] clinic ([**Telephone/Fax (1) 61627**] on [**3-24**] at 9am. His office is located in the [**Hospital Ward Name 23**] building on the [**Location (un) 1773**] ([**Hospital Ward Name **]). . Because of your severe osteoporosis, you should follow up in endocrine clinic at [**Hospital1 18**] with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] on [**Last Name (LF) 766**], [**5-1**] at 2pm ([**Telephone/Fax (1) 9072**]. . Please follow up in Dr.[**Name (NI) 27221**] clinic for evaluation of the peri-rectal lesion near the site of your old surgical scar. Call his office at [**Telephone/Fax (1) 1416**] for an appointment. . Appointment scheduled prior to this hospitalization: Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2130-5-22**] 3:00 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "731.3", "998.59", "V09.81", "584.5", "518.5", "317", "682.6", "327.23", "581.1", "285.1", "599.0", "041.04", "278.01", "486", "998.12", "041.11", "682.2", "714.0", "737.41", "790.7", "733.13", "344.1", "286.9", "428.0", "733.00", "707.03" ]

icd9cm

[ [ [] ] ]

[ "93.90", "81.62", "03.59", "03.53", "81.06", "96.72", "81.63", "55.23", "38.93", "99.04", "99.05", "84.51", "84.52", "99.07", "83.39", "81.05", "96.04" ]

icd9pcs

[ [ [] ] ]

22063, 22135

10922, 19110

293, 299

22425, 22445

3637, 10899

22952, 24408

3061, 3065

19723, 22040

22156, 22404

19136, 19700

22469, 22929

3080, 3618

228, 255

327, 2235

2257, 2974

2990, 3045

25,963

160,782

46318

Discharge summary

report

Admission Date: [**2117-8-19**] Discharge Date: [**2117-9-7**] Service: GENERAL SURGERY HISTORY OF PRESENT ILLNESS: Patient is an 86-year-old female with a known history of AFib, hypertension, and diabetes type 2, came into the Emergency Department on [**8-19**] with a three day history of constipation and lower abdominal pain. Patient did have flatus. The patient was seen by her PCP and was prescribed an enema for constipation. Was given some response, but still the pain persisted. The patient was seen again by her PCP on [**8-18**] and reported having nausea and vomiting x3, abdominal distention, and tenderness. On [**8-19**], the patient was sent in for an abdominal CT scan. The CT scan indicated a high grade mechanical obstruction with appearance of closed loop, obstruction of small bowel in the right lower quadrant, questionable adhesions as the cause, a large extraluminal intraperitoneal air collection, and large amount of stool throughout the entire colon without evidence of diverticulitis. The patient was admitted to the General Surgery Service for treatment of a small bowel obstruction. LABORATORIES ON ADMISSION: Patient's white blood cell count 7.5, hematocrit 37.1, platelets 341. PT 12.8, PTT 21.1, INR 1.1. Potassium 4.5, sodium 133, chloride 93, bicarb 30, BUN 45, creatinine 1.1, glucose 136. On admission, the patient was afebrile at 97.6, heart rate 89, blood pressure 170/90, respiratory rate 18, 96% on room air. She is alert and oriented in no apparent distress. Her cardiovascular exam showed regular, rate, and rhythm. Lung exam: Clear to auscultation bilaterally. Abdominal exam showed distention, tympanitic, mildly tender to deep palpation of the right lower quadrant, no peritoneal signs. Rectal exam showed stool and heme negative in the vault. On hospital day #1, [**8-20**], the patient was started on TPN and serial exams showed that the patient still had abdominal distention and tenderness to palpation in the bilateral lower quadrants. On hospital day #2, the patient was known to be in tachycardia in fibrillation. Patient was known to have a history of chronic AFib. On this day, the patient's potassium was repleted. Abdominal exam still showed soft, distended. Abdominal film on the [**8-22**] showed persistent dilated loops of small bowel with air-fluid levels, and the patient was then prepped for surgery which was to take place on [**8-23**]. On [**8-23**], the patient underwent an exploratory laparotomy and a lysis of adhesions. Gastrostomy and feeding jejunostomy tubes were also placed. The patient tolerated the procedure well. For details of the operation, please refer to the operation note, and the patient was then transferred to the Surgical ICU for recovery. While in the SICU, the patient was noticed to be in chronic AFib. Patient was placed on 3 liters oxygen nasal cannula with good saturation, and lung sounds were clear bilaterally upper lobes and diminished slightly in the lower bases. Nasogastric tube was removed on [**8-24**] and her G tube was placed to gravity. Tube feeding impact with fiber 1.5 strength was started through the J tube at 10 cc an hour, no residuals per auscultation. No stools or flatus were noted on that day. Patient was taking sips on [**8-24**], but no more than 30 cc an hour and her abdominal examination was still soft, distended, and tender. The patient was also receiving TPN. Also on [**8-24**], the patient was noticed to have a systolic blood pressure between 140-170. A nitroglycerin drip was started to keep her systolic blood pressure below 160. On [**8-25**], with the patient still in the Surgical Intensive Care Unit, the patient's blood pressure, hypertension had resolved with oral antihypertensives and Lopressor 25 mg IV q.4. Nitroglycerin drip was discontinued at this time. The patient was also experiencing frequent runs of supraventricular tachycardia, which self converted. The patient was tolerating her sips with no nausea or vomiting, still taking fiber tube feeds via her PEG at 10 cc/hour. Noticed to have a residual of 50 cc. Her TPN was running at 74 cc an hour. Abdominal exam showed mildly soft, distended, and tender with no bowel sounds. On [**8-26**], which is postoperative day #3, the patient showed AFib with rare to occasional PVCs, and systolic blood pressure was maintained below 160 on oral medications and IV Lopressor. Patient's TPN was running at 73 cc an hour and still taking tube feeds impact with fiber now at 20 cc through her J tube. No residual was noted. Patient is still tolerating sips with no nausea or vomiting. Her abdominal exam still showed a firm abdomen distended with bowel sounds present. The G tube was still to gravity at this time. The patient had no stool or flatus, and on this date the patient was out of bed to chair and able to walk with assistance. The patient was transferred to the floor on postoperative day #3. On postoperative day #6, [**8-29**], the patient still had moderate distention. Abdomen was soft, nontender. Patient was afebrile and tolerating sips. Patient did have a bowel movement by this time, and was doing well clinically. KUB on the date showed dilated small bowel loops with multiple air-fluid levels. Also ring-like densities overlying the femoral neck and stool with contrast noted throughout the entire colon. This was read as being suspicious for an early small bowel obstruction. On postoperative day #8, the patient was doing well and continuing with the tube feeds and ambulating. The patient was complaining of a fair amount of right upper quadrant pain and an ultrasound was taken at that point. The gallbladder was viewed as being normal without stones, wall edema, or pericholecystic fluid. There was a small amount of perihepatic ascites, but no intra or extrahepatic biliary ductal dilation. Postoperative day 39, [**9-1**], the patient was reported to be doing well, passing gas and having bowel movements. Abdominal exam still showed that she was still soft, distended, but positive bowel sounds. Her abdominal x-ray showed a multiple mildly gas distended loops of small bowel. Gas is present in the colon and a small amount of gas under the right hemidiaphragm. This was consistent with a postoperative ileus as read by the radiologist. By postoperative day 11, [**9-3**], the patient was doing well. Still had several bouts of AFib, which was self contained. The patient at this time was started off on a regular diet, and her tube feeds were cycled. TPN was discontinued at this time, and discharge planning was initiated. On [**9-4**], the patient continued to do well. TPN was discontinued. Patient was placed on a regular diet and her G tube was clamped for two hours out of every four. Rehab planning was instituted. Postoperative day 13, [**9-5**], the patient was tolerating her p.o. well and her tube feeds were continued. Her G tube was clamped for the floor. Her abdominal exams showed that she was still slightly distended, but now at baseline, slightly tympanitic also at baseline with positive bowel sounds, afebrile, and screening for Heathwood placement. Postoperative day 15, the patient is improving on J tube feeds and was discharged to [**Hospital **] Rehab today. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Discharged to [**Hospital **] Rehab. DISCHARGE DIAGNOSES: 1. Exploratory laparotomy with lysis of adhesions, gastrostomy, and jejunostomy. 2. Hypertension. 3. Atrial fibrillation. 4. Diabetes mellitus type 2. 5. Glaucoma. DISCHARGE MEDICATIONS: 1. Acetaminophen 650 mg p.o. q.4-6h. as needed. 2. Hydrochlorothiazide 25 p.o. q.d. 3. Albuterol nebulizer solution, one nebulizer q.6h. prn. 4. Lisinopril 10 mg p.o. q.d. 5. Metoprolol 125 mg p.o. 3x/day. 6. Pantoprazole 40 mg p.o. q.24h. 7. Dorzolamide 2%/timolol 0.5% ophthalmologic solution one drop OU b.i.d. 8. Glycerine suppositories one suppository p.r. prn. 9. Bisacodyl 10 mg p.r. q.d. 10. Digoxin 0.25 mg p.o. q.d. 11. Levothyroxine sodium 50 mcg p.o. q.d. 12. Estrogen conjugated 0.625 mg p.o. q.d. 13. Metoclopramide 10 mg p.o. q.i.d. a.c./h.s. FOLLOW-UP PLANS: The patient is to followup with Dr. [**Last Name (STitle) 957**] in his office in [**7-15**] days. Please call his office for an appointment time. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4007**] Dictated By:[**Name8 (MD) 846**] MEDQUIST36 D: [**2117-9-7**] 08:29 T: [**2117-9-7**] 08:35 JOB#: [**Job Number 98473**]

[ "365.9", "560.81", "560.2", "280.9", "997.4", "560.1", "E878.8", "427.31", "427.0" ]

icd9cm

[ [ [] ] ]

[ "43.19", "96.6", "54.59", "99.15", "46.39" ]

icd9pcs

[ [ [] ] ]

7404, 7569

7592, 8151

8169, 8543

129, 1146

1161, 7292

7317, 7383

4,437

186,595

16688

Discharge summary

report

Admission Date: [**2118-3-31**] Discharge Date: [**2118-4-5**] Date of Birth: [**2044-11-4**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 73[**Hospital 4622**] nursing home resident with a history of hypertension and Alzheimer's dementia who presented with an episode of loss of consciousness after defecating. By report by the nursing home staff, the patient had been recently constipated but otherwise in his usual state of health and had been a recent aggressive bowel regimen. On the day of admission, the patient had a large bowel movement with some bright blood per nursing home records. He was found unconscious on the toilet with no report of head trauma or a fall. The patient was unresponsive to voice, and vital signs revealed a temperature of 99.5, heart rate was in the 70s, and blood pressure was 90/50. The patient was transferred to [**Hospital1 188**] for further evaluation. He was unresponsive to sternal rub and did not have a gag reflex. His systolic blood pressure was in the 70s. His fingerstick at that time was 200, and the patient received one dose of Narcan with no response. He was intubated for airway protection and taken to the Intensive Care Unit for further monitoring. Of note, the patient had guaiac-positive brown stool in the Emergency Department, and his laboratory studies were significant for a hematocrit of 32 (which is the patient's baseline) and a creatinine of 3.3 (which was elevated from a bowel sounds of 1). The patient was given 2 liters of normal saline, and his blood pressure improved to 120 systolic. PAST MEDICAL HISTORY: 1. Hypertension. 2. Dementia; Alzheimer's type. 3. Psychosis. 4. History of depression. 5. Elevated cholesterol. 6. History of prostatitis. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Mirtazapine 15 mg p.o. q.h.s. 2. Trazodone 25 mg p.o. once per day (at 1:30 p.m.). 3. Olanzapine 2.5 mg p.o. once per day (at 4 p.m.). 4. Olanzapine 5 mg p.o. once per day (at 10 p.m.). 5. Gabapentin 600 mg p.o. twice per day. 6. Terazosin 1 mg p.o. q.h.s. 7. Calcium carbonate 500 mg p.o. once per day. 8. Multivitamin one tablet p.o. once per day. 9. Lactulose 30 cc p.o. twice per day. 10. Colace 200 mg p.o. once per day. 11. Propranolol 5 mg p.o. twice per day. SOCIAL HISTORY: The patient lives at [**Location 47222**]. At baseline, the patient is interactive, walks, and talks; but is not oriented. He has a supportive family involved in his care. REVIEW OF SYSTEMS: On review of systems, the patient has had no recent fevers, no cough, and no localizing symptoms (per nursing home staff). He has no prior history of a seizure disorder. PHYSICAL EXAMINATION ON PRESENTATION: On physical examination, the patient was afebrile with a temperature of 98, heart rate was 72, blood pressure was 130/70, respiratory rate was 14, and oxygen saturation was 100% on ventilator. In general, the patient was intubated and responded to sternal rub as well as manipulation of the endotracheal tube. The neck was supple with no midline tenderness and no lymphadenopathy. Head and neck examination revealed pupils were minimally reactive and mild bloody secretions from the mouth; likely secondary to traumatic nasogastric tube placement. The lungs revealed rhonchorous breath sounds bilaterally with decreased breath sounds at the bases, and no wheezes. Cardiovascular examination revealed a regular rate and rhythm. A 2/6 systolic ejection murmur at the left upper sternal border. The abdomen was soft with no tenderness, and no masses. Rectal examination revealed soft brown guaiac-negative stool. Extremities had no edema. Neurologic examination revealed flaccid extremities but increasing rigidity of the upper extremities with full range of motion. There was no obvious facial droop. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratory studies revealed the patient's hematocrit was 31.9 (unchanged from baseline of 32). Chemistry-7 panel was significant for a blood urea nitrogen of 53 and a creatinine of 3.3. Initial creatine kinase was 724 with a troponin of less than 0.3, MB was 12, and index was 1.7. INR was within normal limits. PERTINENT RADIOLOGY/IMAGING: A chest x-ray revealed no pneumothorax, no pneumonia, and proper placement of the endotracheal tube. A head computed tomography revealed no acute bleed, with normal ventricles and fossae, with no mass effect. Electrocardiogram revealed a normal sinus rhythm at 70 beats per minute with normal axis and intervals. Decreased R waves in V5 and V6 (which were old). No acute ST changes. HOSPITAL COURSE BY ISSUE/SYSTEM: 1. LOSS OF CONSCIOUSNESS ISSUES: The patient's syncope was evaluated by telemetry which showed no arrhythmias over 48 hours. An electroencephalogram was normal, and a transthoracic echocardiogram was a limited study but demonstrated no significant valvular abnormalities. The etiology of the loss of consciousness was probably a vasovagal event secondary to defecation in combination with dehydration. Blood cultures were negative, and the patient remained afebrile throughout and demonstrated no evidence for infection or sepsis. He maintained good blood pressures with continued intravenous fluids and was extubated on the second hospital day. He had no further episodes of loss of consciousness during his hospitalization. 2. ACUTE RENAL FAILURE ISSUES: The patient's renal failure was likely due to dehydration. His creatinine improved to baseline with intravenous fluids. His creatinine remained normal with oral intake. The patient's rhabdomyolysis also resolved with intravenous hydration with downward trending creatine kinases. 3. ANEMIA ISSUES: The patient's hematocrit decreased with intravenous fluids, and he was transfused with 2 units of packed red blood cells. His hematocrit increased appropriately and remained stable at 35 status post transfusion. He had intermittently guaiac-positive stools, and further investigation revealed that he had not had a recent colonoscopy. An outpatient colonoscopy was arranged for further evaluation and will be followed up by the patient's primary care provider. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE DISPOSITION: Discharged to [**Hospital 47222**]. DISCHARGE DIAGNOSES: 1. Dehydration. 2. Acute renal failure. 3. Rhabdomyolysis. MEDICATIONS ON DISCHARGE: 1. Mirtazapine 15 mg p.o. q.h.s. 2. Trazodone 25 mg p.o. once per day (at 1:30 p.m.). 3. Olanzapine 2.5 mg p.o. once per day (at 4 p.m.). 4. Olanzapine 5 mg p.o. once per day (at 10 p.m.). 5. Gabapentin 600 mg p.o. twice per day. 6. Terazosin 1 mg p.o. q.h.s. 7. Calcium carbonate 500 mg p.o. once per day. 8. Multivitamin one tablet p.o. once per day. 9. Lactulose 30 cc p.o. twice per day. 10. Colace 200 mg p.o. once per day. 11. Propranolol 5 mg p.o. twice per day. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to have an outpatient colonoscopy on [**2118-4-13**] with Dr. [**First Name11 (Name Pattern1) 3613**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. 2. The patient was to follow up with his primary care provider. [**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**] Dictated By:[**Last Name (NamePattern1) 6916**] MEDQUIST36 D: [**2118-4-5**] 10:50 T: [**2118-4-5**] 10:53 JOB#: [**Job Number 47223**]

[ "584.9", "401.9", "311", "294.10", "578.1", "276.5", "780.2", "728.89", "331.0" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6312, 6349

6370, 6433

6460, 6950

1855, 2345

6983, 7500

4690, 6236

6251, 6287

2557, 4656

159, 1605

1627, 1828

2362, 2537

9,253

154,196

411

Discharge summary

report

Admission Date: [**2146-8-20**] Discharge Date: [**2146-8-30**] Service: MEDICINE Allergies: Valium Attending:[**First Name3 (LF) 3565**] Chief Complaint: Hypotension, Hypoxia Major Surgical or Invasive Procedure: Trach change [**8-21**], [**8-25**], [**8-26**]. [**Last Name (un) 295**] in place at time of discharge. Bronchoscopy [**8-21**] History of Present Illness: [**Age over 90 **]yo from [**Hospital **] rehab with h/o HTN, osteoperosis, and chronic resp failure [**1-5**] to parkinson's disease, trached and peged d/t multiple aspiration events brought to the ED from his NH with concern for AMS. He had an unresponsive episode last night, was reportedly hypoxic (unclear degree). Staff at NH were also concerned about possible facial droop. The wife rescinded the DNR order prior to arrival and stated he is to be full code. EMS suctioned a golf ball sized mucous plug from his trach. He has had episodes of mucus plugging in the past. Recent hospitalization for hip fracture and ileus. Urine culture from [**7-17**] grew resistant ecoli. He was started on a 7 day course of ceftriaxone on [**2146-7-18**]. Other micro history: urine w ESBL kleb, resistant ecoli, pseudomonas resistant to zosyn in sputum and VRE swab. . ED Course: Admission vitals at 0620 53 120/50 15 100. Code stroke called with concern for new facial droop. CT head wo contrast was negative for acute intracranial hemorrhage. Once family arrived they confirmed that facial droop was old. Pt was documented DNR but was reversed for transport. Family also clarified that code status is NO COMPRESSIONS, but would want epinephrine and similar drugs. Started ceftriaxone 1g for presumed UTI. Briefly hypotensive to 80's at 7am, got 1L IVF. Vitals prior to transfer: 121/53, 55, 13, 100% on vent (FiO2 40%, tidal volume 500, PEEP 5, rr 13). Access: 20g hand, 22g hand, 18 R forearm. Foley catheter from rehab not exchanged. . On the floor, pt c/o L hip pain. Past Medical History: 1. h/o aspiration PNA - Tx with levo, unasyn, vanco/zosyn in the past 2. h/o aspiration s/p swallow eval with swallowing difficulty, s/p [**Date Range 282**] placement on [**10-9**] - pt continues to feed for pleasure at HebReb 3. Parkinson disease 4. Osteoporosis 5. T11/12 compression fx 6. LLE osteomyelelitis as a child/Chronic osteomyelitis, quiescent. 7. granulomatous liver disease 8. LUE rotator cuff tear 9. Prostate cancer s/p orchiectomy in [**2126**] 10. s/p laminectomy L4-5 11. Cataracts s/p surgery [**46**]. Glaucoma 13. Hypertension 14. h/o of treatment for pseudomonas and aspiration PNA at heb reb 15. s/p Trach with night ventilator support. 16. s/p wrist fx 17. chronic constipation 18. Chronic abd pain- per Heb Reb notes 19. Recent admission following vasovagal event at heb/reb s/p chest compressions complicated by PTX s/p chest tube 20. L ant pubic rami fracture, L ant iliac fracture Social History: The patient has a sixty-pack-year history of tobacco. He quit in [**12/2098**]. He lives at [**Hospital **] rehab MACU for last 3 hrs. He is a retired history professor. [**First Name (Titles) **] [**Last Name (Titles) **], no alcohol intake. - Tobacco: none currently - Alcohol: none currently - Illicits: none Family History: Non-contributory Physical Exam: Admission Physical Exam: Vitals: T: 97.5 BP: 104/45 P:75 R:14 O2: 100% (FiO2 40%, tidal volume 500, PEEP 5) General: Alert, elderly male, trach on vent, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, trach site intact, no LAD Lungs: diffuse wheezes and rhonchi to auscultation 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, [**Last Name (Titles) **] site intact Skin: diffuse nonpitting edema dependent areas, stage 1 skin breakdown GU: foley in place Ext: cool, well perfused, 2+ pulses, pitting edema to mid calves, no clubbing or cyanosis . Discharge Physical Exam: General: Alert, elderly male, trach on vent, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, trach site intact, no LAD Lungs: diffuse wheezes and rhonchi to auscultation 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, [**Last Name (Titles) **] site intact Skin: general anasarca GU: foley in place Ext: cool, well perfused, 2+ pulses, pitting edema to mid calves, no clubbing or cyanosis . Pertinent Results: At admission: [**2146-8-20**] 06:25AM BLOOD WBC-14.1* RBC-3.37* Hgb-9.4* Hct-28.1* MCV-83 MCH-27.8 MCHC-33.4 RDW-17.9* Plt Ct-357 [**2146-8-20**] 06:25AM BLOOD Neuts-84* Bands-2 Lymphs-6* Monos-3 Eos-2 Baso-0 Atyps-0 Metas-2* Myelos-1* [**2146-8-20**] 06:25AM BLOOD PT-12.5 PTT-24.4 INR(PT)-1.1 [**2146-8-20**] 06:25AM BLOOD Glucose-122* UreaN-27* Creat-0.9 Na-128* K-6.1* Cl-91* HCO3-28 AnGap-15 [**2146-8-21**] 03:18AM BLOOD Albumin-2.8* Calcium-7.9* Phos-3.4 Mg-2.3 [**2146-8-21**] 12:43PM BLOOD calTIBC-220* VitB12-448 Folate-GREATER TH Ferritn-96 TRF-169* [**2146-8-20**] 06:25AM BLOOD Osmolal-279 [**2146-8-21**] 09:23AM BLOOD Tobra-7.4 [**2146-8-20**] 06:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2146-8-20**] 07:01PM BLOOD Type-ART Rates-/14 Tidal V-450 PEEP-5 FiO2-40 pO2-121* pCO2-50* pH-7.39 calTCO2-31* Base XS-4 Intubat-INTUBATED Vent-CONTROLLED [**2146-8-20**] 06:25AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.006 [**2146-8-20**] 06:25AM URINE Blood-NEG Nitrite-POS Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG [**2146-8-20**] 06:25AM URINE RBC-4* WBC-174* Bacteri-MOD Yeast-NONE Epi-<1 TransE-<1 [**2146-8-20**] 05:00PM URINE Hours-RANDOM UreaN-52 Creat-3 Na-146 K-4 Cl-140 [**2146-8-20**] 06:25AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG Micro: Blood Culture [**8-20**] negative x2 [**2146-8-20**] Sputum culture: [**2146-8-20**] 4:51 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2146-8-27**]** GRAM STAIN (Final [**2146-8-20**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. RESPIRATORY CULTURE (Final [**2146-8-27**]): SPARSE GROWTH Commensal Respiratory Flora. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. DORIPENEM Susceptibility testing requested by DR.[**Last Name (STitle) 3566**],[**First Name3 (LF) 3567**] [**2146-8-25**]. DORIPENEM>32MCG/ML NON-SUSCEPTIBLE. MIC interpretations are based on manufacturer's guidelines that are FDA approved Sensitivity testing performed by Etest. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SECOND MORPHOLOGY. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. AMIKACIN AND DORIPENEM Susceptibility testing requested by DR.[**Last Name (STitle) 3566**],[**First Name3 (LF) 3567**] [**2146-8-25**]. DORIPENEM >32MCG/ML NON-SUSCEPTIBLE. MIC interpretations are based on manufacturer's guidelines that are FDA approved Sensitivity testing performed by Etest. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | PSEUDOMONAS AERUGINOSA | | AMIKACIN-------------- =>64 R 16 S CEFEPIME-------------- 16 I 8 S CEFTAZIDIME----------- 8 S 16 I CIPROFLOXACIN--------- 2 I =>4 R GENTAMICIN------------ =>16 R 8 I MEROPENEM------------- 4 S 8 I PIPERACILLIN/TAZO----- S R TOBRAMYCIN------------ 8 I 2 S C.Dif negative x3 [**8-21**], 22, 23 [**2146-8-21**] Bronchoalveolar lavage: [**2146-8-21**] 3:58 pm BRONCHOALVEOLAR LAVAGE **FINAL REPORT [**2146-8-24**]** GRAM STAIN (Final [**2146-8-21**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2146-8-24**]): ~3000/ML Commensal Respiratory Flora. YEAST. ~1000/ML. Isolates are considered potential pathogens in amounts >=10,000 cfu/ml. GRAM NEGATIVE ROD(S). ~1000/ML. FURTHER WORKUP ON REQUEST ONLY. Isolates are considered potential pathogens in amounts >=10,000 cfu/ml. [**2146-8-22**] Urine cx: [**2146-8-22**] 6:37 pm URINE Source: Catheter. **FINAL REPORT [**2146-8-23**]** URINE CULTURE (Final [**2146-8-23**]): GRAM POSITIVE COCCUS(COCCI). ~4000/ML. [**2146-8-23**] Sputum Cx: [**2146-8-23**] 3:45 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2146-8-25**]** GRAM STAIN (Final [**2146-8-23**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2146-8-25**]): Commensal Respiratory Flora Absent. Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. YEAST. SPARSE GROWTH. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # 330-8016C, [**2146-8-20**]. GRAM NEGATIVE ROD(S). RARE GROWTH. Radiology: [**2146-8-20**] CT HEAD NONCONTRAST: IMPRESSION: No acute intracranial hemorrhage or mass effect. If concern for acute infarct is high, please note that MR is more sensitive if not contra-indicated. Total opacification of the right mastoid air cells, middle ear cavity and mucosal thickening in the right ethmoid air cells and maxillary sinus. [**2146-8-20**] CXR: 1. Low lung volumes with bibasilar opacities which are stable and could reflect atelectasis vs pneumonia. 2. Apparent inferior dislocation of the left humeral head, unchanged - please correlate clinicaly. [**2146-8-22**] CXR: Tracheostomy tube is unchanged in position. Left-sided PICC follows a normal course terminating in the upper SVC. A rounded opacity at the right base is somewhat less apparent on the [**Known lastname 3545**] exam; however, there is increased right-sided effusion and atelectasis. Left basilar atelectasis and small effusion are also present. Cardiomediastinal silhouette is stable. There is atherosclerotic calcification of the aortic arch. Prominent mediastinal and hilar densities are compatible with calcified adenopathy. TTE [**2146-8-23**]: Poor image quality.There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets are moderately thickened. The study is inadequate to exclude significant aortic valve stenosis. Mild (1+) aortic regurgitation is seen. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2145-4-14**] , no definite change (the RV appears similar). [**2146-8-25**] CT ABDOMEN/PELVIS WITH CONTRAST: IMPRESSION: 1. Bilateral pleural effusions. 2. Small right lower lobe infiltrate. 3. [**Month/Day/Year 282**] tube in place in the pylorus of the stomach. 4. No evidence of colitis. 5. Scattered diverticula without evidence of diverticulitis. 6. Normal-appearing appendix. 7. Anasarca. 8. Stable left iliac, left pubic rami, and bilateral inferior rami fractures. CXR [**2146-8-26**]: Following right thoracentesis, there is no visible pneumothorax. Small residual right pleural effusion is evident. Previously reported pulmonary edema has nearly resolved. Left lower lobe opacity and adjacent pleural effusion appears slightly improved. Otherwise no relevant changes. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: [**Age over 90 **]y M hx of HTN, osteoperosis, and chronic resp failure [**1-5**] to aspiration from parkinson's disease, trach/[**Month/Day (2) **] d/t multiple aspiration events s/p unresponsive episode at nursing home, ?hypoxia, mucus plugging and hypotension, and concern for left facial droop. 1. HYPOTENSION: Patient initially presented with leukocytosis and bandemia. Initially was placed on broad spectrum antibiotics with vancomyin, tobramycin, and cefepime. He was aggressively fluid resuscitated prior to arrival with >5LNS. Received PICC line [**2146-8-21**]. Urine, blood, and sputum were aggressively cultured. CXR failed to show striking infiltrate, though ventilator associated pnuemonia was suspected. His BP continued to trend to the 70s-80s, and so was started on dopamine drip on [**8-21**] with appropriate BP response. Sputum cultures from [**8-20**] eventually revealed two distinct, resistant pseudomonas species, prompting an antibiotic shift to zosyn/tobramycin on [**8-23**]. He underwent bronchoscopy and BAL on [**8-23**]. Vancomycin was discontinued at that time. Weaning his pressors proved to be extremely difficult, and therefore alternative explanations to his hypotension were sought. Adrenal insufficiency was ruled out with a normal AM cortisol of 14 and a normal cosyntropin stimulation test. Midodrine was started for any possible autonomic dysfunction given his advanced parkinsons disease. He was started on levothyroxine 50mcg daily due to a low free T4 at 0.79. Dopamine was changed to levophed on [**8-24**]. He underwent ABD/PELVIS CT on [**8-25**] for abdominal pain, which failed to reveal an infectious source. Tamsulosin was discontinued due to concern that it affected his BP control. Fluorinef was briefly used, though eventually discontinued as he was grossly fluid overloaded without sifnicitant hemodynamic effect. Levophed was stopped on [**2146-8-27**] and his systolic blood pressure has since ranged from 110s-140s. He will continue a 14d antibiotic course for VAP, with tobramycin ending [**9-2**] and zosyn ending [**9-4**]. 2. FACIAL DROOP: Felt to be non-stroke and confirmed baseline by his family. CT head negative in the ED and neuro did not feel that pt was having a stroke. 3. VENTILATOR ASSOCIATED PNEUMONIA: He was persistently hypoxic on admission. Most concerning is ongoing mucus plugging but generally tolerated his home vent settings. Chest xray poorly penetrated but possibly suggested RLL infiltrate. Noted to have high volume of secretions concerning for evolving pna. He was continued on home combivent inh and acetylcysteine for mucolytic.It was decided to treat for a 14d VAP course on zosyn/tobramycin when 2 resistant pseudomonas species grew in his sputum. He received vancomycin for approximately 6 days which was stopped after culture data failed to reveal gram positive isolates. He was oxygenating well and tolerating short periods of time on tracheostomy mask by the time of discharge, and remained on his home vent settings. 4. ALTERED MENTAL STATUS: Resolved. Likely [**1-5**] UTI vs pna vs hypoxia or other underlying infectious etiology. Rescinded code stroke after family confirmed appearance baseline. Some AMS may have been due to narcotic overtreatment of his recent hip fractures, as his mental status seemed to improve with more conservative dosing. 5. UTI: History of resistant ecoli and ESBL org in past. Started on broad abx per above. Foley catheter was exchanged (arrived with condom cath from Nursing Home). Urine cultures failed to reveal pathogenic levels of bacteria. 6. HYPONATREMIA: initial hyponatremia to 128 eventually resolved with volume resuscitation, likely was due to hypovolemia. 7. PELVIC FRACTURES: Prior admission, pt had new nondisplaced fracture involving left superior and inferior pubic rami w known left iliac [**Doctor First Name 362**] fracture. Pain control was continued with tramadol, oxycodone, tylenol, lidocaine patch, and ice. Hip x-ray without acute fracture. 8.TRACHEOSTOMY: Patient chronically trached with occasional time off the vent. High trach pressures concerning. Per wife, pt often spends 12-5pm off trach (sat 92% on mask) when he is well. He was continued on home combivent inh and acetylcysteine for mucolytic. He was bronched on [**8-21**] and ET tube was exchanged for larger size at that point. A noticeable cuff-[**Month/Year (2) 3564**] continued, and his trach was again upgraded to a 9.0 on [**8-25**], however substantial cuff pressures were needed to prevent leakage. A [**Last Name (un) 295**] tracheostomy tube was then placed on [**2146-8-26**] with improvement of his [**Date Range 3564**]. 9. Parkinson's disease: Chronic. Patient with severe dysphagia and tracheostomy. He continued home carbidopa/levidopa, entacapone, pramipexole. 10.MACULAR DEGENERATION: cont home eye gtt w warm compresses following. 11. FLUID OVERLOAD: Patient roughly 8L positive fluid balance due to aggresive fluid resuscitation, hypotension, and multiple IV meds. He will require diuresis back down to his dry weight in his nursing home. 12. CODE STATUS: wife clarified that code status is NO COMPRESSIONS, but would want epinephrine and similar drugs. 13. ANEMIA: His HCT trended down from admission 28 to 21-22. Received one PRBC transfusion. Iron, b12, folate wnl. hapto 282, retic: 2.1, LDH: wnl PENDING TESTS AT DISCHARGE: -Blood cultures [**2146-8-25**] (no growth to date) TRANSITIONAL CARE ISSUES: - continue zosyn 4.5mg q6hr through [**2146-9-4**] - continue tobramycin 240mg q36hr through [**2146-9-2**] (LAST DOSE [**8-29**], needs one dose on [**9-1**] ONLY) - diuresis down to dry weight - check TSH and free t4 in 6 weeks - trend periodic HCT for anemia - DVT prophylaxis with SC heparin due to inactivity - trend electrolytes and Cr with diuresis Medications on Admission: *holding lasix 1. bisacodyl 10 mg Suppository QAM 2. carbidopa-levodopa 25-100 mg Tablet [**Month/Year (2) **]: Five (5) Tablet PO SEE COMMENT (): PO 7 times daily: 05, 08, 11, 14, 17, 20, 23. 3. lactulose 10 gram/15 mL Solution [**Month/Year (2) **]: Fifteen (15) ML PO TID (3 times a day). 4. dorzolamide-timolol 2-0.5 % Drops [**Month/Year (2) **]: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day): to both eyes. 5. latanoprost 0.005 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic HS (at bedtime): both eyes. 6. pramipexole 0.125 mg Tablet [**Hospital1 **]: One (1) Tablet PO four times a day: At 0500, 0800, 1100, 1400. 7. pramipexole 0.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO QPM (once a day (in the evening)). 8. entacapone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO see below (): seven times daily: 05, 08, 11, 14, 17, 20, 23 9. tamsulosin 0.4 mg Capsule, Ext Release 24 hr [**Hospital1 **]: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 10. lorazepam 0.5 mg Tablet q4hours 11. ipratropium-albuterol 18-103 mcg/Actuation Aerosol [**Hospital1 **]: Four (4) Puff Inhalation twice a day. 12. docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]: Ten (10) ML PO BID (2 times a day): (take 100 mg [**Hospital1 **]) . 13. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO TID (3 times a day). 14. cholecalciferol (vitamin D3) 400 unit Qday 15. erythromycin ethylsuccinate 200 mg/5 mL Suspension for Reconstitution [**Hospital1 **]: 10ml q6hours 16. polyethylene glycol 3350 17 gram/dose Powder [**Hospital1 **]: One (1) PO DAILY (Daily). 17. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 18. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback [**Hospital1 **]: One (1) Intravenous Q24H (every 24 hours) for 6 days. 19. simethicone 80 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO BID (2 times a day). 20. fluticasone 50 mcg/Actuation Spray, Suspension [**Hospital1 **]: One (1) Nasal twice a day. 21. racepinephrine 2.25 % Solution for Nebulization [**Hospital1 **]: 0.5 ML Inhalation q 2 hrs prn as needed for shortness of breath or wheezing. 22. omeprazole 40 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1) Capsule, Delayed Release(E.C.) PO once a day. 23. ascorbic acid 500 mg Capsule, Extended Release [**Hospital1 **]: One (1) Capsule, Extended Release PO once a day. 24. chlorhexidine gluconate 0.12 % Mouthwash [**Hospital1 **]: One Hundred-Fifteen (115) ML Mucous membrane four times a day: swish and spit . 25. acetaminophen 650 mg/20.3 mL Solution [**Hospital1 **]: One (1) PO TID (3 times a day) as needed for fever or pain. 26. oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 27. morphine 5 mg/mL Solution [**Hospital1 **]: Five (5) mg Injection every four (4) hours as needed for pain: use for breakthough pain or if unable to take by G-tube. 28. Acetylcysteine 100 mg intratracheal [**Hospital1 **] 29. Gentamicin nebulizer 80 mg [**Hospital1 **] Discharge Medications: 1. bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Rectal once a day as needed for constipation. 2. carbidopa-levodopa 25-100 mg Tablet [**Hospital1 **]: Five (5) Tablet PO 7X DAILY (): 05, 08, 11, 14, 17, 20, 23. 3. dorzolamide-timolol 2-0.5 % Drops [**Hospital1 **]: One (1) Ophthalmic twice a day: to both eyes. 4. latanoprost 0.005 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic HS (at bedtime). 5. pramipexole 0.125 mg Tablet [**Hospital1 **]: One (1) Tablet PO QID (4 times a day): 05, 08, 11, 14. 6. pramipexole 0.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO QHS (once a day (at bedtime)). 7. entacapone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO 7 times daily (): 05, 08, 11, 14, 17, 20, 23. 8. lorazepam 0.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. 9. ipratropium-albuterol 18-103 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOb, wheeze. 10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO three times a day. 11. cholecalciferol (vitamin D3) 400 unit Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 12. erythromycin ethylsuccinate 200 mg/5 mL Suspension for Reconstitution [**Hospital1 **]: Ten (10) ml PO Q6H (every 6 hours). 13. polyethylene glycol 3350 17 gram/dose Powder [**Hospital1 **]: One (1) PO once a day. 14. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]: Two (2) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for L hip, back. 15. omeprazole 40 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1) Capsule, Delayed Release(E.C.) PO once a day. 16. ascorbic acid 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 17. chlorhexidine gluconate 0.12 % Mouthwash [**Hospital1 **]: One (1) ML Mucous membrane every six (6) hours. 18. acetaminophen 650 mg/20.3 mL Solution [**Hospital1 **]: One (1) PO three times a day as needed for fever or pain. 19. levothyroxine 50 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 20. midodrine 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3 times a day). 21. Piperacillin-Tazobactam 4.5 g IV Q8H ***INFUSE OVER 3 HOURS*** 22. Tobramycin 240 mg IV Q36H 23. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 24. calcitonin (salmon) 200 unit/actuation Spray, Non-Aerosol [**Hospital1 **]: One (1) Nasal QHS (once a day (at bedtime)): alteranting nostrils. 25. heparin (porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) Injection TID (3 times a day). 26. Lasix 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 27. Outpatient Lab Work Please check CBC, sodium, potassium, chloride, bicarb, BUN, creatinine, mag, phosp twice weekly to monitor chronic anemia as well as renal function while on diuretics 28. Outpatient Lab Work Please just thyroid function test in 6weeks to determine if levothyroxine dose needs to be adjusted Discharge Disposition: Extended Care Facility: [**Hospital 100**] Rehab Discharge Diagnosis: Primary: Pneumonia Hypotension Hypothyroid 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 Mr [**Known lastname **] it was a pleasure taking care of you. You were brought to [**Hospital1 **] for evaluation of altered mental status. Head imaging was negative for stroke. While in house you developed hypotension as well as difficulty weaning of ventilation. . Imaging and labs were concerning for potential pneumonia and you were started on broad spectrum antibiotics. With treatment of pneumonia your breathing improved. In addition we switched your trach with improvement in symptoms. . To treat your hypotension you were started on midodrine and treated for infection. . Medications changes: To treat infection: 1. Take Tobramycin 240mg IV every 36hrs. Your last dose of tobramycin at [**Hospital1 **] occurred on [**8-30**]; your last dose will be due on the 29th. 3. Take Zosyn 4.5mg every 6hrs. Your last dose of antibiotics will be on [**9-4**]. . To treat low blood pressure: 1. Take Midodrine 10mg. Take one capsult three times daily . To treat hypothyroid 1. Take Levothyroxine 50mcg daily. ** You will need repeat TFTs in 6weeks with plan for dose alteration if needed. . To prevent clot formation you were start on SQ heparin. . Again it was a pleasure taking care of you. Please contact with any questions or concerns Followup Instructions: Please follow-up with PCP [**Last Name (NamePattern4) **] 1 week

