ChanBeDu/relevant_section_length · Datasets at Hugging Face

7,930

151,398

52351

Discharge summary

report

Admission Date: [**2106-1-6**] Discharge Date: [**2106-2-17**] Date of Birth: [**2046-4-11**] Sex: M Service: SURGERY Allergies: Epogen Attending:[**First Name3 (LF) 668**] Chief Complaint: transfer from [**Hospital3 **] for hypotension and SOB Major Surgical or Invasive Procedure: [**2106-1-13**] Exploratory laparotomy, lysis of adhesions and stricturoplasty [**2106-1-10**] right IJ line placement [**2106-1-21**] Right-sided chest ultrasound, diagnostic and therapeutic thoracentesis. [**2106-2-10**] Paracentesis History of Present Illness: 59 yo man with hepatitis c, cirrhosis, ESRD on HD since [**Month (only) **] [**2104**], transferred from [**Hospital6 **]. He was admitted there from [**2106-1-3**] to present. He initially presented with sore throat and difficulty swallowing for about one week. At presentation, he denied any fever, chills, chest pain, shortness of breath, cough, abdominal pain, or other acute complaints. On presentation, he was found to be hypotensive with bp of 75/44 with pulse in normal range. He was bolused with IVF and admitted to the ICU. . Of note, the patient is known by his Nephrologist, Dr. [**First Name (STitle) **], to have chronically low blood pressure on order of sbp in 70-80 range. He otherwise remained asymptomatic. He underwent scheduled hemodialysis. He was initially treated with Penicillin VK and Fluconazole to cover both strep throat and possible Candidal esophagitis ([**Female First Name (un) **] is questionable by records; admission note reports white plaques, while all other notes, including ENT consult note after performing detailed inspection, do not describe this). On day of transfer, he complained of mild dyspnea as well. His antibiotics were switched over to Zithromax and he was given nebs. . Regarding his labs studies there: WBC 13.7 on admit; trended down to 9.7. Hct of 32.7 -> 28.5 Plt of 114 -> 80 BUN/Creat of [**11-17**].3. Urinalysis: mod LE, WBC [**1-18**], sm blood, mod bacteria, [**4-22**] epithelial cells Chest film: Mild atelectasis in right lung base . Oral culture: C. albicans (from d/c summary) Throat culture: No strep groups A, C, or G On interview here, he reports mild continued sore throat, but improved compared to previous. Resolution of rhinorrhea. No sinus symptoms. No headache or meningeal symptoms. No CP, SOB. Reports resolving mild cough with minimal sputum production. Does endorse some bilateral upper quadrant abdominal pain, worsened with cough or movement in bed. He reports this has been present for past several days. No encephalopathy. No n/v or hematemesis. No diarrhea or blood in stool. Past Medical History: - etoh cirrhosis (per OSH) with h/o hepatic encephalopathy - portal hypertension, + ascites, MELD 32 - no prior variceal bleeding - HCV - ESRD on HD (M/W/F) - AOCD - +TOB - LE edema - COPD - T3 hypothyroidism - h/o thrombocytopenia - DJD - h/o PNA, bronchitis - h/o paroxysmal SVT Social History: Married, lives with wife and mother-in-law. Used to work as an auto mechanic. Patient strongly denies every drinking heavily, used to have a "couple of beers" and stopped drinking anything after he was dx with liver dz. Unclear how he contracted Hep C. Smokes few cigarettes per day, ppd x 45 yrs, no IVDA. Family History: Etoh abuse, hyperlipidemia, thyroid disease, anemia Physical Exam: VS: T 97.8 HR 150 BP 89/53 RR 17 O2 Sat 99% on FT 50% GEN: sallow, NAD Skin: diffuse echymoses throughout HEENT: dry OP, erythema no thrush/lesions in posterior OP, mild icterus, PERRL CVS: tachy, regular, unable to appreciate any m/r/g Lungs: CTA. Dull at bases, no rales, wheezes, rhonchi Abd: protuerant, distended and firm, tender to percussion throughout, fluid wave +, tinpanic throughout, BS+, no rebound/guarding Ext: trace symmetric edema with venous stasis changes and induration Neuro: A&O x 3, full strength throughout, no asterixis Pertinent Results: Labs on admission:[**2106-1-6**] WBC-9.8 RBC-3.29* Hgb-10.9* Hct-33.4* MCV-102* MCH-33.2* MCHC-32.6 RDW-19.2* Plt Ct-55* PT-21.8* PTT-43.9* INR(PT)-2.1* Glucose-96 UreaN-11 Creat-4.2* Na-139 K-4.0 Cl-101 HCO3-32 AnGap-10 ALT-44* AST-86* LD(LDH)-353* AlkPhos-230* TotBili-1.6* Albumin-1.7* Calcium-8.1* Phos-1.2* Mg-1.6. Imaging: Abdominal ultrasound ([**1-7**]): 1. Markedly shrunken and cirrhotic liver with no focal liver lesions identified. 2. Massive ascites 3. Patent umbilical vein.. CXR ([**1-7**]): 1. Right middle lobe and right lower lobe opacities could be due to atelectasis or aspiration. 2. Unchanged COPD. CT chest ([**1-8**]): 1. Bilateral ground-glass opacities could represent infection or hemorrhage. 2. Right middle lobe and right upper lobe consolidations with element of atelectasis might be due to aspiration. The right middle lobe and right lower lobe atelectasis could be also secondary to high position of the hemidiaphragm. 3. The distal lumen of the right internal jugular line catheter terminates in IVC. 4. Severe ascites with cirrhotic appearance of the liver. 5. Cholelithiasis with no evidence of cholecystitis. 6. Left renal cortical cyst. Brief Hospital Course: 59yo man with ESLD, ESRD on HD, known chronic low blood pressure, chronic hepatitis C, COPD, paroxysmal SVT, thrombocytopenia transferred from outside hospital with likely bronchitis. Bronchitis/PNA: Repeat CXR with evidence of RLL and RML infiltrate. On levo/flagyl for ? aspiration PNA. D/c zithromax. Patient initially admitted to [**Hospital Ward Name 121**] 10, howver he was transferred to the MICU on HD 3 due to episode of ongoing SVT with HR to the 170's. He received adenosine x 4, diltiazem and Lopressor. EP evaluated and felt this was an atrial tachycardia and he was started on amiodarone drip. Also, on [**1-10**], his tunnelled dialysis catheter was replaced as the current line was felt to be too far into the atrium, potentially causing atrial irritation. On [**1-12**] the patient complained of abdominal pain, diffuse in nature and an increase in absominal distention. Patient also had 5 episodes of bilious, non-bloody emesis. NGT placed. No BM x 5 days per patient report. CT scan was obtained which demonstrated complete small bowel obstruction at the distal terminal ileum. After 12 hours of conservative management, a follow-up CT scan 12 hours did not demonstrate progression of the contrast. Patient taken to the OR for exploratory laparotomy, lysis of adhesions and stricturoplasty. Drain left in place following surgery with copius amounts of output. Replacement provided with NS and 5% Albumin. Blood cultures drawn on day of surgery yielded VRE. Patient had been started on Daptomycin on [**1-16**]. VAC dressing in place. Following the surgery, the patient remained hypotensive, treated with pressors. Remained on Amiodarone for SVT control. Followed by EP. Patient continued with a right sided pleural effusion. A bronchoscopy was performed on [**1-13**] with no evidence of obstruction. Mucous plugging was reported. As this was not responding a diagnostic and therapeutic thoracentsesis was performed on [**1-21**]. A right-sided moderate pleural effusion, most likely outside of thorax was reported with 1900 cc of fluid returned. Tube was not left in secondary to lack of further fluid remaining at the end of the procedure. Cultures of this fluid were no growth. Patient also followed by Renal. Due to continuing low BP's, patient was dialyzed using CVVHD. Patient received TPN while in ICU. Tube feeds were started, however these were discontinued due to patient intolerance and TPN remained in place via PICC line. On [**1-26**] patient had AVNRT converted with Adenosine. Converted to sinus with no recurrence. At this time, patient was on Amiodarone 200 mg PO BID and low dose beta blocker IV. In addition, on [**1-26**], the patient was presented at the Liver Transplant meeting, and the decision was made at that time that the patient would be placed on the inactive list due to the current severity of his illness. On [**1-28**], patient was complaining of worsening abdominal pain. CT of abdomen obtained showing multiple dilated loops of small bowel with air and gas and contrast seen in the colon, most likely representing postoperative ileus. There was also a focal region of small bowel wall thickening in the right abdomen, likely proximal-to-mid ileum. Patient continued with serial exams, no intervention at this time. ? mesenteric ischemia secondary to low BP's. Patient remained on pressors, with attempts to wean but keep SBP greater than 80. Over the next week patient was on and off pressors PRN, eventually not requiring pressure support and on [**2-4**] the patient was transfered to [**Hospital Ward Name 121**] 10. CVVHD was discontinued and intermittent HD started on [**1-29**] which patient has tolerated. Routine hemodialysis continued q M-W-F. Patient has received intermittent blood transfusions, transfused at dialysis. Patient has a reported allergy to Epoietin, however it is not documented what the reaction is. EP was consulted while patient on surgical floor for adjustment to cardiac meds. Amiodarone was drecreased to 200 QD and IV beta blocker converted to PO and then eventually d'/c'd on [**2-10**]. Tachycardia subsequently recurred necessitating restarting lopressor. Cardiology was consulted. Ablation for sinus tach was not felt to be an intervention that would have much success. Rate control was recommended with lopressor. Amiodarone was to continue. Dobhoff placed on [**2-5**]. Evaluated again by nutrition, recs implemented, however patient having difficulty tolerating TF with multiple BM's and feeling of fullness. TF was started very slowly and increased to goal of 40cc/hr. TPN was administered until [**2-12**]. Tube feedings were stopped briefly and resumed with diluted Nutren. TPN was also resumed on [**2106-2-17**] for insufficient caloric intake while increasing tube feeding. Paracentesis was performed for 3.5 liters on [**2-10**]. Albumin was given post paracentesis. Cell count was negative. WBC was 130 with 17 polys. Repeat paracentesis was done on [**2106-2-16**] with removal of 6 liters. WBC was 97 and polys 10. Last HD was [**2-17**]. Vital signs were notable for sbp of 90. He remained on lopressor and amiodarone for svt. Midodrine continued for hypotension. He will be d/c'd to rehab on TPN until tube feedings are at goal and tolerated. He will require periodic paracentesis per Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] ([**Telephone/Fax (1) 673**]). [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **], RN ([**Telephone/Fax (1) 10575**]should be called to schedule these taps. He will also follow up in the cardiology clinic on [**2-23**] at 1pm with Dr. [**Last Name (STitle) **]. Medications on Admission: Zithromax 250mg qD x 4d DuoNeb qid Nexium 40mg Cytomel 25mg [**Hospital1 **] Selenium 200mg Magnesium 400mg folate 1mg thiamine 100mg midodrine 10mg Mon/Wed/Fri before hemodialysis Lactinex 2 tab po TID Dulcolax supp prn Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation every four (4) hours as needed. 3. Midodrine 5 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Epoetin Alfa 10,000 unit/mL Solution Sig: dose to be administered in HD Injection ASDIR (AS DIRECTED). 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Liothyronine 25 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 10. Oxycodone 5 mg/5 mL Solution Sig: 5-10 mg PO Q6H (every 6 hours) as needed. 11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): hold for systolic bp<100 or hr<60. thank you. . 12. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 13. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 14. 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. 15. Picc line Care per protocol 16. Insulin Glargine 100 unit/mL Solution Sig: Three (3) units Subcutaneous at bedtime. 17. Insulin Lispro (Human) 100 unit/mL Solution Sig: follow sliding scale Subcutaneous four times a day. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: right pleural effusion COPD exacerbation HRS, on HD SVT/sinus tachycardia small bowel obstruction Anemia ascites, recurrent Discharge Condition: good Discharge Instructions: Please call Dr.[**Name (NI) 670**] office [**Telephone/Fax (1) 673**] if fever, chills, nausea, vomiting, increased abdominal pain/distension or drainage from abdominal wound/incision. Followup Instructions: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 62**] [**2-22**] at 1300[**Hospital **] clinic. [**Hospital Ward Name 23**] Center, [**Hospital1 18**] Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2106-3-4**] 11:40 Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 11082**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2106-3-30**] 10:10 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2106-2-26**] 3:20 Completed by:[**2106-2-17**]

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icd9cm

[ [ [] ] ]

[ "54.91", "33.24", "54.59", "99.04", "99.07", "39.95", "99.05", "38.93", "96.6", "99.15", "00.17", "45.02", "99.06", "34.91", "96.07", "33.22" ]

icd9pcs

[ [ [] ] ]

12694, 12773

5131, 10789

319, 557

12941, 12948

3932, 3937

13182, 13778

3298, 3351

11061, 12671

12794, 12920

10815, 11038

12972, 13159

3366, 3913

225, 281

585, 2651

3950, 5108

2673, 2956

2972, 3282

57,052

112,122

38161

Discharge summary

report

Admission Date: [**2189-9-2**] Discharge Date: [**2189-9-8**] Date of Birth: [**2126-8-23**] Sex: M Service: CARDIOTHORACIC Allergies: Nifedipine / Metoprolol Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2189-9-2**] - Aortic valve replacement (23mm St. [**Male First Name (un) 923**] mechanical valve), Ascending aorta replacement(30mm Gelweave tube graft). History of Present Illness: 62 year old gentleman with a history of a bicuspid Aortic valve and moderate Aortic stenosis who has been followed by serial echocardiograms. He notes increasing exertional dyspnea and fatigue over the past several months. Past Medical History: Bicuspid aortic valve Aortic stenosis Aortic aneurysm Hypertension GERD Social History: Lives with: significant other, [**Name (NI) **] Occupation: Retired maintainance technician Tobacco: None ETOH: 7/week Family History: Father had bicuspid Ao valve and AVR-died 69yo of "clot". Brother has bicuspid valve and arrhythmia problem. Physical Exam: Pulse: 55 Resp: 16 O2 sat: B/P Right: 110/74 Left: 118/70 Height: 72" Weight: 210 lbs General: NAD, well appearing Skin: Dry [x] intact [x] HEENT: NCAT [] PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] JVD[x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] [**2-14**] sys murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema -none right groin cath site- no erythema or drainage, tiny hematoma at puncture site, non-tender Varicosities: None [] small spider veins Neuro: Grossly intact, nonfocal exam Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit- Right: Left: none Pertinent Results: [**2189-9-2**] ECHO PREBYPASS No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Overall right ventricular systolic function is normal with normal free wall contractility. The aortic root is mildly dilated at the sinus level. There is a focal calcification in the aortic root measuring 8mm x 4mm. The ascending aorta is markedly dilated with a maximum diameter of 5.1 cm. The aortic arch is normal. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve is bicuspid with severely thickened/deformed aortic valve leaflets. A fibrinous echodensity is present on the aortic side of the non-coronary cusp of the aortic valve, consistent degenerative disease (suggest clinical correlation). There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results at the time of the study. POSTBYPASS The patient is A-paced and is on an intermittent phenylephrine infusion. A new mechanical aortic valve is seen. It is well-seated with washing jets in the expected locations. There is trace aortic insufficiency in total. Calculated aortic valve area is 2.0 cm2 with peak and mean gradients of 36 mmHg and 18 mmHg respectively at a cardiac output of about 6 liters/minute. An ascending aortic graft is seen. Thoracic aorta is otherwise normal. Left ventricular systolic function continues to be normal (LVEF>55%). Mild (1+) mitral regurgitation persists. Pre-op [**2189-9-2**] 09:38AM HGB-13.5* calcHCT-41 [**2189-9-2**] 09:38AM GLUCOSE-103 LACTATE-1.2 NA+-137 K+-3.7 CL--105 [**2189-9-2**] 12:30PM PT-16.2* PTT-31.0 INR(PT)-1.4* [**2189-9-2**] 12:30PM WBC-13.6*# RBC-2.70*# HGB-8.8*# HCT-26.2*# MCV-97 MCH-32.7* MCHC-33.6 RDW-12.9 [**2189-9-2**] 02:07PM UREA N-10 CREAT-0.6 SODIUM-140 POTASSIUM-4.4 CHLORIDE-111* TOTAL CO2-22 ANION GAP-11 [**2189-9-6**] 07:15AM BLOOD WBC-6.9 RBC-2.88* Hgb-9.4* Hct-28.2* MCV-98 MCH-32.8* MCHC-33.5 RDW-13.0 Plt Ct-255# [**2189-9-7**] 09:25AM BLOOD PT-22.5* PTT-59.2* INR(PT)-2.1* [**2189-9-6**] 07:15AM BLOOD Glucose-104* UreaN-7 Creat-0.8 Na-140 K-4.0 Cl-104 HCO3-29 AnGap-11 Brief Hospital Course: Mr. [**Known lastname 85120**] was admitted to the [**Hospital1 18**] on [**2189-9-2**] for surgical management of his aortic valve stenosis and ascending aortic aneurysm. He was taken directly to the operating room where he underwent an aortic valve replacement with a 23mm St. [**Male First Name (un) 923**] mechanical valve and replacement of his ascending aorta. His bypass time was 89 minutes with a crossclamp time of 66 minutes. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Over the next several hours, he awoke neurologically intact and was extubated. On POD 1 the patient was transferred to the telemetry floor for further recovery. All chest tubes and pacing wires and other lines were removed per cardiac surgery protocol. Initially beta blocker was started at a low dose due to a systolic blood pressure. Betablocker was increased slowly because the patient did have junctional rhythm with stable systolic pressure. Low dose lisinopril was also resumed. He was diuresed toward the preoperative weight. He was started on Coumadin with heparin bridge for aortic mechanical valve. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD #6 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics and his INR was therapuetic. Couamdin dosing will be followed by the [**Hospital **] [**Hospital 197**] clinic with a goal INR 2.5-3.0. The patient was discharged home with visitng nurse services in good condition with appropriate follow up instructions. Medications on Admission: Lisinopril 5', HCTZ 25', protonix 40', MVI Discharge Medications: 1. Aspirin 81 mg [**Hospital 8426**], Delayed Release (E.C.) Sig: One (1) [**Hospital 8426**], Delayed Release (E.C.) PO DAILY (Daily). Disp:*100 [**Hospital 8426**], Delayed Release (E.C.)(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Pantoprazole 40 mg [**Hospital 8426**], Delayed Release (E.C.) Sig: One (1) [**Hospital 8426**], Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 [**Hospital 8426**], Delayed Release (E.C.)(s)* Refills:*0* 4. Oxycodone-Acetaminophen 5-325 mg [**Hospital 8426**] Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 [**Hospital 8426**](s)* Refills:*0* 5. Acetaminophen 325 mg [**Hospital 8426**] Sig: Two (2) [**Hospital 8426**] PO Q4H (every 4 hours) as needed for pain. 6. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO twice a day: 20mEq [**Hospital1 **] x 1 week the 20mEq QD x 1 week. Disp:*45 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 7. Lisinopril 2.5 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO once a day. Disp:*30 [**Hospital1 8426**](s)* Refills:*2* 8. Metoprolol Tartrate 25 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO TID (3 times a day). Disp:*90 [**Hospital1 8426**](s)* Refills:*2* 9. Lasix 20 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO twice a day: [**Hospital1 **] x 1 week then QD x1 week. Disp:*21 [**Hospital1 8426**](s)* Refills:*0* 10. Warfarin 5 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO ONCE (Once) for 1 doses. Disp:*1 [**Hospital1 8426**](s)* Refills:*0* 11. Warfarin 2 mg [**Hospital1 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] once a day: INR goal 2.5-3 mech AVR. Disp:*120 [**Last Name (Titles) 8426**](s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA, [**Hospital1 1559**] Discharge Diagnosis: Aortic stenosis/Ascending aortic aneurysm, s/p Aortic valve replacement (23mm St. [**Male First Name (un) 923**] mechanical valve), Ascending aorta replacement(30mm Gelweave tube graft). Hypertension GERD Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with percocet Incisions: Sternal - healing well, no erythema or drainage Edema: trace bilateral pedal edema Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage 2) Please NO lotions, cream, powder, or ointments to incisions 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart 4) No driving for approximately one month until follow up with surgeon 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] at [**Hospital 18**] clinic [**2189-9-24**] at 1:45 PM, **Please have CXR done prior to clinic appointment Cardiologist Dr.[**Last Name (STitle) 4610**] [**2189-10-7**] at 2:00 PM Please call to schedule appointments with your: Primary Care Dr.[**Doctor Last Name 27303**] [**Telephone/Fax (1) 85121**] in [**4-13**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication: Mechanical aortic valve Goal INR 2.5-3.0 First draw [**2189-9-9**] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then as directed by Dr [**Last Name (STitle) 4610**] through [**Hospital **] [**Hospital 197**] Clinic Results to [**Hospital1 **] coumadin clinic-fax [**Telephone/Fax (1) 33001**] Completed by:[**2189-9-8**]

[ "424.1", "746.4", "285.9", "530.81", "458.29", "441.2", "401.9", "276.2", "V58.61" ]

icd9cm

[ [ [] ] ]

[ "35.22", "38.45", "39.61" ]

icd9pcs

[ [ [] ] ]

8099, 8172

4449, 6106

308, 467

8421, 8614

1918, 4426

9385, 10353

969, 1080

6199, 8076

8193, 8400

6132, 6176

8638, 9362

1095, 1899

249, 270

495, 721

743, 816

832, 953

72,163

174,752

34824

Discharge summary

report

Admission Date: [**2188-3-14**] Discharge Date: [**2188-5-10**] Date of Birth: [**2105-3-31**] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 64**] Chief Complaint: Acute R knee pain; R knee infection Major Surgical or Invasive Procedure: [**2188-3-14**]: ortho - I&D of R knee and polyethylene exchange [**2188-3-27**]: ortho - I&D of R knee wound and manipulation under anesthesia [**2188-4-4**]: plastics - R knee gastrocnemius flap [**2188-4-24**]: thoracics - PEG placement [**2188-4-24**]: thoracics - tracheostomy [**2188-4-29**]: PICC placement [**2188-5-6**]: interventional radiology - post-pyloric dobhoff History of Present Illness: Mr. [**Known lastname 79747**] had a total knee arthroplasty performed on [**2188-3-4**] and did very well postoperatively until the day before admission when he had acute onset of R knee pain. He had a temperature of 101 at home and was taken to an OSH ED where he was transferred to [**Hospital1 18**]. Past Medical History: HTN, Peripheral neuropathy, elevated cholesterol, and osteoarthritis, carotid bruit, right carotid has between 16 and 49% ICA stenosis, same on the left, both with antegrade flow on this [**8-/2187**] study. R TKA [**2188-3-4**] Social History: He is a retired executive from the Emhart Corporation. He is a widower. He lives in [**State 3914**], a former smoker, smoked up to two packs per day, but quit after smoking for about 45 years. He drinks two glasses of alcohol per day. Family History: Positive for cancer in his brother and in-laws. Mother had cardiomyopathy and cardiac hypertrophy, father had a CVA, lung disease in a brother, COPD. [**Name2 (NI) **] disease in a brother. Daughter has skin cancer. Physical Exam: At the time of discharge: Satting 96% on trach mask VS: Tm 99.6, Tc 99, HR 78, BP 118/44, RR 32 GEN: awake and alert, responds to simple commands, no acute distress HEART: RRR, distant S1/S2 LUNGS: coarse diffuse breath sounds [**Last Name (un) **]: soft, nontender, PEG tube clamped off with trace amount of yellow output EXTREM: non-edematous, no rashes. Dressing in place over right knee. Pertinent Results: [**2188-3-14**] 01:40AM BLOOD WBC-19.7*# RBC-3.15* Hgb-10.0* Hct-30.1* MCV-96 MCH-31.9 MCHC-33.3 RDW-14.1 Plt Ct-388# [**2188-3-15**] 06:20AM BLOOD WBC-15.7* RBC-2.36*# Hgb-7.6* Hct-23.3* MCV-99* MCH-32.2* MCHC-32.7 RDW-13.9 Plt Ct-261 [**2188-3-16**] 05:50AM BLOOD WBC-11.5* RBC-2.72* Hgb-8.6* Hct-25.6* MCV-94 MCH-31.7 MCHC-33.7 RDW-14.9 Plt Ct-250 [**2188-3-17**] 04:30AM BLOOD WBC-10.2 RBC-2.80* Hgb-8.8* Hct-26.6* MCV-95 MCH-31.5 MCHC-33.1 RDW-14.5 Plt Ct-298 [**2188-3-18**] 04:47AM BLOOD WBC-7.7 RBC-2.69* Hgb-8.5* Hct-25.1* MCV-93 MCH-31.6 MCHC-33.8 RDW-15.1 Plt Ct-337 [**2188-3-19**] 11:00AM BLOOD WBC-7.9 RBC-2.69* Hgb-8.4* Hct-25.5* MCV-95 MCH-31.1 MCHC-32.8 RDW-15.2 Plt Ct-365 [**2188-3-20**] 06:33AM BLOOD WBC-9.2 RBC-2.77* Hgb-8.6* Hct-26.3* MCV-95 MCH-31.0 MCHC-32.6 RDW-14.9 Plt Ct-401 [**2188-3-14**] 01:40AM BLOOD Plt Smr-NORMAL Plt Ct-388# [**2188-3-15**] 06:20AM BLOOD PT-19.4* PTT-38.1* INR(PT)-1.8* [**2188-3-14**] 01:40AM BLOOD Glucose-125* UreaN-24* Creat-0.9 Na-135 K-4.2 Cl-101 HCO3-22 AnGap-16 [**2188-3-15**] 06:20AM BLOOD Glucose-117* UreaN-33* Creat-1.8* Na-132* K-4.5 Cl-103 HCO3-20* AnGap-14 [**2188-3-16**] 05:50AM BLOOD UreaN-42* Creat-2.2* Na-132* K-4.1 Cl-104 [**2188-3-17**] 04:30AM BLOOD Glucose-103 UreaN-39* Creat-2.0* Na-137 K-3.9 Cl-110* HCO3-19* AnGap-12 [**2188-3-18**] 04:47AM BLOOD Glucose-114* UreaN-37* Creat-2.1* Na-139 K-4.0 Cl-109* HCO3-23 AnGap-11 [**2188-3-19**] 11:00AM BLOOD Glucose-147* UreaN-31* Creat-1.8* Na-138 K-3.7 Cl-107 HCO3-21* AnGap-14 [**2188-3-20**] 06:33AM BLOOD Glucose-100 UreaN-28* Creat-1.8* Na-138 K-4.0 Cl-107 HCO3-22 AnGap-13 [**2188-3-17**] 04:30AM BLOOD ALT-54* AST-103* LD(LDH)-291* AlkPhos-73 TotBili-2.4* [**2188-3-19**] 11:00AM BLOOD ALT-37 AST-47* AlkPhos-69 TotBili-2.2* [**2188-3-15**] 06:20AM BLOOD Calcium-7.4* Phos-3.7 Mg-2.2 [**2188-3-20**] 06:33AM BLOOD Calcium-7.8* Phos-3.0 Mg-2.3 Micro: culture and sensitivities from 4 OR specimens and from ED aspiration all grew pan sensitive MSSA. Tissue [**3-14**]: Staph aureus | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S Abdomenal ultrasound ([**4-17**]): 1. Normal appearance of the gallbladder and liver 2. Bilateral renal cysts. 3. Single septation and equivocal nodularity in a cyst arising from the lower pole of the right kidney. No vascular flow seen, but suggested MRI of the kidney suggested for more definitive assessment. Chest x-ray ([**5-4**]) When compared to the prior studies, there has been no appreciable change. Tracheostomy is appropriately placed and unchanged. There is again noted areas of confluent opacities within the left lower and left upper lobes as well as within the right perihilar and peripheral areas in the right lung. These are all relatively stable and can be consistent with sequela of ARDS or more chronic fibrotic changes as described on multiple previous examinations. ABG prior to discharge ([**4-10**]): 7.45/35/108 Brief Hospital Course: The patient was admitted on [**2188-3-14**] after being evaluated in the ED and having his knee aspirated. Later that day, he was taken to the operating room by Dr. [**Last Name (STitle) **] for R knee I&D and liner exchange without complication. Please see operative report for details. Postoperatively the patient did well. The patient was initially treated with a PCA followed by PO pain medications on POD#1. Infectious disease was consulted. The patient was started preoperatively on vancomycin and this was continued until culture results returned. His cultures from the ED joint aspiration and from the OR grew back pan sensitive MSSA. ID recommended changing antibiotics to Nafcillin, which we did. They were to start rifampin once LFTs normalized. A PICC line was placed for long term antibiotics. He was started on lovenox for DVT prophylaxis starting on the morning of POD#1. The patient had two drains that were maintained until POD 2. He was kept in a knee immobilizer for 2 days and then worked with physical therapy. The Foley catheter was removed without incident. The surgical dressing was removed on POD#2 and the surgical incision was found to be clean and dry but with a 4x4 cm area of congested skin overlying the patella and straddling the incision. This area eventually desquamated and a beefy red dermal layer was seen below. Plastics was consulted and we discussed whether a gastroc flap would be appropriate, ultimately it was decided that we should treat the wound conservatively and see where the line of demarcation would be and if there was any viable tissue. Regranex was started to help with skin growth. The patient returned to the OR on [**3-27**] for a wound debridment and R knee manipulation under anesthesia. After the procedure, the regranex was changed to [**Hospital1 **] bacitracin. During the procedure and through the following days, the wound began to develop an eschar. As conservative treatment was failing, plastics was reconsulted. He was taken to the OR on [**4-4**] with plastic surgery for a gastroc flap; he was sent to the [**Hospital Unit Name 153**] postop for a transient pressor requirement. He was weaned from pressors within the first hour in the [**Hospital Unit Name 153**] and was transferred back to the floor by POD1. His routine labs showed an elevated creatinine of 2.2. Nephrology was consulted and it was felt that he had some ATN. He was hydrated aggressively and creatinine trended back down to normal. Additionally he was found to have elevated LFTs with an elevated Tbili. An ultrasound was done which showed a normal gallbladder without evidence of obstruction. He did not have any abdominal pain. He was transferred to [**Hospital Unit Name 153**] after hypoxia on the floor. MEDICAL INTENSIVE CARE UNIT HOSPITAL COURSE BELOW: 1. Acute Respiratory Distress: He was initially placed on 4L nasal cannula and then required NRB. He was given 40 mg IV lasix on the floor and put out 900 cc urine prior to transfer with symptomatic relief. On arrival to the MICU he was speaking in full sentences, comfortable, and subjectively improved. A CXR was consistent with worsening pulmonary edema/CHF vs infection. CHF was supported by increased BNP. He was given additional IV Lasix. Because of concern for aspiration PNA, he underwent speech and swallow evaluation which was normal. CE and EKG in the unit were negative for MI. Over the course of several days, his respiratory distress worsened requiring BiPAP. His CXR showed interval worsening of infiltrates and raised concern for ARDS. He was also intermittantly febrile. He was therefore intubated on [**4-12**] and treated with Vancomycin and Meropenem for hospital acquired pneumonia, although no organism was ever isolated. His condition did not improve for over 12 days and in the interim he was started on Azithromycin and Flagyl to cover for anerobes and atypicals. Patient had also been trialed on five day course of steroids. He ultimately underwent tracheostomy placement, and over the ensuing days was weaned off the vent and placed on trach mask. Unfortunately, he had an aspiration event after coming off the vent and his respiratory status worsened. He was started back on vanco and Zosyn for HAP/aspiration pna and should complete an 8-day course of vanco/Zosyn to end on [**5-14**]. At time of discharge, he is maintaining good oxygenation on trach mask, with high flow oxygen at FiO2 of 50%. Patient had also been diursed during his hospital course using a lasix drip to euvolemic state. 2. Septic Knee / Infection: He had an increasing WBC count while in the unit. He was continued on meropenem and rifampin while in the unit as per ID recs. Antibiotics were then changed to levofloxacin and rifampin for treatment of septic knee. While he was treated for HAP as above, the Levo and Rifampin were temporarily stopped. However, these SHOULD BE RESTARTED when he finishes the eight-day course of vanc/Zosyn as above for HAP. He was seen routinely by physical therapy. The operative extremity was neurovascularly intact. After the gastroc flap procedure, he was followed by plastics. They have recommended that he continue 45 degree flexion until [**5-9**], at which time he can progress to 90 degree flexion until [**5-16**], then full range-of-motion as tolerated. Antibiotics for septic knee should resume with levo 500mg daily and Rifampin 300mg [**Hospital1 **] on [**5-14**]. 3. Hypotension: Patient had intermittent periods of hypotension requiring use of levophed. It was unclear if patient's hypotension was related to sepsis (likely not). At time of discharge, he has been stable off pressors for over one week with good blood pressures. 4. Gastric Dysmotility / Food and Nutrition: While in the unit, a PEG tube was placed due to prolonged intubation and altered mental status. He was started on tube feeds through the PEG but was noted to have high residuals, in addition to which he aspirated resulting in pneumonia as outlined above. There was concern about ileus versus obstruction, the PEG was placed to suction and he was started on TPN. CT abdomen with PO contrast showed no obstruction. A post-pyloric tube was placed and tube feeds started without complication. The TPN was weaned off. At time of discharge, he continues on tube feeds. In 4 to 6 weeks, he should follow-up with thoracics to discuss removal of the post-pyloric tube and repositioning of the PEG tube into the small bowel. This procedure must wait until the PEG tube tract has had a chance to mature, which generally takes 4 to 6 weeks. Note that both the tracheostomy and PEG tube were placed by the thoracics service (Dr. [**Last Name (STitle) **]. 5. Anemia: His hematocrit was generally stable in the mid 20s. The cause for his anemia was thought to be multifactorial in setting of chronic disease, frequent phlebotomy, and blood loss from procedures. On the day of discharge, he was transfused one unit PRBCs for hematocrit of 22. 6. Disposition and Follow-up Plans: He should follow-up in plastics clinic one week after discharge: [**Telephone/Fax (1) 4652**]. He should follow-up with Dr. [**Last Name (STitle) **] in orthopedics clinic in 2 weeks: [**Telephone/Fax (1) 79748**], and should continue Lovenox until that follow-up. He should follow-up in [**Hospital **] clinic with Dr. [**Last Name (STitle) 11482**] Pe??????[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]: [**Telephone/Fax (1) 170**]. He should follow-up in infectious diseases clinic with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. An appointment has been made for [**2188-5-27**] at 10am in the [**Hospital **] Medical Office Bldg at [**Doctor First Name **] on the ground floor. Dr. [**Last Name (STitle) **] has requested that all laboratory results be faxed to infectious disease R.Ns. at [**Telephone/Fax (1) 432**]. All questions regarding outpatient antibiotics should be directed to the when clinic is closed. 6. Code Status: His code status is DNR/DNI, as confirmed with his daughter and health-care proxy, [**Name (NI) **]. Medications on Admission: amlodipine 10 mg daily, lisinopril 10 mg daily, simvastatin 40 mg one-half tablet daily, ascorbic acid 500 mg daily, aspirin 81 mg daily, cyanocobalamin 500 mcg daily, glucosamine chondroitin daily, ibuprofen 600 mg daily, multivitamin with [**Last Name (LF) **], [**First Name3 (LF) 14595**] lipoic acid, and vitamin E. Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 2. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: do not take more than 4 grams of tylenol per day. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. 6. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous DAILY (Daily) for 3 weeks. 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Aspirin 81 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Rifampin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours): Start on [**5-15**] and continue until follow-up in infectious diseases clinic. 10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours). 11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 12. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-11**] Drops Ophthalmic PRN (as needed). 13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 14. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 15. Ferrous Sulfate 300 mg (60 mg [**Month/Day (2) **])/5 mL Liquid Sig: One (1) PO DAILY (Daily). 16. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours): Continue for eight days until [**5-14**]. 17. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours): Continue for eight days until [**5-14**]. 18. Insulin Regular Human 100 unit/mL Solution Sig: ASDIR Injection ASDIR (AS DIRECTED): per sliding scale. 19. Metoclopramide 5 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours). 20. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 21. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours). 22. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 23. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 24. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 25. Levofloxacin 25 mg/mL Solution Sig: Three (3) Intravenous once a day: Start on [**5-15**] after vanco/Zosyn finished. Continue until follow-up in infectious diseases clinic. 26. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 27. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Infected right total knee arthroplasty Acute respiratory distress syndrome Aspiration pneumonia Gastric dysmotility Discharge Condition: Stable Discharge Instructions: experience severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers >101.5, shaking chills, redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your PCP regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You may not drive a car until cleared to do so by your surgeon or your primary physician. 5. Please keep your wounds clean. You may get the wound wet or take a shower starting 5 days after surgery, but no baths or swimming for at least 4 weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out in clinic by Dr. [**Last Name (STitle) **]. 7. Please call your Dr. [**Last Name (STitle) **] office to schedule or confirm your follow-up appointment at 2 weeks. 8. Please DO NOT take any NSAIDs (i.e. celebrex, ibuprofen, advil, motrin, etc). 9. ANTICOAGULATION: Please continue your lovenox for 3 weeks to prevent deep vein thrombosis (blood clots). After completing the lovenox, please take Aspirin 325mg twice daily for an additional three weeks. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower after POD#5 but do not take a tub-bath or submerge your incision until 4 weeks after surgery. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by VNA in 2 weeks. If you are going to rehab, the rehab facility can remove the staples at 2 weeks. 11. VNA (once at home): Home PT/OT, dressing changes as instructed, wound checks, and staple removal at 2 weeks after surgery. please draw CBC,ESR,CRP, LFT, BUN, CREAT when home every week per ID. 12. ACTIVITY: Weight bearing as tolerated on the operative leg. No strenuous exercise or heavy lifting until follow up appointment. ***Continue to use your CPM machine as directed.*** . 13. Antibiotics: Please continue vancomycin and zosyn through [**5-14**]. Once these are discontinued, please restart LEVAQUIN 500 PO QDAY AND RIFAMPIN 300MG PO BID FOR KNEE INFECTION. These can be continued through his follow-up appointment with infectious disease. Physical Therapy: Per plastics. Okay for WBAT and ROM as tolerated per ortho. Treatments Frequency: Physical therapy -- WBAT. Wound checks. VNA to remove staples at 2 weeks. Followup Instructions: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13447**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2188-4-29**] 11:30 He should follow-up in plastics clinic one week after discharge: [**Telephone/Fax (1) 4652**]. He should follow-up with Dr. [**Last Name (STitle) **] in orthopedics clinic in 2 weeks: [**Telephone/Fax (1) 79748**], and should continue Lovenox until that follow-up. He should follow-up in [**Hospital **] clinic with Dr. [**Last Name (STitle) 11482**] Pe??????[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]: [**Telephone/Fax (1) 170**]. He should follow-up in infectious diseases clinic with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. An appointment has been made for [**2188-5-27**] at 10am in the [**Hospital **] Medical Office Bldg at [**Doctor First Name **] on the ground floor. Dr. [**Last Name (STitle) **] has requested that all laboratory results be faxed to infectious disease R.Ns. at [**Telephone/Fax (1) 432**]. All questions regarding outpatient antibiotics should be directed to the when clinic is closed. Completed by:[**2188-5-10**]

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icd9cm

[ [ [] ] ]

[ "96.04", "83.82", "86.74", "99.15", "38.93", "96.6", "86.22", "43.11", "93.16", "96.72", "00.84", "31.1", "86.86" ]

icd9pcs

[ [ [] ] ]

16584, 16650

5395, 12387

353, 735

16810, 16819

2241, 5372

19429, 20568

1594, 1813

13858, 16561

16671, 16789

13512, 13835

16843, 18087

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19249, 19309

19331, 19406

12404, 13486

278, 315

18099, 19231

763, 1070

1092, 1322

1338, 1578

5,129

139,355

6892+55800

Discharge summary

report+addendum

Admission Date: [**2201-1-13**] Discharge Date: [**2201-1-20**] Date of Birth: [**2126-10-7**] Sex: F Service: MEDICINE Allergies: Alcohol / Tapazole / Shellfish / Prozac / Biaxin / Sudafed Attending:[**First Name3 (LF) 759**] Chief Complaint: shortness of breath x 2 weeks Major Surgical or Invasive Procedure: None History of Present Illness: 74 yo F w/ h/o COPD, and HTN who presents c/o SOB x 2 weeks. Patient feeling well until [**10-29**] when she was admitted to OSH for CP and dyspnea. Patient admitted to MICU at OSH for HTN urgency and treated with nitro gtt. She was ruled out for MI w/ neg trop, and persantine MIBI done was normal. . Since d/c from the OSH, patient reports feeling unwell with a "cold" over the last 3 weeks. She c/o cough w/ clear sputum, congestion, and aches over this time. Denies F/C, abd pain, or N/V. Also c/o pain starting in her back w/ coughing x 2 weeks. She reports this pain also spreads around to her chest. Reports sharp CP mostly w/ coughing, usually self-limited, but ocassionally lasts up to 30 minutes. No radiation of pain. . Over last 2 days, patient reports worsening of her SOB. +decreased exercise tolerance, no longer able to ambulate around her apartment. Also reports sputum changing to yellow over last 2 days. Still denies any fevers or chills. Some LE edema, stable. Reports increased orthopnea over last couple of weeks. +sick contact - son and granddaughter w/ "cold." Patient had flu shot this year and pneumovax last year. Patient reports feeling "terrible" this AM w/ increased SOB, went to PCP for [**Name9 (PRE) **] who sent patient to [**Hospital1 18**] ED. . Of note, patient has abrasion on left cheek. On further inquiry, patient admits to fall w/ syncope 3 days ago. She reports dog jumped on her, knocked her to ground, she hit head and "passed out." Denies headache currently, and denies HA after event. . In ED, patient w/ O2 sat of 66% on RA, improved to 90's on NRB. Given nebs, prednisone, and azithromycin. CXR negative. CTA ordered. ABG 7.34/67/231 on NRB. Past Medical History: COPD (no [**Hospital1 1570**]'s on file here) HTN Migraines Insomnia Hypoglycemia Motion Sickness Normal pMIBI [**10-29**] at [**Hospital 8125**] Hospital Social History: Lives alone in apartment in son's house. Son works for [**Location (un) **] fire dept. +h/o tobacco ([**1-25**] PPD x 60yrs) quit 2 weeks ago. Denies EtOH or drug use. Family History: Son (24) and daughter (42) both deceased [**12-26**] to malignant brain tumors. Physical Exam: VS: T: 97.5; HR: 95; BP: 169/70; RR 20; O2 98% FaceTent @10L GEN: elderly woman, lying in bed, speaking in full sentences, NAD HEENT: PERRL bilat, EOMI bilat, anicteric, dryMM, OP clear NECK: JVP not elevated CV: RRR, normal s1s2, no murmurs, no S3/S4 CHEST: some accessory muscle use. +exp wheezes bilaterally, poor air movement; no crackles. ABD: NABS, soft, ND, NT, no masses EXT: trace pedal edema bilaterally NEURO: A&Ox3, CN 2-12 intact bilat, strength 5/5 in UE/LE bilaterally, sensory exam intact bilat Pertinent Results: [**2201-1-13**] 07:40PM BLOOD pO2-231* pCO2-67* pH-7.34* calTCO2-38* Base XS-7 [**2201-1-13**] 05:40PM BLOOD CK-MB-7 proBNP-444 [**2201-1-13**] 05:40PM BLOOD cTropnT-<0.01 [**2201-1-13**] 08:19PM BLOOD ALT-20 AST-30 AlkPhos-102 TotBili-0.2 [**2201-1-13**] 05:40PM BLOOD Glucose-120* UreaN-15 Creat-0.7 Na-125* K-5.9* Cl-87* HCO3-31 AnGap-13 [**2201-1-13**] 05:40PM BLOOD WBC-5.9 RBC-4.22 Hgb-14.2 Hct-39.5 MCV-94 MCH-33.7* MCHC-36.0* RDW-13.8 Plt Ct-251 . CTA: 1. No evidence of thoracic aortic dissection or pulmonary embolism. 2. Atherosclerotic calcifications of the aorta and coronary arteries. 3. Small pericardial effusion. 4. Emphysema. 5. Small hypodensity in the right lobe of the thyroid. This could be further evaluated with ultrasound on a nonemergent basis. 6. Atrophic right kidney, partially imaged. There appears to be compensatory hypertrophy of the left kidney. 7. Compression deformities of the T5 and T7 vertebral bodies, acuity indeterminate. . Brief Hospital Course: 74 yo F w/ h/o COPD, and HTN who presents c/o SOB, cough, CP, and recent syncopal episode. The following issues were investigated during this hospitalization: . #) COPD exacerbation: Pt's shortness of breath and hypoxia (Pa02 of 60% on presentation) were thought to be from COPD exacerbation. CHF felt to be unlikely given lack of findings on exam and BNP 444. PE ruled out with CTA. EKG unremarkable. Recent normal MIBI. Her COPD exacerbation was likely due to bronchitis vs. viral URI. Given the severity of her exacerbation, she was initially admitted to the MICU, where she recieved frequent nebs, IV solumedrol, and levofloxacin. She did not require intubation. She was gradually tapered down to 3L NC. Pt was eventually transferred to the medicine wards. Her steroids were changed to gradual, prednisone taper. Her nebs were changed to MDI w/ spacer. As well, she completed 7days of levofloxacin. Pt responded well to these therapies, though she continued to have 02 requirement. Her oxygen saturations with ambulation were ~87-89% on 3L. Of note, she has no known PFTs. She will need these as an outpatient, once her acute flare has resolved. Additionaly, she would likely benefit from outpatient pulmonary follow-up, for which she is scheduled. Lastly, smoking cessation was encourage & she received nicotine patch. . # CP: Pt complained of sharp back & chest pain that were mostly associated w/ cough. Though this discomfort was thought to be musculoskeletal pain or pleurisy related to URI, she was ruled out for MI & had CTA to rule out PE. As above, pt had unremarkable EKG as well as history of recent normal MIBI. . # HYPONATREMIA: Though to be related to HCTZ. Serum Na dropped as low 125. Improved with fluid restriction and holding HCTZ. . # S/P SYNCOPE/FALL: Story consistent with mechanical fall. Patient reports to fall w/ syncope 3 days prior to admission, when her dog jumped on her, knocked her to ground, she hit head and "passed out." No headache during hospitalization, nor any at the time of the event. Neuro exam non-focal. Given that she was doing well several days out from event, no imaging was undertaken as it is unlikely that she developed SDH. . # Vertebral compression fractures: Incidentally discover T5 and T7 compression fractures on CT. Acuity unknown. No pain. She was started on Calcium and Vitamin D and SPEP/UPEP was negative. Patient will be referred to PCP for outpatient [**Name9 (PRE) 8019**] of etiology and further treatment. . # HTN: Patient had hypertensive urgency on admission. Required IV hydralazine while in MICU to bring down BP. Her PO meds were up-titrated to improve BP control. Confirmed w/ PCP that patient is both on [**Last Name (un) **] and ACEi. She was maintained on this regiment with good effect. Medications on Admission: Hyzaar 100/25mg (2 tab) PO daily Advair 250/50mcg 1 puff INH [**Hospital1 **] Aspirin 81 mg PO daily Fiorinal 50/325mg ([**11-25**] tab) PO Q6H prn Albuterol INH prn Amitriptyline 75mg PO QHS Triazolam 0.25mg PO QHS Meclizine 25mg PO Q4H prn Ca/Vit D MVI Nasonex Lisinopril 10mg PO daily Discharge Medications: 1. Prednisone 50 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: Take one tablet by mouth each day for two days after discharge from the hospital. . Disp:*2 Tablet(s)* Refills:*0* 2. Prednisone 10 mg Tablet Sig: See Instructions Tablet PO See Instructions: After taking 50mg each day for two days, take four (4) 10mg tablets (total of 40mg) once a day for 7 days. Then take three (3) 10mg tablets (total of 30mg) once a day for 7 days. Then take two (2) 10mg tablets (total of 20 mg) once a day for 7 days. Then take one (1) 10mg tablet (total of 10mg) once a day for 7 days. Then take half a tablet (total of 5mg) once a day for 7 days. Then stop. . Disp:*88 Tablet(s)* Refills:*0* 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). Disp:*90 Tablet, Chewable(s)* Refills:*2* 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 7. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2) Spray Nasal DAILY (Daily). Disp:*qs * Refills:*2* 8. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Oxygen Continuous Oxygen at 2 liters via nasal cannula. 10. Outpatient Physical Therapy Outpatient Pulmonary Rehabilitation ** (Take this to your local hospital) Discharge Disposition: Home With Service Facility: [**Location (un) 6549**] Discharge Diagnosis: Primary: COPD exacerbation . Secondary: HTN Discharge Condition: Stable, with home oxygen Discharge Instructions: You were treated for COPD exacerbation. . Please contact your PCP or call 911 if you develop worsening shortness of breath, chest pain, fever, chills, nausea, vomiting, diarrhea or any other concerning change in your health. . Please take your medications as prescribed. Followup Instructions: Please follow-up with your primary care doctor within one week of your discharge. . You also have the following appointments: Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2201-2-9**] 7:30 ([**Location (un) **] of [**Hospital Ward Name 23**] Building, [**Hospital Ward Name 5074**] of [**Hospital1 69**]) Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2201-2-9**] 7:30 Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2201-2-9**] 8:00 ([**Location (un) 436**] of [**Hospital Ward Name 23**] Building, [**Hospital Ward Name 5074**] of [**Hospital1 69**]) Name: [**Known lastname 4513**],[**Known firstname **] A. Unit No: [**Numeric Identifier 4514**] Admission Date: [**2201-1-13**] Discharge Date: [**2201-1-20**] Date of Birth: [**2126-10-7**] Sex: F Service: MEDICINE Allergies: Alcohol / Tapazole / Shellfish / Prozac / Biaxin / Sudafed Attending:[**First Name3 (LF) 2544**] Addendum: With regards to the syncope work-up, an echo was ordered to evaluate for valvulopathy. The patient's cardiac exam was unremarkable and she did not experience any additional episodes of syncope. The fall was thought to be mechanical, due to the patient's dog jumping on her. Cardiac etiology was felt to be unlikely, though an echo was ordered. This was not performed due to a backup of orders and given the low likelihood of a cardiac etiology, further work-up was deferred to the outpatient setting. Discharge Disposition: Home With Service Facility: [**Location (un) 2155**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2545**] MD [**MD Number(2) 2546**] Completed by:[**2201-1-20**]

[ "241.0", "491.22", "305.1", "733.13", "799.02", "276.1", "733.00" ]

icd9cm

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Discharge summary

report

Admission Date: [**2187-9-22**] Discharge Date: [**2187-10-5**] Date of Birth: [**2161-9-19**] Sex: F Service: MEDICINE Allergies: Reglan / Erythromycin Base Attending:[**First Name3 (LF) 1377**] Chief Complaint: Liver failure Major Surgical or Invasive Procedure: None History of Present Illness: : Patient is a 26 y/o female with PMHx GERD, depression, asthma, who presents from an OSH with hepatotoxicity from acetaminophen toxicity. The patient had a tonsillectomy 4 days ago and was taking roxicet 10ml q6hrs and liquid tylenol 30ml q6hrs for the past 4 days. She developed nausea on [**9-20**] and RUQ abdominal pain on [**9-21**] and presented to [**Hospital 7188**] Hospital. Her tylenol level there was 118. Her LFTs were: ALT 7466 AST 8129, INR 3.8. She was given dilaudid, phenergan, 7 grams of NAC PO, however vomited approximately [**12-10**] an hour later. She had an U/S of the liver that was "basically normal." She was then was transferred to [**Hospital1 18**] for further management. . In the ED, initial VS were: T 98 HR 130 BP 120/69 RR 16 O2 98%. On exam she had normal mentation though overall ill appearing. Her HR ranged 106-130s. She c/o dry heaves and was given ativan and benadryl. Toxicology was consulted who recommended reloading of NAC --> 7.5 grams over 1 hour, followed by 50mg/kg (625mg/hr) over 4 hours, then 100mg/kg (312.5mg/hr) over 16 hours. She also got benadryl and ativan for nausea. On transfer, vitals were 112, 98% 129/84, 12. Past Medical History: 1. Asthma 2. GERD 3. Depression 4. Endometriosis PSxHx: 1. Laparoscopy for endometriosis ([**2186-3-9**]) 2. Tonsillectomy ([**2187-9-8**]) Social History: Single, works as nurse, denies EtOH/Tob/IVDU/rec drugs Family History: Father w/ COPD, HTN, AAA s/p repair (long time smoker), peptic ulcer disease. Mother w/ diverticular bleed. Aunt with diverticulosis. Physical Exam: Physical Exam on Admission: 98 130 120/69 16 98% General: Awake and alert, although ill-appearing and actively vomiting HEENT: NCAT, PERRL Lungs: CTA b/l CV: RRR, tachy Abd: tender RUQ, no G/R Ext: wwp neuro: awake and alert Vitals: Tm 99.7, Tc 99.1. 118-133/64-85, HR 87-96, RR 18-20, Sat 100% RA. General: young woman sleeping in bed in no acute distress Heart: regular rate and rhythm, nl s1, s2, no m/r/g Lungs: CTAB Abdomen: normal bowel sounds, soft, mild tenderness to palpation epigastrium. Extremities: no edema bilaterally, pulses 2+ bilaterally radial and dp Neurological: appropriately alert and interactive Pertinent Results: Admission Labs: [**2187-9-21**] 11:47PM BLOOD WBC-11.1* RBC-3.65* Hgb-11.9* Hct-34.8* MCV-95 MCH-32.5* MCHC-34.2 RDW-12.7 Plt Ct-255 [**2187-9-21**] 11:47PM BLOOD Neuts-90.7* Lymphs-8.8* Monos-0.5* Eos-0.1 Baso-0 [**2187-9-21**] 11:47PM BLOOD PT-32.2* PTT-33.8 INR(PT)-3.2* [**2187-9-22**] 06:17PM BLOOD Fibrino-133* [**2187-9-21**] 11:47PM BLOOD Glucose-123* UreaN-18 Creat-1.5* Na-137 K-4.3 Cl-104 HCO3-19* [**2187-9-21**] 11:47PM BLOOD ALT-2339* AST-6921* AlkPhos-82 TotBili-3.7* [**2187-9-21**] 11:47PM BLOOD Calcium-7.8* Phos-2.2* Mg-2.0 [**2187-9-22**] 10:00AM BLOOD calTIBC-207 Ferritn-3414* TRF-159* [**2187-9-22**] 10:00AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2187-9-22**] 03:44PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE [**2187-9-22**] 03:44PM BLOOD [**Doctor First Name **]-NEGATIVE [**2187-9-22**] 10:00AM BLOOD IgG-641* [**2187-9-22**] 06:17PM BLOOD HIV Ab-NEGATIVE [**2187-9-21**] 11:47PM BLOOD Acetmnp-52* [**2187-9-22**] 10:00AM BLOOD HCV Ab-NEGATIVE [**2187-9-21**] 11:47PM BLOOD pO2-108* pCO2-27* pH-7.42 calTCO2-18* Base XS--4 Intubat-NOT INTUBA Comment-GREEN TOP [**2187-9-21**] 11:47PM BLOOD Lactate-3.1* [**2187-9-22**]: CERULOPLASMIN 23 18-53 mg/dL Imaging: CXR [**2187-9-22**]: Heart size is top EPSTEEPSTEIN-[**Doctor Last Name **] VIRUS EBNA IgG AB IN-[**Doctor Last Name **] VIRUS EBNA IgG AB normal. Mediastinum is unremarkable. The right lower lobe consolidation highly concerning for aspiration or infection. There is also evidence of interstitial pulmonary edema that might obscure additional foci of infection. Evaluation of the patient after diuresis is recommended as well as addressing the right lower lobe consolidation again that might represent either aspiration or pneumonia. No pneumothorax is seen. No appreciable pleural effusion is seen. RUQ U/S [**2187-9-22**]: IMPRESSION: Heterogeneous echogenic liver, consistent with hepatotoxicity. CXR [**2187-9-23**]: FINDINGS: Cardiac silhouette is upper limits of normal in size. Pulmonary vascular engorgement is accompanied by perihilar haziness, as well as worsening confluent opacities within the lower lobes. Although the findings may all be attributed to pulmonary edema related to acetaminophen overdose, coexisting aspiration is possible. CXR [**2187-9-27**]: IMPRESSION: 1. Standard position of right PICC at the cavoatrial junction. 2. Stable moderate bilateral pleural effusions and mild pulmonary edema. 3. Unchanged confluent basilar consolidations. Given the clinical history, pneumonia is possible, though atelectasis and aspiration also within the differential. CXR [**2187-9-28**]: New consolidation in the right upper lobe is most likely pneumonia. Bibasilar consolidation has not cleared since it was first imaged on [**9-22**] and a mild pulmonary edema and moderate bilateral pleural effusions worsened slightly. Mild enlargement of the heart and/or pericardial effusion is stable. Dr. [**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) **] was paged to report these findings at the time of dictation. TTE [**2187-9-29**]: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. CXR [**2187-9-30**]: There are low inspiratory volumes. There is upper zone redistribution and diffuse vascular blurring, consistent with CHF. There is more confluent opacity in the right perihilar area. In addition, at the lung bases, there is bibasilar patchy opacity consistent with collapse and/or consolidation. Small effusions cannot be excluded. A right-sided PICC line is present, the tip is poorly visualized but likely overlies the proximal/mid SVC. Compared with [**2187-9-27**] at 2048 p.m., the findings are similar, allowing for differences in technique. [**2187-9-30**] Radiology CT ABDOMEN W/O CONTRAST 1. No CT evidence of pancreatitis. 2. Patchy bibasilar consolidation and ground-glass is concerning for ARDS, but could represent infection, aspiration, hemorrhage or edema. 3. Small bilateral pleural effusions. [**2187-10-1**] Radiology CTA CHEST W&W/O C&RECON 1. No evidence of PE. 2. Bilateral ground-glass opacities involving all lobes. In combination with right hilar lymphadenopathy this is concerning for atypical pneumonia. Differential diagnosis includes asymmetric pulmonary edema, aspiration, or ARDS. Discharge Labs: [**2187-10-5**] 05:14AM BLOOD WBC-5.5 RBC-2.39* Hgb-7.8* Hct-24.0* MCV-100* MCH-32.5* MCHC-32.4 RDW-13.9 Plt Ct-436 [**2187-10-5**] 05:14AM BLOOD PT-15.3* PTT-39.5* INR(PT)-1.3* [**2187-10-5**] 05:14AM BLOOD Glucose-144* UreaN-6 Creat-1.2* Na-137 K-3.5 Cl-105 HCO3-24 AnGap-12 [**2187-10-5**] 05:14AM BLOOD ALT-90* AST-30 AlkPhos-67 TotBili-1.2 [**2187-10-5**] 05:14AM BLOOD Lipase-71* [**2187-10-5**] 05:14AM BLOOD Albumin-3.0* Calcium-7.8* Phos-4.8* Mg-2.2 Micro: [**2187-10-4**] BLOOD CULTURE -pending [**2187-10-3**] BLOOD CULTURE - pending [**2187-9-30**] BLOOD CULTURE -pending [**2187-9-28**] blood cultures - negative [**9-27**]: blood culture - 2/4 bottles STAPHYLOCOCCUS, COAGULASE NEGATIVE. 2/4 bottles no growth. [**2187-10-3**] URINE CULTURE-FINAL - no growth [**2187-9-29**] URINE URINE CULTURE-FINAL {STAPH AUREUS COAG +, CORYNEBACTERIUM SPECIES (DIPHTHEROIDS)} [**2187-9-27**] URINE CULTURE-FINAL - no growth [**2187-10-2**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL - negative [**2187-9-28**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL - negative [**9-24**]: MRSA nares screen - positive [**2187-9-22**]: Rubella IgG/IgM Antibody positive. VARICELLA-ZOSTER IgG SEROLOGY positive. CMV IgG negative, IgM negative [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB - positive [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB - positive [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB - negative TOXOPLASMA IgG ANTIBODY - negative TOXOPLASMA IgM ANTIBODY - negative Brief Hospital Course: Ms. [**Known lastname 3075**] is a 26 yo previously healthy female with a PMH of asthma (last ED admission [**2-/2187**]), and GERD who was s/p T+A who was taking tylenol and roxicet for pain and developed nausea, vomiting and abdominal pain. On presentation to the outside hospital she was found to be an acute liver failure with LFTs in the 7000s, and INR=3.8. She was transferred to the surgical ICU where she was followed by the transplant team. She was started on NAC and her LFTs, INR, and Cr continued to improve before being transferred to the medical floor. . Acute Liver failure - patient had elevated LFTs and INR on arrival to the floor. She was continued on the NAC drip until her INR dropped to 1.5 at which time it stopped. Her LFTs continued to downtrend. Her RUQ U/S showed no other possible causes of her liver failure and a full blood hepatitis serologies showed immunity to HAV, HBV, and no exposure to HCV. . Acute renal failure- likely secondary to direct acetaminophen toxicity. Her Cr peaked at 2.2. Her FeNA was indicative of intrinsic renal failure. She was continued on IV hydration while she had poor po intake, and her Cr improved to 1.2 on day of discharge. . Pancreatitis- she was complaining of worsening abdominal pain as her diet was advanced, she complained of epigastric pain. Her Lipase was newly elevated and she was maintained on a clear diet and slowly advanced as her pain medication requirements decreased. This was also likely due to her acteaminophen toxicity. Pt was tolerating solid food with mild-moderate nausea and pain on day of discharge. . Tachypnea, tachycardia- Pt had respiratory distress during part of her admission, but it was initially unclear if her symptoms were due to an asthma exacerbation, pneumonia, excessive volume resuscitation in the ICU, or possibly PE. A CXR on [**9-28**] demonstrated a new consolidation in RUL, and with her fevers, there was a concern for HCAP. Treatment was begun with vanc and pip/tazo on [**9-28**]. D-dimer drawn on [**9-30**] was elevated at 2885 but Pt has several other possible causes for this including active infection, pancreatitis, etc. Pt had CTA chest on [**10-1**] to r/o PE given pt's continued O2 requirement and tachypnea on antibiotics, but prelim read did not show any evidence of PE. Did demonstrate bilateral ground glass opacities. Pt reported significant improvement in her breathing after ~4.7 L net diuresis on [**10-1**], so it was likely due to hypervolemia. Pt no longer had O2 requirement by [**10-2**]. However, she remains anemic despite her diuresis, which may be contributing to her symptoms. A repeat CXR on [**10-4**] showed near complete resolution of diffuse pulmonary opacities and bilateral pleural effusions. The rapidity of clearance suggests that the majority of disease was secondary to pulmonary edema. However, given the initial concern for possible RUL pneumonia and her prior numerous episodes of vomiting, and her intermittent fevers, Pt was transitioned to oral levofloxacin and metronidazole, which were continued on discharge as an outpatient for a total of 8 day course for possible HCAP / aspiration pneumonia. # Bacteremia: 2/2 blood culture bottles (aerobic and anaerobic) from [**9-27**] are growing coag neg Staph, however the other 2 bottles from [**9-27**] and all other blood cultures have been negative. This suggests a contaminant, an no other blood cultures have shown any growth. . # RUL Pneumonia: Not clearly seen on CT. Pt was treated w/ vanc/zosyn for HCAP (day 1 = [**9-29**]), then switched to PO levofloxacin and metronidazole (to cover for aspiration pna given plentiful vomiting) on [**10-2**], which will be continued until [**10-7**] for 8 day course for HCAP / aspiration pneumonia. The reported opacity on CXR was completely clear on [**10-4**], so it may have been due to pulmonary edema. . # Pleural effusions: Patient has persistent moderate pleural effusions of unclear etiology, though may be related to pneumonia, liver disease, or pancreatitis. TTE negative for heart failure. Pt was initially diuresed with furosemide 10mg IV and had large volume diuresis. Pt then continued to have large volume diuresis on her own, which suggests that this was most likely due to very aggressive fluid resuscitation during her ICU stay, perhaps in combination with her acute renal failure. Pt did not have any oxygen requirement on discharge and reported that her respiratory status had returned to baseline. . # Anemia: HCT was in the 30s on admission and now down to 21; borderline macrocytic, most likely from reticulocytosis. Pt had no obvious GI bleeds, and stool is guiac neg. Reticulocyte count, LDH, and haptoglobin were normal. Her anemia is thought to be due to direct effects of acetaminophen on marrow or indirect via kidneys. Pt will need to have her Hct rechecked in [**12-10**] weeks to document recovery and improvement. . # Depression: The patient was followed by psychiatry as she had overdosed on tylenol. They felt that it was not likely an intentional overdose and she did not require being sectioned or having a 1:1 sitter. However given her history of depression they were concerned about her mood and wished for her to go to an inpatient psychiatry unit (voluntarily) which she declined, in favor of a partial program, which we have arranged as an outpatient. TRANSITIONAL ISSUES: -Pt needs follow-up Hct and Cr in [**12-10**] wks to document recovery. -Pt needs close psychiatric follow-up for her depression. Medications on Admission: 1. Prevacid 2. Celexa 3. Advair 4. Singular 5. Albuterol Discharge Medications: 1. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation twice a day. 2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for anxiety, insomnia for 2 weeks: This medication is sedating. Do not use while driving or operating machinery. Disp:*20 Tablet(s)* Refills:*0* 3. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea for 2 weeks: This medication is sedating. Do not use while driving or operating machinery. Disp:*25 Tablet(s)* Refills:*0* 6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 7. Effexor XR 75 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day. 8. Junel FE 1.5/30 (28) 1.5-30 mg-mcg Tablet Sig: One (1) Tablet PO once a day. 9. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 3 days: End on [**10-8**]. Disp:*3 Tablet(s)* Refills:*0* 10. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 3 days: End on [**10-8**]. Disp:*9 Tablet(s)* Refills:*0* 11. oxycodone 10 mg Tablet Sig: One (1) Tablet PO every [**3-14**] hours for 2 weeks: This medication is sedating. Do not use while driving or operating machinery. Do not use with alcohol. Disp:*25 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: acute liver failure secondary to acetaminophen intoxication acute kidney failure pancreatitis pneumonia anemia Secondary: asthma GERD depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**Known lastname 3075**], . It was a pleasure caring for you. You were transferred to [**Hospital1 18**] from another hospital after you were found to have liver damage from tylenol. You were also found to have kidney injury and pancreatitis (an inflammation of the pancreas). We treated this with medications and your liver function, kidney function, and pancreatic function are all improving. You had shortness of breath and leg swelling, which greatly improved when we gave you medication to eliminate much of the excess fluid that you were given in the ICU. You were also found to have a pneumonia, which we are treating with antibiotics. Although you continued to low-level fevers, we feel that this is most likely due to the inflammation that many organs of your body suffered from the tylenol. Your blood cultures and urine cultures have only grown contaminants, and your latest cultures have not shown any growth at all. At the time of discharge, you were tolerating normal food, and your pain and nausea were controlled. . We made the following changes to your medications: -Stop tylenol (acetaminophen) -Stop roxicet (oxycodone/acetaminophen) -Stop sonata -[**Name2 (NI) **] lorazepam (ativan) 0.5mg tablets, 1 by mouth at bedtime for anxiety or insomnia -Start promethazine (Phenergan) 25mg tablets, 1 by mouth every 6 hrs as needed for nausea -Start oxycodone 5mg tablets, 1 by mouth every 4 hours for severe pain -Start levofloxacin 750mg tablets, 1 by mouth daily for 3 days, ending [**10-8**] -Start metronidazole 500mg tablets, 1 by mouth every 8 hours for 3 days, ending [**10-8**] . Please take your other medications as previously prescribed. Please complete your full course of levofloxacin and metronidazole. . We have made appointments for you to see your primary care physician and your liver specialist within one to two weeks (see below). . We have also made arrangement for you to go to the partial day program at [**Doctor Last Name 16471**] for your depression. Followup Instructions: Department: [**Hospital3 249**] When: THURSDAY [**2187-10-11**] at 9:10 AM With: Dr. [**First Name4 (NamePattern1) 2184**] [**Last Name (NamePattern1) 2185**] Address: [**Location (un) 830**] [**Location (un) 86**], [**Numeric Identifier 718**] Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] South [**Hospital **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage *This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor in follow up. . Department: LIVER CENTER When: MONDAY [**2187-10-29**] at 9:50 AM With: [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . Department: [**Hospital3 249**] When: FRIDAY [**2187-11-9**] at 2:35 PM With: [**Name6 (MD) **] [**Name6 (MD) 28883**], MD [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage *Dr. [**First Name4 (NamePattern1) 3742**] [**Last Name (NamePattern1) **] is your new physician in [**Name9 (PRE) 191**] and Dr. [**Last Name (STitle) **] works closely with Dr. [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) 6215**], [**First Name3 (LF) **] both will be involved in your care. For insurance purposes please indicate Dr. [**Last Name (STitle) 6215**] as your Primary Care Physician. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**] Completed by:[**2187-10-7**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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337, 1513

2574, 7684

1944, 2539

16659, 16771

1535, 1677

1693, 1749

27,192

148,686

26798

Discharge summary

report

Admission Date: [**2169-5-9**] Discharge Date: [**2169-5-11**] Date of Birth: [**2116-5-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 106**] Chief Complaint: hypotension, hypoxia Major Surgical or Invasive Procedure: Aflutter ablation History of Present Illness: Mr. [**Known lastname **] is a 52 year old male with a history of atrial fibrillation admitted for atrial flutter ablation. . He was initially diagnosed with atrial fibrillation approximately three years ago. Three months ago, he was evaluated at the [**Hospital6 1708**] and subsequently underwent a pulmonary vein ablation. This was complicated by a left ventricular hematoma and perforation resulting in cardiac tamponade and cardiac arrest. He was taken urgently to the operating room for repair. He had a 15 day ICU course and then one month hospital stay. Postop, he reverted to atrial fibrillation and was discharged on amiodarone. He was then found to be in atrial flutter at [**Hospital 1263**] hospital. He also had an unsuccessful cardioversion several weeks ago and remained in atrial flutter. . He saw Dr. [**Last Name (STitle) **] for second opinion in early [**Month (only) 547**]. Due to symptoms (palpitations, SOB) it was recommended that he undergo an atrial flutter ablation. He had the ablation today. After the procedure, he was hypotensive to 70's/50's and dopamine 10 mcg/min was started. He was bradycardic, diaphoretic, and also received atropine 1mg x 1. Weaning off dopamine was attempted, but 5mcg/min was required to keep SBP>95. He recieved a total of approx 2 L of fluid peri/post procedure. He also developed bilateral groin bleeding after coughing, and pressure was applied with good hemostasis. Also, dopamine infiltrated into L antecub IV, so local phentolamine was given. Upon arrival to the floor, pt continued to require dopamine to maintain BP, and then became hypoxic (O2 sats decreased to 60's, then up to 89% on 8 L FM). Pt was transferred to the CCU for further care. . Pt currently c/o SOB, but denies chest pain, N/V, lightheadedness. Past Medical History: Atrial fibrillation s/p pulm vein isolation c/b by LV perforation Atrial flutter Social History: Mr. [**Known lastname **] moved here from [**Country 3992**]. He practiced as a pediatrician in [**Country 3992**]. He currently lives with his wife and has three children between ages of 10 and 19. Family History: Non-contributory Physical Exam: Vitals: 98.9 113/77 87 25 89% on 8L FM GEN: mild resp distress, occasionally coughing HEENT: OP clear CV: RRR, nl S1 S2, [**2-27**] sys murmur @ apex. JVP @ approx 9 cm. LUNG: crackles [**3-25**] way up on R, crackles at L base ABD: soft, nt, nd, +BS EXT: L antecub area with mild erythema (cicrled with marker). Bilateral groin sites intact, without bruits or hematomas. 1+ R DP/PT, 2+ L DP/PT pulses. NEURO: A&Ox3 Pertinent Results: REPORTS: . TTE [**2169-5-9**]: Conclusions: The left atrium is elongated. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. There is no pericardial effusion. . CHEST (PORTABLE AP) [**2169-5-9**] 7:01 PM IMPRESSION: Mild pulmonary edema. Cardiomegaly. Left lower lobe opacity consistent with aspiration or pneumonia. . LABS: . [**2169-5-9**] 07:04PM TYPE-ART TEMP-37.2 PO2-60* PCO2-40 PH-7.38 TOTAL CO2-25 BASE XS-0 INTUBATED-NOT INTUBA [**2169-5-9**] 06:55PM ALT(SGPT)-59* AST(SGOT)-54* [**2169-5-9**] 06:55PM MAGNESIUM-1.7 [**2169-5-9**] 06:55PM TSH-1.0 [**2169-5-9**] 06:55PM FREE T4-2.1* [**2169-5-9**] 06:55PM WBC-14.6*# RBC-5.23 HGB-15.3 HCT-45.8 MCV-88 MCH-29.2 MCHC-33.4 RDW-14.9 [**2169-5-9**] 06:55PM PLT COUNT-253 [**2169-5-9**] 06:55PM PT-13.3* PTT-22.4 INR(PT)-1.2* [**2169-5-9**] 11:40AM INR(PT)-1.1 Brief Hospital Course: 52 yo M with h/o atrial fibrillation and atrial flutter s/p atrial flutter ablation, complicated by hypotension and hypoxia. . Rhythm: #) Atrial Flutter: S/P ablation, remained in NSR during the CCU stay. - continued amiodarone (although at lower dose) per EP recs - coumadin was held prior to his procedure, and then restarted prior to discharge, and pt was instructed to have INR followed as an outpatient. He was placed on his home dose of coumadin. - monitored LFTs and TFTs while on amiodarone (LFT's remained mildly elevated) - transient bradycardia s/p ablation procedure was likely [**2-23**] vagal stimulation, which subsequently resolved. BB was held after this episode and was held on discharge. . Pump: #) Hypotension: Felt to be secondary to ablation as procedure was close to fat pad with vagal innervation. - pt was weaned off dopamine after 1 day in the CCU. Pt continued to have SBP in 80's, but was asymptomatic. - initial echo was negative for pericardial effusion/tamponade, with EF>55%. Subsequent echo showed no significant change. . #) Pulmonary edema/hypoxia: CXR and physical exam were consistent with CHF. Likely [**2-23**] to fluids given for hypotension in setting of decreased HR after ablation. - Pt responded well to Lasix 20mg IV (put out over 2 L), and was weaned off O2 prior to discharge . Valves: #) Pt had moderate MR (old). No acute intervention was needed during the admission. . #) IV infiltration: L antecub IV infiltrated with dopamine prior to transfer to the CCU. Pt underwent dermal injections of phentolamine to reverse effects of dopamine. - L antecub area showed no signs of necrosis, and was stable during the CCU stay . #) Elevated LFTS: mildly elevated 2 weeks prior to admission, repeat LFT's on admission also mildly elevated. Thought possibly to be from amiodarone. - amiodarone was continued at lower dose . #) Elevated WBC count: possible [**2-23**] PNA (? aspiration), given LLL opacity, althout subtle finding on portable film. Pt was afebrile during the admission. - PA/lat CXR showed improving LLL opacity, possibly [**2-23**] atalectasis vs. edema . #) PPX: Hep SC during the admission, coumadin on d/c . #) FEN: Cardiac diet . #) Dispo: home Medications on Admission: Toprol-XL 200 mg QD amiodarone 400 mg QD Coumadin 2.5 mg QD (last dose 4/13) Lasix 40 mg every other day Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 3. Outpatient Lab Work You will need your INR and CBC checked on Monday, [**2169-5-15**]. Please have these results faxed to your PCP. Discharge Disposition: Home Discharge Diagnosis: Aflutter s/p ablation, complicated by hypotension and hypoxia Pulmonary edema Symptomatic bradycardia Discharge Condition: Stable. Off pressors. Satting well on RA. Discharge Instructions: Please seek medical attention immediately if you experience chest pain, arm pain, jaw pain, palpitations, nausea, vomiting, fevers, chills, or dizziness. Please take all medications as prescribed. You should NOT take your Toprol, unless directed to do so at a future date. You should take a lower dose of your amiodarone. Please continue to take your coumadin at the normal dose. Please attend all follow-up appointments. You are being set up with a heart monitor. Please follow the directions that were given to you when the heart monitor was placed. You will need your INR and CBC checked on Monday, [**2169-5-15**]. Please have these results faxed to your PCP. Followup Instructions: Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in 1 week. His phone number is [**Telephone/Fax (1) 65213**]. Please follow-up with Dr. [**Last Name (STitle) **] at the following scheduled appointment. He would like to see you in 1 month, so you can call to see if they have an earlier appointment. Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**] Date/Time:[**2169-6-30**] 2:00 Completed by:[**2169-6-10**]

[ "458.29", "799.02", "518.4", "780.2", "427.32" ]

icd9cm

[ [ [] ] ]

[ "37.26", "37.29", "37.34" ]

icd9pcs

[ [ [] ] ]

6916, 6922

4198, 6404

334, 354

7068, 7112

2972, 4175

7832, 8353

2502, 2520

6560, 6893

6943, 7047

6430, 6537

7136, 7809

2535, 2953

274, 296

382, 2165

2187, 2270

2286, 2486

22,505

168,178

48917

Discharge summary

report

Admission Date: [**2130-10-4**] Discharge Date: [**2130-10-16**] Date of Birth: [**2095-1-27**] Sex: F Service: MEDICINE Allergies: Haldol / Bacitracin / bee sting Attending:[**First Name3 (LF) 3991**] Chief Complaint: foreign body ingestion Major Surgical or Invasive Procedure: EGD; foreign body removal History of Present Illness: 35 yo F w/ PMH major depression, anxiety, bipolar disorder and h/o foreign body ingestion p/w 2 weeks significant depression, SI, and ingestion of 2 pens. Pt reports worsening depression and thoughts of suicide over the last two weeks but denies forming any concrete plan. Pt has history of swallowing knives, razor blades, and most recently pens. Admitted [**2130-7-27**] for ingestion of two pens which were removed by GI, one of which was embedded in the gastric mucosa. Pt reports some LUQ abdominal pain but denies any other symptoms. Denies n/v. Denies visual or auditory hallucinations. Followed by therapist [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 102732**]. Numerous prior psychiatric admissions for depression and suicidal behavior. Prior suicide attempt by Aspirin overdose. . In the ED the pt had a KUB showing evidence of 2 metalic pen tips in stomach. GI was consulted and recommend ICU admission with plan to scope tomorrow. Pt has previously been challenging to scope and has required intubation so ICU is preferred. . On the floor, the pt was 99 87 135/80 20 98%RA. She was sitting comfortably in bed, complaining only of some mild LUQ pain. Plan was initially to scope in the am, however GI was able to come in overnight and so pt was intubated and scoped with removal of two pen cartridges, no perforation or perturbation of the mucosa. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. . Past Medical History: Past Medical History: DM, asthma, PFO, HTN, GERD, migraines, chronic pain Past Psychiatric History: (per OMR, note by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9100**]- [**2130-3-21**]) Borderline personality disorder, PTSD, depression. Enrolled at MMHC DBT program. Has history of multiple suicide attempts (>20 by her report) by OD, jumping out of windows, and stepping in front of cars. Last SA was ingestion of 1000mg ASA, requiring ICU admission. Also has extensive history of SIB, including cutting her stomach (last done a few weeks ago) and swallowing objects such as pens, razors, and needles (last done 06/[**2128**]). Treatment team includes [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 47996**], LICSW, as primary outpatient therapist, and MMHC DBT team (Dr. [**Last Name (STitle) 1119**] of [**Last Name (LF) 102730**], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], and Dr. [**Last Name (STitle) **]. Social History: Social History: (per Mass Mental) Patient currently lives alone in an apartment in [**Location (un) 686**]. She attends DBT day program at Mass Mental. (Per OMR) From [**Location (un) 86**] are, adopted at 3 days of age. Endorses significant trauma history but prefers not to disclose details at this time. Dropped out of school in 4th grade [**2-1**] psychiatric hospitalizations and has never worked. Receives SSI and lives alone in a section 8 apartment for the last 1 year, which she likes. Has previously lived in [**Location 18750**] house x4 years. Denies forensics history. Substance Abuse History: Denies EtOH, tob, other drugs Family History: Unknown (adopted) Physical Exam: ADMISSION PHYSICAL EXAM: 99 87 135/80 20 98%RA. General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, 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 DISCHARGE PHYSICAL EXAM unchanged Pertinent Results: ADMISSION LABS: [**2130-10-4**] 05:40PM BLOOD WBC-10.4 RBC-4.28 Hgb-11.8* Hct-34.7* MCV-81* MCH-27.5 MCHC-34.0 RDW-13.5 Plt Ct-332 [**2130-10-4**] 05:40PM BLOOD Neuts-64.6 Lymphs-28.8 Monos-4.0 Eos-2.1 Baso-0.5 [**2130-10-4**] 05:40PM BLOOD Plt Ct-332 [**2130-10-5**] 04:02AM BLOOD PT-13.9* PTT-25.9 INR(PT)-1.2* [**2130-10-4**] 04:55PM BLOOD Glucose-107* UreaN-5* Creat-0.8 Na-139 K-5.3* Cl-103 HCO3-21* AnGap-20 [**2130-10-4**] 04:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2130-10-5**] 04:02AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.6 PERTINENT LABS AND STUDIES: KUB [**10-4**]: No free air. Two metallic foreign bodies in the expected region of the stomach. . CXR [**10-4**]: No acute intrathoracic process. No free air . EGD [**10-4**] Indications: Pen Ingestion Procedure: The procedure, indications, preparation and potential complications were explained to the patient, who indicated her understanding and signed the corresponding consent forms. A physical exam was performed. The patient was administered moderate sedation. A physical exam was performed prior to administering anesthesia. Supplemental oxygen was used. The patient was placed in the left lateral decubitus position and an endoscope was introduced through the mouth and advanced under direct visualization until the third part of the duodenum was reached. Careful visualization of the upper GI tract was performed. The procedure was not difficult. The patient tolerated the procedure well. There were no complications. Otherprocedures: The foreign bodies (2 pens) were successfully removed using a snare in the stomach body. Impression: (foreign body removal) Otherwise normal EGD to third part of the duodenum Brief Hospital Course: 35 yo F w/ PMH major depression, anxiety, bipolar disorder and h/o foreign body ingestion p/w 2 weeks significant depression, SI, and ingestion of 2 pens, now medically stable to go to a psych bed as of [**2130-10-6**]. . ACUTE CARE: # Foreign body ingestion. Patient admitted to MICU for elective intubation and EGD for foreign body ingestion mgmt. EGD with pen cartridge removal. Pt tolerated intubation and extubation. . CHRONIC CARE: # Multiple psych d/o. Continue home meds however patient with worsening SI overnight preceding weeks. Per psych, added geodon 20mg qam to 60mg qhs. QTc was <440. . # Diabetes: maintained on ISS. BG was 150-240s. . # Asthma. Continue home albuterol/flovent. . # Allergies: flonase/use fexofenadine instead of loratadine . TRANSITIONS IN CARE: # Communication: [**First Name9 (NamePattern2) 102698**] [**Known lastname 56072**] [**Telephone/Fax (1) 102733**] (mom) # Code: Full (discussed with patient) # PENDING STUDIES AT TIME OF DISCHARGE: none # ISSUES TO ADDRESS AT FOLLOW UP: - psychiatric comorbidities and ongoing SI, intention to swallow foreign bodies Medications on Admission: ALBUTEROL - 90 mcg Aerosol - 2 inhalations po four times a day as needed for wheeze CODEINE SULFATE - 15 mg Tablet - [**1-1**] Tablet(s) by mouth every [**4-5**] hours as needed for prn headache EPINEPHRINE [EPIPEN] - 0.3 mg/0.3 mL (1:1,000) Pen Injector - use as instructed for allergic reaction x1 Allergy to Bee Stings FLUTICASONE - 50 mcg Spray, Suspension - 2 sprays both nostrils once a day FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 1 inhalation(s) po twice a day IBUPROFEN - 800 mg Tablet - 1 Tablet(s) by mouth every eight hours as needed for pain with food;take no more than 3 a day xxKETOCONAZOLE - 2 % Cream - Apply to affected area daily LAMOTRIGINE [LAMICTAL] - (Prescribed by Other Provider) - 100 mg Tablet - 3 Tablet(s) by mouth at bedtime per psych LISINOPRIL - (On Hold from [**2130-6-14**] to unknown for Hold as of 615/11) - 20 mg Tablet - 0.5 (One half) Tablet(s) by mouth once a day LORATADINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day METFORMIN - 500 mg Tablet - 2 Tablet(s) by mouth twice a day METHYLPHENIDATE [RITALIN LA] - (Prescribed by Other Provider) - 30 mg Capsule, ER Multiphase 50-50 - two Capsule(s) by mouth qd per psych; unit dose unsure but takes 60 mg a day METOCLOPRAMIDE - 5 mg Tablet - 1 Tablet(s) by mouth po tid 30 min ac METRONIDAZOLE [METROGEL] - 1 % Gel - apply to face twice a day MUPIROCIN - (Prescribed by Other Provider) - 2 % Ointment - apply to affected areas twice a day MUPIROCIN CALCIUM [BACTROBAN NASAL] - 2 % Ointment - 1 application left nostril twice a day OMEPRAZOLE - 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth [**Hospital1 **] 30 min ac PROPRANOLOL - 20 mg Tablet - 1 Tablet(s) by mouth twice a day RANITIDINE HCL - 300 mg Tablet - 1 Tablet(s) by mouth once a day take with Prilosec THORAZINE - (Prescribed by Other Provider) - - 100 mg po once a day Trazodone 100mg qhs Geodon 60mg qhs Discharge Medications: 1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for sob/wheezing. 2. codeine sulfate 15 mg Tablet Sig: 1-2 Tablets PO every [**4-5**] hours as needed for headache. 3. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) Intramuscular as instructed as needed for bee sting. 4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 5. fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation [**Hospital1 **] (2 times a day). 6. ibuprofen 800 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain: take with food. no more than 3 a day. 7. lamotrigine 100 mg Tablet Sig: Three (3) Tablet PO QHS (once a day (at bedtime)). 8. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. 9. metformin 500 mg Tablet Sig: Two (2) Tablet PO twice a day. 10. methylphenidate 20 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO TID (3 times a day). 11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily): 30min ac. 12. propranolol 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 13. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): take with prilosec. 14. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 15. ziprasidone HCl 60 mg Capsule Sig: One (1) Capsule PO QHS (once a day (at bedtime)). 16. chlorpromazine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 17. metoclopramide 5 mg Tablet Sig: One (1) Tablet PO three times a day: 30min ac. 18. metronidazole 1 % Gel Sig: One (1) Topical twice a day: apply to face twice a day. 19. mupirocin 2 % Ointment Sig: One (1) Topical twice a day: apply to affected area twice a day. 20. ketoconazole 2 % Cream Sig: One (1) Topical once a day. Discharge Disposition: Extended Care Facility: [**Hospital1 **] 4 Discharge Diagnosis: primary: foreign object ingestion secondary: major depression, bipolar disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 56072**], As you know, you were admitted to the hospital for ingestion of 2 pens. You had these removed and you did well with the procedure. You are being discharged to psychiatric inpatient care to undergo ongoing care for your psychiatric conditions. I encourage you to avoid swallowing objects in the future. Please keep your follow up appointments. There were no changes to your medications. Followup Instructions: Department: [**Hospital3 249**] When: FRIDAY [**2130-10-13**] at 10:40 AM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3990**], [**First Name3 (LF) **] [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: THURSDAY [**2130-11-2**] at 6:20 PM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3990**], [**First Name3 (LF) **] [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: DERMATOLOGY When: MONDAY [**2130-11-6**] at 2:15 PM With: [**Doctor First Name **]-[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8476**], MD, PHD [**Telephone/Fax (1) 1971**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3990**] DO 12-BJM

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icd9cm

[ [ [] ] ]

[ "98.03", "45.13" ]

icd9pcs

[ [ [] ] ]

11156, 11201

6243, 7250

316, 343

11325, 11325

4499, 4499

11925, 13170

3897, 3916

9291, 11133

11222, 11304

7369, 9268

11476, 11902

3956, 4480

7261, 7343

1770, 2220

254, 278

371, 1751

4515, 6220

11340, 11452

2264, 3220

3252, 3881

2,718

148,278

155

Discharge summary

report

Admission Date: [**2158-5-3**] Discharge Date: [**2158-5-6**] Date of Birth: [**2079-12-14**] Sex: F Service: MEDICINE Allergies: Ativan / Valium / Haldol / Adhesive Tape / Sulfonamides / Codeine / Morphine / Erythromycin/Sulfisoxazole / Amoxicillin Attending:[**First Name3 (LF) 1650**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 78 yo f with h/o COPD with home O2 3L requirement, CAD s/p CABG in [**2140**], CHF with EF 30%, PVD s/p aortofemoral bypass, RLL granuloma, HL, and h/o dementia who presents to the ED in respitatory distress. Pt and son gave history in the [**Name (NI) **] that that she became more SOB with increased o2 requirement (unknown how much she increased it to). She came in to the hospital tonight for SOB and reported some increase in her allergies but no fever. In the ED her vitals soon after arrival were HR 110s BP 194/79 RR30 o2 sat 94% on 8L face mask. She was found to be in obvious respiratory distress using accessory muscles, tachypnic, poor air flow, and speaking in one word sentences. She became diaphoretic with CP and got 0.4mg of SL nitro with resolution of chest pain. She became tachy to 123 with RR 37 and BP 200/90 then was started on a nitro gtt at 2mg/kg/hr which was increased to 3mg/kg/hr. At some point dropped her sats to 85%. She was started on BiPAP with obvious improvement. Her CXR showed pulm vascular congestion. She was given 2mg IV magnesium, solumedrol 125 IV x1, azithromycin 500mg for COPD exacerbation. Her EKG showed sinus tach with prominent p waves and LVH as well as ST elevation in v1 & v2 which was similar to prior. Cardiology was consulted and said this is likely strain in the setting of respiratory distress. Exam notable for wheezes, poor air movement, and rhonci throughout. She received 20 IV lasix prior to leaving the ED. Vitals at time of transfer were HR 101 BP 159/64 RR30 02 sat 100% on BiPap. On the floor, VS were BiPAP 8/8 Fio2 100 with afebrile RR 25, HR 99 BP 149/55. She was wearing the BiPAP but able to answer yes and no to questions. Able to confirm history that last few days had increased SOB, non productive cough, wheezing, weakness, and increased allergies including nasal congestion, runny nose, and sinus pressure. Review of systems: (+) for increased frequency of urination (-) Denies fever, chills tions, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria or urgency. Denies arthralgias or myalgias. Past Medical History: -COPD with home O2 -coronary artery disease s/p CABG '[**40**]; cath in [**2150**] showed severe native 2VD, patent LIMA->LAD, SVG->OM. -ejection fraction 30% in [**2156**] -peripheral vascular disease, status post aortofemoral bypass -depression -right lower lobe granuloma -hypercholesterolemia -dementia and history of psychosis with psychotic episodes -severe spinal cord stenosis s/p spinal cord stimulator yrs ago Social History: - Tobacco: Denies - Alcohol: Denies - Illicits: Denies Family History: not obtained at this time Physical Exam: Vitals: BiPAP 8/8 Fio2 100 with afebrile RR 25, HR 99 BP 149/55 General: A & O x3, increased WOB HEENT: Sclera anicteric, unable to access MM Neck: difficult to access JCD given so much accessory muscle use Lungs:poor air movement throughout, diffuse rhonchi and mild wheezes CV: tachycardic, nl S1/S2 Abdomen: soft, non-tender, non-distended, + bowel sounds present, no rebound tenderness or guarding, no organomegaly GU:foley with good clear UOP Ext: warm, well perfused, 1+ pulses, tenderness to big toe, ? stage 1 ulcer between big and second toe Pertinent Results: Labs on Admission: [**2158-5-3**] 04:50AM WBC-10.6# RBC-4.11* HGB-11.7* HCT-36.9 MCV-90 MCH-28.5 MCHC-31.7 RDW-15.1 [**2158-5-3**] 04:50AM NEUTS-81* BANDS-0 LYMPHS-6* MONOS-11 EOS-0 BASOS-1 ATYPS-0 METAS-1* MYELOS-0 [**2158-5-3**] 04:50AM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ [**2158-5-3**] 04:50AM PLT SMR-NORMAL PLT COUNT-191 [**2158-5-3**] 04:50AM PT-12.5 PTT-26.1 INR(PT)-1.1 [**2158-5-3**] 04:50AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2158-5-3**] 04:50AM URINE RBC-[**2-17**]* WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 [**2158-5-3**] 04:50AM URINE HYALINE-0-2 [**2158-5-3**] 04:50AM CALCIUM-9.2 PHOSPHATE-4.3 MAGNESIUM-1.7 [**2158-5-3**] 05:02AM LACTATE-1.2 [**2158-5-3**] 07:32AM LACTATE-0.7 [**2158-5-3**] 10:28AM CK-MB-NotDone cTropnT-<0.01 proBNP-9443* [**2158-5-3**] 10:28AM CK(CPK)-65 [**2158-5-3**] 03:01PM OSMOLAL-268* [**2158-5-3**] 03:01PM CK-MB-NotDone cTropnT-<0.01 [**2158-5-3**] 03:01PM CK(CPK)-66 [**2158-5-3**] 06:21PM URINE OSMOLAL-281 [**2158-5-3**] 06:21PM URINE HOURS-RANDOM SODIUM-91 . ECHO: [**2158-5-3**] The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe regional left ventricular systolic dysfunction with septal, anterior and apical akinesis. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**12-17**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. . Compared with the report of the prior study (images unavailable for review) of [**2157-9-21**], the LVEF is slightly lower and the estimated PA pressure has increased. . CHEST X-RAY [**2158-5-4**] 1. Interval improvement in congestive heart failure. 2. Mild interval increase in bilateral pleural effusions and retrocardiac left lung base opacity likely representing atelectasis. 3. COPD, with no new evidence of pneumonia. . SHOULDER X-RAY [**2158-5-5**] THREE VIEWS OF THE RIGHT SHOULDER: There is mild glenohumeral joint degenerative change, with spurring at the inferior glenoid. There is minimal acromioclavicular joint degenerative change. There has been prior midline sternotomy, with intact sternal wires partially visualized, as is a left brachiocephalic venous stent. Soft tissues appear unremarkable, as does the visualized right lung apex. IMPRESSION: Mild glenohumeral joint degenerative change. Brief Hospital Course: 78 yo f with h/o COPD with home O2 3L requirement, CAD s/p CABG in [**2140**], CHF with EF 30%, PVD s/p aortofemoral bypass, RLL granuloma, HL, and h/o dementia who presents to the ED in respitatory distress with likely component of COPD, systolic CHF, and ? LLL pneumonia. She was initially admitted to the MICU and was transferred to the floor on [**2158-5-4**]. Hospital course by problem list: . # COPD: Pt arrived from [**Location **] with BiPAP 8/8 and was able to quickly wean off. She did not require noninvasive ventilatory support for the duration of her ICU stay. Initially received solumedrol 125 IV q8 hrs then transitioned to po prednisone daily. Levoquin was used in place of azithro for COPD exacerbation due to allergy to erythomycin. She tolerated well and was able to be weaned down to 3L which is her home dose. She was discharged on a 5 day course of Levofloxacin (to end on [**2158-5-7**]) and a Prednisone taper as follows: 40mg on [**2158-5-6**], change to 20mg on [**2158-5-7**] for 3 days, then 10mg on [**2158-5-10**] for 3 days, then stop. . # Acute on chronic CHF exacerbation: BNP elevated to 9000. Echo on HD1 showed severe regional LV systolic dysfunction with septal, anterior, and apical akinesis (EF 25-30%); no aortic stenosis; mild-mod mitral regurg, mod tricuspid regurg; severe pulm artery systolic hypertension; very small pericardial effusion - no signs of tamponade; compared to [**9-/2157**], the LVEF is slightly lower and the estimated PA pressure has increased. The patient received a dose of IV lasix on arrival to the ICU and was maintained on a nitro gtt. Respiratory status improved rapidly and the nitro drip was weaned off. She was started on a Captopril for her heart failure. Blood pressure should be controlled below 140/90. . # Shoulder Pain: She reported increased shoulder pain during her echocardiogram. Shoulder x-ray did not show fracture. She was seen by the Chronic Pain Service who performed a cortisone injection on [**2158-5-5**]. She should follow-up with her pain specialist, Dr. [**Last Name (STitle) 1651**]. . # Foot pain: continued gabapentin, tramadol, carisoprodol. . # GI: continued home loperamide [**Hospital1 **]. . # Dementia: continued home aricept & zyprexa & chlordiazepoxide & tylenol. . # CODE STATUS: DNR/DNI Medications on Admission: Tylenol extra strength 1 tab PO TID Clindamycin for dental procedures Chlordiazepoxide 1-2 tabs QHS Gabapentin 300mg PO TID Loperamide 2mg PO BID Albuterol Advair 500/50 [**Hospital1 **] Tramadol 100mg PO BID Furosemide 20mg PO daily Aricept 10mg PO daily Pantoprazole 40mg PO daily Zyprexa 2.5mg PO daily [**Doctor First Name **] PO daily Carisoprodol 350mg PO TID Discharge Disposition: Extended Care Facility: [**Hospital 745**] Health Care Center Discharge Diagnosis: Foot/shoulder pain COPD exacerbation Acute on chronic CHF exacerbation transient leukopenia dementia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You came to the hospital with elevated blood pressure, increased shortness of breath, and congestive heart failure. We were able to control your blood pressure and control the exacerbation of COPD and heart failure. You had pain in your shoulder and feet, we performed Xray and determined that you did not have a fracture. You had a cortisone injection on [**2158-5-5**] by the pain team. You improved with treatment and was discharged in stable condition. Please follow up with your primary care doctor. The following changes were made to your medications: START Levofloxacin to finish on [**2158-5-7**] START Prednisone with the following doses: 40mg on [**2158-5-6**] 20 mg on [**2158-5-7**], [**2158-5-8**], [**2158-5-9**] 10mg on [**2158-5-10**], [**2158-5-11**], [**2158-5-12**] START Captopril 12.5mg by mouth three times per day. It was a pleasure taking care of you. We wish you the best on your road to recovery. Followup Instructions: Department: GERONTOLOGY When: THURSDAY [**2158-5-11**] at 10:30 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 719**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: PAIN MANAGEMENT CENTER When: FRIDAY [**2158-5-12**] at 9:50 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 1652**] Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Parking on Site [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 1653**]

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icd9cm

[ [ [] ] ]

[ "99.29", "81.92", "99.23" ]

icd9pcs

[ [ [] ] ]

9517, 9581

6794, 7180

387, 393

9726, 9726

3725, 3730

10864, 11565

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69,047

163,230

9602

Discharge summary

report

Admission Date: [**2192-1-10**] Discharge Date: [**2192-1-23**] Date of Birth: [**2134-9-17**] Sex: M Service: NEUROSURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 1271**] Chief Complaint: Neck Pain, Thrombocytopenia Major Surgical or Invasive Procedure: Cervical evacuation epidural hematoma [**2192-1-10**] History of Present Illness: [**Known firstname **] [**Known lastname 26065**] is a 57-year-old right-handed man, with a history of tonsillar carcinoma in [**2182**] s/p radiation alone, who was recently admitted for progressive neck pain and R side hemiparesis and MRI findings concerning for recurrence of his cancer versus radiation scarring. He is status post cervical laminectomy for tissue diagnosis which is still pending. Also,he was incidentally found to have possible babeseosis for which has been started on Azithromycin prophylactically. He had been at rehab doing well and reports that his neck pain has improved since surgery and he has increased range-of-motion of his neck. On routine labs he was discovered to have leukocytosis to the 31.2 and thrombocytopenia to 12 and was sent to [**Hospital1 18**] ED for further evaluation. Past Medical History: Past Oncological History: - Tonsillar carcinoma diagnosed [**2182**] and treated with XRT. Other Past Medical History: - Cervical myelopathy believed to be secondary to prior head and neck radiation - Alcoholic cirrhosis with chronic thrombocytopenia and history of varices, and he is status post banding - Anxiety - Chronic back pain on long term opiates - Babeseosis Social History: Social History: He lives with his wife and 9-year-old son. [**Name (NI) **] smoked 1.5 packs of cigarettes per day for 35 years; he stopped in [**2182**]. He drank alcohol heavily in the past but he stopped in [**2176**]. He used cocaine in the remote past. - Tobacco: He smoked from age 13 to 48, 1.5 PPD, so 50+ pack years - Alcohol: Former heavy drinker, last drink was in [**Month (only) **] [**2182**]. - Illicits: Used cocaine in the past, none recently. Family History: Family History: His father died at age 47 from smoking-related lung cancer. His mother is alive and healthy. His 2 brothers are deceased, one from leukemia and the other from drug abuse and psychiatric problems. His 2 sisters are healthy. He has 4 children and they are all healthy. Physical Exam: PHYSICAL EXAM: O: 96.7 88 124/77 16 100 RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 3->2 bilaterally EOMI bilaterally Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3->2 bilaterally 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 - weaker on the Right (5-), Left is ([**3-28**]) XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. Patient continues to have R-sided weakness as follows: Deltoid ([**1-27**]) Biceps ([**1-27**]) Wrist extension ([**2-27**]) Grip ([**1-27**]) Iliopsoas ([**12-30**]) Quads ([**1-27**]) Hamstrings ([**1-27**]) G/S ([**2-27**]) [**Last Name (un) 938**] ([**2-27**]) L is [**3-28**] throughout Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 3+ 3+ Left 2+ 2+ Toes downgoing bilaterally Unable to assess pronator on R, no pronator drift on L EXAM on Discharge: Patient has full strength on Left, but Right strength is as follows: L Deltoid, Bicep, WE, grip, Tricep 2-3/5 LLE has been 0-1/5 Posterior neck incision has been draining serosang fluid and requires daily wound dressing changes and PRN. Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2192-1-23**] 1:07 PM 20 [**2192-1-23**] 6:18 AM 9.5 10.0 28.8 10 [**2192-1-18**] 3.1* 2.48* 8.1* 24.0* 97 32.9* 33.9 18.8* 37* [**2192-1-10**] 11:45AM 4.2 2.51* 8.6* 24.4* 97 34.4* 35.4* 18.1* 38* [**2192-1-10**] 09:26AM 4.0 2.19* 7.4* 21.7* 99* 34.0* 34.3 17.7* 39* [**2192-1-10**] 04:48AM 4.8# 2.59*# 8.9*# 25.6*#1 99* 34.3* 34.7 17.6* 28*# [**2192-1-9**] 03:33PM 31.2* 2 3.79* 13.1* 38.0* 100* 34.6* 34.4 17.7 12*# CT C-Spine [**1-9**] 1. Large intermediate density collection at the site of laminectomy on the posterior cervical region. The lack of enhancement and density of this lesion suggests the presence of a hematoma. 2. Extra-axial intermediate density material within the cervical canal causing leftward displacement of the cervical spine. The lack of enhancement of this material also suggests the presence of hematoma but abscess cannot be excluded. If clinically indicated, MRI could be performed for better evaluation. MRI C-Spine [**1-9**]: 1. Large collection in the C1-C3 laminectomy beds, extending into the right posterior epidural space in the more inferior cervical spine, most consistent with a hematoma. No evidence of rim enhancement to suggest an abscess. The most severe mass effect on the spinal cord occurs at C2-3, where no cerebrospinal fluid is seen surrounding the cord. 2. Essentially unchanged appearance of the rim-enhancing lesion in the upper cervical spinal cord, compatible with either tumor or radiation necrosis. Biopsy results are pending. CT C-Spine [**1-11**]: S/p hematoma evacuation - no evidence of epidural hematoma CT C-spine [**1-16**]: Interval increased fluid reaccumulation at the laminectomy site and site of previous drain placement in overlying posterior cervical soft tissue. These areas demonstrate no rim enhancement to suggest abscess. Video Swallow [**1-16**]: IMPRESSION: Trace aspiration was present on thin liquids. There is a large amount of residual barium material within the valleculae. Minimal movement is present at the base of the tongue. There is a significant amount of retropulsion into the nasopharynx. For further details, please refer to the speech pathology report on OMR. Brief Hospital Course: Mr. [**Known lastname 26065**] was admitted to [**Hospital1 18**] on the NSurg service, and was kep in the PACU for close monitoring and Q1 neuro checks, as no ICU beds were available. he immediately began to receive Platelet transfusions. His repeat plt level following 3 packs of platelet transfusion was 38. A threshold of 80 was set for the patient to be taken to the operating room. His strength in his Left upper extremity began to slowly worsen. he additionally dropped his HCT from 38 on admission to 21 on [**1-10**]. Several consults were obtained to aid in further working up of his pancytopenia, including Heme, OMed, GSurg, and GI. No obvious source of internal bleeding was identified on CT Scan. He continued on platelet infusions and PRBC infusions throught the day on [**1-10**], and following 8 packs of platelet transfusions and 2 [**Location **], his platelets and HCT were 23.8 and 84 respectively. He was then taken to the OR [**1-10**] evening for evacuation cervical epidural hematoma. He tolerated this procedure well, he remained intubated and went to SICU overnight for monitoring. CT of c-spine the next morning showed no epidural hematoma. Patient was weaned to extubation on [**1-11**] and tolerated this will. He reamined in the ICU until [**1-12**]; his platelets remained in the 70s without transfusion, his HCT was stable at 27, and the strength in his RUE and RLE improved to his pre-surgical state. On [**1-12**], he transferred out of the ICU to the stepdown unit. His platelet count dropped again to 48; he was therefore transfused 1 unit (bringing total to 11 units). Immediately following this, his JP was pulled. It was left open to drain, and it did so for approximately 3-4 days (serosanguenous fluid). He was noticed to have a stage I pressure ulcer to his coccyx, which was treated with cream and frequent monitoring and turns. The patient's platelet count was persistently less than 50 from [**1-12**] through [**1-19**], and was subsequently given a transfusion for every low count. He received a total or over 20 units of platelets during his hospitilization, with the intent of keeping platelets higher than 50 to prevent reaccumulation into his epidural space. However, it was determined that this was futile, as his platelets count did not significantly rise despite numerous transfusions. The decision was made to keep the transufion threshold to 30, and to check his platelets only 2x/weekly weekly. This was a recommendation from the Hematology service. On [**2192-1-21**] his decadron was tapered off. Incision was noted to be draining serosang fluid but did not appear to be CSF. Wound was requiring daily wound dressing changes. On [**1-23**] his platelet count was 10, and transfused with 1 pk of platelets. Repeat PLT was 20. Insurance approval was obtained and patient was stable for discharge on [**2192-1-23**] to rehab. Medications on Admission: 1. Docusate Sodium 100 mg Capsule [**Date Range **]: Two (2) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily) as needed for constipation. 3. Polyethylene Glycol 3350 17 gram/dose Powder [**Date Range **]: One (1) packet PO DAILY (Daily) as needed for constipation. 4. Levothyroxine 112 mcg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 5. Nadolol 20 mg Tablet [**Date Range **]: Two (2) Tablet PO DAILY (Daily). 6. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Date Range **]: Two (2) Tablet PO DAILY (Daily). 7. Calcium Carbonate 500 mg Tablet, Chewable [**Date Range **]: One (1) Tablet, Chewable PO DAILY (Daily). 8. Rifaximin 200 mg Tablet [**Date Range **]: One (1) Tablet PO TID (3 times a day). 9. Heparin (Porcine) 5,000 unit/mL Solution [**Date Range **]: 5000 (5000) units Injection TID (3 times a day). 10. Oxycodone 5 mg Tablet [**Date Range **]: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 11. Atovaquone 750 mg/5 mL Suspension [**Date Range **]: Seven [**Age over 90 1230**]y (750) mg PO BID (2 times a day): 10 Days. D1 [**2192-1-1**] to [**2192-1-10**] for babeseosis in a compromised host. 12. Azithromycin 500 mg Recon Soln [**Month/Day/Year **]: 1000 (1000) mg Intravenous Q24H (every 24 hours): 10 Days. D1 [**2192-1-1**] to [**2192-1-10**] for babeseosis in a compromised host . 13. Dexamethasone 4 mg IV Q6H 14. Fentanyl 25 mcg/hr Patch 72 hr [**Month/Day/Year **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 15. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 16. Celexa 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. Discharge Medications: 1. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO DAILY (Daily). 2. Citalopram 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 3. Fentanyl 25 mcg/hr Patch 72 hr [**Last Name (STitle) **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 4. Multi-Vitamins W/Iron Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 5. Levothyroxine 112 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 6. Nadolol 20 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 7. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 8. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs PO Q6H (every 6 hours) as needed for severe pain. 9. Rifaximin 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID (3 times a day). 10. Lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO TID (3 times a day). 11. Famotidine 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q12H (every 12 hours). 12. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical TID (3 times a day) as needed for skin irritation. 13. Spironolactone 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 14. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 15. Potassium Chloride 20 mEq Packet [**Last Name (STitle) **]: Two (2) Packet PO X2 (). 16. Metoprolol Tartrate 5 mg/5 mL Solution [**Last Name (STitle) **]: One (1) Intravenous Q4H (every 4 hours) as needed for HR>110. 17. Methocarbamol 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). 18. Cephalexin 500 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q12H (every 12 hours) for 10 days: Started on [**1-23**]. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Epidural Hematoma Thrombocytopenia Cirrhosis - End Stage Liver Disease Stage I pressure ulcer (coccyx) Discharge Condition: Stable 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. ?????? You have staples in place ?????? 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. ?????? You may only shower with the collar or back brace on. ?????? 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. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine. ?????? Any weakness, numbness, tingling in your extremities. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, and drainage. ?????? Fever greater than or equal to 101?????? F. ?????? Any change in your bowel or bladder habits (such as loss of bowl or urine control). ** You have been placed on Keflex as a precaution, please continue as prescribed** Followup Instructions: Follow up with Dr. [**Last Name (STitle) 739**] on [**2192-2-1**] at 10:45 for appointment and staple removal Follow up with a hepatologist at Liver Center for your cirrhosis within 2 weeks after your discharge. The hepatology service recoomends a low NA diet for your acites, to continue on lasix 40mg everyday and aldactone 100mg everyday for 1-2 months. While one these medications you will need to have your electrolytes and CBC drawn once every week this should be faxed to your primary care physician and the liver center. You should have a CT of the chest with contrast as an outpatient with your PCP to exclude [**Name Initial (PRE) **] exclude an enhancing soft tissue lesion that was suspicious on a non contrast CT Scan. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2192-1-23**]

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icd9cm

[ [ [] ] ]

[ "96.71", "03.09" ]

icd9pcs

[ [ [] ] ]

13234, 13313

6579, 9475

304, 360

13460, 13468

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11274, 13211

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237, 266

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2674, 2895

1352, 1603

1636, 2089

4,696

159,133

45412

Discharge summary

report

Admission Date: [**2121-5-13**] Discharge Date: [**2121-5-22**] Date of Birth: [**2049-6-18**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 783**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: Hemodialysis Splinting of left wrist History of Present Illness: 71F with ESRD on HD, IDDM, PVD, AF s/p PPM, cirrhosis, CAD, with a recent mechanical fall during which she sustained fracture of L forearm, referred to ED from cardiologist's office for lethargy. She has been taking vicodin at home for pain from fracture and had apparently been more "sleepy" lately. She went to her cardiologist's office today for a routine visit and was noted to be very lethargic, so sent to ED. In ED, somnolent; ABG 7.29/63/88. Placed on BiPAP and mental status improved, but within one hour of stopping BiPAP, became lethargic again. Narcan given with minimal response. Restarted BiPAP and sent to MICU for hypercarbic resp failure. Past Medical History: 1. ESRD/CRI - Patient receives HD @ "[**Last Name (un) 96929**]" center in [**University/College **] - M/W/F. 2. IDDM - Course has been complicated by polyneuropathy, nephropathy, retinopathy, and Charcot foot bilaterally - patient does not check her FS at home, she received 70 u in am and 30 u in pm of 70/30. Followed by Dr. [**First Name (STitle) 1313**] ? in [**Last Name (un) **]. 3. Peripheral vascular disease 4. AF - Pt is s/p pacemaker placement. She is not anticoagulated due to multiple falls. 5. Anemia 6. Hyperlipidemia 7. Cirrhosis secondary to cholestasis 8. Hypertension 9. Coronary artery disease- Pt had three vessel disease on cardiac cath from [**2111**]. She is s/p NSTEMI in [**2110**]. Stress test '[**12**]. Moderate, fixed perfusion defect in the inferior wall. Mild global hypokinesis. 10. Dilated ischemic cardiomyopathy- Pt's most recent echo was [**2119-6-26**]. EF 40%; mod LA/RA dilation; mild LVH/mild global HK (most prominent in the septum); 1+ MR. Mod pulmonary HTN 11. Adrenal adenoma 12. S/P TAH for leiomyoma 13. Right facial droop in [**7-/2119**] for which she declined workup or treatment. 14. Depression 15. s/p mechanical fall, L elbow/olecranon Fx on [**2120-1-6**] - conservative management Social History: Pt lives in her own home in [**Location (un) 1110**]. She has 24 hour help at this time, although recently helper can't come in over the weekend, the son has been speding more time with her. The patient rare walks with a walker and mostly gets about in a wheelchair. She is very close with her daughter, [**Name (NI) 2808**], who visits often and her son, [**Name (NI) 96930**], who is her healthcare proxy. His phone number is [**Telephone/Fax (1) 96931**]. DNR/DNI. Pt used tobacco in the past - quit 24 years ago. Denies ETOH or drug use. Family History: Fa - DM, CAD; Ma - Breast Ca; Physical Exam: Tm/Tc 98.4 BP 137/71 (120-160/50-71) HR 89 (80-95) RR 16 O2 94% 4L I/O 250/150 (not including dialysis) General: obese WF, supine in bed, awake and participating in conversation, A&Ox3 HEENT: op clear, mmm, sclera anicteric Neck: supple, no jvp Lungs: Clear to auscultation anteriorly and laterally Heart: s1 s2 2/6 SEM, regular rhythm Abd: soft nt/nd, hypoactive bowel sounds Ext: 1.5 x 1.5 cm full thickness ulcer over left malleolus; 2 x 2 cm full thickness ulcer over right heel; no evidence of acute infection. No edema, clubbing, cyanosis. Neuro: CN2-12 intact, poor sensation in lower ext Skin: 1-2 cm of erythema and tenderness around tunneled HD catheter, old sutures still in place Pertinent Results: XRAY WRIST [**2121-5-15**]: Overlying cast material obscures detail. There is an old, distracted fracture of the olecranon which is similar in appearance compared to [**2120-3-26**]. There is a split fracture of the radial stylus. There is a lucent line within the mid-body of the scaphoid, likely also consistent with a fracture. There is a minimally displaced fracture of the distal portion of fifth metacarpal. There is a small, nondisplaced fracture of the ulnar styloid. There are degenerative changes at the first carpometacarpal joint. There is widening of the scapholunate interval. There are diffuse vascular arterial calcifications. IMPRESSION: 1. Multiple fractures of the distal radius, distal ulna, fifth metacarpal, and scaphoid as detailed above. 2. Degenerative changes at the first CMC joint. . CT ABDOMEN/PELVIS [**2121-5-13**]: 1. No evidence of intraabdominal hematoma or ascites. 2. Left adrenal adenoma, as characterized by MRI in [**Month (only) 404**] [**2114**]. 3. Extensive vascular calcifications including a calcified splenic artery aneurysm. 4. Incidentally noted are atrophied kidneys, hepatomegaly and splenomegaly, cholelithiasis and diverticulosis. Brief Hospital Course: MICU Course: Although the cause of her acute respiratory failure remains unclear, a retrocardiac infiltrate on CXR could not be ruled out, so antibiotics for CAP were started. Also consider infected HD catheter; blood cultures are pending. Since mental status cleared and respiratory status stable, called out. A/P: 71 y/o F with MMP p/w somnolence and hypotension. . 1) Somnolence: On arrival to MICU, mental status was alert and oriented but sleepy; after one hour, HO called to see patient for lethargy and minimal response to sternal rub. VBG confirmed hypercarbia, BiPAP restarted and patient became more alert. Then slept through night without event, alert and oriented to person, place, and time ([**2121-5-9**]) in the morning. Consider hypercapnea in the setting of OSA vs. narcotic use vs. pneumonia. Mental status continued to wax/wane in terms of her mental status despite discontinuation of Vicodin. Sleep service was consulted and patient dismissed them before they were able to complete an evaluation. She was recommended for outpatient follow-up with Dr. [**First Name8 (NamePattern2) 4051**] [**Last Name (NamePattern1) 437**] in Sleep Medicine. . 2) ? Pneumonia: In consideration of hypercapnea and possible retrocardiac opacity, patient was started on a 7-day course of ceftriaxone, azithromycin. 3) Wrist fracture: Pt's L forearm imaged as she sustained fall prior to admission to hospital (reportedly fell OOB). Imaging showed multiple fractures of the distal radius, distal ulna, fifth metacarpal, and scaphoid. Degenerative changes at the first CMC joint. Plastic surgery consulted and they recommended conservative management with thumb spica cast. Patient was advised to follow-up with Dr. [**Last Name (STitle) **] following discharge. . 4) ESRD: On HD, renal following. Continued on sevelamer. She was treated with Vancomycin for suspicion of HD catheter infection. . 5) CAD: No active issues. Troponin leak of 0.27, likely secondary to ESRD. Continue ASA, statin, lopressor. . 6) Thrombocytopenia: Baseline platelets 50-100K, of uncertain etiology. Documented negative HIT antibody x 2 in past. . 7) Cirrhosis: Documented as secondary to cholestasis. Continue ursodiol. . 8) FEN: Renal, diabetic diet. Maintain K>4, Mg>2. . 9) Prophylaxis: Continue PPI per home regimen. Heparin SC as DVT prophylaxis; will monitor platelets carefully. . 10) Code status: DNR/DNI. Medications on Admission: 1. Protonix 40 mg a day. 2. Renagel 800 mg p.o. t.i.d. 3. Atorvastatin 20 mg a day. 4. Lopressor 25 mg b.i.d. 5. Ursodiol 500 mg b.i.d. 6. Zoloft 75 mg a day. 7. Folic acid 1 mg a day. 8. Neurontin 300 mg every day. 9. Advil 400 mg in the morning. 10. Aspirin 81 mg p.o. daily. 11. Klonopin .5 12. lyrica 25 after dialysis 13. Vicodin PRN Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). Disp:*90 Tablet, Chewable(s)* Refills:*2* 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Clonazepam 0.25 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO once a day. Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0* 6. Zoloft 50 mg Tablet Sig: 1.5 Tablets PO once a day. 7. Ursodiol 500 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for as needed for wrist pain. 11. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 35 units qAM; 15 units qPM units Subcutaneous twice a day. 12. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: Per sliding scale Subcutaneous qACHS. 13. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO once a day for 2 doses: Take after next two dialysis sessions. Disp:*2 Tablet(s)* Refills:*0* 14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day. Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Somnolence Hypercapnea Pneumonia Tunnelled hemodialysis catheter infection Left wrist fracture End-stage renal disease Discharge Condition: Stable. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm low sodium diet. . Several changes have been made to your medications: 1) Lyrica has been discontinued due to somnolence. 2) Vicodin has been discontinued due to somnolence. 3) Your dose of Klonopin has been reduced to 0.25 mg once daily due to somnolence. 4) You have two remaining doses of Cefpodoxime to treat your for a possible pneumonia. You should take these pills after your next two dialysis sessions. 5) You can take advil and tylenol as needed for your wrist pain. You should avoid taking any narcotics. 6) You have been started on a medication called Lanthanum. 7) The dose of your Metoprolol has been reduced to 12.5 mg twice daily. . Your wrist fracture is being managed with a splint. You are scheduled to follow-up with Orthopaedics in two weeks. . You should return to the hospital if you are experiencing shortness of breath, chest pain, altered mental status, or other concerning symptoms. Followup Instructions: Please call [**Telephone/Fax (1) 250**] to schedule a follow-up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the next 1-2 weeks. . You are scheduled to follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the Department of Orthopaedics on [**6-4**] at 10:50 a.m. Her office is located on the [**Location (un) 1773**] of the [**Hospital Ward Name 23**] Building on the [**Hospital1 18**] [**Hospital Ward Name 516**]. Please call ([**Telephone/Fax (1) 2007**] if you need to reschedule. . You also have a previously scheduled appointment with Dr. [**Last Name (STitle) **] on [**2121-7-29**] at 2:10 p.m. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

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Discharge summary

report

Admission Date: [**2162-2-8**] Discharge Date: [**2162-2-11**] Date of Birth: [**2096-8-14**] Sex: M Service: MEDICINE Allergies: Codeine Attending:[**Doctor First Name 2080**] Chief Complaint: Syncope with subdural hematoma Major Surgical or Invasive Procedure: None History of Present Illness: This is a 65 yo male with history of DMII, hypertension, migraine with aura, h/o right lower extremity sarcoma who was transferred from an OSH ED for further management of small SDH which patient sustained after syncopal episode with brief LOC. Patient reports that this morning he was at work standing up while speaking with a client when he noticed vision became acutely blurry. The next thing he recalls is waking up on the ground. He denies any preceding CP, SOB, palpitations or diaphoresis. Reportedly, the patient had a witnessed fall backwards with about 10-15 seconds of LOC. His colleagues thought he appeared blue and initiated chest compressions very briefly before he awoke. EMS was called and he was taken to [**Hospital 86766**] Hospital where he was found to have a 3mm right anterior falx subdural hematoma. He was transferred to [**Hospital1 18**] for neurosurgery evaluation. . In the ED, initial VS: T: 97.9 HR: 80 BP: 176/72 RR: 19 O2Sat:100 RA. He had a repeat head CT read as 1.5-2 mm in diameter, 8 mm in length SDH along right frontal falx. He was seen by neurosurgery who recommended ICU admission with Q1H neuro checks. A CXR was benign and CT neck without fracture or dislocation. . Currently, he reports [**3-6**] bilateral neck pain. He does experience some mild dizziness when he flexes or turns neck from side to side. . ROS: Denies fever, chills, night sweats, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: H/O palpitations (no previous work-up) Sarcoma of right proximal thigh, s/p chemotherapy and XRT [**3-5**], s/p resection in [**9-4**] Dyslipidemia HTN DM II Migraine with Aura h/o nephrolothiasis s/p CCY s/p appendectomy Social History: Works in sales. Lives in [**Location 15749**] with his wife. Denies any history of tobacco. Rare ETOH. No illicit drug use. Family History: Multiple maternal uncles with death in their 40's and 50's of unclear etiology. Physical Exam: Vitals - T:98.5 BP:154/85 HR:82 RR:18 02sat: 99RA GENERAL: well appearing, obese male, NAD HEENT: 1in x 1in abrasion on occiput, PERRL, EOMI, OP clear CARDIAC: s1/s2 present, no s3 or s4 appreciated. No murmurs. LUNG: CTAB, no wheezes or crackles ABDOMEN: RUQ surgical scar, +BS, soft, NT, ND EXT: no LE edema NEURO: CN II-XII grossly intact, 5/5 strength in all 4 extremities, no pronator drift, normal finger to nose and nl rapid alternating movements,light touch sensation intact, cold sensation intact Pertinent Results: Admission labs [**2162-2-8**]: WBC-9.0 RBC-3.57* Hgb-11.3* Hct-34.1* MCV-96 MCH-31.7 MCHC-33.2 RDW-13.7 Plt Ct-165 Neuts-86.0* Lymphs-9.8* Monos-3.7 Eos-0.3 Baso-0.2 PT-11.8 PTT-23.5 INR(PT)-1.0 Glucose-152* UreaN-23* Creat-1.1 Na-138 K-4.3 Cl-101 HCO3-26 AnGap-15 CK(CPK)-61 Iron-51 calTIBC-394 VitB12-370 Folate-GREATER TH Ferritn-630* TRF-303 Discharge labs [**2162-2-11**]: WBC-4.8 RBC-3.59* Hgb-11.7* Hct-34.5* MCV-96 MCH-32.4* MCHC-33.8 RDW-13.8 Plt Ct-179 Glucose-190* UreaN-27* Creat-1.2 Na-140 K-3.7 Cl-101 HCO3-30 AnGap-13 Calcium-9.1 Phos-2.5* Mg-1.8 Microbiology: MRSA screen negative Imaging: [**2-8**] EKG: Sinus rhythm with borderline A-V conduction delay. Probable prior inferior myocardial infarction. No previous tracing available for comparison. Clinical correlation is suggested. [**2-8**] CT Head: 1. Small focus of high-density material along the anterior superior falx, with mild atrophy of adjacent right frontal cortex. This could conceivably represent a tiny subdural hematoma.. 2. Small subgaleal hematoma at the left posterior vertex. [**2-8**] C-spine CT: No acute fracture or malalignment of the cervical spine. [**2-8**] CXR: 1. Low lung volumes with mildly decreased expansion of the right lung as compared to the left. Minimal left basilar atelectasis. No focal consolidation. 2. Borderline-to-mildly enlarged cardiac silhouette. [**2-9**] TTE: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. 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 leaflets are mildly thickened. There is no mitral valve prolapse. Physiologic mitral regurgitation is seen (within normal limits). The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved regional and global systolic function. Mild right ventricular cavity dilation with normal function. [**2-9**] EKG: Sinus rhythm with modest A-V conduction delay. Consider left atrial abnormality. Probable prior inferior myocardial infarction. Since the previous tracing of [**2162-2-8**] no significant change. [**2-9**] LENIs: No evidence of right or left lower extremity DVT. Brief Hospital Course: This is a 65 yo male with history of HTN, DMII, migraine and sarcoma presenting with syncopal episode with LOC and subsequent small SDH. # Syncopal Episode with LOC: Etiology unclear given normal orthostatic measures, normal Echo, no signs of MI, no DVTs, no signs of seizure activity or vagal cause. His syncope may have been related to hypoglycemia given his diabetes or dizziness from newly diagnosed benign paroxysmal positional vertigo. # Subdural Hematoma: Secondary to head trauma following syncopal episode. Neurosurgery saw the patient on admission and recommended conservative management. His neurological exam was normal throughout hospital stay. He has an appointment to follow-up with neurosurgery 8 weeks after discharge and will have repeat head CT at that time right before the appointment. - His aspirin was held pending neurosurgery follow up. # Vertigo: Patient had positional vertigo and positive [**Last Name (un) **]-Hallpike on the left. He was diagnosed with benign paroxysmal positional vertigo and seen by PT who taught him the Epley maneuver. He was given a prescription for outpatient physical therapy to work on vestibular therapy. # Bradycardia: Patient had two episodes of bradycardia down to 20-30s while in the MICU. He was asymptomatic and asleep during these episodes. Electrophysiology was consulted and felt this was due to a combination of vagal tone and beta blocker. His atenolol was discontinued, and he had no further episodes of bradycardia. # Normocytic Anemia: Patient reports history of anemia possibly secondary to XRT. He has normal folate and B12 levels with iron studies showing mild iron deficiency. This should be followed up as an outpatient. # Hypertension: After discontinuing his atenolol as above, his valsartan was doubled and amlodipine 5mg daily was added to control his blood pressure. # DM II: His home metformin, avandia and glimepride were held while in the hospital and resumed on discharge. While inpatient, he was on a sliding scale of insulin. # Dyslipidemia: Continued statin Medications on Admission: Metformin 1000mg [**Hospital1 **] Avandia 4mg [**Hospital1 **] Atenolol 100mg QPM Glimepride 4mg [**Hospital1 **] Lovastatin 40mg QPM Diovan 80mg [**Hospital1 **] ASA 81 mg daily Discharge Medications: 1. Lovastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime. 2. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Avandia 4 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Glimepiride 4 mg Tablet Sig: One (1) Tablet PO twice a day. Tablet(s) 8. Outpatient Physical Therapy Please do vestibular rehabilitation. Discharge Disposition: Home Discharge Diagnosis: Primary: Subdural hematoma Syncope Benign paroxysmal positional vertigo Secondary: Hypertension Diabetes mellitus type 2 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 after passing out and hitting your head. You had a small amount of bleeding around your brain but this was stable and did not cause any neurological changes. Your heart rate was slow overnight, and your atenolol was stopped. You were diagnosed with benign paroxysmal positional vertigo as the cause of your dizziness. Please follow-up with your PCP and neurosurgery as below. The following changes were made to your medications: 1. Stopped atenolol because of your slow heart rate. 2. Increased diovan to 160mg twice daily to control your blood pressure. 3. Started amlodipine to control your blood pressure. 4. Stop your aspirin until you see neurosurgery in follow-up. Your dizziness should improve with the Epley maneuver taught by physical therapy. You will also have outpatient physical therapy. Followup Instructions: Your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5126**] asked that you call [**Telephone/Fax (1) 23662**] to schedule a follow-up appointment. Please follow-up with the neurosurgeons here at [**Hospital1 18**] on [**4-6**] and will have a repeat head CT scan right before your appointment. Your CT scan will be done at 10 AM on the [**Location (un) **] of the clinical center building, [**Hospital1 7768**]. After your CT, you will have an appointment with Dr. [**Last Name (STitle) **] of neurosurgery at 10:45 AM in the [**Hospital **] Medical building, [**Last Name (NamePattern1) 10357**]. If you need to reschedule, please call ([**Telephone/Fax (1) 18865**].

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icd9cm

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icd9pcs

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Discharge summary

report+addendum

Admission Date: [**2122-7-19**] Discharge Date: [**2122-7-21**] Date of Birth: [**2095-2-8**] Sex: F Service: MEDICINE Allergies: No Allergies/ADRs on File Attending:[**First Name3 (LF) 348**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: 27 yo female with history of migraine headaches and menometorrhagia presents with altered mental status found to have hyponatremia. In [**2121-10-28**], she started a new position as a senior analyst in investment consulting for a firm in [**Location (un) 311**]. Her job is stressful but per her mother's report she has been doing well. Around the same time, the family reports that the patient's cousin hacked into her blackberry and her facebook account. She was suspicious that her friends might be involved in the hacking because she reports they knew information that they should not have known. As a result of her job and the hacking, she became more stressed with increased migraines, insomnia, and fatigue. She went to see her physician in [**Name9 (PRE) 311**] for her fatigue. They prescribed her with iron tabs for iron deficiency anemia given her heavy periods. However, she did not take her iron pills because she has always been skeptical of medications. She had to take time off from work because of her migraines and since she was very paranoid about technology. She tried to report the hacking to the authorities but they turned her down since she did not have enough evidence. She has been increasingly paranoid that people were hacking her phone and social media accounts. In addition, she had to break off an unhealthy relationship at this time. She came home to visit her parents and arrived on [**7-7**]. Her parents report that she was acting normally for the first week. At baseline, she is "a model child" who is moral and extremely close with her parents, especially her mother. She has been complaining of a headache daily. Two days ago, she checked facebook for the first time since the incident. Immediately afterward, she was very upset with a worsening headache. She was yelling at her parents for "not understanding and being calm" and then apologize for causing them anxiety. Over the past 48 hours, she has reported being dehydrated, and has been drinking profuse amounts of water. At one point, she was pouring a pitcher of water on herself. She reports feeling unwell, not like herself, and with a headache. Her headaches are typically unilateral but now her headache is bilateral and frontal. She has had trouble sleeping. Of note, she traveled to [**Country 480**] one year ago. Her mother also reports a bug bite a few months ago. Today, her headache worsened and she had projectile vomiting. She denies fevers, diarrhea, cough, or dysuria. She was more confused today, making secret phone calls, having outbursts of yelling, and asking for the car keys but not saying where she is going. The family brought her into the ED. She was claiming that she didn't recognize her parents, that her parents were not her parents and that they were trying to hurt her. Upon arrival to the ED, her VS were 98.1 69 16 117/63 100% on RA. She was complaining of an intermittent headache and hysterically crying at the same time. Her exam was initially nonfocal. She was tachycardic and profusely asking for water. She was uncooperative and combative, restrained by security, and was given 5 of haldol and 2 of ativan IM. CT head was normal. In addition she was given 2mg of versed for an LP. During the LP, her sodium returned low at 123. LP results were pending at the time of transfer. She was given vanco, ceftriaxone, acyclovir with decadron 10mg to cover for bacterial meningitis. Prior to transfer, she was arousable but sedated, with a foley in place draining clear urine. Admission Vitals: T98.1 HR 71 BP 128/72 RR 20 SpO2 100% 2LNC. On arrival to the MICU, she was sedated and fatigued. Past Medical History: Migraine headaches Menometrorrhagia Social History: Completed Masters Program in Economics in [**Location (un) 311**], prior to starting her position as an Investment Consultant in [**Location (un) 311**]. Denies tobacco, drug use with infrequent EtOH. Never sexually active. Mother is [**Name8 (MD) **] MD (trained as family practitioner), working in public health. Father is trained as an atttorney. Family History: Mother and maternal side with history of migraines. Physical Exam: Admission Exam Vitals: 98.3 91 119/71 20 99% on RA General: Alert, oriented, no acute distress, quiet and noding off at times, flat affect HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops Lungs: CTAB, no wheezes, rales, ronchi Abdomen: +BS, soft, non-tender, non-distended Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities Discharge Exam General: Alert, oriented, no acute distress, pleasant and conversant HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops Lungs: CTAB, no wheezes, rales, ronchi Abdomen: +BS, soft, non-tender, non-distended Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities Pertinent Results: Admission Labs: [**2122-7-19**] 03:15PM BLOOD WBC-5.8 RBC-3.59* Hgb-11.0* Hct-32.0* MCV-89 MCH-30.5 MCHC-34.2 RDW-13.1 Plt Ct-241; Neuts-86.2* Lymphs-9.5* Monos-3.9 Eos-0.2 Baso-0.2 [**2122-7-19**] 07:30PM BLOOD WBC-7.2 RBC-3.68* Hgb-11.4* Hct-32.7* MCV-89 MCH-31.1 MCHC-34.9 RDW-13.1 Plt Ct-244; Neuts-92.4* Lymphs-5.4* Monos-1.9* Eos-0.2 Baso-0.2 [**2122-7-19**] 03:15PM BLOOD Glucose-114* UreaN-5* Creat-0.6 Na-123* K-2.5* Cl-85* HCO3-23 AnGap-18 [**2122-7-19**] 07:30PM BLOOD Glucose-127* UreaN-4* Creat-0.6 Na-130* K-3.2* Cl-96 HCO3-24 AnGap-13 [**2122-7-19**] 11:30PM BLOOD Na-137 K-3.7 Cl-102 [**2122-7-20**] 09:09AM BLOOD ALT-17 AST-43* LD(LDH)-234 AlkPhos-32* TotBili-0.5 [**2122-7-19**] 07:30PM BLOOD Calcium-8.3* Phos-3.3 Mg-1.5* [**2122-7-19**] 11:30PM BLOOD Calcium-9.0 Mg-2.6 Iron-53 [**2122-7-19**] 11:30PM BLOOD calTIBC-303 Ferritn-19 TRF-233 [**2122-7-20**] 09:09AM BLOOD VitB12-972* Folate-17.7 [**2122-7-19**] 07:30PM BLOOD Osmolal-265* [**2122-7-19**] 11:30PM BLOOD TSH-1.1 [**2122-7-20**] 05:40PM BLOOD Cortsol-24.4* (after cosyndtropin stim) [**2122-7-20**] 04:11PM BLOOD Cortsol-6.1 [**2122-7-20**] 04:00AM BLOOD Cortsol-0.8* [**2122-7-20**] 05:40PM BLOOD HIV Ab-NEGATIVE [**2122-7-19**] 03:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2122-7-19**] 11:59PM BLOOD Type-[**Last Name (un) **] Temp-36.8 pH-7.40 [**2122-7-19**] 03:18PM BLOOD Lactate-2.8* [**2122-7-19**] 11:59PM BLOOD freeCa-1.21 [**2122-7-19**] 04:48PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-6 Lymphs-85 Monos-9 [**2122-7-19**] 04:48PM CEREBROSPINAL FLUID (CSF) TotProt-22 Glucose-68 Discharge Labs: [**2122-7-21**] 09:10AM BLOOD WBC-7.5 RBC-3.83* Hgb-11.7* Hct-35.2* MCV-92 MCH-30.4 MCHC-33.1 RDW-13.2 Plt Ct-259 Glucose-81 UreaN-9 Creat-0.8 Na-142 K-3.9 Cl-107 HCO3-25 AnGap-14 Calcium-8.9 Phos-3.4 Mg-2.1 [**2122-7-21**] 06:28PM BLOOD Lactate-1.4 Micro: Crypto Ag: neg Blood Cx: PND CSF Cx (bacterial, AFB, fungal): neg/prelim RPR: negative Imaging: CT Head: no acute process EKG: Sinus rhythm. Non-specific ST-T wave changes in leads V2-V3. No previous tracing available for comparison. US Pelvis: IMPRESSION: Limited pelvic ultrasound. No son[**Name (NI) 493**] abnormality detected on transabdominal examination. MRI: IMPRESSION: Grossly normal examination, specifically without apparent etiology to altered mental status. Brief Hospital Course: Ms. [**Last Name (un) 78654**] was admitted to the ICU for treatment of symptomatic hyponatremia and was treated as below for her active medical problems. After correction of hypoNa, pt was transfered to CC7 for a brief course, after which she was discharged. Pt and mother requested to FU MRI results on outpatient basis and, having been cleared by psychiatry, pt was discharged. Active Issues: # Hyponatremia: Hypotonic with patient appearing euvolemic on exam. Most likely psychogenic polydipsia given profound history of water intake and reports of paranoia. Her urine lytes [**Location (un) 31538**] urine osmolarity and her serum osmolarity were low as well. Although urine osm were 120 (vs <100 expected for psychogenic polydypsia), the pt may have been on fluids at the time of the exam. SiADH is on ddx (and can co-present in pts with psychosis and psychogenic polydypsia, although pelvic US negative for mass, CXR not available). Pt's hyponatremia improved with fluid restriction after 1L 3% normal saline. Additional testing done on admission: TSH wnl, cortisol stim test appropriate, infx (CSF culture prelim, crypto, blood culture no growth to date, negative UA) unlikely, tox screen negative. Pelvic US negative for mass and head CT/MRI unremarkable. LP results unremarkable. Pt was evaluated by psychiatry, who remakred that acute psychosis in ED was [**1-29**] hyponatremia. Further evaluation is necessary re. pt's initial paranoid behavior. - Consider CXR if concern for malignancy causing siADH - Consider measuring ACTH, as below - Pls consider porphyrins (or PNG deaminase) if repeat episode in pt with hyponatremia and psychosis - Pls follow up pt's paranoia - FU Blood Cx - FU final CSF Cx # Paranoia vs somebody really stealing her facebook account. Psychiatry was consulted who were not completely convinced this was new presentation of manic or pyschotic disorder. They will continue to follow her clinically. # Low am cortisol with normal stim test. This rules out primary adrenal insuffiency, however primary adrenal insufficiency and low ACTH remains a possibility. The patient should get endocrine follow up for this. -endo follow up -consider measureing ACTH # Altered mental status: Most likely secondary to hyponatremia vs possible undiagnosed psychiatric illness. Tox screens negative except for urine benzos which is likely a result of benzo administration in the ED. CT head showed no acute intracranial process. She was on IV acyclovir with low clinical suspicion it was discontinued and herpes PCR negative. - FU CSF lyme titer # Headaches: Worsening in setting of stress. [**Month (only) 116**] be migraines versus rebound headache. No headaches at time of discharge. Transitional Issues: - FU pt's mental status (concern for delusional disorder vs. schizophrenia) - Pls re-eval pt's serum sodium - Consider CXR if concern for malignancy causing siADH - Consider measuring ACTH, as below - Pls consider porphyrins (or PNG deaminase) if repeat episode in pt with hyponatremia and psychosis - possibility of AIP - Pls eval if pt was menstruating prior to onset of polydypsia (if AIP, pt would be more likely to be symptomatic at time of blood loss) - FU Blood Cx - FU final CSF Cx Medications on Admission: Excedrin migraine aspirin prn Discharge Medications: 1. Aspirin-Caffeine-Butalbital [**12-29**] CAP PO PRN HEADAHCE headache Discharge Disposition: Home Discharge Diagnosis: Hyponatremia Altered Mental status Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure to care for you in the hospital. . You were brought to the hospital after being confused. You were found to have a low sodium level in your blood. This was corrected over your hospital stay. We think this was caused by drinking too much water, other causes were ruled out by several blood tests. You had an MRI of the head. We discussed with you staying here until the radiologists had completed interpretation of the MRI. You were unable to stay in the hospital. We will call you with the results of the MRI. No changes were made to your home medication list. . Please do not drink excess amounts of water. . Please follow up with your primary care physician in the next 1 week Followup Instructions: Department: [**Hospital **] MEDICAL GROUP When: MONDAY [**2122-7-27**] at 3:45 PM With: DR. [**First Name8 (NamePattern2) 132**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 133**] Building: [**Street Address(2) 3375**] ([**Location (un) **], MA) [**Location (un) 858**] Campus: OFF CAMPUS Best Parking: On Street Parking Department: MEDICAL SPECIALTIES When: THURSDAY [**2122-8-6**] at 3:20 PM With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 16624**], MD [**Telephone/Fax (1) 1803**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage ****Your insurance records are incomplete- please call our registration department at ([**Telephone/Fax (1) 22161**] before your first appointment. If you do not have any insurance listed, you may be required to pay up front for these visits. Completed by:[**2122-7-23**] Name: [**Known lastname 12666**]-[**Last Name (un) 5772**],[**Known firstname 12667**] Unit No: [**Numeric Identifier 12668**] Admission Date: [**2122-7-19**] Discharge Date: [**2122-7-21**] Date of Birth: [**2095-2-8**] Sex: F Service: MEDICINE Allergies: No Allergies/ADRs on File Attending:[**First Name3 (LF) 1775**] Addendum: - Please FU Lyme titer Discharge Disposition: Home [**First Name11 (Name Pattern1) 1034**] [**Last Name (NamePattern1) 1778**] MD [**MD Number(2) 1779**] Completed by:[**2122-7-23**]

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Discharge summary

report

Admission Date: [**2140-10-28**] Discharge Date: [**2140-11-29**] Date of Birth: [**2061-9-27**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 2145**] Chief Complaint: fall one month ago Major Surgical or Invasive Procedure: [**11-11**]- Pulmonary embolus; IVC filter placed [**11-14**]- Burr holes for SDH [**11-14**]- Trach and PEG [**11-18**] - left craniotomy for evacuation of reaccumulation of L SDH [**11-19**] - abd ultrasound History of Present Illness: The patient is a 79 yo R-handed man with Afib (on coumadin), HTN, hyperlipidemia and blindness R-eye who was sent to the ED by his PCP after [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 55006**] showed SDH. The patient reports that he had a fall about one month ago while walking in the [**Doctor Last Name 6641**] with a couple of friends. [**Name (NI) **] remembers that he hurt his head while falling backwards. He denies loss of consciousness and was able to walk without problems after he was helped back to his feet by his friends. At the time he did notdevelop a headache, weakness, double vision or numbness. During the past month, the patient noted that he has been off balance more frequently. He denies any further falls. He also developed headaches. These were dull, located on both sides patient is not able to specify the location) and were intermittent. He cannot point to factors that made the headache worse or better. Day of admission, the patient visited his PCP for his gait problems. A head- CT was obtained that showed SDH. The patient was then sent to the ED. Past Medical History: -Afib(was on coumadin) -HTN -DJD; s/p TKR L and R -Hyperlipidemia -PNA -BPH -Compartment syndrome R-arm -Blind on the R-eye for 50 yrs (etiology not known) Social History: Social History: Smoking: cigars; used to smoke cigarettes, quit 25yrs ago EthOH: [**1-10**] beer/day Level of activity: independent in ADL Family History: Family History: -sister: stroke Physical Exam: Vitals: T afebrile HR78 [**Last Name (un) 3526**] [**Last Name (un) 3526**] BP 178/81 RR21 sO298% RA Gen: NAD, sitting on stretcher Neck: no LAD; no Carotid Bruits; full range neck movements Lungs: Clear to auscultation bilaterally Cardiovascular: Regular rate and rhythm, normal S1 and S2, no murmurs, gallops and rubs. Abdomen: normal bowel sounds, soft, nontender, nondistended Extremities: no clubbing, cyanosis, ecchymosis, or edema Skull: no bruits. Mental Status: Awake and alert, cooperative with exam, normal affect. Oriented to place, month, day, and date, person. Attention: DOWbw. Memory: Registration: [**3-10**] items; Recall [**2-11**] at 5 min. Language: fluent; repetition: intact; Naming intact; Comprehension: intact; no dysarthria, no paraphasic errors. Writing: intact. [**Location (un) **]: intact; Prosody: normal. Fund of knowledge normal; No Apraxia. No Neglect. Cranial Nerves: II: Visual acuity intact on L; blind on R. Visual field L-eye are full to confrontation, pupil reactive to light, 2-->1 mm. III, IV, VI: Extraocular movements intact without nystagmus, lateral gaze R-eye slightly decreased. Fixation and saccades are normal. V: Facial sensation intact to light touch and pinprick. VII: Facial movement normal and symmetrical. VIII: Hearing intact to finger rub bilaterally. IX: Palate elevates in midline. XII: Tongue protrudes in midline, no fasciculations. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. Motor System: Normal bulk and tone bilaterally. No adventitious movements, no tremor, no asterixis. 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 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 No pronator drift Sensory system: Sensation intact to light touch, pin prick, temperature (cold), and proprioception in all extremities. Vibration decreased in both lower extremities (down from knees). Reflexes: B T Br Pa Pl Right 2 2 2 1 - Left 2 2 2 1 - Grasp reflex absent. Toes: upgoing bilaterally. Coordination: Normal [**Last Name (LF) 11140**], [**First Name3 (LF) **], HTS. Gait: deferred. LABS and IMAGING: 142 105 12 88 4.6 27 1.1 Ca 9.3 Mg 2.1 P 2.9 PT 15.3 PTT 32.7 [**First Name3 (LF) 263**] 1.6 WBC 7.6 Hct 39.6 PLT 248 neutro 67 Ly 20 Mono 7.6 Eo 4.4 CT-head (OSH): small chronic SDH R-frontal; larger acute on subacute on chronic subdural hematoma L-frontal (mainly subacute). A repeat CT-head has been ordered by the ED. EKG: Afibb, rate 77 Pertinent Results: [**2140-10-28**] GLUCOSE-88 UREA N-12 CREAT-1.1 SODIUM-142 POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-27 ANION GAP-15 [**2140-10-28**] CALCIUM-9.3 PHOSPHATE-2.9 MAGNESIUM-2.1 [**2140-10-28**] WBC-7.6 RBC-4.09* HGB-13.5* HCT-39.6* MCV-97 MCH-33.0* MCHC-34.1 RDW-14.1 [**2140-10-28**] NEUTS-67.0 LYMPHS-20.1 MONOS-7.6 EOS-4.4* BASOS-0.9 MACROCYT-1+ [**2140-10-28**] PLT COUNT-248 [**2140-10-28**] PT-15.3* PTT-32.7 [**Month/Day/Year 263**](PT)-1.6 RADIOLOGY HEAD CT WITHOUT IV CONTRAST: [**2140-10-30**] Stable to slight increase in size of left subdural collection. Minimal increase in shift of midline structures to the right. Stable small right subdural collection. MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST; [**2140-11-3**] 1. Large acute infarct involving almost the entire right middle cerebral arterial distribution. 2. Abrupt loss of signal within the mid portion of the right M1 segment. This is either due to embolic occlusion or thrombosis. 3. Unchanged bilateral subdural hematomas. 4. Mild rightward subfalcine herniation, unchanged since earlier head CT. CTA OF THE CHEST W/CONTRAST AND RECONS;[**2140-11-11**] 1) Acute pulmonary embolus in the segmental branches to the right middle and right upper lobe. Central pulmonary arterial tree is patent and the left side appears normal. 2) Minimal rim of pleural fluid and minor subpleural atelectasis at the right base. No consolidation or gross pulmonary edema demonstrated. VENA CAVA FILTER [**2140-11-11**] Successful placement of a retrievable inferior vena cava filter with its tip immediately below the level of the renal veins. The tip of the filter is at approximately the level of the inferior endplate of the L1 vertebral body. A Bard Recovery filter was used which is possible to be retrieved at any time. [**Last Name (un) **] DUP EXTEXT BIL (MAP/DVT) [**2140-11-13**] No DVT . CXR [**2140-11-20**]: Tracheostomy tube is 5 cm above carina. No pneumothorax. There is persistent opacity at the left base consistent with atelectasis/consolidation in the left lower lobe. Cannot rule out associated small left pleural effusion. The right lung remains clear. . CT of head [**2140-11-21**]: CT OF THE HEAD WITHOUT CONTRAST: No new intracranial hemorrhage is identified. Increased conspicuity of both right and left subdural hemorrhages from interval increased hypodensity of these collections is noted, without appreciable change in size. The ventricles are stable and normal in size. Large right middle cerebral artery distribution infarction with preservation of cortical density (presumably from leptomeningeal vascular collateralization) is not significantly changed. Infarction of the right caudate nucleus body is also unchanged. Of note, increased hypodensity of the right cerebral peduncle is consistent with evolving Wallerian degeneration. Prior left craniotomy defect and soft tissue scalp hematoma are noted. Left maxillary and ethmoid air cell mucosal thickening is not significantly changed. IMPRESSION: Stable bilateral subdural hemorrhages with no new intracranial hemorrhage identified. No hydrocephalus or shift of the normally midline structures. . [**2140-11-22**] BILATERAL LOWER EXTREMITY ULTRASOUND: Grayscale and color Doppler son[**Name (NI) 55007**] were performed of the left and right common femoral, superficial femoral, and popliteal veins. In all of these vessels bilaterally, there is echogenic material consistent with intraluminal thrombus. There was loss of compressibility and color flow within all of these vessels. The superior extent of this cannot be evaluated. No waveforms were identified. IMPRESSION: Extensive bilateral DVT. The superior-most extent of this cannot be evaluated on this study, and if further evaluation of that is required, a CT can be obtained. . [**2140-11-23**] ABDOMEN CT: In the limited images obtained throughout the bases of the lungs, there is right pleural thickening, left pleural effusion, and left posterolateral non-well-defined parenquimal opacity/consolidation. There is a tiny calcified granuloma in the lateral basal segment of the right lower lobe. In segment III of the liver, there is a hypodense subcentimeter focal lesion, too small to be characterized. There are no other focal intraparenchymal lesions. There is no biliary duct dilatation. The spleen, pancreas, adrenals, and left kidney are unremarkable. Multiple stones are seen within the gallbladder. In the upper pole of the right kidney, there is an exophytic, round, well-defined cystic nonenhancing lesion measuring 49 x 44 mm. Normal excretion is seen from both kidneys. There is no free fluid or free air within the abdomen. The small bowel loops are unremarkable. There is a feeding tube in the left upper quadrant. There is no lymphadenopathy. The aorta is normal in caliber. There is a filter in the IVC. There is contrast in the IVC above the renal veins and IVC filter, there is no contrast seen below the IVC filter in the IVC, iliac or femoral veins. Note is made that the study was done in late arterial phase, and there are no delayed images as this is a single monophasic study. The hepatic veins, the portal and splenic veins are patent. There is a fat-containing small umbilical hernia. PELVIC CT WITH CONTRAST: The bladder is not distended with a Foley catheter in its interior. There is no free fluid. Diverticula are seen in the sigmoid colon without the stranding of the adjacent pericolonic fat. There is no lymphadenopathy. BONE WINDOWS: There are no concerning bone lesions. There is a small island in the right iliac [**Doctor First Name 362**]. Moderate degenerative changes are seen in the lumbar spine. IMPRESSION: 1. The liver is normal in size with a subcentimeter non-characterized hypodense round lesion in the segment III; otherwise the density of the liver is unremarkable. 2. Left pleural effusion. Left basal consolidation. 3. Right simple renal cyst. 4. Diverticulosis without diverticulitis. 5. There is a filter in the IVC. Contrast is seen above the filter, contrast is not seen in the veins located below the filter in the IVC. Note is made that this is a single monophasic study. . [**2140-11-23**] TTE: Findings: LEFT ATRIUM: Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Mild symmetric LVH with normal cavity size. Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Mild global LV hypokinesis. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic root diameter. Focal calcifications in aortic root. AORTIC VALVE: Moderately thickened aortic valve leaflets. Mild AS. Trace AR. MITRAL VALVE: Normal mitral valve leaflets. Moderate (2+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Based on [**2132**] AHA endocarditis prophylaxis recommendations, the echo findings indicate a moderate risk (prophylaxis recommended). Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Conclusions: The left atrium is elongated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild global left ventricular hypokinesis. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Moderate (2+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is top normal. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with mild global left ventricular hypokinesis. Moderate mitral regurgitation. Mild aortic valve stenosis. Brief Hospital Course: This 79 y/o white male was admitted through the emergency department. Summary on Neurosurgery service: He was sent from his PCP's office when after sustaining a fall one month ago - he has had c/o of progressive gait instability. He had a CT scan on the outside which revealed a large subdural collection that was chronic in nature. The plan at the time of admission was to admit to neurosurgery, to a telemetry bed. D/C his Coumadin and reverse his [**Year (4 digits) 263**] of 1.6. He was given 2 units of FFP and one dose of Vit K. He has had serial CT scans that have been stable in nature. After reversal of the [**Year (4 digits) 263**] it is planned that he will go to the OR for burr holes for drainage of the left subdural hematoma. He was loaded on dilantin as well and continued maintenance dose of 100mg TID eventually switched to Keppra. . on [**2140-11-3**] while patient sitting on the chair found to have a left sided weakness and left sided new facial droop and unable to follow commands. MRI of the head revealed Right Middle Cerebral Artery infarct. On the same day patient transferred to neuro intensive care unit where he was intubated.while he was in ICU inconsistently follows commands,left pupil reactive to light 3->2mm. unable to assess right eye secondary to opacity which is old. Gag/cough reflex is present, moves right upper arm frequently to chest, moves right lower extremties to tactile stimuli, flexion left lower no movement on the left arm. Patient was able to extubated [**2140-11-9**], and able to transfer patient to neuro-stepdown with telemetry. on [**2140-11-11**] morning [**Doctor Last Name **] int was restless, respiratory rate up to 30's and episode of O2 saturation dropped to 80's given lasix/albuterol however patient continued to be restless. Stat CTA of the chest revealed acute pulmonary embolus in the segmental branches to the right middle and right upper lobe. Patient started on heparin gtt with goal PTT:40-60, medicine consulted for pulmonary issues and new PE. bilateral lower extremity Doppler showed no evidence of DVT on initial study, though repeat study following week showed extensive bilateral DVT. sputum culture from [**2140-11-11**] showed CITROBACTER KOSERI which is initially covered with ampicillin until sensitivity showed sensitive to Levaquin which then started on LEVOFLOXACIN, added Flagyl for presumed aspiration pneumonia. [**2140-11-11**] IVC filter placed with new PE, contraindication to anticoagulation to prevent possible DVT. . Patient taken to OR for burr hole for evacuation of left SDH with JP drain and placed a Trach. Postoperatively patient taken to ICU for close neuro and hemodynamic monitoring. postoperative neurologic exam is; opens eyes to voice, left pupil reactive to light, Right eye surgical,follows commands, sticks out his tongue, wiggles his right toes.Postop head CT significant for Status post partial drainage of left cerebral convexity subdural hemorrhage, with interval re-hemorrhage, SDH drain kept, dressing changed and patient transferred to neuro step-down floor. Patient with reaccumulation of SD collection and brought back to OR for formal craniotomy on Left for evacuation of SDH. On [**11-19**] LFT were decreased but overall still elevated, his K was elevated as well as his BUN and creatinine. A medical consult was called for. Recs were followed and Kayexalate was given, K was followed closely, abd ultrasound was obtained showed No evidence of Budd-Chiari syndrome, with patent hepatic veins.Cholelithiasis, without evidence of cholecystitis. There is no intra or extrahepatic biliary ductal dilatation. Simple cyst of the right kidney. He was placed on metoprolol for rate control as he went into a-flutter overnight from afib. Fluid bolus was given for decreased urinary output. These symptoms resolved. Postoperatively from the Formal craniotomy Mr. [**Known lastname 55008**] [**Last Name (Titles) 263**] had been slightly elevated and is being followed closely - he is being treated to bring [**Last Name (Titles) 263**] <1.4 ( he was receiving Vit K x 3 doses as well as FFP) - currently [**2140-11-23**] he is 1.4. On [**2140-11-22**] bilateral lower extrem. dopplers were obtained and there are multiple clots in the lower venous system. This has prompted a CT of the abd/pelvis with venous phase for further evaluation. This exam showed clots not extending above IVC filter. He was transferred to the medicine service on this day [**2140-11-22**]. On the medicine service, the patient was treated for each medical problems as the followings: 1. Atrial fibrillation- The patient was initially on metoprolol and uptitrated for rate control, but the patient seemed to respond better to diltiazem on a trial dose than metoprolol. Thus, on [**11-24**], switched to diltiazem and was titrated up to 90 mg qid which controlled rate well ranging from 70s-90s. No anticoagulation was started given craniotomy on [**11-18**]. Neurosurgery recommended not restarting anticoagulation for [**3-11**] weeks from craniotomy (at least until [**12-12**]) . 2. Hospital acquired (ventilator) LLL PNA/C.diff colitis- in the setting of leukocytosis, fever, and hypotension, the patient was started on vancomycin, cefepime, and flagyl ion [**2140-11-21**]. ID was consulted and agreed with empiric treatment with broad abx. CXR on [**2140-11-20**] showed LLL infiltrates. Later, the patient was found to have C. diff + stools. With abx treatment, the patient subsequently defervesced and WBC trended down. On discharge, it was felt that Vanco was not needed (no MRSA h/o, neg MRSA swab), and patient was discharged on 1 week of Cefepime therapy and 10 days of Flagyl to complete a 2 week course of Cefepime for ventilator-associated PNA and Flagyl for C.dif. . 3. PE/Bilat DVT- s/p IVC filter and trach. The respiratory status remained stable even in the setting of LLL PNA with effusion. The CT of abdomen to assess the clot burden to the IVC filter showed that there were no clots extending above the IVC filter. No anticoagulation as above and provided supplement O2 and nebs treatment. Pt was discharged on facemask and breathing appropriately through trach. . 4. SDH s/p burr hole, craniotomy- Neurologically remained stable with spontaneous bilateral eye openings and R extremities movement. The patient is able to follow commands. [**Date Range 263**] was stable at 1.4-1.5 with aggressive vit K supplement. FFPs were given without lowering [**Date Range 263**] effectively. DIC workup was negative. Pt is to continue to have aggressive Vit K supplementation at rehab with checks of [**Date Range 263**] to ensure he does not rise above [**Date Range 263**] 1.5. Continued Keppra for sz prophylaxis. Pt's staples were removed on [**11-28**] by the neurosurgical service prior to discharge. Pt had a follow up head CT on [**11-29**] on day of discharge which did not show any residual SDH. Pt was cleared for discharge by neurosurgical team. Pt was to follow up with Dr. [**Last Name (STitle) 55009**] 4 weeks after discharge. . 5. Elevated LFTs- Was likely secondary to hypovolemia as improved with fluids. . 6. Acute renal failure- normalized with IVF. . 7. FEN- s/p PEG [**11-14**]. With collaboration with nutrtion, the patient is currently on Deliver 40cc/hr with Promod 40gm/day with flush 100cc to avoid hypernatremia (Na 146 on day of discharge). Albumin is low [**2-10**] dilutional. Vitamin K supplement to lower [**Month/Day (2) 263**], ferrous sulfate, ascorbic acid. . 8. Code- DNR but intubate if needed. . 9. PPX: PPI. No heparin or coumadin until at least 3-4 weeks after craniotomoy. . 10. DISPO - DNR, but able to be intubated/mechanically ventilated via trach. Pt to be d/c'ed to rehab facility in stable condition, on supplemental o2 through trach, with TFs through PEG. Pt is to have follow up head CT on [**12-2**], and will follow up with the neurosurgeon Dr. [**Last Name (STitle) 739**] in 6 weeks after discharge. Medications on Admission: Medications: -coumadin -atenolol; dose? -MVI -niacin Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer treatment Inhalation Q4-6H (every 4 to 6 hours) as needed for shortness of breath or wheezing. Disp:*qs nebulizers* Refills:*0* 2. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) tablet PO DAILY (Daily). Disp:*30 tablet* Refills:*2* 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer treatment Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. Disp:*qs nebulizer treatment* Refills:*0* 4. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*qs ML(s)* Refills:*0* 6. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Five (5) mL PO DAILY (Daily). Disp:*qs mL* Refills:*2* 7. Ascorbic Acid 90 mg/mL Drops Sig: Six (6) mL PO DAILY (Daily). Disp:*qs mL* Refills:*2* 8. Phytonadione 5 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily) for 1 weeks. Disp:*qs Tablet(s)* Refills:*0* 9. Morphine 2 mg/mL Syringe Sig: 2-4 mg Injection Q4H (every 4 hours) as needed for pain. Disp:*qs mg* Refills:*0* 10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days. Disp:*30 Tablet(s)* Refills:*0* 11. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 12. PICC Line Care 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. Cefepime 2 g Piggyback Sig: Two (2) grams Intravenous Q12H (every 12 hours) for 6 days. Disp:*24 grams* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary diagnoses: Bilat Acute on chronic Subdural Hematoma Right Middle cerebral artery infarct Pulmonary embolism Bilateral deep vein thromboses Left lower lobe pneumonia C. difficile colitis Acute renal failure secondary to hypovolemia Shock liver secondary to hypovolemia Secondary diagnoses: Atrial fibrillation Hypertension Discharge Condition: Afebrile, stable on supplemental oxygen, stable to be discharged to rehab. Discharge Instructions: 1. Please follow up with his doctor in [**1-10**] weeks after discharge. Please follow up with Dr. [**Last Name (STitle) 739**] from neurosurgery in 4 weeks after discharge. Please call ([**Telephone/Fax (1) 18865**] to schedule that appointment. . 2. Please take medications as below. Do not restart coumadin until instructed by physician (no coumadin until at least [**12-12**]). . 3. If develops fever/chills, drainage from surgical site, change in mental status, shortness of breath, chest pain, or any other problems, please call Dr. [**Last Name (STitle) 26803**] or report to the nearest ER. . 4. Please follow [**Last Name (STitle) 263**] levels twice weekly. Goal [**Last Name (STitle) 263**] < 1.5. If [**Last Name (STitle) 263**] remains above 1.5, continue to extend his Vit B12 therapy. Followup Instructions: As above [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**] Completed by:[**2140-11-29**]

[ "E888.9", "008.45", "434.91", "276.52", "427.31", "369.60", "041.04", "518.81", "E849.0", "584.9", "511.9", "424.0", "415.19", "593.2", "401.9", "453.40", "570", "852.21", "562.10", "599.0", "486" ]

icd9cm

[ [ [] ] ]

[ "38.91", "96.72", "99.04", "38.93", "38.7", "01.31", "96.04", "88.72", "31.1", "43.11", "33.23" ]

icd9pcs

[ [ [] ] ]

22667, 22739

12836, 20831

302, 514

23114, 23191

4597, 12813

24047, 24180

2013, 2031

20935, 22644

22760, 23037

20857, 20912

23215, 24024

2046, 2504

23058, 23093

244, 264

542, 1641

2954, 4578

2519, 2938

1663, 1821

1853, 1981

2,552

172,641

51613+59363

Discharge summary

report+addendum

Admission Date: [**2130-1-22**] Discharge Date: [**2130-1-27**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4232**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: None History of Present Illness: 83 yo female with osteoarthritis, pseudogout and dementia pw h/o BRBPR after recent course of steroids and NSAIDs for a pseudogout flare. Patient is very poor historian secondary to her dementia, but relates BRBPR x days to weeks. She was transferred from OSH to [**Hospital1 **] for mgmt per family request. She denied any CP, SOB or CP. . She was recently admitted at the [**Hospital1 **] for knee pain (from [**12-5**] to [**12-13**]). She was diagnosed with pseudogout and had been treated with 5 days of steroids and discharged on 7 days of naproxen. . The patient was HD stable in the ED. Her Hct was 33.5 which is around her baseline of 32-35. An ECG showed no ischemic signs. The PCP and GI was contact[**Name (NI) **] in the [**Name (NI) **]. She was given Protonix and admitted for further monitoring. Past Medical History: -Dementia -OA -Pseudogout -s/p R total knee replacement -s/p TAH at age 20 -High cholesterol Social History: No smoking, occasional alcohol, no drug use. Used to live with husband in an apartment. At NH since last admission ([**Hospital **] HEALTH CARE). Has sister. Also has son, though unclear where son lives. Family History: NC Physical Exam: VS: T: 97.0 BP:140/80 HR:68 RR:18 O2sat: 98%RA GEN: pleasant elderly female, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: +b/s, soft, ntnd, no masses, old, well healed abdominal scar EXT: no C/C/E SKIN: no rashes/no jaundice NEURO: AAOx1, cannot describe color of stool, confused about what "stool" is. Strength 5/5 x4, sensation intact and symmetric x4. Pertinent Results: [**2130-1-22**] 07:00AM PT-12.0 PTT-23.3 INR(PT)-1.0 [**2130-1-22**] 07:00AM PLT COUNT-223 [**2130-1-22**] 07:00AM WBC-5.5 RBC-3.76* HGB-11.0* HCT-33.5* MCV-89 MCH-29.4 MCHC-32.9 RDW-15.3 [**2130-1-22**] 07:00AM NEUTS-66.0 LYMPHS-27.2 MONOS-4.3 EOS-1.7 BASOS-0.7 [**2130-1-22**] 07:00AM ALBUMIN-3.9 CALCIUM-10.4* PHOSPHATE-4.0 MAGNESIUM-2.0 [**2130-1-22**] 07:00AM cTropnT-<0.01 [**2130-1-22**] 07:00AM GLUCOSE-99 UREA N-18 CREAT-0.9 SODIUM-143 POTASSIUM-5.5* CHLORIDE-106 TOTAL CO2-27 ANION GAP-16 [**2130-1-22**] 10:10AM POTASSIUM-3.7 [**2130-1-22**] 03:45PM HCT-26.9* . GI bleeding study: IMPRESSION: No definite evidence of active GI bleeding. A faint area of increased radiotracer uptake on the lateral view after one hour was seen within the rectum, but was less intense on the lateral view one half-hour later. Brief Hospital Course: 83 yo female with pseudogout and dementia pw h/o BRBPR after recent course of steroids and NSAIDs for a pseudogout flare. . 1. BRBPR: BRBPR x days to weeks. Likely related to recent course of steroids and NSAIDs for a pseudogout flare (5 days of steroids and 7 days of naproxen). HD stable, Hct stable on admission. LGIB more likely than UGIB given history and HD stability. It is likely that she developed a mild bleed secondary to recent steroids/NSAIDs causing ulcerations. Hct was trended frequently. There was frank blood on the bed sheets on the day of admission. Her Hct dropped from 33 to 26 on that day. She was on a PPI IV BID. Pt was kept NPO for possible studies and transferred to the MICU and GI was consulted. Given that pt remained HD stable, it was believed that it was in part at least due to dilution. A tagged RBC scan was performed and was essentially unrevealing with some question of increased uptake in the rectal area. She had no further bloody stools during her hospitalization received 4units blood total in transfusion over the course of her stay. . The GI team discussed the option of doing a colonoscopy to look for a source of GI bleeding. However, the patient's sister, who is her health care proxy, preferred that she not have a colonoscopy unless it was absolutely medically necessary. The GI service felt that the patient would benefit from a colonoscopy as an outpatient, but that she is hemodynamically stable at the current time. A further discussion of the benefit of colonoscopy could be had with the patient's primary care physician who is more familiar with her and her family's long term goals of care. Her hematocrit on discharge was 26.2. . 2. Anemia: Hct stable at baseline on admission (baseline of 32-35). Recent workup during admission in [**11-21**] revealed anemia of chronic disease based on iron studies. Further workup included: TSH wnl, SPEP neg, UPEP negative. However, Hct was trended on day of admission and dropped (see above), likely unrelated to her baseline anemia. She was discharged on iron therapy. . 3. Dementia: Progressive Alzheimer's disease. Recent w/u for other causes included the following labs: RPR nonreactive, LFTs and lytes normal, and TSH normal. Pt frequently wanders around and required sitter during previous admissions. She was kept briefly with 1:1 sitter as well. Pt was continued zyprexa and aricept for medical management. . 4. Pseudogout: Recently diagnosed during last admission in [**11-21**]. Currently no c/o joint pain. Recent flare resolved with 5 days of steroids and 7 days of naproxen. Patient on long term on tylenol for pain relief given underlying osteoarthritis. If pseudogout would recur again, it was recommended during last admission to start colchicine for prophylaxis after another course of naprosyn with close monitoring of creatinine. However, given GIB, no NSAIDs or steroids should be given at this point. . 5. FEN: IVF, repleted electrolytes as needed. . 6. PPx: Heparin sc, PPI IV BID, sitter. . 7. Code status: Full. . 8. Contact: Sister [**Name (NI) **]: [**Telephone/Fax (1) 106957**]. HCP is sister [**Name (NI) **] [**Name (NI) **]. [**Telephone/Fax (1) 99629**] . 9. Primary Care Provider [**Name Initial (PRE) **]: For future hospitalizations, the primary care provider should not be listed as [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD because she no longer follows this patient. Medications on Admission: 1. Olanzapine 5 mg qd 2. Donepezil 5 mg qHS 3. Tylenol 650 mg TID Discharge Medications: 1. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO DAILY (Daily). 2. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 6. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO twice a day. 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 TID PRN (). Discharge Disposition: Extended Care Facility: [**Hospital **] Health Care - [**Hospital1 **] Discharge Diagnosis: Primary Diagnosis: 1. GI bleed . Secondary Diagnosis: 1. Dementia 2. Pseudogout 3. Osteoarthritis Discharge Condition: Afebrile. Hemodynamically stable. Tolerating PO. Discharge Instructions: Please call your primary doctor or return to the ED if you have fever, chills, chest pain, shortness of breath, nausea/vomiting, bleeding from your rectum, blood in your stools, vomiting of blood or any other concerning symptoms. . Avoid the use of NSAID medications, such as ibuprofen and naproxen. Please take all your medications as directed. . Please keep you follow up appointments as below. Followup Instructions: Please follow up with your primary care doctor Dr. [**Last Name (STitle) 97545**] at [**Hospital3 **] [**Telephone/Fax (1) 35276**] in 1 week from now. . Please also follow up with: . Provider: [**First Name11 (Name Pattern1) 278**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 394**], O.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2130-2-6**] 11:30 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 4236**] Completed by:[**2130-1-26**] Name: [**Known lastname 17467**],[**Known firstname 2219**] Unit No: [**Numeric Identifier 17468**] Admission Date: [**2130-1-22**] Discharge Date: [**2130-1-27**] Date of Birth: [**2046-1-11**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 11538**] Addendum: The patient was discharged on a seven day course of ciprofloxacin for a UTI. Culture results pending. Discharge Disposition: Extended Care Facility: [**Hospital **] Health Care - [**Hospital1 **] [**Name6 (MD) 634**] [**Name8 (MD) 635**] MD [**MD Number(1) 636**] Completed by:[**2130-1-27**]

[ "285.29", "294.10", "275.49", "712.36", "788.20", "E932.0", "331.0", "578.9", "E935.9", "599.0", "272.0" ]

icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

8804, 9003

2843, 6271

268, 275

7296, 7347

1980, 2820

7797, 8781

1472, 1477

6388, 7057

7174, 7174

6297, 6365

7371, 7774

1492, 1961

223, 230

303, 1117

7229, 7275

7193, 7208

1139, 1235

1251, 1456

239

127,976

43509

Discharge summary

report

Admission Date: [**2175-1-12**] Discharge Date: [**2175-1-28**] Date of Birth: [**2097-11-10**] Sex: M Service: CARDIOTHORACIC Allergies: Gentamicin Attending:[**First Name3 (LF) 1267**] Chief Complaint: Increasing chest pain Major Surgical or Invasive Procedure: [**2175-1-12**] Two Vessel Coronary Artery Bypass Grafting utilzing the left internal mammary to left anterior descending artery and vein graft to obtuse marginal. History of Present Illness: Mr. [**Known lastname 31523**] is a 77 year old male with extensive history of coronary artery disease undergoing multiple angioplasties and stents in the past. Over the last six months, he admits to experiencing increasing anginal symptoms. His chest pain improves with Nitroglycerin and rest. Cardiac catheterization at the [**Hospital1 18**] on [**2175-1-3**] revealed a 70% stenosis in the left main coronary artery, and an 80% lesion in the left anterior descending artery. The RCA and circumflex had only 40% stenoses. His LVEF was estimated at 49%. His aortic and mitral valves were normal and without significant gradients. Based on the above results, he was referred for future cardiac surgical intervention. He denied orthopnea, PND, pedal edema, syncope, presyncope and palpitations. He was subsequently admitted for coronary revascularization. Past Medical History: Coronary artery disease with history of multiple stents and angioplasties, hypertension, type 2 diabetes mellitus, mild renal insufficiency, history of TIA, chronic anemia, history of bladder carcinoma s/p cystectomy and ileostomy, history of GI bleed Social History: 40 pack year history of tobacco, quit smoking in [**2129**]. Admits to 1-2 drinks per day Family History: Mother and sister with "heart problems" ?? age Physical Exam: Vitals: BP 160/80, HR 63, RR 16, SAT 96% on room air General: elderly male in no acute distress HEENT: oropharynx benign Neck: supple, no JVD, no carotid brutis Heart: regular rate, normal s1s2, 3/6 systolic ejection murmur Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds, ielostomy pink Ext: warm, no edema, no varicosities Pulses: 1+ distally Neuro: nonfocal Brief Hospital Course: Mr. [**Known lastname 31523**] was admitted on [**1-12**] and underwent two vessel coronary artery bypass grafting by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. The operation was uneventful and he was brought to the CSRU on minimal inotropic support. Within 24 hours, he awoke neurologically intact and was extubated without difficulty. He weaned from intravenous therapy and maintained stable hemodynamics. On postoperative day one, he transferred to the SDU. Beta blockade was resumed and advanced as tolerated. Most of his other preoperative medications were also resumed. He experienced bouts of paroxysmal atrial fibrillation for which Warfarin anticogulation was eventually initiated.Amiodarone was also started. This was then stopped when the patient went into SR. The [**Last Name (un) **] Center was consulted to assist in the management of his diabetes mellitus.He continued to have intermittent bursts of rapid afib and a flutter over the next several days.EP consult was obtained. They recommended possible follow-up ablation and coumadin was restarted [**1-25**]. Patient underwent an atrial focus ablation on [**1-26**] without complication. He was started on coumadin that day and after 2 doses of 5mg of coumadin, his INR rose to 7.8. He was given 5mg vitamin K and on POD# 15 his INR was down to 3.0 and he was cleared for discharge to home. Medications on Admission: Isosorbide 20 [**Hospital1 **], Lopressor 50 [**Hospital1 **], Tricor 145 qd, Diovan 160 qd, Plavix 75 qd, Glipizide 2.5 qd, Aspirin 325 qd, Xalantan eye gtts 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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Glipizide 2.5 mg Tab, Sust Release Osmotic Push Sig: Three (3) Tab, Sust Release Osmotic Push PO DAILY (Daily). Disp:*90 Tab, Sust Release Osmotic Push(s)* Refills:*2* 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 8. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 9. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: no coumadin [**1-28**] and 1mg [**1-29**], then per Dr. [**Last Name (STitle) **]. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Coronary artery disease with history of multiple stents and angioplasties, hypertension, type 2 diabetes mellitus, mild renal insufficiency, history of TIA, chronic anemia, history of bladder carcinoma s/p cystectomy, history of GI bleed, postoperative atrial fibrillation Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Followup Instructions: Cardiac surgeon, Dr. [**Last Name (STitle) **] in 4 weeks Dr. [**Last Name (STitle) **] in [**2-24**] weeks Dr. [**Last Name (STitle) **] in [**2-24**] weeks Completed by:[**2175-1-28**]

[ "250.00", "427.31", "272.0", "E879.9", "585.9", "401.9", "997.1", "414.01", "V10.51" ]

icd9cm

[ [ [] ] ]

[ "37.34", "88.72", "37.26", "36.15", "39.61", "36.11" ]

icd9pcs

[ [ [] ] ]

5000, 5049

2226, 3616

300, 466

5366, 5373

5692, 5881

1749, 1797

3825, 4977

5070, 5345

3642, 3802

5397, 5669

1812, 2203

239, 262

494, 1351

1373, 1626

1642, 1733

9,966

155,230

6333

Discharge summary

report

Admission Date: [**2167-7-2**] Discharge Date: [**2167-7-18**] Date of Birth: [**2101-1-27**] Sex: M Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 2108**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: lumbar puncture central venous line placement History of Present Illness: 66M with CAD s/p BMS to RCA, DM, intermittent porphyria, afib, bipolar disorder, depression, seizures, depression who presented to OSH with altered mental status. History obtained from patient's wife. [**Name (NI) **] was initially seen at [**Hospital3 **] after his wife noticed slurred speech and confusion starting the morning of admission. Prior to that, he was in his usual state of health, occasional word finding difficulties since his stroke a few years ago but able to walk around and communicate well. Over the course of yesterday, day of admission, mental status progressively worsened to the point where he was getting more confused and "worked up" and yelling. Per wife, this is similar to his presentation for stroke 5 years ago, except at that time he was weaker and mostly had speech slurring rather than combativeness. It is not like his porphyria, with which he usually gets lethargic. Initial exam at OSH with slurred speech otherwise nonfocal neuro exam. Labs were notable for WBC 16.9, INR 1.9, He got progessively agitated in the ICU at [**Hospital1 **] despite receiving benzos and haldol, was intubated for aspiration risk and risk of harm to self due to agitation. He was seen by neurology who felt pt may be having complex partial seizure disorder, and recommended staring keppra howevever pt's wife refused this. Also on the differential was serotonin syndrome considering prozac, buspar and lithium at home, however per wife patient had been taking medications as directed (she lays them out for him in a pill box). He was given aspirin 325 mg for concern for stroke and CT head was checked which was negative. CXR was negative for infiltrate, UA not suggesive of UTI and bcx negative x 2 prior to transfer. VS on transfer 99.1 80 16 181/86 sat 100% on vent. Vent settings on transfer AC 650 TV, RR=12, 5 PEEP, 50% FIO2. He was also started on a propofol drip and fentanyl boluses, with eyes opening to voice. Tmax at OSH was 101. Prior to transfer, he had put out only 45 mL over 2 hours and he was put on low dose maintenance fluid at 60 mL/hr. In the ambulance, he received several propofol boluses for agitation and had systolic blood pressures in the high 80s and low 90s. On the floor, he is intubated, sedated. Unable to assess review of systems but appears comfortable. Past Medical History: * CAD -- s/p rotablation of the mid LAD -- s/p RCA bare-metal stent [**2162-11-22**] * Afib * s/p pacemaker '[**56**] * NIDDM * hyperlipidemia * intermittent porphyria * mediastinal mass s/p resection [**2-13**]; path c/w thymic cyst * COPD * s/p Billroth II for ulcer * h/o small bowel obstruction * h/o hernia repairs x6 * s/p appendectomy * s/p R Port-A-Cath for hematin Social History: 90-pack-year exsmoker, discontinued some time ago (he cannot specify). Works as a truck driver and lives with his wife. [**Name (NI) **] does not drink any alcohol. Family History: Grandfather with MI age 73. Physical Exam: General: intubated, sedated HEENT: intubated, mmm, pupils equal round and reactive, not maintaining mid line gaze with head turn Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly, several surgical scars present on abdomen GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2167-7-2**] 07:42PM BLOOD WBC-14.7*# RBC-3.96* Hgb-11.9* Hct-35.7* MCV-90# MCH-30.2# MCHC-33.5 RDW-15.8* Plt Ct-234 [**2167-7-11**] 04:27AM BLOOD WBC-20.8*# RBC-4.75 Hgb-14.0 Hct-42.2 MCV-89 MCH-29.4 MCHC-33.1 RDW-15.2 Plt Ct-448* [**2167-7-16**] 07:05AM BLOOD WBC-13.2* RBC-4.26* Hgb-12.7* Hct-38.4* MCV-90 MCH-29.8 MCHC-33.0 RDW-16.2* Plt Ct-323 [**2167-7-2**] 07:42PM BLOOD Neuts-84.3* Lymphs-9.6* Monos-5.7 Eos-0.3 Baso-0.2 [**2167-7-2**] 07:42PM BLOOD PT-19.4* PTT-28.5 INR(PT)-1.8* [**2167-7-13**] 05:07AM BLOOD PT-20.0* PTT-31.3 INR(PT)-1.8* [**2167-7-14**] 05:28AM BLOOD PT-23.7* PTT-33.5 INR(PT)-2.2* [**2167-7-15**] 07:25AM BLOOD PT-27.3* PTT-33.5 INR(PT)-2.6* [**2167-7-16**] 07:05AM BLOOD PT-30.9* PTT-37.5* INR(PT)-3.0* [**2167-7-17**] 07:05AM BLOOD PT-27.1* INR(PT)-2.6* [**2167-7-2**] 07:42PM BLOOD Glucose-103* UreaN-18 Creat-1.5* Na-142 K-3.8 Cl-109* HCO3-21* AnGap-16 [**2167-7-11**] 12:41PM BLOOD Glucose-305* UreaN-30* Creat-1.4* Na-141 K-3.8 Cl-95* HCO3-31 AnGap-19 [**2167-7-11**] 12:41PM BLOOD Glucose-305* UreaN-30* Creat-1.4* Na-141 K-3.8 Cl-95* HCO3-31 AnGap-19 [**2167-7-15**] 07:25AM BLOOD Glucose-192* UreaN-25* Creat-1.2 Na-140 K-3.3 Cl-103 HCO3-29 AnGap-11 [**2167-7-16**] 07:05AM BLOOD Glucose-184* UreaN-18 Creat-1.0 Na-141 K-3.4 Cl-105 HCO3-27 AnGap-12 [**2167-7-17**] 07:05AM BLOOD Na-140 K-3.8 Cl-105 [**2167-7-2**] 07:42PM BLOOD ALT-10 AST-31 LD(LDH)-393* AlkPhos-64 TotBili-0.6 [**2167-7-5**] 04:37AM BLOOD ALT-12 AST-21 LD(LDH)-227 AlkPhos-53 TotBili-0.3 [**2167-7-16**] 07:05AM BLOOD Albumin-3.3* Calcium-8.9 Phos-2.8 Mg-1.9 [**2167-7-3**] 05:19AM BLOOD Triglyc-209* [**2167-7-7**] 04:32AM BLOOD Triglyc-148 [**2167-7-3**] 05:19AM BLOOD TSH-0.49 [**2167-7-2**] 07:42PM BLOOD [**Doctor First Name **]-NEGATIVE [**2167-7-13**] 05:07AM BLOOD Vanco-21.2* [**2167-7-15**] 07:25AM BLOOD Vanco-14.2 [**2167-7-2**] 07:42PM BLOOD Digoxin-1.2 [**2167-7-13**] 05:07AM BLOOD Digoxin-1.5 [**2167-7-13**] 05:07AM BLOOD Digoxin-1.5 [**2167-7-2**] 07:42PM BLOOD Lithium-0.8 [**2167-7-7**] 04:32AM BLOOD Lithium-0.3* [**2167-7-13**] 05:07AM BLOOD Lithium-1.1 MICROBIOLOGY: [**2167-7-9**] 05:38PM BLOOD EASTERN EQUINE ENCEPHALITIS SEROLOGY-PND [**2167-7-9**] 05:38PM BLOOD WEST NILE VIRUS SEROLOGY-PND [**2167-7-3**] 12:51 pm CSF;SPINAL FLUID Source: LP. GRAM STAIN (Final [**2167-7-3**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2167-7-6**]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. VIRAL CULTURE (Preliminary): No Virus isolated so far. [**2167-7-4**] 5:38 pm SEROLOGY/BLOOD Source: Line-Central line. **FINAL REPORT [**2167-7-7**]** RAPID PLASMA REAGIN TEST (Final [**2167-7-7**]): NONREACTIVE. Reference Range: Non-Reactive. [**2167-7-11**] 12:41 pm BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Aerobic Bottle Gram Stain (Final [**2167-7-12**]): GRAM POSITIVE COCCI IN CLUSTERS. Reported to and read back by [**Last Name (LF) 24518**], [**First Name3 (LF) **] ON [**2167-7-12**] [**2068**]. [**2167-7-12**] BLOOD CULTURES X 2: PENDING AT THE TIME OF DISCHARGE [**2167-7-4**] 1:00 pm URINE **FINAL REPORT [**2167-7-5**]** Legionella Urinary Antigen (Final [**2167-7-5**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. [**2167-7-6**] 4:46 am SEROLOGY/BLOOD Source: Line-central. **FINAL REPORT [**2167-7-9**]** LYME SEROLOGY (Final [**2167-7-9**]): NO ANTIBODY TO B. BURGDORFERI DETECTED BY EIA. Reference Range: No antibody detected. Negative results do not rule out B. burgdorferi infection. Patients in early stages of infection or on antibiotic therapy may not produce detectable levels of antibody. Patients with clinical history and/or symptoms suggestive of lyme disease should be retested in [**3-12**] weeks. [**2167-7-3**] 12:51 pm CSF;SPINAL FLUID Source: LP. **FINAL REPORT [**2167-7-3**]** CRYPTOCOCCAL ANTIGEN (Final [**2167-7-3**]): CRYPTOCOCCAL ANTIGEN NOT DETECTED. (Reference Range-Negative). Performed by latex agglutination. Results should be evaluated in light of culture results and clinical presentation. [**2167-7-3**] CSF VARICELLA ZOSTER VIRUS (VZV) Not Detected Not Detected DNA, QL RT PCR CMV DNA, QL PCR NOT DETECTED Not Detected Enterovirus RNA, Qualitative Real-Time, PCR Enterovirus RNA, RT-PCR Not Detected Not Detected Herpes Simplex Virus PCR Specimen Source: Cerebrospinal Fluid Result Negative IMAGING: [**2167-7-2**] CHEST X RAY: The newly inserted endotracheal tube tip is appropriately positioned 1 cm below the clavicular head. Median sternotomy wires, coronary artery vascular clips and the dual chamber pacemaker are unchanged in position since [**2166-3-22**]. The cardiac size is at the upper limits of normal. Lung volumes are low, vascular crowding on this radiograph may be accounted for by low lung volumes. There is no evidence of acute consolidation, edema or atelectasis. The tip of the nasogastric tube is not included in the field of view of this radiograph but appears to descend well below the gastroesophageal junction CTA CHEST [**2167-7-4**]: 1. No evidence of central pulmonary embolism or acute aortic syndrome. 2. Dense left lower lobe consolidation concerning for pneumonia. 3. 15 x 7 mm left thyroid nodule. Recommend non-emergent ultrasound if not already performed. 4. Scattered subcentimeter mediastinal and hilar nodes, increased in size since [**2166-3-22**], likely reactive. [**2167-7-6**] CTA HEAD: Chronic-appearing left MCA territory infarct involving the left precentral gyrus. No evidence of aneurysm, flow-limiting stenosis, or acute intracranial process. [**2167-7-13**] HEAD CT W/O CONTRAST: No evidence of an acute intracranial process. If there is a high clinical concern for infarct, an MRI should be considered [**2167-7-14**] VIDEO SWALLOW: FINDINGS: Barium passed readily through the oropharynx into esophagus without evidence of obstruction with slow oral phase. There was no aspiration or penetration with administered preparations. For full details, please see the speech and swallow division note in the online medical record. IMPRESSION: No aspiration or penetration. Brief Hospital Course: ALTERED MENTAL STATUS, ENCEPHALITIS: based on LP results, the patient likely had viral encephalitis. He had a negative HSV PCR and negative VZV studies, however given vesicular rash on his face per ID consult this likely was VZV. EEE and West [**Doctor First Name **] serologies were sendouts and still pending at the time of discharge. EEG without any seizures, CTA of the head without any acute abnormalities (MRI could not be performed given pacemaker). The patient suffered acute kidney injury and ventilator associated PNA as complications of this (see below). He was also seen by neurology in consultation who agreed w/ continuing acyclovir for ?VZV encephalitis for a total course of 21 days (to end [**2167-7-23**]). The patient improved neurologically but still not at baseline, he had good stregnth ([**6-11**] in UE bicep, tricep, grip, deltoid, and LE quad, hamstring, plantarflex, dorsiflex) he was AOx2, (person, hospital, [**Hospital **], not oriented to time), his EOMI were full and PERRL, he was able to read and interact occasionally. He was able to swallow without difficulty and passed a speech and swallow test (video). He lacked motivation likely related to the ongoing delerium and needed much encouragement with meals and with interaction, physical therapy and occupational therapy. He will f/u with neurology in 1 month (appt made) and per ID he does not require any ID follow up. HYPOXIC RESPIRATORY FAILURE, PNEUMONIA: He was treated with vancomycin and cefeipme, last dose will be on [**2167-7-18**]. COAG NEGATIVE STAPH BACTEREMIA: From cultures on [**7-11**], per ID thought to be a contaminant, repeat cultures on [**7-12**] without growth. BIPOLAR DISORDER: lithium, prozac and buspar continued. ATRIAL FIBRILLATION: home dose of coumadin was 7.5mg 3x/week, 5mg 4x/week, given decreased PO intake and antibiotics this dose was reduced to 2mg po daily. INR 2.6 on discharge. INR should be rechecked on Sunday [**7-19**] or Monday [**7-20**]. He was continued on his home dose of metoprolol, his digoxin was stopped given a dig level of 1.5. A repeat dig level should be checked on Monday [**7-20**] and if < 1 his digoxin should be started at a lower dose of 125mcg daily. After restarting at this dose a repeat level should be drawn in about 2 weeks with a goal level of 0.8. HYPERTENSION, BENIGN: metoprolol and amlodipine continued. His low dose hydral was held and his BP was stable. THRUSH: nystatin H/O CAD: lipitor continued, baby aspirin started. No active issues. Medications on Admission: lithium 450 mg [**Hospital1 **] amlodipine 5 mg daily fluoxetine 20 mg daily warfarin 7.5 mg 3x/week digoxin 0.25 mg daily glimepiride 4 mg [**Hospital1 **] hydralazine 10 mg TID atorvastatin 20 mg daily metoprolol 100 mg TID buspar 30 mg [**Hospital1 **] buspar 15 mg at noon daily amiodarone 100 mg daily warfarin 5 mg 4x/week Discharge Medications: 1. cefepime 2 gram Recon Soln Sig: Two (2) grams Injection Q8H (every 8 hours): last dose on [**2167-7-18**]. 2. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours): last dose [**2167-7-18**]. 3. acyclovir sodium 500 mg Recon Soln Sig: Eight Hundred (800) mg Intravenous Q8H (every 8 hours): last dose [**2167-7-23**]. 4. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: check INR for goal [**3-12**]. 5. lithium carbonate 450 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO BID (2 times a day). 6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day: please check Digoxin level on [**7-20**] (monday) and if less than 1 please start this dose. 9. insulin lispro 100 unit/mL Solution Sig: sliding scale units Subcutaneous four times a day. 10. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. amiodarone 200 mg Tablet Sig: [**2-8**] Tablet PO DAILY (Daily). 12. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 13. buspirone 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 14. buspirone 10 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 15. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 16. nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID (4 times a day). 17. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary Diagnosis: Encephalitis, likely viral from VZV Pneumonia, bacterial, ventilator associated Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted with encephalitis and also developed pneumonia. You were treated with acycylovir and antibiotics and are improving. Followup Instructions: Department: NEUROLOGY When: TUESDAY [**2167-9-1**] at 2:30 PM With: DRS. [**Name5 (PTitle) **] & [**Doctor Last Name **] [**Telephone/Fax (1) 44**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

15441, 15511

10953, 13480

290, 337

15654, 15654

3897, 6491

15994, 16289

3286, 3315

13859, 15418

15532, 15532

13506, 13836

15836, 15971

3330, 3878

6958, 10930

6524, 6914

229, 252

365, 2690

15551, 15633

15669, 15812

2712, 3087

3103, 3270

2,135

177,747

12743

Discharge summary

report

Admission Date: [**2190-11-18**] Discharge Date: [**2190-11-21**] Date of Birth: [**2118-8-9**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Fever with abdominal pain, transferred from MICU after ERCP Major Surgical or Invasive Procedure: ERCP History of Present Illness: 72 y/o M w/ h/o cholecystectomy, CBD stones p/w fever and abdominal pain for the last week. Patient has a long standing h/o CBD stones and has had cholecystitis in past for which he underwent gall bladder surgery. He has recurrent h/o CBD stones with fever and abdominal pain. He has been on antibiotics in the past. For the last week, he has been having fever to around 102 degrees with intermittent abdominal pain. It was associated with dark discoloration of urine. Patient did not notice any changes in the stool color. Not associated with yellowish discoloration of sking or pruritis. . Patient was admitted to the MICU for ERCP. In the MICU, he had a BP of 90/50, HR of 90-100. He was started on Unasyn, Flagyl 500 mgIV, Hydrocortisone 100 mg IV (stress dose steroid), 3L NS. An ERCP was performed which showed pus and sludge extruding from biliary tree. A stent placed in the CBD. Past Medical History: Multiple sclerosis COPD Neurogenic bladder H/O [**First Name3 (LF) 499**] CA s/p resection s/p cholecystectomy s/p resection of RUL lesion (benign) . Social History: Lives at home with wife. [**Name (NI) **] has a 55yr pack smoking history. He was a social drinker in college. Family History: Wife: Renal [**Name (NI) 3730**] Mother: [**Name (NI) **] ca Physical Exam: Vitals: 98.3, 120/77, 85, 20, 97/2L Gen: confortable, AAOx3 HEENT: mildly icteric sclera, PERRLA, EOMI, MMM Heart: distant heart sounds, faint S1/S2, murmurs not appreciable Lungs: occasional rhonchi in upper lobes bilaterally Abd: soft/ND/NT, BS+, epigastric hernia site Ext: 1+ pedal edema Neuro: no focal deficits Pertinent Results: ERCP S&I ([**Numeric Identifier 39322**]) PORT [**2190-11-18**] Extrahepatic bile duct dilatation. The small filling defect was proved to be sludge and pus by report of the ERCP. ERCP during the procedure. * [**2190-11-21**] 07:00AM BLOOD WBC-7.4 RBC-3.75* Hgb-10.8* Hct-34.0* MCV-91 MCH-28.9 MCHC-31.8 RDW-14.6 Plt Ct-187 [**2190-11-18**] 03:10PM BLOOD Neuts-64 Bands-28* Lymphs-3* Monos-3 Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2190-11-18**] 03:10PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-1+ Stipple-1+ Tear Dr[**Last Name (STitle) **]1+ [**2190-11-21**] 07:00AM BLOOD Plt Ct-187 [**2190-11-21**] 07:00AM BLOOD Glucose-114* UreaN-6 Creat-0.5 Na-145 K-3.1* Cl-100 HCO3-37* AnGap-11 [**2190-11-21**] 07:00AM BLOOD ALT-85* AST-26 LD(LDH)-221 AlkPhos-161* TotBili-0.7 [**2190-11-20**] 07:12AM BLOOD Lipase-27 [**2190-11-21**] 07:00AM BLOOD Calcium-9.0 Phos-2.1* Mg-1.6 [**2190-11-18**] 08:55AM BLOOD Cortsol-13.7 [**2190-11-18**] 08:55AM BLOOD CRP-22.6* [**2190-11-18**] 03:10PM BLOOD HoldBLu-HOLD [**2190-11-18**] 11:15AM BLOOD Type-MIX [**2190-11-18**] 04:54PM BLOOD Lactate-0.9 [**2190-11-18**] 11:15AM BLOOD O2 Sat-77 Brief Hospital Course: # Cholangitis: Presented with clinical picture of Cholangitis. Had an ERCP stent placement. Was started on unasyn. Bl Cx were drawn which were negative. . # Hypotension: Initially had SBP 90/50 in ED, responded to IVF. Was put on stress dose steroids in ED, which was switched over to regular steroid dose which he had been taking as an outpatient. We held his lopressor. . # Urinary retention: was most likely from Neurogenic bladder [**2-10**] Multiple sclerosis. He had a foley placed for retention which was then D/C'ed. . # Guiaic positive stools: He had guaiac pos stools. His HCT was stable and he did not have any active bleeding. . # UTI: UA on admission showed [**10-28**] WBC's, UCx grew E.coli. He was continued on unasyn. . # HTN: continued on lopressor . # MS - on daily steroids . # COPD - continued on nebs Discharge Medications: 1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Cholangitis COPD Urinary tract infection Multiple sclerosis History of [**Hospital1 499**] cancer Neurogenic bladder Discharge Condition: all vitals are stable. Discharge Instructions: Please take all your medications and follow up with all your appointments. Please report to the ED or to your physician if you have worsening symptoms or any concerns at all. Followup Instructions: Please make an appointment to see your Primary care physician [**Last Name (NamePattern4) **] [**7-18**] days. . Please make an appointment to see your Gastroenterologist in [**2-11**] weeks. Completed by:[**2190-12-1**]

[ "562.00", "041.4", "578.1", "599.0", "596.54", "576.1", "V10.05", "276.51", "340", "458.9", "496", "576.8" ]

icd9cm

[ [ [] ] ]

[ "51.87", "38.93" ]

icd9pcs

[ [ [] ] ]

4992, 5047

3228, 4052

376, 383

5208, 5233

2035, 3205

5456, 5679

1619, 1682

4075, 4969

5068, 5187

5257, 5433

1697, 2016

277, 338

411, 1301

1323, 1475

1491, 1603

23,510

185,381

7298+7299

Discharge summary

report+report

Admission Date: [**2115-6-11**] Discharge Date: [**2115-6-13**] Date of Birth: [**2049-8-17**] Sex: M Service: VASCULAR CHIEF COMPLAINT: Left foot ulceration with gangrene NOTE: The history of present illness obtained from patient and former discharge summaries. The patient is a reliable historian. HISTORY OF PRESENT ILLNESS: A 65-year-old white male with long medical history of peripheral vascular disease, status post left CFA to DP with in situ saphenous vein in [**2114-6-8**], status post left TMA in [**2111**] presents with a chronic infected left foot and Achilles tendon exposure refractory to conservative treatment. The patient denies fevers, chills or glucose changes. He denies shortness of breath, paroxysmal nocturnal dyspnea, orthopnea since his recent episode of failure in [**Month (only) 547**] of this year. He denies chest pain, palpitations. He has a history of atrial fibrillation and has been cardioverted to normal sinus rhythm. He denies headache, syncope, seizures, neurosis and no further sickness, right hand numbness or tunnel vision since he underwent left carotid endarterectomy. The patient now is admitted for elective BKA and hemodialysis preoperatively. ALLERGIES: HYDRALAZINE CAUSES VASCULITIS. CIPROFLOXACIN CAUSES SWELLING, ALTHOUGH THE PATIENT WAS ON LEVOFLOXACIN WITHOUT DIFFICULTY. ACE INHIBITOR CAUSES SWELLING, ALTHOUGH THE PATIENT IS ON AN ACE INHIBITOR AT THE PRESENT TIME AND ASYMPTOMATIC. VANCOMYCIN CAUSES HIVES. PAST MEDICAL HISTORY: 1. Hypothyroidism secondary to radiation therapy to the neck for throat cancer. 2. Bradycardia with atrial fibrillation. The bradycardia was secondary to his beta blocker dose which was in [**Month (only) 547**] of last year. He has since then undergone cardioversion, hypertension, type I diabetes since [**2093**]. He is now on no oral agents or insulin. 3. Chronic renal insufficiency 4. Hemodialysis Mondays, Wednesdays and Fridays since [**2112**]. 5. History of cerebrovascular accident. 6. History of transient ischemic attack. 7. History of pneumonia in [**2112**]. 8. History of Staphylococcus aureus septicemia in [**Month (only) **] of '[**12**]. 9. History of right rib fractures. 10. History of myocardial infarction in [**2093**]. 11. History of recurrent congestive failure. Most recent episode was in [**Month (only) 547**] of this year. 12. History of Methicillin resistant Staphylococcus aureus. 13. History of gastroesophageal reflux disease. 14. History of carotid disease, status post left CEA. PAST SURGICAL HISTORY: 1. Left carotid endarterectomy in '[**12**]. 2. Left AV fistula with right IJ Quinton in '[**12**]. 3. Left fifth MPJ head resection in [**2113**]. 4. Left common femoral artery to DP with in situ saphenous vein in [**Month (only) 547**] of '[**14**]. 5. Left TMA in [**2111**]. 6. Diaphragmatic repair with re-exploration and evacuation of hematoma in [**2104**]. 7. Lysis of adhesions and partial colectomy for small bowel obstruction in [**2112**]. 8. The patient had left heart catheterization at [**Hospital3 **] in [**2107**]. He had no coronary artery disease at that time. 9. He had a percutaneous gastrostomy tube placed in [**2107**]. 10. He has a left first ostectomy of an MPJ and an Achilles tendon lengthening in [**Month (only) 547**] of last year. He is dialyzed at home. His dry weight is 139. MEDICATIONS: 1. Epogen 13,000 units at dialysis 2. Serevent multi dose inhaler 21 mg 2 puffs [**Hospital1 **] 3. Levothyroxine 200 mcg qd 4. Albuterol nebulizers q6h prn 5. Flovent 110 mcg 3 puffs q 12 hours 6. Claritin 10 mg qd 7. Oxazepam 15 mg at hs prn 8. Micronase 1.25 mg qd prn, best if glucose greater than 200. 9. Quinine sulfate 1 to 2 tablets post pre dialysis days only. 10. Norvasc 5 mg 1 q p.m. on Monday, Wednesday and Friday and 1 [**Hospital1 **] on non dialysis days. 11. Lopressor 25 mg [**Hospital1 **] 12. Calcium carbonate 4 gm tid 13. Nepro supplement 1.5 cans qid per nasogastric tube irrigated with 2 ounces of water pre and post tube feed bolus. 14. Levaquin 500 mg q other day 15. Coumadin 5 mg alternating with 7.5 mg. The reason for the patient taking Coumadin is unclear. This will be clarified with his primary care physician. [**Name10 (NameIs) **] may be continued or discontinued according to information obtained. PHYSICAL EXAM: VITAL SIGNS: Temperature 98.9??????, pulse 68, respirations 19, blood pressure 144/85, 87% on room air, 97% at 2 liters of O2. His left AV fistula has an excellent thrill. GENERAL: Alert, cooperative white male in no acute distress. HEAD, EARS, EYES, NOSE AND THROAT: He has no jugular venous distention, no carotid bruits. His carotid, brachial and radial pulses are intact. The abdominal aorta is non prominent. His femoral pulses are intact bilaterally with a left femoral bruit. The right DP and PT are palpable and the left DP and PT are absent. CHEST: Clear to auscultation bilaterally. HEART: Regular rate and rhythm, distant. There are no murmurs. ABDOMEN: Soft, nontender. The G-tube site is clean, dry and intact. EXTREMITIES: The lower extremities show chronic venostasis changes. The left foot shows a plantar heel ulceration and dry gangrene. First metatarsal head dry gangrene in multiple areas on the leg with ulceration and dry gangrene. NEUROLOGIC: Unremarkable. HOSPITAL COURSE: The patient was admitted to the vascular service. He was continued on his preadmission medications except for the Coumadin which has been held since [**6-5**]. Renal service followed the patient and arranged for hemodialysis prior to surgery. His preoperative labs included a CBC with a white count of 6.4, hematocrit 28.7, platelets 140. PT and INR were normal. BUN of 64, creatinine 3.5, potassium 4.2. Chest x-ray was unremarkable with a resolution of right lower lobe pneumonia and no other acute chronic disease. Electrocardiogram was a normal sinus rhythm with T-wave changes which were unchanged from a previous electrocardiogram of [**Month (only) 404**] of this year. On [**2115-6-12**], the patient underwent a left BKA. He tolerated the procedure well. He was transferred to the PACU in stable condition. Postoperatively, he remained well controlled analgesic wise. His dressings were clean, dry and intact. On postoperative day 1, there were no overnight events. He was continued on his levofloxacin. The stump dressing was clean, dry and intact. This would be moved on postoperative day 2. Nutritional services saw the patient and made recommendations and adjustments to his tube feedings which includes a Nepro bolus of 480 cc 4x a day with 2 ounces of free water pre and post feeding. Physical therapy was requested to see the patient for post amputation exercises. Rehabilitation was requested to begin screening for rehabilitation potential. The patient's PCA was discontinued and morphine sulfate 2 to 4 mg intravenous subcutaneous intramuscular was instituted at q3h prn for pain. His Coumadin was reinstituted at 5 mg qd. The patient was discharged in stable condition and he should follow up with Dr. [**Last Name (STitle) **] in two to four weeks' time for skin clip removal. The skin clip will remain in place until seen by him. His PT/INR should be monitored until the patient is at a steady therapeutic state and then can be monitored 3x a week and then as needed. Coumadin dosing will be determined prior to discharge after talking to primary care physician. DISCHARGE MEDICATIONS included all of his admitting medications with the inclusion of the morphine 2 to 4 mg intravenous subcutaneous intramuscular q3h prn. DISCHARGE DIAGNOSES: 1. Gangrenous left lower extremity status post left BKA 2. End stage renal disease, on dialysis Monday, Wednesday and Friday 3. Diabetes, stable 4. Hypertension, stable 5. History of Methicillin resistant Staphylococcus aureus 6. History of coronary artery disease, status post myocardial infarction in [**2093**] 7. Recurrent congestive heart failure compensated 8. Gastroesophageal reflux disease 9. Peripheral vascular disease [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2115-6-13**] 18:07 T: [**2115-6-14**] 10:47 JOB#: [**Job Number 26964**] Admission Date: [**2115-6-11**] Discharge Date: [**2115-7-15**] Date of Birth: [**2049-8-17**] Sex: M Service: [**Doctor Last Name 1181**] HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 26965**] is a 65 year-old male with end stage renal disease and peripheral vascular disease admitted on [**6-11**] originally to the Vascular Service for elective left below the knee amputation due to nonhealing ulcers. Mr. [**Known lastname 26965**] has a history of multiple vascular interventions on his left leg including femoral distal bypass in [**2114-4-8**], but has a chronic pain and a nonhealing ulcer on his left foot, which has failed conservative therapy. With the exception of his pain Mr. [**Known lastname 26965**] felt well on admission. He denies fevers or chills, chest pain, shortness of breath. PAST MEDICAL HISTORY: Remarkable for end stage renal disease secondary to ANCA vasculitis. The patient was hemodialysis since [**2112**]. The patient has a history of type 2 diabetes since [**2093**]. The patient has a history of peripheral vascular disease as noted above including previously mentioned left leg interventions as well as amputation of fifth metatarsals on his right foot. The patient has a history of congestive heart failure with an echocardiogram in [**2115-3-8**] showing a left ventricular ejection fraction of 40 to 45%, right ventricular dilatation and mild pulmonary hypertension, as well as mild global right ventricular hypokinesis. The patient has a history of atrial fibrillation status post cardioversion. The patient has a history of hyperthyroidism, hypertension, history of previous cerebrovascular accident, history of throat cancer status post chemotherapy and radiation therapy, history of MRSA bacteremia, history of GERD. History of chronic aspiration pneumonias status post PEG placement. ALLERGIES: The patient is allergic to Hydralazine to which he developed a vasculitis. Cipro to which he gets swelling, ace inhibitors to which he gets swelling and Vancomycin to which the patient gets hives. MEDICATIONS ON ADMISSION: Coumadin, which was initially on hold for surgery, subQ heparin, Levofloxacin 250 mg po once a day, which was begun on [**6-12**] for aspiration pneumonia, Epogen 1300 units subQ once a week, Serevent two puffs b.i.d., Levothyroxine 200 micrograms po q day, quinine sulfate 325 mg po Monday, Wednesday and Friday prehemodialysis, Norvasc 5 grams Monday, Wednesday, Fridays, 5 grams twice a day Tuesday, Thursday, Saturday and Sunday. Lopressor 25 mg po twice a day. Calcium carbonate 4 grams po twice a day. Flovent 110 micrograms three puffs b.i.d., Claritin 10 mg po once a day and Percocet prn. SOCIAL HISTORY: Remarkable for a forty pack year smoking history. The patient quit smoking in [**2103**]. LABORATORIES ON ADMISSION: The patient had a white count of 6.4, hematocrit of 28.7, which is around baseline for the patient. His INR was 1.4. PTT was 36.3 and his BMP was within normal limits. PHYSICAL EXAMINATION ON ADMISSION: The patient was afebrile with a temperature of 98.8, pulse 74, blood pressure 136/62, sating 94% on 2 liters O2. Generally, he was cachectic ill appearing male in no acute distress. He had no JVD, but his lungs were remarkable for bibasilar rales. Cardiovascular is regular rate and rhythm with no murmurs. Abdominal examination was benign with the PEG site being clean, dry and intact. Extremities left lower extremity was bandage with the bandage being clean, dry and intact. No edema. Chronic venostasis changes. Right lower extremity had no edema and also had evidence of chronic venous changes. Left AV fistula had palpable thrill and a good bruit. IMPRESSION: In short, this was a 65 year-old male with end stage renal disease and peripheral vascular disease and a myriad of other medical problems that was admitted for elective left below the knee amputation secondary to nonhealing ulcer. HOSPITAL COURSE: 1. Vascular: The patient underwent left below the knee amputation as planned on [**6-12**] and was doing well postoperatively until [**6-16**] when he began having mental status changes. Workup of the mental statue changes is discussed in the endocrine section below. The patient's wound did not heal well and became necrotic, gangrenous and thus the patient was taken back to have his below the knee amputation revised to an above the knee amputation on [**2115-6-26**]. Postoperatively the patient's wound healed well and at the time of discharge was clean, dry and intact with no erythema and no exudate. 2. Endocrine: The patient is a known type 2 diabetic who was taking Micronase at home that was discontinued on admission, because the patient was NPO for surgery. The patient's sugars were fine postop until he began having mental status changes on the 9th where he became lethargic, noninteractive with his family, narcotics were discontinued without results and blood sugars were noted to be in the low 40s to 70s. Review of medications revealed that the patient had been given Glyburide due to a nonupdated medication sheet brought from home. Blood sugars remained in the 20 to 80 range. The patient despite boluses with D50 was started on a D10 drip. His sugars were maintained within normal limits. Unfortunately Glyburide does not clear the system with dialysis, so the patient was maintained on a D10W drip with D50 boluses needed throughout the course of the next three days while waiting for Glyburide to clear his system. Subsequent to weaning the patient off of the D10 drip he was maintained on standing doses of NPH insulin and with sliding scale. 3. Infectious disease: The patient was afebrile throughout the course of his hospital stay until [**6-26**] when he spiked a temperature. Subsequent blood cultures grew MRSA. Because the patient's allergy to Vanco he was started on Synercid. The patient underwent a TTE to rule out endocarditis, which showed no vegetations. He also had another positive MRSA blood culture on [**7-2**] after the placement of a PICC line. The PICC line was removed after subsequent catheter tip culture grew MRSA positive. The patient remained afebrile with negative blood cultures from MRSA for the remainder of his hospital stay and was sent home for an add two weeks of Synercid. The patient also had a positive blood cultures, which grew B fragilis. The source for this was thought to be the sacral decubitus ulcer. The patient was started on Flagyl po for this and given a two week course per ID recommendation. 4. Cardiac: The patient had a history of atrial fibrillation, but was in normal sinus rhythm on admission. Throughout the course of his stay he had episodic atrial fibrillation, but remained hemodynamically stable. The patient was restarted on his Coumadin prior to discharge with hopes of titrating him back to a therapeutic level. The patient is followed by his nephrologist Dr. [**Last Name (STitle) 1366**]. 5. Sacral decubitus ulcer: During the course of his hospital stay due to his prolonged immobilization postoperative and while being in the Intensive Care Unit the patient developed severe sacral decubitus ulcer stage 3 to 4, which required multiple debridement by plastic surgery while he was in house. Because the patient's peripheral vascular disease it was thought that the patient is probably not a good candidate for flap reconstruction. The patient was referred to general surgeon Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for follow up and further debridement of this wound as an outpatient and continued on wet to dry dressings three times a day. 6. Pulmonary: The patient had a history of chronic aspiration pneumonias and had difficulty being weaned from oxygen as an inpatient. Thus he was treated with a short course of Levofloxacin while in house even though his chest x-ray remained clear without signs of pneumonia during the course of his stay. The patient was also continued on his chronic obstructive pulmonary disease inhalers and oxygen prn. 7. Fluids, electrolytes and nutrition: The patient continued G tube feeds throughout the course of his stay. 8. Gastrointestinal: The patient had repeated diarrhea following initiation of Synercid treatment. He was C-diff negative multiple times and it was thought that the diarrhea was secondary to antibiotic use. DISCHARGE CONDITION: The patient was discharged home on [**2115-7-15**] in good condition to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] regarding treatment of his sacral ulcer, with Dr. [**Last Name (STitle) 73**] regarding his atrial fibrillation and cardiac issues, Dr. [**Last Name (STitle) 26966**] his primary care attending regarding his general care and with Dr. [**Last Name (STitle) 1366**] for issues surrounding his hemodialysis. DISCHARGE DIAGNOSES: 1. Peripheral vascular disease status post left below the knee amputation revised to above the knee amputation. 2. End stage renal disease. 3. Type 2 diabetes. 4. Hypertension. 5. Sacral decubitus ulcer status post debridement times two. 6. MRSA bacteremia. 7. B fragilis bacteremia. 8. Congestive heart failure. 9. Atrial fibrillation. 10. Hyperthyroidism. MEDICATIONS ON DISCHARGE: Synercid 500 mg intravenous q 8 times seven days, Flagyl 500 mg po q 8 times ten days, zinc sulfate 50 mg po Monday, Wednesday and Friday, Nephrocaps one tab po q day, calcium carbonate 1 gram po t.i.d., insulin NPH 8 units at breakfast and 6 units at bedtime. Reglan 25 mg po q 6 hours, aspirin 81 mg po q day, Salmeterol two puffs b.i.d., Flovent 110 micrograms two puffs po b.i.d., quinine sulfate 325 mg po Monday, Wednesday and Friday prior to hemodialysis, Lopressor 25 mg po b.i.d., Synthroid 200 micrograms po q day, Ranitidine 150 mg po q day, Coumadin 2.5 mg po q day and Norvasc 5 mg po q.h.s Monday, Wednesday and Friday and 5 mg b.i.d. Tuesday, Thursday, Saturday and Sunday. DR.[**Last Name (STitle) 313**],[**First Name3 (LF) 312**] 12-766 Dictated By:[**Name8 (MD) 26967**] MEDQUIST36 D: [**2115-7-18**] 15:47 T: [**2115-7-21**] 08:32 JOB#: [**Job Number 26968**]

[ "440.23", "790.7", "996.62", "585", "428.0", "427.31", "496", "707.0", "707.14" ]

icd9cm

[ [ [] ] ]

[ "96.6", "84.17", "39.95", "86.22", "84.15" ]

icd9pcs

[ [ [] ] ]

16834, 17297

17318, 17687

17714, 18634

10508, 11109

12380, 16812

2579, 4365

4380, 5378

159, 326

8591, 9234

11453, 12362

9257, 10481

11126, 11231

62,807

185,872

37266

Discharge summary

report

Admission Date: [**2142-11-26**] Discharge Date: [**2142-11-30**] Date of Birth: [**2090-11-11**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 974**] Chief Complaint: head on motor vehicle collision Major Surgical or Invasive Procedure: insertion of left chest tube History of Present Illness: Mrs. [**Known lastname 174**] is a 52 year old woman who was involved in a head-on motor vehicle collision. She did lose consciousness and is amnestic to the event. She was brought to the [**Hospital1 18**] ED, where her GCS was 14 on arrival (she was confused and unoriented). Past Medical History: PMH: scleroderma PSH: c-section x3, breast implants Social History: Married, lives with husband, 3 older children, has her own therapist ETOH occasional Tobacco none Family History: non contributory Physical Exam: O: T: BP:108/62 HR:93 R 16 O2Sats 97% Gen: WD/WN, comfortable, NAD. HEENT: Laceration left eyebrow Pupils: PERRLA EOMs full Neck: In collar, non tender Chest Clear but decreased breath sounds left side COR RRR Abd soft, some tenderness from lower abdom ? from seatbelt Extrem: Warm and well-perfused, laceration left knee Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light,2.5-1.0mm 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 [**4-17**] throughout. No pronator drift Sensation: Intact to light touch Toes downgoing bilaterally Pertinent Results: CXR [**2142-11-26**]: Left-sided pneumothorax CT C-spine [**2142-11-26**]: No fracture or malalignment in the cervical spine. Congenital fusion at C2-3 as detailed. Large left apical pneumothorax. CT Head [**2142-11-26**]: Small foci of hemorrhage within the inferior frontal lobes without significant edema or mass effect. CT Torso [**2142-11-26**]: Large left pneumothorax with no rib fracture seen, and no current evidence of tension. Dilated esophagus; chronicity unclear, but causing risk for aspiration. Unusual appearance of the uterus may relate to history of numerous C-sections; correlate with any available prior (outside) imaging studies. Cystic 3 mm pancreatic lesion for which MRCP should be considered for further characterization. Heterogeneous appearance of bilateral breast implants. US can be performed if there is clinical concern for rupture. XR R Knee [**2142-11-26**]: Soft tissue laceration, otherwise unremarkable CXR [**2142-11-26**]: New left chest tube - interval re-expansion of the left lung with no discernible pneumothorax. CXR [**2142-11-26**]: There has been interval retraction of the left sided chest tube with tip now positioned adjacent to the left mediastinal border. Otherwise, no change. CXR [**2142-11-26**]: Left-sided chest tube remains in place, with no visible residual pneumothorax. Subcutaneous emphysema persists in the left chest wall. The overall appearance of the chest is similar to the recent study except for slight worsening of a left retrocardiac opacity, which could be due to a combination of contusion and atelectasis. Distention of thoracic esophagus is without change. CT Head [**2142-11-27**]: Interval increase in size of multiple bifrontal hemorrhagic contusions and a small focus of SAH and questionable intraventricular hemorrhage/volume averaging in the left occipital [**Doctor Last Name 534**]. Attention to be paid on close follow up. Given the interval increase, concern for Diffuse axonal injury- to correlate clinically and consider MR if there is no contraindication and if clinically indicated. CXR [**2142-11-27**]: As compared to the previous radiograph, the extent of the left-sided pneumothorax is unchanged. Also unchanged is the course and position of the left chest tube and the presence of a small left basal and retrocardiac opacity. The air collection in the left soft tissues is unchanged. Also unchanged are the aspect of the cardiac silhouette and the appearance of the right lung. Brief Hospital Course: On primary survey, the patient's airway was secure. She was breathing spontaneously without respiratory distress and her oxygen saturations were in the high 90s on room air. She was hemodynamically stable. Secondary survey revealed a left eyebrow lac, left scalp hematoma, and right knee lac. FAST exam was negative. The patient underwent multiple imaging studies, which ultimately revealed the following injuries: Left apical pneumothorax Left frontal hemorrhagic contusion Left parietal subgaleal hematoma Right knee laceration A chest tube was inserted by the emergency department staff. This was noted to have been inserted too far on the subsequent chest x-ray and so was withdrawn to an appropriate position. The chest tube was put to suction. A follow-up chest x-ray showed resolution of the pneumothorax. Following a water seal trial the tube was removed without difficulty and a post pull film revealed resolution of the pneumothorax. Neurosurgery was consulted for the hemorrhagic contusion. They recommended admission to the T-SICU for frequent neurochecks and a repeat head CT the following morning. She was started on Keppra prophylactically the following morning by the trauma service for a total of seven days. A repeat head CT was performed, which showed interval increase in size of multiple bifrontal hemorrhagic contusions and a small focus of SAH and questionable intraventricular hemorrhage/volume averaging in the left occipital [**Doctor Last Name 534**]. This was reviewed by the Neurosurgery service and due to the fact that her neurologic exam was normal they simply wanted a repeat scan in 4 weeks. The Occupational Therapy service evaluated Ms. [**Known lastname 174**] due to her head injury to access for any cognitive impairment. She was found to be a bit below her baseline in ADL's and cognition and was therefore seen by them on a daily basis. She was also evaluated by the Behavioral Neurology service and will be followed by them as an outpatient. Of note the initial Abdomonal Ct demonstrated a 3 mm pancreatic cystic lesion near the head/neck junction for which further evaluation could be considered by MRCP. This could be done on a nonurgent basis. She also had some symptoms of dysuria and frequency with a positive urinalysis and was started on Ciprofloxicin. The final culture is >100K EColi. She will complete a 3 day course of Cipro on [**2142-12-1**]. Medications on Admission: Celexa 10mg PO daily, Prilosec 10mg PO BID Discharge Medications: 1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: [**12-15**] Tablet, Chewables PO QID (4 times a day) as needed for reflux. 4. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Thru [**2142-12-3**]. Disp:*10 Tablet(s)* Refills:*0* 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for constipation. 8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): Thru [**12-1**] 09. Disp:*6 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis S/P MVC 1. Left pneumothorax 2. Left frontal hemorrhagic contusion 3. Left parietal subgaleal hematoma 4. Right knee laceration 5. UTI Secondary diagnosis 1. Scleroderma Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. CALL YOUR DOCTOR 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: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from Behavioral Neurology ([**Telephone/Fax (1) 1690**]) will see you on [**2142-12-24**] at 10:30AM. You will need a referral from your PCP prior to the appointment. His office is located in the [**Hospital Ward Name 516**], [**Hospital Ward Name 860**] Bldg. [**Location (un) **] 253 Call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 600**] for a follow up appointment in 2 weeks. Call the [**Hospital 4695**] Clinic at [**Telephone/Fax (1) 1669**] for a follow up appointment with Dr. [**First Name (STitle) **] in 4 weeks with a Head CT scan without contrast. The secretary can book this for you. Call the Trauma Clinic at [**Telephone/Fax (1) 2359**] for an appointment on [**2142-12-5**] to have your knee sutures removed. Completed by:[**2142-11-30**]

[ "873.42", "041.4", "851.86", "599.0", "577.2", "860.0", "710.1", "E812.0", "891.0" ]

icd9cm

[ [ [] ] ]

[ "34.04", "86.59" ]

icd9pcs

[ [ [] ] ]

8155, 8161

4697, 7113

348, 378

8393, 8393

2192, 4674

9484, 10328

892, 910

7206, 8132

8182, 8372

7139, 7183

8538, 9461

925, 1269

277, 310

406, 685

1521, 2173

8407, 8514

707, 761

777, 876

22,741

153,509

30067

Discharge summary

report

Admission Date: [**2136-6-4**] Discharge Date: [**2136-6-5**] Date of Birth: [**2117-7-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3556**] Chief Complaint: confusion Major Surgical or Invasive Procedure: Intubation with mechanical ventilation, now extubated History of Present Illness: 18 yo M who was [**Last Name (un) 4662**] to ED by friends when confused and [**Last Name (un) 71714**]. Per his friends the patient was completely normal earlier in the day (He is visiting from [**State 4565**]). They happened upon him tonight and he was alternating between confusion (laughing inappropriately) and combative. Friends reported that had smoked MJ before but unknown if any other substances. Also found to have large hematoma over left frontal skull. No witnessed fall. Patient unable to give history. . Patient presented to ED afebrile 98.2, tachy 130's, hypertensive > 180's, blood sugar 149, oxygenating well on room air. Patient intubated to allow for head imaging. Head CT neg for bleed. Once intubated, on propafol, HR to 90's, SBP to 120's. Discussed with tox who were concerned for anticholinergic syndrome, PCP, [**Name10 (NameIs) 71715**], or dextromethorphan. EKG with normal intervals. Past Medical History: None Social History: Student at [**Location (un) 511**] College of Art. Lives in the dorms. Was smoking Marijuana just prior to admission, but denies other illicit drug use. Family History: NC Physical Exam: VS - 97.0 73 128/71 Resp - AC 500/18/50%/5 Sat 100% gen - intubated sedated skin - no rashes, no erythema, no diaphoresis even in axilla heent - op clear, neck - in collar cor - RRR no m/r/g chest - CTAB abd - soft, non-distended ext - no edema neuro - paralyzed Pertinent Results: [**2136-6-4**] 07:36PM FIBRINOGE-265 [**2136-6-4**] 07:36PM PT-12.9 PTT-23.5 INR(PT)-1.1 [**2136-6-4**] 07:36PM PLT COUNT-349 [**2136-6-4**] 07:36PM WBC-13.7* RBC-4.61 HGB-15.1 HCT-42.6 MCV-92 MCH-32.6* MCHC-35.3* RDW-13.5 [**2136-6-4**] 07:36PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2136-6-4**] 07:36PM TSH-1.1 [**2136-6-4**] 07:36PM ALBUMIN-4.9* CALCIUM-9.6 PHOSPHATE-3.9 MAGNESIUM-2.2 [**2136-6-4**] 07:36PM CK-MB-3 cTropnT-<0.01 [**2136-6-4**] 07:36PM LIPASE-25 [**2136-6-4**] 07:36PM ALT(SGPT)-14 AST(SGOT)-24 LD(LDH)-259* CK(CPK)-229* ALK PHOS-75 AMYLASE-57 TOT BILI-0.3 [**2136-6-4**] 07:36PM estGFR-Using this [**2136-6-4**] 07:36PM GLUCOSE-160* UREA N-19 CREAT-1.1 SODIUM-144 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-22 ANION GAP-22* [**2136-6-4**] 07:48PM PO2-55* PCO2-45 PH-7.34* TOTAL CO2-25 BASE XS--1 COMMENTS-GREEN TOP [**2136-6-4**] 09:49PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2136-6-4**] 09:49PM URINE HOURS-RANDOM . [**2136-6-4**] - CT C-spine **preliminary report** Endotracheal tube and nasogastric tubes are viewed respectively. There is no malalignment or acute fracture of the cervical spine. There is no prevertebral soft tissue swelling. Please note, CT is unable to provide intrathecal detail comparable to MRI. The visualized portions of the lung apices are unremarkable. IMPRESSION: No evidence of acute fracture or malalignment of the cervical spine . [**2136-6-4**] - CT head **preliminary report** FINDINGS: There is no evidence of acute intracranial hemorrhage, shift of normally midline structures, hydrocephalus, major or minor vascular territorial infarction. The density values of the brain parenchyma are within normal limits. There is a large subcutaneous hematoma over the left frontal area measuring at least 9 cm in diameter with areas of hyperdensity suggestive of ongoing bleeding. No underlying skull fracture or foreign body is detected. The visualized portions of the paranasal sinuses and the mastoid air cells are unremarkable. IMPRESSION: 1. No evidence of acute intracranial pathology, including no sign of intracranial hemorrhage. 2. Large left frontal subcutaneous hematoma with foci of hyperdensity reflective of ongoing bleeding. No underlying skull fracture. . [**2136-6-4**] - pCXR: FINDINGS: An endotracheal tube is present with the distal tip approximately 3.7 cm from the carina. A nasogastric tube is evident coiled within the gastric body. The lung volumes are low. The lungs otherwise are clear. The mediastinum is unremarkable. The cardiac silhouette is within normal limits accounting for patient and technical factors. No pleural effusion or pneumothorax is evident. IMPRESSION: Endotracheal tube in satisfactory position. Low lung volumes, but otherwise, lungs are clear. Brief Hospital Course: 18 yo M who was brought to ED by friends when confused and [**Month/Day/Year 71714**]. . # Altered Mental Status: 18 y.o. patient with no past medical history brought in by friends to [**Name (NI) **]. Reportedly, he smoked Marijuana and had a panic attack, causing him to run his head into a wall. Afterward he was intermittently confused and [**Last Name (LF) 71714**], [**First Name3 (LF) **] ambulance called. Electrolytes were wnl. Tox screen negative for both drugs of abuse and ASA, triCyc, and tylenol. He was intubated and sedated in order to obtain head and neck CTs. No fractures noted of the skull or C-spine. Physicial exam and CT head revealed a large subcutaneous hematoma, but no parenchemal or other internal bleeding by imaging. Toxicology was consulted and felt possible agents included PCP, [**Name10 (NameIs) **], or dextromethorphan. His mental status improved quickly and he was extubated within 12 hours. Most likely his mental status changes were secondary to head trauma given hematoma. His repeat neuro exam was normal. The patient was scheduled on a flight home to [**State 4565**] on the day of discharge. It was felt he was safe to fly, and was instructed to follow up with his primary care physician (Dr. [**Last Name (STitle) **] in [**3-3**] days to be sure he did not have concussive symptoms. The patient's sister, [**Name (NI) **], was contact[**Name (NI) **] and updated. A message was left for the patient's PCP. . # Leukocytosis: No localizing sign of infection. Differential normal. Level was trending down, and likely [**3-2**] to trauma/acute inflammation. . # FEN - NPO while intubated, then regular diet. Electrolytes wnl. . # PPX - hep sc, PPI . Full Code Medications on Admission: None Discharge Medications: None Discharge Disposition: Home Discharge Diagnosis: 1. Respiratory failure secondary to intoxication 2. Marijuana intoxication 3. Altered mental status 4. Scalp hematoma 5. Hypertension -- resolved Discharge Condition: Stable, neurologic exam normal Discharge Instructions: You were admitted with altered mental status, now improved back to your baseline. . Please follow up with your doctor in [**3-3**] days. . Call your doctor or return to the Emergency Room immediately if you have confusion, severe or worsening head pain, blurred vision, or any other symptom that concerns you. Followup Instructions: Call your doctor when you get home; Set up a follow up appointment in [**3-3**] days to be sure you do not develop symptoms of a concussion. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**] Completed by:[**2136-6-5**]

[ "920", "E854.1", "969.6", "E917.9", "E849.9", "300.01", "E849.8" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

6533, 6539

4729, 4829

323, 379

6728, 6761

1855, 4706

7119, 7419

1549, 1553

6504, 6510

6560, 6707

6475, 6481

6785, 7096

1568, 1836

274, 285

407, 1333

4845, 6449

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1377, 1533

57,614

115,745

8706

Discharge summary

report

Admission Date: [**2133-10-2**] Discharge Date: [**2133-10-4**] Date of Birth: [**2066-4-15**] Sex: M Service: MEDICINE Allergies: Pneumococcal Vaccine Attending:[**First Name3 (LF) 2387**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None. History of Present Illness: This is a 67 year old man with a history of kidney/liver transplant on immunosupression, DM2, PVD s/p right [**Doctor Last Name **]-AT and atrial fibrillation s/p DCCV on [**2133-10-1**] who presents with shortness of breath. Around [**6-3**] pm on the night prior to admission he developed insidius shortness of breath associated with chest pressure. He describes the pressures as constant, [**2134-6-3**] in severity. He had a hard time laying flat overnight and did not get much sleep. He also reported fatigue with minimal activity. He denied fever, chills, palpitations, LE edema, cough or sputum production. He denied radiation of the pain to his jaw or arm and denied diaphoresis or lightheadedness. He has had similar symtoms in the past, most recently in [**March 2133**], when they were associated with LE edema. His symptoms persisted untill the morning and he presented to the ED. Apparently he had been on asymtomatic atrial fibrillation since [**March 2133**]. An echocardiogram in [**July 2133**] showed mild symmetric left ventricular hypertrophy (LVEF >55%) with preserved global and regional biventricular systolic function. Also notable were mild diastolic LV dysfunction and mild moderate mitral regurgitation. Yesterday, [**2133-10-1**], he underwent succesfull DCCV. He was feeling well after the procedure. He reports however, that he missed his dose of lasix for the day. He had been taking his antihypertensive medications and blood thiners. In the ED, he was noted to be hypertensive with BP 180/87, tachypneic with RR 40 and had a SaO2 of 76% RA. He was placed on NRB and subsequently on BiPAP. His respirations decreased to 20 and was subsequently placed on NC. His CXR showed worsening of his pleural effusions. He received nitro ggt, lasix 60 mg IV and Lovenox (given a subtherapeutic INR). Prior to transfer his vitals were 98 74 119/66 23 97%4Lt. On review of systems, he denies ankle edema, palpitations, syncope or presyncope, 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. Past Medical History: - Renal and Liver transplant in [**2123**]; ESLD [**12-29**] EtOH use, ESRD thought [**12-29**] DM2 - DM type II - Hypertension - Bilateral lower extremity neuropathy - Peripheral Vascular Disease - Right foot BKA [**7-/2133**] - MRSA - Osteomyelitis - s/p R [**Doctor Last Name **]-AT bypass [**2129**] - Hernia Repair X2 - Arthritis - Tonsillectomy - Cholecystectomy Social History: No tobacco h/o significant EtOH abuse, stopped before transplant lives with wife Family History: Father:CM, asbestos poisoning, lung cancer, DM. Mother: died of natural causes, had DM Physical Exam: GENERAL: 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 no JVD or HJR CARDIAC: Pectus excavatum. PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: RUQ surgical scar. Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: R BKA. 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: [**2133-10-2**] 10:55AM BLOOD WBC-9.5# RBC-4.98 Hgb-10.8* Hct-34.8* MCV-70* MCH-21.7* MCHC-31.0 RDW-18.5* Plt Ct-254 [**2133-10-4**] 06:05AM BLOOD WBC-5.4 RBC-4.71 Hgb-10.3* Hct-33.0* MCV-70* MCH-21.8* MCHC-31.1 RDW-18.1* Plt Ct-219 [**2133-10-1**] 09:00AM BLOOD PT-20.3* INR(PT)-1.9* [**2133-10-4**] 06:05AM BLOOD PT-22.4* PTT-35.9* INR(PT)-2.1* [**2133-10-4**] 06:05AM BLOOD Glucose-157* UreaN-41* Creat-1.4* Na-136 K-4.8 Cl-102 HCO3-24 AnGap-15 [**2133-10-2**] 10:55AM BLOOD CK-MB-NotDone proBNP-9331* [**2133-10-2**] 10:55AM BLOOD CK(CPK)-62 [**2133-10-2**] 10:55AM BLOOD cTropnT-0.02* [**2133-10-2**] 08:04PM BLOOD CK(CPK)-58 [**2133-10-2**] 08:04PM BLOOD CK-MB-NotDone cTropnT-0.04* [**2133-10-3**] 04:50AM BLOOD CK(CPK)-51 [**2133-10-3**] 04:50AM BLOOD CK-MB-NotDone cTropnT-0.06* [**2133-10-4**] 06:05AM BLOOD Calcium-9.5 Phos-4.4 Mg-1.6 [**2133-10-3**] 04:50AM BLOOD tacroFK-15.3 [**2133-10-2**] 10:55AM URINE Blood-LG Nitrite-NEG Protein->300 Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2133-10-2**] 10:55AM URINE RBC-[**10-16**]* WBC-0-2 Bacteri-OCC Yeast-NONE Epi-0 EKG [**10-1**]: Normal sinus rhythm with occasional ventricular premature beats. No other diagnostic abnormality. Since the previous tracing [**2133-8-5**] no diagnostic interim change. . CXR [**10-2**]: Interval increase in size of small bilateral pleural effusions. No evidence of CHF. Brief Hospital Course: # SOB - Likely [**12-29**] LV dysfunction in setting of elevated BP, BNP. Patient in NSR on initial presentation. Ruled out for MI. Pt's SOB resolved after IV lasix and was placed back on his home PO lasix dose, on which he continued to diurese well. . # AF s/p DCCV - was in NSR throughout hospitalization until AM of [**10-4**], at which time he converted back to atrial fibrillation at a rate between 80s-100s. Currently rate-controlled, asymptomatic. - uptitrate home metoprolol dose to 100 mg po bid - continue warfarin, goal INR 2.0 - 3.0. Pt was found to be slightly subtherapeutic on admission, home dose was slightly uptitrated to 6 mg/d from 5 mg/d. - patient remained well rate-controlled and asymptomatic after converting to atrial fibrillation. It was discussed that he should follow up closely with his cardiologist (Dr. [**Last Name (STitle) **] and discuss further management options, including repeat attempt at cardioversion. . # HTN - Increased nifedipine, metoprolol doses. . # s/p kidney, liver transplant - Found to have significantly elevated tacrolimus level on admission. Decreased dose during admission with plans for repeat check at home this coming Thursday following discharge. Nephrology follows patient closely as an outpatient and will f/u on repeat drug level. - continue mycophenolate, tacrolimus - f/u tacro level Medications on Admission: Furosemide 20mg three tablets once daily Metoprolol Succinate 100mg one tablet by mouth daily Mycophenolate Mofetil 500mg one tablet by mouth twice daily Pregabalin (lyrica) 100mg once daily Tacrolimus (prograf) 1mg three capsules twice daily Warfarin 5.0mg once daily Insulin NPH and Regular Human (Humulin 70/30) Ranitidine HCL 75mg tablet twice daily Nifedipine 30mg once daily Discharge Medications: 1. Warfarin 2 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 2. Ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 3. Pregabalin 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Mycophenolate Mofetil 250 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 5. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 6. Humulin 70/30 100 unit/mL (70-30) Suspension Sig: AS DIRECTED Subcutaneous . 7. Outpatient Lab Work Please draw serum tacrolimus level, PT/INR, blood urea nitrogen, serum creatinine, serum potassium on [**2133-10-8**]. Results showed be faxed to Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 17382**]) and Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 21335**]). 8. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO twice a day. Disp:*120 Capsule(s)* Refills:*1* 9. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 10. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. Disp:*30 Tablet Sustained Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Primary Diagnosis: acute diastolic heart failure, paroxysmal atrial fibrillation Secondary Diagnoses: 1. hypertension 2. end-stage liver disease s/p liver transplant 3. end-stage renal disease s/p renal transplant 4. peripheral vascular disease s/p below-knee amputation 5. anemia Discharge Condition: Level of Consciousness:Alert and interactive Activity Status:Out of Bed with assistance to chair or wheelchair Mental Status:Clear and coherent Discharge Instructions: You were seen at [**Hospital1 18**] for shortness of breath. You were found to have excess fluid in your body which was likely causing your symptoms. You received intravenous diuretics which removed the extra fluid from your body and improved your symptoms. During your hospitalization, it was discovered that you returned to a rhythm of atrial fibrillation. It is currently at a reasonable rate, controlled with medication. You should discuss long-term management of this rhythm with your cardiologist, Dr. [**Last Name (STitle) **]. The following medications were changed during your hospitalization: INCREASED metoprolol from 100 mg daily (succinate) to 100 mg twice daily (tartrate) to better control heart rate INCREASED nifedipine to better control blood pressure INCREASED warfarin to ensure adequate thinning of blood DECREASED tacrolimus to 2mg twice daily, as you were found to have a blood level of this medication that was too high during your hospitalization Please weigh yourself daily if possible and notify your physician if you notice a weight change > 3 lbs. Adhere to a low-salt, low-cholesterol diet. You will need your blood checked this Thursday, [**10-8**], to recheck your tacrolimus level, as well as to monitor your kidney function and warfarin dosage. If you experience worsened shortness of breath, chest pain, fevers, or any other symptoms that worry you, please contact your PCP or go to the Emergency Department. Followup Instructions: Please contact your cardiologist, Dr. [**Last Name (STitle) **], to schedule an appointment within the next 1-2 weeks to discuss a plan for managing your atrial fibrillation, which recurred during this hospitalization. You can contact his office at [**Telephone/Fax (1) 7960**]. Provider: [**Name10 (NameIs) 13953**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2977**] Date/Time:[**2133-10-7**] 9:30 Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2133-10-16**] 10:50 Completed by:[**2133-10-4**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8420, 8471

5511, 6869

301, 309

8797, 8908

4098, 5488

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32685

Discharge summary

report

Admission Date: [**2179-10-29**] Discharge Date: [**2179-11-10**] Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 165**] Chief Complaint: Sternal drainage after CABG Major Surgical or Invasive Procedure: Sternal debridement([**10-30**]) and bilateral pectoral flap([**11-2**]) History of Present Illness: 87yo woman s/p MI on [**9-17**] while on vacation in [**State 5887**], was taken emergently to cath lab(99% LMain) and then operating room for CABG(LIMA-OM1, RIMA-LAD). Discharged to rehab and then home. She presented to ER @ [**Hospital3 76158**] [**10-22**] and subsequently found to have sternal drainage. At that time she was transferred to [**Hospital1 18**] for further management Past Medical History: CAD s/p MI/CABG CRI(1.3) ^chol Hypothyroid DJD Colitis w/bleed Rt TKR Hyst CCY Cardiomyopathy(EF 30%) Social History: Retired Lives with daughter [**Name (NI) **] tobacco No ETOH Family History: noncontributory Pertinent Results: [**2179-11-9**] 05:13AM BLOOD WBC-6.7 RBC-3.04* Hgb-8.7* Hct-26.9* MCV-88 MCH-28.6 MCHC-32.4 RDW-15.3 Plt Ct-393 [**2179-11-8**] 03:28AM BLOOD WBC-8.1 RBC-3.17* Hgb-9.2* Hct-27.6* MCV-87 MCH-29.2 MCHC-33.5 RDW-15.5 Plt Ct-405 [**2179-11-9**] 05:13AM BLOOD Plt Ct-393 [**2179-11-7**] 03:23AM BLOOD PT-14.3* PTT-27.2 INR(PT)-1.2* [**2179-11-9**] 05:13AM BLOOD Glucose-78 UreaN-19 Creat-1.1 Na-141 K-4.1 Cl-102 HCO3-30 AnGap-13 RADIOLOGY Final Report CHEST (PORTABLE AP) [**2179-11-8**] 7:57 AM CHEST (PORTABLE AP) Reason: check LLL collapse [**Hospital 93**] MEDICAL CONDITION: 87 year old woman with REASON FOR THIS EXAMINATION: check LLL collapse INDICATION: Assess left lower lobe collapse. COMPARISON: [**2179-11-5**]. SEMI-UPRIGHT AP CHEST: The left PICC is in unchanged position, with tip overlying the junction of the brachiocephalic vein. Bilateral paramedian drains are in unchanged position. The left lower lobe collapse is slightly improved since [**11-5**], and moderate cardiomegaly also appears improved. A small-to-moderate left effusion persists. IMPRESSION: Persistent but improved left lower lobe collapse. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4346**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname 10734**] [**Hospital1 18**] [**Numeric Identifier 76159**] (Complete) Done [**2179-10-30**] at 12:50:03 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2092-9-23**] Age (years): 87 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Abnormal ECG. Atrial fibrillation. H/O cardiac surgery. Left ventricular function. ICD-9 Codes: 402.90, 427.31, 440.0 Test Information Date/Time: [**2179-10-30**] at 12:50 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5209**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2007AW2-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 30% to 35% >= 55% Aortic Valve - Peak Gradient: 5 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 3 mm Hg Findings LEFT ATRIUM: Mild LA enlargement. Mild spontaneous echo contrast in the body of the LA. No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Moderate regional LV systolic dysfunction. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Simple atheroma in aortic root. Normal ascending aorta diameter. Simple atheroma in ascending aorta. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve leaflets. No masses or vegetations on aortic valve. Minimally increased gradient c/w minimal AS. Mild (1+) AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate mitral annular calcification. Calcified tips of papillary muscles. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. patient. Conclusions 1. The left atrium is mildly dilated. Mild spontaneous echo contrast is seen in the body of the left atrium. No thrombus is seen in the left atrial appendage. 2. No atrial septal defect is seen by 2D or color Doppler. 3. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is moderate regional left ventricular systolic dysfunction with antero and anteroseptal hypokinesis. 4. . Right ventricular chamber size and free wall motion are normal. 5. There are simple atheroma in the aortic root. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 6. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. No masses or vegetations are seen on the aortic valve. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Mild (1+) aortic regurgitation is seen. 7. The mitral valve leaflets are moderately thickened. Trivial mitral regurgitation is seen. Brief Hospital Course: Patient admitted to cardiac surgery on [**10-29**] with sternal drainage. Seen by plastic surgery and infectious disease services preoperatively. Brought to the operating room for sternal debridement on [**10-30**] and returned to operating room for bilat Pec and omental flap closure on [**11-2**]. Did well post operatively extubated on POD5/2 continued to improve and transferred from ICU to floors on POD [**8-5**]. Bacteremia identified as MRSA and antibx regime narrowed to Vancomycin, dose adjusted to trough levels. Continued slow improvement and transferred to rehabilitation on POD 11. Medications on Admission: Levothyroxine 100' Pravachol 40' Ceftriaxone 1' Azithromycin Zetia 10' Vancomycin 1gm Q18hrs Lasix 40' Ambien 5' Lisinopril 2.5' Aldactone 25' ASA 81' Lactobacillus MVI Lovenox 40" Plavix 75' Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO once a day. 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 11. Vancomycin 1,000 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750) mg Intravenous once a day: will determine duration at ID follow up 1/14. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) **] Discharge Diagnosis: s/p Sternal debridement [**10-30**] and bilateral pectoral and omental flap [**11-2**]. PMH: s/p CABG [**2179-9-17**], s/p MI, h/o post op AF, s/p flutter ablation [**2179-9-22**], h/o campylobacter in stool, MRSA sternum, CRI, ^chol, hypothyroid, DJD, colitis, s/p R TKR, s/p TAH, s/p [**Doctor Last Name **],cardiomyopathy w/ EF 30%. Discharge Condition: Good. Discharge Instructions: Keep wound clean and dry. OK to shower, no bathing or swimming. Take all medications as prescribed. No heavy lifting or driving for 6 weeks. Call with fever, redness or wound drainage. Followup Instructions: Dr [**Last Name (STitle) 7772**] in 4 weeks, pt to call [**Telephone/Fax (1) 1504**] to schedule appointment. Dr [**First Name (STitle) **] in plastics surgery clinic in 1 week, pt to call [**Telephone/Fax (1) 14596**] to schedule appointment Already scheduled appointment: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 22367**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2179-12-13**] 9:30 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2179-11-10**]

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icd9cm

[ [ [] ] ]

[ "88.72", "99.04", "33.24", "54.74", "83.82", "77.61" ]

icd9pcs

[ [ [] ] ]

8212, 8282

6426, 7023

263, 338

8663, 8671

1009, 1551

8904, 9454

973, 990

7265, 8189

1588, 1611

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7049, 7242

8695, 8881

196, 225

1640, 6403

366, 754

776, 879

895, 957

59,260

176,324

43694

Discharge summary

report

Admission Date: [**2167-1-24**] Discharge Date: [**2167-1-27**] Date of Birth: [**2091-4-11**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2297**] Chief Complaint: syncope, chills, nausea, vomiting, diarrhea Major Surgical or Invasive Procedure: [**2167-1-24**] - Arterial line placement History of Present Illness: 75 yo M with metastatic gallbladder cancer on gemzar/cisplatinum (last dose [**2167-1-16**]), bladder cancer s/p cystectomy, recent admissions for partial SBO ([**1-5**] - [**1-7**]) and for biliary obstruction ([**1-20**] - [**1-22**]) now presenting with hypotension, nausea, vomiting. . The patient was admitted [**Date range (1) 30498**]/12 following ERCP, performed due to biliary obstruction. During the ERCP, diffuse ulceration was noted in the distal esophagus, at the GE junction, and in the body of the stomach. Cannulation of the biliary duct was initially difficult but was successful and deep after placement of a 5 mm x 5 FR pancreatic stent. A 12 mm long segment of severe narrowing was noted at the level of the hilum consistent with a stricture. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. A WallFlex TM biliary RX uncovered 8 mm x 80 mm stent (REF: 7062, LOT: [**Numeric Identifier 93920**]) was placed successfully. The pancratic stent was removed after placement of the metal stent. . ERCP was complicated by nausea, vomiting, and elevated lipase. The patient was treated with bowel rest and IV fluids, and his diet was advanced prior to discharge on [**2167-1-22**]. Hospital course was also notable for new diagnosis of bilateral DVTs for which patient was started on lovenox treatment. . Yesterday, the patient developed weakness, nausea, and vomiting. He estimates that he had 10 episodes of non-bloody emesis. He also had some black diarrhea overnight last night. Then, at 3 a.m., the patient awoke with nausea and vomiting. He spent the next couple of hours sitting on a couch, during which time he experienced shaking chills and also syncopized for a couple of minutes. He regained consciousness and his family helped him to the toilet, at which point he had no BM had more syncope, and his family called EMS. When EMS arrived, initial BP was 70s/40s. . The patient also complains of cough and the sensation fo being unable to take a deep breath, which started during his recent admission. He has had hiccups for several weeks now, and has been taking baclofen twice daily for this. . In the ED, initial vitals signs were T 98.4 BP 73/37 HR 122 RR 16 Sat 93%. Exam was significant for AOx2, course breath sounds bilaterally. Patient was bolused with IVF. Labs were notable for WBC 6.9 (73N, 15bands), Hct 34 (27 at discharge), platelets 1000 (588 at discharge), Cr 1.4 (0.7 at discharge), ALT 16, AST 15, AP 675 (627 at discharge), Tbili 2.5 (2.2 at discharge), lactate 5.1, UA w 83 WBCs, positive nitrites, few bacteria. CXR demonstrated new L basilar infiltrate and bilateral pleural effusion. Patient was started on vanco/cefepime for presumed HCAP. LIJ was placed for fluid resuscitation. Patient remained hypotensive in SBP 80s, requiring initiation of levophed. ED course otherwise notable for patient reporting abdominal pain. CT abd/pelvis demonstrated known tumor, mildly distended stomach, with some fluid in the lower esophagus, could relate to partial gastric antral obstruction in the presence of symptoms. CT abd/pelvis also showed pleural effusion, ascites, improved left hydronephrosis. Repeat lactate returned 2.1. At time of transfer, patient had received 4L IVF and had a LIJ and two peripheral 18 gauge IVs. Vital signs on transfer were 98.5 HR119 BP85/50, RR34 98%3L. . On arrival to the ICU, the patient complained of heartburn and abdominal bloating. His nausea had resolved. He had the sensation of needing to defecate. However, he did not pass any stool. . Review of systems: No fever. +chills. +cough and dyspnea. No chest pain. +syncope. +abdominal discomfort and bloating, increased from baseline. Urine has been darker than usual. Has urinary ostomy. +hiccups. No rash. No focal weakness. +Chronic bilateral toe tingling L>R. No visual changes. Past Medical History: ONCOLOGY HISTORY - [**2158**] - cystoprostatectomy by Dr. [**Last Name (STitle) 7391**] revealed bladder TCC invading the lamina propria involving intravesicular portion of the left ureter - [**2165**] - resection for local recurrence. - [**10/2166**] - CT abdomen w hypodense liver lesion and mesenteric band-like nodularity in the right upper quadrant concerning for peritoneal carcinomatosis, pleural thickening along the ascending colon. - [**11/2166**] - colonoscopy w severe narrowing at the hepatic flexure [**12-25**] extrinsic compression, CT torso and MRCP demonstrated regular hypoenhancing mass centered within the gallbladder fossa and infiltrating portions of the right and left hepatic lobes, extending to hepatic flexure most c/w gallbladder cancer, also w loss of intervening fat plane between the extension of the tumor out of the liver and the hepatic flexure and duodenal bulb, intrahepatic bile duct dilation, extrinsic compression of the hepatic duct, and enhancing soft tissue nodules in the greater omentum consistent with peritoneal carcinomatosis. - [**2166-12-30**] - CT-guided liver biopsy carcinoma with clear cell features diffusely positive for cytokeratin cocktail and cytokeratin 7 and negative for Hep Par 1 packs 2 TTF-1, cytokeratin 20 and P63 most compatible with a tumor of biliary pancreatic or upper gastrointestinal origin - [**2167-1-5**] - KUB partial small-bowel obstruction - [**2167-1-9**] - Gemzar/cisplatin started - [**2167-1-20**] - Presentation w abd pain and elevated bilirubin, ERCP w 12mm long segment of severe narrowing, sphincterotomy and placement of WallFlex TM biliary RX uncovered stent . PAST MEDICAL HISTORY - Metastatic gallbladder cancer - Recurrent bladder CA s/p primary resection ([**2159**]), penile/urethral metastatsis resection ([**2165**]) - HTN - HLD - LVH w mild LVOT obstruction and mildly dilated thoracic aorta - h/o cystectomy - h/o resection penile recurrence Social History: Lives with wife in [**Name (NI) 86**]. Emigrated from [**Country 532**] remotely. Retired engineer. Quit tobacco 20+ years ago, 36 pack years. Denies EtOH, denies illicits. Family History: Father with bladder cancer. Mother with either CVA or MI. Physical Exam: ADMISSION EXAM: . General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, LIJ in place Lungs: Coarse breath sounds bilaterally CV: Tachycardic, regular, normal S1 + S2, no murmurs, rubs, gallops Abdomen: distended, diffusely tender, especially in RUQ, very quiet bowel sounds, +guarding in RUQ, urinary ostomy bag in place with yellow urine. Ext: warm, well perfused, 2+ pulses, 3+ bilateral lower extremity edema Neuro: CN II-XII intact. Moving all extremities . DISCHARGE EXAM: . Pertinent Results: ADMISSION LABS: . [**2167-1-24**] 07:30AM BLOOD WBC-6.9# RBC-5.02 Hgb-11.3* Hct-34.4* MCV-69* MCH-22.5* MCHC-32.8 RDW-17.1* Plt Ct-1000*# [**2167-1-24**] 07:30AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-2+ Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-2+ Acantho-2+ Ellipto-2+ [**2167-1-24**] 07:30AM BLOOD PT-15.2* PTT-28.1 INR(PT)-1.4* [**2167-1-24**] 07:30AM BLOOD Glucose-110* UreaN-23* Creat-1.4* Na-136 K-4.1 Cl-97 HCO3-23 AnGap-20 [**2167-1-24**] 07:30AM BLOOD ALT-16 AST-15 AlkPhos-675* TotBili-2.5* [**2167-1-24**] 07:30AM BLOOD proBNP-1532* [**2167-1-24**] 07:30AM BLOOD cTropnT-<0.01 [**2167-1-24**] 12:44PM BLOOD CK-MB-1 cTropnT-<0.01 [**2167-1-24**] 05:17PM BLOOD CK-MB-1 cTropnT-<0.01 [**2167-1-24**] 07:30AM BLOOD Albumin-2.6* [**2167-1-24**] 07:49AM BLOOD Lactate-5.1* [**2167-1-24**] 01:05PM BLOOD freeCa-1.03* . MICROBIOLOGY: . [**2167-1-24**] Urine culture - pending [**2167-1-24**] Blood culture (x 2) - pending [**2167-1-24**] MRSA screen - pending . IMAGING STUDIES: . [**2167-1-24**] CHEST (PORTABLE AP) - Slight prominence of the hila, could be due to vascular engorgement. Bibasilar opacities could represent atelectasis, aspiration, or infection in the appropriate clinical setting. . [**2167-1-24**] CT ABD & PELVIS W/O CON - Moderate-sized right and a small left pleural effusion, with bibasilar compressive atelectasis. Patchy opacities in the left lower lobe, concerning for acute infection/aspiration. known infiltrating gallbladder fossa mass, allowing for differences in Technique is similar to the prior study. Infiltration of the gastric antrum and ascending colon, with resultant gastric outlet obstruction. Moderate-to-large volume ascites, consistent with worsening omental metastatic disease, which is suboptimally assessed in this non-contrast study. Additional hypodense liver lesion, likely cysts. Lack of air within the biliary stent and left lobe of liver suggests stent occlusion. Interval improvement in the previously noted left hydroureteronephrosis in this patient status post urinary diversion and ileal conduit. . [**2167-1-24**] DUPLEX DOPP ABD/PEL POR AND LIVER OR GALLBLADDER US - Please note, patient had difficulty remaining in left lateral decubitus after obtaining only sagittal images, at which point the decision was made to transfer to the right lateral decubitus position. After obtaining left-sided images, patient was able to again return to left lateral decubitus position, at which point the right-sided transverse images were acquired. The right kidney measures 11.5 cm. The left kidney measures 10 cm. There is no evidence of hydronephrosis, stones, or masses. Patient is status post urinary diversion and ileal conduit. No bladder assessment performed. Significant ascites idenitifed throughout the abdomen. Brief Hospital Course: IMPRESSION: 75M with PMH significant for metastatic gallbladder carcinoma, bladder carcinoma (s/p primary resection with ileal conduit formation), hypertension and hyperlipidemia with recent hospitalization for ERCP in the setting of biliary stricture with metal stent deployment complicated by post-procedural pancreatitis and evidence of DVTs who now presents with nausea, emesis and hypotension concerning for septic shock requiring pressor support with evolving pneumonia, acute renal insufficiency and hyperbilirubinemia. Given worsening clinical status despite aggressive resuscitation and pressors, patient was transitioned to comfort measures only and expired on [**2167-1-27**]. . # ACUTE HYPOXIC RESPIRATORY FAILURE - Following volume resuscitation needs given his septic shock, the patient developed worsening respiratory concerns and hypoxia with an increased oxygen requirement. His CXR imaging demonstrated marked pleural effusions. After discussion with the family, it was clarified that he would not want to be intubated, thus he was made comfortable on supportive oxygen. . # SHOCK - Presented with hypotension and evidence of volume depletion with leukocytosis and bandemia in the setting of metastatic gallbladder carcinoma, with acute renal insufficiency and hyperbilirubinemia. Shock appears distributive or vasodilatory in the setting of sepsis. Possible sources of infection include: biliary obstruction or stent obstruction with gram negative or anaerobic enteric seeding vs. aspiration pneumonitis (CT imaging showed LLL opacification) or pneumonia vs. urinary tract infection. Patient was empirically antibiosed with Vancomycin, Levofloxacin and Zosyn. Lactate 5.1 on admission, trending downward with IV fluid resuscitation. Following aggressive volume resuscitation, his hypotension and tachycardia improved and his pressor support was weaned. His serial lactate and central venous oxygen saturations improved with broad spectrum antibiotics - Vancomycin, Levofloxacin and Zosyn (started [**2167-1-24**]). ACS surgery had been consulted given his evidence of delayed emptying and possible gastric obstruction with known biliary obstruction and felt no surgical intervention was feasible. They recommended palliation with possible duodental stent placement in discussion with the gastroenterology team based on his imaging findings. His imaging showed evidence of gastric antral obstruction. Given his overall poor prognosis, the family opted to enagage comfort measures only and a Dilaudid infusion was started. . # NAUSEA, EMESIS AND GASTRIC OUTLET OBSTRUCTION - CT imaging revealed tumor that extends to the gastric antrum and hepatic flexure with mildly distended stomach and some fluid in the lower esophagus; possibly related to partial gastric antral obstruction vs. delayed transit and slow emptying given his nausea and bilious emesis concerns. NGT remains in place. Evidence of tumor causing obstruction without definable surgical options - would likely require palliative stenting. ERCP 2-days prior allowed passage of endoscope to the level of the duodenum for biliary stenting, now with evidence of on-going obstruction. ACS surgery had been consulted given his evidence of delayed emptying and possible gastric obstruction with known biliary obstruction and felt no surgical intervention was feasible. ERCP team was also notified. Given his overall poor prognosis, the family opted to enagage comfort measures only and a Dilaudid infusion was started. . # ACUTE RENAL INSUFFICIENCY - Patient presents with baseline creatinine of 0.7-0.9 now with admission creatinine of 1.4 in the setting of septic shock, hypotension and low urine output. This likely represents poor forward flow and hypoperfusion with pre-renal azotemia in the setting of vasodilation and sepsis physiology generating hypotension. ATN certainly could have developed in the this time frame. Following fluid resuscitation, his creatinine continued to worsen. . # ASCITES - Likely malignant in the setting of know gallbladder carcinoma with metastatic involvement. Now with septic shock picture in the setting of multiple sources of infection. His RUQ ultrasound showed concern for no pneumobilia with possble obstruction at the level of his biliary stent. . # METASTATIC GALLBLADDER CARCINOMA, BLADDER CANCER - Metastatic gallbladder carcinoma currently receiving Gemzar/Cisplatinum. Bladder carcinoma treated with primary resection and cystectomy with ileal conduit. His outpatient Oncologist was notified of the admission and discussed with the family the overall very poor prognosis. Comfort measures were employed following that discussion. . # DEEP VENOUS THROMBOSES - DVT in both posterior tibial veins on the right and one posterior tibial vein on the left in 2/29. Heparin gtt started this admission (switched from Lovenox given renal dysfunction). He was maintained on a heparin gtt until comfort measures were established. . # HYPERTENSION - Hypotensive in the setting of sepsis, as noted above. Holding Metoprolol, Verapamil, Lisinopril. . Medications on Admission: Medications (per recent discharge summary) - enoxaparin 70mg q12hrs - metoprolol succinate 50mg daily - verapamil 120mg Extended Release daily - docusate sodium 100mg [**Hospital1 **] - senna [**Hospital1 **] - polyethylene glycol daily - oxycodone 5mg q6hrs prn - omeprazole 20mg daily - lisinopril 20mg daily - baclofen 10mg [**Hospital1 **] prn hiccups Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: septic shock and metastatic gallbladder cancer Discharge Condition: expired Discharge Instructions: patient expired on [**2167-1-27**]. Followup Instructions: none

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icd9cm

[ [ [] ] ]

[ "38.93", "38.91" ]

icd9pcs

[ [ [] ] ]

15402, 15411

9906, 14967

348, 391

15502, 15512

7108, 7108

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265, 310

419, 4000

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4315, 6256

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65,558

174,246

39906

Discharge summary

report

Admission Date: [**2188-10-14**] Discharge Date: [**2188-11-14**] Date of Birth: [**2121-1-11**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: Pancreatitis Major Surgical or Invasive Procedure: None History of Present Illness: 67 F transferred to ICU from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with gallstone pancreatitis complicated by acute renal failure and respiratory failure requiring intubation. Patient was initially admitted on [**10-9**] for abdominal pain w/ CT showing gallstones, dilated CBD and pancreatic ducts, pancreatitis, probable common duct stone, and small-mod ascites. Admitted and started on Zosyn. On arrrival, labs were WBC 19K, AP 120, AST 223, ALT 142, Tbili 1.9, amylase 993, and lipase 2200. She was then transferred to [**Hospital1 18**] for [**Hospital1 **] on [**10-9**]. During the procedure, the ampulla was found to be edematous and boggy, preventing a sphincterotomy and a 10F 7 cm plastic stent was placed; mild sludge was seen with bile flow into the duodenum. After the procedure, patient returned to [**Hospital3 26615**]. Labs after procedure: Tbili 3.1, AST 89, ALT 155, [**Doctor First Name **] 1120, Lip 1375, WBC 26k (60 segs, 34 bands). Hypocalcemic to 6.4. On [**10-10**], patient was noted to be in respiratory distress w/ CXR showing bilateral pleural effusions L>R, but did not require intubation. On [**10-11**] labs continued to trend down: Tbili 2.4, [**Doctor First Name **] 604, and Lip 492. Patient received PICC for TPN but unclear if TPN administered. Urine output continued to decrease and creatinine continued to increase: BUN/Cr 54/2.1 on [**10-12**] and 69/3.0 on [**10-13**]. Urine output did not respond to diuretics and diagnosed with ARF w/ possible ATN. During stay, patient received a significant fluid volume: admission weight was 79 kg and transfer note describes 40 kg weight gain. The morning of [**10-14**] patient was in worse respiratory distress with a pCO2 of 65 and was consequently intubated. CXR showed slight increase in R-sided pleural effusion. Patient was transferred in the afternoon due to need to greater acuity of care and consideration of surgical options. Past Medical History: obesity, seasonal allergies tonsillectomy, cesarean section, appendectomy Social History: no tobacco, rare EtOH Family History: neg for pancreatic or liver diseases Physical Exam: T 99.6 HR 100 BP 112/46 RR 14 SpO2 93% on 50% FIO2 gen: sedated, intubated, not arousable to voice cardiac: tachycardic, no M/R/G chest: scattered rhonchi abd: distended, + BS, unable to assess tenderness ext: pitting edema, anasarca Pertinent Results: ON ADMISSION: CBC: WBC-20.8 Hgb-10.4 Hct-30.0 Plt Ct-197 Chem: Glucose-113 UreaN-99 Creat-4.5 Na-133 K-5.2 Cl-101 HCO3-20 AnGap-17 LFTs: ALT-21 AST-41 AlkPhos-103 Amylase-47 TotBili-1.6 Blood and Urine culture: NO GROWTH CT Scan (Noncontrast): 1. Pancreatitis with significant fat stranding increased as compared to the previous study, no focal fluid collection 2. Free fluid in the anterior perihepatic space, anterior to the pancreas and in the pelvis. 3. Dilated small bowel loops likely related to ileus. 4. Cholelithiasis. 5. Bilateral basal collapse/consolidations with pleural effusions. 6. Anasarca DURING ADMISSION: [**2188-10-20**] Hep B Panel: HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE\ [**2188-10-20**] C diff toxin: POSITIVE [**2188-10-28**] Urine Culture: E coli >100,000 ORGANISMS/ML AMPICILLIN------------ 16 I AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ON DISCHARGE: Brief Hospital Course: Ms. [**Known lastname **] was admitted to the TSICU on [**2188-10-14**] for treatment of acute gallstone pancreatitis complicated by respiratory and renal failure. She was transferred to the floor on [**2188-10-27**] and recovered well during the remainder of her stay. Her hospital course is described by system below. Neuro: Patient's sedation was weaned in ICU, although patient's mental status was slow to improve with minial responsiveness until HD4 when she began to follow commands. After transfer to floor, patient's mental status improved dramatically with ability to follow commands and communicate appropriately. She was oriented x3 for most of the time, but had episodes of dilirium that gradually decreased in frequency. Her pain was well controlled with IV dilaudid initially and later with tylenol and po oxycodone. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Patient was hemodynamically stable throughout ultafiltration and dialysis. Pulmonary: The patient's asthma was managed with albuterol inhalers with Duonebs for persistent wheezing. GI: Pancreatitis steadily resolved throughout hospitalization as evidenced by decrease in amylase/lipase, improvement in pain, and increased po tolerance. Patient was treated with tube feeds through NG tube while in ICU and later with TPN on the floor while abdominal pain resolved. NG tube was removed on [**2188-10-25**] after patient began to pass flatus. She underwent a speech/swallow study on [**2188-10-29**] after improvement in mental status and was able to tolerate liquids and solids without evidence of aspiration. She was started on clear liquids on [**10-30**] which she tolerated well but was reverted back to sips because of abdominal pain. Diet was kept at sips. Patient will ultimately need a cholecystectomy, however given acute medical issues currently, will reasses in [**1-30**] weeks and determine optimal surgical time. GU: Patient was transferred in acute renal failure, essentially anuric and grossly fluid overload with anasarca. Lasix diuresis was attempted, however patient did not respond. CVVH was started on [**2188-10-16**] with 3L extracted daily. Intermittent HD was started on [**2188-10-19**] for continued ultrafiltration and treatment of hyperkalemia. Renal team was consulted throughout this period and recommendations for treatment of likely ATN were followed daily. By [**2188-10-29**], patient's Cr, K, and phos began to normalize and patient started making urine. Her renal funtion improved gradually,no longer requiring dialysis. Her foley was d/ced on [**2188-11-12**].She was able to void witout any difficulty. ID: On arrival, patient was afebrile with negative blood cultures and no evidence of infected fluid collections on CT scan. However, WBC count continued to rise daily and peaked at 36.2. Although patient was not having diarrhea, Cdiff was sent and found to be positive. Patient was started on po vanc via NG tube while in ICU with improvement in CBC. When NG tube was dced, patient was switched to IV flagyl. After transfer to floor, patient's WBC began to rise again although she remained afebrile. U/A was positive and empiric cipro was started. Urine culture grew [**First Name9 (NamePattern2) **] [**Last Name (un) 36**] to cipro and patient completed 3 day course of treatment. IV flagyl was changed to po vanc on [**2188-10-28**] after patient passed speech/swallow study.Her antibiotics were discontinued on [**2188-10-12**]. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. On the day of discharge the patient was on TPN,sips, needed help with ambulation,voiding spontaneously and the pain was well controlled. Medications on Admission: claritin prn Discharge Medications: 1. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 2. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation QID (4 times a day). 3. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 4. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. 5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. 8. insulin regular human 100 unit/mL Cartridge Sig: insulin sliding scale Injection qid. 9. TPN TPN via PICC Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: gallstone pancreatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**5-5**] 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. Followup Instructions: Please call Dr[**Name (NI) 2829**] office at ([**Telephone/Fax (1) 2363**] to schedule an appointment in [**1-30**] weeks Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2188-11-27**] 1:00 Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2188-11-27**] 1:00

[ "041.4", "008.45", "995.94", "276.7", "584.5", "276.69", "276.0", "577.0", "599.0", "493.90", "293.0", "729.73", "518.81", "427.1", "574.20" ]

icd9cm

[ [ [] ] ]

[ "39.95", "96.72", "96.6", "99.15", "45.24", "38.97" ]

icd9pcs

[ [ [] ] ]

8687, 8734

3988, 7774

328, 334

8801, 8801

2772, 2772

9554, 9912

2463, 2502

7838, 8664

8755, 8780

7800, 7815

8952, 9531

2517, 2753

3965, 3965

276, 290

362, 2311

2786, 3949

8816, 8928

2333, 2408

2424, 2447

18,776

195,218

49953+59189

Discharge summary

report+addendum

Admission Date: [**2136-4-30**] Discharge Date: [**2136-4-30**] Date of Birth: [**2087-3-10**] Sex: F Service: MEDICINE Allergies: Pneumovax 23 / Phenothiazines / Influenza Virus Vaccines Attending:[**First Name3 (LF) 443**] Chief Complaint: Palpitations, chest pressure, SOB Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: Patient is a 49 yo woman w/ h/o Hodkin's Lymphom, s/p XRT to chest and chemotherapy who was in USOH until the evening of [**4-30**] when she developed palpitations and shaking. The patient reports that she was feeling well while outside gardening this afternoon. While gardening she noted many insect bites on her body. Following this she had some pain in her L hip and placed a lidocaine patch on her leg at which point she felt as if her heart was racing. She removed the patch and took a shower without improvement in her symptoms. When she continued to feel unwell and brought herself to the emergency department. . Pt presented to [**Hospital1 **] [**Location (un) 620**] ER at 11:55PM, where was noted to be tachycardic with HR 110's-120's, other VSS. Pt was initially given benadryl + solumedrol + epinephrine (thought ?allergic rxn). After arrival to the ED she developed severe substernal chest pressure and SOB. She denied associated nausea, diaphoresis and lighheadedness. [**Location (un) **] was done and noted to have R axis deviation, STE in I and aVF w/ ST depressions in inferolateral leads. Pt was then given baby ASA x 4, lopressor 5mg IV x 1, NTG SL x 2, morphine 2mg IV x 1, and started on heparin gtt. CXR there was ?c/w pulmonary edema per report. She was then transferred to [**Hospital1 18**] [**Location (un) **] for cardiac cath. . Upon arrival here, pt was noted to be tachycardic, O2 sat ranged from mid 80's - 90's on [**Last Name (LF) **], [**First Name3 (LF) **] was placed on O2. Cardiac cath demonstrated clean coronary arteries. R heart cath demonstrated: RA mean 9, RV 41/4, PCWP 25, PAP 41/31, PA sat was 73%, CO 8.7, CI 4.77. Initial ECHO was concerning for MR, but intra-cath LV gram demonstrated only mild MR. [**First Name (Titles) **] [**Last Name (Titles) **] with good lead placement in cath lab was normal. Pt was kept on heparin gtt and transferred to CCU for further w/u of ?PE. Currently the patient feels "much better". She denies chest pain, SOB, palpitations, or other complaints. Past Medical History: -H/o Hodgkin's Lymphoma s/p XRT and chemotherapy -H/o multinodular thyroid goider, s/p thyroidectomy w/ resultant hypothyroidism, hypoparathyroidism -Osteoporosis s/p L hip fracture -s/p splenectomy Social History: She denies tobacco use. Drinks alcohol socially. Denies illicit drug use. She lives with her 14 year old daughter. She owns a retail store in [**Location (un) 620**]. Family History: Positive for CAD in her father. Physical Exam: VS: T 98 BP 141/77 HR 102 RR 18 96% 6L O2 Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 6 cm. CV: PMI located in 5th intercostal space, midclavicular line. Tachy, regular, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. R groin sheath in place 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: [**Location (un) **] at OSH: sinus tachycardia at 132 bpm, ST elevations in I, [**Last Name (LF) **], [**First Name3 (LF) **] depressions in V4-V6 . Admission [**First Name3 (LF) **]: sinus rhythm at 105 bpm, no ST changes . TELEMETRY demonstrated: NSR . CARDIAC CATH performed on [**2136-4-30**] demonstrated: clean coronary arteries. R heart cath demonstrated: RA mean 9, RV 41/4, PCWP 25, PAP 41/31, PA sat was 73%, CO 8.7, CI 4.77. . CXR: Per report, OSH CXR w/ pulmonary edema . LABORATORY DATA OSH: WBC 13.3 w/ 70.9 N, 18.9 L, 8.8 M, 0.8 E, 0.7 B (?drawn b/f or after solumedrol), Hgb 10.7, Hct 31.9, Plts 353, Na 139, K 3.1, Cl 101, bicarb 26.9, BUN 19, Cr 1.0, Gluc 158, Ca 6.9, TSH 0.547 CK 211 Troponin T < 0.01 CK-MB 0.8 Brief Hospital Course: Pt is a 49 yo woman w/ h/o Hodkin's Lymphoma, s/p XRT to chest and chemotherapy who p/w CP and palpitations, found to have high filling pressures on R heart cath. . 1) Pump/hemodynamics: Pt found to have elvated PAP and PCWP on cardiac cath today. Otherwise high CO. Unclear etiology at this time. ?PE, as pt presented w/ palpitations and CP and w/ high filling pressures, but would have expected low CO. TSH was low/nl at OSH. Patient was briefly on hep gtt for empiric rx of PE until CTA of the chest came back negative for PE. TSH was rechecked during this admission and came back at 0.28. Patient was monitored on tele and discharged chest pain free and hemodynamically stable. There was 1+ MR on LV-gram. The patient should have an outpatient echo in [**1-8**] weeks after discharge in order to assess for any MV prolaps or other valvular dysfunction. . 2) CAD: No CAD on cardiac cath. CP resolved. . 3) Rhythm: Pt persistently tachycardic. Patient appears to be tachycardic at baseline. Etiology could be thyroid disease vs. anxiety vs. infection vs. PE. ?continued tachycardia [**1-6**] epi given at OSH. Patient was monitored on telemetry. Patient remained slightly tachycardic (sinus) which seems to be her baseline. TSH was rechecked during this admission and came back at 0.28. . 4) Hypoxia: Patient had desats to mid-80s on RA per OSH record. Continued to have oxygen requirement initially. Etiology infection vs. PE vs. edema. CXR from OSH c/w edema. Also has high filling pressures on cath. ? pulm. edema following IVF bolus and epi at OSH. No recent symptoms suggestive of infection. CTA came back negative for PE. Lasix prn, but patient was autodiuresing and off oxygen upon discharge. . 5) Hypothyroidism: Continued outpt levoxyl. Rechecked TSH which came back at 0.28. Further follow up is recommended as an outpatient given that the level was on the lower end of normal. . 6) S/p L hip fracture: Continued percocet prn. . 7) FEN: Reg low salt diet, monitored and repleted lytes PRN. . 8) PPX: hep gtt briefly, then Heparin sc. . 9) Access: PIV . 10) Code: Full Medications on Admission: Lidocaine 5% patch prn Levoxyl 125mcg daily Percocet prn Rocaltrol 0.5mcg daily Forteo 20mcg SC daily Calcium Discharge Medications: 1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Calcitriol 0.25 mcg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Topical once a day as needed for pain. 6. Forteo 750 mcg/3 mL Pen Injector Sig: Twenty (20) mcg Subcutaneous once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. Chest pain, s/p cardiac cath with clean coronaries and negative CTA 2. Sinus Tachycardia 3. 1+ Mitral regurgitation on LV-gram . Secondary Diagnosis: 1. H/o Hodgkin's disease s/p XRT and chemo 2. s/p Hip fracture (left) on narcotics prn 3. Osteoporosis Discharge Condition: Afebrile. Hemodynamically stable. Ambulating. Tolerating PO. Discharge Instructions: You have been evaluated for chest pain. A cardiac catheterization has been performed but did not show any narrowing or occlusion of your coronary arteries. You also received a CT study to rule out a clot in your lungs which was negative. . Please call your primary doctor or return to the ED with fever, chills, chest pain, shortness of breath, 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: Please follow up with your primary care doctor ([**Last Name (LF) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 3070**]) in [**12-6**] weeks from now. . Please also schedule an outpatient echocardiogram (ultrasound study of your heart) in [**1-8**] weeks from now to assess your valves (there was a small leak of one of your valves, the mitral valve, which should be followed up). Please have your PCP schedule an appointment for the echocardiogram or call [**Hospital1 18**] at ([**Telephone/Fax (1) 27177**] to schedule an appointment on the [**Hospital Ward Name 516**] (you were discharged on a holiday and no appointments could be made). Name: [**Last Name (LF) 16798**],[**Known firstname 16799**] Unit No: [**Numeric Identifier 16800**] Admission Date: [**2136-4-30**] Discharge Date: [**2136-4-30**] Date of Birth: [**2087-3-10**] Sex: F Service: MEDICINE Allergies: Pneumovax 23 / Phenothiazines / Influenza Virus Vaccines Attending:[**First Name3 (LF) 3780**] Addendum: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from [**Hospital1 **] [**Location (un) 407**] called at 10PM on [**2136-4-30**] after discharge of the patient to clarify that the patient did not recieve epinephrin at the OSH as erroneously stated in the discharge summary. The patient did also not recieve an IVF bolus per Dr. [**Last Name (STitle) **]. He instead speculated coronary vasospasms responsible for her symptoms and gave nitro. Discharge Disposition: Home [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3782**] MD [**MD Number(2) 3783**] Completed by:[**2136-4-30**]

[ "V10.72", "799.02", "427.89", "244.0", "733.00", "786.50" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