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Discharge summary

report

Admission Date: [**2154-5-17**] Discharge Date: [**2154-5-28**] Date of Birth: [**2104-10-10**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 12131**] Chief Complaint: cool and painful right foot Major Surgical or Invasive Procedure: - RLE CFA/[**Doctor Last Name **] thrombectomy, fasciotomy and aortic stent placement - pericardiocentesis (apical approach) - Left VATS and pericardial window creation History of Present Illness: Ms. [**Known lastname **] is a 49y/o lady with recurrent breast cancer metastatic to liver/bone/stomach/likely lung, complicated by recurrent left pleural effusions s/p pleurex catheter placement [**5-15**], and also right-sided PE 1 month ago now on Lovenox, who was transferred from an OSH due to arterial thrombus, is now s/p thrombectomy, and is transferred to the CCU s/p pericardiocentesis after being incidentally found to have pericardial effusion with TTE evidence of tamponade. The patient originally presented to [**Hospital 487**] hospital on [**5-16**] with about 10 hrs of coolness and pain in her R foot that started about 10 PM the night before. The pain originated in her thigh but then travelled down to the dorsum of her right foot where it persisted prior to admission. The pain is not worsened by walking but is alleviated by pain medication and rest and she denies symptoms of claudication, leg swelling, or rest pain in the past. OSH arterial duplex was performed at LGH that by report demonstrated no flow in the right DP, with a monophasic PT. She was started on a heparin drip (with bolus) and transferred here for further management. Of note the patient reports baseline DOE since [**11/2153**] and denies chest pain, palpitation, fevers, or chills. While here, she was evaluated by vascular surgery and taken to the OR for RLE CFA/[**Doctor Last Name **] thrombectomy, fasciotomy and aortic stent placement. Imaging revealed a pericardial effusion so Cardiology was consulted. Pulsus was 6 but TTE showed evidence of tamponade physiology so she was taken to the cath lab for pericardiocentesis (apical approach). Removed 475cc bloody fluid, mean pericardial pressure was 17. Drain is in place. TTE showed residual fluid, no tamponade. On arrival to the ICU, patient is in pain from the groin site where the procedure took place earlier. Feels tired but no other major complaints. REVIEW OF SYSTEMS (+): Mild DOE recently, after walking a few blocks. Ongoing poor appetite and fatigue. (-): No prior history of stroke, TIA, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: PAST MEDICAL HISTORY: Breast cancer metastatic to bone, liver, stomach, and likely lung -recurrent L sided pleural effusions -s/p repeated drainage and L pleural catheter placement [**5-15**] -treated with Xeloda and Tykerb, but recently stopped Xeloda -Oncologist (Dr. [**Last Name (STitle) **] at LGH) planned to institute new regimen next Monday Rt-sided PE one month ago, on Lovenox PAST SURGICAL HISTORY: R mastectomy [**11/2151**] B/L oophorectomy [**2152**] C-section Social History: -Home: She is recently widowed and lives at home with her daughter and son, who is autistic. -Occupation: She has been unemployed since her cancer recurred. -Tobacco: Quit smoking about 15 yrs ago and smoked only 3 cigarettes/week before that. -EtOH: None. -Illicits: None. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: Tcurrent: 37.7 ??????C (99.8 ??????F) HR: 79 (79 - 87) bpm BP: 111/59(79) {111/58(78) - 114/59(80)} mmHg RR: 19 (17 - 22) insp/min SpO2: 94% GENERAL: tired-appearing lady in no respiratory distress. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Dry MM. NECK: Supple with no JVD. CARDIAC: S1 and S2, no murmur, no rub, no muffled heart sounds. CHEST: pericardial drain in placed draining small amount of bloody fluid LUNGS: CTA anteriorly, no rhonchi/wheezing ABDOMEN: Soft, NTND. No tenderness. No masses. EXTREMITIES: RLE is wrapped in ACE bandage; LLE with 1+ DP and PT pulses, RLE warm with no palpable pulses but Dopplerable DP pulse Discharge VS: 98.1 92/54 72 18 98%RA GENERAL: tired-appearing lady in no respiratory distress. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Dry MM. NECK: Supple with no JVD. Rt. IJ site bandaged, no bleeeding, swelling, tenderness, erythema. CARDIAC: S1 and S2, no murmur, no rub, no muffled heart sounds. CHEST: CTA anteriorly, no rhonchi/wheezing. Left pleurex catheter in place. VATS site bandaged with sutures, no leakage, heamtoma, tenderness. ABDOMEN: Soft, NTND. No tenderness. No masses. EXTREMITIES: RLE is wrapped in ACE bandage, fascotomy sites sutured, minimal pedal edema; LLE with 1+ DP and PT pulses, RLE warm with no palpable pulses but Dopplerable DP pulse Pertinent Results: Admission Labs: [**2154-5-17**] 12:15AM BLOOD WBC-7.3 RBC-3.73* Hgb-12.1 Hct-37.9 MCV-102* MCH-32.4* MCHC-31.9 RDW-19.1* Plt Ct-223 [**2154-5-17**] 12:15AM BLOOD Neuts-66.9 Lymphs-22.4 Monos-7.3 Eos-2.6 Baso-0.8 [**2154-5-17**] 12:15AM BLOOD PT-13.5* PTT-146.9* INR(PT)-1.3* [**2154-5-17**] 12:15AM BLOOD Glucose-123* UreaN-6 Creat-0.7 Na-134 K-3.2* Cl-103 HCO3-25 AnGap-9 [**2154-5-17**] 11:12AM BLOOD ALT-21 AST-40 AlkPhos-98 [**2154-5-17**] 11:12AM BLOOD CK-MB-2 cTropnT-<0.01 [**2154-5-17**] 11:12AM BLOOD Calcium-7.9* Phos-2.9 Mg-1.8 Discharge labs: [**2154-5-28**] 07:00AM BLOOD WBC-4.9 RBC-3.18* Hgb-9.7* Hct-30.8* MCV-97 MCH-30.5 MCHC-31.6 RDW-18.0* Plt Ct-206 [**2154-5-27**] 09:05AM BLOOD Neuts-94* Bands-0 Lymphs-6* Monos-0 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2154-5-27**] 09:05AM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-1+ Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Ovalocy-2+ Tear Dr[**Last Name (STitle) **]1+ [**2154-5-28**] 07:00AM BLOOD Plt Ct-206 [**2154-5-28**] 07:00AM BLOOD PT-13.5* PTT-35.8 INR(PT)-1.3* [**2154-5-28**] 07:00AM BLOOD LMWH-0.86 [**2154-5-25**] 06:15AM BLOOD ACA IgG-1.5 ACA IgM-10.8 [**2154-5-28**] 07:00AM BLOOD Glucose-89 UreaN-8 Creat-0.4 Na-139 K-3.8 Cl-107 HCO3-24 AnGap-12 [**2154-5-28**] 07:00AM BLOOD ALT-16 AST-40 LD(LDH)-239 AlkPhos-285* TotBili-0.4 [**2154-5-28**] 07:00AM BLOOD Albumin-1.9* Calcium-7.7* Phos-2.1* Mg-1.9 Pericardial Fluid: [**2154-5-17**] 06:10PM OTHER BODY FLUID WBC-4125* Hct,Fl-8.5* Polys-28* Lymphs-25* Monos-23* Mesothe-10* Macro-12* Other-2* [**2154-5-17**] 06:10PM OTHER BODY FLUID TotProt-3.9 Glucose-82 LD(LDH)-299 Amylase-17 Albumin-2.5 STUDIES: Echo ([**2154-5-17**]): Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is unusually small and does not fully expand in diastole. There is a large pericardial effusion. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. IMPRESSION: Large pericardial effusion with evidence tamponade physiology. Echo ([**2154-5-17**]): Pre-pericardiocentesis (images [**1-18**]): Large circumferential pericardial effusion. There is RV diastolic collapse consistent with tamponade physiology. Saline bubble injection during pericardiocentesis (images 11,13) indicate catheter appropriately in pericardial space. Post-pericardiocentesis (images 32-38): Overall left ventricular systolic function is normal (LVEF>55%). There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. Normal global biventricular cavity size and systolic function. CTA AORTA/BIFEM/ILIAC RUNOFF W IMPRESSION: 1. Thrombus within the distal aorta just above the bifurcation extending into the right common iliac artery with approximately 50% occlusion of the lumen. Thrombus in the right anterior tibial and right posterior tibial arteries, with no opacification beyond the distal third of the leg. The posterior tibial artery is attenuated throughout its course. 2. The left pelvic and left lower extremity vasculature beyond the aortic bifurcation is widely patent. 3. Large left partially loculated pleural effusion with a Pleurx catheter in place and little aeration of the visualized left lobe. Moderate pericardial effusion. 4. Numerous hyperenhancing hepatic lesions and sclerotic bony foci, likely metastatic disease in the setting of known breast cancer. ECHO ([**2154-5-18**]): 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 and appear underfilled. There is a small circumferential pericardial effusion. No right ventricular diastolic collapse is seen. IMPRESSION: Suboptimal image quality. Small circumferential pericardial effusion w/o echocardiographic signs of tamponade physiology. Normal biventricular cavity sizes with preserved global biventricular systolic function. If clinicallly indicated, serial evaluation is suggested. ECHO ([**2154-5-19**]): 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. There is abnormal septal motion/position. There is a small pericardial effusion. No right ventricular diastolic collapse is seen. IMPRESSION: Suboptimal image quality. Small anterior pericardial effusion w/o echocardiographic signs of tamponade physiology. There is a septal bounce seen, consistent with effusive-constrictive physiology - commonly seen in the first week post pericardiocentesis. Normal biventricular cavity sizes with preserved global biventricular systolic function Compared with the findings of the prior study (images reviewed) of [**2154-5-18**], the pericardial effusion is smaller with less fluid accumulation posteriorly. ECHO ([**2154-5-20**]): Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is abnormal septal motion/position. There is a small pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. IMPRESSION: Limited study. Small anterior pericardial effusion with likely cellular debris overlying the free wall of the right ventricle. No evidence of tamponade. Septal bounce, consistent with effusive-constrictive physiology post pericardiocentesis. Normal biventricular systolic function. Compared with the prior study (images reviewed) of [**2154-5-19**], the findings are similar. Pericardial Biopsy [**2154-5-22**]: Pericardium (A): Poorly differentiated carcinoma consistent with breast origin, (see note). Note: The carcinoma is positive for CK7, mammoglobin, and very focally for progesterone receptor and negative for CK20, TTF-1, GCDFP and estrogen receptor. CXR [**2154-5-24**] INDINGS: In comparison with the study of [**5-23**], there is no evidence of pneumothorax. Subcutaneous gas is seen along the left lower chest and upper abdomen wall. The apparent engorgement of pulmonary vessels on the previous study has substantially decreased. Retrocardiac opacification is consistent with volume loss in the lower lobe. Brief Hospital Course: BRIEF PATIENT SUMMARY: Ms. [**Known lastname **] is a 49 y/o lady with metastatic breast cancer who presented with cold right foot, now s/p intervention for arterial thrombus who was found to have pericardial effusion with tamponade for which she is s/p pericardiocentesis. ACTIVE ISSUES: #. Pericardial Effusion: The patient presented with evidence of a pericardial effusion with evidence of tamponade physiology on echo. patient is s/p pericardiocentesis with no current evidence of tamponade. The patient had pericardial drain removed on [**2154-5-19**]. Pericardial fluid analysis revealed no bacteria on gram stain and no growth on culture. Repeat TTE after removal of drain, performed on [**2154-5-20**], demonstrated no significant increase in pericardial fluid. However, effusion then re-accumulated. Patient had pericardial window in the OR by thoracic surgery team on [**5-22**]. A pericardial drain was placed, and subsequently removed once drainage had decreased and patient was stable on anticoagulation. The site was sutured. #. Left pleural effusion: s/p pleurx [**5-15**] (also drained 1L on [**5-17**]). We appreciated Thoracic Surgery recs. Pleurx was intermittently drained throughout hospitalization. #. Right arterial thrombus: She is now s/p R groin/[**Doctor Last Name **] cutdown, aortic stent, RLE thrombectomy, and 4 compartment fasciotomies. Her malignancy makes her hypercoagulable, but the fact that she developed an arterial thrombus while on Lovenox is difficult. Vascular surgery is following very closely. Vascular surgery will decide upon outpatient anticoagulation regimen. We continued patient on heparin gtt (goal PTT 60-80 per Vascular) while on the CCU service. Fasciotomy sites WTD/ with ace-wrap. nylon suture close in a few days s/p procedure. Pain control was achieved with tylenol, dilaudid IV. We appreciated Vascular surgery recommendations while the patient was on the CCU service. The patient's extremity is currently warm with dopplerable pulses. She was initially anticoagulated with a heparin drip, but eventually discharged on 80mg lovenox [**Hospital1 **], and a factor Xa level was checked after the second dose to ensure that she was therapeutic. #. Hypotension: hypotension periodically to SBP 70s-80s, fluid responsive. Likely volume depleted (poor PO intake, might be 3rd spacing into pleural effusion). Pain meds might have a very minimal contribution as well. It is very reassuring that she was mentating fine with no lab evidence of end-organ malperfusion. Pt received multiple boluses of IVF on night of [**2154-5-18**], for a total of approximately 4L fluid. In setting of Hct decreasing, repleted with 2u pRBCs on [**2154-5-19**]. # Anemia: Pt??????s Hct on admission 37.9 --> 31.8, likely secondary to hemoconcentration on admission. Pt??????s Hct further dropped from 27.8 --> 24.4 night of [**5-18**], in the setting of receiving 3-4L IVF, and also other cell lines decreased, so now may have a component of hemodilution. No e/o bleeding (no bloody or melenic bowel movements, no overt bleeding from surgical wound) aside from small amount of bloody drainage from pericardial drain. Pt w/ actively cross-matched units. Received 2 units of pRBCs on [**2154-5-19**]. hemolysis and DIC labs unremarkable. #. Recent pulmonary embolism: Was on a heparin drip throughout CCU stay. She was on Lovenox (100mg daily) as an outpatient, but she had a LE arterial thrombus on Lovenox (daily dosing). Following discussion between hem/onc and vascular surgery, it was decided to start her on [**Hospital1 **] 80mg lovenox for anticoagulation, given the proven efficacy of lovenox over warfarin in cancer-associated thrombosis. Factor Xa level was checked and was therapeutic prior to discharge. #. Breast cancer: stage IV. Metastatic to bone, liver, stomach, and likely lung - recurrent left sided pleural effusions s/p repeated drainage and left pleural catheter placement [**5-15**]. Right sided PE one month ago. continued Tykerb 1250mg daily initially. She was eventually transferred to the OMED service and following discussion with outpatient oncologist [**Doctor First Name 391**] Khitrik-Palchuk, she was started on a new regimen on navelbine + trastuzumab. She started the treatment inhouse and will followup with Dr. [**Name (NI) 87677**] to complete the cycle as an outpatient. #. Depression: stable. continued home Wellbutrin, Celexa. Had social work see patient. TRANSITIONAL ISSUES: -complete cycle of navelbine+trastuzumab as an outpatient. -continue 80mg [**Hospital1 **] lovenox for anticoagulation. -f/u with vascular surgery for removal of RLE sutures. Medications on Admission: HOME MEDICATIONS: Lovenox 100mg SC daily Tykerb 1250mg daily Wellbutrin 80mg QAM Celexa 80mg daily Oxycontin 15mg PRN [does not take often] Prilosec 20mg daily TRANSFER MEDICATIONS: Heparin IV sliding scale (goal PTT 60-80) Tykerb *NF* (lapatinib) 1250 mg Oral DAILY BuPROPion (Sustained Release) 100 mg PO QAM Citalopram 80 mg PO/NG DAILY Morphine Sulfate 2-4 mg IV Q4H:PRN pain Omeprazole 20 mg PO DAILY Ondansetron 4 mg IV Q8H:PRN nausea Vancomycin 1000 mg IV ONCE Duration: 1 Doses Administer 10 hrs after entering PACU. Give with cefazolin unless serious beta-lactam allergy. CefazoLIN 2 g IV Q8H Duration: 2 Doses Administer first post-op dose hrs after entering PACU, and second (final) dose administered 10h after entering PACU Discharge Medications: 1. enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg Subcutaneous Q12H (every 12 hours): Please inject only to 70mg (or 0.7ml) subcutaneous every 12 hours. Disp:*60 syringes* Refills:*0* 2. bupropion HCl 100 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO QAM (once a day (in the morning)). 3. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*18 Tablet(s)* Refills:*0* 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. VinORELbine (Navelbine) 35 mg IV Days 1, 8 and 15. ([**2154-5-24**], [**2154-5-31**] and [**2154-6-7**]) (30 mg/m2 - dose reduced by 33% to 20 mg/m2) Reason for dose reduction: recent procedure Administer IV push through running IV over 6-10 minutes. Use port closest to the IV bag not the patient. 7. Trastuzumab 145 mg IV Days 8, 15 and 22. ([**2154-5-31**], [**2154-6-7**] and [**2154-6-14**]) (2 mg/kg) Maintenance dose. infuse over 30 minutes, if loading dose tolerated well. 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 10. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: metastatic breast cancer recurrent pericardial effusion with pericardial window placement arterial thrombus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname **], It was a pleasure taking care of you at the [**Hospital1 771**]. You were transferred to [**Hospital1 **] Hospital because you had a clot in your right lower extremity artery. The vascular surgery team removed the clot and decompressed the swelling in your leg with a fasciotomy. While you were here you were found to have fluid collected around your heart. A drain was placed to remove the fluid but it recurred so a pericardial window was cut into the lining of your heart to help the fluid drain. The fluid had cancer cells in it. You were then transferred to the oncology service for chemotherapy, and were started on navelbine and herceptin. You will need to followup with your oncologist to complete a course of this chemotherapy. Your next sessions are [**2154-5-31**], [**2154-6-7**], and [**2154-6-14**]. Your oncologist's office (Dr [**Name (NI) 87677**]) will contact you regarding when to come in. Please contact the office if you have not heard from them by the end of tomorrow. We increased your dose of lovenox to prevent you from getting further blood clots. Please followup with your providers, see below. We made the following changes to your medications: STARTED: -Standing Acetaminophen for pain -Oxycodone for pain -Senna and colace to help you move your bowels INCREASED Lovenox to 70mg twice daily. The syringes come in 80mg. You will inject 0.7ml instead of the full 0.8ml. DECREASED citalopram from 80mg to 40mg because there can be an interaction with your omeprazole. (The two medications combined can cause irregularities in your heart rhythm). STOPPED: Tykerb Followup Instructions: Name: [**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 112415**], MD Specialty: Primary Care Provider [**Name Initial (PRE) **]: Tuesday [**6-4**] at 1pm Location: [**Hospital 46644**] MEDICAL ASSOCIATES Address: ONE PARKWAY, [**Location (un) **],[**Numeric Identifier 87435**] Phone: [**Telephone/Fax (1) 76162**] Name: [**Name6 (MD) **] [**Last Name (NamePattern4) 112416**],MD Location: [**Location (un) **] HEMATOLOGY/ONCOLOGY When: [**6-10**] at 11:45am Phone: [**Telephone/Fax (1) 80105**] Department: VASCULAR SURGERY When: WEDNESDAY [**2154-6-19**] at 2:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD [**Telephone/Fax (1) 2625**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2154-6-6**]

[ "V12.55", "423.8", "197.0", "444.81", "285.9", "197.8", "311", "V49.86", "198.89", "197.7", "V10.3", "444.22", "458.9", "511.81", "198.5", "444.09", "V15.82", "423.3" ]

icd9cm

[ [ [] ] ]

[ "86.59", "88.48", "88.42", "00.45", "83.09", "37.12", "38.08", "38.06", "39.90", "39.50", "99.25", "37.0", "00.40", "39.79" ]

icd9pcs

[ [ [] ] ]

18808, 18891

11866, 12141

334, 504

19043, 19043

5377, 5377

20886, 21740

3796, 3911

17312, 18785

18912, 19022

16549, 16549

19226, 20411

5934, 11843

3423, 3489

3926, 3936

16567, 16711

3958, 5358

16347, 16523

20440, 20863

267, 296

12156, 16326

16733, 17289

532, 2990

5393, 5917

19058, 19202

3034, 3400

3505, 3780

23,979

161,541

25388

Discharge summary

report

Admission Date: [**2168-8-17**] Discharge Date: [**2168-8-19**] Date of Birth: [**2091-5-6**] Sex: F Service: MEDICINE Allergies: Codeine / Phenergan / Lasix / Bumex / Hydrochlorothiazide / Ciprofloxacin Attending:[**Last Name (NamePattern1) 2499**] Chief Complaint: A-fib with RVR Major Surgical or Invasive Procedure: none History of Present Illness: 77 yo F with PMHx of Stage IV lung Ca, metastatic to brain who was recently admitted with diverticulitis and was discharged to Rehab on [**2168-8-12**]. Pt was initially doing well, but did report general malaise/lethary for the last week. She was noted to have hand swelling bilaterally and labs were notable for acute renal failure. Pt otherwise denied fevers/chills/diarrhea/CP/SOB/cough/jt pain/abd pain. She reported that the nausea had resolved since recent admission and she has been having normal BMs. There was no report of AFib with RVR until arrival to ED. . VS on arrival to ED: T 96.7 BP 90/60 HR 136 RR 18 Sats 99% on 4L NC. Pt received 2L IVF with Diltiazem 5mg IV and continued to have Afib with RVR in 130s. There was very scant UOP in the ED and after inability to rate control due to marginal BP, decision was made for transfer to [**Hospital Unit Name 153**]. . On arrival to [**Name (NI) 153**], pt was comfortable, denying any CP/SOB/abd pain. She was sleepy and describes feeling much better than she during the prior admission. Past Medical History: 1. History of stage 1A poorly-differentiated large cell carcinoma with squamous and adenocarcinoma features resected in [**2162-1-20**]. 2. History of type 2 diabetes, hypertension, and peripheral vascular disease with carotid stenosis for over 10 years. 3. History of hyperlipidemia. 4. s/p cholecystectomy, s/p appendectomy, s/p hysterectomy 5. History of intermittent atrial fibrillation. 6. Status post knee replacements. 7. PVD 8. Carotid stenosis 9. s/p VP shunt 10. three cesarean sections . Social History: Quit smoking in [**2153**] after 40 pack-year history. Lives with her daughter and nine year old granddaughter in [**Name (NI) 8391**]. Retired school lunch clerk. . The patient started smoking cigarettes at age 16 and she quit at age 62. This places her at approximate 50-pack-year history of smoking since she smoked one to one and a half packs of cigarettes per day. She tells me she was not exposed to asbestos or heavy chemicals. She lives in house with her daughter. Family History: Father with CAD/MI, deceased at age 47. Mother died from TB in her 30's. Sister died from lung ca., another sister died from breast ca., another sister died unknown ca., another sister with CHF. Divorced. Physical Exam: PE: T 97.9 HR 143 BP 93/56 RR 15 Sats 97% 2L GEN: NAD, comfortable, alert & oriented x 3 HEENT: NCAT, EOMI, PERRLA, MM dry CV: Irreg irreg no apprec m/r/g Resp: CTAB no apprec wheezes or rales ABD: soft, mildly distended, NTTP, NABS Extremities: 2+pitting edema tracks to knees bilaterally Neuro: CN 2-12 grossly intact, moving all four extremities well strength 5/5. Gait not assessed . Pertinent Results: LABS on admit: 133 104 23 105 AGap=16 ----------------< 3.7 17 4.5 (up from recent discharge 1.9) . WBC 6.0 Hgb 8.2 Hct 25.4 Plts of 59 . N:71.1 L:24.2 M:4.2 E:0.3 Bas:0.1 . ALT: 14 AP: 95 Tbili: 0.2 Alb: 2.8 AST: 16 LDH: 272 Lip: 23 . Urine +protein +bili +trace ketones . Urine lytes showed FENA 0.8 Creat:134 Na:32 K:46 Cl:17 Osmolal:279 [**2168-8-17**] 02:14PM TYPE-[**Last Name (un) **] PO2-40* PCO2-45 PH-7.18* TOTAL CO2-18* BASE XS--12 [**2168-8-17**] 02:14PM LACTATE-0.9 [**2168-8-17**] 09:58AM URINE HOURS-RANDOM UREA N-135 CREAT-138 SODIUM-38 POTASSIUM-43 CHLORIDE-25 [**2168-8-17**] 09:58AM URINE OSMOLAL-276 [**2168-8-17**] 09:58AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.019 [**2168-8-17**] 09:58AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.019 [**2168-8-17**] 09:58AM URINE BLOOD-SM NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2168-8-17**] 09:58AM URINE BLOOD-SM NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG Brief Hospital Course: Assessment & Plan: 77 yo F with PMHx of Stage IV lung Ca, metastatic to brain who was recently discharged with Abx for diverticulitis presents with ARF and Afib with RVR. . Patient initially admitted for a fib with RVR. Her rate was controlled with metoprolol and LENIs were performed which demonstrated extensive DVTs. An IVC filter was placed because the patient's brain metasteses represented a relative contraindication to anticoagulation. The patient also had ARF but her diagnostic work-up was interrupted before the etiology of this condition could be fully explored. Because of the prognosis of her metastatic lung cancer, she and her family ultimately made the decision to transition to comfort measures only care. She was transferred to the OMED service and expired on [**2168-8-19**]. Medications on Admission: Levetiracetam 500 mg [**Hospital1 **] Pantoprazole 40 mg Senna 8.6 mg 1-2 Tablets PO BID prn Oxycodone 10 mg Tablet [**Hospital1 **] Oxycodone 5 mg q4hr prn Vancomycin 1gram q48hr until [**2168-8-18**] to complete a 10 day course. Piperacillin-Tazobactam 2.25 gram IV Q6H until [**8-21**] to complete a 14 day course. Docusate Sodium 100 mg [**Hospital1 **] Filgrastim 300 mcg/mL q24hr Zofran 4 mg Tablet prn Discharge Disposition: Expired Discharge Diagnosis: Expired during admission Discharge Condition: Expired during admission Discharge Instructions: Expired during admission Followup Instructions: Expired during admission Completed by:[**2168-8-19**]

[ "V15.82", "V66.7", "427.31", "276.51", "V43.65", "198.3", "V10.11", "287.5", "585.9", "403.90", "433.10", "443.9", "272.4", "453.8", "250.00", "584.9" ]

icd9cm

[ [ [] ] ]

[ "38.7", "38.93" ]

icd9pcs

[ [ [] ] ]

5491, 5500

4228, 5031

356, 362

5568, 5594

3123, 4205

5667, 5722

2491, 2698

5521, 5547

5057, 5468

5618, 5644

2713, 3104

302, 318

390, 1449

1471, 1981

1997, 2475

27,823

105,449

32287

Discharge summary

report

Admission Date: [**2157-1-1**] Discharge Date: [**2157-1-5**] Date of Birth: [**2080-1-23**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 348**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: Intubation History of Present Illness: This is a 76 year-old male with a history of sarcoid and recent admission who presents with altered mental status. . In the ED, the patient had initial vitals of 100.1 with BP 137/100 HR 80s rr 100% RA. While in the ED the patient was treated empirically for pneumonia with levofloxacin and vancomycin. O2 sats ranged from 90-100% eventually being placed on 100% NRB. He was given 0.5 mg ativan at 23:40. Due to hypoxia to 74% and increased work of breathing the patient was intubated at 1AM. He was sedated on propofol. The ED attempted to contact the nursing home without success to address code status. There is mention in the ED note that the patient may have taken oxycodone prior to presentation. . Upon discussion with the family the patient has not been feeling well for the last 1 week. He was not specific about his discomfort, but has been increasing his pain medications. The family is concerned that he has been increasing his intake of oxycodone and has become more confused as a result. The reason for his increased intake of oxycodone (i.e. the location of increased pain) is unclear. The family reports that he took at least 8 percocets in the last 36 hours. The do not recall any localizing symptoms including no fever, chills, chest pain, shortness of breath, diarrhea. The family was concerned about his general health such that they took him to his PCP on thursday and he saw his nurse practitioner [**First Name (Titles) **] [**Last Name (Titles) **]. Both health care practitioners were not concerned for any acute change in his health and are well known to the patient. . ROS: unable to be obtained as the patient is intubated and sedated. Past Medical History: 1) Sarcoidosis 2) GERD 3) Paroxysmal atrial fibrillation 4) CVA with resulting memory difficulty 5) Hypertension 6) Anemia 7) Chronic Back Pain (post-herpetic neuralgia)on chronic prednisone Social History: Retired physician, [**Name Initial (NameIs) **], 2 grandchildren. Son-in-law [**Name (NI) **] very supportive. Divorced from wife, who recently died. Patient has never smoked. Patient rarely consumes alcohol. Patient lives alone at [**Hospital1 100**] Senior Life. His meals are provided for him, he does go shopping on his own and is quite active. He ambulates with a walker since fracturing his acetabulum recently. Family History: NC, no family history of sarcoid Physical Exam: Vitals: Afebrile, normotensive, satting well on room air, at times requires 1-2L NC. General Appearance: Thin Eyes / Conjunctiva: constricted pupils approx , mildly reactive Head, Ears, Nose, Throat: Normocephalic, Poor dentition Lymphatic: Cervical WNL, Supraclavicular WNL Cardiovascular: (S1: Normal), (S2: Normal), No(t) Rub Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ), (Breath Sounds: Clear : ) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right: Absent edema , Left: Absent edema Skin: small faruncle on left leg, no surrounding erythema Musculoskeletal: Skin: Warm Neurologic: Sedated, Tone: Not assessed, down going plantar reflexes, withdraws all extremities to pain Pertinent Results: LABS ON ADMISSION: . HEMATOLOGY: [**2156-12-31**] 07:30PM BLOOD WBC-10.7 RBC-4.69 Hgb-13.7* Hct-39.5* MCV-84 MCH-29.3 MCHC-34.8 RDW-15.5 Plt Ct-233 [**2156-12-31**] 07:30PM BLOOD Neuts-87.8* Lymphs-5.9* Monos-5.2 Eos-0.8 Baso-0.4 [**2157-1-1**] 05:54AM BLOOD PT-35.2* PTT-36.2* INR(PT)-3.7* . CHEMISTRY: [**2156-12-31**] 07:30PM BLOOD Glucose-107* UreaN-18 Creat-1.2 Na-141 K-4.1 Cl-99 HCO3-33* AnGap-13 [**2156-12-31**] 07:30PM BLOOD ALT-27 AST-32 CK(CPK)-222* AlkPhos-96 TotBili-1.1 [**2156-12-31**] 07:30PM BLOOD Lipase-33 [**2156-12-31**] 07:30PM BLOOD CK-MB-10 MB Indx-4.5 cTropnT-0.10* [**2157-1-1**] 05:54AM BLOOD CK-MB-7 cTropnT-0.06* [**2156-12-31**] 07:30PM BLOOD Calcium-9.2 Phos-2.2*# Mg-2.3 . TOX: [**2156-12-31**] 07:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . URINE: [**2156-12-31**] 08:10PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-1 pH-7.0 Leuks-NEG [**2156-12-31**] 08:10PM URINE RBC-0 WBC-0-2 Bacteri-NONE Yeast-NONE Epi-0 . MICROBIO: blood, urine, sputum - no growth to date . . RADIOLOGY: CT HEAD ([**12-31**]) FINDINGS: Exam is moderately limited by motion, although there is no gross intracranial abnormality. There is no evidence of shift of normally midline structures, large hemorrhage or fracture. The paranasal sinuses and mastoid air cells are grossly clear except to note persistent mucosal retention cyst in the right anterior ethmoid sinus. IMPRESSION: Moderately limited exam without large intracranial hemorrhage or fracture. . MRI HEAD (Prelim [**1-1**]) No evidence of acute ischemia or infarction. Moderate degree of chronic small vessel ischemia again seen. No gross vascular abnormalities. Major vessels patent and well perfused. . CTA CHEST ([**12-31**]) prelim sl. limited by resp motion. no central/segmental PE similar chronic lung changes related to sarcoidosis, possibly worse at L hilum. small bilateral pleural effusions. MRI L-SPINE: IMPRESSION: 1. Multilevel spondylosis of the lumbar spine which is most severe at level of L4-L5. 2. Grade 1 anterolisthesis of L4 over L5 is associated with mild canal narrowing and bilateral moderate neural foraminal narrowing. Brief Hospital Course: 76 year-old male with a history of sarcoidosis and atrial fibrillation who presents with 1 week of malaise and worsening respiratory status. . # Altered mental status: unclear etiology though increased pain meds (fentanyl patch, percocet, pregabalin) seem at least partly the cause. It seems that the patient took 8 percocets in one day when he normally takes 2. Resolved after intubation. Per outpatient PCP patient is on a strict narcotics regemin and usually keeps to this. . # Respiratory failure: brief period of hypoxemia followed by persistent O2 requirement. Patient was found to be aspirating. It is thought that the altered mental status may have worsened his aspiration events and caused him to become hypoxic. After extubation his persistent O2 requirement improved with regular PT and chest PT. Patient had difficulty understanding and complying with the incentive spirometry. . # Hip pain: New pain seems to be refered from his L-spine. He has been seen by ortho as an outpatient. A repeat MRI showed L4-L5 disease. The pain team was consulted and his pain medications were adjusted. Pain did not limit his movement with PT. A lidocaine patch was started, his fentanyl patch was decreased and his home dose of percocer and pregabalin was continued upon discharge. . # Sarcoidosis: Not currently treated (except for inhalers as prednisone is not for sarcoid per pulmonologist). Continued inhalers. . # Atrial fibrillation: Currently rate controlled and anticaogulated. INR initially therapeutic and so was held. He was discharged on coumadin. . # History CVA: Head CT no acute hemorrhagic event. . # GERD: continued pantoprazole Medications on Admission: Discharge meds as of 11.24, family believes them to be correct 1. Percocet 2.5-325 mg up to 8/day per family 2. Lidocaine 5 %(700 mg/patch) 3. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO QAM (once a day (in the morning)). 4. Pregabalin 75 mg Capsule Sig: Three (3) Capsule PO QPM (once a day (in the evening)). 5. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q48H (every 48 hours). 6. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q48H (every 48 hours). 7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY 8. Warfarin 5 mg 9. Docusate Sodium 100 mg 10. Senna 8.6 mg . 11. Omeprazole 20 mg Capsule, [**Hospital1 **] 12. Donepezil 5 mg Tablet Sig: One (1) Tablet PO qhs 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID 14. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY 15. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 16. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Inhalation Inhalation [**Hospital1 **] 17. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol 18. Calcitrate-Vitamin D 315-200 mg-unit Tablet Sig: Two (2) Discharge Medications: 1. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. 4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day) as needed for wheezing. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 7. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 12. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-17**] Drops Ophthalmic PRN (as needed). 13. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 14. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 15. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 16. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO twice a day as needed for pain: No more than 2 per day - preferably 1.5 . 17. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for Hip pain. 18. Pregabalin 75 mg Capsule Sig: Three (3) Capsule PO QPM (once a day (in the evening)). 19. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO QAM (once a day (in the morning)). Discharge Disposition: Extended Care Facility: [**Location (un) 582**] Of [**Location (un) 5176**] Discharge Diagnosis: Hypoxic respiratory failure Aspiration Discharge Condition: Stable, At times requires 1L O2 via NC. Discharge Instructions: You were admitted to the hospital because of confusion. In the ED you had low oxygen level which required you to be intubated and sent to the ICU. You did well and the tube was removed the next day and you were transfered to a medical floor. On the floor you required oxygen to keep your oxygen levels up. This improved with the chest PT and walking around with PT. You were evaluated by the speech and swallow team who recomended a special diet for you to help you swallow safely. We think that you may have aspirated some food into your lungs which caused your oxygen level to go low. You will need to be very careful when you eat. Medication changes: Fentanyl patch to 100 Lidocaine patch for back Please continue the rest of your medications as presiously directed. You should not take more than 2 percocets per day per your primary care doctor. Please return to the hospital or call your doctor if you have temperature greater than 101, shortness of breath, worsening difficulty with swallowing, chest pain, abdominal pain, diarrhea, or any other symptoms that you are concerned about. Followup Instructions: Please call Dr. [**Last Name (STitle) 5351**] at [**Telephone/Fax (1) 608**] after rehab to set up a follow up appointment. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11642**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2157-3-1**] 1:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], MD Phone:[**Telephone/Fax (1) 5068**] Date/Time:[**2157-5-19**] 2:00

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icd9cm

[ [ [] ] ]

[ "96.04" ]

icd9pcs

[ [ [] ] ]