9842, 10005

4566, 6649

350, 375

7678, 7740

3809, 4543

8309, 9819

2860, 2893

6810, 7329

7379, 7379

6675, 6787

7764, 8286

2908, 3790

277, 312

403, 2437

7552, 7657

7398, 7531

2459, 2660

2676, 2844

55,141

133,088

50523

Discharge summary

report

Admission Date: [**2152-6-23**] Discharge Date: [**2152-6-25**] Date of Birth: [**2082-5-7**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: flu like symptoms Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 33559**] is a 70 yo M w/ h/o BPPV, HTN who p/w 18 days of flu-like symptoms which got better then worse over 5 days + dry cough, intermittend abd pain, night sweats, low volume dark urine, poor PO intake, malaise, headache, myalgias. Pt also endorses low-grade fevers ?100.4 intermittently. CXR was ordered on [**6-23**] by pt's PCP which showed [**Name Initial (PRE) **] retrocardiac opacity. Apparently, the pt checked this online and self-referred to the ED. . On arrival to the ED, his vitals were T 98.0 HR 146 BP 91/63 R 12 O2 sat 97% on RA. By the time he was placed in a room, his temp had risen to 101.7. EKG initially showed SVT and he was given 6mg adenosine and HR fell to 110s and BPs to 110/70. Then, he reverted back to SVT. But the ED team did not feel further dosage of adenosine was needed. He got 9L IVF in ED with minimal UOP. A foley was then placed and his UOP was 100cc prior to transfer. The ED team thought the pt likely to be very dehydrated with fever and underlying PNA. CVL was placed for better access and levophed started which is running at 0.06 at time of transfer. . Prior to transfer from the ED, the pt is alert, oriented and conversational. His vitals are notable for HR 110s-130s, BP 96/74, 28, 99% on 2L NC. D-dimer was elevated in the ED and CTA chest was considered but not done due to concern over low UOP. Thus, CT abd was done on route to the ICU. Of note, pt also recieved levofloxacin, ceftriaxone, and tylenol in the ED. . On arrival to the ICU, pt c/o diaphoresis and mild abd pain but otherwise states he is feeling much better Past Medical History: Hypertension BPPV- symptoms at present are different. Social History: Lives with his wife who has [**Name (NI) 5895**] Disease (followed by Dr. [**Last Name (STitle) **] at [**Hospital1 18**]), pt owns his own law firm specializing in environmental law. Smoked a pipe x 10years, quit in his 20's, no illicit or IV drug use. Family History: Father- died of COPD, ETOH abuse Mother- alive in good health at age [**Age over 90 **] Sister- d. suicide. had schizophrenia Sister- alive and well Pertinent Results: CXR PA/LAT: FINDINGS: In comparison with the study of [**2150-9-18**], there is continued atelectasis or scarring at the left base with low lung volumes. On the lateral view, there is some suggestion of increased opacification just behind the cardiac silhouette. This is not confirmed on the frontal projection. However, in view of the clinical symptoms, this could represent a focus of pneumonia. No vascular congestion or pleural effusion. Remainder of the lungs is clear. . EKG: multiple EKGs came with pt from ED all taked btwn 8p and 9p at rates 130-150s and all with what looks like accelerated junctional rhythm. left axis deviation, nl QRS. J point elecation in V3,4. TWI in V1. No ST changes. Poor R wave progression. Baseline EKG from 1 yr ago NSR. [**2152-6-23**] 01:30PM WBC-6.8 RBC-4.34* HGB-13.1* HCT-39.7* MCV-92 MCH-30.1 MCHC-32.9 RDW-13.1 [**2152-6-23**] 01:30PM NEUTS-84* BANDS-0 LYMPHS-10* MONOS-3 EOS-0 BASOS-0 ATYPS-3* METAS-0 MYELOS-0 [**2152-6-23**] 01:30PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2152-6-23**] 01:30PM PLT SMR-LOW PLT COUNT-110* [**2152-6-23**] 01:30PM SED RATE-50* [**2152-6-23**] 01:30PM UREA N-22* CREAT-1.4* SODIUM-135 POTASSIUM-4.0 CHLORIDE-96 TOTAL CO2-26 ANION GAP-17 [**2152-6-23**] 01:30PM ALT(SGPT)-23 AST(SGOT)-20 LD(LDH)-207 ALK PHOS-150* TOT BILI-0.5 Brief Hospital Course: Pneumonia: Admitted with left lower lobe consolidation, CAP, treated with CTX and azithromycin. Cultures negative to date at time of discharge, legionella urine antigen negative. Discharged with 7 day course of azithromycin. Hypotension: Profound hypovolemia in setting of CAP, initially requiring pressors following ~10 L fluid resucitation. Cultures negative, biomarkers negative. Tolerating POs, blood pressure stable at time of discharge. In ED, with run of SVT, resolved on arrival to floor with IVF. As noted, biomarkers negative. Inpatient cardiology evaluation deferred given restoration and maintenance of sinus rhythm. [**Month (only) 116**] benefit from outpt holter/cardiology evaluation +/ beta blockade if tachyarrhythmia is a recurrent issue. Pancreatic mass: Question of pancreatic headmass on CT. LFTs within normal limits, pancreatic enzymes also wnl. MRCP performed, official read pending at time of discharge. Pt will follow up with his PCP to discuss results. He may need an outpt ERCP if findings suggest malignancy. Medications on Admission: Aspirin 81mg daily Prozac 20mg daily advil 400mg Q 4 prn (avg 1600mg/day for last 5 days) Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Azithromycin 500 mg Tablet Sig: One (1) Tablet PO once a day for 6 days. Disp:*6 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Pneumonia Hypovolemic shock Supraventricular tachycardia Secondary Hypertension Discharge Condition: Stable, afebrile, alert and oriented x 3, ambulatory Discharge Instructions: You were admitted with a pneumonia. Your low blood pressures were likely from dehydration related to your pneumonia. You were treated with antibiotics and you improved. As you know, an abnormality was noted in your pancreas on your CT scan and you had an imaging study called an MRCP, the radiology read for which is currently pending at the time of your discharge. As we discussed, you will follow up with your PCP next week to discuss these results. Please take the antibiotic, azithromycin as directed. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 58**] next week to follow up on the remainder of your culture results and your MRCP results. Completed by:[**2152-6-25**]

[ "785.59", "995.92", "038.9", "577.9", "401.9", "427.89", "584.9", "486" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

5381, 5387

3906, 4959

332, 339

5519, 5574

2505, 3883

6133, 6305

2336, 2486

5100, 5358

5408, 5498

4985, 5077

5598, 6110

275, 294

368, 1969

1991, 2047

2063, 2320

19,352

149,713

19417

Discharge summary

report

Admission Date: [**2176-7-2**] Discharge Date: [**2176-7-17**] Date of Birth: [**2112-12-9**] Sex: M Service: CARDIOTHORACIC Allergies: Hytrin Attending:[**First Name3 (LF) 2969**] Chief Complaint: Lung Mass Major Surgical or Invasive Procedure: Flexible broncoscopy Cervical Medistinscopy with LN biopsy right VATS wedge resection of RUL leison History of Present Illness: This is a 63 year old man who was found to have a RUL nodule on work up. He was evaluated in the thoracic clinic and the decision was made to remove this via a VATS wedge resection. In the interim, he presened to clinic and had an admisssion for effusion/pneumonia, the details of which can be found in a seperated discharge summary. Today, he presents in his baseline state of health, which is fairly poor (see PMH) for resection. Past Medical History: 1) Severe PVD, awaiting revascularization procedure in R lower extremity scheduled for [**11-23**]. Rest pain in RLE, with nonhealing right lateral foot ulcer 2) CAD (cath in [**2-7**] revealed mild CAD with EF 56%) 3) S/p multiple CVA, with residual left hemiparesis, complicated by seizure disorder 4) S/p L CEA on [**5-7**] 5) S/p L SC and R BC stents, on Plavix 6) Iron deficiency anemia diagnosed in [**6-7**], on iron supplementation 7) DM type 2 8) Gastritis, negative biopsy, history of + H. pylori s/p Rx [**6-/2175**] 9) Hyperlipidemia 10) Hypertension 11) + PPD and dynamic pulmonary nodule, sputum AFB negative X3 in [**8-/2175**], BAL AFB smear negative, negative for malignancy Social History: He lives with his wife. They have 2 sons, one who lives in the area. Ex-smoker, with 20-25 pack-year smoking history. No EtOH. Family History: Non-contributory. Physical Exam: 97.7 57 16 96%RA 137/42 NAD RRR CTA Abd: benign Ext: warm, well perfused Pertinent Results: [**2176-7-2**] 02:05PM GLUCOSE-244* UREA N-31* CREAT-0.9 SODIUM-136 POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-24 ANION GAP-16 [**2176-7-2**] 02:05PM CALCIUM-10.7* PHOSPHATE-4.2 MAGNESIUM-1.6 [**2176-7-2**] 02:05PM WBC-25.7*# HCT-40.9 [**2176-7-2**] 02:05PM PLT COUNT-265 Brief Hospital Course: The patient was admitted to the hospital after being kept in PACU overnight for cardiac monitoring (enzymes were negative x3). He was hep-locked on POD 1, and meds were given via his G-tube. On POD 1 he was trasferred to the CSRU for hypoxia, chest XR showed ? of hemothorax. Over the next 24 hrs he has a falling hematocrit, for which he was transfused PRBC and platelets due to his recent use of plavix. On the night of POD 2, the patient was intubated secondary to worsening pumonary function, worsening mental status and worsening CXR c/w hemothorax. On the AM on POD 3, he returned to the OR for VATS chest exploration which found gross hemothorax and oozing at his staple line. The details of this procedure can be found in the appropriate op-note. Post-operatively, he was returned to the unit. He was extubated on POD 1 and did well from this point, aggressive pulmonary toilet was initiated. His BP ran hign postoperativly, and his meds were adjusted appropriatly. He underwent broncoscopy in the unit which showed heme tinged secretions but no pna or gross plugging. He was being treated for pneumonia however with vancomycin, ceftaz, flagyl, and fluconazole (which is lifelong, per his [**Month/Day/Year 1106**] surgeon). Over the next few days he improved somewhat, but not enough to transfer to the floor. He then made gradual progress ove the next several days as his respiratory status and mental status began to markedly improve. On [**7-11**] his central line was removed and a PICC line was placed for longterm antibiotics. On [**7-12**] the patient had a fever to 102F and was pancultured with urine culture growing 10,000-100,000 yeast. The remainder of the cultures were unremarkable and two of the blood cultures are still pending at this time though are no growth to date. Also, on [**7-12**] the patient had a video swallow study performed that he failed and thus had to remain NPO. At this time it was determined that use of the PEG be the means to continue enteral feeding and to give medications. The patient was continued on tubefeeds of promote with fiber at 55mL per hour as the goal rate. On [**7-14**] the patient was deemed fit for discharge to the floor as he had now improved remarkably and was off the ventilator. Also of note the patient did receive occasional doses of lasix 20mg to keep his fluid balance even as measured over 24 hour periods. The patient then had another oral and pharyngeal swallow study performed on [**7-16**] and again failed and the patient remained NPO until the time of discharge. At the time of discharge the patient was noted to be significantly improved and to have regained baseline mental status and activity level, having worked with physical therapy. The patient was eager to eat though had to remain NPO as described above. He was also afebrile and was requiring minimal care of his wounds. Antibiotics were to be continued for pneumonia described above for a total of three weeks and fluconazole was to continue indefinitely. Medications on Admission: fluconazole 200 tums 500"" albuterol finasteride 5' diltiazem 30"" MVI Iron Protonix 40' quinine 325 hs colase novolin hydrazine hctz 25' asa 325' lipitor 80' percocet prn plavix 75' hep SQ mirtazapine 15' procrit 10K per week glyburide 5" lopressor 100''' Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 2. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Five (5) ml PO BID (2 times a day). 3. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) ml PO BID (2 times a day). 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 5. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation Q6H (every 6 hours) as needed. 6. Novolin R 100 unit/mL Solution Sig: Four (4) units Injection Q lunch: Also, novolin sliding scale as included. 7. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q6H (every 6 hours). 8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 13. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. 14. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One (1) Packet PO BID (2 times a day). 15. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): NG. 16. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day). 17. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 20. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous Q 24H (Every 24 Hours) for 7 days: total 21 days- start [**7-4**]- end [**7-25**]. 21. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 22. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed: for PICC LIne. 23. Ceftazidime 1 g Recon Soln Sig: One (1) gram Intravenous three times a day for 7 days: 21 days course start [**7-4**]- end [**7-25**]. 24. medications pt is aspiration risk--no meds to be given po all meds to be given via NG or IV Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 730**] [**Last Name (NamePattern1) 731**] Discharge Diagnosis: Lung Cancer type 2 diabetes Hx CVA seizure dz peripheral [**Last Name (NamePattern1) 1106**] disease gastritis hypertension hypercholesteremia Discharge Condition: Good Discharge Instructions: You should call Dr.[**Doctor Last Name 4738**] office if you experience increasing pain, especially in the chest, shortness of breath, redness or drainage from your wound sites. Fever >101.4 is concerning and should be evaluated. Followup Instructions: You should see Dr. [**Last Name (STitle) **] in 1 [**2-5**] to 2 weeks, call his office for an appointment. ([**Telephone/Fax (1) 1504**]

[ "482.41", "707.04", "285.1", "197.2", "162.3", "V44.1", "V09.0", "518.5", "511.8", "198.89", "998.11", "482.82", "707.03", "112.2" ]

icd9cm

[ [ [] ] ]

[ "96.05", "96.71", "99.05", "34.4", "96.6", "34.21", "38.93", "32.29", "96.04", "40.3", "99.04" ]

icd9pcs

[ [ [] ] ]

7736, 7834

2154, 5180

282, 384

8021, 8028

1856, 2131

8307, 8449

1726, 1745

5487, 7713

7855, 8000

5206, 5464

8052, 8284

1760, 1837

233, 244

412, 848

870, 1564

1580, 1710

31,509

162,560

34797

Discharge summary

report

Admission Date: [**2126-8-27**] Discharge Date: [**2126-9-2**] Date of Birth: [**2053-7-20**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: Respiratory distress, cardiac arrest Major Surgical or Invasive Procedure: Cardiac catheterization with drug-eluting stent History of Present Illness: Ms. [**Known lastname 79692**] is a 73yo woman with h/o DM2, CHF, and HTN who presented to [**Hospital3 **]w/ respiratory distress with subsequent asystolic cardiac arrest. . Per EMS records, she was having difficulty breathing this morning at midnight, about 1 hour after she had gone to bed. She woke up her daughter stating she couldn't breath. Per daughter, she has had a dry cough and has had worsening DOE. When EMS arrived, she was able to speak/answer questions but was in respiratory distress. Her vitals were BP 142/100 HR 140 RR 24 02sat <60 on RA. . On transport, the patient became unresponsive in the ambulance 2 min prior to arrival to the OSH. At the OSH her VS were T 98.1 BP 144/48 HR 30 RR 2 02sat 50% on NRB. The decision was made for emergent intubation. At this time, she went into asystolic arrest. CPR was initiated and atropine/epi were administered with return of pulse (her total arrest time was 1-2 min according to her daughter). She was intubated and set to Fi02 100% AC 600/15 with (ABG 7.26/36/88). A femoral line was placed. A CXR was read as bilateral fluffy infiltrates c/w volume overload vs ARDS. She was given vanc/zosyn. She became hypotensive to SBP of 70's and was started on a dopamine gtt. Soon after she went into a wide complex tachycardia; dopamine was stopped and she was started on an amio gtt (w/ 150mg bolus) with conversion back to sinus bradycardia. Pressor was changed to levophed. She was given ASA 300mg and transferred to [**Hospital1 18**]. . In the [**Hospital1 18**] ED, initial VS were: T 96.5 BP 93/23 HR 93 RR 17 02 sat 100% on vent. The levophed gtt was uptitrated [**3-16**] to hypotension. She was given atropine 0.5mg for HR "in the 50's" and amiodarone was stopped because of bradycardia. A RIJ was placed under sterile conditions. She was given levaquin x1. Cardiology was consulted and a bedside echo was done. Her CVP was 16 and SV02 was 80. Labs were significant for a WBC 31.3, lactate 2.5, proBNP 1065, trop T 0.06, and negative UA. . She was initially admitted to the MICU, where she was continued on levophed. She had an episode of hyperkalemia that was treated with calcium and dextrose. She received 20mg of IV lasix with 300cc Uop over the next few hours. Insulin gtt was started for improved glucose control. . Further review of systems not possible at this time. Past Medical History: Chronic systolic heart failure (LVEF of 40% from [**6-20**] echo) DM (non-compliant w/ meds) HTN recent D&C 3 weeks ago for uterine polyp (not malignant) recent hospitalization for SOB (in [**State 4260**]), intubation not required . Cardiac Risk Factors: (+)Diabetes, (?)Dyslipidemia, (+)Hypertension . Cardiac History: CABG: none . Percutaneous coronary intervention: none . Pacemaker/ICD: none Social History: Lives independently in [**State 4260**]. No tobacco, minimal alcohol. Family History: Non-contributory Physical Exam: VS: Tm=Tc 99.0, BP 113/43, HR 74, RR 27, O2 99% on AC 0.40 500/18 +10 Gen: Elderly woman, intubated and sedated. Withdraws from painful stimuli but not responsive to voice. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple; JVP not visible though patient has thick neck. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2, somewhat faint heart sounds. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Breathing comfortably with vent. Crackles L>R bases. No wheeze. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP Pertinent Results: [**2126-8-27**] 05:20AM BLOOD WBC-31.3* RBC-4.29 Hgb-13.1 Hct-38.7 MCV-90 MCH-30.6 MCHC-33.8 RDW-13.4 Plt Ct-508* [**2126-8-27**] 05:20AM BLOOD Neuts-92.9* Lymphs-4.2* Monos-2.6 Eos-0.2 Baso-0.1 [**2126-8-27**] 05:20AM BLOOD Glucose-399* UreaN-17 Creat-1.0 Na-136 K-5.3* Cl-105 HCO3-20* AnGap-16 [**2126-8-27**] 05:20AM BLOOD Calcium-8.2* Phos-4.1 Mg-1.6 [**2126-8-27**] 12:24PM BLOOD ALT-67* AST-38 LD(LDH)-255* AlkPhos-78 Amylase-221* TotBili-1.0 [**2126-8-27**] 05:20AM BLOOD CK(CPK)-208* [**2126-8-27**] 12:24PM BLOOD CK(CPK)-179* [**2126-8-27**] 09:38PM BLOOD CK(CPK)-282* [**2126-8-28**] 05:03AM BLOOD CK(CPK)-290* [**2126-8-28**] 09:42PM BLOOD CK(CPK)-381* [**2126-8-29**] 04:14AM BLOOD CK(CPK)-381* [**2126-8-29**] 01:56PM BLOOD CK(CPK)-361* [**2126-8-27**] 05:20AM BLOOD CK-MB-10 cTropnT-0.06* MB Indx-4.8 proBNP-1065* [**2126-8-27**] 12:24PM BLOOD CK-MB-9 cTropnT-0.08* [**2126-8-27**] 09:38PM BLOOD CK-MB-7 cTropnT-0.05* [**2126-8-28**] 05:03AM BLOOD CK-MB-5 cTropnT-0.06* [**2126-8-28**] 09:42PM BLOOD CK-MB-5 [**2126-8-29**] 04:14AM BLOOD CK-MB-4 cTropnT-0.05* [**2126-8-29**] 01:56PM BLOOD CK-MB-4 cTropnT-0.04* [**2126-9-1**] 06:40AM BLOOD WBC-12.9* RBC-3.21* Hgb-9.9* Hct-28.6* MCV-89 MCH-31.0 MCHC-34.8 RDW-13.7 Plt Ct-399 [**2126-9-1**] 05:25PM BLOOD Glucose-254* UreaN-16 Creat-1.0 Na-139 K-4.4 Cl-100 HCO3-27 AnGap-16 [**2126-9-1**] 05:25PM BLOOD Calcium-9.2 Phos-4.1 Mg-2.1 [**2126-8-27**] CXR 1. Ill-defined bilateral perihilar consolidations, differential includes ARDS and multifocal pneumonia. Acute cardiogenic pulmonary edema is possible, although the cardiac silhouette is not particularly enlarged, and clinical history is not entirely consistent with pulmonary edema. 2. 8-mm right lower lobe nodule is relatively [**Name2 (NI) 15410**], most probably representing a granuloma. When the patient is clinically able, CT could be performed to confirm this suspicion. [**2126-6-27**] EKG 00:42 NSR with RBBB and TWI in inferior leads. 02:58 Regular WCT at 154 with LBBB pattern, BP 110/40 03:05 Sinus brady at 56 with TWI in inferior leads and deep TWI in V1-V6, ? STD in V3-V6. 05:03 NSR with LAD and LBBB. 07:17 ? AFlutter (no p waves visible but regular rate at 63) 14:00 LBBB at 64, irreg irreg. [**2126-8-27**] 2D-ECHOCARDIOGRAM The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild to moderate regional left ventricular systolic dysfunction with septal and apical hypokinesis. LVEF 40%. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. [**2126-8-28**] CARDIAC CATH 1. Selective coronary angiography of this left dominant system revealed single vessel coronary artery disease. The LMCA was without angiographically apparent stenosis. The LAD revealed a mid 80% lesion after the second marginal. The Lcx and RCA and no angiographically apparent stenoses. 2. Resting Hemodynamics revealed elevated right and left sided filling pressures with a RVEDP of 15 mmHg and a PCWP of 19. PASP was mildly elevated at 40 mmHg. Systemic arterial pressures were normal on levophed. Cardiac index was preserved at 3.2L/min/m2. 3. Left Ventriculography was deferred. 4. Successful PTCA/stent to mid LAD with a 2.5x13mm Cypher stent. The second diagonal branch was compromised as a result and there was rescued and dilated with a 2.0mm balloon finishing with kissing balloon inflations in LAD and diagonal. Excellent result with normal flow and no residual stenosis. FINAL DIAGNOSIS: 1. Single vessel coronary artery disease. 2. Mild left ventricular diastolic dysfunction 3. Successful PTCA/stent to mid LAD with a drug eluting stent. [**2126-8-28**] CXR Still moderate pulmonary edema has markedly improved. ET tube, NG tube and right IJ catheter remain in place in standard positions. There are small bilateral pleural effusions, greater on the left side. Linear atelectases are in the bases bilaterally. [**2126-8-30**] CXR The patient was extubated in the meantime interval. The right internal jugular line tip terminates in mid distal SVC. The cardiomediastinal silhouette is stable. There is overall improvement in the left retrocardiac opacity consistent with partial resolution of atelectasis. The right lower lobe opacity is still present suggesting unresolved atelectasis as well. Minimal vascular engorgement is present in the perihilar area but no evidence of frank pulmonary edema is seen. [**2126-8-27**], [**2126-8-28**] BLOOD CULTURES: No growth [**2126-8-28**] RESPIRATORY CULTURE (Final [**2126-8-30**]): RARE GROWTH OROPHARYNGEAL FLORA. YEAST. RARE GROWTH. [**2126-8-27**] Right groin CATHETER TIP-IV WOUND CULTURE (Final [**2126-8-30**]): No significant growth. [**2126-8-28**] R IJ CATHETER TIP-IV WOUND CULTURE (Final [**2126-9-2**]): No significant growth. [**2126-9-1**] CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2126-9-2**]): Feces negative for C.difficile toxin A & B by EIA. Brief Hospital Course: A/P 73 yo woman with h/o DM, systolic CHF with EF 40%, and HTN who presented with respiratory distress requiring intubation complicated by asystolic cardiac arrest and s/p cath with DES to LAD. . # Acute on chronic systolic and diastolic heart failure: Recent admission for CHF exacerbation. At this admission, echo showed moderate regional left ventricular systolic dysfunction with septal and apical hypokinesis; LVEF 40%. Lung exam and lower extremity peripheral edema was consistent with fluid overload, which improved with diuresis. Pt was discharged in stable condition on her home dose of Lasix. . # CAD: CPK were elevated to 381 with normal CPK; trop was mildly elevated to 0.05. Cardiac cath showed a small LAD with 80% occlusion, and a drug-eluting stent was placed. It was thought that this lesion may have precipitated her cardiac arrest. Pt was medically maximized with ASA 325, plavix, high-dose statin, beta blocker, and ACE-I. Pt was discharged with cardiology follow-up and may need to be considered for a pacemaker in the future. . # Abdominal pain: Pt has a history of longstanding but stable LLQ pain which had been worked up in past at OSH. Her recent colonoscopy was unremarkable, and she is s/p D+C with normal findings per patient's report. She had no acute abdomen on exam. Her LFTs were notable only for mild transaminitis, ALT > AST which may be [**3-16**] to her acute cardiac event and decreased forward flow. She was noted to have guiac positive stools during this admission but her HCT was stable. She was restarted on her home dose iron and received colace for constipation prophylaxis, of note patient does not usually take colace. She subsequently developed diarrhea with an elevated WBC and low-grade temp to 99.7 which was in the setting of recent antibiotics but her stool was negative for C. diff. The stool softeners were held and the diarrhea resolved prior to discharge. The patient was discharged with GI follow up. # Leukocytosis: The patient was empirically started on broad coverage with vancomycin and zosyn as she was admitted in respiratory failure requiring intubation and ventilation with a WBC in the 30s. She was worked up for an infectious pulmonary process as she reportedly had thick yellow sputum prior to admission and still had a lingering cough during hospital course. She may also have aspirated during her code. However sputum culture was negative. In addition, all blood, urine, and catheter tip (R groin, R IJ) cultures came back negative. Her c. diff was also negative. The increased WBC was thought to be secondary to demarginalization vs. iatrogenic (she is enrolled in study in which she might be given hydrocortisone; note that WBC was 21 at [**Location (un) **]). The patient completed a 7-day abx course prior to discharge. . # HTN: The patient was initially hypotensive at the OSH and was started on dopamine then switched to levophed. At [**Hospital1 18**], levophed was increased initially but was eventually tapered off. Her blood pressure additionally improved after extubation. She was restarted on a beta blocker and an ACE I which were uptitrated as tolerated for cardioprotection. . # Acute renal failure: The patient had acute renal failure with a Cr of 1.5. The renal failure was likely secondary to decreased forward flow in the setting of her cardiac arrest. At discharge her Cr was stable at 0.9 to 1. The patient was diuresed with low doses of Lasix and also autodiuresed nicely later on during her admission. Lisinopril 5mg PO daily was started after resolution of ARF. . # Wide Complex Tachycardia: The EKG at the OSH showed wide complex tachycardia which was thought to be [**3-16**] to dopamine. She was started on an amiodarone drip with conversion back to sinus rhythm. At [**Hospital1 18**], amiodarone was stopped due to bradycardia. Of note, the patient has LBBB at baseline so she could have had sinus tachycardia with aberrance that was misinterpreted as Vtach. . # DM: Glycemic control was maintained with Glargine 26 U and Humalog SS. Metformin was held in the setting of her ARF and was not restarted prior to discharge. Her glyburide was held during her hospitalization and she was discharged on her home dose of glyburide with outpatient follow up for fingersticks. Medications on Admission: Glucophage 500 [**Hospital1 **] Glyburide 7.5 [**Hospital1 **] Lantus 50 units QHS Lasix 40mg daily Toprol XL 25mg daily Lisinopril 2.5mg daily Discharge Medications: 1. Glyburide 5 mg Tablet PO QPM 2. Glyburide 5 mg 1.5 Tablets PO QAM 3. Clopidogrel 75 mg One Tablet PO DAILY 4. Aspirin 325 mg One Tablet PO DAILY 5. Lisinopril 5 mg One Tablet PO DAILY 10AM 6. Lasix 40 mg One Tablet PO once a day. 7. Metoprolol Succinate 25 mg One Tablet PO once a day: start 5pm. 8. Ferrous Sulfate 325 mg (65 mg Iron) One Tablet PO once a day 9. Atorvastatin 80 mg One Tablet PO once a day. 10. Insulin Glargine 100 unit/mL Fifty (50) units Subcutaneous at bedtime. 11. Omeprazole 40 mg Capsule One Capsule, Delayed Release(E.C.) PO once a day. 12. Glucometer Ascensia Contour test strips sig 1 bottle Refills: one 13. Glucometer Ascensia Glucometer Sig: one refills: none Discharge Disposition: Home With Service Facility: Excel [**Hospital6 407**] Discharge Diagnosis: Primary Diagnosis -Acute systolic congestive heart failure -Coronary artery disease . Secondary diagnosis -Hypertension -Diabetes type II -Abdominal pain with guiac + stools -Acute renal failure -Leukocytosis Discharge Condition: Good Discharge Instructions: The following medications have been added: -Aspirin 325 mg PO daily -Atorvastatin 80 mg PO daily -Ferrous sulfate 325mg PO daily -Lisinopril 5mg PO daily -Omeprazole 40g PO daily . The following medications have been discontinued: -Diovan -Metformin . The following medications have been changed: Lasix 40mg PO daily . The following medications will be continued at their previous dose: -Metoprolol XL 25mg PO daily -Glyburide 5mg (1.5 tabs qAM, 1 tab qPM) . 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 doctor when you get home. Please follow up with your cardiologist in [**State **] about when to restart Diovan. . Please follow up your blood sugar with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 79693**] [**Name8 (MD) 2601**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2126-9-10**] 2:30 at Health Care Associated North Suite at [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Building at [**Hospital1 18**] . Please follow up with Gastroenterologist [**Name6 (MD) **] [**Last Name (NamePattern4) 2163**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2126-9-9**] 11:15 [**Location (un) **] [**Hospital Ward Name **], [**Hospital Unit Name **] [**Location (un) 453**]. . Please follow up with cardiology with Dr. [**Last Name (STitle) 73**] Phone number [**Telephone/Fax (1) 62**] Date/Time: [**2126-9-9**] 1:00 at [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Building Completed by:[**2126-10-7**]

[ "428.43", "414.01", "428.0", "250.00", "584.9", "E879.8", "578.1", "789.09", "458.29", "401.9", "518.81", "288.60", "427.1", "E849.7", "280.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.20", "96.71", "36.07", "00.66", "00.45", "88.56", "37.23", "00.40" ]

icd9pcs

[ [ [] ] ]

14810, 14866

9598, 13897

351, 401

15119, 15126

4233, 8124

15735, 16728

3296, 3314

14091, 14787

14887, 15098

13923, 14068

8141, 9575

15150, 15712

3329, 4214

275, 313

429, 2773

2795, 3193

3209, 3280

17,879

194,155

12917+12918

Discharge summary

report+report

Admission Date: [**2163-7-8**] Discharge Date: [**2163-7-18**] Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old female with a history of coronary artery disease, status post coronary artery bypass graft in [**2156**], congestive heart failure, hypercholesterolemia, hypertension, question of sick sinus syndrome, lower gastrointestinal bleed, secondary to diverticulosis, who is being transferred from an outside hospital status post non ST elevation myocardial infarction, status post episode of atrial fibrillation with rapid ventricular rate and hypotension. Patient's symptoms began with left-sided chest pressure in the evening of [**7-5**] with radiation to her left shoulder and diaphoresis. Patient denied shortness of breath, lightheadedness, nausea, vomiting, palpitations. Patient did not call for help, but instead waited for her visiting nurses to see her the following morning on [**7-6**], approximately 12 hours later. She was brought to [**Location (un) **] Emergency Department. A report of electrocardiogram with ST depressions across the precordium, however, we do not have copies of these electrocardiograms. Patient was made chest pain free with oxygen and nitroglycerin. Initial CK was 1132 with an MB of 161.6 and troponin of 21.8. Patient was started on aspirin, Plavix and Lovenox. Patient remained stable until early morning of [**7-8**] when she developed chest pain and lightheadedness and was found to be rapid atrial fibrillation with a rate in the 130s and blood pressure in the 80s to 90s. Patient was given Atenolol 12.5 mg po and digoxin 0.25 mg intravenously. Patient spontaneously converted to sinus bradycardia in the 50s. Blood pressure was still in the 70s and 80s. Patient was started on Neo-Synephrine and maintained on her nitroglycerin drip and transferred to [**Hospital6 256**] for possible catheterization. Currently, patient denies chest pain, shortness of breath, lightheadedness, nausea or vomiting. REVIEW OF SYSTEMS: The patient denies angina. Does have dyspnea on exertion and claudication. No fevers, chills, nausea, vomiting, lightheadedness, palpitations. No dysuria, no recent melena, nor bright red blood per rectum, no paroxysmal nocturnal dyspnea, no orthopnea. Does have urinary incontinence. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post coronary artery bypass graft in [**2156**] with saphenous vein graft to right coronary artery, saphenous vein graft to left circumflex and left internal mammary artery to left anterior descending. 2. Hypertension. 3. Congestive heart failure. 4. Hypercholesterolemia. 5. Question of sick sinus syndrome. 6. Holter monitor in [**2162-1-15**] showed sinus bradycardia and accelerated idioventricular rhythm. 7. Status post lower gastrointestinal bleed secondary to diverticulosis as recently as [**2163-6-27**]. 8. History of gastroesophageal reflux disease and Barrett's esophagus. 9. Status post CVA in [**2162-9-15**]. 10. Remote history of colon cancer in [**2154**]. Recent colonoscopy within normal limits. 11. History of meningioma on MRI. 12. Macular degeneration. 13. Osteoarthritis in her knees. 14. Status post dilation of pyloric stricture in [**2156**]. 15. History of ischemic colitis of descending and sigmoid colon in [**2162-1-15**]. HOME MEDICATIONS: Quinine 260 mg po q.d., Norvasc 5 mg po q.d., Zestril 20 mg po b.i.d., Zocor 20 mg po q.d., Atenolol 12.5 mg po q.d., Prevacid 30 mg po q.d., Isordil 10 mg po t.i.d., Lasix 40 mg po b.i.d., potassium chloride 20 mg po b.i.d., Os-Cal 500 mg po b.i.d., Ciprofloxacin 1 tablet po b.i.d. TRANSFER MEDICATIONS: Protonix 40 mg po q.d., quinine 260 mg po q.d., Lasix 40 mg po b.i.d., potassium chloride 10 b.i.d., Atenolol 12.5 b.i.d., Os-Cal 500 b.i.d., iron sulfate 325 mg po b.i.d., Zocor 20 mg q.d., Plavix 75 mg po q.d., nitroglycerin drip at 15, Neo-Synephrine drip at 10, Colace 100 mg po b.i.d., aspirin 81 mg po q.d., Zestril 2.5 mg po q.d., Lovenox 40 subcutaneously b.i.d. FAMILY HISTORY: Positive for coronary artery disease in a sister who died at age [**Age over 90 **]. Also positive for cancer. SOCIAL HISTORY: Lives alone with VNA with meals on wheels. Elderly husband. Daughter and son involved in her care. Daughter is [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39685**]. Phone number [**Telephone/Fax (1) 39686**]. Son is [**Name (NI) **] [**Name (NI) **]. Phone number [**Telephone/Fax (1) 39687**]. No tobacco or alcohol history. PHYSICAL EXAMINATION: Temperature 98.7. Heart rate 59. Blood pressure 139/43 off Neo-Synephrine. Oxygen saturation 99% on two liters. General: Patient alert in no acute distress. Head, eyes, ears, nose and throat: Oropharynx with moist mucous membranes. Neck: No carotid bruits, no jugular venous distention. Cardiovascular: Regular rate and rhythm, grade 2/6 systolic ejection murmur at the right upper sternal border. Lungs were clear to auscultation bilaterally. Abdomen soft, nontender, nondistended with positive bowel sounds. Extremities without edema and 2+ dorsalis pedis pulses bilaterally. Left foot with macerated interdigital skin, without erythema and without exudate. LABORATORY DATA: By report, echocardiogram with an ejection fraction of 55% and aortic stenosis. Not further quantified nor qualified. CKs from 1132 to 996 then 553 to 216. MB fraction of 152, 91, 44, 13. Index of 14, 9.1, 8, 6. Troponin 21.8, 31.7, 24.5, 15.2. Chem-7: Sodium 138, potassium 3.5, chloride 99, bicarbonate 33, BUN 25, creatinine 1.2, white blood cell count 15.4, hematocrit 33.5, platelets 302,000. Electrocardiogram: There is an electrocardiogram which shows atrial fibrillation with a rate in the 150s, ST elevations in V1 through V3, and ST depressions in V5 through V6 followed by an electrocardiogram that showed sinus bradycardia [**Company 39688**] wave inversions in V1 through V4 and aVL and biphasic T wave. HOSPITAL COURSE: 1. Coronary artery disease: Patient is status post non ST elevation myocardial infarction. Patient's CKs continued to trend downward. She was continued on her aspirin, statin and Lovenox. Her nitroglycerin drip was weaned off. Patient had no further episodes of chest pain. Given patient's age and "Do Not Resuscitate, Do Not Intubate" status, it was decided that medical management would be the best option. No cardiac catheterization was performed. Patient was restarted on her ACE inhibitor, home Lasix. Patient's beta-blocker was discontinued secondary to bradycardia. Patient to get a repeat cardiac echocardiogram to evaluate her ejection fraction and to quantify her aortic stenosis. Results are pending at the time of dictation. In terms of her rhythm, patient remained in sinus rhythm for the remainder of her hospitalization. Patient was not started on beta-blocker nor amiodarone secondary to her bradycardia. Patient was not anticoagulation secondary to her fall risk in her knees. In terms of her hematocrit, her hematocrit remained stable. Creatinine and urine output also remained stable. Patient was started on Bactrim for three days for proteus urinary tract infection which was pansensitive. A Podiatry Consult was obtained for patient's sores on her left foot. Patient was seen by Physical Therapy who recommended short term rehabilitation. Patient's code status remained "Do Not Resuscitate, Do Not Intubate." DISCHARGE STATUS: Discharged patient to rehabilitation. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: 1. Quinine sulfate 260 mg po q.d. 2. Zocor 20 mg po q.d. 3. Aspirin 325 mg po q.d. 4. Lasix 40 mg po b.i.d. 5. Potassium chloride 20 mg po q.d. 6. Captopril 25 mg po t.i.d. 7. Colace 100 mg po b.i.d. 8. Iron sulfate 325 mg po b.i.d. 9. Prevacid 30 mg po q.d. 10. Os-Cal 500 mg po b.i.d. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**] Dictated By:[**First Name3 (LF) 39689**] MEDQUIST36 D: [**2163-7-13**] 13:49 T: [**2163-7-13**] 13:49 JOB#: [**Job Number 39690**] cc:[**Last Name (NamePattern1) 39691**] Admission Date: [**2163-7-8**] Discharge Date: [**2163-7-18**] Service: ADDENDUM HOSPITAL COURSE: This is an addendum to the hospital course beginning [**2163-7-12**]. 1. Vascular: The patient had planned to be discharged back to rehabilitation without any intervention given that she had no cardiac symptoms during this hospitalization and her troponin had trended down; however, on [**2163-7-12**], the patient developed the sudden onset of chest pressure. The patient noted some response of her symptoms with the application of sublingual Nitroglycerin. Electrocardiogram was notable for some anterior ST elevations. She was subsequently started on Heparin and Integrilin. Plavix had also been added to her regimen. The patient had no elevations in her CKs but did have another elevation in her troponin to 5.9. The patient had previously refused cardiac catheterization during this hospitalization and continued to do so now in the setting of new evidence of an non-ST elevation myocardial infarction. This episode was not accompanied by atrial fibrillation as her prior episode at the outside hospital. Over the next day or two, the patient was noted to have a fall in her hematocrit and melenic stools thought to be secondary to GI bleed. The patient was transfused and ultimately consented to cardiac catheterization. Of note echocardiogram on [**2163-7-12**], had noted an ejection fraction of 35-40%, mild symmetric left ventricular hypertrophy, moderate aortic stenosis, impaired left ventricular relaxation, and mild pulmonary systolic hypertension. Cardiac catheterization was ultimately performed on [**2163-7-15**], and revealed multi-vessel disease including stenoses of her native vessels with two patent grafts; however, a significant thrombus was noted proximally in the saphenous vein graft to left anterior descending graft. Given the heavy thrombus burden, a direct intervention of either angioplasty or stenting was deferred secondary to recent GI bleeding. As a result, there was no direct intervention during this cardiac catheterization. Postcatheterization the patient's hematocrit remained stable. Over the final several days of her hospital stay, her cardiac regimen was maximized. She was started back on her Lasix two days prior to discharge at less than her prior dose. She appeared relatively euvolemic at the time of discharge. The patient had no further episodes of atrial fibrillation and was in normal sinus rhythm throughout her hospital stay. She was maintained on low-dose Lopressor for rate control. The decision was made not to anticoagulate given her GI bleeding risk. The patient was noted to be borderline bradycardiac at times during her hospital stay. She was taken off of her Norvasc and continued on low-dose Lopressor. The patient was asymptomatic for her borderline bradycardia. 2. Pulmonary: The patient was with no evidence of active congestive heart failure during this hospitalization. As noted, she was started back on Lasix prior to discharge, and her ACE inhibitor was maximized. 3. Hematologic: The patient is with a history of GI bleed secondary to diverticulosis. The patient was noted to have melanic stools in the setting of Heparin and Integrilin during her non-ST elevation myocardial infarction. The patient's GI blood loss required transfusion. After discontinuation of antiplatelet agents, the patient's hematocrit remained stable throughout the remainder of her hospital stay, although her stools remained guaiac positive. 4. GI: The patient was with GI bleed as noted above. Serial hematocrits were checked, and the patient's hematocrit was stable at 32.2 at the time of discharge. Hematocrit should be followed at rehabilitation as an outpatient and transfuse to keep greater than 30. 5. Renal: The patient presented with elevated creatinine in the setting of her initial non-ST elevation myocardial infarction likely secondary to hypoperfusion secondary to atrial fibrillation and ischemia. The patient's creatinine gradually trended back to baseline. She was started back on her Lasix at the time of discharge. 6. Infectious disease: The patient was treated with seven days of Bactrim for a urinary tract infection, positive for proteus. 7. Podiatry: The patient was noted to have a superficial ulceration between the web spaced of her left foot. She was seen by the Podiatry Service while in-house, and they recommended daily application Betadine and dressing changes, as well as positioning of sterile 4 x 4 gauze pads between her web spaces q.d. The patient will have outpatient follow-up with her podiatrist and primary care physician. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSIS: 1. Coronary artery disease status post non-ST elevation myocardial infarction. 2. Atrial fibrillation. 3. Hypertension. 4. Hypercholesterolemia. 5. Anemia secondary to gastrointestinal bleed and post cardiac catheterization. 6. Gastrointestinal bleed. 7. Urinary tract infection. 8. Superficial left foot ulcer. DISCHARGE MEDICATIONS: Lasix 40 mg p.o. b.i.d., Zestril 40 mg p.o. q.d., Protonix 40 mg p.o. q.d., sublingual Nitroglycerin 0.4 mg p.r.n. chest pain, Lopressor 12.5 mg p.o. b.i.d., Senna 1 tab p.o. q.d., Bisacodyl 10 mg p.o./p.r. q.d. p.r.n. constipation, Potassium Chloride 20 mEq p.o. q.d., Colace 100 mg p.o. b.i.d., Tylenol p.r.n., Zocor 20 mg p.o. q.d., Iron Sulfate 325 mg p.o. b.i.d., Quinine Sulfate 260 mg p.o. q.h.s., Os-Cal 500 mg p.o. b.i.d. DISCHARGE INSTRUCTIONS: 1. The patient is to receive foot care with application of Betadine to second and third web spaces q.d. Toes should be separated with 2 x 2 dry sterile dressings, and the patient should be arranged for follow-up with her podiatrist at the time of discharge. 2. The patient should have her in's and out's closely monitored to keep euvolemic. Her Lasix dose can be adjusted as necessary. She was previously on 80 mg p.o. b.i.d. prior to this hospitalization but was discharged on 40 mg p.o. b.i.d. 3. The patient's hematocrit should be checked q.o.d. for the next several days and transfused to keep greater than 30. 4. The patient should have follow-up arranged with her podiatrist, as well as her primary care physician. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-153 Dictated By:[**Last Name (NamePattern4) 4689**] MEDQUIST36 D: [**2163-7-18**] 11:31 T: [**2163-7-18**] 11:35 JOB#: [**Job Number 39692**]

[ "599.0", "410.91", "428.0", "V45.81", "272.0", "578.9", "401.9", "707.15", "427.31" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7530, 7539

4059, 4172

13267, 13699

12922, 13243

8300, 12867

13724, 14685

3362, 3647

4562, 5981

2031, 2321

3670, 4042

114, 2011

2343, 3343

4189, 4539

12892, 12901

68,201

143,434

47577

Discharge summary

report

Admission Date: [**2187-8-22**] Discharge Date: [**2187-8-30**] Date of Birth: [**2128-5-2**] Sex: F Service: SURGERY Allergies: Grass Pollen-Bermuda, Standard / [**Doctor Last Name **] / Dust & Pollen Filter Mask Attending:[**First Name3 (LF) 148**] Chief Complaint: Jaundice. Major Surgical or Invasive Procedure: [**2187-8-22**]: 1. Pylorus-preserving pancreaticoduodenectomy. 2. Open cholecystectomy. 3. Staging laparoscopy. [**2187-8-23**]: 1. Reopening of recent laparotomy and control of intra-abdominal bleeding. History of Present Illness: This very nice 59-year-old woman recently became jaundiced. A workup ensued and found her to have biliary obstruction on account of a mass in the head of her pancreas. This mass was ultimately visualized by CAT scan and seemed to be a resectable lesion. It was finally analyzed by endoscopic ultrasound and a biopsy of this proved adenocarcinoma. The patient has been informed of the diagnosis. She was admitted for planned Whipple surgery. Past Medical History: Her medical history is significant for hypercholesterolemia, sleep apnea, asthma, overactive bladder, arthritis, gout, HTN, borderline hypothyroidism, obesity, and mild GERD. Her surgical history is significant for hysterectomy in [**2178**] as well as a left knee arthroscopy in [**2183**]. She has had two pilonidal cyst operations, tonsillectomy, and adenoidectomy in the distant past. Her GI procedures include the aforementioned ERCP and EUS and she is currently stented. Social History: Occassion alcohol. No tobacco or illicits. Family History: Non-contributory. Physical Exam: On Admission: AVSS/afebrile GEN: Well appearing in NAD. HEENT: Sclerae anicteric. O-P clear. NECK: Supple. LUNGS: CTA(B). COR: RRR ABD: Protuberant. Soft/NT/ND. EXTREM: No c/c/e. NEURO: A+Ox3. Non-focal/grossly intact. . At Discharge: VS: 98.8 PO, 88, 144/88, 20, 94% RA GEN: Well appearing in NAD. HEENT: Sclerae anicteric. O-P clear. NECK: Supple. LUNGS: CTA(B). COR: RRR ABD: Subcostal and umbilical incisions with steri-strips OTA c/d/i. Appropriately tender to palpation along incision, otherwsie soft/NT/ND. EXTREM: No c/c/e. NEURO: A+Ox3. Non-focal/grossly intact. Pertinent Results: On Admission: [**2187-8-22**] 07:21PM GLUCOSE-185* UREA N-12 CREAT-0.9 SODIUM-144 POTASSIUM-4.6 CHLORIDE-110* TOTAL CO2-21* ANION GAP-18 [**2187-8-22**] 07:21PM CK(CPK)-314* [**2187-8-22**] 07:21PM CK-MB-5 cTropnT-<0.01 [**2187-8-22**] 07:21PM CALCIUM-8.4 PHOSPHATE-4.4 MAGNESIUM-2.1 [**2187-8-22**] 07:21PM WBC-11.9*# RBC-4.47 HGB-12.0 HCT-37.6 MCV-84 MCH-26.9* MCHC-32.0 RDW-15.7* [**2187-8-22**] 07:21PM PLT COUNT-307 [**2187-8-22**] 07:21PM PT-12.5 INR(PT)-1.1 [**2187-8-22**] 04:54PM GLUCOSE-157* LACTATE-3.4* NA+-141 K+-4.6 CL--105 TCO2-23 [**2187-8-22**] 04:54PM HGB-13.3 calcHCT-40 [**2187-8-22**] 04:54PM freeCa-1.18 [**2187-8-22**] 04:54PM freeCa-1.18 . At Discharge: [**2187-8-26**] 04:42AM BLOOD WBC-11.8* RBC-3.20* Hgb-9.1* Hct-28.4* MCV-89 MCH-28.5 MCHC-32.1 RDW-16.1* Plt Ct-172 [**2187-8-23**] 10:50AM BLOOD Neuts-73.4* Lymphs-22.0 Monos-3.9 Eos-0.1 Baso-0.6 [**2187-8-26**] 04:42AM BLOOD Plt Ct-172 [**2187-8-30**] 06:10AM BLOOD K-3.9 [**2187-8-23**] 10:50AM BLOOD ALT-649* AST-719* AlkPhos-83 Amylase-40 TotBili-2.0* [**2187-8-30**] 06:10AM BLOOD Mg-1.9 . Imaging: [**2187-8-22**] Abdominal x-ray: FINDINGS: Study is suboptimal secondary to patient body habitus and patient motion. Nasogastric tube is seen extending into the expected location of the stomach. There is a line.catheter extending along the the right abdomen to the level of the T11 vertebral body. A horizontal line of surgical staples is seen extending across the abdomen. Horizontal linear density in the left upper quadrant is felt to most likely be artifactual. Otherwise, no definite evidence of a radiopaque needle or other surgical foreign body. Surgical staples also noted overlying the upper left pelvis. . [**2187-8-22**] CXR: Elevation of the right hemidiaphragm may be due to right lower lobe atelectasis, common postoperative finding. Upper lungs are clear. Pleural effusion is minimal if any. No pneumothorax. Normal cardiomediastinal silhouette. Right jugular line tip projects over the low SVC and a nasogastric tube passes into the stomach. . Pathology: SPECIMEN SUBMITTED: Jejunum, Whipple specimen, Gallbladder, Whipple's node. DIAGNOSIS: 1. Gallbladder (A): Chronic cholecystitis. 2. Lymph node, "Whipple," (B-C): One lymph node with no carcinoma seen. 3. Jejunum, segment (D): Unremarkable small intestine. 4. Pancreas and duodenum, Whipple procedure (E-T): Adenocarcinoma, moderately differentiated, 2.5 cm, See Synoptic Report. Pancreas (Exocrine): Resection Synopsis MACROSCOPIC Specimen Type: Pancreaticoduodenectomy, partial pancreatectomy. Tumor Site: Pancreatic head. Tumor Size Greatest dimension: 2.5 cm. Additional dimensions: 1.8 cm x 1.6 cm. Other organs/Tissues Received: Gallbladder, Jejunum. Whipple's lymph node. MICROSCOPIC Histologic Type: Ductal adenocarcinoma. Histologic Grade: G2: Moderately differentiated. EXTENT OF INVASION Primary Tumor: pT3: Tumor extends beyond the pancreas but without involvement of the celiac axis or the superior mesenteric artery. Regional Lymph Nodes: pN1b: Metastasis in multiple regional lymph nodes. Lymph Nodes Number examined: 20. Number involved: 4. Distant metastasis: pMX: Cannot be assessed. Margins: Margins uninvolved by invasive carcinoma: Distance from closest margin: 5 mm. Specified margin: Posterior retroperitoneal. Venous/Lymphatic vessel invasion: Absent. Perineural invasion: Present. Additional Pathologic Findings: Chronic pancreatitis. Comments: Adenocarcinoma extends into peripancreatic fat and into the duodenal mucosa. Clinical: Pancreatic cancer. Gross: The specimen is received fresh in four parts, each labeled with the patient's name, "[**Known lastname 60542**], [**Known firstname **]" and the medical record number. Part 1 is additionally labeled "gallbladder." It consists of a gallbladder measuring 12.0 x 2.7 x 2.3 cm. The gallbladder is opened to reveal velvety pink mucosa. There are no stones and approximately 10 cc of residual, green sludgy bile. Part 1 is represented in cassette A. Part 2 is additionally labeled "Whipple's node." It consists of a lymph node, measuring 2.3 1.7 x 0.5 cm. The lymph node is bisected and submitted entirely in B-C. Part 3 is additionally labeled "jejunum." It consists of a segment of jejunum measuring 14.5 cm in length and 5.8 cm in circumference. The serosal surface is smooth and shiny. The resection margins are stapled. The bowel is opened to reveal unremarkable tan and pink mucosa. The resection margins are submitted in cassette D. Part 4 is additionally labeled "Whipple." It consists of a pancreaticoduodenectomy specimen that measures 12.8 x 5.2 x 4.5 cm in overall dimension. The pancreatic portion is composed of the head and measures 5.2 x 4.5 x 2.6 cm. The duodenal segment measures 12.8 cm in length and 6.4 cm in circumference. Both proximal and distal resection margins are stapled with staple lines at each measuring 4.5 cm. It is oriented by the surgeon with a black silk suture indicating bile duct, a blue suture indicating the pancreatic neck margin and a green suture indicating the superior mesenteric artery. The posterior retroperitoneal margin is identified and is inked [**Location (un) 2452**]. The pancreatic parenchymal margin is inked in blue. The uncinate margin is inked black. The duodenum is opened to reveal a prominent fold, 1.2 cm from the proximal resection margin. The bile duct segment measures 8.5 cm from ampulla to the distal end. A segment of the cystic duct is present and joins the common bile duct. The bile duct is patent. The bile duct is opened to reveal unremarkable mucosa. The pancreas is serially sliced to reveal a tumor that measures 2.5 x 1.8 x 1.6 cm and that lies 0.5 cm from the posterior retroperitoneal margin. The uninvolved pancreatic parenchyma is unremarkable. The peripancreatic adipose tissue is dissected to reveal several potential lymph nodes. It is represented as follows: E = common bile duct margin and cystic duct, F = pancreatic parenchymal margin, G = uncinate/SMA margin, H = distal duodenal resection margin, I = proximal duodenal resection margin, J = duodenum with prominent fold, K = ampulla, L = chronic pancreatitis, M = tumor, N = tumor in relation to posterior retroperitoneal margin, O-P = tumor, Q-R = lymph nodes submitted whole, S-T = remainder of peri-pancreatic fat. Brief Hospital Course: The patient was admitted to the General Surgical Service on [**2187-8-22**] for treatment of a pancreatic mass causing obstructive jaundice. On [**2187-8-22**], the patient underwent pylorus-preserving pancreaticoduodenectomy (Whipple), open cholecystectomy and staging laparoscopy. In the PACU, the patient was noted to be tachycardic with a SBP in the 90's and a urine output averaging 10-15mL/Hr. Immediate post-operative HCT was 37. Serial hematocrits were followed, which progressively declined to a low of 24.1 by 1am on POD#1. She remained hypotensive and oliguric. EKGs and cardiac enzymes were negative x2. She was transferred to the SICU for closer monitoring. She received 2units of PRBCs and her HCT improved to 31. Her pressures, however, remained in the 80s to mid 90s, despite being on two pressors. She also became progressively acidemic, with her pH going from 7.2 to 7.13, with a base defecit of -12 and lactate of 9. Later in the AM, she again dropped her HCT to 28 and remained acidemic. At this point, given that she did not responded to transfusions, and remained hypotensive with a significant concern for postoperative bleeding, the patient was taken back to the OR for exploratory laparotomy that revealed a clot by the SMA, which was successfully evacuated and post-operative bleeding controlled (reader referred to the Operative Notes for details). Overnight, she was placed on CPAP. She received three dose peri-operative IV Cipro and Cefazolin. She remained in the SICU until POD#3, during which time she remained hemodynamically stable. . Later on POD#3, the patient was transferred to the floor. She arrived on the floor NPO except medications, on IV fluids, with a foley catheter and a JP drain in place, and Dilaudid PCA for pain control. Once on the floor, the [**Hospital 228**] hospital course was otherwise uneventful and followed the Whipple Clinical Pathway. Post-operative pain was initially well controlled with the Dilaudid PCA, which was converted to oral pain medication when tolerating clear liquids. The NG tube was discontinued on POD#3 prior to transfer to the floor, and the foley catheter discontinued at midnight of POD#4. The patient subsequently voided without problem. The patient was started on sips of clears on POD#4, which was progressively advanced as tolerated to a regular diet by POD#7. JP amylase was sent in the evening of POD#6; the JP was discontinued on POD#7 as the output and amylase level were low. . On the floor, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirrometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. The patient's blood sugar was monitored regularly throughout the stay; sliding scale insulin was administered when indicated, but the patient did not require insulin for home discharge. . At the time of discharge on [**2187-8-30**], the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Staples were removed, and steri-strips placed. The patient was discharged home with VNA services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Protonix 40mg PO daily Discharge Medications: 1. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*0* 2. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*4* 3. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q3-4 HOURS: PRN as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 5. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation: Over-the-counter. Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: 1. Pancreatic cancer. 2. Obstructive jaundice. 3. Postoperative hemorrhage. Discharge Condition: Good Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain 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 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 [**4-8**] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Please call ([**Telephone/Fax (1) 35953**] to arrange a follow-up appointment with Dr. [**Last Name (STitle) **] (PCP) in [**1-2**] weeks. . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 2833**] Date/Time:[**2187-9-14**] 8:45. Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**]. Completed by:[**2187-8-30**]

[ "244.9", "278.00", "327.23", "493.90", "998.11", "157.0", "196.2", "576.2", "E878.2", "401.9", "530.81", "274.9", "276.2", "272.0", "575.11", "790.01" ]

icd9cm

[ [ [] ] ]

[ "54.21", "54.12", "52.7", "51.22", "99.07", "38.91", "99.04" ]

icd9pcs

[ [ [] ] ]

12975, 13030

8658, 12039

352, 559

13150, 13157

2239, 2239

15163, 15559

1613, 1632

12112, 12952

13051, 13129

12065, 12089

13181, 14635

14651, 15140

1647, 1647

2939, 8635

303, 314

587, 1033

2253, 2925

1055, 1537

1553, 1597

52,460

132,936

51185

Discharge summary

report

Admission Date: [**2185-4-22**] Discharge Date: [**2185-5-4**] Date of Birth: [**2102-1-24**] Sex: F Service: MEDICINE Allergies: Beta-Adrenergic Blocking Agents / Pletal Attending:[**First Name3 (LF) 1515**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Right heart catheterization History of Present Illness: [**Known firstname 730**] [**Known lastname **] is an 83-year-old woman with h/o CAD s/p CABG in [**2158**] (LIMA->LAD,SVG->OM1,SVG->D1,SVG->PDA) prior DESx2->SVG to OM1, known occlusion of SVG->RCA, recent DES to SVG->D1 at OSH and [**2185-4-20**] with repeat DES to D1, HTN, hyperlipidemia, DM2, who was recently admitted with complaint of new chest pain [**4-19**] that felt like normal angina but more intense. Previously had angina once monthly, but now more frequent. One day prior to admission the pt had 3 episodes of SS CP with radiation to left arm, first two were relieved with SL nitro, final episode was more intense so the pt went to the ED. During her admission, patient underwent cardiac catheterization, with anatomy as described below. She had an uncomplicated stent placed to SVG to D1 for 70% in stent stenosis. After the procedure she had two episodes of chest pain that resolved with nitroglycerin. She was then discharged with increased dosing of Metoprolol. That evening the patient developed her typical sscp. This resolved with SL NTG, but then recurred. Took another nitro with temporary relief but when pain returned she presented to the ED. . Initial ED at 23:37 were 97.8, 62, 155/62, 18 and 97/RA. ECG showed inferolateral ST depressions that resolved with resolution of patient's chest pain. She was treated with Nitroglycerin SL 0.4mg SL, ASA 325mg, Metoprolol 25mg, morphine IV. In the ED, patient developed respiratory distress in setting of hypertension thought to be pulmonary edema. She was given Lasix IV and then started on a heparin gtt, nitroglycerin gtt for treatment of pulmonary edema. Patient was started on CPAP for respiratory support. . On arrival to the ICU patient c/o 5/10 chest pain. HR in 70's, BP 120/70, RR 23, 93% on CPAP. Past Medical History: # CAD s/p MI and CABG '[**58**](LIMA->LAD,SVG->OM1,SVG->D1,SVG->PDA) - known occlusions of LMCA and SVG->RCA - s/p SVG->OM1 DES [**11/2177**] - [**6-28**] new stenosis SVG->OM1(prior [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 8574**]) s/p DES - [**2-27**] SVG->D1 complex 95% stenosis w/ thrombus--> DES - [**3-31**] stenting of SVG-diagonal - Current anatomy as of [**2185-4-20**] was occluded LM, LAD, LCx, RCA 100% mid vessel, LIMA -> LAD (Patent w/ colaterals to RCA), SVG to OM patent with stents, SVG to D1 with 70% in stent restenosis, SVG to RCA is occluded. Patient had DES to SVG to D1 . # Diastolic CHF with EF 50-55%, 1+AR, 1+MR in [**10-29**] # AFib,diagnosed at admission to [**Hospital3 **] [**2-/2184**] # Hyperlipidemia [**2-27**]; TC 146, LDL 56, HDL 73, TG 83 # DMII, HbA1c 7.2 [**2-27**] # HTN # PVD - s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3098**] stent [**6-27**] - s/p Bilateral LE stents (not clear where) # COPD (FEV1 1.22 73% ), 120 PYHx of tobacco # Blepharitis # Left adrenal adenoma # R. renal mass s/p RF ablation . Cardiac Risk Factors: + CAD, +Diabetes, +Dyslipidemia, +Hypertension . Cardiac History: CABG, in [**2158**] anatomy as follows: # CAD s/p MI and CABG '[**58**](LIMA->LAD,SVG->OM1,SVG->D1,SVG->PDA) . Percutaneous coronary intervention, anatomy as follows: - known occlusions of LMCA and SVG->RCA - s/p SVG->OM1 DES [**11/2177**] - [**6-28**] new stenosis SVG->OM1(prior [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 8574**]) s/p DES - [**2-27**] SVG->D1 complex 95% stenosis w/ thrombus--> DES - [**3-31**] stenting of SVG-diagonal . Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. She lives with her sister in [**Name (NI) 3307**] in a 2 story house that has one bathroom upstairs. Smoked for approx 50 yrs, quit [**2158**]. 120 pk/yr hx. Rare EtOH. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: Gen: Elderly female 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: No JVD. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: Admission labs: [**2185-4-21**] 06:50AM WBC-12.1* RBC-4.04* HGB-11.6* HCT-33.6* MCV-83 MCH-28.7 MCHC-34.5 RDW-13.9 [**2185-4-21**] 06:50AM PLT COUNT-268 [**2185-4-21**] 06:50AM GLUCOSE-144* UREA N-24* CREAT-0.9 SODIUM-136 POTASSIUM-3.5 CHLORIDE-97 TOTAL CO2-29 ANION GAP-14 [**2185-4-22**] 12:40AM NEUTS-87.5* LYMPHS-8.1* MONOS-3.8 EOS-0.3 BASOS-0.2 . Cardiac Enzymes: [**2185-4-21**] 06:50AM BLOOD CK(CPK)-59 [**2185-4-22**] 12:40AM BLOOD CK(CPK)-97 [**2185-4-22**] 06:23AM BLOOD CK(CPK)-99 [**2185-4-22**] 12:30PM BLOOD CK(CPK)-400* [**2185-4-22**] 08:31PM BLOOD CK(CPK)-428* [**2185-4-23**] 05:49AM BLOOD CK(CPK)-311* [**2185-4-24**] 06:30AM BLOOD CK(CPK)-125 [**2185-4-22**] 12:40AM BLOOD cTropnT-<0.01 [**2185-4-22**] 06:23AM BLOOD CK-MB-NotDone cTropnT-0.03* [**2185-4-22**] 12:30PM BLOOD CK-MB-44* cTropnT-0.38* proBNP-[**Numeric Identifier **]* [**2185-4-22**] 08:31PM BLOOD CK-MB-44* MB Indx-10.3* cTropnT-0.52* [**2185-4-23**] 05:49AM BLOOD CK-MB-27* MB Indx-8.7* cTropnT-0.83* [**2185-4-24**] 06:30AM BLOOD CK-MB-7 . EKG SR 76 IVCD anterolateral 1-3 mm downsloping STD 1 mm STE aVR 1 mm STD II,F (changes improved on pain-free EKG) . Femoral Vascular U/S [**4-21**] -No evidence of pseudoaneurysm or hematoma. . Chest X-ray ([**2185-4-22**]) - Increased interstitial opacities and tiny pleural effusions consistent with mild volume overload, stable cardiomegaly. Lungs hyperinflated. . ECHO ([**2185-4-22**]): The left atrium is normal in size. The right atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with basal and mid-inferior hypokinesis. The remaining segments contract normally (LVEF = 45-50%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. Moderate mitral regurgitation. Compared with the prior study (images reviewed) of [**2184-3-8**], inferior hypokinesis was present on both studies, but is more pronounced now. Severity of mitral regurgitation has increased. The other findings are similar. . Right Heart Catheterization: was performed by percutaneous entry of the right internal jugular vein, using a 7 French pulmonary wedge pressure catheter, advanced to the PCW position through an 8 French introducing sheath. **PRESSURES RIGHT ATRIUM {a/v/m} 12/10/9 RIGHT VENTRICLE {s/ed} 45/6 PULMONARY ARTERY {s/d/m} 45/16/29 PULMONARY WEDGE {a/v/m} 19/19/16 **CARDIAC OUTPUT HEART RATE {beats/min} 60 RHYTHM NSR O2 CONS. IND {ml/min/m2} 125 A-V O2 DIFFERENCE {ml/ltr} 58 CARD. OP/IND FICK {l/mn/m2} 3.0/2.2 **RESISTANCES PULMONARY VASC. RESISTANCE 347 SVC LOW 59 PA MAIN 58 AO 96 COMMENTS: 1. Resting hemodynamics revealed normal right and left sided filling pressures with an RVEDP of 6 mmHg and a mean PCWP of 16 mmHg. There was moderate pulmonary hypertension with a PASP of 45/16 mmHg. There was a normal cardiac index of 2.2 L/min/m2. FINAL DIAGNOSIS: 1. Normal left sided filling pressure. 2. Moderate pulmonary hypertension. . CT Chest ([**2185-4-28**])- Most recent chest CT showed moderate-to-severe emphysema, extensive right pleural calcification, probably restrictive, mild-to-moderate cardiomegaly, with particular left atrial enlargement possible chordopapillary calcification and probable pulmonary hypertension. Today's examination shows new small bilateral, nonhemorrhagic pleural effusions layering posteriorly and new heterogeneous opacification predominantly in the lung that is dependent with the patient supine, particularly pronounced in the posterior segment of the right upper lobe. The transverse diameter of the left atrium at the level of the left circumflex coronary artery has increased from 44 to 54 mm, probably a real indication of progressive left atrial enlargement suggesting that all of the findings could be due to cardiac decompensation, although right upper lobe pneumonia or pulmonary hemorrhage should also be considered. The diameter of the dilated intrapericardial right pulmonary artery, 29 mm, is unchanged. Wide spread atherosclerotic calcification is present in the head and neck vessels, nondilated thoracic aorta, and native coronary arteries. The left coronary bypass graft is stented. There is no pericardial effusion. Diffuse enlargement of the left adrenal gland is unchanged, probably hypertrophy. IMPRESSION: 1. New mild-to-moderate pulmonary edema and small pleural effusions associated with increased left atrial size and chronic pulmonary hypertension consistent with mitral valvular pathology and acute cardiac decompensation. 2. Right upper lobe consolidation could be either pneumonia, hemorrhage, or pronounced edema due to moderate emphysema and/or mitral regurgitation. 3. Severe generalized atherosclerosis including native coronaries. Probable pulmonary hypertension. 4. Stable left adrenal hyperplasia. 5. Calcific right pleural thickening. . Discharge labs: Na 130, K 4.9 Cl 92 Bicarb 29 BUN 42 Creat 1.2 Hct 29, WBC 12.4 Plt 360 Brief Hospital Course: 83F with CAD s/p CABG with extensive native vessel diffuse s/p taxus stent to SVG-diag on [**4-20**], HTN, COPD, DM, presenting with unstable angina and acute on chronic diastolic heart failure and profound new hypoxia. . # NSTEMI: Patient with crescendo chest pain prompting admission and had NSTEMI with peak CK 428, MB 44 and TropnT 0.38. Patient was not home long enough to miss a dose of plavix so med non-compliance not a likely factor. Chest pain was controlled on nitro drip and she had no further episodes of chets pain during admission. Suspect demand ischemia in setting of hypertension/pulmonary edema. It was decided not to proceed to cardiac catheterization given the recent cardiac cath showing no intervenable lesions and patient was started on ranexa for management of chronic angina. She was continued on statin, ASA, Plavix, BB, ACEi with some medication changes for optimization of her regimen. . Acute On chronic diastolic congestive Heart Failure: originally thought to be the cause of hypoxia. Current weight is 50 kg. Pt's regimen changed to Torsemide 20 mg [**Hospital1 **] for management of fluid retention. Pt is compliant with a low Na diet and should have a 1500c fluid restriction. . # Dyspnea - Patient was severely dyspneic on admission requiring admission to the CCU with BiPAP. She intially diuresed with improvement in oxygenation, however after extensive diuresis, patient still had significant oxygen requirement. Pulmonology was [**Hospital1 4221**] for further recommendations. A Chest CT was performed that showed small bilat pulmonary effusions, mild-to-moderate pulmonary edema and right upper lobe consolidation could be either pneumonia, hemorrhage, or edema. Pt had no symptoms of infection or pneumonia and was deemed to be hypovolemic after aggressive diuresis. Her COPD was well controlled on Advair and Spiriva. Therefore, it is thought that hypoxia and DOE is due to pulmonary hemorrhage possibly [**1-24**] Plavix and ASA usage post stent. This condition will likely improve slowly and pt will require O2 via NP with ambulation for some time. Pt has f/u with her outpatient pulmonologist in the beginning of [**Month (only) 205**] but this may need to be scheduled earlier if she fails to improve as expected. . # Hemoptysis - Patient has several epsiodes of very small volume hemoptysis while in the hospital. She was hemodynamically stable during all episodes. This was intially attributed to upper airway bleeding given that patient was on ASA, plavix and heparin and had a recent nosebleed. However, it also may indicate a pulmonary hemmorhage as described above. Hemoptysis is currently resolved. . #Hypertension: Patient's home blood pressure medications were uptitrated to achieve goal systolic blood pressure of 90-110. . #Rhythm: Remained in normal sinus rhythm throughout admission. Had episode of Atrial Fibrillation in [**2-27**], outpatient cardiologist made decision not to anticoagulate per most recent discharge summary. She was continued on metoprolol for rate control and a full dose aspirin. . #DM2: HbA1C in [**1-/2185**] was 7.2. On metformin and glyburide as an outpatient which were held on admission given the possibility of interventional procedure with contrast dye load. She was covered with insulin sliding scale then transitioned back to home regimen with poor control necessitating increase of Glyburide to [**Hospital1 **]. She should have blood sugar checks before meals with humalog sliding scale as ordered. . #COPD: Stable, she was continue on Advair, Spiriva and Albuterol . #Leukocytosis: Patient had a leukocytosis on admission with no clinical history to suggest infectious source, Urinalysis was negative, chest X-ray showed asymmetrical opacifications but not clear pneumonia. She remained afebrile and white count trended down during admission without antibiotics. . # Decreased esophageal motility: Swallow evaluation initiated to assess whether silent aspiration contributing to hypoxia. Video swallow shows no aspiration but [**Month (only) **] motility noted. Upper GI confirmed the same. Per [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 77062**] from speech/swallow, cont aspiration precautions to prevent HOB flat and keep upright after meals. No dietary modification is necessary. See attached note. Medications on Admission: Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation every four (4) hours as needed for wheeze. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY(Daily). Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Furosemide 20 mg Tablet Sig: One (1) Tablet PO QPM MFW (). Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Isosorbide Mononitrate 120 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. Metformin 1,000 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)Tab, Sust Rel Osmotic Push 24hr PO qam. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1 Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Multivitamins Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. Temazepam 15 mg Capsule Sig: One (1) Capsule PO at bedtime as needed for insomnia. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tab SL 1 Tablet(s) sublingually q5' x3 for chest pain; to ED if not effective . Discharge Medications: 1. Oxygen 2-4L NP continuously for O2 sat 86% on RA. Please give ambulatory tank as well thanks 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 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. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 9. Ranolazine 500 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO bid (). Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*2* 10. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 13. Metformin 500 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO once a day. Disp:*120 Tablet Sustained Release 24 hr(s)* Refills:*2* 14. Torsemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 16. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation four times a day as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: [**Street Address(1) 19427**] Nursing & Rehab Center - [**Location (un) 3307**] Discharge Diagnosis: Acute on Chronic Diastolic Congestive Heart Failure Chronic Obstructive Pulmonary disease Pulmonary Hemorrhage causing hypoxia Diabetes Mellitus type [**Street Address(2) 106225**] Elevation Myocardial Infarction Discharge Condition: stable Discharge Instructions: You had chest pain and a small heart attack. We adjusted your medicines and gave you a new diuretic to get rid of extra fluid. We started a new medicine, Ranexa, to help decrease the chest pain. . You also had some difficulty breathing while in the hospital. This was intially thought to be related to volume overload from heart failure and you were diuresed with lasix however symptoms did not improve and the lung doctors [**First Name (Titles) **] [**Last Name (Titles) 4221**]. They felt you had some blood collecting in your lung and that it would resolve gradually. You will be discharged with oxygen and we hope you will be able to wean off slowly. . New Medicines: 1. Ranexa: to prevent chest pain 2. Norvasc: we increased this from 5mg to 10 mg 3. Metoprolol: we increased this to 37.5 mg twice daily 4. Torsemide: a diuretic to prevent fluid buildup 5. Discontinue furosemide 6. Glyburide: increased to twice daily 7. Pantoprazole was d/c'ed: Start Ranitidine 150mg daily . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day or 6 pounds in 3 days. Adhere to 2 gm sodium diet . Please call Dr. [**Last Name (STitle) **] if you have further chest pain, trouble breathing, increasing swelling in your legs, light headedness, coughing up blood, or any other unusual symptoms. . Followup Instructions: Cardiology: Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 8645**] Date/Time:[**2185-6-7**] 4:00 . Primary Care: [**Last Name (LF) **],[**First Name8 (NamePattern2) 1141**] [**Last Name (NamePattern1) 2671**] Phone: [**Telephone/Fax (1) 4775**] Date/time: [**5-18**] at 9:00am. . Podiatry: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 8645**] Date/Time:[**2185-6-8**] 11:00 . Urology: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11190**], MD Phone:[**Telephone/Fax (1) 8645**] Date/Time:[**2185-6-30**] 9:15 . Pulmonology: Dr. [**Last Name (STitle) 4507**] Phone:([**Telephone/Fax (1) 3554**] Date/time: [**2185-6-30**] 10:30a Completed by:[**2185-5-18**]

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Discharge summary

report

Admission Date: [**2129-8-16**] Discharge Date: [**2129-9-12**] Date of Birth: [**2087-4-4**] Sex: M Service: SURGERY Allergies: Ketamine Attending:[**First Name3 (LF) 1481**] Chief Complaint: Metastatic renal cell carcinoma with duodenal obstruction and fistula. Major Surgical or Invasive Procedure: Roux-en-Y duodenojejunostomy & cholecystectomy on [**8-16**] History of Present Illness: 42-year-old man diagnosed with Left renal cell carcinoma in 8/[**2127**]. Surgery was performed on [**2127-9-24**]. The pathology specimen demonstrated a renal cell carcinoma, grade IV/IV, 9 cm, T4 lesion, composed of areas of papillary renal cell carcinoma and areas of mucinous tubular and spindle cell carcinoma. Since he had positive surgical margins following his surgery, subsequently received XRT/Chemo. F/U MRI demonstrated residual disease at the surgical site 93 cm) and theleft inferior abdominal wall at the site of surgical approach (4cm). Underwent Cyberknife treatment on [**2128-7-6**] to the tumor bed recurrence region, though follow-up CT revealed metastatic spread of disease. Then enrolled Sutent/Gemzar trial from [**Date range (1) 72347**], but was discontinued due to recurrent issues of pain. He saw GI on [**2129-2-25**] and was found to have a cratered non-bleeding 15mm ulcer in the 3rd/4th part of the duodenum, c/w radiationenteritis. Pt current end stage dz. Given recurrent erosion into duodenum and persistent periduo abscess pt underwent roux-en-y duodenojejunostomy and CCY [**2129-8-16**]. [**2129-8-27**] ACLS for unresponsiveness. Gradually minimally responsive/hypotension/seizure. Intubated on floor and admitted to SICU. Past Medical History: Renal Cell cancer s/p Left radical nephrectomy [**2127-9-24**], Duodenal ulcer PSH: s/p Roux-en-Y duodenojejunostomy & CCY [**2129-8-16**] Social History: The patient has moved to [**Location (un) 86**] from [**Male First Name (un) 1056**] in [**2121**]. He is living in [**State 792**]with his aunts. The patient has a girlfriend, but has never been married and has no children. He does not smoke, drink or use illicit drugs. Family History: He states both his parents are healthy. He states he is one of seven children, he has three older and three younger siblings, and they are all healthy. He denies any family history of coronary artery disease, diabetes, or cancer. Physical Exam: VSS Gen: A&o x 3, NAD HEENT: NGT in place. CVS: RRR no r/g/m Pulm: CTAB ABD: Soft, NT/ND + Bs. Well healed incision. Drain site c/d/i. Ext: WWP, No edema LE b/l. Pertinent Results: [**8-11**] Pathology: Omental nodule (A-D):Metastatic carcinoma with papillary features, see note. The tumor cells are positive for keratin cocktail (AE1/AE3; CAM 5.2 ),vimentin,PAX-2, P504s (Amacar) and mucicarmine. The tumor is negative for CK7, CK20, CD10 and P63. II) Gallbladder (B): Chronic cholecystitis, cholesterolosis. [**8-18**] gall bladder US: Findings consistent with common duct obstruction. No extravasation of tracer identified to suggest bile leak. [**8-23**] GB SCAN: c/w CBD obstruction, no extravasation of tracer. 08/07/08BAS/UGI AIR/SBFT:Extrinsic compression from metastatic disease at proximal duodenum with barium flowing freely through that site, and no evidence of obstruction. [**8-27**] P ABD XR: retained contrast throughout, no obstruction /ileus, no free air [**8-27**] BAS/UGI AIR/SBFT: Compr effect of mets on prox duodenum, no obstruction, barium at ileum at 90 min. [**2129-8-28**] CT HEAD W/ CONTRAST No evidence for metastasis. [**8-28**] EGD: Large clot in fundus, no active bleeding. Duo anastomosis visualized & ulcerated mass--likely tumor. No obv vessel or active bleed Brief Hospital Course: [**8-16**]: Roux-en-Y duodenojejunostomy with disconnection of fistula. Port placed. Pt trated with NGT, NPO, IVF, epidural managed by acute pain service. Pt transfused in PACU for low hct. [**8-17**]: Chronic pain service consulted. Epidural changed to PCA. NGT and foley continued. [**2129-8-18**] Radiology GALLBLADDER SCAN, followed LFTs. [**2129-8-19**]: PT again transfused 2 units PRBC for HCT of 22. [**2129-8-20**]: Clamping trial for NGt toleratd well. Dc'd foley and NGT. Sips for comfort. [**2129-8-21**] Radiology CHEST (PORTABLE AP. [**2129-8-25**] Radiology BAS/UGI AIR/SBFT. [**2129-8-26**] Radiology BAS/UGI AIR/SBFT. Pt NPO, IVF. [**2129-8-27**] Radiology PORTABLE ABDOMEN, CXR Code blue called because PT non responsive, HR 190s Bp 110 systolic, iV lopressor pushed x 2. Narrow complex tachycardia, Adenosine pushed with resolution. ETT placed PT transerred to the SICU. [**2129-8-28**] INPT GI CONSULT, CT HEAD W/ CONTRAST, New Picc line placed by IV team. Pt transfused. UGI bleed. IV protonix started. Vanc and Zosyn started for fever. EGD performed with ulcerated tumor mass in duodenum. [**2129-8-29**]: PT continued to be transfused fo low hct without obvious bleeding. [**8-30**]- [**9-4**]: Chronic pain to see patient. HCT stable. Palliative care consulted. Pain control and nausea difficult to control. Oncology discussed prognosis with patient. Staples removed from wound. TPN for nutrition. PT consulted. [**9-5**]: IR unable to place PEG. Palliative care involved and recs to increase bowel meds to alleviate nausea and to promote motility with octreotide, dexamethasone, reglan. [**9-7**]: Fmaily meeting regarding hospice and final prognosis. [**9-8**] surgery team and palliative care and case managment involveed in appropriate disposition and medical optimization for best quuality of life. TPN continued. [**9-9**]: Clamp trial of NGT . [**9-10**]- [**9-11**]: NGt back to suction due to continued nausea. PT transitioned off PCA to IV pain medications in anticipation of hospice care. TPN continued. Medications on Admission: Hyoscyamine 0.125''', ms contin 30-60 q8prn, morphine 15mg q4h prn, omeprazole 20'', zofran 4 q8prn, miralax, compazine Discharge Medications: 1. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 2. Prochlorperazine 25 mg Suppository Sig: One (1) Suppository Rectal Q12H (every 12 hours). 3. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 4. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 5. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 6. Metoprolol Tartrate 7.5 mg IV Q4H Hold for SBP < 100 or HR < 50 7. Pantoprazole 40 mg IV Q12H 8. Famotidine 20 mg IV Q12H 9. Dexamethasone 10 mg IV Q12H 10. Metoclopramide 20 mg IV Q6H 11. Octreotide Acetate 300 mcg IV Q8H 12. Ondansetron 8 mg IV Q8H:PRN 13. HYDROmorphone (Dilaudid) 2-3 mg IV Q3H:PRN pain hold for sedation or RR<10. 14. Prochlorperazine 10 mg IV ONCE Duration: 1 Doses Discharge Disposition: Extended Care Facility: [**Hospital 671**] [**Hospital 4094**] Hospital Discharge Diagnosis: Renal cell carcinoma with duodenal perforation and fistula. Upper gastrointestinal hemorrhage from tumor. New malignant colocutaneous fistula Carcinomatosis with functional ileus. Discharge Condition: [**Hospital 72348**] transfer to hospice care. Vital signs stable. Discharge Instructions: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Followup Instructions: Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2129-9-20**] 1:20 Completed by:[**2129-9-12**]

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icd9cm

[ [ [] ] ]

[ "99.60", "96.07", "45.91", "38.93", "99.04", "97.49", "51.22", "99.29" ]

icd9pcs

[ [ [] ] ]

6954, 7028

3749, 5822

339, 402

7252, 7321

2597, 3726

8395, 8568

2166, 2399

5992, 6931

7049, 7231

5848, 5969

7345, 8372

2414, 2578

228, 301

430, 1695

1717, 1857

1873, 2150

32,512

118,639

26154+57485

Discharge summary

report+addendum

Admission Date: [**2157-7-26**] Discharge Date: [**2157-8-4**] Date of Birth: [**2126-9-28**] Sex: F Service: MEDICINE Allergies: Penicillins / Ventolin Hfa Attending:[**First Name3 (LF) 759**] Chief Complaint: low back pain Major Surgical or Invasive Procedure: replacement of suprapubic catheter PICC line placement History of Present Illness: 30 y/o F with spinabifida presents with mid lower back pain and bilateral flank pain starting 5 days ago (last Friday) and worsening over time. On arrival to the floor, the pain is [**10-21**]. The pain radiates to the front, suprapubically. Does not radiate up her back or down her legs. Has suprapubic tube that she has not changed recently. She usually changes it on her own at home with the help of her cousin. She noticed that it has been leaking small amounts of urine from the catheter site. She also notices her urine has been red the last several days. Has a history of UTIs with MRSA and enterococcus R to cipro and S to bactrim. Pt denies fever or chills, although states she has been sweaty at times last several days. . Pt also having some abdominal pain. Has not had a bowel movement in about two weeks, usually has one every several days. Does have chronic constipation problems. Had nausea and vomitting x3 today, non bloody or bilious emesis. Pt is hungry. . Pt also has complained of some chest pain starting in the ambulance ride over. The pain does not radiate, not diaphoretic. Associated with some shortness of breath that has since resolved. EKG in emergency room was normal. Has hx of atypical chest pain and GERD. . Pt also has noticed some increased muscle spasms in her R leg, has it chronically, but it has been increasing last several days. Past Medical History: PMH: 1. Spinabifida with hydrocephalus, VP shunt, Chiari malformation 2. Siezures ? 3. UTIs/Pyelonephritis with suprapubic cath 4. Ovarian Cysts 5. Sacral decubitus ulcer 6. Atypical Chest Pain 7. Hx of PE with vena cava filter (placed at [**Hospital1 756**] about 1 yr ago) Social History: pt living with her mother, cousin helps with activities of daily living, uses wheelchair, needs assistance with ambulation. smokes 1 ppd, no alcohol, no illicit drugs Family History: NC Physical Exam: Physical Exam: Vitals: T: 9609 BP: 99/86 P: 81 RR: 13 O2Sat: 100% Gen: 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. [**1-12**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: Imaging: . CXR - Single AP view of the chest in upright position demonstrates low lung volumes. Bibasilar subsegmental atelectasis. The cardiomediastinal silhouette is within normal limits. There is no pneumothorax, consolidation, or pleural effusion. A left-sided VP shunt is seen with the distal portion coiled in the left upper abdomen. An old VP shunt is seen on the right with the uppermost portion projecting over the right mid lung zone. Thoracolumbar scoliosis is again seen. . CT [**7-27**] TL Spine: IMPRESSION: 1. Spina bifida. No fracture or subluxation. 2. Mild bilateral renal pelviectasis, new since [**2157-6-11**]. 3. Small bilateral pleural effusions. 4. Stable cystic lesion in the right adnexa. 5. MR should be considered if there is clinical concern of intraspinal lesions such as infection or hemorrhage. . Renal US: IMPRESSION: Unremarkable renal ultrasound with no hydronephrosis seen. . CT of head: A new left frontal approach intraventricular catheter terminates in the frontal [**Doctor Last Name 534**] of the left lateral ventricle adjacent to the foramen of [**Last Name (un) 2044**]. The lateral and third ventricles have increased in size since [**2155-1-3**]. There is no acute intracranial hemorrhage, shift of normally midline structures or major vascular territorial infarct. Tectal beaking is unchaged. There is mucosal thickening and aerosolized secretions in the right maxillary sinus, and a left maxillary sinus mucus retention cyst. IMPRESSION: 1. Interval enlargement of the lateral and third ventricles, concerning for shunt malfunction. 2. Stigmata of Chiari 2 malformation again noted.. 3. Aerosolized secretions in the right maxillary sinus, which may indicate acute sinusitis. . Lower Extremity US: no DVT Labs: [**2157-7-26**] 10:00AM BLOOD WBC-13.5*# RBC-4.88 Hgb-9.4* Hct-34.3* MCV-70* MCH-19.3* MCHC-27.4* RDW-16.7* Plt Ct-397 [**2157-7-30**] 04:02AM BLOOD WBC-10.7 RBC-4.57 Hgb-8.9* Hct-33.1* MCV-72* MCH-19.4* MCHC-26.8* RDW-17.0* Plt Ct-347 [**2157-8-1**] 05:54AM BLOOD WBC-9.4 RBC-4.23 Hgb-8.3* Hct-29.7* MCV-70* MCH-19.6* MCHC-27.9* RDW-17.7* Plt Ct-372 [**2157-7-26**] 10:00AM BLOOD Glucose-159* UreaN-5* Creat-0.4 Na-135 K-3.6 Cl-103 HCO3-20* AnGap-16 [**2157-7-30**] 04:02AM BLOOD Glucose-117* UreaN-3* Creat-0.4 Na-140 K-4.3 Cl-103 HCO3-30 AnGap-11 [**2157-8-1**] 05:54AM BLOOD Glucose-114* UreaN-3* Creat-0.4 Na-142 K-4.5 Cl-104 HCO3-32 AnGap-11 [**2157-7-26**] 10:00AM BLOOD ALT-22 AST-15 CK(CPK)-726* AlkPhos-89 TotBili-0.1 [**2157-7-29**] 05:18PM BLOOD ALT-22 AST-13 AlkPhos-91 TotBili-0.1 [**2157-7-26**] 10:00AM BLOOD Lipase-17 [**2157-7-26**] 10:00AM BLOOD CK-MB-15* MB Indx-2.1 [**2157-7-26**] 10:00AM BLOOD cTropnT-<0.01 [**2157-7-28**] 11:44PM BLOOD calTIBC-330 Ferritn-14 TRF-254 [**2157-7-28**] 11:44PM BLOOD TSH-1.7 [**2157-7-26**] 10:04AM BLOOD Glucose-144* Lactate-3.2* Na-135 K-3.4* Cl-103 calHCO3-21 Brief Hospital Course: Pt was admitted for back pain. We started her empirically on vanco/ceftriaxone for presumed pyelo vs. UTI because of her history of frequent infections. Her urine was not infected (seems to be contaminated), and renal US was normal. Tried to control the pain and imaged spine with CT scan. Unable to MRI spine per neurosurg because of her adjustable shunt. Were unable to see any pathology for her pain on CT scan, but cannot rule out abscess or other smoldering neurological problem. Neuro exam has remained unchanged throughout visit. She likely does not have an acute neurological emergency, but would ultimately like to image back. . Of note, on the third day of admission, her blood pressure reportedly dropped to 70-80. She felt dizzy. She had no access, so no boluses could be given. She was transferred to the MICU for management of the hypotension. On arrival to the micu her sbp was 108. She was no longer complaining of dizziness. Of note, she recieved a dose of morphine at noon and her first dose of oxybutynin at 230. the hypotension occured around 5pm. Has not had any hypotension since then. . She also has been having fevers. She spiked to 101.2 on [**7-30**]. Started on vanco/ceftriaxone again. They had been stopped when infection seemed unlikely. ID was consulted. She continued to have low grade fevers and feel hot/chills. ID thought that possibly it was due to DVT, but LE US was negative. Unknown source of fever, another reason we would like to image the back. Is to complete 5 day course of ceftriaxone from the [**7-30**] when it was started per ID recommendations. . Other problems addressed during this admission were eye irritation treated with eye drops, constipation for 3 weeks treated with aggressive bowel regimen, sacral wound examined by the wound nurse and found to be healing appropriately, and probable sleep apnea which we suggest be followed up as an outpatient. . She also continued to sometimes leak from her suprapubic catheter. It was changed twice as an inpatient and unknown why it is still leaking. Says it happens at home a lot. Were considering just increasing the size of the catheter. No infection. See below for microbiology to date: . [**7-26**] urine: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. . [**7-28**] urine: URINE CULTURE (Final [**2157-7-29**]): PROBABLE ENTEROCOCCUS. ~1000/ML. . No other urine or blood has grown anything up to date. Medications on Admission: Medications on Admission: Home Meds: Gabapentin Docusate Folic Acid Vit B / Folic Acid Tizanadine Ompeprazole Benadryl Discharge Medications: 1. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed. 12. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 14. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 2 days: Are completing total of 5 day course per ID recs. Discharge Disposition: Extended Care Discharge Diagnosis: Primary Diagnosis: 1. Back pain 2. Fevers (unknown source) 3. Hypotension 4. Spinabifida Discharge Condition: vital signs stable, SBPs around 90-100, febrile to 99.9 yesterday, with 7/10 back pain, ambulating in her wheelchair with help, normal mentation. Discharge Instructions: You were admitted to the hospital for low back pain. We tried to treat you pain with medicines but it continued. We did a CT of your spine to rule out bony abnormalities, and it was negative. Ultrasound of your kidneys were negative, too, so we didn't think you had a kidney infection. We were unable to determine the cause of your back pain. We really think you should get an MRI for further workup, and we can't give you one here because our neurosurgeons cannot readjust your shunt after the imaging. . You also had some low blood pressure during your stay. We think it may have been from some of the pain medicines we were giving you. We took you to the ICU for closer mointoring. They were able to get a PICC line in and give you fluids to help your blood pressure. . You also spiked fevers during your hospital stay. We don't know what is causing this, so that is another reason we think you should have an MRI, to rule out any possible infections in your back. . We will transfer you to [**Hospital6 **] where your shunt was placed and they will be able to do an MRI there. Followup Instructions: transferred to [**Hospital1 112**], they can discuss follow up when you are discharged Completed by:[**2157-8-1**] Name: [**Known lastname 158**],[**Known firstname 11447**] Unit No: [**Numeric Identifier 11448**] Admission Date: [**2157-7-26**] Discharge Date: [**2157-8-4**] Date of Birth: [**2126-9-28**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 1472**] Addendum: Pt was unable to be transferred on [**8-1**] - [**8-4**], so she stayed as an inpatient. She was very frustrated and was tolerating all her meds PO. She had no events overnight. Tm of 99.3 on [**7-31**] was her last low grade fever. She had unchanging back pain. She requested to go home and we agreed that she was in no acute danger from being at home. We still cannot determine the cause of her back pain and want close follow up with her neurosurgeons. . We continue to think she needs an MRI to complete the workup. She completed her 5 day course of ceftriaxone for possible culture neg UTI. Do not recommend further antibiotic treatment at this time. Etiology of low grade fevers remains unknown, no growth in any other cultures. . We tried to contact the bed facilitator at [**Name (NI) 10986**] multiple times a day for transfer. We called her neurosurgeon Dr. [**Last Name (STitle) 11449**] at [**Hospital1 10986**] for twice and then talked with her the day of admission. An appointment was made with [**Hospital1 10986**] radiology for T and L spine MRI one Wed, [**8-10**] at 6pm with neurosurg follow up to readjust shunt. Then, no [**Last Name (LF) 3032**], [**8-12**], she will have an appointment with Dr. [**Last Name (STitle) 11449**] at [**Hospital1 10986**] neurosurgery at 1:00 pm. Her PCP is aware of the situation and his office has been contact[**Name (NI) **]. We left a detailed message on his answering machine and will fax him a copy of the discharge summary. She will follow up with an appointment the week of [**8-14**]. . Discharge Disposition: Home Facility: [**Hospital6 11450**] - [**Location (un) 42**] [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1473**] Completed by:[**2157-8-28**]

[ "724.5", "741.00", "458.29", "V15.88", "996.31", "564.00", "V45.2", "780.6", "596.54", "707.03", "788.37", "E879.6" ]

icd9cm

[ [ [] ] ]

[ "57.95", "38.93" ]

icd9pcs

[ [ [] ] ]

13219, 13434

5754, 8230

299, 355

9878, 10026

2850, 5731

11164, 13196

2272, 2276

8400, 9707

9766, 9766

8282, 8377

10050, 11141

2306, 2831

246, 261

383, 1771

9785, 9857

1793, 2071

2087, 2256

54,005

177,768

24422

Discharge summary

report

Admission Date: [**2174-8-18**] Discharge Date: [**2174-8-29**] Date of Birth: [**2112-11-24**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 668**] Chief Complaint: Confusion/lethargy Major Surgical or Invasive Procedure: [**2174-8-24**]: Esophagogastroduodenoscopy [**2174-8-25**]: Visceral angiography, intracranial angiography with embolization [**2174-8-25**]: Exploratory laparotomy, decompressive laparotomy [**2174-8-25**]: Abdominal washout [**2174-8-27**]: Abdominal washout History of Present Illness: This is a 61 yom with Hep C cirrhosis genotype I with grade II varices and hepatic encephalopathy on lactulose/rifaximin with calculated MELD score of 22 as of [**2174-8-11**]. He is currently on the liver Tx list with workup complete. He was recently admitted on [**6-/2174**] for volume overload now presenting with confusion and lethargy. Most of the history is obtained from his daughter who reports an acute decompensation yesterday with increaed confusion. He has been taking lactulose 6x/day in addition to miralax but has not had any BM for 2 days. He denies any increase in ascites, fevers, CP, SOB, abd pain, or increased swelling of his extremities. His daughter does note an increase in his jaundice. He denies any blood in his stool or melena. . On the floor, pt is interactive but slow to respond and appears to be searching for words. He appears frustrated by his confusion. Past Medical History: 1. HCV cirrhosis: genotype I -grade II varices no h/o variceal bleeding -hepatic encephalopathy on lactulose/rifaximin (admitted [**Month (only) **] [**2173**] and [**2174-6-27**]) 2. IDDM 3. Hemorrhoids Past Surgical History: R hip replacement x 2, remote appendectomy. Social History: Married, has 3 daughters. [**Name (NI) **] works as an engineer at Teradyne (on short-term disability). He denies any alcohol use or tobacco use. Remote history of IVDA. Family History: Mom with DM. Physical Exam: ADMISSION EXAM Vitals: 97.3 130/80 55 18 100% RA General: Pleasant AA male in NAD. He is oriented to person, place and year, but not month. HEENT: OP dry, EOM intact. Scleral icterus present Neck: Supple Heart: RRR no m/r/g Lungs: CTAB Abdomen: Soft, NT, ND, no palpable liver Extremities: Trace edema bilaterally in the LE Neurological: A/o x2.5. asterixis present DISCHARGE EXAM Expired Pertinent Results: ADMISSION LABS: [**2174-8-18**] 04:40PM BLOOD WBC-4.9 RBC-2.69* Hgb-8.9* Hct-27.4* MCV-102* MCH-33.2* MCHC-32.6 RDW-18.4* Plt Ct-42* [**2174-8-18**] 04:40PM BLOOD Neuts-56.7 Lymphs-31.4 Monos-11.2* Eos-0.2 Baso-0.4 [**2174-8-18**] 04:40PM BLOOD PT-30.3* PTT-62.3* INR(PT)-3.0* [**2174-8-18**] 04:40PM BLOOD Glucose-177* UreaN-15 Creat-1.1 Na-117* K-5.0 Cl-87* HCO3-25 AnGap-10 [**2174-8-18**] 04:40PM BLOOD ALT-182* AST-492* LD(LDH)-630* AlkPhos-218* TotBili-8.2* [**2174-8-18**] 04:40PM BLOOD Albumin-1.9* Calcium-9.2 Phos-2.9 Mg-1.7 Iron-130 CT abdomen/pelvis [**2174-8-24**]: 1. No intra-abdominal hemorrhage. 2. Sequelae of portal hypertension including varices and moderate perihepatic simple ascites. 3. Severe degenerative changes of the left hip. Visceral arteriography [**2174-8-25**]: 1. Normal celiac artery angiogram with selective catheterization of the gastroduodenal artery and left gastric artery. 2. Normal superior mesenteric artery angiogram. 3. No active arterial extravasation from the visceral aortic branches. TTE [**2174-8-26**]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. 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 moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2174-7-4**], the LV cavity is slightly smaller, there is some turbulence in the LVOT with a mild functional outflow tract gradient. TTE [**2174-8-28**]: The left atrium and right atrium are normal in cavity size. Left ventricular systolic function is hyperdynamic (EF>75%). No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Physiologic mitral regurgitation is seen (within normal limits). Tricuspid regurgitation is present but cannot be quantified. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. No interval change in comparison to [**2174-8-26**]. Brief Hospital Course: 61-year-old African-American pleasant male with genotype 1 hepatitis C-induced cirrhosis who is on the liver transplant list presenting with confusion/lethargy [**12-29**] to encephalopathy and/or hyponatremia. . Pertaining to his hospital course [**2174-8-18**] to [**2174-8-24**]: . # Hep C cirrhosis with HE: Pt is on the liver transplant list with Meld of 28 on admission. Family had noted an increase in confusion over past few days prior to admission in setting of not having BMs despite taking his lactulose and miralax. Patient was given frequent lactulose with miralax and started stooling adequately. Mental status and asterixis was waxing and [**Doctor Last Name 688**] throughout his hospital stay. He was also continued on rifaximin and nadolol. His infectious workup was negative. His lasix was initially held given hyponatremia. . # Hyponatremia: Pt with Na+ of 117 on admisssion. He has chronically low sodium, however his baseline was 125. His renal ultrasound was normal. Renal was consulted and after he did not respond to fluid restriction, he was started on one dose of tolvaptan, however did not respond and this was discontinued. After starting the tolvaptan his urinary output decreased and there was concern for HRS. He was about to be challenged with a volume challenge when he was no longer holding his pressures and required transfer to the unit. . # DM - Pt was given 5U of glargine nightly (takes levamir at home). He was also maintained on insulin sliding scale while in the hospital. . On [**8-24**]- the patient became oliguric, and developed hypotension despite fluid bolus and hypothermia and was felt that he could have sepsis of unknown origin and he was transferred to the SICU. Pertaining to his hospital course [**2174-8-24**] to [**2174-8-29**]: . On [**2174-8-24**], the patient was transferred to the SICU on the transplant surgery service for hypothermia (T 93) and hypotension (SBP 80). Blood and urine cultures were repeated, which showed no growth. Blood was also negative for fungemia. He was transfused 2u PRBC for hct 24.7, after which hct 22.1. Rectal exam revealed positive occult blood without gross blood. Nasogastric lavage revealed coffee grounds fluid which did not clear significantly after 1L lavage. He was further transfused and started on octreotide and pantoprazole gtts. He was intubated and EGD found no obvious source of bleeding. Bronchoscopy found no obvious bleed. He developed epistaxis, for which ENT was consulted, and his nasopharynx was packed. . On [**2174-8-25**], he was taken to IR. Arteriography of the celiac and superior mesenteric arteries revealed no obvious UGI bleed. Bilateral inferior maxillary arteries were embolized for his continued epistaxis. At the end of the procedure, his abdomen was distended and he was increasingly difficult to ventilate. He was brought emergently to the operating room for decompressive laparotomy, which revealed no intraperitoneal bleed or hematoma. He was left with an open abdomen and returned to the SICU. He developed worsening hypotension, requiring norepinephrine gtt, and his abdomen was re-explored, revealing some blood, but insufficient to explain his transfusion requirements. Bloodwork (low haptoglobin, high LDH) suggested hemolysis with no clear aetiology. . On [**2174-8-26**], hypothermia resolved and CVVH was started for worsening renal function. He continued to have a mild ooze from his nose and mouth and was transfused for hct <30. . On [**2174-8-27**], he underwent abdominal washout at the bedside, which was unrevealing. There was again no obvious source of bleeding. The bowel appeared less edematous and the Ioban dressing was replaced. Post-operatively, he required additional vasopressors, and vasopressin gtt was added. For sedation, propofol gtt was changed to fentanyl and midazolam gtts. Cortisol stimulation test was equivocal. . On [**2174-8-28**], he remained hypotensive and continued to bleed from JP, NGT, left ear, and mouth. Refractory hypotension to pressors, some response to volume. Bedside ECHO showed hyperdynamic empty LV and hypodynamic strained RV with PAP in the 60's. started nitric oxide with improved BP, PaO2. Switched to meropenem and Micafungin for broad empiric coverage. brief episode of Afib with RVR. Spontaneous conversion to SR. Delisted from liver transplant list on account of his critical illness. Overnight, his hypotension worsened, requiring up to three vasopressors, though these were weaned to one by morning. . On [**2174-8-29**], in the morning, he received 2 units PRBCs for a hematocrit of 26.1, with response in hematocrit to 30.6, but subsequent continued decline to 29.1. He received 1 unit of frozen plasma with no subsequent change in INR. In the early afternoon, per the patient's family's request, the patient was rendered comfort measures only, and he died at 14:20. Medications on Admission: Calcium plus D3 clotrimazole 10mg troche 5x daily Vitmain D2 [**Numeric Identifier 1871**] U q week lasix 20mg po bid levemir 5U nightly humalog up to 20U daily as needed lactulose 30ml po 6x daily nadolol 20mg po daily omeprazole 20mg po daily polyethylene glycol 3350 17g powder daily when no BM rifaximin 550mg po bid spironalactone 50mg po daily Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Expired. Discharge Condition: Expired. Discharge Instructions: He who has gone, so we but cherish his memory. Followup Instructions: None. Completed by:[**2174-8-30**]

[ "276.4", "998.11", "784.7", "070.44", "276.7", "E878.8", "V58.67", "456.21", "276.1", "584.5", "286.9", "250.00", "V49.83", "287.5", "729.73", "571.5", "038.9", "V49.86", "V43.64", "785.52", "995.92", "572.4", "416.8", "276.50", "518.81" ]

icd9cm

[ [ [] ] ]

[ "33.23", "45.13", "38.91", "96.72", "99.15", "54.12", "99.29", "39.95", "21.01", "54.11", "96.04", "38.97", "88.47", "88.41" ]

icd9pcs

[ [ [] ] ]

10289, 10298

4965, 9859

322, 585

10350, 10360

2460, 2460

10455, 10491

2011, 2025

10260, 10266

10319, 10329

9885, 10237

10384, 10432

1762, 1807

2040, 2441

264, 284

613, 1512

2477, 4942

1534, 1739

1823, 1995

57,036

162,444

31143

Discharge summary

report

Admission Date: [**2191-3-1**] Discharge Date: [**2191-3-2**] Date of Birth: [**2106-3-17**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: 84 y.o female with history of alzheimer's depression, hypothyroidism who presented to the emergency room with reported hypotension at her skilled nursing facility today. By report, the patient was found by EMS to have a systolic BP in the 80s and a heart rate in the 150s after they were called by the extented care facility for generalized weakness. This returned to normal prior to her being transferred to [**Hospital1 18**]. Apparently she had been also complaining of some chest heaviness at the time. . On arrival, her vital signs were temp of 96.8, hr of 89, bp 96/56, RR 14 and oxygen saturation of 94% on RA. An echo was performed by cardiology due to a troponin of 0.12, and there was concern about an intimal flap in the abdominal aorta. There was no focal wall motion abnormality. A CT torso was then obtained, which showed no evidence of PE or dissection. CXR was clear, however she got ceftriaxone and vancomycin and 3L of NS. She was then admitted to the MICU for further management. Prior to transfer, her vitals were 96.5 70 96/64 18 100% on RA. . On arrival to the ICU, the patient denied all complaints. History was somewhat limited due to advanced dementia however. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: hypothyroidism dementia depression Social History: The patient is divorced. She does not smoke tobacco or drink alcohol. She has a Ph.D. in languages and literature. She currently resides at [**Last Name (un) **] house. Family History: Family history is notable for her father who died in his 50s from cancer and mother who died at age 36 from cancer. She has a brother who died from cancer in his 60s, but has a sister at age 77 who was in good health and a brother age 75 who has a history of heart disease. There is a history of a maternal aunt who had some memory problems beginning in her late 80s who died in her 90s. Physical Exam: General: Alert, oriented x1, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, pupils equal round and reactive to light Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, 2/6 systolic ejection murmur, s1 not appreciated, normal s2. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: multiple skin tags and nevi. Pertinent Results: [**2191-3-1**] 02:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2191-3-1**] 02:40PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0 [**2191-3-1**] 01:55PM GLUCOSE-81 LACTATE-1.8 K+-4.2 [**2191-3-1**] 01:45PM GLUCOSE-82 UREA N-13 CREAT-0.8 SODIUM-139 POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-23 ANION GAP-16 [**2191-3-1**] 01:45PM ALT(SGPT)-23 AST(SGOT)-30 ALK PHOS-127* TOT BILI-0.4 [**2191-3-1**] 01:45PM cTropnT-0.12* [**2191-3-1**] 01:45PM CALCIUM-8.9 PHOSPHATE-4.4 MAGNESIUM-2.1 [**2191-3-1**] 01:45PM TSH-2.0 [**2191-3-1**] 01:45PM CORTISOL-12.3 [**2191-3-1**] 01:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2191-3-1**] 01:45PM WBC-9.6 RBC-4.29 HGB-13.1 HCT-38.4 MCV-90 MCH-30.5 MCHC-34.1 RDW-13.3 [**2191-3-1**] 01:45PM NEUTS-54.6 LYMPHS-40.1 MONOS-3.1 EOS-1.8 BASOS-0.4 [**2191-3-1**] 01:45PM PLT COUNT-175 [**2191-3-1**] 01:45PM PT-11.9 PTT-23.3 INR(PT)-1.0 Cardiac Echo: The left atrium is elongated. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The diameters of aorta at the sinus, ascending and arch levels are normal. The descending thoracic aorta is mildly dilated. A dissection of the abdominal aorta is suggested (clip [**Clip Number (Radiology) **]), but cannot be confirmed. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be quantified. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Possible abdominal aortic dissection. Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. If clinically indicated, an abdominal CT or MRI are suggested to assess for possible Type B aortic dissection. AP PORTABLE CHEST, [**2191-3-1**], AT 1359 HOURS. HISTORY: Hypertension and chest pressure. COMPARISON: None. FINDINGS: No consolidation or edema is evident. There is mild elevation of the right hemidiaphragm of unknown chronicity. Linear atelectasis is seen in the retrocardiac left lower lobe. The mediastinum is otherwise unremarkable. The cardiac silhouette is within normal limits for size. No effusion or pneumothorax is noted. The bones are diffusely osteopenic but otherwise unremarkable. IMPRESSION: No acute pulmonary process. CT torso with contrast [**2191-3-1**]: Wet Read: ENYa TUE [**2191-3-1**] 5:16 PM 1. No PE or acute aortic pathology. 2. Borderline right hilar lymphadenopathy. 3. No definite focal air-space consolidation. Bibasilar atelectasis. Brief Hospital Course: 84 y.o woman with history of alzheimer's dementia, hypothyroidism depression who presents to the ICU with reported tachycardia and hypotension. On arrival to the ICU she was comfortable and without complaints . #Hypotension and tachycardia: The patient likely had an arrythmia, either atrial flutter (reported rate of 150) or fibrillation, which resolved prior to arrival to the hospital. This would also explain her mild troponin leak of 0.12, which could reflect demand ischemia. There is no evidence of infection currently, and diagnostic tests have found no evidence of pulmonary embolism. There was concern for aortic dissection on her echo in the emergency room, however there was no evidence of this on CTA of her torso as a follow-up study. Her blood pressures were within normal limits during her stay in the ICU. . #Delirium: The patient had a history of alzheimers and she was quite confused on admission the ICU. The patient became delirious by the morning which was likely secondary to being in the ICU. Her laboratory and radiologic investigations showed no likely organic cause for her delirium. She required frequent re-orientation and she was sent back to her skilled nursing facility where she would be at lower risk for developing delirium. Medications on Admission: loperamide 2mg tid prn diarrhea levothroxine 100mcg qday citalopram 10mg qday b12 1000mcg daily tums 1 tab tid vitamin d 800U tid Discharge Medications: 1. levothyroxine 50 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. loperamide 2 mg Capsule Sig: One (1) Capsule PO three times a day as needed for diarrhea. 4. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO every eight (8) hours. 6. Tums 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day. Discharge Disposition: Extended Care Facility: [**Last Name (un) 35689**] House Discharge Diagnosis: Syncope Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital because you felt weak and tired. When the paramedics arrived, they found that your blood pressure was low and your heart rate was elevated, however these got better before you arrived at the hospital. You had some studies that showed no new problems. [**Name (NI) **] likely what happened was your heart went into an abnormal rhythm but then got better. Followup Instructions: You should make an appointment with your primary care provider within the next 2 weeks. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2191-3-3**]

[ "331.0", "294.10", "427.89", "311", "293.0", "780.2", "244.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8087, 8146

6117, 7385

322, 329

8198, 8198

3276, 6094

8763, 9017

2287, 2679

7566, 8064

8167, 8177

7411, 7543

8348, 8740

2694, 3257

1574, 2022

270, 284

357, 1555

8213, 8324

2044, 2081

2097, 2271

21,192

140,260

3027

Discharge summary

report

Admission Date: [**2124-8-6**] Discharge Date: [**2124-8-11**] Date of Birth: [**2086-10-17**] Sex: M HISTORY OF PRESENT ILLNESS: A 38-year-old male with a history of human immunodeficiency virus with last CD4 in the 200s, and viral load of approximately 50, per the patient three weeks ago, hepatitis C, chronic renal insufficiency, of hyperkalemia who presents with a 3-day history of nausea and sharp umbilical/epigastric abdominal pain. The patient first noted nausea without abdominal pain intermittently over the three days prior to admission without emesis. The evening before admission after dinner, the patient had the sudden onset of lightheadedness accompanied by severe nausea and abdominal pain. No chest pain or shortness of breath. Emergency Room. Upon arrival, the patient was noted to have mental status changes, bradycardia to the 20s, and a systolic blood pressure in the 150s/palp. He was treated with atropine 1 mg times two and epinephrine 1 mg times three with improvement of his heart rate to approximately 50. Initial laboratories revealed a potassium of 6.8. The patient was given bicarbonate, calcium gluconate, insulin, and glucose. Initial electrocardiogram showed severe bradycardia at approximately 18 beats per minute. A repeat electrocardiogram showed a wide QRS complex and peaked T waves in leads V1 and V2. A repeat potassium was approximately 5 after the above interventions. Laboratories revealed an increase in liver function tests, amylase, and lipase. An abdominal CT showed peripancreatic fat stranding, perihepatic subcapsular fluid with splenomegaly. Approximately two hours later, a repeat potassium was 6.6 with continued peak T waves in the precordial leads. The patient was again treated with calcium gluconate, bicarbonate, insulin, glucose, Kayexalate, and 4 puffs of albuterol. He was then subsequently transferred to the Medical Intensive Care Unit for further evaluation. PAST MEDICAL HISTORY: 1. Human immunodeficiency virus diagnosed two years ago; last CD4 approximately 200s, and viral load of 50, per the patient three weeks ago. 2. Scrofula and positive lymphadenopathy node biopsy from the neck diagnosed in [**2123-12-23**]. 3. Hypertension. 4. History of hyperkalemia. 5. Chronic renal insufficiency. 6. Hepatitis C. MEDICATIONS ON ADMISSION: Verapamil 240 mg p.o. q.d., Minoxidil 2.5 mg p.o. b.i.d., Kaletra 3 tablets b.i.d., Epivir 1 tablet p.o. b.i.d., Zerit 1 tablet p.o. b.i.d., Prilosec 1 tablet p.o. q.d., isoniazid, pyrazinamide, ethambutol. ALLERGIES: Allergy to BACTRIM, RIFAMPIN, and COMPAZINE. SOCIAL HISTORY: He works as an interior designer. He denies alcohol or tobacco use. Denies any intravenous drug use. He arrived from [**Male First Name (un) 1056**] six years prior. His primary care physician is [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 14427**] ([**Telephone/Fax (1) 14428**]). PHYSICAL EXAMINATION ON ADMISSION: In general, ill-appearing, in no apparent distress currently. Vital signs were temperature of 100.6, heart rate 84, blood pressure 144/74, respiratory rate 12. HEENT revealed pupils were equal, round, and reactive to light. Extraocular movements were intact. Mucous membranes were moist. No thrush noted. Neck was supple without any lymphadenopathy or jugular venous distention. Lungs were clear to auscultation bilaterally. Cardiovascular revealed a regular rate and rhythm, S1 and S2 normal. No murmurs. Abdomen was soft, positive guarding, no rebound. Exquisite tenderness with light palpation of the epigastrium and periumbilical region. Normal active bowel sounds noted. Neurologically, alert and oriented times three. Moved all four extremities. Guaiac-negative per the Emergency Room. Extremities revealed no cyanosis, clubbing or edema. LABORATORY DATA ON ADMISSION: White blood cell count 8.1 with 52% neutrophils, 42% lymphocytes, hematocrit 36, platelets 157. Coagulation studies revealed an INR of 2. Chem-7 revealed a sodium of 128, potassium of 6, chloride 99, bicarbonate 15, BUN 39, creatinine 2.5, glucose 169. AST 224, ALT 121, amylase 169. Creatine kinase 94. Troponin of less than 0.3. Alkaline phosphatase 116, total bilirubin 2, albumin 3.2, calcium 8.2, magnesium 2, phosphorous 5.1, lipase 155. RADIOLOGY/IMAGING: Chest x-ray showed no evidence of infiltrates or effusions. Abdominal CT showed atelectasis bilaterally at the lung bases, small subscapular perihepatic fluid gallbladder sludge, left periaortic lymph node, splenomegaly at 15.5 cm, left inguinal lymph node, and peripancreatic duct changes consistent with pancreatitis. The initial electrocardiogram showed wide complex QRS with severe bradycardia and low junctional escape. Electrocardiogram #2 revealed continued wide complex rhythm with ventricular rate of approximately 50s to 80s, with peak T waves in the precordial leads. Final electrocardiogram after several described interventions showed normal sinus rhythm at 80 with peak T waves in V1, V2, and V3. HOSPITAL COURSE: Mr. [**Known lastname **] was admitted to the [**Hospital1 346**] Medical Intensive Care Unit for treatment of hyperkalemia and pancreatitis. Thus, the hospital dictation will be dictated by problem. 1. GASTROINTESTINAL: The patient has a prior history of pancreatitis with up to five episodes in the past, most recently in [**Month (only) 116**] at [**Hospital1 69**]. His most recent problem was an acute flare. Several possible hypotheses/reasons for the pancreatitis including possible gallstones noted by the gallbladder sludge seen in the Emergency Room, also thought secondary to his human immunodeficiency virus or human immunodeficiency virus medications. He was made n.p.o. initially and was intravenous fluid resuscitation. He was given Demerol p.r.n. for pain, and laboratories were followed over the course of several days. His antiretroviral medications were held because of the potential that they could cause pancreatitis. The Gastrointestinal team was consulted and felt that it was possible his pancreatitis could be related to his gallbladder sludging or human immunodeficiency virus medications and recommended endoscopic retrograde cholangiopancreatography. In addition, the Surgery team was consulted and initially recommended endoscopic retrograde cholangiopancreatography to check for the presence of a common bile duct stone. On hospital day two, an endoscopic retrograde cholangiopancreatography was performed which showed sludge within the gallbladder, thickened gallbladder wall, and evidence of small ascites, but no common bile duct dilatation. Meanwhile, he continued to receive intravenous fluids and his amylase and lipase had trended down from initial high values of amylase 159 and lipase 155, to amylase of 106 and lipase of 95 on the second day of hospital admission. In consultation with Surgery and Gastrointestinal teams, it was felt that his acute pancreatitis could possibly still be due to the presence of gallbladder sludging that was seen on MRCP and it was recommended to get a HIDA scan. Throughout, his liver function tests remained elevated, and a HIDA scan on [**8-8**] showed gallbladder sludge with calcified thickened liquid and dilatation of the common bile duct with normal gallbladder filling. At this time, the etiology of the pancreatitis remained unclear. By hospital day five, the patient was tolerating p.o. liquids quite well, and his pancreatic had returned to [**Location 213**]. He was tolerating p.o. and denied nausea, vomiting, and abdominal pain. He was discharged to have close followup with his primary care physician at [**Hospital6 **]. His hepatologist, Dr. [**Last Name (STitle) 14429**] at [**Hospital6 **], was aware of his treatment here and discussed it with attending Dr. [**First Name8 (NamePattern2) 8771**] [**Last Name (NamePattern1) 951**] at the [**Hospital1 188**]. The patient was to meet with his hepatologist Dr. [**Last Name (STitle) 14429**] for further discussion of his pancreatitis with possible scheduled cholecystectomy in the future as was scheduled previously; however, cancelled secondary to acute hospitalization here at [**Hospital1 69**]. In addition, throughout the hospital course, Mr. [**Known lastname **] continued to have an elevated transaminitis. This was possibly secondary to viral hepatitis as he has a history of hepatitis C, possibly also related to his anti-TB medications. Hepatitis serologies were positive for hepatitis B surface antibody, and his anti-TB medications were held throughout his hospital stay. His course was again discussed with Dr. [**Last Name (STitle) 14429**], his hepatologist, and he will continue to receive his continued care at [**Hospital6 14430**]. In discussion with Dr. [**Last Name (STitle) 14431**], his Infectious Disease physician, [**Name10 (NameIs) **] will be discharged from the hospital without his human immunodeficiency virus or anti-TB medications until further notice. 2. RENAL: Mr. [**Known lastname **] presented to the hospital with acute renal failure and chronic renal insufficiency suspected to be a prerenal etiology given his several-day history of nausea, decreased p.o. intake, and pancreatitis. His BUN and creatinine improved with fluid hydration, and intravenous fluids were continued throughout his hospitalization. Her hyperkalemia with electrocardiogram changes was felt initially secondary to acute renal failure. The Renal staff was consulted and felt the most likely etiology of his hyperkalemia was suggestive of RTA or adrenal insufficiency. A random cortisol was drawn which was normal. Mr. [**Known lastname **] hyperkalemia normalized throughout the course of two days after receiving continued Kayexalate in the Medical Intensive Care Unit. He was transferred to the floor because his electrocardiogram completely normalized, and his potassium normalized to 4.4. On hospital day four, in consultation with his [**Hospital6 14430**] physicians, the patient was noted to have at least four previous episodes of hyperkalemia. He has been evaluated extensively at [**Hospital6 **] with VMA, metanephrine, aldosterone levels, ACTH, and cortical stem tests and have all been negative repeatedly. A renal biopsy at that time showed immune complex glomerulonephritis with membranoproliferative pattern and arterial sclerosis. The etiology was felt secondary to hepatitis C and hypertension. On hospital day four, a supine and standing renin and aldosterone levels upon which were found to be at the lower range of normal. On the day of hospital discharge Mr. [**Known lastname **] potassium was normal times several days. He had no other episodes of chest pain or electrocardiogram changes and it was thought he could be best followed up with further follow up with his primary physicians at [**Hospital6 14430**]. 3. CARDIOVASCULAR: Mr. [**Known lastname **] presented with severe bradycardia and peak T waves related to his hyperkalemia. As his hyperkalemia was treated and his level responded to a normal level, his electrocardiograms converted back to a normal sinus rhythm. He was monitored on telemetry for two days after his potassium normalized, and he had no episodes of arrhythmias. By the time he was discharged he had no further complaints throughout the duration of his hospital course. 4. INFECTIOUS DISEASE: Infectious Disease was consulted because of the possibility that his human immunodeficiency virus and his human immunodeficiency virus medications could be a source of his pancreatitis. His antiretroviral medications were discontinued. In addition, his transaminitis could be caused by his anti-TB medications, especially INH, and these were discontinued as well. However, at the time of discharge it was not felt that his pancreatitis was due to his antiretrovirals and this should not preclude from receiving his medications in the future, as his pancreatitis was most likely due to gallbladder etiology which will be explored further by his primary care physician at [**Hospital6 **]. In discussion with Dr. [**Last Name (STitle) 14431**], his Infectious Disease physician, [**Name10 (NameIs) 14432**] that he will be discharged from the hospital without antiretroviral and anti-TB medications until further notice. He will follow up with Dr. [**Last Name (STitle) 14433**] at that time. DISCHARGE STATUS/CONDITION: Mr. [**Known lastname **] was discharged to home on hospital day four in good condition. He was tolerating p.o. well and denying any nausea, vomiting, or abdominal pain. DISCHARGE FOLLOWUP: He was discharged with close follow up with his physicians at [**Hospital6 **]. Prior to discharge Nutrition spoke with him about avoiding high fat and high potassium foods. DISCHARGE PLAN: Plan at discharge was to have a scheduled cholecystectomy after he is fully clinically recovered with this episode. DISCHARGE DIAGNOSES: 1. Pancreatitis. 2. Hyperkalemia. 3. Human immunodeficiency virus. 4. Scrofula. 5. Chronic renal insufficiency. MEDICATIONS ON ADMISSION: 1. Verapamil 240 mg p.o. q.d. 2. Reglan 10 mg p.o. q.i.d. p.r.n. 3. Compazine 10 mg p.o. p.r.n. 4. Procrit 10,000 units every week. 5. Colace 100 mg p.o. b.i.d. 6. Prilosec 40 mg p.o. q.d. 7. Actigall 200 mg p.o. t.i.d. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 9783**] Dictated By:[**Last Name (NamePattern1) 14434**] MEDQUIST36 D: [**2124-8-22**] 22:39 T: [**2124-8-25**] 08:06 JOB#: [**Job Number 14435**]

[ "042", "577.0", "403.91", "584.9", "276.7", "011.90", "276.5", "070.54" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12991, 13109

13135, 13623

5094, 12639

12660, 12836

147, 1956

3892, 5076

12853, 12970

1978, 2317

2627, 2986

67,504

190,085

34957

Discharge summary

report

Admission Date: [**2192-3-17**] Discharge Date: [**2192-3-20**] Date of Birth: [**2114-9-21**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Chest pain/ Shortness of breath Major Surgical or Invasive Procedure: Cardiac Cath Pericardial fluid drained History of Present Illness: 77 yo M with hx of asthma, HL, Multiple myeloma presented to [**Hospital3 **] in [**Location (un) 620**] with cough and fever of one week duration . The patient describes intermittent pleuritic chest pain and general malaise and weakness during a 5 day driving trip from [**State 15946**]. He said he took nsaids without relief. He denied fevers/chills but endorsed a runny nose. At [**Location (un) 620**], he had a low-grade fever and was originally treated empirically for presumed PNA. However on the day of admission he became tachypneic into the 140s and underwent a CT-A of his chest to rule out PE which showed a large pericardial effusion. Patient also had evidence of pericardial tamponade with elevated neck veins, tachycardia. His systolic BP was stable between 110- 115. He had a pulsus paradoxus of 30 to 40 mmHg. He was transfered here and underwent emergent ECHO which showed large pericardial effusion and hypercontractile ventricle. He then underwent a RH cath. His effusion was drained, a drain was placed and he was admitted to the CCU. On arrival, his vitals were Afebrile, 107, 114/70, 22, 94% 2L Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: None -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: Multiple myeloma - IgG kappa monoclonal protein essential thrombocytosis asthma Social History: -Tobacco history: none -ETOH: occasionally -Illicit drugs: none - Lived in Montreal and moved to MA 20 years ago Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. . Physical Exam: On admission: T=afebrile BP=114/70 HR=110 RR=20 O2 sat=94%RA GENERAL: NAD, lying in bed post-cath. 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 no JVD CARDIAC: PMI located in 5th intercostal space, midclavicular line. irregular tachycardic heart rate, distant heart sounds, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi in frontal fields (pt could not sit s/p cath) ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ On discharge: alert, walking around halls without difficulty. RRR, lungs CTAB. Pertinent Results: Labs on admission: [**2192-3-17**] 11:30PM OTHER BODY FLUID TOT PROT-6.7 GLUCOSE-110 LD(LDH)-587 AMYLASE-44 ALBUMIN-2.3 [**2192-3-17**] 11:30PM OTHER BODY FLUID WBC-2988* RBC-[**Numeric Identifier 79970**]* POLYS-35* LYMPHS-37* MONOS-16* EOS-3* ATYPS-1* MACROPHAG-8* [**2192-3-17**] 08:39PM GLUCOSE-128* UREA N-16 CREAT-1.2 SODIUM-125* POTASSIUM-5.4* CHLORIDE-96 TOTAL CO2-20* ANION GAP-14 [**2192-3-17**] 08:39PM estGFR-Using this [**2192-3-17**] 08:39PM LACTATE-1.7 K+-4.6 [**2192-3-17**] 08:39PM WBC-15.6* RBC-3.51* HGB-10.2* HCT-30.4* MCV-87 MCH-29.1 MCHC-33.6 RDW-16.8* [**2192-3-17**] 08:39PM NEUTS-78.2* LYMPHS-10.8* MONOS-9.5 EOS-1.0 BASOS-0.4 [**2192-3-17**] 08:39PM PLT COUNT-871* [**2192-3-17**] 08:39PM PT-15.8* PTT-33.6 INR(PT)-1.4* Sodium [**2192-3-17**] 08:39PM BLOOD Na-125* [**2192-3-18**] 09:20PM BLOOD Na-127* [**2192-3-20**] 07:20AM BLOOD Na-128* Creatinine [**2192-3-17**] 08:39PM BLOOD Creat-1.2 [**2192-3-18**] 09:20PM BLOOD Creat-1.3* [**2192-3-20**] 07:20AM BLOOD Creat-1.1 Microbiology: Blood cultures x5: no growth upon discharge Urine culture: no growth Legionella urine ag: negative Sputum cx: GRAM STAIN (Final [**2192-3-18**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN SHORT CHAINS AND IN CLUSTERS. RESPIRATORY CULTURE (Final [**2192-3-20**]): MODERATE GROWTH Commensal Respiratory Flora. Pericardial fluid: [**2192-3-17**] 11:30 pm FLUID,OTHER PERICARDIAL FLUID. GRAM STAIN (Final [**2192-3-18**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ACID FAST CULTURE (Preliminary): ACID FAST SMEAR (Final [**2192-3-20**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. Imaging: ECHO [**3-17**] The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thicknesses are normal. Left ventricular systolic function is hyperdynamic (EF 75%). Right ventricular chamber size and free wall motion are normal. There are three aortic valve leaflets. The mitral valve leaflets are mildly thickened. There is a moderate to large sized pericardial effusion. The effusion appears circumferential. No right atrial or right ventricular diastolic collapse is seen. There is significant, accentuated respiratory variation in tricuspid valve inflows, consistent with impaired ventricular filling. IMPRESSION: Moderate to large circumferential pericardial effusion with early tamponade physiology. ECHO [**3-18**] Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular free wall is hypertrophied. There is a small pericardial effusion, possibly loculated, subtending the right ventricular free wall and also the basal lateral wall of the left ventricle. There are no echocardiographic signs of tamponade. No right atrial or right ventricular diastolic collapse is seen. Compared with the prior study (images reviewed) of [**2192-3-17**] the pericardial effusion is mostly gone. ECHO [**3-20**] The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2192-3-19**], the pericardail effusion now appears slightly larger. CXR [**3-18**] Comparison is made to prior study from the day before. There is patchy airspace opacification at the bilateral lower lobes, small bilateral pleural effusions. Heart and mediastinum within normal limits. No pneumothorax. Brief Hospital Course: 77 yo M with asthma, MM, HL presents with one week of fatigue/malaise and chest pain with pericardial effusion. The most likely etiology is viral pneumonia with associated pericardial effusion. . ACTIVE ISSUES . # PERICARDIAL EFFUSION [**1-4**] respiratory viral process: He presented with a large effusion by TTE, explaining his chest pain. Percardiocentesis was done and the >500cc was drained. The drain was left in place until there was no further drainage. To rule out other causes, further testing was done: TSH normal (2.2), HIV negative, [**Doctor First Name **] negative. Pericardial fluid studies were unrevealing. He continued to spike fevers and infectious work-up did not reveal any additional causes. We felt this was likely due to his pericarditis. Repeat TTEs were done s/p drainage and when the drain was pulled, showing resolution of the effusion. Since he continued to have mild chest discomfort, he was started on colchicine on discharge until follow-up with his outpatient cardiologist, after consultation with his outpatient oncologist. An echocardiogram will be repeated as an outpatient. His upper respiratory symptoms improved and he will finish out a 7-day course of levofloxacin for his presumed pneumonia. . # RHYTHM: Pt presented with rapid A-Fib, which appeared to be new and coincided with his effusion. It is likely that the effusion is the cause of his Afib through dynamic wall stretch. On the morning after admission, pt had an asymptomatic episode of bradycardia into the 30s while converting to sinus rhythm. He had received 2.5mg lopressor IV push as well as a 12.5mg PO am dose. In this setting his BP transiently decreased to SBP 70s but quickly increased to 100s. He had no further episodes and his EKGs were stable upon discharge, in NSR. . # HYPONATREMIA: Looking through past records, it appears that this hyponatremia (nadir to 125) is new. Urine studies and very small response to fluid boluses made this clinical picture more consistent with SIADH. The sodium improved to 128, but he will be receiving outpatient lab work to monitor his sodium. . # ACUTE KIDNEY INJURY: Creatinine peaked at 1.3, initially thought to be secondary to hypovolemia. Resolution to 1.1 on discharge. Renal function should be followed up as an outpatient. . INACTIVE ISSUES . # ASTHMA: Chronic and stable. He was continued on his home Advair and albuterol on discharge. . # MULTIPLE MYELOMA: He is followed closely as outpatient with skeletal surveys, appears to be "smoldering" and he has not undergone treatment so far. Medications on Admission: Advair 500/50 twice a day. Lipitor 0.5 mg daily. Albuterol p.r.n.. Aspirin 81mg daily Discharge Medications: 1. atorvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. Disp:*3 Tablet(s)* Refills:*0* 3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 4. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 6. acetaminophen 500 mg Capsule Sig: [**12-4**] Capsules PO every eight (8) hours as needed for pain fever. 7. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Pericardial Effusion Pneumonia, viral . Multiple myeloma Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had a collection of fluid around your heart that we believe was related to your fever and possible pneumonia. This was causing your chest pain. You were transferred to [**Hospital1 18**] and a drain was placed in the space around your heart and fluid was drained out. This fluid was sent to the lab to check for abnormal cells and infection. These tests are currently pending and will be followed up by Dr. [**Last Name (STitle) **] and our team. Your pain and breathing improved after removal of the fluid and 2 subsequent echocardiograms did not show that the fluid was coming back. You will need to follow up with a new cardiologist: Dr. [**Last Name (STitle) **] at [**Location (un) 620**] as well as Dr. [**Last Name (STitle) **]. Another echocardiogram will be done in about a 1-2 weeks. . We made the following changes to your medicines: 1. Start taking Levofloxacin for your pneumonia, you have 3 more days to complete a 7 day course 2. Please start taking Colchicine, once daily. This medication is used to treat the inflammation around your heart. Please continue this medication until you see Dr. [**Last Name (STitle) **]. Please note, you will need to have your kidney function rechecked when you see Dr. [**Last Name (STitle) 22882**]. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] A. Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 3862**] Phone: [**Telephone/Fax (1) 79971**] When: Thursday, [**3-22**], 4:15PM Cardiology Follow up: 4pm [**4-16**] Please see Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **] on [**4-16**] at 4pm. His office is located at [**Hospital1 18**] [**Location (un) 620**], [**Street Address(2) 3001**], [**Location (un) 620**], MA. Phone number is [**Telephone/Fax (1) 4105**]. Echocardiogram: Your follow up echocardiogram is scheduled for Monday [**4-2**] 1pm. His office is located at [**Hospital1 18**] [**Location (un) 620**], [**Street Address(2) 79972**], [**Location (un) 620**], MA. Phone number is [**Telephone/Fax (1) 4105**].

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Discharge summary

report+addendum

Admission Date: [**2162-5-3**] Discharge Date: Date of Birth: [**2108-11-18**] Sex: F Service: MED DISCHARGE DATE: Pending. HISTORY OF PRESENT ILLNESS: This is a 53 year old woman nine months status post cadaveric renal transplant for adult polycystic kidney disease with postoperative course complicated by pericardial effusion status post drainage and eventual window followed by reactivation CMV infections and then MRSA bacteremia endocarditis status post two courses of vancomycin. She presents two weeks after completion of her second course of vancomycin after waking up the morning prior to admission with temps to 103. She took four Tylenol and the temperature came down to 99. She went to sleep but woke up the morning of admission with persistent temperature, called her cousin to bring her into the Emergency Room and was also noted to have confusion, lethargy with some nausea, vomiting, diarrhea, headaches and generalized achiness all over. She denied any focal symptoms of cough, runny nose or chronic sinusitis. She was short of breath but has a history of asthma, unclear if changed from baseline. She did become dyspneic while talking to us on examination but denied chest pain, abdominal pain, dysuria. PAST MEDICAL HISTORY: Status post cadaveric renal transplant in [**2161-8-3**] for adult polycystic kidney disease, type II diabetes, currently on sliding scale insulin at home. Hypertension. Hypercholesterolemia. Status post recurrent MRSA endocarditis in the mitral valve Status post CMV reactivation treated with Valcyte and has had negative titers post-treatment. Asthma. GERD. Status post pericardial effusion, status post drainage and window in [**2162-1-3**]. Status post TAH for fibroids. Status post tubal ligation. ALLERGIES: Zestril causes tongue and lip swelling, Pentamidine causes bronchospasm, Bactrim and dapsone causing [**Doctor First Name **]-[**Location (un) **] syndrome. MEDICATIONS ON ADMISSION: Sliding scale insulin, tacrolimus 7 mg [**Hospital1 **], prednisone 5 mg qd, Advair [**Hospital1 **], albuterol prn, Lasix 40 mg po qd, atorvastatin po qd, Aciphex 20 mg po qd, Procrit 10,000 units q Friday and Neurontin 300 mg qhs. SOCIAL HISTORY: She is the oldest of three daughters married to her third husband. She has adult children and lives with her husband. FAMILY HISTORY: Positive for adult polycystic kidney disease and diabetes. PHYSICAL EXAMINATION: On admission, temperature was 104.4. blood pressure 140/52, heart rate 120, respiratory rate 18, sating 98 percent on room air. In general, she was confused, ill-appearing in no acute distress, talking complete sentences with mild dyspnea. HEENT - pupils were equal, round and reactive to light. There were moist mucous membranes. Extraocular muscles were intact. Heart was regular and tachycardic with normal S1 and S2, [**2-6**] murmur loudest at the apex. Pulmonary exam was clear to auscultation bilaterally with no wheezes, rales or rhonchi. Abdomen was soft, nontender, nondistended with positive bowel sounds, positive palpable kidney in her right lower quadrant. Extremities - no edema, no splinter, [**Last Name (un) 1003**] or Osler lesions. Neurologic exam - she was initially oriented times two. Cranial nerves were intact and good strength and sensation in all four extremities. LABORATORY: On admission, white count was 10.8, hematocrit 28.0, platelets 209, sodium 138, K 4.3, chloride 101, bicarb 22, BUN 43, creatinine 2.6, glucose 299, calcium 8.8, magnesium 1.5, CK 46, troponin 0.20. Albumin was 3.7. INR was 1.5. ALT was 8, AST 12, amylase 32, alkaline phosphatase 91, LDH 338, lipase of 15 and total bilirubin of 0.9. EKG was sinus tachycardic at 106 as well as left axis, no LVH, T wave inversions in AVL and T wave flattening in V5 through V6. Chest x-ray showed linear atelectasis within the mid left lung zone, probable pulmonary arterial hypertension and pericardial effusion. HOSPITAL COURSE: This is a 53 year old woman with adult polycystic kidney disease status post renal transplant in [**2161-8-3**] complicated by MRSA endocarditis of the mitral valve in [**Month (only) 956**] and [**2162-3-4**] with also a pericardial effusion requiring window in [**2162-1-3**] who presents with fever, mental status changes and acute renal failure. The patient was initially admitted to the MICU, was started on vancomycin, Zosyn and ceftriaxone and had TEE done in the Emergency Department. TEE confirmed mitral valve vegetations that were changing in size from her previous TEE. Later that evening in the MICU, the patient had an LP done with 700 white blood cells and poly predominance and 200 white blood cells, initially gram stain negative for 4+ PMNs. She also initially had CT and MRI of the head which were essentially negative. Blood cultures drawn in the Emergency Department came back later that evening with two out two and then four out of four gram positive cocci in pairs and clusters which apparently turned into MRSA. The patient's mental status improved and the patient was transferred to the floor. PROBLEM LIST: MRSA bacteremia: The patient continued to have positive blood cultures during her hospitalization. The patient was continued on vancomycin, started on rifampin and was also treated with a seven day course of gentamicin to help try to clear her of her MRSA bacteremia as she did continue to have temperature spikes and had a PICC line placed to continue these antibiotics. Blood cultures remained stable but she did have positive blood cultures, on [**5-3**], four out of six on day of admission, on [**5-6**] two out of two, [**5-7**] and 5 were still negative, [**5-9**] was one out of two with MRSA, [**5-11**] four out of four negative and [**5-14**] one out of one is MRSA. At the time of this dictation, [**5-17**] and [**5-18**] cultures are still pending. Of note, the patient did have CSF culture grow MRSA later on in the course even with the negative gram stain. This was attributed likely to a high grade bacteremia that penetrated the blood-brain barrier. The patient's mental status improved by the following morning. The patient eventually had an MRI of her C- spine, L-spine and T-spine to rule out any parameningeal focuses and this was done and showed no definite evidence of an abscess. She did have some mild degenerative disc disease in her cervical spine but was otherwise stable. The patient did have the initial TEE in the Emergency Room which showed LVEF of 55 percent and mild thickening of the aortic valve but no masses or vegetations are seen on the aortic valve. The mitral valve leaflets were mildly thickened with a large 1.5 x 1.2 cm calcified mass on the atrial side of the base of the posterior mitral valve leaflet consistent with a healed vegetation and there was also a large 1.5 x 1.0 cm calcified mass on the atrial side of the base of the anterior mitral valve leaflet consistent with a healed vegetation. There was a small 0.5 filamentous, mobile echodensity associated with the base of the anterior mitral valve leaflet on the atrial side consistent with a vegetation but no mitral valve abscess was seen at the time and there was moderate to severe 3+ MR seen during this TEE. Otherwise, there was no evidence of an effusion and was otherwise stable. She was followed initially by CT Surgery and seen for evaluation for possible surgery. However, surgery was deferred at this time as she continued to have transiently positive blood cultures and they wanted her bacteremia cleared prior to surgery as she would present a risk of infection of her eventual bioprosthetic valve. The patient was continued on vancomycin, rifampin and completed a seven day course of gentamicin for synergy and cultures remained stable. The patient did eventually have a repeat TEE to evaluate any further changes in her valve and that did show that the mitral valve leaflets were moderately thickened. There was a large complex vegetation 2 x 2 cm on the posterior leaflet of the mitral valve with mobile elements. In addition, there are moderate to large mobile vegetations involving the anterior mitral leaflet and leaflet base. A perivalvular involvement could not be excluded. There was moderate to severe 3+ MR again seen and there was moderate 2+ TR with severe pulmonary artery systolic hypertension but no other vegetations or effusions were noted. The patient had a normal LVEF of greater than 55 percent. However, it was noted that LV function may be depressed given the severity of the MR which was not reflected in the echo results. As the valve appearance was changing with vegetations, plans again for surgery were noted but however, we are waiting for at least two weeks negative blood cultures on antibiotics prior to moving to surgery because of the concern of risk of infecting the valve. Also, there were concerns with the high grade bacteremia that she had and if she had any other focal processes that weren't being appropriately treated or drained. The patient had an MRI of her pelvis which showed a large subcutaneous collection with extension to the right lateral abdominal wall musculature. The complex fluid collection is nonspecific and may represent an abscess or hemato seroma. The patient had this finding also confirmed on ultrasound of her transplanted kidney which showed right lower quadrant transplant kidney showing evidence of little or no diastolic flow peripherally and restrictive indices near 1.0. Again was noted the large collection just lateral to the transplant kidney which did show evidence of a hematocrit effect within. Findings were consistent with hemorrhage within a lymphocele and most likely an infected lymphocele. The kidney showed evidence of polycystic kidney disease. Eventually, the patient had a repeat chest x-ray which just showed resolving CHF after some diuresis was added in terms of IV Lasix. She also had a white blood cell scan looking for any occult signs of infection that weren't being properly addressed. She had mild diffusely increased uptake in the right lung which could represent a pulmonary inflammatory process. She also had a large focus of abnormal uptake in the right abdominal pelvic wall which could represent an abscess and she had diffusely increased uptake in the right hemipelvis which appeared anterior to the right ileum, also possibly another site of an abscess. These findings were attributed to possible right-sided pneumonia versus CHF versus an abdominal wall collection which was planned to be drained. It was initially aspirated by CT-guided means with 300 cc which was sent for studies and confirmed that she had 4+ PMNs and positive gram positive cocci in pairs and clusters on the gram stain but negative culture. As no drain was placed, the patient had this reevaluated by ultrasound and as it was still present on that evaluation, the patient had a drain placed in this to continue to aspirate and drain this fluid collection. Repeat aspiration showed no organisms, again 4+ PMNs and a negative culture. Otherwise, the mass that was a finding on the white blood cell scan in the right hemipelvis was likely attributed to her new transplanted kidney which may have suffered some ATN or other source as nothing else was evidenced on the MRI that she had. She also had eventually a CT of her chest to evaluate mild uptake in the right lung and also some episodes of dyspnea with exertion and Pulmonary was involved at this time. There was evidence of patchy foci of peripheral ground-glass opacification within the right lower lobe that was attributed to likely pneumonia. The patient did have one sputum sample sent which was a poor sample and only grew out moderate Staph aureus. Otherwise, the rest of the cultures remained negative. She also had a band-like area of opacity within the lingula which appeared improved and was attributed to residual focal atelectasis versus scar. The patient also had a small persistent pericardial effusion and resolution of a small right pleural effusion. There was note of a 2 cm diameter low- density lesion within the spleen. However, the patient did have this evaluated on ultrasound and MRI of her abdomen of which nothing else was made of note. The patient was started on Levaquin based on these findings initially and the patient responded well to these. Eventually, there was concern that some of her respiratory symptoms may be related to pneumonia and/or sinusitis. The patient was transitioned to an Augmentin regimen which should cover better for sinusitis and for pneumonia and she is to continue on this to complete a two week course. The patient did eventually have an MRI of her abdomen to evaluate her original kidney of concern but there may be pockets of infection that don't get appropriate vascular supply and antibiotic treatment. The MRI of the abdomen was essentially normal with numerous bilateral renal cysts consistent with her history of polycystic kidney disease. No enhancing solid lesions were seen in the kidneys to suggest infection or malignancy. There was interval decrease in size of the right lower quadrant abdominal wall collection after drainage and a right adrenal adenoma. Otherwise, the patient was continued on vancomycin and rifampin which she will continue indefinitely prior to surgery and indefinitely after surgery. She will continue to follow with Infectious Disease team. The patient did have viral studies sent from her CSF which remained negative. She had a CMV viral load sent which was also negative here. She had HSV culture sent from her lip swab which was positive for HSV-1. She completed a seven day course of acyclovir for this. The patient also had her left upper extremity fistula from her hemodialysis evaluated by ultrasound and there was no evidence of any infectious tract at that site either. There is no history of a graft placement at that site either. She had that placed in [**2156**]. Otherwise, the patient will continue on vancomycin and rifampin again for an indefinite course of length, continue to have close Infectious Disease and Transplant follow-up and the eventual plan for a valve replacement as concern for continued vegetations and infection and worsening heart failure secondary to increasing mitral regurgitation. Acute and chronic renal failure: The patient is status post transplant for adult polycystic kidney disease with baseline creatinine of about 1.5-2 since surgery. She was continued on the immunosuppressive regimen of tacrolimus and prednisone and levels were followed steadily. The tacrolimus was titrated up once she was started on rifampin because of concern for the cytochrome P450 metabolism system. Her levels remain stable at the dose she is currently on. However, this may be titrated further as she initially came in with acute renal failure which was attributed to ATN. The patient was hydrated initially with minimal response with a steady creatinine. Eventually, she started diuresing on her own and starting making output on her own and her creatinine started to improve and so her initial presentation of acute renal failure was attributed to ATN. However, after creatinine improved, the patient was completing her course of seven days of gentamicin and the patient's creatinine started to rise further. There is unclear source of patient's present acute renal failure. It could be gentamicin toxicity versus acyclovir toxicity versus forward flow versus over-diuresis. Currently, the patient has started back on some IV hydration in addition to her Lasix trying to maintain her urine output and hydration. Her blood pressure medicines are decreased to try to help improve forward flow. The gentamicin and acylovir have been discontinued and we will continue to follow it. Currently, her creatinine seems to be plateauing. She recently had her transplant evaluated during her ultrasound- guided drainage and found no focal abnormality but may consider reevaluating if creatinine continues to rise. Continue to follow levels of her immunosuppressive regimen closely with rising creatinine and this was all managed closely with her renal transplant team. Again, her urine output was continued to be followed closely also. The patient did have a Foley placed and did have urinary tract infection and urine culture consistent with yeast. Her Foley is currently being discontinued and we will continue to recheck her UA and urine culture after the Foley is removed to make sure she has cleared the yeast. If not, we may consider treating this UTI. Again, we will continue to follow her creatinines and urine output closely and follow all the levels of her antibiotics and immunosuppressive regimen as closely as we can. CHF: The patient has elevated right heart pressures on the TEE likely secondary to worsening left heart failure from valvular disease. The patient was started on aggressive diuresis and after-load reduction initially to which she responded well. Because of her angioedema to ACE inhibitors, she was started on hydralazine and nitrates with Lasix and her blood pressure came under much better control and diuresis improved. Currently, we have just maintained on Lasix and decreasing doses of hydralazine and nitrates to improve her forward flow for kidney perfusion, but otherwise her respiratory status is stable. The patient had follow-up chest x-rays which confirmed improving congestive heart failure. Asthma: The patient has a history of asthma, stable on her home regimen of Advair and albuterol. She was given occasional nebs for occasional asthma exacerbations which were short term and responded well to the inhalers. This can continue to be followed. Sinusitis: The patient has a history of chronic sinusitis, continued on [**Doctor First Name **], started on Beconase here while Flonase is not on the formulary. She was started on Augmentin for her pneumonia and sinusitis coverage as discussed above. Anemia: The patient has known chronic disease anemia secondary to her renal disease and chronic infectious state. The patient's iron studies confirmed that the patient did require a couple of transfusions. She did receive one unit on [**5-4**], 2 units on [**5-13**]. She had a repeat level today with goal hematocrit greater than 30. She did have likely some evidence of hemolysis early in her course secondary to her valve with slightly elevated platelets. However, her crit remained stable after transfusions. She did also have some mildly guaiac positive stools but these are also stable and would continue to be followed. Type II diabetes: The patient was stable and initially controlled on oral regimen before her transplant and now just on sliding scale insulin at home. However, for better control, the patient was started on Glargine which 11 units seemed to control her pretty well with sliding scale insulin as needed in between. She was continued to be followed for episodes of hypoglycemia with worsening renal failure and concern for prolonged elevated levels of her long-acting insulin. CONDITION ON DISCHARGE: Good. The patient has no O2 requirements and is afebrile at this time. DISCHARGE STATUS: Discharged to Rehab. DISCHARGE DIAGNOSES: MRSA bacteremia. Status post renal transplant secondary to adult polycystic kidney disease. Urinary tract infection. Pneumonia. Sinusitis. HSV-1 infection. Abdominal wall abscess. Acute and chronic renal failure. Anemia. CHF. Asthma. Type II diabetes. DISCHARGE MEDICATIONS: Will be dictated at the time of final discharge. FOLLOW UP: The patient will follow up with her transplant nephrologist, Dr. [**Last Name (STitle) **], as previously scheduled and the patient will follow up with her transplant surgeon, Dr. [**Last Name (STitle) 28184**], as previously scheduled and the patient will have CT Surgery follow up. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 28185**] Dictated By:[**Doctor Last Name 14365**] MEDQUIST36 D: [**2162-5-19**] 10:38:34 T: [**2162-5-19**] 14:36:17 Job#: [**Job Number 28186**] Name: [**Known lastname 4907**],[**Known firstname **] Unit No: [**Numeric Identifier 4908**] Admission Date: [**2162-5-3**] Discharge Date: [**2162-7-15**] Date of Birth: [**2108-11-18**] Sex: F Service: MED Allergies: Bactrim / Pentamidine / Zestril Attending:[**First Name3 (LF) 2670**] Chief Complaint: Fever, headache, confusion, lethargy, nausea, vomiting. Major Surgical or Invasive Procedure: Lumber puncture TEE Peritoneal Abscess Drainage US [**2162-5-17**] Incision and drainage of RLQ abdominal wall seroma Cardiac Cath [**2162-6-9**] PICC line placement on Right arm Post-pyloric tube placement [**2162-6-28**] PEG placement on [**2162-7-2**] History of Present Illness: Please see the D/C summary from [**2162-5-19**] for the detail. 53 yo female s/p cadavaric renal transplant in [**8-6**] for adult polycistic kidney disease with potoperative course complicated by pericardial effusion s/p drainage and window followed by reactivation of CMV infections and then MRSA bacteremia endocarditis of mitral valve s/p two courses of vancomycin. Pt initially presented on [**2162-5-3**] 2 weeks after completing her second course of vancomycin with chief complaint of fever, headache, and altered mental status. Patient woke up in the morning prior to admission with temp of 103, took two APAP, temp still elevated, took 2 more and temps came down to 99. Pt then went to sleep but woke up in the am with persistent temp and called her cousin to bring her into the [**Name (NI) **]. She denies any focal symptoms of cough, runny nose, unchanged chronic sinusitis, +HAs. +SOBs while talking, denies chest pain, abdominal pain, but notes that she is "achy" all over in her back and legs. Also admits that she has had diarrhea since a day prior to admission. She denies nausea but note s that she has a sensation of something in her throat, and gag on occasion. She was started on Vanc/Zosyn in ED. Past Medical History: 1. Renal transplant for Adult polycystic kidney disease 2. Hypertension 3. Hypercholesterolemia 4. DM2 5. Chronic anemia 6. pericardial wondow [**3-5**] 7. S/P CMV reactivation 8. Asthma 9. GERD 10. TAH for fibroids '[**46**] 11. S/P tubal ligation 12. Gastric mucosal calcinosis by EGD on [**September 2161**] 13. L arm AV fistula Social History: No tobacco, occasional alcohol, no drugs Family History: Polycystic kidney disease Father with diabetes Physical Exam: T96.3, BP 111-139/50-86 P98-108 99-100%RA Gen-drowsawake, inappropriately answering questions but animated. HEENT-anicteric, no conjunctival pallor, Right ptosis, right facial droop, MM-moist, no LAD CV- tachy normal S1/S2, no S3/S4, [**4-8**] HSM at apex radiating to axilla, back, LSB. resp- few crackles at right base, decreased breath sounds at bilateral bases, no whezes, fair air entry GI-normal BS, does not seem to be tender, no mass, Right flank open wounds with wet-dry dressing appears clean, well granulated, and not oozing, G-tube in place with no pus or erythema. Ext-1+DP bilaterally, no edema, L radial artery pulse diminished but pt has left A-V fistula. Neuro: alert and oriented x1 to her name, CN exam: right ptosis, right facial droop, EOMI, no nystagmus, good hearing bilaterally, tongue midline. Strength: [**4-7**] RUE, 4-5/5 LE bilaterally, L biceps/triceps [**4-7**], L wrist flexion/extension 1-2/5 painful to ROM. L finger grasp 1-2/5 painful with movement and to palpation. Sensation generally intact however limited exam due to her MS. Pt able to get up to a chair with assistance. Pertinent Results: UNILAT UP EXT VEINS US LEFT [**2162-5-5**] FINDINGS: [**Doctor Last Name **] scale and doppler ultrasound examination of the left forearm demonstrates a patent cephalic vein and patent A-V fistula graft of the left brachial artery and left cephalic vein. The proximal cephalic vein at the graft site measures approximately 2 cm in diameter. No fluid collections, abscess, or fistulous tract is identified. IMPRESSION: No fluid collections or fistulous tract identified. MRI T-/L-spine ([**5-9**]) IMPRESSION: 1. Evaluation of thoraic and lumbar spine demonstrates no definite evidence of abscess. 2. Evaluation of cervical spine is limited secondary to patient's motion. There is a suggestion of degenerative disc disease at the level of the C3-4, C5-6 and C6-7. However, evaluation is limited secondary to patient motion. MRI PELVIS W/O & W/CONTRAST; MR RECONSTRUCTION IMAGING ([**5-10**]) IMPRESSION: Large subcutaneous collection with extension into the right lateral abdominal wall musculature. This complex fluid collection is non- specific and may represent an abscess, hematoma or seroma. RENAL TRANSPLANT U.S. RIGHT [**2162-5-10**] IMPRESSION: Again seen is a right lower quadrant transplant kidney showing evidence of little or no diastolic flow peripherally and resistive indices near 1.0. There is a large collection just lateral to the transplant kidney which was previously described as a lymphocele but now shows evidence of a hematocrit effect within. Findings are consistent with hemorrhage within a lymphocele, and less likely an infected lymphocele. The native kidney shows evidence of polycystic kidney disease. WHITE BLOOD CELL STUDY [**2162-5-11**] IMPRESSION: 1) Mild, diffusely increased uptake in the right lung, which may represent a pulmonary inflammatory process. Can not rule out pneumonia. 2) Large focus of abnormal uptake in the right abdominal/pelvic wall, which could represent an abscess. 3) Diffusely increased uptake in the right hemi-pelvis, which appears to be anterior to the right ileum, which could be another site of abscess. US HEMATOMA SUBCUT DRAIN INCIS; CT GUIDED NEEDLE PLACTMENT ([**2162-5-14**]) IMPRESSION: Successful aspirate of right lower pannus fluid collection, draining approximately 300 cc of dark bloody fluid. The specimens were sent to microbiology. CT CHEST W/O CONTRAST [**2162-5-16**] IMPRESSION: 1. Patchy foci of peripheral ground glass opacification within the right upper lobe. Although some of the ground glass opacities were present previously, those located medially within the anterior segment appear new. In the setting of immunosuppression and positive findings on a nuclear medicine white blood cell scan in the right lung, these findings are concerning for infection. 2. Band-like area of opacity within the lingula appears improved and is attributed to residual focal atelectasis versus scar. The previously noted left lower lobe process has resolved, and a left pleural effusion has significantly decreased in size. 3. Persistent small pericardial effusion and resolution of small right pleural effusion. 4. New 2 cm diameter low-density lesion within the spleen, of uncertain etiology. Splenic infarct or abscess should be considered in the appropriate clinical setting, but this is difficult to assess on this unenhanced study. Consider a dedicated left upper quadrant ultrasound or complete abdominal CT for more completer characterization. GUIDANCE FOR ABSCESS; PERITONEAL ABSCESS DRAINAGE US; GUIDANCE FOR ABSCESS [**2162-5-17**] Preliminary ultrasonographic images of the superficial tissues of the right lower quadrant demonstrate a large cavity measuring 10.5 x 9.6 x 7.8 cm. The superior aspects contain essentially clear fluid with greater amounts of free flowing debris seen throughout the lower dependent portions of the cavity. The collection is superficial to the abdominal musculature and the renal transplant. Status post successful superficial abscess drainage with 8 French [**Last Name (un) 4909**] catheter. 5cc specimen was sent for culture and sensitivity. MR RECONSTRUCTION IMAGING [**2162-5-18**] 1) Numerous bilateral renal cysts, compatible with history of polycystic kidney disease. No enhancing solid lesions are seen in the kidneys to suggest foci of infection or malignancy. 2) Interval decreased size of right lower quadrant abdominal wall collection. MRA BRAIN W/O CONTRAST [**2162-5-24**] 1. Areas of restricted diffusion within the left temporal and left parietal lobe, not enhancing. Appearance of these lesions is most consistent with embolic etiology (and/or septic emboli). Focal cerebritis is considered less likely. 2. Absent flow in the short segment of the left middle cerebral artery is most suggestive of acute embolic disease in conjunction with the temporal and parietal lobe findings. LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**2162-5-27**] IMPRESSION: 1) Small simple cysts within the liver which is otherwise unremarkable. 2) No evidence of abscess in the right lower quadrant. CT HEAD W/O CONTRAST [**2162-6-2**] IMPRESSION: Since the previous examinations, the left temporal lobe infarction extended to involve greater territory than was previously apparent. No new areas of infarction are observed. There is no evidence of recent hemorrhage. CT ABDOMEN W/O CONTRAST [**2162-6-10**] 1 High-attenuation ascites worrisome for hemorrhage surrounding the liver. No perirenal fluid collection surrounding the transplant kidney is seen. CT ABDOMEN W/O CONTRAST [**2162-6-17**] IMPRESSION: 1) Decrease in size of subcapsular hepatic hematoma. 2) Unchanged appearance of multiple low-density hepatic foci. 3) Stable appearance of splenic infarction. 4) Stable appearance of left pelvic/inguinal soft-tissue density mass. 5) Diffuse ground glass opacities at the lung bases which are worse than on the prior examination. Appearances are most consistent with congestive heart failure or volume overload. However, in a patient who is being immunosuppressed, consideration should also be made for diffuse pulmonary infection. TEE [**2162-7-8**] Conclusions: No mass/thrombus is seen in the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular systolic function is normal (LVEF>55%). There right ventricular function appears depressed. The aortic leaflet is tricuspid. There is thickening of the base of the ?NCC of the aortic valve. Trace aortic regurgitation is seen. No obvious aortic root abscesses are seen. The mitral valve leaflets are moderately thickened. There are moderate-sized mobile echodensitiy on the bases of the anterior and posterior mitral leaflets (posterior >anterior) consistent with vegetations. There are no leaflets perforations seen. There is moderate to severe (3+) mitral regurgitation. Given the extent of vegetations, a mitral annular abscess cannot be fully excluded. The pulmonary artery systolic pressure was not measured. There is no pericardial effusion. Compared to the prior TEE study of [**2162-5-26**] (tape reveiwed), the mitral valve remains thickend with mobile echodensities at the bases of the anterior and posterior mitral valve leaflets consistent with vegetations. The large highly mobile prolapsing segment seen on the piror study is no longer present. There is thickening of the base of the ?NCC of the aortic valve which was present of the prior study. The pulmonary artery systolic pressure was not measured on the current study. HEAD CT [**2162-7-12**] FINDINGS: There is no evidence of intra or extraaxial hemorrhage. There is no hydrocephalus, mass effect, or shift of normally midline structures, and the ventricles, cisterns and sulci are unremarkable. The area of hypodensity extending to the cortex in the left temporoparietal area is unchanged. The [**Doctor Last Name **]-white matter distinction is preserved elsewhere, and there is no evidence of new territorial infarction. The residual gyral enhancement associated with contrast administration, which was seen on the most recent study, has resolved. There is no definite evidence of infarction elsewhere. The visualized osseous structures, paranasal sinuses, and soft tissues are unrmarkable. IMPRESSION: 1. Stable appearance of the previously seen large left temporoparietal infarct 2. No evidence of intracranial hemorrhage or acute territorial infarction. 3. No other significant interval change. Brief Hospital Course: Hospital course after [**5-19**] 1)ID: As noted earlier, pt was started on vancomycin, rifampin and gentamycin for persistent MRSA bacteremia, endocarditis, and meningitis. On [**5-16**] CXR and CT lung showed RUL ground glass opacity, and WBC scan showed increased uptake at the RUL. Pt initially started on levofloxaxin but switched to Ceftaz for hospital acquired pneumonia which was eventually d/c'd on [**5-23**] because sputum culture was negative for gram negative rods but did grow MRSA. As noted earlier, pt was found to have a fluid collection around RLQ abdominal wall (pannicular seroma) which was drained by pigtail, and was followed by incision and drainage in the OR. The tissue was sent to pathology which only showed fibrous exudate with reactive changes. The MRI report of native polycystic kidneys showed no signs of infection or malignancy. Pt has a left upper extremity AV fistula which did not have any evidence of infectious tract by ultrasound. Pt was on Gentamycin inititally but was discontinued due to possible renal toxicity with increasing creatinine. Pt was initially on rifampin for the synergy effect with vancomycin, but MRSA from [**5-22**] Cx was Rifampin resistant so Rifampin was discontinued. CMV viral load was negative and HSV negative in CSF. Pt was started on linezolid on [**5-26**] in addition to Vanco since there was a corncern that she might be developing VISA. [**Hospital3 4910**] was checking the MBC and MIC. However, Linezolid was thought to have possible antagonistic acitvity to Vanco, therefore it was discontinued after 2 days, and she was switched to Daptomycin 500mg IV q 48 and was eventually changed to 500 mg q24. Since then, patient has been on daptomycin 500 mg qd and vancomycin by level which was switched to Vanc 1gm q48 on [**7-12**] after improvement in CrCl. She will be on daptomycin and vancomycin indefinitely until and after the valve replacement surgery. Patient needs to have vancomycin trough level checked to keep it above 15. Pt also completed 7 day course of acyclovir for HSV1 on her lips. Pt also developed pseudomonas pneumonia while she was in the MICU with positive sputum culture from [**6-3**] to [**6-18**] which was treated with a course of piperacillin. Pt also had a yeast UTI which was treated with fluconazole, and another UTI with pseudomonas and E.Coli. Piperacillin was initially started on [**7-9**] for pseudomonas, but later E.Coli sensitivity came back resistant to piperacillin, so it was switched to Zosyn which is sensitive against both bacteria. Patient will need to complete a total of 14 day course of Zosyn (last day [**2162-7-25**]) for her psuedomonas/E.Coli UTI. Last positive blood culture for MRSA was from [**2162-5-22**], and last positive sputum culture was from [**2162-6-16**]. Patient will be on Vancomycin and daptomycin indefinitely until mitral valve replacement. 2)Renal: Pt initially presented with ARF (Cr 2.6) on CRI (1.5-2.0 baseline) thought to be from pre-renal azotemia secondary to sepsis. Patient was initially on tacroliumus and prednisone for post-transplant immunosuppression, but they were held on [**5-25**] for persistent bacteremia and endocarditis that could not be cleared with multiple antibiotics. It was thought that clearing her infection was more important at that time than reducing the risk of rejection. Creatinine continued to be elevated (high of 5.1) and it was thought that ARF could also be from Gentamycin ATN or acyclovir crystal nephropathy. Gentamycin was eventually discontinued. Pt completed a 7 day course of acyclovir for her oral HSV on [**5-18**]. Her baseline creatinine level after the renal transplant is between 1.5 - 2.0, on admission Cr level 2.6, and her Cr level returned to her baseline at 1.5 by [**2162-5-22**] after she started producing urine and was able to hydrate her with IVF. However, pt became volume overloaded after [**Month/Day/Year **] and went into pulmonary edema secondary to severe mitral regurgitation. After that, pt was receiving lasix for aggressive diuresis which raised her cratinine to 2.3-2.4. Pt was then gently and slowly hydrated with D5W to correct hypernatremia (Na 150). After several days of net positive volume status with gentle IVF [**Month/Day/Year **], her creatinine was lowered to 1.6 During the latter part of her hosptial stay, the main issue was the fluid balance with the goal of euvolemia. Pt was very prone for pulmonary edema from MR [**First Name (Titles) **] [**Last Name (Titles) **], but diuresis caused her renal function to go down. Pt went into MICU on [**6-25**] for fluid overload after tube feed via NGT was initiated and patient recovered after aggressive diuresis. Currently, pt is euvolemic or slightly dry but the balance between pulmonary function and renal function is at an optimal level. PEG was placed on [**7-2**] and tube feed was initiated. Pt was later toloerating some po liquids. Since the blood culture has been negative since [**5-22**], pt afebrile, and the reatinine level came down to 1.7 but increased slightly to 1.8, tacrolimus was re-started on [**7-10**]. Current dose is tacrolimus 4 mg [**Hospital1 **] with goal of level [**2-5**]. Pt needs to get a lab (CBC, BMP, tacrolimus level, vanc level) in 1 week from the discharge. Pt needs to follow up with Dr. [**Last Name (STitle) **] in 3 weeks from the discharge for her post-transplant renal management. 3)Neuro: Pt was initially admitted for fever and altered mental status, eventually diagnosed with MRSA meningitis which was treated and resolved. MRI of spine was negative for spinal infectious processes. Pt then developed left temporal lobe CVA from septic emboli on [**5-21**]. Initially pt was found to be in confusional state and neurology was consulted. On exam, she was alert, disoriented to place and time, fluent langauge but she was having word finding difficuly. She was able to perform elemental repetition but unable to do more complex tasks. Cranial nerve exam notable for right ptosis but no Horner's Syndrome. LP was recommended but her husband refused to consent. MRI of the head showed multiple likely septic emboli and left temporal hyperintensity. Pt was started on IV acyclovir because of the left temporal lobe enhancement concerning for HSV meningitis. After 3 days of IV acyclovir, patient's renal function worsened with hypotensions. EEG showed no evidence of seizures. Repeat head CT showed evolving infarct, changes consistent with encephalomalacia. MRI [**6-10**] demonstrated no additional CVAs. Her language improved over time, and she is able to comprehend, answer questions and follow commands, however still mumbling and difficult to uderstand. She was confused and agitated at first requiring sitters, restraints and standing Haldol, but it improved over time requiring no sitter but still getting standing haldol 1mg tid. On [**7-6**] pt developed left wrist/hand pain and weakness that was new. The weakness and pain were isolated to the wrist and worsened by flexion and extension. The exam was inconsistent with CVA since her other left arm muscles were not affected, and pt was in severe pain. The X-ray of the wrist showed no evidence of fracture or dislocation. Etilogy was thought as another septic embolic stroke, sprain or tenosynovitis after prolonged restraints around her wrists for agitation. Neurology was consulted, MRI of the head ordered but was limited by motion artifacts, and subsequent head CT showed only old stroke at the left temporal/parietal and no new changes. It was thought that she had a small septic emboli to one of the distal left arm arteries causing pain and possibly caused a damage to the posterior interosseous nerve, which would explain the wrist drop, weak grasp muscles, and pain. The left wrist was on splint which seemed to minimize the pain. Overall, her mental status improved after the septic emboli event. Pt can state her name, recognizes her husband, and follow simple commands. She is able to get out to chair and able to make simple words. However, she still appears confused and disoriented at times, and making inappropriate response. Patient still has residual Wernicke's type aphasia where she can make fluent speech but her comprehension is not completely intact. She should see Dr. [**First Name (STitle) **] (neurology) in outpatient once discharged to a rehab for evaluation of her stroke and also for possible EMG and nerve conduction studies for her wrist drop. 5)[**Last Name (STitle) 4911**] valve endocarditis: Patient with known vegetation on mitral valve and subsequent severe mitral regurgitation. Initial plan was to have the mitral valve replaced by CT surgeon Dr. [**Last Name (Prefixes) **], but was unfortunately postponed due to her multiple medical complications including persistent bacteremia, MRSA meningitis, septic embolism to the brain and spleen, subcapsular liver hematoma, CHF and pulmonary edema. CT surgery did not want to operate on her until until blood culture for at least 14 days. TEE on [**5-13**] showed increased size in vegetation. TEE from [**5-25**] again showed large vegetation on the mitral valve involving the anterior and posterior leaflets with a large mobile element. No mitral valve abscess was seen but could not be excluded. Again showing 3+MR. Compared with the findings of the prior study of [**2162-5-14**], the mitral vegetation appears larger and has a greater mobile element. The severity of mitral regurgitation appeared similar. The LA appears more dilated. The RV systolic function appears worse. The LV systolic function remains hyperdynamic. Repeat Echo done on [**2162-6-9**] showed the mitral valve vegetation that is somewhat larger (previously more spherical) and more mobile. The mitral annular echodensity is more prominent c/w possible healing/fibrosing abscess. Right ventricular hypokinesis was more prominent at that time. Pt underwent cardiac cath on [**6-9**] because of anticipated MVR, but cath complicated by embolized swann cath, likely now in coronary venous system. Post-procedure additional complication of groin bleed with fluid collection around the liver and hct drop from 28 to 20. Pt has been transfused to hct 33. This complication further postponed the mitral valve replacement surgery. Repeat abdominal CT on [**6-17**] showed decreased size in the subcapsular hepatic hematoma, and pt's Hct has been stable since. Pt got another TEE on [**7-9**] which showed absence of the large mobile vegetation. Pt will be followed up by CT surgeon Dr. [**Last Name (Prefixes) 4912**] in the future for possible mitral valve replacement. 6)CHF: Multiple TTE and TEE showed EF function ranging from 60-80% in four cardiac echo studies. However pt had elevated TR gradient, and severe ([**2-4**]+) mitral regurgitation in addition to the growing mitral valve vegetation. Pt had elevated right heart pressure secondary to worsening valvular disease. Pt responded well to afterload reduction with hydralazine and nitrate, avoiding ACE-inhibitor because of its effect on renal function. BP was initially controlled with those meds, but after diuresis with lasix and metolazone pt no longer required them to control BP. Pt was repeated getting fluid overloaded and having respiratory distress requiring multiple trips to MICU. From [**Date range (1) 4913**] she was in the MICU where she was intubated for airway protection after the CVA. Pt was extubated on [**6-14**], post-pyloric placed and tube feed was started, and has been stable on the floor since with improvement in the renal function. However, On [**6-24**] pt became tachypnic using accessory muscles due to fluid overload and was sent back to the MICU for BIPAP trial. Her respiratory status improved after aggressive diurses but her creatine level went up as well. Patient was initially diuresised with IV lasix and metolazone but was discontinued with the plan to keep her euvolemic and correction of lytes and free water gently. Pt's lung remained clear since but she continues to appear dry with slow rehydration since concerning for pulmonary edema. PEG placed on [**7-2**] with tube feed with free water started. Pt was having moderate amount of residuals but able to tolerate tube feeds. Bedside speech and swallow evaluated the patient on [**7-5**] with marked improvement, although she was still aspirating occasionally. Video swallowing done on [**7-6**] and pt now able to tolerate thickened pureed. Her volume status remained sensitive throughout the hospital stay, and easily tipped over to either fluid overload/pulmonary edema or hypovolemia with worsening renal function. Underlying problem is her severe mitral regurgitation. Until she gets a mitral valve replacement, this issue would not be solved. 7)Arrythmia: Pt developed CVA from septic emboli on [**5-21**]. Pt went to fluro-guided LP on [**5-24**] and one hour after the LP was done, pt became tachypnic and bradycardic in the 60's (normally in the 100's) with EKG showing possible junctional rhythm. The conduction defect was thought to be from the extemsion of the mitral valve vegetation. After transferring to the MICU and being intubated and sedated, pt was having episodes of bradycardia (40's) and tachycardia (120's) with several runs of V-tach and ectopy including bigeminy. Arrythmia initially concerning for myocardial abscess due to large extension of the vegetation, but TEE showed no evidence of abscess. Pt remained on tele once back to the floor with no significant events. QT interval were monitored because she was on standing heldol for agitation. 8)Anemia: Pt has a history of chronic anemia from chronic illness or from her renal disease. Pt's Hct continued to drop intermittenly with unclear reason and she was transfused several times to keep her Hct near 30. There was a big Hct drop when subcapsular hematoma of the liver developed on [**6-10**] after the cardiac cath. During remaininder of the course, Hct was stable at near 30. Pt has been getting Epogen once a week (on Fri) and will be discharged with that regimen. Fe studies were consistent with anemia of chronic disease. 9)Diabetes: Pt originally on lantus 11u + insulin ss which was changed to NPH 13u am and 7u pm. However she did not require insulin since when tubefeed was at minimal setting. The finger stick level were within the normal range 100-160 without use of insulin at first. As pt tolerated more tube feed and po, am and pm NPH were restarted. 10)Nutrition: Pt was initially on the tube feed for nutrition after the CVA event and intubation at MICU, but was having gastric fullness. Post-pyloric/dobhoff was inserted on [**2162-6-23**] and tube feed resumed, but pt puled out the dobhoof on the same day due after a tachypnic episode. PEG was placed on [**2162-7-2**] and ultracal started. Pt initially having high residuals on tube feed but improved with Reglan 5mg qid. On [**7-5**], bedside speech/swallow evaluation showed marked improvement compared to previously although pt still aspirating clears. Pt underwent video swallow on [**7-6**] where she was able to tolerate nectar thick pureed liquid, but pt still had some difficulty with solids and thin clears. Pt was able to tolerate some thick liquids after that. Pt has been getting tubefeed at 70cc/hr without any problem. [**Name (NI) **] should have nutrition evaluate her at the rehab to advance her diet to more solids if she continues to show improvement neurologically. Medications on Admission: Lipitor 10 mg qd Albuterol inhaler Aciphex 20 mg qd Advair moteleukas 10 mg qd Lasix 40 mg [**Hospital1 **] Reglan 10 mg QID, ACHS Prednisone 5mg qd Epogen 10,000 qweek Neurontin 300 mg qd Prograf 7mg be level Discharge Medications: 1. Epoetin Alfa 10,000 unit/mL Solution Sig: 10,000 unit Injection QFRI (every Friday). 2. Miconazole Nitrate Powder Sig: One (1) Appl Miscell. PRN (as needed). 3. Acetaminophen 160 mg/5 mL Elixir Sig: [**Telephone/Fax (1) 4914**] mg PO Q4-6H (every 4 to 6 hours) as needed. 4. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed. 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 8. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO QD (once a day). 9. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Thirteen (13) units Subcutaneous qAM. 10. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Seven (7) units Subcutaneous qPM. 11. Insulin Regular Human 100 unit/mL Cartridge Sig: per sliding scale unit Injection per sliding scale: Per Sliding scale. 12. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-4**] Sprays Nasal QID (4 times a day) as needed. 13. Albuterol Sulfate 0.083 % Solution Sig: [**12-4**] Inhalation Q6H (every 6 hours) as needed. 14. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 15. Haloperidol 2 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 16. Haloperidol 1 mg Tablet Sig: 1-2 Tablets PO Q2H (every 2 hours) as needed for extreme agitation. 17. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO BID (2 times a day). 18. Ondansetron HCl 2 mg/mL Solution Sig: One (1) Intravenous Q6H (every 6 hours) as needed for Nausea. 19. Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 20. Metoclopramide HCl 5 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours). 21. Vancomycin HCl 10 g Recon Soln Sig: One (1) gm Intravenous Q48H (every 48 hours). 22. Piperacillin-Tazobactam 2-0.25 g Recon Soln Sig: 2.25 gm Intravenous Q6H (every 6 hours) for 10 days. Discharge Disposition: Extended Care Facility: [**Hospital1 49**] - [**Location (un) 50**] Discharge Diagnosis: Primary Diagnosis: 1. MRSA meningitis 2. MRSA bacteremia 3. Mitral valve endocarditis 4. Severe mitral regurgitation 5. Acute Renal failure/ATN 6. Septic embolism to left temporal lobe and spleen 7. L wrist drop seondary to septic embolism 8. Pulmonary edema 9. Hepatic subcapsular hematoma 10. Pseudomonas pneumonia 11. Yeast UTI 12. Pseudomonas UTI 13. E. Coli UTI 14. Fluent aphasia/mental status change 15. Anemia Secondary Diagnosis: 1. Renal transplant for Adult polycystic kidney disease 2. Hypertension 3. Hypercholesterolemia 4. DM2 5. Chronic anemia 6. pericardial wondow [**3-5**] 7. S/P CMV reactivation 8. Asthma 9. GERD 10. TAH for fibroids '[**46**] 11. S/P tubal ligation 12. Gastric mucosal calcinosis by EGD on [**September 2161**] 13. L arm AV fistula Discharge Condition: Fair, hemodynamically stable, Creatinine back to her baseline, mental status stable requiring no sitter or restraint. Discharge Instructions: Patient needs to take all of the medications listed as instructed. Pt needs to take antibiotic Zosyn for 10 more days for UTI, and she needs to be on vancomycin and daptomycin indefinitely until cleared by CT surgeon. Patient needs to have lab (CBC, BMP, vanc level, tacrolimus level) in a week and have the result faxed to [**Telephone/Fax (1) 2858**] Followup Instructions: Patient needs to have blood drawn in 1 week from the discharge for CBC, BMP, tacrolimus level, and vancomycin level, and have the result faxed to [**Telephone/Fax (1) 2858**] Patient is scheduled to see Dr. [**Last Name (STitle) 4915**] in 3 weeks for a follow up. However, she preferred to see her nephrologist Dr. [**Last Name (STitle) **] [**Name (STitle) 4916**] instead. Pt needs to call Dr.[**Name (NI) 4917**] clinic to arrange for that appointment if she chooses to see Dr. [**Last Name (STitle) 4916**] instead. Patient should also get a follow up appointment with Dr. [**First Name (STitle) **] (neurology) for her stroke and left wrist drop. Provider: [**Name10 (NameIs) 461**],[**Name11 (NameIs) 460**] TRANSPLANT CENTER (NHB) Where: LM [**Hospital 4918**] CLINIC Phone:[**Telephone/Fax (1) 242**] Date/Time:[**2162-8-31**] 8:30 [**First Name4 (NamePattern1) 460**] [**Last Name (NamePattern1) 461**] MD [**MD Number(1) 2671**] Completed by:[**2162-7-15**]

[ "995.92", "421.0", "996.81", "428.0", "599.0", "320.3", "038.11", "998.59", "434.11" ]

icd9cm

[ [ [] ] ]

[ "43.11", "54.19", "38.93", "88.56", "99.04", "88.72", "96.72", "54.91", "00.14", "96.6", "96.04", "37.21", "03.31" ]

icd9pcs

[ [ [] ] ]

50078, 50148

32133, 47705

20550, 20807

50964, 51083

23690, 32110

51486, 52491

22492, 22540

19193, 19457

47966, 50055

50169, 50169

47731, 47943

3975, 5096

51107, 51463

22555, 23671

19543, 20438

2451, 3957

20455, 20512

20835, 22062

50609, 50943

5111, 19033

50188, 50588

22084, 22418

22434, 22476

19058, 19171

14,342

135,687

24066

Discharge summary

report

Admission Date: [**2186-4-6**] Discharge Date: [**2186-4-13**] Date of Birth: [**2108-6-10**] Sex: M Service: MEDICINE Allergies: Lasix / Paxil / Allopurinol / Lipitor / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 4963**] Chief Complaint: BRBPR, hypotension Major Surgical or Invasive Procedure: Colonoscopy Bleeding Scan Embolization Intubation History of Present Illness: This is a 77 year old man with CAD (s/p cath [**8-29**] with LAD stent; [**1-30**] with patent stent), COPD, prior GIB, here with BRBPR x3 episodes at home. The first episode was at about 10pm on the night prior to admission, and was red blood mixed with stool. The second episode was a gush of bright red blood. The 3rd episode was only a small amount of blood. He has not had a BM since that time. He had a colonoscopy by Dr. [**Last Name (STitle) 2305**] on [**3-28**] with polypectomy x4 (2 in the ascending colon, 1 in the distal ascending colon, 1 in the transverse colon). He restarted his plavix on [**4-1**] as instructed, and had not yet restarted aspirin. He denies having had diarrhea or constipation, or black or bloody stools prior to these episodes of BRBPR. He denies N/V, abdominal pain. He has been eating normally and has a normal appetite. He complained of dizziness and feeling like he was "blacking out" upon standing in the ED. Denies CP, SOB, palpitations. No orthopnea or PND. In the ED, VS: 96.6, 123, 89/52, 30, 96% on RA. Rectal exam showed BRBPR but abdomen was benign. NGL was negative. Two 16g IVs were placed and he was given 1L NS. 1U prbcs also started. GI was contact[**Name (NI) **] and recommended tagged RBC scan, and if positive go to IR for intervention. Tagged RBC scan is currently deferred pending BP stability. Surgery was also consulted. He is admitted to the MICU for GI bleeding and hypotension. Past Medical History: CAD -cath [**1-30**]- 50% Lcx, 60 % Ostial RCA, LAD stent patent -cath [**8-29**], LAD stent (cypher) -s/p NSTEMI [**4-29**] cardiogenic shock, PEA arrest COPD on chronic daily Prednisone, home O2 2L continuous BPH Sarcoid Gout Moderate AS Chronic Systolic Heart failure EF 50% in [**12-31**] Hx Pneumothorax Depression GIB-- AVM on at hepatic flexure- s/p embolization by IR (after 4 bleeding scans, c scope, push enteroscopy,etc. required 15 units of prbc's on this previous admission in [**2183**]) L Achilles tendon rupture Social History: Retired Cab driver. Lives with wife and [**Name2 (NI) **]. 60 pack [**Female First Name (un) **] tobacco hx, quit 45 years ago. No etoh or illicit drug hx. Family History: Father with DM. Physical Exam: VS: 97.7, 103, 97/71, 100% on 2L nc GEN: NAD, lying flat in bed at rest. HEENT: PERRL, anicteric, MM dry, OP clear NECK: Neck veins flat. LUNGS: CTAB, fair air movement, no wheezes. CV: Distant heart sounds. RRR. Soft II/VI systolic murmur. ABD: +BS, soft, NT/ND. No hepatomegaly. EXTREM: Warm, 2+ DP pulses b/l. L foot in Cam walker boot. Pertinent Results: EKG: NSR at 95 bpm. LAD, RBBB, LAFB. No ST-T changes. No significant change from prior. Brief Hospital Course: A/P: This is a 77 year old man with CAD, COPD, prior GI bleed, here with BRBPR, anemia, and hypotension s/p colonoscopy and polypectomy. He was in the MICU and when stable, transferred to the floor. # GI Bleed/Anemia: Blood loss anemia from GI bleeding. Of note, patient had a prior major bleed from AVM at hepatic flexure requiring transfusion of 15U PRBC and IR embolization. Recent baseline HCT had been variable, but averaging around 30-32. HCT 30 on admission. Tagged red blood cell scan revealed brisk bleeding in the distal ascending colon/hepatic flexure. IR embolized branch of the right colic artery. Post- embolization, patient returned to the floor with SBP in 70s-80s, +copious melanotic stools. He did not, however, require pressors. Received 11u pRBCs (last was [**4-8**]). Antihypertensives, ASA, Plavix held. Pt had persistent BRBPR so underwent colonoscopy on [**4-8**] which revealed a visible vessel at post-polypectomy site which was injected. His HCT remained stable since. Started POs on [**4-10**], which he tolerated well. His primary cardiologist, Dr. [**Last Name (STitle) **], recommended restarting aspirin, which was done prior to departure. Upon discharge, he was scheduled with close cardiac follow-up. He was also to have his VNA check a CBC three days post-discharge for close monitoring. # Shortness of breath: Patient had an episode of SOB on [**4-9**] early morning. This was thought to be secondary to fluid overload (in setting of holding diuretics and getting blood) so was given IV ethacrynic acid. Also treated with BiPAP, Nitro gtt, and Solu-Medrol with improvement. He improved fairly rapidly with these interventions and did have similar episodes during his hospitalization. Cardiac enzymes were cycled and troponin was mildly elevated to 0.13, CK peak 120, MB peak 15, thought to be secondary to demand ischemia. Upon transfer out of the ICU, he continued to autodiurese several additional liters of excess fluids. Additionally, ethacrynic acid was restarted prior to discharge. # Hypotension: Secondary to GI bleeding. Managed hemorrhage as above. Blood pressure remained borderline low but stable. Ultimately improved toward his baseline, and his antihypertensives were restarted prior to discharge without any complications. # CAD: s/p DES to LAD in [**2183**] (patent stent on cath in [**1-30**]). Aspirin and Plavix were initially held given bleeding. Antihypertensives were held for hypotension. Statin was continue (switched to simvastatin as lovastatin is non formulary). Did not have CP or other symptoms of coronary insufficiency during this admission. Had one set of negative cardiac enzymes upon admission, but further cycling was not indicated. His primary cardiologist, Dr. [**Last Name (STitle) **], recommended restarting aspirin, which was done prior to departure. Upon discharge, he was scheduled with close cardiac follow-up. # COPD: On chronic daily Prednisone, home O2 2L. Recent admission in [**3-3**] for COPD exacerbation. Upon admission was breathing comfortably, not wheezing, good O2 sat on home O2 regimen. Continued home inhalers (changed to fluticasone and salmeterol as his home medications are nonformulary). Briefly was treated with stress dose steroids as above, which were not continued as SOB was thought to be secondary to volume overload vs. COPD exacerbation. Discharged on prior home dosages of inhalers and daily prednisone. # CHF: EF 50%, patient also has moderate AS. Diuretics were held while hypotensive. Restarted prior to discharge. # BPH: Initially held tamsulosin for hypotension and continued Finasteride. Tamsulosin was restarted prior to discharge, and he had no difficulty with post-Foley voiding. # Gout: Stable, continued colchicine. # Depression: Stable, continued Remeron. # Code status: Full. Confirmed with patient. Medications on Admission: Albuterol nebs prn Albuterol INH prn Clopidogrel 75 mg DAILY (restarted [**4-1**]) Colchicine 0.6 mg DAILY Ethacrynic Acid 25 mg DAILY Diclofenac Sodium 0.1 % Drops Finasteride 5 mg DAILY Lisinopril 5 mg DAILY Lovastatin 20 mg qhs Metoprolol Succinate 75 mg DAILY Mirtazapine 15 mg HS Mom[**Name (NI) 6474**] 220 mcg (60 doses) Inhalation twice a day. Formoterol Fumarate 12 mcg Capsule Inhalation twice a day. Omeprazole 20 mg twice a day. Tamsulosin 0.4 mg HS Tiotropium Bromide 18 mcg Capsule Inhalation DAILY Acetaminophen 325 mg Q6H prn pain. Alendronate 70 mg QSUN Senna 8.6 mg [**Hospital1 **] prn constipation. Docusate Sodium 100 mg [**Hospital1 **] prn constipation. Sodium Chloride Sprays Nasal QID (4 times a day) as needed. Bisacodyl 10 mg [**Hospital1 **] prn constipation. Prednisone 5 mg DAILY Aspirin 325 mg once a day (not yet restarted) Discharge Medications: 1. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Diclofenac Sodium 0.1 % Drops Sig: One (1) drop Ophthalmic daily (): OU daily . 3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. 9. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-25**] Sprays Nasal QID (4 times a day) as needed. 10. Lovastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 12. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO at bedtime. 13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, pain. 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipaion. 16. Ethacrynic Acid 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Bisacodyl 5 mg Tablet Sig: 1-2 Tablets PO once a day. 18. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Neb Inhalation Q6H (every 6 hours) as needed for SOB. 19. Albuterol 90 mcg/Actuation Aerosol Sig: [**1-25**] puff Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 20. Mom[**Name (NI) 6474**] 220 mcg (60 doses) Aerosol Powdr Breath Activated Sig: One (1) Inh Inhalation twice a day. 21. Formoterol Fumarate 12 mcg Capsule, w/Inhalation Device Sig: One (1) Capsule Inhalation twice a day. 22. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSun. 23. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 24. Outpatient Lab Work Visiting nurse to check HCT level [**2186-4-15**]. Please call his primary physician's office at [**Telephone/Fax (1) 19980**] and have this information relayed to the covering physician. [**Name10 (NameIs) **] HCT on discharge [**2186-4-13**] is 30.8. Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary: Gastroentestinal bleeding, cardiac disease Secondary: Moderate Aortic stenosis, Chronic Systolic Heart failure EF 50%, depresssion Discharge Condition: Stable, no evidence of further blood loss and breathing at baseline. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction:1.5L You were admitted for bleeding from your colon. You were treated with both radiology intervention and colonoscopy for this bleeding. You were transfused 11 units of blood. Once stable, you were discharged home for continued recovery. Please take all medications as prescribed. Your Plavix (Clopidogril) has been held while you were in the hospital. Do not restart this medication until you meet with your Cardiologist, Dr. [**Last Name (STitle) **], and seek his advice. All your other medications have been continued. Please keep all outpatient appointments. Seek medical advice if you notice fevers, chills, shortness of breath, increased swelling in your legs, bloody or black stool, overall worsening of your condition or for any other symptom which is concerning to you. Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 198**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 19980**], Monday, [**4-17**] at 4pm. Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2186-4-20**] 4:20 Provider: [**Name10 (NameIs) **] GATES, RNC MSN Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2186-5-16**] 1:15 Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2186-5-18**] 2:40 **Additionally, you will continue to have VNA services. They will check your blood counts on Saturday, [**4-15**] and relay this information to Dr.[**Name (NI) 61212**] office.

[ "428.21", "424.1", "285.1", "276.52", "428.0", "135", "V58.65", "998.11", "274.9", "E878.8", "491.21", "600.00" ]

icd9cm

[ [ [] ] ]

[ "88.47", "39.79", "45.43", "99.04" ]

icd9pcs

[ [ [] ] ]

10279, 10328

3132, 6994

339, 390

10512, 10583

3016, 3109

11541, 12347

2621, 2638

7900, 10256

10349, 10491

7020, 7877

10607, 11518

2653, 2997

281, 301

418, 1881

1903, 2432

2448, 2605

56,769

118,511

43140

Discharge summary

report

Admission Date: [**2169-9-1**] Discharge Date: [**2169-9-8**] Date of Birth: [**2100-1-8**] Sex: F Service: MEDICINE Allergies: Naprosyn / Amoxicillin / Dyazide / Band-Aid / Latex / Seroquel Attending:[**First Name3 (LF) 613**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: pleurodesis, chest tube placement History of Present Illness: The patient is a 69F with NSCLC multifocal adenocarcinoma with bronchoalveolar features diagnosed in [**2164**], with chronic malignant R-sided pleural effusion s/p pleurodesis ([**3-/2168**]) and a newly diagnosed left sided pleural effusion, recent admission for Afib with RVR with extensive PMHx including COPD on 4L home O2 and s/p bileaflet mechamic mitral valve on lovenox who was admitted to the floor on [**2169-9-1**] after elective left-sided pleurodesis and chest tube placement. She tolerated the procedure well; they removed 1300mL of pleural fluid. She became hypotensive to 75/50 immediately post-procedure, which improved after 1 L of IVF. Her lovenox what held this morning, but was given in the chest disease center prior to transfer to floor. She was also given morphine, percocet and Ancef pre-procedure. Her vital signs prior to transfer were afebrile, 111/60 84 sinus rhythm 93% 4L. On the floor she was pleasant and alert but mildly confused c/w prior hospitalizations. . On the floor, this morning patient went into atrial fibrillation with rapid ventricular rate to 160s with blood pressure to the 70s systolic. Reports felt generally unwell SOB, chest pain, mentating at baseline. She was given metoprolol 5mg then 2.5mg IV and diltiazem 10IV x2, and no PO. She was has been given 2L IVF and a 500cc bag is hanging. Chest tube output has been 1L overnight (still on suction) with minimal urine output (100cc since midnight, concentrated). Foley placed this AM. She is on 4L O2, which is her baseline. Access is port and PIV. Vitals on transfer: HR: 92-102 AFIB, BP in 83/60, 94% on 4L NC. Past Medical History: * Lung cancer - well-differentiated adenocarcinoma with bronchoalveolar features. s/p VATS [**2164**], pleurodesis [**3-/2168**] for R pleural effusion, 11 cycles premetrexed, now on carboplatin/paclitaxel since [**2169-7-26**]. [**2169-8-8**] was cycle 1, dose 3. * COPD * CAD - s/p MI [**7-/2149**] * Bileaflet mechanical MVR ([**2-/2159**]) - on warfarin, target INR 2.5-3.5. LVEF 50% ([**9-/2167**]) * TIA ([**7-/2163**]) * Hypertension * Hyperlipidemia * Grave's disease s/p radioablation * Crohn's disease - off meds since [**2162**] * Breast cancer - s/p radiation, tamoxifen * Psoriasis * Herpes zoster * Depression * Anxiety * Macular degeneration Social History: Retired nurse. Lives with boyfriend, [**Name (NI) **], who is an attorney. No children of own. Smoked 1ppd x 30 yrs, quit 20 years ago. No EtOH. No other drug use. Family History: Her parents are deceased: Father (lung cancer); mother (stroke). She has 2 brothers (one with bladder cancer). She has no children. Physical Exam: General: Caucasian female, agitated [**Name (NI) 4459**]: Sclera anicteric, dry mucus membranes, oropharynx clear Neck: JVP 4cm at 30 degrees, supple Lungs: Left sided chest tube in place draining serosanguinous fluid, Right sided port in place, crackles at bases CV: S1, S2 irregular rhythm, borderline increased rate, no murmurs Abdomen: soft, NTND, no guarding GU: no foley Ext: cool, distal pulses intact Pertinent Results: CXR: IMPRESSION: New left chest tube with no pneumothorax. Bilaterally decreased pleural effusions. . [**2169-9-1**] 06:00PM BLOOD WBC-2.3*# RBC-4.39 Hgb-12.6 Hct-39.3 MCV-90 MCH-28.8 MCHC-32.1 RDW-21.2* Plt Ct-358# [**2169-9-2**] 05:07AM BLOOD WBC-3.2* RBC-4.10* Hgb-12.0 Hct-36.3 MCV-89 MCH-29.3 MCHC-33.1 RDW-21.4* Plt Ct-383 [**2169-9-1**] 06:00PM BLOOD PT-12.1 PTT-33.9 INR(PT)-1.0 [**2169-9-1**] 06:00PM BLOOD Plt Ct-358# [**2169-9-1**] 06:00PM BLOOD Glucose-114* UreaN-13 Creat-0.8 Na-141 K-4.5 Cl-106 HCO3-27 AnGap-13 [**2169-9-2**] 05:07AM BLOOD Glucose-125* UreaN-16 Creat-1.0 Na-140 K-3.8 Cl-105 HCO3-26 AnGap-13 [**2169-9-2**] 12:59PM BLOOD CK(CPK)-63 [**2169-9-2**] 09:29PM BLOOD CK(CPK)-49 [**2169-9-3**] 05:05AM BLOOD CK(CPK)-46 [**2169-9-3**] 05:05AM BLOOD CK-MB-3 cTropnT-<0.01 [**2169-9-1**] 06:00PM BLOOD Calcium-8.5 Phos-3.0 Mg-1.8 [**2169-9-2**] 03:23PM BLOOD T4-7.9 [**2169-9-2**] 12:59PM BLOOD TSH-33* [**2169-9-2**] 03:58PM BLOOD Lactate-1.4 Brief Hospital Course: 69yo F with NSCLC with chronic malignant R-sided pleural effusion s/p pleurodesis ([**3-/2168**]), newly diagnosed left sided pleural effusion s/p elective pleurodesis and chest tube placement on [**2169-9-1**], hospital course complicated by atrial fibrillation with rapid ventricular rate and asymptomatic hypotension requiring ICU admission. . #PLEURAL EFFUSION: She has a chronic right sided malignant pleural effusion and was found to have a new left sided pleural effusion, which was likely due to progressive disease. She underwent palliative pleurodesis and chest tube placement by interventional pulmonology. She continued to have high volume output from her chest tube so on hospital day 4 she received an injection of talc. Her chest tube output decreased, and the chest tube was ultimately removed. She began to have increased cough productive of purulent sputum the day after the tube was removed, so she was started on Mucomyst nebs and guafenisen which provided some relief. . #ATRIAL FIBRILLATION: She has a history of paroxysmal atrial fibrillation maintained on dual AV nodal [**Doctor Last Name 360**] therapy and on hospital day two went into atrial fibrillation with a rapid ventricular rate and asymptomatic hypotension. She developed shortness of breath during episodes of RVR. She was started on amiodarone (bolus, drip, then PO) and converted to sinus rhythm. She went back into atrial fibrillation with RVR twenty four hours later during repositioning. She was given another bolus of amiodarone and started on metoprolol, after which she converted to sinus rhythm. She was started on po amiodarone, 400mg [**Hospital1 **]. Upon discharge she will have 2.5 more days at [**Hospital1 **] dosinf for her amiodarone load. [**9-11**] she will start 400mg daily for 1 week, to be followed by a maintenance dose of 200mg daily. . #HYPOTENSION: She became hypotensive in the setting of atrial fibrillation with RVR. This was likely due to hypovolemia and her tachyarrhythmia. She was given IV fluid and required vasopressors for <24 hours. Her cardiac enzymes were normal. Pulsus paradoxus was within normal limits. Blood and urine cultures were obtained and she was started on ceftriaxone for UTI. In preparation for discharge, she was changed from ceftriaxone to po cefpodoxime. . # DELIRIUM: During transfer to the ICU she was quite agitated with reduced orientation and inattention consistent with delirium. She was given IV haldol 2.5prn for agitation as she was trying to physically remove her port. With treatment of the hypotension, atrial fibrillation, and UTI her agitation improved. She was transitioned to comfort care. . # COPD: She was continued on supplemental oxygen and ipratropium nebs for comfort. She has a nebulizer at home and will be discharged with DuoNebs for shortness of breath or wheezing. . # MECHANICAL MVR. She was continued on Lovenox for anticoagulation as preventing an ischemic event was considered part of palliation. . # GOALS OF CARE: The MICU team met with the health care proxy who recognized the patients chronic, progressive medical condition. The major concern was patient comfort and safe transition to home. The patient and family met with the palliative care team. Her code status was made DNR/DNI and comfort measures only. The patient voiced desire to go home rather than to a nursing facility or inpatient Hospice, and so arrangements were made for the patient to go home with 24 hour nursing care and Hospice services. . Medications on Admission: ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs inhaled every 4 hours as needed for shortness of breath BUPROPION HCL - 150 mg Tablet Sustained Release - 2 Tablet(s) by mouth once a day DILTIAZEM HCL - 240 mg Capsule, Sustained Release - 1 Capsule(s) by mouth once a day ENOXAPARIN [LOVENOX] - (Prescribed by Other Provider) - 60 mg/0.6 mL Syringe - 50mg Q 12 hour FLUTICASONE - 50 mcg Spray, Suspension - 1 sprays(s) in each nostril twice a day for 5 days LEVOTHYROXINE [SYNTHROID] - 100 mcg Tablet - 1 Tablet(s) by mouth once a day LISINOPRIL - 30 mg Tablet - 1 Tablet(s) by mouth once a day METOPROLOL SUCCINATE [TOPROL XL] - 50 mg daily SIMVASTATIN - 10 mg Tablet - one Tablet(s) by mouth once a day TRAZODONE - 50 mg Tablet - 0.5 (One half) Tablet(s) by mouth three times a day and [**2-11**] to 1 at bedtime as needed for anxiety/insomnia RISPERIDONE - 0.125 - 0.25 mg PO TID PRN anxiety and insomnia. ASPIRIN [ASPIRIN LOW DOSE] - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily FOLIC ACID - (OTC) - 0.4 mg Tablet - 1 Tablet(s) by mouth daily Discharge Medications: 1. Bupropion HCl 150 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO QAM (once a day (in the morning)). 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for stomach upset. Disp:*1 bottle* Refills:*0* 5. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection Subcutaneous Q12 (). 6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 7. Morphine 10 mg/5 mL Solution Sig: 2-4 mg PO Q4H (every 4 hours) as needed for pain, dyspnea. 8. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 9. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 5.5 days. 10. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) flush Intravenous PRN (as needed) as needed for line flush. 11. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) flush Intravenous PRN (as needed) as needed for DE-ACCESSING port. 12. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for anxiety. 13. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML Miscellaneous Q2H (every 2 hours) as needed for cough. Disp:*50 nebs* Refills:*0* 14. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day for 7 days: Starting [**9-11**]. Disp:*7 Tablet(s)* Refills:*0* 15. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO twice a day for 2.5 days. Disp:*5 Tablet(s)* Refills:*0* 16. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: Starting [**9-18**] . Disp:*30 Tablet(s)* Refills:*0* 17. Risperdal 0.25 mg Tablet Sig: 0.5-1 Tablet PO three times a day as needed for anxiety, aggitation. 18. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) neb Inhalation every six (6) hours as needed for shortness of breath or wheezing. 19. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for anxiety. 20. Sodium Chloride 0.9 % 0.9 % Syringe Sig: One (1) 3ml Flush Injection q8 hours as needed for line flush. Discharge Disposition: Home With Service Facility: [**Hospital 269**] Hospice Care Discharge Diagnosis: Primary: malignant right pleural effusion atrial fibrilation Secondary: urinary tract infection NSCLC Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital with difficulty breathing and fluid in your lungs. You had a tube placed in the left side of your chest to drain fluid. The fluid was from your cancer and improved after you had powder injected into your chest to scar the layers of the lung and prevent recurrent fluid buildup. You had an abnormal heart rhythm, atrial fibrilation, and your blood pressure became low, so you you were transferred to the medical ICU. There, they started you on a medicine called amiodarone for your heart rhythm. You also got medicine and fluid to help bring up your blood pressure. When your blood pressure was better and your heart rate was controlled, you came to the regular medicine floor. The chest tube was removed, and you got some medicine to help a cough you were having that was productive of sputum. . You and [**Male First Name (un) **] discussed with palliative care your desire to go home and be comfortable instead of pursuing further invasive testing so you were discharged from the hospital to home with hospice. . You were found to have a urinary tract infection, so you were started on an antibiotic for this. You will take cefpodoxime (Vantin) for 5 more days for this. . We made the following changes to your medications: - Start taking cefpodoxime (Vantin) 200mg twice a day for 5 more days. - For pain, you may take Tylenol (acetaminopen) 500mg 1 or 2 tablets every 6 hours. If you still have pain after that, you can take morphine 2-4mg every 2 hours for pain or difficulty breathing. - You may use Mucinex (guaifenisen) 1200mg twice a day for cough. - You may use Mucomyst (acetycysteine) in the nebulizer ever 2 hours as needed for cough and sputum production. - You may use ipratropim/albuterol (DuoNebs) in the nebulizer every 6 hours as needed for shortness of breath or wheezing - Start taking amiodarone 400mg twice a day for 3 more days. Then, starting Monday [**9-11**], take 400mg daily for one week, and then 200mg daily after that. - Continue taking trazodone as needed for sleep, but stop using it during the day for anxiety - You may take Ativan (lorezapam) 0.5mg every 4 hours as needed for anxiety. - You may take bisadocyl (Dulcolax) daily as needed for constipation - You may take Aluminum-magnesium-hydrox-simethecone (Malox) 4 times a day as needed for upset stomach - Stop taking diltiazem - Stop taking simvastatin - Stop taking lisinopril - Stop taking metoprolol - Stop taking asprin Followup Instructions: Department: CARDIAC SERVICES When: THURSDAY [**2169-9-14**] at 9:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: HMFP When: THURSDAY [**2169-9-21**] at 11:40 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9993**], MD [**Telephone/Fax (1) 1387**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 551**] Campus: EAST Best Parking: Main Garage . Department: CARDIAC SERVICES When: THURSDAY [**2169-10-12**] at 11:20 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

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icd9cm

[ [ [] ] ]

[ "34.92", "34.04", "34.06" ]

icd9pcs

[ [ [] ] ]

11457, 11519

4475, 7966

339, 374

11665, 11665

3484, 4452

14316, 15435

2904, 3039

9100, 11434

11540, 11644

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3054, 3465

13103, 14293

280, 301

402, 2020

11680, 11819

2042, 2703

2719, 2888

75,249

113,789

38042

Discharge summary

report

Admission Date: [**2135-5-27**] Discharge Date: [**2135-5-31**] Date of Birth: [**2074-1-7**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1943**] Chief Complaint: Alcohol withdrawal and possible withdrawal seizure Major Surgical or Invasive Procedure: None History of Present Illness: 61 year-old gentleman with history of alcohol abuse, complicated by alcohol withdrawal with delirium tremens and seizures, presenting from home after a witnessed seizure yesterday and feeling very sick wanting to quit drinking. He was in his prior state of health and was discharged from [**Hospital1 18**] on [**2135-2-27**] after being admitted for alcohol withdrawal. He was sober until 2 weeks ago when he started drinking a case of beer daily until 2-3 days ago when he started to feel bad. He noted that his baseline palpitations became much more frequent, he had watery diarrhea 4-5 times per day without any blood, nausea, vomit and body pain. He thought it was secondarely to drinking heavily for 2 weeks, so started to cut back down during the last two days to 4-5 beers per day, but he was not able to keep them down. He denies any fever, chills, rigors, cough, shortness of breath, chest pain, leg swelling. Yesterday morning he was requesting help to a AA friend, when his friend witnessed how he started to have generalized tonic-clonic seizures and stopped spontaneously. Therefore, he came to the emergency room. His last drink was 1-2 days ago. In the ER patient his initial VS were Pain [**5-7**], T 99.8 F, HR 102 BPM, BP, 161/82 mmHg, RR 22 BPM, SpO2 98% on RA. he was reported in NAD, CTAB, not guaiac, diffuse abdominal pain, positive bowel sounds, tremors, A&O X3. ECG was unchanged from prior. Pt labs showed no WBC, HCT at baseline at 38, PLT of 141, sodium of 126, bicarbonate of 19, glucose 110 with AG of 23, negative CE, AST 533, ALT 427, Lip 78, TB, 1.7, alb 4.5, OH level of 99 and otherwise negative Utox. UA was not done. Patient required 5 mg of IV valium at [**2040**], [**2125**], 2230 and 2300 for a total of 20 mg IV. Pt receive 8 mg of IV zofran. He was admited to the medical floor. In the medicine floor his CIWA was betwen 29-36 and received 10 mg of IV valium at 1:00 and 1:50 (total 20 mg) without any response. he received zofran for nausea without any effect. he was considered high risk of seizures with auditory, tactile and visula disturbances. He was placed on NS @ 100 cc/hr. It was considered he was high risk and with high nursing requirements, so he was transfered to the ICU. his VS prior to transfer: BP 129/77 mmHg, HR 98 BPM, RR 18 X', SpO2 97% RA Past Medical History: Alcohol Abuse - Has had multiple admissions for alcohol withdrawal, per records - c/b seizures, DT's - Recurrent patter after short periods of sobriety. Hepatitis C - followed at [**Hospital6 **] Depression Scoliosis Social History: Alcohol abuse as above. 40 pack year smoking history, quit 2 years ago. Denies a history of IV drug use. Has one tattoo from age 16 done at home. No blood transfusions. Family History: Father with alcoholism Physical Exam: EXAM ON ADMISSION: VITAL SIGNS - 97.2, 75, 108/57, 22, 97% on RA GENERAL - NAD HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - slight bibasliray crackles, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES - mild tremors, WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**6-1**] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait 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: [**2135-5-27**] 07:00PM BLOOD WBC-8.4 RBC-4.22* Hgb-13.4* Hct-38.8* MCV-92 MCH-31.9 MCHC-34.6 RDW-14.1 Plt Ct-141* [**2135-5-27**] 07:00PM BLOOD Neuts-77.8* Lymphs-16.3* Monos-4.6 Eos-0.8 Baso-0.5 [**2135-5-27**] 07:00PM BLOOD Glucose-110* UreaN-10 Creat-0.8 Na-126* K-4.0 Cl-84* HCO3-19* AnGap-27* [**2135-5-27**] 07:00PM BLOOD ALT-427* AST-533* CK(CPK)-524* AlkPhos-83 TotBili-1.7* [**2135-5-27**] 07:00PM BLOOD Lipase-78* [**2135-5-27**] 07:00PM BLOOD CK-MB-11* MB Indx-2.1 cTropnT-<0.01 [**2135-5-27**] 07:00PM BLOOD Albumin-4.5 Calcium-8.6 Phos-2.2* Mg-2.3 [**2135-5-29**] 03:56AM BLOOD calTIBC-211* Ferritn-1662* TRF-162* [**2135-5-27**] 07:00PM BLOOD ASA-NEG Ethanol-99* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ====================== DISCHARGE LABS: [**2135-5-31**] 05:55AM BLOOD WBC-5.5 RBC-3.94* Hgb-12.0* Hct-36.4* MCV-92 MCH-30.5 MCHC-33.0 RDW-13.7 Plt Ct-202 [**2135-5-31**] 05:55AM BLOOD Glucose-103* UreaN-4* Creat-0.7 Na-137 K-3.8 Cl-100 HCO3-25 AnGap-16 [**2135-5-30**] 05:30AM BLOOD ALT-206* AST-180* [**2135-5-31**] 05:55AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.0 ======================= ECG ([**5-27**]): Sinus rhythm. Short P-R intervals. Left ventricular hypertrophy. Non-diagnostic small Q waves in inferior leads. Modest septal T wave changes that are non-specific. Compared to the previous tracing of [**2134-9-20**] there is no significant diagnostic change. Brief Hospital Course: # Alcohol withdrawal: Pt with long history of ETOH abuse who reported visual hallucinations and h/o seizures. He was transferred to the MICU due to high risk of DTs. Pt was monitored in the MICU and was requiring Valium q1-2hrs. He was treated with banana bag. He was then called out to the floor when valium was changed to PO and his CIWA scale decreased to q4h. He was sincerely interested in stop drinking, and wanted to get help. He was seen by SW, who was going to provide outpatient treatment referrals. He decided to leave AMA at 6:22am on [**2135-5-31**], before everything was set up for him. By the time the night float intern arrived on the floor, he was already in the elevator, and couldn't be persuaded to stay. # Alcoholic hepatitis: Pt with elevated AST and ALT with a ratio of 1.2. Bilirubin is slightly elevated to 1.7 with normal alk phos. LFTs were trending down during this hospital stay. # Hyponatremia - Pt with hypovolemic hyponatremia, which was likely secondary to alcohol binge and dehydration. This resolved with IVF and nutrition. # Anion gap metabolic acidosis - Pt presented with a gap of 23 and a bicarbonate of 19. There was likely an additional component of alkalosis from vomiting. The gap closed with IVF. Medications on Admission: None Discharge Medications: None since patient left AMA without being seen by MD Discharge Disposition: Home with Service Discharge Diagnosis: PRIMARY DIAGNOSES: - Alcohol withdrawal - Alcohol abuse SECONDARY DIAGNOSES: - Alcohol withdrawal seizures and delirium tremens - Hepatitis C - followed at [**Hospital6 **] - Depression - Scoliosis Discharge Condition: Alcohol Withdrawal: Minimal anxiety and tremulousness. Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: [This instruction was prepared ahead of time, but patient did not receive this prior to leaving AMA] You were admitted to [**Hospital1 69**] because of alcohol withdrawal. Your withdrawal symptoms resolved at the time of discharge. Your liver took a hit from the alcohol, but your liver enzymes were getting better during this hospital stay. You should stop drinking alcohol. Your liver could be permanently damaged if you continue to drink, and you could die from the complications from alcohol. Your medications have been changed: - please take thiamine, folate and multivitamin - you can take imodium as needed for diarrhea Followup Instructions: Please follow up with your primary care doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], within two weeks after discharge. Please call [**0-0-**] to make an appointment.

[ "070.70", "311", "780.39", "276.2", "787.91", "285.29", "291.81", "287.5", "276.1", "427.31", "303.91", "571.1" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6894, 6913

5511, 6762

365, 371

7155, 7210

4085, 4085

8016, 8219

3153, 3177

6817, 6871

6934, 6991

6788, 6794

7360, 7993

4866, 5488

3192, 3197

7012, 7134

275, 327

399, 2708

4101, 4850

3211, 4066

7225, 7336

2730, 2948

2964, 3137

11,212

140,957

4664

Discharge summary

report

Admission Date: [**2149-3-5**] Discharge Date: [**2149-3-11**] Date of Birth: [**2073-4-9**] Sex: M Service: MEDICINE Allergies: Bactrim / Ciprofloxacin / Percocet Attending:[**First Name3 (LF) 425**] Chief Complaint: Dyspnea and fatigue Major Surgical or Invasive Procedure: AV Nodal Ablation Temporary Pulmonary Artery Catheterization History of Present Illness: Patient is a 75 year old male with significant cardiac history including CAD s/p MI and CABG, CHF (EF 20%), and aflutter, recently admitted in mid- [**Month (only) 404**] for ? conversion of symptomatic aflutter; who now presents with worsening dyspnea and fatigue since discharge. Pt reports feeling that he tires more easily and has to stop more frequently when ambulating. Able to climb stairs "slowly". Pt also notes increased swelling of his legs. Denies any cough, fevers, or night sweats; no known sick contacts. However, last night has shaking chills, 'never felt so cold in my life'. Also describes sx of orthopnea and orthostasis, no LOC. Pt has had a decrease in his appetite, no known weight loss. Reports compliance with all medications on a daily basis. No N/V/diarrhea or abdominal pain. No dysuria, but pt does note a decrease in the quantity of urine output in the past 2 wks. . In the [**Name (NI) **] pt given 40 mg IV lasix with little effect and became hypotensive requiring dopamine gtt, after starting dopamine gtt, became more tachycardiac into 100's. Patient's rhythym was thought to represent VTach for which the patient was given lidocaine without effect. Dopamine gtt was discontinued with decrease of heart rate to low 100's. Past Medical History: #. CAD s/p Anterior wall MI (PCI) #. CABG x 4 [**5-20**] LIMA to D1, radial to LAD, SVG to PDA #. CHF - ischemic cardiomyopathy (EF 20-30% [**2149-3-6**]) #. Atrial Fibrillation #. Hyperlipidemia #. Moderate Pulmonary Hypertension #. Interstitial fibrosis #. Recurrent DVT/PE s/p IVC filter #. S/P placement of biventricular ICD #. Hx Renal cell carcinoma ([**2129**]), s/p left nephrectomy ([**2137**]) #. Hx Bladder CA #. Previous Hypothyroidism, now hyperthyroidism ([**2149-2-19**]) #. S/P Right CEA #. S/P TIA with no residual symptoms ([**2143**]) #. GERD #. S/P previous Upper GI Bleed #. Skin cancers #. CKD - baseline appears to be 1.2-1.4 Social History: Patient is widowed and lives with his son and his family. He has a total of four children. Family History: nc Physical Exam: Vitals in ED: 96.1/ bp 96-104/ 40-50/ hr 104/ 99% on 2L, drops to 80% on RA during ambulation GEN: elderly male, well developed, flat affect, NAD HEENT: atraumatic, anicteric, clear OP, dry mucous membrane NECK: elevated JVP, no carotid bruits, no LAD CARDIAC: distant heart sound, irregular, +systolic murmur, no rubs LUNGS: distant BS throughout, + crackles [**1-20**] way up bilat. No accessory muscle use, no conversational dyspnea ABD: distended, soft, nt, hypoactive bs EXT: deeply pitting edema B/L up to groin. Shiny skin, loss of hair. Cool toes, faint DP pulses b/l NEURO: A/O X3, CN II-XII intact, no focal. 5/5 strength in all 4 extremities. Pertinent Results: Admission Labs: . [**2149-3-5**] 03:15PM PT-31.5* PTT-34.7 INR(PT)-3.4* [**2149-3-5**] 03:15PM PLT COUNT-256 [**2149-3-5**] 03:15PM HYPOCHROM-OCCASIONAL ANISOCYT-OCCASIONAL POIKILOCY-1+ MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL SCHISTOCY-1+ [**2149-3-5**] 03:15PM NEUTS-66 BANDS-0 LYMPHS-17* MONOS-15* EOS-1 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 NUC RBCS-3* [**2149-3-5**] 03:15PM WBC-7.4 RBC-4.22* HGB-14.1 HCT-43.7# MCV-103* MCH-33.5* MCHC-32.4 RDW-15.7* [**2149-3-5**] 03:15PM T3-231* FREE T4-5.9* [**2149-3-5**] 03:15PM TSH-LESS THAN [**2149-3-5**] 03:15PM CK-MB-NotDone proBNP-[**Numeric Identifier 19723**]* [**2149-3-5**] 03:15PM CK(CPK)-57 [**2149-3-5**] 03:15PM GLUCOSE-110* UREA N-72* CREAT-2.7*# SODIUM-136 POTASSIUM-5.7* CHLORIDE-103 TOTAL CO2-18* ANION GAP-21* [**2149-3-5**] 03:17PM DIGOXIN-<0.2 [**2149-3-5**] 03:17PM TSH-<0.02 [**2149-3-5**] 03:17PM cTropnT-<0.01 Pertinent labs/Studies: . Creatinine: 2.7 ->> 2.1 ([**3-5**] to [**3-11**]) [**2149-3-11**] 06:00AM BLOOD PT-23.4* PTT-33.6 INR(PT)-2.3* . [**2149-3-5**] 57 -> 127 -> 36 -> 34 [**2149-3-5**] cTropnT- <0.01 -> <.01 -> <.01 -> >/01 . [**2149-3-5**] 03:15PM proBNP-[**Numeric Identifier 19723**]* . [**2149-3-6**] VitB12-1523* Folate-GREATER TH [**2149-3-6**] %HbA1c-6.3* [Hgb]-DONE [A1c]-DONE . Thyroid: [**2149-3-5**] TSH-<0.02 [**2149-3-5**] T3-231* Free T4-5.9* anti-TPO < 1 ; anti-thyroglobulin < 1 ; thyroglobulin - pending . [**2149-3-6**] [**Last Name (un) **] stim test: Cortisol T0 - 14.2 -> 28.6 (30min)-> 34.4 (60min) . Imaging: [**2148-3-5**]: Portable Chest - CHEST, TWO VIEWS: Comparison with [**2149-1-28**]. The patient is status post CABG. The pacer leads are unchanged in position. There is blunting of the right costophrenic angle consistent with a small pleural effusion and atelectasis. There is also blunting of the left costophrenic angle consistent with a pleural effusion. There is mild pulmonary, [**Year (4 digits) 1106**] upper zone redistribution. IMPRESSION: Mild CHF. . [**2148-3-6**]: Renal US - The right kidney measures 13.1 cm and is normal in appearance with no hydronephrosis, stone, or mass. Cortical echogenicity is normal. No perinephric collections are seen. The bladder is partially distended and normal in appearance. There is a fluid collection consistent with reservoir for penile prosthesis present with a catheter within it. IMPRESSION: Normal-appearing right kidney. . [**2149-3-6**]: Echocardiogram - MEASUREMENTS: Left Atrium - Long Axis Dimension: *5.2 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *6.7 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *6.9 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 5.1 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 4.6 cm Left Ventricle - Fractional Shortening: *0.10 (nl >= 0.29) Left Ventricle - Ejection Fraction: 20% to 30% (nl >=55%) Aorta - Valve Level: 3.3 cm (nl <= 3.6 cm) Aorta - Ascending: *4.2 cm (nl <= 3.4 cm) Aorta - Arch: *3.3 cm (nl <= 3.0 cm) Aortic Valve - Peak Velocity: 1.9 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 1.2 m/sec Mitral Valve - E Wave Deceleration Time: 190 msec TR Gradient (+ RA = PASP): *33 to 40 mm Hg (nl <= 25 mm Hg) . Findings: LEFT ATRIUM: Moderate LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. Dilated IVC (>2.5 cm), with minimal respiratory variation c/w elevated RA pressure of >20 mmHg. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Severe global LV hypokinesis. No resting LVOT gradient. No LV mass/thrombus. No VSD. RIGHT VENTRICLE: Normal RV wall thickness. Dilated RV cavity. RV function depressed. AORTA: Normal aortic root diameter. Focal calcifications in aortic root. Moderately dilated ascending aorta. Focal calcifications in ascending aorta.Mildly dilated aortic arch. Focal calcifications in aortic arch. AORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve leaflets. Mild AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. No MS. Moderate (2+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid valve supporting structures. Moderate [2+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. Normal main PA. No Doppler evidence for PDA PERICARDIUM: No pericardial effusion. Conclusions: The left atrium is moderately dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is severe global left ventricular hypokinesis (ejection fraction 20-30 percent). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. The ascending aorta is moderately dilated. The aortic arch is mildly dilated. There are focal calcifications in the aortic arch. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is at least moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . Compared with the findings of the prior study (images reviewed) of [**2149-1-28**], no major change is evident. . Discharge Labs: . [**2149-3-11**] 06:00AM BLOOD Hct-36.9* [**2149-3-11**] 06:00AM BLOOD PT-23.4* PTT-33.6 INR(PT)-2.3* [**2149-3-11**] 06:00AM BLOOD UreaN-66* Creat-2.1* K-4.0 [**2149-3-6**] 06:45PM BLOOD ALT-22 AST-31 AlkPhos-56 TotBili-0.7 [**2149-3-11**] 06:00AM BLOOD Mg-1.9 [**2149-3-11**] 06:00AM BLOOD T3-PND Free T4-PND [**2149-3-11**] 11:11AM BLOOD Type-ART pO2-60* pCO2-32* pH-7.40 calHCO3-21 Base XS--3 [**2149-3-11**] 11:11AM BLOOD O2 Sat-90 Brief Hospital Course: Patient is a 75 year old male with significant cardiac history including CAD, s/p MI and CABG, with a-flutter and a-fib, s/p [**Hospital1 **]-v ICD, CHF who presented to [**Hospital1 18**] with persistent dyspnea and fatigue since discharge (approximately one month ago) found to be hypotensive and tachycardiac in ED. . #. Cardiovascular 1. CAD: The patient has known CAD, s/p CABG in [**2135**] with previous placement if a [**Hospital1 **]-Ventricular pacer/ICD. On presentation the patient was dyspneic with evidence of CHF thought likely to be [**2-20**] ischemic cardiomyopathy with superimposed afib. Given the patient's hypotension with SBP < 90, the patient was initially placed on a dopamine gtt in the ED. However, this caused worsening of the patient's rapid ventricular response with worsening of symptoms. In the ED the patient's rhythm was thought to represent VTach for which the patient was given lidocaine, without good effect. Review upon admission to the CCU however revealed that the patient was not in VTach but had more likely aberrant conduction of his SVT. Dopamine gtt was discontinued and the patient was instead loaded with amiodarone in the E.D. On presentation the patient had a V-paced ECG without obvious changes consistent with ischemia. The patient did not report chest pain and the majority of his symptoms appeared to be consistent with CHF. The patient ruled out for myocardial infarction by cardiac enzymes x 3. On admission to [**Hospital1 18**], the patient was already taking ASA, Lipitor, metoprolol and digoxin. Initially the patient's digoxin was discontinued although his blood levels were not supra therapeutic on admission. On discharge the patient's metoprolol was changed to Carvedilol given his depressed EF. . #. Pump : The patient was known to have CHF w/ systolic dysfunction secondary to ischemic cardiomyopathy on admission. A previous echocardiogram showed a LVEF of 20-30%. On admission, CXR and physical exam were consistent with significant volume overload, but diuresis was limited by persistent hypotension. This hypotension was thought initially to be due to cardiogenic shock secondary to the patient's ischemic cardiomyopathy and afib as well as possible sepsis as the patient was noted to have warm extremities with evidence of peripheral vasodilation. However, the patient remained afebrile, without elevated white count or source of infection. The patient was found on admission to have suppressed TSH and elevated T3 and T4 however. It was thought that the patient's hyperthyroidism may have instead accounted for his physical findings and all antibiotics were discontinued. After the patient's SBP stabilized on [**3-6**], gentle lasix diuresis was initiated to effect a net diuresis of 700cc. Repeat echocardiogram performed on [**3-6**] revealed an EF of 20-30% with moderate LA and RA enlargement, severe global LV hypokinesis, mild AS, Mod MR/TR and moderate PA systolic hypertension. Given an inability to control the patient's rhythm medically, the patient [**Month/Year (2) 1834**] AVN ablation (see below) with improvement in blood pressure and rate control. Brief right heart cath performed during the AV nodal ablation was consistent with left heart failure with a PCWP of 36. With improved rate control and pressure the patient was more effectively able to be diuresed with net diuresis of approximately 5-6 liters since admission with IV antibiotics, usually requiring lasix 40mg - 120mg IV qd to achieve goals of 500-1000cc/day. The patient was transitioned to PO lasix with regimen of 60mg PO bid to keep I=O. Upon discharge patient appeared euvolemic to mildly fluid overloaded with more aggressive diuresis limited by patient's creatinine, which was 2.1 on day of discharge (2.7 on admission). Prior to discharge digoxin was added back to the [**Hospital 228**] medical regimen for improved ionotropy and to help prevent repeat hospitalization. Additionally, given the patient's depressed EF, his beta blocker was changed from his outpatient regimen of metoprolol to carvedilol. . 3. Rhythm - On admission, the patient presented in a fib with RVR, which was thought to be exacerbating patient's hypotension given pre-existing LV systolic dysfunction. Of note, the patient previously had a biventricular ICD placed for depressed EF and ventricular dys synchrony. The rate on admission to CCU was low 100s. The patient was initially started on amiodarone for rate and rhythm control which unfortunately failed to control the patient's rhythm. Given the patient already had a [**Hospital1 **]-V ICD in place, he was thought to be a good candidate for AVN ablation. Additionally, given the patient's previous pulmonary toxicity secondary to amiodarone, he was thought not to be a good candidate for long term amiodarone therapy. AV nodal ablation was performed on [**3-7**], with excellent effect. The patient is currently V/V/I paced with heart rate around 80. Currently the patient is still in Atrial fibrillation but obviously without conduction. However, given his persistent afib the patient will require anticoagulation. The patient is currently with a therapeutic INR of 2.3 with discharge medical regimen of Coumadin 2mg po qhs. This will need to be monitored carefully and adjusted as needed given the patient's regimen had to be altered throughout his hospital course to allow for his procedures. In the future the patient may benefit from attempted conversion using quinidine and DCCV to augment the patient's CO with a normal atrial kick as per EP's recs. However, the goal of this hospitalization was stabilization of the patient with optimization of his current medical regimen. Additional follow up with the patient's cardiologist for above considerations is already arranged. . #. Hyperthyroidism : Historically the patient has a history of hypothyroidism, thought originally to be secondary to amiodarone therapy. As noted above, the patient was actually found to be hyperthyroid on admission without clear precipitant. Antibody testing was negative including anti-peroxidase and anti-thyroglobulin, making Grave's disease less likely. Additionally, the patient has not recently been treated with amiodarone therapy (greater than one year) making amiodarone effect not likely. To date, the exact etiology of the patient's hyperthyroidism is not known but the patient is receiving follow up with endocrine. The patient was seen in house by the endocrine service who made recommendations to treat the patient's hyperthyroidism given potential cardiac side effects. Currently the patient is on Methimazole 20mg po bid with scheduled follow up with Endocrine. The patient has been warned of potential side effects of methimazole including agranulocytosis and has been instructed about warning signs such as sore throat, fever, chills. . # ARF - Patient is reported to have baseline creatinine of 1.2 - 1.4 on previous admission. This admission the patient suffered acute on CRF with admission creatinine of 2.7 thought likely to be secondary to hypoperfusion given patient's hypotension on admission. With improved cardiac function the patient's creatinine began to decrease, even in the setting of fairly aggressive diuresis. On discharge the patient has a creatinine of 2.1 which will need continued monitoring as the patient continues therapy with lasix. Of note the patient has a history previously of renal cell carcinoma s/p left nephrectomy. Renal ultrasound of the remaining right kidney revealed no obstruction. . # Pulm HTN/ pulm fibrosis/chronic stable PE. Patient with pulmonary disease likely secondary to amiodarone toxicity. Patient was continued on outpatient regimen of Advair, spiriva and PRN albuterol (not used this admission). as noted, amiodarone was used temporarily but without plans to continue now that patient is adequately rate controlled. The patient has an IVC filter in given history of previous PE. . # Elevated MCV: Etiology unclear, this has been present since [**2146**]. B12 and Folate were checked this admission, both within normal limits. . # FEN - patient was maintained on a low sodium/cardiac/renal diet with fluid restriction < 1200cc/day. The patient was instructed about a low sodium diet and instructed to weight himself daily to guide lasix therapy . # Code status- Code status was reviewed with the patient on admission. The patient is currently DNR/DNI, not to receive compressions or intubation. HOWEVER, the patient reports that should he develop an arrythmia, he would want to receive up to one external shock. However, again he would NOT want compressions or intubation. Medications on Admission: Warfarin 2 mg QOD Escitalopram 20 mg Niacin 1000 mg Folic Acid 1 mg [**Hospital1 **] Atorvastatin 40 mg Multivitamin Furosemide 40 mg QOD Hydrocortisone 1 % Cream Zolpidem 5 mg Metoprolol Tartrate 50 mg Aspirin EC 81 mg Digoxin 125 mcg QOD Discharge Medications: 1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Methimazole 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 6. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. 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* 8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). Disp:*30 Tablet(s)* Refills:*2* 9. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 10. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: Primary: Congestive Heart Failure Atrial Fibrillation Hypotension Hyperthyroidism . Secondary: #. CAD s/p Anterior wall MI (PCI) #. CABG x 4 [**5-20**] LIMA to D1, radial to LAD, SVG to PDA #. CHF - ischemic cardiomyopathy (EF 20-30% [**2149-3-6**]) #. Atrial Fibrillation #. Hyperlipidemia #. Moderate Pulmonary Hypertension #. Interstitial fibrosis #. Recurrent DVT/PE s/p IVC filter #. S/P placement of biventricular ICD #. Hx Renal cell carcinoma ([**2129**]), s/p left nephrectomy ([**2137**]) #. Hx Bladder CA #. Previous Hypothyroidism, now hyperthyroidism ([**2149-2-19**]) #. S/P Right CEA #. S/P TIA with no residual symptoms ([**2143**]) #. GERD #. S/P previous Upper GI Bleed #. Skin cancers #. CKD - baseline appears to be 1.2-1.4 Discharge Condition: Good. Patient is afebrile, hemodynamically stable with SBP > 100 with O2 sat > 90% at rest. Patient has elevated creatinine from normal baseline which will be monitored as an outpatient. Discharge Instructions: 1. Please take all medications as prescribed . 2. Please keep all outpatient appointments. . 3. You have a diagnosis of congestive heart failure. It is very important that you weigh yourself every morning. if your weight increases by more than 3 lbs from your baseline, you should call your cardiologist immediately to see if a change in your medical regimen may be warranted. Additionally it is important that you adhere to a strict diet with no more than 2g sodium per day. Followup Instructions: 1. You have an appointment to be seen with [**Doctor Last Name 11139**] on Thursday 23rd at 1:45p.m. You will need to have your INR checked at this time as your coumadin dose has been adjusted during your hospital course. Please call the office of Dr. [**Last Name (STitle) 19724**] at [**Telephone/Fax (1) 11144**] with any questions or scheduling needs. . 2. Please have lab work drawn at your PCP's office within 2 to 3 days of discharge to have your INR monitored. You are being discharged with coumadin which requires careful monitoring of your blood levels. . 3. Please follow up with your cardiologist, Dr. [**Last Name (STitle) **]. You have an appointment with Dr. [**Last Name (STitle) **] on [**3-24**] at 10:00. Please call his office at ([**Telephone/Fax (1) 5909**] for any questions or scheduling needs. . 4. You were found to have hyperthyroidism during your admission to [**Hospital1 18**] which may have been contributing to your heart failure and symptoms. You were seen by Dr. [**Last Name (STitle) **] who recommended treatment with Methimazole. As you have been instructed, this medication is very effective but requires careful monitoring as it very rarely can have serious side effects such as decreasing your WBC count dramatically. Please call the office of Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 19725**] to make an appointment to be seen for follow up. She will monitor your response to therapy as well as monitor for any potential side effects such as those outlined above.

[ "427.32", "412", "V45.02", "397.0", "V45.81", "V10.52", "428.23", "272.4", "428.0", "585.9", "414.8", "V10.51", "515", "424.0", "242.90", "530.81", "427.31", "584.9" ]

icd9cm

[ [ [] ] ]

[ "00.17", "89.64", "37.34" ]

icd9pcs

[ [ [] ] ]

19683, 19768

9616, 18244

312, 375

20557, 20746

3151, 3151

21270, 22792

2457, 2461

18535, 19660

19789, 20536

18270, 18512

20770, 21247

9154, 9593

2476, 3132

253, 274

403, 1659

3167, 9138

1681, 2332

2348, 2441

25,774

129,783

43646

Discharge summary

report

Admission Date: [**2126-1-7**] Discharge Date: [**2126-1-22**] Date of Birth: [**2053-7-17**] Sex: F Service: MEDICINE Allergies: Flagyl / Synthroid / Penicillins Attending:[**First Name3 (LF) 398**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: video-assisted thorascopy (twice) lysis of pleural adhesions, decortication hematoma evacuation intubation. Central venous access. Arterial access. History of Present Illness: 72 F with DM, anemia, hypothyroidism, HTN s/p 2 falls presenting to the ED with CK 2500, renal failure, PNA and MSSA bacteremia, who required VATS and decortication x 2 [**2126-1-8**] for empyema and [**2126-1-17**] for hematoma evacuation. The patient's course was complicated by failure to wean from the ventilator and pneumomediastinum. The patient eventually was made comfort measures only by her family, who felt that the patient had previously expressed the desire to not be kept alive on a machine for an extended period of time. The patient died on [**2126-1-22**] at 8:34 PM secondary to respiratory failure. Past Medical History: diabetes htn hypothyroidism hypercholesterolemia uterine ca s/p TAH/BSO anemia on aranesp EF 65% recent MSSA bacteremia Social History: lives by self, drinks 8oz of etoh every night, +tob [**1-13**] pack per day, has 40 pack year history, chair lift at home to [**Location (un) 17879**]. Not very active. Pertinent Results: pleural fluid: [**1-14**] urine cx: VRE [**1-7**] [**Numeric Identifier 93844**] wbc, 9667 rbc, 99 pmns, pH 6.62 [**1-8**]: LDH 5445 neg gluc; alb 1.5 Brief Hospital Course: As above, the patient had a prolonged course of respiratory failure with pneumonia and MSSA bacteremia, requiring VATS twice with decortication and hematoma evacuation but evenutally died after being made CMO after failure to wean from mechanical ventilation Medications on Admission: protonix 40, asa 325, mvi, colace 100 [**Hospital1 **], calcium carbonate 1250 [**Hospital1 **], glipizide 10 [**Hospital1 **], accupril 40, klonopin 0.5 [**Hospital1 **], synthroid 0.125, imipramine 40, cosopt 1 gtt ou [**Hospital1 **], percocet and ambien prn, oxacillin, aranesp 40 1x per week. Discharge Disposition: Expired Discharge Diagnosis: MSSA bacteremia pneumonia Discharge Condition: Expired.

[ "719.45", "428.0", "038.11", "518.84", "244.9", "305.1", "496", "482.41", "287.5", "998.11", "401.9", "995.92", "510.9", "285.1", "250.00", "511.1", "584.5" ]

icd9cm

[ [ [] ] ]

[ "34.91", "38.91", "88.73", "34.51", "99.05", "99.04", "34.04", "96.04", "34.09", "86.11", "96.6", "96.72", "93.90", "00.17" ]

icd9pcs

[ [ [] ] ]

2231, 2240

1623, 1883

299, 449

2309, 2320

1444, 1599

2261, 2288

1909, 2208

252, 261

477, 1096

1118, 1239

1255, 1425

29,911

124,659

31432

Discharge summary

report

Admission Date: [**2129-11-21**] Discharge Date: [**2129-11-28**] Date of Birth: [**2068-9-23**] Sex: F Service: ORTHOPAEDICS Allergies: Penicillins Attending:[**First Name3 (LF) 3190**] Chief Complaint: Back and leg pain Major Surgical or Invasive Procedure: Thoracolumbar fusion for sccoliosis History of Present Illness: Ms. [**Known lastname 50359**] has a long history of back and leg pain due to her scoliosis. She now presents for surgical intervention. Past Medical History: DJD, anxiety, reactive airway dz, chronic HA; [**Doctor First Name **]: knee scopes, cervical fusion c4-5 Social History: Denies Family History: N/C Physical Exam: NAD RRR CTA B Abd soft NT/ND BUE- good strength at biceps, triceps, wrist extension and flexion, finger extension and flexion and intrinsics; sensation intact in all dermatomes; hyperreflexic at biceps, triceps and brachioradialis BLE- good strength at hip flexion and extension/abduction/adduction, knee flexion and extension, ankle dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL; sensation intact distally; reflexes deminished at quads and Achilles Pertinent Results: [**2129-11-25**] 03:11AM BLOOD WBC-10.2 RBC-2.66* Hgb-8.4* Hct-24.3* MCV-91 MCH-31.6 MCHC-34.6 RDW-13.6 Plt Ct-201 [**2129-11-24**] 03:20AM BLOOD WBC-10.4 RBC-2.92* Hgb-9.1* Hct-26.0* MCV-89 MCH-31.1 MCHC-34.9 RDW-14.1 Plt Ct-147* [**2129-11-23**] 10:25PM BLOOD WBC-10.1 RBC-2.98* Hgb-9.5* Hct-27.4* MCV-92 MCH-31.8 MCHC-34.6 RDW-14.0 Plt Ct-164 [**2129-11-23**] 02:24AM BLOOD WBC-9.6 RBC-3.01* Hgb-9.5* Hct-27.4* MCV-91 MCH-31.5 MCHC-34.6 RDW-14.2 Plt Ct-147* [**2129-11-22**] 05:14PM BLOOD WBC-8.9 RBC-3.19* Hgb-9.9* Hct-29.4* MCV-92 MCH-31.1 MCHC-33.7 RDW-14.2 Plt Ct-157 Brief Hospital Course: Ms. [**Known lastname 50359**] was admitted to the service of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] for a thoracolumbar fusion for her scoliosis. She was informed and consented for the procedure and elected to proceed. Please see Operative Note for procedure in detail. Post-operatively she was administered antibiotics and pain medication. She was in the SICU for two days where her hematocrit was closely followed. Her catheter and drain were removed POD 3 and 4 respectively and she was able to take PO's. She was diagnosed with a UTI and was placed on Cipro for 10 days. Her pain was well controlled and she remained afebrile throughout her hosptial course. She will return to clinic in ten days. She was discharged in good condition. Medications on Admission: Fentanyl patch 50, ativan .5 tid, ativan 2 qhs, zoloft 200 qd, toprol XL 25 [**Last Name (LF) **], [**First Name3 (LF) **], baclofen, benadryl, colace, nexium, zantac. Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Sertraline 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Diphenhydramine HCl 25 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) as needed. 4. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q12H (every 12 hours) as needed. 9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 10. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 11. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 12. Baclofen 10 mg Tablet Sig: One (1) Tablet PO DAILY 1200 (). 13. Baclofen 10 mg Tablet Sig: One (1) Tablet PO DAILY 1600 (). 14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO 0800,1200,1600 (). 16. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 18. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 1 weeks. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at [**Hospital6 1109**] - [**Location (un) 1110**] Discharge Diagnosis: Scoliosis UTI Post-op anemia Discharge Condition: Good Discharge Instructions: Please continue to take your pain medication with an over the counter laxative. Call the clinic if you notice any redness or discharge from the incision site. Call the clinic for any additional concerns. Physical Therapy: Activity: Activity as tolerated TLSO for ambulation; may be out of bed to chair without. Treatments Frequency: Please continue to change the dressings daily with dry, sterile gauze. Followup Instructions: Please follow up in the Spine Clinic during your previously scheduled appointments. Completed by:[**2129-11-28**]

[ "285.1", "458.29", "V45.4", "293.0", "493.90", "599.0", "737.30" ]

icd9cm

[ [ [] ] ]

[ "77.39", "84.51", "99.07", "81.04", "03.90", "99.04", "81.64", "81.05", "81.63", "84.52" ]

icd9pcs

[ [ [] ] ]

4256, 4401

1776, 2558

296, 333

4474, 4481

1177, 1753

4938, 5054

669, 674

2776, 4233

4422, 4453

2584, 2753

4505, 4712

689, 1158

4730, 4821

4843, 4915

239, 258

361, 500

522, 629

645, 653

11,844

119,696

5454

Discharge summary

report

Admission Date: [**2192-8-1**] Discharge Date: [**2192-9-5**] Date of Birth: [**2113-8-9**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 11754**] Chief Complaint: lightheadedness at clinic neutropenic fever myelodypslastic syndrome Major Surgical or Invasive Procedure: blood, platelet transfusions IV antibiotics Diverting transverese colosteomy w/ rod placement and removal Permacath placement History of Present Illness: This is a 78 year old male with a history of aplastic anemia requiring chronic transfusions who presents from clinic where he was getting his labs drawn. Pt states that after getting his blood drawn, he became lightheaded, felt weak and shaky. He was helped down by the staff and an ambulance was called. Pt states that he has felt weak and shaky for about the past week. He has also had some cold sweats and shaking chills, but has not taken his temperature. He states his temperature was elevated at clinic, and was 100.7 orally in ED. Patient admits to a chronic, non-productive cough, but reports no recent increase in its severity. No abdominal pain or diarrhea. Last BM was this morning. Denies dysuria, urinary frequency, or urgency. Denies any sore throat, rash, myalgias, or arthralgias. Past Medical History: 1) Aplastic anemia dx [**4-19**] by bone marrow biopsy. Given some questions about a history of TB, he was treated with INH for one month and then started on prednisone 60mg daily on [**2192-7-5**]. He requires platelet transfusions weekly, and blood transfusions every few months. Complicated by retinal hemorrhage. 2) Pt remembers living in a sanitorium from age [**2-25**]. This prompted an investigation for TB, with subsequent sputum and bone marrow negative for acid fast bacilli. However, given a concern for this in face of starting steroids, Mr. [**Known lastname 22093**] is being treated with Isoniazid and Pyridoxine since [**2192-5-29**]. Chest CT showed evidence of granulomatous disease in the past, but no active disease. 3) kyphoscoliosis 4) L inguinal hernia. It is reducable and has been present for a long time. It is not painful Social History: Lives with wife in [**Name (NI) **]. Has two grown daughters nearby. [**Name2 (NI) **] tobacco, quit 40 years ago Rare alcohol when he goes out Family History: There is no history of blood disorders. Physical Exam: PHYSICAL EXAMINATION: VITAL SIGNS: ED: Tmax: 100.7 HR: 111 BP: 126/83 RR: 20 O2: 99% RA T: 98.5 HR: 95 BP: 127/71 RR: 16 O2: 99% RA GENERAL: elderly male, comfortable lying in bed, No acute distress. HEENT: Conjunctivae are pink. Oropharynx is moist and clear, without petechiae. Neck: supple, no JVD, no LAD. LUNGS: Clear to auscultation and percussion bilaterally. HEART: RRR nl s1, s2, no gallops, rubs, or murmurs. ABDOMEN: Soft, distended (unchanged per pt) nontender, normoactive BS. Spleen not enlarged. Groin: reducible large L inguinal hernia. EXTREMITIES: no edema NEUROLOGIC: Alert and oriented with coherent speech and comprehension. CN II-XII nonfocal. Motor [**4-19**] upper and lower bilaterally. Pertinent Results: [**2192-8-1**] 11:25AM BLOOD WBC-0.8*# RBC-2.40* Hgb-7.6* Hct-21.9* MCV-91 MCH-31.6 MCHC-34.7 RDW-17.8* Plt Ct-7*# [**2192-8-1**] 11:25AM BLOOD Neuts-39* Bands-2 Lymphs-50* Monos-9 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2192-8-1**] 11:25AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL [**2192-8-2**] 03:45PM BLOOD PT-12.8 PTT-22.2 INR(PT)-1.1 [**2192-8-17**] 06:25AM BLOOD Fibrino-649* D-Dimer-1690* [**2192-8-17**] 06:25AM BLOOD FDP-10-40 [**2192-8-1**] 11:25AM BLOOD Gran Ct-310* [**2192-8-2**] 08:15AM BLOOD Glucose-125* UreaN-37* Creat-1.3* Na-137 K-4.8 Cl-102 HCO3-25 AnGap-15 [**2192-8-1**] 11:25AM BLOOD ALT-23 AST-23 LD(LDH)-208 AlkPhos-50 TotBili-0.5 [**2192-8-3**] 07:55AM BLOOD Lipase-29 [**2192-8-1**] 11:25AM BLOOD Albumin-3.2* Calcium-8.9 Phos-2.9 Mg-2.1 [**2192-8-16**] 06:50AM BLOOD Hapto-443* [**2192-8-17**] 06:25AM BLOOD VitB12-1604* Folate-16.3 . CT RECONSTRUCTION [**2192-8-2**] 6:12 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST INDICATION: Gram-negative rod sepsis, febrile neutropenic, on steroids, evaluate for perforation colitis or abscess. COMPARISON: [**2192-5-18**]. IMPRESSION: 1. No evidence of intraabdominal abscess or bowel perforation. 2. Multiple punctate calcifications in the liver and spleen consistent with prior granulomatous infection. 3. Bilateral bowel-containing inguinal hernias without evidence of bowel obstruction. 4. Stable tiny (2 mm) left lower lobe pulmonary nodule. 5. Slight decrease in prominence of the numerous mesenteric lymph nodes. . CT CHEST W/O CONTRAST [**2192-8-6**] 4:12 PM INDICATION: Latent TB, on treatment, but now with steroids and new fevers. COMPARISON: Chest CT scan from [**2192-6-6**]. IMPRESSION: Multiple new ill-defined pulmonary nodules, some of which are located along bronchovascular bundles. The largest is an 11 x 14 mm right middle lobe nodule. Given the rapid appearance of these nodules, an infectious etiology is most likely. Given the patient's TB status, reactivation tuberculosis is high on the differential diagnosis. Additional considerations include fungal organisms, Nocardia, and bacterial pathogens. . CT CHEST W/O CONTRAST [**2192-8-13**] 2:19 PM Reason: ? worsening pulmonary nodules, starting empiric voraconazole Comparison was done to the CT chest of [**2192-8-6**]. IMPRESSION: Decrease in size of the right middle lobe nodule with appearance of a new nodule in the lingula. Mild bilateral lower lobe bronchiectasis with focal bronchiectasis in the lingula. Decrease in the tree-in-[**Male First Name (un) 239**] opacities in the left upper lobe. These findings could all represent [**Doctor First Name **] infection. A fungal infection is less likely given the decrease in size of the nodules within a period of one week. Tuberculous infection and Nocardia still remains in the differential diagnosis. . MR CONTRAST GADOLIN [**2192-8-17**] 12:08 PM Reason: ?infectious lesion or bleed COMPARISONS: None. IMPRESSION: [**Month/Day/Year **] MRI of the brain without evidence of an infectious process, intracranial hemorrhage, or an enhancing mass lesion. . CT CHEST W/CONTRAST [**2192-8-18**] 2:09 PM REASON FOR THIS EXAMINATION: PLEASE INCLUDE PELVIS CT 1) interval change of pulmonary nodules bilaterally 2) pelvic abscess? given scrotal ulcer and large hemorrhoids COMPARISON: [**2192-8-2**] CT of the abdomen and pelvis and chest CT dated [**2192-8-13**]. IMPRESSION: 1. Bilateral pulmonary nodules are stable to decreased in size. Probable stability of centrilobular nodular opacities within the left upper lobe. 2. Large extraluminal gas collection extending from right lateral aspect of the rectum to base of the penis and scrotum. Findings are consistent with perirectal abscess or other gas producing infectious process. 3. Multiple punctate calcifications in the liver and spleen consistent with prior granulomatous infection. Calcified and atrophic left kidney is suggestive of prior tuberculous infection. 4. Stable hypodense lesions in the right kidney and within the left lobe of the liver and caudate lobe of the liver, too small to accurately characterize. 5. Bilateral bowel-containing inguinal hernias without evidence of bowel obstruction. . Procedure date [**2192-8-18**]; Tissue received [**2192-8-21**] PERIANAL TISSUE Skin and subcutaneous tissue with acute inflammation and necrosis. Fungal (GMS) stain is negative. . CHEST PORT. LINE PLACEMENT [**2192-8-19**] 12:01 AM Reason: s/p CVL placement IMPRESSION: Support lines and tubes in satisfactory position, possible lower lobe pneumonia. . CHEST PORT. LINE PLACEMENT [**2192-9-3**] 12:20 PM Reason: r/o pneumothorax History of left subclavian Port-A-Cath placement. The left subclavian CV line overlies the SVC with its tip encroaching on the lateral wall of the SVC. The right jugular CV line is at the cavoatrial junction. No pneumothorax. Apparent widening of the superior mediastinum could be due to the tortuous aorta previously noted and accentuated on the semi-upright AP film, but reevaluate on followup studies. There is a small area of opacity consistent with atelectasis in the left lower lobe. . Microbiology: Blood cx's [**8-1**]: [**1-20**] pseudomonas blood cx [**8-2**]: negative Cryptococcal antigen: negative Galactomannan: negative Histoplasma ag: negative TB PCR - negative . [**2192-8-1**] 11:25 am BLOOD CULTURE LEFT ARM VENIPUNCTURE. **FINAL REPORT [**2192-8-7**]** AEROBIC BOTTLE (Final [**2192-8-4**]): REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 22094**] 7F [**2192-8-2**] AT 1014. PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ 2 S IMIPENEM-------------- =>16 R MEROPENEM------------- 8 I PIPERACILLIN---------- 8 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S ANAEROBIC BOTTLE (Final [**2192-8-7**]): NO GROWTH. . [**2192-8-8**] 6:15 pm BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [**2192-8-8**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). ACID FAST SMEAR (Final [**2192-8-10**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. FUNGAL CULTURE (Final [**2192-8-21**]): NO FUNGUS ISOLATED. RESPIRATORY CULTURE (Final [**2192-8-10**]): 10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA. VIRAL CULTURE (Preliminary): HERPES SIMPLEX VIRUS TYPE 1. CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY.. GEN-PROBE AMPLIFIED M. TUBERCULOSIS DIRECT TEST (MTD) (Preliminary): SENT TO STATE FOR M.TB DIRECT TEST [**2192-8-12**]. . [**2192-8-10**] 9:00 am SPUTUM Source: Induced. GRAM STAIN (Final [**2192-8-10**]): >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final [**2192-8-10**]): TEST CANCELLED, PATIENT CREDITED. FUNGAL CULTURE (Final [**2192-8-24**]): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2192-8-11**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. . [**2192-8-19**] 12:40 am SWAB Site: PERITONEAL **FINAL REPORT [**2192-8-25**]** GRAM STAIN (Final [**2192-8-19**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. WOUND CULTURE (Final [**2192-8-25**]): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for Pseudomonas aeruginosa, Staphylococcus aureus and beta streptococcus). SENSIS ON ENTEROCOCCUS PER DR [**Last Name (STitle) **]. GOLD. ENTEROCOCCUS SP.. MODERATE GROWTH STRAIN 1. ENTEROCOCCUS SP.. MODERATE GROWTH STRAIN 2. PSEUDOMONAS AERUGINOSA. RARE GROWTH. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | ENTEROCOCCUS SP. | | AMPICILLIN------------ =>32 R <=2 S CHLORAMPHENICOL------- <=4 S LEVOFLOXACIN---------- =>8 R 1 S PENICILLIN------------ =>64 R 2 S VANCOMYCIN------------ =>32 R <=1 S ANAEROBIC CULTURE (Final [**2192-8-23**]): Mixed bacterial flora-culture screened for B. fragilis, C. perfringens, and C. septicum. None isolated. . Brief Hospital Course: Mr. [**Known lastname 22093**] is a 78 y.o. man with a history of aplastic anemia, who presented with febrile neutropenia. Respiratory status improved on RA and IS to bedside. Hemorrhoidal bleeding stopped and improved with [**Last Name (un) **] baths and topical hydrocortisone. His inguinal hernia has been nonreducible and nontender. Blood sugars have been well controlled on ISS and [**Hospital1 **] FS, now discontinued since off steroids. Portacath placed [**9-3**] and central line pulled, sent for culture. # Febrile neutropenia - Patient initially presented with febrile neutropenia and was started on cefepime. No vancomycin was administered given no history of permanent lines. Blood cultures initially grew out pansensitive pseudomonas. Surveillance cultures were negative. Patient initially stayed afebrile for several days, however then began having low grade fevers. Given concern for immune supression from steroids as well as lack of benefit for his aplastic anemia, his prednisone was tapered off. In addition, Mr. [**Known lastname 22093**] was continued on INH and Vitamin B6 for suppression of his suspected prior tuberculosis. He was also started on atovaquone for PCP [**Name Initial (PRE) 1102**]. Mr. [**Known lastname 22093**] remained hemodynamically stable and asymptomatic. Further work-up of fevers was undertaken. Cryptococcal antigen, galactomannan and histoplasma antigen were sent off and were all negative. A BAL was performed and TB-PCR sent to the state lab given concern for reactivation of his childhood TB in face of decreased immune function. TB-PCR was negative and nothing grew out on BAL cultures, but eventually returned PCR pos for HSV. Acyclovir was started on [**2192-8-16**]. On [**8-13**] liposomal amphotericin was started as empiric coverage for fungal infection and vancomycin was added for broader bacterial coverage. A CT-guided biopsy of the pulmonary nodules seen on chest CT was planned, however patient's platelet count decreased to 6000 and the biopsy was deferred. The right pulmonary nodule had decreased in size on repat chest CT. On [**8-15**], patient had an episode of loss of consciousness with witnessed shaking, no loss of urine or tongue biting. His EKG showed ST segment elevation in leads VI-V3 new from prior and the patient was subsequently taken for emergent ECHO which was unchanged from prior. Cardiac enzymes were negative x3. EEG showed encephalopathy but no epileptiform waveforms. CXR was unchanged from priors. Patient was started on metoprolol 25mg [**Hospital1 **] per cardiology. Psychiatry was consulted secondary to patient depressed affect and change in mental status. Per psychiatry, change in behavior was due to encephalopathy from infection and recommended head MR, haldol IV at night and treating his infection. Head MR [**First Name (Titles) **] [**Last Name (Titles) 11580**]. Patient did not have any subsequent episodes and his vitals continued to be stable. Patient continued to spike low graded fevers and cultures were sent with no growth. Patient was noted to have some diarrhea but no formed bowel movements on [**8-15**]. Nurse noted scrotal edema on [**8-17**] and wound care was consulted regarding skin breakdown in the region of the perineum. On [**8-17**], cefipime was discontinued and tobramycin, clindamycin and zosyn were started for better pseudamonal coverage. On [**8-18**], Mr. [**Known lastname 22093**] had a torso CT which showed findings consistent with a perirectal abscess. Surgery was consulted and found a rectal fistula tracking into the perineaum. The patient was taken emergently to the OR for debridement and a diverting tranverse colostomy. Pathology of skin sample submitted showed acute inflammation and necrosis but no fungus on gram stain. Patient tolerated the surgery well, was extubated and subsequently returned to 7 Feldburg [**8-20**] where he continued to be afebrile, tolerating a full diet and weaned off oxygen. On [**8-21**] G-CSF was started to promote wound healing. Clindamycin and tobramycin were discontinued and changed to ciprofloxacin. Acyclovir was discontinued on [**8-23**], ambisome on [**8-25**], and vancomycin on [**8-26**]. Swab of perineum at time of surgery grew VRE, pseudamonas and corynebacterium. Vancomycin was discontinued and daptomycin was begun on [**8-27**]. Atovaquone was discontinued on [**8-30**] and ciprofloxacillin was discontinued on [**9-4**]. Mr. [**Known lastname 22093**] remained afebrile and no further growth was noted on suubsequent cultures. He will continue to take zosyn and daptomycin until [**9-10**]. He will continue on INH until follow-up at [**Hospital **] clinic on [**10-7**]. . # Rectal abscess/tranverse colostomy - CT abd, pelvis showed perirectal abscess, found to have a rectal fistula into perineal and scrotal region, s/p OR drainage of the abscess and a diverting transverse colostomy; ostomy care and surgery following - rod removed from ostomy [**9-1**] - TID dressing changes of peri-rectal abscess . # Hypertension - on metoprolol 50mg [**Hospital1 **] - consider increasing metoprolol if still hypertensive - disctoniued captopril as it can cause neutropenia . # Anemia, thrombocytopenia, agranulocytosis - pt had gradual worsening of his anemia, requiring several blood transfusions over the course of his admission. He was noted to have some bright red blood originating from an intenal hemorrhoid. Following platelet transfusion, his hemorrhoidal bleeding stopped. Patient continued to require interval transfusions secondary to his aplastic anemia. Mr. [**Known lastname 22093**] was tapered off prednisone in order to promote healing of his rectal wound and started G-CSF, neutropenic, ANC stable. Still requiring intermittent platelet transfusions for counts <10K. . # hx of TB - INH was continued during the hosptial course. Rifampin was discontinued as ID was comfortable with a single [**Doctor Last Name 360**]. TB-PCR was negative, no need additional for additional coverage. He will follow-up in [**Hospital **] clinic regarding duration of INH treatment. . # FEN - neutropenic diet, electrolyte repletion . # PPx - PPI, no need for anticoagulation given thrombocytopenia, avoid all heparin products . # code - full Medications on Admission: Prednisone 60mg PO daily (since [**7-5**]) pantoprazole 40mg PO daily folic acid 1mg PO daily, isoniazid 300mg PO daily (since [**5-29**]) pyridoxone 50mg PO daily (since [**5-29**]) Discharge Medications: 1. Isoniazid 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pyridoxine 50 mg 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. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 6. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for transfusion. 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for fever. 8. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal TID (3 times a day). 9. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 10. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl Topical PRN (as needed). 11. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] () as needed. 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 15. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 16. Morphine Sulfate 1-5 mg IV Q4H:PRN 17. Piperacillin-Tazobactam Na 4.5 gm IV Q8H 18. Daptomycin 300 mg IV Q24H 19. Medication zosyn and daptomycin to be continued until [**2192-9-10**] Discharge Disposition: Extended Care Facility: [**Hospital3 **] Hospital Discharge Diagnosis: 1. Pseudomonal sepsis 2. Rectal abscess s/p debridement 3. HTN 4. Aplastic anemia with anemia, thrombocytopenia, and agranulocytosis 5. s/p colonic resection with diverting ostomey 6. Prior tuberculosis Discharge Condition: Afebrile, wound appears clean, pain controlled. Discharge Instructions: If you have fevers/chills, shortness of breath, chest pain, nausea/vomiting, abd pain, please call your PCP or come to the ED for evaluation. 1. Take medications as directed. 2. Complete a total 2 week course of abx. (Please continue daptomycin and zosyn until [**9-10**]). 3. Attend all follow up appointments. 4. Continue isoniazid until ID appointment on [**10-12**]. 5. Continue daily Neupogen injection until follow-up appointment with Dr. [**Last Name (STitle) 410**] [**9-20**]. 6. Check CBC/platelets three times a week and tranfuse if Hct<25, platelets <10. Per the following protocol: Packed RBCs for HCT<25. If <21, [**Name8 (MD) 138**] MD. Platelets: if am (or any other) plt count: <20,000/ul: Recheck plts at 5 PM; <10,000/ul: give one bag plt product. Check post platelet count. If <10,000, repeat procedure above until plts >10,000. if <10,000/ul or bleeding, [**Name8 (MD) 138**] MD. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5026**], MD Where: [**Hospital6 29**] HEMATOLOGY/BMT Phone:[**Telephone/Fax (1) 3237**] Date/Time:[**2192-9-20**] 10:00 Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Where: [**Hospital6 29**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2192-9-20**] 10:00 Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] TAN Where: LM [**Hospital Unit Name 4337**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2192-10-12**] 9:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD Where: [**Hospital6 29**] SURGICAL SPECIALTIES [**Location (un) **] Phone:[**Telephone/Fax (1) 1231**] Date/Time:[**2192-9-14**] 11:30 Completed by:[**2192-9-5**]

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icd9cm

[ [ [] ] ]

[ "99.05", "46.03", "86.22", "33.24", "61.0", "38.93", "99.04" ]

icd9pcs

[ [ [] ] ]

20611, 20663

12572, 18863

382, 510

20910, 20960

3197, 6350

21911, 22711

2404, 2446

19096, 20588

20684, 20889

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20984, 21888

2461, 2461

10991, 12549

2483, 3178

274, 344

6379, 9898

538, 1345

1367, 2225

2241, 2388

11,164

158,523

23166

Discharge summary

report

Admission Date: [**2169-1-18**] Discharge Date: Date of Birth: [**2099-6-17**] Sex: M Service: Vascular Surgery This is a 69-year-old gentleman, admitted to the vascular service on [**2169-1-18**]. CHIEF COMPLAINT: Abdominal aortic aneurysm. HISTORY OF PRESENT ILLNESS: This is 69-year-old male who has a history of abdominal pain, underwent workup for cholecystic disease and an incidental finding of an 8 cm aneurysm was noted. The patient was referred to Dr. [**Last Name (STitle) 1391**] for further evaluation and treatment. He is now admitted for elective abdominal aortic aneurysm repair. The patient was admitted to the preoperative holding area on [**2168-12-27**]. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Combivent inhaler q.i.d., Motrin p.r.n., atenolol 50 mg every day. PAST MEDICAL HISTORY: Not documented. PAST SURGICAL HISTORY: Not documented. SMOKING HISTORY: Two packs per day times years. The patient quit. Length of cessation is unknown. The patient does not use alcohol. HOSPITAL COURSE: The patient was admitted to the preoperative holding area. He underwent an abdominal aortic repair with an aorto-iliac graft and a cholecystectomy. He tolerated the procedure well and was transferred to the PACU in stable condition. He immediately postoperatively was stable. He remained intubated overnight and he had an epidural placed in the operating room for analgesic control. Physical exam demonstrated a dopplerable biphasic DP and PT bilaterally with palpable femorals. His postoperative hematocrit was 34.5 with a BUN of 14 and creatinine 1.4. Chest x-ray was unremarkable and the right IJ was in appropriate placement. On postoperative day #2 there were no overnight events. The patient remained afebrile on SL IMV. His hematocrit remained stable. His creatinine bumped to 2.5. Renal recommended ultrasounds to rule out hydronephrosis or obstruction. The patient remained in the PACU. The patient was transferred on postoperative day #1 to the SICU for continued care. Serial CKs and troponins were obtained, with total CKs of 335, 1066 and 1314. Troponins were 0.01, 0.08 and 0.07. The patient remained in the SICU on postoperative day #2 intubated. The epidural was discontinued and the ICU would manage analgesic control. The patient was extubated on postoperative day 2, but required reintubation secondary to respiratory distress. The patient was transfused on postoperative day 2 for a hematocrit of 27.4. Post transfusion hematocrit was 31.6. Nutritional assessment was made on postoperative day 3 and TPN was increased. A right femoral hemodialysis catheter was placed on [**2169-1-10**] and the patient was dialyzed for volume overload. He continued to require blood transfusion for a persistent low hematocrit of 27.3. His right IJ Swan was discontinued on [**2169-1-21**] and converted to a triple lumen catheter. Post procedure x-ray was unremarkable. Post transfusion hematocrit was 29.2. The patient remained on CVVH, requiring adjustment of flow rates. Chest x-ray continued to show improvement. This was on postoperative day #7. The patient continued to receive transfusions for a hematocrit of 28.1. The patient was finally weaned off pressors on [**2169-2-3**]. Left subclavian dialysis catheter was placed on [**2169-1-24**]. The patient was extubated on postoperative day #8. He continued to require transfusion. His hematocrit drifted to 26.4 He continued on TPN and CVVH. Hemodialysis was instituted on postoperative day #8. Post transfusion hematocrit on postoperative day 9 was 28, up from 26.5. The wounds were clean, dry and intact. He was then transitioned to nasal cannula and continued on hemodialysis. He remained NPO on TPN. The patient required an EEG for postoperative confusion. It was consistent with subcortical dysfunction consistent with encephalopathy. The patient did begin to verbalize. His first words were "no." Post transfusion hematocrit was 29.1 and he received continued TPN. On postoperative day #11 the patient had an episode of rapid atrial fibrillation, requiring cardioversion. He continued to remain in the SICU. Dialysis was continued. The patient postoperatively was continued on hemodialysis. His TPN was continued. His hematocrit was 28.4. He continued to be transfused. On postoperative day 12 the patient developed a postoperative fever to T-max of 102 and back pain. A chest x-ray was obtained which showed questionable density in the right base. White count was 19. Dialysis was discontinued. The patient was pancultured. Vancomycin and Zosyn for possible pneumonia or line infection were instituted. The patient's CVL and peripheral line cultures grew Gram positive cocci. Zosyn dosing adjustment was made and blood cultures were repeated. ID was consulted and recommendation was to remove the offending line and monitor serial cultures and continue vancomycin. All dialysis catheters were removed secondary to positive cultures. Vancomycin was continued and dosed at renal dosing. The patient continued on hemodialysis. On postoperative day 13 the patient required reintubation for increasing respiratory distress and abdominal distention. The patient was reintubated secondary to respiratory acidosis and hyperkalemia. The right subclavian and left IJ lines were placed and the CVVH was restarted. The acidosis improved. The hypotension improved and the hyperkaliemia improved. The chest x-ray was consistent with pulmonary edema. Hematocrit was 23 and the patient was transfused. His troponin was 0.15. Cardiology was consulted. On postoperative day the patient was weaned from his vent and was extubated. Repeat blood cultures obtained from the central line demonstrated [**Female First Name (un) 564**]. The patient was begun on caspofungin 70 mg IV x1 and then 30 mg every day. The patient underwent an echocardiogram on postoperative day #1 to rule out for intracardiac vegetations. It showed mild left ventricular hypertrophy with ejection fraction of 60% to 70%. There was no mention of vegetative changes intracardiac. The patient was instituted on tube feeds. Ophthalmology was consulted to rule out evidence for ophthalmic candidiasis, which on exam was negative. The patient was started on levofloxacin for a UTI on postoperative day #21, which was [**2169-2-8**]. A bedside swallow was obtained on [**2169-2-10**]. They felt the patient did not demonstrate any signs or symptoms of aspiration at the bedside, but silent aspiration could not be ruled out. They recommended to initiate a P.O. diet consist with soft solids and thin liquids, and demonstrate to the patient aspiration precautions. They also recommended that ENT be consulted regarding patient's prolonged hoarseness. The patient was transferred to the VICU on postoperative day #26. A PICC line was placed on [**2169-2-15**] in interventional radiology for continued IV antibiotic therapy. The patient continued on tube feeds and P.O. food was started. Calorie counts were obtained. The patient was begun on a steroid taper on [**2169-2-16**]. The patient was discharged to home with services in stable condition. It was recommended to follow with Dr. [**Last Name (STitle) 1391**] and call for an appointment in 2 to 3 weeks. Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**] of the [**Hospital **] Clinic, and the nephrology department in 1 week. FINAL DIAGNOSES: 1. Renal failure. 2. Respiratory failure requiring reintubation. 3. Failure to thrive requiring TPN and tube feedings. 4. Aortic abdominal aneurysm, status post aorto-iliac bypass with an incidental cholecystectomy secondary to stones. 5. History of chronic obstructive pulmonary disease. 6. History of anxiety. 7. History of hypertension. 8. History of bladder carcinoma. 9. Central line infection with septicemia, both methicillin resistant Staphylococcus aureus and yeast. 10. Dialysis started. 11. Fungemia. 12. Anemia requiring blood transfusions. DISCHARGE MEDICATIONS: 1. Albuterol ipratropium aerosol 1 to 2 puffs q.4h. as needed. 2. Fluticasone propionate aerosol puffs 2 b.i.d. 3. Salmeterol xinafoate disk q.12h. 4. Lansoprazole 30 mg every day. 5. Ipratropium bromide solution inhalation q. 6 hours. 6. Lopressor 25 mg 1.5 tablets b.i.d. 7. Prednisone 20 mg q.24h. for 2 doses, then prednisone a total of 15 mg q.24h. for 5 doses, then prednisone 10 mg every day for a total of 5 doses, then prednisone 5 mg for a total of 5 doses, then discontinue. 8. IV caspofungin 50 mg q.24h. 9. Vancomycin 1 gram q.48h. for a total of 21 days. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**] Dictated By:[**Last Name (NamePattern1) 2382**] MEDQUIST36 D: [**2169-4-17**] 12:54:36 T: [**2169-4-19**] 09:50:31 Job#: [**Job Number 59590**]

[ "998.2", "V10.51", "574.10", "790.7", "403.91", "496", "996.62", "427.31", "997.72", "998.11", "593.81", "441.4", "458.29", "518.5", "041.19", "584.5", "112.5", "553.1" ]

icd9cm

[ [ [] ] ]

[ "51.22", "96.72", "38.44", "38.95", "89.64", "96.04", "39.95", "99.62", "99.15", "38.93", "39.31", "96.6", "53.49", "99.04" ]

icd9pcs

[ [ [] ] ]

8025, 8879

766, 834

1067, 7409

898, 1049

7426, 8002

238, 266

295, 739

857, 874

62,918

128,857

35879+58039

Discharge summary

report+addendum

Admission Date: [**2194-1-10**] Discharge Date: [**2194-1-28**] Date of Birth: [**2113-3-28**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3227**] Chief Complaint: admitted after MVA Major Surgical or Invasive Procedure: [**Last Name (un) **] bolt placement [**2194-1-11**] History of Present Illness: (patient unable to give history due to intubation/sedation) 78M getting out of car when struck Past Medical History: Alzheimer's Disease Social History: non-contributory Family History: non-contributory Physical Exam: PHYSICAL EXAM upon admission: T:96.6 BP:110 / 52 HR:40 R14 O2Sats 100 Gen: WD/WN, in hard collar, intubated, sedated examined on stretcher in trauma bay ED HEENT: facial abrasions, no battle signs, raccoon eyes, no CSF or blood in ears or nares Pupils:2.5mm trace reactive Neck: hard collar Skin: multiple abrasions on all 4 extremities and face Neuro:intubated, sedated, does open eyes to voice, follows commands, moving all 4 extrems spontaneously. Toes upgoing bilaterally Pertinent Results: CT head [**2193-1-20**]: FINDINGS: An evolving infarction in the superior right middle cerebral artery territory is again seen. Previously noted foci of hemorrhage within the infarction is slightly less dense. Multiple other previously described foci of parenchymal and subarachnoid hemorrhage have become slightly less dense as well. Hyperdense subdural blood remains present along the left tentorium. There is no evidence of new acute hemorrhage. The hypodense left frontal subdural collection is stable in size. Moderate diffuse ventricular dilatation is stable, with blood again seen in the posterior lateral ventricles. There is no evidence of new cerebral edema or new major vascular territorial infarction. There is mucosal thickening and aerosolized secretions in the right sphenoid sinus. IMPRESSION: 1. Evolving subacute infarction in the right superior middle cerebral artery territory with slightly decreased density of blood products. 2. Expected evolution of intra-axial and extra-axial intracranial hemorrhage. No evidence of new acute hemorrhage. 3. Stable chronic subdural collection along the left convexity. 4. Stable diffuse ventricular dilatation with stable intraventricular hemorrhage. CXR [**2193-1-19**]: FINDINGS: In comparison with the study [**1-19**], the opacification at both bases persists, most likely reflecting bilateral atelectasis. The possibility of supervening pneumonia cannot definitely excluded in the absence of a lateral view. The degree of free intraperitoneal gas is decreased, a finding related to prior tube placement. Tracheostomy tube and right central catheter remain in place. Upper Extremity U/S Right [**2194-1-23**]: Nonocclusive thrombus in the right axillary and upper right basilic veins. Brief Hospital Course: The patient was admitted to the ICU after having an MVA and was intubated and sedated. On repeat imaging his bleeds were increasing. Therefore on [**2194-1-11**] a bolt was placed to monitor ICP. Additionally it was felt that his neuro exam was slightly worse. His ICP remained normal and the bolt was removed on [**2194-1-13**]. The patient received a trach and peg on [**2193-1-16**] as he was unable to be extubated. His family consented to this procedure but they did make his code status DNR. On [**1-17**] the patient was found to have drainage from the wound on his right elbow. This wound was from the initial accident. The culture from the site grew coag. neg. staph. Ortho was consulted who recommended dressing changes [**Hospital1 **]. The WBC was 18 that day as well. The following day CXR revealed a new infiltrate. ID was consulted and the patient was placed on triple antibiotics for a ventilator-associated-pneumonia. The WBC started to decrease and the neuro exam remained stable. He was transferred to the neuro stepdown unit on [**1-20**]. His exam has remained unchanged. He opens his eyes slightly and has purposeful movement with RUE. LUE has no withdrawal. He moves his legs spontaneously. The patient was treated for a pneumonia and completed his course of antibiotics. He has been afebrile for several days and his WBC is trending down. His oxygen requirement has been stable. The patient was noted to not be moving the RUE very often and nursing felt that he as guarding it. A clavicle fx was found which is non-displaced. He does not need surgery on it and has no restrictions for ROM or weightbearing on the arm. The patient was evaluated by PT and OT who recommended rehab. He is currently on a trach mask and is not requiring frequent suctioning. He will be discharged today [**2194-1-28**]. Medications on Admission: Aricept Discharge Medications: 1. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane TID (3 times a day) as needed. 2. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day) as needed. 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 7. Sodium Chloride 1 gram Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day) as needed for ppx. 11. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 12. Insulin Please see attached insulin fixed dose and sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: SUBDURAL HEMATOMA SUBARACHNOID HEMORRHAGE INTRAVENTRICULAR HEMORRHAGE INTRAPARENCHYMAL HEMORRHAGE PNEUMONIA, VENTILATOR AQUIRED RIGHT NON-DISPLACED CLAVICLE FRACTURE Discharge Condition: neurologically stable Discharge Instructions: General Instructions ??????Take your pain medicine as prescribed. ??????Exercise should be limited to walking; no lifting, straining, or excessive bending. ??????Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ??????Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ??????You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. 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. [**First 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:[**2194-1-28**] Name: [**Known lastname **],[**Known firstname 422**] Unit No: [**Numeric Identifier 13059**] Admission Date: [**2194-1-10**] Discharge Date: [**2194-1-28**] Date of Birth: [**2113-3-28**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2112**] Addendum: The patient is requiring suctioning every hour by nursing. This was written incorrectly above. [**First Name4 (NamePattern1) 1239**] [**Last Name (NamePattern1) 2268**] PA-C Discharge Disposition: Extended Care Facility: [**Hospital3 1933**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2115**] MD [**MD Number(2) 2116**] Completed by:[**2194-1-28**]

[ "E849.5", "881.01", "810.00", "780.60", "434.91", "851.86", "E814.7", "276.3", "331.0", "997.31", "482.0", "294.10", "807.01" ]

icd9cm

[ [ [] ] ]

[ "31.1", "43.11", "38.93", "86.59", "96.72", "01.10", "33.24" ]

icd9pcs

[ [ [] ] ]

8375, 8579

2940, 4771

338, 393

6153, 6177

1161, 2917

7429, 8352

611, 629

4829, 5873

5964, 6132

4797, 4806

6201, 7406

644, 660

280, 300

421, 518

674, 1142

540, 561

577, 595

19,989

109,853

27890

Discharge summary

report

Admission Date: [**2173-7-20**] Discharge Date: [**2173-8-16**] Service: CARDIOTHORACIC Allergies: Iodine; Iodine Containing / Cephalosporins / Gabapentin / Quinolones / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Emergent ascending aorta and hemiarch replacement Open J-tube Tracheostomy History of Present Illness: Mrs. [**Known lastname 67952**] is an 82 yo F who was transferred from [**Hospital **] Hospital with a diagnosis of type A dissection, obtained by CT scan in the course of work-up for shortness of breath and chest pain. She was taken to the operating room urgently for repair of her type A dissection. Past Medical History: HTN DMII Hypercholesterolemia osteoporosis R. breast ca, s/p mastectomy R. arm lymphedema Spondylolisthesis s/p TAH Social History: Lives with husband Denies tobacco or EtOH Family History: NC Physical Exam: At time of discharge: Alert, follows commands, moves all 4 extremities, however very minimal on left PERRL, does not open eyes spontaneously RRR, no murmurs appreciated Lungs with coarse BS b/l, no w/r/r Abd soft, NT/ND, +bs, J-tube in place LE with trace edema b/l, UE with 2+ edema Pertinent Results: CTA head [**7-22**]: 1. Subacute ischemic infarction in the area of the R. central gyrus, likely related to the recent aortic repair surgery. No embolus, thrombus, or areas of significant stenosis seen. 2. Moderate-sized pleural effusion with compressive atelectasis in the left lung. [**2173-8-16**] 03:13AM BLOOD WBC-4.8 RBC-3.24* Hgb-9.6* Hct-28.1* MCV-87 MCH-29.7 MCHC-34.4 RDW-15.3 Plt Ct-286 [**2173-8-16**] 03:13AM BLOOD Glucose-115* UreaN-12 Creat-0.2* Na-139 K-4.1 Cl-99 HCO3-36* AnGap-8 Brief Hospital Course: On [**2173-7-20**], Ms. [**Known lastname 67952**] was transferred from [**Hospital **] Hospital to the cardiac surgery service under the care of Dr. [**Last Name (STitle) **] with a diagnosis of a Type A aortic dissection. She underwent emergency ascending aortic arch and hemi arch replacement with a 24mm Gelweave graft. Cross clamp time was 70 mins., total bypass time was 110 mins., and circ. arrest time was 22 mins. Post-operatively she was transferred to the CSRU in stable condition. On POD 1 she was noted to have left sided weakness, was not opening her eyes spontaneously, and a neurology consult was obtained. A CTA of her head revealed ischemia in the right precentral gyrus. She continued to be in afib and was placed on amiodarone, ASA, and heparin ggt. A dobhoff feeding tube was placed on POD 3 and she was started on enteral nutrition. She was extubated, but required agressive respiratory therapy for management of secretions. She had a bronch on POD#5 which revealed mucous plugging. She remained lethargic and required intermittent bronchs. She was also unable to complete a swallowing evaluation and had tube feeds. Her neuro status gradually improved, but she still remains quite lethargic. On POD#15 she underwent placement of an open J tube. She continued to progress and did continue to require aggressive respiratory therapy, and eventually had a trach on POD#21. She had not had afib for 10 days and did not require further anticoagulation. Neuro was in aggreement with this as well. On POD#22 she had a R thoracentesis and 700cc of straw colored fluid was obtained. An bilateral ultrasound of the chest showed minimal effusions on [**2173-8-13**]. She continued to progress and on POD#26 she was discharged to rehab in stable condition. Medications on Admission: Vasotec 2.5", zocor 40', oscal 500"', actonel 35mg Wqk, glucophage 500" Discharge Medications: 1. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q3-4H (Every 3 to 4 Hours) as needed. 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 5. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Captopril 12.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for SBP <100, HR <60. 12. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO BID (2 times a day). 13. Metoclopramide 5 mg IV Q6H:PRN nausea/vomiting 14. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for temperature >38.0. 16. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. 17. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Type A aortic dissection Right sided CVA AFib DMII HTN Discharge Condition: Stable Discharge Instructions: Call your doctor or go to the ER if you experience any of the following: severe pain, increasing nausea/emesis, worsening shortness of breath, fevers >101.5, pus draining from wound, or any other concerning symptoms. Continue chest PT, suctioning as needed, and tube feeds at goal. Followup Instructions: Dr. [**Last Name (STitle) **] - call for an appointment [**Telephone/Fax (1) 170**] for 4 weeks. Make an appointment with Dr. [**Last Name (STitle) 13090**] for 2-3 weeks Completed by:[**2173-8-16**]