10514, 10592

5807, 5960

291, 304

10675, 10717

3591, 3596

11868, 12299

2665, 2699

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332, 1998

3610, 5784

5976, 7465

2020, 2213

2229, 2649

68,842

127,088

53909

Discharge summary

report

Admission Date: [**2200-5-29**] Discharge Date: [**2200-6-13**] Date of Birth: [**2118-5-15**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 473**] Chief Complaint: Pancreatic head mass Major Surgical or Invasive Procedure: [**2200-5-30**]: ERCP . [**2200-5-30**]: Successful uncomplicated placement of an 8 French internal- external biliary drain to the right posterior system. . [**2200-6-6**]: OPERATIVE PROCEDURE: 1. Open pancreatic biopsy. 2. Open cholecystectomy. 3. Roux-en-Y hepaticojejunostomy. 4. Gastrojejunostomy. 5. Umbilical hernia repair. History of Present Illness: 82yoF with AFib on coumadin, CKD, and DM with recent hospitalization [**5-12**] - [**2200-5-16**] for obstructive jaundice, found to have a pancreatic head mass with FNA positive for adenocarcinoma, now returns with cholangitis and biliary stent migration. Repeat ERCP attempted although unsuccessful due to duodenal narrowing; this prompted placement of a PTBD ([**2200-5-30**]). She is currently admitted to the [**Hospital Unit Name 153**] post-procedure, on RA and hemodynamically stable. Initially, she presented in early [**Month (only) 547**] with painless obstructive jaundice in association with 25lb weight loss over the past 8 months. She had no other symptoms, including no fevers/chills, N/V/D/C, no change in appetite, no abnormal bowel movements. During the workup at that time, she was found to have intra/extra hepatic biliary dilatation on ultrasound, from likely extrinsic compression of the pancreatic mass. She underwent an ERCP which demonstrated probable tumor infiltration into the duodenum with distal CBD stricture and subsequently underwent biliary stent placement, following which her LFTs improved. She was treated with IV unasyn then po ciprofloxacin for 7days. She had done okay until symptoms of fever, nausea, and abdominal pain prompted return to the hospital and readmission earlier today ([**2200-5-30**]). Past Medical History: Afib on coumadin CKD (Cr 1.7 - 2.1) DM2 - diet controlled PMR Hypothyroidism Tonsillectomy Pancreatic adenocarcinoma Social History: Lives with husband and son. Retired hostess. No tobacco, social etoh, no illicits. Family History: No known hx of pancreatic cancer (best friend died from pancreatic cancer) Physical Exam: Admission exam VS - 98.7 100 18 111/72 18 100%ra GENERAL - well-appearing caucasian female in NAD, resting comfortably HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no JVD LUNGS - CTA bilat, no r/rh/wh HEART - irregular, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**6-14**] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait Discharge exam: Pertinent Results: Blood cultures:[**2200-5-30**] 6:15 am BLOOD CULTURE ENTEROBACTER CLOACAE COMPLEX. FINAL SENSITIVITIES. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. GRAM NEGATIVE ROD #2. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER CLOACAE COMPLEX | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Aerobic Bottle Gram Stain (Final [**2200-5-30**]): GRAM NEGATIVE ROD(S). Reported to and read back by [**First Name8 (NamePattern2) 247**] [**Last Name (NamePattern1) **] ON [**2200-5-30**] @1010 PM. Anaerobic Bottle Gram Stain (Final [**2200-5-30**]): GRAM NEGATIVE ROD(S). [**2200-6-8**] 04:21AM BLOOD WBC-15.9* RBC-3.90* Hgb-11.0* Hct-36.2 MCV-93 MCH-28.2 MCHC-30.4* RDW-15.7* Plt Ct-168 [**2200-6-11**] 12:15PM BLOOD Glucose-136* UreaN-35* Creat-1.3* Na-139 K-4.2 Cl-105 HCO3-24 AnGap-14 [**2200-6-9**] 06:10AM BLOOD ALT-77* AST-54* AlkPhos-227* TotBili-1.3 [**2200-6-11**] 12:15PM BLOOD Calcium-8.5 Phos-3.0 Mg-1.7 [**2200-5-30**] ECG: Atrial fibrillation with borderline rapid ventricular response and a single ventricular premature beat. Right ventricular conduction delay. Non-specific anteroseptal T wave abnormalities. Grossly unchanged from previous tracing. [**2200-6-9**] ECG: Atrial fibrillation. Compared to the previous tracing of [**2200-6-8**] the ventricular response is slightly faster. Otherise, no significant change. [**2200-6-6**]: PATHOLOGY: Pending Brief Hospital Course: 82yoF with h/o Afib on Coumadin, CKD, tDM2, PMR, recently diagnosed pancreatic adenocarcinoma (per report pt does not know) s/p ERCP with CBD stent placement 2 weeks ago, who presents with epigastric abdominal pain, nausea, hematemesis x1, ALT/AST > 1000, and acute cholangitis . # Cholangitis: Initially presented afebrile and looking well, though after admission quickly became febrile and peri-septic, w/ labs indicating cholangitis. Biliary tree complicated by previous cholangitis, s/p stent placement in early [**Month (only) 547**], and by pancreatic adenocarcinoma in head of pancreas. She was started on broad spectrum antibiotics, and urgently taken to ERCP (INR reversed w/ FFP). This was unsuccessful [**3-13**] friable duodenal tissue, presumably from the cancer. She was intubated during the ERCP required transient pressors and was transferred to the [**Hospital Unit Name 153**]. In IR, a percutaneous external/internal drain was placed and she was extubated shortly thereafter. she was treated empirically with vanc/zosyn which was narrowed to cefepime; this was discontinued prior to discharge. She remained afebrile for at least 72 hours prior to discharge. # Upper GI bleed: The pt has a known pancreatic cancer known to be invading duodenum. She reported questionable hematemesis. No obvious source on ERCP. Her coumadin was held and pantoprazole was started. She was eventually restarted on coumadin, received 2mg of coumadin on [**2200-6-13**] with an AM INR of 2.6, which was therapeutic. # Pancreatic cancer: pt knows she has a pancreatic mass, but has not yet been told she has cancer on admission. Had appointment for the next Monday where likely this would have been done. Her diagnosis was made known to her during this hospitalization. She was evaluated by Dr. [**Last Name (STitle) 468**] in house and on [**6-3**] was transferred to the surgical service. She subsequently underwent aforementioned procedure and tolerated it well with eventual return of bowel function while tolerating a regular diet. She was supplemented with TPN, which was eventually tapered off and discontinued prior to discharge. # Atrial fibrillation: CHADS score is 2. Her coumadin held on admission for a possible GI bleed, and then reversed w/ FFP for the ERCP. Amiodarone was held initially due to tranaminitis but given improvement in her LFTs after the drain was place, it was restarted for better rate control. She did develop some afib with RVR but was asymptomatic. Cardiology was consulted at the time, with recommendations to resume her home beta-blocker, and amiodarone dose with PRN IV doses of metoprolol. She remaiend largely in sinus rhythm within the high 90s to 100s for heart-rate,with occasional bursts to 120s, which would spontaneously resolve. #Acute on chronic renal failure: baseline Cr 1.7-2.1, on admission 2.4 with elevated BUN likely prerenal azotemia in setting of recently being restarted on lasix, and being peri-septic. In the [**Hospital Unit Name 153**] she was given IVF but became overloaded and diuresis was initiated in the ICU and continued on the floor. Her creatinine eventually settled to 1.3. She was resumed on her home lasix dose of 20mg qd and was voiding independently without issue. #Hypoxia -CXR on [**5-31**] was read as LLL collapse and or consolidation, right perhilar opacity similar to prior without overt CHF. Reviewed with radiology and they feel that it is more consistent with atelectasis rather than pneumonia. Given that her CXR on [**5-29**] was clear, it was more consistent with atelectasis and edema rather than a post obstructiv pneumonia. They perihilar opacity could reflect edema as well and the pt improved with diuresis. Repeat CXR showed improvement. While on the floor she maintained good oxygen saturations without supplementation. #Hypothyroidism:--continued Synthroid #DM2: monitor blood sugars. a1C is 6.0% this admission, RISS were continued. The patient was transferred to the HBP Surgical Service on [**2200-6-3**] for elective possible Whipple resection. The patient was consulted by Cardiology, Geriatrics and Anesthesia as pre op and she was cleared for operation. On [**2200-6-6**], the patient went in OR and during the case she was found to have locally advanced cancer and Whipple was aborted. The patient underwent open pancreatic biopsy, open cholecystectomy, Roux-en-Y hepaticojejunostomy, gastrojejunostomy and umbilical hernia repair, which went well without complication (reader referred to the Operative Note for details). In The PACU patient received one unit of pRBC and several fluid boluses for low urine output. After a brief, uneventful stay in the PACU, the patient arrived on the floor NPO with NGT, on IV fluids and antibiotics, with a foley catheter, and epidural for pain control. The patient was hemodynamically stable. Neuro: The patient received Bupivacaine/Dilaudid via epidural catheter. Epidural was d/cd on POD # 2 and she was given Dilaudid PCA for pain control with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. The patient was started on PO Trazodone for insomnia per Geriatric, she reported to see hallucinations on POD # 6 and Trazodone was discontinued. CV: The patient has a history of A-fib, her Coumadin was held prior surgery and her HR was 90-110. After surgery (on POD # 2) patient developed rapid A-fib with HR 120-140. Her Amiodarone was restarted, her Lopressor was increased and she received IV Diltiazem. Cardiology was consulted and their recommendations were followed. The patient's PO Lopressor was doubled, she was restarted on PO Lasix and her Coumadin was restarted on POD # 4. The INR was therapeutic on POD # 6, and patient's HR returned to her baseline. Pulmonary: The patient was found to have crackles on POD # 2, early ambulation and incentive spirrometry were encouraged. Patient was restarted on daily Lasix and her breathing improved prior discharge. GI/GU/FEN: Post-operatively, the patient was made NPO with IV fluids and was continued TPN. Diet was advanced when appropriate, which was well tolerated. TPN was weaned off on POD # 6. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. ID: The patient's white blood count and fever curves were closely watched for signs of infection. She underwent 2 weeks treatment with IV Cefepime for her blood infection with ENTEROBACTER and CITROBACTER, which was discontinued prior to discharge. Her wound was evaluated daily and no signs and symptoms of infection were noticed. PTBD drain and PICC line were removed prior discharge. Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. Hematology: The patient's complete blood count was examined routinely; she received one unit of pRBC post op for low urine output. Hct was stable prior discharge. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. Physical Therapy evaluated the patient and recommended discharge in Rehab. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diabetic diet, ambulating with assistance, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: 1. warfarin 1 mg Tablet Sig: One (1) Tablet PO every Mon, Wed, Fri. 2. furosemide 20 mg Tablet Sig: One (1) Tablet PO QOD: every other day. 3. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 8. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 9. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for anxiety. 10. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. 12. ferrous gluconate 325 mg (37.5 mg iron) Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 13. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Medications: 1. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. oxycodone 5 mg Tablet Sig: 1/2-1 Tablet PO every four (4) hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 4. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 8. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)) for 2 weeks. Disp:*56 Tablet(s)* Refills:*0* 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 12. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Please check INR on [**2200-6-14**] and adjust Coumadin dose as necessary. 13. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 14. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 15. Vitamin D3 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 16. Iron (ferrous sulfate) 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO every other day. 17. estradiol 10 mcg Tablet Sig: One (1) Vaginal once a week. Discharge Disposition: Extended Care Facility: Bear [**Doctor Last Name **] Nursing Center - [**Location (un) 2199**] Discharge Diagnosis: 1. Cholangitis 2. Locally advanced pancreatic mass (Final pathology pending) 3. Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker). Discharge Instructions: You were admitted to the surgery service at [**Hospital1 18**] for surgical resection of your pancreatic mass. You have done well in the post operative period and are now safe to be discharge in Rehab to complete your recovery with the following instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. You were restarted on coumadin, and your INR on [**2200-6-13**] was 2.6, within goal, you received 2mg of coumadin on [**2200-6-13**] prior to discharge. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**6-19**] 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. *Steri-strips will fall off within 7-10days; do not remove these. Followup Instructions: Department: SURGICAL SPECIALTIES When: MONDAY [**2200-6-23**] at 9:00 AM With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2835**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Please follow up with Dr. [**First Name (STitle) **] in [**2-10**] weeks after discharge Completed by:[**2200-6-13**]

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icd9cm

[ [ [] ] ]

[ "99.15", "51.10", "52.12", "53.49", "38.97", "51.22", "44.39", "51.37", "51.98" ]

icd9pcs

[ [ [] ] ]

15696, 15793

5370, 12987

323, 657

15937, 15937

3031, 5347

17517, 17922

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4432

Discharge summary

report

Admission Date: [**2108-4-16**] Discharge Date: [**2108-4-19**] Date of Birth: [**2039-3-10**] Sex: M Service: MEDICINE Allergies: Levaquin Attending:[**First Name3 (LF) 2186**] Chief Complaint: respiratory distress, slurred speech Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 19017**] is a 69-year-old male with past medical history significant for severe COPD on home oxygen at 4L, HTN, GERD, CAD (prior NSTEMI), hyperlipidemia, h/o resistant pseudomonas PNA and chronic back pain who was brought to ED via EMS after wife noticed he had worse confusion and altered mentation this evening. Patient denies recent cough, fevers, chills or increased/discolored sputum production. Of note, he had recent ED visit on [**4-5**] for worse weakness and depression and was seen by psychiatry and SW and discharged home. Much of history collected from wife given patient's AMS. In ED a fentanyl patch was noticed on his back and he was having some slurred speech so there was concern for narcotic induced hypercarbia after initial ABG showed pH 7.28, pCO2 116, pO2 56, HCO3 57. He is also taking Ativan and Percocet at home regularly for anxiety and low back pain. He complained of some generalized weakness along with 1 week of more focal right hand weakness. Therefore, neurology was called to evaluate him in ED and his exam was non-focal. A CT head was done which was unremarkable. Neuro recommended CTA head and neck. There was also concern for COPD flare up from possible infection as well but CXR was unremarkable for PNA. Initial vitals in ED were: T98.2F, HR 93, BP 137/77, RR 28 and O2 Saturation 99% on 6L. He was given albuterol nebs, ipratropium nebs, 125mg IV Solumedrol, 1g IV Ceftriaxone, 500mg IV Azithromycin and Naloxone .4mg x1 for presumed narcotic induced respiratory distress. He became quite agitated after Naloxone so he was given 2.5mg IV Haldol. Lactate was normal at 0.8 and he also had hyperkalemia to 5.4 range. WBC count was normal at 8.6 and Hct near baseline at 37.2. FSG was 184. Repeat ABG much improved s/p BIPAP with pH 7.36, pCO2 85, pO2 65, HCO3 50. On evaluation in the MICU, he appeared confused, somewhat agitated and was not cooperative with initial questions but then calmed down within minutes and was able to give a limited history. Speech somewhat garbled at baseline and patient was only oriented to place and year but did not know month or why exactly he was in ICU. REVIEW OF SYSTEMS: As per HPI. Limited ROS otherwise due to patient's AMS. Patient also endorses decreased appetite and wife also corroborates poor PO intake x 1 week. Past Medical History: 1. Severe COPD on 4 L O2 at home 2. History of VRE UTI 3. History of MRSA 4. CAD w/ NSTEMI ([**2101**]) (last cath in [**4-/2103**] w/o abnormalities. 5. Steroid induced hyperglycemia 6. Hypertension 7. Hyperlipidemia 8. Chronic low back pain after L1-2 laminectomy 9. Bilateral shoulder pain 10. Cataracts bilaterally - s/p surgery for both 11. GERD 12. BPH 13. History of resistant Pseduomonas PNA Social History: Lives in [**Location 686**] with his wife. [**Name (NI) **] was born in [**Country 7936**]. He has 4 adult children. He is a retired mechanic. History of alcoholism but only drinks rare glass of wine "every few weeks". Denies illicit drugs. Prior history of tobacco use. Family History: Noncontributory Physical Exam: Admit Exam: Vitals- T 99.3F, HR 100, BP 152/70, RR 22, oxygen sat 88% on 1.5L NC General: alert and oriented x 1, no acute distress, very cachectic HEENT: PERRLA, sclera anicteric, dry MM, oropharynx clear, poor dentition noted Neck: supple, JVP ~6cm, no LAD, no thyromegaly Lungs: mild bilateral wheezes at bases and mid-fields with end expiration, otherwise no crackles or rhonchi CVS: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, or gallops Abdomen: non-tender, non-distended, normoactive bowel sounds present, soft, no rebound, no guarding, no HSM. Neuro: CNs [**2-17**] in tact, sensation to light touch in tact, moving all extremities. Mild decreased right sided hand grasp. Downgoing toes. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Access: 2 PIVs in place Pertinent Results: Admission Labs [**2108-4-15**] 09:00PM BLOOD WBC-8.6 RBC-4.49* Hgb-11.1* Hct-37.2* MCV-83 MCH-24.6* MCHC-29.7* RDW-14.5 Plt Ct-296 [**2108-4-15**] 09:00PM BLOOD Neuts-88* Bands-0 Lymphs-8* Monos-3 Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0 [**2108-4-15**] 09:00PM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-NORMAL Macrocy-NORMAL Microcy-OCCASIONAL Polychr-OCCASIONAL Target-1+ [**2108-4-15**] 09:00PM BLOOD PT-11.5 PTT-30.3 INR(PT)-1.0 [**2108-4-15**] 09:00PM BLOOD Glucose-179* UreaN-17 Creat-0.7 Na-137 K-6.2* Cl-85* HCO3-48* AnGap-10 [**2108-4-15**] 09:00PM BLOOD Calcium-9.9 Phos-4.6* Mg-2.0 [**2108-4-15**] 09:00PM BLOOD cTropnT-<0.01 [**2108-4-15**] 11:44PM BLOOD Type-ART pO2-56* pCO2-116* pH-7.28* calTCO2-57* Base XS-21 Intubat-NOT INTUBA Most Recent Labs [**2108-4-17**] 05:45AM BLOOD WBC-11.6*# RBC-3.46* Hgb-8.6* Hct-28.6* MCV-83 MCH-24.9* MCHC-30.2* RDW-15.2 Plt Ct-279 [**2108-4-17**] 05:45AM BLOOD PT-11.2 PTT-28.8 INR(PT)-0.9 [**2108-4-17**] 05:45AM BLOOD Glucose-88 UreaN-17 Creat-0.6 Na-140 K-4.7 Cl-95* HCO3-37* AnGap-13 [**2108-4-16**] 06:13AM BLOOD ALT-12 AST-19 LD(LDH)-173 AlkPhos-73 TotBili-0.2 [**2108-4-17**] 05:45AM BLOOD Calcium-8.6 Phos-1.7* Mg-2.5 [**2108-4-16**] 05:23PM BLOOD Type-ART pO2-97 pCO2-74* pH-7.40 calTCO2-48* Base XS-16 Urine Studies [**2108-4-15**] 09:15PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 [**2108-4-15**] 09:15PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2108-4-15**] 09:15PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0-2 [**2108-4-16**] 06:00PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.015 [**2108-4-16**] 06:00PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-9.0* Leuks-NEG [**2108-4-16**] 06:00PM URINE RBC-[**11-24**]* WBC-0-2 Bacteri-OCC Yeast-NONE Epi-[**3-9**] ================================= MICROBIOLOGY: [**2108-4-16**] URINE CULTURE - NO GROWTH [**2108-4-15**] BLOOD CULTURE x 2 - NO GROWTH TO DATE (FINAL REPORT PENDING) ================================= IMAGING: CXR ([**2108-4-17**]) - FINDINGS: As compared to the previous radiograph, there is no evidence of newly appeared focal parenchymal opacity suggesting pneumonia. Unchanged hyperinflation of both lungs, the right lung base is better ventilated than on the previous examination. No pleural effusions. Normal size of the cardiac silhouette. Moderate tortuosity of the thoracic aorta. CXR ([**2108-4-15**]) - IMPRESSION: COPD. No definite signs of pneumonia. If needed, correlation with a lateral view may aid. CT Head ([**2108-4-15**]) - IMPRESSION: No acute intracranial process. Brief Hospital Course: 69-year-old male with severe COPD on home 4L NC, HTN, hyperlipidemia, CAD, GERD, depression and chronic back pain on multiple sedating pain medications and psychiatric medications who presented with AMS, hypercarbic respiratory distress. # Severe COPD & Hypercarbic Respiratory Distress: Initial desaturations and hypercarbia was felt to be related to narcotic- and benzodiazepine-induced respiratory depression. He is also a CO2-retainer at baseline. Patient had been taking fentanyl patches, percocet, and ativan at home. The patient had cultures with no growth, was afebrile, and had a clear CXR, making infection less likely. Moreover, he had no sputum changes or worse cough from usual baseline. He was initially treated as a COPD exacerbation with albuterol/ipratropium nebs, solumedrol, ceftriaxone, azithromycin. Ceftriaxone was ultimately stopped, and steroids were switched to oral prednisone. He was continued on a 5-day course of azithromycin. While he was in the MICU, meetings were held with the patient, his family, and the palliative care team. Given his advanced end stage COPD status and his wished to focus on his comfort, the patient was made CMO (comfort measures only). He was given the option of BiPAP to help with his breathing but did not like the way the BiPAP mask felt. Given his CMO status, his medication regimen was adjusted (see below). He was discharged to a [**Hospital1 1501**], with plans for eventual transition to hospice. # Altered Mental Status: As above, felt to be secondary to hypercarbia and narcotics. CT head negative for any acute process. Mental status improved over the [**Hospital 228**] hospital course. Pt was started on haloperidol and clonopin to help with anxiety and agitation. Pt's ativan was also increased from nightly PRN to q6hours PRN. # Coronary Artery Disease: Past medical history significant for prior NSTEMI in [**2101**]. On admission, he had no complaints of current chest pain or palpitations. After decision was made for comfort care, many of his cardiac medications were stopped, including lisinopril, pravastatin, and aspirin. # Chronic Back Pain: Given concern for decreased respirations and somnolence with hypercarbia, sedating narcotics were held on admission. He was started on [**Year (4 digits) 1988**] tylenol as well as lidoderm patches for pain control. At the time of discharge, the patient was not complaining of any pain. # Goals of Care: While the patient was in the ICU, meeting was held between the patient, his family, the ICU team, and the palliative care team. The decision was made to transition to comfort care. Many non-essential medications were stopped at that time (see medications section below). At discharge, he was started on morphine elixir for shortness of [**Year (4 digits) 1440**]. He was also started on haldol and klonopin for anxiety, as described above. He was discharged to a [**Hospital1 1501**], with plans for eventual transition to hospice. Medications on Admission: :(per OMR notes with PCP [**2108-4-5**]) Fentanyl 50 mcg/hr Patch One Patch Transdermal Q72H Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY Nitroglycerin 0.3 mg tablet, 1 tab prn chest pain: Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) Lorazepam 0.5 mg Tablet, 1 Tablet PO at bedtime as needed for anxiety: DO NOT TAKE MORE THAN AMOUNT DIRECTED Lactulose 10 gram/15 mL Syrup: 30 ML PO daily prn constipation Pantoprazole 40 mg Tablet po q24hr Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO Bedtime Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY Polyethylene Glycol 17 gram/dose PO DAILY prn constipation Trimethoprim-Sulfamethoxazole 160-800 mg Tablet PO 3X/WEEK Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID Senna 8.6 mg Tablet Sig: One Tablet PO BID prn constipation Calcium 600 + D(3) 600-400 mg-unit Tablet One PO once a day. Alendronate 70 mg Tablet One (1) Tablet PO q Monday. Fluticasone-Salmeterol 250-50 mcg/Dose Disk [**Hospital1 **] Tiotropium Bromide 18 mcg capsule daily Albuterol Sulfate 90 mcg 2 puff inh q6hours prn SOB/wheeze Albuterol Sulfate 2.5 mg /3 mL (0.083 %) neb q6 prn SOB Ipratropium Bromide 0.02 % Solution 1 inh q6 prn SOB/wheeze Oxycodone-Acetaminophen 5-325 mg 1-2 Tablets PO Q6H prn pain Aspirin 81md daily Discharge Medications: 1. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain : [**Month (only) 116**] repeat after 5 minutes if chest pain does not resolve. If pt still has chest pain after 3 doses (15 minutes), please notify MD. 2. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety: Do not take more than directed. 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO once a day as needed for constipation. 5. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) dosr PO once a day as needed for constipation. 6. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 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. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed for dyspnea. 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation Inhalation Q6H (every 6 hours) as needed for SOB. 13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours): Do not exceed 4 grams in 24 hours. 14. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for back pain: leave on for 12 hours and then leave off for 12 hours. Adhesive Patch, Medicated(s) 16. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days: Course ends on [**2108-4-21**]. 19. Morphine 10 mg/5 mL Solution Sig: 2.5 - 5 mL PO q1h as needed for shortness of [**Date Range 1440**]. Disp:*1 500 mL bottle* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare Center - [**Location (un) **] Discharge Diagnosis: Primary Diagnosis -Altered mental status secondary to excessive narcotics -Severe chronic obstructive pulmonary disease Secondary Diagnosis -Anxiety -Hypertension -Chronic low back pain -Coronary Artery Disease Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital for altered mental status. It was felt that your mental status changes were likely related to an excess amount of pain medications as well as your underlying severe COPD. A meeting was held with you any your family while you were in the ICU and, according with your wishes, the decision was made that we would focus primarily on keeping you comfortable. Your medications were adjusted in keeping with these goals. You are now being discharged to an extended care facility with the ultimate goal of keeping you comfortable. CHANGES TO YOUR MEDICATIONS: - STOP Fentanyl Patch - STOP Finasteride - STOP Lisinopril - STOP Montelukast (Singulair) - STOP Pantoprazole - STOP Pramipexole - STOP Pravastatin - STOP Calcium/Vitamin D - STOP Alendronate (Fosamax) - STOP Percocet - STOP Aspirin - CHANGE your lorazepam (ativan) to 0.5 mg every 4 hours as needed for anxiety - INCREASE your albuterol nebs to every 4 hours as needed for shortness of [**Location (un) 1440**] / wheezing - START Tylenol 1 gram every 6 hours - START Prednisone 20 mg daily - START Lidoderm patch daily as needed for back pain - START Haldoperidol (Haldol) 1 mg twice a day - START Clonopin 0.5 mg twice a day - START Azithromycin 250 mg daily for 2 more days (ending [**2108-4-21**]) - START Morphine Elixir 5-10 mg PO every 1 hour as needed for shortness of [**Month/Day/Year 1440**] It was a pleasure taking part in your medical care. Followup Instructions: You should follow-up with the physicians at your long-term care facility.

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Discharge summary

report

Admission Date: [**2133-3-28**] Discharge Date: [**2133-4-2**] Date of Birth: [**2072-12-20**] Sex: M Service: [**Company 191**] HISTORY OF PRESENT ILLNESS: This is a 60-year-old man with CAD, PVD who had difficulty speaking after left carotid endarterectomy in [**2133-2-16**]. The patient has had bilateral carotid stenosis. On [**2-21**] while he was sitting in a chair he developed sudden onset of right arm and leg numbness, followed by right arm and leg weakness. He also had difficulty speaking. He was admitted to [**Hospital3 **] and underwent a left carotid endarterectomy on [**2-26**] and afterwards began having severe left sided headache behind his left eye that lasted for hours and was constant. Nevertheless, he visited [**Hospital3 **] for continued headaches and nausea and vomiting. During one of those visits he had a contortion of his right face and bilateral arm jerking and was started on Dilantin with presumptive diagnosis of seizures. He has recovered from that event when was again discharged home. On [**3-13**] he again presented with persistent headaches, confusion and inability to talk. He had difficulty getting his words out. He had a head CT at [**Hospital3 **] which showed a linear hyperintense region in the left central temporal lobe but also other lesions in the left posterior parietal lobes. At that time he was transferred to the [**Hospital1 69**]. MRI of his head showed left MCA/ACA and left MCA/PCA watershed strokes with acute and subacute hemorrhage conversions. It was thought at that time that he had extended his watershed infarcts after carotid endarterectomy leading to a carotid hyperperfusion syndrome. The patient was discharged from the neurologic Intensive Care Unit to a rehab facility. On Thursday, [**2133-3-26**], patient's wife noticed erythema on patient's face. On [**3-27**] the visiting nurse [**First Name (Titles) 8706**] [**Last Name (Titles) 11282**] of a rash on his arms as well. The patient was noted to be febrile and was admitted to the [**Company 191**] Firm. In the EW, patient's Dilantin was discontinued and he was given Tegretol instead. PAST MEDICAL HISTORY: 1) Left CEA in [**2133-2-16**]. 2) CVA in [**2133-2-16**]. 3) Paroxysmal atrial fibrillation. 4) CAD. 5) PVD. 6) Hypercholesterolemia. 7) History of amaurosis fugax. 8) Status post lymph node removal. MEDICATIONS: On admission, Lopressor 25 mg po bid, Dilantin 200 mg po tid, Prilosec 40 mg po q day, Lipitor, Ambien. ALLERGIES: Iodine. SOCIAL HISTORY: The patient lives in [**Location 3146**], tobacco since [**2126**], one pint of alcohol per day. The patient works as a carpenter. FAMILY MEDICAL HISTORY: CAD. PHYSICAL EXAMINATION: On admission, temperature 98.3, pulse 86, blood pressure 94/65, respiratory rate 18, saturations 96% on room air. In general, alert, oriented times three, no apparent distress. HEENT: Pupils are equal, round, and reactive to light, mucus membranes moist, oropharynx clear. No lymphadenopathy. Cardiovascular, regular rate and rhythm, no murmurs. Lungs clear to auscultation bilaterally. Abdomen soft, nontender, non distended, positive bowel sounds. Extremities, no cyanosis, erythema, edema. Neuro, cranial nerves II through XII intact. Skin red maculopapular blanching erythema on face, torso and extremities, sparing the soles. Bilateral lower extremity petechiae, no significant oral lesions noted. HOSPITAL COURSE: 1. Derm: Over the course of patient's stay on [**Company 191**] Firm, patient had rigors and fevers of up to 101 degree. The patient was initially continued on Tegretol. The patient had worsening rash throughout his torso with lip swelling and tongue swelling. The patient did not experience any respiratory difficulties throughout the course of his stay on the [**Company 191**] service. A derm consult was obtained. The dermatology team recommended discontinuing Tegretol. Their thought was that the patient's symptoms were secondary to his hypersensitivity to Dilantin. The patient was treated symptomatically with IV fluids, Zantac, Benadryl and Synalar cream. The patient was transferred to the Medical Intensive Care Unit overnight for observation given risk of respiratory distress. [**Hospital **] Medical Intensive Care Unit stay was uneventful. Skin biopsy was also consistent with hypersensitivity reaction. Over the course of patient's stay in the hospital, patient's rash started to improve with decreasing erythema and edema. 2. Neuro: Patient was seen by neurology service. They recommended stopping all anti-epileptic medications since they thought that his symptoms were likely secondary to carotid reperfusion syndrome and anti-seizure medications are not necessarily beneficial under these circumstances. 3. GI: Patient's LFTs were slightly elevated during his admission. The patient's Lipitor was held due to increased LFTs. His increased LFTs were likely secondary to Dilantin. Patient to follow-up with his PCP to make sure LFTs are trending down and before restarting Lipitor. DISCHARGE DIAGNOSIS: 1. Dilantin hypersensitivity reaction. DISCHARGE MEDICATIONS: [**Doctor First Name **] 60 mg po bid, Zantac 150 mg po bid, Synalar ointment, Eucerin cream. Discharged to home. patient to follow-up with PCP next week as well as with dermatology. Patient's PCP to assess blood pressure before restarting Atenolol. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 11283**] Dictated By:[**Name8 (MD) 5753**] MEDQUIST36 D: [**2133-4-21**] 16:51 T: [**2133-4-21**] 16:57 JOB#: [**Job Number 11284**]

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icd9cm

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Discharge summary

report

Admission Date: [**2139-8-24**] Discharge Date: [**2139-9-4**] Date of Birth: [**2086-3-6**] Sex: M Service: MEDICINE Allergies: Erythromycin Base / Protamine / Minoxidil Attending:[**First Name3 (LF) 1515**] Chief Complaint: CHIEF COMPLAINT: Chest Pain REASON FOR MICU ADMISSION: Hypotension, need for dialysis Major Surgical or Invasive Procedure: CVVH History of Present Illness: Mr. [**Known lastname 17839**] is a 53 y/oM with h/o of ESRD on HD h/o MI and CABG, DM presents with chest pain. Over the last several weeks he has been noticed increased swelling, abdominal girth, and slowly progressive dyspnea on exertion, and has developed orthopnea. He has also developed chest pain that is similar to prior angina; initially this occured with exertion only but awoke him from sleep at 2am. He had associated dyspnea and diaphoresis, but no nausea. He took a sl ntg tablet which relieved the pain, but the pain later occured at rest in the morning that did not respond and he called EMS and presented to the [**Hospital1 18**] ED for further evaluation. He did take his 81mg asa this morning. He is on warfarin for h/o stroke, but was subtherapeutic at 1.6. In the ED, initial VS: HR 84 BP 80/p. He was hypoxic to the mid 80s on room air. He was given IVF for hypotension, but only about 600-700cc given his EF of 25%. There was difficulty in obtaining IJ access initially, but eventually catheter placement was successful, but probably terminates in the subclavian. His troponin was elevated to 0.72 above his baseline of 0.4, and ECG showed widened QRS and PR prolongation felt to be c/w hyperkalemia. He also had slight worsening of ST depressions laterally. He was given calcium, insulin, and glucose, and admitted to the MICU for CVVH. In the unit, he c/o [**2-3**] chest discomfort, with BP ranging from 80-90/40s initially. Cardiology consultation was obtained. . ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: - DM I with diabetic retinopathy, nephropathy, neuropathy CAD: --CABG: [**2125**] LIMA-LAD, SVG-PDA, SVG-RI, SVG-OM (occluded) --PCI: [**2135-1-21**] LMCA with no flow limiting stenoses; LAD contained a 90% proximal lesion before becoming totally occluded just after a large septal; LCX contained diffuse disease, up to a 95% mid vessel; OM1 was totally occluded; ramus branch had a 70% proximal lesion; RCA was totally occluded proximally. Congestive heart failure: LVEF 25-30% ([**7-3**]) with 2+ MR CVA [**2135**] R BKA L AKA Right fem-tibial bypass surgery in [**2125**]. RLE bursitis Cellulitis in [**2131**]. Chronic renal failure due to acute tubular nephropathy in [**2131**] s/p renal transplant (second living related renal transplant in 993) Listeria infection in [**2132**]. Shingles in [**2132**]. Squamous cell carcinoma was diagnosed and removed in [**2133**]. Anemia of chronic disease Glaucoma Gastroparesis Gastritis Diveriticulosis Social History: Lives at home with Fifteen pack year history of tobacco use per OMR. No history of alcohol, IVDU. Family History: Noncontributory Physical Exam: VS: T=98.1 BP=90-112/29-85 HR=93-100 RR=15-21 O2 sat= 99% on 2L GENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP at mandible. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No murmurs. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored appearing, no accessory muscle use. Intermittent crackles diffusely. Decreased breath sounds at R base. No wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: Patient has R AKA, and L BKA. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Left: Carotid 2+ Femoral 2+ Pertinent Results: [**2139-8-24**] 1:45p Trop-T: 0.72 MB: 6 . 134 93 65 AGap=25 ------------- 190 7.4 23 5.8 ∆ estGFR: [**9-7**] (click for details) . Ca: 9.9 Mg: 2.8 P: 6.7 ∆ . 12.7 7.9 ------ 297 41.9 N:72.5 L:19.1 M:6.1 E:1.4 Bas:0.9 . PT: 17.5 INR: 1.6 . [**2139-8-24**] 7:15p CK: 42 MB: Notdone Trop-T: 0.77 . = = = ================================================================ PORTABLE CXR [**8-24**] FINDINGS: Single AP semi-upright portable chest radiograph is obtained. A dialysis catheter is again noted with a right IJ approach with its tip in the expected location of the right atrium. Midline sternotomy wires are again noted. The heart remains moderately enlarged. Pulmonary vascular congestion is noted which is mild. There is a stable small right pleural effusion. Retrocardiac linear opacity is improved and likely represent residual atelectasis. Upper lungs are well aerated. Mediastinal contour is grossly unremarkable. Bones appear grossly intact. The clip projects over the left lung base medially. Atherosclerotic calcification along the course of the descending aorta is noted. IMPRESSION: Cardiomegaly, mild congestion, small right pleural effusion. Improved left lower lobe atelectasis. . . CTA [**8-24**] IMPRESSION: 1. Suboptimal evaluation of posterior branch pulmonary arteries due to pleural effusions and overlying ateletctasis/consolidation as well as patient respiratory motion. Given this, no evidence of pulmonary embolus. 2. No aortic dissection. Cardiomegaly. 3. Large right and moderate left pleural effusions with overlying atelectasis/consolidation. . . TTE [**8-25**] The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. There is severe global left ventricular hypokinesis (LVEF = 15 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler and tissue velocity imaging are consistent with Grade III/IV (severe) LV diastolic dysfunction. The right ventricular cavity is markedly dilated with severe global free wall hypokinesis. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. The pulmonic valve leaflets are thickened. There is no pericardial effusion. . IMPRESSION: Severe biventricular global hypokinesis. Biventricular cavity dilation. Severe diastolic dysfunction with elevated filling pressures. Moderate mitral and tricuspid valve regurgitation. Moderate pulmonary hypertension. . Compared with the prior study (images reviewed) of [**2139-3-4**], left ventricular function has declined. Severe diastolic dysfunction with elevated cardiac filling pressures is now apparent. Estimated pulmonary artery pressures are higher. The severity of mitral regurgitation is slightly decreased. . . Cardiac Cath [**8-27**]: 1. Arterial conduit angiography demonstrated patent grafts (LIMA-LAD, SVG-diagonal, SVG-PDA). The LAD had a 90% lesion just beyond the touchdown of the graft and was diffusely diseased. The RCA was diffusely diseased up to 90% in the PL branch. The native coronary arteries were not engaged. 2. Resting hemodynamics demonstrated mild to moderately elevated right and left sided filling pressures (RVEDP 19 mm Hg, PCWP mean 21 mm Hg). The pulmonary arterial blood pressure was moderately elevated (PASP 51 mm Hg). The systemic arterial blood pressure was low (SBP 72 mm Hg, MAP 57 mm Hg). The cardiac index was low at 1.9 l/min/m2. The pulmonary artery vascular resistance was high at 311 dynes-sec/cm5. The systemic vascular resistance was normal at 889 dynes-sec/cm5. Dopamine was started due to low SBP and low cardiac index. 3. Left ventriculography was deferred. 4. Successful PTCA and stenting of LAD distal to the LIMA-LAD anastomosis with a 2.5x15mm Promus stent. Final angiography revealed no residual stenosis at the stented location with up to 80% diffuse distal disease in the LAD remaining, no angiographically apparent dissection and TIMI III flow (see PTCA comments). . FINAL DIAGNOSIS: 1. Diffuse three vessel coronary artery disease. 2. Patent LIMA-LAD, SVG-diagonal, and SVG-PDA grafts. 3. Moderate biventricular diastolic dysfunction. 4. Moderate pulmonary hypertension. 5. Low cardiac index. 6. SuccessfuL PCI of the LIMA-LAD anastomosis site. Brief Hospital Course: 53 yo gentleman with CAD s/p CABG, post infarction cardiomyopathy (EF 20-25%), moderate to severe MR, DM1, PVD s/p B LE amputations, ESRD s/p renal Xplant x2 now on HD with chest pain, and acute on chronic systolic heart failure. S/p cardiac left and right cardiac catheterization. . . MICU COURSE [**Date range (1) 17948**] ====================== 1. Chest Pain: Given initial history, pattern of chest pain appeared to be consistent with unstable angina. Cardiology was consulted on arrival to the MICU. Given risk factors for ACS and subtherapeutic warfarin, IV heparin was started. Plavix 300 mg po x 1 was given. Cardiac enzymes were trended. Although NTG gtt would have been ideal, the patient was hypotension and on levophed; thus this was not started. Instead, morphine was used for pain control. Statin was increased to 80 mg daily. Echo showed worsening global hypokinesis. On [**8-25**], Cardiology again saw the patient and felt that this was not ACS; thus, plavix and heparin gtt were discontinued. . 2. Acute on Chronic Systolic CHF: This medical issue was soon thought to be the driver of his cardiogenic shock. Mixed venous sats were trended. Pt was continued on levophed, but ultimately, this was weaned off. CVVH was started with goal - 1 to -1.5 L. Inotropes were considered, but felt not to be necessitated at this time, but that fluid status would be ultimately helpful in pt's cardiogenic recovery. Due to his multiple cardiac issues, the patient was transferred to the CCU team. . 3. Hyperkalemia: CVVH was performed. Resolution of hyperK. . 4. Diabetes: Initially, pt on [**11-28**] of his glargine dose due to NPO status, but this was resumed in the AM at full dose. . 5. ESRD: Renal following. CVVH was completed while in MICU. . 6. h/o Stroke: Initially, warfarin on hold and heparin started. Once heparin d/c, INR was 2.2. To restart warfarin by CCU team. . . . CICU COURSE ([**Date range (1) 17949**]) ======================= . # Acute on Chronic Systolic CHF: Patient has known global hypokinesis with EF 15%. Unclear what the precipitant of acute exacerbation was. Underwent CVVH series with significant removal of fluid (LOS fluid balance: negative 7 liters). Underwent HD in-house following completion of CVVH; all anti-hypertensive medications (Captopril and Metoprolol) were held prior to HD sessions due to low BPs, and Captopril was d/c'ed prior to discharge as blood pressures were lower than ideal for HD. He was also given a dose of Midodrine prior to HD sessions. Patient was told to follow up with his outpatient cardiologist regarding re-initiation of his ACEi. Prior to discharge, patient had CXR which showed improved pleural effusions, resolved pulmonary edema/atelectasis. . # Chest Pain/CAD: Patient has known CAD with CABG and PCI in past. Cardiac enzymes were flat (x3), without EKG changes, but with persistent intermittent chest pain. Initially treated with ASA, plavix, heparin gtt, then underwent cardiac cath [**8-27**] with stent to LIMA-LAD graft, chest pain free since cath. Discharged on ASA, statin, plavix, BB. Holding ACEi as BPs low in-house, and patient was instructed to follow up with his cardiologist regarding re-initiation of his ACEi. . # Low Grade Fever: Initial low grade fever without leukocytosis or evidence of infection. Pulled R IJ [**9-1**], culture negative to date. CXR showed no evidence of focal consolidation. Urine grew Klebsiella, but pt has history of recurrent UTIs but did not appear infected, suspected chronic colonization. Low-grade fevers resolved without antibiotics. . # Hypotension: Patient had SBP 70's-100's while in-house, tolerated MAPs of 50's without symptoms. Initially on Levophed, then Dopamine with concern for cardiac cause given low EF d/t cardiomyopathy, but pressors d/c'ed in the CCU. - Hold parameters for metoprolol - Discontinued captopril - Hold antihypertensives in the AM prior to dialysis session . # Hypoxia: Possibly [**12-29**] fluid overload from CHF initially, resolved with CVVHD. Brief episode with exertion and will have PT/rehab as an outpatient. . # ESRD on HD: Patient initially on CVVHD from MICU to remove fluid for CHF exacerbation in the setting of ESRD on HD as an outpatient. Continued CVVHD with fluid removal in the CCU despite low SBP in 70's and 80's (MAP ~50-60) as pt asymptomatic and likely chronic low BPs. Once patient was believed to be near dry weight, CVVH was d/c'ed and patient was re-started on HD. Received Midodrine and held all antihypertensive medications prior to HD for low BP. Cr improved s/p HD. . # h/o Stroke (suspected cardioembolic): On Coumadin as an outpatient. INR was initially subtherapeutic following Vit K at OSH, and patient was on heparin gtt. Patient was intermittently in afib in-house. He was restarted on home dose Coumadin with Heparin bridge until INR was therapeutic. However, INR was supratherapeutic on the day of discharge, and patient was instructed not to take Coumadin until his INR was checked by the [**Hospital 197**] Clinic. . # Diabetes: Pt was on Glargine, SSI in-house. . # Hyperkalemia: K 7.4 on admission, now resolved. Unclear etiology (per patient and wife, has been going to dialysis three times a week regularly). K improved s/p HD. . # Groin pain, back pain: Stable, on home Oxycodone as needed. . . CODE: Full CONTACT: Wife Medications on Admission: Alendronate 70mg PO weekly omeprazole 40mg PO daily (lunch) lisinopril 5mg po daily (took) aspirin 81mg po daily phoslo 667mg TID with meals warfarin 2mg qhs Mon Wed Fri warfarin 3mg qHS on Tues, Thurs, Sat Sun Pen VK 500mg QID (for tooth abscess) metoprolol xl 25mg po daily folic acid 1mg po qhs prednisone 5mg po qhs multivit daily once daily at bedtime reglan 5mg [**Hospital1 **] at breakfast, dinner allopurinol 100mg po daily qAM Insulin 26 units of lantus at dinner insulin humalog sliding scale Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ranitidine HCl 75 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). [**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 6. Xeroform Petrolatum Dressing 5 X 9 Bandage Sig: One (1) Topical as directed. [**Hospital1 **]:*30 bandages* Refills:*2* 7. PhosLo 667 mg Capsule Sig: One (1) Capsule PO TID with meals. Capsule(s) 8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 10. Reglan 5 mg Tablet Sig: One (1) Tablet PO twice a day: at breakfast and dinner as directed. 11. Insulin Lispro 100 unit/mL Solution Sig: as directed per sliding scale Subcutaneous as directed. 12. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 13. Insulin Glargine 100 unit/mL Solution Sig: Twenty Six (26) units Subcutaneous at dinnertime daily. 14. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO TID prn as needed for pain. 15. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual every 5 minutes as needed as needed for chest pain. 16. Nitrostat 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual as needed as needed for chest pain: as directed. 17. Epogen Injection 18. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. 19. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week: as directed. 20. Midodrine 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for the morning of dialysis for 15 doses: Please take this medication only on days that you will undergo dialysis. This medication should be taken prior to dialysis. [**Hospital1 **]:*15 Tablet(s)* Refills:*0* 21. Outpatient Lab Work Please have your INR monitored on Monday [**9-7**] at dialysis. The results should be faxed/forwarded to the [**Hospital 191**] [**Hospital 197**] Clinic. P: [**Telephone/Fax (1) 2173**] F: [**Telephone/Fax (1) 3534**] Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Acute exacerbation of chronic systolic heart failure Coronary Artery Disease/Angina Chronic renal failure Diabetes Mellitus Discharge Condition: Medically stable. Discharge Instructions: You presented to the hospital for chest pain and shortness of breath, and were found to have low blood pressure and too much fluid in your body due to an exacerbation of your known congestive heart failure. You were admitted to the intensive care unit and initiated on CVVH (a form of dialysis) and had fluid removed. You were initially on medication to increase your blood pressure, but those were subsequently discontinued. An echocardiogram of your heart was performed, and showed poor pumping function of your heart. Your blood pressures remained low, but you did not have any symptoms. Due to the low blood pressures, your Lisinopril was discontinued in the hospital, and you should not take this medication until your cardiologist, Dr. [**First Name (STitle) 437**], tells you to re-start the medication. . Because you continued to have chest pain in the hospital, you underwent cardiac catheterization and had a stent placed to open a blockage of one of the blood vessels supplying your heart. . The following medication changes were made: -Omeprazole was stopped -Ranitidine was started -Plavix was started -Atorvastatin was started -Aspirin was increased to 325mg daily -Penicillin V was stopped, as you completed your full outpatient course -Lisinopril was stopped. Please consult Dr. [**First Name (STitle) 437**] regarding re-starting this medication when your blood pressure improves -Coumadin will be held until you have your INR is re-checked at dialysis on Monday, as your INR was high on the day of discharge. . If you experience chest pain, shortness of breath, fevers, or other concerning symptoms, please return to the hospital. . Because you have heart failure, you should weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5L/day Followup Instructions: Please follow up with your nephrologist and your cardiologist as recommended once you leave the hospital. . You had an appointment with [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. Phone:[**Telephone/Fax (1) 277**] on [**2139-9-24**], which you were unable to make because you were in the hospital. Please call Dr. [**Last Name (STitle) 261**] to reschedule an appointment. . You have the following appointment scheduled: -Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], MD Date/Time:[**2139-10-6**] 10:10 Please have your INR monitored on Monday [**9-7**] at dialysis. The results should be sent to the [**Company 191**] coumadin clinic. You should not resume your coumadin until you have been instructed to restart by your coumadin clinic.