[ "250.00", "441.01", "401.9", "427.31", "272.0", "518.5", "518.0", "997.02", "997.3", "553.20", "997.1" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.72", "31.1", "46.39", "33.21", "96.04", "38.93", "39.61", "53.59", "38.45" ]

icd9pcs

[ [ [] ] ]

5228, 5300

1784, 3563

316, 393

5399, 5408

1263, 1761

5738, 5940

939, 943

3685, 5205

5321, 5378

3589, 3662

5432, 5715

958, 1244

266, 278

421, 725

747, 864

880, 923

67,659

163,635

28725

Discharge summary

report

Admission Date: [**2179-7-5**] Discharge Date: [**2179-7-28**] Date of Birth: [**2135-3-5**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5790**] Chief Complaint: Transfer intubated from OSH for hemoptysis, pneumothorax, hemothorax on CT Scan consistent w/Boerhaave's Syndrome Major Surgical or Invasive Procedure: [**7-6**] Left thoracotomy and repair of esophageal perforation with intercostal muscle flap buttress. [**7-6**] A line placement, R IJ line placement [**7-8**] Minilaparotomy and placement of an 18-French G/J-tub(transgastric jejunal). [**7-12**] Percutaneous tracheostomy tube. [**7-12**] Transthoracic ultrasound. Thoracentesis on the right side. History of Present Illness: 44 yo M w/hx EtOH admitted to [**Hospital1 **] this AM at 10:00 for left chest, LUQ pain intermittent radiation to left shoulder, associated with cough, shortness of breath that developed after a history of vomiting following drinking 8 cans of beer the day prior to admission. VS on admission 97.4 92 90/63 98% RA; per report on exam he was profoundly diapohretic and appeared in distress. He was wheeled to CT scan in work-up and en route developed hematemesis; NGT placed put out immediately 1400 cc of dark bloody fluid. The patient was started on octreotide and protonix. CT was remarkable for large bloody effusion with pneumothorax on the left. A chest tube 28 Fr was thus placed, which put out immediately again dark bloody fluid; 1800 cc total for the day. After this time the patient was intubated for both respiratory distress, and ease for endoscopy (per report), placed on a propofol drip, and paralyzed with vecuronium. Throughout the day the patient had one episode of hypotension to the 60s that resolved with IVF; he was then given 3 units of pRBC; he otherwise remained hemodynamically stable with HR in the 70s-80s, SBP 90s-100s. During the day prior to admission here at [**Hospital1 18**] he was given: 10 liters of IVF, 3 units of pRBC; he put out 2800 cc urine, 1500 cc bloody fluid from NGT, 1840 cc bloody dark fluid from the left chest tube. The patient was medflighted to [**Hospital1 18**] from [**Hospital1 **] for further management intubated, sedated on propofol and versed, per report received vecuronium en route for further paralysis. Past Medical History: per report, past hospitalization for "EtOH related problems" at [**Hospital 8**] Hospital during which he had "alcoholic coma" Social History: + EtOH, 12 beers/day, works as carpenter/wood [**Last Name (un) 33982**], + tobacco, no IVDU Family History: + family history of EtOH abuse Pertinent Results: [**2179-7-20**] 05:17AM BLOOD WBC-10.9 RBC-2.98* Hgb-9.5* Hct-28.3* MCV-95 MCH-32.0 MCHC-33.6 RDW-15.4 Plt Ct-623* [**2179-7-11**] 01:57AM BLOOD WBC-9.5 RBC-3.03* Hgb-9.8* Hct-28.5* MCV-94 MCH-32.5* MCHC-34.4 RDW-15.3 Plt Ct-202 [**2179-7-5**] 08:29PM BLOOD WBC-3.8* RBC-3.99* Hgb-12.7* Hct-36.7* MCV-92 MCH-31.9 MCHC-34.7 RDW-14.9 Plt Ct-136* [**2179-7-20**] 05:17AM BLOOD Plt Ct-623* [**2179-7-18**] 03:41AM BLOOD PT-15.3* INR(PT)-1.3* [**2179-7-5**] 08:29PM BLOOD PT-16.5* PTT-36.3* INR(PT)-1.5* [**2179-7-20**] 05:17AM BLOOD Glucose-111* UreaN-14 Creat-0.6 Na-135 K-4.5 Cl-103 HCO3-26 AnGap-11 [**2179-7-14**] 10:14PM BLOOD Glucose-124* UreaN-13 Creat-0.7 Na-140 K-3.7 Cl-105 HCO3-26 AnGap-13 [**2179-7-11**] 05:32PM BLOOD Glucose-138* UreaN-14 Creat-0.8 Na-142 K-3.9 Cl-106 HCO3-29 AnGap-11 [**2179-7-5**] 08:29PM BLOOD Glucose-109* UreaN-15 Creat-0.7 Na-135 K-3.9 Cl-107 HCO3-21* AnGap-11 [**2179-7-13**] 02:55AM BLOOD ALT-15 AST-38 LD(LDH)-263* AlkPhos-55 TotBili-0.5 [**2179-7-5**] 08:29PM BLOOD ALT-35 AST-40 AlkPhos-43 TotBili-2.5* [**2179-7-20**] 05:17AM BLOOD Calcium-8.1* Phos-3.6 Mg-2.0 [**2179-7-15**] 04:26PM BLOOD Calcium-8.1* Phos-2.6* Mg-2.2 [**2179-7-11**] 05:32PM BLOOD Calcium-7.9* Phos-3.8 Mg-1.7 [**2179-7-5**] 08:29PM BLOOD Albumin-3.0* Calcium-6.0* Phos-2.6* Mg-1.0* [**2179-7-6**] 05:37AM BLOOD calTIBC-185* Ferritn-911* TRF-142* [**2179-7-6**] 05:37AM BLOOD Triglyc-50 [**2179-7-18**] 03:49PM BLOOD Vanco-11.7 [**2179-7-7**] 05:34AM BLOOD Vanco-5.2* [**2179-7-14**] 08:57AM BLOOD Type-ART pO2-145* pCO2-34* pH-7.49* calTCO2-27 Base XS-3 [**2179-7-7**] 12:49PM BLOOD Type-ART pO2-72* pCO2-45 pH-7.35 calTCO2-26 Base XS-0 [**2179-7-5**] 08:41PM BLOOD Type-ART pO2-107* pCO2-39 pH-7.29* calTCO2-20* Base XS--6 [**2179-7-14**] 08:57AM BLOOD Glucose-137* K-3.6 [**2179-7-5**] 10:04PM BLOOD Glucose-104 Lactate-1.1 Na-133* K-3.6 Cl-105 [**2179-7-5**] 11:36PM BLOOD Hgb-12.3* calcHCT-37 O2 Sat-98 [**2179-7-14**] 08:57AM BLOOD freeCa-1.04* Brief Hospital Course: OPERATIONS DURING ADMISSION [**7-6**] Left thoracotomy and repair of esophageal perforation with intercostal muscle flap buttress. [**7-6**] A line placement, R IJ line placement [**7-8**] Minilaparotomy and placement of an 18-French G/J-tub(transgastric jejunal). [**7-12**] Percutaneous tracheostomy tube. [**7-12**] Transthoracic ultrasound. Thoracentesis on the right side. CONSULTATIONS DURING ADMISSION None BRIEF HOSPITAL COURSE BY PROBLEM 1. BOERHAAVE'S SYNDROME WITH SEVERE ASPIRATION PNEUMONIA/ARDS The patient was admitted to [**Hospital1 18**] on [**7-5**] with findings as delineated above concerning for Boerhaave's Syndrome. He was taken emergently to the operating room where he underwent a left thoracotomy and repair of esophageal perforation with intercostal muscle flap buttress; three chest tubes and an NGT were left in place during the operation. On POD 1 he was extubated, however, developed increased work of breathing and so was reintubated following CXR findings concerning for severe aspiration pneumonia in the RML (consistent with his history of Boerhaave's). His postoperative course was noteable initially for increased fluid requirements given likely infection and third-spacing that responded to both crystalloid and colloid (in the form of albumin). He was also noted to have persistent fevers up to 102 initially in the postoperative period. He was given perioperative broad-spectrum coverage, namely fluconazole, vancomycin, unasyn, and flagyl. The pleural fluid was (as expected) multi-microbial in both samples: viridans strep, SCN, corynebacterium, GNR (x2) MOLD, and viridans strep, corynebacterium, GNR, yeast. Given his persistent fevers and aspiration pneumonia, on [**7-11**] he had a sputum culture, and then [**7-15**] had a BAL that grew resistent Klebsiella. His unasyn was discontinued and he was placed on ciprofloxcin in addition to his vancomycin, flagyl, and fluconazole for the above cultures. Reassuringly, repeat pleural fluid culture taken [**7-12**] during thoracentesis for fluid overload was without growth, indicating that his fevers were likely from the aspiration given adequate coverage for the perforation. Given the need for prolonged nutrition in the setting of esophageal perforation, the patient was initially started on TPN and then placed on tube feeds after he underwent successful placement of a G/J tube on [**7-12**]. He self d'c'd his NGT the following day. Given his prolonged need for ventilation the patient underwent tracheostomy on [**7-12**] (Portex 8.0mm). He was quickly weaned off the ventilator to trach collar 02 40%. On [**7-15**] he underwent evaluation for and placement of a PMV valve tolerated well. 3. FLUID OVERLOAD The patient also became slightly fluid overloaded in the setting of need fluid resuscitation, and so was diuresed after he became hemodynamically stable. He also underwent a thoracentesis on [**7-12**] for the same reason. 4. EtOH WITHDRAWAL The patient has a severe history of EtOH abuse, and we had high concern for EtOH withdrawal. He was thus kept on a CIWA scale, however, secondary to his ventilatory and oxygenation requirement he was kept intubated and on propofol and fentanyl drips until his tracheostomy placement; he thus did not experience any DTs or other signs of withdrawal. 5. REMAINDER OF HOSPITAL COURSE: On [**7-19**] the patient was transferred out of the ICU to telemetry. He was ambulating with PT well His posterior chest tube was dc'd. On [**7-22**] his Trach tube was down sized to # 6.0 mm uncuffed portex trach. His Apical chest tube was backed out 3 cm. His Foley catheter was removed. On [**7-24**] the patient self-decannulated. He has had no breathing difficulties since that time. On [**7-25**] his apical chest tube was again drawn back four cm, which he tolerated well. His G-Tube was kept to bag drainage until drainage less than 600 cc/ 24 hours. Throughout this time the patient was kept on SQH for DVT prophylaxis, and pantoprazole for GI prophylaxis. THE PATIENT CANNOT TAKE ANY PO INTAKE UNTIL [**8-4**]. Medications on Admission: alleve PRN Discharge Medications: 1. Tube Feeds via J-Tube Replete with fiber Full strength: Cycle: Rate 120 mL/x16 hrs. 2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. Disp:*400 ML(s)* Refills:*0* 3. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTUES (every Tuesday). Disp:*5 Patch Weekly(s)* Refills:*2* 4. Acetaminophen 160 mg/5 mL Solution Sig: Twenty (20) mL PO Q6H (every 6 hours) as needed for fever. Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Esophageal perforation s/p: Left thoracotomy and repair of esophageal perforation with intercostal muscle flap buttress Respiratory Failure/Aspiration/ARDA: Trach ETOH Abuse Discharge Condition: Good Discharge Instructions: Please call Dr. [**Last Name (STitle) **] office with any Questions or concerns. Please call with fevers >101.5 increase sob or resp. secretions. Call if unable to tolerate feeds or vomiting. Followup Instructions: You have an appointment with Dr [**Last Name (STitle) **] on: UPPER GI (HOSPITAL) RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2179-8-3**] 10:00 [**Location (un) 8661**] clinical center on the [**Location (un) **] -Radiology. Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**] Date/Time:[**2179-8-3**] 1:30 on the [**Location (un) **] [**Location (un) **] clinical center. Nothing to Eat or Drink After Midnight prior to this appointment Completed by:[**2179-8-3**]

[ "571.2", "345.90", "511.89", "512.8", "510.9", "276.6", "303.91", "530.4", "786.3", "518.5", "507.0" ]

icd9cm

[ [ [] ] ]

[ "38.91", "42.87", "33.23", "31.1", "99.15", "33.24", "38.93", "96.6", "34.91", "44.39", "45.13" ]

icd9pcs

[ [ [] ] ]

9362, 9421

4722, 8062

433, 785

9638, 9644

2737, 4699

9885, 10401

2686, 2718

8874, 9339

9442, 9617

8838, 8851

8079, 8812

9668, 9862

280, 395

813, 2409

2431, 2560

2576, 2670

13,421

116,424

5244

Discharge summary

report

Admission Date: [**2134-3-2**] Discharge Date: [**2134-3-14**] Date of Birth: [**2065-12-31**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 9554**] Chief Complaint: congestive heart failure Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: This is a 68yo M with h/o IPF(on 4L home O2), h/o PE/DVT, diastolic heart failure with EF 55% who was admitted to the [**Hospital Unit Name 196**] service on [**3-5**] for severe CHF. According to the patient, he gained 10lbs and has increasing orthopnea despite increased lasix dose. On admission, pro-BNP noted to be 23K. Patient did not tolerate lasix and natrecor gtt secondary to hypotension. Patient also did not tolerate dopamine gtt secondary to tachycardia. Patient was evaluated by the CHF service and was electively cathed to evaluate right sided pressure. Catheterization showed mild pulmonary hypertension(34/20) with minimal improvement with 100% O2 and NO(38/22 and 32/19 respectively). ALso RA 19, RVEDP 19, PCWP 19 suggestive of restrictive cardiomyopathy. CI 1.8(4LO2) to CI 2.09(NO) cath completed by right femoral arterial sheath with minimal bleeding. Of note, patient had atrial fibrillation responding to beta blockade Past Medical History: 1. Idopathic pulmonary fibrosis, followed by Dr. [**First Name (STitle) **] and undergoing pulmonary rehab. Chronic home O2, 4 L. 2. htn 3. Pulm embolism '[**31**] 4. DVT '[**29**] 5. hyperlipidemia 6. CRI, baseline creat at 1.5 7. depression 8. diastolic CHF: EF 50-55% 9. hearing loss 10. macular degeneration 11. cholelithiasis 12.?sarcoidosis Social History: Retired in [**2127**]. Worked at [**Company 2676**] for 20 years as metal worker. social EtOH. one pack-year tobacco history. quit 35 years ago. Lives with wife.H as 1 son and 1 grandson. They live 25 minutes away. Family History: Mother passed from CAD, father from brain tumor. Physical Exam: T96.6 P90 RR11 BP 95/84 100% on 4L Gen- NAD caucasian gentleman HEENT-unremarkable, no carotid bruit CV_RRR, no r/m/g resp-crackles [**1-21**] bilaterally [**Last Name (un) 103**]-soft, nontender/nondistended ext-right groin swan in place, no hematoma, no femoral bruit, 2+pitting edema Pertinent Results: pro BNP 23, 485 bilateral LENI -no DVT TTE [**3-4**] EF50%2+TR 2+MT pMIBI [**10-22**]:normal without perfusion defects Brief Hospital Course: This is a 68yo M with h/o IPF(4L home O2), h/o PE/DVT, diastolic heart failure with EF 55%, now has restrictive cardiomyopathy. He was admitted in CCU for tailored diuresis.Despite aggresive diuresis with natrcor, lasix drip, bumex and metolazone, he fails to diurese. A search for the cause of restrictive cardiomyopathy included fat pad biopsy of the heart to rule out amyloidosis which was negative. Pyrophosphate scan and cardiac MRI was impossible since patient was unable to lie flat. Renal team was consulted for renal biopsy. According to them, since there is no protein in the urine, this is not consistent with renal amyloidosis and hence biopsy was not indicated. ULtrafiltration was considered but this is not a long term solution. Goal of care was discussed extensively with patient and family. Patient opted for comfort measures and hence was sent home with hospice. Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*30 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. Morphine Concentrate 20 mg/mL Solution Sig: One (1) PO Q4-6H (every 4 to 6 hours) as needed: titrate to patient comfort. Disp:*QS QS* Refills:*0* 4. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. Disp:*30 Tablet(s)* Refills:*0* 5. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Transdermal q 3 days as needed for secretions: may place more than one patch to control secretions as needed. Disp:*30 30* Refills:*0* 6. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed. Disp:*30 Tablet(s)* Refills:*0* 7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed: titrate to patient comfort. Disp:*30 Tablet(s)* Refills:*2* 8. Bumex 2 mg Tablet Sig: Two (2) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 9. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. Disp:*QS ML(s)* Refills:*0* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: restrictive cardiomyopathy Idopathic pulmonary fibrosis, followed by Dr. [**First Name (STitle) **] and undergoing pulmonary rehab. Chronic home O2, 4 L. hypertension Pulm embolism '[**31**] DVT '[**29**] hyperlipidemia Chronic renal insufficiency, baseline creat at 1.5 depression diastolic congestive heart failure hearing loss macular degeneration cholelithiasis sarcoidosis Discharge Condition: poor Discharge Instructions: This patient's goals revolve around comfort. All reasonable efforts should be made to relieve pain or shortness of breath or whatever other discomforts the patient experiences. To this end, his ativan, scopolamine patch, and morphine should be titrated accordingly. Followup Instructions: PCP: [**Name10 (NameIs) 1576**],[**Name11 (NameIs) 1575**] [**Telephone/Fax (1) 1144**] [**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**] Completed by:[**2134-3-14**]

[ "428.30", "389.9", "427.1", "428.0", "135", "574.20", "414.01", "416.8", "593.9", "425.4", "427.31", "427.89", "401.9", "997.1", "E879.0", "515" ]

icd9cm

[ [ [] ] ]

[ "99.04", "88.56", "37.21", "00.13", "89.64", "38.93" ]

icd9pcs

[ [ [] ] ]

4548, 4623

2476, 3359

340, 365

5045, 5051

2331, 2453

5366, 5611

1958, 2008

3382, 4525

4644, 5024

5075, 5343

2023, 2312

276, 302

393, 1338

1360, 1708

1724, 1942

57,004

154,572

42083

Discharge summary

report

Admission Date: [**2152-10-11**] Discharge Date: [**2152-10-13**] Date of Birth: [**2077-6-18**] Sex: F Service: MEDICINE Allergies: No Allergies/ADRs on File Attending:[**First Name3 (LF) 1115**] Chief Complaint: GI bleed, hypotension Major Surgical or Invasive Procedure: Emergent colonoscopy with 2 surgical clips placed a site of bleeding in the Cecum. History of Present Illness: 75F with h/o adenomatous polyps and multiple colonoscopies, HTN, diabetes who presents as transfer from OSH with GI bleeding. The patient underwent colonoscopy at [**Location (un) 2274**] [**Location (un) **] on [**10-10**] (day prior to presentation) with snare polypectomy of a 12mm polyp in the cecum. The procedure had no complications and she was discharged home. She tolerated PO post-procedure. On the day of admission, she awoke around 5am with a "funny feeling". She went to the bathroom where she passed bright red blood and clots. Her husband who is a physician reports the toilet water was not watermelon colored, but frank blood. She had a total of 4 episodes of passing BRBPR associated with lightheadness and an ambulance was called. She was transported to [**Hospital **] Hospital where she had an additional large volume passing of bright red blood and clots. She lost consciousness for approx. 3 minutes in the setting of this episode per her husband who witnessed it. She did not lose a pulse during this time but was cold and clammy and awoke slightly confused but soon cleared. Labs were notable for hematocrit of 31 from recent baseline of 37-38. She was transfused 1 unit PRBC and transferred to [**Hospital1 18**] for further management. . In the [**Hospital1 18**] ED, initial vs were: 96.4 78 128/69 20 100% 4L NC. Labs were notable for Hct 31, INR 1, lactate 1.4, UA grossly positive. While in the [**Hospital1 18**] ED, the patient passed approx. 600cc bright red blood with clots. During this episode, her SBP dropped to the 60s, though the patient was mentating. She did have some lightheadness associated with this episode. Her BP improved immediately after the episode and she was never placed on pressors. Massive transfusion protocol was initiated and the patient received 2 units PRBCs and 1 unit FFP. GI was consulted and recommended ICU admission and plan for colonoscopy tonight. Surgery was consulted and requested KUB which was negative for free air under the diaphragm. Angio was consulted as well and felt she did not need a CTA at that time. Patient was given 1 gram Ceftriaxone for presumed UTI. At time of transfer, SBP remained in the 140s-150s and HR 80s. . Upon arrival to the ICU, the patient appears comfortable. She [**Hospital1 **] abdominal pain, N/V. She reports she has not had any additional BRBPR since the single episode in the [**Hospital1 18**] ED. She [**Hospital1 **] h/o steroid use, reports using ibuprofen 800mg TID:PRN, last ASA 81mg was 5-6 days ago. She [**Hospital1 **] a h/o GI bleeds. She [**Hospital1 **] fever, chills, dysuria, urgency and frequency. . Review of sytems: (+) Per HPI (-) [**Hospital1 4273**] fever, chills, night sweats, recent weight loss or gain. [**Hospital1 4273**] headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No dysuria. Denied arthralgias or myalgias. Past Medical History: breast cancer diagnosed [**3-/2152**] s/p left breast lumpectomy and radiation, now on chemotherapy hypertension hyperlipidemia h/o adenomatous polyps with colonoscopy x 5 diabetes frequent UTIs hypothyroidism ?autoimmune disease (was on etanercept for ?RA, last dose >1 year ago, now on duloxetine for possible PMR) Social History: Lives in [**Location 13011**] with her husband who is a retired physician. [**Name10 (NameIs) 4273**] tobacco use, endorses 3 drinks/week. Former teacher and shopkeeper. Family History: Father with [**Name2 (NI) 499**] cancer at age 86. Maternal aunt with breast cancer. No FH of GI bleeds, bleeding disorders. Physical Exam: Admission Exam Vitals: T: 99.2 BP: 149/61 P: 81 R: 16 O2: 98%RA General: Alert, oriented x3, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, conjunctiva pale Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Rectal: deferred given known recent GI bleed GU: foley in place with pale yellow urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: A&Ox3, answering questions appropriately, moving all extremities DISCHARGE EXAM: T: 98.7, BP: 153/67, P 69, R16, 100%RA General: Alert, oriented x3, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, conjunctiva pale Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Rectal: deferred given known recent GI bleed GU: foley in place with pale yellow urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: A&Ox3, answering questions appropriately, moving all extremities Pertinent Results: ADMISSION LABS: BLOOD [**2152-10-11**] 11:34AM BLOOD WBC-7.7 RBC-3.50* Hgb-11.3* Hct-31.5* MCV-90 MCH-32.3* MCHC-35.9* RDW-12.4 Plt Ct-290 [**2152-10-11**] 11:34AM BLOOD Neuts-83.1* Lymphs-13.1* Monos-2.9 Eos-0.4 Baso-0.5 [**2152-10-11**] 11:34AM BLOOD Glucose-188* UreaN-19 Creat-0.6 Na-137 K-3.9 Cl-106 HCO3-24 AnGap-11 [**2152-10-11**] 07:28PM BLOOD Calcium-8.4 Phos-2.9 Mg-1.6 URINE [**2152-10-11**] 01:10PM URINE RBC-7* WBC->182* Bacteri-MOD Yeast-NONE Epi-<1 [**2152-10-11**] 01:10PM URINE Blood-SM Nitrite-POS Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG DISCHARGE LABS: [**2152-10-13**] 05:52AM BLOOD WBC-5.8 RBC-3.77* Hgb-11.7* Hct-33.0* MCV-88 MCH-31.0 MCHC-35.4* RDW-12.4 Plt Ct-273 [**2152-10-13**] 05:52AM BLOOD Glucose-171* UreaN-6 Creat-0.6 Na-140 K-3.8 Cl-105 HCO3-25 AnGap-14 [**2152-10-13**] 05:52AM BLOOD Calcium-9.3 Phos-2.6* Mg-2.0 MICROBIOLOGY: URINE CULTURE (Final [**2152-10-12**]): GRAM NEGATIVE ROD(S). ~1000/ML. IMAGING: KUB FINDINGS: The decubitus film may not include the outer margin of the abdomen; however, there is no definite free air seen. There is no evidence of bowel obstruction. Small bowel loops appear to be centered within the abdomen which can be seen in patients with ascites. IMPRESSION: 1. No definite free air; however, decubitus films may not include the entire abdomen. 2. Possible ascites. PROCEDURES: Diverticulosis of the sigmoid [**Month/Day/Year 499**] and descending [**Month/Day/Year 499**]. Blood and clots were seen throughout the [**Month/Day/Year 499**]. Stool was seen in the cecum. Normal mucosa in the terminal ileum. A clot was seen at the polypectomy site in the cecum. The site was vigorously washed and two clips were placed at the polypectomy site. There was no active bleeding noted. Otherwise normal colonoscopy to cecum Brief Hospital Course: 75F history of HTN, h/o colonic polyps, DM who underwent colonoscopy with 12mm polypectomy on day prior to admission transferred from OSH with multiple large volume bloody stools and brief period of hypotension consistent with lower GI bleed related to recent polypectomy. Patient underwent emergent colonoscopy and clipping of the polypectomy site by GI with no reoccurance of symptoms. # Lower GI bleed at polypectomy site: The patient underwent colonoscopy at [**Location (un) 2274**] [**Location (un) **] on [**10-10**] (day prior to presentation) with snare polypectomy of a 12mm polyp in the cecum. The procedure had no complications and she was discharged home. She tolerated PO post-procedure. On the day of admission ([**10-11**]) she awoke passing BRBPR. Patient had subsequent large blood BM at OSH w/ LOC transfused 1 unit for HCT of 31 and transfered to [**Hospital1 18**]. ICU course was significant for colonoscopy revealing diverticulosis of the sigmoid [**Hospital1 499**] and descending [**Hospital1 499**] with blood and clots seen throughout the [**Hospital1 499**]. A clot was seen at the polypectomy site in the cecum and subsequently two clips were placed at the polypectomy site. There was no active bleeding noted. Patient recived 2 units pRBC and 1 FFP while in house and had no subsequent events of BRBPR with a stable HCT in the high 30s at the time of discharge. # Hypotension: Patient was found to by hypotensive to the 80s systolic in the ED, etiology was most likely secondary to vagal stimuli in the setting of syncopal episode and voluminous BRPBR causing hypovolemia. She became normotensive soon after without intervention. # ?UTI: Patient was noted to have a positve UA with WBCs on presentation, with no symptoms other than urinary frequency which was at her baseline. She recieved 3 doses of IV ceftriaxone while in the MICU and was discharged without additional abx as urine cx grew <1000 CFUs of GNRs. # Diabetes: Chronic issue that was stable during hospitalization. # HTN: Vasoactive medications were held during active GIB and re-started during hospital course. # Breast cancer: s/p lumpectomy and XRT, now on chemotherapy. She was continued on anastrazole. # Hypothyroidism: stable. She was continued on levothyroxine. # Hyperlipidemia: She was continued on simvastatin. # PMR: She was continued on duloxetine. TRANSITIONAL ISSUES: -patient is a full code -patient had many questions regarding on going treatment of her UTIs and the issue of possible anatomic causes of her urinary frequency were raised. She may benefit from urologic assessment at her PCP's discresion. -Aspirin was held at time of discharge, and may be restarted [**10-18**]. Medications on Admission: cymbalta 20 daily anastrozole 1 daily lisinopril 40 daily levothyroxine 175 daily HCTZ 25 daily simvastatin 20 daily cyclobenzaprine 10 daily ibuprofen 800 tid:prn (never takes more than 3/day) aspirin 81mg daily folic acid qhs Ca/Vit D tylenol 1000mg tid:prn metformin 1000mg [**Hospital1 **] Discharge Medications: 1. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 6. anastrozole 1 mg Tablet Sig: One (1) Tablet PO once a day. 7. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 9. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO once a day. 10. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO once a day. 11. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Gastrointestinal bleed Urinary Tract Infection Secondary: breast cancer hypertension hyperlipidemia diabetes hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you while you were admitted to the hospital. You were admitted with a gastrointestinal bleed and underwent an emergent colonoscopy where bleeding was noted at the site of your reccent polypectomy. This site was clipped and the bleeding resolved. You received several units of blood while in the hospital and were monitored initially in the intensive care unit. You were subsequently transitioned to the general medical floor with stable blood counts and no evidence of on going bleeding. You may notice some dark clotted blood with your stools for the next several days, but this is expected. If however you developed large amounts of blood in your stool, have bright red blood, begin to feel dizzy or light headed, weak or have any other concerning symptoms you should return to the hospital immediately. You also had a urinary tract infection and recieved IV antibiotics while in the hospital. The following changes were made to your medications: -HOLD Aspirin 81 mg daily until seen by your primary care doctor Followup Instructions: Please follow up with your primary care doctor in the next [**3-25**] days.

[ "244.9", "998.11", "E879.8", "562.10", "725", "V10.3", "V15.3", "250.00", "455.0", "V12.72", "578.9", "790.01", "455.3", "458.29", "599.0", "272.4", "401.9" ]

icd9cm

[ [ [] ] ]

[ "45.43" ]

icd9pcs

[ [ [] ] ]

11258, 11264

7383, 9757

311, 396

11442, 11442

5528, 5528

12673, 12752

3977, 4104

10439, 11235

11285, 11421

10120, 10416

11593, 12650

6139, 7360

4119, 4818

4834, 5509

9778, 10094

249, 273

3069, 3432

424, 3051

5545, 6123

11457, 11569

3454, 3773

3789, 3961

47,234

197,966

42685

Discharge summary

report

Admission Date: [**2183-1-27**] Discharge Date: [**2183-2-14**] Date of Birth: [**2111-12-22**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 348**] Chief Complaint: fall Major Surgical or Invasive Procedure: -[**2183-1-27**] RIGHT CRANIOTOMY FOR SUBDURAL HEMATOMA EVACUATION -PEG Tube Placement History of Present Illness: This is a 72 year old man who is Portuguese speaking, on Coumadin for DVT. He fell down [**2-28**] stairs on [**2183-1-26**], +head trauma, unknown LOC. Per family, he felt well and refused to go to hospital.He later developed severe HA overnight and emesis x 10. His family was unable to wake him in the morning stating he was minimally responsive to speech. He was found only reactive to pain by EMS and was taken to [**Hospital **]. There he was +posturing, paralyzed with vecuronium and intubated. CT head showed a 2.5cm R SDH with 1cm shift on CT, negative CT C spine, INR 3.5. He had a [**Location (un) 7622**] to [**Hospital1 18**], given 1gm Dilantin, no reversal agents. Midazolam and Fentanyl in flight. Past Medical History: Prostate CA, hypercholest, HTN, DVT Social History: Lives with wife, speaks portuguese Family History: UNKNOWN Physical Exam: Admission Exam: O: T: BP: 144/70 HR: 66 R:18 O2Sats 100% on CMV PEEP 5, TV 500, Rate 12 Gen: intubated, off-sedation, on ventilator HEENT: Pupils: R-5, L-3 nonreactive b/l, no corneal reflex Right temporal brusing, abrasion to scalp and chin Neck: Supple. Lungs: CTA bilaterally. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. +Extensor posturing Localizes to pain RUE only All extremities response to noxious stimuli Sustained Clonus b/l LE . Discharge Exam: VS: Tm 99.5 BP 85-135/50-60 HR 80-90 RR 20 O2 Sat 98% RA GEN: Ill appearing man, responsive to all questions in Portugese HEENT: Craniectomy scar is c/d/i CV: RRR, distant heart sounds, normal s1/s2, no s3/s4, no m/r/g PULM: Rales at the L base. Scattered rhonchi heard most prominently at the basal lung fields. ABD: Non tender, moderately distended, NABS, no rigidity, rebound or guarding EXT: WWP NEURO: Responsive to name, makes eye contact, drastically improved from time of transfer to medicine Pertinent Results: Admission Labs: [**2183-1-27**] 01:15PM BLOOD WBC-7.7 RBC-4.05* Hgb-11.8* Hct-34.5* MCV-85 MCH-29.1 MCHC-34.3 RDW-13.7 Plt Ct-108* [**2183-1-27**] 01:15PM BLOOD Neuts-91* Bands-1 Lymphs-4* Monos-2 Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0 [**2183-1-27**] 01:15PM BLOOD Glucose-219* UreaN-13 Creat-0.5 Na-140 K-3.2* Cl-103 HCO3-24 AnGap-16 [**2183-1-27**] 06:15PM BLOOD ALT-28 AST-20 LD(LDH)-264* AlkPhos-102 TotBili-0.5 [**2183-2-1**] 07:00PM BLOOD Lipase-16 [**2183-1-27**] 01:15PM BLOOD cTropnT-<0.01 [**2183-1-27**] 01:15PM BLOOD CK-MB-2 [**2183-1-27**] 01:15PM BLOOD Calcium-7.6* Phos-3.5 Mg-1.6 [**2183-1-27**] 01:15PM BLOOD Osmolal-299 [**2183-1-27**] 06:15PM BLOOD Phenyto-11.6 [**2183-1-27**] 01:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2183-1-27**] 02:41PM BLOOD Type-ART FiO2-100 pO2-305* pCO2-38 pH-7.34* calTCO2-21 Base XS--4 AADO2-370 REQ O2-66 Intubat-INTUBATED . Discharge Labs: [**2183-2-13**] 05:21AM BLOOD WBC-4.2 RBC-2.72* Hgb-7.8* Hct-23.3* MCV-86 MCH-28.6 MCHC-33.3 RDW-14.3 Plt Ct-285 [**2183-2-13**] 05:21AM BLOOD Glucose-137* UreaN-13 Creat-0.4* Na-137 K-3.9 Cl-105 HCO3-24 AnGap-12 [**2183-2-12**] 04:13AM BLOOD ALT-115* AST-50* AlkPhos-109 TotBili-0.2 Chest XR [**2183-1-27**] 1. ET tube 5 mm distal to the right main bronchus. Recommend retraction by approximately 4-5 cm to achieve appropriate positioning. 2. Enteric tube in appropriate position. 3. Subtle irregularity along anterolateral left eighth and ninth ribs, to be correlated with focal tenderness for possible fracture. 4. Low lung volumes, accentuating bronchovascular markings CT head [**2183-1-27**] 1. Large right subdural hematoma along the entire right cerebral hemisphere and along the right tentorium cerebelli. 2. Large, 2.5 cm wide right parietal epidural hematoma with "swirl" sign, suggesting hyperacute epidural hematoma. 3. Severe right, and moderate left cerebral edema with 1.5 cm shift to the left. 4. Effacement of the suprasellar cisterns and right ambient cistern, concerning for impending herniation. 5. Small amount of SAH vs. pseudo SAH (due to edema) in the Sylvian fissures. prior OSH exam is not available for comparison CT head [**2183-1-28**] FINDINGS: There has been interval right-sided craniotomy with evacuation of the right subdural and epidural hematoma. There is decreased leftward shift of normally midline structures, now measuring 4 mm (previously 15 mm). The basal cisterns now appear patent. There is decreased cerebral edema with improved demonstration of [**Doctor Last Name 352**]-white differentiation. There is a small residual subdural hematoma layering along the entire right convexity and tentorium, measuring 5 mm in thickness. There is a small residual right parietal epidural hematoma, measuring 6-mm in thickness. No subarachnoid or intraventricular hemorrhage is seen. Craniotomy changes and associated hardware are present. A large amount of post-operative pneumocephalus is noted. The visualized portions of the paranasal sinuses and mastoid air cells are well aerated. Aerosolized fluid pooling in the posterior nasopharynx likely represents retained secretions relAted to intubated status. IMPRESSION: 1. Interval right craniotomy and evacuation of right subdural and epidural hematoma with marked improvement in mass effect and cerebral edema. Leftward midline shift now measures 4mm (previously 15 mm). Basal cisterns now appear patent. 2. Small residual right subdural hematoma and small residual right parietal epidural hematoma. 3. Post-operative pneumocephalus. [**2183-1-28**] CXR IMPRESSION: 1. Small bore feeding tube is seen within the stomach in proper position. 2. Endotracheal tube approximately 2.9 cm from the carina. 3. Left subclavian central line with tip terminating in the mid SVC . [**2183-2-11**] CT Head: The patient is status post right frontal temporoparietal craniotomy for right hemispheric subdural hematoma evacuation. Again seen is a small right subdural collection surrounding the right cerebral convexity, maximally measuring 7 mm. In comparison to the prior study, there is decreased attenuation of the subdural hematoma, suggesting interval evolution. There is mild decrease in the hyperdense hematoma layering the tentorium cerebelli. Mild effacement of the right hemispheric sulci, predominantly in the temporoparietal regions, is stable. Minimal leftward shift of midline structures, is unchanged. Mild compression of the right lateral ventricle is unchanged. No acute intraparenchymal hemorrhage, edema, or mass is seen. There is interval resolution of previously seen pneumocephalus. Calcification in both cavernous carotid arteries are noted. The imaged paranasal sinuses are clear. Minimal fluid is seen within both mastoid air cells. No abnormal enhancement is seen in the post-contrast images. IMPRESSION: 1. Status post evacuation of right subdural hematoma, with interval evolution of previously seen small residual right-sided SDH. Mild interval decrease in the layering SDH in the tentorium cerebelli, compared to [**2183-2-1**]. 2. Stable minimal leftward shift of midline structures. No new hemorrhage or acute infarction. . [**2183-2-12**] CXR: Left PIC line ends in the right atrium, approximately 4 cm below the level of the superior cavoatrial junction. Lungs are low in volume, making it difficult to exclude mild interstitial edema, particularly in the left lung. Large pneumoperitoneum seen on [**2-10**] is less recognizable today, and could be smaller, but is definitely still present. Mild-to-moderate cardiomegaly is stable. Pleural effusion is small, if any. No pneumothorax. . RUQ Ultrasound ([**2183-2-12**]): Limited views of the liver obtained due to a small acoustic window. The liver parenchyma is grossly normal. There are echogenic areas within the right and left lobe of liver which are subcentimeter and most likely represent scarring. No suspicious focal liver lesions identified. No intra- or extra-hepatic duct dilation is identified. The common duct measures 5 mm. There is normal hepatopetal flow within the portal vein. The gallbladder is normal in appearance. There is no free fluid identified. Nasogastric tube noted within the stomach. The upper portion of the right kidney appears normal. No evidence of right hydronephrosis. IMPRESSION: Limited study. 1. Grossly normal liver parenchyma. Normal portal vein. . Video Esophagram ([**2183-2-13**]): Oropharyngeal swallowing videofluoroscopy was performed in conjunction with the speech and swallow division. Multiple consistencies of barium were administered. Barium passed freely through the oropharynx without evidence of obstruction. There was penetration with nectar liquids and aspiration with thin liquids. IMPRESSION: Aspiration with thin liquids and penetration with nectar liquids. For details, please refer to speech and swallow note in OMR. Brief Hospital Course: Primary Reason for Admission: 71 M history of prostate CA, skin CA, DVT 2 yrs ago on coumadin, HTN, admitted for large subdural hematoma s/p fall, now s/p hematoma evacuation transferred to medicine from neurosurg for fever workup. . NEUROSURGERY COURSE: . This patient was orginally admitted to the NSICU under the care of the Neurology department. He was given Mannitol and his physical exam improved. He received a loading dose of Dilantin at the outside hospital as well as VIT K IV. When he arrived at the [**Hospital1 18**], he had a diffuse rash as well as fever. It was thought to be due to his Dilantin administration. His dilantin was discontinued and he was transitioned to Keppra. He developed another rash after administration of Vit K. After long discussion with his family, they consented for a right craniotomy for evacuation of the clot. Dr. [**First Name (STitle) **] took him to the OR on [**2183-1-27**] and performed a right craniotomy for SDH. An epidural JP drain was left in place. Intra-op INR was 1.1. He was taken to the SICU intubated. His post-op CT showed good evacuation with significant improvement in MLS. He was opening eyes to noxious stimuli. He was purposeful on the left and WD the RLE. He was not moving his right arm. His exam continued to improve and in Portugese he was following a few basic commands. He has right sided weakness at present due to Kernohan's phenomenon. His JP drain was removed and he was extubated prior to transfer to the step-down unit. He had fevers on [**2183-1-30**] and [**2183-1-31**] for which cultures were sent and found to be negative. His exam continued to fluctuate and he was evaluated by medicine for intermittent fever spikes wihtout clear source as well as assisting in deciding about managment of remote DVT/PE with current negative LENI's. Cultures including CSF were sent. Pt spiked fever again on [**2-5**]. Work-up was re-initiated. Speech and swallow eval was ordered. His hct was down to 25 and stool guiacs were ordered. He was hyponatremic to 130 and salt tabs were started. On [**2183-2-6**], he was transferred to medicine for workup of persistent fever. . MEDICINE COURSE . Active Problems: . # Subdural/Epidural Bleed: Management per neurosurgery (see [**Hospital 4695**] Hospital Course). His anticoagulation was held for the remaineder of his admission and CT head was repeated - showed continued improvement in his intracranial bleed. He should not be anticoagulated in the future unless directed by neurosurgery to resume anticoagulation. He will follow up with Neurosurgery (see follow up instructions). At the time of discharge, he had full function of the LUE and LLE and had intact sensation of the RUE and RLE but minimal motor function on the right. Per Neurology, he is expected to improve significantly in terms of R sided motor function with intensive PT. . # Fever: After transfer to medicine, he continued to have low grade fevers, the cause of which is unclear. Possibilities include metastatic cancer, granulamatous lung disease, PNA, central fever, DVTs or drug reaction. Infection was felt to be unlikely given his persistent low grade fever despite 5d of Vanc/Cefepime and repeatedly negative culture data. Antibiotics were stopped and he was monitored. He continued to have low grade fevers, but became tachypnic and tachycardic. CXR was performed and showed a new LLL PNA. He was started on Vanc/Zosyn for HAP and defervesced. In retrospect, he may have had an ealry PNA, which was the cause for his fevers vs. chemical pneumonitis with a superimposed bacterial infection which revealed itself later in his course. He will need a total of 10d course of Vanc/Zosyn for HAP. . # AMS: Unnecessary medications were stopped. His mental status waxed and waned throughout his course, though he continued to slowly improve. His AMS was most likely multifactorial given his intracranial bleed and prolonged hospital stay, which likely contributed to his delerium. Neurology was consulted and EEG was performed. There was no e/o subclinical seizure and Neurology felt his mental status was likely related to his intracranial bleed c/b delerium. At the time of discharge, his mental status was markedly improved. Specifically, he was responsive to all questions in Portugese and was able to reiterate the plan of care going forward. . # DVT: Pt has b/l DVTs. No anticoagulation was initiated given his severe ICH. He has an IVC filter. He should not be anticoagualted in the future given his severe intracranial hemorrhage unless directed to resume anticoagulation by neurosurgery. . # Nutrition: Pt failed repeated speech/swallow [**Last Name (LF) 92279**], [**First Name3 (LF) **] PEG tube was placed and tube feeds were started. Pt tolerated tube feeds well. On [**2183-2-12**] pts mental status had improved significantly, so speech and swallow was re-consulted; recommended video swallow study. Video study showed continued abnormal deglutition, but he was cleared for nectal thick liquids and pureed solids. He should take his pills ground in pureed foods. He will require ongoing tube feeds per below: Two Cal HN Full strength; Additives: Beneprotein, 28 gm/day Starting rate: 33 ml/hr; Do not advance rate Residual Check: q4h Hold feeding for residual >= : 200 ml Flush w/ 100 ml water q4h . # siADH: On transfer to medicine, pt had siADH, likely realted to ICH vs PNA. He was placed on free H2O restriction and given NaCl supplementation. His Na normalized and remained normal for several days prior to discharge. He no longer requires NaCl supplementation. . # Transaminitis: Likely antibiotic related. RUQ ultrasound normal. - cont Vanc/Zosyn, monitor LFTs . Chronic Problems: . # Metastases: CT C/A/P shows [**Last Name (un) 2043**] mets. Per oncologist, pt has >3 year life expectancy. He will need to follow up with with his oncologist once he is more medically stable. . # HTN: Well-controlled. - cont metoprolol . Transitional Issues: Pt was d/c'ed to rehab. He will need Neurosurgery and Oncology follow up. He should engage in rehab for his neurologic deficits and will require ongoing nutritional support and evaluation of his capacity to tolerate an advancing PO diet. Medications on Admission: Paroxetine 10mg senna colace [**Hospital1 **] doxazosin 4mg qhs isosorbide mononitrate 20mg [**Hospital1 **] coumadin 5mg Discharge Medications: 1. paroxetine HCl 10 mg/5 mL Suspension Sig: One (1) 5ML PO DAILY (Daily). 2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. senna 8.8 mg/5 mL Syrup Sig: Five (5) ML PO BID (2 times a day). 5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. polyvinyl alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed) as needed for dry eyes/red eyes. 7. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1) Ophthalmic QID (4 times a day). 8. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours) for 10 days: 1g iv q12h. 10. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours) for 10 days: 4.5g iv q8h. 11. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 12. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) PO once a day as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**] Discharge Diagnosis: RIGHT ACUTE SUBDURAL HEMATOMA RESPIRATORY FAILURE FEVER THROMBOCYTOPENIA ANEMIA ALLERGIC REACTION / RASH TO DILANTIN OR VITAMIN-K/FFP HYPONATREMIA DYSPHAGIA Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr [**Known lastname **], You were admitted to the hospital through the emergency department for a subdural hematoma after a fall. Your exam was very poor initially and then improved after recieving medications to control your response to your coumadin. You were then taken to the operating room for evacuation of your subdural hematoma. You were supported by intensive care until you were able to come off of the ventilator and the drain in your head was removed. You were transferred to the step down unit and were seen by Physical Therapy and Nutrition. You continued to get tube feeds. You then developed a pneumona, for which we gave you antibiotics. You are now safe to retutn to rehab. You will need intensive physical therapy and ongoing supervision by medical doctors. General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin, prior to your injury, you may safely resume taking this after Neurosurgery approved the use of anticoagulation ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Please note the following changes to your medications: STOPPED Imdur STOPPED Warfarin STARTED Metoprolol STARTED Vancomycin STARTED Zosyn STARTED Levetiracetam STARTED Erythromycin 0.5% Ophth Oint Followup Instructions: Follow-Up Appointment Instructions ?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in 4 weeks. ?????? You will need a CT scan of the brain without contrast.

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Discharge summary

report

Admission Date: [**2137-6-30**] Discharge Date: [**2137-7-6**] Date of Birth: [**2086-3-6**] Sex: M Service: MEDICINE Allergies: Erythromycin Base / Protamine Attending:[**First Name3 (LF) 826**] Chief Complaint: Hearing loss, nausea, vomitting, fevers. Major Surgical or Invasive Procedure: dialysis, PICC line placement History of Present Illness: Patient is a 51 yo M on chronic prednisone and other immune-suppressants with DM1, renal failure (2 failed transplants, with recent dialysis re-initiation), CHF, HTN, and HL who, following discharge from [**Hospital1 18**] on [**2137-6-29**] where he was admitted for acute on chronic renal failure and worsening CHF, re-presented on [**2137-6-30**] to the [**Hospital1 18**] ED with bilateral hearing loss, nausea, non-bloody emesis, and fevers/chills x 1 day. Upon arrival to the ED, his vitals were HR 106, BP 112/37, RR 16, o2 sat 95 RA, T 100.9. He was given vancomycin and ceftriaxone and 1L NS bolus. While this improved his BP initially, he was again hypotensive to the 70s shortly thereafter. Pressors were given, and the patient was transferred to the MICU. On arrival to the MICU the patient was stable with a BP in 110. He still endorsed mild hearing loss, but denied any chest pain, shortness of breath, nausea, fever, chills, abdominal pain, dysuria, or diarrhea. MICU course: Patient was found to be in diabetic ketoacidosis (+ketones in blood), anemic (Hct 20), and with a low-grade fever. While in the MICU, his ketoacidosis was successfully treated and he was transfused to a Hct 28. Anemia labs were consistent with anemia of chronic disease / chronic kidney disease. A search for a cause of the fevers revealed negative blood cultures, normal chest x-ray, and non-albicans yeast in the urine. He was transferred to the regular medical service. Past Medical History: 1. DM I diagnosed age 11. Complicated by retinopathy, nephropathy, neuropathy, gastroparesis, multiple amputations [**12-28**] infections, last HgA1C 7.3 in [**4-1**], on Lantus. 2. CAD: s/p 3V CABG in [**2125**] 3. CHF: EF 35% + diastolic dysfunction 4. CVA: small L internal capsule lacune [**4-/2136**], minimal residual defect, likely cardioembolic, on coumadin. 5. CKD due to acute tubular nephropathy in [**2131**] s/p renal transplant [**2122**], re-initiated dialysis [**6-1**]. 5. s/p R BKA 6. s/p L AKA 7. Peripheral vascular disease, with multiple bypass grafts and amputations, s/p Right fem-tibial bypass surgery in [**2125**]. 8. h/o MRSA wound infection [**2133**] 9. Anemia of chronic disease 10. Squamous cell carcinoma resected [**2133**] 11. Glaucoma 12. Listeria infection in [**2132**] 13. Shingles in [**2132**] 14. Diverticulosis on colonoscopy [**5-1**] 15. H/o gastritis on EGD [**5-1**] 16. h/o metal fragments in eye (MRI contraindicated) Social History: Lives at home with wife. Fifteen pack year history of tobacco, quit smoking >10 years ago. Denies alcohol. Family History: diabetes, strokes and heart attacks Physical Exam: VSx24H: Tm 98.9 Tc 98 HR 96-102 BP 93-128/40-70s RR 12-18 02 96-97% RA General: Lying in bed. Appears older than stated age. Obese, comfortable, in no acute distress. HEENT: Head normocephalic, mild anisocoria L>R, pupils round reactive to light/accomodation, EOMI, no scleral icterus. Neck: supple. JVP not visualized [**12-28**] obese neck. Heart: tachycardic, regular, faint S1, S2. no S3/S4 or murmurs. Pulmonary: clear to auscultation with no wheezes or rales. Abdomen: +BS, protuberant, nontender, no organomegaly. Extremities: multiple upper extremity digital amputations. 2+ radial pulses bilaterally. R BKA and a L AKA. His right stump has trace edema, with small bandaged ulcer on distal lateral aspect. Neuro: Alert, oriented x 3, appropriately interactive. Spells WORLD forward, will not attempt backwards. 9 quarters = ?$1.75? Patient reports that his thinking is "fuzzy" at baseline since his CVA 1 year ago. CNVII: mild R facial droop (upper-motor neuron pattern), CNVIII: decreased high frequency hearing bilaterally, CNIX/XII: mild R tongue atrophy and deviation. CNs otherwise grossly intact. Sensation intact to light touch upper and lower extremities bilaterally. Strength 5 bilaterally, but there is slight R pronator drift. Lines: PICC L upper arm, nontender, nonerythematous. Permanent HD catheter R upper chest, mild tenderness to palpation 2in diameter around site, non-erythematous. Pertinent Results: [**2137-6-30**] 07:00PM BLOOD WBC-9.1 RBC-3.08* Hgb-9.2* Hct-27.3* MCV-89 MCH-30.0 MCHC-33.8 RDW-18.0* Plt Ct-325 [**2137-6-30**] 07:00PM BLOOD PT-18.4* PTT-32.2 INR(PT)-1.7* [**2137-6-30**] 07:00PM BLOOD Plt Ct-325 [**2137-7-1**] 01:07AM BLOOD Ret Aut-3.6* [**2137-6-30**] 07:00PM BLOOD Glucose-356* UreaN-38* Creat-8.4*# Na-131* K-4.4 Cl-90* HCO3-22 AnGap-23* [**2137-6-30**] 07:00PM BLOOD CK(CPK)-283* [**2137-7-1**] 01:07AM BLOOD CK(CPK)-313* [**2137-7-1**] 07:25AM BLOOD CK(CPK)-318* TotBili-0.3 DirBili-0.1 IndBili-0.2 [**2137-7-2**] 03:06AM BLOOD ALT-15 AST-23 AlkPhos-79 TotBili-0.2 [**2137-6-30**] 07:00PM BLOOD CK-MB-4 cTropnT-0.44* [**2137-7-1**] 01:07AM BLOOD CK-MB-5 cTropnT-0.40* [**2137-7-1**] 07:25AM BLOOD CK-MB-4 cTropnT-0.38* [**2137-7-2**] 03:06AM BLOOD Albumin-3.2* Calcium-8.0* Phos-5.1*# Mg-1.8 [**2137-7-1**] 07:25AM BLOOD Hapto-285* [**2137-6-30**] 07:00PM BLOOD Acetone-MODERATE [**2137-7-1**] 07:25AM BLOOD Cortsol-14.7 [**2137-7-1**] 08:21PM BLOOD Cortsol-12.0 [**2137-7-1**] 09:02PM BLOOD Cortsol-20.3* [**2137-7-1**] 09:20PM BLOOD Cortsol-21.5* [**2137-7-2**] 03:06AM BLOOD Vanco-19.8 [**2137-7-1**] 12:51PM BLOOD rapmycn-8.2 [**2137-7-6**] 05:56AM BLOOD WBC-9.8 RBC-3.44* Hgb-10.2* Hct-32.5* MCV-95 MCH-29.8 MCHC-31.5 RDW-18.3* Plt Ct-500* [**2137-7-6**] 05:56AM BLOOD Neuts-75* Bands-1 Lymphs-13* Monos-6 Eos-2 Baso-0 Atyps-0 Metas-1* Myelos-2* NRBC-1* [**2137-7-6**] 05:56AM BLOOD Glucose-283* UreaN-21* Creat-3.7* Na-138 K-4.8 Cl-110* HCO3-17* AnGap-16 [**2137-7-6**] 05:56AM BLOOD ALT-18 AST-15 AlkPhos-89 TotBili-0.2 [**2137-7-6**] 05:56AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.9 CXR: Left basilar atelectasis. No pneumonia or CHF. . CT ABDOMEN AND PELVIS [**2137-7-1**]: No evidence for retroperitoneal hemorrhage. No free fluid. Diffuse atherosclerotic calcifications. Standard noncontrast appearance of right renal transplant. . PICC placement [**2137-7-1**]: Uncomplicated ultrasound and fluoroscopically guided double lumen PICC line placement via the left basilic venous approach. Final internal length is 43 cm, with the tip positioned in SVC. The line is ready to use. . EKG [**2137-7-2**]: Sinus tachycardia. The ischemic appearing ST-T wave changes recorded on [**2137-6-30**] persist, though they have decreased. These findings remain consistent with active anterolateral ischemic process. Rule out myocardial infarction. Followup and clinical correlation are suggested. . HD catheter U/S [**2137-7-3**]: No pericatheter fluid collections. . Cardiac Echo [**2137-7-5**]: No valvular vegetations. EF 30%. Brief Hospital Course: A/P: 51 yo M DM1>30years, CAD s/p CABG, CKD on HD, ESRD s/p renal transplant on chronic prednisone and other immunosuppressive medications, transferred from MICU with diabetic ketoacidosis, hypotension, and anemia. While in the MICU his hearing loss returned to baseline, his BP stabilized, he received HD and careful glucose control which together led to a resolution of his electrolyte abnormalities, and he was transfused to a Hct >30. #) BP control: On arrival to the medical service, he was tachycardic and mildly hypertensive (after being hypotensive on admission). His home Metoprolol was restarted and his blood pressure was subsequently controlled. #) DKA: Resolved in MICU. Lantus and ISS were initiated upon arrival to medical service. On the day of discharge, electrolyte abnormalities had improved significantly. #) ECG changes: Initial elevated troponin was likely secondary to demand ischemia in setting of hypotension. CKMB was never elevated. By the day of transfer to the medicine service, Troponin was trending down and the patient was asymptomatic. ACS was thus ruled out. Statin and aspirin were continued. #) CHF: Known systolic and diastolic dysfunction, EF 30%, recent CHF exacerbation. On transfer to the medicine service, the patient's lungs were clear, initial CXR showed no sign of CHF, and the patient was hemodynamically stable. #) Hearing loss: Likely secondary to Lasix toxicity, although patient has been on various doses of this medication for many years. Patient believes it was caused by the Midoxinil that he just started during his previous hospitalization. Both Midoxinil and Lasix were discontinued upon admission and his hearing rapdily returned back to baseline. Prior to discharge Lasix was restarted at a low dose and the patient tolerated this well. #) Anemia: No signs of active bleeding or hemolysis. Anemia studies to date indicate AOCD. Patient was transfused to a Hct>30. Hct on the day of discharge was 32.5 (up from 20 on the day of admission). #) ESRD: Newly re-started on dialysis. Currently with right sided dialysis catheter. Site was mildly tender to palpation, and in setting of low-grade fevers, a line infection was suspected. U/S of the HD catheter site, however showed a patent catheter with no surrounding inflammation or abscess. Blood cultures were all negative. Nephrocaps were continued. #) h/o CVA: Once Hct>30, coumadin was restarted. #) Deconditioning: PT was consulted on [**2137-7-4**]. They evaluated the patient and felt that he was back to his baseline and safe for discharge home. They did, however, recommend home PT to optimize home mobility/independence and safer transferring technique. #) FEN: The patient tolerated oral diet well. Electrolytes normalized. He was proviced with a Diabetic, heart healthy, renal diet. #) Constipation: Docusate sodium, Senna. #) PPx: He received HepSC TID. #) Access: PIV, dialysis catheter, PICC placed. #) Full code #) Communication: Sub-Intern: [**First Name8 (NamePattern2) 17937**] [**Last Name (NamePattern1) 976**] #[**Numeric Identifier 17938**] Senior Resident: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15264**] Attending:[**Attending Info **] Medications on Admission: At time of discharge the day prior: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 9. Sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Metolazone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [**Attending Info **]:*60 Tablet(s)* Refills:*0* 11. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) Unit/ml Injection TID (3 times a day) as needed for DVT prophylaxis for 7 days. [**Attending Info **]:*25 ml* Refills:*0* 12. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 13. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 14. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for constipation. 15. Furosemide 80 mg Tablet Sig: 2.5 Tablets PO BID (2 times a day) as needed for CHF. [**Attending Info **]:*150 Tablet(s)* Refills:*0* 16. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). [**Attending Info **]:*60 Tablet(s)* Refills:*0* 17. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Minoxidil 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). [**Attending Info **]:*15 Tablet(s)* Refills:*0* 19. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily) as needed for CRF, secondary hyperparathyroidism. [**Attending Info **]:*30 Cap(s)* Refills:*0* 20. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 21. Insulin Glargine Subcutaneous 22. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. [**Attending Info **]:*10 Tablet, Rapid Dissolve(s)* Refills:*0* 23. Lantus 20 U, humalog sliding scale Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). [**Attending Info **]:*30 Tablet(s)* Refills:*2* 3. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO EVERY OTHER DAY (Every Other Day). 7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 8. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 9. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). [**Attending Info **]:*120 Tablet(s)* Refills:*2* 12. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 14 days. [**Attending Info **]:*28 Tablet(s)* Refills:*0* 14. Lantus 100 unit/mL Solution Sig: One (1) 40 units Subcutaneous once a day: Please administer 40 units at dinner time daily. 15. Humalog 100 unit/mL Cartridge Sig: One (1) injection Subcutaneous three times a day: Please use humalog sliding scale as directed and administer prior to each meal. 16. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation. 17. Wound Care please provide wound care to right leg wound daily with Aquacel AG. 18. Aquacel-Ag 1.2-2 X 2 %- Bandage Sig: One (1) bandage Topical once a day. 19. Outpatient Lab Work INR Please fax results to Dr. [**First Name4 (NamePattern1) 3403**] [**Last Name (NamePattern1) **] at [**Company 191**] at [**Telephone/Fax (1) 6309**] 20. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. [**Telephone/Fax (1) **]:*30 Capsule(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Diabetic Ketoacidosis fungal urinary tract infection Iatrogenic Hearing loss End Stage Renal Disease on Hemodialysis Anemia of chronic Disease Hypotension Coronary Artery Disease Congestive Heart Failure, systolic and diastolic dysfuction Discharge Condition: Afebrile, tolerating po intake, back to functional baseline. Discharge Instructions: You were admitted with diabetic ketoacidosis, low blood pressure, and a urinary tract infection. We have made some changes to your medications including the stopping of your sirolimus and lasix and the continuation of your carvediol that was started on your last admission. Please continue to take voriconazole and discuss with your nephrologist when to discontinue this medication. You are to return to your regularly scheduled hemodialysis at [**Location (un) **] on Monday, [**7-8**]. During your dialysis, they will also perform ultrafiltration as needed in replacement of your lasix dose. Please have your INR check within the next 5 days by your PCP and continue coumadin 2.5mg daily until otherwise instructed by PCP. Please call your physician or return to the emergency room if you have any fevers, chills, chest pain, shortness of breath, vomiting, or diarrhea. Followup Instructions: Please resume your regularly scheduled dialysis on Monday, [**7-8**] at [**Location (un) **]. Please call your primary care physician and schedule [**Name Initial (PRE) **] follow up appointment within the next week. Please speak with your nephrologist on Monday morning at dialysis and schedule a follow up appointment. Completed by:[**2137-10-11**]

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Discharge summary

report

Admission Date: [**2166-12-1**] Discharge Date: [**2166-12-16**] Date of Birth: [**2132-4-17**] Sex: F Service: MEDICINE Allergies: Allopurinol / Lisinopril Attending:[**First Name3 (LF) 783**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: 1. Liver biopsy History of Present Illness: 34 year old woman with history of type I diabetes and hyperlididemia who reports feeling lethargic over the last week and a half. Her symptoms initially began with generalized pruritis in the setting of having recently started allopurinol (she was told to stop it soon after initiation for a rising creatinine). Approximately 5 days prior to admission she developed nausea, diarrhea and abdominal pain. She saw her nephrologist on [**11-27**] and was diagnosed with viral gastroenteritis. She was asked to hold her zestril and lasix until she felt she was improving. However, over the weekend she felt that her face/eyes were swelling and had difficulty breathing as well as decreased energy. She reports fevers at home to 100.8F and abdominal pain, flank pain and leg pain. She went to the clinic on [**12-1**] and was sent to the ED. No new exposures, no sick contacts. Denies chest pain. Had flu vaccine [**10-9**]. In ED was found to be in acute renal failure and to have a transaminitis. She received benedryl, albuterol, and IVF. She was found to be hyperkalemic with a K=6.6. Admitted to the MICU. There peripheral access was unobtainable and central access was attempted without success. Called out the following day. ROS: No recent travel. No pets at home. Reports taking naproxyn only intermittently and never more than once/day. No herbal supplements. No mushrooms or other exotic foods. No BRBPR. No melena. Reports taking dicloxacillin approximately 1 month ago for a right eye surgery. No adverse event to this medication. Lab Hx: Transaminases had been normal until [**8-9**]. Past Medical History: Diabetes Mellitus Type I -retinopathy, neuropathy, nephropathy Hypertension Hyperlipidemia Asthma Gout Anemia s/p chole [**10-7**] Right eye retinal detachment h/o pyelonephritis h/o thalesemia b/l cataracts surgery Social History: Denies tobacco, ETOH or IVDU lives at home and most recently stayed at sister's place 6 siblings. worked as computer programmer previously, but now on disability Originally from West Indies and moved to the United States at age 9. No recent travel. Family History: DM, HTN Physical Exam: On admission ([**12-1**]) T 97.8 BP 118/68 HR 82 RR 18 O2Sat 97%RA Gen: alert, oriented. Resting comfortably in bed. HEENT: NC/AT, EOMI, puffy lids, neck and face. Able to stick out tongue. Neck: supple. CV: rrr, no mrg Lungs: clear Abd: soft, diffusely tender, +BS, no rebound, guarding Ext: 1+ LE edema, hand edema Back: L>R CVAT Neuro: A&O x 3. Skin warm/dry ** On transfer ([**12-2**]) Tm/Tc 101.7 HR 97-122 (108) BP 103-154/42-61 RR 21-28 O2Sat 94-100%3L NC I/O 5950/2720 +3230 Gen: tired appearing, obese african american woman, pleasant, alert and oriented x3. Feverish. c/o right sided abdominal pain and lower extremity and back pain. HEENT: Periorbital and labial edema, sclera injected, tongue not protuberant; bullous lesions on lips; no mucosal lesions. CV: Regular, no mrg Lungs: clear on anterior exam Abd: soft, obese, diffusely tender, no rebound, no guarding Ext: diffusely tender LE, trace edema. Neuro: non focal. skin: no urticaria; dry scaling excoriations Pertinent Results: CBC [**2166-12-1**] 01:40PM WBC-12.4*# RBC-3.94* HGB-8.7* HCT-28.9* MCV-73* MCH-22.2* MCHC-30.2* RDW-17.7* [**2166-12-1**] 01:40PM NEUTS-60 BANDS-11* LYMPHS-13* MONOS-6 EOS-5* BASOS-0 ATYPS-5* METAS-0 MYELOS-0 [**2166-12-1**] 01:40PM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-3+ POLYCHROM-1+ TARGET-OCCASIONAL BURR-OCCASIONAL STIPPLED-OCCASIONAL FRAGMENT-OCCASIONAL [**2166-12-1**] 01:40PM PLT COUNT-386 Chemistries [**2166-12-1**] 01:40PM GLUCOSE-235* UREA N-90* CREAT-3.1*# SODIUM-128* POTASSIUM-8.0* CHLORIDE-100 TOTAL CO2-13* ANION GAP-23* [**2166-12-1**] 01:40PM TOT PROT-8.0 CALCIUM-8.9 PHOSPHATE-3.7 MAGNESIUM-2.2 Potassium [**2166-12-1**] 01:40PM POTASSIUM-8.0* hemolyzed [**2166-12-1**] 04:18PM K+-6.5* [**2166-12-1**] 08:10PM POTASSIUM-6.6* [**2166-12-1**] 09:59PM K+-6.0* LFTs [**2166-12-1**] 01:40PM ALT(SGPT)-1293* AST(SGOT)-1206* ALK PHOS-584* TOT BILI-2.2* [**2166-12-1**] 03:55PM LD(LDH)-1513* CK(CPK)-451* AMYLASE-43 DIR BILI-1.6* [**2166-12-1**] 03:55PM LIPASE-24 [**2166-12-1**] 03:55PM ALBUMIN-3.3* URIC ACID-13.4* U/A, urine lytes [**2166-12-1**] 05:50PM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.014 [**2166-12-1**] 05:50PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [**2166-12-1**] 05:50PM URINE RBC-[**2-7**]* WBC-[**5-15**]* BACTERIA-MANY YEAST-NONE EPI-[**5-15**] [**2166-12-1**] 05:50PM URINE EOS-NEGATIVE [**2166-12-1**] 05:50PM URINE HOURS-RANDOM UREA N-617 CREAT-146 SODIUM-17 POTASSIUM-38 [**2166-12-1**] 05:50PM URINE OSMOLAL-384 Hepatitis Serologies [**2166-12-1**] 03:55PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc Ab-NEGATIVE [**2166-12-1**] 03:55PM HCV Ab-NEGATIVE [**2166-12-3**]: [**Doctor First Name **] negative, Anti-smooth Muscle Ab negative Other [**2166-12-1**] 03:55PM ACETMNPHN-NEG [**2166-12-1**] 03:55PM ACETONE-NEG [**2166-12-1**] 03:55PM TSH-1.1 C3 89 (90-180), C4 26 (10-40) HIV negative Lipase 85 GGT 473 EBV IgM neg, IgG +, PCR- pending HSV 1&2- DAT negative, cultures pending VZV cultures negative CMV IgG, IgM negative monospot negative Iron Studies TIBC 212 Iron 58 Transferrin 163 EKG sinus at 104, slightly peaked T waves Abd U/S IMPRESSION: Normal liver vasculature. No ascites. No hydronephrosis. No biliary dilatation. CXR IMPRESSION: No CHF or pneumonia. CXR IMPRESSION: No central venous catheter identified. No acute cardiopulmonary disease. Culture data ([**12-2**]) BCx negative UCx negative DFA influenxa negative, culture negative Liver Bx [**12-8**]: Preliminary report shows acute and chronic inflammation, plasma cells, eos and neutrophilic infiltrate. No viral inclusions, no granulomas, no biliary disease. Most c/w drug-mediated process Brief Hospital Course: 34 y/o F with allergic reaction (pruritis and angioedema), acute renal failure, and acute hepatitis likely secondary to Allopurinol. A brief [**Hospital 11822**] hospital course is outlined below. 1. Acute Drug-Induced Hepatitis- The patient presented to clinic on [**12-1**] with intense pruritis and dyspnea. This progressed to facial and lip swelling and increased difficulty breathing upon arrival to the ED. She was initiated on benadryl, steroids and H2 blockers and admitted to the MICU for overnight monitoring. She remained respiratory stable and hemodynamically stable in the MICU and did not require intubation or pressor support. By labs, she was noted to have acute hepatitis with AST=1206 ALT=1293 Tbili=584 and Alk/Phos=2.2. In addition, she was in acute renal failure with Cr =3.1. Her baseline creatinine was 1.2-1.3. She was hydrated overnight with good reversal of her renal function to 1.8 the following morning. Liver ultrasound was performed and demonstrated no mass or ductal disease. Given her clinical stability she was transferred to the general medicine service on hospital day #2. On the medicine service, IVF hydration continued. Ace-I, lasix, statin, NSAIDs and allopurinol all held. Allopurinol had been discontinued since [**11-21**] as documented in previous notes. In addition, zestril and lasix had been held since [**11-27**] as documented in OMR notes. Her LFTs trended down as she was off all these medications. By [**12-6**], hospital day#6, AST=753 and ALT=636 with conservative management. Of note, she was seen and evaluated by the hepatology servie from the beginning of her admission. She was started on ursodiol given her hyperbilirubinemia and intense itching. However neither of these improved much with medication. Itching persisted despite symptomatic management with anti-histamines, sarna lotion, H2-blockers and eucerin cream. Beginning [**12-7**] her LFT's again began to climb. The only new medicine she had been started on was fexofenadine and levofloxacin (3 day treatment for UTI), both of which were discontinued. Liver serologies had been sent and were all negative. Hep A,B,C negative. [**Doctor First Name **] and Anti-smooth muscle antibody negative. Monospot negative. CMV negative. HSV 1 and 2 negative. Given her climbing LFTs (AST had now trended back up >1000, with total bili=3.1) she was scheduled for liver biopsy on [**2166-12-8**]. Liver biopsy was performed and demonstrated acute and chronic inflammation, plasma cells, eoinophils and neutrophilic infiltrate. No viral inclusions, no granulomas, no biliary disease. The process was thought to be most consistent with a drug mediated reaction. Although allopurinol toxicity generally causes granulomatous hepatitis and there were no granulomas present, allopurinol was still thought to be the most likely culprit medication. She was initiated on steroids with prednisone 40mg PO Qday on [**12-10**]. Following initiation of her steroid regimen, all indices of her LFT's began to decline. By [**12-15**], the day of discharge, AST=164 ALT=320 and Tbili=1.6. She also noticed improvement in her pruritis and much improved reduction of her facial and lip swelling. She was discharged home with a steroid taper and follow-up scheduled with her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on [**1-1**] and Hepatology on [**12-25**]. 2. Angioedema/Pruritis: Allergic reaction thought to be secondary to allopurinol. Other potential precipitating medications included zestril, NSAIDS (naproxyn) and lipitor. She was seen and evaluated by the Allergy service during her hospital stay. It was recommended that she never recieve allopurinol again. In addition, NSAIDS,zestril and lipitor should be avoided until her labs normalize and she remains clinically stable. 3. Acute on CRI: Her baseline Cr is 1.2-1.3 based on OMR notes. On presentation, her Creatinine was elevated at 3.1. This improved quickly with hydration. Cr fell to 1.8 by hospital day number 2, and eventually her creatinine came down to 0.9. On the day of discharge this is where she is at. 4. UTI- Urinalysis on [**12-4**] showed moderate leukocytes and >50 bacteria, so she was started on a 3 day course of levofloxacin which was completed on [**2166-12-7**]. 5. ID- Urine and blood cultures from admission were negative as were subsequent culture specimens. No infectious etiology to her hepatitis was identified, as outlined above (also see results section). 6. Diabetes I- The patient has long-standing type I diabetes since the age of 13. She has documented retinopathy, neuropathy and nephropathy. Her blood sugars remained fairly well controlled until starting steroids. Her blood sugars were noted to be >400 on several occasions after starting prednisone, despite increasing her NPH regimen. [**Last Name (un) **] was consulted and evaluated the patient. She had previously been followed by Dr. [**Last Name (STitle) 3617**] at [**Last Name (un) **], most recently seen in [**2164**]. Her NPH was eventually titrated up to 80mg qam and 80mg qhs. In addition, she was switched from regular to Humalog sliding scale and her scale was titrated up as well. She will be discharged on this regimen with close follow-up with [**Last Name (un) **]. Her first follow-up appointment will be on [**12-17**] with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**]. The patient does not qualify for services, but she feels comfortable using her sliding scale and she reports she'll be staying with her sister who is a nurse. 7. Asthma- continued on albuterol inhalers prn 8. Anemia- Given 1U PRBC on [**12-7**] in setting of her liver biopsy when she had a hct of 27 (hct=28 on admission). Her hematocrit increased appropriately following transfusion and has remained stable at 33. Medications on Admission: Lipitor 80 mg daily NPH 32 units qam, qhs; 10 novalog q breakfast, dinner Lisinopril 20mg daily Lasix 80mg daily Flovent qAM Albuterol prn Allopurinol- started 1 month ago and stopped 1 week ago Naproxyn- used sporadically for joint arthritis; at most 1 per day; Tylenol- up to two per day for joint pains Remote h/o using lipitor med hx: started allopurinol in the middle of [**Month (only) 321**] and stopped on [**11-21**] because of increased creatinine. Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. Disp:*1 tube* Refills:*3* 3. Lansoprazole 30 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* 4. Diphenhydramine HCl 25 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) as needed for itching. Disp:*30 Capsule(s)* Refills:*3* 5. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl Topical QID (4 times a day). 6. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Prednisone 10 mg Tablets, Dose Pack Sig: per taper below Tablets, Dose Pack PO once a day: 30mg(3 tabs)x 4days 20mg(2 tabs)x 5days 15mg(1.5 tabs)x5days 10mg(1 tab) x 5days 5mg(0.5tab)x 5days, then Stop. Disp:*40 Tablets, Dose Pack(s)* Refills:*0* 8. Insulin NPH Human Recomb 100 unit/mL Syringe Sig: Eighty (80) Units Subcutaneous qam,qhs. Disp:*30 Units* Refills:*2* 9. Insulin Lispro (Human) 100 unit/mL Solution Sig: see sliding scale Subcutaneous qac,qhs. Disp:*30 syringes* Refills:*2* 10. Syringe Syringe Sig: One (1) Miscell. once a day. Disp:*60 syringes* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis 1. Acute drug-induced hepatitis 2. Angioedema 3. Pruritis 4. DMI 5. HTN Secondary Diagnosis 1. hyperlipidemia 2. Asthma 3. Gout Discharge Condition: good. Discharge Instructions: Please contact PCP for any fevers, chills, shortness of breath, abdominal pain, increased itching, or confusion. Please check your blood sugars 4 times/day and take your insulin as scheduled based on the sliding scale. If you have questions with your regimen please contact your PCP or [**Name (NI) **]. Follow-up with [**Last Name (un) **] on [**12-17**] as scheduled below. Followup Instructions: Please follow-up at [**Hospital **] Clinic Wed [**12-17**] at 9:30am with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**] NP. Provider: [**Name10 (NameIs) 1947**],[**Name11 (NameIs) 722**] [**Hospital 1947**] CLINIC Where: CC-2 [**Hospital 1947**] UNIT Phone:[**Telephone/Fax (1) 3153**] Date/Time:[**2166-12-23**] 2:30 Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], M.D. Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2167-1-1**] 2:20 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6719**], M.D. Where: [**Hospital6 29**] [**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2167-2-17**] 4:45 [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

[ "250.41", "V58.67", "357.2", "E944.7", "274.9", "250.51", "276.1", "250.61", "362.01", "584.9", "729.1", "276.7", "995.1", "403.91", "698.8", "573.3", "285.9", "583.81", "272.4" ]

icd9cm

[ [ [] ] ]

[ "50.11", "99.04", "38.93" ]

icd9pcs

[ [ [] ] ]

13926, 13932

6299, 12108

300, 318

14122, 14129

3513, 6276

14554, 15402

2477, 2486

12618, 13903

13953, 14101

12134, 12595

14153, 14531

2501, 3494

246, 262

346, 1956

1978, 2195

2211, 2461

7,911

102,407

21927+57267

Discharge summary

report+addendum

Admission Date: [**2115-9-17**] Discharge Date: [**2115-10-9**] Date of Birth: [**2044-5-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1711**] Chief Complaint: Increased fatigue and dyspnea on exertion Major Surgical or Invasive Procedure: s/p cath History of Present Illness: 71 yo male with 100py smoking history transferred from OSH for cath. The patient had not seen a doctor in over 50 years. he was seen by his wife's PCP on day of admission, and was found to have CHF by CXR. The patient was sent to [**Hospital3 3583**] ED and found to be hypertensive to 211/90 with EKG changes of inferior and lateral Q waves and ST elevations, 92% on RA, and positive cardiac enzymes (Trop I 0.038 --> 0.210). He was given NTP, lasix, aspirin, plavix 300mg x 1, heparin gtt, and lopressor 25mg po x1. he was transferred to [**Hospital1 18**] for cath. In the Cath lab, HD, RA 10, PC WP 27, CO2.0. He was found to have triple [**Last Name (un) 12599**] disease with mild LAD stenosis (feeding the Cx) so effective LM. Of note, pt had increased DOE x 2 weeks. No CP, palpitations. Occassional cough productive of yellow sputum. No fevers/chills, leg edema, orthopnea, PND, high salt intake or change in diet. Past Medical History: None Social History: lives with wife 100 pack year smoking history remote etoh h/o asbestos exposure Family History: nc Physical Exam: HR: 78 BP: 154/71 RR: 17 92% on 4 liters GEN: NAD HEENT: JVP -11 cm CV: RRR, nl s1, s2, no M/R/G Pulm: Bibasilar crackles, expiratory wheezes Abd: soft, NT, ND Femoral: 2+ pulses, blt bruits ext: no c/c/e R TP pulse faint, dopperable R DP, L TP, L DP Pertinent Results: [**2115-9-17**] 09:48PM CK(CPK)-307* [**2115-9-17**] 09:48PM CK-MB-7 [**2115-9-17**] 02:50PM TYPE-ART PO2-115* PCO2-46* PH-7.34* TOTAL CO2-26 BASE XS--1 [**2115-9-17**] 02:40PM GLUCOSE-119* UREA N-35* CREAT-1.2 SODIUM-138 POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-24 ANION GAP-15 [**2115-9-17**] 02:40PM NEUTS-72.8* LYMPHS-18.9 MONOS-6.5 EOS-1.3 BASOS-0.5 [**2115-9-17**] 08:50AM WBC-10.4 RBC-4.54* HGB-14.3 HCT-41.4 MCV-91 MCH-31.5 MCHC-34.4 RDW-14.4 [**2115-9-17**] 08:50AM PLT COUNT-233 [**2115-9-17**] 07:00AM CK-MB-8 cTropnT-0.21* Echo: Conclusions: 1. The left atrium is mildly dilated. 2. The left ventricular cavity is mildly dilated. There is severe global left ventricular hypokinesis with apical akinesis. Overall left ventricular systolic function is severely depressed. (< 30 EF) 3. The aortic root is mildly dilated. 4. The aortic valve leaflets are moderately thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Mild (1+) aortic regurgitation is seen. 5. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. HEMODYNAMICS RESULTS BODY SURFACE AREA: 2.06 m2 HEMOGLOBIN: 14.3 gms % FICK **PRESSURES RIGHT ATRIUM {a/v/m} 11/13/9 RIGHT VENTRICLE {s/ed} 54/16 PULMONARY ARTERY {s/d/m} 54/18/30 PULMONARY WEDGE {a/v/m} 31/35/27 AORTA {s/d/m} 169/85/119 **CARDIAC OUTPUT HEART RATE {beats/min} 80 RHYTHM SINUS O2 CONS. IND {ml/min/m2} 125 A-V O2 DIFFERENCE {ml/ltr} 60 CARD. OP/IND FICK {l/mn/m2} 4.3/2.1 **RESISTANCES SYSTEMIC VASC. RESISTANCE 2047 PULMONARY VASC. RESISTANCE 56 **% SATURATION DATA (NL) SVC LOW 67 PA MAIN 68 AO 99 OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed. **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM **RIGHT CORONARY 1) PROXIMAL RCA DISCRETE 60,80 2) MID RCA NORMAL 2A) ACUTE MARGINAL NORMAL 3) DISTAL RCA DISCRETE 60 4) R-PDA DIFFUSELY DISEASED 99 4A) R-POST-LAT DIFFUSELY DISEASED 4B) R-LV NORMAL **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM **LEFT CORONARY 5) LEFT MAIN TUBULAR 50 6) PROXIMAL LAD NORMAL 6A) SEPTAL-1 NORMAL 7) MID-LAD DIFFUSELY DISEASED 90 8) DISTAL LAD NORMAL 9) DIAGONAL-1 NORMAL 10) DIAGONAL-2 DISCRETE 60 12) PROXIMAL CX DISCRETE 90 13) MID CX NORMAL 13A) DISTAL CX NORMAL 14) OBTUSE MARGINAL-1 DIFFUSELY DISEASED 99 15) OBTUSE MARGINAL-2 DIFFUSELY DISEASED 99 TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 53 minutes. Arterial time = 39 minutes. Fluoro time = 7.1 minutes. Contrast: Non-ionic low osmolar (isovue, optiray...), vol 100 ml, Indications - Hemodynamic Premedications: ASA 325 mg P.O. Anesthesia: 1% Lidocaine subq. Anticoagulation: Other medication: Fentanyl 25 mcg IV Integrilin 7.5 cc/hr IV Furosemide 40 mg IV TNG 40-200 mcg/min IV Midazolam 0.5 mg IV Cardiac Cath Supplies Used: - ARROW, ULTRA 8, 40CC 200CC MALLINCRODT, OPTIRAY 100CC 150CC MALLINCRODT, OPTIRAY 100CC COMMENTS: 1. Coronary angiography of this right dominant circulation revealed severe three vessel coronary artery disease. The LMCA had a distal 50% tapering. The LAD was diffusely diseased and had a 90% stenosis in the mid vessel between moderate sized D1 and D2 branches. D2 had a 60% narrowing. The LCX had a 90% ostial lesion and supplied small OM1 and OM2 branches before terminating in the AV groove. Both OM branches were diffusely diseased and sub-totally occluded. The RCA was diffusely diseased with a 60-80% stenoses in the proximal vessel and a 60% distal narrowing. A moderate sized PDA was subtotally occluded and appeared to fill in part via L->R collaterals. 2. Resting hemodynamics revealed markedly elevated filling pressures with a mean PCWP of 27 mmHg in the setting of moderate to severe systemic arterial hypertension. There was evidence of moderate pulmonary hypertension with PA pressures of 50/18/30. The cardiac output was mildly reduced at 4.3 L/min. No gradient across the aortic valve was detected. 3. Left ventriculography was not performed due to the patient's elevated filling pressures and recent non-invasive assessment of his underlying LVEF. 4. Distal aortography demonstrated moderate distal aortic disease as well as disease in the external iliacs. 5. An intra-aortic balloon pump was placed at the conclusion of the case without known complication. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Moderate pulmonary hypertension. 3. Successful placement of an IABP. ATTENDING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) 900**] [**Name Initial (NameIs) **]. Brief Hospital Course: 1. Myocardial Infarction: The patient had a large ST elevation MI. At cath, he was found to have 3VD and markedly elevated filling pressures with a wedge of 27 and moderate pulmonary hypertension and a IABP was placed in hopes that the patient would go the CABG. Echo on admission revealed severe LV global hypokinesis. During the days following the diagnostic cath, he was not a surgical candidate given his mental status (see below). He was taken back for high-risk catherization and received 4 [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 10157**] to the LAD lesion. He was placed on Plavix, BB, ASA, Statin, and Acei. He will continued the Plavix for at least 9 months. His ACE-I and BB can be titrated up as his blood pressure and kidney function will tolerate. 2. Congestive Heart Failure - Given patients elevated filling pressures and chest x-ray consistent with failure, patient was diuresed in house. He was given Lasix on a prn basis. As his oral intake increases, he may need daily Lasix. 3. Asystole/Apnea: The patient had his first asystolic pause on [**9-18**] which was a 7 second pause with junctional escape. This was felt to be a vagal episode as these occurred in the setting of sleep apnea, heavy sedation, and were presence by bradycardia. The pauses became more frequent and EP was consulted after the patient had an 18 second asymptomatic pause. At that time, his BB was held and EP thought that he did not need a pacemaker given that these were vagal episodes. Since these were related to his sleep apnea, we decided against starting BiPap given the patients tenuous mental status and that he would not tolerate it. The BB was added back very slowly, however the patient had pauses of up to 30 seconds on the days between [**10-1**] and [**10-2**]. During these pauses, he would be awake, bradycardic, his respirations would cease, and would be responsive with a preserved blood pressure. However on [**10-2**] he syncopized during a 36 second pause, he was transcutaneously paced and went intubated for an emergent pacer placement. He received a DDI pacer with a lower rate of 50 bpm and an ICD. He will need to follow up in the device clinic on [**10-9**]. 4. Melana - The patient had multiple episodes of melana when he first arrived to the hospital. He was transfused twice for these episodes. Since his mental status was unstable and it was felt that he would not be able to corporate with a colonoscopy or EGD, he was taken for a virtual colonoscopy which revealed a thickened area of his sigmoid colon. By sigmoidoscopy, he had a small polyp that was non-bleeding that likely not responsible for this melana. He again had melana on [**10-5**] and his HCT dropped to 26. He was transfused 1 unit and had an EGD and colonoscopy which showed gastritis and two non-bleeding angioectasias which were cauterized. In addition, the patient had multiple non bleeding diverticular lesions throughout the colon. He will need to be on a high fiber diet as an outpatient and have a repeat colonoscopy in 5 years. If the patient continued to have GI bleeding, he should have a push enteroscopy for cauterization of AVMs. He should continue Protonix and have H. Pylori serologies checked as an outpatient. 5. UTI/phimosis/Foley trauma - Patient was seen by urology in house for severe phimosis and a Foley was blindly placed and patient was put on Ciprofloxacin for ten days as UTI prophylaxis. He then partially removed his Foley catheter and had significant prostate trauma from this. Urology inserted a second Foley and the patient passed several clots and had a good amount of hematuria. The Foley was discontinued on [**10-7**] and the patient was able to void without problems. The patient should follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] as an outpatient regarding his phimosis. 6. Mental Status: When the patient was admitted, the patient did not have mental status changes. However, he became acutely delirious after he returned from his first cath and had a balloon pump in. He was unable to be restrained with IV and PO medications. Therefore, so that he did not pull out his IABP, he was intubated and sedated. The IABP was removed on [**9-18**] and he was extubated on [**9-19**]. He continued to be severely delirious requiring standing and prn Haldol. He was seen by psychiatry who felt that this was all delerium and hypoxia. Repeat ABGs did not revelad significant hypoxia or hypercarbia. He continued to wax and wane with his mental status often not oriented to place or time. This culminated to becoming unresponsive and frequently apneic on the day of his 30 second asystolic pauses. Following his pacemeker, his mental status dramatically improved. He no longer needed psychoactive medications or a sitter. He continues to have slight confusion at night which is improving with time. 7. Apnea: The patient was observed to have sleep apnea. However, as his mental status waned, and he had more severe asystolic episodes, he became apneic while awake for episodes for up to 30 seconds. A pulmonary consult was obtained and this was though to be both central and obstructive in nature. The patient was tried on BiPap and continued to have apneic pauses. In addition, as he became more responsive, he would not tolerate the machine. After the patient received his pacemaker, he did not have any further witnessed events of apnea. He will need to follow up in the pulmonary clinic for a sleep study. 8. Pneumonia: Several days after admission, the patient was diagnosed with a retrocardiac infiltrate on chest xray. Sputum culture demonstrated MRSA. The patient was treated with a 7 day course of vancomycin. Following the second intubation, the patient developed a RLL infiltrate though to be due to aspiration. He was treated for 6 days on Zosyn and then switched to Levofloxacin and Flagyl. His lung exam markedly improved and he was breathing with a O2 sat in the high 90s on room air. The levofloxacin and Flagyl will need to be continued until [**10-17**]. He will also need to have a follow up chest xray to confirm resolution of his infiltrate. 9. Acute vs. chronic renal insufficency - The patient was admitted with a creatinine of 1.2, with his baseline unknown. his creatine steadidly rose to a peak of 2.5 though to be due to intravascular depletion secondary to CHF and contrast nephropathy. Over the last week of his hospital stay, his creatinine decreased to 1.6. This can be monitored as an outpatient. 10. Anemia: The patient recieved several transfusions during his three weeks stay. His anemia was though to be due to melana and chronic disease. This can be worked up further as an outpatient. His hematocrit was 27 on day of discharge and he was transfused 1 unit. Medications on Admission: none Discharge Medications: 1. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO QD (). 5. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-30**] Sprays Nasal PRN (as needed). 6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO once a day. 9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 8 days. 10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 8 days. Discharge Disposition: Extended Care Facility: Lifecare Center of [**Location (un) 3320**] Discharge Diagnosis: Asystole myocardial infarction delerium phimosis pneumonia sleep apnea acute renal failure Discharge Condition: good Discharge Instructions: Call your cardiologist if you have chest pain. If you have another episode of dark tarry stools, call your PCP. Take all your medications as prescribed. Never stop the Plavix for the nest 9 months unless a cardiologist tells you to. Followup Instructions: You have a PCP appointment on Tuesday [**2122-10-21**]:15AM with Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **]. Call [**Telephone/Fax (1) 18696**] for directions. Follow up with your cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5310**] - [**Telephone/Fax (1) 5315**]- Monday, [**11-4**] 1:30PM. Call for directions. Call [**Telephone/Fax (1) 21817**] if you have any questions about your pacemaker. This is the phone number to the device clinic. Follow up with urology - Dr. [**First Name (STitle) **] [**Name (STitle) **] - appointment on [**10-28**] at 2:00 [**Hospital **] clinic is located on [**Location (un) 470**] of [**Hospital Ward Name 23**] Building at [**Hospital1 **] [**Last Name (Titles) 516**] ([**Street Address(2) 57460**]) Follow up with Pulmonary for a sleep study. Name: [**Known lastname 10670**],[**Known firstname 2636**] Unit No: [**Numeric Identifier 10671**] Admission Date: [**2115-9-17**] Discharge Date: [**2115-10-9**] Date of Birth: [**2044-5-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 713**] Chief Complaint: MI Major Surgical or Invasive Procedure: Cardiac catherization x2 pacer placement intubation x2 sigmoidoscopy EGD colonoscopy bronchoscopy Brief Hospital Course: The patient has the following appointment below Discharge Disposition: Extended Care Facility: Lifecare Center of [**Location (un) 1541**] Discharge Diagnosis: Asystole myocardial infarction delerium phimosis pneumonia sleep apnea acute renal failure Discharge Condition: good Discharge Instructions: Call your cardiologist if you have chest pain. If you have another episode of dark tarry stools, call your PCP. Take all your medications as prescribed. Never stop the Plavix for the nest 9 months unless a cardiologist tells you to. Followup Instructions: You have an appointment in the pacemaker clinic - Provider: [**Name10 (NameIs) 1727**] CLINIC Where: [**Hospital6 189**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 1728**] or [**Telephone/Fax (1) 4004**] Date/Time:[**2115-11-8**] 11:30. Call for directions. [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 714**] MD [**MD Number(1) 715**] Completed by:[**2115-10-9**]

[ "E879.8", "507.0", "780.57", "401.9", "427.5", "V15.84", "428.0", "788.29", "537.83", "605", "482.41", "294.8", "307.9", "867.0", "414.8", "V64.1", "285.29", "562.10", "410.71", "599.7", "416.8", "799.0", "V09.0", "599.0", "414.01", "305.1", "E928.9", "518.81", "211.3", "584.5", "458.29", "285.1" ]

icd9cm

[ [ [] ] ]

[ "45.23", "36.05", "00.13", "99.04", "89.45", "99.20", "89.64", "36.06", "96.04", "37.94", "37.23", "45.24", "97.44", "93.90", "38.93", "36.07", "37.78", "96.71", "44.43", "88.56", "37.61" ]

icd9pcs

[ [ [] ] ]

16186, 16256

16114, 16163

15991, 16091

16391, 16397

1754, 4166

16681, 17099

1462, 1466

13288, 14180

16277, 16370

13259, 13265

6225, 6441

16421, 16658

1481, 1735

4185, 6208

15949, 15953

395, 1321

10326, 13233

1343, 1349

1365, 1446

30,646

188,007

33055

Discharge summary

report

Admission Date: [**2107-12-21**] Discharge Date: [**2107-12-27**] Date of Birth: [**2060-4-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: Facial and bilateral upper extremity swelling Major Surgical or Invasive Procedure: angiography upper extremities bilaterally [**12-24**] R.Midline placement [**12-22**] History of Present Illness: Ms. [**Known lastname **] is a 47 year-old man with a history of Down's Syndrome, DMII, ESRD, HTN, Hyperlipidemia presenting with worsening of facial and bilateral upper extremity swelling L>R since yesterday. . Approximately two weeks ago, the patient was admitted to an OSH and had his left-sided HD catheter replaced. During this admission, he had an episode of hypotension, though no further details are known. He was discharge on a tapering course of prednisone. . Over the last week, the [**Hospital 228**] health care proxy has noted increased facial and bilateral upper extremity swelling with acute worsened over the past 24hrs. She noted him to be uncomfortable, breathing heavily and holding his head as if he had a headache. He also had a mild fever of 99.5 yesterday. Past Medical History: 1. Down's Syndrome 2. End-stage renal disease 3. Diabetes mellitus 4. Hypertension 5. Hyperlipidemia Social History: lives with his sister, who is his primary caretaker Family History: Diabetes in both parents and hypertension and emphysema. Physical Exam: VS- 97.5 122/60 94 18 98%RA General - Extremely swollen face and upper extremities bilaterally with a protruding [**Last Name (un) 2599**] and multiple areas of echymoses in upper extremities. he appears to be in NAD. CV - RRR, NL S1/S2, No m/r/g Pulm - Clear Abdomen - Soft, NT, ND, +NABS Extremities - Significant facial edema and upper extremity edema bilaterally; lower extremitities without edema Skin- patches of echymosis in upper extremities bilaterally, normal cap refill Pertinent Results: ADMISSION LABS [**2107-12-21**] 04:15AM BLOOD WBC-10.1 RBC-4.01* Hgb-12.8* Hct-40.0 MCV-100* MCH-31.9 MCHC-32.0 RDW-23.3* Plt Ct-152 [**2107-12-21**] 04:15AM BLOOD Neuts-83.9* Lymphs-12.4* Monos-2.9 Eos-0.7 Baso-0.1 [**2107-12-21**] 04:15AM BLOOD Plt Ct-152 [**2107-12-21**] 06:25PM BLOOD PT-14.2* PTT-150.0* INR(PT)-1.2* [**2107-12-22**] 11:21AM BLOOD Fibrino-592* [**2107-12-22**] 11:21AM BLOOD Ret Man-8.0* [**2107-12-21**] 04:15AM BLOOD Glucose-76 UreaN-100* Creat-6.8* Na-136 K-3.7 Cl-94* HCO3-26 AnGap-20 [**2107-12-22**] 11:21AM BLOOD LD(LDH)-283* TotBili-1.2 DirBili-0.3 IndBili-0.9 [**2107-12-22**] 06:22AM BLOOD Calcium-6.1* Phos-10.2* Mg-2.1 [**2107-12-22**] 11:21AM BLOOD Hapto-186 [**2107-12-22**] 11:21AM BLOOD Hapto-186 [**2107-12-23**] 03:47AM BLOOD calTIBC-217* Ferritn-841* TRF-167* IMAGING: [**12-21**] CT chest Thrombosis of the right subclavian and brachiocephalic veins. SVC opacifies well via collateral flow through the chest wall. Limited assessment of the left subclavian vein due to right upper extremity injection. Lack of opacification of the internal jugular veins could possibly be due to timing of the scan. These vessels could be further evaluated with Doppler [**Name (NI) 13416**], if needed. . [**12-22**] Head CT Thrombosis of the right subclavian and brachiocephalic veins. SVC opacifies well via collateral flow through the chest wall. Limited assessment of the left subclavian vein due to right upper extremity injection. Lack of opacification of the internal jugular veins could possibly be due to timing of the scan. These vessels could be further evaluated with Doppler [**Name (NI) 13416**], if needed. . [**12-22**] Bilateral Subclavian Angiography Bilateral arm venograms showed bilateral subclavian vein occlusion, with profuse collateral vein formation, likely resultant from stenosis and thrombosis. Multiple attempts to cross the right subclavian occlusion were unsuccessful, likely due to its chronic nature. There were no immediate complications. . Brief Hospital Course: Mr. [**Known lastname **] is a 47 man with Down's Syndrome, DMII, ESRD, HTN and Hyperlipidemia who presented with evolving SVC syndrome over the last 24hrs vs chronic clot. His sister (who is his HCP) had noticed that he had upper extremitiy and facial swelling over the past week but had acutely worsened over the 24 hours prior to admission. He was taken to [**Hospital6 3105**] 2 weeks prior to admission for changing of his left IJ over a wire, had transient hypotension and had been started on a steroid taper. 1) SVC syndrome His presentation (face and upper extremity swelling) was concerning for SVC syndrome. He showed no signs of respiratory compromise. He had a CT done that showed a clot in left subclavian with with SVC filling due to collaterals suggestive of chronic nature. A heparin drip was initiated in the ED. As he was stable he was initially admitted to the medical floor, however clinically he had acute swelling of his face which continued to worsen despite heparin therapy. He was transferred to MICU for close observation. He was taken to angio the following day to explore whether a stent could be placed but clot was visualized in the right and left IJ and subclavian and no stent could be placed. He was continued on the heparin gtt and began to improve clinically. He was started on coumadin and transferred to the floor. He was discharged home with VNA services once INR theraputic. INR supratheraputic at 4.6 on discharge, no concern for bleeding, and his HCP was advised to hold his coumadin for 48 hours and follow up with coumadin clinic at PCP's office for dosing. [**Hospital 197**] clinic follow up arranged prior to d/c. He will need life long anticoagulation. 2) End-stage renal disease: Throughout his hospitalization his electrolytes, acid/base, fluid status remained relatively stable. He continued to be dialyzed through his L subclavian dialysis catheter which was surrounded by clot. He was continued on his outpatient schedule of dialysis, M,W,T,F. He was continued on nephrocaps, calcium acetate, sevelamer. Dialysis team was in contact with his outpatient nephrologist. 3) Anemia: Hct 33, stable. MCV 98. Labs do not suggest hemolysis. Iron studies suggest anemia of chronic disease. HCT remained stable throughout admission. 4)Hypertension - he was restarted and discharged on his outpatient regimen of lisinopril [**Hospital1 **]. 5)Hyperlipidemia- he was continued on lipitor 6)Hypothyroidism- he was continued on levothyroxine 7) Type II Diabetes: he was continued on glipizide xl 2.5 mg daily. Also continued Aspirin. 8) Code Status: DNR/DNI (discussed with HCP/sister on [**2106-12-21**]) Medications on Admission: 1 .Asprin 81mg 2. Lipitor 10mg qhs 3. Lisinopril 10mg qd 4. Levothyroxine 88mg 5. Glipizide 12qam 6. Renagel 2 w/meals 7. Nephrocaps 1 daily qhs 8. Phoslo 667 mg 1 with meals 9. Prednisone 5mg qd Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO DAILY (Daily). 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 8. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. Warfarin 2.5 mg Tablet Sig: take as directed by coumadin clinic Tablet PO as directed: do not take any until after talking with coumadin clinic nurse [**First Name (Titles) **] [**Last Name (Titles) **]. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: personal touch Discharge Diagnosis: Thrombosis of bilateral subclavian veins and right internal jugular vein. SVC Syndrome (improved since admission) . Secondary Diagnoses End Stage Renal Disease on hemodialysis Hypertension Hyperlipidemia Hypothyroidism Type II DM Discharge Condition: Stable Supratheraputic INR 4.6 Still with head and neck swelling but significantly improved since admission with no respiratory distress, breathing comfortable with out supplemental oxygen. Discharge Instructions: You were admitted to the hospital because of concerns about swelling of your head and face as well as difficulty breathing. You were found to have occlusion of veins in your arms and neck, specifically subclavian veins in both arms and the right internal jugular vein. You were treated with blood thinners. Coumadin therapy was started and you were treated with heparin until your INR (coumadin blood level) was theraputic. You will have to have frequent blood draws to check your INR, or level of coumadin. You will be followed by the coumadin nurse at Dr. [**Name (NI) 76864**] office. Your coumadin level was high on discharge so you should not take coumadin tonight or Wednesday. The visiting nurses will draw your blood on [**Name (NI) 16337**] and the coumadin nurse from Dr.[**Name (NI) 1985**] office, [**First Name4 (NamePattern1) 16212**] [**Last Name (NamePattern1) 13275**] will be in touch to advise you of the dose of coumadin to take. Please call your doctor or go to the emergency department if you develop any concerning symptoms including difficulty breathing, severe headache, worsening head or neck swelling, fevers, or any other worrisome symptoms. Followup Instructions: Your coumadin blood levels will be followed by the coumadin nurse at Dr.[**Name (NI) 1985**] office, her name is [**Name (NI) 16212**] [**Name (NI) 13275**]. You have an appointment to follow up and establish care with the coumadin clinic at Dr.[**Name (NI) 1985**] office on [**2108-1-3**] at 1:40. This appointment is at [**Location (un) **] in [**Hospital1 487**]. You have an appointment scheduled to follow up with Dr. [**Last Name (STitle) **] on [**1-19**] at 4:00. You should follow up with your nephrologist, Dr.[**First Name4 (NamePattern1) 7019**] [**Last Name (NamePattern1) **] ([**Street Address(2) 76865**], [**Location (un) 7661**] MA #[**Telephone/Fax (1) 40062**]), to discuss how you will receive your dialysis in the future.

[ "758.0", "250.00", "459.2", "285.21", "272.4", "403.91", "327.23", "585.6", "453.8", "244.9" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.93", "88.67" ]

icd9pcs

[ [ [] ] ]

7935, 7980

4070, 6747

361, 448

8254, 8446

2043, 4047

9670, 10422

1469, 1527

6993, 7912

8001, 8233

6773, 6970

8470, 9647

1542, 2024

276, 323

476, 1260

1282, 1384

1400, 1453

21,283

174,606

24181

Discharge summary

report

Admission Date: [**2176-4-3**] Discharge Date: [**2176-4-23**] Date of Birth: [**2116-9-5**] Sex: M Service: MEDICINE Allergies: Caspofungin / Levaquin Attending:[**First Name3 (LF) 6169**] Chief Complaint: diarrhea Major Surgical or Invasive Procedure: none History of Present Illness: 59 y/o man with a history of AML diagnosed [**1-21**] s/p 7+3 induction on [**2175-2-4**] with persistent blasts w/o maturation in repeat marrow bx, s/p reinduction with HIDAC on [**2176-3-2**], now day #215 s/p allo stem cell transplant (HLA matched sibling-brother) in [**7-20**], presents with a 3.5 week h/o diarrhea. The pt states the diarrhea began [**3-10**], with watery brown semi-solid to solid BMs, up to 10-12 per day. He felt that he occasionally could not make it to the bathroom. No blood or mucus in the stool. He tried to limit his lactose intake, but this did not improve his diarrhea. He has not had any sick contacts, foreign travel (only recently went to [**Location (un) 7349**]), no camping. No changes in medications or new antibiotics recently. He did have a "skin rash" recently at [**Hospital **] Hospital, thought [**1-18**] levaquin. The pt was hospitalized [**Date range (1) 61436**] at [**Location (un) **], and stated that he was given IVF hydration, stool studies sent, he underwent flex sigmoidoscopy showing "rectal ulcers" that were biopsied, with path pending per pt. He says their workup was "unrevealing." During his hospitalization, he was given flagyl and levaquin, and hydrocortisone. His diarrhea has continued despite these measures. He has no abd pain, no nausea or vomiting. + low grade fevers but chills. No dark urine. No night sweats. He notes a 13 lb weight loss since [**2-29**]. Decreased energy. Poor po intake (b/c he fears that it will 'go right through him.' Eating boost tid, with soups mainly. + bloating, and the sensation of "having to have a bm" that can be as severe as a [**5-25**], but is usually a [**1-26**]. He has not taken any meds for the bloating or diarrhea until recently, when Dr. [**First Name (STitle) 1557**] told him to take Imodium. Past Medical History: Past Oncologic History: #. [**1-21**]: Initial presentation of malignancy: Pt had a routine physcial at his PCP's office that showed pancytopenia. His last CBC was one year earlier and WNL. He was admitted to [**Hospital **] hospital where a bone marrow showed acute myelogenous leukemia. The patient was referred to Dr. [**First Name (STitle) 1557**] for further treatment. Prior to seeing his PCP he felt completely well. He had not noticed any bleeding, fevers, chills, night sweats, HA, weight loss, or shortness of breath. . #. AML - Hospitalization at [**Hospital1 18**]: [**Date range (1) 61437**]: Initial bone marrow biopsy showed marrow involvement by AML evolving in a background of myelodysplastic syndrome. 90% blasts were seen on aspirate. Cytogenetics were abnormal with multiple structural and numerical aberrations. Among these are a missing 7 and 21, a deletion of 5q, additional material of undetermined origin on 17q, and 4 to 5 structurally abnormal markers. The patient was started on 7+3 therapy on [**2-4**]. He tolerated the induction well with only the development of fevers. However on day +13 of induction, he underwent repeat bone marrow which demonstrated persistent leukemia. A repeat marrow on day +20 showed a hypocellular marrow with young cells that were thought to be of normal maturation. His peripheral smear demonstrated few blasts, also thought to represent early cells of normal maturation. His peripheral smear continued to show blasts and on day +28, his marrow was re-biopsied. This showed a increase in the number of blast forms without maturation. He underwent reinduction with HIDAC starting [**2175-3-3**]. He had no mucositis or CNS dysfunction His repeat marrow on day +14 of re-induction showed 95% cellular bone marrow comprised almost exclusively of immature cells, consistent with myeloblasts. His counts were monitored closely to see if he would return with MDS or persistent AML. As his counts began to return he had noted 10% blasts in the periphery. It was felt that this could represent persistent AML versus early recovering marrow. He also developed a PNA during this admission. . ORIGINAL CYTOGENETICS: #. [**2175-2-17**] cytogenetics: 49,[**Last Name (LF) **],[**First Name3 (LF) **](5)(q11.2q33),-7,add(17)(q25),-21,+[**2-18**][cp19]/46,XY[1]; This abnormal karyotype shows multiple structural and numerical aberrations. Among these are a missing 7 and 21, a deletion of 5q, additional material of undetermined origin on 17q, and 4 to 5 structurally abnormal marker . #. 8/22/05-10/05 Hospitalization at [**Hospital1 18**]: allo transplant from brother, did well. . #. [**Hospital1 18**]: Patient was admitted [**Date range (3) 61438**] for neutropenic fever. He was discharged from that hospitalization on levofloxacin. No fever source was identified on that admission. . #. [**Date range (1) 61439**]/05: Hospitalization at [**Location (un) **]: febrile neutropenia . #. [**Date range (1) 61440**]/05: Hospitalization at [**Location (un) **]: [**1-18**] ?Klebsiella from GI tract? per pt, febrile neutropenia . #. end of [**2175-11-16**]: Hospitaliz. at [**Location (un) **]: Staph epi bacteremia, on Vanco/Cefepime, febrile neutropenia . #. The patient had a positive CMV viral load on [**2175-10-11**] at 1,600 copies (previous negative on [**10-7**]). CMV VL on [**2176-2-29**] was undetectable. . #. As of [**2-19**], the pt remains in clinical complete remission. . 1. AML (multiple cytogentic aberrations)- diagnosed [**1-21**], S/P 2. alloSCT from sibling donor 3. Depression, well controlled on medication per pt. 4. HSV-2, only 1 flare in 3 years 5. Tonsillectomy and Adenoidectomy - [**2121**] 6. HTN, well controlled on medic per pt. 7. Pulm Aspergillus 8. CMV viremia Social History: no tobacco, though smoked pipes in college X 2 years, no etoh, no IVDA. Lives in [**Location **] with wife. [**Name (NI) **] is a retired finance professor, originally worked at [**University/College **], now working at the [**Last Name (un) 61441**]. Family History: No fHX of Leukemia or lymphoma. Mother- bone cancer of unknown etiology. Father- 3 vessel bypass graft, HTN Physical Exam: Vitals: temp: 98.9 BP: 104/68 P: 89 RR: 14 O2sat: 99% RA. Wt 130 lbs, 66 inches. General: Thin CM in NAD. Breathing comfortably on RA. Well spoken. AOX3. Appropriate. + bitemporal wasting. HEENT: PERRL EOMI. MM dry, OP clear w/o lesions Neck: No lad, no jvd Lungs: CTAB CV: RRR S1 and S2 audible w/o m/r/g Abd: Soft, NT, ND, NABS, No masses. No HSM. P. vasc: 2+ DP pulses b/l. Dry skin. No cyanosis/clubbing. Neuro: CN 2-12 intact. Motor [**4-19**] throughout. Sensory [**4-19**] throughout. Gait WNL. Pertinent Results: MARROWS DURING INTITIAL DX: #. [**2175-2-22**] BM Bx: Cellular myeloid-dominant marrow with markedly left-shifted myelopoiesis and increased myeloblasts (day 20 status post myeloblative chemotherapy) Note: Although myeloblasts appear increased on the hemodilute aspirate smear, an accurate count can not be determined due to poor specimen quality. Re-biopsy is recommended if clinically indicated. . [**2175-3-2**] BM Bx: C/W AML. Immunophenotypic findings c/w involvement by AML w/an immature phenotype. . [**3-18**] BM Bx: biopsy consists of blood, cortical bone, and a few fragments of > 95% cellular bone marrow comprised almost exclusively of immature cells, consistent with myeloblasts. . MOST RECENT ECHO [**7-20**] EF >60%. The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Trace aortic regurgitation is seen. . Imaging: [**2176-4-3**]: CXR CHEST, PA AND LATERAL: An opacity is present in the left lower lobe. The remaining lungs are clear. The mediastinal and hilar contours are unremarkable. The heart is normal size. No pleural effusions are visualized. The surrounding soft tissue and osseous structures are unremarkable. IMPRESSION: Left lower lobe pneumonia. . [**2176-4-8**]: AP CHEST RADIOGRAPH: Left sided PICC line is seen with tip overlying the distal SVC. Cardiac, mediastinal, and hilar contours appear unchanged. Pulmonary vascularity remains within normal limits. Compared to prior study, the left lower lobe opacity appears slightly worse. There has also been interval increase in right lower lobe opacity, consistent with pneumonia. IMPRESSION: Bibasilar pneumonia, slightly worsened in the interval. . [**4-9**] CXR IMPRESSION: AP chest compared to [**4-4**] and 24: Bibasilar pneumonia is clearing. Upper lungs are clear. Heart size is normal. There is no appreciable pleural effusion. Tip of a left-sided central venous line projects over the SVC. Mediastinal widening at the thoracic inlet due to combination of adenopathy and fat deposition and tortuous vessels is longstanding. . CTA [**4-9**] IMPRESSION: 1. No evidence of pulmonary embolism. 2. Persistent bilateral lower lobe consolidations, also with patchy lingular involvement. The degree of consolidation is increased at the right base. . CT ABD [**4-9**] IMPRESSION: 1. Diffuse edema of the descending colon, sigmoid colon, and rectum with consistent with colitis. This finding is non-specific and may represent infectious etiology. A drug reaction if the patient is on chemotherapy could give this appearance. Less likely is ischemia as the abdominal vasculature is widely patent. Inflammatory bowel disease is also less likely. Clinical correlation is recommended. 2. No evidence for pulmonary embolus. Bilateral airspace consolidation within the lower lobes, left greater than right, consistent with pneumonia. 3. Cholelithiasis without evidence for cholecystitis with mild central biliary ductal dilatation. 4. Multiple rounded low-attenuation foci within the kidneys bilaterally, which cannot be definitively characterized as simple renal cysts. A renal ultrasound is recommended for definitive characterization. . CT HEAD [**4-9**] FINDINGS: There is no evidence of acute intracranial hemorrhage. No mass effect. No shift of normally midline structures. Bilateral ventricles are symmetric and not dilated. Note is made of right carotid artery calcification. There is fluid in bilateral ethmoid sinuses, representing sinusitis. Calcified dural plaques are seen. IMPRESSION: No acute intracranial hemorrhage. Ethmoid sinusitis. . CT CHEST [**4-19**] IMPRESSION: Improving of the bilateral lower lobe consolidation Brief Hospital Course: 59 y/o gentleman with h/o AML day 217 post allo SCT (HLA matched sibling) presents with 3.5 week h/o diarrhea, 13 lb weight loss, decr po intake. His course was complicated by bilateral lower lobe PNA requiring an admission to the ICU. . #. [**Hospital Unit Name 153**] course for desaturation/acute respiratory distress: The pt's course was complicated by PNA. On admission CXR, the pt demonstrated a LLL infiltrate. He was started on levaquin, however, his PNA worsened with chest CT the following day showing bilateral lower lobe consolidations. His coverage was broadened to include Vanco, Flagyl and Ganciclovir to cover for CMV PNA. His voriconazole was continued throughout this time. He did not require intubation. Pt's sats remained stable on face mask, now weaned down to 50% Fio2, upper 90s sats. He was suctioned and given chest PT in the ICU. His Vancomycin was discontinued, and azithromycin was added empirically for Legionella coverage (although urinary antigen negative). ID consultants continued to follow pt in the [**Hospital Unit Name 153**], and recommended sending EBV VL, 2 more sputums for PCP, [**Name10 (NameIs) **] continuing the current regimen of Cefepime (started [**4-5**]), Flagyl (started [**4-4**]), Azithro (added [**4-10**]) and Ganciclovir (started [**4-4**]), keeping a low threshold for bronch. However, the pt did not require bronchoscopy. EBV and PCP were negative. Respiratory status improved and patient was transferred back to 7 [**Hospital Ward Name 1826**] for further care. He was maintained on Albuterol/Atrovent nebs and supplemental oxygen was weaned as tolerated. Repeat Chest CT on [**2176-4-19**] showed interval improvement in pneumonia. . #. Bilateral lower lobe PNA: being covered with Cefepime/Flagyl/Voriconazole. Pt most likely has bacterial PNA given appearance with air bronchograms/consolidation seen on Chest CT. Less likely CMV PNA or MRSA PNA, although was recently hospitalized in [**Location (un) **], CT. Vancomycin discontinued and added back X 2, but now discontinued. He was being covered with Azithro for Legionella PNA though Legionella urinary ag negative while in the ICU but this was discontinued [**4-12**] after [**Hospital Unit Name 153**] call out. His PCP DFA was negative. His CMV VL was negative X 3, but do not suspect CMV PNA. Serum galactomannan negative. He was weaned from face mask to nasal cannula and saturated well with nebs and nasal cannula. Albuterol nebs and supplemental oxygen were weaned. Patient did well on room air and was followed by physical therapy. At time of discharge, patient was doing well on room air without ambulatory desaturation below 94-95%. He was discharged home on Cefpodoxime to complete 3 week course of antibiotics from time of clinical improvement. Continued Voriconazole for antifungal coverage. . #. Diarrhea, improved: DDX includes Rotavirus in immunosuppressed individual, GVHD, CMV colitis, other infectious. Less likely osmotic diarrhea, medication induced, or inflammatory. OSH report showing rectal ulcerations, biopsy: no cytopathic effect. CMV VL at OSH neg, CMV VL here negative X 3. He was given IVIg the morning after admission. The pt was on Ganciclovir IV for several days, however this was stopped after he demonstrated improvement in diarrhea. GI was consulted for possible colonoscopy with biopsy, but given improvement in diarrhea, colonoscopy was deferred. Repeat CMV VL was sent which was positive but not within detectable range, and patient was re-started on Ganciclovir; he received treatment dose for 4 days and then converted to Valganciclovir maintenance dose. At time of discharge, patient having [**1-19**] formed BMs/day, marked improvement from admission condition. Weaned down to Prednisone 10mg, to be tapered as outpatient. . # Anxiety/Depression: Continued on outpatient Ritalin, Desipramine, and Escitilopram . #. HTN: Patient with long-standing history of HTN, which improved after chemotherapy. Outpatient Metoprolol was continued and titrated up to 25mg TID. . #. Incidentaloma: CT Chest on [**2176-4-19**] showed low-density right kidney lesion which should be evaluated with ultrasound to exclude the possibility of complex cyst or malignancy. Findings were emailed to oncologist, to follow-up as outpatient. Patient without flank pain or renal insufficiency. #. FULL CODE Medications on Admission: 1. CellCept [**Pager number **] mg b.i.d. 2. Ursodiol 300mg po bid 3. Multivitamin 4. Folic acid 800mcg po qd 5. Lopressor 12.5mg po bid 6. Lexapro 20mg po qd 7. Desipramine 100mg po qd 8. Ritalin 10mg po qAM and qNoon 9. Acyclovir 400mg po tid 10. Magnesium supplement 11. Alprazolam 0.5mg po qd prn 12. Meds he has not taken in weeks: Prep H, Peptobismol, TUMS Discharge Medications: 1. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 2. Methylphenidate 10 mg Tablet Sig: Two (2) Tablet PO once a day: 1 tablet in the morning 1 tablet at noon. Disp:*60 Tablet(s)* Refills:*0* 3. Desipramine 25 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Disp:*100 Tablet(s)* Refills:*0* 4. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*0* 5. Atrovent 18 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation four times a day for 10 days. Disp:*1 trade size* Refills:*0* 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*20 Tablet(s)* Refills:*0* 8. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*14 Tablet(s)* Refills:*1* 9. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*28 Tablet(s)* Refills:*0* 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 11. Flushes Heparin and saline flushes for PICC per protocol 12. Dressing PICC dressing care and changes per protocol Discharge Disposition: Home With Service Facility: [**Hospital 5065**] Healthcare Discharge Diagnosis: Bilateral lower lobe pneumonia, presumed bacterial Diarrhea post-transplant CMV Hypertension Discharge Condition: diarrhea resolved, sat'ing well on room air Discharge Instructions: 1. Take all medications as prescribed and make all follow-up appointments. 2. If you experience fevers, chills, diarrhea, difficulty breathing, or any other concerning signs/symptoms, please contact the BMT fellow or report to the Emergency Department Followup Instructions: As instructed, please report to 7Feldberg on Thursday at 10 AM to meet with Dr. [**First Name (STitle) 1557**]. Completed by:[**2176-4-27**]

[ "482.9", "205.01", "V42.81", "110.5", "300.4", "008.61", "078.5", "799.02", "403.91", "593.9" ]

icd9cm

[ [ [] ] ]

[ "99.15", "99.14", "38.93" ]

icd9pcs

[ [ [] ] ]

16765, 16826

10643, 15008

290, 297

16963, 17009

6870, 10620

17309, 17452

6222, 6332

15430, 16742

16847, 16942

15034, 15407

17033, 17286

6347, 6851

242, 252

325, 2153

2175, 5934

5950, 6206

72,775

147,873

40298

Discharge summary

report

Admission Date: [**2170-1-5**] Discharge Date: [**2170-1-29**] Date of Birth: [**2139-7-27**] Sex: F Service: OTOLARYNGOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 8480**] Chief Complaint: Neck pain Major Surgical or Invasive Procedure: [**2170-1-14**], [**2170-1-16**]: I and D of neck infection History of Present Illness: Ms. [**Known lastname 88409**] is a 30 year-old female who presented on [**2170-1-5**] with 4 days right sided neck pain in the the lower right lateral neck and supracalivcular/apical area. She noted this because of discomfort and tenderness when pushing there. She has associated fever. She has a migraine (retroorbital and R temporal) that per her report is consistent with her chronic migraine headache. She denies sore throat, dysphagia, [**Last Name (LF) 88410**], [**First Name3 (LF) 691**] neurologic symptoms, cough, sob, rash, dyspnea on exertion, chest pain, abd pain, diarrhea, nausea, vomiting, dysuria, flank pain, GI bleeding, or lumps or bumps. Other 13pt detail ROS is negative in full. She reports negative HIV test with former PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. She reports negative PPD prior to immigrating from [**Country 16573**]. In the ED -- T 101.6, 95, 145/57, 16, 99%RA Got tylenol, Morphine 4mg, Vanco, Clinda, Unasyn Past Medical History: No surgeries No hospitalizations G2P1 - 1 miscarriage Social History: From [**Country 16573**] -- came to US 1 year ago. Works in group home for mentally retarded individuals. Non smoker, non drinker. Married with 1 child. Husband and 2yo daughter alive and well. Family History: Father died in his sleep at 76. Mother, brother, and sister are alive and well. Physical Exam: On admission: Vitals - T 99.0, 148/80, 80, 16 SpO2 100%RA Anicteric, no [**Doctor First Name **], OP dry but clear, no visible swelling Neck tnder in R inferior posterior strap area and supraclavicular area Lungs - CTA bilat COR - RRR no MRG ABD - soft, nt, no hsm EXT - no edema SKIN - no rash NEURO - a & o x3, non focal, grossly normal Pertinent Results: Admission Labs [**2170-1-5**] WBC-4.6 RBC-3.80* Hgb-12.5 Hct-36.2 MCV-95 MCH-32.9* MCHC-34.5 RDW-12.8 Plt Ct-182 Neuts-65.1 Lymphs-26.2 Monos-6.9 Eos-0.5 Baso-1.2 Glucose-100 UreaN-8 Creat-1.0 Na-140 K-4.0 Cl-102 HCO3-26 AnGap-16 ALT-15 AST-20 CK(CPK)-81 AlkPhos-35 Pertinent Data: HIV Ab-NEGATIVE QUANTIFERON(R)-TB GOLD NEGATIVE MRI NECK ([**2170-1-7**]): 1. Diffuse increased signal intensity and patchy heterogeneous enhancement in the right sternocleidomastoid muscle, soft tissues of the right carotid space, extending into the right parapharyngeal and retropharyngeal spaces as well. Nonenhancing area is noted in the retropharyngeal space, may relate to fluid collection and an evolving abscess cannot be completely excluded. MR of the C-spine can be considered for better assessment. 2. Lesser degree of enhancement in the right internal jugular vein. To correlate with color Doppler ultrasound to assess for patency. 3. Small T2 hyperintense foci in the right lobe of thyroid- need further evaluation with ultrasound. Brief Hospital Course: The patient is a 30 F who presented to [**Hospital1 18**] ED on [**2170-1-5**] with right sided neck pain. Imaging was concerning for a deep soft tissue infection/bacterial lymphadenitis. Initial CT scan and MRI of the neck confirmed a deep space/retropharyngeal space infection consistent with phlegmon. After initially having persistent fevers on Vanc/Unasyn, she was switched to Vanc/Zosyn per ID recs. During this period, she was noted to be transiently leukopenic/neutropenic, with a dropping white count along with functional neutropenia and atypical cells. Heme/onc was consulted; review of her smear revealed large atypical cells, consistent with a possible viral infection. HIV Ab and VL returned negative and EBV and CMV serologies were consistent with prior infection. After ~2 days without fever she again became febrile with elevated temperatures (as high as 105). Thus, she underwent repeat MRI on [**2170-1-14**] showing worsening of the soft tissue disease including increase in retropharyngeal fluid and necrotic lymph nodes. She was taken to the OR by ENT on [**1-14**] for drainage of neck collection and debridement of necrotic cervical lymph nodes and surrounding tissue. Intra-op findings notable for necrosis of the medial surface of the mid one third of the sternocleidomastoid muscle, primarily involving the fascia with involving some muscle fibers deep to the fascia, also some necrotic tissue of the carotid sheath fascia as well as of the fat medial to the carotid sheath and of some lymphadenopathy in the mid jugular chain around level 3. She was extubated and taken to the PACU and then to the floor post-operatively. She was continued on IV Antbiotics with vancomycin, meropenem per ID recommendations. Over the ensuing two days she developed worsening odynphagia and fevers again re-developed to Tm 105 on [**1-16**], concerning for persistent infection. She was taken to the OR on [**1-16**] for additional debridement with drainage of right parapharyngeal and retropharyngeal space fluid collection and excision of right level II lymph node, closure of venotomy right upper internal jugular vein. The patient tolerated these procedures without complications, for details please see separately dicated operative reports. The patient was kept intubated and transfered to the ICU for closer monitoring and wound changes to help further debridement. She had a penrose in place to drain the retropharynx and a three gauze in place in her neck wound. She underwent a repeat CT on [**1-18**] which should no reaccumulation of fluid or necrotic debris. The penrose was removed on [**1-18**], and replaced with a wick to help stent the retropharyngeal opening and allow drainage. She underwent twice daily dressing changes initially with three gauze soaked with 1/2 strength dakin's solution which was diluted eventually to single saline gauze s her wound showed progressive healthy granulation tissue without further evidence of necrosis. He continued on IV antibiotics per ID. Her WBC stabilized and she was aferile for four days. She was then gently diuesed to alleviate tongue swelling and subsequently extubated on [**2170-1-23**] without difficulty. Further details of her hospital course reviewed below by systems: Neuro: CV: Endocrine: on imaging, she was noted to have thyroid nodules/abnormal TSH. MRI of the neck to have a small hyperintense focus of the right lobe of the thyroid. TSH was also elevated slightly at 5.3 on admission. This finding is not interpretable in the setting of acute illness. She will need a dedicated thyroid ultrasound and re-check of her TSH once she has recovered from this acute illness. ID: ID service recommended a 2 week course of moxifloxicin on discharge. Prior to discharge, a single blood culture from [**2170-1-23**] was positive. This was thought to be skin contamination. The patient was afebrile for 48 hours prior to discharge. Cultures of the PICC tip and blood cultures were sent at the request of ID prior to discharge. Wound: The patient will follow-up with plastic surgery for closure (Dr. [**First Name (STitle) **]. Moist to dry dressing were established and assisted by VNA services. Medications on Admission: prn tylenol and NSAIDS Discharge Medications: 1. moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO once a day for 14 days. Disp:*14 Tablet(s)* Refills:*0* 2. acetaminophen Oral 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Lymphadenitis and soft tissue infection of the neck Necrotizing facscitis of the right neck Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with fever, neck pain and abnormal soft tissue appearance in the neck on CT scan concerning for infection. You were given broad spectrum antibiotics. An MRI showed an infection of the muscle of the neck. You were taken to the OR twice for debridement of necrotic tissue and lymph nodes and subsequently required dressing changes. You were intubated and in the ICU during this hospitalization. You will need to complete the antibiotic course as prescribed. Please follow up with ID regarding your antibiotic therapy. Followup Instructions: - Follow-up with the resident/fellow [**Hospital **] clinic (Dr. [**Last Name (STitle) **] in [**1-28**] weeks. Please call [**Telephone/Fax (1) 41**] to schedule an appointment. -Follow-up with Plastic surgery Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2756**]. 1 week. Call to schedule. - Follow-up with infectious diseases (Dr. [**Last Name (STitle) **], [**Last Name (un) **]). [**Telephone/Fax (1) 2756**]. [**2170-2-15**] at 9AM [**Last Name (NamePattern1) 439**] [**Last Name (un) 2443**] Building, Ground floor. [**Hospital1 18**]. Follow-up with [**Hospital 18**] medical departnment to ensure regular follow-up care by a primary care physicaion. Please follow-up at the [**Hospital1 7975**] ST. HEALTH CENTER, [**Telephone/Fax (1) 7976**]. They are located in [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]. NOTE: You currently only have pre-natal insurance which does not cover any health issues for yourself. Please come to this appt where they can help you apply for medical insurance for yourself as well. Completed by:[**2170-1-29**]

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icd9cm

[ [ [] ] ]

[ "38.93", "96.72", "00.14", "40.21", "83.09", "83.39", "39.32", "40.29", "83.45" ]

icd9pcs

[ [ [] ] ]

7754, 7811

3216, 7411

319, 381

7947, 7947

2156, 3193

8659, 9785

1701, 1782

7484, 7731

7832, 7926

7437, 7461

8098, 8636

1797, 1797

270, 281

409, 1392

1811, 2137

7962, 8074

1414, 1471

1487, 1685

74,798

111,577

54730

Discharge summary

report

Admission Date: [**2115-8-17**] Discharge Date: [**2115-8-23**] Date of Birth: [**2057-3-21**] Sex: F Service: NEUROSURGERY Allergies: Cephalosporins Attending:[**First Name3 (LF) 78**] Chief Complaint: SDH Major Surgical or Invasive Procedure: [**2115-8-17**]: Right Craniectomy and evacuation of SDH History of Present Illness: This is a 58 year old woman with history of ETOH and narcotic abuse who was found after a fall down a flight of stais. EMS arrived and took her to an OSH about 5pm. She was stuporous but moving her legs. She was intubated for airway protection. She was given Mannitol 25 g and Dilantin was started but stopped for BP changes. She was given Fentanyl/3 and Versed/50 in the [**Location (un) **]. Past Medical History: CAD [**Last Name (un) **] CA s/p colectomy Depression/Anxiety ETOH/Narcotic abuse Elevated LFT's Social History: per her estranged sister, she [**Name2 (NI) 546**] in a single family home with "transients" and abuses drugs and ETOH. No known accupation. We contact[**Name (NI) **] her sister [**Name (NI) **] [**Name (NI) 111905**] [**Telephone/Fax (1) 111906**] who is estranged from her sister and reports no other contacts for her and does not wish to be her HCP. Family History: non-contributory Physical Exam: O: 130/84 HR:99 O2Sats 100% Gen: Intubated, no corneal reflexes, no cough, no gag, Pupils: Right 3 and MR [**First Name (Titles) **] [**Last Name (Titles) 2325**] 4 MR, Right periorbital hematoma, Collar in place, No WD UE, TF LE. Pertinent Results: [**8-17**] Trauma Xray- IMPRESSION: 1. Acute left-sided rib fractures and acute right midclavicular fracture. Old bilateral rib fractures are also seen, and likely old left scapular fracture. 2. Standard positioning of endotracheal tube and orogastric tube. 3. Widening of the mediastinum for which correlation with CTA chest is recommended. 4. Bilateral airspace opacities which could reflect atelectasis but contusion or aspiration is not excluded. 5. No acute fracture or dislocation within the pelvis. [**8-17**] CT Torso- IMPRESSION: 1. Multiple fractures including a distracted fracture of T7 involving the posterior elements, right mid clavicular fracture, right scapular fracture and left rib fractures (ribs 2, 6 and [**8-27**]). An MRI of the thoracic spine is suggested to evaluate for cord or ligamentous injury. 2. Opacities in the right upper lobe and both lung bases with associated tree-in-[**Male First Name (un) 239**] opacities suggest aspiration pneumonia. 3. Right-sided duplicated collecting system with mild to moderate hydroureter of the ureter draining the upper pole likely partially due to ectopic insertion of the ureter inferiorly within the bladder. 4. Endotracheal and orogastric tubes in proper positions. [**8-17**] CT Head- IMPRESSION: 1. Large right subdural hematoma causing midline shift and obliteration of the right basal cisterns concerning for uncal herniation. 2. Multiple hemorrhagic foci including subarachnoid blood in the right frontal lobe and bilaterally in the frontoparietal regions close to the vertex, intraparenchymal hemorrhage in the left inferior frontal lobe, and a focus of hemorrhage in the left posterior fossa associated with the left occipital fracture and in the region of the transverse sinus suggesting venous epidural hematoma. 3. Multiple fractures, including in the calvarium, cranial base and facial bones as described above. A dedicated facial CT is suggested for further assessment of the fractures. 4. Right orbital fracture involving the roof with subperiostial hematoma along the lateral aspect of the roof with mild thickening of the superior rectus muscle. 5. Large subgaleal hematoma overlying the left calvarium. [**8-18**] MRI Spine: IMPRESSION: 1. Left occipital bone fracture and left posterior fossa hemorrhage, better assessed on preceding head CT scans. 2. Minimally displaced C2 fracture, as described on the prior neck CTA, without evidence of associated ligamentous disruption. No spinal canal narrowing or cord impingement. 3. Chronic compression deformities of the C7 and T2 vertebral bodies. 4. Burst fracture of T7 vertebral body with minimal retropulsion. No evidence of ligamentous disruption. No significant spinal canal narrowing and no cord compression. 5. Nondisplaced spinous process fractures at T5, T6, and T7. Interspinous ligament edema from T2-3 through T6-7. 6. Fracture parallel to the T8 superior endplate without loss of height or retropulsion. No evidence of ligamentous disruption. 7. The feeding tube is coiled in the pharynx prior to entering the esophagus. [**8-18**] CTA Neck- IMPRESSION: 1. Type 3 fracture of the C2 vertebral body with intra-articular involvement, but no evidence of disruption of the atlantoaxial articulation, in this limited imaging. 2. Though the fracture involves both foramina transversaria, there is no evidence of associated vertebral artery dissection or other injury. 3. Normal cervical carotid arteries with no evidence of acute injury. 4. Abnormal appearance to the left transverse sinus with adjacent contrast collection suggesting acute injury with contrast extravasation, related to known left lateral occipital bone fracture. There is no evidence of dural venous sinus thrombosis. 5. Unremarkable included intracranial arterial circulation, with no flow-limiting stenosis or occlusion. 6. Extensive particularly paramediastinal airspace opacity, right more than left, which may represent atelectasis, contusion or a combination of the two, associated with slightly displaced rib fractures, better-delineated on the preceding torso CT. [**8-18**] CT Head: IMPRESSION: 1. Status post evacuation of the right subdural hematoma, with small residual subdural blood products. 2. Persistent leftward shift of normally midline structures and right basilar cisternal effacement have improved, as described above. 3. Subarachnoid and intraventricular hemorrhage, as described above. 4. Multiple fractures, unchanged. [**8-18**] CXR-FINDINGS: After power flush, the PICC line has been re-directed so that the tip lies in the mid portion of the SVC. Otherwise, little change. [**8-18**] CXR- NG tube has been advanced, now the tip is in the stomach. ET tube has been repositioned, now the tip is 3.2 cm above the carina. Of note, the NG tube is coiled in the hypopharynx. Left lower lobe retrocardiac opacity has worsened. Right lower lobe opacity is unchanged. Right upper lobe opacity is stable. Opacities are a combination of areas of atelectases and aspiration. There is no evident pneumothorax. Left PICC tip is in the lower SVC. [**8-20**] EEG: [**8-20**] CT Head- IMPRESSION: 1. Status post right craniotomy for subdural hemorrhage evacuation with residual blood products and brain parenchymal herniation through the craniectomy defect as described above. 2. Evolving right frontal hypodensity that may represent infarction, contusion, or both. 3. Stable appearance of multiple fractures as described above [**8-20**] CT Max-Face: IMPRESSION: Fractures involving the medial and lateral right orbital wall, orbital roof, nondisplaced and without extraocular muscle entrapment although thickening of the superior rectus muscles suggested as an injured. Left inferior orbital wall blowout fracture. No fracture of the nasal bones, maxilla, or mandible. Stable appearance of fracture adjacent to left occipital condyle and clivus and right petrous apex and sphenoid body. [**8-20**] Chest Xray- FINDINGS: As compared to the previous radiograph, the patient has undergone spine stabilization surgery. According devices project over the spine and the mediastinum, partly obliterating the visualization of the endotracheal tube. Therefore, the tip of the tube cannot be directly visualized. The lower parts of the nasogastric tube project over the stomach. The left PICC line is in unchanged position. Unchanged is a moderate retrocardiac atelectasis, combined to minimal blunting of the left costophrenic sinus, potentially caused by a small left pleural effusion. There is no convincing evidence of pneumothorax. Minimal atelectasis at the bases of the right lung. Known right clavicular fracture. No pulmonary edema. No evidence of pneumonia. [**8-21**] EEG: [**8-21**] CXR: As compared to the previous radiograph, there is no relevant change with the exception of slightly increasing left pleural effusion and a subsequent left basal atelectasis. No evidence of pneumothorax. The monitoring and support devices as well as the surgical stabilization devices are in constant position. [**8-22**] EEG: [**8-22**] CXR: Brief Hospital Course: Pt was taken to the OR emergently from the ED and underwent a craniectomy & evacuation of her SDH with drain placement. She received 2 units PRBC in OR and 2 liters of IV fluid. Her postoperative CT revealed good evacuation/decompression. Overnight she was given a dilantin bolus for a corrected level of 4. She had a fever to 102 so blood cx were sent. Optho was consulted for her orbital fracture. Ortho was consulted for her spinal fractures. She was kept in a hard collar and on logroll precautions. On [**8-18**] she was neurologically stable but having respiratory difficulties. The ICU team performed a bronchoscopy. Her drain was removed and she was cleared for Neuro checks q3 hours. An MRI of her spine was ordered to further evaluate for spinal cord damage. On [**8-19**] she was brought to the operating room with the orthopedics team and underwent a T1-10 fusion and decompression. Surgery was without complication but she continued to have a poor exam postoperatively. A Head CT was performed which revealed an evolving right frontal infarct vs edema. Cervical and Thoracic braces as well as a helmet were ordered. On [**8-20**] Neurology was consulted for the R frontal edema vs CVA. Her lipitor was discontinued and an EEG ordered was ordered per their recs. Neuro exam remained poor. Her Hct dropped from 28 to 22, but her exam was not concerning for intrabdominal or intracranial hemorrhage. Stool Guaiac was positive so 1U PRBCs was transfused. On [**8-21**] her neurological exam continued to be poor but improved compared to [**8-20**]. Her EEG was negative for seizures. On [**8-22**] social work worked on identifying the patient and guardianship. A family meeting was held with the patient's sister who decided to make patient comfort measures only. She was extubated and expired. Medications on Admission: Trazadone Citalopram Ultram Naltrexone Ativan Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Right SDH Right displaced occipital fx traumatic SAH R orbital wall, roof fxs C2 displaced fx of the transforamen R clavical fx T7 burst fx R retro-orbital hematoma R hydroureter Discharge Condition: expired Discharge Instructions: none Followup Instructions: none