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icd9cm

[ [ [] ] ]

[ "88.56", "00.45", "37.23", "00.66", "38.95", "36.07", "39.95", "00.40" ]

icd9pcs

[ [ [] ] ]

17327, 17384

9048, 14407

387, 393

17552, 17572

4172, 8744

19463, 20282

3249, 3266

14961, 17304

17405, 17531

14433, 14938

8761, 9025

17596, 19440

3281, 4153

279, 349

421, 2140

2162, 3117

3133, 3233

24,021

164,968

45372

Discharge summary

report

Admission Date: [**2101-5-26**] Discharge Date: [**2101-5-28**] Date of Birth: [**2047-6-15**] Sex: F Service: NEUROLOGY Allergies: Penicillins / Codeine Attending:[**First Name3 (LF) 618**] Chief Complaint: muteness, right sided weakness Major Surgical or Invasive Procedure: intra-arterial TPA administration History of Present Illness: The patient is a 53 year old woman with multiple vascular risk factors now presenting with acute onset muteness and right sided weakness. The patient is unable to give a history so the story is taken from family. The patient has been in her usual state of health until today. The husband tells me around 5:50 pm, she told him she was hungry. She was lying on the couch. He went outside for about 20 minutes and when he returned at 6:10 he found her still lying on the couch, unresponsive, starring to the left and not moving her right side. He tried to shake her and "snap" her out of this state. When he was unsuccessful, he called EMS who arrived about 20 minutes later. She arrived at [**Hospital1 18**] at 7:10 pm and a code stroke was activated. Neurology arrived at the bedside within 30 seconds. She had a left gaze preference, decreased movement on the right and a right facial droop. She was intubated after vomiting x1 on the stretcher. She was taken to CT scan which reveal a hyperdense right MCA. She was transported back to the ED and preparations were made to admininster TPA. Past Medical History: 1. CAD - pMIBI ([**2100-7-14**] negative EKG changes, no CP, no perfusion defects, EF 70%) 2. Diastolic CHF, 2+ MR 3. hypertension 4. diabetes mellitus type II 5. hepatitis c - untreated 6. cervical cancer - s/p TAH/BSO/peritoneal washing for adnexal masses 7. abdominal aortic aneurysm repair in [**2085**] with 8. s/p chole [**2088**] 9. PVD: aorto/fem bypass then with Thrombectomy and patch angioplasty of common femoral arteries in [**2091**] 10. iv drug abuse - quit methadone program. actively using now. 11. asthma/chronic obstructive pulmonary disease / emphysema 12. total body pain 13. abdominal pain with adhesions Social History: smokes [**1-17**] ppd x 35 yrs denies etoh history of heroin use, on methadone Family History: No diabetes; MI (dad-?age); heart disease (brother - quintuple bypass); HTN (dad); cancer (breast-aunt; lung-brother); depression (mom, dad). Physical Exam: Exam on admission: Vitals: 98.6 150/80 88 16 General: woman vomiting on stretcher Neck: supple Lungs: clear to auscultation CV: regular rate and rhythm Abdomen: non-tender, non-distended, bowel sounds present Ext: warm, no edema Neurologic Examination: awake, alert, not following any commands; decreased blink to threat on right, left gaze preference, right facial droop; right side more flaccid; spontaneous mvt on left, none on right, no w/d to noxious stimuli on right leg, slight w/d on right arm, reflexes 2+ and symmetric, toe up on the right Pertinent Results: [**2101-5-26**] 11:49PM GLUCOSE-133* UREA N-16 CREAT-0.5 SODIUM-136 POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-25 ANION GAP-15 [**2101-5-26**] 11:49PM CALCIUM-8.7 PHOSPHATE-4.3 MAGNESIUM-1.8 [**2101-5-26**] 11:49PM WBC-13.1* RBC-3.64* HGB-9.9* HCT-28.6* MCV-79* MCH-27.2 MCHC-34.6 RDW-14.9 [**2101-5-26**] 11:49PM PLT COUNT-406 [**2101-5-26**] 11:49PM PT-15.2* PTT-38.3* INR(PT)-1.4* [**2101-5-26**] 09:39PM %HbA1c-6.3* [Hgb]-DONE [A1c]-DONE [**2101-5-26**] 07:42PM GLUCOSE-97 LACTATE-1.5 NA+-139 K+-3.1* CL--105 TCO2-29 [**2101-5-26**] 07:25PM UREA N-17 CREAT-0.5 [**2101-5-26**] 07:25PM ALT(SGPT)-17 AST(SGOT)-14 LD(LDH)-279* CK(CPK)-28 ALK PHOS-203* AMYLASE-33 TOT BILI-0.4 [**2101-5-26**] 07:25PM LIPASE-30 [**2101-5-26**] 07:25PM CK-MB-NotDone cTropnT-0.02* [**2101-5-26**] 07:25PM ALBUMIN-3.4 CHOLEST-70 [**2101-5-26**] 07:25PM TRIGLYCER-82 HDL CHOL-40 CHOL/HDL-1.8 LDL(CALC)-14 [**2101-5-26**] 07:25PM TSH-0.31 [**2101-5-26**] 07:25PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2101-5-26**] 07:25PM WBC-12.6* RBC-3.70* HGB-9.8* HCT-29.8* MCV-80* MCH-26.5* MCHC-33.0 RDW-14.7 [**2101-5-26**] 07:25PM PT-14.1* PTT-26.9 INR(PT)-1.2* [**2101-5-26**] 07:25PM PLT COUNT-362 [**2101-5-26**] 07:25PM FIBRINOGE-486* * * * [**2101-5-26**] CT/CTA of Head NON-CONTRAST HEAD CT SCAN: There is a hyperdense left middle cerebral artery concerning for hyperdense clot. There is subtle hypodensity and effacement of portions of the left temporal lobe consistent with acute infarction. There is no evidence of intracranial hemorrhage or mass effect. There is no hydrocephalus. The osseous structures are unremarkable. The visualized paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: 1. Hyperdense left middle cerebral artery with subtle hypodensity in the left temporal lobe with focal effacement consistent with acute infarction. CTA HEAD: There is calcific atherosclerotic disease of both internal carotid arteries. A thrombus is seen at the level of the left supraclinoid internal carotid artery and there is no opacification of the left middle cerebral or anterior cerebral arteries. The right anterior circulation is unremarkable. The vertebrobasilar arteries as well as both posterior cerebral arteries are patent. IMPRESSION: 1. Clot at the level of the left supraclinoid internal carotid artery. This results in occlusion of the left anterior cerebral and middle cerebral arteries. NOTE ADDED AT ATTENDING REVIEW: There is poor opacification of the vasculature throughout the left middle and anterior cerebral artery territories suggesting infarction in this region. * * * [**5-26**] CXR: SINGLE PORTABLE AP SUPINE CHEST RADIOGRAPH: The patient is status post median sternotomy, skin staples are still seen in the midline. The endotracheal tube is 3.3 cm above the carina. OG tube tip is not visualized but is below the diaphragm. There are bilateral perihilar opacities as well as increased interstitial markings. Cardiomegaly. There are bilateral pleural effusions. IMPRESSION: 1. Pulmonary edema 2. Endotracheal tube and orogastric tube in appropriate positions. * * * ia-TPA Procedure: PROCEDURE: Following written informed consent from the patient's family, the patient was positioned supine on the angiography table. Potential risks of the procedure discussed with the family included hemorrhage/bleeding from a portion of the body including the brain, worsened stroke, lack of successful treatment, death, vessel injury, and need for surgery. Preprocedure timeout was performed to confirm patient, procedure, and site. Standard sterile prep and drape of the inguinal regions bilaterally. Local anesthesia with 7 cc of 1% lidocaine subcutaneously in the right inguinal region. General anesthesia was administered by the anesthesiology service. Using combination of palpatory and fluoroscopic guidance, a 19-gauge single wall puncture of the right limb of the patient's aortobifemoral bypass graft was performed. A 0.035-inch guidewire was advanced through the needle into the abdominal aorta using fluoroscopic guidance. Needle was exchanged for a 6-French vascular sheath, which was attached to continuous heparinized saline flush. Using a 6- French MPD catheter, the left common carotid artery was selected and common carotid arteriography was performed. The catheter was then advanced into the left internal carotid artery. The microcatheter and microwire were used to attempt to gain access to the thrombus/embolus. The catheter was positioned at the trailing edge of the embolus. Based on the findings of a diagnostic arteriogram, it was determined the patient may benefit from was a suitable candidate for intraarterial thrombolysis. A total of 4 mg of intraarterial TPA was administered from this catheter position in divided doses of 1 mg each. Note that the patient already received a maximal dose of intravenous TPA. No effect was noted from the intraarterial TPA. On comparison between the diagnostic arteriogram and the previously performed CT arteriogram there was no change in the clot burden between the two studies accounting for differences in technique. At this point, it was determined that further intervention was likely to carry more risk and benefits. At this point, the case was discussed with the patient's family and Dr. [**Last Name (STitle) **] of neurology. Based on these discussions, the procedure was terminated. All wires and catheters were removed. The sheath was sutured in place with a single 0 silk suture and a sterile transparent dressing was applied. The sheath was going to be transitioned from continuous heparinized saline flush to pressure transduction by the Intensive Care Unit. The patient was transferred to the Intensive Care Unit in stable condition. There were no immediate complications. 100 mL of Optiray 240 radiographic contrast was utilized. FINDINGS: There is complete occlusion of the supraclinoid internal carotid artery on the left. The downstream portion of the left common carotid artery is patent. Mild irregularity at the left carotid bulb consistent with the known atherosclerotic plaque seen on a prior ultrasound of [**2100-11-1**]. IMPRESSION: Complete occlusion of the supraclinoid internal carotid artery. A microcatheter was placed in the thrombus/embolus and 4 mg of intraarterial TPA was administered into the thrombus. * * * [**5-27**] CXR: SINGLE VIEW CHEST, AP: The ET tube is slightly high lying with the tip approximately 1 cm above the superior margin of the clavicles. There has been interval increase in the size of the bilateral pleural effusions. Interval placement of a left subclavian CVL is seen with the tip in the superior SVC. There is no pneumothorax. Persistent perihilar haziness is consistent with pulmonary edema. The patient is status post median sternotomy and CABG. IMPRESSION: 1. Worsening bilateral pleural effusions. 2. Left subclavian CVL tip terminates at the junction of the brachiocephalic veins. No pneumothorax. * * * [**2101-5-28**] HEAD CT: FINDINGS: There is significant interval increase in contralateral midline shift, now 14 mm compared to 6 mm yesterday. The left lateral ventricle in its entirety is almost completely effaced. There is increase in size of the right lateral ventricle in particular, the posterior and temporal [**Doctor Last Name 534**] concerning for the interval development of obstructive hydrocephalus due to compression of the foramen of [**Location (un) 9700**]. There is also new effacement of the basal cisterns on the right consistent with uncal herniation. There is heterogeneity within the large left ACA territorial infarct which may represent a component of hemorrhage, however there appears to be no significant interval change compared to the appearance yesterday. Again noted is the dense left MCA consistent with thrombus. IMPRESSION: 1. Significant interval worsening. Increased subfalcine herniation and new right-sided uncal herniation. Interval increase in size of right lateral ventricle indicating Foramen [**Last Name (un) 2044**] obstruction from subfalcine herniation. 2. Heterogeneity in the density within the infarcted territory with increased density in the medial aspect which may represent petecheal hemorrhage into the infarcted area. 3. The pertinent findings have been discussed immediately with Dr. [**Last Name (STitle) 46162**] and the necessity for immediate neurosurgical intervention, if the patient is considered salvageable has been discussed. Brief Hospital Course: The patient is a 53 year old woman with a history of CAD s/p recent CABG and porcine valve (mitral) surgery now presenting with acute onset anterior global aphasia, right sided weakness. Her head ct shows a hyperdense right MCA. She is getting TPA and will go to the neuro icu for further management. We will repeat her head CT one hour after tpa and if still has hyperdense right mca, will take her to angio. Summary of Plan: 1. will give tpa and repeat head ct in one hour, if still shows hyperdense sign, will take her for intra-arterial tpa 2. let blood pressure autoregulate 3. will check stroke risk factors, lipids, hA1c 4. will check a TTE * * * After obtaining informed consent from her family, Ms. [**Known lastname 39008**] was brought to Interventional Radiology where she was found to have complete obstruction of the left supraclinoid ICA. 4 mg of intra-arterial TPA was administered but the thrombus failed to lyse. Ms. [**Known lastname 39008**] was then brought to the intensive care unit for further monitoring and care. For the first 36 hours her physical exam was stable, in that when she was not sedated she remained mute, but opened her eyes to sternal rub. She moved the left side spontaneously but her right leg had no movement, and she would weakly extend her right arm to noxious stimuli. Her chest x-rays revealed pulmonary edema, and her fluids were adjusted to achieve an overall negative fluid balance. On [**5-28**] AM her pupillary exam changed, so that her left pupil became dilated and minimally reactive. A repeat head CT revealed "significant interval worsening. Increased subfalcine herniation and new right-sided uncal herniation. Interval increase in size of right lateral ventricle indicating Foramen [**Last Name (un) 2044**] obstruction from subfalcine herniation." as well as evidence of petechial hemorrhage into the infarct. She was administered mannitol at this time. A family meeting was held, and due to her poor prognosis for survival and for return of function, her family decided to forego any neurosurgical intervention and instead to institute comfort measures only. She was extubated and all treatments were discontinued. She died on [**5-28**]. Medications on Admission: -asa 81 -docusate -protonix -trazodone -methadone -metoprolol -furosemide -nicotine patch Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Stroke Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

[ "414.00", "428.30", "V42.2", "518.81", "428.0", "V45.81", "250.00", "434.91", "496", "070.70" ]

icd9cm

[ [ [] ] ]

[ "96.71", "38.93", "99.10", "96.6" ]

icd9pcs

[ [ [] ] ]

13971, 13980

11579, 13801

313, 348

14030, 14040

2981, 10066

14093, 14192

2243, 2387

13942, 13948

14001, 14009

13827, 13919

14064, 14070

2402, 2407

243, 275

376, 1479

10075, 11556

2422, 2639

2663, 2962

1501, 2130

2146, 2227

26,300

144,517

5872+55706

Discharge summary

report+addendum

Admission Date: [**2191-9-4**] Discharge Date: [**2191-9-7**] Date of Birth: [**2118-2-26**] Sex: F Service: [**Hospital Unit Name 196**] Allergies: Iodine; Iodine Containing / Ambien Attending:[**First Name3 (LF) 2901**] Chief Complaint: Here for hydration prior to elective carotid artery intervention Major Surgical or Invasive Procedure: R carotid artery stenting History of Present Illness: 73 yo F with IDDM, HTN, dyslipidemia, CRI with baseline 2.2-3.5, severe PVD, CAD s/p LCX stent (cypher 3.5 x 23 mm stent in [**10-23**]), hx of iodine allergy, CHF with EF ~50%, R. breast CA s/p mastectomy on tamoxifen for ~3 yrs, s/p PTCA of instent R. RAS + PTCA/stent of ostial L. RAS [**1-22**], s/p thrombectomy/profundoplasty of acute thrombosis of aortofemoral graft [**10-23**], R. ICA stenosis (80-99% by doppler [**2190-8-7**]) who presents for elective R. ICA stenting. On CREST trial so needs Plavix 75 [**Hospital1 **] and ASA 325 [**Hospital1 **]. Past Medical History: IDDM, HTN, dyslipidemia CRI with baseline 2.2-3.5 severe PVD CAD s/p LCX stent CHF with EF ~50% R. breast CA s/p mastectomy on tamoxifen for ~3 yrs s/p PTCA of instent R. RAS + PTCA/stent of ostial L. RAS [**1-22**] s/p thrombectomy/profundoplasty of acute thrombosis of aortofemoral graft [**10-23**] R. ICA stenosis (80-99% by doppler [**2190-8-7**]) Social History: Pt is married and lives with her husband, grandchildren and son. + tob x50pyrs (quit) occ EtOH no illicits Family History: Denies cardiac disease. Physical Exam: 97.1 107/69 54 18 97%RA Gen: Pleasantly conversive, lying comfortably in bed, NAD HEENT: MMM, PERRL Neck: R carotid bruit; no JVD CVS: RRR, S1/S2 NL, 2/6 SEM @ RUSB Chest: CTA bilat Abd: soft, NT/ND Ext: trace pedal edema; 2+ DP pulses Neuro: AAOx3, CN II-XII grossly intact; strength 5/5 U/L Ext Bilat Pertinent Results: R. ICA stenosis (80-99% by doppler [**2190-8-7**]) Brief Hospital Course: Received R-ICA stent placement [**2191-9-5**]. Hospital course s/p stent placement was hemodynamically unremarkable. The pt was discovered to have developed disorientation and change in mental status at 5.30am on [**2191-9-6**], which resolved without further intervention over the next 24 hours. No acute changes were visible on head CT. Medications on Admission: Diltiazem SR 120mg po qd ISDN 40mg po tid Hydralazine 100mg po tid Lipitor 20mg po qd Toprol XL 50mg po qd Cozaar 50mg po qd Lasix 20mg po qd:prn ASA 81mg po qd Plavix 75mg po qd Tamoxifen 20mg po qd NPH 34units SQ qAM / 19units SQ qPM Humalog 5units SQ qhs Discharge Medications: Diltiazem SR 120mg po qd ISDN 40mg po tid Aspirin 325mg po bid Atorvastatin 20mg po qd Clopidogrel 75mg po bid Furosemide 20mg po qd NPH 34units SQ qAM / 19units SQ qPM Humalog 5units SQ qhs Tamoxifen 20mg po qd Discharge Disposition: Home Discharge Diagnosis: Occlusion of right internal carotid artery treated by placement of right internal carotid artery stent. Discharge Condition: Good. Discharge Instructions: Please call your doctor and return to the hospital emergency department for any fever, nausea, vomiting, disorientation or delerium. Please come to the reception area of the [**Hospital Ward Name **] 4 catheterization laboratory any time on the morning of Friday [**9-9**] for follow-up by Dr.[**First Name (STitle) **]. Please inform the receptionist, who will page Dr.[**First Name (STitle) **]. Followup Instructions: Please come to the reception area of the [**Hospital Ward Name **] 4 catheterization laboratory any time on the morning of Friday [**9-9**] for follow-up by Dr.[**First Name (STitle) **]. Please inform the receptionist, who will page Dr.[**First Name (STitle) **]. Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 1401**], M.D. Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 2386**] Date/Time:[**2191-11-3**] 11:30 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**] Completed by:[**2191-9-7**] Name: [**Known lastname 3945**],[**Known firstname 732**] Unit No: [**Numeric Identifier 3946**] Admission Date: [**2191-9-4**] Discharge Date: [**2191-9-7**] Date of Birth: [**2118-2-26**] Sex: F Service: [**Hospital Unit Name 319**] Allergies: Iodine; Iodine Containing / Ambien Attending:[**First Name3 (LF) 949**] Chief Complaint: CC:[**CC Contact Info 3947**] History of Present Illness: 73 yo F with IDDM, HTN, dyslipidemia, CRI with baseline 2.2-3.5, severe PVD, CAD s/p LCX stent (cypher 3.5 x 23 mm stent in [**10-23**]), hx of iodine allergy, CHF with EF ~50%, R. breast CA s/p mastectomy on tamoxifen for ~3 yrs, s/p PTCA of instent R. RAS + PTCA/stent of ostial L. RAS [**1-22**], s/p thrombectomy/profundoplasty of acute thrombosis of aortofemoral graft [**10-23**], R. ICA stenosis (80-99% by doppler [**2190-8-7**]) who presents for elective R. ICA stenting. On CREST trial so needs Plavix 75 [**Hospital1 **] and ASA 325 [**Hospital1 **]. Major Surgical or Invasive Procedure: Right internal carotid artery stent placed. Brief Hospital Course: Delerium: Patient developed altered mental status at 2-3am after having been administered Ambien. Given her recent procedure (right carotid stent) we believe that her change in mental status may have been due to the medication that was given, though a reperfusion encephalopathy was another consideration. CT scan was done to rule out any acute cranial pathology and was negative. 24 hours after the incident patient began to have a more clear sensorium. Prior to discharge patient was alert and oriented to person, place and time, without any focal neurological deficits. Discharge Disposition: Home Discharge Diagnosis: Carotid artery occlusion Delirium Acute on Chronic Renal Failure Discharge Condition: Good. Alert and Oriented to person, place and time. No neurological deficits on exam. Stable for discharge home. Discharge Instructions: Please call your doctor and return to the hospital emergency department for any fever, nausea, vomiting, disorientation or delerium. Please make sure you take all your medications as prescribed and that you keep all your appointments. Followup Instructions: 1. Please come to the reception area of the [**Hospital Ward Name **] 4 catheterization laboratory any time on the morning of Friday [**9-9**] for follow-up by Dr.[**First Name (STitle) **]. Please inform the receptionist, who will page Dr.[**First Name (STitle) **]. Primary appointment: Provider: [**Name10 (NameIs) 3948**] [**Last Name (NamePattern4) 3949**], M.D. Where: [**Hospital 3950**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 3951**] Date/Time:[**2191-11-3**] 11:30 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 950**] MD, [**MD Number(3) 951**] Completed by:[**2191-9-7**]

[ "V45.82", "433.10", "414.01", "250.50", "V10.3", "584.9", "403.91", "428.0", "443.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

5772, 5778

5175, 5749

5106, 5152

5887, 6001

1876, 1928

6285, 6922

1513, 1538

2599, 2812

5799, 5866

2317, 2576

6025, 6262

1553, 1857

4443, 4474

4502, 5068

1018, 1372

1388, 1497

4,511

140,328

13787

Discharge summary

report

Admission Date: [**2157-2-8**] Discharge Date: [**2130-1-30**] Date of Birth: [**2132-7-8**] Sex: M Service: MEDICINE CHIEF COMPLAINT: Negative pressure pulmonary edema with hemorrhage. HISTORY OF PRESENT ILLNESS: This is a 24 year old male patient who was admitted for elective podiatric surgery on operation was performed [**2157-2-8**], in the afternoon and was a right foot MBA implant, FDL tendon transfer. Surgery began approximately 12:45 and the patient left the operating room at 1706. Estimated blood loss was 200cc and oxygen saturation was greater than 99% throughout. The patient was extubated. He was noted to have good respiratory effort with good airway, occasionally requiring chin lift. The patient found to have an oxygen saturation of 46%. Artificial respiratory was immediately initiated using an Ambu bag and a nasal oral airway was placed. Nasal and oral suctioning revealed bloody frothy sputum. At 1734, a chest x-ray showed slight left ventricular enlargement and widespread ill-defined loss of consistency in the lungs, most severe at the lung bases and also in the mid and upper zone, more on the right. The radiologist noted that these findings were consistent with pulmonary edema. The podiatry surgical team was notified and attended the patient in the Post Anesthesia Care Unit and pulmonology consultation was obtained. The patient was given Morphine to help with respiration and repeatedly suctioned. Ventilation was maintained with an Ambu bag. The patient was reintubated at [**2078**] and moved to the Medical Intensive Care Unit for further management. A bronchoscopy was performed at [**2183**] to evaluate the patient's airway for source of bleeding. The differential at that time included negative pressure pulmonary edema, a tear in the airway or aspiration. Bronchoscopy revealed diffuse pulmonary hemorrhage with no focal bleeding site located. Blood tinged secretions were observed bilaterally. This was most consistent with negative pressure pulmonary edema with hemorrhage. PAST MEDICAL HISTORY: 1. On [**2157-2-8**], status post elective right foot orthopedic surgery. 2. Acne. MEDICATIONS ON ADMISSION: Multivitamin. ALLERGIES: No known drug allergies. PRIMARY CARE PHYSICIAN: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3271**]. PHYSICAL EXAMINATION: On admission, the patient was noted to have shallow breathing and splinting secondary to pain. On admission to the Medical Intensive Care Unit, the patient had temperature of 97.3, heart rate 76, blood pressure 124/54, respiratory rate 10. The patient was intubated on 100% oxygen. In general, the patient was a well developed, well nourished male who was intubated. Cardiovascular - The patient had regular rate and rhythm, S1 and S2. Pulmonary - The patient had crackles noted bilaterally, right greater than left. Abdominally, the patient had positive bowel sounds, was nontender and nondistended. Extremities - The right foot incision was clean, dry and intact and it was dressed. There was a posterior splint that was intact. The patient's bed was broken. LABORATORY DATA: On admission to the Medical Intensive Care Unit, the patient had a white blood cell count of 5.4, hematocrit 40.3, platelet count 190,000. Prothrombin time 13.9, partial thromboplastin time 29.3, INR 1.3. Chem7 showed a sodium of 139, potassium 4.8, chloride 106, bicarbonate 27, blood urea nitrogen 15, creatinine 1.4, glucose 99. Liver function tests showed ALT 13, AST 18, LDH 163, alkaline phosphatase 42. HOSPITAL COURSE: Upon arrival to the Medical Intensive Care Unit, the patient was maintained on ventilatory support in order to protect the patient's airway and allow adequate oxygenation. The patient's blood was typed and crossed and two units were held in the blood bank. A central line was placed. Overnight the patient self extubated and did well. Podiatry recommended continuing postoperative antibiotic prophylaxis with intravenous Kefzol. On hospital day two, the patient was able to maintain oxygen saturation without external ventilatory support although the patient was noted to have shallow breaths and splinting secondary to pain and coughing. A chest x-ray showed partial resolution of the pulmonary edema with a residual infiltrate at both bases. The patient was given a Morphine PCA and encouraged to use pain medications in order to allow deeper breathing and adequate coughing to clear secretions. Inspiratory volume was noted to improve rapidly. Given the patient no longer needed ventilatory support and was otherwise stable, he was transferred in the evening to the general medicine floor for further management. Overnight, the patient had an elevated temperature to 101.2 and blood cultures times four bottles were obtained. The patient had continued improvement on his chest x-ray and urinalysis showed no signs of infection. The patient had pain in his feet and upon deep inspiration as well as with coughing, and the patient continued to use Morphine PCA for pain control. Additionally, the patient's bed on the general medicine floor was broken and maintenance was called several times. The patient was maintained on either five liter nasal cannula or 100% oxygen face mask in order to keep oxygen saturation above 92%. The patient continued to have bloody sputum production and continued to receive intravenous Kefzol for postoperative prophylaxis as well as being kept on bedrest. Intravenous D5 one half normal saline was continued because the patient had poor p.o. intake. Overnight, the patient spiked a fever to 102.4. Blood cultures were again obtained. The patient used his PCA for pain control throughout the night on hospital day four and the patient was able to maintain an oxygen saturation of 95% in room air. A complete blood count with differential showed a decreased white blood count from hospital day three with moderately elevated eosinophils consistent with a possible reactive fever. The patient's prophylactic antibiotics were discontinued. The patient was transferred to a chair and his broken bed was switched with a functional bed. Chest x-ray showed significant clearing of the pulmonary edema. At midday, the patient's Foley, PCA and intravenous fluids were discontinued and the patient's surgical wound was inspected by podiatry. The patient's foot was placed in a cast and physical therapy worked with the patient. The patient was switched to a p.o. pain control regimen with good results. In the evening, the patient was comfortable with oxygen saturation at 96% in room air. It is anticipated that the patient will continue to improve and be stable and be discharged. Criteria for discharge include an ability to maintain adequate oxygen saturation in room air, increased p.o. intake, adequate pain control on a p.o. regimen, adequate mobility and no fevers. DISCHARGE DIAGNOSES: 1. Right foot MBA implant, FDL transfer. 2. Negative pressure pulmonary edema with hemorrhage. DISPOSITION: It is anticipated the patient will be discharged home in good condition. He is to follow up with his primary care physician in one week. MEDICATIONS ON DISCHARGE: Please see discharge work sheet for up to date discharge medications. [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**] Dictated By:[**Last Name (NamePattern1) 3849**] MEDQUIST36 D: [**2157-2-11**] 18:56 T: [**2157-2-13**] 09:42 JOB#: [**Job Number **]

[ "E878.8", "734", "786.3", "780.6", "518.4" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04", "77.88", "38.93", "93.53", "81.57", "33.23", "83.75" ]

icd9pcs

[ [ [] ] ]

6966, 7216

7243, 7576

2193, 2376

3619, 6945

2398, 3601

152, 204

233, 2058

2080, 2166

30,316

189,322

15333

Discharge summary

report

Admission Date: [**2190-11-16**] Discharge Date: [**2190-11-18**] Date of Birth: [**2106-4-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 17865**] Chief Complaint: Shortness of breath, diaphoresis. Major Surgical or Invasive Procedure: None History of Present Illness: 84M with h/o CVA, afib, h/o PE, recurrent aspiration PNA, recent admission for abdominal distension presenting from [**Hospital 7137**] with an O2 sat of 65%, HTN to 192/130, HR 150s. He was placed on oxygen and sent to [**Hospital1 18**] for evaluation. . In the ED, initial vitals were: 99.8 145/99 164 31 94%RA. He was in mild respiratory distress, exam with rhonchi/wheezes similar to prior aspiration. Labs showed WBC 16, subtherapeutic INR of 1.4 -> given enoxaparin. UA dirty, initial CXR not too impressive with mild pulmonary edema and a possible left lower lobe process. EKG with Afib and RVR. He was given 2L IVF, but no HR meds. Also received combivent nebs x2, vancomycin and pip-tazo. Since arrival to the ED, he had a slow decline in his O2 sat. With the decline in hsis O2 sat, the patient was put on BiPap and subsequently vomited and dropped his sats further. For his vomiting the patient was given one dose of zofran and a repeat chest x-ray was performed that showed substantial incease in bilateral opacties and mild pulmonary edema. EKG showed atrial fibrillation with RVR at a rate in the 150s with similar morphology to his baseline. For his atrial fibrillation, the patient was given 5mg IV lopressor x2. His vitals prior to transfer were: 113/70 130 fib 30s, 98% NRB. . Review of systems is unobtainable secondary to baseline aphasia. Past Medical History: CVA (L MCA hemorrhagic) with severe contractions, R weakness, aphasia, dementia Atrial fibrillation Diastolic dysfunction Osteoarthritis Pulmonary embolism s/p IVC filter Depression DM2 - not on medications Sick Sinus Syndrome s/p pacemaker Hypertension Chronic colonic pseudoobstruction Recurrent aspiration pneumonia - NPO with PEG tube UGI bleed - EGD deferred given goals of care discussion with HCP "Reactive airways" Social History: Lives at nursing home - [**Hospital3 2558**]. HCP is [**Name (NI) **] [**Name (NI) **]. Denies tobacco, ivdu, former heavy etoh, but unable to quantify. Was married with 2 children, all of whom have died. Does have a common law wife, [**Name (NI) 26681**], but [**First Name4 (NamePattern1) **] [**Name (NI) **] is his confirmed HCP. Family History: NC Physical Exam: GENERAL: nonverbal HEENT: PERRLA/EOMI. MM dry. CARDIAC: tachycardic, irregularly irregular LUNGS: upper airway sounds bilaterally ABDOMEN: NABS. Soft, NT, ND. EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: Alert, nonverbal. Pertinent Results: Admission labs: [**2190-11-16**] 07:25AM WBC-16.5*# RBC-3.92* HGB-12.0* HCT-36.4* MCV-93 MCH-30.7 MCHC-33.1 RDW-17.3* [**2190-11-16**] 07:25AM NEUTS-68.8 LYMPHS-27.7 MONOS-2.0 EOS-1.2 BASOS-0.3 [**2190-11-16**] 07:25AM PLT COUNT-216 [**2190-11-16**] 07:25AM GLUCOSE-162* UREA N-31* CREAT-1.0 SODIUM-146* POTASSIUM-4.7 CHLORIDE-106 TOTAL CO2-29 ANION GAP-16 [**2190-11-16**] 07:25AM ALT(SGPT)-13 AST(SGOT)-19 CK(CPK)-70 ALK PHOS-75 TOT BILI-0.5 [**2190-11-16**] 07:25AM LIPASE-44 [**2190-11-16**] 07:25AM PT-16.2* PTT-29.1 INR(PT)-1.4* . Discharge labs: [**2190-11-18**] 05:18AM BLOOD WBC-8.5 RBC-3.00* Hgb-9.1* Hct-27.3* MCV-91 MCH-30.4 MCHC-33.4 RDW-17.2* Plt Ct-176 [**2190-11-18**] 05:18AM BLOOD Glucose-120* UreaN-39* Creat-1.4* Na-153* K-3.2* Cl-112* HCO3-28 AnGap-16 [**2190-11-18**] 05:18AM BLOOD Calcium-8.8 Phos-2.1* Mg-2.1 . CXR: FINDINGS: In comparison with the study of [**11-16**], there may be slight decrease in the bilateral pulmonary opacifications, predominantly involving the mid and lower lung zones. Again, the possibilities of extensive aspiration versus some elevation of pulmonary venous pressure must be considered. Single-channel pacemaker device remains in place and there is continued dilatation of gas-filled loops of bowel within the abdomen. . AXR: Again seen is marked diffuse colonic dilatation, similar in appearance as compared to prior CT from [**2190-9-6**]. There is no evidence of pneumoperitoneum or pneumatosis. A gastric tube is again seen. A cardiac pacer wire and an IVC filter are unchanged in location. Degenerative changes are seen in the lumbar spine. IMPRESSION: Stable appearance of pseudo-colonic obstruction as compared to multiple prior examinations. Brief Hospital Course: 84M with h/o CVA, afib, h/o PE, recurrent aspiration PNA, recent admission for abdominal distension presenting from [**Hospital 7137**] with an O2 sat of 65%. #. Urinary Tract Infection: Patient was intially treated with vanc/zosyn. Unfortunately, there was no urine culture sent prior to receiving abx. #. Respiratory Distress - Pt has history of aspiration as well as flash pulmonary edema. The patient also had a witnessed aspiration event in the ED when BiPap was attempted. Pt is covered for HAP with vanc/zosyn, switched to cefpodoxime to complete 8 day course upon discharge. The Initial CXR showed some evidence of left lower lobe process. Patient was also in afib with RVR and likely flashed from that as well. BNP was >[**2181**]. He was diuresed with Lasix. His BB was uptitrated for improved rate control. Must also consider PE given known history and subtherapeutic INR. #. Atrial Fibrillation with rapid ventricular response: In the MICU, he was initially on dilt gtt and transitioned to home beta-blocker, which was titrated up. He was initially subtherapeutic on coumadin, received a dose of lovenox in the ED. He was briefly bridged with heparin gtt. #. Pulmonary embolism s/p IVC filter: He was initially subtherapeutic on coumadin, received a dose of lovenox in the ED. He was briefly bridged with heparin gtt. #. Hypertension: Pt was hypertnesive to the 190s at [**Hospital 7137**]. He was continued on BB and AceI at baseline. #. Chronic colonic pseudoobstruction: He was continued on his home regimen including reglan. #. Aspiration: Pt has chronic aspiration. He has not been taking po's for some time and has PEG tube. He was continued on his tube feeds. #. Depression - Continue citalopram #. Gout - Continue allopurinol CODE STATUS: DNR/[**Hospital 24351**] Hospice, no invasive or painful procedures, no escalation of care except for antibiotics, treating respiratory distress with morphine. EMERGENCY CONTACT: HCP [**Name (NI) **] [**Name (NI) **] ([**Telephone/Fax (1) 44547**]) Medications on Admission: 1. Nitroglycerin 0.4 mg SL prn 2. Lansoprazole 30 mg [**Hospital1 **] 3. Senna 8.6 mg two tabs PO HS 4. Citalopram 10mg daily 5. Docusate Sodium 100 mg [**Hospital1 **] prn constipation 6. Allopurinol 100 mg daily 7. Lidocaine 5 % patch daily 8. Lisinopril 2.5 mg daily 9. Potassium Chloride 20 mEq [**Hospital1 **] 10. Metoclopramide 5 mg [**Hospital1 **] 11. Fluticasone 110 mcg two puffs [**Hospital1 **] 12. Ipratropium-Albuterol 18-103 mcg 1-2 puffs Q6H prn wheezing 13. Warfarin 15 mg daily 14. Bisacodyl 10 mg PR HS 15. Fleets enema twice weekly 16. Metoprolol Tartrate 50 mg TID 17. Simethicone 120 mg QID 18. Ipratropium Bromide 0.02 % Solution 1 inhalation Q6H prn SOB 19. Caltrate 600mg + 400 IU Vitamin D [**Hospital1 **] 20. Natural Tears 2 drops both eyes [**Hospital1 **] + prn 21. Alrex .2% 1 drop right eye TID Discharge Medications: 1. Morphine 10 mg/5 mL Solution [**Hospital1 **]: 5-10 mg PO Q4H (every 4 hours) as needed for pain or shortness of breath. 2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 3. Citalopram 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 4. Allopurinol 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Last Name (STitle) **]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 6. Metoclopramide 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 7. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 8. Simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: 1.5 Tablet, Chewables PO QID (4 times a day). 9. Diltiazem HCl 60 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4 times a day). 10. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 11. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal HS (at bedtime). 12. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg PO BID (2 times a day). 13. Acetaminophen 500 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a day). 14. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Last Name (STitle) **]: [**1-22**] Drops Ophthalmic [**Hospital1 **] (2 times a day). 15. Fleet Enema 19-7 gram/118 mL Enema [**Hospital1 **]: One (1) Rectal twice a week. 16. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal [**Hospital1 **]: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day. 17. Cefpodoxime 100 mg/5 mL Suspension for Reconstitution [**Hospital1 **]: Two Hundred (200) mg PO twice a day for 5 days. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary: Aspiration . Secondary: Atrial fibrillation with rapid ventricular response Acute renal failure Urinary tract infection Pulmonary embolus Hypertension Colonic pseudoobstruction Depression Gout Discharge Condition: HR 90s-110s, SBP 100-110s, O2 sat 99% on NRB, aphasic Discharge Instructions: You were admitted for low oxygenation. This is likely due to aspiration and fluid in the lungs. You were treated with antibiotics to cover a pneumonia, which also covered your urinary tract infection. Please complete a course of oral antibiotics. Your heart medications were changed from metoprolol to diltiazem to improve control of your heart rate. Also, please stop taking your coumadin as your INR is currently too high. Followup Instructions: Please continue with hospice care.

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icd9cm

[ [ [] ] ]

[ "96.6" ]

icd9pcs

[ [ [] ] ]

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4650, 6690

352, 359

9805, 9861

2907, 2907

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2567, 2571

7571, 9466

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279, 314

387, 1751

2923, 3458

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2215, 2551

40,236

177,806

8478

Discharge summary

report

Admission Date: [**2181-6-28**] Discharge Date: [**2181-7-10**] Date of Birth: [**2098-1-8**] Sex: F Service: ORTHOPAEDICS Allergies: Fosamax / Prozac Attending:[**First Name3 (LF) 8587**] Chief Complaint: Left hip drainage Major [**First Name3 (LF) 2947**] or Invasive Procedure: [**6-28**]: I & D L hip, large haematoma evacuated [**7-2**]: I & D L hip, surface VAC + Hemovacs x2 thru VAC sponge History of Present Illness: 83yo F s/p L DHS (intertroch fx) on [**4-28**] c/b failed fixation by migration of screw & infection, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**6-12**] w/ Abx Spacer then s/p Left Hemi [**6-18**] w/ ORIF Greater Troch, now p/w increasing L hip pain. Past Medical History: -Coronary Artery Disease status post MI in [**2180-12-24**] (3VD on cardiac cath but managed non-operatively) -Depression -Anxiety -Atrial Fibrillation (not on anticoagulation) -Crohn's Disease -Chronic obstructive pulmonary disease -distant history of tonsillectomy and adenoidectomy -L hip ORIF [**2181-4-28**] Social History: Pt transported here from [**Hospital6 **] Family History: She reports multiple family members with heart problems. Physical Exam: Gen: AFVSS HEENT: Clear OP, MMM NECK: Supple, No LAD, No JVD CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops LUNGS: CTA, BS BL, No W/R/C ABD: Soft, NT, ND. NL BS. No HSM EXT: No edema. 2+ DP pulses BL SKIN: No lesions NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [**11-24**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2181-6-27**] 07:50PM SED RATE-48* [**2181-6-27**] 07:50PM CRP-68.1* [**2181-6-27**] 07:50PM WBC-20.8* RBC-3.54* HGB-10.7* HCT-32.7* MCV-92 MCH-30.2 MCHC-32.7 RDW-15.8* Brief Hospital Course: Mrs. [**Known lastname 29878**] is an 83 year old femaile who was admitted from [**Hospital6 **] for increasing hip pain after being discharged on [**6-20**] for a presumed left hip infection, washout and hemiarthroplasty. Mrs. [**Known lastname 29878**] had numberous cultures drawn from her wound, but they never grew out anything. The patient was discharged to her rehab center on lovenox and her previous meds. She was then admitted for this hospital stay on [**2181-6-28**]. She was brought to the OR on [**2181-6-28**] for I&D of her left hip and a large hematoma was evacuated and a surface VAC was placed. On POD1 the patient was restarted on lovenox and home medications. The VAC produced 200-300cc of serosangous drainage per day and as a result was brought back to the OR on [**7-2**] for another washout and surface VAC placement. During her procedures, intra-op cultures were drawn but all returned negative. The infectious disease team was consulted and her medications were adjusted. It was felt taht dispite the negative cultures, we would aggresively treat this as an infection due to the high suspicion and aftermath of a missed infection. The wound continued to drain a large amount of serosangous fluid and on [**7-7**] the orthopaedic team decided to stop the patient's lovenox and begin the patient on low dose coumadin with an INR goal of 1.3-1.5 for DVT prophylaxis. On [**7-9**] the wound had completely stopped draining and she was felt stable to return to the rehab center. She is being discharged today back to her nursing home in stable condition. Medications on Admission: Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Buspirone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Captopril 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Metoprolol Tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2 times a day). Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO BID (2 times a day). Psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily). Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization Sig: Two (2) Puff Inhalation q6h PRN as needed for wheeze. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H PRN () as needed for sob, wheeze. Vancomycin 750 mg IV Q 24H Please restart Morphine Sulfate 0.5-2 mg IV Q4H:PRN pain Heparin Flush (10 units/ml) 2 mL IV PRN line flush Lovenox SQ 40mg daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. 3. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Buspirone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 10. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Metoprolol Tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2 times a day). 12. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4 hours) as needed for pain. 14. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO BID (2 times a day). 15. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily). 16. Warfarin 2 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)): INR goal: 1.3-1.5. Disp:*30 Tablet(s)* Refills:*2* 17. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization Sig: Two (2) Puff Inhalation q6h PRN as needed for wheeze. 18. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H PRN () as needed for sob, wheeze. 19. Vancomycin 750 mg IV Q 24H Please restart 20. Morphine Sulfate 0.5-2 mg IV Q4H:PRN pain 21. 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. 22. Vancomycin 750 mg Recon Soln Sig: One (1) Intravenous once a day for 4 weeks. Disp:*56 750mg soln* Refills:*0* 23. Outpatient Lab Work Draw weekly: Vancomycin trough BUN and creatinine CBC w/diff Fax results to infectious disease: [**Telephone/Fax (1) 432**] Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: Left hip hematoma s/p hemiarthroplasty Discharge Condition: stable Discharge Instructions: Keep dressing clean and dry. If you experience any shortness of breath, new redness, increased swelling, pain, or drainage, or have a temperature >101, please call your doctor or go to the emergency room for evaluation. Please resume all of the medications you took prior to your hospital admission. Take all medication as prescribed by your doctor. You have been prescribed a narcotic pain medication. Please take only as directed and do not drive or operate any machinery while taking this medication. There is a 72 hour (Monday through Friday, 9am to 4pm) response time for prescription refil requests. There will be no prescription refils on Saturdays, Sundays, or holidays. Please plan accordingly. Physical Therapy: Left lower extremity is weight bearing as tolerated. PT daily for ambulation advance, no limits, patient currently OOBTC with assist. Fall precautions Treatments Frequency: please keep incision dry Take out stitches on POD#10 Followup Instructions: 2 weeks in orthopaedic trauma clinic with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP. Please call [**Telephone/Fax (1) 1228**] to schedule this appointment. Other Appointments: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SPECIALTIES CC-3 (NHB) Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2181-7-25**] 2:00 DR. [**First Name (STitle) **] BLOOD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2181-8-13**] 10:00

[ "996.66", "496", "707.05", "412", "996.77", "E878.1", "300.4", "707.23", "414.01", "V43.64", "599.0", "V44.3", "707.07", "707.20", "427.31", "707.25" ]

icd9cm

[ [ [] ] ]

[ "80.85", "99.04", "86.28", "83.19", "93.59" ]

icd9pcs

[ [ [] ] ]

7070, 7155

1926, 3518

7238, 7247

1725, 1903

8252, 8771

1153, 1211

5032, 7047

7176, 7217

3544, 5009

7271, 7982

1226, 1706

8000, 8151

8173, 8229

241, 436

464, 741

763, 1077

1093, 1137

57,313

165,894

36207

Discharge summary

report

Admission Date: [**2150-1-11**] Discharge Date: [**2150-2-4**] Date of Birth: [**2079-8-25**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2181**] Chief Complaint: hypotension, syncope Major Surgical or Invasive Procedure: PICC line History of Present Illness: This is a 70year-old female with a history of Ulcerative Colitis who presents from [**Hospital6 302**] with hypothermia, bradycardia and hypotension. The patient has no family but was was reported to be last seen normal yesterday. A neighbor checked on her today and observed her to be stumbling around the house. The precise events are unclear, but at that time, the patient is reported to have syncopized and was helped to the ground. There was no documented history of trauma. She was found to be hypotensive and bradycardic by EMS. HR was 42, blood glucose 132. She was aphasic and there was concern per EMS that she might have a right sided facial droop. . Upon arrival to [**Hospital6 302**] she was noted to be non-verbal with an upper airway occluded with food. She was pale and hypothermic. Her pupils were 3 mm and non-ractive. Her initial vitals were T: 86.9 HR: 30 BP: 66/p. She was intubated and started on dopamine and levophed. CT scan of the head was negative for intracranial hemorrhage. CT chest/abdomen/pelvis was concerning for a small bowel obstruction and peripancreatic stranding. She received ceftriaxone 1 gram IV and vancomycin 2 gram IV. She also received 10 mg IV decadron. Blood pressures improved to the 80s systolic by the time of transfer. Labs were notable for a WBC count of 16.0, Hct of 25.0, Plts of 80. Differential was 92.3 % neutrophils, 2.0% lymphocytes. Creatinine was 7.3 with potassium 6.5 and bicarbonate of 7. TSH 3.61. She was med-flighted to [**Hospital1 18**] for further management. . On arrival to [**Hospital1 18**] her initial vitals were T: 85.5, HR: 61 BP: 100/41, RR: 12, O2: 100% on 100% FiO2. She continued to be unresponsive. The ostomy was noted to be pink with clear liquid and gas in bag. Of note, UA was grossly positive. The patient was examined by Surgery, but they did not feel that her physical exam was consistent with a small bowel obstruction. She received an additional 2.5 liters of normal saline. It is unclear if she received any bicarbonate. Per notes, FAST exam was concerning for a pericardial effusion. Dopamine was able to be weaned off. She received IV flagyl. She was transferred to the [**Hospital Unit Name 153**] for further evaluation. . On arrival to the [**Hospital Unit Name 153**] she is intubated, sedated, withdraws to pain but is otherwise unresponsive. Past Medical History: Ulcerative Colitis s/p colectomy with end ileostomy Schizoaffective disorder Chronic renal insufficiency ([**Hospital Unit Name 5348**] creatinine unknown) Hypertension Social History: Social History: Unknown Family History: Family History: Unknown Physical Exam: General: Intubated, no sedation, minimally responsive to painful stimuli HEENT: pupils 3 mm and minimally reactive, sclera anicteric, MM dry, food in airway Neck: JVP not elevated, no LAD CV: regular rate and rhythm, normal s1 and s2, no murmurs, rubs, gallops Lungs: Decreased breath sounds at left base, otherwise clear anteriorly GI: soft, ostomy with liquid stool in right lower quadrant, non-disteneded, faint bowel sounds, no organomegaly GU: foley with minimal cloudy urine Ext: WWP, 2+ pulses, no clubbing, cyanosis or edema, bruises on lower extremities bilaterally Pertinent Results: =========== Labs =========== admission labs [**2150-1-11**] 08:00PM BLOOD WBC-19.5* RBC-2.83* Hgb-8.7* Hct-27.4* MCV-97 MCH-30.8 MCHC-31.8 RDW-16.0* Plt Ct-109* [**2150-1-11**] 08:00PM BLOOD PT-15.7* PTT-41.0* INR(PT)-1.4* [**2150-1-11**] 09:48PM BLOOD Glucose-200* UreaN-58* Creat-6.5* Na-141 K-4.4 Cl-124* HCO3-8* AnGap-13 [**2150-1-11**] 09:48PM BLOOD ALT-15 AST-19 AlkPhos-92 TotBili-0.2 [**2150-1-11**] 08:00PM BLOOD Lipase-3360* [**2150-1-12**] 04:45AM BLOOD Calcium-7.2* Phos-2.5* Mg-1.0* [**2150-1-15**] 04:00PM BLOOD VitB12-1405* [**2150-1-12**] 04:45AM BLOOD Osmolal-319* [**2150-1-15**] 04:00PM BLOOD TSH-2.5 [**2150-1-12**] 07:16AM BLOOD Cortsol-13.0 [**2150-1-12**] 08:00AM BLOOD Cortsol-32.8* [**2150-1-12**] 08:43AM BLOOD Cortsol-37.2* [**2150-1-11**] 08:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-POS ============= Neurology ============= EEG This is a mildly abnormal EEG in the waking and drowsy states due to the presence of left temporal slow transients suggestive of an area of subcortical dysfunction in this region. Otherwise, no epileptiform features were seen. ============ Radiology ============ RUQ U/S [**1-11**] 1. No intra- or extra-hepatic biliary ductal dilatation, no choledocholithiasis seen. 2. Gallbladder is not visualized. 3. Trace perihepatic free fluid. RUE U/s IMPRESSION: No evidence of deep vein thrombosis. CT Head [**1-15**] No evidence of hemorrhage or stroke. CT Chest [**1-15**] IMPRESSION: 1. No parenchymal infection or aspiration. 2. Small bilateral pleural effusions. 3. Prominent pericardial recess, less likely a cyst. 4. Possible tracheobronchomalacia, severity not assessed. Brief Hospital Course: Impression: 70year-old female with a history of Ulcerative Colitis who presents from [**Hospital6 302**] with hypothermia, bradycardia and hypotension found to have acute renal failure, severe acidosis and elevated pancreatic enzymes. Will be discharged to rehabiliation facility. Has an appointment set up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3636**] as PCP and with Dr. [**Last Name (STitle) 118**] for renal outpatient. ***Of note: patient should have outpt f/u with pcp regarding the elevated ca [**60**]-9 which was checked for unclear reasons earlier during this hospital stay. Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **] discussed this finding with the patient. Shock: Patient on presentation was hypothermic, hypotensive and bradycardic concerning for shock of unclear etiology. She arrived intubated to the ICU from OSH. Concern for severe infection. However, culture data was negative. Patient responded appropriately to cortisol stimulation test. There was a ? of right sided pna on cxr, but a CT chest did not demonstrate pneumonia. Extubated on [**1-13**]. Patient was maintained on broad spectrum antibiotics on admission until [**1-16**]. CT Head was positive for possible sinus infection, so patient was treated with azithromycin. After initial hypotension, patient became hypertensive and was started on Nifedipine in the ICU. On discharge to the floor, she no longer met SIRS criteria and did not demonstrate hypotension. Acute Renal Failure: Likely secondary to ATN. No evidence of hydronephrosis on CT scan to suggest obstruction. Urine eos negative. Patient was treated supportively, and did not need dialysis to maintain neutral pH. She did require frequent infusions of bicarb. Per PCP, [**Name10 (NameIs) 5348**] renal function is creatinine = 3. With creatine trending down from 6.3 on admission to 4.6 on day of transfer, renal function is slowly resolving toward [**Name10 (NameIs) 5348**]. However, the patient will certainly need to obtain a nephrologist for outpatient HD. Venous mapping may be indcated while in-house. Renal is following and will continue to make recommendations regarding long-term plan. Elevated pancreatic enzymes: Unclear etiology, may be secondary to poor perfusion. [**Month (only) 116**] also be the cause of her original presentation. On CT abdomen, no mediastinal hemorrhage, some peripancreatic stranding, long stretch of dilated bowel (collapsed bowel behind it) potentially consistent with incomplete sbo vs local ileus in the setting of pancreatic inflammation. Patient does not have clear risk factors as is s/p cholecystectomy and no known history of alcoholism. Enzymes trended down over course of admission. On discharge to floor, this sub-acute pancreatitis is considered to be an in active issue. Altered Mental Status: Patient had altered mental status at [**Month (only) 5348**] and schizophrenia. Likely secondary to severe infection and acute renal failure with electrolyte abnormalities. Non-contrast head CT was negative for bleed. EEG negative for seizure. Urine tox positive for TCAs. RPR negative. B12 wnl. A psychiatry consult was obtained; per psych, the patient's psych meds were held in the setting of acute illness. The patient's mental status was not thought to be an expression of schizoaffective disorder. Schizoaffective disorder: Held all medications for given altered mental status per Psychiatry. Hyperglycemia: No documented history of diabetes. Required ISS while in house. Anemia/Upper GI bleed: One time event w/ only 300cc's total of coffee ground emesis that resolved on its own. Ostomy output was guaiac positive, but virtually no drop in HCT. Unclear [**Month (only) 5348**]. Normocytic. Would consider scope after acute illness has resolved, but currently considered to be an inactive issue. Epistaxis: Pt was transferred back to [**Hospital Unit Name 153**] on night of [**1-19**] in setting of massive epistaxis and spitting up bright red blood. Due to epistaxis and [**Date Range 5348**] altered mental status (see above), pt desated down to 70s on RA, which improved upon deep suctioning of blood clots. She was seen urgently by ENT who identified an area in the L middle turbinate as being the likely source, which was packed and the bleeding resolved. The patient will have the packing in place for a total of 5 days and will remain on cephalexin during this time. Serial Hcts were 27.0 --> 26.5 (at time of bleeding) --> 29.8 --> 20.7 --> 21.6. She was then transfused 2 units pRBC at which point the Hct appropriately increased. There was a subsequent episode of epistaxis on [**1-24**]. As scheduled the nasal packing was removed on [**1-24**] by ENT and to have continued humidified shovel mask and epistaxis precautions. Around 10pm patient developed cough after sip of water. She was orally suctioned without return. She was later deep suctioned via right nostril by RT and blood tinged sputum returned. Subsequently desatted to 84% on 35% humidified shovel mask. ENT was paged and assessed patient at bedside and saw minimal active bleeding from post-nasopharynx (raw appearing diffuse oozing along posterior septum w/o active bleeding along posterior pharyngeal wall). On FOE, patent airway w/o clots. Nasal packing was applied via left nostril. However, she subsequently but transiently dropped sats to 80s despite NRB. She recovered spontaneously and was tranferred to the [**Hospital Unit Name 153**] for monitoring. She then was transfered to MICU-6 for arterial embolization. She was transiently intubated for the procedure and was then extubated following without difficulty. After monitoring overnight he was determined to be stable, and was transfered to the floor. Aspiration Pneumonia: Pt. was found to be hypoxic on [**1-25**], found to have radiographic evidence of aspiration pneumonia. Started on Vancomycin/Zosyn on [**1-25**], continued for 7 day course. FEN: Patient was NPO after aspiration pneumonia, transitioned to clear liquids, and then to ground consistency . Medications on Admission: Benzotropine 1 mg [**Hospital1 **] Ranitidine 150 mg [**Hospital1 **] Risperidone 4 mg QHS Amitriptyline 10 mg TID Nifedipine 30 mg daily Metoprolol 25 mg [**Hospital1 **] Colace 100 mg daily Tramadol 50 mg TID Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection Q8H (every 8 hours). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 4. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 6. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 7. Risperidone 1 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO BID (2 times a day). 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 9. Insulin Regular Human 100 unit/mL Solution Sig: One (1) See Sliding Scale Injection ASDIR (AS DIRECTED): See Sliding Scale. 10. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours) as needed for pain. 11. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital 5503**] Rehab Discharge Diagnosis: Primary: Hypovolemic Shock Aspiration Pneumonia Refractory Epistaxis Secondary: Ulcerative Colitis s/p colectomy with end ileostomy Schizoaffective disorder Chronic renal insufficiency ([**Hospital 5348**] creatinine 3.0) Hypertension Discharge Condition: Stable, responsive, not ambulatory, can move all 4 extremities spontaneously, eating, drinking, voiding without complaints. Discharge Instructions: You were initially admitted because you had fainted and fallen to the ground. When you arrived to [**Hospital3 **], you had very low blood pressure and your mental status was impaired. As a result, you were transferred to the ICU. You were given fluids through your IV, and were given antibiotics, to which you responded and were transferred out of the ICU to the floor. On the floor you were doing well until you had several episodes of nose bleeds, which formed clots that prevented you from breathing. You were sent back to the ICU twice and the second time you underwent a procedure to block off one of the arteries in your left nostril, which has prevented much of the bleeding from coming back. In addition, you had been having difficulty swallowing, and at one point you may have aspirated some of your food/saliva into your lung, causing a pneumonia. As a result you were placed on antibiotics again for that. You have an appointment scheduled with Dr. [**First Name (STitle) 3636**] on [**2150-2-13**]. In addition, you have been scheduled with an appointment with the kidney doctors on [**Name5 (PTitle) 3816**], [**2-17**], at 10:30AM. If you experience any additional nose bleeds, lightheadedness, loss of consciousness, numbness or tingling on one side of your body, please contact your primary care provider [**Name Initial (PRE) 2227**]. Followup Instructions: 1. Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2150-2-13**] 1:30 2. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2150-2-17**] 10:30 Completed by:[**2150-2-4**]

[ "785.52", "790.29", "784.7", "295.72", "287.5", "V44.2", "403.10", "584.5", "507.0", "348.39", "585.9", "276.2", "461.9", "599.0", "285.1", "578.9", "038.9", "518.81", "995.92", "577.0", "556.9", "276.7" ]

icd9cm

[ [ [] ] ]

[ "96.71", "88.41", "21.01", "99.04", "38.93", "39.72" ]

icd9pcs

[ [ [] ] ]

13157, 13209

5301, 8143

335, 346

13489, 13615

3607, 5278

15026, 15346

2987, 2996

11648, 13134

13230, 13468

11412, 11625

13639, 15003

3011, 3588

275, 297

374, 2721

8158, 11386

2743, 2914

2946, 2955

10,487

108,477

14078

Discharge summary

report

Admission Date: [**2136-12-1**] Discharge Date: [**2136-12-5**] Date of Birth: [**2069-5-26**] Sex: F Service: MEDICINE Allergies: Rofecoxib Attending:[**First Name3 (LF) 759**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: Flexible Sigmoidoscopy History of Present Illness: 67yo female with uterine CA s/p XRT complicated by procatitis and rectal ulcer. Pt received multilpe XRT tx for uterine CA in [**2134**] and had subsequently underwent resection (incomplete) for vaginal recurrence. Pt had initially noticed some rectal spotting as early as [**2134**] subsequent to receiving XRT treatments for her uterine CA, however due to her pressing cardiac issues had not paid it much mind. The patient underwent a flexible sigmoidoscopy in [**2136-7-5**] which showed severe radiation change in rectum and sigmoid and areas of active bleeding within the rectum which were treated with bipolar coagulation of the bleeding. The patient subsequently underwent another sigmoidoscopy in [**2136-8-5**] which found an area of nodular thickened mucosa on the anterior wall of the rectum about 5-7cm from the anal verge. The bleeding was thought to be secondary to radiation change and or infiltrating recurrent uterine cancer submucosally and was treated with bipolar coagulopathy. The patient was in her usual state of health until Thurs, after [**Holiday **], pt had noticed some brisk bleeding from the rectum which were described as bright red clots coming by the handful. She went to [**Hospital **] [**Hospital 41987**] Medical Center where she was found to have stable vital signs, and Hct of 32.8. She was given 1unit PRBC and admitted for observation and bed rest. On [**12-1**], the patient reported increased bleeding, now described as gushing out when sitting down on the toilet to go urinate. The bleeding was no longer clots but now flowing bright red blood. The patient was given another unit of PRBCs and transferred to [**Hospital1 18**] for surgical evaluation. Past Medical History: PAST MEDICAL HISTORY: 1. Hypercholesterolemia 2. Hypertension 3. Insulin-dependent diabetes mellitus 4. Methicillin resistant staphylococcus aureus 5. Gastroesophageal reflux disease 6. Congestive heart failure 7. Ovarian cancer 8. Postoperative atrial fibrillation following coronary artery bypass graft 9. Asbestosis . PAST SURGICAL HISTORY: 1. Coronary artery bypass graft x 3, off-pump complicated by recurrent wound infection of sternal site 2. Status post cholecystectomy 3. Status post appendectomy 4. Status post right leg plate, open reduction and internal fixation 5. Status post bilateral cataract extraction Social History: The patient is a retired teacher. She lives alone. She has no tobacco or ETOH history. Family History: The patient denies any history of CA in her family Physical Exam: -VS: HR: 50 BP: 161/39 RR: 12 SaO2: 100% -GEN: well nutritioned female lying in bed in NAD, pale, alert, oriented, appropriate, speaking in full sentences in soft voice. -CV: RRR, S1, S2, no murmurs, rubs, gallops -CHEST: CTA bilaterally -ABD: obese, vertical 10cm well healed surgical scar (presumably from prior hysterectomy), soft, tympanic, non-tender, BS+ -EXT: warm, well perfused, no clubbing, cyanosis, edema. -NEURO: alert, oriented x3. Pertinent Results: [**2136-12-1**] 05:46PM WBC-5.5 RBC-3.85* HGB-11.2* HCT-33.5* MCV-87 MCH-29.1 MCHC-33.5 RDW-15.7* [**2136-12-1**] 05:46PM PLT COUNT-337# [**2136-12-1**] 05:46PM PT-13.0 PTT-20.1* INR(PT)-1.1 [**2136-12-1**] 05:46PM TSH-1.2 [**2136-12-1**] 05:46PM ALBUMIN-3.5 CALCIUM-9.4 PHOSPHATE-3.6 MAGNESIUM-2.2 [**2136-12-1**] 05:46PM ALT(SGPT)-10 AST(SGOT)-13 LD(LDH)-157 ALK PHOS-70 TOT BILI-0.3 [**2136-12-1**] 05:46PM GLUCOSE-130* UREA N-45* CREAT-1.6* SODIUM-144 POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-33* ANION GAP-11 AP UPRIGHT PORTABLE CHEST [**2136-12-2**] AT 8:15 AM: The most recent prior study that I have for comparison is a study dated [**2134-10-12**]. There has been interval placement of a bipolar pacer. The patient is in failure with gross pulmonary edema. [**2136-12-3**]: A-V paced rhythm 50 bpm Pacemaker rhythm - no further analysis Since pervious tracing, no significant change [**2136-12-4**]: Colonoscopy Findings: Excavated Lesions A large >3 cm ulcer with active oozing of blood was found in the distal rectum. Hemostasis and tissue destruction were successfully achieved with argon plasma coagulation. Other Extensive telangiectasis with active oozing of blood was visualized up to 30 cm into sigmoid colon. Hemostasis and tissue destruction at sites of most active oozing were successfully achieved with argon plasma coagulation. Impression: 1. Ulcer in the distal rectum and extensive telangiectasis with active oozing of blood was visualized up to 30 cm into sigmoid colon. These findings are consistent with radiation proctocolitis. 2. Hemostasis and tissue destruction at sites of most active oozing was successfully achieved with argon plasma coagulation Brief Hospital Course: A/P: 67yo female with uterine CA s/p XRT complicated by procatitis and rectal ulcer who now presents with BRBPR. . 1. GI Bleed: She was initially sent to the ICU for monitoring. She did not have any active bleeding and her vital signs and hematocrit were stable. She was transferred to the floor on [**2136-12-2**] for further management. She underwent a flexible sigmoidoscopy on [**2136-12-4**] which showed an ulcer in the distal rectum and extensive telangiectasis with active oozing of blood up to 30 cm into the sigmoid colon. The most active lesions were coagulated with an argon plasma laser. A repeat sigmoidoscopy as an outpatient was scheduled for [**2136-12-12**] for further plasma coagulation. Post procedure, she passed several clots and hematocrit dropped four points, and this was expected per GI. She had no brisk rectal bleeding and was otherwise hemodynamically stable. She was discharged to home with strict instructions to return immediately if she developed further bleeding prior to her scheduled GI appointment. She was advised to stop all Aspirin/NSAIDS. . 2. CV: A) Coronaries: The patient has a significant CAD history including multiple catheterizations, stent placements and CABG in past. Her Aspirin was held. Her long acting beta= amd calcium channel blockers were switched to shorter acting. B) Pump: The patient also has a known history of CHF with EF of 50% (however with 3+MR). Her lasix was initially held on transfer to the floor. She then developed shortness of breath with wheezing and was in mild acute heart failure. This improved quickly with diuresis, upright positioning, and oxygen. She was therafter maintained on lasix and remained euvolemic for the rest of her hospitalization. C) Rhythm: Pt has a history of afib but is currently in NS with a pacemaker. She was continued on amiodarone. . 3. DM: The patient has DM I. Her NPH dose was halved while NPO and covered with HISS. . 4. CRI: The patient's creatinine remained within her baseline throughout the admission. Medications on Admission: MEDICATIONS: 1. Protonix 40 mg by mouth once daily 2. Cardizem Ext Release 120mg once daily 3. Lasix 80 mg by mouth twice a day 4. Lescol 40 mg QHS 5. Toprol XL 150 mg by mouth once daily 6. Insulin NPH 34 units in the morning, 10 units in the evening, humalog sliding scale 7. Amiodarone 200mg once daily 8. Nitroglycerin patch 0.2mg/hour on 8AM and off at 8PM 9. Fe sulfate 325mg once daily . ALLERGIES: 1. Percocet 2. Vioxx 3. Fried shrimp Discharge Medications: 1. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Insulin NPH Human Recomb 150 unit/1.5 mL Syringe Sig: 34 units in am and 10 units in pm units Subcutaneous twice a day: Take your NPH insulin and Humalog sliding scale as you were prior to admission. Check your blood sugar at least 3 times daily. 7. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: 1.5 Tablet Sustained Release 24HRs PO once a day. 8. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 10. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Discharge Disposition: Home With Service Facility: staff builders TLC out of [**Hospital1 **] Discharge Diagnosis: Radiation induced proctocolitis Radiation induced rectal ulcers Lower gastrointestinal bleeding Congestive Heart failure Coronary artery disease Hypertension Diabetes Mellitus GERD Ovarian Cancer Discharge Condition: Stable and improved. She was passing decreasing amounts of clots, and occasional specks of bright blood per rectum. She was hemodynamically stable with stable hematocrit and no brisk rectal bleeding. She was able to ambulate independently without difficulty. Discharge Instructions: 1. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. 2. Adhere to 2 gm sodium diet 3. Fluid Restriction: 1.5 Liters. 4. Call your doctor or return to the emergency room immediately if you experience shortness of breath or if you experience brisk bleeding from your rectum. You should expect to have a small amount of blood from your rectum after your recent procedure. 5. Follow up with GI for another flexible sigmoidoscopy on [**2136-12-12**]. Followup Instructions: 1.Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Where: [**First Name8 (NamePattern2) **] [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) ENDOSCOPY SUITE Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2136-12-12**] 11:30 2. Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Where: GI ROOMS Date/Time:[**2136-12-12**] 11:30 3. Follow up with your primary care provider within one week.