[ "518.0", "278.00", "305.90", "434.91", "805.2", "810.00", "737.10", "V49.86", "E880.9", "593.5", "305.00", "802.6", "E849.0", "300.00", "311", "E915", "807.05", "934.8", "V10.05", "805.02", "801.25", "285.1" ]

icd9cm

[ [ [] ] ]

[ "77.79", "38.91", "01.31", "03.53", "81.05", "96.6", "81.64", "03.90", "96.72", "96.05" ]

icd9pcs

[ [ [] ] ]

10648, 10657

8715, 10522

281, 340

10880, 10890

1558, 5690

10943, 10951

1273, 1291

10619, 10625

10678, 10859

10548, 10596

10914, 10920

1306, 1539

238, 243

368, 764

5699, 8692

786, 885

901, 1257

25,070

160,586

3831

Discharge summary

report

Admission Date: [**2186-4-25**] Discharge Date: [**2186-5-5**] Date of Birth: [**2122-4-20**] Sex: F Service: Medicine/[**Hospital Ward Name 332**] Intensive Care Unit/Bone Marrow Transplant HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old female with a history of non-Hodgkin lymphoma (status post autologous bone marrow transplant) who was recently admitted with syncope of unclear etiology who presented with a recurrent syncopal episode. The patient is status post a recent admission on [**2186-4-20**] with syncope without a prodrome with a fall and seventh left rib fracture. During that hospitalization, the patient had a 10-beat run of supraventricular tachycardia and bradycardia to the 30s. Electrophysiology felt there was no evidence of sinus node dysfunction and recommended atenolol and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor. The patient was also started on Neurontin for headaches. She has had a recent lumbar puncture and magnetic resonance imaging with no evidence of central nervous system lymphoma. An echocardiogram was unremarkable. The patient was also started on prednisone as an outpatient for questionable temporal arteritis. On the morning of admission, the patient sat up on the edge of her bed and blacked out. She was possibly confused for a few seconds and had bowel incontinence. The patient woke up and went back to bed. Thirty minutes later, she stood up and lost consciousness again and found herself on the floor. She again had bowel incontinence. The patient pressed her [**Doctor Last Name **] of Hearts monitor button both times. There were no palpitations or shortness of breath, and there were no witnesses to these falls. The patient has had continued headaches for six weeks with a left eye droop, which is now slightly better. The patient denies nausea, vomiting, fevers, chills, constipation, or diarrhea. Otherwise, review of systems was negative. PAST MEDICAL HISTORY: 1. Follicular low-grade lymphoma in [**2175**] secondary to cervical lymphadenopathy. She is status post autologous bone marrow transplant from her brother in [**2185-2-5**]. She was initially treated with six cycles of CHOP with recurrence when diagnosed. The patient then went on to have autologous bone marrow transplant in [**2179**]. The patient was treated with Rituximab in [**2184-7-5**] for nasopharyngeal recurrence. The patient then went on to have an autologous bone marrow transplant in [**2185**]. The patient had a recent admission to the Neurology Service in [**2186-3-6**] with persistent temporal headaches. Her primary oncologist is Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. 2. Hypothyroidism and history of a thyroid nodule. 3. Asthma. 4. Fibromyalgia. 5. Left cataract. 6. Chronic headaches. 7. Status post cholecystectomy. 8. Status post total abdominal hysterectomy with bilateral salpingo-oophorectomy. 9. Recent admission in [**2186-4-6**] with syncope; ruled out for a myocardial infarction, had a rib fracture, bradycardia, and supraventricular tachycardic episodes with pauses and discharge of [**Doctor Last Name **] of Hearts monitor. ALLERGIES: ASPIRIN, OXYCODONE, and CODEINE (which cause nausea and vomiting). MEDICATIONS ON ADMISSION: 1. Folate 1 mg by mouth once per day. 2. Levothyroxine 75 mcg by mouth once per day. 3. Gabapentin 300 mg by mouth three times per day. 4. Prednisone 10 mg by mouth once per day. 5. Atenolol 25 mg by mouth once per day. 6. Tylenol No. 3 as needed. SOCIAL HISTORY: The patient is married. She has one son. She lives in [**Location 1456**] with her husband. She is from [**Country 2559**]. Negative for alcohol, drug, or tobacco. She does not work. PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 99.2 degrees Fahrenheit, her pulse was 93, her blood pressure was 136/56, her respiratory rate was 18, and her oxygen saturation was 100% on room air. In general, in no acute distress. Alert and oriented times three. The mucous membranes were moist. The patient had left eye ptosis. The neck was supple. There were no carotid bruits. The heart was regular with no murmurs, rubs, or gallops. Pulmonary examination revealed the lungs were clear to auscultation. The abdomen was benign. Extremities revealed no edema. On neurologic examination, cranial nerves II through XII were intact. Strength was [**5-10**] throughout all extremities. Reflexes were 2+ throughout. Normal finger-to-nose. SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1. SYNCOPE ISSUES: Upon admission, it was still unclear what was causing the patient's syncope. Her syncopal episodes were associated with episodes of bradycardia as well as hypotension. These were without warning and occurred suddenly; most often in the early morning. The patient had two episodes of syncope while resting in bed. These episodes were noted on telemetry. The patient would be bradycardic to the 30s with blood pressures of 60/palpable with spontaneous resumption of her blood pressure to 100/60s without intervention except laying supine. The Electrophysiology Service saw the patient on admission and performed a tilt table test on [**4-26**]. This showed normal sinus node function. No supraventricular tachycardia with a baseline heart rate in the 40s. After 25 minutes on the table at 60 degrees, the patient developed hypotension to the 50s which resolved after returning to the supine position. Electrophysiology surmised that the patient's symptoms were likely due to autonomic dysfunction rather than cardiac disease. The patient had a second episode of bradycardia with hypotension on [**4-28**] with good mentation. Her blood pressure returned to [**Location 213**] with an intravenous fluid bolus. The patient's atenolol was then discontinued. Because the patient had been complaining of persistent left temporal headaches, with worsening over the past days, a magnetic resonance imaging of the neck was obtained which showed a soft tissue mass at the left skull base centered at the jugular foramen. This was thought likely to be a recurrence of the patient's non-Hodgkin lymphoma. The left internal carotid artery was anterolaterally displaced on imaging, and it was thought to be causing these syncopal episodes as well as vagal stimulation. On [**4-29**], the patient was transferred to the Bone Marrow Transplant Service for further treatment and evaluation of possible lymphoma recurrence. Upon arrival to the Bone Marrow Transplant Unit, the patient suffered from two to three episodes of hypotension, bradycardia, and near syncope. These episodes were sudden and occurred while the patient laying in bed. The patient had some decreased mentation with difficulty to arouse her. Telemetry monitoring showed her heart rate down to the high 20s and low 30s. At this time, the [**Hospital Ward Name 332**] Intensive Care Unit resident was called, and the patient was transferred to the Intensive Care Unit for closer monitoring. It was thought that the mass in the patient's neck had to be biopsied. Ear/Nose/Throat Service and Neurology Service consultations were obtained regarding biopsy. The patient was also seen by Radiology/Oncology Service, as well as Neurology Service, and Neurology/Oncology Service. The patient was then transferred to the Intensive Care Unit on [**4-29**]. 2. SOFT TISSUE MASS ISSUES: The patient had a biopsy by Neurosurgery on [**4-29**] on the [**Hospital Ward Name **]. After this biopsy, the patient was returned to the [**Hospital Ward Name 332**] Intensive Care Unit for further care. Preliminary pathology from the soft tissue mass does show lymphoma; however, it appeared to be different than her previous non-Hodgkin lymphoma. It was thought at the time of this dictation that the patient's mass was due to an [**Doctor Last Name 3271**]-[**Doctor Last Name **] virus associated post transplant lymphoproliferative disease. At the time of this dictation, the final pathology was still pending. After one day in the Intensive Care Unit, the patient suffered no more episodes of vagal stimulation and syncope, and she was transferred back to the Bone Marrow Transplant Service on [**4-30**] for further care. The patient received high-dose Decadron while in the Intensive Care Unit with resolution of her headache. This was discontinued upon transfer to the Bone Marrow Transplant Service, and she was given a one time dose of Rituxan. The patient tolerated this well and was planned for weekly Rituxan treatment. However, after two days on the Bone Marrow Transplant Service the patient's headache began to worsen again. The patient was restarted on Decadron and then switched to prednisone 20 mg by mouth once per day. The patient had some improvement, but she suffered from mild headaches which are relieved with Fioricet and morphine sulfate immediate release tablets. Due to the persistence of the patient's headaches, the Radiology/Oncology Service was again consulted regarding further treatment of this mass. It was planned to start daily irradiation for one month at the patient's closest radiation facility in [**Location (un) 1456**]. This will start on Tuesday, [**2186-5-9**]. This has been set up by the Radiology/Oncology team here at the [**Hospital1 190**]. The patient will likely continue weekly Rituxan while obtaining radiation therapy. All decisions regarding treatment will be made by the patient's primary oncologist (who is Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]). The patient will continue on Decadron 8 mg by mouth twice per day as well upon discharge. We await the final pathology of the mass. 3. VAGAL EPISODE ISSUES: It was thought that the patient's vagal episodes were due to impingement on the carotid sinus by this mass in the patient's neck. The Neurology Service suggested starting medications propantheline and midodrine to offset vagal stimulation. These were started with good effect, and the patient was to be discharged on these medications. She was to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] in Neurology/Oncology upon discharge. After episode on [**4-29**], the patient had no further episodes of hypotension or bradycardia. She was kept on telemetry during her hospital stay and maintained heart rates in the 80s and blood pressures at 120s/60s. 4. HYPOTHYROIDISM ISSUES: The patient was continued on her home dose of levothyroxine. A thyroid-stimulating hormone was checked during this admission and was 2.3; so there were no changes to her medications. 5. PAIN CONTROL ISSUES: The patient's headaches were to be controlled with morphine sulfate immediate release. The patient will not be discharged on Fioricet as this was thought to be causing withdrawal headaches. She has adverse reactions to codeine and oxycodone, but she is able to take the morphine. She will also continue on the steroids as explained above. DISCHARGE DIAGNOSES: 1. Non-Hodgkin lymphoma. 2. Jugular foramen mass on the left. 3. Resolved syncope and bradycardia. 4. Hypothyroidism. 5. Fibromyalgia. 6. Headaches. 7. Asthma. MEDICATIONS ON DISCHARGE: 1. Propantheline 15 mg by mouth q.6h. 2. Gabapentin 300 mg by mouth three times per day (for headaches). 3. Levothyroxine 75 mcg by mouth every day. 4. Folate 1 mg by mouth once per day. 5. Midodrine 5 mg by mouth three times per day. 6. Colace. 7. Decadron 8 mg by mouth twice per day. 8. Ativan as needed (for nausea). 9. Morphine sulfate immediate release 15-mg tablets by mouth q.4-6h. as needed (for headaches). 10. Rituxan weekly. 11. Milk of Magnesia as needed (for constipation). 12. Fluconazole 100 mg by mouth once per day (for prophylaxis). DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] in Neurology on [**5-10**]. 2. The patient was instructed to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in Oncology on [**5-10**]. 3. The patient was set to begin radiation in [**Location (un) 1456**] in Tuesday, [**5-10**]. 4. Prior to discharge, a disk was made with the patient's magnetic resonance imaging loaded. The patient was to take this disk out prior to discharge to discharge on [**Last Name (un) 469**] Four. DISCHARGE DISPOSITION: The patient was to be discharged to home with her husband with no [**Hospital6 407**] services requested. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], M.D. [**MD Number(1) 10999**] Dictated By:[**Last Name (NamePattern1) 9244**] MEDQUIST36 D: [**2186-5-5**] 15:07 T: [**2186-5-6**] 14:13 JOB#: [**Job Number 17216**]

[ "238.7", "493.90", "244.9", "996.85", "784.0", "780.2", "202.81", "729.1" ]

icd9cm

[ [ [] ] ]

[ "38.93", "83.21", "89.59", "89.61", "37.26", "20.49" ]

icd9pcs

[ [ [] ] ]

12493, 12878

11076, 11244

11271, 11844

3319, 3574

11877, 12468

4580, 11055

237, 1980

2002, 3293

3591, 4546

15,889

163,343

28728

Discharge summary

report

Admission Date: [**2136-9-2**] Discharge Date: [**2136-9-3**] Date of Birth: [**2093-6-18**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 371**] Chief Complaint: S/p MVC. Major Surgical or Invasive Procedure: None. History of Present Illness: 43 male unrestrained passenger in MVC, struck windshield. Questionable loss of consciousness. Past Medical History: Down's syndrome, CHF, home oxygen dependent, gout Physical Exam: Alert, oriented x3. No focal neurologic deficits. CTA B. RRR. S, NT, ND. Extremities warm, well-perfused, no injury. Brief Hospital Course: Patient was evaluated as a trauma in the ER. His work-up included CT scan which revealed parafalcine subdural hematoma. He was admitted to the Trauma ICU for neuro checks, and repeat head CT demonstrated no change. His neurologic status remained at his baseline. Neurosurgical consultation agreed with discharge, no Dilantin, and follow-up in 6 weeks with interval head CT. Medications on Admission: Lasix 80 mg [**Hospital1 **] allopurinol lisinopril 5 mg daily Vitamin K home oxygen Discharge Medications: 1. Medications Please resume all pre-hospitalization medications. Discharge Disposition: Home Discharge Diagnosis: S/p MVC. Parafalcine subdural hematoma. Discharge Condition: Stable. Normal neurologic exam per family members and [**Name2 (NI) 64202**], stable head CT. Discharge Instructions: Please call your doctor or return to the ER for any of the following: * Any change in mental or neurologic status, such as sleepiness, numbness, weakness, unexplained nausea or vomiting, changes in vision or awareness. * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomitting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomitting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 100.4 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. Followup Instructions: Follow-up with Neurosurgery, Dr. [**Last Name (STitle) 548**] in 6 weeks. Please call his office to schedule appointment, ([**Telephone/Fax (1) 88**]. Please obtain interval CT head scan on the day of follow-up, prior to appointment. Completed by:[**0-0-0**]

[ "E816.1", "428.0", "852.26", "758.0", "515", "274.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

1287, 1293

682, 1061

320, 328

1378, 1475

2598, 2861

1196, 1264

1314, 1357

1087, 1173

1499, 2575

539, 659

272, 282

356, 451

473, 524

71,184

137,789

522

Discharge summary

report

Admission Date: [**2189-1-15**] Discharge Date: [**2189-1-17**] Date of Birth: [**2136-6-19**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4327**] Chief Complaint: STEMI Major Surgical or Invasive Procedure: [**2189-1-15**] - Left heart cardiac catheterization with bare metal stent placed in the LAD History of Present Illness: 52 year old male with coronary artery disease s/p MI s/p PCI to LAD and LCx ([**2181**], [**2186**]) and s/p right atrial tachycardia ablation [**6-/2188**] with decreased ejection fraction (EF 20% from 40% in [**2186**]), presenting with chest pain found to have STEMI enroute by EMS. Patient woke up 3:30 am this morning at home and reports tightness across his chest, not localizing anywhere specific. Patient reports the chest pain is similar to his past MI 4 years ago when he got stents placed in the LAD. He took 325 aspirin PO before he got here. he is clammy. pain was [**5-4**] initially. After nitro the pain was [**2-4**]. He was taking lisinopril, metaprolol. Stopped taking those meds because he ran out refills, no other reason. . In ED, he was 80 BP 138/100 Resp 20 O2 Sat 100%. EKG noted STE in V1-V4, with Qs in II, III, AVF. Exam was notable for diaphoresis and chest tightness 40 min prior to presentation. Labs were notable for trop of 0.01 otherwise benign. He was given plavix, heparin gtt, taken to the cath [**Month/Year (2) **] for urgent intervention. He was found to have LAD in stent thrombosis, used 160cc of dye, was given bival in labs. BMS x 1 to LAD, RFA access. Angiosealed. . In CCU, patient appeared to be in good spirit. . 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: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: a. Cypher drug-eluting stent (3.5 x 18 mm) to LAD at [**Hospital **] in [**8-28**]. b. Endeavor DES (3.0 x 15mm) to distal LCx in [**12-3**]. -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: -COPD/emphysema, pulm nodule documented on CTA [**7-2**] -systolic CHF (EF of 20% on echo [**9-/2188**]) -Syncopal event found to have incessant atrial tachycardia s/p successful right atrial tachycardia ablation [**2188-7-10**]. His symptoms of atrial tachycardia were lightheadedness, dizziness and he has had no recurrence of this. -Tobacco use Social History: -works as truck dispatcher; works helping to set up major events (graduation concerts etc) has been very busy lately -Tobacco history: He has been a heavy smoker, up to three packs/day, but currently one pack/week. He has no known history of hypertension. -ETOH: 6 beers/week -Illicit drugs: none Family History: There is a family history of cardiac disease with his father having had an MI and CVA in his 60s and his mother an MI at approximately age 70. Otherwise, no family history of early MI. Physical Exam: ADMISSION EXAM: . VS: T=97.8 BP=102/67 HR=80 RR=16 O2 sat= 97% GENERAL: 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 without JVD, difficult anatomy. CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits, cath site is intact. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: ADMISSION LABS: . [**2189-1-15**] 04:30AM BLOOD WBC-8.6 RBC-5.05 Hgb-15.7 Hct-45.3 MCV-90 MCH-31.1 MCHC-34.6 RDW-13.7 Plt Ct-197 [**2189-1-15**] 04:30AM BLOOD PT-10.7 PTT-29.8 INR(PT)-1.0 [**2189-1-15**] 06:00AM BLOOD Glucose-141* UreaN-19 Creat-0.8 Na-139 K-4.4 Cl-108 HCO3-25 AnGap-10 [**2189-1-15**] 04:41AM BLOOD Glucose-128* Lactate-1.1 Na-142 K-4.2 Cl-107 calHCO3-25 . PERTINENT LABS AND STUDIES: [**2189-1-15**] 04:30AM BLOOD cTropnT-<0.01 [**2189-1-15**] 04:30AM BLOOD Lipase-32 [**2189-1-15**] 04:30AM BLOOD Fibrino-319 . [**2189-1-15**] CATHETERIZATION (PRELIM): 1. Selective coronary angiography of this right dominant system demonstrated single vessel coronary artery disease. The LMCA had minimal luminal irregularities. The LAD had a subtotal occlusion of previously placed stent consistent with stent thrombosis. The LCx had minimal luminal irregularities. The RCA had minimal luminal irregularities. 2. Limited resting hemodynamics revealed systemic arterial normotension with central aortic pressure of 125/88 mmHg. . FINAL DIAGNOSIS: 1. STEMI with single vessel coronary artery disease. 2. Systemic arterial normotension. . [**2189-1-15**] ECHOCARDIOGRAM The left atrium is elongated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is severe regional left ventricular systolic dysfunction with mid- and distal anterior, septal and apical akinesis. There is moderate hypokinesis of the remaining segments (LVEF = 25%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is an anterior space which most likely represents a prominent fat pad. . IMPRESSION: Severe regional left ventricular systolic dysfunction, c/w LAD disease. Compared with the prior study (images reviewed) of [**2188-10-13**], the findings are similar. . [**2189-1-15**] CXR In comparison with the study of [**7-9**], there is continued enlargement of the cardiac silhouette. Relatively mild pulmonary vascular congestion without pleural effusion or acute focal pneumonia. Brief Hospital Course: 52 year-old Male with a history of MI s/p DES to LAD in [**8-/2181**] and LCx in [**11/2186**] (on Plavix), HTN, HLD, presenting with chest pain found to have acute ST-elevation myocardial infarction enroute by EMS. . # ACUTE ST-ELEVATION MYOCARDIAL INFARCTION - Patient presented with chest pain and was found to have a STEMI on EKG upon arrival. He had a cardiac catheterization which showed a right dominant system, known LAD, LCx lesions. He was found to have in-stent thrombosis due to medication non-compliance, and a single bare-metal stent was placed in LAD. The patient was treated with Aspirin 325 mg daily. He was also changed from Plavix to Prasugrel. He was started on Lisinopril and Metoprolol. The patient received smoking cessation counseling and was counsled regarding the importance of quitting. . # SYSTOLIC CONGESTIVE HEART FAILURE - The patient was known to have severe global left ventricular hypokinesis (LVEF = 25 %) with distal LV-apical akinesis on a prior echocardiogram from 9/[**2188**]. An Echo performed during this hospitalization revealed continued apical akinesis so the patient was started on Coumadin. He will require repeat echocardiography and possible evaluation for ICD placement to prevent suddent cardiac death, in about one month. . # RHYTHM - The patient maintained a sinus rhythm, and had history of recent ablation by Dr. [**Last Name (STitle) **] for incessant atrial tachycardia. No evidence of dysrrhythmia this admission other than some intermittent runs of non-sustained ventricular tachycardia, which resolved without issue. . # HYPERTENSION - We continued Metoprolol and Lisinopril. . # HYPERLIPIDEMIA - We continued high dose Atorvastatin. . TRANSITION OF CARE ISSUES: 1. Patient counseled on smoking cessation, lifestyle modifications and the importance of medication use in the setting of in-stent stenosis. 2. Patient will require repeat echocardiogram and possible evaluation for ICD placement at the end of [**2189-1-25**]. 3. Patient will require a cardiac MR imaging study 1-month following his discharge. A prescription was provided to the patient. Medications on Admission: 1. aspirin 325 mg Tablet PO DAILY. 2. clopidogrel 75 mg Tablet PO DAILY. 3. atorvastatin 80 mg Tablet PO DAILY 4. lisinopril 20 mg Tablet PO once a day. 5. Toprol XL 100 mg Tablet PO once a day. 6. gemfibrozil 600 mg Tablet PO BID. 7. nitroglycerin 0.4 mg Tablet Sublingual Q5Min prn chest pain. Discharge Medications: 1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 2. prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 5. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: 1.5 Tablet Extended Release 24 hrs PO once a day. Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*1* 6. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM: Your PCP will tell you when to change your dose. Disp:*30 Tablet(s)* Refills:*0* 8. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual Every 5 minutes up to 3 tablets as needed for chest pain. Disp:*15 tablets* Refills:*0* 9. Outpatient [**Name (NI) **] Work PT/INR on Wednesday [**2189-1-21**]. Please fax results to Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 4328**]. 10. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) injection Subcutaneous Q12H (every 12 hours). Disp:*14 injection* Refills:*0* 11. eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 12. Outpatient Radiology Cardiac MRI to be scheduled one month from discharge (around [**2189-2-17**]) Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: . 1. Coronary artery disease 2. Acute ST-segment elevation myocardial infarction . Secondary Diagnoses: 1. Hypertension 2. Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 4318**], It was a pleasure taking care of you during your admission to [**Hospital1 18**]. You were found to have a heart attack and were taken to the cardiac cath [**Hospital1 **] where you had a stent placed in one of the arteries in your heart. It is essential that you continue to take your medications as prescribed to prevent another heart attack. It is also important to stop smoking to decrease your risk of future heart attacks. You have been started on warfarin (Coumadin) to prevent blood clots from forming in your heart. Please take this medication at the same time each day. You should have your blood drawn on Wednesday [**1-21**], this measures how thin your blood is and your PCP will adjust your warfarin dose as needed. The following changes were made to your medications: STOP clopidogrel (Plavix) START prasugrel 10mg by mouth daily START warfarin 5mg by mouth at the same time once daily START Lovenox 80mg injection twice daily START eplerenone 25mg by mouth daily CHANGE lisinopril to 5mg by mouth daily CHANGE metoprolol XL to 150mg by mouth daily Continue all other medications as prescribed. You will need a cardiac MRI one month from discharge. Followup Instructions: Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] ([**Telephone/Fax (1) 4326**]) on Monday [**1-19**] to make a follow-up appointment in the next few weeks. You should also see your cardiologist, Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 62**]), within the next 1-2 weeks.

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icd9cm

[ [ [] ] ]

[ "00.40", "88.56", "00.66", "37.22", "36.06", "00.45" ]

icd9pcs

[ [ [] ] ]

10678, 10684

6692, 8805

310, 405

10885, 10885

4206, 4206

12270, 12589

3268, 3454

9151, 10655

10705, 10807

8831, 9128

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3469, 4187

10828, 10864

2347, 2557

265, 272

433, 2239

4222, 5241

10900, 11012

2588, 2938

2261, 2327

2954, 3252

7,277

162,185

53725

Discharge summary

report

Admission Date: [**2123-8-20**] Discharge Date: [**2123-9-8**] Service: ACOVE HISTORY OF THE PRESENT ILLNESS: The patient is an 84-year-old man with history of myelodysplastic syndrome and lower gastrointestinal bleeding secondary to arteriovenous malformations. The patient presented to the operating room after awaking on the day of admission with acute shortness of breath and palpitations. When the EMTs arrived to the scene and found the patient, they noted that he was tachycardiac. he received Adenosine and ultimately went into normal sinus rhythm. In the emergency room he was again tachycardiac after receiving Dobutamine for hypertension. On arrival to the ER, the patient's blood pressure was 80. He was subsequently started on Neo-Synephrine to maintain hypotension. Chest x-ray revealed right lower lobe pneumonia. The patient was admitted to the MICU for further management. PAST MEDICAL HISTORY: History was notable for myelodysplasia, history of arteriovenous malformations, peptic ulcer disease, hypertension, colon cancer status post resection, vocal cord tumor status post XRT. MEDICATIONS: 1. Atenolol. 2. Multivitamin. 3. Omeprazole. ALLERGIES: The patient is allergic to CODEINE. SOCIAL HISTORY: The patient never married. The patient has no children. The patient quit smoking 30 years ago. The patient does not drink or use drugs. PHYSICAL EXAMINATION: Examination on admission is notable for a temperature of 100.5, pulse 85, blood pressure 99/50, respiratory rate 40, 95% on 100% rebreather. The patient had no JVD on examination. Pupils equal, round, and reactive to light. The patient had crackles at the right base; regular rate and rhythm, normal S1 and S2. ABDOMEN: Soft, nontender, nondistended, normoactive bowel sounds. LABORATORY DATA: Labs on admission revealed the hematocrit of 10.3, hematocrit 21, sodium 144, potassium 5.5, chloride 115, bicarbonate 12, BUN 47, creatinine 2.2. HOSPITAL COURSE: The patient had a very prolonged hospital course. He was initially admitted to the MICU and treated for right lower lobe pneumonia with Vancomycin, Ceftriaxone, and Flagyl. The patient's sputum cultures ultimately grew ....................and he was then treated with Bactrim and ultimately Zosyn and Flagyl. Hospital course was also complicated by hypotension. He was treated with pressors, which ultimately resolved. He also went into rapid atrial fibrillation and he was treated with Amiodarone and Lopressor as tolerated. He had a Swan-Ganz catheter placed, which was consistent with cardiogenic shock. The patient required intubation after two days secondary to worsening respiratory distress. He was ultimately extubated on [**9-4**] and he had to use BiPAP intermittently since he did not tolerate extubation immediately. The patient's respiratory status did not improve significantly even after extubation. He had a lot of difficulty clearing his own secretions. On [**9-7**], it was decided to make the patient comfort measures only. The patient expired on [**9-8**]. DATE OF EXPIRATION: [**2123-9-8**]. FINAL DIAGNOSES: 1. Hypotension. 2. Right lower lobe pneumonia. 3. Sepsis. [**First Name8 (NamePattern2) 1569**] [**Last Name (NamePattern1) 8560**], M.D. [**MD Number(1) 8561**] Dictated By:[**Last Name (NamePattern4) **] MEDQUIST36 D: [**2124-6-21**] 16:08 T: [**2124-6-21**] 16:15 JOB#: [**Job Number 43839**]

[ "518.81", "427.31", "038.19", "578.9", "486", "584.9", "410.91", "785.51", "280.0" ]

icd9cm

[ [ [] ] ]

[ "99.61", "38.91", "96.72", "38.93", "89.64", "96.6", "96.04", "99.15" ]

icd9pcs

[ [ [] ] ]

1979, 3106

3123, 3462

1412, 1961

934, 1232

1249, 1389

13,970

146,441

48124

Discharge summary

report

Admission Date: [**2151-8-1**] Discharge Date: [**2151-8-31**] Date of Birth: [**2084-12-14**] Sex: M Service: THORACIC SURGERY ADMISSION DIAGNOSES: 1. Spontaneous pneumothorax. 2. Emphysema. 3. History of supraventricular tachycardia. 4. Pulmonary hypertension. 5. Spinal stenosis. 6. Interstitial lung disease. 7. History of steroid induced psychosis. DISCHARGE DIAGNOSES: 1. Spontaneous pneumothorax status post V.A.T.S., status post pleurodesis, status post decortication. 2. Biliary sepsis status post open cholecystectomy, status post percutaneous cholecystomy. 3. Interstitial lung disease. 4. Emphysema. 5. Multifocal atrial fibrillation. 6. Pulmonary hypertension. 7. Spinal stenosis. 8. History of syphilis. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 1968**] is a 66 year-old gentleman with an extensive past medical history as mentioned above who is admitted to the hospital for operative management for an expanding tension pneumothorax on the right side. He was admitted on [**2151-8-31**]. PHYSICAL EXAMINATION: On initial was his temperature was 97.9. Pulse 96 with a blood pressure of 99/42. Respiratory rate 20. Sating 96% on 3 liters. He did not appear to be in acute distress, but he did have notably decreased breath sounds bilaterally. His heart was regular rate and rhythm. His abdomen was soft and flat. Extremities were warm. There was no edema present. ADMISSION LABORATORIES: Admission white count was 12.3 with a hematocrit of 42.8. His BUN and creatinine at the time of admission were 46 and 1.5 respectively. His K initially was 5.6 at the time of admission and was subsequently corrected. HOSPITAL COURSE: After the patient was admitted he planned to undergo a V.A.T.S. procedure, but on the morning of surgery the patient's pneumothorax began enlarging and became somewhat hemodynamic compromise and was taken urgently to the Operating Room where he underwent thoracoscopic decortication and thoracotomy with pleurodesis. Postoperatively, the patient became tachycardic and hypotensive with diminish in urine output and was taken to the Intensive Care Unit and treated for what was presumed to be hypovolemia. Subsequently while on the floor the patient's blood pressures remained in the 70s/40s, 80s/50s and it was determined that this was likely the patient's baseline after extensive attempts to manipulate the blood pressure with fluids and diuresis, etc. Notably early on in the [**Hospital 228**] hospital course he seemed to be going through an addisonian crisis and has only subsequently learned that the patient had been taking chronic steroids. This was not known by the patient and he did not provide this in his admission history. After the patient's chronic doses of steroids were restarted the patient's electrolyte abnormalities and fluid problems somewhat improved after the patient was transferred to the floor he continued to remain with his blood pressures in the 80s/40s and repeatedly underwent episodes which were initially thought to be atrial fibrillation, which were treated with intravenous Metoprolol, but were subsequently determined to be multifocal atrial tachycardia. Approximately one and a half weeks postoperatively after the patient's V.A.T.S. he developed a notable erythema over the abdomen over the right lateral aspect of the back. This was accompanied by belly pain, which progressively worsened. General surgery was consulted. Laboratory tests were drawn including liver function tests and ultrasound of the gallbladder. Ultrasound of the gallbladder did not show an acute problem with cholelithiasis. There was some inflammation noted. He had some dilatation noted. The patient had a percutaneous cholecystostomy on [**2151-8-14**] in order for drainage as he was a poor operative candidate fore a cholecystectomy. Subsequent to this the patient's symptoms were not relieved and he remained febrile, tachycardic and appeared somewhat septic. He was taken urgently to the Operating Room on [**2151-8-16**] for an open cholecystectomy at which time a gangrenous gallbladder was found with clotted blood. He was subsequently cared for in the Intensive Care Unit for his inability to maintain blood pressures over 70 systolic and repeated episodes of his atrial tachycardia. Electrophysiology was also consulted to see the patient and they were in assistance in somewhat managing this rhythm. It is determined that the patient's blood pressure would be fine if he was maintained at his baseline rate and he should be given Toprol XL for control of this tachycardia and otherwise there were no operative interventions for alleviation of this arrhythmia. Due to the patient's extensive time in Intensive Care Unit and lack of mobility he became quite debilitated. The last week of his hospitalization was dedicated to providing the patient with increasing strength and he was given hyperalimentation where he was given nutritional supplements through tube feeds in order for him to improve his body weight and also he was given aggressive physical therapy. It was noted that he had bilateral lower extremity weakness, which was somewhat out or proportion to his upper extremity weakness and given this with occasional episodes of incontinence the patient was having neurology was consulted and the patient had an MRI of the spine in order to evaluate for a compressing lesion or cauda equina syndrome. This turned out to be negative. Attempts at rehabilitating the patient while in the hospital were extremely difficult as the patient at present is unable to stand even with assistance, but his weight is improving and he is able to take excellent po intake. Neurology was consulted for this weakness and also suggested that the patient might have a steroid induced myopathy and/or alcohol induced myopathy as he ___________ supplementing thiamine and folate and electrolytes, this was all done and neurology would like to see the patient in outpatient follow up and he should be scheduled for an EMG to evaluate his lower extremity weakness as an outpatient. Essentially at the time of discharge the patient is medically stable. His normal blood pressure does run in the 80s/40s and at times 70s/40s although the patient has no mental status changes with this and does not experience any symptoms of dizziness or shortness of breath with these episodes. He is in normal sinus rhythm currently, although he periodically does revert to his multifocal atrial tachycardia, which has been greatly reduced with the addition of Toprol XL, but is rate controlled when necessary with intravenous Lopressor. Otherwise in terms of respiratory status he continues to have his emphysema and interstitial lung disease for which he is on chronic steroids on which he should be maintained as per his primary care physician, [**Name10 (NameIs) **] there is no evidence of pneumonia or volume overload. In terms of his cardiac status as mentioned previously aside from this tachycardia he had a repeated evaluations for acute myocardial infarction during episodes of his arrhythmia and nothing conclusive was ever noted. No note of acute ischemia was found on his electrocardiograms. From a gastrointestinal standpoint the patient is taking adequate po intake without difficulty. He occasionally does have some rectal incontinence, but this may be secondary to an inability to ambulate to the bathroom according to the patient. In terms of his renal status, the patient is renally stable. His BUN and creatinine have been fine and he has been making good urine. At present the patient has no evidence of any sort of infection. All blood cultures drawn throughout this hospital especially during the period of his biliary sepsis were not notable and he did receive multiple courses of antibiotics during those episodes. Hematologically, his hematocrit is stable. Neurologically the patient is stable. As noted the patient is neurologically stable, but does need an outpatient neurological evaluation for which he has been instructed and given the phone numbers to attend. Otherwise at the time of discharge the patient's laboratories included white count of 10.4, hematocrit stable at 32.7. The patient's final urinalysis at the time of discharge showed no evidence of urinary tract infection. His sodium was 133 with a K of 4.2 with serum bicarb of 99 and 29 respectively. His BUN and creatinine were 39 and 0.7. His glucose was 139. DISCHARGE MEDICATIONS: 1. Toprol XL 75 mg po q day. 2. Magnesium oxide 140 mg po q.d. 3. Folate 1 mg po q.d. 4. Thiamine 100 mg po q.d. 5. Lasix 40 mg po b.i.d. 6. Potassium chloride 20 milliequivalents po b.i.d. 7. Prednisone 50 mg po q.d. 8. Protonix 40 mg po q.d. 9. Albuterol inhaler one to two inhalations b.i.d. prn. 10. Combivent inhaler one to two inhalations b.i.d. prn. 11. Combivent one to two puffs b.i.d. DISCHARGE CONDITION: Good. He is discharged to an extended care facility for rehabilitation. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**] Dictated By:[**Last Name (NamePattern1) 101471**] MEDQUIST36 D: [**2151-8-31**] 10:53 T: [**2151-8-31**] 11:07 JOB#: [**Job Number 101472**]

[ "492.8", "427.31", "276.5", "574.00", "416.8", "515", "512.0", "255.4", "789.5" ]

icd9cm

[ [ [] ] ]

[ "34.51", "34.6", "96.6", "34.24", "87.53", "51.01", "88.72", "33.28", "51.22" ]

icd9pcs

[ [ [] ] ]

8936, 9294

404, 756

8507, 8914

1698, 8484

170, 383

1075, 1680

785, 1052

29,551

114,721

53040

Discharge summary

report

Admission Date: [**2184-2-9**] Discharge Date: [**2184-2-14**] Date of Birth: [**2133-11-12**] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 14197**] Chief Complaint: Right thigh pain Major Surgical or Invasive Procedure: 1. Radical resection of right thigh mass 2. Prophylactic internal fixation right femur with an 11 hole DC plate 3. Exposure of superficial femoral and profunda arteries with a separate medial thigh incision by Vascular surgery History of Present Illness: The patient is a 50-year-old gentleman who presented with a large mass in his right anterior thigh 2-3 months ago. It was extremely painful. He was evaluated and found to have a large mass deep in his quadriceps adjacent to the bone. Biopsy of this showed elements of sarcoma and carcinoma intermixed and he also was found to have pulmonary metastases. He has medullary carcinoma of the thyroid. He underwent treatment with preoperative radiation and chemotherapy as the radiosensitizer but the mass got even larger and unfortunately his pulmonary metastases increased in size and number. It was recommended that he consider chemotherapy for his pulmonary mets but he strongly desired to have this thigh mass removed first and therefore he was brought to the operating room today for that procedure. Past Medical History: Patient developed small R thigh pain/mass in [**7-5**] which was felt to be was bursitis but as the mass enlarged the area was more painful which prompted another ER evaluation and MRI confirming presence of this mass in the R thigh. Patient was originally seen at [**Hospital 1263**] Hospital. CT guided biopsy on [**2183-10-24**] was consistent with carcinoma with spindle and epithelial morphology focally CK positive and TTF-1 positive. The patient also underwent U/S guided biopsy of a thyroid nodule which showed atypical cells but not clearly malignant. Further imaging with PET and CT demonstrates a R thyroid lobe mass, scattered small pulm nodules, mildly FDG avid region in the L adrenal gland and L psoas muscle and a 20cm R thigh mass in the region of the femur without bony involvement or FDG uptake within the skeleton. Social History: Was living with niece temporarily. Unemployed, former bricklayer. Former smoker, quit within past year. Family History: Unknown, as he is adopted. Physical Exam: NAD, alert RLE: [**Last Name (un) 938**]/DF/PF intact, SILT over tib/sp/dp, palpable DP incision c/d/i, benign Pertinent Results: Hgb [**2184-2-13**]: 9.1 (stable) Brief Hospital Course: Patient was admitted for the above listed surgery, tolerated it well. Complication was a broken screw at the distal end of the DC plate. EBL: 1000cc. While in the PACU the patient became tachycardic and hypotensive with low UOP, his thigh incision was draining bloody fluid (300cc in 2 hours). His dressing was reinforced and his heart rate was controlled with medication. He was transferred to the ICU o/n. The tachycardia and hypotension were secondary to hypovolemia, he was transfused a total of 4 units pRBC's (Hgb 7.7) o/n. His heart trended down, his UOP increased and his BP normalized. Of note he was started on Hydrocortisone in the ICU secondary to a low random cortisol (0.6). He was transferred to the floor on POD 1 in stable condition. He was started in SSI secondary to elevated blood sugar secondary to the steroid. Hydrocortisone was discontinued on POD 2 after discussion with endocrine. His BP remained stable. His blood sugar normalized after the steroid was discontinued. His Hgb trended up following the initial transfusion, but on POD 2 the Hgb was 8.4 and he was transfused 2 units pRBC's. His Hgb trended up to 9.1 where it remained stable. At discharge he was voiding spontaneously, tolerating PO diet, and pain was controlled. He was cleared for safe discharge to rehab by PT. He was afebrile and hemodynamically stable at discharge. Medications on Admission: COLACE 50 mg-- MS CONTIN 100 mg--1 tablet(s) by mouth twice daily Morphine 30 mg--1 tablet(s) by mouth [**4-4**] as needed for pain PROTONIX 40 mg--1 tablet(s) by mouth daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Morphine 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 4. Trazodone 50 mg Tablet Sig: 1-2 Tablets PO QHS (once a day (at bedtime)) as needed for insomnia. 5. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3 hours) as needed. 6. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once a day. 7. 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: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Right thigh carcinoma/sarcoma Discharge Condition: Stable Discharge Instructions: 1. Lovenox daily for 4 weeks. 2. Weight bearing as tolerated right lower extremity. 3. [**Doctor Last Name **] brace for comfort when ambulating. 4. R knee ROM as tolerated. 5. You may shower, no bathing. Pat incision dry when finished. 6. Daily dressing changes with dry sterile guaze. [**Month (only) 116**] wrap with an ACE bandage. Physical Therapy: 1. Weight bearing as tolerated right lower extremity. 2. [**Doctor Last Name **] brace for comfort when ambulating. 3. R knee PROM and AROM as tolerated. Treatments Frequency: Dry sterile dressing changes to right thigh incisions changed daily Followup Instructions: Follow up in [**Hospital Ward Name 23**] [**Location (un) **] with Dr [**Last Name (STitle) **] in 2 weeks with AP and Lat X-ray of the right femur.

[ "171.3", "458.29", "V10.87", "255.41", "V15.3", "401.9", "197.0", "250.00", "285.1" ]

icd9cm

[ [ [] ] ]

[ "99.04", "83.39", "79.35" ]

icd9pcs

[ [ [] ] ]

4904, 4974

2624, 4004

337, 566

5048, 5057

2566, 2601

5706, 5858

2391, 2420

4230, 4881

4995, 5027

4030, 4207

5081, 5420

2435, 2547

5438, 5592

5614, 5683

281, 299

594, 1395

1417, 2253

2269, 2375

43,128

150,895

52709+59458

Discharge summary

report+addendum

Admission Date: [**2129-8-11**] Discharge Date: [**2129-10-11**] Date of Birth: [**2085-8-31**] Sex: F Service: MEDICINE Allergies: Haldol Attending:[**First Name3 (LF) 2009**] Chief Complaint: Fever, hypotension Major Surgical or Invasive Procedure: right IJ placement and removal left PICC placement [**8-20**] attempted right hip fluid collection drainage by interventional radiology [**9-5**] History of Present Illness: Ms [**Known lastname 108741**] is a 43 year old woman with history of transverse myelitis leading to paraplegia, depression, frequent pressure ulcers, presenting with chills and reporting she felt "as if dying". Upon presentation, she denied any shortness of breath, nausea, vomiting, but did report diarrhea with two loose bowel movements per day. Patient reported that she had a fallout with her VNA and has not had any professional wound care since early [**Month (only) 205**]. Patient has a long history of psychiatric and behavioral problems. [**Name (NI) **] [**Name2 (NI) **] review, patient was dismissed from the [**Company 191**] practice due to abusive behavior against staff. She does not have a primary care provider at this time. In the ED: Temp 98.9 HR: 90 BP: 109/62 RR: 16 O2 Sat: 97% RA. Patient initially thought to be agitated yelling her EMS transporters were "white devils". Patient kept in observation area, although with rigors, complaining of feeling cold and back pain. Patient rolled and found to have a stage IV decubitus ulcer on coccyx and buttocks, heels. Right IJ inserted and Sepsis protocol was initiated. Patient given 5L NS and started on Norepinephrine drip. CVP documented as 2 with SvO2 of 80%. Patient started on Vancomyxin and Zosyn. Past Medical History: Of note, patient adheres to Jehovah's Witness belief and should not be transfused with any blood products. Recent ([**10-23**]) removal of ??????ex-fix?????? tibio-talar fusion of L ankle. Paraplegia due to transverse myelitis Multiple complications from pressure wounds Depression with suicidal ideation, treated at [**Hospital1 **] Borderline hypertension GERD Hx thalassemia per pt, worked up in past at [**Hospital1 2025**] Social History: Jehovah's Witness belief and should not be transfused with any blood products. Chronic NH resident but has had arguments and behavioral problems with multiple NHs in past. Threw coffee at a nurse. Tob: 1pack every few days for 10 years EtOH: Denies Illicit drugs: Denies - but tested positive for cocaine in urine in ED in the past. Family History: Noncontributory. Physical Exam: Vital signs: T 97.0 HR 122 BP 93/54 O2 Sat 100% 2L NC GENERAL: Appears in no acute distress, resting comfortably in bed. HEENT: EOMI, PERRL, Mucous membranes moist. CV: Regular rate, no murmurs, rubs or gallops. Normal S1 and S2 Lungs: Clear to auscultation bilatearally Skin: Stage IV decubitus ulcer along sacrum / coccyx with spontaneous drainage and purulence. Genitalia with desquamation and abnormal external genitalia. Heels with pressure ulcers bilaterally with clear borders and no drainage. Plantar wound with eschar. PSYCH: Patient with circumlocution, reporting several conflicts with health care personnel. Not agitated, easily directable. Though mostly linear. Pertinent Results: ================== ADMISSION LABS ================== [**2129-8-11**] 01:50PM BLOOD WBC-10.3 RBC-4.98 Hgb-8.1* Hct-30.7* MCV-62* MCH-16.2*# MCHC-26.3* RDW-17.5* Plt Ct-914* [**2129-8-11**] 01:50PM BLOOD Neuts-89.0* Bands-0 Lymphs-9.9* Monos-0.8* Eos-0.3 Baso-0.1 [**2129-8-11**] 01:50PM BLOOD PT-15.6* PTT-32.8 INR(PT)-1.4* [**2129-8-11**] 01:50PM BLOOD Glucose-99 UreaN-10 Creat-0.6 Na-135 K-4.9 Cl-102 HCO3-18* AnGap-20 [**2129-8-11**] 01:50PM BLOOD Calcium-8.5 Phos-3.2 Mg-2.3 [**2129-8-11**] 04:00PM BLOOD Lipase-17 [**2129-8-11**] 01:56PM BLOOD Lactate-6.3* [**2129-8-11**] 04:12PM BLOOD Lactate-2.9* [**2129-8-11**] 06:17PM BLOOD Lactate-1.6 Cultures: Blood Cultures: 07/24*2 ([**1-19**] + Peptostreptococcus), [**8-14**], 7/31*3, 8/04*2, [**8-24**], 8/10*2, 8/13*2, [**9-7**], 8/21*2 all negative except as indicated Urine Cultures: [**8-11**], [**8-24**] (yeast, GNRs), [**8-25**], [**9-2**], [**9-5**] (Ecoli w resistence: AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- I CEFEPIME-------------- 2 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 32 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 2 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- =>128 R PIPERACILLIN/TAZO----- =>128 R TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R) Stool for Cdiff toxin: [**8-11**], [**8-24**], [**8-26**], [**8-28**], [**9-12**] - all negative Imaging: [**2129-8-25**] CXR FINDINGS: The lungs are clear without consolidation or effusion. Retrocardiac opacities seen on [**8-20**] have resolved. The hilar and cardiomediastinal contours are unchanged. Marked scoliosis is again seen. The remainder of the visualized osseous and soft tissue structures are normal. The PICC is in unchanged position, while the right IJ central venous line has been removed. IMPRESSION: No evidence for pneumonia. [**8-27**] LLE Duplex: FINDINGS: The grayscale and Doppler evaluation of the right common femoral, superficial femoral, popliteal veins demonstrate normal compressibility, flow, augmentation. The left common femoral waveform was interrogated for comparison. No intraluminal thrombus was identified. IMPRESSION: No DVT in the right lower extremity. [**8-31**] RLE Duplex: FINDINGS: There is normal color Doppler signal, pulse Doppler waveform, compressibility, and augmentation within the veins of the left lower extremity, including the left common femoral, left superficial femoral, and left popliteal veins. Proximal calf veins demonstrate color flow. IMPRESSION: Negative for DVT within the common femoral, superficial femoral, and popliteal veins. [**9-2**] CT A/P: 1. Large posterior ulceration extending to the left iliac bone, with associated inflammation consistent with osteomyelitis. 2. 4 x 1 cm low-density fluid collection within the residual joint of the right hip. 3. Large right renal angiomyolipoma. 4. Small fat-containing right lumbar hernia. [**9-5**] CT P: CT-guided needle placement in the right hip yielded no fluid; the hypodense area seen on the CT scan therefore likely represents organizing granulation tissue or phlegmon rather than a loculated fluid collection. Brief Hospital Course: 43 year old woman with transverse myelitis and paraplegia c/b severe pressure ulcers and several prior wound infections who presented on [**8-11**] with sepsis successfully treated with early goal-directed therapy thought [**2-19**] decubiti and osteomyelitis also with E.coli and subsequent E.cloacae urinary tract infection stable on current regimen of vancomycin and meropenem. Abx for empiric treatment of osteomyelitis. Patient also now with sister as legal guardian as of [**2129-10-7**], which is set to expire in [**2129-12-19**]. . #. Osteomyelitis - Upon presentation, the patient had several decubiti that could be probed to the bone. An Infectious Disease consult was called and followed the patient throughout her hospitalization. She was initially treated with vancomycin, cipro, and flagyl. As she continued to spike through this regimen, she was changed to vancomycin and piperacillin-tazobactam. She continued to spike and there was some concern for drug fever although the offending drug was unclear. Vancomycin was stopped and the patient was maintained on sole therapy with zosyn. As she continued to spike fevers and was repeatedly cultured without isolation of probable offending bacteria, the patient was imaged to look for possible fluid collection. All antibiotics were stopped for approximately 2 days after an area of possible fluid collection was located in the patient's right hip. She was thereafter sent to interventional readiology for aspiration of the fluid. Unfortunately, her course in IR was complicated when the IR needle broke off in her hip and had to be retrieved with a small incision by surgery. There was discussion as to the potential benefit of bone biopsy if the patient continued to spike but the patient was resistent to this idea due to her protracted and complicated course. She was started on vancomycin, flagyl, and ceftazadime on [**9-7**] and defervesced with this regimen. On [**9-25**], patient developed fevers and a UTI. Patient was started on meropenem and vancomycin which, as per ID, was sufficient for empiric treatment for osteomyelitis. The patient will take antibiotics for 6 total weeks, until end of [**Month (only) 359**], for empiric treatment at [**Hospital1 **]. . #. Sacral decubitus ulcer / heel ulcers: Most likely source of infection. Able to probe to bone. Plastic surgery team consulted but did not feel like she was a surgical candidate given chronic infection and the size of the wound. They did not believe that she needed an MRI to assess for osteomyelitis, given presumed diagnosis as they were able to probe to bone. Wound care nursing made recommendations regarding how to treat wounds and followed patient throughout her stay with drastic improvement in her decubiti during her stay. Patient has wound care recommendations in discharge summary to [**Hospital1 **]. . #. UTI: The patient was found to have a highly resistant E.coli UTI on [**9-5**]. She defervesced with ceftazadime and, since this antibiotic was necessary for her osteomyelitis treatment, she was continued on this antibiotic for her UTI as well as her osteo. Patient subsequently developed a UTI with fevers with E.cloacae sensitive to meropenem growing within urine on urine culture. Patient was summarily begun on meropenem and, in addition, was started on vancomycin for possible bacteremia that was, most likely, a contaminant, but was also used for empiric treatment of her osteomyelitis. Patient now on meropenem and vancomycin empirically for osteomyelitis treatment at [**Hospital1 **]. . #. Urinary Incontinence: The patient's urinary incontinence was thought to be contributing to maceration of her pelvic tissues. Urology was consulted and the patient was started on ditropan TID with some benefit per her. She had foley's in place throughout her stay but has an incompetent urethra with leaking of fluid around the foley balloon. Urology also discussed possible surgical procedures with the patient (including a procedure to tighten the urethra) but felt there was nothing additional to do while in-patient given current other medical problems. The patient's urologist was part of the consulting team and was involved. She should follow up with him once her acute issues are under better control. . #. Likely Schizoaffective Disorder: Psychiatry was consulted after she threatened suicide during this hospitalization. They did not believe that she was at risk of suicide. Patient also constantly was accusing staff of prejudice due to her self declared adherence to both the [**Hospital1 **] and jehova's witness faiths. Psychiatry diagnosed her with shizophrenia vs. schizoaffective disorder, and started her on Risperdal 2mg [**Hospital1 **] with 2mg [**Hospital1 **] PRN. She was maintained on risperidone. . #. Anemia: Patient has beta-thalassemia trait along with anemia of chronic disease. Lowest HCT was 22.4, however patient declined transfusions given that she is a Jehova's witness. She was supplemented with iron, folate, and a multivitamin with stable hematocrit around 25. She was slightly tachycardic during her stay but was otherwise unsymptomatic. . #. Thrombocytosis: The patient had a very significant thrombocytosis to 1.2 million at its highest. Once on her current antibiotic regimen, her platelets began to trend downward. She was maintained on an aspirin. . #. FEN: Patient was kept on a regular diet. Nutrition was consulted and calorie counts were performed. They found that she was getting less than 50% of the calories she needed, and less than 30% of required protein. They recommended tube feeds, however the patient was not amenable to this. She was started on a multivitamin, Vitamin A, and Vitamin C per nutrition's recommendations. . #. Prophylaxis: SQ Lovenox, patient eating, does not need PPI . #. CODE: FULL, confirmed with patient. No blood products. . Medications on Admission: Dulcolax supossitories Colace Bactrim 80mg/400mg Penciclovir 1% topical Vitamin C 500mg daily Fluticasone 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. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 3. Menthol-Cetylpyridinium 3 mg Lozenge Sig: [**1-19**] Lozenges Mucous membrane PRN (as needed). 4. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous Q24H (every 24 hours). 5. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 6. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 7. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-19**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 11. Risperidone 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. Risperidone 2 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety, agitation. 16. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily) as needed. 19. Acyclovir 5 % Ointment Sig: One (1) Appl Topical ASDIR (AS DIRECTED). 20. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 21. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily) as needed. 22. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 23. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-19**] Sprays Nasal TID (3 times a day) as needed for congestion . 24. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 25. Nicotine (Polacrilex) 2 mg Gum Sig: One (1) Gum Buccal Q1H (every hour) as needed. 26. Papain-Urea 830,000-10 unit/g-% Ointment Sig: One (1) Appl Topical DAILY (Daily). 27. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 28. Benzoyl Peroxide 10 % Gel Sig: One (1) Appl Topical DAILY (Daily). 29. Meropenem 500 mg IV Q6H 30. Vancomycin 1000 mg IV Q 12H Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: 1. Septic shock 2. Grade 4 Sacral, perineal, and ischial decubitus ulcers 3. Pressure ulcers over heels bilaterally 4. Chronic osteomyelitis 5. Likely Schizoaffective Disorder 6. Thrombocytosis 6. Anemia with presumed beta-thalassemia trait Discharge Condition: good, vital signs have been stable, afebrile for the last 7 days, eating, drinking without complaint. Patient has a tendency to believe that people are prejudiced towards her due to her religion, it is helpful if people explain to her the procedures being done before doing it in a calm fashion. In addition, patient has a guardian (sister) appointed by the courts. Also, patient ambulates via wheel chair and has several decubitis ulcers and heel wounds which need constant attention and dressing as outlined in the discharge instructions. Discharge Instructions: You were admitted to the hospital in septic shock, due to the infection in from your ulcers. You were treated with IV fluids and IV antibiotics. The wound care nurse wrapped and treated your ulcers daily. She also recommended placing a VAC on your right ischial wound, which was placed and helped heal part of the wound. You also had several services come see your wounds, including orthopedics and plastics. Orthopedics had placed some staples in your lower right abdomen which was later removed after the area had healed. In addition, you were started on two antibiotics, meropenem and vancomycin, because you had started having a urinary tract infection, and a possible infection in your blood and your bones. A guardianship process was commenced, and your sister was formally appointed your guardian. Followup Instructions: Infectious Disease Clinic Appointment [**First Name4 (NamePattern1) 8495**] [**Last Name (NamePattern1) 8496**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2129-11-10**] 11:00 You also need to establish care with a primary care attending. Please call [**Hospital **] Health Center at [**Telephone/Fax (1) 3581**] to arrange. Please check weekly ESR/CRPs to assess for resolution of inflammatory response, and weekly vancomycin troughs, and fax to the Infectious Disease Clinic: [**Telephone/Fax (1) 1419**] Completed by:[**2129-10-11**] Name: [**Known lastname 17805**],[**Known firstname **] R Unit No: [**Numeric Identifier 17806**] Admission Date: [**2129-8-11**] Discharge Date: [**2129-10-11**] Date of Birth: [**2085-8-31**] Sex: F Service: MEDICINE Allergies: Haldol Attending:[**First Name3 (LF) 4842**] Addendum: As an addendum: The patient needs a repeat pelvic CT in 4 weeks to assess the resolution of the fluid collections and the possible osteomyelitis. Please inform the [**Hospital **] clinic as noted in original discharge summary and planning about the results after scan is completed. In addition, agreed upon empiric treatment of antibiotics for a duration of 6 weeks was secondary to patient's initial refusal to undergo more intensive and directed forms of treatment, which would include bone biopsies of existing wound sites. Even with her guardian now in place, it was determined that to avoid any further problems/refusals with treatment from the patient, an appropriate course of action would be to treat with empiric coverage for 6 weeks. Discharge Disposition: Extended Care Facility: [**Hospital3 14**] & Rehab Center - [**Hospital1 15**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4843**] MD [**MD Number(2) 4844**] Completed by:[**2129-10-12**]

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icd9cm

[ [ [] ] ]

[ "80.15", "38.93", "81.91" ]

icd9pcs

[ [ [] ] ]

18640, 18879

6566, 12453

287, 435

15574, 16120

3298, 6543

16979, 18617

2565, 2583

12612, 15187

15310, 15553

12479, 12587

16144, 16956

2598, 3279

229, 249

463, 1746

1768, 2198

2214, 2549

44,910

174,615

36442

Discharge summary

report

Admission Date: [**2195-4-30**] Discharge Date: [**2195-5-20**] Date of Birth: [**2167-5-16**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1271**] Chief Complaint: found down Major Surgical or Invasive Procedure: [**2195-4-30**] Wound washout [**2195-5-13**] wound washout [**2195-5-18**] PICC line placement [**2195-5-19**] Initiation of packing of occipital wound / needs to be done daily History of Present Illness: HPI:27 year old found down at the bottom of stairs with GCS 6. He was intubated at the OSH and given 50 of mannitol as well as cerebrex. His head CT showed ?EDH and skull fractures. The patient was medflighted here and neurosurgery was called for evaluation. Past Medical History: PMHx:drug and ETOH abuse per brother Social History: Social Hx:per OSH records patient has h/o drug and ETOH abuse Family History: Family Hx:unknown Physical Exam: PHYSICAL EXAM: T:97.6 BP: 131/86 HR:84 RR:22 O2Sats:100% vented Gen: WD/WN, comfortable, NAD. HEENT: Pupils:2mm, non-reactive bilaterally Open occipital wound palpated. EOMs-unable to test Neck: In cervical collar. Lungs: On ventilator. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: GCS 3. Patient has no corneals, no gag, no cough. Cranial Nerves: I: Not tested II: Pupils equally round but nonreactive. III-XII: unable to test Motor: No movement to deep noxious stimuli in any extremity. Sensation: Does not appear to feel pain. Toes mute bilaterally ON DISCHARGE Awake alert oriented x 3, speech clear, CN II-XII intact, tongue ML, trace left pronator drift, motor full otherwise, sensation intact. Pertinent Results: CT head from OSH: No hemorrhage appreciated. There are multiple areas of skull fracture in the occipital region. Repeat CT at [**Hospital1 18**]: tiny SDH along tentorium, fractures are again noted. No epidural hematoma is seen. MRV HEAD W/O CONTRAST Study Date of [**2195-5-1**] 12:27 AM FINDINGS: There is no acute infarct seen. Hemorrhagic contusions are identified involving both cerebellar tonsils with increased signal seen within both cerebellar tonsils, which are displaced inferiorly to the upper cervical region. Additionally, foci of hemorrhage are seen in the left cerebellar hemisphere along the vermis and also along the lateral aspect of the cerebellum adjacent to the left occipital bone fracture. Blood is visualized in the subarachnoid space as well as in the occipital horns of both lateral ventricles. There is no hydrocephalus seen. There is no midline shift. Mucosal changes are seen in the sinuses. IMPRESSION: 1. Left occipital bone deformity identified with hemorrhagic contusions in the left cerebellar hemisphere and also involving both cerebellar tonsils. The cerebellar tonsils appear herniated below the foramen magnum. 2. Focus of increased signal around the fourth ventricle on FLAIR with involvement of the left facial colliculus. This could also reflect edema from contusion. 3. Subarachnoid hemorrhage with blood within the lateral ventricles. No evidence of hydrocephalus. MRV OF THE HEAD: The head MRV demonstrates normal flow in the superior sagittal and right transverse sinus. The left transverse sinus demonstrates narrowing in its midportion at the site of fracture. However, continuous flow signal is identified indicating patency. No collateral vessels are identified. IMPRESSION: No evidence of sinus thrombosis. The left transverse sinus appears compressed and narrowed in the mid portion. The superior sagittal and right transverse sinuses are normal. MR BRACHIAL PLEXUS W/O CONTRAST Study Date of [**2195-5-1**] 6:05 PM MR BRACHIAL PLEXUS: For the purposes of this study due to the fact that the patient was intubated and with an A-line in place, the right arm was imaged up and the left arm down. Allowing for this difference both brachial plexi morphologically appear normal without evidence of adjacent hematoma or avulsion. Comparison with the most recent MR [**Name13 (STitle) 2853**] confirms these findings. There is striking edema within the cerebellar tonsils as well as the left cerebellar hemisphere. Cerebellar tonsils appear slightly inferiorly herniated which is better evaluated on a prior MRI/MRA brain. There is edema within the left occipital bone. Note is made of consolidation at the left lung base, which is likely due to aspiration and/or contusion. There is prominent edema throughout the left paraspinal muscles, particularly involving the semispinalis capitis and splenius capitis with edema approaching the lower cervical spinal nerve roots but not abutting them. IMPRESSION: 1) Normal MR appearance of the brachial plexi. 2) Extensive left paraspinal muscle injury as above. 3) Left cerebellar hemisphere and cerebellar tonsillar contusions; please see prior MRI brain for better assessment. 4) Left lung base consolidation, which in this setting is likely due to aspiration and/or contusion. CT HEAD W/O CONTRAST Study Date of [**2195-5-2**] 9:42 AM FINDINGS: Similar appearance to subdural blood layering along the tentorium bilaterally. Subarachnoid blood in the posterior horns of lateral ventricles and interpeduncular cistern is unchanged. Frontoparietal subarachnoid blood layering in the sulci towards the vertex is similar to prior (series 2, image 23). Punctate foci consistent with contusion are again seen in the cerebellum. Again seen is diffuse sulcal effacement consistent with mild global edema. There is persistent mild effacement of the fourth ventricle. The third and lateral ventricles appear unchanged. Caudal displacement of the tonsils appear similar to prior. There is no shift of normally midline structures and no evidence of major vascular territorial infarct. Again seen is an extensively comminuted left occipital bone fracture extending into the skull base (for details see the CT of [**2195-4-30**]). There is subcutaneous emphysema in the left occipital subgaleal tissues with overlying skin staples, unchanged from prior. Mucosal thickening is again seen in the ethmoidal, sphenoidal and bilateral maxillary sinuses with circumferential thickening on the right. IMPRESSION: 1. Stable appearance of subdural hemorrhage layering along the tentorium and stable appearance of subarachnoid hemorrhage including layering in the lateral ventricles and interpeduncular cistern. 2. Cerebellar contusion. Mild global edema persists with mild effacement of the fourth ventricle, but no midline shift and no interval change in ventricular size. 3. Unchanged displacement of the cerebellar tonsils inferiorly, better assessed on the prior study of [**2195-5-1**]. CT HEAD W/O CONTRAST Study Date of [**2195-5-8**] 8:08 AM IMPRESSION: 1. Interval improvement in diffuse sulcal effacement as well as mass effect on the fourth ventricle. 2. Interval evolution of subdural hematoma and cerebellar contusion, with resorption of subarachnoid and intraventricular hemorrhage. CT HEAD W/ & W/O CONTRAST Study Date of [**2195-5-11**] 3:41 PM IMPRESSION: 1. Thick rim-enhancing subcutaneous fluid collection abutting the fracture site and extending inferiorly which appears to be increasing in size. Assessment for change and enhancement is not possible given lack of any prior contrast-enhanced studies. Given the clinical symptoms, it is worrisome for superinfection. 2. Regions of enhancement surrounding the previously described hemorrhagic contusions within the left cerebellar tonsil and left cerebral hemisphere. While this finding can be seen in noninfected hematomas, given the overlying suspicious fluid collection, additional foci of infection cannot be excluded by imaging. [**Last Name (LF) 82567**],[**Known firstname **] [**Medical Record Number 82568**] M [**2106-5-24**] Radiology Report CT HEAD W/ & W/O CONTRAST Study Date of [**2195-5-11**] 3:41 PM [**Last Name (LF) **],[**First Name3 (LF) 742**] NSURG FA11 [**2195-5-11**] 3:41 PM CT HEAD W/ & W/O CONTRAST Clip # [**Clip Number (Radiology) 82569**] Reason: eval for infection / pt with left occipital open skull fract Contrast: OPTIRAY Amt: 90 [**Hospital 93**] MEDICAL CONDITION: 27 year old man with left occipital sk fx. REASON FOR THIS EXAMINATION: eval for infection / pt with left occipital open skull fracture s/p washout and closure without [**Last Name (un) 2043**] repair...now with bump in WBC from 14 to 20 without obvious source... CONTRAINDICATIONS FOR IV CONTRAST: None. Provisional Findings Impression: JKPe MON [**2195-5-11**] 8:06 PM There is interval increase in size to a rim-enhancing left posterior occipital fluid collection tracking from the bony fracture site inferiorly which is suspicious for superinfection. Additional smaller foci of enhancement involving the left cerebellum and left cerebellar tonsil are noted at the site of prior hemorrhagic contusions and likely relate to enhancement around the hematoma although superinfection cannot be excluded by imaging. Final Report HISTORY: Rising white cell count with known left occipital open skull fracture status post washout and closure. Comparison is made to [**5-2**] and [**5-8**] CT examinations as well as [**5-1**] MRI examination. TECHNIQUE: Axial acquired images were obtained through the brain prior to and after the administration of intravenous contrast. CT OF THE HEAD WITHOUT AND WITH INTRAVENOUS CONTRAST: Unenhanced images of the brain display hypodensity at the patient's known sites of prior hemorrhagic contusions within the left cerebellar tonsil and left cerebellar hemisphere. The brain parenchyma appears otherwise normal with no new regions of hemorrhage noted. A 13 x 27 mm (AP and TR) thick rim-enhancing fluid collection is noted to extend craniocaudally from the fracture site inferiorly along the left occipital bone. Its size as well as the degree of internal fluid content appears predominantly new from the [**5-2**] exam and increased from the [**5-8**] exam. Mild induration of the adjacent subcutaneous fat is noted along this collection. Additional non-liquified enhancing components are also present more inferiorly within the posterior musculature. Additionally, adjacent to the fracture site, there is mild enhancement noted along the previously demarcate hemorrhagic left cerebellar contusions, the one more laterally is less conspicuous than the 9 x 11 mm more medial collection. Additional smaller foci of enhancement are noted within the left cerebellar tonsil which was also noted to have a hemorrhagic contusion on prior MR. The degree of mass effect within the posterior fossa appears slightly improved with post-surgical changes from prior suboccipital craniotomy again noted. There is increased opacification involving the right maxillary sinus with remaining paranasal sinuses displaying minimal mucosal disease. Mild opacification of both of the mastoid air cells bilaterally is also unchanged. IMPRESSION: 1. Thick rim-enhancing subcutaneous fluid collection abutting the fracture site and extending inferiorly which appears to be increasing in size. Assessment for change and enhancement is not possible given lack of any prior contrast-enhanced studies. Given the clinical symptoms, it is worrisome for superinfection. 2. Regions of enhancement surrounding the previously described hemorrhagic contusions within the left cerebellar tonsil and left cerebral hemisphere. While this finding can be seen in noninfected hematomas, given the overlying suspicious fluid collection, additional foci of infection cannot be excluded by imaging. [**Known lastname **],[**Known firstname **] [**Medical Record Number 82568**] M [**2106-5-24**] Radiology Report CT HEAD W/ & W/O CONTRAST Study Date of [**2195-5-18**] 4:07 PM [**Last Name (LF) **],[**First Name3 (LF) 742**] NSURG FA11 [**2195-5-18**] 4:07 PM CT HEAD W/ & W/O CONTRAST Clip # [**Clip Number (Radiology) 82570**] Reason: eval for possible abcess in left cerebellar region / eval po Contrast: OPTIRAY Amt: 90 [**Hospital 93**] MEDICAL CONDITION: 28 year old man with open skull fracture - with wound infection s/p wash out... REASON FOR THIS EXAMINATION: eval for possible abcess in left cerebellar region / eval postop wound washout.... thank you CONTRAINDICATIONS FOR IV CONTRAST: None. Provisional Findings Impression: JKPe MON [**2195-5-18**] 7:44 PM PFI: Marked interval decrease in size of rim-enhancing posterior subcutaneous fluid collection with small approximately 9 x 25 mm rim-enhancing collection noted to persist inferiorly. The regions of intraparenchymal rim enhancement surrounding the prior sites of hemorrhagic contusions are less conspicuous on today's exam which suggests no underlying parenchymal infection. Final Report HISTORY: Open ankle fracture status post debridement of superinfected subcutaneous collection. Comparison is made to [**2195-5-1**] MRI and [**2195-5-11**] head CT. TECHNIQUE: Axial contiguous images were obtained through the brain without and with intravenous contrast. CT OF THE BRAIN WITHOUT AND WITH INTRAVENOUS CONTRAST: Unenhanced images of the brain demonstrate no evidence of acute intracranial hemorrhage, mass effect, shift of midline structures, hydrocephalus, or acute major vascular territorial infarct. Regions of low attenuation within the left cerebellar hemisphere and vermis persist and correlate to the sites of prior intraparenchymal hemorrhagic contusions. Post-contrast administration there is better identification of improvement of the previously identified large thick rim-enhancing subcutaneous fluid collection which has underwent interval evacuation. There is some persistent fluid noted about the skull fracture site with subcutaneous emphysema; however, the rim-enhancing component has decreased with only a small pocket noted to persist inferiorly measuring 9 x 25 mm (series 3 image 5). Additional post-surgical changes involving the suboccipital craniotomy are stable as is the overall appearance of the minimally displaced left occipital skull fracture. There is no finding to suggest underlying osteomyelitis. The regions of intraparenchymal contusion again display very mild rim enhancement; however, this is less conspicuous than the most recent enhanced examination of [**5-11**] suggesting evolving intraparenchymal hematomas. Moderate-to-severe chronic mucosal thickening involving the right maxillary sinus and right [**Doctor Last Name 13856**] bullosa are again noted. The remaining paranasal sinuses and mastoid air cells are well aerated. There is partial opacification noted to persist involving the right mastoid air cells. IMPRESSION: 1. Significant interval decrease in size to the known superinfected subcutaneous fluid collection abutting the fracture site. Only a small pocket remains which displays rim enhancement more inferiorly. 2. Decreased rim enhancement surrounding the hemorrhagic intraparenchymal contusions involving the left cerebellar hemisphere with no new regions of intraparenchymal enhancement or extra-axial fluid collections to suggest subdural/epidural empyema. The study and the report were reviewed by the staff radiologist. [**Known lastname **],[**Known firstname **] [**Medical Record Number 82568**] M [**2106-5-24**] Radiology Report [**Numeric Identifier 76392**] EXCH PERPHERAL W/O PORT Study Date of [**2195-5-18**] 5:09 PM [**Last Name (LF) **],[**First Name3 (LF) 742**] NSURG FA11 [**2195-5-18**] 5:09 PM PICC LINE PLACMENT SCH Clip # [**Clip Number (Radiology) 82571**] Reason: right picc up the neck. needs repo [**Hospital 93**] MEDICAL CONDITION: 28 year old man with new picc placmt REASON FOR THIS EXAMINATION: right picc up the neck. needs repo Provisional Findings Impression: JXXb MON [**2195-5-18**] 9:00 PM Repositioning of PICC line with tip of the PICC line in SVC and the line is ready to use. Final Report CLINICAL INFORMATION: The patient is an 28-year-old man who had infection and needed PICC line placed for antibiotics. The existing PICC line was misplaced and needed to be repositioned by IR. OPERATORS: Dr. [**First Name8 (NamePattern2) 82572**] [**Name (STitle) **] and Dr. [**First Name (STitle) 4685**] [**Name (STitle) 4686**], the attending radiologist who was present and supervised during the whole procedure. PROCEDURE: PICC line reposition. ANESTHESIA: Lidocaine was used for local anesthesia. PROCEDURE AND FINDINGS: After the risks and benefits of the procedure as well as local anesthesia were explained, the patient was brought to the angiography suite and placed supine on the imaging table. The right arm and the existing PICC line was prepared and draped in the usual sterile fashion. A scout image was taken which demonstrated the PICC line tip was located in the right IJ. A decision was made to reposition the existing PICC line. The PICC line was then pulled back under fluoroscopic guidance with the tip located in the right brachiocephalic vein and then the PICC line was advanced forward with the tip lodged into the SVC. The wire was then removed. The PICC line was aspirated and flushed easily. The PICC line was secured to the skin and sterile dressing was applied. The patient tolerated the procedure well, and there were no immediate complications. IMPRESSION: Repositioning of PICC line with the tip of PICC line in SVC and the catheter is ready to use. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **] DR. [**First Name (STitle) **] [**Name (STitle) **] Approved: WED [**2195-5-20**] 8:23 AM Brief Hospital Course: Pt was admitted to the neurosurgery service after eval in the ED for depressed skull fracture. He was taken to the OR where under general anesthesia he underwent a wound washout with minimal elevation of depressed skull fracture. He tolerated this well and was transferred to TICU. On exam he was found to have left upper extremity weakness. He underwent CT c-spine that showed no fracture and cervical MRI which showed no ligamentous injury. His hard collar was removed. He also had brachial plexus MRI which showed no injury. He also had MRV which showed the left transverse sinus demonstrating narrowing in its midportion at the site of fracture and therefore was started on aspirin. EEG testing was completed which showed Left slowing, no seizure foci. He was kept NPO until formal swallow eval copuld be done [**12-29**] absent gag reflex. On [**5-5**] he was transferred out of the Intensive Care Unit to [**Hospital Ward Name 2982**] Step down. Speech and swallowing evaluation was done and he was started on a regular; dysphagia diet with no difficulty. On [**5-7**] in the evening Mr. [**Known lastname 48036**] fell to the floor striking his head as he was trying to get out of bed. CT of the head was negative for new findings. He remained stable over the weekend. It was noted that his WBC count jumped from 14 - 20 in 24 hours. A contrasted head CT was ordered as well as a UA. His urine and sputum cultures were negative. His wound looked clean with a small area of scabbing vs necrosis and was without drainage. A contrasted head CT was obtained [**12-29**] to increased WBC. His CT revealed thick rim enhancing subcutaneous fluid collection abuting fracture site with enhancement surrounding the site was concering for infection, wound was aspirated and sent for cultures. The following day, patient had a nonfocal exam and recieved a lumbar puncture to rule out central nervous system infection. He was brought to the OR on [**2195-5-13**] after bedside eval of wound revealed active exudative drainage. He was closed with interrupted sutures. ID consult was obtained the day prior and recs were followed. He was started on Nafcillin and Micafungin IV for definative treatment. A PICC line was placed on [**2195-5-18**] for abx use. Contrast CT of the brain was obtained for re-eval of possible intracranial abcess vs infarct (enhancement eval). The results showed interval improvement. No plan for re-wash out at this time. ID continue's to follow. Posterior wound remains with element of serous drainage. Wound packed with Idodiform gauze and will be re-packed daily. CSW eval obtained for clarity of use of IV drug use history. Pt denies use of drugs outside of marijuana and alcohol at this time. Rehab screening is in progress. He and his father agree to [**Name (NI) **] rehab. He is to be discharged today [**2195-5-20**] Medications on Admission: Medications prior to admission: Received Cerebrex and 50 of mannitol at OSH. Also received intubation medication. Discharge Medications: 1. Outpatient Lab Work PLEASE HAVE THESE LEVELS DRAWN WEEKLY AND FAX'D TO THE FOLLOWING NUMBER: [**Telephone/Fax (1) **] ATTN: DR.[**Last Name (STitle) **] CBC WITH DIFFERENTIAL CHEM 10 LFT'S ESR CRP 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**11-28**] Tablets PO Q4H (every 4 hours) as needed for headache. 10. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itcing. 11. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. 12. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed) as needed for sore throat. 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 14. Nafcillin 2 g IV Q4H Duration: 4 Weeks at this pt [**2195-5-18**], pt will require 4 weeks of nafcillin IV from start date...thanks 15. 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. 16. Micafungin 100 mg Recon Soln Sig: One (1) Intravenous once a day for 6 weeks: 6 WEEK COURSE TOTAL / STARTED ON [**2195-5-15**]. 17. Nafcillin 2 gram Piggyback Sig: One (1) Intravenous every four (4) hours for 6 weeks: 6 WEEKS TOTAL / STARTED ON [**2195-5-15**]. Discharge Disposition: Extended Care Facility: [**Last Name (un) 6978**] House of [**Hospital1 **] Discharge Diagnosis: Open depressed skull fracture MSSA infection in scalp wound left transverse sinus stenosis dysphagia Yeast infection / scalp tissue cx. Discharge Condition: Stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ?????? 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: YOUR SUTURES SHOULD REMAIN IN PLACE UNTIL [**2195-6-2**] (TOTAL OF 20 DAYS) PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.[**Last Name (STitle) **] TO BE SEEN IN 2WEEKS WITH A CONTRASTED CT SCAN OF THE BRAIN. THE APPOINTMENTS LISTED BELOW ARE TO SERVE AS A REMINDER. THEY WERE POSTED IN OUR SYSTEM PLEASE CALL THESE PROVIDERS IF YOU CANNOT MAKE THESE APPOINTMENTS....HOWEVER IT IS IMPORTANT THAT YOU ATTEND THESE APPOINTMENTS. THANK YOU Provider: [**Name10 (NameIs) 12082**] CARE ID Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2195-6-17**] 3:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13447**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2195-8-19**] 10:30 [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2195-5-20**]

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Discharge summary

report

Admission Date: [**2133-9-17**] Discharge Date: [**2133-9-22**] Date of Birth: [**2084-5-25**] Sex: F Service: SURGERY Allergies: Penicillins / Codeine Attending:[**Doctor First Name 5188**] Chief Complaint: Abdominal pain, vomiting Major Surgical or Invasive Procedure: Right Chest tube placement at bedside History of Present Illness: 49 year old female with history of cervical cancer status post multiple (?26) abdominal surgeries for TAH/BSO and complications resulting in colostomy and urostomy presented to OSH on [**2133-9-17**] with one day of abdominal pain and vomiting. Per OSH report, also experienced chills, fevers, and decreased colostomy output. Noted to have WBC count 13.5. Abdominal CT was consistent with obstruction. In OSH received NS 1L, cipro IV, and narcotics for pain control. Received Narcan and was intubated "due to airway concern" - overdose on narcotic analgesics; ABG 7.20/73/77 on NC 4 LPM, anion gap 17. Also had R subclavian, NG tube placed. . In the [**Hospital1 18**] ED, T 98.4, HR 126, BP 137/100, RR 14, 99% on AC ventilation. Received propofol gtt, flagyl 500mg IV x1, and morphine 4mg IV. Past Medical History: Past Medical History: - Cervical CA s/p TAH/BSO w/incidental appy and damaged bladder ([**2106**]), s/p mult procedures repair ending in urostomy and colostomy - Depression - ?Hepatitis . Social History: Lives with boyfriend. On Disability due to multiple abdominal surgeries/complications. Denies alcohol, drug, or tobacco use. Family History: Noncontributory Physical Exam: Tmax: 37.7 ??????C (99.9 ??????F) Tcurrent: 36.1 ??????C (97 ??????F) HR: 106 (105 - 118) bpm BP: 145/91(105) {113/56(70) - 156/104(115)} mmHg RR: 19 (14 - 28) insp/min SpO2: 98% GEN: Well-appearing, well-nourished, HEENT: EOMI, sclera anicteric, no epistaxis or rhinorrhea, MMM NECK: No JVD, trachea midline CV: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Coarse breath sounds diffusely ABD: Multiple surgical incision scars; colostomy and urostomy bags in place; hypoactive bowel sounds; soft, not distended; difficult to assess for tenderness EXT: No C/C/E NEURO: responds to few questions (e.g. Are you in pain?); Moves all 4 extremities. SKIN: R subclavian in place and dressed; no jaundice, cyanosis, or gross dermatitis. No ecchymoses. . At Discharge: Vitals: 98.9, 81, 107/53, 18, 96% on RA GEN: NAD, A/Ox3 CV: RRR, no m/r/g RESP: CTAB ABD: Soft, ND, slightly tender to palpation. +BS, passing flatus, +Stool Ostomy: stoma beefy red, viable with liquid yellow effluence Urostomy: conduit intact with clear yellow urine Extrem: no c/c/e Pertinent Results: [**2133-9-19**] 04:32AM BLOOD WBC-9.7 RBC-3.35* Hgb-11.8* Hct-33.9* MCV-101* MCH-35.3* MCHC-34.9 RDW-13.6 Plt Ct-223 [**2133-9-17**] 07:24PM BLOOD Neuts-81.9* Lymphs-14.2* Monos-3.3 Eos-0.3 Baso-0.3 [**2133-9-19**] 04:32AM BLOOD PT-12.8 PTT-25.8 INR(PT)-1.1 [**2133-9-19**] 04:32AM BLOOD Glucose-95 UreaN-10 Creat-0.7 Na-144 K-3.3 Cl-106 HCO3-29 AnGap-12 [**2133-9-19**] 04:32AM BLOOD ALT-43* AST-39 LD(LDH)-216 AlkPhos-143* TotBili-1.1 [**2133-9-19**] 04:32AM BLOOD Calcium-8.7 Phos-2.3* Mg-1.9 [**2133-9-18**] 12:17AM BLOOD Type-ART Rates-/14 pO2-124* pCO2-50* pH-7.33* calTCO2-28 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED [**2133-9-17**] 07:32PM BLOOD Lactate-1.3 [**2133-9-21**] 04:50AM BLOOD WBC-6.6 RBC-3.02* Hgb-10.9* Hct-30.4* MCV-101* MCH-36.1* MCHC-35.8* RDW-13.3 Plt Ct-232 [**2133-9-22**] 05:34AM BLOOD Glucose-92 UreaN-5* Creat-0.7 Na-140 K-3.9 Cl-106 HCO3-28 AnGap-10 [**2133-9-22**] 05:34AM BLOOD Calcium-9.0 Phos-3.3# Mg-2.1 . Brief Hospital Course: 49 year-old female with history of cervical cancer and many abdominal surgeries s/p colostomy and [**Hospital 80011**] transferred from OSH for further management of suspected small bowel obstruction. Admitted to Medical ICU. . # Abdominal pain, nausea ?????? Surgery involved. At this time diagnosis of SBO suspected, although surgeons are waiting to see CT abdomen from OSH to solidify diagnosis. Supported by large number of abdominal surgeries patient has had (-> risk for adhesions). Also with mildly elevated transaminases and alk phos. Differential also includes gastroenteritis, cholecystitis, cholangitis. Mildly febrile and with leukocytosis. Given history of possibile pneumobilia on CT at OSH hospital, ddx also includes biliary-enteric anastomosis or fistula. ?history of hepatitis. - intially NPO - NGT to low continuous suction, removed [**9-20**] and started on sips - Hydrate with IVF until adequate PO - Pain control (minimize narcotics) . #Pneumothorax: Pt had PTX most likely [**1-3**] line placement at OSH. Chest-tube was placed and almost complete resolution of PTX. -chest tube to suction until [**9-20**] - placed to waterseal -chest tube removed [**9-21**] without complication . # Respiratory failure ?????? Pt previously intubated for hypercarbic respiratory failure. Likely secondary to narcotics. Pt successfully extubated and on 4L NC on [**9-18**] . # [**Name (NI) 3674**] pt with Hct of 33.9 down from 38.1. Likely dilutional from fluids and blood loss from chest tube placment. . # Acute renal failure ?????? Creatinine 0.7 today, much improved from admission. History of vomiting and poor PO intake, this may be secondary to dehydration. Urine output >30 cc per hour. - Continue to hydrate - Maintain UOP >30cc/hr . # UTI - UA with positive nitrite, trace ketones, >50 WBCs, and many bacteria. Given one dose of ciprofloxacin in ED. Given that patient has ileostomy, she will likely always have a 'dirty' UA. - Hold off on treating at this time as may just be a contaminant - Follow urine culture . Patient was successfully extubated in ICU. Continued with confusion. Restraints applied. Remained NPO with IVF. Mental status cleared slowly. Transferred to Stone 5 for further management on [**9-20**]. . [**9-20**] -Pt pulled NGT out due to agitation r/t naroctic medications. Maintained in 2 point restraints overnight. Mental status much improved in morning. Ostomy with gas but no stool. KUB repeated-resolving ileus. . [**9-21**] -Abdomen slightly distened. Started on clear liquids. Tolerating well. No N/V. Right chest tube removed at bedside, uncomplicated. CXR completed 2 hours after, lungs clear, no evidence of pneumothorax. Ostomy RN contact[**Name (NI) **] to assist with management of leaking ostomy and urostomy. Assisted OOB with nursing. Ambulated without assist. Lives independently with boyfriend. Diet advanced to regular food in evening. Tolerated well. . [**9-22**] -Continues to tolerate Regular food. Ostomy and Urostomy putting out adequate amounts of urine/stool. Pain well controlled with oral medication. Abdominal pain decreased. Ostomy continues to leak even with efforts of Ostomy RN due to patient's anatomy. Plan for discharge home today with VNA for continued management of Ostomy appliance and skin assessment. Medications on Admission: Seroquel 25mg PO BID Zantac 150mg PO QHS Cymbalta 60mg PO BID Discharge Medications: 1. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain: Not to exceed 4gm per day. . 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation for 1 months: Take with Hydrocodone. Disp:*60 Capsule(s)* Refills:*0* 6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 2 weeks: Do not exceed 4000mg of Acetaminophen in 24hrs. Disp:*45 Tablet(s)* Refills:*0* 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation: Take with Hydrocodone. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) **] Nursing Services Discharge Diagnosis: Primary: Small bowel obstruction Post-extubation confused related to medications Right pneumothorax-Chest tube inserted. UTI Acute renal failure . Secondary: Depression, hepatitis C, cervical CA, TAH/BSO-Bladder injury (urostomy & Colostomy) Discharge Condition: Stable Tolerating a regular diet Adequate pain control with oral medication Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Monitoring Ostomy output/Prevention of Dehydration: -Keep well hydrated. -Replace fluid loss from ostomy daily. -Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. -Try to maintain ostomy output between 1000mL to 1500mL per day. [**Name8 (MD) **] MD if output greater than 2 liters or under 500ml in 24 hours. . Urostomy: -Continue with urostomy managment prior to admission. . Diet: -Continue with a low residue diet until your follow-up appointment with your PCP. [**Name10 (NameIs) **] to Hand out provided to you by nursing for guidance. Followup Instructions: 1. Follow-up with PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 48826**] in 1 week and as needed. [**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**] Completed by:[**2133-9-22**]

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icd9cm

[ [ [] ] ]

[ "96.71", "34.04" ]

icd9pcs

[ [ [] ] ]

7958, 8026

3622, 6908

308, 348

8313, 8391

2652, 3599

10088, 10403

1546, 1563

7021, 7935

8047, 8292

6934, 6998

8415, 10065

1578, 2332

2346, 2633

243, 270

376, 1173

1217, 1385

1401, 1530

5,617

164,900

6492

Discharge summary

report

Admission Date: [**2149-4-28**] Discharge Date: [**2149-5-7**] Service: The patient is a 79 year old male who is status post partial right hip replacement at [**Hospital1 2025**] many years ago followed by right total hip replacement by Dr. [**Last Name (STitle) 23689**] four years prior to admission who has had a chronic and progressively worsening right hip pain for four years. He also complained of right groin pain, worse with ambulation. He has been evaluated by Pain Service and treated with MS Contin and MSIR p.r.n., Neurontin and Celexa. However, he could not tolerate even low dose of MS Contin because of sedation and hallucination. He underwent right hip injections with bupivacaine with some decrease of his pain prior to his admission. He also has a severe L4 to L5 spinal stenosis and degenerative joint disease documented by magnetic resonance scan on [**2148-12-27**] and had steroid and lidocaine injections at the end of [**Month (only) 956**] without significant benefit. Neurosurgery was consulted earlier and their thought was that his pain is due to his problems and not due to his spinal stenosis. PAST MEDICAL HISTORY: Osteoarthritis, hypertension, abdominal aortic aneurysm 4.5 cm, iron deficiency anemia status post right knee replacement, status post right hip replacement for years prior to admission status post cerebrovascular accident in [**2143**] with residual dysarthria and right lower extremity weakness, history of upper GI bleed secondary to ANSAID abuse requiring 3 units of transfusions in [**2148-12-27**] status post open cholecystectomy for perforated gangrenous cholecystitis by Dr. [**Last Name (STitle) **] in [**2146-12-27**], severe L4 to 5 stenosis and degenerative joint disease. ALLERGIES: Tetanus and penicillin. SOCIAL HISTORY: Smoker for 75 years, quit 10 years ago. The patient was admitted to medical service for pain control. On admission, he was afebrile with stable vital signs. He was a pleasant gentleman with no apparent distress. His chest was clear to auscultation bilaterally. Heart was regular with no murmurs. Abdomen was soft, nontender, nondistended with normal bowel sounds. There is edema of his extremities, chronic venous stasis changes. He had good strength in his left lower extremity and right hip pain with palpation over the trochanter and pain on extremity rotation. He also complained of some right knee pain with flexion. His right hip x-ray demonstrated an increased lucency surrounding the cement bone interface with some loosening of the hardware. He was evaluated by Dr. [**Last Name (STitle) 23689**], [**First Name3 (LF) **] orthopedic surgeon and it was decided to take him to the Operating Room for excision arthoplasty of his right hip. This was done on [**2149-5-2**]. During the procedure, he had estimated blood loss of 1300 cc, requiring transfusion of one unit of packed red blood cells in the Operating Room and one unit postoperatively. He also became hypotensive in the Operating Room. After the procedure, he was transferred to Surgical Intensive Care Unit where he was ruled out for myocardial infarction by electrocardiogram and enzymes. On the following day, he was transferred to the floor in stable condition. He was complaining of postoperative pain which wasn't adequately controlled and therefore he was placed on morphine PCA. He was transferred two additional units of red blood cells during the next two postoperative days. Otherwise, he did well on the floor and his diet was advanced. His right lower extremity was placed on traction and he was transferred from bed to chair on a daily basis. He was started on Vancomycin intravenous because while his preoperative cultures from hip aspiration grew some rare Staphylococcus negative. PICC line was placed for long term antibiotic administration. On on postoperative day number three, he became confused during the night. It was thought to be sun downing and his PCA was discontinued because of his history of intolerance of MSIR and MS Contin. His pain was then managed with OxyContin and Percocet for breakthrough. He tolerated this well. His confusion was managed with small dose of Haldol overnight. Coumadin was started for prophylactic anticoagulation. He is ready to be discharged to rehabilitation on postoperative day number 5. At that time, he is afebrile with stable vital signs, heart rate of 80 and pressure of 120/70. He is taking in good p.o. Foley was discontinued and he voided spontaneously. His chest is clear to auscultation bilaterally. Heart is regular. Abdomen is soft, nontender and nondistended. His right hip incision is clean with no redness with still some serous discharge from the wound but no signs of infection. His Hemovac were discontinued on the morning of postoperative day five. Infectious Disease consult was obtained and Vancomycin was recommended for 6 months. His cultures are growing Staphylococcus coagulase positive, final sensitivities are pending. He will be discharged to rehabilitation when bed becomes available. DISCHARGE MEDICATIONS: 1. Vancomycin one gram intravenous q.12h. to be continued through [**2149-6-13**]. 2. Celexa 20 mg p.o. q.d. 3. Neurontin 500 mg p.o. t.i.d. 4. Metoprolol 25 mg p.o. q. a.m. 5. Captopril 25 mg p.o. q.d. 6. Colace 100 mg p.o. b.i.d. 7. OxyContin 10 mg p.o. b.i.d. 8. Percocet one to two tabs p.o. q2-4h. p.r.n. for breakthrough. 9. Dulcolax 10 mg PR q.d. p.r.n. 10. Haldol 1-3 mg intravenous p.r.n. 11. Coumadin, as of [**5-7**] he received four doses of 5 mg of Coumadin and his INR on [**5-7**] was 1.9. He should get 2.5 mg of Coumadin on [**5-7**]. DISCHARGE INSTRUCTIONS: He should have Coumadin adjusted for goal INR of between 2 and 2-1/2. His Vancomycin trough levels, creatinine, CBC, AST should be checked weekly while he is on Vancomycin. He should call Infectious Disease Clinic in [**3-30**] weeks and follow-up with Dr. [**Last Name (STitle) 23689**] in [**1-28**] weeks for removal of his staples. He will be discharged to rehabilitation when bed becomes available. Dictated By:[**Name8 (MD) 20287**] MEDQUIST36 D: [**2149-5-7**] 10:10 T: [**2149-5-7**] 11:19 JOB#: [**Job Number 24910**]

[ "711.05", "441.4", "041.19", "996.67", "438.20", "280.9", "V43.64", "458.2", "715.90" ]

icd9cm

[ [ [] ] ]

[ "81.91", "80.05", "38.93" ]

icd9pcs

[ [ [] ] ]

5108, 5671

5696, 6239

1163, 1788

1805, 5085

23,707

148,820

5335+5336

Discharge summary

report+report

Admission Date: [**2151-3-4**] Discharge Date: [**2151-3-7**] Date of Birth: [**2092-4-12**] Sex: F Service: MEDICINE Allergies: Compazine / Droperidol / Sulfonamides / Gadolinium-Containing Agents / Demerol / Morphine Attending:[**First Name3 (LF) 330**] Chief Complaint: usual degranulation symptoms; admit for nursing care Major Surgical or Invasive Procedure: Right subclavian central venous line History of Present Illness: This is a 58 year old woman with h/o mast cell activation syndrome amd multiple recent admissions who presents with her usual syndrome of degranulation 1 day after recent discharge. She reports having abdominal pain and chest pain, then itchiness, then flushing, then shortness of [**First Name3 (LF) 1440**]. She drove herself to the ED and gave her an epi shot in the car on the way. . Her symptoms at this time are consistent with her previous flares, except she reports some associated RLQ pain as opposed to her usual epigastric pain. It was [**10-12**] but is improved to [**4-12**] with pain medications. She also reports slightly worse itching than usual. On ROS she reports bowel movments with blood, as reported on her previous admission. . In the ED she was noted to be in respiratory distress and received solumedrol 125, multple albuterol nebs, famotidine, dilaudid, benadryl, anzemet with gradual improvement over a few hours. However, pt was unable to come off of continuous nebulizer secondary to subjective SOB; pt has good O2 sats off nebulizer. Dr. [**Last Name (STitle) 79**] is away until [**3-5**] so pt is admitted to medicine. Past Medical History: 1. Mast cell activation syndrome: Followed by [**First Name8 (NamePattern2) 21734**] [**Last Name (NamePattern1) **] who is an allergist at [**Hospital1 112**], #[**Telephone/Fax (1) 21735**]. Also followed here by Dr. [**Last Name (STitle) 79**] in GI. Has been intubated twice. 2. Depression/anxiety/bipolar d/o, has attempted suicide in the past 3. MI in [**2147**] after receiving cardiac arrest dose epi instead of anaphylactic dose epi 4. HTN 5. OA 6. GERD. gastritis and esophagitis on recent EGD [**2151-1-8**]. also had shortening of villi. 7. Paradoxical Vocal Cord Dysfunction viewed on fiberoptic laryngoscopy 8. Anemia, iron studies c/w AOCD 9. Hemorrhoids 10. pt reports recent EGD demonstrated vegetable bezoar. Social History: mother died of MI at 76 y/o. Father is [**Age over 90 **] y/o, alive and well. Sister had breast Ca w/bilateral mastectomies at age 52. Family History: Social Hx: Lives by herself in [**Location 9583**], recently divorced from her husband of 37 years. Smoked cigarettes for one year during college, none since. No EtOH. Has 2 children. Works as an ED tech in [**Hospital1 2436**]. Physical Exam: PE: V: t96.9, p125, 124/63, rr25, 100% continuous nebs Gen: mild distress from syndrome, not in respiratory distress HEENT: PERRLA, OP clear Resp: diminished [**Hospital1 1440**] sounds bilaterally, no wheeze but tight CV: RRR nl s1s2 2/6 systolic murmur in RUSB Abd: soft. TTP RLQ, no rebound or guarding. hyperactive bowel sounds. Ext: trace edema Pertinent Results: [**2151-3-4**] 10:32AM WBC-5.3 RBC-3.58* HGB-11.0* HCT-33.0* MCV-92 MCH-30.7 MCHC-33.3 RDW-14.2 [**2151-3-4**] 10:32AM PLT COUNT-261 [**2151-3-4**] 02:15AM ALT(SGPT)-17 AST(SGOT)-20 CK(CPK)-224* AMYLASE-41 TOT BILI-0.3 [**2151-3-4**] 02:15AM LIPASE-31 . CT abdomen: 1. No evidence of appendicitis or other cause of the patient's right lower quadrant pain identified. 2. New non specific 9-mm rounded, low-density lesion in the posterior spleen . This could represent a manifestation of the patient's known mastocytosis; however, clinical correlation is suggested. 3. A small amount of contrast in the distal esophagus suggests possible gastroesophageal reflux. . Labs on Discharge [**2151-3-6**] 02:24PM BLOOD Hct-37.1 [**2151-3-6**] 06:48AM BLOOD Plt Ct-302 [**2151-3-5**] 03:00AM BLOOD PT-11.6 PTT-23.2 INR(PT)-1.0 [**2151-3-6**] 06:48AM BLOOD Glucose-93 UreaN-6 Creat-0.6 Na-145 K-3.5 Cl-106 HCO3-31 AnGap-12 [**2151-3-6**] 06:48AM BLOOD Albumin-3.4 Calcium-8.6 Phos-3.8 Mg-2.1 Brief Hospital Course: 58 yo woman with systemic mastocytosis who presents with typical flare. * * #) Mastocytosis flare: Symptoms typical on admission. Initially started on continuous nebs. Which were weaned off to prn. She complained of subjective wheezing however on exam did not have much air movement as pt not taking deep breaths. No clear wheezing on exam. The patient was started on prednisione. the patient was discharged on a prednisone taper. The patient was also maintained on benadryl, singulair, cromolyn inhalers and hydromorphone. * #) Abd pain: On presentation c/o RLQ pain with nausea and vomiting was initially concerning for appendicitis. CT scan of abdomen was done which was unremarkable. The following day she complained of epigatric pain radiating to back. She stated that she's had this pain in the past with her flares. LFTs and pancreatic enzymes were within normal limts. * #) Anemia/BRBPR: consistent with report on previous admission. Colonoscopy in the past revealed hemorrhoids. The patient's Hct remained stable throughout her admission. * #) Psych The patient was maintained on her home regimen of seroquel and cymbalta. * #) HTN: The patient was maintained on diltiazem * #) PPx: ppi, h2 blocker. pneumoboots. * #) FEN: IVF, lytes repleted PRN, regular diet. . #) access: R subclavian [**2151-3-4**] . #) Dispo: home with followup. Medications on Admission: 1. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 18 doses: Please take 3 tablets per day for 3 days, then 2 tablets per day for 3 days, then 1 tablet per day for 3 days. Disp:*18 Tablet(s)* Refills:*0* 2. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO daily (). 3. Estradiol 0.05 mg/24 hr Patch Semiweekly Sig: One (1) Patch Semiweekly Transdermal twice per week (). 4. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 5. Quetiapine 200 mg Tablet Sig: Three (3) Tablet PO QHS (once a day (at bedtime)). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 8. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 2. Quetiapine 200 mg Tablet Sig: Three (3) Tablet PO QHS (once a day (at bedtime)). Disp:*30 Tablet(s)* Refills:*2* 3. 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* 4. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Three (3) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 5. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 6. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Cromolyn 100 mg/5 mL Solution Sig: One Hundred (100) ML PO q6h (). Disp:*[**Numeric Identifier 890**] ML(s)* Refills:*2* 8. Prednisone 10 mg Tablets, Dose Pack Sig: Five (5) Tablets, Dose Pack PO once a day for 18 days: Please take 5 tablets a day for 3 days, then 4 tablets a day for 3 days, then 3 tablets a day for 3 days, then 2 tablets a day for 3 days, then 1 tablet a day for 3 days, then [**1-4**] tablet a day for 3 days, then off. Disp:*47 Tablets, Dose Pack(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis Mastocytosis . Secondary Diagnosis 1. Mast cell activation syndrome: Followed by [**First Name8 (NamePattern2) 21734**] [**Last Name (NamePattern1) **] who is an allergist at [**Hospital1 112**], #[**Telephone/Fax (1) 21735**]. Also followed here by Dr. [**Last Name (STitle) 79**] in GI. Has been intubated twice. 2. Depression/anxiety/bipolar d/o, has attempted suicide in the past 3. MI in [**2147**] after receiving cardiac arrest dose epi instead of anaphylactic dose epi 4. HTN 5. OA 6. GERD. gastritis and esophagitis on recent EGD [**2151-1-8**]. also had shortening of villi. 7. Paradoxical Vocal Cord Dysfunction viewed on fiberoptic laryngoscopy 8. Anemia, iron studies c/w AOCD 9. Hemorrhoids 10.Pt reports recent EGD demonstrated vegetable bezoar Discharge Condition: Good, vitals stable Discharge Instructions: seek medical serivices if you should have chest pain, shortness of [**Month/Day/Year 1440**], fevers, or any other worrisome symptom . please take your medications as prescribed . keep followup appointments Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1954**] Date/Time:[**2151-3-10**] 11:35 . Provider: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2151-4-22**] 12:30 Completed by:[**2151-3-8**] Admission Date: [**2151-3-10**] Discharge Date: [**2151-3-12**] Date of Birth: [**2092-4-12**] Sex: F Service: MEDICINE Allergies: Compazine / Droperidol / Sulfonamides / Gadolinium-Containing Agents / Demerol / Morphine Attending:[**First Name3 (LF) 21731**] Chief Complaint: abdominal pain, anorexia, nausea, headache, and ? resp distress (typical of her mastocytosis histamine release episodes). Major Surgical or Invasive Procedure: none. History of Present Illness: 58 year old woman with h/o mast cell activation syndrome, multiple recent admissions for the same, who presents with her usual symptoms of degranulation, including abdominal pain, anorexia, nausea, headache, and chest tightness. She was just discharged 3d prior to this admission after presenting with the same complaints, spent four days in the hospital, some time in the MICU because of her complaints of severe SOB. . Today she complains of 1d of her usual nausea, abdominal pain and chest pain, then progressing to itchiness and shortness of [**First Name3 (LF) 1440**]. She drove herself to the ED and per her report gave herself an epi shot once in the ED after checking with the ED staff. Also in the ED received methylprednisolone, benadryl, hydromorphone, lorazepam, albuterol/ipratropium x3. No further epi given as sats 100%RA and h/o epi induced MI. Her symptoms at this time are consistent with her previous flares. She continues to demand pain medication, specifically IV dilaudid. Spoke with Dr. [**Last Name (STitle) 79**], plan to treat as per usual regimen. Past Medical History: 1. Mast cell activation syndrome: Followed by [**First Name8 (NamePattern2) 21734**] [**Last Name (NamePattern1) **] who is an allergist at [**Hospital1 112**], #[**Telephone/Fax (1) 21735**]. Also followed here y Dr. [**Last Name (STitle) 79**] in GI. Has been intubated twice. 2. Depression/anxiety/bipolar d/o, has attempted suicide in the past 3. MI in [**2147**] after receiving cardiac arrest dose epi instead of anaphylactic dose epi 4. HTN 5. OA 6. GERD. gastritis and esophagitis on recent EGD [**2151-1-8**]. also had shortening of villi. 7. Paradoxical Vocal Cord Dysfunction viewed on fiberoptic laryngoscopy 8. Anemia, iron studies c/w AOCD 9. Hemorrhoids 10. pt reports recent EGD demonstrated vegetable bezoar. Social History: divorced. + tobacco (4 pack years, quit in college), + EtOH (none currently, drank in college), - IVDU or illicit drug use. Works as ED tech. Family History: Mother died of MI @ 76, Sister w/ breast cancer and bilateral mastectomy. Physical Exam: VS: T 98.6 112/60 80 20 gen: pale caucasian woman, appearing ill, lying in bed with legs bent in fetal position, rocking back and forth HEENT: PERRL/EOM intact, OP clear, MMM, no JVD, no carotid bruit. neck: no masses, no LAD. CV: RRR, nl s1s2, [**2-8**] syst murmur at apex chest: poor effort, no rales or wheezing; CTA after cough abd: soft, tender to palp in epigastric region, though less so with distraction, normal BS, no HSM extr: warm well perfused, 2+ dp pulses, no cyanosis, no LE edema. neuro: non-focal. Pertinent Results: CXR [**2151-3-10**]: Interval resolution of bibasilar atelectasis. No evidence for pneumonia. . CT abd/pelvis [**2151-3-4**]: 1. No evidence of appendicitis or other cause of the patient's right lower quadrant pain identified. 2. New non specific 9-mm rounded, low-density lesion in the posterior spleen. This could represent a manifestation of the patient's known mastocytosis; however, clinical correlation is suggested. 3. A small amount of contrast in the distal esophagus suggests possible gastroesophageal reflux. . [**2151-3-11**] 06:10AM BLOOD WBC-12.7*# RBC-3.87* Hgb-11.4* Hct-34.8* MCV-90 MCH-29.5 MCHC-32.9 RDW-14.1 Plt Ct-342 [**2151-3-10**] 02:45PM BLOOD Glucose-161* UreaN-14 Creat-0.8 Na-141 K-3.4 Cl-108 HCO3-23 AnGap-13 [**2151-3-10**] 02:45PM BLOOD ALT-15 AST-13 CK(CPK)-24* AlkPhos-67 Amylase-49 TotBili-0.2 [**2151-3-11**] 06:10AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.2 [**2151-3-10**] 02:45PM BLOOD Albumin-3.9 [**2151-3-10**] 02:53PM BLOOD Hgb-12.1 calcHCT-36 [**2151-3-10**] 02:45PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.008 [**2151-3-10**] 02:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR [**2151-3-10**] 02:45PM URINE RBC-0-2 WBC-[**3-7**] Bacteri-MOD Yeast-NONE Epi-[**3-7**] Brief Hospital Course: 58 year old woman with h/o mast cell activation syndrome, psychiatric comorbidities such as anxiety with behaviors consistent with symptom presentation of anxiety causing her symptoms rather than her mast cell activation and, now presenting with her usual complaints of nausea, abd pain, chest tightness, itch. . # Mast cell granulation syndrome: No evidence of resp compromise; no indication for steroids. Pain was treated with dilaudid 2mg IV q2hr prn, and Zofran, Ativan, Benadryl as needed. Pt. felt well at the time of discharge, with complete resolution of her abdominal symptoms. A 24-hour urine histamine test was performed during this hospitalization, and the results were pending at the time of discharge. . # Psych: unclear how much of her comorbid conditions are contributing to her current presentation. Avoid central access in this patient with access to multiple dangerous medications and history of multiple suicide attempts. Continue Seroquel, Wellbutrin, Ambien. . # GERD: continue PPI . # CV: continue Cardizem . # Code: Full. Medications on Admission: gastrocom 2 (200mg) amps 4x daily cardizem 120mg daily, vivelle dot 0.05 twice a week diphenhydramine 50mg hs zantac 300mg hs seroquel 600mg hs protonix 40mg qam singulair 10mg qs naproxen qam ambien 10mg hs wellbutrin XL 150mg qam celexa 40mg qam, 20mg qpm Discharge Medications: 1. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**6-10**] hours as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 2. Diphenhydramine HCl 25 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) as needed. 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 4. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 5. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. 6. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Quetiapine 200 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 11. Topiramate 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. Zofran 8 mg Tablet Sig: One (1) Tablet PO once a day as needed for nausea. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. ? mastocytosis-related histamine flare. 2. Depression/anxiety/?bipolar d/o. 3. anxiety as a possible cause of symptoms at times 4. HTN 5. OA 6. GERD Discharge Condition: good, stable. Discharge Instructions: Please continue to take all your medications exactly as prescribed. Please call your PCP if you have any concerning symptoms. Followup Instructions: Please continue to follow up with your PCP: [**Name10 (NameIs) **] FRENCH, [**0-0-**] as you have been doing. Provider: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2151-4-22**] 12:30 Completed by:[**2151-3-13**]

[ "715.35", "296.80", "530.81", "401.9", "786.59", "300.4", "786.05", "279.8", "789.03" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

16221, 16227

13761, 14811

9788, 9796

16424, 16440

12458, 13738

16615, 16904

11826, 11901

15119, 16198

16248, 16403

14837, 15096

16464, 16592

11916, 12439

9627, 9750

9824, 10902

10924, 11651

11667, 11810

8,941

135,699

21137

Discharge summary

report

Admission Date: [**2192-5-7**] Discharge Date: [**2192-5-14**] Date of Birth: [**2120-11-20**] Sex: M Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 783**] Chief Complaint: severe headache Major Surgical or Invasive Procedure: none History of Present Illness: 71 yo [**Male First Name (un) 4746**] with metastatic melanoma to lungs, LNs, presents with sudden onset severe bifrontal headache which increased steadily until today. Patient c/o mild nausea and generalized weakness, but denies any visual changes. He was evaluated at [**Hospital1 **] Med Center in NH, where CT showed a large left temporal hemorrhage and smaller left parietal and pontine bleeds. He was transferred to [**Hospital1 18**] for further management. He arrived in the ED in stable condition with SBP in the 130s and 140s. He was treated with dilantin and decadron, platelets, morphine, and zofran. He was seen by Neurosurgery and Neurology. Past Medical History: Melanoma- diagnosed [**3-19**], treated with XRT in summer,[**2190**], with known right axillary and skin mets. Sarcoidosis with h/o hypercalcemia Hypertension Coronary artery disease Chronic renal insufficiency Hypothyroidism Gout GERD Erectile dysfunction AAA-5cm in [**8-19**] Benign prostatic hypertrophy Carotid stenosis R(90%), L(70) s/p CEA [**7-/2186**] and [**9-/2186**] Social History: lives with wife [**Name (NI) **] in [**Name (NI) **], wife has durable power of attorney for health care works as electrical engineer previous Tobacco use: 2ppd; EtOH: 2 drinks bourbon/day; denies illicits Family History: no h/o melanoma, skin cancer mother d. 60s of cervical cancer father d. cirrhosis Physical Exam: T 98.7 HR 65 RR 16 BP 156/70 98%RA General: 71yo [**Male First Name (un) 4746**], looks stated age, NAD HEENT: PERRL, anicteric, OP clear, MMM, left upper lip with ulcerated skin leasion, pearlescent nodule under left eye Neck: supple with right anterior cervical LAD CV: RRR, nl S1S2, no m/r/g, no JVD Resp: CTAB Abd: NABS, soft, NT/ND Ext: no rash, no c/c/e, warm Neuro: A&Ox3 (but later forgot name of hospital) CN II-XII intact Motor [**3-21**] UE and LE B Sensation intact grossly to fine touch toes downgoing B Reflexes 2+ patellar B Pertinent Results: [**2192-5-7**] 09:18PM HGB-12.9* calcHCT-39 O2 SAT-91 [**2192-5-7**] 06:28PM WBC-8.2 RBC-4.18* HGB-13.9* HCT-39.7* MCV-95 MCH-33.2* MCHC-35.0 RDW-14.6 [**2192-5-7**] 06:28PM PLT COUNT-160 [**2192-5-7**] 06:28PM PT-13.2 PTT-25.4 INR(PT)-1.1 [**2192-5-7**] 09:18PM freeCa-1.14 [**2192-5-7**] 09:18PM GLUCOSE-113* LACTATE-1.5 NA+-140 K+-4.0 CL--105 Brief Hospital Course: The patient was admitted to the MICU for further monitoring of his BP and oxygen status. Neurosurgery and Neurology continued to follow status of the brain hemorrhage. No surgical interventions were recommended, and the patient was treated with Decadron for edema prophylaxis and dilantin for seizure prophylaxis. There were no further episodes of bleeding. BP control required a labetolol drip. Once stable the patient was switched to po labetolol, with goal SBP 130-160, and moved to the floor for further monitoring. The patient required iv morphine for pain control in the MICU, then po oxycodone, which was discontinued prior to discharge. The patient received 5 radiation treatments to the brain for palliative therapy during his hospitalization. His code status was defined as DNR/DNI. The patient continued to demonstrate decreased cognitive function during his hospitalization, responding slowly to questioning and with failures in short term memory and orientation to place. Neurology continued to follow. Medications on Admission: ASA 81mg po Qday Lipitor 80mg po Qday Norvasc 10mg po Qday Toprol XL Diovan 80mg po Qday Synthroid 0.075mg po Qday Fosamax 75mg qweek Allopurinol 100mg po Qday Zetia 10mg po Qday Folate Discharge Medications: 1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 2. 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* 3. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO QD (once a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*30 Tablet(s)* Refills:*2* 6. Dexamethasone 2 mg Tablet Sig: Three (3) Tablet PO Q6H (every 6 hours). Disp:*360 Tablet(s)* Refills:*2* 7. Labetalol HCl 200 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*2* 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*180 Tablet, Chewable(s)* Refills:*2* 9. Valsartan 40 mg Tablet Sig: Three (3) Tablet PO QD (once a day). Disp:*90 Tablet(s)* Refills:*2* 10. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO QD (once a day). Disp:*60 Tablet(s)* Refills:*2* 11. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 8300**] VNA Discharge Diagnosis: Metastatic melanoma Hypertension Chronic Renal Insufficiency CAD/PVD Sarcoidosis Hypothyroidism Gout Anemia Gerd Carotid Stenosis Discharge Condition: stable Discharge Instructions: If headache, dizziness, or severe nausea develop, please call physician and go to Emergency Department immediately. Please follow-up with primary care physician for careful blood pressure monitoring. Followup Instructions: Radiation Oncology: Radiation Therapy Monday [**2192-5-14**] at 12:15pm Primary Care Physician: [**Name10 (NameIs) **] schedule an appointment with Dr. [**Last Name (STitle) 56062**] within the next 2-3 weeks. Neurology: please see Dr. [**Last Name (STitle) 56063**] at [**Hospital1 **] Hospital [**2192-6-20**] at 2:30pm [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

[ "197.0", "135", "V10.82", "198.3", "530.81", "196.3", "431", "274.9", "198.2" ]

icd9cm

[ [ [] ] ]

[ "92.29" ]

icd9pcs

[ [ [] ] ]

5317, 5376

2717, 3745

325, 331

5550, 5558

2335, 2694

5807, 6264

1664, 1747

3981, 5294

5397, 5529

3771, 3958

5582, 5784

1762, 2316

270, 287

359, 1022

1044, 1425

1441, 1648

67,624

178,414

36251

Discharge summary

report

Admission Date: [**2180-5-6**] Discharge Date: [**2180-5-8**] Date of Birth: [**2129-9-3**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1115**] Chief Complaint: nausea / vomiting Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 50 yoM w/ a h/o DMI, ESRD on HD, presenting with nausea/vomiting, found to be in DKA. He states he has had 4 episodes of n/v this a.m. Since then has had a slight sore throat but rest of ROS is completely negative. No F/C, no sweats, no cough, SOB, chest pain, abd pain, diarrhea or constipation, rashes, or other sypmtoms. He has had q1h urinary frequency and thirst. No lightheadedness. The patient states that he has been taking 10u of lantus qhs and sliding scale, since discharge from [**Hospital1 18**] on [**5-4**] his BG have been around 300+. . Of note the patient was recently admitted ([**Date range (1) 29120**]) for DKA and gastroenteritis. He was admitted to the MICU for an insulin drip and hyperkalemia, he was transitioned to sc insulin and discharged. In addition he had initiated HD on that admission (had a AV fistula placed in the past in anticipation of this. In addition he was treated with levofloxacin for possible RLL pneumonia. . In the ED, initial VS: T 98.4 HR 85 BP 156/85 RR 18 O2sat: 100% RA. He had some peaked T waves in the ER, normal QRS duration. He was given calcium gluconate. J point elevation on EKG, so cardiac enzymes sent as well. Femoral line was placed in the ER, 10u insulin x 1 given, then 7u/hr. He rec'd 2 L NS. Past Medical History: - Diabetes, insulin dependent x 24 years - Hypertension. - ESRD on HD Social History: Currently employed in 2 nursing homes. No hx of EtOH, smoking. Has issues coping w/ insulin regiment yet denies financial hardships as a cause. Instead, likely due to miscommunication; pt is from [**Country 2045**] & may not necessarily understand the ramifications of poor glycemic control & has poor vision. Family History: Grandmother diagnosed w/DM2. Father is alive at 68 and is "never sick". Mother died suddenly at 37. Siblings w/sickle cell. 1 child w/DM1. Physical Exam: On admission Vitals - T: 97.4 BP: 186/81 HR: 88 RR: 14 02 sat: 97% RA GENERAL: NAD, AOx3 HEENT: MM slightly dry, OP clear, JVP 9cm, neck no lymphadenopathy CARDIAC: RRR, 2/6 SEM at the USB LUNG: CTAB ABDOMEN: soft, NT, ND, no masses or organomegaly EXT: WWP, chronic venous stasis changes NEURO: AOx3, grossly normal On discharge VS: 98.1, 124/81, 81, 16, 98%RA F/S: 86 (yesterday - 246, 287) Gen: NAD, AAOx3 HEENT: PERRLA, EOMI, MMM, Op clear, JVP 9 cm, no LAD CV: S1S2, RRR, 2/6 SEM at upper sternal border Chest: CTA b/l Abd: soft, ND, NT, +BS, no HSM Ext: fistula in LUE, +bruit, +thrill, no e/c/c Neuro: AAOx3, CN II-XII grossly intact Pertinent Results: CHEST (PORTABLE AP) Study Date of [**2180-5-6**] 5:52 PM FINDINGS: As compared to the previous radiograph, the pre-existing right lower lobe opacity has completely resolved. On the left, the pre-existing opacity has improved, but is still clearly visible. Blunting of the costophrenic sinus suggests the presence of a small left-sided effusion. Whenever possible, findings should be reevaluated with an AP and lateral chest radiograph. CBC [**2180-5-8**] 05:48AM BLOOD WBC-10.7 RBC-2.76* Hgb-7.7* Hct-22.9* MCV-83 MCH-27.9 MCHC-33.7 RDW-17.0* Plt Ct-287 [**2180-5-7**] 03:06AM BLOOD WBC-14.2*# RBC-2.85* Hgb-7.8* Hct-23.6* MCV-83# MCH-27.4 MCHC-33.1 RDW-16.4* Plt Ct-354 [**2180-5-6**] 12:35PM BLOOD WBC-9.2# RBC-2.77* Hgb-7.7* Hct-24.8* MCV-90# MCH-27.7 MCHC-30.9*# RDW-15.8* Plt Ct-267 Chemistry [**2180-5-8**] 05:48AM BLOOD Glucose-62* UreaN-61* Creat-9.6* Na-140 K-4.7 Cl-102 HCO3-25 AnGap-18 [**2180-5-7**] 03:06AM BLOOD Glucose-21* UreaN-56* Creat-8.6* Na-142 K-3.9 Cl-103 HCO3-28 AnGap-15 [**2180-5-6**] 10:53PM BLOOD Glucose-354* UreaN-57* Creat-8.4* Na-136 K-4.8 Cl-100 HCO3-23 AnGap-18 [**2180-5-6**] 08:09PM BLOOD Glucose-603* UreaN-56* Creat-8.4* Na-133 K-4.2 Cl-96 HCO3-24 AnGap-17 [**2180-5-6**] 05:07PM BLOOD Glucose-773* UreaN-57* Creat-8.6* Na-129* K-4.9 Cl-90* HCO3-22 AnGap-22* [**2180-5-6**] 02:00PM BLOOD Glucose-906* UreaN-54* Creat-8.6* Na-126* K-6.4* Cl-86* HCO3-19* AnGap-27* [**2180-5-6**] 12:35PM BLOOD Glucose-887* UreaN-55* Creat-8.8*# Na-125* K-7.2* Cl-85* HCO3-21* AnGap-26* [**2180-5-8**] 05:48AM BLOOD Calcium-9.2 Phos-7.0*# Mg-2.2 [**2180-5-6**] 08:09PM BLOOD Calcium-8.7 Phos-3.7# Mg-2.0 [**2180-5-6**] 12:35PM BLOOD Calcium-9.1 Phos-5.4*# Mg-2.2 LFT [**2180-5-6**] 05:07PM BLOOD ALT-17 AST-14 AlkPhos-103 TotBili-0.2 Cardiac Enzymes [**2180-5-7**] 03:06AM BLOOD CK-MB-3 cTropnT-0.27* [**2180-5-6**] 10:53PM BLOOD CK-MB-3 cTropnT-0.23* [**2180-5-6**] 02:00PM BLOOD CK-MB-3 cTropnT-0.22* Brief Hospital Course: 50 yo M with DMI, ESRD on HD, HTN, admitted for nausea and vomiting, found to be in DKA . #. DKA - On admission patient was found to have ketones in his urine. He is a type I diabetic. Patient says that he was been taking his insulin as directed since his discharge 1 week ago. It is unclear what precipitated this last episode of DKA. Infectious workup was negative. He was initially admitted to the ICU for insulin drip for which he required a high initial rate of insulin (29/hr initially, then 21/hr). His anion gap closed and patient was transitioned back to his home insulin regimen and called out to the floor. He reports that he sticks to a diabetic diet and has had diabetic teaching through the [**Last Name (un) **], but also describes regularly having [**Company **], [**Last Name (un) **] [**Doctor Last Name **], and [**Last Name (un) **]. Nutrition saw him on this admission and provided further reinforcement on what constitutes a diabetic diet. His home lantus was increased from 14 units to 16 units at night. Patient was set up with a follow up appointment with his PCP and at the [**Hospital **] Clinic. . #. Anemia - likely related to ESRD and epo deficient state. Patient has refused transfusions in the past as well as on this admission. He will continue on epo at HD sessions. TSH, folate, and B12 were drawn for work up of his anemia and results were still pending on discharge. These will be communicated with his PCP once they return. . #. ESRD - Patient did not receive HD on this admission; the renal team followed the patient. He is set up to start outpatient HD on [**2180-5-9**] as an outpatient and will continue on a Tuesday, Thursday, Saturday schedule. . #. Hypertension - patient was continued on carvedilol and furosemide . #. Hypercholesterolemia - patinet was continued on simvastatin . #. Code - DNR/DNI per patient Medications on Admission: Lanthanum 500 mg po tid with meals Aspirin 81 mg po daily Carvedilol 12.5 mg po bid Amlodipine 10mg po daily Lantus 14units sc qhs Furosemide 80 mg po daily Colace 100 mg po bid B Complex-Vitamin C-Folic Acid 1 mg po daily Humalog sliding scale Simvastatin 20 mg po daily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Lantus 100 unit/mL Solution Sig: Sixteen (16) units Subcutaneous at bedtime. 5. Humalog 100 unit/mL Solution Sig: per sliding scale units Subcutaneous qAC and qHS: dose humalog insulin according to sliding scale. 6. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day. 7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Capsule PO once a day. 9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 10. Lanthanum 1,000 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Tablet, Chewable(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Diabetic ketoacidosis Secondary Diagnosis: Diabetes Mellitus, type I ESRD on HD (Tues, Thurs, Sat schedule) Hypertension Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You were admitted to [**Hospital1 69**] for nausea and vomiting. You were found to be in diabetic ketoacidosis. You were initially admitted to the intensive care unit for continuous monitoring. Your blood sugars gradually improved. Please be sure to eat healthy, check your blood sugar regularly, and take your insulin as it has been prescribed to you. Your medications have changed, please make note of the following changes: - please increase your lantus insulin from 14 units to 16 units at bedtime daily The rest of your medications have not changed, please continue to take them as originally prescribed Please keep all your medical appointments and dialysis sessions. If you experience chest pain, shortness of breath, or any other worrisome symptoms, please return to the emergency room. Followup Instructions: MD: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Specialty: Primary Care Date/ Time: [**5-10**] at 10:45am Location: [**Street Address(2) 82189**] , [**Location (un) 2268**] Phone number: [**Telephone/Fax (1) 9470**] MD: Dr [**Last Name (STitle) **] [**Name (STitle) 27172**] Specialty: Nephrology Date/ Time: [**5-12**] at 9:30am Location: [**Last Name (un) **] Phone number: [**Telephone/Fax (1) 3637**]

[ "403.91", "428.0", "V58.67", "272.4", "585.6", "276.7", "V45.11", "250.13", "285.21" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

7936, 7942

4854, 6725

330, 337

8126, 8126

2903, 4831

9101, 9535

2085, 2225

7047, 7913

7963, 7963

6751, 7024

8274, 9078

2240, 2884

273, 292

365, 1647

8025, 8105

7982, 8004

8141, 8250

1669, 1741

1757, 2069

5,032

199,413

43807

Discharge summary

report

Admission Date: [**2177-5-16**] Discharge Date: [**2177-5-18**] Date of Birth: [**2141-12-3**] Sex: F Service: MEDICINE Allergies: Doxycycline / Ibuprofen / Penicillins Attending:[**First Name3 (LF) 2181**] Chief Complaint: Elective PCN Desensitization for Syphilis Major Surgical or Invasive Procedure: ICU Level of Care for Desensitization History of Present Illness: 35F with a history of syphilis who was referred in by her ID physician for LP to rule out neurosyphilis and to start inpatient treatment of syphilis. . She was diagnosed with syphilis on [**2176-1-23**] on routine blood work at [**Hospital1 **]: she had a positive RPR of 1:256 as well as negative HepBsAG and Ab, neg HIV, and neg HCV. She was admitted to [**Hospital1 18**] on [**2176-2-17**] for an ICU penicillin desensitization. She did not stay for the completion of her IV PCN therapy as due to a housing situation. She was assumed to have neurosyphilis given the high titer, but declined LP for rule/out. She was put on an alternative regimen that she stopped due to rash, then completed a course of azithromycin for 3 weeks. Her f/u titer on [**2176-3-7**] was 1:128. . She had a long gap without medical attention due to multiple psychosocial stressors and crack abuse. She decided to seek treatment for her syphilis on [**2177-1-17**], as she now had a more stable housing situation and is covered by MassHealth. Her RPR titer on [**2177-1-17**] was 1:128, thus requiring similar desensitization. . On ROS, patient endorses malaise, occasional blurry vision, inguinal lymphadenopathy, and arthralgias of both knees over the past year. She states she has had "boils" in the vaginal and vulvar areas over the past year, which can start as lumps that then ulcerate or disappear. She has one such lump in her groin now. She denies fever, personality changes, ataxia, photophobia, headache, stiff neck, skin lesions, gummas, rash, nausea, vomiting, and urinary incontinence. . Past Medical History: Childhood asthma Anal prolapse [**9-16**] s/p repair at [**Hospital1 112**] Social History: Sexually active with one male partner, using condoms every time; patient does not want partner to know diagnosis. She lives with her two children, ages 16 and 20, and is unemployed. She smokes crack 1-2x/week, most recently several weeks ago, and less frequently than over the last year. She smokes 0-2 marijuana blunts each day. She has occasional alcohol use ([**12-11**] pint malibu every month). Believes she contracted syphilis from a rape 10 years ago. Family History: noncontributory Physical Exam: VS: Tm 98.4 Tc 97.3 BP:105/73 HR:63 RR:12 O2sat 98% RA GEN: pleasant, comfortable, NAD SKIN: Mild desquamation on palms. 1.5 x 1 cm firm nodule under R mons pubis; no abrasions or ulcers. No rash, condyloma lata, or nickel and dime lesions. HEENT: PERRL, EOMI, anicteric, MMM, no mouth sores, very poor dentention. NECK: FROM. Negative Kernig and Brudzinski. No JVD. Carotid upstrokes brisk and symmetric. CV: RR, S1 and S2 wnl, no m/r/g RESP: CTA b/l with good air movement throughout. No rales, rhonchi, or wheezes. ABD: Soft, NT/ND, +BS, no masses or hepatosplenomegaly EXT: No c/c/e. Warm, well-perfused with 2+ DP bilaterally. LYMPH NODES: No supraclavicular, cervical or axillary lymphadenopathy. Bilateral smooth, rubbery, mobile, 1 cm inguinal lymphadenopathy x2. NEURO: AAOx3. CN II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. 3+ R biceps and brachioradialis reflex, 1+ patellar reflex bilaterally, otherwise 2+ biceps, triceps, brachioradialis, patellar, and Achilles tendon reflexes. Babinski down-going. Able to state days of week backward; for months of year backward, stated [**Month (only) 216**] after [**Month (only) 359**]. MMSE: 29/30. Gait normal. No pronator drift or dysdiadochokinesia. Pertinent Results: [**2177-5-18**] 07:25AM BLOOD WBC-7.2 RBC-4.50 Hgb-14.1 Hct-42.0 MCV-93 MCH-31.2 MCHC-33.5 RDW-13.0 Plt Ct-421 [**2177-5-17**] 04:42AM BLOOD WBC-7.1 RBC-4.06* Hgb-12.6 Hct-37.5 MCV-92 MCH-30.9 MCHC-33.5 RDW-13.3 Plt Ct-381 [**2177-5-16**] 09:31PM BLOOD WBC-7.0 RBC-4.05* Hgb-12.9 Hct-37.6 MCV-93 MCH-31.8 MCHC-34.2 RDW-13.0 Plt Ct-384 [**2177-5-16**] 12:56PM BLOOD WBC-7.7# RBC-4.12* Hgb-13.2 Hct-38.3 MCV-93 MCH-32.1* MCHC-34.6 RDW-13.2 Plt Ct-385 [**2177-5-18**] 07:25AM BLOOD Neuts-42.6* Lymphs-49.7* Monos-5.5 Eos-1.4 Baso-1.0 [**2177-5-16**] 09:31PM BLOOD Neuts-53.2 Lymphs-40.4 Monos-5.0 Eos-0.8 Baso-0.6 . [**2177-5-17**] 04:42AM BLOOD PT-14.3* PTT-28.8 INR(PT)-1.2* [**2177-5-16**] 12:56PM BLOOD PT-14.8* PTT-29.9 INR(PT)-1.3* . [**2177-5-18**] 07:25AM BLOOD Glucose-67* UreaN-20 Creat-1.0 Na-139 K-3.9 Cl-103 HCO3-28 AnGap-12 [**2177-5-17**] 04:42AM BLOOD Glucose-121* UreaN-20 Creat-1.1 Na-138 K-3.9 Cl-104 HCO3-28 AnGap-10 [**2177-5-16**] 12:56PM BLOOD Glucose-88 UreaN-16 Creat-0.9 Na-139 K-3.4 Cl-104 HCO3-28 AnGap-10 [**2177-5-18**] 07:25AM BLOOD Calcium-9.7 Phos-4.9* Mg-1.9 [**2177-5-16**] 12:56PM BLOOD Calcium-9.4 Phos-3.5 Mg-2.1 . RAPID PLASMA REAGIN TEST (Final [**2177-5-19**]): REACTIVE. QUANTITATIVE RPR (Final [**2177-5-19**]): REACTIVE AT A TITER OF 1:8. . [**2177-5-16**] 01:01PM CEREBROSPINAL FLUID (CSF) WBC-4 RBC-0 Polys-0 Lymphs-98 Monos-2 [**2177-5-16**] 01:01PM CEREBROSPINAL FLUID (CSF) TotProt-30 Glucose-65 [**2177-5-16**] 01:01PM CEREBROSPINAL FLUID (CSF) VDRL-PND . CSF GRAM STAIN (Final [**2177-5-16**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. Brief Hospital Course: 1) S/p penicillin desensitization protocol: The patient was admitted to the medical intensive care unit for elective PCN desensitization, which she tolerated well. She did not need methylpred, famotidine, Benadryl, or epi. . 2) Syphilis: Following densitization, the patient was started on a full dose 4 million units IV q4h of Pen G on [**2177-5-16**]. Prior to abx, she had an LP which showed 4 WBC (98%L) 0 RBC, negative gram stain, Protein and Glucose normal. She had no signs or symptoms of meningitis, meningovascular syphilis, tabes dorsalis, or general paresis to suggest neurosyphilis; her neuro exam was stable without focality. Her treatment algorithm was as follows: if LP was positive for VDRL, treatment would be PCN 4 MU IV q4h x 2 wks. If LP was negative for VDRL, she would have benzathine pen G 2.4 mu im qwk x 3 only plus oral PCN at 250 mg po qd to avoid low serum levels and cancellation of the desensitization. . On [**2177-5-18**], the patient decided to leave against medical advice as she did not want to wait for the results of her testing, in particular the CSF VDRL send-out test. Her serum RPR was still pending at that time, but came back after her departure at 1:8 titer. Her CSF VDRL is stil pending. . 3) Headache and back pain: In the am of [**2177-5-18**], the patient complained of frontal HA and pain along spine, non-tender to palpation. She had pain on neck flexion; she had negative Kernig and Brudzinski signs, with no vision changes, photophobia, N/V, or focal neuro deficits. A trial of tylenol the night before was deemed inadequate by the patient. She was given 500 mg caffeine benzoate in 1L NS infused over 1 hr with good result for post-LP HA. Her HA resolved with this treatment . 4) Diarrhea: The patient had an episode of brown diarrhea the night before she left AMA with strings of white "worms" further defined as mucous, pain with defecation, and a bit of blood on the toilet paper after she wiped. She flushed before anyone saw the stool. She had this "white" diarrhea before when she had anal prolapse, but none since she was treated with surgery. She has no history of fissures or hemorrhoids. This was deemed most likely a side effect of penicillin, but C.diff cultures were sent as a precaution from a subsequent stool sample. 5) Social: The patient left AMA before a social work consult to ensure the patient would have the highest likelihood of following up with her syphilis treatment program. . Medications on Admission: 1. Ibuprofen prn for toothache 2. Tylenol prn for headache Discharge Medications: 1. Penicillin V Potassium 250 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 2. Ibuprofen prn for toothache 3. Tylenol prn for headache Discharge Disposition: Home Discharge Diagnosis: Neurosyphilis. Discharge Condition: Stable vital signs, ambulating independently. Discharge Instructions: You have neurosyphilis which would ideally be treated with iv penicillin but you have chosen to leave the hospital against medical advice. Please follow-up with your primary care doctor, Dr. [**First Name (STitle) **] [**Name (STitle) **], as scheduled tomorrow [**2177-5-19**]. Followup Instructions: Please follow-up with your primary care doctor, Dr. [**First Name (STitle) **] [**Name (STitle) **], as scheduled tomorrow [**2177-5-19**].