[ "V10.43", "569.85", "556.2", "280.0", "427.31", "V10.42", "272.0", "250.00", "E879.2", "403.91", "V45.82", "414.00", "530.81", "V45.81", "428.0" ]

icd9cm

[ [ [] ] ]

[ "45.43", "99.04" ]

icd9pcs

[ [ [] ] ]

8751, 8824

5084, 7125

275, 299

9064, 9327

3361, 5061

9845, 10310

2814, 2866

7631, 8728

8845, 9043

7151, 7608

9351, 9822

2409, 2692

2881, 3342

230, 237

327, 2034

2078, 2386

2708, 2798

13,398

134,939

8085

Discharge summary

report

Admission Date: [**2153-3-25**] Discharge Date: [**2153-4-3**] Date of Birth: [**2087-4-19**] Sex: F Service: CARDIOTHORACIC Allergies: Tetracycline Analogues / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 1283**] Chief Complaint: Decreased exercise tolerance with dyspnea on exertion Major Surgical or Invasive Procedure: Redo Aortic Valve Replacement (21mm SJM mechanical valve) and Ascending Aorta Replacement (22mm gelweave graft) on [**2153-3-28**] History of Present Illness: 65 y/o female s/p Aortic Valve Replacement (mechanical) on [**2138-1-23**] who been followed by routine echo's who has noticed decreased exercise tolerance with dyspnea on exertion. Along with chest tightness with exertion over the past 6 months. Also had an episode of CHF with hospital admission in [**7-31**] and following caridac cath in [**1-29**]. Most recent echo revealed severe prosthetic valve AS. Cath confirmed AS and revealed a dilated Ascending aorta. CT was then done and showed a 4.9 x 5.3cm ascending aorta. She presented to [**Hospital1 18**] on [**3-25**] for anticoagulation with heparin, after holding her coumadin, for a planned AVR and ascending aortic replacement on [**3-28**]. Past Medical History: s/p Aortic Valve Replacement (21mm [**Company 1543**]-[**Doctor Last Name **]) [**2138-1-23**] Hypertension Congestive Heart Failure Chronic Obstructive Pulmonary Disease Peptic Ulcer Disease Obesity h/o Small Bowel Obstruction s/p lysis of abd. adhesions [**2145**] Arthritis Former Tobacco Abuse Abd./Incisional Hernia s/p Cholecystectomy s/p Hysterectomy s/p Hiatal Hernia Repair s/p left total knee arthroplasty [**4-29**] complicated by staph. septic arthritis s/p debridement [**6-29**] s/p R shoulder [**Doctor First Name **]. Social History: Quit smoking 15 yrs ago after 1ppd x 25 yrs. Drinks several beers/day. Lives alone Family History: Non-contributory Physical Exam: VS: 72 16 130/88 134/90 5'3" 224# General: WD/WN obese female in NAD HEENT: NC/AT, EOMI, PERRL, OP Benign Neck: Supple, FROM, -JVD, -Adenopathy, -thyromegaly, -carotid bruits Chest: CTAB -w/r/r, well-healed sternal incision Heart: RRR, +S1S2 with 2/6 SEM, -radiation Abd: Soft, NT/ND, +BS, obese, multi well-healed incisions Ext: Warm, well-perfused, 1+ edema, mild varicosities Neuro: Non-focal, A&O x 3, MAE Pertinent Results: Carotid U/S [**3-26**]: Normal carotid study. Echo [**3-28**]: Prebypass: There is moderate symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal(LVEF>55%). The ascending aorta is moderately dilated. There are simple atheroma in the descending thoracic aorta. A mechanical aortic valve prosthesis is present. The transaortic gradient is higher than expected for this type of prosthesis. There is severe aortic valve stenosis. Mild to moderate ([**11-27**]+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. Post Bypass: LV and RV function somewhat depressed EF 45 %. Mechanical valve seen in the aortic position. Leaflets move well and the valve is well seated. Trace aortic regurgitation present. Trace mitral regurgitation present. CXR [**3-30**]: Enlargement of the postoperative cardiomediastinal silhouette is stable since [**3-29**], pulmonary vascular engorgement persists but consolidation at the right lung base has improved. There is no appreciable pleural effusion or indication of pneumothorax. Right internal jugular vascular introducer tip projects over the brachiocephalic vein. No pneumothorax [**2153-3-25**] 05:00PM BLOOD WBC-7.7 RBC-4.08* Hgb-11.6* Hct-35.2* MCV-86 MCH-28.4 MCHC-32.9 RDW-15.5 Plt Ct-235 [**2153-3-29**] 03:01AM BLOOD WBC-14.6* RBC-3.99* Hgb-11.4* Hct-32.7* MCV-82 MCH-28.6 MCHC-34.8 RDW-16.9* Plt Ct-139* [**2153-4-1**] 04:43AM BLOOD WBC-7.4 RBC-3.37* Hgb-9.4* Hct-29.0* MCV-86 MCH-28.0 MCHC-32.5 RDW-17.0* Plt Ct-125*# [**2153-3-25**] 05:00PM BLOOD PT-17.2* PTT-21.7* INR(PT)-1.6* [**2153-3-28**] 05:36AM BLOOD PT-12.7 PTT-46.1* INR(PT)-1.1 [**2153-4-1**] 10:30AM BLOOD PT-13.1 PTT-28.9 INR(PT)-1.1 [**2153-3-25**] 05:00PM BLOOD Glucose-107* UreaN-17 Creat-0.8 Na-140 K-3.4 Cl-100 HCO3-28 AnGap-15 [**2153-4-1**] 04:43AM BLOOD Glucose-90 UreaN-24* Creat-1.3* Na-136 K-4.0 Cl-97 HCO3-31 AnGap-12 [**2153-3-26**] 12:56PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG Brief Hospital Course: Ms. [**Known lastname 20915**] presented to [**Hospital1 18**] on [**3-25**] in order to start a heparin drip for anticoagulation after discontinuing coumadin, prior to surgery. On [**3-28**] she underwent an elective redo AVR and ascending aortic replacement, which she tolerated well (see Op Note). Post-operatively, she was transferred to the cardiac intensive care unit in stable condition. She was weaned from vasopressor support, extubated without event, and transferred out of the cardiac intensive care unit to the floor. She would remain in stable condition throughout her hospital course. She was restarted on coumadin, and also a heparin drip until therapeutic on heparin. She was soon out of bed and ambulating. Her wound appeared to be healing well throughout her hospital course, and her sternum exhibited no signs of instability. With her INR at 2.0, and on a 3 mg/day dose of Coumadin, she was discharged in good condition. She will follow-up with Dr. [**Last Name (Prefixes) **] within the next month for post-operative evaluation. 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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. 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* 5. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Conjugated Estrogens 0.625 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Trazodone 100 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:*30 Tablet(s)* Refills:*2* 9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 2 weeks. 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 11. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day for 2 days: then INR to be drawn and called to Dr.[**Name (NI) 28872**] office for continued dosing. Disp:*120 Tablet(s)* Refills:*0* 12. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 **] vna Discharge Diagnosis: Prosthetic Aortic Stenosis/Ascending Aortic Aneurysm s/p Redo Aortic Valve Replacement (mechanical) and Ascending Aorta Replacement Hypertension Congestive Heart Failure Chronic Obstructive Pulmonary Disease Peptic Ulcer Disease Discharge Condition: stable/good Discharge Instructions: You may take shower. Wash incisions with water and gentle soap and pat dry. Do not apply lotions, creams, ointments, or powders to incision. Do not drive for 1 month. Do not lift more than 10 pounds for two months. If you develop a fever, or notice redness or drainage from incisions please contact office immediately. [**Last Name (NamePattern4) 2138**]p Instructions: Dr. [**Last Name (Prefixes) **] in 4 weeks Dr. [**Last Name (STitle) 2912**] in [**12-29**] weeks Dr. [**First Name (STitle) **] in [**11-27**] weeks

[ "278.00", "428.30", "424.1", "V58.61", "496", "416.8", "V58.83", "429.4", "441.2", "401.9", "428.0" ]

icd9cm

[ [ [] ] ]

[ "88.72", "38.45", "99.04", "35.22", "39.61" ]

icd9pcs

[ [ [] ] ]

7095, 7146

4463, 5522

365, 497

7418, 7431

2366, 4440

1903, 1921

5545, 7072

7167, 7397

7455, 7775

7826, 7978

1936, 2347

272, 327

525, 1230

1252, 1787

1803, 1887

17,212

123,000

7055+7056

Discharge summary

report+report

Admission Date: [**2191-5-23**] Discharge Date: [**2191-5-30**] Date of Birth: [**2142-7-25**] Sex: M Service: Coronary Care Unit CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old gentleman transferred from [**Hospital3 **] for shortness of breath. The patient had been in his usual state of health until 10 days prior to admission when he developed general malaise. He then took a trip to [**State 531**] within the last few days prior to admission. A couple of days prior to admission, the patient described increased shortness of breath. The patient states that he felt extremely weak and could only walk 400 feet to 500 feet before experiencing extreme shortness of breath. The patient had a computed tomography at [**Hospital3 **] which revealed a right lower pulmonary embolism along with a pericardial effusion. The patient had been concerned with starting heparin. The patient was transferred to [**Hospital1 188**] for further evaluation. Initially on the floor, the patient was noted to have a heart rate in the 150s, his blood pressure was 110/60s, and was mentating without difficulty. Upon arrival here, the patient was also noted to be in atrial flutter with a systolic blood pressure of 110. He was sweaty and clammy. The patient received diltiazem times two and converted to a normal sinus rhythm. PAST MEDICAL HISTORY: The patient's past medical history is otherwise significant for a history of back surgeries; cervical surgery times two. ALLERGIES: He has no known drug allergies. MEDICATIONS ON ADMISSION: Ambien as needed. SOCIAL HISTORY: The patient is married with three children. No tobacco. No ethanol. He does have significant second hand smoke exposure. FAMILY HISTORY: His father had a history of stroke at the age of 75. REVIEW OF SYSTEMS: Review of systems was completely negative. PHYSICAL EXAMINATION ON PRESENTATION: The patient's temperature was 98 degrees Fahrenheit, his blood pressure was 127/83, his pulse was 103, his respiratory rate was 17, and he was saturating 98% on 3 liters. In general, the patient was a very pleasant middle-aged gentleman. He was lying in bed in no acute distress. Head, eyes, ears, nose, and throat examination revealed normocephalic and atraumatic. The pupils were equal, round, and reactive to light. The extraocular movements were intact. The oropharynx was clear. The mucous membranes were moist. The neck was supple and obese. Cardiovascular examination revealed normal first heart sounds and second heart sounds. There were somewhat distant heart sounds. The lungs were clear to auscultation bilaterally/anteriorly. The abdomen was obese, soft, nontender, and nondistended. There was no hepatosplenomegaly. The extremities revealed no clubbing or cyanosis. There was trace bilateral pedal edema. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories from the outside hospital revealed his white blood cell count was 12.8, his hematocrit was 36.8, and his platelet count was 346. Sodium was 138, potassium was 4.3, chloride was 102, bicarbonate was 28, blood urea nitrogen was 15, creatinine was 0.9, and blood glucose was 106. His creatine kinase was 387, his MB was 18, BMP was 36.9, and his troponin was 0.01. Outside hospital, right lower lobe filling defect, consistent with pulmonary embolism. PERTINENT RADIOLOGY/IMAGING: An electrocardiogram revealed atrial flutter at a rate of 161. SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1. CARDIOVASCULAR EXAMINATION ISSUES: On [**2191-5-23**] the patient underwent a transthoracic echocardiogram which revealed an ejection fraction of greater than 55%, left atrium was normal in size, right atrium was normal in size, and his left ventricular ejection fraction was greater than 55%, normal right atrium, aortic valve was structurally normal, mitral valve was structurally normal, moderate to large size pericardial effusion. No echocardiographic signs of tamponade. Significant respiratory variation and mitral and tricuspid valve flow. The patient was taken to the Coronary Care Unit. The patient received liberal intravenous fluids. He was planned for a pericardial drainage as well as window placement. Pericardiocentesis was conducted on [**2191-5-24**]. Approximately 700 cc of sanguinous fluid was removed. The etiology was unclear. Viral cultures were negative at the time of this dictation. [**Location (un) **] virus was still pending. Human immunodeficiency virus negative. Antinuclear antibody negative. Microbiologic data was all negative. A pericardial window was placed on [**2191-5-25**]. The chest tube was discontinued on [**2191-5-28**]. Fluid and tissue were sent for biopsies and were positive for reactive changes. No evidence of malignancy or other organisms. The patient had a repeat echocardiogram performed on [**2191-5-30**] which revealed the following. No significant change compared to prior echocardiogram with the exception of resolution of moderate sized pericardial effusion, and the presence of only a physiologic pericardial effusion. The patient also underwent a cardiac catheterization on [**2191-5-24**] which revealed pericardial tamponade with no evidence of hemodynamically significant coronary artery disease. 2. PULMONARY EMBOLISM ISSUES: Per outside hospital, the patient had a pulmonary embolism per computed tomography angiogram. Heparin was held here given effusion and call for a repeat computed tomography scan. A repeat scan was done on [**2191-5-24**] which was negative for a pulmonary embolism. The scan was normal with the exception of a pericardial effusion. Oxygen saturations were on the low side. The patient had an oxygen requirement. However, by the time of discharge, the patient was stable on room air. A chest x-ray on the day of discharge revealed only a small pericardial effusion and bibasilar atelectasis. It was felt in retrospect that the patient had not had a pulmonary embolus. The patient had evidence of expiratory wheezes throughout his hospitalization. It was felt that the patient could have an element of chronic obstructive pulmonary disease secondary to extensive to second-hand smoke exposure. The patient was maintained on albuterol and Atrovent nebulizers while in the hospital and was discharged on albuterol meter-dosed inhaler. The patient was advised to have an appointment set up with his primary care physician within one week and then to have pulmonary function tests performed within six weeks of discharge. The patient was also to see his cardiologist within two weeks of discharge. 2. RHYTHM ISSUES: The patient was maintained in a normal sinus rhythm after his initial episode of atrial flutter which stabilized after he was maintained on diltiazem. Otherwise, the patient was maintained on Lopressor initially three times per day and then changed to Toprol-XL 200 mg one by mouth every day by the time of discharge. The patient was also maintained on aspirin. No heparin or other anticoagulation was initiated. 3. INFECTIOUS DISEASE ISSUES: The patient had an elevated white blood cell count with a temperature spike to 102 degrees Fahrenheit. All blood cultures and fluid cultures were negative at the time of this dictation. The patient was afebrile at the time of discharge for greater than 48 hours, and his white blood cell count normalized to approximately 13. MEDICATIONS ON DISCHARGE: (Included the following) 1. Aspirin 325 mg by mouth once per day. 2. Toprol-XL 200 mg by mouth once per day. 3. Albuterol meter-dosed inhaler 1 q.6h. as needed (for wheezing). DISCHARGE DIAGNOSES: 1. Pericardial effusion; status post tap and window placement. 2. Pleural effusion. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up with his primary care physician within this week. His primary care physician was also to set up pulmonary function tests within two months. 2. The patient was instructed to follow up with his cardiologist (Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] and Dr. [**Last Name (STitle) 171**] in two to three weeks (telephone number [**Telephone/Fax (1) 26353**] for an appointment). MAJOR SURGICAL/INVASIVE PROCEDURES PERFORMED: 1. Cardiac catheterization. 2. Status post pericardial tap and pericardial window and drainage. CONDITION AT DISCHARGE: Stable. The patient was stable on room air. He had no evidence of significant pericardial effusion, pericardial tamponade, or other cardiovascular abnormalities at the current time. The patient was able to ambulate with Physical Therapy without difficulty. He has had no recurrent chest pain or difficulties with ambulation. DISCHARGE STATUS: The patient was to be discharge to home. [**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3812**] Dictated By:[**Last Name (NamePattern1) 5843**] MEDQUIST36 D: [**2191-5-30**] 14:40 T: [**2191-5-31**] 11:57 JOB#: [**Job Number 26354**] Admission Date: [**2191-5-23**] Discharge Date: [**2191-5-30**] Date of Birth: [**2142-7-25**] Sex: M Service: CCU. HISTORY OF PRESENT ILLNESS: The patient is a 48 year old male who was transferred from [**Hospital3 **] with a pericardial effusion and question of pulmonary embolus. The patient reports that he had been dyspneic for about 10 days prior to admission. About ten days prior to admission, he developed symptoms of generalized malaise. The patient then went on a trip to [**Location 26355**], on return had noted increasing shortness of breath. This progressed to the point that the patient was able to walk only 400 to 500 feet before experiencing significant shortness of breath. The patient reports that prior to this, he had been in his usual state of health. He had an upper respiratory tract type infection approximately one month prior. Since this time, he has had a persistent cough. The patient presented to [**Hospital3 **] where a CTA showed a right lower lobe pulmonary embolus, in addition to a pericardial effusion. The patient was also noted to have a heart rate to the 150's and was transferred to [**Hospital1 346**] for further care. REVIEW OF SYSTEMS: The patient reported a history of a fast heart rate in the past few months, for which he has been told to lose weight but had reported to have a normal thyroid function. The patient also complained of some cough and vague epigastric discomfort but denied chest pain. The patient also complained of insomnia over the last several days but denied paroxysmal nocturnal dyspnea or orthopnea. The patient also complained of lower extremity swelling. PAST MEDICAL HISTORY: 1. Cervical disease status post surgery times two. ALLERGIES: No known drug allergies. MEDICATIONS: Ambien prn. SOCIAL HISTORY: The patient is married. He is a bar owner. He has three children. He denies tobacco, denies alcohol use; however, he does have a 25 year history of significant second hand smoke. FAMILY HISTORY: The patient reports that his father had a history of a stroke at age 75. PHYSICAL EXAMINATION: On admission, temperature was 98.0; blood pressure 127/83; pulse 103; respirations 17; saturating 98% on three liters. This was a pleasant, middle-aged gentleman, lying in bed in no acute distress. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements intact. Oropharynx clear. Cardiovascular revealed tachycardia but regular, somewhat distant heart sounds but normal S1 and S2. Lungs were notable for decreased breath sounds at the bases but otherwise clear. Abdomen was soft, nontender, nondistended, with good bowel sounds. The extremities were warm and well perfused with trace bilateral lower extremity edema. LABORATORY DATA: On admission, white count was 17.8; hematocrit of 36.8. CK was 387. MB 18. Troponin less than 0.01. HOSPITAL COURSE: 1. Pericardial effusion: The patient was found to have a large pericardial effusion, without evidence of tamponade. He had a pulse of 25, measured both by A line as well as by non invasive blood pressure cuff. The patient's pericardial effusion was drained in the catheterization laboratory, with the placement of a pig tail catheter on the morning of [**5-24**]. At this time, 700 cc of sanguinous fluid was removed. The patient's pig tail catheter stopped draining fluid on the subsequent day. Transthoracic echo revealed clot versus fluid. On [**5-25**], the patient was taken to the operating room for a pericardial window and biopsy. The patient tolerated these procedures well and his chest tube and pericardial tube drains were discontinued on [**2191-5-28**]. The patient will have a repeat echocardiogram on [**2191-5-30**] to ensure adequate resolution of his pericardial effusion. After drainage of the pericardial effusion, the patient's pulsus resolved. The patient had cultures both from original placement of the pigtail catheter as well as at the time of the pericardial window. The cultures showed polys but no organisms and all cultures remained no growth to date. The sample sent for cytology revealed inflammatory changes but no evidence for infection and no evidence for malignancy. The etiology of the patient's pericardial effusion was deemed likely to be viral, although malignant effusion was also considered. On chest CT, the patient had no evidence of lymphadenopathy and no lung nodules. [**Location (un) **] virus and HIV were pending at the time of this discharge summary. The patient will follow-up with cardiology for further monitoring. 2. Respiratory: The patient had a persistent oxygen requirement during his hospitalization. Per outpatient hospital CTA, he was reported to have a right lower lobe pulmonary embolus. The scans accompanied the patient and radiology at [**Hospital1 69**] felt that this was an inaccurate read of the original scan. The patient had a repeat CT angiogram to assess for pulmonary embolus. The patient had a negative CT angiogram on [**5-24**]. A repeat chest CT performed on [**5-27**] confirmed interval increase of bilateral pleural effusions. There was no evidence for pneumonia on chest x-ray nor on chest CT. The patient's oxygen saturations improved with incentive spirometry and increased ambulation. The patient will be followed closely as an outpatient and should have further pulmonary testing performed as an outpatient. 3. Cardiac rhythm: The patient was admitted in atrial flutter, with a rate in the 150's. The patient had an episode of diaphoresis during this and received Diltiazem with return to sinus rhythm. The patient had no further episodes of atrial flutter on this admission. The patient did have sinus tachycardia of unclear etiology. His thyroid function tests were normal and there was no evidence of a pulmonary embolus. The patient was rate controlled with Lopressor which was titrated to blood pressure and rate. The patient was started on aspirin given his history of atrial flutter. 4. Infectious disease: The patient was admitted with an elevated white count and had a temperature spike to 102. The patient had cultures which all remained no growth to date at the time of this discharge summary. His temperature curve and his white blood cell count were trending down at the time of discharge and he remained off antibiotics. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: 1. Pericardial effusion. 2. Pleural effusion. 3. Atrial fibrillation. MEDICATIONS ON DISCHARGE: 1. Aspirin 325 mg q. day. 2. Toprol XL 150 mg q. day. 3. Ambien prn. FOLLOW-UP PLANS: The patient will follow-up with his primary care physician in the week following discharge. In addition to this, the patient will follow-up with Dr. [**Last Name (STitle) 911**] and Dr. [**Last Name (STitle) 171**] of cardiology. DR [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **] 12.932 Dictated By:[**Name8 (MD) 12502**] MEDQUIST36 D: [**2191-5-29**] 04:59 T: [**2191-5-31**] 08:02 JOB#: [**Job Number 26356**]

[ "427.31", "428.0", "427.32", "423.9", "511.9", "496" ]

icd9cm

[ [ [] ] ]

[ "37.0", "37.21", "88.55", "38.91", "37.12" ]

icd9pcs

[ [ [] ] ]

11106, 11180

15547, 15621

15647, 15720

1607, 1626

11998, 15463

7790, 8402

3525, 7442

11203, 11981

8417, 9224

15738, 16228

10303, 10751

165, 187

9253, 10283

10773, 10890

10907, 11089

15488, 15526

2,712

198,266

1159

Discharge summary

report

Admission Date: [**2101-2-10**] Discharge Date: [**2101-2-15**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 689**] Chief Complaint: Hyperglycemia Major Surgical or Invasive Procedure: None History of Present Illness: Patient is an 86 y/o male with type II diabetes, CAD, CHF EF 25%, AVR, CRI who presents to outpt cardiac clinic in reported rapid atrial fibrillation and hyperglycemia. Patient was sent to the ED and rapid afib resolved but patient found with blood sugar > 600. Patient urine ketones were negative and mentating normally. Patient got 1L NS in the ED and sent to the [**Hospital Unit Name 153**] for glucose management. Patient states that he has no CP, or palpitations. Denies any SOB, fever, chills. Denies any n/v. Patient states that his urination has increased and he is "very thirsty." Patient states that he has been compliant on all his medication but has been eating a lot of sweets over the holidays. . ROS: Patient complaining of bilateral leg cramping in the calf. Past Medical History: -Atrial fibrillation -AMI - Anterior wall MI in [**2088**] -> cath revealed LAD disease -> CABG. -Aortic stenosis - Found at the same time as his AMI - presented with syncope, angina, found to have valve area of 0.9 cm squared. Got a bovine aortic valve replacement -CHF (EF25%) -CRI (baseline 1.3-1.5) -s/p pacer ([**8-/2100**]) for tachy-brady syndrome -Nephrolithiasis - [**2081**], [**2096**]. -BPH, s/p TURP [**2077**]. -Macular degeneration - cecreased vision in L eye. -Benign colonic polyps, s/p polypectomy. -shingles/postherpetic neuralgia -Diabetes type 2 Social History: Mr. [**Known lastname 7435**] is a recent widow and lives alone in [**Location (un) 4628**]. Has 5 children who live close by. He used to work as a butcher. He denies any history of smoking, and drinks approximately one drink per night but none since [**Month (only) 116**]. He denies any illicit drug use. Family History: His father died at the age of 63 from liver and rectal cancer (colon ca. metastatic to liver?). His mother died of alzheimer's disease at 63. He doesn't know of any coronary disease, but his brother recently died at the age of 86 - he had CHF. Physical Exam: Exam on admission: T 96.5 BP 102/63 HR 73 RR 18 O2Sat 96% Gen: Patient appears in pain from leg cramp Heent: PERRL, EOMI, OP clear, MMM Neck: No LAD, JVP at 8cm Cardiac: Irregularly Irregular, S1/S2 no murmurs Lungs: Slight crackles at right base o/w clear Abdomen: Soft, NTND NABS Ext: no edema, tender to palpation, no ulcers on feet Neuro: AAOx3 Pertinent Results: Labs on admission [**2-10**]: WBC 6.7, Hgb 15.6, Hct 44.9, MCV 90, Plt 162 (diff: Neuts 69.9, Lymphs 22.0, Monos 7.1, Eos 0.8, Baso 0.1) PT 37.9*, INR(PT) 11.7 Na 127, K 5.5, Cl 87, HCO3 20, BUN 50, Cr 1.6, Glu 672 LDH 405, Ca 9.9, [**Doctor Last Name **] 4.8, Mg 2.0 proBNP 6327* . Cardiac enzymes: [**2101-2-10**] 04:26PM BLOOD CK-MB-10 cTropnT-0.09* [**2101-2-10**] 09:50PM BLOOD CK-MB-9 cTropnT-0.09* CK(CPK)-112 [**2101-2-11**] 04:18AM BLOOD CK-MB-11* MB Indx-3.6 cTropnT-0.08* CK(CPK)-302* . Labs on discharge: WBC 8.3, Hgb 14.8, Hct 43.0, MCV 92, Plt 160 (diff: Neuts-83.3* Lymphs-10.9* Monos-4.9 Eos-0.7 Baso-0.3) PT 25.0, PTT 35.5, INR(PT) 4.6 Na 132, K 4.7, Cl 95, HCO3 28, BUN 24, Cr 1.4, Glu 111 Ca 9.7, Phos 2.9, Mg 1.9 . MICRO: [**2-10**]: blood cx NGTD x2 [**2101-2-10**] 10:11 pm URINE **FINAL REPORT [**2101-2-12**]** URINE CULTURE (Final [**2101-2-12**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [**2101-2-15**]: urine cx PND . IMAGING: [**2-11**] CXR: Cardiac and mediastinal contours are stable. Permanent pacemaker remains in satisfactory position. The lungs are grossly clear except for a calcified granuloma at the left apex. There is minimal blunting of the left costophrenic sulcus laterally, most likely due to pleural thickening and less likely due to pleural effusion. . [**2-10**] CXR: Cardiac and mediastinal contours are stable with mild cardiomegaly. The aorta is calcified. There is a single-lead left-sided pacemaker in place with its tip in the right ventricle, unchanged. The patient is post-median sternotomy and aortic valve replacement. The lungs appear clear. Small pleural effusion seen on the prior study at the left costophrenic angle has since resolved. There is minimal blunting, possibly due to pleural thickening. Pulmonary vasculature is normal and there is no pneumothorax. Calcification is seen of the mitral annulus. Several healed/healing left posterior rib fractures are seen. IMPRESSION: No CHF or pneumonia. Brief Hospital Course: ## Hyperglycemia - Mr. [**Known lastname 7435**] was started on an insulin drip to help bring his elevated blood glucose under control. On hospital day #2, the insulin drip was discontinued and he was able to be maintained on a HISS. Once his insulin drip was discontinued, he was also able to be transferred out of the ICU and to a medicine floor. With his history of CRI, the team decided that glipizide would be better than glyburide so he was started on glipizide 5mg PO BID and his glyburide was discontinued. He received volume resuscitation while in the ICU, but due to his h/o CHF and an EF of 25%, his IVF were discontinued once he was taking adequate POs on the floor. However, his Cr began to rise and his electrolytes on hospital day #4 were consistent with hypovolemia, possibly due to persistent hyperglycemia and glucosuria, so he received 1L NS at 100/hr and had his electrolytes rechecked. They were unchanged, so he was continued on IVF overnight until the liter was completed. Electrolytes were slightly better the following morning, but his Cr remained elevated as did his glucose. Additional fluids were given and repeat lytes showed a Na of 129, no change in his Cr (still 1.5), and his glucose remained elevated. His IVF were discontinued. Repeat UA was checked and showed a glucose of 250 in his urine. He had been receiving approximately 16u of Humalog daily for elevated fingersticks, so he was started on 20u of Lantus at night on hospital day #5 to attempt to bring his glucose under better control. His FS were improved on Lantus, without any low values, so he was discharged on daily Lantus with strict instructions to check his FS TID to monitor for low levels. . ## UTI - On admission, a urinalysis was done and a UTI was identified. Mr. [**Known lastname 7435**] was started on a 7 day course of Bactrim empirically. Urine culture was contaminated (mixed flora) so no organism was able to be identified originally. Bactrim was discontinued on [**2101-2-14**] and he was started on cipro instead as we were concerned that Bactrim was responsible for his elevated Cr. Repeat UA on [**2101-2-14**] was concerning for acute interstitial nephritis and possibly persistent UTI. Urine eos were sent and were positive. Repeat urine cx is pending on discharge. . ## CHF - He was continued on Toprol XL and digoxin originally and his diuretics were held as he was in need of volume repletion. On hospital day #2, he developed rapid atrial fibrillation and his Toprol XL was changed to metoprolol for [**Hospital1 **] dosing and better rate control. He was well rate controlled on this dose. He had no problems with SOB or edema during his hospitalization. He tolerated his IVF infusions well, without any evidence of CHF. On discharge, he was switched back to his Toprol XL. . ## CAD - He was continued on his statin, ASA and bblocker (changed from Toprol XL to metoprolol [**Hospital1 **] as stated above during his hospitalization). Per the patient and his daughter, he is no longer taking the ASA (both were unclear why) so the patient refused the ASA during his hospital stay. His cardiac enzymes were cycled on admission and revealed a slight elevation in his troponins (peak 0.09), CK-MB (peak 11), and CK (peak of 302). They all trended down by hospital day #3. He denied any chest pain, pressure or palpitations. It was felt to most likely be some demand ischemia because of his rapid rate. EKGs were unchanged from his baseline. . ## Afib - On admission, he was in good rate control, but on hospital day #2, he developed a rapid rate overnight. He was given a dose of IV lopressor x1 and his toprol XL was changed to [**Hospital1 **] metoprolol with good results. His rate came back down to the 80s-100s by hospital day #3, though he did remain in atrial fibrillation. His INR was elevated on admission (11.7) so his coumadin was held until hospital day #3 when his INR was 2.7. He was restarted on coumadin 2.5mg PO QHS as that is the most recent dose he was taking at home. His coumadin dose was changed on 2mg on hospital day #5 as his INR went up to 3.0, then 4.6. On discharge, he was advised NOT to take any Coumadin until he follows up with his PCP. . ## Post-herpetic neuralgia - He was continued on his outpatient dose of cymbalta. . ## Leg cramps - His cramps were felt to likely be from dehydration, but he was started on quinine as well to help with the pain. He no longer had leg cramps on the day of discharge, so he was not continued on quinine upon discharge. . ## CRI - His Cr on admission was elevated at 1.6. He was given IVF and it came down to 1.1 but then trended back up to 1.5. It remained at 1.5 despite attempts at fluid resuscitation, so the team began to look at other causes, including medications. He had been started on Bactrim during his stay, and his UA was consistent with AIN, so Bactrim was discontinued and he was started on cipro instead. His Cr on discharge was 1.4. . ## FEN - He was given IVF for volume repletion. He was put on [**First Name8 (NamePattern2) **] [**Doctor First Name **], low salt, heart healthy diet. His electrolytes were checked daily and were repleted as needed. . ## PPx - He was given heparin SC for DVT prophylaxis. No GI prophylaxis was indicated, but he was started on a bowel regimen as he had not had a bowel movement in several days. . ## Dispo - To home, with PT x1 for home safety evaluation and VNA for diabetes education. Medications on Admission: Digoxin 0.125 mg qd, Toprol XL 25mg daily Spironolactone 25 mg [**Hospital1 **], Atorvastatin 10 mg qd, warfarin ECASA 325 mg qd, amoxicillin dental prophylaxis. Glyburide 5 mg qd, Cymbalta 60 mg qam and 30 mg qpm. Furosemide 20 mg qd. Discharge Medications: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO QAM (once a day (in the morning)). 4. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO QPM (once a day (in the evening)). 5. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 days. Disp:*4 Tablet(s)* Refills:*0* 7. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous at bedtime. Disp:*1 months supply* Refills:*2* 11. Outpatient Lab Work Please go to your PCP's office and have the following labwork done: 1. Chem 7 and INR 2. urinalysis Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary diagnosis: Hyperglycemia Atrial fibrillation Acute on chronic renal insufficiency Acute interstitial nephritis Secondary diagnosis: CHF CAD BPH Post-herpetic neuralgia Type II DM Macular degeneration Discharge Condition: Good. Afebrile, BP 114/68, HR 108. Discharge Instructions: 1. Please call your PCP or go to the ER if you develop fever >101, chills, shortness of breath, difficulty breathing, chest pain, chest pressure, rapid heart rate, palpitations, or any other worrisome symptoms. lbs. 3. Please adhere to a low salt (<2 gm sodium), diabetic, heart healthy diet. 4. Please check your fingersticks 3-4x every day. 5. Please follow up with Dr. [**Last Name (STitle) 2204**] later this week. 6. Several medications have been changed. Please STOP taking glyburide and instead take glipizide twice a day for your diabetes. You also have a new medication for your diabetes, a long acting insulin called Lantus. It is taken once a day, usually at night. Please hold off on taking lasix or spironolactone until further notice by your PCP. [**Name10 (NameIs) 2172**] INR is still elevated, so please do NOT take Coumadin until Dr. [**Last Name (STitle) 2204**] advises you to do so. 7. Please complete the course of Ciprofloxacin for your urinary tract infection (2 more days). Followup Instructions: 1. Please follow up with Dr. [**Last Name (STitle) 2204**] this week. His office will call you and give you the date of your appointment. You need to have your labs checked (electrolytes, BUN/Cr, and INR) and a repeat urinalysis on WEDNESDAY, prior to your visit. Dr. [**Last Name (STitle) 2204**] will need to decide at your appointment if you can restart your diuretics (lasix and spironolactone). 2. Please call [**Last Name (un) **] Diabetes Center to schedule an appointment as a new patient. The number for their clinic is [**Telephone/Fax (1) 2384**]. 3. The VNA will visit you on Thursday to do a PT evaluation.

[ "585.9", "584.5", "250.02", "V42.2", "053.19", "427.31", "599.0", "362.50", "428.0", "424.1", "600.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11618, 11675

4744, 10175

275, 281

11928, 11965

2655, 2938

13012, 13635

2022, 2270

10462, 11595

11696, 11696

10201, 10439

11989, 12989

2285, 2290

2955, 3153

222, 237

3172, 4721

309, 1088

11837, 11907

11715, 11816

2304, 2636

1110, 1680

1696, 2006

45,783

139,015

1349

Discharge summary

report

Admission Date: [**2136-6-6**] Discharge Date: [**2136-6-13**] Date of Birth: [**2067-4-8**] Sex: M Service: MEDICINE Allergies: Betadine Attending:[**First Name3 (LF) 898**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: 69yo male with history of metastatic prostate cancer was admitted from the Emergency Department with hypotension. . He reports that he has had increasing weakness over the last one week with difficulty taking more than three steps. Associated symptoms include fatigue and light-headedness. He initially presented to his PCP's office on the day of admission with blood pressure of 80/palp. He was then transferred to the Emergency Department. . Upon arrival in the ED, temp 98.2, BP 80/48, HR 106, RR 17, and pulse ox 98% on room air. While in the ED he received ~ 3L NS with transient improvement in his blood pressure to 101/51, although his BP again declined to 80s/60s. He also received compazine 10mg PO x 1 and morphine 2mg IV x 1. Past Medical History: - Metastatic prostate cancer (diagnosed in mid1-[**2117**]'s) to the spine with history of cord compression, status-post radical prostatectomy, radiation therapy, steroid therapy, and chemotherapy with mitoxantrone, taxotere +/- avastin, and multiple hormonal therapies including Premarin and ketoconazole. . - RP fibrosis s/p bilateral percutaneous nephrostomy and revision on the left - Recurrent DVT and had an IVC filter placed [**2-13**] - Type 1 diabetes mellitus - Hypertension - H/o urinary incontinence s/p artificial sphincter - Herpes simplex virus stomatitis - Radiation esophagitis - Multifocal atrial tachycardia - History of cervical spinal stenosis as well as chronic low back pain and facet arthropathy; previously followed in the [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] Clinic where cervical epidural steroid injections last summer showed improvement but thoracic and lumbar injections exacerbated his pain. - S/p vertebroplasty at T10 to L1 for tumor invasion of the vertebral bodies - upper GI bleed ([**2134**]) - History of DVT previously on coumadin but stopped "a while ago" after 6 months (per pt) due to difficulty controlling levels - systolic CHF related to chemotherapy drugs, EF 45% - Status-post T8 kyphoplexy, [**11/2135**] - DVT [**3-/2136**] put on warfarin Social History: Social history is significant for the absence of current tobacco use. Pt quit smoking in [**2119**] wth a history of 45-pack-year. There is no history of alcohol abuse. The patient is a retired software engineer who lives in [**Location 8242**] with his wife. His two sons and one daughter live nearby. Family History: Uncle with prostate cancer. No family history of premature coronary artery disease or sudden death. Physical Exam: Gen: fatigued appearing, no acute distress, resting comfortably in bed HEENT: Clear OP, dry mucous membranes NECK: Supple, No LAD, No JVD CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops LUNGS: CTA, BS BL, No W/R/C ABD: Soft, NT, ND. NL BS. No HSM EXT: 2+ pitting edema bilaterally with left leg > right BACK: nephrostomy tube sites draining without evidence of purulence or drainage through dressings SKIN: No lesions NEURO: A&Ox3. Appropriate. CN 2-12 intact. 5-/5 upper extremity strength; [**3-8**] lower extremity strength bilaterally and symmetric. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: Admission labs: [**2136-6-6**] 02:10PM BLOOD WBC-10.7 RBC-2.64* Hgb-8.0* Hct-24.1* MCV-91 MCH-30.4 MCHC-33.4 RDW-15.2 Plt Ct-241 [**2136-6-6**] 02:10PM BLOOD Neuts-94.0* Lymphs-3.4* Monos-2.0 Eos-0.4 Baso-0 [**2136-6-6**] 02:10PM BLOOD PT-17.2* PTT-26.7 INR(PT)-1.6* [**2136-6-6**] 02:10PM BLOOD Glucose-315* UreaN-48* Creat-2.4*# Na-114* K-4.9 Cl-88* HCO3-19* AnGap-12 [**2136-6-7**] 01:26AM BLOOD Calcium-8.0* Phos-3.7 Mg-2.1 [**2136-6-7**] 01:26AM BLOOD Cortsol-25.5* [**2136-6-7**] 01:26AM BLOOD Free T4-1.3 [**2136-6-7**] 01:26AM BLOOD TSH-4.6* [**2136-6-6**] 02:15PM BLOOD Lactate-1.7 . MRI C/T/L spine: No cord compression is seen. Multiple metastasis is noted. Degenerative changes in the cervical region with mild indentation on the spinal cord by bulging from to C4-C6-C7. Extensive bony involvement by metastasis of upper sacrum and both posterior iliac bones with postop possible soft tissue extension on the left side from the iliac metastasis. Retroperitoneal soft tissue prominence with bilateral dilated ureters. Further evaluation with abdominal and pelvic CT recommended. . CT Abd/PElvis: The lung bases demonstrate a small left greater than right pleural effusion. Heart size is normal. There is no pericardial effusion. The liver, gallbladder, spleen, adrenals, and pancreas are unremarkable. Bilateral percutaneous nephrouretral stents are noted in both kidneys. The left kidney has moderate cortical thinning and has decreased in size since [**2136-2-9**]. The kidneys enhance and excrete contrast symmetrically without hydronephrosis. Bilateral internal stents terminate in the distal bladder. The abdominal loops of large and small bowel are unremarkable without evidence of pneumatosis, free air or obstruction. There are numerous periaortic lymph nodes from the renal veins to the aortic bifurcation, which have slightly increased in size since [**2136-2-9**], for example, an aortocaval node measuring 2.4 x 1.3 cm measured 12 x 10 mm on [**2136-2-9**]. There is increased soft tissue density along the left greater sciatic foramen and asymmetry of the left musculature as well as increased bony destruction since [**2136-2-9**] with possible involvement of the left sciatic nerve. A penile implant and post prostatectomy clips somewhat limit evaluation of the distal ureters. Pelvic free fluid and adenopathy which have increased since [**2136-2-9**]. Bone windows demonstrate diffuse metastatic sclerotic disease which has increased in severity at the level of the pelvis but is otherwise similar since [**2136-2-9**]. Diffuse anasarca is noted. IMPRESSION: 1. Increased bony destruction and soft tissue extension of a metastatic disease to involve the left sciatic foramen. 2. Increased periaortic and pelvic nodes since [**2136-2-9**]. 3. Diffuse anasarca has increased since [**2136-2-9**]. 4. No evidence of hydronephrosis. There is moderate cortical thinning of the left kidney since [**2136-2-9**]. . Scrotal U/S: Diffuse scrotal soft tissue edema, without fluid collection seen. Normal exam of the underlying testes. . Discharge labs: [**2136-6-13**] 05:35AM BLOOD WBC-7.7 RBC-3.66* Hgb-10.9* Hct-32.8* MCV-90 MCH-29.7 MCHC-33.2 RDW-15.5 Plt Ct-203 Brief Hospital Course: ASSESSMENT / PLAN: 69yo male with metastatic prostate cancer was admitted from the ED with hypotension, weakness, and acute renal failure. . # Hypotension: He was initially admitted to MICU and IV fluid rescusitated. Etiology of his hypotension appears most likely related to sepsis with genitourinary source vs hypovolemia in the setting of dehydration. UA with 11-20 WBCs and moderate bacteria therefore he was started on zosyn presumptively. Further management of UTI described below. Anti-hypertensives and narcotics intially held then restarted as tolerated. . # Urinary Tract Infection, Complicated: Urinalysis on admission with 11-20 WBC's and he was initially started on zosyn. This was narrowed to ciprofloxacin then urine culture subsequently grew STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA therefore he was narrowed further to Bactrim. He should continue to complete a 14 day course. . # Hyponatremia: Likely hypovolemic hyponatremia secondary to dehydration. Cortisol and thyroid functions tests were done to rule out hypothyroidism and adrenal insufficiency and these were normal. Sodium corrected to 128 with IVF resuscitation. . # Acute Renal Failure: Creatinine 2.4 on admission, trending down to baseline of 1.2 with IV fluid resuscitation. Etiology thought to be pre-renal from hypovolemia as well as UTI. Post-renal obstruction appears less likely given that nephrostomy tubes continue to drain. . # Weakness: Patient with history of metastatic prostate cancer with known thoracic and lumbar mets presented with 5 days of progressively worsening weakness. He had subjective weakness and numbness as well as objective asymmetrical weakness on exam. This is concerning for possible cord compression vs pathologic fracture. He admited to back pain, but this has been chronic and not worsened recently. He has chronic fecal incontinence which was unchanged. His functional status has severely declined over week prior to admission such that while he was able to ambulate a week ago, he can now not even lift his leg from bed . He underwent MRI T/L spine to r/o cord compression which was negative but subsequently had pelvic CT that did show pelvis mass impinging on sciatic nerve. He was started on IV steroids with improvement of symptoms. Radiation oncology was consulted for possible palliative radiation, but this was not able to be offered. He was offered rehab palcement, but preferred to go home with home PT given overlal prognosis. . # Metastatic Prostate Cancer: Patient follows with Dr. [**Last Name (STitle) **], and he unfortunately has been resistant to multiple therapies. He is no longer on active treatment. Dr. [**Last Name (STitle) **] continued to visit patient to discuss goals of care and palliative care consult was called. Patient wanted to transition to home hospice care. . # Type 1 Diabetes Mellitus: Most recent A1c in [**3-12**] was 8. Reportedly has had difficult to control diabetes with large variations in blood sugars. He was continued on insulin regimen with good control. . # Pain: Patient continued to have pain although tolerable level. He was continued on tylenol, MSContin and oxycodone for pain control. Palliative care was involved and assisted with ensuring adequate pain control. . # DVT: Patient with lower extremity DVT diagnosed in [**2136-3-4**]. Reportedly has had difficulty controlling level of anticoagulation with warfarin and refuses to use lovenox at home. INR on admission sub-therapeutic at 1.6 . He was continued on lovenox and coumadin until therapeutic then coumadin alone. . # Anasarca: Patient with pitting edema to knees bilaterally as well as scrotal edema likely secondary to low albumin and malnutrition. His albumin was low and ensure supplements were encouraged. He had [**Year (4 digits) **] consult and scrotal ultrasound to ensure there was no other etiology for scrotal edema. He was taking adequate Po's while inpatient. . # Chronic systolic heart failure (non-ischemic): Patient with an EF of 45% on his last TTE secondary to chemotherapy. Patient hypovolemic and hypotension on admission. Lasix was initially held then restarted as patient became anasarcic. Medications on Admission: 1. Cephalexin 500mg PO qid 2. Clonazepam .5mg PO qhs prn sleep 3. Econazole cream 4. Lantus 16 units qAM 5. Humalog sliding scale - 201-250 2u; 251-300 3 u; 301-350 4 u; 351-400 6 u 6. Leuprolide 22.5mg q 3 months 7. Lisinopril 5mg daily 8. Metoprolol Tartrate 50mg PO bid 9. MS Contin 00mg PO tid 10. Nystatin S+S 11. Oxycodone 60mg PO q4h prn pain 12. Pantoprazole 40mg PO daily 13. Prochlorperazine 10mg PO q6h prn nausea 14. Warfarin as directed 15. Acetaminophen prn 16. Aspirin 81mg PO daily 17. Bisacodyl prn 18. Docusate 100mg PO daily 19. Loperamide 20. Senna 1 tab daily prn constipation Discharge Medications: 1. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for anxiety, insomnia. 2. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18) units Subcutaneous qam. 3. Insulin Lispro 100 unit/mL Solution Sig: asdir per sliding scale Subcutaneous three times a day: with meals. 4. Leuprolide (3 Month) 22.5 mg Syringe Sig: One (1) Intramuscular q3mo. 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [**Year (4 digits) **]:*60 Tablet(s)* Refills:*0* 6. Nystatin 100,000 unit/mL Suspension Sig: One (1) PO three times a day: Swish and Spit . 7. Oxycodone 15 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. [**Year (4 digits) **]:*20 Tablet(s)* Refills:*0* 8. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. [**Year (4 digits) **]:*10 Tablet(s)* Refills:*0* 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 13. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 14. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO four times a day as needed for pain. 15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 16. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation. 17. Morphine 15 mg Tablet Sustained Release Sig: Three (3) Tablet Sustained Release PO Q8H (every 8 hours). [**Year (4 digits) **]:*21 Tablet Sustained Release(s)* Refills:*0* 18. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). [**Year (4 digits) **]:*7 Adhesive Patch, Medicated(s)* Refills:*0* 19. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days: Until [**6-23**]. [**Month/Year (2) **]:*20 Tablet(s)* Refills:*0* 20. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). [**Month/Year (2) **]:*90 Tablet(s)* Refills:*0* 21. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY (Daily). [**Month/Year (2) **]:*14 packets* Refills:*0* 22. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Month/Year (2) **]:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Primary: Hypotension Weakness Malnutrition Anasarca Metastatic Prostate Cancer History of DVT Secondary: Diabetes Mellitus, type 1 Coronary Artery Disease Chronic Systolic Heart Failure (EF 45%) Discharge Condition: Afebrile. Pain well-controlled Discharge Instructions: You were admitted to the hospital with low blood pressure and weakness. We gave you some IV fluids to improve your blood pressure. We also started you on antibiotics for urinary tract infection. We did an MRI which did not show compression of our spinal cord but did show a pelvic mass that is the likely reason for your weakness. You were started on steroids and symptoms improved. The following changes were made to your medications: 1) START lasix 20mg daily 2) START prednisone 60mg daily 3) STOP Keflex 4) START bactrim until [**2136-6-23**] 5) INCREASE Humalog sliding scale 6) INCREASE Lantus to 18U in the morning 7) HOLD lisinopril 8) DECREASE MS contin from 100mg to 45mg three times daily 9) DECREASE oxycodone to 30mg every 4 hours as needed for pain 10) START dilaudid 2mg every 4 hours as needed for pain 11) DECREASE metoprolol from 50mg to 25mg twice daily 12) START miralax 17 grams daily 13) START lidocaine patch daily Please call your PCP with any questions or concerns. Followup Instructions: An appointment was made for you with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Tuesday, [**6-19**] at 11am. You were started on lasix to help remove some of the extra fluid. You will need some labs drawn next week and to meet with your PCP to determine whether to continue this medication. Completed by:[**2136-6-23**]

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Discharge summary

report

Admission Date: [**2127-1-28**] Discharge Date: [**2127-2-4**] Date of Birth: [**2050-4-4**] Sex: F Service: CARDIOTHORACIC SURGERY HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is a 76-year-old female patient with increasing dyspnea on exertion. The patient was noted to have a significant murmur by physical exam, and echocardiogram showed significant aortic stenosis with aortic insufficiency, as well. The patient underwent cardiac catheterization at [**Hospital6 1109**] which revealed an LAD lesion of 60-70%, otherwise nonobstructive coronary artery disease. It also revealed an aortic stenosis with aortic valve area of 0.7 cm2. The patient was referred to Dr. [**Last Name (Prefixes) **] for aortic valve replacement. PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Hypertension. PREOP MEDICATIONS: 1. Lipitor 40 mg qd. 2. Atenolol 25 mg qd. 3. Tricor 160 mg qd. 4. Aspirin. 5. Tylenol. 6. Tums. ALLERGIES: The patient states no known drug allergies. PHYSICAL EXAMINATION UPON ADMISSION TO HOSPITAL: Unremarkable. HOSPITAL COURSE: The patient was admitted as an outpatient to the preoperative holding area. She went to the operating room on [**2127-1-28**] where she underwent coronary artery bypass graft x 1 with a LIMA to the LAD, as well as an aortic valve replacement with a #21 mm [**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial valve. Postoperatively, she was on Neo-Synephrine and propofol drip. She was transported from the operating room to the Cardiac Surgery Recovery Unit. Postoperative day #1, she remained fairly hypoxic, on mechanical ventilation, but was ultimately weaned and extubated. She remained on Nitroglycerin and insulin IV drips, was awake, alert and responsive. On postoperative day #2, she remained on Nitroglycerin for hypertension. Chest tubes were discontinued on postoperative day #2, and the patient remained hemodynamically stable. She also remained hypoxic at that time, and a pulmonary medicine consultation was obtained. It was their assessment that the patient had significant atelectasis and would benefit from aggressive pulmonary toilet. They also recommended bronchodilators, as well as diuresis as tolerated. On postoperative day #3, the patient was transitioned from her Nitroglycerin drip to captopril for hypertension, and she has tolerated this well. She had a PAO2 of 65 at that time, was begun on Lopressor, and mobility was being increased with cardiac rehabilitation guidelines. The patient had some transient confusion at nighttime in the first couple of nights in the Intensive Care Unit, but this cleared by postoperative day #3. The patient was transferred on postoperative day #3 from the Intensive Care Unit to the telemetry floor where she continued to progress with cardiac rehabilitation, physical therapy, and increased mobility. The patient remained in normal sinus rhythm with good vital signs. On postoperative day #5, the patient was progressing well, was on nasal cannula supplemental oxygen, was increasing ambulation and physical therapy, and continuing with Lopressor and lasix for diuresis. On postoperative day #4 and #5, the patient continued to progress with increasing mobility and gaining independence with ambulation. On postoperative day #7, today, [**2127-2-4**], the patient remains in good condition. She is hemodynamically stable. She is no longer requiring supplemental oxygen, and she is ready to be discharged home. PHYSICAL EXAMINATION TODAY: Vital signs are stable. Her weight today is 72.5 kg which is just up marginally from her preoperative weight of 71 kg. Lungs are clear to auscultation bilaterally. Her wound is clean, dry and intact. Her abdomen is soft, nontender, nondistended. She has 1+ pedal edema bilaterally. MOST RECENT LABORATORY VALUES: White blood cell count 11.4, hematocrit 28.5, platelet count 194, sodium 138, potassium 4.3, chloride 98, CO2 23, BUN 42, creatinine 1.1, glucose 133. She has a chest x-ray pending from today. Most recent chest x-ray prior to today is from [**2-1**] which showed patchy opacity in the left base presumed previously to be atelectasis which was improving by her x-ray on the 20 and, again, today's x-ray is pending. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg po qd. 2. Metoprolol 75 mg po bid. 3. Captopril 25 mg po tid. 4. Lipitor 40 mg po qd. 5. Tricor 160 mg po qd. 6. Percocet 5/325, 1-2 tablets po q 4-6 h prn pain. 7. Colace 100 mg po bid. 8. Lasix 40 mg po bid x 10 days. 9. Potassium chloride 20 mEq po bid x 10 days. FO[**Last Name (STitle) **]P: 1. The patient is to follow-up with Dr. [**Last Name (Prefixes) **] in approximately 1 month for a postoperative visit. 2. She is to follow-up with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 4640**], in [**2-14**] weeks. 3. She is to follow-up with her cardiologist in [**3-18**] weeks, as well. DISCHARGE CONDITION: Good. DISCHARGE DIAGNOSES: 1. Aortic stenosis, status post aortic valve replacement. 2. Coronary artery disease, status post coronary artery bypass graft. 3. Postoperative atelectasis. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 964**] MEDQUIST36 D: [**2127-2-4**] 10:57 T: [**2127-2-4**] 11:19 JOB#: [**Job Number 53836**]

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icd9cm

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Discharge summary

report

Admission Date: [**2106-11-25**] Discharge Date: [**2106-11-30**] Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5018**] Chief Complaint: CODE STROKE Major Surgical or Invasive Procedure: MERCI clot retrival from MCA History of Present Illness: Ms. [**Known lastname **] is an 88 year-old right-handed woman with a history of TIA and hypertension who presented with a right hemiparesis in the setting of newly-discovered atrial fibrillation for whom a code stroke was called. . According to the patient's daughter, Ms. [**Known lastname **] was acting normally on the morning of admission. She was last known well at about 2 pm when she went into her room to rest and watch televsion, which is her afternoon custom. At about 5 pm, Ms. [**Known lastname **] daughter visited the patient to provide her with evening medications. When she walked in, she discovered her mother had new right-sided weakness and was having trouble communicating verbally. Concerned her mother was having a stroke, the patient's daughter dialed 911 immediately. The patient was initially transported to [**Hospital3 **] where a non-contrast CT of the head was thought to be negative. An EKG demonstrated atrial fibrillation. She was mediflighted to the [**Hospital1 18**] for further evaluation and care. . At the time of her arrival, a code stroke was called. She was given an NIHSS score of 14 for loc questions (2), right facial palsy (2), right upper (3) and lower (3) extremity weakness, severe aphasia (2), and dysarthria (2). A CT demonstrated no clear evidence of a large vessel territorial infarct. A CTA of the head and neck was thought to show possible occlusion in the M2 segment of the left MCA with intact distal flow. CTP demonstrated increased mean transit time in the left MCA territory with relative preservation of blood volume compatible with region of penumbra. Although she was not considered a t-PA candidate due to symptom onset over four hours prior to arrival, she was rushed to angiography where MERCI clot retrieval was performed. Past Medical History: - TIA (dysarthria, completely resolved with no ongoing deficits) - HTN - colon cancer, s/p resection x 2 (no chemo/radiation), most recently complicated by PNA - hypothyroidism - cholcystectomy Social History: - widowed - lives with her daughter (she has her own apartment within the same complex) - her daughter helps with medication management - enjoys shopping Family History: - positive for aneurysm (father in 60s-70s) - negative for stroke Physical Exam: ON ADMISSION: Vitals: P: 65 R: 18 BP: 222/72 SaO2: 100 General: Awake. Eyes open Ext: right lower extremity is externally rotated NEUROLOGIC EXAMINATION: Mental Status: * Degree of Alertness: Awake * Language: Makes some incoherent vocalizations in response to questions. Pt able to correctly follow some midline (close your eyes) and appendicular (squeeze my hand) commands. Cranial Nerves: * II: PERRL 3 to 2 mm and brisk. Blinks to threat * III, IV, VI: EOMI. * VII: Right facial droop * VIII: Hearing intact to voice (turns to name, etc) Motor: * Tone: decreased in right extremities Strength: * Left Upper Extremity: able to lift versus gravity for at least ten seconds * Right Upper Extremity: offers no resistance to gravity; she does withdraw purposefully from nailbed pressure * Left Lower Extremity: able to lift versus gravity for at least ten seconds * Right Lower Extremity: withdraws (versus triple flexion) in response to nailbed pressure Reflexes: * Babinski: extensor right, flexor left Sensation: * pinprick: makes vocalizations in response to pinprick throughout * nailbed pressure: withdraws all limbs from stim Pertinent Results: [**2106-11-25**] 10:22PM %HbA1c-5.9 eAG-123 [**2106-11-25**] 08:40PM URINE HOURS-RANDOM [**2106-11-25**] 08:40PM URINE GR HOLD-HOLD [**2106-11-25**] 08:40PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2106-11-25**] 08:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2106-11-25**] 08:00PM GLUCOSE-123* UREA N-12 CREAT-1.0 SODIUM-140 POTASSIUM-3.4 CHLORIDE-101 TOTAL CO2-32 ANION GAP-10 [**2106-11-25**] 08:00PM estGFR-Using this [**2106-11-25**] 08:00PM CK-MB-3 [**2106-11-25**] 08:00PM cTropnT-0.02* [**2106-11-25**] 08:00PM CALCIUM-9.7 PHOSPHATE-3.1 MAGNESIUM-2.3 [**2106-11-25**] 08:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2106-11-25**] 08:00PM WBC-8.8 RBC-4.46 HGB-14.8 HCT-41.4 MCV-93 MCH-33.2* MCHC-35.7* RDW-13.9 [**2106-11-25**] 08:00PM PLT COUNT-255 [**2106-11-25**] 08:00PM PT-13.6* PTT-25.9 INR(PT)-1.2* EXAMINATION: CTA head and neck with perfusion. INDICATION: Right hemiparesis. COMPARISON: [**2106-11-25**] CT of the brain at 17:49 from [**Hospital1 **]. The images were scanned into our PACS system for review. TECHNIQUE: Non-contrast head CT was performed. Intravenous contrast was administered and serial axial images of the head and neck were obtained in the arterial phase. Multiplanar 3-D reformatted images were also obtained including three-dimensional reconstructions that were obtained at a separate workstation. CT perfusion was then performed. FINDINGS: NON-CONTRAST HEAD CT: There is no evidence of hemorrhage or mass. The right corona radiata has asymmetric hypodense appearance within the frontal lobe. There is no evidence of large cortical infarct. CTA HEAD AND NECK: There is moderate calcific arteriosclerosis of the aortic arch. The brachiocephalic, left common carotid and left subclavian arteries have separate origins off the arch. The right common carotid artery has minimal calcific arteriosclerosis distally but no flow-limiting stenosis. The cervical right internal carotid artery has minimal (<10% lumenal narrowing) atherosclerosis at its origin but no flow-limiting stenosis. The right external carotid artery has normal course, caliber and branching pattern. The left common carotid artery is markedly tortuous proximally, extending medially posterior to the trachea at the T1 and T2 levels. There is no flow-limiting stenosis. The cervical left internal carotid artery has minimal atherosclerotic irregularity (<10% lumenal narrowing) but no flow-limiting stenosis. Both cervical internal carotid arteries are retropharyngeal at the level of C1. The left vertebral artery is slightly dominant. There is mild atherosclerosis of both vertebral artery origins but no flow-limiting stenosis. CTA HEAD: There is moderate calcific arteriosclerosis of the carotid siphons but no flow-limiting stenosis. The left A1 segment provides dominant supply to the A2 segments. The right A1 segment is hypoplastic. The right middle cerebral artery has normal course, caliber and branching pattern. The left middle cerebral artery has an occlusive filling defect within an anterior division of the M2 segment. More distal M2 and M3 branches fill via collaterals. There is fetal origin of the right posterior cerebral artery. No left posterior communicating artery is identified. Both posterior cerebral arteries have regions of moderate luminal narrowing, particularly the right P2 segment. The anterior communicating artery is patent. There is moderate luminal narrowing of the right M1 segment. CT PERFUSION: There is prolonged mean transit time throughout the majority of the left MCA territory, particularly with symmetric loss of blood flow. Centrally, the CBV is also reduced compatable with developing infarct. However, there is preservation of cerebral blood volume along the periphery of the region of prolonged MTT compatable with ischemic penumbra. The examination is otherwise significant for a right maxillary sinus mucus retention cyst and degenerative osseous changes most prominent in the cervical spine. There is mild mediastinal adenopathy, partially visualized. The scout film reveals cardiomegaly. Tonsilloliths are also incidentally noted. IMPRESSION: 1. Non-contrast head CT reveals no evidence of hemorrhage or large cortical infarct. 2. Occlusive clot within a left anterior M2 branch. 3. CT perfusion compatible with an area of ischemic penumbra in the left MCA territory. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] DR. [**First Name8 (NamePattern2) 11136**] [**Last Name (NamePattern1) 11137**] Approved: FRI [**2106-11-26**] 4:11 PM MERCI clot retrival Radiology notes: HISTORY: Left MCA territory infarction. CTA of the head showing acute occlusion of left M2 branch. PROCEDURE: Diagnostic cerebral angiogram with left common carotid angiogram, left internal carotid angiogram and right common femoral angiogram. INTERVENTIONAL PROCEDURE: Intra-arterial thrombolysis using Merci clot retrieval V 2.5 Soft. Closure of right common femoral puncture site with 8 French Angio-Seal closure device. OPERATOR: Dr. [**Last Name (STitle) **]. FELLOW: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. ANESTHESIA: The procedure was performed under general anesthesia. The patient's hemodynamic parameters were continuously monitored by the anesthesia team throughout the procedure. DETAILS OF THE PROCEDURE: Treatment options, indications of the procedure, alternative management and risks of the procedure were explained to the family and consent obtained. The patient was brought to the interventional neuroradiology suite and placed in supine position on the biplanar table. A pre-procedure timeout documenting the patient identity, nature of the procedure and relevant blood work were done using two independent identifiers. Both groins were prepped and draped in normal sterile fashion. After using local anesthetic into the right groin, the right common femoral artery was accessed using a 19-gauge single wall needle. Using Seldinger technique, a 4 French Avanti sheath was successfully placed over a 0.035 [**Last Name (un) 7648**] wire. The [**Last Name (un) 7648**] wire was removed and through the sheath, a 4 French Berenstein 2 catheter was placed with the aid of a 0.035 angled Glidewire. The Berenstein 2 catheter was successfully navigated into the left common carotid artery and cerebral angiogram performed. After review of the angiogram images with the stroke team, intervention was deemed warrented. At this time, general anesthesia was induced by the anesthesia team. An exchange length Glidewire was advanced into the distal right internal carotid artery under fluoroscopic guidance. The 4 French Avanti vascular sheath was exchanged for an 8 French 25 cm Terumo sheath. The Berenstein 2 catheter was exchanged for Merci 8 French base catheter. The exchange length Glidewire was exchanged for a gold tip Glidewire over which an 18L Merci microcatheter was directed to the left M1 segment. The gold-tip angled Glidewire was navigated beyond the thrombus within the proximal left M2 segment. A single attempt was performed with the Merci clot retrieval device. Post-clot retrieval hand injection angiogram demonstrated patent left M2 segment with successful removal of the thrombus without residual stenosis. Wires and catheters were removed and angiogram was done from the right common femoral artery which showed no stenosis or extravasation from the right common femoral artery. The site of the puncture was closed using an 8 French Angio-Seal closure device. The patient was transferred to the ICU with post-procedure orders. The procedure was tolerated well and the patient's neurological status post-procedure was unchanged. FINDINGS: Left common carotid angiogram shows a tortuous common carotid artery. The left internal carotid artery fills well along cervical, petrous, cavernous and supraclinoid portions. A normal internal carotid artery bifurcation is identified with normal filling of the ACA. There is an abrupt cut-off of the left proximal M2 segment of the left middle cerebral artery. Using Merci clot retrieval device, the clot was successfully removed and a patent vessel was demonstrated post-removal without residual stenosis. Right common femoral angiogram showed normal filling of the vessel. There was no extravasation of contrast. IMPRESSION: Successful intra-arterial thrombolysis of the left M2 segment thrombus using Merci retrieval device. Post-thrombectomy hand injection angiogram demonstrated patent flow without stenosis of the left M2 segment. The study and the report were reviewed by the staff radiologist. CLINICAL INDICATION: 88-year-old female with left MCA stroke. Evaluate evolution of lesion. COMPARISON: [**2106-11-25**] at 8 p.m. TECHNIQUE: Axial CT images through the head were acquired without intravenous contrast. FINDINGS: There is increased hypodensity, loss of [**Doctor Last Name 352**]-white differentiation, and sulcal effacement in the left MCA territory. There is no evidence for hemorrhage. There is no evidence for hydrocephalus. Visualized bony structures are grossly unremarkable. The visualized portions of the paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: Evolution of left MCA territory ischemic stroke with increased loss of [**Doctor Last Name 352**]-white differentiation, sulcal effacement, and hypodensity. No evidence for hemorrhage. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] DR. [**First Name (STitle) **] [**Name (STitle) 12563**] Approved: FRI [**2106-11-26**] 11:03 AM HEAD MRI WITHOUT CONTRAST, [**2106-11-26**] INDICATION: Large left middle cerebral artery territory infarct. The patient presented with occlusion of the anterior division of the left middle cerebral artery and underwent successful intra-arterial thrombolysis on [**2106-11-25**] using Merci retrieval device. COMPARISON: Non-contrast head CT dated [**2106-11-26**]. Head CTA and conventional cerebral angiograms dated [**2106-11-25**]. TECHNIQUE: Sagittal T1-weighted and axial T2-weighted, FLAIR, gradient echo, and diffusion-weighted images of the head were obtained. No intravenous contrast administered. FINDINGS: There is slow diffusion and high T2 signal in the left middle cerebral artery territory, including the left frontal lobe, the insula, the external capsule, and portions of the lentiform nucleus. There is also a punctate signal abnormality on diffusion-weighted images in the left parietal cortex. These findings are consistent with an evolving early subacute infarction. There is no evidence of associated high signal on T1-weighted images or low signal on gradient echo images to suggest hemorrhagic transformation. There are multiple small foci of high T2 signal in the supratentorial white matter of the cerebral hemispheres, likely representing chronic small vessel ischemic disease in a patient of this age. There is mild-to-moderate cerebral atrophy with associated prominence of the ventricles and sulci. The arterial flow voids of the circle of [**Location (un) 431**] and of the M1 segment of the middle cerebral arteries appear unremarkable. IMPRESSION: Large evolving, early subacute infarction in the left middle cerebral artery territory. DR. [**First Name11 (Name Pattern1) 95**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 96**] Approved: SAT [**2106-11-27**] 9:24 PM Brief Hospital Course: 88 W found to be be R-sided hemiparetic & aphasic on [**11-25**] (normal state of health 3hrs prior), she found to be in AFib at OSH with L MCA stroke. Pt transfered to [**Hospital1 18**], intubated for IR, s/p [**Hospital1 **] retrieval of L M2 clot. HOSPITAL COURSE Neurologic: Patient was admitted to the NeuroICU. F/u head CT on [**11-26**] demonstrated evolution of left MCA territory ischemic stroke with increased loss of [**Doctor Last Name 352**]-white differentiation, sulcal effacement, and hypodensity. No evidence for hemorrhage. She was started on warfarin 5 mg. Patient remained to be aphasic and hemiparetic with no improvement despite successful clot retrieval and reperfusion of the left MCA distribution. Follow-up MRI confirmed the distribution of the stroke on DWI/ADC. She was extubated on [**11-26**]. Given the gravity of the stroke and her deteriorating condition (related at least in part to Left-MCA-distribution edema), the family opted to make her DNR/DNI, and then later HCP/daughter (K.), with the rest family in agreement, decided to make patient comfort-care measures only (CMO). No further brain imaging was pursued. The patient was at this time febrile (treated with PR acetaminophen), but HDS with increased RR to the 20s-30s and desaturations to the upper 80s%. She was transferred to the Neuro floor for arrangement of palliative/hospice care measures. Our [**Hospital1 18**] Palliative care team was consulted, and their recommendations were followed. All non-comfort-oriented diagnostic tests and medications were stopped. All invasive measures were withdrawn, including painful examinations (e.g. testing withdrawal responses to noxious stimuli), non-observational vitals monitoring. She was started on a scopolamine patch and Levsin SL for increasing respiratory secretions, and given PRN morphine (Roxanol) 5-10mg SL q1h for any apparent discomfort, largely assessed by increased respiratory rate. She remained tachypneic and requiring SL morpine for discomfort/irregular respirations, and expired on the floor on the morning of [**11-30**] before transfer to an external hospice care facility. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 88380**] pronounced the death, notified the family, and completed the hospital paperwork after we were alerted by the patient's nurse that she had stopped breathing. Medications on Admission: - colace 100 mg po bid - senna 1 tab po qhs - mvi po daily - atenolol 25 mg po bid - lisinopril 30 mg po qam - lasix 20 mg po qam - levothyroxine 500 mcg po daily Discharge Medications: none. patient died. Discharge Disposition: Expired Discharge Diagnosis: death while CMO s/p large left-sided MCA infarction Discharge Condition: died. Discharge Instructions: none. patient died. Followup Instructions: none. patient died. [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**] Completed by:[**2106-12-1**]

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icd9cm

[ [ [] ] ]

[ "39.74", "88.41" ]

icd9pcs

[ [ [] ] ]

18135, 18144

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266, 296

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3774, 5330

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2528, 2595

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18165, 18218

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190,766

24005

Discharge summary

report

Admission Date: [**2120-2-22**] Discharge Date: [**2120-3-2**] Date of Birth: [**2068-12-26**] Sex: M Service: NEUROSURGERY Allergies: Penicillins / Levaquin Attending:[**First Name3 (LF) 38982**] Chief Complaint: Head ache, fall from standing Major Surgical or Invasive Procedure: None this admission. History of Present Illness: 51yo male who fell from standing while under EtOH. Presented to ED complaining of sever headache. No nausea or vomiting or visual changes. H/o old left sided weakness secondary to old cord contusion. Past Medical History: HTN pancreatitis degenerative joint disease left hemiparesis 2 to old cord contusion h/o left foot osteomyelitis cervical spondylosis right ulnar ORIF left foot surgery right shoulder surgery umbilical hernia repair L5S1 laminectomy Social History: homeless, former wide receiver for [**Location (un) 511**] Colonials, farm team to [**Company **] Family History: not obtained Physical Exam: VS: 98.2, 88, 135/87,14,96% alert and oriented X3, no apparent distress, Ht regular rat and rhythm, lungs clear, abdomen soft, full pulses lower extremities, cranial nerves 2 thru 12 intact, motor shows [**3-12**] left leg strength otherwise full, no pronator drift, sensory intact, speech and comprehension intact Pertinent Results: [**2120-2-22**] 02:05PM BLOOD WBC-3.1* RBC-3.85* Hgb-12.0* Hct-38.2* MCV-99* MCH-31.3 MCHC-31.5 RDW-15.4 Plt Ct-106* [**2120-2-22**] 02:05PM BLOOD Neuts-59.5 Lymphs-29.4 Monos-5.8 Eos-4.7* Baso-0.5 [**2120-2-22**] 06:35PM BLOOD PT-11.7 PTT-26.5 INR(PT)-0.9 [**2120-2-22**] 02:05PM BLOOD Plt Ct-106* [**2120-2-22**] 02:05PM BLOOD Glucose-60* UreaN-24* Creat-0.9 Na-138 K-4.0 Cl-100 HCO3-21* AnGap-21* [**2120-2-22**] 02:05PM BLOOD ALT-18 AST-46* LD(LDH)-265* AlkPhos-58 Amylase-205* TotBili-0.8 [**2120-2-22**] 02:05PM BLOOD Lipase-21 [**2120-2-23**] 04:28AM BLOOD Albumin-3.7 Calcium-8.4 Phos-3.9 Mg-2.0 [**2120-2-22**] 02:05PM BLOOD ASA-NEG Ethanol-135* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Brief Hospital Course: Patient was admitted to ICU for close neurological monitoring after CT of head showed acute subarachnoid hemorrhage. Also had xray of spine. Pt was kept in hard collar until cervical studies were clear then it was removed. Thoracic studies showed old compression fractures. Lumbar studies showed acute wedge fracture at L1 and was fit in TLSO brace. Head CT was repeated and showed improvement but not complete resolution of blood. He was trnsferred out of the ICU to floor bed on [**2-24**]. He continued to be neurologically intact with the exception of left leg strength. GI was consulted in regard to elevated LFT's but was felt consistent with chronic pancreatitis.patient was seen by PT/OT and felt to be safe for discharge. Medications on Admission: fentanyl patch oxycodone prn Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. Amitriptyline HCl 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Hydromorphone HCl 2 mg Tablet Sig: 1 to 3 Tablet PO Q4-6H (every 4 to 6 hours) as needed. 10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 11. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] house Discharge Diagnosis: Traumatic subarachnoid hemorrhage L1 wedge fracture Discharge Condition: Neurologically stable Discharge Instructions: Wear TLSO brace whenever upright or sitting up in bed. Followup Instructions: Follow up with Dr. [**First Name (STitle) **] in one month with xrays lumbar spine AP and Lat, call [**Telephone/Fax (1) 2731**] for appt. Completed by:[**2120-3-1**]

[ "805.4", "577.1", "E888.9", "852.01" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

3865, 3963

2048, 2781

318, 341

4059, 4082

1321, 2025

4185, 4354

957, 971

2860, 3842

3984, 4038

2807, 2837

4106, 4162

986, 1302

249, 280

369, 570

592, 826

842, 941

20,759

162,336

47543

Discharge summary

report

Admission Date: [**2197-7-11**] Discharge Date: [**2197-7-18**] Service: SURGERY Allergies: Aspirin Attending:[**First Name3 (LF) 3376**] Chief Complaint: Hypotension, acute renal failure Major Surgical or Invasive Procedure: none History of Present Illness: The patient is an 83 year old female with a past medical history significant for ulcerative colitis s/p colectomy and end ileostomy for UC/colon adenoma [**2197-5-10**], HTN, afib on anticoagulation, who was referred from [**Hospital 100**] rehab for worsening renal function: Cr 4.3 (1.3 on [**7-6**]; 3.7 on [**7-10**]; 4.2 on [**7-11**]) and low urine output. Renal US at [**Hospital 100**] rehab reportedly showed no obstruction. Of note, the patient was recently admitted to surgical service on [**2197-6-15**] - [**2197-6-19**] when she presented wtih Cr 1.8, fevers and underwent necrotic wound debridment. Cr on discharge was 1.5. . In the ED, vital signs 97.8; 68; 120/70; 18; 96%RA. Patient's labs are significant for Cr was 4.3, BUN 42, K 5.3, trop 0.12. UA with > 50 WBC and many eosinophils. lactate 1.7. Dig: 2.3. INR 8.3. EKG showed sinus bradycardia rate of 52. While in the ED, the patient became hypotensive with SBP in 70-80. HR 52. She was mentating well and asymptomatic. She was given IV with improvement in BP. She was treated with kayexalate, insulin, D50, Ciprofloxacin, total of 3L IV NS. She also received Vit K 2.5 mg po once. The patient denies any complaints. She reports that she has been feeling well. No fever, chills, Nausea, vomiting, urinary symptoms. Note from [**Hospital 15303**] rehab notes decreased output through stoma and decreased urine output. Past Medical History: -Atrial fibrillation. She is on Plavix and Coumadin. -Hypertension. -Anemia. -History of gastrointestinal bleeding. -History of ovarian cancer. -Glaucoma. -Macular degeneration. -Depression. -Gastroesophageal reflux disease. -Lumbar scoliosis and spinal stenosis. -Ovarian cancer, remote, treated with hysterectomy- oophorectomy -Ulcerative colitis s/p ilestomy [**4-22**] -type 2 DM -CAD/NSTEMI following her recent surgery Social History: She is a widow, quit smoking [**2174**]. Lived in senior center in [**Location (un) **] until recently, now has been staying at [**Hospital 100**] Rehab. Two daughters and three grandchildren. One daughter lives in area. Currently at [**Hospital 100**] Rehab facility Family History: Positive for CAD, diabetes, negative for inflammatory bowel disease, or colon cancer. Physical Exam: VS: 96.7; 119/42; 54; 21; 98% 2L NC General: pleasant, well-appearing, NAD, conversant HEENT: NC, AT, PERRL, no scleral icterus, MM dry Heart: regular, nl S1S2, no M/r/G Lungs: CTA bilaterally Abdomen: + BS, soft, NT, ND, stoma in place, pink and no sign of infection, LLQ wound vac in place Ext: no edema Skin: no exanthems Neuro: appropriate, CN 2-12 and motor is grossly intact Pertinent Results: Admission laboratories [**2197-7-11**] 01:19PM CBC: WBC-10.1# RBC-3.79* Hgb-10.5* Hct-31.4* MCV-83 MCH-27.7 MCHC-33.4 RDW-17.3* Plt Ct-335 Neuts-71.8* Lymphs-23.7 Monos-2.5 Eos-1.8 Baso-0.3 Coagulation: PT-65.6* PTT-53.2* INR(PT)-8.2* Chemistries: Glucose-186* UreaN-42* Creat-4.3*# Na-132* K-5.3* Cl-99 HCO3-21* AG-17 Calcium-7.5* Phos-5.3* Mg-1.9 Liver enzymes/GI: ALT-12 AST-19 CK(CPK)-15* AlkPhos-115 Amylase-67 TotBili-0.3 Other: Digoxin-2.3* Lactate-1.7 K-5.1 Micro: Gram positive cocci in 2 out of 4 bottles from [**7-11**] CXR [**2197-7-11**]: No acute cardiopulmonary process with persistent linear atelectasis or scarring best appreciated at the left base. . ECHO [**2197-5-15**]: The left atrium is mildly dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with focal thinning/akinesis of the distal septum, apex, and distal anterior walls. The remaining left ventricular segments contract normally. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size is normal with focal hypokinesis of the apical free wall. 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 prominent mitral annular calcification. There is a minimally increased gradient consistent with trivial mitral stenosis. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. IMPRESSION: Regional left ventricular systolic dysfunction c/w coronary artery disease. Minimal functional mitral stenosis. Pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [**2194-12-1**], the regional left ventricular systolic dysfunction is new and c/w interim ischemia (mid-distal LAD lesion). The rhythm is now atrial fibrillation (previously sinus). Brief Hospital Course: This 83 year old woman status post colectomy and end ileostomy for colon adenoma and UC on [**5-10**] c/b NSTEMI, presented with acute renal failure on chronic renal insufficiency and hypotension. Her hypotension resolved with fluids and she was admitted to the MICU for further management. It was believed renal failure was largely prerenal in origin, given her low FeNa. Her hypotension was attributed firstly to poor PO intake and her usual antihypertensive medications. Furthermore, her digoxin level was very high. The renal service . # Hypotension: Most likely hypovolemia but could be component of sepsis given bacteremia - IVF, adequate hydration - follow urine output . #Bacteremia--gram positive cocci in [**2-19**] bottles, one aerobic, one anaerobic . # Acute on Chronic renal failiure: Etiology not clear. Pt appears to have pre-renal component, but elevation in Cr is out of proportion to what one would expect in pre-renal. FeNA <1%. Pt volume down. Renal US w/o obstruction. UA with many eos, but also with a lot of WBC. - IVF - adequate hydration - renally dose meds . Afib/RVR. Curently in sinus. INR supratherapeutic. - hold dilt, b-blocker, coumadin - hold digoxin -> f/u level, likely can discontinue this medication . # CAD/NSTEMI: - continue Plavix, statin - hold Imdur, B-blocker, digoxin . # S/p ileostomy/colectomy. On prednisone for colitis, but probably could taper off. Touch base with surgery. . # DM. Hold metformin. Cover wtih ISS. . FEN: Renal/cardiac/diabetic diet . ACCESS: R PICC placed [**2197-6-2**] . PPX: on AC, bowel regimen, famotidine po . Code: DNR/DNI (paperwork in chart) Medications on Admission: Prednisone 5 mg daily Plavix 75 mg daily Isosorbide 30 mg daily Norvasc 5 mg daily Lisinopril 20 mg daily ToprolXL 12.5 mg daily Neurontin 300 mg 2x daily Prilosec 40 mg daily Paxil 20 mg daily Sulfasalazine 1000 mg 2x daily Occuvite 2x daily Lopid 600 mg 2x daily Lomotil prn Lipitor 20 mg daily Glyburide 1.25 mg daily FeSo4 50 mg daily Calcium+Vit D 600 mg daily Timol gtts 2x daily Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 8. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Loperamide 2 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 11. Megestrol 40 mg/mL Suspension Sig: Twenty (20) ml PO DAILY (Daily). Disp:*500 ml* Refills:*2* 12. 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. 13. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 14. Warfarin 1 mg Tablet Sig: 0.5 Tablet PO once a day: to keep INR [**2-18**]. Disp:*30 Tablet(s)* Refills:*2* 15. Outpatient [**Name (NI) **] Work PT, INR, chem-7 qod to monitor anticoagulation & renal function. target INR [**2-18**] 16. Insulin SC Sliding Scale Please see attached sliding scale order sheet. Please adjust for optimal blood sugar control. 17. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 18. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 1 weeks. Disp:*28 Capsule(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: acute renal failure acute tubular necrosis s/p total abdominal colectomy, end ileostomy hyperkalemia wound infection hypertension CAD ulcerative colitis depression anemia poorly controlled diabetes Discharge Condition: good Discharge Instructions: It is extremely important for you to maintain adequate hydration. You make shower. You should follow up with your doctor who is taking care of your diabetes medications. Please call Dr.[**Name (NI) 3377**] office if you develop fevers>101, decreasing urine output, inability to tolerate oral diet, inability pass gas or stool, or if you have any other problems or concerns. Followup Instructions: Follow up with Dr. [**Last Name (STitle) 1120**] in 1 month. Please call her office at ([**Telephone/Fax (1) 3378**] to set up an appointment. Contact Dr.[**Name2 (NI) 4857**] (renal) office at ([**Telephone/Fax (1) 773**] to arrange a follow up appointment in 1 week. Contact your diabetes doctor's office to arrange a follow up appointment in 1 week. Completed by:[**2197-7-18**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9309, 9375