[ "349.0", "787.91", "724.5", "305.20", "094.9", "305.60", "493.90" ]

icd9cm

[ [ [] ] ]

[ "03.31", "38.93" ]

icd9pcs

[ [ [] ] ]

8325, 8331

5554, 8015

340, 379

8390, 8438

3885, 5490

8765, 8908

2583, 2600

8124, 8302

8352, 8369

8041, 8101

8462, 8742

2615, 3866

259, 302

407, 1992

2014, 2091

2107, 2567

5519, 5531

65,270

132,260

7964

Discharge summary

report

Admission Date: [**2115-3-10**] Discharge Date: [**2115-3-11**] Date of Birth: [**2037-2-5**] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 1515**] Chief Complaint: STEMI/VF ARREST Major Surgical or Invasive Procedure: - Cardiac Catheterization - Impella Placement History of Present Illness: 78M with recent duodenal ulcer bleed presented to OSH with CP and anterior ST-segment depression. Transferred to [**Hospital1 18**] for PCI. Arrived to [**Hospital1 **] in VF arrest. Received epi by EMS. Shocked x2 in the ED and was given amiodarone. Reportedly, pt was in a.fib on transfer to the cath lab. On angiography, he was noted to have thrombus in mid-RCA, as well as acute thrombotic occlusion of LAD. In the cath lab, the LAD lesion was initially treated and an IABP was placed. Then, the RCA lesion was treated, initially with POBA alone, followed by stenting because of thrombotic occlusion. Initial Hct here 18.6, so transfused a total of 5 units of PRBCs. After RHC demonstrated severely elevated left-sided filling pressures, Impella placed and IABP pulled. On arrival to the CCU, the patient's VS were T= 98.1 BP= 116/52 HR= 150 RR= 14 O2 sat= 93% on ventilator. He was intubated and sedated and was not able to provide any further historical information. Past Medical History: - peripheral neuropathy - hyperlidipemia - chronic low back pain Social History: - Unable to obtain, as pt was intubated. Family History: - Unable to obtain, as pt was intubated. Physical Exam: VS: T= 98.1 BP= 116/52 HR= 150 RR= 14 O2 sat= 93% on ventilator GENERAL: 78 y/o M intubated and sedated. Does not respond to painful stimuli. HEENT: NC/AT. PERRL. ET tube in place. CARDIAC: Faint HS. RRR; No m/r/g appreciaed. LUNGS: Respirated lung sounds. Lungs CTA B anteriorly. ABDOMEN: Soft, ND. No HSM or tenderness. BS present. EXTREMITIES: No pitting edema noted in the bilateral lower extremities. Cold extremities. PULSES: Right: DP unable to find PT dopplerable Left: DP unable to find PT dopplerable NEURO: Intubated, Sedated. PERRL. Does not respond to painful stimuli. Babinski equivocal bilaterally. Pertinent Results: Admission Labs [**2115-3-10**] 07:00AM BLOOD WBC-8.9 RBC-2.04* Hgb-6.1* Hct-18.6* MCV-91 MCH-30.0 MCHC-32.9 RDW-18.8* Plt Ct-244 [**2115-3-10**] 07:00AM BLOOD Neuts-91.5* Lymphs-4.7* Monos-3.6 Eos-0.2 Baso-0.1 [**2115-3-10**] 07:00AM BLOOD Glucose-226* UreaN-16 Creat-0.9 Na-139 K-3.3 Cl-111* HCO3-19* AnGap-12 [**2115-3-10**] 01:00PM BLOOD Type-ART pO2-75* pCO2-47* pH-7.20* calTCO2-19* Base XS--9 [**2115-3-10**] 01:00PM BLOOD Lactate-2.6* Most Recent Lab Values [**2115-3-10**] 11:35PM BLOOD WBC-17.0* RBC-3.44* Hgb-9.7* Hct-31.0* MCV-89 MCH-28.1 MCHC-32.0 RDW-19.1* Plt Ct-261 [**2115-3-10**] 11:35PM BLOOD PT-19.5* PTT-73.4* INR(PT)-1.8* [**2115-3-10**] 11:35PM BLOOD Glucose-290* UreaN-28* Creat-2.3*# Na-138 K-5.8* Cl-110* HCO3-12* AnGap-22* [**2115-3-10**] 11:35PM BLOOD Calcium-6.9* Phos-7.8*# Mg-2.0 [**2115-3-11**] 03:18AM BLOOD Type-ART Temp-36.8 pO2-60* pCO2-53* pH-7.01* calTCO2-14* Base XS--18 [**2115-3-11**] 01:07AM BLOOD Lactate-11.1* K-5.6* Cardiac Biomarkers [**2115-3-10**] 11:35PM BLOOD CK(CPK)-8101* [**2115-3-10**] 11:35PM BLOOD CK-MB-GREATER THAN 500 cTropnT-GREATER THAN 25 [**2115-3-10**] 12:29PM BLOOD CK(CPK)-[**Numeric Identifier 28562**]* [**2115-3-10**] 12:29PM BLOOD CK-MB-GREATER THAN 500 cTropnT-GREATER THAN 25 TTE ([**2115-3-10**] at 9:48 am) - There is moderate regional left ventricular systolic dysfunction with anteroseptal and inferoseptal hypokinesis extending to the apex with near akinesis at the base (LVEF 30-35%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The aortic valve is not well seen. There is no mitral valve prolapse and at least moderate [2+] mitral regurgitation. There is a trivial/physiologic pericardial effusion. TTE ([**2115-3-10**] at 9:00 pm) - An intracardiac device (Impella) is seen in the left ventricle. The device is then seen being pulled toward the left ventricular outflow tract into a more proximal position. The LVEF is severely depressed. Compared to the prior study from today, the LVEF has decreased and an Impella device is now seen. Cardiac Cath ([**2115-3-10**]) *PRELIM REPORT* COMMENTS: 1. Selective coronary angiography in this right dominant system revealed two vessel coronary disease. The LMCA had no obstructive disease. There was a total occlusion of the proximal LAD with significant clot burden. The LCx had moderate disease. The RCA had a 90% mid-vessel stenosis with thrombus. 2. Successful PTCA and stenting of the proximal LAD with a 2.5 x 18mm Mini Vision stent. Final angiography revealed no residual stenosis, no angiographically apparent dissection, and TIMI 2 flow. (see PTCA comments for details) 3. Successful placement of an 8 French IABP. 4. Successful PTCA and stenting of the mid RCA with a 3.5 x 12mm Mini Vision bare metal stent. Final angiography revealed no residual stenosis, no angiographically apparent dissection, and TIMI 2 flow. (see PTCA comments for details) FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Severe systolic ventricular dysfunction. 3. Acute anterior myocardial infarction, managed by acute ptca. PTCA of vessel. 4. Successful PTCA and stenting of the proximal LAD. 5. Successful placement of an IABP. 6. Successful PTCA and stenting of the mid RCA. Cardiac Cath ([**2115-3-10**]) *PRELIM REPORT* COMMENTS: 1. Right heart catheterization revealed pulmonary arterial hypertension with PASP of 39mmHg. The cardiac output and index were maintained on IABP at 5.89 l/min and 2.91l/min/m2. Right and left heart filling pressures were elevated with a PCWP of 35mmHg. 2. Successful placement of a 2.5 Impella device. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Elevated right and left heart filling pressures. 3. Successful placement of a 2.5 Impella device. Brief Hospital Course: The patient was admitted to the CCU after his catheterization procedure with Impella in place. In the evening, he was noted to develop a LBBB, which was consistent with myocardial damage from his massive anterior wall STEMI. Later in the evening, his Impella device was felt to have moved and to no longer be properly positioned. The position of the Impella was readjusted by the interventional cardiology fellow under echocardiographic guidance. Throughout the night, the patient's clinical status deteriorated and he became increasingly acidotic. It was felt that he could have ischemic bowel; however, the patient was too clinically unstable to undergo a CT scan. The patient's family was called into the hospital, and the gravity of his situation was explained to them. They felt that he would not want to live in his current state and decided that they would withdraw care. Pressors were weaned down and the patient expired. Medications on Admission: - omeprazole 20 mg [**Hospital1 **] - paroxicam 20 mg once daily (was instructed to no longer take) - tramadol 50 mg [**Hospital1 **] - viagra 100 mg PRN - gabapentin 300 mg once a day (?twice a day) - pravachol 20 mg daily Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

[ "427.41", "427.5", "410.11", "V45.81", "532.90", "414.01", "557.0", "276.2", "285.9", "785.51", "272.4" ]

icd9cm

[ [ [] ] ]

[ "00.46", "37.68", "37.61", "00.66", "96.04", "88.56", "96.71", "37.23", "99.62", "00.41", "36.06" ]

icd9pcs

[ [ [] ] ]

7251, 7260

6014, 6945

311, 358

7311, 7320

2217, 5152

7376, 7386

1525, 1567

7219, 7228

7281, 7290

6971, 7196

5849, 5991

7344, 7353

1582, 2198

256, 273

386, 1362

1384, 1451

1467, 1509

7,420

125,993

25754

Discharge summary

report

Admission Date: [**2174-7-18**] Discharge Date: [**2174-8-2**] Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 473**] Chief Complaint: duodenal perforation and ERCP-induced pancreatitis Major Surgical or Invasive Procedure: none History of Present Illness: Ms [**Known lastname 11622**] is an unfortunate [**Age over 90 **] year-old female who was transferred from [**Hospital3 3765**] for ERCP-induced pancreatititis. Her lipase and amylase were in the 1000's at time of transfer. Her initial presentation was abdomenal pain, bloating, decrease in appetite, fatique. Her initial labs inlude alk phos in the 800's, T-Bili 3.3, and elevated LFT's. Initial ultrasound of RUQ was negative for cholecystitis. Hence, an ERCP was attempted and was obviously unsuccessful. Past Medical History: Afib Reflux esophagitis Depression Hypothyroid HTN Dementia Arthritis Social History: Grew up in NJ. Worked as schoolteacher. Husband had dementia over several yrs, lived in nursing home for 5 yrs until his death last yr. Pt now lives with 1 of her 2 sons. Notably there have been several recent deaths -- 2 sisters and also friends. Physical Exam: Initial exam at [**Hospital1 18**] revealed that she was afebrile with vitals being stable. She was mildly uncomfortable. She was alert and oriented. Her heart was irregularly irregular. Her lungs were clear to asculation, except bibasilar rales. Her abdomen was distended, with fluid wave, diffusely tender, without rebound or guarding. Her extremities were non-edematous and without clubbing or cyanosis. Pertinent Results: [**2174-7-30**] 05:53AM BLOOD WBC-18.4* RBC-3.09* Hgb-8.9* Hct-29.0* MCV-94 MCH-28.8 MCHC-30.8* RDW-14.9 Plt Ct-323 [**2174-7-30**] 05:53AM BLOOD ALT-22 AST-53* LD(LDH)-272* AlkPhos-575* TotBili-0.8 [**2174-7-18**] 12:51AM BLOOD Lipase-174* [**2174-7-21**] 04:34AM BLOOD Lipase-21 Brief Hospital Course: ***Patient Expired [**2174-8-2**]*** Upon arrival to [**Hospital1 18**], the patient was immediately admitted to the intensive care unit. She was stable during her first few days in the unit and was subsequently transferred to the floor. However, she eventually became septic from peritonitis caused by the duodenal perforation/pancreatitis and deteriorated. She was re-admitted to the intensive care unit, where she continued to deteriorate. All efforts were made to reverse her condition, including being placed on heavy antibiotics such as Vancomycin, Levofloxacin, and Metronidazole, blood transfusions, TPN nutrition. However, the family (mainly son) and patient came the conclusion that a "do not resusitate" status is most appropriate, give the circumstance. Hence, the patient eventually deteriorated and re-admitted to the intensive care unit, where she ultimate expired on [**2174-8-2**]. Discharge Disposition: Expired Discharge Diagnosis: Expired [**2174-8-2**] Discharge Condition: Expired Discharge Instructions: non-applicable Followup Instructions: none Completed by:[**2174-12-30**]

[ "276.5", "294.8", "998.2", "574.90", "530.11", "276.6", "401.9", "577.0", "458.9", "997.4", "292.81", "276.2", "E935.2", "244.9", "427.31", "286.9", "716.90" ]

icd9cm

[ [ [] ] ]

[ "89.65", "99.04", "38.93", "99.15" ]

icd9pcs

[ [ [] ] ]

2858, 2867

1930, 2835

267, 273

2933, 2942

1625, 1907

3005, 3041

2888, 2912

2966, 2982

1192, 1606

177, 229

301, 814

836, 907

923, 1177

72,454

178,408

39178

Discharge summary

report

Admission Date: [**2172-4-24**] Discharge Date: [**2172-5-10**] Date of Birth: [**2105-6-19**] Sex: M Service: NEUROLOGY Allergies: Penicillins / Clindamycin / Dilaudid Attending:[**First Name3 (LF) 2569**] Chief Complaint: Headache Major Surgical or Invasive Procedure: cerebral angiogram History of Present Illness: Reason for Consult: Called by Emergency Department to evaluate ICH Pt. name is [**Known firstname **] [**Name (NI) **]. HPI: The pt is a 66 year-old RHM w/ HL/DM and ? HTN who developed sudden onset R sided retroorbital HA, nausea, took tylenol without relief. Within minutes developed L sided weakness and L facial droop, but apparently was responding appropriately and following commands, albeit slowly. His wife noted his speech was like speaking w/ a mouth full of marbles. He seemed unsettled, moving things around on the kithchen counter w/o purpose. EMS was called. He was able to walk to the ambulance, but needed support and direction. At [**Hospital3 10310**] Hospital GCS was 15, BP was 139/63 but ranged between 139 - 167 systolic. Pt. developed worsening nausea, emesis and pounding HA around 21.30, BP at that time was noted as 204/95. CT head revealed a large R frontal IPH w/ SAH. He was tx w/ fosphenytoin 1g, intubaed (etomidate, succinyl choline, versed) and started on ativan gtt. Transferred to [**Hospital1 18**]. VS here on propofol were 118/51 83 on CMV/AC. Exam was notable for GCS of 5, unresponsive to verbal, grins to noxious, eyes midline brisk, no deviation, present corneal and gag w/o VOR, w/o localization to noxious, brisk flexor on R to noxious away from stimulus and R flex on nox to LUE. RLE w/ brisk withdrawal, while, LLE w/ grin and RLE flx. L toe is up and tone LLE >> RLE. Per discussion w/ wife, there were no prodromal symtptoms or signs. He was in USOH, watching a Bruins game. No new medications, no hx of drug use. He was not straining at the time, no hx of recent trauma. . Past Medical History: [ ? ] HTN [ + ] HL [ + ] DM [ - ] Afib [ - ] prior CVA/TIA/ICH Social History: Lives in [**Location 14663**] MA w/ wife. Is a retired electrical company manager, now volunteers at the police office Family History: bio father unknown. Mother's side: [ + ] HTN [ - ] HL [ - ] DM [ - ] CVA/TIA [ - ] CAD/PVD [ pancreatic, breast ] Cancer [ - ] Intracerebral anneurysms/AVM [ - ] Connective tissue disorders ([**Last Name (un) 42664**] Dahnlos, Marfans, PKD) Physical Exam: Vitals: T: 97.1 P:83 R: 16 BP: 118/51 SaO2: 100% on CMV assist General: Obtunded. HEENT: NC/AT, no scleral icterus noted Neck: Supple. Pulmonary: CTA bilaterally, laterally Cardiac: RR, nl. S1S2, no M/R/G Abdomen: soft, NT/ND, no masses or organomegaly noted. Extremities: warm, dry, no edema; clubbing present Pulses: 2+ radial, DP bilaterally. Neurologic: GCS of 5 (eye opening 1, motor 3, verbal 1) off propofol x 10 minutes. MS: unresponsive to verbal, grins to noxious. Eyes midline briskly reactive 4->2, no deviation. Present are corneal and gag, there is no VOR. -Motor/sensory: Normal bulk. No posturing. Increased tone in LLE > LUE. LUE not antigravity, extends to noxious and causes RUE to flex w/o localization. RUE withdraws briskly to noxious, flexor. LLE, trace triple flexion to noxious sluggishly, RLE flexes briskly to nox applied at LLE. RLE to nox brisk withdrawal away from stiumuls. -DTRs: diffusely brisk in b/l UEs symmetrically as of right now, LLE 3+, RLE 2+. Plantar response: RIGHT - flexor LEFT - extensor Pertinent Results: 141 104 21 164 AGap=13 ------------[ 4.1 28 1.0 CK: 118 MB: 2 Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Pending 15.5 12.9 39 210 N:84.6 L:10.1 M:3.5 E:1.5 Bas:0.3 PT: 12.0 PTT: 23.4 INR: 1.0 EKG at OSH: NSR, no sT/T changes. Hematology [**2172-5-5**] 04:30AM BLOOD WBC-12.1* RBC-3.69* Hgb-10.8* Hct-32.0* MCV-87 MCH-29.3 MCHC-33.9 RDW-13.0 Plt Ct-413 [**2172-5-4**] 05:20AM BLOOD WBC-15.6* RBC-3.95* Hgb-11.7* Hct-34.3* MCV-87 MCH-29.6 MCHC-34.1 RDW-13.0 Plt Ct-370 [**2172-5-3**] 06:20AM BLOOD WBC-11.1* RBC-3.85* Hgb-11.1* Hct-33.2* MCV-86 MCH-28.7 MCHC-33.3 RDW-12.8 Plt Ct-302 [**2172-5-2**] 06:00AM BLOOD WBC-10.9 RBC-3.43* Hgb-10.1* Hct-29.8* MCV-87 MCH-29.4 MCHC-33.8 RDW-12.8 Plt Ct-291 [**2172-5-1**] 04:30AM BLOOD WBC-10.8 RBC-3.39* Hgb-10.0* Hct-29.4* MCV-87 MCH-29.6 MCHC-34.1 RDW-12.8 Plt Ct-252 [**2172-4-30**] 02:07AM BLOOD WBC-14.2* RBC-3.57* Hgb-10.3* Hct-30.1* MCV-84 MCH-28.7 MCHC-34.1 RDW-12.7 Plt Ct-243 [**2172-4-29**] 02:27AM BLOOD WBC-13.1* RBC-3.70* Hgb-10.3* Hct-31.0* MCV-84 MCH-27.9 MCHC-33.2 RDW-12.7 Plt Ct-223 [**2172-4-28**] 02:10AM BLOOD WBC-15.7* RBC-3.44* Hgb-9.5* Hct-29.2* MCV-85 MCH-27.7 MCHC-32.5 RDW-12.9 Plt Ct-185 [**2172-4-27**] 01:25AM BLOOD WBC-16.7* RBC-3.53* Hgb-10.2* Hct-30.3* MCV-86 MCH-28.9 MCHC-33.6 RDW-13.0 Plt Ct-183 [**2172-4-25**] 02:08PM BLOOD WBC-12.0* RBC-3.72* Hgb-11.1* Hct-32.5* MCV-87 MCH-29.8 MCHC-34.2 RDW-12.9 Plt Ct-212 [**2172-4-25**] 01:42AM BLOOD WBC-15.6* RBC-3.84* Hgb-11.5* Hct-33.6* MCV-87 MCH-29.9 MCHC-34.1 RDW-13.0 Plt Ct-265 [**2172-4-24**] 06:03AM BLOOD WBC-14.9* RBC-4.12* Hgb-12.4* Hct-36.0* MCV-88 MCH-30.1 MCHC-34.4 RDW-12.9 Plt Ct-267 [**2172-4-23**] 11:30PM BLOOD WBC-15.5* RBC-4.50* Hgb-12.9* Hct-38.8* MCV-86 MCH-28.7 MCHC-33.2 RDW-12.8 Plt Ct-210 Coags [**2172-5-5**] 04:30AM BLOOD Plt Smr-NORMAL Plt Ct-413 [**2172-5-4**] 05:20AM BLOOD Plt Smr-NORMAL Plt Ct-370 [**2172-5-3**] 06:20AM BLOOD Plt Smr-NORMAL Plt Ct-302 [**2172-4-25**] 01:42AM BLOOD Plt Ct-265 Chem 7 [**2172-5-5**] 04:30AM BLOOD Glucose-138* UreaN-25* Creat-0.8 Na-131* K-4.3 Cl-97 HCO3-26 AnGap-12 [**2172-5-4**] 05:20AM BLOOD Glucose-54* UreaN-24* Creat-0.7 Na-136 K-4.2 Cl-99 HCO3-25 AnGap-16 [**2172-5-3**] 06:20AM BLOOD Glucose-161* UreaN-21* Creat-0.8 Na-136 K-4.2 Cl-99 HCO3-26 AnGap-15 [**2172-5-2**] 06:00AM BLOOD Glucose-260* UreaN-22* Creat-0.7 Na-132* K-4.3 Cl-97 HCO3-27 AnGap-12 [**2172-5-1**] 04:30AM BLOOD Glucose-176* UreaN-20 Creat-0.8 Na-135 K-4.2 Cl-100 HCO3-29 AnGap-10 [**2172-4-30**] 02:07AM BLOOD Glucose-116* UreaN-20 Creat-0.7 Na-137 K-4.0 Cl-103 HCO3-26 AnGap-12 [**2172-4-28**] 02:10AM BLOOD Glucose-163* UreaN-21* Creat-0.9 Na-139 K-3.9 Cl-105 HCO3-26 AnGap-12 [**2172-4-26**] 02:20AM BLOOD Glucose-195* UreaN-20 Creat-0.8 Na-139 K-3.8 Cl-105 HCO3-24 AnGap-14 [**2172-4-24**] 06:03AM BLOOD Glucose-186* UreaN-19 Creat-1.0 Na-137 K-4.5 Cl-103 HCO3-26 AnGap-13 [**2172-4-24**] 02:18PM BLOOD CK(CPK)-102 [**2172-4-24**] 02:18PM BLOOD CK-MB-2 cTropnT-<0.01 [**2172-4-24**] 06:03AM BLOOD CK-MB-2 cTropnT-<0.01 [**2172-4-23**] 11:30PM BLOOD cTropnT-<0.01 [**2172-5-5**] 04:30AM BLOOD Calcium-8.2* Phos-4.0 Mg-2.2 [**2172-5-4**] 05:20AM BLOOD Calcium-8.0* Phos-4.5 Mg-2.3 [**2172-5-3**] 06:20AM BLOOD Calcium-8.1* Phos-3.7 Mg-2.1 [**2172-5-2**] 06:00AM BLOOD Calcium-7.8* Phos-2.7 Mg-2.0 Cholest-114 [**2172-5-1**] 04:30AM BLOOD Calcium-7.7* Phos-3.8 Mg-2.1 [**2172-4-30**] 02:07AM BLOOD Calcium-7.9* Phos-3.9 Mg-2.0 [**2172-4-29**] 02:27AM BLOOD Calcium-7.9* Phos-3.5 Mg-2.0 [**2172-4-28**] 02:10AM BLOOD Calcium-7.9* Phos-2.9 Mg-1.8 [**2172-4-27**] 01:25AM BLOOD Calcium-7.5* Phos-2.0* Mg-2.1 [**2172-4-26**] 02:20AM BLOOD Calcium-8.1* Phos-1.5* Mg-1.6 [**2172-4-25**] 01:42AM BLOOD Calcium-8.0* Phos-2.1* Mg-2.2 [**2172-4-24**] 06:03AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.8 [**2172-5-2**] 06:00AM BLOOD %HbA1c-7.4* eAG-166* [**2172-5-4**] 01:59PM URINE Blood-NEG Nitrite-NEG Protein-25 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-4* pH-7.0 Leuks-NEG [**2172-4-25**] 02:08PM URINE Blood-SM Nitrite-NEG Protein-100 Glucose-1000 Ketone-15 Bilirub-NEG Urobiln-1 pH-5.5 Leuks-NEG [**2172-4-24**] 01:39AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2172-5-4**] 01:59PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2 [**2172-4-25**] 02:08PM URINE RBC-[**7-16**]* WBC-[**7-16**]* Bacteri-FEW Yeast-NONE Epi-0-2 [**2172-4-24**] 01:39AM URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG Radiologic Data: CT from OSH 2130 reveals a 4.5 x 3.9 x 5.0 cm R frontal hemorrhage in MCA/ACA territory, w/ SAH in frontal lobes w/ mild masse effect on R frontal [**Doctor Last Name 534**] w/o IVH. [**Hospital1 18**] CT head and CTA C- head: large right frontal parenchymal hemorrhage w/ subarachnoid blood similar to prior study. New/increased left hemispheric SAH (2:22, 2:18). Mass effect on right lateral ventricle. 2mm leftward shift of midline structures. New intraventricular hemorrhage right > left lateral ventricles. CTA: patent carotid, vertebral arteries, patent Circle of [**Location (un) 431**]. No aneurysm identified MRI +/- [**2172-4-27**]; IMPRESSION: Redemonstration of a large right frontal intraparenchymatous hematoma as described in detail above, causing effacement of the sulci, and mild midline shifting towards the left, approximately 2.9 mm of shifting is demonstrated in the transverse projection. After the administration of gadolinium contrast, there is evidence of prominent arterial and venous vessels surrounding the inferior aspect of the hemorrhage with a prominent single vessel coursing along the lateral aspect of the hematoma and slightly increased flow voids in this area, the possibility of an underlying vascular malformation cannot be completely excluded, other entities occult by the hematoma are also considerations, followup is recommended. No significant areas with magnetic susceptibility are identified to suggest amyloid angiopathy, however, this entity cannot be completely ruled out. Cerebral angiogram [**4-29**] FINDINGS: Left common carotid arteriogram showed normal carotid bifurcation. Normal filling of the internal carotid along the cervical, petrous, cavernous and supraclinoid portions. Both anterior and middle cerebral arteries were seen and appeared normal. There was no aneurysm or arteriovenous malformation seen. There was normal venous phase of the study. The external carotid artery with its branches were normal with no dural AVF. Right common carotid arteriogram showed some atherosclerotic changes in the common carotid and proximal internal carotid with no significant stenosis. There was normal filling of the internal carotid along the cervical, petrous, cavernous and supraclinoid portions. There was some displacement of intracranial vessels due to mass effect from the right frontal bleed with area of reduced vascularity representing the area of intracerebral hemorrhage. There was early bifurcation of the right middle cerebral artery. The anterior cerebral artery was seen and appeared normal. There was no aneurysm or arteriovenous malformation. The venous phase of the study was normal with prominent superficial cortical veins. Right external carotid artery showed normal filling of the vessel and its branches with no evidence of dural AV fistula. Left vertebral arteriogram showed normal filling of the dominant distal vertebral artery. Basilar appears normal in course and caliber. The left PICA, both AICAs, SCAs and PCAs were seen and appeared normal. The right PCA appears smaller than the left PCA. There was no aneurysm or arteriovenous malformation. IMPRESSION: Diagnostic cerebral angiogram was done, which did not show any aneurysm, arteriovenous malformation, or dural AV fistula to account for the patient's intracerebral hemorrhage. CXR [**4-30**] FINDINGS: As compared to the previous examination, there is no relevant change. The Dobbhoff tube is in unchanged position, with the tip projecting over the distal part of the stomach. The course and position of the left-sided central venous access line is also unchanged. Unchanged size of the cardiac silhouette with mild retrocardiac atelectasis. No newly appeared focal parenchymal opacities CXR [**5-1**] IMPRESSION: Improving left lower lobe pneumonia. CT head [**5-5**] IMPRESSION: 1. No significant change in the previously noted right frontal hematoma with surrounding edema and mass effect on the right lateral ventricle with 3.4 mm leftward shift of the midline structures. No new acute intracranial hemorrhage. No acute fracture. 2. Small amount of fluid/mucosal thickening in the left side of the sphenoid sinus. CT torso [**5-7**] (prelim) chest: small left effusion w/ relaxation atelectasis. right base atelectasis. no pulm nodule or mass. no consolidation. small scattered nodes but no mediastinal or hilar adenopathy by size criteria. dobhoff reaches stomach. airways widely patent. abd/pelv: no evidence of malignancy. liver, spleen, kidneys, adrenals and pancreas appear normal. min biliary studge. msall and large bowel normal in caliber and appearance. air in bladder, correlate with catheterization. atherosclerosis without aneurysm EEG [**5-8**] pending Brief Hospital Course: Hospital course by problem; . Neurology; The patient was admitted to the neurology ICU for q1h neurochecks. His SBP was maintained 100-160 mmHg and HOB greater than 30 degrees. He was started on keppra 500 mg [**Hospital1 **] for seizure prophylaxis. Serial CT head imaging remained stable. An MRI brain was concerning for possible AVM, but subsequent conventional angiogram did not show any evidence of vascular malformation. The most likely cause of bleed is either hypertension or amyloid angiopathy. He was noted to be drowsy with fluctuating lvel of consciousness while in the hospital. He underwent MRI for evaluation followed by CT torso to rule out underlying mass , both of which did not show any evidence of underlying mass/ malignancy. He had unwitnessed fall on [**5-5**] in the afternoon, after which he had CT scan which did not show evidence of change in size of bleed or new bleed. He was initially started on keppra which was later stopped as he developed rash. he underwent EEG which was normal . Resp; The patient required intubation for airway protection but was extubated [**4-28**] without difficulty. He was noted to have left lower zone infiltrate on chest Xary and was started on broad spectrum antibiotics (cipro and vanco). After transfer to floor, he was noted to have rising wbc on [**5-3**] and [**5-4**], however he did not have fever. The trend was closely monitered and it showed downward trend on [**5-5**]. . ID; The patient spiked fevers to 103 on [**4-25**] and had leukocytosis. Blood and urine cultures have been negative to date. One sputum sample grew gram positive rods. CXR showed a possible LLL infiltrate. He was started on vancomycin and ciprofloxacin for presumed ventilator-associated pneumonia [**4-25**] and antibiotics were stopped after a course of 11 days as he showed clinical and lab signs of resolution and developed skin rash. . CV; The patient required phenylephrine to maintain MAP > 70 early in the hospital course but has been normotensive since extubation. His home ace-inhibitor has been resumed. . Endo; The patient was maintained on a regular insulin sliding scale and NPH. His home glyburide has been resumed. Derm- he developed rash over left arm followed by anterior abdominal wall and also on legs. The most likely cause is thought to be medication induced, either due to vancomycin, ciprofloxacin or keppra. This should be watched closely in next few days. OT/PT/Rehab; He was evaluated by rehab team. He was unable to pass speech and swallow test and was on tube feeds till [**5-6**]. It was discussed with family and it was decided to proceed with PEG tube for feeding issues. he underwent PEG tube on [**2172-5-8**]. As his mental status improves, his ability to take POs should be reassessed. OT/PT recommended for extended care facility for further care. Medications on Admission: - Glyburide 5mg [**Hospital1 **] - Quinipril 5mg daily - Metformin 500mg [**Hospital1 **] - Simvastatin 40mg daily - ASA 81 daily Discharge Medications: 1. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for eye care. 2. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed) as needed for eye care. 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Quinapril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. 7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for temp > 101, pain. 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for c. 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for Thrush. 11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 12. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [**2-8**] Inhalation Q6H (every 6 hours) as needed for wheezing. 15. Insulin Lispro Subcutaneous Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Right frontal bleed, ? hypertensive in origin Discharge Condition: Mental Status: Confused - sometimes Level of Consciousness: Lethargic but arousable Activity Status: Out of Bed with assistance to chair or wheelchair Discharge Instructions: You were admitted for evaluation of stroke. You had CT scan of brain as well as MRI which showed bleed in right frontal lobe of brain. You were evaluated by neurosurgery and underwent angiogram which did not show evidence of AVM or aneurysm. The most likely cause of bleed is thought to be related to hypertension. You were dound to have pneumonia for which you were treated with antibiotics. You were started on medication called keppra for prevention of seizures which was later stopped while in the hospital as you developed rash , most likley to either antibiotics or keppra. You underwent PEG tube placement for feeding. You underwent CT scan of torso which did not show evidence of mass. You underwent EEG which showed ... Please take your medications as prescribed. Please call 911/ your doctor if questions. Please follow up with the appointments as scheduled. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2172-6-15**] 2:30 Please call [**Last Name (LF) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 67627**] PCP's office after discharge for follow up. [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

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Discharge summary

report

Admission Date: [**2102-11-5**] Discharge Date: [**2102-11-29**] Date of Birth: [**2031-7-16**] Sex: F Service: MEDICINE Allergies: Phytonadione Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: respiratory distress Major Surgical or Invasive Procedure: PICC line placement Tracheostomy placement RIJ placement and removal History of Present Illness: 71W pmhx recurrent Cdif, ESRD on HD, DM, Dementia, CVA, b/l AKA, CAD, Afib, recently discharged from the [**Hospital1 18**] on [**10-30**] for possible VRE UTI, Cdiff and also osteomyelitis on levaquin/linezolid/PO vanco presents from NH found unarousable after a HD session today her VS 99.4 132/81 97 20 and o2 sat 93RA, cxr performed for chest congestion, became less responsive and BP 143/92 P 149, T 102.9 R22 o2 sat 89%RA. The transferred to ED. . In the ED, Vs 100.4 139 133/99 20 100% ? NRB, then in triage was noted to be 133 148/112 40 100% NRB, Tm in ED 102.2 was noted to have crackles b/l she was intubated for tachypnea. Otherwise received zosyn, in addition to her outpatient antibiotics, and when an OG tube was placed there was the a question of fecal discharge from the OG tube, but with no abd tenderness. A CT scan was performed which showed no obstruction, but a Distended gallbladder with gallstones and mild surrounding stranding, raising possibility of cholecystitis. Surgery was consulted but based on no clinical evidence on examination of sedated pt, with no RUQ abd pain, surgery recommendations were to follow LFTs, and consider cholecystostomy tube as needed . She was then tx'd to the ICU for further treatment. Here, she was sedated, VS were stable, bilious fluid was noted from her ET tube. Radiology was consulted for RUQ US. Past Medical History: -- ESRD on HD T/Th/Sat -- PVD -- IDDM -- Dementia -- s/p CVA -- Hypothyroidism -- Decubitus Ulcer -- Recurrent C. Diff (negative as of [**10-20**]) -- Anemia -- VRE UTI - currently being treated with macrobid -- B/L AKA -- CAD -- A Fib, on coumadin -- CHF - EF 25% in [**2100**] Social History: Divorced. Has 2 children. [**First Name9 (NamePattern2) 2957**] [**Doctor First Name **] who per report is mentally ill and not involved in decision making. Son [**Name (NI) 4468**] was HCP but during recent hospitalization she had a legal guardian assigned. HCG [**First Name4 (NamePattern1) 3608**] [**Last Name (NamePattern1) 4334**] [**Telephone/Fax (1) 5350**] Emergency [**Telephone/Fax (1) 76176**] - Court appointed. Family History: Non-contributory Physical Exam: Admission: VS 100.9 110 145/70 14 99RA GEN: Sedated, min responsive, NAD HEENT: PERRL, anicteric, ET tube CV; ireg ireg, no mrg CHEST cta b/l ant ABD: soft decreased BS, G tube, increased HR with RUQ palpation, nondistended EXT: sacral decub Stage 4, 3 cm diameter- no purulent discharge. cool extremities, b/l AKA, well healed, no discharge NEURO: sedated . Discharge: Pertinent Results: EKG: afib 140s bpm, slight LAD, ST depression in lat leads, w TWI V4-V5 unchanged from previous. . Echo: The left atrium is markedly dilated. The right atrium is markedly dilated. The estimated right atrial pressure is 0-5mmHg. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF 60%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion . Head CT: No evidence of intracranial hemorrhage. Evidence of prior infarcts in the right cerebral hemisphere, in particular, a large chronic-appearing infarction involving the right middle cerebral artery territory. . CXR's: CXR [**11-4**]: Slightly elevated L hemidiaphram, Dialysis catheter in place, ET tube in place CXr [**11-8**]: The bibasilar opacities appear less distinct which may be related to breathing versus small new pleural effusions superimposed upon atelectasis. Cannot exclude pneumonia. There is no appreciable vascular congestion. The endotracheal tube, nasogastric tube, and right internal jugular catheter are stable in position. CXR [**11-13**]: In comparison with the study of [**11-12**], there is continued decrease in the right pleural effusion. Again the area behind the heart cannot be evaluated for possible pneumonia. Blunting of the left costophrenic angle is consistent with left effusion. Various tubes remain in place. CXR [**11-18**]:Right lower lobe atelectasis is new. ET tube is in standard position. There is no pneumothorax. Bilateral internal jugular catheters remain in place. The left lung is grossly clear. There are no sizable pleural effusions. New right lower lobe atelectasis. CXR: [**11-23**]: In comparison with the study of [**11-23**], the tracheostomy tip is about 2.5 cm above the carina, essentially unchanged. There has been development of increasing opacification at the right base without obscuration of the hemidiaphragm, consistent with some combination of pleural effusion and atelectasis. The left hemidiaphragm is also not sharply seen, with the same probable etiologic factors. CXR [**11-26**]: Two portable images of the chest were obtained and compared to prior examinations dating back to [**2102-11-20**]. Low lung volumes are again noted. There is improved aeration of the lung bases. There is persistent partial obscuration of the left hemidiaphragm, likely secondary to underlying atelectasis. There is a right perihilar prominence that is slightly indistinct, likely secondary to underlying pulmonary venous congestion. In addition, there is a new right perihilar opacity, may reflect crowding of the vasculature associated with the low lung volumes, however cannot exclude atelectasis and an evolving pneumonia. . CT ABD: IMPRESSION: 1. Cholelithiasis, within a distended gallbladder with mild wall thickening and surrounding stranding, raising the possibility of cholecystitis. Please correlate with patient's symptoms. These findings could be further evaluated by ultrasound if clinically indicated. . US: RUQ CBD 1cm, no intrahepatic ductal dilatation, stones, no cholecystitis, small amt of fluid in [**Location (un) **] pouch. . CBC: [**2102-11-4**] 10:40AM BLOOD WBC-19.6*# RBC-3.58* Hgb-11.1* Hct-36.2 MCV-101* MCH-30.9 MCHC-30.6* RDW-18.2* Plt Ct-425 [**2102-11-4**] 09:00PM BLOOD WBC-29.8*# RBC-3.88* Hgb-12.4 Hct-40.2 MCV-104* MCH-31.9 MCHC-30.8* RDW-17.9* Plt Ct-531* [**2102-11-29**] 04:06AM BLOOD WBC-8.9 RBC-2.33* Hgb-7.2* Hct-23.6* MCV-101* MCH-30.7 MCHC-30.4* RDW-17.0* Plt Ct-297 [**2102-11-4**] 10:40AM BLOOD Neuts-89.2* Bands-0 Lymphs-7.7* Monos-2.6 Eos-0.1 Baso-0.4 [**2102-11-13**] 04:00AM BLOOD Neuts-65 Bands-0 Lymphs-19 Monos-12* Eos-1 Baso-0 Atyps-1* Metas-1* Myelos-1* NRBC-3* . Coags [**2102-11-4**] 09:00PM BLOOD PT-26.2* PTT-36.6* INR(PT)-2.7* [**2102-11-6**] 07:04AM BLOOD PT-76.5* PTT-63.8* INR(PT)-10.0* [**2102-11-6**] 07:22PM BLOOD PT-76.0* PTT-72.3* INR(PT)-9.9* [**2102-11-29**] 04:06AM BLOOD PT-13.6* PTT-29.2 INR(PT)-1.2* . LFT's [**2102-11-4**] 09:00PM BLOOD ALT-12 AST-18 CK(CPK)-19* AlkPhos-242* Amylase-92 TotBili-0.3 [**2102-11-4**] 09:00PM BLOOD Lipase-51 [**2102-11-27**] 04:40AM BLOOD Lipase-83* . Cardiac enzymes: [**2102-11-5**] 03:35AM BLOOD CK-MB-3 cTropnT-0.22* [**2102-11-4**] 09:00PM BLOOD cTropnT-0.30* . Miscellaneous [**2102-11-5**] 03:35AM BLOOD TSH-2.0 [**2102-11-4**] 09:00PM BLOOD Cortsol-53.6* [**2102-11-14**] 03:42AM BLOOD CRP-27.3* [**2102-11-4**] 09:00PM BLOOD CRP-139.2* [**2102-11-19**] 04:39AM BLOOD Digoxin-2.2* . ABG: [**2102-11-4**] 09:54PM BLOOD Type-ART Rates-14/14 Tidal V-500 PEEP-5 FiO2-100 pO2-370* pCO2-39 pH-7.33* calTCO2-21 Base XS--4 AADO2-319 REQ O2-58 -ASSIST/CON Intubat-INTUBATED [**2102-11-18**] 09:32AM BLOOD Type-[**Last Name (un) **] Temp-36.7 Rates-/33 Tidal V-300 PEEP-5 FiO2-40 pO2-31* pCO2-43 pH-7.35 calTCO2-25 Base XS--2 Intubat-INTUBATED Vent-SPONTANEOU . Culture Data: Sputum : [**2102-11-5**]: GRAM STAIN >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD. KLEBSIELLA PNEUMONIAE. MODERATE GROWTH. Sensitive to Zosyn, Meropenem and Gentamicin. Sputum [**11-10**]: Klebsiella (Sensitive to Zosyn, Meropenem and Gentamicin) and Acinetobacter (Sensitive to Gentamycin and Tobramycin) Sputum [**11-16**]: Pseudomonas (Sensitive to Zosyn, Meropenem, tobramycin and Gentamicin) BAL [**11-18**]: Pseudomonas(Sensitive to Zosyn, Meropenem and Gentamicin) and Acinetobacter (Sensitive to Gentamycin and Tobramycin) Sputum [**11-25**]: Pseudomonas (Sensitive to Zosyn, Meropenem and Gentamicin) Urine [**2102-11-5**]: KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML. (Sensitive Zosyn, Meropenem and Gentamicin.)ESCHERICHIA COLI. >100,000 ORGANISMS/ML.(Sensitive to all but Cipro and Amp/Sulbactam, S= Zosyn, Meropenem and Gentamicin) C.diff negative x 3 Blood Cx [**Date range (1) 76177**]: no growth Blood Cx [**11-13**]: coag negative staph 2/4 bottles Blood Cx [**11-16**]- [**11-26**]: no growth Multiple catheter tips: no growth Brief Hospital Course: # Fevers: - Brief overview: The patient had an extensive work up for fever given almost daily fevers to 101-102. She was treated with multiple antibiotics and followed closely by the infectious diseases team. The conculsion of this work up was that she had Klebsiella PNA and UTI which were both sucessfully treated. However, she is colonized but not infected by ESBL Pseudomonas Pneumonia. In addition, after multiple manipulations of her antibiotics (ex.stopping and restaring Meropenem), it was concluded that given her decrease in fever when off abx, her lack of leukocytosis or symptoms (no cough or secretions) that her repeated fevers were most likely due to a drug fever. All antibiotics were stopped on [**2102-11-27**] other than PO Vanco which was kept to taper off given a long history of recurrent C.Diff. She should have PO Vancomycin for a 6 week taper that started on [**2102-11-27**] to continue until [**2103-1-8**]. This may need to be adjusted if other antibiotics are started in the interim. - In detail: The patient presented to us with a diagnosis of recurrent C. difficile and presumed osteomyelitis. She was on a 6 week course of Linezolid and Levofloxacin for presumed osteomyelitis of her sacral ulcer and a 6 week taper of PO Vancomycin for C. diff. Linezolid and Levofloxacin were then discontinued as there was no objective data showing osteomyelitis (culture or radiology) and the wound looked quite clean without any purulence. Initally, there was a question of elevated LFT's and possible cholecystitis but the was quickly ruled out with normalizing LFT's and normal RUQ U/S. There was also an ongoing concern for line infection and her femoral line and then later her dialysis catheter were both changed - although blood cultures were no growth and catheter tips then showed no gowth. She did receive a 14 day course of Vancomycin IV dosed by hemodialysis and levels for a possible line infection and then also for a preliminary concern for MRSA PNA (which was not borne out on sputum/BAL culture data). In the first several days of admission, she was diagnosed with a a ESBL Klebsiella and ESBl E.coli PNA and UTI based on culture data. She was started on Meropenem with a plan for a 14 day course. She received 5 days of Meropenem with worsening fevers despite decreasing leukocytosis. Per ID recs, Meropenem was discontinued for question of drug fever. She was off Meropenem for 7 days. It was then restarted for 5 days with Gentamycin after her sputum now grew Pseudomonas sensitive to Gentamycin and Meropenem. She continued to spike fevers despite adequate treatment and multiple investigations in to possible infections. She had a fever to 104 F on [**11-27**], and other than a fever of 102.9 on [**11-29**], she has been afebrile which represents a dramatic decrease in her fever curve. Further following for infections may be better done by following sputum quantity/color and WBC count. . # Respiratory Failure- It is unclear what precipitated the patient's tachypnea. PE is unlikely as the patient was anticoagulated. An echo shows normal EF and the patient had a recent hemodialysis session just prior to admission which would make volume overload and pulmonary edema somewhat less likely. There were no new EKG changes (old lateral ST depressions) and her cardiac enzymes were negative making a cardiac pathology unlikely. Pneumonia was the most likely possibility with a fever and elevated WBC despite a normal CXR as her sputum culture showed a significant number of neutrophils and grew ESBL Klebsiella and E.coli. She was treated for Klebsiella PNA with Meropemem which then cleared the sputum. She then grew Pseudomonas which was treateed with Gentamycin and Tobramycin as above. However, she continued to fail attempts at weaning despite no sedation. Specifically, she had high RSBI's, no cough and would have long periods of apnea. She was given aggressive hemodialysis with fluid removal for component of pulmonary edema with no improvment in weaning. Due to failure to wean and ventilator dependance, a family meeting was convened with her son (co-guardian) and court appointed guardian to discuss tracheostomy. It was agreed to place a tracheostomy, and on [**2102-11-24**] interventional pulmonology place a tracheostomy. She has remained on comfortably a ventilator without any sedation with settings MMV, FIO2 40%, PEEP 5 and Pressure Support of 12. . # Leukocytosis - Her leukocytosis was likely secondary to infection. It was initially 23, rose to a peak of 30 in the first 2 days of admission and then trended down to 8.9. See above discussion of infectious evaluation. . # Wound care - Her sacral decubitous ulcer remained clean and unchanged. Wound care was given as per wound care consult. A plastics consult was obtained. The plastic surgery team advised that the patient was not a surgical canditate and that no further surgical treatment - debridement or reconstruction- was warranted. Due to the concern for fecal contamination of her gluteal wound, a rectal tube was placed. The patient is not a candidate for diverting colostomy. . # Afib: Her afib was well controlled on digoxin. Her coumadin was discontinued permanently given that her risk of bleeding outweighs her risk of ischemic stroke as she has had a intracranial bleed in the past. . # ESRD: Patient was continued on hemodialysis during her hospital course and was followed by the renal consult service. She was continued on Nephrocaps and Sevelamer. During the early portion of her hospital stay, a moderated amount of fluid was removed during hemodialysis to remove any pulmonary edema and maximize ventilatory weaning attempts. . # CVA- Aspirin was held for procedures - tracheostomy - but should be restarted at discharge. . # Diabetes: The patient was well controlled on NPH 8 units [**Hospital1 **]. . # Hypothyroidism - Maintained on home dose of synthroid. TSH within normal limits . # Anemia - has been stable on epoeitin. . # FEN: Receiving G-Tub feeding. . # Access: The patient was transfered from the ED with a right femoral line. This was left in place initially as she had a significantly elevated INR likely secondary to [**Month (only) **] vit K and antibiotics. She was not given vitamin K given the reported allergic history. Coumadin and aspirin were held. She was given FFP and a left IJ was placed without complications. She subsequently had a PICC placed on [**2102-11-28**] and the left IJ was discontinued. She maintained her double lumen dialysis catheter but there has been recent difficulty in using one of the ports despite TPA, the other port remains patent for hemodialysis. . # CODE: Full Code. Contact both son [**Name (NI) 4468**] [**Name (NI) 76178**] and legal guardian [**Name (NI) 3608**] [**Name (NI) 4334**] - dual guardians per court order. HCG [**First Name4 (NamePattern1) 3608**] [**Last Name (NamePattern1) 4334**] [**Telephone/Fax (1) 5350**] Emergency [**Telephone/Fax (1) 76176**] - Court appointed. Medications on Admission: Prevacid 30 mg Daily Sevelamer 1600 mg QID Warfarin 1 mg QHS Metoclopramide 5 mg PO QIDACHS Levothyroxine 150 mcg Daily Lactobacillus Acidophilus TID [**Doctor First Name **]-Vite Daily Digoxin 125 mcg Daily Epoetin Alfa 5,000 As directed Nystatin 100,000 unit/mL Suspension [**Doctor First Name **]: Five (5) ML PO QID PRN Metoprolol Tartrate 50 TID Acetaminophen 160 mg/5 mL Solution [**Doctor First Name **]: Five (5) mL PO Q6H PRN Linezolid 600 mg PO Q12H for 6 weeks. (started [**10-30**]) Insulin NPH Human Recomb 8U [**Hospital1 **] Vancomycin 125 mg PO Taper benprotein 2 scoops TID Aspirin 325 mg Daily Levofloxacin 500 mg Daily x 6 weeks Discharge Medications: 1. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 2. insulin Pt was on insulin sliding scale and standing insulin as per attached sheet. 3. Epoetin Alfa 10,000 unit/mL Solution [**Hospital1 **]: per P&T guidelines Injection ASDIR (AS DIRECTED). 4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 6. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Last Name (STitle) **]: One (1) Cap PO DAILY (Daily). 7. Vancomycin 125 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q6H (every 6 hours) for 6 weeks: Until [**2103-1-8**]. 8. Levothyroxine 75 mcg Tablet [**Month/Day/Year **]: Two (2) Tablet PO DAILY (Daily). 9. Sevelamer 800 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Acetaminophen 325 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO Q6H (every 6 hours) as needed for Pain / Fever. 11. Citalopram 20 mg Tablet [**Month/Day/Year **]: 0.5 Tablet PO DAILY (Daily). 12. Aspirin 325 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Hospital1 **] Discharge Diagnosis: Primary Respiratory failure with failure to wean Klebsiella and E.coli PNA Klebsiella and E.coli UTI . Secondary Pseudomonas lung colonization Drug Fever - Meropenem Sacral Debcuitous Ulcer ESRD Discharge Condition: stable Discharge Instructions: Mrs. [**Known lastname 76178**] was admitted for respiratory failure and was treated ventilation, transitioned to tracheostomy. She also received HD and multiple antibiotics for fevers and question of infectionl. Please see full discharge summary for details. . In particular, she should be continued on HD every other day. She should continue her PO vancomycin for a total of 6 more weeks from [**11-27**] (until [**2103-1-8**]) when her other antibiotics were discontinued. This may need to be adjusted if other antibiotics are started in the interim. For continued infection surveillance, sputum color/quantity and white blood cell count may be more useful than fever curve as she likely has been having drug-related fevers. . For medical decision please contact both: [**Name (NI) 4468**] [**Name (NI) 76178**] (sone) and [**Name (NI) 3608**] [**Name (NI) 4334**] (legal guardian) - dual guardians per court order. HCG [**First Name4 (NamePattern1) 3608**] [**Last Name (NamePattern1) 4334**] [**Telephone/Fax (1) 5350**] Emergency [**Telephone/Fax (1) 76176**]. Followup Instructions: Please follow up with your primary care physician in the next 7-10 days. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "528.9", "995.92", "428.0", "790.92", "038.49", "285.21", "250.40", "294.8", "427.31", "428.32", "518.81", "780.6", "008.45", "707.03", "999.9", "244.9", "482.0", "V49.76", "585.6", "V12.54", "996.62" ]

icd9cm

[ [ [] ] ]

[ "00.14", "38.93", "96.04", "99.04", "96.56", "96.72", "99.07", "96.6", "39.95", "31.1", "33.22" ]

icd9pcs

[ [ [] ] ]

18352, 18427

9356, 16343

302, 372

18667, 18676

2963, 3811

19793, 20005

2535, 2553

17044, 18329

18448, 18646

16369, 17021

18700, 19770

2568, 2944

7551, 9333

242, 264

400, 1769

3821, 7534

1791, 2073

2089, 2519

64,656

154,021

18446+56945+56952

Discharge summary

report+addendum+addendum

Admission Date: [**2125-3-22**] Discharge Date: [**2125-4-2**] Date of Birth: [**2050-4-16**] Sex: M Service: CARDIOTHORACIC Allergies: Rofecoxib / Celebrex Attending:[**First Name3 (LF) 1505**] Chief Complaint: dyspnea on exertion, chest pain Major Surgical or Invasive Procedure: coronary artery bypass x 4 (LIMA-LAD, SVG-OM, SVG-Dx, SVG-PDA) History of Present Illness: This patient is a 74 year old white male with a history of coronary disease, s/p stents to the RCA and LCx in [**2124-11-2**]. He continues to have dyspnea on exertion and chest pain, despite the intervention. The patient underwent cardiac catheterization and coronary angiography at [**Hospital1 **] Heart Center which revealed multi-vessel disease. He is transferred to [**Hospital1 18**] for surgical evaluation. Past Medical History: coronary artery disease s/p stents [**November 2124**] (RCA-1, Cx-2) hypertension narcolepsy obstructive sleep apnea (uses CPAP) peripheral neuropathy skin cancer (basal and squamous cell) spinal stenosis Social History: Lives with: wife Occupation: retired biology professor Tobacco: 15 pack years, quit in [**2085**] ETOH: 1 glass of wine per night Family History: father had coronary artery disease died at 66 years of age Physical Exam: Admission: Pulse: 76SR Resp: 18 O2 sat: 97%RA B/P Right: 148/68 Left: Height: 5'[**26**]" Weight: 166lb General: Skin: Dry [x] intact [x] no rash HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [] Edema Varicosities: None [] no varicosities RLE (s/p arterial bypass) pink in color, skin is very taught with trace edema about ankle LLE well healed scar s/p LTKR Neuro: Grossly intact X Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: NP Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: Left: no bruits Pertinent Results: [**2125-3-27**] 03:06AM BLOOD WBC-8.1 RBC-2.75* Hgb-8.7* Hct-25.7* MCV-93 MCH-31.5 MCHC-33.8 RDW-14.3 Plt Ct-122* [**2125-3-27**] 03:06AM BLOOD Glucose-110* UreaN-20 Creat-1.1 Na-136 K-4.5 Cl-108 HCO3-24 AnGap-9 PREBYPASS No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. POSTBYPASS Biventricular systolic function remains preserved. The study is otherwise unchanged from the prebypass period. [**2125-3-30**] 05:50AM BLOOD WBC-7.3 RBC-3.30* Hgb-9.9* Hct-29.3* MCV-89 MCH-30.0 MCHC-33.8 RDW-16.1* Plt Ct-135* [**2125-3-22**] 07:25PM BLOOD WBC-5.5 RBC-3.95* Hgb-11.9* Hct-36.7* MCV-93 MCH-30.1 MCHC-32.4 RDW-14.4 Plt Ct-200 [**2125-3-30**] 05:50AM BLOOD UreaN-37* Creat-1.7* K-4.2 [**2125-3-29**] 05:45AM BLOOD Glucose-106* UreaN-38* Creat-1.6* Na-135 K-4.3 Cl-103 HCO3-24 AnGap-12 [**2125-3-22**] 07:25PM BLOOD Glucose-106* UreaN-27* Creat-1.3* Na-139 K-4.3 Cl-106 HCO3-25 AnGap-12 [**2125-3-22**] 07:25PM BLOOD ALT-14 AST-17 LD(LDH)-183 AlkPhos-107 Amylase-54 TotBili-0.3 Brief Hospital Course: The patient was transferred for preoperative evaluation and Plavix washout. Echocardiography revealed an ejection fraction of 60% and no significant valvular abnormalities. Carotid ultrasound revealed right ICA stenosis of 40-59%, left ICA stenosis of 60-69%. The patient was placed on Heparin due to his recent drug eluting stents. He developed chest pain on hospital day two which was relieved with nitroglycerin and morphine. EKG did not reveal any ischemic changes. The patient remained on nitro and Heparin drips. He was brought to the Operating Room on [**2125-3-26**] where he underwent coronary artery bypass x 4. Vancomycin was used for peri-operative prophylaxis as he was inpatient for greater than 24 hours preop. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU on Neo Synephrine and Propofol infusions for further recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. He was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker and statin were resumed and the patient was diuresed toward his preoperative weight. CTs and temporary pacing wires were removed per protocol. He received several transfusions and his hematocrit remained stable. he was discharged home on a week course of Lasix as he remained 8 kilograms over his preoperative weight. Wounds were clean and healing well, he was ambulating independently and pain was well controlled on oral analgesics. Discharge medications, instructions and precautions , as well as follow up instructions were discussed with him prior to discharge. Medications on Admission: allopurinol 300', plavix 75', cozaar 100', toprol xl 25', provigil 400', colchicine 0.6', doxazosin 2'', nifedipine ER 90', gabapentin 400', simvastatin 40', asa 325', vit D 1000'' Discharge Medications: 1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 weeks. Disp:*30 Tablet(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 4 weeks. Disp:*50 Tablet(s)* Refills:*0* 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 8. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 9. Modafinil 100 mg Tablet Sig: Four (4) Tablet PO daily (). 10. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*135 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass [**2125-3-26**] Hypertension Narcolepsy Obstructive Sleep apnea (uses CPAP) Peripheral neuropathy Discharge Condition: Alert and oriented x3, nonfocal Ambulating, gait steady Sternal pain managed with Percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**Last Name (STitle) **] [**Name (STitle) 5929**]. [**4-19**] 9am at [**Hospital1 **] for wound check and post-op follow-up [**Telephone/Fax (1) 6256**] Please call for appointments: Dr. [**Last Name (STitle) 5874**] at [**Hospital1 **] ([**Telephone/Fax (1) 6256**]please see same day as Dr. [**Last Name (STitle) **] Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 8036**]) in 2 weeks Completed by:[**2125-3-30**] Name: [**Known lastname **],[**Known firstname 7052**] L Unit No: [**Numeric Identifier 9404**] Admission Date: [**2125-3-22**] Discharge Date: [**2125-4-2**] Date of Birth: [**2050-4-16**] Sex: M Service: CARDIOTHORACIC Allergies: Rofecoxib / Celebrex Attending:[**First Name3 (LF) 741**] Addendum: The patient was discharged on metoprolol 50mg TID Discharge Medications: 1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 weeks. Disp:*30 Tablet(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 4 weeks. Disp:*50 Tablet(s)* Refills:*0* 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 8. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 9. Modafinil 100 mg Tablet Sig: Four (4) Tablet PO daily (). 10. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 437**] VNA [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2125-3-30**] Name: [**Known lastname **],[**Known firstname 7052**] L Unit No: [**Numeric Identifier 9404**] Admission Date: [**2125-3-22**] Discharge Date: [**2125-4-2**] Date of Birth: [**2050-4-16**] Sex: M Service: CARDIOTHORACIC Allergies: Rofecoxib / Celebrex Attending:[**First Name3 (LF) 741**] Addendum: Mr.[**Known lastname 9434**] discharge date was changed due to oxygen desaturation. Aggressive diuresis was initiated. Repeat chest xrays followed his progression. Oxygen was added to his CPAP machine overnight due to desaturations. Home oxygen was arranged and follow up with Mr.[**Known lastname 9434**] pulmonologist, Dr.[**Last Name (STitle) 9435**], is necessary for further evaluation. He will be discharged on diuretics. Physical therapy cleared him for home discharge. On POD# 7 Mr. [**Known lastname **] was discharged to home with VNA. All follow up visits were advised. Discharge Medications: 1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 weeks. Disp:*30 Tablet(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7 days. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 4 weeks. Disp:*50 Tablet(s)* Refills:*0* 6. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 7. Modafinil 100 mg Tablet Sig: Four (4) Tablet PO daily (). 8. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 11. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 437**] VNA Followup Instructions: Dr. [**Last Name (STitle) **] [**Name (STitle) 9436**]. [**4-19**] 9am at [**Hospital1 **] for wound check and post-op follow-up [**Telephone/Fax (1) 5412**] Please call for appointments: Dr. [**Last Name (STitle) 9437**] at [**Hospital1 **] ([**Telephone/Fax (1) 5412**]please see same day as Dr. [**Last Name (STitle) **] Dr. [**First Name8 (NamePattern2) 255**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 9438**]) in 2 weeks Please arrange to see Dr.[**Last Name (STitle) 9435**], pulmonologist, in the next week or 2 for follow up re:CPAP/oxygen use#([**Telephone/Fax (1) 9439**] [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2125-4-2**]

[ "V45.82", "V43.65", "356.9", "V10.83", "414.01", "401.9", "V58.66", "327.23", "518.5", "724.02", "411.1", "347.10" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

12287, 12345

3550, 5235

318, 383

7025, 7122

2107, 3527

12368, 13088

1223, 1284

11003, 12264

6853, 7004

5261, 5444

7146, 7639

1299, 2088

247, 280

411, 830

852, 1059

1075, 1207

71,139

137,539

43017+58577

Discharge summary

report+addendum

Admission Date: [**2129-2-26**] Discharge Date: [**2129-3-8**] Service: MEDICINE Allergies: Sulfamethoxazole / glyburide Attending:[**First Name3 (LF) 4327**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catheterization Intubation and mechanical ventilation History of Present Illness: Ms. [**Known lastname 2856**] is a [**Age over 90 **] year old female with history of CAD s/p MI and 2-vessel CABG in [**2097**], presenting with troponin elevation to 0.35, new ST depressions, and hypotension after nitroglycerin and furosemide, transferred to [**Hospital1 18**] for further evaluation. She developed left-sided chest pain and shortness of breath at 9am prior to admission with a report of bloody, loose stools as well. She denies any prior bloody stools, nausea/vomiting, or dizziness. She took one nitroglycerin with relief of pain. Patient lives alone with visiting nurse services, but was not herself this AM per report of her family. The family is unsure if she had been taking her medications reliably and per the representatives from Meals on Wheels she may have been losing weight lately due to poor PO intake. She was taken to the outside hospital ([**Hospital1 **]) and notable labs were creatinine of 1.2, normal CBC, and grossly normal complete metabolic panel. CK 57 and Trop 0.35, as above. CXR showed evidence of pulmonary edema after 1.5L of IVF, and EKG demonstrated new ST depressions compared to old without evidence of >1mm STEs in 2 contiguous leads, so she was started on a heparin gtt. She became hypotensive with nitroglycerin and furosemide treatment (30mg). Her pain seemed to improve with morphine, but no further morphine was given due to hypotension. She was then transferred to [**Hospital1 18**] for cardiac intervention. . In the [**Hospital1 18**] ED, she dropped her oxygen sats to the high 70s was initiated on a NRB. She was then intubated for hypoxemia and oxygenated well after that. She was persistently hypotensive and levophed was initiated at that time. EKG showed evolving STEMI (elevations in III, avR, V1-V2 and depression in I, II, aVL, V4-V6) with reciprocal ST depressions. She was then transferred to the cath lab for intervention. . There was a delay in getting to the cath lab due to hypoxemia and volume overload. The family also initially did not want her to be intubated. Following family discussion, it was decided to intubate her and take her to cath lab to diagnose the problem and potentially fix it. In the cath lab, arterial access was obtained in the left radial artery. Left forearm angiography showed a very small and tortuous vessel. A left subclavian lesion was crossed with a balloon for pre-dilation. The lesion was then re-crossed from the groin approach and stented with a 6.0 x 24 mm PS Blue stent (BMS), with 10% residual stenosis and no significant pressure gradient. Final angiography revealed normal flow, no dissection or thrombosis. Coronary angiography showed a right dominant system, with left main ostial lesion of 90% stenosis with post stenotic dilation, diffuse noncritical disease in LAD, 50% stenosis of LCx at origin into an ulcerated OM1 with a filling defect but normal flow. RCA showed a proximal 90% stenosis and diffuse disease with total occlusion and collaterals filling distal vessel from LCA. Grafts were identified as an occluded SVG-RCA and widely patent LIMA-LAD. No stents were placed in the coronaries. Post-procedure ECG demonstrated resolution of ST segment changes. . 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: 1. CARDIAC RISK FACTORS: (+) Diabetes, (+) Dyslipidemia, (+) Hypertension 2. CARDIAC HISTORY: - CABG: 2-vessel CABG in [**2097**] (LIMA-LAD and SVG-RA) - PERCUTANEOUS CORONARY INTERVENTIONS: - PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: - s/p endarterectomy - hypothyroidism Social History: Lives indepedently, but functioning has been declining as of late. History of smoking, EtOH, and IVDU history due to sedation/intubation. Family History: Noncontributory Physical Exam: ADMISSION PHYSICAL EXAM: GENERAL: intubated/sedated, not withdrawing to pain stimuli HEENT: NCAT. Sclera anicteric. PERRL but pinpoint. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of [**10-14**] cm (close to earlobe). Left EJ in place, C/D/I. CARDIAC: irregularly irregular, normal S1, S2 with IV/VI blowing, systolic murmur radiating to the axilla. No rubs/gallops/thrills/ lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Ventilated, with crackles over lateral lung fields. No wheezes, rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: [**1-3**]+ bilateral LE edema. No femoral bruits. Right groin site C/D/I without hematoma or bruits. Left wrist site with TR band in place SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Hematoma over left antecubital fossa NEURO: very sedated with pinpoint pupils, reflexes intact but unable to assess strength PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ . DISCHARGE PHYSICAL EXAM: Pertinent Results: ADMISSION LABS: [**2129-2-26**] 02:45PM BLOOD WBC-14.4* RBC-3.91* Hgb-12.5 Hct-37.1 MCV-95 MCH-31.9 MCHC-33.5 RDW-14.1 Plt Ct-199 [**2129-2-26**] 02:45PM BLOOD Neuts-89.5* Lymphs-8.3* Monos-1.4* Eos-0.4 Baso-0.4 [**2129-2-26**] 04:30PM BLOOD PT-12.1 INR(PT)-1.1 [**2129-2-26**] 04:30PM BLOOD cTropnT-0.45* [**2129-2-26**] 04:00PM BLOOD Tidal V-400 PEEP-5 pO2-227* pCO2-39 pH-7.29* calTCO2-20* Base XS--6 Intubat-INTUBATED Vent-CONTROLLED [**2129-2-26**] 04:00PM BLOOD Hgb-11.6* calcHCT-35 O2 Sat-98 Cardiac Enzymes: [**2129-2-26**] 04:30PM BLOOD cTropnT-0.45* [**2129-2-26**] 10:50PM BLOOD CK(CPK)-1004* [**2129-2-26**] 10:50PM BLOOD CK-MB-131* MB Indx-13.0* cTropnT-1.53* [**2129-2-27**] 04:30AM BLOOD CK-MB-170* MB Indx-12.4* cTropnT-2.27* [**2129-2-27**] 04:30AM BLOOD CK(CPK)-1371* [**2129-2-27**] 10:34AM BLOOD CK-MB-137* MB Indx-10.9* cTropnT-2.45* [**2129-2-27**] 10:34AM BLOOD CK(CPK)-1259* [**2129-3-1**] 10:40AM BLOOD CK-MB-11* MB Indx-7.4* cTropnT-3.67* [**2129-3-1**] 10:40AM BLOOD CK(CPK)-149 [**2129-3-1**] 03:36PM BLOOD CK-MB-10 MB Indx-8.0* cTropnT-4.25* [**2129-3-1**] 03:36PM BLOOD CK(CPK)-125 [**2129-3-1**] 09:30PM BLOOD CK-MB-8 cTropnT-4.67* [**2129-3-1**] 09:30PM BLOOD CK(CPK)-94 Relevant Labs: [**2129-2-27**] 05:54PM BLOOD Glucose-207* UreaN-46* Creat-2.2* Na-139 K-5.0 Cl-104 HCO3-21* AnGap-19 [**2129-3-1**] 03:36PM BLOOD Glucose-108* UreaN-60* Creat-2.6* Na-136 K-5.0 Cl-102 HCO3-19* AnGap-20 [**2129-3-7**] 05:15AM BLOOD Glucose-99 UreaN-78* Creat-2.1* Na-143 K-5.6* Cl-104 HCO3-26 AnGap-19 [**2129-2-26**] 10:50PM BLOOD TSH-2.5 Discharge Labs: [**2129-3-8**] 06:59AM BLOOD Hct-30.0* [**2129-3-8**] 06:59AM BLOOD Glucose-85 UreaN-72* Creat-1.8* Na-144 K-4.8 Cl-103 HCO3-28 AnGap-18 Studies: LHC [**2-26**]: Findings ESTIMATED blood loss: <100 cc Hemodynamics (see above): Coronary angiography: right dominant LMCA: Ostial 90% with post stenotic dilation LAD: Diffuse noncritical disease with anterior wall supply from large septal branch and diagonal which receives the LIMA. Competitive flow from the LIMA is seen. LCX: Origin 50% stenosis into and ulcerated OM1 which was large and with a filling defect and normal flow. RCA: Proximal 90% stenosis and diffuse disease with total occlusion and collaterals filling distal vessel from LCA. SVG-RCA: Occluded LIMA-LAD: Widely patent in the proximal and visualized portion of the retrograde LIMA. Other: The left subclavian artery was seen to have a 99% stenosis proximal to the LIMA with at least a 60mm Hg gradient. Interventional details Delay was encountered prior to the cath lab due to need for clarification of Code Status, goals of care and the need to intubate the patient for respiratory failure. The patient arrive on IV Levophed to maintain SBP >100 mm Hg. Arterial access was obtained in the left radial artery. Difficulty was encountered angiography of the left forearm angiography was performed showing the vessel to be very small and tortuous. A Magic Torque wire was advanced into the subclavian artery and then an 0.035" angled glide wire was used to cross the left subclavian lesion and the distal wire was placed in the distal aorta. A Slip catheter was used to exchange for an 0.018" Steel core wire and a 5.0 x 40 mm and then 7.0 x 40 mm Balloon were used to predilate. The lesion was then recrossed from the groin approach using another 0.018" Steel core wire and the lesion was stented with a 6.0 x 24 mm mm PS Blue stent. The stent was then postdilated to 7.0 mm. There was 10% residual stenosis and no significant pressure gradient upon pullback across the stent. Final angiography revealed normal flow, no dissection or thrombosis. The patient remained critically ill at the end of the case post procedure ECG demonstrated resolution of ST segment changes. Assessment & Recommendations 1. Wean FiO2 as tolerated by peripheral saturation. 2. ASA indefinitely 3. Plavix (clopidogrel) 75 mg daily X 1 month and preferably 9 months. 4. Secondary prevention CAD, CHF 5. IV Amiodarone for paroxysmal atrial fibrillation. 6. Wean Levophed as tolerated. [**2-27**] echo: Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is severe global left ventricular hypokinesis (LVEF = 20-25 %). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size is normal with depressed free wall contractility. The aortic valve leaflets are severely thickened/deformed. Significant aortic stenosis is present (not quantified). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is severe mitral annular calcification. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. [**3-6**]/ CXR: REASON FOR EXAM: Patient with dyspnea and CHF. Comparison is made with prior study, [**3-4**]. Large bilateral pleural effusions are grossly unchanged. Moderate cardiomegaly is stable. Patient is status post CABG. Moderate pulmonary edema is unchanged. Right PICC tip is in the lower SVC. Brief Hospital Course: [**Age over 90 **] year old female with history of CAD s/p MI and 2-vessel CABG, with evidence of diffuse, chronic coronary artery disease with appropriate collateralization and a stenotic left subclavian artery, now s/p BMS. . #. Left subclavian artery stenosis with STEMI: Subclavian artery likely feeding into LIMA-LAD [**Last Name (LF) **], [**First Name3 (LF) **] a stenotic lesion in this location led to an anteroseptal STEMI on EKG. Coronary arteries are diffusely diseased, but not amenable to percutaneous intervention. She is now s/p BMS placement to left subclavian artery with resolution of EKG changes and her enzymes have downtrended. Patient was on heparin gtt and plavix loaded prior to cath. She was started on ASA 325mg daily, plavix 75mg daily, and atorvastatin 80mg daily. Beta blocker and ACE inhibitor initially held secondary to hypotension. Metoprolol was restarted but lisinopril continue to be held [**2-3**] to [**Last Name (un) **]. . # Acute on chronic systolic and diastolic CHF/3+ MR: Echo revealed severe global left ventricular hypokinesis (LVEF = 20-25 %) as well as severe (3+) mitral regurgitation is seen. The patient developed hypoxia, large pleural effusions, and pulmonary edema secondary to her heart failure. Initially, her diuresis was limited [**2-3**] to low blood pressures, but as her blood pressures recovered, she was placed on IV lasix which was transitioned to torsemide with good effect. Large doses needed to be used due to her [**Last Name (un) **]. She should continue on this regimen with titration as necessasry to continue volume removal without causing the patient to be sympomatic from hypovolemia. Pt will continue on metoprolol and torsemide. Lisinopril held for now due to renal failure. It should be restarted at 2.5 mg once creatinine is at baseline. Morphine was given for shortness of breath. O2 may be weaned as tolerated. . # [**Last Name (un) **]: Post contrast, pt developed [**Last Name (un) **], with rise in creatnine to 2.6 from admission of 1.6. In combination with contrast, pt likely has poor forward flow, and heart failure leading to high right atrial pressure, causing poor perfusion gradient of kidney. Over time and with diuresis the patient's kidney function has improved. Lisinopril held during kidney injury. . # Paroxysmal atrial fibrillation: patient had evidence of peri-procedural AF, for which she received IV amiodarone 150mg x1 with conversion to NSR. She returned to AF after the procedure. She then received IV amiodarone loading at 1 mg/min for a total of 6 hours, with transition to 0.5 mg/min and then oral amiodarone. Amiodarone was subsequently discontinued without resolution of atrial fibrillation. The patient was placed back on a beta blocker. Patient also noted to have rate dependent Right bundle branch block which developed when rates increased. This was not present after initiating metoprolol. . #. Hypoxemia: Most likely secondary to volume overload given her OSH CXR. Her desaturations prompted intubation in the midst of unstable hemodynamics prior to catheterization. Patient is DNR/DNI but her family agreed that it would be appropriate to intubate her in this situation as it was easily reversible. She remained intubated post-procedure secondary to depressed mental status from anesthetic sedation, but vent was successfully weaned the following morning. Diuresis was held until her blood pressures stabilized. Pt had lots of fluid accumulation in her lungs and an elevated JVD. She was diuresed with good effect and improvement in her breathing, requiring less O2 and breathing much more comfortably. Morphine can be given for shortness of breath. . #. Hypotension: In setting of hypoxemia and nitroglycerin, furosemide, and morphine administration, she developed hypotension to SBPs in the 70s, prompting initiation of levophed. Post-catheterization, she tolerated lower doses of pressors but continued to require levophed to maintain MAP>60. Diuresis was held until hemodynamics stabilized post-procedurally. On discontinuation of levofed, her pressures remained the same, and over the course of her hospitalization her blood pressure normalized ranging in the 90s-120s/40s-50s. Her wide pulse pressure is most likely due to large vessel atherosclerosis. . #. Coronary artery disease: Diffuse, chronic disease, as evidenced by cardiac catheterization prior to CCU admission. No interventions were done due to appropriate collateralization to every vascular territory. As stated above, a BMS was placed to patient's left subclavian. Pt continue ASA, plavix, atorvastatin, metoprolol. . #. UTI: Patient has UA suggestive of UTI. At time of discharge, pt's urine culture was still pending. Will need to follow up on urine culture results to make sure cefpodoxime treatment is appropriate. Pt should continue cefpodoxime till [**3-12**] for presumptive UTI. . #. Hyperlipidemia: Continue lipitor . #. DM2: had poor PO intake, and thus fingersticks and insulin were discontinued. . #. Hypothyroidism: continue levothyroxine . # GERD-like symptoms: Patient given ranitidine and Maalox/diphenhydramine/lidocaine combination. . # Anxiety: Continue lorazepam 0.25-0.5 mg PO Q8H PRN for anxiety. . Dispo: Transitioning to hospice. No outpatient f/u appts made. . Code status: DNR/DNI . TRANSITIONAL: Monitor for improvement in kidney function Titrate diuretics as needed Transitioning to Hospice Cefpodoxime till [**3-14**] Medications on Admission: - atenolol 12.5mg daily - synthroid 100 mcg daily - lisinopril 5mg daily - simvastatin 10mg daily - lasix 20mg daily - allopurinol 100mg daily - potassium chloride 10mEq daily - Plavix 75mg daily Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for Chest pain. 6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. morphine 10 mg/5 mL Solution Sig: 2.5 mg PO Q4H (every 4 hours) as needed for dyspnea. 8. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 11. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. 12. torsemide 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 13. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 6 days: Stop on [**2129-3-14**]. Discharge Disposition: Extended Care Facility: [**Location 12243**] Senior Care - [**Hospital1 189**] Discharge Diagnosis: ST Elevation myocardial infarction Acute Kidney Injury Acute systolic congestive heart failure Coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: You had a heart attack and a cardiac catheterization was done that revealed a blockage in one of your arteries that was opened with a bare metal stent. It is very important that you take plavix every day for one month. Do not stop taking aspirin or plavix every day unless Dr. [**Last Name (STitle) 911**] says that it is ok. Doing so will risk another heart attack. Your heart as weak and you had fluid that built up in your lungs. This was treated with medicines to remove the fluid and you will continue to take torsemide every day to keep the fluid from reaccumulating. Weigh yourself every morning before breakfast is possible. . We made the following changes to your medicines: 1. Continue to take aspirin and plavix every day to keep the stent from clotting off. 2. Take niroglycerin as needed for chest pain 3. Stop taking furosemide, take torsemide instead to remove extra fluid 4. Stop taking simvastatin, take atorvastatin instead to help lower cholesterol 5. STOP taking potassium as your kidneys are not working as well. 6. Start ranitidine to help your stomach upset 7. Start morphine and ativan as needed for pain, anxiety or trouble breathing 8. Start senna and miralax to prevent constipation 9. Stop taking lisinopril as your kidney function has worsened. Followup Instructions: none Completed by:[**2129-3-8**] Name: [**Known lastname 14600**],[**Known firstname 471**] Unit No: [**Numeric Identifier 14601**] Admission Date: [**2129-2-26**] Discharge Date: [**2129-3-8**] Date of Birth: [**2038-6-16**] Sex: F Service: MEDICINE Allergies: Sulfamethoxazole / glyburide Attending:[**First Name3 (LF) 949**] Addendum: UA- revealed (see below); Pt discharged on cefpodoxime, which should cover this organism. KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Discharge Disposition: Extended Care Facility: [**Location 14602**] Senior Care - [**Hospital1 1612**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 950**] MD, [**MD Number(3) 951**] Completed by:[**2129-3-9**]

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icd9cm

[ [ [] ] ]

[ "00.40", "88.56", "38.93", "96.04", "39.50", "39.90", "00.45" ]

icd9pcs

[ [ [] ] ]

20762, 20999

10976, 16436

246, 309

18135, 18135

5740, 5740

19568, 20739

4526, 4543

16682, 17868

17993, 18114

16462, 16659

18270, 19545

7318, 10953

4583, 5695

4174, 4285

6258, 7302

196, 208

337, 4058

5757, 6241

18150, 18246

4316, 4355

4080, 4154

4371, 4510

5721, 5721

57,889

111,845

34430

Discharge summary

report

Admission Date: [**2102-4-6**] Discharge Date: [**2102-4-14**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Endotracheal intubation Flexible bronchoscopy [**2102-4-8**] History of Present Illness: Ms. [**Known firstname 79145**] is a [**Age over 90 **] year-old female with a history of HTN, DM, ?chronic aspiration, and Alzheimer's dementia who was transferred from the ED intubated after presenting with hypoxia and tachypnea. She was in her usual state of health until two days ago when she began experiencing a nonproductive cough and dyspnea. Her symptoms worsened and her [**Age over 90 **] and son-in-law, whom she lives with, brought her to the ED. On presentation, her VS were 98.1 74 154/82 18 79%RA. She appeared to be in acute respiratory distress, with increased work of breathing. She was placed on a NRB and was satting in the 80-85% range, and a CXR demonstrated left sided consolidation. She was started on levofloxacin and ceftriaxone and intubated because of worsening tachypnea and hypoxia and then transferred to the [**Hospital Unit Name 153**]. . Per discussion with her [**Hospital Unit Name **], the patient has not received a flu shot this year but did receive the pneumovax about five years ago. She has no sick contacts and has no recent hospital or nursing home exposure. She last had pneumonia one year ago and was treated as an outpatient. Review of systems is otherwise negative for fevers, chills, arthralgias, nausea, vomiting, diarrhea, and chest pain. Ms. [**Known lastname 22114**] has chronic constipation at baseline. Past Medical History: HTN DM2 (diet controlled) ?Chronic aspiration Alzheimer's dementia Breast cancer (diagnosed seven years ago) Lower back pressure ulcer Social History: Ms. [**Known lastname 22114**] is Russian speaking and wheelchair bound at baseline. She lives with her [**Known lastname **] and son-in-law in [**Location (un) 14307**] and moved to the United States from [**Country 532**] five years ago. She does not smoke or drink alcohol. She has VNA services for dressing changes for her lower back pressure ulcer. She has only seen her PCP once and most of her medical history is part of the [**Hospital6 **] system. Family History: No heart disease or diabetes. Otherwise non-contributory. Physical Exam: On discharge satting 100% on 4L NC, HR 59, BP 161/58. PHYSICAL EXAM GENERAL: NAD, opens eyes to voice, but does not interact HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: Decreased lung sounds on Right, crackles on left ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: Muscle wasting, no edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: moves all extremities, downgoing toes, responds to noxious stimuli. Pertinent Results: [**2102-4-14**] 04:13AM BLOOD WBC-10.9 RBC-4.05* Hgb-12.3 Hct-37.3 MCV-92 MCH-30.4 MCHC-33.0 RDW-14.5 Plt Ct-384 [**2102-4-6**] 04:15PM BLOOD WBC-15.7*# RBC-4.37 Hgb-13.5 Hct-40.0 MCV-92 MCH-30.9 MCHC-33.8 RDW-15.1 Plt Ct-351 [**2102-4-10**] 03:38AM BLOOD Neuts-72.0* Lymphs-21.0 Monos-4.8 Eos-1.9 Baso-0.3 [**2102-4-11**] 03:39AM BLOOD PT-13.5* PTT-25.8 INR(PT)-1.2* [**2102-4-14**] 04:13AM BLOOD Glucose-123* UreaN-25* Creat-1.1 Na-141 K-4.2 Cl-97 HCO3-36* AnGap-12 [**2102-4-8**] 04:44AM BLOOD ALT-38 AST-30 LD(LDH)-159 AlkPhos-134* TotBili-0.3 [**2102-4-6**] 04:15PM BLOOD cTropnT-<0.01 [**2102-4-6**] 04:15PM BLOOD CK-MB-NotDone proBNP-5423* [**2102-4-13**] 04:48AM BLOOD Calcium-8.6 Phos-2.6* Mg-2.2 [**2102-4-12**] 03:12PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2102-4-12**] 03:12PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM [**2102-4-12**] 03:12PM URINE RBC-92* WBC-14* Bacteri-FEW Yeast-NONE Epi-0 Urine, Blood and sputum cultures negative Studies: ECHO: EF 70-75%, Preserved regional and global biventricular systolic function. Severe pulmonary hypertension. Moderate mitral regurgitation. Mild to moderate functional mitral stenosis from mitral annular calcification. Mild to moderate tricuspid regurgitation. RUQ US: 1. Limited evaluation of gallbladder without evidence of cholelithiasis. 2. Very limited evaluation of the liver. Mass and hepatic calcifications are better evaluated on concurrent CT abdomen. 3. Splenic calcifications suggest prior granulomatous disease. CTA CHEST: 1. Negative examination for pulmonary embolism. 2. Large to moderate amount of bilateral pleural effusion associated with adjacent atelectasis. 3. Multifocal areas of consolidation of right upper lobe, right middle lobe, and both lower lobes are probably related to pneumonia. 4. Known mass in left axilla that seems to be invading the left breast. 5. Multiple calcified nodules in the liver and spleen suggest prior granulomatous exposure. 6. Hypodense mass in right hepatic lobe. Dedicated abdominal evaluation is suggested. CXR [**2102-4-13**]: There is interval development of new whiteout of right hemithorax with right mediastinal shift, finding consistent with a complete atelectasis of the right lung. Given the rapid development it is consistent with a mucus plug aspiration. The left lung aeration is preserved and demonstrates the presence of a mild to moderate pulmonary edema. A left pleural effusion is present. The NG tube tip is in the stomach. Brief Hospital Course: Ms. [**Known lastname 22114**] is a [**Age over 90 **] year-old female with a history of HTN, DM, ?chronic aspiration, and Alzheimer's dementia who was transferred from the ED intubated after presenting with hypoxia and tachypnea. #. Respiratory failure/Pneumonia: Patient presented with hypoxia and tachypnea and chest radiograph c/w a LUL consolidation pneumonia. She was started on ceftriazone/azithromycin for community acquired pneumonia on presentation. On her second hospital day her chest radiograph changed significantly with the consolidation in her left upper lobe generally resolving suggesting this was more consistent with mucous plugging and volume loss. She went on to have a CT scan that showed multifocal pneumonia as well as probable pulmonary edema with large bilateral pleural effusions. She was transiently intubated with reexpansion of a previously collapsed upper lobe. Given that her pulmonary edema and large pleural effusions were likely contributing to her volume loss and respiratory compromise an attempt was made to diurese with furosemide boluses, to which she responded well with decreasing oxygen requirements, down to 4L NC at dischage. Pt also had intermittent lobar collapse, thought to be due to mucous plugging and aspirating of secretions. She generally responded to deep suctioning but was unable to effectively cough to clear her own secretions. #. Hypertension: The patient has severe and labile hypertension and was continued on an aggressive anti-hypertensive regimen at home including beta [**Last Name (LF) 7005**], [**First Name3 (LF) 14595**]-1 [**First Name3 (LF) 7005**], CCB, and ACE inhibitor. In the setting of diuresis, pt was intermittently hypotensive requiring fluid boluses. She also at times was hypertensive, requiring prn doses of hydralazine. #. Alzheimer's dementia: The patient has severe dementia at baseline, but is on no treatment for this at home. As of extubation her mental status was at baseline (opens eyes to voice but does not interact or follow commands). #. Breast cancer: The patient has a necrotic mass in her left axilla of locally advanced breast cancer. No aggressive therapies are being pursued. # Lower back pressure ulcer: Care per wound nurse recommendaitons #. DM2: Finger sticks were monitored QID and treated with ISS. #. Nutrition: Given pt's repeated aspiration, pt was fed via NGT. Contacts: [**Name2 (NI) 2957**] makes health decisions, [**First Name8 (NamePattern2) 7346**] [**Last Name (NamePattern1) 79146**] [**Telephone/Fax (1) 79147**] (c). Granddaughter, [**Name (NI) 1457**] [**Name (NI) 79146**], was pharmacist in [**Country 532**] and can be reached at [**Telephone/Fax (1) 79148**] (c). Code: CPR not indicated but intubation allowed - confirmed with daughter and granddaughter. . Medications on Admission: Diltiazem 180 [**Hospital1 **] Doxazosin 2 qd Enalapril 20 [**Hospital1 **] Furosemide 20 qd Toprol 100 [**Hospital1 **] Potassium 8 meq qd Arimidex Simvastatin 20 qd Catapres 2( Clonidine patch 0.2 mg/24 hours) Clonidine 0.2 po tid Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): Per NGT. 2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Per NGT. 3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Per NGT. 4. Docusate Sodium 50 mg/5 mL Liquid Sig: [**2-10**] PO BID (2 times a day) as needed for constipation: Per NGT. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed: Per NGT. 6. Captopril 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): Per NGT. 7. 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. 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb Inhalation Q6H (every 6 hours). 9. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Per NGT. 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Digoxin 0.125 mg IV EVERY OTHER DAY 12. Arimidex 1 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Pneumonia Secondary: Hypertension Discharge Condition: Stable, breathing comfortably on 4L NC. Discharge Instructions: Ms [**Known lastname 22114**]: You were admitted with shortness of breath and low blood oxygen levels and you were intubated (a breathing tube was placed) in the emergency room because of your shortness of breath. You were found to have a pneumonia and you were treated with antibiotics. Your pneumonia improved, but you continued to be short of breath due to aspiration of your saliva and heart failure. For your heart failure your medications were changed to control your blood pressure and remove fluid as it was collecting in your lung. Because your cough is very weak you continued to have difficulties during this admission with secretions, and several times your secretions would fill your airway and cause collapse of the lung which we would then see on xray. Sometimes it would help to do deep suction to remove the secretions, but sometimes this did not help. . . The following medication changes were made during this admission: . Diltiazem was STOPPED. Doxazosin was STOPPED. Enalapril was CHANGED to captopril. Furosemide was INCREASED. Toprol was CHANGED to metoprolol. Potassium was STOPPED. Catapres was CHANGED to oral clonidine pill. Clonidine 0.2mg was CHANGED to a different dose of clonidine. . The following medications were started: Digoxin, famotidine, senna, colace, albuterol, ipratropium. . All of your other home medications remain the same. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5 L. If you develop shortness of breath, chest pain, or any other concerning symptom please call your primary care doctor or return to the hospital. Followup Instructions: [**Hospital 100**] Rehab: Please make an appointment for the pt to see the primary care doctor (Dr. [**Last Name (STitle) 8682**] [**Telephone/Fax (1) 133**]) when she leaves rehab. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "331.0", "428.0", "294.10", "511.9", "250.00", "518.0", "707.20", "427.31", "V10.3", "486", "518.81", "174.9", "424.0", "401.9", "707.03" ]

icd9cm

[ [ [] ] ]

[ "96.04", "38.91", "96.07", "33.24", "96.71", "96.6" ]

icd9pcs

[ [ [] ] ]

9856, 9922

5731, 8544

276, 338

10001, 10043

3156, 5708

11733, 12054

2389, 2449

8827, 9833

9943, 9980

8570, 8804

10067, 11710

2464, 3137

229, 238

366, 1736

1758, 1894

1910, 2373

27,542

122,694

45909

Discharge summary

report

Admission Date: [**2197-9-15**] Discharge Date: [**2197-10-2**] Date of Birth: [**2135-5-12**] Sex: F Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 3276**] Chief Complaint: acute onset orthostatis and presyncope Major Surgical or Invasive Procedure: None History of Present Illness: Ms [**Known lastname 86746**] is a 62 year old woman with locally advanced esophageal adenocarcinoma undergoing chemo-radiation therapy (cycle 2 Cisplatinum/5-FU) who developed acute onset orthostasis and presyncope while in [**Hospital **] clinic, with tachycardia to 130s and hypoxia (88%RA). She was given 1 L NS, O2 sats improved to 91% on 6L NC. 5-FU pump stopped, about 2 hours prior to planned stop time. PIV was placed, and IV NS started with improvement in pulse to 90s and BP to 130s/60s; pt sent to ED for evaluation. . ROS: Significant for nausea, sore throat, pain on swallowing, skin changes in the area of radiation field, cough secondary to radiation. Negative for weight change, change in vision, hearing, sinus congestion, vomiting, constipation, diarrhea, melena, BRBPR, chest pain (pleuritic or otherwise), palpitations, dizziness or lightheadedness currently, hematuria, dysuria, fevers, chills, night sweats, LE swelling, numbness, tingling, weakness, recent long trips with immobilization. Past Medical History: Onc History: Ultrasound-guided lymph node biopsy on [**7-14**], cytology positive for malignant cells consistent with signet-ring cell carcinoma. By EUS, the tumor was noted to be a fungating ulcerative infiltrative circumferential non bleeding 6 cm mass at 34 cm in the esophagus. The mass caused a partial obstruction. The stomach and duodenum were considered normal and she was staged as a T3, N1 son[**Name (NI) 5326**]. Therapy was initiated with cisplatin and continuous infusion 5FU, followed by XRT. She was finishing a second cycle of chemo (it was cut two hours short by admission) and XRT (she has four days left which are scheduled for this week) when admitted. . Past Medical History: -Esophageal cancer (signet-ring cell carcinoma T3, N1), dx [**2197-6-27**]: J-tube placed [**7-25**] -h/o H Pylori '[**89**] & '[**92**] -GERD -Hiatal hernia -HTN -Hyperlipidemia . Social History: Lives with husband. [**Name (NI) **] two children. Retired warehouse assembly work. Tobacco: Quit [**2164**], 5y x1ppwk, occasional etoh, never heavy use, no illicit drugs. Family History: Mother deceased 79: MI, Father deceased 87: MI, Siblings (3S, 2B): 1 brother deceased MI age 40, 1 brother deceased s/p kidney transplant age 55 Physical Exam: Physical Exam: VS: T: 97.7 HR: 81 BP: 141/97 RR: 22 Sat: 100% on 4L NC Gen: NAD, comfortable, speaking in full sentances HEENT: NCAT, PERRL, sclera anicteric, OP clear, MMM Neck: Supple, no LAD, no JVD CV: RRR S1/S2, no m/r/g Resp: cta b/l with occasional wheeze Abdomen: obese, soft, NTND, BS+, J tube in place Ext: No c/c/e. DP pulses are 2+ bilaterally, slight tenderness in left calf Neuro: A + O x 3, CN II-XII grossly intact, Motor [**4-22**] both upper and lower extremities Skin: Pink, warm, no rashes. Skin changes on back consistent with radiation Pertinent Results: Imaging: CT chest: 1. Large bilateral pulmonary emboli involving the main left and right pulmonary arteries. 2. Prominent mediastinal lymph nodes noted. 3. Diffuse thickening of the distal esophagus, consistent with patient's history of esophageal cancer. . CT head: Usual rounded relatively hypodense lesion within the suprasellar region, possibly representing pituitary tumor, primary or secondary to versus aneurysm. Dedicated CTA of the circle of [**Location (un) 431**] is recommended. . CT abdomen/pelvis: 1. Large esophageal mass and single 1 cm lymph node just inferior to the esophageal hiatus. 2. J-tube in situ with moderate stranding of the subcutaneous tissues; no evidence of fluid collection, abscess, or obstruction. 3. Tiny bilateral pleural effusions. Brief Hospital Course: In the ED, VS: 130/90, 96.7, 80, 28, 99% 2L NC. She had CTA showing bilateral massive PE; ECG w/o evidence of strain. CT head showed a suprasellar lesion concerning for 1 cm aneurysm. Neurosurgery and oncology were consulted; she was started on anticoagulation out of concern for hemodynamic compromise from PE. She was admitted to the MICU. . MICU Course: She was continued on heparin gtt. MRI head was done and showed a suprasellar mass. MRA of the head was normal, ruling out an aneurysms. The neurosurgeons requested the patient follow up as an outpatient. She remained hemodynamically stable in the MICU, and was called out to the floor after 1 day. . While on the floor, the patient was transitioned from a heparin drip to lovenox injections to treat her large bilateral pulmonary emboli. She initially required 4L nasal cannula to provide adequate oxygenation, however, her oxygen requirement decreased over the course of stay. At discharge, the patient was requiring 2L nasal cannula to maintain her oxygenation. Her home regimen of estrogen replacement therapy was also held. The patient was followed by physical therapists while in the hospital and was able to ambulate well with portable oxygen at the end of her stay. . Once stable on the floor, the patient completed her course of radiation therapy, to complete 25 treatments. She will follow up as an outpatient for discussion of further chemotherapy for her esophageal cancer. . Tube feeds were initiated while the patient was in the hospital. Her tube became clogged several times and was then replaced by Thoracics for a larger diameter tube. The patient had several G-tube checks in interventional radiology to confirm the placement and patency of the tube. At discharge, tube feeds were running smoothly. The patient had difficulty swallowing secondary to XRT to the esophagus. Her pain was controlled with both a Fentanyl patch in addition to liquid oxycodone and magic mouthwash. . The patient spiked one fever during her hospitalization. Blood, urine and stool cultures were all negative for infection. Chest xray did not show evidence of pneumonia. The patient did have erythema around her feeding tube. CT scan did not demonstrate any abscess, however, the patient was treated empirically for a cellulitis with antibiotics. She was discharged to complete a two week course of Augmentin. Medications on Admission: atenolol 25mg daily atorvastatin 40mg daily benzonatate 100mg QHS conjucated estrogen-medroxyprogestace (Premphase) 0.625mg/0.625mg-5mg daily irbesartan 75mg daily lorazepam 1mg Q2-3H PRN nausea maalox:benadryl:lidocaine 15min before meals and QHS PRN ondansetron 8mg Q8H:PRN nausea pantoprazole 40mg daily prochlorperazine 10mg Q8H:PRN nausea Discharge Medications: 1. oxygen Diagnosis: bilateral pulmonary emboli Please dispense oxygen 3L NC and titrate to O2 saturation greater than 94%. 2. Senna 8.6 mg Tablet [**Location (un) **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Simvastatin 40 mg Tablet [**Location (un) **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Benzonatate 100 mg Capsule [**Location (un) **]: One (1) Capsule PO TID (3 times a day) as needed for cough. Disp:*90 Capsule(s)* Refills:*0* 5. Lorazepam 1 mg Tablet [**Location (un) **]: One (1) Tablet PO Q4H (every 4 hours) as needed for nausea. Disp:*120 Tablet(s)* Refills:*0* 6. Baclofen 10 mg Tablet [**Location (un) **]: 0.5 Tablet PO TID (3 times a day) as needed for Hiccups. Disp:*90 Tablet(s)* Refills:*0* 7. Enoxaparin 100 mg/mL Syringe [**Location (un) **]: One (1) Subcutaneous Q12H (every 12 hours). Disp:*60 INJ* Refills:*2* 8. Docusate Sodium 50 mg/5 mL Liquid [**Location (un) **]: One (1) PO BID (2 times a day). 9. Olanzapine 2.5 mg Tablet [**Location (un) **]: One (1) Tablet PO QID (4 times a day) as needed. Disp:*120 Tablet(s)* Refills:*0* 10. Ondansetron 8 mg Tablet, Rapid Dissolve [**Location (un) **]: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours). Disp:*90 Tablet, Rapid Dissolve(s)* Refills:*2* 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Location (un) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 12. Fentanyl 75 mcg/hr Patch 72 hr [**Location (un) **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:*10 Patch 72 hr(s)* Refills:*2* 13. Metoprolol Tartrate 50 mg Tablet [**Location (un) **]: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 14. 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* 15. Oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: One (1) PO Q4H (every 4 hours) as needed for esophageal pain. Disp:*100 ml* Refills:*0* 16. Amoxicillin-Pot Clavulanate 875-125 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) for 12 days. Disp:*24 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Esophageal cancer Bilateral pulomary emboli Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital because you were short of breath and had a rapid heart rate. While you were in the hospital, you were diagnosed with bilateral pulmonary emboli (or clots in your lungs). . You also had some difficulty swallowing, most likely due to your radiation treatments for your cancer. We started you on tube feeds to maintain your nutritional status. You are being sent home with tube feeding to help maintain your nutrition as well as visiting nurse. Please attempt to take food by mouth . Followup Instructions: -Please follow up with neurosurgery, Dr. [**Last Name (STitle) **], [**Telephone/Fax (1) 1669**], on [**2197-10-24**] at 10:00 AM. The office is located on [**Hospital Unit Name 97773**] on the [**Hospital Ward Name **] of [**Hospital1 **]. . ~Please follow up with Dr. [**Last Name (STitle) 3274**] on [**2197-10-5**]. His office should contact you with an appointment. If you do not receive a call from his office, please call to confirm your appointment time ([**Telephone/Fax (1) 3280**]. . [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]

[ "536.41", "E878.3", "272.0", "682.2", "553.3", "530.81", "284.89", "415.19", "536.42", "150.8", "584.9" ]

icd9cm

[ [ [] ] ]

[ "92.29", "97.02", "96.6", "99.25" ]

icd9pcs

[ [ [] ] ]

9028, 9079

4006, 6389

308, 315

9167, 9176

3212, 3470

9744, 10356

2473, 2619

6784, 9005

9100, 9146

6415, 6761

9200, 9721

2649, 3193

230, 270

343, 1359

3479, 3983

2084, 2267

2283, 2457

12,796

118,237

3159

Discharge summary

report

Admission Date: [**2186-1-3**] Discharge Date: [**2186-1-23**] Date of Birth: [**2156-9-21**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 689**] Chief Complaint: fevers, abd pain Major Surgical or Invasive Procedure: PICC LINE History of Present Illness: 29 y.o. male with hx of mental retardation, s/p kidney transplant 21 years ago on immunosuppressants and Hep C x20 years presents with mental status changes, anorexia and fevers. Went to PCP's office for evaluation, found to have fever to 102 and tender abd. Has hx of ascites [**2-16**] liver failure and hypoalbuminemia. Mother also reports that pt had BRBPR 2-3 days ago with bowel movements. Stools have been brown with no diarrhea. Pt denies N/V. Doe snot report abd pain but mother states that he does not always say when is bothering him because he does not like hospitals. Pt gets liver care at [**Hospital1 1774**]. Mother also reports that pt has become tranfusion dependent over past 2 years and last transfusion [**12-9**]. Baseline HCT 27-33. In [**Name (NI) **], pt was GUIAC + with no bright red blood. Pericentesis revealed 6500 WBC with 88% PMNs. Pt received one dose of CTX in ED. Pt was also hypotensive to 80's in ED which resolved with fluids. Past Medical History: Cirrhosis Hep C S/p Kidney transplant- Living related at age 7. Dandy Walker cyst/ Mental Retardation Depression Blindness Social History: Lives at home with parents. Pt is able to understand everyting. Sometimes with delayed responses. Family History: non-contributory Physical Exam: VS T:101.1, P:86, BP:85/60->129/92 RR16 O2Sat: 100% GENERAL: Mildly pale male, NAD. No Jaundice HEENT: Pupils equal, scleral injection on the L, pale conjunctive, no icterus. NECK: Supple with no LAD. CARDIOVASCULAR: RRR no murmurs. LUNGS: CTAB ABDOMEN: Mild distension. No fluid wave. No tenderness to deep palpation. EXTREMITIES: Mult ecchymoses on legs. No edema, no jaundice. NEURO: [**Name (NI) **], pt responding yes and no to all questions. Does not respond to questions about location and date. Mother feels that MS is as baseline. Pertinent Results: [**2186-1-3**] 07:48PM ASCITES TOT PROT-0.8 GLUCOSE-90 LD(LDH)-82 ALBUMIN-LESS THAN [**2186-1-3**] 07:48PM ASCITES WBC-6850* RBC-525* POLYS-88* LYMPHS-0 MONOS-3* MESOTHELI-1* MACROPHAG-8* [**2186-1-3**] 04:22PM LACTATE-3.3* [**2186-1-3**] 04:10PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.014 [**2186-1-3**] 04:10PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG [**2186-1-3**] 04:10PM URINE RBC-[**6-24**]* WBC-0-2 BACTERIA-MOD YEAST-NONE EPI-0-2 [**2186-1-3**] 04:10PM URINE HYALINE-[**3-19**]* [**2186-1-3**] 04:06PM GLUCOSE-95 UREA N-37* CREAT-1.0 SODIUM-137 POTASSIUM-4.9 CHLORIDE-106 TOTAL CO2-22 ANION GAP-14 [**2186-1-3**] 04:06PM ALT(SGPT)-64* AST(SGOT)-100* ALK PHOS-113 AMYLASE-90 TOT BILI-4.0* [**2186-1-3**] 04:06PM CALCIUM-8.5 PHOSPHATE-4.0# MAGNESIUM-1.6 [**2186-1-3**] 04:06PM WBC-11.7*# RBC-2.53* HGB-9.7* HCT-27.0* MCV-106*# MCH-38.1* MCHC-35.8* RDW-23.1* [**2186-1-3**] 04:06PM NEUTS-88* BANDS-7* LYMPHS-4* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2186-1-3**] 04:06PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-2+ MACROCYT-3+ MICROCYT-OCCASIONAL POLYCHROM-1+ OVALOCYT-OCCASIONAL SCHISTOCY-OCCASIONAL BURR-1+ TEARDROP-OCCASIONAL ACANTHOCY-1+ ELLIPTOCY-OCCASIONAL [**2186-1-3**] 04:06PM PLT COUNT-113* [**2186-1-3**] 04:06PM PT-14.7* PTT-30.2 INR(PT)-1.5 [**2186-1-9**]: CXR: Lordotic positioning. The heart is not enlarged. There is no CHF. There is a small right base effusion. The left costophrenic sulcus is clear. Aside from some atelectasis at the right base, the lungs are grossly clear. No free air is detected beneath the diaphragm. Clips are noted over the mid abdomen. [**2186-1-9**] A/P: 1. Colonic wall thickening involving the ascending colon and hepatic flexure, consistent with colitis. 2. No evidence of bowel obstruction. 3. Cirrhosis with ascites, splenomegaly, patent portal vein. 4. Bilateral pleural effusions, right more than left. [**2186-1-3**]: No evidence of cholecystitis. The gallbladder is distended as it was previously in [**2185-5-15**], but the gallbladder is otherwise unremarkable in appearance. No intra- or extrahepatic biliary ductal dilatation. Brief Hospital Course: 29 y.o. male with hx of MR and kidney transplant presents with fevers and ascites. Found to have SBP and c.diff colitis. . # SBP: Tap showed 6850 with 88% PMN's. Met criteria for SBP. bandemia on diff. This was felt to be likely spontaneous as no other recent abd procedures. Pt hypotensive on admission but resolved with fluid. No abd tenderness. Elevated tbili but no evidence of obstruction on U/S, likely [**2-16**] cirrhosis. Pt remained hemodynamically stable, and was initially maintined on Cipro 500mg PO BIC for 5 days. However, the decision was made by the Liver service to contine on Cipro. Patient' cultures remained negative. . # Anemia: On admission pt's mother reported that he had had some slight blood in stools recently. Hct was initially 27 but then dropped to 23 and pt was transfused 2 units. Hct initially came up to 28.9 but then on the 3rd day of admission he had a black tarry stool with slight amount of blood. GI was consulted who felt that EGD/colonoscopy was indicated once patient stable. HCT again stabilized in 29-30 range, but on [**2186-1-9**], again fell to 21. Patient's INR also noted to be 2.2. Patient transfued 1U PRBC, and AM HCT 30. Patient also maintained on Vitamin K. However, on the morning of [**2186-1-10**], patient with 100cc of BRBPR. He remained hemodynamically stable, but was transferred to the MICU for onservation. Patient's bleeding felt likely [**2-16**] c-diff colitis in setting of negative NG lavage. Patient also reconfirmed to have an elevated INR (> 2) and a falling fibrinogen from 103 to 192 on the medical floor to 59 in the ICU. Patient supported with PRBC to keep HCT > 28, platlets with goal > 50 in setting of bleeding, FFP with goal INR < 1.7 and cryoprecipitate with goal fibrinogen > 100. . # Diarrhea: Mother stated this has been present for several months and pt has been taking imodium almost every other day to help control it. On HD#2 stool cultures turned positive for c.diff and pt was started on flagyl. Plan to continue on Flagyl for 14 days, but during admission, patient with worsening diarrhea. Hence, Cholestyramine added to regimen. Patient remained afebrile, but course was complicared by both guiac positive stool and on [**2186-1-9**], 100cc of bright red blood per rectum. Patient remained hamodynamically stable, but was transferred to the MICU. There, patient had a negative NG Lavage. Patient had a CT of A/P, which revealed colitis consistent with c-diff infection. Patient supported with blood products (see below) and sent to the floor on [**2186-1-10**]. . # S/P Kidney transplant: Pt has never had problems with kidney. Creat remained stable throughout hospitalization. Patient was on prednisone outpatient as part of his immunosuppresant regimen, and felt to have adrenal insufficiency in setting of beirf hypotension on admission, and so patient mainteined on stress dose steroids with Dexamethasone at 4mg [**Hospital1 **]. This was initially tapered on the floor, but dose increased to 4mg [**Hospital1 **] in ICU. . # Weakness/Ataxia: Pt has developed worsening ataxia over the past few years per mother. [**Name (NI) **] he is very weak. ? of whether secondary to steroid mcypathy vs adrenal insufficiency. Again, patient maintained on stress dose steroids, but was too weak during his hospitalization to ambulate or participate with PT. . # Cirrhosis: pt's Child-[**Doctor Last Name 14477**] class is C. Patient also with grade I esophageal vricies. Patient initially on Nadalol and Spirolactone, but both stopped in setting of GIB. However, spironolactone gradually added back in setting of blood product support. Liver service consulted and followed throughout hospitalization. . # Septic Shock: On morning of [**2186-1-18**], Pt developed worsening abdominal pain found to be febrile. Peritoneal fluid with 70 wbc, but grew yeast (C. albicans). Blood cx from [**1-19**] grew yeast as well and pt was started on caspofungin with ID following. On [**1-21**] AM pt was increasingly hypotensive on the floor and Pt transferred to MICU where he required pressors to maintain adequate blood pressure. Pt required intubation and continued hemodynamic support. Despite maximal medical management Pt's condition continued to detoriate. After discussions with family and ICU attending, decision made to withdrawl care and concentrate on comfort. Pt died from respiratory failure secondary to septic shock shortly thereafter. Medications on Admission: Fosamax Spironlolactone 25mg QD Nadolol 20 QD Prednisone 5mg QD Imuran 75mg QD Discharge Medications: none Discharge Disposition: Home with Service Discharge Diagnosis: primary diagnoses: C-diff colitis spntaneous bacterial peritonitis DIC lower GI bleed fungemia septic shock secondary diagnoses: hep c cirrhosis ascites Discharge Condition: deceased Discharge Instructions: none Followup Instructions: none

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icd9cm

[ [ [] ] ]

[ "96.08", "96.04", "38.93", "54.91", "96.07", "99.10", "96.33", "99.05", "21.01", "38.91", "99.04" ]

icd9pcs

[ [ [] ] ]

9038, 9057

4447, 8879

330, 341

9255, 9265

2211, 4424

9318, 9325

1617, 1635

9009, 9015

9078, 9187

8905, 8986

9289, 9295

1650, 2192

9208, 9234

274, 292

369, 1336

1358, 1483

1499, 1601

10,992

145,405

15660

Discharge summary

report

Admission Date: [**2105-2-13**] Discharge Date: [**2105-2-20**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 689**] Chief Complaint: CC: s/p fall w/ pelvic and wrist fracture transfered to medical svc. for medical mgt of hyponatremia and concurrent medical disorders. Major Surgical or Invasive Procedure: Right wrist open reduction and internal fixation on [**2105-2-18**]. Orthopaedic surgeon was Dr. [**Last Name (STitle) **] [**Name (STitle) 1005**] at [**Hospital1 827**]. History of Present Illness: 83 year old with hx of Afib (on coumadin), carotid stenosis, longstanding difficult to manage HTN on numerous Rx, diastolic Heart Failure, prior steady gait, who presented on [**2-13**] w/ presumed mechanical fall while getting dressed at home. Injuries sustained included R superior and inferior pubic rami fracture, Right acetabular fracture, Right wrist fracture. Admitted overnight to trauma SICU for observation, hematocrit and neurologic monitoring as her INR was supratherapeutic in the setting of coumadin. On admission, patient had a sodium of 113, K+ = 2.7, HCO3 29, Cl 73, WBC 19 w/ left shift, INR 3.2, though noted to be mentating well throughout. CXR was negative for PNA/CHF, UA+ UCx no growth, Blood Cx no growth. Head CT was without bleed. She was managed for hypovolemic hyponatremia, hypokalemia, hypochloremia w/ held diuretics and slow and calculated normal saline repletion restoring normal levels while in the SICU w/ correction of serum sodium to 124 after 24 hours. Coumadin was initially held for supratherapeutic INR. ICU course also notable for hemodynamically stability throughout and transfusion of 1 unit of PRBC. She was transfered to the medical service. Past Medical History: -Afib (on coumadin) -HTN (refractory, several recent medication adjustments including addition of clonidine patch) -No hx of stroke, DM, or high cholesterol -diastolic heart failure ([**2-25**] age and HTN) -ankle fracture -knee arthroscopy -Bilateral 80-99% carotid stenosis (intevention is under ongoing consideration by her primary cardiologist, Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] who also manages her htn). Social History: She lives alone. Her daughter is a case manager at [**Hospital1 18**]. Denies hx of Tob or drugs. She drinks an occasional glass of wine with dinner. Family History: Father - stroke at age 81 , no premature coronary disease Physical Exam: EXAM AT TIME OF ADMIT TO MEDICAL SERVICE, FOLLOWING ICU COURSE Gen: NAD vs: 99.6, 75-114 (78), 107-163/46-74 (136/32), 13-17, 96-100% RA I/O: NET ICU negative 685cc Neck: no JVD, +Right carotid bruit, no thyromegaly CV: IRRREGULAR, 2/6 SEM at LSB Lung: Clear to auscultation anterolaterally aBd: +BS soft, nontender Ext: no c/c/e, dressings in place Mental status: Alert, oriented x3 Pertinent Results: ____________________________________________________ [**2105-2-13**] 08:30PM GLUCOSE-110* UREA N-24* CREAT-0.9 SODIUM-122* POTASSIUM-3.7 CHLORIDE-82* TOTAL CO2-29 ANION GAP-15 [**2105-2-13**] 08:30PM CALCIUM-8.8 PHOSPHATE-2.8 MAGNESIUM-1.6 [**2105-2-13**] 08:30PM HCT-35.9*# [**2105-2-13**] 08:30PM PLT COUNT-181 [**2105-2-13**] 08:30PM PT-19.4* PTT-40.0* INR(PT)-2.4 [**2105-2-13**] 06:00PM GLUCOSE-89 UREA N-20 CREAT-0.5 SODIUM-128* POTASSIUM-2.9* CHLORIDE-96 TOTAL CO2-23 ANION GAP-12 [**2105-2-13**] 06:00PM CK(CPK)-70 [**2105-2-13**] 06:00PM cTropnT-<0.01 [**2105-2-13**] 06:00PM CK-MB-NotDone [**2105-2-13**] 06:00PM HCT-24.3*# [**2105-2-13**] 12:18PM LACTATE-0.9 NA+-117* K+-3.0* [**2105-2-13**] 12:00PM GLUCOSE-137* UREA N-29* CREAT-0.9 SODIUM-117* POTASSIUM-3.1* CHLORIDE-77* TOTAL CO2-29 ANION GAP-14 [**2105-2-13**] 12:00PM CK(CPK)-141* [**2105-2-13**] 12:00PM CK-MB-5 [**2105-2-13**] 12:00PM cTropnT-<0.01 [**2105-2-13**] 12:00PM WBC-16.8* RBC-3.84* HGB-12.0 HCT-33.3* MCV-87 MCH-31.2 MCHC-36.0* RDW-12.8 [**2105-2-13**] 12:00PM NEUTS-95.5* BANDS-0 LYMPHS-2.6* MONOS-1.7* EOS-0.1 BASOS-0 [**2105-2-13**] 12:00PM PLT COUNT-179 [**2105-2-13**] 12:00PM PT-22.8* PTT-45.5* INR(PT)-3.3 [**2105-2-13**] 11:25AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2105-2-13**] 11:25AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2105-2-13**] 11:25AM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2105-2-13**] 07:00AM GLUCOSE-136* UREA N-34* CREAT-1.0 SODIUM-113* POTASSIUM-2.7* CHLORIDE-73* TOTAL CO2-29 ANION GAP-14 [**2105-2-13**] 07:00AM WBC-19.6*# RBC-3.88* HGB-12.3 HCT-33.6* MCV-87# MCH-31.8 MCHC-36.7*# RDW-12.7 [**2105-2-13**] 07:00AM NEUTS-95.8* BANDS-0 LYMPHS-2.7* MONOS-1.4* EOS-0.1 BASOS-0 [**2105-2-13**] 07:00AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2105-2-13**] 07:00AM PLT COUNT-191 [**2105-2-13**] 07:00AM PT-22.5* INR(PT)-3.2 _____________ Following tests obtained: [**2105-2-13**] CHEST (PA & LAT): no CHF/PNA [**2105-2-13**] Radiology CT HEAD W/O CONTRAST: no acute bleed [**2105-2-13**] Radiology CT C-SPINE W/O CONTRAST: [**2105-2-13**] Radiology CT PELVIS W/O CONTRAST: [**2105-2-13**] Radiology WRIST(3 + VIEWS) RIGHT: [**2105-2-13**] Radiology CT ABDOMEN W/CONTRAST: [**2105-2-13**] Radiology CT PELVIS W/CONTRAST: [**2105-2-13**] Radiology T-SPINE: [**2105-2-13**] Radiology L-SPINE (AP & LAT): Summary of pertinant results: -R inf/sup pubic rami fx, ant column fx, sacral fx (LC1) -R DR [**Last Name (STitle) **] (extra-art, non-angulated) CT Abd/Pelvis: R sup and inf pubic rami fx, R acetabular fx CT head: neg R Wrist films: R wrist fx __________________________________________________________ [**2105-2-20**] 06:55AM BLOOD WBC-10.6 RBC-3.47* Hgb-11.3* Hct-31.3* MCV-90 MCH-32.7* MCHC-36.2* RDW-13.3 Plt Ct-261 [**2105-2-20**] 06:55AM BLOOD Plt Ct-261 [**2105-2-20**] 06:55AM BLOOD Glucose-110* UreaN-14 Creat-0.6 Na-130* K-4.2 Cl-96 HCO3-26 AnGap-12 [**2105-2-19**] 06:25AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.8 Brief Hospital Course: 83 year old with hx of Afib (on coumadin), carotid stenosis, longstanding recalcitrant HTN on numerous Rx, diastolic Heart Failure, prior steady gait, who presented on [**2-13**] w/ presumed mechanical fall sustaining fractured right pelvis and right wrist. Course c/b hypovolemic hyponatremia, hypokalemia, hypochloremia. Had ORIF right wrist [**2-18**]. No surgical intervention indicated per ortho on pelvic fracture. ### HYPONATREMIA: Sodium decline as follows: Na [**11-27**] 140 [**2104-12-29**] 128 [**2105-1-30**] 129 [**2105-2-13**] 113 on this presentation. Initially Rx'ed for hypovolemic hypotonic hyponatremia felt [**2-25**] renal losses in the setting of diuretics. Diuretics held during admission. Recieved continuous replacement and corrected to 124. Then, as euvolemic (Urine Osm 352), was free water restricted (to 1.5L/day) with improved Na to 131 on [**2105-2-19**]. Suspect she is near baseline with regards to sodium and provided her sodium is stable or continues to trend up, will not need further free water restriction. Continue to hold diuretics. If further sodium infusions are required at rehab, would monitor for signs of volume overload given her diastolic heart failure. ### RIGHT HIP FRACTURES: Right inferior pubic ramus and right acetabular fractures. No evidence of bowel or solid organ injury. No surgical intervention indicated. Physical therapy consult worked with patient in this regard. Weight bearing as tolerated on right lower extremity. ### RIGHT WRIST FRACTURE: Impacted distal radius fracture s/p ORIF ([**2-18**]). Right upper extremity is in a splint at time of discharge and non-weight bearing. ### POST OPERATIVE PAIN: Has been receiving morphine 1-3mg iv or oxycodone 5-10mg while being monitor closely for sedation or altered mental status as she has a history of sensitivity to narcotics. ### ANEMIA: Minimal blood loss in OR. HCT trended slightly [**Last Name (un) 8636**] on [**2-19**], likely secondary to frequent phlebotomy. She was given one unit PRBC on [**2-19**] which she tolerated. ### AFIB: -coumadin was resumed post operatively. Goal INR is [**2-26**]. Coumadin dose will need to be adjusted at rehab. HR was normal on below regimen ### HTN: good control on below regimen. Her goal sbp 140-160 given carotid stenosis. during admission at discharge metoprolol 100g po bid--> changed to Toprol at D/C enalapril 20mg po bid --> change to 40mg po qd at D/c clonidine TTS 2 patch td qSAT nifedipine 30 tid, hold SBP < 140--> change to procardia 120mg daily at d/c held and d/c'd HCTZ held and d/c'd Lasix ### CAROTID STENOSIS: Seen by her cardiologist on this admit for pre-op clearance w/ respect to her carotid disease. While discussions of potential intervention (stent vs CEA) are ongoing, the patient was not symptomatic w/ respect to her carotid disease and further considerations can be adressed in the future, after rehab. ### PPX: pneumoboots, sc heparin, protonix ### CODE: full Medications on Admission: Coumadin 1.5/3.0 alternating Toprol 100mg hs Vasotec 40mg a day HCTZ 25mg a day Alprazolam PRN Procardia 120mg a day Lasix 40mg a day Clonidine Patch Timolol Prednisone eye drops Discharge Medications: 1. Clonidine HCl 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 2. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 8. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 9. Enalapril Maleate 20 mg Tablet Sig: Two (2) Tablet PO once a day. 10. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO at bedtime. 11. Procardia XL 60 mg Tab, Sust Release Osmotic Push Sig: Two (2) Tab, Sust Release Osmotic Push PO once a day. 12. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): goal INR [**2-26**]. 13. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 15. Morphine Sulfate 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4 hours) as needed for pain: hold for excess sedation, rr < 10. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - Acute Rehab Discharge Diagnosis: HYPONATREMIA RIGHT WRIST FRACTURE RIGHT HIP FRACTURES ATRIAL FIBRILLATION HYPERTENSION ANEMIA Discharge Condition: Comfortable. Hemodynamically stable Discharge Instructions: Please call to make follow up appointment with PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 3329**] following rehab. Please call to make an orthopaedics follow up with Dr. [**Last Name (STitle) **]. [**Doctor Last Name 1005**] in 2weeks, ([**Telephone/Fax (1) 8746**] Followup Instructions: Please call to make follow up appointment with PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 3329**] following rehab Please call to make an orthopaedics follow up with Dr. [**Last Name (STitle) **]. [**Doctor Last Name 1005**] in 2weeks, ([**Telephone/Fax (1) 8746**] Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2105-8-17**] 3:15 Completed by:[**2105-2-20**]

[ "428.0", "808.0", "276.1", "E888.9", "276.5", "V58.61", "790.92", "813.41", "285.1", "427.31", "808.2", "402.91", "428.32", "805.6", "276.8" ]

icd9cm

[ [ [] ] ]

[ "79.32", "99.04" ]

icd9pcs

[ [ [] ] ]

10824, 10897

6121, 9138

397, 570

11035, 11072

2937, 5682

11447, 11998

2451, 2510

9367, 10801

10918, 11014

9164, 9344

11096, 11424

2525, 2883

222, 359

598, 1792

5691, 6098

2898, 2918

1814, 2268

2284, 2435

10,130

156,668

7768

Discharge summary

report

Admission Date: [**2161-1-30**] Discharge Date: [**2161-2-19**] Date of Birth: [**2109-7-8**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 51 year old male with metastatic colon cancer status post chemotherapy and radiation at [**Hospital 4068**] Hospital, who presents with weakness, fatigue, nausea, vomiting and back pain at site of former x-ray therapy. Positive fever, positive chills. He fell three weeks ago and complained of back pain since then. The patient denied drainage or redness from the wound until today, now draining foul smelling material. The patient was admitted to [**Hospital 4068**] Hospital last week with dehydration and hyponatremia. PAST MEDICAL HISTORY: 1. Subtotal colectomy with ileorectal anastomosis in [**2157**]. 2. Metastases to liver and pelvis. 3. Right ureteral stent placement. 4. Small bowel obstruction with lysis of adhesions. 5. Non-insulin dependent diabetes mellitus. 6. X-ray therapy in [**2157**]. SOCIAL HISTORY: No alcohol. Quit tobacco. MEDICATIONS: 1. Prilosec. 2. Celebrex. 3. Glucotrol. 4. Roxicontin. PHYSICAL EXAMINATION: Temperature 96.9 F.; 82; 138/80; 21; 100% on room air. In general, he is an ill appearing white male. Regular rate and rhythm. Lungs are clear. Abdomen soft, flat, nontender. Back: Indurated fluctuant right flank with foul-smelling purulent drainage. Positive erythema. Rectal is heme positive brown stool. LABORATORY: His sodium was 126, potassium 4.8, 88, 29, 18, 1.4 and 90. His white blood cell count was 10.5, hematocrit 32, platelets 480. HOSPITAL COURSE: The patient was admitted on [**2161-1-30**], and the patient had his back abscess drained. After CT scan showed distal small bowel leak to the well drained retroperitoneal abscess, it was clear that the patient had an enterocutaneous fistula. The patient was started on total parenteral nutrition through a right IJ line for nutrition preoperatively. The patient was started on Levofloxacin and Flagyl intravenously. Duplex ultrasound was obtained for his right lower extremity swelling, which was negative. The patient was taken to the Operating Room on [**2161-2-4**], for resection of enterocutaneous fistula and ileostomy and incision and drainage of the flank wound. Postoperatively, the patient was started on Levofloxacin, Flagyl and Kefzol. Immediately postoperatively, the patient was admitted to the Intensive Care Unit for septic shock. The patient's blood pressure had dipped into the 80's systolic. The patient was also febrile. The patient was given intravenous fluids and was started on pressure support of Levophed. The patient stayed three days in the Intensive Care Unit, was weaned off the Levophed and was transferred to the Floor. The patient was continued on his Levofloxacin and Flagyl and was continued on total parenteral nutrition. The patient's diet was advanced on [**2161-2-8**] with a regular diet and Boost supplements. On [**2161-2-9**], on postoperative day number five, the patient's PCA was discontinued. The patient was started on Percocet and breakthrough morphine for pain. The patient was seen by Physical Therapy and Occupational Therapy as well. On [**2161-2-10**], it was noted that the patient's ostomy output was increased to 4500 cc. At that time, the patient was started on motility slowing [**Doctor Last Name 360**] Lomotil. The patient was hyponatremic and this was supplemented with cc per cc normal saline replacements from his ostomy as well as in his TPN. Part of this problem was the high ostomy output. A GI consultation was obtained because of this high output and the patient was started on Questran per their recommendations, 4 grams p.o. twice a day. The patient was also started on Octreotide 100 micrograms per hour intravenous q. eight hours. On [**2161-2-13**], postoperative day number nine, it was noted that the patient's ileostomy drainage had decreased slightly. A VAC dressing had been placed to his back wound on postoperative day number eight and this was changed on [**2161-2-13**]. The patient was taken off the Levofloxacin and Flagyl on postoperative day number eight. The patient was started on tincture of opium as well as a motility slowing [**Doctor Last Name 360**]. On postoperative day number 12, the patient's Somatostatin dose was increased and rehabilitation options were looked in to as the hyponatremia seemed to be under control with the TPN and the replacements. On postoperative day number 13, it was noted that the patient had Methicillin resistant Staphylococcus aureus growing from his abdominal wounds which had been draining some purulent material. The patient was started on Vancomycin for this reason. On postoperative day number 14, the patient's ileostomy replacement was changed to 1/2 cc per cc replacement. Also, on postoperative day number 14, it was decided that the patient should have a CT scan to see why the abdominal and back wounds continued to drain. The CT scan showed extensive undrained infection in the abdomen, right lower quadrant, extending to the right flank, hip and buttock. At this point, Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) 916**] discussed with the patient options for intervention as well as Hospice. The patient had decided that he wished to return home with Hospice care and saw no need for further intervention. On postoperative day number 15, these measures for Hospice were set in place. The patient did not want a VAC dressing as he felt this was uncomfortable. The patient was put on dry-to-dry dressing changes on his abdomen and back wound three times a day and p.r.n. The patient wished not to have an intravenous for intravenous antibiotics or for intravenous fluids. The PICC line was removed and the patient was taken off of the Vancomycin intravenously as well as the TPN. The patient was sent home with Hospice on the following medications. DISCHARGE MEDICATIONS: 1. Levofloxacin 500 mg p.o. q. day. 2. Flagyl 500 mg p.o. three times a day. 3. Lopressor 25 mg p.o. twice a day. 4. Lomotil two tablets p.o. four times a day. 5. Questran 4 grams p.o. twice a day. 6. Nystatin 5 cc swish and spit four times a day. 7. Oxy-Contin 40 mg p.o. twice a day. 8. Tylenol 650 mg p.o. q. four to six hours p.r.n. 9. Compazine 5 to 10 mg p.o. q. six hours p.r.n. 10. Ativan Elixir 0.25 mg. DISCHARGE INSTRUCTIONS: 1. The patient was discharged on a regular diet. DISCHARGE DIAGNOSES: 1. Status post enterocutaneous fistula resection and ileostomy, now with abscesses in abdomen and hip. CONDITION AT DISCHARGE: Guarded. The patient and family understand the patient's prognosis and the patient made the decision to have Hospice involved in his care. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**] Dictated By:[**Last Name (NamePattern1) 6067**] MEDQUIST36 D: [**2161-2-19**] 12:25 T: [**2161-2-19**] 12:56 JOB#: [**Job Number 28155**]

[ "261", "197.7", "V10.05", "250.00", "567.2", "197.6", "276.1", "569.81", "038.9" ]

icd9cm

[ [ [] ] ]

[ "46.23", "54.91", "38.93", "83.45", "99.15", "46.74" ]

icd9pcs

[ [ [] ] ]

6494, 6609

5975, 6398

1607, 5952

6422, 6473

1132, 1589

6625, 7042

155, 699

721, 991

1008, 1109

48,527

166,505

41424

Discharge summary

report

Admission Date: [**2143-3-18**] Discharge Date: [**2143-3-23**] Date of Birth: [**2057-6-18**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 4393**] Chief Complaint: variceal bleeding Major Surgical or Invasive Procedure: Endoscopy with variceal banding History of Present Illness: Mr [**Known lastname 25699**] is a pleasant 85 yo gentleman with history of esophageal varices s/p banding, Hep B, alcoholic cirrhosis who admitted to [**Hospital3 **] hospital on [**2143-3-13**] for acute variceal bleeding. Pt states that he was at home when he first noticed bleeding from his nose. This was followed by bloody emesis and bright red blood in his stools. At the OSH, he received 4 U PRBCs on the 9th, 1 on the 10th, 1 on the 11th, and crit was subsequently stable in low 30s since the 12th. Repeat endoscopy was performed today with additional banding. He was treated with protonix, octreotide and vasopressin. He was also treated with nadolol, which could not be uptitrated due to bradycardia. During the hospitalization he underwent paracentesis and was negative for SBP. He was transferred to [**Hospital1 **] for TIPS procedure given recurrent bleeding with banding. He was transferred directly to the MICU. Past Medical History: - Hepatitis B-diagnosed [**2140**], + varices, ? EtOH related, childs B/C cirrhosis - Recent hospitalization [**2143-2-28**] for varices, recieved 4 u PRBCs at that time - Hypertension - Pancytopenia - Bradycardia while sleeping Social History: Social History: Works at shaws, lives alone but gets assistance from his daughter - [**Name (NI) 1139**]: none recently, history of [**1-6**] ppd since teenager - Alcohol: denies, last drink 5 yrs ago - Illicits: none Family History: Unknown, non-contributory Physical Exam: ADMISSION EXAM: Vitals: T:97 BP:144/65 P:56 R: 18 O2: 95% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, distended, dull to percussion laterally, bowel sounds present, no rebound tenderness or guarding, GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: aao x3, CNs [**2-16**] intact, motor function grossly normal . DISCHARGE EXAM: BP 97/52-110/64 HR 58-64 94% on RA Pertinent Results: ADMISSION LABS: [**2143-3-18**] 10:02PM GLUCOSE-114* UREA N-17 CREAT-0.8 SODIUM-135 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-27 ANION GAP-8 [**2143-3-18**] 10:02PM estGFR-Using this [**2143-3-18**] 10:02PM ALT(SGPT)-42* AST(SGOT)-68* ALK PHOS-174* TOT BILI-2.7* [**2143-3-18**] 10:02PM ALBUMIN-2.4* CALCIUM-7.5* PHOSPHATE-2.3* MAGNESIUM-1.8 [**2143-3-18**] 10:02PM WBC-7.9 RBC-3.63* HGB-11.6* HCT-33.6* MCV-93 MCH-31.9 MCHC-34.5 RDW-19.8* [**2143-3-18**] 10:02PM NEUTS-89* BANDS-0 LYMPHS-2* MONOS-5 EOS-3 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 [**2143-3-18**] 10:02PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-OCCASIONAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-OCCASIONAL ACANTHOCY-OCCASIONAL [**2143-3-18**] 10:02PM PLT SMR-VERY LOW PLT COUNT-72* [**2143-3-18**] 10:02PM PT-15.6* PTT-30.4 INR(PT)-1.4* . EKG: [**2143-3-12**]-atrial bigeminy with occasional PVCs, inferior q waves, no ST changes, tw flattening in V4-V6. . MICROBIOLOGY: [**2143-3-19**] HBV Viral Load: <40 HepBe Ag Neg, HepBe Ab Reactive . Echo: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with basal inferior dyskinesis. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . Abd U/S: IMPRESSION: 1. Cirrhotic liver without focal lesion identified. 2. Moderate abdominal ascites. 3. Cholelithiasis. 4. Patency of the hepatic vasculature as described. . Discharge labs: [**2143-3-23**] 05:15AM BLOOD WBC-6.4 RBC-3.18* Hgb-10.7* Hct-30.5* MCV-96 MCH-33.6* MCHC-35.0 RDW-20.0* Plt Ct-71* [**2143-3-23**] 05:15AM BLOOD PT-16.6* PTT-32.1 INR(PT)-1.5* [**2143-3-23**] 05:15AM BLOOD Glucose-151* UreaN-25* Creat-0.8 Na-136 K-4.2 Cl-103 HCO3-28 AnGap-9 [**2143-3-23**] 05:15AM BLOOD ALT-29 AST-48* AlkPhos-166* TotBili-1.2 Brief Hospital Course: ASSESSMENT AND PLAN: 85yoM with h/o Hepatitis B/EtOH Cirrhosis (c/b portal hypertension w/ bleeding esophageal varices s/p banding and ascites), HTN, ?[**Hospital 90129**] transferred from [**Hospital3 1443**] Hospital on [**3-18**] for GI bleeding despite banding, s/p endoscopy on [**3-22**] with banding. . #. Variceal Bleed: Patient had received 4U of blood at the outside hospital prior to transfer. He had also had endoscopies performed on [**3-13**] and [**3-18**], both with banding of varices. He was transferred for consideration of TIPS procedure, however, this was not performed out of concern for the risks of hepatic decompensation, encephalopathy, and other complications related to patient's advanced age. The patient remained stable after overnight observation in the ICU and was called out to the floor on the following day. Hct remained stable on the floor ~ 30. The patient was monitored on telemetry and showed no hemodynamic instability. He did not require blood transfusion. There were no further signs of bleeding. Nadolol 20 mg [**Hospital1 **] was started. The patient was initially on an octreotide and pantoprazole drip. These were stopped as bleeding resolved. The patient completed 5 days of ceftriaxone for SBP prophylaxis after bleed. He was discharged on pantoprazole 40 mg per day x 4 weeks and sucralfate 1 mg QID x 2 weeks. Repeat endoscopy was performed on [**3-22**], which showed band ulcers, and 1 grade II varix, which was banded. The patient was scheduled for repeat endoscopy at [**Hospital1 18**] on [**5-14**] with Dr. [**Last Name (STitle) **] and with follow-up in Dr.[**Name (NI) 37751**] clinic. Aspirin was stopped - this medication should be discussed with the [**Name6 (MD) 228**] primary MD. . #. Hepatitis B/alcoholic cirrhosis c/b variceal bleeding. MELD 11. Inactive carrier of HepB. HepB VL returned at less than 40. HepBe Ag negative and Ab postive. The patient was encouraged to continue his abstinence from alcohol. Nadolol was started as above. Spironolactone was increased to 100 mg per day and lasix was started at 40 mg per day. The patient will need weekly chem7 to check potassium and creatinine while on diuretics until values are stable. . # MDS: Listed on outside hospital records. Thrombocytopenia likely due to cirrhosis from splenic sequestration. The patient will need outpatient f/u for this issue. . #. VRE rectal swab ordered . # DVT prophylaxis was with pneumoboots. # Communication: daughter [**Name (NI) **]: [**Telephone/Fax (1) 90130**], [**Telephone/Fax (1) 90131**] . Transitional Issues: - continue protonix x 4 weeks, sucralfate x 2 weeks - repeat endoscopy on [**5-14**], f/u in Dr.[**Name (NI) 37751**] clinic - discussion re: aspirin - dicussion of diuretics Medications on Admission: 1. ASA 81 mg daily 2. Lisinopril 5 MG daily 3. Omeprazole 20 mg [**Hospital1 **] 4. Spironolactone 25 mg [**Hospital1 **] 5. Nadolol 40 mg daily 6. Metoprolol ER 25 mg daily Discharge Medications: 1. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 2. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. nadolol 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for 1 months: Last day is [**2143-4-17**]. 5. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day) for 2 weeks: Last day is [**4-5**]. 6. Outpatient Lab Work Repeat Chem7 in 1 week on [**3-28**] to check potassium. Discharge Disposition: Extended Care Facility: [**Hospital 3137**] Care Center - [**Location (un) 1468**] Discharge Diagnosis: Primary: Esophageal variceal bleed Hepatitis B/ Alcoholic cirrhosis . Secondary: Possible MDS Hypertension Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted for an esophageal variceal bleed. You were observed briefly in the intensive care unit where your blood count and blood pressure were stable. You had no further episodes of bleeding. You received a blood transfusion at the outside hospital but not at [**Hospital1 18**]. We performed an endoscopy, which showed an additional enlarged vein in your esophagus - a band was placed. The enlarged veins are due to your liver disease - it is extremely important that you not drink alcohol because this can worsen your liver disease. . We started new medicines to help prevent another bleed in the future. You will need to have a repeat endoscopy - information for this is listed below. You should also follow-up with Dr. [**Last Name (STitle) **] as an outpatient. . We made the following changes to your medications: We STOPPED Aspirin - you should restart this medication at the discretion of your primary MD We STOPPED Lisinopril We STOPPED Omeprazole We STARTED Nadolol 20 mg twice per day (to prevent bleeding) We STARTED Pantoprazole 40 mg once per day for the next month We STARTED Sucralfate - 4 times per day for the next 2 weeks . Your follow-up information is listed below. Followup Instructions: Department: LIVER CENTER When: WEDNESDAY [**2143-5-29**] at 1:20 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . We are also working to schedule you for a repeat endoscopy. This is planned tentatively for [**2143-5-14**]. You will receive a phone call about this appointment. If you do not hear about this appointment in the next week, you should call Dr.[**Name (NI) 37751**] office at [**Telephone/Fax (1) 2422**] to make sure the repeat endoscopy is scheduled. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]

[ "789.59", "070.32", "401.9", "284.1", "572.3", "571.5", "238.75", "456.20", "287.5" ]

icd9cm

[ [ [] ] ]

[ "42.33" ]

icd9pcs

[ [ [] ] ]

8527, 8612

4955, 7506

290, 324

8763, 8763

2513, 2513

10229, 11018

1787, 1814

7928, 8504

8633, 8742

7729, 7905

8948, 9809

4585, 4932

1829, 2441

2457, 2494

7527, 7703

9838, 10206

233, 252

352, 1282

2529, 4569

8778, 8924

1304, 1535

1567, 1771

61,913

137,387

43586

Discharge summary

report

Admission Date: [**2131-4-4**] Discharge Date: [**2131-4-18**] Date of Birth: [**2098-4-16**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 11344**] Chief Complaint: Seizures Major Surgical or Invasive Procedure: Deep electrode placement and removal Deep bed-side brain stimulation Long-term epilepsy monitoring History of Present Illness: Mr [**Known lastname **] is a 33 year-old right-handed man admitted for who presents with a history of refractory seizure disorder that has been admitted for deep electrode placement (5/ 20) and subsequent recording. His seizures started when he was 7 years old. Th events usually occur at night. His aura consists of a tingling electric sensation in both feet that ascends up to his hips. The episodes will follow, although not immediately (it may take 4 ours for the event to develop). Once it starts, he [**First Name8 (NamePattern2) **] [**Last Name (un) 93750**] away and rule to eventually loose his consciousness. It usually lasts for 5 minutes. He does not have generalized tonic -clonic movements. He feels drowsy sleepy afterward, typically takes about 20 minutes to return to his baseline. He has 1 episode per month. It troubles him as far as he feels he cannot keep a job (degree in computer sciences) because employers are reluctant to keep him after witnessing one episode. His last seizure was a 5 days ago, but the events disrupt is quality of life. He is now on three medications with incomplete control due to increasing seizure frequency and potentially fatigue as a side effect. LMG 350 [**Hospital1 **] and LEV 3000 [**Hospital1 **]. His ZNS 200 qhs has been stopped. He underwent bilateral deep electrode and bilateral strip electrodes placement on 5/ 20. His exam remains unchanged, although there is evidence of minor bleeding in his CT scans after the surgery. His examination remains unchanged. He denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, light-headedness, vertigo, tinnitus or hearing abnormalities or problems with smell. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills,sleep deprivation or any aggravating factor that may precipitate the episodes. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: Epilepsy - complex partial seizures Social History: Lives with his parents.Is a computer technician.His job involves driving and he last went to work in [**2116**].No history of smoking,alcohol or drug use. Family History: There is a history of seizures in some cousins on his father's side of the family. Physical Exam: Physical Exam: 98.9F, 148/ 78, 72 bpm, RR 14 SO2 100% in RA. Gen: Lying in bed, NAD. HEENT: NC/AT, moist oral mucosa Neck: supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally Abd: Soft, nontender, non-distended. No masses or megalies. Percussion within normal limits. +BS. Ext: no edema, no DVT data. Pulses ++ and symmetric. Neurologic examination: No meningismus. No photophobia. MS: General: alert, awake, normal affect Orientation: oriented to person, place, date, situation Attention: 20 to 1 backwards +. Follows simple/complex commands. Speech/Language: fluent w/o paraphasic errors; comprehension, repetition, naming: normal. Prosody: normal. Memory: Registers [**1-16**] and Recalls [**1-16**] when given choices at 5 min Praxis/ agnosia: Able to brush teeth. No field cuts. CN: I: not tested II,III: VFF to confrontation, PERRL 3mm to 2mm, fundus w/o papilledema. III,IV,VI: EOMI, no ptosis. No nystagmus V: sensation intact V1-V3 to LT VII: Facial strength intact/symmetrical VIII: hears finger rub bilaterally IX,X: palate elevates symmetrically, uvula midline [**Doctor First Name 81**]: SCM/trapezeii [**3-20**] bilaterally XII: tongue protrudes midline, no dysarthria Rinne: R ear: AC>BC, LEFT ear AC> BC [**Doctor Last Name 15716**]: central. Motor: Normal bulk. Tone: normal. No tremor, no asterixis or myoclonus. No pronator drift: Delt;C5 bic:C6 Tri:C7 Wr ext:C6 Fing ext:C7 Left 5 5 5 5 5 Right 5 5 5 5 5 IP: Quad: Hamst: Dorsiflex: [**Last Name (un) 938**]:Pl.flex Left 5 5 5 5 5 Right 5 5 5 5 5 Deep tendon Reflexes: Bicip:C5 Tric:C7 Brachial:C6 Patellar:L4 Toes: Right 1 1 1 1 DOWNGOING Left 1 1 1 1 DOWNGOING Sensation: Intact to light touch, vibration, and temperature. Propioception: normal. Coordination: *Finger-nose-finger normal. *Rapid Arm Movements normal. *Fine finger tapping: normal. *Heal to shin: normal. *Gait/Romberg: normal. Pertinent Results: CThead [**2131-4-17**] No intracranial hemorrhage, status post electrode removal. [**2131-4-18**] 05:25AM BLOOD WBC-7.3 RBC-3.94* Hgb-11.9* Hct-35.0* MCV-89 MCH-30.2 MCHC-34.0 RDW-13.3 Plt Ct-394 [**2131-4-17**] 04:35AM BLOOD WBC-6.0 RBC-3.88* Hgb-11.0* Hct-34.3* MCV-88 MCH-28.4 MCHC-32.2 RDW-13.0 Plt Ct-402 [**2131-4-16**] 06:35AM BLOOD WBC-6.4 RBC-4.09* Hgb-12.2* Hct-36.1* MCV-88 MCH-29.7 MCHC-33.7 RDW-13.1 Plt Ct-410 [**2131-4-14**] 06:05AM BLOOD WBC-7.2 RBC-4.37* Hgb-12.8* Hct-38.2* MCV-88 MCH-29.4 MCHC-33.6 RDW-13.1 Plt Ct-445* [**2131-4-18**] 05:25AM BLOOD Glucose-84 UreaN-17 Creat-1.2 Na-141 K-4.2 Cl-105 HCO3-27 AnGap-13 [**2131-4-17**] 04:35AM BLOOD Glucose-88 UreaN-16 Creat-1.2 Na-140 K-4.2 Cl-105 HCO3-26 AnGap-13 [**2131-4-18**] 05:25AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.3 Brief Hospital Course: Mr [**Known lastname **] was admitted for the placement of deep electrodes and for long-term monitoring of the seizures. Epileptiform events were captured when he was off his Keppra. There have been no complications regarding the surgeries required to place the deep electrodes and to remove them. He had two episodes of fever. An infection was ruled out. He was on Cefazolin when you had the depth electrodes in place. On [**2131-4-17**] the Depths and strips were removed, and he had no complications. A CT head pre and post operatively showed no subdural collections. Medications on Admission: LAMOTRIGINE - 100 mg Tablet - 3 Tablet(s) by mouth twice daily - No Substitution LAMOTRIGINE [LAMICTAL] - 25 mg Tablet - 2 Tablet(s) by mouth twice a day. - No Substitution LEVETIRACETAM [KEPPRA] - 750 mg Tablet - 4 Tablet(s) by mouth twice a day - No Substitution LORAZEPAM [ATIVAN] - 1 mg Tablet - 1 Tablet(s) by mouth once a day as needed for seizures or auras ZONISAMIDE [ZONEGRAN] - 100 mg Capsule - 2 Capsule(s) by mouth once a day - No Substitution Discharge Medications: 1. Levetiracetam 500 mg Tablet Sig: Six (6) Tablet PO BID (2 times a day): Brand-name, please. No substitution allowed. Disp:*30 Tablet(s)* Refills:*0* 2. Lamotrigine 100 mg Tablet Sig: 3.5 Tablets PO BID (2 times a day): Brand-name, please. No substitution allowed. Disp:*30 Tablet(s)* Refills:*0* 3. Zonisamide 100 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). Disp:*30 Capsule(s)* Refills:*0* 4. Ativan 1 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:*10 Tablet(s)* Refills:*0* 5. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO see below for 8 days: take 0.5 mg twice a day for 4 days, then 0.5 mg once a day for 4 days, then stop the ativan. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Seizure disorder. Discharge Condition: He had a normal neurological exam apart from issues with short-term memory, and a mild postural tremor probably related to medication. Discharge Instructions: You have been admitted for placement of deep electrodes and recording of your seizures. we have been able to successfully record your events once you were off Keppra. There have been no complications regarding the surgeries required to place the deep electrodes and to remove them. You will be discharged on Keppra 3000 [**Hospital1 **], Lamictal 350 [**Hospital1 **] and Zonegram 200 mg. You are also on a taper of Ativan. Ativan taper is as follows: Ativan 1 mg twice day [**4-23**] Ativan 0.5 mg twice a day [**4-27**] Ativan 0.5 mg once a day [**5-1**] please stop taking the Ativan Followup Instructions: You will follow up with Dr. [**Last Name (STitle) 851**]/ Dr. [**Last Name (STitle) 877**] in the [**Hospital 875**] clinic. You will see [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN Phone:[**Telephone/Fax (1) 876**] Date/Time:[**2131-4-23**] 11:15 Please contact Neurosurgery: Dr [**Last Name (STitle) **] [**Last Name (NamePattern4) **] office on [**Telephone/Fax (1) 1669**] regarding the removal of your sutures. You should be able to have them removed on [**2131-4-23**] when you come for your Epilepsy appointment. Completed by:[**2131-4-18**]