5137, 6761

247, 253

9617, 9624

2925, 5114

10049, 10436

2422, 2509

7197, 9286

9396, 9596

6787, 7174

9648, 10026

2524, 2906

175, 209

281, 1672

1694, 2121

2137, 2406

76,084

134,653

41466

Discharge summary

report

Admission Date: [**2179-12-26**] Discharge Date: [**2180-1-11**] Date of Birth: [**2117-9-14**] Sex: F Service: SURGERY Allergies: Penicillins / Codeine / ivp dye Attending:[**First Name3 (LF) 1384**] Chief Complaint: Necrotizing soft tissue infection of groin Major Surgical or Invasive Procedure: Debridement of the perineum, [**2179-12-27**] Debridement of the perineum, [**2179-12-28**] Debridement of the perineum, [**2179-12-31**] Debridement of perineum and groin open wound with VAC placement, [**2180-1-5**] Primary closure of perineal wound, [**2180-1-10**] History of Present Illness: 62-y.o. female DM popped a "pimple" on her R inner thigh on [**12-22**] and the wound subsequently developed swelling and tenderness, which she noted on [**12-24**]. She also had fever to T 102. Today she presented to an outside ED, where aspiration was attempted with reported withdrawal of serosanguinous fluid only, no pus. She received vancomycin. She was then transferred to the [**Hospital1 18**] ED, where she received clindamycin. Past Medical History: Diabetes mellitus with neuropathy, CKD on HD Tue/[**Doctor First Name **]/Sat per HD dialysis line in the R subclavian, hypertension, hypothyroidism, anxiety. Past Surgical History: CABG x 3 [**2167**], cholecystectomy [**2173**]. Social History: Currently smoking, 1 ppd x 50 yrs, denies EtOH consumption, denies recreational drug use. Family History: Denies family history of immunological disorders Physical Exam: T: 99.0 P: 87 BP: 117/48 RR: 20 O2sat: 95% on RA General: awake, alert, NAD HEENT: NCAT, EOMI, anicteric Heart: RRR Lungs: normal excursion, no respiratory distress Back: no vertebral tenderness, no CVAT Abdomen: soft, NT, ND, no mass, no hernia Pelvis: R proximal posteromedial thigh and R perineum with moderately tender swelling and erythema with irregular areas of central skin necrosis, black with overlying sloughing, no crepitus, no fluctuance, no expressible discharge, + + foul odor Extremities: WWP, no CCE, no tenderness Pertinent Results: On Admission [**2179-12-26**] WBC-26.0* RBC-3.70* Hgb-11.0* Hct-33.3* MCV-90 MCH-29.8 MCHC-33.2 RDW-14.7 Plt Ct-238 Neuts-94.4* Lymphs-3.6* Monos-1.7* Eos-0 Baso-0.2 PT-15.3* PTT-28.6 INR(PT)-1.3* Glucose-193* UreaN-77* Creat-7.1* Na-126* K-4.9 Cl-88* HCO3-18* AnGap-25* Albumin-2.6* Calcium-8.6 Phos-6.3* Mg-2.1 Brief Hospital Course: Ms. [**Known lastname **] was admitted to the surgical service on [**2179-12-26**]. She was treated conservatively with antibiotics but did not improve and was taken the operating room on [**2179-12-27**] for surgical debridement and drainage of her perineal necrotizing soft tissue infection. Per Dr.[**Name (NI) 1381**] note, the area of cellulitis was incised and a wide swatch of necrotic tissue was excised from the vulva medially out to the thigh laterally down to the perineal fascia. Please refer to his operative note for additional details. Ms. [**Known lastname **] was extubated post-operatively but required pressors in the PACU to keep her blood pressure sufficient and thus was transferred to the SICU for post-operative monitoring on pressors. She returned to the operating room on [**2179-12-28**] for further debridement. She remained intubated post-operatively and was transferred back to the ICU where she was weaned to extubate without complication. She remained on a low dose of neosynephrine and this too was weaned on [**2179-12-29**]. Cardiovascularly stable, off pressors, she was transferred to the floor on [**2179-12-30**] and remained cardiovascularly uncomplicated for the remainder of her hospitalization. On [**2179-12-31**], she returned to the operating room for further wound debridement, washout and vac placement and returned the floor without complication. The vac was removed on [**2180-1-3**] due to what appeared to be increased fibrinous drainage. It was decided to hold off on vac replacement and instead use [**Hospital1 **] wet-to-dry dressing changes for wound care until she returned to the operating room with plastic surgery on [**2180-1-5**] for further washout and debridment. A vac was placed in the operating room on [**2180-1-5**] by plastic surgery. She had no acute issues relating to her wound in the interval between [**2180-1-5**] and [**2180-1-10**]. The vac functioned appropriately. She returned the the operating room for definitive primary closure by plastic surgery on [**2180-1-10**]. The wound was closed primarily with a small 4x4 cm area unable to be closed at the time. The fascia was closed underneath the defect and it was fitted with a vac sponge. She was discharged to rehab on [**2180-1-11**] with a small wound vac in her perineal wound, tolerating regular diet, pain controlled on oral pain medications and at her baseline level of activity. Additional pertinents of her hospitalization by systems: GU: Ms. [**Known lastname **] received hemodialysis throughout her hospitalization here on her usual Monday-Wednesday-Friday schedule. As per her usual, she continued to make urine approximately once daily. A foley catheter was placed in the OR on [**2179-12-30**] to prevent contamination of wound due to its close proximity to her urethra/genitalia. It was removed on [**2180-1-3**] AM but replaced in the PM due to urinary urgency and distention. The foley was removed again on [**2180-1-6**], this time without complication. Endo: Ms. [**Known lastname 4675**] was on an insulin sliding scale for the management of her diabetes. She received 7 units of NPH in the AM with a sliding scale starting at a glucose level of 120 with 2 units and increasing by 2 units every 40 mg/dl of glucose to a level of 400. Her blood sugars were relatively well controlled throughout her hospital stay with FS in the 120s-low 200s. She had an episode of hypoglycemia on [**2180-1-11**], day of discharge, with her blood sugar measured at 40 and expressing somnolence. She responded appropriately to an ampule of dextrose with FS on repeat in the 150s. Her blood pressure and heart rate were monitored and were stable throughout. Her insulin regimen was reviewed and it was determined that her hypoglycemia was the result of her being NPO [**2180-1-10**] for the OR and with poor oral intake the PM of [**2180-1-10**] and in the AM of [**2180-1-11**]. In consultation with nephrology, it was decided to not make any changes to her insulin regimen. Her PCP was [**Name (NI) 653**] and follow-up for diabetes management was made for [**2180-1-21**]. She was discharged to the skilled nursing facility with detailed instructions on blood sugar monitoring and management. Heme: Ms. [**Known lastname **] received one blood tranfusion during her hospitalization of 2 units for a hematocrit of 23.9 on [**2180-1-10**]. This was done not so much as a concern of bleeding but in order to optimize her status for the operating room and potential for blood loss. The operation proceeded without complication and without significant blood loss. ID: Ms. [**Known lastname **] was initially started on aztreonam/cipro/flagyl for antibiotic coverage. The infectious disease service was consulted early in the hospitalization. Vancomycin was added with hemodialysis, then clindamycin. She ultimately settled on a regimen of vancomycin and meropenem. She completed her 14 day course of this regimen on [**2180-1-10**]. Medications on Admission: Aspirin 81', Lisinopril 40 QOD non-dialysis days, Lasix 100', Lipitor 20 QHS, Synthroid 175', NPH insulin 15', Humalog 8', compazine unknown dose Q8H PRN, Prozac 60', Xanax 2 QID, Discharge Medications: 1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. levothyroxine 50 mcg Tablet Sig: 3.5 Tablets PO DAILY (Daily). 3. fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 4. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 9. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 10. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO HD PROTOCOL (HD Protochol). 11. alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 12. insulin regular human 100 unit/mL Solution Sig: One (1) Injection once a day: Breakfast: NPH 7 Units Insulin SC Sliding Scale Q4H Regular Glucose Insulin Dose 0-70 mg/dL: Proceed with hypoglycemia protocol ----- 71-119 mg/dL: 0 Units ------ 120-159 mg/dL: 2 Units ------ 160-199 mg/dL: 4 Units ------ 200-239 mg/dL: 6 Units ------ 240-279 mg/dL: 8 Units ------ 280-319 mg/dL: 10 Units ------ 320-359 mg/dL: 12 Units ------ > 360 mg/dL Notify M.D. . Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare & Rehabilitation Center - [**Location (un) **] Discharge Diagnosis: Necrotizing soft tissue infection of perineum Chronic Renal Failure on Hemodialysis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call Dr.[**Last Name (STitle) 17650**] office [**Telephone/Fax (1) 6331**] if any of the warning signs are noted. You will be transferring to [**Hospital **] Nursing and Rehab Center in [**Location (un) **] [**Telephone/Fax (1) 90219**] You were admitted for a severe bacterial infection in your groin. This was treated with surgical drainage and debridement of the unhealthy tissue. This was followed with 2 weeks of antibiotic coverage to treat residual bacteria. You were taken to the operating room multiple times during this hospitalization to further clean the wound by both general and plastic surgery. You wound was closed by plastic surgery on [**2180-1-10**]. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please remember to take colace with narcotic pain medications to prevent constipation. Also, please avoid driving or operating heavy machinery while taking these pain medications. Avoid lifting weights greater than [**4-11**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. You will have a followup appointment with plastic surgery, Dr. [**First Name (STitle) **] [**1-14**]. Please see below for further details. 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. 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. Please call Dr.[**Name (NI) 1381**] office [**Telephone/Fax (1) 673**] if you have any of the following: fever, chills, increased redness/drain of buttock wound or malfunction of tunnelled dialysis line. Followup Instructions: Ms. [**Known lastname **] should follow up with Dr. [**First Name (STitle) **] from [**Hospital1 18**] Plastic surgery at the [**Hospital **] Medical Office Building, [**Location (un) 442**], on the [**Hospital1 18**] [**Hospital Ward Name 517**] Provider: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 2612**], MD Phone:[**Telephone/Fax (1) 6331**] Date/Time:[**2180-1-14**] 11:15 She should also see Dr. [**Last Name (STitle) 816**] (Hepatobiliary surgery) on the [**Location (un) **] of the [**Hospital **] Medical Office Building in 1 week. Please call [**Telephone/Fax (1) 17195**] to schedule a follow-up appointment. You have a follow-up appointment scheduled with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**1-21**] at 12 PM to evaluate your overall health and diabetes management. The office phone number is [**Telephone/Fax (1) 15916**]. The address is [**Apartment Address(1) 90220**] [**Location (un) 2199**], MA Completed by:[**2180-1-11**]

[ "250.60", "682.5", "403.91", "305.1", "V45.81", "414.00", "709.8", "536.3", "682.2", "285.9", "583.81", "276.1", "616.4", "357.2", "250.80", "585.6", "682.6", "250.40" ]

icd9cm

[ [ [] ] ]

[ "86.74", "39.95", "38.95", "83.45", "71.3", "86.22", "83.39" ]

icd9pcs

[ [ [] ] ]

9104, 9204

2418, 7423

335, 606

9332, 9332

2081, 2395

12403, 13417

1459, 1509

7653, 9081

9225, 9311

7449, 7630

9483, 10886

10901, 12380

1284, 1335

1524, 2062

253, 297

634, 1079

9347, 9459

1101, 1261

1351, 1443

75,493

115,664

34417

Discharge summary

report

Admission Date: [**2189-10-11**] Discharge Date: [**2189-10-24**] Date of Birth: [**2135-5-27**] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 11415**] Chief Complaint: Moped vs [**Doctor Last Name **] Major Surgical or Invasive Procedure: [**2189-10-11**]: External fixator placement left leg with left leg fasciotomies and VAC placement [**2189-10-12**]: ORIF left tibial plateau fracture with I&D and VAC change [**2189-10-14**]: I&D left leg with medial wound closure and VAC change to lateral wound [**2189-10-16**]: I&D left leg lateral wound with closure History of Present Illness: Mr. [**Known lastname 79127**] is a 54 year old man who was a driver of a moped that hit a [**Doctor Last Name **]. He was taken to the [**Hospital1 18**] for further evaluation and care. Past Medical History: Cardiomyopathy (unclear etiology) Afib Social History: Patient moved from [**Location (un) 41654**] to [**Location (un) 86**] 5 years ago. He works as a cook in a restaurant. He lives with multiple friends ([**3-2**] people) in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. -Tobacco history: None -ETOH: Occasional -Illicit drugs: None Family History: Mother with DM2, died at the age of 42 of MI. Father died at 60 of unknown cause. No family history of early arrhythmia, cardiomyopathies; otherwise non-contributory. Physical Exam: Upon admission: General Evaluation Exam Sensorium: Awake (x) Awake impaired () Unconscious () Airway: Intubated () Not intubated (x) Breathing: Stable (x) Unstable () Circulation: Stable (x) Unstable () Musculoskeletal Exam Neck Normal (x) Abnormal () Comments: Spine Normal (x) Abnormal () Comments: Clavicle R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Shoulder R Normal (x) Abnormal () Comments: L Normal () Abnormal (x) Comments: significant pain with passive ROM, no limits on ROM. Arm R Normal (x) Abnormal () Comments: L Normal () Abnormal (x) Comments: tender to palpation over medial and lateral epicondyles Elbow R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Forearm R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Wrist R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Hand R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Pelvis R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Hip R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Thigh R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Knee R Normal () Abnormal () Comments: L Normal () Abnormal () Comments: Leg R Normal () Abnormal () Comments: L Normal () Abnormal () Comments: Ankle R Normal () Abnormal () Comments: L Normal () Abnormal () Comments: Foot R Normal () Abnormal () Comments: L Normal () Abnormal () Comments: Pertinent Results: [**2189-10-11**] 11:26PM HCT-28.0* [**2189-10-11**] 11:26PM PT-14.2* PTT-34.5 INR(PT)-1.2* [**2189-10-11**] 07:21PM GLUCOSE-157* UREA N-15 CREAT-1.1 SODIUM-136 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-28 ANION GAP-9 [**2189-10-11**] 07:21PM CALCIUM-8.4 PHOSPHATE-1.9*# MAGNESIUM-1.8 [**2189-10-11**] 07:21PM WBC-7.3 RBC-3.44* HGB-10.0* HCT-28.7* MCV-83 MCH-29.1 MCHC-35.0 RDW-13.5 Brief Hospital Course: Mr. [**Known lastname 79127**] presented to the [**Hospital1 18**] on [**2189-10-11**] after the moped he was driving struck a [**Doctor Last Name **]. He was evaluated by the orthopaedic surgery service and found to have a left tibial plateau fracture with associated compartment syndrome. He was emergently taken to the operating room and underwent left leg fasciotomies with VAC placement and closed reduction and external fixator placement of his left tibia. He tolerated the procedure well, was extubated, transferred to the recovery room, and then to the floor. On [**2189-10-12**] he returned to the operating room and underwent an ORIF of his left tibial plateau fracture with I&D of his compartments and VAC changes. On [**2189-10-13**] he was transfused 2 units of packed red blood cells due to acute blood loss anemia. On [**2189-10-14**] he returned to the operating room and underwent an I&D of his compartments with VAC change to lateral wound and closure of his medial wound. He was also transfused with 2 units of packed red blood cells due to acute blood loss anemia. On [**2189-10-16**] he returned to the operating room and underwent an I&D of his lateral compartment and closure. He was seen by cardiology during his hospital stay to help with management of his tachycardia. His lopressor was increased per cardiology. Throughout his hospital stay he was seen by physical therapy to improve his strength and mobility. He had several episodes of tachycardia while walking during physical therapy sessions, but this improved after medication changes, and he was cleared for discharge by medicine and by physical therapy. The rest of his hospital stay was uneventful with his [**Date Range **] data and vital signs within normal limits and his pain controlled. He is being discharged today in stable condition. His INR was therapeutic on discharge, and arrangements were made for INR followup with his outpatient provider. Medications on Admission: Coumadin Lisinopril Metoprolol Omeprazole Simvastatin Torsemide ASA Discharge Medications: 1. Outpatient [**Name (NI) **] Work PT/INR draws To be done at the [**Hospital3 33953**] Community Health Center (Dr. [**First Name (STitle) **] Goal INR [**12-31**] 2. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 4. warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day: Target INR [**12-31**]. To be followed by Dr. [**Last Name (STitle) **]. [**Doctor Last Name **] [**Telephone/Fax (1) 17826**] at the [**Hospital3 33953**] Community Health Center. Disp:*30 Tablet(s)* Refills:*2* 5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. Disp:*30 Tablet(s)* Refills:*0* 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Pain: Do not drive while taking this medication. Disp:*50 Tablet(s)* Refills:*0* 9. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. 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* 11. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 14. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Moped vs. [**Doctor Last Name **] Left tibial plateau fracture Compartment syndrome left leg Acute blood loss anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Continue to be touchdown weight bearing on your left leg Continue your coumadin dosing as you were prior to being admitted to the hospital. You need your next blood draw on [**Doctor Last Name 766**], [**2189-10-26**]. If you have any increased redness, drainge, or swelling, or if you have a temperature greater than 101.5, please call the office or come to the emergency department. Followup Instructions: Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopaedics in 2 weeks, please call [**Telephone/Fax (1) 1228**] to schedule that appointment Please follow up with Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 17826**] about your coumadin dosing. You should call on [**Telephone/Fax (1) 766**] to arrange this. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]

[ "799.02", "823.00", "958.2", "V58.61", "425.4", "E812.2", "785.0", "427.31", "958.92", "285.1" ]

icd9cm

[ [ [] ] ]

[ "79.06", "78.67", "84.71", "86.59", "78.07", "86.28", "83.14", "81.47", "96.59", "83.45", "78.17", "79.36" ]

icd9pcs

[ [ [] ] ]

7548, 7554

3669, 5623

355, 683

7715, 7715

3258, 3646

8310, 8813

1296, 1465

5741, 7525

7575, 7694

5649, 5718

7898, 8287

1480, 1482

283, 317

711, 901

1496, 3239

7730, 7874

923, 963

979, 1280

10,829

116,480

45459+45460+45461

Discharge summary

report+report+report

Admission Date: [**2112-2-28**] Discharge Date: [**2112-3-17**] Date of Birth: [**2049-5-31**] Sex: F Service: [**Hospital Unit Name 153**] THIS DISCHARGE SUMMARY COVERS THE [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 13533**] FROM [**2112-3-9**] THROUGH [**2112-3-17**]. CHIEF COMPLAINT: Hypoxia. HISTORY OF PRESENT ILLNESS: This is a 62 year old female with pancreatic carcinoma originally admitted to the hospital on [**2112-2-28**], with complaints of nausea, vomiting and dizziness. She was found to have left hydronephrosis. On the Floor, she became more hypoxemic to 93% on non-rebreather and was transferred to the Intensive Care Unit on [**2112-3-1**] and was intubated there. She had been started on Ampicillin, Gentamicin and Flagyl for Klebsiella urosepsis versus cholangitis on [**2-29**]. During her Intensive Care Unit course, the patient had four out of four blood cultures positive for Klebsiella and had a percutaneous nephrostomy to relieve left hydronephrosis and an Emergency Room CT scan which was negative for cholangitis. The patient was treated for Klebsiella bacteremia in the Intensive Care Unit and had a left lower lobe pneumonia, and was started on Ceftriaxone and Flagyl. She was extubated on [**2112-3-4**]. She received aggressive chest Physical Therapy and nebulizers to allow for this but had a persistent O2 requirement upon transfer back to the floor on [**3-6**]. Her oxygen requirement there increased daily as well as her white blood cell count. On [**3-7**], her antibiotics were changed to a broader spectrum, Zosyn/Vancomycin, and she continued to become more hypoxemic. Her oncologist, Dr. [**Last Name (STitle) 150**] saw her on the floor and was reluctant to start palliative chemotherapy until her infection issues were resolved. She was febrile on the floor up to 101.7 F., on [**3-8**]. On the day of transfer to the Intensive Care Unit she looked worse clinically with a saturation down to 91% on 50 liter face mask, on 90 to 93% on nonrebreather, and the Medical Intensive Care Unit team was asked to evaluate. MEDICATIONS ON TRANSFER: 1. Heparin 5000 units subcutaneously three times a day. 2. Protonix 40 mg p.o. q. day. 3. Regular insulin sliding scale. 4. Vancomycin one gram intravenous q. 12, day three. 5. Zosyn 4.5 mg intravenously q. six, day three. 6. MSIR 50 mg q. four to six hours p.r.n. 7. Ativan 0.5 mg p.r.n. 8. Zofran 4 mg intravenously q. six hours p.r.n. 9. Benadryl p.r.n. 10. Tylenol. 11. Atrovent. 12. Albuterol p.r.n. PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Klebsiella pneumonia. 3. Urinary tract infection. 4. Osteopenia. 5. Pancreatic cancer with liver metastases. 6. Thyroid disease. SOCIAL HISTORY: One half pack per day smoker times many years. ALLERGIES: No known drug allergies. FAMILY HISTORY: No history of cancer. REVIEW OF SYSTEMS: The patient denies dyspnea, chest pain, shortness of breath or any other pain. She wishes to have all possible medical interventions. PHYSICAL EXAMINATION: Vital signs upon transfer are temperature 100.8 F.; pulse 107; blood pressure 97/50; saturation of 93% on 100% nonrebreather; respiratory rate 25; arterial blood gas was 7.48, 30, 8, 58. Fingerstick was 109. In general, an thin elderly female on a nonrebreather, tachypneic, alert and oriented times three. Head: Extraocular movements are intact. Dry mucosal membranes. Neck with right internal jugular catheter in place. Cardiovascular: Tachycardic, S1, S2, no murmurs, rubs or gallops. Abdomen soft, nontender, nondistended, positive bowel sounds. Back with no costovertebral angle tenderness; left nephrostomy in place. Pulmonary: Bronchial breath sounds in left base with egophony and dullness to percussion in the left base; otherwise clear to auscultation. Extremities with no cyanosis, clubbing or edema, warm, well perfused. [**2-29**] dorsalis pedis pulses bilaterally. Neurological intact. LABORATORY: White blood cell count 33.4, hematocrit 25.8, platelets 386, INR 1.4. Chem 7 was sodium 138, potassium 3.9, chloride 97, bicarbonate 28, BUN 8, creatinine 0.5, glucose 94. ALT 15, AST 28, LD 557, alkaline phosphatase 203, total bilirubin 2.0, amylase 75, lipase 44. Calcium 7.5, phosphorus 2.6, magnesium 1.6, albumin 2.3. Repeat chest x-ray showed a left lower lobe consolidation, patchy bilateral infiltrates versus pulmonary edema. Micro-data was unrevealing since four of four blood cultures positive on [**3-1**] for Klebsiella. CT scan of the abdomen on [**3-8**] revealed left lower lobe atelectasis, small bilateral pleural effusions and numerable liver metastases and spleen metastases and interval resolution of left hydronephrosis. Initial impression was a 62 year old female with pancreatic cancer metastatic to liver, left hydronephrosis, status post left nephrostomy, status post recent Klebsiella pneumonia bacteremia with worsening hypoxia and infiltrate on chest x-ray; slightly elevated total bilirubin and leukocytosis. MEDICAL INTENSIVE CARE UNIT COURSE BY PROBLEM: 1. ACUTE RESPIRATORY FAILURE: The patient was initially hypoxemic believed to be secondary to congestive heart failure in the setting of aggressive volume resuscitation with sepsis. Initially, the patient was brought to the Intensive Care Unit and started on the MUST protocol. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test was negative. The patient's initial lactates were in the 2 range and she was given one unit of packed red blood cells for her low hematocrit. The patient initially had AmBisome started, however, this was discontinued after she was afebrile for 24 hours. She had a persistent O2 requirement in the Intensive Care Unit and was on a nonrebreather mask for two days, however, with diuresis and antibiotics she was able to avoid intubation and in fact be weaned on her high flow face mask very slowly. The patient was initiated on aggressive chest Physical Therapy as well as suctioning. She was able to provide sputum which did not grow out anything and after diuresis she did well. An echocardiogram was performed which showed a normal left ventricular ejection fraction with impair left atrial relaxation and so it was assumed that the diastolic congestive heart failure could be related to her respiratory failure. The patient also had Gentamicin initially started upon transfer to the unit, however, this was discontinued along with AmBisome on [**3-11**] and the MUST protocol was discontinued on [**3-10**] as she was afebrile, her blood pressure stable and her lactate was only 1.2. 2. HYPOTENSION: The patient was initially hypotensive upon transfer to the Unit. This improved upon diuresis. The patient was noted to become hypotensive acutely after morphine administration. A Fentanyl patch was started for pain control with p.r.n. MSIR p.o. around the clock which seemed to hold her blood pressure up better. The patient was not on any pressors in the unit. 3. PANCREATIC CANCER: The patient achieved pain control with morphine p.r.n. as well as a Fentanyl patch. Palliative chemotherapy was not an option given her infectious issues and the patient's family initially wanted her to be a full code with aggressive care. However, upon multiple discussions with the family and the patient, the family is now resolved to having the patient be a "DO NOT RESUSCITATE" "DO NOT INTUBATE" and transfer to Hospice; however, the patient herself wished to remain a Full Code and these issues remained unresolved at the time of transfer out of the unit today. Her bilirubin was rising in the unit to a high of 2.4, however, it had started to fall after this and no other interventions were done. Her INR was elevated to a high of 1.6, however, dropped back down to 1.3 after 5 mg of Vitamin K subcutaneously. Other liver function tests were stable in the unit. 4. NUTRITION: The patient was initially kept NPO, however, she was able to tolerate clear liquids. By the time of discharge, the patient was started on TPN and was kept on TPN throughout the unit stay. 5. LEFT PICC LINE AND A-LINE: Right IJ triple lumen catheter was pulled once a left PICC line was placed and tip sent for culture which never grew out anything. The patient had A-line discontinued upon transfer back to the floor. 6. ENDOCRINE: Regular insulin sliding scale, fingerstick four times a day. 7. INFECTIOUS DISEASE: Urine culture positive for yeast on [**3-9**]; the Foley catheter was replaced and a recheck of urinalysis was negative. Repeat urine cultures did not grow out anything and so she was not started on any anti-fungals for this. However, she did have a positive yeast infection by clinical examination and was on three days of miconazole intravaginal suppositories. 8. DEPRESSION / ANXIETY: The patient was actively going through the acceptance stages for dying as she had been told that she has a very grave prognosis; angry at house staff at times, refusing to participate in getting out of bed or chest Physical Therapy at times, however, does it with encouragement. The patient was started on Ritalin empirically to treat depression and fatigue and malaise while in the Intensive Care Unit. The rest of her hospital stay should be dictated by the Floor Team accepting her. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-207 Dictated By:[**Name8 (MD) 6867**] MEDQUIST36 D: [**2112-3-17**] 14:30 T: [**2112-3-17**] 15:29 JOB#: [**Job Number 97006**] / Admission Date: [**2112-2-28**] Discharge Date: [**2112-3-22**] Date of Birth: [**2049-5-31**] Sex: F Service: ACOVE Medicine Service ADDENDUM: The patient is a 62-year-old female. This will serve as an Addendum to the Discharge Summary that was previously dictated. The [**Hospital 228**] hospital course did not change significantly for her metastatic pancreatic cancer. The patient's case was discussed with her primary oncologist (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 150**]) who felt that given the patient's poor functional status and extremely grim prognosis that the patient was likely not a candidate for palliative chemotherapy. For hypoxic respiratory failure, the patient continued on a 50% face mask. Her oxygen saturations ranged from 94% to 98%. The patient was also maintained on vancomycin, Zosyn, and Flagyl until she completed a 14-day course; which she completed prior to discharge. Otherwise, the patient had no further episodes of desaturations and no further admissions to the Medical Intensive Care Unit for hypoxic acute respiratory compromise. For diastolic congestive heart failure, the patient's goals were to maintain even input and output. She was started on a beta blocker at 12.5 mg twice per day for tachycardia. The patient's tachycardia was felt likely secondary to pain; although, in the setting of a deep venous thrombosis a pulmonary embolism could not be ruled out. For deep venous thrombosis, the patient had lower extremity Doppler studies given that she had asymmetric lower extremity edema which were significant for bilateral deep venous thrombosis extending from the femorals to the popliteals bilaterally. The patient was started on heparin and Coumadin. Her INR was not therapeutic at the time of discharge and was 1.4. The patient was to be continued on heparin drip at 1100 units per hour as well as Coumadin until her INR is greater than 2. This was to be continued at [**Hospital1 **]. For pain, the patient was maintained on a Fentanyl patch which was increased to 125 mcg q.72h. Her MS04 intravenous was discontinued, and the patient was continued on morphine sulfate immediate release at 30 mg one by mouth q.6h. with good pain control. For fluids/electrolytes/nutrition, the patient was continued on total parenteral nutrition and full liquids. Her diet should be advanced at [**Hospital1 **] as tolerated. The patient's total parenteral nutrition orders will be sent with the patient's discharge paperwork. For prophylaxis, the patient was maintained on heparin, and Coumadin, proton pump inhibitor, and a bowel regimen. She was also ambulated from bed to chair. For decubitus ulceration, the patient developed a decubitus ulceration to which Duoderm was applied and remained stable during her hospitalization. The patient's code status was full. For hematologic issues, the patient's hematocrit levels remained stable throughout her hospitalization. It should be noted that the patient has a transfusion reaction to blood and should be given Benadryl prior all blood transfusions. DISCHARGE DIAGNOSES: 1. Metastatic pancreatic cancer. 2. Bilateral lower extremity deep venous thrombosis. 3. Respiratory failure. 4. Status post nephrostomy. 5. Diastolic congestive heart failure. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient should have a follow-up appointment with her primary care physician within two weeks of discharge. 2. The patient should have her electrolytes and complete blood count checked regularly as she needed transfusions and will be on total parenteral nutrition. 3. The patient's INR level should also be checked to insure that she is therapeutically anticoagulated. 4. The patient's diet should be advanced as tolerated so that she can get off total parenteral nutrition if at all possible. CONDITION AT DISCHARGE: The patient's condition on discharge was fair. She was stable on 50% face mask without desaturations. She was tolerating total parenteral nutrition and full liquids. She was able to ambulate from bed to chair. Her blood counts have remained stable. DISCHARGE DISPOSITION: The patient was to be discharged to [**Hospital6 310**] for physical as well as pulmonary rehabilitation. MEDICATIONS ON DISCHARGE: (The patient's medications on discharge included) 1. Ipratropium nebulizers 1 q.6h. as needed. 2. Albuterol nebulizers 1 q.4h. as needed. 3. Albuterol nebulizers 1 q.4h. as needed. 4. Methylphenidate 5 mg one by mouth in the morning. 5. Morphine sulfate 30 mg one by mouth q.6h. as needed (for pain). 6. Pantoprazole 40 mg one by mouth once per day. 7. Metoprolol 12.5 mg one by mouth twice per day (to be advanced as tolerated). 8. Senna 8.5-mg tablets one tablet by mouth twice per day as needed. 9. Bisacodyl 5-mg tablets two tablets by mouth once per day as needed. 10. Docusate 100 mg one by mouth twice per day as needed. 11. Coumadin 5 mg one by mouth at hour of sleep (to be adjusted based on INR). 12. Lorazepam 0.5-mg tablets one tablet by mouth q.4-6h. as needed (for anxiety). 13. Fentanyl patch 125-mcg transdermal patch q.72h. (to be titrated up as needed). . 14. Zofran 4-mg tablets one tablet by mouth q.4-6h. as needed (for nausea). 15. Heparin drip at 1100 units per hour until INR greater than 2. 16. Benadryl 25-mg tablets one tablet by mouth prior to transfusion of blood products. It should be noted that the patient's code is a full code. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**] Dictated By:[**Last Name (NamePattern1) 5843**] MEDQUIST36 D: [**2112-3-22**] 12:02 T: [**2112-3-22**] 12:37 JOB#: [**Job Number 97007**] Admission Date: [**2112-2-28**] Discharge Date: [**2112-3-22**] Date of Birth: [**2049-5-31**] Sex: F Service: ACOVE Medicine Service ADDENDUM: The patient is a 62-year-old female. This will serve as an Addendum to the Discharge Summary that was previously dictated. The [**Hospital 228**] hospital course did not change significantly for her metastatic pancreatic cancer. The patient's case was discussed with her primary oncologist (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 150**]) who felt that given the patient's poor functional status and extremely grim prognosis that the patient was likely not a candidate for palliative chemotherapy. For hypoxic respiratory failure, the patient continued on a 50% face mask. Her oxygen saturations ranged from 94% to 98%. The patient was also maintained on vancomycin, Zosyn, and Flagyl until she completed a 14-day course; which she completed prior to discharge. Otherwise, the patient had no further episodes of desaturations and no further admissions to the Medical Intensive Care Unit for hypoxic acute respiratory compromise. For diastolic congestive heart failure, the patient's goals were to maintain even input and output. She was started on a beta blocker at 12.5 mg twice per day for tachycardia. The patient's tachycardia was felt likely secondary to pain; although, in the setting of a deep venous thrombosis a pulmonary embolism could not be ruled out. For deep venous thrombosis, the patient had lower extremity Doppler studies given that she had asymmetric lower extremity edema which were significant for bilateral deep venous thrombosis extending from the femorals to the popliteals bilaterally. The patient was started on heparin and Coumadin. Her INR was not therapeutic at the time of discharge and was 1.4. The patient was to be continued on heparin drip at 1100 units per hour as well as Coumadin until her INR is greater than 2. This was to be continued at [**Hospital1 **]. For pain, the patient was maintained on a Fentanyl patch which was increased to 125 mcg q.72h. Her MS04 intravenous was discontinued, and the patient was continued on morphine sulfate immediate release at 30 mg one by mouth q.6h. with good pain control. For fluids/electrolytes/nutrition, the patient was continued on total parenteral nutrition and full liquids. Her diet should be advanced at [**Hospital1 **] as tolerated. The patient's total parenteral nutrition orders will be sent with the patient's discharge paperwork. For prophylaxis, the patient was maintained on heparin, and Coumadin, proton pump inhibitor, and a bowel regimen. She was also ambulated from bed to chair. For decubitus ulceration, the patient developed a decubitus ulceration to which Duoderm was applied and remained stable during her hospitalization. The patient's code status was full. For hematologic issues, the patient's hematocrit levels remained stable throughout her hospitalization. It should be noted that the patient has a transfusion reaction to blood and should be given Benadryl prior all blood transfusions. DISCHARGE DIAGNOSES: 1. Metastatic pancreatic cancer. 2. Bilateral lower extremity deep venous thrombosis. 3. Respiratory failure. 4. Status post nephrostomy. 5. Diastolic congestive heart failure. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient should have a follow-up appointment with her primary care physician within two weeks of discharge. 2. The patient should have her electrolytes and complete blood count checked regularly as she needed transfusions and will be on total parenteral nutrition. 3. The patient's INR level should also be checked to insure that she is therapeutically anticoagulated. 4. The patient's diet should be advanced as tolerated so that she can get off total parenteral nutrition if at all possible. CONDITION AT DISCHARGE: The patient's condition on discharge was fair. She was stable on 50% face mask without desaturations. She was tolerating total parenteral nutrition and full liquids. She was able to ambulate from bed to chair. Her blood counts have remained stable. DISCHARGE DISPOSITION: The patient was to be discharged to [**Hospital6 310**] for physical as well as pulmonary rehabilitation. MEDICATIONS ON DISCHARGE: (The patient's medications on discharge included) 1. Ipratropium nebulizers 1 q.6h. as needed. 2. Albuterol nebulizers 1 q.4h. as needed. 3. Albuterol nebulizers 1 q.4h. as needed. 4. Methylphenidate 5 mg one by mouth in the morning. 5. Morphine sulfate 30 mg one by mouth q.6h. as needed (for pain). 6. Pantoprazole 40 mg one by mouth once per day. 7. Metoprolol 12.5 mg one by mouth twice per day (to be advanced as tolerated). 8. Senna 8.5-mg tablets one tablet by mouth twice per day as needed. 9. Bisacodyl 5-mg tablets two tablets by mouth once per day as needed. 10. Docusate 100 mg one by mouth twice per day as needed. 11. Coumadin 5 mg one by mouth at hour of sleep (to be adjusted based on INR). 12. Lorazepam 0.5-mg tablets one tablet by mouth q.4-6h. as needed (for anxiety). 13. Fentanyl patch 125-mcg transdermal patch q.72h. (to be titrated up as needed). . 14. Zofran 4-mg tablets one tablet by mouth q.4-6h. as needed (for nausea). 15. Heparin drip at 1100 units per hour until INR greater than 2. 16. Benadryl 25-mg tablets one tablet by mouth prior to transfusion of blood products. It should be noted that the patient's code is a full code. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**] Dictated By:[**Last Name (NamePattern1) 5843**] MEDQUIST36 D: [**2112-3-22**] 12:02 T: [**2112-3-22**] 12:37 JOB#: [**Job Number 97008**]

[ "518.81", "038.49", "428.0", "707.0", "197.7", "996.65", "995.92", "591", "157.2" ]

icd9cm

[ [ [] ] ]

[ "38.93", "51.10", "99.07", "55.03", "96.71", "96.04", "99.04", "99.15" ]

icd9pcs

[ [ [] ] ]

19484, 19591

2859, 2882

18458, 18641

19618, 21087

18674, 19189

3061, 12672

19204, 19459

2902, 3038

327, 337

366, 2112

2137, 2552

2574, 2738

2755, 2842