[ "780.62", "V58.69", "E936.3", "333.1", "345.40" ]

icd9cm

[ [ [] ] ]

[ "93.59", "01.22", "02.93" ]

icd9pcs

[ [ [] ] ]

7982, 7988

6179, 6753

325, 426

8050, 8187

5363, 6156

8825, 9403

3035, 3120

7260, 7959

8009, 8029

6779, 7237

8211, 8802

3150, 3568

277, 287

454, 2787

3592, 5344

2809, 2846

2862, 3019

30,751

179,980

32160

Discharge summary

report

Admission Date: [**2156-8-30**] Discharge Date: [**2156-10-20**] Date of Birth: [**2092-1-16**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: right lower extremity infection Major Surgical or Invasive Procedure: -[**2156-8-30**] Incision and drainage of right leg with fasciotomies into the deep compartment -[**2156-9-2**] ERCP A 7 cm by 10 fr Cotton-[**Doctor Last Name **] pancreatic stent was placed successfully. -[**2156-9-3**] Drainage of deep intramuscular abscesses of right thigh. Repeat irrigation and debridement of the soft tissues of the right thigh. Open irrigation and debridement of right knee. -[**2156-9-6**] Washout and drainage of right leg and knee. Debridement of dead tissue. Repair of patellar tendon. -[**2156-9-10**] Right knee arthrotomy with anterior synovectomy. Debridement to the level of muscle. Dressing change under anesthesia. -[**2156-9-14**] Arthrotomy, right knee. Debridement, wound to the level of muscle. Application of VAC sponge. -[**2156-9-18**] Irrigation debridement to bone of open right thigh wound. Incision and drainage,m arthrotomy right open knee. Application of VAC dressing greater than 50 cm2 entire anterior right thigh, right hip, right posterior medial thigh. -[**2156-9-21**] Arthrotomy right knee with irrigation and debridement of joint and quadriceps muscles. Application of vacuum-assisted closure sponge. -[**2156-9-24**] Irrigation and debridement thigh musculature, calf musculature. Arthrotomy and synovectomy right knee. Placement of vacuum dressings. -[**2156-9-27**] Percutaneous endoscopic gastrostomy tube placement with upper endoscopy. Exploration and washout of right leg wound. Placement of a vacuum-assisted closure device to right leg wound. -[**2156-9-30**] Fascia irrigation and debridement. Fascia arthrotomy and vacuum dressing replacement. Debridement of joint and necrotic tendon. -[**2156-10-4**] Staged irrigation and debridement down to muscle thigh and proximal calf. Arthrotomy, right knee and irrigation and debridement. Change of vacuum dressing. Closed portion of medial wound, more than 30 cm. -[**2156-10-6**] Preparation of wound bed. Local flap advancement. Meshed split thickness skin graft measuring 39 cm x 4 inches and also placement of a wound VAC, wound assistive closure device. -[**2156-10-19**] ERCP previous stent removal. New 7 cm by 10 Fr Cotton [**Doctor Last Name **] biliary stent was placed successfully across the mass in the distal CBD. The stent will need removal in ~8 weeks. History of Present Illness: 64 y/o diabetic male presented to OSH with R foot (metatarsal area) ulcer that became infected and developed into an ascending soft tissue infection over the week prior to admission. He was treated with antibiotics. He had a normal WBC, but bandemia change. A CT scan demonstrated gas within the muscular plane to the quadriceps muscle. He was transferred to [**Hospital1 18**] for further evaluation. Past Medical History: PMH: NIDDM, hyperlipidemia, HTN, depression, left inguinal hernia, R foot ulcer x 1.5 years PSH: LIH repair Social History: Lives with son Physical Exam: On admission: VS: 96.5, 88, 98/70, 16, 95% RA Gen: NAD, A+O x 3, MM dry Chest: CTA bilat. CV: RRR Abd: soft, NT/ND Ext: Right LE 2+pulses DP, + edema from mid-calf to lateral hip with scant erythema and no weepy skin, + sensation to 1st interspace. Pertinent Results: [**2156-8-30**] 12:33AM BLOOD WBC-9.6 RBC-3.04* Hgb-9.5* Hct-27.9* MCV-92 MCH-31.3 MCHC-34.0 RDW-13.5 Plt Ct-508* [**2156-9-3**] 09:19PM BLOOD WBC-20.5*# RBC-3.20* Hgb-9.7* Hct-28.7* MCV-90 MCH-30.2 MCHC-33.7 RDW-15.3 Plt Ct-298 [**2156-9-16**] 02:33AM BLOOD WBC-13.0* RBC-2.61* Hgb-7.7* Hct-23.7* MCV-91 MCH-29.7 MCHC-32.7 RDW-17.9* Plt Ct-625* [**2156-9-21**] 10:37AM BLOOD WBC-18.5* RBC-2.90* Hgb-8.5* Hct-25.9* MCV-89 MCH-29.3 MCHC-32.9 RDW-17.1* Plt Ct-733* [**2156-8-30**] 12:33AM BLOOD ALT-70* AST-64* CK(CPK)-557* AlkPhos-250* Amylase-40 TotBili-1.1 [**2156-9-1**] 06:38AM BLOOD ALT-62* AST-92* AlkPhos-149* TotBili-5.8* DirBili-5.3* IndBili-0.5 [**2156-9-10**] 02:17AM BLOOD ALT-46* AST-43* AlkPhos-469* TotBili-2.0* . ABDOMEN U.S. (COMPLETE STUDY) PORT [**2156-9-1**] 1:09 PM IMPRESSION: 1. No evidence of intra- or extra-hepatic biliary dilatation. 2. Gallbladder sludge. Mild gallbladder wall edema, likely caused by third spacing. 3. Somewhat heterogeneous pancreatic parenchyma. No focal lesions seen. . [**2156-9-2**] ERCP The pancreatic duct was partially filled with contrast and visualized in the head of the pancreas. This was normal.. Procedures: A 7 cm by 10 fr Cotton-[**Doctor Last Name **] pancreatic stent was placed successfully using a Oasis system stent introducer kit. Impression: Normal biliary tree - a biliary stent was emperically placed. Normal limited pancreatogram. . CT HEAD W/O CONTRAST [**2156-9-9**] 9:07 AM IMPRESSION: 1. No acute intracranial pathology. 2. There is either mucosal thickening or an air-fluid level in the left pterygoid recess of the sphenoid sinus and opacification of some of the left mastoid air cells. This may be secondary to intubation or a coexistent inflammatory process. . MRA BRAIN W/O CONTRAST [**2156-9-12**] 7:41 PM IMPRESSION: 1. Technically limited MRI brain without evidence of hemorrhage, edema, or infarction. 2. Irregularity within basilar artery may represent atheromatous disease or artifact. Recommend repeat imaging for further evaluation. . MR CERVICAL SPINE W/O CONTRAST [**2156-9-12**] 7:41 PM FINDINGS: The images are markedly limited due to motion. Vertebral body alignment is satisfactory at all levels. Due to motion artifact, the neural foramina are poorly seen at most levels. At C2-3, there is a small central disc protrusion without evidence of canal narrowing. At C3-4, there is a small posterior osteophyte, which causes moderate encroachment on the thecal sac and raises the suspicion for cord compression. At C4-5, there is small osteophyte producing spinal canal narrowing. At C5-6, there is a small osteophyte without evidence of spinal cord compression. At C6-7 and C7-T1, there is no evidence of spinal canal narrowing. Hyperintesity on T1 and T2 weighted images in vertebral bodies at C3 and C5 likely represent marrow fat due to [**Last Name (un) 13425**] II degenerative change. Hyperintensity on T1, T2 and STIR images at C7 likley represents a hemangioma. IMPRESSION: 1. Technically limited exam due to marked patient motion. 2. There are multilevel degenerative changes and canal narrowing, with possible cord compression at C3-4. Repeat scanning can be obtained for further evaluation if clinically indicated. . MR HEAD W & W/O CONTRAST [**2156-9-14**] 7:50 PM FINDINGS: The conventional brain images show no evidence for an intracranial mass, hydrocephalus or shift of normally midline structures, visible minor or major vascular territorial infarction. The diffusion-weighted images are normal. The principal vascular flow patterns are identified. There is redemonstration of prominent mucosal thickening and/or fluid within both mastoid sinus complexes, which could represent an allergic or some other type of inflammatory process. Of probable similar etiology is high T2 signal within the left pterygoid recess of the sphenoid sinus. CONCLUSION: Normal brain MRI scan aside from extensive bilateral mastoid sinus signal abnormalities, possibly representing an allergic or some other type of inflammatory process. MR ANGIOGRAPHY OF THE CIRCLE OF [**Location (un) **] AND ITS TRIBUTARIES TECHNIQUE: Three-dimensional time-of-flight imaging with multiplanar reconstructions. FINDINGS: There are two areas of irregularity of the supraclinoid portion of the left internal carotid artery, which on the projected images appear to be possible aneurysms, measuring a few millimeters in diameter. However, when the source images are reviewed, I believe these findings represent origins of the normal anterior choroidal artery and posterior communicating artery, which are extremely diminutive in caliber distally, presumably representing an anatomic variant. There are no other vascular abnormalities seen. . MR BRACHIAL PLEXUS W/O CONTRAST [**2156-9-16**] 10:35 AM IMPRESSION: 1. Study limited by patient motion. No abnormality identified within the brachial plexus structures. 2. Non-specific edema surrounding the periphery of the rotator cuff muscles, left greater than right. 3. Probable left thyroid cyst. . THYROID U.S. [**2156-9-17**] 2:46 PM Overall measurements of the right gland approximately 4.3 x 1.7 x 1.3 cm. Overall measurements of the left gland are approximately 4.4 x 1.5 x 1.6 cm. IMPRESSION: 1.2cm spongy nodule in the mid right lobe, with no suspicious features. . VIDEO OROPHARYNGEAL SWALLOW [**2156-9-22**] 3:22 PM IMPRESSION: 1. Aspiration without cough reflex. 2. Mild pharyngeal delay. 3. Moderate-to-severe retained contents in the vallecula. . EMG Study Date of [**2156-9-23**] FINDINGS: This was a technically challenging study as the patient was unable to keep his arm at rest during the nerve conduction studies and was delirious so that cooperation was problem[**Name (NI) 115**]. Motor nerve conduction studies (NCSs) of the left median nerve demonstrated a mildly prolonged distal latency, borderline normal response amplitudes, mildly reduced conduction velocity. F responses were absent. Motor NCSs of the left ulnar nerve demonstrated a normal distal latency, moderately reduced response amplitudes, moderately slowed conduction velocities. F responses were absent. Sensory responses of bilateral median nerves were absent. Sensory NCSs of bilateral ulnar nerves demonstrated markedly reduced response amplitudes and mildly slowed conduction velocities. Sensory NCSs of bilateral radial nerves demonstrated a borderline normal response amplitude on the left, a moderately reduced response amplitude on the right [note that this study was particularly difficult due to patient positioning] and normal conduction velocities bilaterally. Sensory NCSs of the left lateral antebrachial cutaneous nerve of the forearm demonstrated a present yet moderately reduced response amplitude and normal conduction velocity. Sensory NCSs of left medial antebrachial cutaneous nerve of the forearm was normal. Concentric needle electromyography of selected muscles representing the left C5-T1 myotomes was performed. Moderate ongoing denervation was present in left biceps; increased insertional activity and occasional fibrillation potentials were present in left deltoid. Short-duration, small amplitude, polyphasic motor units were admixed with high amplitude, long duration motor units in biceps and deltoid; moderate chronic reinnervation in left triceps. Though relaxation was incomplete, ongoing denervation was present in the left C5 paraspinal muscles. Low amplitude, short duration myopathic motor unit potentials with early recruitment and increased muscle insertional activity was present in the left first dorsal interosseous and the right deltoid muscle. IMPRESSION: Complex, abnormal study. The electrophysiologic findings are most consistent with a severe, acute superimposed on chronic cervical polyradiculopathy, most severely affecting C5-6 myotomes on the left. The findings also suggest a mild- to- moderate, generalized, sensorimotor polyneuropathy and probable superimposed myopathy, which may be related to his critical illness. . CHEST (PA & LAT) [**2156-10-2**] 10:33 AM IMPRESSION: AP and lateral chest compared to [**9-24**] through 12: 1. Small bilateral pleural effusion, new or newly apparent since [**9-24**]. 2. New pneumoperitoneum. . COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2156-10-11**] 04:50AM 16.7* 2.97* 8.9* 27.2* 92 29.9 32.6 15.5 751* DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos [**2156-9-5**] 01:22AM 81* 3 10* 3 0 0 0 2* 1* Source: Line-art BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**2156-10-11**] 04:50AM 751* Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2156-10-11**] 04:50AM 162* 18 0.5 137 4.2 98 27 16 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili IndBili [**2156-10-7**] 05:00AM 150* 176* 475* 56 0.4 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2156-10-11**] 04:50AM 8.0* 3.1 1.6 . ERCP [**10-19**] Procedures: The plastic stent was removed using a snare and sent for cytology. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Sludge was extracted successfully using a 9-12 mm RX balloon. Cold forceps biopsies were performed for histology from the distal CBD. Cold forceps biopsies were performed for histology at the major papilla . A 7 cm by 10 Fr Cotton [**Doctor Last Name **] biliary stent was placed successfully across the mass in the distal CBD. Impression: 1. A plastic stent previously placed in the biliary duct was found in the major papilla and was removed using a snare and sent for cytology. 2. Cannulation of the biliary duct was performed with a sphincterotome using a free-hand technique. 3. Cholangiogram showed a distal CBD filling defect fixed to the CBD wall suggestive of a mass. The CBD diamter upstream was up to 10 mm. The intrahepatics were normal. 4. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. 5. Sludge was extracted successfully using a 9-12 mm RX balloon. 6. Cold forceps biopsies were performed for histology from the distal CBD. 7. Cold forceps biopsies were performed for histology at the major papilla . 8. A 7 cm by 10 Fr Cotton [**Doctor Last Name **] biliary stent was placed successfully across the mass in the distal CBD. Recommendations: 4. No NSAIDs, anticoagulants or antiplatelets for 7 days if possible 5. Call Dr[**Name (NI) 12202**] office in one week for the biopsy and cytology results 6. Final management will be based on the biopsy and cytology results. ERCP in 8 weeks to remove the stent and reevaluate. Brief Hospital Course: This is a 64 year old male who presented with necrotizing fasciitis of the right leg. He had a complicated hospital course, detailed here in a systems-based fashion: ID: He underwent multiple I&D/debridements/vac changes, starting on [**8-30**], as detailed in Procedures. His blood cultures and wound cultures initially grew MRSA, and he was started on ABX. On [**9-3**], the wound culture also grew [**Last Name (LF) **], [**First Name3 (LF) **] he was started on Zosyn. A TTE was performed on [**9-7**], demonstrating questionable endocarditis of the aortic valve, but a TEE performed on 10/244 was negative for vegetations or thrombus. On [**9-30**], the wound grew Citrobacter, which was pan-sensitive. He was followed by [**Month/Year (2) 1957**] for management of his septic knee, which was finally closed on [**10-4**]. Plastics performed a STSG on [**10-6**]. Daptomycin was d/c'd on [**10-11**]. At the time of discharge, over 90% of the graft had taken; the knee area was questionable, but was being followed closely by PRS. He was having multiple bowel movements, but C.diff was negative x 3. Neuro: On [**9-8**], the patient did not seem to be moving his proximal left arm. A CT head on [**9-9**] was negative for hemorrhage, edema, mass effect, and infarction. Neurology was consulted on [**9-11**]. A L shoulder XR was negative for fracture/dislocation. An MRI/MRA of the head & C spine ([**9-12**]) demonstrated canal narrowing with possible cord compression at C3-4. A repeat ([**9-14**]) demonstrated C2-3 small posterior disc protrusion, C3-6 R paracentral posterior spondylytic ridge, C2-6 congenital narrowing of AP diameter with spinal cord compression, and L and R neural foraminal stenosis. An EMG performed on [**9-23**] demonstrated polyradiculopathy of the L cervical spine. [**Month/Day (4) 1957**] Spine was consulted. A soft cervical collar was placed as per their recommendations for 1 week without improvements in symptoms. He was felt to be a poor operative candidate at this time. Neurology continued to follow him for his waxing/[**Doctor Last Name 688**] mental status, which was attributed to his infectious process and narcotic use. Psych: Patient has deficits in orientation, memory, and attention consistent with delirium. Etiology of delirium likely multifactorial (ongoing illness, active infection, multiple medications, metabolic derangements). Have provided considerable psychoeducation to pt and his son to increase family's comfort. . Pulm: On [**9-27**] CXR showed indistinctness at the left base that could represent a developing pneumonia in view of the clinical appearance of fever. [**10-5**] CXR showed Right upper lobe pneumonia. This was covered by Daptomycin. . GI: A RUQ US ([**9-1**]) demonstrated gallbladder sludging with minimal wall edema. An ERCP performed the following day demonstrated normal biliary tree and normal pancreatogram. A biliary stent was empirically placed. Repeat ERCP on [**10-19**] with stent removal and new CBD stent placed successfully across the mass in the distal CBD . FEN: Following extubation on [**9-8**], he was fed via Dobhoff tube. He failed a swallow evaluation on [**9-10**], and was maintained NPO with tube feeds. He pulled it out on several occasions secondary to confusion, and was placed on 1:1 observation. A PEG was placed on [**9-27**]. On [**10-8**], he passed a swallow evaluation, and was allowed ground solids with thickened liquids, which he tolerated well. Continue with tubefeedings and ground solid diet. . Medications on Admission: Actos, HCTZ, metformin, lipitor, glucotrol, zoloft, lotrel Discharge Medications: 1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for rash. 2. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg Subcutaneous Q12H (every 12 hours). 3. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y (650) mg PO Q6H (every 6 hours) as needed for fever or pain. 9. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. 10. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day) as needed for constipation. 11. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 13. HYDROmorphone (Dilaudid) 0.25 mg IV Q4H prn breakthrough pain 14. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 15. Insulin Glargine 100 unit/mL Solution Sig: Fifty Eight (58) Units Subcutaneous at bedtime. 16. Insulin Regular Human 100 unit/mL Solution Sig: Sliding Scale Injection three times a day: See sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Necrotizing soft tissue infection of right lower extremity. Septic right knee joint. Pancreatitis Polyradiculopathy Left cervical spine - left arm weakness C5-6 moderate post spondylytic ridge, congenital narrowing of bony central spinal canal cord compression Resolving delirium - deficits in orientation/attention. Necrotizing soft tissue infection of right lower extremity. Septic right knee joint. Pancreatitis Polyradiculopathy Left cervical spine - left arm weakness C5-6 moderate post spondylytic ridge, congenital narrowing of bony central spinal canal cord compression Resolving delirium - deficits in orientation/attention. Discharge Condition: Afebrile, vital signs stable, tolerating G tube feeds and diabetic ground solids/thickened liquids, pain well controlled on PO medication. Limited activity in the knee immobilizer on RLE. Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please take any new meds as ordered. * Limited activity with R knee immobilizer. Followup Instructions: Plastic Surgery Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern1) 6751**], MD Phone:[**Telephone/Fax (1) 5343**] Date/Time:[**2156-10-21**] 3:30 Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2156-11-8**] 8:40 Orthopedics Spine Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2156-11-8**] 9:00 Orthopedics Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2156-11-30**] 09:20 Gastroenterology Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2156-12-2**] 9:00. Stent removal. Dr. [**Last Name (STitle) 2340**] (Neuro) [**Telephone/Fax (1) 2343**]. Please call to schedule an appointment. Please follow-up with Dr. [**Last Name (STitle) **] on [**2155-12-18**] at 11:30am. Call [**Telephone/Fax (1) 1231**] with questions or concerns. You will have a CTA Pancreas prior to that appointment. Arrive at 9:30 to [**Hospital Ward Name 23**] [**Location (un) **] for your CT scan. Completed by:[**2156-10-20**]

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icd9pcs

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30384

Discharge summary

report

Admission Date: [**2145-9-7**] Discharge Date: [**2145-9-12**] Date of Birth: [**2090-7-16**] Sex: M Service: MEDICINE Allergies: Cefepime / Cipro Attending:[**First Name3 (LF) 3913**] Chief Complaint: Hypotension, cough Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 47367**] is a 55 yo male s/p allogeneic stem cell transplant for AML [**6-/2143**] with chronic GVHD on long-term steroids, DM, hx of PE on coumadin. . He presents to his [**Hospital 3242**] clinic with fatigue for several days, and anorexia, with about 12-16 hours of worsening shortness of breath. . Endorses increased cough with yellow sputum production and chills, but no fever. This morning, he reported an acute episode of dyspnea that did not rapidly improved, and occured with little amounts of activity and somewhat improved with rest. No PND/orthopnea. No hemoptysis. . He has had no new rashes, and has not had documented fevers. He has no diarrhea, but has been nauseated without vomiting. He reports mild epigastric pain. He has a mild headache made somewhat worse with light, but he feels that this is very consistent with flares of GVH and not different (has occured he estimates about 8 times). . In clinic SBP 70's, and he was given saline with improvement, but then the BP decreased down to the 80's. Labs from clinic showed that Cr increased to 2.9 (baseline 1.1). WBC increased somewhat. He was transferred to the ED for further evaluation. . In the ED, initial vs were: 4 97.6 72 105/73 18 99% He was given total of 3L of saline, and recent vital signs were 98.8 129/85 80 16 96% on 2L at time of transfer. A bedside "shock" ultrasound US in ED showed no cardiac effusion, no evidence of gross RV overload. EKG was not significantly changed. Her INR was 3.0. Of note, he was also complaining of left sided shoulder/neck pain associated with shortness of breath and diaphoresis. . For interventions, he received 1 gm vanc and 1gm aztreonam, 40 mg medrol, and 2 L IVF in clinic, and another liter in the ED. Past Medical History: - AML-M7: s/p matched unrelated allogenic transplant on [**2143-6-24**] - Chronic extensive GVHD of skin and liver, liver biopsy [**4-23**] consistent with GVHD, managed with cyclosporine, steroids, periodic CellCept, and has received 1 cycle of Rituxan. - Type 2 DM - Hyperlipidemia - H/o AVN bilateral hips - HTN - H/o nephrolithiasis, lithotripsy and previous nephrostomy tube and emergent surgery to repair ureteral damage - h/o left interpolar renal lesion, followed with MRs - h/o BCC s/p excision - h/o SCC left cheek, s/p Mohs' [**5-/2144**] - h/o multiple back surgeries: Lumbar L5-S1 surgery x 3, and cervical spine fusion (bone graft, no hardware) - h/o anterior cervical diskectomy and instrument arthrodesis at C5-C6 and C6-C7 for degenerative cervical spondylitic disease with spinal cord compression and foraminal stenosis at C5-C6 and C6-C7 [**2-/2144**]- Dr. [**Last Name (STitle) 548**] - Chronic numbness, neuropathic pain in left upper extremity. - Multilevel compression fractures T11, T12, L1 and mild compression L3 and L4. - h/o pulmonary embolism [**11/2144**] on anticoagulated from [**11/2144**]-present - h/o RSV [**11/2144**] requiring ICU admission - h/o OSA, planned BIPAP, followed by Dr. [**Last Name (STitle) 4507**] Social History: Lives with his wife, and one of children, worked as a [**Company 22957**] technician until [**Month (only) 547**] when he took early retirement and he is no longer working. Tob: previously smoked 1ppd for many years but quit 2.5 years ago EtOH: h/o social use; none recently Family History: Mother died suddenly in her 70s. Father died of unknown cancer with tumors visible across body. One sister has thyroid cancer. One brother has diabetes and kidney stones. One sister has [**Name (NI) 5895**]. Physical Exam: Tmax: 36.7 ??????C (98.1 ??????F) Tcurrent: 36.7 ??????C (98.1 ??????F) HR: 85 (85 - 85) bpm BP: 101/66(75) {101/66(75) - 101/66(75)} mmHg RR: 11 (11 - 11) insp/min SpO2: 97% Heart rhythm: SR (Sinus Rhythm) . 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: mild RUQ->mid epigastrium tenderness GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . No calf or thigh tenderness. Skin: depigmentation on hands, redness of neck, but no notable skin changes otherwise. No rashes. Pertinent Results: [**9-9**] CT chest without contrast IMPRESSION: 1. Mostly resolved parenchymal opacities, leaving several parenchymal bands which are felt most likely to represent residua of a prior infectious or inflammatory process. 2. Subacute to chronic rib fractures, including along the right posterior seventh rib, where there is faint but suspicious sclerosis extending further laterally than would usually be expected in the setting of an uncomplicated rib fracture. In the setting of prior treated hematological malignancy, the finding of vague sclerosis raises concern for a bone marrow abnormality such as myelofibrosis or potentially a form of disease recurrence. Mostly, however, the bones appear within normal limits. . [**9-9**] PFT's SPIROMETRY Pre drug Post drug Actual Pred %Pred Actual %Pred %chg FVC 3.86 5.05 76 3.83 76 -1 FEV1 2.83 3.60 79 2.69 75 -5 FEV1/FVC 73 71 103 70 98 -4 . [**9-8**] RUQ US IMPRESSION: 1. Polyp at neck of gallbladder (1.2cm), which was also seen on prior ultrasound scan [**2145-2-9**]. This has not changed significantly since prior ultrasound scan, but followup imaging is advised. . [**9-8**] Echo The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). 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 regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is borderline pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. . Micro: [**9-8**] CMV VL negative [**9-8**] sputum: oropharyngeal flora [**9-8**] urine cx negative [**9-8**] viral screen and cx negative [**9-7**] blood cx negative . ON ADMISSION: [**2145-9-7**] 01:05PM BLOOD WBC-11.1* RBC-4.39* Hgb-16.0 Hct-49.0 MCV-112* MCH-36.5* MCHC-32.7 RDW-14.9 Plt Ct-264 [**2145-9-7**] 01:05PM BLOOD Neuts-85.1* Lymphs-7.0* Monos-5.2 Eos-2.5 Baso-0.3 [**2145-9-7**] 01:05PM BLOOD PT-30.5* INR(PT)-3.0* [**2145-9-7**] 01:05PM BLOOD UreaN-28* Creat-2.9*# Na-140 K-4.4 Cl-101 HCO3-29 AnGap-14 [**2145-9-7**] 01:05PM BLOOD ALT-24 AST-20 LD(LDH)-201 CK(CPK)-37* AlkPhos-155* TotBili-0.3 [**2145-9-7**] 01:05PM BLOOD cTropnT-0.05* [**2145-9-7**] 01:05PM BLOOD Albumin-4.2 Calcium-9.3 Phos-2.6* Mg-2.4 [**2145-9-7**] 08:13PM BLOOD Lactate-1.9 . ON DISCHARGE: [**2145-9-12**] 05:40AM BLOOD WBC-7.2 RBC-3.45* Hgb-12.5* Hct-38.3* MCV-111* MCH-36.2* MCHC-32.7 RDW-15.0 Plt Ct-211 [**2145-9-12**] 05:40AM BLOOD Neuts-68.8 Lymphs-17.2* Monos-7.9 Eos-5.7* Baso-0.4 [**2145-9-12**] 05:40AM BLOOD Plt Ct-211 [**2145-9-12**] 05:40AM BLOOD Glucose-80 UreaN-18 Creat-0.9 Na-143 K-3.7 Cl-104 HCO3-30 AnGap-13 [**2145-9-12**] 05:40AM BLOOD ALT-25 AST-18 LD(LDH)-181 AlkPhos-112 TotBili-0.2 [**2145-9-12**] 05:40AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.1 UricAcd-4.6 Brief Hospital Course: 55 y/o male with ?viral syndrome vs. other atypical infection with hypotension that is suspected to be hypovolemia or adrenal insufficiency, with acute renal failure. . # Lethargy: concern for viral syndrome, including activation of CMV, or a respiratory virus. He has been known EBV+ in the past. This could also be related to sensation of dyspnea that he has been having, and warranted further cardiovascular and pulmonary work-up in parallel with the infectious work-up. In the ICU, continued broad spectrum antibiotics of vancomycin and aztreonam (given allergy). Infectious workup largely negative including CMV VL, respiratory panel, EBV VL, fungal markers, blood cultures, urine cultures, CT chest. Pt's lethargy improved with IVFs, antibiotics, and stress dose steroids. Did not ever need pressors. . # Dyspnea/Cough: Concern for infectious process. Regarding VTE, his risk should be reduced with therapeutic INR, though the concern for coumadin failure merits consideration, though would be unlikely and he has no other signs and symptoms of DVT. PFTs completed [**9-9**], with official report pending at time of this summary. CT chest showing resolving parenchymal processes, resolving infectious/inflammatory process. Continued broad spectrum antibiotics initially. When no infiltrate noted on CXR, decreased ABX to 5 days of azithromycin for treatment of bronchitis. . # Hypotension: A bedside "shock" ultrasound US in ED showed no cardiac effusion, no evidence of gross RV overload. EKG unchanged. Patient's hypotension was fluid/stress dose steroids responsive. Initially given stress dose steroids with plans to resume home dose. Also given IVF repletion. BPs normalized. Likely etiology was slight adrenal insufficiency in setting of viral syndrome despite negative infectious workup. Patient discharged with prednisone 7.5 mg daily. . # Acute Renal Failure: Likely pre-renal azotemia. Improved with IVFs. Cr 0.9 on discharge. . # Mild epigastric/RUQ tenderness: No laboratory e/o hepatitis. RUQ US showing polyp at neck of gallbladder (1.2cm), which was also seen on prior ultrasound scan [**2145-2-9**]. No other findings to explain epigastric pain. This pain has resolved on discharge. . # Pulmonary Embolism [**11-23**]: continued coumadin with INR goal [**1-19**]. # Diabetes: Continued NPH 12 units [**Hospital1 **], with close sugar monitoring and diabetic diet. Medications on Admission: ACYCLOVIR - 400 mg Tablet - 1 Tablet(s) by mouth three times a day BUDESONIDE [ENTOCORT EC] - (Dose adjustment - no new Rx) - 3 mg Capsule, Sust. Release 24 hr - 1 (One) Capsule(s) by mouth twice a day FOLIC ACID - (Dose adjustment - no new Rx) - 1 mg Tablet - 1 (One) Tablet(s) by mouth once a day HYDROMORPHONE - 2 mg Tablet - [**12-18**] Tablet(s) by mouth every [**3-22**] hours as needed for pain INSULIN LISPRO [HUMALOG] - SS LISINOPRIL - (Dose adjustment - no new Rx) - 5 mg Tablet - 1 Tablet(s) by mouth once a day METOPROLOL TARTRATE - 25 mg Tablet - 1 (One) Tablet(s) by mouth twice a day OXYCODONE - 20 mg Tablet Sustained Release 12 hr - 3 (Three) Tablet(s) by mouth every morning (60 mg), 1 tablet every 2pm (20 mg) and 3 tablets every evening (60 mg) PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once day PREDNISONE - 2.5 mg Tablet - 2 (Two) Tablet(s) by mouth once a day RISEDRONATE [ACTONEL] - 35 mg Tablet q Saturday TESTOSTERONE [ANDROGEL] - 50 mg/5 gram (1 %) Gel in Packet - Apply to upper torso once daily WARFARIN [COUMADIN] - (Dose adjustment - no new Rx) - 2.5 mg Tablet - 2 (Two) Tablet(s) by mouth once a day or as directed CHOLECALCIFEROL (VITAMIN D3) [DELTA D3] - (Dose adjustment - no new Rx) - 400 unit Tablet - 1 Tablet(s) by mouth DAILY (Daily) INSULIN NPH HUMAN RECOMB - (Prescribed by Other Provider) - 100 unit/mL Suspension - 12 units twice a day Please take first dose in the morning and the second dose at bedtime Discharge Medications: 1. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. Disp:*2 Tablet(s)* Refills:*0* 2. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 5. OxyContin 60 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO twice a day: QAM and QPM. 6. OxyContin 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO once a day: at 1400 every day. 7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 8. Budesonide 3 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO twice a day. 9. Prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): For total 7.5 mg daily. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week: On Saturdays. 13. AndroGel 1 %(50 mg/5 gram) Gel in Packet Sig: One (1) packet Transdermal once a day: Apply to upper torso once daily as directed. 14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve (12) units Subcutaneous twice a day. 15. Insulin Lispro 100 unit/mL Solution Sig: Varied units Subcutaneous four times a day: As per home sliding scale. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Hypotension/adrenal insufficiency Bronchitis Acute renal failure . Secondary diagnosis: AML s/p MUD allogeneic SCT [**6-/2143**] Chronic GVHD of skin/liver h/o PE Diabetes mellitus Discharge Condition: Stable, afebrile, BP 113/76, RR 16, sats 96% on RA, INR 1.8. Discharge Instructions: You were admitted with fatigue, shortness of breath, cough, low blood pressure and acute renal failure. We were concerned for early sepsis and you were in the ICU initially. You received broad spectrum antibiotics and stress dose steroids, but a full workup (including viral swabs, cultures, ECHO, and CT chest) were unrevealing. CT chest showed resolving infiltrates and your symptoms improved so the antibiotics were switched to azithromycin for presumed bronchitis. Your prednisone was increased due to presumed mild adrenal insufficiency. . The following medication changes were made: 1) Prednisone increased to 7.5mg daily 2) Azithromycin (antibiotic) started, to be completed as outpatient 3) Your lisinopril (blood pressure medication) and metoprolol were discontinued. Do NOT resume these medications until speaking to Dr. [**Last Name (STitle) **]. . You need to have your INR checked on Tuesday, [**2145-9-14**]. You also need to follow up with Dr. [**Last Name (STitle) **] and [**First Name8 (NamePattern2) 3235**] [**Last Name (NamePattern1) 3236**] within the next week. Please call their office tomorrow to make this appointment. . of the following symptoms: fever, chills, shortness of breath, difficulty breathing, abdominal pain, cough, flu symptoms, or any other worrisome symptoms. Followup Instructions: You need to have your INR checked on Tuesday, [**2145-9-14**]. . Please call Dr. [**Last Name (STitle) **] and [**First Name8 (NamePattern2) 3235**] [**Last Name (NamePattern1) 72254**] office to make an appointment to be seen later this week. They can be reached at [**Telephone/Fax (1) 3241**]. Completed by:[**2145-9-17**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13420, 13426

7958, 10348

295, 301

13670, 13733

4642, 6836

15084, 15412

3663, 3873

11897, 13397

13447, 13447

10374, 11874

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237, 257

329, 2080

13554, 13649

13466, 13533

6850, 7433

2102, 3354

3370, 3647

70,182

182,356

45458

Discharge summary

report

Admission Date: [**2110-2-9**] Discharge Date: [**2110-2-19**] Date of Birth: [**2034-8-16**] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2110-2-11**] Mitral valve replacement [**2110-2-17**] permanent pacemaker insertion History of Present Illness: 75 year old female with history of mitral regurgitation and chronic atrial fibrillation. Serial echocardiograms have shown worsening mitral regurgitation and mitral valve prolapse and increased pulmonary hypertension. In preparation for mitral valve surgery, she underwent cardiac catheterization which revealed no significant coronary artery disease. She is referred for mitral valve repair/replacement. She is admitted today for PAT and heparin after a coumadin washout. Past Medical History: Mitral valve regurgitation s/p mitral valve replacement Chronic Diastolic Congestive heart failure Mitral Valve Prolapse with Regurgitation Atrial Fibrillation - Coumadin for roughly 1 year Hypertension Dyslipidemia Diabetes Mellitus Type II Asbestosis Anemia h/o 1 blood transfusion Gastroesophageal reflux disease Depression Varicose veins Osteoporosis remote history of pneumonia Past Surgical History: D+C in distant past Colonoscopy with polypectomy Social History: Lives with: Son who is bipolar in [**Location (un) 701**], MA. Occupation: Retired Tobacco: Never but is exposed to significant second hand smoke. ETOH: Very rare Family History: Son died of PE/Mother died of CAD at age 61/Father died of CAD in early 80's/Brother died of cancer at age 59 Physical Exam: Pulse: 63 sr Resp: 22 O2 sat: 97% RA B/P Right: 118/56 Left: Height: 65" Weight: 174 General: WDWN mildly anxious Skin: Warm, dry and intact. No lesions or rashes noted. HEENT: NCAT, PERRL [X] EOMI [X], sclera anicteric Full dentures. Neck: Supple [X] Full ROM [X] No JVD Chest: Lungs clear bilaterally [X] Heart: Irregular rate and rhythm, III/VI holosystolic murmur Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Trace-1+ LE Edema. Bowing on LE at knees. Arthritic nodules on hands. Varicosities: Grossly varicosed bilaterally. Thighs worse then lower legs. Neuro: Grossly intact, No focal deficts Pulses: Femoral Right:2+ Left:2+ DP Right:1+ Left:1+ PT [**Name (NI) 167**]:1+ Left:1+ Radial Right:2+ Left:2+ Carotids: cardiac murmur is transmitted Pertinent Results: [**2110-2-19**] 07:40AM BLOOD Hct-32.2* [**2110-2-18**] 05:45AM BLOOD WBC-7.7 RBC-3.67* Hgb-10.5* Hct-30.8* MCV-84 MCH-28.6 MCHC-34.0 RDW-14.4 Plt Ct-182 [**2110-2-9**] 02:45PM BLOOD WBC-6.0 RBC-3.78* Hgb-11.0* Hct-32.3* MCV-85 MCH-29.0 MCHC-33.9 RDW-14.7 Plt Ct-218 [**2110-2-19**] 07:40AM BLOOD PT-17.2* PTT-27.0 INR(PT)-1.5* [**2110-2-18**] 05:45AM BLOOD Plt Ct-182 [**2110-2-17**] 06:21AM BLOOD PT-13.8* PTT-24.7 INR(PT)-1.2* [**2110-2-18**] 05:45AM BLOOD Glucose-88 UreaN-25* Creat-1.1 Na-140 K-4.3 Cl-102 HCO3-29 AnGap-13 [**2110-2-9**] 02:45PM BLOOD Glucose-123* UreaN-49* Creat-1.4* Na-140 K-4.0 Cl-103 HCO3-27 AnGap-14 [**2110-2-9**] 02:45PM BLOOD %HbA1c-6.4* eAG-137* [**Known lastname **],[**Known firstname **] [**Medical Record Number 97001**] F 75 [**2034-8-16**] Radiology Report CHEST (PA & LAT) Study Date of [**2110-2-18**] 9:26 AM [**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2110-2-18**] 9:26 AM CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 97002**] Reason: lead placement [**Hospital 93**] MEDICAL CONDITION: 75 year old woman with heart block s/p dual chamber PM. Assess lead placement REASON FOR THIS EXAMINATION: lead placement Final Report HISTORY: Pacemaker placement. FINDINGS: In comparison with study of [**2-14**], there has been placement of a pacemaker device with leads extending to the right atrium and apex of the right ventricle. No evidence of pneumothorax. Other than somewhat better lung volumes, there is little change in the appearance of the heart and lungs. DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**] Approved: TUE [**2110-2-18**] 11:19 AM [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 97003**] (Complete) Done [**2110-2-11**] at 9:37:12 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2034-8-16**] Age (years): 75 F Hgt (in): 64 BP (mm Hg): 112/58 Wgt (lb): 174 HR (bpm): 71 BSA (m2): 1.85 m2 Indication: Atrial fibrillation. Mitral valve disease. ICD-9 Codes: 786.05, 424.0 Test Information Date/Time: [**2110-2-11**] at 09:37 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2010AW001-0:00 Machine: IE33 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *8.0 cm <= 4.0 cm Aortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec Findings LEFT ATRIUM: Marked LA enlargement. No spontaneous echo contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Overall normal LVEF (>55%). [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Normal aortic arch diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Myxomatous mitral valve leaflets. Eccentric MR jet. Severe (4+) MR. [**Name13 (STitle) 15110**] to the eccentric MR jet, its severity may be underestimated (Coanda effect). TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [[**12-7**]+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Conclusions Pre-bypass: The left atrium is markedly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are myxomatous. An eccentric, posteriorly directed jet of Severe (4+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). The 3D views of the mitral valve show a flail A3 portion of the anterior leaflet. There is no pericardial effusion. Post-bypass: The patient is not receiving inotropic support post-CPB. There is a well-seated bioprosthetic valve in the mitral position with good leaflet excursion. There is no paravalvular regurgitation. There is a very small jet of transvalvular regurgitation. The mean pressure gradient across the valve is 4 mm Hg at a cardiac output of 3.5 L/min. Left ventricular systolic function post-MVR is mildly depressed (LVEF 45%). All other findings are consistent with pre-bypass findings. The aorta is intact post-decannulation. All findings were discussed with the surgeon intraoperatively. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2110-2-12**] 12:23 Brief Hospital Course: She was admitted on [**2110-2-9**] for intravenous heparin to bridge from coumadin prior to surgery. On [**2110-2-11**] she was brought to the operating room where she underwent a mitral valve replacement. 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 noted to have av block post operatively but hemodynamically stable, on [**2-13**] EP was consulted for evaluation. Baseline cr 1.4 with peak increase post operatively 1.6, medications adjusted. She continued in AV block and remained in intensive care due to rhythm. On [**2-17**] she was taken for permanent pacemaker insertion. She continued to progress, was transferred to the floor and was ready for discharge to rehab on post operative day 8 and 2. Medications on Admission: ***Coumadin 2mg daily*** followed by Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] dose [**2110-2-5**] Celebrex 200mg po daily Metformin 500mg po daily Paroxetine 20mg po daily Hyzaar 100mg po daily Omeprazole 20mg po daily Atenolol 50mg po daily Lescol 80mg po daily Actonel q week (Wednesday) Furosemide 20mg po daily Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metformin 500 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO DAILY (Daily). 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 9. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) for 5 doses. 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once : please give 2mg on [**2-20**] and check INR [**2-21**] for further dosing . 12. Outpatient Lab Work Labs: PT/INR for coumadin dosing with goal INR 2.0-2.5 for atrial fibrillation - first draw [**2-21**] please draw at least twice a week and as needed - received 2mg [**2-17**], 5mg [**2-18**], 2mg [**2-19**] INR 1.5 13. Lescol 40 mg Capsule Sig: Two (2) Capsule PO once a day. 14. Losartan 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Last Name (un) **] Center - [**Location (un) 701**] Discharge Diagnosis: Mitral valve regurgitation s/p mitral valve replacement AV block and tachy-brady syndrome s/p permanent pacemaker Atrial Fibrillation Hypertension Dyslipidemia Diabetes Mellitus Type II Asbestosis Anemia Gastroesophageal reflux disease Depression Varicose veins Osteoporosis remote history of pneumonia Colonoscopy with polypectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating with assistance Sternal pain managed with ultram prn Discharge Instructions: For first week no shower due to pacemaker insertion site - should be able to shower after device clinic visit, please bath daily until able to shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions - left subclavian (pacemaker insertion site) do not wash until after seen in device clinic Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Left arm keep elbow at or below shoulder level for 6 weeks due to pacemaker insertion Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2110-2-25**] 10:00 [**Name6 (MD) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2110-3-20**] 1:00 Please call to schedule appointments Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**12-7**] weeks Cardiologist Dr. [**Last Name (NamePattern4) 40823**] [**Last Name (NamePattern1) **] in [**12-7**] weeks Labs: PT/INR for coumadin dosing with goal INR 2.0-2.5 for atrial fibrillation - first draw [**2-21**] please draw at least twice a week and as needed - received 2mg [**2-17**], 5mg [**2-18**], 2mg [**2-19**] INR 1.5 Completed by:[**2110-2-19**]

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icd9cm

[ [ [] ] ]

[ "37.83", "39.61", "35.23", "37.72" ]

icd9pcs

[ [ [] ] ]

11640, 11721

8924, 9832

317, 406

12097, 12194

2597, 3626

13131, 13815

1583, 1694

10212, 11617

3666, 3744

11742, 12076

9858, 10189

12218, 13108

1337, 1387

1709, 2578

258, 279

3776, 8901

434, 909

931, 1314

1403, 1567

13,542

159,797

42659

Discharge summary

report

Admission Date: [**2105-9-17**] Discharge Date: [**2105-10-9**] Service: [**Hospital Unit Name 196**] Allergies: Penicillins / Quinine / Sulfonamides Attending:[**First Name3 (LF) 317**] Chief Complaint: SSCP Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: 84 yo woman with h/o Canadian Heart Class IV CAD s/p MI and CABG in [**2081**] (SVG to LAD) and PTCA x 6 ([**10/2096**] - stent to SVG-LAD, [**8-/2099**] - repeat stent to SVG-LAD, [**7-/2100**] - stent to LMCA-LCx, [**9-/2100**] - angio for ISR, [**12/2100**] - brachytherapy for LMCA-LCx; stent to RCA, stent to PDA, [**5-/2101**] - LMCA intervention) also with HOCM, HTN, CRI, who p/t an OSH on [**2105-9-17**] with chest pain, accelerating x 3 days. Her pain localized under her left breast, was found to have a NSTEMI w/ a positive troponin (0.12), and was admitted for cardiac cath. Past Medical History: 1. CAD - s/p CABG '[**81**], multiple stents 2. HOCM 3. CRF (creatinine 3.0) s/p fistula placement rt. arm 4. HTN 5. CHF - EF 33% 6. HTN 7. Gout 8. LLL lung resection for carcinoid 9. s/p cholecystectomy [**10**]. s/p abd hysterectomy 11. s/p rt ant tib surgery [**12**]. rt. hip fracture [**10-28**], now with artificial hip Social History: tob - none etoh - none drugs - none Family History: significant CAD in family Physical Exam: Vitals: HR 67, RR 21, BP 174/55 Gen: elderly caucasian woman, lying in bed, NAD Skin: warm and dry HEENT: OP clear, MMM CV: [**2-28**] syst murmur at LUSB, JVP 15cm Lungs: crackles diffusely Abd: thin, soft, NT/ND, +BS Ext: thin, no LE edema Pulses: on the right: 2+ carotids, 2+ femoral, 2+ DP, 2+ PT; on the left: 2+ carotids, 1+ DP, 2+ PT Neuro: unable to walk [**1-26**] R hip Pertinent Results: WBC-10.5 RBC-3.15* Hgb-9.7* Hct-29.7* MCV-95 Plt Ct-330 Glucose-77 UreaN-74* Creat-5.1* Na-138 K-4.4 Cl-99 HCO3-24 Calcium-9.8 Phos-6.7* Mg-2.1 Recent Cardiac Enzymes: [**2105-10-1**] 11:34AM BLOOD CK(CPK)-24* [**2105-10-1**] 06:24AM BLOOD CK(CPK)-18* [**2105-9-30**] 05:55AM BLOOD CK(CPK)-25* [**2105-9-29**] 12:15PM BLOOD CK(CPK)-36 [**2105-10-1**] 06:24AM BLOOD cTropnT-10.39* [**2105-9-25**] 06:21AM BLOOD cTropnT-9.32* [**2105-9-25**] 12:00AM BLOOD cTropnT-9.58* [**2105-9-24**] 10:31PM BLOOD cTropnT-9.28* [**2105-9-30**] ECHO: Conclusions: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction. Overall left ventricular systolic function is moderately depressed. Resting regional wall motion abnormalities include mid to apical anteroseptal akinesis/hypokinesis and anterior and anterolateral wall hypokinesis. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened with trace aortic regurgitation. There is mild to moderate aortic valve stenosis (valve gradient low due to reduced stroke volume). The mitral valve leaflets are moderately thickened. Moderate to severe (3+) mitral regurgitation is seen. There is moderate mitral annular calcification with a mild left ventricular inflow gradient. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Impression: Moderate regional systolic LV dysfunction c/w CAD Moderate to severe mitral regurgitation. Mild to moderate aortic stenosis. Mild pulmonary artery systolic hypertension Compared with the prior study (tape reviewed) of [**2105-9-21**], a slightly higher aortic valve gradient is now measured (likely related to slightly better technical quality of Doppler spectral measurement in the current study). Left ventricular systolic function and mitral valve appear similar. Tricuspid systolic gradient is now slightly lower. Cath [**10-23**]:FINAL DIAGNOSIS: 1. Two vessel (LAD, LCX) coronary artery disease. 2. Patent SVG to LAd with normal flow. 3. Successful stenting of the mid LCX with a bare meta (heparin coated) CAth [**10-18**]:FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. PCI of the SVG->LAD. URINE CULTURE (Final [**2105-10-3**]): ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Sensitive to Gent; Resistant to levo/flagyl Brief Hospital Course: This is an 84 y/o F w/ h/o HOCM, CRI, CAD s/p CABG in '[**81**] (SVG to LAD) and PTCA x 6 who presented to OSH with accelerating chest pain. Found to have NSTEMI, with a positive troponin of 0.12 and was admitted for cardiac cath. On cardiac cath [**9-18**] she was found to have an ulcerated 80% lesion in the proximal SV to LAD graft. She underwent succesful PTCA/stenting of the proximal and mid SVG to LAD with 2 Zeta stents. Limited resting hemodynamics showed elevated central aortic pressures (200/65mmHg). LV gram was not performed due to renal insufficiency. The patient recieved IV hydration with bicarb prior to and post-cath. In the holding area post-cath she became hypoxic requiring non-rebreather with O2 sats still in the low 90's. She was felt to be fluid overloaded and a CXR was consistent with florid CHF. She was given 20 mg IV lasix,then lasix 100mg IV and was started on Natrecor drip. She was then transferred to the CCU for further management. She continued to have SSCP rated from [**Date range (1) 92236**] after arriving in CCU. SL NTG and Nitro paste were tried with minor relief. Then the patient was started on Nitro drip + morphine with relief. Of note, she has tolerated nitrates well despite her h/o HOCM. Her cardiac enzymes were also elevated overnight post-cath and this was felt to be possibly related to showering of microemboli from her SVG into her microvasculature. She subsequently had resolution of her CK's and chest pain resolved. However, on return to the floor she had persistent chest pains despite nitro drip, prompting re-look catheritization. Re-look cath on [**9-23**] showed the LCX to have serial 70% lesions at the mid-segment. The SVG-->LAD was patent (mild residual stenosis at the proximal stent). The mid-LCX was successfully stented with a bare meta (heparin coated) stent. Of note, the patient required non-rebreather tx and was transferred to CCU for management of her CHF. The patinet was diuresed on natrecore and lasix in the unit and transferred back to the floor on [**9-25**]. On return to the floor she was found to be mildly SOB, without chest pressure or palpitations. JVP was up at 10cm's and she had crackles on exam to apices with decreased air movement at the bases. She was given 200mg IV lasix for goal diuresis of -500cc. She was continued on lasix prn for goal of even to -500cc/day. Oxygen status improved and she was able to maintain 96%O2 on RA. Set-up was made for diialysis on [**9-28**] with permcath placement. On her second day of dialysis, treatment was terminated early secondary to chest pain and SOB. NTG x 3 was given with sub-total relief of symptoms. She had an increased O2 requirement to 4L O2, with increasing SOB overnight. She desaturated to 88% on 6L NC and was started on a non-rebreather. At this time, she was found to have elevated JVP, tachypnea and rales up to the apex. EKG was performed and showed no evidence of acute MI (in the setting of baseline LBBB). She was given 200mg IV lasix and 250mg IV diuril with minimal response. Nitro drip was titrated up to 200mcgs and 4mg IV morphine was given to alleviate chest pain. Foley catheter was placed with minimal return (<10cc). Natrecor drip was started at 0.01mcg/kg/min. ABG demonstrated 7.23/65/66 with bicarb of 21, c/w an acute respiratory acidosis. BIPAP was placed for respiratory support and she was again transferred to the CCU. Of note, she was found to have evidence as well of a new LLL pneumonia by CXR ,with a WBC of 15.6, and was started on Levaquin/Flagyl. Hemodialysis after transfer to CCU removed 2.0kg, but was c/b hypotensive episodes w/ SBP decreased to the 70's. Hypotension resolved with 500 cc NS IVF support. Subsequent hemodialysis was well tolerated with maintenance of her blood pressures. Of note, she did have shoulder/chest pain + throat itchiness on HD #4. This was alleviated with 4mg morphine and NTG. Chest pain was noted to be resolved by the end of treatment. She was transferred back to the floor in stable condition for continued medical management. She has been on room air and maintaining sats >93% since return from CCU on [**10-1**]. Lungs are clear. She has been euvolemic with current course of Hemodialysis Tu,Th,Sat. She has remained chest pain free for >3 days. Of note, she is completing a course of Gentamicin antibiotics for an uncomplicated E.Coli UTI. She will need 2 more doses upon discharge. A brief [**Hospital 92237**] hospital problem list is outlined below: 1)CHF: better compensated with diuresis JVD flat; ACE-I, b-blocker; re-started dig at 0.25 qd. Decreased to 0.0625 qM,W,F on [**10-9**]. 2)CAD: ASA, plavix, statin, BB. tenatative nitrates given HOCM - has tolerted ntg gtt to date; Remains chest pain free s/p stenting of SVG to LAD and LCX. 3)ID: [**9-20**] -cultured and treated for Enteroccocus UTI w/ levaquin. Developed MRSE/enterocccus UTI and completed 7 day course of Vancomycin. She was subsequently started on Levo/Flagyl for infiltrate on CXR and elevated WBC. However, given absence of infiltrate on subsequent CXR, Levo/Flagyl was D/C'd. Repeat urine cultures demonstrated E.coli R to levaquin/[**Last Name (LF) **], [**First Name3 (LF) **] she was started on Gent at 100mg Bolus, + 60mgQHD x 1 week for uncomplicated E.Coli UTI. This was increased to 80mg QHD on [**10-9**]. She will need two more doses after discharge to complete her course. 4)CRF: HD per renal, through tunneled dialysis cath. Early treatments c/b hypotensive episodes requiring fluid support. She has tolerated recent treatments well, while maintaining BP's. She will continue HD Tu,Th,Sat. She will remain on Renegel 1600 TID. She will continue w/ Epo injections at 5,000 Units qHD. +neprocaps and QDay electrolyte lab draws. 5)Hypercalcemia: SPEP/UPEP negative. PTH elevated, likely secondary to ESRD, but will need outpatient follow-up to check Vitamin D levels and potentially a Parathyroid U/S to evaluate for adenoma. 6)severe arthritis: darvocet 7)FEN: low Na, cardiac, renal diet, fluid restrict 1500cc. 8)Access: L PICC in place, L dialysis cath 9)RLQ abdominal pain: No guarding or rebound. CT abdomen/pelvis negative for bleed. LFTs normal. Known guaiac positive stools. She will need f/u with GI on outpatient basis for follow-up. Hct stable. 10)hip pain- needs R. hip repair once medically stable. Evaluated here by Dr. [**Last Name (STitle) **]. We have had plain films of the R hip with 5 views for planned hip repair once medically stable. She will follow-up with Dr. [**Last Name (STitle) **] in [**2-26**] weeks. Continue percocet prn for pain control. Encourage ambulation/PT to improve functional status. 11)prophylaxis-PPI,Heparin SQ 12) anemia: likely [**1-26**] chronic dx, + GI bleed. Transfused to maintain hct>30. 13) Respiratory: Has been on room air since return from CCU on [**10-1**]. Lungs are clear. If becomes SOB and appears volume overloaded, she may need emergent HD. This has not been an issue to date. Of note, she has previously has had poor response to medical diuresis: 200mg IV lasix and 250mg IV diuril were used prior to CCU stay w/ poor effect. 14) sleep: please try trazadone or hydroxizine (vestoril) for sleep. She has significant difficulties falling asleep at night. Medications on Admission: pindolol folic acid aldactone plavix lipitor lasix sodium bicarbonate digoxin protonix nitro patch Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (once a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a day). 5. Pyridoxine HCl 100 mg Tablet Sig: Two (2) Tablet PO QD (once a day). 6. Cyanocobalamin 250 mcg Tablet Sig: One (1) Tablet PO QD (once a day). 7. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day). 8. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). 9. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). 10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. Sodium Citrate-Citric Acid 500-334 mg/5 mL Solution Sig: Twenty (20) ML PO TID (3 times a day). 13. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 14. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 15. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 16. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 17. Sevelamer HCl 400 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 18. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours). 19. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 20. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 21. Aluminum Hydroxide Gel 600 mg/5 mL Suspension Sig: 5-10 MLs PO Q8H (every 8 hours) as needed. 22. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 23. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 **]-[**Location (un) 1110**] Discharge Diagnosis: 1. NSTEMI 2. Chronic renal failure 3. Urinary tract infection 4. GI bleed Discharge Condition: good. hemodynamically stable. chest pain free. Discharge Instructions: Please report fever,chills, chest pain or shortness of breath to your pcp. Please weigh yourself daily and report weight gain >3lbs/day. Please maintain a low sodium diet and restrict your fluid intake to 1.5 Liters per day. Followup Instructions: 1. Please follow-up with Dr. [**Last Name (STitle) **] in [**12-26**] weeks. 2. Hemodialysis every Tuesday, Thursday, Saturday 3. Provider: [**Name10 (NameIs) **] DENSITY TESTING Where: [**Hospital6 29**] MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 4586**] Date/Time:[**2105-10-13**] 3:00

[ "584.9", "733.82", "414.02", "414.01", "425.1", "E929.3", "041.4", "458.21", "599.0", "285.21", "428.0", "410.71", "905.3", "403.91", "578.9", "593.9", "428.43", "588.89" ]

icd9cm

[ [ [] ] ]

[ "37.22", "39.95", "36.01", "38.95", "36.06", "93.90", "99.04", "88.56", "00.13", "88.57" ]

icd9pcs

[ [ [] ] ]

13703, 13771

4335, 11584

268, 293

13889, 13937

1788, 1940

14211, 14509

1344, 1371

11733, 13680

13792, 13868

11610, 11710

4069, 4312

13961, 14188

1386, 1769

1957, 3856

224, 230

321, 913

935, 1275

1291, 1328

9,003

177,756

50680

Discharge summary

report

Admission Date: [**2184-1-15**] Discharge Date: [**2184-1-21**] Date of Birth: Sex: M Service: NEUROLOGY ADMISSION DIAGNOSIS: Stroke. DISCHARGE DIAGNOSIS: Stroke, status post TPA. HISTORY OF PRESENT ILLNESS: This is an 80 year old the evening of [**2184-1-14**], when the patient had acute onset of right sided weakness during a card game. He slumped over in his chair at the table and had no loss of consciousness, but was not able to speak afterwards. Paramedics were called and the patient was brought to [**Hospital1 1444**] Emergency Department where on Head CT showed no hypodensity and no evidence of any hemorrhage. The patient at that point was noted to have a NIH stroke scale of 19. He was considered to be a TPA candidate and had no contraindications. The patient received TPA approximately one hour and forty minutes after onset of symptoms and was afterwards monitored in the unit. The patient's post TPA course was significant for agitation with the patient receiving 19 mg of Lopressor and 10 mg of Ativan in the Emergency Department for blood pressure and agitation control. The patient was monitored in the Neurosurgical Intensive Care Unit for post TPA monitoring for any evidence of hemorrhage. The patient's agitation continued with some alteration in mental status. An electroencephalogram was performed which showed diffuse swelling though no epileptiform activity. The patient had carotid ultrasounds performed which were normal. A transthoracic echocardiogram showed an ejection fraction of 30 to 40% and no evidence of any cardiac etiology of his stroke. Magnetic resonance scan was performed which showed an area of restricted diffusion in the left basal ganglia and insular cortex, otherwise no structural abnormality. The patient's MRA showed normal Circle of [**Location (un) 431**] as well as otherwise normal vessels. The patient was transferred to the floor and continued to improve with regards to his examination. Speech and Swallow was consulted which recommended a regular diet for the patient as well as further speech therapy secondary to mild dysarthria. Physical examination at discharge - On general examination, the patient's lungs are clear to auscultation bilaterally. Cardiac examination reveals a regular rate and rhythm with no murmur. The abdomen is soft, nontender, nondistended. Extremities are warm and well perfused. On neurological examination, the patient is awake and alert, in no acute distress. The patient is oriented to person, date and [**Hospital3 **] Hospital. Speech is fluent with normal naming and normal repetition. Attention is good with days of the week backwards. On cranial nerve examination, the patient's pupils are equally round and reactive to light. Extraocular movements are intact with no nystagmus present. Fundi appear normal. Facial movements are symmetric. Tongue and palate are midline with full range of movement. There is normal sternocleidomastoid and trapezius strength. On motor examination, the patient has full strength on the left side and mild 4+ out of 5 weakness on the right in an upper motor neuron distribution. The patient's reflexes are symmetric and 1+ bilaterally. Sensation is intact bilaterally to light touch and pin prick. The patient has mildly slow rapid alternating movements and finger-nose-finger though steady and accurate. The patient's gait is significant for mild unsteadiness. The patient's evaluation by physical therapy and occupational therapy recommends rehabilitation secondary to gait. Anticipated discharge is on [**2184-1-21**], to rehabilitation at [**Hospital3 **]. CONDITION ON DISCHARGE: Good. The patient is to receive occupational therapy and physical therapy and speech and language therapy at rehabilitation. MEDICATIONS ON DISCHARGE: 1. Synthroid 137 mcg p.o. q.d. 2. Fluoxetine 20 mg p.o. q.d. 3. Zantac 150 mg p.o. b.i.d. 4. Oxycontin 20 mg p.o. t.i.d. 5. Lopressor 12.5 mg p.o. b.i.d. 6. Percocet one tablet p.o. q6hours p.r.n. back pain. 7. Senokot one to two tablets p.o. p.r.n. constipation. 8. Milk of Magnesia 30 ccs p.o. q.d. p.r.n. constipation. 9. Albuterol MDI two puffs q4hours p.r.n. wheezing. 10. Aspirin 325 mg p.o. q.d. FOLLOW-UP: The patient will follow-up in neurology with the stroke team in approximately one month. In the meantime, he will be kept on Aspirin as adequate anticoagulation following his stroke and will receive appropriate physical therapy and occupational therapy as well as speech therapy at rehabilitation. The patient will continue on his outside regimen of Percocet and Oxycontin for pain control of spinal stenosis. [**Last Name (LF) **],[**Name8 (MD) **] M.D. [**MD Number(1) **] Dictated By:[**Last Name (NamePattern1) 38109**] MEDQUIST36 D: [**2184-1-20**] 18:01 T: [**2184-1-20**] 18:40 JOB#: [**Job Number 105448**]

[ "V45.82", "434.91", "401.9", "414.01", "412" ]

icd9cm

[ [ [] ] ]

[ "99.10" ]

icd9pcs

[ [ [] ] ]

188, 214

3836, 4923

157, 166

243, 3658

3683, 3810

3,401

198,984

12830

Discharge summary

report

Admission Date: [**2133-11-13**] Discharge Date: [**2133-11-16**] Date of Birth: [**2057-9-6**] Sex: M Service: CCU CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: The patient is a seventy-six-year-old male with a history of four vessel disease, status post coronary artery bypass graft in [**2127**] who presented to [**Hospital3 1443**] Hospital on the morning of admission with a one week history of substernal chest pain. The patient has had episodes on the morning of admission for less then two minutes at rest. The patient arrived at the Emergency Department in atrial fibrillation with one episode of nonsustained ventricular tachycardia. The patient responded to intravenous Amiodarone and intravenous Nitroglycerin, intravenous Lopressor and was pain free with the addition of a bolus of Integrilin along with aspirin and Plavix and Heparin. One week prior to admission, the patient had chest pain which he described as someone sticking needles in the center of his chest. The patient had accompanying diaphoresis which lasted a couple of hours and went away with lying down. The next day, the patient had diffuse abdominal pain which lasted a few days and was constant in nature. The patient described as a thorn and he also had nausea with one to two episodes of vomiting. There was no blood in his vomit. He thinks it may have looked bilious but he can not remember. The patient went to the hospital after this vomiting episode and was diagnosed with pneumonia by chest x-ray. The patient was given antibiotics and noticed that his urine "came out in drops". The patient also had chest pain with this difficulty urinating and vomiting. The patient went back to [**Hospital3 1442**] Hospital and had difficulty breathing while lying flat. The patient felt slightly short of breath otherwise, but not noticeable. The patient normally sleeps with one pillow at home. The patient has no history of paroxysmal nocturnal dyspnea. The patient has nocturia. He can walk a mile without shortness of breath. The patient has no edema. Otherwise, he had no chest pain or nausea or vomiting at the moment. [**Name2 (NI) **] did have shortness of breath with lying down. The patient did have cough and he did have belly pain which improved with placement of a Foley catheter. PAST MEDICAL HISTORY: Past medical history was otherwise, significant for four vessel coronary artery bypass graft in [**2127-6-14**] with left internal mammary bypassing the left anterior descending artery and three reversed autogenous saphenous vein grafts to bypass the ramus intermedius, the obtuse marginal branch and the circumflex and the posterior descending artery. The patient would have a catheterization twenty-four hours after the substernal chest pain but also had sepsis so catheterization at that time was delayed and the patient had a coronary artery bypass graft instead. The patient also has a history of diabetes, no history of hypertension. The patient has a history of duodenal ulcer, paroxysmal atrial fibrillation and increased cholesterol, which was checked six months ago and was okay. The patient's cholesterol is controlled with diet. MEDICATIONS: Medications on admission include, Captopril 12.5 mg by mouth three times a day, Digoxin 0.125 mg by mouth every a.m. and Ecotrin. The patient was also on a Z-pack prior to admission. ALLERGIES: No known drug allergies. SOCIAL HISTORY: No ethanol, smoking. The patient had smoked thirty to forty years ago, approximately one-half pack per day. FAMILY HISTORY: Family history was noncontributory. PHYSICAL EXAMINATION: Physical examination on admission included vital signs, 95.0 F, 64, 112/62, 32 and 90% on six liters. The patient was switched to a non-rebreather mask. Otherwise, general appearance: well appearing thin male, appeared anxious. Head, eyes, ears, nose and throat examination: pupils were equal and reactive to light and accommodation, moist mucous membranes, fissured tongue. Neck: no jugular venous distension lying down, no carotid bruits. Cardiac: Regular rate and rhythm, no murmurs, rubs or gallops, question of diastolic murmur in aortic area. Unable to assess well at this time, secondary to non-rebreather mask. Pulmonary: crackles anteriorly two-thirds up bilaterally. Good breath sounds. Abdomen: positive bowel sounds, soft, tender in the suprapubic area, improving after insertion of a Foley catheter. No hepatomegaly, no splenomegaly, nondistended. Extremities: no cyanosis, clubbing or edema, weak pulses bilaterally, Dopplerable, right extremity had a venous sheath, which was left in place, no hematoma or ecchymosis. Skin: pale and intact. LABORATORY DATA: Laboratory studies on admission included a white blood cell count 10.1, hematocrit 44.1, platelet count 295,000. Electrolytes included sodium 137, potassium 4.1, chloride 100, bicarbonate 21, blood, urea and nitrogen 16, creatinine 1.3 and glucose 115. Digoxin was less then 0.2. International normalized ratio was 1.05. Cardiac enzymes included creatine kinase 153, MB 20, Troponin 11.3. Arterial blood gas showed pH 7.39/32/68. Electrocardiogram showed normal sinus rhythm at 71 beats per minute with ST waves elevations in I and arteriovenous fistula, no left ventricular hypertrophy, Q waves in [**Last Name (LF) 1105**], [**First Name3 (LF) **] elevations in V1 and V2, V3 and a possible right bundle branch block with a QRS of 122. This is changed from previous electrocardiograms. Cardiac catheterization was performed, which showed cardiac output of 3.36 and cardiac index of 1.69, hemodynamic measurements were significant for elevated wedge of 24. Left ventriculography showed mitral regurgitation. LEVF percentage was not performed. Angiography showed a right dominant system with LMCA 100%, distal left main, LAD patent but small, diffusely diseased, left circumflex with patent ramus, severely diseased, distal circumflex RCA with 100% proximal SVG 1) To the PDA patent but severely diffusely diseased. 2) Jump graft to ramus and then right PLVBR equal patent, no significant graft disease, good distal RCA blood flow. LIMA to the LAD was patent but the distal LAD was small and appeared diffusely diseased. There was 100% native LM and RCA, which were severely disease, SVBG, to the PDA patent and the SVBG to the ramus distal RCA bed patent LIMA but small diffusely diseased LAD. HOSPITAL COURSE: Given the above, the patient's issues were treated by system in the Cardiac CCU. 1) Cardiac. The patient was found to be in congestive heart failure causing his shortness of breath. This was thought to be possibly secondary to paroxysmal atrial fibrillation and infection. Therefore, an echocardiogram was performed. This echocardiogram showed an ejection fraction of less then 25%, otherwise, the left atrium was mildly dilated, the left ventricular cavity was also moderately dilated and there was severe global left ventricular hypokinesis. Overall, left ventricular systolic function was severely depressed. The right cavity was moderately dilated and systolic function was also depressed. The aortic valve leaflets were moderately thickened with mild 1+ aortic regurgitation, mitral valve leaflets were mildly thickened with moderate pulmonary artery systolic hypertension. The patient was also put on Lasix given in increased amounts at the beginning of his hospital stay. The patient was continued on Captopril and he continued on Digoxin. Otherwise, for rhythm, the patient had ventricular tachycardia at the outside hospital and atrial fibrillation in the past. Beta blocker was held, given his recent decompensation. The patient was monitored on telemetry for ischemia. The patient was continued on aspirin, no stents were placed. The patient was continued on aspirin and Plavix, Heparin and had a cardiac catheterization performed. Otherwise, his lipid panel was rechecked as well as his liver function tests and the patient was started on Lipitor. 2) Pulmonary. The patient was continued on Lasix. A repeat chest x-ray was obtained to assess for pneumonia and the patient was begun on antibiotics. 3) Gastrointestinal. The patient had a history of duodenal ulcer and now presented with nausea, vomiting and abdominal pain. The patient was given Zofran for nausea and Protonix, otherwise, he was continued on the Foley catheter to decompress his bladder. 4) GU/BPH. The patient was begun on Terazosin to aid in his obstructive symptoms. Finally, the patient was discharged to home after stabilization of his acute cardiac issues. DISCHARGE MEDICATIONS: The patient's medications on discharge included his previous dose of Captopril, his previous dose of Digoxin, his previous dose of aspirin, as well as Plavix and Lipitor. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15176**], M.D. [**MD Number(1) 15177**] Dictated By:[**Doctor Last Name 10182**] MEDQUIST36 D: [**2133-12-24**] 10:04 T: [**2133-12-27**] 18:55 JOB#: [**Job Number 39493**]

[ "V45.81", "427.31", "428.0", "414.02", "414.01", "410.71" ]

icd9cm

[ [ [] ] ]

[ "99.20", "37.23", "88.56" ]

icd9pcs

[ [ [] ] ]

3542, 3579

8565, 9012

6395, 8542

3601, 6378

150, 163

191, 2303

2325, 3401

3417, 3526

50,597

139,495

6723

Discharge summary

report

Admission Date: [**2180-3-24**] Discharge Date: [**2180-4-9**] Date of Birth: [**2106-5-7**] Sex: F Service: NEUROSURGERY Allergies: Cipro Cystitis / Bactrim / Lidocaine Attending:[**First Name3 (LF) 78**] Chief Complaint: headache Major Surgical or Invasive Procedure: [**2180-3-24**] Diagnostic cerebral angiogram [**2180-3-29**] Cerebral angiogram with coiling of the PCOMM aneurysm History of Present Illness: This is a 73 year old woman who was seen in the neurology clinic for double vision and headaches that began [**3-7**]. Patient has a history of migraines, temporal arteritis, and hypertension. A CTA was performed which showed a 8mm R PCOMM aneurysm. Neurosurgery was called and patient was sent in for admission for a diagnostic cerebral angiogram and possible intervention. Past Medical History: PMH: hypertension GERD migraine headaches temporal arteritis Social History: Social History: She is a nurse. She is divorced and lives with her partner [**Name (NI) 4580**]. She smoked in the past. She has one glass of wine per week. She never used drugs. Family History: Family History: Her mother died at 94 of cardiac disease. Her father died at 65 of cardiac disease. Her sister died at 73 of lymphoma. Her brother died at 72 of cardiac disease. She has another brother with cardiac disease. One daughter is 50 and has breast cancer. Another daughter is 51 and has migraine headaches. She has a helathy 46-year-old daughter and a healthy 48-year-old son. Physical Exam: PHYSICAL EXAM: O: T: 98.2 BP: 136/84 HR: 88 R 18 O2Sats 98% Gen: WD/WN, NAD, wearing sunglasses in a darken room. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4 to 3 mm bilaterally. III, IV, VI: Extraocular movements were restricted with up gaze bilaterally (pt reports she has pain when looking up or right lateral), difficult to fully assess as she becomes uncomfortable and closes both eyes. 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 deviated to right Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-20**] throughout. No pronator drift Sensation: Intact to light touch Coordination: normal on finger-nose-finger On the day of discharge [**2180-4-9**]: The patient is neurologically intact strength is full sensation is full patient is able to ambulate independently pupils are equal and reactive face is symetric no pronator drift angio site is dry clean there is no hematoma or ertythema- pedal pulses are present Pertinent Results: [**2180-3-24**] STUDY: CTA of the head. FINDINGS: There is no evidence of acute intracranial hemorrhage, mass, mass effect, or shifting of the normally midline structures. The ventricles and sulci are slightly prominent, likely age related and involutional in nature. Punctate atherosclerotic calcifications are visualized in the carotid siphon. The soft tissues and bony structures are grossly unremarkable. Saccular aneurysm is identified at the right posterior communicating artery, measuring approximately 8 x 3 mm in sagittal projection (image #16, series 401B). There is no evidence of other aneurysms or narrowing of the major vascular structures. The anterior, middle and posterior cerebral arteries are patent as well as the posterior circulation, codominance of the vertebral arteries. IMPRESSION: Saccular aneurysm identified at the origin of the right posterior communicating artery, measuring approximately 8 x 3 mm in sagittal projection with no evidence of underlying subarachnoid hemorrhage. CT head [**2180-3-26**]: No CT evidence for acute intracranial hemorrhage; specifically, there is no subarachnoid blood. CT Head [**2180-3-28**]: FINDINGS: There is a new subarachnoid hemorrhage predominantly within the basal cisterns and the anterior interhemispheric and right Sylvian fissures. There is no evidence of cerebral edema, mass effect or shift of normally-midline structures. There is preservation of [**Doctor Last Name 352**]-white matter differentiation. Prominent ventricles and cortical sulci, most notably bifrontal, likely represent age-related atrophy; there is no finding to suggest developing hydrocephalus. The visualized portions of the paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: New subarachnoid hemorrhage, related to the known right PCom aneurysm. [**2180-3-28**] EMBOLIZATION FINDINGS: Right internal carotid artery arteriogram demonstrates an 8 mm x 4 mm aneurysm with a 2.15 mm neck in the region of the right posterior communicating segment. Right internal carotid artery arteriogram status post coil embolization shows minimal filling at the neck of the aneurysm. Right common femoral artery arteriogram shows widely patent right common femoral artery. [**Known firstname 636**] [**First Name8 (NamePattern2) **] [**Known lastname 12424**] underwent cerebral angiography and coil embolization of a right posterior communicating artery aneurysm that was uneventful. [**2180-3-29**] TCD Impression: Normal TCD evaluation. There was no evidence of vasospasm. [**2180-3-31**] LENIS: IMPRESSION: No evidence of lower extremity deep vein thrombosis. [**2180-4-6**] Head CTA: Redistribution of SAH with small amount of blood in the right occipital [**Doctor Last Name 534**] of the right lateral ventricle. CTA demonstrates mild narrowing of the Right M1 and M2 segments of the MCA [**2180-4-9**] 06:55AM BLOOD WBC-5.4 RBC-3.26* Hgb-10.3* Hct-32.2* MCV-99* MCH-31.7 MCHC-32.1 RDW-14.4 Plt Ct-337 [**2180-4-9**] 06:55AM BLOOD Plt Ct-337 [**2180-4-9**] 06:55AM BLOOD PT-11.3 PTT-29.0 INR(PT)-1.0 [**2180-4-9**] 06:55AM BLOOD Glucose-88 UreaN-4* Creat-0.7 Na-137 K-3.6 Cl-104 HCO3-22 AnGap-15 [**2180-4-9**] 06:55AM BLOOD Calcium-8.3* Phos-2.6* Mg-2.3 Brief Hospital Course: Ms [**Known lastname 12424**] was admitted through the emergency room for complaints of diplopia and headache. CTA revealed Pcomm aneurysm that was confirmed on cerebral angiogram. She was admitted to the ICU for close observation. Her images were reviewed and it was decided that she would undergo a coiling of the anuerysm scheduled for [**3-29**]. She was started on Dexamethasone for headache management with good effect. Pre-op work up was done on [**3-28**]. In the evening, she reported the worse headache of her life and became hypertensive. A STAT head CT was done which showed a new SAH on the right along the R sylvian fissure and basal cisterns. No signs of hydrocephalus. Her neuro exam remained stable. She was taken to angio with Dr [**First Name (STitle) **] on [**3-29**] midnight for coiling of the PCOMM aneurysm. Post-op she did well. Nimodipine and Keppra was started. Her SBP was liberalized to 80-200. TCDs on [**3-29**] showed no vasospasm. She remained stable but conitnued to have headaches. Her fiorocet was increased. the migraine medications were discontinued per the recommendations of Dr [**Last Name (STitle) 25589**] On [**3-30**], The patient constinued to experience headache and fiorocet increased. decadron was also uincreased for headache.sub Q heparin initiated. On [**3-31**], TCDs were performed which were consistent with no vasospasm. LENIS were performed which were negative for DVT. The foley catheter was discontinued. Goal was to keep fluid balance even and IVF at 125cc/hr. The patient tolerated a regular diet. The patient ambulated in the [**Doctor Last Name **] of the intensive care unit. the patient reported no bowel movement since tuesday [**3-28**] and the bowel regime was increased. Decadron 4 q 8 was continued for headache. The patient reported improved headache, denied diplopia, improved photophobia. On exam the patient was alert and oriented to person, place, and time. The pupils were 4-3mm and 3-2 mm on the left. Ptosis left. Lateral eye movements right eye were reported painful. the strength was full. The angio groin site was intactm pedal pules were strong/palpable. On [**4-1**], patient remained stable, but reported headache that was temporarily relieved with pain medications. Her blood pressure is liberalized and IVF are continued. She is encouraged to be OOB. She was neurologically stable and more comfortable on [**4-2**], underwent a CTA and was found to have no vasospasm. On [**4-4**] she was transitioned from IV Dilaudid to oral oxycodone and fioricet for headache control. She had TCDs which showed no spasm. Overnight she was febrile to 101.7, fever workup was done and patient had a positive UA- Macrobid was started on [**4-5**]. She remained stable and was cleared for SDU transfer but kept in the ICU as there was no beds. Overnight she was again febrile to 102 and she was started on Zosyn in the setting of 1 out of 2 blood culture bottles positive for GNR. Blood cultures were also repeated at the time of her fever.urine was positive for E coli On [**4-6**] she developed severe headache and continued to have persistent nausea and vomiting. CT/CTA head was performed which demonstrated no new bleed and only mild narrowing of the Right MCA, M1 and M2. Compazine was added for control of nausea. IVF were continued at 125cc/hr and she was transferred to the stepdown unit when headache and nausea improved. She did well on [**4-7**] AM. In the afternoon she had a episode of desat to 88%, CXR was done and was stable. She then later c/o headache and nausea. TCDs were done and showed no vasospasm. On [**4-7**], the patients antibiotics were changed to ceftriaxone. The patient desaturated to 88% x 1 briefly and a CXR was performed which was consistent with Small bilateral pleural effusions and dependent atelectasis. mobility and incentive spirometry was encoraged. transcranial dopplers were performed without evidence of vasospasm. On [**4-8**], electrlyes were sent phosphorus, potassium, magnesium were repleated. cycodone was thought to be contributing to patients nausea was changed to dilaudid. On [**4-9**], the patient was doing quite well. her neurological exam was intact. She exhibited full strength and sensation. There was no pronator drift. The patient continued to be alert and oriented to person, place, and time. Physical therapy saw the patient and deemed her safe for discharge home with physical therapy. The patient will have VNA and home infusions. The patient was sent home with a midline catheter for IV antibiotic treatment. Medications on Admission: Medications: atenolol 50 mg qd amlodipine 5 mg qd prisolec 20 mg [**Hospital1 **] aspirin 81 mg qd vitamin D 1000 IU zomig 2.5 mg prn oxycodone 2.5 mg prn 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. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): home medication- please continue per your primary care. 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. topiramate 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 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). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 6. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for Headache: contains tylenol do not exceed 4 grams tylenol within 24 hours. Disp:*30 Tablet(s)* Refills:*0* 7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for headache: hold for lethargy- do not drive while taking. Disp:*60 Tablet(s)* Refills:*0* 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 11. prochlorperazine 25 mg Suppository Sig: One (1) Suppository Rectal Q12H (every 12 hours) as needed for nausea. Disp:*4 Suppository(s)* Refills:*0* 12. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush: Heparin Flush (10 units/ml) 2 mL IV PRN line flush to midline . Disp:*30 ML(s)* Refills:*1* 13. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4 hours) for 2 days: last day [**2180-4-20**]- please dispense two days supply from hospital pharmacy upon discharge. Disp:*24 Capsule(s)* Refills:*0* 14. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO every four (4) hours for 8 days: total of 21 days- last dose [**2180-4-20**]. Disp:*96 Capsule(s)* Refills:*0* 15. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig: Two (2) grams/50cc Intravenous Q24H (every 24 hours): CeftriaXONE 2 gm IV Q24H for 2 weeks beginning [**4-7**] through [**2180-4-21**] for ecoli bacteremia/UTI . Disp:*60 grams/50cc* Refills:*2* Discharge Disposition: Home With Service Facility: Home Solutions Discharge Diagnosis: Posterior communicating artery aneurysm Subarachnoid hemorrhage Headache Anxiety Diplopia UTI-Ecoli Bateremia- Ecoli Fever Discharge Condition: headache/nausea oriented to person, place, and time strength full sensation full pupils are equal and reactive angio site is well healed- no hematoma or erythema noted Discharge Instructions: Angiogram with Embolization placement Medications: ?????? Take Aspirin 325mg (enteric coated) once daily. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? After 1 week, you may resume sexual activity. ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate. ?????? No driving until you are no longer taking pain medications What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site *SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call our office. If bleeding does not stop, call 911 for transfer to closest Emergency Room! Followup Instructions: Please follow-up with Dr [**First Name (STitle) **] in 4 wks with a MRI/MRA Brain with and without contrast ([**Doctor Last Name **] coiling protocol). Please call [**Telephone/Fax (1) 4296**] to make this appointment. Please follow up in the Infectious Disease Clinic regarding the treatment of your bacteremia treated with IV antibiotics Ceftriaxone. Please call the infectious disease clinic at [**Hospital1 18**] for an appointment upon completion of your antibiotics. You may call [**Telephone/Fax (1) 457**] to make an appointment. Completed by:[**2180-4-9**]

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icd9cm

[ [ [] ] ]

[ "39.72", "88.41", "88.44" ]

icd9pcs

[ [ [] ] ]

13363, 13408

6209, 10790

306, 424

13575, 13745

2961, 6186

15718, 16288

1143, 1516

10996, 13340

13429, 13554

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31,982

121,137

25922

Discharge summary

report

Admission Date: [**2156-9-7**] Discharge Date: [**2156-9-13**] Date of Birth: [**2087-3-18**] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Worsening shortness of breath and edema Major Surgical or Invasive Procedure: Intubation History of Present Illness: This is a 69 year-old male with a history of refractory HF (EF 10%), CAD s/p CABG, AF s/p recent cardioversion, ICD, severe RA, hyperlipidemia who presents for evaluation of worsening SOB and edema. The pt was recently discharged from [**Hospital1 18**] for exacerbation of heart failure. Milirone was increased at that time to 0.75mcg/kg/min and IV lasix drip was helpful for diuresis. At home, he was receiving HCTZ 25mg prior to Lasix 40 mg IV in AM then oral Lasix in PM. [**Name (NI) 1094**] wife and [**Name (NI) 269**] noted the pt to be more short of breath and edematous and called EMS. Pt was taken to the nearest ED, and from there, pt was transferred to [**Hospital1 18**] where he gets his usual care. . At the OSH, initial vitals were HR: 58 BP: 72/52 RR: 20-22 O2Sat: 90% on 2L. Past Medical History: CAD, s/p CABG x 4 in [**7-/2148**] ischemic cardiomyopathy- S/P ICD. NYHA class 4, on home O2 atrial fibrillation, recent cardioversion ([**7-/2156**]) HIT with + ab screen treated w/ argatroban in past Depression / memory loss hyperlipidemia Mirtal regurgitation GIB from gastric ulcer in [**3-/2154**] H/O AVMs s/p injection in [**2152**] and [**2153**] Rheumatoid arthritis H/O sacral ulcer-healed S/P right 5th toe amputation S/P right 4th toe ulcer S/P inguinal hernia repair Relative adrenal insufficiency Thrombocytopenia thought to be autoimmune, s/p bone marrow bx H/O C-diff Anemia Chronic renal insufficiency Social History: Retired orthopedic surgeon, lives at home with wife, quit smoking 50 years ago, social drinker, no other drug use. Family History: Sister with DM, mother died of liver cancer, father has CAD. Physical Exam: VS - T 97.6, BP 86/52, P 70, R 20, 95% on 2L Gen: chronically ill appearing male, AOX3 HEENT: NCAT. Soft, mobile mass on posterior head. PERRL. EOMI. Neck: JVP=12cm supple CARD: RRR, + heave. no m/r/g PULM: Rales midway up bilaterally. Good air movement. ABD: Soft, NT, ND, no massses or organomegaly EXT: 3+ pretibial edema, both feet in boots 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: [**2156-9-7**] 09:48PM WBC-4.6 RBC-3.43* HGB-8.3* HCT-26.8* MCV-78* MCH-24.1* MCHC-30.8* PLT COUNT-59* [**2156-9-7**] 09:48PM PT-15.6* PTT-30.4 INR(PT)-1.4* [**2156-9-7**] 09:48PM GLUCOSE-130* UREA N-70* CREAT-2.0* SODIUM-125* POTASSIUM-3.1* CHLORIDE-84* TOTAL CO2-31 ANION GAP-13 CALCIUM-8.3* PHOSPHATE-3.6 MAGNESIUM-2.1 From OSH: BNP 2309 (1439 on [**8-18**]) EKG from OSH demonstrated A-V dual-paced rhythm with no significant change compared with prior dated [**2156-8-22**]. 2D-ECHOCARDIOGRAM performed on [**2156-8-22**] demonstrated: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No thrombus is seen in the right atrial appendage The ascending aorta is mildly dilated. There are three aortic valve leaflets which are mildly thickened. Aortic stenosis is present (not quantified). CARDIAC CATH performed on [**2156-8-5**] demonstrated: COMMENTS: 1. Entry hemodynamics revealed top normal right sided filling pressures with RVEDP of 9 mm Hg. Mean PCWP was elevated at 17 mm Hg. PASP was mildly elevated at 36 mm Hg. Cardiac index was depressed at 1.8 l/min/m2. 2. Following milrinone infusion, right atrial pressure decreased from mean 13 to 3 mm Hg). PCWP decreased to 10 mm Hg. Cardiac index improved to 2.65 l/min/m2. 3. Right internal jugular venous sheath and PA catheter were secured by suture and dressed in sterile fashion. FINAL DIAGNOSIS: 1. Depressed cardiac index and elevated left sided filling pressures. 2. Improved hemodynamics following milrinone infusion with increased cardiac index, decreased right atrial pressure, and decreased left sided filling pressures. Brief Hospital Course: Patient was a 69 yo M with severe ischemic cardiomyopathy wtih EF of 20% s/p ICD placement, CAD s/p CABG, AF, hyperlipidemia, and severe RA who presents with CHF exacerbation. . Congestive Heart Failure: Pt had severe ischemic cardiomyopathy with EF of 20%, NYHA class 4, on milrinone drip at home. He was admitted with a CHF exacerbation, likely due to recurrence of underlying atrial tachycardia. Patient had VTach shortly after admission, and he was transferred to the CCU. His Lasix and Diruil were stopped. He then became hypertensive with SBP 130s and P 90s. He was restarted on his Lasix. Patient had a VTach arrest on [**9-11**], during which he vomited and was not protecting his airway. He was intubated on the floor. He was started on a lidocaine gtt and was extubated shortly thereafter. He then developed a fever, thought to be secondary to aspiration pneumonitis. The patient was started on Levofloxacin and Metronidazole for potential aspiration pneumonia, and he was found to have a new RUL infiltrate on CXR. The patient was continued on this regimen until [**2156-9-13**], at which point he and his family decided that he would be made CMO. He passed away on [**2156-9-13**] from cardiac arrest secondary to apnea. Medications on Admission: Carvedilol 25 mg [**Hospital1 **] Digoxin 125 mcg QOD Escitalopram 10 mg DAILY Ferrous Sulfate 325 mg (65 mg Iron) DAILY Furosemide 20 mg PO PRN Milrinone 0.75mcg/kg/min Intravenous continuous infusion. Pantoprazole 40 mg daily Prednisone 5 mg DAILY Discharge Disposition: Expired Discharge Diagnosis: Primary: Congestive Heart Failure Coronary Artery Disease Rheumatoid Arthritis Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Completed by:[**2156-10-17**]

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icd9cm

[ [ [] ] ]

[ "99.61", "96.04", "99.60", "88.72" ]

icd9pcs

[ [ [] ] ]

5768, 5777

4225, 5468

322, 334

5899, 5908

2508, 3953

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5494, 5745

3970, 4202

5932, 5941

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243, 284

362, 1158

1180, 1801

1817, 1934

59,889

193,765

48948

Discharge summary

report

Admission Date: [**2114-3-10**] Discharge Date: [**2114-3-21**] Date of Birth: [**2033-11-17**] Sex: F Service: NEUROSURGERY Allergies: Lisinopril / Verapamil / Beta-Adrenergic Agents Attending:[**First Name3 (LF) 78**] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: Left sided subdural hematoma drainage History of Present Illness: From admission note: Pt is a 80-yo female resident of [**Location 6682**] House Rehab with PMHx sig. for ESRD on HD, h/o CVAs, SDH s/p fall in [**9-25**], recent coag-neg Staph bacteremia (completed 14 day course of vanc in [**1-26**]) who presents with 2 days of sig. neurological deterioration, including R sided weakness, loss of ability to ambulate or comb her hair, L facial droop, and dysarthria. Pt is unable to provide a history. Per Neuro note, at 8:15 PM, pt was noted to have slurred speech and left facial droop. Pt has baseline R > L sided weakness from SDH. She had denied HA, vision changes, cough, diarrhea, and fever/chills. Pt was recently admitted for anemia. Work-up was only sig. for anemia of chronic disease. Her EPO dose was increased. Of note, pt had hypoactive delirium during her hospitalization. Metabolic w/u at the time was neg. EEG showed mild to mod encephalopathy but no evidence of seizure activity. Serial CT scans showed stable subdural hematomas. With discontinuation of dilantin and keppra, her symptoms resolved within 2 days. In the ED, VS were: Temp 100.2 (Tmax 100.4), HR 60s-70s, BP 150/70, SaO2 97% RA. Code Stroke was called. Neurology and Neurosurg were consulted. No focal deficits were noted on exam. In addition, she was >3 hrs out from onset of sxs and thus not a candidate for tPA. CT head suggests "stable bilateral evolving subdural collections with no new hemorrage evident, stable minimal rightward shift of midline structures." Neurosurgery did not feel that there was a change in bleed. Per daughter, pt's mental status is back to baseline. Neuro deferred LP at this point. Neuro did recommend restarting dilantin due to h/o seizures in the past. Pt was admitted for toxic/metabolic work-up. Past Medical History: DM CAD PVD HTN (labile) h/o SDH and IPH in [**9-25**]. [**9-25**] s/p syncopal fall resulting in acute SDH and IPH (non surgical) Lower extremity edema/venous insufficiency Arthritis Lumbar disc disease Chronic kidney disease on HD, previously via left UE fistula but that was infected [**6-25**] at an area of repaired aneurysm so no via tunnelled HD cath Pulmonary hypertension Toxic Multinodular Goiter Anemia- low iron and EPO s/p Breast biopsy s/p Hysterectomy, s/p excision of a left ear mass s/p right toe amputation of digits one, two, three, four, and five Social History: Pt currently resides at [**Hospital **] Rehab and was to be discharged tomorrow. At baseline, she ambulates with a walker. She denies tobacco/etoh use. Family History: Diabetes Physical Exam: Mental status: Awake and alert, intermittently uncooperative with exam, inattentive. Oriented to person, place (hospital, [**Location (un) 86**], but not [**Hospital1 **]), but not date (does not say anything). Inattentive, cannot spell world forwards. Speech is nonfluent, able to name high frequency objects (chair, hand), but not low frequency objects. Makes one paraphasic error ([**Last Name (un) **]->[**Name2 (NI) 102794**]), says tip-top, but does not name any other word list words. Slight dysarthria. Does not attempt to describe stroke scale cookie jar picture. Does not comply with testing for right-left confusion. No evidence of neglect. Cranial Nerves: Unable to visualize fundi bilaterally. Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Extraocular movements intact bilaterally without nystagmus. Visual fields full to confrontation. Sensation intact V1-V3 to pinprick. Flattening of the L NLF especially with smiling. Sternocleidomastoid full strength bilaterally. Tongue midline, non-compliant with moving tongue. Motor: No observed myoclonus or asterixis. Postural tremor in L>R upper extremity. both arms stay extended >10 seconds, but right drifts faster than left. [**Doctor First Name **] Tri [**Hospital1 **] WE FE FF IP H Q DF PF R 4+ 5 5 5 5- 5- 3 5- 5- 5 5 L 5- 5- 5- 5 5 5- 3 5- 5- 5 5 Sensation: Intact to light touch, pinprick, and cold sensation throughout. Did not comply with testing for extinction to DSS. Reflexes: 2+ and symmetric in biceps, brachioradialis. 1+ and symmetric in knees, toes. Toe downgoing on the left (no toes on right). Coordination: Non compliant with finger-nose-finger and fine-finger movement testing. Pertinent Results: CT head [**3-9**]: Left subdural has increased in size. Maximum width is now 3.8 cm compared to 2.7 cm, after consideration of difference in angulation. Right subdural also appears slightly increased in extent. No change in midline shift seen and no herniation identified. Revised findings conveyed to the clinical team at 10 AM on [**2114-3-9**]. MRI head [**3-11**]: Persistent and unchanged evolving subdural hematoma along the convexity, larger on the left side as described in detail above with different stages of chronicity. No diffusion abnormalities indicating acute ischemic event. Small vessel disease is demonstrated as areas of hyperintensity signal in the subcortical white matter and lacunar ischemic changes in both cerebellar hemispheres. Bilateral mucosal thickening in the maxillary sinuses, larger on the right side. Brief Hospital Course: 80y/o F with ESRD on HD, HTN, anemia, PVD, DM coming in from [**Last Name (un) 1188**] house for worsened mental status, found to have expanding SDH. # Neurologic deficits: Although pt's baseline is abnormal and pt generally is disoriented, pt was thought to be worsening. Pt was evaluated for toxic metabolic etiology, as well as seizures, but ultimately altered mental status was thought to be due to enlarging SDH. Pt was followed by neurology, neurosurgery and pain and palliative care, all discussing options with the family. Decision was made to undergo evacuation of SDH. On [**3-14**], pt underwent a left craniotomy and evacuation of chronic SDH. A subgaleal drain was placed. Pt underwent a CT head without contrast within 4 hours of the procedure. Postoperatively, the pt remained dysarthric, but her dysarthria ultimetly improved and patient was fluent with her speech, although she had periods of confusion even on the day of discharge, recalling the events of the previous day incorrectly. A CT head was performed on [**3-16**] which demonstrated normal postoperative changes. The subgaleal drain was removed, and the pt was transferred to the floor. On [**3-17**], the pt was oriented x 3 and full strength, but remained dysarthric. On [**3-18**], three doses of subcutaneous vitamin K were given for INR 1.8. She had her PICC line repositioned. Pt's aspirin was held for bleed and procedure but will ultimately need to be restarted to due high risk of CVA. # End stage renal disease: Pt was followed by nephrology and continued on her scheduled [**Month/Day (4) 2286**] on Tuesdays, Thursdays and Saturdays. She was also continued on her renal supplements including EPO. # Anemia of Chronic Disease: HCT remained stable at baseline 25-30 and pt was continued on EPO at HD, she was also transfused 2 units of blood on this admition. # Diabetes Mellitus: BSs well controlled, with frequently recorded asymptomatic hypoglycemia. Pt's output nateglinide was stopped and started on ISS while inpatient. # Toxic multinodular goiter: TFTs were consistent with sick euthyroid, thus pt was continued on her recently adjusted dose of methimazole and asked to follow up as an out pt with endocrinology. # Hyperlipidemia: Pt was continued on atorvastatin. As stated on her discharge instructions, patient was advised to follow up with her primary care physician within [**Name Initial (PRE) **] week of discharge to review her new medications and follow up with regard to her ongoing anemia. Medications on Admission: Atorvastatin 10 mg PO DAILY Labetalol 200 mg PO BID: Hold on mornings of [**Name Initial (PRE) 2286**]. Docusate Sodium 100 mg PO BID Senna 8.6 mg PO BID (2 times a day) as needed. Aspirin 81 mg PO DAILY Cinacalcet 30 mg (2) Tablet PO DAILY Nateglinide 60 mg PO TID Sevelamer Carbonate 800 mg PO TID W/MEALS B Complex-Vitamin C-Folic Acid 1 mg PO DAILY Methimazole 5 mg PO once a day. Epoetin Alfa 10,000 unit/mL (1) infusion Injection every seventy-two (72) hours with hemodialysis. Discharge Medications: 1. hospital bed Sig: One (1) once a day: End stage renal dz, weakness, skin wounds, needs frequent repositioning. Needs a semi electric hospital bed. Disp:*1 1* Refills:*0* 2. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Nateglinide 60 mg Tablet Sig: One (1) Tablet PO TIDAC (3 times a day (before meals)). 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 7. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 9. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*0* 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. Tablet(s) 12. Alternating pressure pad Sig: One (1) on going: Pt. with ESRD, needs frequent repositioning to prevent bed soars. Disp:*1 * Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Bilateral Subdural Hematoma ESRD Discharge Condition: Neurologically stable Discharge Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. ####### You are perscribed a lot of medications that are not perscribed by our service, please make arrangements and an appointment with your primary care physician to be seen after this hospitalization to go over your medications and update any new medications you have been started on. You were also transfused several units of blood b/c your blood counts fell a few times, please pursue a work up of your anemia with your primary care physician#### Followup Instructions: Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7746**], MD Phone:[**Telephone/Fax (1) 3666**] Date/Time:[**2114-3-29**] 1:00 Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2114-3-29**] 11:45 You will need to have your sutures and staples removed on [**2114-3-25**] please call our office to meet schedule an appointment with the Nurse practitioner: [**Telephone/Fax (1) 1669**] Completed by:[**2114-3-29**]

[ "443.9", "242.20", "459.81", "272.4", "285.21", "585.6", "250.00", "416.8", "E888.9", "852.20", "403.11" ]

icd9cm

[ [ [] ] ]

[ "01.31", "39.95" ]

icd9pcs

[ [ [] ] ]

9915, 9972

5526, 8040

333, 372

10049, 10073

4664, 5503

12085, 12547

2929, 2939

8575, 9892

9993, 10028

8066, 8552

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2954, 2954

272, 295

400, 2154

3625, 4645

2969, 3609

2176, 2744

2760, 2913

27,355

153,655

47259

Discharge summary

report

Admission Date: [**2104-9-17**] Discharge Date: [**2104-9-22**] Date of Birth: [**2049-8-29**] Sex: F Service: SURGERY Allergies: Toprol Xl Attending:[**Doctor First Name 100050**] Chief Complaint: Right breast cancer Major Surgical or Invasive Procedure: Right modified radical mastectomy. History of Present Illness: This 55-year-old female presented with carcinoma of the right breast diagnosed [**2102-9-12**]. This was originally diagnosed by fine needle aspiration. She was managed with neohormonal therapy, Arimidex, with good response until late spring of [**2104**]. At that time, imaging suggested that the cancer was increasing in size and was multicentric in nature. Of note, her clinical course was complicated by venous outflow obstruction of a right upper extremity AV fistula leading to varices that involved the right side of the torso, extending up into the neck, into the axilla, and around to the back. It also led to engorgement of her right breast. On [**2104-9-9**], she underwent a venogram and dilatation of a tight stenosis centrally of the outflow from the fistula. She had some response of the dilated veins. It was felt that she was not a candidate for chemotherapy due to multiple other medical problems, including her end-stage renal disease and HIV infection since [**2086**], as well as severe hypertension. Due to the multifocal nature of her disease, she was not a candidate for breast-conserving surgery. In the context of the disease progression, mastectomy was felt to be the only appropriate way to proceed for local control. Past Medical History: HIV--dx [**2086**]. No opportunistic infections. Last CD4 ([**2100-12-17**]): 110. Last viral load ([**2100-12-17**]): 33,600. Has not been taking all her medications, and her ID doctor and she are discussing a "clean start" ESRD--on HD since [**10-3**]. She has a permacath in the left side, but this week has started using her R upper arm fistula. h/o aseptic meningitis h/o Bell's palsy HTN Asthma Carpel tunnel Panic d/o - reportedly takes 3-5mg klonapin daily Nephrotic syndrome Social History: Social History: No smoking, history of cocaine use (positive tox screen when requesting escalating narcotics) Family History: Mother, throat ca, colon cancer Father, cad, dm Physical Exam: On day of discharge: T 98.5 HR 107 BP 120/66 RR 18 100% RA Gen: AAO x 3 Cards: RRR Pulm: CTA b/l Abd: S/NT/ND wound: clean, dry, intact, no swelling, discharge or hematoma Pertinent Results: [**2104-9-19**] 04:55AM BLOOD WBC-5.0 RBC-2.47* Hgb-8.4* Hct-25.5* MCV-103* MCH-34.1* MCHC-33.0 RDW-16.3* Plt Ct-118* [**2104-9-19**] 04:55AM BLOOD Glucose-114* UreaN-43* Creat-8.4*# Na-136 K-4.9 Cl-99 HCO3-29 AnGap-13 Brief Hospital Course: The patient was admitted to the surgery service following her surgery. She tolerated the procedure well, was extubated and transferred to the surgical intensive care unit for continued monitoring. [**9-18**] the patient was stable and was transferred to the floor, underwent dialysis without complication. The patient remained in the hospital for wound checks to assess for hematoma, swelling, discharge and discomfort following the surgery and hemodialysis. She remained stable and her wound was clean, dry and intact with no evidence of hematoma. Following dialysis on [**9-22**] she is discharged home Medications on Admission: 1. Valacyclovir 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 3. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Tablet, Chewable(s)* Refills:*2* 4. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO QSAT (every Saturday). Disp:*30 Tablet(s)* Refills:*2* 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 9. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 10. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety/agitation. Disp:*30 Tablet(s)* Refills:*0* 12. Lamivudine 150 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for SOB, wheeze. Disp:*1 disk* Refills:*0* 14. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*60 Disk with Device(s)* Refills:*2* Discharge Medications: 1. Valacyclovir 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 3. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Tablet, Chewable(s)* Refills:*2* 4. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO QSAT (every Saturday). Disp:*30 Tablet(s)* Refills:*2* 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 9. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 10. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety/agitation. Disp:*30 Tablet(s)* Refills:*0* 12. Lamivudine 150 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for SOB, wheeze. Disp:*1 disk* Refills:*0* 14. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*60 Disk with Device(s)* Refills:*2* 15. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 16. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Carcinoma of the right breast. Discharge Condition: Stable Discharge Instructions: Please call or return to the emergency room if you experience a fever greater than 101.5, chills, shortness of breath, increasing pain, swelling, or drainage from your wound or any other concerning symptoms. Followup Instructions: Please call the office of Dr. [**Last Name (STitle) 11635**] to schedule a follow up appointment in [**2-3**] weeks at [**Telephone/Fax (1) 17898**] Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2104-9-29**] 1:45 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2104-9-29**] 2:05 Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2104-10-22**] 3:30

[ "585.6", "493.90", "403.91", "V45.1", "174.8", "300.01", "V08" ]

icd9cm

[ [ [] ] ]

[ "39.95", "85.43" ]

icd9pcs

[ [ [] ] ]

6965, 6971

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292, 329

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2514, 2734

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2256, 2305

5054, 6942

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3394, 5031

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2320, 2495

233, 254

357, 1605

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83,040

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3215

Discharge summary

report

Admission Date: [**2114-8-18**] Discharge Date: [**2114-8-29**] Date of Birth: [**2041-7-1**] Sex: M Service: SURGERY Allergies: Ciprofloxacin Attending:[**First Name3 (LF) 2777**] Chief Complaint: Acute ischemia of the right lower extremity. Major Surgical or Invasive Procedure: [**8-19**]: OPERATION PERFORMED: Right popliteal and anterior tibial artery thrombectomy with greater saphenous vein patch angioplasty. [**8-23**]: PROCEDURES: 1. Exploration of medial calf and drainage of hematoma. 2. Right anterior and lateral fasciotomy [**8-19**]: OPERATION PERFORMED: Right popliteal and anterior tibial artery thrombectomy with greater saphenous vein patch angioplasty. Temporary HD catheter placement History of Present Illness: 73 M presented to [**Hospital1 **] with acute onset abdominal pain, nausea and vomiting x3 this afternoon. Pain resolved and at 1700 on day of admission had acute onset right foot pain. Pain was severe ache, with nothing relieving. No prior episodes. Pt has been treated for UTI over past few weeks. Reports feeling well prior to today. Tolerating good PO and urinating normally. +BM, non-bloody. He has had good BP control at home. Past Medical History: PMH: 1. prostate ca s/p seeds ([**3-12**]) 2. Chronic renal insufficiency (baseline unknown) 3. HTN 4. Hyperlipidemia 5. Gout 6. trauma to right leg, s/p knee surgery ([**2075**]'s) Social History: SH: retired truck driver, never smoked, no EtOH. Married with children Family History: FH: non contributory Physical Exam: PE: 97.5 F 86 130/68 18 96% 2L NC Gen: appears uncomfortable, A&Ox3 Cor: RRR Pulm: CTAB Abd: soft, nontender, nondistended. No bruit, no pulsatile mass LE: RLE (affected): cool at the level of the ankle, decreased sensation in foot. Motor decreased. Delayed cap refill. No tissue loss or wounds. Pulses: Fem [**Doctor Last Name **] AT DP PT [**Name (NI) 167**] 2 2 dop dop dop Left 2 2 2 2 2 Temporary HD line Pertinent Results: [**2114-8-29**] 06:10AM BLOOD WBC-13.5* RBC-3.35* Hgb-9.6* Hct-29.6* MCV-89 MCH-28.7 MCHC-32.4 RDW-15.9* Plt Ct-635* [**2114-8-29**] 06:10AM BLOOD PT-20.7* PTT-51.1* INR(PT)-1.9* [**2114-8-29**] 06:10AM BLOOD Glucose-97 UreaN-41* Creat-3.5* Na-144 K-4.3 Cl-101 HCO3-32 AnGap-15 [**2114-8-29**] 06:10AM BLOOD Calcium-9.3 Phos-4.2 Mg-1.8 [**2114-8-23**] 09:27AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009 URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG URINE RBC-[**7-11**]* WBC-[**4-5**] Bacteri-MOD Yeast-NONE Epi-0-2 ORTABLE CHEST RADIOGRAPH, [**2114-8-24**] INDICATION: Line placement. FINDINGS: Right internal jugular catheter terminates in the mid superior vena cava. No visible pneumothorax, but extreme lung apices have been excluded from the study, precluding assessment for a very small pneumothorax. Heart size is normal. The aorta is tortuous. Minor areas of atelectasis are present in both lung bases. MRA: FINDINGS: There is extensive atheromatous disease seen in the thoracic and the abdominal aorta. There is extensive ulcerated plaque present in the lower thoracic as well as the upper abdominal aorta. The infrarenal abdominal aorta shows minimal eccentric plaque. The iliac vessels do not demonstrate significant plaque. There is atelectasis versus an infiltrate at the right lung base. The liver, gallbladder, spleen, adrenal glands appear unremarkable. The pancreas is atrophic. There are bilateral renal lesions that are incompletely assessed due to lack of intravenous contrast. Correlation with prior ultrasound and CT demonstrate that most of these are cysts. There is a 2.4 x 2.1 cm cystic lesion at the lower pole of the left kidney that has imaging characteristics suggestive of a hemorrhagic cyst and better documented on CT of [**2114-8-18**]. There is no abdominal pelvic lymphadenopathy. There is no free fluid in the abdomen or pelvis. There is colonic diverticulosis without evidence of diverticulitis. There is a well-circumscribed high T1 weighted, high T2 weighted lesion in the body of T11, likely representing a hemangioma. Multiplanar 2D and 3D reformations provided multiple perspectives of the imaging findings. IMPRESSION: 1. Extensive atherosclerosis in the thoracic and the abdominal aorta. Extensive ulcerated plaque is seen in the lower thoracic and the upper abdominal aorta. The iliac vessels do not demonstrate significant plaque. 2. Atelectasis/infiltrate at the right lung base. This can be further assessed with a chest radiograph. ECHO: Conclusions The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad. IMPRESSION: Normal global and regional biventricular systolic function. RENAL US: FINDINGS: The right kidney measures 7.3 cm. The left kidney measures 10.4 cm. Multiple simple cysts identified within both kidneys. For example, in the right upper pole, there is a 2.3 x 1.8 x 1.7 cm simple cyst. In the lower pole of the right kidney, there is a 3.8 x 3.1 x 3.6 cm simple cyst. In the left kidney, there is a 4.4 x 2.9 x 3.9 cm simple cyst. No evidence of hydronephrosis, solid renal masses or calculi. IMPRESSION: Bilateral renal cysts. No evidence of hydronephrosis. Brief Hospital Course: Mr. [**Known lastname 15052**],[**Known firstname 15053**] was admitted on [**8-18**] with cold leg. He agreed to have an elective surgery. Pre-operatively, he was consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were obtained, all other preparations were made. To note on admission he has IV CKD. On admission creatine was 5. CT scan calcification of either mural thrombus or intimal flap at the level of renal arteries. As well as multiple hyperdense renal cysts. Renal did follow the patient during the hospital course. They are aware and will follow at rehab, for his nephrologist is associated with [**Hospital1 **] and [**Hospital1 18**]. [**8-19**]: OPERATION PERFORMED: Right popliteal and anterior tibial artery thrombectomy with greater saphenous vein patch angioplasty. He was prepped, and brought down to the operating room for surgery. Intra-operatively, he was closely monitored and remained hemodynamically stable. He tolerated the procedure well without any difficulty or complication. Post-operatively, he was extubated and transferred to the PACU for further stabilization and monitoring He was then transferred to the VICU for further recovery. While in the VICU he received monitored care. When stable he was delined. His diet was advanced. A PT consult was obtained. Pt did receive multiple blood transfusions. To keep HCT around 30 for end stage renal disease. While in the VICU his CK's were elevated. He still c/o RLE pain. An US was done showed fluid collection. It was decided ed that he would undergo further intervention. [**8-23**]: OPERATION PROCEDURE: 1. Exploration of medial calf and drainage of hematoma. 2. Right anterior and lateral fasciotomy. He was prepped, and brought down to the operating room for surgery. Intra-operatively, he was closely monitored and remained hemodynamically stable. He tolerated the procedure well without any difficulty or complication. Post-operatively, he was extubated and transferred to the PACU for further stabilization and monitoring He was then transferred to the VICU for further recovery. While in the VICU he received monitored care. When stable he was delined. His diet was advanced. A PT consult was obtained. When he was stabilized from the acute setting of post operative care, he was transferred to floor status Pt also had both asterixis and myoclonus. A neurology consult was obtained. This was secondary to toxic and metabolic encephalopathy. On the floor, she remained hemodynamically stable with his pain controlled. He progressed with physical therapy to improve her strength and mobility. He continues to make steady progress without any incidents. He was discharged to a rehabilitation facility in stable condition. To note pt was being followed by his nephrologist. He was on verge of getting HD. A Renal Consult was obtained. He still makes urine. Because of his fragile status. A temporary HD catheter was placed. He did receive HD. This may not be permanent. Renal At [**Hospital **] rehab will follow. The latest word is that he may not receive HD permanently. He may recover from ARF on CRI. If this is the case renal will remove temporary HD catheter, Medications on Admission: atenolol 50', norvasc 10', simvistatin 20', allopurinol 300' Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every 48 hours). 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: INR goal is [**3-6**]. 7. Reglan 5 mg Tablet Sig: One (1) Tablet PO four times a day. 8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 12. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Insulin Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Glucose Insulin Dose 0-60 mg/dL [**2-2**] amp D50 61-139 mg/dL 0 Units 0 Units 0 Units 0 Units 140-159 mg/dL 2 Units 2 Units 2 Units 2 Units 160-179 mg/dL 4 Units 4 Units 4 Units 4 Units 180-199 mg/dL 6 Units 6 Units 6 Units 6 Units 200-219 mg/dL 8 Units 8 Units 8 Units 8 Units 220-239 mg/dL 10 Units 10 Units 10 Units 10 Units 240-259 mg/dL 12 Units 12 Units 12 Units 12 Units 260-279 mg/dL 14 Units 14 Units 14 Units 14 Units 280-299 mg/dL 16 Units 16 Units 16 Units 16 Units > 300 mg/dL Notify M.D. Discharge Disposition: Extended Care Facility: [**Hospital1 **] [**Location (un) **] Discharge Diagnosis: Acute ischemia of the right lower extremity CRI Temporary HD catheter PAD Thrombus Hypovlemia requiring blood products CRI, HTN, lipids, gout Discharge Condition: Stable Discharge Instructions: Incision Care: Keep clean and dry. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. -If you have staples, they will be removed during at your follow up appointment. What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [**3-6**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to ambulate several times per day. * No heavy ([**11-15**] lbs) until your follow up appointment. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2114-9-13**] 1:45 RENAL WILL FOLLOW AT [**Hospital **] REHAB IN [**Location (un) **] Completed by:[**2114-8-29**]

[ "584.5", "V58.61", "403.90", "998.12", "V10.46", "444.22", "585.4", "274.9", "272.4" ]

icd9cm

[ [ [] ] ]

[ "83.14", "39.56", "38.08", "83.09" ]

icd9pcs

[ [ [] ] ]

10959, 11023

5929, 9100

317, 749

11210, 11219

2099, 5906

15723, 15974

1530, 1553

9211, 10936

11044, 11189

9126, 9188

11243, 11243

13886, 15700

11259, 13860

1568, 2080

233, 279

777, 1219

1241, 1425

1441, 1514

1,997

194,292

10412

Discharge summary

report

Admission Date: [**2127-10-23**] Discharge Date: [**2127-10-29**] Date of Birth: [**2070-6-17**] Sex: M Service: ONCOLOGY HISTORY OF PRESENT ILLNESS: The patient is a 57 year old male with non-small lung carcinoma diagnosed in [**2125-2-2**], at which time he presented with cough. A chest x-ray revealed a left upper lobe mass and CT scan guided biopsy confirmed the diagnosis of non-small cell lung carcinoma. The patient underwent eight cycles of Taxotere Carboplatin between [**4-14**] and [**5-5**], for which the patient reportedly had an excellent response. In [**2127-4-3**], the patient received XRT complicated by esophagitis. In [**2127-6-3**], the patient was started on weekly Taxotere with only minimal response. The patient underwent pleuracentesis on [**2127-9-25**], and again on [**10-2**], for symptomatic relief of malignant pleural effusions. On [**2127-10-15**], the patient was started on Gemcitabine and EGFR inhibitor. The patient presented to clinic today for day number eight of chemotherapy with Gemcitabine. The patient reports having worsening cough associated with shortness of breath beginning three days prior to admission. The patient had been taking codeine without relief in symptoms. In the Clinic, the patient's O2 saturations were recorded as 93% on four liters. The patient was admitted for hypoxia. PAST MEDICAL HISTORY: 1. Non-small cell lung carcinoma, metastatic. MEDICATIONS ON ADMISSION: 1. Codeine. 2. Robitussin DM. 3. Fiber laxative. 4. Sc benzoate. 5. OSI-774. ALLERGIES: Intravenous contrast. SOCIAL HISTORY: The patient is married with four children. Former child psychologist. [**Country 3992**] war veteran. History of tobacco, quit in [**2100**]. PHYSICAL EXAMINATION: On admission febrile; pulse 136; pressure 115/70; no pulsus paradoxus. O2 saturation 94 on 50% shovel mask. In general, awake, alert, tachypneic, shallow breath. HEENT: Extraocular muscles are intact. Anicteric sclerae. Moist mucous membranes. Cardiovascular: regular rate; tachycardic to 136. No murmurs, rubs or gallops appreciated. Lungs with crackles at left base; otherwise clear. Dullness to percussion at left base; using accessory muscles of respiration. Abdomen soft, nontender, normal bowel sounds. Extremities with no edema. ADMISSION LABORATORY: White blood cell count 7.1, hematocrit of 33.9, ANC 5830. Chest x-ray, left pleural effusion with layering on lateral decubitus. EKG sinus tachycardia; no changes compared to previous EKG. HOSPITAL COURSE: The patient is a 57 year old male with metastatic non-small lung carcinoma status post chemotherapy and XRT who presents with a three day history of worsening cough and dyspnea on exertion, with hypoxia and evidence of increasing pleural effusion on chest x-ray. On admission, the patient was hemodynamically stable and started on supplemental O2, morphine and Prednisone taper. Was started intravenous fluids for sinus tachycardia was thought to be secondary to hypovolemia. The patient's respiratory status continued to decline and the patient was intubated on hospital day number three. The patient became progressively hypotensive and was started on Neo-Synephrine for blood pressure support. In addition, the patient began spiking fevers and was started on Ceftazidine and Vancomycin for a presumed superimposed pleural infection. The patient's white count and platelets began to decrease likely secondary to Gemcitabine chemotherapy. A family meeting was held and given metastatic cancer, it was decided to make the patient comfort measures only. The patient was started on Ativan and morphine infusions. The patient passed away on [**2127-10-29**]. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-702 Dictated By:[**Last Name (NamePattern1) 1297**] MEDQUIST36 D: [**2128-8-26**] 15:20 T: [**2128-8-31**] 15:14 JOB#: [**Job Number 34477**]

[ "197.7", "162.3", "486", "508.1", "427.89", "518.81", "197.2" ]

icd9cm

[ [ [] ] ]

[ "34.91", "96.04", "96.72", "33.23" ]

icd9pcs

[ [ [] ] ]

1465, 1584

2550, 3952

1769, 2532

169, 1369

1391, 1439

1601, 1746

15,560

192,863

53922

Discharge summary

report

Admission Date: [**2112-12-14**] Discharge Date: [**2112-12-20**] Service: CHIEF COMPLAINT: Shoulder pain, failure to thrive, mental status change. HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **] year old gentleman with a past medical history significant for intermittent atrial fibrillation and benign prostatic hypertrophy, who was evaluated at an outside hospital for right shoulder pain, unclear of the work-up done at the outside hospital as there was no documentation. History was obtained from the daughter. The patient was seen at an outside hospital and was discharged. The patient continued to have shoulder pain, change in mental status and was sent here to [**Hospital1 69**]. In the Emergency Department, the patient had denied chest pain and shortness of breath. He was admitted to the coronary Intensive Care Unit for asymptomatic bradycardia. He was seen by the electrophysiology service who did not see need for pacemaker or asymptomatic Winkebach. Chest x-ray revealed a retrocardiac opacity, questionable pneumonia and 4 out of 4 blood cultures were positive for gram negative rods which were identified as pan sensitive Klebsiella. The patient has reported allergies to multiple antibiotics including cephalosporins which cause anaphylaxis, Quinolones which cause rash and unclear childhood Penicillin allergy and unclear allergy to macrolides. Repeat chest x-ray showed improvement of retrocardiac opacity. The patient was transferred from the CCU to the Medical Intensive Care Unit for decreased urine output which had resolved over one day and was transferred to the floor. PAST MEDICAL HISTORY: Significant for benign prostatic hypertrophy, atrial fibrillation, history of gastrointestinal bleed in [**2105**]. Status post skin cancer, in remission, unclear when. Skin cancer was diagnosed. Unclear of treatment. MEDICATIONS ON DISCHARGE: The patient was on Aztreonam 250 mg q. six hours which was started on [**12-13**], Finasteride 5 mg q. day, Pantoprazole 40 mg q. day, Colace 100 mg twice a day, Tylenol prn and heparin subcutaneous. As previously stated, allergies are as follows: Cephalosporin causing anaphylaxis, Quinolone causing rash, Penicillin unclear childhood allergy, Macrolides, unclear reaction. HOME MEDICATIONS: Prilosec. Finasteride. SOCIAL HISTORY: Lives in [**Hospital3 **] with private caretaker. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: Vital signs on transfer to the floor revealed 97.0; blood pressure 144/86; pulse of 51; saturating 97% on room air. He is lethargic, elderly gentleman, appearing younger than his stated age, in no apparent distress. HEAD, EYES, EARS, NOSE AND THROAT: He has a right surgical pupil. Left pupil was 2 mm which was minimally reactive. His oropharynx is dry. Neck is supple without lymphadenopathy. No jugular venous distention. Chest: He had bronchial breath sounds bilaterally throughout. Cardiac examination: Bradycardiac and irregular with a normal S1 and S2, no murmurs. Abdomen: Quiet bowel sounds, some slight tenderness on deep palpation but otherwise soft. No hepatosplenomegaly. Extremities: Left heel eschar, 2 by 2 cm without erythema or proximal streaking. The patient also has a left thigh pressure sore which does not appear to be infected. Neurologically, he is alert and oriented times one. LABORATORY DATA: White count of 21.1 with a left shift; 91 neutrophils, 5 lymphocytes, 4 monocytes. Hematocrit of 33.0. Platelets of 143. PTT of 25.3; INR of 1.1. Sodium of 142; potassium of 4.0; chloride of 114; bicarbonate of 20; BUN 35; creatinine 1.3; glucose 171. ALT of 15; AST of 24; LDH of 148. Alkaline phosphatase of 154. Total bilirubin of 1.5. Albumin 2.7. Calcium 8.1. Magnesium of 2.1. Phosphorus of 3.2. TSH of .68. He did have a calculated [**Doctor First Name **] of .1%. Urinalysis showed large blood, negative leukoesterase, 20 to 50 red cells, 0 to 2 white cells, no bacteria. Again, he had blood cultures, four bottles, positive for pansensitive Klebsiella. HOSPITAL COURSE: On transfer to the floor, the patient was continued on Aztreonam until intravenous access was lost. Intravenous team could not place another peripheral line. The patient's daughter refused central venous access. The patient was started on oral Levofloxacin and continued to do well. Klebsiella was sensitive to Quinolones, although the patient has a stated rash to Quinolones. There was no sign of rash or reaction to the medicine during the course of his hospital stay. His fluoroquinolone should be continued through [**2112-12-25**] and discontinued after that. This will give him a total two week course of antibiotics. Most likely source of his Klebsiella is a pulmonary source. The patient could not tolerate CT of the abdomen. Right upper quadrant and total abdominal ultrasound was negative. Mental status: The patient was originally admitted for change in mental status. He responded well initially to intravenous fluids and then with improvement of his infection. His third issue is his acute renal failure. The patient did have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of less than 1% and slightly elevated creatinine above his baseline. This also responded with intravenous hydration. Fourth issue is his asymptomatic bradycardia. He has Mobitz type I or Wenckebach heart block. He was evaluated by the electrophysiology service. No pacer will be placed. He did have transthoracic echo done which showed an ejection fraction of 40 to 45%. Fluids, electrolytes and nutrition: Speech and swallow did see the patient at the bedside and assessed adequate function. He was encouraged to take increased p.o. CONDITION ON DISCHARGE: Fair. DISCHARGE STATUS: Rehabilitation facility. MEDICATIONS ON DISCHARGE: Albuterol neb prn. Levofloxacin 250 mg p.o. q. day. Should continue through [**2112-12-25**] for a full two week course of antibiotics for his Klebsiella bacteremia. Finasteride 5 mg p.o. q. day. Colace 100 mg p.o. twice a day. Pantoprazole 40 mg p.o. q. day. Tylenol prn. The patient will follow-up with Dr. [**Last Name (STitle) 10145**], his primary care provider, [**Name10 (NameIs) **] discharged from the rehabilitation facility. DR.[**Last Name (STitle) **],[**First Name3 (LF) 2467**] 12-746 Dictated By:[**Last Name (NamePattern1) 11207**] MEDQUIST36 D: [**2112-12-20**] 01:43 T: [**2112-12-20**] 07:13 JOB#: [**Job Number 110600**]

[ "427.31", "707.0", "426.13", "276.5", "584.9", "038.49", "719.41", "486", "783.7" ]

icd9cm

[ [ [] ] ]

[ "88.72" ]

icd9pcs

[ [ [] ] ]

2409, 2427

5829, 6506

4078, 4882

2300, 2324

2450, 4060

104, 161

190, 1635

4898, 5726

1658, 1879

2341, 2392

5751, 5803

79,655

131,754

28708

Discharge summary

report

Admission Date: [**2125-4-10**] Discharge Date: [**2125-4-14**] Date of Birth: [**2050-1-9**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4691**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [**2125-4-10**] exploratory laparotomy, LOA, hemorrhagic bowel, no resection, cirrhotic liver found History of Present Illness: Asked to see this 75 F who presents to the ED with sudden onset of abdominal pain starting at 10 PM last night. This was associated with nausea and emesis x [**1-19**], non-bloody. Pain diffuse without any radiation. She denies having pain like this previously. She also denies fevers, chills, diarrhea, constipation, urinary symptoms, cough, shortness of breath, or chest pain. Past Medical History: CAD s/p prior MI while in NY city, [**2106**], either had angioplasty or stent placed, is unable to provide further details - Recent Cath [**2120**]: LMCX 30% ostial stenosis LAD mid 90% stenosis s/p BMS LCx total chronic occlusion RCA mid vessel 50% stenosis -Hypertension requiring multiple agents -DM on oral agents -RTA with stable K on kayexelate -CKDV with baseline Cr 1.4-1.6 -s/p GU surgery - Colonoscopy [**2119**] Grade 1 internal hemorrhoids Polyp in the distal sigmoid colon (polypectomy) Otherwise normal colonoscopy to cecum Social History: Spanish speaking, former smoker Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: PHYSICAL EXAMINATION Temp:98.6 HR:60 BP:194/63 Resp:20 O(2)Sat:98 Normal Constitutional: uncomfortable HEENT: Normocephalic, atraumatic Oropharynx within normal limits Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, tender epigastrium, no G/R Rectal: Per resident, heme pos stool GU/Flank: No costovertebral angle tenderness Extr/Back: No cyanosis, clubbing or edema Skin: Warm and dry Neuro: Speech fluent Psych: Normal mentation Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae Pertinent Results: [**2125-4-10**] 02:08AM BLOOD WBC-8.1 RBC-4.37 Hgb-14.6 Hct-43.1 MCV-99* MCH-33.4* MCHC-33.9 RDW-14.6 Plt Ct-86* [**2125-4-10**] 11:25AM BLOOD WBC-10.0 RBC-3.65* Hgb-12.3 Hct-35.9* MCV-98 MCH-33.6* MCHC-34.1 RDW-14.6 Plt Ct-78* [**2125-4-11**] 01:56AM BLOOD WBC-16.0*# RBC-3.28* Hgb-10.9* Hct-32.4* MCV-99* MCH-33.2* MCHC-33.7 RDW-14.9 Plt Ct-69* [**2125-4-11**] 12:01PM BLOOD WBC-12.8* RBC-3.07* Hgb-10.6* Hct-29.5* MCV-96 MCH-34.4* MCHC-35.7* RDW-14.8 Plt Ct-58* [**2125-4-12**] 02:44AM BLOOD WBC-9.7 RBC-2.73* Hgb-9.1* Hct-26.9* MCV-99* MCH-33.5* MCHC-34.0 RDW-15.0 Plt Ct-66* [**2125-4-13**] 04:35AM BLOOD WBC-7.5 RBC-2.99* Hgb-10.0* Hct-29.3* MCV-98 MCH-33.4* MCHC-34.0 RDW-14.9 Plt Ct-68* [**2125-4-10**] 02:08AM BLOOD Plt Ct-86* [**2125-4-10**] 11:25AM BLOOD PT-19.3* PTT-37.2* INR(PT)-1.7* [**2125-4-10**] 11:25AM BLOOD Plt Ct-78* [**2125-4-11**] 01:56AM BLOOD PT-18.8* PTT-33.8 INR(PT)-1.7* [**2125-4-10**] 02:08AM BLOOD Glucose-267* UreaN-29* Creat-1.5* Na-138 K-3.5 Cl-104 HCO3-24 AnGap-14 [**2125-4-10**] 11:25AM BLOOD Glucose-215* UreaN-24* Creat-1.3* Na-139 K-3.4 Cl-112* HCO3-21* AnGap-9 [**2125-4-11**] 01:56AM BLOOD Glucose-218* UreaN-33* Creat-2.1* Na-138 K-4.1 Cl-110* HCO3-16* AnGap-16 [**2125-4-11**] 12:01PM BLOOD Glucose-197* UreaN-41* Creat-2.2* Na-140 K-4.0 Cl-110* HCO3-20* AnGap-14 [**2125-4-11**] 08:14PM BLOOD Glucose-174* UreaN-43* Creat-2.2* Na-139 K-4.2 Cl-111* HCO3-19* AnGap-13 [**2125-4-12**] 02:44AM BLOOD Glucose-185* UreaN-47* Creat-2.4* Na-137 K-4.2 Cl-111* HCO3-20* AnGap-10 [**2125-4-13**] 04:35AM BLOOD Glucose-132* UreaN-45* Creat-2.0* Na-142 K-3.8 Cl-114* HCO3-23 AnGap-9 [**2125-4-10**] 02:08AM BLOOD ALT-41* AST-56* AlkPhos-149* TotBili-0.5 [**2125-4-10**] 11:25AM BLOOD ALT-25 AST-35 AlkPhos-93 Amylase-36 TotBili-0.6 [**2125-4-11**] 01:56AM BLOOD ALT-28 AST-45* CK(CPK)-1561* AlkPhos-75 TotBili-0.8 [**2125-4-11**] 12:01PM BLOOD LD(LDH)-335* [**2125-4-11**] 08:14PM BLOOD CK(CPK)-2132* [**2125-4-12**] 02:44AM BLOOD ALT-28 AST-74* AlkPhos-61 TotBili-0.9 [**2125-4-10**] 11:25AM BLOOD Albumin-2.2* Calcium-7.0* Phos-3.6 Mg-1.2* [**2125-4-11**] 01:56AM BLOOD Albumin-2.2* Calcium-7.7* Phos-3.3 Mg-2.0 [**2125-4-11**] 12:01PM BLOOD Calcium-7.9* Phos-3.2 Mg-1.9 [**2125-4-11**] 08:14PM BLOOD Calcium-7.8* Phos-2.9 Mg-2.5 [**2125-4-12**] 02:44AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.4 [**2125-4-13**] 04:35AM BLOOD Calcium-8.0* Phos-2.4* Mg-2.2 [**4-10**] CT a/p 1. Findings consistent with mesenteric ischemia with nonenhancing loops of distal small bowel within the pelvis. Air within the superior mesenteric vein and more proximal mesenteric veins in addition to portal venous gas. Occlusion of the proximal superior mesenteric artery, new since the prior study. 2. Enhancing nodule within a complex cyst within the right kidney, concerning for renal cell carcinoma, papillary type. Further evaluation with MRI is recommended. 3. Cirrhotic liver. 4. Cholelithiasis. 5. Prominent pancreatic ductal side branches, most consistent with a side branch IPMN. [**2125-4-11**]: ECHO: Conclusions The left atrium is mildly dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with mild focal hypokinesis of the basal to mid inferolateral wall. The remaining segments contract normally (LVEF = 55-60 %). The aortic valve is not well seen. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. An eccentric, posteriorly directed jet of mild to moderate ([**11-19**]+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild focal left ventricular dysfunction c/w CAD. Mild to moderate eccentric mitral regurgitation. [**2125-4-11**]: EKG: Sinus rhythm. Prolonged P-R interval. Left ventricular hypertrophy with repolarization change. Compared to the previous tracing of [**2125-5-11**] no definite change Brief Hospital Course: The patient was admitted to the ACS Surgical Service for evaluation and treatment of abdominal pain. Patient was taken to the OR from the ED as there was a concern for mesenteric ischemia. She underwent exlporatory laparotomy with resection of small bowel for SBO. She remained intubated post-op and was taken to the ICU for monitioring. Neuro: The patient received sedation with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: Patient was intubated post-operatively. She was extubated on POD ...The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. GI/GU/FEN: Post-operatively, the patient was made NPO with IV fluids. Diet was advanced when appropriate, which was well tolerated. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. ID: The patient's white blood count and fever curves were closely watched for signs of infection. Endocrine: The patient's blood sugar was monitored throughout her stay; insulin dosing was adjusted accordingly. Hematology: The patient's complete blood count was examined routinely; no transfusions were required. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, 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. Transferred to the surgical floor on POD #3. Started on regular diet. Foley catheter was discontinued on POD #3 and she voided without difficulty. She resumed her pre-hospital medications. Her antibiotics continued but were changed to an oral dose. Her vital signs are stable and she is afebrile. Her platlet count is 68 and white blood cell count is normal. She is preparing for discharge home with 1 week course of antibiotics. She will need to follow up with the Acute care service in 2 weeks. Of note, renal MRI has been scheduled for [**4-30**] to evaluate the kidney lesion. Medications on Admission: amlodipine 10 mg daily, lipitor 20 mg daily, HCTZ 50 mg daily, Insulin humalog mix 75/25, isosorbide mononitrate 60 mg daily, lisinopril 40 mg daily, Toprol XL 200 mg daily, ranitidine 150 mg daily, ASA 325 mg daily Discharge Medications: 1. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 5 days. Disp:*15 Tablet(s)* Refills:*0* 2. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily). 3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily). 6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. Disp:*5 Tablet(s)* Refills:*0* 8. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: abdominal pain bowel ischemia 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 abdominal pain. You underwent a cat scan of your abdomen which showed a decreased blood flow to your intestines. You were taken to the operating room where you had an exploratory laparotomy and lysis of adhesions. You are now preparing for discharge home with the following instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *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 [**3-27**] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Please follow up with the acute care service in 2 weeks. You can schedule this appointment by calling # [**Telephone/Fax (1) 600**] Completed by:[**2125-4-14**]

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icd9cm

[ [ [] ] ]

[ "54.59" ]

icd9pcs

[ [ [] ] ]

9877, 9883

6243, 8838

318, 420

9957, 9957

2149, 6220

12239, 12404

1459, 1541

9105, 9854

9904, 9936

8864, 9082

10108, 11707

11723, 12216

1556, 2130

263, 280

448, 829

9972, 10084

851, 1393

1409, 1443